Every finding on record at La Crescenta Healthcare Center

Based on observation, interview and record review, the facility failed to ensure that food brought into the facility from outside was labeled and stored appropriately for one of one sampled Resident refrigerator in accordance with the facility's policy and procedure titled Food Brought from Outside the Facility. This failure had the potential to result in residents getting a foodborne illness such as food poisoning, since the food safety, freshness and ownership cannot be verified. Findings: During a concurrent observation and interview on 5/8/2026 at 10:15 AM with the Infection Preventionist (IP) in the entero food supply room, an unlabeled white bag was in the refrigerator for Resident's personally supplied food. IP removed the bag stating there is no label identifying who the item belongs to or dates identifying when to throw the item away. During a concurrent observation and interview on 5/8/2026 at 10:15 AM with the IP in the entero food supply room: three transparent bags with fruit one plastic purple water bottle one gallon container of Neopolitan ice cream one gallon container of rocky road ice cream It was in the freezer for Resident's personally supplied food. IP stated there is no label showing who the items in the Resident's freezer belonged to. During a concurrent interview and record review on 5/8/2026 at 11:30 AM with the IP, the facility's hand out titled Food Brought from Outside the Facility, undated was reviewed. The handout indicated, containers will be labeled with the resident's name, and the use by date. The IP stated there was no labeling indicating who the food in the Resident's refrigerator belonged to. The IP further stated labelling of foods is to know who the food belongs to and when the food should be thrown away. Residents could get sick or upset that their own food was thrown away. During a review of the policy and procedure (P&P) titled, Food Brought from Outside the Facility, version RC1 0305.04, the P&P indicated food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility-prepared food.

Based on observation, interview and record review, the facility failed to ensure Registered Nurse (RN) 3 performed hand hygiene for one of one sampled resident (Resident 50) after Registered Nurse (RN) 3 administered medications to Resident 50 via gastrostomy tube (GT) (a small tube placed through the belly directly into the stomach to provide nutrition, liquids, and medicines ) and then proceeded to administer eye drops (Artificial Tears) to Resident 50 on 5/7/2026. This deficient practice had the potential to transfer bacteria and/or virus (tiny germs that cause infections) from Resident 50's GT site to Resident 50's eyes.Findings: During a review of Resident 50's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing), attention to gastrostomy (a surgical procedure that creates a small, artificial opening through the abdominal wall directly into the stomach), diabetic chronic kidney disease (kidneys are damaged and gradually lose their ability to filter waste and excess fluid from the blood) and legal blindness (severe vision loss). During a review of Minimum Data Set (MDS, a resident assessment tool), dated 4/10/2026, the MDS indicated Resident 50's cognitive skills (ability to make daily decisions) was severely impaired. The MDS indicated, Resident 50 was dependent with all activities of daily living (ADL's). During a review of Resident 50's Physician Order Report dated 5/1/2026 to 5/7/2026, the Report indicated to administer crushable medications via GT, and artificial tears one drop to both eyes twice a day. During a concurrent observation and interview on 5/7/2026 at 8:36 AM with RN 3, in Resident 50's room RN 3 changed gloves after providing Resident 50 with her GT medications and prior to administering Resident 50's eye drops without performing hand hygiene. RN 3 stated, she forgot to perform hand hygiene when changing gloves. RN 3 stated, the use of gloves does not replace hand hygiene. RN 3 stated, not performing hand hygiene after administering GT medication and prior to administering Residents 50's eye drops had the potential to result Resident 50 acquiring an eye infection. During an interview on 5/7/20206 at 9:28 AM with the Director of Nurses (DON), DON stated, it was the facility's policy to prevent the spread of infections, so staff must perform hand hygiene before moving from a contaminated body site to a clean body site during resident care and the use of gloves does not replace hand hygiene. DON stated, when performing two different task such as administering GT medication and administering eyedrops, hand hygiene must be performed between changing gloves to prevent infections. DON stated, RN 3 not performing hand hygiene, had the potential to transfer bacteria and/or virus from Resident 50's GT site to Resident 50's eyes which could result in an eye infection that could negatively affect Resident 50's quality of life. A review of the facility's policy and procedure (P&P) titled, Hand Hygiene, (undated) indicated; a)facility considers hand hygiene the primary means to prevent the spread of infections, b) hand hygiene before moving from a contaminated body site to a clean body site during resident care, and c) the use of gloves does not replace hand washing/hand hygiene, integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections. A review of the facility's policy and procedure (P&P) titled, Infection Control Program, (undated) indicated; important facets of infection prevention include instituting measures to avoid complications or dissemination (spreading) and educating staff and ensuring that they adhere to proper techniques and procedures.

Based on observation, interview, record review, the facility failed to ensure the call light was accessible and within reach for one of six sampled residents (Resident 14), who was dependent with all activities of daily living (ADL), visually impaired, and a high risk for fall as indicated in the resident's care plan and facility's policy and procedures titled Call Lights-Answering Of. This deficient practice had the potential to result in Resident 14 not able to call for assistance for ADL care, and in cases of emergency such as a fall with injury which can negatively affect Resident 14's quality of life. Findings: During a review of Resident 14's admission Record, the AR indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute or chronic respiratory failure (the lungs cannot get enough oxygen into the blood or cannot remove carbon dioxide (a waste gas) from the blood), atherosclerotic heart disease (a condition where fat, cholesterol, and other substances build up in the walls of arteries, forming buildup that narrows the arteries restricting blood flow and potentially causing heart attacks or strokes), weakness, and arthritis (inflammation, pain, stiffness, and swelling in one or more joints). During a review of Minimum Data Set (MDS, a resident assessment tool), dated 2/9/2026, the MDS indicated Resident 14's cognitive skills (ability to make daily decisions) was moderately impaired. The MDS indicated, Resident 14 was dependent with all ADLs. During a review of Resident 14's facility document titled Fall Risk Data Collection dated 4/3/2026, the Fall Risk Data Collection indicated Resident 14 was at high risk for fall. During a review of Resident 14's care plan (CP) dated 4/7/2026, the CP indicated the resident had moderately impaired vision with intervention that included to assist with ADL's as needed and keep call light within reach. During a review of Resident 14's CP dated 4/7/2026, the CP indicated the resident was high risk for fall related to balance problem, weakness with the intervention to keep call light within reach. During a concurrent observation and interview on 5/5/2026 at 9:30 AM with Registered Nurse (RN) 2, in Resident 14's room, Resident 14 was observed in bed with the call light hanging on the right-side of the bed. RN 2 stated, Resident 14's call light should be closer to Resident 14's and was not within Resident 14's reach. RN 2 stated, Resident 2 was able to use her call light so the call light should be accessible for Resident 14 in cases of medical emergency or for when Resident 14 needs to call for assistance from facility staff. During an interview on 5/6/20206 at 8 AM with the Director of Nurses (DON), DON stated, residents in the facility should always have the call light accessible and within reach. DON stated, Resident 14 was able to use call light for assistance and was assessed as a high risk for fall resident. The DON stated Resident 14 required assistance with her ADL's so access to her call light was very important. DON stated, Resident 14 not having access to her call light, had the potential for Resident 14 not to receive the care she needs, especially during emergency, such as a fall with injury which can negatively affect Resident 14's quality of life. A review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, (undated), indicated, for residents who cannot independently perform ADLs, necessary services will be provided to ensure adequate nutrition, grooming, and personal hygeine. A review of the facility's policy and procedure (P&P) titled, Call Lights-Answering Of, dated 3/6/2026, indicated, ensure call light is placed within the Resident reach and maintain Resident's safety.

Based on interview and record review, the facility failed to accurately document the code status (a medical order indicating what emergency treatments a resident wants or does not want if their heart or breathing stops) of one of five sampled residents (Resident 5) was for full code (in the event of the resident's heart stops beating or stops breathing, all life-saving measures such as CPR and intubation will be used to attempt to save a resident's life) in the resident's clinical record when Resident 5 chose selective treatments as indicated on the Physician Orders for Life-Sustaining Treatment (POLST actionable medical order signed by a doctor or medical provider that translates a seriously ill patient's end-of-life wishes). This failure had the potential to result in Resident 5 receiving treatment against her wishes. Findings: During a review of Resident 5's admission Record indicated Resident 5 was admitted on [DATE] with diagnoses that included osteoporosis (weak and brittle bones due to lack of calcium and vitamin D), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and hypertension (high blood pressure). During a review of Resident 5's History and Physical (H&P) dated [DATE], the H&P indicated Resident 5 had the mental capacity to make medical decisions. During a review of Resident 5's POLST dated [DATE], the POLST indicated Resident 5 was do not resuscitate (DNR instructs healthcare providers not to perform cardiopulmonary resuscitation [CPR -chest compressions and rescue breaths to manually keep oxygenated blood flowing to the brain and vital organs] if a patient's breathing or heartbeat stops and medical intervention was selective treatment and did not want intubation (a medical procedure where a plastic tube is inserted through the mouth or nose into the windpipe to maintain an open airway and deliver oxygen for breathing) or CPR. During a review of Resident 5's Advanced Directive (a legal document indicating resident preference on end-of-life treatment decisions) dated [DATE], the Advanced Directive indicated, Resident 5 wishes for no ventilator (a medical device to help support or replace breathing), no heroic measures, no CPR. During a concurrent interview and record review on [DATE] at 4:06 pm with the Registered Nurse Supervisor (RN) 1, the physician order report dated [DATE] was reviewed. The physician order report indicated Resident 5 was full code (a patient wants all available life-saving interventions used if their heart or breathing stops). RN 1 stated Resident 5 should not be full code since Resident 5 indicated on the POLST for DNR with selective treatment. order should show selective treatment in accordance with her advanced directive. RN1 further stated it was important to have the correct order to ensure that the correct treatment was provided. RN 1 stated if there was a medical emergency, Resident 1's wishes would not be implemented since the order indicated was inaccurate. Resident 1 and the resident that at risk of having measures she did not want. During a review of the facility's policy and procedure (P&P) titled, Charting, version OP5 0601.00, the P&P indicated all documentation shall be specific, complete, and accurate. During a review of the facility's P&P titled, Physician's Orders for Life Sustaining Treatment (POLST), version OP2 0317.01, the P&P indicated, POLST is a medical order, not merely a preference document. During a review of the facility's P&P titled, Advanced Directives, version OP2 0303.00, the P&P indicated, the facility will comply with the wishes of a resident as expressed in an Advance Directive and will not condition the provision of care or otherwise discriminate against an individual based on whether the individual has executed an Advance Directive.

Based on interview and record review, the facility failed to provide medically-related social services to one of five sampled residents (Resident 21) when the Social Service Designee (SSD) did not follow up to ensure Resident 21's Advance Directive (AD a legal document indicating resident preference on end-of-life treatment decisions) and DPOA ( Durable Power of Attorney) provided by the resident's responsible party (RP) was for a health care and not for financial in accordance with the facility's policy and procedure titled Advance Directives. This failure had the potential to result in Resident 21 receiving treatment against her wishes and placing Resident 21's safety at risk. Findings: During a review of Resident 21's face sheet (front page of the chart that contains a summary of basic information about the resident), it indicated Resident 21 was admitted on [DATE] with diagnoses that included cerebral infarction (stroke - loss of blood flow to a part of the brain), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 21's history and physical (H&P) dated 2/2/2026, the H&P indicated Resident 21 does not have the mental capacity to make medical decisions. During a review of Resident 21's Social Services Assessment - Initial, dated 2/12/2024, The Social Services Assessment indicated Resident 21 has an Advance Directive, but resident representative did not bring a copy of AD for the facility. During an interview on 5/6/2026 at 2:32 PM, the SSD stated, When an Advance Directive is provided, she will copy and place it in the chart and provide a copy to the medical records person. SSD further stated she does not review the Advance Directive or compare it to the Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life). During a concurrent interview and record review on 5/7/2026 at 2:42 PM with the SSD, Resident 21's Durable Power of Attorney (DPOA - a legal document that authorizes a chosen person to manage a resident's financial, legal, or medical affairs) dated 8/25/2023 was reviewed. The DPOA indicated this document does not authorize anyone to make medical and other health-care decisions. The SSD stated the DPOA form was copied and placed in Resident 21's medical record without being reviewed by the SSD. SSD further stated she will follow up with resident representatives only if she remembers to do so. During a concurrent interview and record review on 5/7/2026 at 3:10 PM with the Administrator (ADM), the facility's Social Services Manager's job description dated 9/23/2003 was reviewed. The job description indicated one of the SSD's essential duties and responsibilities is to facilitate Advance Directive decision-making process. The ADM stated the SSD is responsible for presenting the Advance Directive received in the morning meeting for proper review. During a concurrent interview and record review on 5/7/2026 at 3:10 PM with the ADM Resident 21's DPOA dated 8/25/2023 was reviewed. The DPOA indicated this document does not authorize anyone to make medical and other health-care decisions. The ADM stated the DPOA provided by Resident 21's RP was for financial reasons and not healthcare. The ADM further stated the SSD should have done a preliminary review of the DPOA so that the SSD could have followed up with the resident representative regarding a healthcare DPOA instead of a financial DPOA. During a review of the facility's Social Services Manager's job description dated 9/23/2003, the job description indicated the SSD completes required forms and documents in accordance with company policy and state and/or federal regulations. During a review of the facility's P&P titled, Advance Directives, version OP2 0303.00, the P&P indicated, the facility reviews the Advance Directive whether it's a DPOA for healthcare or if it contains specific instructions from the resident at the end of life to make sure it coincides with the physician's orders.

Based on interview and record review, the facility failed to implement an antibiotic stewardship program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics) for antibiotic use when two of five sampled residents (Residents 61 and 89) did not meet criteria for antibiotic use and facility did not report it to the attending physician. This failure had the potential to result in residents receiving unnecessary antibiotics leading to antibiotic resistance (when bacteria evolve to survive and multiply despite the presence of antibiotic drugs designed to kill them). 1. During a review of Resident 61's face sheet (front page of the chart that contains a summary of basic information about the resident), it indicated Resident 61 was admitted on [DATE] with diagnoses that included encephalopathy (any disease, damage, or malfunction that affects the brain's structure or function, resulting in an altered mental state), and chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty breathing). During a review of Resident 61's Minimum Data Set (MDS-a comprehensive assessment and screening tool) dated 3/9/2026, the MDS indicated Resident 61 has severely impaired cognitive (thought process) skills for daily decision making. Resident 61 requires a helper to do more than half the effort for roll left and right, sit to lying, lying sitting on side of bed, sit to stand and chair/bed to chair transfer. Resident 61 requires a helper to do all of the effort for toileting hygiene, shower/bathe, dressing, and tub/shower transfer. During a review of Resident 61's Medication Administration Record (MAR), dated 5/2026, the MAR indicated Resident 61 received Doxycycline hyclate (a broad-spectrum (powerful medication that act against a wide variety of disease-causing bacteria) antibiotic used to treat various bacterial infections) was given twice a day starting 5/4/2026 - 5/11/2026 for fever. During a concurrent interview and record review on 5/8/2026 at 9:30 AM with the Infection Preventionist (IP), Resident 61's urinalysis (UA - a common urine test that detects infections, kidney disease and/or diabetes) results dated 5/5/2026 at 4:01 AM was reviewed. The UA indicated there was no infection detected. The IP stated there was no documented evidence that the facility staff communicated with the physician regarding negative results of the UA. During a concurrent interview and record review on 5/8/2026 at 9:30 AM with the Infection Preventionist (IP), Resident 61's urine culture (UCX - a laboratory test that identifies bacteria or yeast in a urine sample to diagnose urinary tract infections) results dated 5/6/2026 at 8:49 PM, indicated there was no abnormal infectious organism growth seen. The IP stated the there was no documented evidence that the facility staff communicated with the physician regarding negative results of the UCX. During a concurrent interview and record review on 5/8/2026 at 9:30 AM with the Infection Preventionist (IP), Resident 61's McGeer's Criteria (a standardized surveillance tool used to identify infections in long-term care facilities to ensure consistent reporting and monitor infection rates) dated 5/6/2026 at 1:37 PM was reviewed. The McGeer's Criteria was not completed. The IP stated that the McGeer's Criteria should indicate Resident 61 did not meet the criteria for antibiotics because of negative UA and UCX results. The IP further stated there was no physician communication indicating Resident 61 does not meet criteria for antibiotic use. IP stated, it is important to make sure that the antibiotics are appropriate for the resident and to ensure they should be on the antibiotics. During an interview on 5/8/2026 at 2:46 PM with the Director of Nursing (DON), the DON stated, negative lab results or McGeer's criteria not being met should be reported to the physician so that the nurses will know whether the antibiotic should be continued or stopped. The DON further stated failure to report negative labs when on an antibiotic can lead to the resident [having] unnecessary treatment and develop resistance to antibiotics. During a review of the facility's policy and procedure (P&P) titled, General Infection Control Report Guidelines, version IC 0112.00, the P&P indicated, the IP is to review the McGeer's Criteria for accuracy, identify all symptoms present, treatment being provided, and determine if it is a true infection - will need to meet the criteria listed in the form. The P&P also indicated that all residents on an antibiotic will have monitoring done for proper follow up with the Attending physician. During a review of the facility's P&P titled, Antibiotic Stewardship Program, version IC 0113.00, the P&P indicated, it is the policy to implement an Antibiotic Stewardship Program which will promote appropriate use of antimicrobials while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. This policy has the potential to limit antimicrobial resistance in the post-acute care setting, while improving treatment efficacy, and reducing treatment-related costs. The P&P also indicates residents receiving antibiotics will be reviewed and a separate report will be made for those that did not meet the McGeer Criteria. 2. During a review of Resident 89's face sheet (front page of the chart that contains a summary of basic information about the resident), it indicated Resident 89 was admitted on [DATE] with diagnoses that included encephalopathy (any disease, damage, or malfunction that affects the brain's structure or function, resulting in an altered mental state), pneumonia (an infection/inflammation in the lungs), and dementia (a progressive state of decline in mental abilities). During a review of Resident 89's Minimum Data Set (MDS-a comprehensive assessment and screening tool) dated 1/20/2026, the MDS indicated Resident 89 has severely impaired cognitive skills for daily decision making. Resident 89 requires a helper to do less than half the effort for toileting hygiene, upper body dressing, roll left and right, sit to lying, sit to stand, and chair/bed to chair transfer. Resident 89 requires a helper to do all of the effort for shower/bathing and toilet transfer. During a review of Resident 89's physician order report dated 1/14/2026-1/20/2026, the physician order report indicated azithromycin (a commonly prescribed antibiotic used to treat bacterial infections of the ears, lungs, sinuses, skin, and throat) was started on 1/16/2026 - 1/20/2026 for pneumonia. During a concurrent interview and record review on 5/8/2026 at 9:30 AM with the Infection Preventionist (IP), Resident 89's McGeer's Criteria (a standardized surveillance tool used to identify infections in long-term care facilities to ensure consistent reporting and monitor infection rates) dated 1/16/2026 was reviewed. The McGeer's Criteria indicated the criteria for antibiotics was not met due to Resident not having at least one of the constitutional criteria (fever, leukocytosis (high white blood cell count), change in mental status from baseline or acute functional decline). The IP stated there was no communication with the physician stating the McGeer's criteria was not met. IP stated, it is important to make sure that the antibiotics are appropriate for the resident and to ensure they should be on the antibiotics. During an interview on 5/8/2026 at 2:46 PM with the Director of Nursing (DON), the DON stated, negative lab results or McGeer's criteria not being met should be reported to the physician so that the nurses will know whether the antibiotic should be continued or stopped. The DON further stated failure to report negative labs when on an antibiotic can lead to the resident [having] unnecessary treatment and develop resistance to antibiotics. During a review of the facility's policy and procedure (P&P) titled, General Infection Control Report Guidelines, version IC 0112.00, the P&P indicated, the IP is to review the McGeer's Criteria for accuracy, identify all symptoms present, treatment being provided, and determine if it is a true infection - will need to meet the criteria listed in the form. The P&P also indicated that all residents on an antibiotic will have monitoring done for proper follow up with the Attending physician. During a review of the facility's P&P titled, Antibiotic Stewardship Program, version IC 0113.00, the P&P indicated, it is the policy to implement an Antibiotic Stewardship Program which will promote appropriate use of antimicrobials while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. This policy has the potential to limit antimicrobial resistance in the post-acute care setting, while improving treatment efficacy, and reducing treatment-related costs. The P&P also indicates residents receiving antibiotics will be reviewed and a separate report will be made for those that did not meet the McGeer Criteria.

Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 85) did not store at the bedside that is accessible to other residents and visitor, and self-administer Albuterol Inhaler (medication used to quickly treat or prevent bronchospasms, including asthma symptoms (wheezing, tightness) and breathing difficulties) that was observed at Resident 85's bedside table in accordance with the facility's policy and procedure Medication Storage. Resident 85 stated, the Albuterol inhaler was given by her doctor and had been using it as needed every six hours when she had trouble breathing. Resident 85 did not have a Physician Order to administer the Albuterol inhaler. Resident 85 did not have an order for self-administration of the Albuterol inhaler. This deficient practice had the potential for Resident 85 and other residents with access to the medication to have excessive dose of Albuterol inhaler that could result in tachycardia (heart rate that is too fast) that could lead to compromised health and wellbeing of the residents. Findings: During a review of Resident 85's admission record indicated the resident was admitted with diagnoses that included hypertension (high blood pressure), chronic pulmonary edema (a condition caused by too much fluid in the lungs), chronic kidney disease (a long-term condition where the kidneys are damaged and gradually lose their ability to filter waste and excess fluid from the blood), and chronic obstructive pulmonary disease (COPD) (long-term, progressive lung disease that makes it hard to breathe by damaging the airways and air sacs). During a review of Resident 85's History and Physical Examination (H&P), dated 4/29/2026, indicated Resident 85 had the capacity to make healthcare decisions. During a review of Minimum Data Set (MDS, a resident assessment tool), dated 4/29/2026, indicated Resident 85's cognitive skills (ability to make daily decisions) was intact. The MDS indicated, Resident 85 requires setup and clean-up assistance (helper sets up and cleans up; resident completes activity) with eating, and partial/moderate assistance (helper does less than half the effort) with toileting, bathing, dressing and personal hygiene. During a concurrent observation and interview on 5/5/2026 at 8:58 AM with Licensed Vocational Nurse (LVN) 1 in Resident 85's room. Resident 85 was in bed; an Albuterol Inhaler was observed on Resident 85's bedside table with other belongings. LVN 1 stated, the Albuterol inhaler should not be with Resident 85, it should be properly stored in the medication cart. LVN 1 stated, Resident 85 did not have an order for the Albuterol and to self-administer her medications. LVN 1 stated, Resident 85 able to reach and access the medication Albuterol inhaler and had the potential for overuse the medication without proper monitoring that could result in adverse effect, such as tachycardia. Resident 85 stated, the Albuterol inhaler had been her medication from her doctor, and she uses it as needed every six hours if she has trouble breathing, she did not remember when she started using it. During an interview on 5/5/2026 at 9:15 AM with Registered Nurse (RN) 2, RN 2 stated, Resident 85 did not have an order for the Albuterol Inhaler and does not have an order to self-administer her medications. RN 2 stated, the Albuterol Inhaler should have been stored properly in a lock storage and not with Resident 85 to prevent the potential for overuse that could result in adverse side effects. During a concurrent interview and record review on 5/6/2026 at 7:45 AM with the Director of Nurses (DON), Resident 85's POR - Physician Order Report dated 5/1/2026 to 5/5/2026 was reviewed. The POR indicated, the Albuterol Inhaler to be administered every six hours as needed was not ordered until 5/5/2026 (day the Surveyor found the Albuterol at Resident 85's bedside and reported it to LVN 1). DON stated, Resident 85 did not have a physician order for the Albuterol until 5/5/2026 when Surveyor found it at bedside. DON stated, even with an order, the Albuterol inhaler should not be with Resident 85. During an interview on 5/6/2026 at 8:05 AM with the DON, DON stated, medications should not be at Resident 85's bedside, it should be in a locked storage area only accessible to authorized personnel. Resident 85 should not have accessed to the Albuterol inhaler because of the potential for overuse of the medication that could result in adverse effect such as tachycardia that could lead to an emergency event and negatively affect Resident 85's quality of life. A review of the facility's policy and procedure (P&P) titled, Medication Storage, dated 5/2021, indicated; a) the medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications, b) provider pharmacy dispenses medications in containers, medications are to remain in these containers , this may include medication carts, rooms and cabinets, and c) in order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications are allowed access to medication carts

Based on observation, interview and record review, the facility failed to provide oxygen therapy as ordered by the physician to one of one sampled resident (Resident 14), who was not receiving oxygen due to NC (a flexible tube with two prongs that rest in the nostrils to deliver supplemental oxygen) was in a bag attached to an oxygen concentrator (a machine that takes air from the surroundings, extract oxygen and filter it into purified oxygen). This deficient practice had the potential for Resident 14 not to receive adequate oxygenation that could lead to respiratory decompensation (when respiratory system fails to meet the body's oxygen and carbon dioxide needs, requiring immediate intervention like oxygen), shortness of breath (SOB) and respiratory distress. Findings: During a review of Resident 14's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute or chronic respiratory failure (the lungs cannot get enough oxygen into the blood or cannot remove carbon dioxide (a waste gas) from the blood), atherosclerotic heart disease (a condition where fat, cholesterol, and other substances build up in the walls of arteries, forming buildup that narrows the arteries restricting blood flow and potentially causing heart attacks or strokes). During a review of Minimum Data Set (MDS, a resident assessment tool), dated 2/9/2026, the MDS indicated Resident 14's cognitive skills (ability to make daily decisions) was moderately impaired. The MDS indicated, Resident 14 was dependent with all ADL's. During a review of a Physician Order Report dated 5/1/2026, the Report indicated to administer oxygen at 2 liters per minute via NC continuously to Resident 14. During a review of Resident 14's care plan (CP), revised on 5/4/2026, the Care Plan indicated, the resident had alteration in respiratory status related to respiratory failure, with the intervention to administer oxygen through a N/C continuously. During a concurrent observation and interview on 5/5/2026 at 9:30 AM with Registered Nurse (RN) 2 in Resident 14's room, Resident 14 was observed lying in bed and was not receiving oxygen for at least 10 minutes. The NC was observed stored in a bag attached to the oxygen concentrator rather than placed on Resident 14. RN 2 confirmed that Resident 14 was not receiving oxygen despite the active order for continuous oxygen at 2 liters per minute. RN 2 stated since Resident 14 was not receiving continuous oxygen, there was a potential for respiratory decompensation (inadequate oxygen), including shortness of breath and respiratory distress. During an interview on 5/6/2026 at 8AM with the Director of Nursing (DON), the DON stated staff should follow all physician orders as well as the facility's oxygen administration policy. The DON confirmed that Resident 14's physician order for continuous oxygen was not followed which compromised the respiratory need of the resident. The DON further stated since the Resident 14 not receiving oxygen for at least ten minutes had the potential to result in inadequate oxygenation, which could lead to respiratory decompensation, shortness of breath, and respiratory distress, negatively affecting the resident's quality of life. A review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 10/21/2025, indicated; a)attached the oxygen delivery device to the oxygen unit, b) turn the unit on the desired flow rate and assess equipment for proper functioning, and assist in placing oxygen delivery device on the resident and make sure it fits properly and stable. A review of the facility's P&P titled, Physician Orders, dated 6/27/2025, indicated, physician orders are obtained to provide a clear direction in the care of the resident.

Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, notice of transfer of potential financial liability usually paid by Medicare (a federal health insurance) but may not be paid for in this instance because it is not medically reasonable and necessary, or custodial care) to beneficiaries before the non-covered extended care items or services are provided by the facility for two of three sampled residents (Resident 3 and Resident 60) who were discharged from Medicare Part A and continue to live in the facility. 1.Resident 3 last covered day of Medicare Part A service was on 4/13/2026. 2. Resident 60 last covered day of Medicare Part A service was on 3/10/2026. This deficient practice had violated Resident 3 and Resident 60 and/or their responsible party (RP) the right to be informed about the right to appeal, and potentially not be aware of possible charges for services rendered that were not covered after their last Medicare Part A coverage day, which could result in financial hardship. Findings: 1.During a review of Resident 3's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (a blockage in an artery interrupts blood flow to the brain, causing brain tissue to die from lack of oxygen and nutrients), cervical disc degeneration (the natural wear and tear of the cushioning discs in your neck), and atrial fibrillation (a steady beat, the heart quivers (fibrillates), which can cause blood to pool, increasing the risks of blood clots, stroke, and fatigue) During a review of Minimum Data Set (MDS, a resident assessment tool), dated 4/26/2026, indicated Resident 3's cognitive skills (ability to make daily decisions) was severely impaired. 2. During a review of Resident 60's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction, encephalopathy (disease, damage, or malfunction of the brain and cirrhosis of liver (severe, permanent scarring of the liver caused by long-term damage). During a review of Minimum Data Set (MDS, a resident assessment tool), dated 2/26/2026, indicated Resident 60's cognitive skills (ability to make daily decisions) was severely impaired. During a concurrent interview and record review on 5/7/2026 at 3:41 PM, the MDS Nurse/Beneficiary Coordinator (MDSN/Beneficiary Coordinator 1) stated that SNF Beneficiary Protection Notification Review documents for Residents 3 and 60 indicated their Medicare Part A coverage ended on 4/13/2026 and 3/10/2026, respectively, without documentation that a required SNF Advance Beneficiary Notice (ABN) was provided to the residents or their representatives. The MDSN stated that he and the Social Services Director are responsible for issuing these notices but acknowledged he did not provide them due to misunderstanding of the CMS requirements. MDSN stated that failing to issue the SNF ABN violated resident rights. During an interview on 5/7/2026 at 4:15 PM with the Social Service Director (SSD/ Beneficiary Coordinator 2), SSD stated, herself and the MDSN are responsible for providing beneficiary notice to residents and/or RP in advance when there will be changes with their benefits. SSD stated, she did not provide SNF ABN to Resident 3, Resident 60 and/or their RP, she missed it. During a concurrent interview and record review on 5/8/2026 at 8:08 AM with the Director of Nursing (DON), the Electronic Health Records were reviewed for Residents 3 and 60 which indicated no documentation that a SNF Advance Beneficiary Notice (ABN) was provided before their Medicare Part A coverage ended on 4/3/2026 and 3/10/2026, respectively. The DON stated that both Residents 3 and 60 still reside in the facility and that failure to provide required notice of changes in benefits constituted a resident rights issue. During an interview on 5/8/2026 at 8:20 AM, the Administrator (ADM) stated that the facility follows state and federal regulations and stated that a SNF Advance Beneficiary Notice (ABN) should have been provided to Residents 3 and 60 and/or their representatives before their Medicare Part A coverage ended. The Administrator explained that both Beneficiary Coordinators missed issuing the notices to the representative or resident. He stated that providing the SNF ABN in advance ensures residents are aware of benefit changes and their right to appeal, even if they have secondary insurance. The Administrator acknowledged that failing to provide the SNF ABN violated the residents' right to be informed. A review of the facility's policy and procedure titled, Medicare Advance Beneficiary and Medicare Non-Coverage Notice, dated 6/6/2025 indicated: Procedure under SNF ABN a) residents are informed in advance when changes will occur to their bills, b) if the benefits coordinator believes during resident stay that Medicare Part A will not pay for an otherwise covered skilled service, the resident and/or the representative is notified in writing why the services may not be covered and of the resident's potential liability for payment of non- covered services, and c) SNF ABN is issued to the beneficiary before those non-covered extended care items or services are furnished to the beneficiary. A review of the facility's policy and procedure titled, Resident Rights, dated 5/7/2026 indicated; a) the company will inform the resident both orally and in writing his or her rights as a resident, b) the facility must inform each resident during the resident stay, services available in the facility and of charges for those services, including any charges for services not covered under Medicare.

Based on interview and record review, the facility failed to post accurate nurse staffing information of actual hours worked by Registered Nurses (RN), License Vocational Nurse (LVN) and Certified Nurse Aides (CNA) per shift on 5/7/26 in accordance with the facility's policy and procedure titled Posting Direct Care Staffing Numbers. This deficient practice of posting inaccurate nurse staffing information failed to ensure that residents, their representatives, visitors, and regulatory personnel had access to correct and reliable staffing data. This had the potential to misrepresent the actual number of nursing staff available to provide resident care and could negatively affect transparency and the facility's compliance with required posting regulations. Findings: During a review of the facility's document titled Nursing Staffing Daily Posting (posting of staffing information), dated 5/7/2026, the document did not indicate the number of actual time worked per shift for each nursing category (licensed or non-licensed); instead, the document contained a combined total of projected hours of each nursing category in 24 hours. During a concurrent interview and record review on 5/7/2026 at 2:37 PM with the Staffing Coordinator (SC), the facility's Nursing Staffing Daily Posting was reviewed. The SC stated the Nursing Staffing Daily Posting contained the projected hours for the morning shift, afternoon shift, and evening shifts and calculated the number of projected hours worked in a 24-hour period for each nursing category. The SC stated the actual hours worked were kept in a binder and not posted at the nurse's station. During an interview with the Director of Staff Development (DSD) on 5/7/2026 at 2:37 PM, the DSD stated that the Nursing Staffing Daily Posting was posted for staff and visitors to see and if it was not accurate, there was a potential for poor care and confusion of actual nursing staff hours. The DSD stated it was important to post accurate and actual hours for nursing staff to ensure safe staffing and patient care. During a review of the facility's policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers and dated 3/30/2022, the P&P indicated, Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include. the actual time worked during that shift for each category and type of nursing staff.

Based on interview, and record review, the facility failed to provide a safe and secured environment for one of five sampled residents (Resident 1), reviewed for accidents/safety, who was identified at risk for elopement (when a person with cognitive [thought process] impairment leaves a safe area, such as a care facility or home, without awareness of the potential dangers), wandering (a person that roams around and becomes lost or confused about their location) out of the facility, and at risk for falls by failing to: 1. Implement care plan interventions to visually monitor hourly, and check whereabouts (the place where a person is located), of Resident 1, who had been assessed at Risk for Elopement and Falls which resulted in Resident 1 leaving without authorization or supervision during Resident 1's scheduled physician (Oncologist -a physician who has special training in diagnosing and treating cancer) appointment, outside the facility on 7/17/2025. 2. Ensure the facility staff communicated with the medical transport driver (Driver 1) and the Oncologist Office Staff of Resident 1's needs to be supervised visually and monitored for whereabouts due to Resident 1's elopement risk, while the resident is in the Physician's [Oncologist] Office on 7/17/2025, prior to the scheduled appointment on 7/17/2025. 3. Ensure Registered Nurse (RN) 1 and the facility's Social Services Director (SSD 1) provided Resident 1 with a facility staff to accompany the resident at the physician [Oncologist] appointment on 7/17/2025, outside the facility, when Resident 1 was sent with Driver 1 (not a facility staff) on 7/17/2025 at 1:15 PM, who dropped off and left Resident 1 unsupervised in the Oncologist Office. As a result of these deficient practices, Resident 1 eloped and was reported missing by Driver 1 and Oncologist Office Staff on 7/17/2025 at 2:30 PM at the Oncologist Office, which was 10 miles away from the facility. These deficient practices placed Resident 1 at risk for falls, motor vehicle accidents and exposed Resident 1 to other environmental elements that can lead to serious injury, serious harm, serious impairment or death. On 7/22/2025 (five days after Resident 1 was reported missing), the Oncologist Office Staff informed the facility that Resident 1 was back in Resident 1's family member's (FM 1) home. On 7/18/2025 at 7:41 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified and notified the Administrator (ADM) and the Director of Nursing (DON) of an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance [not following rules] with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the facility's failure to provide one-on-one supervision to Resident 1, who was at high risk for elopement, during a physician's (Oncologist) appointment, outside of the facility that resulted to Resident 1 eloping from the Oncologist's office on 7/17/2025 and was placed at risk for falls, motor vehicle accidents and exposed to harsh environmental conditions that can lead to serious injury, serious harm, serious impairment, and/or death. On 7/19/2025 at 2:17 PM, the Administrator (ADM) provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On 7/19/2025 at 3:25 PM, while onsite and after the surveyor verified/confirmed the facility's full implementation of the IJ Removal Plan through observation, interview, record review, and determined that the IJ situation was no longer present, the IJ was removed onsite on 7/19/2025 at 3:25 PM, in the presence of the ADM and the Director of Nursing (DON). After the IJ was removed, the surveyor verified that the facility's non-compliance remained at a lower scope of isolated (when one or a very limited number of residents are affected and/or one or a very limited number of staff are involved) and lower severity of Level 2 (noncompliance with the requirements for participation that results in the potential for no more than minimal physical, mental, and/or psychosocial harm to the resident, but has the potential to result in more than minimal harm that is not immediate jeopardy). The IJ Removal Plan dated 7/19/2025 included the following information: 1. On 7/17/2025 at 2:30 PM, the facility was notified that Resident 1 was missing, the ADM, DON, Marketing Director, Central Supply Personnel, Rehabilitation Director, and Registered Nurse (RN) organized a search of the clinic and surrounding area. 2. On 7/18/2025 at 8 PM, the Regional Director of Clinical Operations provided a one-on-one in-service education to the ADM, DON, and SSD 1. The training covered the following: -Identification of residents at risk of elopement; -Risk assessment and care planning related to elopement; -New policies and procedures for residents' safety during External Medical and other Off-site (not in the facility) Visits for residents identified with risk for elopement. The requirement that the facility staff or a designated resident representative accompany such resident to appointments and the necessity of verbal and documented communication utilizing the consultation packet and providing the information including the Elopement Risk Evaluation Form to the receiving clinic regarding the resident's elopement risk. 3. The facility's Interdisciplinary Team (IDT- a group of professionals from different fields, designed with the purpose of supporting the health and well-being of participants) re-evaluated all four current residents (Residents 2, 3, 4 and 5) identified at risk for elopement and reviewed appropriate interventions. 4. On 7/18/2025, DON and ADM provided in-service training to all available facility staff concerning the elopement risk identification binder and new policy and procedures. In-service will continue approximately from 7/18/2025 to 7/21/2025 until all active facility staff have received the training. Staff on leave of absence or vacation will receive in-service training upon returning to work before the start of their shift. New employees will receive this training upon hire, and it will be repeated by the Director of Staff Development (DSD) annually. 5. Upon admission, the admitting nurse will evaluate each resident for elopement risk utilizing the designated evaluation form. Care plans and interventions should be identified. IDT will review and verify residents at risk have the necessary precautions in place. 6. The DON or a designee will review appointments daily to confirm that any resident identified at risk for elopement will be accompanied by either facility staff or a resident representative. The facility's nursing supervisor is responsible for verifying residents at risk for elopement are properly accompanied to their appointments. 7. Medical record personnel or their designee will conduct weekly audits of residents with off-site appointments and audit results will be submitted to the ADM and DON for follow-up, as necessary. 8. The SSD will review the off-site appointment schedule for residents each weekday and present the report to ADM and DON, and for any resident identified at risk, an arrangement will be made for a staff or a resident representative to accompany resident to appointment. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 5/20/2025, with diagnoses including encephalopathy (a change in brain function due to injury or disease), hypertension (high blood pressure), chronic pulmonary embolism (a blockage in one of the blood vessels in a person's lungs, most often caused by a blood clot that travels from another part of the body), malignant neoplasm (abnormal growth of tissue [cancerous cells] that can travel to other parts of the body) of the rectum (end part of the large intestine), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's History and Physical (H&P) signed and dated 5/20/2025 by Resident 1's primary physician (Physician 1), the H&P indicated Resident 1 had a diagnosis that included dementia. The H&P indicated Resident 1 needed scheduled treatments at the Oncologist Office located at the General Acute Care Hospital (GACH) 1. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated [requirements imposed by the federal government] resident assessment tool) with assessment date of 5/26/2025, the MDS indicated Resident 1 had moderately impaired (decision poor; cues/supervision required) cognition (the process of knowing and understanding). The MDS also indicated that Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for oral and personal hygiene, upper body dressing, roll left and right, and sit to lying position. The MDS also indicated that Resident 1 used a walker and wheelchair for her mobility and required partial/moderate assistance (helper does less than half the effort) on walking ten feet on uneven surfaces, wheeling 50 feet with two turns, and wheeling 150 feet with a manual wheelchair. The MDS indicated Resident 1 had wandering behavior present that occurred around one to three days during the MDS assessment date During a review of Resident 1's Elopement Risk Assessment (ERA) dated 5/20/2025, the ERA indicated Resident 1 was assessed with the following: Mobility Status: Resident 1's status was marked check for Able to propel a wheelchair. Behaviors: Resident 1's status was marked check for Wanting to go home, to work, or somewhere else. And history of wanting to leave the facility within the last 30 days. The ERA indicated a conclusion that Resident 1 was identified as At risk for elopement. The ERA indicated to develop a care plan for Resident 1's risk for elopement. During a review of Resident 1's care plan for Falls dated 5/21/2025, the care plan indicated Resident 1 was at risk for falls with Fall Risk Assessment score of 18. The care plan indicated that a Fall Risk Assessment with a score of 14 and above is considered high risk for falls. The care plan goal included decreasing the resident's risk for falls and injury with interventions. The care plan interventions included providing assistance with transfers and mobility, and visual monitoring every hour for Falling Star Program. (a fall prevention initiative that uses visual cues to identify residents at high risk of falling. It involves assessing residents, assigning them a fall risk score, and then using signs, such as a falling star graphic on their doors or at their bedside to alert staff to take extra precautions). During a review of Resident 1's Care Plan dated 5/22/2025, the Care Plan indicated that Resident 1 was at risk for elopement and wandering out of the facility. The care plan goals indicated to decrease Resident 1's risk for elopement and wandering out of the facility and provide a safe and supervised environment for wandering. The care plan interventions included avoiding overstimulation (experiencing too much sensory or mental input at once, causing a feeling of being overwhelmed and unable to process information effectively) which can occur in noisy environments, provide activities that will divert resident's attention from wandering, create a secure environment by securing doors and alarms, check the resident's whereabouts and place a wander-guard bracelet (resident's security system that sound off an alarm to alert caregivers when residents have wandered from the protected zone) for elopement precautions. During a review of Resident 1's Physician's Orders dated 5/22/2025, the Physician's Order indicated to place wander-guard bracelet on for elopement precautions and monitor for [wander-guard] proper placement and battery function every shift. During a review of Resident 1's IDT Care Conference Notes dated 5/22/2025, timed at 1:55 PM, conducted with the Social Service Director (SSD) 1 on 7/18/25 at 5:30 PM, the IDT Notes indicated Resident 1's current plan of care was discussed with FM 1 by phone that included fall risk assessment, visual monitoring every hour, elopement risk wander guard on the arm and interventions to manage risks. The IDT Note indicated FM 1's plan was to discharge Resident 1 to an Assisted Living Facility (ALF - provides housing and personal care services to individuals who need help with daily activities, but not the level of medical care provided in a nursing home) or Board and Care (refers to a residential care option catering to individuals requiring assistance with daily living activities). The IDT Note indicated the discharge date was not determined yet due to Resident 1's current condition and waiting for progress within 30 days due to encephalopathy and needs improvement in function. The IDT Notes did not indicate how Resident 1 would be monitored/supervised when going out on appointments outside of the facility. During a review of Resident 1's Social Service Progress Note (SSPN) dated 7/3/2025, the SSPN indicated that Resident 1 insists on going to FM 1's home and the facility's SSD 1 attempted to contact FM 1 several times, but FM 1 did not answer. The SSPN also indicated that the SSD 1 discussed with Resident 1 regarding placement to an ALF in which the resident replied, She [Resident 1] will think about it. During a review of Resident 1's Physician's Orders dated 7/14/2025, the Physician's Order indicated a follow-up appointment with the Oncologist at the Oncologist Office on 7/17/2025 at 1:20 PM. During a review of Resident 1's Progress Note (PN) dated 7/17/2025, timed at 12:30 PM, the PN indicated that Resident 1 went to the [Oncologist] appointment and picked up by medical transportation (to the appointment) in stable condition. During a review of Resident 1's PN dated 7/17/2025 timed at 2:30 PM, the PN further indicated that a phone call was received by the facility from the Oncologist Office Staff looking for Resident 1 because [Resident 1] took the restroom keys with her. At 2:30 PM, Driver 1 called the facility and notified the facility that Driver 1 could not find Resident 1 at the Oncologist Office. At 4 PM, the facility's supervisor notified the Police Department that Resident 1 was missing. During a review of a facility record titled Risk Meeting Notes (RMN) dated 7/18/2025, the RMN indicated that Resident 1 did not return from the Oncologist appointment to the facility. The RMN also indicated the following: 1. On admission, Resident 1 expressed the desire to go home with FM 1. 2. The plan is to continue to work and communicate with the Police Department in locating the resident (Resident 1) to ensure safety. The record indicated Will continue to attempt to reach out to FM 1. During an interview on 7/18/2025 at 1:10 PM with the DON, the DON stated, on 7/17/2025 immediately after the medical transportation driver (Driver 1) notified the facility of Resident 1's elopement, the DON went to the Oncologist office and looked for Resident 1. The DON stated that he also searched for Resident 1's home address indicated on the admission Record. The DON stated Resident 1 was alert and oriented and had never attempted to elope or wander during appointments outside the facility. The DON acknowledged that Resident 1 was identified by the facility as being at risk for elopement, and the facility staff did not send a facility staff to provide supervision and stay/accompany with Resident 1 while in the Oncologist Office [on 7/17/2025] because Resident 1 was alert and oriented and able to verbalize her needs. During an interview on 7/18/2025 at 2:10 PM with SSD 1, SSD 1 stated upon Resident 1's admission to the facility, the facility was made aware that Resident 1 was homeless (no home) and FM 1 informed the facility that Resident 1 would need a placement upon discharge. SSD 1 stated that on 7/3/2025, Resident 1 was asking to go to FM 1's house and SSD 1 tried to contact FM 1. SSD 1 stated she did not document in Resident 1's records or progress notes Resident 1's risk for elopement and how Resident 1 would be monitored/supervised when going out to the Oncologist appointments, scheduled outside the facility. During an interview on 7/18/2025 at 2:55 PM with Registered Nurse (RN) 1, RN 1 stated Resident 1 did not appear to be a wanderer (a person with dementia roams around and becomes lost or confused about their location). RN 1 stated on 7/17/2025, she escorted Resident 1 on the way out of the facility prior to the Oncologist appointment and endorsed Resident 1 to Driver 1. RN 1 stated she removed Resident 1's wander-guard battery in front of Driver 1. RN 1 stated she did not want to mention that Resident 1 was an elopement risk in front of Resident 1. RN 1 stated Driver 1 should have been made aware by SSD 1 of Resident 1's risk for elopement. RN 1 stated that it was more appropriate that the facility's SSD (SSD 1) communicate Resident 1's risk for elopement to Driver 1 and the Oncologist office staff, when SSD 1 made the physician appointments for Resident 1. During an interview on 7/18/2025 at 3:40 PM, Driver 1 stated he dropped off Resident 1 at the Oncologist's Office on 7/17/2025 at around 1:15 PM and informed the Oncologist Office staff by saying, Call me when Resident 1 is ready for pick up. Don't let Resident 1 go anywhere else. However, Driver 1 stated he did not receive instructions from RN 1 or any facility staff that he needed to stay and supervise or accompany Resident 1 one-to-one, while in the Oncologist Office. Driver 1 stated he did not receive a call back from the Oncologist office staff that Resident 1 was ready to be picked up, so Driver 1 went back to the Oncologist Office on 7/17/2025 at around 2:15 PM (approximately one hour after dropping the resident off), but Driver 1 stated he did not see Resident 1 at the waiting area of the Oncologist Office. Driver 1 stated the Oncologist Office staff told him (Driver 1) that Resident 1 went to the restroom. Driver 1 stated he then waited for about five to ten minutes more for Resident 1 in the waiting area, but Resident 1 did not come back. Driver 1 stated the Oncologist Office staff tried to find Resident 1 around 2:30 PM but could not find Resident 1. Driver 1 stated he called the facility immediately, when Oncologist office staff informed him, they could not find Resident 1. During an interview on 7/18/2025 at 4:55 PM with the Oncologist Office Staff (OS) 1, OS 1 stated she recalled when checking in Resident 1 for the Oncology (the branch of medicine that studies, diagnoses, and treats cancer) appointment on 7/17/2025 at around 1:10 PM, OS 1 stated Resident 1 was accompanied by only one person (Driver 1) who did not stay with Resident 1, during the appointment. OS 1 stated the person (Driver 1) who took Resident 1 to the Oncology appointment asked what time to pick the resident (Resident 1) up and left the resident in the physician office. OS 1 stated the Oncologist office staff were not informed by facility staff to always supervise Resident 1 due to risk of elopement or that the resident was at risk for elopement. During a follow-up phone interview on 7/22/2025 at 10 AM with the Administrator (ADM), the ADM stated Resident 1 remained missing and had not returned to the facility. During a review of an email communication sent to the California Department of Public Health (CDPH), from General Acute Care Hospital (GACH) 1, who oversee the Oncologist Office, dated 7/22/2025 timed at 10:30 PM, an email communication titled Notification of Potential Reportable Event was reviewed. The email communication indicated that GACH 1 was notified by the Oncologist Office of A potential reportable neglect event. The email further indicated On 7/18/2025, a social worker (unknown) was made aware of an incident that occurred on 7/17/2025. The email indicated that a resident (Resident 1) with history of forgetfulness and dementia who was a patient at the Oncologist Office was dropped off at the Oncologist Office without a caregiver or a chaperone to attend to the resident's needs and Therefore [Resident 1] attended the appointment alone. The email further indicated At the conclusion of the appointment, [Resident 1] checked out the [Oncologist Office] and asked for the key to the restroom which was provided. The patient [Resident 1] did not return to the lobby to return the key. [Oncologist Office staff] went to check on [Resident 1] in the restroom and did not find [Resident 1]. The key was found later in the lobby. Further review of GACH 1's email communication dated 7/22/2025 indicated that [Driver 1] was in the parking lot of the [Oncologist Office] waiting for [Resident 1] did not see Resident 1. The email indicated the Police Department was notified of the concern for missing person. The email further indicated that the facility reported to GACH 1 that this had been a trend for Resident 1 and had eloped from the same facility in the past, as well as other facilities. The email indicated that on 7/22/2025, Resident 1 called the Oncologist Office Staff and informed the Oncologist Office that she was safe and staying at FM 1's house at the moment. During a review of the facility's policy and procedure (P&P) titled Safety Supervision of Residents undated, the P&P indicated that resident supervision is a core component of the systems approach to safety. The P&P indicated the type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. During a review of the facility's P&P titled Resident Elopement undated, the P&P indicated The facility will provide a safe environment and preventive measures for elopement with the aim to monitor and document patients at risk for elopement.

Based on observation, interview, and record review, the facility failed to ensure residents reviewed for accidents/hazards received adequate supervision to prevent accidents and injury for one of two sampled residents (Resident 1), who had a recent fall, and who was identified at high risk for falls upon admission on [DATE], by failing to:1. Ensure the facility communicated and provided awareness to licensed nurses (Licensed Vocational Nurse [LVNs 1 and 2] and Registered Nurse [RN] 1) and certified nurse assistants (CNAs 1, 2, 3 and 4) that Resident 1 was identified as high risk for falls due to recent history of falls history of falls and interventions to visually monitor every hour, in accordance with the care plan for falls and the physician order.2. Ensure the Restorative Nursing Assistants (RNA - provides rehabilitative care to patients recovering from illnesses or injuries) check the fall risk visual identifiers (Red name band and/or red star on the room, bed, and wheelchair) for residents identified as high risk for falls, during the RNAs daily resident rounds, in accordance with the facility's policy and procedure (P&P) titled Falling Star Program. These deficient practices resulted in Resident 1 having an unwitnessed fall (unknown date) as discovered by CNA 1, LVN 1, and RN 1 in the morning shift (7 AM to 3 PM) of 6/19/2025, resulting in an acute (sudden onset) comminuted (fragments) right intertrochanteric (upper part of the femur) fracture (crack or break in the bone) with moderate displacement (a broken bone where the two ends have moved out of their normal alignment) and angulation (the bone is bent in a curved position) on 6/19/2025. Resident 1 sustained bruising to the right knee and right inner thigh and complained of pain to the right hip. The facility transferred Resident 1 to General Acute Care Hospital (GACH 1) on 6/19/2025 because Resident 1 could not move her right leg due to pain and had a surgery of the right femur (bone of the thigh).Findings:During a review of Resident 1's admission Record (AR), the AR indicated the Resident 1 was admitted to the facility on [DATE] with diagnoses that included nondisplaced (the bone cracks or breaks but retains its proper alignment) fracture of the sacrum (the triangular bone at the base of your spine, below your lower back and between your hip bones), unspecified fall, left artificial hip joint, and idiopathic (cause unknown) peripheral autonomic neuropathy (nerve damage often causes weakness, numbness and pain, usually in the hands and feet).During a review of Resident 1's facility document titled Fall Risk Data Collection (FRDC), dated 5/14/2025, the FRDC indicated Resident 1 had one to two falls for the past three months. The FRDC indicated Resident 1 was not able to stand or balance on both feet. The FRDC indicated Resident 1 was identified as high risk for falls. The FRDC further indicated IDT met with the resident's family (Family 1 and 2) and discussed plan of care . Informed of risks upon fall risk assessment, red star fall program, and visual monitoring every hour and interventions to manage risks.During a review of Resident 1's History and Physical Examination (H&P), dated 5/15/2025, the H & P indicated Resident 1 had the capacity to make healthcare decision. The H&P indicated Resident 1's diagnoses included s/p fall with left hip fracture. During a review of Resident 1's physician order titled General Order dated 5/15/2025, the order indicated Visual monitoring every hour for Falling Star Program.During a review of Resident 1's care plan titled High risk for falls that may result to physical harm dated 5/15/2025, the care plan indicated a goal developed on 5/15/2025, to decrease the resident's risk of falls and injury with intervention. The care plan interventions with an approach date of 5/15/2025, included Resident 1 to be placed in the facility's Falling Star Program, provide awareness to staff that patient has history of falls and continued to be at risk for falls. The care plan interventions dated 7/3/2025, indicated Visual monitoring every hour for falling star program (two months after Resident 1 was identified as high risk for falls on 5/15/2025)During a review of Minimum Data Set (MDS, a resident assessment tool), dated 5/20/2025, the MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, partial/moderate assistance (helper does less than half the effort) with personal; hygiene and dressing and substantial/maximal assistance (helper does more than half the effort) with bathing and toileting. During a review of Resident 1's facility document titled SBAR [Situation, Background, Assessment, Recommendations] - General (document used for residents change of condition), dated 6/19/2025 timed at 7:37 AM, the SBAR indicated at 7:30 AM, Resident 1 complained of right knee pain, and had discoloration (bruising) on the right knee and right inner thigh. The SBAR indicated [Resident 1] was unable to move her right leg due to pain. The SBAR indicated the resident was confused because she was trying to get out of bed .The SBAR indicated pain medication was given for pain management. The SBAR indicated the physician was made aware, and X-ray (used to create images of the inside of the body) was ordered. The document indicated on 6/19/2025 timed at 2 PM, the X-ray result indicated an acute comminuted right intertrochanteric fracture. The document indicated, at 3:40 PM, Primary Medical Doctor (PMD) ordered to transfer Resident 1 to [GACH] 1. During a review of Resident 1's physician order, dated 6/19/2025, the order indicated Resident 1 was transferred to [GACH 1] for further evaluation of acute comminuted right intertrochanteric fracture.During a review of Resident 1's GACH 1 Records titled Emergency Department Reports (EDR), dated 6/19/2025, the EDR indicated Resident 1 presented to the GACH 1 Emergency Department with right hip tenderness (sensitivity to pain) due to a right hip fracture. The EDR indicated under Medical Decision Making indicated Patient [Resident 1] seen and evaluated and given the presentation, the diagnoses included but not limited to fracture, fall, UTI (urinary tract infection - infection of the urinary system), no dislocation, contusion (a bruise). During a review of Resident 1's GACH 1 Records titled History and Physicals (H & P), dated 6/19/2025, the H & P indicated Resident 1 was recently admitted to GACH 1 after a fall leading to an insufficiency fracture (a crack in a bone that occurs without a definite injury). The GACH 1 record indicated Resident 1 was residing at a facility and had a fall a few days ago. The GACH 1 record indicated the X-ray report was consistent with a right intertrochanteric fracture.During a review of Resident 1's GACH 1 Records titled Surgery and Procedure Reports (SPR), dated 6/20/2025, the SPR indicated Resident 1 had a surgery of the right femur.During a review of Resident 1's GACH 1 Records titled Discharge Summaries Notes (DSN), dated 6/23/2025, the DSN indicated Resident 1 had a hip and femur fracture repair. The DSN indicated Resident 1 was transferred to another facility for rehabilitation on 6/23/2025. During phone interview on 7/3/2025 at 10:20 AM with Resident 1's family member (FAM 1), FAM 1 stated, Resident 1 was alert and able to verbalize her needs. FAM 1 stated, someone in the facility called him on 6/19/2025 and informed him that Resident 1 had a fall and sustained a fracture and will be transferred to GACH 1. FAM 1 stated, Resident 1 was still at GACH 1 and had surgery because of the fracture. FAM 1 stated to call Resident 1 in GACH 1. During phone interview on 7/3/2025 at 10:35 AM with Resident 1, Resident 1 stated, she was still recovering at [GACH 1] at this time because she had a fall at the facility. Resident 1 stated she was getting up from her wheelchair when her wheelchair moved, and she fell on the ground. Resident 1 stated, she could not remember when, where and the time she had the fall. Resident 1 stated, she could not remember how she got up or who helped her get back on her wheelchair after the fall.During an interview on 7/3/2025 at 10:50 AM with CNA 1 (worked 7 to 3 shift on 6/15, 6/17, 6/18, and 6/19), CNA 1 stated, in the morning of 6/19/2025 (7AM to 3 PM shift), not sure of the time, CNA 1 noticed Resident 1's right leg was swollen and had purple discoloration, so she informed her supervisor (RN 1). CNA 1 stated, she was not aware if Resident 1 had a fall prior to the morning shift. CNA 1 stated she was not aware if Resident 1 was on any type of special monitoring such as every hour visual monitoring for risk for falls. CNA 1 stated she normally checks on Resident 1 every two hours during her shift. During an interview on 7/3/2025 at 11:40 AM with LVN (license Vocational Nurse) 1, LVN 1 stated, she was the licensed nurse assigned to Resident 1, in the morning (7 AM to 3 PM) of 6/19/2025, when CNA 1 reported to RN 1 that Resident 1's right leg had purple discoloration and swollen. LVN 1 stated that Resident 1's primary medical doctor (PMD) ordered x-ray which showed fracture to the right leg. LVN 1 stated Resident 1 was sent to [GACH 1] for further evaluation. LVN 1 was asked if Resident 1 was on frequent visual monitoring and why. LVN 1 stated she was not sure if Resident 1 was on visual monitoring and unsure if the monitoring was every one hour or every two hours. LVN 1 stated, the previous shift (11 PM to 7 AM) did not mention if Resident 1 had a fall during their shift. During an interview on 7/3/2025 at 1:35 PM with CNA 2 (worked 3 PM to 11 PM shift, on 6/14, 6/15, 6/18 and 6/19), CNA 2 stated, she knows Resident 1, and normally checks on Resident 1 every 2 hours just like every other resident on her assignments. During an interview on 7/3/2025 at 1:45 PM with CNA 3 (worked 11 to 7 shift on 6/18/2025), CNA 3 stated, she knows Resident 1, and did not know if Resident 1 was not on any special type of frequent visual monitoring, so she checks on her four times a shift (approximately every two hours in an 8 hour shift) and normally checks on this resident every 2 hours just like every other resident on her assignments.During an interview on 7/3/2025 at 2 PM with CNA 4 (worked 7 to 3 shift on 6/14/2025), CNA 4 stated, he knows Resident 1, and CNA 4 was not aware of her every one-hour visual monitoring for risk for falls.During an interview on 7/3/2025 at 2:05 PM with LVN 2, LVN 2 stated, she knows Resident 1, but was not aware Resident 1 had a history of fall nor on one-hour visual monitoring for risk for falls.During an interview on 7/9/2025 at 2:20 PM with Treatment Nurse (TN) 1, TN 1 stated, she worked on 6/19/2025 in the morning shift (7 AM to 3 PM). TN 1 stated, there was bruising and purple discolorations on Resident 1's right knee and right inner thigh when she observed the resident on 6/19/2025, prior to [GACH 1] transfer. During an interview on 7/9/2025 at 2:30 PM with RN (Registered Nurse) 1, RN 1 stated, she worked on 6/19/2025, in the morning shift (7 AM to 3 PM). RN 1 stated, she assessed Resident 1 right away when CNA 1 told her about the bruising found on Resident 1' s right knee and thigh. RN 1 stated, there was quite a bit of discoloration/bruising on Resident 1's right knee and thigh so she notified the PMD on the same day (6/19/2025) and X-ray and blood tests were ordered. RN 1 stated, Resident 1 was transferred to [GACH 1] on 6/19/2025, for further evaluation. During an interview on 7/9/2025 at 3:20 PM with RNA 1, RNA 1 stated, she works five days a week doing Range of Motion Exercises (ROM) for the residents. RNA 1 stated, she is aware of the facility's Red Star Program for those residents who were identified at risk for falls. RNA 1 stated, RNAs does not have a list of residents included in the Red Star Program, and she was not aware that RNAs were responsible to ensure residents on the Redstar program had visual identifier. During a concurrent observation inside the facility's Dining Room (DR) and interview with the MDS Nurse (MDSN), on 7/9/2025 at 4 PM, a facility record titled Resident on Staff Fall Monitoring dated 5/28/2025, was observed posted on the wall of the DR. During the interview, the MDSN stated, the posted record is the document posted for the facility staff to monitor for fall. The posted record indicated a list of eight resident names and room numbers. The posted record further indicated Monitor (staff in charge) CNA, please remind assigned CNAs to change the residents for incontinent episodes . The posted record further indicated in bold letters Residents Must Be Checked. During the record review, the posted record did not include Resident 1's name on it. The MDSN stated, there was another list for the facility's Red Star Program, but the resident's list was not posted anywhere. The MDSN could not answer why the resident's list for the facility's Red Star Program was not posted for facility staff information and why Resident 1's name and room number were not included on the posted record list for the facility staff to include in monitoring for residents on fall monitoring, as indicated from Resident 1's Fall Risk Data Collection dated 5/14/2025. During a concurrent interview and record review, on 7/9/2025, at 4:15 PM, the Administrator (ADM) handed over a resident's list titled Red Star (undated) that included 22 residents' names and their corresponding room numbers. The undated Red Star list did not include Resident 1's name and room number. The ADM stated, she got the Red Star list from the facility's internal records. The ADM did not have an answer as to why Resident 1 was not on the Red Star list as indicated in the IDT recommendations on the Fall Risk Data Collection dated 5/14/2025. The ADM stated she did not know why the Red Star list was not posted for facility staff to be aware on who are all the residents to be monitored for fall risk. The ADM was asked if she can provide the list of residents included in the Red Star list for May and June 2025 and stated she was not able to find the lists of residents for these months.During a concurrent interview and record review of the facility's P&P titled Falling Star Program, provided by the facility's Administrator on 7/9/2025, at 4:17 PM, the ADM stated the facility uses this specific policy to implement the facility's Falling Star Program. During the concurrent review of the policy, the policy indicated The Restorative Nursing Assistant (RNA) will be responsible for checking of the [residents'] visual identifiers during daily rounds. During the concurrent interview, the ADM did not have an answer as to why the RNAs were not aware of checking identifiers for residents identified as high risk for falls and included in the Falling Star Program. The ADM stated there was another policy for the Falling Star Program specific for the RNAs but could not find it at this time. During a concurrent interview and record review of Resident 1's care plan (CP) for falls developed on 5/15/2025, on 7/9/2025, at 4:30 PM, the MDSN stated the indicated care plan intervention in the CP included Resident 1 was placed in the facility's Red Star Program. The MDSN stated the CP also indicated the intervention of visual monitoring every hour was just added on 7/3/2025 (35 days after the unwitnessed fall on 6/19/2025). The MDSN stated since the care plan interventions for every hour monitoring was just added on 7/3/2025, that means Resident 1 did not have hourly visual monitoring implemented prior to 6/19/2025 (unwitnessed fall).During an interview on 7/9/2025 at 4:50 PM, the MDSN stated, he was aware Resident 1 was assessed on 5/14/2025 for high fall, with the planned interventions to place Resident 1 on the facility's Red Star Fall Program with visual checks every hour. The MDSN did not have an answer as to why Resident 1 was not included on the list of Red Star Residents provided by the ADM and did not know why the RNAs were not aware of the responsibility to check visual identifiers of the high fall risk residents. The MDSN stated, the intervention of visual monitoring every hour due to Resident 1's risk for falls should have been initiated upon admission on [DATE] and not just added on 7/3/2025, to ensure facility staff had the proper guidance to prevent and protect from falls. The MDSN stated, since there was no intervention of visual monitoring every hour there was no guidance to how to take care of Resident 1, and if no guidance, Resident 1 had the potential for recurrent falls or accidents. A review of the facility's P & P titled, Fall Management (undated), the P&P indicated: a)based on previous evaluation and current data, staff will identify interventions related to resident specific risk and causes to try to reduce the risk of resident falling, and try to minimize complications from falling, b) any resident admitted will have a fall risk data collection form completed, a score of fourteen (14) or above is considered a high fall risk, a fall prevention plan will be implemented (Falling Stars Program).A review of the facility's policy and procedure (P & P) titled, Falling Star Program (undated), the P&P indicated the following information: - The purpose of the Falling Star Program is to identify residents at highest risk for falls and/or injuries and designed to monitor residents and determine the predisposing factors and underlying reasons for fall incidents, develop and implement a plan of care to minimize the risk for fall or major injuries . Use of visual identifiers to alert staff of the residents' high risk for falls and/or injuries would be implemented. -The red star will be affixed by the license Nurse/Designee in the resident's name at the room entrance, on top of the resident ‘s bed, in the wheelchair and/or walker, and a red name band. If the resident has Fall Risk Data Collection Score of 14 and above, along with following additional criteria: 1. Resident has more then one (1) fall within the last ninety (90 days). 2. Resident has history of major injuries, including but not limited to a fracture. -The facility's IDT will review the Fall Risk Data Collection and conduct resident observations, discuss during the schedule meeting (i.e., weekly Fall Risk Meeting), evaluate the resident's status, and determine if the resident will need to continue being included in the program or will need to discontinue if resident is no longer deemed appropriate for the program.-Individualized plans of care will be implemented by the IDT to minimize the risk of resident of falling with major injuries. Sample strategies. Depending on resident-specific care needs are as follows: 1. Creating an area for residents on high risk for falls/injuries. 2. Staff assigned in the designated area will be provided ongoing training on fall prevention strategies. 3. Specialized activity programming for the residents designated area to meet the resident preferences, including a happy feet program 4. Scheduled safety rounds with assigned staff.-Restorative Nurse Assistant (RNA) will be responsible for checking of the visual identifiers during their daily rounds. A review of the facility's P & P titled, Safety Supervision of Residents 8/23/2024, the P&P indicated: 1. Resident safety and supervision and assistance to prevent accidents are company-wide priorities.2. Implementing interventions to reduce accident risk and hazard shall include communicating interventions to all relevant staff and assigning responsibility to carrying out interventions, and ensuring interventions are implemented. A review of the facility's P & P titled, Comprehensive Plan of Care (undated), the P&P indicated that comprehensive plan of care must address the resident's individual needs, reflect interventions to meet short- and long-term resident goals and include interventions to attempt to manage risk factors.

Based on observation, interview, and record review, the facility failed to ensure the facility's waste dumpsters cover were kept closed and not exposed to elements in the trash area. This failure had a potential to result in pest infestation [an increase in the numbers of a pest species (insect or small animal that is harmful, such as rats, mice, or cockroaches) in a given area], odors, unsanitary environment, and a spread of bacteria (small living things that could be dangerous and cause illnesses) and insects (small animals such as ants, and flies). Findings: During an observation on 4/22/2025 at 10:20 AM in the facility ' s trash area, the blue waste dumpster was overflowing with trash, and the lid was not closed. One of two facility ' s black waste dumpsters was not closed with lid. During an interview on 4/22/2025 at 2:35 PM with the Administrator (ADM), the ADM stated, she was responsible to do the facility ' s round in the trash area to make sure the facility ' s waste dumpsters were closed and the area surrounding the trash area was clean. The ADM stated, she got a report from a facility ' s staff that the dumpster was overflowing with trash and the dumpsters ' lids were not closed so she had the housekeeper come and cleaned the trash area around 11 AM on 4/22/2025. The ADM stated the facility ' s dumpsters were big and the lids were heavy, so sometimes staffs were not able to close the lids after they threw away the trash. The ADM stated, the dumpsters should always be closed to prevent pest from entering. During a review of the facility ' s policy and procedure (P&P) titled, Pest Control, undated, indicated routine inspections are conducted at the company for evidence of pests. The P&P indicated to keep facility grounds free of trash and brush, and to keep the dumpster area clean and the lid closed.

Based on observation, interview, and record review, the facility failed to maintain the facility ' s dishwasher in operating condition to keep in a safe and efficient manner when the dishwasher failed the chlorine sanitizer (an effective, chlorine-based, substance or product used to reduce the number of harmful germs on all food contact surfaces to a safe level when cleaned and processed through an approved ware wash operation) test on 4/22/2025 at 9:05 AM. This failure had a potential to result in the facility ' s foodware (items used for containing, serving, or consuming prepared food, including cups, bowls, plates, etc.) and cookware (pots, pans, and other utensils used for cooking food) were not cleaned and sanitized, which could lead to a wide spread of foodborne illness (a condition that occurs when consuming contaminated food or beverages, which caused by the ingestion of harmful germs) within the facility ' s residents. Findings: During an observation on 4/22/2025 at 9 AM with the Dishwasher Aid (DA 1) in the kitchen, the dishwasher ' s water temperature was at 120 degrees Fahrenheit (F, unit of temperature). During a concurrent observation and interview on 4/22/2025 at 9:05 AM with DA 1 in the kitchen, DA 1 demonstrated how he checked the dishwasher for chlorine level to make sure the foodware was sanitized after the washing cycle. The chlorine testing strip (a narrow, elongated piece of pad which contains a chemical that reacts with chlorine in the water. The reaction causes the pad to change color that correlates to the chlorine concentration) did not change color when DA 1 dipped the testing strip in the dishwasher water to indicate the chlorine was in the correct level [50-100 PPM (or parts per million, a unit of concentration that indicates how many parts of a substance are present in one million parts of a solution)]. DA 1 completed another cycle to retest for chlorine level again, the testing strip did not change color. DA 1 stated, the testing strip should change color from white to purple that matched the reading of 50 PPM to indicate the food ware was sanitized. DA 1 stated, the dishwasher was not working appropriately. DA 1 stated the last time he checked the dishwasher ' s chlorine level was at 6 AM, about 3 hours prior to the demonstration, and the testing result was at 50 PPM. During an interview on 4/22/2025 at 9:15 AM with the Dietary Supervisor (DS), the DS stated, the dishwasher was supposed to be working with chlorine sanitizer at all times to make sure the facility ' s food ware were cleaned and sanitized. The DS stated food ware that had been cleaned by the dishwasher after 6 AM might still be contaminated. The DS stated, they would stop using the dishwasher and wait for maintenance to come and fix it. During an interview on 4/22/2025 at 9:45 AM with the Administrator (ADM), the ADM stated, the Maintenance Supervisor (MS) already came to see the dishwasher but he could not fix it, so she requested the vendor technician to come already. The ADM stated, they would use disposable foodware for lunch time while waiting for the dishwasher to be fixed. During a review of the facility ' s Extra Service Request report, dated 4/22/2025, timed at 11:21 AM, the report indicated the dishwasher ' s sanitizer line was pulled up and not reaching the chlorine chemical in the bucket. The report indicated the technician had to replace the sanitizer line with a new straight line so that the sanitizer could be pumping, and the chlorine test result could get back to normal (50-100 PPM). During an interview with the ADM on 4/25/2025 at 2:45 PM, the ADM stated, the dishwasher supposed to be operating in a safe and efficient manner at all times to ensure the facility ' s food ware and cook ware were cleaned and sanitized to prevent a spread in foodborne illness. During a review of the facility ' s policy and procedure (P&P) titled, Sanitation and Infection Control - Dishwashing Procedures (Dishmachine), dated 2018, indicated chemical low temperature dish-machines must maintain a water temperature of 120F-140F. Use a chemical sanitizing rinse to achieve and maintain 50-100 PPM of chlorine at the dish surface or according to manufacturer ' s specifications.

Based on observation, interview, and record review, the facility failed to follow its policy for Medication Pass Guidelines and the professional standard of practice for one of one sampled resident (Resident 49) who received his scheduled 9 AM medications more than one hour late. This deficient practice had resulted in Resident 49, who also receives medication to lower blood pressure, felt frustrated, and had the potential for Resident 49 to have elevated blood pressure and not to optimize the effect of his drug therapy that could negatively affect Resident 49's quality of life Findings. A review of Resident 49's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (a condition that affects nerves in your central nervous system, causes a range of symptoms like blurred vision and problems with how we move, think and feel), hypertension (high or raised blood pressure), atrial fibrillation (an irregular and often very rapid heart rhythm), malignant neoplasm of prostate (prostate cancer) and anxiety disorder (feelings of nervousness or anxiousness and involve excessive fear or anxiety). During a review of Resident 49's History and Physical Examination (H&P), dated 12/12/2024, indicated Resident 49 was alert and oriented and follows simple commands. A review of Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/31/2025, indicated Resident 49's cognitive skills (ability to make daily decisions) was intact. The MDS indicated Resident 49 was independent with eating, supervision or touching assistance (Helper provides verbal cues and or touching steadying) with dressing, and partial/moderate assistance (helper does less than half the effort) with toileting, bathing and personal hygiene. A review of Resident 49's care plan (CP) for diagnosis of hypertension, dated 4/1/2025, indicated intervention include administer medications as ordered. A review of Resident 49's care plan (CP) for risk for constipation dated 4/1/2025, indicated intervention include administer medications as ordered. A review of Resident 49's care plan (CP) for cardiac function deficit due to atrial fibrillation, dated 4/1/2025, indicated intervention include administer medications as ordered. During a concurrent observation and interview on 4/22/2025 at 10:50 AM with Resident 49, in Resident 49's room, sitting upright in bed with head of bed elevated, Resident 49 was angry and with glaring eyes, tense jaw, and clenched fist. Resident 49 stated, he had been waiting for his medications for a while, it was late, and he was very angry and frustrated. During an interview on 4/22/2025 at 10:55 AM, with LVN (License Vocational Nurse) 1, in Resident 49's room, LVN 1 stated, she was aware that she had not administered Resident 49 ' s 9AM medications and will be administering the medications late because she was busy with other residents. LVN 1 stated, it was important to give the scheduled medication on time because it might affect the effectiveness of the drug therapy, such as managing his depression and discomfort from muscle spasm, and especially the medication for Resident 49 ' s hypertension. LVN 1 stated, she will inform Resident 49's Primary Medical Doctor (PMD) about the late administration of the medication today. A review of Resident 49's facility document titled Medication Administration History dated 4/22/2025, the document indicated the following list of medications given late: 1.Calcium 600 mg (unit of measurement of mass) + D (3) 5 mcg (unit of measurement of mass) tablet (200 Unit) - for supplement - scheduled at 9AM administered at 11:11 AM. 2.Carisoprodol 175 mg - for muscle spasm - scheduled at 9AM administered at 11:11 AM. 3.Cranberry Tablet 450 mg - for supplement - scheduled at 9AM administered at 11:11 AM. 4.Daily Multivitamin-minerals tablet - for supplement - scheduled at 9AM administered at 11:11 AM. 5.Docusate sodium capsule 100 mg - for constipation - scheduled at 9AM administered at 11:11 AM. 6.echinacea capsule 400 mg - for supplement - scheduled at 9AM administered at 11:11 AM. 7.Eliquis 5mg - for atrial fibrillation - scheduled at 9AM administered at 11:11 AM. 8.Enalapril maleate tablet 10 mg - for hypertension - scheduled at 9AM administered at 11:11 AM. 9.ergocalciferol 50 mcg - for supplement - scheduled at 9AM administered at 11:11 AM. 10. Flecainide Tablet 100 mg - for atrial fibrillation - scheduled at 9AM administered at 11:11 AM. 11. Glucosamine sulfate 500 mg - for supplement - scheduled at 9AM administered at 11:11 AM. 12. lactulose 10 gm - for constipation - scheduled at 9AM administered at 11:11 AM. 13. magnesium citrate 200 mg - for supplement - scheduled at 9AM administered at 11:11 AM. 14. omega 3 fish oil 2000mg - for supplement - scheduled at 9AM administered at 11:11 AM. 15. Pepogest (peppermint oil) 1 capsule - for supplement - scheduled at 9AM administered at 11:11 AM. 16. PreserVision AREDS capsule - for supplement - scheduled at 9AM administered at 11:11 AM. 17. Refresh Tears 2 drops - for dry eyes - scheduled at 9AM administered at 11:11 AM. 18. Sertraline 50 mg - for depression manifested by social isolation - scheduled at 9AM administered at 11:11 AM. 19. Slippery elm bark capsule 1200 mg - to soothe gastrointestinal tract - scheduled at 9AM administered at 11:11 AM. 20. Vitamin A 10,000 units -for supplement - scheduled at 9AM administered at 11:11 AM. During an interview and concurrent record review Medication Administration History on 4/23/2025 at 2:30 PM with RN (Registered Nurse) 1, indicated 20 medications were given more than one hour late at 11:11 AM. RN 1 stated, she was not sure why LVN 1 was late giving the medications scheduled on 4/22/2025 at 9 AM, RN 1 stated LVN 1 Probably she got busy with other residents. RN 1 stated, administering the medication late may affect the effectiveness of the drug therapy, and the medications to lower high blood pressure if given late had the potential to cause Resident 49's blood pressure to go up. During an interview on 4/24/2025 at 9:30 AM, with the DON (Director of Nurses), DON stated, to optimize drug therapy, medication orders should be administered safely and timely. DON stated, scheduled medications should be administered plus/minus 60 minutes of the scheduled time. DON stated, Resident 49's medications was administered late, which had cause anger and frustration, and since he had medication to lower his blood pressure that was administered late as well, it had the potential to cause 49's blood pressure to go up. During a review of the facility ' s policy and procedure (P&P) titled, Quality of Care, (undated), the P&P indicated; a) purpose based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, b) The facility will implement resident-directed care and treatment consistent with the resident ' s comprehensive assessment and care plan, and c) The facility will provide needed care or services (i.e., manage symptoms) for residents to improve and/or attain their highest practicable physical, mental and/or psychosocial wellbeing. During a review of the facility ' s policy and procedure (P&P) titled, Medication pass Guidelines, (undated), the P&P indicated; a) purpose is to assure the most complete and accurate implementation of physicians medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe and timely manner, and b) administer medications within 60 minutes of the scheduled time.

Based on observation, interview, and record review, the facility failed to follow the facility ' s policy for Infection Control Program and Hand Hygiene for six of 16 sampled residents ' (Resident's 57, 35, 30, 66,41, and 64) during dinning observation in the Front Dining Room (FDR) by failing to ensure: 1. The Activity Director (AD) who was observed serving, preparing food trays and touching Resident's 57, 35 and 30 without performing hand hygiene before and after direct contact. 2. Director of Staff Development (DSD) was observed serving, preparing food trays and touching Resident's 66, 41 and 64 without performing hand hygiene before and after direct contact. This deficient practice had the potential to cause and/or spread infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) in the facility. Finding: During a review of Resident 57's Admission Record, indicated the facility admitted Resident 57 on 2/18/2022 with diagnoses that included cerebral infarction (a stroke), diabetic with chronic kidney disease (the kidneys are damaged and can't filter blood as well as they should), and congestive heart failure (heart isn't pumping blood effectively enough to meet the body's needs). During a review of Resident 35's Admission Record, indicated the facility originally admitted Resident 35 on 2/7/2024 and was readmitted on [DATE] with diagnoses that included cerebral infarction, diabetes (blood sugar, is too high), and atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery). During a review of Resident 30's Admission Record, indicated the facility originally admitted Resident 30 on 10/ 27/2022 and was readmitted on [DATE] with diagnoses muscle wasting and atrophy (the loss of muscle mass and strength), benign prostatic hyperplasia (enlarged prostate), and white matter disease (damage to the white matter in the brain, which is the tissue containing nerve fibers that connect different areas of the brain and spinal cord). During a review of Resident 66's Admission Record, indicated the facility admitted Resident 66 on 2/28/2025 with diagnoses that included diabetes, chronic kidney heart disease, and atherosclerotic heart disease. During a review of Resident 41's Admission Record, indicated the facility admitted Resident 41 on 8/14/2018 with diagnoses that included iron deficiency anemia (a condition in which blood lacks adequate healthy red blood cells), chronic kidney disease, and atherosclerotic heart disease. During a review of Resident 64's Admission Record, indicated the facility admitted Resident 64 on 1/21/2023 with diagnoses that included peripheral autonomic neuropathy (the nerves that are located outside of the brain and spinal cord (peripheral nerves) are damaged), hypertension secondary to other renal disorders (conditions that affect the kidneys, the body's filters that remove waste and excess fluid from the blood), and cardiac arrhythmias (an irregular heartbeat). During an observation on 4/22/2025 at 12:30 PM in the Facility ' s Dining Room (FDR), AD was serving, preparing food trays and touching Resident's 57, 35 and 30 shoulders and hands to position the Residents in front of the food tray without performing hand hygiene before and after direct contact with each resident. In a concurrent observation, the DSD was serving, preparing food trays and touching Resident ' s 66, 41 and 64 shoulders and hands to position the Residents in front the food tray without performing hand hygiene before and after direct contact. During an interview on 4/22/2025 at 12:45 PM with AD and DSD, AD stated, she was not aware that she had to perform hand hygiene before and after direct contact with every Residents during mealtime, and she will start doing it now that she knows. DSD stated, she thought she was only supposed to perform hand hygiene at the beginning of passing food trays and not before and after direct contact with residents, she added she will start doing it now that she knows. During a concurrent observation and interview on 4/22/2025 at 1 PM with RN (Registered Nurse) 1 in the FDR, RN 1 stated, currently there are 16 Residents using the front dining room, the staff who are helping pass the food trays are expected to perform hand hygiene before and after direct contact with every resident. RN 1 stated, not performing hand hygiene between Residents was an infection control issue and had the potential for cross-contamination and spread of infection. During an interview on 4/23/2025 at 7:36 AM with IPN (Infection Preventionist Nurse), IPN stated, the staff who are passing trays during mealtime are expected to do hand hygiene between residents. If the staff does no perform hand hygiene, it had the potential for cross contamination of infection between residents and spread of infection between residents in the facility. During an interview on 4/24/2025 at 9:23 AM with the DON (Director of Nurses), DON stated, during mealtime, while passing and preparing tray and taking care of residents, the staff are expected to perform hand hygiene between residents to prevent possible cross contamination which is the potential to cause and/or spread infection in the facility. A review of the facility ' s P&P titled, Hand Hygiene, dated 2/2017, indicated; a) the facility considers hand hygiene the primary means to prevent the spread of infection, b) all personnel shall be trained and regularly in-service on the importance of hand hygiene in preventing the transmission of healthcare- associated infections, c)all personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel , residents,, and visitors, and d) use an alcohol-based hand rub containing at least 62% alcohol or soap and water to the following situations: before and after direct contact with resident, after contact with objects in immediate vicinity of the resident, and before and after assisting a resident with meals. A review of the facility's P&P titled, Infection Control Program, (undated), indicated; a)the elements of the infection prevention and control program consist of policies and procedures, outbreak management and infection prevention, b) prevention of infection includes: instituting measures to avoid complications or disseminations, educating staff and ensuring that they adhere to proper techniques and procedures and c) following established general and disease specific guidelines such those of the Center for Disease Control and Prevention (CDC) and California Department of public Health.

Based on observation, interview and record review, the facility failed to accommodate the needs two of two sampled residents (Resident 184 and 33) in accordance with the facility's policy and procedure by failing to ensure the call light (a device used by residents to signal his or her needs for assistance) was within reach (within arm's length). This deficient practice had the potential for Resident 184, who was at high risk of falls, and Resident 33, who has visual deficits, to not be able to call the facility staff to ask for help or assistance, especially during emergencies. Findings: 1. During a review of Resident 184's Admission Record, indicated the facility originally admitted Resident 184 on 3/26/2025 and readmitted on [DATE] with diagnoses that included encephalopathy (a general term for brain disease, damage, or malfunction), disorder of bone density and structure (a condition where bones become weak and brittle, making them more prone to fractures), and atherosclerotic heart disease (thickening or hardening of the arteries). During a review of Resident 184's History and Physical Examination (H&P), dated 4/17/2025, indicated chief complaint was weakness and neurological physical examination was grossly intact. During a review of Resident 184's Minimum Data Set (MDS - a resident assessment tool), dated 3/31/2025, indicated Resident 184 was dependent (helper does all the effort) with eating, toileting and bathing, and required substantial/maximal assistance (helper does more than half the effort) with dressing and personal hygiene. A review of Resident 184's facility document titled, Fall Risk Data Collection dated 4/15/2025, indicated Resident 184 was high risk for fall. A review of Resident 184's care plan (CP) for high risk for fall that may result in physical harm due to balance problem and muscle weakness dated 4/16/2025, the CP intervention included keep call light within reach. During a concurrent observation and interview on 4/22/25 at 11:00 AM with Registered Nurse (RN) 1 and License Vocational Nurse (LVN) 1 in Resident 184's room. Resident 184 was lying in the bed with head of bed elevated at 30 degrees eyes closed, the call light was hanging on the left side of the bed, the button was about six inches from the floor. LVN 1 stated, the call light for Resident 184 could not be reached by Resident 184, and she was not able to use call light for assistance when she needed care. RN 1 stated, Resident 184's call light should always be within reach, so Resident 184 can ask for help especially for emergencies from accidents or fall. During an interview on 4/23/25 at 1:00 PM with Resident 184, Resident 184 stated that she knows how to use the call light, and she uses it if she needs assistance with the staff. 48854 2. A review of Resident 33's Admission Record, indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a gradual decline in mental ability usually caused by a brain disease), Parkinson's disease a brain disorder in which there is a lack of the chemical messenger dopamine, which helps control muscle movement; leads to muscle stiffness, weakness, and trembling), and osteoarthritis (inflammation of the joints due to the breakdown of the cartilage lining the bones in joints). A review of Resident 33's H&P, dated 11/27/2024, indicated the resident has a history of fractures (a break in a bone). The H&P also indicated the resident has a history of mental illness. A review of Resident 33's MDS, dated [DATE], indicated Resident 33 has severely impaired cognition (the ability to think and process information). The MDS also indicated that the resident is dependent on activities such as toileting and bathing and required substantial/maximal assistance to roll in bed from left to right. A review of Resident 33's care plans for visual deficit, dated 3/14/2025, included an intervention to keep call light within reach. During an observation and interview on 4/22/2025 at 8:58 AM inside Resident 33's room, Resident 33 was lying in bed and stated help. Resident 33's call light was observed hanging on the left side of the bed, not within reach of the resident. During a concurrent observation and interview on 4/22/2025 at 9:03 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 33 cannot reach the call light because it is hanging on the side of the bed. CNA 1 stated Resident 33 knows how to use and uses the call light to call for help. CNA 1 stated the resident would not be able to call for help if the call light is not within reach. During an interview on 4/24/25 at 9:28 AM with DON (Director of Nurses), DON stated, he expects staff to answer call light promptly, and call lights should always be within the residents reach as per policy. DON stated, the call light needs to be within reach so residents can call for assistance with ADLs, and especially during an emergency from accidents or falls. A review of the facility's policy and procedure (P&P) titled, Fall Management, (undated), indicated; a) the staff will identify interventions related to the resident's specific risks and causes to try to reduce the risk of the resident falling, b) a fall prevention program will be developed for each resident that will provide staff with functional strategies to minimize risk for fall and c) fall risk factor includes; lower extremity weakness, functional impairments, heart failure and neurological disorders. A review of the facility's policy and procedure (P&P) titled, Call Lights-Answering Of, (undated), indicated; a facility staff will provide an environment that helps meet the resident's need, b) respond to resident's call light in a timely manner, and c) ensure that the call light is placed within the Resident's reach.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to address Resident 32's refusal to have the long nails with fungal infection and for podiatric (a physician specialized in foot treatment) treatment on 7/13/2024, 8/24/2024, 10/24/2024 and 1/7/2025 (total 4 days). This deficient practice had a potential result in Resident 32's inadequate and incomplete provision of care and result in worsened foot infection and pain. Findings: During a review of Resident 32's Admission Record, indicated Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included postherpetic trigeminal neuralgia (a condition characterized by persistent, severe facial pain that can develop after a shingles [a viral infection that causes a painful, blistering rash that typically appears on one side of the body] outbreak), secondary parkinsonism (a condition where symptoms similar to Parkinson's disease [like tremors, stiffness, and slow movements]), and peripheral autonomic neuropathy [nerve damage outside the brain and spinal cord (a column of nerve tissue that runs from the base of the skull down the center of the back)]. During a review of Resident 32's Podiatric Evaluation and Treatment (PET), dated 7/13/2024, indicated Resident 32 was assessed with onychomycosis (a fungal infection of the nails) and left great toe ingrown nail (occurs when the side of a nail, typically a toenail, grows into the surrounding skin, causing pain, and potentially infection). The PET indicated Resident 32 refused treatment. During a review of Resident 32's Physician Oder Report, indicated Resident 32 had a physician order on 7/24/2024 to Podiatry services for treatment of hypertrophied (thicken) toenails and/or other foot problems needed. During a review of Resident 32's PET, dated 8/24/2024, 10/24/2024 and 1/7/2025, indicated Resident 32 refused to have the left great toenail treatment and toenails care during all dated visits. During a review of Resident 32's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 2/8/2025, indicated Resident 32's cognition (ability to think, remember, and reason with no difficulty) was moderately impaired, and was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in personal hygiene. During a concurrent observation and interview on 4/24/2025 at 10:05 AM with Registered Nurse (RN) 2 in Resident 32's room, Resident 32's toes were about 5 millimeters (mm-a unit of measurement) in length and the resident ' s left great toe was partially black. Resident 32 stated, his left great toe had been bleeding for almost a year on and off. Resident 32 stated, he could not recall if he refused nail treatment or nail care. Resident 32 stated, if he ever refused the treatment, it was because he felt like his toenails were not taken care of enough by the doctor, which caused him pain. RN 2 stated, Resident 32's left great toe had [NAME] dry brown substance that appear like dry blood underneath the nail. During an interview on 4/24/2025 at 10:12 AM with RN 2, RN 2 stated, she was not aware that Resident 32 had been refusing toenails care and treatment. RN 2 stated, the podiatrist ' s assistant usually give report to the charge nurse after each doctor ' s visit. RN 2 stated, she could not recall if she got reported for Resident 32's refusal to toenails care and treatment. During a concurrent record review and interview on 4/24/2025 at 10:35 AM with RN 1, Resident 32 ' s PET dated 7/13/2024, 8/24/2024, 10/24/2024 and 1/7/2025, and Resident 32 ' s care plan records were reviewed. RN 1 stated, she was the RN Supervisor who was in charge of Resident 32. RN 1 stated, if Resident 32 refused toenails care and treatment, there should be a care plan to address his refusal and education for the risk of refusal to care should be provided to Resident 32. RN 1 stated, she could not find any care plan for Resident 32 ' s refusal to toenails care and treatment. During a concurrent record review and interview on 4/24/2025 at 10:50 AM with the Director of Nursing (DON), Resident 32 ' s medical records including Resident 32 ' s Progress Notes and Care Plans were reviewed. The DON stated, there was no care plan and any other documented evidence that Resident 32 ' s refusal to toenails care and treatment was addressed, or if alternative treatments were discussed and provided to the resident. The DON stated, there should be an interdisciplinary team (IDT, a coordinated group of experts from several different fields) meeting, and a care plan should be developed and implemented for Resident 32 ' s refusal to toenails care and treatment. During a review of the facility ' s policy and procedure (P&P) titled, Refusal of Treatment, undated, indicated: -Treatment is defined as care provided for purposes of maintaining/restoring health, improving functional level, or relieving symptoms. -Risks versus benefits will be discussed by the assigned staff with the resident/resident representative. -A member of the interdisciplinary team (IDT) interviews residents refusing treatment to determine what is being refused and why in order to address the resident ' s concerns. -An IDT member assesses the reasons for the resident's refusal of treatment and attempts to clarify and educate the resident and/or family as to the consequences of such refusal. -The care plan team assesses the resident ' s needs and offers the resident alternative treatments while continuing to provide all other services outlined in the care plan. During a review of the facility ' s P&P titled, Comprehensive Plan of Care, undated, indicated the comprehensive plan of care must address the resident ' individual needs, strengths, and preferences; and reflect the company ' s efforts to provide alternative methods when a resident wishes to refuse certain treatments or services.

Based on observation, interview, and record review, the facility failed to provide respiratory care and treatments in accordance with the professional standards of practice, care plan goals, physician's order and the facility's policy and procedure for one of one sample residents (Resident 78) who was observed without oxygen for more than 30 minutes, while pulse oximeter reading (a measure of how much oxygen is carried by red blood cells in the blood, expressed as a percentage, with a normal range being 95-100%) decreased to 85%. The Physician ordered Resident 78 to receive oxygen at 2 liters (standard unit used to measure the rate of oxygen flow) as needed for shortness of breath or oxygen saturation less than 93 percent. This deficient practice had the potential for Resident 78 to experience hypoxia (not enough oxygen is available to meet the needs of the body's cells) and/or respiratory distress (difficulty breathing), hospitalization and death. Findings: During a review of Resident 78's Admission Record, indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included peripheral autonomic neuropathy (happens when the nerves that are located outside of the brain and spinal cord are damaged, pneumonia (an infection that affects one or both lungs), and chronic kidney disease (a condition where the kidneys don't function properly over a long period). During a review of Resident 78's History and Physical Examination (H&P), dated 4/17/2025, indicated Resident 78 does not have the capacity to make healthcare decisions. A review of Resident 78's Minimum Data Set (MDS- a resident assessment tool) dated 2/20/2025, indicated Resident 78 required partial/moderate assistance (helper does less than half the effort) with eating, dressing and personal hygiene, and substantial/maximal assistance (helper does more than half the effort) with toileting. A review of Resident 78's facility document titled General Order (a physician order), dated 4/15/2025, indicated to provide the resident oxygen at 2 liters as needed for shortness of breath or oxygen saturation less than 93 percent, and record oxygen saturation. A review of Resident 78's care plan (CP) for alteration in respiratory status due to risk for legionella (severe type on pneumonia), pneumonia unspecified organism, and shortness of breath, dated 4/16/2025, intervention includes, provide oxygen at 2 liters as needed for shortness of breath or oxygen saturation less than 93 percent. A review of Resident 78's care plan (CP) for Anemia with risk for weakness, fatigue and shortness of breath, dated 4/19/2025, intervention includes, provide supplemental oxygen as ordered. During an observation on 4/23/2025 at 11:38 AM in Resident 78's room, Resident was in bed laying on his back with occasional cough, oxygen machine was on, connected to a nasal cannula (a device/tubing that gives you additional oxygen through the nose), which was on top of Resident 78's bed and not connected to Resident 78's nose for more than 30 minutes. During a concurrent observation and interview on 4/23/2025 at 11:40 AM with LVN (license Vocational Nurse) 1, CM (Case Manager) 1, and RN (Registered Nurse) 1, in Resident 78 ' s room. LVN 1 stated, Resident 78 should be getting oxygen via nasal cannula, she was not sure why it was not on the patient. CM 1 stated, pulse oximeter should have been checked prior to administering supplemental oxygen. RN 1 stated, Resident 78 not receiving oxygen can cause respiratory distress and potentially get hypoxia. During a concurrent interview and record review on 4/23/2025 at 11:43 AM with LVN 1, Resident 78 EHR (Electronic Health Record) dated 4/23/25 was reviewed and did not indicate pulse oximeter was checked, or supplemental oxygen was administered. LVN 1 stated, she did not remember Resident 78 ' s pulse oximeter reading at the beginning of her shift, and she forgot to record it. During a concurrent observation, interview on 4/23/2025 at 11:45 AM with LVN 1, CM 1 and RN1 in Resident 78' s room, Resident 78 pulse oximeter reading was low at 85 percent on room air and went up to 95 percent when supplemental oxygen at 2 liters per minute was administered via nasal cannula. LVN 1 stated, Resident 78 needed supplemental oxygen as per his pulse oximeter reading. CM 1 stated, pulse oximeter reading should have been monitored at the beginning of the shift to get a baseline and to ensure Resident 78 receives oxygen as needed. RN 1 stated, Residents 78 who had physician order for oxygen as needed, pulse oximeter reading should be done at the beginning of the shift, to ensure oxygen was administered as needed because of the potential for respiratory distress and hypoxemia. A review of Resident 78 ' s facility document titled Medication Administration History, dated 4/1/2025 to 4/25/2025, the document did not indicate pulse oximeter was checked, and 2 liter of oxygen was administered as needed for pulse oximeter reading less than 93 percent on 4/23/2025. During an interview on 4/24/2025 at 9:32 AM with DON (Director of Nurses), DON stated, Resident 78 had an order for supplemental oxygen as needed, then the pulse oximeter reading should have been done at the beginning of the shift, supplemental oxygen should have been administered as ordered and ensure it was on the patient. DON stated, a pulse oximeter reading of 85 percent and Resident 78 not receiving supplemental oxygen had the potential for respiratory distress and /or hypoxemia that can negatively affect Resident 78 ' s quality of life. A review of the facility ' s policy and procedure (P&P) titled, Physician Orders, (undated), indicated: physician orders are obtained to provide a clear direction in the care of the resident. A review of the facility ' s policy and procedure (P&P) titled, Oxygen Administration,(undated), indicated: a) a resident will need oxygen therapy when hypoxemia (low oxygen in blood) occurs, and pulse oximetry monitoring, and clinical examinations determine the adequacy of oxygen therapy, b) monitor the residents response to oxygen therapy, check pulse oximetry values during initial adjustments of oxygen flow, check pulse oximetry as indicated by the physicians order, and c) monitor the resident for signs of hypoxemia as appropriate such as pulse oximetry and breathing patterns.

Based on observation, interview, and record review the facility failed to follow the facility ' s policy and procedure for self-administration of medications for one out of one sampled resident (Resident 75) when: 1. Resident 75 was not assessed prior to self-administration of medications. 2. Resident 75 was observed storing medications at the bedside. This deficient practice had the potential for Resident 75 and other resident who can have access to the medications to be at risk of harm from potential side effects or adverse effect (undesired effect of medication) that the medications could pose on Resident 75. Findings: A review of Resident 75 ' s Admission Record indicated the resident was admitted on [DATE] with diagnoses that included right leg wound, left leg fracture (break in the bone), and hypertension (elevated blood pressure). A review of Resident 75 ' s History and Physical (H&P), dated 9/28/2024, indicated the resident does have the capacity to understand and make decisions. A review of Resident 75 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 4/4/2024, indicated the resident has intact cognition (the ability to process thoughts and information.) The MDS also indicated the resident is independent in self-care activities including eating, toileting, and personal hygiene. A record review of Resident 75 ' s physician order report for 4/2025, included orders for: May keep artificial tears and Flonase (a medication administered to the nose to aid in treating allergies) nasal spray at bedside in locked cabinet, ordered on 4/22/2025. Monitor for proper self-administration of Flonase nasal spray and artificial tears weekly, ordered on 4/22/2025. Artificial Tears 1 (one) drop, as needed, ordered on 4/22/2025. The order included instructions, may self administer 1 drop into each eye as often as needed. Flonase Allergy Relief spray, 50 mcg (microgram, a unit of measurement), 1 or 2 sprays into each nostril once a day, ordered on 4/22/2025. The order included instructions, may self administer 1 or 2 sprays into each nostril once a day as needed for nasal congestion. During an observation and interview on 4/22/2025 at 9:23 AM inside Resident 75 ' s room, a bottle of nasal spray, labeled Saline Nasal Spray, and a bottle of eye drops without a cap labeled, Clear Eyes, were observed on Resident 75 ' s table. While the surveyor was interviewing Resident 75, the resident grabbed the bottle of nasal spray from the table, uncapped the bottle, and administered 1 spray into each nostril. Resident 75 stated he self-administers the nasal spray every 3 to 4 hours. During a follow-up interview on 4/22/2025 at 9:25 AM, Resident 75 stated he bought the nasal spray (spray into the nose) and eye drops himself and has been using them for more than 1 month. Resident 75 stated the facility has not conducted a meeting with him regarding the self administration of medications. Resident 75 stated he has always kept the medications on his table so that they are easily accessible. During a concurrent observation and interview on 4/22/2025 at 9:41 AM inside Resident 75 ' s room with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was not aware that Resident 75 was keeping medications at bedside and self-administering them. LVN 2 stated the medications must be stored inside of a locked container to prevent access to other residents who may be confused. During a concurrent interview and observation on 4/22/2025 at 9:44 AM with LVN 2, Resident 75 ' s medical records were reviewed. LVN 2 stated there is no record that Resident 75 was assessed for the capacity to self-administer medications. LVN 2 stated there are no records of medication administration for Resident 75 ' s nasal spray and eye drops. LVN 2 added there are no orders for Resident 75 ' s nasal spray and eye drops, and that Resident 75 may self-administer his own medications. During an interview on 4/22/2025 at 9:49 AM with Registered Nurse (RN) 1, RN 1 stated residents are only permitted to self-administer medications if they have been assessed and evaluated. RN 1 stated if the residents self-administer without being evaluated, they could be self-administering the medications incorrectly which could lead to overdose and interactions with their current medications. RN 1 also stated the resident ' s use of the medication must be logged and monitored. During a concurrent interview and record review on 4/25/2025 at 10:51 AM with the Director of Nursing (DON), the facility ' s policies and procedures (P&P) titled, Self-Administration of Medication, undated, was reviewed. The DON stated the P&P indicated residents must be assessed prior to allowing them to self-administer their own medications. The DON stated that the resident ' s self-administration of medications must also be tracked by staff by giving the resident a log to record when they self-administer their medication. The DON also stated that not following the policy puts the resident at risk for harm such as overdosing on medication. The DON added not storing the medications in a locked container could allow other residents to use the medications, which could lead to the spread of infection. A review of the facility ' s P&P titled, Self-Administration of Medication, undated, indicated the following: If a resident desires to participate in self-administration, the interdisciplinary team will assess the ability of the resident to participate. The nurse will interview the resident to determine their ability to identify, prepare, secure, and administer medications. The nurse will obtain a physician ' s order for each resident conducting self-administration of medications. Storage of self-administered medications will comply with state and federal requirements for medication storage. A review of the facility ' s P&P titled, Bedside Medication Storage, dated 2007, indicated the following: The interdisciplinary team (IDT) will review and approve resident competencies and understanding prior to permission of bedside storage of medications as established in the nursing care centers policies and procedures. A written order for the bedside storage of medications is present in the resident ' s medical record. Bedside storage of medications is indicated on the resident medication administration record (MAR) for the appropriate medications. The manner of storage prevents access by other residents.

Based on interviews and record reviews, the facility failed to prevent from falling and sustaining injuries for one of two sampled residents (Resident 1), who was high risk for falls, had behaviors of getting up unassisted, and required personal safety devices (equipment and monitoring devices used for the elderly for safety), when up in the wheelchair, failing to: 1. Provide Resident 1 with adequate supervision (refers to an intervention and means of mitigating the risk of an accident) while up in the wheelchair, as indicated in the facility's Fall Prevention-Falling Star Policy to prevent or decrease the risk of injury from falls. 2. Implement interventions indicated in Resident 1's care plan, dated 10/31/2020, to place a personal safety alarm (alerting devices intended to monitor a resident's movement; the devices emit an audible signal when the resident moves in a certain way) and to wear a self- release seat belt (a flexible band or strap, typically made of leather, plastic, or heavy cloth, worn around the natural waist or near it, meant to protect the person who is seated in the wheelchair to prevent them from sliding or falling out of the wheelchair) while in the wheelchair to prevent from sliding down. Licensed Vocational Nurse (LVN) 2 did not inform Certified Nurse Assistant (CNA) 1 that Resident 1 should not be left alone and unsupervised, required the use of the personal safety alarm, and self-release seat belt when up in the wheelchair. On 12/5/2020, CNA 1 and LVN 2 left Resident 1 in the Nursing Station, unsupervised and without a personal safety alarm and self- release safety belt in place while up in the wheelchair. These deficient practices resulted in Resident 1 wheeling himself outside the facility's patio and falling onto his left side after standing up from the wheelchair, on 12/5/2020. On 12/8/21, three days after the resident fell , Resident 1 complained of left hip pain and sustained a fracture (complete or partial break in a bone) to the left hip. Resident 1 was transferred to the General Acute Hospital (GACH) on 12/9/2020 at 2:58 AM where the resident underwent surgery to fix the fracture on the left hip. Findings: A review of Resident 1's Admission Record dated 10/30/2020, indicated the resident was admitted to the facility with diagnoses that included left side [CONDITION(S)] (paralysis) and dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). A review of Resident 1's Fall Risk Data Collection dated 10/30/2020, indicated the resident was at high risk for falls with a score of 20 (10 or above represents high risk). A review of Resident 1's Care Plan (CP) with start date on 10/31/2020, indicated the resident had increased susceptibility to fall due to dementia and trying to get out of bed and chair unassisted. The CP indicated the approach to prevent fall, to start on 10/31/2020, was to place resident's personal safety alarm while in wheelchair. The CP indicated another approach to start on 11/14/2020 was for the resident to have a self-release seat belt while the resident was in the wheelchair to prevent the resident from sliding down due to lower extremity (part of the body that includes the leg, ankle, and foot) [CONDITION(S)] (condition in which there was an abnormal increase in muscle tone or stiffness of muscle, which might interfere with movement). A review of Resident 1's History and Physical (H & P) dated 11/2/2020, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, standardized assessment and care-screening tool) dated 11/6/2020, indicated the resident had a moderately impaired cognition (process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive assistance (the resident was involved in activity; staff provide weight bearing support) from two staff with transferring to and from bed, chair, wheelchair, and standing position. A review of Resident 1's Physician Order Report dated 11/13/2020, indicated an order for the resident to have a self-release seat belt while in wheelchair every shift to prevent from sliding down from the wheelchair. A review of Resident 1's Progress Note dated 12/5/2020 entered at 4:30 PM, indicated Resident 1 was found lying on the floor near the fountain (by the patio) on his left side. The Progress Note indicated the resident got out of his wheelchair which caused the fall. The Progress Note indicated the resident complained of slight discomfort on his left knee. A review of Resident 1's Situation Background Assessment and Recommendation (SBAR, a communication tool between members of the health care team about the resident's condition) form, dated 12/05/2020 entered at 5:51 PM, indicated the resident had an unwitnessed fall at 4:30 PM. The SBAR form indicated the resident was found lying on the floor near a fountain (by the patio) and was very confused. The SBAR form indicated, Resident 1 complained of discomfort on his left knee and Physician 1 (PH 1) was notified. A review of Resident 1's Activities of Daily Living Administration History (AH) dated from 12/1/2021 to 12/30/2020, indicated the order for personal safety alarm while in wheelchair was started on 12/7/2021 (two days after the resident's fall on 12/5/2020). A review of Resident 1's Progress Notes dated 12/8/2020 entered at 12:30 PM (three days after the resident fell ), indicated the resident was performing active range of motion (moving part of the body using muscles) with the Physical Therapist (PT) when the resident complained of left hip pain. PH 1 ordered an x-ray (an imaging device that creates pictures of the inside of the body) of Resident 1's left hip. A review of Resident 1's radiology (a branch of medicine that uses imaging technology to diagnose and treat disease) report dated 12/8/2020 at 6:41 PM, indicated a left hip x-ray was performed and the result showed an acute (sudden) left hip intertrochanteric (bony protrusions on the femur [thighbone] and the points where the muscles of the thigh and hip were attached) fracture. A review of Resident 1's Progress Notes dated 12/9/2020 entered at 12:58 AM, indicated Resident 1 had an abnormal x-ray result and the PH 1 ordered to send the resident to the GACH for further evaluation and treatment. The Progress Notes indicated Resident 1 was transferred to the GACH at 2:58 AM via ambulance. A review of Resident 1's Discharge Summary from GACH dated 12/12/2020, indicated that on 12/10/2021, Resident 1 underwent an open (cutting of skin and tissues so that the surgeon has a full view of the structures or organs involved) reduction internal fixation (operation that involved the surgical implementation of implants such as rods, screws or nails for the purpose of repairing a bone) of the left intertrochanteric fracture. During a concurrent telephone interview with the Director of Nursing (DON) and review of Resident 1's Fall Risk Data Collection dated 10/30/2020, on 2/25/2021 at 11:15 AM, the DON stated Resident 1's admission fall assessment scored a 20 which made Resident 1 a very high risk for falls. The DON stated the facility should have placed Resident 1 in the facility's Falling Star Fall Prevention Program to alert the staff that Resident 1 was identified as a high risk for falls. During a telephone interview on 2/25/2021 at 11:35 AM, the DON stated she could not find documented evidence that Resident 1 was included in the facility's Falling Star Fall Prevention Fall Program prior to the fall on 12/5/2020. The DON stated the facility's Falling Star Fall Prevention Fall Program included interventions such as alerting the facility staff of residents who were assessed as high risk for falls and implementing care plan interventions such as putting a self-release seat belt and personal safety alarm when in the wheelchair. The DON stated Resident 1 did not have a physician's order to use a personal safety alarm while in the wheelchair as indicated in the Resident 1's care plan on 10/31/2020. The DON stated that it was important to have a physician's order for Resident 1 to use the personal safety alarm for all facility staff to be aware and implement the safety intervention. During the same interview, on 2/25/2021 at 11:35 AM, the DON stated had the personal safety alarm been in place in the wheelchair on 12/5/2020, staff would have heard the personal safety alarm when Resident 1 tried to stand up on his own from the wheelchair and staff would have gone to Resident 1's location immediately and could have prevented the fall. The DON stated she could not find documented evidence of Resident 1's personal safety alarm being placed in the wheelchair and the failure to implement this intervention led to Resident 1's fall. During an interview with CNA 1, on 2/25/2021 at 4:50 PM, CNA 1 stated she cared for Resident 1 on the date and time of his fall on 12/5/2021 (at 4:30 PM). CNA 1 stated she clearly remembered the events leading up to Resident 1's fall incident. CNA 1 stated she placed Resident 1 in the wheelchair between 4:30 PM and 5 PM as requested by LVN 2. CNA 1 stated Resident 1 did not have a personal safety alarm and a self-release seat belt in place when she sat Resident 1 in his wheelchair. CNA 1 stated she did not see the personal safety alarm device and the self-release seat belt in the resident's room. CNA 1 stated she did not receive a report or update from LVN 2 or from the outgoing CNAs on 12/5/2020 that Resident 1 was a high risk for falls and required the use of a personal safety alarm and self-release seat belt when up in the wheelchair. During an interview with CNA 1, on 2/25/2021 at 4:50 PM, CNA 1 stated Resident 1 was very confused. CNA 1 stated she left Resident 1, sitting in the wheelchair, at the Nurse's Station to go to another resident's room. CNA stated that a short while after, she heard a facility staff calling for her (CNA 1) because Resident 1 was found on the floor, by the facility patio. CNA 1 stated she and another male CNA (unable to recall who) picked Resident 1 off the floor and placed him back to his bed. CNA 1 stated if she had received report, she would know what Resident 1 needed and would help her provide better care and prevent such accidents. During an interview with LVN 1 on 3/5/2021 at 2:12 PM, LVN 1 stated it was the facility's policy to use personal safety alarms for residents at high risk for falls when in their wheelchair. During a telephone interview with LVN 2 on 11/3/2021 at 3:19 PM, LVN 2 stated she remembered the day Resident 1 fell on [DATE] (at 4:30 PM), when she asked CNA 1 to help Resident 1 to transfer in the wheelchair. LVN 2 stated CNA 1 wheeled Resident 1 to the Nurse's Station so we (licensed nurses) could monitor (supervise) Resident 1 since he tends to stand up on his own and forgets to call for assistance. LVN 2 stated she left the Nurse's Station to continue with her rounds and CNA 1 remained with Resident 1. LVN 2 stated while she was doing her rounds, that's when another nurse (cannot recall who) told her resident was found on the floor by the patio, near the fountain. LVN 2 stated that CNA 1 left Resident 1 unsupervised, at the Nurse's Station to go to another resident's room. LVN 2 stated no one was left at the Nurse's Station to monitor Resident 1 and the resident could have wheeled himself to the patio. During a concurrent telephone interview with LVN 2 and review of Resident 1's AH dated 12/1/2020 to 12/30/ , on 11/3/2021 at 3:25 pm, the AH indicated LVN 2 signed the AH (on 12/5/2021) to indicate the self- release seat belt was applied while Resident 1 was up in wheelchair. LVN 2 stated, she only assumed that CNA 1 placed Resident 1's self- release seat belt while the resident was up in wheelchair, so she signed the AH form on 12/5/2021. LVN 2 stated she did not personally check if the self- release seat belt was used, so she was not sure if Resident 1's self-release seat belt was use on 12/5/2021. LVN 2 stated, she did not instruct CNA 1 and she assumed CNA 1 knew that Resident 1 needed to have the personal safety alarm, self-release seat belt while up in his wheelchair, and needed to be supervised because he was a high risk for falls. A review of the facility's Fall Prevention- Falling Star (FP) Policy dated 12/01/2005, the FP Policy indicated the program was developed to provide each resident with adequate supervision and assistive devices to prevent or decrease the risk of injury from falls. The purpose of the Falling Star Program was to alert all staff about residents who were at risk for falls. A review of the facility's Field Guide: Falls Policy dated 5/2017, the policy indicated one of the strategies was the use of assistive devices and engage front-line staff members (staff who had direct resident care such as the licensed nurses and CNAs) by doing safety huddles (short briefing to the licensed nurses and CNAs at usually at the start of their shift or held at a predictable time and place, and focused on the patients most at risk) and bedside hands-off (the transfer of patient information and knowledge, along with authority and responsibility, from one nurse to another nurse or team of clinicians during transitions of care during change of shift).

Based on interview and record review, the facility failed to notify the resident's physician immediately for one of two sampled residents (Resident 1) for a change in condition for significant decline in physical functioning and left lower extremity pain (LLE) over a nine-day period by failing to: 1. Assess, address, and report Resident 1's complaints of left lower extremity pain and decline in physical function from minimal assistance (person requires less than 25% assistance) for transfers, bed mobility, and ambulation on 2/20/21 to maximum assist (person requires more than 75% assistance) for transfers and bed mobility and inability to ambulate on 2/23/21 after a resident's fall on 2/22/21. The decline in physical function persisted until 3/4/21. 2. Implement Resident 1's care plan for ADL (activities of daily living) Functional/Rehabilitation Potential to monitor for any decline in ADL function and inform the physician. 3. Implement the facility's policy and procedures titled, Changes in Resident Condition, for facility staff to notify the resident's attending physician where there is a significant change in the resident's physical, mental, or psychosocial status. These deficient practices resulted in the delay in the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's decline in transfers and bed mobility from minimum assist to maximum assist was identified on 2/23/21 and persisted until 3/4/21. Resident 1 complained of pain in the left leg at rest, during range of motion (ROM), and upon weight bearing, and was unable to walk from 2/23/21 to 3/4/21. These changes of condition were not reported to the attending physician (MD 1) immediately. MD 1, during his in-person visit on 3/4/21, identified Resident 1's left hip pain and ordered an X-ray (image of the internal composition of a part of the body) which revealed an acute left [CONDITION(S)]. Resident 1 was transferred to GACH 2 on 3/5/21 and received pain management for severe pain, surgical consult for left hip surgery, and the left leg was placed on a non-weight bearing status. Cross Reference to F697 Findings: A review of Resident 1's Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted back on 2/22/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool) admission assessment dated [DATE], indicated Resident 1 had short and long-term memory problems, had moderately impaired cognitive skills for daily decision making, did not exhibit any depressed mood behaviors, and did not have any limitations to both upper and lower extremity range of motion (ROM, full movement potential of a joint). The MDS indicated Resident 1 required extensive one person-assistance with bed mobility and two-person extensive assistance for transferring. A review of Resident 1's Progress notes titled, SBAR (Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication) Communication Tool and Progress Note dated 2/22/21 timed at 12:30 am, indicated Resident 1's bed alarm was heard. Upon checking on the resident, the resident was found lying on the floor, on his left side by the right side of the bed. The SBAR Progress Note indicated Resident 1 sustained skin tears on the left parietal (left side of scalp above ear) area and the left elbow. The SBAR Progress Note indicated Resident 1's body assessment was completed with no other injuries noted and Resident 1 was able to move all extremities without any limitation and no complaints of pain. The SBAR Progress Note indicated Resident 1's attending physician (MD 1) was notified at 12:56 am. A review of Resident 1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a facility document titled Incident/Accident Post Review with observation date 2/22/21, timed at 8:39 am and recorded date of 2/24/21, timed at 11:40 am, electronically signed by the facility's interdisciplinary team (IDT; a group of healthcare providers from different fields who work together or toward the same goal to provide the best care or best outcome for a patient) indicated the IDT met to discuss the plan of care for Resident 1 due to the fall that happened on 2/22/21 at 12:30 am. The Incident/Accident Post Review indicated the facility would continue to monitor for any change in condition. A review of the GACH 1 ED Physician Notes dated 2/22/21 indicated Resident 1 presented to GACH 1 for left sided forehead laceration due to a fall from bed, the same morning (2/22/21). The GACH 1 ED Physician Notes indicated Resident 1 complained of pain to the left hip and laceration to the head after a fall and the exacerbating factor was movement. The GACH 1 ED Physician Notes indicated Resident 1 fell off the bed onto the left side with history taken from Resident 1's family member (FM 1). The GACH 1 ED Physician Notes indicated Resident 1 could not tolerate and refused the computed tomography scan (CT scan; combines a series of X-ray images taken from different angles around the body). The GACH 1 ED Physician Notes indicated Resident 1 was discharged back to the facility the same day (2/22/21). A review of a facility document titled Resident Progress Notes dated 2/22/21 timed at 2:25 pm, indicated Registered Nurse (RN) 1's notes indicating Resident 1 returned from the GACH 1 ED, still confused, and restless. RN 1's Resident Progress Notes indicated speaking to MD 1 and received an order to administer [MEDICATION(S)] (anti-anxiety medication) tablet 0.5 milligrams (mg) orally every six hours to Resident 1, as needed for agitation manifested by inability to relax. A review of Resident 1's care plan titled, ADL (activities of daily living) Functional/Rehabilitation Potential dated 2/22/21 indicated, monitor for any decline in ADL (activities of daily living) function and inform MD (attending physician) and responsible party. A review of Resident 1's Physical Therapy Treatment Encounter Notes indicated the following information: a. On 2/23/21, 2/24/21, and 2/26/21 indicated the resident required maximum assist with bed mobility (move in bed including turning side to side and moving from laying down to sitting up position in bed) and transfers (move from bed to chair or any other surface) and did not ambulate (walk). b. On 2/27/21, indicated (Resident 1) States 7/10 pain on LLE with weight bearing [putting weight on the extremity]. The Treatment Encounter Notes indicated Resident 1 required maximum assist with transfers and no ambulation occurred. c. On 3/1/21, indicated Resident 1 required maximum assistance to get up from supine (lying position in bed) to sitting position by the edge of bed and no ambulation occurred. d. On 3/3/21, indicated Resident 1's bed mobility was at moderate assist, pre-gait (to position the limb for swing) was at maximum assist, and no ambulation occurred. f. On 3/4/21, indicated Resident 1 exhibited bed mobility as moderate assist and maximum assist for transfers. The Notes indicated Resident 1 noted with complaints of LE (lower extremity) pain upon lateral weight shift on left LE with a pain scale of 5 out of 10 using the facial pain scale (scale using facial expressions to determine level of pain, zero is no pain, 10 is excruciating pain). The Notes indicated Nursing aware. A review of a facility document titled Resident Progress Notes dated 3/4/21 timed at 1:20 pm, indicated RN 1's notes indicating MD 1 was in the facility and examined by MD 1, resident complaints of pain left hip when touch (sic). RN 1 wrote that MD 1 ordered an X-ray because Resident 1 was complaining of left hip pain. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's X-ray report dated 3/4/21 timed at 9:38 pm, indicated an acute (new) mild superior displaced left subcapital (the point where the neck of the femur joins the head) femoral neck fracture (femoral neck fracture- a type of [CONDITION(S)] of the thigh bone (femur)-just below the ball of the ball-and-socket hip joint. This type of fracture disconnects the ball from the rest of the femur) with soft tissue swelling and a joint effusion. A review of the GACH 2 record titled Emergency Department (ED) Note-Provider dated 3/5/21 indicated Resident 1 had pain in the left hip, after a fall from a week ago, transferred to GACH 1 and returned the same day. Facility did not get a copy of imaging result (x-ray). Left hip x-ray done in the facility on 3/4/21, because of persistent pain that showed acute left femoral neck fracture. The ED Note-Provider indicated under physical examination showed Resident 1's left lower extremity shortening (left leg shorter than the right leg) and external rotation (extremity is rotated away from the body), and pain during log roll (rolling in bed). The ED Note-provider indicated Resident 1 admitted with pain to the left leg and left hip upon palpation, however, was unable to give an extensive history. The ED Note-provided indicated Resident 1 was administered narcotic pain medications intravenously (administered through the vein) such as [MEDICATION(S)] (pain medication for severe pain) and [MEDICATION(S)] (pain medication for severe pain). A review of the GACH 2 Discharge Summary dated 3/9/21, indicated Resident 1 was discharged from GACH 2, on 3/9/21. The Discharge Summary indicated FM 1 refused surgery because Resident 1 was not a good candidate for hip surgery due to age and comorbidities (involves more than one diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Discharge Summary indicated FM 1 refused skilled nursing facility placement and therefore, was discharged to home with home health care (a wide range of health care services that can be given in your home for an illness or injury) with an order to remain non-weight bearing on the left leg. A review of a facility document titled Incident/Accident Post Review with completion and recorded date of 3/9/21, indicated the facility's IDT met and discussed Resident 1's fall incident and status when Resident 1 was residing in the facility. The Incident/Accident Post Review summary indicated that upon Resident 1's return to the facility, on the same day (2/22/21 around 2:15 pm), after being transferred to the acute hospital after the fall, The emergency medical technicians (EMTs) mentioned that everything was okay with resident. Resident 1 continued to be confused and restless. The post review summary indicated that there was no X-ray report sent with Resident 1 upon return to the facility from the acute hospital, on 2/22/21. The post review summary indicated that on 3/5/21, the facility requested the X-ray report performed in GACH 1 on 2/22/21. The post review summary indicated GACH 1 informed the facility that there was no X-ray performed to Resident 1, when Resident 1 was transferred to GACH 1, on 2/22/21. A review of a facility document titled Summary of Interviews/Investigation submitted by the facility to the Department of Public Health on 3/10/21, indicated that on 3/4/21, MD 1 came to visit Resident 1 in the facility. The summary indicated that when MD 1 touched Resident 1's hips, the resident complained of pain. The summary indicated MD 1 ordered x-ray of the hip. During an interview, on 3/18/21 at 10:50 am, RN 1 stated Resident 1 was normally up and sitting in the wheelchair before his fall and he was able to eat by himself with some cueing. After the fall, he was mostly in bed. RN 1 stated on 3/4/21 she was made aware the resident complained of pain and she informed MD 1. RN 1 stated MD 1 came to see Resident 1 the same day, and MD 1 stated the resident complained of pain and had pain to touch in the left hip area and ordered an X-ray of the left hip. The results later revealed a left [CONDITION(S)]. During an interview on 3/18/21 at 11:08 am, Certified Nursing Assistant (CNA) 1 stated she worked with Resident 1 before and after the resident's fall on 2/22/21. CNA 1 stated before Resident 1's fall, the CNAs would sit Resident 1 up in the wheelchair. After the fall, CNA 1 stated she did not get Resident 1 out of bed. When asked the reason Resident 1 did not get out of bed, CNA 1 took a long time to respond and stated she could not remember why. CNA 1 stated she did not remember if she reported Resident 1 not wanting to get out of bed for multiple days to the charge nurse (LVN 1) or the RN supervisor (RN 1 and RN 2). During a telephone interview with Physical Therapy Assistant (PTA) 1 on 3/22/21 at 4:14 pm, PTA 1 stated that on 2/26/21 and 2/27/21, during PT sessions, Resident 1 was pointing to his left leg, with non-verbal expressions of pain. PTA 1 stated Resident 1 would grimace or resist when PTA 1 would ask Resident 1 to perform an activity during the PT session. PTA 1 stated that was how he interpreted Resident 1 was having some pain. PTA 1 stated Resident 1 needed maximum assist with transfers and could not walk. PTA 1 stated he verbally informed the charge nurse (unknown) of Resident 1's pain. PTA 1 stated that if the resident was not getting better or they get worse, he should report it to his supervisor (PT 1). PTA 1 stated he did not report Resident 1's decline in functioning and continued pain to PT 1. During a telephone interview on 3/23/21 at 11:37 am, FM 1 stated before the resident was walking perfect like a young man. FM 1 stated, at present, Resident 1 had recurring pain and a [CONDITION(S)]. FM 1 stated Resident 1 had a hard time with the decline in function and pain. During a telephone interview and record review of Resident 1's Physical Therapy (PT) Evaluation and Plan of Treatment notes dated 2/20/21, on 3/23/21 at 2:02 pm, Physical Therapist (PT) 1 stated he evaluated Resident 1 for PT on 2/20/21 (prior to the 2/22/21 fall). PT 1 stated Resident 1 was able to walk about 50 feet with a front-wheeled walker (FWW- a framed walker with two wheels on the front legs) with minimal assist (person requires less than 25% assistance) and was able to perform bed mobility and transfers with minimal assist. PT 1 stated Resident 1 had full joint range of motion (ROM; the measurement of the amount of movement around a specific joint or body part) in all extremities had no complaints of pain in all extremities prior to the fall. In the same telephone interview and record review, on 3/23/21 at 2:02 pm, PT 1 reviewed Resident 1's Physical Therapy Treatment Encounter Note dated 2/23/21 and stated that on 2/23/21 (a day after the fall on 2/22/21) during Resident 1's PT session, PT 1 stated Resident 1 was easily agitated, and his transfers declined to a maximum assist. PT 1 stated the licensed nurses informed him that on 2/23/21, Resident 1 had some pain before starting the PT session. PT 1 stated when PT 1 assessed Resident 1 for LLE ROM, PT 1 noted Resident 1 had four out of 10 pain on the facial pain scale. PT Treatment Encounter Note indicated, Patient noted to be easily agitated. It is noted that patient had an incidence of fall and exhibits transfer as max assist with grimacing upon ROM of left LE [lower extremity] with PS [pain scale] of 4/10 [4 out of 10] on a facial scale. PT 1 stated Resident 1 was not able to verbalize the pain but Resident 1 grimaces and that was how PT 1 could tell Resident 1 was having some pain. PT 1 stated Resident 1 did not walk that day (2/23/21) because the resident was easily agitated and had LLE pain. PT 1 stated he informed the licensed nurses (unknown) again that Resident 1 had LLE pain after the PT session, on 2/23/21. During a telephone interview and record review of Resident 1's Physical Therapy Treatment Encounter Notes dated 3/4/21, on 3/23/21 at 2:02 pm, PT 1 stated during the 3/4/21 PT treatment session, Resident 1 started complaining of pain when he stood up and shifted weight to his left side. PT 1 stated the licensed nurses were aware of Resident 1's LLE pain. PT 1 stated that on 3/4/21, Resident 1 still required maximum assist with transfers and could not ambulate. PT 1 stated if a resident required maximum assist when a resident previously required minimum assist with transfers, this would be considered a decline in function. PT 1 also stated if a resident was able to ambulate 50 feet before, during the initial PT evaluation and more than a week later, the same resident was not able to walk anymore, this was considered a decline in function. PT 1 stated it was the therapist's responsibility to report to the licensed nurses if a resident was showing a decline in function. PT 1 stated he did not let the licensed nurses know that day (3/4/21) about Resident 1's decline in function because he thought Resident 1 was getting a little better. During a telephone interview on 3/24/21 at 9:05 am, Licensed Vocational Nurse (LVN) 1 stated she was Resident 1's charge nurse and had worked with the resident on multiple days. LVN 1 stated prior to Resident 1's fall on 2/22/21, Resident 1 was alert and confused and was mostly up in the wheelchair and did not complain of any pain. LVN 1 stated that after Resident 1's fall, Resident 1 was mostly in bed and did not want to get up. LVN 1 stated she did not ask the certified nursing assistants (CNA) why the resident was not out of bed and the CNAs did not tell her why he did not get out of bed. LVN 1 stated if a resident previously was up in wheelchair and later did not want to get out of bed for multiple days this should be considered a decline in function, and therefore should be considered a change in condition. LVN 1 stated she did not report Resident 1's change of condition to the Registered Nurse (RN) supervisor (RN 1). LVN 1 stated that it was not good for a resident to be in bed all the time, the more they are in the bed, the more they will decline in their activities of daily living or their condition overall. LVN 1 stated nurses should assess the resident to see why the resident did not want to get up anymore, so the RN 1 could call MD 1 to inform him of the COC and decline. LVN 1 stated she failed to consider Resident 1's status, a change of condition. LVN 1 stated MD 1 was not notified of Resident 1's COC. During a telephone interview on 3/25/21 at 9:28 am, the Director of Nurses (DON) stated a change in condition is anything that is abnormal for that specific resident from his baseline. The DON stated that a decline in resident's function or activities of daily living would be considered a change in condition if the resident exhibited the behavior on multiple shifts such as all three shifts in one day. The DON stated a COC should be initiated by the licensed nurses if it had been ongoing for one day. The DON stated that waiting one or two weeks was too long and the licensed nurses should have already done something about the resident's decline in function. During a concurrent review of Resident 1's Resident Progress Notes, SBAR notes, and IDT notes from 2/23/21 to 3/4/21, the DON stated she could not find documented evidence that an SBAR or COC form was completed by the licensed nurses for Resident 1 for a decline in physical function or for not getting out of bed or not walking for several days, since the fall. The DON stated the licensed nurses would complete an SBAR or COC to notify MD 1 and the responsible party (FM 1), and to assess the resident such as ordering any laboratory work or any new orders. The DON stated if the facility notified MD 1, the facility staff (licensed nurses and therapists) could have identified and addressed Resident 1's [CONDITION(S)] earlier and implemented interventions such as immobilizing the left leg, provided Resident 1 with appropriate pain medications, or applied ice on the left extremity. A review of the facility's policy titled, Routine Checks of Residents, dated 11/2010, indicated staff shall check on residents routinely to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns. The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the resident's condition and medical needs. The Nursing Supervisor/Charge Nurse will document any possible changes of condition or resident-specific requests. A review of the facility's policy titled, Changes in Resident Condition, dated 10/2017 indicated the licensed nurse was responsible for notifying the resident, attending physician and legal representative when there is a significant change in the resident's physical, mental, or psychosocial status.

Based on interview and record review, the facility failed to provide pain management (the process of alleviating pain) for one of two sampled residents (Resident 1), who sustained a fall, by failing to: 1. Assess Resident 1's non-verbal scale of pain appropriately according to the correct degree/level of pain and to include behavior indicators of pain such as grimaces, winces, and restlessness. Resident 1 continued to have left lower extremity (LLE) pain, was unable to get out of bed or walk from 2/22/21 to 3/4/21 until the attending physician (MD 1), during his in-person visit, identified Resident 1's left hip pain and ordered an X-ray (image of the internal composition of a part of the body) which showed an acute left hip fracture on 3/4/21. 2. Administer pain medication in accordance with Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no other pain medication ordered and available from 2/22/21 to 3/4/21 as needed for Resident 1's moderate to severe pain. Resident 1 did not receive the appropriate pain medication for non-verbal signs of Resident 1's assessed pain manifested on 2/22/21, 2/23/21, 2/25/21, 2/27/21, 3/3/21, 3/4/21, and 3/5/21. 3. Implement Resident 1's current care plan interventions to assess non-verbal signs of pain as manifested by facial expressions, protective body movement, identifying origin of pain and consult the attending physician (MD 1) if measures failed to provide adequate pain relief. 4. Implement the facility's policy and procedure on Pain Management, by not notifying MD 1, and not recognizing the presence of Resident 1's unrelieved pain through verbal and non-verbal behaviors such as facial grimacing, winces, restlessness, resistive to care, changes in daily living, and activity involvement and by rating the pain using the pain rating scale to assist in determining the appropriate type of pain therapeutic regimen and interventions. Resident 1 did not receive the appropriate pain interventions from 2/22/21 (after the fall) up to 3/5/21, when the resident would grimace in pain pointing to the left side and refused to get out of bed for 11 days (2/22/21 to 3/5/21). The facility's' failure to recognize Resident 1's left hip pain, resulted in Resident 1's unrelieved pain as manifested by facial grimacing and complaints of pain during physical therapy, decline in physical function for bed mobility and transfers, from minimum assist to moderate/maximum assist, and refusal to get out of bed for 11 days, after the fall incident on 2/22/21 up to 3/5/21. This deficient practice also resulted in the delay of Resident 1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was transferred to the general acute care hospital (GACH) 2 on 3/5/21 and stayed in GACH 2 for 4 days, and received appropriate pain management for severe pain with narcotic (an opioid [class of drug with addictive property] medication prescribed by a doctor to relieve moderate to severe pain), surgical consult for possible surgery to the left hip, PT and OT treatment while Resident 1's LLE was placed on a non-weight bearing (an exercise, motion, or activity to do without supporting one's own weight) status. Findings: A review of Resident 1's Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted back on 2/22/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Progress notes titled, SBAR (Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication) Communication Tool and Progress Note dated 2/22/21 timed at 12:30 am, indicated Resident 1's bed alarm was heard upon checking on the resident, the resident was found lying on the floor, on his left side by the right side of the bed. The SBAR Progress Note indicated Resident 1 sustained skin tears on the left parietal (left side of scalp above ear) area and the left elbow. The SBAR Progress Note indicated Resident 1's body assessment was completed with no other injuries noted and Resident 1 was able to move all extremities without any limitation and no complaints of pain. The SBAR Progress Note indicated Resident 1's attending physician (MD 1) was notified at 12:56 am. A review of a facility document titled Incident/Accident Post Review with observation date 2/22/21, timed at 8:39 am and recorded date of 2/24/21, timed at 11:40 am, electronically signed by the facility's interdisciplinary team (IDT; a group of healthcare providers from different fields who work together or toward the same goal to provide the best care or best outcome for a patient) indicated the IDT met to discuss the plan of care for Resident 1 due to the fall that happened on 2/22/21 at 12:30 am. The Incident/Accident Post Review indicated the facility would continue to monitor the resident for any change in condition. A review of Resident 1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's care plan titled Pain, dated 2/22/21 indicated, Staff assessment indicated pain or possible pain as manifested by non-verbal sounds, vocal complaints of pain, facial expression, protective body movements or posture. The care plan approaches included, observing the resident for non-verbal indication of pain and identifying origin of pain, administering pain medication as ordered: acetaminophen [over-the-counter; OTC] tablet; 325mg; amount: 650mg, by mouth twice daily as needed for mild pain and evaluate effectiveness and to consult MD 1, if above measures fail to provide adequate pain relief. A review of Review of Resident 1's Physical Therapy (PT) Evaluation and Plan of Treatment dated 2/20/21, indicated Resident 1's left lower extremity was within functional limits (WFL; a person's ability is outside of the normal range, but it is sufficient enough for activities of daily living), pain at rest was 0 out of 10 (no pain), bed mobility, transfers, and gait was evaluated at minimum assist (resident perform 75 percent of the work to move and the physical therapist provides about 25 percent of the work) level. The PT evaluation indicated Resident 1 was able to walk minimum assist using a front wheeled walker (a walking frame used as a tool for disabled or elderly people who need additional support to maintain balance or stability while walking) with 50 feet. A review of Resident 1's Occupational Therapy (OT) Evaluation and Plan of Treatment dated 2/22/21, indicated the resident had 4 (moderate pain) out of 10 pain in the left leg with movement. The OT evaluation indicated Resident 1 verbalized the pain level and the pain limited Resident 1's functional activities. A review of the GACH 1 ED Physician Notes dated 2/22/21 indicated Resident 1 presented to GACH 1 for left sided forehead laceration due to a fall from bed, the same morning (2/22/21). The GACH 1 ED Physician Notes indicated Resident 1 complained of pain to the left hip and laceration to the head after a fall and the exacerbating factor is movement. The GACH 1 ED Physician Notes indicated Resident 1 fell off the bed onto the left side with history taken from Resident 1's family member (FM 1). The GACH 1 ED Physician Notes indicated Resident 1 could not tolerate and refused the computed tomography scan (CT scan; combines a series of X-ray images taken from different angles around the body). The GACH 1 ED Physician Notes indicated Resident 1 was discharged back to the facility the same day (2/22/21). A review of a facility document titled Resident Progress Notes dated 2/22/21 timed at 2:25 pm, indicated Registered Nurse (RN) 1's notes indicating Resident 1 returned from the GACH 1 ED, still confused, and restless. RN 1's Resident Progress Notes indicated speaking to MD 1 and received an order to administer [MEDICATION(S)] (anti-anxiety medication) tablet 0.5 milligrams (mg) orally every six hours to Resident 1, as needed for agitation manifested by inability to relax. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool) admission assessment dated [DATE], indicated Resident 1 had short and long-term memory problems, had moderately impaired cognitive skills for daily decision making, did not exhibit any depressed mood behaviors, and did not have any limitations to both upper and lower extremity range of motion (ROM, full movement potential of a joint). The MDS indicated Resident 1 required extensive one person-assistance with bed mobility and two-person extensive assistance for transferring. A review of Resident 1's Physical Therapy Treatment Encounter Notes indicated the following information: a. On 2/23/21, indicated Resident 1 was maximum assist (person requires more than 75 percent assistance to complete task) with grimacing upon range of motion (ROM) and left lower extremity (LLE) with pain scale of four out of 10 on a facial scale (scale using facial expressions to determine level of pain, zero is no pain, 10 is excruciating pain). b. On 2/25/21, indicated, Patient (Resident 1) complained of pain on the left thigh, charge nurse was notified for pain management. c. On 2/27/21, indicated (Resident 1) States 7 out of 10 pain on LLE with weight bearing [putting weight on the extremity]. d. On 3/3/21, indicated Resident 1's bed mobility was at moderate assist, pre-gait (to position the limb for swing) was at maximum assist, and no ambulation occurred. f. On 3/4/21, indicated Resident 1 noted with complaints of LLE pain upon lateral weight shift on left LE with a pain scale of 5 out of 10 using the facial pain scale. The Notes indicated Nursing aware. A review of Resident 1's Medications Administration History indicated no pain medication was administered to Resident 1 on 2/23/21, 2/25/21, 2/26/21, 2/27/21, or 3/3/21. The Medications Administration History indicated the first administration of acetaminophen, one tablet 325mg, two tablets, (for mild pain) was given to Resident 1, on 3/4/21 at 12:30 pm for 4 (moderate pain) out of 10 pain on the left hip, using the behavior pain scale manifested by grimacing. The Medications Administration History indicated Resident 1 received acetaminophen two tablets 325 mg (for mild pain), again on 3/4/21 at 9:35 pm, for 3 (moderate pain) out of 10 pain on the left hip manifested by grimacing. A review of Resident 1's Pain Monitoring Administration History indicated from 2/20/21 to 3/5/21, the licensed nurses documented zero (meaning no pain) out of 10 pain in all three shifts (11 pm to 7 am, 7 am to 3 pm, and 3 pm to 11 pm). A review of a facility document titled Resident Progress Notes dated 3/4/21 timed at 1:20 pm, indicated RN 1's notes indicating MD 1 was in the facility and examined by MD 1, resident complaints of pain left hip when touch (sic). RN 1 wrote that MD 1 ordered an X-ray because Resident 1 was complaining of left hip pain. A review of the Resident's Progress Notes titled, SBAR for left hip pain dated 3/4/21 at 5:06 pm, indicated the pain level of 4 (moderate pain) out of 10 pain on Resident 1's left hip. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's X-ray report dated 3/4/21 timed at 9:38 pm, indicated an acute (new) mild superior displaced left subcapital (the point where the neck of the femur joins the head) femoral neck fracture (femoral neck fracture- a type of hip fracture of the thigh bone (femur)-just below the ball of the ball-and-socket hip joint. This type of fracture disconnects the ball from the rest of the femur) with soft tissue swelling and a joint effusion. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Medications Administration History indicated Resident 1 received acetaminophen two tablets 325mg each by mouth on 3/5/21 timed at 1:46 pm for a pain level of 4 (moderate pain) out of 10 pain on the left hip as manifested by grimacing. A review of the Medications Administration History indicated Resident 1, received another acetaminophen two tablets 325mg each by mouth on 3/5/21 timed at 5:48 pm for a pain level of 3 (moderate pain) out of 10 pain on the left hip manifested by grimacing. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident Progress Notes dated 3/4/21 timed at 11:39 pm, indicated FM 1 decided not to transfer Resident 1 to the GACH for the meantime and would decide the next day. The 3/5/21 Resident Progress Notes timed at 5:17 pm, indicated FM 1 agreed to have Resident 1 transferred to GACH 2 for evaluation. The Resident Progress Note timed at 8:20 pm, indicated Resident 1 was transferred to GACH 2 via ambulance. A review of a facility document titled, Observation Detail List Report with an observed date of 3/4/21 timed at 5:07 pm, and a documented date of 3/17/21 timed at 11:03 am, indicated a nursing note for Resident 1's left hip pain. The Report indicated that Resident 1 was currently in pain indicated by moaning, vocal complaints of ouch and facial grimacing. The Report also indicated Resident 1 had moderate pain. A review of the GACH 2 record titled Emergency Department (ED) Note-Provider dated 3/5/21 indicated Resident 1 had pain in the left hip, after a fall from a week ago, transferred to GACH 1 and returned the same day. Facility did not get a copy of imaging result (x-ray). Left hip x-ray done in the facility on 3/4/21, because of persistent pain that showed acute left femoral neck fracture. The ED Note-Provider indicated under physical examination showed Resident 1's left lower extremity shortening (left leg shorter than the right leg) and external rotation (extremity is rotated away from the body), and pain during log roll (rolling in bed). The ED Note-provider indicated Resident 1 admitted to pain to the left leg and left hip upon palpation, however, was unable to give an extensive history. The ED Note-provided indicated Resident 1 was administered narcotic pain medications intravenously (administered through the vein) such as [MEDICATION(S)] (pain medication for severe pain) and [MEDICATION(S)] (pain medication for severe pain). A review of the GACH 2 Discharge Summary dated 3/9/21, indicated Resident 1 was discharged from GACH 2, on 3/9/21. The Discharge Summary indicated FM 1 refused surgery because Resident 1 was not a good candidate for hip surgery due to age and comorbidities (involves more than one diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Discharge Summary indicated FM 1 refused skilled nursing facility placement and therefore, was discharged to home with home health care (a wide range of health care services that can be given in your home for an illness or injury) with order to remain non-weight bearing on the left leg. A review of a facility document titled Incident/Accident Post Review with completion and recorded date of 3/9/21, indicated the facility's IDT met and discussed Resident 1's fall incident and status when Resident 1 was residing in the facility. The Incident/Accident Post Review summary indicated that upon Resident 1's return to the facility, on the same day (2/22/21 around 2:15 pm), after being transferred to the acute hospital after the fall, The emergency medical technicians (EMTs) mentioned that everything was okay with resident. Resident 1 continued to be confused and restless. The post review summary indicated that there was no X-ray report sent with Resident 1 upon return to the facility from the acute hospital, on 2/22/21. The post review summary indicated that on 3/5/21, the facility requested the X-ray report performed in GACH 1 on 2/22/21. The post review summary indicated GACH 1 informed the facility that there was no X-ray performed to Resident 1, when Resident 1 was transferred to GACH 1, on 2/22/21. A review of a facility document titled Summary of Interviews/Investigation submitted by the facility to the Department of Public Health on 3/10/21, indicated that on 3/4/21, MD 1 came to visit Resident 1 in the facility. The summary indicated that when MD 1 touched Resident 1's hips, the resident complained of pain. The summary indicated MD 1 ordered x-ray of the hip. During a telephone interview and record review of Resident 1's Physical Therapy (PT) Evaluation and Plan of Treatment notes dated 2/20/21, on 3/23/21 at 2:02 pm, Physical Therapist (PT) 1 stated he evaluated Resident 1 for PT on 2/20/21 (prior to the 2/22/21 fall). PT 1 stated Resident 1 was able to walk about 50 feet with a front-wheeled walker (FWW- a framed walker with two wheels on the front legs) with minimal assist (person requires less than 25% assistance) and was able to perform bed mobility and transfers with minimal assist. PT 1 stated Resident 1 had full joint range of motion (ROM; the measurement of the amount of movement around a specific joint or body part) in all extremities and had no complaints of pain in all extremities prior to the fall, on 2/22/21. In the same telephone interview, on 3/23/21 at 2:02 pm, PT 1 reviewed Resident 1's Physical Therapy Treatment Encounter Note dated 2/23/21 and stated that on 2/23/21 (a day after the fall on 2/22/21) during Resident 1's PT session, PT 1 stated Resident 1 was easily agitated, and his transfers declined to a maximum assist (person requires more than 75% assistance). PT 1 stated the licensed nurses informed him that on 2/23/21, Resident 1 had some pain, before starting the PT session. PT 1 stated when PT 1 assessed Resident 1 for left lower extremity (LLE) ROM, PT 1 noted Resident 1 had four out of 10 pain (moderate pain) on the facial pain scale. The PT Treatment Encounter Note indicated, Patient noted to be easily agitated. It is noted that patient had an incidence of fall and exhibits transfer as max assist with grimacing upon ROM of left LE with PS [pain scale] of 4/10 (sic) on a facial scale. PT 1 stated Resident 1 was not able to verbalize the pain but Resident 1 grimaces and that was how PT 1 could tell Resident 1 was having some pain. PT 1 stated he informed the licensed nurses again that Resident 1 had LLE pain after the PT session, on 2/23/21. PT 1 stated he did not remember who the licensed nurse was that told him Resident 1 had pain that day, on 2/23/21, or who he spoke to and reported the resident's pain, after the PT session, on 2/23/21. PT 1 stated Resident 1 did not walk that day (2/23/21) because the resident was easily agitated and had LLE pain. During a telephone interview with Physical Therapy Assistant (PTA) 1 on 3/22/21 at 4:14 pm, PTA 1 stated that on 2/26/21 and 2/27/21, during PT sessions, Resident 1 was pointing to his left leg, with non-verbal expression of pain. PTA 1 stated Resident 1 would grimace or resist when PTA 1 would ask Resident 1 to perform an activity during the PT session. PTA 1 stated that was how he interpreted Resident 1 was having some pain. PTA 1 stated Resident 1 needed maximum assist with transfers and could not walk. PTA 1 stated he also worked with Resident 1 on 3/3/21 and that day, Resident 1 was still complaining of pain and noticed Resident 1 was being more restless. PTA 1 stated Resident 1 was still pointing to his left leg and exhibited facial expressions about 6 to 7 (moderate to severe pain) out of 10 pain on the facial pain scale. PTA 1 stated he informed the licensed nurses about Resident 1's pain. PTA 1 could not recall who the licensed nurses he reported to. PTA 1 stated that if the resident was not getting better or they get worse, he would report it to his supervisor (PT 1). PTA 1 stated he did not report Resident 1's decline in functioning and continued pain to PT 1. PTA 1 stated he verbally informed the charge nurse of Resident 1's pain. PTA 1 stated that usually a therapist would report a resident's pain to the licensed nurse, then the therapist would wait for a response from the licensed nurses and then go back to see the resident. PTA 1 stated unfortunately, he did not check back on Resident 1 during the days that he had worked with Resident 1, after reporting Resident 1's pain to the licensed nurses (unknown). During a telephone interview on 3/23/21 at 11:37 am, Family Member (FM 1) stated she spoke with Resident 1 over the phone (unsure what dates) while he was in the facility, because FM 1 could not visit in person. During the phone calls, FM 1 stated Resident 1 informed her that Resident 1 had pain after the fall. FM 1 stated she thought Resident 1 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . FM 1 stated before the fall, Resident 1 was walking perfect like a young man. FM 1 stated, at present, Resident 1 had recurring pain and a hip fracture. FM 1 stated Resident 1 had a hard time with the decline in function and pain. During a telephone interview and record review of Resident 1's Physical Therapy Treatment Encounter Notes dated 3/4/21, on 3/23/21 at 2:02 pm, PT 1 stated during the 3/4/21 PT treatment session, Resident 1 started complaining of pain when he stood up and shifted weight to his left side. PT 1 stated the licensed nurses was aware of Resident 1's LLE pain. PT 1 stated the pain persisted, so he notified the nurses of the pain. PT 1 stated the licensed nurses was aware of the pain. PT 1 stated it was the therapist's responsibility to report to the licensed nurses and let them know if a resident was having pain during the therapy session so that the nurses can assess and inform the physician and see what they recommend. PT 1 stated that therapists should also let the licensed nurses know about the resident's pain so that the licensed nurses can provide pain medication. Once the therapists inform the nurses, the nurses should give the residents pain medication and reassess. PT 1 stated that if a person had a fracture, but it was not diagnosed , then a person would continue to have pain and usually a resident would have precautions to not put weight on that extremity. PT 1 stated if a resident required maximum assist when a resident previously required minimum assist with transfers, and previously was able to ambulate and now was not able to walk anymore, this would be considered a decline in function. PT 1 stated he did not let the licensed nurses know that day (3/4/21) about Resident 1's decline in function because he thought Resident 1 was getting a little better. During a telephone interview on 4/1/21 at 11:28 am, when asked to clarify the facility's definition of the different levels of pain in the facility's pain scale, RN 1 stated that mild pain was between 1 to 2 out of 10 pain, moderate pain was considered between 3, 4, or 5 out of 10 pain, severe pain was between 7 to 10 out of 10 pain. RN 1 stated Resident 1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 1 stated if Resident 1 was complaining of 3 or 4 or 5 out of 10 pain, then that would be considered as moderate pain and Resident 1 should have been provided a pain medication for moderate pain. RN 1 stated Resident 1 was provided medication for mild pain on 3/4/21, because that was the only pain medication ordered for Resident 1. RN 1 stated that she should have called MD 1 to inform him that Resident 1 was experiencing moderate pain and ask for another pain medication to help the moderate pain. RN 1 stated that if a resident had moderate pain, but took medication meant for mild pain, the resident most likely would still be in pain. RN 1 stated the medication for mild pain would not resolve the pain. RN 1 stated that it was very important to call MD 1 immediately and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview and concurrent review of Resident 1's Medication Administration History for 3/4/21 to 3/5/21, on 4/1/21 at 11:43 am, the director of nurses (DON) stated Resident 1 complained of 4 out of 10 pain on 3/5/21 and should have been given [MEDICATION(S)] as ordered on 3/5/21, because that was the new physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During another telephone interview on 3/25/21 at 9:28 am, the DON stated that the pain reported and observed by the PTA 1 and PT 1 should have been assessed so that something could have been done earlier. The DON stated Resident 1 had pain and the licensed nurses should have addressed the resident's pain and administered the appropriate pain medications as ordered. The DON stated that the facility staff could have addressed Resident1's fracture earlier, such as immobilizing the left leg, giving the resident pain medications, put ice on the injury site. The DON stated that in general, a person who had a fracture, would be in pain. A review of the facility's policy titled, Pain Management, dated 10/2017 indicated, Pain can be expressed through behaviors in both verbal and non-verbal patients .non-verbal behaviors .include: crying, whining, gasping, moaning, groaning, facial grimacing, winces .bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement, tense body language, restlessness, resistive to care, changes in daily living, sleeping patterns, cognitive abilities and activity involvement. It also indicated, pain rating scale indicates: 0-No pain, 2-Mild Pain 4 to 6-Moderate Pain 8 to 10-Severe Pain, which will also assist in determining the appropriate type of pain therapeutic regimen interventions. The policy indicated, to observe both verbal and non-verbal patients for signs and symptoms of pain, notify a nurse immediately. Notify the physician.

Based on observation, interviews, and record review, the facility failed to establish and maintain an effective water management program to prevent the development and transmission of Legionnaire's disease (LD; a serious and often deadly form of lung infection [pneumonia], acquired by breathing in water droplets caused by the bacteria, [legionella; the bacteria that causes LD]) in the facility's water system that affected 1 of 79 sampled residents (Resident 1) and placed 78 of the 79 residents in the facility's census at risk for developing pneumonia (infection in one or both lungs causes inflammation of the air sacs). The facility had one (1) positive case (Resident 1) of LD on 2/5/2021. The facility did not have an effective water management program to reduce the risk, of the growth and spread of the bacteria, legionella, in the water system. The facility did not take water samples to test and confirm the source of the bacteria, since they were notified of the positive LD case by the public health nurse (PHN 3) on 02/18/2021. After receiving a phone notification from the Acute Communicable Disease Control ([CONDITION(S)]), the facility did not implement water management plan to stop or limit the spread of legionella in the water system to protect all the residents from potentially developing a deadly pneumonia. These deficient practices indicated the facility failed to test water samples and did not stop usage of facility's water by residents for drinking, oral hygiene, and showers. Absent of an effective water management program resulted Resident 1 got sick and transferred to the General Acute Care Hospital (GACH) due to fever, nausea, vomiting, and tarry stool. Resident 1 tested positive for LD, a chest x-ray (a photographic or digital image of the internal composition of something, especially a part of the body) showed left lung infiltrate (filling of airspace with fluid), and the Computed Tomography (CT; scan that can reveal anatomic details of internal organs, medical imaging method) showed extensive left multilobar (pneumonia involves more than one lobe [section] of the lung) pneumonia. This deficient practice placed the 78 residents in the facility at serious risk of developing severe respiratory infection (pneumonia). Findings: A review of the facility's Admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care planning tool) dated 12/9/2020 indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with activities of daily living (ADLs) such as bed mobility, transfer, toilet use, and personal hygiene. A review of Resident 1's Progress Notes, dated 2/4/2021, indicated at 3:24 p.m., the resident exhibited nausea and vomiting, one episode of tarry stool (black colored stool), and a fever of 102.5 Fahrenheit. A review of Resident 1's History and Physical (H&P) dated 2/17/2021, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR) report dated 2/4/2021, indicated at 4:49 p.m., Resident 1 exhibited nausea, vomiting, diarrhea, a fever of 100.9 Fahrenheit, and tarry stool. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's GACH Emergency Department (ED) Final Report notes dated 2/4/2021 timed at 5:46 p.m., indicated Resident 1 was admitted to the GACH due to weakness, nausea, vomiting, tarry stool, and fever. Resident 1 had an oxygen saturation (parameter that defines blood oxygen content, oxygen delivery, and measures the percentage of oxyhemoglobin [oxygen-bound hemoglobin] in the blood) of 88% a (normal oxygen blood saturation level in humans are 95 to 100 percent) and was placed on three liters of oxygen via nasal cannula (a lightweight tube consist of two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows). A review of Resident 1's GACH chest x-ray result, taken on 2/4/2021, indicated diffused (spread) left lung infiltrate (filling of airspace with fluid), suspicious for pneumonia (infection that inflames air sacs in one or both lungs). A review Resident 1's CT scan of the chest/abdomen/pelvis taken from the GACH on 2/5/2021, indicated extensive left multilobar (pneumonia involves more than one lobe [section] of the lung) pneumonia. A review of the laboratory result report for Legionella Pneumophilia [MEDICATION(S)] Urine Test (laboratory test that detects a molecule of Legionella bacteria in the urine) dated 2/5/2021, indicated Resident 1's urine specimen tested positive for the legionella bacteria. A review of Resident 1's readmission face sheet, indicated Resident 1 was readmitted back to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the [CONDITION(S)] Program Guidance for the Surveillance, Investigation, and Control of [CONDITION(S)] in Los Angeles County dated August 2019 indicated the Short-term Mitigation Strategies: Options to minimize patient exposure to potable water sources. The guidance included the following strategies: 1. Restrict patient showering until remediation strategies have been shown to be effective (strongly recommended). 2. Restrict drinking directly from potable water sources until remediation introduced; supply bottled water to patients. 3. Introduce point-of-use filters (filtration system used to eliminate waterborne pathogens [organism that causes a disease]) for faucets and showerheads. A review of the California Department of Public Health (CDPH) Healthcare-Associated Legionnaire's Disease Investigation Quick sheet dated March 2017 indicated that transmission occurred through inhalation or aspiration of water contaminated with Legionella and the incubation period for the bacteria was 2 to 10 days. After obtaining environmental samples, implement control measures until the water culture results are available. The control measures include: avoiding tap water for drinking; substituting with bottled water or collecting water from a faucet with point-of-point filter (0.2 micron), avoid taking ice from the ice machine (pending culture results), avoid using showers in the area of concern, (point-of-use filters may be installed on the showers to allow for temporary use pending water sampling results). A review of the U.S. Department of Health and Human Services Centers for Medicare and Medicaid Services Survey and Certification (S&C) 17-30 letter revised on 6/9/2017, indicated Medicare certified healthcare facilities to have and implement water management program to reduce the risk of growth and spread of legionella and other opportunistic pathogens in building water system. On 3/4/2021, at 9:35 a.m., an unannounced joint onsite visit was made to the facility with the [CONDITION(S)], Environmental Health (EH), Public Health Laboratory (PHL) and Health Facilities Inspection Division (HFID) Interdisciplinary team (IDT) for the identification and investigation of the facility's water sources and confirmed case of legionella. On 3/4/2021 at 9:55 a.m., during an interview, the administrator stated the facility had 79 total residents inhouse. The administrator stated Resident 1 was hospitalized on [DATE] and tested positive for LD (2/5/2021). The administrator stated this was the facility's first LD case. The administrator stated that after the facility was notified of Resident 1's LD diagnosis, the administrator had conducted her own research of the Legionnaires' Disease. A review of the facility's Census indicated that on 3/4/2021, the facility's total residents census was 79. Out of the 79 residents, 15 residents were using their bathroom faucets independently for basic hygiene such as face washing and brushing teeth. Out of the 79 residents, 11 residents were at risk for aspiration (residents with impaired swallowing who might aspirate water and it can accidently go into to the lungs during drinking) including Resident 1 who tested positive for LD. On 3/4/2021 at 10 a.m., during an interview, the Infection Preventionist (IPN) nurse stated that she received a phone call from the Los Angeles Public Health Department on 2/18/2021 and spoke to Public Health Nurse (PHN) 3 notifying the facility of Resident 1's positive LD case. During the entrance conference with the Public Health IDT team, on 3/4/2021 at 10:15 a.m., the IP nurse stated that Resident 1 who tested positive for LD was non-ambulatory (cannot walk) and was using the facility's shower rooms located closest to her previous room prior to hospitalization . A review of the facility map indicated that Resident 1's previous room prior to hospitalization on [DATE] were adjacent to all four shower rooms (A, B, C, and D). During an interview, on 3/4/2021 at 10:28 a.m., the administrator stated the facility started to work on the facility's water management program as soon as the facility was notified of Resident 1's positive LD. The administrator stated the facility did not have an existing water management program before PHN 3 notified the facility of Resident 1's positive LD on 2/18/2021. The administrator stated she was still working on the facility's water management program at the time of the Public Health IDT onsite visit (3/4/2021). The administrator acknowledged that all facilities had to develop a water management program as indicated in the S&C letter from CDPH dated 6/2/2017. During an interview, on 3/4/2021 at 10:54 a.m., the DSD (Director of Staff Development) stated they instructed the Certified Nursing Assistants (CNA) to continue showering the residents and to sanitize the showers before each resident's use. The DSD stated that all the shower rooms were deep cleaned and disinfected. The DSD stated all residents were using the facility's drinking water from the kitchen. The DSD stated she knew legionella bacteria spreads through infected water, gets in the person's lungs via inhalation or aerosol (a fine spray or mist). The DSD stated Resident 1 was drinking thickened fluids prepared from the kitchen. During an interview, on 3/4/2021 at 10:55 a.m., the administrator stated the facility continued to use all sources of the facility's water system (even after notification from PHN 3 on 2/18/2021 [showers, bathroom sink faucets, drinking water system]) and continued to utilize the ice coming from the ice machines for residents' use. The administrator stated the facility's immediate interventions upon notification on 2/18/2021 by PHN 3 included checking (visual) the water system tubing for leaks to look for possible sources of the bacteria, checked (visual) for stagnant water, and checking (visual) of the ice machine and nebulizers. The administrator stated that there were no point-of-use filters installed in the showers, residents' bathroom faucet sinks, or in the drinking water system in the kitchen. The administrator stated that she communicated with a laboratory (private lab) for water sampling after PHN 3's notification to the facility on [DATE], however, water samples were not sent out for testing yet for the legionella bacteria. During another interview with the administrator, on 3/4/2021 from 11:14 to 11:33 a.m., the administrator stated when she found out about Resident 1's positive LD case, she communicated with the facility's regional office and received guidance about how to develop the facility's water management plan. The administrator stated she had researched about Legionnaires' disease in the Centers for Disease Control (CDC) website and immediately implemented the following interventions: sweep off the building to ensure there was no standing water, inspected all the shower rooms and residents' rooms to ensure there were no leaks, infection control inspection and maintenance of the facility's building cleanliness, and deep cleaning of the ice machine. The administrator stated the facility did not implement interventions (as indicated in the [CONDITION(S)], CDPH, and CDC Legionnaires' disease guidance) to keep other residents (78 other residents that might acquire LD) in the facility safe from acquiring the legionella bacteria, after notification of Resident 1's positive LD on 2/18/2018. During an interview, on 3/4/2021 at 10:56 a.m., the director of nurses (DON) stated Resident 1 did not go out of the facility from 9/30/2020 to 2/3/2021. The DON stated Resident 1 was residing in a multiple occupancy room prior to the GACH transfer on 2/4/2021. The DON stated the resident's drinking water was continued to be obtained from the drinking water system located in the facility's kitchen. On 3/4/2021 at 11:12 a.m., during the facility tour with the DON, DSD, IP nurse, and administrator in the facility's four Shower Rooms (A, B, C, and D), the DON stated there were no point-of-use filters installed in all the Shower Room's (Shower Rooms A, B, C, and D) shower heads. During observations of the Resident 1's, Resident 2's, Resident 6's bathroom sink faucets, there were no point-of-use filters observed installed in the faucet sinks for each resident's room. On 3/4/2021 at 11:18 a.m., during an observation of Resident 6's room, the bathroom faucet sinks did not have a point-of-use filter installed. During an interview, Resident 6 stated that the CNAs assists her to shower in the facility's Shower Rooms, drinks water from the water pitcher provided by the facility staff every day and uses her own room's bathroom sink for face washing and oral care. On 3/4/2021 at 11:25 a.m., during an interview, Cook 1 stated that the facility's drinking water is filtered and an outside company comes every month to check and clean the machine. On 3/4/2021 at 11:44 a.m., during the exit conference conducted by the DPH IDT team to the facility, PHN 1 provided initial verbal recommendations to the facility such as avoiding tap water use for drinking, using bottled waters or install point-of-use filters, installing showers and faucets with filters (0.2 micron filter [size of the filter]), develop a facility water management program to be approved by PHN 1, prepare a Legionnaires' outbreak notification letter, and provide notification of receiving facilities during any resident transfer. During a continuation of facility staff interviews, on 3/4/2021 at 3:55 p.m., Cook 2 stated the facility's practice of passing water to the residents involved filling the pitchers with water from the kitchen, each water pitcher would be filled with ice from the facility's ice machine twice every shift (day, evening, and nigh shifts). On 3/4/2021 at 4:48 p.m., during an interview, CNA 2 stated that legionella bacteria are transmitted through infected water and found in the faucet with running water or when a resident is taking a shower. CNA 2 stated she received the in-service about the Legionnaires' disease from the facility a week ago. Per CNA 2, last time she gave shower to her assigned residents were one day ago. CNA 2 stated that for the residents' hydration they get water from the kitchen. On 3/4/2021 at 4:48 p.m., during an interview, CNA 3 stated that legionella bacteria come from the water and found in the kitchen, showers, and ice machine. CNA 3 stated she received the in-service from the facility about Legionnaires' disease two weeks ago. CNA 3 stated that CNAs continued to provide water coming from the kitchen to all their assigned residents for drinking. On 3/4/2021 at 4:48 p.m., during an interview, Licensed Vocational Nurse (LVN) 2 stated that legionella bacteria spreads through the mist and water and can cause pneumonia after drinking water or through inhalation. LVN 2 stated that legionella bacteria can be found in the showers, mist oxygen, and kitchen. LVN 2 stated she received the in-service from the facility after the facility discovered Resident 1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/4/2021 at 5:15 p.m., during an observation, Resident 1 was observed sitting on her bed and receiving supplemental oxygen via nasal cannula. On 3/4/2021 at 5:18 p.m., during a concurrent observation and interview of Resident 2 in his room, Resident 2 stated that he continued to have showers twice a week, gets his drinking water provided by the facility staff, and brushes his teeth and wash his face in his bathroom faucet three times a day. Resident 2 stated he can walk to the bathroom by himself. A review of a facility policy titled Legionella Water Management Program revised on 7/2017 and obtained from the administrator on 3/4/2021, indicated a policy acquired from a policy resource company that provides policies to long term care facilities. The policy indicated that the facility would be committed to the prevention, detection, and control of water-borne contaminants, including legionella by having and implementing water management program. A review of the U.S. Department of Health and Human Services Centers for Disease Control and Prevention/Legionnaire's Disease: A problem for health care facilities, dated June 2017, indicated that Legionnaire's disease (LD) is a serious, and often deadly, lung infection (pneumonia). People usually get it by breathing in water droplets containing Legionella germs. People can also get it if contaminated water accidentally goes into the lungs while drinking. Legionella grown best in buildings with ineffectively managed large water systems. Contaminated water droplets can be spread by showerheads, sink faucets, and ice machines, people who are at increased risk for LD are adults [AGE] years or older, current or former smokers, and people with a weakened immune system or chronic diseases. On 3/4/2021 at 6:46 p.m., the Department called an Immediate Jeopardy (IJ [a situation in which the facility's noncompliance with one of more requirements of participation has caused, or is likely to cause, serious injury, harm or impairment, or death to a resident]), in the presence of the facility administrator and the DON. The facility failed to have an effective water management program, and policy and procedures to reduce the risk of the growth and spread of the legionella bacteria, and failed to use available resources, such as the infection control guidelines from [CONDITION(S)], CDC, and CDPH to establish and implement a system to stop or limit the growth of legionella in the water. On 3/7/2021 at 1:49 p.m., after the facility submitted an acceptable plan of action (POA), the survey team verified the implementation of the POA by observation and record review and confirmed the removal of the immediate jeopardy in the presence of the administrator, DON, infection control (IP) nurse, and director of staff development (DSD). The plan of action included: 1. The facility's revised Water Management Program was completed and submitted to the Department on 3/4/2021. The facility's water Management Program was sent to [CONDITION(S)] for approval on 3/5/2021. 2. The facility signed a contract from a licensed water safety provider to evaluate and develop a thorough water management program and will be completed by 4/5/2021. 3. The facility's four shower rooms (Shower Rooms A, B, C, and D) and the 15 identified ambulatory residents (Residents 2 to 16) bathroom faucet sinks were closed down until a point-of-use filters ([0.2 micron filters] a device where a contaminated fluid is passed through a special pore-sized membrane to separate microorganisms and suspended particles from the liquid) were installed in the facility's water systems that included the drinking water system. 3. A DO NOT USE sign was placed on the kitchen juice and drinking water system temporarily until further advised. 4. Bottled purified waters were used as a substitute for the facility's drinking water and will continue until the point-of-use filter (0.2 micron) is in place. 5. The dietary department will be utilizing bottled water for cooking, coffee, and juice. 6. The ice machine will not be utilized and a DO NOT USE SIGN was placed on 3/4/2021. Facility will use outside vendors for ice supply until results are obtained from the sample collected on 3/4/21 by California Department of Public Health (CDPH). 7. The facility will obtain a 3-day supply of 1300 gallons of water from an outside company and will be replenished every 3 days for residents' personal hygiene use (washing face and oral care). Central Supply and Maintenance Supervisor is responsible for ensuring that water is available in Residents rooms and nursing stations for Resident consumption needs daily and per shift. 8. On 3/4/2021, all 15 residents identified as ambulatory and able to do self-care activities like basic hygiene face washing including oral care will be provided hand sanitizers and hand sanitizing wipes to use as an alternative to water and a purified water bottle to use for any ADL (activities of daily living) needs. 9. All 15 residents were moved to an area where they can be monitored. Facility staff will continue to ensure that the 15 residents were reminded frequently not to use the tap water in the bathroom sinks until the point-of-use filters were in place. 10. Daily shift huddles and in- services will continue for all shifts until all staff are completed. 12. The facility initiated the process of securing a permit from the Office of Statewide Health Planning and Development (OSHPD) on the installation of the 0.2-micron filters in the facility bathroom sinks and showers. 13. Plans for completion and installation of the 0.2-micron filters to the water systems by 3/12/2021. 14. The facility created a line list of residents who had signs and symptoms of pneumonia in the past 6 months for submission to [CONDITION(S)] to evaluate the need of LD testing among the residents who might had been affected by the legionella bacteria. A review of an email communication from Environmental Health and [CONDITION(S)] to the facility, dated 3/16/2021, indicated the Final Data of Environmental Samples Collected on 3/4/2021, showed the final results of water samples collected from the facility during the DPH joint onsite visit on 3/4/2021. The final results indicated positive legionella pneumophila (causative agent for Legionnaires' disease) was found from water samples collected the facility's Shower Rooms A and B and Resident 1's previous bathroom sink (prior to 2/4/2021 GACH transfer).

Based on interview and record review, the facility failed to ensure residents with limited range of motion received appropriate rehabilitation services for one of three sampled residents (Resident 1). The facility staff did not incorporate range of motion (ROM - the extent of movement of a joint) exercises during care and did not conduct a joint mobility assessment quarterly or as needed, per the plan of care. The facility also failed to provide Resident 1 with therapy services upon admission and quarterly thereafter, per facility policy. This deficient practice resulted in Resident 1 experiencing severe pain and suffering an acute supracondylar humerus fracture (an elbow fracture that occurs when an elbow has bent backwards beyond its normal range of motion). Findings: A review of the clinical record indicated Resident 1 was admitted to the facility, on 4/13/16, with [DIAGNOSES REDACTED]. A review of the Resident Data Collection form, dated 4/13/16, indicated Resident 1 was admitted to active hospice and had contractures to both hands and both legs. A review of the History and Physical completed by the physician, dated 4/21/16, indicated Resident 1 was admitted to the facility with the [DIAGNOSES REDACTED]. A review of the Self Care Deficit care plan, dated 4/13/16, indicated Resident 1 required total assistance due to impaired cognition and physical limitations/disability. The care plan goal was for the resident to participate in activities of daily living (ADLs) if able and maintain dignity and comfort. The care plan interventions indicated to incorporate ROM (the extent of movement of a joint) exercises during care unless contraindicated, joint mobility assessment quarterly or as needed, observe changes in ROM, and refer to therapy if needed. A review of the Alteration in Comfort care plan, dated 4/13/16, indicated Resident 1 had pain caused by contractures. The care plan goals indicated to alleviate pain with interventions, improve quality of life with interventions, and maintain and enhance the resident's functional ability with interventions. The care plan interventions indicated to encourage and promote activity participation. A review of the Minimum Data Set (MDS - a care screening and assessment tool), dated 4/25/16, indicated Resident 1 was severely impaired in cognitive skills of daily decision making, was totally dependent on staff for ADLs, and required one person physical assist. The MDS indicated the resident had impairment to all extremities. A review of the Care Area Assessment Summary form indicated the care area for ADL function/Rehabilitation potential was not triggered and the care planning decision remained blank. A review of Resident 1's clinical record indicated there was no assessment for rehabilitation services intervention through an initial or ongoing assessment, per facility policy. A review of the Situation, Background, Assessment, and Recommendation form (SBAR), dated 7/20/16, indicated Resident 1 had slight [MEDICAL CONDITION] (swelling) on the right upper extremity (arm), and nursing interventions included monitoring and resting the extremity on a pillow. A review of the SBAR form, dated 7/24/16 indicated Resident 1 had [MEDICAL CONDITION] to the right elbow with warmth and tenderness, facial grimacing, and pain medication was given. During an interview with the Director of Nursing (DON), on 8/4/16, at 9 a.m., he stated on 7/20/16 he went to Resident 1 to assess the [MEDICAL CONDITION] to the right elbow and stretched out the right arm gently. There was no facial grimacing at that time. The DON stated the right elbow was placed on a pillow and the [MEDICAL CONDITION] subsided on 7/23/16. A review of the physician's order, dated 7/24/16, indicated Resident 1 was to receive an X-ray of the right elbow. The facility's X-ray report dated 7/24/16, concluded Resident 1 had an acute supracondylar humerus fracture (an elbow fracture that occurs when an elbow has bent backwards beyond its normal range of motion). A review of the progress note from the medical clinic, dated 7/27/16, indicated Resident 1 presented to the clinic with right elbow swelling and tenderness. The X ray showed a right distal humerus fracture with mild displacement (an elbow fracture that occurs when an elbow has bent backwards beyond its normal range of motion). During a phone interview with Resident 1's family member, on 8/8/16, at 11:21 a.m., she stated the resident had contractures to both arms and the right side was more contracted. On 7/20/16, the resident had [MEDICAL CONDITION] to the right elbow and it was warm to touch. The family member stated she went back to the facility on [DATE] and noted the elbow was still warm and the [MEDICAL CONDITION] had improved. During an interview and record review of the care plan, on 8/14/16, at 9:10 a.m., when the DON was asked, what is the joint mobility assessment, the DON stated he was unsure of what the joint mobility Assessment was. When asked who was responsible for completing the assessment, he was unsure. A review of Resident 1's clinical record indicated there was no documented evidence a joint mobility assessment was conducted for Resident 1. The DON stated that without this assessment, the facility was unable to determine whether or not ROM was contraindicated, and if facility staff should have stretched out or extended Resident 1's arm gently. A review of the facility's blank Contracture Screen form indicated a section to screen a resident's elbow, extension to flexion from 0 to 145 degrees (extension describes the action of straightening the elbow, flexion describes the action of bending the elbow), or if the resident had normal range. A review of the clinical record indicated Resident 1 did not receive this contracture screening. During an interview with the Director of Rehab Services, on 8/14/16, at 10:30 a.m., she stated Resident 1 was contracted to both upper extremities and there was no physician order for [REDACTED]. The Director of Rehab Services stated even though Resident 1 received active hospice care, the Contracture Screening form should have been completed for Resident 1 to indicate the degree of elbow extension to flexion and that residents with contractures should get restorative nursing assistant (RNA) services to maintain and improve ROM, which Resident 1 did not receive. The Director of Rehab services stated the contracture screening would have helped determine Resident 1's limits to prevent injury and anyone who performed ROM needs to be trained. If an extremity was extended too far, the pull of the tendon and bone can cause a fracture. The Director of Rehab stated the type of fracture Resident 1 had can occur with stretching the elbow too far. A review of the physician orders, dated 7/25/16, indicated Resident 1 was to receive [MEDICATION NAME] (a narcotic used to treat pain), and immobilization of the right elbow. A review of the pain management flowsheet, dated 7/25/16 to 7/27/16, indicated Resident 1 had a pain score of 6 to 8, out of 10 (0 indicating no pain and 10 indicating the worst possible pain level). During this time, Resident 1 received [MEDICATION NAME] six times. A review of the orthopedic consult (specializing in the musculoskeletal system) progress note, dated 7/27/16, indicated Resident 1 was recommended for non-operative treatment and an arm splint was applied. A review of the facility's policy and procedure, dated 2/2013 titled, Rehabilitation Therapy Screens, indicated a physician's order was not required for a therapy screen to establish a skilled need for therapy services. At least one discipline of Physical, Occupational, or Speech Therapy would screen a resident for therapy services upon admission and quarterly thereafter. If an initial evaluation was performed upon admission, an admission screen was not necessary. A review of the facility's policy and procedure, dated 2/2013 titled, Therapy Contracture Assessment Procedure, indicated the rehabilitation staff ensured the appropriate assessment for rehabilitation services intervention through an initial and ongoing assessment. A routine admission, quarterly, or change of condition therapy screen may indicate a joint contracture was present. If a therapy screen identified joint function was limited by contracture, a contracture screen was used to identify the specific deficits in ROM. The contracture screen was performed at least quarterly with ROM measurements taken. The therapist would assess whether to continue existing intervention or update the plan of care.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was admitted to the facility with no pressure sore (bedsores, injuries to skin and underlying tissue resulting from prolonged pressure on the skin, most often develop on skin that covers bony areas of the body), and was identified as low risk for pressure sore, was provided necessary treatment and services for prevention of new sores developing and prevention of infection by failing to: (1) Promptly assess the development of pressure sore to the upper and lower back areas. (2) Promptly assess the worsening of the pressure sores to the upper and lower back areas. These deficient practices resulted in Resident 1 being admitted to the general acute care hospital (GACH) to [MEDICAL CONDITION] (blood infection), [MEDICAL CONDITION] (potentially serious bacterial skin infection), and the development of five new pressure sores identified in the emergency department as multiple Undetermined / Stage IV pressure sores. Findings: A review of the admission record indicated Resident 1 was admitted to the facility, on 9/2/15, and re-admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the initial Minimum Data Set (MDS - an assessment and care planning tool), dated 10/23/15, indicated Resident 1 was alert, able to make some needs known, sometimes she understood staff and sometimes staff understood her. Resident 1 required extensive assistance with activities of daily living such as personal care, dressing, and transfers. A review of the Braden Scale For Predicting Pressure Sore Risk form, dated 9/2 to 10/19/15, indicated Resident 1 had some sensory impairment which limited ability to to feel pain or discomfort, and skin was occassionally moist which required an extra linen change once a day. The pressure sore risk form indicated Resident 1 was a low risk for pressure sores and had a total score of 18. A review of Resident 1's Nursing Weekly Summary Form, dated from 10/24/15 to 11/29/15, indicated no skin breakdown to the back area and skin was intact with no treatment orders. However, a review of the Nursing Weekly Summary Form, dated 11/30/15 to 12/7/15, indicated Resident 1 developed a blister on the right upper back. There was no further description of the blister indicated. A review of Resident 1's Situation Background Assessment Recommendation (SBAR) form, dated 11/30/15, indicated a change of condition due to a right upper back, open blister to the back and an order was obtained for antibiotic ointment for 21 days. A review of the SBAR form, dated 12/7/15, indicated a change of condition due to right upper back abscess (a collection of pus that has built up within the tissue of the body, signs and symptoms of abscesses include redness, pain, warmth, and swelling) / [MEDICAL CONDITION] (potentially serious bacterial skin infection). A review of the Medicare Daily notes, dated from 10/23/15 to 12/1/15, indicated Resident 1 had a pressure sore open blister to the right upper back. There was no further documentation of the description of the pressure sore open blister. A review of the Medicare Daily notes, from 12/2/15 to 12/7/15, indicated Resident 1 had a pressure sore / open blister to the right upper back. There was no further documentation of the description of the blister. During an interview with Resident 1's family member, on 2/9/16, at 10 a.m., she stated she visited Resident 1 every day and was not aware she had so many pressure sores. The family member stated staff informed her, on 12/7/15, Resident 1 had a small blister on her right upper back. However, she discovered the pressure sores (not blisters) on 12/9/15, when Resident 1 complained of pain to the back. Resident 1's family member stated she had the certified nursing assistant 1 (CNA 1) for Resident 1, remove the dressings to expose the multiple pressure sores and demanded the facility transfer Resident 1 to the acute hospital. During an interview with CNA 1, on 2/9/16, at 3 p.m., he stated Resident 1's wounds were there since 11/30/15. CNA 1 stated the wounds were not new and that he did not report to the family member or treatment nurse because he thought they already knew the condition of the wound. A review of the Medicare Daily notes, dated from 12/7/15 to 12/8/15, indicated Resident 1 did not have a pressure sore, but [MEDICAL CONDITION] to the right upper back. There was no further documentation or description of the [MEDICAL CONDITION] to the right upper back. A review of the facility policy and procedure titled, Skin Care Management, dated 9/2009, indicated the facility staff would document in the progress notes on the Weekly Pressure Ulcer Record which would include the size, stage, location, drainage, odor, and presence of pain. The licensed nurses would document in the Daily Monitoring Pressure Ulcer Record on a daily basis which needs to include status of the surrounding skin and presence of possible complications. The Director of Nursing would maintain a log book, the Quality Assurance Team would develop a tracking/trending basis for required process improvement. During an interview with the Staff Developer, on 2/9/16, at 3:10 p.m., he stated he could not provide documented evidence that this was done (documentation of description of sore and status of surrounding area) for Resident 1 when she was first identified as having a blister to the right upper back. The Staff Developer stated a blister was considered a Stage II pressure sore (partial thickness loss of dermis, presenting as a shallow open sore with a red / pink wound bed) and should have been identified and treated as a pressure sore. A review of the Discharge Orders/Resident Transfer Form, dated 12/9/15, indicated Resident 1 was transferred to the general acute care hospital at 9:45 p.m., with wounds to the right upper back (two), a left lateral upper back wound, and two middle upper back. A review of the Emergency Department Reports, on 12/9/15, at 10:52 p.m., indicated Resident 1 was transferred from the skilled nursing facility to the general acute care hospital (GACH) for evaluations of the pressure sores on her upper back. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Initial Physician Pressure Ulcer Progress Note (from the GACH), dated 12/9/15, at 10:36 p.m., and 12/10/15, at 12:26 a.m., indicated the registered nurse assessed the following: -Right upper back and left upper back pressure sore, Stage UTD(undetermined) -Right upper back pressure sore (multiples) 7 x 3 cm and 4 x 1.9 cm (lower wounds) -Left upper back (multiples) 3 x 2 cm and 1 x 1 cm Stage UTD -Left shoulder pressure sore, Stage UTD -Left heel, Stage UTD and Right heel 4 x 4 cm, Stage UTD. A review of the facility's policy and procedure titled, Pressure Ulcer -Definition and Stages, dated 2/2007, indicated Stage II was partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough and may also present as an intact or open/ruptured serum filled blister. During interview and record review with the Staff Developer, on 2/9/16, at 2:20 p.m., he stated a blister was considered a Stage II pressure sore and he could not explain why the treatment nurse did not treat it like a pressure sore. The Staff Developer stated he did not have any documentation of the measurements or assessment of the blister to the right upper back. The Staff Developer stated he could not locate the information for Resident 1 in the Weekly Pressure Ulcer Log because the resident was not on the list to monitor since the facility staff did not identify the blister as a pressure ulcer. A review of the care plan, dated 11/30/15, indicated Resident 1 developed non-pressure/non-surgical wound to the right upper back (site #1) and was at risk for wound infection. The plan of care interventions included assessing the wound for decrease in size and improved wound appearance, staff to follow wound treatment protocol. However, there was no documentation regarding the size or appearance of the wound/blister to the back. A review of the care plan, dated 12/6/15, indicated Resident 1 further developed an abscess to the non-pressure/non-surgical wound to the right upper back (site #1), mid upper back (site # 2), mid upper right back (site #3), and was at risk for wound infection. The plan of care included assessing the wound for decrease in size and improved wound appearance or signs of healing. Staff to follow wound treatment protocol. However, there was no documentation regarding the size or appearance of the wound/blisters to the back. During an interview with the Staff Developer, on 2/9/16, at 3:55 p.m., he stated there was much confusion because staff had identified Resident 1's wounds as non-pressure/non-surgical and therefore was not implementing the protocol for pressure sores. The Staff Developer stated Resident 1 had pressure sores on her back that was presented initially with blisters and should have been assessed as Stage II pressure sore. He stated the facility failed to identify the wounds as a pressure sore Stage II and therefore did not treat it accordingly. The Staff Developer stated the facility had a high turnover of treatment nurses and he could not explain how Resident 1 who was identified as having a small blister to the right upper back, developed multiple unstageable pressure sores to the upper and lower back in a period of one week. A review of the treatment nurse's sign in sheets indicated Resident 1 had five different treatment nurses from 11/30/15 to 12/7/15. During an interview with the treatment nurse, on 2/10/16, at 1 p.m., she stated that on 12/7/15 she proceeded to provide treatment services to Resident 1's right upper back blister as indicated in the treatment sheet. However, when she removed the dressing, she was horrified to find multiple pressure ulcers on the back with black yellowish eschar (a dry, dark scab or falling away of dead skin), and slough (dead tissue that can be stringy or thick and adherent on the tissue bed). The treatment nurse stated she immediately notified management and they called the Wound Consultant and the Director of Nursing to assess the pressure ulcers. During an interview with the Wound Consultant, on 2/17/16, at 2 p.m., he stated that on 12/7/16, he came to the facility to assess Resident 1's pressure sores. He stated during his observation with the Director of Nursing, he noted multiple pressure sores to the resident's upper and lower back. The Wound Consultant stated the areas had black eschar (a dry, dark scab or falling away of dead skin), some areas with yellowish slough (dead tissue that can be stringy or thick and adherent on the tissue bed) and in need of debridement (the removal of damaged tissue or foreign objects from a wound). The Wound Consultant stated they were not blisters and he recommended Santyl ointment (pressure sore ointment used to debride dead skin) because the antibiotic ointments currently ordered would not work on the resident due to the pressure sore sites having slough and eschar. A review of the facility's policy and procedure titled, Pressure Ulcer-Definition and Stages, dated 2/2007, indicated Un-stageable as full thickness tissue loss with in which the base of the ulcer is covered in slough ( yellow, tan, gray, green or brown) and /or eschar ( tan, brown , or black( in the wound bed. Until the slough and or eschar is removed to expose the base of the wound, the true depth and stage cannot be determined.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with necessary care and services to attain optimal improvement in condition and did not deteriorate outside the limits of normal and recognized processes. Resident 1 who had severe generalized pain was not assessed for pain, re-evaluated for effectiveness of pain medication, and was not administered pain medication, as ordered by the physician, in a timely manner. This deficient practice resulted in unnecessary and ongoing pain and suffering. Findings: A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility, on 6/29/15, at 6:30 p.m., with glio[DIAGNOSES REDACTED] multiforme(malignant tumor involving abnormal cell growth with the potential to invade or spread to other parts of the body which begins within the brain), diabetes mellitus (abnormal blood sugar), [MEDICAL CONDITION] (uncontrolled electrical activity in the brain resulting in an uncontrolled shaking of the body), and [MEDICAL CONDITION] (lung disease that makes it hard to breathe). The Minimum Data Set (MDS - an assessment and care screening tool), dated 7/6/15, indicated Resident 1 was alert with periods of confusion. She was able to make her needs known to staff and staff understood her. The MDS indicated due to her weakness and bowel and bladder incontinence (unable to restrain natural discharges or evacuations), she was dependent on staff for her activities of daily living including bed mobility, transfers, dressing, and personal hygiene. A review of the Pain Care Plan, dated 7/8/15, indicated Resident 1 had pain related [MEDICAL CONDITION]. The care plan indicated interventions which included assessing level of pain using pain scale 0-10 (10 being the worst possible pain), staff to administer pain medications as ordered by the physician, and to consult the physician if current measures fail to provide adequate pain relief. A review of the Situation / Background / Assessment or Data Collection / Recommendation (SBAR- a tool used to facilitate prompt and appropriate communication among health care professionals), dated 7/23/15, indicated Resident 1 was in severe, generalized pain with pain level rated 10 out of 10 (10 being the worst possible pain). Resident 1's mental status was alert and oriented to person, place, and time. A review of the narrative notes, dated 7/23/15, at 6 p.m., indicated Resident 1 was shaking, crying, and in great pain, mostly on her back and abdomen. A review of the Physician Orders, dated 7/23/15, at 6 p.m., indicated Resident 1 was to receive [MEDICATION NAME] (a narcotic pain medication) 5/325 mg (milligrams) by mouth every four hours as needed for moderate to severe pain. During a review of the SBAR under Narrative Notes, dated 7/23/15, at 6:15 p.m., Resident 1's son reported the pain medication given was not effective and did not take away the pain. A review of the SBAR indicated at 6:30 p.m., another dose of [MEDICATION NAME] 5/325 mg by mouth was administered. A review of the SBAR under narrative notes, dated 7/23/15, at 9 p.m., indicated Resident 1 was in terrible pain, shaking and crying again. A review of the physician's orders [REDACTED]. A review of the Infusion Medication Administration Record, [REDACTED]. A review of the Doctor's Progress Notes, dated 7/24/15, indicated Resident 1 complained of severe back pain. According to the Nurse's Notes, dated 7/24/15, at 4 p.m., Resident 1 was seen and examined by the physician with new orders for [MEDICATION NAME] 0.5 ml (a narcotic pain medication) by mouth every two hours as needed for pain. However, a review of the Infusion Medication Administration Record, [REDACTED]. There was no pain assessment found to indicate if [MEDICATION NAME] was effective in relieving Resident 1's severe pain or an assessment of the rating of the pain. During an interview with the Director of Nursing (DON), on 1/4/16, at 2:30 p.m., she stated the facility staff was giving Resident 1 [MEDICATION NAME] instead of [MEDICATION NAME], because the pharmacy had not made the delivery. The DON stated the facility staff should have notified the physician the [MEDICATION NAME] was not available, should have notifed the pharmacy they did not have the [MEDICATION NAME] in the house supply, and should have made arrangements for the [MEDICATION NAME] to be delivered STAT (immediately) within the hour. The DON stated she could not explain why the medication was given on 7/25/15, at 2 a.m., when the facility staff received the [MEDICATION NAME] on 7/25/15, at 1:08 a.m. A review of the Pain Management Flow Sheet, dated 7/25/15, indicated Resident 1 was not administered the [MEDICATION NAME] by mouth which was ordered on [DATE], at 4 p.m., until 7/25/15, at 2 a.m., 10 hours after the physician ordered it. A review of the [MEDICATION NAME] label indicated it was filled by the pharmacy on 7/25/15, at 11:59 p.m., and was delivered at 1:08 a.m. During an interview with Family Member 2 and 3, on 1/4/16, at 5 p.m., they stated Resident 1 was in severe pain and the [MEDICATION NAME] given to Resident 1 on 7/24/15, at 5:10 p.m. and 9:10 p.m. was not effective. Family member 2 stated Resident 1 was crying and moaning. They were informed by the nursing staff that all they can do was give the [MEDICATION NAME] because the [MEDICATION NAME] had not arrived. During an interview with Pharmacist 1, on 1/11/15, at 2:50 p.m., she stated all pain medications were treated as STAT (immediately). Pharmacist 1 stated the medication should be delivered and administered within 4 hours. A review of the Omnicare - Facility's Pharmacy Services and Procedures Manual, Receipt of STAT/Emergency Deliveries, dated 12/1/07, indicated the facility should immediately notify the pharmacy when facility received from a physician a medication order which may require a stat/emergency delivery. If a necessary medication was not contained within the facility's stat/emergency supply, and the facility determined that a stat/emergency delivery was necessary, the facility should arrange either an earlier scheduled delivery, delivery by contract courier, or for the medication to be dispensed and delivered by a third party pharmacy, to ensure timely receipt. A review of the facility's policy and procedure titled, Pain Assessment, dated 3/00, indicated the facility staff would target the site of pain, pain experience was very subjective, pain was whatever the resident says it is. The policy indicated a full assessment of pain includes: origin, location, severity, alleviating, exacerbating factors, current treatment, and response to treatment. The assessment included observing indicators of pain including moaning, crying, and other vocalizations, wincing or frowning, and other facial expressions, body posture such as guarding or protecting an area of the body or lying very still or decrease in usual activities. The policy indicated facility staff were to document the pain assessment results on the Resident Data Set. A review of the facility's policy and procedure titled, Pain Management Flow Sheet, indicated staff should record the follow-up observations (pain after interventions) one-hour post intervention. During an interview with Family Member 1, on 1/6/16, at 3 p.m., she stated Resident 1 was in severe pain and that was why the physician told her he would order something stronger, [MEDICATION NAME]. Family member 1 stated she, Family 2, and 3 kept asking when the [MEDICATION NAME] was coming and why Resident 1 had not received the [MEDICATION NAME]. Family member 1 stated staff continued to tell them that the medication had not arrived and they did not have any in house supply of [MEDICATION NAME] in the facility.

Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was admitted to the facility with no pressure sores and was identified as high risk for developing pressure sores, was provided necessary treatment and services for prevention and to promote healing of pressure sores by failing to: (1) Promptly assess the development of pressure sore to the sacral and coccyx area (tail bone). (2) Implement the care plan for Skin Breakdown. These deficient practices resulted in Resident 1 developing an Unstageable pressure sore (full tissue loss in which the base of the ulcer is covered by slough - yellow, tan, gray or brown, and/or black eschar, in the wound bed) and a Stage III pressure sore (full tissue loss wherein subcutaneous fat may be visible, but bone tendon or muscle are not exposed). Findings: A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility, on 6/29/15, at 6:30 p.m., with glio[DIAGNOSES REDACTED] multiforme (malignant tumor involving abnormal cell growth with the potential to invade or spread to other parts of the body that begins within the brain), diabetes mellitus (high blood sugar), [MEDICAL CONDITION] (uncontrolled electrical activity in the brain resulting in an uncontrolled shaking of the body) and [MEDICAL CONDITION] (lung disease that makes it hard to breathe). According to the initial Minimum Data Set (MDS - standardized assessment and care planning tool), dated 7/6/15, indicated Resident 1 was alert with periods of confusion, was able to make her needs known to staff, and staff understood her. The MDS indicated due to Resident 1's weakness and bowel and bladder incontinence (unable to restrain natural discharges or evacuations), she was dependent on staff for her activities of daily living including, bed mobility, transfers, and personal hygiene. The MDS indicated Resident 1 had no pressure sores and was identified as not being at risk for developing pressure sores. A review of the initial nursing admission assessment, dated 6/29/15, indicated Resident 1 had no pressure sores upon admission, but there was redness to the right and left groin area. Further review of the Braden Scale - For Predicting Pressure Sore Risk indicated a total score of 20, which indicated Resident 1 was a high risk for development of pressure sores (injury to the skin or tissue over a bony area). A review of the care plan for Skin Breakdown, dated 7/8/15, indicated Resident 1 had fragile skin, was at risk for developing pressure sores (in contrast to the MDS), and had skin breakdown due to incontinence of bowel and bladder. The care plan's interventions included informing the physician and responsible party for any abnormal changes, monitor skin care for skin tears, bruising, swelling, redness, irritation and breakdown. The interventions included weekly skin checks and documentation, which included assessing the pressure ulcers conducted by a licensed nurse, on a weekly basis or upon change of condition. A review of the Weekly Pressure Ulcer Record, dated 7/21/15, completed by Staff 5 remained incomplete. Staff 5 documented Resident 1 had scattered pressure sores, and a Stage II sore to the peri-anal areas which was acquired at the facility. There was no documentation as to the measurements or the number of sites identified. A review of the facility's Ulcer Risk Guidelines and Treatment Protocols, dated 12/2005, defines Stage II Pressure Sore as partial thickness loss of dermis presenting as a shallow, open ulcer with a red-pink wound bed, without slough. It may present as an intact of open-ruptured serum filled blister. This stage should not be used to describe skin tears or excoriations. According to the discharge orders, on 7/25/15 (approximately one month after admission), Resident 1 was transferred to the acute care hospital at 11:17 a.m., with treatment orders for peri-anal redness and peri-anal scattered pressure sore, Stage II. There was no documentation or description of the Stage II scattered pressure sore in the medical record. A review of the Resident Transfer Form, completed by a registered nurse, on 7/25/15, indicated Resident 1 had no pressure sores and had clear skin. A review of the acute care hospital's Pressure Ulcer Assessment, conducted by Registered Nurse 3, on 7/25/15, at 4:14 p.m., indicated Resident 1 presented with unstageable pressure sores to both sides of the sacrum, and multiple skin tears in peri-anal and groin areas. The Pressure Ulcer Assessment, conducted by Registered Nurse 4, on 7/25/15, at 7:10 p.m., indicated unstageable pressure sores to the sacrum, a Stage III pressure sore to the coccyx area, and skin tears to the peri-areas. A review of the Skin/Wound Document Photograph, dated 7/25/15, by Staff 4 (a licensed nurse) identified the sacrum pressure sore as unstageable. The Stage III coccyx pressure sore, measured 10 cm (length) by 5 cm (width), was reddish in color with sanguineous drainage. A review of the medical record with the director of nursing (DON), indicated the physician was not notified until 7/24/15, for a treatment order for the Stage II scattered pressure sores to the peri-anal areas. The DON could not locate any documentation describing the scattered pressure sores to the peri-anal areas. During interview, on 1/4/16, at 3 p.m., the director of nursing (DON) stated she could not verify if Resident 1's pressure sores remained the same, improved, or became worse. During an interview, on 1/4/15, at 1:20 p.m., the DON stated the facility failed to implement their Skin Care Management policy for Resident 1. The DON stated she was not informed by the facility staff Resident 1 developed pressure sores. The DON stated the care plan could not be implemented because the treatment nurses missed identifying and assessing the pressure sores to the sacral and coccyx areas. The facility policy and procedure titled, Pressure Ulcer Treatment Policy, dated 3/00, indicated the facility staff must notify the family or responsible party and must document notification. During an interview with Family Member 1, on 1/4/15, at 10 a.m., she stated the facility staff did not notify the family. She stated the family was aware that due to Resident 1's incontinence, she had redness to the peri-anal areas, but they were not aware of any skin breakdown such as pressure sores. During an interview with the DON, on 1/4/15, at 1:25 p.m., she stated the facility failed to notify the family of Resident 1 and there was no documentation to show evidence the family was notified of Resident 1's pressure sores which developed on 7/21/15. The facility's policy and procedure titled, Skin Care Management, dated 12/1/05, indicated a significant change of status in skin breaks required documentation in the licensed progress notes and on the Weekly Pressure Sore Record. The policy indicated documentation was to include size, stage, location, odor, and pain, initiation of care plan, and notification of the interdisciplinary wound team. The licensed nurse would document the status of all pressure sores to include the dressings, surrounding skin condition, presence of possible complications, and pain using the Daily Monitoring Pressure Ulcer Record. The policy indicated the licensed nurse would communicate all identified pressure sores to the resident's family or responsible party and would document family notifications in the patient's medical record and the care plan. Residents with newly identified or known pressure sores would be assessed by the Interdisciplinary Team Members. During an interview, on 1/4/15, at 1:40 p.m., the DON stated she was not informed by her treatment nurses that Resident 1 had developed pressure sores and therefore could not have the pressures sores assessed by the Interdisciplinary Team Members.

Based on observation, interview and record review, the facility failed to provide an effective pain management program for 4 out of 15 sample residents (6, 11, 4, 14), who were assessed as having pain or being at risk for pain. Resident 6 had [MEDICAL CONDITION], wound, back, and hip pain. Resident 11 had hip, neck, shoulder, and back pain, and [MEDICAL CONDITION] (meaning "porous bones" that become weak and brittle, that a fall or even mild stresses such as bending over or coughing can cause a fracture). Resident 4 had right hip and wrist fractures, and Resident 14 had left hip revision surgery after a fracture, and [MEDICAL CONDITION]. Nursing staff either failed to administer pain medications as ordered to control pain, failed to assess if the medications were effective when given, failed to address the resident's complaint of pain when expressed either verbally or non-verbally, and failed to rule out pain for residents who exhibited uncontrolled screaming behavior by conducting a complete pain assessment as required by the facility's policies and procedures, which led to uncontrolled pain management for these four residents. Findings: a. A review of the Resident Admission Record and History and Physical, revealed Resident 6 was a [AGE] year old male, readmitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE], indicated Resident 6 had unclear speech, was usually understood, and understands. The MDS assessment indicated the resident had moderately impaired cognitive skills (decisions poor, cues/supervision required), required extensive to total assistance from staff for activities of daily living, and was incontinent of bowels. The MDS assessment did not indicate the presence of pain at the time of the assessment, and the Care Area Assessment (CAA) was not triggered for care planning. Review of Resident 6's physician's orders [REDACTED]. The physician's orders [REDACTED]. A review of the Pain Evaluation form dated September 21, 2011, revealed Resident 6 was assessed at risk for pain, experienced pain in the past, and the current drug and non-drug interventions were repositioning and verbal support, with no pain reported during that assessment. The past pain interventions were Tylenol 650 mg every 6 hours as needed, and current non-pharmacological interventions listed were repositioning, verbal support, distraction, relaxation, and family support. The pain care plan for Resident 6, dated September 21, 2011, indicated alteration in comfort; at risk for pain due to urinary tract infection [MEDICAL CONDITION] and history of [MEDICAL CONDITION], status [REDACTED]. On October 29, 2011, abdominal pain was added to the care plan. The goal was the resident's pain will show positive improvement/reduced to a tolerable level after interventions. Some of the interventions included to assess level of pain using a pain scale, comfort, acknowledge resident's pain, discuss with resident the history of pain and measures used in the past, provide and assist with non-pharmacological measures for pain relief, such as position change, quiet conversation, restful environment and diversional activity. For the non-verbal resident some of the interventions were to observe for non-verbal communication that will indicate pain, such as restlessness, agitation, grimacing, tearfulness, and consult with the doctor if the measures fail to provide adequate pain relief, administer pain medication as ordered, and evaluate the effectiveness. A review of [MEDICAL CONDITION] care plan for Resident 6, dated September 21, 2011, indicated the potential for pain and depression due to a terminal condition with [DIAGNOSES REDACTED]. Interventions included to assess for pain and medicate as ordered, evaluate effectiveness of the pain medication, and provide comfort. Resident 6 also had a care plan dated October 13, 2011, to address pain from a pressure ulcer, with interventions to assess for pain and administer pain medication as ordered. On November 7, 2011 at approximately 10:20 a.m., Resident 6 was heard yelling loudly, "Please help me, oh Lord please!" Upon entering his room, Resident 6 was observed lying on the bed with furrowed brows, moaning, and his hands were up in the air. At the same time, the Certified Nursing Assistant (CNA 1) was applying the resident's incontinence pad and then proceeded to pull up his pants. At that time, CNA 1 said the resident had a lot of pain. While CNA 1 was pulling Resident 6's pants on she asked him if he was having pain, and the resident said, "Yeah, in different places," but CNA 1 continued pulling his pants up while he was screaming. Resident 6 was also heard saying, "No, no, help." At that time another CNA entered the room to assist CNA 1. Now both CNAs were pulling Resident 6's pants on while the resident continued to scream, "No, no, help me," and constantly moaning. The two CNAs did not stop giving care to Resident 6. At this time the Evaluator went outside of the room. On the same day at approximately 10:35 a.m., the Evaluator returned to the room. Resident 6 was observed in bed, with his shirt and incontinent pad on, but no pants on. CNA 1 was interviewed at this time regarding why the resident had his pants off. She said, she did not get the resident up, took his pants off, but left the diaper on because he "Poops." Resident 6 was asked where he hurts, and he said, "My side," pointing to his left side. CNA 1 told the resident she wants to turn him, and asked which side to turn him to, Resident 6 said, "Either way it hurts." In an interview with CNA 1, on November 7, 2011, at approximately 11:05 a.m., she was asked if she reported Resident 6's continued pain to the licensed nurse. CNA 1 said, "I'm sure she gave him medication this morning." On November 7, 2011, at approximately 11:15 a.m., in an interview with the Licensed Vocational Nurse (LVN 4) who was in charge of Resident 6 was asked what type of pain medication the resident received, she said she gave him his routine pain medication, and pointed to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"No." She was asked if she knew Resident 6 verbalized he was in pain when moved, to which she replied, "Yes, I was there." LVN 4 was asked if she attempted to stop the care when the resident was in pain, but she didn't reply. She was asked if she attempted any non-pharmacological interventions, and if that didn't work, did she administer any more pain medications, to which she replied, "No." A review of the Pain Management Flow sheet dated November 7, 2011, at 2 p.m., revealed the resident's pain was assessed to be at 6 (moderate pain), on a pain scale rating of 1 to 10, with 10 being the most severe pain. The flow sheet listed non-pharmacological interventions such as repositioning, emotional support, verbal support, relaxation, and the behavior scale/indicator of pain was moaning and groaning. According to the flow sheet, Tylenol #3 was administered at 2 p.m., with 0 out of 0 after given. Even though Resident 6 exhibited some of the same types of behavior during the morning observation, there were no other pain medications administered to increase his comfort other than the 2 p.m. Tylenol #3, according to the flow sheet. The behavior care plan for Resident 6, dated November 8, 2011, indicated the resident's behavior was screaming and yelling, with episodes of constantly yelling and praying at times. The goal was resident's negative behavior will be altered by interventions. Interventions included to identify situations that might have caused behavioral problem and assist resident in resolving identified issues, and to observe for pain or discomfort that might trigger negative behavior. An interview was conducted with LVN 2 on November 8, 2011 at 12:25 p.m., regarding the pain evaluation and/or assessment information. LVN 2 was asked how nursing staff assess residents for pain who have communication difficulties or may not be able to make their needs known, or may not be able to express their pain. LVN 2 said nursing staff are to assess for facial grimacing, restlessness, and whether the resident had a past history of pain. LVN 2 also said they should assess for pain every shift and document the information on the MAR. She said staff are to complete a pain assessment upon admission for surgery, arthritis or bone issues. The Pain Evaluation form dated November 9, 2011, revealed Resident 6 was re-assessed as currently having pain, was at risk for pain, experienced pain in the past, the location of the pain was back and hips, and the cause of pain was turning. Non-verbal and verbal indicators of pain included crying, moaning, groaning, grimaces, wrinkled forehead, and furrowed brow. Resident 6 was assessed as being cognitively impaired with hearing impairment. The pain rating was 8 out of 10 on a scale of 1 to 10, with 10 being the most severe pain. The past pain interventions were Tylenol #3 every four hours as needed for severe pain, and Tylenol 325 mg, 2 tablets three times a day for seven days. The current pain interventions including drug and non-drug, were repositioning, verbal support, distraction, relaxation, and family support. Review of the facility's Pain Assessment policy and procedures, dated March 2000, revealed the purpose of the assessment includes the frequency and intensity of signs and symptoms of pain and can be used to identify indicators of pain as well as to monitor resident's response to pain management interventions. The policy indicated the pain experience is very subjective; pain is whatever the resident says it is, observe the resident for indicators of pain such as moaning, crying, other verbalizations, wincing, frowning, other facial expressions, body posture such as guarding, protecting an area of the body, lying very still, or decreased activities. b. On November 7, 2011, at approximately 2:35 p.m., until 2:45 p.m., Resident 11 (non-English speaking) was heard screaming from her room, which could be heard from nursing station II. Upon entering the resident's room, she was observed lying in her bed, eyes closed, tears where coming down her left cheek, furrowed brows, and at the same time she was rubbing her left leg saying, "Ay, yay, ya, mama jan." During the same observation the following staff members, the maintenance supervisor, the medical records director, and a Restorative Nursing Assistant (RNA 1), were observed passing by Resident 11's room without checking her to see why she was screaming. At approximately 2:45 p.m., a Licensed Vocational Nurse (LVN 5) and RNA 1 came to Resident 11's room, after the Evaluator intervened and asked staff what Resident 11 was saying and why she was crying. LVN 5 was asked if the resident received any pain medications, to which she replied that the resident had no orders for any pain medications. On November 7, 2011, at approximately 3 p.m., a review of Resident 11's entire physician's orders [REDACTED]. After the interview with LVN 5, a review of the medical record revealed there was a physician's orders [REDACTED]. However, according to the MAR, no pain medication was administered for the entire day of November 7, 2011. During observation on November 8, 2011, at approximately 8:10 a.m., Resident 11 was observed lying in bed, rubbing her left leg, crying and saying, "Ay, ya, ya." During another observation at approximately 9 a.m., Resident 11 was moaning, and a family member who assisted with translation said the resident was saying she had pain in her left side and left leg. A Certified Nursing Assistant (CNA 2) assigned to Resident 11 was also present, and was asked what the resident was saying, but CNA 2 said she did not know. CNA 2 was asked if she knew someone who could translate what the resident was saying, but she said, "No." CNA 2 was asked what the behavior of the resident saying ay, ya, ya, and rubbing her left leg, could mean, to which CNA 2 said she didn't know. And when asked if she had reported this behavior to a licensed nurse, she said, "No." On November 8, 2011, at approximately 9:15 a.m., in an interview with LVN 5, she said she administered [MEDICATION NAME] 50 mg at approximately 9:15 a.m., however, the resident was observed still crying. LVN 5 was asked, why the resident was still crying, LVN 5 said the resident's daughter had said the resident wants to go home. When asked why she administered the pain medication, LVN 5 did not say anything. On November 8, 2011, at approximately 9:30 a.m., in an interview with the activity assistant who spoke the resident's language and who assisted in translating said the resident told him she was in pain. Resident 11 was observed rubbing her left leg and pointed to her left side. On November 8, 2011, at approximately 10:30 a.m., a review of Resident 11's MAR indicated [REDACTED]. The alternative treatments documented at that time were repositioning, emotional support, and relaxation. The behavior indicators of pain were whining, grimaces and wrinkled forehead. After administration of the [MEDICATION NAME] pain medication, the resident's pain was re-assessed to be 2 out of 10 (mild pain). A review of Resident 11's admission record revealed an [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Pain Evaluation form dated October 4, 2011, indicated Resident 11 was at risk for pain, experienced pain in the past, no pain was reported, demonstrated communication difficulty (talking), had a pain rating of 0 out of 10, and there was no past pain interventions. The current pain interventions were repositioning, distraction, massage and family support. The Admission Minimum Data Set (MDS) assessment dated [DATE], indicated Resident 11 was sometimes understood, sometimes understands, had short-term memory problems, was moderately impaired in cognitive skills for daily decision making, was totally dependent on staff for activities of daily living, had functional limitation to her upper extremities, and was always incontinent of both bowel and bladder. The care area assessment (CAA) dated October 13, 2011, indicated the resident had verbalized pain and was noted to have pain during rehabilitation treatment evaluation. The CAA assessed the resident as having impaired physical mobility with multiple medical conditions, [DIAGNOSES REDACTED]. The resident was assessed at risk for pain and discomfort and at risk for decline in function. The pain care plan dated October 13, 2011, revealed alteration in comfort, at risk for pain due to [MEDICAL CONDITION], wound. history of cervical spondylosis (disorder in which there is abnormal wear on the cartilage and bones of the neck and is a common cause of chronic neck pain), lumbar spondylosis (chronic pain in the lower part of the vertebral column due to the misplacement of the vertebrae) and rotator cuff syndrome. One of the goals was the resident's pain will show positive improvement/reduced to a tolerable level after interventions. Some of the interventions were to assess the level of pain using a pain scale, comfort, and acknowledge resident's pain, discuss with resident the history of pain and measures used in the past, provide or assist with non-pharmacological measures for pain relief, such; as position change, quiet conversation, restful environment, and diversional activity. The care plan further indicated for a non-verbal resident observe for non-verbal communication that will indicate pain, such as; restlessness, agitation, grimace, tearfulness, and consult with the physician if the measures fail to provide adequate pain relief, administer pain medication as ordered, and evaluate effectiveness. According to the MAR indicated [REDACTED]. After the observation and discussing this concern with the nursing staff, an order for [REDACTED]. An interview was conducted with LVN 2 on November 8, 2011 at 12:25 p.m., regarding the pain evaluation and/or assessment information. LVN 2 was asked how nursing staff assess residents for pain who have communication difficulties or may not be able to make their needs known, or may not be able to express their pain. LVN 2 said nursing staff are to assess for facial grimacing, restlessness, and whether the resident had a past history of pain. LVN 2 also said they should assess for pain every shift and document the information on the MAR. She said staff are to complete a pain assessment upon admission for surgery, arthritis or bone issues. Review of the facility's Pain Assessment policy and procedures, dated March 2000, revealed the purpose of the assessment includes the frequency and intensity of signs and symptoms of pain and can be used to identify indicator of pain as well as to monitor resident's response to pain management interventions. The policy indicated the pain experience is very subjective; pain is whatever the resident says it is; observe the resident for indicators of pain such as moaning, crying, other verbalizations, wincing, frowning, other facial expressions, body posture such as guarding, protecting an area of the body, lying very still, or decreased activities. The policy indicated in a resident who has dementia and cannot verbalize they are feeling pain, symptoms of pain can be manifested by particular behaviors such as calling out for help and/or pained facial expressions. c. According to the admission information, Resident 14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the initial Patient Data Collection sheet dated November 1, 2011, revealed the resident was alert but not oriented due to dementia and [MEDICAL CONDITION]. The Nurse's Notes for the initial assessment intake information dated November 1, 2011, indicated the resident did not want to be touched, cried out during care, and struck out at staff during care. However there was no documented assessment indicating the reasons for this behavior. It was documented that the resident was "unable to verbalize her needs", and that she had no complaints of pain or discomfort. On November 1, 2011, on admission, there were physician's orders [REDACTED]. The Pain Evaluation form dated November 2, 2011, indicated the resident was at risk for pain and experienced pain in the past. The form also indicated the resident was cognitively impaired, had communication difficulties, and unclear speech. This resident had a history of [REDACTED]. and procedures. On November 7, 2011, at 11 a.m., Resident 14, who was in her room, could be heard screaming from Nursing Station 2. The screaming went on for 30 minutes. At that time the Evaluator asked Licensed Vocational Nurse 1 (LVN 1), who was also at the station, if she was going to check on the resident. LVN 1 went into the resident's room, came back out and said the certified nursing assistants were giving the resident a bed bath. LVN 1 stated the resident does not like showers, and she always screams during her morning care bed baths. LVN 1 was asked if the resident had received any pain medications, to which she replied, no, because the resident never complained of pain. An interview was conducted with LVN 2 on November 8, 2011 at 12:25 p.m., regarding the pain evaluation and/or assessment information and the lack of a care plan for pain. LVN 2 was asked how nursing staff assess residents for pain who have communication difficulties or may not be able to make their needs known, or may not be able to express their pain. LVN 2 said nursing staff are to assess for facial grimacing, restlessness, and whether the resident had a past history of pain. LVN 2 also said they should assess for pain every shift and document the information on the MAR. She said staff are to complete a pain assessment upon admission for surgery, arthritis or bone issues. The initial Pain Management Flow Sheet for November 2011, reviewed at this time, was blank. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was also no documentation on the MAR indicated [REDACTED]. According to the facility's Pain Assessment policy and procedure, staff were to "observe" for indicators of pain including moaning, crying, and striking out at anyone who tries to move or touch a body part, and to observe for joint pain, hip pain, or bone pain. The policy also indicated the interventions for pain should be included in the resident's comprehensive care plan. d. According to the admission information Resident 4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a standardized comprehensive assessment of the resident's problems and conditions) dated August 30, 2011, that was initiated upon admission, indicated the resident had unclear speech and was sometimes understood and sometimes understands. The MDS indicated the resident was "unable to answer the question regarding pain", and was totally dependent on staff for all activities of daily living. The Pain Evaluation form dated August 20, 2011, indicated the resident did not verbalize pain. The area to assess whether the resident was "at risk for pain" was left blank. The "Indicators of Pain or Possible Pain" sections for staff to assess were, non-verbal sounds such as crying, whining, gasping, moaning or groaning; facial expressions such as grimaces, winces, wrinkled forehead, furrowed brow, and clenched teeth or jaw; and protective body movements or postures such as bracing, guarding, rubbing or massaging a body part, or clutching or holding a body part during movement. These sections were listed as "N/A" (not applicable). The section that addresses whether the "resident demonstrates signs of" cognitive impairment or communication difficulties, was listed as N/A. The Pain Rating and Past Pain Interventions were also listed as N/A. A review of the physician's orders [REDACTED]. A review of the Nursing Weekly Summary forms completed by licensed staff, from September 1, 2011 to November 3, 2011, revealed the "Pain" assessment area regarding whether there were any non-verbal/behavioral pain indicators present if a resident was unable to answer, indicated by checking either "yes" or "no", were left blank. The non-verbal indicators listed on the form were crying, moaning, grimacing, and guarding. The behavioral indicators listed were resistance to care, yelling, restlessness, and hitting. Interdisciplinary Progress Notes for August 2011 to November 8, 2011, indicated the resident was crying out, screaming, or agitated and screaming. There was no documentation to indicate pain had been ruled out as a reason for the resident's behavior. The care plan for behavior dated August 23, 2011, indicated the resident was crying, screaming and yelling. The intervention related to pain was to observe for pain or discomfort that might trigger negative behavior. There was no specific care plan for pain. On November 7, 2011, at 4:40 p.m., an attempt was made to interview the resident regarding any pain she may be having. She did not answer the questions, but stared straight at the Evaluator. In an interview conducted with LVN 2 on November 8, 2011 at 12:25 p.m., regarding pain management, she was asked how nursing staff assess residents for pain who have communication difficulties or may not be able to make their needs known, or may not be able to express their pain. She said nursing staff are to assess for facial grimacing, restlessness, and whether the resident had a past history of pain. She stated staff should assess for pain every shift and document the information on the MAR, and staff are to complete a pain assessment upon admission for pain that could be caused by surgery, wounds, and arthritis or other bone issues. A review of the Nursing Weekly Summary forms for the months of September, October, and November 2011, revealed the assessment section that assessed a resident who was unable to answer questions regarding pain (are there non-verbal/behavioral pain indicators present) was left blank. After the interview with LVN 2, a care plan for pain was developed and dated November 8, 2011, that included interventions for non-verbal communication that could indicate pain, such as restlessness, agitation, grimace, and tearfulness. The use and evaluation of the effectiveness of pain medications (Tylenol 650 milligrams (mg) every 4 hours as needed for mild pain, [MEDICATION NAME] 5/500 mg every 4 hours as needed for mild to severe pain, and [MEDICATION NAME] 50 mg every 6 hours as needed for moderate to severe pain) were also added as interventions. According to the facility's Pain Assessment policy and procedure, staff were to "observe" for indicators of pain including moaning, crying, and striking out at anyone who tries to move or touch a body part, and to observed for joint pain, hip pain, or bone pain. The policy also indicated the interventions for pain should be included in the resident's comprehensive care plan.