Every finding on record at Monte Vista Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure comfortable room temperatures for two of two sampled residents (Resident 4 and Resident 17) when failing to maintain temperature levels within the range of 71 to 81 degrees Fahrenheit ( F - temperature scale) in accordance with the facility's Policy and Procedure (P&P) titled Homelike Environment.This deficient practice resulted in Resident 4 Resident 17 feeling uncomfortable in Resident 4 and 17's rooms and the potential for hyperthermia (a medical condition where your core body temperature rises above normal because your body absorbs or produces more heat than it can release) to Resident 4 and Resident 17. Findings: a. During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus (abnormal blood sugar levels) and abnormal gait. During a review of Resident 4's History and Physical (H&P), dated 8/10/2026, the H&P indicated Resident 4 had the capacity to understand and make decisions. The H&P indicated Resident 4 had chronic (long-lasting) left side (of the body) weakness. During a review of a Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 8/11/2026, the MDS indicated Resident 4 needed maximal assistance (helper does more than half the effort) with lower body dressing, toilet and tub/shower transfers, and chair/bed-to-chair transfers. During an observation, on 8/28/2026 at 10:33 AM, Resident 4 was sitting on a chair at the side of Resident 4's bed, watching television, and was shirtless. During an observation, on 8/28/2026 at 12:20 PM, Resident 4 was sitting on a chair at the side of Resident 4's bed and a fan directly facing the resident. During a concurrent observation and interview on 8/28/2026 at 3:38 PM with Resident 4 inside the resident's room, Resident 4 was sitting on a chair beside Resident 4's bed and next to the wall that had a sliding glass door. Resident 4 was shirtless and stated, My shirt is off because it [is] hot! It's hot in here! Yes, I am hot! Resident 4 stated I told someone [staff member with no name recall] that it's hot, but I don't know what their name is, they know. Resident 4 stated It would be nice for them to cool this room off so I can be comfortable. During an observation and concurrent interview on 8/28/2026 at 3:33 PM inside Resident 4's room with the Maintenance Supervisor (MS), the MS stated a significant rise in temperature was felt when walking inside Resident 4's room. The MS took the facility's digital laser thermometer and obtained the following temperatures from inside the room, Wall by the sliding glass door = 85 degrees F Wall above Resident 4's head of the bed = 82 degrees F Entrance door wall = 79 degrees F Wall holding the television = 82 degrees F The MS stated the acceptable room temperature range was 81 degrees F or lower. The MS stated, It is hotter in here [Resident 4's room] than the (adjacent) hallway. During an interview with the Administrator (ADM) on 8/28/2026 at 5:00 PM with the ADM, the ADM stated temperatures in resident rooms should remain at comfortable level for the residents (in general). b. During a review of Resident 17's AR, the AR indicated the facility admitted Resident 17 on 8/8/2026 with diagnoses that included dementia (a progressive state of decline in mental abilities) and reduced mobility. During a review of Resident 17's MDS, dated [DATE], the MDS indicated Resident 3's cognition (ability to think and make decisions) was severely impaired. The MDS indicated Resident 3 was dependent (helper does all of the effort, the resident does none of the effort to complete the activity) on toileting hygiene and showers/bathes self. During a concurrent interview and observation on 8/26/2026 at 3:08 PM, the MS stated there were two thermostats used to control temperature inside the facility. The MS stated thermostat 1 was set at 74 degrees F and the actual temperature reading was 79 degrees F. The MS stated thermostat 2 was set at 74 degrees F and the actual temperature reading was 80 degrees F. The MS stated both thermostats were located in the same hallway. The MS stated the thermostat setting was usually set at 74 degrees F. During an interview on 8/26/2026 at 4:45 PM with the Director of Nursing (DON), the DON stated the DON did not know what the required temperature range was but the DON would ask the ADM. The DON stated the temperature needed to be within that range for a comfortable environment for the residents (in general). During an observation and interviews on 8/26/2026 at 5:04 PM, inside Resident 17's room, with the MS and Resident 17, Resident 17 was lying in bed, there was a fan on top of the bedside table that was blowing air toward Resident 17. The MS used the facility's digital laser thermometer and obtained a temperature from the wall near Resident 17's head of the bed. The MS stated the temperature reading was 83.3 degrees F. Resident 17 stated It feels hot when asked how Resident 17 was doing. During an observation on 8/26/2026 at 5:08 PM, The MS changed the thermostat's temperature setting from 74 degrees F to 72 degrees F when asked for the reason the temperature setting was kept at the usual temperature setting (74 degrees F) during hot weather. During a review of the facility's P&P titled Homelike Environment, revised 2/2021, 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 P&P indicated the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics included comfortable and safe temperatures (71 degrees F – 81 degrees F).

Based on interview and record review, the facility failed to provide requested medical records within 48 hours from the written request for one of two sampled residents (Resident 1).This failure resulted in untimely access to Resident 1's medical records by Resident 1's authorized representative (Legal Services and the Family Member [FM]) and resulted in a violation of Resident 1's rights.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 2/3/2025 and readmitted the resident on 3/4/2025 with diagnoses including metabolic encephalopathy (brain dysfunction caused by chemical imbalances in the body, systemic illness, or organ failure rather than direct physical damage or disease within the brain itself), chronic obstructive pulmonary disease (COPD- a long standing lung disease causing difficulty in breathing), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). The AR indicated the FM was Resident 1's responsible party.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 3/30/2025, the MDS indicated Resident 1's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and required substantial/maximal assistance with mobility.During a review of the facility's email correspondence with Resident 1's Legal Services regarding Resident 1's medical-record request, the email indicated the following:6/29/2026, at 11:32 AM: the Medical Records (MR), emailed Resident 1's requested medical records to Resident 1's Legal Services.6/30/2026, at 12:00 PM: Resident 1's Legal Services followed up and stated the request was served to the facility on 6/16/2026.During an interview with the Certified Paralegal (CP, Legal Services) on 7/8/2026 at 10:30 AM, the CP stated the completed medical-record request for Resident 1 was personally delivered to the MR on 6/16/2026. The CP stated the request included a valid HIPAA authorization form. The CP stated repeated follow-up attempts with the facility did not result in the timely release of the records. The CP stated Resident 1's medical records were provided (emailed) on 6/29/2026.During an interview and concurrent record review on 7/8/2026 at 11 AM with the Director of Nursing (DON), the facility's medical records request log titled Records Request was reviewed with the DON. The DON stated the log indicated all medical-record requests received during the past two months. The DON stated the log contained one medical record request for Resident 1, dated 6/16/2026, submitted by the Legal Services on behalf of the FM.During an interview with the DON on 7/8/2026 at 12 PM, the DON stated Resident 1's medical record request was submitted to the facility on 6/16/2026. The DON stated the requested records were not provided (emailed to the Legal Services) until 6/29/2026 because the request was being reviewed by the facility's legal team before being released. The DON stated the legal team's review did not excuse the delay or remove the facility's responsibility to process the request within its 48-hour policy. The DON stated that timely access of resident records protected resident rights and prevented unnecessary delays.During a review of the facility's policy and procedure (P&P) titled, Release of Information revised 11/2009, the P&P indicated a resident may have access to his or her records within 48 hours (excluding weekends and holidays) of the resident's written or oral request.

Based on interview and record review, the facility failed to ensure complete and accurate medical records for one of three sampled residents (Resident 1) when Resident 1's Documentation Survey Report (DSR - certified nursing assistant's [CNA's] documentation of care provided to the resident) regarding turning and repositioning Resident 1 every two hours was not completed on 4/12/2026, 4/13/2026, 4/15/2026, 4/17/2026, 4/18/2026, and on 4/20/2026 to 4/25/2026.This failure resulted in Resident 1's medical record containing incomplete information and had the potential for Resident 1 to receive inappropriate care and treatment resulting in delayed wound healing or worsening of Resident 1's pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence).Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses including malignant neoplasm of prostate (prostate cancer), malignant neoplasm of bone and articular cartilage (primary bone cancer), pressure ulcer sacral (localized damage to the skin and/or underlying tissue of the tailbone), and paraplegia (partial or complete paralysis of the lower half of the body).During a review of Resident 1's History & Physical Examination (H&P), dated 4/10/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 4/19/2026, the MDS indicated Resident 1's cognitive (the ability to think and process information) skills for daily decision making were independent (decisions consistent/reasonable). The MDS indicated Resident 1 required extensive assistance of staff to move around in bed, to move to or from bed, chair, and wheelchair, and with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's CPs, titled Sacrum Unstageable Pressure Injury and Right Gluteus (buttocks) Pressure Injury Stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible), dated 4/9/2026, the CPs indicated a goal of, Will heal without further complication until next review date and an intervention of, Turn and reposition every 2 hours and prn (done as needed or requested). During a review of Resident 1's DSR, dated April 2026, the DSR indicated there was no documentation that Resident 1 was turned and repositioned regarding turning and repositioning Resident 1 every two hours on:a. 4/12/2026 at 7 AM, 9 AM, 11 AM, and 1 PM.b. 4/13/2026 at 5 AM, 7 AM, 9 AM, 11 AM, and 1 PM.c. 4/15/2026 at 11 PM.d. 4/17/2026 and 4/22/2026 at 3 PM, 5 PM, 7 PM, and 9 PM.e. 4/18/2026 at 7 AM, 9 AM, 11 AM,1 PM, and 11 PM.f. 4/20/2026 to 4/25/2025 at 7 AM, 9 AM, 11 AM,1 PM.During a concurrent interview and record review on 6/3/2026 at 3:30 p.m. with the Director of Nursing (DON), Resident 1's DSR, dated April 2026, and the facility's policy and procedure (P&P) titled, Charting and Documentation, revised July 2017, were reviewed. The P&P's policy statement indicated, 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. The P&P's policy interpretation and implementation indicated, The following information is to be documented in the resident medical record: Treatments or services performed. The DON stated the facility's P&P was not followed when Resident 1's DSR had missing documentation on some dates. Additionally, the DON stated there should be documentation indicating Resident 1 was turned every two hours.

Based on interview and record review, the facility failed to ensure comprehensive person-centered care plans (CP) were developed for two of two sampled residents (Resident 36 and Resident 14) in accordance with the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered and Fall Risk Assessment. This failure had the potential to result in unmet individualized needs for Residents 36 and 14 and the potential to affect the resident's physical and psychosocial well-being.Cross Reference F689Findings: a. During a review of Resident 36's admission Record (AR), the AR indicated Resident 36 was admitted to the facility on [DATE] with diagnoses that included intervertebral disc displacement (a spinal condition where the soft, gel-like center of a spinal disc pushes through its tough outer ring into the spinal canal) - lumbar region (lower part of the back), cerebellar ataxia (involuntary muscle coordination causing unsteady movements), repeated falls, and lack of coordination, abnormalities in gait and mobility (abnormal walking, characterized by unsteadiness, shuffling, limping, or stiffness). During a review of Resident 36's History and Physical (H&P), dated 10/26/2025, the H&P indicated Resident 36 did not have the capacity to understand and make decisions. During a review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 1/22/2026, the MDS indicated Resident 36's cognition (the ability to think and process information) was moderately impaired (moderate problems with thinking and memory). The MDS indicated Resident 36 was dependent (helper does all of the effort) with toilet hygiene, lower body dressing and needed maximal assistance (helper does more than half the effort) with upper body dressing. During a review of Resident 36's Fall Risk Assessments (FRA), dated 1/13/2026, 2/3/2026, and 2/9/2026, the FRAs indicated Resident 36 was at risk for falls. During a review of Resident 36's Change in Condition Evaluation (COC), the COC indicated Resident 36 sustained falls on 1/30/2026, 2/9/2026, 2/15/2026, 3/1/2026, and 3/23/2026. During an interview and concurrent record review on 4/24/2026 at 2:28 PM with the Director of Nursing (DON), Resident 36's paper and electronic medical record (chart) was reviewed, the DON stated Resident 36 did not have CPs addressing Resident 36's falls that occurred on 1/30/2026, 2/9/2026, 2/15/2026, 3/1/2026 and 3/23/2026. The DON stated fall CPs were important to [help prevent] re-occurrence of falls and for injuries to be prevented. During a review of the facility's undated P&P titled Fall Risk Assessment, the P&P indicated the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. b. During a review of Resident 14's AR, the AR indicated Resident 14 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including acute respiratory failure with hypoxia (a medical emergency where the lungs suddenly fail to get enough oxygen [O2, a colorless gas essential to living organisms] into the blood causing severe shortness of breath), and heart failure, unspecified. During a review of Resident 14's undated H&P, the H&P indicated, Resident 14 did not have the capacity to understand or make medical decisions. During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14's cognitive skills (ability to think and process information) for daily decision making were moderately impaired (decisions poor; cues/supervision required). The MDS indicated Resident 14 was dependent (helper does all of the effort) to requiring partial/moderate assistance (helper does less than half the effort) with activities of daily living (ADL – routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 14 received continuous 02 therapy on admission and while a resident (at the facility). During a review of Resident 14's Order Summary Report (OSR), dated active as of 4/24/2026, the OSR indicated a physician's order, dated 2/26/2026, for 02 at three (3) liters per minute (LPM - the speed or volume of 02 a device delivers in one minute) via nasal cannula continuously. During a concurrent interview and record review on 4/23/2026 at 1:44 PM with the Registered Nurse Supervisor (RNS), Resident 14's medical records were reviewed. The RNS stated Resident 14 had a physician's order for 02 at 3 LPM ordered on 2/26/2026 for respiratory failure. The RNS stated Resident 14 did not have a CP that addressed Resident 14's supplemental 02 therapy. The RNS stated creating a CP was important for the staff (in general) to have a plan for a specific problem including interventions for the residents (in general). During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, date revised March 2022, 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 P&P indicated the comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. The P&P indicated assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review the facility failed to ensure three of three sampled residents (Resident 20, 24, 36) received medication or treatment in accordance with the physician's orders and the facility's policy and procedures (P&P) by: A. Failing to administer two grams of lidocaine (medication used to numb tissues for procedures or pain relief) external ointment 5% as indicated on the medication physician order for Resident 20. B. Failing to provide Restorative Nurse Assistant (RNA, specialized rehabilitative care provided by nurse assistants with extra training to help residents regain or maintain mobility, strength, and independence in activities of daily living) services as indicated in Resident 24's physician order.C. Failing to initiate Fall Risk Assessments after Resident 36 sustained falls on 1/30/2026, 2/19/2026, 3/1/2026, 3/23/2026, and on 4/15/2026.This deficient practice had the potential to result in harm and a physical decline to Resident 20, Resident 24, and Resident 36. Additionally, there was a potential for recurrent falls to Resident 36. Cross Reference F689Findings: A. During a review of Resident 20's admission Record (AR), the AR indicated Resident 20 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including spondylosis (degeneration of the bones and disks in the neck) and type 2 diabetes mellitus (condition in which the body cannot properly store or use glucose, the body's main source of energy) with diabetic chronic (long standing) kidney disease (common complication of diabetes that reduces how well kidneys filter waste). During a review of Resident 20's Care Plan (CP), initiated 11/4/2024, the CP's focus indicated acute (sudden)/chronic pain related to multiple medical conditions. The CP's interventions indicated to administer pain medication as ordered. During a review of Resident 20's physician order dated 3/11/2026, the physician order indicated Lidocaine external ointment 5%. The physician order indicated to apply 2 grams (gm-unit of weight) to the right upper arm topically (the application of a substance directly onto a specific surface area of the body, usually the skin) two times a day for right arm pain. During a review of Resident 20's Minimum Data Set (MDS- a resident assessment tool), dated 3/25/2026, the MDS indicated Resident 20 had intact cognition (ability to understand and process information) and was dependent on staff for bathing and toileting. During a concurrent observation and interview on 4/23/2026 at 9:02 AM with Licensed Vocational Nurse (LVN) 2, medication administration for Resident 20's Lidocaine ointment was observed. LVN 2 administered an unmeasured amount of ointment to Resident 20. LVN 2 stated LVN 2 was not sure how much lidocaine was applied (administered) to Resident 20 because the medication label did not indicate how much ointment was 2 gm. LVN 2 stated it was important to give an accurate dose [of Lidocaine] to ensure Resident 20 did not get too much or too little medication. During an interview on 4/23/2026 at 10:29 AM with the Director of Nursing (DON), the DON stated correct dosages of medications should be given to ensure residents are not over dosed or under dosed and [an incorrect dose] could cause harm. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated medications are administered in accordance with prescriber orders, including any required time frame. B. During a review Resident 24's AR, the AR indicated Resident 24 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (form of paralysis causing muscle weakness or total loss of motor function on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (type of stroke caused by a blockage in blood vessels supplying the brain resulting in tissue death [NAME] to lack of oxygen) affecting the left non-dominant side, contracture (permanent, shortening of muscles, causing rigid, stiff joints and reduced movement) of the left knee, contracture of the left elbow, contracture of the left hip, lack of coordination, and generalized muscle weakness. During a review of Resident 24's H&P, dated 1/23/2026, the H&P indicated Resident 24 had the capacity to understand and make decisions. During a review of Resident 24's MDS, dated [DATE], the MDS indicated Resident 24 was cognitively intact, had impairment (weakened, or damaged,) on one side of Resident 24's upper and lower extremities (arm and leg), and Resident 24 used a walker and a manual wheelchair for mobility. The MDS indicated Resident 24 required maximal assistance (helper does more than half the effort) with activities of daily living such as upper body dressing and bathing. During a review of Resident 24's CP, dated 4/23/2026, the CP's focus indicated Resident 24 was at risk for decline in range of motion (ROM, how far a person can move a joint or muscle in various directions) and risk for decreased muscle strength . The CP's interventions indicated RNA program to assist Resident 24 with ambulation using a HW support and L HKAFO application, to maintain current level of function. During a review of Resident 24's Order Summary Report (OSR), dated active as of 4/24/2026, the OSR included a physician's order (PO), dated 12/9/2025, the PO indicated RNA program to assist patient with ambulation using a hemi walker (HW, mobility aid designed for individuals who can only use one hand or arm, often due to one sided weakness) support and L [left] Hip-Knee-Angle-Foot Orthosis (HKAFO, custom molded full-leg bracing system that extends from the pelvis [large basin-shaped bone at the base of the spine] down to the foot) application, in order to maintain current level of function 4X/WK [four times a week] every Tuesday, Friday, Saturday, and Sunday. During a review of Resident 24's RNA program medical record, dated April 2026, the record indicated Resident 24 did not receive RNA services on Sunday 4/5/2026, Tuesday 4/7/2026, and on Sunday 4/19/2026. During an observation and concurrent interview on 4/21/2026 at 11:33 AM with Resident 24, at Resident 24's bedside, Resident 24 was sitting on a wheelchair and stated, I don't always get my RNA therapy four times a week, sometimes I only get it three times. The resident stated, I don't like to miss sessions, I can still walk, a little. During a concurrent record review and interview on 4/23/2026 at 2:55 PM, with Restorative Nursing Assistant 1 (RNA 1), Resident 24's RNA program medical record was reviewed. RNA 1 stated Resident 24's RNA treatment was missed on 4/5/2026, 4/7/2026 and 4/19/2024. RNA 1 stated RNA 1 did not recall why Resident 24 did not receive RNA treatments on those dates. RNA 1 stated it was important for Resident 24 to receive RNA treatments for Resident 24 to keep using Resident 24's good leg. During an interview on 4/23/2026 at 3:24 PM with the Registered Nurse Supervisor (RNS), the RNS stated it was important for RNA services to be done to maintain the function of Resident 24's extremities. During an interview on 4/24/2026 at 9:46 AM with the Director of Staff Development (DSD), the DSD stated RNA treatments should not be missed to maintain, stabilized, and hopefully improve Resident 24's mobility function. During an interview on 4/24/2026, at 2:33 PM with the DON, the DON stated RNA orders should be followed to prevent decline and to maintain what the resident's mobility. During a review of the facility's P&P titled Restorative Nursing Services, dated 7/2017, the P&P indicated residents will receive RNA care as needed to help promote optimal safety and independence. The P&P indicated restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care. The P&P indicated restorative goals may include but not limited to supporting and assisting the resident in developing, maintaining or strengthening their physiological and psychological resources, maintaining their dignity, independence and self-esteem. During a review of the facility's P&P titled Activities of Daily Living (ADL's), Supporting, dated 3/2018, the P&P indicated residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADL's. The P&P indicated residents will be provided with care, treatment, and services to ensure that their ADLs do not diminish. C. During a review of Resident 36's AR, the AR indicated Resident 36 was admitted to the facility on [DATE] with diagnoses that included intervertebral disc displacement (a spinal condition where the soft, gel-like center of a spinal disc pushes through its tough outer ring into the spinal canal) - lumbar region (lower part of the back), cerebellar ataxia (involuntary muscle coordination causing unsteady movements), repeated falls, and lack of coordination, abnormalities in gait and mobility (abnormal walking, characterized by unsteadiness, shuffling, limping, or stiffness). During a review of Resident 36's H&P, dated 10/26/2025, the H&P indicated Resident 36 did not have the capacity to understand and make decisions. During a review of Resident 36's MDS, dated [DATE], the MDS indicated Resident 36's cognition (the ability to think and process information) was moderately impaired (moderate problems with thinking and memory). The MDS indicated Resident 36 was dependent (helper does all of the effort) with toilet hygiene, lower body dressing and needed maximal assistance (helper does more than half the effort) with upper body dressing. During a review of Resident 36's Change in Condition Evaluation (COC), the COC indicated Resident 36 sustained falls on 1/30/2026, 2/19/2026, 3/1/2026, 3/23/2026, and 4/15/2026. During an interview and concurrent record review on 4/24/2026 at 2:24 PM with the Director of Nursing (DON), Resident 36's COC's indicating falls, dated 1/30/2026, 2/19/2026. 3/1/2026, 3/23/2026 and 4/15/2026 were reviewed, the DON stated post fall risk assessments were not completed after Resident 36's falls that occurred on 1/30/2026, 2/19/2026, 3/1/2026, 3/23/2026 and 4/15/2026. The DON stated it was important to complete fall risk assessments after every fall to find out the root cause of the fall, to prevent future falls, and to find out how to correct it [root cause]. During a review of the facility's undated P&P titled Fall Risk Assessment, the P&P indicated the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The P&P indicated upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. During a review of the facility's P&P titled Assessing Falls and Their Causes, dated 3/2018, the P&P's purpose indicated the procedure is to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. The P&P's general guidelines indicated residents must be assessed upon admission and regularly afterward for potential risk of falls and relevant risk factors must be addressed promptly. The P&P indicated when a resident falls, the following information should be recorded in the resident medial record: completion of a falls risk assessment.

Based on observation, interview, and record review the facility failed to ensure one bag of breaded fish, in one of one freezer (Freezer 1), was labeled and dated as indicated in the facility's policy and procedure (P&P) titled, Food Receiving and Storage.This deficient practice had the potential to result in foodborne illnesses (type of illness caused by consuming contaminated food or beverages) to the residents residing at the facility and consuming the food.Findings: During a concurrent observation and interview on 4/21/2026 at 9:07 AM during the kitchen tour with the Dietary Manager (DM), Freezer 1 had one bag of breaded fish with an undated label. The DM stated the bag of breaded fish did not contain a label that indicated a received, date and use by, date which was required for resident food safety.During a review of the facility's P&P titled, Food Receiving and Storage, dated 11/2022, the P&P's policy statement indicated foods shall be received and stored in a manner that complies with safe food handling practices. The P&P's refrigerated/frozen storage section indicated all foods stored in the refrigerator or freezer are covered, labeled, and dated ( use by date).

Based on observation, interview, and record review, the facility failed to implement infection (the invasion and growth of germs in the body) prevention and control practices by failing to ensure:a.Personal care items found inside the [NAME] and [NAME] restroom (a shared restroom situated between two bedrooms, featuring direct access from both rooms) for 4 of 7 sampled residents (Resident 54, Resident 9, Resident 39, and Resident 45) were labeled and stored properly.b. The lint screen/trap for one of one sampled commercial laundry dryer (CLD) was free of accumulation of lint c. An Enhanced Barrier Precaution (EBP - an infection-control practice to prevent the spread of bacteria in nursing homes) sign was posted outside of 1 of 7 sampled residents (Resident 70).These deficient practices had the potential to result in cross contamination (the process by which microorganisms are unintentionally transferred from one area/object to another with a harmful effect) and/or the development and transmission of disease (an illness or sickness) and infections to the residents including Residents 54, 9, 39, 45, 70. Additionally, the deficient practice had the potential to result in a damp environment leading to mold and bacterial growth in the dryer and the spread of microorganisms throughout the facility.Findings: a. During a review of Resident 54's admission Record (AR), the AR indicated Resident 54 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including personal history of poliomyelitis (polio - a highly contagious virus [a very tiny germ] that spreads through contact with infected poop or contaminated food/water) and heart failure. During a review of Resident 54's History and Physical (H&P), dated 6/11/2025, the H&P indicated Resident 54 had the capacity to make medical decisions. During a review of Resident 54's Minimum Data Set (MDS - a resident assessment tool), dated 2/10/2026, the MDS indicated Resident 54's cognitive skills (ability to think and process information) for daily decision making were intact (decisions consistent/reasonable). The MDS indicated Resident 5 required partial/moderate assistance (helper does less than half the effort) with oral hygiene (the ability to use suitable items to clean teeth). During a review of Resident 9's AR, the AR indicated Resident 9 was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes mellitus (DM II – adult-onset disorder characterized by difficulty in blood sugar control and poor wound healing) without complications, and pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) of sacral (a triangular bone at the base of the spine between the hip bones) region, unstageable. During a review of Resident 9's History of Present Illness (HPI), dated 3/27/2026, the HPI indicated Resident 9 had the capacity to understand and make decisions. During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9's cognitive skills for daily decision making were intact. The MDS indicated Resident 9 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene. During a review of Resident 39's AR, the AR indicated Resident 39 was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes mellitus with other simplified complication, and essential (primary) hypertension (HTN – high blood pressure). During a review of Resident 39's H&P, dated 1/23/2026, the H&P indicated Resident 39 did not have the capacity to understand and make decisions. During a review of Resident 39's MDS, dated [DATE], the MDS indicated Resident 39 required substantial/maximal assistance (helper does more than half the effort) with oral hygiene. During a review of Resident 45's AR, the AR indicated Resident 45 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including COVID-19 (Coronavirus Disease of 2019 - a highly contagious respiratory illness caused by the SARS-CoV-2 virus), and urinary tract infection (UTI – an infection in the bladder/urinary tract), site not specified. During a review of Resident 45's H&P, dated 1/17/2026, the H&P indicated Resident 45 did not have the capacity to understand and make decisions. During a review of Resident 45's MDS, dated [DATE], the MDS indicated Resident 45's cognitive skills for daily decision making were intact. The MDS indicated Resident 45 required supervision or touching assistance with oral hygiene. During an observation on 4/21/2026 at 12:37 PM, Resident 54 and Resident 9's shared room had an EBP sign posted outside of the room and a wall mounted PPE (personal protective equipment – clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) holder was inside the room by the door. During a concurrent observation and interview on 4/21/2026 at 1:12 PM with Certified Nursing Assistant (CNA) 2, inside the [NAME] and [NAME] restroom of Residents 54, 9, 39, 45 there was an unlabeled gray colored emesis basin with a personal size toothpaste and two (2) toothbrushes stored on the sink counter. CNA 2 stated the emesis basin, toothpaste, and toothbrushes were personal care items and CNA 2 thought the personal care items belonged to Resident 45. CNA 2 stated personal care items should be labeled with the resident's (in general) name and probably placed inside a bag and stored at the resident's bedside for infection control. During an interview on 4/24/2026 at 9:40 AM with the Infection Preventionist (IP), the IP stated emesis basins, toothpaste, and toothbrushes were personal care items and should be labeled with the resident's room number, resident's initials, and stored at the resident's bedside. The IP stated the rooms of Residents 54, 9, 39, and 45 were on EBP and labeling and storing personal care items properly was important to avoid cross contamination and for infection control. During a review of the facility's policy and procedure (P&P) titled, Policies and Practices – Infection Control, revised April 2025, the P&P indicated the facility's infection control policies and practices were intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The P&P indicated one of the objectives of the facility's infection control and practices were to prevent, detect, investigate, and control infections in the facility. b. During a concurrent observation, interview, and record review on 4/24/2026 at 11:42 AM with the Housekeeping (HK) and the Maintenance Supervisor (MS), in the laundry room, the CLD had a thick accumulation of lint on the lint screen/trap and clumps of lint fell off and onto the floor of the CLD. The Daily Cleaning Lint Trap (DCLT), dated April 2026 was reviewed. The DCLT indicated the lint traps were cleaned every 2 hours on 4/24/2026 with 11 AM being the last time the lint trap was cleaned. The MS stated the lint trap was just cleaned about forty-five minutes ago. The HK stated the HK cleaned the CLD every 2 hours but only cleaned the floor of the CLD. The HK stated the HK did not know how to clean the lint screen/trap. The HK and the MS stated cleaning the lint screen/trap of the CLD was important to prevent fires in the facility. During a review of facility's P&P titled, Maintenance Service, date revised December 2009, the P&P indicated maintenance service should be provided at all areas of the building, grounds, and equipment. c. During a review of Resident 70's AR, the AR indicated Resident 70 was admitted to the facility on [DATE] with multiple diagnoses including bacteremia (condition in which bacteria are present in the bloodstream) and chronic (long standing) diastolic congestive heart failure (inability of the heart to efficiently pump blood through the body, causing buildup of blood in the veins and of other body fluids in tissue). During a review of Resident 70's H&P undated, the H&P indicated Resident 70 did not have capacity to understand and make decisions. The H&P indicated Resident 70 had a foley catheter (thin, flexible tube inserted through the urethra [tube that lets urine leave the body] into the bladder [hollow muscular balloon-like organ that stores urine] to continuously drain urine into a collection bag). During a review of Resident 70's Order Recap Report (ORR), dated 4/2026, the ORR indicated Resident 70 had a physician's order for EBP due to: indwelling medical device (foley catheter) with order date 4/21/2026. During a review of Resident 70's Care Plan (CP), initiated 4/21/2026, the CP's focus indicated Resident 70 required EBP related to indwelling urinary catheter. The CP's interventions indicated to place EBP signage at [Resident 70's] door entry. During a concurrent observation and interview on 4/21/2026 at 11:38 PM with the Director of Nursing (DON), the doorway to Resident 70's room was observed without EBP signage. The DON stated Resident 70 had a foley catheter and was on EBP. The DON stated the DON would place an EBP sign outside Resident 70's door. During an interview on 4/24/2026 at 9:43 AM with the IP, the IP stated a foley catheter was an indwelling medical device and anyone with an indwelling medical device required EBP. The IP stated if a resident was on EBP, a sign was posted near the door to indicate that any high contact care with the resident required the caregiver to wear at least a gown and gloves. The IP stated if there was no signage indicating EBP, the resident could be exposed to potential infections. During a review of the facility's P&P titled, Enhanced Barrier Precautions, dated 4/2024 the P&P indicated EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of multidrug resistant organisms' colonization.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 44) was treated with dignity when Certified Nursing Assistant (CNA) 1 failed to close the door of Resident 44's shared room and/or the door of the shared restroom while Resident 44 was using the toilet on 4/21/2026.This deficient practice could potentially result in Resident 44 feeling bothered, invaded, or humiliated, and the potential to negatively impact Resident 44's psychosocial (the emotional and social requirements that individuals must have to feel safe, supported, and capable of functioning well in their environment) well-being.Findings:During a review of Resident 44's admission Record (AR), the AR indicated Resident 44 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a long standing lung disease causing difficulty in breathing) with acute (sudden) exacerbation (worsening of a disease), and unspecified dementia(a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbance, psychotic (relating to or affected with a psychosis - a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) disturbance, mood disturbance, and anxiety (intense, excessive, and persistent worry and fear about everyday situations).During a review of Resident 44's Minimum Data Set (MDS - a resident assessment tool), dated 3/18/2026, the MDS indicated Resident 44's cognitive skills (ability to think and process information) for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 44 required substantial/maximal assistance (helper does more than half the effort) to partial/moderate assistance (helper does less than half the effort) for activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 44 was frequently incontinent (lack of control) of urine (7 or more episodes) and bowel (2 or more episodes).During a concurrent observation and interview on 4/21/2026 at 1:25 PM with CNA 1, Resident 44 was using the toilet and occasionally groaned. CNA 1 was standing outside of the restroom. The doors to Resident 44's shared room and shared restroom were open. CNA 1 stated the doors were open because Resident 44's roommate (unnamed) was not in the room. CNA 1 stated CNA 1 should have closed Resident 44's door to the restroom for [Resident 44's] privacy.During an interview on 4/23/2026 at 1:44 PM with the Registered Nurse Supervisor (RNS), the RNS stated, when a resident (in general) used the toilet, the door to the restroom should be closed to give the resident privacy and for dignity.During a review of the facility's policy and procedure (P&P) titled, Dignity, date revised February 2021, the P&P indicated residents are treated with dignity and respect at all times. The P&P indicated staff promoted, maintained and protected resident privacy, including bodily privacy during assistance with personal care.

Based on interview and record review, the facility failed to create a Baseline Care Plan (BCP, a form where one can summarize a person's health conditions, care needs, and current treatments) for one of one sampled resident (Resident 70) with 48 hours of admission.This deficient practice had the potential to result in unmet needs for Resident 70.Findings: During a review of Resident 70's admission Record (AR), the AR indicated Resident 70 was admitted to the facility on [DATE] with multiple diagnoses including bacteremia (a condition in which bacteria are present in the bloodstream) and chronic (long standing) diastolic congestive heart failure (inability of the heart to efficiently pump blood through the body, causing buildup of blood in the veins and of other body fluids in tissue).During a review of Resident 70's History and Physical (H&P), date of admission 4/17/2026, the H&P indicated Resident 70 did not have capacity to understand and make decisions.During an interview on 4/24/2026 at 3:15 PM with the Director of Nursing (DON), the DON stated Resident 70's BCP was created on 4/23/2026 and almost one week after Resident 70 was admitted on [DATE]. The DON stated Resident 70's BCP should have been created upon Resident 70's admission [to the facility]. During a concurrent interview and record review on 4/24/2026 at 3:21 PM with the Registered Nurse Supervisor (RNS), Resident 70's BCP dated 4/23/2026 was reviewed. The RNS stated Resident 70's BCP was created on 4/23/2026. The RNS stated the purpose of the BCP is to get to know Resident 70 better and let staff know the plans for care.During a review of the facility's policy and procedure (P&P) titled, Care Plans - Baseline, dated 3/2022, the P&P indicated a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.

Based on observation, interview, and record review, the facility failed to implement safety measures to ensure one of four sampled residents (Resident 36) who had a history of multiple falls and was at risk for falls. On 4/24/2026 Resident 36's bed was not in the lowest position and Resident 36's bilateral (two sides) floor mats were not on Resident 36's bedside.The deficient practice had the potential to result in falls, injury, and a physical decline to Resident 36.Cross Reference F684 and F656.Findings:During a review of Resident 36's admission Record (AR), the AR indicated Resident 36 was admitted to the facility on [DATE] with diagnoses that included intervertebral disc displacement (a spinal condition where the soft, gel-like center of a spinal disc pushes through its tough outer ring into the spinal canal) - lumbar region (lower part of the back), cerebellar ataxia (involuntary muscle coordination causing unsteady movements), repeated falls, and lack of coordination, abnormalities in gait and mobility (abnormal walking, characterized by unsteadiness, shuffling, limping, or stiffness).During a review of Resident 36's History and Physical (H&P), dated 10/26/2025, the H&P indicated Resident 36 did not have the capacity to understand and make decisions. During a review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 1/22/2026, the MDS indicated Resident 36's cognition (the ability to think and process information) was moderately impaired (moderate problems with thinking and memory). The MDS indicated Resident 36 was dependent (helper does all of the effort) with toilet hygiene, lower body dressing and needed maximal assistance (helper does more than half the effort) with upper body dressing.During a review of Resident 36's care plan (CP), initiated 2/11/2026, the CP's goal indicated low bed in use. The CP's interventions indicated keep the bed in the lowest position at all times when resident is resting, unless care is being provided. During a review of Resident 36's Change in Condition Evaluations (COC), the COCs indicated Resident 36 sustained falls on 1/30/2026, 2/9/2026, 2/15/2026, 3/1/2026, and 3/23/2026.During a review of Resident 36's Fall Risk Assessment (FRA), dated 4/4/2026, the FRA indicated Resident 36 was at risk for falls.During a review of Resident 36's Order Summary Report (OSR), dated active as of 4/24/2026, the OSR indicated a physician's order (PO), dated 1/14/2026, the PO indicated to place bilateral floor mats at Resident 36's bedside.During an observation and concurrent interview on 4/24/2026 at 9:45 AM with the Director of Nursing (DON), inside Resident 36's room, Resident 36 was lying in bed alone in Resident 36's room. Resident 36's floor mats were folded up vertically and leaning up against the wall and Resident 36's bed was not in the lowest position. Upon entering Resident 36's room, the DON lowered Resident 36's bed to the lowest position then unfolded Resident 36's floor mats and laid them on the floor on each side of Resident 36's bed.During an interview on 4/24/2026 at 10:33 AM with the Director of Rehabilitation (DOR), the DOR stated for Resident 36, who was at high risk for falls, a low bed (lowest position) and floor mats [at the bedside] were important to [prevent] falls and ensure Resident 36 did get a fracture [if the fall occurred].During an interview with the DON on 4/24/2026 at 2:33 PM, the DON stated Resident 36 had already sustained many falls and had a history of jumping off Resident 36's bed. The DON stated Resident 36's bed should be at the lowest position to prevent injuries to Resident 36. The DON stated floor mats needed to be placed on the floor next to Resident 36's bed and not leaning on the wall for Resident 36's safety.During a review of the facility's policy and procedure (P&P), titled Safety and Supervision of Residents, revised 7/2017, the P&P's policy statement indicated the facility strives to make the environment as free from accident hazards as possible. The P&P indicated the care team shall target interventions to reduce accident risks.ensuring that interventions are implemented, evaluating the effectiveness of interventions, and modifying or replacing interventions as needed.During a review of the facility's P&P titled Falls and Fall Risk, Managing, revised 3/2018, the P&P indicated based on previous evaluations and current data, 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.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 32), who was receiving enteral feeding (tube feeding), was provided appropriate treatment and services to prevent complications to Resident 32's gastrostomy tube (GT, a surgical opening fitted with a device to allow feedings and/or medications to be administered directly to the stomach common for people with swallowing problems). On 4/23/2026, Resident 32 did not have an abdominal binder (a wide, compressive belt made of elastic or fabric that wraps around the stomach) wrapped around Resident 32's GT area, Resident 32's GT site had an undated soiled dressing (a piece of material such as a pad applied to a wound to promote healing and protect it from infection), and the GT site had redness, inflammation, and dried-up drainage around the GT site.This deficient practice had the potential to result in an infection (the invasion and growth of germs in the body) to Resident 32 and displacement (partial or complete unintended removal of a feeding tube) of Resident 32's GT.Findings:During a review of Resident 32's admission Record (AR), the AR indicated Resident 32 was originally admitted to the facility on [DATE] with multiple diagnoses including cerebral palsy (a group of permanent disorders affecting movement, posture, and muscle coordination caused by abnormal brain development or damage before, during, or shortly after birth), unspecified, displacement of other gastrointestinal prosthetic devices, implants and grafts, subsequent encounter, and encounter for attention to gastrostomy.During a review of Resident 32's History and Physical Examination (H&P), dated 2/22/2025, the H&P indicated Resident 32 did not have the capacity to understand and make decisions.During a review of Resident 32's Care Plan (CP), date revised 1/7/2026, the CP's focus indicated Resident 32 required tube feeding r/t (related to) dysphagia (difficulty swallowing). The CP's goal indicated Resident 32's insertion site (GT) would be free of s/sx (signs and symptoms) of infection. The CP's interventions indicated to provide local care to GT site as ordered and to monitor for s/sx of infection.During a review of Resident 32's CP, date revised 1/7/2026, the CP's focus indicated Resident 32 was at risk for Resident 32's GT getting pulled out by Resident 32. The CP's interventions indicated to apply/place abdominal binder at all times, inspect skin integrity inside and outside of the abdominal binder, and to monitor GT and the site Q (every) shift.During a review of Resident 32's Minimum Data Set (MDS - a resident assessment tool), dated 4/12/2026, the MDS indicated Resident 32's cognitive skills (ability to think and process information) for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 32 was dependent (helper does all the effort) for activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 32 had a feeding tube as a nutritional approach on admission and while a resident at the facility.During a review of Resident 32's Order Summary Report (OSR), dated active as of 4/23/2026, the OSR included a physician's orders, dated 4/6/2026, indicating,1.Cleanse the GT site with normal saline (NS, sterile mixture of salt and water designed to match the natural fluid balance of the human body), pat dry, apply dry dressing and secure with tape as needed for soiled or dislodged GT.2.May have abdominal binder wrapped around the GT area related to history of pulling out GT every shift.During a concurrent observation and interview on 4/23/2026 at 8:12 AM with Licensed Vocational Nurse (LVN) 1, Resident 32 did not have an abdominal binder wrapped around Resident 32's GT area. Resident 32's GT site had an undated soiled dressing. Resident 32's GT site had redness, inflammation, light brownish colored dried-up drainage, and crusty dried-up skin around the GT site. LVN 1 stated, staff (in general) checking the GT site, providing GT care, and reporting to the treatment nurse was important to prevent skin irritation, MASD [moisture associated skin damage caused from prolonged exposure to moisture], and infection. LVN 1 stated, having an abdominal binder on as ordered was important [to prevent] Resident 32 from pulling out Resident 32's GT and be sent back to the hospital, [Resident 32] had pulled it out before.During an interview on 4/23/2026 at 12:07 PM with the Treatment Nurse (TN), the TN stated resident's (in general) GT site care and dressing changes were done daily and prn [as needed]. The TN stated a date on the dressing [was important] so staff knew when the last time the dressing was changed. The TN stated Resident 32 had problems with the GT site leaking and Resident 32's GT site had redness, and it was important to monitor [Resident 32's GT site] to avoid infections the. The TN stated Resident 32's dressing should have been changed. The TN stated Resident 32 should have the abdominal binder on to prevent Resident 32 from pulling out the GT.During a concurrent interview and record review on 4/24/2026 at 12:35 PM with the Registered Nurse Supervisor (RNS), Resident 32's medical records were reviewed. The RNS stated Resident 32's skin assessment was done upon admission and weekly. Resident 32's Progress Note - Wound Care (PNW), by the Physician Assistant-Certified (PA-C), dated 2/25/2026 was reviewed, the note indicated Resident 32's GT wound site, peristoma (the area of skin around the stoma) dermatitis (inflammation of the skin) was healed. A review of Resident 32's Weekly Nursing Progress Note (WNPN), dated 3/23/2026 and 4/7/2026, the notes indicated Resident 32's GT was patent and intact. A review of Resident 32's Licensed Nurse Skin Assessment Form (LNSA), dated 3/27/2026 and 4/24/2026, the forms did not indicate any documentation about Resident 32's GT site. A review of Resident 32's Admission/readmission Date Tool (ARDT), dated 4/5/2026 and timed at 3:21 PM, the tool indicated redness around GT. The RNS stated Resident 32's GT site had redness with irritation, and the site should have been monitored, the dressing changed, and physician notified (unnamed). The RNS stated applying the abdominal binder on Resident 32 was important to prevent Resident 32 from pulling out Resident 32's GT which Resident 32 had done in the past.During a review of the facility's policy and procedure (P&P) titled, Gastrostomy/Jejunostomy Site Care, date revised October 2011, the P&P's purpose indicated to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown, and infection. The P&P indicated to assess the stoma's (a surgically created small opening in the abdomen that leads directly into the stomach) site for signs of redness, pain or soreness, swelling, or drainage and report any of these signs of infection immediately to the supervisor and the resident's physician.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 14) received proper respiratory (relating to breathing) care such as oxygen (02 [a colorless, odorless, tasteless gas essential for living]) therapy in accordance with the physician's order.This deficient practice resulted in Resident 14's not receiving the correct dose of supplemental 02 and the potential to result in complications such as shortness of breath and respiratory failure. Findings:During a review of Resident 14's admission Record (AR), the AR indicated Resident 14 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including acute respiratory failure with hypoxia (a medical emergency where the lungs suddenly fail to get enough oxygen into the blood causing severe shortness of breath), and heart failure, unspecified.During a review of Resident 14's undated History and Physical Examination (H&P), the H&P indicated Resident 14's did not have the capacity to understand and make medical decisions.During a review of Resident 14's Minimum Data Set (MDS - a resident assessment tool), dated 3/5/2026, the MDS indicated Resident 14's cognitive skills (ability to think and process information) for daily decision making were moderately impaired (decisions poor; cues/supervision required). The MDS indicated Resident 14 was dependent (helper does all of the effort) to requiring partial/moderate assistance (helper does less than half the effort) with activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 14 was receiving continuous 02 therapy.During a review of Resident 14's Order Summary Report (OSR), dated active as of 4/24/2026, the OSR indicated a physician's order, dated 2/26/2026, for 02 at three (3) liters per minute (LPM - the speed or volume of 02 a device delivers in one minute) via nasal cannula (N/C - a small plastic tube that fits into a person's nostrils for providing supplemental oxygen) continuously.During a concurrent observation and interview on 4/21/2026 at 9:50 AM with Resident 14, Resident 14 was sitting up in bed watching tv. Resident 14 was receiving two and half (2 1/2) LPM 02 via N/C. Resident 14 had one (1) nasal prong (the two smaller tubes that are parts of the N/C that deliver the 02 inserted directly one in each nostril) inside Resident 14's left nostril. Resident 14 stated, Resident 14 always used 02 and did not know who placed the 02 N/C on Resident 14.During a concurrent observation and interview on 4/21/2026 at 10:01 AM with the Treatment Nurse (TN), Resident 14 was sitting up in bed watching tv. Resident 14 was receiving 2 1/2 LPM 02 via N/C with 1 nasal prong inside Resident 14's left nostril. The TN stated Resident 14 only had 1 of nasal prong in Resident 14's nostril. The TN stated ensuring both nasal prongs were in Resident 14's nostrils was important for Resident 14 to receive the right dose of 02 since Resident 14 had chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing).During a concurrent interview and record review on 4/23/2026 at 1:44 PM with the Registered Nurse Supervisor (RNS), Resident 14's physician orders were reviewed. The RNS stated Resident 14 had an order for 02 at 3 LPM dated 2/26/2026 for respiratory failure. The RNS stated Resident 14 had the tendency of removing Resident 14's N/C and staff should be monitoring Resident 14. The RNS stated Resident 14 was not receiving the ordered dose of 02 when both nasal prongs were not in Resident 14's nostrils. The RNS stated Resident 14 not getting the correct 02 dose could lead to episodes of desaturation (a dangerous drop in blood oxygen levels) and respiratory failure. The RNS stated it was important for the nasal prongs to be in Resident 14's bilateral [both] nostrils, for the correct dose of 02 to be administered.During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, date, revised October 2010, the P&P indicated the purpose of the P&P was to provide guidelines for safe oxygen administration. The P&P indicated the nasal cannula was a tube that was placed approximately one-half inch into the resident's nose.

Based on observation, interview, and record review, the facility failed to post nurse staffing information of actual hours worked by licensed and unlicensed nursing staff who were directly responsible for resident care, per shift daily, in a prominent location and make readily accessible to residents and visitors for viewing on 4/21/2026, 4/22/2026, 4/23/2026 and 4/24/2026. This deficient practice resulted in inaccurate nursing hours posted by the facility and had the potential to result in residents and family members obtaining misleading information posted.Findings:During an observation on 4/24/2026 at 12:35 PM, the facility's posted document titled Projected Census and Direct Service Hours Per Patient Day (DPHHD) on 4/21/2026, 4/22/2026, 4/23/2026, and 4/24/2026, the DPHHD indicated the projected hours for direct care staff for shifts 7 AM to 3 PM, 3 PM to 11 PM, and 11 PM to 7 AM. The DPHHD did not indicate the actual hours worked per shift.During an interview and concurrent record review with the Director of Staff Development (DSD), on 4/24/2026 at 12:41 PM, the facility's posted DHPPD dated 4/21/2026, 4/22/2026, 4/23/2026 and 4/24/2026 were reviewed, the DSD stated projected nursing hours were posted at the beginning of the day. The DSD stated actual worked direct care hours were not calculated/generated until the following day and were kept in a binder inside the front office. The DSD stated actual worked nursing hours were not posted for the public to view. DSD stated it was important for actual nursing hours to be posted to ensure we [the facility] tracked the actual nursing hours provided to the residents.During an interview and concurrent record review on 4/24/2026 at 2:35 PM with the Director of Nursing (DON), the DON stated actual nursing hours should be posted for patient care ratios and for the safety of the residents. During a review of the facility's policy and procedure (P&P) titled Staffing, Sufficient and Competent Nursing, revised on 8/2022, the P&P indicated direct care daily staffing numbers (the number of nursing personnel responsible for providing direct care to residents) are posted in the facility for every shift.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 48) had two home medication bottle contents verified by a licensed pharmacist as indicated by the facility's policy and procedure (P&P) titled, Medications Brought to the Facility by the Resident/Family.This deficient practice had the potential for Resident 48 to receive medication and/or tablets other than what was indicated on the medication bottle labels and the potential to affect Resident 48's physical well-being.Findings: During a review of Resident 48's admission Record (AR), the AR indicated Resident 48 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease (a condition that occurs late in life and worsens with time in which brain cells degenerate; it is accompanied by memory loss, physical decline, and confusion) and generalized muscle weakness.During a review of Resident 48's Minimum Data Set (MDS- a resident assessment tool), dated 3/2/2026, the MDS indicated Resident 48's cognition (ability to understand and process information) was moderately impaired and Resident 48 was dependent (helper does all of the effort) for toileting and bathing.During a review of Resident 48's Order Summary Report (OSR), dated with active orders as of 4/24/2026, the OSR indicated the following physician orders:Glucosamine Hydrochloride tablet give 1500 milligrams (mg - unit of weight) by mouth one time a day for supplement two tablets per day.Mens 50+ Multivitamin Oral Tablet (Multiple Vitamins with Minerals) give one tablet by mouth one time a day for supplement.During an observation on 4/24/2026 at 11:52 AM with Licensed Vocational Nurse (LVN) 1, the following two medication bottles were observed in medication cart # 2:220 tablet bottle of Glucosamine Hydrochloric acid (HCl, a chemical substance) with Chrondoitin/methylsulfonylmethane (MSM) complex (dietary supplement).275 tablet bottle of Men's 50+ Multivitamin (dietary supplement).LVN 1 stated the medication bottles were not from the facility's pharmacy and had been brought into the facility by Resident 48's family. LVN 1 stated LVN 1 did not know if the pharmacist had checked Resident 48's medication bottles.During an interview on 4/24/2026 at 2:48 PM with the Director of Nursing (DON), the DON stated the contents of the medication bottles had not been verified by the facility's pharmacist. The DON stated it was important to verify the contents of home medication bottles for resident safety and to ensure that whatever is indicated on the label is [are the contents] inside the medication bottle.During a review of the facility's undated P&P titled, Medications Brought to the Facility by the Resident/Family, the P&P indicated if a medication is not otherwise available and/or it is determined to be essential to the resident's life, health, safety, or well-being to be able to take a medication brought in from outside, the director of nursing services and nursing staff, with support of the attending physician and consultant pharmacist, shall check to ensure that: d. the contents of each container have been verified by a licensed pharmacist.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 4) had a consent (when a patient gives permission for something to happen) for the COVID-19 (Coronavirus Disease of 2019 - a highly contagious respiratory illness caused by the SARS-CoV-2 virus) vaccine (medications used to prevent diseases usually given by injection or by mouth) prior to being administered the vaccine and as indicated by the facility's policy and procedure (P&P) titled, Coronavirus Disease (COVID-19) - Vaccination of Residents.This deficient practice had the potential to result in Resident 4 not making informed decisions due to not being aware of the potential risks and benefits associated with the vaccine.Findings:During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a long standing lung disease causing difficulty in breathing), unspecified and sepsis (a life-threatening blood infection [(the invasion and growth of germs in the body), unspecified organism.During a review of Resident 4's History and Physical Examination (H&P), dated 4/19/2026, the H&P indicated Resident 4 could make needs known but could not make medical decisions.During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 4/23/2026, the MDS indicated Resident 4's cognitive skills (ability to think and process information) for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 4 was dependent (helper does all of the effort) to requiring partial/moderate assistance (helper does less than half the effort) for activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated, Resident 4's COVID-19 vaccination was not up to date.During a concurrent interview and record review on 4/24/2026 at 9:40 AM with the Infection Preventionist (IP), the facility's Residents Immunization (RI), dated 4/23/2026 was reviewed. The RI indicated Resident 4 received the COVID-19 vaccine on 9/17/2025. The IP stated there was no record of a consent for Resident 4's COVID-19 vaccine. The IP stated the facility did not provide the COVID-19 vaccine to the residents (in general). The IP stated an outside contracted pharmacy (CP) came to the facility to administer the vaccine to the residents. During an interview on 4/24/2026 at 2:38 PM with the IP, the IP stated the CP did not have a COVID-19 consent for Resident 4. The IP stated a consent was when a resident gave the okay, the permission, to be administered medications. The IP stated, obtaining a consent was important to get the permission from Resident 4 to administer the COVID-19 vaccine.During a review of the facility's P&P titled, Coronavirus Disease (COVID-19) - Vaccination of Residents, date revised October 2025, the P&P indicated residents must sign a consent to vaccinate form prior to receiving the vaccine. The P&P indicated the resident's medical record included documentation that indicated, at a minimum, a signed consent.

Based on interview and record review, the facility failed to develop a comprehensive care plan (CP, a person-centered plan that outlines a resident's specific health needs, goals, and tailored interventions required to achieve their highest level of physical, mental, and psychosocial well-being) for two of three sampled residents (Residents 1 and Resident 2), as evidenced by: 1.Resident 1's vaccine (a type of medicine that helps the body to fight a disease before getting it, so illness is prevented or stays mild) refusal was not addressed in the care plan. 2. Resident 2's influenza (a highly contagious respiratory illness caused by influenza viruses that infect the nose, throat, and the lungs) status was not addressed in the care plan. This failure had the potential to result in unmet individualized medical needs for Resident 1 and Resident 2 and had the potential to affect the residents' physical and psychosocial well-being.Findings:a.During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 7/7/2025 with a readmission date of 1/30/2026 with diagnoses including sepsis (the body's extreme and dangerous reaction to an infection) and urinary tract infection (an infection that affects any part of the urinary system including the kidneys, ureters, bladder, and urethra). During a review of Resident 1's History and Physical Examination (H&P), dated 2/1/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 2/4/2026, the MDS indicated Resident 1's cognitive (the ability to think and process information) skills for daily decision making were moderately impaired (makes poor decisions requiring cues or supervision). The MDS indicated Resident 1 required supervision or touching assistance with lower body dressing, showering, and toileting hygiene, and was independent with eating, oral hygiene, upper body dressing, and personal hygiene. During a review of Resident 1's vaccine consent forms, dated 2/3/2026, the consent forms indicated Resident 1 declined the Covid-19 (an infectious disease caused by the SARS-Cov-2 virus), Respiratory Syncytial Virus (RSV, a respiratory virus that infects the lungs), influenza, and pneumococcal (an infectious disease caused by the bacteria Streptococcus pneumoniae) vaccines. b.During a review of Resident 2's AR, the AR indicated the facility originally admitted Resident 2 on 8/21/2023 and was readmitted on [DATE] with diagnoses including unspecified fracture of right femur (a broken bone on the right thigh), subsequent encounter for closed fracture with routine healing (a follow up visit indicating the break is healing normally) and hemiplegia and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (a medical condition where blood flow to the brain is disrupted, causing brain tissue damage) affecting left non-dominant side (the side of the body that is used less). During a review of Resident 2's H&P, dated 4/17/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making were severely impaired (never/rarely makes decisions). The MDS indicated Resident 2 was dependent on toileting, showering, and dressing, required substantial to maximal assistance with oral and personal hygiene, and required partial to moderate assistance with eating. During an interview on 3/4/2026 at 11:22 AM with the Infection Prevention Nurse (IP), the IP stated the IP was informed on 2/28/2026 that Resident 2 had tested positive for influenza. Additionally, the IP stated it was the facility's policy to input a care plan if a resident (in general) declined vaccine administration upon admission to the facility. During a concurrent interview and record review on 3/4/2026 at 3:15 PM with the IP, Resident 1's and Resident 2's CP were reviewed. The IP stated that Resident 1 did not have a care plan in place addressing Resident 1's refusal of the vaccines. The IP stated that Resident 2 did not have a care plan in place addressing Resident 2's diagnosis of influenza. The IP stated it was important to have individualized CP in place for Residents 1 and Resident 2 to ensure the residents' needs were met. During an interview on 3/4/2026 at 4 PM with the Director of Nursing (DON), the DON stated it was important to have individualized CP in place for Residents 1 and Resident 2. The DON stated that an individualized CP would ensure the facility was addressing the current medical conditions of Residents 1 and Resident 2. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the P&P's Policy Statement 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 P&P's Policy Interpretation and Implementation indicated, The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including; services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; reflects currently recognized standards of practice for problem areas and conditions.

Based on interview and record review, the facility failed to follow its Policy and Procedure (P&P) titled, Influenza Vaccine for one of three sampled employees (Licensed Vocational Nurse [LVN] 1) when the facility did not obtain LVN 1's influenza vaccine (an annual vaccine designed to protect against infection from influenza [a highly contagious respiratory illness caused by influenza viruses that infects the nose, throat, and the lungs] viruses) administration record to ensure tracking and documentation of employee influenza vaccination. This failure resulted in LVN 1's employee file being incomplete and had the potential for influenza transmission to vulnerable residents (in general), causing harm, and an inability to track vaccination records.Findings:During an interview on 3/4/2026 at 11:02 AM with LVN 1, LVN 1 stated LVN 1 received the influenza vaccine in August of 2025 but had not provided proof of vaccination to the facility. During a concurrent interview and record review on 3/4/2026 at 2:45 PM with the Director of Staffing Development (DSD), LVN 1's Personnel Action Form (PAF, a form used to process newly hired employees) dated 12/3/2025 and Employee file were reviewed. The DSD stated the PAF indicated that LVN 1 was hired on 12/3/2025. The DSD stated there was no record of LVN 1's influenza vaccination in LVN 1's employee file. The DSD stated it was the policy of the facility to obtain a copy of employees' (in general) influenza documentation and place in the employees' (in general) file. The DSD stated it was important to have LVN 1's influenza vaccination information on file to ensure LVN 1 had protection against influenza. During an interview on 3/4/2026 at 4 PM with the Director of Nursing (DON), the DON stated it was important to have LVN 1's influenza vaccine documentation on file because it would indicate whether LVN 1 had received the influenza vaccine. The DON stated it was important to have LVN 1's influenza vaccine documentation for the safety of the residents (in general). During a review of the facility's Policy and Procedure (P&P) titled, Influenza Vaccine, revised March 2022, the P&P's Policy Statement indicated, All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The P&P's Policy Interpretation and Implementation indicated, Employees hired or residents admitted between October 1st and March 31st shall be offered the vaccine within five working days of the employee's job assignment or the resident's admission to the facility. For those who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's/employee's medical record. The infection preventionist will maintain surveillance data on influenza vaccine coverage and reported rates of influenza among residents and staff. Residents and staff may obtain their influenza vaccines from their personal physicians. Documentation of previous vaccination should be provided to the facility.

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation - Reporting and Investigating, dated 4/2021, for one of three sampled residents (Resident 3) on 1/30/2026 by failing to report Resident 3's allegation of abuse within two hours and failing to remove Certified Nursing Assistant (CNA) 1 from resident contact immediately after Resident 3 made an allegation of abuse involving CNA 1.These deficient practices had the potential for Resident 3 to feel unsafe and for Resident 3 to be subjected to abuse.Findings:During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] with multiple diagnoses including dementia (a progressive state of decline in mental abilities) and urinary tract infection (UTI- an infection in the bladder/urinary tract).During a review of Resident 3's Minimum Data Set (MDS - resident assessment tool), dated 2/5/2026, the MDS indicated Resident 3 had moderately impaired cognition (ability to understand and process information) and was dependent (helper does all of the effort to complete activity) on staff for toileting hygiene and bathing.During a review of Resident 3's Progress Notes (PN), dated 1/30/2026 and timed at 1:55 PM, the PN indicated two CNAs reported Resident 3 had complained that a CNA (unidentified) grabbed Resident 3's upper arm resulting in a small area of redness. The PN further indicated the two CNAs stated the redness on Resident 3's arm was present before Resident 3 was assisted by the CNAs.During a review of Resident 3's Change in Condition Evaluation (COC), dated 1/30/2026 and timed at 2:30 PM, the COC indicated a CNA grabbed Resident 3's upper arm, resulting in a small area of redness. The COC further indicated Resident 3's mental status was assessed, and Resident 3 did not know the current location, situation and date/time.During a review of Resident 3's Post-Event Review -V2 (PER), dated 1/30/2026 and timed at 6 PM, the PER indicated Resident 3 alleged a Certified Nurse Assistant (CNA) scratched or ripped Resident 3's arm. The PER indicated Resident 3 had a diagnosis of dementia and an active UTI and provided inconsistent statements to staff consistent with dementia and UTI related delirium.During an interview on 2/17/2026 at 2:12 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated LVN 1 worked as a charge nurse during the 7 am to 3 PM shift on 1/30/2026. LVN 1 stated Resident 3 was generally forgetful, anxious and would repeatedly ask for things even after it was already provided to Resident 3. LVN 1 stated CNA 1 reported to LVN 1 that Resident 3 alleged CNA 1 had grabbed Resident 3's arm while changing Resident 3's soiled brief. LVN 1 then went to Resident 3's room to assess Resident 3's skin and found no new marks or discoloration on Resident 3's arms. Afterwards, LVN 1 reported the incident to the Infection Prevention Nurse (IPN) and LVN 1 began documenting the incident. LVN 1 stated Resident 3's PN dated 1/30/2026 at 1:55 PM was correct and the incident happened around that time.During an interview on 2/17/2026 at 2:37 PM with the IPN, the IPN stated on 1/30/2026 CNA 1 had reported the incident with Resident 3 to the IPN. The IPN instructed CNA 1 to report the incident to LVN 1. The IPN went into Resident 3's room to assess Resident 3's skin and the IPN did not note any scratches, opened skin or redness. The IPN stated the incident occurred around 2 PM on 1/30/2026. The IPN stated it was important to report any allegation of abuse within two hours to ensure an investigation can be done properly and ensure the residents were protected.During a telephone interview on 2/17/2026 at 3:19 PM with CNA 1, CNA 1 recalled the incident with Resident 3 on 1/30/2026. CNA 1 stated on 1/30/2026 after changing Resident 3's soiled brief with CNA 2, Resident 3 accused CNA 1 of ripping off Resident 3's skin while being repositioned. CNA 1 stated CNA 1 did not hurt Resident 3 and tried to show Resident 3 that Resident 3's skin was not torn. CNA 1 stated CNA 1 reported the allegation to LVN 1 and wrote a statement about the incident. CNA 1 stated CNA 1 also reported the incident to the IPN because LVN 1 was a new employee and CNA 1 was unsure how to proceed after the allegation. CNA 1 stated the incident occurred sometime between 2:30 PM and 3 PM on 1/30/2026. CNA 1 stated CNA 1 was not instructed to leave the patient care area and entered Resident 3's room one more time after Resident 3's allegation to answer Resident 3's call light. CNA 1 stated an employee with an allegation of abuse from a resident should not enter the resident's room because it could scare the resident.During an interview on 2/17/2026 at 4:55 PM with the Director of Nursing (DON), the DON stated the DON was in meetings on 1/30/2026 from 2 PM to 3 PM and the facility staff should have reported Resident 3's allegation immediately instead of waiting for the DON to become available. The DON stated, CNA 1 should have been suspended immediately and the incident reported right away to prevent any interference with the facility investigation and to protect the well-being of Resident 3. During a review of the facility's P&P titled, Abuse, Neglect, Exploitation and Misappropriation - Reporting and Investigating, dated 4/2021, the P&P indicated, 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 3. 'Immediately' is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury. 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete.

Based on interview and record review, the facility failed to report an injury of unknown origin for one of ten sampled residents (Resident 2) to the local Ombudsman (an official appointed to investigate individuals' complaints against facility administration), to the Police, and to the State Survey Agency within two (2) hours of obtaining Resident 2's right hip X-ray results, in accordance with facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating. This failure had the potential to place Resident 2 at risk for further injury and/or harm from abuse and/or other sources.Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness in the arm, leg, and face on one side of the body) following cerebral infarction (stroke, damage to brain tissue caused by loss of blood flow to a part of the brain). During a review of Resident 2's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 4/19/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 10/9/2025, the MDS indicated Resident 2 was dependent (helper does all the effort to complete the activity) on others for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and chair/bed-to-chair transfers. During a review of Resident 2's bilateral hip X-ray results, dated 12/21/2025 and timed at 9:14 am, the X-ray results indicated Resident 2 had a suspected acute right femur fracture. During a review of Resident 2's Change In Condition Evaluation (CIC), dated 12/21/2025 and timed at 1:56 pm, the CIC indicated Resident 2's bilateral hip X-ray results indicated Resident 2 had a suspected right femur fracture and Resident 2's primary physician recommended Resident 2 to be transferred to GACH 1 for further evaluation. During a review of Resident 2's Nurses Note (NN), dated 12/21/2025 and timed at 4:30 pm, the NN indicated Resident 2 was picked up by an ambulance and transferred out to GACH 1 at 4:20 pm. During a review of Resident 2's GACH 1 right hip X-ray, dated 12/22/2025 and timed at 9:11 am, indicated Resident 2 had an acute right femur fracture. During an interview on 1/9/2026 at 3:30 pm with the Director of Nursing (DON), the DON stated the facility did not do an investigation to determine how Resident 2 sustained the right femur fracture and did not report Resident 2's injury of unknown origin (right femur fracture) to the local Ombudsman (an official appointed to investigate individuals' complaints against facility administration), to the Police, and to the State Survey Agency within two (2) hours of obtaining Resident 2's right hip X-ray results. The DON stated the facility did not follow their policy on investigating injuries of unknown origin. During a review of the facility's policy and procedure (P&P) tiled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 9/2022, the P&P indicated, All reports of resident abuse (including injuries of unknown origin) .are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.

Based on interview and record review, the facility failed to investigate an injury of unknown origin for one of ten sampled residents (Resident 2) after Resident 2's bilateral hip (involving both hips) X-ray (picture or digital image of the inside of the body) results, dated 12/21/2025 and timed at 9:14 am, indicated Resident 2 had a suspected acute right femur (thigh bone) fracture (a partial or complete break in the bone). Resident 2 was transferred and admitted to General Acute Care Hospital (GACH) 1 on 12/21/2025 at 4:44 pm. Resident 2's GACH 1 right hip X-ray results, dated 12/22/2025 and timed at 9:11 am, indicated Resident 2 had an acute right femur fracture. This failure had the potential to place Resident 2 at risk for further injury and/or harm from abuse and/or other sources. Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness in the arm, leg, and face on one side of the body) following cerebral infarction (stroke, damage to brain tissue caused by loss of blood flow to a part of the brain). During a review of Resident 2's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 4/19/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 10/9/2025, the MDS indicated Resident 2 was dependent (helper does all the effort to complete the activity) on others for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and chair/bed-to-chair transfers. During a review of Resident 2's bilateral hip X-ray results, dated 12/21/2025 and timed at 9:14 am, the X-ray results indicated Resident 2 had a suspected acute right femur fracture. During a review of Resident 2's Change In Condition Evaluation (CIC), dated 12/21/2025 and timed at 1:56 pm, the CIC indicated Resident 2's bilateral hip X-ray results indicated Resident 2 had a suspected right femur fracture and Resident 2's primary physician recommended Resident 2 to be transferred to GACH 1 for further evaluation. During a review of Resident 2's Nurses Note (NN), dated 12/21/2025 and timed at 4:30 pm, the NN indicated Resident 2 was picked up by an ambulance and transferred out to GACH 1 at 4:20 pm. During a review of Resident 2's GACH 1 right hip X-ray, dated 12/22/2025 and timed at 9:11 am, indicated Resident 2 had an acute right femur fracture. During an interview on 1/9/2026 at 3:30 pm with the Director of Nursing (DON), the DON stated the facility did not do an investigation to determine how Resident 2 sustained the right femur fracture and did not report Resident 2's injury of unknown origin (right femur fracture) to the local Ombudsman (an official appointed to investigate individuals' complaints against facility administration), to the Police, and to the State Survey Agency within two (2) hours of obtaining Resident 2's right hip X-ray results. The DON stated the facility did not follow their policy on investigating injuries of unknown origin. During a review of the facility's policy and procedure (P&P), dated 9/2022, the P&P indicated, All reports of resident abuse (including injuries of unknown origin) .are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a diagnosis of dementia (loss of memory and other mental abilities severe enough to interfere with daily life), received care and services to prevent a fall by failing to: Assess and monitor Resident 1 for causes leading to episodes of restlessness (the inability to rest or relax) and constantly trying to climb out of Resident 1's bed. As a result, on 1/20/2022, at 4:35 am, Resident 1 climbed out of her bed unnoticed by Certified Nurse Assistant 1 (CNA 1), fell , and sustained a fracture (broken bone) on the right hip. Resident 1 required transfer to a General Acute Care Hospital (GACH) via 911 (emergency services) where Resident 1 had a surgery on 1/22/2022 to repair the hip fracture. Cross reference F689 Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 12/26/2021, with diagnoses that included dementia, schizoaffective disorder (a mental disorder), syncope (fainting resulting from certain stressful triggers), abnormalities of gait (the way a person walks), and mobility (how a person moves). A review of Resident 1's Fall Risk Assessment, dated 12/26/2021, indicated Resident 1 had a history of falls and was at risk for falls. A review of Resident 1's Medication Administration Record (MAR), dated 12/26/2021 to 12/31/2021, indicated Resident 1 had 14 episodes of constantly trying to get out of bed from 12/29/2021 to 12/31/2021. A review of Resident 1's History and Physical Examination, dated 12/29/2021, 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 comprehensive assessment and care screening tool), dated 12/31/2021, indicated Resident 1 had severe impaired cognition (when a person has very hard time remembering things, making decisions, concentrating, or learning). The MDS indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight- bearing support) from staff with two plus person physical assist for bed mobility (how resident moves to and from lying position, turns to side to side, and positions body while in bed) and transfers. A review of Resident 1's MAR, dated 1/1/2022 to 1/31/2022, indicated Resident 1 had 45 episodes of constantly trying to climb out of bed from 1/1/2022 to 1/4/2022. A review of Resident 1's untitled Care Plan, dated 1/5/2022, indicated Resident 1 had the potential to demonstrate physical behaviors of getting out of bed unassisted, related to dementia. The care plan indicated the nursing interventions included to assess and anticipate Resident 1's needs, food, thirst, toileting needs, comfort level, body positioning, and pain. The care plan indicated the nursing interventions also included to analyze key times, places, circumstances, triggers, what deescalates Resident 1's behavior, and document the nursing interventions. A review of Resident 1's Change of Condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains), dated 1/20/2022, timed at 4:35 am, indicated Resident 1 had an unwitnessed fall and Licensed Vocational Nurse 1 (LVN 1) observed Resident 1 lying on the floor. The COC indicated LVN 1 noted Resident 1's right thigh swollen, and Resident 1 had pain. The COC indicated LVN 1 notified Resident 1's physician and sent Resident 1 to the GACH for evaluation of Resident 1's right thigh. A review of Resident 1's Progress Notes, dated 1/20/2022, timed at 7:30 am, indicated LVN 1 observed Resident 1 awake in bed on 1/20/2022 at 2 am. The notes indicated Resident 1 removed her adult brief (disposable adult underwear) and tried to get out of her (Resident 1's) bed unassisted. The notes indicated CNA 1 assisted Resident 1 by putting Resident 1's brief on, and as CNA 1 turned her back, Resident 1 removed her brief once again. The notes indicated, LVN 1 saw Resident 1 at 3 am, awake with continued episodes of trying to climb out of Resident 1's bed on both sides. LVN 1 noted Resident 1 agitated (feeling or appearing troubled or nervous). The notes indicated LVN 1 encouraged (gave support and advice), CNA 1 to monitor Resident 1 closely (close surveillance or supervision, especially of people liable to suffer a sudden and dangerous deterioration in health). The notes indicated at 4:35 am, LVN 1 saw Resident 1 lying down on the floor mat (used to reduce force and reduce injury), and Resident 1's head was next to the foot of Resident 1's bed. The notes indicated LVN 1 observed Resident 1 awake with Resident 1's right lower extremity (lower leg) swollen and painful to touch. The notes indicated Resident 1's physician ordered to transfer Resident 1 to the GACH via 911 at 4:55 am. The notes indicated LVN 1 called 911 at 5 am. and the paramedics (emergency staff) transferred Resident 1 to the GACH on 1/20/2022, at 5:25 am. A review of Resident 1's GACH Progress Notes, dated 1/20/2022, timed at 9:55 pm, indicated Resident 1 was confused, had a past medical history of dementia, and had a fall from her bed. The notes indicated the GACH admitted Resident 1 with a diagnosis of a right femoral trochanteric (one of the bony prominences toward the near end of the thighbone/the femur) fracture (broken hip bone). A review of Resident 1's GACH Progress notes, dated 1/22/2022, timed at 3:48 pm, indicated Resident 1 underwent surgery that involved GACH to intubate (insertion of a tube either through the mouth or nose and into the airway to aid with breathing) Resident 1, antegrade (moving or extending forward) nailing of the right intertrochanteric (between the bone bumps at the top of the thigh bone) hip fracture. During a telephone interview on 7/13/2022 at 9:16 am, CNA 1 stated she was assigned to Resident 1 on 1/20/2022, the date when Resident 1 fell . CNA 1 stated she reported to LVN 1, more than once, that Resident 1 was restless and tried to climb out of Resident 1's bed. CNA 1 stated LVN 1 told CNA 1 to get a chair and sit outside of Resident 1's room. CNA 1 stated she explained to LVN 1 that she could not sit outside of Resident 1's room because she was assigned to care for 15 other residents. CNA 1 stated she told LVN 1 that she would continue to visually check on Resident 1. CNA 1 stated she was in another resident's room (unidentified) when she heard LVN 1 call for her help. CNA 1 stated LVN 1 found Resident 1 on the floor, inside Resident 1's room, next to Resident 1's bed. During a telephone interview on 7/21/2022 at 10:16 am, LVN 1 stated at the start of her shift (11pm-7am) on 1/19/2022, Resident 1 was sitting in a wheelchair at the nursing station. LVN 1 stated she received report from the previous shift (3 pm - 11 pm) nurse (unidentified) that Resident 1 had been having episodes of trying to get out of Resident 1's bed and chair; therefore, the nurse (unidentified) placed Resident 1 by the nursing station to monitor and prevent Resident 1 from falling. LVN 1 stated she could not remember if there was a method used to ensure close monitoring was being done by CNA 1 for Resident 1 who was agitated and restless. LVN 1 stated she observed CNA 1 outside of Resident 1's room, but she did not know if CNA 1 was outside Resident 1's room the entire shift. LVN 1 stated CNAs (in general) during the 11pm - 7am shift were assigned to care for 13-14 residents. LVN 1 stated she herself was also responsible for monitoring Resident 1. LVN 1 stated when she returned from her break, she observed Resident 1 lying on the floor mat in Resident 1's room next to the bed. During a telephone interview on 7/29/2022 at 9:47 am, Director of Nursing 2 (DON 2) stated it was the responsibility of LVNs and CNAs to divide their time amongst each other and monitor Resident 1 who was showing signs of agitation and restlessness. DON 2 stated staff (CNA 1 and LVN 1) needed to monitor Resident 1. DON 2 stated an option would have been for LVN 1 to sit outside Resident 1's room and complete her charting while monitoring Resident 1. DON 2 stated it was the responsibility of the LVN 1 to document behaviors and possible triggers that may be affecting Resident 1 who was exhibiting signs of restlessness and agitation. During an interview on 11/3/2022, at 3:46 pm and a record review of Resident 1's MAR dated 12/26/2021 to 12/31/2021, DON 2 stated Resident 1 had 14 episodes of trying to get out of bed from 12/29/2021 to 12/31/2021. DON 2 stated there was no evidence at the time of the interview that an interdisciplinary meeting (IDT, a group of diverse health care professionals from different fields) was done to analyze Resident 1's behaviors of trying to get out of bed. DON 2 stated there was no documented evidence of any nursing interventions done regarding Resident 1's behaviors of trying to get out of bed. DON 2 stated the residents (in general) with diagnosis of dementia, could not verbalize their needs and stated something was bothering Resident 1. DON 2 stated it was a way for Resident 1 to communicate her needs to nursing staff by attempting to get out of bed. A review of the facility's Dementia-Clinical Protocol, dated November 2018, indicated facility's staff would review the current physical, functional, and psychosocial status of individuals with dementia, and would summarize the individual's condition, related complications, and functional abilities and impairments. The policy indicated the staff would monitor the individual with dementia for changes in condition and declining function and would report these findings to the physician. A review of the facility's policy titled, Routine Resident Checks, dated July 2013, indicated staff shall make routine resident checks to help maintain resident safety and well-being. The Policy indicated routine resident checks involve entering the resident's room and/or identifying the resident elsewhere in the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance. the policy indicated the person conducting routine check shall report promptly to the nurse supervisor/charge nurse any changes in the resident's condition and medical needs. The policy indicated the nursing supervisor/charge nurse shall keep documentation related to these routine checks, including the time, identity of the person making checks, and any outcomes of each check. A review of the policy titled, Falls and Fall Risk Managing, dated December 2007, indicated the staff with the input of the attending physician, would identify appropriate interventions to reduce the risk of falls. If a systemic evaluation of a resident's fall risk identifies several possible interventions, that staff may choose to prioritize interventions. The policy indicated the staff would monitor and document each resident's response to interventions intended to reduce falling or the risks for falling.

Based on observation, interview, and record review, the facility failed to provide care and services to prevent accidents to one of three sampled residents (Resident 1) by failing to ensure: 1. Certified Nursing Assistant 1 (CNA 1) used the mechanical lift (a device used by staff to transfer residents from a bed to a chair or other similar places) to transfer Resident 1 from a bed to a wheelchair with the assistance of another staff, as indicated in the facility's policy and procedure. 2. Mechanical lift slings (device which consists of cable, chain, rope, or webbing and placed under the resident and attached to the mechanical lift to facilitate lifting) were inspected for wear and tear before each use and tracked how long they have been in use, as indicated in the sling manufacturer's recommendations and the facility's policy and procedure. These deficient practices resulted in Resident 1's fall on 4/28/22 at 10:55 a.m. from the mechanical lifting machine. Resident 1 experienced pain and was transferred to the General Acute Care Hospital (GACH) Emergency Department (ED) on 4/28/22 at 11:15 a.m. and was found to have an acute nondisplaced fracture (fracture in which the bone cracks or breaks but remains in proper alignment) in the left distal fibula/lateral malleolus (left ankle). Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)] (a physical disability which affects movement and posture) and severe obesity (overweight). A review of Resident 1's Activities of Daily Living (ADL) Self Care Performance Deficit Care Plan, initiated on 8/23/21 and revised on 2/3/2022, indicated Resident 1 required extensive two staff participation with transfers. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 4/11/22, indicated Resident 1's cognitive (ability to think and process information) status was intact. Resident 1 understood and was able to verbalize her needs. The MDS indicated Resident 1 was totally dependent on two or more staff to transfer to and from the bed, chair, wheelchair, and to a standing position. A review of Resident 1's Fall Risk Assessment, dated 4/28/22, indicated Resident 1 was at risk for falls due to the resident was on [CONDITION(S)] medication (medication that affects behavior, mood, thoughts, or perception) and impaired vision in adequate light with glasses on. A review of Resident 1's Situation, Background, Appearance, Review (SBAR) and Notify Communication Form, dated 4/28/22, indicated CNA 1 stated while she was transferring Resident 1, the mechanical lift sling ripped from the strap that attaches to the lift, and Resident 1 fell on the floor. Resident 1 complained of a new five (5) out of ten (10) pain (a pain scale wherein zero means no pain and ten means worst pain possible) on her left ankle and a 5 out of 10 headache. Resident 1's Primary Physician was notified and recommended for Resident 1 to transfer to the GACH ED via paramedics for further evaluation and management. A review of Resident 1's Licensed Nurse Progress Notes, dated 4/28/22, indicated Resident 1 was transferred to the GACH ED, at 11:15 am, via emergency medical services (911). A review of Resident 1's GACH left ankle X-ray report, dated 4/28/22 at 12:21 pm, indicated Resident 1 sustained an acute nondisplaced fracture in the left distal fibula/lateral malleolus (left ankle). A review of Resident 1's GACH ED Provider Note, dated 4/28/22 at 2:24 pm, indicated a splint (a device used to support and protect a broken bone or injury) was applied to Resident 1's left ankle to stabilize her left ankle fracture. The GACH ED Physician discussed Resident 1's case with her Primary Physician who will assist in having Resident 1 follow-up with an orthopedist (a doctor who specializes on injuries and diseases affecting the bones, muscles, and joints) as an outpatient. The GACH ED Physician wrote discharge instructions for Resident 1 to follow-up with orthopedics for casting (a protective shell of fiberglass, plastic, or plaster, and bandage that is molded to hold a fractured bone in place while it heals) in the next week, to return to the ED for new or worse symptoms, and to take Acetaminophen (a non-narcotic pain medicine) for pain. A review of Resident 1's Licensed Nurse Progress Notes, dated 4/28/22 at 8:19 pm, indicated Resident 1 returned to the facility from the GACH ED at 7:15 pm. A review of Resident 1's Post-Fall Care Plan, dated 4/28/22, indicated an intervention to use the mechanical lift with two staff trained on the mechanical lifting device, and to check the sling to ensure it is not worn out and is safe to use. A review of the Interdisciplinary Team (IDT, a team of professionals from various disciplines who work in collaboration to address the resident's care) Review, dated 4/29/22, indicated the IDT reviewed Resident 1's fall. The IDT Review indicated Resident 1's severe obesity contributed as a risk factor to the fall; Resident 1's last weight taken on 4/2/22 was 280.1 pounds. The IDT Review indicated the mechanical lift and sling were inspected and the causative factor for the fall was due to the sling suddenly ripped. During a concurrent observation and interview with Resident 1 on 5/18/22 at 2:30 pm, Resident 1 was sitting in a wheelchair by the front door of the facility. Resident 1 had a splint on the left leg. Resident 1 denied having pain and said, I'm fine. It's (left ankle) getting better. Resident 1 declined to talk further. During an interview with the Administrator on 5/18/22 at 2:35 pm, she stated the mechanical lift sling strap tore while Resident 1 was being transferred from her bed to the wheelchair on 4/28/22. The Administrator stated Resident 1 was particular with what kind of sling to use so the facility accommodated her. The Administrator stated laundry staff checked all the slings for wear and tear, for fraying, and rips after the slings were washed and the laundry staff air dried all the slings. The CNAs (in general) also checked the slings for wear and tear, fraying, and rips before each use. During an interview with the Laundry Staff (LS 1) on 5/18/22 at 3 pm, she stated she did not check if the mechanical lift slings were in good condition for use after she washed them. LS 1 stated the CNAs checked the slings before they use the slings. During an interview with CNA 2 on 5/18/22 at 3:08 pm, she stated she was trained on how to use the mechanical lift. CNA 2 stated staff were not supposed to use the mechanical lift alone. CNA 2 stated she checked the slings visually and pulled on sling straps before each use. During an interview with Restorative Nursing Assistant 1 (RNA, a CNA who is trained to assist residents with restorative care such as exercises, walking, and restorative equipment) on 5/18/22 at 3:17 pm, she stated she was assisting Resident 1's roommate inside the room when Resident 1 fell from the mechanical lift. RNA 1 stated she heard Resident 1 fall but did not see anything because the privacy curtains were drawn. When she checked on Resident 1, she saw CNA 1 with Resident 1 who was on the floor. RNA 1 stated there were no other staff with CNA 1 at Resident 1's bedside. During an interview with CNA 1 on 5/18/22 at 3:27 pm, she stated she assisted Resident 1 to get up out of bed using the mechanical lift on 4/28/22. CNA 1 stated as soon as she pulled the mechanical lift away from the bed, the sling strap ripped from the fabric and Resident 1 fell to the floor. She stated the sling ripped from the square where the loop trap was connected to the fabric. CNA 1 stated the sling did not look like it was worn out. CNA 1 stated no other staff member assisted her with the mechanical lift. CNA 1 stated she understand two staff members are required to assist in transferring Resident 1 with the mechanical lift. CNA 1 stated there was another staff (unidentified) coming into the room to help with the transfer, but she left to grab the wheelchair. During an interview with Registered Nurse Supervisor (RN 1) on 5/18/22 at 3:36 pm, she stated when CNA 1 notified Licensed Vocational Nurse 1 (LVN1) on 4/28/22 that Resident 1 was on the floor, she and LVN1 immediately went into Resident 1's room to assess the resident. During the assessment, Resident 1 complained of 5 out of 10 headache and a 5 out of 10 left ankle pain. RN 1 notified 911 and Resident 1's physician. RN 1 stated all staff who use the mechanical lift were trained on the use of the mechanical lift. Two or more staff members were required to assist when transferring Resident 1 with the mechanical lift. During a concurrent interview and a review of CNA 1's, CNA 2's and RNA 1's Competency Records with the Director of Staff Development (DSD) on 5/18/22 at 3:55 pm, the DSD stated a minimum of two staff were required to use the mechanical lift when transferring Resident 1. The DSD stated staff were supposed to check the sling for wear and tear before use. The competency record titled, Skill Check - Mechanical Lift Transferring for CNA 1, CNA 2, and RNA 1 were reviewed with the DSD. The competency record did not indicate to inspecting the sling for wear and tear before each use. During an interview with the Administrator on 5/18/22 at 4:11 pm, she stated as soon as the staff notice wear and tear and/or fraying on slings, the slings were replaced. The Administrator stated in February of 2022, the facility got a new mechanical lift and 10 new slings. Resident 1 did not like the new slings and preferred to use the old slings. Resident 1 also liked sending her slings to the laundry. The Administrator stated the facility did not track when the slings were replaced or when they were first used. The Administrator stated, We just watch for wear and tear and replace them (slings) because we have an abundance of slings. The Administrator stated the facility did not have any documentation to indicate the slings were inspected prior to use or when the slings were replaced. The Administrator stated the Maintenance Department only maintains the mechanical lift and not the slings. During a phone interview with Resident 1 on 5/24/22 at 3:25 pm, the resident stated staff members have used the mechanical lift to transfer the resident from the bed to chair many times in the past three years. Resident 1 stated two staff members usually assisted with the transfer when they utilized the mechanical lift. When staff were busy, the RN supervisor or the licensed nurse would help the CNA (in general) with the mechanical lift. Resident 1 further stated, CNA 1 was alone at that time when Resident 1 fell , but another staff was supposed to come in to assist her. Resident 1 stated she did not like the new slings and preferred to use the shower slings (slings used to assist residents into the shower chair) because they were thicker. Resident 1 stated the sling she used the day she fell was faded and old and could be the reason why the sling ripped. A review of the facility's policy and procedure, titled Using a Mechanical Lifting Machine, dated 7/2017, indicated, at least two nursing assistants are needed to safely move a resident with a mechanical lift. The policy indicated staff are to make sure that all necessary equipment (slings, hooks, chains, straps and supports) are on hand and in good condition. A review of the Manufacturer's Recommendations, titled Sling and Belt Safety Instructions, dated 2009, indicated slings should be checked before every use for wear and tear. The life of a sling will depend on how often it is used and laundered. It is recommended that slings be in service for no longer than two years from the date of purchase. This is simply a guideline and slings may need to be removed prior to this time, depending on wear and tear. It is imperative that the integrity of all slings be checked prior to each use. The following items all have an impact on the life expectancy of a sling: water washing temperature, detergents and disinfectants, resident incontinence, frequency of use, type and weight of resident, and age of sling. What to look for when determining if a sling should be replaced: discoloration, fraying, rips or [CONDITION(S)] in material, loose stitching, and warranty tag. Look at the date punched on the warranty tag, and if over two years, it is recommended the sling be replaced. If the numbers are faded or the tag is worn off or shredded, then replace the sling.

Based on interview and record review, the facility failed to ensure staff provided Basic Life Support (BLS, activation of the emergency response system, early cardiopulmonary resuscitation [CPR, refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased]) for one of two sampled residents (Resident 1) who required such emergency care, by failing to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) and LVN 2 performed CPR to Resident 1 who was full code (a patient who chooses to be resuscitated if he or she stops breathing of if the heart stops beating or wishes to have full treatment in life-threatening situations to do CPR) when Resident 1 was suddenly found to be unresponsive, not breathing, and did not have a heart rate. 2. Ensure LVN 1 and LVN 2 called 911 (emergency services) for Resident 1 to receive emergency services when the resident was found to be unresponsive not breathing and did not have a heart rate. 3. Ensure all staff currently working at the facility had current BLS certifications. On [DATE] at 5:30 am, LVN 1 found Resident 1 unresponsive, not breathing, and without a heart rate. LVN 1 and LVN 2 failed to perform CPR and did not call 911 for Resident 1. Resident 1's physician (MD 1) pronounced Resident 1 dead on [DATE] at 6:30 am. On [DATE] at 9 am, during an onsite visit investigation, the California Department of Public Health (CDPH) identified the facility did not require all staff to have BLS certifications. As a result, Resident 1 did not receive CPR, 911 emergency services, and died on [DATE] at 6:30 am. These deficient practices also had the potential for 28 current residents in the facility who were considered full code not to receive BLS services in case of any emergency exposing them to injury and or death. On [DATE], at 5:13 pm, CDPH called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents), in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON). CDPH informed the ADM and the DON the facility failed provide BLS to Resident 1 and failed to ensure all staff had BLS certifications which placed 28 residents in the facility at risk for injury and or death. On [DATE], at 3:35 pm, CDPH removed the IJ in the presence of the ADM after the facility submitted an acceptable Plan of Action (POA, action to correct the deficient practices) as follows: a. On [DATE], DON in-serviced LVN 1 and all licensed nurses, on physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. On [DATE], Social Services and Medical Records audited all residents' POLSTs, Care Plans were updated, and orders were entered into the facility's electronic records. Nursing to perform BLS and CPR for residents who are on full code status including residents who have not completed POLST. c. On [DATE], a certified CPR instructor started training all currently CPR uncertified staff with a completion date of [DATE]. d. Staff will not be on schedule if they do not have a current CPR certification after [DATE]. e. On [DATE], DON in-serviced non-CPR Certified Nursing Assistants (CNAs) if any resident is nonresponsive, and not breathing, or no pulse they will notify the Licensed Nurse immediately so the Licensed Nurse can perform CPR and call 911 if warranted according to the POLST/Advanced Directive. f. On [DATE], Nurse Consultant in-serviced LVN 1, Director of Staff Development (DSD), DON and ADM on F678 and on staff having CPR certifications. Cross Reference F656, F684, and F726 Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on [DATE] and readmitted the resident on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Social Service Review, dated [DATE], indicated Resident 1 was alert to name, limited verbal response with confusion and disorientation to time, place and person. Resident 1 did not have advanced directives (a written statement of a person's wishes regarding medical treatment to ensure those wishes are carried out should the person be unable to communicate them to a doctor) and did not have the capacity to formulate. POLST had been offered however the residents' son did not make any decision (POLST is a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated [DATE], indicated Resident 1 had severe impairment in cognition (mental action or process of acquiring knowledge and understanding), and was dependent on staff for transfers. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Progress Notes, dated [DATE], timed at 5:30 am, indicated LVN 1 found Resident 1 unresponsive, vital signs (VS, clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions), not detected. The other charge nurse helped assess the resident. Oxygen was administered still no pulse and VS. 6 am, LVN 1 called MD 1 and left a message. 6:30 am, MD 1 called back and pronounced Resident 1 dead. During a telephone interview on [DATE] at 8:16 pm, Registered Nurse 1 (RN 1) stated when a resident did not have a POLST or an advanced directive, the resident was considered a full code per facility's policy. RN 1 stated when a resident's VS were failing or absent, the staff would call the charge nurse to start CPR and RN sup would call 911 immediately. RN 1 stated staff should continue to perform CPR until emergency services arrived. During a phone interview on [DATE] at 8:37 pm, LVN 1 stated he was assigned to Resident 1 on [DATE]. LVN 1 stated Resident 1's death happened during his shift and there was no POLST in Resident 1's chart. LVN 1 stated if there was no POLST, Resident 1 was considered a full code. LVN 1 stated Resident 1 was not breathing and LVN 1 called LVN 2 to help him. LVN 1 stated he did not perform CPR to Resident 1 and did not call 911. LVN 1 stated he asked MD 1 what do you think is happening, and MD 1 responded if a resident has no vital signs, meaning the patient is dead. LVN 1 stated the DON called him a few days after (unidentified date) and told him next time if a resident did not have a POLST or advance directive, he needed to perform CPR. During a telephone interview on [DATE] at 9 am, the DSD stated if a resident did not have a POLST or an advanced directive, the residents was considered full code. DSD stated staff knew the difference between a DNR (Do Not Resuscitate) or full code. DSD stated staff notified the charge nurse, grabbed the crash cart (a cart stocked with emergency medical equipment, supplies for use by medical personnel especially during efforts to resuscitate a patient experiencing [CONDITION(S)] (when the heart stops beating suddenly), in cases of emergency. DSD stated CNAs were not required to have BLS certification. During a telephone interview on [DATE] at 9:15 am, DON stated it was the facility's policy to perform CPR if a resident did not have a POLST. DON stated LVN 1 should have performed CPR on Resident 1. During a telephone interview on [DATE] at 4:45 pm, MD 1, stated he supervised R1's care at the facility. MD 1 stated Resident 1 refused to sign the POLST. MD 1 stated FAM 1 refused to act as Resident 1's decision maker. MD 1 stated he pronounced Resident 1's dead on [DATE] at 6:30 a.m. During a telephone interview on [DATE], at 3:50 am, LVN 2 stated that on [DATE] at 5:35 am, LVN 1 called for help. LVN 2 stated Resident 1 appeared pale, not breathing, no pulse, and no blood pressure. LVN 2 stated they (LVN 1 and LVN 2) should have started performing CPR to Resident 1. LVN 2 stated they (LVN 1 and LVN 2) did not call 911. LVN 2 stated that if Resident 1 did not have a POLST, the resident was a full code. A review of the facility's untitled document submitted by DSD on [DATE], indicated 49 facility staff who were employed by the facility and taking care of residents, consisting of 28 CNAs, nine administrative staff, six dietary staff, and six ancillary services staff, did not have BLS/CPR training or certifications. A review of the facility's Emergency Procedure-Cardiopulmonary Resuscitation, policy, and procedure, with a revised date of February 2018, indicated personnel have completed training on the initiation of CPR or BLS, including defibrillation (an electronic device that applies an electric shock to restore the rhythm of the heart), for victims of sudden [CONDITION(S)]. The policy indicated if the Do Not Resuscitate (DNR) status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Preparation for CPR: Obtain and /or maintain American Heart Association Certification in basic Life Support (BLS) or CPR for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [CONDITION(S)] is likely, begin CPR. Instruct a staff member to activate the emergency response system(code) and call 911.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice by failing to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) and LVN 2 performed cardiopulmonary resuscitation (CPR, refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased) as indicated in the facility's Emergency Procedure-Cardiopulmonary Resuscitation, policy and procedure, to Resident 1 who was full code (a patient who chooses to be resuscitated if he or she stops breathing of if the heart stops beating or wishes to have full treatment in life-threatening situations to do CPR) when Resident 1 was suddenly found to be unresponsive, not breathing, and did not have a heart rate. 2. Ensure LVN 1 and LVN 2 called 911 (emergency services) for Resident 1 to receive emergency services when the resident was found to be unresponsive not breathing and did not have a heart rate. On [DATE] at 5:30 am, LVN 1 found Resident 1 unresponsive, not breathing, and without a heart rate. LVN 1 and LVN 2 failed to performed CPR and did not call 911 for Resident 1. Resident 1's physician (MD 1) pronounced Resident 1 dead on [DATE] at 6:30 am. On [DATE] at 9 am, during an onsite visit investigation, the California Department of Public Health (CDPH) identified the facility did not require all staff to have BLS certifications. As a result, Resident 1 did not receive CPR, 911 emergency services, and died on [DATE] at 6:30 am. These deficient practices also had the potential for 28 current residents in the facility who were considered full code not to receive BLS services in case of any emergency exposing them to injury and or death. Cross Reference F656, F678, and F726 Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on [DATE] and readmitted the resident on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Social Service Review, dated [DATE], indicated Resident 1 was alert to name, limited verbal response with confusion and disorientation to time, place and person. Resident 1 did not have advanced directives (a written statement of a person's wishes regarding medical treatment to ensure those wishes are carried out should the person be unable to communicate them to a doctor) and did not have the capacity to formulate. POLST had been offered however the residents' son did not make any decision (POLST is a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated [DATE], indicated Resident 1 had severe impairment in cognition (mental action or process of acquiring knowledge and understanding), and was dependent on staff for transfers. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Progress Notes, dated [DATE], timed at 5:30 am, indicated LVN 1 found Resident 1 unresponsive, vital signs (VS, clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions), not detected. The other charge nurse helped assess the resident. Oxygen was administered still no pulse and VS. 6 am, LVN 1 called MD 1 and left a message. 6:30 am, MD 1 called back and pronounced Resident 1 dead. During a telephone interview on [DATE] at 8:16 pm, Registered Nurse 1 (RN 1) stated when a resident did not have a POLST or an advanced directive, the resident was considered a full code per facility's policy. RN 1 stated when a resident's VS were failing or absent, the staff would call the charge nurse to start CPR and RN sup would call 911 immediately. RN 1 stated staff should continue to perform CPR until emergency services arrived. During a phone interview on [DATE] at 8:37 pm, LVN 1 stated he was assigned to Resident 1 on [DATE]. LVN 1 stated Resident 1's death happened during his shift and there was no POLST in Resident 1's chart. LVN 1 stated if there was no POLST, Resident 1 was considered a full code. LVN 1 stated Resident 1 was not breathing and LVN 1 called LVN 2 to help him. LVN 1 stated he did not perform CPR to Resident 1 and did not call 911. LVN 1 stated he asked MD 1 what do you think is happening, and MD 1 responded if a resident has no vital signs, meaning the patient is dead. LVN 1 stated the DON called him a few days after (unidentified date) and told him next time if a resident did not have a POLST or advance directive, he needed to perform CPR. During a telephone interview on [DATE] at 9 am, the DSD stated if a resident did not have a POLST or an advanced directive, the residents was considered full code. DSD stated staff knew the difference between a DNR (Do Not Resuscitate) or full code. DSD stated staff notified the charge nurse, grabbed the crash cart (a cart stocked with emergency medical equipment, supplies for use by medical personnel especially during efforts to resuscitate a patient experiencing [CONDITION(S)] (when the heart stops beating suddenly), in cases of emergency. DSD stated CNAs were not required to have BLS certification. During a telephone interview on [DATE] at 9:15 am, DON stated it was the facility's policy to perform CPR if a resident did not have a POLST. DON stated LVN 1 should have performed CPR on Resident 1. During a telephone interview on [DATE] at 4:45 pm, MD 1, stated he supervised R1's care at the facility. MD 1 stated Resident 1 refused to sign the POLST. MD 1 stated FAM 1 refused to act as Resident 1's decision maker. MD 1 stated he pronounced Resident 1's dead on [DATE] at 6:30 a.m. During a telephone interview on [DATE], at 3:50 am, LVN 2 stated that on [DATE] at 5:35 am, LVN 1 called for help. LVN 2 stated Resident 1 appeared pale, not breathing, no pulse, and no blood pressure. LVN 2 stated they (LVN 1 and LVN 2) should have started performing CPR to Resident 1. LVN 2 stated they (LVN 1 and LVN 2) did not call 911. LVN 2 stated that if Resident 1 did not have a POLST, the resident was a full code. A review of the facility's untitled document submitted by DSD on [DATE], indicated 49 facility staff who were employed by the facility and taking care of residents, consisting of 28 CNAs, nine administrative staff, six dietary staff, and six ancillary services staff, did not have BLS/CPR training or certifications. A review of the facility's Emergency Procedure-Cardiopulmonary Resuscitation, policy, and procedure, with a revised date of February 2018, indicated personnel have completed training on the initiation of CPR or BLS, including defibrillation (an electronic device that applies an electric shock to restore the rhythm of the heart), for victims of sudden [CONDITION(S)]. The policy indicated if the Do Not Resuscitate (DNR) status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Preparation for CPR: Obtain and /or maintain American Heart Association Certification in basic Life Support (BLS) or CPR for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [CONDITION(S)] is likely, begin CPR. Instruct a staff member to activate the emergency response system(code) and call 911.

Based on observation, interview and record review the facility failed to implement interventions to prevent and control the spread of respiratory diseases such as Coronavirus 19 (COVID-19, a severe respiratory illness caused by virus and spread from person to person) and Influenza virus (a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and sometimes the lungs) for 13 of 13 sampled residents (Resident 5, 7, 15, 18, 20, 24, 29, 36, 46, 47, 54, 56 and 209) by failing to: a. Quarantine (separate and restrict the movement of people who were exposed to a contagious disease to see if they become sick) Resident 5, 7, 15, 18, 20, 24, 29, 36, 46, 47, 54, 56 and 209) who had symptoms of cough into a Yellow Zone (an area in the facility where residents suspected, had contact with or with symptoms of respiratory infection were confined). b. Ensure staff (in general) who had close resident contact with Resident 5, 7, 15, 18, 20, 24, 29, 36, 46, 47, 54, 56 and 209) donned (put on) full protective personal equipment (PPE, protective clothing, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from the spread of infection or illness). c. Test Resident 5, 7, 15, 18, 20, 24, 29, 36, 46, 47, 54, 56 and 209 for COVID-19 and for Influenza virus. d. Ensure staff perform hand hygiene after contact with the residents and equipment. These deficient practices had the potential to spread COVID-19 and or influenza virus to residents, staff, and visitors that could lead to severe respiratory illness, hospitalization , and/or death. On 11/10/2021 at 7:39 pm, the Department of Public Health (DPH) called an Immediate Jeopardy situation (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) with regards to the facility's failure to implement infection control practices according to the local DPH guidelines and the facility's policies and procedures for infection control in the presence of the facility's Director of Nursing (DON), the Administrator (ADM) and the Infection Prevention Nurse (IPN, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment). On 11/11/2020 at 4:44 pm, while onsite and after confirming the facility's implementation of the immediate corrective actions, DPH accepted the Plan of Action (POA, interventions to correct the deficient practices) and removed the IJ in the presence of the DON and ADM. The acceptable POA was as follows: 1. On 11/10/2021, the facility placed all residents into quarantine in the facility's Yellow Zone. 2. On 11/10/2021, the facility tested all residents in the facility. 3. On 11/10/2021 and on 11/11/2021, the facility tested all staff for COVID-19. 4. The facility completed testing all the residents in the facility for influenza on 11/10/2021. 5. On 11/10/2021, all staff was provided with proper PPE and provided in-services on proper PPE use and hand hygiene. 6. On 11/10/2021, the facility placed additional signages for donning (put on) and doffing (remove) PPEs and had isolation carts (store and organize all the supplies required to mitigate the risk of transmitting infection) in front of every residents' rooms. 7. On 11/11/2021 the facility's Infection Prevention/DSD Consultant provided an in-service education to the facility's IPN regarding the DPH, CDC, and California Department of Public Health (CDPH) infection control guidelines regarding residents with respiratory infection symptoms such as cough. Findings: A review of the facility's untimed Long Term Care Surveillance Line List for Respiratory Infection (a table that summarizes information about person(s) who may be associated with an outbreak), dated 11/9/2021, indicated Residents 5, 7, 15, 18, 20, 24, 29, 36, 46, 47, 54, and 56 had symptoms of cough. The Line List indicated Resident 56's cough symptoms started on 10/29/2021, Resident 15 and Resident 5's cough symptoms started on 11/6/2021, Resident 24, 7, and 36's cough symptoms started on 11/7/2021, Resident 47, 29, 20, 54's symptoms of cough started on 11/8/2021, Resident 18's symptoms of cough started on 11/9/2021, and Resident 46's symptoms of cough started on 11/10/2021. A review of the LTC Surveillance Line List for Respiratory Infection, dated 11/11/2021 provided by the IPN indicated one additional resident, Resident 209 had symptoms of cough. During an entrance conference interview on 11/9/2021 at 8:45 am, the IPN stated Residents 5, 7, 15, 18, 20, 24, 29, 46, 47, and 54 had symptoms of cough and were not quarantined or isolated and remained in the facility's Green Zone (an area in the facility where residents without symptoms of respiratory infection such as cough were placed) with other residents who did not have any respiratory symptoms. The IPN stated the facility transferred Resident 56 to a general acute care hospital (GACH) on 11/5/2021 due to cough. A review of Resident 18's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 18's MDS dated [DATE], indicated Resident 18 had no impairment in memory and cognition, and required extensive assistance with one person on activity of daily living. During an observation and interview on 11/10/2021 at 12:48 pm, Resident 18 was observed coughing while sitting on a wheelchair at the doorway of his room in the facility's Green Zone. Resident 18 stated he started feeling congested and began coughing on 11/9/2021. A review of Resident 24's Admission Record indicated the resident was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 24's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 9/1/2021 indicated Resident 24 had severely impaired memory and cognition (ability to think and reason), and required extensive assistance with one person on activity of daily living. During an observation on 11/9/2021, at 9:42 am, in the facility's Green Zone, no PPE or signage, Resident 24 was inside her room sitting in a wheelchair and repeatedly coughing. The curtain between Resident 24 and her roommate Resident 42, was opened. During an interview on 11/9/2021, at 9:44 am, Certified Nursing Assistant 3 (CNA 3) stated Resident 24 was coughing all night on 11/8/2021. During an interview on 11/9/2021, at 9:49 am, Resident 42 was awake stated she told the DON (unidentified date and time) about Resident 24 coughing. Resident 42 stated she was concerned because she has asthma (a condition that cause the lungs inflammation that cause difficulty breathing) and stated Resident 24's cough got worse over the weekend (11/6/2021 to 11/7/2021). During an observation and interview on 11/10/2021 at 11:30 am, Resident 24 was observed sitting in a wheelchair going back to her room in the hallway (Green Zone) and was coughing productively ([MEDICATION(S)]). Resident 24 stated she returned to her room from the rehabilitation room (exercise treatment room) because she was coughing too much. Resident 24 stated she had been coughing a lot, since 11/7/2021. During an interview with on 11/10/2021 at 12:45 pm, the IPN stated the residents (unidentified) with new or worsened cough were not tested for Pneumonia (lung inflammation caused by bacterial or [CONDITION(S)] infection) and or Influenza infection because most of the residents (unidentified) with cough received pneumonia, influenza and COVID-19 vaccines. A review of Resident 29's Admission Record indicated Resident 29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 29's MDS dated [DATE], indicated Resident 29 was cognitively intact in memory and cognition and required extensive with activities of daily living. During an observation and interview on 11/10/2021 at 8:44 am, inside Resident 29's room, in the facility's Green Zone without PPE signage, Resident 29 was awake coughing lying in bed under the covers. Resident 29 stated he was trying to cough the phlegm, (thick [MEDICATION(S)]) out. Resident 29's door was opened, and Resident 29 was coughing. During a telephone interview on 11/10/2021 at 4:48 pm during a telephone interview with the Public Health Nurse (PHN) stated she provided the IPN via email a list of reportable conditions. The PHN stated the IPN informed her that there were residents (unidentified) with cough. The PHN stated she did not inform the IPN not to isolate the residents with cough because she could not make any comments or suggestions because she was not present in the facility. During an interview on 11/10/2021 at 6:05 pm, the IPN stated not all residents (unidentified) with symptoms of cough were tested for COVID-19. The IPN stated he was aware of the DPH infection control guidance to isolate or quarantine the residents with cough and aware respiratory virus could spread through droplets. During an interview on 11/10/2021, at 6:11 pm, the ADM stated there was confusion with taking care of residents who had a cough. ADM stated the residents with cough should be isolated, quarantined away from residents who did not have symptoms and the whole facility should be in a yellow zone. A review of Resident 36's Admission Record indicated the facility admitted Resident 36 on 9/22/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 36's MDS, dated [DATE], indicated Resident 36 had no cognitive and memory impairment, that required extensive assistance with activities of daily living. During an observation and interview on 11/9/2021, at 10:28 am, Resident 36 was observed touching his chest while coughing in the hallway in the facility's Green Zone. Resident 36 stated his cough made it harder for him to breathe. During an interview on 11/9/2021, at 11:57 am, the IPN stated the residents (unidentified) who had cough were not isolated from other residents without cough. The IPN stated cough was a sign and symptom of respiratory infection such as COVID 19 and influenza. A review of Resident 42's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 42's MDS, dated [DATE] indicated Resident 42 was able to express her ideas and wants and had no impaired memory and cognition. A review of the Admission Record, Resident 46 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS, dated [DATE], indicated Resident 46 had severely impaired memory and cognition (ability to think and reason) and required total assistance with one person assistance on activities of daily living. During a medication administration observation on 11/10/2021 at 9:05 am, inside Resident 46's room, Licensed Vocational Nurse 4 (LVN 4) was not wearing an N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) and not wearing a gown while administering medication to Resident 46 who was observed with productive cough. LVN 4 stated she had not previously heard or was reported to her by the other staffs that Resident 46 had productive cough. LVN 4 stated she was not informed to isolate the staff with cough or to wear gown or N95 mask when taking care of the residents with productive cough. A review of Resident 56's Admission Record indicated the facility admitted Resident 56 on 12/17/2018 and readmitted the resident on 10/22/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 56's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/9/2021 at 12:30 pm, the DON stated a new onset cough or worsened cough was a symptom of respiratory infection such as influenza virus. The DON stated the facility did not perform influenza virus test to the residents (unidentified) with new onset or worsened cough. The DON stated the residents (unidentified) should had been tested because of the current flu season as indicated in the facility's policy and procedure. A review of Resident 47's Admission Record indicated Resident 47 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 47's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 10/17/2021, indicated Resident 47 had the cognitive skills (ability to perceive and react, process and understand, store and retrieve information, make decisions and produce appropriate responses) for decision making. A review of Resident 47's Change of Condition dated 11/10/2021, timed at 11:30 am, indicated Resident 47 had cough and was transferred to the hospital via paramedics for shortness of breath. During an observation and interview on 11/9/2021 at 9:58 am, in the facility's green zone, no PPE signage, inside Resident 47's room, Resident 47 was sitting on the side of her bed receiving a breathing treatment and was coughing. Resident 47 is in a room with a roommate without any isolation precautions in place. Resident 47 stated she was receiving the breathing treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 11/9/2021 at 10:21 am in Resident 47's room, Licensed Vocational Nurse (LVN) 3, LVN 3 entered Resident 47's room to administer breathing treatment and medications. LVN 3 was not wearing an N95 and no gown. During an observation on 11/10/2021 at 9:18 am in Resident 47's room, Certified Nurse Assistant 2 (CNA) 2 was assisting Resident 47's roommate to the restroom. CNA 2 was not wearing gown and N95. During a concurrent observation and interview on 11/10/2021 at 9:21 am with Resident 47, in Resident 47's room, Resident 47 was sitting on the side of her bed asking for her medication and breathing treatment. Resident 47 was heard coughing. Resident 47 was still in a room with a roommate without any isolation precautions in place. Resident 47 stated she was not feeling well and stated she wanted her medication so she could feel better. During an interview on 11/10/2021 at 4:30 pm, IPN stated Resident 47 was transferred to the hospital for episode of shortness of breath earlier on 11/10/2021. During an observation on 11/10/2021, at 2:55 pm, Resident 209 was coughing productively with her room door open. A review of Resident 209's Admission Record indicated the facility admitted Resident 209 on 10/29/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 209's History and Physical dated 10/30/2021, indicated Resident 209 had the capacity to understand and make decisions. During an interview on 11/10/2021 at 4:35 pm, the IPN stated Influenza virus could be transmitted by droplets (such as a particle of moisture discharged from the mouth during coughing, sneezing, or speaking; these may transmit infections while airborne to others). The IPN stated the staff (unidentified) were not required to wear a gown and N95 mask because the residents with cough were not on isolation or quarantined. A review of the facility's policy and procedure, titled Prevention and Control of Seasonal Influenza indicated, traditionally, influenza viruses have been thought to spread from person to person primarily through large-particle respiratory droplet transmission (e.g., when an infected person coughs or sneezes near a susceptible (at risk) person (approximately six (6) feet or less) through the air. Indirect contact transmission via hand transfer of influenza virus from virus-contaminated surfaces or objects to mucosa (surfaces of the face (e.g., nose, mouth) may also occur. All respiratory secretions and bodily fluids, including diarrheal stools, of residents with influenza are considered to be potentially infectious; however, the risk may vary by strain. A review of the facility's policy and of the Department of Public Health, Guidelines for Preventing and Managing COVID-19 in Skilled Nursing Facilities, dated 10/21/2021, indicated every staff member or resident with symptoms of COVID-19 (fever, cough, dyspnea [difficulty breathing], new loss of taste or smell, chills/rigors [tremor], myalgias (muscle pain), (rhinorrhea (runny nose), vomiting or diarrhea, sore throat, fatigue, headache, and confusion) should be tested as soon as possible, regardless of vaccination status. The guideline indicated all symptomatic residents should be presumed infectious pending test results and should be in quarantine in a private room in the Yellow Cohort (mixed quarantine and symptomatic residents), if possible. The guideline also indicated during the influenza season, residents with acute respiratory symptoms should also be tested for influenza. http://publichealth.lacounty.gov/acd/ncorona2019/healthfacilities/snf/prevention/#cohorting A review of Interim Guideline for COVID-19 [MEDICATION(S)] Testing in Skilled Nursing facilities, dated 10/20/2020, indicated symptomatic residents tested for point of care [MEDICATION(S)] test with negative results should be confirmed with COVID-19 Polymerase Chain Reaction (PCR) test. The guideline also indicated residents to be quarantined in the Yellow Cohort pending PCR confirmation and when PCR results are confirmed negative, residents can be moved to the green cohort with droplet precautions until after the resident is clinically improved and 24 hours after resolution of fever. http://publichealth.lacounty.gov/acd/ncorona2019/healthfacilities/snf/[MEDICATION(S)]/ A review of the facility's policy and procedure titled, Influenza, Prevention and Control of Seasonal, dated Revised August 2014, indicated Policy Interpretation and Implementation, Influenza Modes of Transmission, 1. Traditionally, influenza viruses have been thought to spread from person to person primarily through large-particle respiratory droplet transmission (e.g., when an infected person coughs or sneezes near a susceptible person). a. Transmission via large-particle droplets requires close contact between source and recipient persons because droplets generally travel only short distances (approximately six (6) feet or less) through the air. 2. Indirect contact transmission via hand transfer of influenza virus from virus-contaminated surfaces or objects to mucosal surfaces of the face (e.g., nose, mouth) may also occur. Under Infected Residents and Visitors-3e. During periods of increased community influenza activity, rapid screening of residents for symptoms of influenza and separation from other residents during screening may be necessary. A review of the facility's policy and procedure, titled Isolation-Initiating Transmission Based Precautions revised January 2012, indicated if the resident had symptoms of respiratory infection during the Influenza season, the resident should be tested for Influenza. A review of the Admission Record indicated Resident 53 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 53's MDS dated [DATE], indicated the resident was severely impaired with cognitive skills for daily decision making. During an observation on 11/09/2021 at 9:45 am, together with IPN, observed IPN touched the resident's urinary drainage bag without performing hand hygiene, not wearing gloves, before and after manipulating the resient's urinary tube and drainage bag. IPN stated it was important to don gloves before handling the FC drainage bag to avoid infection to the resident. During an interview on 11/10/2021 at 9:11 am, the DON stated staff were encouraged to wear gloves and perform handwashing before and after touching the residents' urinary bag to prevent infection. A review of the Policy and Procedure (P&P), titled, Urinary Catheter Care, dated 09/2014, P&P indicated to maintain clean technique when handling or manipulating the catheter, tubing or drainage bag.