Every finding on record at Pasadena Nursing Center

Based on observation, interview and record review, the facility failed to protect two (2) of three (3) sampled residents (Resident 1 and Resident 2) from verbal abuse (the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability) based on the facility's policy and procedure. This deficient practice had resulted in Resident 1 and Resident 2 experiencing verbal abuse which could affect both of the residents emotional and psychosocial wellbeing. Findings1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus (DM, a metabolic disease, involving inappropriately elevated blood glucose levels), schizoaffective disorder (a chronic mental illness that causes a person to experience dramatic changes in their thoughts, moods, and behaviors), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and anxiety disorder (mental health condition marked by persistent excessive worry, fear, or nervousness that interferes with daily life), During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 5/22/2026, the MDS indicated Resident 1 had moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 needed setup or clean-up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) when eating, shower/ bathe self, personal hygiene, and tub/shower transfer. The MDS also indicates Resident 1 was independent (resident completes the activity by themself with no assistance from a helper) in oral hygiene, toileting hygiene, upper body dressing, lower body dressing, and putting on/taking off footwear, rolling left and right, sit to lying and sitting on the side of the bed, sit to stand, chair /bed-to-chair transfer, toilet transfer, walking 10, 50 and 150 feet. During a review of Resident 1's Behavior Related Incidents ([NAME]) , dated 7/6/2026 , the [NAME] indicated Resident 1 had a Resident-to-Resident altercation with roommate (Resident 2). Resident 1 claims that Resident 2 grazed the right side of his face. 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses of schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (or also called clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems) and anxiety disorders. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had intact cognitive skills for daily decision making. The MDS also indicated Resident 2 was independent in oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, personal hygiene, rolling left and right, sitting to lying, lying to sitting on the side of the bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub and shower transfer, walking 10, 50 and 150 feet. During a review of Resident 1's [NAME] , dated 7/6/2026 , the [NAME] indicated Resident 2 had a Resident-to-Resident altercation with roommate (Resident 2). Resident 1 claims that Resident 2 grazed the right side of his face. During a review of the facility's Summary of Investigation (SOI) dated 7/10/2026 to 7/20/2026 was reviewed, the SOI indicated,On 7/6/2026, Resident 3 (Roommate) stated there was an exchange of words between the two residents (Resident 1 and Resident 2).On 7/16/2026, Resident 1 stated Resident 2 said bad things to him. Resident 2 called him names such as Faggot and Nigger and used profanity.On 7/16/2026, Resident 2 stated Resident 1 used bad words with a raised voice and called his mom a Slut during the Resident-to-Resident altercation on 7/6/2026.Resident 3 (Roommate) stated on 7/6/2026 both residents were yelling at each other and there was use of bad words by both residentsCertified Nurse Assistant 2 (CNA 2) stated the two residents (Resident 1 and Resident 2) were observed exchanging words with offensive language thrown back and forth at each other, with every profanity uttered by one being reciprocated with profanity by the other.CNA 1 stated she heard Resident 2 mentioned offensive language (the N word) directed towards Resident 1.Use of profanity was evident as the two residents (Resident 1 and Resident 2) were in an argument. The investigation established that the incident consisted of a mutual verbal argument between two residents. (Resident 1 and Resident 2). During the exchange, both residents directed inappropriate language and profanity toward one another. The evidence demonstrated that the interaction was reciprocal, with both residents actively participating in the verbal exchange. During an interview on 7/16/2026 at 9:38 AM with CNA 1, CNA 1 stated she heard both of the residents yelling at each other. Resident 2 stated I cannot handle you anymore, you opened my closet. You fucking nigger! Resident 1 stated I am not a nigger! Resident 1 also stated, I want to get him! (Resident 2) CNA 1 stated both of the residents became agitated and cursing at each other. CNA 1 also stated, when residents use the F words, these words were cursing, it falls into the area of verbal abuse. During an interview on 7/16/2026 at 11:30 AM with CNA 2, CNA 2 stated Resident 1 and Resident 2 were arguing and they were yelling at each other. CNA 2 heard both Residents saying the F word to each other. Resident 2 told Resident 1 that he took so long to use the restroom. It was loud and they were yelling at each other. It is considered verbal abuse if the residents were cursing each other. During an interview on 7/16/2026 at 12:09 PM with Resident 2, Resident 2 stated, Resident 1 said the F word to me and a derogatory statement about my mother. I am mad because it should not be happening. During a concurrent interview and record review on 7/16/2026 at 1:52 PM with the Director of Nursing (DON), Resident 1's Care Plan (CP) for behavior exacerbation dated 3/3/2026. was reviewed The CP indicated Resident 1 came out his room provoked and was seen pacing in the hallway yelling f__k God, f__k Jesus multiple times. Resident 1 was in the hallway yelling racial slurs to staff, resident1 was repeating Nigger over and over. Resident 1 approached the nursing station calling nurses cunts, bitches and niggers. The CP interventions indicated,Assess and address for contributing sensory deficits.Restrict resident access to other residents when noted for increased aggressive behavior.Redirect Resident.Recognize warning sign - observe for residents raised voice, clenched fists or verbal threats.Hold resident as the last resort to protect another resident if needed.Notify Family/Responsible Party.Notify medical doctor (MD).Provide close monitoring while the resident is in aggressive posture.When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff should walk away calmly, and approach later.The DON stated the interventions were not followed by the staff because Resident 1 was cursing his roommate. Resident 1 and Resident 2 were both yelling at each other. Yelling and cursing falls into the area of verbal abuse. During an interview on 7/16/2026, at 12:55 PM with the DON, the DON stated, Resident 1 was cursing other people, and his roommates. Residents 1 and 2 were yelling at each other, that is Resident to Resident abuse. If we heard the Residents cursing, we needed to stop and redirect the residents. If the other residents heard it, they would get upset or mad. Residents' yelling and cursing fall under the area of verbal abuse. During a review of the facility's Policy and Procedure (P&P) titled, Abuse, Prevention Program, revised 12/2016, the P&P indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.Protect our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual.6. Identify and investigate all possible incidents of abuse.7. Investigate and report any allegations within timeframes required by federal requirements. During a review of the facility's P&P titled, Resident-to-Resident Altercations, revised 12/2022, the P&P indicated all altercations, including those that may represent resident-to-resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator.1. Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to the staff.2. Behaviors that may provoke a reaction by residents or others include:a. verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting race or ethnic group, intimidating;4. If two residents are involved in an altercation, staff:b. identifies what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation;

Based on interview and record review, the facility failed to report an allegation of verbal abuse (the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability) for one (1) of two sampled residents (Resident 8) within a 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement based on the facility's policy and procedure. This deficient practice had the potential to compromise or impede the protection of Resident 1 and Resident 2 which could affect resident's emotional and mental wellbeing. Findings:1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus (DM, a metabolic disease, involving inappropriately elevated blood glucose levels), schizoaffective disorder (a chronic mental illness that causes a person to experience dramatic changes in their thoughts, moods, and behaviors), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and anxiety disorder (mental health condition marked by persistent excessive worry, fear, or nervousness that interferes with daily life), During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 5/22/2026, the MDS indicated Resident 1 had moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 needed setup or clean-up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) when eating, shower/ bathe self, personal hygiene, and tub/shower transfer. The MDS also indicates Resident 1 was independent (resident completes the activity by themself with no assistance from a helper) in oral hygiene, toileting hygiene, upper body dressing, lower body dressing, and putting on/taking off footwear, roll left and right, sit to lying and sitting on the side of the bed, sit to stand, chair /be-to-chair transfer, toilet transfer, walk 10, 50 and 150 feet. During a review of Resident 1's Behavior Related Incidents ([NAME]) , dated 7/6/2026 , the [NAME] indicated Resident 1 had a Resident-to-Resident altercation with roommate (Resident 2). Resident 1 claims that Resident 2 grazed the right side of his face. 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] ,with diagnoses of schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (or also called clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems) and anxiety disorders. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had intact cognitive skills for daily decision making. The MDS also indicated Resident 2 was independent in oral hygiene, toileting hygiene, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair /be-to-chair transfer, toilet transfer, tub and shower transfer, walk 10, 50 and 150 feet. During a review of Resident 1's [NAME] , dated 7/6/2026 , the [NAME] indicated Resident 2 had a Resident-to-Resident altercation with roommate (Resident 2). Resident 1 claims that Resident 2 grazed the right side of his face. During a review of the facility's Summary of Investigation (SOI) dated 7/10/2026 to 7/20/2026 was reviewed, the SOI indicated, On 7/6/2026, Resident 3 (Roommate) stated there was an exchange of words between the two residents ( Resident 1 and Resident 2) On 7/16/2026, Resident 1 stated Resident 2 said bad things to him. Resident 2 called him names such as faggot and nigger and used profanity. On 7/16/2026, Resident 2 stated Resident 1 used bad words with raised voice and called his mom a slut during the Resident-to-Resident altercation on 7/6/2026. Resident 3 (Roommate) stated on 7/6/2026 both residents were yelling at each other and there was use of bad words by both residents Certified Nurse Assistant 2 (CNA 2) stated the two residents (Resident 1 and Resident 2) observed exchanging words with offensive language thrown back and forth at each other, with every profanity uttered by one being reciprocated with profanity by the other. CNA 1 stated she heard Resident 2 mentioned offensive language (the N word) directed towards Resident 1. Use of profanity was evident as the two residents (Resident 1 and Resident 2) were into argument. The investigation established that the incident consisted of a mutual verbal argument between two residents. (Resident 1 and Resident 2). During the exchange, both residents directed inappropriate language and profanity toward one another. The evidence demonstrated that the interaction was reciprocal, with both residents actively participating in the verbal exchange. During an interview on 7/16/2026 at 9:38 AM with CNA 1, CNA 1 stated she heard both of the residents yelling at each other. Resident 2 stated I cannot handle you anymore, you opened my closet. You fucking nigger! Resident 1 stated I am not a nigger! Resident 1 also stated, I want to get him! (Resident 2) CNA 1 stated both of the residents became agitated and cursing at each other. CNA 1 also stated, when residents use the F words, these words were cursing, it falls on verbal abuse. During an interview on 7/16/2026 at 11:30 AM with CNA 2, CNA 2 stated Resident 1and Resident 2 were arguing and they were yelling at each other. CNA 2 heard both Residents saying the F word to each other. Resident 2 told Resident1 that he took so long to use the restroom. It was loud and they were yelling at each other. It is considered verbal abuse if the residents were cursing each other. During an interview on 7/16/2026 at 12:09 PM with Resident 2, Resident 2 stated, Resident 1 said the F word to me and a derogatory statement about my mother. I am mad because it should be happening. During an interview on 7/16/2026 at 9:38 AM with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated she heard both of the residents yelling at each other. Resident 2 stated I cannot handle you anymore, you opened my closet. You Fucking nigger! Resident 1 stated I am not a nigger! Resident 1 also stated, I want to get him! CNA 1 stated both of the residents became agitated and cursing at each other. CNA 1 also stated, when residents use the F words, these words were cursing, it falls on verbal abuse. they should have reported to the Administrator (ADM) During an interview on 7/16/2026 at 11:46 AM with CNA 3, CNA 3 stated If residents were yelling to each other, we need to report it right away. If incident occurs, the staff should inform the charge nurse, the DON or the ADM because yelling is under verbal abuse, and it can also be emotional because the words might affect the resident mentally and emotionally. The Residents who have been cursed or yelled at will be angry, or emotional. The cursing words that were said can affect them emotionally. During an interview on 7/16/26 at 12:03 PM with CNA 3, CNA 3 stated yelling and cursing is considered verbal abuse. It should be reported to the ADM and DON because they are the Abuse coordinator. We are mandated reporters and we should report it immediately to make sure the residents will not have physical altercation. During an interview on 7/16/2026 at 3:22 PM with CNA 1, CNA 1 stated when Resident 2 used the word Fucking nigger it falls on verbal abuse, those were cursing. They should have reported to the Administrator. Resident 2was being racist to Resident 1, we should have told the Administrator. During an interview on 7/16/2026, at 3:51 PM, with the Director of Nursing (DON), the DON stated, Resident 1 and Resident 2 were yelling at each other. If there were cursing words, yelling, and derogatory words, it was part of verbal abuse. They should have included that in the report because it was also type of abuse. If there was no report regarding verbal abuse, the residents involved might try to hit each other, and they will still be upset at each other and possibly emotionally affected by the incident. The staff would not be able to monitor the residents. During an interview on 7/16/26 at 3:55 PM with the ADM, The ADM stated yelling and cursing falls under verbal abuse, and they should be included in the report. They did not include verbal abuse in the report for Resident 1 and Resident 2's Resident to Resident altercation, they were just focused on physical aggression incident. The staff did not mention the exchange words of profanity between Resident 1 and Resident 2. During a concurrent interview and record review on 7/16/26 at 3:56 PM with the ADM, the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting revised 7/2017, The P&P indicated all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies:a. The State licensing/certification agency responsible for surveying/licensing the facility;b. The local/State Ombudsman;c. The Resident's Representative (Sponsor) of Record;d. Adult Protective Services (where state law provides jurisdiction in long-term care);e. Law enforcement officials;f. The resident's Attending Physician; andg. The facility Medical Director.2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:a. Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury.The ADM stated they need to report all allegations of abuse within 2 hours because we need to keep the residents safe.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services in accordance with the facility's policies and procedures (P&P) by failing to ensure two (2) licensed nurses witnessed the disposition of discontinued medications and record accurately. This deficient practice had the potential to result in the inability to identify loss of medications and potential for drug diversion (illegal distribution or abuse of prescription medications or their use for unintended purposes).Findings: During a concurrent observation in the medication room and interview with Supervisor (RNS) on [DATE] at 3:18 PM, with the Director of Nursing (DON), RNS was observed sitting alone inside the medication room disposing medications. RNS was observed removing medications from the bubble pack (also known as a blister pack or compliance pack, which is a method of organizing a resident's medications into individual, sealed compartments) and putting them in a blue container without a lid. RNS stated she was disposing of the medications for residents who were no longer in the facility and medications that have been discontinued. The DON stated the medications in the blue bin will be dispensed into the incineration bin (is a secure, specialized disposal container designed to collect expired, unused, or contaminated pharmaceuticals). During a concurrent interview and record review on [DATE] at 10:29 AM with the DON, the medication destruction records dated [DATE] and [DATE], were reviewed. The medication destruction record dated [DATE] indicated the DON signed as the second licensed nurse. The DON stated she signed the medication destruction record dated [DATE] but did not witness the destruction of the medications with the RNS. The medication destruction record, dated [DATE], indicated the list and quantity of medications disposed of and one licensed staff signature. There was no signature of a second licensed nurse as witness. The DON stated Licensed Vocational Nurse (LVN 1) disposed of medications on [DATE] and the signature of a second licensed nurse was missing. The DON stated if there was no second signature, it meant that no other licensed nurse witnessed the medication destruction/disposal. The DON stated the P&P was not followed to have two licensed nurses when disposing medications. The DON also stated During an interview on [DATE] at 10:15 AM with RNS, the RNS stated she was alone in the medication room during the destruction/disposition of the medications. RNS stated there was no second licensed staff that witnessed removal of medications from its packaging and when poured into the incinerator bin. RNS stated that the witness should be present throughout the process. During a concurrent interview and record review on [DATE] at 10:33 AM, the P&P titled, Discarding and Destroying Medications, dated [DATE], was reviewed. The P&P indicated that the medication disposition record contains the signature of witnesses. The DON stated if there was no second signature, it meant that no other licensed nurse witnessed the medication destruction/disposal.

Based on observation, interview, and record review, the facility failed to follow its policy for discarding and disposing of medications by failing to:Discard one (1) expired Lantus (long acting man-made insulin used to control high blood sugar) injectable pen (portable, easy to use device used by people with diabetes [chronic condition where the body either cannot produce enough insulin or cannot use it properly] to inject insulin) which was stored in Medication Cart 2.Discard two (2) expired glucose control solutions (a liquid with a known amount of sugar used to verify the blood glucose meter [portable electronic device that measures the amount of sugar [glucose] in the blood] and test strips [small, disposable plastic strips coated with chemicals that react with a tiny drop of blood] are working correctly) used to calibrate blood glucose meter which were stored in Medication Carts 1 and 2.This deficient practice had the potential for residents to receive Lantus insulin that had become ineffective, which could affect the residents' diagnosis management of diabetes and using expired glucose control solutions had the potential to result in inaccurate glucometer calibration which can potentially result in erroneous blood sugar readings which could lead to residents experiencing change in condition and hospitalization. Findings: 1. During a concurrent observation and interview on [DATE] at 9:44 AM with Licensed Vocational Nurse 1 (LVN 1) and the Director of Nursing (DON), Medication Cart 2 was observed with 1 Lantus injectable pen labeled with expiration date of [DATE]. LVN 1 and DON stated the expired Lantus injectable pen should have been discarded. The DON and LVN 1 stated that if expired insulin was administered, it could potentially result to residents experiencing adverse effects from receiving expired insulin that could lead to change in conditions and hospitalization. During a concurrent interview and record review on [DATE] at 2:42 PM, the P&P titled. Medication Labeling and Storage, revised [DATE], the DON stated the P&P indicated multidose vials that have been open or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date. 2. During a concurrent observation, interview, and record review on [DATE] at 10 AM, the glucose control solutions manufacturer's instructions leaflet (printed document packed with a product that provides the user with essential information on its safe and proper use) was reviewed. The DON and LVN 1 stated the manufacturer's instructions leaflet indicated to use the control solution within 90 days of first opening. The glucometer control solution in Medication cart 1 was labeled with use by date of [DATE]. The glucometer control solution in Medication cart 2 was labeled with open date of [DATE]. The DON and LVN 1 stated that the glucometer control solutions stored in Medication carts 1 and 2 were past the use by dates. The DON and LVN 1 stated using expired control solutions to calibrate glucometers will give inaccurate calibration and potentially affect glucometer readings when checking the blood sugar of residents. During an interview with the DON on [DATE] at 2:42 PM, the DON stated that there was no specific P&P regarding glucometer control solutions, but the facility is to follow the manufacturer's instructions. The DON stated using expired control solutions to calibrate the glucose meters can result in inaccurate calibration that can potentially result in erroneous blood sugar readings for the residents which can also potentially result in hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) if insulin was given based on blood sugar readings that could lead to change in condition and hospitalization.

Based on interview and record review, the facility failed to prevent physical abuse (intentional bodily injury) for one (1) of four (4) sampled residents (Resident 1) when Resident 2 hit Resident 1 on the face on 4/27/2026. This failure had the potential to result in mental and emotional distress for Resident 1.1. During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of paranoid schizophrenia (a chronic mental condition where a person loses touch with reality through intense, irrational distrust) and anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable fear or worry that interferes with daily life). During a review of Resident 1'S Minimum Data Set (MDS - a resident assessment tool), dated 4/21/2026, the MDS indicated the resident was cognitively intact (ability to think, remember, and reason) with cognitive skills for daily decision making. The MDS also indicated Resident 1 needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with walking 50 feet with two turns, chair/bed-to-chair transfers, going from sitting to standing, upper and lower body dressing (the ability to dress and undress above and below the waist), putting on/taking off footwear and needed setup or clean-up assistance (helper set up or cleans up; resident completes activity) with eating. During a review of Resident 1's Behavior Related Incidents documentation dated 4/27/2026, Resident 1's Behavior Related Incidents documentation indicated Resident 1 was noted to have been involved in a behavior of physical aggression from his roommate, Resident 2. The form indicated under the Interdisciplinary Team (IDT; a group of different professionals who work closely together to solve a complex problem or achieve a shared goal) Recommendations portion, the documentation indicated Resident 1 stated on the day of the altercation, he (Resident 1) went to his room and walked, stopped and looked at his roommate, Resident 2 and made him (Resident 1) feel uncomfortable and stated Resident 2 believed that he (Resident 1) is creepy. Resident 1 stated Resident 2 then swayed his hand and touched the right side of his (Resident 1) face. It also indicated that, upon asking Resident 2 what happened, he (Resident 2) stated he did not like Resident 1.2. During a review of Resident 2's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of paranoid schizophrenia and violent behavior. During a review of Resident 2'S MDS, dated [DATE], the MDS indicated the resident was cognitively intact with cognitive skills for daily decision making. It indicated Resident 2 needed partial/moderate assistance (helper does less than half the effort) with walking 50 feet with two turns, chair/bed-to-chair transfers, and going from sitting to standing. The MDS also indicated Resident 2 needed supervision or touching assistance with lower body dressing and putting on/taking off footwear and needed setup or clean-up assistance with upper body dressing, personal hygiene and eating.During a review of Resident 2's Care Plan dated 3/29/2026, Resident 2's Care Plan indicated Resident 2 had a history of a physical altercation with another resident while in a prior board and care facility because Resident 2 did not like the other resident. The Care Plan also indicated an intervention to assist the resident to develop a more appropriate method of coping and interacting and to encourage the resident to express feelings appropriately. During an interview on 5/11/2026 at 10:50 AM with Resident 2, Resident 2 stated on 4/27/2026, he was watching a movie with his roommate, Resident 1 in their room and noticed Resident 1 looking at him funny and did not like how Resident 1 looked at him (Resident 2) and he (Resident 2) punched Resident 1 on the face. During an interview on 5/11/2026 at 11:00 AM with Resident 1, Resident 1 stated on 4/27/2026, Resident 2, who was his roommate at the time had hit him because he (Resident 1) was staring at him (Resident 2). During an interview on 5/11/2026 at 11:30 AM with the Director of Nursing (DON), the DON stated on 4/27/2026, there was an altercation between Resident 1 and 2 when Resident 2 hit Resident 1 in the face. The DON stated Resident 1 told staff that he (Resident 1) knows he was walking and stopped and stared at Resident 2 and thinks that is why Resident 2 hit him (Resident 1). During a concurrent interview and record review on 5/12/2026 at 10:55 AM with the DON, Resident 1's Electronic Medical Record (EMR; a digital collection of medical information about a person such as health history, diagnoses, medicines, tests, allergies, immunizations and treatment plans that is stored on a computer) dated 4/27/2026 to 5/12/2026 was reviewed. Resident 1's EMR did not have a care plan specifically for Resident 1's behavior of stopping and staring at others. The DON stated, there was no care plan initiated for Resident 1's behavior of stopping and staring at others and because it was triggering for Resident 2, it should have been care planned, especially since Resident 1 now has another roommate, it is important to address it so if he does that behavior to someone else, they can try to prevent another altercation in case it is triggering for another resident. During a concurrent interview and record review on 5/12/2026 at 1:55 PM with the DON, the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 1/29/2026 was reviewed. The P&P indicated, a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented to each resident. The P&P also indicated, the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a compressive, person-centered care plan for each resident and assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. The DON agreed with the policy and stated the purpose of a care plan is to plan the care for the resident and indicates interventions for the nurses to follow so they can monitor that specific behavior. During the same concurrent interview and record review on 5/12/2026 at 1:55 PM with the DON, the facility's P&P titled, Behavioral Assessments, Intervention and Monitoring, revised March 2019 was also reviewed. The P&P indicated the interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly and safety strategies will be implemented immediately to protect he resident and others from harm. The P&P also indicated:Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities.Interventions and approaches will be based on detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. The care plan will include, as a minimum:A description of the behavioral symptoms including: frequency, intensity, duration, outcomes, location, environment and precipitating factors or situations;Targeted and individualized interventions for the behavioral and/or psychosocial symptoms;Rationale for the interventions and approaches;Specific and measurable goals for the targeted behaviors andHow the staff will monitor for effectiveness of the interventions.The DON agreed with the policy and stated Resident 1's behavior of stopping and staring should have been care planned as soon as the resident's behavior was noted on 4/27/2026 so that it could potentially prevent another altercation between either him and Resident 2 or another resident. During a review of the facility's P&P titled, Abuse Prevention Program, revised December 2016, the P&P indicated, the facility's residents have the right to be free from abuse. This includes but not limited to freedom from physical abuse. The P&P also indicated and as a part of the resident abuse prevention, the administration will protect the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual.

Based on interview and record review, the facility failed to inform and a provide written information to formulate an advanced directive (written statement of a person's wishes regarding medical treatment which were made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for two (2) of 2 sampled residents (Resident 13 and 20) reviewed for advanced directives, as indicated on the facility policy. This deficient practice had the potential to cause conflict in carrying out Resident 13 and 20's wishes for medical treatment and resident's health care decisions.Findings: 1. During a review of Resident 13's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 13's Minimum Data Set (MDS- a resident assessment tool), dated [DATE], the MDS indicated Resident 13 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 13 required partial/moderate assistance (helper does less than half the effort) with shower and required supervision (helper provides cues) with toileting hygiene, oral hygiene, upper and lower body dressing, personal hygiene, sit to lying, and walking. During an attempted interview on [DATE] at 4:30 PM, the surveyor placed a call but was unable to speak with Resident 13's conservator (a person or an organization legally appointed by a court to manage the financial affairs or personal care of someone who can no longer make decisions for themselves) to verify if the facility had discussed resident's advanced directive. 2. During a review of Resident 20's admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses that included bipolar disorder, anxiety disorder (a mental health disorder characterized by feeling of worry, or fear that are strong enough to interfere with one's daily activities) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 20's Minimum Data Set (MDS- a resident assessment tool), dated [DATE], the MDS indicated Resident 20 had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 20 was dependent with lower body dressing and putting on/taking off footwear and required substantial/maximal assistance (helper does more than half the effort) with toileting, shower and upper body dressing. The MDS further indicated Resident 20 required supervision (helper provides cues) with personal hygiene and required setup assistance (helper sets up; resident completes activity) with eating and oral hygiene. During a concurrent interview and record review of Resident 13 and 20's chart and the Electronic Medical Record (EMR, an electronic version of the resident's medical history that is maintained by the provider over time) on [DATE] at 3:12 PM, the Medical Records Director (MRD) stated there were no signed advanced directives acknowledgement forms in the chart and EMR for both Residents' 13 and 20. During a concurrent interview and record review on [DATE] at 2:56 PM, the Social Services Director (SSD) stated a signed advanced directives acknowledgement form which contains information and verification that the residents were informed and provided with written information to formulate an advance directive should be in the chart in case of emergencies and placed together with the Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) so the staff are aware if the resident is a full code or Do Not Resuscitate DNR (do not resuscitate- a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation [CPR] if breathing stops or the heart stops beating). The SSD also stated a signed advanced directive acknowledgment form should be in the chart to ensure the facility knows who to call and decide in case they no longer have the capacity to decide for themselves. During an interview on [DATE] at 3:15 PM, Registered Nurse 1 (RN 1) stated the residents' advanced directives acknowledgment forms should be in the chart in case the residents get incapacitated (unable to manage one's own affairs, care for oneself, or make decisions due to physical or mental limitations) they will be provided with the care that is expected and noted on the advanced directives acknowledgment forms. RN 1 also stated an advanced directives acknowledgement form should be in the chart to be able to identify who is the person to call that knows the resident and was aware if the residents have an advanced directive or not. During an interview on [DATE] at 9:37 AM, Director of Nursing (DON) stated advanced directives acknowledgment forms should be in the chart and should be accessible to the staff in case of emergency to ensure accurate information and care would be provided to the resident. The DON also stated there was no documented evidence through an advanced directive's acknowledgement form or documentation in the resident's progress notes that the conservator was asked if Residents 13 and 20 had an advanced directive or not or was given information about formulation of advanced directives. During a review of the facility's Policy and Procedure (P&P) titled, Advanced Directives, dated [DATE], the P&P indicated that if the resident does not have an advanced directive, information about whether or not the resident has executed an advanced directive, this is displayed prominently in the medical record in a section of the record that is retrievable by any staff.

Based on observation, interview and record review, the facility failed to provide a safe, clean and homelike environment for two (2) of four (4) sampled residents (Resident 14 and 27) reviewed for environment, as indicated on the facility's policy, when:Resident 14 was observed sitting on a bed that has no bed sheet to cover the mattress, leaving the mattress' surface exposed.Resident 27's brown pillow, which had fallen into a trashcan, was not cleaned or replaced, and was placed back to the resident's freshly made bed.The facility did not ensure no cup of juice was left by the bariatric Geri chair (a heavy duty mobile recliner with a wider seat [often 22 to 36 inches] and a higher weight capacity [typically 350 to 700 plus pounds] designed to assist plus size patients with mobility issues in transitioning from bed to a comfortable, supported sitting position) by the hallway.Facility did not ensure soiled clothing (black pant) was placed inside the laundry bin, not on the floor in the shared (Restroom A). These deficient practices had the potential to negatively impact on the safety, comfort, and quality of life of Resident 14, 27 and other residents in the facility. Findings: 1.During a review of Resident 14's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of depression (severe feelings of sadness and hopelessness) and schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves). During a review of Resident 14'S Minimum Data Set (MDS – a resident assessment tool), dated 3/24/2026, the MDS indicated the resident was moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were moderately impaired. The MDS also indicated Resident 14 needed set up or clean up assistance (helper sets up or clean up, residents complete the activity) on eating or oral hygiene (the ability to use suitable items to clean teeth). It indicated, the resident needed supervision or touching assistance (helper provide verbal cues and provide touching / steadying and or contact guard assistance) on personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing drying face and hands. During a concurrent observation and interview on 4/14/2026 at 10:06 AM in Resident 14's room, Resident 14 was observed sitting on a bed without a bed sheet to cover the mattress. Resident 14 stated that his bed had been uncovered for about one and a half hours. During an interview on 4/16/2026 at 11:40 AM with the Certified Nursing Assistant (CNA 1), CNA 1 stated residents are not supposed to sit or lie down on a bed without a bed sheet covering it. CNA 1 also stated that the residents might feel bad if beds are not covered or not made. During an interview on 4/16/2026 at 11:49 AM with Resident 14, Resident 14 stated, I like it better when the bed is clean and covered; it feels more comfortable. 2. During a review of Resident 27's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of schizophrenia and anxiety (a feeling of nervousness, panic, and fear). During a review of Resident 27'S MDS, dated [DATE] the MDS indicated the resident was cognitively intact (ability to think, remember, and reason) with cognitive skills for daily decision making. Resident 27 needed set up or clean up assistance on personal hygiene. During an observation on 4/14/2026 at 10:15 AM at Resident 27's room, CNA 2 was observed changing Resident 27's bed. A brown pillow fell inside the trashcan, then CNA 2 picked up the brown pillow and placed it on top of Resident 27's clean pillow. During an observation on 4/14/2026 at 10:27 AM in Resident 27's room, Resident 27 was observed hugging the brown pillow. Resident 27 stated that the brown pillow was a gift from the resident's mom. During an interview on 4/16/2026 at 11:14 AM with Resident 27, Resident 27 stated, I feel nasty; it is like hugging a pillow with shit, urine, and dump on it. Resident 27 also stated, I like everything clean. During an interview on 4/16/2026 at 11:23 AM with CNA 2, CNA 2 stated Resident 27's brown pillow fell into the trashcan and that she put it back on the clean bed. CNA 2 also stated, I should not have put it back on the bed; it was already dirty and could possibly cause sickness to the resident. During a concurrent interview and record review on 4/17/2026 at 2:21 PM with the Assistant Director of Nursing (ADON), the facility's Policy and Procedure (P&P) titled Homelike Environment, revised on 1/21/2026, was reviewed. The ADON stated that the P&P indicated residents are to be provided with a safe, clean, comfortable, and homelike environment. The ADON also stated that the P&P for a homelike environment was not followed. 3. During an observation on 4/14/2026 at 9:04 AM, a half full cup of cranberry juice was seen placed at the back lower metal frame of the bariatric Geri chair parked in the hallway. During an observation on 4/14/2026 at 9:06 AM, the Administrator (ADM) picked up the cup of juice from the Geri chair after pointing it out and stated it should not be in there. During an interview on 4/16/2026 at 3:22 PM, Registered Nurse 1 (RN 1) stated the cup of juice should not be left in the hallway because any of the residents who pass by the hallway can pick up and drink from it. RN 1 also stated it would not be safe for someone to accidentally drink from the cup since whoever left them could have some type of infection. During an interview on 4/16/2026 at 3:38 PM, the Assistant Director of Nursing (ADON) stated the staff should have removed the cup of juice from the Geri chair to ensure no residents will pick up and drink the remaining juice. ADON also stated another resident could pick up the juice and drink from it could end up getting sick or have stomach issues especially since we do not know what the other resident that left the juice has and we do not know how long it has been left on the Geri chair. 4. During an observation on 4/14/2026 at 9:06 AM in shared Restroom A, a soiled black pant was observed on the floor inside shared restroom A. During an observation on 4/14/2026 at 10:14 AM in Room A, a soiled black pant was observed on the floor in Room A by bed C. During an observation on 4/14/2026 at 11:54 AM in shared restroom A, a soiled black pant was observed on the floor by the toilet in Restroom A. During an interview on 5/15/18, at 2:45 PM, with Certificated Nursing Assistant 1(CNA 1), CNA 1 stated each resident has his/her laundry bin. CNA 2 stated that soiled laundry should not be left on the floor in the shared restroom or in the resident's room. Soiled laundry should be placed in the laundry bin to prevent infection or spread disease. During an interview on 5/15/18, at 3:05PM with ADM, ADM stated soiled laundry should be placed into the labeled laundry bin and not scattered on the floor to minimize contact, prevent the spread of germs, and avoid contaminating surfaces. A review of facility's policy and procedures (P&P) titled, Laundry and bedding soiled dated 1/21/2026, the P&P indicated that personal clothing they becomes soiled with blood or body fluid is covered or removed and immediate laundered before leaving the work area.

Based on observation, interview, and record review, the facility failed to accurately measure the mozzarella cheese used to prepare the spinach au gratin served for lunch on 4/15/2026. This deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake, and weight loss for the 32 residents who received the spinach au gratin.Findings: During an observation on 4/15/2026 at 11:29 AM, Dietary Aide (DA 1) was observed adding mozzarella cheese to a tray of spinach without measuring it. DA 1 used her hand to add the mozzarella cheese to the tray.During an interview on 4/15/2026 at 3 PM, DA 1 stated she did not measure the mozzarella cheese added to the spinach for spinach au gratin, which was served for lunch. DA 1 stated she should have measured the mozzarella cheese to meet the requirements of a therapeutic diet (a specialized diet ordered by a physician or dietitian to manage a medical condition or health needs).During an interview on 4/15/2026 at 3:06 PM with the Dietary Service Supervisor (DSS 1), DSS1 stated that spinach au gratin was served for lunch on 4/15/2026. DSS 1 also stated 32 residents received spinach au gratin with cheese.During a concurrent interview and record review on 4/15/2026 at 3:07 PM with DSS 1, the facility's policy and procedure titled, Standardized Recipes, revised on 1/21/2026, was reviewed. DSS 1 stated that the policy indicated standardized recipes shall be developed and used in food preparation. DSS 1 also stated that the mozzarella cheese used for the spinach au gratin should have been measured.

Based on observation, interview, and record review, the facility failed to maintain the food service area in a clean and sanitary condition and failed to follow its proper food handling procedures to ensure food safety by failing to ensure: 1. Maintain the refrigerator with sufficient space to allow for proper internal air flow2. The can opener was not chipped along the metal blade area, and it was free from a hair-like residue from green cleaning pad. These deficient practices have the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization.Findings: During a concurrent kitchen observation and interview on 4/14/2026 at 1:05 PM, with Dietary Supervisor (DSS 1), the refrigerator has trays of sandwiches on top of gallons of milk and did not have sufficient space to allow for proper internal air flow. DSS 1 stated the refrigerator was overstocked, and the trays of sandwiches on top of gallons of milk blocks the refrigerator's vent. During a concurrent kitchen observation and interview on 4/14/2026 at 1:41 PM, with DSS 1, DSS 1 stated that the can opener has a chipped metal along the blade and had hair like residue from green cleaning pad. During an interview on 4/15/2026 at 2:55 PM, with Dietary Services [NAME] (Cook 1), [NAME] 1 stated, the refrigerator was not supposed to be overpacked due to poor air circulation which can lead to refrigerator's internal temperature not maintained, which could potentially cause food spoilage when temperatures are not maintained consistently. During an interview on 4/15/2026 at 2:56 PM, with [NAME] 1, [NAME] 1 stated the can opener should be maintained in a clean condition, and free of chipped parts, as damage to the can opener could potentially cause food contamination and illness to the residents. During a concurrent interview and record review on 4/15/2026 at 2:58 PM with the DSS 1, the facility's Policy and Procedures (P&P) titled Food Receiving and Storage, revised on 1/21/2026, was reviewed. DSS 1 stated the P&P indicated that foods shall be received and stored in a manner that complies with safe food handling practices. DSS 1 also stated that P&P also indicated that refrigerated foods are stored in such a way that promotes adequate air circulation around the food storage containers and refrigerators/ walk-ins should not be overcrowded. DSS1 also stated the facility did not follow the P&P the refrigerator was overcrowded. During a concurrent interview and record review on 4/15/2026 at 3:00 PM with DSS 1, the facility's P&P titled Sanitation, revised on 1/21/2026, was reviewed. DSS 1 stated the P&P indicated all utensils, counters, shelves and equipment must be clean, maintained in good repair, and are free from break, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. DSS1 stated the facility did not follow the P&P for sanitation because the can opener was chipped with hair like residue from green cleaning pad.

Based on interviews, and record review, the facility failed to coordinate a Level II Preadmission Screening and Resident Review (PASARR, initial screening for all applicants to Medicaid-certified nursing facilities [meets federal and state standards for care and is approved to receive payment from Medicaid {a government health insurance program that provides free or low-cost coverage to eligible low-income individuals and families} for services provided to eligible residents] for possible serious mental disorder [MD, a health condition characterized by clinically significant alterations in thinking, mood, or behavior associated with distress and/or impaired functioning], intellectual disability [ID, a condition characterized by significantly subaverage intellectual functioning and substantial limitations in adaptive behavior] or a related condition, which is completed prior to admission to a nursing facility) evaluation for one (1) of three (3) sampled residents (Resident 18) reviewed for PASARR in accordance with the facility's policy. This deficient practice had the potential to result in inappropriate placement of Resident 18 and had the potential for not receiving necessary and appropriate level of treatment and evaluation in the facility.Findings: During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 18's Minimum Data Set (MDS- a resident assessment tool), dated 4/2/2026, the MDS indicated Resident 18 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 18 required setup assistance (helper set up; resident completes activity) with eating and shower and was independent (resident completes the activity by themselves with no assistance from helper) with oral, toileting and personal hygiene, upper and lower body dressing, and putting on/taking off footwear. During a review of Resident 18's Medical Records the Medical Records indicated Resident 18 had a positive PASARR Level 1 screening on 4/30/2025. During a concurrent interview and record review of Resident 18's Electronic Medical Records (EMR, an electronic version of the resident's medical history that is maintained by the provider over time) on 4/15/2026 2:06 PM, the Assistant Director of Nursing (ADON) stated PASARR Level II was attempted on 5/4/2025 but was not completed because the facility staff were unresponsive to two or more separate attempts from PASARR Level II evaluator during communication within 48 hours of the PASARR Level I screening. ADON stated she was assigned to complete the PASARR Level I screenings for the residents in the facility and was the contact person for PASARR. ADON stated that the Registered Nurse Supervisor (RNS) should have taken the call from the PASARR Level II evaluator when ADON was not available to coordinate the evaluation and for Resident 18 to receive the appropriate treatment. During an interview on 4/17/2026 at 3:57 PM, the Director of Nursing (DON) stated the facility should be available to coordinate with the Level 11 PASARR evaluator to ensure the resident's behavior was being managed, followed by behavioral services, and monitored to ensure treatment was effective and the resident was appropriately placed. During a review of the facility's Policy and Procedure (P&P) titled, PASARR Completion Policy, dated 1/21/2026, the P&P indicated that the facility would ensure that all admissions have the appropriate PASARR completed.

Based on observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards by placing a box fan (a square-shaped electric fan) on top of a four (4) - wheeled walker (a mobility aid with a 4 pronged base and rubber tips designed to provide more stability and support that a standard single-point cane) in the foot area of the resident's room for one (1) of three (3) sampled resident (Residents 13) reviewed for accidents, in accordance with the facility policy. This deficient practice placed Resident 13 at risk for injury and serious harm.Findings: During a review of Resident 13's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included unsteadiness on the feet, lack of coordination, and extrapyramidal and movement disorder (involuntary uncontrollable body movements or muscle stiffness caused by brain dysfunction). During a review of Resident 13's Minimum Data Set (MDS- a resident assessment tool), dated 3/9/2026, the MDS indicated Resident 13 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 13 required partial/moderate assistance (helper does less than half the effort) with shower and required supervision (helper provides cues) with toileting hygiene, oral hygiene, upper and lower body dressing, personal hygiene, sit to lying, and walking. During a review of Resident 13's Care Plan, revised 3/11/2026, the Care Plan indicated the resident was at risk for falls and an intervention included provide a safe environment for the resident. During an observation on 4/14/2026 at 9:50 AM in Resident 13's room, Resident 13 was seen walking back and forth to her closet, which was located near a box fan that was tilted and positioned sideways on top of a 4-wheeled walker with a seat, to get some clothes. The box fan had a taped cut-out piece of cardboard attached to the front of the fan. During a concurrent observation in Resident 13's room and interview with Certified Nursing Assistant 3 (CNA 3) on 4/14/2026 at 10:36 AM, CNA 3 verified that there was a box fan sitting sideways on top of the 4 wheeled walker with a seat in Resident 13's room. CNA3 stated the box fan should not have been placed on top of a 4 wheeled walker for safety. During an interview on 4/16/2026 at 9:33 AM, the Maintenance Service Supervisor (MSS) stated that placing a box fan on a walker was unacceptable. MSS also stated the box fan should be on the floor because the fan could fall and injure someone if placed on top of a walker. MSS further stated attaching and taping a cut out piece of cardboard to the front of the fan could cause the fan to overheat and potentially start a fire. During an interview on 4/17/2026 at 11:35 AM, Assistant Director of Nursing (ADON) stated the cut-out piece of cardboard placed and taped to the front of the fan was a fire hazard. ADON also stated placing the fan on a walker could pose a safety risk for Resident 13 because the fan could fall and the resident could trip and fall from the fan. During a review of the facility's Policy and Procedure (P&P) titled, Safety and Supervision of Residents, dated 1/21/2026, the P&P indicated that the facility strives to make the environment as free from accident hazards as possible. The P&P also stated that residents' safety and supervision and assistance to prevent accidents are facility-wide priorities. During a review of the facility's P&P titled, Hazardous Areas, Devices, and Equipment, dated 1/21/2026, the P&P indicated that all hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Examples of hazards included but are not limited to devices and equipment that are improperly used.

Based on observation, interview, and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 35) reviewed for hydration, was provided with bedside water to maintain proper hydration. This deficient practice has the potential to put the resident at risk for dehydration (a condition occurring when the body loses more fluids, primarily water).Findings: During a review of the admission Record, the admission Record indicated Resident 35 was admitted to the facility on [DATE] with diagnoses including hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood), hemiplegia (weakness to one side of the body), transient ischemic attack (TIA- a temporary blockage of blood flow to the brain ), and cerebral infarction (stroke - damage to the tissues in the brain due to a loss of oxygen to the area) without residual deficits. During a review of the Minimum Data Set (MDS, a resident assessment tool), dated 4/6/2026, the MDS indicated Resident 35 is assessed to be cognitively (a mental process of acquiring knowledge and understanding) moderately impaired. The MDS indicated Resident 35 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity.) with eating, oral hygiene, and personal hygiene. During a review of Resident 35`s Care Plan, revised 4/9/2026, the Care Plan indicated Resident 35 is at risk for Urinary Tract Infection (UTI -is a bacterial infection in the urinary system [bladder, urethra, or kidneys]) related to potential poor fluid intake, with a goal for the resident to be free from infection. The care plan interventions included offering fluids between meals, during activities, during medication pass, and during meals. During an observation and interview on 4/14/2026 at 10:02 AM, in Resident 35's room, Resident 35 was observed walking in the bathroom with an empty water pitcher. Resident 35 filled up the pitcher with tap water and drank it. Resident 35 stated neither the Certified Nurse Assistant (CNAs) and the facility staff refill the resident's water nor offer the resident with something to drink in between mealtimes. During an interview on 4/15/2026 at 09:14 AM with CNA 1, CNA 1 stated offering and refilling water between meals and as needed should be done by the facility staff for all the residents. During a concurrent observation in Resident 35's room and interview on 4/15/26 at 10:42 AM with CNA 1, CNA 1 confirmed that there was no pitcher of water at bedside available for Resident 35 to drink. During an interview on 4/15/2026 at 1:38 PM with Administrator (ADM), ADM stated tap water was not sterile and could pose risks to residents and make them sick. ADM also stated facility staff should provide adequate fluids to all residents to prevent dehydration. During a review of the facility`s Policy and Procedure (P&P) titled, Hydration, dated 1/21/2026, the P&P indicated the physician will manage significant fluid and electrolyte imbalance and associated risks, appropriately and in a timely manner. The P&P indicated for minor, uncomplicated fluid and electrolyte imbalance, oral rehydration may suffice and the staff will provide supportive measures such as supplemental fluids.

Based on observation, interview, and record review, the facility staff failed to ensure one (1) of two (2) medication carts were locked and unattended in the hallway, as indicated on the facility's policy. This deficient practice had the potential for non-authorized staff or residents to access the medication cart, which could result in diversion or if the medications were ingested, may cause serious injury/harm to the resident.Findings:During a medication pass observation on 4/16/2026 at 9:16 AM, the Licensed Vocational Nurse 1 (LVN 1) did not lock the medication cart before going to Room A to administer medications. Three (3) residents were observed walking and passing by in front of the unlocked and unattended medication cart in the hallway. During an interview on 4/16/2026 at 9:28 AM, LVN 1 stated she forgot to lock the medication cart before leaving the medication cart prior to entering Room A. LVN 1 stated residents who pass by, or other facility staff might access and take medications from the medication cart because it was unlocked and unattended. LVN 1 stated the medication cart should always be locked for the safety of the residents. During an interview on 4/16/2026 at 4:23 PM with Administrator (ADM), the ADM stated the medication cart should be kept closed, locked, and secured when it was not in use or unattended by staff. ADM stated it is not safe for residents because the residents can access the medications in the cart and consume them. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 1/26/2026, the P&P indicated that during administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide.

Based on observation, interview, and record review, the facility staff failed to coordinate hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) with Hospice Agency for one (1) of two (2) sampled residents (Resident 18) reviewed for hospice in accordance with the facility's policy by failing to ensure Resident 18 had:1. A physician's order of the required visits by the hospice staff (Skilled Nursing [SN], Hospice Aid [HA], Social Worker [SW], and Spiritual Care [SC).2. Physician certification (formal medical statement signed by a doctor confirming that a resident has a terminal illness with life expectancy of 6 months or less if the disease follows its normal course) and recertification (routine mandatory check-in that happens when a resident in hospice lives longer than the initial 6-month estimate) of the terminal illness.3. A hospice calendar for April 2026 of the expected scheduled visits from the hospice staff. These deficient practices have the potential to result in a delay in the delivery of hospice care and services to Resident 18. Findings: During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm (an abnormal, uncontrolled growth of cells that can invade surrounding tissue and spread to other parts of the body) of maxillary sinus (cheek) and lower lobe (section) of the left lung and basal cell carcinoma (slow growing, usually curable cancer) of the skin of other parts of the face. During a review of Resident 18's Minimum Data Set (MDS- a resident assessment tool), dated 4/2/2026, the MDS indicated Resident 18 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 18 required setup assistance (helper set up; resident completes activity) with eating and shower and was independent (resident completes the activity by themselves with no assistance from helper) with oral, toileting and personal hygiene, upper and lower body dressing, and putting on/taking off footwear. During a review of the Physicians order dated 4/3/2026 at 10:44 PM, the physician's order indicated Resident 18 may be admitted to Hospice 1 (HP 1) service. During a concurrent observation in Resident 18's room and interview on 4/14/2026 1:52 PM, Resident 18 was lying in bed and stated he was unsure how often hospice staff come in to see him. During a review of Resident 18's HP 1 binder on 4/14/2026 at 2:57 PM, the resident's HP 1 binder did not include April 2026 calendar of the expected scheduled visits from the hospice staff and a Physician certification and recertification of the terminal illness. During the concurrent interview and record review with Licensed Vocational Nurse 3 (LVN 3) on 4/16/2026 at 11:34 AM, Resident 18's HP 1 binder for the month of April 2026 was reviewed. LVN 3 stated the HP 1 binder did not have the hospice order with the plan of care, the frequency of visits by the hospice interdisciplinary team (IDT, comprised of team members from different disciplines working together, with a common purpose, to set goals, make decisions, and share resources and responsibilities) and a calendar with their scheduled visits for the month of April 2026. LVN 3 also stated all this information should be in the HP 1 binder so the facility staff could coordinate Resident 18's care with hospice staff. LVN 3 also stated having the calendar will allow them to know what to follow up and when hospice staff are supposed to come. During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 4/16/2026 at 12:04 PM, Resident 18's HP 1 binder was reviewed. ADON stated there should be a physician's order with the certification of the terminal illness specific to the resident in the HP 1 binder with the plan of care including the frequency of visits by hospice IDT. The ADON also stated the HP 1 binder should have all this information to ensure the facility staff are aware of the anticipated dates of the hospice IDT visits, do a follow up if they failed to come and provide coordination and continuity of care with the facility staff for Resident 18.During an interview on 4/16/2026 at 3:07 PM, Registered Nurse 1 (RN 1) stated the physicians order with the frequency of visits by each of the HP 1 IDT should be in the HP 1 binder to be able to know when they are expected to come and visit Resident 18. RN 1 stated this will ensure the resident was getting the services as ordered. RN 1 also stated if this information was not in the HP 1 binder, it could cause a lot of miscommunications and Resident 18 may not receive the hospice services timely. During an interview on 4/17/2026 at 9:31 AM, the Director of Nursing (DON) stated the schedule of the hospice IDT visit should be in the binder to ensure the care is being collaborated with the hospice and the staff at the facility. The DON also stated the HP calendar reflecting the schedule of the hospice IDT visit is important to ensure the care will be provided to the resident and the facility staff would be able to contact HP if they missed a visit and verify if they would be coming or not. During a review of the facility's Policy and Procedure (P&P) titled, Hospice Program, dated 1/21/2026, the P&P indicated it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. The P&P also indicated that the facility would obtain the following information from the hospice:The most recent hospice plan of care specific to each resident.Hospice election form.Physician certification and recertification of the terminal illness specific to each resident.

Based on observation, interview, and record review, the facility failed to observe infection control measures for one (1) of 1 sampled resident (Residents 7) reviewed for tube feeding (a medical method of delivering liquid nutrition, fluids, and medications directly into the stomach or small intestine through a soft, flexible tube) by failing to ensure Resident 7's Gastrostomy tube (GT- tube feeing via the) was not touching the floor. This deficient practice can result in contamination of the resident's care equipment (tube feeding) and place the residents at risk of infection. During a review of Resident 7's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis that included gastrostomy (is a surgical inserting a feeding tube into the stomach, enabling direct nutrition, hydration, or medication delivery), dysphagia (difficulty swallowing food or liquid from the mouth to the stomach.), and type 2 diabetes mellitus (a condition in which the body cannot regulate blood sugar levels in the blood). During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool), dated 2/6/2026, the MDS indicated Resident 7 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 7 required substantial/maximal assistance (helper does more than half the effort) with upper/lower body dressing and was dependent (helper does all the effort) with oral hygiene, toileting hygiene, and personal hygiene. During an observation on 4/14/2026 at 9:48 AM in Resident 7's room, Resident 7's GT's feeding port (external opening of a feeding tube) was touching the floor and it does not have a cap covering the GT feeding port. During a concurrent observation on 4/14/2026 at 12:37 PM with Licensed Vocational Nurse 3 (LVN 3) in Resident 7's room, LVN 3 confirmed Resident 7's GT feeding port was touching the floor, , and missing the cap. LVN 3 picked up the GT feeding tube, wiped the GT feeding port with alcohol pad, and covered it with the cap then walked away. During an interview on 4/15/2026 at 2:19 PM with LVN 3, LVN 3 stated, any parts of the GT feeding should not be touching the floor for infection control reasons and the GT feeding port not covered with a cap and touching the floor placed Resident 7 at risk of acquiring an infection. LVN 3 stated GT should be covered with a cap when not in use. During an interview on 4/16/2026 at 12:28 PM with Infection Prevention Nurse (IPN), IPN stated uncovered GT feeding port and it was touching the floor was unacceptable. IPN state it posed an infection risk, including GI (gastrointestinal- referring to the bodily system comprising the stomach and intestines) infection such as diarrhea, nausea, and vomiting. During a review of the facility's Policy and Procedure (P&P) titled, Enteral (administering nutrients or medicine directly into the GI tract) Feedings-safety Precautions, dated 1/21/2026, the P&P indicated to maintain strict aseptic technique (focus on maintaining contamination free environment during procedures) at all times when working with enteral nutrition systems and formulas.

Based on interview and record review, the facility failed to offer and provide Influenza (flu, a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs) immunization for one (1) of five (5) sampled residents (Resident 13) reviewed for infection prevention, control, and immunizations (process of protecting a person from a disease by giving a vaccine that helps the body build immunity). This deficient practice had the potential to increase Resident 13's risk of infection and suffer from severe complications such as pneumonia (lung infection), hospitalization, and death. Findings: During a review of Resident 13's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included disorder involving immune mechanism (body's internal security team, composed of cells, tissues, and organs that detect and destroy harmful invaders like bacteria, viruses and toxins), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 13's Minimum Data Set (MDS- a resident assessment tool), dated 3/9/2026, the MDS indicated Resident 13 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 13 required partial/moderate assistance (helper does less than half the effort) with shower and required supervision (helper provides cues) with toileting hygiene, oral hygiene, upper and lower body dressing, personal hygiene, sit to lying, and walking. The MDS indicated Resident 13 did not receive the influenza vaccine in the facility for the year's influenza season. During a concurrent interview and record review on 4/16/2026 at 3:48 PM, the influenza immunization record from 2015 - 2026 was reviewed. Infection Prevention Nurse (IPN) stated Resident 13's influenza immunization was historical which indicated Resident 13 received the immunization on 8/21/2018. IPN stated there was no influenza immunization offered to Resident 13 since admission on [DATE]. The IPN further stated it is important to offer influenza immunizations so the residents would have a chance to fight upper respiratory infections and prevent illnesses that could negatively affect their health and well-being. During an interview on 4/17/2026 at 11:24 AM, the Assistant Director of Nursing (ADON) stated influenza immunizations should be offered to the residents to ensure they are protected from flu virus. ADON added that if the residents get sick with the influenza, the residents will have milder symptoms and reduce the risk of severe illness. During a review of the facility's Policy and Procedure (P&P) titled, Influenza Vaccine, dated 1/21/2026, the P&P indicated that all residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The P&P also indicated that between October 1st and March 31st each year, the influenza vaccine shall be offered to residents unless the vaccine is medically contraindicated, or the resident has already been immunized

Based on interview and record review, the facility failed to offer and provide Coronavirus-19 (Covid-19, an acute respiratory illness in humans caused by coronavirus, capable of producing severe symptoms and in some cases death, especially in older people and those with underlying health conditions) immunization for one (1) of five (5) sampled residents (Resident 13) reviewed for infection prevention, control, and immunizations (process of protecting a person from a disease by giving a vaccine that helps the body build immunity) in accordance with the facility policy. This deficient practice had the potential to increase Resident 13's risk of acquiring and transmitting Covid-19 virus to other residents in the facility. Findings: During a review of Resident 13's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included disorder involving immune mechanism (body's internal security team, composed of cells, tissues, and organs that detect and destroy harmful invaders like bacteria, viruses and toxins), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should) and type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 13's Minimum Data Set (MDS- a resident assessment tool), dated 3/9/2026, the MDS indicated Resident 13 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 13 required partial/moderate assistance (helper does less than half the effort) with shower and required supervision (helper provides cues) with toileting hygiene, oral hygiene, upper and lower body dressing, personal hygiene, sit to lying, and walking. The MDS indicated Resident 13 was not up to date with Covid-19 vaccination. During a concurrent interview and record review on 4/16/2026 at 3:48 PM, the Covid-19 record from 2015 to 2026 was reviewed. Infection Prevention Nurse (IPN) stated Resident 13's Covid-19 immunization was historical, which indicated Resident 13 received the immunization on 1/19/2022. IPN also stated there was no Covid-19 immunization offered to Resident 13's upon admission and till now. Resident 13 stated there were no records/documented evidence that indicated it was offered. The IPN further stated it was important to offer Covid-19 immunizations so the residents would have a chance to fight upper respiratory infections and prevent illnesses that could negatively affect their health and well-being. During an interview on 4/17/2026 at 11:24 AM, the Assistant Director of Nursing (ADON) stated Covid-19 immunizations should be offered to the residents to ensure they are protected from the Covid-19 virus. The ADON stated if a resident, who received Covid 19 immunization, get sick with Covid-19, the resident is more likely to experience milder symptoms and a reduced risk of severe illness. During a review of the facility's Policy and Procedure (P&P) titled, Coronavirus Disease (COVID-19)- Vaccination of Residents, revised 8/2025, the P&P indicated that residents are offered the Covid-19 vaccine unless the immunization is medically contraindicated or the resident is fully vaccinated. The P&P also indicated that residents who are eligible to receive the Covid-19 vaccine are offered the vaccine.

Based on observation, interview, and record review, the facility failed to ensure the call light was within resident's arm's reach for one (1) of four (4) sampled residents (Resident 2) reviewed for environment in accordance with the facility's policy. This deficient practice had the potential for Resident 2 not to be able to call the facility staff for help or assistance, especially during an emergency.Findings: During a review of Resident 2's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included unsteadiness on the feet, lack of coordination, and anxiety disorder (a mental health disorder characterized by feeling of worry, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 4/1/2026, the MDS indicated Resident 2 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 2 was independent (resident completes the activity by themselves with no assistance from helper) with eating, oral, toileting, and personal hygiene, shower, upper and lower body dressing and putting on/taking off footwear. During a review of Resident 2's Care Plan, initiated on 7/9/2025 and revised on 4/8/2026, the Care Plan indicated the resident was at risk for fluctuating Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily) due to residents mood/behavior and included an intervention to ensure the resident's call light is within reach. During a review of Resident 2's Care Plan, initiated on 7/9/2025 Resident 2's Care Plan also indicated Resident 2 was at risk for fall related to poor balance from psychotropic drug (any substance that acts on the brain to change a person's mood, thoughts, feelings, or behavior) use and included an intervention to ensure the resident's call light is within reach. During a concurrent observation in Resident 2's room and interview on 4/14/2026 at 8:57 AM, Resident 2 was lying in bed watching television. Resident 2's call light was on the left side of the resident's bed, on the floor, which was confirmed by Certified Nursing Assistant 1 (CNA 1), who then clipped the call light within the resident's reach. During an observation in Resident 2's room on 4/14/2026 at 1:54 PM, Resident 2 was lying in bed with the call light not within reach. The call light was on the left side of the resident's bed on the floor. During an interview on 4/15/2026 at 12:40 PM, CNA 2 stated Resident 2's call light should be within the resident's reach so the resident could alert staff if he needed something. CNA 2 also stated that Resident 2 uses his call light to ask for assistance. During an interview on 4/16/2026 at 9:31 AM, the Assistant Director of Nursing (ADON) stated the call lights should be close to the residents' and within the residents' reach so they could call if they need something from the staff and could alert the staff for any emergencies. During a review of the facility's Policy and Procedure (P&P) titled, Answering the Call Light, dated 1/21/2026, the P&P indicated its purpose was to ensure timely responses to the resident's requests and needs. The P&P also indicated in the general guidelines to ensure that the call light is accessible to the resident when in bed.

Based on interview and record review, the facility failed to ensure an accurate assessment of the Minimum Data Set (MDS, a resident assessment tool) for one of two sampled residents (Resident 1) to reflect the resident's functional ability of walking. This deficient practice had the potential for the facility not to develop and implement an individualized care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives, interventions and timeframes to meet a resident's medical, nursing, and mental psychosocial needs) which could negatively affect Resident 1's overall well-being.Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE], with the diagnoses including but not limited to schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and difficulty walking. During a record review of Resident 1's Minimum Data Set, dated [DATE], the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was independent (decisions consistent/reasonable). The MDS indicated Resident 1 required setup or clean-up assistance with eating. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying assistance as resident completes activity) with oral and toileting hygiene, upper and lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or support trunks or limbs) with shower. The MDS indicated Resident 1 required partial/moderate assistance to walk 10 feet (unit of measurement). During an interview on 4/3/2026 at 9 AM with Restorative Nurse Assistant (RNA), RNA stated Resident 1 has been walking with staff supervision and did not need a cane or walker since resident's admission on [DATE]. RNA stated there has not been any change with the residents' level of assistance with walking, for which Resident 1 only required supervision from staff. During an interview on 4/3/2026 at 10:40 AM with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated Resident 1 has always been requiring supervision. Resident 1 was being supervised by staff in the hallway after Resident 1 had his smoke break on 3/29/2026. During a concurrent record review and interview on 4/3/2026 at 3:30 PM with MDS nurse (MDSN), Resident 1's MDS dated [DATE] was reviewed. MDSN stated Resident 1 requires supervision with walking. MDSN stated Resident 1's MDS dated [DATE] indicated resident required partial/moderate assistance with walking. MDSN stated he should have coded resident's MDS for functional ability for walking as supervision. The MDSN stated it was important for the MDS to be accurate to ensure the development and implementation of an individualized resident care plan. During a review of the facility's policy and procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, reviewed on 2/26/2026, indicated any person completing a portion of the MDS must sign and certify the accuracy of that portion of the assessment.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one of two sampled Residents (Resident 1) when Resident 2 punched Resident 1's face on 3/9/2026. This failure resulted in Resident 1 having a skin tear to the left upper lip and possible psychosocial harm.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included but not limited to other encephalopathy (damage or disease that affects the brain), anxiety disorder (fear characterized by behavioral disturbances), and schizoaffective disorder (a mental health problem were a person experiences loss of contact with reality as well as mood symptoms). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 3/4/2026, the MDS indicated Resident 1 was assessed having moderately impaired (decisions poor; cues/supervision required) cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with lower body dressing, putting on/taking off footwear, rolling left and right, and sit to lying. The MDS indicated Resident 1 was dependent (helper does all of the effort) with toileting hygiene, shower/bathe self, and sit to stand. During a review of Resident 1's INC (incident)- Behavior Related Incidents form, dated 3/9/2026, the INC-Behavior Related Incidents form indicated the following:Under Brief Summary of Incident: At 8 AM, a commotion was heard by the Charge Nurse (CN) around the patio area were both Resident 1 and Resident 2 were. Certified Nursing Assistant 1 (CNA 1) explained that there were words exchanged (unknown what was said) and Resident 2 threw a punch that landed on Resident 1's left lip. Resident's 1 was noted with a superficial (situated or occurring on the skin or immediately beneath it) skin tear to the left upper lipUnder Skin Assessment: Resident 1's skin tear measured 0.4 centimeter (cm- unit of measurement in length) skin tear with slight bleedingUnder Assessment/Evaluation (other): Resident 1 threw a verbal comment to Resident 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to iron deficiency anemia (when the body doesn't get enough iron causing fatigue, pale skin, and dizziness), paranoid schizophrenia (a mental health disorder where a person experiences intense, irrational suspicion, paranoia, and hearing voices), and vascular dementia (a decline in mental abilities caused by damaged blood vessels reducing blood flow and oxygen to the brain, damaging brain tissue). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was assessed having moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 2 required supervision or touching assistance with oral hygiene, upper body dressing, rolling left and right, sit to lying, sit to stand, and toilet transfer. The MDS indicated Resident 2 required partially/moderate assistance (helper does less than half the effort) with toileting hygiene, lower body dressing, putting on/taking off footwear, and walking 10 feet (ft- unit of measurement for distance). During a review of Resident 1's Physician's Order, dated 2/17/2026, the Physician's Order indicated one on one monitoring (a high-level safety intervention in healthcare settings where a single, trained staff member is assigned to directly observe and supervise one specific resident at all times). During a review of Resident 2's Care Plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs), revised on 2/25/2026, the Care Plan indicated Resident 2 was at risk for transient, stress-related suicidal ideation, related to history of mental illness manifested we will move him closer to the nurse's station and put him on one-on-one sitter. During a review of Resident 2's Care plan, revised on 2/25/2026, the Care Plan indicated Resident 2 had an episode of physical interaction with another Resident. The Care Plan intervention indicated to anticipate care needs and make provisions prior to resident becoming overly stressed, intervene as needed to protect the rights and safety of others, provide close monitoring while resident is in aggressive posture, and to restrict resident access to other residents for safety. During a review of the facility's Interview Record form, dated 3/8/2026, the Interview Record form indicated CNA 1 was looking on the rack and choosing the clothes near the elevator. Resident 1 was sitting in his wheelchair at CNA 1's left side when Resident 1 wheeled in the hallway near Resident 2. Resident 1 said to move and said excuse me and Resident 2 moved a little bit. Resident 1 made a comment, and Resident extended his hand up in the air and hit the lip of Resident 1 in a split second. During an interview with Resident 1 on 3/18/2026, at 11:50 AM, Resident 1 stated she sustained a cut inside her mouth after she was hit with a fist by another resident. Resident 1 stated she did not know the name of the resident who hit her. During an interview on 3/18/2026, at 12:30 PM, with CNA 1, CNA 1 stated on 3/9/2026 she was assigned to Resident 2 for one on one monitoring. CNA 1 stated she was assigned to supervise and monitor Resident 2's behavior and make sure he was safe. CNA 1 stated Resident 2 has a history of mood swings and aggressive behavior. CNA 1 stated Resident 2 was sitting in his wheelchair next to her while she looked for clothes for Resident 2 in the clothes rack. CNA 1 stated Resident 1 approached her and Resident 2 in her wheelchair and said, Excuse me. CNA 1 stated Resident 2 moved his wheelchair a little bit and Resident 1 said, Fuck you! to Resident 2. CNA 1 stated Resident 2 turned towards Resident 1 and punched her. CNA 1 stated she could not prevent the incident from happening because she was facing the clothes rack and had clothes in her hands. CNA 1 stated Resident 2 had already punched Resident 1 in the mouth by the time she turned towards Resident 2. During an interview on 3/18/2026, at 1:26 PM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated on 3/9/2026, during morning medication administration, LVN 1 observed Resident 2 in the hallway by the clothes rack with CNA 1. LVN 1 stated Resident 1 turned the corner and was going towards the patio when Resident 2 moved his arm and hit Resident 1's mouth. LVN 1 stated Resident 1 stated, Ow, you hit me [NAME]! LVN 1 stated she did not hear the conversation that transpired between Resident 1 and Resident 2 in the hallway. During an interview on 3/18/2026, at 1:41 PM, with the Director of Nursing (DON), the DON stated Resident 2 was on one on one monitoring because of his history of aggressive behavior towards another resident in the facility. DON stated CNA 1 was choosing Resident 2's clothes when Resident 1 passed by and said something bad to Resident 2. DON stated Resident 2 hit Resident 1 after Resident 1 said something bad to Resident 2. DON stated Resident 1 sustained a small cut on her upper lip. During an interview on 3/18/2026, at 3:15 PM, with CNA 2, CNA 2 stated she was sometimes assigned to Resident 2 for one on one monitoring. CNA 2 stated the responsibility of facility staff assigned to Resident 2 for one on one monitoring was to supervise Resident 2 and provide redirection when he got aggressive. CNA 2 stated Resident 2 was easily triggered and aggravated by other residents. CNA 2 stated Resident 2 had psych issues and needed to be watched at all times to prevent altercations with other residents. CNA 2 stated residents on one on one monitoring should not be left alone and unsupervised. CNA 2 stated CNA 1 should not have kept her eyes away from Resident 2. During an interview on 3/18/2026, at 3:40 PM, with the Director of Staffing Development (DSD), DSD stated a one on one sitter's task was to stay and pay attention to the actions of the resident being supervised. DSD stated sitters were not supposed to take their eyes away from the residents on one on one monitoring because these residents can make unexpected movements and anything can happen. During a follow-up interview on 3/18/2026, at 3:48 PM, with the DON, DON stated CNA 1's responsibility was to keep an eye on Resident 2 because he had a history of hitting, scratching, and fighting with other residents in the facility. The DON stated CNA 1 was not watching Resident 2 when she was looking for the clothes in the clothes rack. The DON stated if CNA 1 watched Resident 2, then the incident between Resident 1 and Resident 2 could have been prevented. During a review of the facility's policy and procedure (P&P), titled, Abuse Prevention Program, revised on 12/2016, the P&P indicated that as part of the resident abuse prevention, the administration will protect the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual.

Based on interview, and record review, facility failed to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) of one of two sampled residents (Resident 1) by: 1. Failing to revise Resident 1's care plan for moderate risk for fall related to gait/ balance problems after the resident's Minimum Data Set (MDS, standardized care and screening tool) and Physical Therapy Treatment Encounter Notes (PT Note - documents sequential implementation (executing one task at a time, in order)of the plan of care established by the physical therapist, including changes in patient/client status and variations and progressions of specific interventions used) were completed on 7/15/2024 and 7/16/2024 to reflect the resident's, need for partial moderate assistance (helper does less than half the effort. Helper lifts, holds or support trunk or limbs. But provides less than half the effort) and contact guard assist (CGA, maintaining close contact with the resident to provide immediate support and prevent falls without fully taking over their movements) when ambulating. 2. Failing to provide partial moderate assistance and/ or CGA to Resident 1 when the resident was ambulating on 9/22/2024 in the dining/ activity room in accordance with the resident's MDS and PT note. These deficient practices resulted in Resident 1 falling on 9/22/2024 at 3:20 PM. On 9/23/2024 at 9 AM, Resident 1 complained of left hip pain and was sent to general acute care hospital (GACH) 1 at 6:12 PM and was found to have sustained left sub capital fracture (these fractures occur in the neck of the thighbone). On 9/24/2024 at 5:07 PM, Resident 1 had surgery of left total hip arthroplasty (the surgical reconstruction or replacement of a joint). Findings: During a review of Resident 1's admission record indicated the facility admitted Resident 1 on 4/8/2024 with diagnosis which include lack of coordination, anxiety (a feeling of fear, dread, and uneasiness), and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 1's History and Physical (H&P) dated 4/9/2024 indicated Resident 1 is not competent to understand his medical condition. During a review of Resident 2's Minimum Data Set (MDS, standardized care and screening tool), dated 7/16/2024, indicated Resident 1 was assessed to be cognitively impaired (process of thinking and reasoning). The MDS also indicated Resident 1 was assessed to need partial moderate assistance (helper does less than half the effort. Helper lifts, holds or support trunk or limbs. But provides less than half the effort) on walk 10 feet ([ft., a unit to measure the length or distance] once standing, the ability to walk at least 10 ft. in a room, corridor, or similar space) and walk 50 ft. with two turns (once standing, the ability to walk at least 50 ft. and make 2 turns). During a concurrent interview and record review on 10/2/2024 at 11:33 AM with the License Vocational Nurse (LVN 1), Resident 1's Fall Risk Assessment (checks to see how likely it is that you will fall) dated 4/8/2024 and timed at 4:09PM was reviewed. LVN 1 stated the Fall Risk Assessment score was nine (9) which means the resident is at moderate risk for fall. During a concurrent interview and record review on 10/2/2024 at 11:40 AM with LVN 1, Resident 1's Situation, Background, Assessment, and Recommendation (SBAR- is a structured communication framework that can help teams share information about the condition of a patient or team member or about another issue your team needs to address) dated 9/22/2024 and timed at 9:28 PM was reviewed. The SBAR indicated Resident 1 had a fall in the afternoon, resident lost his balance in the dining room/activity room. During a concurrent interview and record review on 10/2/2024 at 11:45 AM with LVN 1, Resident 1's SBAR dated 9/23/2024 and timed at 9 AM was reviewed. The SBAR indicated Resident 1 was complaining of pain on his left hip and primary physician (PMD) ordered STAT (without delay) X-ray (imaging creates pictures of the inside of your body) of the left hip. The SBAR indicated X-ray result indicated acute left sub capital fracture. PMD ordered to transfer Resident 1 to GACH 1. During a review of Resident 1's Radiology (a branch of medicine that uses imaging technology to diagnose and treat disease) Result Report (done in the facility) examination date 9/23/2024 timed at 12:15 PM, the radiology result report indicated the resident have a left sub capital fracture with 2.3- centimeter (cm, unit of measure in the metric system) displacement and with history of falling. During a review of Resident 1's Order Summary Report for the month of September 2024, indicated an order dated 9/23/2024 to transfer Resident 1 to GACH 1 for further evaluation, due to status post fall and fracture of left hip X-ray result. During a review of Resident 1's progress notes dated 9/23/2024 timed at 3:45 PM, the progress notes indicated, Resident 1 was sent to GACH 1. During an interview on 10/2/2024 at 11:55 AM, with the Certified Nursing Assistant (CNA 1), CNA 1 stated Resident 1 ambulates and used wheelchair as a walker with no assistance or supervision by staff on 9/22/2024. CNA 1 also stated on 9/22/2024 at around 3 to 4 PM, in the activity room, CNA 1 saw Resident 1 on the floor laying flat on his left side and called the charge nurse for help. During an interview on 10/2/2024 at 1:49 PM with Registered Nurse (RN 1), RN1 stated on 9/22/2024 prior to Resident 1's fall incident in the activity room, RN 1 saw Resident 1 walking using the back of the wheelchair and no facility staff was assisting the resident at the hallway. RN 1 stated, RN 1 was not aware that Resident 1 needs partial moderate assistance or contact guard assist while walking. During a concurrent interview and record review on 10/2/2024 at 1:55 PM with RN 1, Resident 1's GACH 1's record was reviewed. RN1 stated the GACH 1 record indicated under MD (medical doctor) Progress notes entered on 9/24/2024 timed at 5:07 PM, Resident 1 had left hip arthroplasty. RN1 also stated, Resident 1 had left total hip arthroplasty with 10 cm incision. During a concurrent interview and record review on 10/2/2024 at 2:30 PM with the RN 1, Resident 1's MDS dated [DATE] was reviewed. RN 1 stated Resident 1's MDS indicated partial/moderate assistance on walk 10 ft. and walk 50 ft. with 2 turns. RN 1 stated this means Resident 1 needs assistance while the facility staff holds the resident's back when walking. RN 1 also stated if somebody was there to provide partial moderate assistance while Resident 1 was ambulating/ walking, we could have prevented Resident 1 from falling on 9/22/2024 which caused the resident to have left hip fracture and surgical procedure. Resident 1 stayed at GACH 1 for 5 days from 9/23/2024 to 9/27/2024. During an interview on 10/2/2024 at 2:54 PM with Activity Coordinator (AC), AC stated on 9/22/2024 between 3:30 PM to 4 PM while AC was in the activity room and giving snacks to the other residents, Resident 1 went to activity to get his snacks. Resident 1 walked to the activity room by walking behind the wheelchair and pushing on the handles to walk by himself with no assistance by the facility staff. AC also stated, AC heard the thud sound and when she turned around to check, Resident 1 was on the floor lying flat on his left side. AC also stated if facility staff was with Resident 1 at that time to provide moderate assistance while Resident 1 was walking, the fall could have been prevented. During a concurrent interview and record review on 10/2/2024 at 4PM with LVN 2, Resident 1's MDS dated [DATE] and the PT notes dated 7/15/2024 timed at 8:59AM was reviewed. LVN 2 stated, Resident 1's MDS and PT note indicated the resident needed assistance when walking and it was not implemented on 9/22/2024. LVN 2 stated, it was important to follow the MDS and PT note recommendation to give the resident the care they needed. During a concurrent interview and record review on 10/3/2024 at 3:56 PM with LVN 1, Resident 1's Care Plan for moderate risk for fall dated 5/1/2024 was reviewed. LVN 1 stated the care plan indicated Resident 1 is at moderate risk for fall related to gait/ balance problem. LVN 1 stated Resident 1's care plan was not person- centered (focusing care on the needs of the individual) and it should be indicated in the care plan that Resident 1 should be assisted during ambulation/ when walking. LVN 1 also stated, there should be a care plan to address Resident 1's need for partial moderate assistance in accordance with the resident's MDS completed on 7/16/2024. LVN 1 also stated, Resident 1's care plan should have reflected the resident's need for CGA with gait/ when walking in accordance with Resident 1's PT note that was completed on 7/15/2024. During a concurrent interview and record review on 10/3/2024 at 9:40 PM with the Physical Therapy Assistant (PTA), Resident 1's PT note dated 7/15/2024 entered at 8:59 AM was reviewed. The PT note indicated for Resident 1's gait the resident needed CGA x 225 ft with four-wheel walker (FWW). PTA stated CGA means to hold and guide the resident while walking. PTA also stated, a facility staff needs to be with the resident when ambulating to assist the resident while holding the resident's back area when walking for safety and to prevent the resident from falling. During a review of facility's P&P titled Care Plans, Comprehensive Person Centered revised date12/2016 indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. During a review of facility's Policies and Procedure (P&P) titled Falls and Fall Risk, Managing revised date 3/2018 indicated, based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P&P also indicated the staff will implement resident centered fall prevention plan to reduce the specific risk factor(s) of fall for each resident at risk or with history of fall.

Based on observation, interview and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and transmitted from person to person) by failing to: 1. Ensure designated staff in one (the Red Zone/area with COVID-19 positive residents) of three resident cohorting areas (areas used to house residents with similar COVID-19 risk) for COVID-19. a. Certified Nursing Assistant 1 (CNA 1), who was assigned to the Red Zone, crossed between the Red to the Green (area with residents who are COVID-19 free) Zone to provide care to the residents during the shift. b. Registered Nurse 1 (RN 1) provided medication to Red Zone residents first and then returned to provide medications to residents in the Green Zone. 2. Ensure facility was closed to new admission. There were three of three new admission of COVID-19 positive residents (Resident 1, Resident 2, and Resident 3). These deficient practices had the potential to result in the spread of COVID-19, placing 48 residents and the staff at risk of infection with COVID-19 and becoming seriously ill, leading to hospitalization and/or death. On 1/13/2022 at 4:48 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADMIN) and the Infection Preventionist (IP) for the facility's failure to implement measures to prevent the transmission of COVID-19 infection, which threatened the health and safety of the residents and staff. On 1/15/2022 at 2:50 p.m., the IJ was lifted after the facility submitted an acceptable Plan of Action (POA) and the Administrator was notified. The survey team verified and confirmed on-site the implementation of the POA through observation, interview, and record review. The accepted POA included the following actions: 1. The Director of Nursing (DON) assessed residents in rooms 3, 4, 5, 6, 7 and 10 on 1/14/2022. There was no change in condition noted on any of the residents. Residents in rooms 3, 4, 5, 6, 7 and 10 were designated as Yellow Zone rooms and are being observed for any signs and symptoms of COVID-19 infections. Medical Director (MD) and Responsible Party were made aware by RN and Social Service Director on 1/14/2022. 2. Current staff were given immediately given an in-service on cohorting, personal protective equipment (PPE, protective items or garments worn to protect the body or clothing to protect residents from cross-transmission), designated staffing areas, and interfacility transfer rules on 1/14/2022. 3. Designated Red Zone barriers was enhanced to help remind and prevent staff and residents from crossing to another zone by the Maintenance Director on 1/14/2022. This set up was approved by Public Health Nurse. 4. The DON updated the staffing schedule to include Red Zone assignments on 1/14/2022. This same process will follow the Staffing guidelines based on Mitigation Plan and Emergency Staffing Guidelines based on the Local Public Health Guidelines. On night shift, a CNA was designated in the Red Zone to take vital signs and notify nurse of signs and symptoms of COVID-19. The License Nurse gives medication to Green or Yellow Zone first and then goes into the Red Zone to give the residents medication last and stays in the Red Zone the rest of the shift. At least two licensed nurses on the morning and evening shifts. One licensed nurse is in the designated red zone throughout the shift while the other licensed nurse remains in the yellow and green zone. Other nursing support such as Director of Staff Development (DSD), IP or DON will assist if needed. 5. For the 3 residents referred to for interfacility transfer, the MD and Responsible Party made aware. 6. On 1/14/2022, compliance will be monitored by the IP Nurse or designee daily and report findings to the Quality Assessment and Assurance/Quality Assurance and Performance Improvement (QAA/QAPI, a program to improve the quality of life and quality of care and services delivered in nursing homes) Committee regarding: a. Cohorting b. Use of appropriate PPE c. Compliance to Staff Assignments Findings: A review of the facility's census during onsite visits conducted on 1/13/2022 indicated the facility had 48 residents in-house. There were 2 residents in the red zone, 4 residents in yellow zone and 41 residents in the green zone. 1a. During an observation on 1/13/2022 at 12:20 p.m. Certified Nursing Assistant 1 (CNA 1) exited the red zone barrier with N95 and face shield and without isolation gown and went into residents' room in the green zone picked up a lunch tray. During a concurrent interview with CNA 1 about her assignment, she stated that she had been working between the red zone and green zone providing care to residents during her shift. A review of the Nursing Staffing Assignment and Sign-In Sheet dated 1/13/2022 for the 7 a.m. to 3 p.m. shift, indicated CNA 1 was assigned to Rooms 1AB, 2A, 3AB and 4AC. A review of the Facility's Cohorting Area Map indicated Rooms 2 was a red zone resident room and rooms [ROOM NUMBERS] were green zone resident rooms. 1b. During an interview on 1/13/2022 at 12:30 p.m., Registered Nurse 1 (RN 1) stated she administered medications for two residents in the red zone around 10 a.m and then returned to green zone to continue administering medication to residents in the green zone. When asked if her assignment was acceptable with the Infection Preventionist Nurse (IPN); she stated Yes and that her assignment was not acceptable based on infection control policy. During an interview on 1/13/2022 at 12:58 p.m., with RN 1 and Administrator, RN 1 verify she had administered medication to residents in the red zone around 10 a.m., and currently administering medication to residents in the green zone. During an interview on 1/13/2022 at 1:05 p.m. with IPN 1 to verify the cohorting procedures, IPN 1 stated staff working in the red zone should stay in the red zone and not to crossed over to green zone. IPN 1 stated if staff from green zone go to red zone, then they should stay in the red zone until they leave for their shift. During an interview on 1/13/2022 at 2 p.m., the Local Public Health Department Nurse (PHN 1) came to visit the facility and confirmed the recommendation from the Local Public Health for designated staffing for the red zone was that staff should stay in red zone and cannot go to any other zone. During an interview on 1/14/2022 at 2:17 p.m., IPN 2 stated per facility policy staff assigned to the red zone should stay for their entire shift in the red zone and should not cross over to the green or yellow zone. 2. During an interview on 1/13/2022 at 2:46 p.m., with PHN 2, she reported three residents were new admission to the facility without prior notification to the Local Public Health, Resident 1, 2 and 3. A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted Resident 1 on 1/10/2022 with diagnosis of COVID-19. During an interview on 1/13/2022 at 3:25 p.m., with Resident 1, who was alert and oriented did not want to provide his real name or information about the transfer. A review of Resident 2's Admission Record (Face Sheet) indicated the facility admitted Resident 2 on 1/7/2022 with diagnosis of COVID-19. During an interview on 1/13/2022 at 3:51 p.m., with Resident 2, who was alert, oriented and currently in the red zone, stated he was notified he was going to be transferred to another facility. A review of Resident 3's Admission Record (Face Sheet) indicated the facility admitted Resident 3 on 1/10/2022 with diagnoses including COVID-19. During an attempt to interview Resident 3 on 1/12/22 at 3:51 p.m., the resident was in the red zone but was not alert and orient enough to answer question. During an interview on 1/15/2022 at 1:28 p.m., the Administrator stated after the IJ was called the facility will not admit new residents without Local Public Health approval. During the abbreviated survey, the Administrator did not provide the requested facility's policies and procedures on infection control and mitigating COVID-19.

Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to provide care for 28 of 46 residents by failing to: 1. Ensure there was a licensed nurse on duty between 11 a.m. to 3 p.m. on January 14, 2021 to provide care for 28 of 46 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 and 28), who were positive for COVID-19 (Coronavirus disease, a severe respiratory illness caused by [MEDICAL CONDITION] and spread from person to person). 2. Have an Infection Preventionist Nurse (IPN), from January 8, 2021 to January 14, 2021, to oversee facility's staff compliance to infection control guidelines that included compliance of staff to use appropriate personal protective equipment such as face mask for protection from the COVID - 19 virus. The facility also failed to provide sufficient nursing staff to provide care for 46 of 46 residents by failing to: 3. Ensure the facility had the following administrative staff: a. From December 1, 2020 to January 14, 2021, there was no Director of Nursing (DON), who was responsible for management of staffing to determine the staffing needs of the nursing department necessary to meet the nursing needs of the 46 of 46 residents. b. From October 28, 2020 to January 14, 2021, there was no Director of Staff Development (DSD), who was responsible for overseeing the facility had enough certified nursing assistant to care for 46 of 46 residents. c. From December 31, 2020 to January 14, 2021, there was no Minimum Data Set nurse/Resident Assessment Coordinator (MDS), who was responsible for conducting and coordinating the development and completion of the resident assessment for 46 of 46 residents. This deficient practice resulted in the residents in the Red Zone (area for COVID-19 positive residents) not having care provided by a licensed nurse for four hours, and the CNAs, who were caring for the residents felt overwhelmed. The facility had no IPN for six days and as a result, the IPN's duty to fit test all the facility staff were not completed. The facility had no DON for forty-five days and no DSD for seventy-nine days. As a result, there were no DON and DSD to provide advance planning of the facility staffing to maximize staff availability and determine the nursing department needs (direct care such as treatments, counselling, patient education and administration of medication) of the patients. The facility had no MDS nurse for 15 days, and the MDS duties (conduct and coordinate the development and completion of the resident assessments) were not completed. On January 14, 2021 at 6:45 p.m., the Administrator and Assistant Director of Nursing (ADON) were notified of an Immediate Jeopardy (IJ, a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) regarding the facility's failure to provide adequate staff to provide care for residents in both the Yellow Zone (an area in the facility where resident exposed to or suspected of COVID-19 are cohorted) and Red Zone (designated area in the facility for residents who tested positive for COVID-19) . On January 21, 2021 at 5:45 pm, the IJ was abated after the facility's administrative staff provided an acceptable Plan of Action (POA, interventions to correct the deficient practices). The surveyor verified and confirmed the implementations of the POA while onsite by observation, interview and record review. The IJ was removed in the presence of the Administrator and the Office Manager, the POA was as follows: 1. On January 15, 2021, Nursing Home Administrator (NHA) contacted the emergency services for the county and public health nurse to request for additional county support due to staffing COVID surge. 2. New registry contract was signed on January 15, 2021, by the facility's NHA with staffing agency for personnel need requirements for the facility. 3. The facility has the following staff working: a. Director of Nurses: Current ADON was currently acting DON and has been hired on and has been working at the facility and transitioned on January 15, 2021. The facility has a current RN supervisor that works 7 a.m. to 3 p.m. b. Infection Control Nurse: The Infection Control Designee (ICD) nurse position will be shared by two employees. IP would be starting part time on January 21, 2021 and Consultant would be second part time IP nurse. c. DSD has been hired and will start on January 18, 2021. The DSD will work 20 hours per week as per Title 22 regulation according to facility size. d. MDS has been hired an offer letter has been signed to start on January 25, 2021. Currently, MDS is being completed by a part time per diem licensed vocational nurse (LVN) MDS nurse. (Cross reference F 880) Findings: 1. A review of the facility's census, dated January 14, 2021, indicated a total of 46 residents. Twenty-eight residents were in the Red Zone, and 18 residents were in the Yellow Zone. A review of the Nursing Staffing and Assignment dated January 14, 2021, indicated the 7 a.m. to 3 p.m. staffing in the Red Zone was composed of three Certified Nursing Assistants (CNAs) and one Licensed Vocational Nurse (LVN). A review of the Nursing Staffing and Assignment dated January 14, 2021, indicated the 7 a.m. to 3 p.m. staffing in the Yellow Zone was composed of two CNAs and one LVN. On January 14, 2021 at 2:23 p.m., CNA 3 was observed entering the Red Zone. (CNA 3 had been observed working in the Yellow Zone as a DSD assistant during initial tour earlier in the day). During a concurrent interview, CNA 3 stated she was asked to assist the staff in the Red Zone. On January 14, 2021 at 2:35 p.m., during a concurrent interview, CNA 2 and CNA 4 stated there was no licensed nurse in the Red Zone. CNA 4 stated the licensed nurse had left at 11 a.m. Both CNAs asked if they could get help, CNA 4 stated she was overwhelmed with the lack of staff and stated, Ya No Puedemos. (Spanish, meaning We can't do this anymore.) and Pueden Ayudarnos? (Spanish meaning Can you help us?) During an interview on January 14, 2021 at 2:55 p.m., the Administrator stated the ADON had worked a double shift the day before (January 13, 2021), assisted the staff in the Red Zone, and she left the facility at 8 a.m. on January 14, 2021. The Administrator stated an LVN from a sister facility worked in the Red Zone from 8 a.m. to 11 a.m. on January 14, 2021, then left, leaving the Red Zone without a licensed nurse. 2. A review of the facility policy, Scope Infection Control Preventionist Position, dated May 2020, indicated the Infection Control Preventionist (ICP) assumes the responsibility for the Infection Control Program of the facility. The major objectives of the ICP included assurance of the quality of patient care by reducing infection risks to residents and personnel through surveillance, provide education pertinent to infection, ascertaining the need for monitoring programs in any given area of the facility, and maintaining programs (fit testing and staff infection control practices) to identify and ultimately eliminate infection hazards. A review of the facility's, Mitigation Plan for COVID-19 infection, dated November 11, 2020, Section 3.6 Infection Prevention and Control: indicated the facility has a full time IPN from the hours of 8:00 a.m.- 4:30 p.m., Monday to Friday. He/She was the designated lead individual to address and improve infection control based on public health advisories (state and federal). On January 14, 2021 at 12:59 p.m., during an entrance conference, the Administrator stated the facility did not have an IP nurse since January 8, 2021. The administrator was asked who was responsible for implementing and monitoring the facility's infection control practices, and the administrator stated there was no one currently responsible for monitoring the infection control program in the facility. During an interview, on January 14, 2021 at 2:04 p.m., the Administrator stated it was the responsibility of the IP nurse to have the staff fit tested . The Administrator stated fit testing had been started by the former IP nurse, but once the IP nurse had quit, the fit testing was never completed. A review of the, Fit Testing Questionnaire, on January 14, 2021 at 5:30 p.m., indicated 33 out of 51 staff in the facility were not fit tested . The Administrator verified in a concurrent interview that the former IP had started to do fit testing, but it was never completed and there was no one currently assigned to fit test the remaining staff. 3. On January 14, 2021 at 12:59 p.m., during a conference, the Administrator stated the facility was in an outbreak situation related to COVID-19 that started on January 4, 2021. The Administrator stated the facility was short staffed and several employees had quit including the DON, DSD, and MDS nurse. a. Review of the job description: Director of Nursing dated May 2017, indicated the Director of Nursing has 24-hour accountability, was responsible for the delivery of high quality and cost-effective health care while achieving positive clinical outcome, and patient/family and employee satisfaction. The DON was responsible for the overall operations, integration, coordination and direction of the nursing and patient care within the facility. The responsibilities included the management of staffing to determining the staffing needs of the nursing department necessary to meet the nursing needs of the patients, recruit and interview hire, and orient nursing staff. During an interview on January 14, 2021 at 2:55 p.m., the Administrator stated the ADON had worked a double shift the day (from 2 p.m. January 13, 2021 to 8 a.m. January 14, 2021) and administered medications to the residents in the Red Zone. On January 14, 2021 at 3 p.m., during an interview, the ADON stated the staffing needs of the facility were not being met due to an increase in call offs, staff who had quit and refusal of registry staff to work in the Red Zone. The ADON stated that because she was having to assist in the Red Zone, due to lack of licensed staff, she was unable to complete her duties as ADON which included, determining the staffing needs necessary to meet the needs of the residents, scheduling and finding alternate sources for staffing of all shifts. b. A review of the undated Job Description: Director of Staff Development, indicated it was the primary function of the Director of Staff Development to plan and implement facility orientation, job skills training, in-service education and ensure continuing certification of the approved Certification Training Program approved by the Department of Public Health Services for all nursing assistants as required by regulation. On January 14, 2021 at 12:59 p.m., during an interview, the Administrator stated CNA 3 was the interim DSD assistant since the facility did not have a DSD. During an interview on January 14, 2021 at 1:49 p.m., CNA 3 stated she was being assigned DSD duties in addition to her duties as a CNA. CNA3 stated the duties included daily and monthly scheduling, daily assignments and ordering supplies such as Personal Protective Equipment (PPEs). CNA 3 stated she did not have any training or certification on how to be a DSD. CNA 3 stated she worked the morning shift from 7 a.m. to 1 p.m., on January 14, 2021, in the Red Zone as a CNA, then went home to decontaminate (the process of removing substances/microorganisms) and returned as DSD assistant in the Yellow Zone. A review of the, Nursing Staffing and Assignment, dated January 14, 2021, indicated CNA 3 was assigned to work as a CNA in the Red Zone from 7 a.m. to 3 p.m. c. A review of the undated Job Description: MDS Coordinator/Resident Assessment Coordinator indicated it is the primary function of the Resident Assessment/Care Plan Coordinator to conduct and coordinate the development and completion of the resident assessment in accordance with current federal, state and local standards, guidelines, and regulations, established policies and procedures .to ensure that the highest degree of quality of care is maintained at all times. During an interview on January 14, 2021 at 3:35 p.m., the Administrator stated the MDS duties include assessment and care planning with the interdisciplinary team. The Administrator stated the facility had placed an ad and was in the process of trying to hire an MDS nurse. During an interview on January 15, 2021 at 1:43 p.m., the ADON stated there had not been an MDS nurse since December of 2020. The MDS duties, which included resident assessments, were not being addressed. The ADON stated when possible and if available the LVN's could assist with MDS duties however, there was no designated staff assigned to perform those duties at the time. A review of the facility's Mitigation Plan (MP) for COVID-19 dated November 11, 2020, indicated under section 3.7 Emergency Staffing Strategies: It was the policy of the facility to maximize staff availability. The Staff that are not scheduled to work can be called to provide staff for the facility. The MP indicated the following: 1. Staff can work 12 hours or double shift to provide staffing for the facility. 2. The facility will utilize staffing registries if coverage for staffing needs during an emergency is not met. 3. The facility can demonstrate that there has been advanced planning in alignment with emergency preparedness plan. The DSD is the designated individual assigned with the responsibility for conducting a daily assessment of staffing status and needs and has implemented or was ready to implement backup plans as needed.

Based on observation, interview and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus, a severe respiratory illness caused by [MEDICAL CONDITION] and spread from person to person) in accordance with the local Public Health guidelines, facility's policies, and facility's Mitigation Plan (MP, a plan created to control the spread and impact of COVID-19 in the facility) by failing to: 1. Ensure two of three staff (Housekeeping Staff 1 and Certified Nursing Assistant 2) in the red zone (area where residents who are COVID-19 positive are isolated) and one of three staff (Certified Nursing Assistant 1) in the yellow zone (area where residents who have possibly been exposed to COVID-19 are isolated and monitored) were using properly fit tested (test to ensure a protective device (face mask) achieve a close facial fit that there was efficient filtration of airborne particles) size of N95 face mask (a particulate-filtering facepiece respirator that can filter at least 95% of airborne particles) when in the clinical setting. The facility had 33 of 51 staff not properly fitted tested for N95 face masks. 2. Have an Infection Preventionist Nurse (IPN), who was responsible for fit testing for all facility staff for the N95 face mask, implementing and monitoring the facility's infection control practices that included surveillance monitoring of personnel compliance of infection control guidelines, and providing infection control education to facility staff. 3. Have a thermometer that was in good working condition to ensure temperatures of three of three surveyors were checked including checking the temperature of staff and visitors who enters the facility. 4. Have trash cans in four resident rooms (three rooms in the yellow zone and one room in the red zone) to dispose of contaminated Personal Protective Equipment (PPE). These deficient practices had the potential to result in spread of COVID-19, and placing all 44 of 44 residents (28 residents in the Red Zone and 18 residents in the Yellow Zone) in the facility and staff at risk for COVID-19 infection that could lead to severe respiratory illness, hospitalization and/or death. On January 14, 2020 at 6:46 p.m., the facility's Administrator and Assistant Director of Nursing (ADON) were notified of the Immediate Jeopardy (IJ, a situation in which a facility's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death to a resident). The facility had 44 residents in the facility, and an IJ was identified due to the facility's staff failure to implement infection control practices according to local Public Health Guidelines, the facility's policies, and facility's MP for COVID-19. On January 19, 2021 at 4:26 p.m., during an onsite visit, the IJ was abated after an acceptable Plan of Action (POA) was submitted to the Department. The following corrective plans were developed and implemented by the facility: 1. The facility's ADON/Designee identified the three staff wearing incorrect fitting masks and immediately revisited fit testing assessment records and provided new properly fit N95 masks. Fit testing was started for the rest of the 51 employees on January 15, 2021 and was completed on January 17, 2021, by the interim infection control nurse. 2. The facility's administrator hired a full-time Infection Prevention Nurse working 40 hours a week under the facility's consulting contract temporarily. The facility already posted the job opening for a full time Infection Preventionist Nurse position. 3. The facility's ADON/Designee checked the thermometer used to screen staff and visitors on January 15, 2021. The thermometer was changed to a new working thermometer on January 15, 2021. 4. The facility's Administrator/Designee provided the three rooms in the yellow zone and one room in the red zone with trash bins for disposing of used personal protective equipment on January 15, 2021. 5. In-service training to staff has been provided by interim infection control nurse/designee on January 15, 2021, on the following topics: a. N95 mask fit testing, properly fitted mask, how to properly use and wear N95 b. Scope of Infection Preventionist Nurse for infection control, prevention and management c. Checking thermometer if broken or needing a battery replacement d. Isolation Precaution-Disposal of PPE Findings: 1a. During a tour of the facility's yellow zone on January 14, 2021 at 1:58 p.m., CNA 1 was observed wearing a gown, goggles and N95 mask. CNA 1 was wearing the N95 mask that was not snug against the skin and was observed loose fitting around the face. During a concurrent interview, CNA 1 was asked if he had been fit tested for his face mask, and CNA 1 stated he had not been fit tested . During an interview on January 14, 2021 at 2:04 p.m., the Administrator stated it was the responsibility of the IPN to have the staff fit tested . The Administrator stated fit testing had been started by the former IP nurse, but once the IP nurse had quit, the fit testing was never completed. 1b. During an observation, on January 14, 2021 at 2:23 p.m., Housekeeping Staff (HS 1) was observed working in the red zone wearing a N95 mask and a face shield. During a concurrent interview, HS 1's N95 mask was observed sliding down on the face below the nose. HS 1 was asked if she had been fit tested for her mask, HS 1 stated she did not know what fit testing meant. After it was explained to HS 1 what was meant by fit testing, HS 1 stated she had never been fit tested . 1c. During an observation and concurrent interview in the red zone, on January 14, 2021 at 2:35 p.m., CNA 2 was observed wearing an N95 mask and face shield. CNA 2 was observed pulling the mask up onto the bridge of her nose multiple times, the sides of the mask were observed loose fitting and were not snug against the skin on the face. In a concurrent interview, CNA 2 was asked if she had been fit tested for her mask. CNA 2 stated she had not been fit tested . A review of the facility's Mask Fit Testing Screening Questionnaire dated from November 18, 2020 to December 9, 2020, indicated 25 out of 51 facility staff filled out the questionnaire for fit testing and 33 staff out of 51 total staff in the facility were not fit tested . A review of the Temporary Enforcement Guidance - Healthcare Respiratory Protection Annual Fit-Testing for N95 Filtering Facepieces During the COVID-19 Outbreak, dated March 14, 2020, indicated, this memorandum provides temporary enforcement guidance to Compliance Safety and Health Officers for enforcing the Respiratory Protection standard, 29 CFR § 1910.134, with regard to supply shortages of N95 filtering facepiece respirators due to the COVID-19 outbreak. The Respiratory Protection standard has specific requirements, including a written program, medical evaluation, fit-testing, and training, that employers must follow to ensure workers are provided and are properly using appropriate respiratory protection when necessary to protect their health. 2. On January 14, 2021 at 12:59 p.m., during an entrance conference, the Administrator stated the facility did not have an IP nurse since January 9, 2021. During a concurrent interview, the administrator was asked who was responsible for implementing and monitoring the facility's infection control practices. The administrator stated the facility had placed an ad to try to hire an IP nurse, but at the present time, there was no staff monitoring the facility's infection control program. A review of the facility's policy, titled Scope Infection Control Preventionist Position, dated May 2020, indicated the Infection Control Preventionist (ICP) assumes the responsibility for the Infection Control Program of the facility. The major objectives of the ICP includes the following to assure the quality of patient care by reducing infection risks to residents and personnel through surveillance, provide education pertinent to infection including reducing infection risks to residents and personnel through surveillance and ascertaining the need for infection control monitoring programs in any given area of the facility and maintaining such programs to identify and ultimately eliminate infection hazards, A review of the facility's Mitigation Plan for COVID-19 infection, dated November 11, 2020, Section 3.6 Infection Prevention and Control, indicated the facility has a full-time IP nurse from the hours of 8:00 am-4:30 pm, Monday to Friday. The IP nurse is the designated lead individual to address and improve infection control based on public health advisories (state and federal). 3. On January 14, 2021, at 12:57 p.m., upon entering the facility, the three surveyors were screened by the Administrator for sign and symptoms of COVID-19 symptoms including temperature checks. The infrared, non-contact thermometer being used to check staff and visitor's temperatures was non-functional. The thermometer was not replaced at that time, and the temperature for each of the three surveyors was not obtained. During an interview on January 14, 2021 at 12:57 p.m., the Administrator stated the thermometer would need to be replaced. During an interview on January 14, 2021 at 1:58 p.m., CNA 1 stated he had taken his own temperature when he arrived at the start of the shift. CNA 1 stated he often took his own temperature and recorded any signs or symptoms of COVID-19 illness on his own due to lack of staff available to screen. CNA 1 could not remember what his temperature was at the start of his shift, on January 14, 2021. A review of the facility's Mitigation Plan for COVID-19 infection, dated November 11, 2020, Section 3.6 Infection Prevention and Control, indicated the facility would screen and document every individual entering and exiting the facility (staff, HCP, vendors, transportation, and emergency services) for COVID-19 symptoms. Proper screening includes temperature checks and monitoring for the following signs and symptoms: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea. 4. On January 14, 2021 at 2:03 p.m., during a tour of the yellow zone, rooms [ROOM NUMBER] were observed as not having a trash can with a lid near the room exit door for doffing (removal) of disposable PPE. Only available were yellow barrels for washable gowns and individual small trash cans without a lid by the bed of each resident. During an interview on January 14, 2021 at 2:05 p.m., Licensed Vocational Nurse 1 (LVN 1) stated resident rooms were required to have a trash can with a lid specifically for doffing disposable PPE to avoid contamination or spread of infection. During a tour of the red zone on January 14, 2021 at 2:35 p.m., plastic carts containing disposable PPEs were observed outside of 13 out of 14 resident's rooms located in the red zone. During an observation of the resident in room [ROOM NUMBER], the room did not have a trash can with a lid near the room exit door for doffing of disposable PPE. There was also no trash can with a lid outside the room. During an interview on January 14, 2021 at 2:36 p.m., CNA 3 stated each resident's room was supposed to have a trash can with a lid near the room exit to be used for doffing disposable PPE's. CNA 3 stated staff is supposed to remove PPE prior to exiting a resident's room in order to not spread infection to other staff or residents. A review of the facility's Mitigation Plan for Covid-19 infection, dated November 11, 2020, section 3.8, Personal Protective Equipment, indicated trash disposal bins are positioned as close as possible to the exit inside of the resident room to make it easy for staff to discard PPE after removal, prior to exiting the room, or before providing care for another resident in the same when there are units with separated cohort spaces for both COVID (+) and COVID (-) residents.

Based on interview and record review, the facility failed to ensure 43 of 43 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42 and 43) are free from neglect to ensure care provided by facility staff was not disrupted and ensure residents could continue residing in the facility when an eviction notice was served to the facility by the local law enforcement on 1/31/2020. The eviction notice indicated any occupants residing within the premises would be vacated on 2/5/2020. This deficient practice resulted in placing 43 sampled residents for no pre-arranged discharge with other facilities and had a potential to result in resident's health and safety needs were not being met. Findings: During an interview with the Director of Nurses (DON) on 1/29/2020, at 3:03 p.m., the DON stated the facility staff did not receive their paychecks for the payroll due on 1/24/2020. During an interview with the Administrator on 1/30/2020, at 10:30 a.m., the Administrator stated the staff were upset about not getting paid and staff could resign. During an interview with the Director of Staff Development (DSD) on 1/30/2020, at 12:26 p.m., the DSD stated the staff had expressed to her that they would not come to work because of not getting paid since Friday (1/24/2020). A review of the facility's document titled, Skilled Nursing Facility Payroll, dated 1/21/2020, indicated there were 120 staff (53 male staff and 67 female staff) on the 1/24/2020 payroll. During an interview with the facility's Property Owner on 1/31/2020, at 9:47 a.m., the facility's Property Owner stated that the facility's Licensee did not pay the property fees for four months. The eviction notice was obtained as a court order for the facility Licensee to pay for the owing fees. During an interview with the facility's Administrator on 1/31/2020, at 10:17 a.m., the facility's Administrator stated a Notice to Vacate (an eviction notice ordered by court to vacate occupants in premises) was served to the facility by the local law enforcement on 1/31/2020. The facility's Administrator stated if the facility's Licensee did not pay the rent, the residents would have to be evicted by 2/5/2020. During a concurrent review of the Notice to Vacate with the Administrator indicated that any occupants residing in the facility was ordered to vacate the premises on 2/5/2020. A review of the facility's document titled, Daily Census, dated 1/31/2020, indicated the Daily Census indicated there were 43 residents residing in the facility. On 1/31/2020, at 10:40 a.m., the DON provided a hand-written list indicating the care needs for the 43 residents residing in the facility. During a concurrent interview with the DON, she stated one resident had a gastrostomy tube ([DEVICE], a tube inserted through the abdomen that delivers nutrition directly to the stomach), nine residents were ambulatory, four residents required assistance with ambulation, 27 wheelchair-bound residents, two bedbound residents, and one resident who required geri chair for mobility (a large padded chair with wheeled bases and designed to assist residents with limited mobility out of bed). On 1/31/2020, at 11 a.m., a telephone conference was conducted with the facility's Property Owner, the facility's Licensee, the facility's Administrator, the administration personnel of California Department of Public Health (CDPH) and CDPH legal officers. The eviction notice issue provided by the facility was discussed. The facility's Property Owner and the facility's Licensee did not reach an agreement to solve the eviction notice issue. During an interview with the facility's Administrator on 2/3/2020, at 9:20 p.m., the Administrator stated he was not able to provide any written discharge plans for safely discharging all residents to the destination that could meet each resident's individual health and safety needs. On 2/3/2020, at 9:20 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) in the presence of the Administrator and the DON. The facility failed to ensure 43 of 43 sampled residents had the right to be free from neglect. The facility's Licensee did not meet payroll for 1/24/2020 (non-payment for nursing services). The facility's Licensee failed to maintain control of the property where the residents resided due to not paying the property lease fees for four months. The facility had no written plans to discharge residents safely to other facilities should it become necessary to make an emergency transfer or discharge. As a result, these deficient practices resulted in placing all 43 residents at risk for discharging to inappropriate settings (e.g. lower level of care or shelter) and not to receive necessary care, treatment and services, medication, food, and water that could lead to life threatening health complications and eventually death. The facility failed to develop a written plan to safely transfer/discharge all residents to a destination that is safe and able to meet their individual health and safety needs after the notice of eviction was served to the facility on [DATE] (Cross Refer to F 624). On 2/5/2020, at 10:08 a.m., the California Department Public Health (CDPH) appointed Temporary Management (TM) team and the Health Facility Inspection Division (HFID) team and the Temporary Manager entered the facility and served the documents, Notification of Temporary Management Appointment, to the administrator. The document indicated the immediate need for a TM was to ensure sufficient staffing to maintain resident due to Licensee's inability to pay staff and the landlord has served the Licensee with an eviction notice, which was due to be enforced on 2/5/2020. On 2/20/2020, at 10:30 a.m., after the facility submitted an acceptable plan of action (POA), the survey team verified and confirmed on-site the implementation of the POA by record review and interview and confirmed the removal of the immediate jeopardy in the presence of the Administrator. The Administrator provided an acceptable POA as follows: 1. The facility had made arrangements with several Recruitment and Registry companies to supplement and to provide staffing should any staffing shortages occur. Registry staff will be oriented by the charge nurse regarding the care needs for their residents. 2. If any interruption of services or staffing were to occur the Facility will implement its evacuation policies and procedures and discharge plan to the identified Skilled Nursing Facilities and/or Acute Care Hospitals by utilizing 12 Skilled Nursing facilities within a 30 miles radius to safely accommodate all resident needs. Our plan, if needed, was to evacuate the residents to an appropriate level of care in a safe and orderly fashion. 3. The facility has made arrangement with transportation companies who agreed to transfer residents should evacuation be necessary. Any resident who could not be placed in an appropriate level of care in an emergency, 911 would be called to transfer to Acute Care Hospitals. A review of the facility's Staffing policy and procedure, revised date 10/2017, indicated the facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. A review of the facility's Abuse Prevention Program policy and procedure, revised date 12/2016, indicated the facility residents had the rights to be free from abuse, neglect, misappropriation of resident property and exploitation. As part of the resident abuse prevention, the administrator will develop and implement policies and procedure to aid the facility in preventing abuse, neglect, exploitation, mistreatment of [REDACTED]. A review of the facility's Employee Handbook policy and procedure, date 10/2015, indicated paydays were semi-monthly paid on the 10th and 25th. If the scheduled payday falls on Saturday, paychecks will be available on the preceding Friday.

Based on interview and record review, the facility failed to develop discharge plans for 43 of 43 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42 and 43) when an eviction notice was served to the facility by the local law enforcement on 1/31/2020. The eviction notice indicated any occupants residing within the premises to be vacated on 2/5/2020. This deficient practice resulted in placing 43 sampled residents for no pre-arranged discharge with other facilities and at risk for discharging to facilities that do not meet the health and safety needs of residents. Findings: A review of the local law enforcement agency's Notice to Vacate dated 1/31/2020 that was served to the facility, on 1/31/2020, indicated the judgment was for the debtor (Licensee), members of the judgement debtor's household, and any occupants residing with the judgement debtor. The order to vacate the premises was on 2/5/2020. On 1/31/2020, at 9:47 a.m., during an interview, the facility's Property Owner verified that the eviction notice was provided by the County Sheriff Department. The Property Owner stated the facility's Licensee (facility's owner) had not paid fees for the property for four months and had obtained a court order for Licensee to pay. The Property Owner stated the eviction notice was a court order. During an interview with the facility's Administrator on 1/31/2020, at 10:17 a.m., the facility's Administrator stated a Notice to Vacate was served to the facility by the local law enforcement on 1/31/2020. The facility's Administrator stated if the facility's Licensee did not pay the rent, the residents would have to be evicted by 2/5/2020. On 1/31/2020, at 11 a.m., a telephone conference was conducted with the facility's Property Owner, the facility's Licensee, the facility's Administrator, the administration personnel of California Department of Public Health (CDPH) and CDPH legal officers. The eviction notice issue provided by the facility was discussed. The facility's Property Owner and the facility's Licensee did not reach an agreement to solve the eviction notice issue. On 1/31/2020, at 10:40 a.m., during an interview, the director of nurses (DON) provided a hand-written list indicating the care needs of the 43 residents in the facility. During a review of the facility's list and concurrent interview, the DON stated the list of residents were 1 resident had a gastrostomy tube ([DEVICE], a tube inserted through the abdomen that delivers nutrition directly to the stomach), 9 residents ambulatory, 4 residents required assistance with ambulation, 27 wheelchair bound residents, 2 bedbound residents, and 1 resident requiring geri chair (a large padded chair with wheeled bases and designed to assist residents with limited mobility out of bed). On 2/3/2020 at 9:20 p.m., during an interview, the Administrator stated they did not develop written plans to safely discharge all residents to a destination that is safe and able to meet their individual health and safety needs, after the notice of eviction was served to the facility on [DATE]. On 2/3/2020, at 9:20 p.m., the Department called an Immediate Jeopardy (IJ), a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) in the presence of the administrator and the director of nursing (DON). The facility failed to develop a written plan to safely discharge all residents to a destination that is safe and able to meet their individual health and safety needs after the notice of eviction was served to the facility on [DATE]. The facility's Licensee failed to maintain control of the property over which the residents resided due to nonpayment of rent for four months. On 2/5/2020, at 10:08 a.m., the California Department Public Health (CDPH) appointed Temporary Management (TM) team and the Health Facility Inspection Division (HFID) team and the Temporary Manager entered the facility and served the documents, Notification of Temporary Management Appointment, to the Administrator. The document indicated the immediate need for a TM was to ensure sufficient staffing to maintain residents due to Licensee's inability to pay staff and the landlord has served the Licensee with an eviction notice, which was due to be enforced on 2/5/2020. On 2/20/2020, at 10:30 a.m., after the facility submitted an acceptable plan of action (POA), the survey team verified and confirmed on-site the implementation of the POA by record review and interview and confirmed the removal of the immediate jeopardy in the presence of the Administrator. The Administrator provided an acceptable POA as follows: 1. To utilize the 12 Skilled Nursing Facility within a 30-mile radius to safely accommodate all resident needs, if needed, the facility would evacuate the residents to an appropriate level of care in a safe and orderly fashion. 2. The facility had made arrangement with transportation companies who agreed to transfer residents should evacuation be necessary. Any resident who could not be placed in an appropriate level of care in an emergency, 911 would be called to transfer to Acute Care Hospitals in the area. 3. The Facility Ombudsman is working with the facility to assist with the discharge of the residents and has been appraised of all recent occurrences. 4. A list was prepared of responsible parties and the status of ambulation for each resident to assist with any transfer in a safe and orderly fashion. 5. The facility's admission department would be responsible to contact the transportation company. 6. The Medical Records will be responsible to hand out the prepared envelopes, which include the Face Sheet, History & Physical (H&P), and Physician orders. 7. The LVN will prepare and distribute the medications for each resident as they go into the ambulance 8. The Dietary Department will hand out water and snacks to the residents. 9. The Minimum Data Set (MDS - a care area assessment and screening tool) nurse will document where each resident will be transferred. 10. The Social Service Director (SSD) will contact families and responsible parties to update them on situation and to which facility the resident was transferred. A review of the facility's policy and procedure for Emergency Transfer or Discharge, revised date 2016, indicated should it become necessary to make an emergency transfer or discharge to a hospital or other related institution that included notifying the receiving facility, preparing the resident for transfer, prepare a transfer form to send with the residents, notifying the representative or other family members, and assist in obtaining transportation.