Every finding on record at Kennedy Care Center

Based on observation, interview, and record review, the facility failed to create a comprehensive and individualized care plan for one of the three sampled residents (Resident 1) who was diagnosed with oropharyngeal (the middle part of the throat located directly behind the mouth) phase dysphagia (difficulty or discomfort when swallowing). This deficient practice had the potential to cause miscommunication between the direct caregivers on what interventions to provide for Resident 1. During a review of Resident 1's admission record indicated that Resident 1 was admitted on [DATE] with diagnoses Including oropharyngeal phase dysphagia, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN-high blood pressure). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 7/16/2026, the MDS indicated Resident 1 had moderate cognitive impairment (slight, noticeable decline in memory and thinking skills that is greater than normal aging). The MDS indicated Resident 1 required between partial/moderate and substantial/maximal assistance for most Activities of Daily Living (ADLs such as oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, putting on/taking off footwear, sit to stand, toilet transfer, sit to lying, sit to stand, toilet transfer, chair/bed-to-chair transfer. walk 10 feet, and personal hygiene). The same MDS indicated Resident complaints of difficulty swallowing or pain when swallowing and was on a mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids). During a review of Resident 1's physician order dated 7/14/2026 indicated, CCHO [Controlled Carbohydrate] diet IDDSI [International Dysphagia Diet Standardizations Initiative] 6: Soft and Bite Sized texture, Thin Liquids consistency. During a review of Resident 1's care plan initiated 7/15/2026 with focus, Speech Therapy: Resident requires Skilled SLP [speech language pathology] (Swallow) due to Complaints of difficulty or pain with swallowing, Dysphagia. The interventions included the following:Diet as orderedDiet texture modifications as indicated During a concurrent interview and record review of Resident 1's care plan with the Director of Nursing on 8/21/2026 at 4 pm, the DON stated that care plans were plans of care anticipated about interventions to provide to residents while in the facility. The DON stated that all residents must have care plans initiated to ensure that everyone is aware about what protocols or interventions to be carried out for a particular resident. The DON stated that the care plans must be individualized and specific based on the resident's condition, diagnosis, medications etcetera. The DON confirmed that Resident 1 was on CCHO soft bite size diet and verified that the interventions were not specific stating that they should have indicated the exact order and texture ordered for Resident 1. During a review of the facility policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, reviewed 2/2026, indicated, A comprehensive, person-centered care plan that Includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs Is developed and Implemented for each resident. The same P&P indicated under policy interpretation and implementation including the following: The interdisciplinary team (IDT), In conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.The care plan Interventions are derived from a thorough analysis of the Information gathered as part of the comprehensive assessment.

Based on observation, interview, and record review, three of four sampled residents (Residents 1, 2, and 3), who were identified as at high risk for elopement (Refers to an unauthorized departure. It happens when a patient or resident leaves a hospital, clinic, or care facility without notifying the staff or before being officially discharged . This is especially critical when the patient requires supervision for their own safety) and with wandering behaviors (locomotion behavior associated with conditions like dementia or autism. It involves repetitive, aimless, or disoriented pacing, roaming, or leaving a safe area) the facility failed to: Ensure the reception/lobby area is monitored and supervised after 6 PM when the receptionist signs out/leaves for the day to prevent residents at risk for elopement from eloping the facility. Ensure the wander guards (An electronic monitoring device worn on ankle or wrist to help ensure safety by alarm activation if a resident attempts to leave a safe area) and wanderguard alarm doors were functional to alert staff when a resident(s) attempts to elope/leave the facility. Resident 1 and Resident 3 wore a Wander Guard device at all times according the careplan (CP) and medication administration record (MAR) for 5/2026. These deficient practices resulted in Resident 1 eloping from the facility on [DATE] at 5:50 PM without staff awareness, remaining missing overnight for over 20 hours and missed scheduled medications. On [DATE] at 3:35 PM, 2 (two) police officers returned Resident 1 to SNF 1. Resident 1 complained of right phalangeal (finger) to the right pinky (small) pain, had right finger discoloration and left knee abrasions and discoloration. On [DATE] at 7:36 PM, Resident 1 was transferred to a general acute care hospital (GACH) 1 for further evaluation and management where Resident 1 was diagnosed with Phalangeal fracture (break in bone) to the right pinky with splint (brace/immobilizer) and placing Resident 1, Resident 2 and Resident 3 at increased risk for elopement/repeated, fall with injuries, hospitalization and death. Findings 1. During a review of Resident 1's admission Record, dated [DATE], indicated Resident 1 was admitted with diagnoses of dementia, diabetes type 2 (DM2- high blood sugar), and metabolic encephalopathy (disturbance of brain function, it causes confusion, memory loss and coma in severe cases). A review of Resident 1's Minimum Data Set (MDS- resident assessment tool), dated [DATE], indicated Resident 1 had severely impaired cognition (ability to think, remember and reason). The MDS indicated Resident 1 required supervision (oversight, encouragement, or cueing) for eating, oral hygiene, and personal hygiene. The MDS indicated Resident 1 required partial assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for toileting, shower/bathe, upper and lower body dressing, putting on footwear, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed transfer, and walk 10 feet. A review of Resident 1's Nursing Elopement and Wandering Risk Observation/Assessment dated [DATE] at 9:59 AM, indicated Resident 1 was at high risk for elopement due to history of attempting to leave a previous facility, dementia, and metabolic encephalopathy. The Nursing Elopement and Wandering Risk Observation/Assessment indicated that Resident 1 required a Wander Guard due to exhibiting unsafe wandering (moving from place to place without a fixed plan) behavior and that Resident 1 had expressed/verbalized that she planned to leave the facility. A review of Resident 1's Care Plan (CP - (a personalized document that outlines a resident's needs, goals, and the specific services required to achieve them, ensuring consistent and holistic care) Elopement: Resident is at risk for elopement/exit seeking/wandering related to altered cognitive status, dated [DATE], indicated the facility staff will attempt to refocus Resident 1 when the resident is exhibiting elopement/exit seeking/wandering behavior, check exit, stairwell, and door alarms on a routine schedule for operability. The CP indicated that licensed nurses will check the function of the wander guard alarm per manufacturer recommendations, check placement of wander alarm every shift, and equip with a device that alarms when resident wanders. The CP indicated to check for proper functioning of the device and alarms every shift and monitor whereabouts frequently. A review of Resident 1's CP Risk for Falls r/t generalized weakness dated [DATE] indicated Resident 1 needs a safe environment with adequate, glare-free light, a working and reachable call light, and even floors to prevent falls. A review of Resident 1's Medication Administration Record (MAR) dated [DATE], indicated Resident 1 had a Wander Guard bracelet that expired [DATE] and was last documented wearing the Wander Guard bracelet on [DATE] during the morning shift (7 am to 3 pm). The MAR indicated Resident 1 missed the medications: Lantus SoloStar (medication to treat diabetes) on [DATE] that was scheduled for 9 PM. Losartan (medication to treat high blood pressure) on [DATE] that was scheduled for 9 PM. The MAR indicated Resident 1received Acetaminophen (pain medication) on [DATE] at 7:06 PM after returning to the facility due to complaints of right and left hand pain. A review of Resident 1's SNF 1 Timeline of Events, the timeline indicated the following: On [DATE] at 3 PM Resident 1 seen by Certified Nursing Assistant (CNA) 1 in her room during initial rounds On [DATE] at 4 PM Resident 1 seen walking around the facility On [DATE] at 5:30 PM Resident observed in her room with the Charge Nurse 1 On [DATE] at 6 PM Resident seen wandering around station 1 in the front lobby while drinking coffee. On [DATE] at 6:30 PM Resident not noted in the facility. On [DATE] at 6:57 PM Administrator informed Resident 1 is missing from the facility. On [DATE] at 7:15 PM Administrator notified Los Angeles Police Department about Resident 1 missing. On [DATE] at 3:15 PM Police called facility to confirm Resident 1 had been located. On [DATE] at approximately 3:35 PM Resident returns to the facility with noted left knee abrasions (superficial injuries), and right-hand discoloration. On [DATE] at 7:36 PM Resident 1 is sent out to the hospital for further evaluation. On [DATE] at approximately 12:15 PM Resident 1 returns to facility from hospital with noted phalangeal (the anatomical term for the individual bones that make up the fingers and toes) fracture (break in the bone) to the right pinky with splint (a rigid or flexible medical device used to protect, support, and immobilize injured body parts like fractured bones) in place. On [DATE] Resident 1 discharged from facility to a lateral skilled nursing facility. A review of Resident 1's Interact Situation Background Assessment Recommendation (SBAR - is a structured communication framework that can help teams share information about the condition of a patient or team member or about another issue your team needs to address.) Summary for Providers dated [DATE] at 6:50 PM, indicated . upon routine rounds (Resident 1) was not in her assigned room. Staff search resident room & surrounding premises. Search expand to nearby streets and surrounding areas. Law enforcement notified at approximately 7:28 PM. A review of Resident 1's 72-hour Charting dated [DATE] at 9:32 PM, indicated Resident 1 refused medication (unspecified) at 5 PM. The 72-hour Charting further indicated that a certified nursing assistant (CNA) 1 reported that Resident 1 was missing from (Resident 1's0 room around 5;50 PM. A review of Resident 1's undated nor timed Note Text Admission/re-admission Summary Note documented by, Director of Staff Development (DSD), indicated Resident 1 noted with right (rt) finger discoloration with no pain. may transfer to GACH 1 for further evaluation and management. A review of Resident 1' Nurse's Note dated [DATE] at 5:53 PM, indicated Resident 1 was safely returned to facility . she (Resident 1) was looking for job. A review of Resident 1's Nurse's Note dated [DATE] at 7:36PM, indicated Resident 1 was transferred to GACH 1 . body check done noted left knee abrasions and right had discoloration . A review of Resident 1's Nurse's Note dated [DATE] at 12:15 PM, indicated Resident 1 was readmitted from the hospital . noted with Phalangeal (finger) to the right pinky (small) with splint (brace/immobilizer) in place A review of Resident 1's Social Service Note dated [DATE] at 2:12 PM, indicated Resident 1 will be discharged today [DATE] at 5 PM going to . A review of Resident 1's Nurse's Note late entry dated [DATE] at 12:37 PM, indicated Resident 1 was brought back by 2 (two) police officers at 3:35 PM yesterday ([DATE]). Corrective time for assessment for elopement assessment. A review of Resident 1's Psychological Note dated [DATE] at 2:46 PM, indicated Resident 1 returned to the facility following hospitalization. Resident 1 had been informed of (Resident 1) transfer to another facility and a family member had approved of the resident's transfer. 2. A review of Resident 2's admission Record, dated [DATE], indicated Resident 2 was admitted with diagnoses of dementia and encephalopathy. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had moderate impaired cognition. Resident 2 was independent (no help or staff oversight at any time) for eating, oral hygiene, personal hygiene, toileting, shower/bathe, upper and lower body dressing, putting on footwear, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed transfer, and walk 150 feet. A review of Resident 2's Elopement and Wandering Risk Assessment dated [DATE] indicated Resident 2 was at risk for elopement and required a Wander Guard due to exhibiting unsafe wandering behavior. A review of Resident 2's CP Resident is at risk for elopement/ wandering, dated [DATE], indicated apply wander guard as ordered, check placement, and function as indicated. 3. A review of Resident 3's admission Record, dated [DATE], indicated Resident 3 was admitted with diagnosis of chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems), fractures, and encephalopathy. A review of Resident 3's MDS, dated [DATE], indicated Resident 3 had moderate impaired cognition. Resident 3 required supervision (oversight, encouragement, or cueing) assistance for eating, oral hygiene, personal hygiene, toileting, shower/bathe, upper and lower body dressing, putting on footwear, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed transfer, and walk 150 feet. A review of Resident 3's Elopement and Wandering Risk Assessment dated [DATE] indicated Resident 3 was at risk for elopement due to exhibiting unsafe wandering behavior. A review of Resident 3's CP Resident is at risk for elopement/ wandering, dated [DATE], indicated check exit, stairwell and door alarms on a routine schedule for operability, check function of wander alarm per manufacturer recommendations. Check placement of wander alarm every shift. A review of Resident 3's MAR dated [DATE], indicated Resident 3 had a physician order to wear a Wander Guard bracelet due to wandering/exit seeking behaviors. During an interview on [DATE] at 12:08 PM with the Administrator, the Administrator stated Resident 1 had been discharged from the facility on [DATE] to a more appropriate facility due to her recent elopement from the facility on [DATE]. The Administrator stated on [DATE] at approximately 6:50 PM, Social Services (SS) informed the Administrator that Resident 1 was missing from the facility and that he notified the police department. The Administrator stated that he called around to different hospitals to search for Resident 1.The Administrator stated the SS, Director of Nursing (DON) and himself went to look/search for Resident 1 the evening of [DATE] but were unable to find Resident 1. The Administrator stated that the next day, on [DATE] at approximately 3:15 PM, a police officer called the facility to report Resident 1 was located and would be returning to the facility. The Administrator stated he did not report to California Department of Public Health that Resident 1 had eloped from the facility because he was more concerned with finding Resident 1. The Administrator stated he interviewed the Charge Nurse (CN) 1 who was working on [DATE] and had reported seeing Resident 1 on [DATE] at around 5:15 PM when the CN 1 went to offer Resident 1 medication in Resident 1's room, however Resident 1 refused th medication The Administrator stated that CNA 1 helped translate for Resident 1, and t5hat on [DATE] at around 5:45 PM Resident 1 agreed to take the medication and that was the last time CN 1 saw Resident 1. The Administrator stated that according to the facility's internal investigation, a visitor accidentally held the door open for Resident 1 to leave the facility on [DATE]. During a phone interview on [DATE] at 12:34 PM with CNA1, stated that she had started her shift on [DATE] at 3 PM and noted Resident 1 in Resident 1's room during CNA1's initial rounds. CNA1 stated that on the same day at around 3:30 PM, CNA1 assisted Resident 1 to the restroom. On the same day at around 4 PM, Resident 1 was observed walking around the facility and at around 4:45 PM, CNA1 offered Resident 1 some hot coffee. CNA1 stated around 5 PM, and the charge nurse asked her to talk to Resident 1 because Resident 1 was refusing to take medications. CNA1 stated she talked to Resident 1, who is Spanish speaking, and encouraged Resident 1 to take the medications. CNA1 stated Resident 1 is confused and always talked about wanting to go home to her family/loved one. CNA1 stated that on the same she passed Resident 1's dinner tray around 5:45 PM, and last saw Resident 1 at around 6 PM wandering around Nurses' Station 1 in the front lobby while drinking coffee. CNA1 stated she did not see Resident 1 in the facility at approximately 6:30 PM and reported to the charge nurse that Resident 1 was not around. A phone interview was attempted on [DATE] at 12:35 PM with the Charge Nurse CN1 who was on shift on [DATE] and a voice message was placed. No answer or call back received from CN1. During an interview on [DATE] at 1:17 PM with SS, SS stated that on [DATE] at approximately 6:50 PM, SS was in the facility when SS was notified that Resident 1 could not be located. SS stated that SS reported to the Administrator to that Resident 1 was missing. SS stated staff searched the building and drove around the surrounding areas in search of Resident 1. SS stated that on [DATE], two police officers found Resident 1 sitting on a porch at Resident 1's former house. SS stated that the people living in the house observed Resident 1 sitting outside on the front porch and called the police after they asked Resident 1 to leave but Resident 1 refused. The distance from where the police found Resident 1 was about 15 minutes' drive from the facility, which is not a walking distance. SS stated that Resident 1 must have taken a bus to get to the location where the police located Resident 1. During an interview on [DATE] at 2 PM with the Receptionist, the Receptionist stated he was working his regular shift on [DATE] and was getting ready to leave/sign out at around 6 PM. The Receptionist stated that on [DATE], he observed Resident 1 walking around the front lobby near the entrance/exit of the facility as Resident 1 usually does. The Receptionist stated he usually sits at a desk in front of the facility entrance/exit and checks in visitors who come in and that he can see people come and go. The Receptionist stated on [DATE] unsure of the time, Resident 1 waved hi to him as she was walking by the lobby like she usually does. The Receptionist stated Resident 1 was not carrying bags and was dressed in her normal clothing. The Receptionist stated no wander guard alarms went off the day of [DATE], even when Resident 1 walked around the front lobby of the facility. The Receptionist stated before leaving his shift, on [DATE] at around 6 PM, he informed Registered Nurse (RN) 1 that he was leaving for the day. During a phone interview on [DATE] at 2:28 PM with RN 1, RN 1 Supervisor stated that on [DATE] she worked from 3-11 PM at the facility. The RN1 supervisor stated that upon arrival to her shift, she began her usual workflow which consists of responding to physician messages, walk around and help other staff with residents, and rounds on residents. The RN1 supervisor stated she had not noticed Resident 1 was not in the facility until about 6:50 PM when one of the CNAs (unable to recall the name), assigned to the same area as Resident 1's room, informed her that Resident 1 was not in the facility nor in Resident 1's room.RN1 stated that CN1 reported to her that Resident 1 was unaccounted for, and that Resident 1's dinner tray was still in her room untouched. RN1 stated she immediately initiated a page code yellow and staff began searching for Resident 1 in other resident rooms, closets, under the bed, restrooms, and the Administrator was notified. The RN1 stated no wander guard alarms went off in the facility the evening of [DATE]. During an interview on [DATE] at 1:45 PM with the DSD, the DSD stated that on [DATE] she was asked to assess Resident 1 after returned back to the facility at approximately 4 PM. The DSD stated Resident 1 mentioned that she had gone out to look for a job to have some money but could not recall how she ended up at the old address. The DSD stated Resident had a right small finger discoloration and was not wearing the Wander Guard bracelet. The DSD stated Resident 1 was unable to recall how she got the injury to her right hand. The DSD stated on Resident 1's admission assessment, the DSD noted Resident 1's blood sugar (BS) level was elevated/high at 202. The DSD stated that the medical doctor (MD) gave an order to transfer Resident 1 to GACH for further evaluation. The DSD stated GACH diagnosed Resident 1 with a fracture to the right small finger. During a concurrent observation and interview on [DATE] at 2:47 PM with the DSD, in front of the lobby, Resident 2 was asked to approach the exit door to ensure that her Wander Guard that was on her right wrist was functioning correctly. The DSD acknowledged and stated that the door alarms did not trigger as and when Resident 2 approached the exit door. Resident 2 stood in front of the exit door and no alarm sounded to alert staff Resident 2 was near an exit door. The DSD stated the wander guard bracelet was not working or that the wander guard battery was dead. The DSD stated that Resident 1, Resident 2, and Resident 3required a Wander Guard bracelets due to the residents being at high risk for elopement. The DSD stated that Resident 1 was discharged from the facility on [DATE]. The DSD stated any resident with an elopement assessment score of 10 or higher is required to wear a wander guard bracelet. The DSD did not know when the Wander Guard alarm system was last checked per manufacturer instructions. During a concurrent observation and interview on [DATE] at 2:59 PM with Licensed Vocational Nurse (LVN)1, during the facility Resident Council meeting, Resident 3 was asked to show the LVN1 her Wander Guard bracelet to ensure it was on correctly. Resident 3 stated I don't even know what a Wander Guard is. LVN1 checked both wrists and ankles on Resident 3 and stated no Wander Guard was on as required per physician's order. LVN1 stated she thought she saw Resident 3's wander guard bracelet on the morning of [DATE] at 8 AM, even though she could not remember the location of where Resident 3 had it on. LVN1 stated Resident 3 has a history of taking her Wander Guard off. During an interview on [DATE] at 3:17 PM with the DON, the DON stated Resident 1 had eloped on [DATE] and believes Resident 1 took the bus to go to the resident's old house/address where the resident and family member used to live, and that' s where the police found (Resident 1) on [DATE]. The DON stated, it is the facility's responsibility to redirect residents who are at risk for elopement and demonstrating wandering behavior in the facility. The DON stated Resident 1 who has dementia, is fall risk, and has chronic health conditions like diabetes is at risk of serious injury or death, such as traffic related injuries, dehydration, malnutrition, falls, becoming lost and unable to find way back, exploitation or abuse. DON stated delay in receiving necessary medications or medical treatment could worsen confusion, anxiety, or behavioral symptoms. The DON stated the wander guard is a critical component of the facility's elopement prevention program, it provides staff with immediate notification when an at-risk resident attempts to exit through a protected door. The system should be tested routinely to ensure it is functioning properly. If the system is not working properly, residents are at risk for leaving the facility unnoticed, delayed staff response to attempted exits, elopement resulting in injury of death, increased risk of falls or accidents outside the supervised environment, exposure to environmental hazards and unsafe conditions, inability of staff to implement timely interventions to prevent an unsafe exit. The DON verified the alarms failed to sound when Resident 2 approached the door, which placed Resident 2 at risk for elopement. The DON stated that elopement is a reportable event, and the facility is responsible for reporting to appropriate agencies withing the required timeframes so that a timely investigation and implementation of corrective actions to prevent recurrence. The DON stated failure to report delays external review and may allow systemic issues to go unaddressed, impacting resident safety. During a review of the Resident Wristband Transmitter (Wander Guard) manufacturer instructions, undated, indicated, it is very important to test your Resident Wristband Transmitters on a regular basis. It is the facility's responsibility to implement a regular testing procedure. The manufacturer recommends testing Resident Wristband Transmitters Daily. To test Resident Wristband Transmitter: Take door system tester and pass tester withing proximity of resident wearing Resident Wristband Transmitter. Door system tester will display whether the Resident Wristband Transmitter is transmitting correctly and will give warning in case of low battery. A review of the facility's investigation, the facility was unable to determine why the Wander Guard system failed to activate when Resident 1 exited the facility. A review of the facility's policy and procedures (P&P) titled Wandering and Elopement dated 2/2026 indicated, if a resident is missing and not located, notify law enforcement officials and volunteer agencies as necessary. During a review of the facility's P&P titled Unusual Occurrence Reporting dated 2/2026, indicated, the facility will report to appropriate agencies of occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and or regulations within 24 hours of such incident or as required by federal and state regulations. A written report detailing the incident and actions taken by the facility shall be sent to the state agency within 48 hours of reporting the event or as required by federal and state regulations.

Based on interview and record review, the facility failed to ensure an allegation involving an incident of unknown source resulting in serious bodily injury was reported to the California Department of Public Health (CDPH-state agency who ensures oversight of state and federal regulations to long term care facilities) immediately, but not later than two hours after becoming aware of the incident, for one of four sampled residents (Resident 1) by failing to report that Resident 1 eloped (unauthorized departure of a resident from an around-the-clock care setting) from the facility on on 5/5/2026 at 5:50 PM. Resident 1 remained missing overnight and was returned to the facility by two police officers on 5/6/2026 at 3:35 PM two police officers. On 5/6/2026 at 7:36 PM, Resident 1 was transferred to a general acute care hospital (GACH) where the Resident 1 was diagnosed with fractured (broken) right fifth finger of unknown origin. This deficient practice delayed notification to the state agency responsible for oversight and investigation of incidents involving potential abuse, neglect, or injuries of unknown source, delaying external review of the circumstances surrounding Resident 1's elopement and injury.Findings: During a review of Resident 1's admission Record, dated 4/19/2026, indicated Resident 1 was admitted with diagnoses including dementia (progressive impaired ability to think, remember, or make decisions that interferes with daily activities), diabetes mellitus type II (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as fuel), and metabolic encephalopathy (a disturbance of brain function that may cause confusion and impaired cognition). During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool), dated 4/22/2026, indicated Resident 1 had severe impaired cognition (ability to think, remember and reason) . Resident 1 required supervision (oversight, encouragement, or cueing) for eating, oral hygiene, and personal hygiene. Resident 1 required partial assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for toileting, shower/bathe, upper and lower body dressing, putting on footwear, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed transfer, and walk 10 feet. During a review of Resident 1's Elopement and Wandering Risk Assessment, dated 4/22/2026, indicated Resident 1 was assessed as high risk for elopement due to dementia, metabolic encephalopathy, a history of attempting to leave a previous facility, unsafe wandering behaviors, and verbalizing intent to leave the facility. The assessment indicated Resident 1 required a Wander Guard device. During a review of facility investigation of elopement, Resident 1 eloped from the facility on 5/5/2026 at approximately 6:30 PM and was discovered missing at approximately 6:50 PM. Resident 1 remained missing overnight until located by law enforcement on 5/6/2026 at approximately 3:15 PM and returned to the facility at approximately 3:35 PM. During a review of the May 2026 Medication Administration Record (MAR), Resident 1 missed physician-ordered medications scheduled for 9:00 PM on 5/5/2026 while absent from the facility. The MAR further indicated Resident 1 complained of bilateral hand pain and received Acetaminophen on 5/6/2026 at 7:06 PM. During an interview on 6/23/2026 at 12:08 PM, the Administrator stated he was notified on 5/5/2026 at approximately 6:50 PM that Resident 1 was missing from the facility. The Administrator stated he immediately contacted the local police department, telephoned area hospitals, and, along with the Director of Nursing (DON) and Social Services (SS), searched the surrounding community for Resident 1. The Administrator stated Resident 1 was located by law enforcement on 5/6/2026 and returned to the facility. The Administrator further stated he did not report the elopement to the California Department of Public Health because he was more concerned with locating Resident 1. During an interview on 6/23/2026 at 1:17 PM with SS, SS stated that on 5/5/20296 at approximately 6:50 PM, SS was in the facility when SS was notified that Resident 1 could not be located. SS stated that SS reported to the Administrator to that Resident 1 was missing. SS stated staff searched the building and drove around the surrounding areas in search of Resident 1. SS stated that on 5/6/2026,two police officers found Resident 1 sitting on a porch at Resident 1's former house. SS stated that the people living in the house observed Resident 1 sitting outside on the front porch and called the police after they asked Resident 1 to leave but Resident 1 refused. The distance from where the police found Resident 1 was about 15 minutes' drive from the facility, which is not a walking distance. SS stated that Resident 1 must have taken a bus to get to the location where the police located Resident 1. During an interview on 6/23/2026 at 1:45 PM, the Director of Staff Development (DSD) stated DSD assessed Resident 1 upon return to the facility on 5/6/2026 and observed discoloration of Resident 1's right fifth finger. The DSD stated Resident 1 was transferred to the hospital for further evaluation and subsequently returned with a diagnosis of a fractured right fifth finger. During an interview on 6/23/2026 at 3:17 PM, the Director of Nursing (DON) stated Resident 1's elopement was a reportable event. The DON stated the facility is responsible for reporting such incidents to the appropriate agencies within the required timeframes so a timely investigation and implementation of corrective actions can occur. The DON stated failure to report delays external review of the incident and may allow systemic issues affecting resident safety to remain unaddressed. During a review of the facility's policy and procedures (P&P) titled Wandering and Elopement dated 2/2026 indicated, if a resident is missing and not located, notify law enforcement officials and volunteer agencies as necessary. During a review of the facility's P&P titled Unusual Occurrence Reporting dated 2/2026, indicated, the facility will report to appropriate agencies of occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and or regulations within 24 hours of such incident or as required by federal and state regulations. A written report detailing the incident and actions taken by the facility shall be sent to the state agency within 48 hours of reporting the event or as required by federal and state regulations.

Based on observations, interview, and record review, the facility failed to ensure nursing staff maintained current cardiopulmonary resuscitation (CPR) certification in accordance with the standards of nursing practice for one of five sampled employees, Infection Prevention Nurse (IP). This deficient practice was identified during an employee records review and had the potential to place residents at risk for delayed or ineffective response during resident emergencies including cardiac arrest and respiratory failure. Findings: During a brief facility tour and observation on [DATE] at 9:25 AM, IP nurse was observed in the hallways and resident care areas. During a review of employee records on [DATE] at 1:45 PM, five employee records were reviewed for the following items: Hire date, state licensure number and expiration date, CPR expiration date, background check, and mandatory abuse prevention trainings completion. During a review of IP nurse employee records on [DATE] at 1:45 PM, employee record indicated, IP nurse hiring date as [DATE]. There was no evidence that a CPR certification had been acquired and/or renewed prior to the expiration date. During a record request and verification process on [DATE] at 10:51 AM, the facility director of nursing (DON) emailed the surveyor, IP nurse is in the process of renewing her CPR card, temporarily removed from schedule pending renewal of CPR certification. During a telephone interview on [DATE] at 12:08 PM with the director of staffing development (DSD), DSD stated, direct patient care staff and licensed staff are required to have a CPR card to work in the facility. CPR recertification and training are important because it is a way to develop skills to assist residents during emergencies including cardiac arrests. DSD further stated, IP nurse is a new hire as of February 2026, did not provide CPR certification to the facility upon hiring. DSD agreed it is a deficiency and not according to the standards of practice for licensed staff to provide resident care without proper credentials including CPR certification.During a telephone interview on [DATE] at 12:25 PM with the DON, DON stated staff cannot be on the floor providing care for residents without the proper credentials including current CPR certification. CPR certification is required because it is a training tool providing the skills for staff to participate during resident medical emergencies. DON acknowledged the deficiency the facility should have followed up and ensured IP nurse has acquired a current CPR certification. During a review of the facility's policy and procedures (P&P) titled Staffing, Sufficient and Competent Nursing, reviewed February 2026, the P&P indicated Competent staff: Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by the state law.

Based on interview, observation and record review, the facility failed to maintain a safe, and functional environment for residents, staff and visitors by failing to ensure one of two entry doors in the facility was free from mechanical and/or electrical failure and in a safe operating condition.This deficient practice resulted to the theft of Resident 1's mobile phone by an unhoused individual (HL 1) who entered the facility without staff awareness on 1/9/2026, placing all residents, staff, and visitors at risk of avoidable abuse and misappropriation of property.Findings:During a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), malignant neoplasm of the endocrine pancreas (a rare type of cancer that starts as a growth of cells in the pancreas), muscle weakness (weakening, shrinking, and loss of muscle) and difficulty in walking. During a review of the Minimum Data Set (MDS - resident assessment tool) dated 1/10/2026, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 1 required moderate assistance to total dependence from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Vortex Industries, LLC (door service company), receipt dated 1/9/2026, the receipt indicated, Main entry door: performed inspection and found that the closer no longer had latching force and was not closing the door properly. Opened the valve up all the way and it was dead, the closing force was also not responding properly and wanted to slam with the valves barely opened.During an interview with Maintenance Director (MTD) on 2/17/2026 at 10:51 a.m., MTD stated that the front door of the facility was recently fixed by an outside vendor due to some error in the parts of the door, the magnet that holds the door to make sure that the door would close automatically was not working properly. MTD stated that the doors are checked frequently by maintenance staff to ensure that they are working properly. MTD stated that he does not have a maintenance log where he keeps documentation of door entrances maintenance check. During an interview with Resident 1's Family Member (R1FM) on 2/17/2026 at 11:06 a.m., R1FM stated, in the morning of 1/9/2026, an unhoused individual entered the facility without facility's staff knowledge, stayed and slept in one of the beds where Resident 1 was staying. R1FM stated, Resident 1 pressed the call light multiple times upon discovering HL1 was sleeping in the same room as hers and acted strange, but no staff answered her call light for a while. R1FM further stated, Resident 1 felt terrified of the incident and felt unsafe while in the facility. R1FM stated, they discovered in the morning that Resident 1's mobile phone was missing and reported it to the facility staff.During an interview with Licensed Vocational Nurse 1 (LVN 1) on 2/17/2026 at 12:09 p.m., LVN 1 stated, she noticed HL1 was in Resident 1's same room early morning of 1/9/2026 but they didn't have a resident assigned in that bed. LVN 1 asked HL1 what he was doing in the facility, where HL1 stated, he checked in while holding and showing her a mobile phone. LVN 1 stated, HL1 looked like a homeless person and was carrying a plastic bag that looked like a grocery bag. LVN 1 escorted HL1 out from the facility upon realizing that he did not belong in the facility. LVN 1 stated, she did not document the incident and she did not report it to the management and staff. LVN 1 further stated, they have issues with the front door of the facility where it doesn't completely close all the way and locked from the outside upon entering the door.During an interview with Administrator (ADM) on 2/17/2026 at 1:16 p.m., ADM stated, an HL1 entered the facility without staff's knowledge and stole Resident 1's mobile phone on 1/9/2026. ADM stated, an outside vendor was consulted to check their front entrance door. ADM stated, the outside vendor had to replace parts of the door because it was not working properly.During a review of facility's P&P titled, Maintenance Service, review date 4/2025, the P&P indicated that, Maintenance Service shall be provided to all areas of the building, grounds, and equipment. Functions of maintenance personnel include, but are not limited to: maintaining the building in good repair and free from hazards. The maintenance director is responsible for maintaining records/reports: inspection of building; work order request; maintenance schedules.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of four sampled residents, (Resident 1) by failing to: Ensure Resident 1 was assessed and evaluated after an incident of theft and misappropriation of property by an unhoused individual (HL 1) who gained access to the facility without consent on 1/9/2026.Ensure a complete documentation of the incident was completed and documented according to facility's policy and procedure (P&P) titled, Charting and Documentation, and Abuse, Neglect, Exploitation and Misappropriation Prevention Program.These deficient practices placed Resident 1 in delayed intervention to provide treatment and care and to ensure safety of Resident 1 and possibly all other residents, staff and visitors in the facility.Findings:During a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), malignant neoplasm of the endocrine pancreas (a rare type of cancer that starts as a growth of cells in the pancreas), muscle weakness (weakening, shrinking, and loss of muscle) and difficulty in walking.During a review of the Minimum Data Set (MDS - resident assessment tool) dated 1/10/2026, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 1 required moderate assistance to total dependence from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS also indicated that Resident 1 experienced mood symptoms such as little interest or pleasure in doing things, feeling down, depressed or hopeless and trouble falling or staying asleep, or sleeping too much during half or more of the days, with totaling severity score of 10 (indicates moderate to severe symptoms of depression).During an interview with Resident 1's Family Member (R1FM) on 2/17/2026 at 11:06 a.m., R1FM stated, in the morning of 1/9/2026, an unhoused individual entered the facility without facility's staff knowledge, stayed and slept in one of the beds where Resident 1 was staying. R1FM stated, Resident 1 pressed the call light multiple times upon discovering HL1 was sleeping in the same room as hers and acted strange, but no staff answered her call light for a while. R1FM stated they discovered in the morning that Resident 1's mobile phone was missing and reported it to the facility staff. R1FM further stated, Resident 1 felt terrified of the incident and felt unsafe while in the facility and R1FM and Resident 1 both requested the facility to transfer her to another facility.During an interview with Licensed Vocational Nurse 1 (LVN 1) on 2/17/2026 at 12:09 p.m., LVN 1 stated, she noticed HL1 was in Resident 1's same room early morning of 1/9/2026 but they didn't have a resident assigned in that bed. LVN 1 asked HL1 what he was doing in the facility, where HL1 stated, he checked in while holding and showing her a mobile phone. LVN 1 stated, HL1 looked like a homeless person and was carrying a plastic bag that looked like a grocery bag. LVN 1 escorted HL1 out from the facility upon realizing that he did not belong in the facility. LVN 1 stated, she did not document the incident and she did not report it to the management and staff. LVN 1 stated, she did not check upon Resident 1 and she did not assess Resident 1 if she was affected by the incident. LVN 1 stated, she does not know how long HL1 stayed in the room and what he did the entire time he was in the facility. LVN 1 further stated, they have issues with the front door of the facility where it doesn't completely close all the way and locked from the outside upon entering the door which is how HL1 gained access to the facility.During an interview with Director of Nursing (DON) on 2/17/2026 at 12:48 p.m., DON stated, she was made aware of the incident that happened on 1/9/2026 by the Administrator (ADM) that a person (HL1), with no business to be in the facility, gained access to the facility without staff's knowledge and stayed in one of the bed where Resident 1 was admitted to. DON stated, they investigated the incident and they found out that the front door was broken and was not completely closing and locking upon opening. DON stated, it was also reported to them that Resident 1's mobile phone went missing after HL1 gained access to the facility.During a follow-up interview and concurrent record review with DON on 2/17/2026 at 1:01 p.m., DON reviewed Resident 1's medical record and stated, there was no documentation of the incident that happened with Resident 1 and HL1 and no documentation if any assessment was completed with Resident 1 after the incident. DON stated, there should be documentation of the incident to validate and support what the staff did during the incident and ensure resident was safe after the incident.During a review of facility's P&P titled, Charting and Documentation, review date 4/2025, the P&P indicated that, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facility communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Documentation of procedures and treatments will include care-specific details, including: the date and time the procedure/treatment was provided, the assessment date and/or any unusual findings obtained during the procedure/treatment.During a review of facility's P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, review date 4/2025, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including,but not necessarily limited to:a. facility staff;b. other residents;c. consultants;d. volunteers;e. staff from other agencies;f. family members;g. legal representatives;h. friends;i. visitors; and/orj. any other individual.Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Investigate and report any allegations within timeframes required by federal requirements. Protect residents from any further harm during investigations.

Based on interview and record review, the facility failed to implement their policy regarding reporting of theft and misappropriation of property and to submit a conclusion report of investigation within five days or in accordance with state or federal law for one of four sampled residents (Resident 1). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of theft and misappropriation of property was investigated which can also lead to a delay in prevention of further misappropriation of property and undetected type of abuse for all residents, staff and visitors in the facility. Cross Reference F602Findings: During a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), malignant neoplasm of the endocrine pancreas (a rare type of cancer that starts as a growth of cells in the pancreas), muscle weakness (weakening, shrinking, and loss of muscle) and difficulty in walking.During a review of the Minimum Data Set (MDS - resident assessment tool) dated 1/10/2026, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 1 required moderate assistance to total dependence from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS also indicated that Resident 1 experienced mood symptoms such as little interest or pleasure in doing things, feeling down, depressed or hopeless and trouble falling or staying asleep, or sleeping too much during half or more of the days, with totaling severity score of 10 (indicates moderate to severe symptoms of depression).During a review of Resident 1's medical record, as of 2/17/2026, there was no personal inventory list that was documented and inventoried during Resident 1's stay in the facility. During an interview with Medical Record Director (MRD) on 2/17/2026 at 12:28 p.m., MRD stated and confirmed that Resident 1's personal belongings were not inventoried and documented in Resident 1's medical records.During an interview with Resident 1's Family Member (R1FM) on 2/17/2026 at 11:06 a.m., R1FM stated, in the morning of 1/9/2026, an unhoused individual entered the facility without facility's staff knowledge, stayed and slept in one of the beds where Resident 1 was staying. R1FM stated, Resident 1 pressed the call light multiple times upon discovering HL1 was sleeping in the same room as hers and acted strange, but no staff answered her call light for a while. R1FM further stated, Resident 1 felt terrified of the incident and felt unsafe while in the facility. R1FM stated they discovered in the morning that Resident 1's mobile phone was missing and reported it to the facility staff.During an interview with Licensed Vocational Nurse 1 (LVN 1) on 2/17/2026 at 12:09 p.m., LVN 1 stated, she noticed HL1 was in Resident 1's same room early morning of 1/9/2026 but they didn't have a resident assigned in that bed. LVN 1 asked HL1 what he was doing in the facility, where HL1 stated, he checked in while holding and showing her a mobile phone. LVN 1 stated, HL1 looked like a homeless person and was carrying a plastic bag that looked like a grocery bag. LVN 1 escorted HL1 out from the facility upon realizing that he did not belong in the facility. LVN 1 stated, she did not document the incident and she did not report it to the management and staff. LVN 1 stated, she did not check upon Resident 1 and she did not assess Resident 1 if she was affected by the incident. LVN 1 stated, she does not know how long HL1 stayed in the room and what he did the entire time he was in the facility. LVN 1 stated, the Certified Nurse Assistant (CNA) assigned to Resident 1 also noticed HL1 in the same room and thought that there was a new resident assigned to that bed. LVN 1 further stated, they have issues with the front door of the facility where it doesn't completely close all the way and locked from the outside upon entering the door.During an interview with Director of Nursing (DON) on 2/17/2026 at 12:48 p.m., DON stated, she was made aware of the incident that happened on 1/9/2026 by the Administrator (ADM) that a person (HL1), with no business to be in the facility, gained access to the facility without staff's knowledge and stayed in one of the bed where Resident 1 was admitted to. DON stated, they investigated the incident and they found out that the front door was broken and was not completely closing and locking upon opening. DON stated, it was also reported to them that Resident 1's mobile phone went missing after HL1 gained access to the facility. DON stated, they investigated the incident and was able to retrieve back the mobile phone, but it was broken when it was returned to the facility. DON stated, this incident was not reported to the district office because it did not meet their criteria of reporting theft and misappropriation of property.During a follow-up interview and concurrent record review with DON on 2/17/2026 at 1:01 p.m., DON reviewed Resident 1's medical record and stated, there was no documentation of the incident that happened with Resident 1 and HL1 and no documentation if any assessment was completed with Resident 1 after the incident. DON stated, there should be documentation of the incident to validate and support what the staff did during the incident and ensure resident was safe after the incident.During an interview with Administrator (ADM) on 2/17/2026 at 1:16 p.m., ADM stated, an HL1 entered the facility without staff's knowledge and stole Resident 1's mobile phone on 1/9/2026. ADM stated, this incident was investigated internally and was reported to the Police due to the theft of Resident 1's mobile phone by an unknown person who gained access in the facility without staff's knowledge. ADM stated, there was an issue with their front entry door and it was not locking and closing completely. ADM stated, this incident was not reported to the state licensing/certification agency because it did not meet their criteria of reporting to the district office. When asked what the criteria are that the facility needs to report to the district office, ADM did not answer and looked on his mobile phone while being interviewed.During a review of facility's policy and procedures (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, review date 4/2025, the P&P indicated, All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility. Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury, or within 24 hours of allegation that does not involve abuse or result in serious bodily injury. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone. Findings of all investigations are documented and reported. The individual conducting the investigation as a minimum:. documents the investigation completely and thoroughly. Follow-up Report: Within five business days of the incident, the administrator will provide a follow-up investigation report.During a review of facility's P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, review date 4/2025, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:- Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property- Investigate and report any allegations within timeframes required by federal requirements.

Based on interviews and record reviews, the facility failed to ensure adequate supervision and security measures by failing to:Protect one of four sampled residents (Resident 1), from misappropriation (the unauthorized, improper, or unlawful use of funds or other property for purposes other than that for which intended) of property and personal belongings.Document and list inventory of Resident 1's personal belongings upon admission according to facility's policy and procedures (P&P) titled, Personal Property.These deficient practices resulted in the theft of Resident 1's mobile phone by an unhoused individual (HL 1) while Resident 1 was in the facility.Findings:During a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), malignant neoplasm of the endocrine pancreas (a rare type of cancer that starts as a growth of cells in the pancreas), muscle weakness (weakening, shrinking, and loss of muscle) and difficulty in walking.During a review of the Minimum Data Set (MDS - resident assessment tool) dated 1/10/2026, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 1 required moderate assistance to total dependence from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS also indicated that Resident 1 experienced mood symptoms such as little interest or pleasure in doing things, feeling down, depressed or hopeless and trouble falling or staying asleep, or sleeping too much during half or more of the days, with totaling severity score of 10 (indicates moderate to severe symptoms of depression).During a review of Resident 1's medical record, as of 2/17/2026, there was no personal inventory list that was documented and inventoried during Resident 1's stay in the facility. During an interview with Medical Record Director (MRD) on 2/17/2026 at 12:28 p.m., MRD stated and confirmed that Resident 1's personal belongings were not inventoried and documented in Resident 1's medical records.During an interview with Resident 1's Family Member (R1FM) on 2/17/2026 at 11:06 a.m., R1FM stated, in the morning of 1/9/2026, an unhoused individual entered the facility without facility's staff knowledge, stayed and slept in one of the beds where Resident 1 was staying. R1FM stated, Resident 1 pressed the call light multiple times upon discovering HL1 was sleeping in the same room as hers and acted strange, but no staff answered her call light for a while. R1FM further stated, Resident 1 felt terrified of the incident and felt unsafe while in the facility. R1FM stated, they discovered in the morning that Resident 1's mobile phone was missing and reported it to the facility staff.During an interview with Licensed Vocational Nurse 1 (LVN 1) on 2/17/2026 at 12:09 p.m., LVN 1 stated, she noticed HL1 was in Resident 1's same room early morning of 1/9/2026 but they didn't have a resident assigned in that bed. LVN 1 asked HL1 what he was doing in the facility, where HL1 stated, he checked in while holding and showing her a mobile phone. LVN 1 stated, HL1 looked like a homeless person and was carrying a plastic bag that looked like a grocery bag. LVN 1 escorted HL1 out from the facility upon realizing that he did not belong in the facility. LVN 1 stated, she did not document the incident and she did not report it to the management and staff. LVN 1 stated, she did not check upon Resident 1 and she did not assess Resident 1 if she was affected by the incident. LVN 1 stated, she does not know how long HL1 stayed in the room and what he did the entire time he was in the facility. LVN 1 stated, the Certified Nurse Assistant (CNA) assigned to Resident 1 also noticed HL1 in the same room and thought that there was a new resident assigned to that bed. LVN 1 further stated, they have issues with the front door of the facility where it doesn't completely close all the way and locked from the outside upon entering the door.During an interview with Director of Nursing (DON) on 2/17/2026 at 12:48 p.m., DON stated, she was made aware of the incident that happened on 1/9/2026 by the Administrator (ADM) that a person (HL1), with no business to be in the facility, gained access to the facility without staff's knowledge and stayed in one of the bed where Resident 1 was admitted to. DON stated, they investigated the incident and they found out that the front door was broken and was not completely closing and locking upon opening. DON stated, it was also reported to them that Resident 1's mobile phone went missing after HL1 gained access to the facility. DON stated, they investigated the incident and was able to retrieve back the mobile phone but it was broken when it was returned to the facility.During a follow-up interview and concurrent record review with DON on 2/17/2026 at 1:01 p.m., DON reviewed Resident 1's medical record and stated, there was no documentation of the incident that happened with Resident 1 and HL1 and no documentation if any assessment was completed with Resident 1 after the incident. DON further stated, there was no documentation of Resident 1's personal belongings inventory upon admission. DON stated, there should be documentation of the incident to validate and support what the staff did during the incident.During a review of facility's P&P titled, Personal Property, reviewed date 4/2025, the P&P indicated, Resident belongings are treated with respect by facility staff, regardless of perceived value.The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary. The facility promptly investigated any complaints of misappropriation or mistreatment of resident property. During a review of facility's P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, review date 4/2025, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident propertyInvestigate and report any allegations within timeframes required by federal requirements.During a review of facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, review date 4/2025, the P&P indicated, All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The individual conducting the investigation as a minimum:. documents the investigation completely and thoroughly.

Based on observation, interview, and record review the facility failed to implement their infection control policy for one of five sampled residents (Resident 2). Resident 2, who was on enhanced barrier precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, microorganisms resistant to most antibiotics]), the facility failed to ensure protective gown was used when Resident 2 was repositioned in bed on 12/30/25 at 8:39 a.m.This deficient practice had the potential to spread infection to other residents and staff.During a review of admission Record indicated the facility admitted Resident 2 on 11/13/25 and re-admitted on [DATE] with diagnoses including cerebrovascular (CVA, loss of blood flow to a part of the brain) with left side weakness, reduced mobility and generalized muscle weakness. During a review of Resident 2's Care Plan initiated on 11/16/25 indicated Resident 2 required EBP during high-contact care activities due to the presence of chronic wounds. The Care Plan goal indicated EBP will be appropriately utilized to reduce the risk of transmission of MDRO. The care plan interventions included utilizing the use of Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) by using including gowns and gloves during high contact resident care activities.During a review of Resident 2's Minimum Data Set (MDS- resident assessment tool), dated 12/29/25 indicated Resident 2 had moderately impaired cognitive skills. The MDS indicated Resident 2 was dependent (helper does all of the efforts) on staff for toileting hygiene, shower/bathe, upper/lower body dressing and putting on/taking off footwear. Resident 2 needed substantial assistance (helper does more than half the effort) for oral hygiene and set-up assistance with eating. During an observation on 12/30/25 at 8:39 a.m., Resident 2 was lying in bed with a breakfast tray at his bedside. Certified Nurse Assistant 1 (CNA1) entered Resident 2's room. CNA 1 was wearing gloves but had no protective gown. CNA 1, using Resident 2's bed linens, pulled up and repositioned Resident 2 so that Resident 2 can eat breakfast.During a follow-up interview on 12/30/25 at 8:46 a.m. CNA 2 stated he did not wear a protective gown while repositioning Resident 2 because he did not know Resident 2 was on EBP. During an interview on 12/30/25 at 8:47 a.m. Director of Staff Development (DSD) stated Resident 2 was on EBP due to multiple wounds. DSD stated Resident 2's name posted outside his room had an orange circle next to Resident 2's name to indicate that Resident 2 was on EBP. DSD stated CNA 1 should wear protective gown and gloves when performing high contact care activities like repositioning or changing Resident 2 to prevent the transmission of infections. During a review of the facility's policy and procedure (P&P) titled Enhanced Barrier Protections, reviewed on 4/25, the P&P indicated EBPs are utilized to prevent the spread of MDROs to residents. The same Policy indicated EBP refers to infection prevention and control interventions designed to reduce the transmission of MDROs during high contact resident care. Gloves and gowns are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Examples of high contact resident care activities requiring the use of gowns and gloves for EBPs included dressing, transferring and providing bed mobility.

Based on observation, interview, and record review, the facility failed to ensure over the counter medications (OTC) were labelled with the date when the containers were first opened for one of one medication cart reviewed. During observation on 12/30/25 at 9:56 a.m., one container of acetaminophen (medication for short term relief of minor aches and pain) and one container of docusate sodium liquid (DSS, medication to relieve constipation) had no date indicating when they were first opened. This deficient practice had the potential to administer the medications to residents beyond the recommended days of use after opening the container. During observation and concurrent interview on 12/30/25 at 9:56 a.m. with Licensed Vocational Nurse (LVN 2), the acetaminophen and DSS containers were found in the medication cart that had no dates indicating when they were initially opened. During concurrent interview, LVN 2 stated the acetaminophen and the DSS did not have a date when it was opened. LVN 2 stated the acetaminophen and the DSS should have a date written on the containers when it was first opened .so we know how long we can use it for. During an interview on 12/30/25 at 1:07 p.m., the director of nursing (DON) stated the acetaminophen and the DSS containers should have the dates when it was initially opened written on the container to know how long .it is safe to administer the medications. During review of the facility's policy and procedure (P&P) titled Medication Labelling and Storage reviewed on 4/25, the P&P indicated labelling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. [NAME]-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on observation, interview, and record review the facility failed to follow physician order to administer medication based on professional standards of clinical practice for one of five sampled residents (Resident 1). For Resident 1, the facility failed to administer the Nicotine (an addictive poisonous chemical found in tobacco) Patch (medication used to help stop smoking cigarettes)14 milligrams (mg- unit of measurement) per 24hours (14mg/24hrs) for smoking cessation. This failure had the potential to result in unmet care needs, ineffective management of smoking cessation and compromise Resident 1's health.During a review of the admission Record indicated the facility admitted Resident 1 on 12/3/25 with diagnoses including tobacco use and generalized muscle weakness. During a review of Resident 1's Physician Order dated 12/5/25 at 9:15 a.m., indicated an order for Nicotine Patch 14mg./24 hours apply one patch transdermal (application of medication through the skin) one time a day for smoking cessation for six weeks and remove per schedule. During a review of the Minimum Data Set (MDS- resident assessment tool), dated 12/10/25, indicated Resident 1 was cognitively intact. Resident 1needed substantial assistance (helper does more than half the effort) for toileting hygiene, shower/bathe, lower body dressing and putting on/taking off footwear. Resident 1 needed moderate assistance (helper does less than half the effort) with upper body dressing and supervision with eating and oral hygiene. During observation of medication administration and concurrent interview on 12/30/25 at 8:11 a.m., Licensed Vocational Nurse (LVN 1) stated Resident 1's Nicotine Patch was not available. During follow-up interview on 12/30/25 at 10:15 a.m., LVN 1 stated Resident 1's physician needs to be notified that the Nicotine Patch was not available. LVN 1 stated Resident 1 can have withdrawals or side effects if the nicotine patch is not administered. During an interview on 12/30/25 at 1:07 p.m., the director of nursing (DON) stated the Nicotine Patch was a house supply and was available for administration to Resident 1. DON stated LVN 1 should have obtained the nicotine patch from the medication room. During a review of the facility's policy and procedure (P&P) titled Administering Medications reviewed on 4/25 indicated medications are administered in a safe and timely manner and as prescribed. The same Policy indicated the medications are administered in accordance with prescriber orders, including any required timeframe.

Based on observation, interview, and record review, the facility failed to ensure staff follow physician's order and facility's policy with wearing personal protective equipment (PPE-a barrier precaution which includes the use of gloves, gown, mask, face shield, when anticipating coming in contact with blood, body fluids or other communicable toxins or agents) when providing care to one of three sampled residents (Resident 2) who was on an enhanced barrier precaution (utilized to prevent the spread of multi-drug resistant organisms) room. This deficient practice placed residents at a higher risk of acquiring and transmitting infections to other residents, staff and visitors in the facility.During a review of Resident 2's admission Record, it indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including sepsis (a life-threatening blood infection), urinary tract infection (UTI- an infection in the bladder/urinary tract), and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 9/5/2025, indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 2 required maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 2's Order Summary Report (OSR) dated 8/31/2025, the OSR indicated, physician ordered, Enhanced Barrier Precautions during high contact resident care activities. During a concurrent interview and observation with Licensed Vocational Nurse 2 (LVN 2) on 9/11/2025 at 9:56 a.m., LVN 2 was observed inside Resident 2's room and changing Resident 2's incontinent brief while Resident 2 was lying on her side. LVN 2 stated, I'm changing the resident right now. LVN 2 was observed not wearing complete PPE while providing close contact care to Resident 2. During a follow-up interview with LVN 3 on 9/11/2025 at 9:50 a.m., LVN 3 stated, Resident 2 asked to be checked if her incontinent brief was wet, so she went ahead and checked Resident 2's incontinent brief. LVN 3 stated, she was not wearing the full PPE because she was in and out of the room and forgot to put a complete PPE back on. When asked what type of transmission-based precaution Resident 2 was on, LVN 3 stated, I think she was on droplet precaution (safety measures used to stop the spread of germs that travel in the small, wet drops that come from a person's mouth or nose when they cough, sneeze, or talk). During an interview with Director of Nursing (DON) on 9/11/2025 at 1:12 p.m., DON stated, residents who are on enhanced barrier precautions, staff must wear full PPE which included gowns, gloves, goggles or face shield if needed when dealing with body fluids. DON stated, if staff do not wear full PPE while providing close contact care, it puts others at risk of infection. DON further stated, Resident 2 was on an enhanced barrier precaution, not droplet precaution for transmission-based precaution. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, revised on 4/2025, the P&P indicated, Enhanced Barrier Precautions (EBP) are utilized to prevent the spread of multi-drug resistance organisms (MDROs - bacteria that are resistant to more than one antibiotic and can cause serious infections) to residents. EBP refer to infection prevention and control interventions designed to reduce the transmission of MDROs during high contact resident care activities. Examples of high contact resident care activities requiring the use of gown or gloves for EBPs include: dressing, bathing/showering, providing hygiene or grooming, changing briefs or assisting with toileting, transferring, providing bed mobility, changing linens, prolonged, high-contact with items in the resident's room, with resident's equipment or with resident's clothing or skin, device care or use and wound care.

Based on interview and record reviews, the facility failed to ensure resident received treatment and care in accordance with professional standards of practice for one of three sampled residents, (Resident 1) by failing to follow and implement physician's order and when Resident 1's blood pressure was elevated according to facility's policy and procedure titled, Changes in Resident's Condition or Status.This deficient practice placed Resident 1 in delayed intervention to provide treatment for urinary tract infection (UTI- an infection in the bladder/urinary tract) as required per facility's policy and procedure upon changes in condition.During a review of Resident 1's admission Record, it indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including toxic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), obstructive and reflux uropathy (a condition in which the flow of urine is blocked and urine flows backward from your bladder into your kidneys) and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 6/20/2025, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 required maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS also indicated Resident 1 has an indwelling urinary catheter (a soft hollow tube which is passed into the bladder to drain urine, for persons who cannot empty their bladder in the usual way). During a review of Resident 1's Care Plan (CP) for indwelling catheter: urinary retention: dated 6/16/2025 and revised on 9/2/2025, the CP indicated a goal of, (Resident 1) will show no signs and symptoms (s/sx) of urinary infection. During a concurrent interview and record review with Director of Nursing (DON) on 9/11/2025 at 12:42 p.m., DON stated, on 8/23/2025, Resident 1 complained of pain and weakness and staff notified the Medical Doctor 1 (MD 1). DON stated, she interviewed Registered Nurse 1 (RN 1) and found out that MD 1 ordered for a urine sample to be collected and to test for UTI, but it was not carried out by RN 1. DON reviewed Resident 1's medical record and stated the order for urine sample was not entered in Resident 1's medical record, and there was no change of condition documentation completed on 8/23/2025 when Resident 1 complained of pain and weakness. DON stated the urine sample order for Resident 1 was missed and delayed for two days. DON stated, Resident 1 had a delay in the care and treatment. During a review of facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, reviewed date 4/2025, the P&P indicated, The nurse will notify the resident's attending physician or physician on call when there has been a(an): i. specific instruction to notify the physician of changes in the resident's condition. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. During a review of facility's P&P titled, Urinary Tract Infection/Bacteriuria - Clinical Protocol, review date April 2025, the P&P indicated, The physician will order appropriate treatment for verified or suspected UTIs and/or urosepsis based on a pertinent assessment.

Based on interview and record review the facility failed to ensure residents' information was not sent to the personal cell phones of facility staff members. This deficient practice had the potential for unauthorized release of residents' information to the public. During an interview on 9/11/25 at 9:06 a.m., restorative nursing assistant (RNA 1, a certified nursing assistant (CNA) with specialized training in rehabilitation skills) stated she received text messages on her personal cellphone from the rehabilitation department regarding residents who would need to be on the RNA program. RNA 1 stated the text messages would include the name of the residents and their room number. During an interview on 9/11/25 at 10:18 a.m. the physical therapist (PT) stated when a resident needs to be on the RNA program, a group text message would be sent to the director of rehabilitation, the physical therapist, occupational therapist, director of staff development and the RNA. The PT stated the text messages would include the name of the residents, their room number and the specific RNA program. The PT stated the purpose of the text message was for the group to know that there is an RNA program for the resident. During an interview on 9/11/25 at 10:26 a.m., certified nursing assistant (CNA 2) stated she receive text messages on her personal cellphone that would include the name of the resident, the care they would need and their room number. During an interview on 9/11/25 at 1:16 p.m., the director of nursing (DON) stated .personal phones should not be used when the patients (residents) name and room number are included. DON further stated don't transmit resident information to staff personal phone. DON stated this is due to the Health Insurance Portability and Accountability Act (HIPAA, establishes standards to protect people's medical records and other protected health information). During a review of the facility's policy and procedures (P&P) titled Telephones, Employee Use of reviewed on 4/25, the P&P indicated cell phones may be used for personal calls and text messaging when the employee is on meal and break periods. Employee cell phones remain off and/or silent during all other work hours. During a review of the facility's P&P titled Compliance Risks - Privacy, Security and Breach Notifications reviewed on 4/25, the P&P indicated the facility complies with the laws governing privacy, security, and breach notification of protected health information set forth in the Health Insurance Portability and Accountability Act (HIPAA) and other privacy and security rules. The same Policy indicated personnel are trained in the policies and practices that protect the privacy, confidentiality and security of resident-identifiable information throughout the facility.

Based on observation, interview, and record review, the facility failed to protect the residents' privacy and dignity by failing to ensure the indwelling urinary catheter (a soft hollow tube which is passed into the bladder to drain urine, for persons who cannot empty their bladder in the usual way) drainage bag was always covered for one of three sampled residents (Resident 1).This deficient practice had the potential to affect Resident 1's sense of self-worth and self-esteem.During a review of Resident 1's admission Record, it indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including toxic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), obstructive and reflux uropathy (a condition in which the flow of urine is blocked and urine flows backward from your bladder into your kidneys) and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 6/20/2025, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 required maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS also indicated Resident 1 has an indwelling urinary catheter. During a review of Resident 1's Order Summary Report, dated 6/13/2025, it indicated that physician ordered, Indwelling urinary catheter is in privacy bag and catheter leg strap/leg bag on at all times. During a review of Resident 1's Care Plan (CP) for bladder: at risk for complications with urinary system related to complaints of dysuria (refers to pain or discomfort during urination), complaints or urinary frequency, indwelling catheter, dated 5/22/2025 and revised on 9/2/2025, the CP indicated an intervention that included, privacy cover to catheter bag as indicated to promote dignity. During an observation of Resident 1 on 9/11/2025 at 9:22 a.m., observed Resident 1's indwelling urinary catheter with no privacy bag. Resident 1 had two other roommates in the same room. During an interview with Treatment Nurse 1 (TXN 1) on 9/11/2025 at 9:24 a.m., TXN stated and confirmed, Resident 1's urinary catheter does not have any privacy bag, and it is being exposed to other residents, visitors and staff. During an interview with Director of Nursing (DON) on 9/11/2025 at 1:12 p.m., DON stated, urinary catheter should be covered with privacy bag for resident's dignity. DON stated, they need to educate residents and resident's family members the importance of privacy in resident's foley catheter collection bag. During a review of facility's policy and procedure (P&P), titled, Urinary Catheters approved on 8/18/2021, the P&P indicated preventative measures for controlling common infections are critical component of the overall plan of care for residents with a urinary catheter. During a review of facility's P&P titled, Dignity, reviewed date 4/2025, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping the resident to keep urinary catheter bags covered.

Based on observation, interviews, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen for 76 of 76 residents when: Improper Storage of Fooda. Improper Storage and labeling of Food b. Prepared leftover tuna stored in the refrigerator c. Dietary staff did not follow cool down methodd. Multiple food items with expiration datese. Dietary Cooks did not follow the thawing process 2. Equipment Cleanliness/Cross-contaminationa. The stove was dirtyb. The floor in front of the stove was dirtyc. Multiple large silver pans were dirty 3. Dietary staff was competent in the thawing process for large pork roast.These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses and other toxins) medically compromised residents who received food from the kitchen. Findings: During the initial tour to the kitchen on 8/5/2025 at 8 A.M., entered the kitchen and met with Dietary [NAME] (DC) 1. During the observation of the walk-in refrigerator, observed the following:2 large pieces of cooked pork roast with a prepared on 8/1/2025 and a use by date of 8/6/2025A large container of cooked left-over chicken noodle soupA large container of prepared tuna,The stove top, kitchen floor, and large silver pans were dirty. During a concurrent interview, DC 1 stated the pork roast was prepared by night shift Dietary [NAME] 3. DC 1 stated the cooked pork roast stored in the refrigerator was not safe to eat and was going to prepare a new pork roast for lunch today. During a concurrent record review with DC 1, the facility of the cooling down method log was reviewed,. DC 1 stated the cool down method it was not followed properly. DC 1 stated if the cool down method is not followed properly and the meat is not cooked correctly the residents can get very sick. DC 1 stated if cooked food is not stored properly the residents can get very sick, get stomach aches, and vomiting. During a follow-up visit to the kitchen and interview Dietary Supervisor (DS) on 8/5/2025 at 10:46 A.M., DS stated the staff are not supposed to keep cooked food in the refrigerator for longer than 72 hours. DS stated if food is not cooked and stored properly the residents can vomit and have stomach aches. DS stated that all dishes, pots, and pans are supposed to be washed properly to prevent bacteria growth. DS stated improperly washed dishes can cause bacteria to get in the food the residents are consuming and make the residents sick. DS stated the dietary staff is supposed to mop the kitchen floor and clean the stove as needed and after cooking each meal. During an interview with Registered Dietician (RD) on 8/5/25 at 10:56 a.m., RD stated she discarded the cooked pork roast that was stored in the refrigerator. RD stated cooked food is only supposed to be stored in the refrigerator for 72 hours. RD stated the Dietary staff is not supposed to store cook leftover foods in the refrigerator. Dietary Cooks and kitchen staff are not supposed to store cooked foods in the refrigerator for longer than 72 hours. RD stated dietary cooks and kitchen staff are not supposed to store leftover cooked food in the refrigerator. During a follow-up visit to the kitchen and interview on 8/6/2025 at 2:45 P.M., DC 2 stated the thawing process for large pork roast is to sit it in the refrigerator for 3-4 hours before cooking. DC 2 stated he has been training from the DS regarding the thawing process. DC 2 stated if food is not thawed properly, cooked, and stored properly the residents can get very sick. During a record review, the facility policy and procedures titled Thawing of Meats dated 2023, indicated, Procedure: Thawing meat properly can be done in these four ways: 1. In the refrigerator at 41-degree Fahrenheit or colder. Allow 2 to 3 days to defrost, depending on the quantity and total weight of the meat. Label defrosting meat with pull and use by date. During a record review, the facility P&P titled Leftover Foods dated 2023, indicated, Policy: Leftover foods will be stored and served in a safe manner. Procedure: 1. Storage of leftovers b. Label and date c. Use refrigerated leftovers within 72 hours.

Based on interviews and concurrent record review, the facility failed to ensure staff completed annual and upon hire Tuberculin (TB - is a serious illness that mainly affects the lungs) skin test, staff had TB skin test results on file, and annual physical examination completed for four out of seven employees (Licensed Vocational Nurse (LVN 1 and 2, Occupational Therapist (OT - assess a person's physical, cognitive, and emotional abilities and develop treatment plans to improve their functional skills, adapting the environment or activities as needed), and Treatment Nurse). This failure had a high probability of TB transmission to residents, guests, and staff to result in the facility.Findings: During an interview and concurrent record review on 8/7/25 at 8:42 AM, seven of seven employee files were reviewed with the Director of Staff Development (DSD) and the following were noted: 1. LVN 1 was hired on 3/14/2022. There was no annual Tuberculin (TB - is a serious illness that mainly affects the lungs) skin test for the years 2023 and 2024, no background check since 2022, no annual skills competency for the years 2023 and 2025, and no abuse training for 2023 or 2025. 2. LVN 2 was hired on 9/17/2024. TB skin test was completed on 9/17/2024, however, there was no documented TB test result.3. Treatment Nurse was hired on 7/11/2025 and there was no TB skin test or result.4. Occupational Therapist was hired on 10/3/2022. There was annual TB skin test, no abuse training since 2022. During the same interview on 8/7/2025 at 8:42 AM, DSD stated she has been employed with the facility for 2 years. DSD stated she is not sure how many years documents are supposed to be kept in the employees files. DSD stated that the facility Medical Director (MD) completes the employees' physical examination annually. During a concurrent record review there was no Tuberculin (TB) skin test for LVN 1 for the years 2023 and 2024. DSD stated TB skin tests are supposed to be completed annually. DSD stated the importance of TB skin test is to ensure the nurses do not infect the residents with TB. During an interview with Director of Nursing (DON) on 8/7/2025 at 9:19 AM, DON stated all staff are supposed to complete TB skin test upon hire and yearly. DON stated if the staff do not complete annual competencies yearly, they can forget how to care for the residents and could make mistakes with certain skills. During a record review, the facility policy and procedures (P&P) titled Tuberculosis, Employee Screening for revised 4/2025, indicated, Screening1. Each newly hired employee as screened for LTBI and active TB afetr an employment has been made but prior to the employee's duty assignment.

Based on observation, interview and record review, the facility failed to serve palatable food for seven of seven residents (Residents 7, 17, 18, 24, 28, 49, and 75) reviewed for food palatability reviewed for food palatability. This deficient practice had the potential to result in meal dissatisfaction, decrease food intake and placed residents at risk for unplanned weight loss for the residents. 1. During a record review, Resident 7’s admission Record indicated the facility originally admitted the resident on 2/27/2024 and readmitted the resident on 5/17/2025 with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness and anemia (a condition where the body does not have enough healthy red blood cells). During a record review, Resident 7’s nutritional malnutrition, initiated 2/28/2024, indicated Resident 7 was at risk for malnutrition due to diagnosis of diabetes. The care plan goal was for the resident to not have significant weight loss to the extent possible. A further review of the care plan indicated the interventions included to cater to the resident’s food preferences and to monitor the resident’s intake and output (the measurement and recording of all fluids entering and leaving a person’s body). During a record review, Resident 7’s quarterly Minimum Data Set (MDS – a resident assessment tool), dated 5/24/2025, indicated the resident had moderate cognitive impairment. The MDS also indicated Resident 7 had adequate hearing and vision, clear speech, able to be understood and able to understand others. The MDS further indicated the resident required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. assistance may be provided throughout the activity or intermittently) with eating. During a record review, Resident 7’s Dietary Note, dated 7/17/2025 indicated the resident had poor oral intake. The note further indicated the registered dietician recommended to increase the resident nutritional supplement to three times per day due to the resident’s poor oral intake. During a record review, Resident 7’s Order Summary Report, dated 8/11/2025 indicated the physician ordered Resident 7 to receive a: - Regular controlled carbohydrate diet (a diet that focuses on provident the same amount of carbohydrates every day to control blood sugar levels) on 5/18/2025; and -No added sugar house shakes on 7/17/2025. During an interview during lunch on 8/5/2025 at 1:17 PM, Resident 7 stated the food at the facility was horrible. Resident 7 stated he believed he lost 20 pounds in the recent months. During a concurrent observation of the amount eaten on Resident 7’s meal tray, Resident 7 consumed about 10% of the lunch served. During an interview on 8/8/2025 at 1:54 PM, the Dietary Supervisor (DS) stated being aware of Resident 7’s complaints about the food. The DS stated if Resident 7 requests an alternative meal of grilled cheese when Resident 7 doesn’t like the meal served. The DS further stated Resident 7 has requested a grilled cheese sandwich about three days out of the week. 2.During a record review, Resident 24’s admission Record indicated Resident 24 was admitted to the facility on [DATE] with diagnoses that included displaced intertrochanteric fracture of the right femur (fracture of the hip bone), left bundle-branch block (a problem in the heart's electrical system), polyneuropathy (malfunction of multiple nerves throughout the body), muscle weakness and hypertension (high blood pressure). During a record review of Resident 24’s history and physical (H&P) dated 7/15/2025 indicated Resident 24 has the capacity to understand and make decisions. During a record review, Resident 24's Minimum Data Set (MDS - a resident assessment tool) dated 7/15/2025, indicated the resident 24’s cognition (The mental ability to make decisions of daily living) was moderately impaired, Resident 24’s required setup or clean-up assistance with eating, oral hygiene and personal hygiene. During a facility tour on 8/5/2025 at 10:50 A.M., Resident 24 stated she has been in the facility for 3 weeks and the quality, appearance and taste of food provided by the facility was disgusting stating she sent her food tray back most of the time without touching it. Resident 24 stated she has had to request her niece to bring bought food from the restaurant. During a follow-up visit with Resident 24 on 8/7/2025 at 12:41 P.M., Resident 24 stated she was unable to eat the eggs served for breakfast at the facility, Resident 24 stated the eggs appeared unappealing, were rubbery to touch and tasted awful. Resident 24 stated she felt desperate, stating she needed to use additional expenses to her have her niece bring food from the restaurant. During an observation on 8/5/2025 at 12:46 P.M., Resident 24’s family member was observed removing pre-parked meals from a tall lunch bag and organizing the meals for Resident 24 at the bedside. During an interview on 8/8/2024 at 1:26 P.M., Registered Dietician (RD), stated, she was unaware of any complaints regarding food taste, texture, appearance and palatability. RD stated comes to the facility every Monday and visits newly admitted Residents to discuss their dietary orders. RD stated she did not recall visiting Resident 24 who had been in the facility for 3 weeks. RD stated she sampled lunch food tray audit on 7/5/2025 for the puree diet, it needed a little salt and she also sampled a lunch on 7/31/2025, the chicken was boiled, she (RD) told DM “it would be nice to put a little seasoning.” RD further stated complaints regarding food taste, texture, appearance and palatability are addressed by the Dietary Manager (DM). During an interview on 8/14/2025 at 1:55 P.M., DM stated most complaints from residents regarding food are personal preferences. DM stated she does not keep a log of the amount of food that returns to the kitchen uneaten. DM stated she visits Resident’s if a complaint is brought to her attention and/or quarterly. DM stated the facility uses a contracted company for menus, states menus are posted in the Resident rooms weekly and copies are provided to Residents, DM stated she does not change the menu, she (DM) notifies RD if there is an issue with the menus and/or food. DM stated Resident who do not eat their meals are at risk weight loss and can get sick from lack of nutrition. During an interview on 8/8/2025 at 4:39 P.M.,, Director of Nursing (DON) stated she was unaware Residents had complaints regarding facility food. DON stated DM is supposed to report food concerns to the DON, also, department heads are assigned rooms to check on Residents Monday -Friday for any concerns and issues. DON stated if Resident do not eat their food, nutritional needs are not met placing Residents at risk for weight loss, dehydration, skin breakdown complications from inadequate food intake. 3. During an interview on 8/5/25 at 9:02 A.M., Resident 49 stated the food is not palatable and the dietary department is serving chicken too often at least 4 times a week. Resident 49 stated he spoke with the facility Dietary Supervisor (DS) and expressed his concerns about the food and nothing has changed. During an interview on 8/6/2025 at 9:34 A.M., Resident 18 stated the food in the facility does not taste very good and that the food tasted unseasoned and the cooks serves chicken almost every day either for lunch or dinner. Resident 18 stated she is glad she is going home on 8/8/2025. Resident 18 stated she spoke with the DS when she was admitted and gave DS her food preferences, but the cooks serve whatever they want to Resident 18. Resident 18 stated, some days the food is so horrible I do not know what it is. During an interview on 8/5/25 at 10:10 A.M , Resident 17 stated the food that is served in the facility is not palatable (not edible), has no taste, and sometimes I cannot recognize what food product is on my plate. Resident 17 stated the dietary staff serve chicken at least 4 times in one week. Resident 17 stated it makes him angry that he cannot receive a decent tasty meal for 1 whole week. During an interview on 8/5/25 at 11:19 A.M., Resident 28 stated the cooks prepare too much chicken in one week. Stated there is no seasoning on the food and the food is not cooked well enough for her. Resident 18 stated the vegetables lack nutrition because they are boiled and watered down. Resident 28 stated it makes her angry that she has to purchase food from the grocery store so that she can eat a decent meal. Stated she has reported the food palatability and food choices with the Dietary Supervisor at least 10 times and nothing has changed. During an interview on 8/5/25 at 12:23 P.M., Resident 75 stated she often asks her family to bring her food from the outside because the food served from the kitchen does not taste good and requests for a sandwich if she does not like her food. Resident 75 stated the eggs served for breakfast are too rubbery to chew. Resident 75 stated the cooks in the kitchen need to create a better food menu. Resident 75 stated she is tired of eating the same thing day after day. Resident 75 stated she has discussed the palatability of the food and food preferences on several occasions and nothing has changed. During a record review, the facility policy and procedures (P&P) titled, “Food and Nutrition Services,” reviewed 4/2025, indicated, “Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.” The P&P further indicated, “reasonable efforts will be made to accommodate resident choices and preferences.”

Based on interview and record review, the facility failed to provide each resident with a nourishing and palatable diet for five out of five sampled residents (Residents 17, 18, 28, 49, and 75). This failure had the potential to result in weight loss, functional decline, dehydration, and skin impairment for Residents 17, 18, 28, 49, and 75). Resident 17 stated not getting nourishing and palatable diet makes him angryFindings: During an interview on 8/5/25 at 9:02 A.M., Resident 49 stated the food is not palatable and the dietary department is serving chicken too often at least 4 times a week. Resident 49 stated he spoke with the facility Dietary Supervisor (DS) and expressed his concerns about the food and nothing has changed. During an interview on 8/6/2025 at 9:34 A.M., Resident 18 stated the food in the facility does not taste very good and that the food tasted unseasoned and the cooks serves chicken almost every day either for lunch or dinner. Resident 18 stated she is glad she is going home on 8/8/2025. Resident 18 stated she spoke with the DS when she was admitted and gave DS her food preferences, but the cooks serve whatever they want to Resident 18. Resident 18 stated, some days the food is so horrible I do not know what it is. During an interview on 8/5/25 at 10:10 A.M , Resident 17 stated the food that is served in the facility is not palatable (not edible), has no taste, and sometimes I cannot recognize what food product is on my plate. Resident 17 stated the dietary staff serve chicken at least 4 times in one week. Resident 17 stated it makes him angry that he cannot receive a decent tasty meal for 1 whole week. During an interview on 8/5/25 at 11:19 a.m., Resident 28 stated the cooks prepare too much chicken in one week. Stated there is no seasoning on the food and the food is not cooked well enough for her. Resident 18 stated the vegetables lack nutrition because they are boiled and watered down. Resident 28 stated it makes her angry that she has to purchase food from the grocery store so that she can eat a decent meal. Stated she has reported the food palatability and food choices with the Dietary Supervisor at least 10 times and nothing has changed. During an interview on 8/5/25 at 12:23 P.M., Resident 75 stated she often asks her family to bring her food from the outside because the food served from the kitchen does not taste good and requests for a sandwich if she does not like her food. Resident 75 stated the eggs served for breakfast are too rubbery to chew. Resident 75 stated the cooks in the kitchen need to create a better food menu. Resident 75 stated she is tired of eating the same thing day after day. Resident 75 stated she has discussed the palatability of the food and food preferences on several occasions and nothing has changed. During the lunch dining observation on 8/7/25 at 12:45 PM, Resident 87 food did not look palatable or nutritious. During an interview with the Registered Dietician (RD) on 8/8/25 at 1:29 PM, RD stated she comes to the facility once a week on Tuesdays and that the DS has not brought to her attention the complaints about the food, palatability, and textures of the food from the residents. The RD stated she interviewed the new residents upon admission and followed up with them quarterly and as needed about their diets and food choices. The RD stated the DS is supposed to follow-up with the residents about any food complaints, food palatability, food dislikes, and reports back to her. Stated Complaints about the food are directed to the DS. RD stated she has tasted the food on 7-31-25 and 8-5-25 during lunch time for both dates. RD stated the staff cooked boiled chicken. RD stated it would be nice to put some seasonings on the boiled chicken because it lacked flavor. RD stated the puree mash potatoes also needed more seasoning. Stated the DS can at any time report to her about the residents not liking the food. RD stated she can change the food menu at any time to meet the nutritional needs for the Residents. During an interview with the Dietary Supervisor on 8/8/25 at 1:59 PM, the Dietary Supervisor (DS) stated she has been employed with the facility for 2 years. DS stated she was not aware the Residents are complaining about personal preferences for food. The DS stated she provides a weekly menu and alternative menus to all the residents and place a copy in their room. The DS stated she also posts a copy of the weekly menu on the wall in the resident room or gives the residents a copy of the menus in their hand to read especially if they are bed bound. The DS stated she discussed the menu with the residents upon admission to the facility. DS stated if the residents are admitted after hours, she will meet with the residents the next day to discuss their food preferences. DS stated the RD is the only one that can change the food menus. Stated healthcare menu direct contracted company that provide the menu. State she orders the food from Dairy King. Stated the resident's food menu is a cycled menu that changes every winter, summer, spring, and fall. DS stated she informs the DSD that the residents are not eating the food. The DS stated she does not keep a log of the food trays not eaten by the residents. DS stated if the residents are not eating the right amount of nutrition daily, they can lose weight and their health can decline. During an interview with the DSD on 8/8/25 at 2:22 PM, the DSD stated that the DS has never reported to her that the residents were not eating their meals. DSD stated the nurses assigned to the residents are also responsible for reporting to the Charge Nurses if the Resident are not eating their food. DSD stated if the residents are not eating a nutritive diet daily they can develop pressure injuries and can become dehydrated. During a record review, the facility policy and procedures titled Food Preparation dated 2023, indicated, Policy: Food shall be prepared by methods that conserve nutritive value, flavor, and appearance. Procedure: Poorly prepared food will not be served-such food is to either be improved, prepared again, or replaced with an appropriate substitution. Note that increased amounts of herbs and spices (not salt) may be added, since potency of products may vary.

Based on observation, interview, and record review, the facility failed to answer call lights in a timely manner for six of six sample (Residents 18, 28, 49, 71, 75, and 106). This failure had the potential to cause a delay in care and services necessary for the residents. Findings: During a record review, Resident 18's admission Record indicated Resident 18 was admitted to the facility on [DATE] with a diagnosis of muscle weakness (decrease in the force your muscles can generate, making it harder to move your body) and Displaced intertrochanteric fracture of the left femur (break in your thigh bone). During a record review, Resident 18's History and Physical (H&P) dated 7/18/25, indicated the resident was alert and cooperative. During a record review, Resident 18's Minimum Data Set (MDS- a resident assessment tool) dated 7/27/2025, indicated the resident was cognitively intact (mental ability to make decisions of daily living), and needed minimal to moderate assistance with activity of daily living (ADL-basic task we do every day to take care of ourselves). During a record review, Resident 18's care plan on skin initiated on 7/29/2025, indicated the resident was at risk for pressure sore or skin breakdown related to bowel (stool) and bladder (urine) incontinence (inability to voluntarily pass urine and stool), had limitation in mobility 2nd to s/p left hip fracture. During a record review, Resident 28's admission Record indicated Resident 28 was admitted to the facility on [DATE] with a diagnoses of fibromyalgia (a ongoing condition that causes pain all over the body, along with fatigue and sleep) and spinal stenosis (when the spaces within your spine narrow, putting pressure on your spinal cord and nerves). During a record review of Resident 28's H&P dated 12/3 /2024, indicated Resident 28 has the capacity to understand and make decisions. During a record review, Resident 28's MDS dated [DATE], indicated the resident was cognitively intact, and was independent with ADL. During a record review, Resident 49's admission Record indicated Resident 49 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with a diagnosis of muscle weakness (lack of physical or muscle strength) and paraplegia (a condition where a person has partial or complete paralysis or the lower half of their body, including both legs). During a record review, Resident 49's MDS dated [DATE], indicated the resident was cognitively intact, and required moderate to maximum assistance with ADL. During a record review, Resident 49's care plan initiated on 7/15/2025, indicated Resident 49 had balance deficit, impaired dynamic balance, impaired range of motion, and impaired static balance. During a record review, Resident 71's admission Record indicated Resident 71 was admitted to the facility on [DATE] with a diagnoses of acute kidney failure (a sudden and rapid loss of kidney function) and essential hypertension (high blood pressure). During a record review, Resident 71's H&P dated 4/7/2025, indicated the resident had the capacity to understand and make decisions. During a record review, Resident 71's MDS dated [DATE], indicated the resident was cognitively intact, and needed moderate to maximum assistance with ADL. During a record review, Resident 71's care plan initiated on 5/22/2025, indicated the resident had impaired balance, loss of muscle strength, and weakness. During a record review, Resident 75's admission Record indicated Resident 75 was admitted to the facility on [DATE] with a diagnosis of muscle weakness (decrease in the force your muscles can generate, making it harder to move your body) and Type 2 diabetes (a condition where your body has trouble using insulin, a hormone that regulates blood sugar, or doesn't make enough of it) During a record review, Resident 75's H&P dated 2/1/25, indicated Resident 75 was able to decide for ADL, and was able to make needs known. During a record review Resident 75's MDS dated [DATE], indicated the resident was independent with ADL. During a record review, Resident 106 admission Record indicated Resident 106 was admitted to the facility on [DATE] with a diagnoses of human immunodeficiency virus Disease (HIV - a virus that weakens the body's defense system) and essential hypertension. During a record review, Resident 106's MDS dated [DATE], indicated the resident was cognitively intact. During an interview on 8/5/2025 at 8:32 A.M., Resident 49 stated when he calls the nurse for assistance it takes 1 to 2 hours before he can get assistance to empty his urinal or to get a cup of ice and water. Resident 49 stated it makes him angry when getting assistance from the staff is delayed for long periods of time. During an observation and interview on 8/5/2025 at 10:10 A.M., Resident 71 noted sitting in his wheelchair in the hallway. Resident 71 stated there is a delay in answering call lights at night on the 3 P.M. to 11 P.M. shift. Resident 71 stated about 1 month ago (unable to recall the date) he pressed the call light for the nurses to assist him with changing his adult incontinent brief. Resident 71 stated the nurse never came and he fell asleep. Resident 71 stated he felt angry and ashamed that he must wait long periods of time to get assistance. During an interview on 8/5/2025 at 11:19 A.M., Resident 28 stated the nurses are very nice to her and treat her with dignity and respect, but during the 3 P.M. to 11 P.M. shift the nurses do not answer her call light in a timely manner. Resident 28 stated that approximately 2 weeks ago (unable to recall the date) she called the nurse to get her some ice and water, and it took the nurse approximately 1 and a half hours before she brought the ice to her room. Resident 28 stated it makes me angry when there is a delay with assistance. During an observation and interview on 8/5/2025 12:23 PM, Resident 75 noted sitting up on the side of her bed. Resident 75 stated it takes over an hour to two hours to get towels at night. Resident 75 stated she feels sad and angry that it takes that long when she calls for the nurses' assistance. During an observation and interview on 8/6/2025 at 7:55 A.M., Resident 106 noted sitting up in bed in his room. Resident 106 stated the delays in his care, makes him angry and sad. Resident 106 stated the nurses on the 3 P.M to 11 P.M. shift do not answer his call light on time. Resident 106 stated he waits in excess of 1 hour or more to get assistance. During an observation and interview on 8/6/2025 at 9:34 A.M., Resident 18 noted sitting up in bed. Resident 18 stated the nurses treat her with dignity and respect but they just do not answer the call lights on time. Resident 18 stated she is waiting at least 1 hour or more for the staff to answer her call light on the 3 P.M. to 11 P.M. shift. Resident 18 stated she reported to the Charge Nurse (name unspecified), but nothing was done about it. Resident 18 stated it makes her upset that she must wait long periods of time to get assistance to the bathroom. Resident 18 she is glad she is going home in a few days. During a record review, the facility policy and procedures titled Answering the call light revised on 4/2025, indicated, Purpose: The purpose of this procedure is to respond to the residents and needs.

Based on interview and record review, the facility failed to provide foot care consistent with professional standards to maintain skin integrity for one of four sampled residents (Resident 1) by failing to: 1.Ensure that the Magnetic Resonance Imaging (MRI - uses a strong magnetic field and radio waves to create detailed images of the inside of the body, aiding in the diagnosis and monitoring of various conditions) recommended by the Wound Physician Specialist (WPS) to rule out (R/O) osteomyelitis (a bone infection that can occur when bacteria spread to the bone, causing pain, swelling, and potentially leading to serious complications if left untreated) on 2/12/2025 after Resident 1's left plantar foot (located on the bottom of the foot) wound has reopened. 2.Implement the facility's policy and procedures (P&P) titled, Wound Care by completing the documentation of the services provided on 2/7/2025 through 2/11/2025, 2/13/2025, 2/14/2025, 2/15/2025, 2/16/2025, 2/18/2025, and 2/19/2025 and following a professional standard practice of an accurate and thorough patient-centered assessment in Resident 1's medical record. 3. Develop an individualized care plan (CP) for Resident 1's left lower foot wound when Resident 1 was readmitted on [DATE]. These deficient practices resulted in Resident 1 being transferred to the general acute care hospital 1 (GACH 1) on 2/19/2025 with admitting diagnosis of sepsis (a life-threatening blood infection) due to necrotizing soft tissue infection (a rare but life-threatening bacterial infection that rapidly destroys the skin, muscle, and fascia [connective tissue]) of left lower extremity (LLE) and a left ankle disarticulation (a type of limb amputation that is performed by separating the limb through a joint instead of cutting through a bone) was performed on 2/20/2025. Then on 2/27/2025, an incision and drainage (I&D - a medical procedure used to treat abscesses) and left below the knee amputation (BKA - a surgical procedure where the lower leg and foot are removed below the knee joint) was performed on 2/27/2025 on Resident 1. Findings: During a review of Resident 1's Admission Record indicated Resident 1, was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures, [a sudden, temporary disruption of the brain's normal electrical activity, potentially causing changes in behavior, movements, feelings, or awareness]), chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), chronic congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and a past medical history of type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 2/1/2025, it indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 required maximum assistance to totally dependent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Physician History and Physical (H&P), dated 1/28/2025, the H&P indicated, Resident 1 can make needs known but cannot make medical decisions. During a review of Resident 1's Braden Scale (a tool used in healthcare to assess a patient's risk of developing pressure injurie Pressure injuries [areas of skin damage caused by prolonged pressure, often over bony areas, leading to reduced blood flow and tissue damage] by evaluating six key areas: sensory perception, moisture, activity, mobility, nutrition, and friction/shear) dated 1/19/2024, it indicated, Resident 1's score was 13 (a score of 13 indicates a moderate risk, meaning that the individual is at a higher risk of developing a pressure injury than someone with a higher score). During a review of Resident 1's WPS progress notes, it indicated the following: i.Dated 1/24/2024, This patient (Resident 1) was readmitted with a left lower leg wound. ii.Dated 7/17/2024, This patient (Resident 1) was reconsulted for the evaluation and treatment for a blister (a small, fluid-filled pocket that forms on the upper layers of the skin) located on the left plantar foot. iii.Dated 9/4/2024, The left foot wound is shrinking and is expected to heal within the next few weeks. The wound has been reclassified from a blister to arterial ulcer (open wounds that develop when there is inadequate blood flow to the affected area). iv.Dated 2/12/2025, This patient (Resident 1) left plantar foot wound has reopened [according to the facility's SBAR dated 2/7/2025], and treatment is being resumed. Due to the depth extension of the side, it is warranted to have the patient undergo an MRI to rule out osteomyelitis. v.Dated 2/19/2025, This patient (Resident 1) was evaluated today, and it was noted that he developed a boggy (abnormal texture of tissues characterized by sponginess, usually because of high fluid content) necrotic (dead or dying tissue in the body, often caused by a lack of blood supply or other injuries) area on the dorsal aspect of the foot (refers to the top or upper side of the foot, opposite the sole or bottom) which is suspected to be communicating with the lateral (to the side) metatarsal (long bones that form the main part of the foot) wound. There is suspicion for osteomyelitis and possible wet gangrene (a serious condition where tissue dies due to a bacterial infection). Current measurements: 4.5-centimeter (cm, unit of measurement) (length) by (x) 3.5 cm (width) x UTD (undetermined [depth]). During a review of Resident 1's CP, the CP indicated the following Resident 1 was: i.At risk for hyperglycemia (high blood sugar, occurs when there's too much glucose [sugar] in the bloodstream) / hypoglycemia (low blood sugar) due to diagnosis of DM initiated on 9/29/2022, the CP had a goal of, will be free from signs and symptoms (s/s) of hypo/hyperglycemia daily, with interventions including, monitor skin for redness and circulatory problems, report to medical doctor any abnormal findings. ii.At risk for skin breakdown related to Braden risk score: 13, date initiated 6/17/2024, the CP had a goal of, (Resident 1) will prevent or delay skin breakdown to the extent possible given risk factors; and (Resident 1) will be compliant with treatments and intervention measures to prevent skin breakdown. iii.At risk for skin breakdown related to open wound to left outer foot, initiated on 2/7/2025, the CP had a goal of, (Resident 1) will be compliant with treatments and intervention measures to prevent skin breakdown and will prevent or delay skin breakdown to the extent possible given risk factors. During a concurrent interview with Registered Nurse 1 (RN 1) and record review of Resident 1's CP on 3/20/2025 at 12:53 p.m., RN stated, there was no CP developed in regard to Resident 1's left foot wound when Resident 1 was readmitted on [DATE]. RN 1 further stated, there was also no CP developed on Resident 1's a blister on the left plantar foot was reopened on 7/17/2024 and when the blister was reclassified from a blister to arterial ulcer on 9/4/2024. RN 1 stated, an individualized CP should be developed with interventions so that all staff are on the same page to manage residents' care. During a review of Resident 1's Physician Order Summary Report (POSR), the POSR indicated: i.Dated 2/7/2025, Treatment - left foot open wound - cleanse with normal saline (NS - a mixture of salt and water that can be applied directly to the wound site) pat dry, apply Medi-honey (a brand of medical-grade honey-based dressings used for wound and burn management, promoting a moist environment for healing and debridement), dress with cushion dressing (Cushion dressing [a type of wound dressing, like a soft, padded bandage, designed to protect and cushion a wound, often made of foam or similar materials, and can absorb fluid.]) every shift. (order was discontinued on 2/10/2025) ii.Dated 2/10/2025, Treatment- left foot open wound- Cleanse with NS, Pat Dry, Apply Santyl (used to remove dead tissue from wound) and Mupirocin (a medication that treats skin infections caused by bacteria) two percent (% - unit of measurement) ointment, dress with cushion dressing every shift. (order was discontinued on 2/12/2025) iii.Dated 2/12/2025, Treatment- left foot open wound- Cleanse with NS, Pat Dry, Apply Santyl and Mupirocin (Mupirocin (used to treat secondarily infected skin lesions [any abnormal changes or growths on the skin] due to specific bacteria) used to treat secondarily infected traumatic skin lesions due to specific bacteria) 2% ointment, Dress with Gentell super absorbent dressing (offers excellent absorbent capacity for the treatment of moderate or heavy exuding [discharge] wound) every shift. During a review of Resident 1's situation, background, assessment, recommendation (SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents), dated 2/7/2025, the SBAR indicated, Resident (1) is noted with Moisture-Associated Skin Damage (MASD - a type of skin inflammation and erosion caused by prolonged exposure to moisture) to sacrum (the large, triangle-shaped bone in the lower spine that forms part of the pelvis) and left outer foot open wound. Left foot open wound appears approximately 1 centimeter (cm - unit of measurement) in size, skin open, area reddened. During a review of Resident 1's Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) Wound Note on 2/13/2025, the IDT wound note indicated, Resident (1) was seen and assessed by WPS and noted with left plantar foot ulcer 2.0 cm (length) x 1.5 cm (width) x 0.9 cm (depth). During a review of Resident 1's medical record in GACH 1, it indicated: i.Admission diagnosis of sepsis due to necrotizing soft tissue infection of LLE ii.Date of Admission: 2/20/2025 at 12:21 a.m.: emergency room physical exam upon admission indicated, Musculoskeletal (the system comprising muscles, bones, joints, and connective tissues like tendons and ligaments that work together to enable movement and provide structure to the body): Bilateral (both) Lower Extremity (BLE): swelling and tenderness present, BLE edema (a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body), thrombotic thrombocytopenic purpura (TTP - a rare, life-threatening blood disorder) to left foot, ankle to calf, copious purulent drainage (a large or excessive amount of fluid or discharge) noted coming from the left dorsum of foot (the upper surface or top of the foot) Sacral decubitus ulcer (a localized area of skin damage that develops over a bony prominence) noted. Skin: wound to lateral plantar surface of left foot. Active purulent and watery gaseous, foul-smelling discharge. iii.Operative report dated 2/20/2025 indicated, Procedure performed: ankle disarticulation, left side. The necrotic area was large over the dorsum of the foot (the upper surface or top of the foot). The leg was edematous, and it was difficult to tell if the infection spread proximally. Surgical pathology (the study of tissues and fluids removed during surgery to help diagnose diseases and guide treatment decisions, using both visual inspection and microscopic examination) report dated 2/21/2025 indicated, gangrenous ulcer (acute necrotizing inflammation) a sudden, severe inflammation that causes tissue death, often due to bacterial infection, and requires immediate medical attention) of the left ankle (a severe infection where dead tissue (necrosis) forms in an open wound or ulcer) with underlying abscess (a localized collection of pus that forms in the body's tissues due to a bacterial infection) formation with acute necrotizing inflammation, fat necrosis (a condition where fat cells die and break down), and fibrosis (the scarring or thickening of tissue, often occurring as a body's response to injury or chronic inflammation, leading to stiffening and potentially affecting organ function); iv.Operative report date 2/27/2025 indicated, Procedure performed: below knee amputation, through tibia and fibula (the two long bones in the lower leg), left side. v.Surgical pathology report dated 2/27/2025 indicated, skin with ulceration (a break in the skin that does not heal properly), underlying focal (localized) purulent fasciitis (also known as flesh-eating disease is a bacterial infection where bacteria invade the body, often through a cut or wound, and spread rapidly, causing the death of soft tissue) and devitalized bone (bone tissue that has lost its vitality or is no longer living). During a concurrent interview and record review with Licensed Vocational Nurse 1 (LVN 1), on 3/18/2025 at 1:28 p.m., LVN 1 stated, she documented the change of condition on 2/7/2025 when Resident 1's left foot wound was observed to be reopened. LVN 1 stated, Resident 1's WPS changed the skin treatment order when he (WPS) came in the facility on 2/12/2025 and she does not know about WPS's order for MRI to rule out osteomyelitis. LVN 1 reviewed WPS's progress notes on 2/12/2025. LVN 1 appeared to be surprised when she reviewed the notes and stated, LVN 1 appeared to be surprised when she reviewed the notes and stated, I didn't know about the MRI recommendation. I didn't know about that [MRI]. When asked to describe Resident 1's left plantar foot during her skin treatment of Resident 1. During a review of Resident 1's Treatment Administration Record (TAR) for left foot open wound, the TAR indicated, LVN 1 changed Resident 1's wound dressing during the morning (AM: 7 am - 3:30 p.m.) shift on 2/15/2025, 2/16/2025 and 2/17/2025. During an interview with Certified Nursing Assistant 1 (CNA 1) on 3/18/2025 at 1:48 p.m., CNA 1 stated, Resident 1 complained a lot and refuses for his legs to be touched. CNA 1 stated, Resident 1 required at least two persons assist and even then, he does not want to be repositioned because of his legs. During an interview with LVN 2, on 3/18/2025 at 3:17 p.m., LVN 2 stated, she was a permanent licensed nurse during evening (PM: 3:30 p.m. - 11 p.m.) shift. LVN 2 stated, Resident 1 was non-compliant during nursing care and would verbally say, do not touch me, or don't move me. LVN 2 stated, she was unsure of what kind of skin treatment was being done for Resident 1's left foot wound and was unable to describe the status of Resident 1's skin. LVN 2 reviewed Resident 1's TAR record which indicated, she documented the treatment dressing changes for the left open wound on 2/19/2025 during evening shift. LVN 2 stated, the WPS changed Resident 1's left foot wound dressing in the morning of 2/19/2025 and was ordered to be transferred to GACH 1 but she (LVN 2) was unable to explain how she did the dressing changes and describe Resident 1's left foot prior during the evening shift and prior to Resident 1 transferring to GACH 1. During a review of Resident 1's TAR for left foot open wound on 2/16/2025, 2/17/2025, 2/18/2025 and 2/19/2025, the TAR indicated, LVN 2 changed Resident 1's wound dressing during the PM shift. During an interview with Treatment Nurse (TXN 1) on 3/19/2025 at 3:02 p.m., TXN 1 stated, Resident 1 has an arterial wound on his foot and the dressing change are done on a daily basis with the help of other staff. TXN1 stated, Resident 1 would yell and scream if he was being repositioned or when his foot and legs are being touched. TXN 1 stated, when the WPS came in the morning of 2/19/2025, they did the dressing changed together and there was purulent pus drainage coming out from the wound with odor. TXN 1 further stated, when he (TXN 1) does daily dressing changes, they do not document the complete assessment data in residents' medical record. During a review of Resident 1's TAR on 2/13/2025, 2/14/2025, 2/17/2025, 2/18/2025, and 2/19/2025. for left foot open wound, the TAR indicated, TXN 1 changed Resident 1's wound dressing during the morning shift. During an interview with LVN 3, on 3/19/2025 at 3:47 p.m., LVN 3 stated, she was a permanent licensed nurse during evening shift. LVN 3 stated, Resident 1 has a dark-pigmented skin and does not like to be repositioned or moved. During a review of Resident 1's TAR on 2/15/2025, 2/16/2025, and 2/17/2025 for left foot open wound, the TAR indicated, LVN 3 changed Resident 1's wound dressing during the PM shift. During an interview with LVN 4, on 3/20/2025 at 9:27 a.m., LVN 4 stated, she was a permanent licensed nurse during the night (11:30 p.m. - 7 a.m.) shift. LVN 4 stated, Resident 1 required at least two staff with repositioning and nursing care. LVN 4 stated, Resident 1 has a wound on his foot, and she does the skin treatment during her shift. LVN 4 stated, she was unable to recall and describe Resident 1's left foot. LVN 4 stated, they (facility LVNs) do not document any skin assessment data after doing skin treatment, they only sign the TAR. During a review of Resident 1's TAR on 2/12/2025, 2/13/2025, 2/14/2025 and 2/18/2025. for left foot open wound, the TAR indicated LVN 4 changed Resident 1's wound dressing during the night shift. During a follow-up interview with Registered Nurse 1 (RN 1) on 3/20/2025 at 1:06 p.m., RN 1 stated, if there was an order of MRI by a specialist, they need to get an order from the primary physician and transfer resident to a hospital to conduct the MRI test. RN 1 further stated, it is very important to have proper lighting when doing a skin treatment especially at night so they can assess thoroughly and monitor the skin while doing the treatment. During an interview with the Medical Director (MDD), on 3/20/2025 at 12:19 pm, MDD stated, it is very important to follow up on a doctor's order and recommendation such as an MRI because it is used to rule out osteomyelitis. MDD stated that residents with DM have a delayed wound healing, and they need to monitor their blood sugar level. MDD stated, if a resident has osteomyelitis, the treatment may include amputation or a long-term antibiotic treatment. MDD stated, not all residents with osteomyelitis wound end up being amputated. During an interview with WPS, on 3/20/2025 at 1:22 p.m., WPS stated, he recommended to do an MRI on Resident 1's left foot on 2/12/2025 because of how deep the wound was and he was not sure if it was extending to the bone, so he wanted to rule out osteomyelitis. WPS stated, he was also concerned for ischemia (a condition where there is a reduced blood flow to a specific part of the body) and possible gangrene. WPS stated, on 2/19/2025, a week after, he was shocked when he observed a wound on Resident 1's left dorsal foot which looked like a wet gangrene. WPS stated it was very atypical (not typical) to have a wound on dorsal foot and he was not sure if the nurses who do the routine dressing changes noticed but it was very noticeable when he first removed the old dressing. WPS stated, Resident 1 was very sensitive, and he needed to be very delicate with him which required assistance with another nurse when he does his skin treatment. WPS stated, he uses a flashlight and an overhead light when he does Resident 1's skin treatment because of his dark-pigmented skin. WPS stated, it is very important to use proper lighting when doing any skin treatment and dressing changes on residents especially with a person who has a dark-skinned because a wound may be more severe than it would look it. During an interview with Director of Nursing (DON), on 3/20/2025 at 3:18 p.m., DON stated, during skin treatment, it is important to have proper lighting so they can do a full visual and fully assessed wounds especially with residents with dark-pigmented skin. DON stated, if there were any changes on the skin, nurses need to document it on residents' medical records. DON stated, if a resident refuses treatment and is non-compliant with nursing care, they should have a care plan with specific goals and interventions to manage the care. During a review of the facility's P&P titled, Wound Care, dated 4/17/2024, the P&P indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing . The following information should be recorded in the residents' medical record: 1.The type of wound care given. 2.The date and time the wound care was given. 3.The position in which the resident was placed. 4.The name and title of the individual performing wound care. 5.Any change in the resident's condition. 6.All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7.How the resident tolerated the procedure. 8.Any problems or complaints made by the resident related to the procedure. 9.If the resident refused the treatment and the reason(s) why. 10.The signature and title of the person recording the data. Report other information in accordance with facility policy and professional standards of practice. During a review of the facility's P&P titled, Prevention/Management of Pressure Ulcers/Injuries [is a localized area of skin damage that develops when prolonged pressure is applied to the body], dated 4/17/2024, the P&P indicated, The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Inspect the skin daily when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries (i.e., non-blanchable erythema [a persistent redness of the skin that does not fade when pressure is applied]). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency. During a review of the facility's P&P titled, Foot Care, revised on 4/17/2024, the P&P indicated, Residents are provided with foot care and treatment in accordance with professional standards of practice. Overall foot care includes the care and treatment of medical conditions to prevent foot complications from these condition (e.g., diabetes, peripheral vascular disease (a condition that affects the blood vessels outside of the heart and brain) ) immobility, etc). During a review of the facility's P&P titled, Refusal of Treatment, dated 4/17/2024, the P&P indicated, The date and time the staff tried to give a medication or treatment was attempted; a.The medication or treatment refused; b.The resident's response and reason(s) for refusal; c.The name of the person attempting to administer the treatment; d.That the residents were informed (to the extent of their ability to understand) of the purpose of the treatment and the consequences of not receiving the medication/or treatment; e.The residents' condition and any adverse effects due to such refusal; f.The date and time the physician was notified as well as the physician's response; g.All other pertinent observations; and h.The signature and title of the person recording the data.

Based on observation, interview, and record review, the facility failed to maintain a system to prevent and control the transmission of COVID-19 (Coronavirus disease 2019 is an infectious disease caused by virus that can result in different symptoms from mild to severe respiratory illnesses and is spread during close contact and through the air from person to person) infection for eight of eight sampled residents (Resident 1, 2, 3, 4, 5, 6, 7 and 8) by failing to ensure seven staff: -Housekeeper [HK] 1, -Occupational Therapy Aide [OTA], -Maintenance Director, -Laundry Worker [LW] 1, Licensed Vocational Nurse [LVN] 1, Certified Nursing Assistant [CNA] 1 and CNA 2) were fit tested (a test to verify that a respirator is both comfortable and provides the wearer with the expected protection) for their N95 mask (a respirator, a respiratory protective device designed to achieve a very close facial fit and provide efficient filtration of airborne particles). As a result, on 8/25/2022, the OTA tested positive for COVID-19 after not being fit tested , the facility had a COVID-19 Outbreak (when a disease or illness spreads rapidly among individuals in an area or population at the same time), and on 9/1, 9/8, and 9/9/2022, Residents 1 and 2, Residents 3, 4, 5, 6 and Residents 7 and 8 respectively, tested positive for COVID-19 (eight total residents). This placed all staff and residents in the facility at risk of being infected and becoming seriously ill, possibly leading to hospitalization and / or death. Findings: a.A review of the color-coded facility floor plan dated 8/24/2022, indicated that all 76 residents were in the green zone (space designated for residents not exposed to COVID-19). A review of the OTA ' s laboratory result dated 8/25/2022, indicated she tested positive for COVID-19. A review of Resident 2 ' s admission record indicated the facility admitted the resident on 6/21/2022 with diagnoses including, high blood pressure, and muscle weakness. A review of the Minimum Data Set (MDS - an assessment and care screening tool) dated 6/27/2022 indicated Resident 2 was cognitively intact (had no trouble remembering, learning new things, or making decisions) and required extensive assistance with one person assist for bed mobility, dressing, eating and personal hygiene. According to a review of Resident 2 ' s nursing progress notes, dated 8/30 and 8/31/2022, the resident experienced fevers of 99.8 degrees Fahrenheit and 100.1 degrees Fahrenheit, respectively. Resident 2 received cooling measures. A review of Resident 2 ' s Physician's Order, dated 8/31/2022, indicated Resident 2 was to receive a stat (right away) chest x-ray for cough, administer Paxlovid (a medication used to treat COVID-19) one tablet one time a day until 9/6/2022 for COVID-19 and azithromycin (an antibiotic) 250 milligram (mg) tablet one time a day until 9/4/2022 for pneumonia (lung infection). A review of the results of Resident 2 ' s chest x-ray dated 8/31/2022 indicated the resident had pneumonia. A review of Resident 2 ' s laboratory result dated 9/1/2022 indicated the resident tested positive for COVID-19. According to a review of the COVID-19 Outbreak Notification Letter from the Los Angeles County Department of Public Health (LAC DPH), dated 9/2/2022, indicated the facility was experiencing a COVID-19 outbreak. A review of the Medication Administration Record (MAR) dated 8/2022 and 9/2022, indicated Resident 2 received supplemental oxygen of one liter (L) per minute from 8/31/2022 to 9/10/2022, when her oxygen saturation fell below 97%. A review of the facility line list dated 9/9/2022 indicated the OTA had close contact (being within six feet of another person for at least 15 minutes) with Resident 2 and Resident 6 on 8/23 and 8/24/2022. A review of the Center for Disease Control and Prevention (CDC) Guideline titled, What to Do If You Were Exposed to COVID-19, indicated one can develop COVID-19 up to ten days after being exposed (https://www.cdc.gov/coronavirus/2019-ncov/your-health/if-you-were-exposed.html). A review of Resident 6 ' s admission record indicated the facility readmitted the resident on 8/1/2022 with diagnoses including respiratory failure, atrial fibrillation and high blood pressure. According to a review of Resident 6 ' s MDS dated [DATE], the resident ' s cognition was severely impaired (trouble remembering, learning new things, or making decisions) and required one-person physical assist with toileting and personal hygiene. A review of Resident 6 ' s Change of Condition form dated 8/26/2022 indicated he was exposed to COVID-19 by staff (OTA). A review of Resident 6 ' s Interdisciplinary Team note dated 8/26/2022 indicated he was directly exposed to COVID-19, was being monitored for signs and symptoms of COVID-19 and would remain in the yellow zone (space designated to be occupied by residents potentially exposed to COVID-19). A review of the laboratory tests dated 9/8/2022, indicated Resident 6 tested positive for COVID-19. During an observation on 9/21/2022 at 1:53 PM of the personal protective equipment (PPE) storage area, the Maintenance Director was observed wearing a Honeywell TC-84A-8480 N95 mask. During a concurrent interview, the Maintenance Director stated he was not fit tested and was given his mask by the facility. During an observation and concurrent interview on 9/21/2022 at 2:25 PM, Housekeeper (HK1) was observed wearing a Honeywell TC-84A-8480 N95 mask. HK1 stated she was not fit tested for this mask and, I got it from the front desk (facility reception area). HK1 stated she worked in the yellow and red zones (space designated specifically for COVID-19 positive residents). During an interview on 9/21/2022 at 2:48 PM and concurrent review of the facility ' s N95 fit test log, the Infection Preventionist (IP) stated she could not find any fit testing documentation for HK1, the Maintenance Director, or Licensed Vocational Nurse (LVN) 1. During an interview on 9/21/2022 at 2:57 PM, LVN 1 stated she had not been fit tested for a N95 respiratory mask. During an interview on 10/6/2022 at 2:40 PM, the IP stated she could not provide fit testing documentation for the OTA, Laundry Worker and CNA1 or CNA2. She stated that all staff were to be N95 tested yearly, or upon hire. The IP stated N95 masks protect us and others from COVID-19 and other airborne viruses. b. A review of Resident 1 ' s admission record indicated the facility admitted Resident 1 on 4/28/2022 with diagnoses including dementia (loss of memory, thinking and reasoning) and hypothyroidism (a condition where the thyroid gland does not produce enough hormone). A review of Resident 1 ' s MDS dated [DATE], indicated the resident had moderately impaired cognition (decisions poor, cues/supervision required), and required extensive assistance with one person assist for personal hygiene, dressing, bed mobility, transfer, and toilet use. A review of the laboratory test dated 9/1/2022 indicated Resident 1 tested positive for COVID-19. A review of the social services note dated 9/1/2022, indicated Resident 1 was moved to the red zone. A review of Resident 3 ' s admission record indicated the facility admitted the resident on 5/9/2022 with diagnoses including peripheral vascular disease (PVD -a slow and progressive circulation disorder) and chronic kidney disease (kidneys are damaged and unable to filter blood the way they should). A review of Resident 3 ' s IDT note dated 8/28/2022 indicated Resident 3 was placed in the yellow zone for exposure from a COVID-19 positive staff member working at the facility from 8/23/2022 to 8/24/2022. A review of Resident 3 ' s change in condition (COC) form dated 9/8/2022 indicated Resident 3 tested positive for COVID-19 and complained of a sore throat. A review of Resident 4 ' s admission record indicated the facility admitted the resident on 6/21/2022 with diagnoses including emphysema (a lung condition that causes shortness of breath), heart failure and Type II diabetes (impairment in the way the body regulates and uses sugar [glucose] as a fuel, high blood sugar). A review of the COC form dated 9/8/2022 indicated Resident 4 tested positive for COVID-19 on 9/7/2022. A review of Resident 5 ' s admission record indicated the facility readmitted the resident on 11/20/2020 with diagnoses including protein calorie malnutrition (a condition where one does not consume enough to meet their nutritional needs which can lead to a weak immune system) and atherosclerotic heart disease (a buildup of fats, cholesterol and other substances that decreases blood flow to the heart). A review of the MDS dated [DATE] indicated Resident 5 ' s cognition was mildly impaired and required extensive assistance with one person assist for personal hygiene, dressing, bed mobility, transfer, and toilet use. A review of the facility census dated 9/7/2022 indicated Residents 5, 7, and 8 shared a room. A review of COC dated 9/8/2022 indicated Resident 5 tested positive for COVID-19. A review of Resident 7 ' s admission record indicated the facility readmitted the resident on 7/5/2017 with the diagnoses including pancreatic cancer, Type II diabetes, and protein calorie malnutrition. A review of Resident 7 ' s MDS dated [DATE] indicated the resident had moderately impaired cognition and required extensive assistance with one person assist for dressing, bed mobility, personal hygiene, and toilet use. A review of Resident 7 ' s IDT note dated 8/28/2022 indicated Resident 7 was exposed to a COVID-19 positive staff member working at the facility from 8/23/2022 and 8/24/2022 and that the resident would remain in isolation (in the yellow zone) for 14 days. A review of Residents 7 and 8 COVID-19 laboratory tests dated 9/9/2022 indicated the tests were positive. A review of Resident 8 ' s admission record indicated the resident was readmitted to the facility on [DATE] with diagnoses including shortness of breath, paranoid schizophrenia (a severe mental illness) and benign prostatic hyperplasia (enlargement of the prostate). A review of Resident 8 ' s MDS dated [DATE] indicated the resident had moderately impaired cognition and required extensive assistance with one person assist for dressing, bed mobility, personal hygiene, and toilet use. A review of Resident 8 ' s IDT note dated 8/28/2022 indicated Resident 8 was in isolation due to exposure from a COVID-19 positive staff working at the facility from 8/23/2022 to 8/24/2022, would be monitored for symptoms of COVID-19 and will continue with isolation for 14 days. During a phone interview with the facility ' s Medical Director on 10/27/2022 at 10:35 AM, when asked about the importance of fit testing, he stated, This is the first time I am hearing of fit testing. It ' s not uniform in every facility or hospital. I am completely unaware that this is a mandatory test. I go there (to the facility) and they give me a mask, I was never tested . A review of the Center for Disease Control and Prevention (CDC) guideline titled, The Respiratory Protection Information Trusted Source, revised 9/3/2021, indicated users were required to be fit tested to confirm the fit of any respirator that forms a tight seal on your face before using it in the workplace. Fit testing was important to ensure the expected level of protection was provided by minimizing the total amount of contaminant leakage into the facepiece through the seal. It also indicated that one should be fit tested yearly to ensure that N95 mask fits properly (https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/respsource3fittest.html#:~:text=You%20should%20be%20fit%20tested ,type%2Fbrand%2C%20or%20size). A review of the facility ' s policy and procedure titled, Coronavirus (COVID-19) - Infection Prevention and Control Measures, revised July 2020, indicated that while in the building, personnel were required to strictly adhere to established infection prevention and control policies including appropriate use of PPE. A review of the facility ' s policy and procedure titled, Coronavirus Disease 2019 (COVID-19) Mitigation Plan for Skilled Nursing Facilities, undated, indicated that facility staff were fit tested for N95 masks.

Based on interview and record review, the facility failed to identify and evaluate risks for accidents and hazards and did not modify care plan interventions when necessary for one of three sampled residents (Resident 1). Resident 1 was assessed as moderate risk for falls, memory problems, and altered awareness of immediate physical environment. The facility failed to: 1. Develop and implement effective interventions to address Resident 1 not calling for assistance to use the toilet, including toileting schedule. 2. Implement the facility's policy on Falls and Fall Risk Managing by not re-evaluating whether to continue or change current interventions. 3. Re-evaluate Resident 1's increased fall risks after the first fall on [DATE]. 4. Implement the facility's policy on Falls - Clinical Protocol by not ruling out delayed fall complications such as subdural hematoma (a pool of blood between the brain and its outermost covering). As a result, on [DATE] at 9:54 a.m., approximately 35 hours after Resident 1 sustained a second unwitnessed fall, Resident 1 had an altered level of consciousness (the state of being awake and aware of one's surroundings) became less responsive, did not speak, and did not follow commands. Resident 1 was sent to General Acute Care Hospital 1 (GACH 1) where she was diagnosed to have a large left sided subdural hematoma (pooled blood that pushes on the brain), was not a candidate for surgery and was placed on comfort measures. Resident 1 returned to the facility on [DATE], remained on comfort care, and ultimately died on [DATE] at 10:20 a.m. Findings: On [DATE], an unannounced visit was made to the facility to investigate a complaint regarding falls. A review of Resident 1's admission record (face sheet ) indicated the facility admitted Resident 1, an [AGE] year old female, on [DATE], with [DIAGNOSES REDACTED]. The face sheet indicated Resident 1 had a Responsible Party (RP). A review of Resident 1's Fall Risk assessment dated [DATE], indicated Resident 1 had no falls within previous six months, but had altered awareness of immediate physical environment. The assessment indicated Resident 1's total score was nine out of 13 which represented moderate fall risk. A review of the Risk for Falls Care Plan dated [DATE], indicated related and due to Resident 1's weakness, dizziness, changes in blood pressure, and orthostatic [MEDICAL CONDITION]. The short-term goal was to minimize falls and risk for injury. The care plan interventions included providing a clutter free environment, well lit room, dry floors, and monitoring for weakness, dizziness and fatigue every shift. The interventions did not include the staff physical assistance Resident 1 required or the use/need of assistive devices (cane, walker, wheelchair). A review of the Physician's Orders and Nursing Progress Notes dated from ,[DATE] - [DATE], indicated there were no orders for Resident 1 to receive a low bed, side rails, or placement of floor mats. A review of the History and Physical form dated [DATE], indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Physical Therapy (PT) Evaluation and Plan of Treatment form dated [DATE], indicated Resident 1 required moderate assistance with bed mobility and transfers, had difficulty in walking, and had balance, gait, and strength impairment. A review of Resident 1's Occupational Therapy (OT) Evaluation and Plan of Treatment form dated [DATE], indicated Resident 1 had a [DIAGNOSES REDACTED]. The OT evaluation indicated Resident 1 required maximal assistance with toileting. A review of the ADL Function care plan dated [DATE] indicated staff would assist Resident 1 with grooming, hygiene, bathing and toileting. A review of the Minimum Data Set (MDS - standardized assessment and care-screening tool) dated [DATE], indicated Resident 1 was able to make decisions and had some memory problems. Resident 1 required one-person guided maneuvering or other non-weight bearing assistance with bed mobility, transfers, toileting and personal hygiene. Resident 1 required extensive assistance with walking, and used a walker or wheelchair to assist with mobility. A review of Resident 1's Investigative Report and the Internal Incident Report dated [DATE], at 11 p.m., indicated Resident 1 had an unwitnessed fall with injuries. The report indicated staff observed Resident 1 laying outstretched in a supine position (flat on the back), on the floor next to her bed. Resident 1 had a head injury, with a large bump to the left side of forehead with bleeding, a skin tear (measured 3 centimeters (cm - unit of measure) in length by 1.5 cm in width) on the left temporal area (located on the side of the head between the forehead and the ear). Resident 1 was also complaining of pain. The staff called 911 and Resident 1 refused to go to the hospital. The staff provided wound care to the skin tear, educated Resident 1 to use the call light, notified the doctor, and initiated 72-hour neurological monitoring (neuro-check, assessment of level of consciousness, and the reaction to light). A review of the facility's report indicated a nurse last saw Resident 1 in her room approximately twenty minutes before the fall. A review of Nursing Progress Notes dated [DATE] at 12 a.m., indicated the on-call physician was notified and ordered to encourage Resident 1 to go to the GACH in the morning. A review of Nursing Progress Notes dated [DATE] at 3:04 a.m., indicated LVN 4 asked Resident 1 if she had any pain, and Resident 1 pointed to the bump on her head. A review of Nursing Progress Notes dated [DATE] at 6:14 a.m., indicated Resident 1 continued to complain of pain to the bump on left forehead. Licensed Vocational Nurse 4 (LVN 4) offered pain medication, but Resident 1 refused. A review of Nursing Progress Notes dated [DATE] at 3:16 p.m., indicated Resident 1 at times remembers the event, was encouraged to go to hospital, but refused. The note indicated neurochecks were conducted with no notable change in cognitive or neurological status. A review of Resident 1's Physician's Progress Notes written by Nurse Practitioner 1 (NP 1) dated [DATE] and timed at 8:42 p.m., indicated Resident 1 had a large ecchymosis (bruise) over the right cheekbone extending toward the neck, and raccoon eyes (bruise around the eyes), the left side larger than the right. NP 1 indicated fall precautions discussed with the staff and the resident and ordered a psychiatric consultation (the medical specialty devoted to the diagnosis, prevention, and treatment of [REDACTED]. A review of Resident 1's Care Plan developed on [DATE] (after the fall on [DATE]) for the resident's activities of daily living (ADLs - dressing, eating transfers, walking, toilet use, and personal hygiene) and non-compliance with the use of the call light when walking to the restroom, had a goal for Resident 1 to call for assistance when she needed to go to the restroom. The interventions included explaining to Resident 1 her fall risk. The care plan did not include Resident 1 required assistance with mobility, transfer, or ambulation per the fall risk assessment. A review of the Physician's Progress Notes dated [DATE], documented by the NP, indicated Resident 1 had a small hematoma on the left forehead covered with a dressing, the left raccoon eye was fading and the large ecchymosis over the right cheekbone extending toward the neck was fading. The progress note indicated Resident 1 had generalized weakness and dizziness. The NP recommended for Resident 1 to change positions slowly and ordered fall precautions, and PT/OT evaluation. A review of the clinical record indicated Resident 1 did not have a re-assessment of Fall Risk to indicate changes in fall history, patient care equipment, mobility, cognition, or a change in total fall risk score. A review of the Fall Scene Investigation Report, dated [DATE], indicated at 10:45 p.m. Resident 1 was in her room when she sustained a second unwitnessed fall (approximately one month after the first fall on [DATE]). The investigation report indicated Resident 1 was found by the Certified Nursing Assistant (CNA), at the foot of the bed, sitting on the floor. The resident indicated she tried to sit down on the bed but fell to the floor. A review of Resident 1's Care Plan developed on [DATE], for the fall sustained the same day, included in the approaches to remind Resident 1 to call for assistance whenever she needed assistance with ADLs. The care plan did not include Resident 1 required assistance or mobility, transfer, or ambulation per the fall risk assessment. A review of Resident 1's medical records for [DATE] to [DATE], indicated the facility did not conduct a fall risk re-assessment after Resident 1's second fall on [DATE]. A review of the Nursing Progress notes, dated [DATE], indicated Resident 1 had no change in level of consciousness, no complaints of pain, and was encouraged to call staff for any assistance as needed. A review of the SBAR dated [DATE] at 9:54 a.m., indicated Resident 1 had altered mental status, decreased level of consciousness, and was unable to follow commands and the NP was notified with no new orders. A review of the Nursing Progress notes, dated [DATE], at 10:07 p.m., indicated Resident 1 was awake, alert and verbally responsive. The note indicated Resident 1 was monitored for confusion with no episodes noted at this time. A review of physician progress notes [REDACTED]. The NP indicated Resident 1 had poor lung effort, not oriented, non-verbal, weakness in the upper and lower extremities, and pupils were round, equal with sluggish response to light. Medical Doctor 1 (MD 1) ordered to transfer Resident 1 to GACH 1 for evaluation on the same day. A review of Resident 1's GACH 1 Computerized Tomography scan (CT - combines a series of X-ray images taken from different angles around the body and uses computer processing to create cross-sectional images) of the brain dated [DATE], indicated a very large left sided subdural hematoma. A review of Resident 1's GACH 1 Discharge Summary dated [DATE], Resident 1 became aphasic (an impairment of language, affecting the production or comprehension of speech and the ability to read or write. [MEDICAL CONDITION] is always due to injury to the brain-most commonly from a stroke, particularly in older individuals) was not a candidate for surgical interventions, the decision was to keep the resident comfortable and transfer back to the facility on comfort measures. A review of the nursing progress notes dated [DATE], indicated Resident 1 was readmitted to the skilled facility and was nonverbal. A review of the progress notes, dated [DATE], indicated Resident 1 had eyes closed and was not responding to verbal or tactile stimuli (touch sensation). Resident 1 was declared expired at 10:20 a.m. A review of the Certificate of Death indicated the primary cause of death to be [MEDICAL CONDITION] (bleeding) and [MEDICATION NAME] head trauma, on [DATE], at 10:20 a.m. During an interview on [DATE] at 10:40 a.m., the responsible party (RP - Resident 1's family member), stated she made many visits to see Resident 1 at the facility and on [DATE], she was at the facility when she observed a black and blue bruising on the left side of Resident 1's face and left arm. The RP stated Resident 1 was grimacing when moving her neck and left arm. The RP stated she asked nursing staff how Resident 1 got her bruises, and they stated Resident 1 fell in her room. During an interview on [DATE] at 12:04 p.m., and 2:29 p.m., the Director of Nursing (DON) stated she was working when Resident 1 had an unwitnessed fall on [DATE] and on [DATE]. During an interview and record review, on [DATE] at 12:02 p.m., the DON stated the licensed nurse did not re-assess Resident 1's fall risk after [DATE]. The DON stated it was not the facility's practice to utilize their fall risk assessment tool after a fall. A review of the Coroner's Report dated [DATE] indicated Resident 1 had a reported medical history of [REDACTED]. The report indicated the causes of death were [MEDICAL CONDITION] and [MEDICATION NAME] head trauma. A review of the facility policy titled, Falls and Fall Risk Managing, revised [DATE], indicated under Monitoring Subsequent Falls and Fall Risk, the staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions A review of the facility policy titled, Fall Risk Assessment, revised [DATE], indicated the nursing staff shall seek to identify and document resident risk factors for falls. The policy indicated the staff would review the resident's record for history of falls, especially falls within the last 90 days. The policy indicated assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls. A review of the facility policy titled, Falls - Clinical Protocol, revised [DATE], indicated the nurse shall assess, document and report change in cognition or level of consciousness, all active diagnoses. Under Monitoring and Follow-up, indicated the staff with the physician's guidance would follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. The policy indicated that delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall.

Based on observation, interview and record review, the facility failed to ensure seven of 18 sampled residents (Residents 2, 5, 6, 7, 11, 13, and 14), and one of ten randomly selected residents (RSR 19) were provided necessary care and services by failing to: Resident 5, the facility failed to assessed the resident for non-verbal signs and symptoms of pain, and a need for reevaluation of the effectiveness of scheduled pain medication. This practice resulted to Resident 5 experiencing unnecessary pain during activities of daily living. Resident 2, who received Losartan (medication used to treat high blood pressure) the facility failed to consistently monitor resident's blood pressure prior to medication administration as ordered by the physician, which placed the resident at risk of medication side effect. Resident 6, who received [MEDICATION NAME] (medication used to treat high blood pressure), and [MEDICATION NAME] (medication used to slow the heart rate down), the licensed failed to consistently monitor resident's heart rate prior to medication administration as ordered by the physician. The deficient practice placed the resident at risk of the side effect of the medication, and had a potential for ineffective evaluation of the effectiveness of the medications. Resident 7, who received [MEDICATION NAME] and [MEDICATION NAME] (medication used to treat high blood), and [MEDICATION NAME] failed to consistently monitored resident's blood pressure and heart rate prior to medication administration as ordered by the physician. Also, the facility failed to ensure the resident's pacemaker (a battery-operated device implanted into a resident's chest which uses an electrical impulse to affect the resident's heart rate and rhythm) was checks every six months as ordered by the physician. The deficient practice placed the resident at risk of side effect of medication, and had a potential for unrecognized pacemaker malfunction. Resident 11, failed to ensure the resident's pacemaker was checked every six months as ordered. This deficient placed the resident at risk for unrecognized pacemaker malfunction. Resident 13, the facility failed to assess the permacath (a special catheter inserted in the large vein on upper chest area which allows access for [MEDICAL TREATMENT] (A procedure used to clean a resident's blood when the kidneys are failing)), consistently before and after [MEDICAL TREATMENT] treatment. The deficient practice placed the resident at risk of unrecognized infection and malfunction. Resident 14, the facility failed to assess the arteriovenous shunt [MEDICAL TREATMENT] after [MEDICAL TREATMENT] treatment. The deficient practice placed the resident at risk of delay intervention. Resident 19, who had a [DIAGNOSES REDACTED]. This failure resulted in Resident 19 continuing to have moderate to severe pain of her arms, wrist, bilateral upper and lower extremities, and general body pain, requiring narcotic pain medication. Findings: a. During the initial tour of the facility accompanied by licensed vocational nurse (LVN) 5, on March 21, 2016 at 8:30 a.m., Resident 5 was observed in bed, and was grinding his teeth loudly (it was audible from across the room). He was also making kissing sounds. Resident 5 was observed on March 21, 2016 at 2 p.m., while certified nurse assistant (CNA) 6 and CNA 11 were caring for him. CNA 6 and CNA 11 used a sling lift (a device that utilizes a cloth sling to allow movement of a resident from one location to another) to move Resident 5 from a clinical reclining chair to the bed. When the lift raised him from the recliner chair, Resident 5 cried out loudly and continued to call out loudly while he was moved through the air and placed down on the bed. His face was observed lined in a grimace. The resident's yell became higher in pitch as he was lowered onto his bed. He called out, Eyeeeeee!, as he was moved by CNAs to remove the sling that was under his body following the transfer. CNA 11 mimicked Eye,eye,eye the sound made by Resident 5. CNA 11 told Resident 5 he would be OK. The resident began to bite his clothing. He continued to yell, and when his limbs were moved, the yell pitch became higher. His fists were closed and he pushed his arms away from his body and against the staff. While his legs were being moved to allow his brief to be changed, he became more agitated and yelled loudly, Naaaa! The CNAs removed his shirt, one on each arm. The shirt did not button so CNAs pulled it over Resident 5's head. As CNAs moved his arms into position to allow the shirt to be removed his yell volume and pitch increased. When he was not being moved, the resident's voice volume and pitch decreased. After being still for several minutes, Resident 5 stopped yelling and became silent. He began to bite his clothing again. According to the admission record, Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated February 24, 2016, indicated Resident 5's cognitive skills for daily decision-making were severely impaired and he was rarely or never able to understand or be understood by others. The resident was totally dependent on the staff with all activities of daily living. The MDS indicated Resident 5 showed other behavior symptoms not directed toward others (example hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste or verbal/vocal symptoms like screaming or disruptive sounds), and his behavior occurred daily. The MDS indicated the resident received scheduled pain medication regimen, had no indicators of pain, and did not reject care. The resident had the following physician's orders [REDACTED].>1. February 8, 2016, an order for [REDACTED]. 2. January 20, 2016, an order for [REDACTED]. 3. January 20, 2016, an order for [REDACTED]. There was a physician's orders [REDACTED]. The physician's orders [REDACTED]. 1. [MEDICATION NAME] sulfate (a narcotic pain medication) 5 mg administer sublingually (SL, under the tongue) every two hours as needed for pain or respiratory distress (difficulty breathing) and 2. [MEDICATION NAME] 650 mg to administer one (1) suppository via rectum not to exceed 3 grams in 24 hours. During an interview after the care was provided to Resident 5, on March 21, 2016 at 2:10 p.m., CNA 11 stated the way the resident was acting was normal for him. CNA 11 stated the resident did not want to be bothered by the staff. She stated the signs she looks for that shows that the resident was in pain are facial grimaces and body movement that shows the resident is trying to get away from the pain. She stated that she did not believe that Resident 5 was in pain because When you let him alone, he quiets down. CNA 11 stated if she did think a resident was having pain, she would mention it to her charge nurse so he could be get pain medication before he was moved. CNA 11 stated, But, I think he got pain medication before we started to move him today. During an interview on March 21, 2016 at 2:30 p.m., when asked about Resident 5's behavior, LVN 2 stated that yelling was usual for the resident. She stated that she was sure he was not having pain because he quieted as soon as staff stopped handling him. She also stated that Resident 5 had [MEDICATION NAME] ordered for restlessness which he had received at 9:55 a.m. A review of the Medication Administration Record (MAR) for March 2016 indicated that Resident 5 had received [MEDICATION NAME] on March 21, 2016 at 9:55 a.m. for restlessness. The documentation indicated the [MEDICATION NAME] was assessed as being effective. Resident 5 also received [MEDICATION NAME] on March 21, 2016 at 9 a.m. [MEDICATION NAME] was ordered twice a day for pain management. On March 23, 2016 at 10:45 a.m., Resident 5 was heard screaming from his room. The scream was heard from down the hall and around a corner. Upon entering Resident 5's room, CNA 8 was observed providing morning care for Resident 5. Resident 5's face was observed to be lined in a grimace and his four limbs were drawn up close to his trunk and his hands were balled into fists. When CNA 8 moved the resident's limbs or trunk, the pitch of Resident 5's yell changed and became higher. During an interview on March 23, 2016, at 10:55 a.m. CNA 8 stated that Resident 5 was better because He is not trying to hit me today. She further stated that Resident 5 always yelled out during bed bath and that this was normal for him. CNA 8 stated she did not believe that Resident 5 was having pain. During an interview and review of the Narcotics Administration Record at on March 23, 2016, at 11 a.m., LVN 1 stated that she had just administered [MEDICATION NAME] to Resident 5 for pain at 10:55 a.m. She stated the resident received [MEDICATION NAME] at 7 a.m. On March 23, 2016 at 12 p.m., during an interview with the hospice medical doctor (H-MD) stated that he believed that Resident 5 grinding his teeth was a form of self-stimulation (a repetitive behavior used to decrease anxiety) and that Resident 5's behavior (yelling and fighting care for example) were related to his mental problems and not related to pain. He stated that he discontinued the [MEDICATION NAME] because he did not want Resident 5 to have respiratory depression from [MEDICATION NAME]. He also stated that he was concerned because Resident 5 had an addictive personality given his history of alcoholism. When asked if Resident 5 was experiencing any pain, he stated it was not likely but that it was possible that Resident 5 may have pain with repositioning and should be monitored for indicators of pain such as facial grimaces. During an interview on March 25, 2016 at 2:35 p.m. with the director of nurses (DON), she stated that she continued to believe that Resident 5's behavior was related to his mental problems and was behavior and not related to pain. She stated, The hospice doctor says it's behavior and not pain. A review of the MAR for March 2016 indicated Resident 5 was assessed each shift as having no pain. These pain assessments included March 21, 2016 at 2 p.m. and March 23, 2016 at 10:45 a.m. when Resident 5 was observed having non-verbal signs of pain. Resident 5's care plan for alteration in comfort dated February 24, 2016 indicated the resident should be monitored for non-verbal signs and symptoms of pain such as facial grimacing, moaning and guarding behavior. The approach included to offer pain medicine and call the medical doctor if ineffective. Another care plan for declined health status implemented by hospice on February 24, 2016, indicated interventions included: monitor for signs and symptoms of pain and medicate appropriately and monitor for effectiveness of pain medications A review of October 2010 facility policy and procedures titled Pain Assessment and Management indicated under general guidelines that pain management included assessing the potential for pain, effectively recognizing the presence of pain and modifying approaches as necessary. The policy further outlined that if the resident's pain has not been or cannot be determined, current standards should be utilized to help determine appropriate options. b. According to the admission record, Resident 11 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, a comprehensive assessment and care screening tool) dated March 17, 2016 indicated that Resident 11's cognitive skills for daily decision-making were severely impaired and required extensive assistance from staff for all activities of daily living. The MDS indicated the resident had a cardiac pacemaker (a battery-operated device implanted into a patient's chest which uses an electrical impulse to affect the resident's heart rate and rhythm). A review of the physician's orders [REDACTED]. A document in the Resident 11's clinical record titled Pacemaker Alert showed the pacemaker implant date was July 7, 2008 and that a check was due on January 7, 2015. There was no documentation to indicate whether or not the pacemaker checks occurred. During concurrent interview and record review on March 25, 2016 at 11:15 a.m., the director of nursing (DON) was unable to verify if or when Resident 11's pacemaker had been checked. She verified there was an order for [REDACTED]. She stated that an EKG (electrocardiogram or heart rhythm tracing) had been ordered for the pacemaker in January 2016, but acknowledged that an EKG cannot substitute for a pacemaker check because the EKG does not reveal battery life of the pacer while the check does. With regard to pacemaker follow-ups, she stated we have work to do. Review of an undated policy and procedures titled Permanent Pacemaker Care Protocol, indicated the staff should obtain information about the pacemaker from resident or family. If unable to obtain information about the pacemaker, the staff should call the Cardiologist (heart specialist) as soon as possible. The facility policy did not address a procedure for staff to follow to ensure pacemaker checks actually occur. c. According to admission record, Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, dated [DATE], Resident 13 was able to make her needs know and was capable of making daily-decisions related to care. She did require extensive to totally dependent from the staff with activities of daily living that related to movement. A review of [MEDICAL TREATMENT] Communication Forms between March 1, 2016 and March 24, 2016 indicated the resident was not assessed before and after [MEDICAL TREATMENT] treatment for [REDACTED]. During an interview on March 25, 2016 at 10:30 a.m., licensed vocational nurse (LVN) 1 stated the [MEDICAL TREATMENT] Communication Form should be filled out to reflect the resident's catheter status before and after the resident left and returned from [MEDICAL TREATMENT]. She acknowledged the importance of assessing the catheter site to enhance communication among the nurses. A review of July 23, 2003 revised facility's policy and procedures indicated that all observations, medications administered, services performed, etc. must be documented in the resident's clinical record. d. A review of Resident 19's admission record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment and care screening tool) dated December 11, 2015, indicated Resident 19 was able to make concrete request as well as respond adequately to simple, direct communication. Resident 19 was assessed as requiring limited assistance with eating and totally dependent on staff for bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, and bathing. On March 21, 2016, at 1:30 p.m., during an interview, Resident 19 stated that she received pain medication earlier, around 7:30 a.m., but was not sure if she can have another one to ease the pain on her hands and knees. Resident 19 stated she had been feeling more pain on her joints lately and was getting more pain medication for it. Resident 19 also stated I feel that my RA is flaring up, I need to see a rheumatologist. A review of the physician progress notes [REDACTED]. The documentation indicated treatment plan included a rheumatology follow-up and for pain to be controlled. The physician's orders [REDACTED]. A review of the physician's orders [REDACTED]. A review of the physician progress notes [REDACTED]. Treatment plan indicated was for Resident 19 to have a rheumatology consult to be scheduled. The physician's orders [REDACTED]. A review of the Resident 19's Interdisciplinary Team Conference Record, dated March 11, 2016, indicated that resident's increase in pain was discussed as well as Resident 19 being agreeable to treatment plan for around the clock pain medication. The nurse's notes, dated March 14, 2016 at 2:30 p.m., indicated licensed vocational nurse (LVN 1) contacted Resident 19's primary physician to obtain a routine pain medication. The note indicated the physician increased the dosage and frequency of [MEDICATION NAME] to 7.5/325 mg every 4 hours as needed for severe pain/arthritis pain. A review of the physician's orders [REDACTED]. On March 21, 2016, at 3:10 p.m., during an interview, the social service designee (SSD) stated that she arranges and follows-up with residents' dental, podiatry, eye doctor consults. She stated that specialty physicians such as rheumatology and cardiology (specialty medicine that deals with disorders of the heart) are arranged by the licensed nurses. On March 21, 2016, at 3:16 p.m., during an interview, LVN 2 stated if there was a physician's orders [REDACTED]. On March 21, 2016, at 3:20 p.m., during an interview, director of nursing (DON) verified the physician's orders [REDACTED]. On March 21, 2016, at 3:22 p.m., during an interview, LVN 1 stated that the rheumatology consults that were ordered in December 2015 should have been followed up. She verified that on March 14, 2016, at 2:30 p.m., physician ordered for Resident 19 to have an RA consult as soon as possible. Physician also ordered [MEDICATION NAME] 40 mg by mouth daily for four days due to arthritis flare up. LVN 1 stated Resident 19's primary physician did not know any specific rheumatologist so he asked the facility staff to find one. LVN 1 added that since the facility did not know any rheumatologist either, the primary physician ordered for Resident 19 to see an orthopedist consult instead, who may also be able to possibly recommend a specific rheumatologist. A review of Resident 19's Controlled Drug Record (individual resident narcotic record) and pain assessment flowsheet, indicated the resident was administered [MEDICATION NAME] 5/325 mg one tablet by mouth as needed for severe pain, [MEDICATION NAME] 7.5/325 mg one tablet by mouth every 4 hours as needed for severe pain/arthritis pain, and [MEDICATION NAME] 50 mg one tablet by mouth every 6 hours as needed for pain. A monthly recap of the [MEDICATION NAME] 5/325 mg, [MEDICATION NAME] 7.5/325 mg, and [MEDICATION NAME] 50 mg one tablet doses received are as follows: January 2016 - 19 tablets February 2016 - 27 tablets March 1, 2016 to March 23, 2016 - 21 tablets On March 25, 2016, at 2:45 p.m., during an interview, Resident 19 stated that she experiences pain when she uses her hand during activities of daily living (ADL) such as combing/ braiding her hair. She also added that she constantly feels pain on her knees ankles, wrists, elbows, and fingers. The resident stated she takes pain medication in the morning and afternoon, but this does not take all the pain away. Resident 19 also verbalized that prior to hospitalization last December 2015, she was getting RA injections weekly which were very helpful. She thought that it was stopped because she was feeling much better. On March 25, 2016, at 2:55 p.m., during an interview, CNA 14 stated Resident 19 lets her know verbally when she is in pain. CNA 14 stated the resident gets pain medication before she start working with her. On March 25, 2016, at 3:15 a.m., during an interview, director of staff development (DSD) stated staff identifies pain through resident's facial grimacing, verbalization of pain. She stated that non-pharmacological interventions such as repositioning and diversional activities are used before the administration of pain medication to manage resident's pain. DSD also added that if pain persists, staff will talk to the physician to check pain medication orders and will recommend increase in dose/frequency. Staff will then obtain a routine pain medication order if increasing the pain medication dose or frequency is ineffective to manage pain. A review of Resident 19's care plan initiated on December 7, 2015 and recently updated on February 26, 2016, titled Alteration in comfort related to [DIAGNOSES REDACTED]. Also included are the use non-pharmacological pain interventions, administration of pain medication as ordered, and physician notification for significant changes. According to the facility's untitled and undated policy and procedures, the facility will develop a referral process for ancillary services to appropriately identify and provide for the residents' needs identified through direct requests by the resident or family, interdisciplinary team conferences, and physician assessment which enable residents to attain or maintain their highest practicable, mental, and psychosocial well being. e. A review of Resident 2's admission record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. ([MEDICAL CONDITION] brain disease). The Minimum Data Set (MDS, a resident assessment and care screening tool) dated February 29, 2016, indicated Resident 2's cognitive and communication were impaired. She was also assessed as requiring extensive assistance from the staff with bed mobility and totally dependent on staff for transfer, locomotion, dressing, toilet use, eating personal hygiene, and bathing. A physician's orders [REDACTED]. Losartan should not be given if the systolic blood pressure (SBP, top number in a blood pressure reading) is less than 110. A review of the Medication Administration Record (MAR) indicated on March 12, 2016 at 9:00 a.m., that the blood pressure was not taken when Losartan was given. On March 22, 2016, at 11:35 a.m., during an interview, and record review of Resident 2's MAR with licensed vocational nurse (LVN), LVN 1 stated that the blood pressure should be checked and documented prior to administration of blood pressure medication. A review of Resident 2's care plan initiated on February 24, 2016, for at risk for alteration in blood pressure related to HTN, indicated staff's intervention to give meds as ordered by observing the blood pressure parameters established by the physician. A review of April 2008 facility's policy and procedures, titled Charting and Documentation indicated that all observations, medications administered, services performed, etc., must be documented in the resident's clinical record. f. A review of Resident 6's admission record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. On January 24, 2016 an order for [REDACTED]. [MEDICATION NAME] should not be given if the apical pulse (heart rate) is less than 60 beats per minute. The Medication Administration Record (MAR) indicated on February 1, 20, and 29, 2016, the resident's heart rate was not taken when [MEDICATION NAME] was given. The heart rate was not documented on the MAR on February 1 and 21, 2016 when [MEDICATION NAME] was given. On March 25, 2016 at 10:40 a.m., during an interview and review of Resident 6's MAR with licensed vocational nurse (LVN 1), LVN 1 stated that the resident's heart rate should be taken prior to [MEDICATION NAME] and [MEDICATION NAME] medications administration. A review of April 2008 facility's policy and procedures titled Charting and Documentation indicated that all observations, medications administered, services performed, etc., must be documented in the resident's clinical record. g1. A review of Resident 7's clinical record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. An order dated July 28, 2015 indicated to administer [MEDICATION NAME] (blood pressure lowering medication) 40 mg. The order indicated to hold the medication if the heart rate (HR) was less than 60 and SBP less than 110. The MAR for the month of January 2016 indicated that the resident's HR and blood pressure were not documented on January 29 and 30, 2016. The MAR for the month of February 2016 indicated that Resident 7's heart rate was not documented for the entire month. The MAR for the month of March 2016 indicated that Resident 7's heart rate was not documented on March 4, 7, 11, and 17, 2016. On March 25, 2016 at 10:25 a.m., during an interview and review of Resident 6's MAR with LVN 7 she stated that the heart rate should have been taken prior to [MEDICATION NAME] and [MEDICATION NAME] administration and documented. A review of the facility's policy and procedure dated April 2008, titled Charting and Documentation indicated that all observations, medications administered, services performed, etc., must be documented in the resident's clinical record. g2. Resident 7 had a physician's orders [REDACTED]. A review of undated Pacemaker Check log indicated the log was blank. A review of Resident 7's care plan dated July 11, 2015, titled Pacemaker indicated that licensed staff will schedule pacemaker check as ordered. During an interview and review of Resident 7's clinical record on March 23, 2016 at 10:51 a.m., with the registered nurse (RN) supervisor stated that a pacemaker check should be done every six months. She was unable to provide documentation that the resident pacemaker was checked. A review of the facility's undated policy and procedures titled Pacemaker Care Guideline indicated to record the pacemaker test and pulse rate in the care plan. h. Resident 14's admission record indicated the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident had left upper arm arteriovenous fistula (AV shunt a connection or passageway between an artery and a vein). A Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated March 9, 2016 indicated resident's cognitive skills for daily decision-making were intact and required limited assistance from the staff with activities of daily living. The resident had a physician's orders [REDACTED]. A review [MEDICAL TREATMENT] Communication Form dated February 18 and 25, 2016, indicated the vital sign, time the resident came back to the facility, and bruit pulse assessment were blank. During an interview and review of Resident 14's clinical record with registered nurse supervisor on March 24, 2016, at 12:30 p.m., he stated for post [MEDICAL TREATMENT] the charge nurse should have assessed the resident [MEDICAL TREATMENT] for any bleeding, swelling, and vital sign. The facility policy and procedures titled [MEDICAL TREATMENT] Access Care dated October 2010, indicated the general medical nurse should document in the resident's medical record every shift as follows 1. Location of catheter. 2. Condition of dressing (intervention if needed). 3. If [MEDICAL TREATMENT] was done during shift. 4. Any part of report from [MEDICAL TREATMENT] nurse post-[MEDICAL TREATMENT] being given. 5. Observations post-[MEDICAL TREATMENT].