Every finding on record at Montrose Springs Skilled Nursing & Wellness Center

Based on interview and record review, the facility failed to ensure three of 25 sampled residents (Residents 91, 75 and 3) or the resident's representatives (RP) received information on how to execute an Advanced Directive (AD-a legal document indicating resident preference on end-of-life treatment decisions) in accordance with State law and the facility's Policy and Procedure (P&P) for Advanced Directive. This deficient practice had the potential for care and services to be provided in a manner inconsistent with the resident's and/or family wishes. Findings: 1. During a review of Resident 91's Face Sheet (FS), the FS indicated Resident 91 was admitted on [DATE] with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), chronic kidney disease (CKD – a gradual, lasting loss of kidney function and damage that lasts for three months or longer), diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), and depression (a mood disorder that causes a persistent feelings of sadness and a loss of interest in activities). During a review of Resident 91's History and Physical (H&P), dated 2/9/2026, the H&P indicated Resident 91 was alert and oriented to person, place and time. During a review of Resident 91's Minimum Data Set (MDS – a comprehensive assessment and screening tool), dated 5/2/2026, the MDS indicated Resident 91 has severe cognitive (ability to reason and process information) impairment. During a concurrent interview and record review on 7/22/2026 at 10:30 AM with the Social Services Director (SSD), Resident 91's Social Services Assessment, dated 2/12/2026 was reviewed. The assessment indicated Resident does not have an Advance Directive and is unable to formulate due to impaired cognition. SSD stated information on Advanced directive was given to Resident 91's RP, but there was no documented evidence the AD was provided to the RP. During a concurrent interview and record review on 7/23/2026 at 3:30 PM with the SSD, Resident 91's Advanced Directive, dated 3/30/2026 was reviewed. The Advanced Directive was notarized (an official impartial witness that verifies identity and prevents fraud when people sign important legal documents) while Resident 91 was a resident of the facility. SSD stated she did not know the Advanced Directive existed and cannot consider it valid because the process for making the Advanced Directive was not followed. During a concurrent interview and record review on 7/23/2026 at 4:00 PM with the Director of Nursing (DON), Resident 91's Social Services Assessment, dated 2/12/2026 was reviewed. The assessment indicated resident does not have an Advance Directive and is unable to formulate due to impaired cognition. The DON stated that he did not agree with the SSD's assessment regarding cognition and there was no information stating understanding of education of an advanced directive. During a concurrent interview and record review on 7/23/2026 at 4 PM with the Director of Nursing (DON), Resident 91's Advanced Directive, dated 3/30/2026 was reviewed. The Advanced Directive was notarized (a state appointed individual verified the identity of the resident and stamp the document) while Resident 91 was a resident of the facility. The DON stated the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) should have been involved when the Advanced Directive was notarized because Resident 91 was in the facility. The DON stated that it was important to follow the proper procedure when forming an Advanced Directive for healthcare. During a review of the facility's Policy and Procedure (P&P) titled, Advanced Directive, dated 7/31/2024, the P&P indicated information and education regarding making an Advanced Directive will be given upon admission. If Resident or Resident Representative decides to make an Advanced Directive or make changes to an Advanced Directive, the Ombudsman will be notified. 2. During a review of Resident 3's Face Sheet (a summary page that provides key details about a resident), the Face Sheet indicated that Resident 3 was admitted to the facility on [DATE] with diagnoses including but not limited to; glaucoma (an eye condition that damages the optic nerve and can lead to vision loss or blindness), muscle weakness (lack of physical or muscle strength), and cognitive communication deficit (difficulty with speech, reading, writing, or listening). During a review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 9/26/2025, the MDS indicated that Resident 3 was cognitively impaired, confused, disoriented (lacking mental action or process of acquiring knowledge and understanding) partial to moderate assistance from another person for functions of daily living. During a review of Resident 3's medical record on 7/22/2026 at 10:07AM, the medical record did not indicate the resident had an Advanced Directive or was given information on how to formulate one. During an interview on 7/23/2026 at 3:05PM with the Director of Nursing (DON), the DON stated that residents are assessed for advanced directive on admission and it was not done for Resident 3. The DON stated that by not completing the Advance Directive form in a timely manner, there is potential for services to not be performed during medical emergencies according to the residents' wishes. 3. During a review of Resident 75's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] , with diagnoses that included epilepsy (a brain disorder that causes repeated, unprovoked seizures [ abnormal bursts of electrical activity in the brain]), multiple sclerosis (a disease that can cause numbness, weakness, trouble walking, vision changes and other symptoms) and quadriplegia (a severe medical condition characterized by the partial or total loss of function in all four limbs and the torso). The AR indicated Resident 75 had an RP on record. During a review of Resident 75's Minimum Data Set (MDS- a resident assessment tool) dated 6/18/2026, indicated the resident cognitive status (level of mental functioning) was severely impaired. The MDS indicated, Resident 75 was dependent (helper does all the effort) with eating, and require substantial/maximal assistance (helper does more than half the effort) with all activities of daily living (ADLs). During a concurrent interview and record review on 7/22/2026 at 3 PM with Social Service Assistant (SSA), and Social Service Director (SSD). Resident 75's facility document Advance Healthcare Directive (AHCD) Acknowledgement Form dated 4/19/2024, and Resident 75's electronic health record (EHR) was reviewed. Resident 75's AHCD signed by SSA, indicated Resident 75 had no capacity to understand and make decision, but did not have a signature of Resident 75's RP. Resident EHR did not have any documentation whether an effort was made by the facility to address Resident 75 not having an Advance Directive. The SSA stated, the AHCD was not complete because it did not have a signature of Resident 75's RP. The SSA stated, she did not have any documentation that an effort was made to consult with Resident 75's RP to address Resident 75's not having an Advance Directive. SSD stated, Resident 75's AHCD should have been brought up with the RP to ensure Resident 75's medical care and services are performed according to their wishes. During an interview on 7/23/2026 at 11:09 AM with the Director of Nurses (DON), the DON stated, he could not find any documentation that the facility attempted to discuss with the RP regarding the formulation of an advance directive upon Resident 75's admission. The DON stated that Resident 75 not having an advance directive had the potential for medical care and services to not be performed according to the Resident and/or family wishes. During a review of the facility's policy and procedure (P&P) titled Advance Directives, dated 7/31/2024, the P&P indicated, a) upon admission the admission staff or designee will provide written information to the resident concerning his or her right to make decisions concerning medical care. including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directive, b) if the resident has an advance directive the facility shall request a copy of the document from the resident or the resident's representative. During a review of the facility's policy and procedure (P&P) titled, Advance Directive, the P&P indicated that, Upon admission, the admission Staff or Designee will provide written information to the resident concerning his or her right to make decisions concerning medical care; including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives.

Based on observation, interview, and record review, the facility failed to provide appropriate services and treatments to maintain or prevent further decline in joint range of motion (ROM, full movement potential in a joint) for two of 25 sampled residents (Residents 115 and 122) when: 1a. Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) staff performed RNA treatments on Resident 115 that were not ordered by the physician. 1b. RNA staff did not document the application and removal of Resident 115's left hand splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint). 2a. RNA staff performed RNA treatments on Resident 122 that were not ordered by the physician. 2b. Resident 122's RNA order did not indicate a safe wear time parameter for RNA application and removal of both elbow splints and both resting hand splints. These deficient practices had the potential to cause injury, pain, and skin breakdown to Residents 115 and 122 when receiving RNA treatments that were not ordered, and lack of monitoring of application and removal of splints. Findings: 1. During a review of Resident 115's Face Sheet, the Face Sheet indicated Resident 115 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to acute respiratory failure (any condition that affects breathing function and result in lungs not functioning properly) with hypoxia (low oxygen level in tissues), epilepsy (disorder that causes episodes of seizures or altered consciousness), and contracture (loss of motion of a joint) of left hand. During a review of Resident 115's Minimum Data Set (MDS, resident assessment tool) dated 6/8/2026, the MDS indicated Resident 115 had intact cognition (sufficient judgement, planning, organization to manage average demands in one's environment). The MDS indicated Resident 115 had functional limitations in ROM impairments on one side of the upper extremity (UE, shoulder, elbow, wrist, hand) and one side of the lower extremity. The MDS indicated Resident 115 required substantial assistance with eating, oral hygiene, upper body dressing, and sit to lying and required dependent assistance with bathing, lower body dressing, and bed to chair transfers. During a review of Resident 115's Order Listing Report dated 7/23/2026, the Order Listing Report an order dated 6/11/2026 for RNA order to do active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) on right lower extremity (RLE, hip, knee, ankle, foot) three times a week as tolerated by resident and an order dated 6/11/2026 for RNA order to do AAROM on left LE (LLE) three times a week as tolerated by resident. During a review of Resident 115's Care Plan Report (CP), a CP dated 7/13/2026 indicated Resident 115 was at risk for further functional decline related to diagnosis and resident is on RNA program as follows: -RNA order to do AAROM on LLE three times a week as tolerated by resident -RNA order to do AAROM on RLE three times a week as tolerated by resident The CP interventions indicated RNA program as indicated. During an observation and interview on 7/21/2026 at 11:01 AM, Resident 115 was lying in bed and stated he received RNA exercises about three times a week and RNA staff put on a left hand splint. Resident 115's hands were in a fisted position and Resident 115 was able to slowly open the right hand. During an observation and interview on 7/22/2026 at 9:48 AM in Resident 115's room, Restorative Nursing Aide (RNA 1) and Restorative Nursing Aide (RNA 2) performed RNA treatment with Resident 115. RNA 1 demonstrated elbow exercises and Resident 115 followed RNA 1 to bend and straighten both elbows. RNA 1 completed passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 115's right shoulder to less than shoulder height, straightened the right elbow and opened the right hand. RNA 2 completed PROM to Resident 115's left shoulder to less than shoulder height, straightened the left elbow, and straightened to left fingers. RNA 2 put on a left hand splint. RNA 1 then completed PROM exercises to Resident 115's right hip, knee, and ankle. RNA 2 then completed PROM exercises to Resident 115's left hip, knee, and ankle. 1a. During a review of Resident 115's July 2026 RNA Documentation Survey Report (DSR), the RNA DSR indicated RNA staff completed RNA interventions on 7/1/2026, 7/3/2026, 7/6/2026, 7/8/2026, 7/10/2026, 7/15/2026, 7/17/2026, 7/20/2026, 7/22/2026 for the following interventions/tasks: -RNA order for LUE AAROM once a day three times a week or as tolerated -RNA order for RUE AAROM once a day three times a week or as tolerated -RNA to don left resting hand splint to left hand, up to two hours, three times a week or as tolerated -RNA to perform PROM of LLE, three times a week or as tolerated -RNA to perform PROM of LUE, three times a week or as tolerated -RNA to perform PROM of RLE, three times a week or as tolerated -RNA to perform PROM of RUE, three times a week or as tolerated During an interview and record review on 7/23/2026 at 9:35 AM with Registered Nurse Supervisor (RNS 2), Resident 115's medical records were reviewed. RNS 2 stated Resident 115 had an order dated 6/11/2026 for RNA to do AAROM on RLE three times a week as tolerated by resident and an order dated 6/11/2026 for RNA to do AAROM on LLE three times a week as tolerated by resident. RNS 2 reviewed Resident 115's RNA tasks in the last 30 days and RNS 2 stated RNA staff completed RNA treatment for AAROM on BUE, PROM on BUE, PROM on BLE and put on a left resting hand splint without an active physician's order. RNS 2 stated Resident 115's RNA tasks had more tasks than what was ordered. RNS 2 stated there should only be RNA tasks for the RNA program ordered. RNS 2 stated the RNA program was specific to each resident and was ordered and assessed by therapists. RNS 2 stated RNA staff carried out RNA treatment orders and the RNA order should be followed at all times. RNS 2 stated Resident 115 should not have received RNA treatment for BUE and PROM on BLE and RNA staff should not have put on a left resting hand splint. During an interview and record review on 1:23 PM with RNA 1, RNA 1 confirmed Resident 115 received RNA for AAROM/PROM for BUE and BLE and RNA staff put on a left hand splint on 7/22/2026 RNA session. RNA 1 stated the RNA tasks did not always reflect what the RNA staff should be doing with each resident. During an interview on 7/23/2026 at 4:42 PM with the Director of Nursing (DON), DON stated the RNA program required orders and RNA staff should complete RNA tasks that were ordered. DON stated the RNA tasks should reflect what the RNA orders were so that RNA staff would not be confused to perform RNA treatments that were not ordered. During a review of the facility's policies and procedures (P&P) dated 1/30/2026, titled, Restorative Nursing Program, the P&P indicated the Restorative Nursing Program provides medically necessary, goal-directed nursing interventions to maintain or improve a resident's formal functional abilities after they have completed therapy, when therapy is not indicated but a resident can benefit from ongoing, structured activities, and when ordered by a provider based on resident clinical condition and personal goals. 1b. During a review of Resident 115's July 2026 RNA Documentation Survey Report (DSR), the RNA DSR indicated RNA staff completed RNA interventions on 7/1/2026, 7/3/2026, 7/6/2026, 7/8/2026, 7/10/2026, 7/15/2026, 7/17/2026, 7/20/2026, 7/22/2026 for the following intervention/task: RNA to don left resting hand splint to left hand, up to two hours, three times a week or as tolerated. The RNA DSR did not indicate application or removal schedule and total wear time of the left resting hand splint during RNA. During an interview and record review on 7/23/2026 at 9:35 AM with RNS 2, RNS 2 reviewed Resident 115's RNA tasks and stated RNA staff did not document how long Resident 115 wore the left resting hand splint. RNS 2 stated it was important to monitor how long a resident wore a splint, because a splint could restrict blood flow and could cause injuries if a splint was put on for too long. During an interview on 7/23/2026 at 10:20 AM with the Director of Rehabilitation (DOR), DOR stated RNA staff should monitor how long a resident wore a splint, because the time a resident wore a splint was an indication of decline if a resident could not tolerate a splint as ordered. DOR stated if a resident wore a splint for too long, the splint could cause redness, soreness, bruising, and skin breakdown. During an interview and record review on 7/23/2026 at 1:23 PM with RNA 1, RNA 1 stated RNA staff did not document application and removal of splints. RNA 1 stated there was nowhere in the medical record RNA staff could enter splint application and removal. RNA 1 stated if a resident took off a splint early, RNAs would not have anywhere to document that information. RNA 1 stated RNA staff should monitor and document how long a resident wore a splint, because the RNA order to wear the splint for a certain time should be followed. During an interview on 7/23/2026 at 4:42 PM with DON, DON stated splints had a specific wear time, because splints could become uncomfortable if a resident wore a splint for too long. DON stated the time a resident wore a splint needed to be monitored because the splint wear time was part of the RNA order. During a review of the facility's policies and procedures (P&P) dated 5/4/2023, titled, Restorative Nursing Program Splinting, the P&P indicated a physician's order for the use of splints will be obtained and entered in the resident's medical record. The order will include the following: a. type of splint, b. schedule of application and removal of splint. 2. During a review of Resident 122's Face Sheet, the Face Sheet indicated Resident 122 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to contracture, right and left shoulder, contracture right and left elbow, contracture right and left wrist, contracture right and left hip, contracture right and left knee, contracture right and left foot, and acute respiratory failure with hypoxia. During a review of Resident 122's MDS dated [DATE], the MDS indicated Resident 122 could not speak and rarely had the ability to understand others. The MDS indicated Resident 122 had functional limitations in ROM impairments on both sides of the UE and both sides of the LE. The MDS indicated Resident 122 was dependent on staff for eating, toileting, bathing, dressing, and bed to chair transfers. During a review of Resident 122's Order Listing Report dated 7/23/2026, the Order Listing Report did not indicate any active RNA treatment orders. During a review of Resident 122's Care Plan Report (CP), the CP dated 2/26/2026 indicated Resident 122 was at risk for further functional decline related to diagnosis. The CP indicated Resident 122 is on RNA program as follows: -RNA to don resting hand splint to LUE three times a week as tolerated by resident -RNA to don resting hand splint to RUE three times a week as tolerated by resident -RNA to perform PROM on RUE once a day, three times a week as tolerated -RNA to perform PROM on LUE once a day three times a week as tolerated. The CP interventions indicated to provide RNA program as indicated. During a review of Resident 122's July 2026 RNA Task Schedule, the RNA Task Schedule indicated RNA treatment was completed on 7/8/2026 and 7/20/2026 for the following tasks: -RNA to don left knee extension splint on LLE for two to four (2-4) hours once a day, three times a week as tolerated - RNA to don right knee extension splint on LLE for 2-4 hours once a day, three times a week as tolerated -RNA to perform PROM on LLE once a day three times a week as tolerated -RNA to perform PROM on RLE once a day three times a week as tolerated -RNA to don elbow extension splint to LUE, three times a week as tolerated by resident -RNA to don elbow extension splint to RUE, three times a week as tolerated by resident -RNA to don R PRAFO on RLE for 2-4 hours once a day three times a week as tolerated -RNA to don L PRAFO on RLE for 2-4 hours once a day three times a week as tolerated -RNA to don resting hand splint to LUE, three times a week as tolerated by resident -RNA to don resting hand splint splint to RUE, three times a week as tolerated by resident -RNA to perform PROM on LUE once a day three times a week as tolerated by resident -RNA to perform PROM on RUE once a day three times a week as tolerated by resident During an observation on 7/21/2026 at 10:04 AM, Resident 122 was lying in bed with eyes closed. Resident 122 was wearing right and left elbow splints and right and left wrist/hand splints on. Resident 122 did not talk and did not arouse to verbal cues. 2a. During an interview and record review on 7/23/2026 at 9:35 AM, RNS 2 reviewed Resident 122's RNA tasks and stated RNA staff completed RNA treatment on 7/8/2026 and 7/20/2026. RNS 2 stated Resident 122 should not have received RNA treatment on 7/8/2026 and 7/20/2026 because there were no orders for an RNA program. RNS 2 stated the RNA program was specific to each resident and was ordered and assessed by therapists. RNS 2 stated RNA staff carry out RNA treatment orders and the order should be followed at all times. RNS 2 stated the RNA tasks should reflect what was ordered and there should not be any RNA tasks since Resident 122 did not have any orders for an RNA program. During an interview and record review on 1:23 PM with RNA 1, RNA 1 confirmed Resident 122 received RNA on 7/8/2026 and 7/20/2026 even though RNA staff were informed Resident 122 was on therapy services. RNA 1 stated the RNA tasks did not always reflect what the RNAs should be doing with each resident. RNA 1 stated the RNA tasks were confusing. RNA 1 stated therapy staff would communicate a resident was on therapy services and to stop RNA, but the RNA task was still active and sometimes RNA staff did not always remember and completed the RNA treatment. During an interview on 7/23/2026 at 4:42 PM with the DON, DON stated the RNA program required orders and RNA staff should do what was ordered. DON stated the RNA tasks should reflect what the RNA orders were so that RNA staff would not be confused to perform RNA treatments that were not ordered. During a review of the facility's policies and procedures (P&P) dated 1/30/2026, titled, Restorative Nursing Program, the P&P indicated the Restorative Nursing Program provides medically necessary, goal-directed nursing interventions to maintain or improve a resident's formal functional abilities after they have completed therapy, when therapy is not indicated but a resident can benefit from ongoing, structured activities, and when ordered by a provider based on resident clinical condition and personal goals. 2b. During a review of Resident 122's Order Listing Report dated 7/23/2026, the Order Listing Report indicated a completed order dated 2/26/2026 for: -RNA to don elbow extension splint to LUE three times a week as tolerated by resident -RNA to don elbow extension splint to RUE three times a week as tolerated by resident - RNA to don resting hand splint to LUE three times a week as tolerated by resident and a completed order -RNA to don resting hand splint to RUE three times a week as tolerated by resident and a completed order During an interview and record review on 7/23/2026 at 9:35 AM, RNS 2 stated the RNA task to put on the UE elbow and resting hand splints did not include the wear time for the splints. RNS 2 stated RNA staff could not decide how long to put on a splint, because RNA staff were not certified and licensed like a therapist and did not have the knowledge and training to decide how long a resident could safely wear a splint. RNS 2 stated nursing staff needed to clarify the RNA orders and tasks to indicate how long to wear each splint. RNS 2 stated a splint could cause a restriction to the blood flow and cause injuries if a splint was worn for too long. During an interview and record review on 7/23/2026 at 10:20 AM, DOR stated therapists evaluated and assessed a resident to successfully wear a splint for contracture management. DOR stated therapists evaluated the maximum wear time for a splint, because that time was the longest time a resident could safely tolerate that splint. DOR stated if splints were worn for too long, splints could cause redness, soreness, bruising, skin breakdown and hygiene problems. DOR stated it was the therapist's responsibility to include a safe application time for a splint for all RNA orders. During an interview and record review on 7/23/2026 at 1:23 PM, RNA 1 stated Resident 122's RNA task did not indicate how long Resident 122 should wear the elbow splints and resting hand splints. RNA 1 stated the RNA tasks should have a splint wear time so RNA staff knew how long to put on a splint for. RNA 1 stated RNA staff could put on a splint for too long and hurt the resident. RNA 1 stated RNA staff should inform therapy or nursing staff to rewrite the order and RNA task. During an interview on 7/23/2026 at 4:42 PM, DON stated all RNA orders and tasks should include the time limits to wear a splint, because a resident could become uncomfortable if a resident wore a splint for too long. During a review of the facility's policies and procedures (P&P) dated 5/4/2023, titled, Restorative Nursing Program Splinting, the P&P indicated A physician's order for the use of splints will be obtained and entered in the resident's medical record. The order will include the following: a. type of splint, b. schedule of application and removal of splint.

Based on observation, interview, and record review, the facility failed to minimize the risk of avoidable accidents associated with the use of therapeutic modalities (types of electrical, thermal, or mechanical energy that causes physiological changes to create a therapeutic benefit) in the Rehabilitation Department by failing to: 1. Ensure that an ultrasound (equipment used to produce high-frequency sound waves that travel deep into tissue and create therapeutic heat) and electrical stimulation (therapeutic treatment that sends electrical impulses from a machine to the body) combination unit (TE 1) was maintained in safe operating condition as required since the annual calibration test (process that ensures the reading and functionality of a device is accurate and in full working order) conducted on 6/25/2025. 2. Ensure that the concerns indicated from the Annual Calibration Safety Test for the ultrasound and TE 1, dated 6/25/2025 were corrected and addressed. The equipment continued to remain in service without repair, replacement, or removal from use. 3. Ensure facility staff were informed that the ultrasound and TE 1 were unsafe to operate after failing the safety test verification on 6/25/2025. This deficient practice had the potential to result in accidental harm, including deep tissue burns, to any residents who could have received the ultrasound modality during therapy. Findings: During an observation and interview on 7/22/2026 at 9:13 AM in the Rehabilitation Gym, the Director of Rehabilitation (DOR) stated the facility used electrical stimulation and ultrasound as modalities for therapeutic treatment. A standing unit with wheels and sound head (TE 1) was observed inside the rehabilitation gym. The DOR stated TE 1 was a combination unit for both electrical stimulation and ultrasound. The DOR stated TE 1 should be calibrated annually to ensure safe use of the unit. The DOR stated an annual calibration was completed last year and the technician was scheduled to come this month for this year's annual calibration. During an observation of TE 1, there was no sign or indication the ultrasound component of TE 1 was not safe to use. During an interview and record review on 7/23/2026 at 10:20 AM with the DOR, the annual calibration safety test verifications for TE 1 dated 6/25/2025 and 7/22/2026 were reviewed. The DOR stated the TE 1 safety test verification dated 6/25/2025 and 7/22/2026 indicated Fail for Verify Current Limiting Function. The DOR stated the facility did not fix or replace any part for TE 1 after the failed safety test verification on 6/25/2025. DOR confirmed the 7/22/2026 safety test verification indicated Fail again for the same test. The DOR stated the technician on 7/22/2026 indicated a wire was faulty and needed to be replaced. The DOR stated TE 1 should still be operable. The DOR stated TE 1 was not taken out of service. During the same interview, the DOR called the vendor and spoke with the Technician Supervisor (Tech 1). Tech 1 stated Fail for the test Verify Current Limiting Function indicated the sound head connected to the ultrasound machine needed to be replaced, because the connection may not provide the correct measurement and data. Tech 1 stated the ultrasound portion of TE 1 was not safe to use, and the sound head had to be replaced. Tech 1 stated the vendor provided a proposal after the 6/25/2025 calibration test and did not hear from the facility to approve the fix. In the same interview, the DOR stated she did not follow up after the 6/25/2025 annual calibration and safety test when the safety test verification indicated Fail. The DOR confirmed no residents on therapy used the ultrasound portion of TE 1 since the 6/25/2025 safety verification test, but any resident on therapy had the potential to use the machine if the ultrasound modality was indicated in therapy treatment. The DOR stated the TE 1 was never taken out of service since 6/25/2025 for the ultrasound component. The DOR confirmed therapy staff were not aware the ultrasound unit could not be safely used. The DOR stated if the ultrasound unit was used on a resident on therapy and it was not safe to use, the ultrasound could cause burns and cause injury on a deeper tissue level. During an interview on 7/23/2026 at 4:42 PM with the Director of Nursing (DON), the DON stated it was important to maintain therapy equipment and ensure the equipment was functional and in good working order. The DON stated it was important for the equipment to be safe and the data feedback was accurate to use the machine effectively. The DON stated TE 1 was an electrical equipment and it could be hazardous for residents using the machine if TE 1 was not working properly. The DON stated it was not acceptable to have unsafe equipment for residents to use. During an interview on 7/23/2026 at 11:39 AM with DOR, the DOR stated the facility did not have a user or manufacturer manual for TE 1. During an interview and record review of the facility's policies and procedures (P&P) on 7/23/2026 at 4:20 PM with Medical Records Director (MRD), the MRD stated the facility did not have any P&P regarding maintenance of therapy equipment. The MRD stated the facility had a policy for general maintenance service. During a review of the facility's P&P revised 1/1/2012, titled Maintenance Service, the P&P indicated the Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on observation, interview and record review the facility failed ensure to store food items in accordance with professional standards for food service safety by food failing to label food items with an open date and/or use by date for one of one facility kitchen. The following items are: -two open packet of tortilla with no use by date -three open packet of tortilla with no open date and use by date -one open bag of parmesan cheese no open date and use by date -one open bag of pepperoni with no use by date -one open bag of French fries with no open date and use by date This deficient practice had the potential to result in growth of microorganisms (disease causing organism) that could cause foodborne illness (food poisoning or food illness due to pathogens (harmful organism that cause illness such as bacteria, viruses) that could negatively affect the health and safety of the residents who consumed the food. Findings: During an initial kitchen tour and interview with the Registered Dietician (RD) on 7/21/2026 at 8:45 AM the following were observed without a label an open date and/or use by date: In the walk-in freezer: -two open packet of tortilla with no use by date -three open packet of tortilla with no open date and use by date -one open bag of parmesan cheese no open date and use by date In Freezer 2: -one open bag of pepperoni with no use by date -one open bag of French fries with no open date and use by date During a concurrent interview on 7/21/2026 at 8:45 AM, the RD stated, it is imperative that all open food items in the kitchen should have an open date and a used by date to ensure proper food rotation, prevent spoilage, and prevent serving expired food to the residents. The RD stated, spoiled and/or expired food had the potential to result in growth of microorganisms, that could cause food borne illnesses to residents that consumed it, which can negatively affect their health and safety. During an interview on 7/23/2026 at 10:15 AM with the Director of Nursing (DON), the DON stated, the facility's policy and procedure for food storage indicated to label and date all food items. The DON stated that the regulation indicates for food items to have an open date and use by date and we follow that regulation to ensure the food we serve are good for consumption. The DON stated, not having a label of an open date and use by date had the potential for the facility to serve food that are spoiled, expired and no longer good for consumption. The DON stated, spoiled and/or expired food had the potential to result in growth of microorganisms which could cause food borne illnesses and GI distress that could negatively affect the health and safety of some of the residents who consumed it. During a review of the facility's policy and procedure (P&P) titled, Food Storage, revised on 11/2022, the policy indicated to label and date all food items. During a review of the Food Code 2022, indicated 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. Indicated READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES.

Based on observation, interviews, and record review, the facility failed to properly dispose of garbage and refuse (food waste and scraps) for one of three metal dumpsters and three of four plastic trash cans were not fully covered with their lids closed due to excess garbage bags and overflowing opened boxes. This was not in accordance with the facility's Waste Management policy and procedure. This deficient practice created the potential to attract birds, flies, insects, pests, and rodents, and increased the risk of spreading infections. Infection can occur when harmful bacteria or viruses enter the body, multiply, and cause illness. These conditions pose a health and safety risk to residents, visitors, and staff in the facility. Findings: During a concurrent observation and interview on 7/22/2026 at 7:35 AM with the Maintenance Supervisor (MS) in the facility's garbage area, one of three metal dumpsters and three of four plastic trash cans were observed not being fully covered with their lids. The lids could not close due to excess garbage bags and overflowing opened used boxes. The MS stated that the trash bins and trash cans should be completely covered with lids closed to prevent rodents, insects, and birds from getting into the trash, as these pests can contribute to the spread of infection. During an interview on 7/23/2026 at 10:06 AM with the Director of Nurses (DON), the DON stated that the facility did not have a specific policy for garbage and refuse disposal. However, the DON explained that the facility's trash bins and trash cans should be completely covered with their lids closed, as failing to do so could attract rodents and other pests that might harbor viruses and/or bacteria, potentially posing a health and safety risk to residents, staff, and visitors. During a review of the facility's policies and procedures (P&P) titled Waste Management, 4/21/2022, indicated: a) dispose of non-regulated waste in appropriate container, when waste bags are 3/4 the full, close bag and dispose bag into a large, covered waste bin, and b) food waste will be placed in covered garbage and trash cans.

Based on observation, interview, and record review, the facility failed to provide timely physical therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function), occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities), and speech-language pathology (SLP, profession that identifies, assesses, and treats speech, language, cognitive communication and swallowing disorders) evaluations for one of 10 sampled residents (Resident 6) as ordered by the physician on 6/26/2026. This deficient practice had the potential to cause a decline in Resident 6's mobility, activities of daily living, and swallowing function due to a delay in provision of PT, OT, and SLP services.Findings: During a review of Resident 6's Face Sheet, the Face Sheet indicated Resident 6 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (disease of the blood vessels, especially blood vessels to the brain) affecting right dominant side, difficulty walking, muscle weakness, and dysphagia (difficulty swallowing). During a review of Resident 6's Minimum Data Set (MDS, resident assessment tool) dated 6/25/2026, the MDS indicated Resident 6 had moderate cognitive impairment mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS indicated Resident 6 had functional limitation in range of motion (ROM, full movement potential of a joint) in one side of the upper extremity (UE, shoulder, elbow, wrist, hand), and one side of the lower extremity (LE, hip, knee, ankle, foot). The MDS indicated Resident 6 required setup assistance with eating, supervision with oral hygiene, upper body dressing, sit to lying and substantial assistance with lower body dressing and bathing. During a review of Resident 6's Order Listing Report dated 7/23/2026, the Order Listing Report indicated an order dated 6/26/2026 for Part B [a type of medical insurance] services - PT, OT, ST. During a review of Resident 6's PT Evaluation and Plan of Treatment dated 7/2/2026, the PT Evaluation indicated Resident 6 had impaired LE strength and required substantial assistance with bed mobility, functional transfers, and walking 15 feet. During a review of Resident 6's OT Evaluation and Plan of Treatment dated 7/2/2026, the OT Evaluation indicated Resident 6 had impaired shoulder ROM and required substantial assistance with toilet transfers and moderate assistance with UB dressing and oral hygiene. During a review of Resident 6's SLP Evaluation and Plan of Treatment dated 7/2/2026, the SLP Evaluation indicated Resident 6 required a puree consistency for swallowing. During an observation and interview on 7/21/2026 at 11:01 AM, Resident 6 was lying in bed with the privacy curtains drawn. Resident 6 stated he used to get exercises but was not receiving exercises anymore. Resident 6 stated he really wanted to do exercises. During a concurrent interview and record review on 7/23/2026 at 9:35 AM with Registered Nurse Supervisor (RNS 2), Resident 6's active orders were reviewed. RNS 2 stated the active orders indicated an order dated 6/26/2026 for Part B services - PT, OT, SLP. RNS 2 stated this was an order for an evaluation and treatment for PT, OT, and SLP due to an insurance change and the nurse would inform the therapy department to complete the order for a PT, OT, and SLP evaluation. During a concurrent interview and record review on 7/23/2026 at 10:41 AM with Director of Rehabilitation (DOR), Resident 6's active orders and therapy records were reviewed. DOR stated Resident 6 had an order dated 6/26/2026 for Part B services - PT, OT, SLP. DOR stated this meant Resident 6 had an insurance change and it was an order to complete a PT, OT, and SLP evaluation. DOR reviewed Resident 6's therapy records and stated PT, OT, and SLP evaluated Resident 6 on 7/2/2026. DOR stated Resident 6 should have been evaluated right away or between 24 to 48 hours after a physician's order. DOR stated PT, OT and SLP did not evaluate Resident 6 until 6 days after the physician ordered the resident to receive an evaluation. DOR stated there was a delay in evaluating Resident 6 for PT, OT, and SLP and it could have delayed Resident 6's ability to return to physical functioning, functional mobility, and any other reason why a resident would require therapy services. During an interview on 7/23/2026 at 4:42 PM with the Director of Nursing (DON), DON stated residents with physician's orders for therapy evaluation should receive a therapy evaluation within 48 to 72 hours. DON stated there was a delay in providing therapy services to Resident 6. During an interview and record review on 7/23/2026 at 4:40 PM with Medical Records Director (MRD), MRD stated the facility did not have any other policy for carrying out therapy evaluation orders other than the policy and procedure titled, Physician Orders. During a review of the facility's policies and procedures revised 8/2020, titled, Physician Orders, the policy and procedure indicated the licensed nurse will confirm that physician orders are clear, complete, and accurate as needed.

Based on observation, interview and record review the facility failed to notify the physician for the significant change in condition for two of five sampled residents (Resident 67 and 24) in accordance with the facility's policy and procedure titled Change of Condition Notification. The facility failed to: 1. For Resident 67, the facility failed to inform the physician for increased skin breakdown and severe itching on the back. This deficient practice had the potential to negatively affect Resident 67's physical comfort and increase the risk of skin breakdown. 2. For Resident 124 the facility failed to notify and follow up with the physician when the resident was found of the floor on 6/21/2026 with right forehead bump measuring 0.5 centimeter (cm) by 0.5 cm This deficient practice placed Resident 124 at potential risk for delays in receiving appropriate monitoring instructions from the physician, which could result in complications not being promptly identified or treated, such as head injury or internal bleeding. Findings: 1. During a review of Resident 67's admission Record (AR) dated 4/23/2026, the AR indicated the facility admitted Resident 67 on 4/23/2026 with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), difficulty in walking. Cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain). During a review of Resident 67's Minimum Data Set (MDS – a resident assessment tool) dated 4/30/2026, the MDS indicated Resident 67 required substantial/ maximal assistance with personal hygiene, putting on/taking off footwear, lower body dressing, shower/bathing self, toileting hygiene. The MDS also indicated Resident 67 required partial/moderate assistance in upper body dressing, and oral hygiene. During a review of Resident 67's History and Physical (H&P) dated 5/1/2026, indicated Resident 67 had the capacity to understand and make decisions. During a review of Resident 67's care plan titled At Risk for Pressure Ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) and Skin Breakdown Related to Limited Mobility revised on 7/14/2026, the care plan included an intervention to assess skin integrity during routine care to identify skin problems. when rendering care and routinely to identify any skin problems. During a review of Resident 67's Medication Administration Record (MAR), dated 7/21/2026, the MAR indicated Resident 67 was administered Benadryl (an over-the-counter medication used to treat allergy symptoms) at 9:57 AM for itching. During an interview on 7/21/2026 at 9:21 AM with Resident 67, Resident 67 stated he had been experiencing severe itching to his back for two days. Resident 67 stated he had informed nursing staff on several occasions that his back was itching. Resident 67 further stated he had been receiving Benadryl, but nothing else has been done and he continued to experience moderate to severe itching. During an observation on 7/24/2026 at 1:30 PM with the License Vocational Nurse (LVN 2), a diffuse (widely spread out through a tissue or an area) rash was observed across the left and right side of. The rash on Resident's 67 back had red and brown flat and circular rash with open dry brown scabs. During an interview on 7/24/2026 at 1:33 PM with LVN 2, LVN 2 stated that the rash had not been reported to LVN2. LVN 2 stated she did not complete a change in condition assessment, notify the physician, and refer Resident 67 to Social Services to obtain a dermatology consultation. During an interview on 7/24/2026 at 1:37 PM with CNA 3, CNA 3 stated Resident 67 had received a shower in the morning, however CNA 3 stated he did not observe the rash during the shower. During an interview on 7/24/2026 at 2:50 PM with the Director of Nurses (DON), DON stated the resident's complaint of itching should have been immediately addressed by nursing through physician notification, implementation of interventions and or revision of care plan. And documentation of a change in condition with monitoring for 72 hours. During a facility's policy and procedure (P&P) titled Change of Condition Notification revised on 8/25/2022, the P&P indicated the facility will promptly notify the physician, and the resident or resident's representative of a change in condition. The P&P further indicated the resident's care plan will be updated to reflect the resident's current status, and the licensed nurse will document each shift for at least 72 hours following the change in condition. 2. During a review of Resident 124's admission Record (AR), indicated that Resident 124 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including metabolic encephalopathy (a change in how the brain works due to an underlying condition), diabetes mellitus (high blood sugar), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (a result of disrupted blood flow to the brain, also known as a stroke). During a review of Resident 124's Minimal Data Set (MDS- a resident assessment tool) dated 5/23/2026, the MDS indicated that Resident 124 was moderately impaired in cognition (decisions poor, cues/supervision required). The MDS also indicated that Resident 124 required partial/moderate assistance (helper does less than half the effort) on rolling left and right, as well as sitting to lying. During a review of Resident 124's Change in Condition Evaluation (COC) dated 6/21/2026, the COC indicated the resident had a fall, and a message was left with the clinician (also known as physician) on 6/21/2026 timed 2:00 AM. During a review of Resident 124's Nursing Progress Notes (NPN) dated 6/21/2026 timed 7:44 AM, the NPN indicated that Resident 124 was noted with a bump on the right forehead measuring 0.5 by 0.5 centimeters (cm). The NPN also indicated that MD (doctor) was called but did not indicate whether the physician responded and or any orders or instructions given from the physician. During a review of Resident 124's NPN dated from 6/21/2026 to 6/30/2026, there was no documentation indicating date and time that any follow up call to the physician or the physician's responses regarding Resident 124's fall occurred on 6/21/2026. During a concurrent record review and interview conducted on 7/24/2026 at 11:30 AM with Licensed Vocational Nurse (LVN) 1, Resident 124's Change of Condition (COC) and Nurse Progress Notes (NPN) were reviewed. LVN 1 stated she had not been instructed to follow up with Resident 124's physician and did not make any follow up calls. She explained that she believed the Registered Nurse Supervisor (RNS) was responsible for notifying the physician regarding the resident's change of condition. LVN 1 further stated she did not endorse the need for follow up to the next shift because she understood it to be the RNS's duty to communicate with the physician. During a concurrent record review and an interview on 7/24/2026 at 1:40 PM with RNS 2, Resident 124's COC dated 6/21/2026 and NPN were reviewed. RN 2 stated she could not find documentation that indicated Resident 124's physician was informed of COC. RN 2 stated LVN and RN shared responsibility on ensuring the physician be notified as soon as possible and obtaining orders for necessary interventions for the resident. During a concurrent record review and interview on 7/24/2026 at 2:00 PM with the Director of Nursing (DON), Resident 124's clinical records were reviewed. DON stated he could not find documentation indicating that Resident 124's physician was informed of the COC following a fall. DON stated leaving a message was not considered as notifying about the situation. DON also stated that RNS has the responsibility on assessing residents at the time COC occurred and LVNs were the primary person for calling the physician and making follow up calls if they did not get response from the first call. DON further stated that by not reaching and notifying the physician, who may have higher clinical thinking, would put resident at risk for not receiving necessary clinical intervention, and that might have a negative impact to the resident's wellness. During a review of the facility's policy and procedure (P&P) Change of Condition Notification in 2022. The P&P indicated that the facility will promptly inform the resident, consult with the resident's physician, when the resident endures a significant change in their condition caused by, but not limited to an accident. The P&P indicated that the facility will ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner.

Based on observation, interview and record review, the facility failed to exercise reasonable care for the protection of the resident's property from loss or theft for one of three sampled residents (Resident 53) who lost her personal wheelchair nine months ago when the facility used her personal wheelchair for other residents that needed a wheelchair. As a result of this deficient practice Resident 53 verbalized feeling sad and did not get out of bed more to mobilize, which could lead in decreased in range of motion, decline in quality of life and psychosocial wellbeing. Findings: During a review of Resident 53's Face Sheet (a summary page that provides key details about a resident), the Face Sheet indicated that Resident 53 was admitted to the facility on [DATE] with diagnoses including but not limited to; polyneuropathy (multiple nerves outside of the brain and spinal column are damaged often causing severe pain), adult failure to thrive (a condition in older adults marked by physical and mental decline), anxiety disorder (a strong feeling of fear, worry, and uneasiness about what might happen in the future), and depression. During a review of Resident 53's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 4/21/2026, the MDS indicated that Resident 53 was mild cognitive impairment and required substantial to maximal assistance from another person for functions of daily living and mobility. The MDS also indicated that Resident 53 uses a wheelchair as her mobility device. During an interview on 7/21/2026 at 10:50AM with Resident 53, Resident 53 stated that her wheelchair has been missing for about nine months which she reported many of the facility staffs' Resident 53 stated that when she was in another room at the facility, a physical therapist would come and take her personal wheelchair and use it for other residents. Resident 53 stated that she would tell them not to take her wheelchair, but they would take it anyway and now it is missing. During a concurrent interview and record review on 7/22/2026 at 8:50AM with Registered Nurse Supervisor (RNS) 1, Resident 53's Personal Effects Inventory Form dated 7/29/2025 was reviewed. The Personal Effects Inventory Form indicated that Resident 53 had a personal wheelchair when she was admitted to the facility. RNS 1 stated that Resident 53 did not have a wheelchair when she changed her room. RNS1 stated that the Personal Effects Inventory Form should be updated when a resident changed room. RNS 1 admitted , she does not know why Resident 53s form was not updated. During an interview on 7/22/2026 at 11:20AM with Social Services Director (SSD), SSD stated that she was just made aware of Resident 53s missing wheelchair about an hour ago and that the department is looking for it. SSD stated that missing personal items could make residents worried and feel bad. During an interview on 7/23/2026 at 2:35PM with the Director of Nursing (DON), the DON stated that the facility ensures residents personal property is kept safe from loss or theft by filling out an inventory list on admission that lists all the residents' personal belongings. The DON stated that when a resident's personal belonging is missing it would psychologically make them feel bad and if it is believed by the resident that the item was stolen, trust can be lost. During an interview on 7/24/2026 at 2:30PM with Resident 53, Resident 53 stated that if her wheelchair had not been missing for almost nine months, she probably would have gotten out of bed more and mobilize more. Resident 53 stated, not having her personal wheelchair made her feel bad and have less trust with staff after this incident. During a review of the facility's policy and procedure (P&P) titled Personal Property, dated 10/2/2025, indicated, The facility will ensure that all resident's personal property is respected, safe guarded, and properly documented. An inventory of personal belongings will be completed upon admission and updated as necessary to reflect additions, removals, or changes.

Based on observation, interview, and record review the facility failed to complete a Minimum Data Set (MDS - a resident assessment tool) for Significant Change in Status Assessment (SCSA) to reflect one of five residents (Resident 11) current condition who experienced a significant change of having a cerebral infarction (happens when a blood clot blocks a vessel in the brain) in accordance with the facility's policy and procedure titled Change in Condition Using Triaged Trace. This failure had the potential to negatively affect the delivery of care and services by delaying the comprehensive reassessment of Resident 11's current condition and the development of appropriate interventions. Findings: During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral infarction, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 11's MDS dated [DATE], the MDS indicated Resident 11's cognition (the ability to process thoughts) was moderately impaired and required partial/moderate assistance with putting on/taking off footwear, shower/bathe self, lower body dressing, toileting hygiene. Supervision/touching assistance with personal hygiene, upper body dressing, and oral hygiene. MDS further indicated Resident 11 required supervision or touching assistance to walk 10 feet and was continent of bowel and bladder. During a review of Resident 11's care plan titled The Resident Has a Decreased Ability to Perform Self-Care Related to Decreased Range of Motion, initiated on 6/9/2026, the care plan identified impaired activity tolerance, impaired balance/safety, impaired coordination, impaired sensation, impaired visual perception, and established the goal for Resident 11 to safely perform all self-care activities. During a review of Resident 11's Activities of Daily Living (ADL) Documentation Survey Report, documentation by Certified Nurse Assistants (CNAs) indicated Resident 11 did not ambulate in the room or outside the room from 6/9/2026 through 6/30/2026. The documentation further indicated bladder and bowel incontinence from 6/10/2026 through 6/30/2026. During a review of Resident 11's physical therapy evaluation dated 6/9/2026, the evaluation indicated Resident 11 was non-ambulatory due to the resident's current condition and safety concerns. The evaluation further identified the need for physical therapy to improve balance, coordination, functional activity tolerance, strength and safety awareness. During an interview on 7/24/2026 at 12:30 PM with Certified Nurse Assistant 3 (CNA 3), CNA 3 stated Resident 11 was no longer able to walk independently with his walker as before the stroke. CNA 3 further stated Resident 11 required increased assistance with activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and staff provided most of the assistance. CNA 3 also stated Resident 11 experienced bowel and bladder incontinence after the stroke, compared to the resident's status before the hospitalization. During an interview on 7/24/2026 at 12:59 PM with the Minimum Data Set Coordinator (MDSC), MDSC stated due to Resident 11's change in condition, including increased ADL assistance, bowel and bladder incontinence, and changes in ambulation following the stroke, a SCSA should have been completed. The MDSC further stated the MDS dated [DATE] did not reflect Resident 11's present condition completing a SCSA would have prompted revision of Resident 11's care plan, informed the interdisciplinary team (IDT - a coordinated group of experts from several different fields who work together) and ensured coordinated interventions to address the resident's current needs and prevent further decline. During an interview on 7/24/2026 at 2:43 PM with the Director of Nursing (DON), DON stated that when a resident experiences a decline in status, such as cerebral infarction, a SCSA should be completed within 14 days to assess the resident's current status. The DON further stated the assessment would ensure the resident's care plan accurately reflected the resident's current needs and interventions to prevent further decline. During a review of the facility's policy and procedure (P&P) titled Change in Condition Using Triaged Trace revised on 10/24/2017, indicated the facility will promptly inform the resident or resident's representative when the resident endures a significant change in their condition caused by as significant change in the resident's physical, mental, or psychological status. The P&P further indicated a new MDS assessment must be completed within 14 days when a resident experiences a significant change in condition. During a review of the facility's policy and procedure (P&P) titled RAI Process revised on 10/4/2016, the P&P indicated the facility will utilize the Resident Assessment Instrument (RAI) process as the basis for accurately addressing each resident's functional capacity and health status.

Based on observation, interview, and record review and the facility failed to develop a person-centered care plan for one of five residents (Resident 67) to address the resident's preferences for activities of choice in accordance with the facility's policy and procedure titled Activities Program. This deficient practice placed Resident 67 to not receive specific resident care and services according to their individual needs that could lead in a decline in the resident's quality of life. Findings: During a review of Resident 67's admission Record (AR) dated 4/23/2026, the AR indicated the facility admitted Resident 67 on 4/23/2026 with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), difficulty in walking. Cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain). During a review of Resident 67's Minimum Data Set (MDS - a resident assessment tool) dated 4/30/2026, the MDS indicated Resident 67 required substantial/ maximal assistance with personal hygiene, putting on/taking off footwear, lower body dressing, shower/bathing self, toileting hygiene. The MDS also indicated Resident 67 activities of preferences were: books, newspapers, and magazines to read, music, keep up with news, get fresh air when the weather is good. During a review of Resident 67's History and Physical (H&P) dated 5/1/2026, indicated Resident 67 had the capacity to understand and make decisions. During a review of Resident 67's Multidisciplinary Care Conference dated 7/23/2026, the Multidisciplinary Care Conference indicated that Resident 67 preferred to stay in his room most of the day and attended activities of Resident 67's choice. During an interview on 7/24/2026 at 1:43 PM with the Activities Director (AD1), AD1 stated Resident 67 did not have an activity care plan in the medical record. AD 1 stated AD 1 was unsure why an activity care plan had not been developed. During a review of the facility's Policy and Procedure (P&P) titled Activities Program revised on 3/27/2025, the P&P indicated an activity plan should be developed and implemented for each resident and integrated into the resident's individualized care plan. The P&P further indicated the care plan should be reviewed at least quarterly.

Based on interview and record review, the facility failed to provide care and services to meet the professional standard of practice for two of 25 sampled residents (Residents 57 and 129) in accordance with the facility's policy and procedure titled Orthostatic Hypotension (low blood pressure [the force of circulating blood pushing against the walls of your body's arteries] reading that is measured by recording blood pressure and heart rate while lying down, sitting and then after standing at 1 and 3 minutes to detect significant drops indicating orthostatic hypotension) and Physician Orders. The facility failed to: 1. Obtain and document Resident 57's orthostatic blood pressure while standing, sitting and lying down on 7/12/2026. 2. Perform and document the first orthostatic BP reading on 7/21/2026 as ordered by the physician. This deficient practice had the potential to result in delayed identification of significant blood pressure changes, including orthostatic hypotension. This could lead to untreated dizziness, increased risk for falls, undetected cardiac instability, and worsening neurological symptoms, especially given Resident 129's history of multiple strokes. Findings: 1. During a review of Resident 57's Face Sheet (FS-an admission record), the Face Sheet indicated Resident 57 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and a loss of interest in activities), paranoid schizophrenia (a disorder that causes a person to have intense fears, false beliefs, and hears things that are not real), and bipolar disorder (a treatable brain disorder that causes extreme shifts in a person's mood, energy, and ability to function). During a review of Resident 57's Minimum Data Set (MDS-a comprehensive assessment and screening tool) dated 5/6/2026, the MDS indicated Resident 57 has moderately impaired cognitive (ability to reason and process information) skills for daily decision making. During a review of Resident 57's Order Listing Report (OLR) dated 7/23/2026, the OLR indicated Resident 57 to have orthostatic blood pressure monitored every Sunday evening. During a review of Resident 57's Medication Administration Record (MAR) dated 7/1/2026 to 7/31/2026, the MAR indicated on 7/12/2026, Resident 57's blood pressure of 112/58 while lying and sitting. The MAR indicated no documented evidence that Resident 57's orthostatic BP for standing and lying down was obtained. During a concurrent interview and record review on 7/23/2026 at 1:30 PM with Registered Nurse Supervisor (RNS) 2, Resident 57's Weights and Vitals Summary indicated blood pressure on 7/12/2026 was taken while the resident was sitting and no BP was taken while lying down. RNS 2 stated, Resident 57's BP while in the lying position was not taken on the evening of 7/12/2026. During an interview on 7/23/2026 at 4:00 PM with the Director of Nursing (DON), the DON stated the likelihood of having the same blood pressure while lying and sitting are slim, but it is possible. The DON further stated the orthostatic BP for Resident 57 on the evening of 7/12/2026 was only measured in the sitting position. DON stated It was important to measure the orthostatic BP of the resident that included lying, sitting and standing to see if there were side effects from antipsychotic medications (any drug that affects brain activities associated with mental processes and behavior) prescribed, monitor how the heart was functioning and make sure there are no sudden drops in blood pressure. 2. During a review of Resident 129's FS, the FS indicated Resident 129 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke - loss of blood flow to a part of the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness or partial paralysis affecting only one side of the body), and syncope (fainting, a brief loss of consciousness and muscle control followed by a quick, full recovery). During a review of Resident 129's History and Physical (H&P), dated 7/15/2026, the H&P indicated Resident 129 has the mental capacity to make and understand medical decisions. During a review of Resident 129's Order Listing Report (OLR) dated 7/23/2026, the OLR indicated Resident 129's orthostatic BP should be measured for three mornings starting on 7/21/2026. During a review of Resident 129's MAR, for the month of July 2026, the MAR indicated orthostatic BP was not done on 7/21/2026. During a review of Resident 129's Nursing Care Plan (CP) dated 7/23/2026, the CP did not indicate the development of a care plan goal for measuring orthostatic blood pressure, interventions implemented and findings while checking orthostatic blood pressure because a care plan for orthostatic blood pressure was not initiated. During an interview on 7/21/2026 at 12:20 PM with Resident 129, Resident 129 stated he was not doing so well, he had worked with physical therapy (skilled, medically necessary services provided by a qualified therapist to diagnose, manage, and treat physical impairments, functional limitations or disabilities) and has been feeling dizzy even when he was laying down. Resident 129 also stated he has had three recent strokes (loss of blood flow to a part of the brain). During a concurrent interview and record review on 7/23/2026 at 1:30 PM with RNS 2, Resident 129's Physician and Telephone Orders Form dated 7/20/2026 was reviewed. The form indicated Resident 129 had physician's orders for orthostatic blood pressure readings for the next three mornings (7/21/2026 - 7/23/2026). The form was acknowledged by another RNS (not identified) on 7/20/2026. RNS 2 stated the first orthostatic blood pressure reading should had been done on the morning of 7/21/2026, but it was not done. RNS 2 also stated, the licensed nurses document after the task was done did not adjust the time to show exactly when the blood pressures were taken. During an interview on 7/23/2026 at 4:00 PM with the Director of Nursing (DON), the DON stated orders received are immediately entered and carried out if able. The physician order for Resident 129's orthostatic blood pressure reading should have started on 7/21/2026. There was no documentation indicating why it was not done on 7/21/2026. The DON further stated it was important for orthostatic blood pressures to be implemented correctly to monitor sudden drops in blood pressure due to medications and to monitor how the heart is functioning by checking the heart rate. The DON stated there was no documentation indicating orthostatic BP and heart rate readings were done minutes apart. During a review of the facility's Policy and Procedure (P&P) titled, Orthostatic Hypotension, dated 1/1/2012, the P&P indicated orthostatic blood pressure will be taken and recorded as ordered by the physician. The P&P also indicated to record: blood pressure with corresponding heart rate with each position change and after three minutes, all observations while measuring orthostatic blood pressures and any teaching given. The P&P also indicated to develop an individualized care plan to address issues related to orthostatic hypotension. During a review of the facility's P&P titled, Physician Orders, dated 8/21/2020, the P&P indicated the licensed nurse is responsible for documenting and carrying out the order

Based on observation, interviews, and record reviews, the facility did not provide the necessary services to maintain adequate oral hygiene for one of three sampled residents (Resident 106). Specifically, the facility failed to ensure CNA 1 performed oral care for the resident after assisting her with her meal. This deficient practice had the potential to place Resident 106 at risk for diseases of the mouth, gums, and teeth, and aspiration (something other than air gets into your airways) of the food pieces in the mouth could further lead to pneumonia (an infection/inflammation in the lungs).Findings: During a review of Resident 106's admission Record (AR), indicated that Resident 106 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease (a hardening of your arteries), dementia (a progressive state of decline in mental abilities) and personal history of transient ischemic attack (TIA- a temporary blockage of blood flow to the brain) During a review of Resident 106's Physician Orders dated 11/28/2025, the order indicated to provide regular standard portion puree texture diet. During a review of Resident 106's Minimum Data Set (MDS - a resident assessment tool) dated 7/2/2026, the MDS indicated that Resident 106 required substantial assistance (helper does more than half the effort). During a review of Resident 106's Care Plan dated 4/30/2025, the Care Plan goal indicated that Resident 106's activities of daily living (ADLs) needs will be met promptly daily. Care plan interventions included encouraging self-care with morning care, oral, and personal hygiene and monitoring resident frequently and anticipate resident needs and meet them promptly. During a concurrent observation and interview on 7/21/2026 at with the Certified Nurse Assistant (CNA) 1, Resident 106 was observed awake, with visible traces of food between teeth and on the gum when she opened her mouth. During an interview with CNA 1, it was confirmed at the bedside that oral care for Resident 106 had not been completed. CNA 1 stated she was expected to offer and assist the resident with oral care after the resident finished her breakfast. During an interview on 7/21/2026 at AM with the Registered Nurse Supervisor (RNS) 2, RNS 2 stated Resident 106 required assistance and monitoring on oral hygiene. RNS 2 stated Resident 106's dental health will be at risk for tooth cavity or gum infection if not done. During an interview on 7/23/2026 at 3:20 PM with the Director of Staff Development (DSD), DSD stated that she was responsible for supervising CNAs and ensuring they provide proper care and assistance to residents. DSD stated oral hygiene is important and assigned CNA for Resident 106 should have provided once the resident was done with her meal. DSD also stated by not having oral hygiene maintained, the resident can be at risk for bad mouth odor, cavities (holes, or areas of tooth decay, that form in teeth surfaces), or even aspirate anything remaining from the gum and that can lead to pneumonia. During a review of the facility's policy and procedures (P&P) titled Oral Care dated 1/1/2012 indicated that all residents receive appropriate oral care daily. P&P also indicated that it is the responsibility of each staff member within nursing department to ensure good oral care for each resident.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 18) who was assessed at risk for developing pressure ulcer (a skin injury due to prolonged unrelieved pressure or friction on the skin and other areas of the body) was provided with a left heel foam dressing (adaptable dressings that provide a cushioning effect, suitable for bony prominences or areas of increased friction) in accordance with the physician's order and the facility's policy and procedures (P&P) titled Pressure Injury Prevention. This deficient practice had the potential to result in development of pressure ulcer and/or skin breakdown, which could negatively affect Resident 's quality of life. Findings: During a review of Residents 18's admission Record (AR), the AR indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included diabetes with diabetic neuropathy (nerve leading to numbness, tingling usually starts in the feet and hands), hemiplegia and hemiparesis (paralysis and partial weakness on one side of your body) affecting the right dominant side, history of stage 1 pressure ulcer of left heel (early warning sign of a pressure ulcer), and generalized muscle weakness. During a review of Resident 18's Order Listing Report (OLR) (Physician Orders) dated 11/7/2025, the report indicated, treatment to left heel to apply foam dressing for wound prevention. During a review of Resident 's Minimum Data Set (MDS, a resident assessment tool), dated 4/17/2026, the MDS indicated Resident 18's cognitive skills (ability to make daily decisions) was moderately impaired. The MDS indicated Resident 18 required substantial/maximal assistance (helper does more than half the effort) toileting, bathing, and lower body dressing. During a review of Resident 18's care plan (CP) dated 1/10/2026, the CP indicated, Resident 18 was at risk for pressure ulcer and skin breakdown related to muscle weakness, diabetes, hemiplegia and hemiparesis, intervention includes, administer treatment as ordered and pressure relieving devices as ordered. During a review of Resident 18's Braden Scale (early identification of patients at risk for forming pressure sores) for Predicting Pressure Ulcer Risk dated 5/27/2026, the record indicated Resident 18 was completely immobile and at risk for developing pressure ulcer. During a concurrent observation and interview on 7/22/2026 at 2:44 PM with Registered Nurse (RN) 2 in Resident 18's room, Resident 18 was lying in bed, her left heel was on top of a pillow and was observed with slight redness and without a foam dressing as indicated in the physician order dated 11/7/2025. RN 2 stated, Resident 18's left heel had slight redness without foam dressing. RN 2 stated, Resident 18 should have the foam dressing on her left heel as ordered because she is immobile and had the potential to develop pressure ulcer. During an interview on 7/23/2026 at 2:30 PM with Director of Nurses (DON), the DON stated, Resident 63 had history of pressure ulcer on her left heel, the foam dressing is used to cushion the left heel for wound prevention. DON stated, not having the foam dressing to the left heel had the potential for Resident 18 to develop a pressure ulcer again. During a review of the facility's policy and procedure (P&P) titled, Pressure Injury Prevention, 7/21/2024, indicated a) the purpose is to prevent the development of pressure injury in resident identified risk b) implement interventions identified in the plan of care which include but are not limited to, use of heel protectors, off- loading pressure from heels and c) risk factors to consider in the plan of care includes diabetes, vascular disease and history of pressure injuries.

Based on observation, interview and record review, the facility failed to provide care and services for one of two sampled residents (Resident 6) with an indwelling urinary catheter (a medical drainage tube used to empty the bladder) to prevent Urinary Tract Infection (UTI- an infection in the bladder/urinary tract) by ensuring the catheter tubing does not touch the floor, in accordance with the facility's Policy and Procedure (P&P) for Suprapubic Catheter (catheter surgically placed into the bladder to drain urine) the Re-insertion and Management and Infection Control - Policies and Procedures. This failure had the potential to result in Resident 6 developing an infection in the urinary tract due to cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) from the floor to urinary catheter. Findings: During a review of Resident 6's Face Sheet (FS) , the FS indicated Resident 6 was admitted on [DATE] with diagnoses that included benign prostatic hyperplasia (BPH - non cancerous growth or enlargement of the prostate gland that can squeeze the urethra and cause lower urinary tract symptoms like a weak urine stream or trouble emptying the bladder), obstructive and reflux uropathy (urinary condition that causes blockage of urine flow or backward flowing urine from the bladder to the kidneys), chronic kidney disease (CKD - a gradual, long-lasting loss of kidney function), and urogenital implants (a man-made medical device placed inside the body to support the urinary or reproductive system). During a review of Resident 6's Minimum Data Set (MDS-a comprehensive assessment and screening tool) dated 6/25/2026, the MDS indicated Resident 6 has moderately impaired cognitive skills (ability to reason and process information) for daily decision making. Resident 6 requires a helper to do more than half of the effort for shower/bathe self, lower body dressing, and putting on/taking off footwear. Resident 6 requires a helper to do less than half the effort for toileting hygiene. During a review of Resident 6's Order Listing Report (OLR) dated 7/22/2026, the OLR indicated to assess Resident 6's urine should be assessed for signs of infection such as cloudiness, sediments and/or odor every shift. During a concurrent observation and interview on 7/21/2026 at 10:43 AM with Certified Nursing Assistant (CNA) 2 in Resident 6's room, the urinary catheter tubing was touching the floor. CNA 2 stated that the urinary catheter tubing was touching the floor and should not be. During an interview on 7/23/2026 at 1:30 PM with Registered Nurse Supervisor (RNS) 2, RNS 2 stated urinary catheter bags are kept in a basin on the floor to prevent part of the urinary catheter from touching the floor to prevent because touching the floor could cause contamination of the catheter and possibly an infection to the residents. During an interview on 7/23/2026 at 4:00 PM with the Director of Nursing (DON), the DON stated the urinary catheter tubing, and bag should not touch the floor. Keeping the urinary catheter off the floor is for infection prevention purposes. During a review of the facility's Policy and Procedure (P&P) titled, Suprapubic Catheter Re-insertion and Management, dated 1/30/2026, the P&P indicated routine care of a urinary catheter includes using the clean technique (a set of practices used in health care to reduce the total number of germs and stop them from spreading) when handling a urinary catheter, monitor for signs of infection and secure the catheter to prevent tension or dislodgement. During a review of the facility's P&P titled, Infection Control - Policies and Procedures, dated 5/19/2022, the P&P indicated to implement the facility's infection control policies and procedures to help prevent and manage transmission of diseases and infections.

Based on observation, interview and record review, the facility failed to maintain accurate medical records in accordance with acceptable professional standards of practice and facility's policy and procedure titled Completion and Correction for one of three sampled residents (Resident 124) when Treatment Nurse (TXN 1) falsified the resident's clinical record by writing a telephone order on 6/23/2026 and signed on Resident 124's Treatment Administration Record (TAR) that treatment was provided on 6/21/2026 when TXN 1 did not work and did not provide care to the resident on 6/21/2026. This deficient practice resulted in the medical record inaccurately representing care provided to Resident 124 that could lead to the health condition to decline.Findings: During a review of Resident 124's admission Record (AR), indicated that Resident 124 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including metabolic encephalopathy (a change in how the brain works due to an underlying condition), diabetes mellitus (high blood sugar), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (a result of disrupted blood flow to the brain, also known as a stroke). During a review of Resident 124's Nursing Progress Notes (NPN) dated 6/21/2026 timed 7:44 AM, the NPN indicated that Resident 124 was found on the floor by nursing staff (unspecified) during round and was noted with a bump on the right forehead measuring 0.5 by 0.5 centimeters (cm- a unit of length in the metric system). The NPN indicated ice was applied and Resident 124's skin was intact. During an observation on 7/21/2026 at 2:45 PM in the resident's room, Resident 124 was observed awake and alert, speech clear, no skin discoloration on the face was noted. During a review of Resident 124's Treatment Administration Record (TAR) dated from 6/21/2026 to 6/30/2026, the TAR was documented with a (check mark) and TXN 1's initial indicating treatment and monitoring were provided to the resident on 6/21/2026. During a review of the facility's Nursing Staffing Assignment and Sign-in Sheet (NSASS) dated 6/21/2026 Shift 7 AM to 3:30 PM, the sign in sheet indicated TXN 2 instead of TXN 1's name and TXN 2 signed in for the treatment nurse assignment. During a review of TXN 1's Timecard Report (TCR), dated 6/16/2026 to 6/30/2026, the TCR indicated that TXN did not work on 6/21/2026. During a concurrent record review and interview with TXN 1 on 7/24/2026 at 11:50 AM, Resident 124's Physician's Orders and TAR were reviewed. TXN 1 stated she falsely documented a telephone treatment order dated 6/21/2026 that indicated the following: Resident 124's Order Listing Report (OLR) dated 6/21/2026, indicated that a treatment order written on 6/23/2026 for treatment to be provided on 6/21/2026 to monitor: Resident 124's right eyebrow for increase in size of discoloration and visual changes, and notify MD (doctor) of any changes; Resident 124's right orbital region for increase size of discoloration and or visual changes and notify MD of any changes. During a follow up interview on 7/24/2026 at 11:50 AM, TXN 1 admitted , she put the telephone order on 6/23/2026, but the dated the order as 6/21/2026. TNX stated she did not provide such treatment on 6/21/2026 because she was not at the facility on 6/21/2026. When asked why she falsely documented the wrong date on the telephone order, TXN 1 looked away and did not answer the question. TXN stated she did not talk to any doctor regarding the treatment order she documented on 6/21/2026 and responded stated, Not all orders required talking to a doctor. During a concurrent review of Resident 124's clinical records and interview with TXN 1 on 7/24/2026 at 12:09 PM, TXN 1 stated that she did not work on 6/21/2026 and did not maintain accurate documentation that reflect actual information in resident's medical record. During an interview on 7/24/2026 at 2 PM with the Director of Nursing (DON), DON stated every staff member was supposed to have knowledge of maintaining accurate medical records. DON stated late entry was usually acceptable if the staff missed documentation instead of falsifying about what the staff did not do. DON stated falsification was not what the facility's practices were. During a review of the facility's policy and procedures (P&P) Completion and Correction dated 3/25/2026, the P&P indicated that any person making direct observations or rendering direct services to the resident will document in the medical record; documentation will reflect medically relevant information concerning the resident and will be documented in a professional manner.

Based on observation, interview and record review, the facility failed to ensure the resident's bedrooms accommodated no more than four residents for eight rooms of 41 rooms (Rooms 2, 19, 23, 26, 39 with five beds in the room, and rooms [ROOM NUMBER] with six beds in the room) in the facility. This deficient practice had the potential to negatively affect the residents' privacy, safety, and quality nursing and emergency care services. Findings: During a review of the Client Accommodation Analysis submitted by the facility on 7/21/2026, the letter indicated the following rooms did not meet the federal requirement of no more than four beds per resident room in a multiple-resident room: From 7/21/2026 to 7/24/2026, during the recertification survey, the following were observed: room [ROOM NUMBER] has five (5) beds with three (3) beds occupied room [ROOM NUMBER] has six (6) beds with six (6) beds occupied room [ROOM NUMBER] has six (6) beds with five (5) beds occupied room [ROOM NUMBER] has five (5) beds with four (4) beds occupied room [ROOM NUMBER] has six (6) beds with six (6) beds occupied room [ROOM NUMBER] has five (5) beds with five (5) beds occupied room [ROOM NUMBER] has five (5) beds with five (5) beds occupied room [ROOM NUMBER] has five (5) beds with five (5) beds occupied During the survey, multiple observations on 7/21/2026, 7/22/2026, 7/23/2026 and 7/24/2026, were conducted at random times from 7:30 AM to 5:00 PM. The residents in rooms 2, 4, 17, 19, 22, 23, 26, and 39 had enough space for individualized beds, bedside tables, overbed tables (an adjustable tablet with lockable wheels designed to roll over a bed or a chair and provide a flat and stable surface), and individualized resident care equipment. During the resident council meeting on 7/22/2026 at 2:43 PM in the facility's activity room, the resident council was interviewed. The residents did not report any concerns related to the room sizes and space for the residents. During a review of the facility's room waivers letter submitted by the Administrator (ADM) on 7/21/2026 indicated Rooms 2, 4, 17, 19, 22, 23, 26, and 39 had adequate space for nursing caring and for wheelchairs, Geri-Chair (a specialized, wheeled recliner chair designed for individuals with limited mobility, particularly seniors) access, and multiple beds per room and do not adversely affect the health and safety of the residents. During a record review of the facility's Active Admissions Last 30 Days on 6/23/2026 a new resident was admitted to room [ROOM NUMBER]. During a review of the facility's policy ad procedures (P&P) titled Room Waivers, dated 1/2015, indicated that the Administrator, Director of Nurses and Social Services will observe the rooms to ensure they are in accordance with the special needs of the resident, and will not have an adverse effect on the residents' health and safety of any resident in the rooms.

Based on observation, interview, and record review, the facility failed to ensure the room space was at a minimum of 80 square feet (sq.ft.- a unit of measurement) for 18 of 41 resident rooms (room [ROOM NUMBER], 17, 19, 22, 23, 26, 27, 28, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39). This deficient practice had the potential to negatively affect the quality-of-care delivery and the ability of the nursing care to safely provide care and privacy to the residents. Findings: During a recertification survey, on 7/21/2026 the facility's Administrator (ADM) requested a room waiver for 18 out of 41 rooms that do not meet the required 80 sq. ft. per resident. The ADM would like to continue to apply for a room waiver for those 18 rooms. During a review of the Client Accommodation Analysis (CAA) dated 7/21/2026, the CAA indicated the following rooms did not meet the required square foot per resident in a multiple resident bedroom. Room #/ # of beds/ # of residents/ Sq. Ft./ Sq. Ft. per resident room [ROOM NUMBER]/ 6 beds/ 6 residents/ 457.35/76.23 room [ROOM NUMBER]/ 6 beds/ 6 residents/ 417.75/69.63 room [ROOM NUMBER]/ 5 beds/ 5 residents/ 334.3/66.86 room [ROOM NUMBER]/ 6 beds/ 6 residents/ 470.5/78.41 room [ROOM NUMBER]/ 5 beds/ 5 residents/ 380/76 room [ROOM NUMBER]/ 5 beds/ 5 residents/ 325/65 room [ROOM NUMBER]/ 3 beds/ 3 residents/ 212.2/70.73 room [ROOM NUMBER]/ 3 beds/ 3 residents/ 223.4/74.46 room [ROOM NUMBER]/ 3 beds/ 3 residents/ 225.3/75.1 room [ROOM NUMBER]/ 3 beds/ 3 residents/ 212.2/70.73 room [ROOM NUMBER]/ 3 beds/ 3 residents/ 225.3/75.1 room [ROOM NUMBER]/ 3 beds/ 3 residents/ 212/70.67 room [ROOM NUMBER]/ 3 beds/ 3 residents/ 212.2/70.73 room [ROOM NUMBER]/ 3 beds/ 3 residents/ 223.4/74.6 room [ROOM NUMBER]/ 3 beds/ 3 residents/ 212.2/70.73 room [ROOM NUMBER]/ 3 beds/ 3 residents/ 223.4/74.46 room [ROOM NUMBER]/ 3 beds/ 3 residents/ 223.4/74.46 room [ROOM NUMBER]/ 5 beds/ 5 residents/ 367.5/73.5 During the recertification survey from 7/21/2026 to 7/24/2025, the rooms were observed, and no issues were identified due to the room size. During a review of the facility's Room Waiver Request Letter (RWR), dated 7/21/2026, the RWR letter listed 18 rooms in the facility that are below the required 80 sq. ft per resident in a multiple resident room. The letter also indicated these rooms do not adversely affect the residents health and safety. During a Resident Council/group interview on 7/22/2026 at 2:43 PM in the facility's activity room with the resident council, no concerns were brought up regarding the room sizes for the residents.

Based on interview and record review the facility failed to ensure a Significant Change in Status Assessment (SCSA) was completed for one of three sampled residents (Resident 1) following a significant change in the residents' condition, including significant weight loss and loss of the ability to ambulate. This deficient practice resulted in an inaccurate Minimum Data Set (MDS) for Resident 1, placing the resident at risk for receiving care and services that did not reflect Resident 1's current clinical condition. Findings: During a review of Resident 1's admission Record dated 7/7/2025, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including DM, Cerebral Infarction (occurs when the blood supply to part of the brain is blocked or reduced), Vascular Dementia (a state of decline in mental abilities resulting from reduced blood to the brain). During a review of Resident 1's History and Physical (H&P) dated 7/1/2026, indicated, Resident 1 does not have the capacity to make medical decisions. During a review of Resident 1's Quarterly Minimum Data Set (MDS - a resident assessment tool) dated 11/28/2025, indicated Resident 1 experienced a weight loss of 10% or more in the last six months and did not walk 50 feet with or without an assistive device. During an interview on 7/22/2026 at 2:53 PM with Certified Nurse Assistant (CNA 1), CNA 1 stated, Resident 1 is not ambulatory and requires two persons assist for transfers. CNA 1 stated staff does most of Resident 1's Activities of Daily Living (ADL- routine tasks activities such as bathing, dressing, and toileting a person performs daily to care for themselves). During an interview on 7/23/2026 at 10:47 AM with the MDS Coordinator (MDSC 1), MDSC 1 stated Resident 1 should have had a SCSA rather than a quarterly assessment since Resident 1 experienced two significant changes in condition that met the criteria for a SCSA. During an interview on 7/23/2026 at 5:41 PM with the Director of Nurses (DON), DON stated that when the change of condition affects more than one area of the resident's health status, it was considered a SCSA and required a care plan revision and for the MDS to be revised and updated. During a review of the facility's Policy and Procedure (P&P) titled Change of Condition Using Triage Trace, dated 10/24/2017, the P&P indicated the facility will complete a new MDS within 14 days when there is a significant change in condition.

Based on observation, interview and record review the facility failed to revise and update resident care plan (CP) for one of three sampled residents (Resident 1) when resident had a change of diet texture. This failure had the potential to result in inaccurate provision of services related to the resident's nutritional needs and swallowing status. Findings: During a review of Resident 1's admission Record dated 7/7/2025, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including DM, Cerebral Infarction (occurs when the blood supply to part of the brain is blocked or reduced), Vascular Dementia (a state of decline in mental abilities resulting from reduced blood to the brain). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/25/2026, the MDS indicated Resident 1's cognitive (the ability to process thoughts) was moderately impaired. The MDS also indicated Resident 1 was dependent on putting on putting on/taking off footwear. Substantial/maximal assistance on personal hygiene, lower/upper body dressing, shower/bathe self, toileting hygiene and supervision with eating. During a review of Resident 1's Order Summary Report, the Report indicated Resident 1 had an order on 2/28/2026 for No Added Salt (NAS) Consistent Carbohydrate (CCHO - consistent, constant, or controlled carbohydrate diet) diet Level 5 Minced and Moist Texture (soft and moist need very little chewing easy to mash with your tongue), level 2 mildly thick consistency (flows off a spoon quickly but slower than water) diet. During an observation on 7/22/2026 at 1:10 PM in Resident 1's room Resident 1 was observed eating a level 5 Minced and Moist Texture (soft and moist need very little chewing easy to mash with your tongue) diet. Family 1 (FM 1) who was present during the observation, stated Resident 1 did not like the texture of the food and was unaware why the change of food texture was done. During a review of Resident 1's Care Plan (CP) titled Resident has Potential for Alteration in Nutrition Secondary to Therapeutic Altered Diet revised on 12/2/2025, the CP indicated Resident 1 was on NAS CCHO level 6 soft & bite-sized texture with interventions for dietary evaluation and explain to the resident the rationale of diet. During an interview on 7/23/2026 at 10:47 AM with the MDS Coordinator (MDSC 1), MDSC stated that when there is a change in a resident's plan of care the care plan should be revised to indicate the resident's current condition. During an interview on 7/23/2026 at 5:41 PM with the Director of Nurses (DON), DON stated Resident 1's care plan should have been revised following the diet texture change to indicate the residents' current needs. During a review of the facility's Policy & Procedure (P&P) titled Person-Centered Care Planning revised 4/24/2025, the P&P indicated that the facility would develop person-centered care plans that identify the services necessary to attain or maintain each resident's highest practicable physical, mental, and psychosocial well-being. The P&P further indicated that the Interdisciplinary Team (IDT - a coordinated group of experts from several different fields who work together) would review and revise the care plan following each quarterly and comprehensive assessment.

Based on interview and record review the facility failed to monitor blood glucose levels for one of three sampled residents (Resident 1) who had diagnosis of Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) had glucose (simple sugar - the body's primary source of energy from food) monitored when Insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) was administered twice a day for 12 days and had physician order with parameters (limits) to hold insulin if glucose was less than 70. This deficient practice resulted in Resident 1 not receiving appropriate daily blood sugar monitoring needed before safely administering insulin and placed Resident 1 at risk for undetected hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), delayed intervention for abnormal blood sugar levels, inappropriate insulin management, and preventable diabetic complications. Findings: During a review of Resident 1's admission Record dated 7/7/2025, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including DM, Cerebral Infarction (occurs when the blood supply to part of the brain is blocked or reduced), Vascular Dementia (a state of decline in mental abilities resulting from reduced blood to the brain). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/25/2026, the MDS indicated Resident 1's cognitive (the ability to process thoughts) was moderately impaired. The MDS also indicated Resident 1 was dependent on putting on putting on/taking off footwear. Substantial/maximal assistance on personal hygiene, lower/upper body dressing, shower/bathe self, toileting hygiene. During a review of Resident 1's Order Summary Report dated 6/17/2025, the Report indicated a physician order for lispro (a fast-acting insulin used to control blood sugar) inject 3 unit subcutaneously (SQ - under the skin in the layer of fatty tissue) two times a day for DM rotate site, hold if blood sugar is less than 70. During a review of Resident 1's Medication Administration Record (MAR) dated 6/1/2026 - 6/30/2026, the MAR indicated insulin was administered twice a day at 11:30 AM and at 4:30 PM without glucose monitoring. The MAR did not indicate a blood glucose result prior to the administration of insulin. Blood glucose on 6/26/2025 was 116, on 6/27/2025 was 151 and on 6/28/2026 was 110. During a review of Resident 1's Care Plan for The Resident has Diabetes Mellitus, dated 4/16/2025, the care plan indicated that Resident 1 would be free from any signs and symptoms of hypoglycemia. The care plan indicated to conduct fasting serum blood sugar as ordered by the physician. During a concurrent interview and record review on 7/23/2026 at 4:30 PM with Registered Nurse 2 (RN 2), Resident 1's MAR dated 6/17/2026 thru 6/28/2026 was reviewed. RN 2 stated the physician order indicated to hold insulin if Resident 1's blood glucose was less than 70 mg/dL. The MAR indicated from 7/17/2026 thru 7/28/2026 the glucose was not monitored, and insulin was still administered twice a day at 11:30 AM and at 4:30 PM. RN 2 stated it is important to monitor glucose levels to prevent hypoglycemia or hyperglycemia. During an interview on 7/23/2026 at 5:41 PM with the Director of Nurses (DON), DON stated the glucose should have been monitored as indicated by the physician's order and must be followed through. The DON stated the physician's order for insulin had parameters for when to administer and hold insulin, therefore Resident 1's blood sugar should have been obtained prior to insulin administration. During a review of the facility's policy and procedure (P&P) titled Physician Orders dated 8/21/2020, indicated, the License Nurse will confirm that physician orders are clear, complete and accurate as needed. The P&P indicated that medication orders will include condition or diagnosis for which medication is ordered.

Based on interview, and record review the facility failed to ensure one of three sampled residents (Residents 1) were free from physical abuse by Certified Nurse Assistant (CNA) 1 by failing to: 1. Protect Resident 1 when Responsible Party (RP) 1 observed CNA 1 being rough during Resident 1 ' s peri care (also known as perineal care, refers to the cleaning and maintenance of the genital and anal areas), on 3/14/2025 and informed CNA 1 to be gentler. RP 1 reported to the facility ' s Infection Preventionist (IP) Nurse witnessing CNA 1 was rough during Resident 1 ' s peri care and complained of vaginal pain on 3/14/2025. 2. Protect Resident 1 from further abuse by CNA 1 when IP Nurse and Licensed Vocational Nurse (LVN) 1 allowed CNA 1 to continue caring for Resident 1 on 3/14/2025 and the next day, 3/15/2025. On 3/15/2025, RP 1 found Resident 1 in distress as reported by Resident 1 ' s roommate (Resident 2), who witnessed Resident 1 screaming, in distress and verbalized pain, while CNA 1 performed peri care towards Resident 1. CNA 1 continued to ignore Resident 1's screams and verbalization of pain on 3/15/2025 during peri care. These failures resulted in Resident 1 ' s rights violated when Resident 1 screamed and cried in tears and verbalized pain in the vaginal area during peri care and feeling scared towards CNA 1. Resident 2, verbalized being scared and uncomfortable on 3/15/2025, upon witnessing and hearing Resident 1 cried and screamed while CNA 1 rendered care to Resident 1. Findings: 1. During a review of Resident 1 ' s Admission Records (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included traumatic subdural hemorrhage (a collection of blood between the brain and its outer covering due to a head injury, leading to a temporary or prolonged loss of awareness), Type 2 Diabetes( high blood sugar), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1 ' s History and Physical (H&P, a comprehensive physician ' s note regarding the assessment of the resident ' s health status), dated 3/13/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 3/20/2025, the MDS indicated the resident was severely impaired in cognition (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 1 was dependent (helper does all the effort) with rolling to left and right, sit to lying, toilet transfer, tub/shower transfer. 2. During a review of Resident 2 ' s AR, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included joint replacement surgery (a surgical procedure that replaces a damaged joint with an artificial implant), hypertension (high blood pressure), and hyperlipidemia (high cholesterol). During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated the resident cognition is intact. During a review of Resident 2 ' s History and Physical (H&P, a comprehensive physician ' s note regarding the assessment of the resident ' s health status), dated 3/7/2025, indicated Resident 1 is alert oriented, thought process, thought content without any abnormal thoughts, delusions, or hallucinations, normal cognition including orientation, attention, and memory, normal insight and judgment. During review of facility document titled Nursing Staffing Assignment and Sign in Sheet dated 3/14/2025 indicated CNA 1 was assigned to care for Resident 1 from 7 AM to 3 PM. During review of facility document titled Nursing Staffing Assignment and Sign in Sheet dated 3/15/2025 indicated CNA 1 was assigned to care for Resident 1 from 7 AM to 3 PM. During review of a facility document titled Alleged abuse dated 3/15/2025 timed at 4 PM, the document indicated the Director of Nurses (DON) spoke to [RP 1] who claimed she saw [CNA 1] performing peri care with Resident 1. The document indicated [RP 1] claimed that [CNA 1] wiped Resident 1 with the washcloth repeatedly in a rough manner. The document indicated [RP 1] claimed she told [CNA 1] to be gentle, but [CNA 1] ordered her [RP 1] out of the room, closed the curtain and continued with the care. The document indicated [RP 1] claimed [CNA 1] later came out of Resident 1 ' s room with the dirty briefs. The document indicated [RP 1] stated she did not like how CNA 1 responded so RP 1 called the police. During a review of Resident 1 ' s Care Plan (CP) dated 3/13/2025, the CP indicated Resident 1 ' s ADL (activities of daily living) function rehabilitation potential altered manifested by requires cues, reminders, and supervision ADL assistance needed: personal hygiene, toileting, bathing. The interventions included, Do not rush resident, allow enough time to complete task at own pace, explain all necessary procedure prior to rendering care and treatment plan. During a review of Resident 1 ' s Care Plan (CP) dated 3/15/2025, the CP indicated Resident 1 was At risk for psychosocial distress (a set of painful mental and physical symptoms that are associated with normal fluctuations of mood in most people) related to allegations by [RP 1] that staff [CNA1] was rough during care with interventions that included, Change caregiver to ensure immediate safety, monitor for psychosocial distress manifested by tearfulness, fearfulness related allegation of roughness. During a review of the Police Report dated 3/15/2025 timed at 5:48 PM, the Report indicated on Saturday, 3/15/2025 at approximately 6 PM, Police Officer responded at the facility regarding an abuse investigation concerning Resident 1. The Report indicated Resident 1 speaks a foreign language. On Friday 03/14/2025 at approximately 9 AM, [RP 1] visited Resident 1 at the facility. [RP 1] entered the room and noticed [Resident 1] was in distress and grasping for air attempting to say something. Resident 1 was in pain, stressed out, and agitated. [Resident 1] said CNA 1 was mistreating her. [RP 1] added that she witnessed CNA 1 aggressively grabbed her [Resident 1] by the arm, attempting to move her on her side to clean the resident ' s vaginal area. [RP 1] stated [Resident 1] was recovering from a dislocated shoulder and had fragile muscle. [RP 1] stated [CNA 1] was rough when cleaning [Resident 1] and ultimately causing pain. [RP 1] stated [CNA 1] showed no interest in treating [Resident 1] in a fair manner. [RP 1] asked [CNA 1] about what was going on, when [CNA 1] quickly closed the curtains on [RP 1]. [RP 1] reported the incident. The next day, Saturday 3/15/2025 at approximately 9 AM, [RP 1] went back to the facility. [CNA 1] was in the room changing [Resident 1] before she arrived. When [RP 1] arrived, she observed Resident 1 in distress again about to cry and took RP 1 some time to calm Resident 1 down. Resident 2 (Resident 1 ' s roommate) stated she heard Resident 1 screaming in pain before [RP 1] had arrived. [Resident 2] stated [CNA 1] continued to ignore [Resident 1] screams, closed the curtain and walked out of the room. During a review of an electronic (e-mail) mail sent by the DON on 3/28/2025 timed at 5:03 PM, the e-mail indicated the DON had just completed Resident 1 ' s roommate ' s interview with the help of a translator and would need to further investigate. The e-mail indicated the DON called CNA 1 and placed CNA 1 on administrative leave (a temporary, paid or unpaid, suspension of an employee's duties, typically initiated by an employer for specific reasons) pending further investigation. During an interview on 3/28/2025 at 9:40 AM with Resident 1, Resident 1 stated, CNA 1 hurt her many times. Resident 1 stated CNA 1 hold her body very hard and rough, and clean her vaginal area very rough. Resident 1 nodded her head and stated Yes in Resident 1 ' s primary language, when asked if she was scared with CNA 1. During an interview on 3/28/2025 at 9:50 AM with RP 1, RP 1 stated that on 3/14/2025, on a Friday at around 9 AM, RP 1 came to the facility to visit Resident 1. RP 1 stated when she entered Resident 1 ' s room, the privacy curtains were pulled back. RP 1 stated she heard Resident 1 moaning, so RP 1 opened the privacy curtain and saw CNA 1 was cleaning Resident 1. RP 1 stated CNA 1 asked her to get out and close the curtain, so RP 1 introduced herself and informed CNA 1 that she is Resident 1 ' s responsible party. RP 1 stated CNA 1 did not listen to her and still informed RP 1 to close the curtain and get out. RP 1 stated she closed back the privacy curtain but stayed inside the room. RP 1 stated that after a few minutes, RP 1 heard Resident 1 saying in her primary language You hurting me, it hurts. RP 1 stated she opened the privacy curtain and asked CNA 1 to be gentle, but CNA 1 continued wiping Resident 1 ' s peri area with the towel (wash cloth) repeatedly in a rough manner. RP 1 stated CNA 1 did not stop even after RP 1 had approached her. RP 1 stated that when CNA 1 finished Resident 1 ' s peri care, CNA 1 just left the room with no explanation. During the same interview on 3/28/2025 at 9:50 AM, RP 1 stated that on that same day (3/14/2025) at around 11 AM, the Infection Preventionist (IP) nurse came in and RP 1 reported witnessing CNA 1 was rough during Resident 1 ' s peri care and Resident 1 complained that her vagina hurts. RP 1 stated that IP nurse informed her that she would inform Licensed Vocational Nurse (LVN) 1. RP 1 stated that CNA 1 continued to be assigned to Resident 1 on 3/14/2025 until the end of the AM shift, up to the afternoon (7 AM to 3 PM). RP 1 stated CNA 1 was still the assigned CNA who assisted Resident 1 with incontinence care (refers to cleaning and drying of the perineal area after involuntary leakage of urine) in the afternoon. During the same interview on 3/28/2025 at 9:50 AM, RP 1 stated the next day, 3/15/2025, RP 1 stated she came back to the facility to visit Resident 1 at around 9 AM. RP 1 stated she found Resident 1 in tears, crying, and gasping for words. RP 1 stated Resident 1 informed RP 1 that CNA 1 was very rough during peri care and turned her from side to side forcefully. RP 1 stated she reported Resident 1 ' s allegations to Registered Nurse (RN) 1 on the same day, 3/15/2025 at around 10 AM. RP 1 stated that RN 1 did not reassure her or Resident 1 that CNA 1 ' s roughness against Resident 1 will not happen again. RP 1 stated RN 1 did not inform her and Resident 1 what interventions RN 1 would do to prevent the incident from happening again. RP 1 stated that RN 1 assigned another CNA to Resident 1 around 12 PM, on 3/15/2025. RP 1 stated she tried to call the DON but was unsuccessful. RP 1 stated she called the police on 3/15/2025 between 4 to 5 PM, because she was concerned for Resident 1 ' s safety. RP 1 stated the police arrived at the facility on 3/15/2025 and the police was there for a while. RP 1 stated the DON called her after the police left the facility and informed her that what CNA 1 did was Bad customer service. During an interview on 3/28/2025 at 10:34 AM with CNA 2, CNA 2 stated on 3/15/2025 at around 12 PM, CNA 2 was informed by RN 1 that her assignment had changed, and CNA 1 would be assigned to Resident 1. During an interview on 3/28/2025 at 10:45 AM with CNA 1, CNA 1 stated she was assigned to Resident 1 on 3/14/2025 and 3/15/2025, during the AM shift, 7 AM to 3 PM. CNA 1 stated Resident 1 is confused and speaks in the resident ' s primary language. CNA 1 stated she does not speak and understand Resident1 ' s primary language. CNA 1 stated that during care Resident 1 would usually moan and say something in her primary language that she did not understand. CNA 1 stated that on Friday, 3/14/2025 at around 9 AM was the first time she had Resident 1 assigned to her. CNA 1 stated that while she was changing Resident 1 ' s incontinence brief, the privacy curtain was closed. CNA 1 stated that someone came into the room and pulled the curtain and stated she was RP 1. CNA 1 stated she told RP 1 to close the curtain so she can finish cleaning up Resident 1. CNA 1 stated she closed the curtain then Resident 1 said something in her primary language and then RP 1 opened the curtain again. CNA 1 stated RP 1 told her that Resident 1 was saying that it hurts, and RP 1 told her to just take it easy. CNA 1 stated she said Okay. CNA 1 stated that later the same day, she went back to Resident For the second change. During the same interview on 3/28/2025 at 10:45 AM with CNA 1, CNA 1 stated that on Saturday, 3/15/2025, CNA 1 was assigned back to Resident 1. CNA 1 stated she performed peri care and changed Resident 1 ' s incontinence brief in the morning at around 9 AM. CNA 1 stated that later that day, the charge nurse (RN 1) called CNA 1 and stated she would be removed from that assignment with Resident 1. CNA 1 stated she did not get any report if Resident 1 required one person or two-person assistance for ADLs and did not get a report how Resident 1 communicate and the primary language that she speaks. CNA 1 stated she cleaned Resident 1 ' s peri area with a towel. CNA 1 stated that she was trying to finish Resident 1 ' s peri care that ' s why she did not stop, even if RP 1 approached her. CNA 1 stated that some residents are sensitive during peri care. During an interview on 3/28/2025 at 11:22 AM with LVN 2, LVN 2 stated that if the family member is the RP, the family member has the right to be present during the resident ' s care. LVN 2 stated that if CNA 1 did not understand Resident 1 ' s primary language, CNA 1 should find someone that speaks Resident 1 ' s language or ask RP 1 to help. LVN 2 stated if Resident 1 reported that it hurts during care, the staff or CNA 1 should call another staff to help with Resident 1 ' s ADL care and bed mobility (turning/repositioning). During an interview on 3/28/2025 at 12:08 PM with the IP Nurse, the IP Nurse stated on 3/14/2025 at around 11 AM, RP 1 reported to her that CNA 1 was rough with Resident 1 during peri care. The IP Nurse stated she informed LVN 1 on 3/14/2025. During an interview on 3/28/2025 at 12:30 PM with LVN 1, LVN 1 stated she was assigned to Resident 1 on 3/14/2025 during the AM shift, from 7 AM to 3 PM. LVN 1 stated on 3/14/2025 between 8 AM to 12 PM, the IP nurse reported to her that CNA 1 was rough with Resident 1 during peri care and RP 1 was not happy with the care. LVN 1 stated she did not talk to RP 1 or Resident 1 regarding their concern. LVN 1 stated she talked to CNA 1 and ask her to be gentler. LVN 1 stated some residents are more sensitive than others. LVN 1 stated she did not change CNA 1 ' s assignment and did not investigate and reported the allegation to the abuse coordinator, the Administrator. LVN 1 stated she did not document Resident 1 or RP 1 allegations towards CNA 1. LVN 2 stated she is a mandated reporter; however, she did not consider being rough as an allegation of abuse. During an interview on 3/28/2025 at 1:27 PM with RN 1, RN 1 stated on 3/15/2025 between 10 AM and 11 AM, RP 1 reported to her that CNA 1 was rough with Resident 1 when cleaning the peri area with a towel, and she was not happy and comfortable with CNA 1. RN 1 stated she assigned CNA 2 to Resident 1. RN 1 stated she did not see being rough as a form of abuse. RN 1 stated CNA 1 worked the whole shift on 3/15/2025 stated she did not report to the DON or ADM at that time (3/15/2025). RN 1 stated in the afternoon of 3/15/2025, RP 1 called the police, and the police showed up at the facility around 4 PM and that was the time, LVN 1 decided to report to the DON. RN 1 stated the DON informed RN 1 to file an allegation of abuse and investigate. During an interview on 3/28/2025 at 1:46 PM with the DON, the DON stated being rough is subjective (something is based on or influenced by personal feelings, opinions, or perspectives) and has a broad meaning. The DON stated if he would have received a complaint/report from a resident or family, that a facility staff was being rough with a resident, he would interview the resident and the family. The DON stated he would investigate and based on the findings he would know if it was abuse or not. The DON stated he would expect his staff to do the same. The DON stated if staff does not understand the resident during care, for example because the resident speaks a different language, the staff, like CNA 1 should get an interpreter to help them. During an interview on 3/28/2025 at 4:07 PM with Resident 2, Resident 2 stated she was roommate with Resident 1 on 3/15/2025. Resident 2 stated on 3/15/2025, after breakfast at around 9 AM, Resident 2 heard Resident 1 screaming and speaking in her language, You are killing me, stop. Resident 2 stated she speak and understand Resident 1 ' s language. Resident 2 stated she was sitting in bed and look through the curtain and saw Resident 1 lying in bed and CNA 1 was cleaning her. Resident 2 stated CNA 1 closed the curtain right away and she was not able to see anything anymore and just heard Resident 2 screaming. Resident 2 stated that for more than five minutes, Resident 1 was screaming You killing me. Resident 2 stated that after a few minutes, she saw RP 1 come and Resident 2 reported the incident to RP 1. Resident 2 stated during the night shift, there was another CNA, CNA 3 who assisted Resident 1 with cleaning and peri care, but she did not hear Resident 1 complained at all. Resident 2 stated this incident when Resident 1 cried and screamed while CNA 1 assisted Resident 1 made her scared and uncomfortable. Resident 2 stated she was planning to live at a nursing home in the future but after the incident she witnessed with Resident 1, Resident 2 would not consider living in the nursing home for long term in the future. During an interview on 4/1/2025 at 2:21 PM with the DON, the DON stated he interviewed the roommate, Resident 2 for the first time on 3/28/2025, with the help of a translator, and see the need for further investigation. The DON stated he placed CNA 1 on administrative leave pending further investigation on 3/28/2025. The DON stated CNA 1 worked on 3/14/2025, 3/15/2025, from 7 AM to 3 PM, but suspended at the end of shift on 3/15/2025. The DON stated CNA 1 worked on 3/18/2025, 3/19/2025, 3/20/2025, 3/21/2025 and 3/22/2025, 3/25/2025 and 3/26/2025, 3/27/2025, and 3/28/2025 during the AM shift (7 AM to 3 PM) and suspended on 3/28/2025 at the end of the shift, for further investigation. During a review of facility policy & procedure (P&P) titled Abuse - Prevention, Screening, and Training Program revised July 2018, the P&P indicated To address the health, safety, welfare, dignity, and respect of residents by preventing abuse, neglect, misappropriation of resident property, exploitation, and mistreatment .Abuse is defined as the willful, deliberate (intentional) infliction of injury, unreasonable confinement (the state of being forced to stay in a closed space) . not required to treat symptoms and/or imposed for the purposes of discipline or convenience, intimidation . mistreatment, and injuries of unknown source or punishment with resulting physical harm, pain, or mental anguish . During the review of facility P&P titled Abuse Prevention and Management revised 05/30/2024, the P&P indicated The Facility does not condone (to forgive or approve) any form of resident abuse, neglect, misappropriation of resident property . and/or mistreatment . Reports of resident abuse, mistreatment, neglect . or injuries of an unknown source, and any suspicion of crimes are promptly reported and thoroughly investigated. During a review of facility P&P titled Residents Rights revised 01/01/2012, the P&P indicated Residents of skilled nursing facilities have a number of rights under state and federal law. The facility will promote and protect those rights. Residents have freedom of choice, as much as possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules and regulations and applicable state and federal laws governing the protection of resident health and safety.

Based on observation, interviews, and record reviews, the facility failed to implement the facility's policy and procedure to prevent, protect, report timely and thoroughly investigate the any allegation of abuse for one or the three sampled residents (Resident 1) who reported to the facility on [DATE] that a certified nursing assistant who provided care to him during ADL (activities of daily living) was rough but dismissed his request even after he requested from the staff to be gentle due to his severe contractures (a fixed tightening of muscle, tendons, ligaments, or skin that prevents normal movement of the associated body part that result in pain) of the arms and legs. As a result, Resident 1 sustained an acute impacted fracture (sudden broken bone pushed together in broken pieces due to traumatic injury) of the left upper arm and was displaced (bone was out of its normal position) causing the resident unbearable pain and discomfort and hospitalization . Findings: During a review of Resident 1's Admission Record (Face Sheet), the facility admitted Resident 1 on 5/2/2023 with diagnoses including hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated), weakness, polyarthritis (arthritis [conditions that cause joint pain and inflammation] that affects five or more of your joints), muscle wasting (a condition where muscles lose mass and strength) and muscle atrophy (the loss of muscle tissue, leading to a decrease in muscle mass and strength). During a review of Resident 1's History and Physical (H&P), dated 5/2/2023 indicated, Resident 1 had the mental capacity to make medical decisions. During a review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 2/5/2025, indicated the resident's cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired, and required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) on toileting, dressing and personal hygiene. The MDS indicated Resident 1 had functional limitations in the upper and lower extremities. During a review of Resident 1's care plan for arthritis, not dated, indicated to prevent Resident 1 from trauma to joint x 90 days, the interventions indicated the facility will provide careful handling during care, avoid overexertion to reduce discomfort, gently provide range of motion (ROM) exercises during care. During a review of Resident 1's Change in Condition (COC) Evaluation Form, dated 3/7/2025, timed at 11:36 AM, Resident 1 was noted with discoloration and bruising on the upper part of the left arm but denied feeling any pain. To prevent further movement of the affected arm, staff placed a rolled-up blanket for support. An ice pack was offered to help with swelling, but the resident declined. The doctor and Director of Nursing (DON) were notified, and the doctor ordered an emergency (STAT) X-ray of the left shoulder and upper arm to check for any fractures or injuries. During a review of the X-ray Result report dated 3/7/2025 timed at 2:59 PM, indicated Resident 1 had a fracture in his left upper arm bone near the shoulder that was described as acute impacted and displaced fracture. A review of the physician order dated 3/7/2025, not timed, indicated to transfer Resident 1 to the hospital due to left shoulder fracture. During a review of Resident 1's Progress' Note, dated 3/7/2025 at 9:38 AM, the Progress Note indicated Resident 1 has a new aching pain in the left upper arm, rated as moderate 5/10 (pain scale 0-no pain and 10-severe pain). The note indicated Resident 1's pain occurs occasionally, has rarely affected sleep, and has sometimes limited Resident 1's daily activities and the resident has voiced complaints of pain. A review of the GACH dated 3/7/2025 timed at 8:19 PM indicated to refer Resident 1 to an orthopedic surgeon (doctors specialized in diagnoses, treatment, and performs surgery on conditions affecting the musculoskeletal system including bones, joints, ligaments, tendons, muscles, and nerves) as soon as possible, ideally one-week further evaluation on the proximal humerus fracture found on X-ray today which sustained last week. The GACH discharge record indicated to administer Tramadol 50 milligrams tablet to be given by mouth every six hours as needed for three times daily. During a review of Resident 1's Progress' Note, dated 3/7/2025 at 9:29 PM the Progress Note indicated Resident 1 was being monitored after a left shoulder fracture. Resident 1 arrived in the facility stable, alert, and able to communicate. Resident 1 reported mild pain (3/10) and was prescribed Tramadol (a pain medication) but chose to take medication until bedtime. Resident 1 had bruising present on the left upper arm, unable to move the arm due to a prior contracture, and there was no swelling noted. Two staff members assisted Resident 1 with care for safety, and repositioning was done every two hours for comfort and skin protection. Resident 1's medications have been well tolerated. During a review of the investigation report dated 3/7/25, timed 12 midnight, indicated Resident 1 had pain level of 7/10 and skin discoloration. The report indicated Resident 1 reported that last week before he was sent to the hospital a different guy came to change him who was very rough from the beginning. Resident 1 stated I said please be gentle, I have body pain due to my arthritis and he said, shut up. I will change you the way I change other people. He turned me to the side and that was when he really pulled me by my arm. It hurt so bad. I screamed. He said shut up. The he pushed me hard. It was very painful. He told me to turn. I told him I cannot, and he purposely pulled my legs open. I cannot open my legs because of arthritis. I hurt so bad. The report indicated Resident 1 said something in a foreign language and when asked the guy what he said, He said I am finished with you and walked away. During a concurrent observation and interview on 3/11/2025 at 9:50 AM, with Resident 1, in Resident 1's room, Resident 1 was observed lying on his bed with visible discomfort and extensive bruising and discoloration in various shades of deep purple, red, and yellow on his left elbow, arm and shoulder with contractures on all extremities. In an interview Resident 1 stated, he was feeling discomfort and pain on the left shoulder. Resident 1 stated he sustained an injury while receiving care from a CNA (CNA 1) who was unfamiliar to him. Resident 1 stated, I have severe contractures, so I need a bit more help and time, but he didn't know that. I told him but he dismissed me. Resident 1 stated recalled telling the CNA 1 to be gentler but CNA 1 dismissed me and continued repositioning him forcefully. Resident 1 stated he has severe contractures and requires additional time and assistance with care, but CNA 1 did not appear to know about his condition and handled him roughly, causing pain. Resident 1 explained due to his pre-existing arthritis and chronic pain, he did not realize the severity of the injury until Friday 3/7/2025, when the pain became unbearable. Resident 1 stated he then informed the nurses who assessed him and facilitated his transfer to the hospital in which an X-rays confirmed fractures in his left shoulder. During an interview of Resident 1's roommate, Resident 2, on 3/11/25, at 10:15 AM, Resident 2 stated while he was in the room with Resident 1, he heard CNA 1 interacting with Resident 1 on multiple occasions and observed CNA 1 handling Resident 1 roughly. Resident 2 stated he could hear Resident 1 expressing discomfort during care by CNA 1 and CNA1 did not request assistance from other staff when attending to Resident 1. During an interview on 3/11/2025 at 11:25 AM, CNA 2 stated on 3/7/2025, Resident 1 was observed with bruising on the elbow that extended to the shoulder. CNA 2 stated Resident 1 informed him that Resident 1 had been rough while giving him care which he reported to the charge nurse on the same day. During an interview on 3/11/2025 at 2PM with the DON stated Resident 1 denied falling and only reported pain on the left shoulder on 3/7/25, the attending physician was notified, and the resident was transferred to the hospital for surgical evaluation. The DON stated the resident returned to the facility on the same day and was ordered to be administered pain medication and referral to the orthopedic surgeon. The DON stated he initiated the investigation on 3/7/2025 but did not interview CNA1 who matched the description that the resident reported and did not suspend the CNA1 to work since CNA1 just returned to work on today (3/11/2025). During a concurrent interview and record review 3/11/2025 at 2:30 PM with the DON indicated the Facility Reported Incident (FRI) intake (a report provided by the facility to the Department of Public Health), dated 3/10/2025 timed at 1:37 PM, indicated the facility reported to the an allegation of injury of unknown origin related to Resident 1 who reported on 3/7/2025 at 10 AM that Resident 1 had contractures, discoloration on the left upper arm and refused to be touched by the DON. The FRI report did not indicate Resident 1's report of allegation of abuse. During an interview on 3/11/2025 at 3:15 PM, with CNA 1, CNA 1 denied handling Resident 1 roughly and claimed he assisted Resident 1 multiple times. CNA 1 stated that he used a sheet to reposition the resident rather than pulling his arms and asking a staff to assist with repositioning Resident 1. CNA 1 stated he did not ask any staff to assist with repositioning Resident 1.CNA 1 stated repositioning Resident 1 with significant mobility limitations required maximum assistance. CNA 1 was unable to explain how the resident sustained visible injuries and denied hearing any complaints of pain at the time of care. During an interview on 3/11/2025 at 3:30 PM with the DON, the DON stated that CNA 1 should not have been rough with Resident 1. The DON stated that proper care protocols were not followed, which contributed to the resident's injury. A review of the investigation report dated 3/11/2025, not timed, indicated the DON went to Resident 1's room with CNA 1 without exchange of words. Then CNA 1 walked out. The DON came back and asked Resident 1 if that was the CNA. The report indicated Resident 1 confirmed that CNA1 was the staff that took care of him and was rough. DON reassured Resident of his safely. A review of facility's policy and procedure (P&P) titled Abuse-Prevention, Screening, & Training Program revised on July 2018, indicated the facility does not condone any form of resident abuse, The P&P indicated the facility conducts mandatory staff training programs during orientation, annually and as needed on recognizing abuse, to whom and when to report without fear of reprisal. The P&P indicated The facility identifies, corrects, and intervenes in situations in which abuse, neglect, exploitation, misappropriation of resident property/and or mistreatment is more likely to occur. The P&P indicated The facility provides, and staff sign an acknowledgement of their responsibility to report alleged or suspected abuse, neglect, exploitation, misappropriation of resident property/and/or mistreatment. A review of facility's P&P titled Abuse-Reporting & Investigations revised on May 2018, indicated To protect the health, safety, and welfare of Facility residents by ensuring that alt reports of resident abuse, mistreatment, neglect, exploitation or injuries of an unknown source and suspicion of crimes are promptly reported and thoroughly investigated. The P&P indicated The administrator or designated representative conducting the investigation will interview individuals who may have information relevant to the allegation or suspected crime; Individuals who may have information relevant to the allegation or suspected crime are the resident, witnesses to the incident, other residents under the care of the staff member involved, roommates, family, visitors, etc.

Based on interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1) with diagnosis of Diabetes Mellitus (DM, a chronic disease where a person has high blood sugar [glucose] levels because the body does not produce or use insulin [a type of hormone] normally and required blood sugar monitoring and/or medications to lower blood sugar levels) by failing to ensure to: 1. All appropriate discharge orders for diabetes management from the General Acute Care Hospital (GACH 1) were verified with the attending physician/Medical Doctor (MD) 1 upon admission to the skilled nursing facility on [DATE]. 2. The Director of Nursing (DON) or designee thoroughly reviewed Resident 1's medical history of DM and discharge orders from the General Acute Care Hospital (GACH) 1 that indicated resident was receiving Insulin (medication given by injection to lower blood sugar level) prior to admission to the facility and verified with the physician if blood sugar monitoring and/or Insulin should be continued to be administered to the resident while residing in the facility. 3. The licensed staff verified Resident 1's admission orders and notified the physician that resident with DM did not have orders to monitor the resident's blood sugar or if the resident needed to continue insulin to prevent hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar). 4. Ensure plan of care was implemented by ensuring Resident 1 was monitored for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) from the date of admission to the facility on [DATE] and discharged from the facility on [DATE] (a total of six days). As a result of this deficient practice Resident 1 was transferred to the GACH 1 via 911 (an emergency number for medical assistance) due to altered level of consciousness and was admitted to the emergency room (ER) and with blood sugar of 823 (normal blood sugar level is between 70 to 100) mg/dL (milligrams per deciliter, a unit of measurement). The resident was transferred to ICU (intensive Care Unit- a unit in the hospital for residents with life threatening condition) where resident received vasopressin (medications given into the vein to increase blood pressure which then increases the blood flow to the body) and continuous insulin drip (a hormone therapy continuously given directly into vein and enters the bloodstream to lower and/or control high blood sugar level) was started due to critical high blood sugar and was diagnosed with Diabetic Ketoacidosis (DKA, a serious complication of diabetes and occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic). Resident 1 required ICU care from [DATE] until Resident 1 expired on [DATE] at 8:07 PM (a total of 6 days after Resident 1 was admitted to the GACH 1). Findings: A review of Resident 1's Admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included DM. A review of Resident 1's Clinical Admission Evaluation indicated Resident 1 was admitted to the facility on [DATE] at 8:20 PM. The Clinical Evaluation indicated Resident 1 had a diagnosis of DM. During a review of Resident 1's clinical record titled, Hospital Discharge Instructions, indicated Resident 1 was admitted to the GACH 1 on [DATE] with diagnosis that included DM and was discharged on [DATE] from the GACH 1 to the facility. The record indicated Resident 1 received 6 units of Novolog (a medication that lowers the blood sugar given via injection under the skin ) on [DATE] at 12 PM for the blood sugar level of 241 mg/dL (eight hours prior to admission of the resident in the facility). A review of Resident 1's History and Physical (H&P) from the facility dated [DATE], indicated Resident 1 had fluctuating capacity to understand and make decisions. The H&P indicated Resident 1 had a diagnosis of DM. A review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated [DATE], indicated the resident had severely impaired cognition (ability to remember and process information). The MDS also indicated Resident 1 had a diagnosis of DM. A review of Resident 1's Order Summary Report for ,d+[DATE], included to administer Sitagliptin Phosphate (Januvia is the brand-name of an oral medication that control the blood sugar) an oral tablet 100 mg and give 1 tablet by mouth in the morning for DM with meal. A review of Resident 1's care plan for Potential for injury related to hypoglycemia secondary to the use of oral hypoglycemic agents or insulin therapy, initiated on [DATE], created by Registed Nurse (RN) 1 indicated Resident 1 the facility staff are to monitor for [signs and symptoms] of hypoglycemia/hyperglycemia such as changes on [level of consciousness], skin [temperature], change in mood, thirst and notify MD. A review of Resident 1's Medication Administration Record (MAR) for ,d+[DATE] indicated Resident 1 was administered Sitagliptin daily from [DATE] to [DATE]. The MAR had no documented evidence that Resident 1's blood sugar was monitored. The MAR also did not show documented evidence that staff monitored Resident 1 for signs and symptoms of hypoglycemia or hyperglycemia, as indicated in the resident's care plan. A review of Resident 1's Skilled Evaluation form for the dates of [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (a total of six days) did not have documented evidence that the licensed nurse verified with the Nurse Practitioner (NP) or MD 1 if the resident needed an order to check the blood sugar or to administer insulin based on the resident's history of diabetes and receiving insulin while in the GACH 1 prior to admission to the facility. A review of Resident 1's Change in Condition Evaluation (CIC), dated [DATE], timed at 6:45 PM, indicated Resident 1 was found unresponsive on [DATE] at 6:30 P.M. The CIC report indicated Resident 1 had a pertinent diagnosis of diabetes. The CIC had no documented evidence Resident 1's blood sugar was checked when Resident 1 had a change of condition. The CIC indicated Resident 1's physician and family was notified. The CIC indicated Resident 1 was transferred via 911 to GACH 1. A review of Resident 1's Transfer Form, dated [DATE], timed at 7:15 PM, indicated Resident 1 was transferred back to GACH 1 for the loss of consciousness. The Transfer Form also indicated DM as a relevant diagnosis. The Transfer Form indicated 911 was called on [DATE] at 7 P.M. A review of Resident 1's Emergency Documentation Notes from GACH, dated [DATE], indicated the resident admitted to the emergency department on [DATE] at 7:54 PM with chief complaint of hyperglycemia. The notes indicated the blood sugar was 400+ on scene (in the facility from the 911 call). The notes indicated Resident 1 will need ICU admit and was started on insulin drip at 6 units/h (units per hour). A review of Resident 1's Critical Care IP (in Patient) Progress Notes from GACH, dated [DATE], timed at 10:57 PM, indicated Resident 1 was admitted to the emergency department with a blood sugar of 823 mg/dL and the resident's condition was critical. A review of Resident 1's Progress Notes from GACH 1, dated [DATE], indicated Resident 1 was admitted back to GACH 1 due to altered mental status, elevated blood sugar levels and was diagnosed with DKA. A review of Resident 1's Procedure Note from GACH 1, dated [DATE], indicated an endotracheal intubation (a medical procedure in which a tube is placed into the windpipe (trachea) through the mouth to provide artificial breathing and life support) procedure was performed on Resident 1 on [DATE] at 12:16 PM. A review of Resident 1's Critical Care IP Progress Notes from GACH, dated [DATE], indicated Resident 1 was intubated and placed on mechanical ventilation (a machine that provides artificial breathing to a person). A review of Resident 1's Physician Orders- Medication from GACH 1 indicated Resident 1 received the following medications between [DATE] to [DATE]: a. Insulin drip: Insulin regular IV (intavenous-given into the vein) additive 100 Unit(s) + NS [Normal Saline] 0.9% (base) 100 mL (milliliter-a unit of measurement). The order was started on [DATE] at 11:12 PM and was discontinued on [DATE] at 12:15 PM and physician order for insulin was changed to ISS (insulin sliding scale-insulin dose given based on the blood sugar level) on [DATE]. b. Vasopressin Vasopressin IV additive 40 Unit(s) + NS 0.9% 100 mL. The physician order indicated to start on [DATE] at 8:30 PM. A review of Resident 1's Critical Care IP Progress Notes from GACH 1, dated [DATE], indicated Resident 1 was pronounced brain dead (when a person no longer has any brain functions) on [DATE] at 6 PM (five days after admitted back in GACH 1). A review of Resident 1's Certificate of Death, indicated Resident 1 died on [DATE] at 8:07 PM due to cardiac arrest (when the heart stops beating suddenly) as the primary cause of death. During a concurrent interview and record review of Resident 1's clinical records that included the physician orders, Order Summary report, Nursing Progress notes and MAR on [DATE] at 11:41 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had no physicians' order to receive insulin or to monitor for blood sugar. LVN 1 stated there was no evidence that Resident 1 was administered any insulin or had her blood sugars monitored during the resident's stay in the facility. LVN 1 stated Resident 1 had a diagnosis of DM and included insulin as one of the medications Resident 1 was ordered to receive in GACH. During an interview on [DATE] at 11:08 AM with MD 1, MD 1 stated most oral diabetic medications like Sitagliptin do not drastically lower the blood sugar. MD 1 stated putting an order to monitor the resident's blood sugar would depend on the orders sent by the transferring hospital. MD 1 stated continuation of insulin and blood sugar monitor would depend on the discharge paperwork provided by the hospital to the facility. MD 1 stated the transition from the hospital to the facility is critical and stated if what was happening in the hospital was working so the orders should be the same. During an interview on [DATE] at 11:30 AM with LVN 2, LVN 2 stated prior to admission to the facility, the facility was contacted by the hospital via phone call to inform the facility about the resident. LVN 2 stated if a newly admitted resident has a diagnosis of DM, she expected the physician to order blood sugar monitor. LVN 2 stated when admitting residents to the facility, the physician was usually contacted to verify the resident's medication orders which was part of the admission process. During a concurrent interview and record review of Resident 1's medical records that included the physician orders, Order Summary report, Nursing Progress notes and MAR with Registered Nurse (RN) 1 on [DATE] at 1PM, RN 1 stated communications with the physician were documented on Skilled Evaluation. RN 1 stated there was no documented evidence that the facility staff communicated to MD 1 that Resident 1, with diagnosis of DM, did not have an order for insulin or to check or monitor the blood sugar. RN 1 stated if blood sugar was not monitored for residents with DM, the residents could suffer from hyperglycemia (high blood sugar levels) or hypoglycemia (low blood sugar levels). RN 1 stated a resident that is experiencing hyperglycemia or hypoglycemia could have altered mental status or go into a comatose state (coma, a stated of deep sleep and cannot be awakened). During an interview on [DATE] at 9:45 AM with the DON, the DON stated, on [DATE] there was no physician's order to check for blood sugar when the physician ordered Resident 1 to start Januvia and the Metformin (medication taken by mouth to lower blood sugar level) was discontinued. The DON also indicated if a resident with the DM was admitted without an order for blood sugar monitoring, it was beyond his scope of practice to ask and verify with the MD if the blood sugar of the resident should be checked. A review of the facility's job description titled, Director of Nursing Services, undated, indicated the DON assumes ultimate responsibility for coordinating plans for the total care of each resident. The document also indicated the DON participates in admission of residents. A review of the facility's policy and procedure (P&P) titled, Admission and Orientation of Residents, revised ,d+[DATE], indicated the attending physician will provide medication orders, including a medical condition or problem associated with each medication. The P&P also indicated the physician will provide routine care orders to maintain or improve the resident's function. The P&P indicated eligibility for admission will be determined by facility staff, including the DON. A review of the facility's P&P titled, Progress Notes, revised ,d+[DATE], indicated the resident's progress notes will reflect the resident's current status, progress or lack of progress, changes in condition, adjustment to the facility, and other relevant information. A review of the facility's P&P titled, Physician Orders, revised ,d+[DATE], indicated the licensed nurse will confirm that physician orders are clear, complete, and accurate as needed. A review of the facility's P&P titled, Diabetic Care, revised ,d+[DATE], indicated the following: 1. The facility will provide the necessary care and services to permit each diabetic resident to attain or maintain optimal well-being while monitoring their care in accordance with their individualized Comprehensive Assessment and Care Plan. 2. The Attending Physician will write parameters for notification for blood sugar that is out of control. 3. A Licensed Nurse will document clearly and consistently all diabetic monitoring. 4. Nursing Staff will monitor the resident for signs and symptom of hypoglycemia or hyperglycemia, initiate interventions if necessary, and notify the Attending Physician and responsible party if signs and symptoms are present. 5. The Interdisciplinary Team (IDT) will ensure the Care Plan addresses the resident's diabetes, goals, and interventions, and update the Care Plan as necessary. 6. All documentation related to the resident's diabetic condition will be maintained in the resident's medical record.

Based on interview and record review, the facility failed to ensure the physician was immediately consulted and notified when there was a change in the resident's condition, in accordance with the facility's policy for one of two sampled residents (Resident 1). On 9/6/2021 at 11:00 PM, Resident 1's head bandage dressing (a pad or compress applied to a wound) was noted to be dry and intact, but one (1) hour after on 9/7/2021 at 12:00 AM, Resident 1's head bandage was noted to have been saturated with blood (indication of active bleeding from the wound) but Registered Nurse 1 (RN 1) did not call Resident 1's attending physician to notify of the increase in bleeding from the wound on Resident 1's head. This deficient practice resulted in a delay in Resident 1's intervention and was transferred to General Acute Care Hospital (GACH) on 9/7/2021 at 2:15 AM, requiring Resident 1 to receive blood transfusion (a medical procedure in which healthy blood is given to you through an intravenous line [IV, a soft flexible tube placed inside a vein, usually in the hand or arm]) at GACH emergency department due to a significant dropped in hemoglobin (HGB, oxygen-carrying component of blood) to a critical level. Resident 1 was admitted to the Intensive care unit (ICUs, specialist hospital wards that provide treatment and monitoring for people who are very ill) on 9/07/2021 for further monitoring and treatment and was subsequently discharged under hospice care (a comprehensive set of services to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient) on 9/17/2021. Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, standardized assessment and care screening tool) dated 9/07/2021, indicated Resident 1's cognitive skills (ability to think and reason) were mildly impaired. Resident 1 required extensive assistance with one-person physical assist for bed mobility, transferring, dressing, toilet use and personal hygiene. A review of Resident 1's SBAR (situation-background-assessment-recommendation, a report form used by the facility as their Incident report form) report dated 9/06/2021, indicated at 5:30 AM, Resident 1 was found on the floor in prone position (laying on the abdomen) with significant amount of blood around his face. SBAR report indicated the resident was confused, disoriented, and had several skin lacerations (a deep cut or tear in skin) on his head, nose, and right elbow. Local emergency number was called (911) and Resident 1 was transferred to GACH. A review of Resident 1's Emergency (ER) Documentation from GACH dated 9/06/2021, indicated Resident 1 noted with head lacerations (deep cut or tear on the skin), facial bruise (an injury appearing as an area of discolored skin on the body), and abrasions (wearing off the skin) on both arms. The laceration on Resident 1's forehead (part of the face above the eyebrows) was measured at 5 centimeters (cm, a unit of measurement). The wound was reapproximated (to close a wound) and repaired using sutures. Moderate sharp debridement (removal of dead tissues in the wound) was required, and a dressing was placed. The laceration on Resident 1's occiput (back of the head) was measured at 4 cm. The wound was reapproximated and repaired using 4 staples. Mild sharp debridement was required, and a dressing was placed. A review of Resident 1's Emergency Department Discharge Instructions from the GACH dated 9/06/2021, indicated to call the healthcare provider right away if any of the following occur: a. Fever of 100.4 degrees Fahrenheit or higher, or as directed by your healthcare provider b. Increasing pain, redness, swelling, or drainage from the wound c. Bleeding from the wound that does not stop after a few minutes of steady and firm pressure A review of Resident 1's Nurses Progress Notes dated 9/06/2021, indicated at 3:45 PM, Resident 1 came back to the facility from the GACH, via private van accompanied by his son. Resident 1 was noted with laceration to forehead with 5 sutures, top of the head with 4 staples with minimal bleeding, bilateral multiple skin discoloration, and abrasion to upper arm. A review of Resident 1's Nurses Progress Notes dated 9/07/2021, indicated that on 9/06/2021 at 11:00 PM, Resident 1 head bandage dressing was dry and intact. One hour after on 9/07/2021 at 12:00 AM, Resident 1's head bandage dressing was saturated with blood, dressing was reinforced with gauze pads (a bandage used to cover wounds). The Nurse's Progress Notes also indicated, on 9/07/2021 at 2:00 AM (two hours after), Resident 1's head bandage dressing was saturated with blood, and the Blood Pressure (BP, a measure of the force that your heart uses to pump blood around your body) was 97/54 millimeter of mercury ([mmHg, unit of measurement] indicated a low blood pressure, normal is 120/80 mmHg). The Nurse's Progress Notes indicated on 9/07/2021 at 2:10 AM, 911 was called for profuse bleeding on the wound site at the head and Resident 1 was transferred back to GACH on 9/7/2021 at 2:15 AM. A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's History and Physical (H&P) Report from GACH dated 9/07/2021, indicated Resident 1 returned due to constant bleeding from head wound despite holding pressure at the Skilled Nursing Facility. The H&P indicated laboratory report indicated a significant drop in hemoglobin from 8.1 grams per deciliter (g/dL, unit of measurement) to 5.9 g/dL (normal range for men is 13.5 to 17.5 g/dL), and Resident 1 was transfused with 1 unit of Packed Red Blood Cells (PRBC, a type of blood replacement product used for blood [CONDITION(S)]) in the GACH's emergency department. During a telephone interview on 11/03/2021 at 8:55 AM, RN Supervisor (RN 1) stated that at the beginning of her shift on 9/06/2021 at around 11:00 PM, she went to visit Resident 1 in his room. RN 1 stated Resident 1 had a bulky dressing around his head stained with some blood. RN 1 stated at midnight, she went to see Resident 1 and found the dressing on his head saturated with blood. RN 1 stated she placed a new bulky dressing but after one hour, it was saturated again with blood. RN 1 stated when she checked Resident 1's BP, his systolic bp (the top number, measures the force your heart exerts on the walls of your arteries each time it beats) was in the 90's and heart rate was over 100 beats per minute. RN 1 stated that at around 2:00 AM, she called 911 to transfer Resident 1 to GACH due to profuse bleeding. During a telephone interview on 12/14/2021 at 11:00 AM, LVN 2 stated on 9/06/2021 at 10:00 PM, Resident 1 complained that his head dressing was too tight. LVN 2 stated the head dressing was not saturated with blood and that there was only slight bleeding. LVN 2 stated she rewrapped the head with new dressing. LVN 2 stated she endorsed to the next shift nurse around 11:00 PM that she just placed a new dressing on Resident 1's head wound. During a telephone interview on 12/14/2021 at 12:22 PM, RN Supervisor (RN 2) stated she endorsed to the next shift registered nurse that Resident 1 came back to the facility on [DATE] at 3:45 PM and a new dressing was just placed on 9/06/2021 between 10:00 to10:30 PM. RN 2 stated that if a resident was admitted or readmitted from GACH, facility will review GACH's discharge instructions and orders, notifies primary physician, and carry out orders and instructions from GACH records. RN 2 stated, it was important to follow discharge instructions from GACH to call the physician immediately for changes in wound condition of Resident 1 such as increase bleeding from the wound to make sure appropriate treatment, prompt action and to avoid worsening of condition. During a follow-up telephone interview on 12/15/2021 at 11:15 AM, RN 1 stated Resident 1's head wound was oozing (seeping out) with blood. RN 1 stated she did not call Resident 1's physician after the dressing change on 9/7/2021 at 12:00 AM. RN 1 stated it was considered a change of condition and as per their policy, to notify the physician immediately if Resident 1's head wound continues to bleed. RN 1 stated she only notified Resident 1's primary physician on 9/7/2021 at 2:00 AM about the uncontrolled bleeding from resident's wound on the head. During a telephone interview on 12/15/2021 at 12:15 PM, LVN 3 stated she did not call or spoke at all with Resident 1's primary physician on 9/7/2021 at 12 AM when the head bandage was noted to have been saturated with blood. LVN 3 stated it was RN 1 who called 911 and talked with Resident 1's physician on 9/07/2021 to transfer Resident 1 to GACH. During a telephone interview on 12/16/2021 at 12:12 PM, the Director of Nursing (DON) stated if a resident had wound stitches, and the wound dressing has just had bloodstain, staff should continue to monitor the resident's condition. DON stated if the wound continues to bleed, it warranted to call the physician for the change of condition and send the patient to acute hospital for further evaluation and treatment. A review of the Facility's P&Ps titled Change of Condition Notification revised April 2015, indicated that the facility will promptly consult with the resident's Attending Physician (primary physician) when the resident endures a significant change in their condition caused by, but not limited to a significant change in the resident's physical, mental or psychosocial status.

Based on interview and record review, the facility failed to immediately consult the physician and notify a resident's responsible party when a resident had a change in respiratory condition for one of three sampled residents (Resident 1). Resident 1 was identified to have a productive cough (a cough that produces phlegm or mucus, clearing it from the lungs) on [DATE] and [DATE]. This deficient practice resulted in the delay in diagnosis, care and services for Resident 1's respiratory condition. On [DATE] at 5:15 a.m., Resident 1 was gasping for air, had a cardiopulmonary arrest (sudden heart and/or lung failure), and expired (died ) in the facility, on [DATE] at 6:15 a.m. Resident 1's family was notified of resident's condition after resident had died . Cross reference F 684. Findings: A review of Resident 1's undated Face Sheet indicated he was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's History and Physical (H&P) dated [DATE], indicated the resident did not have the capacity to understand and make decisions. The H&P indicated Resident 1's designated resident representative (the person who has a level of control over a person legal and medical decision) was his family member. A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated [DATE], indicated Resident 1 required extensive assistance with one facility staff for bed mobility, transfer, dressing, and personal hygiene. A review of Resident 1's Care Plan for High Risk for COVID - 19 (a severe respiratory illness caused by virus and spread from person to person) Exposure, dated [DATE], indicated to do daily vital sign (v/s) monitoring and observe for change in condition every (Q) shift and notify Medical Doctor (MD). A review of Resident 1's Licensed Personnel Progress Notes, dated [DATE] timed at 6:30 a.m., indicated Resident 1's vital signs were checked as follows: temperature at 98.1 degree Fahrenheit (F, unit of measurement, normal levels: 97 degree F to 99 degree F), heart rate at 95 beats per minute (HR, normal levels: 60 to 100 beats per minute), respiratory rate at 18 breaths per minute (R, normal levels: 12 to 16 breaths per minute), and his blood pressure (BP) was ,[DATE] millimeters of mercury (mm/Hg; unit of measurement used to measure the pressure in the blood vessels, normal levels: below ,[DATE] mm Hg and above ,[DATE] mm Hg). The note indicated Resident 1's [MEDICATION NAME] (medication used to lower blood pressure) was put on hold. A review of Resident 1's physician's orders [REDACTED]. resident to the emergency room if his condition worsened. A review of Resident 1's Radiology Report dated [DATE] timed at 3:30 p.m., indicated a slight right upper lobe infiltrate (small amount of fluid in the upper part of the right lung also known as pneumonia (lung infection)). A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's Care Plan, dated [DATE], identified problems of alteration in respiratory function related to pneumonia (lung infection) and abnormal lungs sounds, Wheezing (a high-pitched [MEDICATION NAME] sound that comes when you breathe). The care plan approaches included to obtain oxygen saturations, vital signs as ordered, monitor the lung sounds, pallor (an unhealthy pale appearance), cough, and character of sputum. A review of Resident 1's Skilled Nurse's Notes dated [DATE], Shift: 3 p.m.-11 p.m. (no time), indicated Resident 1 had a productive cough. The Nurse's Note indicated Resident 1 was being monitored for antibiotic therapy and pneumonia. There was no documented evidence of the character of Resident 1's sputum and if Resident 1's physician was notified. A review of Resident 1's Licensed Personnel Progress Notes, indicated no entry was made for [DATE]. A review of Resident 1's Skilled Nurse's Notes dated [DATE] Shift: 3 p.m.-11 p.m. (no time), indicated Resident 1 had a productive cough. There was no documentation to indicate the color and characteristics of Resident 1's sputum, lung sounds and oxygen saturation. There was no documented evidence that Resident 1's physician was notified. A review of Resident 1's Licensed Personnel Progress Notes, indicated no entry for [DATE]. A review of Resident 1's Licensed Personnel Progress Notes, dated [DATE] timed at 5:15 a.m. indicated, Began passing med notice resident gasping for air. Raised head of bed, notified supervisor, and called 911 (emergency services). Resident in distress. BP ,[DATE] - P - 58 - R - 12 T - 97.3. Registered Nurse Supervisor 2 (RNS 2) performed cardio-pulmonary resuscitation (CPR, a lifesaving procedure performed when the heartbeat stops beating). The Fire Department (FD) arrived at 5:25 a.m., continued CPR, and FD took over at 6:15 a.m. Stop resuscitation attempts called and notified Physician 1, left message with the family and notified DON via text message. The progress notes did not indicate Resident 1's oxygen saturation was check or that oxygen was administered. A review of Resident 1's Licensed Personnel Progress Notes, dated [DATE] timed at 6:30 a.m., indicated, Resident pronounced unresponsive by Fire Department, expired at 5:34 a.m. A review of the FD incident report, dated [DATE], indicated FD arrived at Resident 1's bedside at 5:40 a.m. Resident 1 was found supine in bed, pulseless (no heartbeat) with apnea (not breathing) and facility staff performing CPR. Resident 1 was last seen 20 minutes prior to facility calling 911. Resident 1 was asystole (no electrical heartbeat activity on heart monitoring device) from 5:40 a.m. to 6:06 a.m. after being given three doses of [MEDICATION NAME] (medication to stimulate and/or increase a heartbeat). Resident 1 was pronounced (death declared) at 6:06 a.m. A review of Resident 1's Certificate of Death, indicated the resident expired on [DATE] at 6:15 a.m. The Certificate of death indicated the immediate cause of death was acute cardiopulmonary arrest. Other conditions listed were [MEDICAL CONDITION] (chronic [MEDICAL CONDITION] lung disease that causes obstructed airflow from the lungs) and [MEDICAL CONDITIONS] (a condition where the arteries become narrowed and hardened). A review of Resident 1's Consent to Treatment dated [DATE], indicated Family Member 1 (FM1) was the designated resident representative (the person who has a level of control over a person legal and medical decision). A review of Resident 1's Physician order [REDACTED]. During a telephone interview, on [DATE] at 4:09 p.m., Resident 1's family member (FM1) stated on the day the resident died , the facility left him a message that Resident 1 passed away. FM 1 stated, It came unexpected because a week before that I called him. FM 1 stated Resident 1 was not sick, and Resident 1 didn't need anything when asked. FM 1 stated the nurse stated the resident died of pneumonia. During a telephone interview on [DATE] at 8:58 a.m., Registered Nurse Supervisor 1 (RNS 1) stated he worked on [DATE], during the 11 p.m.-7 a.m. shift and received a report that two nights prior, Resident 1 had a low oxygen saturation. RNS 1 stated Resident 1 was already asleep when he made his rounds at the beginning of the shift. RNS1 stated he noticed Resident 1 was struggling for breath the following morning (unable to recall time), during blood sugar check. RNS 1 stated oxygen was applied and vital signs were taken. RNS 1 was unable to tell Resident 1's oxygen level that time. RNS 1 stated RNS 2 started CPR. RNS 1 stated paramedics came after ,[DATE] minutes and took over CPR for approximately 30 minutes before the Resident 1 was pronounced dead. During a telephone interview, on [DATE] at 9:57 a.m., Licensed Vocational Nurse (LVN 1) 1 stated whenever a resident had a change of condition, either the charge nurse or RN supervisor can call inform the doctor and family member. LVN 1 stated I don't know if somebody called the family member for Resident 1. During a telephone interview on [DATE] at 11:05 a.m., Certified Nursing Assistant (CNA 1) 1 stated he was assigned to care for Resident 1 on [DATE], from 11 p.m. through [DATE] at 7 a.m. CNA 1 stated he went to Resident 1's room at 1 a.m., and observed the resident was awake, talking, and had no shortness of breath. CNA 1 stated when he went back between 4:30 a.m. and 5 a.m., Resident 1 looked pale, his eyes were very white, and was not waking up. CNA 1 stated he called RNS 1. During a telephone interview, on [DATE] at 10:30 a.m., the Director of Nursing (DON) stated he could not find documented evidence that Resident 1's physician was notified of Resident 1's productive cough as indicated by the licensed nurse's documentation on [DATE] and [DATE]. The DON verified no entries were made in the Licensed Personnel Progress notes for [DATE] and [DATE]. During that same interview and record review on [DATE] at 10:30 am, the DON reviewed the Licensed Personnel Progress noted, dated [DATE] timed at 5:15 a.m., the DON stated the entry was an inaccurate and was lacking crucial information. The DON stated he had questioned the documentation, why CPR was performed on the resident when the documentation indicated the resident had vital signs and was breathing. The DON stated the note did not indicate that Resident 1's oxygen saturation was checked or that oxygen was applied to the resident who was in obvious respiratory distress (gasping for air). The DON acknowledged inaccuracies with documentation throughout Resident 1's medical record. DON stated he could not find documented evidence that the responsible party had been notified of Resident 1's change in condition or death. During a telephone interview on [DATE] at 2:23 p.m., Physician 1 stated the facility staff did not inform him at any occasion that Resident 1 had developed a cough or given a report of Resident 1's respiratory condition. Physician 1 stated the facility did not report Resident 1's cough and monitored for suspected COVID -19. During a telephone interview, on [DATE] at 10:00 a.m., RN 1 stated once a change of condition was noted, the care plan should be updated and the appropriate assessment would include complete vital signs: blood pressure, temperature, respiration rate, pulse, and O2 saturation and administration of oxygen if saturation level was low or if the resident was in respiratory distress (difficulty breathing or abnormal breathing). RN 1 stated she did not worry about detailed documentation, because she preferred to spend her time with the residents not charting. During a telephone interview on [DATE] at 11:10 a.m., RN 2 stated if a resident was found to be in respiratory distress vital signs should be checked, which include O2 saturation. RN2 stated immediate nursing interventions should include administering oxygen, breathing treatments, notifying the physician, and calling 911 if necessary. A review of the facility's policy titled, Change of Condition Notification, revised date [DATE], indicated a licensed nurse should notify the resident's family after a significant change in condition. The policy indicated the, Physician must be notified when any sudden and marked adverse change in the resident's condition which was manifested by signs and symptoms different than usual denote a new problem, complication or permanent change in status and require a medical assessment, coordination and consultation with the attending physician and a change in treatment plan.

Based on interview and record review, the facility failed provide the necessary treatment interventions after a resident had a change in respiratory condition for one of three sampled residents (Resident 1). Resident 1 was identified to have a productive cough (a cough that produces phlegm or mucus, clearing it from the lungs) on [DATE] and [DATE], and the facility failed to: 1. Obtain oxygen saturations (measurements of the amount of oxygen circulating in the blood) and monitor the lung sounds (sounds generated by the movement of air through the respiratory system as indicated in Resident 1's care plan for a problem of alteration in respiratory function related to pneumonia (lung infection). 2. Provide assessment that was accurate and complete every shift to observe Resident 1's change of condition for lung sounds, appearance, presence of a cough, and character of sputum, as indicated in Resident 1's care plan for high risk for COVID - 19 (a severe respiratory illness caused by virus and spread from person to person) and a problem of alteration in respiratory function related to pneumonia. 3. Complete a Twenty-Four Hour Report or incident report as indicated in the facility's Change of Condition Notification policy. This deficient practice resulted in delayed care and services for Resident 1's respiration condition. On [DATE] and [DATE], Resident 1's physician was not informed that the resident had developed a cough. On [DATE] at 5:15 a.m., Resident 1 was gasping for air, then had a cardiopulmonary arrest (sudden heart and/or lung failure), and expired in the facility, on [DATE] at 6:15 a.m. Findings: A review of Resident 1's undated Face Sheet indicated he was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's History and Physical (H&P) dated [DATE], indicated the resident did not have the capacity to understand and make decisions. The H&P indicated Resident 1's designated resident representative was his family member. A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated [DATE], indicated Resident 1 required extensive assistance with one facility staff for bed mobility, transfer, dressing, and personal hygiene. A review of Resident 1's Care Plan for High Risk for COVID - 19 (a severe respiratory illness caused by virus and spread from person to person) Exposure, dated [DATE], indicated to do daily vital sign (v/s) monitoring and observe for change in condition every (Q) shift and notify Medical Doctor (MD). A review of Resident 1's Change of Condition nursing note, dated [DATE] timed at 6:30 a.m., indicated Resident 1's vital signs were assessed was temperature (T) at 98.1 degree Fahrenheit (F, unit of measurement, normal levels: 97 degree F to 99 degree F), heart rate (HR) at 95 beats per minute (normal levels: 60 to 100 beats per minute), respiratory rate (R) at 18 respiration per minute (normal levels: 12 to 16 breaths per minute), and his blood pressure (BP) was ,[DATE] millimeters of mercury (mm/Hg; unit of measurement used to measure the pressure in the blood vessels, normal levels: below ,[DATE] mm Hg and above ,[DATE] mm Hg). The note indicated the resident's [MEDICATION NAME] (medication used to lower blood pressure) would be held. A review of Resident 1's physician's orders [REDACTED].) levels) count, CXR (chest X-ray), bed rest, elevating of legs, and to send the resident to the emergency room if his condition worsened. A review of Resident 1's radiology report dated [DATE] timed at 3:30 p.m., indicated a slight right upper lobe infiltrate (small amount of fluid in the upper part of the right lung also known as pneumonia). A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's Care Plan, dated [DATE], identified problems of alteration in respiratory function related to pneumonia (lung infection) and abnormal lungs sounds, Wheezing (a high-pitched [MEDICATION NAME] sound that comes when you breathe). The care plan approaches included to obtain oxygen saturations, vital signs as ordered, monitor the lung sounds, pallor (an unhealthy pale appearance), cough, and character of sputum. A review of Resident 1's Skilled Nurse's Notes dated [DATE], Shift: 3 p.m. to 11 p.m. (no time), indicated Resident 1 had a productive cough. The Nurse's Note indicated Resident 1 was being monitored for antibiotic therapy and pneumonia. There was no documented evidence of the character of Resident 1's sputum and if Resident 1's physician was notified that Resident 1 had a productive cough. A review of Resident 1's Licensed Personnel Progress Notes, indicated no entry was made for [DATE]. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's Skilled Nurse's Notes dated [DATE] Shift: 3 p.m. to 11 p.m. (no time), indicated Resident 1 had a productive cough. There was no documentation to indicate the color and characteristics of Resident 1's sputum, lung sounds and oxygen saturation. There was no documented evidence that Resident 1's physician was notified that Resident 1 had a productive cough. A review of Resident 1's Licensed Personnel Progress Notes, indicated no entry for [DATE]. A review of Resident 1's Licensed Progress notes for [DATE] to [DATE], did not indicate the facility staff obtained Resident 1's oxygen saturation levels and observe for change of condition every shift as indicated in Resident 1's care plan. A review of Resident 1's Skilled Nurse's Notes, dated [DATE], shift 11p.m. to 7 a.m. (no time), indicated Resident 1 was alert and oriented, vital signs included: temperature: 97.8 degrees Fahrenheit, pulse (HR, heart rate): 78 beats per minute, respirations 19 per minute, blood pressure ,[DATE] millimeters of mercury, oxygen saturation 96% (normal levels: ,[DATE] percent). The note indicated Resident 1 was verbally responsive and able to verbalize and express his needs. A review of Resident 1's Licensed Personnel Progress Notes, dated [DATE] timed at 5:15 a.m. indicated, Began passing med notice resident gasping for air. Raised head of bed, notified supervisor, and called 911 (emergency services). Resident in distress. BP ,[DATE] - P - 58 - R - 12 T - 97.3. Registered Nurse Supervisor 2 (RNS 2) performed cardio-pulmonary resuscitation (CPR, a lifesaving procedure performed when the heartbeat stops beating). The Fire Department (FD) arrived at 5:25 a.m., continued CPR, and FD took over at 6:15 a.m. Stop resuscitation attempts called and notified Physician 1, left message with the family and notified Director of Nursing (DON) via text message. The progress notes did not indicate Resident 1's oxygen saturation was check or that oxygen was administered. A review of Resident 1's Licensed Personnel Progress Notes, dated [DATE] timed at 6:30 a.m., indicated, Resident pronounced unresponsive by Fire Department, expired at 5:34 a.m. A review of the FD incident report, dated [DATE], indicated FD arrived at Resident 1's bedside at 5:40 a.m. Resident 1 was found supine in bed, pulseless (no heartbeat) with apnea (not breathing) and facility staff performing CPR. Resident 1 was last seen 20 minutes prior to facility calling 911. Resident 1 was asystole (no electrical heartbeat activity on heart monitoring device) from 5:40 a.m. to 6:06 a.m. after being given three doses of [MEDICATION NAME] (medication to stimulate and/or increase a heartbeat). Resident 1 was pronounced (death declared) at 6:06 a.m. A review of Resident 1's Certificate of Death, indicated the resident expired on [DATE] at 6:15 a.m. The Certificate of death indicated the immediate cause of death was acute cardiopulmonary arrest (sudden heart and/or lung failure). Other conditions listed were [MEDICAL CONDITION] (chronic [MEDICAL CONDITION] lung disease that causes obstructed airflow from the lungs) and [MEDICAL CONDITIONS] (a condition where the arteries become narrowed and hardened). During a telephone interview, on [DATE] at 4:09 p.m., Resident 1's family member (FM1) stated on the day the resident died , the facility left him a message that the Resident 1 passed away. FM 1 stated, It came unexpected because a week before that I called him. FM 1 stated Resident 1 was not sick, and Resident 1 didn't need anything when asked. FM 1 stated the nurse stated the resident died of pneumonia, but the mortuary, where the facility sent the resident, told the family, Resident 1 had COVID-19 (severe respiratory illness caused by virus and spread from person to person). During a telephone interview on [DATE] at 8:58 a.m., RNS 1 stated he worked on [DATE], during the ,[DATE] shift and received a report that two nights prior, Resident 1 had a low oxygen saturation. RNS 1 stated Resident 1 was already asleep when he made his rounds at the beginning of the shift. RNS1 stated he noticed Resident 1 was struggling for breath the following morning (unable to recall time), during blood sugar check. RNS 1 stated oxygen was applied and vital signs were taken. RNS 1 did not know Resident 1's oxygen level that time. RNS 1 stated RNS 2 started CPR. RNS 1 stated paramedics came after ,[DATE] minutes and took over CPR for approximately 30 minutes before the Resident 1 was pronounced dead. During a telephone interview, on [DATE] at 9:57 a.m., Licensed Vocational Nurse (LVN) 1 stated whenever a resident had a change of condition, either the charge nurse or RN supervisor can call inform the doctor and family member. LVN 1 stated I don't know if somebody called the family member for Resident 1. During a telephone interview on [DATE] at 11:05 a.m., Certified Nursing Assistant (CNA) 1 stated he was assigned to care for Resident 1 on [DATE], from 11 p.m. through [DATE] at 7 a.m. CNA 1 stated he went to Resident 1's room at 1 a.m., and observed the resident was awake, talking, and had no shortness of breath. CNA 1 stated when he went back between 4:30 a.m. and 5 a.m., Resident 1 looked pale, his eyes were very white, and was not waking up. CNA 1 stated he called RNS 1. During a concurrent telephone interview on [DATE] at 10:30 a.m., the Director of Nursing (DON) stated Resident 1 has a physician order [REDACTED]. The DON stated Resident 1 was not tested for influenza and Coronavirus infection (COVID-19). The DON stated [MEDICATION NAME] (a medication used to treat the flu virus) was ordered by the physician due to facility's, Protocol during flu season. During that same telephone interview, on [DATE] at 10:30 a.m., the DON stated he could not find documented evidence that the licensed nurses obtained Resident 1's oxygen saturation levels, assessed lung sounds, and sputum as indicated in the care plan. The DON stated these assessments should have been implemented every shift and documented. The DON stated he could not find documented evidence that Resident 1's physician was notified of Resident 1's productive cough as indicated by the licensed nurse's documentation on [DATE] and [DATE]. The DON verified no entries were made in the Licensed Personnel Progress notes for [DATE] and [DATE]. The DON stated the licensed nurses did not assessed Resident 1's lung sounds, reported Resident 1's cough, and closely monitored for suspected COVID - 19. During that same interview and record review on [DATE] at 10:30 am, the DON reviewed the Licensed Personnel Progress noted, dated [DATE] timed at 5:15 a.m., the DON stated the entry was an inaccurate and was lacking crucial information. The DON stated he had questioned the documentation, why CPR was performed on the resident when the documentation indicated the resident had vital signs and was breathing. The DON stated the note did not indicate that Resident 1's oxygen saturation was checked or that oxygen was applied to the resident who was in obvious respiratory distress (gasping for air). The DON acknowledged inaccuracies with documentation throughout Resident 1's medical record. During that same telephone interview on [DATE] at 10:30 a.m., the DON stated he could not find documented evidence that the responsible party had been notified of Resident 1's change in condition or death. The DON stated if a preferred mortuary was not listed in the medical record, the family would be asked if they have one selected during the notification call. The DON stated if the family did not have a preference, then the facility's contracted mortuary would be used. During a telephone interview on [DATE] at 1:45 p.m., Medical Records (MR1) stated she could not find documented evidence that a Twenty-Four Hour Report or incident report was completed by the facility when Resident 1 expired on [DATE]. During a telephone interview on [DATE] at 2:23 p.m., Physician 1 stated he ordered [MEDICATION NAME] due to associated infection concerns ([MEDICAL CONDITION] that can take advantage of a weakened immune system and cause another infection) and not for COVID-19 concerns. Physician 1 stated the facility staff did not inform him at any occasion that Resident 1 had developed a cough or given a report of Resident 1's respiratory condition. Physician 1 stated the facility did not report Resident 1's cough and monitored for suspected COVID -19. During a telephone interview, on [DATE] at 10:00 a.m., RN 1 stated once a change of condition was noted the care plan should be updated and the appropriate assessment would include complete vital signs: blood pressure, temperature, respiration rate, pulse, and O2 saturation and administration of oxygen if saturation level was low or if the resident was in respiratory distress (difficulty breathing or abnormal breathing). RN 1 stated she did not worry about detailed documentation, because she preferred to spend her time with the residents not charting. During a telephone interview on [DATE] at 11:10 am, RN 2 stated if a resident was found to be in respiratory distress vital signs should be checked, which include O2 saturation. RN 2 stated immediate nursing interventions should include administering oxygen, breathing treatments, notifying the physician, and calling 911 if necessary. A review of Resident 1's medical records and verified the facility's medical record department, indicated Resident 1 had no completed assessment every shift of Resident 1's lung sounds, appearance, presence of a cough, and character of sputum on shifts: 1. [DATE] for the 11 p.m. to 7 a.m. shift. 2. [DATE] for the 11 p.m. to 7 a.m. shift 3. [DATE] for the 7 a.m. to 3 p.m. shift 4. [DATE] for the 11 p.m. to 7 a.m. shift. A review of the facility's policy titled, Change of Condition Notification, revised date [DATE], indicated the, Physician must be notified when any sudden and marked adverse change in the resident's condition which was manifested by signs and symptoms different than usual denote a new problem, complication or permanent change in status and require a medical assessment, coordination and consultation with the attending physician and a change in treatment plan. The policy indicated the licensed nurse will document each shift for at least seventy-two (72) hours. The policy indicated, Documentation pertaining to a change in the resident's condition will be maintained in the resident's medical record and on the Twenty-Four Hour Report. A review of the Center for Disease Control's website for Coronavirus Disease 2019 (COVID-19, updates on [DATE]), indicated symptoms to watch for which may indicate a person has COVID-19 included: cough, diarrhea, nausea or vomiting (https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html).

Based on observation, interview and record review, the facility failed to implement interventions to prevent and control the spread of COVID 19 (Coronavirus disease, a mild to severe respiratory illness that spread from person to person) in accordance to the facility's infection control policy and the Mitigation Plan ( MP, plan to reduce loss of life and impact of COVID 19 in the facility) for 8 of 8 sampled residents (Residents 1 ,2 ,3, 4, 5, 6, 7, and 8) by failing to: 1. Cohort (group) Residents 1, 2, 3 and 4 who tested positive for COVID 19 in the Red Zone (an area where COVID 19 residents are confined), from Residents 5, 6, 7, and 8 who tested negative for COVID 19 in the Green Zone (an area for residents without signs and symptoms of COVID 19). 2. Hire a full time Infection Prevention Nurse (IPN, a nurse who helps prevent and identify the spread of infectious disease in the healthcare environment) to monitor, prevent and control the spread of COVID-19 in the facility. 3. Ensure the Phlebotomist ( PH 1, a laboratory worker trained in drawing blood for testing) wore a gown when she entered the Red Zone to collect specimens (sample of body fluid for medical testing such as blood, urine and saliva swabs for COVID 19 tests) and removed her soiled (used/dirty) gloves prior entering the Green Zone. 4. Ensure Resident 1 wore a mask while sharing the same room with Resident 6 and Resident 7 who both tested negative for COVID 19. 5. Ensure the Red Zone area had designated restroom, breakroom for staffs who takes care of COVID 19 positive residents (COVID staff), and placed signages (postings) to remind staff to wash their hands, to don (put on), doff (take off) Personal Protective Equipment (PPE, such as gown, gloves, mask, face shield) before and after providing care to the residents. These deficient practices had the potential to result in the spread of COVID-19 from Residents 1, 2, 3, 4 and placed Resident 5,6,7,8, other residents, staff at risk for COVID 19 infection that could lead to severe respiratory illness, hospitalization and/or death. On 7/9/20 at 7:10 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) were identified in the presence of the Registered Nurse 2 (RN 2) and Director of Staff Development (DSD). The Administrator was not in the facility and the Director of Nursing (DON) was available via telephone calls. The IJ was called in the presence of RN 2 and the DSD (the DON was available through a teleconference) regarding the facility's failure to implement interventions to prevent the spread of COVID 19 infection that threatened the health and safety of the residents and staff. On 7/13/20 at 6:08 p.m., the IJ was lifted after the facility submitted an acceptable plan of action (POA, interventions to correct the deficient practices), the survey team verified and confirmed the implementations of the POA while onsite the by observation, interview, and record review. The survey team removed the IJ situation in the presence of the Administrator and the DSD. The Administrator provided an acceptable POA as follows: 1. On 7/9/20 before 7:15 p.m. Residents 1, 2, 3 and 4 were transferred to the Red Zone. On 7/10/20, the DSD/Interim IPN provided in-service to remind facility' staff that those residents who tested positive for COVID 19 must be transferred to the Red Zone as soon as cohort can be established. 2. On 7/9/2020, the facility's DSD was promoted to an Interim IPN, he initiated the Center of Disease Control Infection Prevention training on 7/10/20 and received the certificate on 7/12/20. The IPN was a full-time employee and was spending adequate time in the facility providing in-service to nursing staff regarding management of COVID-19. 3. On 7/9/20, RN 2 educated vendors' staff including lab technician (LT, person who works in the lab) to don appropriate PPE prior to entering the Red Zone. 4. On 7/10/20, the DSD/Interim IPN provided facemasks to Residents 1, 2, 3 ,4, 5, 6, 7, 8 and other residents. 5. On 7/9/2020 at 7:15p.m., the DSD/Interim IPN immediately placed the signages for handwashing, donning and doffing of PPE in-front of rooms with positive COVID 19 residents. Administrative staff expanded the Red Zone to include designated restroom and breakroom for COVID staff. Findings: A review of Resident 1's admission record indicated the facility admitted the resident on 3/22/17 with [DIAGNOSES REDACTED]. A review of Resident 1's laboratory (lab/test) result, dated 7/6/20, indicated the resident tested positive for COVID 19. Laboratory Technician 1 (LT 1) reported the positive result to the facility on [DATE] at 12:14 a.m. A review of Resident 2's admission record indicated the facility admitted the resident on 5/22/20 with [DIAGNOSES REDACTED]. A review of Resident 2's lab result, dated 7/7/20, indicated the resident tested positive for COVID 19 on 7/7/20 and LT 1 reported the positive result to the facility on [DATE] at 12:14 a.m. A review of Resident 3's admission record indicated the facility admitted the resident on 3/25/20 with [DIAGNOSES REDACTED]. A review of Resident 3's lab result, dated 7/7/20, indicated the resident tested positive for COVID 19 on 7/7/20 and LT 1 reported the positive result to the facility on [DATE] at 12:14 a.m. A review of Resident 4's admission record indicated the facility admitted the resident on 5/6/16 with [DIAGNOSES REDACTED]. A review of the Resident 4's lab result, dated 7/5/20, indicated the resident was tested positive for COVID 19 and LT 1 reported the result to the facility on [DATE] at 12:11 a.m. A review of Resident 5's admission record indicated the resident admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 5's lab resulted indicated the resident tested negative for COVID 19 on 7/2/20, and LT 2 reported the result to the facility on [DATE] at 12:04 a.m. A review of Resident 6's admission record indicated the facility admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 7/9/20 resident 6 tested positive for COVID 19 and LT 2 reported the positive result to the facility on [DATE] at 9:25 p.m. A review of Resident 7's admission record indicated the facility admitted the resident on 6/11/20 with [DIAGNOSES REDACTED]. A review of Resident 7's lab result indicated the resident tested negative for COVID 19 on 6/18/20. A review of Resident 8's admission record indicated the facility admitted the resident on 3/25/19 with [DIAGNOSES REDACTED]. A review of Resident 8's lab result indicated the resident tested negative for COVID 19 on 7/2/2. A review of Resident 8's most current lab result indicated the resident tested positive for COVID 19 on 7/9/20 and LT 1 reported the positive result to the facility on [DATE] at 1:24 a.m. 1. During the tour of the Green Zone and a concurrent interview with Registered Nurse 1 (RN 1) on 7/9/20 at 3:25 p.m., she stated the DON instructed her to transfer all positive COVID 19 residents (Residents 1, 2, 3, 4 and other residents who had been transferred before the onsite visit) to designated COVID 19 facilities (Skilled Nursing Facilities that admitted positive COVID 19 residents). RN 1 stated these residents remained in the Green Zone with their roommates who tested negative for COVID 19. During a review of Resident 1's 2's 3's and 4's laboratory results and concurrent interview with RN 2 on 7/9/20 at 3:50 p.m., she stated RN 1 informed her that the DON received a positive COVID 19 lab results on 7/9/2020 via email from 12: 11 a.m. to 12:14 a.m. for Residents 1, 2, 3, and 4. RN 2 stated she and RN 1 did not moved Resident 1, 2, 3, and 4 to the Red Zone since these residents would be transfer to designated COVID 19 facilities. During a tour of the facility and a concurrent interview on 7/9/20 at 4: 10 p.m., the DSD stated Resident 5, 6, 7 and 8 tested negatives for COVID 19. During a concurrent observation of the Green Zone and interview with the DSD on 7/9/20, at 4:30 p.m., he stated while waiting to be transferred to COVID designated facilities, positive COVID 19 residents were staying in the Green Zone and sharing the same room with negative COVID 19 residents. The locations for these residents are as follow: a. Resident 1 (Bed C) who tested positive for COVID 19 remained in the same room with Resident 6 (Bed A), Resident 7 (Bed B) and Resident 8 (A room next to Resident 1's room and sharing the same bathroom with Resident 1) who tested negative for COVID 19. b. Resident 2 (Bed C) and Resident 3 (Bed D) both tested positive for COVID 19 remained in the Green Zone. c. Resident 4 (Bed C) who tested positive for COVID 19 remained in the same rooms with Resident 5 (Bed A) who tested negative for COVID 19. During a telephone interview with the DON/IPN on 7/9/20 at 5:40 p.m., in the presence of the DSD and RN2, he stated facility's staff were able to cohort the residents in the Red Zone, but he decided to transfer the residents to the COVID 19 designated facilities to ensure residents received immediate respiratory care and rehabilitation services as needed. The DON stated on 7/9/2020, at around midnight, he received the lab results from the LT, and at 9:15 a.m. he instructed his staff to leave positive COVID 19 residents the same room in Green Zone. The administrator stated he instructed his staff to keep the residents' doors closed and to ensure the residents wear masks while waiting for to be transferred. During a record review of the resident line listings affected by COVID 19 and a concurrent telephone interview with the IPN on 7/14/20 at 10 a.m., he stated two residents Resident 6 (who shared room with Resident 1), and Resident 8 (who was in the adjacent/next room and shared the same restroom with Resident 1) tested positive for COVID 19 on 7/9/20 due to exposure to COVID 19 residents. The DSD stated Resident 6 and 8 previously tested negative for COVID 19. A review of the facility's policy and procedure, undated, titled Designation of Areas to Contain the Spread of COVID-19, indicated residents who positive for COVID-19 are confined to Red Zone. A review of the facility's COVID 19 Mitigation Plan, dated 5/29/20, indicated the facility will maintain a safe and secure environment for residents, staffs and visitors by designation of space that can safely isolate COVID 19 positive residents without posing a risk to the life and safety of other residents or staffs. The MP indicated facility's staff will cohort the residents in three distinct areas: Green Zone, Yellow Zone (an area who are under investigation) and Red Zone. The MP indicated residents who tested positive for COVID 19 should be separated from all residents who tested negative and all residents under investigation. Resident who tested positive for COVID 19 should be separated from all residents who tested negative and will not share common area or bathrooms. 2. During a concurrent observation of the facility's resident care area and interview on 7/9/20 at 3:50 p.m., the facility's IPN was not present in the facility. RN 2 stated the facility's IPN resigned (quit) two-month ago and the DON had assumed the responsibilities of the IPN while performing the duties of the DON at the same time. RN 2 stated the DON/IPN was on quarantine (on isolation due to illness or exposure to contagious disease) and was not available at the facility to perform the responsibilities of the IPN. RN 2 stated the DON/IPN did not give clear direction to move positive COVID 19 residents to the Red Zone and the residents who was exposed (had contact with) to positive COVID 19 residents to the Yellow Zone for further monitoring. During a telephone interview on 7/9/20 at 5:40 p.m., with the DON/IPN in the presence of the DSD and RN2, he stated he was a certified IPN, but he was unable to perform the IPN's duties since 7/7/20 due to illness. The DON stated there was no full-time certified IPN at the facility at this time. A review of the facility's COVID 19 Mitigation Plan, dated 5/29/20, indicated the facility has a full time IPN. The MP indicated the IPN shall spend adequate time in the facility focused on activities dedicated to infection control infection. The infection control lead and the DON will evaluate the cohort daily and implement or adjust the group according to the surveillance. The infection Control Preventionist will monitor and improve infection control practices based on local, health and federal. 3. During an observation on 7/9/20 at 5:11 p.m., PH 1 unzipped the tarp barrier (plastic barrier dividing Zed Zone from Green Zone) from the Red Zone, entered the Green Zone and removed her contaminated (used/dirty) gloves. A concurrent interview was conducted; the PH 1 stated she entered the Red Zone to picks up the specimens in the refrigerator. PH 1 stated she had a clean gown in her bag, but she did not wear it. The Phlebotomist did not give an explanation to why she did not wear a gown when she entered the Red Zone to collect specimens and did not doff her contaminated gloves before entering the Green Zone. According to the California Department of Public Health (CDPH) guidance, dated 4/14/2020, www.cdph.ca.gov, indicated the use of PPE is crucial for healthcare workers that have prolonged, close direct contact with patients/residents with possible or confirmed COVID 19 infection or their bodily fluids. 4. During an observation in Room Resident 1's room with the DSD on 7/9/20 at 4: 33 p.m., Resident 1 was sitting in the wheelchair trying to enter the bathroom and the resident was not wearing a mask. A concurrent interview was conducted; Resident 1 stated he had been waiting to be transferred to a COVID designated facility since 9 a.m., when RN 1 informed him that he had COVID 19 infection. Residents 6 and 7 (Resident 1's Roommates) were lying in bed without wearing masks. During a telephone interview on 7/9/20 at 5:40 p.m., with the DON/IPN in the presence of the DSD and the RN2, he stated at 9:15 a.m., he instructed his staff to keep Residents, 1's, 2's, 3's and 4's room doors closed and to ensure the residents wear masks while awaiting to be transferred. A review of the facility's policy and procedure, dated 6/6/20, titled COVID 19 Infection Control Manual, indicated facility's staff will follow the CDC's, Local Health Department's guidance in recognition and management of COVID 19 and ensure residents wear facemasks. 5. During an observation on 7/9/20 at 5:14 pm with Licensed Vocational Nurse 1 (LVN 1), the entrance door to the Red Zone was blocked by a bed. The entrance had no signage to indicate the area was a Red Zone. There was no signage to remind staff to perform handwashing, donning and doffing of PPE for infection control precautions. During the observation of the Red Zone on 7/9/20 at 6: 15 p.m., there were no designated restroom, breakroom for COVID staff in the Red Zone. A concurrent interviewed was conducted; the DS stated staff from the Red Zone and Green Zone were using the same breakroom and restroom. The DSD stated there were no designated restroom, breakroom for staff in the Red Zone. A review of the facility's Mitigation Plan, dated 5/29/20, indicated signage shall be posted immediately outside resident rooms with pictures of appropriate donning and doffing of PPE and appropriate infection control and preventions precautions and required PPE in accordance with the CDPH guidelines. The MP indicated residents who tested positive of COVID 19 should be separated from all residents who tested negative and will not share common area or bathrooms. Cohorting should be done with as such separation as possible with clear signage to separate the area. A review of the facility's policy and procedure, undated, titled Designation of Areas to Contain the Spread of COVID-19, indicated a separate break area for employees working in Red Zone should be identified. If possible, Red Zone should have a dedicated employee restroom.

Based on observation, interview, and record review, the facility failed to follow professional standards of practice by not ensuring staff skillfully responded to an emergency according the their policy and procedures for a life threatening medical emergency in a timely and effective manner; and failed to maintain updated staff records including information that would reflect the Basic Life Support (BLS - a level of medical care which is used for victims of life threatening medical situations until they can be given full medical care at hospital) certification status for the staff, for 1 or two sampled residents (Resident 1). Because these violations presented an immediate jeopardy situation to residents' health and safety, Immediate Jeopardy (IJ) was declared on [DATE], at 7 p.m., with the Director of Nursing (DON), and Director of Staff Development (DSD) because of the facility staff's failure to provide skilled and timely emergency response to a resident (1) who was in need of immediate emergent care during a Code Blue (all-staff alert to gather in a life-saving effort) situation; and for the facility's failure to ensure the nursing staff responding to such situations were properly trained in providing emergency care and services, according to professional standards to respond to life threatening medical emergency situations in a timely and effective manner. In addition, the facility failed to ensure emergency equipment, which included walkie-talkies, was available for use, and failed to maintain updated staff records with updated information including current Basic Life Support (BLS - a level of medical care which is used for victims of life threatening medical situations until they can be given full medical care at a hospital) certification status for the staff. According to the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR - techniques including chest compressions designed to pump the heart to get blood circulating and deliver oxygen to the brain to stimulate the heart to start working) and Emergency Cardiovascular Care (ECC - emergency medical procedures in which basic life support efforts are taken) healthcare providers are encouraged to tailor rescue actions to the most likely cause of arrest. The AHA recommends for immediate recognition and activation of the emergency response system once the healthcare provider identifies the adult victim who is unresponsive with no breathing or no normal breathing (i.e., only gasping). The healthcare provider briefly checks for no breathing or no normal breathing when the provider checks responsiveness. The provider then activates the emergency response system. The healthcare provider should not spend more than 10 seconds checking for a pulse, and if a pulse is not definitely felt within 10 seconds, should begin CPR and use the automated external defibrillator (AED - portable device used to identify and treat via electrical therapy the irregular heart rhythem) when available (Highlights of the 2010 American Heart Association (AHA) Guidelines for CPR and ECC, Pages 1, 2, 5). On [DATE], the Department received and initiated an Entity Reported Incident that indicated Resident 1 had died during an emergency response rescue attempt on [DATE]. On [DATE], at 6:10 p.m., during an interview regarding the death of Resident 1, Licensed Psychiatric Technician 1 (LPT 1) stated the following: 1a. LPT 1 stated Resident 1 had been having labored breathing on [DATE]. She administered a breathing treatment to the resident; he did not improve and still had labored breathing. She did not use her walkie-talkie (two way radio transmitter) to call Registered Nurse Supervisor 2 (RNS 2) because she failed to re-charge the battery that day. Instead she left Resident 1 to page RNS 2 on the telephone at the nurse's station. She waited at the nurse's station until RNS 2 returned her call, at which time she requested his assistance because of Resident 1's change in condition, and then returned to Resident 1's room. Certified Nursing Assistant 1 (CNA 1) was also in the room, and was not directed by LPT 1 to assist in this situation or to inform RNS 2. Not having the walkie-talkie available to immediately call RNS 2 for assistance, and not directing CNA 1 to act accordingly, caused a delay in life-saving emergency response for Resident 1. 1b. LPT 1 stated when she returned to Resident 1's bedside, he still had labored breathing and he was still receiving the breathing treatment. She called out his name several times but the resident did not respond. When asked why she did not start CPR efforts herself when the resident became non-responsive, she stated she called the resident's name several times , but she was scared. She didn't know why she did not start CPR efforts herself as a first responder (the first person to arrive at and assist at the scene of an emergency) or before RNS 2 arrived. Certified Nursing Assistant 1 (CNA 1) was also present and did not act as a first responder. The staffs' delay in commencing CPR procedures immediately as first responders when Resident 1 became unresponsive, delayed life-saving emergency care. 2. During an interview on [DATE], at 1:20 p.m., the DSD was asked for a list of staff members that included the status of their CPR cards. The DSD provided a list that was not current or updated. During a review of a list of the nursing staff CPR re-certifications, there were 50 out of 85 CPR cards that were expired and had missing dates. The DSD stated her files were not current, should have been updated, and she had a stack of staff records that had not been reviewed. The facility's failure to ensure staff were current on CPR and emergency response procedures resulted in a delay in Resident 1's life-saving measures. The Immediate Jeopardy was abated on [DATE], at 11:35 p.m., in the presence of the Administrator, the Vice President of Clinical Services, the Director of Nursing, and the facility ' s consultant when the facility presented an initial acceptable plan of correction which was initiated in response to the IJ which specified: Staff will be in-serviced by DON/DSD on emergency procedures in accordance with the facility's policies. This in-service will begin immediately and completed by [DATE], then monthly for two months. The facility initiated in-services immediately which included: a. In-Service initiated [DATE], 9 p.m., titled, Cardiopulmonary Resuscitation : To institute CPR once cardiopulmonary arrest is recognized to sustain or support a resident's cardiopulmonary functions until medical emergency personnel are available to take over the resuscitation efforts. b. In-Service initiated on [DATE], at 9 p.m., titled, Calling 911 : During an emergency to be able to accurately relay pertinent information and have a smooth transfer of resident from long term care to hospital without delay. c. Staff will be provided with instructional training for CPR certifications if not already CPR certified. Recruited Basic Life Support instructor from outside training company, who began assessment of needs on [DATE], at 10 p.m. Instructions began on [DATE] and continued throughout the day. d. Mock Code Blue drill initiated [DATE] at 2:35 p.m. e. Staff CPR cards and licenses/certifications will be tracked on a monthly basis by the DSD to ensure all CPR cards and licenses/certifications are up to date. This tracking will be implemented immediately and completed by [DATE]. f. New CPR tracking record grid formulated on [DATE] to include all nursing staff with name, date CPR certification card, and licensure expires. Formal computerized grid formulated on [DATE]. g. The DSD will provide the DON the monthly tracking information for CPR cards and licenses/certifications. The DON will report this information to the QA committee for tracking and trending. h. DSD will include in the orientation to newly hired employees regarding emergency care of calling 911 and CPR policy and procedure. Current copy of valid CPR cards and/or licenses and certifications will be obtained from the new employees upon hiring. Findings: According to the Admission Record, Resident 1 was a [AGE] year-old male, admitted to the facility on [DATE], from a general acute care hospital (GACH). He had [DIAGNOSES REDACTED]. A review of the full Minimum Data Set (MDS) a comprehensive assessment and care screening tool dated [DATE], indicated Resident 1 was able to express ideas and wants, had clear speech and was able to understand others. According to the MDS, the resident's memory was moderately impaired but had the ability to recall after cues were given. The MDS indicated Resident 1 was on a mechanically altered diet and did not exhibit signs and symptoms of a swallowing disorder. According to the History and Physical (H&P) dated, [DATE], Resident 1 did not have the capacity to understand and make decisions. Resident 1 had the following physician's orders [REDACTED].>1. Administer oxygen at two liters per minute by way of nasal cannula (a tube that delivers oxygen through the nose) as needed for [MEDICAL CONDITION], dated [DATE]; 2. Administer [MEDICATION NAME] (a drug that relaxes and opens up the muscles around the airway for easier breathing) 0.5 milligrams (mg)- 3 mg solution nebulizer inhaler (a handheld device used to administer medication inhaled into the lungs) four times a day as needed for shortness of breath, wheezing or [MEDICAL CONDITION] dated [DATE]; and 3. Physician order [REDACTED].) dated [DATE], indicated Resident 1 wanted an attempt of cardiopulmonary resuscitation (CPR) and full treatment for [REDACTED]. Resident 1 had a care plan developed on [DATE], for respiratory problems, with interventions that included: assess as an indication of respiratory distress as shortness of breath (SOB), wheezing, coughing and notify the doctor immediately. Elevate the head of the bed as indicated for SOB to help with breathing. Give oxygen inhalation as indicated, and give breathing treatment as ordered. According to the facility's investigation report dated [DATE], on [DATE], at 6:04 p.m., Resident 1 received a breathing treatment in bed, became unresponsive and stopped breathing. A code blue was called and CPR was initiated. After arriving at the facility, the paramedics reported Resident 1's condition to the GACH's physician (MD 1) via telephone. At 6:29 p.m., Resident 1 was declared expired by MD 1. A review of the nurses' notes dated [DATE], at 6:04 p.m., indicated while on a breathing treatment, Resident 1 became unresponsive and stopped breathing. The charge nurse was immediately called; code blue and 911 was called. CPR initiated via chest compressions until the paramedics arrived. At 6:11 p.m., the paramedics arrived and took over CPR on Resident 1. At 6:15 p.m., the paramedics had reported the condition of Resident 1 to the physician (MD 1) via telephone. At 6:29 p.m., Resident 1 was declared expired by MD 1. During interviews with LPT 1 on [DATE], at 3:20 p.m., and [DATE], at 6:20 p.m., she stated that on [DATE], at 5:50 p.m., Resident 1 was eating dinner sitting up on the side of the bed when she noticed he had labored breathing. Her assessment indicated that he was breathing hard and each time the resident inhaled his shoulders would rise. LPT 1 gave Resident 1 a nebulizer (a device used to deliver inhaled medications by producing a spray mist) respiratory treatment at 6:00 p.m. She stated she had never observed the resident in this condition and had never had to offer the resident a breathing treatment before. LPT 1 left Resident 1's bedside to go to North-East nursing station to overhead page RNS 2. She said RNS 2 was on the other side of the facility at the South-West station, and requested that he call her back. LPT 1 stated she waited at the nursing station phone for RNS 2 to call her back. When RNS 2 returned LPT 1's call, she asked him to come and check on Resident 1 who was having labored breathing. LPT 1 stated on her return to Resident 1's bedside, he still had labored breathing and was still receiving the breathing treatment. She called out the resident's name several times but the resident did not respond. LPT 1 stated she noticed Resident 1 was not breathing, his chest was not rising, his eyes were closed, and he had no body movements. LPT 1 stated she was walking out of the room to call a code blue when RNS 2 was at the door of the room, and they both walked back to Resident 1's bedside. LPT 1 stated RNS 2 saw the resident's condition, lowered the head of his bed, started chest compressions on Resident 1, and told her to call a code blue. LPT 1 stated she did not use her walkie-talkie to call RNS 2 because she failed to recharge the battery that day. When LPT 1 was asked why she did not start CPR efforts herself when Resident 1 became non-responsive, she stated she called the resident's name several times, and stated she was scared. She stated she didn't know why she did not start CPR as a first responder before RNS 2 arrived. LPT 1 stated she had never provided CPR to anyone before and had never called a code blue before. She stated she was waiting for RNS 2 to get there. During an interview on [DATE] at 3:20 p.m., regarding the use of the walkie-talkies, the DON stated they are used by front desk personnel, activities staff, RN Supervisors, housekeeping and maintenance staff, and the LPTs for emergencies. She stated this is a way to communicate instead of continuously overhead paging staff and in case of emergencies. During telephone and face-to-face interviews with RNS 2 on [DATE], at 1:30 p.m. and [DATE], at 3:40 p.m., he stated that on [DATE], at around 6:02 p.m., he was paged to Resident 1's room by LPT 1 because the resident was having a hard time breathing. RNS 2 stated that LPT 1 met him at the door and they both walked towards the resident's bedside together. He stated the resident was lying on his bed with the head of the bed elevated approximately 30 to 40 degrees as it should be because he had been receiving a breathing treatment. RNS 2 stated when he reached Resident 1 he noticed the resident had his eyes open gazing upward. He could tell the resident was not breathing because his chest was not moving up and down. RNS 2 then lowered the bed and walked over to the resident's right side and repeatedly told LPT 1 to call a code blue. He started chest compressions and when the crash cart arrived, LPT 1 provided oxygen to Resident 1 with the Ambu bag (a hand held device commonly used to provide manual air to persons not breathing or not breathing adequately). During interviews on [DATE], at 3:30 p.m. and 10:15 p.m., the Certified Nursing Assistant (CNA 1) stated Resident 1 was eating dinner on [DATE], just before 6 p.m., when he leaned forward and started breathing hard but did not appear to be choking. CNA 1 stated LPT 1 was at the Nurse's station and overheard her ask the resident if he was okay. LPT 1 entered the room and administered a breathing treatment. While Resident 1 was receiving a breathing treatment, LPT 1 went to look for RNS 2 and met him at the door of the room. CNA 1 stated RNS 2 and LPT 1 both returned to the resident's bedside together, where Resident 1 was sitting up on the side of the bed. CNA 1 demonstrated how the resident was sitting at the edge of the bed with his shoulders hunched over and his arms dangling between his legs. CNA 1 stated RNS 2 laid Resident 1 down on the bed and started CPR. According to CNA 1, she took it upon herself to bring in the crash cart, because it appeared to be an emergency. CNA 1 stated RNS 2 initiated chest compressions and LPT 1 used the ambu bag. CNA 1 stated she left the room because she had to finish distributing the rest of the dinner trays. During an interview on [DATE], at 2:45 p.m., LPT 2 was asked to explain the CPR process if he was alone in the room with a resident who stopped breathing. LPT 2 stated, I would use the walkie-talkie to call a code blue, make sure the resident is upright in the bed and breathing. During an interview on [DATE], at 3:00 p.m., LVN 2 was asked to explain the CPR process if she was alone in the room with a resident who stopped breathing. LVN 2 stated, I would check the pulse first, if no pulse I will call for assistance by pressing the call light so someone can help me to double check if the resident is really not breathing. I would also check the chart to see if the resident is a no code or have an advance directive, after that I would start CPR. LVN 2 was asked if the facility had a way to identify residents that are no codes and/or full codes. LVN 2 stated the facility does not have a list, but it is on the resident's chart. During interviews on [DATE], at 2:20 p.m., and at 6:05 p.m., the DSD stated that the facility used an outside resource for CPR re-certification for the staff. When asked for the instructor's qualifications, lesson plan and a tracking system for CPR renewals, the DSD stated she did not have the CPR instructor's qualifications or lesson plans. During a review of a list of the nursing staff CPR re-certifications, there were 50 out of 85 CPR cards that were expired and had missing dates. When asked for the original staff credential checklist the DSD stated that she could not find it. The DSD was asked how does she ensure that all staff credentials and re-certifications are updated and how does she compare the old list to the new list. The DSD stated she does not have a current tracking system. According to the AHA the quality of the rescuer education and frequency of retraining are critical factors in improving the effectiveness of resuscitation. (Highlights of the 2010 American Heart Association (AHA) Guidelines for CPR and ECC, Page 26). A review of the facility's policy titled, Medical Emergencies - Code Blue dated [DATE], indicated the facility will provide an appropriate level of response to the resident during medical emergencies. A medical emergency is defined as any of the following conditions requiring immediate medical intervention and the initiation of the Code Blue procedure included respiratory or [MEDICAL CONDITION], and severe respiratory distress. First Responder - The first of facility personnel to arrive and find a resident with any of the above conditions will: identify whether there is cardiopulmonary or respiratory arrest by shaking the person and calling out their name a minimum of three times. Respond to resident immediately and send available staff to call a Code Blue. Commence one person CPR, according to current practice; if alone, do resuscitation for one (1) minute before leaving the resident to call for help. The first responder should not leave the victim to call for help unless absolutely necessary according to the situation. Subsequent Responder(s) - Activate the emergency response system - call 911. Direct all needed personnel to the Code Blue site. Send a Staff member to the entrance door to wait where the ambulance is expected to arrive. The first RN to respond will lead the code unless responsibility is transferred to another licensed staff member (RN or MD). One person CPR will be maintained until there is a second responder available to begin two people CPR. CPR will continue until the paramedics arrive and assume responsibility. The policy indicated any available nursing staff (this includes CNAs) will complete the tasks as given in the first responder and subsequent responder sections of this procedure. Other staff (social workers, security, housekeepers, etc.) will be available to assist in placing phone calls and/or keeping residents away from the area. In the absence of an attending physician, it will be the responsibility of the first licensed staff member to respond to the code to lead, and coordinate the resuscitation efforts until paramedics arrive. Using the Code Blue Cart Checklist from the emergency cart, the nurse will assure that the following tasks have been completed and/or assigned: a. CPR has been initiated. b. 911 has been called. c. Code Blue or Stat has been paged overhead. d. Emergency Cart is on the scene. e. Staff has been assigned to direct the ambulance crew to the unit. f. Attending MD and/or MD on-call has been notified. g. Director of Nursing/Nurse Manager has been notified. h. Notify resident's family. i. Document the event in the resident record. j. Charting of time and condition of the resident at the time of discovery, CPR initiated, when Code Blue called, when physician and family notified, and when nursing staff responded. k. Complete an incident report, if indicated. l. Restock disposable items. m. Sign Emergency Checklist signifying cart readiness. n. Return emergency cart to the designated area. All documentation will be maintained in the resident's medical record. CROSS REFER TO F517

Based on observation, interview, and record review, the facility failed to implement their written plans and procedures to meet all potential emergencies, including but not limited to ensuring: 1. Communication devices (walkie-talkie which is a two-way radio) were charged and available for use during an emergency; 2. Emergency equipment and supplies were available at the crash cart (a wheeled cart with drawers which carries medicine and equipment for the use in emergency resuscitations); and 3. Staff were current on CPR and emergency response procedures. This deficient practice caused a delay in providing the appropriate level of response to one of two sample residents (Resident 1) during a medical emergency. On [DATE], at 7 p.m., an immediate jeopardy (IJ) was declared in the presence of the Director of Nursing (DON), and Director of Staff Development (DSD) because of the facility's failure to follow their procedures to ensure staff were equipped and trained to meet all potential emergencies, including providing the appropriate level of response to a resident during a medical emergency in accordance with their policies. The Immediate Jeopardy was abated on [DATE], at 11:35 p.m., with the Administrator, the Vice President of Clinical Services, the Director of Nursing, and the consultant when the facility presented an initial acceptable plan of correction which was initiated in response to the IJ that specified: Staff will be in-serviced by DON/DSD on emergency procedures in accordance with the facility's policies. This in-service will begin immediately and completed by [DATE], then monthly for two months. The facility initiated in-services to the staff immediately, to be completed by [DATE]. Licensed staff will be in-serviced regarding maintaining the emergency carts (crash carts) to ensure that emergency supplies are present and stored in correct order. The emergency carts will be checked every shift by a licensed nurse and after the emergency cart is used. This training will begin immediately and completed by [DATE]. A new Crash Cart Checklist was formulated to include each shift to monitor crash cart. Findings: On [DATE], the Department received and initiated an Entity Reported Incident that indicated Resident 1 had died during an emergency response rescue attempt on [DATE]. On [DATE], at 3:20 p.m., and [DATE], at 6:10 p.m., during interviews regarding the events that led to the death of Resident 1, Licensed Psychiatric Technician 1 (LPT 1) stated Resident 1 had been having labored breathing on [DATE]. She administered a breathing treatment to the resident, but he did not improve. She did not have a walkie-talkie (two way radio transmitter) available to call Registered Nurse Supervisor 2 (RNS 2) because she failed to re-charge the battery that day. Instead she left Resident 1 to page RNS 2 on the telephone at the nurse's station. She waited at the nurse's station until RNS 2 returned her call, at which time she requested his assistance because of Resident 1's change in condition, and then returned to Resident 1's room. She stated she could have used her walkie-talkie if it had been available to call for help, and started CPR on Resident 1, but she was scared, and waited for RNS 2, causing a delay in CPR that may have saved Resident 1's life. Certified Nursing Assistant 1 (CNA 1) was also in the room, and was not directed by LPT 1 to assist in this situation or to inform RNS 2. Not having the walkie-talkie available to immediately call RNS 2 for assistance, and not directing CNA 1 to act accordingly, caused a delay in life-saving emergency response for Resident 1. When LPT 1 was asked why she did not start CPR efforts herself when the resident became non-responsive, she stated she didn't know why she did not start CPR efforts herself as a first responder (the first person to arrive at and assist at the scene of an emergency) or before RNS 2 arrived. CNA 1 also did not act as a first responder. The staffs' delay in commencing CPR procedures immediately as first responders when Resident 1 became unresponsive, delayed life-saving emergency care. During an interview on [DATE], at 1:20 p.m., the DSD was asked for a list of nursing staff members that included the status of their CPR cards. The DSD provided a list that was not current or updated. The list indicated 50 out of 85 nursing staffs' CPR cards were either expired or had an unknown status. The DSD stated her files were not current, should have been updated, and she had a stack of staff records that had not been reviewed. The facility's failure to ensure staff were current on CPR and emergency response procedures resulted in a delay in Resident 1's life-saving measures. During interviews on [DATE] at 3:20 p.m., and [DATE], at about 10 a.m., the DON stated there was no written policy regarding the use of walkie-talkies. She stated walkie-talkies are used by front desk personnel, activities staff, RN Supervisors, housekeeping and maintenance staff, and the LPTs in case of an emergency. She stated this is a way to communicate instead of continuously overhead paging staff, and for use during an emergency. When asked who was responsible for ensuring walkie-talkies were ready and available for use, she stated each person is responsible for ensuring they are ready for use. The DON stated there are extra walkie-talkies and batteries available when necessary, and are kept in her office. During an inspection of the crash cart located in the South-West station, on [DATE], at 4:40 p.m., in the presence of the DSD, the checklist adhered to the top of the crash cart indicated what was to be supplied. The checklist indicated the items that were to be located in each drawer number 1 to 5, and the items that should be located out on the cart. There were no isolation masks supplied in the cart; two [MEDICATION NAME] (brand name suction tips) had an expiration date of February 2010, and one [MEDICATION NAME] suction tip had an expiration date of [DATE]. The supplies in the crash cart were not organized in the drawer as indicated on the checklist for quick location in an emergency. For example, a stethoscope should have been in drawer 3 but was found in drawer 2; the Ambu bag (used to provide manual air to the lungs) was in drawer 5 but should have been in drawer 4. The crash cart back board was missing (a rigid plastic board used for placing under a victim which helps have a stable backing especially if a person is in a bed and helps perform adequate and effective chest compressions). Later the DSD stated she had found the back board on the treatment cart and put it back on the crash cart where it should have been in the event of an emergency. When questioned about the disorder of the crash cart during the observation, the DSD stated that it would be chaotic trying to look for a back board during an emergency because the resident needs to be on a flat surface when performing CPR (chest compressions and manual air provision). The DSD also stated it was important to easily locate supplies and they should be in the proper drawer, because you are rescuing a life. The DSD was asked who was responsible for reviewing that the crash cart was complete and organized. She produced a Crash Cart Checklist grid for the month of [DATE]. She stated it is the responsibility of the 11 p.m. to 7 a.m. shift nursing staff to verify that the crash cart is completely stocked and organized. A review of the Crash Cart Checklist for [DATE] indicated all items were present even though the isolation masks and CPR back board had been missing. During an interview with the DON on [DATE], at 11 p.m., she stated the back board was missing on [DATE], because it had been taken to another resident's room during a possible code blue, and staff failed to return it to the crash cart. She stated that the back board should have been placed back on the crash cart directly after use. The facility's policy dated [DATE], titled, Cardiopulmonary Resuscitation indicated licensed nursing staff are required to be certified in basic CPR and must be recertified annually. The facility's policy dated [DATE], and titled, Medical Emergencies - Code Blue (all staff emergency reponse to provide life-saving measures) indicated any available nursing staff (including CNAs) will complete the tasks as given in the First Responder or Subsequent Responder sections. This policy indicated a medical emergency is defined as any conditions requiring immediate medical intervention and the initiation of the Code Blue procedure, including respiratory or [MEDICAL CONDITION] and severe respiratory distress. The policy indicated the first of facility personnel to arrive (first responder) and find a resident with any of the above conditions will identify whether there is cardiopulmonary or respiratory arrest, respond to resident immediately and send available staff to call a code blue; commence one person CPR, according to current practice; if alone, do resuscitation for one minute before leaving the resident to call for help; the first responder should not leave the victim to call for help unless absolutely necessary according to the situation. The procedure indicated any available nursing staff (including CNAs) will complete the tasks as given in the First Resonder sections. The policy indicated in the absence of an attending physician, it will be the responsibility of the first licensed staff member to respond to the code to lead, and coordinate the resuscitation efforts until paramedics arrive. Using the Code Blue Cart Checklist from the emergency cart, the nurse will assure that the following tasks have been completed and/or assigned: a. CPR has been initiated. b. 911 has been called. c. Code Blue or Stat has been paged overhead. d. Emergency Cart is on the scene. l. Charting of time and condition of the resident at the time of discovery, CPR initiated, when Code Blue called, when physician and family notified, and when nursing staff responded. n. Restock disposable items. o. Sign Emergency Checklist signifying cart readiness. CROSS REFER TO F281

Based on observation, interview and record review, the facility staff failed to ensure Resident 1 was provided with and used her walker (assistive device to stabilize a person when walking). Resident 1 walked by several staff who saw her without her walker, but did not provide it to her in accordance with her plan of care, for one of one sample residents. This deficient practice resulted in an avoidable fall and fracture to Resident 1's right ankle, and four days of hospitalization . Findings: On December 5, 2014, at 5 p.m., during an investigation of an entity reported incident (ERI), Resident 1 was observed awake and in bed. She was dressed, and had a splint and wrap covering her right foot and leg up to her knee. She appeared to understand, but generally answered with a "ya", "no", or "okay". When asked if she was in pain, she said no. She was not able to describe what happened to her ankle. The director of nursing (DON) was present, and stated that Resident 1 "always" walked without using her walker. When asked if the resident had her walker with her when she fell , the DON said no, that she left her walker in her room. On December 5, 2014, at 6:45 p.m., during an interview with the physical therapist (PT), she stated that Resident 1 was always "noncompliant" with using her walker. She stated that Resident 1's walker had a big sign with the resident's name on it, and "everyone" knew if they saw her walker to find the resident and give it to her. A review of Resident 1's medical record revealed she was originally admitted to the facility on [DATE]. She was readmitted on [DATE], after the November 15, 2014, fall incident when she fractured her right ankle. She had [DIAGNOSES REDACTED]. She was assessed as being at moderate risk for falls on September 22, 2014, and October 14, 2014. A review of the current Minimum Data Set (MDS), an assessment and care screening tool, dated September 22, 2014, revealed Resident 1 required one-person assist with transfers and walking, and she required a front wheel walker (FWW) to assist her with walking. The care plan with the same date indicated problems of impaired decision making, impaired judgement, poor safety awareness, poor trunk control, unsteady balance, short term memory problems, and she had difficulty understanding others at times. The Interdisciplinary Team (IDT) notes dated November 5, 2014, indicated Resident 1 was not using her walker. Staff were to provide her with her walker and remind her to walk with her walker and reinforce education. There was a care plan dated November 5, 2014, for the problem of having episodes of not using her walker and forgetting its location. The goal was to ensure she use her walker when walking. The approach was the same as indicated in the IDT notes, for staff to provide her with her walker and remind the her to walk with her walker, and reinforce education. The Charge Nurse Narrative Notes regarding the incident dated November 15, 2014, indicated that at 5:50 a.m., the resident was seen leaving her room without her walker; reminded resident to use her walker multiple times but resident "refused and continued walking down the hallway." The notes do not indicate that staff provided Resident 1 with her walker as indicated in the plan of care. A review of the facility's "Interview Record" with a Psych Tech (PT-A) dated November 15, 2014 at 7:15 a.m., indicated that he saw Resident 1 walking multiple times without her walker, and he repeatedly redirected and prompted the resident to go back and get her walker. The resident would respond okay and continue to walk. There was no documentation that PT-A provided Resident 1 with her walker in accordance with her plan of care. The ERI report from the facility dated November 20, 2014, indicated that on November 15, 2014, at about 6 a.m., Resident 1 was walking in the hallway without her walker, lost her balance and fell on her buttocks. She was assessed with [REDACTED]. During an interview with the DON on December 5, 2014, at 7:20 pm, when asked about the investigation for the incident, she was unable to provide any information. When asked if she thought the fall could have been prevented, she wasn't sure. She said that Resident 1 was on therapy for endurance prior to the fall, and she was "improving". She said Resident 1 used her FWW and goes everywhere. She forgets her walker and staff remind her and look for it. The DON could not say where the resident fell , whether anyone saw her fall, or who her direct care staff was on that morning. She agreed that there had not been a thorough investigation into the resident's fall, even though they knew what had happened. On December 5, 2014, at 7:30 p.m., PT-B was presented as someone who was working at the time of the incident. In an interview with PT-B at the same time, he stated he was at the opposite end of the hall at the time of Resident 1's fall incident. He said he didn't see Resident 1 fall, but he heard the commotion, and turned and saw her on the floor. He said he couldn't remember if she had her walker. A review of the "Interview Record" from PT-B regarding the incident indicated that he saw Resident 1 walking without her walker and immediately redirected her. The resident responded okay. There was no indication that PT-B provided Resident 1 with her walker as indicated in her plan of care. On January 8, 2015, at 6:45 a.m., an interview with the 11 p.m. to 7 a.m. shift certified nursing assistant (CNA 1), assigned to Resident 1 when the incident occurred was conducted. CNA 1 stated that Resident 1 always got up to go to the morning coffee time on the patio at 6:30 a.m. That was where she was headed when she fell . When asked why Resident 1 fell , she said that her walker was left in her room, and the resident got out of balance and fell . She stated that Resident 1 always forgot her walker and everyone knew the walker, and "everyone knew to take it to her." She stated she was in Room 17 with another resident when the incident occurred. Resident 1 fell right before she got to the patio door exit. CNA 1 said that Resident 1 does not go to the patio to coffee hour any more, and has breakfast in bed. When asked why, she said because she needed help to go there. When asked if she thought this fall could have been prevented, she said "yes." On January 8, 2015, during an interview at 9 a.m. with the 7 a.m. to 3 p.m. receptionist, she stated that the reception desk is supposed to be covered 24 hours 7 days a week. During lunch and breaks, they are not to leave until someone relieves them. She said she had been at the facility since July 2014, and knew Resident 1 was to have her walker; she said everyone knew she was to have her walker. She said if she saw Resident 1 come out of her room without her walker, she would call the CNA right away to bring the walker, but she was not at work when the incident occurred. When asked who was on duty, she stated that person had already left for the day. When asked about the receptionist/door monitor duties, she said that they are to ensure residents do not go out the door, which is at the bottom of the stairs. She provided a job description for the "Resident Door Monitor" that indicated the above information. In addition, the job duties of the door monitor included to re-direct any resident for their safety and well-being. On January 8, 2015, at 9:15 a.m., during an interview and record review with the Rehab Director, he stated that Resident 1 requires a wheel chair, and is supposed to start walking with full weight bearing using a CAM (controlled ankle motion) walker (boot to walk with). She was evaluated on January 7, 2015, and was totally dependent at that time, requiring total assist to stand. He said they don't keep the CAM walker in the resident's room because she may try to get up and use it without help, so they keep it in the Rehab room. He stated her safety awareness is very poor, and she is a very, very high risk for falls, is compulsive, and has a very low attention span. On January 8, 2015, at 9:45 a.m., Resident 1 was observed still waiting to get out of bed. CNA 2 was present and she said that Resident 1 now uses a wheel chair, but can't "drive it", indicating that she can't propel herself where she wants to go. At 10:15 a.m., on January 8, 2015, an interview regarding the incident area and layout of the facility was conducted with the DON. Resident 1's room was to the left of the stairway entrance to the facility, and the door monitor. Her room was at the corner, and the hallway continues with a right turn and goes to an exit that is not used by residents. At approximately 6 a.m., Resident 1 left her room without her walker. She turned right out of her room, and walked by the receptionist/door monitor, which is the only way to go to the patio, and any staff that were in the hallways. She continued by the administrative offices that are staffed in the early morning. She walked around the corner and down the hallway passing the East nursing station, where PT-B was passing medications, turned the corner and walked toward the patio. There was no evidence provided to indicate that staff either escorted her back to her room to get her walker, or ensured that she had supervision while they went to get her walker to provide to her, in accordance with her plan of care and IDT recommendations. The DON was informed that as a result of staff not providing Resident 1 with her FWW assistive device, she lost her balance, fell and fractured her ankle.

Based on observation, interview and record review, the facility failed to ensure that the environment was safe and remained free of fire hazards for all the residents and staff in the facility. The facility failed to follow policies and procedures by not providing proper supervision to residents who smoked and allowing access to cigarettes and lighters for one of one sample residents (1) and seven random sample residents (2, 3, 4, 5, 6, 8, 9). On March 8, 2013 at 9 a.m., an immediate jeopardy (IJ) was called in the presence of Director of Nursing (DON), Director of Staff Development (DSD) and Registered Nurse 3 (RN 3) because of the facility's failure to provide proper supervision to residents who smoked including allowing facility residents to keep smoking paraphernalia in their possession contrary to the facility's policy. The facility's policy titled, " Smoking Policy and Procedure, " indicated all smoking paraphernalia (cigarettes, cigars, lighters, etc.) shall be labeled with the resident's name, secured and maintained by the facility staff. No resident will possess smoking paraphernalia; smoking shall be permitted only in the designated area during the smoking time. The designated area for smoking is located in the middle patio of the building. As of March 15, 2013, the IJ remains unabated since a resident was observed to have smoking paraphernalia (a cigarette lighter) in his possession. The plan of correction submitted by the facility was unacceptable and did not identify specific interventions. Findings: According to the admission record, Resident 1 was admitted to the facility on [DATE].with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-a standardized comprehensive assessment of the resident's problems and conditions) dated January 21, 2013, indicated Resident 1 had the ability to make himself understood and understand others, and was moderately impaired in cognitive skills for daily decision-making. A review of the Safe Smoking Assessment, dated January 14, 2013, indicated the resident was able to smoke independently, did not need a smoking schedule and supervision to smoke, and is able to keep smoking material in person. However, this is contrary to the smoking policy. The Initial History and Physical, dated January 16, 2013, indicated the resident did not have the capacity to understand and make decisions. On February 20, 2013, according to a facility investigation report dated February 20, 2013, Resident 1 admitted that he intentionally started a fire in his room by setting his bed mattress on fire with a cigarette lighter. Resident 1 stated "I get some paper towel and burn it on my bed". He stated he had a lighter he bought during one of his outings in the activities. He said he did it because he wanted to get out of the facility. All rooms remained closed until the fire department cleared the smoke from the facility. On March 5, 2013 at 8:05 a.m., in the presence of Registered Nurse 2, Assistant Director of Nursing (RN 2, ADON) of the nine residents in the smoking area, two were smoking. The smoking area patio was being monitored by Activity Assistant 1. On March 5, 2013 at 8:15 a.m., four residents were observed smoking in a non-smoking area in front of a vending machine and approximately eight feet from room 21 while supervised by Activity Assistant 1. Four residents were smoking in front of a vending machine and there were two signs in this area by rooms 16 and 17 that indicated "No Smoking". On the same day, at approximately 8:15 a.m., during an interview with RN 2 the signs were pointed out by the surveyor to RN 2. She stated the residents should not be smoking in this area then turned to instruct Activity Assistant 1 to move the four smoking residents from the area and to the designated smoking area. On the same day at 9 a.m. Resident 2 was observed in his room with cigarettes and a cigarette lighter in his possession. According to the admission record, Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. The Minimum Data Set (MDS-a standardized comprehensive assessment of the resident's problems and conditions) dated December 28, 2012, indicated the resident had the ability to make himself understood and understand others, and was moderately impaired in cognitive skills for daily decision-making. On March 5, 2013 at 8:40 a.m., during a general observation of the facility in the presence of the DSD, Resident 2 showed a pack of cigarettes and a cigarette lighter he had in his pocket. He also reported that in his previous room at this facility he had a roommate that smoked in the bathroom of the room. He knew this because he could smell the cigarette smoke. During a record review on March 5, 2013 at 10:40 a.m., the Resident Smoking Assessment Form in Resident 2's medical record did not have a date section, the conclusion section is incomplete as it did not indicate if the resident was or was not able to keep cigarettes, carry a lighter and follow the facility's Smoking Policy. During an interview on March 5, 2013 at 10:40 a.m., the DSD stated that the Activity Director did not obtain Resident 2's signature on the facility's Smoking Policy and Procedure because the resident refused to sign there was no documented evidence that the Smoking Policy and Procedure was discussed with Resident 2. On March 5, 2013 at 11:15 a.m., during an interview with RN 2 ADON and DSD, regarding resident smoking assessments, they stated that a Resident Smoking Assessment Form had been started approximately one month ago. This assessment tool was used upon admission to the facility to assess the resident's smoking ability based on mental status and interview with the resident. According to the ADON and the DSD the resident would be re-assessed if necessary. The ADON stated the "re-assessment would be done when CNA's, who supervise the smoking patio, report to the charge nurse if the resident has had any problem outside while smoking." During an interview with the DSD and RN 2 on March 5, 2013 at 11:25 a.m., they both stated that the assessment should have been completed and not left blank because the resident does carry cigarettes and a lighter. During the same interview RN 2 stated the facility should have developed a smoking care plan, but there was no care plan in the medical record. On March 5, 2013 the activity department staff was interviewed regarding resident's outings: During an interview with the Activity Director on March 5, 2013, at 12:15 p.m., she stated residents are taken on shopping outings by the activity assistants to Trader Joe's where residents only buy apples, bananas, sodas and chips. On the same day during an interview at 12:20 p.m., with Activity Assistant 2, she stated she takes the residents on shopping outings to Trader Joe's and the cigarette shops where cigarettes and cigarette lighters are sold. According to Activity Assistant 2, she watches what they buy and if a resident attempts to buy a lighter the cashier signals to her when a resident is trying to buy a lighter and this is how the residents are monitored and deterred from buying cigarette lighters. On March 5, 2013, at 4 p.m., during an interview with the Administrator, he stated that residents were allowed to have cigarettes and lighters but now if they refuse to give up their lighter, they have rights as residents which allow them to keep their lighters. According to the admission record, Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] The Minimum Data Set (MDS-a standardized comprehensive assessment of the resident's problems and conditions), dated December 13, 2012, indicated the resident had the ability to usually made himself understood and understand others, and was severely impaired in cognitive skills for daily decision-making. A review of the undated Resident Smoking Assessment indicated the resident is not able to keep cigarettes, carry a lighter and follow the facility ' s smoking policy. On March 5, 2013 at 5 p.m., during an observation of the smoking patio area with RN 4, Residents 5 and 6 were observed sitting in the smoking area. No facility staff were monitoring the patio area at this time. In the presence of RN 4 two cigarette butts were observed on the ground next to room 21, a no smoking area. On March 5, 2013 at 5:10 p.m., during an interview with Resident 6, he stated there was no one supervising the patio while he was there smoking. When asked how he lit his cigarette he stated that he lit his cigarette with another smoker's cigarette but did not know how that smoker lit his cigarette. The Resident Care Plan for Smoking developed February 15, 2013, for Resident 6 indicated the resident had impaired cognitive skills for decision making, and had hand tremors. The goal of the care plan stated the resident would smoke safely in accordance with facility policy. The approaches of the plan of care included to supervise the resident per facility policy while smoking, and to observe the resident for unsafe smoking behaviors. On March 6, 2013 at 8:15 a.m., during an observation of the smoking patio area there were approximately 12 residents who were being monitored by Activity Assistant 1. There were two residents, a tall male and a female in a wheelchair, sharing a cigarette in an area to the side of the building that houses rooms 23-25, which was an area away from the designated smoking area and not visible by the staff member who was monitoring the area. According to the admission record Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] and the MDS information was not available. A review of the undated Resident Smoking Assessment indicated the resident is able to keep cigarettes, carry a lighter and follow the facility ' s Smoking Policy which was contrary to the smoking policy. On March 6, 2013, at 8:35 a.m., at the patio smoking area the surveyor was approached by Resident 3 and during the course of the interview he stated he has had eight cigarette lighters since he has been at the facility. He added that the facility has a safe smoking policy "that is not elaborated on by the facility staff" he added there was "...no description of what safe smoking policy was." On March 6, 2013 CNA 1 was the receptionist at the front desk where the facility's camera monitor is located. On this day during an observation of CNA 1 at 9:15 a.m., it was noted her duties included visual monitoring of the cameras located throughout the facility including the smoking areas, answering telephone calls, taking messages, faxing documents, observing residents walking towards the front door, and answering resident's questions regarding their appointments. It was also noted that between 9:17 a.m. and 9:20 a.m. she answered two phone calls. During an interview at this time she stated that she gets approximately 4 phone calls within a fifteen minute period. On the same day at 2:50 p.m., it was observed that there were 5 people around her desk waiting to talk to her while she was answering a phone call. According to the admission record, Resident 4 was admitted to the facility on [DATE]. According to the Smoking assessment dated [DATE], the resident is not able to keep cigarettes, carry a lighter and follow the facility ' s Smoking Policy. According to the Safe Smoking assessment dated [DATE], the resident is not able to keep smoking material on person. According to a physician's History and Physical dated June 6, 2012, the resident had the capacity to understand and make decisions. The Minimum Data Set (MDS-a standardized comprehensive assessment of the resident's problems and conditions) dated November 3, 2012, indicated the resident had the ability to make himself understood and understand others, and was severely impaired in cognitive skills for daily decision-making. On March 6, 2013 at 2:45 p.m., Resident 4 was observed sitting by herself with a walker in front of her. She was smoking what she called "little cigars," they looked like brown paper cigarettes. Noticed that resident was smoking her cigarette very close to her fingers and asked if she had ever burned her fingers. She stated that she burns her little finger and index fingers sometimes. She showed a pink area approximately one quarter inch wide on her index finger where she had a burn. It was also noticed she had a hole on her left pant leg at the inner thigh. It was a black pair of slacks and the resident identified it as a cigarette burn and stated..."it does happen once in a while." Resident 4's care plan for Smoking developed February 14, 2013, indicated the resident was safe to smoke independently with supervision. The care plan had a goal indicating the resident will smoke safely in accordance with facility policy and will have no injury related to smoking. Included with the interventions were to store smoking related material per facility policy, supervise resident per facility policy while smoking, assist the resident to and from designated smoking area as needed, and observe resident for unsafe smoking behaviors. The monitor for the cameras was located at the reception desk. On March 6, 2013 at 2:50 p.m., there were 5 people around the receptionist's desk waiting to talk to her while she was answering a phone call. On March 6, 2013 at 4:50 p.m., during an observation with the DSD of the area outside the West hallway door, two cigarette butts were observed on the ground. The Surveyor and the DSD continued walking along the West walkway to the end of the walkway to the West gate, along the way a total of 27 cigarette butts were observed. When the DSD was asked who smokes in this area, he stated that along the walkway residents from rooms 5 to 11 walk out the sliding glass doors to smoke in the walkway and would be unsupervised. At this time the DSD was informed of all the distractions observed at the front desk monitor. The DSD stated the front desk person does have a lot of distractions from people approaching her desk and answering telephone calls. On March 7, 2013 at 3:35 p.m., Resident 4 was observed in the smoking patio sitting by herself with a walker in front of her. The resident is able to get up independently and ambulates with the walker to her room. She states at this time that she always walks back and forth from the patio area to her room. She also states that she has not reported the finger burns to anyone in the facility and that she burns her finger about once a month. She says she never wears a smoking apron because it's not too attractive. There was inconsistent information from staff and residents about the smoking schedule. One smoking schedule sign was posted on the back wall of the activity room located in the basement of the facility. According to the facility's Smoking Policy and Procedure the smoking breaks are at 9 a.m., 11:45 a.m., 1:30 p.m., 4:30 p.m., 7 p.m., and 8:45 p.m. During an interview with the DON on March 7, 2013 at 8:50 a.m., when asked about smoking schedule signs the DON and the surveyor searched the facility and found a second sign on the wall behind front door reception desk. Most smokers congregate to the back of the facility close to the smoking patio area. The DON also indicated that smoking breaks are announced by the overhead speaker system. Despite the smoking break announcements residents are still uncertain about the breaks and still another resident had other information about the smoking breaks. On March 7, 2013 at 10:50 a.m., during an interview with Licensed Vocational Nurse 1, she stated that Resident 8 asks her several times a day about smoking break times. On the same day at 11:15 a.m., in the patio smoking area the DON reminded Resident 9, who was smoking, of the smoking break schedule. The resident responded to the DON by saying that residents who have their own cigarettes can smoke any time they wish and residents who do not have their own cigarettes had to smoke according to the smoking break schedule. The DON left and returned fifteen minutes later at 11:30 a.m., and stated that the smoking schedule posted was for residents who do not own their own cigarettes (determined by the Resident Smoking Assessment) and residents who have cigarettes in their possession can smoke anytime as long as it is in the patio smoking area. She stated that smoking schedules would be posted throughout the facility. At this moment the DSD was present and added that one activity staff member is supervising the patio from 7 a.m. to 3 p.m.; and a CNA supervises the smoking patio area from 3 p.m. to 11 p.m.; from 11 p.m. to 7 a.m., nurses or supervisors will accompany smokers out into the smoking patio area and throughout the day there are cameras that monitor several areas of the facility with the monitor is at the front desk. During an interview with the Director of Rehabilitation on March 7, 2013 at 4:25 p.m., regarding residents using assistive devices for smoking such as cigarette holders, he stated that cigarette smokers smoke cigarettes down to the butt because of the facility smoking schedule. Smokers on schedule smoke their cigarettes to the end because their next cigarette won't be for another two hours and they may not like a device such as a cigarette holder because it "strains the nicotine." Smokers who have their own cigarettes usually leave a longer butt because they can re-light another cigarette at any time. The Director of Rehabilitation went on to add that recommendations for smoking device to protect residents' fingers from burning had not been followed. On March 8, 2013 at 9:25 a.m., during an interview with the DON regarding residents keeping cigarettes in their possession, she stated that none of the residents' cigarettes had been confiscated. The facility's Policy titled, Smoking Policy and Procedure, undated, indicated that it is the policy of the facility to accommodate safe resident smoking, consistent with respect for the rights of smoking residents while respecting the rights of all facility residents to live in a safe and healthy environment. Therefore, the smoking residents must follow the smoking policy for their safety and protection, and all residents in the facility. The policy also included procedures which indicated: 1) Each resident and/or responsible party shall sign a form stipulating that they have been informed by the facility of the "Smoking Policy" and the responsibilities that they have as a resident of this facility. 2) That all smoking paraphernalia (cigarettes, cigars, lighters, etc.) shall be labeled with resident's name, secured and maintained by the facility staff. No resident will possess smoking paraphernalia. 3) Smoking shall be permitted only in the designated area during the smoking time. The designated area for smoking is located in the middle patio of the building.

Based on observation, record review, and interviews conducted, it was determined the facility did not maintain comfortable and safe temperature levels inside the Skilled Nursing Facility which could lead to heat stroke (a life-threatening condition with symptoms of high body temperature, rapid pulse, difficulty breathing, and confusion), dehydration (when the body loses water that is not replaced), or death. Issues included the lack of an effective plan to monitor and maintain air conditioning (A.C.) equipment in the facility during a disruption of services for any reason. In addition, there was a delay in implementing additional cooling measures as addressed in the facility's policies and procedures (P&P), that would protect residents against heat stroke, and other affects of excessive heat, such as dehydration, when the facility temperatures reached above 95 degrees Fahrenheit (? F). This affected 125 of 125 residents. Based on information provided by the Director of Nursing, on August 27, 2011, care levels at the facility were as follows: There were 11 residents who were totally dependent on staff, 38 who required extensive assistance from staff, and 68 who required assistance with one or more activities of daily living (ambulation, transferring from one surface to another, grooming, hygiene, and eating). There were 38 residents who had [DIAGNOSES REDACTED]. The risk for heat stroke and/or dehydration is higher in people with diabetes, due to elevated blood sugar levels that cause sugar to spill into the urine, causing excessive urination which may cause significant dehydration. This was widespread with no actual harm with the potential for serious harm that resulted in IMMEDIATE JEOPARDY (IJ) AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY, that was called at 6:30 p.m., on August 27, 2011, in the presence of the Administrator, and Clinical Consultant. The Administrator was informed that the IJ was lifted on September 1, 2011, at 5 p.m., and the scope and severity level was reduced to a D level. Findings: On August 27, 2011, at 4 p.m., complaints of excessive and uncomfortable temperatures and insufficient air conditioning at the facility were received by the Department of Public Health (Department) via the emergency complaint line. An investigation was initiated at 5:30 p.m. According to local weather reports, the San Fernando Valley, where the facility was located, had been experiencing excessive temperatures between 100 degrees Fahrenheit (? F) to 110? F during the week of August 27, 2011. When arriving onsite at 5:30 p.m., on August 27, 2011, the Glendale Fire Department (GFD) was present in response to an emergency call; the Glendale Police Department (GPD) was present at the request of the GFD, and the Long Term Care Ombudsman was present in response to a complaint call, along with a concerned family member. Administrative staff, including the Administrator, and Clinical Consultant, were present, however, they were slow to implement emergency actions to prevent complications of excessive heat, such as heat stroke and dehydration. The Department met with facility Administrative staff, immediately, and because of the lack of staff actions, began directing the administrative staff as to remedies that were required to be in place. The surveyors were then assured that additional measures to ensure resident comfort, including the rental of portable air conditioners for resident rooms and corridors, purchasing extra portable oscillating fans, providing extra icewater stations, and ensuring residents had icewater at their bedsides, would be taken immediately and continue throughout the weekend. There were no preventative maintenance records for the air conditioning units, according to the Administrator. The conditions observed during the onsite investigation from August 27, 2011, through August 29, 2011, included uncomfortably high temperatures that ranged from 80? F to 95? F (according to the GFD's temperature recordings taken at 3:00 p.m.), and high humidity levels, together with the complaints and concerns expressed by family and staff, revealed that these measures, together with the extra oscillating fans, were not sufficient in providing a comfortable and safe environment at the facility. Resident rooms temperatures measured with the Clinical Consultant, the Maintenance Supervisor, and the Ombudsman on August 27, 2011, at 5:40 p.m. were as follows: room [ROOM NUMBER]- 87.0? F room [ROOM NUMBER]- 85.0? F room [ROOM NUMBER]-90.5? F room [ROOM NUMBER]- 84.4? F room [ROOM NUMBER]- 90.4? F room [ROOM NUMBER]-88.1? F room [ROOM NUMBER]- 89.4? F room [ROOM NUMBER]- 91.2? F room [ROOM NUMBER]- 87.6? F room [ROOM NUMBER]- 86.1? F Hallway 87.3? F room [ROOM NUMBER]- 86.3? F room [ROOM NUMBER]- 86.0? F room [ROOM NUMBER]- 86.6? F room [ROOM NUMBER]- 86.7? F room [ROOM NUMBER]- 84.0? F room [ROOM NUMBER]- 86.7? F room [ROOM NUMBER]- 85.9? F room [ROOM NUMBER]- 86.0? F room [ROOM NUMBER]-86.1? F room [ROOM NUMBER]- 87.6? F room [ROOM NUMBER]- 89.9? F room [ROOM NUMBER]- 89.4? F room [ROOM NUMBER]- 88.6? F room [ROOM NUMBER]-87.0? F During the rounds, no residents appeared to be in distress, and those who were interviewable stated that they were hot, but not in any distress. During an interview on August 27, 2011 at 7 p.m., to determine the time the A.C. became inoperable, the director of staff development (DSD) stated the facility staff noticed the air conditioning units weren't working properly around 12 p.m. on that day. The maintenance supervisor was not able to fix the A.C. problems, so he contacted an A.C. service, however they were not able to fix the problem. On August 27, 2011, at 6:30 p.m., the maintenance supervisor stated the facility had 31 small A.C. units throughout the facility that were supported by the two large rooftop chiller units. He stated five of the small A.C. units were blowing warm air. During an interview with the A.C. service technician on August 27, 2011 at 7:45 p.m, he stated the facility had two chillers on the roof supporting the A.C. units in the facility. One of the two chillers had broken down, and he was not able to fix the problem right away, but his crew would return in about an hour with rental A.C. units. The facility's air handling units were still functioning, but not at full capacity, such as diminished air flow, and the need of repairs due to lack of routine maintenance. The temperature measured outside at this time was 76? F. At 9 p.m., the facility provided more portable fans and ice to all resident rooms. The hallway temperature measured at 78.1? F, room [ROOM NUMBER] measured at 78.0? F, and room [ROOM NUMBER] at 73.0? F. The ambient air temperature outside was cooler by this time. On August 28, 2011, between 9:30 a.m. and 10:30 a.m., rounds were made with administrative staff. According to the Administrator, there was still no contract in place for the repair of the A.C. chillers. Ten portable A.C. units (MovinCool OfficePro12) had been strategically placed throughout the facility in individual rooms. Two large portable units (MovinCool OfficePro60) were temporarily placed in the East and West exits. Temperatures were measured to be within acceptable limits. At 5 p.m., Rooms 7 through 13 were measured above 81? F as follows: room [ROOM NUMBER] - 83? F room [ROOM NUMBER] - 88? F room [ROOM NUMBER] - 87.7? F room [ROOM NUMBER] - 83.5? F room [ROOM NUMBER] - 81.9? F room [ROOM NUMBER] - 82.8? F During the rounds, no residents appeared to be in distress, and those who were interviewable stated that they were hot, but not in any distress. On September 1, 2011, at 9:10 a.m., during an interview with the Administrator, she stated that she didn't know why staff didn't call her right away. She stated that the maintenance "person" and/or company that she had on file for the A.C., was contacted for the emergency, and as of this date, he had not called back. That is why the Maintenance Supervisor started to call all over to try and find a company that would service the A.C. immediately. She stated that she had no records on file of the last time the A.C. unit was serviced. There was no maintenance contract in place for routine service, and there was no contract with the "person" for emergency situations that may occur. She also provided a copy of the facility's emergency plan/procedures. There was no contingency plan for mechanical repair or maintenance in the event of this type of situation during an emergency situation for excessive heat. The IJ was lifted on September 1, 2011, at 5 p.m., after receiving signed contracts for the previous and current repair work for the A.C. system and accompanying parts, and for regular maintenance to the system. The facility provided daily temperature logs to the Department, and onsite monitoring continued, as necessary, through September 8, 2011, to ensure continued compliance. On September 8, 2011, at 2:30 p.m., during an exit conference with the Director of Nursing (DON), she provided a service invoice from the A.C. repair company that indicated on September 7, 2011, the chiller system and cooling tower work was completed, with both 1 and 2 circuits operating at normal capacity. This was to supply sufficient cooling to all resident rooms to maintain temperatures between 75? F and 79? F throughout the facility. However, during rounds with the DON at approximatly 3 p.m., temperature checks were conducted, and the temperature in room [ROOM NUMBER] measured 85? F. According to the DON, these residents preferred their door to remain closed, and the individual room mechanism was probably not working properly. The two residents in the room, when asked, stated that they were comfortable. The DON instructed the Maintenance Supervisor to install the "temporary" portable A.C. unit that was purchased "for emergency situations" on the morning of the same day. All other areas measured in the facility were within acceptable temperature limits. The residents interviewed during the rounds had no complaints about the temperatures. Cross Refer To: F456 - 483.70(c)(2) - Essential Equipment, Safe Operating Condition F465 - 483.70(h) - Safe/functional/sanitary/comfortable Environ F517 - 483.75(m)(1) - Written Plans To Meet Emergencies/disasters F518 - 483.75(m)(2) - Train All Staff-Emergencies/drills

Based on observation, staff interviews and documentation review, it was determined that the facility did not maintain all essential equipment in safe operating condition to provide comfortable and safe temperature levels, when the facility temperatures reached above 95 degrees Fahrenheit (? F). The secondary air conditioning (A.C.) chiller was in disrepair, and did not activate when necessary during the heat spell, resulting in the inability to provide safe, comfortable air temperatures throughout the facility. Issues included the lack of an effective plan to monitor and maintain A.C. equipment in the facility during a disruption of services under any circumstances, and lack of a contingency plan in the event of the A.C. equipment failure. This had the potential to lead to residents suffering affects of excessive heat such as heat stroke (a life-threatening condition with symptoms of high body temperature, rapid pulse, difficulty breathing, and confusion), dehydration (when the body loses water that is not replaced), or death. This affected 125 of 125 residents. Based on information provided by the Director of Nursing, on August 27, 2011, care levels at the facility were as follows: There were 11 residents who were totally dependent on staff, 38 who required extensive assistance from staff, and 68 who required assistance with one or more activities of daily living (ambulation, transferring from one surface to another, grooming, hygiene, and eating). There were 38 residents who had [DIAGNOSES REDACTED]. The risk for heat stroke and/or dehydration is higher in people with diabetes, due to elevated blood sugar levels that cause sugar to spill into the urine, causing excessive urination which may cause significant dehydration. This was widespread with no actual harm with the potential for serious harm that resulted in IMMEDIATE JEOPARDY (IJ) that was called at 6:30 p.m., on August 27, 2011, in the presence of the Administrator, Director of Nursing, and Clinical Consultant. The Administrator was informed that the IJ was lifted on September 1, 2011, at 5 p.m., and the scope and severity level was reduced to a D level. . Findings: On August 27, 2011, at 4 p.m., complaints of excessive and uncomfortable temperatures and insufficient air conditioning at the facility were received by the Department of Public Health (Department) via the emergency complaint line. An investigation was initiated at 5:30 p.m. According to local weather reports, the San Fernando Valley, where the facility was located, had been experiencing excessive temperatures between 100 degrees Fahrenheit (? F) to 110? F during the week of August 27, 2011. When arriving onsite at 5:30 p.m., on August 27, 2011, the Glendale Fire Department (GFD) was present in response to an emergency call; the Glendale Police Department (GPD) was present at the request of the GFD, and the Long Term Care Ombudsman was present in response to a complaint call, along with a concerned family member. Administrative staff, including the Administrator and Clinical Consultant, were present, however, they were slow to implement emergency actions to prevent complications of excessive heat, such as heat stroke and dehydration. The Department met with facility Administrative staff, immediately, and because of the lack of staff actions, began directing the Administrative staff as to remedies that were required to be in place. The surveyors were then assured that additional measures to ensure resident comfort, including the rental of portable air conditioners for resident rooms and corridors, purchasing extra portable oscillating fans, extra icewater stations, and ensuring residents (without swallowing problems) had icewater at their bedsides, would be taken immediately and continue through the weekend. There were no preventative maintenance records for the air conditioning units, according to the Administrator. The conditions observed during the onsite investigation from August 27, 2011, through August 29, 2011, included uncomfortably high temperatures that ranged from 80? F to 95? F, (according to the GFD's temperature recordings taken at 3:00 p.m.), and high humidity levels, together with the complaints and concerns expressed by family and staff, revealed that these measures, together with the extra oscillating fans, were not sufficient in providing a comfortable and safe environment at the facility. Resident rooms temperatures measured with the Clinical Consultant, the Maintenance Supervisor, and the Ombudsman on August 27, 2011, at 5:40 p.m. were as follows: Room 1- 87.0? F Room 2- 85.0? F Room 4-90.5? F Room 5- 84.4? F Room 6- 90.4? F Room 7-88.1? F Room 8- 89.4? F Room 9- 91.2? F Room 10- 87.6? F Room 11- 86.1? F Hallway 87.3? F Room 12- 86.3? F Room 13- 86.0? F Room 14- 86.6? F Room 15- 86.7? F Room 16- 84.0? F Room 22- 86.7? F Room 23- 85.9? F Room 28- 86.0? F Room 29-86.1? F Room 32- 87.6? F Room 33- 89.9? F Room 34- 89.4? F Room 35- 88.6? F Room 36-87.0? F During the rounds, no residents appeared to be in distress, and those who were interviewable stated that they were hot, but not in any distress. During an interview with the Director of Staff Development (DSD) on August 27, 2011 at 7 p.m., to determine the time the A.C. became inoperable, he stated the facility staff noticed the air conditioning units weren't working properly around 12 p.m. on the same day. The maintenance supervisor was not able to fix the A.C. problems, so he contacted an A.C. service, however they were not able to fix the chiller units. On August 27, 2011, at 6:30 p.m., the maintenance supervisor stated the facility had 31 small A.C. units throughout the facility that were supported by the two large rooftop chiller units. He stated five of the small A.C. units were blowing warm air. During an interview with the A.C. service technician on August 27, 2011 at 7:45 p.m, he stated the facility had two chillers on the roof supporting the A.C. units in the facility. One of the two chillers had broken down, and he was not able to fix the problem right away, but his crew would return in about an hour with rental A.C. units. The facility's air handling units were still functioning, but not at full capacity, such as diminished air flow, and the need of repairs due to lack of routine maintenance. The temperature measured outside at this time was 76? F. At 9 p.m., the facility provided more portable fans and ice to all resident rooms. The hallway measured at 78.1? F, Room 6 measured at 78.0? F, and Room 23 at 73.0? F. The ambient air temperature outside was cooler by this time. On August 28, 2011, between 9:30 a.m. and 10:30 a.m., rounds were made with administrative staff. According to the Administrator, there was still no contract in place for the repair of the A.C. chillers. Ten portable A.C. units (MovinCool OfficePro12) had been strategically placed throughout the facility in individual rooms. Two large portable units (MovinCool OfficePro60) were temporarily placed in the East and West exits. Temperatures were measured to be within acceptable limits. At 5 p.m., Rooms 7 through 13 were measured above 81? F as follows: Room 7 - 83? F Room 8 - 88? F Room 9 - 87.7? F Room 10 - 83.5? F Room 11 - 81.9? F Room 12 - 82.8? F During the rounds, no residents appeared to be in distress, and those who were interviewable stated that they were hot, but not in any distress. A review of the HVAC (heating, ventilation, and air conditioning) service report dated August 29, 2011, indicated both air conditioning chiller systems were in very poor condition, including the condenser, evaporator, compressor, cooling tower, air handling units, and controls. The report indicated the system should be replaced as soon as possible. On September 1, 2011, at 9:10 a.m., during an interview with the Administrator, she stated that she didn't know why staff didn't call her right away. She stated that the maintenance "person" and/or company that she had on file for the A.C., was contacted for the emergency, and as of this date, he had not called back. That is why the Maintenance Supervisor started to call all over to try and find a company that would service the A.C. immediately. She stated that she had no records on file of the last time the A.C. unit was serviced. There was no maintenance contract in place for routine service, and there was no contract with the "person" for emergency situations that may occur. She also provided a copy of the facility's emergency plan/procedures. There was no contingency plan for mechanical repair or maintenance in the event of this type of situation during an emergency situation for excessive heat. The IJ was lifted on September 1, 2011, at 5 p.m., after receiving signed contracts for the previous and current repair work for the A.C. system and accompanying parts, and for regular maintenance to the system. The facility provided daily temperature logs to the Department, and onsite monitoring continued, as necessary, through September 8, 2011, to ensure continued compliance. On September 8, 2011, at 2:30 p.m., during an exit conference with the Director of Nursing (DON), she provided a service invoice from the A.C. repair company that indicated on September 7, 2011, the chiller system and cooling tower work was completed, with both 1 and 2 circuits operating at normal capacity. This was to supply sufficient cooling to all resident rooms to maintain temperatures between 75? F and 79? F throughout the facility. However, during rounds with the DON at approximatly 3 p.m., temperature checks were conducted, and the temperature in Room 8 measured 85? F. According to the DON, these residents preferred their door to remain closed, and the individual room mechanism was probably not working properly. The two residents in the room, when asked, stated that they were comfortable. The DON instructed the Maintenance Supervisor to install the "temporary" portable A.C. unit that was purchased "for emergency situations" on the morning of the same day. All other areas measured in the facility were within acceptable temperature limits. The residents interviewed during the rounds had no complaints about the temperatures. Cross Refer To: F257 - 483.15(h)(6) - Comfortable & Safe Temperature Levels F465 - 483.70(h) - Safe/functional/sanitary/comfortable Environ F517 - 483.75(m)(1) - Written Plans To Meet Emergencies/disasters F518 - 483.75(m)(2) - Train All Staff-Emergencies/drills

Based on observation, staff interviews and documentation review, it was determined that the facility did not maintain all essential equipment in safe operating condition to provide comfortable and safe temperature levels, when the facility temperatures reached above 95 degrees Fahrenheit (? F), in that the secondary air conditioning (A.C.) chiller was in disrepair, and did not activate when necessary during the heat spell, resulting in their inability to provide safe, comfortable air temperatures throughout the facility. Issues included the lack of an effective plan to monitor and maintain A.C. equipment in the facility during a disruption of services. In addition, there was a delay in implementing additional cooling measures that would protect residents against heat stroke (a life-threatening condition with symptoms of high body temperature, rapid pulse, difficulty breathing, and confusion), and other affects of excessive heat, such as dehydration (when the body loses water that is not replaced), or death. This affected 125 of 125 residents. Based on information provided by the Director of Nursing, on August 27, 2011, care levels at the facility were as follows: There were 11 residents who were totally dependent on staff, 38 who required extensive assistance from staff, and 68 who required assistance with one or more activities of daily living (ambulation, transferring from one surface to another, grooming, hygiene, and eating). There were 38 residents who had [DIAGNOSES REDACTED]. The risk for heat stroke and/or dehydration is higher in people with diabetes, due to elevated blood sugar levels that cause sugar to spill into the urine, causing excessive urination which may cause significant dehydration. This was widespread with no actual harm with the potential for serious harm that resulted in IMMEDIATE JEOPARDY (IJ) that was called at 6:30 p.m. on August 27, 2011, in the presence of the Administrator, Director of Nursing, and Clinical Consultant. The Administrator was informed that the IJ was lifted on September 1, 2011, at 5 p.m., and the scope and severity level was reduced to a D level. . Findings: On August 27, 2011, at 4 p.m., complaints of excessive and uncomfortable temperatures and insufficient air conditioning at the facility were received by the Department of Public Health (Department) via the emergency complaint line. An investigation was initiated at 5:30 p.m. According to local weather reports, the San Fernando Valley, where the facility was located, had been experiencing excessive temperatures between 100 degrees Fahrenheit (? F) to 110? F during the week of August 27, 2011. When arriving onsite at 5:30 p.m., on August 27, 2011, the Glendale Fire Department (GFD) was present in response to an emergency call. The Glendale Police Department (GPD) was present at the request of the GFD, and the Long Term Care Ombudsman was present in response to a complaint call, along with a concerned family member. Administrative staff, including the Administrator and Clinical Consultant, were present, however, they were slow to implement emergency actions to prevent complications of excessive heat, such as heat stroke and dehydration. The Department met with facility Administrative staff, immediately, and because of the lack of staff actions, began directing the Administrative staff as to remedies that were required to be in place. The surveyors were then assured that additional measures to ensure resident comfort, including the rental of portable air conditioners for resident rooms and corridors, purchasing extra portable oscillating fans, extra icewater stations, and ensuring residents (without swallowing problems) had icewater at their bedsides, would be taken immediately and continue through the weekend. There were no preventative maintenance records for the air conditioning units, according to the Administrator. The conditions observed during the onsite investigation from August 27, 2011, through August 29, 2011, included uncomfortably high temperatures that ranged from 80? F to 95? F, (according to the GFD's temperature recordings taken at 3:00 p.m.), and high humidity levels, together with the complaints and concerns expressed by family and staff, revealed that these measures, together with the extra oscillating fans, were not sufficient in providing a comfortable and safe environment at the facility. Resident rooms temperatures measured with the Clinical Consultant, the Maintenance Supervisor, Ombudsman and on August 27, 2011, at 5:40 p.m. were as follows: Room 1- 87.0? F Room 2- 85.0? F Room 4-90.5? F Room 5- 84.4? F Room 6- 90.4? F Room 7-88.1? F Room 8- 89.4? F Room 9- 91.2? F Room 10- 87.6? F Room 11- 86.1? F Hallway 87.3? F Room 12- 86.3? F Room 13- 86.0? F Room 14- 86.6? F Room 15- 86.7? F Room 16- 84.0? F Room 22- 86.7? F Room 23- 85.9? F Room 28- 86.0? F Room 29-86.1? F Room 32- 87.6? F Room 33- 89.9? F Room 34- 89.4? F Room 35- 88.6? F Room 36-87.0? F During the rounds, no residents appeared to be in distress, and those who were interviewable stated that they were hot, but not in any distress. During an interview with the Director of Staff Development (DSD) on August 27, 2011 at 7 p.m., to determine the time the A.C. became inoperable, he stated the facility staff noticed the air conditioning units weren't working properly around 12 p.m. on the same day. The maintenance supervisor was not able to fix the A.C. problems. An A.C. service was called, however they were not able to fix the problem. On August 27, 2011, at 6:30 p.m., the maintenance supervisor stated the facility had 31 small A.C. units throughout the facility that were supported by the two large rooftop chiller units. He stated five of the small A.C. units were blowing warm air. During an interview with the A.C. service technician on August 27, 2011 at 7:45 p.m, he stated the facility had two chillers on the roof supporting the A.C. units in the facility. One of the two chillers had broken down, and he was not able to fix the problem right away, but his crew would return in about an hour with rental A.C. units. The facility's air handling units were still functioning, but not at full capacity, such as diminished air flow, and the need of repairs due to lack of routine maintenance. The temperature measured outside at this time was 76? F. At 9 p.m., the facility provided more portable fans and ice to all resident rooms. The hallway measured at 78.1? F, Room 6 measured at 78.0? F, and Room 23 at 73.0? F. The ambient air temperature outside was cooler by this time. On August 28, 2011, between 9:30 a.m. and 10:30 a.m., rounds were made with administrative staff. According to the Administrator, there was no contract in place for the repair of the A.C. chillers. Ten portable A.C. units (MovinCool OfficePro12) had been strategically placed throughout the facility in individual rooms. Two large portable units (MovinCool OfficePro60) were temporarily placed in the East and West exits. Temperatures were measured to be within acceptable limits. At 5 p.m., Rooms 7 through 13 were measured above 81? F as follows: Room 7 - 83? F Room 8 - 88? F Room 9 - 87.7? F Room 10 - 83.5? F Room 11 - 81.9? F Room 12 - 82.8? F During the rounds, no residents appeared to be in distress, and those who were interviewable stated that they were hot, but not in any distress. The IJ was lifted on September 1, 2011, at 5 p.m., after receiving signed contracts for the previous and current repair work for the A.C. system and accompanying parts, and for regular maintenance to the system. The facility provided daily temperature logs to the Department, and onsite monitoring continued, as necessary, through September 8, 2011, to ensure continued compliance. On September 8, 2011, at 2:30 p.m., during an exit conference with the Director of Nursing (DON), she provided a service invoice from the A.C. repair company that indicated on September 7, 2011, the chiller system and cooling tower work was completed, with both 1 and 2 circuits operating at normal capacity. This was to supply sufficient cooling to all resident rooms to maintain temperatures between 75? F and 79? F throughout the facility. However, during rounds with the DON at approximatly 3 p.m., temperature checks were conducted, and the temperature in Room 8 measured 85? F. According to the DON, these residents preferred their door to remain closed, and the individual room mechanism was probably not working properly. The two residents in the room, when asked, stated that they were comfortable. The DON instructed the Maintenance Supervisor to install the "temporary" portable A.C. unit that was purchased "for emergency situations" on the morning of the same day. All other areas measured in the facility were within acceptable temperature limits. The residents interviewed during the rounds had no complaints about the temperatures. Cross Refer To: F257 - 483.15(h)(6) - Comfortable & Safe Temperature Levels F456 - 483.70(c)(2) - Essential Equipment, Safe Operating Condition F517 - 483.75(m)(1) - Written Plans To Meet Emergencies/disasters F518 - 483.75(m)(2) - Train All Staff-Emergencies/drills

Based on observation, record review, and interviews conducted, it was determined that the facility did not have emergency plans and procedures for all potential emergency situations necessary to ensure that resident safety and comfort would be maintained during a loss of air conditioning (A.C.) during a heat wave emergency, when the facility temperatures reached above 95 degrees Fahrenheit (? F). Issues included the lack of a plan in the event of loss of A.C. during excessive heat, and the facility's inability to follow the existing emergency plan during an actual loss of A.C., and alternate plans to ensure a limited disruption of facility services. This had the potential to lead to residents suffering affects of excessive heat such as heat stroke (a life-threatening condition with symptoms of high body temperature, rapid pulse, difficulty breathing, and confusion), dehydration (when the body loses water that is not replaced), or death. This affected 125 of 125 residents. Based on information provided by the Director of Nursing, on August 27, 2011, care levels at the facility were as follows: There were 11 residents who were totally dependent on staff, 38 who required extensive assistance from staff, and 68 who required assistance with one or more activities of daily living (ambulation, transferring from one surface to another, grooming, hygiene, and eating). There were 38 residents who had [DIAGNOSES REDACTED]. The risk for heat stroke and/or dehydration is higher in people with diabetes, due to elevated blood sugar levels that cause sugar to spill into the urine, causing excessive urination which may cause significant dehydration. This was widespread with no actual harm with the potential for serious harm that resulted in IMMEDIATE JEOPARDY (IJ) that was called at 6:30 p.m. on August 27, 2011, in the presence of the Administrator, Director of Nursing, and Clinical Consultant. The Administrator was informed that the IJ was lifted on September 1, 2011, at 5 p.m., and the scope and severity level was reduced to an F level. . Findings: On August 27, 2011, at 4 p.m., complaints of excessive and uncomfortable temperatures and insufficient air conditioning at the facility were received by the Department of Public Health (Department) via the emergency complaint line. An investigation was initiated at 5:30 p.m. When arriving onsite, the Glendale Fire Department informed the Department that when they arrived at about 3 p.m., internal facility temperature recordings were 95? F in some areas. According to local weather reports, the San Fernando Valley, where the facility was located, had been experiencing excessive temperatures between 100 degrees Fahrenheit (? F) to 110? F during the week of August 27, 2011. During an interview with the Director of Staff Development (DSD) on August 27, 2011 at 7 p.m., to determine the time the A.C. became inoperable, he stated the facility staff noticed the air conditioning units weren't working properly around 12 p.m. on the same day. The maintenance supervisor was not able to fix the A.C. problems. However, according to the Administrator, she was not contacted until approximately 2:30 p.m. During the tour of the facility at 7:30 pm., staff were observed placing bowls of ice incorrectly behind the portable fans in resident rooms in an attempt to cool down the ambient air, not in front of the fan as required. The extra fans and bowls of ice placed in front of fans was implemented after the Department gave directive to do so. During an interview with the DSD on August 30, 2011, he was asked if there was a policy and procedure that addressed actions to be taken during loss of air conditioning during a heat wave emergency. He was unable to provide the policy and procedure. However, the facility provided the Electric Power Interruption Protocol (no date) which indicated if heat is extreme, bowls/pans of ice will be placed in front of the portable fans to increase the effectiveness, twelve portable fans were to be implemented, and hand fans and wet wash clothes were to be distributed to residents for use. None of this was implemented by facility staff when the Department arrived on August 27, 2011 at 5:30 p.m. The DSD also could not provide evidence of training in place for staff to address the residents' safety and comfort in a heat wave and/or disruption of A.C. in an emergency in the facility. Therefore the staff were not able to implement an emergency plan to protect the residents' safety and comfort in a timely manner when the A.C. service broke down at approximately 12 p.m. on August 27, 2011, when the outside temperatures were between 100? F and 110? F. On September 1, 2011, at 9:10 a.m., during an interview with the Administrator, she stated that she didn't know why staff didn't call her right away. She stated that the maintenance "person" and/or company that she had on file for the A.C., was contacted for the emergency, and as of this date, he had not called back. That is why the Maintenance Supervisor started to call all over to try and find a company that would service the A.C. immediately. She stated that she had no records on file of the last time the A.C. unit was serviced. There was no maintenance contract in place for routine service, and there was no contract with the "person" for emergency situations that may occur. She also provided a copy of the facility's emergency plan/procedures. There was no contingency plan for mechanical repair or maintenance in the event of this type of situation during an emergency situation for excessive heat. The IJ was lifted on September 1, 2011, at 5 p.m., after receiving signed contracts for the previous and current repair work for the A.C. system and accompanying parts, and for regular maintenance to the system. The facility provided updated policies and procedures for all types of disaster, and mandatory inservices had been given to all employees. Onsite monitoring continued, as necessary, through September 8, 2011, to ensure continued compliance. Cross Refer To: F257 - 483.15(h)(6) - Comfortable & Safe Temperature Levels F456 - 483.70(c)(2) - Essential Equipment, Safe Operating Condition F465 - 483.70(h) - Safe/functional/sanitary/comfortable Environ F518 - 483.75(m)(2) - Train All Staff-Emergencies/drills

Based on observation, record review, and interviews conducted, it was determined that the facility staff were unable to perform efficiently during an emergency of excessive heat temperatures in the facility. They were not trained for all potential emergency situations necessary to ensure that resident safety and comfort would be maintained during a loss of air conditioning (A.C.) during a heat wave emergency, when the facility temperatures reached above 95 degrees Fahrenheit (? F). Issues include the lack of an emergency plan in the event of loss of A.C. during excessive heat, and the staff's inability to follow the existing emergency plan during an actual loss of A.C. due to lack of training. This had the potential to lead to residents suffering affects of excessive heat such as heat stroke (a life-threatening condition with symptoms of high body temperature, rapid pulse, difficulty breathing, and confusion), dehydration (when the body loses water that is not replaced), or death. This affected 125 of 125 residents. Based on information provided by the Director of Nursing, on August 27, 2011, care levels at the facility were as follows: There were 11 residents who were totally dependent on staff, 38 who required extensive assistance from staff, and 68 who required assistance with one or more activities of daily living (ambulation, transferring from one surface to another, grooming, hygiene, and eating). There were 38 residents who had [DIAGNOSES REDACTED]. The risk for heat stroke and/or dehydration is higher in people with diabetes, due to elevated blood sugar levels that cause sugar to spill into the urine, causing excessive urination which may cause significant dehydration. This was widespread with no actual harm with the potential for serious harm that resulted in IMMEDIATE JEOPARDY (IJ) that was called at 6:30 p.m. on August 27, 2011, in the presence of the Administrator, Director of Nursing, and Clinical Consultant. The Administrator was informed that the IJ was lifted on September 1, 2011, at 5 p.m., and the scope and severity level was reduced to a F level. . Findings: On August 27, 2011, at 4 p.m., complaints of excessive and uncomfortable temperatures and insufficient air conditioning at the facility were received by the Department of Public Health (Department) t via the emergency complaint line. An investigation was initiated at 5:30 p.m. According to local weather reports, the San Fernando Valley, where the facility was located, had been experiencing excessive temperatures between 100 degrees Fahrenheit (? F) to 110? F during the week of August 27, 2011. When arriving onsite at 5:30 p.m., on August 27, 2011, the Glendale Fire Department (GFD) was present in response to an emergency call; the Glendale Police Department (GPD) was present at the request of the GFD, and the Long Term Care Ombudsman was present in response to a complaint call, along with a concerned family member. Administrative staff, including the Administrator and Clinical Consultant, were present, however, they were slow to implement emergency actions to prevent complications of excessive heat, such as heat stroke and dehydration. According to the GFD's temperature recordings, taken when they arrived at about 3:00 p.m., the internal temperatures were 95? F in some areas. The Department met with facility Administrative staff, immediately, and because of the lack of staff actions, began directing the administrative staff as to remedies that were required to be in place. The Department was then assured that additional measures to ensure resident comfort, including the rental of portable air conditioners for resident rooms and corridors, purchasing extra portable oscillating fans, providing extra icewater stations, and ensuring residents (without swallowing problems) had icewater at their bedsides, would be taken immediately and continue throughout the weekend. During an interview with the Director of Staff Development (DSD) on August 27, 2011 at 7 p.m., to determine the time the A.C. became inoperable, he stated the facility staff noticed the air conditioning units weren't working properly around 12 p.m. on the same day. However, according to the Administrator, she was not contacted until approximately 2:30 p.m. During a tour of the facility at 7:30 p.m., staff were observed placing bowls of ice incorrectly behind the portable fans in resident rooms in an attempt to cool down the ambient air, not in front of the fans. The extra fans and bowls of ice placed in front of fans was implemented after the Department gave directive to do so. During an interview with the DSD on August 30, 2011, who is responsible for the training of staff, he was asked if there was a policy and procedure that addressed actions to be taken during loss of A.C. during a heat wave emergency. He was unable to provide the policy and procedure. However, the facility provided the Electric Power Interruption Protocol (no date). This protocol indicated if heat is extreme, bowls/pans of ice will be placed in front of the portable fans to increase the effectiveness, "twelve" portable fans were to be implemented, and hand fans and wet wash clothes were to be distributed to residents for use. None of this was implemented by facility staff when the Department arrived on August 27, 2011 at 5:30 p.m. The DSD also could not provide evidence that inservices had been given to staff regarding the residents' safety and comfort in a heat wave and/or disruption of A.C. in an emergency. Therefore the staff were not able to implement an emergency plan for residents' safety and comfort in a timely manner when the A.C. service broke down at approximately 12 p.m. on August 27, 2011, when the outside temperatures were between 100? F and 110? F. On September 1, 2011, at 9:10 a.m., during an interview with the Administrator, she stated that she didn't know why staff didn't contact her right away. The IJ was lifted on September 1, 2011, at 5 p.m., after receiving updated policies and procedures for all types of disaster, and mandatory inservices had been given to all employees. Onsite monitoring continued, as necessary, through September 8, 2011, to ensure continued compliance. Cross Refer To: F257 - 483.15(h)(6) - Comfortable & Safe Temperature Levels F456 - 483.70(c)(2) - Essential Equipment, Safe Operating Condition F465 - 483.70(h) - Safe/functional/sanitary/comfortable Environ F517 - 483.75(m)(1) - Written Plans To Meet Emergencies/disasters