Every finding on record at Ocean Pointe Healthcare Center

Based on observation, interview, and record review, the facility failed to prepare, store, and serve food in a sanitary manner and environment. This failure had the potential to increase the risk of foodborne illness for the residents who consumed food from the facility's kitchen.Findings: During a concurrent observation and interview in the facility's kitchen on 6/1/2026 at 7:37 A.M. with the Food Services Director (FSD), a metal pot filled with white liquid was in the refrigerator with a use by date of 5/29/2026. The FSD stated the white liquid was a prepared protein shake mixture. The FSD stated that the current date was 6/1/26, therefore the shake mixture should be thrown away. During an observation on 6/1/2026 at 7:55 A.M. in the kitchen, Dietary Aide (DA) 1 was serving food onto a plate while holding the plate's surface with a bandaged thumb. During an interview with the FSD on 6/1/26 at 7:55 A.M., the FSD stated that DA1 should wear a glove on the injured hand when serving food minimize the risk of food contamination (transfer of bacteria, viruses, or chemicals into food). During a concurrent observation and interview on 6/1/2026 1:31 P.M. with FSD in the kitchen:The floor drain near the entrance to the kitchen had collected a pool of standing water. The FSD stated that the floor drain was closed off below the floor level and did not drain. The FSD stated that standing water in a kitchen is not sanitary.Small serving dishes were stored on a low shelf behind a trash can. The FSD stated that storing dishes close to a trash can increase the risk of contamination.Small serving cups were stacked on a shelf above the dish drying station with moisture trapped between each cup. The FSD stated that the moisture between the cups and dishes should not be stacked wet to avoid bacteria growth.A stored food prep container had adhesive residue on its outer surface. The FSD stated that a container with adhesive is not clean.Multiple plastic pitchers had chips and cracks on their surfaces. The FSD stated that chipped or cracked pitchers should be thrown away.A large metal bowl with a plastic pitcher inside was stored under kitchen sink with moisture both in the bowl and the plastic pitcher. The FSD stated that dishes should be stored dry.Plates stored in the plate warmer were stored wet. The FSD stated that the plate warmer should have dry plates only.A large plastic container of Ken's Bleu Cheese Dressing was found in the dry storage with a bulging lid and the label indicated, Keep Refrigerated. A large plastic container of Ken's [NAME] Caesar dressing was also found in the dry storage area with a label indicating Keep Refrigerated. Two plastic containers of lemon juice were found in the dry storage area with a label indicating Keep Refrigerated. The FSD stated that these products were not stored properly. The FSD stated that if these products were served to residents, it could cause illness. The FSD stated that it is important to read the labels to know how to properly store products. During an interview on 6/2/2026 at 1:09 P.M. with the Registered Dietician (RD), the RD stated that kitchen prepared foods are good for 72 hours after they are prepared and should be thrown away after the 72-hour use by date. The RD stated that a cut on the hand should be covered with a glove before handling or serving food. The RD stated that a bandage that contacts food can contaminate the food. The RD stated that standing water in the kitchen is not acceptable and can cause insects, bacteria, or mold. The RD stated that dishware must be air dried and stored in a clean area. The RD stated that stacked wet dishware stays wet and can cause bacteria or mold growth. The RD stated that refrigerated food should be placed in the refrigerator no later than 2 hours after receiving the product. The RD stated that eating expired dressing may cause stomach issues, diarrhea, or food poisoning. During a concurrent observation and interview on 6/3/2026 at 10:02 A.M. with the FSD, the food processor bowl attachment had black residue in the clear handle and cracks on the bottom of the bowl. The FSD stated that the attachment is not clean and should have been replaced.During a review of the facility's policy and procedures (P&P) titled, Food Receiving and Storage, dated 10/2017, the P&P indicated, Foods shall be received and stored in a manner that complies with safe food handling practices. The P&P also indicated, Refrigerated foods must be stored below 41(degrees)F unless otherwise specified by law.

Based on observation and interview, for one of one sampled resident (Resident 77), the facility failed to ensure that Giver (CG) 1 provided and maintained Resident 77's privacy and dignity (basic right to be valued, respected, and treated as a human being) by failing to close the door and close dignity (privacy) curtains door to the room during activities of daily living care (ADL - activities such as bathing, dressing and toileting a person performs daily) according to the facility's policy and procedure (P&P) tiled Quality of Life -Dignity, revised 1/2026 for one of one sampled resident. This deficient practice resulted in violating Resident 77's rights to be treated with privacy and dignity and also had the potential for the resident not to feel dignified and suffer lowered self-esteem.Findings: A review of Resident 77's admission Record indicated the facility admitted Resident 77 on 10/23/2024 and readmitted Resident 77 on 5/26/2026 with diagnoses including dementia (progressive state of decline in mental abilities), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hypertension (HTN - high blood pressure). A review of Resident 77's Minimum Data Set (MDS - resident assessment tool) dated 5/30/2026, indicated Resident 77 is cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 77 is dependent on staff with ADL care. During an observation on 6/1/2026, at 9:41 A.M., in the hallway Resident 77's door room was open and the dignity curtain/s was open and Resident 77 was observed in bed. Resident 77's private area was visible from the hallway and CG 1 was observed provided care to Resident 77. Upon noticing the writer, CG 1 attempted to close the dignity curtain/s. During an interview on 6/1/2026, at 9:42 A.M., with CG 1, CG 1 stated that she was closing the curtain to provide Resident 77 with privacy while she was changing the resident's incontinent brief. CG 1 stated that dignity curtains should be closed during incontinent care to give the resident privacy. During an interview on 6/4/2026, at 11:41 A.M., with the Director of Nursing (DON), the DON stated that resident's dignity curtains should be completely closed during ADL care to provide residents with privacy. The DON stated that leaving the dignity curtain open during incontinent care may cause the residents to feel due to lack of privacy and is not dignifying A review of the Facility P&P titled Quality of Life -Dignity, revised 1/2026 indicated the following: Policy StatementEach resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect andIndividualityPolicy Interpretation and Implementation1. Residents shall be treated with dignity and respect at all times.2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteemand self-worth.10. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance withpersonal care and during treatment procedures.

Based on observation, interview, and record review, for one of one resident (Resident 22) the facility failed to:1. Notify a physician that Resident 22 was self-administering medications and storing medications at the bedside.2. Obtain a physician's order for Resident 22 to self-administer medications and or supplements, and store medications and/or supplements at the bedside3. Conduct an assessment if Resident 22 can self-administer medications and/or supplements and store medications and/or supplements at the bedside. These failures had the potential to result in harm, hospitalization and death to Resident 22.Findings: During a review of Resident 22's admission Record (Face Sheet - includes a resident's identification, medical, and demographic information), the admission Record indicated, the facility initially admitted Resident 22 on 3/16/2021, and then readmitted Resident 22 on 3/19/2025 with medical diagnoses that included obstructive hypertrophic cardiomyopathy (a genetic heart condition where the heart wall becomes abnormally thick, reducing the flow of oxygen-rich blood from the heart to the rest of the body), type 2 diabetes mellitus (DM II, ongoing high blood sugar levels), depression (a serious mood disorder that causes a persistent feeling of sadness, emptiness, and a loss of interest in activities), and muscle weakness. During a review of Resident 22's Minimum Data Set (MDS - resident assessment tool), dated 4/14/2026, the MDS indicated the Resident 22's cognition (mental ability to make decisions of daily living) was intact (person able to comprehend concept and verbalize own needs). The MDS indicated Resident 22 required substantial assistance with activities of daily living (ADL-dressing, toileting, bed mobility and bed-to-chair transfers) and was dependent on staff (when helper does all the effort, resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) with showering. During a concurrent observation and interview with Resident 22 on 6/1/2026 at 8:41 a.m., Resident 22 was in her room and sitting in bed. The writer observed the following ointment and supplements on the resident's bedside table.Lidocaine ointment (topical cream with local anesthetics that temporarily numbs the skin by blocking nerve signals to relief pain),Biotin 25000 microgram (mcg - unit of measurement in medications) per capsule,Vitamin B7 (supplement for skin, nails and hair),Collagen peptides (proteins that provide the building blocks for skin, hair, nails, joints, and bones),Ginger herbal tea with vitamin C (supplement for immune system [bodily function to fight infection]),Probiotics (supplement of healthy gut bacteria strains), and Sinus calm meltaway tablets (herbal remedy for sinus pain/congestion).During the same observation and interview, Resident 22 stated she takes ginger herbal tea due to nausea (to feel like wanting to vomit) caused by all the medication she is taking. Resident 22 stated she usually informs the facility staff what medications and/or supplements she is taking because the staff need to write the medications and/or supplements down and that a facility staff took pictures of the medications and/or supplements but was unable to recall the name of the staff member. During a concurrent observation and interview on 6/3/2026 at 1:37 p.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 reviewed Resident 22's supplements at her bedside. LVN 4 stated she was not aware of the following supplements at Resident 22's bedside table:Lidocaine ointmentBiotin 25000 mcg;Vitamin B7;Collagen peptides;Ginger herbal tea with vitamin C;Probiotics; Sinus calm meltaway tablets. During a concurrent interview and record review on 6/3/2026 at 1:46 p.m. with LVN 4, Resident 22's Order Summary Report, dated 6/3/2026 was reviewed. The Order Summary Report indicated Resident 22 did not have a physician's order for self-administration for the following supplements found at Resident 22's bedside:Biotin 25000 mcg;Vitamin B7;Collagen peptides;Ginger herbal tea with vitamin C;Probiotics; Sinus calm meltaway tablets.LVN 4 stated the usual process when staff noticed medications or supplements at the residents' bedside, they would notify the doctor and receive orders for the administration and storage of them locked in the medication cart. LVN 4 stated, if the resident is awake, alert, and oriented to person, date, time, and situation (person can make informed decision), the facility allows them to self-administer medications or supplements. LVN 4 stated, if residents refuse to surrender their own medications and/or supplements for the facility lock up in storage, then it is discussed in the interdisciplinary team (IDT, a group of multiple specialists, such as a nurse, a social worker, and a physician providing care to residents) meeting. During a review of Resident 22's Care Plan Report, dated 6/3/2026, the Care Plan Report did not include assessments nor care plan interventions for Resident 22 to self-administer medications and/or supplements. During a review of policies and procedures (P&P) titled, Self-Administration of Medications, dated 1/2016, the P&P indicated, The staff and practitioner will document their findings and the choices of residents who are able to self-administer medications. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room . Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party. Nursing staff will review the self-administered medication record on each nursing shift, and they will transfer pertinent information to the medication administration record (MAR) kept at the nursing station, appropriately noting that the doses were self-administered. The staff and practitioner will periodically (for example, during quarterly MDS reviews) reevaluate a resident's ability to continue to self-administer medications.

Based on observation, interview, and record review, the facility failed to provide an appropriately sized bed for one of one sampled resident (Resident 26). This failure resulted in Resident 26 feeling uncomfortable and had the potential for the resident to suffer physical discomfort, pain, and develop pressure ulcers (injuries that occur when sustained pressure cuts off blood and oxygen supply to the skin and underlying tissue leading to tissue death typically forming over bony prominences (like the tailbone, heels, hips, and elbows) or beneath tight medical devices), dissatisfaction, and psychosocial harm.Findings: During a review of Resident 26's admission record, dated 11/25/2025, the admission record indicated Resident 26 was admitted to the facility on [DATE] with diagnoses but not limited to hemiplegia (severe or complete loss of voluntary movement on one entire side of the body) affecting the right side, dysphagia (difficulty swallowing), dysarthria (muscles used to breathe or talk are weakened or paralyzed), and epilepsy (a brain disorder that causes repeated seizures). During a review of Resident 26's history and physical (H&P), dated 8/17/2025, the H&P indicated Resident 26, can make needs known but cannot make medical decisions. During a review of Resident 26's Minimum Data Set (MDS- a resident assessment tool), dated 5/20/2026, the MDS indicated Resident 26 required total physical assistance with toileting, dressing below the waist, and putting on and removing socks and shoes. The MDS also indicated Resident 26's cognitive patterns were moderately impaired (a person's memory or thinking have started to weaken). During a concurrent observation and interview on 6/1/226 at 9:30 A.M. with Resident 26 in Resident 26's room, Resident 26's legs were bent with feet positioned against the footboard of the bed. Resident 26 stated they felt uncomfortable in bed. During an observation on 6/3/2026 at 8:45 A.M. in Resident 26's room, Resident 26's feet were positioned against the footboard of the bed. During a concurrent observation and interview on 6/3/2026 at 12:28 P.M. with Certified Nursing Assistant (CNA) 3 in Resident 26's room, CNA 3 stated Resident 26's bed was too small. CNA stated residents should be comfortable in bed to minimize pain and discomfort. CNA stated good positioning for residents is important to decrease risk of pressure ulcers (damage to the skin and/or tissue usually over a bony prominence). During an interview on 6/3/2026 at 1:01 P.M. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated longer beds are available for taller residents. RNS 1 stated bed positioning is important to reduce the resident's pain and discomfort and to decrease risk of pressure ulcers. RNS 1 stated if a bed was not appropriately sized for the resident, the resident will feel uncomfortable and dissatisfied. During an interview on 6/3/2026 at 4:12 P.M. with the Director of Nursing (DON), the DON stated that proper bed positioning is important for the residents to decrease risk of pressure ulcers and to minimize pain and discomfort. The DON stated it is important that residents are comfortable in bed to meet their physical and psychosocial needs. During a review of the facility's policy and procedures (P&P) titled, Quality of Life Homelike Environment, dated January 2026, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment.

Based on observation, interview, and record review, the facility failed to ensure that for one of 20 sampled residents (Resident 6) was not provided with the bedside table was missing one of four wheels. This failure had the potential to result in accidents and injuries not limited to the bedside table tilting, collapsing, and falling on Resident 6, and hot liquids and food spilling on Resident 6. Findings: During a review of Resident 6's admission Record (Face sheet, which includes a resident's identification, medical, and demographic information), dated 6/4/2026, the admission Record indicated, the facility admitted Resident 6 on 5/11/2020 with medical diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (severe or complete loss of motor function on one side of the body, affecting the arm, leg, and sometimes facial muscles caused by lack of blood supply in the brain), dysphagia (difficulty in swallowing), essential hypertension (chronic high blood pressure), type 2 diabetes mellitus (DM II - chronic disorder of persistent high blood sugar levels), epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures, caused by sudden, abnormal electrical surges in the brain), muscle weakness, and presence of gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach). During a review of Resident 6's Minimum Data Set (MDS - resident assessment tool), dated 4/27/2026, the MDS indicated, Resident 6's cognitive skill for daily decision making was severely impaired - resident never or rarely made decisions. The MDS indicated Resident 6's speech pattern as absence of spoken words, and Resident 6 was dependent on two or more staff for activities of daily living (ADL- like eating, dressing, walking, toileting eating, dressing, transfers, toileting and showering). During an observation on 6/1/2026 at 8:26 a.m. in Resident 6's room, Resident 6 was sitting in bed with bedside table and breakfast tray in front of her. Resident 6 then pushed the bedside table and the bedside table tilted. The breakfast tray almost slid off the bedside table. Upon further inspection, the bedside table was missing one of the four wheels meant to support/stabilize the bedside table. During a concurrent observation and interview on 6/1/2026 at 8:28 a.m. with Certified Nurse Assistant (CNA) 1 in Resident 6's room, CNA 1 noted that Resident 6's bedside table was missing a wheel. Observed CNA 1 removed Resident 6's bedside table with a missing wheel outside the room right away. CNA 1 stated, When we have broken table, we put it outside and call a maintenance guy, and we fill out the paper for repairs. During an interview on 6/3/2026 at 1:04 p.m. with CNA 1, CNA 1 stated that CNA 2 had placed the bedside table and a breakfast tray for Resident 6 on 6/1/2026. CNA 1 stated she told a maintenance personnel to fix the bedside table with a missing wheel. CNA 1 stated, We should remove broken equipment from the residents to prevent injuries and not to hurt them. During an interview on 6/3/2026 at 1:14 p.m. with CNA 2, CNA 2 stated, on 6/1/2026 he placed the bedside table and breakfast tray for Resident 6 and did not notice it was missing the wheel. CNA 2 stated that if he noticed that Resident 6's bedside table was missing a wheel, he would have filled out maintenance log or called the maintenance personnel; removed the bedside table for the maintenance, swapped the bedside table with a functional one, and would have placed a note on the broken bedside table so that no one would use it. CNA 2 stated staff should check if the bedside table is clean, the lever on the side of the bedside table is working properly, and that the bedside tabletop can adjust up and down before giving it to a resident to use. During a review of the facility's Maintenance Log, dated June 2026, the Maintenance Log did not indicate that any bedside tables needed repairs between 6/1/2026 and 6/4/2026. During a review of the facility's policy and procedures (P&P) titled, Use of Supplies and Equipment, dated January 2026, the P&P indicated, the expectation to report all needed repairs to the Environmental Services or Maintenance Director. During a review of the facility's P&P titled, Reporting Equipment Malfunction, dated January 2026, the P&P indicated, if the malfunction continues to occur, complete a Service Request Form and remove the equipment from service. Send Service Request Form to the Maintenance Department.

Based on interview and record review, the facility failed to report an alleged incident of abuse (a willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) to the California Department of Public Health (CDPH) within 24 hours for two of two sampled residents (Resident 79 and Resident 80). This failure resulted in delayed investigation by CDPH to ensure the safety and wellbeing of Residents 79 and 80, with the potential for continued resident to resident altercation, harm/injury and hospitalization.Findings: During a review of Resident's 79 admission Record (also known as a 'face sheet,' which includes a resident's identification, medical, and demographic information), dated 6/4/2026, the admission Record indicated the facility admitted Resident 79 on 12/27/2025 with medical diagnoses that included chronic obstructive pulmonary disease (COPD - a long-term lung disease that makes breathing difficult by blocking airflow into and out of the lungs), mild cognitive impairment (a decline in memory or thinking skills that is noticeable but not severe enough to disrupt daily life), dementia (a progressive state of decline in mental abilities), and abnormalities of gait and mobility (irregular, unsteady, or inefficient walking patterns). During a review of Resident 79's Minimum Data Set (MDS - resident assessment tool), dated 4/3/2026, the MDS indicated, Resident 79's cognitive (mental ability to make decisions of daily living) skills were intact (person able to comprehend concept and verbalize own needs). The MDS indicated Resident 79 required supervision with activities of daily living (ADL- eating, dressing, walking, toileting), touch assistance with transfers to chair, toilet and walking, and partial/moderate assistance (a helper does less than half effort) with toileting and showering. During a review of Resident 80's admission Record, dated 6/4/2026, the admission Record indicated the facility admitted Resident 80 on 03/12/2026 for aftercare with diagnoses not limited to following joint replacement surgery (invasive procedure to replace damaged tissue, bone or joint with artificial metal, plastic prosthesis), presence of left artificial knee joint, abnormalities of gait and mobility (irregular, unsteady, or inefficient walking patterns), atrial fibrillation (irregular heart beat), and hypertension (HTN- high blood pressure). During a review of Resident 80's MDS), dated [DATE], the MDS indicated Resident 80's cognitive skills were intact. The MDS indicated Resident 80 required supervision/touching assistance with ADL (transfers to chair, toilet and walking), and substantial/moderate assistance with lower body dressing and showering. During a review of the facility's Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 3/23/2026, the SOC 341 indicated that, On 3/23/26 at approximately 1:30 a.m., (Resident 79) appeared to have a hallucination (is a false perception of objects or events involving a person's senses such as sight, sound, smell, touch and taste) and display hitting behavior towards (Resident 80). The SOC 341 did not indicate the incident was reported to the CDPH. During a concurrent interview and record review on 6/2/2026 at 9:47 a.m. with the Administrator (Admin), the Grievance Log, dated 3/23/2026 was reviewed. The Grievance Log indicated that on 3/23/2026, Resident 80 reported concerns about recent physical altercation with Resident 79 and as part of resolution, the local Police Department (PD) was called who filed a report on 3/23/26, a room change was initiated (not specified for which resident), and trauma screening was completed. The Admin stated the resident-to-resident altercation complaint of abuse was reported to PD on 3/23/26. The Admin stated he did not report the incident to the CDPH because a resident-to-resident altercation incident there was not considered abuse because one of the residents had dementia and did not cause harm, and therefore not sufficient reason to report the altercation complaint between Resident 79 and Resident 80 based on the facility's AFL (All Facilities Letter) interpretation. During a concurrent interview and record review on 06/03/2026 at 3:27 p.m. with the Admin, the facility's policy and procedures (P&P) titled, Alleged or Suspected Abuse and Crime Reporting, dated January 2026 was reviewed. The P&P indicated, Covered Individuals, must report a reasonable suspicion of a crime to the Department within the designated time frame by e-mail, fax or telephone. The Admin stated he did not report the abuse incident between Resident 79 and Resident 80 to the CDPH.

Based on observation, interview, and record review, the facility failed to develop a baseline care plan addressing supplemental oxygen therapy (a medical treatment that provides extra oxygen to people who cannot get enough through normal breathing) for one of three sampled residents (Resident 75) according to the facility's policy and procedures (P&P) titled Baseline Care plan dated 1/29/2026. This deficient practice resulted in failure to establish a guide for Resident 75s respiratory status that would allow nurses to safely titrate (to gradually adjust the dosage of a medication over time-upward or downward-to find the exact amount that achieves the best results while causing the fewest side effects) flow rates, prevent toxic hyperoxemia (an abnormally high concentration of oxygen in the blood), and detect respiratory deterioration early and had the potential for delayed provision of necessary care and services.Findings: A review of Resident 75's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included, sequelae of cerebral infarction (permanent residual effects, impairments, and complications that persist after someone suffers a stroke), encounter for gastrostomy (a medical device inserted through the abdominal wall directly into the stomach.), dysphagia following cerebral infarction (difficulty or discomfort in swallowing that occurs as a result of a stroke), atrial fibrillation (Afib-an irregular, rapid, and chaotic heart rhythm that begins in the heart's upper chambers), presences of heart assist device (a surgically implanted mechanical pump), depression (a serious mood disorder characterized by persistent feelings of sadness, emptiness, and a loss of interest in activities) and, malignant neoplasm of the prostate (an uncontrolled growth of abnormal cells in the prostate (a walnut-sized gland in the male reproductive system). A review of Resident 75s Minimum Data Set (MDS - a resident assessment tool) dated 6/2/2026, indicated Resident 75's cognition was moderately impaired. The MDS also indicated Resident 75 required partial to moderate assistance with eating and, oral hygiene, substantial maximal assistance for upper body dressing, Resident 75 is dependent on staff for toileting hygiene, shower/bathing self, lower body dressing and putting on/taking off footwear. The MDS also indicated that the Resident is non-ambulatory. A review of Resident 75's Order Summary Report dated 6/4/2026 indicated a physician's order to administer oxygen at two (2) (dose) liters (unit of measure) per minute (duration) via nasal cannula (a thin, flexible medical device used to deliver supplemental oxygen directly into the nostrils) continuously every shift for desaturation (low blood oxygen saturation). During an initial tour on 6/2/2026 at 8:28am, Resident 75 was lying in bed on his right lateral side, an oxygen concentrator machine (a medical device that concentrates oxygen from environmental air and delivers it to the resident in need of supplemental oxygen) was observed at bedside flowing at 3.5-4 liters per (L/min) via nasal cannula. During an interview on 6/2/3036 at 8:35 am, Registered Nurse Supervisor (RNS) 1 stated Resident 75's supplemental oxygen physician order was 2L/min. A review of Resident 75' care plan dated 6/3/2026 indicated a person-centered care plan addressing Resident 75 supplemental oxygen need with clear measurable goals and time of recovery or improvement and, interventions to safely correct hypoxemia (low blood oxygen) was not addressed. During an interview on 6/4/2026 at 1:47pm, the Director of Nursing (DON) stated a base line care plan should be initiated within 24hrs of patient admission. The DON stated Resident 75's needs may not be met if a base line care plan is not initiated. A review of the facility's policy and procedures (P&P) titled Baseline Care plan dated 1/29/2026, indicated that, Nursing facilities are required to develop a baseline care plan within the first 48 hours of admission which provides instructions for the provision of effective and person-centered care to each resident. The baseline care plan shall: include the minimum healthcare information necessary to properly care for a Resident including, but not limited to: Initial goals based on admission orders Physician orders.

Based on observation, interview, and record review, the facility failed to ensure that the environment was free from accidents and hazards by failing to ensure that staff did not leave unidentified white creamy substance in a medication cup at the bedside of one out of one sampled resident (Resident 7). This deficient practice had the potential to result in harm through ingestion of the unidentified white creamy substance, leading to poisoning and/or allergic reactions, unnecessary hospitalizations and even death for residents who are confused and or with wandering behaviors.Findings: A review of Resident 7's admission record indicated Resident 7 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included diabetes mellitus (high sugar in the blood), chronic obstruction pulmonary disease (COPD- is a common lung disease causing restricted airflow and breathing problems), dysphagia (difficulty swallowing) and congestive heart failure (CHF- a condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Resident 7's Minimum Data Set (MDS - a resident assessment tool) dated 5/16/2026, indicated Resident 7's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 7 required setup or cleanup assistance with eating and oral hygiene, partial moderate assistance with toileting hygiene and upper body dressing and, substantial/maximal assistance with lower body dressing, putting on/taking off footwear and shower/bathes. Resident 7 required partial moderate assistance walking 10 feet. During a facility tour on 6/2/2026, at 9:27 am, a medication cup with a white creamy substance was observed placed on a wall caddy within view and easy reach inside Resident 7's room. During an interview on 6/2/2026 at 9:30 am, Certified Nurse Assistance (CNA) 4 stated the white creamy substance in the medication cup looked like Zinc (medication) used to treat skin rashes on residents. During an interview on 6/2/2026 at 9:40 am, Licensed Vocational Nurse (LVN) 5 stated that the white creamy substance in the medication cup is Zinc barrier cream/Skin protectant. LVN 5 stated the medication (white creamy substance) should be discarded after use and not left at bedside, LVN 5 stated a confused/wandering resident can ingest (eat/swallow) the white creamy substance because the white creamy substance looks like ice-cream or cream cheese which could lead to upset stomach or an allergic reaction. During an interview on 6/4/2026 at 1:47pm, Director of Nursing (DON) stated residents are only allowed to have medication at bedside once the resident has been assessed and the resident is able demonstrate to safely self-administer the medication. The DON stated that a doctor's order/approval is required before for a resident to self administer medication. The DON stated medications left unattended at bedside could lead to unintended consequences if consumed/ingested by a Resident such as upset stomach, allergic reactions, unnecessary hospitalizations and possible poor outcomes. A review of facility policy and procedure titled Discarding and Destroying Medication dated, revised 2014 indicated, Medications will be disposed of in accordance with federal, state and local regulations governing management of . pharmaceuticals, ointments, creams, may be discarded into the trash receptacle in the medications room.

Based on observation, interview, and record review, facility failed to ensure one out one sampled Resident (Resident 75) received the sufficient enteral feeding (a medical method of delivering specialized liquid food and nutrients directly into the gastrointestinal (GI) tract.), as per physician order summary dated 6/4/2026 . This deficient practice placed Residents 75 at risk for altered nutritional status such as delayed wound healing and muscle wasting to chronic (ongoing) diseases and increased susceptibility to infections, weight loss, altered hydration status and complications associated with fluid imbalance.Findings: A review of Resident 75's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included, sequelae of cerebral infarction (permanent residual effects, impairments, and complications that persist after someone suffers a stroke), encounter for gastrostomy (a medical device inserted through the abdominal wall directly into the stomach.), dysphagia following cerebral infarction (difficulty or discomfort in swallowing that occurs as a result of a stroke), atrial fibrillation (an irregular, rapid, and chaotic heart rhythm that begins in the heart's upper chambers), presences of heart assist device (a surgically implanted mechanical pump), depression (a serious mood disorder characterized by persistent feelings of sadness, emptiness, and a loss of interest in activities) and, malignant neoplasm of the prostate (an uncontrolled growth of abnormal cells in the prostate (a walnut-sized gland in the male reproductive system). A review of Resident 75s Minimum Data Set (MDS - a resident assessment tool) dated 6/2/2026, indicated Resident 75's cognition (mental ability to make decisions of daily living) was moderately impaired. The MDS also indicated Resident 75 required partial to moderate assistance with eating and, oral hygiene, substantial maximal assistance for upper body dressing, Resident 75 is dependent on staff for toileting hygiene, shower/bathing self, lower body dressing and putting on/taking off footwear. The MDS also indicated that the Resident is non-ambulatory. During facility tour on 6/2/2026 at 8:28am, Resident 75's enteral feeding pump was observed to be turned off at the bedside. The enteral feeding was labeled as initiated on 6/1/2026 at 12:30pm at a rate of 80mls/hr. A residual (remaining) of 900 milliliters (mls - unit of measuring volume) was observed left in an enteral feeding bottle that was labeled 1500ml indicating, that Resident 75had received 400mls less of the enteral feeding than as ordered by the physician. A review of Resident 75's physician order summary dated 6/4/2026 indicated, every shift GT Feeding of Jevity1.5 @ 50ml/hr. x 20hrs. to provide, 1000ml/1500Kcal/24 hrs. via enteral from 2 pm to 10 am or until dose limit is met. During an interview on 6/2/2026 at 8:35 am, Registered Nurse Supervisor (RNS) 1 stated that failure to provide adequate enteral feeding to Resident 75 as per physician's orders can lead to malnutrition, skin breakdown and poor patient outcomes. During an interview on 6/4/2026 at 1:47pm the Director of Nursing (DON) stated, providing inadequate enteral feeding to a Resident could lead to significant weight loss, skin breakdown and open wounds. A review of facility Policy and Procedure (P&P) titled Nutrition & Weight Management, dated 1/29/2026 indicated, The facility provides care and services to each Resident to ensure the Resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Tube feeding or parenteral fluids shall be provided if indicated and in the context of the Resident's overall clinical condition and desired goals.

Based on observation, interview and record review, the facility failed to ensure the resident received the correct oxygen (a colorless, odorless gas that is essential for life and the proper functioning of the body) therapy as prescribed (ordered) by the physician for one (1) out of the three residents (Resident 75). This deficient practice had the potential to cause oxygen toxicity (excess oxygen supply in tissues and organs, typically caused by breathing higher concentrations of supplemental oxygen) resulting in damage to the lungs, coughing, difficulty breathing and even death in severe cases for Resident 75. Findings: A review of Resident 75's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included, sequelae of cerebral infarction (permanent residual effects, impairments, and complications that persist after someone suffers a stroke), encounter for gastrostomy (a medical device inserted through the abdominal wall directly into the stomach.), dysphagia (difficulty or discomfort in swallowing that occurs as a result of a stroke) following cerebral infarction (stroke), atrial fibrillation (Afib-an irregular, rapid, and chaotic heart rhythm that begins in the heart's upper chambers) following cerebral infarction, presences of heart assist device (a surgically implanted mechanical pump), depression (a serious mood disorder characterized by persistent feelings of sadness, emptiness, and a loss of interest in activities) and, malignant neoplasm of the prostate (cancer-an uncontrolled growth of abnormal cells in the prostate (a walnut-sized gland in the male reproductive system). A review of Resident 75s Minimum Data Set (MDS - a resident assessment tool) dated 6/2/2026, indicated Resident 75's cognition (mental ability to make decisions of daily living) was moderately impaired. The MDS also indicated Resident 75 required partial to moderate assistance with eating and, oral hygiene, substantial maximal assistance for upper body dressing, Resident 75 is dependent on staff for toileting hygiene, shower/bathing self, lower body dressing and putting on/taking off footwear. The MDS also indicated that the Resident is non-ambulatory. A review of Resident 75's Order Summary Report dated 6/4/2026 indicated a physician's order to administer oxygen to Resident 75 at two (2) (dose) liters (unit of measure) per minute (duration) via nasal cannula (a thin, flexible medical device used to deliver supplemental oxygen directly into the nostrils) continuously every shift for desaturation (low blood oxygen saturation). During an initial tour on 6/2/2026 at 8:28am, Resident 75 was lying in bed on his right lateral side, an oxygen concentrator machine (a medical device that concentrates oxygen from environmental air and delivers it to the resident in need of supplemental oxygen) was observed at bedside flowing at 3.5-4 liters per (L/min) via nasal cannula. During an interview on 6/2/3036 at 8:35 am, Registered Nurse Supervisor (RNS) 1 stated Resident 75's supplemental oxygen physician order was 2L/min. During an interview with the Director of Nursing (DON) Resident 75 prolonged use of oxygen could cause oxygen toxicity and cell damage (structural or functional changes that occur when cells are stressed beyond their ability to maintain normal balance). A review of the facility's policy and procedures (P&P) titled, Oxygen Administration, dated 1/2026 indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. Review the physician's orders for oxygen administration. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. A review of facility P&P titled Medication Administration dated 1/2026 indicated, Medications are administered.as ordered by the physician and in accordance with professional standards of practice .

Based on observation and interview, the facility failed to ensure that a private caregiver did not provide incontinent care direct care to one of one resident (Resident 77) according to the facility's policy and procedures (P&P) tiled Private Duty Sitter, revised 1/2026. This deficient practice had the potential to result in infection, injury and/or hospitalization for Resident 77.Findings: A review of Resident 77's admission Record indicated the facility admitted Resident 77 on 10/23/2024 and readmitted Resident 77 on 5/26/2026 with diagnoses including dementia (progressive state of decline in mental abilities), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hypertension (HTN - high blood pressure). A review of Resident 77's Minimum Data Set (MDS - resident assessment tool) dated 5/30/2026, indicated Resident 77 is cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 77 is dependent on staff with activities of daily living care (ADL - activities such as bathing, dressing and toileting a person performs daily) care. During an observation on 6/1/2026, at 9:41 A.M., in the hallway Resident 77's door room was open and the dignity curtain/s was open and Resident 77 was observed in bed. Resident 77's private area was visible from the hallway and CG 1 was observed provided care to Resident 77. Upon noticing the writer, CG 1 attempted to close the dignity curtain/s. During an interview on 6/1/2026, at 9:42 A.M., with caregiver (CG 1), CG 1 stated that she was closing the curtain to provide Resident 77 with privacy while she was changing Resident 77 incontinent brief. There was no facility staff assisting with Resident 77's incontinent care. During an interview on 6/4/2026, at 11:41 A.M., with the Director of Nursing (DON), the DON stated that private duty sitters (caregivers) should not provide direct care to residents because they are not trained. The DON stated that the provision of incontinent care by a private duty sitter may potentially lead to a urinary tract infection (UTI - an infection in the bladder/urinary tract) as they have not been given the proper training for incontinent care. A review of the Facility P&P titled Private Duty Sitter, revised 1/2026 indicated,Policy StatementThe use of private duty sitters will be permitted when approved by the residents attending physician and the facility's Director of Nursing Services.3. Private duty nursing personnel must follow the facility's established nursing care policies and procedures, instructions issued by the Nurse Supervisor/Charge Nurse, and may not administer direct care to the resident unless authorized in writing by the attending Physician.

Based on interview and record review, the facility failed to ensure that a Registered Nurse (RN) was on duty on the 7am-3pm, 3pm-11pm, and 11pm-7am shifts on 7/20/2026. The facility had 64 residents in house. This failure had the potential for the residents' clinical needs not to be met and delayed assessments and interventions when needed. Findings: During a review of the facility's Licensed Nursing Schedule, dated July 2025, the Licensed Nursing Schedule indicated that there was no RN on duty for 7/20/2025. During a concurrent interview and record review on 6/4/2026 at 11:50 A.M. with the Director of Staff Development (DSD), the facility nursing assignment sheet, dated 7/20/2025 was reviewed. The nursing assignment sheet indicated that on 7/20/2025, there was no RN on-duty for 8 consecutive hours on all three shifts (7am-3pm, 3pm-11pm, and 11pm-7am). The DSD confirmed and stated that there was no RN on duty for 8 consecutive hours on 7/20/2025. The DSD stated that if there is no RN is on duty, the facility cannot perform assessments on the residents and certain medication will not be administered. The DSD stated this can potentially cause physical and psychosocial harm to the residents. During an interview on 6/4/2026 at 2:45 P.M. with the Director of Nursing (DON), the DON stated if no RN is on-duty at the facility, the residents' clinical needs will not be met such as receiving antibiotic medication and total parental nutrition (TPN- is a medical therapy that delivers essential nutrients-including proteins, carbohydrates, fats, vitamins, and minerals-directly into the bloodstream through an intravenous (IV-inside a vein) line. The DON stated the lack of an RN on duty can potentially cause physical and psychosocial harm to the residents. The DON also stated that the facility did not have a policy and procedure on RN staffing. During a review of the facility's job description titled, Nurse Supervisor, dated 2023, indicated, Ensure that a sufficient number of licensed practical and/or registered nurses are available for your tour of duty to ensure that quality care is maintained.

Based on observation, interview, and record review, the facility failed to ensure that lids of two of three sampled outside garbage bins were closed. This failure had the potential to attract pests that could create a health and safety risk to the residents, visitors, and staff in the facility.Findings: During a concurrent observation and interview on 6/1/2026 at 1:31 P.M. with the Food Services Director (FSD) in the alley behind the facility, two outside garbage and recycling bin lids were left open. The FSD stated that garbage bins must be covered to prevent pests. During a review of The U.S. Food and Drug Administration's Food Code, dated 2022, the regulation indicated, Receptacles and waste handling units for refuse, recyclables, and returnables used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers.

Based on observation, interview and record review, the facility failed to ensure staff completed documentation on dental ancillary (supportive medical) services for one of one sampled resident (Resident 63) according to facility's job description titled, Social Service Designee, dated 2003, and the facility's policy and procedures (P&P) titled, Dental Services, dated 1/2026. This failure had the potential to not meet the physical and psychosocial needs of Resident 63. Findings: During a review of Resident 63's admission record, dated 3/31/2026, the admission record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses but not limited to fracture of the left mandible (lower jawbone), dementia (a state of decline in mental abilities), hypertension (high blood pressure), and dysphagia (difficulty swallowing). During a review of Resident 63's Minimum Data Set (MDS- a resident assessment tool), dated 4/4/2026, the MDS indicated Resident 63 was cognitively (mental ability to make decisions of daily living) intact. During a review of Resident 63's Dental Records, dated 4/18/2026, indicated a dentist evaluated Resident 63, and the resident was awaiting approval for dentures. During an interview on 6/1/2026 at 9:22 A.M. with Resident 63, Resident 63 stated he recently had tooth pain while eating a banana. During a concurrent interview and record review on 6/3/2026 at 2:45 P.M. with the Social Services Director (SSD), Resident 63's Social Services Progress Notes were reviewed in PointClickCare (PCC- facility electronic medical record) between the date of admission 3/31/2026 until 6/3/2026. The SSD confirmed and stated that SSD did not document social service progress notes from 3/31/2026 to 6/3/2026 and did not document the dental services that was provided to Resident 63 on 4/18/2026. The SSD stated, incomplete documentation will have the potential to not meet the needs of the resident. During an interview on 6/3/2026 at 4:12 P.M with the Director of Nursing (DON), the DON stated, if the SSD has not documented dental services provided to (Resident 63), this will have the potential to not meet the needs of the resident. During a review of the facility's job description titled, Social Service Designee, dated 2003, the job description indicated, Record and maintain regular Social Service progress notes indicating response to the treatment plan. During a review of the facility's policy and procedures (P&P) titled, Dental Services, dated 1/2026, the P&P indicated, All dental services provided are recorded in the resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure the complete implementation of infection control practices in the facility, when Licensed Vocational Nurse (LVN) 2 did not clean and disinfect (use of chemical agents to destroy germs) shared resident care equipment before and after use for two of 20 sampled residents (Resident 35 and Resident 30).This failure had the potential for resident harm, as not cleaning and disinfecting shared resident care equipment before and after use can spread pathogens (disease causing germs) between residents throughout the facility, leading to transmission of infection to multiple residents in the facilityFindings: During a review of Resident 35's admission Record (Face sheet, which includes a resident's identification, medical, and demographic information), dated 6/4/2026, the admission Record indicated, the facility initially admitted Resident 35 on 6/10/2024, and then readmitted on [DATE], with medical diagnoses that included metabolic encephalopathy (brain dysfunction caused by chemical imbalances, systemic illnesses, or organ failure), decreased white blood cell count (immune system has fewer infection-fighting cells than normal), paraplegia (partial or complete paralysis [lack of strength and movement] of the lower half of the body, which typically affects both legs and feet), dysphagia (difficulty in swallowing), and essential hypertension (chronic high blood pressure). During a review of Resident 35's Minimum Data Set (MDS - resident assessment tool), dated 2/23/2026, the MDS indicated, Resident 35's cognitive skill for daily decision making was severely impaired (Resident never or rarely made decisions). The MDS indicated Resident 35 was dependent for activities of daily living (ADL- like eating, dressing, walking, toileting) and required two or more helpers with eating, dressing, transfers, toileting and showering. During a review of Resident 30's admission Record, dated 6/4/2026, the admission Record indicated, the facility initially admitted Resident 30 on 4/5/2023, and then readmitted on [DATE], with medical diagnoses that included fracture around other internal prosthetic joint (fracture of the bone near artificial joint), osteoarthritis (stiffness and pain in joints), type 2 diabetes mellitus (DM II, a ongoing disorder of persistent high blood sugar levels) dysphagia (difficulty in swallowing) , heart failure (heart muscle is too weak or too stiff to pump enough blood and oxygen to meet the body's needs) and thyrotoxicosis (a clinical syndrome caused by an excess of circulating thyroid hormones in the bloodstream, which speeds up your metabolism). During a review of Resident 30's MDS) dated [DATE], the MDS indicated, Resident 30 was cognitively intact. The MDS indicated Resident 30 needed moderate assistance with dressing, and personal hygiene, and maximal assistance with transfers to chair, toileting and showering. During an observation on 6/3/2026 at 8:11 a.m. by Resident 35's room, Licensed Vocational Nurse (LVN) 2 was preparing to administer medication to Resident 35 and the following was observed:- LVN 2 took a portable blood pressure (BP) reading machine, an electronic temporal thermometer (machine to measure body temperature), and a portable pulse oximetry machine (device to measure oxygen saturation at a fingertip) to Resident 35 to check their vital signs (measurements of blood pressure, pulse, temperature, breathing, pain level).- LVN 2 then dropped the BP machine on the floor, picked up the BP machine from the floor, and went to a medication cart (med cart - a locked medication storage cabinet) to clean it. LVN 2 used germicidal disposable wipe, wiped it for about 20 seconds, and put the cleaned BP machine back on the top of the med cart without first wiping the top of the med cart surface where the soiled BP machine came in contact prior. - LVN 2 then changed gloves and proceeded with checking the BP of Resident 35. LVN 2 then placed the used BP machine on top of the med cart. LVN 2 did not clean the equipment before moving on with medication administration. During an observation on 6/3/2026 at 8:50 a.m. by Resident 30's room, LVN 2 moved on to check vital signs for Resident 30. Between providing care for Resident 35 and moving on to Resident 30, LVN 2 did not clean nor sanitize the shared patient care equipment in use, which included a BP machine, pulse oximeter, and a thermometer.During a concurrent interview and records review on 6/3/2026 at 11:09 a.m. with LVN 2 manufacturer's instructions for germicidal disposable wipes were reviewed and LVN 2 stated the following:- LVN 2 stated the staff used the germicidal disposable wipe for equipment cleaning and sanitizing for non-disposable items like a BP machine. LVN 2 stated that alcohol-based (solution that destroys germs) wipes should be used for 20 seconds or until dry.- LVN 2 reviewed the manufactures' instructions of germicidal disposable wipe and stated that one of the ingredients was 55% isopropyl alcohol, and it disinfected (use of chemical agents to destroy germs) after three minutes disinfect time (contact time of chemical solution with surface). The manufacturer's instruction indicated disinfects in two (2) minutes.- LVN 2 stated he wiped and disinfected the med cart after all resident medications were administered.- LVN 2 stated the contact time for the germicidal product meant that he needed to wipe it and leave it to air dry, for three minutes, and there was no need to keep it wet in solution for two or three minutes.- LVN 2 stated that he did not recall wiping the equipment between the residents.- LVN 2 stated that it was important to properly sanitize between residents to prevent opportunities for cross contamination (transferring germs from one person or object to another). During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfecting Non-Critical Resident-Care Items, dated January 2026, the P&P indicated, Non-critical items are those that come in contact with intact skin but not mucous membranes. Non-critical resident-care items include blood pressure cuffs. Reusable items are cleaned and disinfected or sterilized between residents. Intermediate and low-level disinfectants for non-critical items include ethyl or isopropyl alcohol. Manufacturers' instructions will be followed for proper use of disinfecting products including recommended use-dilution.

Based on observation and interview, the facility failed to ensure that the resident's call button (a button or remote on a cord that a patient in a hospital or nursing home presses to get help) was within reach for three of seven residents (Residents 8, 47, and 58) when residents 47's according to the facility's policy and procedure (P&P) tiled Call Lights: Accessibility and Timely Response, with revision date 10/2025. This deficient practice had the potential to result in delayed care, falls, accidents and/or hospitalization for Residents 8, 47, and 58. Findings: 1. During a review of Resident 8's admission Record, the record indicated that Resident 8 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (a type of irregular heart beat), Alzheimer's disease (a brain disease that affects memory, thinking skills, and the ability to carry out simple daily tasks), and care following a surgery on the digestive system. During a review of Resident 8's Minimum Data Set (MDS, an assessment tool), dated 4/16/2026, the record indicated that Resident 8 has impaired hearing, speech, vision, decision making skills, and memory. The record also indicated that Resident 8 uses a wheelchair and is dependent on others to perform all daily activities, such as bathing, toileting, dressing, and transferring from the bed to the wheelchair. During a review of Resident 8's Care Plan for communication deficit, initiated on 1/26/2026, the care plan indicated the intervention to address Resident 8's communication deficit is to keep the call light within reach. During a review of Resident 58's admission Record, the record indicated that Resident 58 was admitted to the facility on [DATE], with diagnoses including epilepsy (a disorder that causes an electrical surge in the brain, resulting in brief disruption of brain activity and often uncontrolled spasms of muscles), muscle weakness, and Alzheimer's disease. During a review of Resident 58's MDS, dated [DATE], the MDS indicated that Resident 58 has impaired memory and impaired decision making skills. The MDS indicated Resident 58 uses a wheelchair, and is dependent on others to perform all daily activities. During a review of Resident 58's Care Plan for communication deficit, initiated on 5/14/2025, the record indicated the intervention to address Resident 58's communication deficit is to keep the call light within reach. During an observation on 6/1/2026 at 8:31 A.M. in Resident 8 and Resident 58's room, both Resident8 and 58 were seated in reclining wheelchairs beside their own beds. The residents call light buttons were in the center of each of the residents beds and were not within reach of either resident. During an interview on 6/3/2026 at 9:33 A.M. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated that all call lights need to be within reach of the residents and are usually clipped to the resident's clothing or bedding. During an interview on 6/4/2026 at 1:25 P.M. with the Director of Nursing (DON), the DON stated that call lights should be within reach for all residents. During a review of the facility's policy and procedures (P&P), titled Call Lights: Accessibility and Timely Response, dated 1/2026, the P&P indicated, Call system should be accessible to Residents while in bed or other sleeping accommodations in room and staff should facilitate call light placement within reach of resident and secure it as needed. 2. A review of Resident 47's admission Record indicated the facility admitted Resident 47 on 5/16/2026 with diagnoses including dementia (progressive state of decline in mental abilities), chronic obstructive pulmonary disease (COPD -a chronic lung disease causing difficulty in breathing), and hypertension (HTN - high blood pressure). A review of Resident 47's MDS dated [DATE], indicated Resident 47 is cognitively (mental ability to make decisions of daily living) impaired. The MDS indicated Resident 47 is dependent on staff with activities of daily living (ADL -routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care. During an observation on 6/1/2026, at 10:24 A.M., Resident 47's call button was seen on his nightstand that was at the head of his bed, against the wall and not within reach of the resident. During a concurrent observation and interview on 6/1/2026, at 10:25 A.M., with LVN 1 in Resident 47's room, Resident 47's call button was seen on his nightstand that was at the head of his bed, against the wall and not within reach of the resident. LVN 1 stated that Resident 47's call button was on Resident 47's nightstand. LVN 1 stated resident call buttons need to be within reach of the resident so the residents can call us when they need help. LVN 1 stated that if the call button is not within the reach of the resident may try to get up on their own without assistance and end up falling or having an injury. During an interview on 6/4/2026, at 11:37 A.M., with the DON, the DON stated that the resident call buttons should be within the reach of the resident so that the residents may call for assistance. If the residents call buttons are not within their reach they may end up soiling themselves or potentially fall. A review of the Facility P&P titled Call Lights: Accessibility and Timely Response, with revision date 10/2025 indicated the following, Policy The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to facilitate appropriate response. Policy Explanation and Compliance Guidelines: . 5. Staff should facilitate call light placement within reach of resident and secure it as needed. 6. Call system should be accessible to Residents while in bed or other sleeping accommodations in room.

Based on interview and record reviews, the facility failed to ensure one of four sample resident (Resident 1) was provided with immediate interventions such as monitoring and assessment to assure the safety of the resident after Resident 1 reported an allegation of physical altercation between another resident (Resident 2) according to facility's policy and procedure (P&P) titled, Alleged or Suspected Abuse and Crime Reporting and Charting and Documentation.This deficient practice placed residents being subject to neglect, verbal, mental and physical abuse.Findings:During a review of Resident 1's admission Record, it indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), difficulty in walking, Type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and depression (a mood disorder that causes persistent feeling of sadness and loss of interest).During a review of the Minimum Data Set (MDS - resident assessment tool) dated 1/26/2026, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 1 required moderate assistance to supervision from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 2's admission Record, it indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure) and dementia (a progressive state of decline in mental abilities).During a review of the MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 2 required moderate to maximal assistance from staff for ADLs.During a review of Resident 2's Progress Notes (PN) indicated the following:dated 3/24/2026, the PN indicated, (Resident 2) continues on monitoring for repeated physical and verbal aggression toward others.Dated 3/15/2026, the PN indicated, At around 6 a.m., resident noted with physical aggression towards others in the hallway, attempted to hit with his walker.During an interview with Resident 1 on 3/24/2026 at 12:34 p.m., Resident 1 stated, there had been physical altercations between him and another resident in the facility (Resident 2). Resident 1 stated, he was hit and swung on the mouth and on his head by Resident 2 which happened four to five days ago. Resident 1 further stated, it also happened yesterday (3/23/2026) and he called the Police.During an interview with Licensed Vocational Nurse 1 (LVN 1) on 3/24/2026 at 12:52 p.m., LVN 1 stated, Resident 1 and Resident 2 had history of arguments and both residents don't get along. LVN 1 stated, it had happened few days ago.During an interview with Director of Nursing (DON) on 3/24/2026 at 1:27 p.m., DON stated, Resident 1 had called the Police on 3/23/2026 due to Resident 1's complaint of physical aggression with Resident 2. DON stated, she documented an Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) notes regarding Resident 1's complaint. DON stated, the IDT notes were written only by her, and no other team of the IDT documented how the meeting went. DON stated, it is the license nurses who do the nursing assessment. DON stated, she did not do any nursing assessments such as skin assessment after Resident 1's complaint of physical aggression with Resident 2. DON stated, when a resident reports any type of abuse, they need to assess and monitor the residents, do a change of condition documentation, report to the physician and responsible party, and all their assessment has to be documented.During a concurrent interview and record review of Resident 1's medical record with Medical Record Director (MRD) on 3/24/2026 at 1:55 p.m., there was no nursing documentation completed regarding Resident 1's allegation of physical altercation with Resident 2. MRD reviewed Resident 1's medical record and stated and confirmed, there are no change of condition or SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) documentation if there was any nursing assessment completed such as skin assessment that was conducted after Resident 1 reported the allegation to the nursing staff.During an interview with Administrator (ADM) on 3/24/2026 at 2:19 p.m., ADM stated, they need to do complete documentation with nursing assessment such as change of condition and/or SBAR when a resident reports any type of abuse and physical aggression between another residents and/or staff.During a review of the facility's P&P titled, Alleged or Suspected Abuse and Crime Reporting, revised on 10/2026, the P&P indicated that, Each resident has the right to be free from abuse, neglect, misappropriation of property, and exploitation. Facility will implement policies and procedures to prevent and prohibit abuse neglect, misappropriation of resident property, and exploitation, for example: assessment and care planning appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect. Identification: The facility will monitor the adequacy of assessment, care planning and monitoring of residents with needs or behaviors that may likely lead to conflict, altercation, abuse, neglect, exploitation and misappropriation and mistreatment such as: physically aggressive or self-injurious behaviors, verbally abusive towards others. The facility will take necessary actions that are appropriate based on the nature of allegation and results of investigation.During a review of the facility's P&P titled, Change in a Resident's Condition or Status, dated 1/2025, the P&P indicated that, the nurse will notify the resident's Attending Physician or physician on call when there has been a. accident or incident involving the resident. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.During a review of the facility's P&P titled, Charting and Documentation, revised on 1/2026, the P&P indicated that, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Based on observation, interview, and record review, the facility failed to ensure resident's call light (a device used to notify the nurse that the resident needs assistance) were answered promptly for two of three sampled residents (Resident 2 and Resident 3). This deficient practice had the potential to result in the residents not being able to summon staff for assistance for care and services as needed, which could lead to accidents such as falls with injuries. During a review of the admission Record, the record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including history of falling, muscle weakness (weakening, shrinking, and loss of muscle), fibromyalgia (a condition that causes pain all over the body, sleep problems, fatigue, and often emotional and mental distress) and difficulty in walking. During a review of the Minimum Data Set (MDS - resident assessment tool) dated 12/9/2025, indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately intact. The MDS indicated Resident 2 required moderate assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 2's care plan (CP) for high risk for falls and injury, the CP included interventions such as, have things needed by the resident within reach including call light and other common personal items.During an observation of the facility on 12/30/2025 at 12/30/2025 at 9:40 a.m., a buzzing sound can be heard at Nursing Station 1 and a light bulb was lit. Three staff in the nursing station were observed sitting and looking at a computer monitor. The buzzing sound and light was observed from 9:40 a.m. to 9:47 a.m.During an interview with Resident 2 on 12/30/2025 at 10:03 a.m., Resident 2 stated, she uses the call light especially in the morning where staff sometimes answer the call light immediately, or sometimes, not at all. Resident 2 stated, she pressed the call light about 20 minutes ago because she needed her morning medications.2. During a review of the admission Record, the record indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain) and history of falling. During a review of the MDS dated [DATE], the MDS indicated, Resident 3's skills for daily decisions were severely impaired. The MDS indicated Resident 3 were totally dependent on staff for ADLs.During a review of Resident 3's CP for communication deficit related to hearing impaired, and high risk for falls and injury related to metabolic encephalopathy, the CP included interventions such as, keep call light within reach.During an observation of the facility on 12/30/2025 at 10:59 a.m., a buzzing sound can be heard at Nursing Station 1 and a light bulb was lit on. Two staff in the nursing station were observed sitting and looking at a computer monitor. The buzzing sound and light was observed from 10:59 a.m. to 11:07 a.m.During an interview with Certified Nursing Assistant 2 (CNA 2) on 12/30/2025 at 1:13 p.m., CNA 2 stated, she was assigned to Resident 3 and she was aware that Resident 3 used the call light to request assistance from staff. CNA 2 stated, she was helping another resident when she called and she couldn't answer the call light right away.During a concurrent observation and interview with Licensed Vocational Nurse 2 (LVN 2) on 12/30/2025 at 1:29 p.m., LVN 2 were observed sitting on Nursing Station 1. LVN 2 stated, she heard the buzzing sound while she was sitting in the nursing station, LVN 2 stated, I don't work here, I'm from the registry.During an interview with Licensed Vocational Nurse 1 (LVN 1) on 12/30/2025 at 1:30 p.m., LVN 1 was observed sitting on Nursing Station 1 and was working on a computer. LVN 1 stated, there are buzzing sound and call lights on for two rooms. LVN 1 stated, she is going through paperwork for new admissions and new orders today. LVN 1 further stated, I can use the overhead page system for staff to respond on call lights request.During an interview with Registered Nurse 1 (RN 1) on 12/30/2025 at 2:20 p.m., RN 1 stated, the call lights should be answered immediately, and any staff can answer the call light, and if the call lights were not attended right away, resident may be in harm. RN 1 further stated, all staff is responsible for answering call light, even if they are under registry, and even if they are working on something currently, they are able to use the overheard page to ask for help from staff who are working on the floor.During a review of the facility's policy and procedures titled, Call Lights: Accessibility and Timely Response, reviewed on 1/2025, the P&P indicated that, Staff members who see or hear an activated call light are responsible for promptly responding. If staff member cannot provide what Resident desires, appropriate personnel should be notified.During a review of the facility's P&P titled, Quality of Life - Accommodation of Needs, revised on 1/2025, the P&P indicated that, The resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered.

Based on observation, interview and record review, the facility failed to ensure that staff follow infection prevention when Treatment Nurse 1 (TXN 1) and Certified Nurse Assistant (CNA) 3 did not wear personal protective equipment (PPE- protective items or garments worn which includes the use of gloves, gown, mask, face shield, when anticipating coming in contact with blood, body fluids or other communicable toxins or agents) when providing suprapubic catheter change for one of four sampled residents (Resident 1) who was on Enhanced Barrier Precaution (an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs - bacteria that are resistant to more than one antibiotic and can cause serious infections in nursing facilities).This deficient practice has a potential for Resident 1 risk for acquiring and transmitting infection to other residents, staff and visitors in the facility.Findings:During a review of Resident 1's admission Record , the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including hypertension (HTN-high blood pressure), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) and obstructive uropathy (a condition in which the flow of urine is blocked and urine flows backward from your bladder into your kidneys).During a review of the Minimum Data Set (MDS - resident assessment tool) dated 12/2/2025, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills suggests that the individual has a severe level of cognitive impairment. The MDS indicated Resident 1 requires moderate to maximum assistance from the staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS also indicated that Resident 1 had a suprapubic catheter. During a review of Resident 1's Order summary report dated 12/31/2025, the order summary indicated a physician's order was initiated on 08/05/2025 stated Enhanced Barrier Precaution (EBP) related to suprapubic catheter- Apply enhanced barrier to prevent the spread of infections for specific care activities such as: morning and evening care, toileting and changing incontinence briefs, caring for devices and giving medical treatments, wound care, mobility assistance and preparing to leave the room, cleaning and disinfecting the environment every shift for monitoring.During an observation on 12/30/2025 at 10:46 a.m., a signage of Enhanced Barrier Precaution was posted outside of Resident 1's room. Treatment Nurse 1 (TXN 1) was observed changing Resident 1's suprapubic catheter with Certified Nursing Assistant 3 (CNA 3) at Resident 1's bedside. Neither TXN 1 and CNA 3 wore complete PPE. During an interview with TXN 1 on 12/30/2025 at 12:02 p.m., TXN 1 stated that he forgot to observe the EBP while changing Resident 1's suprapubic catheter change. TXN 1 stated that CNA 3 should have worn PPE while assisting. TXN 1 explained the facility follows EBP protocol to reduce the risk of spreading multidrug-resistant organisms (MDROs). TXN 1 acknowledged that failing to follow EBP could result in staff transmitting bacteria or viruses to other residents. During an interview with Infection Preventionist (IP 1) on 12/30/2025 at 1:27 p.m., IP 1 stated that residents that have suprapubic catheter are placed on EBP. IP 1 added that staff are expected to wash hands and wear proper PPE. IP 1 further stated that if EBP is not followed, there is a high risk of transmitting bacteria to another resident if staff are not wearing proper PPE. During a review of the facility's P&P titled, Suprapubic Catheter Care, revised on 01/2025 indicated the P&P indicated that equipment and supplies listed for suprapubic catheter care procedure included wash basin; soap and water; washcloth; towel; bed protector; drainage sponge (if ordered by physician); and Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed).During a review of the facility's P&P titled, Enhanced Barrier Precautions, reviewed on 01/2025, the P&P indicated that, Facility staff shall perform hand hygiene and will don gown and gloves before performing the following high-contact resident care activities: (may not need to don gowns and gloves prior to entering the resident's room) dressing; bathing/showering; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care on chronic wounds requiring a dressing.

Based on interview and record review, the facility failed to notify a physician after a significant change (COC- a sudden clinically important decline from a patient's baseline in physical, cognitive, behavioral, or functional abilities) in the mental or physical condition of a resident who had abnormal laboratory (lab) results for one of the three sampled residents (Resident 1)This deficient practice could have resulted in in the worsening of Resident 1's symptoms such as pain and sepsis (a life-threatening blood infection).During a review of the admission record for Resident 1indicated Resident 1was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic disturbance), hypertension (HTN-high blood pressure), and dementia (a progressive state of decline in mental abilities). During a review of history and physical (H&P- is a thorough assessment a doctor does to understand a patient's health. It involves asking about the patient's past and current health problems [the history] and then examining the patient's body to look for signs of illness [the physical examination], dated 7/23/2025, indicated Resident 1 can make needs known but cannot make medical decisions. The same H&P listed Family Member (FM)1 as the responsible party (RP). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool) dated 8/25/2025, indicated Resident 1 had moderate cognitive impairment (Difficulty remembering recent events, Forgetting familiar names and faces, and Misplacing items frequently). The same MDS indicated Resident 1 was dependent on facility staff for her Activities of Daily Living such as: (ADLs routine tasks/activities such as oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, lower/upper body dressing, putting on/taking off footwear). During a review of the lab results dated 9/3/2025 5:13 pm for a urinalysis (a laboratory test that analyzes a urine sample to detect potential health issues). The urinalysis (UA) indicated the following lab results were flagged as abnormal: Result Reference rangeCharacterTurbid Clear Blood Moderate NegativeNitrate Protein Positive Negative100md/dl NegativeLeukoesterase Large NegativeWBC (white blood cells-fight infection) 3770 /HPF 0-5Bacteria Moderate None During a concurrent interview and record review of Resident 1's chart with the Registered Nurse Supervisor (RNS) 1 on 9/26/2055 at 2:03 pm, the RNS stated that a COC is based on resident assessment and/or resident reports that they are not doing well. RNS stated that some of the conditions that may trigger a COC included cough, abnormal labs, and pain. The RNS stated that the Medical Doctor (MD) must be notified right away to ensure that meds are ordered such as cough meds for a resident that is coughing. RNS 1 stated that a COC/SBAR is documented, progress notes which will include the MD informed in the resident's chart. RNS 1 stated that Labs such as UA, culture, Complete Blood Count are called in or faxed to the facility by the laboratory staff. RNS 1 stated that the UA must be reported right way by facility staff unless the MD requests to wait for the culture (results indicate exactly what type of bacteria in the UA). The potential effect is a safety risk in that the resident would experience symptoms which will adversely affect the resident such as experiencing continued pain upon urination when a resident had abnormal UA results. RNS 1 confirmed that there was no documented evidence that the MD or family were notified and that the SBAR progress notes were not documented even though RNS 1 confirmed that she (RNS 1) had received Resident 1's UA results. During an interview with the Director of Nursing (DON) on 9/26/2025 at 3:10 pm, the DON confirmed that abnormal UA results are considered a COC and should be followed by informing the MD, the resident's RP, documentations such as SBAR, and progress notes. The DON confirmed that there was no documented evidence that any of the above named actions were implemented. During a review of the Policy and Procedure (P&P) titled Change in a Resident's Condition or Status, revised 1/30/2025, indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). the same P&P indicated under policy interpretation and implementation the followingThe nurse will notify the resident's Attending Physician or physician on call when there has been a(an):- accident or incident involving the resident.- discovery of injuries of an unknown source.- adverse reaction to medication.- significant change in the resident's physical/emotional/mental condition.- need to alter the resident's medical treatment significantly.- refusal of treatment or medications two (2) or more consecutive times);- need to transfer the resident to a hospital/treatment center.- specific instruction to notify the Physician of changes in the resident's condition. During a review of a P&P titled, Lab and Diagnostic Test Results - Clinical Protocol, the P&P indicated, When test results are reported to the facility, a nurse will first review the results.a. If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. The same P&P indicated, Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results:a. Whether the physician has requested to be notified as soon as a result is received.b. Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors).c. Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison.The same P&P indicated that the physician or their designee can be notified via telephone, fax etc and that staff should document information about how, when and to whom the information was provided in the progress notes and not on the lab reports.

Based on interview and record review, the facility failed to provide alternate call system for nine of 62 residents from 3/9/2024 to 3/12/2024 when the facility's call system was nonfunctional. As a result: 1. Resident 58 continued to suffer burning pain to his left leg at a level 9 out of 10 (9/10 - zero is no pain and 10 is severe pain) because the call light system was not working, and staff were not responding to the Resident 58 calling for help/pain medication. 2. Residents 26, 49, 51, 58, 64, 119, 120, and 219 banged on the tables, yelled, and screamed for staff to get help. Residents 49, 64, 119, and 120 waited for 30 minutes to 1 hour for staff assistance. Residents 119 needed help to go to the rest room. Resident 120 needed to be turned and repositioned. Resident 51 felt distressed. 3. Resident 26 stated she was petrified and uncomfortable and that in case of emergency, she would not be able to get help because the facility's call light was not working 4. Residents 49 and 64 needed help for activities of daily living (ADL) and incontinence (inability to voluntarily control the bowels and bladder) care and the call light was not functional and had no means to alert staff for assistance. 5. Resident 64 used her personal phone to call the staff for assistance. 6. On 3/11/2024, Resident 218 fell and Resident 219 (Resident 218's roommate), found Resident 218 on the floor. Resident 219 called for help and wished the facility's the call light system was functional. The facility call light had been nonfunctional/not working (no light or sounding to alert staff) since 3/9/2024 at 3:15 AM. On 3/12/2024 at 7:20 AM, the survey team entered the facility and identified through observation, interview, and record review the facility failed to provide the residents with alternate call system(s) from 3/9/2024 at 3:15 AM to 3/12/2024 to 9:45 AM. On 3/12/2024 at 6 PM, an Immediate Jeopardy (IJ - a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was identified in the presence of the Administrator (ADM) and the Director of Nursing (DON) regarding the facility's call light has been nonfunctional/not working (no light or sounding to alert staff) since 3/9/2024 at 3:15 AM. On 3/14/2024 at 7:51 PM, while onsite at the facility, the IJ was removed in the presence of the ADM and the DON, after the ADM submitted an acceptable IJ Removal Plan (interventions and implementation to correct the deficient practices) which was verified and confirmed through observation, interview, and record review. The acceptable IJ removal plan included the following: 1. Effective 3/9/2024, residents able to utilize manual call bell when the call system was nonfunctional, were provided with manual call bells. Two direct care/clinical staff to complete the rounding log after making (hunger, thirst, repositioning, toileting, ADL, and medications) and interventions evaluated every shift until the call system was repaired. The ADM, DON and/or Director of Staff Development (DSD) will monitor compliance twice a shift. 2. Effective 3/9/2024, two direct care/clinical staff residents will make rounds on residents unable to utilize a manual call bell (residents who were cognitively impaired, confused, visually/hearing impaired, nonverbal, and/or comatose [prolonged unconsciousness brought on by illness or injury]). The two direct care/clinical staff will complete the rounding log after making rounds on residents every 15 minutes to ensure resident needs were met (hunger, thirst, repositioning, toileting, ADL, and medications) and interventions evaluated every shift until the call system was repaired. The ADM, DON and/or DSD will monitor compliance twice a shift. 3. On 3/9/2024, all 62 residents were identified and affected by the non-functioning call system. 4. On 3/12/2024, the Medical Director was notified immediately of the non-functioning call system. 5. The DON, DSD, RN Supervisors/Unit Managers and/or Nurse Consultant in-serviced/educated direct care/clinical and/or registry staff immediately on 03/09/2024. The in-service included: a. The importance of the expectations (keeping residents safe and ensure their needs are met) when the call light system fails. b. Encouraging and reminding residents to utilize manual call bell. c. Rounding on residents every 15 minutes to ensure resident needs were met. d. In-services addressed residents who were cognitively impaired, confused, visually/hearing impaired, nonverbal, comatose, etc. 6. Effective 3/9/2024, the Medical Records Director (MRD), notified the residents and/or family/resident representatives of the non-functioning call system, and interventions in place until call system was repaired. 7. Repair company was scheduled to fix/repair the call light system on 3/12/2024. 8. After the call system was repaired, the facility would continue to monitor of the call light twice per shift for 24 hours by a direct care/clinical staff from 3/12/2024 at 7 PM until 3/13/2024 at 7 PM. The facility will activate the call light system and the direct care/clinical staff would check to ensure the call light was on. The MRD would monitor for compliance and report any findings/trends to the monthly Quality Assurance Performance Improvement (QAPI, a systematic, data-driven approach to improving the quality of care and services provided to residents in long-term care facilities) meeting. 9. Maintenance Supervisor (MS) will monitor call light system every Friday for the next three months and correct identified issues. The ADM will monitor for compliance and report any findings/trends to the monthly QAPI meeting. 10. On 3/21/2024, the IJ Removal Plan to be reviewed during QAPI committee Meeting. Cross Reference F697 Findings: On 3/12/2024 at 7:20 AM, the surveyor team entered the facility to conduct recertification survey and heard several residents, yelling, screaming, shouting, and banging asking for help. a. A review of Resident 218's (Resident 219's roommate) Admission Record indicated Resident 218 was admitted to the facility on [DATE] had diagnoses including memory loss, left eye vision loss, anxiety (a condition of excessive worry about daily issues and situations), and depression (a common but serious mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 218's history and physical (H&P - a physician's first complete patient examination) dated 3/11/2024, indicated, Resident 218 underwent a left total hip arthroplasty (a surgical removal of the diseased parts of the hip joint and replaced them with new, artificial parts) on 3/06/2024. A review of Resident 218's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 3/13/2024, indicated, Resident 218 had severely impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). A review of Resident 218's Morse Fall Risk Screen (a rapid and simple method of assessing a patient's likelihood of falling) dated 3/10/2024, indicated, Resident 218 had a weak gait (pattern of walking/balance function) and had a moderate fall risk. A review of Resident 218's Occupational Therapy Evaluation and Plan of Treatment dated 3/11/2024, indicated, Resident 218 was at risk for fall. A review of Resident 218's Morse Fall Risk Screen (a rapid and simple assessment tool of a patient's likelihood of falling) dated 3/11/2024, indicated, Resident 218 had an impaired gait and was a high risk for fall. A review of Resident 218's Situation-Background-Assessment-Recommendation/Change of Condition (SBAR/COC - a technique that provides a framework for communication between members of the health care team and used as a tool to foster patient safety) dated 3/11/2024 at 8:02 PM, indicated, Resident 218 had an unwitnessed fall. During an interview with Resident 219 (Resident 218's roommate) on 3/12/2024 at 2:09 PM, Resident 219 stated Resident 218, wouldn't use the call light anyway because she (Resident 218) will get out when she wants to. Resident 219 stated that on 3/11/2024, Resident 219 ran out of the room because the call light system was not working and had no other means of calling the staff, and yelled, she [Resident 218] fell , she fell to get the staff's attention when Resident 218 fell on the floor. Resident 219 stated I had to shout to have them [staff] hear me. b. A record review of Resident 219's Admission Record, indicated, Resident 219 was admitted to the facility on [DATE] with a diagnoses of chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung diseases that causes obstructed airflow from the lungs), acute and chronic respiratory failure with hypoxia (the respiratory system cannot adequately provide oxygen to the body leading to insufficient amount of oxygen at the tissue level), hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that is present over a long time with heart muscle not able to pump enough blood for the body's needs). A review of Resident 219's H&P dated 12/18/2023, indicated Resident 219 was alert and oriented to person and place. During an interview with Resident 219 (Resident 218's roommate) on 3/12/2024 at 2:09 PM, Resident 219 stated Resident 218, wouldn't use the call light anyway because she (Resident 218) will get out when she wants to. Resident 219 stated that on 3/11/2024, Resident 219 ran out of the room because the call light system was not working and had no other means of calling the staff, and yelled, she [Resident 218] fell , she fell to get the staff's attention when Resident 218 fell on the floor. Resident 219 stated I had to shout to have them [staff] hear me. During an observation and interview with Licensed Vocational Nurse 3 (LVN 3) on 3/12/2024 at 3:35 PM, LVN 3 was observed rounding the south hallway with a clipboard, going into resident's room asking residents if they needed assistance. LVN 3 stated his shift started at 7AM but was asked by the Director of Nursing (DON) to work overtime until 11:30 PM tonight. LVN 3 stated LVN 3 checked each resident every 15 minutes but if a resident called for help while he was assisting another resident with nursing care, I would not be able to help the other resident at all. When asked when the cow bell or ring bell were made available to the residents, LVN 3 stated, I don't remember. 43497 c. A review of Resident 120's Admission Record, indicated Resident 120 was admitted on [DATE] with diagnoses including unspecified intracapsular fracture (a break along the length of the bone) of left femur (thigh bone) history of falling, atherosclerotic heart disease (damage or disease in the heart's major blood vessels), muscle weakness, dysphagia (inability to swallow), low back pain, intervertebral disc degeneration in the lumbosacral region (wear and tear of lumbar intervertebral disc), hyperlipidemia (elevated cholesterol), hypothyroidism (low thyroid levels), thrombocytopenia (low platelet level), and anorexia (an eating disorder characterized by restriction of food). A record review of Resident 120's MDS dated [DATE], indicated Resident 120 was cognitively intact (able to make needs known) and required moderate staff assistance with upper body dressing, and personal hygiene. During an observation and interview with Resident 120 on 3/12/2024 at 10:07 AM, Resident 120 was observed in bed and yelling for help. Resident 120 stated, he needed to be repositioned and that the call light had not been working since Saturday (3/2/2024). Resident 120 stated, he had to wait for 30 minutes to one hour to get help from staff. Resident 120 was observed to be visibly distressed and uncomfortable. d. A review of Resident 119's Admission Record, indicated Resident 119 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of body and pancreas (pancreatic cancer), malignant neoplasm if liver and intrahepatic bile duct (liver cancer), abnormal weight loss, hypertension (HTN - elevated blood pressure), type 2 diabetes (elevated blood sugar), and hyperlipidemia. A review of Resident 119's MDS dated [DATE], indicated Resident 119's cognition was moderately impaired. During an observation and interview with Resident 119 on 3/12/2024 at 10:32 AM, Resident 119 stated his call light had not been working and had not been able to get any help from staff. Resident 119 stated he needed assistance to go to the bathroom and he had to hold using the bathroom for a long time (time unspecified). When asked how had been calling for help, Resident 51 (Resident 119's roommate) stated he had been banging the bedside table. Resident 51 stated they (Resident 119 and Resident 51) had to bang the tables to get help. e. A review of Resident 51's Admission Record, indicated Resident 51 was admitted on [DATE] and was readmitted on [DATE] with diagnoses including toxic encephalopathy (acute cerebral dysfunction due to different metabolic disturbances), history of falling, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), muscle weakness, dysphagia, COPD, acute and chronic respiratory failure with hypoxia, orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down), malignant neoplasm of bladder (bladder cancer), cardiomegaly (an enlarged heart), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow of the limbs). A review of Resident 51's MDS dated [DATE], indicated Resident 51's cognition was moderately impaired. Resident 51 required moderate staff assistance with oral hygiene and eating, and maximal assistance with upper body dressing. During an observation and interview with Resident 51 on 3/12/2024 at 11:12 AM, Resident 51 was in bed and verbally responsive. Resident 51 stated, his call light had not been working, and had to bang on the bedside table to get assistance. Resident 51 stated the facility had not provided him he with an alternative to call for help and was feeling distressed. During an interview with MS on 3/12/2026 at 11:20 AM, MS stated the facility's call light system had not been working since Saturday (3/2/2024) for all residents. MS stated, they (facility) have been working on replacing a part of the call light system. f. A review of Resident 64's Admission Record, indicated Resident 64 was admitted on [DATE] with diagnoses including rhabdomyolysis (a condition in which damaged skeletal muscle breaks down rapidly), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), muscle weakness, sepsis (a life threatening complication of an infection), urinary tract infection (UTI - infection of any part of the urinary system), hyperglycemia (elevated blood sugar), obesity (a disorder that involves too much body fat), atrial fibrillation (afib - an irregular heart rate), HTN, anxiety disorder, depression, and pressure induced deep tissue damage of sacral region (type of breakdown to the skin). A review of Resident 64's MDS dated [DATE], indicated Resident 64 was cognitively intact. Resident 64 required moderate staff assistance with oral hygiene and eating, and maximal assistance with upper body dressing. During an observation and interview with Resident 64 on 3/12/2024 at 10:58 AM, Resident 64 was in bed in bed awake, alert and verbally responsive. Resident 64 stated, she had not had a functioning call light for three days (3/9/2024, 3/10/2024, and 3/11/2024). Resident 64 stated she used her cell phone to call the facility whenever she needed help. Resident 64 stated, she would call the nurses to change her because she was incontinent. Resident 64 stated, she would be in trouble if she did not have her cell phone because there is no other way to get help from a nurse. g. A review of Resident 49's Admission Record, indicated Resident 49 was admitted on [DATE] and was readmitted on [DATE] with diagnoses including type 2 diabetes (elevated blood sugar), lack of coordination, hyperlipidemia, anxiety disorder, hemiplegia (paralysis of one side of the body), HTN, urine retention (inability to urinate), transient ischemic attack (TIA - a short period of symptoms similar to a stroke), cerebral infarction (stroke - occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply). A review of Resident 49's MDS dated [DATE], indicated Resident 49 was cognitively intact. Resident 64 required moderate staff assistance with oral hygiene, eating, and personal hygiene. During an observation and interview with Resident 49 on 3/12/2024 at 11:40 AM, Resident 49 was in bed awake, alert and verbally responsive. Resident 49 stated, she has not had a functioning call light since the weekend. Resident 49 stated she has to yell out for help, and this makes her anxious. Resident 49 stated, she was not provided with any other options to call for help. 46843 h. A review of Resident 58' s Admission Record dated 3/13/2024, indicated the facility initially admitted Resident 58 on 10/18/2022 with diagnoses that included, toxic encephalopathy, muscle weakness, HTN, hemiplegia, and slurred speech (a motor speech disorder in which muscles used to produce speech are damaged, paralyzed, or weakened), and anarthria (complete loss of speech). A review of Resident 58's MDS dated [DATE], indicated Resident 58 was cognitively intact (able to make decisions concerning care, alert to situation and oriented to place and time). The MDS indicated Resident 58 needed maximal assistance (helper does more than half the effort needed to complete ADL (shower, toileting hygiene, upper and lower body dressing). A review of Resident 58's care plan titled Call lights Malfunctioning/not working (No initiation date), indicated, Resident 58 will be checked at least every 15 minutes. During an interview with Resident 58 on 3/12/2024 at 9:40 am, Resident 58 stated the facility call lights need to be fixed because the call lights had not been working for about three days. Resident 58 stated Resident 58 had difficulty getting pain medication on time due to the call light system not working. Resident 58 stated he really needed the call light, because his left leg pain would start at different times of the day and night. Resident 58 stated that on 3/9/2024 and 3/10/2024 his left leg pain level was nine out of 10 (numerical pain assessment tool where zero is no pain and 10 is severe pain). Resident 58 stated he had to yell for help and for pain medication because the facility's call lights was not working. Resident 58 stated he waited for about two hours for someone to respond to him calling for help. Resident 58 stated he was very upset that no one was there to help him when he needed help. Resident 58 stated he remained in severe pain for at least two hours on 3/10/2024 night. During an interview on with MS 3/12/24 at 12:02 PM, MS stated that on 3/9/2024 at 3:15am, MS notified the Director of Nursing (DON) that the call lights system was not working. MS stated that the next day, on 3/10/2024, MS contacted the company that performs maintenance and repairs on the facility call lights system and the company informed MS that a maintenance person could not be sent out until Tuesday 3/12/2024 after 5 pm to repair the call light system. MS stated MS called another company who too was unable to assist the facility any sooner. MS stated MS tried several times to fix the call light system but needed a part that MS was unable to purchase and had to wait until 3/12/2024 for the repair company to repair the call light system. During an interview with DSD on 3/12/24 at 3:13 PM, after the surveyor team identified nonfunctioning call light system, DSD stated, the facility will designate floaters for each shift until the call light system is repaired. The person assigned as floater will be responsible to check if residents need help. The floater will make rounds every 15 minutes to check if residents need assistance. The person that is assigned as floater will not have any residents assigned to them throughout the shift. The floaters only responsibility will be to check the residents and make sure their needs are met. During an interview with LVN 1 on 3/12/24 at 3:32 PM, LVN 1 stated, recently the facility assigned Restorative Nurse Assistant 1 (RNA 1 - a person trained to assist a patient/resident with performing transfers, bed mobility, positioning and range of motion) as a floater to make rounds to assist other staff when residents need help, such as putting residents back to bed, cleaning and provide incontinence care to residents, and help other staff members with various tasks. During an interview with RNA 1 on 3/12/24 at 3:43 PM, RNA 1 stated that during the weekend (3/9/2024 and 3/10/2024), and Monday (3/11/2024) the facility's administration called RNA 1 in to work overtime as a floater for 16 hours. RNA 1 stated, starting Saturday, 3/9/2024, RNA 1 was to come in at noon to help with the call light situation. RNA 1 stated he was assigned to assist nursing or certified nurse assistants (CNAs) put residents back in bed, or help cleaning residents and continued to perform RNA duties for residents assigned to RNA 1 from physical therapy department. During an interview with LVN 2 on 3/12/24 at 3:52 PM, LVN 2 stated LVN 2 came in to work on Saturday 3/9/2024, and that the facility's call light system was not working. LVN 2 stated the floater was supposed to make rounds (check on residents) hourly. LVN 2 stated sometimes the residents would call the main desk and ask the front desk staff to send someone to the residents' rooms. A review of the facility's policy and procedures (P&P) titled Call Light Answering revised 8/12/2021, indicated, It is the policy of this facility to provide the resident a means of communication with nursing staff as indicated based on resident assessment . In the event that the resident is not able to use the call light, the resident will be checked by the nursing staff during care and more frequently as indicated. A review of the facility's P&P titled Call System, Resident dated 9/2022, indicated, Residents are provided with a 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 . The resident call system remains functional at all times. If audible communication is used, the volume is maintained at an audible level that can be easily heard. If visual communication is used, the lights remain functional. If resident call light system is down, an alternative means of communication will be used such as call bells and frequent room rounds. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan. The resident call system is routinely maintained and tested by the maintenance department. Calls for assistance are answered as soon as possible. Urgent requests for assistance are addressed immediately.

Based on interview and record review the facility failed to ensure Licensed Vocational Nurse 3 (LVN 3), performed cardio pulmonary resuscitation (CPR, is an emergency lifesaving procedure performed when the heart stops beating) for one of three sampled residents (Resident 1) in accordance with the facility's undated policy and procedures (P&P) titled Manual Ventilation and undated document titled Chest Compressions, and the American Heart Association (AHA - organization in the United States that funds cardiovascular medical research, educates consumers on healthy living and fosters appropriate cardiac care in an effort to reduce disability and deaths) Algorithm (a process or set of rules to be followed in calculations or other problem-solving operations) titled Adult Basic Life Support Algorithm for Healthcare Providers for the year 2020 to implement 30 chest compressions and two breaths. Certified nursing assistant 1 (CNA 1) found Resident 1 in bed and unresponsive on [DATE] at 7:35 am. During CPR, LVN 3 placed a non-rebreather mask (a medical device used to deliver oxygen in emergencies to patients who are not able to breath on their own) and administered oxygen at 15 Liters/minute (L/min, unit of measurement) when Resident 1 was not breathing. This deficient practice resulted in the lack of oxygenation (the loss or absence of oxygen supply to body tissues and perfusion (the passage of fluid/blood through the circulatory system [blood stream] to vital body organs) for Resident 1. The paramedics (medical professionals who specializes in emergency treatment) transferred Resident 1 to General Acute Care Hospital (GACH) via emergency service (911- emergency telephone number to request emergency assistance) on [DATE] at 7:43 a.m. Resident 1 died two days later at the GACH. Findings: A review of Resident 1's admission's record (Facesheet) indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hyperosmolality and hypernatremia (a condition in which the blood has a high concentration of salt (sodium), glucose, and other substances. This draws the water out of the body's other organs, including the brain), dysphagia (difficulty or discomfort in swallowing, as a symptom of disease), and muscle weakness (decreased strength of the muscles, affecting both distal and proximal musculature). A review of Resident 1's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated [DATE], indicated the resident had severely impaired cognition (never/rarely makes decisions). The same MDS further indicated Resident 1 required one-person physical assist with bed mobility, transfer, locomotion on unit, dressing, eating and toilet use. A review of the nurses' notes dated [DATE] indicated CNA 1 found Resident 1 found unresponsive on [DATE] at 7:35 a.m. CNA 1 summoned LVN 3 who then assessed Resident 1, and immediately initiated CPR, and LVN 3 started oxygen at 15 liters per minute (LPM) on Resident 1 at 15 Liters using a nonrebreather mask. 911 was called immediately. Resident 1 was transferred to a GACH via emergency services on [DATE] at 7:45 a.m. During an interview with CNA 1, on [DATE] at 10:27 a.m., CNA 1 stated that on [DATE], she was passing the breakfast tray to Resident 1's roommate when she noticed that Resident 1 did not say hi to her [CNA 1] as he usually does. CNA 1 stated she tried to wake up Resident 1 and noticed that Resident 1 was unresponsive. CNA 1 she stated she then pulled the call light (remote control device used as a primary method of patient-nurse communication) and yelled for help and that LVNs 1 and 2 came in to assist Resident 1. During an interview with LVN 1 on [DATE] at 10:56 a.m., LVN 1 stated she responded to CNA 1's call at 7:35 a.m. for help and that upon assessment, Resident 1 did not have a pulse (heartbeat) and no rise and fall of the chest (indicates if a person is breathing in and out). LVN 1 stated she immediately initiated CPR with chest compressions and a non-breather mask was placed on Resident 1. LVN 1 stated a non-rebreather mask delivers a higher amount of oxygen at between 5 and 15 liters. LVN 1 confirmed and stated a non-rebreather mask is used for people that are able to breath unassisted. LVN 1 further stated a patient would not be able to breath and receive oxygen if a non-rebreather mask is placed on a patient who is not breathing on his/her own. During a concurrent interview and record review with the DON, on [DATE] at 11:30 a.m., the facility's P&P titled Emergency Procedure - Cardiopulmonary Resuscitation, revised on ,d+[DATE] was reviewed. The P&P indicated, The facility's procedure for administering CPR shall incorporate the steps covered in the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. 1.d Initiate the basic life support (BLS) sequence of events. 2. The BLS sequence of events is referred to C-A-B (chest compression, airway, breathing). 4. Airway. Tilt head back and chin lift to clear airway. 5. Breathing. After 30 compressions (chest) provide 2 (two) breaths via ambubag or manually (with CPR shield). 6. Trained rescuers should provide ventilations (breathing that allows for gas exchange, how the lungs and respiratory system automatically perform this vital process) with compression-ventilation ratio of 30:2. The DON stated, Staff should have followed the P&P but didn't. The DON further stated an ambu bag is used for patients that are unresponsive to pain, tactile (touch), verbal (in the form of words) and not breathing. The DON stated that checking the rise and fall of the chest was used to check for respirations and when the latter and former are absent, then chest compressions are initiated and delivered in a ratio of 30 (compressions)-to-two (breaths) when there are two staff. The DON further stated that the nonrebreather mask delivers oxygen at a higher concentration to patients that are breathing on their own. The DON stated that if resident was not receiving oxygen, then the brain would not receive oxygen, and which cause brain damage. A review of the American Heart Association Algorithm titled, Adult Basic Life Support Algorithm for Healthcare Providers for the year 2020, indicated, . No breathing or only gasping (a survival reflex triggered by the brain), no pulse felt, start CPR perform cycles of 30 compressions and 2 (two) breaths. A review of the facility's undated document titled, Chest Compressions, indicated, . When multiple trained personnel are present, the simultaneous performance of continuous excellent chest compressions and proper ventilation using a 30:2 compression-to-ventilation ratio is recommended by the AHA for the management of SCA. The importance of ventilation increases with the duration of the arrest. A review of the facility's undated P&P titled Manual Ventilation, indicated a manual resuscitation device (Ambu bag) is a self-inflating bag-valve-mask device designed for the manual ventilation of a resident allowing manual delivery of oxygen or room air to the lungs of a patient who can't breathe spontaneously (a process or event occurring without apparent external cause). 1. Attach oxygen tubing from the manual resuscitation bag to the oxygen tank and adjust the flow to 15 liters per minute (LPM). 2. use the chin lift position and seal the mask around the resident's nose and mouth . 3. Visually check the manual resuscitator oxygen reservoir bag with your hand using a squeezing motion. 4. Visually check the resident for the rise and fall of the chest. Mask adjustments may be required for a proper seal. A review of the facility's P&P titled Emergency Procedure - Cardiopulmonary Resuscitation, revised on ,d+[DATE], indicated, Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation (are devices that apply an electric charge or current to the heart to restore a normal heartbeat), for victims of sudden cardiac arrest. The P&P further indicated, the facility's procedure for administering CPR shall incorporate the steps covered in the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. 1.d Initiate the basic life support (BLS) sequence of events. 2. The BLS sequence of events is referred to C-A-B (chest compression, airway, breathing). 4. Airway. Tilt head back and chin lift to clear airway. 5. Breathing. After 30 compressions (chest) provide 2 (two) breaths via ambubag or manually (with CPR shield). 6. Trained rescuers should provide ventilations (breathing that allows for gas exchange) with compression-ventilation ratio of 30:2.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus Disease 2019, a severe respiratory illness caused by virus and spreads from person to person) in accordance to the facility's infection control policies and the Mitigation Plan (MP, a plan to reduce loss of life and impact of COVID-19 in the facility) for 6 of 6 sampled residents (Residents 1, 2, 3, 4, 5, and 6) and the total of 55 residents in the facility and visitor. The facility failed to: 1. Implement a COVID-19 screening process upon entering and exiting the facility. The facility did not screen two male visitors for signs and symptoms of COVID-19 (such as, sore throat, fever, cough, loss of taste), history of travel, and contact with people sick or positive for COVID-19. 2. Ensure Receptionist 1 disinfected pens and thermometers between use with individuals screened for COVID-19. 3. Ensure Registered Nurse 1 (RN 1) notified, at the end of their shift, designated staff, if having signs and symptoms (sore throat, body aches, etc.) of COVID-19. 4. Ensure all staff performed hand hygiene and wore proper Personal Protective Equipment (PPE - protective clothing, goggles, head/shoe covers, mask, gown, gloves or other garments or equipment designed to protect the wearer's body from infection) while caring for Residents 2 and 3, who were potentially COVID-19 positive and were Persons Under Investigation (PUI - quarantined (period or place of isolation in which people that have arrived from elsewhere or been exposed to infectious or contagious disease are placed) for 14 days since admission to rule out COVID-19). 5. Ensure N95 (a particulate-filtering facepiece respirator that filters at least 95% of airborne particles) mask was worn for single shifts and not multiple shifts. 6. Ensure the staff break roomBased on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus Disease 2019, a severe respiratory illness caused by virus and spreads from person to person) in accordance to the facility's infection control policies and the Mitigation Plan (MP, a plan to reduce loss of life and impact of COVID-19 in the facility) for 6 of 6 sampled residents (Residents 1, 2, 3, 4, 5, and 6) and the total of 55 residents in the facility and visitor. The facility failed to: 1. Implement a COVID-19 screening process upon entering and exiting the facility. The facility did not screen two male visitors for signs and symptoms of COVID-19 (such as, sore throat, fever, cough, loss of taste), history of travel, and contact with people sick or positive for COVID-19. 2. Ensure Receptionist 1 disinfected pens and thermometers between use with individuals screened for COVID-19. 3. Ensure staff notified, at the end of their shift, designated staff, if having signs and symptoms (sore throat, body aches, etc.) of COVID-19. 4. Ensure all staff performed hand hygiene and wore proper Personal Protective Equipment (PPE - protective clothing, goggles, head/shoe covers, mask, gown, gloves or other garments or equipment designed to protect the wearer's body from infection) while caring for Residents 2 and 3, who were potentially COVID-19 positive and were Persons Under Investigation (PUI - quarantined (period or place of isolation in which people that have arrived from elsewhere or been exposed to infectious or contagious disease are placed) for 14 days since admission to rule out COVID-19). 5. Ensure N95 (a particulate-filtering facepiece respirator that filters at least 95% of airborne particles) masks were worn for single shifts and not multiple shifts. 6. Ensure staff break rooms had hand sanitizer, disinfecting wipes, and signage reminding staff of social distancing. 7. Ensure clear designation of cohorting (is an infection prevention and control strategy that includes physical and procedural controls to separate infectious residents and decrease risk of transmission to uninfected residents) zones to include a designated Red Zone (area were residents confirmed to have COVID-19 are placed). 8. Have a full time Infection Preventionist (IP) Nurse, and IP was knowledgeable on cohorting recommendation from the Public Health Nurse (PHN) and as indicated in the facility's COVID-19 Mitigation Plan policy. These deficient practices had the potential to result in the spread of COVID-19 placing all 55 residents in the facility, the staff, and visitors at risk to be infected with COVID-19 and becoming seriously ill, leading to hospitalization and/or death. Because of the serious potential harm related to not following infection control measures to prevent the transmission of COVID-19, as detailed above, on 11/10/2020 at 1:43 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified under the Code of Federal Regulations (CFR) 483.80 (F 880) with a scope and severity of K (pattern- more than a limited number of residents affected by the same practice) in the presence of the facility's Assistant Administrator (AA), Licensed Vocational Nurse 1, and Clinical Resource Registered Nurse 1 (RN 1). On 11/13/2020 at 5:03 p.m., the IJ was lifted after the facility submitted an acceptable plan of action (POA). The surveyor verified and confirmed on-site the implementation of the POA through observations, interviews, and record reviews. The IJ situation was removed in the presence of the AA, Regional Administrator (RA), Regional Director (RD), LVN 1, RN Supervisor 2 (RNS 2), RN 1, RN 2, RN 3, and Director of Staff Development (DSD). The accepted POA included the following actions: 1. Specifics doors were designated as only points of entry and exit to ensure staff and essential visitors are screened. In-service education to all staff regarding screening. 2. Staff were in-serviced on proper hand hygiene and performed skill competency checks on hand hygiene. 3. Staff were in-serviced on the appropriate PPE. 4. Clean and used pen containers were assigned at the front lobby door screening table. Staff educated to disinfect pens and thermometers between use. 5. Staff will be provided with a new N95 mask for the specific model for which they were fit-tested . 6. Hand sanitizer, disinfecting wipes, and signage for social distancing were placed in all break rooms. 7. LVN 1 placed designation of cohorting zones. Staff were in-serviced on color-coded zones and the appropriate PPEs required. 8. RN 1 was designated as the interim IP-part time on 11/10/2020, in addition to their part-time ICP to complete the full-time requirement as of 11/10/2020. Cross Reference with F837. Findings: A review of the facility's census during onsite visits conducted on 10/28/2020 and 11/10/2020, indicated the facility had 55 residents each date. 1. On 10/28/2020 at 10:11 a.m., during an observation when entering the facility using the front door, the door was open, and there was no staff stationed at the entrance to perform COVID-19 screening to anybody entering the facility. On 10/28/2020 at 10:15 a.m., during an observation of the entrance area, RN 1 did not screen two male visitors (MVs 1 and 2) entering the facility and did not encourage them to wash their hands before going into the residents' room areas. On 10/28/2020 at 10:47 a.m., during an interview, LVN 1 stated all staff take their temperature and screen for signs and symptoms of COVID-19 upon entering the facility at the beginning and at the end of their shifts at an area located near the conference room by the entrance. On 11/10/2020 between 7:15 a.m. and 7:45 a.m., during observations upon entering the facility through the main entrance door, the door was open and there was no designated staff at a screening table located at the lobby. During the observation, the thermometer and the pen used by nursing staff were not disinfected in between uses. On 11/10/2020 at 8:47 a.m., during an interview, CNA 4 stated when at work, she performed her own screening by checking her temperature and for signs and symptoms of COVID-19. 2. On 11/10/2020 at 7:33 a.m., during an interview and concurrent review of the End-of-Shift Employee Screening log, RNS 2 stated RNS 1 had a sore throat at the end of her shift but she did not know about it because she (RNS 2) did not check the log. RNS 2 stated RNS 1 did not report the sore throat. RNS 2 further stated RNS 1 should have reported immediately the symptom to the supervisor. On 11/10/2020 at 7:44 a.m., a review of the End-of-Shift Employee Screening log indicated RNS 1 had a sore throat earlier that day. During a concurrent interview, the AA stated, RNS 1 should have reported to administration within the hour. 3. On 10/28/2020 at 10:37 a.m., during an observation, MVs 1 and 2 were standing in the hallway of the Yellow Zone (area for residents suspected to be infected with COVID-19 transmitted by respiratory droplets that are generated by a resident who is coughing, sneezing, or talking) speaking to each other and not wearing masks. On 10/28/2020 at 10:49 a.m., during an observation of the rehabilitation room with LVN 1, the Occupational Therapist (OT) was wearing a surgical mask below the nose, while sitting at a desk with another staff member (Staff Member 1) and both were in close proximity (less than three feet) not keeping at least six feet distance. During a concurrent interview, LVN 1 stated the OT was not wearing her surgical mask correctly and the two staff members were not [MEDICATION NAME] social distancing. 4. A review of the Admission Record indicated the facility admitted Resident 1 on 9/25/2020 with [DIAGNOSES REDACTED]. On 10/28/2020 at 11:35 a.m., during an observation with LVN 1, the Admissions Director (AD), exited Resident 1's room in the Yellow Zone, doffed (removed) and discarded the gown in a bin for soiled linen, located outside the room. The AD did not perform hand hygiene. In a concurrent interview, LVN 1 stated the AD should have performed hand hygiene. On 10/28/2020 at 12:15 p.m., during an observation with RN 1, CNA 1 walked inside a room in the yellow zone not wearing any N95 mask, disposable gown or face shield. During an observation, the room had a yellow star sticker, PPE cart, and droplet isolation signage outside the room. During an observation, CNA 1 exited the same room without performing hand hygiene and was wearing his surgical mask under his nose, not covering the nose. During a concurrent interview, RN 1 stated CNA 1 should have worn the N95, donned (put on) a disposable gown, gloves or face shield, and performed hand hygiene before and after entering a room in the Yellow Zone. A review of the Admission Record indicated the facility admitted Resident 4 on 5/25/2020 with [DIAGNOSES REDACTED]. A review of the Admission Record indicated the facility admitted Resident 5 on 6/1/2020 with [DIAGNOSES REDACTED]. On 11/10/2020 at 7:38 a.m., during an observation, LVN 2 and LVN 3 were both standing inside Resident 4 and 5's room wearing N95 masks, but were not wearing disposable gowns, gloves, and eye protection. During a concurrent interview, LVN 2 and LVN 3 acknowledged they did not don gowns, gloves, and eye protection prior to entering Resident 4 and 5's room which was in the Yellow Zone. LVN 2 and LVN 3 stated they should have worn gowns, gloves, and eye protection. A review of the Admission Record indicated the facility admitted Resident 5 on 2/4/2020 with [DIAGNOSES REDACTED]. On 11/10/2020 at 8:07 a.m., during an observation, CNA 2 was entering Resident 2's room wearing a green universal (not fitted for the specific staff) N95 mask, did not don a gown and gloves upon entering Resident 2's room with a yellow star sticker (indicating Yellow Zone), a signage of Droplet Precautions (intended to prevent transmission of germs spread through close respiratory or mucous membrane contact with respiratory secretions), and a PPE cart located outside the room. 5. On 11/10/2020, at 9:11 a.m., during an observation, CNA 3 was wearing a green universal N95 mask. During a concurrent interview, CNA 3 stated she was assigned to the Yellow Zone. CNA 3 stated N95 masks were reused if the mask was still clean. CNA 3 stated the mask was kept in a paper bag to keep it clean. CNA 3 further stated, sometimes when you ask for a mask, they don't have it. On 11/10/2020 at 9:29 a.m., during an interview, LVN 3 stated staff can reuse their N95 mask the next day if the mask was still clean. 6. A review of the Admission Record indicated the facility originally admitted Resident 3 on 9/21/2017 with [DIAGNOSES REDACTED]. A review of the Patient Report, dated 11/3/2020, indicated Resident 3 tested positive for COVID-19. On 11/10/2020 at 7:48 a.m., during an observation of the residents' areas, indicated there was no designated Red Zone (area for confirmed positive COVID-19 residents). During a concurrent interview, the AA stated and acknowledged the facility did not have any designated Red Zone rooms. The AA stated there were no COVID-19 positive residents in-house requiring a Red Zone even though the facility's mitigation plan included a plan to set up red zone room (s) at the time when resident (s) tested positive for COVID-19. On 11/10/20 at 8:11 a.m., during an interview, AA stated he did not report Resident 3 as a new COVID-19 positive case due to Resident 3 was positive in 7/2020, and she was retested after 90 days, and she was still testing positive. Per AA, after 10 days, Resident 3's isolation was discontinued. On 11/10/20 at 2:50 p.m., during a record review and concurrent interview, AA stated he did not know about the Los Angeles County Department of Public Health (LA DPH) form titled Medical Provider Report of COVID-19 Laboratory Results to notify the proper agencies of COVID-19 positive residents and staff. During the concurrent interview, AA also stated he is the person responsible for conducting the line listing, reporting of the COVID-19 positive staff and residents, and to remove the isolation precautions when a resident has completed their quarantine time. The AA stated he was not IP certified (Infection Preventionist or IP needed to have a certification). 7. On 10/28/2020 at 11:12 a.m., during concurrent observation and interview with LVN 1, the Green Zone (area for residents that are negative for COVID-19, no respiratory symptoms, or residents who recovered from COVID-19) breakroom, located next to the kitchen, did not have hand washing station, disinfecting wipes, or hand sanitizer. There was no signage for social distancing and hand hygiene. LVN 1, present at the time of the observation, stated only two people at a time were allowed in the break room. During the observation, numerous chairs were noted at a long rectangular table. LVN 1 stated staff assigned to the Yellow Zone take their breaks in the Green Zone break room after the Green Zone staff take their breaks. LVN 1 stated there was no designated break room for the staff in the Yellow Zone. 8. On 10/28/2020 at 10:32 a.m., during an observation with LVN 1, Resident 1's room was noted with a yellow star, a PPE cart, and Droplet Precaution signage located outside the room, indicating this room was in the Yellow Zone. Resident 1's room was located between Green Zone rooms. LVN 1 stated Resident 1 had been exposed (PUI) and there was not enough space in the Yellow Zone to accommodate Resident 1. 9. A review of the Admission Record indicated the facility originally admitted Resident 6 on 05/04/2017 and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 11/10/2020 at 7:50 a.m., during an observation, Resident 6's room had a yellow star, PPE cart, and droplet isolation signage were located outside the room. During a concurrent interview, the AA stated the yellow star indicated a Yellow Zone room, but Resident 6's room was a Green Zone room, and the signage should have been removed a couple of days ago. On 11/10/2020 at 11:56 a.m., during a review of the IP's time-card report dated 11/1 -11/15/2020 and a concurrent interview, the AA stated IP was working part-time. The AA stated the IP goes to the facility on nights and weekends. The AA stated RN 1 assisted the facility three times per week for eight hours days, RN 1 was IP certified, but she was not specifically assigned to the IP role. A review of the California Department of Public Health (CDPH) All Facilities Letter AFL 20-84 indicated it was important that each Skilled Nursing Facility (SNF) IP have training in fundamental IPC principles to effectively perform the IP duties. Ongoing education is necessary to remain aware of new information, trends, best practices, and to refresh existing knowledge. The designated IP (or both IPs if there are two part-time staff designated) should complete their initial IP training within 90 calendar days of hire if the IP is an existing SNF employee who was recently designated to this role, initial training should occur within 30 calendar days of designation. An existing IP who has not completed initial IP training must complete the training no later than January 1, 2021. A review of facility's policy and procedure titled, Infection prevention and control: Novel Coronavirus (COVID-19), revised 10/12/2020 indicated immediate reporting/notification and consultation with the Local Public Health Department (LPHD) and/or the CDPH, and notification of residents, staff and resident's representative no later than 5PM the next day. The policy indicated facility staff includes employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents on behalf of the facility, and students in the facility's nurse aide training programs or from affiliated academic institutions. A review of facility's policy and procedure titled Infection prevention and control: Novel Coronavirus (COVID-19) revised 10/12/2020 indicated facilities should have 3 separate cohorting areas as follow: 1. Red Cohort, 2. Yellow Cohort, and 3. Green Cohort. The policy indicated for N95 respirators: when [MEDICATION NAME] extended use of N95 respirators, the maximum recommended extended use period is 8-12 hours and Respirators shall not be worn for multiple work shifts and not reused after extended use. The facility will actively verify absence of fever and absence of any signs and symptoms consistent with COVID 19 infection of any person upon entering the facility with the use of Visitor Screening Tool for COVID-19. The policy indicated the facility will immediately notify the local public health and CDPH office of any New COVID-19 Infection in HCP or any Nursing-Home Onset COVID-19 Infection in a Resident. A review of facility's policy and procedure titled COVID-19 Mitigation Plan undated, indicated the facility will designate an infection preventionist, IP will maintain line list of all patients and staff who are confirmed COVID+ and suspected COVID+, and IP is responsible for overseeing screening of all individuals entering the facility and will maintain records that all screening occurs. 9 A review of CDPH AFL 20-52 indicated the SNF must have a full-time, dedicated Infection Preventionist (IP); this can be achieved by more than one staff member sharing this role, but a plan must be in place for infection prevention quality control. The SNF must ensure HCPs receive infection prevention and control training and can work with the department to develop a reasonable implementation timeline and plan to bring on the necessary IP staff. A review of CDPH AFL 20-22 indicated Ensure screening of all who enter the facility for fever and COVID-19 symptoms. Facilities should document the name and contact information of any visitors to assist with contract tracing in needed. Visitors and residents must have facial coverings (cloth masks or surgical face masks) as mandated by CDPH's Guidance for the Use of Face Coverings (PDF). Ensure residents, visitors, and staff perform hand hygiene (use of alcohol-based hand rub is preferred). Place instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designated areas, hand hygiene). had hand sanitizer, disinfecting wipes, and signage reminding staff of social distancing. 7. Ensure clear designation of cohorting (is an infection prevention and control strategy that includes physical and procedural controls to separate infectious residents and decrease risk of transmission to uninfected residents) zones to include a designated Red Zone (area were residents confirmed to have COVID-19 are placed). 8. Have a full-time Infection Preventionist (IP) Nurse, and IP was knowledgeable on cohorting recommendation from the Public Health Nurse (PHN) and as indicated in the facility's COVID-19 Mitigation Plan policy. These deficient practices had the potential to result in the spread of COVID-19 placing all 55 residents in the facility, the staff, and visitors at risk to be infected with COVID-19 and becoming seriously ill, leading to hospitalization and/or death. Because of the serious potential harm related to not following infection control measures to prevent the transmission of COVID-19, as detailed above, on 11/10/2020 at 1:43 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified under the Code of Federal Regulations (CFR) 483.80 (F 880) with a scope and severity of K (pattern- more than a limited number of residents affected by the same practice) in the presence of the facility's Assistant Administrator (AA), Licensed Vocational Nurse 1, and Clinical Resource Registered Nurse 1 (RN 1). On 11/13/2020 at 5:03 p.m., the IJ was lifted after the facility submitted an acceptable plan of action (POA). The surveyor verified and confirmed on-site the implementation of the POA through observations, interviews, and record reviews. The IJ situation was removed in the presence of the AA, Regional Administrator (RA), Regional Director (RD), LVN 1, RN Supervisor 2 (RNS 2), RN 1, RN 2, RN 3, and Director of Staff Development (DSD). The accepted POA included the following actions: 1. Specifics doors were designated as only points of entry and exit to ensure staff and essential visitors are screened. In-service education to all staff regarding screening. 2. Staff were in-serviced on proper hand hygiene and performed skill competency checks on hand hygiene. 3. Staff were in-serviced on the appropriate PPE. 4. Clean and used pen containers were assigned at the front lobby door screening table. Staff educated to disinfect pens and thermometers between use. 5. Staff will be provided with a new N95 mask for the specific model for which they were fit-tested . 6. Hand sanitizer, disinfecting wipes, and signage for social distancing were placed in all break rooms. 7. LVN 1 placed designation of cohorting zones. Staff were in-serviced on color-coded zones and the appropriate PPEs required. 8. RN 1 was designated as the interim IP-part time on 11/10/2020, in addition to their part-time ICP to complete the full-time requirement as of 11/10/2020. Cross Reference with F837. Findings: A review of the facility's census during onsite visits conducted on 10/28/2020 and 11/10/2020, indicated the facility had 55 residents each date. 1. On 10/28/2020 at 10:11 a.m., during an observation when entering the facility using the front door, the door was open, and there was no staff stationed at the entrance to perform COVID-19 screening to anybody entering the facility. On 10/28/2020 at 10:15 a.m., during an observation of the entrance area, RN 1 did not screen two male visitors (MVs 1 and 2) entering the facility and did not encourage them to wash their hands before going into the residents' room areas. On 10/28/2020 at 10:47 a.m., during an interview, LVN 1 stated all staff take their temperature and screen for signs and symptoms of COVID-19 upon entering the facility at the beginning and at the end of their shifts at an area located near the conference room by the entrance. On 11/10/2020 between 7:15 a.m. and 7:45 a.m., during observations upon entering the facility through the main entrance door, the door was open and there was no designated staff at a screening table located at the lobby. During the observation, the thermometer and the pen used by nursing staff were not disinfected in between uses. On 11/10/2020 at 8:47 a.m., during an interview, CNA 4 stated when at work, she performed her own screening by checking her temperature and for signs and symptoms of COVID-19. 2. On 11/10/2020 at 7:33 a.m., during an interview and concurrent review of the End-of-Shift Employee Screening log, RNS 2 stated RNS 1 had a sore throat at the end of her shift but she did not know about it because she (RNS 2) did not check the log. RNS 2 stated RNS 1 did not report the sore throat. RNS 2 further stated RNS 1 should have reported immediately the symptom to the supervisor. On 11/10/2020 at 7:44 a.m., a review of the End-of-Shift Employee Screening log indicated RNS 1 had a sore throat earlier that day. During a concurrent interview, the AA stated, RNS 1 should have reported to administration within the hour. 3. On 10/28/2020 at 10:37 a.m., during an observation, MVs 1 and 2 were standing in the hallway of the Yellow Zone (area for residents suspected to be infected with COVID-19 transmitted by respiratory droplets that are generated by a resident who is coughing, sneezing, or talking) speaking to each other and not wearing masks. On 10/28/2020 at 10:49 a.m., during an observation of the rehabilitation room with LVN 1, the Occupational Therapist (OT) was wearing a surgical mask below the nose, while sitting at a desk with another staff member (Staff Member 1) and both were in close proximity (less than three feet) not keeping at least six feet distance. During a concurrent interview, LVN 1 stated the OT was not wearing her surgical mask correctly and the two staff members were not [MEDICATION NAME] social distancing. 4. A review of the Admission Record indicated the facility admitted Resident 1 on 9/25/2020 with [DIAGNOSES REDACTED]. On 10/28/2020 at 11:35 a.m., during an observation with LVN 1, the Admissions Director (AD), exited Resident 1's room in the Yellow Zone, doffed (removed) and discarded the gown in a bin for soiled linen, located outside the room. The AD did not perform hand hygiene. In a concurrent interview, LVN 1 stated the AD should have performed hand hygiene. On 10/28/2020 at 12:15 p.m., during an observation with RN 1, CNA 1 walked inside a room in the yellow zone not wearing any N95 mask, disposable gown or face shield. During an observation, the room had a yellow star sticker, PPE cart, and droplet isolation signage outside the room. During an observation, CNA 1 exited the same room without performing hand hygiene and was wearing his surgical mask under his nose, not covering the nose. During a concurrent interview, RN 1 stated CNA 1 should have worn the N95, donned (put on) a disposable gown, gloves or face shield, and performed hand hygiene before and after entering a room in the Yellow Zone. A review of the Admission Record indicated the facility admitted Resident 4 on 5/25/2020 with [DIAGNOSES REDACTED]. A review of the Admission Record indicated the facility admitted Resident 5 on 6/1/2020 with [DIAGNOSES REDACTED]. On 11/10/2020 at 7:38 a.m., during an observation, LVN 2 and LVN 3 were both standing inside Resident 4 and 5's room wearing N95 masks, but were not wearing disposable gowns, gloves, and eye protection. During a concurrent interview, LVN 2 and LVN 3 acknowledged they did not don gowns, gloves, and eye protection prior to entering Resident 4 and 5's room which was in the Yellow Zone. LVN 2 and LVN 3 stated they should have worn gowns, gloves, and eye protection. A review of the Admission Record indicated the facility admitted Resident 5 on 2/4/2020 with [DIAGNOSES REDACTED]. On 11/10/2020 at 8:07 a.m., during an observation, CNA 2 was entering Resident 2's room wearing a green universal (not fitted for the specific staff) N95 mask, did not don a gown and gloves upon entering Resident 2's room with a yellow star sticker (indicating Yellow Zone), a signage of Droplet Precautions (intended to prevent transmission of germs spread through close respiratory or mucous membrane contact with respiratory secretions), and a PPE cart located outside the room. 5. On 11/10/2020, at 9:11 a.m., during an observation, CNA 3 was wearing a green universal N95 mask. During a concurrent interview, CNA 3 stated she was assigned to the Yellow Zone. CNA 3 stated N95 masks were reused if the mask was still clean. CNA 3 stated the mask was kept in a paper bag to keep it clean. CNA 3 further stated, sometimes when you ask for a mask, they don't have it. On 11/10/2020 at 9:29 a.m., during an interview, LVN 3 stated staff can reuse their N95 mask the next day if the mask was still clean. 6. A review of the Admission Record indicated the facility originally admitted Resident 3 on 9/21/2017 with [DIAGNOSES REDACTED]. A review of the Patient Report, dated 11/3/2020, indicated Resident 3 tested positive for COVID-19. On 11/10/2020 at 7:48 a.m., during an observation of the residents' areas, indicated there was no designated Red Zone (area for confirmed positive COVID-19 residents). During a concurrent interview, the AA stated and acknowledged the facility did not have any designated Red Zone rooms. The AA stated there were no COVID-19 positive residents in-house requiring a Red Zone even though the facility's mitigation plan included a plan to set up red zone room (s) at the time when resident (s) tested positive for COVID-19. On 11/10/20 at 8:11 a.m., during an interview, AA stated he did not report Resident 3 as a new COVID-19 positive case due to Resident 3 was positive in 7/2020, and she was retested after 90 days, and she was still testing positive. Per AA, after 10 days, Resident 3's isolation was discontinued. On 11/10/20 at 2:50 p.m., during a record review and concurrent interview, AA stated he did not know about the Los Angeles County Department of Public H (TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure a resident who was assess at risk for elopement (when a resident who is cognitively (mental process of acquiring knowledge and understanding) impaired; wanders away from the facility unnoticed) was monitor for resident's whereabouts and provided with secured door alarms for one of three sampled residents (Resident 1) The facility's failure to monitor Resident 1's whereabouts and secure door alarms resulted into Resident 1 leaving the facility unnoticed on 1/12/19. Resident 1 was admitted to the General Acute Care Hospital (GACH) on 2/14/19, (two days after leaving the facility unnoticed) with severe hypovolemia (is a state of decreased blood volume or diminished body fluid) and severe dehydration (occurs when your body loses more fluid than you take in) with acute kidney injury (An abrupt reduction in the ability of kidneys to filter waste products). Cross Reference F609 Findings: On 2/6/2019, at 12:15 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident Abuse. A review of Resident 1's admission record indicated the resident was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS- an assessment and care planning tool), dated 12/13/18, indicated the resident has clear speech, the ability to express ideas and wants, and clear comprehension (understanding). The MDS indicated Resident 1 requiring extensive assistance from staff with dressing, toilet use, and personal hygiene. A review of Resident 1's Elopement/Wandering Risk Assessment, dated 11/26/2018, indicated the interdisciplinary team (IDT, combining or involving two or more academic disciplines or fields of study) is considering risk for elopement due to repeated verbalization of Resident 1 wanting to go home. The IDT indicated the resident did not want to return to facility during an accompanied short walk outside the facility. The IDT plan to continue to monitor Resident 1's whereabouts and collaborate with resident's family member (FM) to explain risk and benefits for elopement. A review of Resident 1's care plan, dated 11/26/18, for potential for injury and/or accidents related to episode of verbalization of wanting to go home. The goals indicated Resident 1 will be free from injury and/or accidents; Resident 1 will be safe for 3 months. The interventions included monitor Resident 1's location as often as possible; apply wander guard to right ankle; staff to monitor placement and functioning, and respond to the alarm immediately once activated. A review of Resident 1's physician orders, dated 11/26/2018, indicated to apply wanderguard bracelet (A device apply to resident wrist or ankle that make sounds when resident close or pass facility exit doors) on right ankle. Monitor for placement and proper functioning two times a day. A review of Resident 1's Wanderguard Transmitter Test Log indicated the facility failed to monitor the wanderguard ankle bracelet from 1/11/2019 through 1/12/2019. A review of Resident 1's care plan, dated 1/12/19, indicated an actual episode of leaving the facility. The care plan goal is for Resident 1 to return to facility within a reasonable amount of time (2-4 hours). The interventions are to search the immediate surrounding areas, and outside of the facility. The interventions included to call the physician, family member, and the police. A review of Resident 1's GACH's history and physical examination [REDACTED]. Resident 1 reported imbalance that led to a fall. The discharge summary, dated 1/16/2019, indicated the final [DIAGNOSES REDACTED]. During a telephone interview with Resident 1's FM, on 2/6/2019, at 11:03 a.m., who stated Resident 1 left the facility 1/12/2019 at 8:30 a.m., with a wanderguard ankle bracelet, and she was able to view the camera footage of Resident 1 leaving the facility. FM stated that the facility told her Resident 1's friends came to pick him up on 1/12/2019 at 8:30 p.m. During the tour of the facility, on 2/6/2019, at 12:30 p.m., with Licensed Vocational Nurse 1 (LVN 1), the emergency exit double glass door (between rooms [ROOM NUMBERS]) with sign posted warning the alarm will sound did not sound when the right side door was opened. A concurrent interview was conducted with LVN 1 who stated the alarm should have been on, and if a resident tried to leave staff will not hear an alarm to warn resident was trying to leave. During a tour of the facility with the Maintenance Supervisor, on 2/6/2019, at 12:40 p.m., the exit double door by room [ROOM NUMBER] with sign posted warning an alarm will be heard did not make a sound upon opening. The Maintenance Supervisor reset the alarm on the left side of the door and the alarm was heard. The Maintenance Supervisor was unable to activate the alarm on the right side of the door. The emergency exit double door by room [ROOM NUMBER] leads to a busy 2 lane street, the right side door did not alarm and no sound was heard. During an interview with the Maintenance Supervisor, on 2/6/2019, at 2:15 p.m., the Maintenance Supervisor stated he monitored the alarm doors during the morning and evening, and monitored the wanderguard ankle bracelets daily. During the interview and concurrent record review of the Transmitter Test log, there was no documented evidence that Resident 1 wasderguard was check. The Maintenance supervisor stated he was not able to locate Resident 1 on 1/11/19 and 1/12/19 to check the wanderguard bracelet. During an interview with the Administrator, on 2/6/2019, at 2:20 p.m., the Administrator stated there was no camera footage of 1/10/19 through 1/13/19 available because the camera stores a week of footage. The undated facility policy, titled Elopement Policy and Procedure, indicated residents who are at risk for elopement will have an appropriate plan of care developed to address the risk. Visual checks of residents who are at high risk for elopement will be done at least every two hours, every shift to determine his/her whereabouts. If the resident is not found within four hours, notify law enforcement, the resident's physician, and a family member. The undated facility policy, titled Maintenance, indicated the Maintenance staff's purpose is to do effective environmental rounds to maintain the building's interior/exterior repairs and keep them free of hazards. The policy indicated to ensure all doors and alarms are working properly. The facility policy, titled Wanderguard, dated (YEAR), indicated the bracelet will be monitored daily for placement and functions to ensure patient's (resident's) safety.

Based on observation, interview and record review, the facility failed to have a system in place to provide adequate supervision to prevent one of 13 sampled residents, (Resident 2) who was diagnosed with [REDACTED]. This had the potential to result in serious harm which could lead to death. Because of the facility's failure to have a system in place to ensure Resident 1 did not wander out of the facility unsupervised into the alley and onto a busy street, an Immediate jeopardy was called on September 23, 2016, at 1:05 p.m. with the administrator and director of nursing (DON). The administrator presented a plan of correction action to the surveyor on 9/23/16. The Plan of Correction consisted of the following: All existing 48 residents will be assessed today for risk of elopement to ensure those identified as high risk and appropriate plan of care is initiated. Monitoring of high risk residents will be initiated every 30 minutes until a wanderguard system is in place. Resident 2 will be provided with a one-on-one staff (Staff present with the resident at all times) every shift to ensure of her whereabouts at all times until appropriate placement is found effective 9/23/16. All staff or representatives from each shift will be called in today for in-service regarding the above immediate corrective actions. The morning shift have been in-serviced at 1:45 p.m. A Representative from the 3-11 and 11-7 shifts have been called in and were in-serviced at 2:00 p.m. The Director of Nurses and the QA Nurse will remain in the facility until all the 3-11 shift and 11-7 shift facility staff are in-serviced. The Medical Record staff will do audits of all newly-admitted residents the next day to ensure that the Elopement Risk Assessment is completed. During the monthly QA meeting, the Director of Nurses and Quality Assurance Committee will discuss the effectiveness of the current system in place and recommend any changes if indicated. On 9/23/16 at 7 p.m. the surveyor met with administrator and director of nursing (DON) and the Quality Assurance Nurse (QA) and informed them the Immediate Jeopardy was abated. The facility also failed to store and secure oxygen cylinders in a manner that would prevent the cylinders from falling over. This had the potential to result in an explosion of the high pressure from inside the cylinders and cause injury to the residents, staff and visitors. The facility failed to securing televisions to prevent them from falling. the facility failed to ensure the facility maintenance off was kept clean and organized. The facility failed to ensure the sharpie containd that was full did not allow access to residents. These deficient practices placed residents' at risk for injury. Findings: a. On September 19, 2016 at 1:00 p.m., while the surveyors were looking for parking Resident 2 was observed walking alone outside of the facility, in the alley near a busy street, alone without supervision. During an observation, on September 20, 2016 at 1:30 p.m., Resident 2, who was alone, walked out of the facility located close to a busy main street. At the same time, the facility's Maintenance Supervisor 1, who was rolling his equipment across the street for storage saw Resident 2 and redirected her back to the facility. During an observation, on September 23, 2016, at 1:40 p.m., Resident 2 walked out of the facility alone, and walked to the corner. The staff did not notice Resident 2 had left the facility and did not provide redirection. Resident 2 returned to the facility on her own. A review of the clinical records indicated Resident 2 was readmitted to the facility, on June 7, 2012, with [DIAGNOSES REDACTED]. A review of the elopement assessment, dated March 27, 2015 indicated Resident 2's clinical condition included dementia, psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), and major depression (A brain disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The assessment also indicated the resident was ambulatory, exhibited intermittent confusion but was responsive to redirection and or cueing, more than 120 days without having any elopement incident, had two behavior of elopement episode in the last six months. A review of a care plan, dated November 20, 2015, indicated Resident 2 had behavioral problems. The resident had several attempts at getting out of the facility on the following dates; September 19, 2013, October 1, 2013, and December 14, 2013. The care plan indicated the resident was wandering around the facility, was at high risk for unsafe elopement (when a person leaves an area without permission or notification which usually leads to placing that individual in a potentially dangerous situation), and was still exhibiting increased risk for elopement. The goals of the care plan included the resident was to have fewer than three episodes of problem behaviors per week, and to remain safe in the facility daily. The intervention included the following: nursing staff continue to visually check on the resident as often as possible every shift to know resident whereabouts, activity staff and the receptionist would do visual checks and alert nursing staff if resident was observed attempting to leave the facility, facility staff will check all entrance/exit doors to ensure they are closed to prevent resident from attempting to get out of the facility, and to monitor episodes of attempts at getting out of the facility by documenting the attempts on the license nurse's weekly progress notes. During an interview with the DON on September 20, 2016, at 3:15 p.m., she stated they did not update the care plan for Resident 2. The DON further stated the resident exhibited behavior of going out of the facility, but there was no one monitoring the resident. The facility could not limit her going out into the alley. During an interview with Administrator on September 20, 2016, at 4:05 p.m., he stated Resident 2 was able to go out when she wanted to, and there was nothing the facility could do about it. The Minimum Data Set (MDS, an assessment and care screening tool), dated July 8, 2016, indicated Resident 2 was cognitively intact, required supervision in all activity of daily living, had hallucinations, delusions and wandering behavior. During an interview with DON on September 20, 2016, at 4:50 p.m., she stated she did not know the number of episodes as to when and how Resident 2 was wandering outside the facility. During an interview with director of nursing on September 27, 2016, at 5:10 pm., she stated the primary care physician said it is okay for Resident 2 to go out. During an interview with administrator on September 27, at 5:30 p.m., he stated we tried again with wander guard, physician did not want to order wander guard. During a general observation from September 19, 2016 to September 26, 2016, the wander guard system was disconnected at the back door. At the time of the observation the facility stated the wander guard was not working and had not been for about 2 years. The facility's policy and procedure titled, Elopement, dated September 2006 indicated the facility shall provide guidance to staff when residents unexpectedly leave the facility grounds so the staff may locate the resident quickly and have the resident returned safely. Another policy and procedure titled, Policy & Procedure for One on One Monitoring, dated September 2016 indicated when a resident is at risk of elopement based on the Elopement Risk Assessment, the facility shall provide one on one staff on all shifts and will not be assigned to any resident but to the high risk resident only. The staff shall be relieved by the receptionist who is in the facility (7:00 a. m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.) and charge nurse during breaks. b. During the initial tour of the facility on September 16, 2016 at 1:40 p.m., there was an emergency oxygen cylinder tank (E tank) standing between a resident's room (Bed A), and the wall. The E tank was not in a cart or rack to keep it secure from falling down. In the oxygen room there was two cylinder tanks (E and hydrogen (H)) which was not in a rack or a cart, and not secured with a chain. During an observation of the oxygen room and interview with the Maintenance Supervisor on September 23, 2016 at 8 a.m., he stated the tanks should be secured at all times. However, he gave no answer as to why the cylinder in the resident's room (Bed A) was without a rack or cart. The review of an undated facility policy and procedure titled Storage and Transport of Oxygen Cylinders indicted all H cylinders tanks must always be either chained to the wall or secured to an approved oxygen cart or stand. All E cylinders must always be secure in a rack, a cart, or confined by a chain. c. On September 19, 2016, during general observation of the facility, the facility failed to ensure the televisions in room 24 A, 26 B, , 26 d, 27 a, 28 B and 30 D were secure. During an interview with the maintenance supervisor he stated he would secure the televisions. d. On September 21 and 22, 2016, during observation of the facility the maintenance office was observed cluttered with various items that blocked the access to the hot water heater and the generator. In this same office there was employees' clothing stored on top and next to the electrical equipment. e. The sharpie container in the shower room was full not allowing access for sharp objects such as razors to be placed inside away from residents.