Every finding on record at Northridge Care Center

Based on interview and record review, the facility failed to ensure the provision of quality of care services for one of two sampled residents (Resident 1), when the facility did not fully complete a 72-hour Neurological Check (72-hour Neuro Check: monitoring of the brain for any changes or signs of decline for 72 hours) following Resident 1's fall. This deficient practice had the potential to delay identification of changes in the resident's condition and placed the resident at risk for unmet health needs.During a review of Resident 1's Face Sheet (admission Record) the admission record indicated that the facility admitted Resident 1 on 3/10/2025 with diagnoses of alcoholic polyneuropathy (damage to many nerves in your body due to alcohol use); Parkinsonism (a group of brain conditions that cause movement problems such as muscle stiffness, slowed movement and muscle shakiness); and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 6/15/2026, the MDS indicated that Resident 1 is cognitively intact (able to think and process information effectively). The MDS indicated that Resident 1 needs set-up assistance with eating, oral hygiene, and upper body dressing and moderate assistance with toileting, showering, and lower body dressing. During a review of Resident 1's Change of Condition (COC- a significant alteration in a resident's health status requiring physician notification) dated 8/6/2026 at 9:40 a.m., the COC indicated that Resident 1 had an unwitnessed fall on 8/6/2026 and was subsequently transferred to the hospital. During a review of Resident 1's Skin Reassessment (an assessment that is conducted with any new changes to the condition of the resident's skin and when a resident returns from the hospital) dated 8/6/2026, the Skin Reassessment indicated that Resident 1 had an abrasion on her left eyebrow, left cheek and left knee. The Skin Reassessment also indicated that Resident 1 had episodes of confusion and disorientation. During a review of Resident 1's 72-hour Neuro Check form dated 8/6/2026, the form indicated to complete each section according to schedule. The form did not indicate Neuro Checks were completed for the following dates and times: 8/7/2026 at 8:00 a.m.8/7/2026 at 12:00 p.m.8/7/2026 at 8:00 p.m.8/8/2026 at 4:00 a.m.8/8/2026 at 8:00 p.m.8/9/2026 at 4:00 a.m. During a review of Resident 1's care plan titled, Actual Fall, dated 8/6/2026, the care plan indicated that a 72-hour neuro check was required as part of Resident 1's interventions. During an interview on 8/27/2026 at 4:04 p.m. with the Registered Nurse Supervisor 2 (RN 2), RN 2 stated that when a resident (in general) is sent to the hospital, a 72-hour neuro check must be completed and documented upon their return from the hospital. During a concurrent interview and record review on 8/31/2026 at 12:04 p.m., with the Director of Nursing (DON), Resident 1's 72-hour Neuro Check was reviewed. The DON stated that it was not completed but should have been. The DON stated that the Licensed Vocational Nurses (LVNs) are responsible for completing the 72-hour Neuro Check to monitor for any possible changes to the resident's condition. During a review of the facility's policy and procedure (P&P) titled Charting and Documentation, the P&P indicated that documentation in the medical record will be accurate and complete.

Based on interview and record review, the facility failed to complete an annual performance evaluation (a yearly review to assess employees' skills and work quality) for Certified Nursing Assistant 1 (CNA 1). This deficient practice prevented the facility from assessing staff competency and identifying potential training needs that could affect the residents' care. During a concurrent interview and record review on 8/28/2026 at 9:33 a.m. with the Director of Staff Development (DSD), CNA 1's employee file was reviewed. The DSD stated that CNA 1's last annual performance evaluation was completed on 10/15/2024. The DSD stated that CNA 1's performance evaluation was not up to date and should be updated every year. During a concurrent interview and record review on 8/29/2026 at 11:49 a.m. with the Director of Nursing (DON), the DON stated that performance evaluations must be completed for each staff member annually but was not completed for CNA 1. During a review of the facility's policy and procedures (P&P) titled, Performance Evaluations, last reviewed 11/20/2025, the P&P indicated that the job performance of each employee will be reviewed and evaluated at least annually and will be completed by the employees' department directors and supervisors.

Based on interview and record review, the facility failed to ensure the annual performance evaluation (a yearly review to assess employees' skills and work quality) and/or competency check (a yearly test to determine if a person has the required skills and knowledge of a particular subject) was completed for two licensed nurses (Registered Nurse 1 [RN 1], and Licensed Vocational Nurse 1 [LVN 1]). This deficient practice had the potential to prevent RN 1 and LVN 1 from performing their job duties effectively, impeding resident care.During a concurrent interview and record review on 8/28/2026 at 9:33 a.m. with the Director of Staff Development (DSD), RN 1 and LVN 1 employee records were reviewed. The DSD stated that RN 1's last performance review was completed on 11/8/2024. The DSD stated that LVN 1 was hired on 4/16/2024 and has not had any performance evaluations. The DSD further stated that RN 1's last competency check was completed on 4/10/2025. The DSD stated that it is important for annual competency checks to be current to prevent any errors in patient care, and for employees to stay up to date on their skills. During a concurrent interview and record review on 8/29/2026 at 11:49 a.m. with the Director of Nursing (DON), the DON stated that competency skills and performance evaluations must be completed annually for licensed nursing staff, and the DON is responsible for completing them. The DON stated that performance evaluations were not completed for RN 1 and LVN 1, and a competency check was not completed for LVN 1. During a review of the facility's policy and procedures (P&P) titled, Performance Evaluations, last reviewed 11/20/2025, the P&P indicated that the job performance of each employee will be reviewed and evaluated at least annually and will be completed by the employees' department directors and supervisors.

Based on observation, interview, and record review, the facility failed to provide a safe, and hazard-free environment for one of two sampled residents (Resident 1) when Resident 1 had a bedside table placed on top of the floor mat (a mat used to provide a soft landing if a resident falls out of bed). This deficient practice had the potential to cause Resident 1 to fall and possibly injure herself.During a review of Resident 1's Face Sheet (admission Record) the admission record indicates that the facility admitted Resident 1 on 3/10/2025 with diagnoses of alcoholic polyneuropathy (damage to many nerves in your body due to alcohol use); Parkinsonism (a group of brain conditions that cause movement problems such as muscle stiffness, slowed movement and muscle shakiness; and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 6/15/2026, the MDS indicates that Resident 1 is cognitively intact (able to think and process information effectively). The MDS indicates that Resident 1 needs set-up assistance with eating, oral hygiene, and upper body dressing and moderate assistance with toileting, showering, and lower body dressing. During a record review of Resident 1's Fall Risk care plan dated 3/28/2025, the care plan interventions indicated that Resident 1 should be provided with a safe and clutter-free environment. During a review of Resident 1's active physician orders dated 10/6/2025, the orders indicated, Support and safety devices- low bed with floor mat to decrease potential injury every shift. During a concurrent observation and interview on 8/27/2026 at 12:03 p.m. with Certified Nursing Assistant 1 (CNA 1), in Resident 1's room, Resident 1 was lying on her bed. Resident 1 had a floor mat in place with a bedside table on top of the floor mat. CNA 1 stated the bedside table should not be on top of the floor mat and should be moved further away. CNA 1 stated that residents (in general) can potentially grab the table, fall, and hurt themselves. During an interview on 8/27/2026 at 1:44 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that nothing should be on top of the floor mat because that is a safety hazard for the resident. During an interview on 8/27/2026 at 3:20 p.m. with the Registered Nurse Supervisor 1 (RN 1), RN 1 stated that the purpose of the floor mats is to prevent any major physical injuries such a fracture (a broken hip). RN 1 stated that the floor mat should be clear of all clutter so the resident can fall on it if necessary. During an interview on 8/28/2026 at 11:42 a.m. with the Director of Nursing (DON), the DON stated that no furniture should be on top of the floor mat because it can cause injury to the resident, and all staff are responsible for ensuring that the floor mat is free of clutter. During a record review of the facility's policy and procedure (P&P) titled, Falls, and Fall Risk, Managing, last reviewed 11/2025, the P&P indicated that environmental factors that contribute to the risk of falling include obstacles that are in the footpath.

Based on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal his/her need for assistance from staff) was within the resident's reach while in bed for one of four sampled residents (Resident 3).This deficient practice had the potential to delay the provision of care services and result in the resident's needs not being met.Findings:During a review of Resident 3's admission Record, the admission Record indicated the facility initially admitted the resident on 9/15/2004 and was readmitted on [DATE] with diagnoses including encephalopathy (any disease, damage, or malfunction that alters how the brain works) unspecified, multiple sclerosis (MS-a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord) unspecified, and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) without complications.During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 7/27/2026, the MDS indicated that Resident 3 has moderate cognitive impairment (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and totally dependent from staff for toileting hygiene, shower/bathe self, and lower body dressing.During a concurrent observation and interview on 8/25/2026 at 11:00 a.m., with Certified Nurse Assistant 1 (CNA 1) in Resident 3's room, Resident 3 was lying in bed with her call light on the floor not within reach. CNA 1 stated the call light should have been within reach of Resident 3 to be able to call for assistance. CNA 1 also stated by not having the call light within reach could delay the care and services that (Resident 3) needs.During an interview on 8/27/2026 at 10:25 a.m., with the Director of Staff Development (DSD), the DSD stated the call light should have been within reach of Resident 3 to be able to call for assistance. The DSD also stated that without the call light within reach of Resident 3, it will result in a delay of care and services that Resident 3 needs.During a review of the facility's policy and procedure titled, Call System, Resident dated 11/20/2025, the policy indicated residents are provided with means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Calls for assistance are answered in timely manner

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) had a revised Elopement Risk Assessment (a form used by the facility to assess and identify a resident's risk for leaving the facility without notifying the facility staff) completed after Resident 1 walked out of the facility without notifying staff members on 7/22/2026.This deficient practice had the potential for Resident 1 to have an increased risk of elopement, injury and possibly death.Findings:During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted Resident 1 on 4/2/2026 with diagnoses that included fracture (break in the bone) of the right femur (long bone in the upper leg), urinary tract infection (UTI- an infection in the bladder), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).During a review of Resident 1's History and Physical (H&P-a comprehensive assessment of a resident's medical condition) dated 4/29/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 7/8/2026, the MDS indicated Resident 1's cognition (ability to think and make decisions) was severely impaired. The MDS further indicated Resident 1 required set up assist with eating, oral hygiene and personal hygiene and supervision assistance with toileting hygiene, showering, lower body dressing and putting on/taking off footwear.During a review of Resident 1's Elopement Risk assessment dated [DATE], the Elopement Risk Assessment indicated Resident 1 was not at risk for elopement from the facility.During a review of Resident 1's Change of Condition (COC-a form used by the facility to document changes in residents condition including actions taken and notification of the physician and responsible party) dated 7/22/2026, the COC form indicated at around 10 a.m. Resident 1 left the facility without authorization and went walking away from the facility. The COC form further indicated Resident 1 had informed the nursing staff that Resident 1 was going to see Resident 1's mother.During an interview on 8/18/2026 at 1:20 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that LVN 1 completed the COC form on 7/22/2026. LVN 1 stated that LVN 1 was informed by a staff member Resident 1 had walked out the facility on 7/22/2026 without notifying a staff member. LVN 1 stated that LVN 1 went out of the facility and found Resident 1 down the street. LVN 1 brought Resident 1 back into the facility and provided education to Resident 1 that Resident 1 needed to inform staff when Resident 1 wanted to leave the facility. LVN 1 stated that LVN 1 did not complete a new Elopement Risk Assessment following Resident 1 leaving the facility on 7/22/2026.During an interview on 8/18/2026 at 2:45 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated that LVN 1 informed RNS 1 of Resident 1 leaving the facility without notifying a staff member. RNS 1 stated that LVN 1 informed RNS 1 that LVN 1 completed the COC form. RNS 1 stated that RNS 1 did not complete a new Elopement Risk Assessment form. RNS 1 confirmed that after a resident leaves the facility without notifying staff members a new Elopement Risk Assessment should have been completed.During an interview on 8/18/2026 at 3:15 p.m. with the Director of Nursing (DON), the DON confirmed that when a resident does leave the facility without notifying staff the nursing staff should complete a new Elopement Risk Assessment form to evaluate the resident's risk for elopement. The DON confirmed Resident 1 should have an Elopement Risk Assessment completed after leaving the facility on 7/22/2026.During a review of the facility's Policy and Procedure (P&P) titled Wandering and Elopements with a last reviewed date 11/20/2025, the P&P indicated The facility will identify residents who are at risk of unsafe wandering strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.When the resident returns to the facility, the DON services or charge nurse shall.complete and file and incident report, document relevant information in the resident's medical record.

Based on interview and record review, the facility failed to ensure that staffing levels determined by the Facility Assessment (facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations [including nights and weekends] and emergencies), were followed by not having the correct amount of licensed staff on each shift as determined by the Facility Assessment. This deficient practice had the potential to affect 88 of 88 residents residing in the facility to have a decrease in quality of care and decrease in quality of life.Findings: During a review of the Facility assessment dated [DATE], the Facility Assessment indicated that the facility would employee 10 Registered Nurses (RN) and that staffing levels on the night shift (11p.m. to 7a.m.) would include one (1) Registered Nurse (RN) and four (4) Licensed Vocational Nurses (LVN). The Facility Assessment further indicated that on Day shift (7a.m.-3p.m.) the facility would staff five (5) RNs and eight (8) LVNs and on the Evening shift (3p.m.-11p.m.) the facility would staff two (2) RNS and four (4) LVNs. During a review of the facility licensed staff schedule for 7/2026, the facility staffing schedule indicated during the Day shift the facility had one (1) assigned RN and four (4) LVNs assigned to work with residents. On the Evening shift, the facility had one (1) RN and three (3) LVNs. On the Night shift, the facility had one (1) RN and two (2) LVNs assigned. Further review of the 7/2026 licensed staff schedule indicated no RN was assigned to work the night shift on 7/4/2026 and 7/11/2026. During a concurrent interview and record review on 8/7/2026 at 12:30 p.m., with the Assistant Director of Nursing (ADON), reviewed the licensed staff schedule for 7/2026. The ADON confirmed by stating that there was no RN assigned to work on the night shift on 7/4/2026 and 7/11/2026. During a concurrent interview and record review on 8/7/2026 at 2:00 p.m., with the Administrator (ADM), reviewed the Facility assessment dated [DATE]. The ADM stated that the ADM completed the Facility Assessment on 12/18/2025. The ADM confirmed that that the staffing numbers for the facility indicated that the facility would employee 10 RNs and that staffing levels would include one (1) RN and four (4) LVNs on the Night shift, five (5) RNs and eight (8) LVNs on the Day shift, and two (2) RNs and four (4) LVNs on the Evening shift. The ADM stated that the numbers are not accurate for the facility staffing needs. The ADM confirmed by stating that normally the facility will staff one (1) RN and four (4) LVNs on the day shift, one (1) RN and three (3) LVNs on the evening shift, and one (1) RN and two (2) LVNs on the night shift. The ADM confirmed that the Facility Assessment should be updated to be reflective of the facility needs. During a review of the facility's policy and procedure (P&P) titled, Facility Assessment, last reviewed on 11/20/2025, the P&P indicated a facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment.Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources are available to meet the specific needs of our residents.The facility assessment is intended to help our facility plan for and respond to changes in the needs for our resident population and helps to determine budget, staffing, training, equipment and supplies needed. It is separate from the quality assurance and performance improvement evaluation.

Based on observation, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal his/her need for assistance from staff) was within a resident's reach while in bed for one of five sampled residents (Resident 3). This deficient practice had the potential to delay the provision of services and Resident 3's needs not being met.During a review of Resident 3's admission Record, the admission Record indicated the facility initially admitted the resident on 9/15/2025 and was readmitted on [DATE] with diagnoses including non-displaced fracture (broken bone) of the radial styloid process (the hard bony part on the thumb side of your wrist) subsequent encounter for closed fracture with delayed healing, type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with moderate non proliferative diabetic retinopathy (a retina damage caused by long term high blood sugar) with macular edema (swelling central part of the retina), and moderate protein-calorie malnutrition (a condition caused by a lack of proper nutrients). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 6/12/2026, the MDS indicated that Resident 3 has severe cognitive impairment (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required moderate assistance (Helper does less than half the effort) from staff for toileting hygiene, shower/bathe self, and upper body dressing. During a concurrent observation and interview on 7/21/2026 at 10:15 a.m., with Licensed Vocational Nurse 2 (LVN 2), observed Resident 3 lying in bed with her call light on the floor not within her reach. LVN 2 stated the call light should have been placed within Resident 3's reach to enable her to call for assistance when needed. LVN 2 stated not having the call light within the reach of Resident 3 had the potential to result in delays in the delivery of care and services to Resident 3. During an interview on 7/23/2026 at 10:05 a.m., with the Assistant Director of Nursing (ADON), the ADON stated the call light should have been within reach of Resident 3 to enable her to call for assistance when needed. The DON stated that not having the call light within Resident 3's reach will result in delay in meeting Resident 3's needs. During a review of the facility's policy and procedure titled, Answering the Call Light, dated 11/20/2025, the policy indicated ensure timely responses to the resident's requests and needs. Ensure that the call light is accessible to the resident when in bed or wheelchair in room, from the toilet or shower room if necessary.

Based on observation, interview, and record review the facility failed to implement and maintain its infection control program for one out of five sampled residents (Resident 3) when Licensed Vocational Nurse 2 (LVN 2) did not wear the required personal protective equipment (PPE- special clothing or equipment that protects healthcare workers and patients from germs and infections) while Resident 3 was on novel respiratory transmission-based precautions (are enhanced infection control measures used when a patient is suspected or confirmed to have a new or emerging respiratory pathogen that spreads via airborne or droplet routes, in addition to Standard Precautions [are the minimum infection prevention practices applied to all patients to prevent the spread of infections in healthcare and other care settings]).This failure had the potential to spread infection among residents, staff, and visitors.During a review of Resident 3's admission Record, the admission Record indicated the facility initially admitted the resident on 9/15/2025 and was readmitted on [DATE] with diagnoses including nondisplaced fracture (broken bone) of the radial styloid process (the hard bony part on the thumb side of your wrist) subsequent encounter for closed fracture with delayed healing, type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with moderate non proliferative diabetic retinopathy (a retina damage caused by long term high blood sugar) with macular edema (swelling central part of the retina), and moderate protein-calorie malnutrition (a condition caused by a lack of proper nutrients). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 6/12/2026, the MDS indicated that Resident 3 has severe cognitive impairment (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required moderate assistance (Helper does less than half the effort) from staff for toileting hygiene, shower/bathe self, and upper body dressing.During a review of Resident 3's Change of Condition Assessment Form dated 7/16/2026, the form indicated Coronavirus Disease (COVID-19, a disease caused by SARS-CoV2, which is highly contagious and predominantly affects the respiratory tract) test was performed and Resident 3 tested positive. During a concurrent record review, and interview on 7/21/2026 at 9:15 a.m., with the Infection Preventionist Nurse (IPN), the Outbreak letter report from the Public Health Nurse dated 7/17/2026 and the facility policy and procedure titled (PPE) Coronavirus Disease (Covid -19)-Identification and Management of Ill Residents, last reviewed on 11/20/2025 were reviewed. The IPN stated the Outbreak letter indicated information on immediate infection prevention and control actions, including isolation, testing, environmental cleaning, and staff guidance. The IPN stated residents who are COVID-19 positive are placed on novel respiratory transmission-based precautions in their own rooms for isolation. The IPN stated that the facility is following the facility policy and procedure (PPE) Coronavirus Disease (Covid -19)-Identification and Management of Ill Residents, which indicated that staff who enters the room of a resident with suspected or confirmed SARS-CoV-2 will adhere to standard precautions and use a National Institute for Occupational Safety and Health (NIOSH- is the federal institute responsible for conducting research and making recommendations for the prevention of work-related injury and illness) approved particulate respirator with N95 (respirators are disposable masks designed to filter at least 95% of airborne non-oil-based particles, providing reliable respiratory protection in various occupational and health settings) filters or higher, gown, gloves, and eye protection (i.e., goggles or face shield that covers the front and sides of the face). During a concurrent observation, and interview on 7/21/2026 at 10:15 a.m., with Licensed Vocational Nurse 2 (LVN 2), outside Resident 3's room, observed LVN 2 entering Resident's 3 room, which has a signage outside the room indicating novel respiratory transmission-based precautions, without wearing the required PPE. LVN 2 was observed entering the resident's room wearing a mask, gown, and gloves but without the required eye protection. During an interview on 7/23/2026 at 10:05 a.m., with the Assistant Director of Nursing (ADON), the ADON stated the LVN 2 should have worn the required eye protection before going inside Resident 3's room. The ADON also stated without wearing the required eye protection PPE had the potential to contribute to the spread of COVID-19 infection. During a review of the facility's policy and procedure titled, Infection Control, last reviewed on 11/20/2025, the P&P indicated it is the policy of this facility to established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. During a review of the facility's recent policy and procedure titled, Coronavirus Disease (Covid -19)-Identification and Management of Ill Residents, last reviewed on 11/20/2025, indicated it is the policy of this facility strategies used for the rapid identification and management of SARS-COV-2 infected residents are consistent with the current recommendations from the Centers for Disease Control and Prevention. Personal Protective Equipment. Staff who enters the room of a resident with suspected or confirmed SARS-CoV-2 will adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or face shield that covers the front and sides of the face).

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) was free from medications errors by failing to: 1.Ensure the scheduled 9 p.m. dose of atorvastatin calcium (a medication used to lower cholesterol) was administered as ordered or, if not administered, that the omission and reason were documented in the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). 2.Ensure that the licensed nurse who administered the resident's medications accurately documented the medication administration in the MAR. This deficient practice resulted in an inability to determine whether Resident 2 received the prescribed medication and had the potential to result in medication errors, compromise medication safety, and create confusion regarding the delivery of resident care and services.During a review of Resident 2's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Seet indicated that the facility originally admitted the resident on 12/30/2022 and readmitted the resident on 11/01/2025 with diagnoses that included Type 2 diabetes (T2D - a chronic condition in which the body either resists the effects of insulin [an essential hormone that regulates the body's blood sugar {BS} levels] or does not produce enough to maintain normal BS levels), atherosclerotic heart disease (the clogging of the arteries with sticky, fatty deposits called plaque), glaucoma (a group of eye diseases that damage the eye nerve, usually due to abnormally high pressure inside the eye), anemia (a condition where the body does not have enough healthy red blood cells), polyneuropathy (occurs when multiple nerves are damaged simultaneously throughout the body), and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 4/6/2026, the MDS indicated Resident 2 had intact cognition (ability to think, understand, and make decisions). The MDS indicated Resident 2 required moderate assistance from staff with toileting hygiene, supervision or touching assistance with lower body dressing, transferring and walking, and required setup or clean-up assistance with eating, oral/personal hygiene, and bed mobility (movement). During a review of Resident 2's Order Summary Report, the Order Summary Report indicated the following physician orders: Atorvastatin calcium tablet 40 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth at bedtime for hyperlipidemia (excessive fat in the blood), ordered 11/2/2025. Netarsudil dimesylate ophthalmic solution (a prescription eye drop medication used to lower elevated intraocular pressure [IOP - the measurement of the fluid pressure inside the eyes]) 0.02 percent (% - the strength or concentration of the medicine), instill (to put a liquid drop by drop into eyes) one (1) drop in left eye at bedtime for glaucoma, ordered 4/11/2026. Xalatan ophthalmic solution (a medication used to reduce high IOP) 0.005 %, instill one (1) drop in both eyes at bedtime for glaucoma, ordered 11/03/2025. Brimonidine tartrate ophthalmic solution (a prescription eye drop medication used to lower elevated intraocular pressure) 0.15 %, instill one (1) drop in left eye two times a day for glaucoma, ordered 3/9/2026. Cosopt ophthalmic solution (a prescription eye drop medication that combines two medications - dorzolamide and timolol - to lower high IOP) 22.3- 6.8 mg per milliliter (ml - a metric unit of volume, used to measure small amounts of liquid), instill one (1) drop in left eye two times a day for glaucoma, wait five (5) minutes between administration of eye drops to the same eye, ordered 5/18/2026. Gabapentin (a medication used to treat seizures or pain), give 300 mg by mouth two times a day for neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), ordered 11/1/2025. Keppra (a medication used to control seizures) oral solution 100 mg/ml, give five (5) ml by mouth two times a day for seizure prophylaxis (any preventive treatment or action taken to guard against a disease or health problem before it happens), ordered 11/2/2025. Oyster shell calcium (a medication used to prevent or treat calcium deficiencies) tablet 500 mg, give one (1) tablet by mouth two times a day for nail growth for 60 days, ordered 5/5/2026. Insulin glargine (a long-acting insulin used to treat type 1 and type 2 diabetes) subcutaneous (fatty tissue between the skin and muscle) solution 100 unit/ml, inject 10 units subcutaneously at bedtime for T2D, hold if BS is lower than 70 milligrams per deciliter (mg/dL - a unit of measurement), ordered 11/3/2025. Insulin Humalog (insulin lispro - a fast-acting insulin used to manage blood sugar) injection solution 100 unit/ml, inject four (4) units subcutaneously before meals for diabetes mellitus (DM - disorder characterized by difficulty in BS control and poor wound healing), give medication three times a day before meals, ordered 11/4/2025. Insulin lispro injection solution 100 unit/ml, inject as per sliding scale (a method of managing blood sugar where the dose insulin is adjusted based on a resident's pre-meal or bedtime blood glucose level) subcutaneously before meals for T2D, ordered 11/4/2026. During a review of Resident 2's MAR for the month of 5/2026, the MAR indicated the following: On 5/2/2026, atorvastatin calcium tablet 40 mg, scheduled for 9 p.m., was not documented as administered and was left blank. On 5/2/2026, Licensed Vocational Nurse 1 (LVN 1) documented the following scheduled 9 p.m. medications: Insulin glargine 10 units, netarsudil dimesylate ophthalmic solution, and insulin lispro three (3) units. On 5/23/2026, LVN 1 documented the following scheduled 9 p.m. medications: atorvastatin calcium tablet 40 mg, insulin glargine 10 units, netarsudil dimesylate ophthalmic solution, Xalatan ophthalmic solution, brimonidine tartrate ophthalmic solution, cosopt ophthalmic solution, gabapentin 300 mg, Keppra five (5) ml, oyster shell calcium 500 mg, ticagrelor (a medication used to prevent blood clots) 90 mg, and insulin lispro four (4) units. During an interview on 6/25/2026 at 12:29 p.m., with Resident 2, the resident stated that Registered Nurse 1 (RN 1) mostly administered the resident's medications (unable to specify) when LVN 1 was on duty (unable to recall exact date). During a concurrent interview and record review on 6/26/2026 at 1:58 p.m., with LVN 2, LVN 2 reviewed Resident 2's MAR for 5/2/2026 and stated that the scheduled 9 p.m. atorvastatin 40 mg was not documented as administered and was left blank. LVN 2 stated that the licensed nurses should document the appropriate reason using the designated codes and should not leave the MAR blank. If a resident was out of the facility or unavailable to receive the medications, a code should be documented. Otherwise, it could not be determined whether Resident 2 received the medication. During a concurrent interview and record review on 6/29/2026 at 3:42 p.m., with LVN 1, LVN 1 reviewed Resident 2's MAR for 5/2026 and the Nursing Staffing Assignment and Sign-in Sheet for 3 p.m. to 11 p.m. shift (3-11 shift) on 5/2/2026 and 5/23/2026. LVN 1 stated that LVN 1 did not administer Resident 2's medications during the 3 -11 shift on 5/2/2026 and 5/23/2026, LVN 1 stated that Resident 2 had refused LVN 1's services, and therefore LVN 1 was not allowed to observe other nurses preparing or administering Resident 2's medications, including eye drops and insulin. LVN 1 stated that RN 1 was on duty on both dates (5/2/2026 and 5/23/2026), and RN 1 administered Resident 2's medications, but LVN 1 documented the administration in the MAR. LVN 1 was unable to recall at that time why the documentation was completed on behalf of RN 1. LVN 1 further stated that, at times, RN 1 had an emergencies to address and became busy after administering Resident 2's medications; however, the nurse who prepared and administered the medications should document the administration in the MAR immediately after the medications are given. During an interview on 6/29/2026 at 4:15 p.m., with the Director of Nursing (DON), the DON reviewed Resident 2's MAR for 5/2026 and the Nursing Staffing Assignment and Sign-in Sheet for 3 p.m. to 11 p.m. shift on 5/2/2026 and 5/23/2026. The DON stated that on 5/2/2026, the scheduled 9 p.m. atorvastatin entry contained no reason code and was left blank in the MAR. The DON stated that licensed nurses should not leave any medication entry blank and should document whether the medication was offered and declined, the resident was unavailable to receive the medication, or any other applicable reason. The DON further stated that the licensed nurse who prepared and administered the resident's medications should document the medication administration in the MAR to prevent medication errors. During a review of the facility's policy and procedure (P&P) titled, Administering Medications last reviewed on 11/20/2025, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and document the reason. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for medication, the individual administering the medication records in the resident's medical record:a. the date and time the medication was administered;b. the dosage;c. the route of administration;d. the injection site (if applicable);e. any adverse or undesired result;f. any results achieved and when those results were observed; andg. the signature and title of the person administering the drug.

Based on interview and record review, the facility staff failed to follow up with the physician after notification of a change of condition (COC- a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) when a resident had an abnormal laboratory result and failed to monitor the resident after a change of condition for one of five sampled residents (Resident 5). This deficient practice had the potential result to negatively affect the provision of necessary care and services.Findings: a. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on 2/14/2026 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one entire side of the body) following cerebral infarction (refers to tissue death in the brain caused by a blocked blood vessel) affecting left dominant side, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and cerebral infarction unspecified During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool) dated 2/17/2026, the MDS indicated that Resident 5 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), and dependent on staff with toileting hygiene, shower/bathe self, lower body dressing, and lying to sitting on side of bed. During a review of Resident 5's laboratory results for Comprehensive Metabolic Panel (CMP- type of blood test) and CBC differential (a standard blood test that provides a specific breakdown of distinct types of blood cells) dated 2/16/2026 19:08, the document indicated abnormal labs result. During a review of Resident 5's Change of Condition (COC-/ Interact Assessment Form Situation, Background, Assessment, Recommendation [SBAR]- a form filled out by licensed nursing staff for the purpose of communicating information about a resident's condition or other issue to other members of the health care team, including a resident's physician) effective date 2/16/2026 20:00, the document indicated under licensed nurse note, physician notified, awaiting response for new orders. There was no follow up documentation indicating if there was a physician order or not. During a concurrent interview and record review on 6/23/2026 at 4:10 p.m., with the Director of Nursing (DON), reviewed Resident 5's lab results dated 2/16/2026 19:08 and Resident 5's COC/ Interact Assessment Form SBAR effective date 2/16/2026 20:00. The DON stated the nurse should have followed up with the physician regarding Resident 5's abnormal lab results. The DON stated that it can negatively affect and delay providing the necessary care and services that the residents need. b. During a record review of Resident 5's COC/ Interact Assessment Form SBAR effective date 2/16/2026 20:00, the document indicated under licensed nurse note that the physician was notified. During a review of Resident 5's Licensed Nurse Note Type: Change of condition notes, the documents indicated there was no documented evidence that Resident 5's Licensed Nurse Note Type: Change of condition note for 2/17/2026 3 p.m. to 11:00 p.m. shift was completed. During a concurrent interview and record review on 6/24/2026 at 4:15 p.m., with Licensed Vocational Nurse 4 (LVN 4), reviewed Resident 5' COC/ Interact Assessment Form SBAR effective date 2/16/2026 20:00. LVN 4 stated on 2/17/2026 during the 3 p.m. to 11:00 p.m. shift he missed Resident 5' Licensed Nurse Note Type: Change of condition note because he got busy helping other residents that night. LVN 4 also stated he should have completed Resident 5's Licensed Nurse Note Type: Change of condition note, and by not completing the Licensed Nurse Note Type: Change of condition note it can delay providing the necessary care and services that Resident 5 needs. During an interview on 6/25/2026 at 3:45 p.m., with the DON, the DON stated that the licensed nurse should have completed the Licensed Nurse Note Type: Change of condition on 2/17/2026 for the 3 p.m. to 11:00 p.m. shift because there should have been 72 hour monitoring and documentation every shift after Resident 5's 2/16/2026 COC to monitor the resident's condition because it can negatively affect and delay providing the necessary care and services that the resident needs. During a review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, last reviewed on 11/20/2025, the policy indicated the nurse will notify the residents attending physician or physician on call when there has been a need to alter the resident's medical significantly. The nurse will record in the resident's medical record information relative to changes in the residents medical/mental condition or status.

Based on observation, interview, and record review, the facility failed to ensure that a call light (a device used by a resident to signal his/her need for assistance from staff) was within reach of a resident while the resident was in bed for one of three sampled residents (Resident 1). This deficient practice had the potential to delay the resident's ability to request assistance, which could result in delayed staff response, delayed provision of necessary care and services, and unmet resident needs. During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 7/10/2025 and was readmitted on [DATE] with diagnoses that included encephalopathy (brain disorder that affect brain function), type 2 diabetes mellitus (DM-a chronic condition in which the body does not use insulin [a vital hormone produced by the pancreas that regulates blood sugar] effectively, resulting in elevated blood sugar levels) with foot ulcer (an open sore or wound on the foot that may involve the skin and underlying tissue) and chronic respiratory failure (a long-term condition in which the lungs cannot adequately oxygenate the body, resulting in low oxygen levels) with hypoxia (a medical condition where your body's tissues and organs do not receive enough oxygen to function properly). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 4/14/2026, the MDS indicated Resident 1 was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact and required maximal assistance from staff for toileting hygiene, sit-to-lying, and lying-to-sitting on the side of the bed. During a concurrent observation and interview on 6/23/2026 at 10:00 a.m., with Licensed Vocational Nurse 1 (LVN 1) observed Resident 1 lying in bed with the call light placed on top of the bedside table (a small, accessible piece of furniture placed next to a resident's bed) and not within the resident's reach. LVN 1 stated the call light should have been within Resident 1's reach so the resident could request staff assistance. LVN 1 further stated that if the call light was not within reach, the resident could experience a delay in receiving needed care and services. During an interview on 6/25/2026 at 3:45 p.m., with the Director of Nursing (DON), the DON stated the call light should have been kept within Resident 1's reach while the resident was in bed so the resident could request assistance as needed. The DON further stated that failure to ensure the call light was within reach could result in a delay in providing the care and services the resident needed. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, dated 11/20/2025, the P&P indicated to ensure timely responses to the resident's requests and needs. The P&P further indicated to ensure that the call light is accessible to the resident when in bed or wheelchair in room, from the toilet or shower room if necessary.

Based on interview and record review, the facility failed to ensure the clinical record was accurately documented for one of five sampled residents (Resident 4), consistent with accepted standards of professional practice and the care and services provided. This deficient practice had the potential to adversely affect the resident's plan of care, and the delivery of necessary care and services. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included traumatic subdural hemorrhage (a life-threatening collection of blood between the brain and its tough outer covering [the dura], caused by a head injury) without loss of consciousness (a temporary state in which a person in unaware of themselves and their surroundings and cannot respond to stimuli), acute pulmonary edema (sudden buildup of fluid in the lungs), and contusion (bruise) of scalp (the skin on the top and back of your head where your hair grows). During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool) dated 2/21/2026, the MDS indicated Resident 4 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), and was dependent on staff for toileting hygiene, showering/bathing, lower body dressing, and rolling left and right. During a review of Resident 4's Census List dated 2/21/2026, the Census List indicated Resident 4 was discharged to the general acute care hospital (GACH) on 2/21/2026 at 3:36 p.m. During a review of Resident 4's Weights and Vitals (clinical measurements used to assess the body's basic functions) Summary dated 2/22/2026, the Vitals Summary indicated a temperature (the degree of hotness or coldness of the body) of 97.1 degrees Fahrenheit ( - a temperature scale used to measure body temperature), obtained using a non-contact forehead thermometer (a device used to accurately measure human body temperature), was documented on 2/22/2026 at 4:07 a.m. During a concurrent interview and record review on 6/23/2026 at 4:00 p.m., with the Director of Nursing (DON), Resident 4's Census List dated 2/21/2026 and Weights and Vitals Summary dated 2/22/2026 were reviewed. Resident 4's Census List indicated the resident (Resident 4) was transferred to GACH on 2/21/2026 at 3:36 p.m., and the Weights and Vitals Summary dated 2/22/2026 documented a temperature on 2/22/2026 at 4:07 a.m., after Resident 4 had been discharged from the facility. The DON stated the temperature entry had been documented in error and should have been documented accurately. The DON further stated inaccurate documentation could negatively affect the accuracy of the resident's clinical records and could delay the delivery of necessary care and services. During a review of the facility`s policy and procedure (P&P) titled, Charting and Documentation last reviewed on 11/20/2025, the facility P&P indicated all services provided to the resident, progress toward care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The following information is to be documented in the resident medical record: objective observations, treatments or services performed.

Based on interview and record review, the facility failed to maintain a pest-free environment by not ensuring effective pest control in one of four sampled residents' rooms (Resident 3's room). This deficient practice placed the residents at risk for vector-borne diseases (illnesses caused by viruses or bacteria transmitted through the bites of infected living organisms, primarily blood-feeding insects).During a review of Resident 3's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated that the facility admitted Resident 3 on 5/13/2026 with diagnoses that included left total hip replacement, osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 3's History and Physical (H&P - a comprehensive medical document that includes a detailed account of a resident's medical history, a physical examination, a clinical assessment, and a care plan) Evaluation dated 5/15/2026, the H&P Evaluation indicated Resident 3 had the capacity to make decisions and communicate needs. During a review of the Pest Control Service Report dated 4/29/2026, the service report indicated that the facility Maintenance Supervisor (MS) reported concerns regarding American roaches (an average length around four centimeters [cm - a unit of measurement], and these cockroaches may move indoors, seeking warmer environments and food. Cockroaches may enter houses via wastewater plumbing, underneath doors, or via air ducts or other openings in the walls, windows or foundation). The Technician 1, from the pest control services, found live roach activity in drains and recommended that drains be kept clean. The report further indicated that increased pest activity, including potential activity within the facility, could be expected for several days following treatment. During an interview on 5/20/2026 at 11:30 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she (CNA) observed a roach crawling on the wall in Resident 3's room. CNA 1 stated she (CNA 1) while wearing gloves, captured and killed the roach on the floor. CNA 1 described the roach as brownish in color and approximately one and one-half inches (in- unit of measurement) in length. CNA 1 stated a family member was present at the bedside at the time of the incident. During a concurrent interview on 5/20/2026 at 11:42 a.m., with Resident 3 and Family Member 1 (FM 1), in Resident 3's room, FM 1 stated that a couple of days ago, they observed a roach on the ceiling and notified staff. FM 1 stated staff entered the room and killed the roach. FM 1 described the roach as large, brownish in color, and noted it was moving on the wall and ceiling. During a concurrent interview and record review on 5/20/2026 at 2:14 p.m., with Technician 1, Technician 1 reviewed the Pest Control Service Report dated 4/29/2026 and stated that while no roaches were observed inside the building during the visit, roach activity was identified in exterior drains. Technician 1 stated treatment was completed and stated that increased roach activity including potential movement into the building through drains, cracks or gaps, may occur following treatment. During an interview with the Infection Control Preventionist (ICP) on 5/20/2026 at 3:09 p.m., the ICP stated that any observed live or dead roaches should be reported to the supervisory or maintenance staff for communication with pest control services. The ICP further stated that staff were aware roaches can carry pathogens (any disease-producing agent or organism) and may negatively impact resident health. During a review of the facility's policy and procedures (P&P) titled Pest Control last reviewed on 11/20/2025, the P&P indicated, Our facility shall maintain an effective pest control program. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on interview and record review, the facility failed to implement and maintain an effective infection prevention and control program when Certified Nursing Assistant 1 (CNA 1) failed to report the presence of roaches observed in a resident's room for one of four sampled residents' rooms (Resident 3's room). This deficient practice had the potential to create unsanitary conditions and contribute to cross-contamination (the transfer of harmful germs from one surface, object, or food to another), placing residents, staff, and visitors at increased risk for infection.During a review of Resident 3's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated that the facility admitted Resident 3 on 5/13/2026 with diagnoses that included left total hip replacement, osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 3's History and Physical (H&P - a comprehensive medical document that includes a detailed account of a resident's medical history, a physical examination, a clinical assessment, and a care plan) Evaluation dated 5/15/2026, the H&P Evaluation indicated, Resident 3 had the capacity to make decisions and communicate needs. During a review of the Pest Control Service Report dated 4/29/2026, the service report indicated that the facility Maintenance Supervisor (MS) reported concerns regarding American roaches (an average length around four centimeters [cm - a unit of measurement], and these cockroaches may move indoors, seeking warmer environments and food. Cockroaches may enter houses via wastewater plumbing, underneath doors, or via air ducts or other openings in the walls, windows or foundation). The Technician 1, from the pest control services, found live roach activity in drains and recommended that drains be kept clean. The report further indicated that increased pest activity, including potential activity within the facility, could be expected for several days following treatment. During an interview on 5/20/2026 at 11:30 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she (CNA) observed a roach crawling on the wall in Resident 3's room. CNA 1 stated she (CNA 1) while wearing gloves, captured and killed the roach on the floor. CNA 1 described the roach as brownish in color and approximately one and one-half inches (in- unit of measurement) in length. CNA 1 stated a family member was present at the bedside at the time of the incident. During a concurrent interview on 5/20/2026 at 11:42 a.m., with Resident 3 and Family Member 1 (FM 1), in Resident 3's room, FM 1 stated that a couple of days ago, they observed a roach on the ceiling and notified staff. FM 1 stated staff entered the room and killed the roach. FM 1 described the roach as large, brownish in color, and noted it was moving on the wall and ceiling. During an interview on 5/20/2026 at 12:30 p.m., with the MS, the MS stated that no reports - verbal or written, including through maintenance logs, had been received regarding roach activity from staff, including CNA 1. During a follow-up interview on 5/20/2026 at 12:35 p.m., with CNA 1, CNA 1 stated, that after killing the roach in Resident 3's room approximately two days earlier, she (CNA 1) intended to report the incident to the MS but forgot and subsequently left the facility without notifying anyone. When asked why staff should report pest sightings, CNA 1 stated that reporting is necessary so the facility can investigate pest activity and take corrective action. CNA 1 further stated that roaches can carry germs and pose a risk to resident health. During a concurrent interview and record review on 5/20/2026 at 2:14 p.m., with Technician 1, Technician 1 reviewed the Pest Control Service Report dated 4/29/2026 and stated that while no roaches were observed inside the building during the visit, roach activity was identified in exterior drains. Technician 1 stated treatment was completed and stated that increased roach activity including potential movement into the building through drains, cracks or gaps, may occur following treatment. During an interview with the Director of Nursing (DON) on 5/20/2026 at 2:45 p.m., the DON stated when CNA 1 observed and killed a roach in Resident 3's room, the incident should have been reported immediately to supervisory and maintenance personnel for follow-up. The DON further stated that cockroaches pose a risk of transmitting germs and that failure to follow reporting procedures and pest control protocols could negatively impact residents and the facility environment. During an interview with the Infection Control Preventionist (ICP) on 5/20/2026 at 3:09 p.m., the ICP stated that any sighting of live or dead roaches should be reported promptly to supervisory staff or maintenance personnel for communication with pest control services. The ICP further stated that staff were aware roaches can carry pathogens (any disease-producing agent or organism) that may negatively impact resident health and contaminate environments. The ICP stated that failure to report such sightings is inconsistent with the facility's infection prevention and control program. During a review of the facility's policy and procedures (P&P) titled Infection Control last reviewed on 11/20/2025, the P&P indicated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives of our infection control policies and practices are to: a. prevent, detect, investigate, and control infections in the facility; b. maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public, During a review of the Centers for Disease Control and Prevention (CDC - the primary United States federal agency responsible for protecting public health and safety) Guidelines titled Environmental Infection Control in Health-Care Facilities last updated July 2019, the CDC guidelines indicated, E. Environmental Services. 6. Pest Control. Cockroaches, flies and maggots, ants, mosquitoes, spiders, mites, midges, mice are among the typical arthropods (any creature with no backbone, a hard outer shell, and jointed legs) and vertebrate (any animal that has a backbone) pest populations found in health-care facilities. Insects can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector. From a public health and hygiene perspective, arthropod and vertebrate pests should be eradicated from all indoor environments, including health-care facilities,

Based on interview and record review, the facility failed to provide radiology (a branch of medicine that uses imaging technology to look inside the body) services in accordance with the physician's order for one of four sampled residents (Resident 2), following a fall incident. The facility failed to ensure timely completion of a radiology service to evaluate Resident 2's left foot, which was noted to have swelling and pain rated four (4) out of 10 (on a scale where zero indicates no pain and 10 indicates the worst pain imaginable). This deficient practice had the potential to result in a delay in diagnosis and treatment of the resident's condition.During a review of Resident 2's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated that the facility admitted Resident 2 on 1/30/2026 with diagnoses that included right arm fracture (broken bone), epilepsy (a chronic brain disorder that causes a person to have recurring seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), dementia (a progressive state of decline in mental abilities), and history of falling. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 2/3/2026, the MDS indicated Resident 2's cognition (ability to think, reason, and function) was severely impaired. The MDS further indicated that Resident 2 was dependent on staff for toileting hygiene, showering/bathing and upper body dressing, and required maximal assistance for eating, oral and personal hygiene, and lower body dressing, and required moderate assistance for sit-to-stand and chair/bed-to-chair transfers. During a review of Resident 2's Change of Condition (COC - an acute, abnormal alteration in a resident's physical or mental baseline) Assessment Form dated 5/19/2026, the COC Assessment Form indicated the following:At 3:30 a.m., staff found Resident 2 sitting on a landing pad (a cushioned floor pad designed to help prevent injury should a person fall) on the left side of the bed.At 4:20 p.m., Resident 2 reported left foot pain, and swelling noted to the left dorsal (towards the back) foot upon skin assessment. Resident 1 stated that the resident had slid from the bed last night (5/19/2026) at 3:30 a.m. and landed on the left foot with the full body weight. Pain was rated four (4) out of 10. Resident 1's physician was notified and a stat (immediately) order was obtained for an x-ray (a painless, noninvasive medical imaging test that uses a small, safe amount of electromagnetic radiation to produce pictures of the inside of your body) of the left foot. During a review of Resident 2's Physician Order dated 5/19/2026, timed at 4:21 p.m., the Physician Order indicated an order for a stat x-ray of Resident 2's left foot. During a review of Resident 2's radiology results report dated 5/20/2026, the report indicated the following:Examination Date: 5/20/2026 at 9:49 a.m.Reported Date: 5/20/2026 at 10:17 a.m.Conclusion: No acute osseous (bony or made of bone) findings. Recommend a repeat multi-view imaging in one (1) week or sooner if clinically warranted especially if symptoms continue to persist or progress. During a review of Resident 2's Progress Notes dated 5/20/2026, timed at 7:53 a.m., the Progress Notes indicated the Director of Nursing (DON) notified Resident 2's physician that the stat x-ray order for Resident 2's left foot had not yet been completed. During a concurrent interview and record review on 5/20/2026 at 2:25 p.m., with the DON, the DON reviewed Resident 2's COC Assessment Form dated 5/19/2026 and the Physician's stat Order for the left foot x-ray. When the DON was asked how soon the facility was required to provide radiology services for a stat order, the DON stated there was no specific timeframe; however, the service such as x-ray should be completed as soon as possible, typically within four (4) hours of the order. The DON further stated that if the service was not completed within that timeframe, nursing staff should notify the physician regarding the delay; however, this notification was not completed for Resident 2. The DON stated that the stat x-ray order was obtained on 5/19/2026 at 4:21 p.m. and the radiology service was completed on 5/20/2026 at 9:49 a.m. The DON further stated that a stat x-ray may be ordered to rule out a possible fracture or injury related to a fall incident that occurred on 5/19/2026 at approximately 3:30 a.m. During a review of the facility's policy and procedures (P&P) titled Request for Diagnostic Services last reviewed on 11/20/2025, the P&P indicated, Orders for diagnostic services will be promptly carried out as instructed by the physician's order. Emergency requests must be labeled stat to assure that prompt action is taken. During a review of the facility's P&P titled Change in a Resident's Condition or Status, last reviewed on 11/20/2025, the P&P indicated, The nurse will notify the resident's attending physician or physician on call when there has been a(an). need to alter the resident's medical treatment significantly. specific instruction to notify the physician of changes in the resident's condition.

Based on interview and record review, the facility's licensed nurses failed to accurately complete Fall Risk Evaluation assessment for one of four sampled residents (Resident 1). This deficient practice had the potential to place the resident at increased risk for falls and fall-related injuries due to the failure to appropriately identify and evaluate fall risk factors.During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated that the facility originally admitted Resident 1 on 10/10/2020 and readmitted on [DATE] with diagnoses that included congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), hypertension (high blood pressure), and diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 3/23/2026, the MDS indicated Resident 1's cognition (ability to think, reason, and function) was intact. The MDS further indicated that Resident 1 required setup or clean-up assistance from staff for all Activities of Daily Living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Change of Condition (COC - an acute, abnormal alteration in a resident's physical or mental baseline) Assessment Form dated 5/2/2026, timed at 10:33 p.m., the COC Assessment Form indicated that on 5/2/2026, at 10:30 p.m., Registered Nurse 1 (RN 1) saw Resident 1 sitting on the floor. The COC Assessment Form indicated that Resident 1 reported seeing a roach on the floor while lying in bed, attempted to reach for the roach, fell out of bed, and broke the footboard (upright, flat, or rigid support attached perpendicular to the end of a resident's bed). During a review of Resident 1's Fall Risk Evaluation dated 5/4/2026, the Fall Risk Evaluation indicated the following: Under the section for history, current status, predisposing conditions: Upon admission and quarterly, at a minimum, thereafter, observe the resident status in the 11 clinical condition parameters listed below by assigning the corresponding score which best describes the resident. If the total score is 10 or greater, the resident should be considered at high risk for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. History of falls (past three [3] months) was marked as 'No falls in past three (3) months' despite the COC Assessment Form (dated 5/2/2026) documentation of a fall. During a review of Resident 1's Fall Risk Evaluation dated 5/4/2026, the FRE indicated a total fall risk score of seven (7), which did not identify/consider Resident 1 as being at high risk for falls. During a concurrent interview and record review on 5/20/2026 at 2:53 p.m., with the Director of Nursing (DON), the DON reviewed Resident 1's COC Assessment Form dated 5/2/2026 and Fall Risk Evaluation dated 5/4/2026. The DON stated that she (DON) completed the Fall Risk Evaluation dated 5/4/2026. The DON further stated that the Fall Risk Evaluation was completed on 5/4/2026 after the fall incident that occurred on 5/2/2026 to identify the root causes of the fall incident and implement measures to prevent future falls. The DON stated that the 5/2/2026 fall should have been included in the 5/4/2026 assessment when responding to the question regarding history of falls within the previous three months. The DON stated the omission occurred because she was confused when completing that portion of the assessment. During a review of the facility's policy and procedures (P&P) titled Assessing Falls and Their Causes last reviewed on 11/20/2025, the P&P indicated, Purpose: The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. When a resident falls, the following information should be recorded in the resident's medical record. Completion of a falls risk assessment. Appropriate interventions taken to prevent future falls.

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) had complete information documented on the change of condition form (COC-a form used by the facility document changes in resident's condition including actions taken and notification of the physician and responsible party) by failing to document Resident 1's physician's response to Resident 1's change of condition.This deficient practice had the potential to delay necessary treatment, care and services, placing Resident 1 at risk for a decline in overall health status.Findings:During a review of Resident 1's Face Sheet, the Face Sheet indicated that the facility admitted Resident 1 on 9/15/2025 and most recently readmitted Resident 1 on 9/27/2025 with diagnoses that included type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, need for assistance with personal care, dysphagia (difficulty swallowing), urinary tract infection (UTI-an infection in the bladder [a hollow, muscular organ that stores urine or urinary tract [the body's drainage system designed to produce, store and remove urine [liquid waste and extra water]), history of falling and depression (mood disorder that causes persistent feeling of sadness, emptiness and a loss of interest in activities).During a review of Resident 1's History and Physical (H&P) dated 9/16/2025, the H&P indicated Resident 1 has the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/23/2026, the MDS indicated Resident 1's cognition (ability to think and make decisions) was severely impaired. The MDS further indicated Resident 1 required setup assistance with eating and oral hygiene, and supervision with toileting hygiene, upper and lower body dressing and personal hygiene, and dependent on staff for showering. During a review of Resident 1's COC form dated 4/28/2026, the COC form indicated resident (Resident 1) unable to sit up with chills and febrile (elevated body temperature), denied pain or discomfort, but general weakness.All due meds (medications) given with acetaminophen (medication used to treat mild pain and elevated body temperatures) 325 milligrams (mg-unit of measurement) 2 tablets.MD (medical doctor/physician) being informed.During an interview and concurrent record review on 5/12/2026 at 3:20 p.m. with Licensed Vocational Nurse (LVN) 1, the COC form for Resident 1, dated 4/28/2026 was reviewed. LVN 1 confirmed that LVN 1 completed the COC form dated 4/28/2026 for Resident 1. LVN 1 stated that Resident 1 experienced weakness and had an elevated body temperature on 4/28/2026. LVN 1 confirmed that acetaminophen 325 milligrams (mg-unit of measurement) 2 tablets were provided to Resident 1. LVN 1 stated that LVN 1 informed Registered Nurse Supervisor (RNS) 1. LVN 1 stated that RNS 1 informed Resident 1's physician of the change of condition. LVN 1 confirmed that LVN 1 did not document Resident 1's physician's response to Resident 1's change of condition.During an interview on 5/13/2026 at 11:20 a.m. with RNS 1, RNS 1 stated that LVN 1 informed RNS 1 of the change of condition for Resident 1 on 4/28/2026. RNS 1 stated that RNS 1 informed Resident 1's physician and that Resident 1's physician instructed RNS 1 to continue to monitor Resident 1. RNS 1 stated that she informed LVN 1 of Resident 1's physician's instructions. RNS 1 stated that RNS 1 did not document the communication between RNS 1 and Resident 1's physician.During an interview and concurrent record review of 5/13/2026 at 2:30 p.m. with the Director of Nursing (DON), the COC form for Resident 1, dated 4/28/2026 was reviewed. The DON confirmed Resident 1's COC form dated 4/28/2026 indicated that the physician was informed. The DON confirmed that the nursing staff should have documented Resident 1's physician's response on the COC form to ensure continuity of care for Resident 1.During a review of the facility's policy and procedure (P&P) titled Change in a Resident's Condition or Status with a last reviewed date of 11/20/2025, the P&P indicated Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.The nurse will notify the resident's attending physician or physician on call when there has been.significant change in the resident's physical/emotional/mental condition.The nurse will record in the resident's medial record information relative to changes of in the resident's medical/mental condition or status.

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) laboratory results were communicated with the physician in a timely manner.This deficient practice had the potential for Resident 1 to have a delay in care and services, increased risk for worsening infection and decrease in overall health status.Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated that the facility originally admitted Resident 1 on 9/15/2025 and most recently readmitted Resident 1 on 9/27/2025 with diagnoses that included type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, need for assistance with personal care, dysphagia (difficulty swallowing), urinary tract infection (UTI-an infection in the bladder [a hollow, muscular organ that stores urine or urinary tract [the body's drainage system designed to produce, store and remove urine [liquid waste and extra water]), history of falling and depression (mood disorder that causes persistent feeling of sadness, emptiness and a loss of interest in activities). During a review of Resident 1's History and Physical (H&P) dated 9/16/2025, the H&P indicated Resident 1 has the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/23/2026, the MDS indicated Resident 1's cognition (ability to think and make decisions) was severely impaired. The MDS further indicated Resident 1 required setup assistance with eating and oral hygiene, and supervision with toileting hygiene, upper and lower body dressing and personal hygiene, and dependent on staff for showering. During a review of Resident 1's laboratory results report dated 4/28/2026, the laboratory results for complete blood count (CBC- a blood test that measures the number and size of the different cells in your blood) and a basic metabolic panel (BMP-a blood test that checks the levels of different substances in your blood) indicated the laboratory work was completed on 4/28/2026 at 2:45 p.m. The laboratory report further indicated that the laboratory results were sent to the facility on 4/28/2026 at 9:41 p.m. and Registered Nurse 3 (RN 3) reviewed the laboratory results on 4/29/2026 at 6:59 a.m. During an interview and concurrent record review on 5/13/2026 at 1:00 p.m. with RN 3, the CBC and BMP results for Resident 1 on 4/28/2026 were reviewed with RN 3. RN 3 stated he works during the 7 a.m. to 3 p.m. shift. RN 3 confirmed that he reviewed Resident 1's CBC and BMP results, on 4/29/2026 at 6:59 a.m. and that he sent the results to Resident 1's physician. During an interview and concurrent record review on 5/13/2026 at 2:30 p.m. with the Director of Nursing (DON), Resident 1's laboratory results for CBC and BMP, dated 4/28/2026, were reviewed with the DON. The DON confirmed that Resident 1's laboratory results were received by the facility on 4/28/2026 at 9:41 p.m. The DON stated that the laboratory results should be sent to the physician in a timely manner, as soon as possible. The DON stated that the licensed nurse should not have waited until 4/29/2026 to inform Resident 1's physician regarding the laboratory results. During a review of the facility's policy and procedure (P&P) titled Test Results with a last reviewed date of 11/20/2025, the P&P indicated The resident's attending physician will be notified of the results of diagnostic tests.Results of laboratory, radiological and diagnostic tests shall be reported in writing to the resident's attending physician or to the facility. Should the test results be provided to the facility, the attending physician shall be promptly notified of the results. The director of nursing services, or charge nurse receiving the test results, shall be responsible for notifying the physician or such test results.

Based on interview and record review the facility failed to ensure facility staff notified the resident representative after one of three sampled residents (Resident 1) had a change of condition after being found on the floor next to the bed with an injury.This deficient practice resulted in Resident 1's representative not being notified of Resident 1's change of condition and had the potential for of the resident representative to be unable to make informed decisions regarding Resident 1's treatment and plan of care. Findings:During a review of Resident 1's Face Sheet, the Face Sheet indicated that the facility originally admitted Resident 1 on 9/15/2025 and most recently readmitted Resident 1 on 9/27/2025 with diagnoses that included type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, need for assistance with personal care, dysphagia (difficulty swallowing), urinary tract infection (UTI-an infection in the bladder [a hollow, muscular organ that stores urine or urinary tract [the body's drainage system designed to produce, store and remove urine [liquid waste and extra water]), history of falling and depression.During a review of Resident 1's History and Physical (H&P) dated 9/16/2025, the H&P indicated Resident 1 has the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/23/2026, the MDS indicated Resident 1's cognition (ability to think and make decisions) was severely impaired. The MDS further indicated Resident 1 required setup assistance with eating and oral hygiene, and supervision with toileting hygiene, upper and lower body dressing and personal hygiene, and dependent on staff for showering. During a review of Resident 1's Change of Condition form (COC-a form used by the facility to document changes in resident's condition including actions taken and notification of the physician and responsible party) dated 4/29/2026, the COC form indicated at approximately 1:15 a.m., Resident 1 was found in the room on the floor mat next to the bed after hearing the resident (Resident 1) yelled for help, resident (Resident 1) was on floor mat (a mat placed next to a residents bed to prevent injury in case of a fall or accident) and verbalized, she slid from bed because she wanted to go to the restroom.resident (Resident 1) noted to have a skin tear (a wound often occurring in older adults or those with fragile skin) of 3 centimeters (cm-unit of measurement) on the right upper arm near elbow. treatment rendered.Resident 1 is self-responsible. During an interview on 5/13/2026 at 10:10 a.m. with Responsible Party (RP) 1, RP 1 stated that the facility did not inform RP 1 that Resident 1 had a fall in the facility. RP 1 stated that RP 1 called on 4/29/2026 around 8:30 a.m. to check on Resident 1's status and was informed Resident 1 had a fall in the middle of the night. RP 1 stated that RP 1 should have been informed at the time of the fall by facility staff. During an interview on 5/13/2026 at 2:30 p.m. with the Director of Nursing (DON), the DON confirmed Resident 1 was found on the floor mat next to Resident 1's bed on 4/29/2026 around 1:15 a.m. The DON confirmed that facility staff should have notified RP 1 at the time Resident 1 was found next to Resident 1's bed. During a review of the facility's policy and procedure (P&P) titled Change of Condition or Status last reviewed on 11/20/2025, the P&P indicated Our facility promptly notifies the resident, his or her attending physician, the resident representative of changes in the resident's medical/mental condition and/or status.Unless otherwise instructed by the resident, a nurse will notify the resident's representative when the resident is involved in any accident or incident that results in an injury including injuries of an unknown source, there is a significant change in the resident's physical, mental, or psychological status.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) for two of five sampled residents (Resident 1 and Resident 2) when on 10/1/2023, Resident 1 hit Resident 2 in the head with a trashcan lid, and Resident 2 hit Resident 1 in the head with a wooden back scratcher. This deficient practice resulted in Resident 1 and Resident 2 being subjected to physical abuse while under the care of the facility, and both Resident 1 and Resident 2 required transfer to the General Acute Care Hospital (GACH) for possible head injuries as a result of the physical altercation. Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on 11/9/2022 and readmitted on [DATE] with diagnoses included depression (persistent sadness) and anxiety disorder (persistent and excessive worry that interferes with daily activities). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 8/19/2023 indicated Resident 1 was able to remember, communicate, and make decisions. The MDS further indicated that Resident 1 needed extensive assistance from staff with bed mobility and transfer and needed supervision with locomotion (movement from one place to another). A review of Resident 1's Change in Condition (CIC - when there is a sudden change from a resident's health) Evaluation Form dated 10/1/2023, indicated that on 10/1/2023, at approximately 7:30 p.m., facility staff (unidentified) heard a screaming at the staff and resident's lounge. The CIC Evaluation Form indicated that Resident 1 was hit by Resident 2 and noted with a small lesion (wound) with red discoloration (redness) to the left side of the head. The CIC Evaluation Form indicated that Resident 1 then hit Resident 2 and as a result, Resident 2 sustained red discoloration to the forehead. Resident 1's physician ordered to transfer the resident to the GACH for a Computed Tomography (CT - a diagnostic imaging procedure that uses a combination of X-ray [a photographic or digital image of a part of the body] and computer technology to produce images of the inside of the body) of the brain. A review of Resident 1's head CT result dated 10/2/2023 done at the GACH indicated, the reason for the examination was for dizziness due to blunt trauma (injury of the body by forceful impact with a dull object). A review of Resident 1's Physician's Order indicated an order dated 10/2/2023 for treatment for Resident 1's scrape (skin injury) to the left front temporal area (left side of the head) by cleansing the site with Normal Saline (NS - solution composed of salt and water), pat dry, apply antibiotic ointment (medication that are applied on skin to help kill bacteria) and to leave the injury open to air daily for 10 days. A review of Resident 1's Skin Assessment Form dated 10/2/2023, indicated, Resident 1 was involved in a resident-to-resident physical altercation that resulted with Resident 1 sustaining a scrape measuring one (1) centimeter (cm-unit of measure) in length, and one (1) cm in width to Resident 1's left side of the forehead with discoloration (change in natural skin color) measuring at seven (7) cm in length and three (3) cm in width. A review of Resident 2's Admission Record indicated the facility admitted the resident on 6/10/2021 and readmitted on [DATE] with diagnoses that included neuropathy (when nerve damage leads to pain, weakness, numbness or tingling in one or more parts of your body). A review of Resident 2's MDS dated [DATE] indicated Resident 2 was able to remember, communicate, and make decisions. The MDS further indicated that Resident 2 needed extensive assistance from staff with bed mobility and transfer and needed limited assistance from staff with locomotion. A review of Resident 2's CIC Evaluation Form dated 10/1/2023, indicated, at 7:30 p.m., at approximately 7:30 p.m., facility staff (unidentified) heard a screaming at the staff and resident's lounge. The CIC Evaluation Form indicated that Resident 2 had a physical altercation with Resident 1 and was noted with red discoloration to the forehead. The CIC Evaluation Form further indicated that Resident 2's physician ordered for the resident to be transferred to the GACH for a CT of the head. A review of Resident 2's CT of the head result dated 10/2/2023 done at the GACH indicated, the reason for examination was trauma. A review of Resident 2's GACH Discharge Instructions Form dated 10/2/2023, indicated, Resident 2's discharge diagnosis was closed head injury (occur when there is a non-penetrating injury to the brain with no break in the skull [the bony framework of the head]). A review of Resident 2's Skin Assessment Form dated 10/2/2023, indicated, Resident 2 was involved in a resident-to-resident physical altercation resulting in Resident 2 sustaining a bruise (an injury appearing as an area of discolored skin on the body) measuring five (5) cm in length and four (4) cm in width to Resident 2's left hand as a result of blocking the physical assault (intentionally causing or attempting to cause physical harm to another through force or violence) from Resident 1 on 10/1/2023. A review of Resident 3's Admission Record indicated the facility admitted the resident on 12/30/2022 with diagnoses that included diabetes mellitus (the body's inability to control the amount of sugar in the blood). A review of Resident 3's MDS dated [DATE] indicated Resident 3 was able to remember, communicate, and make decisions. The MDS further indicated that Resident 3 needed supervision with locomotion. During an interview with Resident 2 on 10/17/2023 at 12:36 p.m., Resident 2 stated that on 10/1/2023 (unable to recall exact time) while playing a card game with Resident 1 and Resident 3, Resident 1 became angry and was not following the rules of the game. Resident 2 stated that with his wooden back scratcher, Resident 2 gestured to Resident 1 as if he was about to hit Resident 1 with the wooden back scratcher. Resident 2 stated he was unsure if he hit Resident 1 with the wooden back scratcher at that time. Resident 2 then stated that Resident 1 picked up the lid of a nearby trash can and attempted to hit Resident 2 in the head. Resident 2 stated that he used his left arm to block Resident 1's attack. Resident 2 stated that as a result of blocking Resident 1's attack, he sustained a bruise to his left hand. Resident 2 stated that Resident 1 attempted to strike Resident 2's head multiple times, but that Resident 2's head was okay. Resident 2 stated that in his angry state, he used his wooden back scratcher to then hit Resident 1 in the head. Resident 2 stated that Resident 3 was there the entire time and witnessed the altercation. During an interview with Resident 3 on 10/17/2023 at 12:55 p.m., Resident 3 stated that on 10/1/2023 at around 7:30 p.m., he was playing a card game with Resident 1 and Resident 2. He stated that Resident 1 did not agree to one of the rules of the card game being led by Resident 2 at the time. Resident 3 stated that Resident 1 informed Resident 2 that he was no longer going to play the card game, at which point Resident 2 attempted to hit Resident 1 with his back scratcher. Resident 3 stated he then witnessed Resident 1 pick up the lid of a trash can and hit Resident 2 in the head. Resident 3 stated everything happened so quickly, and then he suddenly noticed that Resident 1 was bleeding from the head. Resident 3 stated that facility staff arrived soon after and separated Resident 1 and Resident 2. During an interview with Resident 1 on 10/17/2023 at 2:30 p.m., Resident 1 stated that about two weeks ago (10/1/2023), at around 7:30 p.m., while playing a card game with Resident 2 and Resident 3, Resident 2 hit his head with a wooden back scratcher three to four times. Resident 1 stated that he began bleeding from his head and needed to be transferred to the GACH and have a brain CT done. During an interview with the Director of Nursing (DON) on 10/17/2023 at 5:10 p.m., DON stated, the facility was aware about the on-going card games being played by Resident 1, Resident 2, and Resident 3. The DON stated that Resident 1, Resident 2, and Resident 3 were all alert and had intact cognition (ability to think and make decisions). When the DON was asked if the incident where in Resident 1 and Resident 2 both hit one another in the head multiple times would be considered physical abuse, the DON stated that there is always a possibility of a resident-to-resident altercation to occur because the residents have the ability to lose control as a result of the games being played. The DON stated that facility staff intervened and both Resident 1 and Resident 2 were separated after the physical contact. A review of the facility's policy and procedure (P&P) titled, Abuse & Mistreatment of Residents, reviewed on 7/27/2021, indicated, To uphold a resident's right to be free from verbal, sexual, and mental abuse, corporal punishment (physical punishment), and involuntary seclusion. The policy defined abuse as the willful (intentional) infliction of injury .

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from accident hazards by: 1. Failing to remove the landing mat prior to transferring Resident 1 from the geriatric chair (also known as a geri chair or medical recliner, is a large, padded, comfortable reclining chair that allows to sit comfortably while being fully supported and transported to adjoining areas within a facility) to their bed. 2. Failing to ensure Certified Nursing Assistant 1 (CNA 1) and CNA 2 communicated and worked in sequence with each other while transferring Resident 1 from the geri chair to their bed. This deficient practice resulted in a fall incident on 9/9/2022 in which Resident 1 was transferred to the General Acute Care Hospital 1 (GACH 1) and sustained a right subdural hematoma (serious condition where blood collects between the skull and the surface of the brain) in the frontal and parieto-occipital regions (situated between the parietal and occipital [at the side and back of the skull] bones or lobes), fracture (partial or complete break in the bone) of the right 10th and 11th ribs, and a scalp laceration (wound that is produced by the tearing of soft body tissue) to the back of the head. Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on 8/28/2017 with diagnosis including Alzheimer ' s disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), [CONDITION(S)] (blood has a lower-than-normal number of red blood cells), and long-term use of anticoagulants (blood thinners). A review of Resident 1 ' s Minimum Data Sheet (MDS - a standardized assessment and care-screening tool) dated 6/7/2022 indicated the resident sometimes made self-understood and sometimes could understand others. Resident 1 required two-person physical assistance with bed mobility, transfer, and toilet use. A review of Resident 1 ' s Quarterly Fall Risk assessment dated [DATE], indicated Resident 1 was high fall risk. A review of Resident 1 ' s Care Plan for risk for falls/injury, initiated on 9/3/2022, indicated a goal to reduce risk of falls and injury daily. The care plan interventions included providing Resident 1 with a safe and clutter-free environment. A review of Resident 1 ' s Change of Condition (COC) Assessment Form dated 9/9/2022 indicated, Resident 1 was transferred from geri chair to her bed by two (2) Certified Nursing Assistants (CNAs) using a Hoyer lift (mechanical lift - a patient lift used by caregivers to safely transfer residents). While trying to reposition the Hoyer lift close to the mattress, the wheels of the Hoyer lift got caught in the landing mat. Resident 1 was moving in the sling supported by another CNA but accidentally slid out from the sling and was assisted by the CNA to the landing mat. Resident 1 was immediately assessed by a licensed nurse with no complain of pain or discomfort. Resident 1 was able to move upper and lower extremities without difficulty. A skin tear was observed on the back of the head with minimal bleeding. A neurological check (assessment to determine whether the nervous system is impaired) was done with no changes in mental status. The nurse applied pressure dressing to the cut on the back of the head. Pain medication was given to Resident 1 as prophylactic (preventive) treatment. The Medical Doctor (MD) was notified and ordered to transfer Resident 1 to General Acute Care Hospital 1 (GACH 1) via regular ambulance for further evaluation and treatment. The COC Assessment Form indicated a skin tear on the back of the head measuring 1centimeter (cm - a unit of measurement) in length by 1cm length. A review of Resident 1 ' s General Acute Care Hospital 1 (GACH 1) History and Physical dated 9/10/2022, indicated the following assessment: - Status post (after) fall with [MEDICATION(S)] head trauma (severe injury to the head). - Right subdural hematoma in the frontal as well as parieto-occipital regions, maximal thickness 8 millimeters (mm - unit of measurement). - Fracture of right 10th and 11th ribs. - Scalp laceration, 1 inch long. During an interview on 9/14/2022 at 12:39 p.m., the Director Nursing (DON) stated on 9/9/2022, CNAs 1 and 2 used a mechanical lift to transfer Resident 1 from the geri chair to her bed. The DON stated during the transfer, the front part of the mechanical lift got stuck on the landing mat and the sling holding the resident was moving and Resident 1 slid out of the sling. The DON stated Resident 1 hit her head, but the two CNAs were unable to say where Resident 1 hit her head. The DON stated Resident 1 had a skin tear on the back of her head. The DON stated Resident 1 was transferred to the hospital and was told by Resident 1 ' s daughter the resident had two rib fractures. During an interview on 9/14/2022 at 3:17 p.m., the Director of Staff Development (DSD) stated she did an immediate in-service for CNA 1 and CNA 2. The DSD stated she did a skills checklist with each CNA for the use of the mechanical lift and discussed with the two CNAs about decluttering of the room. The DSD stated she asked CNA 1 and CNA 2 what happened and was told that when Resident 1 was being transferred back to her bed, CNA 1 moved the mechanical lift forward towards the bed and the wheels got stuck on the landing mat causing the sling to move around and Resident 1 slid off the sling. The DSD stated she was told it happened so fast, CNA 1 and CNA 2 were unable to say where Resident 1 hit her head. The DSD stated Resident 1 slid off, but CNA 2 was holding onto the resident ' s legs when her head went first. The DSD stated common factors for a mechanical lift getting stuck on something could be landing mats and electrical cords. The DSD stated that was taught during the in-service. The DSD stated there ' s a risk the mechanical lift could meet resistance with the landing mat. The DSD stated moving forward, she has instructed all staff to remove landing mats before mechanical lift transfers because of this incident. During an interview on 9/16/2022 at 3:38 p.m., with CNA 1, CNA 1 stated she was not taking care of Resident 1 but helped CNA 2 with transferring Resident 1 back to her bed from the geri chair. CNA 1 stated she used a mechanical lift to lift Resident 1 from the geri chair and when she pushed the mechanical lift towards the bed, the front wheels of the mechanical lift got stuck on the landing mat. CNA 1 stated she doesn ' t remember if Resident 1 fell out of the sling feet first or headfirst, but she suddenly fell , and the sling was still connected to the mechanical lift. CNA 1 stated Resident 1 fell on the landing mat and saw bleeding on the back of Resident 1 ' s head. CNA 1 stated she received an in-service from the DSD right after the incident and was taught to pay attention when using the mechanical lift, using a mechanical lift is always a two-person assist, remove landing mats, and to talk to the other person helping and communicate with each other. CNA 1 stated she has used a mechanical lift many times and stated their process is to always remove the landing mats. CNA 1 stated she doesn ' t know what happened that day and she saw there was a landing mat but forgot to take it out. CNA 1 stated she should have taken out the landing mat. During an interview on 9/21/2022 at 3:26 p.m., with CNA 2, CNA 2 stated she brought the mechanical lift to the room to transfer Resident 1 from the geri chair back to bed. CNA 2 stated she felt rushed because of another resident and forgot to take out the landing mat. CNA 2 stated it has been their process to always remove the landing mat during mechanical lift transfers. CNA 2 stated CNA 1 was the one using the mechanical lift and lifted Resident 1 from the geri chair. CNA 2 stated as she was removing the geri chair out of the way, she saw a reflection of the sling moving back and forth. CNA 2 stated CNA 1 had pushed the mechanical lift forward while she was removing the geri chair out of the way. CNA 2 stated she was not back in position when CNA 1 began to move forward with the mechanical lift. CNA 2 stated she saw the sling move back and forth and she caught the resident ' s legs when it was swinging, and Resident 1 suddenly slid out of the sling and landed on the landing mat. CNA 2 stated it happened so fast she doesn ' t remember where Resident 1 hit her head. During a concurrent observation and interview on 9/21/2022 at 3:47 p.m., with CNA 2 and the DSD, CNA 2 demonstrated how the incident had occurred. CNA 2 demonstrated how she removed the geri chair and explained while she was doing that, she saw the sling moving back and forth when CNA 1 had pushed the mechanical lift forward and got stuck on the landing mat. CNA 2 stated she grabbed Resident 1 ' s legs however resident had slid from the bottom part of the sling and landed on the landing mat. CNA 2 stated she is not sure where the resident had hit her head. The DSD demonstrated pushing the mechanical lift over the landing mat and observed how front feels met resistance causing the attached sling to move back and forth. A review of CNA 1 ' s Mechanical Lifts/Mechanical Lift Monitoring Education form was dated 6/24/2014. A review of CNA 2 ' s Mechanical Lifts/Mechanical Lift Monitoring Education form was dated 7/20/2013. During an interview on 9/21/2022 at 4:02 p.m., the DSD stated she taught the CNAs to always be at the head of the resident while they are in the sling and that it would be easier to maneuver the sling due to the strap located on the top back part of the sling. The DSD stated Resident 1 ' s fall could have been prevented if there was no landing mat. The DSD stated CNA 1 and CNA 2 should have worked in sequence with each other. The DSD stated CNA 1 should have waited for CNA 2 to finish moving the geri chair and then go forward with the mechanical lift together. The DSD was unable to provide any recent (within a year) training or competency evaluation related to the use of mechanical lifts. During an interview on 9/23/2022 at 4:02 p.m., the Director of Nursing (DON) stated CNA 1 should have waited and made sure their partner is ready to assist. The DON stated CNA 1 should not have pushed the mechanical lift until CNA 2 was ready. The DON stated CNA 2 would have been ready to catch the resident in the sling when it started swinging. The DON stated the two CNAs should have communicated with each other. The DON further stated CNA 1 and CNA 2 should have removed the landing mat and kept the room free of clutter. The DON stated removing the landing mat and waiting for CNA 2 to be ready and communicating with each other would have prevented Resident 1 from falling. A review of the in-service education provided to CNA 1 and CNA 2 dated 9/9/2022, indicated the following topic/content: - Policy and procedure of mechanical lift. - Two person assist when utilizing the mechanical lift. - De-[CONDITION(S)] the area prior to using the mechanical lift for prevention of the machine getting stuck (i.e., landing pad, bed cords). - Fall precaution measures. A review of the facility ' s policy and procedure titled, Mechanical Lifts, undated, indicated, This facility is a non-lift facility, so mechanical lifts will be used for transferring resident who cannot assist the transfers. A two-person assist is required when using a lift. The policy did not include ensuring the area of transfer was free from clutter for a safe use of the lift. A review of the facility ' s policy and procedure titled, Avoidance of Environmental Hazards, undated, indicated, This facility will strive to provide a hazard-free environment to ensure that the residents safety is maintained .The Direct Care Givers (CNAs) will randomly check the resident ' s unit, with the resident ' s permission, to identify and/or remove items that may present a risk to the resident ' s safety.

Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) was kept free from accident and hazards by failing to provided two-person assist as indicated in the plan of care while the resident attempted to transfer himself from the shower chair to the bed. This deficient practice resulted in Resident 1 sustaining a fall that required the need for transfer to a General Acute Care Hospital (GACH). At the GACH, Resident 1 was identified with a fracture (break in bone due to trauma) requiring the need for surgical intervention. Findings A review of Resident 1's Admission Record indicated an original admitted [DATE] with a recent readmitted [DATE]. Admitting diagnoses for Resident 1 included [CONDITION(S)] (condition affecting the development of the spinal cord), major depressive disorder (characterized by persistently depressed mood), history of falling, [CONDITION(S)] (low blood pressure caused when standing), and personal history of a healed traumatic fracture. A record review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and screening tool) dated 4/1/2021 indicated Resident 1's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision-making was intact. Further review of the MDS indicated that Resident 1 required total dependence with two-person physical assist for transferring from surface to surface such as from a bed to a wheelchair, or from a chair back to a bed. A review of Resident 1's care plan with the focus Low Air Loss Mattress. At risk for falling from low-air-loss mattress due to: Large of heavy Patient with revision date 2/25/2021, indicated under nursing interventions to provide two-person assist with transfers, repositioning, and daily care as indicated. A review of Resident 1's care plan with the focus Fall Risk with revision date 2/25/2021 indicated under interventions for Staff will provide a safe and clutter-free environment. A review of Resident 1's record titled Change of Condition (COC- a system for identifying, evaluating, and reporting deterioration in resident's condition)/Interact Assessment Form dated 6/19/2021 with the time of 9:57 a.m. indicated that Resident 1 fell from the shower chair (a waterproof chair used on elderly with disabilities or injuries) while transferring to the bed. Further record review indicated Resident 1 complained of pain and was transferred to GACH via 911 emergency response. On 7/2/2021 at 2:36 p.m., during an interview with Certified Nursing Assistant 1 (CNA 1), CNA 1 indicated that on the day of Resident 1's fall on 6/19/2021, Resident 1 was being impulsive and impatient. CNA 1 defined impatient as someone wanting something done and wanting it done immediately. CNA 1 stated that when she returned Resident 1 to the resident's room after a shower, Resident 1 attempted to transfer himself from the shower chair onto the bed. CNA 1 indicated that Resident 1 requires two-person assist during transfers, with the importance of having two staff assisting for both the residents' and the staff's safety. CNA 1 stated not having any other staff member present at the time of Resident 1's fall. CNA 1 stated, The safe thing to do was to have had someone else there to help already, but we have to get lucky to have another staff available. CNA 1 indicated that during the mornings, other staff members are too busy administering medications, taking breaks, or providing showers to other residents. On 7/2/2021 at 3:25 p.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), when asked what is the importance for Resident 1 to receive assistance from two (2) staff members during transfers, LVN 1 stated, It is important to transfer the resident with two (2) persons assist for the safety of the residents and for ourselves, to prevent falls resulting in fractures. LVN 1 stated that facility staff need to work together and ask another staff for assistance. LVN 1 stated that another staff should have been there in the room already since the resident is impulsive. On 7/9/2021 at 3:07 p.m., during an interview with Resident 1 at a new Skilled Nursing Facility (SNF), Resident 1 indicated that there was only one (1) staff member assisting Resident 1 back to bed after receiving a shower. Resident 1 indicated falling and needing to have surgery. Resident 1 stated, After the fall, it was painful, crazy painful for my hips. On 8/6/2021 at 1:35 p.m., during an interview with Registered Nurse 1 (RN 1), RN 1 indicated that Resident 1 had a history of previous falls and a healed traumatic fracture. RN 1 described Resident 1 as alert with episodes of confusion and forgetfulness. RN 1 stated that two-person assist is required for Resident 1 to prevent re-occurrence of fracture because it can happen if the resident falls on the same site as a previous fracture. RN 1 stated, Knowing that the resident is aggressive and impulsive, the Certified Nursing Assistant (CNA) should have called someone to assist before going in the room to transfer the resident. This was preventable if the CNA had called for assistance. On 8/10/2021 at 3:30 p.m., during an interview with Director of Staff Development (DSD), DSD indicated that if a resident requires the assistance from two (2) person staff, another qualified staff should be informed in advance to provide assistance within the next 10 minutes. A review of Resident 1's General Acute Care Hospital (GACH) records with admitted [DATE] indicated an x-ray (a digital image of an internal part of the body such as bones), of Resident 1's right hip with pelvis (bony structure where legs are attached) indicated the result, right femoral subcapital fracture (break in the thigh bone). A review of Resident 1's GACH records titled Progress Notes with admitted [DATE] indicated on 6/23/2021, Resident 1's preoperative diagnosis (nature of illness prior to surgical procedure) states, nonunion (when a broken bone fails to heal) of right femoral neck (neck area of thigh bone) with retained hardware (implants from previous surgery) of right femur. Further record review indicated that Resident 1 had a surgical procedure for removal of hardware of right femur and conversion (change) to right hip hemiarthroplasty (a surgical procedure replacing partial hip bones). Record review of an undated facility Policy and Procedure titled Accident/Incident Prevention indicated, This facility strives to prevent accidents by providing an environment that is free from accident hazards over which the facility has control, as well as identification of each resident at risk for accident/incidents and the provision of adequate care plans with procedures to prevent accidents.

Based on interview, and record review, the facility failed to give pain medication timely on two occasions to one of three sampled residents (Resident 1) as ordered by the physician. Resident 1 did not receive the scheduled dose of [MEDICATION NAME] (pain medication) which resulted in the resident having increased pain. Findings: According to the Admission Face Sheet, Resident 1, was admitted to the facility on [DATE] and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment and care-screening tool, dated 2/23/18 indicated Resident 1 was alert and oriented. The resident required supervision from staff for bed mobility, and transfers and limited assistance with one person for some activities of daily living (ADLs). A review of the Pain Risk Assessment indicated Resident 1 was at risk for pain. A review of the Pain Assessment/Management dated 5/16/17 indicated Resident 1 was awake, alert, and oriented. The resident's tolerable level of pain was a 2/10 (0 being no pain at all and 10 being the worst possible pain). The note indicated the [MEDICATION NAME] was ordered for routine pain medication. The plan/recommendations include monitoring pain, administer pain medication as ordered, manage resident's pain within acceptable level and monitor effectiveness of pain meds and document as indicated. A review of the Physician order [REDACTED]. A review of the nurse's notes dated 2/9/18 at 7:35 a.m., indicated the facility did not have the [MEDICATION NAME] available for Resident 1. At 9:15 a.m., the facility had not received the dose of [MEDICATION NAME] for the resident. A review of the Pain Assessment Flow Sheet dated 2/9/18 indicated at 7:30 a.m., Resident 1 had a pain level of 5/10 and the routine [MEDICATION NAME] was given. At 8:00 a.m., the records indicated the resident's pain level decreased to 0/10. During an interview on 3/6/18 at 9:25 a.m., Resident 1 stated that on 2/9/18 the facility did not have the [MEDICATION NAME] available when it was due at 7:30 a.m. The resident did not receive the [MEDICATION NAME] until 10 a.m. that day. Due to the delay of the [MEDICATION NAME], the resident stated that his pain level increased from a 3/10 to an 8/10. At the time of interview, the resident complained of a 7/10 to 8/10, pain level and stated [MEDICATION NAME] had not been receive, as it should have been at 7:30 a.m. The resident further stated he had not seen the medication nurse at all that morning. During a phone interview on 3/6/18 at 10:10 a.m., Licensed Vocational Nurse (LVN 1) stated on 2/9/18, he noticed the [MEDICATION NAME] had not been restock and that it was unavailable for Resident 1. LVN 1 stated he documented the medication was given at 7:30 a.m. and, the post pain medication assessment was documented at 8:00 a.m. LVN 1 stated the pain medication was not given until 10 a.m. LVN 1 stated he should not have documented this information if it was not given. A review of the Pain Assessment Flowsheet dated 3/6/18 indicated Resident 1 had a pain level of 6/10 and [MEDICATION NAME] was given at 7:30 a.m. The form also indicated on 3/6/18 at 8:00 a.m., the medication was effective and the resident's pain level was 0/10. During an interview and review of the Pain Assessment Flowsheet on 3/6/18 at 9:40 a.m. with Resident 1 present, LVN 2 stated she had not seen Resident 1 at all this morning. LVN 2 stated she had not assessed the resident for pain and did not administer pain medication as ordered. LVN 2 verified her signature on the Pain Assessment Flowsheet and stated that she documented that she assessed the resident and gave pain medication, however, it was not done. During an interview and record review on 3/6/18 at 9:53 a.m., the director of nursing (DON) stated the medication and pain assessment should not have been sign if it was not done. The DON stated that this is against the facility's policy. A review of the Alteration in comfort/pain care plan initiated on 9/7/14 indicated the resident has a potential for alteration in pain due to severe low back pain. The goal of the care plan was to reduce episodes of pain or discomfort through appropriate interventions daily. These interventions include monitoring the resident for signs and symptoms of pain, administer pain medication as ordered, and monitor effectiveness of the pain medication. The facility's undated policy and procedure titled, Pain Management, indicated it is use to provide guidelines for the consistent assessment, management, and documentation of pain of the resident, in order to provide maximum comfort and quality of life. Clear documentation of pain assessment and a plan of care are to be completed and maintained by the nursing staff. Any reassessment of pain shall use the Pain Assessment Flowsheet for ongoing evaluation, documentation of interventions, and determining efficacy of pain control. The facility's undated policy and procedure titled, Med Pass, indicated the basic procedure for passing meds includes, Pour-Pass-Chart. Prepare the med correctly, administer the med correctly, and chart the med pass correctly. The 5 Rights, includes right resident, right medications, right dose, right route, and right time. Med passes are to be done within a two-hour window. For example, the med pass must be started up to an hour earlier and finished up to an hour later. A med error is a violation of the 5 Rights.

Based on observation, interview, and record review, the facility failed to implement infection control measures to prevent the spread of scabies (a condition of very itchy skin caused by tiny mites (human skin parasite) that burrow into the skin) as indicated in the facility's Infection Control and Scabies Prevention and Control policies and procedures and the Los Angeles County Department of Public Health (LA DPH) Scabies Prevention and Control Guidelines for Acute and Long Term Care Facilities for 19 sample residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19), other residents in the facility (84 in house resident census), staff, visitors, and into the community, as evidenced by: 1. Residents 1, 2, and 8 had rashes (skin eruption/raised, typically reddened) with itchiness within a 14-day period of time. On 4/26/17 Residents 1 was administered [MEDICATION NAME] Cream ([MEDICATION NAME], kills parasites that live on humans, such as the scabies) and repeated treatment seven days later. On 4/27/17, Resident 2 was ordered the oral medication Ivermectin (used in the treatment of [REDACTED]. Resident 8, one of three roommates of Resident 2 had rashes with itchiness but did not receive [MEDICATION NAME]. Residents 1, 2, and 8's suspicious rashes occurring within a 14-day period were not reported to the local Public Health Department (PHD) and the Licensing and Certification State Agency, as a possible scabies outbreak (sudden rise in occurrences of a disease). 2. Residents 1, 2, 3, 4, 6, 7, and 9 had rashes on 6/1/17. There was no surveillance to identify new cases of rashes, there was no investigation or line listing to control and prevent the spread of scabies. 3. The roommates (Residents 5, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19) of the residents affected with rashes, and the staff and visitors, who were in contact with affected residents, were not identified and investigated for the spread of scabies. 4. Residents 1, 3, 6, and 8, were treated with [MEDICATION NAME] and/or Ivermectin (to treat scabies) and were not placed on contact isolation precautions. 5. Resident 1, was placed on contact isolation precautions on 6/2/17, and Certified Nursing Assistant 1 (CNA 1) when entering the resident's room, did not use the personal protective equipment (including long-sleeved gowns, gloves, etc.) placed outside Resident 1's door for its use. 6. Resident 6 exhibited ongoing rashes and itchiness from 8/21/16 to 6/1/17 had been treated and on 6/1/17, Resident 6 was still symptomatic but no longer receiving treatment for [REDACTED]. Resident 4 had rashes for two to three weeks prior to 6/1/17, and was not receiving treatment for [REDACTED]. These deficient practices resulted in no actual harm with the potential for serious harm when: 1) The affected residents had prolonged discomfort due to the unresolved continued itchiness. 2) The affected residents were administered lengthy and repeated medications and treatments, placing them at risk for side effects. According to the manufacturer's recommendation, [MEDICATION NAME] exacerbates itching and mild burning and/or stinging may occur after its application. According to the Centers for Disease Control and Prevention (CDC), oral Ivermectin should be considered for patients who have failed treatment with or who cannot tolerate FDA-approved topical medications for the treatment of [REDACTED]. According to the manufacturer's recommendation, common side effects from the use of Ivermectin are headache, dizziness, muscle pain, nausea, diarrhea, swelling of hands/ankles/feet and lymph nodes, itching, and skin rash. 3) Residents, staff and visitors, who were in contact with the affected residents, were not identified to promptly implement interventions to prevent and control the disease. An Immediate Jeopardy (IJ) situation was called on 6/1/17, at 9:50 p.m. The Administrator and the Director of Nursing were informed. On IJ was lifted on 6/2/17 at 4:20 p.m., upon review, verification, and acceptance of a written plan of correction, in the presence of the Director of Operations and the Administrator. On 6/2/17, the facility notified the local PHD of the outbreak. A letter dated 6/6/17 titled Rash/Scabies Outbreak Notification, from DPH contained six of a total of 14 actions to be taken by the facility within 24 hours including, closing the facility for transfers and new admissions; treating all symptomatic (with manifestation of scabies) residents and staff with [MEDICATION NAME]; placing symptomatic residents in contact isolation precautions and symptomatic staff off work; and providing [MEDICATION NAME] treatment to all contacts of symptomatic residents. On 6/9/17 the facility received a clearance (from scabies) letter by the PHD. Findings: On 6/1/17, at 10:30 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Infection Control. During a tour of the facility seven residents (Residents 1, 2, 3, 4, 6, 7, and 9) were observed to have rashes, were itching and scratching. 1. On 6/1/17, at 11:15 a.m. Resident 1 was observed lying in bed scratching her upper chest area, which was red. The exposed skin on Resident 1's upper and lower extremities, and her back was noted with spread out rashes with redness and papules (small solid round bumps in the skin). Resident 2 was unable to participate in an interview. Resident 1 had one roommate, Residents 14. On 6/1/17, a review of the Admission Record indicated Resident 1 was originally admitted to the facility, on 11/22/15, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - standardized assessment and care planning tool) dated 5/13/17, indicated Resident 1 had severely impaired cognitive skills for daily decision-making and required extensive assistance with all activities of daily living (ADLs - bathing, transfer, personal hygiene, dressing, etc.). A Short-Term Plan of Care dated 4/15/17, developed for Resident 1's problem of rashes all over the body, had a goal for the rash to resolve within three weeks (5/8/17). The Physician's Orders indicated on 4/24/17, Physician 4 ordered to apply [MEDICATION NAME] Cream from head to toe and to repeat the application in seven days (4/30/17) for [MEDICATION NAME] (preventive). According to the Multidisciplinary Progress Record dated 4/26/17, Dermatologist 1 (physician specialized in skin diseases) evaluated Resident 1's body rash and documented generalized [DIAGNOSES REDACTED]tous (reddened) papules excoriated (scraped), pruritus (itchiness), and status [REDACTED]. Dermatologist 1 documented a follow up evaluation in a week or two (7 to 14 days). The Physician's Orders did not include isolation precaution during the time Resident 1 was treated [MEDICATION NAME] for scabies. Further record review disclosed no documented evidence isolation precautions were implemented during and after [MEDICATION NAME] treatment and there was no further evaluation by Dermatologist 1 (follow up in 7-14 days). On 6/2/17, at 1:30 p.m., during an interview, Treatment Nurse 1 stated Residents 1 was not placed on isolation. On 6/1/17, a review of the Multidisciplinary Progress Record and Physician's Orders for Resident 14 (the roommate of Resident 1), indicated no evaluation, treatment or contact isolation for possible scabies. There was no documented evidence the rash and possible scabies of the roommate (Resident 1) were addressed as risk factor for Resident 14. On 6/2/17, at 1:30 p.m., during an interview, Treatment Nurse 1 stated the facility did not have residents with scabies, it was not necessary to implement isolation precautions for Resident 14. 2. On 6/1/17, at 11 a.m., Resident 2 was observed to have rashes on the back and the left arm. Resident 2 was unable to participate in an interview. Resident 2 had three roommates, Residents 8, 12, and 13. On 6/1/17, a review of the Admission Record indicated Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] indicated Resident 2 had severely impaired cognitive skills for daily decision-making and required extensive assistance with all ADLs. The Physician's Orders included an order dated 4/2/17, to apply to Resident 2 topical (applied directly on the skin) [MEDICATION NAME] (steroid ointment to treat itchiness and swelling of the skin) 1% to rashes on the back for seven days. According to the Multidisciplinary Progress Record dated 4/14/17, Dermatologist 1 evaluated Resident 2 and ordered three medications, [MEDICATION NAME] 10 mg oral tablets, [MEDICATION NAME] Cream 0.05% topical, and [MEDICATION NAME] during two weeks for dermatitis (inflammation of the skin) and pruritus. On 4/26/17, Dermatologist 1 re-evaluated Resident 2 and ordered to continue topical [MEDICATION NAME] 0.05% for two weeks and oral [MEDICATION NAME] for three weeks. According to the Multidisciplinary Progress Record dated 4/27/17, Dermatologist 2 evaluated Resident 2 and ordered Ivermectin orally for three days, [MEDICATION NAME] Cream from head to toe and to repeat in one week, and contact isolation precautions. The [DIAGNOSES REDACTED]. The contact isolation was discontinued on 5/1/17. A nurse's note dated 5/8/17, indicated Physician 1 was informed Resident 1 had generalized rashes, Physician 1 ordered [MEDICATION NAME]. The Multidisciplinary Progress Record dated 5/18/17, indicated Dermatologist 1 evaluated Resident 2, diagnosed [DIAGNOSES REDACTED]tous papules/nodules, excoriated back and partially treated pruritus. Dermatologist 1 ordered again Ivermectin, [MEDICATION NAME] and Westcort Cream 0.05%. The Care Plans - Rash dated 4/26/17 and 5/8/17, did not address a contagious skin disease and the contact isolation precautions ordered. On 6/2/17, at 1:30 p.m., during an interview and review of the record, Treatment Nurse 1 could no find a plan of care addressing contact isolation precautions. 3. A review of the Admission Record of Resident 8 (roommate of Residents 2, 12, and 13), indicated an admitted d 9/4/09 with [DIAGNOSES REDACTED]. According to the history and physical examination [REDACTED]. The MDS dated [DATE] indicated Resident 8 was able to communicate and was totally dependent on staff for ADLs. The Physician's Orders indicated Physician 2's ordered on [DATE] [MEDICATION NAME] (to treat allergy and itchiness) orally 25 mg every six hours as needed for itching and wound evaluation for excoriation surrounding redness on the right upper abdomen. A plan of care was not developed to address the right upper abdomen redness and excoriation. According to the Multidisciplinary Progress Record dated 4/14/17, Dermatologist 1 evaluated Resident 8 and diagnosed furunculosis (skin infection characterized by the presence of multiple boils) to the abdomen and chest. Dermatologist 1 ordered Keflex (oral antibiotic) for 10 days for infected papules to the right upper abdomen, [MEDICATION NAME] to wash for five days the right upper abdomen, [MEDICATION NAME] (topical antibiotic) ointment daily for two weeks to the abdominal rash, Westcort Cream 0.2% daily for three weeks to rash, and [MEDICATION NAME] 10 mg orally every day for three weeks. A plan of care was not developed on 4/14/17, to address Resident 8's skin infection (furunculosis). The Care Plans - Rash dated 4/26/17 had a goal for the infection to clear in 10 days and the rash to resolve in 30 days (5/26/17). The Physician's Orders indicated Physician 2 ordered on [DATE] [MEDICATION NAME] Cream daily for 30 days to the right chest area rash. According to the Multidisciplinary Progress Record dated 5/18/17, Dermatologist 1 evaluated Resident 8 indicating the resident had contact dermatitis and ordered [MEDICATION NAME] cream (topical ointment to treat various skin conditions and itching) daily for three weeks, [MEDICATION NAME] 10 mg orally daily for three weeks, and to discontinue [MEDICATION NAME]. On 6/2/17, at 1:30 p.m., during an interview, Treatment Nurse 1 stated the facility did not have residents with scabies, it was not necessary to evaluate or treat Resident 2's roommates, Residents 12 and 13. 4. On 6/1/17, at 2:30 p.m., Resident 3 was observed in his room and, during an interview, stated he has been itching all over his body for several weeks. According to the admission record, Resident 3 was initially admitted to the facility on [DATE] and re-admitted on [DATE], after a three-day hospitalization . Resident 3's [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] indicated Resident 3 had no memory problem, was able to make decisions, and required limited to extensive assistance with ADLs. The Phsycian's Orders dated 3/28/17,indicated Physician 3 ordered oral [MEDICATION NAME] 10 mg for seven days for itchiness and on 3/31/17, ordered [MEDICATION NAME] 1% ointment for left and right extremities rashes. On 4/11/17, the [MEDICATION NAME] order was changed to [MEDICATION NAME] (for itchiness and swelling of the skin) and Physician 3 ordered evaluation by dermatologist. According to the Multidisciplinary Progress Record, on 4/14/17, Dermatologist 1 documented Resident 3 had chest and back rashes with scattered (spread out) papules and diagnosed [DIAGNOSES REDACTED]tous papules on the back and chest, and pruritus. Dermatologist 1 scrapped the chest and back for scabies testing (to observe the skin under microscope for mites), ordered washing the affected areas daily with [MEDICATION NAME] soap for seven days, give [MEDICATION NAME] 10 mg orally for three weeks, and follow up in two weeks. There was no further documentation from Dermatologist 1. According to the Laboratory Test Result for Scabies Examination, the skin scraping result was negative for scabies. According to the Physician's Orders, Physician 3 ordered: On 4/29/17, [MEDICATION NAME] 1% ointment to apply to rashes all over the body. On 5/10/17, [MEDICATION NAME] Cream and repeat in seven days and Ivermectin 3 mg orally. On 5/18/17, [MEDICATION NAME] (for allergy and itchiness) oral 25 mg two times a day for three days and to apply [MEDICATION NAME] and repeat in seven days. A review of the Interdisciplinary Team Conference Record dated 5/19/17, indicated the onset (start) of the rash was on 3/29/17. On 5/18/17, Dermatologist 1 was at the facility to evaluate Resident 3 but the resident refused. According to the Physician's Orders, on 5/23/17, Physician 3 ordered [MEDICATION NAME] for 14 days. The Care Plan for Rash dated 4/29/17, 5/13/17, 5/18/17, 5/25/17, did not include isolation precautions for the resident, roommates, staff and visitors. This was confirmed by the DON on the same day at 5 p.m. 5. During the initial tour of the facility, on 6/1/17, at 10:45 a.m., Resident 4 was observed lying in her bed scratching her chest and arms, which had reddish rash, and was complaining of itching in the webs of her fingers. Resident 4 had one roommate (Resident 15). A review of the admission record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE], after a four-day hospitalization . Resident 4's [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] indicated Resident 4 had severely impaired cognitive skills for daily decision-making, and required extensive assistance with all her ADLs. On 6/1/17, at 12:30 p.m., during an interview, Family Member 1 stated Resident 4 has complained about itching and rash for about two to three weeks and had asked Family Member 1 to bring some ointment for the itching. Family Member 1 stated the staff did not inform her about the origin of the rash and Family Member 1 was concerned about bringing something contagious home to her young children. Family Member 1 stated she was aware of other residents scratching, complaining of itchiness and having rashes. Further review of Resident 4's clinical record disclosed no documentation identifying the rashes, itchiness and scratching and there was no treatment for [REDACTED]. This was confirmed by the DON on the same day at 5 p.m. 6. A review of the admission record indicated Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admission assessment indicated the resident had no rashes upon admission. The H&P dated 3/15/17 indicated Resident 5 was able to make decision and her skin was clear. According to the Multidisciplinary Progress Record, on 5/22/17, Dermatologist 3 ordered [MEDICATION NAME] and to repeat on 5/24/17 for [MEDICATION NAME]. According to the Physician's Orders, on 5/26/17, Physician 5 ordered to apply Floucinomide ([MEDICATION NAME] - to treat itching and swelling of the skin) ointment to rash on the chest area daily for 21 days. Further review of the clinical record had no evidence of isolation precautions implemented when the resident was treated with [MEDICATION NAME] for [MEDICATION NAME] of scabies. This was confirmed by the DON on the same day at 5 p.m. 7. On 6/1/17, at 11:30 a.m., Resident 6 was observed with reddened rash and scratch marks on his torso and neck. Resident 6 was unable to participate in an interview due to his mental condition. Resident 6 had a roommate (Resident 19). A review of the Admission Record disclosed Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing Admission Assessment indicated Resident 6 had no rashes. The H&P dated 6/14/16, indicate the skin was within normal limits. The MDS assessment dated [DATE] indicated Resident 6 had moderately impaired cognitive skills for daily decision-making and required limited assistance with ADLs. The Resident Care Plan - Short-Term Problem dated 8/21/16, for Resident 6's problem of rashes on right shoulder and right side of the chest, indicated to treat as ordered and notify the physician if the treatment was not effective. The Multidisciplinary Progress Record indicated Dermatologist 1's evaluated Resident 6 on 9/9/16 for body rashes and pruritus. Dermatologist 1 documented Resident 6 received [MEDICATION NAME] a few day ago, and a second dose of [MEDICATION NAME] in seven days (from the first application), and ordered [MEDICATION NAME] for 10 days. Further review of the clinical record indicated no evidence of isolation precautions implemented when [MEDICATION NAME] was administered. This was verified by the DON on 6/1/17, at 5 p.m. On 11/4/16, Dermatologist 1 evaluated Resident 6 for chest rash and new rash on the abdomen and ordered [MEDICATION NAME] Cream 0.1% (to treat skin inflammation and itchiness) for four weeks. On 6/1/17, there was no order to treat Resident 6's rashes and itchiness until after the Evaluator noted the rashes. A review of the clinical record of Resident 6's roommate, Resident 19, disclosed no evidence Resident 19 was evaluated, treated or isolated for rashes/scabies. This was verified by the DON on 6/1/17, at 5 p.m. 8. On 6/1/17 at 11:40 a.m., Resident 7 was observed sitting in a wheelchair in her room, scratching her arms and torso which were noted with rash and scratch marks. Resident 7 had three roommates (Residents 16, 17, and 18) and was unable to participate in an interview due to confusion. A review of the Admission Record indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE], after a two-day hospitalization , with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] indicated Resident 7 had severely impaired cognitive skills for daily decision-making and required limited to extensive assistance with ADLs. According to the Multidisciplinary Progress Record, Dermatologist 1 evaluated Resident 7 for unresolved body rashes on 1/13/17, 2/15/17, 2/23/17, 4/14/17, 4/26/17, and 5/18/17 and ordered: -On 1/13/17, [MEDICATION NAME] wash daily for 10 days, [MEDICATION NAME] daily, and [MEDICATION NAME] 10 mg daily for three weeks. -On 2/15/16, Westcort cream daily for four weeks and [MEDICATION NAME] 10 mg daily for three weeks -On 2/23/17, continue Westcort daily to abdominal rash. -On 4/14/17, [MEDICATION NAME] (Floucinomide) for three weeks to abdominal rash and [MEDICATION NAME] 10 mg daily for three weeks. -On 4/26/17, [MEDICATION NAME] daily for three weeks, to back and abdomen rashes. -On 5/18/17, [MEDICATION NAME] two times (repeat in seven days), Ivermectin oral 6 mg now and repeat in seven days, [MEDICATION NAME] 10 mg daily for three weeks, and Westcort cream daily for three weeks. There was no documented evidence the three roommates (Residents 16, 17, and 18) were evaluated, treated or isolated for rashes/scabies. This was verified by the DON on 6/1/17, at 5 p.m. 9. On 6/1/17 at 11:45 a.m., Resident 9 opened his shirt to expose a rash on his back and upper arms, stating the rash was treated with an ointment and he was itching on and off. A review of the Admission Record indicated Resident 9 was initially admitted to the facility on [DATE], and readmitted on [DATE] after a five-day hospitalization with [DIAGNOSES REDACTED]. The nursing Admission Assessment on 9/26/16 did not indicate presence of rashes. The MDS assessment dated [DATE] indicated Resident 9 had no memory problems and required extensive assistance with ADLs. The Physician's Orders indicated on 5/22/17, Physician 2 ordered [MEDICATION NAME] to a back rash for 30 days. 10. On 6/1/17, a review of the Admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and re-admitted on [DATE] after a five-day hospitalization with [DIAGNOSES REDACTED]. According to the MDS assessment date 6/1/17, Resident 10 was unable to make decisions and needed extensive assistance with ADLs. According to the Multidisciplinary Progress Record, on 5/18/17, Dermatologist 1 evaluated Resident 10 for pruritus, diagnosed the resident with dermatitis, xerosis (abnormally dry skin) and pruritus. Dermatologist 1 ordered [MEDICATION NAME] (for dry skin) cream twice a day for four weeks, [MEDICATION NAME] 10 mg daily for three weeks, and Westcort cream daily for four weeks. 11. On 6/1/17, a review of the Admission Record indicated Resident 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] indicated Resident 11 had severely impaired cognitive skills for daily decision-making and required limited assistance with ADLs. According to the Multidisciplinary Progress Record, on 2/15/17, Dermatologist 1 documented Resident 11 had body rashes with reddened papules on the lower extremities and pruritus. Dermatologist 1 ordered [MEDICATION NAME] wash daily for two weeks, [MEDICATION NAME] gel twice a day to rash for four weeks and oral [MEDICATION NAME] 10 mg daily for three weeks. The Physician's Orders indicate on 5/2/17, Physician 6 ordered [MEDICATION NAME] 1% cream to body rash for 14 days and on 5/4/17, ordered [MEDICATION NAME] Cream daily for 21 days. According to the Multidisciplinary Progress Record, on 5/18/17, Dermatologist 1 evaluated Resident 11 for back rash and ordered [MEDICATION NAME] cream 0.1% to back rash for three weeks. On 6/1/17, at 1 p.m., during an interview, the Infection Control nurse/Director of Staff Development (IC/DSD) was unable to provide documented evidence of a tracking system in place to determine the spread of rashes around the facility. There was no surveillance program and no line listing of symptomatic residents, staff, or visitors. On 6/1/17 at 1:45 p.m., during an interview with the Administrator and the Director of Nursing (DON), it was brought to their attention Residents 1 and 2 were symptomatic for scabies and received [MEDICATION NAME] treatment within a 14-day period which constituted a reportable outbreak. In addition, observation of residents and record review disclosed multiple residents with rashes during the same time period. The DON and the Administrator both stated they did not consider the situation an outbreak, there was no evidence of scabies in the facility and there was no need to notify the local Public Health and/or the State agency. On 6/2/17, the Evaluator attempted to contact Dermatologist 1 for interview but was unable and Dermatologist 1 did not return the calls. On 6/2/17, at 1:30 p.m., during an interview, Treatment Nurse 1 stated Residents 1, 2, and 3, who were treated with [MEDICATION NAME], were not placed on isolation because they did not have scabies. On 6/2/17, at 2 p.m., during an interview, Dermatologist 4 stated he had just finished making rounds and had assessed all the residents with skin problems. Dermatologist 4 stated, Saw pruritus, fungal rashes, and some may be scabies, we don't know until we get a positive test result. But we will treat right away. We will isolate them right away and take it from there. During a tour of the isolation rooms on 6/2/17 at 3:30 p.m., Certified Nursing Assistant 1 (CNA 1) was observed passing water pitchers from a cart. She took a water pitcher and walked into Resident 1's room, which had an isolation cart outside the room. The isolation cart contained personal protective equipment (disposable gowns, gloves, etc.). There was a green stop sign on the wall, outside the room. CNA 1 was observed as she placed the water pitcher on the over-the-bed table, picked up the remote control of a bed, raised Resident 1's head of the bed, straightened the resident's bedding, picked up Resident 1's water cup, poured a cup of water, and handed it to the resident. CNA 1 then grasped and moved the over-the-bed table, exited the room without washing her hands, went to the cart and picked up another water pitcher to bring to another room. At this point, the Evaluator asked CNA 1 about handwashing. CNA 1 proceeded to wash her hand and upon return, during an interview, she stated she knew the cart outside the room indicated the resident was on isolation, but did not know what type of isolation the green color on the stop sign indicated. On 6/2/17, at 4:20 p.m., during an interview, the DON stated the facility followed the Los Angeles County Scabies Prevention and Control Guidelines. The facility's policy and procedure titled Infection Control undated, indicated for contact isolation, color coded stop signs were used to identify that contact precautions were in effect. This notifies staff and visitors of the need for special precautions and/or to contact nursing staff for further instructions. The color green signifies skin as the source of infection. Gowns and gloves are to be worn when providing care or working with environmental surfaces. an order for [REDACTED]. The facility's undated policy and procedure titled Scabies-Prevention and Control, indicated the facility established and implemented policies for the prevention and control of scabies that included notification and education of facility employees, family members, and visitors. As soon as a case of scabies is confirmed or suspected, the symptomatic resident is placed on contact isolation precautions. Personal protective clothing, that includes gloves and long-sleeved gowns, when in direct contact with a patient with signs and symptoms suggestive of scabies will be worn. Immediate action when the threshold for scabies outbreak has been reached will include reporting to Licensing and Certification and the local Public Health Nurse when two or more suspected cases of scabies are identified within a 14-day period, regardless of whether confirmed cases are identified; notifying all facility employees, non-employees and physicians; notify current patients, family members and visitors. According to the County of Los Angeles DPH, Acute Communicable Disease Control Program, Scabies Prevention and Control Guidelines Acute and Long Term Care Facilities, date August 2015, since the scabies mite is an ectoparasite (outside the body - on the skin), an exposed individual is potentially immediately infectious to others, even in the absence of symptoms. Cases are communicable from the time of infestation until mites and eggs are destroyed by treatment. A negative skin scraping from a person with typical scabies does not rule out scabies infestation. Scabies outbreak includes at least two clinically suspect cases identified in patients, healthcare workers, volunteers and/or visitors during a two week period of time. The recommendations include preparing a line listing of symptomatic patients and healthcare workers with a separate line list of their contacts. Evaluate contacts for scabies. Treat symptomatic patients and healthcare workers with an approved scabicide (kill scabies), provide [MEDICATION NAME] scabicide to all contacts of symptomatic cases, and perform environmental cleaning to affected units. Ideally, these steps (treatment, [MEDICATION NAME], and environmental cleaning) should all be accomplished within the same 24-hour period to prevent re-infestation of treated or [MEDICATION NAME] individuals. Provide training to all staff on scabies signs and symptoms. Emphasize that people can be infested and contagious for up to 6 weeks before symptoms begin. Communicate with the affected resident's family members and provide scabies education.