Every finding on record at Live Oak Rehab Center

Based on observation, interview, and record review, the facility failed to ensure provision of dental services for one of two sampled residents (Resident 1) by failing to schedule Resident 1's dental consultation and treatment in accordance with the facility's policy and procedure titled, Dental Services. This failure had the potential to adversely affect Resident 1's oral health and functional ability to chew food.Findings: During review of Resident 1's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 1 on 8/4/2025 and readmitted the resident on 4/9/2026 with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), and unspecified visual loss. During a review of Resident 1's History and Physical (H&P), dated 4/10/2026, the H&P indicated Resident 1 had seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 5/7/2026, the MDS indicated Resident 1 had intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 1 needed partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for oral hygiene, upper body dressing, and personal hygiene. During a review of Resident 1's Dental Progress Note, dated 12/5/2025, the Dental Progress Note indicated Resident 1 had an initial exam and preventive treatment was recommended. During a review of Resident 1's Care Plan Report, dated 5/7/2026, the Care Plan Report indicated that Resident 1 had some natural teeth missing. The staff interventions included were to assess dental condition and refer to dentist as indicated and observe for signs and symptoms of dental disorder and to notify the dentist. During an interview on 8/8/2026 at 11:22 AM with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated that Resident 1 had missing teeth and would take additional time to chew his food. During an interview on 8/11/2026 at 2:42 PM with the Social Services Director (SSD), SSD stated that Resident 1 was last provided with dental services on 12/5/2025 and was not given the dental services this year (2026) which should be given routinely every six months, annually or as needed. The SSD stated regular dental services should be provided to all residents (in general) to improve their quality of life and health. During an interview on 8/11/2026 at 3:45 PM with the Director of Nursing (DON), the DON stated that Social Services should have arranged the dental services for Resident 1 since dental services are very important to the residents. The DON further stated that dental services are critical part of oral care and are important in maintaining resident's dignity. The DON stated that when dental needs are not met, residents may experience discomfort which could result in residents losing weight and appetite. During a review of the facility's policy and procedure (P&P) titled, Dental Services, dated 3/2023, the P&P indicated that routine and emergency dental services are available to meet the residents' oral health services in accordance with the resident's assessment and plan of care.

Based on observation, interview, and record review, the facility failed to prevent a fall for one (1) of two sampled residents (Resident 1) who was assessed to be dependent (helper does all of the effort, resident does none of the effort to complete the activity) with wheeling 50 feet with two turn and needed partial/moderate assistance (helper does less than half the effort; helper lifts, holds or supports trunk or limbs but provides less than half the effort) during transfer from chair to bed by:Failing to accurately assess and document a Fall Risk Evaluation form (a clinical assessment tool used by nursing staff to calculate a resident's likelihood of falling) and develop a resident-centered care plan (a care plan developed and implemented to meet his or her preferences and goals, and addressed the resident's medical, physical, mental, and psychosocial needs) after Resident 1's assisted fall (an event where a resident begins to lose their balance or fall, and a caregiver or nurse is present and physically steps in to slow the resident's descent to the ground or another surface) on 6/4/2026, in accordance with the facility's policy and procedure (P&P).Failing to provide partial/moderate assistance when Resident 1 wheeled himself from the hallway into the resident's room and the facility staff did not provide contact guard assistance (CGA- when the therapist maintains constant, light physical contact for safety and balance) during Resident 1's transfer from wheelchair to the resident's bed on 6/9/2026. This deficient practice placed Resident 1 at risk for another fall.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included repeated falls, hypertensive heart disease with heart failure (when long-term, unmanaged high blood pressure causes the heart muscle to thicken and weak making it difficult for the heart to pump of relax properly), and depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/4/2026, the MDS indicated Resident 1 was assessed having severely (never/rarely made decisions) impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating, rolling left and right, sit to lying, and lying to sitting on side of bed. The MDS indicated Resident 1 required partial/moderate assistance with toileting hygiene, upper/lower body dressing, sit to stand, chair/bed-to-chair transfer, toilet transfer, walking 10 feet (ft.- unit of measurement for distance), and walking 50 ft. with two turns. The MDS further indicated Resident 1 used a manual wheelchair and was dependent on wheeling 50 feet with two turns. During a review of Resident 1's Physical Therapy (PT) Treatment Encounter Note, dated 6/8/2026, the PT Treatment Encounter Note indicated Resident 1 required CGA with sit to stand, bed transfer, and wheelchair transfer. During a review of Resident 1's Order Summary Report, dated 6/18/2026, the Order Summary Report indicated Resident 1 was taking the following medications:Amlodipine besylate (medication for high blood pressure or hypertension oral tablet 5 milligrams (mg- unit of measurement for weight) give 1 tablet by mouth two times a day, with a start date of 4/29/2026.Escitalopram oxalate (medication used to treat major depressive disorders) 5 mg give 1 tablet by mouth one time a day, with a start date of 4/29/2026.Hydralazine HCl (medication used to treat moderate to severe high blood pressure) 100 mg give 1 tablet by mouth two times a day, with a start date of 4/29/2026. During a review of Resident 1's Progress Note, dated 6/4/2026, at 2:45 AM, the progress notes indicated under the Post Fall Evaluation note, Resident 1 had a witnessed fall (an event where someone-such as a staff member, bystander, or family member-directly sees a person lose their balance and come to rest inadvertently on the floor, ground, or other lower surface) on 6/4/2026 at 2:45 AM in Resident 1's room while Resident 1 was adjusting his body to be more comfortable. During a review of Resident 1's Interdisciplinary Team (IDT- a group of healthcare professionals from different disciplines who collaborate to provide comprehensive and coordinated care for a resident) Narrative Form, dated 6/5/2026, at 3:33 PM, the IDT Narrative Form indicated on 6/4/2026 at around 2:45 PM, Resident 1's bed alarm (a safety and monitoring device designed to alert caregivers when a person attempts to leave their bed unassisted) activated, staff responded immediately and noted Resident 1 was attempting to get out of bed without assistance and was safely guided to a seated position on the floor by nursing staff. The IDT narrative form did not indicate interventions such as supervising Resident 1 while in the wheelchair and to address the resident's safety awareness to prevent another fall. During a review of Resident 1's Fall Risk Evaluation form, dated 6/4/2026, the Fall Risk Evaluation form indicated Resident 1 has not had any falls in the past three months and did not take antihypertensive (a class of medication or treatment regimen used to treat hypertension) and psychotropic medications (a prescription drug that alters chemical levels in the brain to affect a person's mind, emotions, perceptions, or behavior). The Fall Risk Evaluation form indicated Resident 8 is at low risk for fall. During a review of Resident 1's Care Plan, dated 8/21/2025, the Care Plan indicated Resident 1 was at risk for falls/injury related to generalized weakness, impaired cognition, poor safety awareness, judgment, poor coordination, use of medications such as antihypertensive, psychotropic, anticonvulsant, and history of repeated falls. The Care Plan indicated an intervention to provide the resident with a safe and clutter-free environment. The Care Plan did not indicate it was revised to address Resident 1's fall on 6/4/2026. During a review of Resident 1's Care Plan, dated 6/4/2026 to 6/9/2026, there was no Care Plan initiated to address Resident 1's actual fall on 6/4/2026. During a review of Resident 1's Progress Note, dated 6/9/2026, at 10:08 PM, the Progress Note indicated Resident 1 had an unwitnessed fall on 6/9/2026, at 3:45 PM in Resident 1's room while attempting to self-transfer into bed. During a review of Resident 1's IDT Narrative Form, dated 6/10/2026, at 1:40 PM, the IDT Narrative Form indicated on 6/9/2026, at approximately 9 PM, Resident 1 remained seated in his wheelchair at the nursing station after the resident's family left and shortly after, the resident wheeled himself to his room and while attempting to transfer from wheelchair to bed, the resident fell on top of the floor mat. The IDT Narrative Form indicated Resident 1 had episodes of forgetfulness.During an interview on 6/18/2026, at 12 PM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 had a tendency to stand up on his own and transfer from his bed to his wheelchair and vice versa. LVN 1 stated Resident 1 had a bed alarm which sounded when Resident 1 sat on the edge of the resident's bed but there was no chair alarm (a safety and monitoring device designed to alert caregivers when a person attempts to get up from their chair or wheelchair unassisted). LVN 1 stated she did not know if Resident 1 had a history of fall prior to the resident's fall on 6/9/2026. LVN 1 stated Resident 1 needed partial/ moderate assistance from staff during transfers and Resident 1 was at risk of falling if the resident stood up on his own or transferred without assistance from staff. LVN 1 stated Resident 1 needed to be watched while the resident is in his wheelchair due to the resident's tendency to stand up from his wheelchair. During an interview on 6/18/2026, at 12:17 PM, with LVN 2, LVN 2 stated Resident 1 was initially able to do everything on his own when he was initially admitted to the facility and recently needed more assistance after he returned from staying at a general acute care hospital on 4/26/2026. LVN 2 also stated Resident 1 was no longer able to stand up on his own after the resident returned to the facility on 4/26/2026. LVN 2 stated Resident 1 was at risk for falls because the resident believed he (Resident 1) was still able to do things by himself. LVN 2 stated Resident 1 had a witnessed fall on 6/4/2026 at around 2:30 AM when Resident 1 tried to get out of his bed. LVN 2 stated she (LVN 2) did not create a care plan for the actual fall or updated Resident 1's care plan for risk for falls after Resident 1 fell on 6/4/2026 to add interventions such as supervising the resident while the resident is in the wheelchair and addressing the resident's safety awareness. During an interview on 6/18/2026, at 12:51 PM, with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated he did not know the exact details of Resident 1's previous fall before 6/9/2026 or the reason why Resident 1 was a fall risk. CNA 1 stated he just assumed Resident 1 was a fall risk because the resident had a bed alarm (a monitoring device designed to alert caregivers immediately when a resident attempts to get out of bed). CNA 1 stated, on 6/9/2026, at approximately 9 PM, Resident 1 sat on the resident's wheelchair outside the resident's room. CNA 1 stated Resident 1 refused to get wheeled back to his room and wanted to stay in the hallway. CNA 1 stated he started charting in front of room [ROOM NUMBER] which was across the hall from Resident 1's room. CNA 1 stated he did not have a visual of Resident 1 while he was charting by room [ROOM NUMBER]. CNA 1 stated he heard a loud sound from Resident 1's room while charting and CNA 1 went inside Resident 1's room and found Resident 1 on his elbow on the floor next to the resident's wheelchair. CNA 1 stated he did not notice Resident 1 wheel himself from the hallway to the resident's room. CNA 1 stated Resident 1 needed staff's partial to moderate assistance when transferring from the resident's wheelchair to the bed and resident was usually able to wheel himself while (MDS indicated Resident 1 is dependent when wheeling himself). During an interview on 6/18/2026, at 1:26 PM, with the Director of Rehab (DOR), the DOR stated Resident 1 tries to do things on his own because he was forgetful and did not know his debility and realize how weak the resident has gotten. DOR stated Resident 1 only asked for help when standing up from wheelchair to walk. DOR stated Resident 1 fatigued easily and needed contact guard or 1 person stand by assist during transfers. DOR stated Resident 1 fell on 6/4/2026 and again on 6/9/2026 and the resident should have gotten more supervision after the resident fell on 6/4/2026 because the resident sometimes gets confused and lacked insight regarding his (Resident 1) physical condition and abilities. During a concurrent interview and record review on 6/18/2026, at 2:09 PM, with Registered Nurse 1 (RN 1), Resident 1's Care Plans were reviewed. RN 1 stated Resident 1 fell in his room during night shift on 6/4/2026. RN 1 stated Resident 1 was at risk for falls because he always tried to get out of the bed by himself and overestimated his strength when it comes to transferring from bed to chair. RN 1 stated Resident 1's Care Plan for fall should have been revised and updated with new interventions on fall prevention and resident safety after his fall on 6/4/2026. RN 1 stated, if Resident 1's care plan was revised or a new care plan was initiated to address Resident 1's fall on 6/4/2026 to add interventions such as supervision while the resident is in his wheelchair and to address the resident's safety awareness could have been implemented to prevent another fall incident such as the fall that happened on 6/9/2026. During the same concurrent interview and record review on 6/18/2026, at 2:09 PM, with RN 1, Resident 1's Fall Risk Evaluation form dated 6/4/2026 was reviewed. RN 1 stated Resident 1's Fall Risk Evaluation form was not accurate. RN 1 stated the Fall Risk Evaluation form indicated Resident 1 has not had a fall in the past three months even if Resident 1 fell on 6/4/2026. RN 1 stated the Fall Risk Evaluation form also indicated Resident 1 was not taking any antihypertensive and psychotropic medications. RN 1 stated it was important for the licensed nurse to assess Resident 1's fall risk accurately so the correct interventions for fall prevention and safety are added to the care plan. During an interview on 6/18/2026, at 2:52 PM, with LVN 3, LVN 3 stated Resident 1 had a history of trying to get up from the bed without assistance. LVN 3 stated, on 6/9/2026, Resident 1 sat on his wheelchair in the hallway with his family from 7:30 PM to 9 PM. LVN 3 stated, at approximately 9 PM, Resident 1's family left the facility and Resident 1 stayed in the hallway. LVN 3 stated CNA 1 proceeded to chart across the hallway which was about five feet away from Resident 1. LVN 3 stated he was charting in the Nurse's Station when he heard Resident 1 fall in the resident's room while transferring himself from his wheelchair to his bed. LVN 3 stated he did not see Resident 1 wheel himself back to the resident's room. LVN 3 stated he found Resident 1 in the resident's room, laying on his left hip on the floor mat. LVN 3 stated Resident 1 complained of hip pain. LVN 3 stated it was the responsibility of the licensed nurses to review and revise the residents' care plan after Resident 1's fall on 6/4/2026 to see which fall interventions were effective or ineffective. LVN 3 stated it was important that the care plan was resident-centered and included the residents' strengths and weaknesses so the correct and proper interventions for safety and fall prevention are followed and to prevent future falls. During an interview on 6/18/2026, at 4:24 PM with the Director of Nursing (DON), the DON stated Resident 1 needed partial to moderate assistance for transfers. The DON stated Resident 1 felt like he (Resident 1) was still strong even if there has been a decline in his functional ability. The DON stated Resident 1 has had three falls in the facility since his original admission on [DATE]. The DON stated Resident 1 had a witnessed fall on 6/4/2026 and an unwitnessed fall on 6/9/2026. The DON stated Resident 1's fall on 6/4/2026 was discussed during the IDT meeting on 6/5/2026 but the interventions discussed to prevent further falls were not resident specific care plans and were not added to Resident 1's care plan (risk for fall and no actual fall care plan) after 6/4/2026. The DON stated it was the responsibility of the licensed nurse on duty to revise the care plan after the fall to ensure the proper interventions such as providing supervision to Resident 1 while in the wheelchair and to address the resident's safety awareness of trying to get up on his (Resident 1) own for fall prevention and safety are communicated to the staff. The DON stated Resident 1's fall risk was not accurately assessed and documented on the Fall Risk Evaluation form dated 6/4/2026 and resulted in a score of 8 which placed Resident 1 low risk for fall. The DON stated an inaccurate Fall Risk Evaluation can lead to future falls because the wrong fall prevention interventions will be followed and implemented. During a review of the facility's policy and procedure (P&P), titled, Safety and Supervision of Residents, revised on 7/2017, the P&P indicated:The facility strives to make sure the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.The facility's individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents.The interdisciplinary care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.Implementing interventions to reduce accident risks and hazards shall include communicating specific interventions to all relevant staff, ensuring that interventions are implemented and documenting interventions. During a review of the facility's P&P, titled, Charting and Documentation, revised on 7/2017, the P&P indicated:All services provided to the resident, progress toward the care plan goals, or any changed in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.The following information is to be documented in the resident medical record: objective observations, changes in the resident's condition, and progress toward or changes in the care plan goals and objectives.Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. During a review of the facility's P&P, titled, Falls and Fall Risk, Managing, revised on 3/2018, the P&P indicated:Based on previous evaluations and current date, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. During a review of the facility's P&P, titled, Care Plans, Comprehensive Person- Centered, revised 3/2023, the P&P indicated:A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition.

Based on interview and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 1) Responsible Party (RP) was notified of a change in treatment plan.This deficient practice has the potential to affect Resident 1's right to be informed about his care.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted on [DATE] with the following but not limited to diagnoses of depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities), gout (common, painful form of inflammatory arthritis) and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/3/2026, the MDS indicated the resident was independent in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathe self, and personal hygiene but required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with oral hygiene, upper body dressing, lower body dressing, and putting on/ taking off footwear. During a review of Resident 1's Order Summary, dated 5/7/2026, the Order Summary indicated resident will be going for dental extraction on 5/8/2026 at 10:30 AM. During an interview on 5/19/2025 at 8:39 AM, Registered Nurse Supervisor 1 (RNS 1) stated Resident 1 got transferred to the resident's dental appointment for dental extraction on 5/8/2026. RN 1 also stated he did not inform the RP of Resident 1's dental treatment cancellation when resident arrived at the dental appointment on 5/8/2026. RN 1 further stated he (RN 1) should have called RP to inform of the cancelled dental extraction. During an interview on 5/19/2026 at 1 PM, RN 2 stated he got report from RN 1 regarding the cancellation of Resident 1's dental treatment plan on 5/8/2026. RN 2 also stated he did not call RP regarding Resident 1's change in treatment, but RP should have been notified because it is the right of the resident/resident's representative to be informed of any changes with the resident's treatment plan. During an interview on 5/19/2026 at 3:30 PM, the facility's Policy and Procedure (P&P) titled, Resident Rights, revised 2/2021, was reviewed. the P&P indicated the resident has the right to be notified of his or her medical condition and of any changes in his or her condition. The P&P also indicated the resident has the right to be informed of, and participate in, his or her care planning and treatment. The Director of Nursing (DON) stated the resident/ resident representative has the right to know about the change in treatment plan.

Based on observation, interview and record review, the facility failed to provide safety measures and supervision by not assisting, and monitoring to ensure a safe environment for Resident 1. This deficient practice not only lead to Resident 1 had skin discoloration on the left thigh but also had the potential to cause further physical harm and injuries. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. Resident 1's diagnoses including but not limited to generalized muscle weakness (a comprehensive loss of strength throughout the body, making it difficult to perform daily tasks, move muscles effectively, or maintain normal endurance), abnormal posture, unspecified anemia (low levels of healthy red blood cells to carry oxygen throughout your body. Symptoms include fatigue, weakness and feeling short of breath), unspecified dementia with other behavioral disturbance (cognitive decline that is causing notable behavioral issues, such as sleep disruption, sexual disinhibition, or social inappropriateness). During a review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 3/6/2026, the MDS indicated Resident 1 had moderately impairment (poor judgements, decision making, cues/supervision required) with cognitive (relates to the conscious and unconscious mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with all daily activities and was not attempted to walk due to medial condition or safety concerns. During a review of Resident 1's Change of Condition (COC) Interact Assessment Form Situation, Background, Assessment, and Recommendation communication form (SBAR, a structured framework used in healthcare to ensure concise and effective communication during critical situations, patient handoffs, or provider calls) dated 5/3/2026 at 4 AM, the SBAR communication form indicated Resident 1 had noted with discoloration to left thigh, no indication of discoloration size. During an interview on 5/5/2026 at 4:13 PM with Certified Nursing Aid 2 (CNA 2), CNA 2 stated she found Resident 1's left thigh had bruise (a discolored mark on the skin caused by blood leaking from broken, tiny blood vessels beneath the skin's surface). when she tried to change Resident 1 on 5/3/2026 near 4 AM. CNA 2 stated she was Resident 1's one-to-one sitter (1:1 sitter- a CNA or technician, assigned to provide continuous, dedicated, and uninterrupted observation of a single patient) for two consecutive nights on 5/2/2026 and 5/3/2026, but she did not know how Resident 1 acquired her left thigh bruise CNA 2 stated she then reported to her charge nurse. CNA 2 stated Resident 1 always flailing her hands and kicking her legs in and out of her bed multiple times during her monitoring. During an interview on 5/6/2026 at 7:35 AM with Licensed Vocational Nurse 1(LVN 1), LVN 1 stated CNA 2 reported the bruise on Resident 1's left thigh to her. She did the assessment on Resident 1and reported to the Director of Nursing (DON). LVN 1 stated Resident 1 could not recall how and where she had acquired her bruise. LVN 1 stated she could not find out how Resident 1 acquired her bruise either. During an interview on 5/6/2026 at 11:33 AM with DON, DON stated she could not find out how Resident 1 got her skin discoloration on her left front thigh area. During an interview on 5/6/2026 at 1:05 PM with the Administrator (ADM), ADM stated he could not find out how Resident 1 got her skin discoloration on her left thigh. During review of five days follow up report dated 5/7/2026 indicated, on 5/3/26 resident verbalized pain on left inner thigh, resident presents with anxiety related behaviors including flailing and kicking during episodes of agitation, which may place her at an increased risk for accidental injury. During a review of the Care Plan (a written document detailing a person's health conditions, care needs, and treatment goals, serving as a guide for caregivers to provide consistent, high-quality support) dated 5/3/2026, the Care Plan did not have indication and intervention for Resident 1's hands were flailing and her legs kicking. During a review of the facility's Policy and Procedure (P&P) titled, Injuries of Unknown Origin, undated, was reviewed. The P&P indicated, injuries of an unknown origin will be investigated, investigation will include record review and observations, conclusion will be based on #2 and will determine the origin/cause, if an origin/cause cannot be determined, the injury will be consideredabuse and will be investigated according to the abuse investigation polic and measures to prevent recurrences will be developed During a review of the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised in September 2022, indicated, Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents.

Based on observation, interview and record review , the facility failed to accommodate the needs of one (1) of two (2) sampled residents (Resident 2) by failing to ensure the call light (patient-safety device, often a button on a cord, used in hospitals and nursing homes to enable patients to alert staff for assistance, thereby preventing falls and ensuring care) was within reach (arm's length of the resident or less than) of Resident 2 on 5/1/2026.This deficient practice had the potential to delay in the necessary care and services and/or needs not being met for Resident 2.Findings:During a review of Resident 2's Face Sheet (admission Record), the Face Sheet indicated the resident was admitted to the facility on [DATE] with the diagnoses of history of falling, vascular parkinsonism (a form of secondary parkinsonism caused by small strokes or blood vessel damage in the brain), cataract (a common, age-related clouding of the eye's natural lens that obstructs light, causing blurry vision and faded colors), and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's Care Plan with focus at risk for falls, revised 3/9/2026, the Care Plan indicated to keep call light within easy reach and encourage resident to use it to get assistance. During a review of Resident 2's Care Plan with focus Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily)/ self-care deficient, revised 4/13/2026, the Care Plan indicated the following but not limited to:Place call light within easy reach.Assist with turning and repositioning when needed. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 4/14/2026, the MDS indicated the resident was independent in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene, shower/bathe self, lower body dressing and putting on/ taking off footwear but required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with oral hygiene and personal hygiene. During a concurrent observation and interview on 5/1/2026 at 12:14 PM in Resident 2's room, Resident 2 was observed sitting in her wheelchair positioned near the lower right side of the resident's bed and slightly slouching. The call light was observed on the left upper corner of the bed. Resident 2 stated she was uncomfortable and needed to be repositioned. Resident 2 also stated she could not reach the call light to alert the staff of her need for assistance. During a concurrent observation and interview on 5/1/2026 at 12:26 PM in Resident 2's room, Certified Nursing Assistant 1 (CNA 1) stated Resident 2's call light is not within Resident 2's reach but should be within reach of the resident. CNA 1 also stated the call light should be within reach so Resident 2 would be able to call for assistance when needed. During an interview on 5/1/2026 at 2:46 PM, the Director of Nursing (DON) stated the call light should always be within the reach of the resident so residents can use it in case the resident needs assistance and that facility staff can provide care or assistance to the resident without any delay. During an interview on 5/4/2026 at 2:30 PM, the Policy and Procedure (P&P) titled Resident Call System, dated 9/2022, was reviewed. The DON stated the policy means the call light should be within reach of the resident, when the resident is in the bed, up on the wheelchair in the room, or from the toilet and from the floor. During a review of the facility's P&P titled Resident Call System, dated 9/2022, the P&P indicated each resident is provided with a means to call staff directly for assistance form his/her bed, when up on wheelchair while inside their room, form toileting/bathing facilities and from the floor.

Based on observation, interview and record review, the facility failed to ensure that one (1) of two (2) sampled residents (Resident 3) were provided with assistance while eating.This deficient practice had the potential for Resident 3 to experience weight loss and nutrient deficiencies.Findings:During a review of Resident 3's Face Sheet (admission Record), the Face Sheet indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses of dementia (a progressive state of decline in mental abilities), protein-calorie malnutrition (a severe nutritional deficiency resulting from inadequate intake of protein and calories), body mass index (a screening tool calculating body fat based on height and weight) less than normal range, underweight (having a body weight below the range considered healthy for a specific height and age) and adult failure to thrive (unexplained weight loss, decreased appetite, malnutrition, and inactivity). During a review of Resident 3's Care Plan with focus alteration in nutritional status, revised 9/4/2025, the Care Plan indicated the following but not limited to:Set up meal tray, assist and give verbal cues if needed. Allow enough time to eat.Up in chair to dining room at mealtime.Offer substitute for any meals refused or poor intakes.Encourage adequate intakes as tolerated. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 3/3/2026, the MDS indicated the resident was moderately impaired (decisions poor; cues/supervision required) in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated, the resident is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene but required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs but provides less than half the effort) with eating. During an observation on 5/1/2026 at 12:30 PM in the hallway, Resident 3 was observed with the resident's lunch tray. Resident 3 was also observed not eating her meal and had no facility staff around and no staff assisting the resident with her (Resident 3) meal. During an observation on 5/1/2026 at 12:49 PM in the hallway, Resident 3 was observed to have no staff around and no staff assisting the resident with her meal. During an observation on 5/1/2026 at 1:06 PM, Licensed Vocational Nurse 1 (LVN 1) was observed telling Resident 3 to eat and continued to care for another resident. During an observation on 5/1/2026 at 1:16 PM in the hallway, Certified Nursing Assistant 4 (CNA 4) was observed taking Resident 3's lunch tray away with only one spoonful consumed. During an interview on 5/1/2026 at 1:20 PM, LVN 1 stated according to Resident 3's MDS, the resident required assistance with eating. LVN 1 also stated Resident 3 did not have assistance while eating on 5/1/2026 during lunchtime but should have assistance while the reisdent is eating. During an interview on 5/1/2026 at 2:46 PM, the Director of Nursing (DON) stated Resident 3 needs someone to supervise, assist the resident during mealtime by guiding the resident's hand to place the spoon in the resident's mouth, and cue the resident while eating. The DON also stated the resident can lose weight if the need to be assisted with meal was not followed. During a review of the facility's Policy and Procedure (P&P) titled Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily), revised 3/2018, the P&P indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate assistance with dining (meals and snacks).

Based on observation, interview, and record review, the facility failed to provide oxygen therapy (treatment that provides supplemental, or extra oxygen) as indicated on the physician's order for two (2) of two sampled residents (Resident 12 and 72) reviewed for respiratory and oxygen in accordance with the facility's policy and procedures (P&P) by failing to:Ensure Resident 12 received oxygen as ordered by the physician and the resident's oxygen tubing (a tubing that connects to the oxygen source used to deliver oxygen) was connected to the oxygen concentrator (a medical device that gives extra oxygen by taking and filtering air from the surroundings) was not lying on the floor. Ensure Resident 72 oxygen nasal cannula (a lightweight, flexible tube used to deliver supplemental oxygen to people with breathing difficulties) and nebulizer mask (a medical device that fits over the nose and mouth to deliver liquid medication directly into the lungs as a fine mist) were not lying on the floor These deficient practices had the potential to place Resident 12 and 72 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which could lead to irreversible damages of health and/or death.Findings: 1. During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 12's diagnoses included acute respiratory failure (occurs when you do not have enough oxygen in your blood) with hypoxia (a dangerous condition that happens when your body doesn't get enough oxygen), type II diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose levels) with hyperglycemia (a condition where the blood glucose [sugar] levels are abnormally high), and pneumonia (an infection/inflammation in the lungs). During a review of Resident 12's Minimum Data Set (MDS, a resident assessment tool) dated 3/26/2026, the MDS indicated Resident 12 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 12 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in eating, oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of the bed, sit-to stand, chair/bed to chair transfer, toilet transfer and tub/ shower transfer. During a concurrent observation and interview on 4/9/2026 at 9:13 AM with Registered Nurse Supervisor 1 (RNS 1) inside Resident 12's room, Resident 12's oxygen tubing was lying on the floor and not connected to the oxygen concentrator. RNS 1 picked up the oxygen tubing from the floor, did not sanitize it and connected it to the oxygen concentrator. RNS 1 stated if the facility staff connects the oxygen tubing to the resident's oxygen concentrator that was lying on the floor it will be infection control issue because the tubing may have been contaminated with bacteria from the floor and Resident 12 can inhale whatever particles or bacteria were on the floor. During a concurrent interview and record review on 4/9/2026 at 9:27 AM with RNS 1, Resident 12's Physician Order (PO) dated 3/24/2026 was reviewed. The PO indicated Oxygen 2 liters per minute (LPM, unit of measurement) via nasal cannula, may titrate up to 5 LPM for oxygen saturation (SpO2, is a measurement of how much oxygen your blood is carrying as a percentage of the maximum it could carry. Normal value is 95% to 100%) if less than 92% every shift for shortness of breath / wheezing, continuously. RNS 1 stated the oxygen order for Resident 12 indicated continuously and the resident's oxygen should be administered to Resident 12 at all times. RNS 1 stated licensed nurses should ensure the oxygen nasal cannula or oxygen tubing were properly connected to the resident and the oxygen concentrator. The licensed staff should monitor if Resident 12 had any incident of oxygen desaturation (a decrease in the oxygen levels in the blood). During a concurrent interview and record review 04/09/2026 9:28 AM with RNS 1, Resident 12's Care Plan (CP) for oxygen desaturation dated 3/19/2026 was reviewed. The CP interventions indicated monitor all vital signs (objective, measurable indicators of the body's most basic, life-sustaining functions, used by health professionals to assess physical health, identify acute medical issues, and monitor illnesses. This includes oxygen saturation) every shift, frequent visual checks throughout shifts. RNS 1 stated all staff should monitor Resident 12 frequently and if Resident 12's oxygen was connected at all times per the resident's CP. During a record review of facility's Policy and Procedure (P&P) titled, Oxygen Administration, revised 10/2020, the P&P indicated: Check the tubing connected to the oxygen cylinder and assure that it is free of kinks Check the mask, tank, humidifying jar (oxygen humidifier - device designed to increase the moisture in the air), etc., to be sure they are in good working order and are securely fastened. Observe the resident upon set up and periodically thereafter to be sure oxygen is being tolerated. The P&P also indicated in the Documentation; after completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: The rate of oxygen flow, route, and rationale. The frequency and duration of the treatment. All assessment data obtained before, during, and after the procedure. 2. During a review of Resident 72 's admission Record indicated Resident 72 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included unspecified asthma, uncomplicate ( a chronic, non-curable, yet manageable inflammatory lung disease causing wheezing, coughing, and breathing difficulties, not further specified as mild, moderate, or severe, and is not currently exacerbated or causing acute complications ), and atrial fibrillation ( chronic arrhythmia causing a rapid, irregular heart rhythm due to chaotic electrical signals in the heart's upper chambers). During a review of the Quarterly Minimum Data Set (MDS- a resident assessment tool) dated 2/25/2026, it indicated Resident 72 had intact cognitive skills for daily decision making. The MDS indicated Resident 72 need setup or clean-up assistance (helper sets up or cleans up) with eating, upper body dressing and oral hygiene. The MDS also indicated Resident 72 needs substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds the trunk or limbs but provides more than half the effort) for toileting hygiene, shower, bathe self, lower body dressing, and putting on/ taking off footwear. During an observation on 4/6/2026 at 11:46 AM in Resident 72's room, observed Resident 72's nasal cannula for her oxygen delivery was lying on the floor and the oxygen concentrator machine was running. Resident 72's nebulizer mask tubing was also touching the floor in front of the nightstand. During a review of Resident 72's PO dated 12/17/2025, it indicated Resident 72 has an order for Acetylcysteine (a prescription medication used to thin and loosen thick mucus in the airways) solution 20 % give10 milliliter inhale orally every 8 hours for mucous secretions, give via nebulizer. During a review of Resident 72's PO dated 11/30/2025 indicated order for oxygen to administer oxygen at 2LPMvia nasal canula and may titrate up to 4LPM for oxygen saturation less than 92% as needed for shortness of breath or wheezing. During an interview on 4/9/2026 at 11:05 AM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the nebulizer mask tubing and nasal cannula are supposed to be inside a clean set up bag when they are not in use and it should have been labeled, dated with date opened or first use and resident's name on it. LVN 2 stated the nebulizer mask tubing and nasal cannula must be changed once it touches the floor and this can help prevent infection and cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another). During an interview on 4/9/2026 at 11:35 AM with RNS 1, RNS 1 stated nasal cannula tubing and nebulizer mask tubing were not supposed to be lying on the floor, and it needs to be changed right away to prevent Resident 72 from getting infection that could result in illness and potential hospitalization. During a record review of facility's P&P titled, Administering Medications through a Small Volume (Handheld) Nebulize Level III revised 3/2023, the P&P indicated: The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Rinse and disinfect the nebulizer equipment according to facility protocol, Change equipment and tubing every seven days, or according to facility protocol. During a record review of facility's P&P titled, Policies and Practices - Infection Control, revised 4/2023, the P&P indicated this facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.

Based on observation, interview, and record review, the facility failed to monitor the use of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) and antibiotic (medication used to treat infection) for two (2) of 2 sampled residents (Residents 5 and 12) as indicated on the care plan and facility policy by failing to monitor: 1. Resident 5 for signs and symptoms (s/s) of hypoglycemia (an abnormally low level of sugar [glucose] in the blood) and hyperglycemia (a condition where the blood glucose [sugar] levels are abnormally high), while on Insulin Glargine (Lantus, a type of long-acting insulin) and Insulin Aspart (Novolog, fast-acting insulin [a hormone that works by lowering levels of glucose {sugar} in the blood]) from 2/16/2026 to 4/9/2026. 2. a. Resident 12 for s/s of hypoglycemia and hyperglycemia while on Insulin Glargine and Insulin Lispro (Humalog, a fast-acting insulin [a hormone that works by lowering levels of glucose {sugar} in the blood] from 3/24/2026 to 4/8/2026. b. Resident 12 for side effects of Ceftriaxone Sodium (is a third-generation cephalosporin antibiotic used for the treatment of a few bacterial infections) and Vancomycin hydrochloride (HCL) (a potent prescription antibiotic used to treat severe bacterial infections) from 3/24/2026 to 4/9/2026. These deficient practices have the potential for Residents 5 and 12 to experience episodes of hypoglycemia and hyperglycemia and not properly monitored while on insulin, and potential for Resident 12 to experience the side effects of using two antibiotics and not being monitored while on antibiotic therapy that may result in hospitalization and harm. Findings:1. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 5's diagnoses included metabolic encephalopathy (an alteration of brain function or consciousness due to failure of other internal organs), type II diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose levels), and chronic kidney disease (CKD, is a condition in which the kidneys are damaged and cannot filter blood as well as they should) During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 3/3/2026, the MDS indicated Resident 5 had moderately impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 5 was substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in eating, oral hygiene, upper and lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of the bed, sit-to stand, chair/bed to chair transfer, toilet transfer and tub/ shower transfer. The MDS also indicated seven insulin injections were administered to Resident 5 for the past seven days. During a concurrent interview and record review on 4/9/2026 at 8:30 AM with Registered Nurse Supervisor 1 (RNS 1), Resident 5's Physician's order (PO) dated 2/16/2026 was reviewed. The PO indicated:1. Insulin Glargine (Subcutaneous (SQ, a shot that delivers medicine into the fatty tissue layer just under the skin, above the muscle, using a short, small needle for slow, steady absorption) Solution 100 units per milliliter (ML, measure of volume) Inject 10 unit subcutaneously one time a day for Type 2 DM. Hold if Blood Sugar (BS) was less than (<) 100. 2. Insulin Aspart (Novolog, fast acting insulin [a hormone that works by lowering levels of glucose {sugar} in the blood]) Subcutaneous Solution 100 unit per ML Inject subcutaneously before meals for Type II DMInject as per sliding scale (method of adjusting medication doses, most commonly insulin, based on the resident's blood glucose level [amount of sugar present in the blood at a given time]):If BS< 70, administer glucagon, recheck Blood sugar in 15 minutes, notify physician, and Change of Condition (COC, is a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains).if 150 to 199 = 0 units;200 to 249 = 2 units;250 to 299 = 4 units;300 to 349 = 6 units;350 to 399 = 8 units;If BS more than (>) 400, give 10 units, notify physician for further orders, recheck sugar, conduct COC, subcutaneously before meals for Type II DM.RNS 1 stated there were no orders for monitoring the s/s of hypoglycemia and hyperglycemia while using insulin. During a concurrent interview and record review on 4/9/2026 at 8:42 AM with RNS 1, Resident 5's Nurses Progress Notes (NPN) dated 4/1/2026 to 4/9/2026 were reviewed. RNS 1 stated there was no documentation indicating that signs and symptoms of hypo- or hyperglycemia were being monitored. RNS 1 stated that because the staff did not document the monitoring, there was no evidence the staff had monitored Resident 5, which meant the licensed staff were not performing the required monitoring. RNS 1 stated if the licensed staff were not monitoring Resident 5, the resident could possibly require hospitalization due to the lack of proper monitoring. During a concurrent interview and record review on 4/9/2026 at 8:37 AM with RNS 1, Resident 5's Care Plan (CP) for Diabetes Mellitus revised on 3/10/2026 was reviewed. Resident 5's CP interventions indicated the following:Observe for s/s of hypoglycemia (diaphoresis, faintness, headache, palpitations, trembling, impaired vision, hunger, difficulty awakening, irritability, personality changes).Observe for s/s of hyperglycemia, polydipsia (excessive thirst or abnormally increase fluid intake), polyuria (excessive urination or producing unusually large amounts of urine), increased blood glucose and ketone levels, deep & rapid breathing, anorexia (a loss of appetite or reduced desire to eat), nausea & vomiting, fruity-smelling RN breath, warm & dry skin, weakness, abdominal pain, general aches.RNS 1 stated there was no documentation that the staff followed the care plan, which meant the staff were not monitoring Resident 5 while on insulin. During a review of the facility's policy and procedure (P&P) titled, Diabetes Clinical Protocol revised 3/2023, the P&P indicated, the Physician and staff will summarize factors that are contributing to, or conditions that are affected by, the resident's diabetes or glucose intolerance and will assess the impact of diabetes on the individual's function and quality of life. The P&P also indicated in Monitoring and follow- up. The P&P also indicated that the Physician will order desired parameters for monitoring and reporting information related to blood sugar management and the staff will incorporate such parameters into the Medication Administration Record and care plan. The P&P also indicated that the staff will identify and report issues that may affect, or be affected by, a patient's diabetes and diabetes management such as foot infections, skin ulceration, increased thirst, or hypoglycemia and the staff and Physician will manage hypoglycemia appropriately. 2.During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 12's diagnoses included methicillin-resistant staphylococcus aureus (MRSA, is a type of bacteria that's developed defense mechanisms resistance to antibiotics) wound of the right foot, type II diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose levels) with hyperglycemia (a condition where the blood glucose [sugar] levels are abnormally high), cellulitis (a bacterial infection that enters your skin and tissue through a wound), and gangrene (a serious, potentially fatal condition involving tissue death [necrosis] caused by infection or lack of blood flow) of the right lower extremity During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 12 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in eating, oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of the bed, sit-to stand, chair/bed to chair transfer, toilet transfer and tub/ shower transfer. The MDS also indicated seven insulin injections were administered to Resident 12 for the past seven days. a. During a concurrent interview and record review on 4/8/2026 at 4:02 PM with Infection Preventionist Nurse (IPN), Resident 12's PO, dated 3/24/2026, was reviewed. The PO indicated:1. Insulin Glargine Subcutaneous Solution 100 units per ML Inject 10 units subcutaneously every 12 hours for Type 2 DM. Hold if BS <100. 2. Insulin Lispro Injection Inject SQ per Sliding Scale subcutaneously before meals for Type 2 DM.Inject as per sliding scale:if 0 to 149 = 0 If BS is <70 and conscious, give 4-6 oz of juice, then recheck BS in 15 minutes. Notify MD of change.150 to 199 = 4;200 to 249 = 6;50 to 299 = 8;300 to 349 = 10;350 to 399 = 12;If BS is 400 and above, notify MD IPN stated there was no monitoring order for signs and symptoms of hyperglycemia and hypoglycemia. Without an order, it means the staff were not monitoring the signs and symptoms of hyperglycemia and hypoglycemia for Resident 12. During a concurrent interview and record review on 4/8/2026 at 4:06 PM with IPN, Resident 12's Care plan (CP) for DM revised 4/2/2026 was reviewed. The CP indicated interventions including the following: Monitor for s/s of hypoglycemia (diaphoresis, faintness, headache, palpitations, trembling, impaired vision, hunger, difficulty awakening, irritability, personality changes). Monitor for s/s of hyperglycemia: polydipsia, polyuria, increased blood glucose and ketone levels, deep & rapid breathing, anorexia, nausea & vomiting, fruity-smelling breath, warm & dry skin, weakness, abdominal pain, general aches.IPN stated the staff did not have documentation for monitoring s/s hyperglycemia and hypoglycemia for Resident 12. The licensed staff did not have documentation showing they followed Resident 12's care plan. During a concurrent interview and record review on 4/8/2026 at 4:16 PM with IPN, Resident 12's Nurses Progress Notes (NPN) dated 3/24/2026 to 4/8/2026 were reviewed. IPN stated the licensed staff did not have a documentation that Resident 12 was monitored for s/s of hypoglycemia and hyperglycemia. IPN stated if there was no documentation, it means it was not done. b. During a concurrent interview and record review on 4/8/2026 at 4:17 PM with IPN, Resident 12's PO, dated 3/24/2026, was reviewed. The PO indicated:1. Ceftriaxone Sodium 2 grams (GMs) intravenously (refers to a way of giving a drug or other substance through a needle or tube inserted into a vein) one time a day for MRSA wound of the right foot until 4/30/20262. Vancomycin HCl 750 MG intravenously every 24 hours for MRSA wound on the right foot until 4/30/2026IPN stated there were no orders for monitoring the side effects (S/E) of Ceftriaxone and Vancomycin. During a concurrent interview and record review on 4/8/2026 at 4:19 PM with IPN, Resident 12's Care Plan (CP) risk for side effects related to vancomycin and ceftriaxone use dated 3/26/2026 was reviewed. The CP interventions indicated: Administer two IV antibiotics separately and flush the lines before and after the IV medications were administered. Monitor for side effects of vancomycin and ceftriaxone use, like Hives, shortness of breath, diarrhea, or DRESS syndrome (Drug Reaction with Eosinophilia and Systemic Symptoms, is a rare, severe, and potentially life-threatening drug-induced reaction) Stop the medication and notify the primary care provider if the resident experiences side effects.IPN stated they should monitor Resident 12 based on the care plan but there was no documentation of the monitoring, which means the Licensed staff did not follow the care plan. During a concurrent interview and record review on 4/9/2026 at 9:51 PM with Registered Nurse 1 (RNS 1), Resident 12's PO, dated 3/24/2026 was reviewed. RNS 1 stated the S/E of Ceftriaxone were diarrhea, rash, dizziness, headache, fatigue, severe abdominal pain, yellow skin eyes, and pale stools. RNS 1 stated the S/E of Vancomycin were rashes, hearing loss, nausea and vomiting, low blood pressure, swelling of extremity, and pain. RNS 1 stated Resident 12 did not have a monitoring order for these antibiotics. During a concurrent interview and record review on 4/9/2026 at 9:55 AM with RNS 1, Resident 12's Care Plan (CP) risk for side effects related to vancomycin and ceftriaxone use, dated 3/26/2026, was reviewed. RNS 1 stated since Resident 2 had two different kinds of antibiotics, the care plan interventions to monitor the side effects should have been specific for each antibiotic use. During a record review of facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised 3/2023, the P&P indicated, a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.3.The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.7. The comprehensive, person-centered care plan:a. includes measurable objectives and timeframes.b. describes the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being, including:c. includes the resident's stated goals upon admission and desired outcomes.d. builds on the resident's strengths; ande. reflects currently recognized standards of practice for problem areas and conditions.10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions changes.

Based on observation, interview, and record review, the facility failed to prepare the correct amount of sweet and sour sauce served during lunch on 4/8/2026 in accordance with the facility's spring menu and policy and procedure (P&P).This deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake and weight loss for 81 residents. Findings: During a concurrent observation and interview on 4/8/2026 at 11:56 AM in the facility kitchen during lunch tray line assembly with [NAME] 1, [NAME] 1 was observed using a one ounce (oz) portion spoon to scoop the sweet and sour sauce with vegetables onto the residents' plates. During a concurrent interview and record review on 4/8/2026 at 11:56 AM with the Dietary Service Supervisor (DSS), the facility's 4/8/2026 spring menu, page 2, was reviewed. The facility's spring menu for 4/8/2026 indicated the serving size for sweet and sour sauce with vegetables is 2 oz. DSS stated it is important to use the correct portion size spoon to ensure residents receive necessary nutrients and to enhance digestion. During a review of the facility's undated P&P titled, Food Preparation Policy, the P&P indicated food is to be prepared in such a manner as to maximize flavor, appearance, and nutritional value. All meals must comply with the physician-ordered diet, approved menu, and portion control standards to ensure consistency, adequate nutrition, and regulatory compliance. It also indicated Portion Control During Meal Service:Standardized portion sizes must be followed for all food items, including meats, in accordance with the approved menu and diet manual.Portion utensils (e.g., scoops, serving utensils, ladles) must be labeled and used to ensure consistent portioning.e. Dietary Supervisor or Lead [NAME] must monitor the meal service to ensure correct portion is being served

Based on observation, interview, the facility's kitchen staff failed to ensure the chicken on the facility's menu was prepared at a safe temperature on 4/8/2026 during lunch time, in accordance with the facility's Policy and Procedure (P&P). This deficient practice has the potential to cause 81 residents to have foodborne illness (foodborne diseases or food poisoning, illnesses caused by consuming food or beverages contaminated with harmful agents). Findings: During a concurrent observation and interview on 4/8/2026 at 11:51 AM in the facility kitchen during lunch tray line assembly with the Dietary Service Supervisor (DSS), DSS was observed checking the temperature of the cooked chicken, which measured 140 degrees Fahrenheit ( F). DSS stated it is very important to keep the cooked chicken at 165 F to prevent residents from developing foodborne illness. During a review of the facility's P&P titled, Food Preparation and Service, revised November 2022, the P&P indicated the following internal cooking temperatures/times for specific foods are reached to kill or sufficiently inactivate pathogenic microorganisms: 165 F for poultry.

Based on observation, interview, and record review, the facility failed to follow proper food storage handling practices in accordance with its policy and procedure (P&P) by: Failing to ensure eight (8) food items were labeled with preparation date, thaw date and/ or use by date. Failing to ensure Dietary Service Supervisor (DSS) perform handwashing and change gloves after picking up an alcohol wrap from the floor and then placed a thermometer into the tray of cooked chicken on the steam table. Failing to ensure three (3) food carts were free of white splattered stains on their doors. These deficient practices have the potential to result in food born illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) to 81 residents receiving food from the kitchen. Findings: 1. During a concurrent observation and interview on 4/6/2026 at 7:52 AM in the facility kitchen with the DSS, the following food items were observed in the freezer: Four (4) bags of prepared sandwiches in the refrigerator have no label to indicate preparation date and use by date.Four (4) bags of chicken thighs in the refrigerator have no labels to indicate the name, date of thawing and use by date. DSS stated in accordance with the facility's P&P, all food items including the prepared 24 sandwiches should be labeled with a preparation date and a use by date once. DSS stated frozen items should be labeled with the item's specific name, thaw date and use by date. DSS stated, the 4 bags of chicken thighs in the refrigerator were placed there for thawing and it was not labeled with the item name, thaw date and use by date. DSS also stated it is very important to label, store, and discard food items per the facility's P&P to ensure that the food items are safe to eat for the residents. During a review of the facility's P&P titled Dating and Labeling, undated, the P&P indicated, to ensure food safety and prevent contamination within the facility, all food items should be properly covered, dated, and labeled in dry storage and refrigerator/ freezer areas. The P&P also indicated any frozen items should be labeled with the thaw date. 2. During a concurrent observation and interview on 4/8/2026 at 11:48 AM in the facility kitchen during tray line assembly with the DSS, observed DSS picked up an alcohol wrap from the floor without changing gloves and DSS did not perform hand hygiene (the act of cleaning hands to prevent the spread of germs, infections, and diseases, recognized as the most important method for infection control. It includes washing with soap and water [for 20 plus seconds] or using alcohol-based hand sanitizer). DSS then used the same hand with the same gloves to place a thermometer into the tray of cooked chicken on the steam table. DSS stated it is important to wash her (DSS) hand with soap and warm water for at least 20 seconds after picking up trash from the kitchen floor and changing gloves before moving to another task such as handling cooked food. This prevents the spread of pathogens from the floor to food preparation surfaces. 3. During a concurrent observation and interview on 4/8/2026 at 12:00 PM in the facility kitchen with the Dietary Consultant (DC), 3 food carts had dried white stains on their doors. DC stated kitchen staff should have maintained cleanliness of the 3 food carts to prevent food borne illnesses. During a review of the facility's P&P titled, Food Preparation and Service, revised November 2022, the P&P indicated, food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. The P&P also indicated:Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.All food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations.

Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed in accordance with the facility's policy and procedure (P&P) when facility failed to ensure:1. Resident 3's tube feeding (the process of delivering liquid nutrition directly into the stomach or small intestine via a soft, flexible tube) machine was free of beige colored stains.2. Laundry staff followed infection control practices as evidenced by two used paper cups and paper towels left in the clean area of the laundry room, and by the presence of light brown splatter stains on the shelves where clean linens were stored.3. Facility staff observed infection control measures for Resident 89 who was on Enhanced Barrier Precautions (EBP- the use of gown and glove for nursing home residents with wounds and indwelling devices during specific-high contact resident care activities associated with multidrug-resistant organisms [MDRO] transmission) by failing to don (wear) personal protective equipment (PPE- a barrier precaution which includes use of gloves, gown, mask, face shield, shoe covers, head covers, respirators, etc. when you anticipate contact with blood or body fluids or other communicable toxins or agents) before checking for gastrostomy tube (G-tube- a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) placement prior to medication administration. These deficient practices have potential to contaminate clean items and placed the residents at a higher risk for cross-contamination and increased spread of infection in the facility.Findings: 1. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 3's diagnoses included metabolic encephalopathy (an alteration of brain function or consciousness due to failure of other internal organs), diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose levels), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a progressive state of decline in mental abilities) During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 2/13/2026, the MDS indicated Resident 3 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 3 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, personal hygiene, sit to lying, lying to sitting on the side of the bed, sit to stand and chair/ bed-to-chair transfer and tub/ shower transfer. During an observation on 4/6/2026 at 10:18 AM inside Resident 3's room, Resident 3 was awake and lying on her bed. The tube feeding (TF) machine was running and there were beige colored stains all over the TF machine. During an observation on 4/7/2026 at 9:15 AM inside Resident 3's room, Resident 3 was awake and lying on her bed. Resident 3's TF machine was turned on and the TF machine had beige colored stains. During a concurrent observation and interview on 4/7/2026 at 3:11 PM with Infection Preventionist Nurse (IPN), IPN stated the TF machine had beige colored stains. IPN stated the TF machine was dirty and the beige colored stains might be from the dried formula. IPN stated the staff should have cleaned the TF machine before using it for infection control. During a review of the facility's P&P titled, Cleaning and Disinfection of Resident-Care Items and Equipment, updated on 4/2023, the P&P indicated Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC, national public health agency of the United States) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA, is a U.S. federal agency under the Department of Labor that ensures safe working conditions by setting and enforcing standards, providing training, and offering assistance to employers and workers) Blood-borne Pathogens Standard. Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin (e.g., respiratory therapy equipment). Such devices should be free from all microorganisms, although small numbers of bacterial spores are permissible. 2. During a concurrent observation and interview on 4/7/2026 at 3:41 PM with the Environmental Services Supervisor (ESS) inside the laundry room, two disposable paper cups (1 cup filled with ice and 1 empty used cup) sitting on the tabletop in the laundry folding area, which was a clean area. ESS stated there should be no cups in the clean area because of infection control During a concurrent observation and interview on 4/7/2026 at 3:56 PM with the ESS inside the laundry room, there were light brown colored splatter stains observed on the lower shelf where folded clean linens were stored. The curtains covering the shelves showed grayish discoloration along the lower hem. ESS stated the curtains needed to be laundered. ESS also stated the dried brown colored stains on the bottom shelf were possibly from a spilled drink. ESS stated the laundry staff should keep the folding area clean to maintain proper infection control. During a concurrent observation and interview on 4/7/2026 at 4PM with ESS inside the laundry room, there were 2 used crumpled paper towels left on top of shelf where clean residents' clothes were hung and stored. ESS stated the laundry staff should not leave used paper towels in the clean area because of infection control. During review of the facility's P&P titled, Cleaning and Disinfection of Environmental Surfaces updated on 4/2023, the P&P indicated, Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities-and the OSHA Bloodborne Pathogens Standard. 8. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 9. Environmental surfaces will be disinfected (or cleaned) on a regular basis and when surfaces are visibly soiled. 3. During a review of Resident 89's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (loss of motor function on the left side of the body caused by a blockage of a blood vessel in the right side of the brain), attention to gastrostomy, and essential hypertension (high blood pressure). During a review of Resident 89's MDS, dated [DATE], the MDS indicated Resident 89 was assessed having severely impaired (never/rarely made decisions) cognitive skills for daily decision making. The MDS indicated Resident 89 was dependent with oral/toileting hygiene, upper/lower body dressing, shower/bathe self, roll left and right, sit to lying, and tub/shower transfer. The MDS indicated Resident 89 had a feeding tube. During a review of Resident 89's Order Summary Report, dated 4/9/2026, the Order Summary Report indicated the following physician's orders: Enhanced Barrier Precautions due to g-tube, with an order date of 2/28/2025. Clonazepam 0.5 milligrams (mg- unit of measurement), give 0.25 mg via G-tube three times a day for seizure (sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) prophylaxis (prevention), with an order date of 3/30/2025. Enteral feed (the delivery of liquid nutrition directly into the gastrointestinal [GI] tract via a feeding tube) order five times a day via gravity or bolus (set amount of formula is given at one time through the feeding tube): Nutren 2.0 237 milliliters (ml- unit of measurement)/can per G-tube for weight management, with an order date of 7/16/2025. During a review of Resident 89's Care Plan titled, Enhanced Barrier Precautions due to G-tube, the Care Plan indicated interventions were to provide Enhanced Barrier Precautions: gloves, gowns, masks. During a concurrent observation and interview on 4/6/2026, at 12:24 PM, in Resident 89's room, an EBP sign was observed posted above Resident 89's bed. Licensed Vocational Nurse 5 (LVN 5) entered Resident 89's room and stated she was going to administer Resident 89's medication through his G-tube. LVN 5 donned gloves, unclamped Resident 89's G-tube and checked it for placement. LVN 5 administered clonazepam and Nutren 2.0 via G-tube and flushed Resident 89's G-tube with 30 ml of water. LVN 5 doffed (removed) her gloves and washed her hands. LVN 5 stated she forgot to wear a gown before checking Resident 89's G-tube residual and administering his medications. During an interview on 4/7/2026, at 1:41 PM, with LVN 6, LVN 6 stated residents with G-tubes were placed on EBP. LVN 6 stated facility staff had to wash their hands and wear PPEs before administering medications and providing G-tube care. LVN 6 stated it was important for facility staff to wear PPEs when providing care for residents on EBP to protect the residents and staff from infection and contamination. During an interview on 4/8/2026, at 10:51 AM, with Registered Nurse Supervisor 1(RNS 1), RNS 1 stated facility staff were supposed to follow EBP and don the appropriate PPEs before providing direct care to residents. RNS 1 stated direct care included changing diapers, wound care, G-tube care and G-tube medication administration. RNS 1 stated facility staff were required to don gloves and gown before providing G-tube care and G-tube medication administration. RNS 1 stated donning PPE prevents the spread of infection to residents in the facility. During a review of the facility's undated P&P titled, Enhanced Barrier Precaution, the P&P indicated the following: Enhanced Barrier Precaution is an infection control intervention designed to reduce transmission of MDROs. Enhanced Barrier Precautions involve gown and glove use during high contact resident care activities for residents known to be infected or colonized with an MDRO as well as those at increased risk of MDRO acquisition (example: residents with wounds or indwelling medical devices) Perform hand hygiene, wear gowns and gloves while performing the following tasks associated with residents who require Enhance Barrier Precautions: Device care, for example, feeding tube Any care activity where close contact with the resident is expected to occur

Based on observation, interview, and record review, the facility failed to ensure two (2) of 2 sampled residents (Residents 47 and 48) reviewed for environment were provided with a homelike environment by failing to maintain a scratch- free, non-discolored wall surface in the residents' room, in accordance with the facility's policy. This deficient practice had the potential for an unsafe and unclean environment and had the potential to negatively affect the residents' quality of life.Findings: 1. During a review of Resident 47's admission Record, the Admissions Record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with anxiety (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities, specific cause or type has not been determined, with symptoms like restlessness, fear, or panic), muscle weakness (a reduced ability of one or more muscles to generate force, making it harder to perform tasks that require strength), and repeated falls (more than one fall per year or multiple incidents within six months). During a review of Resident 47's Minimum Data Set (MDS- a resident assessment tool), dated 2/5/2026, indicated Resident 47 had moderately impaired cognitive skills (mental processes that allow people to think, learn, and solve problems) for daily decision making. Resident 47 needed partial or moderate assistance, (helper does less than half the effort) with shower/bathe self, lower body dressing and putting on/taking off footwear. Resident 47 needs supervision or touching assistance, (helper provides verbal cues and /or touching/steadying and/or contact guard assistance as resident completes activity) for toileting hygiene, upper body dressing and personal hygiene. MDS also indicated Resident 47 needs set up or clean-up assistance, (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for eating, oral hygiene, and toilet transfer. During an observation of Resident 47's room on 4/7/2026 at 12:42 PM, the wall behind Resident 47's headboard was observed to have discoloration and multiple scratches. During an interview with Resident 47 on 4/7/2026 at 12:47 PM in his room, Resident 47 shook his head and pointed toward the wall to indicate his dislike of the discoloration and multiple scratches on the wall behind his headboard. 2. During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 48's diagnoses included adult failure to thrive (a syndrome characterized by unintended weight loss, malnutrition (serious condition that occurs when a resident's diet does not contain the right amount of nutrients), dehydration (condition that occurs when the loss of body fluids, mostly water, exceeds the amount that is taken in), and unspecified dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) with anxiety (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities, specific cause or type has not been determined, with symptoms like restlessness, fear, or panic). During a review of Resident 48's Minimum Data Set (MDS, resident assessment tool) dated 3/23/2026, the MDS indicated Resident 48 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills. The MDS indicated Resident 48 was dependent (helper does all of the effort) with oral hygiene, toileting hygiene, shower/bath self, upper and lower body dressing, putting on/ taking off footwear and sit to lying. Resident 48 needed substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunks or limbs but provides more than half the effort) with eating (via TF). During an observation of Resident 48's room on 4/8/2025 at 9:33 AM, the wall behind Resident 48's headboard was observed to have discoloration and multiple scratches on the wall.During an interview with the Maintenance Supervisor (MS) on 4/8/2025 at 3:15 PM, MS stated the discoloration and scratches on the wall were caused by the bed hitting the wall multiple times during bed transfers. MS stated this was not a homelike environment for the residents. MS also stated the residents appreciate it when everything in their rooms is fixed and well maintained.During a review of the facility's Policy and Procedure (P&P) titled, Homelike Environment, revised 3/2024, the P&P indicated Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment:

Based on interview and record review, the facility failed to protect the confidentiality of the information of one (1) of five sampled residents (Resident 38) observed during medication administration in accordance with the facility's policy and procedure when Licensed Vocational Nurse 1 (LVN 1), left the laptop screen switched on with Resident 38's electronic medication administration record (eMAR, is the digital version of the traditional paper medication administration records used in healthcare facilities) displayed on the screen. This deficient practice had the potential to violate the resident's right to confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the resident and/or the resident's representative) and privacy and misuse of Resident 38's Protected Health Information (PHI, any information that relates to an individual's health status, medical history, or treatment).Findings:During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 38's diagnoses included renal insufficiency (is a condition where kidneys cannot adequately filter waste, balance electrolytes, or manage blood pressure) , asthma (is a condition in which your airways narrow and swell and may produce extra mucus), chronic obstructive pulmonary disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and colon cancer (a cancer of the large intestine, which may affect the colon or rectum) During a review of Resident 38's Minimum Data Set (MDS, a resident assessment tool) dated 3/18/2026, the MDS indicated Resident 38 had intact cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 38 was independent (resident completes the activity by themself with no assistance from a helper) in eating, oral hygiene, upper body dressing, personal hygiene, roll left and right, sit to lying, and lying to sitting on the side of the bed. During a concurrent observation and interview on 4/8/2026 at 9:46 AM with LVN 1, LVN 1 dispensed Resident 38's medication and left the laptop screen turned on with Resident 38's eMAR was displayed on the screen and the monitor was left facing towards the hallway while there were three residents and four staff walking by the hallway. During an interview on 4/8/2026 at 3:26 PM with LVN 1, LVN 1 stated the staff need to make sure the laptop was turned off to secure privacy of Resident 38's information. LVN 1 also stated the staff need to turn off the laptop monitor when the staff need to step away from the medication cart because anyone including residents or staff might see Resident 38's information about the resident's medications and other medical problems on the screen. During a record review of facility's Policy and Procedure (P&P) titled, Protected Health Information (PHI), Management and Protection of, revised 4/2014, the P&P indicated it is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure.

Based on observation, interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 47) reviewed for environment was provided a homelike environment by failing to ensure Resident 47's call light (a communication device that allows residents to alert staff for assistance) was within arm's reach, and the resident's television (TV) was plugged in, and the TV's remote control was functioning. These deficient practices had the potential to negatively affect the residents' quality of life.Findings: During a review of Resident 47's admission Record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with anxiety (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities, specific cause or type has not been determined, with symptoms like restlessness, fear, or panic) muscle weakness (a reduced ability of one or more muscles to generate force, making it harder to perform tasks that require strength), and repeated falls (more than one fall per year or multiple incidents within six months). During a review of Resident 47's Minimum Data Set (MDS- a resident assessment tool), dated 2/5/2026, indicated Resident 47 had moderately impaired (decisions poor: cues/supervision required) for cognitive skills (mental processes that allow people to think, learn, and solve problems) for daily decision making. The MDS also indicated Resident 47 needed partial or moderate assistance, (helper does less than half the effort) with shower/bathe self, lower body dressing and putting on/taking off footwear and the resident needs supervision or touching assistance, (helper provides verbal cues and /or touching/steadying and/or contact guard assistance as resident completes activity) for toileting hygiene, upper body dressing and personal hygiene. In addition, the MDS indicated Resident 47 needs set up or clean-up assistance, (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for eating, oral hygiene, and toilet transfer. During a review of Resident 47's care plan for risk for fall/ injury, revised on 2/16/2026, the care plan indicated intervention to keep the call light within reach. During an observation on 4/6/2026 at 8:36 AM in Resident 47's room, Resident 47's call light was observed located near the resident's feet area which was not within Resident 47's reach. Resident 47 was observed reaching for the call light using the resident's feet but was unsuccessful. During a concurrent observation and interview on 4/6/2026 at 8:41 AM in Resident 47's room with Certified Nurse Assistant (CNA) 2, CNA 2 stated the call light and the TV's cord was near the resident's feet. CNA 2 stated the call light should be within Resident 47's reach so that the resident can request assistance when the resident needs it and to switch on the resident's TV. CNA 2 also stated the TV should be plugged in so the resident can watch the TV anytime the resident wants it CNA 2 added keeping the call light accessible can help prevent the resident from falling or other accidents. During an interview on 4/9/2026 at 9:49 AM with Registered Nurse Supervisor (RNS), RNS stated Resident 47's call light was not supposed to be left near the resident's feet area. RNS stated that the call light should be within the resident's reach so the resident can use it to request assistance in a timely manner, which can also help prevent falls. RNS stated power cord for Resident 47's TV as not supposed to be unplugged. During an observation on 4/8/2026 at 10:22 AM in Resident 47's room, observed Resident 47's TV was off, Resident 47 handed his TV remote control to the surveyor and pointed to the power button. The surveyor tried to switch on the TV using the remote control and the remote control did not work. During a concurrent observation and interview on 4/9/2026 at 10:49 AM with Maintenance Supervisor (MS) in Resident 47's room, MS stated Resident 47's TV was not supposed to be unplugged from the wall, and he should replace the batteries for the TV remote control to ensure it remains in working condition. During a review of the facility's P&P titled, Maintenance Service revised 12/2009, it indicated: maintenance service shall be provided to all areas of the building, grounds, and equipment. During a review of the facility's P&P titled, Homelike Environment revised 02/2021, it indicated, staff provides person-centered care that emphasizes the resident's comfort, independence and personal needs and preferences. During a review of the facility's Policy and Procedure (P&P) titled, Call System, Resident revised 03/2023, the P&P indicated each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on observation and interview, the facility failed to provide oral care for one (1) of three (3) sampled residents (Residents 103) reviewed for activities of daily living (ADL) as indicated on the facility policy. This deficient practice had the potential to cause dry mouth, infection mouth soreness, discomfort and reduce Resident 103's quality of life. Findings:During a review of Resident 103's admission Record, the admission Record indicated Resident 103 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 103's diagnoses included occlusion and stenosis of right middle cerebral artery (the main blood vessel supplying the right side of the brain is either severely narrowed [stenosis] or completely blocked [occlusion], interrupting blood flow) and dysphagia oral pharyngeal phase ( difficulty initiating a swallow, where food or liquid cannot move properly from the mouth to the top of the esophagus). During a review of Resident 103's Minimum Data Set (MDS, resident assessment tool), dated 1/12/2026, the MDS indicated Resident 103 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 103 was dependent (helper does all of the effort) with oral hygiene, toileting hygiene, shower/bath self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene and sitting to lying. During observations on 4/6/2025 at 11:47 AM, in Resident 103's room, Resident 103's mouth was observed with white crust. During observations on 4/7/2025 at 1:02 PM in Resident 103's room, Resident 103's mouth was observed with white crust. During an interview on 4/8/2026 at 4:46 PM, Certified Nurse Assistant 5 (CNA 5) it was very important to provide oral care to dependent residents to prevent infection, and to maintain their overall dignity. During an interview on 4/9/2026 at 9:41 AM with Registered Nurse Supervisor (RNS), RNS stated CNAs were expected to provide oral care to Resident 103 each shift. The RNS further stated that it is very important to provide oral care to dependent residents to prevent serious infections such as aspiration pneumonia (lung infection that occurs when a person inhales [aspirates] something other than air-such as food, liquid, saliva, or stomach contents-into the lungs, leading to inflammation and infection of the air sacs), other infections, and oral diseases, and to maintain the resident's overall dignity. During a review of the facility's Policy and Procedure (P&P) titled, Supporting Activities of Daily Living, revised 3/2023, the P&P indicated Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to cany out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:hygiene (bathing, dressing, grooming, and oral care)

Based on observation, interview, and record review, the facility failed to ensure the tube feeding (TF, a medical method of delivering liquid nutrition, formula, and medications directly into the stomach or small intestine) order for one of four sampled Residents (Resident 48) reviewed for tube feeding, was administered on 4/8/2026 in accordance with the physician's order. This deficient practice had the potential to cause Resident 48 to lose weight and for his health condition to decline. Findings: During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 48's diagnoses included adult failure to thrive (a syndrome characterized by unintended weight loss, malnutrition (serious condition that occurs when a resident's diet does not contain the right amount of nutrients), dehydration (condition that occurs when the loss of body fluids, mostly water, exceeds the amount that is taken in), and unspecified dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) with anxiety (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities, specific cause or type has not been determined, with symptoms like restlessness, fear, or panic). During a review of Resident 48's Minimum Data Set (MDS, resident assessment tool) dated 3/23/2026, the MDS indicated Resident 48 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills. The MDS indicated Resident 48 was dependent (helper does all of the effort) with oral hygiene, toileting hygiene, shower/bath self, upper and lower body dressing, putting on/ taking off footwear and sit to lying. Resident 48 needed substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunks or limbs but provides more than half the effort) with eating (via TF). During a review of Resident 48's Physician Order, dated 2/13/2026, the Physician Order indicated Jevity ( a type of enteral [a form of nutrition that is delivered into the digestive system as a liquid] feeding) 1.2 at 55 milliliters (ml, a unit of volume measurement) per hour for 20 hours via pump to provide 1100 ml/ 1320 kcal (a unit of energy equal to 1,000 small calories) per day via enteral feeding pump starting at 12 PM and off at 8 AM ( or until dose is completed). During a concurrent observation in Resident 48's room and interview with Licensed Vocational Nurse 2 (LVN 2) on 4/8/2025 at 8:35 AM, observed Resident 48 in bed. Resident 48's tube feeding formula bottle was observed to be full, at a level of 1500 ml. LVN 2 stated Resident 48's Jevity 1.2 tube feeding was observed to be at the 1500 ml level. LVN 2 stated that the Jevity container had been labeled by the previous LVN on 4/8/2026 at 1 AM. LVN 2 stated that a full container of Jevity 1.2 is marked at 1500 cc, and if Resident 48's feeding began on 4/8/2026 at 1 AM at a rate of 55 ml/hr, the container should reflect approximately seven hours' worth of feeding used by 8:35 AM on 4/8/2026, not remain full at 1500 ml. LVN 2 stated that Resident 48 had not received any feeding since the Jevity 1.2 container was hung at 1 AM on 4/8/2026. During a concurrent observation in Resident 48's room and interview with LVN 3 at 3:35 PM, LVN 3 stated that the feeding bottle level was still at 1500ml. LVN 3 stated that Resident 48 was not receiving the tube feeding as ordered for 10 hours' worth of the feeding. LVN 3 stated that a resident can lose weight, fail to receive adequate nutrition, and experience a gradual decline in health if tube feedings are not administered as ordered. During a concurrent interview and record review on 4/8/2026 at 4:16 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Enteral Nutrition - Safety Precautions, revised date March / 2023 was reviewed. The P&P indicated its purpose is to ensure the safe administration of enteral nutrition. It also indicated that the facility will remain current in and follow accepted best practices in enteral nutrition.

Based on observation, interview, and record review, the facility failed to ensure the peripherally inserted central catheter (PICC line- a long flexible catheter that is inserted through a vein in the upper arm) care was provided in accordance with standards of practice for one (1) of 19 sampled residents (Resident 100) by: Failing to ensure Resident 100's PICC line was assessed and documented upon admission.Failing to ensure the physician's telephone order to remove the PICC line (inserted from General Acute Care Hospital [GACH]) was followed.Failing to ensure Resident 100's PICC line dressing was changed upon admission and weekly as indicated in the facility's policy and procedure (P&P). These deficient practices had the potential to result in Resident 100 developing an infection on the PICC line insertion site.Findings: During a review of Resident 100's admission Record, the admission Record indicated Resident 100 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), gastro-esophageal reflux disease without esophagitis (when stomach acid flows back into the esophagus causing uncomfortable symptoms), and anxiety disorder (fear characterized by behavioral disturbances). During a review of Resident 100's Clinical admission Form, dated 4/3/2026, the Clinical admission Form indicated Resident 100 had mildly impaired (some confusion) cognitive skills (problems with thinking, memory, judgement). The Clinical admission Form did not indicate Resident 100 had a PICC line upon admission. During an observation on 4/6/2026, at 8:46 AM, in Resident 100's room, Resident 100 was asleep in bed. Resident 100 had a PICC line inserted on the resident's left upper arm covered with a clear dressing dated 3/27/2026. During a concurrent observation and interview on 4/7/2026, at 12:55 PM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 100 arrived from the GACH on 4/3/2026 with the PICC line. LVN 1 stated Resident 100's PICC line dressing was dated 3/27/2026 and the PICC line dressing should have been changed 72 hours after admission to the facility. During a concurrent interview and record review on 4/7/2026, at 12:59 PM, with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated any RNS in charge to assess the residents upon admission and accurately document the assessment in the Clinical admission Form. RNS 1 stated it was important to have a complete and accurate assessment of the condition of the resident upon admission. RNS 1 stated that Resident 100's PICC line was not documented in the Clinical admission Form. RNS 1 stated Resident 100's PICC line was not documented in any of the assessments or resident's progress notes. RNS 1 stated Resident 100 did not have a care plan for the resident's PICC line. RNS 1 stated the RNS should have assessed and documented Resident 100's PICC line in the Clinical admission Form if Resident 100 was admitted to the facility with a PICC line. RNS 1 stated that inaccurate assessment and documentation of residents prevent staff from having a clear understanding of what is going on with the residents, which could affect the care provided. RNS 1 stated he did now know Resident 100 had a PICC line. During the same concurrent interview and record review on 4/7/2026, at 12:59 PM, with RNS 1, Resident 100's Progress Note, dated 4/3/2026, at 9:30 PM, was reviewed. RNS 1 stated the Progress Note indicated, Physician (MD) said that Resident does not need antibiotics (ATBs) and gave the okay to discontinue (d/c- remove) resident's midline (a tube inserted into a vein in the upper arm with the tip ending near the armpit). RNS 1 stated the MD's telephone order should have been put in or added in Resident 100's physician's order and Resident 100's PICC line should have been removed as ordered by MD. RNS 1 stated keeping the PICC line inserted longer than needed could cause Resident 100 to get an infection. During the same interview on 4/7/2026, at 12:59 PM, with RNS 1, RNS 1 stated if the resident has a PICC line, the PICC line dressing should be changed upon admission and every seven days or as needed. RNS 1 stated Resident 100's PICC line dressing should have been changed on 4/3/2026. RNS 1 stated not changing the PICC line dressing can cause infection and accidental pulling which could cause Resident 100 to get sick and hospitalized . During an interview on 4/9/2026, at 11:23 AM, with Licensed Vocational Nurse 7 (LVN 7), LVN 7 stated Resident 100 was admitted from the GACH on 4/3/2026 with a PICC line on the resident's left upper arm. LVN 7 stated he received a telephone order from the MD on 4/3/2026 at around 9 PM to remove Resident 100's PICC line since it was no longer needed. LVN 7 stated he forgot to write and communicate the PICC line removal order to the RNS because he was busy working on Resident 100's admission. During an interview on 4/9/2026, at 12:05 PM, with the Director of Nursing (DON), the DON stated the RNS who assessed Resident 100 upon admission should have documented Resident 100's PICC line in the Clinical admission Form. The DON stated the Treatment Nurse (TN) was also responsible for assessing Resident 100's skin and should have seen Resident 100's PICC line on the resident's left upper arm. The DON stated it was important to document the PICC line to ensure proper care was provided and infection was prevented. The DON stated LVN 7 was not able to communicate the MD's order to remove the PICC line and the PICC lines should be changed every 7 days and as needed in accordance with the facility's policy. During a review of the facility's policy and procedure (P&P), titled, Physician Orders and Telephone Orders, dated 1/2004, the P&P indicated, telephone orders shall be noted promptly. During a review of the facility's P&P, titled, PICC Dressing Change, dated 3/2010, the policy indicated:Dressing changes using transparent dressings are performed 24 hours post-insertion or upon admission, at least weekly, and if the integrity of the dressing has been compromised (wet, loose, or soiled).Assessment of venous access site is performed at least once every shift when not in use.Length of external catheter and upper arm circumference (3 inches or 10 centimeters above insertion site) is obtained upon admission. During a review of the facility's P&P, titled, Quality of Care, revised on 3/2017, the P&P indicated, The facility will provide and implement comprehensive, person-centered care for all residents. All residents will receive treatment and care in accordance with professional standards of practice. During a review of the facility's P&P, titled, Charting and Documentation, revised on 7/2017, the P&P indicated the following:All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.

Based on observation, interview, and record review, the facility failed to ensure licensed staff used two (2) person identifiers (the individual's name, an assigned identification number, date of birth or another person-specific identifier) prior to administering medications to ensure the accurate acquiring, administering of drugs and biologicals to meet the needs for one (1) of 5 sampled residents (Residents 38) observed for medication administration in accordance with the facility's policy and procedure (P&P) . This deficient practice had the potential for medication errors (any preventable event that may cause or lead to inappropriate medication use) result in harm to Resident 38.Findings:During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included renal insufficiency (is a condition where kidneys cannot adequately filter waste, balance electrolytes, or manage blood pressure), asthma (is a condition in which your airways narrow and swell and may produce extra mucus), chronic obstructive pulmonary disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and colon cancer (a cancer of the large intestine, which may affect the colon or rectum) During a review of Resident 38's Minimum Data Set (MDS, a resident assessment tool) dated 3/18/2026, the MDS indicated Resident 38 had intact cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 38 was independent (resident completes the activity by themself with no assistance from a helper) in eating, oral hygiene, upper body dressing, personal hygiene, roll left and right, sit to lying, and lying to sitting on the side of the bed. During an interview on 4/8/2026 at 9:49 AM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the licensed nurse always have to use 2-person identifier before administering medications to the residents to make sure the licensed nurse is giving the correct medication to the correct resident. LVN 1 stated she checked Resident 38's electronic medication administration record (eMAR, is the digital version of the traditional paper medication administration records used in healthcare facilities) with the resident's picture on it, but she did not check Resident 38's armband to ensure it is the same name and correct resident. LVN 1 also stated she should have checked Resident 38's armband to verify the resident's identity as part of the process of the medication administration. During an interview on 4/8/2026 at 3:20 PM with the Director of Nursing (DON), the DON stated the licensed nurses need to use 2-person identifier before medication administration. The DON also stated the licensed nurses can use the e-MAR with the resident's picture and check the armband of the resident to check name and medical records number or have another licensed staff identify to verify it is the same and correct resident before giving the medication. The DON stated they have to make sure we give the right medication to the right Resident. During review of the facility's P&P titled, Medication Administration- General Guidelines, dated on 10/2017, the P&P indicated Residents are identified before medications are administered. Methods of identification include:a. checking identification bandb. checking photographs attached to medical record; andc. if necessary, verifying resident identification with other facility personnel.

Based on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medication was provided for one (1) of five sampled residents (Resident 38) observed during the medication administration as indicated in the facility's Policy and Procedure (P&P) by failing to ensure one opened bottle of Promethazine (an antihistamine medication that prevents and treats the symptoms of an allergic reaction) was properly labeled with date opened and expiration date was legible and the Promethazine bottle was stored in a locked compartment. These deficient practices have the potential for Resident 38 to have an adverse reaction (an undesired, harmful, or unpleasant effect resulting from a medication) from the potentially expired medication. Findings:During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 38's diagnoses included renal insufficiency (is a condition where kidneys cannot adequately filter waste, balance electrolytes, or manage blood pressure) , asthma (is a condition in which your airways narrow and swell and may produce extra mucus), chronic obstructive pulmonary disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and colon cancer (a cancer of the large intestine, which may affect the colon or rectum) During a review of Resident 38's Minimum Data Set (MDS, a resident assessment tool) dated [DATE], the MDS indicated Resident 38 had intact cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 38 was independent (resident completes the activity by themself with no assistance from a helper) in eating, oral hygiene, upper body dressing, personal hygiene, roll left and right, sit to lying, and lying to sitting on the side of the bed. During a concurrent observation on [DATE] at 9:44 AM with Licensed Vocational Nurse 1 (LVN 1), Promethazine bottle was taken inside the Medication Cart 2 (MC 2) and the Promethazine bottle did not have a label with the open date and it was not labeled with the expiration date. LVN 1 dispensed the Promethazine 10 milliliter (ML, measure of volume) to a medicine cup without checking the Promethazine bottle for the open date and expiration date. During a concurrent observation and interview on [DATE] at 9:52 AM with LVN 1, LVN 1 checked the Promethazine bottle and cannot find the open date and expiration date. LVN 1 stated maybe it got erased from the bottle. LVN 1 stated she did not check the Promethazine's expiration date and there was no open date labeled on the bottle. LVN 1 also stated she did not know when the medication bottle was opened and the expiration date. LVN 1 stated the licensed nurses have to check the expiration date to make sure the licensed nurse is not giving potentially expired medication to the resident because it may cause adverse reaction to the resident. LVN 1 also stated the medication bottle should be labeled with the date it was opened. During a concurrent observation and interview on [DATE] at 3:23 PM with the Director of Nursing (DON), the DON checked the Promethazine bottle from MC 2 and the DON was not able to find the label for the open date and the expiration date on the bottle. The DON stated the medication bottle was sticky, it did not have a label indicating the open date and expiration date. The DON also stated the licensed nurses needed to check the medication bottles for expiration dates before giving medications to make sure it is safe to give to the resident. In addition, the DON stated the licensed nurse should have ordered a new medication to replace the bottle and discard the Promethazine bottle since they do not know if it is still safe to use or expired already. The DON stated it is important for the licensed nurse to make sure the medication was not expired to avoid potential adverse reaction to the residents. During a review of the facility's policy and procedure (P&P) titled, Medication Ordering and Receiving from Pharmacy dated 4/2014, the P&P indicated Medications are labeled in accordance with facility requirements and state and federal laws. The P&P also indicated only the dispensing pharmacy can modify or change prescription labels. The P&P indicated:Labels are permanently affixed to the outside of the prescription container.Each prescription medication label includes date dispensed and expiration date.Improper or inaccurately labeled medications are rejected and returned to the dispensing pharmacy.Medication containers having soiled, damaged, incomplete, illegible, confusing, or makeshift labels are returned to the dispensing pharmacy for re-labeling or destroyed in accordance with the medication destruction policy.

Based on observation, interview, and record review, the facility failed to protect one of two sampled residents (Resident 1) from sexual abuse (non-consensual [without the person's permission] touching of one person for the sexual gratification of another) when Resident 2 was observed on video surveillance and by a family member (Visitor 1), pushing Resident 1 down the hallway in a wheelchair and started to touch, caress and squeeze Resident 1's right and left breast while Resident 1 repeatedly pushed Resident 2's hand away on 10/7/2025 at around 12:17 PM. This deficient practice resulted in Resident 1 being sexually abused by Resident 2 while Resident 1 repeatedly pushed Resident 2's hands away from touching her breasts. This had the potential to result in Resident 1 experiencing psychosocial effects (a person's mental, emotional, social, and spiritual health) and humiliation and placed other residents in the facility at risk for sexual abuse from Resident 2. Based on the reasonable person concept (refers to a tool to assist the survey team's assessment of the severity level of negative, or potentially negative, psychosocial outcome [psychosocial effects] of the deficiency may have had on a reasonable person in the resident's position), due to Resident 1's severely impaired cognitive skills (severely impaired (never/rarely made decisions), an individual subjected to abuse may have psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for yourself). On 10/9/2025 at 11:40 AM, the California Department of Public Health (CDPH) called an Immediate Jeopardy situation (IJ, a situation in which the facility'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 to a resident) in the presence of the Director of Nursing (DON) and the Administrator (ADM), due to the facility's failure to protect Resident 1 from sexual abuse by Resident 2 on 10/7/2025. On 10/10/2025 at 5 PM, the facility provided CDPH with an acceptable Immediate Jeopardy Removal Plan (IJRP, action to correct the deficient practice). While onsite and after the surveyor verified/confirmed the facility's full implementation of the IJ Removal Plan through observation, interview and record review, and determined the IJ situation was no longer present, the IJ was removed onsite, in the presence of ADM and the DON. After the IJ was removed, the surveyor verified that the facility's non-compliance remained at a lower scope and severity (refers to the seriousness of the harm to the residents) of G (isolated -refers to the deficiencies affecting a very limited number of resident/s with actual harm (means the resident have experienced a negative outcome or injury due to the non-compliance), that was not immediate jeopardy. The IJ Removal Plan dated 10/10/2025, included the following: 1. On 10/7/2025, Resident 1 and Resident 2 were separated by the licensed nurse (not specified) to ensure safety. Licensed nurse assisted Resident 1 back to the resident's room and another licensed nurse (not specified) assisted Resident 2 back to Resident's 2 room. No room changes were needed because both rooms are in separate hallways far away from each other. 2. On 10/7/2025, Resident 1 was assessed by the licensed nurse, Director of Nursing, and Social Services Director (SSD). Emotional support and reassurance were provided to Resident 1. 3. On 10/7/2025, the Registered Nurse (RN, not specified) communicated with Resident 1's Physician (MD) and family. MD expressed confidence and agreement with continued care at the facility. The DON obtained MD orders for Psychologist (a health practitioner that specializes in the study of mind and behavior or in the treatment of mental, emotional, and behavioral disorders) evaluation, monitor for any potential emotional or mood changes such as sudden mood changes, irritability, withdrawal, sadness, anxiety (fear characterized by behavioral disturbances), emotional outbursts related to alleged incident involving another resident. The licensed nurses will document Resident 1's monitoring in the Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident).4. On 10/7/2025, the DON obtained MD order for Resident 2 to be placed on one (1) to 1 supervision (1:1 supervision, an intervention when a nurse or healthcare professional provides constant observation and support to a resident who is at risk of harm, such as one with cognitive [mental action or process of acquiring knowledge and understanding] impairments, challenging behaviors, or one who may fall or cause harm to himself/herself or to others) for safety and close monitoring. On 10/8/2025 the Psychologist evaluated Resident 2, and the Psychologist stated Resident 2 remained calm and stable. The Psychologist will visit Resident 2 weekly to determine if 1:1 supervision is still needed. Resident 2 will remain on 1:1 supervision for safety until the Psychologist determines the resident is clinically stable. Additionally, the 1:1 supervision will be documented on a monitoring log (Activity/Visual Monitoring Log). 5. On 10/7/2025, the RN notified Resident 2's family and MD. The MD confirmed that Resident 2's current placement is appropriate. The DON obtained orders from MD to monitor Resident 2 for potential triggers that could result in inappropriate action or physical contact. The order also included ensuring redirection (technique used in health care setting to shift a person's focus away from a distressing situation and/ or used to manage challenging behaviors like agitation by diverting attention to a calmer or more positive activity), prioritizing safety and notifying the MD of any episodes. Licensed nurses will be responsible for monitoring every shift and document in the MAR. 6. On 10/7/2025, Resident 1 was evaluated by Psychiatrist (a health practitioner that specializes in the diagnosis and treatment of mental illness). According to the Psychiatrist's evaluation Resident 1 did not have behavioral changes noted. The Psychiatrist made recommendations to continue to monitor Resident 1.7. Effective 10/7/2025, Resident 2 will remain on 1:1 supervision and followed by the Psychologist weekly for four weeks to provide ongoing psychosocial support and behavior monitoring. Social Services will provide psychosocial (relating to the interrelation of social factors and individual thought and behavior) support and daily visits for 72 hours then weekly thereafter for 8 weeks for Resident 1 and 2.8. On 10/7/2025, Resident 2 was evaluated by the Psychiatrist. According to the Psychiatrist's evaluation, Resident 2 did not display mood or safety concern. The Psychiatrist made recommendations to continue to monitor Resident 2.9. On 10/8/2025, Resident 1 was evaluated by the Psychologist with no mood changes. The Psychologist made recommendations for Psychologist's visits for weekly evaluations until further notice. 10. On 10/8/2025, the Psychologist evaluated Resident 2 and determined that Resident 2's behavior is stable and will continue weekly visits until further notice. Resident 2 will remain on 1:1 supervision until the Psychologist determines Resident 2 is stable.11. On 10/9/2025, Facility initiated hallway monitoring to ensure Resident 1 and 2 remain separated.12. On 10/9/2025, Interdisciplinary Team (IDT, means a group of professional and direct care staff that have primary responsibility for the development of a plan for the care and treatment of a patient) conducted a care plan (a comprehensive document that outlines the specific healthcare needs, goals, and interventions for a resident) meeting with Resident 2's family members' and updated the care plan interventions as follows: Continue 1:1 supervision until the Psychologist determines Resident 2 is clinically stable. The Psychologist will continue the weekly visit for four (4) weeks then monthly. Monitor Resident 2 for potential triggers that could result in inappropriate actions or physical contact.13. On 10/9/2025, the ADM, the DON, and Director of Staff Development (DSD) notified the facility staff (all staff- licensed nurses, certified nurse assistant (CNAs), department staff, housekeeping, and dietary) of the IJ findings and initiated an Abuse Prevention in-service covering: Identification of situations where abuse, neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress), or misappropriation of property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) may occur to prevent abuse. Protection of residents from abuse. Immediate intervention, correction, and mandatory reporting of abuse.14. As of 10/10/2025, 122 out of 135 active staff members have received the abuse prevention in-service. 13 active staff members are currently on leave of absence and will receive the training prior to returning to duty.15. On 10/9/2025, the ADM notified the Medical Director and Clinical Consultant of the IJ findings. On 10/10/2025, The Medical Director and Clinical Consultant reviewed and approved the IJ Removal Plan.16. On 10/9/2025, the SSD, Social Services Assistant (SSA) and Minimum Data Set Nurse (MDSN, nurse who specializes in collecting, analyzing, and documenting patient data) conducted interviews with all alert and oriented residents to assess any concerns related to abuse. For residents unable to be interviewed due to cognitive or physical limitations, behavioral and facial expressions observations were conducted. There were no reports of abuse, neglect, or mistreatment identified among any residents.17. On 10/10/2025, after re-assessment, the DON confirmed that there are only 3 residents (Residents 1, 3, and 4) who are wanderers and cognitively impaired which may make them vulnerable for abuse. On 10/20/2025, the DON updated Residents 1, 3 and 4 's care plan to include hourly whereabouts monitoring and documented in the MAR to address their wandering risk.18. Effective 10/9/2025, the RN or designee will conduct 30-minute safety rounds every shift for 90 days throughout the facility hallways to ensure all residents are safe and free from abuse. The monitoring will be documented in the Hallway Monitoring log for 90 days. 19. Effective 10/9/2025, the ADM and the DON will conduct monthly abuse prevention in-services for three months, reinforcing the following: Recognition of situations where abuse, neglect, or misappropriation of resident's property may occur to prevent abuse and protection of residents from abuse. Immediate intervention, correction, and reporting of abuse requirements.20. Effective 10/9/2025, discussion of abuse prevention compliance and resident safety including any concerns related to behavioral triggers and wandering to ensure residents are free from abuse will be a standing agenda item in the daily stand-up meetings to ensure ongoing communication and staff accountability.21. On 10/9/2025, the DON created Daily Abuse Prevention Monitoring Log to identify and document any situations where abuse, neglect or misappropriation of resident property, safety rounds and staff compliance checks. This monitoring log will be used during the ADM and the DON's daily rounds which include the date, resident's name, room number and specific findings/concerns, along with any necessary follow-up action22. The ADM and the DON are responsible for reviewing the hallway monitoring logs daily and submitting summaries to the Quality Assessment and Assurance (QAA, to develop and implement appropriate plans of action to correct identified quality deficiencies) Committee (a group in healthcare settings, particularly nursing homes, that oversees a facility's Quality Assurance and Performance Improvement [QAPI, data driven approach to improve the quality of care and safety in nursing homes] program) for review and follow-up.23. The Administrator, DON, or RN Supervisor will make daily facility rounds x 90 days to ensure staff's adherence to the Abuse Prevention Program. Findings and corrective actions will be documented on the monitoring log.24. The facility has initiated a QAPI Project for Abuse Prevention. The QAPI Committee will review compliance and outcomes monthly for three months and revise interventions as necessary to ensure ongoing effectiveness and sustainability. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and metabolic encephalopathy (disease affecting how brain works). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 8/6/2025, the MDS indicated Resident 1's cognitive skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 1 was dependent (helper does all the effort) with oral hygiene, toileting hygiene, shower, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 1 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) once seated in wheelchair and while wheeling herself at least 150 feet. During a review of Resident 1's Change of Condition (COC, significant change in resident's status that requires intervention) assessment form dated 10/7/2024, timed 1:30 PM, the COC indicated a family member (Visitor 1) reported to nursing staff that Visitor 1 had witnessed another resident inappropriately touching Resident 1. During a review of Resident 1's Psychiatry Progress note dated 10/7/2025, reason for consult indicated urgent for abuse allegations. The note indicated per reports from other resident's family member (Visitor 1), Resident 2 touched Resident 1 inappropriately while Resident 1 is sitting in the wheelchair. 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included dementia, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated Resident 2 was independent (resident completes the activity by themselves with no assistance from a helper) with oral hygiene and personal hygiene. The MDS indicated Resident 2 required set up or clean up assistance (helper sets up or cleans up, resident completes activity) with eating, upper body dressing, lower body dressing, putting on/taking off footwear and walking at least 50 feet to 150 feet in a corridor or similar space. During a review of Resident 2's COC dated 10/7/2025, timed at 1:25 PM, the COC indicated a situation of alleged inappropriate touching another resident (details not specified). Licensed Vocational Nurse 1 (LVN 1) documented LVN 1 was notified by Visitor 1 that Resident 2 was seen touching another resident's breast in the hallway. During a review of Resident 2's order listings for the month of October 2025, an order of one-to-one monitoring, every shift was ordered on 10/7/2025 at 5:22 PM. During a review of undated Visitor 1's documented witness statement, the witness statement indicated the following: On 10/7/2025, Tuesday, around 12:30 PM, when Visitor 1 was feeding another resident (Visitor 1's mom), Visitor 1 was standing beside the mom's chair, then Visitor 1 saw a guy (Resident 2) pushing an old lady's (Resident 1) wheelchair, his (Resident 2) hand was on the lady's (Resident 1) shoulder and then slid down the breast. Visitor 1's written witness statement also indicated, then the lady (Resident 1) was pushing away the guy's (Resident 2) hand. During a concurrent observation and interview with the ADM on 10/8/2025 at 1:40 PM, the facility's video surveillance dated 10/7/2025, timed between 12:15 PM and 12:20 PM was reviewed. Video surveillance showed a recording of Resident 2 standing in the hallway where Resident 1 was passing by while the resident is in her wheelchair. The video surveillance showed Resident 2 started to walk behind and started pushing Resident 1's wheelchair. The video surveillance showed Resident 2 caressed Resident 1's right breast at 12:17:00 PM, and at 12:17:03 PM, Resident 1 was observed pushing off Resident 2's right hand away from Resident 1's right breast. The video surveillance also showed Resident 2 was caressed Resident 1's left breast at 12:17:07 PM, and at 12:17:08 PM, Resident 1 was observed pushing off Resident 1's left hand away from Resident 1's left breast. The ADM verified, the female resident in the wheelchair in the video surveillance is Resident 1, and the male resident behind the wheelchair and pushing Resident 1's wheelchair was Resident 2. The ADM also verified that the family member seen in the video surveillance from 12:17:07 to 12:17:08 was Visitor 1 who witnessed the incident between Resident 1 and 2 and reported the incident to CNA 1. During a concurrent observation in Resident 1's room and an attempt for an interview with Resident 1 on 10/8/2025 at 1:59 PM, Resident 1 was nonverbal. When approached and asked about the incident, Resident 1 could not answer and the resident with a flat affect (a reduced or absent display of emotions in a person's facial expressions, tone of voice, and body language. It is a symptom that can be associated with various mental health conditions). During an attempt for an interview with Resident 2 on 10/8/2025 at 2:02 PM, Resident 2 did not answer the question when asked about the incident on 10/7/2025 with Resident 1. During an interview on 10/8/2025 at 2:37 PM with SSD, SSD stated, yesterday (10/7/2025), the ADM informed SSD that CNA 1 stated Visitor 1 witnessed Resident 1's right breast was touched in circular motion by Resident 2. During an interview on 10/8/2025 at 3:15 PM with LVN 1, LVN 1 stated, on 10/7/2025 (unable to recall time), CNA 1 reported to LVN 1 that Resident 1 was touched on the resident's breast by Resident 2, and Resident 1 pushed it off. During a concurrent record review and interview with the DON on 10/8/2025 at 4:30 PM, facility's video surveillance dated 10/7/2025, timed between 12:15 PM and 12:20 PM was reviewed. The DON stated the video surveillance showed that Resident 1 pushed away Resident 2's hand when Resident 2 touched or massaged Resident 1's right and left breast. The DON stated, this showed Resident 1 was not comfortable or does not want Resident 2 touching or massaging Resident 1's breasts. During an interview with Visitor 1 on 10/9/2025 at 12:40 PM, Visitor 1 stated, on 10/7/2025 at approximately 12:30 PM, Visitor 1 witnessed a female (Resident 1) resident's chest area was being touched by a male resident (Resident 2). Visitor 1 stated she witnessed the female resident (Resident 1) removed the male resident's (Resident 2) hand from the female resident's chest, and Visitor 1 added So, I think she (Resident 1) did not like it. Visitor 1 also stated it is not normal and appropriate for a male resident to touch a female's chest area that is why Visitor 1 reported what she witnessed to CNA 1. During a concurrent record review and interview with MDSN on 10/9/2025 at 1:25 PM, facility's video surveillance dated 10/7/2025, timed between 12:15 PM and 12:20 PM was reviewed. MDSN stated Resident 2's action of pushing Resident 1's wheelchair and touching and squeezing Resident 1's breasts several times was not appropriate and normal. MDSN stated according to the video, Resident 2 was observed squeezing and trying to feel Resident 1's private area (part of the body that is usually covered by clothing) which was Resident 1's breast. MDSN stated this behavior is considered sexual abuse by Resident 2 to Resident 1 and can cause psychosocial effects on Resident 1. During a concurrent observation and interview with the DON on 10/10/2025 at 4:39 PM, the facility's video surveillance dated 10/7/2025, timed between 12:15 PM and 12:20 PM was reviewed. The DON stated according to the video surveillance, Resident 2 was observed caressing Resident 1's breast two times. The DON stated this incident is not acceptable, because there is dignity issue and invasion of privacy. The DON stated this incident is an abuse and can cause decline with Resident 1's wellbeing and can affect Resident 1's mood. During a review of the facility's Policy and Procedure (P&P) titled Resident Rights, revised in February 2021, the P&P indicated Federal and State laws guarantee certain basic rights to all residents of the facility and these rights include the resident's right to be treated with respect, kindness and dignity. The P&P also indicated, resident has the right to be free from abuse. During a review of the facility's P&P titled Abuse, Neglect, Exploitation (taking advantage of a resident for personal gain) and Misappropriation Prevention Program, revised in April 2021, the P&P indicated Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The P&P also indicated, this includes but is not limited to freedom from corporal punishment (which is physical punishment, is used as a means to correct or control behavior, includes, but is not limited to, pinching, spanking, slapping of hands, flicking, or hitting with an object), involuntary seclusion (separation of a resident from other residents or from her/his room or confinement to her/his room against the resident's will, or the will of the resident representative), verbal, mental, and sexual or physical abuse.

Based on observation, interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) received adequate supervision and assistance to prevent accidents and injuries, by failing to provide the assistance needed to Resident 1who was assessed to be dependent (helper does all effort needed to complete activity) to facility staff while toileting on 7/21/2025. This deficient practice resulted in Resident 1 having an unwitnessed fall and being found sitting in front of the toilet in the resident's restroom after the resident was left unattended by facility staff on 7/21/2025. Resident 1 experienced left inner thigh pain with a rating of 7 out of 10 (a tool for assessing pain intensity using scale 0 to 10, where 0 represents no pain and 10 represents the worst pain imaginable). Resident 1 underwent x- ray (an imaging study that takes pictures of bones and soft tissues) of left upper leg (femur/ thigh bone) on 7/21/20245 and result showed a left acute minimally displaced intertrochanteric fracture (a break in the upper part of the thigh bone [femur], specifically in the area between the femoral neck and the lesser trochanter [a bony prominence or projection on the femur near the hip joint, serving as an attachment site for muscles], where the broken pieces have shifted out of alignment). Resident 1 was sent to General Acute Care Hospital (GACH) emergency room (ER) on 7/21/2025, admitted to the GACH's medical surgical unit (a specialized area where patients receive care for a wide range of medical and surgical conditions. These units handle patients recovering from surgery, managing chronic illnesses, or requiring treatment for acute medical issues) on 7/22/2025 and underwent left hip open reduction internal fixation (ORIF- a surgical procedure used to treat fractures or dislocations by realigning the broken bones and stabilizing them with screws, plates, or rods) on 7/25/2025. Resident 1 stayed in GACH from 7/22/2025 until 7/28/2025 (7 days). Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], with diagnoses that included cerebral infarction (also known as a stroke, a condition where part of the brain tissue dies due to a lack of blood supply) and dementia (a progressive state of decline in mental abilities). The admission records also indicated diagnosis of history of falling with onset (the first date that a resident experiences the first symptoms of a medical condition) on 2/3/2025 and repeated falls with onset date of 4/16/2025. During a review of Resident 1's Fall Risk Evaluation, dated 7/14/2025, the Fall Risk Evaluation indicated Resident 1 is at a high risk of falls. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/16/2025, the MDS indicated Resident 1 had severely impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 1 was dependent (helper does all effort needed to complete activity) with toileting hygiene (the ability to maintain perineal hygiene [refers to the care and cleaning of the region between the genitals and the anus]), shower/bathing and lower body dressing and substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with personal hygiene and upper body dressing. The MDS indicated Resident 1 had impairments on both lower extremities (hips, knees, ankles, feet), substantial/maximal assistance with sit to stand mobility (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and toilet transfers (the ability to get on and off a toilet or commode) were not evaluated due to medical condition or safety concerns. The MDS also indicated a bed and w/c alarm were used in Resident 1's care. During a review of Resident 1's Change of Condition (COC)/Situation, Background, Assessment, Recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Interact Assessment Form, dated 7/21/2025, the COC/ SBAR Assessment Form indicated Resident 1 had an unwitnessed fall at 8:50 AM and was found sitting in front of the toilet in the resident's restroom. The COC/ SBAR Assessment Form indicated the assigned Certified Nursing Assistant (CNA) 2 assisted Resident 1 onto a shower chair and into the resident's restroom, then left [the restroom] to grab something from Resident 1's bed. The COC/SBAR indicated CNA 2 then found Resident 1 sitting on the restroom floor. The COC Assessment Form also indicated Resident 1 stated tried to stand up to grab the toilet paper in front of the resident when Resident 1 lost her balance and fell onto the floor. The COC/ SBAR Assessment Form indicated at 2:43 PM, Resident 1 complained of left inner thigh pain with a rating of 7 out of 10 and Norco (the brand name of a medication that combines two pain-relieving drugs: hydrocodone and acetaminophen) 5-325 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) was administered to Resident 1. During a review of Resident 1's Medication Administration Record (MAR), dated 7/21/2025, the MAR indicated Resident 1 received 1,000 mg of Tylenol (brand name for acetaminophen; a pain medication) for 6 out of 10 left thigh pain and Norco for 7 out of 10 left extremity (left leg) pain. During a review of Resident 1's Order Summary Report, dated 7/21/2025, the Order Summary Report indicated for a statim (stat- urgent, without delay) x-ray of left upper leg (femur) due to complaints of pain status post (s/p - after) fall. During a review of Resident 1's Radiology Results Report, dated 7/21/2025, the Radiology Results Report indicated findings of a left minimally displaced acute intertrochanteric fracture. During a review of Resident 1's Order Summary Report, dated 7/21/2025, the Order Summary Report indicated to transfer to GACH ER for further evaluation related to acute minimally displaced intertrochanteric fracture due to s/p fall 7/21/2025. During a review of Resident 1's GACH records titled History & Physical (H&P), dated 7/22/2025, the H&P indicated Resident 1 chief complaint of left hip fracture after a mechanical fall with a left minimally displaced acute intertrochanteric fracture and Resident 1 was complaining of significant pain with movement. The H&P also indicated, Resident 1 was admitted to GACH's medical surgical unit (a specialized area where patients receive care for a wide range of medical and surgical conditions. These units handle patients recovering from surgery, managing chronic illnesses, or requiring treatment for acute medical issues). During a review of Resident 1's GACH records titled Consultation: Orthopedic Surgery, dated 7/22/2025, the Consultation form indicated Resident 1 was scheduled for left hip open reduction internal fixation (ORIF- a surgical procedure used to treat fractures or dislocations by realigning the broken bones and stabilizing them with screws, plates, or rods) on Friday 7/25/2025 at 2:00 PM. During a review of Resident 1's GACH record titled Progress Note, dated 7/25/2025 and timed 10:00 AM, the Progress Note indicated Resident 1 was in the recovery room status post ORIF to treat acute left hip fracture. During a review of Resident 1's GACH Femur X-ray Radiology Report, dated 7/25/2025, the Radiology Report indicated Resident 1 was s/p left hip surgery (date not indicated) with a compression screw and nail now noted within the left femur. During a review of Resident 1's GACH Patient Discharge Summary, dated 7/28/2025, the Discharge Summary indicated Resident 1 had an ORIF on the left hip and will be discharged back to the facility. During a review of Resident 1's MAR, (from the facility) dated 7/28/2025, the MAR indicated Resident 1 was admitted at the facility on 7/28/2025. The MAR also indicated Resident 1 received Tylenol 650 mg for 3 out of 10 left femur fracture pain. During a review of Resident 1's Falling Star Program care plan, revised 7/29/2025, the care plan indicated Resident with falls [in the facility] on 6/8/2025, 7/14/2025 and 7/21/2025 with the goal to reduce risk of falls and/or injury through appropriate intervention(s) daily until the next assessment. The care plan also indicated Resident 1 overestimates her ability to perform tasks independently. During a review of Resident 1's MAR, dated 8/4/2025, the MAR indicated Resident 1 received Norco 5-325 mg for 10 out of 10 left toe pain. During an interview on 8/6/2025 at 10:04 AM with Resident 1, Resident 1 stated she cannot remember what happened with her fall, but she was currently still having left leg pain. During an interview on 8/6/2025 at 1:32 PM with the CNA 2, CNA stated she was taking care of Resident 1 on 7/21/2025 when the fall occurred. CNA 2 stated she assisted Resident 1 onto a shower chair (assistive equipment designed to provide a safe and stable seating option in a shower or bathtub) and moved the shower chair to the toilet so that Resident 1 can use the restroom prior to the resident's shower. CNA 2 stated, CNA 2 left Resident 1 unattended in the restroom to grab wipes from Resident 1's bed. CNA 1 stated when CNA 2 was outside the restroom to grab the wipes, CNA 2 then heard a noise that was really heavy, went back into the restroom and found Resident 1 sitting on the floor in front of the toilet. During an interview on 8/6/2025 at 1:45 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was assigned to Resident 1 on 7/21/2025 and responded to Resident 1 after the fall and was not there when the fall occurred. LVN 2 stated Resident 1 was in the restroom, when CNA 2 left Resident 1 alone while the resident is using the toilet to grab something from Resident 1's bed, then Resident 1 had an unwitnessed fall. LVN 2 stated Resident 1 is known for trying to be independent with activities of daily life (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) despite needing assistance and has a history of falls in the facility. During an interview on 8/7/2025 at 2:42 PM with LVN 3, LVN 3 stated Resident 1 has periods of cognitive confusion, attempts to be independent with ADLS when Resident 1 believes she can complete the task. LVN 3 stated Resident 1 should not have been left alone in the restroom by CNA 2 on 7/21/2025 because it was unsafe for Resident 1 with the resident's cognition and history of falls. LVN 3 also stated leaving Resident 1 alone in the restroom was unsafe because there was no alarm on the shower chair to alert staff if she was attempting to move and without the alarm or staff supervision, staff cannot ensure resident is safe and does not fall. In addition, LVN 3 stated Resident 1 ultimately had a fall requiring hip surgery after being left alone in the restroom. During an interview on 8/7/2025 at 3:46 PM with the Director of Nursing (DON), the DON stated Resident 1 was left alone by staff on 7/21/2025 after stepping away to grab something from Resident 1's bed and it was unsafe to leave Resident 1 alone because Resident 1 was high risk for falls and according to Resident 1's MDS, Resident 1 is dependent to staff for toileting. The DON stated Resident 1 fell because the resident did not receive the necessary supervision and assistance during toileting. The DON stated, Resident 1 was left alone and unattended during toileting on 7/21/2025 and if Resident 1 was not left unattended, the fall could have been prevented. The DON also stated Resident 1 sustained a fracture to the left hip due to the fall on 7/21/2025. During a review of the facility's P&P titled Safety and Supervision of Residents, revised 7/2017, the P&P indicated:a. The facility strives to make the environment as free from accident hazards as possible.b. Resident safety, supervision and assistance to prevent accidents are facility-wide priorities.c. Facility utilizes resident-centered approach to address safety and accident hazards for individual residents.d. Resident supervision is a core component to the system approach to safety and the type and frequency of resident supervision is determined by the resident's assessed needs and identified hazards in the environment. During a review of the facility's policy and procedures (P&P) titled Falls and Fall Risk, Managing, revised 3/2023, the P&P indicated:a. Based on previous evaluations and current date, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.b. Resident conditions that may contribute to the risk of falls include cognitive impairments and delirium (a serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking), incontinence and lower extremity weakness.

Based on observations, interviews and record reviews, the facility failed to ensure proper and effective basic life support ( level of medical care which is used for victims of life-threatening illnesses or injuries until they can be given full medical care at a hospital, and may include recognition of sudden cardiac arrest, activation of the emergency response system) including cardiopulmonary resuscitation (CPR: an emergency lifesaving procedure performed when the heart stops beating) was continuously performed for 1 of 65 identified full code (full support which includes, if the resident has no heartbeat and was not breathing) residents (Resident 1) in the facility during a code blue (an unexpected cardiac or respiratory arrest requiring resuscitation) by: 1. Licensed Vocational Nurse 1 (LVN1), LVN 2 and Certified Nurse Assistant 1 (CNA1) not placing Resident 1 in a supine (lying facing upward) position and placing the resident on a firm flat surface while performing CPR. 2. LVN 1 and CNA 1 not performing continuous, and uninterrupted CPR until emergency medical services (EMS, ambulance services or emergency services that provide treatment and stabilization for the patient) took over. 3. The facility staff did not complete the Emergency Cart 1 (EC #1: A movable collection of emergency equipment and supplies meant to be readily available for resuscitative effort) content checklist to ensure EC #1 content were complete and in working order from [DATE] to [DATE]. These deficient practices resulted in Resident 1 ' s death on [DATE] at 5:40 AM and placed the facility ' s identified 65 full code residents at risk to not receive effective and proper life-saving measures during a code blue, potentially leading to greater harm and/or death to other residents residing in the facility. On [DATE] at 5:45 PM an Immediate Jeopardy (IJ: a situation in which the facility ' s ' noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) regarding the facility's failure to provide continuous and effective basic life support (BLS) including CPR when Resident 1, who is full code was found unresponsive on [DATE] at 5:30 AM. On [DATE] at 12:04 PM the IJ was removed after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyor verified and confirmed the implementation of the Plan of Action (POA) while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM and DON. The acceptable IJ Removal Plan included the following: 1. The Administrator scheduled a CPR training recertification from a certified CPR/BLS instructor from American Professional Ambulance Company. Ambulance company staff will provide CPR training recertification to all CNAs, LVNs, Registered Nurses (RNs), Physical Therapists (PTs), Occupational Therapists (OTs), Physical Therapist Aide (PTAs) and Occupational Therapists Aide (OTAs) to be done in groups of 20. The first session was conducted on [DATE] at 2 PM and 3 PM and two more sessions on [DATE] at 2 PM and 3 PM for the remainder of the staff. 2. The DON and Director of Staff Development (DSD) initiated In-services/education using demonstration to the RNs, LVNs and CNAs on [DATE] and will completed the in-service/education to the remaining RNs, CNAs and LVNs on [DATE] regarding Emergency Services Response including CPR. During the in-service, the DON and DSD provided demonstration on proper positioning of resident during CPR, bag- valve- mask (BVM: a bag valve mask, sometimes known by the proprietary name Ambu bag or generically as a manual resuscitator or self-inflating bag, is a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) mask connection to oxygen source, checking resident's code status and the importance of continuous CPR until EMS takes over the care. The DON and DSD also in-serviced the RNs and LVNs on [DATE] to check Emergency cart 1 and Emergency cart 2 each shift to ensure the cart was efficiently supplied with the necessary emergency items as listed on the checklist and testing the Oxygen (02) gauge (reduces, controls, and measures the flow of oxygen to the patient to ensure a safe and effective working pressure), 02 tank (a metal cylinder containing oxygen under pressure) and suctioning machine (medical equipment that is used to remove obstructions from a person's airway), to ensure functionality. In addition, DSD provided one- to- one (1:1) demonstration/In-service to LVN 2 on [DATE] and provided 1:1 demonstration/in-service to CNA 1 on [DATE] regarding Emergency Services Response including CPR with return demonstration. 3. Effective [DATE], Emergency cart 1 and Emergency cart 2 was checked every shift by the RN Supervisor or Charge Nurse assigned to ensure the Emergency carts were efficiently supplied with the necessary emergency items as listed on the emergency cart checklist and testing the 02 Gauge, 02 tank and suctioning machine to ensure functionality. Effective [DATE], the DON will review Emergency Cart 1 and Emergency Cart 2 checklists weekly to ensure both carts are being checked and signed by RN Supervisor or Charge Nurse each shift. 4. Medical Records representative will conduct a daily audit of Emergency Cart 1 and Emergency Cart 2 checklists to ensure compliance and notify the DON of any findings for immediate action. Medical Records Assistant revised the Emergency Cart 1 and 2 checklists to remove the basic tracheostomy care kit and added the 02 key (used for opening the valve on oxygen/medical air cylinders) to the checklist. 5. All full code residents have been identified and an identifying sticker was placed on each resident medical chart for the nurses to easily identify full code residents. On [DATE], the RN Supervisor on duty for 3 PM to 11 PM shift stayed until [DATE] at 6 AM to provide supervision, assistance and guidance if needed during an emergency situation that would require CPR. The DON relieved (took over) RN supervisor after6 AM on [DATE]. 6. Administrator implemented a competency checklist for Emergency response/CPR effective [DATE] for LVNs, RNs and CNAs to be completed upon hire and annually thereafter and as needed. The competency checklist will be signed off by DSD or DON designee. 7. All the above actions taken was incorporated and updated the facility ' s Cardiopulmonary Resuscitation (CPR) policy and procedure. Findings: A review of Resident 1 ' s Admission Record indicated an initial admission to the facility on [DATE], and readmission on [DATE] with diagnoses of congestive heart failure (the heart is unable to pump blood throughout the body efficiently), end stage renal failure (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis [a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly] or a kidney transplant to maintain life), and dependence on renal dialysis. A review of Resident 1 ' s History and Physical dated [DATE], indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1 ' s Physician Orders for Life-Sustaining Treatment (POLST: a physician order that documents and directs the patient ' s medical considerations regarding life-sustaining interventions) dated [DATE], indicated to attempt CPR, and to provide full treatment (primary goal of prolonging life by all medically effective means). A review of Resident 1 ' s annual Minimum Data Set (MDS: a standardized assessment and care planning screening tool) dated [DATE], indicated Resident 1 required extensive assistance (staff provide weight bearing support) with one-person assist for bed mobility and eating. Resident 1 was totally dependent (full staff performance) with two- person assist for transfers. Resident 1 was totally dependent and required one- person assist for dressing, toilet use, and personal hygiene. A review of Resident 1 ' s Change of Condition (COC) Assessment Form, dated [DATE], indicated Resident 1 ' s symptom (not specified) onset began at 5:30 AM. The COC indicated Resident 1 expired. The COC indicated the current blood pressure was ,d+[DATE] millimeter per mercury (mmHg, unit of measurement), pulse was nine (9) beats per minute, temperature was 51 degrees Fahrenheit (F: a temperature scale) and indicated Resident 1 was a full code. The COC indicated LVN1 last witnessed Resident 1 responsive at 3:30 AM, in which LVN 1 spoke to Resident 1 and closed Resident 1 ' s glass sliding door. The COC indicated at 5:30 AM, Resident 1 was found unresponsive by LVN1, who then initiated a Code Blue (an unexpected cardiac or respiratory arrest requiring resuscitation). The COC indicated CPR was initiated by LVN1, while LVN2 obtained the EC #1. The COC indicated LVN1 called 911 (a number to contact emergency services) on speaker phone while doing chest compressions (hands to push down hard and fast in a specific way on the person's chest. Compressions are the most important step in CPR) on Resident 1. The COC indicated at 5:38 AM, EMS arrived and entered Resident 1 ' s room. The COC indicated EMS personnel verified Resident 1 ' s code status, and that Resident 1 had expired at 5:40AM. During an interview on [DATE] at 7:08 AM, LVN2 stated on [DATE] at 5:30 AM, a code blue was called and LVN2 brought EC #1 to Resident 1 ' s room and assisted in performing CPR and used a BVM on Resident 1 while LVN1 did chest compressions. LVN2 stated Resident 1 was not completely lying flat in bed when CPR was performed since Resident 1 ' s bed was stuck[LI4] in a sitting position.LVN 2 stated the resident ' s head of bed (HOB) was elevated at a 15-degree angle and were unable to lay Resident 1 ' s HOB flat. LVN2 stated while performing CPR on Resident 1, LVN1, LVN2 and CNA1 did not utilize a CPR board (used to provide a flat and hard surface beneath a person who requires chest compressions to pump blood through his or her circulatory system). LVN 2 stated Resident 1 ' s mattress was not hard. LVN2 stated when EMS arrived, LVN2 left the resident ' s room to open the facility ' s front floor. LVN2 stated, LVN 1 and CNA 1 should have performed the CPR continuously on Resident 1 until EMS took over of the chest compressions/ CPR. During an interview on [DATE] at 7:32 AM, the DON stated while performing CPR, a resident must be lay flat and on a firm and hard surface to ensure CPR was effective. The DON stated if a resident was not lying completely flat and on hard surface, CPR was ineffective since the required depth of compressions during CPR was not achieved. During a concurrent interview and record review of EC #1 ' s Emergency Cart Content Checklist on [DATE] at 7:52AM, the Emergency Cart Content Checklist for February 2023 indicated no documented evidence that EC #1 was checked from [DATE] to [DATE]. The DSD stated, it was blank meaning the checklist was not done, and that the checklist should have been completed daily and on every shift by the RN supervisor. The DSD further stated the RN supervisors are responsible for informing the DSD when items needed to be replaced and to replace the missing items from the emergency cart right away. The DSD stated the facility had another emergency cart, EC #2, which was kept downstair in the rehabilitation room. The DSD stated when staff are performing CPR, a resident must be lying flat and on a hard surface to prevent a resident from bouncing up and down during chest compressions, since that would be ineffective. The DSD stated, in service training for BLS had not been provided by the facility or offered to facility staff for at least one year. During an interview on [DATE] at 9:06 AM, RN1 stated charge nurses, RN supervisors and the DON were responsible for checking and ensuring EC #1 ' s content were complete and in working order. RN1 stated on days that RN1 worked in the facility, RN1 had never checked EC#1 if contents were complete and in working order and did not know who checks EC #2. During an interview on [DATE] at 10:35 AM, EMS personnel 1 stated on [DATE], upon arrival to the facility for Resident 1, EMS personnel 1 observed the resident in a high fowler ' s position (seated upright with spine straight. The upper body is between 60 degrees and 90 degrees) and not supine (lying on the back or with the face upward) and there was no CPR board utilized. The EMS personnel 1 stated CPR was not being performed on the resident, and LVN1 was standing at Resident 1 ' s foot of bed, holding the BVM in her hand and another staff (unnamed) was standing at the bedside. The EMS personnel 1 asked LVN 1 why CPR was stopped, LVN1 could not answer. The EMS personnel 1 stated when a resident is identified as being unconscious with no chest rise or pulse, CPR should be initiated immediately, and resident should be placed on a hard, flat surface for CPR to be adequate and effective. The EMS personnel 1 stated Resident 1 had a simple face mask (used to deliver a low to moderate amount of oxygen) that was not connected to oxygen and the oxygen tank was missing the oxygen regulator/ oxygen gauge (reduces, controls, and measures the flow of oxygen to the patient to ensure a safe and effective working pressure). During an interview on [DATE] at 10:50AM, in the presence of the EMS personnel 1, EMS personnel 2 stated upon arrival to the facility on [DATE], Resident 1 was observed in a high fowlers position with Resident 1 ' s head flopping around and chin touching her chest, closing Resident 1 ' s airway. EMS personnel 2 stated LVN1 could not state why CPR was stopped after identifying Resident 1 was a full code. EMS personnel 2 stated Resident 1 ' s jaw was stiff, and Resident 1 had lividity (bluish-purple discoloration of skin after death) on her back side and upper thighs. EMS personnel 2 stated, Resident 1 was not hooked up to oxygen since the EMS personnel 2 observed the BVM reservoir (part of BVM, a bag reservoir, which can be filled with pure oxygen from a compressed oxygen source, thus increasing the amount of oxygen delivered to the patient to nearly 100%) not inflated. During an interview on [DATE] at 1:24 PM, LVN 1 stated as she was getting ready to administer medication to Resident 1 on [DATE] at 5:30AM, LVN1 found Resident 1 unresponsive. LVN1 stated CNA1 went to Resident 1 ' s bed where LVN1 was and assisted in trying to stimulate Resident 1. LVN1 stated she left the resident ' s room to go to the nurse ' s station and called a Code Blue while CNA1 remained with Resident 1 and no CPR was started. LVN 1 stated she immediately returned to Resident 1 ' s room then LVN2 entered the room and LVN2 went out to get EC #1 from the nurse ' s station. LVN1 stated LVN2 re-entered Resident 1 ' s room with EC #1 and that was when LVN1 and LVN2 initiated CPR. During the same interview with LVN1 on [DATE] at 1:24 PM, LVN 1 stated Resident 1 ' s bed was not functional, and the resident ' s head of bed could not go down and was unable to place the resident in a supine position. LVN1 stated Resident 1 was in a horrible position. LVN1 stated the CPR board was not placed under Resident 1 before and during CPR. LVN 1 stated, LVN 1 did the chest compressions while LVN 2 did the BVM on Resident 1. LVN 1 stated, LVN2 stepped out of the resident ' s room to open the door for EMS, and CNA1 and LVN 2 switched. LVN1 stated when she heard EMS coming down the facility hallway, she stopped performing CPR on Resident 1 to clear the way for EMS. LVN1 could not state how long CPR was stopped from the time LVN1 and CNA1 stopped CPR on Resident 1 until CPR administration was resumed by the EMS personnel. LVN1 stated Resident 1 should have been lying flat, with a CPR board at the resident ' s back for better air flow and ventilation and for an effective chest compression. During a concurrent observation of EC #2 and interview on [DATE] at 12:44 PM, Minimum Data Set Nurse (MDSN) stated EC #2 did not have an Emergency Cart Content Checklist and that the checklist must be on the cart to ensure all contents were checked, available and functioning on EC #2. MDSN stated the emergency cart content checklist must be done daily and was important to ensure the checklist was done and complete since emergency carts were used during an emergency situation. During an interview on [DATE] at 11:08 AM, LVN3 stated checking the contents and function of EC #1 on the morning of [DATE] with the DON. LVN3 could not state who was responsible in checking EC #2 on [DATE]. During a concurrent interview and record review of Emergency Cart Content Checklist for EC # 1 and EC #2 on [DATE] at 12:14 PM, MDSN stated the following items were missing from EC #1 Cart content checklist: basic tracheostomy kit (oxygen spare tracheostomy tubes [a surgically created hole (stoma) in your windpipe (trachea) that provides an alternative airway for breathing] that can easily be inserted in an emergency), tape and box of tissues. MDSN stated the following items were missing from EC #2 cart content checklist: suction tubing (flexible tubing used with suction equipment to remove bodily fluids), scissors, and protective gown. THE MDSN stated the light weight wrench or oxygen key (used to open portable oxygen cylinders) was not attached to the oxygen tank, allowing for the oxygen key to be misplaced or overlooked on EC#2. The MDSN stated an oxygen key was required to use the portable oxygen tank on EC #2. The MDSN stated EC #1 content checklist and EC #2 content checklist was not complete according to the checklist and missing items should be replaced immediately since EC #1 and EC #2 were used in emergency situations. During a concurrent observation of EC #2 and interview on [DATE] at 12:15PM, MDSN stated EC#1 did not have a basic tracheostomy kit, tape, and a box of tissues. MDSN stated EC #2 did not have a suction tubing, scissors, and protective gowns. During an interview on [DATE] at 2:21PM, CNA1 stated last witnessed Resident 1 being responsive at 3:30 AM on [DATE]. CNA1 stated Resident 1 was alert and responsive and laying at a 45-degree angle (Fowler's position: standard position in which the patient is seated in a semi-sitting position (,d+[DATE] degrees). CNA 1 stated at 5:30 AM, CNA1 was with Resident 1 ' s roommate, and heard LVN1, who was with Resident 1 call out Resident 1 ' s name three times. CNA1 stated she went to LVN1 and Resident 1 to assist. CNA1 stated calling for LVN2 and LVN2 came with EC #1 and was holding the BVM. CNA1 stated when 911 arrived, CNA1 took over for LVN2 and used the BVM and squeeze the bag to ventilate air to give breath to the resident and LVN1 did the chest compressions. CNA1 stated when they heard EMS was in the hallway, LVN1 told CNA1 to move out of the way so EMS could come in and do their jobs with the machine. CNA1 stated Resident 1 ' s HOB was up at a 45-degree angle and could not put Resident 1 ' s HOB down. A review of EMS Personnel ' s Run Report dated [DATE] at 5:50 AM, EMS Personnel was in route to the facility for CPR in progress for Resident 1. The Report indicated upon arrival; Resident 1 was found in high fowlers with the bed all the way to the ground with no CPR in progress. The Report indicated one LVN was holding a BVM and not giving respirations. The Report indicated Resident 1 had a non-rebreather mask (NRB: a device used in medicine to assist in the delivery of oxygen therapy) on with no oxygen attached. The Report indicated staff showed no signs of fatigue typically present when ,d+[DATE] minutes of CPR was performed. The Reported indicated the BVM was not hooked up to an O2 source and the O2 bottle did not have the adapted (oxygen regulator) to connect the BVM. The Report indicated EMS personnel questioning why CPR was stopped knowing that Resident 1 was full code and LVN1 could not provide EMS personnel how long CPR was stopped for. The Report indicated Resident 1 had obvious signed of rigor mortis (stiffening of the joints and muscles of a body a few hours after death, usually lasting from one to four days) around the jaw and lividity (pooling of blood in gravitationally dependent parts of the body after death) in the sacral area (located below the lumbar spine and above the tailbone) The Report indicated Dead on Arrival (DOA). A review of the facility ' s Licensed Vocational Nurse (LVN) Job Description, dated [DATE], indicated LVN duties including responding to life saving situations based upon nursing standards, polices, procedures, and protocols. A review of the facility ' s undated policy, titled Emergency Cart, indicated emergency cart would be available for use in case of medical emergency, and medical supplied would be provided. The policy indicated key and bandage scissors would be included for emergency use. A review of the facility ' s undated policy, titled CPR, indicated, prior to the arrival of emergency medical services / paramedics, the facility would provide CPR as indicated/needed when a resident suffers a cardiopulmonary arrest (sudden loss of all heart activity due to an irregular heart rhythm) unless contraindicated by advance directives (legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes). The policy indicated paramedics would be called to assess/ provide interventions and/or pronounce resident. A review of the facility ' s policy titled, Code Blue, dated [DATE], indicated to Do CPR. A review of American Heart Association (AHA) Journal, dated [DATE], titled Circulation: Adult Basic Life Support, indicated the following: 1. If the victim is unresponsive, the rescuer will need to determine whether the victim is breathing adequately. To assess breathing, the victim should be supine (lying on his or her back) with an open airway. 2. For resuscitative efforts and evaluation to be effective, the victim must be supine and, on a firm, flat surface. The victim is now appropriately positioned for CPR. 3. The victim must be in the horizontal, supine position on a firm surface during chest compressions to optimize the effect of the compressions and blood flow to the brain. When the head is elevated above the heart, blood flow to the brain is reduced or eliminated. 4. If the victim cannot be removed from a bed, place a rigid board (back board), preferably the full width of the bed, under the victim ' s back to avoid diminished effectiveness of chest compression. 5. Early CPR is the best treatment for cardiac arrest (when the heart stops beating suddenly) until the arrival of advanced cardiovascular life support (ACLS: set of clinical guidelines for the urgent and emergent treatment of life-threatening cardiovascular conditions that will cause or have caused cardiac arrest, using advanced medical procedures, medications, and techniques) care. 6. Early CPR contributes to preservation of heart and brain function, and significantly improves survival. 7. There is evidence to suggest that adult cardiac arrest victims are more likely to be saved if a higher number of chest compressions are delivered during CPR. https://www.ahajournals.org/doi/full/10.1161/circ.102.suppl_1.I-22Retrieved on [DATE]

Based on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) who has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in Resident 1 allegedly subjected to sexual abuse by CNA 1. According to the Forensic Medical Report (a report to clearly convey what has or has not happened to a victim based on evidence), Resident 1 was, tearful during the interview, stating Res 1 was afraid and was told by CNA 1 not to tell anyone. Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on 12/23/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission record indicated Resident 1 ' s decision maker was Family 1. A review of Resident 1 ' s History and Physical, dated 3/30/2022, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 9/28/2022, indicated Resident 1 ' s Brief Interview for Mental Status (BIMS, a screen used to assist with identifying a resident ' s current cognition [ability to understand and make decisions] and to help determine if any interventions need to occur) score was two (2) (a score of one [1] to seven [7 ] indicated the resident has severely impaired cognition). During record review of the facility ' s census dated 10/17/2022, the census indicated Resident 1 was in Room A. During record review of staffing assignments on 10/21/2022 at 12:52 PM, it indicated CNA 1 worked in the facility on 10/17/2022 during the 3 PM to 11 PM shift and was assigned to residents in Room B and Room C. The staffing assignments also indicated CNA 1 was also assigned to work on 10/18/2022 during the 3 PM to 11 PM shift to Room A. A concurrent review of the video surveillance dated 10/17/2022, at 08:54:08 PM with Administrator (Admin) on 10/20/2022 at 3:22 PM, showed a recording of CNA 1 standing in the doorway of Room C. The video surveillance showed CNA 1 calling Resident 1 using hand gesture by waving to Resident 1 to come towards him. Resident 1 was then observed entering Room C at 8:58:19 PM. At 9:04:03 PM (4 minutes and 11 seconds) Resident 1 was observed exiting through Room B, which was an adjoining room to Room C (with shared bathroom). Resident 1 on the video was seen touching her face with her hands as she walked briskly away from Room B to the hallway. A review of the facility ' s Interview Record dated 10/18/2022 at 5:50 PM, indicated Resident 1 stated on 10/17/2022 CNA 1 called her over and went to his room (CNA 1 in Room C) where he was. The Interview record indicated Resident 1 asked CNA 1 what was going on. Resident 1 stated CNA 1 continued to call her over to the room. Resident 1 stated CNA 1 wanted her to be with him. The interview record also indicated Resident 1 stated, He put his thing in my thing and He kissed both of my breasts. A review of the undated Forensic Medical Report (to clearly convey what has or has not happened to a victim based on evidence) indicated on 10/18/2022 Resident 1 was assessed for Sexual Assault- Forensic Medical Examination. The forensic medical report indicated, Resident 1 stated, CNA 1 works at the facility, and he worked on 10/17/2022 around 7:00 PM. He called me into Room B, and he pulled up my shirt and bra and sucked on my chi chi. He then turned me around and pushed me up against the sink, bent me forward and put his penis back there. The forensic medical report indicated; Resident 1 was pointing to her anal area. Resident 1 stated, I was afraid, and he told me not to tell anyone and then laughed at me. A review of the undated Forensic Medical Report also indicated Resident had ecchymosis (bruises) on her right lower quadrant (right lower area) and left upper quadrant (left upper side) of the abdomen. It also indicated Resident 1 was tearful during the interview. A review of Police Report (PR) from Police Department 1 (PD 1) printed on 10/25/2022, indicated on 10/19/2022 timed at 1:14 AM, PD 1 conducted an interview with Resident 1 and the PR indicated the following: 1. Resident 1 stated, CNA 1 was using his hand and waving as if to come here. Resident 1 stated she asked CNA 1 what happened and continued to ask her to come here him. Resident 1 stated she then followed CNA 1 into the room, which she didn ' t remember the room number she walked into but could physically show which room it was. 2. Resident 1 stated, While she was in the room with CNA 1, he approached her and lifted her pink shirt over both her breast. Resident 1 said she asked CNA 1 what he was doing, and CNA 1 told her he was doing his job. Resident 1 then said CNA 1 squeezed both her breast with his hands over her bra. Resident 1 stated CNA 1 then went underneath her bra to grab both her breast. Resident 1 stated CNA 1 also kissed each breast two times. 3. Resident 1 stated, CNA 1 pulled her pants down and his pants down. Resident 1 said CNA 1 used his hand and began to rub his penis back and forth. Resident 1 stated she said CNA 1 penis was erect and curved to the left side. Resident 1 stated CNA 1 then went behind her and he began to touch her back and buttocks using his penis. Resident 1 stated CNA 1 then bent her over. 4. Resident 1 stated, CNA 1 then inserted his penis into her anus. Resident 1 stated she asked CNA 1 what he was doing. 5. PD 1 officer interviewed Director of Staff Development (DSD) and stated, Noticed bruising to Resident 1 ' s right bicep (a muscle in the back of the thigh which helps to flex the leg) and left side of her stomach. PD1 stated he used his work phone and took three digital photographs of Resident 1 and her visible bruising. 6. PD 1 officer asked Resident 1 to show him the area where CNA 1 sexually assaulted the resident. Resident 1 stated Room B and pointed to the area in between the bed and the curtain. A review of Resident 1 ' s Psychosocial Assessment form, dated 10/20/2022 at 3:41 PM, completed by SSD indicated, Resident 1 reported she was recently touched inappropriately by male staff. The psychosocial assessment indicated that although Resident 1 was cooperative during the evaluation, Resident 1 was observed to be puzzled and confused. During an interview on 10/20/2022 at 12:56 PM, the SSD stated the DSD informed her (on 12/18/2022) that Resident 1 reported CNA 1 had touched her inappropriately and had sexual interactions with her. SSD stated upon interview with Resident 1 on 10/18/2022, resident pointed to Room C and stated the guy (CNA 1) who was wearing a red shirt touched her. The SSD stated she watched the surveillance video recording dated 10/17/2022 which showed at around 8:55 PM, CNA 1 (wearing a red shirt) was calling Resident 1 to Room C. During an interview on 10/20/2022 at 1:36 PM, the DSD stated, on 10/18/2022 CNA 2 informed her that Resident 1 reported CNA 1 had touched her sexually. The DSD stated she saw the video and saw CNA 1 was waving to Resident 1 to come to where he was at (Room C). Resident 1 was observed walking into Room C. The DSD stated, We don ' t know what happened inside Room C. There were three (3) other residents in Room C who were not fully awake or alert. During an interview with Resident 1 on 10/20/2022 at 2:24 PM, Resident 1 responded to her name and when asked Resident 1 if she knew CNA 1, Resident 1 giggled and started fidgeting with her hands, but made no comment. A review of Resident 1 ' s Psychology Consult form, dated 10/20/2022, indicated On 10/20/2022, the facility called for an urgent consult. According to the reports, this resident reported a sexual abuse allegation. The psychology consult form indicated Resident 1 stated she was sexually abused by a male nurse. Resident 1 stated a male nurse touched her front chest, but not her breast or other parts of her body. It indicated Resident 1 was confused and disorganized. The resident ' s sexual allegation was confirmed at this time. Recommend continuing current medication. During a telephone interview with CNA 1 on 10/21/2022 at 10:00 AM, CNA 1 stated, he knew Resident 1. CNA 1 stated, Resident 1 was very friendly. CNA 1 stated, he was assigned to take care of Resident 1 a few times. CNA 1 stated, Resident 1 was friendly all the time but makes inappropriate comments, such as that I am her boyfriend or husband. CNA 1 stated he did not report statements made by the resident and should have reported this behavior to his supervisors. CNA 1 added Resident 1 would follow him around, talk to him and sometime pat him hard on his back as a greeting. During the same interview with CNA 1, when asked about Resident 1 going in the room (Room C) with him on 10/17/2022 between 8:50 PM to 9:30 PM, CNA 1 stated, Resident 1 would usually walk around in the hallway and when Resident 1 sees me, Resident 1 would go and start talking to me. CNA 1 stated Resident 1 went into the room (Room C) on 10/17/2022 at night to talk to him while he was changing the other residents. CNA 1 speech pattern began to change. CNA 1 pitch became higher, CNA 1 started stuttering and speech became faster. When CNA 1 was asked if it was acceptable for another resident to be in the room when he was performing care on another resident, CNA 1 stated, I was supposed to ask Resident 1 to leave but I didn ' t. During that same interview, CNA 1 stated, I did not call her, but I did see her passing by. I have a little thing I say to her, it ' s playful. I tell her You ' re so crazy because she is always walking around when she knows I am here. I can ' t explain it. I know it was not okay. I say it in a very friendly way, but it sounds kind of mean. CNA 1 stated it was not appropriate to say that to Resident 1. A review of the facility ' s surveillance video with date and time stamp of 10/17/2022 at 8:55:51 PM to 8:55:54 PM, CNA 1 was seen standing by the door of Room C wearing a red shirt and facing the hallway toward Room A where Resident 1 was standing. A review of the facility ' s surveillance video with date and time stamp of 10/17/2022 at 8:55:55 PM, the video showed CNA 1 inside Room C waiving at Resident 1 who was down the hallway near Room A to come towards him. A review of the facility ' s surveillance video with date and time stamp of 10/17/2022 at 8:56:06 PM, the video showed CNA 1 standing by the door of Room C, waiving to Resident 1 to go inside Room C. Resident 1 then proceeded to go inside Room C. During an interview on 10/25/2022 at 10:52 AM, CNA 5 stated, CNA 5 stated the residents in Room B and C were assigned to him. CNA 5 stated the six residents in those 2 rooms have severe dementia and can ' t really communicate. Rooms B and C were observed with connecting bathrooms. During an interview with Resident 1 on 10/25/2022 at 11:18 AM, Resident 1 stated as she used hand gestures signifying large and elongated example, He put his thing in my butt, and he had sex with me. I didn ' t want to, but he put his thing inside my butt obligating me to have sex with him. He took me inside the room (Room C). There were 3 girls in the room, and I was forced. He put his thing in my butt, I don ' t know why he did that, I thought he was my friend. During an interview with the Administrator (ADM) on 10/25/2022 at 12:01 PM, the ADM stated the facility suspended CNA 1 from working in the facility from 10/18/2022 and terminated CNA 1 on 10/25/2022. During phone interview on 10/27/2022 at 1:40 PM, Charge Nurse (CN) stated it was not acceptable for a resident to go into another resident ' s room. CN stated, The resident needs to be redirected back to her own room. CN stated CNA 1 should have immediately redirected Resident 1 out of the room if Resident 1 was in there talking to him while he was working. A review of the undated facility ' s Policy and Procedure (P&P) titled, Procedure for Prevention of Resident Abuse and Mistreatment, indicated the facility shall uphold resident ' s right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntarily seclusion. The facility shall establish a system to prevent not only abuse, but also those practices and omissions, neglect, and misappropriation of property, that is left unchecked, lead to abuse. It also indicated the Resident shall not be subjected to abuse by anyone, including, but not limited to, facility staff; other resident, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals.

Based on observation, interview, and record review, the facility failed to provide wound care services to prevent pressure injury (pressure ulcer, injury to skin and underlying tissue resulting from prolonged pressure on the skin and/or underlying soft tissue usually present over a bony prominence) for one of two sampled residents (Resident 1) by failing to: 1. Develop a care plan upon admission to address Resident 1's high risk for skin breakdown assessment. 2. Implement repositioning Resident 1 as a preventive measure. 3. Provide Registered Dietitian (RD) consult as recommended on 3/9/2022 by the Interdisciplinary Team to address Resident 1's deep tissue injury (DTI, intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) on the coccyx (tailbone area). 4. Consistently monitor Resident 1's pressure injury from a DTI to a progression of an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough [the yellow/white material in the wound bed; it is usually wet but can be dry. It generally has a soft texture. It can be thick and adhered to the wound bed] or eschar. Stable eschar [dry, adherent, intact without [CONDITION(S)] or fluctuance]) within a week period (3/9/2022 to 3/16/2022). These deficient practices resulted in Resident 1's unstageable pressure ulcer on the Sacro coccyx (Pertaining to both the sacrum [a triangular bone in the lower back formed and situated between the two hipbones of the pelvis] and coccyx) on 3/16/2022 and admission to General Acute Hospital (GACH) on 3/29/2022 due to infection of the wound. Findings: A review of Resident 1's Admission Record indicated the resident was initially admitted on [DATE] and readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a standardized care planning and assessment tool), dated 2/25/2022, indicated Resident 1 was severely impaired with cognitive skills (ability to understand and make decisions) for daily decision making. Resident 1 was totally dependent with all activities of daily living, such as bed mobility, transfer, toileting, personal hygiene, dressing, and locomotion. The MDS indicated Resident 1 was identified as being at risk for developing pressure injuries. Resident 1 was not assessed to have any pressure injuries and no other skin conditions. A review of Resident 1's Wound Risk Assessment, dated 2/18/2022, indicated a score of eight (8) (a score of 8 and greater indicated resident was considered as high risk for skin breakdown). A review of Resident 1's Admission Assessment, dated 2/18/2022, indicated the resident had generalized peeling of the skin and a dry old scab on the left upper shoulder and the sacrum. A review of Resident 1's care plan, dated 3/2/2022, indicated, resident was at risk for developing pressure injury. Staff interventions included were to turn and reposition resident as needed, provide good skin care, assess skin integrity during care and weekly body checks. The care plan was completed 11 days after the initial admission on 2/18/2022. A review of a facility form titled, Change of Condition, dated 3/9/2022, indicated Resident 1 was noted with a DTI on the coccyx, which measured at six (6) centimeters (cm, unit of measurement) by five (5) cm with dark purplish skin. A review of a facility form titled, IDT (Interdisciplinary Team) Wound Management Care Plan, dated 3/9/2022, indicated Resident 1 has a DTI on the coccyx with interventions to assist with turning and repositioning every two (2) hours. The IDT Wound Management Care Plan indicated IDT approaches included RD and Wound consult, monitor pressure injury weekly for stage and size and record. A review of Resident 1's clinical record indicated RD consultation/ nutritional assessment on 2/18/2022. There was no other RD consultation after the recommendation by the IDT on 3/9/2022. A review of a form titled, Trunk Wound Assessment, completed by the Wound Consultant/Physician Assistant (PA), dated 3/16/2022, indicated Resident 1 has a Sacro coccyx unstageable pressure injury. The unstageable pressure injury measured 5 cm by 6 cm by 0.2 cm with 80 percent (%, unit of proportion) slough and 20 % pink wound border. PA recommended weekly follow up with serial debridement and a new treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Skin Progress Report, dated 3/16/2022, indicated DTI on the coccyx was reclassified as unstageable pressure injury measuring at 5 cm by 6 cm by 0.2 as indicated on the PA assessment. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the GACH History and Physical (H&P), dated 3/30/2022, indicated Resident 1 was admitted to the GACH for diaphoresis (sweating, especially to an unusual degree) with an assessment that included pressure injury with mild yellowish drainage, which appeared chronically infected. A review of the GACH Infectious Disease records, dated 4/4/2022, indicated Resident 1's sacral wound culture (a test to find germs that causes infection) has Extended Spectrum Beta Lactamases (ESBL, enzymes produced by some bacteria causing some antibiotics not to work), Escherichia Coli (E coli, a normally harmless bacteria but uses ESBL to become resistant to antibiotics) and [CONDITION(S)] Pneumoniae (a bacteria that can use ESBL to become resistant to antibiotics). A concurrent record review and interview with Medical Records Director (MRD) on 5/11/2022 at 3:09 pm, the MRD stated the only RD consultation records for Resident 1 were on 2/18/2022 and 4/6/2022 (which was after readmission). A review of the GACH Infectious Disease Progress Notes, dated 4/4/2022, indicated Resident 1 was started on the following intravenous antibiotics (medications to treat infections) for infection: 1. [MEDICATION(S)] 500 milligrams (mg) every 8 hours started on 3/30/2022 2. [MEDICATION(S)] 750 mg every 8 hours started on 3/30/2022 3. [MEDICATION(S)] one gram every 8 hours started on 3/31/2022 During an observation in Resident 1's room on 4/26/2022 at 11 am, Resident 1 was in his bed and slightly facing the window laying on his right side. During an observation in Resident 1's room on 4/26/2022 at 12:58 pm, Resident 1 was in his bed and slightly facing the window laying on his right side. During an observation in Resident 1's room on 4/26/2022 at 2:22 pm, Resident 1 was in his bed and slightly facing the window laying on his right side During a concurrent interview with the Wound Care Nurse (WCN) and record review of Resident 1's Admission Assessment, dated 2/18/2022, on 4/26/2022 at 2:28 pm, WCN stated Resident 1 had generalized body skin peeling and a dry old scab on the left upper shoulder and the sacrum. The WCN stated she completed the Admission Skin Assessment but did not complete a baseline care plan to address Resident 1's high risk for skin breakdown because the resident did not have any skin impairment. During a concurrent interview with the WCN and record review of Resident 1's Wound Risk assessment dated [DATE], on 4/26/2022 at 2:35 pm, WCN stated the Wound Risk Assessment indicated Resident 1 had a score of 8 and was high risk for skin breakdown due to being totally dependent on staff. During an interview on 4/28/2022 at 2:40 pm, the Director of Nursing (DON) stated if a resident was admitted and assessed as high risk for skin breakdown, the WCN would be responsible for completing the care plan upon admission to address the high risk for skin breakdown. The DON stated developing a care plan was important because it would guide the nurses on the care, intervention and treatment to be provided to the resident to improve resident's health and avoid worsening of the condition. During an interview with Certified Nurse Assistant 1 (CNA 1) on 4/26/2022 at 3 pm, CNA 1 stated he was not assigned to any residents with pressure injury, and he was assigned to Resident 1. CNA 1 stated he repositioned the resident when he changed Resident 1's diaper. CNA 1 stated he could not remember what time he repositioned Resident 1 and he kept Resident 1 on his right side because his pressure injury was on the left side. During a concurrent observation in Resident 1's room and interview with the WCN on 4/26/2022 at 3:05 pm, Resident 1 was in his bed laying on his right side, facing the window with his back away from the door. The WCN stated when she started her shift (did not specify what time), Resident 1 was facing the door. The WCN stated she changed Resident 1's sacral wound dressing around 10 am and repositioned Resident 1 facing the window on the resident's right side after the dressing change. During a concurrent observation in Resident 1's room and interview on 4/26/2022 at 4:09 pm, the WCN stated the CNAs follows the turning schedule to ensure residents who needed assistance with turning and repositioning were turned every 2 hours. A review of the turning schedule indicated Resident 1 should be facing the door laying on his left side from 2 pm to 4 pm. The WCN stated Resident 1 was facing the window at 3:05 pm and the turning schedule was not followed for Resident 1. During an interview on 4/28/2022 at 3:55 pm, the WCN stated when a resident would stay for more than 2 hours in one position, it places the resident at risk for the development of a pressure injury or worsening of the pressure injury. During a concurrent interview with the DON and record review of Resident 1's care plan on 4/28/2022 at 4:44 pm, DON stated Resident 1's care plan addressing high risk for developing pressure injury was not initiated until 3/2/2022. During an interview on 6/17/2022 at 10:13 am, PA stated she assessed Resident 1's pressure injury on the coccyx on 3/16/2022. PA stated the pressure injury was no longer a DTI because it was already opened and was unstageable. PA stated based on Resident 1's wound bed assessment, the pressure injury was 80 % open and 20% with pinkish discoloration around the border. PA stated it was difficult to determine if it was a Stage 3 or Stage 4, therefore PA classified the pressure injury as unstageable. A review of Resident 1's clinical record did not indicate any assessment from 3/13/2022 to 3/15/2022 reflecting status of Resident 1's DTI on the coccyx. A review of the facility's undated P&P titled, Pressure Sore Management, indicated individual care plan will be developed as indicated and all available measures shall be taken to reduce skin breakdown and pressure injury. A review of the facility's undated P&P titled, Pressure Sores - Risk Factors and Common Causes, indicated one of the common causes for the development of pressure injury included pressure against a skin area for prolonged periods.

On 11/22/20, at 2:30 p.m., during a general observation, it was noticed that housekeeping staff (HS) 2 was coming down the corridor, through the exit door and out of the Red Zone. HS 2's personal protective equipment (PPE) only consisted of a face mask, which covered from his nose, mouth and chin. He did not wear a gown nor gloves, and he did not sanitize his hands with the hand sanitizer, which was on a table outside of the Red Zone. At 2:35 p.m., an interview was conducted with HS1. He stated that he was the only housekeeping staff assigned to the Red Zone. HS 2 mentioned that the only time he wears a gown and gloves is when he entered the residents' rooms and removes the PPEs before he lives the residents' rooms. When asked about washing and/or sanitizing his hands, he said he sanitizes his hands before and after removing the PPEs. It was pointed out to HS 2 that he did not sanitize his hands when he came out of the Red Zone and he said he forgot. Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) in accordance to local Public Health guidelines, facility's policy and Mitigation Plan (MP, a plan to reduce loss of life and impact of COVID-19 in the facility) for 7 of 7 sampled residents (Residents 17, 18, 38, 39, 40, 41 and 42) by failing to: 1. Send Certified Nursing Assistant 4 (CNA 4) home when she looked sick and requested Tylenol (medication use to relieve pain and reduce fever) for her headache and sore throat. CNA 4 provided care to Residents 38, 39, 40 and 41, while she was sick. 2. Ensure an Infection Prevention Nurse (IPN, a nurse who helps prevent and identify the spread of infectious disease in the healthcare environment) was available to monitor, prevent, and control the spread of COVID-19 in the facility. 3. Ensure Housekeeper 1 (HK 1) doffed (removed) and disposed her used/contaminated gown and gloves in the trash can, inside of Residents 17's 18's and 42's room, in the COVID-19 area (Red Zone, area for residents who tested positive for COVID-19) after mopping the floor of the residents' room These deficient practices had the potential to spread of COVID-19 from CNA 4 to Residents 38, 39, 40, 41 and placing other residents and staff at risk for COVID-19 infection that could lead to severe respiratory illness, hospitalization and/or death. On 11/22/20 at 5:05 pm, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Director of Nursing (DON) regarding facility's staff failure to implement infection control practices according to local Public Health guidelines, the facility's policy and MP for COVID-19. On 11/26/20 at 7:15 p.m., the IJ was lifted after the DON and Registered Nurse Consultant (RNC) submitted an acceptable Plan of Action (POA, interventions to correct the deficient practices). The surveyors verified and confirmed the implementations of the POA while onsite by observation, interview and record review. The IJ was removed in the presence of the DON and RNC. The acceptable POA as follows: 1. CNA 4 was placed under quarantine (practice of separating individuals who tested positive for the disease have had close contact with someone with COVID-19 to determine whether they develop symptoms) at home after she tested positive for COVID-19. 2. LVN 2, who has completed the infection control training was assigned as a full time IPN. 3. On 11/23/20, the DON and Director of Staff Development (DSD) provided in-service regarding donning (putting on) and doffing (taking off) personal protective equipment (PPE, equipment (masks, gowns, gloves) worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) with return demonstration. Findings: 1. A review of the facility's Employee Screening tool for COVID-19, completed by the receptionist in the front desk, dated 11/5/20, indicated CNA 4's body temperature at the beginning of the morning shift was at 97.5 Fahrenheit (F). The Employee Screening tool indicated CNA 4 did not have symptoms of fever, headache, congestion, or sore throat. The tool did not indicate whether CNA 4 had used fever relieving medication in the last 24 hours. A review of CNA 4's COVID test result, dated 11/5/20, indicated CNA 4 was tested for COVID-19 on 11/4/20 and on 11/5/20 at 4:08 pm, the test result came back positive. A review of the facility's Nursing Assignment, dated 11/5/20, indicated CNA 4 provided care for Residents 38, 39, 40, and 41, on 11/5/2020, during the morning shift from 6:30 am to 2:42 pm. A review of the facility's Employee Time Sheet, dated 11/5/20, indicated CNA 4 signed in to work at 6:12 am and signed out from work at 2:42 pm. During an observation of the facility on 11/22/20, at 12:05 pm, four residents were in the Yellow Zone (area where patients/residents under investigation/suspected for COVID-19, are allocated) and 48 residents were in the Red Zone (an area in the facility were residents with COVID 19 infections were allocated). During an interview with the DON on 11/22/20, at 12:34 pm, she stated the COVID-19 outbreak (infection that affect one or more residents) started after CNA 4 came to work sick on 11/5/20. The DON stated on 11/7/20, she found out that CNA 4 was taking Tylenol to relieve her headache, and it explained why CNA 4 did not have fever during the COVID-19 screening process. The DON stated CNA 4 should not have come to work after taking Tylenol because the medication could have suppressed the signs and symptoms of COVID-19. During a telephone interview with the DSD on 11/23/20, at 9:34 am, he stated on 11/4/20, CNA 4 did not come to work because she had to take care of a family member who was sick. The DSD stated CNA 4 worked and tested for COVID-19 at another facility (Facility 2) on 11/4/20. The DSD stated Facility 2 had a COVID-19 outbreak on 11/4/20. The DSD stated on 11/5/20 during the morning shift, LVN 1 informed him that CNA 4 requested Tylenol for headache. The DSD stated due to CNA 4 did not have a fever, he and the IPN decided not to send CNA 4 home for self-isolation. The DSD stated on 11/5/20 at 2:42 pm, CNA 4 requested to go home early because she did not feel well. The DSD stated on 11/6/20 at 1:42 pm, he received a text message from CNA 4. The text message indicated CNA 4 was tested for COVID-19 on 11/4/20 and on 11/5/20, the results came back positive. During a telephone interview with LVN 1 on 11/23/20, at 9:48 am, she stated on 11/5/20, between 10:45 am to 11:30 am, during the morning break, CNA 4 requested for Tylenol because CNA 4 had headache, sore throat and was not feeling well. LVN 1 stated CNA 4's voice was different, it sounded congested, and she looked sick. LVN 1 stated she told CNA 4, You are sick, you should not be here. LVN 1 stated she gave CNA 4 Tylenol and checked CNA 4's temperature that read at 98°F. LVN 1 stated she immediately reported to the IPN and the DSD that CNA 4 asked for Tylenol and CNA 4 had been taking Tylenol prior to work for allergies and headache. LVN 1 asked the IPN and DSD What are we going to do? LVN 1 stated she suggested to the IPN and the DSD to send CNA 4 home, because CNA 4 looked sick and sound congested, but the IPN and the DSD informed her that since CNA 4 had no fever, she could stay until the end of the shift. During a telephone interview with the DON on 12/15/20 at 1:25 pm, she stated on 11/6/20 Residents 38, 39, 40 and 41 were tested for COVID-19 after direct exposure to CNA 4 on 11/5/20. The DON stated on 11/8/20 the facility received reports that Residents 38, 39, 40 and 41 had tested positive for COVID-19. a. A review of Resident 38's Admission Record indicated the facility admitted the resident on 11/22/10 and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of 38's COVID test result, dated 11/6/2020, indicated the resident tested for COVID-19 on 11/6/20, and the facility received the positive result for Resident 38 on 11/8/2020. A review of Resident 38's Licensed Nurse Notes, dated 11/18/20, at 12:38 am, indicated Resident 38 was transferred to a General Acute Care Hospital (GACH) via 911(medical emergency telephone number), due to desaturation (decrease oxygen in the blood) with an oxygen level of 81% (normal range is 95%-100%)). The notes indicated Resident 38 received 15 liters per minute (L/M) of oxygen via a non-rebreather mask (medical device used to deliver high concentrated oxygen during an emergency) without improvement. b. A review of Resident 39's Admission Record indicated the facility admitted the resident on 2/18/12 and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 39's COVID test result, dated 11/6/20, indicated the resident was tested for COVID-19 on 11/6/20, and the facility received the positive result for Resident 39 on 11/8/2020. A review Resident 39's Nursing Progress Notes, dated from 11/1/20 to 11/30/20 indicated Resident 39 had no symptoms related to COVID-19. c. A review of Resident 40's Admission Record indicated the facility admitted the resident on 12/28/12 and readmitted [DATE] with [DIAGNOSES REDACTED]. A review of Resident 40's COVID test result, dated 11/6/20, indicated the resident was tested for COVID-19 on 11/6/20, and the facility's received the positive result for Resident 40 on 11/8/20. A review of Resident 40's Licensed Nurse Notes, dated 11/12/20, indicated at 4 pm, the resident's blood oxygen level decreased to 90%. Resident 40 was on oxygen at 2 L/M via nasal cannula (a plastic tube used to deliver oxygen to the nostril). The notes indicated on 11/12/20, at 9:30 pm, Resident 40 was transferred to a GACH as ordered by the resident's Physician for further evaluation. d. A review of Resident 41's Admission Record indicated the facility admitted the resident on 10/15/16 and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Review of Resident 41's COVID test resulted, dated 11/6/2020, indicated the resident was tested for COVID-19 on 11/6/20, and the facility received the positive result for Resident 41 on 11/8/2020. A review of Resident 41's Licensed Nurse Notes, dated 11/11/20, indicated at 10:17 pm, the resident was coughing with difficulty breathing and generalized weakness. The notes indicated Resident 41 was transferred to a GACH per the resident's Primary Care physician's orders [REDACTED].>According to the local Public Health guidelines, dated 6/17/20, titled Guidelines for Preventing and Managing COVID-19 Skilled Nursing Facilities, the facilities were recommended to monitor and manage Health Care Personnel (HCP) that might be exposed to COVID-19. All HCP should self-monitor twice daily, once prior to coming to work and the second ideally timed approximately 12 hours later for possible symptoms of COVID-19. If the HCP had recorded symptoms, they were to contact the healthcare facility and stay home. A review of the facility's policy and procedure, titled COVID 19 Facility Infection Prevention Quality Control Plan, dated 6/19/20, indicated the facility will implement infection control procedures including correct work practices that are necessary to prevent infection from spreading during the healthcare delivery. 2. During an observation of the Red Zone and the Yellow Zone, on 11/22/20, at 12:05 pm, the IPN was not available to monitor and perform infection surveillance or infection control practices in the facility. During an interview on 11/22/20, at 1:54 pm, the DON stated on 11/11/20, the IPN came to work and complained that she felt weak. The rapid test (a type of test to detect COVID 19 and give result on the same day) was done for the IPN and the result came back positive. The DON stated the IPN was sent home for self-quarantine. The DON stated the DSD and LVN 1 were both certified as IPN, but they were not able to implement infection control practices because they had to perform patient care. The DON stated both IPN and the Administrator were on self-quarantine at home since 11/11/20 when they tested positive of COVID 19. The DON stated she was performing the Administrator and IPN's jobs on top of the DON's tasks. The DON stated the staffs were not retrained on not to come in to work when they are sick or have signs and symptoms of COVID 19 because of the shortage of IPN. A review of the facility's Mitigation Plan for COVID 19 Infection, dated 9/24/20, indicated the facility had a full time (work 40 hours a week) Infection Preventionist. This can be achieved by more than one staff member sharing this role but must be in place for infection prevention quality control. The Infection control lead is designated to address and improve infection control based on public health advisories (Federal and State) and spends adequate time in the building focused on activities dedicated to infection control. The facility ensures the health care professionals (staffs) received infection prevention and control training. 3. During an observation in the Red Zone on 11/22/20, at 12:30 pm, HK 1 was in Resident 17's, 18's, and 42's room (all three residents were all tested positive for COVID-19). HK 1 was wearing a mask, gown and gloves while mopping the floor. After HK 1 was done mopping the floor, she walked to the designated staff break room, which was located on the left side of the resident's room, removed the used/contaminated gown, gloves and discarded them in the trash can in the designated staff break room. A concurrent interview was conducted; HK 1 did not provide an explanation to why she walked outside of the resident's room without removing her used/contaminated gown and gloves but walked into the designated staff break room to remove and discard them in a trash can. During an interview with the DSD on 11/22/20, at 12:35 pm, he stated HK1 need to remove and discard her used/contaminated gown and gloves in the trash can inside Resident 17's, 18's and 42's room prior to exiting the room. During a telephone interview with the House Keeping Supervisor (HKS) on 12/12/20 at 2:13 pm, the HKS stated HK 1 needed to remove and discard her used/contaminated gown and gloves in the trash can inside Resident 17's, 18's and 42's room before exiting the room. The HKS stated HK 1 need to change and use new disposable gowns and gloves in each room while working in the Red Zone. According the Center for Disease Control and Prevention, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations; indicated for Environment Services Personnel, to wear all recommended PPE when in the residents' room. PPE should be removed upon leaving the room. a. Gloves: Put on clean, non-sterile gloves upon entry into the patient room or care area. Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene. b. Gowns: Put on a clean isolation gown upon entry into the patient room or area. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. A review of the facility's MP for Infection Prevention Quality Control, dated 5/26/20, indicated the infection control procedure including continuous environmental hygiene, correct work practices, and appropriate use of PPE are all necessary to prevent infections from spreading during healthcare delivery. The MP indicated facility's staff will discard the PPE in the trash disposal bin located near the exit of the resident's room prior to exiting the room. Surveyor: Bartolata, Marilou Based on observation, interview, and record review, the facility failed to monitor for signs and symptoms of COVID-19 including vital signs (show how well your body is functioning, includes blood pressure (measures the force of your blood pushing against the walls of your arteries), heart rate (measures how fast your heart is beating per minute), respiratory rate (measures your breathing per minute) temperature (measures how hot your body is), and oxygen saturation (amount of oxygen within a blood cell) for 8 of 27 residents in the red zone for 9 a.m. and 1 p.m. scheduled monitoring for signs and symptoms of COVID-19 Findings: On 11/22/20 at 12:23 p.m. to 2:35 p.m, during an observation, Licensed Vocational Nurse 3 (LVN 3) was at the Nurse's station on the phone. On 11/22/20 at 12:50 p.m., during a concurrent observation and interview, overheard LVN 3 on the phone with the physician, LVN 3 stated she called a physician regarding a resident's change of condition, the resident was not eating and drinking. On 11/22/20 at 1:13 pm to 1:55 p.m., during a concurrent interview and a review of Resident 2,3 and Resident 4 's current vitals, verified with the DSD, indicated the last documented vital signs for Resident 2 was on 11/22/20 at 5:14 a.m., for Resident 3 was on 11/22/20 at 5:15 a.m., and for Resident 4 was on 11/22/20 at 05:20 a.m. The DSD stated the monitoring for signs and symptoms of COVID-19 was not completed every 4 hours. The DSD stated monitoring of vital signs every 4 hours is important because residents with COVID-19 infection could have an abrupt change of condition. A review of Resident 2's MAR, verified with the DSD, there was no entry on monitoring for signs and symptoms of COVID-19 on 11/22/20. The monitoring on 11/19/20 day and evening shift was blank. A review of Resident 3's MAR, verified with the DSD, indicated there was no entry on monitoring for signs and symptoms of COVID-19 on 11/22/20. The monitoring on 11/19/20 day and evening shift was blank. A review of Resident 4's MAR, verified with the DSD, indicated the monitoring for signs and symptoms of COVID-19 on 11/22/20 was blank. The monitoring on 11/7/20 evening shift, 11/12/20 day and night shift, 11/19/20 day and evening shift was blank. A review of Resident 14's MAR indicated [REDACTED]. The monitoring on 11/12/20 day shift and 11/19/20 evening shift was blank. A review of Resident 15's MAR indicated [REDACTED]. The monitoring on 11/12/20 was blank on 3 shifts, day evening and night shifts. The monitoring was blank on 11/13/20 evening shift and 11/14/20 day shift and 11/19/20 evening shift. A review of Resident 15's oxygen saturation summary indicated the last documented oxygen saturation was on 11/22/20 at 4:39 a.m. A review of Resident 16's MAR indicated [REDACTED]. The monitoring on 11/15/20 night shift, on 11/19/20 day and evening shift and on 11/20/20 night shift was blank. A review of Resident 16's oxygen saturation summary indicated the last documented oxygen saturation was on 11/22/20 at 4:53 a.m. A review of Resident 17's MAR indicated [REDACTED]. The monitoring on 11/19/20 day and evening shift was blank. A review of Resident 17's oxygen saturation summary indicated the last documented oxygen summary was on 11/22/20 at 4:58 a.m. A review of Resident 18's MAR indicated [REDACTED]. The monitoring on 11/19/20 day and evening shift was blank. A review of Resident 2, 3, 4, 14, 15, 16, 17 and Resident 18's MAR, indicated that the monitoring for signs and symptoms of COVID-19 included temperature, respiratory rate, oxygen saturation and monitoring for symptoms included cough, shortness of breath, fatigue, chills, muscle or body aches, sore throat, new loss of taste or smell, headache, congestion or runny nose, diarrhea, nausea or vomiting. On 11/22/20 at 2:25 p.m., during an interview, Licensed Vocational Nurse 3, stated she had not documented the vital signs she had taken. LVN 3 stated she took vital signs at 7 am but she could not find the paper she wrote it on. She handed a list of vital signs and stated she took these vital signs at 10:30 a.m. that day. LVN 3 stated she was supposed to take vital signs and monitor signs and symptoms of COVID-19 every 4 hours and document. A review of the vital signs written on the paper provided by LVN 3 indicated there were 27 residents on the list. The paper had handwritten room numbers with blood pressure, respiratory rate, temperature, and oxygen saturation. There was no written indication of absence or presence of symptoms for each resident. A review of the facility's census indicated the 27 residents were in the red zone. On 11/26/20 at 10:07 a.m., during a concurrent record review and interview with the Medical Records Director (MRD). A review of Resident 4 and Resident 23's MAR indicated [REDACTED]. MRD stated vital signs in the green or yellow zone were done every 8 hours but when residents were transferred to the red zone, vital signs should be completed every 4 hours. The MRD stated licensed nurses were doing it on paper but the vital signs were not documented in the MAR because they have nowhere to document it in the MAR unless they change it to every 4 hours. MRD changed the monitoring of vital signs for residents in the red zone to every 4 hours on the night of 11/24/2020. Now the staff can chart the VS in the MAR indicated [REDACTED]. 12/3/20 at 4:48 p.m., during a telephone interview, the MRD stated the facility is doing half-breed, some staff would document vital signs in the MAR, some staff would document on paper until the changes were made in the computer system where staff can document monitoring of signs and symptoms every 4 hours instead of only every 8 hours. On 12/4/20 at 9:10 a.m., during a telephone interview, LVN 4 stated vital signs were taken every 4 hours for residents in the red zone and documented on a pater and placed in a binder at the nursing station. The paper is not part of a resident's medical record. LVN 4 stated she would keep the paper in her pocket and because the vital signs were not documented in the MAR, other staff and doctors would not be able to see the current vital signs and might miss the changes in the resident's condition. LVN 4 stated there was a tendency to forget to file the paper in the binder. LVN 4 stated she doesn't know how to change the VS monitoring from every 8 hours to every 4 hours in the computer. A review of Resident 2's Admission Record indicated Resident 2 was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 3's Admission Record indicated Resident 3 was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 4's Admission Record indicated Resident 4 was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 14's Admission Record indicated Resident 14 was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 15's Admission Record indicated Resident 15 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 16's Admission Record indicated Resident 16 was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 17's Admission Record indicated Resident 17 was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 18's Admission Record indicated Resident 18 was readmitted on [DATE], with [DIAGNOSES REDACTED]. Its first signs are problems with movement), hypertension (high blood pressure).

Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to provide care for 12 of 36 sampled residents (Resident 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, and 36) by failing to: 1. Ensure the facility designated Infection Preventionist Nurse (IPN) was able to perform the IP nurse duties due to multiple duties (giving patient care in the red zone). 2. Ensure Registered Nurse 1 (RN 1) and Licensed Vocational Nurse 3 (LVN 3) assigned to the Red Zone (area for residents tested positive for COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person)) were able to assess and monitor multiple areas with black color discoloration on Resident 1's right foot. 3. Ensure RN 4 and LVN 5 had enough time to notify the physicians for three residents (Resident 5, 7, and 8), who were in the Red Zone (area for COVID-19 positive residents) and had a change of condition, on [DATE] and [DATE]. 4. Ensure LVN 1 was able to complete and document Resident 9, 10, 11, and 12's vital signs (body temperature, blood pressure, pulse (heart rate), and breathing rate to help assess the general physical health of a person) and signs and symptoms of COVID 19 in the Yellow Zone (an area in the facility where residents exposed to or suspected of COVID- 19 are cohorted). 5. Ensure LVN 3 was able to administer medications in a timely manner for Residents 2, 3, and 4, who were in the Red Zone. 6. Ensure LVN 3 was able to record and document in the resident's Medication Administration Record (MAR), the vital signs every four hours for Resident 2, 3, 4, in the Red Zone. 7. Ensure RN 2 had enough time to report Resident 36's change of condition for respiratory distress, notify Resident 36's physician timely, and monitor their signs and symptoms of COVID-19. These deficient practices resulted in Resident 1's right foot multiple areas with black discoloration was not assessed, resident's physician was not notified, and had no treatment order. Resident 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, and 36 had incomplete vital signs and COVID 19 sign and symptom assessments. Resident 5, 7, 8, and 36's physicians were not notified during the change of condition. Resident 2, 3, and 4 had delayed care after the change of condition and did not receive their medications on time. (Cross Refer to F580, F686, F760, and F880). On [DATE] at 5:03 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Director of Nursing (DON) regarding the facility's staff failure to provide adequate staffing in the Yellow and Red Zones. On [DATE] at 7:10 p.m., the IJ was lifted after the DON and Registered Nursing (RN) consultant submitted an acceptable Plan of Action (POA, interventions to correct the deficient practices). The surveyor verified and confirmed the implementations of the POA while onsite by observation, interview and record review. The IJ was removed in the presence of the DON and RN consultant. The acceptable POA was as follows: 1. The facility hired 1 RN and 2 Licensed Vocation Nurses (LVNs) from the registries to ensure that the facility will have RN coverage and sufficient nursing staff (LVNs and Certified Nursing Assistants (CNAs)). The facility has contracted three nursing registries as a staffing contingency plan. 2. The DON and the RN will make rounds daily to observe the staff performing medication administration, checking vital signs, assessing COVID-19 symptoms and conduction body check and ensure the staff has followed the proper procedure. 3. The licensed nurse and the respiratory therapist (RT) made rounds in the red zone and provided in service (assessment and training on respiratory care) to the staff. 4. The licensed nurse notified the physician of the three residents, who had missed the scheduled medications, and documented the MD instruction on the clinical records. 5. The licensed nurse referred the resident to the wound specialist and carried out the treatment order. 6. The facility scheduled weekly zoom meetings with one pulmonologist and facility medical director to review residents who have change of conditions. The facility will follow up on the recommendations and will document it on the clinical record. 7. A RT will visit the facility at least twice per week for four weeks to assist in assessment and training on respiratory care. Findings: 1. A review of the facility's census, dated [DATE], indicated the 48 residents were in the red zone. A review of the Nursing Staffing and Assignment, on [DATE], indicated the 7 a.m. to 7 p.m. shift staffing in the Red Zone was composed of 1 RN, 2 LVNs and 6 CNAs. On [DATE] at 11:55 a.m., during an observation tour in the red zone and concurrent interview, the Director of Staff Development (DSD) stated he was covering for the facility's Infection Preventionist Nurse (IPN), who was quarantined due to COVID-19. The DSD stated he was performing all around help in the red zone and helping the DON with staffing. The DSD stated he was not able to perform the specific IP role of infection control due to multiple tasks and helping the staff in the red zone. The DSD stated the red zone has 48 residents confirmed positive COVID-19 with six CNAs from staffing agency, two LVN, and one Registered Nurse (registry). On [DATE] at 2:11 p.m., during an interview, the DON stated the facility staff had been busy the last few days due to increased number of staff and residents that tested positive for COVID- 19. The DON stated there were 40 staff and 48 residents that were in isolation after being tested positive for COVID-19, which resulted in the shortage of staffing at the facility. 2. A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated [DATE] indicated resident required extensive assistance (staff provide weight bearing support) on bed mobility, dressing, eating, toilet use, and personal hygiene. Resident 1 was also at risk for developing pressure injuries (localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to a medical or other device). On [DATE] at 12:52 p.m., during an observation and concurrent interview, Resident 1 had multiple areas with black discoloration on the right foot (right foot plantar area/sole of the foot, unknown size, right heel black discoloration, right foot big toe, right fourth and fifth toes black discoloration, in-between right foot 4th and 5th toes. The DSD stated he has no knowledge of Resident 1 multiple areas with black discoloration on the right foot. The DSD stated there was no report of skin issues on the resident. On [DATE] at 1:20 p.m., during an interview, LVN 3 stated she had not checked on Resident 1's right foot and had not provided skin care treatment for [REDACTED]. On [DATE] at 1:25 p.m., during an interview and review of Resident 1 Admission Assessment, dated [DATE], and the physician's orders [REDACTED]. on the assessment and order summary records. On [DATE] at 1:40 p.m., during an interview, RN 1 stated it was his second day working in the facility and there was no report of skin care treatment. RN 1 stated he had not assessed Resident 1 multiple areas with black discoloration on the right foot, had not reported to Resident 1's physician, had not documented the description of the multiple areas with black discoloration on the right foot. RN 1 stated Resident 1 had no treatment order. RN 1 stated he had not assessed and reported to the physician regarding Resident 1's foot because he prioritized reporting a change of condition related to COVID-19 symptoms for other residents and attending to multiple residents with intravenous hydration. On [DATE] at 2:20 p.m., during an interview and review of Resident 1 medical record, the DON stated the staff should had reassessed Resident 1's skin condition (multiple areas with black discoloration on the right foot). The DON stated RN 1 and LVN 2 should had conducted a body skin assessment, document the description, and report to Resident 1's physician for further evaluation and order. 3. On [DATE] at 2:11 p.m., during an interview, DON stated the facility staff had been busy the last few days due to increased number of staff and residents that tested positive for COVID- 19. The DON stated there were 40 staff and 48 residents that were in isolation after being tested positive for COVID-19, which resulted in the shortage of staffing at the facility. On [DATE] at 2:11 p.m., during an interview and concurrent review of Resident 5, 7, and 8 medical records, the DON stated on [DATE] and [DATE], Resident 5, 7, and 8 had a change of condition. The DON stated Resident 5, 7, and 8's medical records had no record of the residents having a change of condition, and their medical records had no records for the type of care provided to the residents, on [DATE] and [DATE]. a. A review of Resident 5's Admission Records indicated Resident 5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On [DATE] at 2:15 p.m., during a concurrent review of Resident 5's nursing progress notes, the DON stated Resident 5 tested positive for COVID-19 on [DATE], and he died at the facility on [DATE]. On [DATE] at 4:33 p.m., during a telephone interview, LVN 5 stated on the night of [DATE], she was working in the Red Zone. LVN 5 stated she had no time to document the significant change of conditions for Residents 5, because she was overwhelmed with her task. LVN 5 stated she was helping other staff to transfer the residents to the hospital and the residents that expired. LVN 5 explained there were not enough staff to care for the residents in the Red Zone LVN 5 stated the staff did not even have a time to sit down. b. A review of Resident 7's Admission Records indicated Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 7's nursing progress notes, dated [DATE] at 9:34 p.m., indicated Registered Nurse Supervisor (RN 4) documented Resident 7 was found unresponsive with no heart rate, respiration and no reading was found in the pulse oximeter (a machine that records the blood oxygen level in the body), the DON, family and the mortuary of choice were informed. On [DATE] at 4:33 p.m., during a telephone interview, LVN 5 stated on the night of [DATE], she was working in the Red Zone. LVN 5 stated she had no time to document the significant change of conditions for Resident 7 because she was overwhelmed and there were not enough staff to care for the residents in the Red Zone and the staff did not even have a time to sit down. On [DATE] at 3:12 p.m., during an interview, RN 4 stated on [DATE] at 9:34 p.m., he was informed by the staff that Resident 7 was not responding. RN 4 stated Resident 7 had a physician order [REDACTED]. RN 4 stated he was busy with the other residents, who were having changes in conditions. On [DATE] at 3:12 p.m., during an interview, RN 4 stated he was overwhelmed with his assignment on the night shift on [DATE], he had to administer eighteen medication administration via IV (intravenous or into the vein) and assess the residents with change of condition, which were transferred to the general acute care hospital (GACH), and two residents that expired. RN 4 explained he informed the DON regarding the staffing shortage, but the DON informed him that she could not send any staff to assist the night shift. c. A review of Resident 8's Admission Record indicated Resident 8 was admitted to the facility, on [DATE], with [DIAGNOSES REDACTED]. On [DATE] at 2:20 p.m., during a record review and concurrent interview, the DON stated there was no recorded evidence the facility staff informed Resident 8's physician of the change in Resident 8's condition. The DON stated, on [DATE], there were no recorded evidence on the type of care provided to Resident 8 for COVID - 19 signs and symptoms manifested, and Resident 8's signs and symptoms were reported to the physician immediately. On [DATE] at 2:33 p.m., during a telephone interview, LVN 6 stated on [DATE], she noticed that Resident 8 was unresponsive. LVN 6 stated she did not call the physician because the resident's code status was a DNR. LVN 6 stated that she did not call Resident 8's physician because she was busy with other residents in the facility, who were having changes in condition on [DATE]. LVN 6 stated on [DATE] during the night shift, she failed to document residents change of condition and the vital signs. LVN 6 stated the facility was shortage of staff to care for the residents in the Red Zone that required constant monitoring for COVID-19 signs and symptoms. 4. On [DATE] at 12:33 p.m., during an observation, four residents (Resident 9, 10, 11, and 12) were observed in the Yellow Zone. On [DATE] at 12:33 p.m., during an interview and concurrent review of Resident 9, 10, 11, and 12's medical records, LVN 1 provided a written document with the Resident 9,10, 11, and 12's room numbers (no name) written on the paper that had all the residents' vital signs for [DATE]. LVN 1 stated she was not able to assess the vital signs and document the signs and symptoms for COVID-19 of Residents 9, 10, 11 and 12, because she was busy assisting staff and providing supplies to the Red Zone. On [DATE] at 12:33 p.m., during an interview, LVN 1 stated, she was overwhelmed with her responsibilities as the Infection Prevention Nurse (IPN) designee and due to the insufficient staffing. LVN 1 stated she was the only charge nurse in the Yellow Zone with the three Certified Nurse Assistants who were not in charge of the vital signs monitoring. On [DATE] at 12: 59 p.m., during an interview, the DON stated the facility's IPN was currently on isolation at home and LVN 1 was the IPN designee. The DON confirmed that there had been a shortage of nursing staff, on [DATE] to [DATE], because of the increased COVID- 19 cases. 5. On [DATE] at 1:13 pm to 1:55 p.m., during a review of Resident 2, 3, and 4s' Medication Administration Records (MAR) for ,[DATE], confirmed with the Director of Staff Development (DSD), the MAR for the following residents indicated: a. A review of Resident 2's Admission Records indicated Resident 2 was readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 2's MAR for medications scheduled on [DATE] at 9 a.m. were blank (not given) for [MEDICATION NAME] (a medication to manage high blood pressure) and [MEDICATION NAME] (steroid medication). b. A review of Resident 3's Admission Records indicated Resident 3 was readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident 3's MAR for medications scheduled, on [DATE] at 9 a.m. and [DATE] at 9 a.m., were blank for Actos (a medicine that helps control blood sugar levels), Jardiance (medication used to lower blood sugar), [MEDICATION NAME] (medication used to lower blood sugar), and [MEDICATION NAME] (used to treat high cholesterol). c. A review of Resident 4's Admission Records indicated Resident 4 was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 4's MAR for the medications scheduled on [DATE], [DATE], and [DATE] at 9:00 a.m. was blank for [MEDICATION NAME] (medication used to lower blood sugar levels). Resident 4's [MEDICATION NAME] (medication used to help control certain kinds of [MEDICAL CONDITION], an abnormal brain activity that can lead to uncontrolled jerking, shaking body movements) was blank on [DATE] at 9:00 a.m., [DATE] at 5:00 p.m. and [DATE] at 9:00 a.m. and at 5:00 p.m. Resident 4's [MEDICATION NAME] (medication used to control blood sugar levels) were blank for scheduled doses, on [DATE] at 9:00 a.m., [DATE] at 5:00 p.m. and [DATE] at 9:00 a.m. and at 5:00 p.m. Resident 4's [MEDICATION NAME] (medication used to control [MEDICAL CONDITION]) scheduled doses on [DATE] at 9:00 a.m., [DATE] at 5:00 p.m., [DATE] at 9:00 a.m. and at 5:00 p.m. were also blank. On [DATE] at 2:15 p.m., during an interview, LVN 3 stated she was behind with her work. LVN 3 stated if there was no documentation on the MAR, then medications were not given. LVN 3 stated she was busy, and she was, Literally on the phone all day calling physicians and also calling hospitals to transfer a resident who had a change of condition. LVN 3 stated she notified the Director of Nursing that she needed help. On [DATE] at 10:05 a.m., during a phone interview, the DON stated the medications can be administered one hour before and one hour after the scheduled administration time. 6. On [DATE] at 1:13 pm to 1:55 p.m., during an interview and concurrent review of Resident 2, 3, and Resident 4s' MARs for ,[DATE], DSD verified that the last documented vital signs for Resident 2 was on [DATE] at 5:14 a.m., for Resident 3 was on [DATE] at 5:15 a.m., and for Resident 4 was on [DATE] at 5:20 a.m. The DSD stated the monitoring for signs and symptoms of COVID-19 was not completed every 4 hours. On [DATE] at 1:13 pm to 1:55 p.m., during an interview and concurrent review of Resident 2, 3, and 4s' MARs for ,[DATE], the DSD verified on [DATE], the residents' MARs had no documented entry monitoring Resident 2, 3, and 4's signs and symptoms for COVID-19. Resident 2, 3, and 4 also had no documented entry monitoring resident's signs and symptoms for COVID-19 on [DATE] day and evening shift was blank. On [DATE] at 1:13 pm to 1:55 p.m., during an interview, the DSD verified Resident 4's MAR also had no documentation entry to monitor the resident's signs and symptoms for COVID-19, on [DATE] evening shift, [DATE] day and night shift, and [DATE] day and evening shift. On [DATE] at 2:15 p.m. and at 2:25 p.m., during an interview, LVN 3 stated she was behind with her work. LVN 3 stated she was busy, and she notified the DON that she needed help. LVN stated she had not documented the vital signs she had taken. LVN 3 stated she took vital signs at 7 a.m. and stated she could not find the paper she wrote the vital signs on. LVN 3 stated she was supposed to take vital signs and monitor signs and symptoms of COVID-19 every 4 hours and document on the residents' MAR. 7. A review of Resident 36's Admission Records indicated the resident was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 36 Physician order [REDACTED]. A review Resident 36's Change of Condition, dated [DATE] at 3:39 p.m., indicated in the nursing notes, at 8:00 a.m., Resident 36's oxygen saturation fluctuated from as low 84% on 5 liters (L, unit of measurement) nasal cannula (n/c, device used to administer oxygen). At 11:46 a.m., 911 (medical telephone emergency) called. At 12:03 p.m., Resident 36 was transferred via gurney to general acute care hospital (GACH). At 12:10 p.m., family was contacted and voice message was left to Resident 36's Medical Doctor (MD). On [DATE], at 11:22 a.m., during a telephone interview, MD 1 stated Resident 36 was COVID-19 positive. The registry nurse called MD 1, on [DATE], after lunch regarding Resident 36's change of condition. Resident 36 was having desaturation (low level of oxygen in the body). MD 1 verified physician orders [REDACTED]. A review of Resident 36's Medication Administration Record (MAR) for the month of ,[DATE], indicated Resident 36 had a written physician order, dated [DATE], to monitor for resident's signs and symptom of COVID-19 to include resident's temperature, respiratory rate, oxygen (O2) saturation (a measurement of blood oxygen level) every shift. On [DATE], at 3:58 p.m., during a telephone interview, RN 2 stated he was a registry staff. RN 2 stated Resident 36 was in Red Zone and was COVID-19 positive. RN 2 stated Resident 36 had shortness of breath desaturated (low oxygen level) on [DATE], he called other staff members to assist, charge nurse called 911. RN 2 stated he called Resident 36's physician after transferred Resident 36 out due to short of staff. A review of the facility's Mitigation Plan, revise dated [DATE], indicated the facility shall remedy healthcare professional shortages by exhausting all measures that included an ongoing staffing assessment daily prior to the following day by the DON and DSD every shift thereafter as assigned to the RN supervisor or charge nurses to ensure adequate delivery of patient care. Based on interview, and record review, the facility failed to ensure follow the facility orders of oxygen administered to residents as needed per attending physician's orders [REDACTED]. Check oxygen saturation, if ordered, to ensure that oxygen use if effective for one of 36 random selective residents (Resident 36). This deficient practice had result Resident received oxygen 10 liter per minutes (L/min) without physician order. Findings: A review of the face sheet for Resident 36, indicated resident was originally admitted to facility on [DATE], and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the minimum data set (MDS, a standardized assessment and care planning tool) for Resident 36 dated [DATE], indicated Resident 36's cognitive skills for daily decision making was severely impaired made decisions, and required total dependence from staff for her activities of daily living with one persons assisted bed mobility and transfer. A review Physician order [REDACTED]. Monitor for signs and symptoms of Covid-19 and document: temperature (99.6 degree Fahrenheit and above). Respiratory rate, oxygen saturation every 4 hours dated ordered on [DATE], and started on [DATE]. Transfer Patient via 911 in regards to fluctuating oxygen saturation and elevated respiratory rate 36. A review Change of Condition dated [DATE] at 3:39 p.m., indicated Resident 36's Respiration rate 21 on [DATE], at 11:02 a.m., Contact precaution/isolation, quarantine Covid 19. Nursing Notes, indicated at 8:00 a.m. Resident 36's in room with oxygen saturation (o2 sat) fluctuating form as low 84% on 5L n/c. Repositioned, elevated head of bed and brought o2 sat up to 93%. At 9:15 a.m. Resident 36 remained stable, o2 sat 88% to 90%, RR 24. At 10:00 a.m., Resident 36 stable, breathing unlabored. O2 saturation 90%, RR 24. At 10:45 a.m., Resident stable, o2 saturation fluctuating from 90% to 93%, RR 24. 11:30 a.m., Resident 36's vital sign blood pressure ,[DATE], temperature 97.6, respiration rate 26, oxygen saturation 80% on 5 L/min n/c sustained. Provided an additional 10 L/min on non-rebreather mask. Resident 36 saturation continued to fluctuate between 79% to 84%, RR 36. At 11:46 a.m., 911 called. 12:03 p.m., Resident 36 was transferred via gurney to general acute care hospital (GACH). At 12:10 p.m., family contacted and voice message left. MD (medical doctor) made aware. A review Medication Administration Record (MAR), indicated monitor for signs and symptom of Covid-19 and document: Temperature, Respiratory rat, O2 saturation every shift order date [DATE], at 2:52 p.m. On [DATE], at 3:58 p.m., telephone spoke with RN 2, he stated, from registry. He assessed Resident 36 in red zone with Covid 19 positive, Resident 36 had shortness of breath (sob) desaturated on [DATE], he call others staff members to assist, charge nurse call 911, then he called physician after sent Resident 36 out due to short staff. On [DATE], at 11:22 a.m., telephone to MD1, he stated Resident 36 had Covid19 positive. The registry nurse called me on [DATE] after lunch Resident desaturation, I told them call 911. I called early morning the RN supervisor told me resident is fine. They delayed called me. On [DATE] at 1:13 pm to 1:55 p.m., during a record review of Resident 2,3 and Resident 4 's Medication Administration Record (MAR) verified with the Director of Staff Development (DSD), The following were observed; A review of Resident 2's MAR with the DSD, the medications scheduled on [DATE] at 0900 was blank. The medications were as follows; [MEDICATION NAME] ([MEDICATION NAME] - a medication to manage high blood pressure) tablet 5 milligrams, give one tablet by mouth one time a day related to unspecified essential hypertension. Hold if systolic blood pressure is less than 110 or heart rate is less than 60. [MEDICATION NAME] was also blank on [DATE] at 0900. [MEDICATION NAME] (steroid) tablet 5 miligrams, give 1 tablet by mouth one time a day for [DIAGNOSES REDACTED] (is a higher than normal level of eosinophils which are a type of disease-fighting white blood cell) [MEDICATION NAME] was also blank on [DATE] at 0900. During the review of Resident 2's MAR, the DSD stated he did not know how to print the MAR and he would call the Medical Record Staff to print the MAR. A review of Resident 2's MAR provided by the Medical Records Assistant (MRA) at 5:10 p.m., indicated the medications due at 0900 were signed and checked as administered. A review of Lexicomp's (Lexicomp provides evidence-based referential drug information for hospital and retail pharmacists, physicians, dentists and nurses to confidently make drug decisions for each unique patient, and to support the appropriate and safe use of medications) Patient Education on [MEDICATION NAME] and [MEDICATION NAME] indicated to use this drug as ordered by the doctor and to follow all instructions closely. A review of Resident 3's MAR indicated the medications scheduled on [DATE] at 0900 was blank. The medications were as follows; Actos (Pioglitazone [MEDICATION NAME]- is an oral diabetes medicine that helps control blood sugar levels) tablet 15 milligrams, give one tablet by mouth once a day. Actos was also blank on [DATE] at 0900. Jardiance (Empagliflozin -is used It is used to lower blood sugar in patients with high blood sugar and to lower the chance of death from [MEDICAL CONDITION] in certain people.) tablet 10 milligrams, give one tablet by mouth once a day. Jardiance was blank on [DATE] at 0900. [MEDICATION NAME] (linagliptin - is used to ) tablet 5 milligrams, give one tablet by mouth once a day. [MEDICATION NAME] was blank on [DATE] at 0900. [MEDICATION NAME] (ezetimibe - is used to treat high cholesterol) tablet 10 milligrams by mouth once a day. [MEDICATION NAME] was blank on [DATE] at 0900. A review of Lexicomp's Patient Education on Actos, [MEDICATION NAME], and [MEDICATION NAME] indicated to use this drug as ordered by your doctor. Read all information given to you. Follow all instructions closely. A review of Lexicomp's Patient Education on Jardiance indicated to use this drug as ordered by the doctor. Read all information given and to follow all instructions closely such as to take with or without food, and to take in the morning. A review of Resident 4's MAR indicated the medications scheduled on [DATE] at 0900 was blank. [MEDICATION NAME] (sitagliptin - is used to lower blood sugar levels) tablet 100 milligrams, give 1 tablet via gastrostomy tube ([DEVICE] is a feeding tube surgically inserted through the stomach used for people who cannot swallow) once a day. [MEDICATION NAME] was also blank on [DATE] and [DATE]. [MEDICATION NAME] ([MEDICATION NAME] - used to help control certain kinds of [MEDICAL CONDITION], an abnormal brain activity that can lead to uncontrolled jerking, shaking body movements) tablet 25 milligrams, give one tablet via [DEVICE] two times a day. [MEDICATION NAME] was blank on [DATE] at 0900, [DATE] at 1700 and [DATE] at 0900 and at 1700. [MEDICATION NAME] (an oral diabetes medicine that helps control blood sugar levels) tablet 1000 milligrams, give 1 tablet via [DEVICE] two times a day. [MEDICATION NAME] was on [DATE] at 0900, [DATE] at 1700 and [DATE] at 0900 and at 1700. [MEDICATION NAME] (lacosamide - medication used to control [MEDICAL CONDITION]) solution, 20 milligrams via [DEVICE] two times a day. [MEDICATION NAME] was blank on [DATE] at 0900, [DATE] at 1700, [DATE] at 0900 and at 1700. A review of Lexicomp's Patient Education on [MEDICATION NAME] and [MEDICATION NAME] indicated to use this drug as ordered by the doctor. Read all information given and follow all instructions closely. A review of Lexicomp's Patient Education on [MEDICATION NAME] indicated to use this drug as ordered by the doctor. Read all information given and to follow all instructions closely such as to take with or without food, do not change the dose or stop this drug, this could cause [MEDICAL CONDITION]. Talk with your doctor and to keep taking the drug as you have been told by your doctor or other health care provider, even if you feel well. A review of Lexicomp's Patient Education on [MEDICATION NAME] indicated to use this drug as ordered by the doctor. Read all information given and to follow all instructions closely such as to take with or without food, to keep taking this drug as you have been told by your doctor or other health care provider. On [DATE] at 12:23 p.m. to 2:35 p.m, during an observation, Licensed Vocational Nurse 3 (LVN 3) was at the Nurse's station on the phone. On [DATE] at 12:50 p.m., during a concurrent observation and interview, overheard LVN 3 on the phone with the physician, LVN 3 stated she called a physician regarding a resident's change of condition, the resident was not eating and drinking. On [DATE] at 2:15 p.m., during an interview, LVN 3 stated she was behind with her work and if there was no documentation on the MAR, then it was not given. LVN 3 stated she was busy and she was literally on the phone all day calling physicians and also calling hospitals to transfer a resident who had a change of condition. LVN 3 stated she notified the Director of Nursing that she needed help. < (TRUNCATED)

Based on interview and record review, the facility failed to ensure the physicians were immediately consulted and notified when there were changes in the residents' conditions, in accordance with the facility's policy and plan of care for four of five sampled residents (Residents 5, 7, 8 and 36). The facility failed to: 1. Immediately inform the physician when Resident 5 had a change in respiratory condition and was identified to have a low blood pressure, increased in heart rate and low oxygen saturation (refers to the extent to which hemoglobin (an element in your blood that binds with oxygen to carry it through the bloodstream to the organs and tissues) is saturated with oxygen, measured with a pulse oximeter (a device that measures the oxygen saturation levels)) levels of 85% (normal oxygen saturation levels are at least 5 percent) on [DATE]. 2. Immediately inform the physician when Resident 7 had a change in respiratory condition and was identified to have cough, shortness of breath, difficulty breathing, chills, fatigue, sore throat, new loss of appetite, headache, congestion and low oxygen saturation levels of 80 to 88 % from [DATE] to [DATE]. 3. Immediately inform the physician when Resident 8 had a change in respiratory condition and was identified to have cough, shortness of breath, difficulty breathing, chills, fatigue, sore throat, new loss of appetite, headache, congestion, and low oxygen saturation levels between 44 to 45% on [DATE]. 4. Immediately inform the physician when Resident 36 had a change in respiratory condition and was identified to have cough, shortness of breath or difficulty breathing, fatigue, chills, muscle or body ache, sore throat, new loss of taste or smell, headache, congestion or runny nose, diarrhea, nausea or vomiting from [DATE] to [DATE]. Inform the physician immediately of Resident 36's low oxygen saturation levels of 79% to 93%, cold and clammy skin noted on [DATE] at 8 a.m. These failures resulted in the delay in diagnosis, care, and services for Residents 5, 7, 8, and 36's respiratory condition. On [DATE] at the beginning of the 7 p.m. to 7 a.m. night shift (no time), Resident 5 was found with oxygen saturation of 86% at 5 liters of oxygen via nasal cannula (a small tube inserted in the nostrils to deliver oxygen) and a blood pressure of ,[DATE] mm/Hg (normal blood pressure is between ,[DATE] mmHg and ,[DATE] mmHg). At 1:09 a.m., on the same night shift, Resident 5 was found not breathing and expired (died ) in the facility. On [DATE] at 9:34 p.m., Resident 7 was found unresponsive with no heart rate, respiration, and no pulse oximeter reading. On [DATE] at 11:25 p.m., Resident 8 was found unresponsive to touch and at 11:30 p.m., the resident stopped breathing. Emergency medical services was called via 911. Resident 8 was pronounced dead at 11:39 p.m. On [DATE] at 12:03 p.m., Resident 36's oxygen saturation level declined to as low as 79 % at 10 liters of oxygen via non-rebreather mask (a mask that typically delivers 70 to 100 percent oxygen). Emergency medical services was called via 911. Resident 36 was transferred to the general acute care hospital (GACH) on [DATE] and expired on [DATE] due to septic shock (a condition sometimes occurring in severe infection, in which the blood pressure fails, and the organs of the body fail to receive sufficient oxygen) and acute hypoxic [MEDICAL CONDITION] (a condition that happens rapidly and without warning, when the body fails to receive adequate oxygen in the blood). Cross Reference to F725 and F695. Findings: A review of the facility's admission record indicated Resident 5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the MDS (Minimum Data Set) a resident assessment and care-screening tool, dated [DATE], indicated Resident 5 was sometimes able to express ideas and wants, and understand others. A review of Resident 5's physician's orders [REDACTED]. The physician order [REDACTED].=Y to document the signs and symptoms of COVID-19 in the nurses notes and inform the physician every shift. A review of the Resident 5's Medication Administration Record [REDACTED]. A review of Resident 5's plan of care for COVID-19 infection dated [DATE], indicated Resident 5 would be assessed for shortness of breath, irregular respiration, wheezing (a high-pitched [MEDICATION NAME] lung sounds made while breathing often associated with difficulty breathing), crackles (crunching lung sounds that can sometimes mean fluid in the lung airways), rhonchi (mucous secretion blockages in the main airways which caused rattling lung sounds), coughing, weakness, activity intolerance, excessive secretions, sore throat, runny nose, and a temperature greater than 99.6 °F (average normal body temperature is generally accepted as 98.6°F) and inform the physician promptly. On [DATE] at 2:11 p.m. during an interview, the Director of Nursing (DON) stated four residents expired on [DATE] and [DATE]. In a concurrent record review, the DON stated there were no documented evidence of the interventions provided to the residents and no documented evidence the physician was informed of Residents 5, 7, and 8 changes in condition related to COVID-19 prior to their death. On [DATE] at 2:15 p.m., during a concurrent record review of Resident 5's nursing progress notes, the DON stated Resident 5 tested positive for COVID-19 on [DATE] and expired at the facility on [DATE]. The note indicated a late entry dated [DATE], timed at 1:09 a.m. that indicated at the beginning (no time) of the licensed nurse's shift (7 p.m. to 7 a.m. shift) Resident 5's oxygen saturation was at 86% on 5 liters of oxygen via nasal cannula and a blood pressure of ,[DATE] mm/Hg. The note indicated that an endorsement was made that Resident 5's code status was a DNR (do not resuscitate; to revive someone from unconsciousness or apparent death) and comfort care (a type of essential care that helps or soothes a person who is dying. The goals are to prevent or relieve suffering). The note indicated that at 12:58 p.m., Resident 5 had shallow respirations, lethargic, and was not responding to verbal stimuli. The note indicated that at 1:09 a.m., Resident 5 had no pulse, no breathing, and pupils were fixed and dilated (pupils does not react to light). On [DATE] at 2:17 p.m. during a subsequent interview, the DON stated there were no documented evidence Resident 5's physician was informed of Resident 5's signs and symptoms of COVID 19 from [DATE] to [DATE] as indicated in the MAR. The DON stated she could not find documented evidence that Resident 5 was assessed for shortness of breath, irregular respiration, wheezing, crackles, rhonchi, coughing, weakness, activity intolerance, excessive secretions, sore throat, runny nose as indicated in Resident 5's care plan. The DON stated licensed nurses should listen and assess the resident's lung sounds. On [DATE] at 2:33 p.m., during a telephone interview, Licensed Vocational Nurse (LVN) 6 stated she was informed by the previous (7 a.m. to 7 p.m.) shift licensed nurse that Resident 5 had a physician order [REDACTED]. LVN 6 stated that on [DATE] (unable to recall exact time) Resident 5 had a low blood pressure, [MEDICAL CONDITION](increased heart rate) and low oxygen saturation level of 85% (normal range between 95 to 100%). LVN 6 stated she did not inform the physician of Resident 5's change of condition because the physician did not want to be called at night and because the resident was a DNR. A review of Resident 5's Physician order [REDACTED]. 2. A review of the facility's admission record indicated Resident 7 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the MDS dated [DATE], indicated Resident 7 required total dependence with staff on activities of daily living. A review of the laboratory report indicated Resident 7 tested positive for COVID 19 on [DATE] and reported to the facility on [DATE]. A review of Resident 7's physician's orders [REDACTED]. The physician order [REDACTED].=Y to document the signs and symptoms of COVID 19 in the nurses notes and inform the physician every shift. A review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED] a. On [DATE] day shift at 88%, evening shift at 87%, and night shift at 87% b. On [DATE] day shift at 85%, evening shift at 87%, night shift at 87% c. On [DATE] day shift at 80%, no oxygen saturation levels documented on evening and night shifts. A review of Resident 7's plan of care dated [DATE], for COVID 19 infection indicated Resident 7 would be assessed for shortness of breath, irregular respiration, wheezing, crackles, rhonchi, coughing, weakness, activity intolerance, excessive secretions, sore throat, runny nose and a temperature greater than 99.6 °F and inform the physician promptly. A review of the nursing progress notes, dated [DATE] at 9:34 p.m., Registered Nurse Supervisor (RN) 4 documented Resident 7 was found unresponsive with no heart rate, respiration and no reading was found in the pulse oximeter (a machine that records the blood oxygen level in the body), the DON, family and the mortuary of choice was informed. On [DATE] at 2:16 p.m. during a record review and concurrent interview, the DON stated there was no documented evidence the facility staff informed Resident 7's physician of the change in Resident 7's condition. The DON stated there were no documented evidence that Resident 7 were assessed for abnormal lung sounds and irregular respirations as indicated in the plan of care, and if interventions were provided for COVID-19 signs and symptoms manifested from [DATE] to [DATE] and reported to the physician immediately. On [DATE] at 3:12 p.m., during an interview, RN 4, who was assigned in the facility's Red Zone (an area where residents who are positive of COVID-19 were grouped at in the facility) stated he did not know Resident 7's current condition when he was informed by the staff that Resident 7 was not responding. RN 4 stated since Resident 7 had a physician order [REDACTED]. A review of Resident 7's POLST dated [DATE], indicated if the resident was found with pulse and/or is breathing, the resident should receive Selective Treatment such as comfort focused treatment described as medical treatment, IV antibiotics medications, IV fluids, and request transfer to the hospital only if comfort need cannot be met in current location. 3. A review of the facility's admission record indicated Resident 8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the MDS dated [DATE], indicated Resident 8 required total dependence with staff on activities of daily living (routine tasks that individuals must carry out every day to take care of themselves). A review of the laboratory test indicate Resident 8 tested positive for COVID 19 on [DATE] and result reported to the facility on [DATE]. A review of the nursing progress notes, dated [DATE] at 8:05 p.m. indicated the COVID 19 positive result was received and reported to Physician 1. The record indicated Physician 1 ordered for Resident 8 to be monitored and if oral (by mouth) intake was below 40% (food consumption) to transfer the resident to the acute hospital. A review of the nursing progress notes dated [DATE] timed at 2 a.m., indicated that around 11:25 p.m., the facility staff found Resident 8 unresponsive to touch, moved her lips (sic), and had stopped breathing at 11:30 p.m. The progress notes indicated that Resident 8's oxygen saturations were between 44 to 45% (at 11:25 p.m.) on 5 liters per minute of oxygen via nasal cannula (a plastic tube used to deliver oxygen to the nose). The progress notes indicated LVN 6 called emergency medical services via 911. The progress notes indicated the RN supervisor assessed the resident and indicated Resident 8 had no heart sounds, no respirations and was pronounced dead at 11:39 p.m. A review of Resident 8's physician's orders [REDACTED]. The physician order [REDACTED].=Y to document the signs and symptoms of COVID-19 in the nurses notes and inform the physician every shift. A review of Resident 8's Medication Administration Record [REDACTED]. On [DATE] at 2:20 p.m., during a record review and concurrent interview, the DON stated there was no documented evidence the facility staff informed Resident 8's physician of the change in Resident 8's condition. The DON stated there were no documented evidence that interventions were provided for COVID-19 signs symptoms manifested on [DATE] and reported to Physician 1 immediately. On [DATE] at 2:33 p.m., during a telephone interview, LVN 6 stated she received a report on [DATE] that Resident 8's code status was a DNR. LVN 6 stated that on the evening of [DATE] LVN 6 noticed that Resident 8 was unresponsive. LVN 6 stated she did not call Physician 1 because physicians do not want to be bothered at night especially if the resident's code status was a DNR. LVN 6 further stated that she did not call Resident 8's physician (Physician 1) because she was busy with other residents in the facility, who were having changes in condition on [DATE]. A review of Resident 8's POLST dated [DATE], indicated if the resident was found with pulse and/or breathing, the resident should receive Selective Treatment such as comfort focused treatment described as medical treatment, IV antibiotics, medications, IV fluids, and request transfer to the hospital only if comfort needs cannot be met in the current location. A review of Resident 8's plan of care dated [DATE], indicated the resident would be assessed for shortness of breath, irregular respiration, wheezing, crackles, rhonchi, coughing, weakness, activity intolerance, excessive secretions, sore throat, runny nose and a temperature greater than 99.6 °F and inform the physician promptly. On [DATE] at 4:55 p.m., during an interview, the DON stated the licensed staff should always inform the physicians for any residents' changes in condition including the sudden changes of condition related to COVID-19. On [DATE] at 11:22 a.m. during a telephone interview, the facility's Medical Director (MD 1) stated if the resident had a change of condition especially related to COVID-19, the primary physician should be informed to determine the right treatment for [REDACTED]. MD 1 stated the POLST described as Selected Treatment means the resident should still receive treatments such as oxygen, IV fluids and transfer to acute hospital, if needed. MD 1 stated if the staff could not reach the resident's primary physician, the licensed nurses should inform the facility's Medical Director or the DON at any time of the day. 4. A review of the facility's admission record indicated Resident 36, indicated resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 36's MDS dated [DATE], indicated the resident's cognitive skills for daily decision making was severely impaired. The MDS indicated the resident required total dependence from staff for activities of daily living with one- person extensive assistance (another person aid in performing the activity, by providing weight-bearing assistance) for bed mobility and transfer. A review of Resident 36's Physician order [REDACTED]. a. On [DATE], to monitor for signs and symptoms of COVID 19 that included cough, shortness of breath or difficulty breathing, fatigue, chills, muscle or body ache, sore throat, new loss of taste or smell, headache, congestion or runny nose, diarrhea, and nausea or vomiting. b. On [DATE], to monitor for signs and symptoms of COVID-19 and document the resident's temperature (99.6 °F and above), respiratory rate, and oxygen saturation every 4 hours. c. On [DATE], (the day after the resident was transferred to the GACH) to administer oxygen at two liters per minute (2 L/min) via nasal canula (a piece of plastic tubing that runs under the nose and is used to administer oxygen) as needed and may titrate (continuously measure and adjust) up to 5 liters per minute for oxygen saturation of less than 92%, as needed for shortness of breath, wheezing, and hyperventilation (breathe at an abnormally rapid rate). A review of Resident 36's Medication Administration Record [REDACTED]. A review of Resident 36's plan of care dated [DATE], for COVID-19 infection indicated Resident 36 would be assessed for shortness of breath, irregular respiration, wheezing, crackles, rhonchi, coughing, weakness, activity intolerance, excessive secretions, sore throat, runny nose and a temperature greater than 99.6 °F and inform the physician promptly. On [DATE], at 3:58 p.m., during a telephone interview, Registered Nurse (RN) 2 who works from a Nursing Registry, stated he assessed Resident 36, who was a COVID-19 positive resident in the facility's Red Zone. RN 2 stated that on [DATE], Resident 36 had shortness of breath and had a decline in oxygen saturation. RN 2 stated the charge nurse called 911 (emergency medical services). RN 2 stated he called Resident 36's physician (Physician 2) after Resident 36 was sent out to the acute hospital because the facility was short of staff. On [DATE], at 11:22 a.m., during a telephone interview, Resident 36's physician (Physician 2) stated Resident 36 was COVID-19 positive. Physician 2 further stated that he had called the facility staff, earlier on [DATE] and [DATE] and was informed by the RN supervisor (unable to recall who) that Resident 36 was fine. Physician 2 stated that RN 2 called Physician 2 on [DATE] after lunch and notified him of Resident 36's desaturation (decline in blood oxygen levels). Physician 2 stated he ordered RN 2 to call 911. Physician 2 stated the facility staff delayed notifying him of Resident 36's declining condition. On [DATE] at 4:20 p.m. during a record review of the licensed nurses notes with the DON, there were no documented evidence that Resident 36 were assessed for abnormal lungs sounds and if other nursing interventions were provided for COVID-19 signs and symptoms manifested from [DATE] to [DATE] and reported to the physician. The nurses' note indicated the following information: a. On [DATE] timed at 7:53 p.m., the licensed nurse updated the physician that Resident 36 did not have signs and symptoms of COVID-19 (however, the MAR indicated [REDACTED]. b. On [DATE], timed at 4:43 p.m., the licensed nurse documented calling the physician and waiting for a return call due to Resident 36's low blood pressure of ,[DATE] mm/Hg and improved after the resident was placed on Trendelenburg position (involves the resident being placed with their head down and feet elevated) in bed. There was no follow-up documentation if the physician had called back the same day. c. The next day, on [DATE], timed at 4:49 p.m., the licensed nurse documented that Resident 36's physician had called back and ordered to transfer the resident to GACH. The nurses' note indicated there were no available beds for COVID-19 positive residents during that time at the GACH. The nurse's notes indicated that Resident 36's physician called the facility and was informed by the facility staff that the resident remained stable on [DATE] timed at 6:52 p.m. d. On [DATE] timed at 11:49 a.m., the nurses' note indicated that emergency medical services was called via 911 because Resident 36's oxygen saturation was fluctuating between 77% to 92% with cold, clammy skin. A review of a facility document titled Change of Condition with effective date [DATE] at 3:39 p.m., indicated the following information: a. At 8 a.m., Resident 36's oxygen saturation was fluctuating from as low as 84% on 5 liters of oxygen via nasal cannula. The notes indicated that after Resident 36 was repositioned, the oxygen saturation went up to 93%. b. At 9:15 a.m., Resident 36 remained stable, the oxygen saturation was between 88% to 90% the respiratory rate was 24 (normal range for an adult person at rest range from 12 to 16 breaths per minute). c. Between the hours of 10 to 10:45 a.m., (Resident 36) stable, and breathing was unlabored (not showing effort). The notes indicated the resident's oxygen saturation was between 90% to 93% and respirations of 24. d. At 11:30 a.m., Resident 36's vital signs were ,[DATE] mm/Hg (blood pressure), temperature of 97.6 °F, respiration rate of 26, oxygen saturation of 80% on 5 liters per minute of oxygen via nasal cannula. The notes indicated Resident 36 was provided with an additional 10 liters per minute of oxygen via a non-rebreather mask (a mask that enables the delivery of high concentrations of oxygen and is recommended for use in patients who are critically ill). The note indicated that Resident 36's oxygen saturation continued to fluctuate between 79% to 84%, and respirations at 36. e. At 11:46 a.m., 911 emergency medical services was called. f. At 12:03 p.m., Resident 36 was transferred to the acute hospital. g. At 12:10 p.m., the note indicated that Resident 36's physician was notified. On [DATE] at 5:16 p.m., a concurrent record review and telephone interview of Resident 36's oxygen physician order [REDACTED]. A review of Resident 36's Discharge Documentation from the general acute care hospital (GACH) electronically signed by the acute hospital physician (Physician 3) on [DATE], indicated Resident 36 was admitted to the GACH on [DATE] and expired on [DATE]. The GACH discharge documentation indicated Resident 36's reason for GACH admission was [MEDICAL CONDITION] (a condition in which the body or a region of the body is deprived of adequate) and dehydration (occurs when more water and fluids leave the body than enter it). The discharge [DIAGNOSES REDACTED]. A review of the facility's policy and procedure, titled Change of Condition dated [DATE], indicated to ensure proper assessment and follow through for any resident with change of condition, the physician shall be called promptly. The policy indicated that if for some reason the physician could not be reached, an alternative physician should be contacted. If the alternate physician could not be reached, the Medical Director is to be contacted. The policy indicated that all contacts or attempts to contact should be documented. The policy indicated that if no physician was available, arrangements are to be made for physician services that may include transfer to the emergency room for appropriate care.