Every finding on record at Inglewood Health Care Center

Based on interview and record review, the facility failed to follow its grievance process for one of three sampled residents (Resident 1) by failing to:Provide written notification of the grievance investigation results and actions taken.Ensure grievance reports were signed.Make the reports available to the resident or the resident's representative. These failures had the potential to result in delayed communication of grievance outcomes, prevent the resident or resident representative from determining whether concerns were adequately investigated and resolved, and impede the residents ability to exercise their right to appeal, request further review, or pursue additional actions regarding unresolved concerns and impact resident well-being. During a review of Resident 1' s Resident Face Sheet, the Resident Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior).During a review of Resident 1's History and Physical (H&P) dated 9/2/2025, the H&P indicated Residen1 had the capacity to understand or make decisions. During a review of Resident 1's Minimum Data set the (MDS- a resident assessment tool) dated 5/20/2026, the MDS indicated Resident 1's cognition (thought process) was moderately impaired. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) for activities of daily living (ADL's- routine task/activities such as bathing, dressing, and toileting a person preforms daily to care for themselves).During an Interview with Resident 1's family member (FM) on 6/24/2026 at 11:30 a.m., the FM stated that multiple grievances were filed with the facility administration regarding medication administration, physician service, and patient care. The FM stated administration did not inform the family of the findings of the investigations, nor was the family provided with any of the actions that would be taken to correct any of the identified problems.During a concurrent interview and record review on 6/25/2026 at 12:30 p.m., with the Administrator, the following three Grievance/Complaint Reports for Resident 1 and the Grievance QA&A logs were reviewed: The Grievance/Complaint Report dated and received on 4/20/2026, indicated under Documentation of facility follow up the date to be resolved by: the area was blank.Under Resolution of Grievance/Complaint: was grievance resolved: the area was blankThe Grievance/Complaint Report indicated a 2nd grievance dated and received on 4/20/2026, indicated under Resolution of Grievance/Complaint: was grievance resolved: the area was blankThe Grievance/Complaint Report dated and received on 5/20/2026, indicated under Documentation of facility follow up: Date to be resolved by: the area was blank.Staff Signature and title was left blankUnder Resolution of Grievance/Complaint: was grievance resolved: identify method used to notify family: the area was blankThe Grievance QA & A logs for April, May, and June 2026, the column noting Administrators Signature was left blank for all eight grievances logged.Resolution of Grievance/Complaint was Grievance resolved: There was no check mark given for yes or no response.The Administrator stated she was aware the documents were incomplete and families were not notified of actions taken and resolutions and stated that failing to follow up on grievances could delay patient care resolutions and impact resident well-being. During a review of the facility's undated policy and procedure (P&P) titled, Grievances and Complaints, the P&P indicated, The administrator (Grievance Official) is responsible for the resolution of all grievances and complaints. All grievances and complaints are investigated, resolved, and documented. The resident or person filing the grievance or complaint on behalf of the resident will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. All reports must be signed and will be made available to resident or person acting on behalf of the resident.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (Resident 1) who refused the covid vaccine and the facility failed to reassess the resident's vaccination status or offer vaccination again during a facility-wide COVID-19 outbreak.This failure had the potential to compromise the resident's health, safety and wellbeing. During a review of Resident 1' s Resident Face Sheet, the Resident Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior).During a review of Resident 1's History and Physical (H&P) dated 9/2/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Preventative Health Care note dated 9/4/2025, the documentation indicated that the resident's family refused the COVID-19 vaccine based on a conscientious objection (when a person declines to participate in a lawful process or procedure due to their personal beliefs, values, or moral concerns).During a review of Resident 1's Progress note dated 12/4/2025, the Progress note indicated, Spoke with resident and family regarding covid vaccine. Will follow up again when family members come into the facility.During a review of Resident 1's Progress Note dated 5/18/2026 at 3:30 p.m., the Progress Note indicated Resident 1 tested positive for Covid on 5/18/2026.During a review of Resident 1's Minimum Data set the (MDS- a resident assessment tool) dated 5/20/2026, the MDS indicated Resident 1's cognition (thought process) was moderately impaired. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) for activities of daily living (ADL's- routine task/activities such as bathing, dressing, and toileting a person preforms daily to care for themselves).During a concurrent interview and record review on 6/25/2026 at 12:30 p.m., with the Infections Infection Preventionist (IP), Resident 1's plan of care was reviewed. There was no plan of care developed or implemented for Resident 1's refusal of the COVID -19 vaccine. The IP stated a plan of care for COVID-19 refusal should have been developed and implemented for Resident 1. The IP further stated that without the plan of care there was no process in place to monitor Resident1's risk for infection and the plan of care would have helped ensure the interdisciplinary team identified Resident 1's risk and implement appropriate infection prevention measures, particularly during a facility-wide COVID-19 outbreak.During a review of the facility's policy and procedure (P&P) titled, Comprehensive Plan of Care. dated 2/9/2026, the P&P indicated Each resident will have a comprehensive care plan developed that includes goals, measurable objectives, and timetables to meet their medical nursing needs. The comprehensive care plan must describe services that are provided to the resident to attain or maintain the residents highest practicable physical, mental and psychosocial well-being. The comprehensive care plan must address the residents individual needs, strengths and preferences reflective of current standards of professional practice and include interventions to prevent avoidable decline in function or functional level which reflect the company's efforts to provide alternative methods when a resident wishes to refuse certain treatments or services.

Based on interview and record review, the facility failed to provide treatment, care, and documentation in accordance with accepted professional standards of practice for one of three sampled residents (Resident 1) by failing to:1.Respond to a Certified Nursing Assistant's (CNA's) written report of a change in condition for Resident 1, communicated through the facility's Stop and Watch process (a process whereby CNAs alert licensed staff via a form in writing of a resident's change in condition).Specifically, the Licensed Vocational Nurse (LVN) did not utilize the facility's Stop and Watch communication tool after it was presented by the CNA, delaying appropriate nursing evaluation of the reported change in condition.2.Ensure accurate and timely nursing documentation when the Licensed Vocational Nurse (LVN) inaccurately documented that Resident 1 had two sacral wounds on 5/20/2026 leaving the inaccurate documentation in Resident 1's medical record for 34 days.These failures were not consistent with accepted standards of nursing practice and had the potential to delay recognition, assessment, communication, and treatment of changes in the resident's condition. 1. During a review of Resident 1' s Resident Face Sheet, the Resident Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior).During a review of Resident 1's History and Physical (H&P) dated 9/2/2025, the H&P indicated Resident 1 had the capacity to understand or make decisions. During a review of Resident 1's Minimum Data set the (MDS- a resident assessment tool) dated 5/20/2026, the MDS indicated Resident 1's cognition (thought process) was moderately impaired. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) for activities of daily living (ADL's- routine task/activities such as bathing, dressing, and toileting a person preforms daily to care for themselves).During an interview on 6/24/2026 at 2:00 p.m., with CNA 1, CNA 1 stated she completed a STOP and WATCH for Resident 1 on 5/20/2026 at 2:00 p.m., noting Resident 1 had a change in condition, Resident 1 was more drowsy than usual, had a rash on the face and had an open wound on the bottom. CNA 1 stated she attempted to give the STOP and WATCH form to the LVN 2 who was the Charge Nurse, but the Charge Nurse refused to take it stating she was not taking the form because it was after 2:00 p.m.During a concurrent interview and record review on 6/24/2026 at 3:00 p.m., with the Director of Staff Development (DSD), Resident 1's Stop and Watch form dated 5/20/26 at 2:00 p.m., was reviewed. The form was incomplete with areas left undocumented, with lines indicating reported to, nurse's name, date but the time were blank. The DSD stated the form is still not filled out or signed by the charge nurse and it should have been completed by the charge nurse. The DSD stated LVN 2 not accepting or completing the Stop and Watch form is against policy and could have placed Resident 1 at risk for delayed needed care. During a review of the facility's policy and procedure (P&P) titled, General Documentation Guideline/Utilization of Forms Certified Nurse Assistant dated 7/17/2025, the P&P indicated, for any changes in condition identified while caring for or observing a resident, the CNA may utilize the stop and watch form. The CNA will circle the change and notify the licensed nurse. The white original copy is given to the licensed nurse to address the change identified and the yellow copy is given to the director of staff development licensed nurse designee for follow up.2. During a review of Resident 1's Resident Progress Notes dated 5/20/2026 at 4:11 p.m., the Resident Progress Note indicated, At approximately 2:30 PM the resident was noted with low O2 saturation, drowsiness, and two sacral wounds. During resident care wounds were assessed and documented per facility protocol.During a review of Resident 1's Resident Progress Notes on 6/24/2026 at 8:00 a.m., the Resident Progress Notes dated 5/20/2026 was edited on 6/22/2026 at 5:08 p.m., the Resident Progress Notes indicated Skin excoriation caused by friction on sacrum noted scattered small red spot on face noted during patient care.During an interview on 6/24/2026 at 10:30 a.m., with Licensed Nurse (LVN) 2, LVN 2 stated the Resident Progress note was changed on 6/22/2026, 33 days after Resident 1 was discharged from the facility. LVN 2 stated an error was made within the documentation and it was later corrected on 6/22/26.During an interview with the Director of Nursing (DON) on 6/24/2026 at 11:00 a.m., the DON stated the charting policy for documentation for corrections should be followed to prevent errors and ensure that patient medical records are accurate. During a review of the facility's undated P&P titled, Charting, the P&P indicated If necessary to change or add information to a resident's medical record it shall be completed by means of an addendum by using the next available line to enter the current date and time, and write clarification or addendum to state the reason and refer back to the entry being amended.

Based on observation, interview and record review, the facility failed to implement their policy and procedure (P/P) titled, Medication Administration General Guidelines which indicated to identify residents using at least two resident identifiers by checking the identification band (patient identification bracelet), checking the photograph attached to medical record and/or verifying resident identification with other nursing care center personnel before administering medication, for one of four sampled residents (Resident 1). This failure had the potential to cause medication errors, allergic reactions and life-threatening consequences for Resident 1.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses of anemia (a condition where the body does not have enough healthy read blood cells), chronic obstructive pulmonary disease(COPD- a chronic lung disease causing difficulty in breathing) and contusion (bruise) of the left knee.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 6/21/2026, the MDS indicated Resident 1 had clear speech, the ability to express ideas and wants, and able to understand others. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, showering/bathing self, and lower body dressing.During a concurrent interview and observation on 06/15/2026 at 11:30 a.m., with Resident 1, Resident 1 was observed without an identification band. Resident 1 stated she asked staff (unable to recall name) for an identification band because she thought she was going to have surgery, however staff did not provide one for her. During a concurrent record review and interview on 06/15/2026 at 11:40 a.m. with the Licensed Vocational Nurse (LVN) 1, Resident 1's Medication Administration Record (MAR) dated 6/15/2026 was reviewed. LVN 1 stated he gave Resident 1 her morning medications. Resident 1's electronic MAR did not indicate Resident 1's picture was attached. LVN 1 stated during medication administration, he verified Resident 1's identification by the dietary slip (a system for resident meal tracking) and a Certified Nurse Assistant (CNA 1) witnessed the identification. LVN 1 could not state what identifiers should be checked to verify Resident 1's identity. LVN 1 stated medication errors may occur if staff failed to accurately identify a resident.During a record review of Resident 1's MAR dated 6/15/2026, the MAR indicated LVN 1 administered ranolazine (medication used to treat chest pain) 500 milligrams (mg- unit of measurement) on 6/15/2025 during the morning (7:00 a.m. - 3:00 p.m.) shift to Resident 1.During an interview on 6/15/2026 at 12:15 p.m., with CNA 1, CNA 1 stated she did not assist LVN 1 with verifying Resident 1's identification on 6/15/2026 during the morning shift (prior to LVN 1 administering medication to Resident 1). During an interview on 6/15/2026 at 1:25 p.m., with the Director of Medical Records (DMR), the DMR stated she was responsible for making resident's identification bands. Resident 1 did not receive an identification band because the resident was admitted to the facility late in the evening and she did not work on weekends.During a review of the facility's undated P/P titled, Resident Identification System, the policy indicated the following systems are required (not an option) to assist staff to correctly identify residents; identification bracelet and resident picture on the electronic health record. During a review of the facility's P/P titled, medication Administration General Guidelines dated 1/2021, the P/P indicated medications are administered as prescribed in accordance with good nursing principles and practices. The P/P indicated residents are identified before medication is administered using at least two resident identifiers. Methods of identification may include: checking identification band, checking photograph attached to medical record and/or identifying identification with other nursing care center personnel.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided timely transportation to a dialysis (a type of treatment that helps to remove extra fluid and waste products from your blood when the kidneys cannot) treatment appointment. This deficient practice caused Resident 1 to be late for his dialysis treatment which caused a shortened and incomplete dialysis treatment, placing Resident 1 at risk for a decline in his medical condition. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted [DATE]. Resident 1 diagnoses included chronic obstructive pulmonary disease([COPD]- a chronic lung disease causing difficulty in breathing), end stage renal disease ([ESRD] -irreversible kidney failure), and dependence on renal dialysis (a life-sustaining requirement for patients with ESRD where the kidneys can no longer filter toxins and fluid). During a review of Patient 1's History and Physical (H&P), dated 9/12/2025, the H&P indicated, Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS]- a resident assessment tool), dated 2/19/2026, the MDS indicated Resident 1's cognitive skills for daily decision making (ability to learn, reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) on staff for toileting hygiene, showering, and dressing. The MDS indicated Resident 1 received dialysis. During a review of Resident 1's Physician Order Report, dated 10/4/2025, the physician order report indicated Resident 1 was to have dialysis treatment on Tuesdays, Thursdays, and Saturdays. The physician order report indicated Resident 1's pick-up time was at 7:15 a.m., with a return time of 12 p.m. During a review of Resident 1's Progress Notes, dated 4/16/2026, the Progress Note indicated on 4/16/2026, Resident 1 was not picked up at his scheduled standing pick up time for dialysis. During a review of Resident 1's Progress Notes, dated 4/16/2026, the Progress Note indicated Resident 1 received an incomplete cycle (two and half hours) of dialysis treatment. During a concurrent interview and record review on 4/29/2026 at 12:23 p.m., with Registered Nurse (RN) 1, Resident 1's View General Order, dated 10/4/2025 was reviewed. The order indicated Resident 1 was to have dialysis treatment on Tuesdays, Thursdays, and Saturdays; with a pick- up time at 7:15 a.m. and return time at 12 p.m. RN 1 stated there were no changes with Resident 1's transportation pick-up time. RN 1 stated Resident 1 should have been picked up on 4/16/2026 by 7:15 a.m. for dialysis treatment. RN 1 stated social services oversaw the resident's transportation. During an interview on 4/29/2026 at 3:34 p.m., with the facility's contracted transportation company, the transportation company stated there was no transportation scheduled initially on 4/16/2026. The transportation company stated they received a call from the facility on 4/26/2026 and Resident 1 was picked up by 10 a.m. The transportation company stated Resident 1's transportation services was reactivated and was to start on 4/21/2026. During an interview on 4/30/2026 at 1:10 p.m., with Social Services Director (SSD), the SSD stated the licensed nurses would give the standing orders for dialysis and she would manage the transportation for the residents. The SSD stated the protocol was to arrange transportation with the company and Resident 1 would have a certain number of pick-ups per contract. The SSD stated she did not keep track of the pick-up days and how many had remained. The SSD stated this resulted in Resident 1 not being transported to dialysis on time and he received partial dialysis treatment. During a review of the facility's policy and procedure (P&P) titled, Transporting of Resident for an Appointment, undated, the P&P indicated residents will be transported to and from an appointment in a safe, courteous, and respectful manner. The P&P indicated resident's transportation for an appointment will be facilitated by Nursing or Social Services personnel. During a review of the facility's P&P titled, Hemodialysis, undated, the P&P indicated the facility was to provide safe, accurate, appropriate care, assessments, and interventions to improve resident outcomes. The P&P indicated the company was responsible for the management and coordination of dialysis care.

Based on observation, interview and record review, the facility failed to meet professional standards of quality for 2 of 6 sampled residents, Resident 1 and Resident 5, by failing to ensure:1). Scheduled medications were administered in a timely manner in accordance to their physician's order.2). Medications were not left at Resident 1's bedside.3). The medication nurse administered and observe Resident 1 swallowed her medications.These failures had the potential to decrease the drug's therapeutic levels when given late, the potential for Resident 1 not taking her scheduled medications and for other residents to take Resident 1's medications out from her bedside and drink it, causing harm and severe drug interactions.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. Resident 1's diagnoses included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), acute kidney failure (a sudden and often reversible reduction in kidney function) and encephalopathy (a brain disorder). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/10/2026, the MDS indicated Resident 1 had clear speech and had the ability to express ideas and wants, and was able to understand. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half) with toileting, shower/bathe, and personal hygiene. During a review of the document titled Disciplinary Action Record, charge nurse Disciplinary Action Notice, dated 4/20/2026, the disciplinary action notice indicated the employee left Resident 1's 9 a.m. medications at the bedside without confirming/observing if Resident 1 had taken the medications. Resident 1's family member found the medications (no time indicated). The Disciplinary Action Notice indicated that leaving Resident 1's medication at her bedside threatened the resident's safety, enabled hoarding of medications and viewed as negligence and failure to follow the standards of care. During a review of Resident 1's Medications Administration History for 4/2026, the administration history indicated the following:1). Amlodipine 10 mg tablet oral medicine for high blood pressure) scheduled at 9 a.m., were charted late (late, beyond one [1] hour after scheduled time) on 4/2/2026, 4/3/2026, 4/8/2026, 4/9/2026, 4/12/2026, 4/14/2026, 4/15/2026 and 4/20/2026.2). Aspirin 81 mg chewable tablet (for stroke prophylaxis), scheduled at 9 a.m., were charted late on 4/2/2026 to 4/3/2026, 4/8/2026, 4/9/2026 and 4/12/2026 3). Buspirone 5 mg tablet (for anxiety), scheduled at 9 a.m. and 5 p.m., were charted late from 4/2/2026 to 4/13/2026, 4/16/2026 to 4/21/2026. 4). Gabapentin 100 mg capsule oral-three times a day (for restless leg syndrome), scheduled at 9 a.m., 1 p.m. and 5 p.m., were charted late from 4/2/2026 to 4/13/2026, 4/16/2026 to 4/21/2026. 5). Quetiapine 25 mg three times a day (for schizoaffective disorder manifested by hearing or seeing things that are not there), scheduled at 9am, 1pm and 5 pm, were charted late from 4/2/2026 to 4/13/2026, 4/16/2026 to 4/21/2026. During an interview on 4/27/2026 at 1:35 p.m., with the License Vocational Nurse (CN 1), the CN 1 stated on 4/20/2026 9 a.m., he left Resident 1's medications at the bedside when the resident asked him to leave it. The CN 1 stated he documented that Resident 1's medications were given on time, but the medications were taken late, between 11 a.m. to 12 noon. The charge nurse stated leaving the medications at the bedside and failure to administer the medications and observe the resident swallow the medications may lead to another resident taking the medications. The medications may get lost and adverse reactions may occur. 2). During a review of Resident 5's admission Record, undated, the admission Record indicated Resident 5 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. Resident 5's diagnoses included toxic encephalopathy, hypertension (high blood pressure), and gastrostomy status (the presence of a gastrostomy tube, a feeding tube inserted directly into the stomach through the abdominal wall). During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5 has clear speech, difficulty communicating some words or finishing thoughts but is able if prompted or given time, and usually understands. The MDS indicated Resident 5 required setup or clean-up assistance (helper sets up or clean-up) with toileting, personal hygiene and eating. During a review of Resident 5's Physician Order Report, dated 4/1/2026 through 4/22/2026, the physician order report indicated to administer aspirin tablet 81 mg via gastric tube (GT, a tube surgically inserted into the stomach for nutrition and medication administration) for Cerebrovascular Accident (CVA, stroke) prevention once a day at 9 a.m. The order indicated to crush the medications as needed, and docusate sodium (for bowel management) 100 mg via GT once a day at 9 a.m. During a concurrent observation and interview on 4/21/2026 at 11:40 a.m., with Licensed Vocational Nurse (LVN 1), at Resident 5's bedside, LVN 1 was observed administering the resident's 9 a.m. medications (aspirin 81 mg tablet, scheduled at 9 a.m. and docusate sodium 100 mg scheduled at 9 a.m.) at 11:40 a.m. LVN 1 stated the medications were administered late because he was assisting other residents. During a review of Resident 5's Medication Administration History, dated 4/1/2026 through 4/28/2026, the administration history indicated the following:1). On 4/21/2026, aspirin 81 mg tablet, scheduled at 9 a.m., was charted late.2). On 4/21/2026, docusate sodium 100 mg scheduled at 9 a.m., was charted late. During a review of the facility's policy and procedure (P&P) titled, Oral Medication Administration, undated, the P&P indicated oral medications should be administered in an accurate, safe and timely manner. The P&P indicated to verify that medications were actually taken.

Based on interview and record review, the facility failed to develop a discharge care plan for one of three sampled residents (Resident 3). This deficient practice had the potential to place Resident 3 at risk for an unsafe discharge with poor outcomes such as medication errors, missed follow-up appointments and lack of necessary home care support.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including peripheral vascular diseases (PVD-a slow progressive narrowing of the blood flow to the arms and legs), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), obesity (chronic disease characterized by excessive body fat) and hypertension (high blood pressure). During a review of Resident 3's History and Physical (H&P) dated 7/31/2025, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 2/4/2026, the MDS indicated Resident 3 was able to understand and be understood by others. The MDS indicated Resident 3 required supervision or touching assistance for walking, and setup or clean-up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for showering/bathing self, sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and transfers. During a concurrent interview and record review on 4/13/2026 at 1:58 p.m., with the Minimum Data Set nurse (MDS 1), MDS 1 stated she could not find a discharge care plan for Resident 3. MDS 1 stated Social Services was responsible for creating discharge plans. MDS 1 stated that it was important to create care plans because the care plan was a guide to a safe resident discharge by implementing interventions such as education for safe medication administration at home, following up with home health and doctor appointments. The care plan ensured there was a pathway for residents' discharge home with continuum of care. During a concurrent interview and record review on 4/14/2026 at 12:03 p.m., with the Social Services Director (SSD), the SSD stated there was no discharge care plan for Resident 3. The SSD stated the Social Services Department was responsible for creating discharge care plans for all the residents. The SSD stated it was important to create discharge care plans for residents to ensure the facility could follow through with personalized care. During a review of the facility's undated Policy and Procedure (P&P) titled, Comprehensive Plan of Care, the P&P indicated each resident will have a comprehensive care plan developed that includes goals, measurable objectives, and timetables to meet their medical, nursing, mental, and psychosocial needs identified during the comprehensive assessment including potential community discharge.

Based on interview and record review, the facility failed to report the resident to resident allegations of abuse for the three (3) of 7 sampled residents, (Residents 1, 2 and 3), as indicated in its policy and procedure (P&P) titled, Abuse Prevention Program, when:1). On 3/31/2026, Resident 2 scratched Resident 1 while Resident 1 was entering the dining room. Resident 1 sustained wound on the chin measuring 1 X 0.2 (unit of measurement not indicated) and to the upper lip measuring 0.2 (unit of measurement not indicated) with minimal blood noted.2). On 3/10/2026, Resident 3 slapped Resident 2 who was sitting in a chair, in the hallway.3). On 3/10/2026, Resident 3 was hitting residents and staff.4). On 3/14/2026, Resident 3 swung purse at Resident 1.5). On 3/25/2026, Resident 3 hit Resident 1. This failure delayed the investigation by the California Department of Public Health (CDPH) and placed the affected residents and other residents at risk for further abuse causing residents humiliation and severe injuries, including hospitalizations.Findings: During a review of Resident 1's admission Record date 4/13/2026, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1's diagnoses included pneumonia (lung infection), presence of cardiac pacemaker (a small, implanted device that regulates a slow heart rate by delivering electrical pulses, typically used to treat irregular heart rhythms or heart blocks), and a displaced intertrochanteric fracture (broken bone) of right femur (hip bone). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment and care planning tool) dated 2/17/2026, the MDS indicated Resident 1 had clear speech, the ability to express ideas and wants, and understands. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) from staff with oral hygiene, lower body dressing and shower/bathe self. During a record review of Resident 1's Situation, Background, Assessment, Recommendation ([SBAR] a structured way to communicate to the care team about a resident's change in condition), dated 3/14/2026, the SBAR indicated Resident 1 stated a dementia (a progressive state of decline in mental abilities) resident (Resident 3) hit Resident 1 with a purse. During a record review of Resident 1's SBAR dated 3/25/2026, the SBAR indicated Resident 1 was hit by Resident 3. During a review of Resident 1's Interview Record, dated 3/25/2026, the interview record indicated Resident 1 (the interviewee) stated, (on unspecified date), Resident 3 hit Resident 1 on her back with her purse while Resident 1 was sitting in her wheelchair. During a review of Resident 1's SBAR dated 3/31/2026 at 3:55 p.m., the SBAR indicated Resident 2 scratched Resident 1's face, while Resident 2 was entering the dining room. Resident 1 sustained wound on the chin measuring 1 X 0.2 (unit of measurement not indicated) and to the upper lip measuring 0.2 (unit of measurement not indicated) with minimal blood noted. During a review of Resident 1's Interview Record, dated 3/31/2026, the interview record indicated Resident 1 stated she was going out of the dining room and the lady with long fingernails scratched her. During a concurrent observation and interview on 4/13/2026 at 11:30 a.m. with Resident 1, Resident 1 was observed with a red scratch on her chin. Resident 1 stated Resident 2 scratched her face with her long fingernails. Resident 1 stated the incident occurred on 3/31/2026 while she was trying to go into the activities room while Resident 2 was coming out of the activities room. 2). During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted on [DATE] with diagnoses of schizophrenia (involves a range of problems that affects thinking, behavior, and emotions), unspecified dementia (when confusion or mild cognitive impairment can't be clearly diagnosed as a specific type of dementia) and hypertension (high blood pressure). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had clear speech, the ability to express ideas and wants, and understands. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) from staff with personal hygiene, lower body dressing and shower/bathe self. During a review of Resident 2's SBAR, dated 3/10/2026 at 3:13 p.m., the SBAR indicated Resident 3, who was in a wheelchair, passed by Resident 2 and slapped her, while she (Resident 2) was sitting in a chair, in the hallway, between rooms [ROOM NUMBERS]. During a review of Resident 2's Progress Notes dated 3/10/2026, at 4:02 p.m., the progress notes indicated Resident 2 was in the hallway sitting in a chair, reading a paper when Resident 3 passed by in her wheelchair and slapped Resident 2 on the right shoulder. During a review of Resident 2's SBAR, dated 3/31/2026 at 4:07 p.m., the SBAR indicated Resident 2 was noted with aggressive behavior towards another resident. Resident 2 scratched Resident 1 (site not specified) while exiting the activity room. 3). During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 3's diagnoses included vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), metabolic encephalopathy (is when the brain has trouble working because of a chemical, or metabolic, problem in the body) and urinary tract infection (UTI- an infection caused by bacteria entering the urinary system, typically the bladder and urethra leading to inflammation, pain, and a strong, persistent urge to urinate). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had clear speech, sometimes understood, and was able to understand sometimes. The MDS indicated Resident 3 required partial/moderate assistance from staff with personal hygiene, toileting hygiene, and lower body dressing. During a review of Resident 3's SBAR, dated 3/10/2026 at 3:50 p.m., the SBAR indicated Resident 3 was hitting residents and staff. During a review of Resident 3's SBAR, dated 3/14/2026 at 1:23 p.m., the SBAR indicated Resident 1 stated that she was hit (area not specified) by Resident 3 swinging purse at her (Resident 1). During a review of Resident 3's SBAR, dated 3/25/2026 at 4:14 p.m., the SBAR indicated Resident 3 was hitting staff and a resident. The SBAR indicated a staff (unidentified) had witnessed Resident 3 hit Resident 1. During a concurrent interview and record review on 4/13/2026 at 12:49 p.m. with the Registered Nurse (RN 1), the All Facilities Letter 24-09 ([AFL] a letter from the Center for Health Care Quality (CHCQ), Licensing and Certification (L&C) Program to health facilities that are licensed or certified by L&C with information that include changes in requirements in healthcare, enforcement, new technologies, scope of practice, or general information that affects the health facility), dated 2/28/2024, was reviewed. AFL 24-09 indicated facilities were required to provide written notice to the appropriate state agency for incidents resulting in physical harm immediately or as soon as possible, but not later than two hours after the incident occurred. RN 1 stated the incident on 3/31/2026 when Resident 2 scratched Resident 1 on the face sustaining injuries was not reported to the CDPH. RN 1 stated the incident should have been reported to the CDPH within 2 hours because Resident 1 sustained a scratch (injury). During a concurrent interview and record review on 4/13/2026 at 1:20 p.m., with the Administrator (ADM), the AFL 24-09 was reviewed. The ADM stated Resident 2 had dementia and the abuse incident was reported to the Ombudsman and the Police. The ADM stated Resident 1 sustained an injury (scratch) on her chin on 3/31/2026. The ADM stated the incident on 3/31/2026 was not reported to the CDPH within 2 hours, and the lack of reporting in a timely manner may cause psycho-social harm to the residents. During an interview on 4/15/2026 at 9:35 a.m. with the ADM, the ADM stated none of Resident 3's incidents (3/10/2026, when Resident 3 slapped Resident 2 who was sitting in a chair, in the hallway and when Resident 3 was hitting residents and staff, on 3/14/2026 when Resident 3 swung purse at Resident 1 and on 3/25/2026, when Resident 3 hit Resident 1) were reported to the CDPH because of AFL 24-09. Resident 3 had dementia and the incidents were only reported to the Ombudsman and the Police, not CDPH. During a review of the AFL 24-09, dated 2/18/2024, the AFL indicated LTC facilities were informed about updates to the mandated reporter process for incidents of elder and dependent adult abuse. For incidents involving resident-on-resident abuse that did not result in bodily harm where the alleged abuser is a resident with dementia, facilities are required to notify the ombudsman and local law enforcement in writing within 24 hours. For incidents resulting in physical harm, facilities are required to notify local law enforcement immediately, but not later than 2 hours after the incident occurred. Facilities are required to provide written notice of the incident to the appropriate state agency. The AFL indicated facilities are responsible for following all applicable laws. The CDPH's failure to expressly notify facilities of statutory or regulatory requirements does not relieve facilities of their responsibility to comply with all laws and regulations. During a review of the State Operations Manual, Appendix PP dated 7/23/25, the SOM at F600 indicated that residents have the right to be free physical or mental abuse. The facility must provide a safe resident environment and protect residents from abuse. SOM at F609 indicated that the facility must develop and implement written policies and procedures that ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements:(B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury.In response to allegations of abuse, the facility must ensure that all alleged violations involving abuse, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials including to the State Survey Agency in accordance with State law through established procedures. During a review of the facility's undated policy and procedure (P&P) titled, Abuse Prevention Program,, the P&P indicated residents have the right to be free from abuse. The P&P indicated, the administration will report any allegations of abuse within timeframes as required by federal requirements.

Based on interview and record review, the facility failed to report to the California Department of Public Health (CDPH), the verbal altercation (a noisy, angry dispute) on 2/3/2026, between the Social Services Director (SSD) and one of three residents' (Resident 1). This deficient practice delayed the investigation by the CDPH and placed Resident 1 at risk for verbal abuse.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included morbid (severe) obesity due to excess calories (chronic disease characterized by having excessive body fat that poses an immediate, serious risk to health, resulting from consistently consuming more energy than the body burns) and hypertension (high blood pressure). During a review of Resident 1's History and Physical (H&P) dated 8/20/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 3/4/2026, the MDS indicated Resident 1 was able to understand and be understood by others. Resident 1 was independent (Resident completes the activity by themself with no assistance from a helper) for eating and oral hygiene. Resident 1 required moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for toileting hygiene, shower/bathing self, and lower body dressing. Resident 1 required setup assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for upper body dressing, putting on/taking off footwear and personal hygiene. Resident 1 required supervision (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with rolling from left to right, from sitting to lying position, lying to sitting on side of the bed, sitting to stand, chair/bed to chair transfer, and was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or tile assistance of 2 or more helpers is required for the resident to complete the activity.) for toilet transfer, tub/shower transfer. The MDS indicated Resident 1 required supervision for walking 10 feet, 50 feet and was dependent for walking 150 feet. During an interview on 3/19/2026 at 9:11 a.m., with RN 1, RN 1 stated Resident 1's FM 1 entered the facility without a facemask (mask, a personal protective equipment to protect against the transmission of germs) and went inside Resident 1's room. The SSD saw FM 1 and asked FM 1 to wear mask. RN 1 stated Resident 1 asked the SSD what the outbreak was and the SSD responded, not to worry about it because Resident 1 was leaving the facility. Resident 1 did not like the SSD's response and called the SSD a bitch (B.) while the SSD was stepping out the room. RN 1 stated the SSD raised her voice and asked Resident 1 why do I have to be a B ? RN 1 stated she got in between Resident 1 and SSD to calm the situation. RN 1 stated Resident 1 reported SSD's behavior was threatening and unprofessional towards her (Resident 1) and should not be in her room. During an interview on 3/20/2026 at 10:10 a.m., with RN 2, RN 2 stated she reported the 2/3/2026 incident (SSD and Resident 1's verbal altercation) to the ADM but did not know if the ADM reported the incident to the CDPH. During an interview on 3/24/2026 at 3:41 p.m., the ADM stated on 2/3/2026, Resident 1 or anyone in the facility did not report feelings of fear or threat and did not hear resident stating she was scared for her life. The ADM stated if there was a report, she would have reported the incident to the CDPH. The ADM stated if an abuse allegation was not reported, it could affect resident's' wellbeing, mental state and repetitive abuse if exposed to abuser. During a review of the facility's undated policy and procedure (P&P) titled, Abuse Prevention Program, the P&P indicated to report any allegations of abuse within timeframes as required by federal requirements. During a review of the facility's undated P&P titled, Abuse, Neglect & Exploitation Prohibition,, the P&P indicated the company should report all abuse allegations to the State agency as designated by state law. During a review of the State Operations Manual (a federal document issued by the Centers for Medicare & Medicaid Services [CMS] that provides guidelines and regulations for healthcare facilities participating in Medicare and Medicaid programs), Appendix PP, dated 7/23/2025, the Appendix PP indicated the facility must ensure that all alleged violations involving abuse or mistreatment should be reported to the State Survey Agency immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. Report the results of all investigations to the State Survey Agency within 5 working days of the incident.

Based on interview and record review, the facility failed to investigate the Social Services Director (SSD) and one of three residents' (Resident 1) verbal altercation (a noisy, angry dispute) on 2/3/2026, as indicated in the facility's policy and procedure (P&P) titled Abuse Investigation & Reporting. This deficient practice placed Resident 1 at risk for verbal abuse (the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, within their hearing distance regardless of their age, ability to comprehend or disability) and psychosocial harm.Findings: 1). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included morbid (severe) obesity due to excess calories (chronic disease characterized by having excessive body fat that poses an immediate, serious risk to health, resulting from consistently consuming more energy than the body burns) and hypertension (high blood pressure). During a review of Resident 1's History and Physical (H&P) dated 8/20/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 3/4/2026, the MDS indicated Resident 1 was able to understand and be understood by others. Resident 1 was independent (Resident completes the activity by themself with no assistance from a helper) for eating and oral hygiene. Resident 1 required moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for toileting hygiene, shower/bathing self, and lower body dressing. Resident 1 required setup assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for upper body dressing, putting on/taking off footwear and personal hygiene. Resident 1 required supervision (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with rolling from left to right, from sitting to lying position, lying to sitting on side of the bed, sitting to stand, chair/bed to chair transfer, and was dependent (Helper does all the effort. Resident does none of the effort to complete the activity. Or tile assistance of 2 or more helpers is required for the resident to complete the activity.) for toilet transfer, tub/shower transfer. The MDS indicated Resident 1 required supervision for walking 10 feet, 50 feet and was dependent for walking 150 feet. During a review of Resident 1's Progress Notes dated 2/3/2026 at 4:16 p.m., the note indicated SSD asked Resident 1's Family Member (FM) 1 who entered Resident 1's room, to put on a face mask (mask, a personal protective equipment to protect against the transmission of germs). The progress note indicated Resident 1 asked SSD if there was an outbreak, but SSD stated she could not disclose the other residents' information. The note indicated Resident 1 was very upset and started yelling at the SSD for not disclosing the information. The note indicated as SSD was exiting Resident 1's room, the SSD overheard Resident 1 called her a bitch (B ). The note indicated SSD walked back to Resident 1's room and kindly asked Resident 1 why she called her a bitch (B.). During a review of Resident 1's clinical records, Resident 1's clinical records had no documentation that an investigation was conducted regarding the SSD and Resident 1's verbal altercation on 2/3/2026. During an interview on 3/19/2026 at 12:23 p.m., Resident 1 stated she was afraid of SSD because she was trying to fight with her at the beginning of last month (February). Resident 1 stated, on 2/3/2026, RN 1 was in the room with her, Resident 1's FM 1 visited and entered the room without a mask. Resident 1 stated, the SSD entered her (Resident 1) room and told FM1 to wear a mask because of an outbreak. Resident 1 stated she asked the SSD what the type of the outbreak and the SSD responded, not to worry about it because she (Resident 1) was going to leave anyway. Resident 1 stated that the SSD was not supposed to enter her room because of the multiple incidents she had with her ([SSD] not specified). Resident 1 stated that was when she called the SSD a B. and the SSD did not like that. During an interview on 3/20/2026 at 8:35 a.m., Resident 1 stated on 2/3/2026, when the incident with the SSD occurred, the SSD was waving her arms, yelling and asking why she (Resident 1) called her a B., tried to go back inside her room. Resident 1 stated she felt threatened when the SSD seemed like she wanted to fight with her (Resident 1). Resident 1 stated the SSD had no professionalism and no sense of respect to someone who was bedridden. During an interview on 3/24/2026 at 3:10 p.m., the Administrator (ADM) stated she have not conducted an investigation regarding the SSD and Resident 1's verbal altercation on 2/3/2026 because she discussed the incident with Resident 1 and Resident 1 agreed to put it as a grievance. During a review of the facility's undated policy and procedure (P&P) titled, Abuse Prevention Program, the P&P indicated to investigate any allegations of abuse within timeframes as required by federal requirements. During a review of the facility's undated P&P titled, Abuse, Neglect & Exploitation Prohibition, the P&P indicated the facility will conduct an investigation of any alleged abuse in accordance with state law. The company will investigate all patterns, trends or incidents that suggest the possible presence of abuse. During a review of the State Operations Manual (a federal document issued by the Centers for Medicare & Medicaid Services [CMS] that provides guidelines and regulations for healthcare facilities participating in Medicare and Medicaid programs), Appendix PP, dated 7/23/2025, the Appendix PP indicated, in response to allegations of abuse or mistreatment, the facility must have evidence that all alleged violations are thoroughly investigated and report the results of investigations to the State Survey Agency, within 5 working days of the incident.

Based on interview and record review, the facility failed to ensure the Social Services Director (SSD) acted in accordance with the professional standards when interacting to one of three sampled residents, (Resident 1). This failure had the potential to affect the resident's psychosocial well-being, leading to emotional harm.Findings: 1). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included morbid (severe) obesity due to excess calories (chronic disease characterized by having excessive body fat that poses an immediate, serious risk to health, resulting from consistently consuming more energy than the body burns) and hypertension (high blood pressure). During a review of Resident 1's History and Physical (H&P) dated 8/20/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 3/4/2026, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 was independent (Resident completes the activity by themself with no assistance from a helper) for eating and oral hygiene. MDS indicated Resident 1 required moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for toileting hygiene, shower/bathing self, and lower body dressing. MDS indicated Resident 1 required setup assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for upper body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 1 required supervision (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with rolling from left to right, from sitting to lying position, lying to sitting on side of the bed, sitting to stand, chair/bed to chair transfer, and was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or tile assistance of 2 or more helpers is required for the resident to complete the activity.) for toilet transfer, tub/shower transfer. The MDS indicated Resident 1 required supervision for walking 10 feet, 50 feet and was dependent for walking 150 feet. During a review of Resident 1's Progress Notes dated 2/3/2026 at 4:16 p.m., the note indicated Social Services Director (SSD) had asked Resident 1's Family Member (FM) 1 to put on a mask as Resident 1's FM1 was entering Resident 1's room. The progress note indicated Resident 1 asked SSD if there was an outbreak, but SSD stated she could not disclose that information. The note indicated Resident 1 was very upset and started yelling at the SSD for not disclosing the information. The note indicated as SSD was exiting Resident 1's room, the SSD overheard Resident 1 called her a bitch (B ). The note indicated SSD walked back to Resident 1's room and kindly asked Resident 1 why she called her a bitch (B.). During an interview on 3/19/2026 at 12:23 p.m., with Resident 1, Resident 1 stated she was afraid of SSD because she was trying to fight with her at the beginning of last month. Resident 1 stated, on 2/3/2026, RN 1 was in the room with her, a FM 1 who was visiting, entered Resident 1's room without a mask. Resident 1 stated, the SSD entered her (Resident 1) room and told FM1 to wear a mask because of an outbreak. Resident 1 stated she asked the SSD what the type of the outbreak and the SSD responded, not to worry about it because she (Resident 1) was going to leave anyway. Resident 1 stated that the SSD was not supposed to enter her room because of the multiple incidents she had with her ([SSD] not specified). Resident 1 stated that was when she called the SSD a B. and the SSD did not like that. During an interview on 3/20/2026 at 8:35 a.m., Resident 1 stated on 2/3/2026, when the incident with the SSD occurred, the SSD who was waving her arms, yelling and asking why she (Resident 1) called her a B., tried to go back inside her room. Resident 1 stated she felt threatened when the SSD seemed like she wanted to fight with her (Resident 1). Resident 1 stated the SSD had no professionalism and no sense of respect to someone who was bedridden. During an interview on 3/20/2026 at 9:11 a.m., with RN 1, RN 1 stated the facility had an Influenza A (a viral infection that attacks the respiratory system, including the nose, throat, and lungs) outbreak (a sudden increase in the occurrence of a disease that exceeds what is typically expected) and visitors were expected to mask up prior to entering the building. RN 1 stated Resident 1's FM1 had entered the facility without a mask, reason why the SSD entered Resident 1's room and asked FM1 to wear mask. RN1 stated when Resident 1 asked the SSD what type the outbreak was and the SSD responded, not to worry about it because Resident 1 was leaving the facility, Resident 1 did not like the SSD's statement. That was when Resident 1 called the SSD a B. as the SSD was stepping out the room. RN 1 stated the SSD raised her voice and asked Resident 1 why do I have to be a B ? RN 1 stated she got in between Resident 1 and SSD to calm down the situation. RN 1 stated Resident 1 reported to her (RN 1) that the SSD was not supposed to be in her room because SSD's behavior was threatening and unprofessional towards her (Resident 1). During an interview on 3/20/2026 at 12:05 p.m., with the SSD, the SSD stated she did not see the incident as a confrontation with Resident 1. The SSD stated when Resident 1's FM1 entered the room without a mask, she followed FM1 and asked her to put on a mask. Resident 1 asked her what type of outbreak there was, and SSD responded to Resident 1 that she could not disclose the other residents' information. The SSD stated as she (SSD) was exiting the resident's room, she (SSD) heard Resident 1 yelling, calling her (SSD) a B. That was when she (SSD) walked back into the room and asked Resident 1 why she had to be a B. The SSD stated she was not trying to confront Resident 1; she was just asking Resident 1 why she (SSD) had to be a B . The SSD stated RN 1 was at the door and was not sure why RN 1 got in between them. It was not like she (SSD) was going at her (Resident 1), but when she realized Resident 1 was not calming down, she (SSD) stepped outside the resident's room. The SSD stated she went back to the room because she thought it was her job to calm Resident 1 down. The SSD stated she probably should not have gone back in the room and ask the resident why she called her a B , instead, she should have allowed RN 1 to deescalate (calm down) the situation. The SSD stated, prior to the incident, Resident 1 had asked her not to go into her room. The SSD stated she only went in Resident 1's room to talk to the FM1 to put on a mask. 2). During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses hypertension (high blood pressure) and dementia (general term for a decline in mental ability such as memory, thinking, or reasoning). During a review of Resident 2's H&P dated 1/12/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was able to understand and be understood by others. The MDS indicated Resident 2 was independent for eating. MDS indicated Resident 2 required setup assistance for oral hygiene. The MDS indicated Resident 2 required maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) The MDS indicated Resident 2 required moderate assistance for shower/bathing self, and lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 2 required supervision for upper body dressing. The MDS indicated Resident 2 required moderate assistance with rolling from left to right, from sitting to lying position, lying to sitting on side of the bed, sitting to stand, chair/bed to chair transfer, for walking 10 feet, and was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or tile assistance of 2 or more helpers is required for the resident to complete the activity.) for toilet transfer, tub/shower transfer, walking 50 feet with two turns and walking 150 feet. During an interview on 3/20/2026 at 8:57 a.m., Resident 2 stated Resident 1 told her, that is why I don't like that B. (SSD) because she (SSD) would not tell me what type of outbreak there was in the facility. Resident 2 stated the SSD was already leaving the room when Resident 1 called her a bitch. The SSD walked back and yelled at Resident 1, stating why do I have to be a bitch?

Based on interview and record review, the facility failed to honor one of two residents (Resident 1) request, not to have a male Certified Nurse Assistant (CNA) assigned to provide care for activities of daily living (ADLs -routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). This deficient practice violated resident's rights and had the potential to affect the resident's psychosocial well-being. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included cerebral infarction (loss of blood flow to part of the brain), Diabetes Mellitus Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Care Plan titled, Resident Refuses Male CNA Care, dated 8/30/2025, the goal indicated Resident 1 will receive required care while maintaining dignity, comfort, and emotional well-being. One of the approaches indicated to assign a female CNA for personal care, document the resident's refusal of care and respect Resident 1's preference for female CAN. During a review of Resident 1's History and Physical (H&P), dated 11/2/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/8/2025, the MDS indicated Resident 1 required partial/moderate assistance with personal hygiene, lower body dressing, upper body dressing, shower/bathe self, toileting hygiene. Resident 1 required supervision or touching assistance with putting on/taking off footwear, and oral hygiene. Resident 1 required setup or clean-up assistance with eating. During a review of the facility's Nursing Assignments [Direct Care], dated 2/26/2026, 11 PM - 7:30 AM shift, the assignment indicated Resident 1 was assigned a male CNA (CNA3) to provide ADL care. During an interview on 2/28/2026 at 11:10 AM with CNA 1, CNA 1 stated Resident 1 had expressed she did not want to have male CNA to provide her ADLs. CNA 1 stated this preference was widely known among the facility staff. During an interview on 2/28/2026 at 12:18 PM with the Director of Nurses (DON), the DON stated Resident 1 preferred to be cared for by a female CNA and was in Resident's 1 care plan. The DON stated Resident 1's preference to have no male CNA to care for her should be honored. During a concurrent interview and record review on 2/28/2026 at 12:18 PM, with the DON, the facility's Nursing Assignments [Direct Care], dated 2/26/2026, was reviewed. The DON stated on 2/26/2026 11PM to 7:30 AM shift, CNA 3, a male CNA was assigned to Resident 1 because of multiple staff that called out sick. The DON acknowledged that, regardless of the changes and adjustments in staff assignment, Resident 1 should not have been assigned a male CNA. The DON stated the facility should have adhered to Resident 1's preference for a male CNA only. Respecting this choice was essential to maintaining the resident's well-being and dignity, and the residents right to make decisions about their care. During a review of the facility's undated policy and procedure (P&P) titled, Quality of Life - Dignity, the P&P indicated residents will always be treated with dignity and respect. The P&P indicated the facility is committed to honor resident choices, preferences, values, and beliefs which begins at the time of admission and continues throughout the residents' stay in the facility.

Based on interview and record review, the facility failed to report Influenza A (viral infection that attacks the respiratory system, including the nose, throat, and lungs) outbreak on 2/2/2026, for two of eight residents (Residents 1 and 8), to the California Department of Public Health (CDPH) within 24 hours, as indicated in the facility's policy and procedure (P&P) titled Unusual Occurrence Reporting. This failure resulted in delayed investigation by the CDPH.Findings: 1). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE]. Resident 1's diagnoses included heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), stage four chronic kidney disease (severe kidney impairment), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). The admission record indicated Resident 1 was self-responsible. During a review of Resident 1's History and Physical (H&P), dated 9/25/2025, the H&P indicated Resident 1 had the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/5/2026, the MDS indicated Resident 1 was cognitively intact and did not reject evaluation or care. During a review of Resident 1's Influenza (Flu) Antigen Test (a test to detect flu) Result Form, dated 2/2/2026 12:00 p.m., indicated a positive result for influenza. 2). During a review of Resident 8's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertensive heart disease (a heart disorder which causes the heart to not pump the blood efficiently), and pleural effusion (abnormal build-up of fluid in the space between the lungs and chest wall).During a review of Resident 8's H&P, dated 7/31/2025, the H&P indicated Resident 8 was capable to understand and make decisions. During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 had moderate cognitive impairment. During a review of Resident 8's Influenza Antigen Test Result Form, dated 2/2/2026 at 12:00 p.m., the result indicated Resident 8's influenza test was positive. During a concurrent interview and record review on 2/24/2026 at 9:40 a.m., with the Infection Preventionist (IP), Resident 1 and 8's Influenza Antigen Test Result Form, dated 2/2/2026, the Los Angeles County Department of Public Health (LAC DPH) Influenza and other Respiratory Virus Diseases Outbreak Toolkit, dated 12/2025, and the facility's undated P&P titled Unusual Occurrence Reporting, were reviewed. The IP stated the LAC DPH indicated two or more laboratory confirmed influenza cases identified within 72 hours of each other are considered an outbreak and must be reported. Resident 1 and Resident 8's positive test results for influenza on 2/2/2026 at 12:00 p.m., were two confirmed cases (an outbreak) not reported to CDPH. The influenza outbreak should have been reported to the CDPH within 24 hours, on 2/3/2026 at 12:00 p.m. The IP stated the influenza is a communicable respiratory disease and should have been reported to the state agency as indicated in the P&P titled Unusual Occurrence Reporting. During an interview on 2/25/2026 at 1:00 p.m., with the Administrator (Admin), the Admin stated the facility did not report the outbreak within 24 hours of the second positive influenza test result. The Admin stated the IP was responsible for reporting the outbreak to the CDPH. During a review of Los Angeles County Department of Public Health Influenza and other Respiratory Virus Diseases Outbreak Toolkit, dated 12/2025, the toolkit indicated two or greater laboratory confirmed influenza cases identified within 72 hours of each other are considered an outbreak. The toolkit indicated any sudden increases in acute respiratory illness cases, such as influenza, over the normal background rate must be reported. During a review of the facility's undated P&P titled Unusual Occurrence Reporting, the P&P indicated the facility will report an epidemic outbreak of any disease, prevalence of communicable disease, via telephone to appropriate agencies as required by current law and/or regulations within 24-hours of such incident. During a review of the facility's undated Job Description titled Infection Preventionist, the job description indicated the IP must implement, coordinate, and direct the facility's infection prevention and control program in accordance with regulations. The IP will report all reportable diseases to the state health department.

Based on interview and record review, the facility failed to ensure the Nurse Practitioner's (NP) verbal order of Tamiflu (medication to treat the Influenza [viral infection that attacks the respiratory system, including the nose, throat, and lungs]) for one of three residents (Resident 1), was transcribed to a telephone order form, the Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) and notify the pharmacy, as indicated in the facility's policy and procedure titled Physician Orders.This failure resulted in Resident 1 missing two doses of Tamiflu on 2/2/2026 and 2/3/2026.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE]. Resident 1's diagnoses included heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), stage four chronic kidney disease (severe kidney impairment), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). The admission record indicated Resident 1 was self-responsible. During a review of Resident 1's History and Physical (H&P), dated 9/25/2025, the H&P indicated Resident 1 had the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/5/2026, the MDS indicated Resident 1 was cognitively intact and did not reject evaluation or care. During a review of Resident 1's Influenza Antigen Test (a test to detect flu) Result Form, dated 2/2/2026 12:00 p.m., indicated a positive result for influenza. During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 2/2/2026, the SBAR indicated Resident 1 tested positive for Influenza A. Resident 1 vomited, had an episode of coughing, and had a body temperature of 103 farenheit (unit of measurement of temperature). During a review of Resident 1's Physician Progress Note, dated 2/10/2026, the note indicated the resident's Medical Doctor (MD 1) ordered Tamiflu for influenza. During a review of Resident 1's Physician Orders, for the month of 2/2026, did not indicate Tamiflu. During a review of Resident 1's MAR for the month of 2/2026, the MAR did not indicate Tamiflu was administered. During a concurrent interview and record review on 2/24/2026 at 10:21 a.m., with the Infection Preventionist (IP), Resident 1's Influenza Antigen Test Result Form dated 2/2/2026, Resident 1's SBAR dated 2/2/2026, Resident 1's Physician Orders dated 2/2/2026, were reviewed. The IP stated the SBAR indicated Resident 1 had fever, cough, and vomiting which were symptoms of influenza. The IP stated on 2/2/2026, around 12:00 p.m., NP 1 was notified of Resident 1's positive influenza test result and verbally ordered Tamiflu 75 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) twice per day for five days. The IP stated she forgot to carry out the order and did not notify the pharmacy. The IP stated Resident 1's Tamiflu order was submitted 2/3/2026 at 4:00 p.m. Resident 1 missed two doses of Tamiflu on 2/2/2026 (evening) and on 2/3/2026 (morning). During a concurrent interview and record review on 2/24/2026 at 3:45 p.m., with Registered Nurse (RN 1), Resident 1's Physician Orders, dated 2/2/2026, and Resident 1's MAR, for the month of 2/2026, were reviewed. RN 1 stated Resident 1's Physician Orders and MAR for the month of 2/2026 did not indicate an order for Tamiflu. During an interview on 2/25/2026 at 12:05 p.m., with NP 1, NP 1 stated on 2/2/2026, the Tamiflu 75 milligrams (mg) was ordered for Resident 1 to treat Influenza A, minimize the impact of the virus, decrease severity of symptoms and decrease the length of illness. NP 1 stated the nurses did not notify him (NP 1) that Resident 1 did not receive the Tamiflu. During a review of the facility's undated P&P titled Physician Orders, the P&P indicated when receiving an order (telephone or verbal), repeat the order to clarify and ensure all necessary informations are received. The licensed nurse will transcribe all components of the order onto a telephone order form, record the time, date and signs the order. Transcribe the written order and document the word noted next to the order along with the licensed nurse's signature, title and date. After noting the order, the receiving licensed nurse transcribes in permanent ink on the MAR and notify the pharmacy of the new order.

Based on interview and record review the facility failed to ensure one out of five sampled residents (Resident 1) was free from abuse when a Certified Nurse Assistant (CNA 1) kicked Resident 1's right shin (the front of the leg below the knee). This deficient practice resulted in Resident 1 sustaining pain and a purplish discoloration to the right shin. This deficient practice had to potential to cause Resident 1 to not feel safe in the facility. Findings:During a review of Resident 1's Face Sheet, the face sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included metabolic encephalopathy (a problem in the brain, when the imbalance affects the brain, it can lead to personality change), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's History and Physical (H&P), dated 5/28/2025, the H&P indicated Resident 1 did not have the capacity to make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 2/5/2026, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 1 was dependent on staff for activities of daily living (ADLs) such as toileting and showering, and required partial assistance from staff for eating, oral hygiene, dressing, and positioning. During a review of Resident 1's SBAR (a structured, four-step communication framework-Situation, Background, Assessment, Recommendation) form, dated 1/23/2026 at 3:04 p.m., the SBAR indicated the Registered Nurse (RN 1) supervisor witnessed CNA 1 kick Resident 1. The SBAR indicated when RN 1 removed Resident 1 from the room, Resident 1 stated she [CNA 1] kicked her and she had pain. Durin a review of Resident 1's Resident Data Collection form, dated 1/23/2026 at 8:05 p.m., indicated Resident 1 had discoloration to the right leg. During an interview on 2/5/2026 at 3:00 p.m., with the Registered Nurse (RN) 1, RN 1 stated she overheard CNA 1 speaking to Resident 1 while CNA 1 was feeding the roommate. RN 1 stated she then observed CNA 1 kick Resident 1 on the right leg. RN 1 stated she immediately removed Resident 1 from the room for safety and reported the incident. RN 1 stated Resident 1 pointed to her right leg and stated she had been hit. RN 1 stated Resident 1 was assessed and noted to have right leg discoloration and pain. RN 1 stated there was never a reason to physically hit a resident and the residents should feel safe in the facility because the facility was the residents' home. During a review of the facility's P&P, titled Abuse, Neglect & Exploitation Prohibition, undated, the P&P indicated each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property.

Based on observation, interview and record review, the facility failed to ensure for one of three sampled residents (Resident 1), who was assessed as being at risk (likelihood) for elopement (leaving the facility unsupervised) and wandering (walking/ travelling from place to place, without any clear aim or purpose) out of the facility and being high risk for falls with a history of multiple falls, was monitored and whereabouts (location in the facility) checked. This failure resulted in Resident 1 wandering out from the facility on 1/9/2026 without the facility's knowledge and supervision leading to the resident's fall and sustaining left hand fourth (4th) and fifth (5th) fingers fracture (brake in bone), left frontal scalp hematoma (a collection or pool of blood that forms outside of blood vessels) and intracranial (within the cranium [skull] the bony dome that houses and protects the brain) hemorrhage (bleeding). Resident 1 was transferred to the General Acute Care Hospital (GACH) 1 on 1/10/2026 for further evaluation and treatment.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility from GACH 1 on 1/10/2026 with diagnoses including closed head injury (a type of brain injury where the brain sustained damage due to external forces, but the skull remains intact), left hand 4th and 5th fingers fractures, dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and generalized muscle weakness. During a review of Resident 1's care plan titled, Category: CAA9 Behavioral Symptoms, dated 1/18/2024, the care plan indicated Resident 1 was identified as being at risk for elopement and wandering out of the facility, wandering without purpose, had an exit-seeking behavior (a resident's attempts to leave a safe environment without regard of their safety or consequences of the actions) and searching behavior (a behavior that is goal-oriented, an expression of need, manifested as wandering, exit-seeking). The care plan goal was to decrease resident's risk of elopement and wandering out of the facility. The care plan interventions included allowing the resident to move around the hallways safely, gently redirecting the resident back to the supervised areas and checking resident's whereabouts. The care plan's additional intervention dated 3/11/2024 included to use wander guard bracelet (a safety device designed to monitor and manage residents who wander away from the care environment) on left wrist for elopement precautions, check alarm for functioning, monitor for proper placement and battery function every shift. During a review of Resident 1's care plan titled Category: CAA11 Falls, indicating problem start date of 1/18/2024, the care plan indicated Resident 1 had increased susceptibility (likelihood) to falling that may cause physical harm due to history of falls, balance problem, loss of muscle strength and wandering. The care plan indicated Resident 1 had a fall risk assessment score of 16 (indicating a high risk for fall). The care plan included documentation indicating Resident 1 had fallen on 12/13/2024, 6/12/2025, and 11/17/2025 without injuries. The interventions to achieve care plan goals in preventing Resident 1 from falling and sustaining injuries included: on 12/13/2024, educating resident and staff on safety precautions; on 1/18/2024, checking resident's whereabouts; and on 6/12/2025, incremental monitoring (unspecified) to address resident's needs and safety precautions. During a review of Resident 1's History and Physical (H&P), dated 6/7/2025, the H&P indicated Resident 1 could not make medical decisions and had the fluctuating capacity (unstable) to understand and make decisions due to dementia. During a review of Resident 1's Physical Therapy (PT) Discharge summary, dated [DATE], the summary indicated Resident 1 had history of falling and lacking insight (understanding) into her condition and risk factors (hazards). The summary indicated Resident 1 required supervision/touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as the resident completes the activity) in transferring from sitting to standing position and when walking 150 feet. The summary indicated walking ten feet on uneven surfaces and taking one step on curb (taking a step down) was not attempted due to Resident 1's medical condition or safety concerns. The summary indicated Resident 1 required 24-hour staff assistance with mobility and daily care tasks. During a review of Resident 1's Elopement Risk Assessment, dated 10/24/2025, the Elopement Risk Assessment indicated Resident 1 was at risk of elopement. The assessment indicated Resident 1 was able to propel (drive) her wheelchair and ambulate (walk). The assessment indicated Resident 1 was oblivious (not aware of) to her needs or safety and wandered without purpose.During a review of Resident 1's Fall Risk Data Collection form, dated 10/24/2025, the Fall Risk Data Collection form indicated Resident 1 was at high risk for falling due to poor decision making, incontinence (no control of bowel and bladder elimination), gait/balance (manner of walking) problem, multiple medications, and multiple medical conditions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/29/2025, the MDS indicated Resident 1 had severe cognitive impairment for daily decision making. The MDS indicated Resident 1 wandered four to six days within the previous week (unspecified). The MDS indicated Resident 1 was independent with sitting to standing position (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed), walking 10 feet, walking 50 feet with two turns. The MDS indicated Resident 1 used a manual wheelchair independently for mobility. During a review of Resident 1's care plan titled CAA11 Falls, dated 11/18/2025, the approach indicated to provide with bed alarm and wheelchair alarm (devices to notify staff when a resident attempts to get out of bed or wheelchair unassisted) to remind Resident 1 not to get up unassisted and alert staff of resident's attempts to get up unassisted, place the resident in a visible area (area where staff can view) after group activities, provide individualized activity to keep the resident engaged (occupied) and distracted from attempting to get up unassisted, encourage/ remind resident to ask for help when needed, if able and provide assistance as identified in transfer and mobility and keep environment free of hazards. Resident 1's care plan goal indicated to decrease resident's risk of fall and injury with the interventions, reduce risk of serious injury from falls and resident will relate the intent (purpose) to use safety measures to decrease risk of fall. During a review of Resident 1's Functional Abilities Assessment (an assessment to determine an individual's physical, cognitive and emotional capabilities in relation to their ability to perform work-related tasks), dated 1/7/2026, the assessment indicated Resident 1 required supervision or touching assistance to transfer from sitting to standing. The assessment indicated Resident 1's walking ten feet was not attempted due to medical condition or safety concerns. During a review of Resident 1's Physician Orders, dated 1/8/2026, the physician's order indicated Resident 1 to wear a wander guard bracelet on the left wrist for elopement precautions. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 1/9/2026, the SBAR indicated on 1/9/2026 at 8:50 a.m., Resident 1 had an unwitnessed fall outside the facility. The SBAR indicated Resident 1 was confused following the fall. The SBAR indicated Resident 1 complained of mild pain and sustained abrasion ([scratch] body part not indicated). The SBAR indicated radiology (x-ray- process of taking pictures to diagnose and treat diseases) was ordered by the physician. During a review of Resident 1's Radiology Report dated 1/10/2026 at 10:40 a.m., the Radiology report indicated Resident 1 had an acute fracture of the left-hand 4th and 5th fingers with minimal angulation (a fracture where the broken ends of a bone are tilted or bent at an angle, deviating from the bone's normal alignment) and displacement (moved out of their normal alignment). During a review of Resident 1's Progress Notes dated 1/10/2026 at 12:33 p.m., the Progress Notes indicated the abnormal diagnostic results (unspecified) were reviewed and new orders (unspecified) were obtained. The Progress Notes indicated Resident 1 was transferred to a GACH 1 for evaluation and treatment. During a review of Resident 1's GACH 1 Emergency Department (ED) Physician Documentation, dated 1/10/2026 at 7:19 p.m., the Physician Documentation indicated Resident 1 presented to the ED due to a mechanical fall (a type of fall that occur due to an external force or interaction with a physical object or condition in the environment, not by an acute medical event) on 1/9/2026. The Physician Documentation indicated Resident 1 reported a swollen left hand but was unable to recall the fall. The ED Physician Documentation indicated Resident 1 was mildly distressed (upset) with raccoon's sign (dark bruising and swelling) on head/ eyes. The ED Physician Documentation indicated Resident 1's radiology report showed acute and minimally displaced fractures of the left 4th and 5th fingers and left frontal scalp hematoma (a collection or pool of blood that forms outside of blood vessels). The ED Physician Documentation indicated Resident 1's differential diagnoses (list of possible conditions or diseases) included intracranial hemorrhage, fracture, dislocation (a medical condition where the bones in a joint are pushed out of their usual place) and electrolyte abnormalities (occur when too much or not enough minerals are in the body). The GACH 1 diagnostic impression indicated Resident 1 had closed head injury and left-hand fingers fractures. During an interview on 1/13/2026 at 8:45 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 had unsteady gait and weakness prior to the fall on 1/9/2026 and required touching assistance in transferring in and out of wheelchair and walking to prevent falls. CNA 1 stated Resident 1 was not allowed to leave the building without staff supervision and assistance prior to, and since the fall on 1/9/2026. During a concurrent observation and interview on 1/13/2026 at 8:50 a.m., with Resident 1, in Resident 1's room, Resident 1 cried, stating she was angry and mad about her pain. Resident 1 could not remember leaving the facility or falling. During a concurrent interview and record review on 1/13/2026 at 11:22 a.m., with Licensed Vocational Nurse (LVN 1), Resident 1's Elopement Risk Assessment, dated 10/24/2025, Fall Risk Data Collection form, dated 10/24/2025, MAR for the month of January 2026, Resident 1's SBAR dated 1/9/2026, and Resident 1's Progress Notes dated 1/9/2026 to 1/11/2026, were reviewed. LVN 1 stated the Fall Risk Data Collection form indicated Resident 1 had an unsteady gait and frequently stood up from her wheelchair without asking for staff assistance and had a wheelchair alarm in place to alert staff when Resident 1 was trying to stand without assistance. LVN 1 stated prior to Resident 1's fall on 1/9/2026, Resident 1 used her wheelchair to go around the unit. LVN 1 stated on 1/9/2026, she did not hear the wheelchair alarm turned on. LVN 1 stated Resident 1's progress notes indicated the resident exited the facility unsupervised and fell on the sidewalk outside the facility. Resident 1 sustained abrasion on the forehead, mild pain and the left hand was red and mildly swollen after the fall. LVN 1 stated Resident 1 should have been continuously supervised when not in her room to avoid falls and elopements. During a concurrent interview and record review on 1/13/2026 at 1:17 p.m., with the Director of Rehabilitation (DOR), Resident 1's Physical Therapy (PT) Discharge summary dated [DATE], Resident 1's Functional Abilities assessment dated [DATE], were reviewed. The DOR stated the discharge summary indicated Resident 1 required 24-hour staff assistance with mobility and daily care tasks. The DOR stated Functional Abilities assessment dated [DATE], indicated walking ten feet was not attempted due to Resident 1's medical condition or safety concerns and she did not know why it (walking ten feet) was not attempted. The DOR stated Resident 1 required supervision/touching assistance in transferring from sitting to standing position and when walking 150 feet. The DOR stated walking ten feet on uneven surfaces and taking one step on curb were not attempted for Resident 1 due to medical condition or safety concerns. The DOR stated the Rehabilitation Department performed Resident 1's quarterly screening on 10/13/2025 and there were no changes in her functional abilities. The DOR stated the Rehabilitation Department was not notified about Resident 1's change (unspecified) in walking abilities. During a concurrent interview and record review on 1/13/2026 at 1:50 p.m., with Registered Nurse (RN 1), Resident 1's care plan titled Category: CAA11 Falls dated 1/18/2024, care plan titled Category: CAA9: Behavioral Symptoms at risk for elopement and wandering out of the facility- wandering without purpose, searching behavior, and exit seeking behavior dated 1/18/2024, and Resident 1's Radiology Report, dated 1/9/2026, were reviewed. RN 1 stated Resident 1's fall care plan did not indicate required interventions to prevent falls and injury. RN 1 stated Resident 1's care plan for fall prevention was not followed because Resident 1 was outside the facility, unsupervised and was not in a visible area by the facility staff. RN 1 stated Resident 1's behavioral care plan intervention indicating to check the resident's whereabouts was vague (unclear) and stated she (RN1) did not know how to implement that intervention. RN 1 stated the behavioral care plan intervention indicated to allow Resident 1 to move around the facility safely was not implemented, because without supervision at the lobby and exit door, the hallway was unsafe when she [RN 1] left the lobby. RN 1 stated Resident 1 had history of dementia, Alzheimer's disease, and generalized weakness that increased Resident 1's risk of falling. RN 1 stated on 1/9/2026 at around 8:45 a.m., Receptionist 1 asked her (RN 1) to observe the front door and lobby, and ensure residents' safety, prevent residents from leaving, and to greet/assist visitors because Receptionist 1 had to go on break. RN 1 stated she did not see Resident 1 or any residents at the lobby, so she left the lobby area to access her bag in the Medication room [ROOM NUMBER]. RN 1 stated the lobby and exit area could not be viewed from Medication room [ROOM NUMBER] for supervision. RN 1 stated she did not assign another staff member to supervise the lobby and exit door, while she went to Medication room [ROOM NUMBER]. RN 1 stated on 1/9/2026 at 9 a.m., she heard the Wander Guard alarm went off (activated) by the front door less than one minute after she entered Medication room [ROOM NUMBER]. RN 1 stated she left Medication room [ROOM NUMBER] to investigate the Wander Guard alarm but did not see any residents in the lobby or near the front door. RN 1 stated she ran outside the facility, passing the lobby, through the front door, and observed Resident 1 falling on the sidewalk, hit her head, hands, and knees before she (RN 1) could reach Resident 1. RN 1 stated, when she observed Resident 1 on the sidewalk, Resident 1's wheelchair was not observed near Resident 1, and she did not hear the wheelchair alarm. RN 1 stated outside the facility was hazardous (dangerous) due to uneven sidewalks, hard surfaces, presence of cars and unknown people were present. RN 1 stated Resident 1 had wandered outside the facility through the lobby area, where there was no facility staff to redirect Resident 1 back inside the facility so that staff can provide supervision to the resident. RN 1 stated Resident 1 could have stood up by herself, got out of her wheelchair, and walked without staff's assistance or supervision on the sidewalk. RN 1 stated Resident 1 was placed at risk of getting hit by a car, tripping (walking/ fall) on an uneven sidewalk, and suffered exposure to the external elements (severe cold weather condition, rape, vehicular accident) when the resident left the facility without staff supervision. RN 1 stated because of the fall, Resident 1 fractured the two fingers on her left hand as indicated in the radiology report 1/9/2026. RN 1 stated on 1/10/2026, Resident 1 was transferred to GACH 1 for further evaluation of the left hand and head injury she suffered after the fall on 1/9/2026. RN 1 stated Resident 1's fall and injuries on 1/9/2026 could have been avoided if staff supervision was provided to implement interventions according to the fall care plan. RN 1 stated fall care plan intervention to provide incremental monitoring was not specific and not measurable. RN 1 stated she did not know how to implement that intervention (provide incremental monitoring). RN 1 stated Resident 1's wandering outside on 1/9/2026 could have been prevented if the interventions in the behavioral care plan were implemented. During an interview on 1/13/2026 at 2:43 p.m., with LVN 2, LVN 2 stated he was the second responder on 1/9/2026 when Resident 1 went outside the facility unsupervised and fell. LVN 2 stated Resident 1's wheelchair was outside the facility when he responded to the wanderguard alarm. LVN 2 stated he did not hear Resident 1's wheelchair alarm on prior to the fall. During an interview on 1/13/2026 at 4:41 p.m., Receptionist 1 stated RN 1 should not have left the lobby and front door to ensure residents who come to the lobby will be supervised. During a concurrent interview and record review on 1/14/2026 at 1:37 p.m., with the Director of Nursing (DON), Resident 1's care plan titled Category: CAA11 Falls, dated 1/18/2024, and the facility's undated P&P titled Safety Supervision of Residents, were reviewed. The DON stated the fall care plan intervention indicating to place Resident 1 in a visible area was not implemented. The DON stated the fall care plan intervention indicating incremental monitoring to address Resident 1's needs and safety was unclear. The DON stated she guessed that (incremental monitoring) meant to monitor Resident 1's location, safety, and needs every two hours. The DON stated this intervention (incremental monitoring) was not documented and there was no proof this was implemented. The DON stated she could have implemented a written log to monitor Resident 1's incremental monitoring to ensure that intervention was implemented. The DON stated Resident 1 was not provided with fall prevention measures because Resident 1 was outside the facility without staff's knowledge and was unsupervised. The DON stated on 1/9/2026 at 9:00 a.m., when she heard and responded to Resident 1's wanderguard alarm, the lobby and exit door were not supervised because there was no staff present to gently redirect Resident 1 back to a supervised area as indicated in Resident 1's behavioral care plan. The DON stated Resident 1 was on her wheelchair outside the facility and did not hear Resident 1's wheelchair alarm prior to the fall. The DON stated the Safety Supervision of Residents P&P indicating interventions should be implemented correctly and consistently (always), was not implemented on Resident 1. The DON stated Resident 1's fall on 1/9/2026 and injuries sustained was a major accident caused by lack of staff supervision and assistance. During a concurrent interview and record review on 1/14/2026 at 3:30 p.m., with the Administrator, the State Operations Manual (SOM) Appendix PP- Guide to Surveyors for Long Term Care Facilities, dated 7/23/2025, was reviewed. The Administrator stated the SOM Appendix PP indicated alarms, such as the wander guard and chair alarms, do not replace staff supervision. The Administrator stated a system-wide approach to prevent resident elopements and falls involve active supervision of the lobby and exit door whenever the automatic-opening exit is unlocked. During a review of the facility's undated P&P titled Safety Supervision of Residents, the P&P indicated the facility strive to make the environment as free from accident hazards as possible. The P&P indicated resident safety and supervision and assistance to prevent accident are company-wide priorities. The P&P indicated the interdisciplinary care team (group of healthcare professionals, including physician, nurses, resident/ resident representative, working together to develop a plan of care for the residents) should analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The P&P indicated the care team should target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The P&P indicated the facility should ensure interventions are implemented correctly and consistently, evaluate the effectiveness of interventions, modify or replace interventions as needed and evaluate the effectiveness of new or revised interventions. The P&P indicated due to the complexity and scope; certain resident risk factors and environmental hazards should be addressed in dedicated P&P including falls and unsafe wandering. During a review of the facility's undated P&P titled, Comprehensive Care Plan, the P&P indicated the comprehensive care plan must describe the services provided to the resident to attain or maintain the residents highest practicable, physical, mental and psychosocial well-being. The P&P indicated the facility must conduct a functional assessment of the resident by completing the MDS and Care Area Assessment (CAA) and the CAA triggered must be considered for care plan development. The P&P indicated to re-evaluate and modify care plans as necessary to reflect changes in care, service and treatment. During a review of the facility's undated P&P titled, Fall Management, the P&P indicated if falling recurs despite initial interventions, staff should implement additional or different interventions or indicate why the current approach remains relevant. The P&P indicated if underlying causes cannot be readily identified or corrected and, will try various interventions based on assessment of the nature or category of falling, until falling is reduced or stopped or until the reason for the continuation of the falling is identified as unavoidable. The P&P indicated the MDS/Interdisciplinary Care conference team should also update the resident's care plan accordingly.

Based on interview and record review, the facility failed to:1. Maintain the COVID vaccination status for 19 employees.This deficient practice had to the potential to cause a delay in response in the event of an outbreak, since the unvaccinated staff cannot be easily identified.During a concurrent interview and record review on 12/4/2025 at 8:00 a.m. with the Infection Prevention Nurse (IPN), a binder titled Staff Vaccination 2025 was reviewed. The binder indicated 19 employees declined to receive a COVID vaccine. The IPN stated she cannot show documentation of what staff are vaccinated. The IPN stated she is supposed to offer the vaccine to all staff. The IPN further stated it is important to know who is or is not vaccinated in case there is an outbreak. It will be easier to track where the outbreak may have started if you know who is not vaccinated.During a review of the facility's policy and procedure (P&P) titled, COVID-19 Vaccination-Staff, (no date), the P&P indicated the infection preventionist maintains a tracking worksheet of staff members and their vaccination status.

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, and sanitary environment when an air filter in the hallway for four of four sampled Residents (Residents 13, Resident 33, Resident 67, and Resident 99) was full of dust and gray, fuzzy substance accumulation.This deficient practice had the potential to exposing residents to an environment that was unclean, and negatively impacting residents' comfort, safety, and quality of life.Findings:a. During a review of Resident 13's admission Record (Face sheet), the admission Record indicated the facility admitted Resident 13 on 12/3/2024 with diagnoses including acute respiratory failure with hypoxia (a life-threatening condition where the lungs cannot get enough oxygen into the blood), shortness of breath, heat failure, and sepsis (a life-threatening blood infection).During a review of Resident 13's History and Physical (H&P) dated 1/15/2025, the H&P indicated the resident was alert, cooperative, had normal affect (a person shows a healthy, appropriate, and varied range of emotional expressions), and normal speech.During a review of Resident 13's MDS Minimum Data Set (MDS - a resident assessment tool) dated 9/1/2025, indicated Resident 13's cognitive function was intact (alert, oriented and able to recall information). During a concurrent observation and interview on 12/2/2025 at 11:02 a.m. outside Resident13's room, Resident 13 stated, Look at this air filter, it's so filthy. It's full of dust. During an interview on 12/4/2025 at 1:25 p.m. in Resident 13's room, Resident 13 stated, I don't feel good walking outside the hallways because the air quality is not good. There could be different air pathogens in the air. I have had multiple lung problems in the past. That is why I always have my doors closed, and have all staff wear mask when they come in my room.b. During a review of Resident 33's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 3/13/2025 with diagnoses including asthma (a lung disease that swells and narrows airways, causing symptoms like wheezing, coughing, chest tightness, and shortness of breath), acute respiratory failure with hypoxia (a life-threatening condition where the lungs cannot get enough oxygen into the blood ), shortness of breath, and obesity (excessive fat in the body).During a review of Resident 33's History and Physical (H&P) dated 3/10/2025, the H&P indicated the resident was alert, oriented, mild dementia (a noticeable decline in memory or thinking skills), and can make own decisions.During a review of Resident 33's MDS Minimum Data Set (MDS - a resident assessment tool) dated 11/13/2025, indicated Resident 33's cognitive function was intact (alert, oriented and able to recall information). During an interview on 12/4/2025 at 1:27 p.m. in Resident 33's room, Resident 33 stated, It is important to have clean air filter, so lungs don't have difficulty breathing. I have asthma. I would feel horrible if the air filters were dirty because my asthma could get worse. c. During a review of Resident 67's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 6/27/2022 with diagnoses including acute respiratory disease (sudden lung issues, often causing cough, fever, and breathing trouble), hypertension ((HTN-high blood pressure), and acute kidney failure (a sudden, severe loss of kidney function where kidneys can't filter waste or fluids). During a review of Resident 67's History and Physical (H&P) dated 11/25/2025, the H&P indicated the resident was alert, oriented, and can make own decisions.During a review of Resident 67's MDS Minimum Data Set (MDS - a resident assessment tool) dated 9/27/2025, indicated Resident 67's cognitive function was intact (alert, oriented and able to recall information). During an interview on 12/4/2025 at 1:28 p.m. in Resident 67's room, Resident 67 stated, I have seen those air filters outside. Breathing clean air is important to keep germs away, helps our health. They should be cleaned out because if the dirt gets in the lungs, it will mess with my lungs.d. During a review of Resident 99's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 4/3/2025 with diagnoses including heart failure (the heart is unable to pump enough blood for the body's needs), pace-maker (a small, battery-powered device implanted under the skin that sends electrical signals to regulate the heart's rhythm), and syncope (fainting, a brief, sudden loss of consciousness and posture due to a temporary decrease in blood flow and oxygen to the brain, often preceded by dizziness, nausea, or lightheadedness).During a review of Resident 99's History and Physical (H&P) dated 4/4/2025, the H&P indicated the resident was alert, oriented, but has fluctuating capacity to understand and make decisions.During a review of Resident 99's MDS Minimum Data Set (MDS - a resident assessment tool) dated 10/11/2025, indicated Resident 99's cognitive function was intact (alert, oriented and able to recall information). During an interview on 12/4/2025 at 1:20 p.m. in Resident 99's room, Resident 99 stated, Those white or black ones, that changes color. I don't like it if they are dirty. Clean air is important. I have a heart pacemaker. Dirty air filters can make me more sick.During an interview on 12/5/2025 at 10:10 a.m. with Housekeeping Supervisor (HS), the HS stated residents had the right to breathe clean air and have clean air filters to prevent them from getting sick from the air they breathe in. HS stated the filters needed to be changed twice monthly to keep filters in good condition. During a concurrent interview and record review on 12/5/2025 at 10:10 a.m. with HS, HS indicated that the facility's Cleaning Air Purifier Log from 5/3/2024 to 11/24/2025 indicated the air purifier filter was changed only once a month. During a review of the facility's Policy and Procedure (P&P), titled Maintaining a Clean Environment, undated, the P&P indicated, Items that collect dust or secretions may harbor microorganisms that can colonize and infect susceptible residents, or be inhaled by employees performing cleaning tasks. During a review of facility's policy and procedure (P&P), titled, The Quality of Life-Homelike Environment, dated 10/2017, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment. 1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment;.

Based on observation, interview, and record review, the facility failed to:1. Ensure linen was folded using proper technique to prevent recontamination.This deficient practice put residents at risk of infection if they came in contact with the contaminated linen.2. Ensure the Laundry Aide did not pour a chemical into a new unlabeled/uncovered container in the laundry room.3. Ensure air purifier filter in the hallway was maintained in a clean condition for four of four sampled Residents (Residents 13, Resident 33, Resident 67, and Resident 99) when the air filter was full of dust and fuzzy, grey buildup accumulation.This deficient practice had the potential to increase the risk of airborne particle (tiny solid or liquid particles in the air) accumulation in the hallway, which could contribute to the spread of infection among residents.4. Ensure the ice machine in the kitchen was maintained in a clean and sanitary condition. This deficient practice had the potential to expose residents to contaminated ice, increasing the risk of foodborne illness. 1. During a concurrent observation and interview on 12/2/2025 at 2:48 p.m. with the Laundry Aide (LA) in the laundry room, the LA was observed folding sheets and allowing the sheets to drag on the floor during folding. The surveyor brought attention to the action, and the LA then took the dirty sheet and placed it on top the clean pile of linen. The LA could not explain what he did wrong or why it was harmful. During an interview on 12/2/2025 at 3:17 p.m. with the Housekeeping Supervisor (HS), the HS stated laundry should not touch the floor while it is being folded. The HS stated this contaminates the laundry and residents who come in contact with it can get sick. During a review of the facility's policy and procedure (P&P) titled, Laundry Handling Practices, (no date), the P&P indicated proper handling of linen will reduce the likelihood of recontamination. During a review of the Laundry Aide job description, dated January 2012, the job description indicated the Laundry Aide will provide laundry services to ensure a safe and sanitary environment for residents. 2. During a concurrent observation and interview on 12/2/2025 at 2:50 p.m. in the laundry room with the Laundry Aide (LA), an uncovered white plastic bucket containing a yellowish liquid was noted sitting on the floor in front of the washer. The bucket was not labeled. The LA stated the liquid in the bucket was bleach. The LA further stated he poured bleach from the original container into the white plastic bucket. The LA could not explain why this practice was not safe. During an interview on 12/2/2025 at 3:17 p.m. with the Housekeeping Supervisor (HS), the HS stated staff should never pour chemicals from one container into a new container. The HS stated, It's dangerous because someone else won't know what it is. During a review of the Material Safety Data Sheet ([MSDS]- a document that provides information about the hazards of a chemical, safe handling practices, and emergency procedures), dated January 2012, the MSDS indicated bleach should be stored in a closed container. During a review of the Laundry Aide job description, dated January 2012, the job description indicated the Laundry Aide will take appropriate actions to secure laundry chemicals. 3. During a review of Resident 13's admission Record, the admission Record indicated the facility admitted the resident on 12/3/2024 with diagnoses including acute respiratory failure with hypoxia (a life-threatening condition where the lungs can't get enough oxygen into the blood), shortness of breath, heat failure, and sepsis (a life-threatening blood infection). During a review of Resident 13's History and Physical (H&P) dated 1/15/2025, the H&P indicated the resident was alert, oriented, normal affect (a person shows a healthy, appropriate, and varied range of emotional expressions), and normal speech. During a review of Resident 33's admission Record, the admission Record indicated the facility admitted the resident on 3/13/2025 with diagnoses including asthma (a chronic lung disease that swells and narrows airways, causing symptoms like wheezing, coughing, chest tightness, and shortness of breath, acute respiratory failure with hypoxia (a life-threatening condition where the lungs can't get enough oxygen into the blood), shortness of breath, and obesity (having a excess body fat). During a review of Resident 33's H&P dated 3/10/2025, the H&P indicated the resident was alert, oriented, and can make own decisions. During a review of Resident 33's MDS Minimum Data Set (MDS – a resident assessment tool) dated 11/13/2025, indicated Resident 33's cognitive function was intact (alert, oriented and able to recall information). During a review of Resident 67's admission Record, the admission Record indicated the facility admitted the resident on 6/27/2022 with diagnoses including acute respiratory disease (sudden lung issues, often categorized as infections, causing cough, fever, and breathing trouble), hypertension ((HTN-high blood pressure), and acute kidney failure (a sudden, severe loss of kidney function where kidneys can't filter waste, fluids). During a review of Resident 67's H&P, dated 11/25/2025, the H&P indicated the resident was alert, oriented, and can make own decisions. During a review of Resident 99's admission Record, the admission Record indicated the facility admitted the resident on 4/3/2025 with diagnoses including heart failure(the heart can't pump enough blood for the body's needs, often due to damage from conditions like high blood pressure or heart attack, leading to fluid backup and symptoms like shortness of breath, fatigue, and swelling), pace-maker (a small, battery-powered device implanted under the skin that sends electrical signals to regulate the heart's rhythm), and syncope (fainting, a brief, sudden loss of consciousness and posture due to a temporary decrease in blood flow and oxygen to the brain, often preceded by dizziness, nausea, or lightheadedness). During a review of Resident 99's H&P, dated 4/4/2025, the H&P indicated the resident was alert, oriented, but has fluctuating capacity to understand and make decisions. During a concurrent observation, and interview on 12/2/2025 at 11:07 a.m. with the Infection Preventionist Nurse (IPN), The IPN stated the air filter was filled with dust and of poor quality. The IPN stated a dirty air filter could cause lung infections (infections that affect the lungs) and other respiratory diseases (any illness affecting the lungs) such as pneumonia (an infection/inflammation in the lungs), COVID-19 (an infectious lung disease caused by the SARS-CoV-2 virus), flu, and asthma, potentially leading to hospitalizations for residents. During an interview on 12/5/2025 at 2:10 p.m. with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated maintaining clean air filters was important to provide residents with clean air, improve their comfort, and prevent airborne illnesses. RNS 1 stated a dirty air filter might get contaminated with bacteria, which could then potentially spread to other residents, especially those with lung diseases. During a review of the facility's Policy and Procedure (P&P), titled Maintaining a Clean Environment, undated, the P&P indicated, Items that collect dust or secretions may harbor microorganisms that can colonize and infect susceptible residents, or be inhaled by employees performing cleaning tasks . 4. During a concurrent observation and interview on 12/2/2025 at 9:02 a.m. with Dietary Aid (DA) 1 in the kitchen, DA 1 stated the ice machine lid had brown, grey dusty particulate and the top of the ice chest had a green slimy film. DA 1 stated the ice machine was deep cleaned by the maintenance staff monthly. DA 1 stated cleaning the ice machine was important to ensure there was no buildup of any dirt and to provide safe consumable ice for the residents. DA 1 stated if the ice machine was not cleaned the residents may acquire illnesses from bacteria that was carried through the ice. During an interview on 12/3/2025 at 12:44 p.m. with the Dietary Supervisor (DS), the DS stated cleaning the ice machine monthly was important to prevent bacterial from building up that may be transferred to the ice. The DS stated if the ice machine was not cleaned, the residents would be exposed to water pathogens that may lead to illnesses and infections. During a review of the facility's monthly Ice Machine Cleaning Log, the Ice Machine Cleaning Log indicated the ice machine was not cleaned on 11/6/2025. During a review of the facility's policy and procedure (P&P) titled Cleaning & Maintaining Ice Machines undated, the P&P indicated .Cleaning. 2. Empty and disinfect the ice storage compartment prior to quarterly maintenance according to the steps shown below:.g. Clean the chest with disinfectant solution according to manufacturer's label directions.

Based on interview and record review the facility failed to ensure two of five sampled residents (Resident 78 and Resident 98) was provided with goods and services when1.Resident 98 had notified staff he would like to retrieve his vehicle.2. Staff were standing over Resident 78 while assisting with eating lunch.These deficient practices of not providing goods and services for Resident 98 to escort him to retrieve his vehicle had the potential for him to feel unacknowledged of his needs and placed Resident 78 at increased risk for choking, aspiration, or inadequate monitoring of the resident's tolerance during meals.1.During a review of Resident 98's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 98 was initially admitted to the facility on [DATE]. Resident 98's diagnoses included respiratory failure (the lungs can't adequately oxygenate the blood or remove carbon dioxide), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and heart failure (the heart can't pump enough blood to meet the body's needs). During a review of Resident 98's History and Physical (H&P), dated 10/27/2025, the H&P indicated Resident 98 had the capacity to understand and make decisions. During a review of Resident 98's Minimum Data Set ([MDS] a resident assessment tool), dated 11/3/2025, the MDS indicated Resident 98's cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired. The MDS indicated Resident 98 required partial/moderate assistance (helper does less than half the effort. Helper helps lifts, holds, or supports trunk or limbs) by staff for toileting hygiene, showering, and dressing. The MDS indicated Resident 98 had the ability to walk 50 feet and make two turns. During a review of Resident 98's, Progress Notes, dated 12/1/2025, the progress notes indicated Resident 98 had requested to go out on pass ([OOP] – temporary, authorized leave for activities such as going home and community participation) to retrieve his vehicle from the hospital parking lot. During an interview on 12/2/2025 at 10:55 a.m., with Resident 98, in Resident 98's room, Resident 98 stated he had requested to leave the facility to retrieve his vehicle from the hospital parking lot. Resident 98 stated the social worker had not followed up with him to retrieve his vehicle. During an interview on 12/3/2025 at 1:11 p.m., with Social Services Director (SSD), the SSD stated she was aware Resident 98 needed to go OOP and needed an escort to leave the facility to run his errands. SSD stated she had no documentation regarding Resident 98's concerns about going OOP. SSD stated she did not check nor follow-up with Resident 98 if he went OOP. SSD stated not following up with Resident 98 could make him feel upset. During an interview on 12/4/2025 at 9:08 a.m., with Registered Nurse (RN) 3, RN 3 stated when Resident 98 expressed he wanted to go out on pass, the facility could provide transportation with an escort. RN 3 stated she was aware Resident 98 wanted to retrieve his vehicle. RN 3 stated social services were to work with Resident 98 no later than the following day (12/2/2025) to check if this issue was resolved. RN 3 stated not following up with Resident 98 about his needs could make him feel his needs are not being acknowledged. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, unknown date, the P&P indicated the resident had the right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility. 2. During a review of Resident 78's Face Sheet, the Face Sheet indicated the facility admitted Resident 78 on 9/4/2025 and was readmitted on [DATE] with diagnoses including encephalopathy (any disease or damage that changes how the brain works), pneumothorax (collapsed lung), urinary tract infection (UTI- an infection in the bladder/urinary tract), hyperlipidemia (excessive fat in the blood) and otalgia (ear pain or earache). During a review of Resident 78's History and Physical (H&P) dated 9/5/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 78's Minimum Data Set (MDS- a resident assessment tool) dated 10/27/2025, the MDS indicated the resident had intact cognition (ability to think, learn, understand and remember) and required dependent assistance (helper does all of the effort) with eating, oral and toileting hygiene, showering, upper and lower body dressing, and putting on and taking off footwear. During a concurrent observation and interview on 12/2/2025 at 12:59 p.m. with Certified Nursing Assistant (CNA) 1 in Resident's 78's room, CNA 1 was observed standing over the resident while feeding Resident 78. CNA 1 stated the importance of sitting down when feeding resident was to ensure the resident was safe, to prevent the resident from choking, and to engage with the resident so the resident does not feel rushed. CNA 1 stated if staff does not sit down when feeding the resident, there would be a potential for the resident to choke, cross contamination when reaching over the resident's tray, and the resident would feel like he or she was being rushed to finish his or her food. During an interview on 12/3/2025 at 12:57 p.m. with CNA 2, CNA 2 stated the importance of sitting down when feeding resident was to ensure the resident and staff were eye level to prevent choking and to engage with the resident so the resident feel like he or she was at home. CNA 2 stated if staff were not sitting down when feeding resident, the resident may choke and prevent cross contamination. During an interview on 12/3/2025 at 1:45 p.m. with Registered Nurse Supervisor (RNS) 2, RNS 2 stated the importance of sitting down when feeding resident was to ensure the safety of the resident and to engage in conversation with the resident to simulate a homelike environment. RNS 2 stated if staff was not seated while feeding the resident was the resident had the potential to choke, the resident will feel like he or she was being rushed, and cross contamination. During a review of the facility's Policy and Procedure (P&P) titled Resident Dining Program, undated, the P&P indicated . F. Staff Training All staff involved in food service will receive training during the orientation process and annually thereafter on: Proper food handling, Resident rights during meal service, Infection control during dining, Responding to choking or aspiration events.

Based on observation, interview, and record review, the facility failed to ensure safe dietary services were provided to 88 of 93 residents who were served food from the kitchen, when:1. On 8/13/2025, from 5:30 am to 2:25 pm, liquid eggs (processed form of whole eggs, also known as cartoned eggs) were thawed (defrost) at room temperature (ambient temperature [actual temperature] measured by a thermometer around 73 degrees Fahrenheit ([ F]- a unit of temperature) without monitoring the time and temperatures. Liquid eggs were at 55 F which was within the danger zone [41-135 F] temperature range where bacteria grow quickly). 2. On 8/13/2025 from 12:10 p.m. to 1:30 p.m., ground beef was thawed at room temperature without time and temperature monitoring. At 12:10 p.m., the ground beef was at 64 F. At 1:30 p.m., [NAME] 3 placed the ground beef back into the refrigerator (fridge). 3. [NAME] 1 failed to check food temperatures (refers to the safe internal cooking temperatures for various types of food to prevent foodborne illnesses) of the regular, mechanical soft and pureed food preparations of beef steaks, mashed potatoes, and a carrot and green bean mix while cooking lunch on 8/12/2025 and the regular, mechanical soft, and pureed food preparations of grits, scrambled eggs, ground turkey, and turkey sausage while cooking breakfast on 8/13/2025. 4. [NAME] 1 failed to check trayline (an assembly line to plate food for meals) food temperatures for lunch on 8/12/2025 and breakfast on 8/13/2025.5. On 8/12/2025, [NAME] 2 failed to check food cooking temperatures for lunch items.6. Dietary staff substituted green beans for carrots without the Registered Dietitian's ([RD] licensed healthcare professional who specializes in nutrition and dietetics) approval. 7. [NAME] 1 did not follow the recipe to thicken pureed food (a texture-modified food for residents who can't handle solid food due to things like chewing or swallowing difficulties, or gut issues) when preparing pureed food for lunch on 8/12/2025 and breakfast on 8/13/2025.8. [NAME] 1 did not follow a recipe to make the gravy (sauce) on 8/12/2025 for lunch.9. On 8/13/2025, [NAME] 1 used a broken metal whisk (a cooking utensil) to prepare breakfast items.10. The kitchen did not have any supervision from qualified personnel like a Dietary Supervisor, Dietary Services Manager (DSM), Certified Dietary Manager, or RD for food safety preparation.These deficient practices had the potential to cause foodborne illness (any illnesses caused by consuming foods or beverages contaminated with harmful bacteria, viruses and parasites or their toxins), food allergies, medical complications such as malnourishment (excesses or imbalances in a resident's intake of nutrients and or energy), choking (blockage of the upper airway by food or other objects that prevents breathing), aspiration pneumonia (a lung infection caused by inhaling oral contents into the lungs) to the 88 residents who received food from the kitchen, resulting in hospitalizations and death.On 8/13/2025 at 5:46 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of Registered Nurse (RN 2) with the Administrator (Admin) present via telephone due to the facility's failure to ensure safe and sanitary dietary services were provided. On 8/15/2025 at 2:45 p.m., the facility submitted an acceptable IJ removal plan ([IJRP] interventions to immediately correct the deficient practices). After verification of IJRP implementation through observation, interview, and record review, the IJ was removed onsite on 8/15/2025 at 3:30 p.m. in the presence of the Admin, Regional [NAME] President of Operations (RVPO), and Licensed Vocational Nurse (LVN 2). The IJRP included the following immediate actions: 1. On 8/13/2025, the improperly thawed liquid eggs, ground beef and the broken whisk were discarded by the dietary staff. [NAME] 2 was removed from the dietary department schedule due to failure to respond to calls from the Admin to receive in-service for the improperly thawed meat and eggs, and temperature monitoring of food. [NAME] 2 remained off duty until the cook participated in individual in-service training sessions and competency assessed in areas including proper thawing and preparation of food, maintenance of sanitary equipment, notification and approval procedures with the RD for substitutions, verification of food temperatures, following recipes (including puree food and gravies) and menus. 2. On 8/13/2025, the Registered Dietitian (RD I) delivered initial in-service training to four of ten (10) dietary staff members, covering procedures for appropriate food thawing preparation (1. Under running water (submerging frozen food under running water at a temperature of 70 F), 2. refrigeration method (thawing food inside a refrigerator with temperature maintained at 41 F or lower to prevent the growth of dangerous microorganisms), and 3. microwave process (a quick and effective thawing method, requiring careful attention to ensure safety and even thawing), the new process for reviewing menus daily to pull frozen items and place in the refrigerator for thawing 3 days before use, equipment sanitation, notification protocols for substitutions, and monitoring food temperatures during cooking process and during trayline. Competency evaluations were conducted with verbal discussion and staff return demonstration to confirm comprehension of the material presented. 3. On 8/14/2025, the RD 1 conducted one-on-one in-service education (personalized, individualized training or professional development session designed to enhance an employee's skills, knowledge, or performance in their current role) to [NAME] 1 covering procedures for appropriate food thawing, the new process for reviewing menus daily to pull frozen items and place in the refrigerator for thawing 3 days before use, equipment sanitation, notification protocols for substitutions, and monitoring food temperatures during cooking process and during trayline, following recipes (including puree food and gravies) and menus. Competency evaluations were conducted with verbal discussion and staff return demonstration to confirm comprehension of the material presented. 4. On 8/14/2025, RD 1 conducted an initial in-service education to 1 more dietary personnel, for a total of 6 out of 10 dietary personnel. The in-service covered procedures for appropriate food thawing preparation, the new process for reviewing menus daily to pull frozen items and place in the refrigerator for thawing 3 days before use, equipment sanitation, notification protocols for substitutions, monitoring food temperatures during the cooking process and during trayline and following menus and recipes. Competency skills check was completed to verify understanding of topics discussed. In-service education will proceed until all dietary staff have received instruction and demonstrated competency. One of the remaining employees is currently on vacation and will receive training prior to their next scheduled shift upon returning to work. The RD 2 will provide ongoing monthly in-services for existing staff and onboard training for new employees. New dietary staff will complete a competency checklist during orientation and annually thereafter, facilitated by the Certified Dietary Manager or RD. 5. On 8/13/2025 and 8/14/2025, RD 1 verified competency with verbal discussions with staff return demonstration of the 6 dietary staff that were provided with in-service education, through skills check evaluation regarding appropriate food thawing (1. Under running water, 2. refrigeration method, and 3. microwave process; thawing food at room temperature will no longer be used), the new process for reviewing menus daily to pull frozen items and place in the refrigerator for thawing 3 days before use, food preparation, equipment sanitation, notification protocols for substitutions, monitoring food temperatures during food preparation and during trayline, location of recipes, and following menus and recipes. All cooks will check food temperatures while cooking and during trayline. The cook will log the temperatures in the temperature log binder. An audit was completed to verify the recipes are available for pureed diet and for gravy. The recipes were confirmed and available in a binder. 6. On 8/14/2025, the Admin provided one-on-one in-service to RD 2 regarding the oversight and approval of meal substitutions. RD I or RD 2 will review all substitutions for appropriate equivalent nutritional value and sign-off on the alternative food item as a substitute on the dietary substitution form. Additionally, the RD will review menus and recipes and conduct inventory of stock to place food orders to ensure recipes are followed and therefore minimize the need for substitutions. 7. On 8/14/2025, dietary staff, Admin, and RD 2 performed a comprehensive sanitation inspection of the kitchen using the Dietary Skills Checklist form, emphasizing correct food thawing procedures and equipment. 8. All 82 residents who received meals from the kitchen were evaluated by the designated Licensed Nurses for any gastrointestinal symptoms of foodborne illness, food allergy, medical complications such as malnourishment, choking, aspiration pneumonia. No issues have been identified. Designated Licensed Nurses notified the attending physicians regarding the identified deficient practice. Nursing Staff will continue to monitor residents for seventy-two (72) hours for any potential symptoms of gastrointestinal symptoms or changes in condition. Should any concerns arise, attending physicians will be promptly informed for fm1her assessment and management as appropriate.Findings: 1. During an observation on 8/13/2025 at 6:15 a.m. in the kitchen, a (cardboard [heavyweight paper-based]) box (container used for packaging) labelled Liquid Egg Product and Keep Refrigerated 33 F - 40 F was on the countertop next to the stove. The cardboard box contained a bag filled with yellow liquid eggs that was cold and hard to touch. During a concurrent interview and record review on 8/13/2025 at 9:53 a.m. with Registered Nurse (RN 1), the facility's policy and procedure (P&P) titled, Food Preparation, dated 2023, was reviewed. RN 1 stated the P&P indicated food preparation should be supervised by the Director of Food and Nutrition Services and reviewed by the Registered Dietitian, employees should prepare food in a safe manner to protect residents from foodborne illnesses and the facility should use proper defrosting methods in defrosting frozen food. RN 1 stated the P&P indicated, prepared food should be stored at proper temperature until serving time and the temperature forms should be utilized. RN 1 stated the P&P also indicated, cold foods must be kept at or under 41 F, and hot foods at or more than 140 F. RN 1 stated food (unspecified) must be kept in safe temperature zones. RN 1 stated there were 88 of 93 residents in the facility who ate food served from the kitchen. RN 1 stated these residents had the potential to develop foodborne illness, dehydration (a state where the body loses more water than it takes in, resulting in a lack of fluid), and hospitalization, if cold food was kept over 41 degrees. During a concurrent observation and interview on 8/13/2025 at 12:10 p.m., with [NAME] 1 in the kitchen, the box labelled Liquid Egg Product and Keep Refrigerated 33 F - 40 F was in the same area on the countertop next to the stove, as previously observed on 8/13/2025 at 6:15 a.m. The box and bag (containing the liquid egg) were wet and felt soft and cold when touched. The temperature of the liquid egg was 55 F. [NAME] 1 stated he removed the box of liquid eggs from the freezer on 8/13/2025 at 5:30 a.m. [NAME] 1 stated the eggs were being thawed until completely defrosted (liquid in consistency). [NAME] 1 stated [NAME] 3 would place the box of liquid eggs in the refrigerator that evening to be cooked tomorrow morning. [NAME] 1 stated he was not trained in how to thaw frozen food. [NAME] 1 stated countertop thawing at room temperature was standard practice in the facility's kitchen. [NAME] 1 stated the facility did not have a temperature monitoring log when thawing food and there was no Pull Schedule (schedule of when to pull food from the freezer) to thaw. During an interview on 8/13/2025 at 1:00 p.m. with RD 1, RD 1 stated food should never be thawed at room temperature. RD 1 stated thawing food at room temperature was not safe and placed residents at risk of foodborne illness. RD 1 stated the cooks should have thawed the frozen eggs in the refrigerator, or through one of three safe methods to prevent bacterial growth and potential illness in residents. RD 1 stated the cooks should have used one of the following safe thawing options: labelling and placing the liquid eggs in the fridge, fully submerging the bag of liquid eggs under running water or microwaving the bag of eggs. RD 1 stated temperatures of thawing food had to be monitored and recorded throughout the thawing process to limit the amount of time that the food temperature was held in the danger zone. During a concurrent observation and interview on 8/13/2025 at 2:25 p.m. with [NAME] 3 in the kitchen, the box labelled Liquid Egg Product and Keep Refrigerated 33 F - 40 F were observed on the countertop. [NAME] 3 stated the liquid eggs on the countertop were left to thaw at room temperature. [NAME] 3 stated she did not measure or record the temperatures and planned to put the liquid eggs in the fridge when fully defrosted to cook on 8/14/2025 for breakfast. [NAME] 3 stated eggs could be thawed at room temperature because eggs were not meat. [NAME] 3 stated thawing liquid eggs at room temperature was standard practice in the facility kitchen. During a concurrent interview and record review on 8/13/2025 at 2:35 p.m. with [NAME] 3, the facility's breakfast, lunch, and dinner menus and recipes dated 8/13/2025 through 8/16/2025 were reviewed. The menus and recipes indicated eggs on the menu for breakfast on 8/14/2025. [NAME] 3 stated eggs were on the menu on 8/14/2025 for breakfast. [NAME] 3 stated the liquid eggs in the box on the countertop had been thawing at room temperature for nine hours and were to be prepared for residents' breakfast on 8/14/2025. 2. During a concurrent observation and interview on 8/13/2025 at 12:10 p.m. with [NAME] 1 in the kitchen, a large tube of red, pink, and white substance was on the countertop. The outside of the plastic tube felt wet, soft and cold. [NAME] 1 stated the red, pink, and white substance in the cylinder-shape ([cylinder], tumbler shape) was ground beef. [NAME] 1 stated the temperature of the ground beef was 64 F. [NAME] 1 stated the large cylinder of raw, ground beef was removed from the freezer on 8/13/2025 around 9:45 a.m. [NAME] 1 stated he thawed the raw ground beef at room temperature to cook and serve as a meat option in case he ran out of the planned meat for dinner that evening of 8/13/2025. [NAME] 1 stated countertop thawing at room temperature was standard practice in the facility's kitchen. During an interview on 8/13/2025 at 2:25 p.m. with [NAME] 3 in the kitchen. [NAME] 3 stated the ground beef was placed in the fridge on 8/13/2025 around 1:30 p.m. (3.75 hours) after it was held at room temperature. [NAME] 3 stated the temperature of the beef was checked and was 39 F. [NAME] 3 stated the beef was safe in the fridge and could be cooked for the residents' future meals.During a concurrent interview and record review on 8/13/2025 at 2:35 p.m. with [NAME] 3, the facility's menu and recipes for 8/13/2025 through 8/18/2025 were reviewed. [NAME] 3 stated, there was no ground beef on the menu for any meals from 8/13/2025 through 8/16/2025. [NAME] 3 stated the thawed ground beef could safely be returned in the fridge and stored, cooked, and served to residents within the next week. 3. During an observation on 8/12/2025 from 11:35 a.m. to 12:45 p.m., in the kitchen, [NAME] 1 did not measure or record food temperatures of the regular, mechanical soft, and pureed food preparations of the beef steaks, mashed potatoes, and the carrot and green bean mix while cooking lunch. During an interview on 8/12/2025 at 12:00 p.m., with [NAME] 1, [NAME] 1 stated, he did not have time to monitor or record any food temperatures during cooking.During an observation on 8/13/2025 from 6:15 a.m. to 8:05 a.m. in the kitchen, [NAME] 1 did not measure or record food temperature when preparing the regular, mechanical soft, and pureed food preparations of grits (corn dish), scrambled eggs, ground turkey, and turkey sausage for breakfast.During an interview on 8/13/2025 at 8:05 a.m., [NAME] 1 stated breakfast was served one hour late and he had no time to monitor or record any food temperatures during cooking. During an interview on 8/13/2025 at 9:53 a.m. with RN 1, RN 1 stated food temperatures must be monitored while cooking and serving meals to decrease the risk of foodborne illness and to improve residents' satisfaction. RN 1 stated foodborne illness had the potential to cause residents to be dehydrated and hospitalized .During an interview on 8/13/2025 at 1:00 p.m. with RD 1, RD 1 stated, cooks should follow the facility's P&P when cooking protein items such as beef and chicken. RD 1 stated the P&P indicated Cooks must monitor and record the food cooking temperature in the temperature log. RD 1 stated not monitoring food temperatures may cause undercooked food, food temperatures in the danger zone, bacterial growth and place residents at risk of foodborne illnesses. 4. During an observation on 8/12/2025 at 12:10 p.m., of the lunch trayline, in the kitchen, [NAME] 1 did not measure or record food temperatures of the regular, mechanical soft, and pureed food preparations of the beef steaks, mashed potatoes, and the carrot and green bean mix for lunch service prior to starting the trayline and serving lunch. During an observation on 8/13/2025 from 6:20 a.m. to 8:05 a.m., of the breakfast trayline in the kitchen, [NAME] 1 did not measure or record food temperatures prior to starting trayline and serving the regular, mechanical soft, and pureed food preparations of grits, scrambled eggs, ground turkey, and turkey sausage for breakfast. During an interview on 8/13/2025 at 8:05 a.m. with [NAME] 1, [NAME] 1 stated he did not have time to measure trayline temperatures prior to serving the regular, mechanical soft, and pureed food preparations of grits, scrambled eggs, ground turkey, and turkey sausage for breakfast on 8/12/2025 and lunch on 8/13/2025. [NAME] 1 stated he did not know where the Food Temperature Log was and placed. During a concurrent interview and record review on 8/14/2025 at 12:33 p.m. with [NAME] 2, the facility's Food Temperature Log for 8/2025 was reviewed. [NAME] 2 stated the Food Temperature Log indicated food temperatures were not measured or recorded for meal items on the following dates and were blank: 1. 8/6/2025, 8/7/2025, 8/8/2025, 8/10/2025, 8/11/2025, 8/12/2025, and 8/13/2025 for hot food served for breakfast.2. 8/6/2025, 8/7/2025, 8/8/2025, 8/10/2025, 8/11/2025, and 8/12/2025 for hot food served for lunch.3. 8/6/2025, 8/9/2025, 8/11/2025, and 8/12/2025 for all food served for dinner.Cook 2 stated the Food Temperature Log was only used to record trayline temperatures prior to starting trayline. [NAME] 2 stated food temperatures were supposed to be measured and recorded prior to starting trayline for every meal. 5. During a concurrent interview and observation on 8/12/2025 at 12:15 p.m., with [NAME] 2 in the kitchen, [NAME] 2 did not measure the temperature of ground turkey while cooking. [NAME] 2 plated (placed on a plate) and served the ground turkey to 16 residents without measuring or recording the temperature. [NAME] 2 stated he did not check the temperature of the ground turkey. [NAME] 2 stated the ground turkey was safe for residents' consumption based on the meat's color. [NAME] 2 stated he had decades of cooking experience and did not need a thermometer (equipment to measure temperature) to check food temperatures. During an observation on 8/12/2025 at 12:45 p.m., CNA 4 served the ground turkey to three residents that was prepared by [NAME] 2 on 8/12/2025 at 12:15 p.m. with the temperature not measured or recorded. During an interview on 8/13/2025 at 1:00 p.m., with RD 1, RD 1 stated cooked food must reach certain temperatures while cooking and prior to serving to limit bacteria growth and decrease the potential for food-borne illnesses. RD 1 stated meat temperatures must be measured and recorded in the food temperature log while cooking and prior to serving. 6. During a review of the facility's menu, dated 8/12/2025, the menu indicated roasted carrots for lunch. During a concurrent observation and interview on 8/12/2025 at 9:55 a.m. with [NAME] 1 in the kitchen, a small bag of carrots was in the fridge. [NAME] 1 stated the facility did not have enough carrots to serve full portions to over 80 residents. [NAME] 1 stated he did not ask RD 1 what to substitute for the carrots. [NAME] 1 stated he will substitute missing carrots with green beans for the vegetable serving. During an observation on 8/12/2025 at 12:00 p.m., in the kitchen, three trays of mixed steamed carrots and green beans, chopped green beans, and pureed green beans instead of carrots were served to 71 residents, for lunch.During an observation 8/12/2025 at 12:33 p.m. in the kitchen, [NAME] 1 ran out of the regular textured steamed carrots and green beans for 9 residents. [NAME] 1 substituted the missing steamed carrots, and green beans mixed with two scoops of mashed potatoes for 4 residents who were on regular textured diets. [NAME] 1 substituted a reheated fried vegetable roll for carrots and green beans and served to 5 residents on regular texture diets.During an interview on 8/12/2025 at 12:37 p.m. with [NAME] 1, [NAME] 1 stated he did not inform RD 1 about the carrots substitutions because he did not have time. [NAME] 1 stated he ran out of regular texture vegetable servings for 9 regular texture trays. [NAME] 1 stated he replaced the missing vegetable serving with an extra scoop of mashed potatoes or a reheated fried vegetable roll. [NAME] 1 stated he knew the nutritional value was not the same but had used all the vegetables he had.During an interview on 8/13/2025 at 1:00 p.m. with RD 1, RD 1 stated she was not notified about any food shortages and was not asked about any dietary substitutions over the past week. RD 1 stated the facility had a list of approved food substitutions in case of shortages. RD 1 stated carrots and green beans were not of similar nutritive value. RD 1 stated deviating (changing or not following) recipes could introduce allergens and cause allergic reactions for residents. RD 1 stated not following the menu and recipes had the potential for residents to lose weight, develop vitamin or mineral deficiencies, and skin issues. 7. During a concurrent observation and interview on 8/12/2025 at 11:35 a.m., [NAME] 1 used an unmarked, white, Styrofoam (made of a lightweight, disposable plastic) cup to transfer white powdered thickener from a plastic storage bin to pureed food items. [NAME] 1 stated the Styrofoam cup was a drinking cup with no measurement indicators. [NAME] 1 stated he eyeballed (looked) to measure the thickener and did not use a system or method to evaluate the thickness of the pureed foods.During an interview on 8/13/2025 at 9:53 a.m. with RN 1, RN 1 stated residents on pureed texture diets had issues with swallowing. RN 1 stated if pureed texture diets were not provided, residents had the potential to choke, aspirate and develop pneumonia, requiring hospitalization and could cause death.During an interview on 8/13/2025 at 1:00 p.m., with RD 1, RD 1 stated, the cooks should follow the manufacturer's instructions and P&P to thicken pureed food items. RD 1 stated, not following instructions to prepare a thickener could cause pureed items to be too runny, potentially causing choking, aspiration, and pneumonia. RD 1 stated not following recipes could alter the calories, vitamins, and minerals of each meal, potentially causing residents' weight loss and skin breakdown. 8. During a concurrent observation and interview on 8/12/2025 at 11:35 a.m. with [NAME] 1 in the kitchen, gravy was observed boiling on the stove. [NAME] 1 stated there was no pre-made gravy available for lunch. [NAME] 1 stated he prepared the gravy by mixing milk, garlic powder, and powdered beef broth. [NAME] 1 stated he did not have a recipe on how to make gravy. [NAME] 1 stated the lunch menu indicated to use pre-made gravy. [NAME] 1 stated he did not have any concerns about exposing residents to allergens, such as milk, or salt content in the gravy. During an interview on 8/13/2025 at 9:53 a.m., with RN 1, RN 1 stated menus, recipes, and diet orders must be followed for residents with electrolyte-restricted therapeutic diets (diets that limit the intake of electrolytes, such as potassium or sodium) orders. RN 1 stated 59 residents were on sodium-restricted diets and were at risk of high blood pressure, stroke, worsening cardiac issues, worsening kidney function, unintended weight gain, fluid retention, hospitalization, and organ failure. During an interview on 8/13/2025 at 1:00 p.m., with RD 1, RD 1 stated the Cooks did not notify her about any need for menu item substitutions or any food shortages over the past week. RD 1 stated any food served to residents must be standardized and cooked according to a recipe. RD 1 stated staff must follow a recipe for every menu item and should not have made and served the gravy without a standardized recipe. RD 1 stated deviating from recipes could introduce allergens and cause allergic reactions. 9. During a concurrent observation and interview on 8/13/2025 at 6:20 a.m. with [NAME] 1 in the kitchen, [NAME] 1 used a broken large metal whisk to combine the powdered-thickened grits in a small metal tray. [NAME] 1 stated the two metal whisk wires had been broken for several days. [NAME] 1 stated he informed RD 1 about the broken whisk on 8/12/2025. [NAME] 1 stated he had to continue using the broken whisk to prepare menu items because there was no other large whisk in the facility. During an interview on 8/13/2025 at 9:53 a.m. with RN 1, RN 1 stated if the Cooks continue to use the broken metal whisk to prepare food in the kitchen, it placed all residents receiving kitchen-prepared diets at risk for broken metal pieces left in the food. RN 1 stated broken metal pieces in food placed residents at risk of infection, choking, and gastrointestinal (relating to the stomach and the intestines) perforation (poke a hole).During an interview on 8/13/2025 at 1:00 p.m. with RD 1, RD 1 stated she was not made aware of broken equipment in the kitchen and was not notified about a broken metal whisk on 8/12/2025. RD 1 stated using a metal whisk was extremely dangerous for residents and placed residents at risk of consuming metal pieces from the whisk. 10. During an interview on 8/12/2025 at 9:45 a.m., the Admin stated the facility did not have a dietary supervisor or Dietary Services Manager (DSM) for two weeks. During an observation on 8/12/2025 from 11:35 a.m. to 12:45 p.m., there was no Dietary Supervisor, DSM, or RD observed overseeing food preparation and trayline for lunch. During an observation on 8/13/2025 from 6:15 a.m. to 8:05 a.m., there was no Dietary Supervisor, DSM, or RD observed overseeing food preparation and trayline for breakfast.During an interview on 8/13/2025 at 1:00 p.m. with RD 1, RD 1 stated the Admin asked her to increase her hours at the facility as much as possible due to lack of dietary supervision in the kitchen. RD 1 stated she could not oversee the facility's kitchen operations daily because she worked at two other facilities. RD 1 stated she performed a monthly sanitation check and in-service for kitchen staff. RD 1 stated she was not involved in ordering food for the facility. RD 1 stated she primarily provided clinical services and visited the facility and kitchen twice per week, for two hours each visit. During an interview on 8/18/2025 at 2:06 p.m. with the Admin, the Admin stated she ordered food for the kitchen but was not certified to work in the kitchen. The Admin stated RD 1 was unable to provide additional hours and Cooks were not trained to oversee the operations of the kitchen. The Admin stated there was no certified supervisory dietary staff overseeing food preparation, equipment function, and menu coordination in the kitchen from 7/29/2025 until 8/15/2025. The Admin stated the presence of a Dietary Supervisor, DSM, or RD in the kitchen could have avoided the deficient practices. During a review of the facility's P&P titled, Food Preparation, dated 2023, the P&P indicated food preparation should be supervised by the Director of Food and Nutrition Services and reviewed by the Registered Dietitian, employees should prepare food in a safe manner to protect residents from foodborne illnesses and the facility should use proper defrosting methods in defrosting frozen food. The P&P indicated, prepared food should be stored at proper temperature until serving time and the temperature forms should be utilized. The P&P also indicated, cold foods must be kept at or under 41 F, hot foods at or more than 140 F, hot beverages at or more than 140 F, ice cream or sherbet at or less than 32 F. The P&P indicated all menus should have standardized recipes used to ensure meals provide necessary nutritive value. The P&P indicated frozen food must be defrosted using proper defrosting methods. The P&P indicated recipes should be used which are quantified for the facility needs. During a review of the facility's P&P titled, Menus, dated 2023, the P&P indicated menu substitutions must be made from the same food group as the omitted item and should be approved and signed off by the RD. The P&P indicated facilities must keep a menu substitution record on file for 30 days. The P&P indicated staff must refer to the List of Menu Substitutes to replace unavailable menu items. The P&P indicated List of Menu Substitutes, carrots- a vitamin A source; potatoes- a starch substitute, and mixed vegetables were a vitamin A source. The List of Menu Substitutes did not list green beans or fried vegetable as acceptable substitutes. The P&P indicated menus for the therapeutic and texture modified diets were written by the consultant dietitian for all diets served by the facility. During a review of the facility's undated Thick-It Usage Chart, the Usage Chart indicated pureed food should be mixed with the correct amount of Thick-It Original Food and Beverage Thickener using the enclosed measuring scoop. The Usage Chart indicated 1.5 tablespoons of Thick-It to be level measured prior to stirring into food. During a review of the facility's undated [NAME] job description, the job description indicated cooks handle, store, and dispose of raw food items in accordance with company and facility procedures, in compliance with state and federal regulations. The [NAME] job description indicated cooks should follow standardized recipes that correspond to the menu cycles developed by Registered Dietitians. The job description indicated that cooks maintained food service equipment in a clean and safe condition at all times. During a review of the facility's undated Registered Dietician - Salaried job description, the job description indicated RDs plan menus that meet resident's nutritional needs and confirms quality assurance processes are followed in preparation of food. The job description indicated that RDs may supervise food preparation using techniques that conserved nutritional values and may assist in the supervision of the Food Services staff and others for whom they were administratively and professionally responsible. During a review of the facility's undated Dietary Services Manager - Hourly, the job description indicated the position may be filled by a RD. The job description indicated the DSM coordinates the total operation of the dietary department, supervises preparation and service of planned menus, ensured food is stored, held, prepared, and served per company's P&P, state and federal guidelines.

Based on interview and record review, the facility failed to provide supervision to one of one sampled resident (Resident 1) while smoking in the smoking patio on 10/8/22, to prevent the resident from leaving the facility unsupervised. Resident 1 had impaired cognition with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), high blood pressure and [CONDITION(S)] (mental illness that can affect your thoughts, mood, and behavior) disorder. Resident 1 was assessed as a high risk for elopement. A Housekeeping Staff (HSK) 1 deactivated the door leading to the smoking patio, opened the door to allow Resident 1 to go out and smoke without supervision. Resident 1 left the facility from the side door of the patio area leading to a busy street. As a result, Resident 1 left the facility unsupervised, exposed to harsh environmental conditions including excessive heat and or cold, had a potential of being hit by a car and medical complications including malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat), dehydration, heat stroke and death. Resident 1 was without medication from 10/8/2022 to 10/26/2022 a total of 20 days. Resident 1's whereabouts are still unknown. On 10/12/2022 at 4:30 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of Director of Nursing (DON) due to the facility's failure to supervise Resident 1 to prevent Resident 1's elopement from the facility. On 10/12/2022 at 10 p.m., the facility submitted an acceptable IJ removal plan (IJRP). After verification of IJRP implementation through observation, interview, and record review, the IJ was removed on 10/13/2022 at 4:27 p.m., in the presence of the DON. The IJPR included the following immediate actions: 1. Staff followed the facility's protocol on Missing Resident, including but not limited to calling the hospitals in the area. Police Department was notified and continues to provide assistance in locating the resident. As soon as housekeeper reported on 10/12/22 to DON about his involvement in elopement incident that occurred on 10/8/22, staff was suspended pending investigation and progressive disciplinary action will be implemented accordingly. The facility continues to call local hospitals and communicate with police department in search of Resident 1 on a daily basis. 2. All current residents who smoke are affected by this deficient practice. All current residents who smoke were reassessed on 10/12/22 by the facility's Interdisciplinary Team ([IDT] team members from different disciplines working together to ensure residents receive the best care and also improve how medical facilities function). Smoking contracts were reviewed with the residents by the IDT and were signed accordingly. All residents who smoke agreed and verbalized understanding of the review and discussion by the Director of Nursing (DON)/Social Services Director about the smoking schedule, required supervision, designated smoking area (patio) and storage of smoking materials in the nurse's station. Smoking schedule will have a designated staff assigned to supervise/monitor residents during smoking times. Assigned staff will be in-serviced by the DON/DSD about residents' safety while monitoring residents during smoking time, with emphasis on minimizing the risk of elopement. All newly admitted and readmitted residents that smoke will be assessed by the facility's Interdisciplinary Team (IDT) for ability to smoke safely and are given smoking contracts to sign. All current residents who smoke will be assessed for the ability to smoke safely by the IDT quarterly, annually, or whenever there are significant changes of status. IDT will monitor smokers for continued ability to smoke safely and recommend changes to plan of care during scheduled care conferences. The Administrator/Designee will randomly monitor residents' safety with smoking daily. 3. All current residents were reassessed for elopement risk initiated on 10/10/22 and completed on 10/12/22. Residents that were identified as at risk for elopement were provided wanderguard alarm system with elopement risk identification and care plan completed. Plans of care are discussions with the direct care staff during nursing staff intershift reporting/huddle are ongoing. All new admissions and readmissions will be assessed for elopement risk by the Licensed Nurse. If deemed at risk for elopement, use of wander guard and a plan of care will be initiated to address resident's safety. IDT will review plans of care during the scheduled care conferences and as needed. 4. Licensed Nurses monitors the wander guard placement and function every shift. Maintenance staff monitors for proper functioning of the wanderguard system and alarms on every exit. Any issues identified during these monitoring will be addressed accordingly and reported to the facility's Administrator during the morning meeting and as needed, for further interventions when appropriate. All current residents will be reassessed for elopement risk by the Licensed Nurse and reviewed by the IDT quarterly, annually, and with significant change in condition. Assigned ambassadors will check residents considered as elopement risk for safety during daily routine rounds on Monday through Friday, and the manager-on-duty during the weekends and holidays. Side exit door will remain closed and used only as an emergency exit. The code to open the door will be changed weekly and when indicated. 5. In-service education was initiated on 10/8/22 and is ongoing by the DON/Director of Staff Development (DSD)/ Designee for current staff on the following topics: prevention of elopement, elopement and missing resident protocols. Additional in-service education for all current staff were initiated on 10/12/22 by the DON about the following topics: smoking policy, smoking schedule, required supervision while residents are smoking, elopement policy, residents at risk for elopement, proper monitoring of function and placement of wanderguards and alarm system on exit doors. In-services will continue until 100% of active staff are educated. Expected completion date for these in-service education topics will be on 10/19/22. These in-service education topics are included in the orientation of newly hired staff by the DSD. 6. Any trends from the rounds and audits being conducted will be reported to the facility's Quality Assurance Performance Improvement (QAPI) committee monthly for three months or until full compliance with protocols and regulations are sustained. 7. The Administrator will monitor for compliance with this plan of action, including but not limited to the policies on smoking, elopement, and monitoring of alarm systems. Any issues will be corrected as soon as identified. In the absence of the Administrator, the Director of Nursing will monitor for compliance. Findings: During a review of Resident 1's face sheet (admission record), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including dementia with behavior disturbances, other stimulant dependence, nicotine dependence, [CONDITION(S)] disorder, hypertension (high blood pressure), and hallucination (an experience in which a person sees, hears, feels, or smells something that does not exist). During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 7/23/2022, the MDS indicated Resident 1 had the ability to usually understand and be understood by others. The MDS indicated Resident 1 required a one-person assistance with bed mobility, transfer from bed, chair, wheelchair or standing position, walking in between locations in his room, dressing, toilet use and personal hygiene. The MDS indicated Resident 1 required supervision with eating, locomotion on unit (how resident moves between locations in his room and corridor on same floor) and locomotion off unit (how resident moves to and returns from off-unit locations and moves to and from distant areas on the floor). The MDS indicated Resident 1 used a cane and wheelchair. During a review of Resident 1's History and Physical (H&P) dated 1/16/2022, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's care plan titled Health Risk Associated with Smoking dated 1/14/2022, the care plan's interventions indicated to inform and encourage resident to observe smoking policy, maintain a safe environment for smoking and store smoking materials securely per protocol. During a review of Resident 1's physician's order dated 01/15/22, the physician's order indicated [MEDICATION(S)] (blood pressure medicine) 5 milligrams ([mg] unit of measurement), 1 tablet two times (BID) daily QD) at 9 am and at 5pm, and [MEDICATION(S)] (medication to treat [CONDITION(S)] disorder) 5mg, 1 tablet QD at 9 pm. During a review of Resident 1's care plan titled At Risk for Elopement and Wandering out of Facility due to prior Living Condition of Homelessness dated 2/10/2022, the care plan's intervention indicated monitor resident's whereabout due to high risk for elopement, allow resident to move around the hallway safely, and redirect resident back to supervised areas. The care plan's intervention also indicated establish daily routine for the resident, offer alternate placement, provide activities that divert resident's attention from wandering, check resident's whereabouts, and check wander guard bracelet for functionality. During a review of Resident 1's physician's order dated 02/10/22, the physician's order indicated personal safety alarm while in wheelchair to remind resident to call for assistance during mobility and transfer due to [CONDITION(S)] disorder. The physician's order indicated wanderguard bracelet (device worn on residents wrist or ankle that triggers alarms and can lock monitored doors to prevent the resident leaving unattended) on right wrist for elopement precautions, monitor for proper placement and battery function every shift. During a review of Resident 1's Progress Notes dated 2/17/2022 and timed at 10:32 a.m., the progress notes indicated Resident 1 was noted wheeling himself to the exit doors, getting up without assistance and was at high risk for elopement. During a review of Resident 1's Elopement Risk assessment dated [DATE], and 7/20/2022, the elopement risk assessment indicated Resident 1 was at risk for elopement. The progress notes indicated staff will monitor Resident 1's whereabouts. During a review of Resident 1's progress notes dated 10/8/2022 and timed 12:32 p.m., the progress notes indicated a Certified Nursing Assistant (CNA) 1, assigned to Resident 1 reported that on 10/8/2022, at 12:10 p.m., Resident 1 was not in his room when CNA 1 served Residents 1's lunch. The progress notes indicated CNA 1 looked around the facility for Resident 1 but did not find the resident. During an interview on 10/12/22 at 9:40 am., the DON stated all residents at risk for elopement had wander guards, and residents who smoked were allowed to smoke in the patio only with supervision. The DON stated on 10/8/22, at 12:30 pm, Registered Nurse (RN) 1 informed her (DON) that Resident 1 was missing from the facility. The DON stated a facility wide search was conducted but the resident was not found. The DON stated on 10/11/22, it was concluded that Resident 1 left via the exit door of the smoking patio. The DON stated the alarm did not go off on at any point on 10/8/22. The DON also stated a housekeeping staff (HSK) 1 confessed that on 10/8/22 around lunch time, Resident 1 asked HSK 1 to take him outside to smoke. HSK 1 took the resident to the smoking patio, left the resident there for a few minutes unsupervised, and when HSK 1 returned to the patio, Resident 1 was not there. The DON stated HSK 1 reported that he (HSK 1) assumed a staff had helped Resident 1 back into the facility. The DON added that HSK 1 only reported the incident to the DON on 10/10/22, two days after Resident 1 had eloped. During an interview on 10/12/22 at 10:50 am, HSK 1 stated on 10/8/22, at approximately 12 pm., Resident 1 was in a wheelchair and asked HSK 1 to take him (the resident) to the smoking patio. HSK 1 stated Resident 1 had a wanderguard and was wheelchair bound. HSK 1 stated he decoded the door leading to the smoking patio, helped Resident 1 to the alley at the smoking patio so the resident could smoke. HSK 1 stated residents were not allowed in the smoking patio without supervision. HSK 1 stated Resident 1 could not go to the patio alone because the resident did not have the code to the door and Resident 1 had a wander guard which would alarm if the resident attempted to go out unassisted. HSK 1 stated he left Resident 1 in the patio smoking, went back into the facility to get something and when he returned the resident was gone. HSK 1 also stated he tried to look for the resident outside the facility without alerting the staff because he was scared of losing his job. HSK 1 stated he decided to notify the DON on 10/10/22 because he was worried for Resident 1's safety given that the exit door led into a very busy street. During a review of the facility's policy and procedure (P/P) P/P titled Resident Elopement, dated 8/15/2001, the P/P indicated the facility will provide a safe environment and preventive measures for elopement. During a review of the facility's P/P titled, Wander/Elopement Alarm System Testing dated 4/15/2002, the P/P indicated regular testing of door monitor and signaling devices in the alarm system verified the integrity of the system and helped maintain employee awareness and vigilance. The P/P indicated regular testing was essential for residents' safety. During a review of the facility's P/P titled Safety Smoking Policy dated September 2004, the P/P indicated the Interdisciplinary Team determined if a resident was a safe or unsafe smoker before allowing the resident to smoke. The P/P indicated all residents who smoked will be supervised when smoking. During a review of the facility's P/P titled Safety Supervision of Residents dated 11/2017, the P/P indicated the facility will ensure residents were safe, supervised and assisted. The P/P indicated resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The policy also indicated the frequency and type of supervision varied per the needs of each resident.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of the coronavirus ([COVID 19]) an illness caused by a virus that can easily spread from person to person), by not ensuring the following: 1.Two out of two Certified Nursing Assistants (CNA) 1 and CNA 2 wore appropriate ( N95, eye protection [goggles or face shield], gown and gloves ) personal protective equipment ([PPE] equipment worn to minimize exposure to hazards that cause injuries and illnesses, fitted N95 mask [mask worn over the face to cover the nose and mouth that provides respiratory protections against aerosols (a suspension of fine solid particles or liquid droplets in air) and prevent infections], eye protection, gloves, and a gown) prior to entering the yellow zone (area designated for residents who have been exposed or are suspected of having COVID-19). 2. One of 1 Licensed Vocational Nurse (LVN) 1 wore the required PPE which included a fit tested N95 mask, eye protection, isolation gown, and gloves while providing direct resident care to Residents 1 and 2 in the red zone (area designated for residents who are positive with COVID-19). 3. Five staff (Registered Nurse (RN) 1, Licensed Vocational Nurse (LVN) 1 and LVN 2, and CNAs 1 and 2) were fit tested for a N95 respirator prior to use while working in the red and yellow zones, out of 35 staff that was working on 1/16/2022. These deficient practices placed all 83 in-house residents (81 of which were in the yellow zone, and 2 in the red zone), 90 staff members, and the community at risk for the transmission and spread of COVID-19. On 1/16/2022 at 4:36 p.m., during an unannounced visit, an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause, serious injury, harm impairment or death to a resident) was declared for F880 and the facility's Registered Nurse (RN) Supervisor, Staffing Coordinator (SC), and Charge Nurse were notified of the findings of staff not wearing the appropriate PPE and N95 mask when caring for residents. On 1/20/2022 at 12:36 p.m., the IJ was lifted in the presence of the Administrator (ADMIN), Interim Director of Nursing (D), Unit Manager, and Infection Preventionist (IP) Nurse, after an on-site verification of the implementation of the acceptable Plan of Action ([POA] a plan with interventions to correct the deficient practices) through observation, interview, and record review. The acceptable POA included the following immediate corrections: 1. RN 1, LVN 1, LVN 2, and CNA 2 were fit tested on [DATE] for a N95-Brand 1 respirator. CNA 1 will be N95 fit tested on [DATE] prior to returning to work. 2. Eight (8) employees out on leave will be fit tested for the N95 respirator as soon as they are able to return to work. The Infection Preventionist Nurse (IP)/Unit Manager (UM) will perform the fit test prior to the start of their shift. 3.The IP/UM has reached out to each of the employees off duty via telephone call on 1/17/22 and 1/18/22 regarding N95 fit testing prior to their return to work. Any Registry Staff assigned to work at the facility, at any shift, will be fit tested for the N95 respirator available at the facility by the IP/UM prior to being given their assignments/start of work, unless the Registry Staff will provide a copy of proof that Registry Staff fit tested the N95 respirator, with the actual N95 respirator available at the facility, from their own registry. 4. The 38 employees (including two [2] Registry Staff) working on 1/16/22 on all three shifts will have a N95 respirator fit test completed prior to starting their next scheduled shift. 5. In-service education has been provided to the facility's Administrator, Interim Director of Nursing, Unit Manager, IP Nurse by the Nurse Consultant on 1/17/22 about the regulatory requirements for N95 respirator fit testing. 6. IP Nurse and Unit Manager started N95 respirator fit testing, N95 respirator competency skill checklist and the PPE competency skills checklist on 1/17/22 with all current staff. This will continue until 100% of staff have N95 fit testing and all skills competency checklists on proper donning/doffing of PPE, including N95 respirator, and hand hygiene have been completed. IP Nurse will complete N95 respirator fit testing on all newly hired employees during orientation prior to working on the floor. IP Nurse will conduct annual N95 respirator fit testing. Employees that are currently on leave will have the N95 respirator fit testing, N95 respirator skills checklist and PPE skills checklist upon return from their leaves prior to working in the facility. Regional Nurse Consultant provided one-on-one (1:1) in-service education with the IP Nurse on 1/17/22 about the schedule for N95 respirator fit testing for all current employees and to complete N95 respirator fit testing with newly hired employees during orientation prior to working on the floor. 7. Interim Director of Nursing and/or IP Nurse will ascertain daily during their inventory of current N95 respirator supplies that the employee will be fit tested if there is a new brand or change in brand of N95 respirator availability prior to working. Administrator will monitor the N95 respirator fit testing compliance monthly. 8. IP Nurse will conduct random N95 respirator skill checklist and PPE skill checklist weekly with staff on all three shifts to ensure compliance with regulations with follow-up as indicated. IP Nurse will complete monthly audit of N95 fit testing that was completed and will submit to the Administrator for review and follow-up as indicated. 9. Finding and trends identified regarding completion of N95 respirator fit testing will be presented by the IP Nurse to the Safety Committee and Quality Assurance and Performance Improvement (QAPI) Committee for review and recommendations monthly, times three months, or until facility sustain compliance with follow-up as indicated. The Administrator is responsible to monitor and ascertain compliance with this plan of action. 10. One to One in-service and competency evaluation were conducted by the Unit Manager on 1/16/22 with LVN #1 regarding use of proper PPE to be worn while providing direct care for residents while working in the red zone with positive COVID-19 residents. 11. Interim Director of Nursing, Unit Manager and the Administrator conducted facility rounds the evening of 1/16/22 to make certain that the facility staff were wearing appropriate PPE during the 3 p.m. to 11 p.m. shift and on the 11 p.m. to 7 p.m. shift. No further issues were noted. 12. Regional Nurse Consultant provided 1:1 in-service education with the IP Nurse on 1/17/22 regarding the monitoring of staff on proper PPE use. 13. In-service education was conducted with facility staff by the IP Nurse and/or Licensed Nurse Designee starting on 1/16/22 regarding the appropriate PPE to wear while providing direct care to residents in all zones with return demonstration on how to properly don {put on (an item of clothing) in a specific sequence to prevent cross contamination} and doff (take off in a specific sequence to prevent cross contamination) PPE. 14. Nursing Management team and charge nurses will continue to conduct facility rounds several times during their shift with a focus on making certain that the facility staff is wearing the correct PPE with follow-up as indicated started on 1/17/22. 15. Findings and trends identified regarding staff compliance with wearing proper PPE in all zones will be presented by the IP Nurse to the Safety Committee and QAPI Committee monthly times three months or until compliance is sustained by the facility with follow-up as indicated. 16. Administrator will be responsible for monitoring and ascertaining compliance with this plan of action. Findings: During a review of the facility's census, dated 1/16/2022, the census indicated the facility had 83 in-house residents that included 81 residents housed in the yellow zone and two residents housed in the red zone. During an observation on 1/16/2022 at 10:40 a.m., the facility's front lobby screener (LS)was observed wearing a N95 respirator incorrectly. The mask was observed under the chin exposing the mouth and nose with one strap unattached at the back. The screener was not wearing a face shield nor eye protection. During an observation on 1/16/2022 at 10:56 a.m., CNA's 2 and 5 were observed wearing a N95 respirator mask without eye protection. CNAs 2 and 5 entered a resident room in the yellow zone without complete PPE and spent more than 15 minutes inside the room providing care. During an interview with LVN 2 on 1/16/2022 at 11:30 a.m., LVN 2 stated CNAs or anyone entering resident rooms at the yellow zone should wear proper PPE ( eye protection, N95 mask, gown and gloves when going inside the room). LVN 2 stated the whole facility was yellow zone and under observation because of exposure to COVID-19. During an interview with CNA 3 on 1/16/2022 at 11:50 a.m., CNA 3 stated the required PPE while in the yellow zone included a N95 respirator and a face shield/googles prior to entering a resident's room. CNA 3 stated if providing direct care, you also have to wear a gown and gloves. CNA 3 stated wearing proper PPE was important to prevent getting the virus and spreading it. During an observation of the red zone on 1/16/2022 at 12 p.m., LVN 1 was observed entering a yellow zone resident's room without donning PPE and providing direct care to Resident 1. LVN 1 was observed to be in the room for more than 15 minutes. LVN 1 was observed wearing a N95 respirator with no face shield and or eye protection, gloves, and gown and or complete PPE. During a review of Resident 1's Admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 10/5/2021, the MDS indicated Resident 1 usually understood and usually understands other. Resident 1 required extensive assistance from staff members for bed mobility, transfer, limited assistance in walking, and locomotion (moving from place to place), toilet use, dressing and extensive assistance with personal hygiene, and bathing. During a review of Resident 1's laboratory summary report, dated 1/15/2022, the summary indicated [CONDITION(S)]-CoV-2 PCR ([COVID-19] polymerase chain reaction ( laboratory test to detect covid virus) was detected. During an interview with LVN 1 on 1/16/2022 at 3:15 p.m., LVN 1 stated wearing a N95 inside a resident room was his practice. LVN 1 stated he provided Resident 1 direct care and administered oral medications. LVN 1 stated that he assists resident to go to the bathroom and help set up Resident 1's bed. LVN 1 stated he was assigned to red zone since the start of the facility's outbreak (a sudden rise in the incidence of a disease, COVID). LVN 1 stated that he had direct contact with Resident 1 when he went inside the room. During an interview with RN 1 on 1/16/2022 at 3:30 p.m., RN 1 stated every time staff entered inside the room (CNAs, housekeeping, dietary, licensed nurses, activities) they should wear appropriate PPE including a N95 respirator to protect vulnerable and high-risk residents or staff from getting the virus or from spreading the virus. RN 1 stated it was not acceptable that LVN 1 would go inside the room of red zone resident without appropriate PPE. RN 1 stated if LVN 1 did not have protection to prevent the spread, he might transmit the virus to other staff and residents. RN 1 stated during in- service training the Director of Staff Development (DSD), Infection Preventionist (IP), RN supervisor and Interim DON reminded everyone to wear appropriate PPE as instructed by the Center for Disease Control and Prevention (CDC) and the Department of Public Health (CDPH) ( according to the CDC and CDPH; in the yellow and red cohorts all staff regardless of vaccination status should wear N95 respirators, gowns, gloves and eye protection goggles or face shields when providing resident care) entering the room. RN 1 stated LVN 1 should know what to wear when entering the red zone room because he has been assigned to work in the red zone since the beginning of the facility's outbreak (1/14/2022). RN 1 stated she did not know why LVN 1 was not wearing appropriate PPE. RN 1 stated any person who has been within 6 feet of a person with lab- confirmed COVID-19 for a cumulative total of more than 15 minutes within a 24-hour period without consistent use of all appropriate PPE was dangerous and could potentially spread the virus throughout the facility quickly. RN 1 stated facility staff were expected to wear appropriate PPE whenever the staff go inside the resident rooms in the yellow or red zones. RN 1 stated she should have stopped LVN 1 from entering Resident 1's room. During a review of the facility's undated COVID-19 Mitigation Plan manual, the plan indicated residents in the yellow and red zone would be treated with enhanced droplet (infection prevention and control interventions to be used in addition to routine practices intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions) and/or contact precautions (precautions intended to prevent transmission of infectious agents, including microorganisms, which are spread by direct or indirect contact with the patient or the patient's environment). The plan indicated if staff are shared across sections in any way the staff would fully doff all PPE and leave all dirty PPE in designated receptacles. During an interview with LVN 3 on 1/16/2022 at 1:26 p.m., LVN 3 stated she worked in the yellow zone. LVN 3 stated because she came into close contact or was assigned to care for the residents in the yellow zone, she should wear a appropriate PPE each time she goes inside the room which included N95, eye protection, gowns, and gloves. LVN 3 stated she did not remember whether or not she was fit tested for the N95. LVN 3 stated N 95 respirators needed to be fit tested to ensure the N95 did not have leaks which allowed for small particles to go inside the mask. LVN 3 stated the facility provided her with a N95 that she has used from the start of the pandemic (affecting an entire country or the world). During a concurrent observation and interview on 1/16/2022 at 2:29 p.m. with the Staffing Coordinator (SC), in the PPE storage room, observed N95 respirator of a particular brand, size, and model. SC stated that particular N95 was the only approved brand size and model for use in the facility. SC stated that she assisted the DSD with staff files. SC stated the staff N95 respirator fitness examination form and history was not complete because it did not indicate which brand, size, and model but the facility ordered the same kind of N95 every time. SC added she was the one responsible for distributing and ordering PPEs for the facility. During an interview on 1/16/2022 at 2:45 p.m. with CNA 2, CNA 2 stated she could not remember if she was fit tested for the use of the N95 respirator. CNA 2 stated proper PPE while in the yellow zone included a N95 respirator and face shield and/or goggles, when in close contact or when going inside a resident's room staff must wear a gown and gloves. CNA 2 stated the importance of proper PPE was to protect CNA 2 or the resident from COVID-19. During a record review of the nursing staffing assignment and sign in sheet dated 1/16/2022, the forms indicated the following: 1. LVN 1 was assigned to work in the red zone. 2. LVNs 2, 3, and 4 and CNAs 1, 2, and 3 were assigned to work in the yellow zone 3. RN 1 was assigned to work in the yellow and red zone. During a record review of the Initial N95 Mask Respiratory Fitness Examination/ History (undated) for LVN 3 and CNA 1, the brand, size, and model was blank, and the information on who administered the fit testing and solution was also blank. The respirator fit test record indicating normal breathing and deep breathing, turning the head to the side, nodding the head up and down, bending over, reading rainbow passage, and sensitivity were blank. The Initial N95 Mask Respiratory Fitness Examination/ History for RN 1, LVN 1 and CNA 2 were not found. During an observation on 1/16/2022 at 3:10 p.m., LVN 4 was observed entering a yellow zone resident room wearing a N95 mask and a face shield but was not wearing a gown or gloves During a record review of LVN 4's Respiratory Fitness Examination/History dated 11/22/2021, indicated the respirator fit test record which included the fit test solution, brand, model, size and who conducted the fit testing was blank. There was no check on normal breathing, deep breathing, turning head to side, nodding head up and down, bending over, reading rainbow passage, sensitivity, the form did not indicate if LVN 4 passed or failed the N95 fit testing. During an interview on 1/16/2022 at 3:30 p.m. with RN 1, RN 1 stated that if the form was not complete, meant it was not done. RN 1 could not locate her fit testing record in her employee file. When asked how about LVN 1 and CNA 1 and 2's fit test records, RN 1 stated it was not in the binder and could not be found in any other binders or staff records. During an interview on 1/16/2022 at 3:45p.m. with RN 1, RN 1 stated when staff provide resident care and come into close contact with residents (within 6 feet or closer) staff must wear a full PPE, which included eye protection, a fit tested N95 respirator, a gown, and gloves. RN 1 stated that if the staff do not wear required the PPE when providing care or coming into close contact with residents, they can potentially spread COVID-19 to other residents throughout the facility, staff, visitors, and community. RN 1 stated it was important for N95 respirators to be fit tested to ensure the N95 did not have leaks, any leak of COVID-19 particles through to the wearer can be passed on to other resident, staff, and community. During a review of the COVID-19 Outbreak Notification Letter dated 1/14/2022, from the facility's Infection Preventionist (IP) and Unit Manager (UM), the notification letter indicated all staff were required to always wear a medical-grade surgical/ procedure mask while in the facility. A fit tested N95 respirator should be worn for the duration of the shift when working in the areas of the facility designated for residents with confirmed COVID-19 (red zone) and for residents in quarantine (yellow zone). Initial and annual N95 respiratory fit testing was required for all staff per the California Division of Occupational Safety and health (Cal/OSHA). During a review of the undated facility's Mitigation Plan, the Mitigation Plan indicated all staff would wear recommended PPE while in the facility per current Department of Public Health (CDPH) PPE guidance. Staff will be trained on proper donning (to put on) and doffing (to take off) procedures. Facility will continuously perform N95 fit testing for employees. Facility designee will conduct the medical clearance to proceed with N95 fit testing of employees. An approved fit tested N95 respirators with an exhalation valve can be used as protection and source control when there are no anticipated high velocity body fluids as per the Centers for Disease Control and Prevention (CDC), in which in case either a surgical N95 respirator should be used, or a face shield can be worn without compromising the fit of the respirator.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received all the necessary care and services to prevent pressure sore(s) from developing and deterioration. The facility failed to: 1. Ensure the licensed nurses assess Resident 1's skin tear, identified and documented skin tear location, notify the resident's physician and obtained treatment order for it. 2. Ensure Resident 1 did not develop a Stage II pressure ulcer ([PU] injuries to skin and underlying issue resulting from prolonged pressure on the skin) to a right buttock. On 2/24/2021 Resident 1 developed a PU to a right buttock that licensed nurses did not assess, did not notified the physician of it, and did not obtained treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Ensure Resident 1 did not develop undetermined (UTD) PU to sacrococcyx (base of the spine [backbone/tailbone]) area measured 7.0 centimeters ([cm] a unit of measurement) in width (measurement of something from side to side) by 7.0 cm in length (measurement of something from end to end) and failed to ensure the licensed nurses assessed this PU initially and continuously. This deficient practice resulted in Resident 1 developing a Stage II PU to sacrococcyx area measured 2.3 cm in length by 2.4 cm in width with 0.2 cm depth that increased in size to a 7.0 cm in length x 7.0 cm in width with scant (small) sanguineous drainage (discharge that contains both blood and serum [a clear yellow liquid] drainage), requiring a wound debridement (removal of damaged, dead or infected skin tissue from a wound) to promote wound healing which had the potential to result in further deterioration of the pressure ulcers and possible infections. Resident 1 was transferred to a general acute care hospital (GACH) and was hospitalized for seven days with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: A review of Resident 1's Admission Record indicated the resident was initially admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 12/15/2020, indicated Resident 1 was totally dependent on staff for activities of daily living and required extensive assistance with bed mobility with a one-person physical assistance and extensive assistance with two-persons physical assistance for toileting, dressing, eating and personal hygiene. The MDS indicated Resident 1 was at risk for developing PU and skin injuries. The MDS did not indicate Resident 1 had any ulcers, wounds, and skin problems. The MDS indicated Resident 1 received skin treatment including pressure reducing device (are used as part of the treatment to reduce or relieve the pressure on the ulcer), applications of nonsurgical dressings, ointments, and medications, and was on turning and repositioning program. A review of Resident 1's Braden Scale (an assessment tool for predicting pressure sore risk) Pressure Sore Risk Assessment (PSRA), dated 10/21/2020 indicated Resident 1 had a score of 18. According to the Braden Scale Risk Assessment, a total score of 15 to18 represented a risk for a pressure sore development. A review of Resident 1's Daily Medicare Notes (DMN), indicated Resident 1's skin was intact, and the resident did not have any PU or skin break down on the following dates and times: 11/19/2020 at 3:40 p.m. 11/24/2020 at 3:14 p.m. 11/25/2020 at 3:03 p.m. 11/26/2020 at 2:57 p.m. 11/28/2020 at 5:07 p.m. 12/4/2020 at 5:06 p.m. 12/5/2020 at 3:43 p.m. 1/28/2021 at 5:01 p.m. A review of Resident 1's Daily Medicare Notes (DMN), indicated Resident 1 had a skin tear of an undocumented location and there were no changes in Resident 1's skin condition on the following dates: 12/1/2020 at 4:49 p.m. 12/2/2020 at 4:53 p.m. 12/3/2020 at 5 p.m. A review of Resident 1's Nursing Progress Notes (NPN) indicated there was no documented evidence of Resident 1's skin tear (area not documented) in the NPN on 12/1/2020, 12/2/2020 and 12/3/2020. During a concurrent interview and record review on 12/10/2021 at 1:50 p.m., of Resident 1's Braden Scale PSRAs, dated 10/21/2020 and 3/16/2021, ADON stated the Braden scale should be completed weekly for one month for residents identified with skin issues including a skin tear, pressure ulcers, or any open skin areas. ADON stated it was not done for Resident 1. A review of Resident 1's recapitulated ([recap] a summary) physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's DMNs, dated 2/3/2021 timed at 8:07 p.m. and dated 2/12/2021 timed at 2:12 p.m., indicated Resident 1's skin was intact and did not have any PU or skin break down. A review of Resident 1's NPNs, dated 1/9/2021 through 4/20/2021, did not indicate Resident 1 had any skin break down or pressure ulcers. A review of Resident 1's Situation, Background, Assessment and Recommendation ([SBAR] an internal communication of critical information that requires immediate attention and action) form dated 2/21/2021, timed at 12:51 p.m., the indicated Resident 1 developed a moisture associated skin damage ([MASD] injury to the skin due to prolong exposure to moisture and its contents, including urine, stool, perspiration, wound exudate, [MEDICATION(S)], or saliva) to the right buttock. A review of Resident 1's Change of Condition (COC) note, dated 2/24/2021 and timed at 11:36 p.m., indicated Resident 1 had MASD and a PU of the right buttock. A review of Resident 1's medical record indicated there was no documented evidence the licensed nurses conducted an ongoing assessment of a PU to a right buttock. In Resident 1's medical record was no documented information available to demonstrate that the resident's physician was notified of a PU to the right buttock, the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review on 12/10/2021 at 1:31 p.m. and 1:48 p.m., of Resident 1's COC note dated 2/24/2021 and timed at 11:36 p.m. and a DMN dated 12/1/2020 and timed at 4:49 p.m., 12/2/2020 timed at 4:53 p.m., and 12/3/2020 timed at 5 p.m., the Acting Director of Nursing (ADON), stated the COC indicated Resident 1 had MASD to the right buttock. The ADON stated upon discovery of Resident 1's skin tear, MASD, and the PU the licensed nurses should have developed a care plan for it and notified Resident 1's physician and the treatment nurse (TN) to obtain a treatment order. A review of Resident 1's Braden Scale (PSRA), dated 3/16/2021 and timed at 12:35 p.m., indicated Resident 1was scored 11. According to the Braden Scale Risk Assessment, a total score of 10 thru 12 represented a high risk for developing a pressure ulcer. A review of Resident 1's MDS, dated [DATE], indicated Resident 1's care level remained the same as the previous MDS dated [DATE]. The MDS indicated Resident 1 was at risk for developing PU/PI and skin injuries and the MDS did not indicate Resident 1 had any ulcers, wounds, and skin problems. The MDS indicated Resident 1 received skin treatments including pressure reducing device, turning, and repositioning program, application of nonsurgical dressings, applications of ointments, and medications. A review of Resident 1's revised care plan, dated 3/17/2021 and titled, Resident at risk for development of pressure ulcer/skin breakdown due to: need total assistance in bed mobility, need total assistance in transfer, frequent incontinence (lack of voluntary control over urination or defecation) bowel and bladder (B/B) weight loss and nutrition, one of the interventions included for staff to assist Resident 1 in turning and repositioning when needed, identify risk factors for development of pressure sores, provide skin care and weekly skin checks. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's care plan, dated 3/24/2021 and titled, Non-pressure Non-surgical wound, right buttock MASD, indicated for licensed nursing staff to assess Resident 1's wound and obtain treatment orders from the physician. A further review of this care plan indicated for the licensed nurses to follow the wound treatment protocol, monitor for signs and symptoms of infection including redness, swelling, warmth, pain, type of drainage, refer to the physician any changes in PU condition, monitor weekly PU progress, refer to rehabilitation (rehab) for wound management if needed, apply [MEDICATION(S)] powder and barrier cream as ordered and leave PU open to air daily for 30 days. A review of Resident 1's Wound Management (WM) note, dated 4/21/2021 and timed at 1:57 p.m., indicated Resident 1's was assessed, and the resident had a Stage II measured 2.3 cm in length by 2.4 cm in width by 0.2 cm in depth Stage II PU on the sacrococcyx area. Stage II PU on the sacrococcyx area was described as having a light amount of serosanguineous drainage with 100 percent (%) of tissue granulation (the development of new skin tissue) and redness of the surrounding skin. A review of Resident 1's NPN, dated 8/23/2021 and timed at 3:55 p.m., as a late entry, indicated on 4/21/2021 at 3:53 p.m., Resident 1's sacrococcyx PU Stage II (shallow opening of the skin tissue with the presence of a blister) was reassessed as undetermined (UTD). According to the article titled, UTD Ulcers, a pressure ulcer covered with slough (a mass of dead tissue separating from an ulcer; usually yellow, tan, gray, green or brown in color) or eschar (dead tissue that sheds or falls off from the skin, usually from a pressure ulcer wounds and brown or black in color) are unstageable. The base of the ulcer needs to be visible to properly stage the ulcer, though, as slough and eschar do not form on Stage I pressure injuries or Stage II pressure ulcers, the ulcer will reveal either a Stage III or Stage IV pressure ulcer. https://www.woundsource.com/patientcondition/pressure-ulcers-unstageable. According to the article titled, Unstageable Full Thickness Skin or Tissue Loss - Depth Unknown (UTD), unstageable PU is a full thickness tissue loss in which actual depth of the ulcer is completely obscure by slough and/or eschar in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Stage III or IV. Stable (dry, adherent, intact without [CONDITION(S)] or fluctuance) eschar on the heels serves as the body's natural biological cover and should not be removed http://bhwound.com/term/npuap-pressure-ulcer-stages/ A review of Resident 1's Wound Care Specialist (WCS) Nurse Practitioner ([NP] a nurse with additional education and training in a specialty area) note, dated 4/29/2021, indicated WCS NP assessed Resident 1's PU to sacrococcyx area as UTD pressure ulcer and measured 7.0 cm in length by 7.0 cm in width. In this note WCS NP documented Resident 1's PU had 80 % of yellow tissue with 20 % granulation and light serosanguinous drainage that required debridement [removal of damaged, dead or infected skin tissue from a wound to help a wound heal) and had necrotic (tissue death) subcutaneous (under the skin) tissue]. During a concurrent interview and review on 12/10/2021 at 2:33 p.m. of Resident 1's WM note, dated 4/21/2021 and timed at 3:53 p.m., with the Licensed Vocational Nurse (LVN 1), stated that on 4/21/2021 he reassessed Resident 1's MASD and performed an initial assessment of Resident 1's sacrococcyx wound, but could not locate his initial note after he searched Resident 1's electronic clinical records for 15 minutes. LVN 1 stated he could not recall and was unsure if he completed an initial assessment of Resident 1's sacrococcyx PU. LVN 1 stated, residents with UTD wounds meant the depth of the wound was unknown and it could be deep to the muscle and/or to the bone. LVN 1 was asked how he determined Resident 1 had a Stage II sacrococcyx PU after he documented Resident 1's wound depth was measured at 0.2 cm. LVN 1 stated he could not recall and stated Resident 1's wound depth was unmeasurable. LVN 1 stated he could not recall if he notified the Wound Care Specialist about Resident 1's sacrococcyx PU wound. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order included for Resident 1 to receive Zinc (an essential mineral that helps maintain skin health) tablets 220 milligrams ([mg] a unit of measure), daily, through GT or 30 days for wound healing. A review of Resident 1's WCS NP note, dated 5/6/2021, indicated Resident 1 was assessed and had an unstageable PU to the sacrococcyx are measured 7.3 cm x 7.3 cm with 30 % of yellow tissue with 10 % granulation, and 60 % brownish/black slough (shedding of the outer layer of skin) with moderate serosanguinous drainage. According to the WCS NP note, Resident 1's wound was darker in color and it was recommended by the WCS NP for Resident 1 to be transferred to the GACH for evaluation of the PU wound. A review of Resident 1's NPN, dated 5/6/2021 at 4:58 p.m., indicated Resident 1 was transferred to the GACH. A review of Resident 1's GACH Emergency Department (ED) history and physical (H/P), dated 5/6/2021 and timed at 3:38 p.m., indicated Resident 1 arrived at the ED from a skilled nursing facility (SNF) with a complaint of a Stage IV pressure ulcer to the sacrococcyx and altered mental status (AMS). The note indicated Resident 1 was assessed having an erosion (a breakdown of the outer layers of the skin) of the right malleolus (bony projection with a shape likened to a hammer head, on either side of the ankle), measured 2.0 cm in size, with a scab of the left malleolus, and a Stage IV pressure ulcer in the supra-gluteal cleft (between the buttocks that runs from just below the sacrum to the perineum) measured approximately 7.0 cm by 4.0 cm in size with erosion extending to bone. A review of the GACH Infectious Disease ([ID] a physician that treats acute and chronic infections caused by bacteria, parasites, fungi and viruses, including COVID-19) Consultant note, dated 5/7/2021 and timed at 12 p.m., indicated Resident 1 was septic possibly due to the PUs and received empiric (medical treatment or therapy based on experience; specifically therapy begun on the basis of a clinical educated guess in the absence of complete or perfect information) [MEDICATION(S)] and [MEDICATION(S)] (antibiotics used to treat infections). A review of the GACH Wound/Plastic Surgery Consultant note, dated 5/10/2021 and timed at 1:39 p.m., indicated due to Resident 1's hemoglobin (Hgb) and hematocrit ([H/H] hemoglobin is a protein in red blood cells and hematocrit is a measurement of the amount of red blood cells as related to total blood cell count) being low, the resident was not a candidate for bedside surgical debridement at that time. In this note the consultant documented Will consider debridement once Hgb greater than 8 for over 48 hours. Plastic surgery/wound care team was consulted for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the facility's undated policy and procedure (P/P) titled, Skin Care Management, indicated patients identified as a risk for development of pressure ulcers will have a plan of care and interventions included in the care plan. The P/P indicated when a PU is identified, the licensed nurse would document in the progress notes on the Weekly Pressure Ulcer Record, and document in the daily monitoring of all pressure ulcers to include status of the dressing, surrounding skin, presence of possible complications and pain using the Daily Monitoring Pressure Ulcer Record. The P/P indicated patients with newly identified or known pressure ulcers will be assessed by the IDT upon notification and weekly thereafter, and a care plan would be developed, implemented, evaluated, and re-evaluated to treat actual pressure ulcers and further reduce further pressure ulcers.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received a thorough skin assessment and was provided services to reduce skin breakdown and prevent pressure ulcer ([PU] injuries to skin and underlying tissue resulting from prolonged pressure on the skin) development. Resident 1 developed an unstageable (full thickness tissue loss in which actual depth [distance from the top to the bottom] of the ulcer is completely obscured by slough [yellow, tan, gray, green, or brown] and/or eschar [tan, brown, or black] in the wound bed) PU/PI of the right heel that required a wound consultation (a specialist in wounds). This deficient practice resulted in Resident 1 developing a 4.5 centimeter ([cm] a unit of measurement) in length ([L] measurement of something from end to end) x 4.1 cm in width ([W] measurement of something from side to side) to the right heel PU/PI wound with necrotic (death tissue) subcutaneous (under the skin) tissue requiring several wound debridement (removal of damaged, dead or infected skin tissue from a wound), developed gangrene (tissue death due to a lack of blood flow or a serious bacterial infection) of the right foot and a right fifth toe amputation (surgical removal of part of the body part). Findings: During a review of Resident 1's Admission Record (face sheet), the face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS), a standardized resident assessment and care-screening tool, dated 5/27/2021, the MDS indicated Resident 1's cognition (ability to reason and think) was severely impaired, required extensive assistance with a two-person physical assist with toileting and personal hygiene and a one-person assist with bed mobility, transfers, and dressing. The MDS indicated Resident 1 was at risk for developing PU/PI and skin injuries but had no PU/PUI. During a review of Resident 1's quarterly Braden Scale (an assessment tool for predicting pressure sore risk) Pressure Sore Risk Assessment (PSRA), dated 2/24/2021, the PSRA indicated Resident 1 was assessed as having a score of 17 (scores of 15-18 represented at risk). Resident 1's assessments, did not indicate a PSRA was completed for the month of 5/2021 or anything after 2/2021. During a review of Resident 1's care plan titled, Pressure Ulcer Risk, dated 3/15/2021, the care plan indicated Resident 1 was at risk for development of pressure ulcer/skin breakdown due to: need assistance in bed mobility, need assistance in transfer, frequent incontinence in bowel and bladder (B&B.), weight loss, malnutrition and healed pressure injuries at risk. The staffs' interventions indicated to apply A&D ointment (moisturizing ointment that protects the skin) to Resident 1's left heel every day for skin maintenance, assist in turning and repositioning if needed, float heels while in bed, identify risk factors making residents at risk for development of pressure sores, pressure relieving/reducing device in bed or in wheelchair, pressure reducing therapeutic mattress, provide skin care and weekly skin checks. During a review of Resident 1's Weekly Summaries, dated 5/7/2021, 5/14/2021, 5/21/2021, 5/28/2021, 6/4/2021 and 6/11/2021 and 4/6/2021, the Weekly Summary indicated Resident 1's skin turgor was fair and did not have documented evidence of any pressure ulcers/pressure injury ([PU/PI]. During a review of Resident 1's Nurse's Progress Note (NPN), dated 6/9/2021 and timed at 2:17 p.m., the NPN indicated Certified Nurse Assistant (CNA 1) reported Resident 1 had redness to the right heel and was assessed by the Treatment Nurse. The NPN indicated both of Resident 1's legs were elevated on a pillow and the staff was waiting for a call back from Resident 1's physician. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's NPN, dated 6/11/2021 through 6/17/2021, the NPN indicated Resident 1 had redness to the heel. The NPN did indicate Resident 1 had any open areas of the skin. During a review of Resident 1's Wound Management Detail Report (WMDR), dated 6/18/2021 and timed at 12:54 p.m., with an observation date recorded on 6/9/2021 at 12:51 p.m., the WMDR indicated Resident 1 developed a 2.2 cm in L, x 2.4 cm in W, Stage I (intact or unopened skin with redness) PU/PI of the right heel with redness. The WMDR indicated Resident 1's physician was notified and an order Resident 1 to keep right heel afloat on pillows. During a review of Resident 1's WMDR, dated 6/18/2021 and timed at 4:58 p.m., the WMDR indicated Resident 1's wound was unstageable with deep tissue and measured 3 cm x 2.2 cm, 100 percent (%) granulation (the development of new skin tissue) and had a purplish discoloration. The WMDR indicated Resident 1's physician was notified of the resident's right heel wound had a change in color and new treatment orders were given. During a review of Resident1 1's NPN, dated on 6/18/2021 and timed at 5:02 p.m., the NPN indicated Resident 1's right heel had a change in color, the physician was notified, and new treatment orders were given to the staff. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Wound Care Specialist (WCS) Nurse Practitioner ([NP] a nurse with additional education and training in a specialty area) note, dated on 6/24/2021, the WCS note indicated Resident 1 had a 4.5 cm x 4.1 cm unstageable (unable to measure open skin sores) PU/PI to the right heel that required debridement (removal of damaged, dead or infected skin tissue from a wound to help a wound heal) and had necrotic subcutaneous tissue. The WCS note indicated Resident 1 had a 3 cm x 2 cm unstageable PU/PI with 10 % slough, 40 % granulation and 50 % purple (discoloration) tissues to the left heel. During a review of Resident 1's WCS note, dated on 6/30/2021, the WCS note indicated Resident 1's wound to the left heel was classified as a Stage III (full thickness or skin loss involving subcutaneous tissue, death of the tissue) PU/PI and the resident's right heel with necrotic subcutaneous tissue required debridement. During a review of Resident 1's NPN, dated on 7/22/2021 and timed at 3:37 p.m., the NPN indicated Resident 1's right 5th metatarsal (toe), right 5th great toe had discoloration and the vascular specialist (a medical doctor that treats disease and conditions of the arteries and veins) was notified. During a review of Resident1 1's NPN, dated on 7/28/2021 and timed at 3:40 p.m., the NPN indicated Resident 1's had skin discoloration to the right foot and toes and an open wound to the 5th toe. The NPN indicated Resident 1's foot was cool upon touch with a reddened appearance and a scanty (small) serosanguinous (blood and clear body fluid) drainage. The NPN indicated Resident 1 was transferred to the general acute care hospital (GACH) for further evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 1's Interdisciplinary team ([IDT] a group of healthcare professionals developing care needs that meets the resident's needs and goals was conducted) notes, dated 6/1/2021, the IDT note indicated there were no concerns regarding Resident 1's skin. Upon further review of Resident 1's clinical record, there was no IDT meeting and/or note from 6/9/2021 through 8/4/2021. During a review of Resident 1's GACH Emergency Department (ED) progress notes dated on 7/28/2021, the GACH progress note indicated Resident 1 had an open wound to the right toe that gradually worsened over the past week and required an inpatient stay. The GACH records indicated Resident 1 had gangrene to the right foot. During a review of Resident 1's GACH progress note dated 8/9/2021, the GACH progress note indicated Resident 1 had necrosis and ulcer to the right 4th and 5th toes and a chronic PU/PI to the right heel. The GACH note indicated Resident 1 underwent an amputation of the right 4th and 5th toes. During an interview on 7/1/2021 at 9:54 a.m. Family Member 1 (FM 1) stated during a visit at the facility in 6/2021, Resident 1 had bleeding open wounds that were without a bandage and had socks. During an interview on 8/12/2021 at 11:40 a.m. Certified Nursing Assistant 1 (CNA 1) stated on 6/9/2021, she informed Licensed Vocational Nurse 1 (LVN 1) and the Treatment Nurse (TN) that Resident 1's skin on the right heel was open, peeling and purple and she observed blood on the bed sheet. CNA 1 stated she was only assigned to care for Resident 1 on 6/9/2021. During a concurrent interview and review of Resident 1's wound care treatment records on 8/12/2021 at 12:07 p.m., TN stated on 6/9/2021, he was made aware of Resident 1's right heel wound by the licensed nurse. TN stated he assessed Resident 1's right heel and Resident 1's right heel had redness and was assessed as a Stage 1 PU/PI. TN stated he was off work after 6/9/2021 and returned to work on 6/14/2021. TN was asked why he documented on WMDR, 9 days later, the TN stated he forgot to document Resident 1's right heel wound changes on 6/9/2021. TN stated when he returned to work on 6/14/2021, he did not notify Resident 1's physician about Resident 1's right heel and he did not call the physician for treatment orders. TN stated he was responsible for notifying Resident 1's physician for any wound changes. TN stated he did not call Resident 1's physician because he did not see that Resident 1's wound was bad. The TN stated on 6/18/2021 he notified Resident 1's physician due to Resident 1's right heel had a change in color. TN stated the Wound Specialist made weekly visits to the facility on Wednesdays or Thursdays. TN stated he was not aware how Resident 1's Stage I right heel became a necrotic in 15 days. TN stated he notified the Wound Specialist about Resident 1's right heel on 6/24/2021. During a review of Resident 1's WCS noted dated on 6/24/2021, TN stated he was trained do perform wound care treatments by the facility's previous TN and did not receive any wound care certification. During a concurrent interview and review of Resident 1's clinical records and the facility's policy titled, Skin Care Management on 8/12/2021 at 3:30 p.m., the Director of Nursing (DON) stated he received pictures of Resident 1's right heel on 6/18/2021 by FM 1 by email. The DON was asked about the facility's policy which indicated a care plan and an IDT should be conducted upon new wounds, pressure ulcers. The DON stated Resident 1 did not have an IDT on 6/9/2021 and Resident 1 had an IDT dated on 6/1/2021 and 8/1/2021. According to the facility's policy, the staff should have documented about Resident 1's wound care and progression daily. The DON stated we really missed a lot and messed up. During a review of the facility's undated policy and procedure (P/P) titled, Skin Care Management, the P/P indicated patients identified as a risk for development of pressure ulcers will have a plan of care and interventions included in the care plan. The P/P indicated when a PU is identified, the licensed nurse would document in the progress notes on the Weekly Pressure Ulcer Record, and document in the daily monitoring of all pressure ulcers to include status of the dressing, surrounding skin, presence of possible complications and pain using the Daily Monitoring Pressure Ulcer Record. The P/P indicated patients with newly identified or known pressure ulcers will be assessed by the IDT upon notification and weekly thereafter, and a care plan would ne developed, implemented, evaluated and re-evaluated to treat actual pressure ulcers and further reduce further pressure ulcers.

Based on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from physical abuse from a Certified Nursing Assistant (CNA 1). Resident 1 stated CNA 1 grabbed her right arm and provided care to her by changing her diaper after the resident refused to be changed. This deficient practice resulted in Resident 1 sustaining a bruise (occurs when an area of skin has suffered trauma; causes blood vessels to burst, trapping blood below the skin's surface) with slight swelling (abnormal enlargement of a body part) and pain to the right arm. This deficient practice had the potential to expose other residents to abuse. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE], with an original admission date of [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 3/27/18, indicated Resident 1 was not able to understand and be understood by others. Resident 1's cognition (thought process) was severely impaired. According to the MDS, Resident 1 required a one-person physical assist with bed mobility, transferring to and from bed, chair or a standing position, dressing, toilet use, personal hygiene, and was frequently incontinent (inability to control) of bowel and bladder. A review of Resident 1's care plan, dated 9/27/17, indicated Resident 1 required extensive assistance with dressing and toileting. The staff's interventions indicated to inform the resident prior to rendering care, explain the procedure, encourage participation, identify situations that might cause behavioral problems and assist the resident in resolving those issues by approaching the resident calmly, unhurriedly and explain all procedures and the reasons. A review of Resident 1's care plan, dated 3/27/18, indicated Resident 1 rejected care. The staff's interventions indicated the following: encourage the resident to verbalize feelings, offer empathy (ability to understand and share the feelings of another), identify situations that might cause behavior, assist the resident in resolving the issues and use a calm and unhurried approach. A review of Resident 1's Progress Notes, dated 5/1/18 and timed at 7 a.m., indicated Resident 1 was noted with a discoloration (change in skin color) on the forearm (the part of the arm between the elbow and the wrist). Resident 1 stated that early morning, the nurse grabbed her arm when she refused to be changed. A review of a Situation Background Assessment and Recommendation ((SBAR) an internal communication) report, dated 5/1/18 and timed at 12:08 p.m., indicated Resident 1's right wrist and forearm was slightly swollen with reddened skin discoloration sustained after being handled. A review of the facility's Incident/Accident Post Review record, dated 5/1/18, indicated Resident 1 had a right forehand discoloration and verbalized that the early morning nurse held her hand to change her. The report indicated Resident 1 admitted she was upset about being changed after refusing. A review of the facility's Investigation Summary report, dated 5/1/18, indicated CNA 2 observed Resident 1's right hand to be discolored. CNA 2 asked what happened and Resident 1 told her that CNA 1 had grabbed her hand. The report indicated CNA 1 stated that on 5/1/18, Resident 1 sat on her bed pulling the curtain from side to side trying to hit her roommate (Resident 2). CNA 1 indicated Resident 1 was hitting the wheelchair next to her bed. According to the report, Licensed Vocational Nurse 1 (LVN 1) stated on 5/1/18, CNA 2 notified her of Resident 1's forearm discoloration. LVN 1 stated Resident 1 verbalized that CNA 1 forcefully held her forearm when she refused to be changed. LVN 1 confirmed that Resident 1's right forearm was discolored and slightly swollen. On 5/9/18, at 7:30 a.m., during a concurrent observation and interview and in the presence of CNA 2, Resident 1 was observed in bed with a bruise covering a large portion of the lower aspect of the resident's right arm. Resident 1 stated CNA 1 tried to change her, but she refused because she was dry and did not need to be changed. Resident 1 stated CNA 1 grabbed her arm forcefully and then changed her. Resident 1 stated that her right shoulder hurts after being pulled and her right arm was bruised. Resident 1 stated her right arm was hurting when CNA 1 grabbed her arm, because CNA 1 was strong. CNA 2 stated she took care of Resident 1 the day before and Resident 1 did not have any bruises. CNA 2 stated the bruise looked like a hand grip. On 5/9/18 at 8:13 a.m., during an interview, Registered Nurse 1 (RN 1) stated that on 5/1/18, Resident 1's right arm was red discolored with a hand mark. RN 1 stated Resident 1 reported that CNA 1 forcefully grabbed her right hand to change her after she refused to be changed. RN 1 stated that she believed Resident 1's complaint of CNA 1 grabbing her hand. RN 1 stated Resident 1 resisted care at times and was grabbed by CNA 1. On 5/9/18 at 8:40 a.m., during an interview, the Director of Nursing (DON) stated Resident 1 reported that CNA 1 grabbed her hand when the resident did not want to be changed. The DON stated she observed Resident 1's right hand to be red and discolored. On 5/9/18, at 8:50 a.m., during an interview, the facility's administrator (ADM) stated an investigation was conducted for Resident 1's allegation of abuse. On 5/9/18, at 9:06 a.m., during an interview, CNA 1 stated Resident 1 constantly hit her right arm against a wheelchair that was next to her bed. CNA 1 stated that the discoloration on Resident 1's right arm resulted from the resident repeatedly hitting the arm against the wheelchair. CNA 1 added that she continued to provide care to Resident 1 as the resident repeatedly would hit her right arm on the wheelchair. CNA 1 added that she did not remove the wheelchair because she wanted to change the resident. On 5/9/18, at 9:27 a.m., during an interview, the social services director (SSD) stated Resident 1 reported that on 5/1/18, CNA 1 grabbed both of her hands because she did not want to be changed. The SSD stated Resident 1 had repeated the same story each time she interviewed the resident. According to the SSD, the bruising on Resident 1's right forearm was consistent with a hand grip. A review of the facility's policy and procedure titled, Abuse and Neglect Prohibition, with a revised date of 5/2013, indicated each resident had the right to be free from mistreatment and abuse. Physical abuse is defined as hitting, slapping, pinching, and kicking. The policy also indicated the facility's staff would be screened for and trained on abuse prevention and reporting. A review of the facility's policy titled, Abuse and Neglect Prohibition California Facility Addendum, dated 7/1/17, indicated the facility would provide quality care for residents and take reasonable steps to prevent mistreatment, abuse and neglect. This policy also indicated physical abuse included: assault, battery and unreasonable physical constraint. A review of the facility's undated policy titled, Freedom from Abuse and Exploitation, indicated the resident had the right to be free from abuse and corporal punishment. It also indicated the facility would not use verbal, mental, physical abuse or corporal punishment on any resident. A review of an undated policy titled, Resident Rights, indicated the facility must provide care to the resident based on the comprehensive assessment, care plan and the resident's preferences and support each resident's choice.

Based on interview and record review, the facility failed to follow its policy and a resident's plan of care to ensure supervision close to the nurse's station and maintain assistive devices in an operable functioning condition for one of three sampled residents (Resident 1). Resident 1, who had a high risk for falls with a history of falls, got out of bed unsupervised without the bed alarm activating and fell through a glass door. This deficient practice resulted in Resident 1 sustaining serious physical injuries requiring an emergency transfer to the general acute care hospital (GACH). Resident 1's injuries consisted of a 1.5 foot piece of broken glass entering into the right upper back and exiting the resident's right middle lower back area, which resulted in Resident 1 being admitted to the GACH for 19 days, requiring pain medications, blood [MEDICAL CONDITION] and intubation (tube placed in the airway to maintain air exchange), with mechanical ventilation (machine to assist in breathing). Resident 1 underwent an emergency surgical procedure to remove the penetrating glass and repair the multiple lacerations (deep cut) as follow: 1. A 20 centimeters (cm) laceration to middle back. 2. A 6-8 cm. laceration to mid-line upper back. 3. Two 5-cm. lacerations to the left lower back. 4. A 6 cm. laceration to the left midline lower back. 5. A 5 cm. laceration to the left wrist. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was initially admitted to the facility on [DATE] and recently readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), an assessment and care-screening tool, dated 1/4/18, indicated the resident was able to understand and be understood by others. The MDS indicated Resident 1 required one-person physical assist in transferring to and from the bed, chair or a standing position, walking in the room and with personal hygiene. According to the MDS, Resident 1 had a history of [REDACTED]. A review of Resident 1's History and Physical (H/P) report, dated 1/23/18, indicated the resident had the capacity to understand and make decisions. A review of care plan, dated 6/30/18, indicated Resident 1 was found on the bathroom floor. The staff's interventions indicated the staff would encourage and remind the resident to ask for help; address identified risk factors from the fall risk assessment; provide assistance in transfers and mobility; and identify the time of the day Resident 1 was most likely to fall. A review of a Fall Risk Meeting Note, dated 7/2/18, indicated the staff would provide Resident 1 with a hazard free environment at all times and anticipate the resident's toileting needs. A review of an MDS, dated [DATE], indicated Resident 1's condition changed and required two or more staff's assistance in mobility and care. According to the MDS, the resident used a walker and wheelchair for mobility and was occasionally incontinent (inability to control) of bowel and bladder. A review of a Nursing Daily Medicare Notes/Change of Condition Note, dated 7/15/18 and timed 10:29 p.m., indicated the resident had a fall on 6/30/18 resulting in a skin tear with discoloration and bruising. The note indicated the staff's interventions included providing the resident with a low bed, floor mats, safety alarm, bilateral side rails while in bed and to monitor the resident's whereabouts. A review of a Progress Note, dated 7/9/18 and timed at 1:57 p.m. indicated Resident 1 lost his balance and fell . A review of a care plan titled Actual Fall with No Injury, dated 7/9/18, indicated Resident 1 had an actual fall. The staff's interventions indicated the staff would frequently remind the resident to use the call light; re-evaluate the resident for non-skid shoes/socks; place on a toileting program and provide frequent visual checks. A review of an invoice form, dated 7/12/18, indicated the facility ordered a pair of nonskid slipper socks and special shoes for Resident 1. A review of a Fall Risk Data Collection, dated 7/12/18 and timed at 12:12 p.m., indicated Resident 1 had a score of 14 (10 or greater = high risk for falls). The report indicated Resident 1 had one to two (1-2) falls within the past 3 months; required consistent assistance; had a gait/balance problem and was receiving one or more medications that had the potential to cause falls (antihypertension and antidepressants). A review of another progress note, dated 7/12/18 and timed at 4 p.m., indicated Resident 1 sustained an opened wound to the left forearm just below the elbow. A progress note, dated 7/29/18 and at timed 2:20 p.m., indicated the charge nurse heard a sudden noise, like breaking glass, from the back station. Upon arrival to Resident 1's room, the resident was found lying on a broken glass door on the floor. According to this note, the resident was bleeding from the lumbar (lower back) area and had lacerations to both forearms. A review of a Situation Background Assessment and Recommendation (SBAR (communication form)), dated 7/29/18 and timed at 2:20 p.m., indicated Resident 1 had a fall that resulted in an injury. According to the SBAR, the resident had a laceration with a protruding foreign object (glass) on the right scapula (shoulder) and was bleeding from the back with cuts on both of the forearms. Resident 1 was whining, gasping, moaning, groaning and complaining of pain to the back and upper extremities. According to the SBAR, Resident 1 was transferred to the GACH at 2:50 p.m. A review of the GACH's Initial Physician Contact report, dated 7/29/18 and timed at 3:18 p.m., indicated Resident 1 was admitted to the GACH on 7/29/18 at 2:58 p.m., with a 1.5 foot glass in the right upper back that had exited the resident's right middle lower back. According to this report, Resident 1 was cold, pale and sweating and the vital signs were as follows: low blood pressure (B/P) ranged 49/10 to 91/56 (normal reference range (NRR)= 120/80-140/90), elevated pulse at 125 beats per minute (NRR =80-100) and respirations 24 (NRR =14-20). This report indicated the resident was in distress and in critical condition, unstable and required an emergency surgery. A review of a Surgical Intensive Care Unit (SICU) note, dated 7/30/18, indicated the following: the glass on Resident 1's back was removed, and the resident received two (2) units of red blood cells ((RBCs) blood cells that carries oxygen from the lungs to the all the body), 2 units of fresh frozen plasma ((FFP) a blood product that helps with blood clotting), one (1) unit of platelet ((plt) small blood cells that help prevent bleeding). It also indicated Resident 1 had surgical procedures to repair a twenty (20) centimeter (cm) middle line back laceration, 6-8 cm middle line upper back laceration near the end of the cervical spine (neck), 2 five (5) cm left lower back laceration, a six (6) cm left midline lower back laceration and a 5 cm left wrist laceration. This report indicated Resident 1 was intubated (tube placed in the airway to maintain air exchange), sedated and had an episode of low systolic blood pressure ((SBP) higher BP reading when the heart pumps blood to the rest of the body. NRR=120-140), of 60-70. According to this report, the resident had an estimated blood loss (EBL) of one hundred (100) cubic centimeters (cc), during surgery and had to receive an additional 2 units of RBC making a total of 4 units of RBCs. A review of the GACH's Discharge Summary report, dated 8/18/18 and timed 1:39 p.m., indicated the resident was admitted on [DATE] and discharged back to the facility on [DATE] (19 days), with a penetrating back wound. On 8/3/18, at 3:04 p.m., during an interview, CNA 1 stated that Resident 1 had an unsteady gait, was at risk for falls and required assistance to ambulate. CNA 1 stated that on 7/29/18, Resident 1 fell through the balcony door. According to CNA 1, the resident had a piece of broken glass penetrating through his back and was bleeding profusely from the site. CNA 1 stated Resident 1's bed alarm did not sound when the resident got out of his bed. On 8/3/18, at 3:09 p.m., during an interview, CNA 2 stated Resident 1's gait was unsteady and required frequent monitoring. CNA 2 added that the resident did not have floor mats to prevent injuries from falls, as indicated in the resident's plan of care. At 3:27 p.m., on 8/3/18, during an interview, Resident 1's roommate, Resident 4, stated that on 7/29/18, Resident 1 got out of the bed, but the alarm did not make any sound/noise and he was wobbly as he walked to the toilet. Resident 4 stated that Resident 1 fell on his back, through the balcony glass door. Resident 4 also stated that Resident 1 was not wearing shoes when he got out of bed. On 8/22/18, at 11:43 a.m., during a telephone interview, Registered Nurse 1 (RN 1) stated that after Resident 1's first fall incident on 6/30/18, a bed alarm, low bed, and floor mats were ordered for the resident. RN 1 stated that after the second fall, on 7/9/18, the resident was supposed to be moved closer to Station 2 for close monitoring. According to RN 1, the bed alarm did not sound on 7/26/18, when the resident fell for the third time. RN 1 stated there was a large piece of broken glass in the resident's back and a lot of bleeding. RN 1 stated that the glass was left in Resident 1's back when the paramedics transferred the resident to the GACH. A review of the facility's floor plan indicated Resident 1 was not close to the nurse's station, as per the plan of care for close supervision. A review of a policy titled, Fall Prevention, with a revision date of 8/2013, indicated the purpose of the policy was to reduce the number of fall incidents and help minimize the risk of injuries from falls. This policy indicated a fall prevention program would be developed for each resident to maintain the highest level of functioning based on the resident's needs. A review of a policy titled, Safety Supervision of Residents, dated 11/2017, indicated the facility would utilized safety, supervision and assistance of residents to prevent accidents.

Based on observation, interview, and record review, the facility failed to ensure a resident who was severely impaired in cognition received pain medication one hour prior to the treatment of [REDACTED]. As a result Resident 9 was observed flinching with facial grimacing, throughout the treatment, complaining of pain and that she was scared, however the licensed vocational nurse (LVN 1) did not stop to assess the need for intervention to relieve the resident's pain. Findings: On October 23, 2013 at 8:26 a.m., Resident 9 was observed lying in bed with contractures (abnormal shortening of the muscle tissue) to both lower extremities (legs). The resident was frowning, had facial grimaces and stated she was in pain. On October 23, 2013, at 10:36 a.m., Resident 9 was observed in bed crying, and when asked why she was crying she stated she was scared of the treatment. The licensed vocational nurse (LVN 1) was observed at the resident's bedside preparing for the resident's wound treatment. LVN 1 was observed during the treatment of [REDACTED]. When LVN 1 removed the soiled dressing from the resident's right foot, which was discolored almost black, the resident began to cry. She had facial grimacing, and she flinched pulling her foot away from the nurse. LVN 1 asked the resident if she was in pain, and the resident nodded her head. At that time LVN 1 stated that the resident had received the scheduled pain medication prior to her treatment, and LVN 1 continued treatment to the resident's foot. The resident was asked by the evaluator if the pain medication helped, and the resident stated "no." The resident was observed flinching throughout the treatment, but LVN 1 did not stop providing the treatment, and reassess the possible need for more intervention. A review of Resident 9's admission record indicated the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated September 28, 2013, indicated Resident 9's cognition was severely impaired and she was totally dependent on staff with her activities of daily living, except in eating. The resident was incontinent of bowel and bladder, had functional limitation in range of motion (full movement potential of a joint, usually the range of flexion and extension) to upper (arms) and lower extremities. The MDS also indicated the resident had pain frequently and the pain intensity was moderate, and had a Stage III pressure ulcer (full thickness skin loss involving damage or necrosis (death tissue) of subcutaneous tissue) and Stage IV pressure ulcer (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structure). A review of the physician's orders [REDACTED]. 1. [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) 5/325 one tablet by mouth one hour prior treatment. 2. Tylenol ([MEDICATION NAME]) 325 milligram (mg), take two tablets (650 mg) by mouth every four hours as needed for mild pain. Not to exceed three grams of [MEDICATION NAME] per 24 hours. 3. [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) 5/325 one tablet by mouth every six hours as needed for moderate to severe pain. On September 20, 2013, the physician had ordered to continue the Santyl ointment treatment to the resident's left hip, sacral area and right fifth metatarsal (little toe) pressure ulcers daily for 30 days. The Nurse's Notes (notes) dated October 23, 2013, at 7:35 a.m., indicated the charge nurse was called to Resident 9's room. The resident verbalized and/or complained of pain, with a pain rating scale of 7 over 10 (a scale from 0 to 10 with 10 being the worst pain a person could experience) to her lower extremities. The documentation indicated the resident received [MEDICATION NAME] 5/325 mg at 6 a.m., was repositioned with help, and the resident verbalized feeling better. The notes indicated at 8 a.m., the charge nurse went back to the resident's room, at which time the resident had no facial grimacing and was watching T.V. At 8:25 a.m., the charge nurse was called back into the resident's room. The resident complained of pain, was repositioned and the resident verbalized feeling better. There was no documentation of a pain assessment for the resident's level of pain or location of the pain before or after the resident was repositioned. At 8:50 a.m., the resident complained of pain and [MEDICATION NAME] 5/325 mg scheduled to be given one hour prior to treatment was given. However, the treatment observation was done on October 23, 2013, at 10:36 a.m., which was one hour, and 46 minutes after the pain medication was administered. When interviewed on October 24, 2013, at 10:50 a.m., LVN 1 admitted the resident's foot was painful to the touch. LVN 1 stated she should have stopped the treatment when the resident complained of pain during treatment, assess and check the resident's pain medication. According to the facility policy and procedure titled pain management revised date November 18, 2008, indicated to assess residents who have wound care orders for pain prior to the treatment, and to provide pain medication as ordered, at least 30 minutes before the treatment. Use the nonverbal indicators on nonverbal residents or residents lacking the mental capacity to use the pain rating scale. Record the follow-up observations (pain after interventions) one-hour post intervention. Record the location/cause of the resident's pain, and if there is an order to medicate the resident 30 minutes before the treatment, document the pain before the medication is given and during/after therapy.

Based on interview, and record review, the facility failed to ensure a resident who had dysphagia (difficulty or inability to swallow) was assessed, monitored, and reported to the physician after vomiting, for one of 12 sampled residents (22). This deficient practice had the potential that the resident may aspirate (choking, inflammation of lung and airway by breathing in foreign material also refers to the accidental sucking in of food particles or fluids into the lungs), and resulted in the delay of necessary care and treatment. Findings: According to the admission record Resident 22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated October 13, 2013, indicated Resident 22 usually understood others and was usually understood by others. The resident was totally dependent on staff for bed mobility, dressing, eating, personal hygiene and bathing. Resident 22 had the following physician's orders [REDACTED]. 1. October 7, 2013, a [MEDICATION NAME] 1.2 formula via enteral pump at 80 cubic centimeters per hour (cc/hr), to provide 1600 cc/1920 calories. On at 12 noon, off at 8 a.m., or until feeding ordered is consumed. 2. November 14, 2013, Mechanical soft with liquid diet for oral gratification (the satisfaction felt when the need for food). 3. December 4, 2013, speech therapist for continuation of dysphagia and speech language (treatment of [REDACTED]. treatment plan five times per week every day for eight weeks. A care plan was initiated on October 7, 2013, for tube feeding secondary to dysphagia. At risk for aspiration dehydration, nausea/vomiting, electrolyte imbalance, and abdominal discomfort. The interventions included to monitor for signs and symptoms of aspiration. Another care plan was initiated on October 15, 2013, for risk of abdominal pain or discomfort, nausea, and vomiting. The interventions included to check for abdominal distention, bowel sounds, color, and amount of vomitus, and to notify the physician if signs and symptoms not resolved by nursing intervention. The interventions also included [MEDICATION NAME] (used to prevent nausea and vomiting) 4 milligrams (mg) every eight hours via GT as needed. The resident's Meal Intake Records notes dated December 28, 2013, for the 3 p.m. to 11 p.m. shift indicated the resident vomited "this evening" and the charge nurse was made aware. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the resident's nurse's notes, nursing weekly summary, daily medicare notes/change of condition notes from December 28, 2013, to December 30, 2013, revealed there was no documented evidence that the resident was assessed and the physician was notified after the resident vomited. During an interview with registered nurse supervisor 1 (RNS 1), on December 31, 2013, at 3:30 p.m., while reviewing the resident's medical record, RNS 1 stated there was no documentation that the resident was assessed and her condition was monitored, and that the physician was notified after the resident vomited on December 28, 2013. During an interview with the director of nurses (DON), and RNS 1 on December 31, 2013, at 3:45 p.m., both stated they were not aware Resident 22 had vomited on December 28, 2013. During an interview with certified nursing assistant 20 (CNA 20) on January 7, 2014, at 11:55 a.m., she stated around one hour after dinner on December 28, 2013, the licensed nurse asked her to clean Resident 22 because the resident had vomited. CNA 20 stated the resident had vomited fluid not the dinner she ate, CNA 20 further stated that the vomitus looked more like the feeding from the GT, and the resident's mouth had a lot of liquid that she cleaned. During an interview on December 31, 2013, at 3 p.m. with the speech therapist, she stated she was not informed that Resident 22 had vomited on December 28, 2013. A review of the facility's policy and procedures titled, Change in Resident Condition, dated February 4, 2008, indicated the physician and legal representative or designated family member are notified when changes in condition or certain events occur. Communication with the interdisciplinary team and direct care staff is also important to ensure that consistency and continuity of care are maintained. Changes in the resident status are documented in the nurse's notes, care plans, and risk meeting notes when indicated. Changes in condition are communicated from shift to shift through the 24 hour report. A review of the facility's policy and procedures titled, Daily Shift Report, dated February 4, 2008, indicated to use as a resource for inter shift reporting to ensure continuity of care.