Every finding on record at Ontario Grove Healthcare & Wellness Centre, LP

Based on observation, interview, and record review, the facility failed to implement their infection control program to help prevent the spread of COVID-19 (a highly infectious disease caused by a respiratory virus) when: 1. Certified Nurse Assistant 1 (CNA 1) failed to wear the required eye protection before entering a COVID-19 isolation room on December 19, 2025. 2. Certified Nurse Assistant 2 (CNA 2) did not ensure that the isolation room door was closed when exiting a COVID-19 isolation room on December 19, 2025. These failures had the potential to cause harm to the 54 residents residing within the facility by causing cross contamination of the environment and increasing the risk of exposure and spread of the COVID-19 virus.1. During an observation on December 19, 2025, at 12:10 PM, the residents inside Room [number] were under droplet isolation precautions (a safety protocol used to stop the spread of germs that travel through respiratory droplets, produced by coughing, sneezing, or talking), as shown by signage posted on the right side of the door.During an observation on December 19, 2025, at 12:15 PM, Certified Nurse Assistant 1 (CNA) 1 was observed entering Room [number] to serve a lunch tray without wearing eye protection, despite the isolation signage posted outside room [number] to inform staff and visitors to be instructed to wear appropriate personal protective equipment (PPE) including masks, gloves, gowns, and eye protection before entering the room.During an interview on December 19, 2025, at 12:15 PM, with the Director of Nursing (DON). The DON stated that residents in room [number] are under droplet isolation for Covid-19 (a virus that causes respiratory illness). Furthermore, the DON stated that eye protection must always be worn before entering a droplet isolation room, while pointing to the face shields (a type of PPE for eye protection) stored and hung in the caddy by the door of Room [number].During an interview on December 19, 2025, at 4:30 PM, with CNA 1, CNA 1 stated she was aware that eye protection is required prior to entering a droplet isolation room but stated that she forgot to put it on before entering Room [number].During a concurrent record review and interview on December 19, 2025, at 4:35 PM, with the Infection Prevention Nurse (IPN) and DON, the facility Policy and Procedure (P&P) titled, Respirator Virus Prevention & Control Plan, revised March 31, 2025, was reviewed. The P&P indicated, .This plan is based on these key focus areas for preventing and controlling the spread of respiratory viruses:. PURPOSE. The purpose of the Respiratory Virus Prevention and Control Plan is to describe our facility's approach to preparing for, preventing, responding to, and controlling the spread of respiratory infections to residents and staff who may develop signs or symptoms of respiratory viral infections by: Maintaining a safe and secure environment for residents, staff, and visitors. Initiating prompt testing and treatment of COVID-19 and influenza to reduce the risk of severe illness, hospitalization, and death. Guidance on recommended Transmission-Based Precautions and personal protective equipment (PPE) when caring for residents with COVID-19 includes N95 or higher-level respirator, eye protection, gown, and gloves. The IPN and DON stated that staff did not follow the P&P. 2. During an observation on December 19, 2025, at 12:18 PM, the residents inside Room [number] were under droplet isolation precautions, as shown by signage posted on the right side of the door.During an interview on December 19, 2025, at 12:20 PM, with the Director of Nursing (DON). The DON stated that residents in room [number] are under droplet isolation for Covid-19.During an observation on December 19, 2025, at 12:25 PM, CNA 2 was observed leaving Room [number] after delivering a lunch tray and walking directly to the nurse's station without closing the door behind her.During an interview on December 19, 2025, at 12:30 PM, with CNA 2, CNA 2 stated that she was aware of the requirement to keep the door closed in a Covid - 19 isolation room. She acknowledged that she forgot to close the door behind her upon leaving.During a follow-up observation on December 19, 2025, at 12:35 PM, the DON engaged in a conversation with the resident in room [number] and subsequently closed the door.During an interview on December 19, 2025, at 4:35 PM with the IPN and DON, the DON stated that the staff is expected to keep the doors closed for residents under droplet isolation to limit the spread of respiratory droplets into common areas.During an interview on December 20, 2025, at 2:20 PM, the Director of Nursing (DON) stated that the facility was not able to locate a written policy and procedures (P&P) specific to door closure for residents under droplet isolation. The DON further stated that it is the facility's practice to keep doors closed for residents under droplet isolation to remain consistent with CDC infection control guidance for managing residents with suspected or confirmed COVID-19.During a concurrent record review and interview on December 20, 2025, at 3:20 PM, with the DON and Administrator, the facility's P&P titled, Testing of Residents and HCP with Signs/Symptoms of Respiratory Illness, revised May 29, 2024, was reviewed. The P&P indicated, . 23. Testing of Residents and HCP with Signs/Symptoms of Respiratory Illness. See CDC guidance on interim guidance for managing healthcare personnel with SAR-Cov-2 Infection or Exposure to SAR-Cov-2. The CDC guidance within the referenced link indicated, . Patient Placement . Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). > If cohorting, only patient with the same respiratory pathogen should be housed in the same room. The DON stated that staff did not follow the P&P.

Based on observation, interview, and record review, the facility failed to store, label, and maintain food and food storage areas in a sanitary manner, as required by professional food service standards when: 1. One bunch of cilantro, which was turning black, was found inside of a plastic bag at the bottom shelf of the refrigerator. 2. One produce storage box that contained whole heads of lettuce was found with debris (dirt). 3. A box, containing fully cooked boneless pork ribs, dated May 9, 2025, was found open with its internal plastic liner unsealed and with freezer burn (food got too dry and frosty due to being exposed to air in the freezer for too long). 4. One 12 quart (qt- unit of measurement) clear plastic container labeled Noodles Pasta, did not have a Use by: date was found inside the dry storage room. These failures had the potential to increase the risk of contamination, bacterial growth (increase of harmful germs that can spoil food and make it unsafe to eat) and foodborne illness (sickness caused by eating food that has been contaminated by germs, like bacteria), and had the potential to affect 53 of 53 residents who receive meals prepared and served form the facility's kitchen. Findings: 1. During a concurrent observation and interview, on June 2, 2025, at 8:17 AM, with [NAME] 1, one bunch of cilantro was found inside a clear plastic bag at the bottom shelf of a six-door refrigerator. The cilantro was turning black in color and was wet to touch. [NAME] 1 stated the cilantro was no longer safe to consume and should have been discarded. During a concurrent interview and record review, on June 4, 2025, at 8:35 AM, with the Dietary Services Supervisor (DSS) and the Assistant Administrator, the facility's policy and procedure (P&P) titled Produce Storage Guidelines, dated 2023, was reviewed. The P&P indicated, May use longer if no signs of spoilage are visible . item Parsley, refrigerator 2 to 3 days. The DSS stated although the facility did not have specific guidance for cilantro, they typically followed the storage timeline for parsley. Both the DSS and Assistant Administrator acknowledged the cilantro found in the refrigerator was spoiled and confirmed it should have been discarded. The DSS stated the policy was not followed by staff. 2. During a concurrent observation and interview, on June 2, 2025, at 8:20 AM, with [NAME] 1, one produce storage box that contained whole heads of lettuce was found inside a six-door refrigerator. The bottom of the box had visible dirt and debris. [NAME] 1 confirmed the box had not been cleaned, and stated it should have been washed prior to use. During a concurrent interview and record review, on June 4, 2025, at 8:41 AM, with the DSS and the Assistant Administrator, the facility's P&P titled P-DS49 Sanitation of Reach in Refrigerator dated July 13, 2023, was reviewed. The P&P indicated, . 2. Weekly tasks f. Scrub the interior and exterior of the refrigerator using hot detergent solution and brush or clean cloth. Pay special attention to shelf guides, gaskets, the door frame and hinge areas. g. Rinse and sanitize the interior and exterior. The DSS acknowledged the policy was not followed, and further stated the storage containers were expected to be clean. 3. During a concurrent observation and interview, on June 2, 2025, at 8:24 AM, with [NAME] 1, an opened box, containing Fully Cooked Boneless Pork Ribs which an open date of May 9, 2025, and a used by date of August 9, 2025, was found inside the freezer. The internal plastic liner was not sealed, and the pork ribs had freezer burn. [NAME] 1 acknowledged the finding, and stated the bag should have been sealed properly after opening to prevent contamination and freezer burn. During an interview on June 2, 2025, at 9:39 AM, with the DSS, the DSS stated the opened box and unsealed bag were not safe for residents due to risk of bacterial growth and ice formation. During a concurrent interview and record review, on June 4, 2025, at 8:43 AM, with the DSS and the Assistant Administrator, the facility's policy and procedure (P&P) titled P-DS52 Food Storage and Handling dated June 4, 2024, was reviewed. The P&P indicated, . 2. Frozen Meat, Poultry and food c. Store items promptly at 0°F or below. Foods should be labeled, date and in their original containers if designed for freezing. Foods to be froze should be stored in airtight . The DSS stated that policy was not followed. The DSS further stated the liner inside the box should have been resealed airtight after opening to prevent freezer burn and exposure to air. The DSS explained that leaving that liner open increased the risk of ice buildup, loss of taste, and bacteria growth. 4. During a concurrent observation and interview, on June 2, 2025, at 8:30 AM, with the DSS, inside the dry storage room, a 12-quart plastic clear container labeled Noodles Pasta was found with a prep date of May 23, 2025. It did not have Use by date. The DSS stated the label was incomplete. The DSS further stated food items must include both prep and use by dates to ensure safe consumption. During a concurrent interview and record review, on June 4, 2025, at 8:45 AM, with the DSS and the Assistant Administrator, the facility's policy and procedure (P&P) titled P-D552 Food Storage and Handling dated June 4, 2024, was reviewed. The P&P indicated, .13. Dry Storage Area .h. label and date all storage products. The DSS stated the policy was not followed. The DSS further stated that all dry goods should have both a prep date and use by date clearly labeled to ensure safe consumption and proper inventory rotation.

Based on observation, interview, and record review, the facility failed to provide accommodation of communication needs to one resident reviewed for language (Resident 24) when Resident 24's communication board was in a different language than the one spoken by Resident 24. This failure had the potential to delay Resident 24's request and did not provide Resident 24 with a method to communicate with facility staff. Findings: During a review of Resident 24's admission Record (contains demographic and medical information), it indicated Resident 24 was admitted to the facility on [DATE], with the diagnoses of atrial fibrillation (n irregular and often very rapid heart rhythm), tachycardia (heart beats faster than normal), and dysphagia (difficulty swallowing). During a review of Resident 24's History and Physical (H&P) dated April 2, 2025, the H&P indicated Resident 24 .speaks Cantonese. During an observation on June 2, 2025, at 11:29 AM, inside of Resident 24's room, Resident 24 had a communication board with her name on it. and Inside the board, it had various pictures labeled in Spanish. During a concurrent observation and interview, on June 2, 2025, at 11:30 AM, with Licensed Vocational Nurse (LVN 1), LVN 1 inspected Resident 24's communication board, and stated Resident 24 spoke Cantonese. LVN 1 further stated the communication board was not in Cantonese and it should have been. During a concurrent interview and record review, on June 5, 2025, at 11:12 AM, with Director of Nursing (DON), the facility's policy and procedure (P&P) titled Accommodation of Residents' Communication Needs, revised March 2017, was reviewed. The P&P indicated to assist residents' to express or communicate their requests, needs, opinions, urgent problems . with adaptive devices . VI. The following are examples of adaptive devices the staff may provide the resident: . B. Communication Boards/Charts . The DON stated the P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure the call light was accessible for three of three residents reviewed for environment (Residents 36, 54, and 159) when Residents 36, 54, and 159's call lights were found inaccessible to the three residents. This failure had the potential to result in leaving Residents 36, 54, 159 unable to use the call light system to call for any assistance the residents may require. Findings: 1. During a review of Resident 36's admission Record (contains demographic and medical information), it indicated Resident 36 was admitted to the facility on [DATE], with diagnoses of dementia (progressive loss of cognitive function, including memory, thinking, and reasoning, that interferes with daily life), dysphagia (difficulty swallowing), and type 2 diabetes mellitus (high blood sugar levels due to the body's resistance to insulin). During a concurrent observation and interview on June 2, 2025, at 4:00 PM, in Resident 36's room, Resident 36 was lying in bed, watching television. Resident 36's call light was wrapped around the side of the bed rail, almost touching the floor. Resident 36 attempted to reach for the call light but was unable to reach it. Resident 36 stated I couldn't reach for it. During a concurrent observation and interview on June 2, 2025, at 4:02 PM, with Licensed Vocational Nurse (LVN 1), in Resident 36's room, LVN 1 inspected the call light and stated it was not accessible to Resident 36. 2. During a review of Resident 54's admission Record, it indicated Resident 54 was admitted to the facility on [DATE], with diagnoses of abnormalities of gait and mobility (difficulty to move around without assistance from staff), cognitive communication deficit (difficulty processing, understanding or expressing communication), and history of falling. During an observation on June 2, 2025, at 9:39 AM, inside Resident 54's room, Resident 54 was lying in bed, watching television. Resident 54's call light was resting on top of the headwall light fixture, above the bed. It was not within Resident 54's reach. During an interview on June 2, 2025, at 9:48 AM, with Resident 54, Resident 54 stated he did not know where the call light was. . During a concurrent observation and interview on June 2, 2025, at 9:50 AM, with Certified Nursing Assistant (CNA 1), CNA 1 confirmed the call light was found not within Resident 54's reach. CNA 1 stated the call light should always be within resident's reach. 3. During a review of Resident 159's, admission Record, it indicated Resident 159 was admitted to the facility on [DATE]. During a review of Resident 159's, Physician History and Physical (H&P) dated May 31, 2025, it indicated Resident 159 had history of right femoral neck fracture (a break in the neck of the thigh bone on the right side, near the hip joint.) During an observation on June 2, 2025, at 10:02 AM, inside Resident 159's room, Resident 159's call light was found under Resident 159's bed and was not within Resident 159's reach. During an interview on June 2, 2025, at 10:05 AM, with Resident 159, Resident 159 stated I don't know where my call light is. During a concurrent observation and interview, on June 2, 2025, at 10:09 AM, with LVN 2, LVN 2 confirmed the location of the call light and acknowledged that it was not within Resident 159's reach. LVN 2 stated It is important to make sure the call light is within the resident's reach in case Resident 159 needs help. During a concurrent interview and record review on June 5, 2025, at 11:42 AM, with the Director of Nursing (DON) and the Assistant Administrator (Assist Admin), the facility's policy and procedure (P&P) titled NP29 Communication - Call System, dated October 9, 2024, was reviewed. The P&P indicated, The facility will maintain a communication system to allow residents to call for staff assistance from their rooms and toileting / bathing facilities. The DON stated the policy was not followed. The DON and Assist Admin acknowledged that having the call light out of reach increases the risk for falls or unmet care needs.

Based on observation, interview, and record review, the facility failed to implement and maintain an effective infection prevention and control program (proper methods used to stop the spread of germs and protect residents, staff and visitors from getting sick) for one of three residents reviewed for infection control (Resident 17) when Resident 17's suction tubing (flexible tube, used to remove bodily fluids and debris from one's airway or surgical site) was left open to air and without a dated label. This failure had the potential to result in cross-contamination (germs or bacteria from one dirty surface or item get spread to something clean, which can make people sick) causing preventable infection to Resident 17. Findings: During a review of Resident17's admission Record (contains demographic and medical information), it indicated Resident 17 was admitted to the facility on [DATE], with diagnoses of dementia (a condition that affects the brain and causes problems with memory, thinking and understanding), congestive heart failure (the heart is weak and doesn't pump blood well, which can cause trouble breathing and body swelling) and gastrostomy status (has a feeding tube in their belly to help them eat when they can't eat by mouth.) During a review of Resident's 17 Physician Orders, dated December 27, 2024, it indicated Enteral Feeding (giving food or liquid nutrition through a tube that goes into the stomach or intestines because the person can't eat by mouth) Order every shift oral care - use swab (a small soft stick used clean a part of the body, like inside the mouth) / suction (a way to gently suck out things like saliva (spit) or mucus from the mouth using a tube) as appropriate. During an observation on June 2, 2025, at 10:15 AM, inside Resident's 17 room, Resident 17 was lying in bed, with head of the bed elevated. A portable suction machine (a small machine that helps remove spit or mucus from someone's mouth using a plastic tube) was on the bedside table, next to the resident. The suction machine was plugged into an electrical outlet, and connected to a suction tubing (a rigid plastic tube used to suction saliva or mucus). The Yankauer tip showed signs of prior use, such as dried residue on the tip. It was uncovered, and resting directly on the bedside table surface. The tubing was not bagged, capped or stored in a clean, sanitary manner and was exposed to open air and surrounding environmental contaminants. There was no date, or label visible on the tubing or canister (a clear container that hold the spit or mucus that the suction machine collects) to indicate when it was last used or when it was last replaced. During an interview on June 2, 2025, at 10:18 AM, inside Resident's 17 room, with Licensed Vocational Nurse (LVN 1), LVN 1 acknowledged the Yankauer had already been used for suctioning and stated, After use, it should be placed inside a plastic bag to prevent contamination. LVN 1 further stated she was not familiar with the facility's policy on how often Yankauer suction tubing should be changed or replaced. During an interview on June 5, 2025, at 11:32 AM, with Director of Nursing, (DON), the DON stated the Yankauer suction tip was single use and must be discarded after each use. The DON acknowledged that the Yankauer found on Resident 17's bedside table had already been used for suctioning and was not stored properly. The DON stated staff were trained to discard used Yankauer tips immediately and confirmed that both the suction canister and tubing should be labeled with the date of when it was last replaced. The DON further stated license nurses are assigned every Sunday to check all suction machines and tubing to ensure proper cleaning, storage and labeling are in place. During a concurrent interview and record review on June 5, 2025, at 11:42 AM, with the DON, the DON reviewed the facility's policy and procedure titled Cleaning & Disinfection of Resident Care Equipment, dated January 1, 2012, which indicated Critical and semi-critical items are sterilized/disinfected in a processing location and stored appropriately until use. The DON stated the policy was not followed by staff.

Based on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.) of livable space per resident for nine of 19 resident rooms (Rooms 26, 27, 28, 29, 30, 31, 32, 33, and 34) when Rooms 26, 27, 28, 29, 30, 31, 32, 33, and 34 measured less than 80 square feet per resident. This failure had the potential for the residents housed in Rooms 26, 27, 28, 29, 30, 31, 32, 33, and 34 to not have the ability to move about freely if the square footage limited their personal space. Findings: During a concurrent interview and record review, with the Assistant Administrator (Assist Admin), on June 2, 2025, at 8:56 AM, the Assist Admin reviewed the Entrance Conference Checklist and stated the facility had room waivers for Rooms 26, 27, 28, 29, 30, 31, 32, 33, and 34 which had less than the required square footage of livable space (less than 80 square feet). During an environmental tour with the Maintenance Supervisor (MS) and the Assist Admin, on June 4, 2025, at 3:36 PM, Rooms 26, 27, 28, 29, 30, 31, 32, 33, and 34 were inspected. The residents' rooms and their measurements of livable space were noted as follows: 1. room [ROOM NUMBER] (three beds) measured: 231 sq. ft. [square feet] (77 sq. ft. per resident) 2. room [ROOM NUMBER] (three beds) measured: 231 sq. ft. [square feet] (77 sq. ft. per resident) 3. room [ROOM NUMBER] (three beds) measured: 231 sq. ft. [square feet] (77 sq. ft. per resident) 4. room [ROOM NUMBER] (three beds) measured: 231 sq. ft. [square feet] (77 sq. ft. per resident) 5. room [ROOM NUMBER] (three beds) measured: 231 sq. ft. [square feet] (77 sq. ft. per resident) 6. room [ROOM NUMBER] (three beds) measured: 231 sq. ft. [square feet] (77 sq. ft. per resident) 7. room [ROOM NUMBER] (three beds) measured: 231 sq. ft. [square feet] (77 sq. ft. per resident) 8. room [ROOM NUMBER] (three beds) measured: 231 sq. ft. [square feet] (77 sq. ft. per resident) 9. room [ROOM NUMBER] (three beds) measured: 231 sq. ft. [square feet] (77 sq. ft. per resident) During a follow up interview with the Assist Admin, on June 4, 2025, at 3:55 PM, the Assist Admin confirmed the measurements of the nine resident rooms and stated Rooms 26, 27, 28, 29, 30, 31, 32, 33, and 34 did not meet the 80 square feet per resident. The rooms were not crowded and did not impose any safety hazards to the residents. There were no complaints of space or room issues from the residents occupying these rooms. The survey team recommends the approval of the room waiver request for the rooms listed in this deficiency.

Based on observation, interview, and record review, the facility failed to implement appropriate treatment and assessment of bowel elimination for one of four sample residents (Resident 1) when record indicated resident 1 has not had bowel movement (BM) from February 7, 2025, through February 11, 2025. This failure potentially resulted in Resident 1 readmission to the hospital with abnormal vital sign. Findings: A review of Resident 1 Face Sheet (contain resident demographic), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included neurogenic bowel (a condition where the nerves that control bowel function are damaged or impaired, leading to abnormal bowel movements). A review of Clinical admission record dated February 7, 2025, indicated Last BM January 27, 2025. A review of the bowel elimination records for February 7, 8, 9, 10, and 11 of 2025 revealed that the chart indicated a mark of number 2, signifying the absence of bowel movements. A review Resident 1's Medical Administration Record (MAR) for February 2025 revealed the following: a. Senna Oral Tablet 8.6 mg was prescribed to be taken as 1 tablet by mouth at bedtime for bowel regularity. It was administered on February 8, 9, and 10, 2025, at 9:00 PM. b. Docusate Sodium Oral Capsule 250 mg was indicated to be taken as 1 capsule by mouth twice daily for stool softening. This medication was administered on February 8, 9, and 10, 2025, at 9:00 AM and 5:00 PM. c.Bisacodyl Suppository 10 mg, intended for rectal insertion of 1 suppository (a solid medical preparation in a roughly conical or cylindrical shape, designed to be inserted into the rectum) every 24 hours as needed for constipation, was not administered. d. Lactulose Oral Solution 20 gm/30mL (gm/mL- gram per milliliter is a measurement of a solution's concentration) was prescribed to be taken as 30 ml by mouth every 6 hours as needed for constipation. It was administered only once on February 10, 2025, at 12:08 PM. During concurrent interview and record review on March 3, 2025, at 12:40 PM, with the Director of Nursing (DON 1), Resident 1' MAR was reviewed. The DON 1 indicated that the suppository had not been administered and expressed her belief that the Licensed Vocational Nurse (LVN) failed to document the resident's lack of bowel movements over several days, possibly due to not receiving a report from the Certified Nursing Assistant (CNA). Additionally, the DON 1 noted that the LVN may not have reviewed the resident's bowel movement records. The MAR revealed that on February 10, 2025, a PRN (as needed) dose of lactulose was administered; however, no nursing notes or reports were made to the physician concerning the resident's absence of bowel movements for multiple days. A review of the facility Policy & Procedure (P&P) titled, Bowel and Bladder Training/Toileting Program , dated August 21, 2020, indicated, .v. Pharmacological Interventions. a. The Resident's physician will give orders (interventions) for a medication regimen. The licensed nurse will carry out the orders.

Based on observation, interviews, and record review, the facility failed to follow its policy and procedure to provide care and services for residents and ensure call lights are answered in a timely manner for one of three sampled residents (Residents 1). This failure has the potential to jeopardize the health and safety of clinically compromised Residents (Residents 1) when Resident 1 ' s requests for assistance with activities of daily living were not responded to promptly. Findings: During the review of Resident 1 ' s admission record (It contains important information about the patient such as their personal details, the reason for their admission, and their medical history), the document indicated Resident 1 was admitted on [DATE], with a diagnosis that included history of falling and displaced intertrochanteric fracture of left femur (a type of fracture [break in the bone ] that occurs in the upper part of the thigh bone). During interview and observation with Resident 1 on September 18, 2024, at 12:32 p.m., Resident 1 stated, it is difficult to get assistance between 3:00 PM and 11:00 PM, and from 11:00 PM to 7:00 AM, they are left on their own as nobody comes. There have been instances when she called for help, but nobody showed up until the morning, she mentioned that sometimes she needs a change of diaper or pull-up and often don ' t receive the necessary help. The resident expressed that it varies among the nurses, with some showing care but not many. Ohers come and say they are the CNA (Certified Nursing Assistant - a healthcare professional who provides patient care under the supervision of licensed nurses) for the night, but the resident does not see them again. During a review of the clinical record for Resident 1 ' s the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated August 29, 2024, indicated, Resident 1 ' s score was a 15, which indicated Resident 1 had no mental impairment. During a review of Resident 1's MDS Section G (Functional Status), dated August 29, 2024, the MDS Section G indicated, Resident 1 needed setup or clean-up assistance during eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. During an interview with the staff, the Director of Staff Developer (DSD 1) on September 18, 2024, at 1:07p.m., DSD 1 indicated, call lights should be answered in a timely manner. During a review of the facility ' s policy and procedure (P&P) titled Communication - Call System, dated January 01, 2012, the P&P indicated, Nursing staff will answer call bells promptly, in a courteous manner.

Based on observation, interview, and record review, the facility failed to provide and promote an environment free from misappropriation of resident property in accordance with the facility policy and procedure for five of seven sampled residents (Residents 1, 2, 4, 5 and 6) when a Certified Nursing Assistant (CNA 1) borrowed money from Residents 1, 2, 4, 5, and 6. These failures had the potential for further misappropriation of residents' properties, placing the residents at risk of emotional and financial burden. Findings: 1. During a review of Resident 1's Admission Record (clinical record with demographic information), it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included hyperlipidemia (elevated fat in the blood) and benign prostatic hyperplasia (enlargement of prostate gland). During a concurrent observation and interview, on March 1, 2023, at 11:15 AM, inside of Resident 1's room, Resident 1 was lying in bed, watching television. Resident 1 stated CNA 1 borrowed twenty dollars ($20.00) from him on February 14, 2023. During a review of a facility provided document titled Interview with Resident Regarding [name of the CNA 1], dated February 16, 2023, it indicated, besides Resident 1, CNA 1 borrowed money from the following residents: a. Resident 2- Thirty dollars ($30.00) b. Resident 4- Twenty dollars ($20.00) c. Resident 5- Ten dollars ($10.00) d. Resident 6- Twenty dollars ($20.00) 2. During a review of Resident 2's Admission Record, it indicated Resident 2 was admitted to the facility on [DATE], with diagnosis of polyneuropathy (malfunction of multiple nerves throughout the body). During a concurrent observation and interview, on March 3, 2023, at 8:10 AM, inside of Resident 2's room, Resident 2 was lying in bed, eating breakfast. Resident 2 stated CNA 1 borrowed thirty dollars ($30.00) from him once, and CNA 1 has not paid him back. Resident 2 could not recall the exact date for the incident. 3. During a review of Resident 4's Admission Record, it indicated Resident 4 was admitted to the facility on [DATE], with diagnoses of epilepsy (convulsions), and depression (constant feeling of sadness or loss of interest in activities). During a concurrent observation and interview, on March 3, 2023, at 8:45 AM, inside of Resident 4's room, Resident 4 was sitting at the edge of the bed. Resident 4 stated CNA 1 borrowed twenty dollars ($20.00) from him a few months ago, and CNA 1 has not paid him back. 4. During a review of Resident 5's Admission Record, it indicated Resident 5 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that makes difficult to breathe), type 2 diabetes mellitus (a condition where body does not produce enough insulin), and hyperlipidemia. During a concurrent observation and interview, on March 3, 2023, at 8:51 AM, inside of Resident 5's room, Resident 5 was sitting at the edge of the bed, reading. Resident 5 stated CNA 1 borrowed ten dollars ($10.00) from him a while ago. Resident 5 could not recall the exact date of the incident. 5. During a review of Resident 6's Admission Record, it indicated Resident 6 was admitted to the facility on [DATE], with diagnoses of type 2 diabetes mellitus, and end stage renal disease (when the kidneys stop working). During a concurrent observation and video interview, on March 3, 2023, at 9:24 AM, with Resident 6, Resident 6 was inside his room, lying down in bed. Resident 6 stated CNA 1 borrowed twenty dollars ($20.00) from him a few months ago. Resident 6 could not recall the exact date of the incident. During an interview with Certified Nursing Assistant (CNA 2), on March 3, 2023, at 9:37 AM, CNA 2 stated staff should not borrow money from the residents because it was financial abuse. During an interview with the Administrator (Admin), on March 3, 2023, at 10:07 AM, the Admin stated CNA 1 was terminated because the facility have confirmed CNA 1 borrowed money from Residents 1, 2, 4, 5 and 6. The Admin further stated borrowing money from residents was considered misappropriation of property. During a concurrent interview and record review, with the Admin, on March 3, 2023, at 10:15 AM, the Admin reviewed a facility document titled, Corrective Action Memo for CNA 1, dated February 23, 2023, which indicated, .Type of violation . Violation of Policy or Procedure . Employer Statement . Employee [CNA 1] violated policy and procedure that could possibly result to misappropriation of resident property and financial abuse. Employee borrowed money from multiple residents . Action taken . Termination. The Admin stated CNA 1 violated their policy for Abuse Prevention. During a concurrent interview and record review with the Admin, on March 3, 2023, at 10:21 AM, the Admin reviewed the facility's policy and procedure (P&P) titled, Abuse Prevention and Screening, revised July 2018, which indicated, .The facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment and develops Facility policies, procedures, training programs and screening and prevention systems to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment . IV. Training . A. The facility conduct mandatory staff training programs during orientation, annually and as needed on: . ii. Identifying what constitutes abuse, neglect, exploitation, misappropriation of resident property, or mistreatment . V. Prevention . K. The facility identifies, correct, and intervenes in situations in which abuse, neglect, exploitation, misappropriation of resident property and/or mistreatment is more likely to occur. The Admin stated CNA 1 did not follow the policy.

Based on observation, interview, record review, the facility failed to follow proper sanitization and food handling practices when: 1. Raw thawing beef and bacon was stored on the same shelf as raw thawing chicken breast. 2. The dishwashing machine was not sanitizing the dishes. 3. The ice machine was found to have brown residue under the ice dispenser and on the ceiling of the ice storage bin. 4. A floor repair was unfinished, and the surface was not easily cleanable. These failures had the potential to expose 51 highly susceptible residents who received food from the kitchen to cause foodborne illness (illness caused by the ingestion of contaminated food or beverage) due to cross contamination (the transfer of harmful substances or disease-causing microorganisms to food). Findings: 1. An inspection of the kitchen was conducted with a Dietary Aide (DA 1), on November 29, 2022, at 8:03 AM. Inside the refrigerator, a metal container of thawing bacon was stored on top of a thawing bag of chicken breast, and a container of thawing raw beef was on the bottom shelf beside the chicken. The thawing pan of raw chicken breast was filled with raw chicken juices. During a subsequent interview with DA 1, on November 29, 2022, at 8:30 AM, DA 1 stated the raw beef and bacon should be stored above the raw chicken breast and not on the same shelf. During an interview with the Registered Dietitian (RD 1), on December 1, 2022, at 2:35 PM, the RD 1 stated the chicken should not be thawing on the same shelf as the beef. The RD 1 further stated the staff should be following the guidelines according to cooking temperature. During a review of FDA (Food and Drug Administration) Food Code 2017 3-401.11, indicated, Greater numbers and varieties of pathogens generally are found on poultry than on other raw animal foods. Therefore, a higher temperature, in combinations with the appropriate time is needed to cook these products. 2. During an observation, on November 30, 2022, at 9:12 AM, in the kitchen, DA 1 tested the dishwashing machine with a chlorine test strip (used to measure the concentration of chlorine in sanitizing solutions). The result from the test strip indicated there was no sanitizer detected or 0 parts per million (PPM- unit of measurement). Two additional tests were performed by DA 1 with the same results of no sanitizer detected. During an follow up with DA 1, on November 30, 2022, at 9:50 AM, she stated the PPM of chlorine should be 50-100 according to the manufacturer's guidelines. During a review of the facility's undated policies and procedure titled Dish Machine Temperature Recording, it indicated The dish machine will be routinely monitored during use. The concentration of the sanitary solution during the rinse cycle is 50 ppm for chlorine sanitizer. During a review of the FDA Food Code 2017 4-204.117, it indicated The presence of adequate detergents and sanitizers is necessary to effect clean and sanitized utensils and equipment. 3. During a concurrent observation and interview, on November 29, 2022, at 8:35 AM, with the Maintenance Supervisor (MS), in the kitchen, the ice machine was found to have brown residue under the ice dispenser and on the ceiling of the ice storage bin. The MS acknowledged the finding and stated the hard water stains were difficult to remove and he has to use a brush to scrub and remove it. During an interview, with the RD 1, on November 30, 2022, at 9:37 AM, the RD 1 stated the ice machine should be kept clean, and they may need to clean it more often to ensure it remains clean. During a review of the Federal FDA 2017 Food Code 4-204.17, it indicated The potential for mold and algae growth in this area is very likely due to the high moisture environment. Molds and algae that form is difficult to remove and present a risk of contamination to the ice stored in the bin. According to the CDC's (Center for Disease Control) Guidelines for Environmental Infection Control in Health Care Facilities, Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC), revised July 2019, https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf), microorganisms may be present in ice, ice-storage chests, and ice-making machines. The two main sources of microorganisms in ice are the potable water from which it is made and a transferal of organisms from hands. Ice from contaminated ice machines has been associated with .blood stream infections, pulmonary (having to do with the lungs) and gastrointestinal (having to do with the stomach and intestinal tract) illnesses. Recommendations for a regular program of maintenance and disinfection have been published. Some waterborne bacteria found in ice could potentially be a risk to immunocompromised patients if they consume ice or drink beverages with ice. 4. During an observation, on November 29, 2022, at 8:05 AM, in the kitchen, the floor near the sink drain was patched with a black substance. During an interview, the RD 1, on November 30, 2022, at 9:37 AM, the RD 1 stated they did some plumbing work and had to remove some of the tiles. She further stated the material used to patch the floor was not smooth and not easily cleanable. During a review of the FDA Food Code 2017 4-202.16 Nonfood-Contact Surfaces indicated, Hard-to-clean areas could result in the attraction and harborage of insects and rodents and allow the growth of foodborne pathogenic microorganisms.

Based on observation, interview, and record review, the facility failed to ensure the pharmacy recommendations identified from the Medication Regimen Review (MRR- thorough evaluation of a resident's medication regimen in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities) were followed up in accordance with federal regulations and facility policy, for two of five residents (Residents 3 and 26) reviewed for unnecessary medications when: 1. The pharmacy recommendation, from May 12, 2022, for Resident 3's use of Seroquel (medication to treat mood disorders), was not communicated to the physician. 2. The pharmacy recommendation, from May 12, 2022, for Resident 26's use of Abilify (medication for mood disorders), was not communicated to the physician. These failures had the potential to place Residents 3 and 26's at risk of experiencing adverse effects such as congestive heart failure (when the heart cannot pump blood adequately), infections, and even death. Findings: 1. During an observation, on November 29, 2022, at 10:20 AM, Resident 3 was in her room, lying down in bed, watching television. During a review of Resident 3's medical record, the Admission Record (contains demographic and medical information), indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included dementia (inability to remember, think or make decisions that interferes with doing everyday activities), psychosis (when people lose contact with reality) and depression (mood disorder that cause persistent feeling of sadness and loss of interest). A review of Resident 3's physician's orders, dated November 27, 2022, indicated Resident 3 had an order to receive Seroquel 50 mg [mg- milligrams unit of measurement], 1 tablet by mouth two times a day for Psychosis . During a telephone interview, with the Consultant Pharmacist (CP), on December 1, 2022, at 3:00 PM, the CP stated he reviewed Resident 3's medications in May 2022 and recommended to assess the risks versus the benefits of receiving Seroquel due to a Black Box Warning [serious life-threatening side effects or risks]. During a concurrent interview and record review, with the Social Services Director (SSD), on December 2, 2022, at 10:13 AM, the SSD reviewed a facility document regarding Resident 3's use of Seroquel titled Note To Attending Physician/Prescriber, dated May 12, 2022, which indicated, A review of the literature by the FDA [Food and Drug Administration] suggest an increased risk of death in elderly patients with dementia who receive atypical and traditional antipsychotics (medication used to treat symptoms of psychosis) . Please assess the risks versus benefits of therapy in this patient in order to keep the facility in compliance. The resident [Resident 3] has orders for Seroquel and has a medical history of dementia. The SSD stated the document has not been signed by a physician. During a concurrent interview and record review, with the Psychiatrist, on December 2, 2022, at 10:54 AM, the Psychiatrist reviewed a facility document regarding Resident 3's use of Seroquel titled Note To Attending Physician/Prescriber, dated May 12, 2022, and stated the facility did not send this document to him. 2. During an observation, on November 29, 2022, at 10:40 AM, in the activity room, Resident 26 was in her wheelchair, participating in activities. During a review of Resident 26's medical record, the Admission Record indicated Resident 26 was admitted to the facility on [DATE], with diagnoses which included epilepsy (convulsions), dementia, depression, Alzheimer's disease (a type of dementia that affects memory, language and thought) and psychosis. A review of Resident 26's physician's orders, dated August 1, 2022, indicated an order for Resident 26 to receive Abilify 20 mg 1 tablet by mouth in the morning for Psychosis . During a telephone interview, with the CP, on December 1, 2022, at 3:10 PM, the CP stated he reviewed Resident 26's medications in May 2022 and recommended to assess the risks versus the benefits of receiving Abilify due to a Black Box Warning. During a concurrent interview and record review, with the SSD, on December 2, 2022, at 10:15 AM, the SSD reviewed a facility's document regarding Resident 26's use of Abilify titled, Note To Attending Physician/Prescriber, dated May 12, 2022, which indicated, A review of the literature by the FDA [Food and Drug Administration] suggest an increased risk of death in elderly patients with dementia who receive atypical and traditional antipsychotics . Please assess the risks versus benefits of therapy in this patient in order to keep the facility in compliance. The resident [Resident 26] has orders for Abilify and has a medical history of dementia. The SSD stated the document had not been signed by a physician. During a concurrent interview and record review, with the Psychiatrist, on December 2, 2022, at 11:00 AM, the Psychiatrist a facility's document regarding Resident 26's use of Abilify titled, Note To Attending Physician/Prescriber, dated May 12, 2022, and stated the facility did not send this document to him. During a concurrent interview and record review on December 2, 2022, at 2:15 PM, with the Director of Nurses (DON), the DON reviewed the facility's policy and procedure (P&P) titled, Consultant Pharmacist Notes to Physicians, dated January 5, 2018, and stated the facility did not follow the policy. During a review of the facility's policy and procedure (P&P) titled, Consultant Pharmacist Notes to Physicians, dated January 5, 2018, which indicated, .The facility, under the Direction of the Director of Nursing, will establish an organized and reproducible system for conveyance of the consultant pharmacist's recommendations to the attending Physician .Procedures .After having received the consultant pharmacist's recommendations for the Attending Physicians, the director of nursing or designee will: .1. Send (mail or fax) the consultant pharmacist's Notes to the Physician's office .3. Once signed and dated by the Physician, these notes may be place in the chart as a Physician's Order. Even if a request is declined by the Physician, it will help the facility document that an irregularity or a potential problem has been addressed: all responses may kept on the Resident's chart.

Based on observation, interview, and record review, the facility failed to implement their infection control program to help prevent the spread of infections and other infectious diseases when four staff members did not complete the screening log (a log used to screen staff and visitors for COVID-19 [A highly infectious disease caused by the SARS-CoV-2 virus] symptoms and exposure upon entering the facility) on multiple occasions. This failure had the potential to place 54 residents residing within the facility to be at risk of exposure to COVID-19 virus. Findings: During a concurrent interview and record review, on December 2, 2022, at 11:50 AM, with the Infection Preventionist Nurse (IPN), the IPN reviewed a facility document titled Daily Nursing Staffing, sign-In Log, from November 12, 2022, to November 30, 2022, which indicated the following: a. On November 12, 2022, Certified Nursing Assistant (CNA 1) signed on the night shift at 11:00 PM. b. On November 13, 2022, Licensed Vocational Nurse (LVN 2) and Certified Nursing Assistant (CNA 2) signed on the night shift, at 11:00 PM. c. On November 19, 2022, Licensed Vocational Nurse (LVN 2) and Certified Nursing Assistant (CNA 2) signed on the night shift, at 11:00 PM. d. On November 20, 2022, Licensed Vocational Nurse (LVN 2) and Certified Nursing Assistant (CNA 3) signed on the night shift, at 11:00 PM. The IPN verified the four staff members worked on those days from 11:00 PM to 7:00 AM. During further interview and record review, with the IPN, on December 2, 2022, at 12:00 PM, the IPN reviewed a facility document titled, Daily screening log of Employees, from November 12, 2022, to November 30, 2022, which indicated the following: a. On November 12, 2022, at 11:00 PM, CNA 1 was not screened for COVID-19 symptoms before entering the facility. b. On November 13, 2022, at 11:00 PM, LVN 2 and CNA 2 were not screened for COVID-19 before entering the facility. c. On November 19, 2022, at 11:00 PM, LVN 2 and CNA 2 were not screened for COVID-19 before entering the facility. d. On November 20, 2022, at 11:00 PM, LVN 2 and CNA 3 were not screened for COVID-19 before entering the facility. The IPN stated all staff members were expected to be screened for signs and symptoms of COVID-19, and to answer the screening log questions accurately before entering the facility. During a concurrent interview and record review, with the IPN, on December 2, 2022, at 12:12 PM, the IPN reviewed the facility's policy and procedure (P&P) titled Infection Prevention & Control Manual, revised October 11, 2022, which indicated, Practice Standards .Entrance Screening .1. Active Screening of all HCP [Healthcare Personnel] entering the Facility (such as employees, medically necessary personnel, contracted staff/vendors, and volunteers) will be done upon entry to the facility . The IPN stated that facility did not follow the policy.

Based on interview and record review, the facility failed to ensure a copy of a completed Physician Orders for Life-Sustaining Treatment (POLST-voluntary form used statewide as a physician order that converts a resident's wishes regarding life-sustaining treatment and resuscitation into physician orders.) was filed in the medical record of one of six residents (Resident 209) reviewed for advance directive (written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated), in accordance with the facility procedure. This failure has the potential to place Resident 209 at risk of unmet care needs in the event of an emergency requiring lifesaving interventions due to the POLST not being accessible. Findings: During a review of Resident 209's Admission Record (contains demographic and medical information), indicated Resident 209 was admitted to facility on November 16, 2022, with diagnoses of urinary tract infection (UTI- infection caused by bacteria in the bladder), and encephalopathy (damage or disease that affects the brain). During a concurrent interview and record review, with a Licensed Vocational Nurse (LVN 3), on December 2, 2022, at 1:45 PM, LVN 3 reviewed Resident 209's medical record and stated Resident 209's POLST was not on file. During a concurrent interview and record review, with the Medical Records Director (MRD), on December 2, 2022, at 1:30 PM, the MRD reviewed Resident 209's medical record and stated Resident 209's POLST was not on file. During a review of the facility's policy and procedure titled Physician's Orders for Life-Sustaining Treatment (POLST), dated June 3, 2020, indicated .The facility will make a copy of the completed POLST from . File the copy in the Advance Directive or legal section of the medical record .

Based on observation, interview, and record review, the facility failed to develop and utilize a planned vegetarian menu for one of 51 residents(Resident 45). This failure has the potential to adversely affect Resident 45's nutritional status. Findings: During a review of Resident 45 clinical record, the Admission Record (contains demographic and medical information), the Admission Record indicated Resident 45 was admitted to the facility on [DATE], with diagnoses of hypertension (high blood pressure), dementia (inability to remember, think, or make decisions that interferes with everyday activity), and weakness. During a review of Resident 45's physician order, dated July 28, 2022, indicated Resident 45 had a diet order of No Added Salt Regular texture, Vegetarian diet. During an observation, on November 29, 2022, at 11:45 AM, in the kitchen, a Cook (Cook 1) was plating food for the residents. During follow up observation and concurrent interview, on November 30, 2022, at 11:59 AM, in the kitchen, Cook 1 was plating food for the residents. Cook 1 served Resident 45 a quesadilla for lunch. Cook 1 stated she prepared Resident 45 a cheese quesadilla. During an interview, with Cook 2, on November 30, 2022, at 3:07 PM, in the kitchen, Cook 2 stated they do not use a planned vegetarian menu. She stated she will just remove the meat from the meal for residents on vegetarian diet. She further stated her dinner plan was to make the Resident 45 an enchilada with cheese. During an interview with the Registered Dietitian (RD 1), on December 1, 2022, at 2:33 PM, in the kitchen, the RD 1 stated they do not have a planned vegetarian menu. The RD 1 further stated they just go based on the resident's preferences then modify the current menu. During a review of the facility's policy and procedure titled, Operation Manual-Dietary Menus Policy Number DS-05, dated April 1, 2014, it indicated, 1. The Dietary Manager will collaborate with the Dietitian to develop menus at least a week in advance. 2. Food served should adhere to the written menu.

Based on observation, interview, and record review, the facility failed to ensure secure storage of medications when one of three medication carts (Treatment Cart) was found to be unlocked while unattended by a licensed nurse. This failure had the potential for medications to be accessed and dispersed by an unauthorized person, in a vulnerable population of 54 residents. Findings: During a concurrent observation and interview, on December 1, 2022, at 5:18 AM, with a Licensed Vocational Nurse (LVN 1), one medication cart (a cart used by licensed nurses to transport medication to resident rooms), was located outside of room [ROOM NUMBER]. It was unlocked while unattended by a licensed nurse. LVN 1 stated it was a treatment cart (a cart used by licensed nurses to transport and store medical treatments and supplies). During further observation and interview, with LVN 1, on December 1, 2022, at 5:22 AM, LVN 1 opened the drawers of the medication cart and acknowledged the cart was left unlocked. LVN 1 counted five drawers in the medication cart containing topical medications (ointments) for nine residents. LVN 1 stated the cart must always be kept locked when unattended. During an interview, with the Director of Nursing (DON), on December 1, 2022, at 2:20 PM, the DON stated medication carts were expected to be locked when left unattended to prevent unauthorized access to the medications. During a concurrent interview and record review, with the DON, on December 1, 2022, at 2:23 PM, the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated January 23, 2021, was reviewed. The P&P indicated, .Procedures .B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access . The DON stated the facility did not follow their policy and procedure.

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours, seven days a week. This failure had the potential to prevent 54 residents from reaching their highest practicable level of well-being when oversite by an RN was not utilized by the facility. Findings: A review of the facility's staffing schedules for the months of October 2022 through November 2022 was conducted on December 1, 2022 at 9:15 AM. It indicated there were no RNs on duty for eight consecutive hours during the following dates: 1. October 6, 2022 2. October 23, 2022 3. October 31, 2022 4. November 25, 2022 A review of the facility's timekeeping punches for the Registered Nurses was conducted on December 1, 2022, at 3:00 PM. It indicated a RN did not work for eight consecutive hours (on duty) on the following dates: 1. October 22, 2022 2. October 27, 2022 3. November 18, 2022 4. November 20, 2022 5. November 21, 2022 During an interview and concurrent record review, on December 2, 2022, at 2:00 PM, the Director of Nursing (DON) and Administrator reviewed the staffing sheets and timekeeping punches. The Administrator stated the facility has a full-time DON, but does not always staff a RN for eight consecutive hours a day, seven days a week. The facility was requested to provide documented evidence to prove the DON worked in the facility on the dates reviewed from staffing schedules and timekeeping punches. The facility was unable to provide documentation. During a follow up interview with the DON, on December 2, 2022 at 2:37 PM, the DON stated he couldn't find proof that he worked on the days reviewed, and acknowledged that there would be no way to prove that he did work those days.

Based on observation, interview, and record review, the facility failed to ensure the advance directives (written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated), were completed in accordance with the facility policy for one of six residents (Resident 27) reviewed for advance directives. This failure had the potential to result in a delay of treatment for Resident 27 related to advance directives, or for life sustaining measures to be rendered against what the resident wanted. Findings: During an observation, on November 29, 2022, at 9:06 AM, Resident 27 was in her room, lying down in bed. During a review of Resident 27's medical record, the Admission Record (contains demographic and medical information), indicated Resident 27 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (kidneys no longer work), dependence on renal dialysis (process that removes wastes in place of your kidneys), diabetes mellitus (when pancreas does not produce enough insulin), and heart failure (heart is unable to pump blood around the body properly). During a concurrent interview and record review, with the Social Services Director (SSD), on December 2, 2022, at 8:25 AM, the SSD reviewed Resident 27's California Advance Health Care Directive (CAHCD), dated May 14, 2022 (approximately six months ago), which indicated it was completed by Resident 27 with two witness signatures. Further review indicated it was missing the Ombudsman's (resolve disputes from a neutral, independent viewpoint) signature. During further interview and record review with the SSD, the SSD verified the CAHCD was not signed by the Ombudsman and should have been. The SSD was not able to find documented evidence that the Ombudsman was informed. The SSD stated, I did not inform the Ombudsman because I did not know about it and I missed it. During a concurrent interview and record review, with the Director of Nursing (DON) and the SSD, on December 2, 2022, at 8:35 AM, the facility's policy and procedure (P&P) titled, Advance Directives Operation Manual- Social Services, dated December 1, 2013, indicated, .II. If the resident chooses to execute an Advance Directive, the Director of Social Services or his or her designees will contact the Ombudsman so that the Ombudsman can witness the resident signing the Advance Directive . The DON and the SSD stated the facility did not follow the policy.

Based on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.- unit of measurement) of livable space per resident for nine of 19 resident rooms (rooms 26, 27, 28, 29, 30, 31, 32, 33, and 34). This failure had the potential to affect the resident's health and safety and prevent the residents from maintaining their highest level of well-being by limiting the movements of these residents in their rooms. Findings: During an entrance conference interview, with the Administrator, on November 29, 2022, at 8:25 AM, the Administrator stated nine of 19 resident rooms had less than the required square footage (80 sq. ft. of livable space per resident). During an environmental tour, with the Maintenance Supervisor (MS), on November 30, 2022, at 12: 20 PM, nine of the 19 resident rooms were observed to be less than 80 sq. ft. per resident. The residents' rooms and their measurements of livable space were noted as follows: 1. room [ROOM NUMBER] (3 beds) measured: 232.1 sq ft (77 sq. ft per resident) 2. room [ROOM NUMBER] (3 beds) measured: 232.1 sq ft (77 sq. ft per resident) 3. room [ROOM NUMBER] (3 beds) measured: 232.1 sq ft (77 sq. ft per resident) 4. room [ROOM NUMBER] (3 beds) measured: 232.1 sq ft (77 sq. ft per resident) 5. room [ROOM NUMBER] (3 beds) measured: 232.1 sq ft (77 sq. ft per resident) 6. room [ROOM NUMBER] (3 beds) measured: 232.1 sq ft (77 sq. ft per resident) 7. room [ROOM NUMBER] (3 beds) measured: 221.5 sq ft (74 sq. ft. per resident) 8. room [ROOM NUMBER] (3 beds) measured: 232.1 sq ft (77 sq. ft per resident) 9. room [ROOM NUMBER] (3 beds) measured: 232.1 sq ft (77 sq. ft per resident) These rooms were not crowded and did not impose any safety hazards. There were no complaints of space or room issues from the residents occupying these rooms. The survey team recommends the approval of the room waiver request for the rooms listed in this deficiency.

Based on interview and record review, the facility failed to maintain medical records that were readily accessible and systematically organized for one of three sampled residents (Resident 1) when Resident 1's complete clinical record (skin assessments and treatments) were not readily available for the state agency to review in a timely manner. This failure had the potential for inconsistent care coordination, unmet care needs, and/ or delay in treatment Findings: During a review of Resident 1's clinical record titled, Admission Record (a document that contains resident demographics), indicated, Resident 1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's clinical record titled, Physician Telephone Order, dated August 17, 2021, at 5:00 PM, by the Skilled Nursing Facility Physician, indicated, Resident 1 had multiple upper and lower body self-inflicted scratches. During a review of Resident 1's clinical record titled, Nursing Summary, dated August 18, 2021, at 1:09 PM, by Licensed Vocational Nurse (LVN 1) , indicated, Resident 1 had unspecified [CONDITION(S)] (a general term that describes skin irritation). During a review of Resident 1's clinical record titled, SBAR [Situation, Background, Assessment Response], dated, August 27, 2021, at 6:24 PM, indicated, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The fall occurred on August 26, 2021, at approximately 6:20 PM. During a review of Resident 1's clinical record titled, [Hospital Name] Emergency Department (ED) Notes, dated, August 27, 2021, at 8:00 PM, by [Hospital Name] Physician, indicated, Resident 1 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's History of Present Illness indicated that Resident 1's daughter had noted that Resident 1 had [CONDITION(S)] (abnormal skin) for the past couple of weeks. Resident 1 had superficial bite-like marks to Resident 1's right arm. During a review of Resident 1's clinical record titled, [Hospital Name], Emergency Department Signature Page, dated August 28, 2021, at 1:55 AM, indicated, Resident 1 had a skin rash that could be consistent with bedbugs. A recommendation was made for further investigation wherever Resident 1 resides. During a review of Resident 1's clinical record titled, Progress Notes, dated August 28, 2021, at 1:04 PM, by LVN 1, indicated, Resident 1 was discharged from Facility 1, per Resident 1 and his/her family request. During a phone interview with the Director of Nursing (DON), on September 12, 2022, at 3:34 PM, stated, the DON was not sure what Facility 1's P&P was regarding how long a resident's medical records needed to be accessible. The DON stated, the DON had provided all the nursing documentation regarding Resident 1's skin assessment and treatment and was unable to find any documentation from August 19, 2021- August 26, 2021. During a concurrent phone interview and record review, on September 15, 2022, at 10:08 AM, with LVN 2, Resident 1's clinical record (skin assessments and treatments) was reviewed. LVN 2 stated, the process was to daily document the treatment that was provided to Resident 1 for any skin issues. LVN 2 stated, Facility 1 changed their charting systems in the year 2022. LVN 2 accessed the old charting system but was unable to find any wound treatment notes for Resident 1, for the date ranges from August 19, 2021- August 26, 2021. During a concurrent interview and record review, on September 15, 2022, at 1:18 PM, with the DON, the P&P titled, Record Retention & Storage Medical Records Manual-General Policy No.-MR-15, dated January 1, 2012, was reviewed. The Record Retention & Storage Medical Records Manual-General Policy No.-MR-15, indicated, The Facility maintains and retains all records in accordance with Federal and State laws and regulations. See Policy No. - MR-15-Form B- Record Retention Guidelines . The DON acknowledged, Resident 1's entire record had not been made readily available, as the state agency's investigation started eight days ago. The DON acknowledged that the records were not organized in a manner to make them easily located. During a follow up concurrent interview and record review on September 15, 2022, at 1:20 PM, with the DON the P&P titled, Record Retention Guidelines Medical Records Manual-General Policy No.- MR-15 Form B, no date, was reviewed. The Record Retention Guidelines Medical Records Manual-General Policy No.- MR-15 Form B, indicated, . Required Retention- Skilled Nursing Facilities (SNFs) are required to retain medical records for at least the following periods: Adults and emancipated minors - 7 years . The DON acknowledged, Resident 1's records were not organized in a way to make them easily accessible, and that Resident 1's skin assessments and treatments were missing for the dates of August 19, 2021, through August 26, 2021. During a phone interview with the DON on September 22, 2022, at 2:07 PM, stated, even with the additional time that was allotted to the facility, the DON was unable to locate the clinical records for Resident 1's that contained the skin assessments and treatments for the time period from August 19, 2021, through August 26, 2021.

Based on interview and record review, the facility failed to notify the Responsible Person (RP; responsible for another person's medical and financial decisions) for one of three residents (Resident 1) of a change of condition when Moisture-associated skin damage (MASD, caused by prolonged exposure to various sources of moisture, including urine or stool, and perspiration) was found on the buttock. This failure resulted in Resident 1's Responsible Person being uninformed and unaware of Resident 1's Moisture-associated damage to the skin. Findings: An abbreviated survey was conducted on March 16, 2022, at 1:03 PM to investigate a complaint related to quality of care. During a review of Resident 1's clinical record, the face sheet indicated an admitted [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .) During an interview and concurrent record review with MDS Nurse (Material Data Set – set of assessments, Licensed Vocational Nurse, LVN 1), on March 16, 2022, at 2:11 PM, LVN 1 stated, Resident 1 did have memory problems. Her answers weren ' t clear. The initial assessment, Section C0700 said that she had Memory problems. With anything that was done with resident 1, the RP would have to be notified. During a review of the clinical record for Resident 1, the Progress Note dated February 25, 2022, indicated Skin Issue: MASD wound noted on right lateral buttock. The note indicated the RP was not notified of the MASD. During a review of the clinical record for Resident 1, the Physicians Orders dated February 26, 2022, at 7:00 AM indicated MASD: Bilateral Buttocks – Cleanse with normal saline. Pat dry. Apply [MEDICATION(S)] cream, cover with dry dressing daily for 21 days. During an interview with Treatment Nurse (Licensed Vocational Nurse, LVN 2), on March 16, 2022, at 2:32 PM, LVN 2 stated, It looks like the Dr was made of aware of the MASD to both buttocks. I see treatment orders, but I don ' t see the assessment. There is no change of condition documented for the MASD to the buttock. There is no documentation in the chart that stated the RP was informed about the MASD. The facility did not provide documentation that stated Resident 1 ' s responsible person was informed of the MASD. During an interview with Director of Nursing (DON) on March 16, 2022, at 5:14 PM, DON stated, We did not notify the RP of the change of condition. The RP is the one we would contact for changes. The RP should have been notified. The DON reviewed Resident 1's clinical record and was unable to provide documentation that the RP was notified of Resident 1 ' s MASD to her buttocks. The facility policy and procedure titled, Change of Condition Notification dated April 1, 2015, indicated, Purpose: To ensure residents, family, legal representatives and physicians are informed of changes in the resident ' s condition in a timely manner. Policy: I. The facility will promptly inform the resident, consult with the resident ' s Attending Physician, and notify the resident ' s legal representative or an interested family member, if known, when the resident endures a significant change in their condition caused by, but not limited to: A. An accident; B. A significant change in the resident ' s physical, mental or psychosocial status; and/or C. A significant change in treatment. 2. Change of Condition related to Attending Physician notification is defined as when the Attending Physician notification is defined as when the Attending Physician must be notified when any sudden and marked adverse change in the resident ' s condition which is manifested by signs and symptoms different than usual denote a new problem, complication or permanent change in status and requires medical assessment, coordination and consultation with the Attending Physician and a change in treatment plan.

Based on interview and record review, the facility failed to notify the physician of a change in condition after a fall for one of three sampled residents (Resident A) when: 1.A change in Resident A's neurological status (the ability of the peripheral and central nervous system to receive, process, and respond to internal and external stimuli) post-fall was not reported to the physician. 2. A requirement for oxygen for Resident A was not reported to the physician in time. These failures resulted in Resident A not receiving further care related to the change in status and Resident A's condition continuing to deteriorate until she died 10 days later. Findings: An unannounced abbreviated survey was conducted on [DATE], at 10:34 AM, to investigate a complaint on accidents. Resident A was not at the facility during the onsite. 1. During a record review of Resident A's Face Sheet (a record that provides the demographic data of the resident) indicated that Resident A was a [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A review of Resident A's SBAR/C(NAME) Assessment (Situation Background Assessment Request /Change of Condition-a record that provides the information of a change of condition) dated [DATE] was conducted. Resident was non-verbal and unable to make needs known .noted purplish discoloration on left temporal (the sides of the skull behind the eye) redness on left shoulder and left hip .Resident is transferred to ER (emergency room ) for further evaluation. A review of Resident A's general acute care hospital (GACH) radiology (x-ray) reports dated [DATE], was conducted. The report indicated Resident A had a CT (computerized tomography scan combines a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images, or slices, of the bones, blood vessels and soft tissues inside your body) scan of the head. In addition, x-rays of her left shoulder, left hip and her head were done. The x-ray report of the left hip, indicated that resident sustained [REDACTED]. A review of Resident A's CT scan of the head report dated [DATE], indicated Resident A had a Large scalp hematoma (a solid swelling of clotted blood within the tissues) on the left. A review of Resident A's discharge instructions from the GACH dated [DATE], indicated .it is important to observe the patient (resident) for any problems developed from the head trauma .Please return to the ER immediately if patient develops any change in mentation (thinking or any work of the mind) or for any medical concerns. This document was reviewed with the Director of Nurses (DON) on February 23, 2018 at 9:56 AM. A review of Resident A's Neurological Flowsheet (a document which tracks data related to changes in pupil size, blood pressure, pulse, respirations, temperature, speech, level of consciousness and movement in extremities) dated [DATE] at 4 PM through [DATE] at 10 PM, was conducted. The data indicated that Resident A had a change in her bilateral (both) pupil reactions starting on [DATE], at 10 AM (51 hours post-fall). The reaction changed from brisk (the normal pupil constricts briskly) reaction to sluggish (very slow reaction to light. A sluggish pupil may be an early focal sign (impairments of nerve, spinal cord, or brain function that affects a specific region of the body, e.g. weakness in the left arm, the right leg, or numbness) of an expanding intracranial (within the skull) lesion and increased intracranial pressure). Further review of Residents A's Neurological Flowsheet indicated under the Instructions The Licensed Nurse will complete the neurological flow sheet for any un-witnessed fall, or witnessed fall with suspected or known head injury for seventy- two (72) hours following the fall. The Attending Physician will be informed if there is a deviation from the resident's normal status for further instruction. During an interview with DON on February 23, 2018, at 9:56 AM, she confirmed that the facility was unable to provide any documented evidence to show that Resident A's change in neurological condition was reported to the attending physician. During a telephone interview with Licensed Vocational Nurse (LVN 1) on [DATE], at 12:34 PM, she stated that she was required to notify the physician if there was any change in Resident A's neurological status. She further stated that she reviewed Resident A's neurological assessment sheet and that it was a documentation error, however, the Neurological Assessment sheet indicated that other licensed nurses on various shifts had documented (who were not employed at the facility during the investigation) that Residents A's pupils reaction remained sluggish, confirming the change in condition. There was no documented evidence that any of the licensed nurses reported this change of condition to Resident A's physician. A review of Resident A's ADL Flowsheet (ADL-activity of daily living) for the month of [DATE], indicated that Resident A deteriorated in her meal intake to consuming less than 50 % of her meals on average from [DATE] (the day of fall), compared to her pre-fall intake average of 90 %. It further indicated that from [DATE] through [DATE](the day of her death) her intake was reduced to one meal with 10% consumption. A record review of the Nursing Progress Notes dated [DATE] (7 days after the reduced oral intake), reflected Resident A's attending physician was notified of the reduced oral intake for which he ordered a swallow evaluation. During an interview with the DON on February 23, 2018, at 1:35 PM, she stated that she reviewed Resident A's clinical record and there is no documented evidence of a swallow evaluation being done on Resident A. During an interview with a Certified Nurse Assistant 1 (CNA 1) on February 6, 2018, at 12:15 PM, she stated that she took care of Resident 1 after the resident returned from the GACH (post-fall). She further stated that Resident 1 was not eating and not responding the way she used to be prior to the fall. CNA 1 stated the she reported Resident A's decline in eating status to the assigned Licensed Vocational Nurse (LVN). There was no nursing documentation between [DATE] at 10:25 PM and [DATE]:08 AM, when the nursing progress note indicated, Resident body picked up by (Name of the morgue) Mortuary at approximately 8:35 AM . There was no documented evidence of the resident's status or the circumstances under which Resident A was found to have expired. During an interview with LVN 2 on February 26, 2018, at 8:55 AM, she stated that she took care of Resident A on the night shift (11 PM to 7 AM) when she (Resident A) died ([DATE]). LVN 2 further stated that Resident A was dependent for all care and was on supplemental oxygen continuously at the time of her death. LVN 2 stated that Resident A's family was aware that the resident was dying. When inquired about the documentation she stated that she could not recall whether she documented all of this information or not. A review of the nursing progress notes for July11, 2017 through [DATE] was conducted. There was no documented evidence that the family had been informed that Resident A was actively dying. The last documented notification of the family was dated [DATE] at 4:13 PM, when they were notified that Resident A had refused both her breakfast, lunch and was being monitored. A review of the facility policy and procedure titled, Fall Management Program, undated, indicated that Post-fall response .B. The Licensed Nurse will complete the neurological flowsheet .c. The Attending Physician will be informed if there is a deviation from the resident's normal status for further instruction. A review of the facility policy and procedure titled Change of Condition Notification undated, indicated The facility will promptly inform the resident, consult with the resident's attending physician, and notify the resident's legal representative or an interested family member, if known, when the resident endures a significant change in their condition caused by, but not limited to: . B. A significant change in the resident's physical, mental or psychosocial status . This policy was reviewed with DON on February 23, 2018 at 9:56 AM, and she stated that the staff were required to follow this policy. 2. A review of Resident A's Nursing Progress Notes dated [DATE], at 9:44 PM, indicated that Resident A was provided with 2 liters per minute (liter- a unit of measurement for oxygen administration) oxygen via nasal cannula (a device used to deliver supplemental oxygen). Resident A's clinical notes did not indicate the indication for supplemental oxygen and the condition of Resident A at that time. There was no documented evidence that the physician had been notified of a change in Resident A's respiratory status. (The staff who administered the supplemental oxygen was no longer an employee at the facility during onsite visit) During an interview with the LVN 1, on [DATE], at 1:15 PM, she reviewed the chart and stated that she could not find a physician's order for oxygen administration in Resident A's clinical record. LVN 1 stated that staff were allowed to initiate supplemental oxygen on a resident in an emergency but were required to obtain the physician's order as early as possible. She further stated that obtaining the physician's order on the next day is not an acceptable practice at the facility. A review of Resident A's physician order dated [DATE], indicated that Resident A was to have oxygen administered at 2 liter per minute per nasal cannula to keep her oxygen saturation levels above 92% (normal pulse oximeter readings usually range from 95 to 100 percent). During an interview with a Registered Nurse (RN 1) on [DATE], at 1:30 PM, she stated that during an emergency staff were allowed to administer oxygen to the residents without a physician order but were required to get an order as early as possible. She further stated that obtaining the order on the next day is not an acceptable practice. The facility was unable to provide any documentation to explain the need to administer oxygen to Resident A, or Resident A's response or lack of response to the oxygen administration. A review of the facility policy and procedure titled Oxygen Therapy undated indicated that A. Administer oxygen per physician orders.

Based on interview, and record review, the facility failed to implement safeguards to prevent accidents for one of three sampled residents (Resident A), when: 1. A Certified Nurse Assistant (CNA 1) who was not familiar with Resident A's inability to assist during repositioning, turned her to the side. This resulted in Resident A falling off of the bed onto the floor requiring an acute care hospitalization and surgical intervention for a fracture of the right hip and femur (thigh). 2. Two Physical Therapists (PT 1 and PT 2) providing bedside physical therapy, assisted Resident A to a sitting position at the edge of the bed, but failed to ensure the bed was locked. This resulted in Resident A sliding off of the bed onto the floor and sustaining a skin tear and hematoma (a solid swelling of clotted blood within the tissues) of the left leg stump (the pedicle remaining after removal of part of the limb). Findings: During the onsite visit Resident A was not at the facility. 1. A review of Resident A's face sheet (a record that provides the demographic data of the resident), indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the facility's incident log indicated that Resident A had a fall with a fracture on October 15, 2017, and a second fall with an injury on October 31, 2017. A review of Resident A's SBAR/C(NAME) Assessment (Situation, Background, Assessment and Request/Change of Condition) sheet dated October 15, 2017, indicated .9:35 PM. Resident being changed by staff. While turned towards the ® (right) side resident rolled off bed onto floor. 9:45 PM Loud noise heard. Staff/charge nurse ran to room with resident laying on floor in supine (face up) position. At this time assess patient with ® leg turned towards the right lower leg, blood at site of old wound . Resident A was transferred to the general acute care hospital (GACH 1) for further care and evaluation. A review of Resident A's SBAR/C(NAME) dated October 15, 2017, indicated under the section titled Things that make the condition or symptom worse are: Assisted x 1, SR (side rails) not up x 2. On the same form under the section titled Things that make the condition or symptom better are : x 2 assistance (two person assistance). A review of Resident A's MDS (an assessment tool) dated October 10, 2017, reflected under section G (functional status) that she scored a 3/2 (extensive assistance/one person assist) for bed mobility, which indicated she was unable to turn over independently. Under the section G 0400 (functional limitation in range of motion), was listed a score of 1 for the lower extremity hip, knee, ankle, foot) which indicated impairment on one side. A review of Resident A's Interdisciplinary Team (IDT- clinical department heads meeting to discuss the incident) notes dated October 17, 2017, indicated .CNA (CNA 1) stated she explained procedure to resident and when CNA (CNA 1) was ready to reposition resident facing towards the window, resident also swung right leg over towards window quickly, causing resident to roll off bed and fall to the floor. CNA (CNA 1) immediately called for assistance. Charge nurse responded by doing quick assessment due to staff noting bleeding from resident's right lower extremity with exposed bone . A review of the history and physical reports from the general acute care hospital (GACH 1), dated October 15, 2017, indicated that Resident A had an x-ray of the right hip done, and it revealed a comminuted (a break in the bone into more than two fragments) intertrochanteric (upper thigh near hip) fracture of the right hip. A review of Resident A's GACH 1 reports titled Consultation Notes dated October 18, 2017, indicated that Resident A underwent an open reduction and internal fixation of right femur (a surgical procedure to the upper thigh) and post operatively Resident A suffered with complications which included hypotension (low blood pressure), she required a blood transfusion and had an acute kidney injury. During a telephone interview with CNA 1, on December 5, 2017, at 1:15 PM, she stated while she was changing the Resident A's linens alone, Resident A turned to the left side very fast and fell over the two one quarter side rails. During an interview with CNA 2 on November 2, 2017, at 12:38 PM, she stated that Resident A was not able to help the staff with turning during daily care and always needed two staff to do the position change. An interview with the Director of Nurses (DON) and Administrator was conducted on November 2, 2017 at 12:58 PM. The Administrator stated that a new Certified Nurse Assistant (CNA 1) was changing Resident A's position alone, during Resident A's fall. She further stated that the bed side rails were not up during that time. During an interview with a Licensed Vocational Nurse (LVN 1) on November 2, 2017, at 1:55 PM, she stated that Resident A was heavy in stature (188 pounds) and was not able to help with daily care and position change by grabbing and holding on to the side rails. During an interview with Resident A's family member on November 2, 2017, at 3:02 PM, she stated her mother's (Resident A) one leg was a BKA and the other leg had no strength for her to use to turn by herself. A record of Resident A's fall risk assessment dated [DATE] (four days prior to first fall), indicated Resident A's level mobility was 'immobile and Resident A was identified as low risk for falls. A record review of Resident A's post fall risk assessment (after the first fall) dated October 17, 2017, indicated next to Did the resident present to facility with fall, or has he/she fallen since admission (recent history of fall) was documented as 'No (even though Resident A had a fall two days prior). It further indicated that Resident A was at low risk for falls even though she had a prior fall. 2. A review of Resident A's SBAR/C(NAME) assessment report dated, October 31, 2017, under section Nursing Notes indicated Resident was assisted by two therapists in sitting at the edge of the bed for the treatment. Resident (A) started to slide down from the edge of the bed and both therapists adjusted her position and lay her in supine position on the floor .Resident (A) presented with an injury at anterior (nearer the front) left stump 0.5 x 1.7 centimeter (cm-a unit of measurement) with scant bleeding and lateral left stump hematoma 4.4 x 4.2 cm. Resident A was transferred out to the GACH 1 for further evaluation. A review of Resident A's physician orders [REDACTED]. During a review of Resident A's MDS (a resident assessment tool) Section G 0400 (a section that demonstrated the functional limitation in range of motion) dated October 27, 2017, indicated that Resident A had decreased her function and was scored as a 2 which indicated she had impairment of both lower extremities. During an interview with PT 1, on November 2, 2017, at 1:38 PM, he stated that he along with PT 2 assisted Resident A to sit at the edge of the bed. The PT 1 stated, Resident A had no gait belt (a device used by caregivers to transfer care receivers with mobility issues, from one position to another, from one location to another, or while assisting ambulating patients, who have problems with balance) on her during fall, which made them unable to hold the Resident properly while she was sliding down from bed. During a telephone interview with PT 2 on December 11, 2017, at 2:48 PM, her statement was in contradiction to PT 1's account of the incident. PT 2 stated, Resident A's fall was an unexpected fall and she was able to hold the resident by her gait belt. She further stated that she saw blood on Resident A's leg, but she did not know how it happened. During an interview with PT 2 on December 28, 2017, at 10:41 AM, she stated the bed was not in the locked position at the time of Resident A's fall. When inquired about the brakes on the bed being checked to ensure they were in the locked position prior to starting the therapy she stated, I checked it. It wasn't moving without lock. A review of the Interdisciplinary Team Conference Notes dated November 1, 2017, indicated, Resident sent to the hospital for further evaluation as safety precaution. Interventions upon return will be max assist x 2 (two persons) at all times, no edge of bed activity for therapy. Therapy to be in bed or wheelchair only. ID (identify) brakes are in lock(ed) position with color code to be done by (name of maintenance staff member).

Based on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Residents 1, 2 and 3), were free from medication errors when a total of 19 doses of intravenous (given in a vein) antibiotics were not administered as ordered between June 24, 2017 through June 29, 2017, due to the lack of available registered nurses (RNs). This failure resulted in antibiotic therapy not being administered as prescribed by the physician, which placed the residents at risk for their infectious process to progress which could lead [MEDICAL CONDITION] (bacterial infection in the blood) and possible death. Findings: 1. During a review of the clinical record for Resident 1, the face sheet (a record providing the demographic data of the resident), indicated that Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During the review of physician orders for Resident 1, dated June 22, 2017, the orders indicated that Resident 1 was to receive [MEDICATION NAME] (medication to treat an infection) 1.5 gram (unit of measurement) intravenously every 12 hours beginning on June 22, 2017 through July 7, 2017. During an interview with the Administrator on June 29, 2017, at 3:47 PM, she reviewed Resident 1's Intravenous Therapy Medication Record (ITMR) for the month of June 2017, which indicated, Resident 1 did not receive the [MEDICATION NAME] 1.5 gram intravenously as ordered by physician on following dates: June 24, 2017 at 8 PM, June 25, 2017 at 8 PM, June 27, 2017 at 8 AM, June 28, 2017 at 8 AM, June 28, 2017 at 8 PM and June 29, 2017 at 8 AM. Further review of Resident 1's physician's orders dated June 23, 2017, indicated that Resident 1 was to receive IV [MEDICATION NAME] (a medicine to treat bacterial infection) 3.375 grams every 12 hours through June 28, 2017. An order dated June 29, 2017, indicated that this medication was to continue through July 1, 2017. During an interview with the Administrator on June 29, 2017, at 3:47 PM, she reviewed Resident 1's ITMR for the month of June 2017, which indicated, Resident 1 did not receive IV [MEDICATION NAME] 3.375 gms. as ordered by the physician for the following dates: June 24, 2017 at 7 PM, June 25, 2017 at 7 PM, June 27, 2017 at 7 AM, June 28, 2017 at 7 AM, June 28, 2017 at 7 PM and June 29, 2017 at 7 AM. During an interview with the Administrator (ADM) on June 29, 2017 at 3:47 PM, she stated that she was not aware of the absence of RNs on the shifts in which the IV antibiotics were scheduled for Resident 1. The Administrator stated since there was no Director of Nurses (DON) employed at the facility at present that she was responsible for adequate staffing. 2. During a review of the clinical record for Resident 2, the face sheet (a record provides the demographic data of the resident), indicated that Resident 2 was initially admitted to the facility on [DATE], with a recent readmission from a General Acute Care Hospital (GACH) on June 27, 2017, after an acute hospitalization for pneumonia (infection of the lungs). A review of Resident 2's physician orders dated June 27, 2017, indicated that Resident 2 was to receive [MEDICATION NAME] (a medicine to treat infection) intravenously (IV, into the vein) 300 mg every eight (8) hours for seven (7) days. A review of Resident 2's ITMR dated June 29, 2017, indicated that Resident 2 received [MEDICATION NAME] 300 mg IV on June 29, 2017 at 10:20 AM instead of 7 AM, as prescribed. During a concurrent interview with RN 2 on June 29, 2017, at 9:58 AM, she stated she worked as a contract nurse and was called in to work at 9 AM on June 29, 2017. 3. During a review of the clinical record for Resident 3, the face sheet (a record provides the demographic data of the resident), indicated that Resident 3 was admitted to the facility initially on April 14, 2017, and was readmitted on [DATE], with [DIAGNOSES REDACTED]. During a record review of Resident 3's physician admission orders [REDACTED]. During an interview with the Administrator on June 29, 2017, at 3:47 PM, she reviewed Resident 3's ITMR for the month of June 2017, which indicated Resident 3 did not receive the Prescribed antibiotic as follows: [MEDICATION NAME]: June 28, 2017 at 9 AM June 29, 2017 at 9 AM Intravenous [MEDICATION NAME] on: June 28, 2017 at 6 AM June 28, 2017 at 12 Noon and June 29, 2017 at 7 AM. During an interview with RN 1, on June 29, 2017 at 4:03 PM, she stated that there was no RN scheduled for the times that the residents (Residents 1, 2 and 3) were prescribed to receive IV antibiotics. A review of the facility file titled, Nursing Staffing Assignment and Sign in Sheet, for the month of June 2017, was conducted. The staffing reflected the following date and shifts, no RNs were scheduled to provide prescribed IV antibiotics: June 24, 2017, 3 PM to 11 PM shift and 11 PM to 7 AM shift. June 25, 2017, 3 PM to 11 PM shift and 11 PM to 7 AM shift. June 27, 2017, 7 AM to 3 PM shift. June 28, 2017, 7 AM to 3 PM shift and 11 PM to 7 AM shift. On June 29, 2017, Resident 3 received her scheduled 7 AM IV antibiotic at 10:20 AM. During an interview with the Administrator on June 29, 2017, at 3:47 PM, she stated that omitted medication dosages were considered as medication errors and the nurses should have followed the medication error policy. She further stated neither the attending physician nor she were notified about the omitted doses by the staff. During a review of the facility policy and procedure titled, Medication Errors, revised on January 2012, indicated .All errors related to the administration of medications or treatments will be reported to the Director of Nursing Services, the attending physician, and the Administrator immediately . On June 29, 2017 at 6:17 PM, after interviews and record reviews, an Immediate Jeopardy (IJ, a situation that had threatened or is likely to threaten the health and safety of a resident) was called in the presence of the Administrator and Regional Nurse Consultant (RNC). The facility failed to ensure that Residents 1, 2 and 3 were free from medication errors, due to the lack of available registered nurses (RNs) to administer their prescribed intravenous (IV) antibiotics. The corrective action plan provided by the facility included: 1. Effective June 29, 2017, the facility will provide sufficient RN coverage, and administer IV medications as ordered by the physician, based on physician ordered frequencies. 2. All residents with IV medications will be identified by the RN Consultant in collaboration with the RN staff. Appropriate physician and responsible party will be informed by the licensed nurse for identified missed doses of IV medication/s. 3. Each resident with missed dose/s of IV medication will be placed on 72 hours alert charting for further monitoring. MD and responsible party will be updated for any significant change in condition observed by a licensed nurse. 4. Currently the facility has ensured that ample RN coverage is available to provide the IV administration as ordered by the physician. RN staffing has been scheduled by the DSD/Staffing Coordinator to include one RN per IV administration time. 5. In the event of a call off resulting in inadequate RN coverage, the contracted registry can be utilized as well as the interim Director of Nurses (DON) to administer the IV administration. 6. In an effort to ensure all licensed nurses are present for their scheduled shift, the interim DON will call the facility at the start of each shift to ensure all scheduled licensed staffs are present. 7. If the facility is unable to obtain RN coverage to administer and manage IV medication, all residents affected will be transferred to a facility that could manage the IV therapy. Consent of transfer will be obtained by a licensed nurse from the responsible party and attending physician. Claremont Healthcare Center and Park Avenue Healthcare Center have been advised of the potential need for transfer and have confirmed there are ample beds available in the event a transfer is necessary. 8. The facility will temporarily suspend taking orders for IV medication/s until RN coverage is resolved. 9. Facility will continue its effort to hire a DON. For the time being, a full time interim DON has been identified and will start on June 30, 2017. The corrective action plan was reviewed and accepted after verifying that the facility had implemented it through observations of IV antibiotic administration, licensed staff interviews, review of the schedule for RN staffing, registry contracts and facility policy revision on June 30, 2017 at 11:45 AM, in the presence of the Vice President of Operations (VPO), RNC and Interim DON. The IJ was lifted at 12:55 PM on June 30, 2017, in the presence of the Vice President of Operations (VPO), RNC and Interim DON.

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1), did not develop pressure sores (injuries to skin and underlying tissue resulting from prolonged pressure on the skin), when Resident 1's removable brace (a device used for support) for the right lower leg was not removed and the skin under the brace was not assessed for 2 days. This failure resulted in Resident 1 sustaining 2 pressure sores on the right leg due to the facility staff's failure to assess Resident 1's skin under the brace. Findings: During a review of the clinical record for Resident 1, the admission record indicated, the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the transfer record from the sub-acute hospital form Resident 1 dated June 18, 2014, reflected Resident 1's brace had been ordered by the sub-acute hospital staff. During a wound care observation of the LVN treatment nurse in Resident 1's room on September 19, 2014 at 8:30 AM, Resident 1 was in bed and was observed to have wound dressings to right lateral knee and right ankle. Review of the admission physician's orders [REDACTED]. During an interview with Licensed Vocational Nurse (LVN) 1 on October 30, 2014 at 3:10 PM, she verified the finding during the record review. During an interview with the Director of Rehab (DOR) on October 30, 2014 at 3:15 PM, she confirmed, she was notified by physical therapy from the subacute hospital, the right leg brace had been ordered for Resident 1. When asked about the type of brace, the DOR stated it was a "customized brace, a static brace (a brace that limits or controls motion around the hip) to support the fracture, due to (Resident 1) not having surgery." The DOR stated Resident 1 did not have any brace for the right leg at the time of admission on June 18, 2014. The DOR was asked what the facility had done to stabilize Resident 1's fracture until the brace was delivered, she stated, "We positioned Resident 1 in bed and the resident was not to get out of bed. Resident 1 had an abductor pillow (a pillow placed between the legs to maintain the legs alignment) for support." The DOR verified there was no order for the brace in Resident 1's clinical record. The DOR was asked if there should have been a physician's orders [REDACTED]." The DOR was asked, when was the brace to be delivered to Resident 1. She stated the orthotist had come to the facility on Friday, June 20, 2014. The orthotist had brought the custom-molded plastic brace that was fitted to Resident 1. The DOR stated the brace did not fit right on Resident 1's right leg. She further stated the orthotist took the brace home with him on Friday June 20, 2014 and was to make the adjustments and bring the brace back. On Saturday, June 21, 2014, the orthotist reapplied the brace to Resident 1's right leg. The DOR stated she assessed Resident's right leg on June 20, 2014, and confirmed there was no skin breakdown on the resident's right leg. The DOR also stated that only she and the orthotist were trained to don (to put on) and doff (take off) Resident 1's brace. The brace was a removable brace. A review of the "Physical Therapy Treatment Record," dated June 23, 2014, reflected the following documentation by the DOR, "Leg brace and sock taken off to check skin integrity...for pressure sores. Noted an open sore on the lateral (side) aspect of fibular head (upper part of the femur bone) and the medial (middle) aspect of the knee joint noted redness." There was no documentation of wound measurements done by the DOR. A review of the clinical nursing notes showed on June 23, 2014 at 11:41 AM, LVN 1 documented, " ...Resident noted w/DTI (deep tissue injury-a unique form of pressure ulcer; pressure-related injury to subcutaneous tissues under intact skin) to (R) lateral aspect of leg w/100% purple wound bed, also w/DTI to (R) medial aspect of leg w/100% purple wound bed." A review of the treatment record dated June 23, 2014, indicated an order for [REDACTED]. For the right medial DTI "Cleanse (L) (left) leg...apply [MEDICATION NAME] to leg brace." During an interview with LVN 2, on September 19, 2014 at 9:40 AM, she stated Resident 1 had DTI's on the right leg that resulted from the brace. A review of the nurse's notes for Resident 1 indicated documented entries for the following dates: On June 21, 2014 at 10:45 AM, Resident 1 had a brace on the right leg. There was no documentation to show the licensed nurse had monitored the skin under the brace. On June 21, 2014 at 7:14 PM, Resident 1 had a brace on the right leg. There was no documentation to show the licensed nurse had monitored the skin under the brace. On June 22, 2014 at 11:07 AM, Resident 1 had a brace on the right leg. There was no documentation to show the licensed nurse had monitored the skin under the brace. On June 23, 2014 at 11:19 AM, Resident 1 found with 2 DTI's to right lateral leg and right medial leg. A review of the clinical record showed Resident 1's brace was not removed and the skin under the brace was not assessed for 2 days, from the application of the brace on June 21, 2014 through June 23, 2014, when the brace was removed by the orthotist. Review of clinical nursing notes showed, from June 24, 2014 through July 24, 2014, the nursing documentation indicated the wounds as; (2) DTI's to the right lateral leg and right medial leg. Further review of the clinical notes, showed on August 4, 2014 at 2:25 PM, the LVN treatment nurse documented that there was a new classification of the wound and a new order, "Purple eschar (dead tissue) has fallen off to R lateral leg leaving site with 70% slough (yellow, tan dead tissue), 30 % red granulation (new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process), 1.5 CM (centimeter(length) x 1.5 CM (width) x 0.2 CM (depth), no drainage, no foul odor noted... Resp. party (self), made aware of reclassification from DTI to pressure ulcer Stage IV and new orders ... " The facility policy and procedure titled, "Immobilizer Care Guideline" dated August 12, 2008, indicated, under "Procedure 4"; "If the immobilizer is removable, the licensed nurse will remove the immobilizer at a minimum every shift...The licensed nurse will assess the following possible complications; a. skin condition; for signs and symptoms of infection or irritation and or any tissue injury..." The facility policy and procedure titled, "Pressure Ulcer and Wound Management" with a revised date of September 20, 2010, indicated under "Policy Statement"; "...to ensure that residents skin status is assessed and appropriate interventions are developed and implemented to maintain skin integrity, assist in wound healing and or prevent avoidable skin breakdown..." During an interview with LVN 1 on October 30, 2014 at 3:50 PM, she verified there was no order for the brace for Resident 1 in the physician's orders [REDACTED].