Every finding on record at Kei-Ai South Bay Healthcare Center

Based on interview and record review, the facility failed to report an allegation of verbal abuse between two residents (Resident 3 and Resident 4) within 2 hours.This failure had the potential to cause further abuse and a delay in investigation by the California Department of Public Health (CDPH).Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included metabolic encephalopathy (brain malfunction due to build up of chemicals or toxins), oral dysphagia (difficulty swallowing), and chronic pain syndrome.During a review of Resident 3's History & Physical (H&P), dated 8/14/2026, the H&P indicated Resident 3 did not have the capacity to understand or make decisions.During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 8/11/2026, the MDS indicated Resident 3 had a memory problem. The MDS indicated Resident 3 was dependent (helper does all of the effort) on staff for personal hygiene, putting on/taking off footwear, upper and lower body dressing, and oral and toileting hygiene. The MDS also indicated that Resident 3 is dependent on staff for rolling left to right, moving from a sitting position to a lying position, and transferring to and from a bed to a chair, or wheelchair. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing), aphasia (a disorder that makes it difficult to speak), and dementia (a progressive state of decline in mental abilities).During a review of Resident 4's H&P, dated 5/26/2026, the H&P indicated Resident 4 did not have the capacity to understand or make decisions but was able to make decisions for activities of daily living.During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 4 was dependent on staff for showering, dressing, and personal hygiene. The MDS indicated Resident 4 was dependent on staff for mobility.During a review of Resident 4's Progress Note, dated 8/21/2026, the progress note indicated Resident 4 had an episode of agitation and verbal aggression toward roommate (Resident 3). The progress note indicated Resident 4 reportedly made inappropriate comments toward her roommate and threatened to hit her while stating, Shut up, I will hit you.During a review of Resident 4's physician order, dated 8/21/2026, the physician order indicated to place Resident 4 on a 5150 hold (a 72-hour involuntary detention for a person experiencing a severe mental health crisis) and transfer to a General Acute Care Hospital (GACH) due to behavioral changes, agitation, verbal aggression and threats of physical harm toward roommate. During a concurrent interview and record review on 8/28/2026 at 12:40 p.m. with the Administrator (ADM), Resident 4's progress note, dated 8/21/2026, was reviewed. The ADM stated the incident between Resident 3 and Resident 4 was not reported to the CDPH within 2 hours.During a review of the facility's Policy & Procedure (P&P), titled Abuse Prevention Program, dated 12/1/2022, the P&P indicated the facility shall report any and all allegation of abuse to the District CDPH, Local Ombudsman and/or Local Law enforcement, either by phone, email or facsimile, within a 2-hour timeframe.

Based on interview and record review, the facility failed to update the care plans for one out of four sampled residents (Resident 1).This failure had the potential for staff to not provide relevant and up to date care for Resident 1. 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 Type 2 Diabetes Mellitus (a disease that results in too much sugar in the blood) with Diabetic Chronic Kidney Disease (long-term kidney damage), repeated falls, and abnormalities of gait (manner of walking) and mobility.During a review of Resident 1's History & Physical (H&P), dated 7/1/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/27/2026, the MDS indicated Resident 1's cognition (ability to think and process) was intact. The MDS indicated Resident 1 required partial assistance (helper does less than half the effort) from staff for personal and toileting hygiene. The MDS indicated Resident 1 required supervision (helper provides verbal cues as resident completes activity) for mobility.During a review of Resident 1's Progress Note, dated 8/18/2026, the Progress Note indicated Resident 1 had increased episodes of agitation and restlessness noted with yelling and screaming. During a review of Resident 1's Change in Condition, dated 8/19/2026, the Change in Condition indicated Resident 1 was noted to have increased agitation and restlessness noted to be yelling and screaming. The physician was informed and ordered Resident 1 be transferred to a GACH for evaluation of increase agitation/restlessness/yelling/screaming and UTI (urinary tract infection) screening.During a review of Resident 1's care plan titled, Alteration in comfort due to pain related to recent hospitalization, recent fall, and history of DM, psych disorder, HLD, and possible syncopal episodes, dated 4/13/2023, the care plan indicated it was last revised on 7/25/2025.During a review of Resident 1's care plan titled, Resident with recent episode of verbal aggression towards roommate, created on 7/25/2025, the care plan indicated it was last revised on 8/27/2025.During a concurrent interview and record review on 8/27/2026 at 11:52 a.m., with Registered Nurse Supervisor 1 (RNS 1), Resident 1's care plans were reviewed. Resident 1's care plans indicated the care plan for alteration in comfort due to pain was revised on 7/25/2025 and the care plan for verbal aggression was revised on 8/27/2025. RNS 1 stated care plans should be updated based on a change of condition, upon admission, upon transfer from the hospital, and every three months. RNS 1 stated if the pain care plan was not updated, the treatment for Resident 1's pain might not be appropriate, and Resident 1 could experience pain. RNS 1 stated if Resident 1's verbal aggression care plan was not updated, other residents could be at risk of abuse from Resident 1. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, the P&P indicated, the interdisciplinary team (a group of health care professionals who work together toward the goals of their patients) must review and updated the care plan: (a) when there has been a significant changed in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was confused with diagnoses of metabolic encephalopathy (a general term for any disease, damage, or malfunction of the brain that causes altered mental states such as confusion, memory loss, and personality changes), unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and exhibited exit seeking behaviors, did not elope (the act of leaving a facility unsupervised and without prior authorization) from the facility on 7/25/2026 by failing to:Follow its Policy and Procedure (P&P) titled, Elopement Prevention and Management, which indicated residents who exhibit wandering (the random or repetitive locomotion that may be goal-directed [i.e. the person appears to be searching for an exit]) behavior and/or are at risk for elopement will receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care. Notify the Physician of Resident 1's attempts to elope from the facility Implement new interventions after Resident 1 made multiple attempts to elope from the facility.These failures resulted in Resident 1 successfully eloping from the facility on 7/25/2026, and placed the resident at risk for accidents, injuries, exposure to harsh environment conditions such as heat, motor vehicle accident and death. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a general term for any disease, damage, or malfunction of the brain that causes altered mental states such as confusion, memory loss, and personality changes), anxiety (excessive fear, worry or nervousness that interfere with daily life), and unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality).During a review of Resident 1's Elopement Risk assessment dated [DATE], the Risk Assessment indicated Resident 1 was forgetful, confused, had impaired abilities with communication and was at risk for elopement. During a review of Resident 1's Care Plan titled, Risk for wandering or elopement dated 7/5/2026, the Care Plan Goal indicated Resident 1 will have no episode of elopement through the next review date. The Care Plan interventions did not address the type of supervision needed for the resident. The Care Plan did not indicate Care Plan interventions were revised or updated after Resident 1's attempts to elope from the facility (on 7/25/2026). During a review of Resident 1's History and Physical (H&P), dated 7/6/2026, the H&P indicated Resident 1 experienced housing instability and had agitation. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/21/2026, the MDS indicated Resident 1 had moderate cognitive impairment (ability to reason, understand, remember, judge, and learn) and did not have any impairments to the upper and lower extremity (arms and legs). Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from staff for bed mobility, transfers, and walking. During a review of Resident 1's Nurses Notes dated 7/25/2026, the Notes indicated on 7/25/2026 at 8:16 a.m., and 7/25/2026 at 9:12 a.m., Resident 1 attempted to leave the facility, and nursing staff redirected the resident back to his room after the Wanderguard alarm alerted them. The Note indicated on 7/25/2026 at 9:35 a.m. Resident 1 could not be found in the facility and was later found on 9/25/2026 at 9:52 a.m. at a bank. Resident 1 was transported to a General Acute Care Hospital (GACH) for evaluation. During a review of Resident 1's Change in Condition (COC) dated 7/25/2026 at 3:43 p.m., the COC indicated Resident 1 left the facility and the physician was notified on 7/25/2026 at 9:45 a.m. (after Resident 1 eloped). and recommended to provide 1:1 sitter (one staff delegated to supervise a single resident) and transfer the resident to a locked facility. During an interview on 7/28/2026 at 1:30 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 7/25/2026 at around 8:15 a.m., Resident 1 pushed open the back door and tried to elope from the facility. He and facility staff reoriented the resident, brought him back to his room and placed a Wanderguard (a device worn on the body that would trigger an alarm if trying to leave the building) on him. LVN 1 stated at around 9:15 a.m., approximately one hour later, the Wanderguard alarm went off, and Resident 1 opened the back door again and made a second attempt to elope from the facility. Resident 1 stepped outside briefly before staff brought him back to his room where they reoriented and re-educated him again. LVN 1 stated at approximately 9:40 a.m., 20 minutes later, a certified nurse assistant (CNA [unspecified]) informed him (LVN 1) that Resident 1 was not in his room. LVN 1 stated they went to look for him throughout the facility and drove around the area but was unable to locate the resident. Resident 1 was found at a nearby bank (time unspecified) being loaded into an ambulance and was informed by Emergency Medical Technicians (EMT) that they would be taking him to the nearby General Acute Care Hospital (GACH). LVN 1 stated that he and other staff members did not observe Resident 1 leave the facility and did not hear the Wanderguard alarm go off.During an interview on 7/31/2026 at 9:14 a.m., with CNA 1, CNA 1 stated on 7/25/2026, Resident 1 made multiple attempts to elope from the facility by leaving through the back door by the resident's room. CNA 1 stated approximately 20 minutes after the resident's 2nd attempt to elope, she noticed Resident 1 was not in his room nor the restroom. She notified LVN 1 and they looked throughout the facility for him but could not find him. She did not see Resident 1 leave the facility and did not hear the Wanderguard go off. During an interview on 7/31/2026 at 11:14 a.m., with Registered Nurse (RN) 1, RN 1 stated she was the RN supervisor on 7/24/2026 during the night shift (11:00 p.m.- 7:00 a.m.) and was still in the facility when Resident 1 eloped (on 7/25/2026). RN 1 stated she was not aware of Resident 1's first two attempts to elope from the facility that morning and she did not hear the Wanderguard alarm go off. Staff (unspecified) notified her (RN 1) that Resident 1 was nowhere to be found in the facility. RN 1 stated the Physician should have been notified and the Plan of Care should have been updated to prevent the resident from eloping. Interventions could include changing rooms or placing a 1:1 sitter to monitor/supervise the resident. During a subsequent interview on 7/31/2026 at 1:36 pm with LVN 1, LVN 1 stated no new interventions were placed when Resident 1 attempted to elope the second time because he already had the Wanderguard on and was easily redirectable. LVN 1 stated, he was about to give the resident a dose of Ativan (a medication used to treat anxiety and can cause sedation) but Resident 1 eloped before he had a chance to administer it. LVN 1 also stated he did not inform RN 1 of Resident 1 attempting to elope the first two times because it was a situation that he and other staff were already handling and felt that Resident 1 was easily redirected. LVN 1 further stated he did not notify the physician for a COC for Resident 1's attempts to elope because he didn't feel there was a need to. During a review of the facility's Policies and Procedures (P&P), titled Elopement Prevention and Management, dated 9/2025, the P&P indicated residents who exhibit wandering behavior and/or are at risk for elopement will receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care. The procedures for monitoring and managing residents at risk for elopement and/or unsafe wandering included evaluating risk factors in order to develop a person-centered care plan, implementing a plan of care to increase staff awareness, modify resident's behavior, and minimize elopement hazards and risks, monitoring response to interventions and document accordingly and evaluating the effectiveness of interventions and make changes as needed.During a review of the facility's P&P, titled Change in a Resident's Condition or Status, dated 5/2017, the P&P indicated a significant change of condition is a major decline or improvement in the resident's status that would not normally resolve itself without intervention by staff.

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Transfer and Discharge, for one of 3 residents (Resident 1), by failing to:Provide Resident 1 Notice of Medicare Noncoverage ([NOMNC], a document issued to inform residents when Medicare-covered care is ending) document in a manner Resident 1 understood.Provide Resident 1 Notice of Discharge to Resident 1 at least 30 days prior to discharge. These failures had the potential to result in miscommunication and Resident 1's discharge needs were not met. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or partial loss of movement on one side of the body) following cerebral infarction (disrupted blood flow to the brain) affecting left non-dominant side (the side of the body a person uses the least). During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 6/13/2026, the MDS indicated Resident 1 had moderate (not severe or extreme) cognitive impairment (problems with the ability to think and reason). Resident 1's MDS indicated Resident 1 required supervision or touching assistance (helper does verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for Activities of Daily Living (ADLs) such as oral and toileting hygiene. The MDS indicated Resident 1 required supervision or touching assistance to roll left and right and to change positions from sitting to standing. During a review of Resident 1's NOMNC dated 6/18/2026, 6/24/2026, and 7/2/2026, the NOMNC documents were in English, signed by Resident 1 notifying last day of coverage. During an interview on 7/2/2026 at 2:49 p.m., with Resident 1, Resident 1 was noted to speak little English and hard of hearing. Resident 1 stated his first language was Japanese and understand little English. Resident 1 stated he did not understand what discharge, meant. During a concurrent interview and record review on 7/7/2026 at 11:54 a.m., with Admissions Manager (AM), Resident 1's NOMNCs dated 6/18/2026, 6/24/2026, and 7/2/2026 were reviewed. The AM stated NOMNC documents should be provided to residents in a language the residents can understand. The AM stated Resident 1 was provided NOMNC in English because they thought Resident 1 could understand and speak English. During a concurrent interview and record review on 7/7/2026 at 12:12 p.m., with the SSD, Resident 1's Notice of Discharge, dated 7/7/2026, was reviewed. The SSD stated the Notice of Discharge was provided to the resident at the time of transfer and not before. During a concurrent interview and record review on 7/7/2026 at 2:37 p.m., with the Director of Nursing (DON) Designee, Resident 1's NOMNC dated, 6/18/2026, 6/24/2026, and 7/2/2026, Resident 1's Notice of discharge date d 7/7/2026 and the facility's P&P titled, Transfer and Discharge (including Against Medical Advice [AMA]), dated 5/2026. The DON Designee stated the NOMNC and Notice of Discharge are two separate notices. The SSD was responsible for providing the Notice of Discharge to the residents. The DON Designee stated Resident 1's primary language was Japanese, and Resident 1 was not provided the NOMNC and Notice of Discharge documents understandable (Japanese language) to the resident. The DON Designee stated that because Resident 1 was not provided Notice of Discharge at least 30 days prior, as indicated in its P&P titled Transfer and Discharge (including AMA), to give Resident 1 the opportunity to plan, fully prepare, and exercise their right to appeal their discharge. During a review of facility's P&P titled, Transfer and Discharge (including AMA), dated 5/2026, the P&P indicated, the facility's transfer/discharge notice should be provided to the resident and resident's representative in a language and manner understood. The P&P indicated, notice should be provided at least 30 days prior to a facility-initiated transfer or discharge.

Based on interview and record review, the facility failed to develop a resident-centered, comprehensive care plan (a detailed, individualized guide of the care needed to provide the resident according to the patient's medical, physical, emotional, and social needs) for one of three sampled residents (Resident 1), who speaks Japanese language (official and primary language of Japan).This failure had the potential for Resident 1's needs to be left unmet.Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or partial loss of movement on one side of the body) following cerebral infarction (disrupted blood flow to the brain) affecting left non-dominant side (the side of the body a person uses the list). During a review of Resident 1's Minimum Data Set (Minimum Data Set [MDS], a resident assessment tool), dated 6/13/2026, the MDS indicated Resident 1 had moderate cognitive impairment (problems with the ability to think and reason). Resident 1's MDS indicated Resident 1 required supervision or touching assistance (helper does verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for Activities of Daily Living (ADLs) such as oral and toileting hygiene, rolling left and right side and changing positions from sitting to standing. During a review of Resident 1's Care Plan titled, Communication Deficit Related to (R/T) hearing impairment as evidenced by: minimal difficulty when not in quiet setting, understands: sometimes, speech impaired as evidenced by: speech slurred, language barrier as evidenced by: English is not the primary language. Is understood sometimes, Japanese is his primary language with (w/) limited English, dated 6/23/2026, the interventions indicated to explain care and procedure to be done, anticipate needs, reduce background noise when speaking to resident, speak distinctly, adjusting tone appropriately, make eye contact with resident when conversing, use clear, direct, and simple terms, observe and report to Medical Doctor (MD) with decrease hearing function, and to refer to Audiologist (a healthcare professional who specializes in diagnosing and treating hearing and balance disorders) as indicated. The Care Plan did not include interventions to address Resident 1's language barrier. During an interview on 7/2/2026 at 2:49 p.m., with Resident 1, Resident 1 was noted to speak little english and hard of hearing. Resident 1 stated his first language was Japanese and understand little english. During a concurrent interview and record review on 7/7/2026 at 2:37 p.m., with the Director of Nursing (DON) Designee, Resident 1's Care Plan titled, Communication Deficit Related To (R/T) hearing impaired as evidenced by: minimal difficulty when not in quiet setting, understands, speech impaired as evidenced by speech slurred, language barrier as evidenced by Japanese the primary language, with (w/) limited English, dated 6/23/2026, was reviewed. The DON Designee stated Resident 1's interventions did not indicate how to address Resident 1' language barrier since Resident 1's primary language is Japanese. The DON designee stated Resident 1's care plan should have been individualized to ensure that staff knew how to communicate with Resident 1. During a review of facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, the P&P indicated, the comprehensive, person-centered care plan should describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to revise the care plan to include person-centered safety measures such staff supervision and monitoring for one of five sampled residents (Resident 1) who was at high risk for falls, had decreased postural alignment (misalignment or imbalance of the body's musculoskeletal structures), poor standing balance (moderate assistance and upper extremity support to stand and reach without loss of balance; unable to weight shift) and impaired safety awareness. This deficient practice resulted in Resident 1 having unwitnessed falls on 11/22/2025, 11/24/2025 and 11/28/2025, and placed the resident at risk for injuries, hospitalization or death. Findings:During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted on [DATE] with diagnoses including history of falling with a fracture (broken bone) of the left femur (thigh bone), anxiety disorder (excessive and persistent worry that interferes with life), abnormalities of gait (manner of walking) and mobility, and muscle weakness.During a review of Resident 1's Morse Fall Risk Screen dated 11/9/2025, the Risk Screen indicated Resident 1 had a history of falling and had a weak gait requiring the use of crutches, cane or walker. The Risk Screen indicated Resident 1 was at a high risk for falls. During a review of Resident 1's Physical Therapy (PT) Evaluation and Plan of Treatment dated 11/10/2025, the PT Evaluation indicated Resident exhibited new onset of decrease in strength, functional mobility, reduced ability to safely ambulate and decreased postural alignment. Resident 1 had fair (maintains balance with minimum assistance or upper extremity support) dynamic sitting balance (the ability to maintain postural control and stability while seated and moving, such as reaching, shifting weight, or turning) and poor standing balance. The PT Evaluation indicated Resident 1's safety awareness was impaired. Risk factors included risk for falls and further decline in function due to physical impairments and associated functional deficits. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 11/15/2025, the MDS indicated Resident 1 had moderate cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 required substantial/ maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, and partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or libs, but provides less than half the effort) with transfers (moving between surfaces to and from bed, chair, and wheelchair) and walking 10 feet. During a review of Resident 1's Care Plan titled, High risk for falls and injury related to recent fall in the last 30 days. dated 11/9/2025, the Care Plan goals indicated Resident 1's risk factors would be managed to minimize falls and injury. The Care Plan interventions indicated for nursing to provide assistance with ADLs, transfers, ambulation and toileting.During a review of Resident 1's Change of Condition (COC) dated 11/22/2025, the COC indicated Resident 1 was status post (s/p) an unwitnessed fall. The COC indicated Certified Nursing Assistant (CNA) 1 observed Resident 1 at the edge of the bed attempting to scoot himself up onto the bed. Resident 1 stated he was using his urinal and slid off the bed and sat on the floor. During a review of Resident 1's Interdisciplinary Team (IDT- a group of healthcare professionals from different disciplines who work together to manage the resident's care) Meeting dated 11/24/2025, the IDT indicated (on 11/22/2025) patient stated he was using his urinal and slid off the bed and sat on the floor. The IDT indicated diagnosis/predisposing factors included resident perceiving self as independent and forgets to call for assistance. New interventions indicated falling star program (visual safety initiative to identify residents at high risk for falls such as the use of yellow wristband as a form of communication reminding staff to provide increased attention, supervision and focus on the resident). During a review of Resident 1's Care Plan titled, Actual Fall Incident as Evidenced by Unwitnessed Fall dated 11/22/2025, the Care Plan interventions indicated staff were to check and assess Resident 1 for the presence of pain or injury and explain to the resident the need to call the nurse for assistance. The Care Plan did not address monitoring or supervision for Resident 1. During a review of Resident 1's COC dated 11/24/2025, the COC indicated Resident 1 was s/p an unwitnessed fall. Resident 1 was found sitting on the floor at the bedside and stated he accidentally slid down from the bed. During a review of Resident 1's IDT Meeting dated 11/25/2026, the IDT Meeting indicated Resident 1 was found sitting on the floor at the bedside. Resident 1 stated he accidentally slid down the bed while sitting at the edge of the bed. The IDT Meeting indicated diagnosis/predisposing factors included resident perceive self as independent and forgets to call for assistance. New Interventions indicated (team) reminded Resident to use call light for assistance. During a review of Resident 1's Care Plan titled, Resident 1 has an actual fall incident found sitting on the floor at bedside dated 11/24/2025, the Care Plan interventions indicated to check range of motion post fall, neuro check, physical therapy consult. The Care Plan did not indicate address monitoring or supervision for Resident 1. During a review of Resident 1's COC dated 11/28/2025, the COC indicated Resident 1 was s/p an unwitnessed fall. Resident 1 was found on the floor with the bed alarm functioning and alerting nursing staff. No apparent injuries were noted. During a review of Resident 1's Care Plan titled, Resident 1 has an actual fall incident found sitting on the floor at bedside dated 11/28/2025, the Care Plan interventions indicated to check and assess resident for presence of pain, change in range of motion, fictional mobility, obtain vital signs, explain to the resident the need to call the nurse for assistance, keep room and common areas free of clutter. The Care Plan did not address monitoring or supervision for Resident 1. During an interview on 3/11/2026 at 1:53 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated when residents were identified as high risk for falls upon admission, nurses would place the bed in the lowest position, ensure the call light was within reach, educate the resident, assist residents when getting out of bed and using the bathroom, and provide frequent monitoring. LVN 1 stated when Resident 1 continued getting up from the bed, additional interventions could have included moving the resident closer to the nurse's station. LVN 1 stated it was important to update the care plan to include interventions such as indicating the frequency of monitoring and supervision needed for the resident. LVN 1 stated the care plan should be updated after each fall to ensure resident safety and prevent potential fractures. During a concurrent interview and record review on 3/11/2026 at 4:28 p.m. with the Assistant Director of Nursing (ADON), Resident 1's care plans dated 11/22/2025, 11/24/2025, and 11/28/2025 were reviewed. The ADON stated the care plans did not indicate the frequency with which Resident 1 was to be monitored or supervised. During an interview on 3/12/2026 at 11:45 a.m., with the Director of Nursing (DON), the DON stated nurses were required to follow the post fall procedures, which included updating the care plan. The DON stated care plans should be developed or updated and individualized for each resident to reflect the care the resident would receive from the nursing staff. The DON stated this was essential because, in the case of Resident 1's actual falls, nurses needed to provide close supervision and monitoring. The DON stated that Resident 1's care plan should have included specific and clear interventions because he had fallen three times, and it was necessary to prevent any future falls or complications. During a review of the facility's policy and procedures (P&P) titled Comprehensive Person-Centered Care Planning dated 12/2016, the P&P indicated identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident. Assessment of residents is ongoing, and care plan is revised as information about the residents and the resident condition changes. The interdisciplinary team must review and update the care plan: when there has been a significant change in residents' conditions, and when the desired outcome is not met.

Based on observation, interview, and record review, the facility failed to label a container of dehydrated mashed potatoes with a use by date and failed to properly sanitize (the process of keeping places free from dirt, infection, disease) cookware. This failure had the potential to result in the preparation and provision of expired food for the residents and the potential to result in the use of improperly sanitized cookware used to prepare food for the residents. Findings:During an observation on 1/20/2026, at 8:25 a.m., in the kitchen, on the counter, near the sink, a clear container labeled Mashed Potatoes did not have a use by date. During an interview on 1/20/2026, at 8:27 a.m., with DS1, DS1stated there should be a use by date once opened. DS1 stated they will throw it away because we won't know when it will expire and the residents could get sick from the food if the use by date is not on the opened product.During an observation on 1/20/2026, at 8:35 a.m., in the kitchen, at the sanitation sink, multiple cookware items were not submerged (completely covered) in the sanitized solution at the sanitizer sink.During an interview on 1/20/2026, at 8:37 a.m., at the sanitation sink, with DS2, DS2 stated, sanitized items should be fully submerged in the water that has a sanitation solution, if the items are not submerged in the water, they are not properly sanitized and can cause an illness. During an interview on 1/23/2026, at 9:10 a.m., with the DSS, in the DSS office, the DSS stated for cookware sanitation, the items must be completely submerged in the sanitizing fluid and there should be an open date and a use by date for all dry food products.During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating Foods (Date Marking), dated 2020, the P&P indicated that expiration dates on commercially prepared, dry storage food items will be followed.During a review of the facility's policy and procedure (P&P) titled, Dishwashing: Manual, dated 2020, the P&P indicated, the pots and pans will be washed in a hot detergent solution in the first compartment, rinsed in clean warm water in the second compartment, and sanitized by either heat or chemicals in the third compartment.

Based on observation, interview, and record review the facility failed to: 1. Ensure one of seven sampled residents (Resident 61) Certified Nursing Assistant (CNA) 1 was seated while feeding Resident 61. This deficient practice of CNA 1 was not seated while feeding Resident 61 had the potential to make her feel uncomfortable.During a review of Resident 61'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 61 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 61's diagnoses dysphagia (difficulty swallowing), hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body), and gastro-esophageal reflux disease ([GERD]- a chronic condition of frequent backflow of stomach acid into the esophagus). During a review of Resident 61's History and Physical (H&P), dated 7/31/2025, the H&P indicated Resident 61 did not have the capacity to make decisions. During a review of Resident 61's Minimum Data Set ([MDS] a resident assessment tool), dated 12/8/2025, the MDS indicated Resident 61's cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 61 was dependent (helper does all the effort) on staff for eating, showering, and dressing. The MDS indicated Resident 61 had a swallowing disorder with complaints of difficulty with swallowing. During a review of Resident 61's care plan, Impaired nutritional and hydration, dated 11/20/2025, the care plan indicated the interventions assist resident during mealtime. During a review of Resident 61's physician order, Order Summary Report, dated 12/15/2025, the physician order indicated regular small portions diet with pureed texture and mildly thick consistency. During an observation on 1/20/2026 at 12:40 p.m., in Resident 61's room, CNA 1 was standing over and feeding Resident 61 during lunch time. During an interview on 1/20/2026 at 12:53 p.m., with CNA 1, CNA 1 stated she was standing over and feeding Resident 61 during lunch time on 1/20/2026. CNA 1 stated she should have been sitting at eye level feeding Resident 61. CNA stated the purpose of seating with the resident so the resident would feel connected to the process of eating. CNA 1 stated it would make Resident 61 feel more dignified. During an interview on 1/21/2026 at 1:48 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated when feeding residents the staff should be sitting. LVN 1 stated standing over Resident 61 while feeding could make her feel rushed to eat and could affect her well-being. During a review of facility's policy and procedures (P&P) titled, Quality of Life-Dignity, dated 8/2009, the P&P indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The P&P indicated demeaning practices and standards of care that compromise dignity was prohibited, staff shall promote dignity and assist residents as needed. During a review of facility's policy and procedures (P&P) titled, Assisting the Impaired Resident with In-Room Meals, dated 9/2013, the P&P indicated the purpose of this procedure was to provide appropriate support for residents who need assistance with eating. The P&P indicated if you were going to be seated during feeding, position a chair where it will be convenient for you and the resident.

Based on observation, interview, and record review the facility failed to: 1. Ensure one of seven sampled residents (Resident 103) had a consent (when a patient agrees to a treatment or procedure understanding of the risk and benefits of treatment) for the antipsychotic medication Seroquel (medication to manage schizophrenia, bipolar, and major depressive disorder). This deficient practice of not obtaining consent antipsychotic medication Seroquel had the potential for Resident 103 not to be educated on the risk and benefits of the medication.During a review of Resident 103'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 103 was admitted to the facility on [DATE]. Resident 103's diagnoses osteoarthritis (a chronic degenerative joint disease the breakdown of articular cartilage causing pain, stiffness, and reduce mobility), muscle weakness (reduction in muscle strength that cause difficulty doing specific task), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 103's Minimum Data Set ([MDS] a resident assessment tool), dated 12/30/2025, the MDS indicated Resident 103's cognition (ability to learn, reason, remember, understand, and make decisions) had no cognitive impairment. The MDS indicated Resident 103 was dependent (helper does all the effort) on staff for eating, showering, and dressing. The MDS indicated Resident 103 was on antipsychotic mediation. During a review of Resident 103's physician order titled, Order Summary Report, dated 10/27/2025, the physician order indicated Seroquel 25 milligrams ([mg] - a metric unit of mass) to give 0.5mg tablet by mouth at bedtime for schizophrenia. During a concurrent interview and record review on 1/23/2026 at 12:10 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 103's consent documents were reviewed. There was no consent for Seroquel 25mg to give 0.5mg tablet by mouth at bedtime for schizophrenia. LVN 1 stated the Seroquel 25mg was being administered at bedtime. LVN 1 stated the purpose of the consent was for Resident 103 to agree with taking the medication and understand the potential side effects. During a concurrent interview and record review on 1/23/2026 at 12:45 p.m., with Assist Director of Nursing (ADON), Resident 103's consent documents were reviewed. There was no consent for Seroquel 25mg to give 0.5mg tablet by mouth at bedtime for schizophrenia. The ADON stated there was no consent for Seroquel 25mg and should have been consented. The ADON stated it was a requirement to get consent for antipsychotic medication. The ADON stated the purpose of getting consent to educate the residents of the medication side effects. During a review of facility's policy and procedures (P&P) titled, Informed Consent Policy, dated 1/2024, the P&P indicated it was to involve residents in their care decisions by facilitating information and obtaining consent for the use of psychotropics drugs. The P&P indicated when there was new or an increase in psychotropic drug the facility was to obtain an informed consent.

Based on observation, interviews, and record review the facility failed to ensure one of seven sampled residents (Resident 112) was weighed on and after admission. This deficient practice of not weighing Resident 112 upon admission and after had the potential to not keep track of weight loss.During a review of Resident 112'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 112 was admitted to the facility on [DATE]. Resident 112's diagnoses benign prostatic hyperplasia (enlargement of the prostate gland), dermatitis (chronic skin inflammation), and gastro-esophageal reflux disease ([GERD]- a chronic condition of frequent backflow of stomach acid into the esophagus). During a review of Resident 112's Minimum Data Set ([MDS] a resident assessment tool), dated 1/19/2026, the MDS indicated Resident 112's cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired. The MDS indicated Resident 112 was partial/moderate dependent (helper does less than half the effort) on staff for toileting hygiene, showering, and dressing. During a review of physician orders titled, Order Summary Report, dated 1/15/2026, the physician orders indicated Resident 112 was to have weekly weights every Monday for 30 days. During a review of Resident 112's Weights and Vitals Summary, dated 1/20/2026, the vital signs indicated no documentation of weight. During a concurrent interview and record review on 1/21/2026 at 2:24 p.m., Resident 112's with Restorative Nurse Assistant (RNA) 1, Order Summary Report, dated 1/15/2026 was reviewed. The physician orders indicated Resident 112 was to have weekly weights every Monday for 30 days.RNA 1 stated Resident 112 was not weighed on admission [DATE]) and was not weighed on Monday 1/19/2026. RNA 1 stated the facility had no way of knowing if the resident was gaining or losing weight. RNA 1 stated it was important to weigh the resident to know If the food provided was appropriate to prevent weight loss. During a concurrent interview and record review on 1/21/2026 at 2:30 p.m., Resident 112's Weight and Vitals Summary, was reviewed. The vital signs indicated no documentation of current weight. LVN 1 stated when the residents were admitted the residents were to be weighed. LVN 1 stated Resident 112 was admitted on admission [DATE]) and was not weighed after admission. LVN 1 stated not having the weight the staff will not be able to keep track if the residents were to become malnourished or if there was an emergency and needed to use certain medications requiring weight. During a review of the facility's policy and procedures (P&P) titled, admission Assessment, dated 10/2022, the P&P indicated the purpose of the procedure was to gather information and to conduct a physical assessment of the resident including vital signs.

Based on interview and record review the facility failed to ensure two of seven sampled residents (Residents 77 and 103) had comprehensive individualized care plans addressing:Resident 103's anti-psychotic medication Seroquel (a medication to treat [schizophrenia]- a mental illness that is characterized by disturbances in thought). 2. Resident 77's peripherally inserted central catheter ([PICC]- a long thin tube inserted into the upper arm to give medication) line.This deficient practice placed residents at risk for unrecognized medication side effects and PICC-related complications due to the absence of staff guidance in the care plan.Findings: A.During a review of Resident 103'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 103 was admitted to the facility on [DATE]. Resident 103's diagnoses osteoarthritis (a chronic degenerative joint disease the breakdown of articular cartilage causing pain, stiffness, and reduce mobility), muscle weakness (reduction in muscle strength that causes difficulty doing specific tasks), and schizophrenia. During a review of Resident 103's Minimum Data Set ([MDS] a resident assessment tool), dated 12/30/2025, the MDS indicated Resident 103's cognition (ability to learn, reason, remember, understand, and make decisions) had no cognitive impairment. The MDS indicated Resident 103 was dependent (helper does all the effort) on staff for eating, showering, and dressing. The MDS indicated Resident 103 was risk of pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). The MDs indicated for skin and ulcer/injury treatment Resident 103 was to have a pressure reducing devices. During a review of Resident 103's physician order titled, Order Summary Report, dated 10/27/2025, the physician order indicated Seroquel 25 milligrams ([mg] - a metric unit of mass) to give 0.5mg tablet by mouth at bedtime for schizophrenia. During a concurrent and record review on 1/22/2026 at 11:19 a.m., with Licensed Vocational Nurse (LVN) 7, Resident 103's physician order titled, Order Summary Report, dated 10/27/2025 was reviewed. The physician order indicated Seroquel 25 mg to give 0.5mg tablet by mouth at bedtime for schizophrenia. LVN 7 stated there was no care plan for Seroquel. LVN 7 stated there should be a care plan with goals and a list of interventions. LVN 7 stated the interventions should list what to monitor such as side effects and behaviors to report. LVN 7 stated the care plan was a guide to look for life threatening side effects so the staff could check if the interventions were effective. During a review of policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 1/2012, the P&P indicated a care plan was to be developed to include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. The P&P indicated identifying problem areas and their causes and develop interventions that were targeted and meaningful to the resident. B.During a review of Resident 77's admission Record, the admission Record indicated Resident 77 was admitted to the facility on [DATE]. Resident 77's diagnoses included sepsis, methicillin-resistant staphylococcus aureus (MRSA - a bacteria that does not respond to antibiotics), and paraplegia (loss of movement and/or sensation, to some degree, of the legs). During a review of Resident 77's MDS, dated [DATE], the MDS indicated the resident was assessed to have clear cognition (ability to think and reason). The MDS indicated Resident 77 required dependent assistance from staff for activities of daily living (ADLs) such as transferring, toileting, lower body dressing and was partially dependent on staff for positioning and upper body dressing. During a concurrent interview and record review on 1/21/2026 at 3:15 p.m. with Registered Nurse (RN) 1, Resident 77's Care Plans were reviewed. No care plan regarding PICC line for Resident 77 was found. RN 1 stated there was not a care plan for PICC line for Resident 77. RN 1 stated one should have been implemented. RN 1 stated that without a care plan there would not be a way to know if all the patient centered interventions were performed and monitored. During an interview on 1/23/2026 at 2:30 p.m., with the Director of Nursing (DON), the DON stated a care plan was a blueprint for the residents' care, needs, interventions and goals. The DON stated if a care plan was not created it was possible that we would not give the residents the complete care they need. During a review of the P&P titled, Care Planning, dated 1/1/2012, the P&P indicated, a comprehensive care plan will be developed for each resident. The care plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. Each resident's care plan will describe the following: services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on interview and record review, the facility failed to: 1. Review, update, and/or revise the care plan to address use of Low Air Loss (LAL) mattress for two of three sampled residents (Residents 2 and 14). This deficient practice had the potential to affect the delivery of necessary care and treatments for Residents 2 and 14.Findings: a.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and last readmitted on [DATE]/2025. Resident 2's diagnoses included dementia (a progressive state of decline in mental abilities), sepsis (a life-threatening blood infection), and encephalopathy (any condition that causes the brain to function abnormally, leading to mental changes like confusion, memory loss, personality shifts, or drowsiness). During a review of Resident 2's History and Physical (H&P), dated 12/1/2025, the H&P indicated Resident 2 did not have the capacity to make decisions. During a review of Resident 2's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 12/23/2025, the MDS indicated the resident was assessed to have severe cognitive (difficulty with thinking) impairment in daily decision making. The MDS indicated Resident 2 required dependent assistance from staff for activities of daily living (ADLs) such as oral hygiene, toileting, showering, and positioning. The MDS indicated Resident 2 was at risk for developing pressure ulcers/injuries. b.During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE]. Resident14's diagnoses included malignant neoplasm of brain (brain cancer), epilepsy (a chronic disorder of the brain characterized by recurrent brief episodes of involuntary movement that may involve a part of the body or the entire body), and acute kidney failure (sudden loss of the ability of the kidneys to function). During a review of Resident 14's H&P, dated 12/11/2025, the H&P indicated Resident 14 could make needs known but could not make medical decisions. During a review of Resident 14's MDS, dated [DATE], the MDS indicated the resident was assessed to have moderate cognitive (difficulty with thinking) impairment in daily decision making. The MDS indicated Resident 14 required dependent assistance from staff for activities of daily living (ADLs) such as toileting, showering, dressing and positioning. The MDS indicated Resident 14 was at risk for developing pressure ulcers/injuries. During a concurrent interview and record review on 1/22/2026 at 3:10 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 2 and 14's Care Plans were reviewed. The care plan that focused on skin breakdown was not revised to show interventions regarding LAL mattress. LVN 3 stated the care plan should have been revised when the LAL was put into use. LVN 3 stated revising care plans were important they serve as a guide for the nursing staff, to make sure all patient centered care and interventions were not missed. During an interview on 1/23/2026 at 2:30 p.m., with the Director of Nursing (DON), the DON stated a care plan was a blueprint for the residents' care, needs, interventions and goals. The DON stated if a care plan was not revised it was possible that the residents would not get the complete and updated care they need. During a review of the policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated December 2016, the P&P indicated, assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary Team must review and update the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment. During a review of the policy and procedure (P&P) titled, Low Air Loss Mattress Use, dated 12/22/2025, the P&P indicated, the nursing staff and the wound care nurse will: incorporate low air loss (LAL) mattress use into the comprehensive care plan.

Based on observation, interview, and record review the facility failed to: 1. Ensure one of seven sampled residents (Resident 97) sling (an orthopedic appliance used to immobilize, support, or protect an injured limb) device was on his right arm.This deficient practice of not placing a sling to Resident 97's right shoulder placed him at risk for dislocation (when a bone is forced out of its normal position at a joint). During a review of Resident 97'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 97 was admitted to the facility on [DATE]. Resident 97's diagnoses cerebral infarction (the death of brain tissue caused by a lack of oxygen), muscle weakness (reduction in muscle strength), and abnormalities of mobility (any limitation in independent, purposeful physical movement, ranging from partial impairment to complete immobility). During a review of Resident 97's Minimum Data Set ([MDS] a resident assessment tool), dated 11/10/2025, the MDS indicated Resident 97's sometime had the ability to make self-understood. The MDS indicated Resident 97 was dependent (helper does all the effort) on staff for eating, showering, and dressing. During a review of Resident 97's physician orders titled, Oder Summary Report, dated 2/25/2025, the physician order indicated to provide a right shoulder sling at all times to prevent subluxation (when a bone is partially pulled or pushed out of place) and at risk for dislocation. During an observation on 1/20/2026 at 9:05 a.m., in Resident 97's room, Resident 97 did not have a sling on the right arm. During an observation on 1/20/2026 at 11:09 a.m., in Resident 97's room, Resident 97 did not have a sling on the right arm. During a concurrent interview and pictured record review on 1/21/2026 at 1:55 p.m. with, Restorative Nurse Assistant (RNA) 1, the picture of Resident 97 not wearing a sling to the right arm was reviewed. RNA 1 stated Resident 97 was to always wear a sling and did not have a sling placed on the right arm. RNA 1 stated the sling was to be worn to support his right shoulder. RNA 1 stated if the right shoulder was not being supported at all times, which placed Resident 97's at risk for his right shoulder to get worse. During a concurrent interview and pictured record review on 1/21/2026 at 3:04 p.m. with, Licensed Vocational Nurse (LVN) 1, the picture of Resident 97 not wearing a sling to the right arm was reviewed. LVN 1 stated Resident 97 was always to wear a sling to the right shoulder. LVN 1 stated the sling was to be placed to prevent any risk for dislocation of the right shoulder. During a review of facility's policy and procedures (P&P) titled, Certified Nursing Assistant, unknown date, the P&P indicated the purpose of the job description to provide to provide the residents with routine daily nursing care and services. The P&P indicated to assist with the application of slings, elastic bandages, and binders. During a review of facility's P&P titled, Assistive Devices and Equipment, dated 7/2017, the P&P indicated the facility provides, maintains, trains, and supervises the use of assistive devices and equipment for residents. The P&P indicated devices, and equipment will be maintained on schedule.

Based on observation, interview and record review, the facility failed to:Ensure low air loss (LAL- aim to improve comfort, and circulation, and reduce the risk of pressure ulcers) mattresses were set to the appropriate weight settings for three of eight sampled residents (Residents 2, 14 and 103). This deficient practice placed residents at risk for ineffective pressure redistribution, discomfort, pain, and pressure ulcer development or worsening. B.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 2's diagnoses included dementia (a progressive state of decline in mental abilities), sepsis (a life-threatening blood infection), and encephalopathy (any condition that causes the brain to function abnormally, leading to mental changes like confusion, memory loss, personality shifts, or drowsiness). During a review of Resident 2's History and Physical (H&P), dated 12/1/2025, the H&P indicated Resident 2 did not have the capacity to make decisions. During a review of Resident 2's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 12/23/2025, the MDS indicated Resident 2 was assessed to have severe cognitive (difficulty with thinking) impairment in daily decision making. The MDS indicated Resident 2 required dependent assistance from staff for activities of daily living (ADLs) such as oral hygiene, toileting, showering, and positioning. The MDS indicated Resident 2 was at risk for developing pressure ulcers/injuries. During an observation on 1/20/2026 at 9:56 a.m. in Resident 2's room, Resident 2's bed was equipped with a LAL mattress that was in place and operating. Weight settings were set at 450 pounds. During a review of Resident 2's weights and vitals summary, the weights and vitals summary indicated Resident 2's weight on 1/15/2026 was 98 pounds. During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE]. Resident 14's diagnoses included malignant neoplasm of brain (brain cancer), epilepsy (a chronic disorder of the brain characterized by recurrent brief episodes of involuntary movement that may involve a part of the body or the entire body), and acute kidney failure (sudden loss of the ability of the kidneys to function). During a review of Resident 14's H&P, dated 12/11/2025, the H&P indicated Resident 14 could make needs known but could not make medical decisions. During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14 was assessed to have moderate cognitive impairment in daily decision making. The MDS indicated Resident 14 required dependent assistance from staff for ADLs such as toileting, showering, dressing and positioning. The MDS indicated Resident 14 was at risk for developing pressure ulcers/injuries. During an observation on 1/20/2026 at 9:59 a.m. in Resident 14's room, Resident 14's bed was equipped with a LAL mattress that was in place and operating. Weight settings were set at 350 pounds. During a review of Resident 14's weights and vitals summary, the weights and vitals summary indicated Resident 14's weight on 12/4/2025 was 275 pounds. During an interview on 1/22/2026 at 3:10 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated nursing staff monitored LAL mattress setting based on residents' weight to ensure proper pressure redistribution and support wound management. LVN 3 stated incorrect settings could cause discomfort, ineffective pressure redistribution, and increased risk for pressure ulcers. During an interview on 1/23/2026 at 2:30 p.m., with the Assistant Director of Nursing (ADON), the ADON stated LAL mattress settings were based on the resident's weight and comfort to ensure effective pressure redistribution and wound management. The ADON stated incorrect settings reduced effectiveness and could cause the mattress to be too firm, increasing the risk for discomfort, pain, and pressure ulcers. During a review of the policy and procedure (P&P) titled, Low Air Loss Mattress Use, dated 12/22/2025, the P&P indicated, residents at risk for or currently experiencing pressure injuries receive appropriate pressure redistribution surfaces. Low air loss mattresses shall be used when clinically indicated, ordered by a physician or other licensed prescriber, and monitored for effectiveness and safety. Verify correct mattress setup and function per manufacturer's instructions. Confirm settings appropriate for residents' weight and comfort. During a review of Resident 103'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 103 was admitted to the facility on [DATE]. Resident 103's diagnoses osteoarthritis (a chronic degenerative joint disease the breakdown of articular cartilage causing pain, stiffness, and reduce mobility), muscle weakness (reduction in muscle strength that cause difficulty doing specific task), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 103's Minimum Data Set ([MDS] a resident assessment tool), dated 12/30/2025, the MDS indicated Resident 103's cognition (ability to learn, reason, remember, understand, and make decisions) had no cognitive impairment. The MDS indicated Resident 103 was dependent (helper does all the effort) on staff for eating, showering, and dressing. The MDS indicated Resident 103 was at risk of pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). The MDs indicated for skin and ulcer/injury treatment Resident 103 was to have a pressure reducing devices. During a review of Resident 103's physician orders titled, Order Summary Report, dated 8/28/2022, the physician order indicated LAL mattress for skin maintenance. During a review of Resident 103's Weights and Vital Summary, dated 1/7/2026, the vital signs indicated Resident 103 weighed 242 pounds ([lbs.]- unit of weight) During an observation on 1/20/2026 at 9:30 a.m., in Resident 103's room, the LAL mattress was set at 280lbs. During a concurrent interview and pictured record review on 1/21/2026 at 2:58 p.m., with Licensed Vocational Nurse (LVN) 1 reviewed. the picture indicated the LAL mattress was set at 280lbs. LVN 1 stated Resident 103 weighed 242 lbs. LVN 1 stated the LAL mattress was set incorrectly and should be set at the resident weight. LVN 1 stated not having the correct settings could increase the risk for Resident 103 for pressure injury and reduce her circulation. During an interview on 1/21/2026 at 3:23 p.m., with Assistant Director of Nursing (ADON), the ADON stated the LAL mattress should be set at weight of the resident. The ADON stated the purpose of the LAL mattress was to prevent pressure ulcers and to prevent worsening pressure ulcers. The review of the facility's policy and procedure titled, Low Air Loss Mattress use, dated 12/22/2025, the P&P indicated all residents identified as being at risk for or currently experiencing pressure injuries receive appropriate pressure redistribution surfaces. The P&P indicated a LAL mattress is a dynamic pressure redistribution support surface providing airflow to help manage moisture and heat at the skin interface. The P&P indicated to confirm LAL mattress settings appropriate for resident's weight and comfort.

Based on observation, interview, and record review the facility failed to ensure one of seven sampled residents (Resident 112) the physician was notified when there was sediment (the solid matter that settles to the bottom of a liquid, such as urine or blood) in the indwelling catheter (a medical device inserted into the bladder to drain urine continuously) tubing. This deficient practice not notifying the physician of the sediment in the indwelling catheter tubing had the potential to cause a urinary tract infection ([UTI]- an infection in any part of the urinary system).During a review of Resident 112'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 112 was admitted to the facility on [DATE]. Resident 112's diagnoses benign prostatic hyperplasia (enlargement of the prostate gland), dermatitis (chronic skin inflammation), and gastro-esophageal reflux disease ([GERD]- a chronic condition of frequent backflow of stomach acid into the esophagus). During a review of Resident 112's Minimum Data Set ([MDS] a resident assessment tool), dated 1/19/2026, the MDS indicated Resident 112's cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired. The MDS indicated Resident 112 was partial/moderate dependent (helper does less than half the effort) on staff for toileting hygiene, showering, and dressing. The MDS indicated Resident 112 had an indwelling During an observation on 1/20/2026 at 9:15 a.m., in Resident 112's room, Resident 112 had sediment in the indwelling catheter. During a review of Resident 112's physician orders, Order Summary Report, dated 1/15/2025, the physician order indicated to monitor for redness, irritation, swelling, and signs/symptoms for UTI.During a concurrent observation and interview on 1/21/2026 at 2:18 p.m., with Licensed Vocational Nurse (LVN) 6, in Resident 112's room, Resident 112 had sediment in the indwelling catheter. LVN 6 stated there was sediment in Resident 112 foley catheter. LVN 6 stated assessment of the indwelling catheter should be done every shift. LVN 6 stated sediment in the urine could be an indication of UTI and the physician should be notified.During an interview on 1/21/2026 at 3:17 p.m., with Assistant Director of Nursing (ADON), the ADON stated it was important to monitor the indwelling catheter every shift especially during care for Resident 112. The ADON stated monitoring the indwelling catheter for early signs of an UTI such as sediment should be reported to the physician.During a review of facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated 9/2014, the P&P indicated the purpose of this procedure was to prevent catheter-associated urinary tract infections. The P&P indicated to observe the resident for complication's associated with urinary catheters. The P&P indicated observe for other signs and symptoms of urinary tract infection and to report findings to the physician or supervisor immediately.

Based on observation, interview and record review, the facility failed to: 1. Ensure a peripherally inserted central catheter ([PICC]- a long thin tube inserted into the upper arm to give medication) dressing was labeled with a date, time and initials for one of one sampled resident (Resident 77). This deficient practice had the potential for the PICC line insertion site to develop an infection and/or hospitalization for Resident 77.Findings: During a review of Resident 77's admission Record, the admission Record indicated Resident 77 was admitted to the facility on [DATE]. Resident 77's diagnoses included sepsis (a life-threatening blood infection), methicillin-resistant staphylococcus aureus (MRSA - a bacteria that does not respond to antibiotics), and paraplegia (loss of movement and/or sensation, to some degree, of the legs). A review of Resident 77's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 1/13/2026, the MDS indicated the resident was assessed to have clear cognition (ability to think and reason). The MDS indicated Resident 77 required dependent assistance from staff for activities of daily living (ADLs) such as transferring, toileting, lower body dressing and was partially dependent on staff for positioning and upper body dressing. During an observation on 1/21/2026 at 10:00 a.m. in Resident 77's room, Resident 77 had a PICC line to the right upper arm, the dressing was not labeled. During an interview on 1/21/2026 at 3:15 p.m. with Registered Nurse (RN)1, RN 1 stated as soon as an IV or PICC line dressing was changed it was to be labeled with date, time, and initials. RN 1 stated IV or PICC line dressings were changed every seven days and as needed. RN 1 stated if not properly managed there could be a risk of infection. During an interview on 1/23/2026 at 2:30 p.m. with Assistant Director of Nursing (ADON), the ADON stated IV dressings needed to be labeled with the date, time and initials, if not done staff would not know when dressing was placed. The ADON stated there was a risk of infection to the IV site. During a review of the facility's policy and procedure (P&P) titled, Peripheral IV Dressing Changes, dated April 2016, the P&P indicated, the purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. Label dressing with date, time, and initials.

Based on interview and record review, the facility failed to: 1. Obtain physician orders prior to initiating low air loss (LAL) mattress therapy for two of eight sampled residents (Residents 2 and 14). This deficient practice had the potential to result in unnecessary treatment and adverse outcomes. Findings:a.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included dementia (a progressive state of decline in mental abilities), sepsis (a life-threatening blood infection), and encephalopathy (any condition that causes the brain to function abnormally, leading to mental changes like confusion, memory loss, personality shifts, or drowsiness). During a review of Resident 2's History and Physical (H&P), dated 12/1/2025, the H&P indicated Resident 2 did not have the capacity to make decisions. During a review of Resident 2's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 12/23/2025, the MDS indicated Resident 2 was assessed to have severe cognitive (difficulty with thinking) impairment in daily decision making. The MDS indicated Resident 2 required dependent assistance from staff for activities of daily living (ADLs) such as oral hygiene, toileting, showering, and positioning. The MDS indicated Resident 2 was at risk for developing pressure ulcers/injuries. During an observation on 1/21/2026 at 9:56 a.m. in Resident 2's room, Resident 2's bed was equipped with a LAL mattress that was in place and operating. b. During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE]. Resident 14's diagnoses included malignant neoplasm of brain (brain cancer), epilepsy (a chronic disorder of the brain characterized by recurrent brief episodes of involuntary movement that may involve a part of the body or the entire body), and acute kidney failure (sudden loss of the ability of the kidneys to function). During a review of Resident 14's H&P, dated 12/11/2025, the H&P indicated Resident 14 could make needs known but could not make medical decisions. During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14 was assessed to have moderate cognitive impairment in daily decision making. The MDS indicated Resident 14 required dependent assistance from staff for ADLs such as toileting, showering, dressing and positioning. The MDS indicated Resident 14 was at risk for developing pressure ulcers/injuries. During an observation on 1/21/2026 at 9:59 a.m. in Resident 14's room, Resident 14's bed was equipped with a LAL mattress that was in place and operating. During a concurrent interview and record review on 1/22/2026 at 3:10 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 2 and 14's physician orders were reviewed. No physician orders for a LAL mattress were found. LVN 3 confirmed no orders were in the system and stated a physician order was required and should be verified before initiating the LAL mattress. During an interview on 1/23/2026 at 2:30 p.m., with the Assistant Director of Nursing (ADON), the ADON stated a physician order was required for a low air loss mattress. The ADON stated placing the LAL mattress without an order was outside the nursing scope of practice and could potentially harm the resident. During a review of the policy and procedure (P&P) titled, Low Air Loss Mattress Use, dated 12/22/2025, the P&P indicated, residents at risk for or currently experiencing pressure injuries receive appropriate pressure redistribution surfaces. Low air loss mattresses shall be used when clinically indicated, ordered by a physician or other licensed prescriber, and monitored for effectiveness and safety. Obtain a written or telephone order specifying Low Air Loss Mattress and clinical rationale.

Based on observation, interview, and record review the facility failed to: 1. Ensure one of seven sampled residents (Resident 99) eye drop medication Timolol (medication to treat high pressure inside the eye) was properly stored. This deficient practice of leaving the eye drop medication Timolol at bedside had the potential for the medication to be used by other residents.During a review of Resident 99'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 99 was admitted to the facility on [DATE]. Resident 99's diagnoses hemiplegia (paralysis affecting one side of the body), chronic obstructive pulmonary disease ([COPD]- a chronic lung disease causing difficulty in breathing) and anxiety (an uneasy feeling of discomfort, apprehension, or dread to a non-specific or unknown threat). During a review of Resident 99's history and physical (H&P), dated 7/17/2025, the H&P indicated Resident 99 had the capacity to understand and make decisions. The H&P indicated Resident 99 had glaucoma (a condition of increased pressure within the eyeball, causing gradual loss of sight). During a review of Resident 99's Minimum Data Set ([MDS] a resident assessment tool), dated 11/17/2025, the MDS indicated Resident 99's cognition (ability to learn, reason, remember, understand, and make decisions) had no cognitive impairment. The MDS indicated Resident 99 required substantial /maximal assistance (helper does more than half the effort to lift, and hold limbs) on the staff for eating, showering, and dressing. During a record review of Resident 99's physician orders titled, Order Summary Report, the physician order indicated Timolol Maleate Ophthalmic Solution (medication to treat high pressure inside the eye) 0.5% to instill one drop in both eyes two times a day for glaucoma. During an observation and interview on 1/20/2026 at 10:43 a.m., in Resident 99's room, there was eye medication Timolol on the nightstand. Resident 99 stated she does not self-administer her medications. Resident 99 stated the nurses were the ones who administered the medication to her. During an interview on 1/21/2025 at 2:50 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the Timolol eye drops were to be administered to Resident 99 and when finished with the medication; it was to be stored back in the medication cart. LVN 1 stated it was important not to leave the medication at the residents' bedside, because the medication could come up missing. LVN 1 stated the resident could mistakenly take the medication and overdose on the prescribed dosing. During an interview on 1/21/2026 at 3:22 p.m., with Assistant Director of Nursing (ADON), the ADON stated no medication should be left on the nightstand. The ADON stated the medication was to be prepared and given by the licensed nurses. The ADON stated that after the medication was given it was to be put back into the medication cart. The ADON stated leaving the medication was unsafe and the residents in the room could have improperly used it or even ingested the medication. During a review of the facility policy and procedures (P&P) titled, Storage Medication, dated 4/2007, the P&P indicated all drugs and biologicals shall be stored in a safe, secure, and orderly manner. The P&P indicated the nursing staff shall be responsible for maintaining medication storage.

Based on observation, interview, and record review, the facility failed to ensure 3 of 4 outside trash bin lids were completely closed. This failure had the potential to result in odors attracting pests and scavengers (organisms that feed on dead matter) to the trash bins.Findings:During an observation on 1/20/2026, at 1:43 p.m., one trash bin had both covers open and another trash bin had one cover partially opened and no staff were in the immediate area. During an interview on 1/20/2026, at 1:44 p.m., with DS3, DS3 stated, trash cans should be covered and if trash is uncovered rain and animals can get into the trash. During an interview on 1/23/2026 at 9:10 a.m., with the DSS, the DSS stated that the lids on the trash bins should be closed at all times. During a review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal dated October 2017, the P&P indicated, all garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use.

Based on observation, interview, and record review, the facility failed to ensure the urinal bottle (handheld container for pee) for Resident 113 had a cover to prevent spillage of urine. This failure had the potential to result in urine spilling onto staff or Resident 113 during care.Findings: During a review of Resident 113's admission Record, dated 1/15/2026, the admission Record indicated Resident 113 has diagnoses for Cellulitis (a common, potentially serious bacterial skin infection) of the right lower limb, Local infection of the skin and subcutaneous (beneath the skin) tissue, and sepsis (a life-threatening medical emergency caused by the body's overwhelming, dysfunctional immune response to an infection, leading to tissue damage, organ failure, and potential death). During a review of Resident 113's Order Summary Report, dated 1/15/2026, the Order Summary Report indicated Resident 113 was on a Regular Diet, and on a 5150 hold due to episodes of agitation and verbally aggressive towards staff. During a review of Resident 113's History & Physical, dated 1/8/2026, the History & Physical indicated Resident 113 has a colostomy (a surgical opening created to allow waste products from bowel to pass from intestines), diabetes mellitus (a disease that result in too much sugar in the blood), hypertension (high blood pressure), and congestive heart failure (a chronic, progressive condition where the heart muscle cannot pump efficiently enough to meet the body's oxygen needs, leading to fluid backup in the lungs and body). During an observation on 1/20/2026, at 11:37 a.m., in room [ROOM NUMBER]C, a partially filled urinal bottle, without a top for containing the urine , was hanging from the upper left bedside railing. During an interview on 1/20/2026, at 11:37 a.m., with LVN2, LVN2 stated if the urinal bottle is uncovered it could spill on the floor and someone can be affected by the bacteria in the urine. During an interview on 1/23/2026 at 11:17 a.m., with IP, in the DON's office, IP stated urinal bottles should always have a cover. It could contaminate the area if it spills. Everyone is responsible for making sure urinal bottles are covered. Staff or visitors could be infected by the urine if it spills on them. If that happened, we would advise staff and visitors to go home, change their clothing, and seek medical help if the resident has an infection. During a review of the facility's policy and procedure titled, Bedpan/Urinal, offering/Removing, dated February 2018, the P&P indicated to cover the urinal immediately with a urinal cover or paper towel.

Based on interview and record review, the facility failed to provide the necessary care and services for one of three sampled residents (Resident 1) by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 2 reassessed Resident 1 after a change of condition ([COC] a sudden or gradual change in a patient's physical, cognitive, behavioral, or functional status) of wheezing (when breathing becomes difficult due to narrowed or blocked airways in the lungs), vomiting, and sweating on [DATE] at 8:00 a.m. This deficient practice resulted in Resident 1's death, at 10:57 a.m., approximately 3 hours after she was observed with shortness of breath, wheezing, vomiting, and sweating. 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 diagnoses included hydrocephalus (a condition in which fluid accumulates in the brain), diabetes mellitus (when the body is unable to control the amount of glucose in the blood), aphasia (a language disorder that affects a person ' s ability to understand and express written and spoken language), gastro-esophageal reflux disease ( a chronic condition that occurs when stomach contents leak into the esophagus, causing irritation), gastrostomy ([G-tube] a surgical opening in the stomach for nutrition, hydration, and medication), and right sided hemiplegia (in ability to move one side of the body) and hemiparesis (weakness to one side of the body). During a review of Resident 1's care plan titled, At risk for aspiration (when food, liquid, or other material is inhaled into the lungs), dehydration, and tube feeding intolerance ., dated [DATE], the care plan indicated Resident 1 will be free from signs and symptoms of dehydration daily. The staff interventions indicated to observe and report signs and symptoms of tube feeding intolerance such as nausea and vomiting, aspiration, choking, cough, change of level of consciousness, increase in shortness of breath, wet voice, gurgled sounding voice, and congestion. During a review of Resident 1's care plan titled, Impaired nutritional and hydration status related to dependence on enteral feed (a method of delivering nutrients and fluids directly into the digestive system through a tube) dated [DATE], the care plan indicated Resident 1 will show evidence of good hydration. The staff interventions included to observe and report coughing, choking, vomiting, congestion, gurgling sounding voice, cyanosis (a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood), runny nose, teary eyes, increase temperature, throat clearing, shortness of breath, rhonchi (abnormal breath sounds that resemble snoring or gurgling)/wheezing to the physician and speech therapist (a licensed professional who assesses and treats communication and swallowing disorders) promptly. During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated [DATE] the MDS indicated, Resident 1's cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 1 was dependent on staff for personal hygiene, showering, and dressing. The MDS indicated Resident 1 required the use of tube feeding (a method of providing nutrition, fluids, and medications directly into the stomach through a tube). During a review of Resident 1's Order Summary Report, indicated active orders as of [DATE], indicated to administer Tylenol (medication used to relive mild pain) 325mg 2 tablets via G-tube every 6 hours as needed for fever, Ipratropium-Albuterol Solution (a medication that dilates the airways of the lungs) 0XXX,d+[DATE].5 milligram ([mg] a unit of mass or weight) per (/) milliliter ([ml] a unit of measurement), inhale orally every 4 hours as needed for shortness of breath, wheezing, and congestion via nebulizer (a small machine that turns liquid medicine into a mist that be easily inhaled) and Zofran (a medication used to prevent nausea and vomiting) 4mg 1 tablet via G-tube every 4 hours as needed for nausea and vomiting. During a review of Resident 1's Change in Condition Evaluation, dated [DATE] at 8:00 a.m. the COC Evaluation indicated Resident 1 had an episode of wheezing, vomiting of clear mucous (viscous [thick] secretions produced by the mucous membranes [moist inner linings of nose, mouth, lungs, and stomach]), and sweating. The COC Evaluation indicated Resident 1's physician was not notified. During a review of Resident 1's Paramedic Run Sheet, dated [DATE] at 10:29 a.m., the Paramedic Run Sheet indicated 911 (an emergency number for any police, fire, or medic) was called at 10:29 a.m. Paramedics arrived at the facility at 10:35 a.m. and continued cardiopulmonary resuscitation ([CPR] an emergency life-saving procedure that is done when breathing or heartbeat has stopped). Paramedics pronounced Resident 1 deceased at 10:57 a.m. During a review of Resident 1's Progress Notes, dated [DATE] at 11:15 a.m., the Progress Notes indicated, Resident 1 had wheezing, sweating, and vomited at 7:45 a.m. The Progress Notes indicated Resident 1 was treated for the symptoms, reassessed, and administered 2 liters (L, unit of measurement) of oxygen. During an interview on [DATE] at 1:28 p.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated Resident 1 was total care (provides all the care for a patient during their shift). CNA 3 stated on [DATE] at 7:45 a.m., Resident 1 looked tired and had lots of saliva (a bodily fluid) coming out of her mouth. CNA 3 stated she reported the resident ' s condition to LVN 2. CNA 3 stated LVN 2 gave Resident 1 a breathing treatment around 8:00 a.m. CNA 3 stated she found Resident 1 unresponsive around 10:13 a.m. and called for help. During a concurrent interview and record review on [DATE] at 1:45 p.m., Resident 1 ' s care plan titled, At risk for aspiration (when food, liquid, or other material is inhaled into the lungs), dehydration, and tube feeding intolerance ., dated [DATE], was reviewed with LVN 1. LVN 1 stated Resident 1 ' s condition changed, and the physician needed to be notified because the resident had shortness of breath, wheezing, vomiting, and sweating per the care plan. LVN 1 stated it was important to notify the physician for the safety and the care of the resident. LVN 1 stated calling the physician would have helped to prevent these conditions from worsening. During a telephone interview on [DATE] at 3:07 p.m. with LVN 2, LVN 2 stated on [DATE] at 7:40 a.m. CNA 2 notified her (LVN 2) that Resident 1 vomited and was sweating. LVN 2 stated she assessed Resident 1 and observed Resident 1 had shortness of breath, was wheezing and sweating. LVN 2 stated she observed vomit on Resident 1 ' s shirt and on the side of the resident ' s mouth. LVN 2 stated on [DATE] at 7:50 a.m. she administered Ipratropium-Albuterol Solution 0XXX,d+[DATE].5 mg/ml, Zofran, and Tylenol. LVN 2 stated at 7:51 a.m., she removed Resident 1 ' s blankets. LVN 2 stated at 8:04 a.m., she took Resident 1 ' s vital signs (measurements of the body ' s basic functions) and the readings were as follows: 1. Blood pressure was ,d+[DATE] millimeters of mercury ([mm/hg] a unit of measurement for pressure, normal range ,d+[DATE]mm/hg), 2. Pulse was 68 (a measurement of a patient's heart rate, normal range ,d+[DATE] beats per minute), 3. Respirations was 22 (number of breaths per minute, normal range 12 to 20), 4. Temperature was 98.5 Fahrenheit (a scale for measuring temperature, normal range 97F to 99F), 5. Oxygen saturation was 95 percent (%) (measures how much oxygen is in the blood, normal range 95% to 100%). LVN 2 stated there were no documented follow-up vital signs after interventions and treatment were provided to Resident 1. LVN 2 stated, If it was not documented then it was not done. LVN 2 stated she did not notify Resident 1's physician of the change of condition because she wanted to administer medications to the other residents in the facility. LVN 2 stated Resident 1's airway should have been the priority. LVN 2 stated it was very important to reassess the resident to assess the effectiveness of the interventions. LVN 2 stated not reassessing and not notifying the physician placed Resident 1 at risk for worsening of her condition. During a telephone interview on [DATE] at 11:15 a.m. with Registered Nurse (RN) 1, RN 1 stated LVN 2 did not report that Resident 1 had shortness of breath, wheezing, vomited and was sweating. RN 1 stated Resident 1's symptoms were considered a change of condition. RN 1 stated once the medications were given to Resident 1, LVN 2 should have reassessed Resident 1 at least 15 minutes after the breathing treatment was administered. RN 1 stated LVN 2 should have reassessed resident's oxygen saturation again after 30 minutes. RN 1 stated LVN 2 should have reassessed and monitored Resident 1 in 15 to 30 minutes intervals to see if the interventions were effective. RN 1 stated the interventions should have been documented in detail, and the physician notified when the symptoms were identified. RN 1 stated if the physician was called another treatment such as an Xray (used to create images of the inside of the body to help diagnose and treat a variety of conditions) could have been ordered. RN 1 stated due to Resident 1 ' s risk for aspiration the Xray would show if the resident had an infection or aspirated (the act of breathing in food or liquid into the lungs). RN 1 stated LVN 1's failure to notify his physician when the resident was observed with shortness of breath, wheezing, vomiting, and sweating, might have resulted in Resident 1's death. During a concurrent interview and record review on [DATE] at 2:30 p.m., Resident 1's care plans titled, At risk for aspiration, dehydration, and tube feeding intolerance ., dated [DATE], and Impaired nutritional and hydration status related to dependence on enteral feed, dated [DATE] were reviewed with the Assistant Director of Nursing (ADON). The ADON stated Resident 1 was at risk for aspiration. RN 1 stated the care plan interventions indicated to call Resident 1' s physician promptly for signs and symptoms of shortness of breath, wheezing, and vomiting. The ADON stated Resident 1's physician was not notified for the sign and symptoms to be corrected with new interventions, and possibly new physician orders. During a concurrent interview and record review on [DATE] at 2:40 p.m., Resident 1's Change in Condition Evaluation, dated [DATE] was reviewed with the ADON. The ADON stated Resident 1's physician was not notified of the resident's change of condition. The ADON stated the physician should have been called as soon as possible because Resident 1 was vomiting and sweating. The ADON stated 30 minutes after treatment, a new set of vitals should have been documented and Resident 1 should have been reassessed. The ADON stated Resident 1 was found unresponsive at 10:13 a.m. and was pronounced dead at 10:57 a.m. The ADON stated if the physician was notified earlier, the physician would have probably ordered a stat (immediately without delay) Xray to rule out aspiration to prevent worsening the condition of the resident. During a concurrent interview and record review on [DATE] at 2:50 p.m., Resident 1's Progress Notes, dated [DATE] at 11:15 a.m. was reviewed with the ADON. The ADON stated reassessing a resident within 30 minutes after interventions were performed was a generalized standard of practice. The ADON stated the vital signs were not documented and that meant the vital signs were not done. The ADON stated auscultation (listening to the sounds of the body) of Resident 1's lung sounds were not documented, and it was unclear if the treatment was effective. During a review of the facility's policy and procedure (P&P) titled, Charge Nurse, dated 2003, the P&P indicated, the Charge Nurse was delegated the administrative authority, responsibility, and accountability necessary for carrying out you assigned duties. The P&P indicated to chart nurses notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident ' s response to the care. The P&P indicated to notify the resident's attending physician and next of kin when there is a change in the resident's condition and ensure that residents who are unable to call for help are checked frequently. The P&P indicated to review care plans daily to ensure that appropriate care is being rendered, inform the Nurse Supervisor of any changes, and ensure the nurses' notes reflect that the care plan is being followed when administering nursing care or treatment. During a review of the facility ' s policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated ,d+[DATE], the P&P indicated, prior to notifying the physician the nurse will make detailed observations and gather relevant and pertinent information. The P&P indicated the staff will monitor and document the resident's progress and response to treatment and the physician will adjust accordingly.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to prevent injury to one of three sampled residents (Resident 1), by failing to: 1. Ensure Certified Nurse Assistant (CNA) 1 did not make a homemade non-temperature regulated warm compress (method of applying heat to the body) and placed it on Resident 1's back. 2. Notify the charge nurse (Licensed Vocational Nurse [LVN] 1 that Resident 1 was having back pain. 3. Follow the facility's policy and procedure (P&P) titled, Compress or Soak, Applying Warm. As a result, CNA 1 prepared a compress that was hot, gave it to Resident 1 who had type 2 diabetes mellitus (a condition of high level of sugar in the blood) and applied it to Resident 1's mid-back (middle portion of the back). Resident 1's skin was burned by the home-made compress made by CNA 1. The resident developed blister (a condition where fluid fills a space between layers of skin) and was treated by the physician for the open blister. Findings: During a review of Resident 1's Admission Record face sheet, dated 3/20/2023, the face sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including compression fracture of first lumber vertebra (a type of broken bone that causes the spine to collapse), type 2 diabetes mellitus, and syncope (fainting or passing out). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/6/2023, the MDS indicated Resident 1's cognitive (the ability to think and process information) and skills for daily decisions making was impaired, and required one-person physical assist for activities of daily living ([ADL] daily self-care activities). During a review of Resident 1's History and Physical (H&P), dated 3/1/2023, the H&P indicated Resident 1 did not have the capacity to make decisions. During a review of the clinical record for Resident 1 titled, The Weekly Non-Pressure Ulcer Observation Tool, dated 3/5/2023, indicated that Resident 1 had a closed fluid blister on the left upper back measuring 10 centimeters ([cm] unit of measurement) by 10 cm. During a review of Resident 1's Change in Condition ([COC] a clinical deviation from a resident's baseline) Evaluation Form, dated 3/5/2023, the COC indicated Resident 1's physician was notified of Resident 1 having a closed fluid filled blister on the mid-back. The physician recommended cleaning the blister with normal saline (a mixture of sodium chloride [salt] and water. It has several uses in medicine including cleaning wounds) and apply a dry dressing every day for 10 days. During a review of Resident 1's Interdisciplinary Team ([IDT]-comprises professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological [mental and emotional] needs) notes dated 3/6/2023, the IDT notes indicated on 3/4/2023, the facility's staff (CNA 1) placed a warm compress on Resident 1's back per family request. CNA 1 did not use the facility's ready-made warm compress. CNA1 made his own warm compress. During the review of Resident 1's clinical record Surgical Consult dated 3/6/2023, indicated Resident 1 was seen by a wound care doctor and was treated for an open blister, superficial skin breakdown with Silvadene (used to treat or prevent serious infection on areas of skin with second degree burn [affect the outer layer of the skin] or third-degree burn [burn reaches to the fat layer beneath the skin]) ointment During an interview on 3/20/23 at 10:05 a.m., with CNA 1, CNA 1 stated on 3/4/2023, he was asked by Resident 1's family member (FM 1) for a warm compress because Resident 1 was having pain in her mid-back. CNA 1 stated he mixed hot and cold water together from the dining room faucet, wet a towel with the water, placed the wet towel in a plastic bag, double bagged the towel to prevent leakage, then put the bag inside a pillowcase. CNA 1 stated he handed the warm towel to Resident 1's family member who then instructed him to put it on Resident 1's back. CNA 1 stated he placed the warm towel on Resident 1's back and layered it with the resident's draw sheet (a small bed sheet placed crosswise over the middle of the bottom sheet of a mattress to cover the area between the person's upper back and thighs, often used by medical professionals to move patients). CNA 1 stated he did not have any intention of hurting Resident 1. He (CNA1) was following the family member's instruction. CNA 1 stated he did not check the temperature of the towel and did not check on Resident 1 again after he (CNA 1) applied the warm compress. CNA 1 stated he did not notify the charge nurse about Resident 1 complaining of pain and the family member request of a warm compress. During an interview on 3/20/2023 at 12:55 p.m., with LVN 1, LVN 1 stated that she was not aware that Resident 1's family requested a warm compress. LVN 1 stated that facility have premade warm compresses with regulated temperatures. CNA 1 could have used it instead of making his own. LVN 1 stated there was no physician order for Resident 1 to get a warm compress. During an interview on 3/24/23 at 3 p.m., with the Director of Nursing (DON), the DON stated CNA 1 and other staff have been in-serviced and educated on how to apply warm or cold compresses to residents. The DON stated there should be a physician's order before warm or cold compresses can be used on residents. Staff should use the facility supply instant hot pack (used to treat minor bumps, bruises, muscle aches, strains, and other minor injuries. Single use and activate with a squeeze and quick shake for fast and effective therapeutic heat treatment) instead of making their own warm pack. During an interview on 4/6/23 at 10:24 a.m., with FM 1, FM 1 stated that he requested a warm compress for Resident 1 because she had a chronic back pain. CNA 1 did not use the normal warm compress that hospitals used, rather staff brought a bag in a pillowcase looks like a balloon and placed it on Resident1's back. FM 1 stated he received a call from the facility the next day that Resident 1 had a burn on her back. During a concurrent interview and observation on 4/6/2023 with the facility maintenance supervisor (MS), the temperature of the hot water in the dining area faucet was checked by MS and observed water temperature registered 119-degree Fahrenheit ([ F] unit of measurement) on the thermometer. The MS stated the temperature of the water heaters that service the resident's rooms, bathrooms and common areas were set to be not more than 120 F. During a review of facility supply warm compressed (instant hot pack) label, the label indicated the temperature of warm compress was 110 F. During a review of the facility's P&P titled, Compress or Soak, Applying Warm revised February 2018, the P&P indicated, that the purpose of the procedure is to ease the body of pain caused by inflammation and congestion, to aid in the treatment of the resident's condition, to improve circulation and to apply heat to an area. The P&P indicated: 1. To verify that there is a physician's order for the procedure. 2. Review the resident's care plans to assess for any special needs. 3. Be sure that resident is in a safe and comfortable position. 4. Avoid spilling warm water on the resident. 5. Check the resident's skin often every five (5) minutes for redness or discoloration. 6. Check temperature with bath thermometer and temperature should be around 115 F. 7. Unless otherwise instructed apply the warm compress for 20 minutes and do not apply a warm compress to a resident who is diabetic or has circulatory problems.

Based on observation, record review and interview the facility failed to ensure the dietary's staff followed its sanitation policy to ensure food was stored, prepared, and distributed under sanitary conditions (crossed referenced to F925). This failure resulted in a cockroach (small insects that cause spread of bacterial infection) and mice (small rodents) infestation of the kitchen and food storage environment, which may result in serious health risk of vector-borne diseases (diseases that result from an infection transmitted to human by insects, cockroaches, and mice) and had the potential for the 98 residents to experience food infection from ingesting live bacteria, food intoxication from ingesting food containing toxins from bacteria, and disease transmission that can lead to life threatening complications and death. On 2/14/2020 at 5:30 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 declared under F812 and F925. The facility's administrator (ADM) and the Director of Nursing (DON) were notified of the immediacy and seriousness of the residents' health and safety being threatened. On 2/17/2020 at 3 p.m., the Department of Public Health (DPH) notified the Administrator that the IJ was lifted after verifying and confirming on-site the facility had implemented the acceptable written plan of action as follows: 1. The kitchen was immediately placed out of service as of February 14, 2020 at 3 PM. 2. All opened and unused food items in the kitchen were immediately discarded on February 14, 2020. 3. The pest control company came to the facility on [DATE] and performed a detailed treatment of [REDACTED]. 4. All meals for the residents were being ordered from approved restaurants nothing was used from the facility's kitchen. 5. Fecal spotting on the pipelines under the mechanical ware of the wash machine was cleaned. 6. Live adult cockroach on wall at pipeline under the ware wash machine would be discarded and the area sanitized. 7. The dead cockroach on the floor under the mechanical ware wash machine was discarded and the area sanitized. Completed on 2/15/2020 at 11 AM. 8. The mice droppings on the floor in the dry storage room, on the floor behind upright coolers, on the floor behind cooks' line, on floor under the 3-compartment sink, on the floor in the emergency food and water storage room were removed. These areas were cleaned/sanitized, and were completed on 2/16/2020 at 11 AM. 9. Employee's food stored with residents' food in the two-door upright cooler was removed and completed on 2/16/2020 at 11 AM. 10. Mice droppings on the rack holding bulk rice in dry storage room were cleaned. 11. Accumulated old food debris on counter behind juice dispenser has been cleaned. Accumulated old food debris on shelve under the steam table has been cleaned. The wood shelving under the mechanical ware wash machine has been discarded and completed on 2/16/2020 at 11 AM. 12. The wet/soiled wiping cloths stored directly on food prep table has been removed and cleaned. The turbid (suspended or dissolved solids that cause the liquid to appear murky) sanitizer bucket stored inside of food prep sink has been removed and completed on 2/16/2020 at 11 AM. 13. The flex line (flexible pipe) submerged into floor sink under mechanical ware wash machine has been repaired. The facility was in process of reviewing bids for the mop sink to be replaced in the facility and completed on 2/16/2020 at 11 AM. 14. The rear door to the kitchen has been adjusted and the gap to the outside no longer exists. Findings: A review of the facility's census report dated 2/14/2020, indicated there were 98 residents residing in the facility. A review of the pest control company work order, dated 2/11/2020 indicated the pest control company provided treatments on 2/11/2020 and once a month service. According to the pest control work order, the target pest were outdoor pests. The pest control work order indicated the areas treated were the interior and the exterior of the facility. On 2/14/2020 at 3 p.m., the facility's kitchen placed was out of service and closed down by the Department of Public Health after an inspection, due to vermin (pests or nuisance animals which cause problems to humans by spreading diseases and consuming food). On 2/14/2020 at 3:13 p.m., the following were observed during an initial tour of the kitchen in the presence of the facility's Administrator (ADM), the Director of Nursing (DON), LA County Department of Public Health Environmental Health Specialist ((EHS), and an inspector who performs inspections of various facilities and properties to determine conformance with applicable State laws and County Ordinance Code sections) observed the following: a. The Facility's Director of Food Services Assistant (DFSA) and other Dietary Staff Members (DS1, and DS2) were observed discarding open and uneaten food items into garbage cans. b. Mice droppings were observed on the floor under shelving of the automatic ware wash and ware wash trays. c. The wood shelving used under automatic ware washer machine with moisture associated rotted wood damage. d. Mice droppings were observed on the floor of the dry food storage area behind a bulk dry rice container. e. Mice droppings were observed on the floor of the residents' emergency food / water storage area, and two pest control bait boxes under shelves. f. Mice droppings were observed behind the area of the cooks' line, that was not attached to the wall. g. Accumulation of dust and old food debris on counter behind the juice dispenser. h. Accumulation of dust and old food debris on the shelf under the steam table for residents' tray line. i. General debris and accumulation of food, dirt and cockroach residue observed around the electric outlets, shelves and flooring. k. Dirt accumulation with miscellaneous debris around the drains located on the floor of cleaning closet, and a missing mop sink. On 2/14/2020 at 3:18 p.m., during an interview in the presence of the ADM, DON and the EHS, the facility's Director of Maintenance (DM) stated the pest control serviceman had been at the facility, a few days prior, on 2/11/2020, and applied a treatment (pesticides or chemicals used to kill, repel, or control pests), and the DM was not sure why there were mice droppings around the facility. The DM stated the cleaning staff pour dirty mop water into the drains located on floor of cleaning closet and he also confirmed there was no mop sink. According to the DM, the dietary's staff cleans the kitchen, not the facility's housecleaning staff. A review of the Director of Maintenance's (DM), job description, dated 2003 indicated the DM's duties and responsibilities included to ensure services performed by outside vendors are properly supervised and completed in accordance with the contract. On 2/14/2020 at 3:21 p.m., during an interview in the presence of the DON, the ADM stated he would own the problem, and the facility's staff will be responsible and will clean the facility immediately. On 2/14/2020 at 3:43 p.m., during an interview, Dietary Staff Member 1 (DTS 1) stated he has seen the cockroaches in the kitchen for the past month and was told to throw out all of the food. According to DTS 1, the Director of Food Services Assistant (DFSA) told the Dietary staff to throw away the food because of the Rat Poo-Poo. DTS 1 stated the kitchen was cleaned every day after the resident's have lunch and dinner and stated, It's Ok, there are not that many la cucaracha. (Spanish for cockroaches). On 2/14/2020 at 3:50 p.m., during an interview in the presence of DTS 1, another member of the dietary's staff, DTS 3, stated he was also told to throw out the food from the kitchen because it was contaminated. DTS 3, embarrassingly smiled and stated he saw a roach in the kitchen the past week, but he did not believe it was necessary to tell the Director of Food Services (DFS) because she saw the bugs too. DTS 3 denied seeing any mice or mice droppings during his work shift at the facility. On 2/14/2020 at 3:58 p.m., during an interview in the presence of DTS 1, and DTS 3, DTS 2 stated he has seen a cockroach in the kitchen in the past month. DTS 2 stated the Pest control service comes to the facility every other week and after the pest control company sprays then the cockroaches are seen. DTS 2 stated the kitchen was swept and mopped daily after the residents have lunch and dinner, but that he has not seen any deep cleaning done in the facility's kitchen at any time. DTS 2 stated he made the DFS aware the few times he saw the cockroaches and she instructed him to tell the pest control company. On 2/14/2020 at 4:10 p.m., during an interview in the presence of DTS 1, DTS 2, and DTS 3, the DFSA shrugged her shoulders and stated she was told to throw out the residents' food but was not sure why. The DFSA stated she had seen cockroaches a while ago. The DFSA stated she was the assistant of the Director of Food Services and refused to answer any other questions about the facility's infestation or about the kitchen being closed. On 2/14/2020 at 4:17 p.m., during an interview in the presence of DTS 1, DTS 2, DTS 3, and DFSA, the DFS stated the facility kitchen is closed due to a roach infestation and mice droppings. The DFS stated she has not seen any roaches at the facility since she started working at the facility more than [AGE] years ago. The DFS stated the pest control company services the facility every other week. The DFS stated the facility's kitchen was a challenge to clean because the kitchen was an older kitchen and she was not allowed to offer the dietary staff overtime to clean the kitchen. The DFS stated she will create a schedule for the dietary staff to deep clean the facility's kitchen at least once a month to prevent further kitchen issues. A review of the facility's job description titled, Director of Food Services dated 2003 indicated the duties and responsibilities included to inspect the food storage rooms, utility/janitorial closets, for upkeep and supply control. Ensure the food services service work areas are maintained in a clean and sanitary manner. Ensure that all food storage rooms, food preparation areas are maintained in a clean, safe, and sanitary manner. On 2/16/2020 at 10:55 a.m., during a follow-up observation of the facility's kitchen in the presence of the ADM, DON, DM, the REHS and the facility's Registered Dieticians (RD1 and RD2) the following was observed: a. An unsealed loose backboard of the automatic dishwasher, and a moist floor mat crusted with food, grime, and cockroach residue. b. Crusted gooey syrup and grime around the beverage dispenser. c. Live cockroach found on the dirty sink perimeter walking around by the dishwasher. d. Fruit flies (8) perched on a container containing mechanical ware wash machine dish liquid. A review of the Los Angeles County of Public Health Official Inspection report, dated 2/16/2020 and timed at 10:30 a.m., indicated cockroaches were observed below the mechanical ware wash machine. According to the Official Inspection report a dead cockroach was observed on the floor under the mechanical ware. Two rodent bait stations on the floor of the dry food storage room adjacent to the kitchen. One rodent bait station was noted on floor of emergency food and water storage room. The Official Inspection report indicated facility may reopen its kitchen after discontinue use of rodenticide within the facility, and clean and sanitize all areas affected by cockroaches. On 2/17/2020 at 11 a.m., during a follow-up observation inspection of the outside of the facility open gaps around the doors were found. Mice droppings were observed next to the door of the electrical room. And inside the facility, mice droppings were observed next to staff lockers inside the staff lunchroom with an accumulation of dirt and old food debris. In a subsequent interview the DM stated he was not aware of the door gaps or mice droppings in and around the facility. A review of the pest control company work order, dated 2/17/2020 and timed at 2:30 p.m., indicated the pest control company provided treatments for the general interior and exterior of the facility. According to the pest control work order, the target pests were German Cockroaches and mice. The pest control work order indicated the areas treated were the interior and the exterior of the facility. A review of an article from the Los Angeles County Department of Public Health titled, Effective Management of Cockroach Infestation, retrieved on 12/6/19 at publichealth.lacounty.gov/eh/docs/specializedvencor_management, indicated the cockroaches may become pests in any structure that has food preparation or storage areas. The contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. When cockroaches that live outdoors come into contact with human excrement in sewers or with pet droppings, they have the potential to transmit bacteria that cause food poisoning if they enter into structures. A review of the Centers for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health Care Facilities, updated on 7/2019 and retrieved on 12/10/19 at https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html, indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control Included cockroaches found in health-care facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (carrier that transfers an infectious organism from one host to another). A review of the facility's policy and procedure titled, Pest Control revised 5/2008 indicated the facility maintains an ongoing pest control program to ensure the building and grounds were kept free of insects, and rodents. According to the policy maintenance services assist, when appropriate and necessary, in providing pest control services. A review of the facility's policy and procedure titled, Sanitization revised 10/2008, indicated the food service area will be maintained in a clean and sanitary manner. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, cockroaches, flies and other insects. All utensils, counters, shelves and equipment shall be kept clean, maintained and in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use of proper cleaning.

Based on observation, interview, and record review, the facility failed to conduct an ongoing monitoring of the kitchen environment and maintain an ongoing pest control service to ensure the kitchen was free from vermin (various small animals or insects that are pests or nuisance animals that spread diseases) for 98 of 98 residents. This failure resulted in a cockroach (small insects that cause spread of bacterial infection) and mice (small rodents) infestation of the kitchen and food storage environment, which placed 98 residents at risk of vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches, and mice) and had the potential for the 98 residents to experience food infection from ingesting live bacteria, food intoxication from ingesting food containing toxins from bacteria, and disease transmission that can lead to life threatening complications and death. On 2/14/2020 at 5:30 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 declared under F812 and F925. The facility's administrator (ADM) and the Director of Nursing (DON) were notified of the immediacy and seriousness of the residents' health and safety being threatened. On 2/17/2020 at 3 p.m., the Department of Public Health (DPH) notified the Administrator that the IJ was lifted after verifying and confirming on-site the facility had implemented the acceptable written plan of action as follows: 1.The kitchen was immediately placed out of service as of February 14, 2020 at 3 PM. 2. All opened and unused food items in the kitchen were immediately discarded on February 14, 2020. 3.The pest control company came to the facility on [DATE] and performed a detailed treatment of [REDACTED]. 4. All meals for the residents were being ordered from approved restaurants nothing was used from the facility's kitchen. 5. Fecal spotting on the pipelines under the mechanical ware of the wash machine was cleaned. 6. Live adult cockroach on wall at pipeline under the ware wash machine would be discarded and the area sanitized. 7. The dead cockroach on the floor under the mechanical ware wash machine was discarded and the area sanitized. Completed on 2/15/2020 at 11 AM. 8. The mice droppings on the floor in the dry storage room, on the floor behind upright coolers, on the floor behind cooks' line, on floor under the 3-compartment sink, on the floor in the emergency food and water storage room were removed. These areas were cleaned/sanitized, and were completed on 2/16/2020 at 11 AM. 9. Employee's food stored with residents' food in the two-door upright cooler was removed and completed on 2/16/2020 at 11 AM. 10. Mice droppings on the rack holding bulk rice in dry storage room were cleaned. 11. Accumulated old food debris on counter behind juice dispenser has been cleaned. Accumulated old food debris on shelve under the steam table has been cleaned. The wood shelving under the mechanical ware wash machine has been discarded and completed on 2/16/2020 at 11 AM. 12. The wet/soiled wiping cloths stored directly on food prep table has been removed and cleaned. The turbid (suspended or dissolved solids that cause the liquid to appear murky) sanitizer bucket stored inside of food prep sink has been removed and completed on 2/16/2020 at 11 AM. 13.The flex line (flexible pipe) submerged into floor sink under mechanical ware wash machine has been repaired. The facility was in process of reviewing bids for the mop sink to be replaced in the facility and completed on 2/16/2020 at 11 AM. 14.The rear door to the kitchen has been adjusted and the gap to the outside no longer exists. Findings: A review of the facility's census report dated 2/14/2020, indicated there were 98 residents residing in the facility. A review of the pest control company work order, dated 2/11/2020 indicated the pest control company provided treatments on 2/11/2020 and once a month service. According to the pest control work order, the target pest were outdoor pests. The pest control work order indicated the areas treated were the interior and the exterior of the facility. On 2/14/2020 at 3 p.m., the facility's kitchen placed was out of service and closed down by the Department of Public Health after an inspection, due to vermin (pests or nuisance animals which cause problems to humans by spreading diseases and consuming food). On 2/14/2020 at 3:13 p.m., the following were observed during an initial tour of the kitchen in the presence of the facility's Administrator (ADM), the Director of Nursing (DON), LA County Department of Public Health Environmental Health Specialist ((EHS), and an inspector who performs inspections of various facilities and properties to determine conformance with applicable State laws and County Ordinance Code sections) observed the following: a. The Facility's Director of Food Services Assistant (DFSA) and other Dietary Staff Members (DS1, and DS2) were observed discarding open and uneaten food items into garbage cans. b. Mice droppings were observed on the floor under shelving of the automatic ware wash and ware wash trays. c. The wood shelving used under automatic ware washer machine with moisture associated rotted wood damage. d. Mice droppings were observed on the floor of the dry food storage area behind a bulk dry rice container. e. Mice droppings were observed on the floor of the residents' emergency food / water storage area, and two pest control bait boxes under shelves. f. Mice droppings were observed behind the area of the cooks' line, that was not attached to the wall. g. Accumulation of dust and old food debris on counter behind the juice dispenser. h. Accumulation of dust and old food debris on the shelf under the steam table for residents' tray line. i. General debris and accumulation of food, dirt and cockroach residue observed around the electric outlets, shelves and flooring. k. Dirt accumulation with miscellaneous debris around the drains located on the floor of cleaning closet, and a missing mop sink. On 2/14/2020 at 3:18 p.m., during an interview in the presence of the ADM, DON and the EHS, the facility's Director of Maintenance (DM) stated the pest control serviceman had been at the facility, a few days prior, on 2/11/2020, and applied a treatment (pesticides or chemicals used to kill, repel, or control pests), and the DM was not sure why there were mice droppings around the facility. The DM stated the cleaning staff pour dirty mop water into the drains located on floor of cleaning closet and he also confirmed there was no mop sink. According to the DM, the dietary's staff cleans the kitchen, not the facility's housecleaning staff. A review of the Director of Maintenance's (DM), job description, dated 2003 indicated the DM's duties and responsibilities included to ensure services performed by outside vendors are properly supervised and completed in accordance with the contract. On 2/14/2020 at 3:21 p.m., during an interview in the presence of the DON, the ADM stated he would own the problem, and the facility's staff will be responsible and will clean the facility immediately. On 2/14/2020 at 3:43 p.m., during an interview, Dietary Staff Member 1 (DTS 1) stated he has seen the cockroaches in the kitchen for the past month and was told to throw out all of the food. According to DTS 1, the Director of Food Services Assistant (DFSA) told the Dietary staff to throw away the food because of the Rat Poo-Poo. DTS 1 stated the kitchen was cleaned every day after the resident's have lunch and dinner and stated, It's Ok, there are not that many la cucaracha. (Spanish for cockroaches). On 2/14/2020 at 3:50 p.m., during an interview in the presence of DTS 1, another member of the dietary's staff, DTS 3, stated he was also told to throw out the food from the kitchen because it was contaminated. DTS 3, embarrassingly smiled and stated he saw a roach in the kitchen the past week, but he did not believe it was necessary to tell the Director of Food Services (DFS) because she saw the bugs too. DTS 3 denied seeing any mice or mice droppings during his work shift at the facility. On 2/14/2020 at 3:58 p.m., during an interview in the presence of DTS 1, and DTS 3, DTS 2 stated he has seen a cockroach in the kitchen in the past month. DTS 2 stated the Pest control service comes to the facility every other week and after the pest control company sprays then the cockroaches are seen. DTS 2 stated the kitchen was swept and mopped daily after the residents have lunch and dinner, but that he has not seen any deep cleaning done in the facility's kitchen at any time. DTS 2 stated he made the DFS aware the few times he saw the cockroaches and she instructed him to tell the pest control company. On 2/14/2020 at 4:10 p.m., during an interview in the presence of DTS 1, DTS 2, and DTS 3, the DFSA shrugged her shoulders and stated she was told to throw out the residents' food but was not sure why. The DFSA stated she had seen cockroaches a while ago. The DFSA stated she was the assistant of the Director of Food Services and refused to answer any other questions about the facility's infestation or about the kitchen being closed. On 2/14/2020 at 4:17 p.m., during an interview in the presence of DTS 1, DTS 2, DTS 3, and DFSA, the DFS stated the facility kitchen is closed due to a roach infestation and mice droppings. The DFS stated she has not seen any roaches at the facility since she started working at the facility more than [AGE] years ago. The DFS stated the pest control company services the facility every other week. The DFS stated the facility's kitchen was a challenge to clean because the kitchen was an older kitchen and she was not allowed to offer the dietary staff overtime to clean the kitchen. The DFS stated she will create a schedule for the dietary staff to deep clean the facility's kitchen at least once a month to prevent further kitchen issues. A review of the facility's job description titled, Director of Food Services dated 2003 indicated the duties and responsibilities included to inspect the food storage rooms, utility/janitorial closets, for upkeep and supply control. Ensure the food services service work areas are maintained in a clean and sanitary manner. Ensure that all food storage rooms, food preparation areas are maintained in a clean, safe, and sanitary manner. On 2/16/2020 at 10:55 a.m., during a follow-up observation of the facility's kitchen in the presence of the ADM, DON, DM, the REHS and the facility's Registered Dieticians (RD1 and RD2) the following was observed: a. An unsealed loose backboard of the automatic dishwasher, and a moist floor mat crusted with food, grime, and cockroach residue. b. Crusted gooey syrup and grime around the beverage dispenser. c. Live cockroach found on the dirty sink perimeter walking around by the dishwasher. d. Fruit flies (8) perched on a container containing mechanical ware wash machine dish liquid. A review of the Los Angeles County of Public Health Official Inspection report, dated 2/16/2020 and timed at 10:30 a.m., indicated cockroaches were observed below the mechanical ware wash machine. According to the Official Inspection report a dead cockroach was observed on the floor under the mechanical ware. Two rodent bait stations on the floor of the dry food storage room adjacent to the kitchen. One rodent bait station was noted on floor of emergency food and water storage room. The Official Inspection report indicated facility may reopen its kitchen after discontinue use of rodenticide within the facility, and clean and sanitize all areas affected by cockroaches. On 2/17/2020 at 11 a.m., during a follow-up observation inspection of the outside of the facility open gaps around the doors were found. Mice droppings were observed next to the door of the electrical room. And inside the facility, mice droppings were observed next to staff lockers inside the staff lunchroom with an accumulation of dirt and old food debris. In a subsequent interview the DM stated he was not aware of the door gaps or mice droppings in and around the facility. A review of the pest control company work order, dated 2/17/2020 and timed at 2:30 p.m., indicated the pest control company provided treatments for the general interior and exterior of the facility. According to the pest control work order, the target pests were German Cockroaches and mice. The pest control work order indicated the areas treated were the interior and the exterior of the facility. A review of an article from the Los Angeles County Department of Public Health titled, Effective Management of Cockroach Infestation, retrieved on 12/6/19 at publichealth.lacounty.gov/eh/docs/specializedvencor_managment, indicated the cockroaches may become pests in any structure that has food preparation or storage areas. The contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. When cockroaches that live outdoors come into contact with human excrement in sewers or with pet droppings, they have the potential to transmit bacteria that cause food poisoning if they enter into structures. A review of the Centers for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health Care Facilities, updated on 7/2019 and retrieved on 12/10/19 at https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html, indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control Included cockroaches found in health-care facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (carrier that transfers an infectious organism from one host to another). A review of the facility's policy and procedure titled, Pest Control revised 5/2008 indicated the facility maintains an ongoing pest control program to ensure the building and grounds were kept free of insects, and rodents.According to the policy maintenance services assist, when appropriate and necessary, in providing pest control services. A review of the facility's policy and procedure titled, Sanitization revised 10/2008, indicated the food service area will be maintained in a clean and sanitary manner. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, cockroaches, flies and other insects. All utensils, counters, shelves and equipment shall be kept clean, maintained and in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use of proper cleaning.

Based on observation, interview and record review, the facility failed to follow physician orders, a resident's care plans for use of assistive devices such as bed and wheelchair alarms and floor mats and provide the necessary supervision for one of three sampled residents who had a high risk for falls with injuries (Resident 1). Resident 1 had a history of [REDACTED]. This deficient practice resulted in Resident 1 falling three times within seven (7) days. Resident 1 sustained injuries from the falls on 7/22/19 and 7/29/19, and was transferred to a general acute care hospital (GACH) for evaluation and treatment. This deficient practice had the potential to result in further falls and injuries to Resident 1 and other residents with high risk for falls. Findings: A review of Resident 1's Admission Face sheet indicated Resident 1was admitted to the facility on [DATE] with a most recent admission on 4/18/19. Resident 1's [DIAGNOSES REDACTED]. the brain that can cause changes in behavior, movements or feelings, and in levels of consciousness) and dementia (decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities). A review of a Morse Fall Risk Screen, (a fall risk assessment), dated 12/13/18, indicated Resident 1 had a score of 65 (a score of 45 and above means high fall risk). A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 6/19/19, indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required a one-person physical assist with bed mobility, dressing, eating, toilet use and personal hygiene. The MDS indicated Resident 1 required a two-person physical assist moving to or from a bed, chair and or wheelchair to a standing position. A review of Resident 1's history and physical (H/P) report, dated 7/5/19, indicated Resident 1 could make his needs known, but could not make medical decisions. A review of Resident 1's care plan, dated 7/6/19 indicated Resident 1 had high risk for falls and injury, poor judgement and safety awareness, history of falls and limited mobility. The staff's interventions included to keep Resident 1's personal items, including the call light within reach, bed in low position and to keep the room clutter free. 1.A review of Resident 1's care plan, dated 7/22/19, indicated Resident 1 had an actual fall incident on 7/22/19. The staff's interventions included to transfer Resident 1 to the hospital for evaluation, assess the resident for pain, injury, change in range of motion, mobility and level of consciousness (the state of being awake and aware of one's surroundings), provide first aid for presence of injury and to determine the cause of the fall. A review of a Situation Background Assessment and Recommendation ((SBAR) an internal communication form), dated 7/22/19 and timed at 2 p.m., indicated Resident 1 had a fall on 7/22/19 and sustained a skin tear (a wound caused by shear, friction, and/or [MEDICATION NAME] force resulting in separation of skin layers). A review of the facility's Transfer Form, dated 7/22/19 and timed at 2:10 p.m., indicated Resident 1 was totally dependent on the staff for bathing, dressing, toileting, transfers and eating. This form indicated Resident 1 who had a high fall risk, had a skin tear on the forehead measuring one by 0.5 centimeters ((cm) unit of measurement). A review of Resident 1's GACH Progress Note dated 7/23/19 indicated Resident 1 was admitted to the GACH on 7/22/19 and discharged on [DATE], following a fall in the facility that resulted in Resident 1 sustaining a frontal head hematoma (a collection of blood outside of blood vessels). A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's Morse Fall Risk Screen, dated 7/25/19, indicated Resident 1's score was higher at 75, compared to the assessment on 12/2018 of 65. A review of Resident 1's physician's orders [REDACTED]. This order also indicated the staff should monitor Resident 1's tab alarm for placement and functioning every shift. The physician order [REDACTED]. A review of Resident 1's Interdisciplinary Team Conference Record ((IDT) a group of medical professionals that work together towards a common goal for a resident), dated 7/26/19 and timed at 4 p.m., indicated on 7/22/19 at 1:20 p.m., Resident 1 was found on the floor in the room, in a right-side lying position with the wheelchair behind the resident. Resident 1 sustained injuries and was transferred to a GACH on 7/22/19 at 2:25 p.m. and returned to the facility on [DATE]. The IDT's recommendations included to use a floor mat at Resident 1's bed side, a bed alarm to remind the staff when Resident 1 attempted to get out of bed unassisted and remind the new CNAs not to leave resident with high fall risk in the room while in wheelchair. On 7/30/19 at 2:30 p.m., during an interview, the facility's Director of Nursing (DON) stated Resident 1 was at high risk for falls and had two falls with injuries within four days. The DON stated that on 7/22/19, Resident 1 who had a tendency of trying to grab a wheelchair, had an unwitnessed fall with a small laceration to the forehead and was transferred to a GACH. The DON stated that at the time of the fall, the wheelchair might not have been in Resident 1's reach and there was no wheelchair alarm to alert the staff Resident 1 was attempting to get up unassisted. A review of Resident 1's SBAR form, dated 7/27/19 and timed at 5 p.m., indicated Resident 1 who was readmitted to the facility two days prior (7/25/19), from the hospital was observed with swelling to the left wrist and hand. A review of Resident 1's nurses' progress note, dated 7/27/19 and timed at 3:30 p.m. indicated on 7/27/19, during lunch, Resident 1's family member (FM1) notified a Charge Nurse that Resident 1's left arm was swollen. The note indicated upon assessment, Resident 1's left wrist and left hand were observed to be swollen. The Note indicated Resident 1 did not know what happened to his left hand and that the left wrist was immobilized. According to this noted, Resident 1's physician ordered an x-ray (process on taking pictures of a body part to diagnose broken bones and other disorders) to be done on the resident's left wrist. A review of Resident 1's an untimed SBAR form, dated 7/29/19 indicated Resident 1 had a fall from a wheelchair on 7/29/19, and sustained an abrasion (a skin scraping or wearing away) and laceration (injury to the skin and the soft tissue) to the forehead. A review of Resident 1's nurses' progress note, dated 7/29/19 and timed at 6:38 p.m., indicated on 7/29/19 at 4 p.m., Resident 1 fell on the floor. The note indicated Resident 1 was on the floor in his room with the wheelchair next to him. The note indicated Resident 1 had a reopened frontal [MEDICAL CONDITION] measuring 2.5 cm by 2.1 cm, a left upper eye brow laceration, a 1.2 by 1.5 cm upper facial abrasion, and a 1.6 cm mid-upper lip laceration with bleeding. A review of Resident 1's Physician order, dated 7/29/19 and timed at 3:43 p.m., indicated Resident 1 should have a sensor pad alarm (a device placed on a chair or bed that makes a sound when the resident tries to get out of bed or chair unassisted), while in the wheel chair to alert the staff when the resident attempted to get up unassisted. This order also indicated the staff should to monitor the alarm for placement and functioning every shift. A review of Resident 1's Verification of Informed Consent for Use of Prolonged Devices, dated 7/29/19, indicated Resident 1 was at risk for falls and was to have a sensor pad alarm while in a wheelchair. A review of an IDT note, dated 7/30/19 and timed at 6:58 p.m., indicated on 7/29/19 at approximately 4 p.m., Resident 1 was found on the floor next to his bed, with the wheelchair on the resident's side. Resident 1 sustained injuries to the frontal head measuring 2.5 cm, a laceration on the left upper eyebrow measuring 2.1 cm, an abrasion on the left upper cheek measuring 1.2 by 1.5 cm, a laceration on the mid upper lip measuring 1.6 cm. This note indicated Resident 1 was observed with minor bleeding from the injured sites. According to this note, Resident 1 fell when a CNA was about to transfer the resident from the wheelchair to the bed. A review of the GACH Emergency Documentation, indicated Resident 1 was admitted to the GACH on 7/29/19 and discharged on [DATE], following a [MEDICAL CONDITION] and bruising to the left cheek. This documentation indicated a staff dropped Resident 1 when moving him from a wheelchair to the bed. According to this documentation, Resident 1 had a left frontal head hematoma (a collection of blood outside of blood vessels) with a superficial laceration and complained of pain to the left elbow and left upper arm. A review of a Summary of Investigation, dated 7/31/19, indicated Resident 1 had an unwitnessed fall on 7/22/19 at approximately 1:20 p.m., sustained a frontal [MEDICAL CONDITION] with minimal bleeding and was transferred to a GACH. The summary indicated Resident 1 was admitted to the GACH from 7/22/19 to 7/25/19. This report indicated Resident 1 had a high risk for fall and injury due to limited mobility, history of falls, confusion and forgetfulness. On 7/30/19 at 2:30 p.m., during an interview, the DON stated that on 7/29/19, Resident 1 had an unwitnessed fall from a wheelchair after a Certified Nursing Assistant 1 (CNA 1) left the resident in an unlocked wheelchair in his room. The DON stated that CNA 1 was newly hired to the facility and was not aware Resident 1 was a high fall risk. On 7/30/19 at 2:45 p.m., during a concurrent observation and interview, Resident 1 was observed in a reclining position in a wheelchair, in the dining room and with no wheelchair alarm. Resident 1 was observed with two lacerations on the mid forehead and the mid upper lip. The DON stated Resident 1 did not have a chair alarm in place but should have, to prevent falls and injuries to the resident. On 7/30/19 at 2:58 p.m., during an interview, CNA 2 stated that on 7/29/19, CNA 1 left Resident 1 who was very agitated unattended in his room, because CNA 1 did not know how to care for Resident 1 and Resident 1 was not supposed to be left unattended due to a history of falls. On 7/30/19 at 3 p.m., during an interview, CNA 1 stated that on 7/29/19, Resident 1 was assisted in a wheelchair to the room. CNA 1 stated that Resident 1 did not have a wheelchair alarm or a floor mat, as prescribed by the physician on 7/26/19. CNA 1 left Resident 1 in a wheelchair with an unlocked left wheel. CNA 1 stated that thirty minutes later, at approximately 3:30 p.m., Resident 1 was found on the floor. According to CNA 1, Resident 1's fall could have been prevented if Resident 1 was left in the hallway where the staff could supervise the resident. On 7/30/19 at 3:15 p.m., during an interview, the facility's Activities Director (AD) stated Resident 1 who had a history of [REDACTED]. The AD stated Resident 1 who had two recent falls from the wheelchair did not have a wheelchair alarm. On 8/1/19 at 1 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated that Resident 1 was very agitated and had a history of [REDACTED]. LVN 1 stated on 7/29/19, CNA 1 should not have left Resident 1 in the room unsupervised. LVN 1 stated Resident 1 did not have floor mat or an alarm in place on 7/29/19, when the resident fell . A review of the facility's policy titled Fall Risk Assessment, with a revised date of 3/2018, indicated the facility would identify and document resident's risk factors for falls and establish a resident centered fall preventive plan based on relevant assessment information. A review of the facility's policy titled, Accidents and Incidents, Investigating and Reporting, with a revised date of 7/2017, indicated the facility would comply with current rules and regulations governing accidents and or incidents involving a medical device.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant 8 (CNA 8) transferred one of 18 sampled residents (Resident 17) from bed to a chair in accordance with the comprehensive assessment and plan of care to prevent fall and injuries, by: 1. Failure to ensure CNA 8 used a Hoyer lift (a brand name of a patient lift machine, a type of assistive device used by a caregiver to facilitate safe patient transfers. They are often used to transfer individuals who are unable to stand or bear their full weight between a bed and a chair or other similar resting place. It involves a pad that connects to the lift frame and a hydraulic or electric pump used to lift the person out of and into the bed or other surfaces) and utilize the assistance of another staff when transferring Resident 17 from bed to wheelchair. 2. Failure to implement Resident 17's plan of care on fall risk by not using a Hoyer lift and another staff assistance when transferring Resident 17. 3. Failure to ensure CNA 8 was knowledgeable of Resident 8's plan of care and the facility provided in-service training on transferring Resident 17 using the mechanical lift and the need of an additional staff to assist with the transfers. 4. Failure to implement the facility's policy on Using a Mechanical Lifting Machine by not having two CNAs safely move Resident 17 with the mechanical lift. As a result, on 3/27/19 at 9:30 a.m. Resident 17 fell during transfer from bed to wheelchair sustaining a left knee fracture (break of the upper end of the left tibia (shinbone)), swelling and pain to both knees, and was admitted to the hospital. Findings: A review of Resident 17's Admission Record (Face Sheet) indicated Resident 17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to Resident 17's Minimum Data Set (MDS - a standardized resident assessment and care-screening tool) dated 2/23/19, Resident 17 required physical assistance by two or more staff member for transfers and one-person physical assistance with dressing, eating, toilet use and personal hygiene. The resident required a wheelchair and a Hoyer lift as assistive devices for locomotion and transfers. A review of Resident 17's History and Physical (H&P) exam dated 12/22/18, and 4/7/19, indicated Resident 17 had the capacity to understand and make decisions. A review of Resident 17's Fall Risk Assessment form dated 2/14/19, indicated Resident 17 had impaired gait (manner of walking) and the score was 51 (45 or greater represented a high fall risk). A review of the Plan of Care, developed on 5/19/16 for Resident 17's high fall risk related to poor safety awareness, visual impairment, limited mobility, and impaired gait, indicated the goal was for Resident 17 to prevent falls and injuries. The interventions included educating staff of Resident 17's assistance with activities of daily living (ADLs), ensuring the wheelchair is locked during transfers and using Hoyer lift during transfer with another staff assistance. A review of the licensed nurses' notes dated 3/27/19 indicated Resident 17 sustained a fall at 9:30 a.m. during transfer from bed to wheelchair. A review of the facility's Investigative Report dated 3/27/19, timed at 9:30 a.m., indicated CNA 8, by herself, manually transferred Resident 17 from a bed to a wheelchair, although CNA 8 was supposed to use the Hoyer lift with the help of another CNA. During transfer Resident 17's legs hit the floor while CNA 8 was holding Resident 17 around the waist. Resident 17 buckled her knees, which made Resident 17's legs quickly hit the ground. CNA 8 was caught off guard and she called out Licensed Vocational Nurse 2 (LVN 2) and CNA 6, who were in the same room taking care of Resident 17' roommate. LVN 2 and CNA 6 came to help CNA 8 when both heard Resident 17 screaming and saw CNA 8 holding Resident 17 up. Resident 17's knees were bent halfway to the floor. LVN 2 and CNA 6 assisted with placing Resident 17 in the wheelchair. Resident 17 was interviewed about what happened and Resident 17 stated she hit her legs at a device before sitting on the wheelchair, while CNA 8 was holding her. Resident 17 was asked to go back to bed for complete head to toe assessment but refused and was wheeled to attend activities. At 11:30 a.m., Resident 17 was assisted back to bed and complained of pain on both lower legs. LVN 3 and Registered Nurse 1 (RN 1) noted dark discoloration, swelling, and intact skin to both shin. LVN 3 administered Resident 17 Tylenol ([MEDICATION NAME] to treat pain) 650 milligram (mg) for pain to both legs. Resident 17's attending physician (when contacted) on 3/27/19 at 11:40 a.m., ordered STAT (immediately) x-ray (a photographic image of the internal composition of a part of the body) to both lower legs. A review of CNA 8's written statement dated 3/27/19, timed 9:33 a.m., indicated CNA 6 instructed CNA 8 on how to use the Hoyer lift to transfer Resident 17, but CNA 8 did not use it. A review of Resident 17's x-ray report on the same day of the fall (3/27/19) of the left tibia and fibula (outer bone of the leg) dated 3/27/19, indicated Resident 17 had a fracture involving the proximal tibia slightly displaced and the lateral (the side) tibial plateau (a break of the upper part of the tibia (shinbone) that involves the knee joint) and soft tissue swelling with vascular (veins and arteries) calcification present. A review of the nursing notes and physician's orders [REDACTED]. A review of GACH 1's Computerized [NAME]ography (CT or CAT - uses a combination of x-rays and a computer to create pictures of the organs, bones, and other tissues. It shows more detail than a regular x-ray) report dated 3/27/19, timed 7:07 p.m., indicated Resident 17 had suspected acute [MEDICAL CONDITION] tuberosity (oval elevation on the anterior surface of the tibia giving attachment to the patellar (knee bone) of both knees with overlying soft tissue swelling). A review of the CT report indicate evaluation was limited for technical reasons and recommendation was for further evaluation with radiographs of both knees to confirm the presence of fracture. A review of Resident 17's both knees x-ray result from GACH 1, dated 3/28/19 at 12:40 a.m., indicated there was no acute fracture, dislocation noted. X-ray report indicated the resident had severe osteopenia (when bones are weaker than normal but not so far gone that they break easily) and MRI was advised to evaluate for hairline fracture, however was not done. On 3/28/19, Resident 17 was discharged from GACH 1back to the facility under care of the resident's physician, with recommendation for orthopedics (a doctor who specializes in musculoskeletal system (bones, joints, nerves, etc.) consultation and instructions for weight bearing as tolerated. A review of Nursing Progress notes dated 3/28/19 (the day after Resident 17's injury and transfer to GACH 1), indicated at 8:30 p.m., Resident 17 returned to the facility with swelling on both lower legs and without cast or immobilizers. According to the physician's orders [REDACTED]. According to the physician's orders [REDACTED]. On 4/1/19, Resident 17 was seen by orthopedic specialist. A review of the orthopedic specialist notes dated 4/1/19, indicated Resident 17 had [DIAGNOSES REDACTED]. According to the orthopedic specialist's order dated 4/1/19, the resident was ordered weight bearing as tolerated, left leg in extension, brace to a left knee, and a physical therapy. A review of Resident 17's Joint Mobility Assessment diagram completed by Occupational Therapist (OT), dated 4/5/19, and Joint Mobility Assessment completed by Physical Therapist (PT) dated, 5/8/19, indicated Resident 17 had a fall on 3/27/19, with left knee fracture, had severe (more than 50 percent limitation) limitation in left knee mobility, had immobilizer to a left knee, and had limited flexion (the action of bending) in right knee. On 5/7/19 at 9:46 a.m., during an interview, Resident 17 stated she was in pain and pointed to her left leg. Resident 17 stated her leg was broken. On 5/7/19, at 11:59 a.m., during an interview, CNA 6 stated on the day Resident 17 fell she and LVN 2 were in the room and heard Resident 17 screaming. When they pulled the privacy curtain, Resident 17 was observed with knees bent, while CNA 8 was holding the resident by the waist. CNA 6 stated Resident 17 was heavy and CNA 8 did not use a Hoyer lift. On 5/7/19, at 12:34 p.m., during an interview, LVN 2 confirmed CNA 8 did not use the Hoyer lift on 3/27/19 and Resident 17 hit her legs on the floor. On 5/7/19, at 1:05 p.m., LVN 3 confirmed her and RN 1 noticed on 3/27/19 Resident 17 had discoloration to the shin areas and she notified the physician. On 5/7/19, at 1:34 p.m., during an interview, Director of Staff Development (DSD), stated CNA 8 was supposed to use a Hoyer lift with the physical help of another staff and CNA 6 educated CNA 8 on methods of transferring Resident 17 using a lift machine. DSD acknowledged she (DSD) did not provided in-service training on the use of lifting devices to CNA 8. DSD further stated CNA 8 worked part time and had not attended in-service training on the use of mechanical lifting devices. On 5/9/19, at 11:15 a.m., during an interview, CNA 2 stated Resident 17's feet were not strong enough to support the resident's weight. CNA 2 stated that was why she always used Hoyer lift with the help from another staff who had to operate the lift and guide the resident's feet not to touch the bar or pole of the machine during transfer. CNA 2 further stated it was necessary to use two persons' assistance during transfer with a Hoyer lift for safety reason and in case the machine get broken. CNA 2 stated DSD and DON provided an in-service on how to transfer a resident using a Hoyer lift to all CNAs, however CNA 8 was not present. On 5/9/19, at 2:51 p.m., during an interview, DON stated CNA 8 was manually transferring Resident 17 alone from a bed to a wheelchair. DON stated CNA 8 was supposed to use a Hoyer lift and another staff member assistance for transfer, however, unfortunately CNA 8 used a poor judgement and acted alone. DON stated due to CNA 8 poor judgement, Resident 17's sustained fractures. When DON was asked why should staff use a Hoyer lift or standing machine for Resident 17's transfer, DON stated Resident 17 was heavy, had muscle weakness, and could not bear weight on her legs. DON also stated staff used a mechanical device for safety reason and to prevent falls and injuries. DON stated two CNAs had to be present to transfer a resident with a Hoyer lift in order for one to guide a resident and the other staff had to operate the machine for safety and prevention of fall. On 5/10/19, at 1:20 p.m., during another interview, DON stated Interdisciplinary Team met and put forth interventions to prevent Resident 17 from having another fall and prevent other residents from falling. On 5/10/19, at 1:23 p.m., during an interview, Administrator stated Resident 17 had a fall and sustained a fracture as a result of being transferred by CNA 8 without using a Hoyer lift and another staff assistance. A review of the facility's policy titled Lifting Machine, using a Mechanical revised 1/2019, indicated the facility shall establish general principles of a safe lifting using a mechanical lifting device; before using the mechanical lift staff should use at least two nursing assistants to safely move a resident with mechanical lift.

Based on interview and record review, the facility failed to prevent Resident 6, who was at risk for falls and had a history of [REDACTED]. The facility failed to: 1. Ensure Resident 6's private caregiver was provided with education and training to provide hands on assistance to the resident when the resident up in a wheelchair. 2. Ensure Resident 6's private caregiver was trained as ordered by the physician. 3. Ensure Resident 6's risk assessment for fall while sitting in a wheelchair, was done and safety needs evaluated and implemented. This deficient practices resulted in Resident 6 fall from his wheelchair and hit his head on the floor. Resident 6 required transfer to General Acute Care Hospital 1 (GACH 1) where he was diagnosed with [REDACTED]. On [DATE], five days after the fall Resident 6 expired. Findings: A review of the Admission Record indicated Resident 6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the History and Physical (H&P) exam completed by Physician 1 on [DATE], indicated Resident 6 had a history of [REDACTED]. Resident 6 had fluctuating capacity to understand and make decisions. A review of a Physicians Order dated [DATE] indicated Resident 1 was to receive [MEDICATION NAME] (opioid (narcotic) pain medication for moderate to moderately severe pain) 50 milligrams (mg) every six hours as needed for moderate pain. There was no mediation ordered for the resident's restless leg syndrome. A review of the physician's orders [REDACTED]. Occupational Therapy was ordered on [DATE], but discontinued on [DATE]. A review of the PT Initial assessment dated [DATE], indicated the reason for the PT referral was due to Resident 6's restless leg syndrome. Resident 6 would get up right away to walk it off causing Resident 6 to fall. Resident 6's functional deficit was assessed as follows: 1. Static (not moving) standing balance - Resident 6 was able to maintain balance with handhold support and occasional minimal assistance. 2. Dynamic (moving) standing balance - Resident 6 was not able to maintain balance while turning head/trunk. 3. Balance and Risk for falls - Resident 6 was at high risk. 4. Gait Distance - Resident 6 was not unable to perform. 5. Gait with Assistive Device - front wheeled walker (FWW). 6. Gait in Level Surfaces - Resident 6 required minimal assistance ,[DATE] percent (%). Resident 6 required ,[DATE]% physical assistance with transferring from a sitting to a standing position. 7. Balance, dynamic sitting - able to maintain balance with upper extremity support (using his own upper extremities to hold on the arm rails, etc.), minimal assistance. The PT documented treatment [DIAGNOSES REDACTED]. PT was necessary for strengthening both lower extremities to improve Resident 6's safety during all functional transfers, gait with assistive device, and to improve Resident 6's tolerance to functional activities to prevent further falls. According to Resident 6's clinical record, there was no documented evidence the resident's private caregiver was provided with training as ordered and that there was a risk assessment done of Resident 6's safety needs while sitting up in a wheelchair. There was a plan of care dated [DATE] for Resident 6's high risk of falls and injury related to Resident 6's constant standing, getting out of bed, and pacing in his room. The goal was to minimize the resident's falls and injuries and to manage risk factors. The interventions included anticipating and meeting Resident 6's needs, one on one (1:1) caregiver 24 hours a day (one caregiver assigned to supervise Resident 6 at all times), assessing contributing factors, re-directing Resident 6's behavior as needed, and assisting Resident 6 with his activities of daily living (ADLs - walking, transfers, bathing, personal, hygiene, eating, and dressing). A review of Resident 6's clinical record indicated there was no documented evidence Resident 6's safety and prevention of possible fall while the resident sitting up in a wheelchair was addressed in a plan of care. A review of the licensed nursing Progress Notes dated [DATE], at 12:25 a.m., indicated Resident 6 had an episode of getting out of the bed without asking for assistance. The notes indicated Resident 6 would stand up if no one was watching him, and there was poor safety judgement. A review of the licensed nursing Progress Notes dated [DATE], at 7:43 a.m. indicated during the night shift, Resident 6 had an episode of getting out of bed without asking for assistance and only slept for 1.5 hours during the night shift. A review of the licensed nursing Progress Notes dated [DATE] timed at 11 p.m. indicated Resident 6 was noted standing up without asking for help and slept on and off and kept getting up from time to time. In the notes there was no documentation of how many times the resident got up or whether the resident was getting from the bed or wheelchair. A review of the licensed nursing Progress Notes dated [DATE], at 11:23 p.m., indicated Resident 6 had an episode of getting up unassisted with the sitter (private caregiver) at the resident's bedside. A review of the licensed nursing Progress Notes dated [DATE] at 11 p.m., documented by Licensed Vocational Nurse 1 (LVN 1), indicated Resident 6 was sitting in his wheelchair and the private caregiver was wheeling him in the hallway. At 1 a.m., Resident 6 was in his room frequently attempting to get up from the bed. At 3:30 a.m., Resident 6 was given [MEDICATION NAME] 50 mg for general pain. At 4:30 a.m. Resident 6 was in the wheelchair and private caregiver was wheeling him. Resident 6 was attempting to get up without assistance. At 5:15 a.m. Resident 6 was bleeding from the right upper eye brow with 3.0 centimeters (cm) in length by 3.0 cm in width laceration (skin cut). While the sitter was wheeling Resident 6, he suddenly moved his body forward and fell on to the floor. After falling, Resident 6 stood up by himself and was assisted by the sitter back into the wheelchair. A review of the licensed nurses notes dated [DATE] at 7:25 a.m., indicated the physician was notified of Resident 6's fall and injury and the resident was transferred to GACH 1 at 6:15 a.m., by a regular ambulance transport. The notes documented the resident did not have changes with alertness, was not in acute distress, did not have shortness of breath, did not complained of pain or dizziness, did not have changes in range of motion and the pupils were reactive to light. A review of GACH 1's Emergency Department (ER) record dated [DATE] at 6:24 a.m., indicated Resident 6's status upon ER arrival and [DIAGNOSES REDACTED]. A review of a Computed Tomography Scan (CT scan - combines a series of X-ray images taken from different angles around a body part and uses computer processing to create cross-sectional images (slices)) of the brain results dated [DATE], indicated Resident 6 had a subacute (developing slowly over 1 - 2 days) hemorrhage (bleeding) with recent blood products present. According to this report Resident 6 had a subdural hematoma to the right frontal forehead and would be transferred to GACH 2 for a higher level of care. On [DATE], Resident 6 was transferred from GACH 1 to GACH 2 in hemodynamically (means that the force at which the heart pumps blood is stable; maintaining stable blood flow in the heart and vessels is important in supporting normal organ functions) stable condition. A review of GACH 2's Discharge Summary (final report) dated [DATE], the family decided to take Resident 6 home under Hospice care (comfort care only). Resident 6 was discharged home on [DATE], in not acute distress, able to follow simple commands, to move all four extremities spontaneously. Resident 6 expired at home on [DATE]. A review of the State of California Certification of Vital Record, County of Los Angeles Department of Public Health Certificate of Death, dated [DATE], indicated Resident 6 died on [DATE], five days after the fall incident at the facility. The resident's cause of death was cardiopulmonary arrest ([MEDICAL CONDITION]), multiple organ failure, end stage [MEDICAL CONDITION] (chronic irreversible kidney failure); contributing factors included [MEDICAL CONDITION] (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues) and [MEDICAL CONDITION] (irregular, rapid heart rate that may cause symptoms like heart palpitations, fatigue, and shortness of breath). A review of the facility's Fall Investigation Summary report, dated [DATE] indicated Resident 6 was impulsive, had poor safety awareness, and would get out of bed or stand up from the wheelchair without calling for assistance. The private caregiver stated she was wheeling Resident 6 in the hallway when suddenly Resident 6 leaned forward and fell from the wheelchair. Resident 6 landed on the ground on his right side, quickly stood up, and the caregiver assisted him back to a wheelchair. The report included an interview with Resident 6's private caregiver. The private caregiver stated at around 3 a.m. she reported to the charge nurse Resident 6 was having leg pain. After the pain medication, Resident 6 was calm, layed in bed for a short period of time, then started getting out of bed and walking in the room. Resident 6 could not stay still, was not able to sleep, refused to stay in bed, and was pacing in the room until 5 a.m. The fall incident happened at around 5:15 a.m., on [DATE]. The report included an interview with LVN 1, who stated giving Resident 6 [MEDICATION NAME] for leg pain at around 3:30 a.m., and informed the private caregiver to assist Resident 6 back to bed because the medication may cause drowsiness. LVN 1 indicated Physician 1 was aware of Resident 6's standing up, getting out of bed, and inability to sleep. The Fall Investigation Summary Conclusion dated [DATE], indicated the fall incident due to Resident 6's movement was unexpected. On [DATE] at 3:45 p.m., during an interview, the Occupational Therapist (OT) stated Resident 6's static and dynamic (in motion) balance was fair for sitting and standing balance. The OT stated fair meant Resident 6 could sit with some movement and not completely losing his balance. The OT stated Resident 6 required hands-on contact assistance in sitting back and not to lean forward. On [DATE] at 10:30 a.m., during an interview, PT stated she discussed safety in the wheelchair with Resident 6, private caregiver and the family on [DATE]. PT stated they reviewed the importance of staying seated in the chair, use of the arm rest while sitting and/or standing in/from the chair, locking the wheel chair, the impact of the resident's impulsive behavior and multiple falls at home. However, PT stated the specific conversations was not documented. On [DATE], at 3:15 p.m., during an interview, the Director of Nursing (DON) stated Resident 6 had a sitter (private caregiver) from the day of admission. On [DATE], at 12:45 p.m., during an interview, the DON stated they followed all of the nursing approaches in Resident 6's care plan, however, a fall risk care plan had not been developed upon admission. DON stated Resident 6's behavior was discussed with the physician, admission coordinator and the DON prior to the resident's admission (could not remember the specific date) to the facility. On [DATE] at 2:45 p.m., during an interview, the Administrator stated on [DATE], according to the surveillance video the private caregiver was wheeling Resident 6 around the facility for 30 to 40 minutes. The Administrator stated Resident 6 was using his legs to propel himself while the caregiver pushed the wheelchair. The Administrator stated Resident 6 lunged from the chair and then jumped right up and sat back in the wheelchair. On [DATE] at 3:15 p.m., the Administrator showed the Evaluator the video footage of Resident 6's fall incident from the Administrator's cellular telephone, in the presence of the DON. On the video footage, Resident 6 leaned forward and rolled out the wheelchair onto the floor, head first. Resident 6 went from lying to a sitting position after one to two seconds and sat on the floor. The video footage ended with the resident still sitting on the floor. During review of the video footage, the private caregiver was not observed assisting Resident 6 upon falling. Resident 6 did not lunge out of the wheelchair or suddenly get out of the wheelchair as stated by the Administrator, the DON, or per LVN 1 documentation. On [DATE] at 12:45 p.m., during an interview, the DON stated she knew Resident 6 was able to move, could suddenly lean forward and fall out of the wheel chair. The DON stated she could only account for what she saw and based it on Resident 6's behavior. Two calls were made and messages left for the private caregiver (sitter), however, no return phone call was received. On [DATE] at 12:30 p.m., during an interview, the registered nurse (RN) supervisor stated she was informed by the sitter/caregiver Resident 6 leaned forward, fell out of the wheelchair and hit his head. The resident sat up on the floor by himself, stood up and attempted to sit in the wheelchair by himself, however, the sitter/caregiver assisted him. The RN supervisor stated she did not witness the actual fall, however, when she came to assess the resident he was still attempting to get out of the wheelchair unassisted. The RN supervisor stated at the beginning of the shift she instructed the sitter/caregiver to keep a close eye on Resident 6 and to stay close to the resident because of his behavior of getting up unassisted. According to the facility's policy and procedure titled Fall Management Program dated ,[DATE], the purpose was to provide residents with a hazard free environment, adequate supervision, and reduce the risk factors leading to falls and injury.

Based on interview and record review, the facility failed to follow its policy and procedures and the physician's order in administering two intravenous antibiotics (into the vein (IV); used to treat infections) for one of the three sampled residents (Resident 1). Resident 1, who had a history of [REDACTED]. This deficient practice resulted in Resident 1 having left foot pain and an abnormal x-ray of osteo[DIAGNOSES REDACTED], which required a transfer to the general acute care hospital (GACH). Findings: A review of an Admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 10/5/17, indicated Resident 1 was not impaired with cognitive skill (thought process) and ability to make decision. According to the MDS, Resident 1 required limited to extensive assistance from staff for all activities of daily living. A review of a Physician Order sheet, dated 9/28/17, indicated Resident 1 had an order to receive IV [MEDICATION NAME] (antibiotic) 50 milligram (mg) every 12 hours at 9 a.m. and 9 p.m., and IV [MEDICATION NAME] (antibiotic) 3.375 mg every eight hours for [MEDICAL CONDITION] of the left foot, to be given at 10 a.m., 6 p.m., and 2 a.m. A review of Resident 1's Medication Administration Record [REDACTED]. Resident 1 missed a total of three doses of IV [MEDICATION NAME] and six doses of IV [MEDICATION NAME]. A review of the facility's dispensing pharmacy consultant's typed note, dated 10/16/17, indicated they were requested to do a medication review specifically for the use of the [MEDICATION NAME] antibiotic for Resident 1. The note indicated the resident missed many doses of the antibiotic therapy for the [DIAGNOSES REDACTED]. On 10/19/17 at 10:55 a.m., during an interview, the director of nursing (DON) stated that the Registered Nurse (RN), who was scheduled to administer Resident 1's IV antibiotics, had a family emergency and had to travel out of the country. The DON stated that he did not know Resident 1 was not receiving the IV antibiotic medications as prescribed by the physician. The DON stated, I have since given an in-service to all staff regarding medication administration. On 10/19/17 at 11:30 a.m., during an interview, the administrator stated that he was not aware that Resident 1 was not receiving his medications as per the physician's orders. On 10/23/18 at 1:10 p.m., an interview was conducted with the dispensing pharmacist (Pharmacist 1). Pharmacist 1 stated that all IV antibiotic medications were delivered to the facility on time for Resident 1 and she did not know why it was not given to the resident. Pharmacist 1 stated that if antibiotics were not given regularly as prescribed by the physician that it could affect the treatment and lead to the organisms developing resistance to the medications. On 1/23/18 at 12:30 p.m., during an interview, Resident 1 stated that he was not aware that he was not receiving all his medications as was ordered by the physician. A review of Resident 1's radiology report, dated 10/17/17, with a clinical indication to have the x-ray was due to pain. The x-ray of the resident's left foot wound indicated compared to the previous exam that osteo[DIAGNOSES REDACTED] could not be excluded. A review of an electronic nurse's note, dated 10/18/17 and timed at 10:21 a.m., indicated the physician requested for Resident 1 to be transferred to the GACH for further evaluation of the left foot osteo[DIAGNOSES REDACTED] after the X-ray results. Another X-ray result, dated 10/18/17 and timed at 12:17 p.m., indicated the X-ray of Resident 1's left foot was done due to pain and that the resident had a previous amputation of the left fourth toe due osteo[DIAGNOSES REDACTED]. The report indicated there was osseous (bone) destruction and erosion (gradual destruction) suspicious for osteo[DIAGNOSES REDACTED]. A review of the GACH's emergency room (ER) note, dated 10/18/17 and timed at 2 p.m., indicated Resident 1 was sent to the ER due to pain and a left foot ulcer to rule out osteo[DIAGNOSES REDACTED]. The note indicated Resident 1's left foot had a foul smelling wound drainage, but was currently receiving IV antibiotics (sic). The GACH were not made aware that Resident 1 had missed many doses of IV antibiotics. A review of the facility's undated policy and procedure (P/P) titled, IV Medication Administration, indicated the purpose was to effectively and safely administer a prescribed medication to destroy organisms causing infections in the amounts that would maintain serum levels to promote healing. The P/P also indicated that antibiotics shall be available and administered within the State guidelines and the nurse shall maintain therapeutic serum levels of the antibiotic dosing by: 1. Giving the medication at regular intervals as ordered by the physician a 2. Not skipping doses or altering the dosing schedule once started. 3. Administering medication no more than one hour before or one hour after the scheduled dose time.