Every finding on record at Royal Terrace Healthcare

Based on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 6) rights were not violated when the facility did not allow Resident 6's family member to visit the resident.This deficient practice had the potential to worsen Resident 6's depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and cause emotional and psychosocial impairments.During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on 1/27/2026 with diagnoses which included depression, malignant neoplasm of endometrium (cancer that starts in the endometrium, the inner lining of the uterus [womb]), and hypertension (high blood pressure).During a review of Resident 6's History and Physical (H&P), dated 1/29/2026, the H&P indicated Resident 6 lacked capacity to make and understand medical decisions.During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 4/7/2026, the MDS indicated Resident 6 had moderately impaired cognitive skills (ability to make daily decisions). The MDS indicated Resident 6 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 6's Order Summary Report (OSR), dated 6/25/2026, the OSR indicated Resident 6 was under the care of hospice, with an active order date of 4/8/2026.During a review of Resident 6's Progress Notes (PN), dated 6/1/2026, the PN indicated the facility did not allow Resident 6's family member to visit Resident 6 without a hospice nurse present.During a review of Resident 6's Progress Notes- Social Services Note (PNSSN), dated 6/1/2026, the PNSSN indicated the facility did not allow Resident 6's family member to come visit Resident 6.During an interview on 6/25/2026 at 12:15 PM with Resident 6, Resident 6 stated that Resident 6 wanted to be visited by Resident 6's family member.During an interview on 6/25/2026 at 2:45 PM with Registered Nurse (RN) 1, RN 1 stated Resident 6's family member was not allowed to visit Resident 6 by family members' self. RN 1 stated by not allowing Resident 6's family member to visit Resident 6, it violated Resident 6's right to visitor(s).During a concurrent interview and record review on 6/26/2026 at 8:28 AM with the Social Service Director (SSD), Resident 6's PNSSN, dated 6/1/2026, was reviewed. The SSD stated Resident 6's family member was not allowed to visit Resident 6 by family members' self, and the SSD did not ask Resident 6 if Resident 6 wanted to be visited by Resident 6's family member. The SSD stated not allowing Resident 6's family member to visit the resident when Resident 6 want to be visited violated Resident 6's right to visitors.During an interview on 6/26/2026 at 1:20 PM with the Director of Nursing (DON), the DON stated that the facility should allow all visitors per resident's will and it is the resident's right to receive visitors.During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revised 10/2025, the P&P indicated that the facility should follow Federal and State laws to guarantee certain basic rights to all residents, including the resident's right to visit and be visited by others from outside the facility.During a review of the facility's policy and procedure (P&P) titled, Visitation, revised 11/2025, the P&P indicated, facility permits residents to receive visitors subject to the resident's wishes and the protection of the rights of other residents in the facility. The P&P indicated, Residents are permitted to have visitors of their choice at the time of their choosing.

Based on interview and record review, the facility failed to ensure that there was sufficient nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted each resident's rights, physical, mental and psychosocial well-being on 6/8/2026 evening shift (from 3 PM to 11 PM).This deficiency practice resulted in incomplete activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) documentation on 6/8/2026 evening shift for one of three sampled residents (Resident 7) and having the potential for all residents not receiving services to meet their needs.During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted Resident 7 on 4/22/2026 with diagnoses which included traumatic subdural hemorrhage (a type of bleeding near brain that can happen after a head injury), anxiety disorder (mental health condition that involves excessive fear, worry, or nervousness that interfere with daily life), and history of falling.During a review of Resident 7's Care Plan (CP), initiated 4/22/2026, revised on 4/25/2026, the CP indicated that Resident 7 had ADL self-care performance deficits, needed to be encouraged to use bell to call for assistance, and needed to be monitored, documented, and reported as needed for any changes, any potential for improvement, reasons for self-care deficit, expected course, and declines in function.During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7 had severely impaired cognitive skills (ability to make daily decisions). The MDS indicated that Resident 7 was dependent (Helper does all of the effort. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 7's Care Plan (CP), initiated 5/6/2026, the CP indicated that Resident 7 is dependent on staff for meeting physical needs.During a review of Resident 7's Care Plan (CP), initiated 5/8/2026, the CP indicated that Resident 7 had a swallowing problem and mouth needed to be checked after meals for pocketed food (when an individual holds or stores food in their mouth-often in their cheeks or between the gums and teeth-without swallowing it) and debris. The CP indicated that the staff needed to monitor, document, and report as needed for any pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, and refusing to eat.During a review of Resident 7's Documentation Survey Report (DSR- documentation of ADLs), dated 6/2026, the DSR indicated that there were no documentation of ADLs on 6/8/2026 evening shift.During a review of the facility's Daily Census (DC), dated 6/8/2026, the DC indicated that there were 49 residents in the facility on 6/8/2026.During a review of the facility's Nursing Staffing Assignment and Sign-in Sheet (NSASS), dated 6/8/2026, the NSASS indicated that there were two Certified Nursing Assistants (CNA) working from 3 PM to 9 PM, and three CNAs working from 9 PM to 11PM on 6/8/2026 evening shift.During an interview on 6/24/2026 at 4:20 PM with CNA 4, CNA 4 stated that the staff could not provide good resident care when there were two CNAs working and each CNA needed to provide care to more than 20 residents each. During an interview on 6/24/2026 at 4:40 PM with CNA 5, CNA 5 stated that it was not sufficient staffing when there were two CNAs working on the evening shift and needed to provide care to 25 residents. CNA 5 stated that the resident's mealtimes were delayed due to no sufficient staffing to assist with feeding, call light response time would be delayed, and there were not sufficient staff to monitor the residents on fall risk precautions.During a phone interview on 6/26/2026 at 3:46 PM with CNA 6, CNA 6 stated that it was not sufficient staffing when there were two CNAs working on the evening shift and needed to provide care to 25 residents. CNA 6 stated that CNA 6 could not provide good quality of care to residents when needed to provide services to 25 residents.During an interview on 6/26/2026 at 3:55 PM with CNA 7, CNA 7 stated that it was not sufficient staffing and was impossible to provide good quality of care to residents when CNA 7 needed to provide care to 25 residents. CNA 7 stated that the staff could not respond and answer the call light promptly, if there were insufficient staffing.During a concurrent interview and record review on 6/26/2026 at 4:10 PM with the Director of Staff Development (DSD), the NSASS, dated 6/8/2026, was reviewed. The DSD stated that there was two CNAs working from 3 PM to 9 PM, and three CNAs working from 9 PM to 11PM on the evening shift of 6/8/2026. The DSD stated that the facility should have assigned four CNAs on 6/8/2026 evening shift. The DSD stated that it was not enough staff when each CNA needed to provide care to 25 residents and it would delay the responding time to answer call lights, delay changing the residents, and no monitoring for high risk of fall residents.During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, revised 4/2025, the P&P indicated, The facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. The P&P indicated that Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including:a. assuring resident safety;b. attaining or maintaining the highest practicable physical, mental, and psychosocial well-being of each resident;c. assessing, evaluating, planning, and implementing resident care plans; andd. responding to resident needs. The P&P indicated, Residents are permitted to have visitors of their choice at the time of their choosing.The P&P indicated that Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident assessments, residents plans of care, and the facility assessment.

Based on interview and record review, the facility failed to ensure two of two sampled residents' (Residents 23 and 36) Minimum Data Set (MDS, a resident assessment tool) reflected an accurate assessment, by failing to: a. Ensure Resident 23's diagnosis of depression (feeling of deep sadness that made a resident lose interest in things they once enjoyed) was coded in MDS assessment dated [DATE]. b. Ensure Resident 36's use of antipsychotic medication was coded accurately in the MDS assessment dated [DATE]. These deficient practices resulted in inaccurate reporting to the Centers of Medicare and Medicaid (CMS, a federal agency that administered the Medicare program and worked with state governments to administer the Medicaid and health insurance portability standards) agency and had the potential to result in Residents 23 and 36 not receiving interventions to address specific care concerns.Findings: a. During a review of Resident 23's admission Record (AR), the AR indicated the facility admitted Resident 23 on 1/27/2026 with diagnoses including secondary malignant neoplasm of brain (an aggressive, cancerous tumor in the brain) and depression. During a review of Resident 23's History and Physical (H&P) dated 1/29/2026, the H&P indicated Resident 23 lacked the capacity to make and understand medical decisions. During a review of Resident 23's Physician Order (PO) dated 3/31/2026, the PO indicated Resident 23 had an active order of mirtazapine (medication to treat depression) 7.5 milligrams (mg- unit of measurement) at bedtime for depression. During a review of Resident 23's MDS dated [DATE], the MDS indicated Resident 23 had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 23 required maximal assistance (helper did more than half the effort) from staff with eating, oral hygiene, toileting hygiene, showering/ bathing, personal hygiene, and mobility. During a review of Resident 23's untitled Care Plan (CP) for depression, revised on 5/20/2026, the CP goal was to minimize Resident 23's behavioral episodes. The CP indicated a nursing intervention to anticipate and meet the resident's needs. During a review of Resident 23's Medication Administration Record (MAR) for 5/2026, the MAR indicated Resident 23 received 20 out of 20 doses of mirtazapine at bedtime for depression. During a concurrent record review and interview with MDS Director (MDSD) on 5/21/2026 at 11:29 AM, Resident 23's MDS dated [DATE] was reviewed. The MDSD stated the MDS dated [DATE] did not indicate Resident 23 had a diagnosis of depression and should have been. The MDSD stated Resident 23's MDS assessment was not accurate. The MDSD stated the MDSD should modify Resident 23's MDS assessment and resubmit it to CMS. The MDSD stated it was important to submit an accurate MDS assessment to CMS so that CMS would have the correct resident information. The MDSD stated the MDSD gathered resident's information by reviewing all of resident's medical records, interviewing the residents and/or the responsible party, and attending the interdisciplinary team (IDT, a team that worked together to plan a resident's care) meeting. The MDSD stated the Director of Nursing (DON) signed the MDS assessment to verify the accuracy. b. During a review of Resident 36's AR, the AR indicated the facility admitted Resident 36 on 3/9/2026 with diagnoses including psychosis (when a resident lost touch with reality) and depression. During a review of Resident 36's PO dated 3/9/2026, the PO indicated an order for Resident 36 to receive quetiapine fumarate 25 mg one tablet by mouth at bedtime for depression. During a review of Resident 36's H&P dated 3/11/2026, the H&P indicated Resident 36 lacked the capacity to make and understand medical decisions. During a review of Resident 36's MDS dated [DATE], the MDS indicated Resident 36 had severely impaired cognition. The MDS indicated Resident 36 required setup assistance from staff with eating. The MDS indicated Resident 36 required supervision from staff with oral hygiene. The MDS indicated Resident 36 required moderate assistance (helper did less than half the effort) from staff with toileting hygiene, showering/bathing, personal hygiene, and bed-to-chair transferring. During a review of Resident 36's MAR for 3/2026, the MAR indicated Resident 36 received one dose of quetiapine fumarate at bedtime on 3/10/2026. During a concurrent record review and interview on 5/21/2026 at 11:43 AM with the MDSD, Resident 36's MDS dated [DATE] was reviewed. The MDSD stated the MDS indicated Resident 36 did not receive antipsychotic medication. The MDSD stated Resident 36's MDS was not an accurate assessment because quetiapine fumarate was an antipsychotic medication. The MDSD stated the MDS assessment should indicate Resident 36 received antipsychotics on a routine basis even if Resident 36 just took one dose of quetiapine fumarate. During an interview with the DON on 5/22/2026 at 9:28 AM, the DON stated the MDS assessment should be accurate. The DON stated the DON acknowledged the MDS assessment was accurate and completed upon submission to CMS by signing the MDS assessment. The DON stated the inaccurate MDS assessment was a discrepancy, and CMS did not receive accurate resident information. During a review of the facility's Policy and Procedure (P&P) titled, Accuracy of Resident Assessment Policy, revised in 5/2025, the P&P indicated the facility should ensure that all resident assessments, including the MDS, are accurate and reflective of the resident's condition during the applicable assessment period. The P&P indicated the staff completing any portion of the MDS or Resident Assessment Instrument (RAI) must accurately document and certify the information entered. The P&P further indicated that each person completed a section of the MDS should sign or electronically certify the accuracy of the information entered.

Based on interview and record review, the facility failed to develop and implement specific, comprehensive, and individualized person-centered care plans (CP) to meet the residents' needs for two of two sampled residents (Residents 2 and 36) by failing to: a. Develop an individualized CP to address the diagnosis of depression (feeling of deep sadness that made a resident lose interest in things they once enjoyed) for Resident 2. b. Develop an individualized CP to address the diagnosis of dementia (a progressive state of decline in mental abilities) for Resident 36. These failures resulted in the residents not receiving individualized care to maintain the residents' highest practicable physical, mental, and psychosocial well-being.Findings: a. During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 1/22/2026 with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and depression. During a review of Resident 2's History and Physical (H&P) dated 1/24/2026, the H&P indicated Resident 2 had full decision-making capacity. The H&P indicated Resident 2 had depression. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 5/1/2026, the MDS indicated Resident 2 had intact cognition (ability to understand). The MDS indicated Resident 2 felt depressed at least half of the 14 day look back period, occurring between 7 and 11 days. The MDS indicated Resident 2 required setup assistance with eating and oral hygiene. The MDS indicated Resident 2 required supervision from staff with personal hygiene. The MDS indicated Resident 2 required maximal assistance (helper did more than half the effort) from staff with toileting hygiene, showering/bathing, and bed-to-chair transferring. During a concurrent record review and interview with the MDS Director (MDSD) on 5/21/2026 at 12:13 PM, Resident 2's entire care plans were reviewed. The MDSD stated there was no CP developed to address Resident 2's diagnosis of depression. The MDSD stated that even if Resident 2 was not taking any medication for depression, the licensed nurse should still develop a specific and individualized CP to address the diagnosis of depression. The MDSD stated staff should know the goal and intervention to address Resident 2's depression. During an interview with the Director of Nursing (DON) on 5/22/2026 at 9:54 AM, the DON stated there should be a specific CP to address Resident 2's depression. b. During a review of Resident 36's AR, the AR indicated the facility admitted Resident 36 on 3/9/2026 with diagnoses including dementia and depression. During a review of Resident 36's H&P dated 3/11/2026, the H&P indicated Resident 36 lacked the capacity to make and understand medical decisions. The H&P indicated Resident 36 had dementia. During a review of Resident 36's MDS dated [DATE], the MDS indicated Resident 36 had severely impaired cognition. The MDS indicated Resident 36 required setup assistance from staff with eating. The MDS indicated Resident 36 required supervision from staff with oral hygiene. The MDS indicated Resident 36 required moderate assistance (helper did less than half the effort) from staff with toileting hygiene, showering/bathing, personal hygiene, and bed-to-chair transferring. During a concurrent record review and interview with the MDSD on 5/21/2026 at 11:43 AM, Resident 23's entire care plans were reviewed. The MDSD stated there was no CP developed to address Resident 23's diagnosis of dementia. The MDSD stated the licensed nurse should develop and initiate the CP for new diagnosis, medication, treatments, and services. The MDSD stated the licensed nurse should initiate the CP when receiving a new order, no later than the end of the shift. The MDSD stated the CP identified the residents' problems and goals and indicated the interventions for specific care concerns. The MDSD stated the CP needed to be specific, individualized, and resident-centered to address each specific diagnosis, medications, and behavior to meet their needs. The MDSD stated staff could not meet the resident's goal without a specific CP. During an interview with the DON on 5/22/2026 at 9:47 AM, the DON stated there should be a specific CP to address dementia care for Resident 23. During a review of the facility's undated Policy and Procedure (P&P) titled, Care Planning, dated 5/2025, the P&P indicated the facility should develop, implement, and maintain individualized, person-centered care plans to address each resident's physical, mental, psychosocial, safety, and functional needs in accordance with assessments, physician orders, resident preferences, regulations, and professional standards of practice. The P&P indicated the CP should include: Resident strengths, needs, and risks. Measurable goals. Interventions and services. Safety and supervision needs. Resident choices and preferences. Approaches to prevent avoidable decline and ad verse outcomes.

Based on interview and record review, the facility failed to meet professional standards of care for three of three sampled residents (Residents 2, 7, and 36) when:a. The facility did not document the blood sugar level on Resident 2's medical record. b. The facility did not rotate the insulin (a hormone that helped a resident's body use sugar for energy) administration site for Resident 2.c. The facility did not document the psychotropic medication monitoring every shift when Resident 36 was taking citalopram hydrobromide (medication for depression [feeling of deep sadness that made a resident lose interest in things they once enjoyed]) and quetiapine fumarate (medication for psychosis [when a resident lost touch with reality]). d. The facility did not rotate the insulin administration site for Resident 7. These failures had the potential to compromise Residents 2, 7, and 36's health and safety. Findings: a. During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 1/22/2026 with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and depression. During a review of Resident 2's History and Physical (H&P) dated 1/24/2026, the H&P indicated Resident 2 had full capacity on decision making. During a review of Resident 2's Physician Order (PO) dated 1/26/2026, the PO indicated Resident 2 had an active order for licensed staff to administer lantus (a long acting insulin that helped a resident control blood sugar) 100 unit/milliliter (ml- unit of measurement) inject 10ml subcutaneously (the fatty tissue area located just beneath the skin at bedtime. The order indicated to hold lantus when Resident 2's blood sugar level was less than 100. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 5/1/2026, the MDS indicated Resident 2 had intact cognition (ability to understand). The MDS indicated Resident 2 required setup assistance with eating and oral hygiene. The MDS indicated Resident 2 required supervision from staff with personal hygiene. The MDS indicated Resident 2 required maximal assistance (helper did more than half the effort) from staff with toilet hygiene, showering/bathing, and bed-to-chair transferring. During a review of Resident 2's Blood Sugar Summary (BSS) for 5/2026, the BSS indicated no blood sugar reading/level documented at bedtime on 5/2/2026, 5/3/2026, 5/4/2026, 5/5/2026, 5/6/2026, 5/7/2026, 5/8/2026, 5/9/2026, 5/10/2026, 5/11/2026, 5/12/2026, 5/16/2026, and 5/17/2026. During a concurrent record review and interview on 5/21/2026 at 12:13 PM with the MDS Director (MDSD), Resident 2's Medication Administration Record (MAR) for 5/2026 was reviewed. The MDSD stated there was no blood sugar reading/levels documentation for the lantus administration on Resident 2's MAR at bedtime on 5/2/2026, 5/3/2026, 5/4/2026, 5/5/2026, 5/6/2026, 5/7/2026, 5/8/2026, 5/9/2026, 5/10/2026, 5/11/2026, 5/12/2026, 5/16/2026, and 5/17/2026. The MDSD stated it was the facility's practice to check the blood sugar before administering insulin whether it was short-acting or long-acting. The MDSD stated the licensed nurse should document the blood sugar level on resident's MAR to prevent hypoglycemia (low blood sugar). During a concurrent record review and interview on 5/22/2026 at 9:54 AM with the Director of Nursing (DON), Resident 2's Nurses' Progress Notes (NPP) for 5/2026 were reviewed. The DON stated there were no bedtime blood sugar reading/levels documented on Resident 2's NPP for 5/4/2026, 5/5/2026, 5/10/2026, 5/11/2026, 5/16/2026, and 5/17/2026. The DON stated the NPP indicated the licensed nurse only documented Resident 2's blood sugar level at bedtime on 5/2/2026, 5/3/2026, 5/6/2026, 5/7/2026, 5/8/2026, 5/9/2026, and 5/12/2026. The DON stated it was important to check and document the blood sugar level before insulin administration. The DON stated the physician would review the documented blood sugar level to adjust the resident's insulin dosage. The DON stated the license nurse should document the blood sugar level on the resident's medical record upon the administration of insulin. The DON stated documentation was proof of action. The DON stated the resident could become hypoglycemia or hyperglycemia (high blood sugar) with uncontrolled sugar. b. During a review of Resident 2's MAR for 5/2026, the MAR indicated Resident 2 received 20 out of 20 doses of lantus at bedtime. During a concurrent record review and interview on 5/21/2026 at 12:13 PM with the MDSD, Resident 2's Administration History (AH) for lantus dated from 5/2/2026 to 5/16/2026 was reviewed. The MDSD stated the AH indicated Resident 2 received lantus in left lower abdomen for three consecutive days on 5/3/2026 to 5/5/2026 and 5/9/2026 to 5/11/2026. The MDSD stated Resident 2's AH indicated Resident 2 received lantus in left lower abdomen for two consecutive days on 5/15/2026 and 5/16/2026. The MDSD stated it was the facility's practice that the licensed nurse should rotate the insulin administration site to minimize discoloration, pain, and wound for the resident. c. During a review of Resident 36's admission Record (AR), the AR indicated the facility admitted Resident 36 on 3/9/2026 with diagnoses including psychosis and depression. During a review of Resident 36's H&P dated 3/11/2026, the H&P indicated Resident 36 lacked the capacity to make and understand medical decisions. During a review of Resident 36's MDS dated [DATE], the MDS indicated Resident 36 had severely impaired cognition. The MDS indicated Resident 36 required setup assistance with eating. The MDS indicated Resident 36 required supervision from staff with oral hygiene. The MDS indicated Resident 36 required moderate assistance (helper did less than half the effort) from staff with toilet hygiene, showering/bathing, personal hygiene, and bed-to-chair transferring. During a review of Resident 36's Physician Order (PO) dated 3/9/2026, the PO indicated for licensed staff to administer citalopram hydrobromide 10 milligrams (mg-unit of measurement) daily to Resident 36 for depression. During a review of Resident 36's PO dated 3/9/2026, the PO indicated for licensed staff to administer quetiapine fumarate at bedtime to Resident 36 for depression. During a concurrent record review and interview on 5/21/2026 at 11:43 AM with the MDSD, Resident 36's MAR for 3/2026 was reviewed. The MAR indicated Resident 36 received 22 out of 22 doses of citalopram hydrobromide daily. The MAR indicated Resident 36 received 1 out of the 2 doses of quetiapine fumarate at bedtime. The MDSD stated there were no documentation for citalopram hydrobromide and quetiapine fumarate monitoring in Resident 36's MAR for 3/2026. The MDSD stated it was the standard of practice to document on the resident's MAR every shift for psychotropic medication monitoring. The MDSD stated when the resident was on antipsychotic/ antidepressant, staff should monitor the resident's behavior every shift. The MDSD stated resident's behavior could be triggered anytime, and the licensed nurse should notify the doctor for any medication adjustment. The MDSD stated it was important to monitor residents on psychotropic medication to ensure medication effectiveness and behavior management. The MDSD stated the psychotropic medication monitoring was for everyone's safety including the staff, residents, and visitors. The MDSD stated staff could not identify the resident's behavior pattern without the psychotropic medication monitoring. During an interview on 5/22/2026 at 9:47 AM with the DON, the DON stated the licensed nurse should monitor the resident's behavior every shift and tally with hashmark on the resident's MAR. The DON stated the licensed nurse should start monitoring the resident's behavior upon admission and when they start taking the psychotropic medication. The DON stated the licensed nurse who received the psychotropic medication order should transcribe the order in the MAR along with the side effect monitoring of the psychotropic medication. The DON stated the licensed nurse should continue to monitor the resident's behavior and document on the MAR every shift and no later than the end of shift. The DON stated this would ensure continuity of necessary care to meet the resident's needs. During a review of the facility's Policy and Procedure (P&P) titled Insulin Administration, revised 5/2025, the P&P indicated the facility should ensure safe insulin administration in accordance with physician orders and accepted nursing practices. The P&P indicated the facility should check and document the blood sugar levels prior to insulin administration in the medical record and MAR. The P&P indicated the licensed nurse should rotate insulin injection sites according to accepted standards of practice. During a review of the facility's P&P titled Psychotropic Medication Management, revised 5/2025, the P&P indicated the facility should ensure safe use of psychotropic medications for residents in accordance with regulatory requirements and accepted standards of practice. The P&P indicated the facility should ensure residents receiving psychotropic medications are monitored for therapeutic effectiveness, behavioral response, adverse reactions or side effects, changes in cognition, mood, appetite, sleep, functional status, and signs of over-sedation or medication d. During a review of Resident 7's AR, the AR indicated the facility admitted Resident 7 on 4/23/2025 and readmitted on [DATE] with diagnoses included type 2 diabetes mellitus, chronic kidney disease (when the kidneys are damaged and cannot filter the blood properly), and hemiplegia (the loss of muscle function and/or sensation of one entire side of the body). During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 required moderate assistance for toileting hygiene, shower/bathe, and dressing. During a review of Resident 7's Order Summary Report (OSR) dated 4/29/2026, the OSR indicated for licensed staff to administer Insulin Asparte Injection Solution (a fast-acting, man-made insulin used to control blood sugar in people with diabetes mellitus) to Resident 7, to be injected subcutaneously before meals and at bedtime depending on Resident 7's blood sugar levels. The OSR indicated to rotate injection site each time an insulin injection was given. During a review Resident 7's Location of Administration Report, dated 3/2026, the Location of Administration Report indicated insulin was administered to Resident 7 at the same injection sites and not rotated on the following dates: 3/6/2026, 3/7/2026, 3/9/2026, 3/12/2026, 3/13/2026, 3/14/2026, 3/15/2026, and 3/17/2026. During a record review Resident 7's Location of Administration Report, dated 5/2026, the Location of Administration Report indicated insulin was administered to Resident 7 at the same injection sites and not rotated on the following dates: 5/6/2026, 5/7/2026, 5/9/2026, 5/10/2026, 5/17/2026, 5/18/2026, 5/19/2026 and 5/20/26. During a concurrent interview and record review on 5/22/2026 at 8:22 a.m. with the Director of Nursing (DON), Resident 7's Location of Administration Report for the months of 3/2026 and 5/2026 were reviewed. The DON stated it is professional nursing practice to inject insulin into subcutaneous tissue, usually in the abdomen or behind the arms. The DON stated licensed nurses should rotate sites after each injection to prevent bruising and to also prevent making the subcutaneous tissue in a particular site harden, which could delay the insulin's absorption rate in the body (an adverse effect when the body takes longer to react to the injected insulin). The DON stated licensed nurses should check the resident's medication administration record which documented the previous site that was used to inject insulin. During an interview on 5/22/2026 at 9:35 a.m. with Registered Nurse 1 (RN 1), RN 1 stated prior to administering insulin, the licensed nurse needed to check the resident's blood sugar and the doctor's order to determine if an insulin injection could be given. RN 1 stated insulin injections should be administered at the subcutaneous tissue. RN 1 stated it was nursing practice to rotate the insulin injection sites. RN 1 stated licensed nurses should not repeatedly inject insulin at the same site because the area can become irritated, painful, and/or swollen. During a review of the facility's Policy and Procedure (P&P) titled, Insulin Administration Policy, dated 5/2025, the P&P indicated the facility shall ensure insulin is administered safely, accurately, and in accordance with physician orders, infection control standards, and accepted nursing practices. The P&P further indicated that insulin injection sites shall be rotated according to accepted standards of practice.

Based on observation, interview, and record review, the facility failed to ensure safe food storage practices in one of one facility kitchen, by failing to: a. Discard five cups of vanilla ice cream dated 5/18/2026 that had spilled over in the kitchen Refrigerator 1. b. Discard one pitcher of prune juice with a use by date of 5/14/2026 in the kitchen Refrigerator 1. These deficient practices had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) for the residents.Findings: During an observation in the facility kitchen in the presence of [NAME] 1 on 5/19/26 at 8:43 AM, there were five cups of vanilla ice cream dated 5/18/26 that had spilled over in the kitchen Refrigerator 1. [NAME] 1 stated there was no expiration date on any of the cups and since they had spilled over and were overflowing, these items should have been removed from the refrigerator and thrown out. During a concurrent observation and interview with [NAME] 1 on 5/19/26 at 8:53 AM, there was one pitcher of brown liquid with a use by date of 5/14/26 in Refrigerator 1. [NAME] 1 stated the brown liquid inside the pitcher was prune juice and it should not be stored inside the refrigerator because it was expired. During an interview with the Dietary Supervisor (DS) on 5/20/26 at 1:50 PM, the DS stated there should not be any expired food items inside the kitchen refrigerators because it could make the residents sick. The DS stated all kitchen staff were responsible to check there were no expired items in the kitchen and refrigerators. The DS stated that if there was an expired item inside the kitchen's refrigerator, it should be removed and thrown away. During an interview with the Director of Nursing (DON) on 5/22/2026 at 9:29 AM, the DON stated there should not be any expired food inside the kitchen's refrigerator. The DON stated the DS was responsible for ensuring there was no expired food inside the kitchen refrigerator. The DON stated if there was any expired food inside the kitchen refrigerator, the food item should be thrown out in the trash. The DON stated expired food could make the residents sick. During a review of the facility's Policy and Procedure (P&P) titled Kitchen Refrigerator and Freezer Policy, revised May 2025, the P&P indicated, The facility shall maintain kitchen refrigerators and freezers in a safe, clean, and sanitary condition to ensure proper food storage and prevent foodborne illness.

Based on observation, interview, and record review, the facility failed to ensure safe handling and storage of food brought into the facility in one of one resident's refrigerator, by failing to: a. Discard one container of peanut butter and chocolate chip frozen dessert and one container of strawberry ice cream with no name or expiration date. b. Discard one cup of vanilla ice cream with no name or expiration date that was sealed with a plastic wrap. These deficient practices had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) for the residents.Findings: During an observation and interview on 5/19/26 at 9:04 AM with the facility's [NAME] 1 (Cook 1) inside the employee's lounge where the resident's refrigerator was located, Cook1 stated the resident's refrigerator should not have items that were not labeled with a name and expiration date. One container of peanut butter and chocolate chip frozen dessert and a strawberry ice cream with no name or expiration date was observed inside the resident's refrigerator. [NAME] 1 stated nursing staff were responsible for checking and cleaning out the resident's refrigerator. During an interview with the Dietary Supervisor (DS) on 5/20/26 at 1:50 PM, the DS stated the resident's refrigerator was located inside the staff's break room. The DS stated nursing staff collect food brought in by family for the residents and place it inside the resident's refrigerator. The DS stated there was no resident food brought in by the family that was kept in the kitchen area. The DS stated food brought in by family should be labeled including the resident's name, room number and expiration date or date the food was placed inside the resident's refrigerator. The DS stated expired or non-labeled foods in the resident's refrigerator should be discarded. During an interview with License Vocational Nurse 3 (LVN 3) on 5/20/2026 at 2:11 PM, LVN 3 stated outside food or food that the resident ordered via delivery should be placed inside the resident's refrigerator located inside the employee's break room. LVN 3 stated when LVN 3 received outside food for the residents, LVN 3 would label the food item with the resident's name, room number and date of when the food item was placed inside the resident's refrigerator. LVN 3 stated the food item inside the resident's refrigerator should have the expiration date. LVN 3 stated if a resident ate expired food, it would make them sick. LVN 3 stated the Infection Control Nurse (IPN) was responsible in checking the food items inside the resident's refrigerator. During an interview with the Director of Nursing (DON) on 5/22/2026 at 9:30 AM, the DON stated the resident's family could bring food from home for the resident. The DON stated resident's food could be stored inside the resident's refrigerator. The DON stated the food items inside the resident's refrigerator should be labeled with the resident's room and day when the food was placed inside the refrigerator. The DON stated the food could only stay inside the resident's refrigerator for a certain amount of time. The DON stated the staff (nurses and CNA's) were responsible for checking the resident's refrigerator for any expired food. The DON stated if there were food items inside the resident's refrigerator that were not labeled with a date of when it was received or at least an expiration date, then the item should be removed from the resident's refrigerator and discarded. The DON stated the housekeeping staff were responsible for ensuring the resident's refrigerator was kept clean. During a review of the facility's Policy and Procedures (P&P) titled, Food Received From Outside Sources Policy, revised May 2025, the P&P indicated, the facility shall promote safe handling, storage and consumption of food brought into the facility by resident's families, visitors or outside sources to reduce the risk of foodborne illness and maintain resident safety. 3. Food items stored in the facility shall be labeled with: a. Residents' name b. Date received c. Food item description4. Expired, spoiled, unlabeled, or unsafe food items shall be discarded.

Based on observation, interview, and record review, the facility failed to implement infection control practices in accordance with its policy and procedure, when: a. Two of two unlabeled wash basins were stacked on top of each other and placed on the floor underneath the sink located in the shared bathroom between Rooms A and B. b. The resident's urinal (container used for urination) was placed on the nightstand for one of one sampled resident (Resident 58). These deficient practices had the potential to spread infection in the facility. Findings: a. During an observation on 5/19/2026 at 10:36 AM inside the shared bathroom between Rooms A and B, two empty wash basins were stacked on top of each other and placed on the floor underneath the bathroom sink. The two wash basins were both unlabeled. The shared bathroom has two doors, with one door leading to Room A and another door leading to Room B. During a concurrent observation and interview on 5/19/2026 at 10:38 AM with Certified Nursing Assistant 2 (CNA 2) inside the shared bathroom between Rooms A and B, CNA 2 stated the two wash basins should each be labeled with a resident's name and be placed at the resident's bedside. CNA 2 stated the two wash basins should not be on the floor of the shared bathroom for Rooms A and B because it could be contaminated with germs and spread infection. CNA 2 stated CNA 2 does not know who placed the two wash basins on the bathroom floor under the sink. During an interview on 5/22/2026 at 8:22 AM with the Director of Nursing (DON), the DON stated the facility had bathrooms that were shared between two resident rooms. The DON stated it was possible that numerous residents will use the same bathroom, depending on various factors such as how many residents were assigned to a room and whether the residents were continent (ability to control the release of urine and stool). The DON stated personal items that the facility provided the resident, such as bed pans and wash basins were specifically given to one resident and should not be shared in order to prevent the transmission (spread) of infection. The DON stated personal items such as wash basins should be labeled with a resident's name or initials and resident's room number. The DON stated wash basins should be kept at the resident's bedside area and should not be left in a shared bathroom, which could lead to the spread of infection. During a review of the facility's Policy and Procedure (P&P) titled, Infection Prevention and Control Policy, revised 5/2025, the P&P indicated The facility is committed to maintaining an effective Infection Prevention and Control Program to help prevent, identify, investigate, and control infections and communicable diseases in accordance with CMS regulations, CDC guidelines, and applicable state requirements. The P&P further indicated the facility shall implement infection prevention and control practices to reduce the risk of transmission of infections among residents, staff, visitors, and vendors. b. During a review of Resident 58's admission Record (AR), the AR indicated the facility admitted Resident 58 on 5/10/26 with diagnoses including encephalopathy (a brain dysfunction caused by infection and/or brain injury), respiratory failure (lungs could not supply oxygen to the blood) and urinary tract infection (infection in the urine). During a review of Resident 58's History and Physical (H&P) dated 5/11/26, the H&P indicated Resident 58 was alert but intermittently confused. During a review of Resident 58's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 5/17/26, the MDS indicated Resident 58 had moderately impaired cognition (ability to understand) and was dependent (helper does all of the effort) for toileting hygiene, shower, lower body dressing, putting on and taking off footwear and personal hygiene. During an observation and interview inside Resident 58's room on 5/19/26 at 11:02 AM, Resident 58 was sitting in a wheelchair watching TV. A urinal was observed next to Resident 58, hanging from Resident 58's nightstand drawer that was opened. There was Resident 58's food items inside the drawer. Resident 58 stated Resident 58 used the urinal and then placed it back on the drawer because Resident 58 did not have a urinal holder. Resident 58 stated Resident 58 had not been offered one. Resident 58 stated Resident 58 had no other place to put the urinal. During an observation inside Resident 58's room on 5/20/26 at 10:23 AM, Resident 58's side table had a urinal containing yellow liquid inside. Some of the yellow liquid was dripping on the outside of the urinal landing on Resident 58's side table. During an observation and interview with License Vocational Nurse 3 (LVN3) on 5/20/26 at 2:08 PM, LVN 3 stated Resident 58's urinal should not be placed on top of Resident 58's side table or hanging from the nightstand drawer. LVN 3 stated the urinal should not be hanging from the drawer because it's not sanitary. LVN 3 stated having a urinal filled with urine on top of the resident's side table was an infection control issue. LVN 3 stated having a urinal filled with urine on top of the resident's side table or nightstand drawer could cause bacteria to spread to Resident 58's food or drink. During an interview with the Infection Prevention Nurse (IPN) on 5/21/26 at 2:30 PM, the IPN stated a urinal placed on top of a resident's side table was an infection control issue because it was not sanitary and could potentially contaminate the resident's food. The IPN stated the urinal should be kept inside the blue urinal holder that should be hanging from the side of the bed of the resident. The IPN stated if staff noticed there was no urinal holder, they should request it from central supply. The IPN stated having a urinal filled with urine on Resident 58's side table posed a risk of spillage and contaminating areas on Resident 58's table. During an interview with the Director of Nursing on 5/22/2026 at 9:34 AM, the DON stated the resident's urinal should not be placed on the nightstand. The DON stated the urinal should be kept inside the urinal holder that should be attached to the side of the resident's bed. The DON stated it was not sanitary to keep the urinal on the nightstand. The DON stated it was an infection control issue for the residents. The DON stated the urinal should be labeled with the resident's room number and removed if soiled. The DON stated the urinal should be emptied as soon as the resident was done urinating and should not be kept with urine inside for long periods of time since it could tip over and the urine could spill. The DON stated the Certified Nursing Assistants (in general) and licensed nurses were responsible for emptying the urinal and to ensure the urinal was placed in an area that the resident would not be at risk of spilling the urine. During a review of the facility's P&P titled, Urinal Labeling and Storage, revised May 2025, the P&P indicated, urinals shall not be stored on floors, bedside meal trays, windowsills, or other inappropriate surfaces.

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced dignity and respect for one of one sampled resident (Resident 4) when Licensed Vocational Nurse 3 (LVN 3) failed to feed Resident 4 at eye-level on 5/19/2026 during Resident 4's lunch meal. This deficient practice resulted in the violation of Resident 4's right to a dignified existence and had the potential to affect Resident 4's feelings of self-worth and self-respect Findings: During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 3/14/2026 and re admitted on [DATE] with diagnoses including protein-calorie malnutrition (when a resident does not eat enough protein and calories to meet nutritional needs), dysphagia (difficulty swallowing), and generalized muscle weakness (loss of overall physical strength). During a review of Resident 4's doctor's progress note (DPN) dated 3/16/2026, the DPN indicated Resident 4 had full decision-making capacity. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 3/21/2026, the MDS indicated Resident 4 had moderately impaired cognition (ability to understand) and was dependent for eating, toileting hygiene, and upper/lower body dressing. During an observation on 5/19/2026 at 12:50 PM inside Resident 4's room, Resident 4 was awake and sitting in bed with a tray table placed across Resident 4's chest. LVN 3 was standing by the left side of Resident 4 and feeding Resident 4 with a spoon. There was no chair observed near Resident 4's bedside. During an interview on 5/19/2026 at 12:54 PM with LVN 3 outside of Resident 4's room, LVN 3 stated LVN 3 fed Resident 4 while LVN 3 was standing up because Resident 4 needed just standby assist (a level of care where a caregiver remains within arm's reach of a resident to ensure their safety, step in, or prevent injury while the resident performs the task). LVN 3 stated LVN 3 was supposed to sit in a chair when feeding the resident at eye-level. LVN 3 stated the purpose of using a chair and feeding at eye-level was for the residents to be fed properly and to make the residents feel comfortable. During an interview on 5/22/2026 at 8:22 AM with the Director of Nursing (DON), the DON stated nursing staff needed to sit next to residents when feeding them to respect the residents' dignity. The DON stated nursing staff should show respect to the residents, which included feeding them at eye-level. The DON stated that when a staff member fed a resident while standing above or over the resident, the resident would feel intimidated (scared, nervous, uncomfortable) or felt disrespected by staff. During a review of the facility's Policy and Procedure (P&P) titled, Dignity Policy, dated 5/2025, the P&P indicated, The facility is committed to ensuring that all residents are treated with dignity, respect, compassion, and individuality at all times. The P&P indicated residents shall be treated in a manner that promotes self-worth, independence, privacy, and quality of life. The P&P further indicated all staff are responsible for promoting and protecting resident dignity at all times.

Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 60) who was admitted in the facility with pressure induced deep tissue damage (damaged skin caused by staying in one position for too long) received care and services to promote wound healing by failing to accurately monitor and assess the correct settings of the low air loss mattress (LALM - tiny laser made air holes in the mattress top surface continually blow out air causing the patient to float, designed to prevent and treat pressure sores, or pressure ulcers) according to Resident 60's weight. This deficient practice placed Resident 60 at risk of poor wound healing and deterioration of current pressure induced deep tissue damage. Findings: During a review of Resident 60's admission Record (AR), the AR indicated the facility admitted Resident 60 on [DATE] with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), pressure induced deep tissue damage of the sacral region (base of the spine, just above the buttocks) and contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the forearm. During a review of Resident 60's Weights and Vital Summary (WVS) dated [DATE], the WVS indicated Resident 60's weight was 118 lbs. (pounds-a unit of measurement). During a review or Resident 60's Order Summary Report (OSR) dated [DATE], the OSR indicated LALM to bed, set according to resident weight, check mattress every shift for proper setting and function and may adjust to resident comfort level every shift for wound management. During a review of Resident 60's untitled Care Plan Report (CPR) initiated on [DATE], the CPR indicated Resident 60 had potential/actual impairment to skin integrity and the interventions included LAL mattress as ordered. During an observation inside Resident 60's room on [DATE] at 10:21 AM, Resident 60 was resting in bed with LALM. Resident 60's LALM was set to approximately 160-170 lbs. normal pressure. During a concurrent observation inside Resident 60's room on [DATE] at 12:31 PM, Resident 60's LALM settings had been changed to approximately 100 lbs. During a review of Resident 60's History and Physical (H&P) dated [DATE], the H&P indicated Resident 60 lacked full medical decision-making capacity due to cognitive impairment (unable to make decisions). During an interview with License Vocational Nurse 3 (LVN 3) on [DATE] at 1:58 PM, LVN 3 stated the LALM settings were done by the treatment nurse, and it should be set to the resident's current weight. LVN 3 stated the LALM should be set according to the resident's weight and physician's (MD) order. LVN 3 stated that if the LALM was not set according to the resident's weight, the pressure could increase the risk of skin breakdown potentially causing more harm to the resident. During an interview with Treatment Nurse 1 (TN1) on [DATE] at 11:19 AM, TN1 stated the LALM settings were set according to the resident's weight. TN1 stated if the LALM was too firm it would defeat the purpose of offloading on the resident's skin. TN1 stated that if the LALM was too soft, the weight would touch the bottom of the bed and could cause an ulcer to the area. TN1 stated TN1 was responsible in setting the LALM and during rounds to ensure the LALM settings were according to the resident's weight. TN1 stated it was not acceptable to have inaccurate setting on a LALM that was supposed to provide comfort and support to the resident's pressure areas. During an interview with the facility's Director of Nursing (DON) on [DATE] at 9:38 AM, the DON stated the LALM should be set to the resident's weight. The DON stated staff needed to follow the doctors' orders. The DON stated the purpose of the LALM was to prevent any type of skin issues such as pressure ulcers in bed bound residents or those at high risk for skin breakdown. The DON stated the licensed nurses and the treatment nurse were responsible for ensuring the correct LALM settings were in place. During a review of the facility's Policy and Procedure (P&P) titled Low Air Loss Mattress revised [DATE], the P&P indicated, The facility shall provide and monitor low air loss mattresses for residents who require pressure redistribution and skin protection to help prevent or manage pressure injuries in accordance with physician orders and resident care needs. Settings are appropriate for the resident's weight and condition.

Based on observation, interview and record review, the facility failed to designate a registered nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis (working 40 or more hours a week) from 12/9/2025 to 12/23/2025 for 52 of 52 residents (census) in the facility.This deficient practice had the potential to impact the quality of care and outcomes that all residents experience in the facility.Findings: During an observation on 12/22/2025 from 8:05 AM to 5 PM and on 12/23/2025 from 8:02 am to 5 pm, there was no designated RN who served as the DON on a full-time basis in the facility. There were 52 residents in the facility on 12/22/2025 and on 12/23/2025. During a phone interview on 12/23/2025 at 9:08 AM with the former DON (FDON), the FDON stated FDON quit the facility in the first week of December 2025. The FDON could not recall the exact date of when the FDON quit the facility. During an interview on 12/23/2025 at 3:48 PM with the Administrator, the Administrator stated that the facility had not designated a specific RN to serve as a full-time DON for the facility since 12/9/2025. The Administrator stated Registered Nurse Consultant (RNC) 1, RNC 2, RN 1, RN 3 and RN 4 were currently the designated DON for the facility since 12/9/2025. During an interview on 12/23/2025 at 3:52 PM with RNC 1, RNC 1 stated that RNC 1 visited the facility 8 to 16 hours per week to provide oversight (having responsibility for supervision and management of nursing services) along with RNC 2. RNC 1 stated RNC 1 was not the designated DON for the facility because RNC 1 had only been an RN for three (3) months. RNC 1 stated the RNs and licensed vocational nurses (LVNs) who worked on the floor (provided direct resident care) in the facility were the designated DON when RNC 1 and RNC 2 were not in the facility. RNC 1 stated that the facility currently did not have a full-time DON since 12/9/2025. During a phone interview on 12/23/2025 at 4 PM with RNC 2, RNC 2 stated that RNC 2 was the designated DON for the facility since 12/9/2025 and visited the facility 8 to 16 hours per week. RNC 2 stated RNC 2 was available by phone 24 hours a day. During an interview on 12/23/2025 at 4:26 PM with RN 1, RN 1 stated RN 1 was not the designated DON for the facility and RNC 2 was the designated DON since 12/9/2025 and visited the facility 16 to 24 hours per week. RN1 stated RN 1 worked as a full-time RN in the facility on the day shift from 7 AM to 3:30 PM. During an interview on 12/23/2025 at 4:50PM with the Administrator, the Administrator stated that the facility should have designated an RN to serve as a DON on a full-time basis for the facility since 12/9/2025. During a review of the facility's Policy and Procedure (P&P) titled, Director of Nursing Services, revised 8/2022, the P&P indicated the DON had to be a registered nurse (RN), licensed by this state, had experience in nursing service administration, rehabilitative and geriatric nursing, and be employed as full-time (40 hours per week). During a review of the facility's P&P titled, Job Description for DON, updated 11/1/2024, the P&P indicated, The Director of Nursing (DON) is responsible for overseeing the administration of nursing services, ensuring compliance with Federal, State, and Local standards, guidelines, and regulations, as well as company policies and procedures. The P&P indicated, The DON leads the nursing team to deliver the highest quality of care, supports best practices, and participates in revising policies and procedures as needed. During a review of the facility's P&P titled, Job Description for RN, updated 11/1/2024, the P&P indicated that the registered nurses need report to DON. During a review of the facility's P&P titled, staffing, revised 10/2017, the P&P indicated that the facility must provide 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.

Based on observation, interview, and record review, the facility failed to ensure the environment remained as free of accident hazards possible and residents received adequate supervision for two of three sampled residents (Residents 2 and 3) when:a. Resident 2's bed sensor pad alarm (an assistive electronic device that makes alerts/sounds to warn caregivers when the resident tries to get up from the bed) did not sound when Resident 2 got up from Resident 2's bed unassisted by staff and walked to the bathroom.b. The facility's licensed nursing staff (in general) failed to conduct a fall risk assessment (an evaluation to determine a resident's likelihood of falling) or inaccurately assessed Resident 3 as low risk for fall following Resident 3's falls on 5/31/2025, 8/4/2025, and 10/4/2025. c. The facility's Interdisciplinary Team (IDT, a group of health care professionals who work together toward the goals of the resident) failed to conduct a comprehensive root cause analysis (systematic process to identify the underlying reasons a fall occurred, which can then be used to prevent future incidents) of Resident 3's falls on 5/31/2025, 8/4/2025, and 10/4/2025 and update Resident 3's care plan interventions to prevent Resident 3 from falling again.These failures had the potential for Resident 2 to sustain injury and/or harm due to falling while in care of the facility. In addition, these violations resulted in Resident 3 falling on 5/31/2025, 8/4/2025, and 10/4/2025 and sustained lacerations (a pattern of injury in which skin and underlying tissues are cut or torn) to the head on 5/31/2025 and 8/4/2025. Findings: a. During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 4/4/2025 with diagnoses including transient cerebral ischemic attack (TIA, a temporary interruption of blood flow to the brain), dysphagia (difficulty swallowing foods or liquids), and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 10/12/2025, the MDS indicated Resident 1 had moderately impaired cognition (ability to make daily decisions). The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity; assistance may be provided throughout the activity or intermediately) from staff for toileting, personal hygiene, and dressing. The MDS indicated Resident 2 required supervision or touching assistance from staff for walking. During a review of Resident 2's Order Summary Report (OSR) dated 10/27/2025, the OSR indicated a physician order dated 9/15/2025 for nursing staff to apply bed sensor pad alarm to Resident 2 every shift for safety due to history of falls and to monitor placement every shift. During an observation on 10/27/2025 at 11:22 AM, in Resident 2's room, Resident 2 got up from Resident 2's bed and walked alone while using a front wheel walker (FWW, a device used to assist individuals with balance and mobility problems). Resident 2 walked to the restroom on the other side of the room from Resident 2's bed. Staff (in general) did not come to Resident 2's room. The sensor alarm for Resident 2 did not sound. Resident 2 shut the bathroom door behind her. During a follow-up interview on 10/27/2025 at 11:41 AM with Resident 2, Resident 2 stated Resident 2 had fallen multiple times at the facility. Resident 2 stated Resident 2 gets dizzy due to chemotherapy (a drug-based medical treatment that uses powerful chemicals to kill or slow the growth of cancer cells). Resident 2 stated Resident 2 was not supposed to walk by herself to the bathroom. Resident 2 stated Resident 2 had walked by herself earlier (when surveyor observed) without assistance from staff (in general) because staff did not always come right away when Resident 2 needed to use the toilet. b. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 1/22/2025 and readmitted on [DATE] with diagnoses including encounter for surgical aftercare following surgery on the digestive system, metabolic encephalopathy (brain disease that alters brain function or structure), and seizures (a sudden, uncontrolled electrical disturbance in the brain). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 was severely impaired in cognitive skills. The MDS indicated Resident 3 required supervision or touching assistance from staff for personal hygiene, bathing and dressing. The MDS indicated Resident 3 required supervision or touching assistance from staff for walking. During a review of Resident 3's General Acute Care Hospital 1 (GACH 1) Emergency Trauma Documentation (ETD) dated 5/31/2025, the ETD indicated Resident 3 presented to GACH 1 Emergency department (ED) on 5/31/2025 with chief complaint of a fall. The ETD indicated Resident 3 hit Resident 3's head when Resident 3 fell in the facility. The ETD indicated Resident 3 had a 3-centimeter (cm-unit of measurement) scalp laceration. The ETD indicated the physician repaired Resident 3's laceration with three staples (specialized staples that are used instead of sutures to mend skin wounds). During a review of Resident 3's GACH 2 ED Provider Note (ED Note), dated 8/4/2025, the ED Note indicated Resident 3 presented to GACH 2 ED on 8/4/2025 with a 4 cm laceration to the head due to an unwitnessed fall at the facility. The ED Note did not indicate any treatment for Resident 3's laceration. During a concurrent interview and record review on 10/27/2025 at 2:20 PM with the Director of Nursing (DON), Resident 3's Change in Condition Evaluation (CIC) dated 5/31/2025, 8/4/2025, and 10/4/2025 were reviewed. The DON stated Resident 3 had fallen at the facility on five separate occasions since being admitted to the facility. The DON stated Resident 3 had fallen three times, (5/31/2025, 8/4/2025, and 10/4/2025) since the facility's last recertification survey. The CIC dated 5/31/2025 indicated on 5/31/2025 at 1:20 PM, Resident 3 was found on the floor lying on the right side. The CIC indicated Resident 3 had a right head hematoma (bruising) and a laceration measuring around 3 cm. long. The CIC indicated Resident 3's physician instructed the facility to send Resident 3 via 911 (emergency response) to a General Acute Care Hospital (GACH) due to unwitnessed fall and to treat Resident 3's hematoma and laceration on Resident 3's head. The CIC indicated 911 was called and that emergency medical services (EMS) took Resident 3 to GACH 1. The CIC dated 8/4/2025 indicated on 8/4/2025 at 1:00 PM, Resident 3 was observed on the floor face down, and had a 5 cm long laceration on the forehead with bleeding. Resident 3 was transferred to (GACH 2) via 911 for further evaluation. The CIC dated 10/4/2025 indicated on 10/4/2025 at 1:20 PM, Resident 3 had an unwitnessed fall and was discovered on the floor. The CIC indicated, Resident 3 verbalized feeling dizzy and fell. The CIC indicated Resident 3's physician instructed the facility to send Resident 3 to GACH 3 for further evaluation. During a concurrent interview and record review on 10/28/2025 at 9:49 AM with the DON, Resident 3's Nursing-Fall Risk Evaluation (FRE) dated 5/22/2025 and 10/4/2025 were reviewed. The DON stated the FRE dated 5/22/2025 inaccurately indicated Resident 3 had no falls in the last 90 days. The FRE dated 10/4/2025 inaccurately indicated Resident 3 was at low risk of falling. The DON stated the FRE dated 5/22/2025 incorrectly indicated Resident 3 was at low risk of falling instead of accurately indicating Resident 3 was at high risk of falling again. The DON stated an FRE was required after each fall to help identify risks of falls prior to the resident falling again. The DON stated if an FRE is completed inaccurately, then residents had the potential to fall again. The DON also stated an FRE was not completed after Resident 3 fell on 5/31/2025. c. During a concurrent interview and record review on 10/28/2025 at 9:49 AM with the DON, Resident 3's Progress Notes (PN) dated 10/27/2025 was reviewed. The PN indicated the IDT fall review committee met following Resident 3's falls on 5/31/2025, 8/4/2025 and 10/4/2025. The DON stated the IDT did not conduct a thorough root cause analysis for Resident 3 for each fall. The DON stated the IDT did not focus on Resident 3's diagnoses as being a contributing factor to Resident 3's repeated falls. The DON stated the IDT did not change interventions to prevent Resident 3 from falling but still expected the current interventions to prevent Resident 3 from falling again. The DON stated if the IDT did not conduct a thorough root cause analysis, Resident 3 would likely fall again. During a concurrent interview and record review on 10/28/2025 at 9:49 AM with the DON, Resident 3's undated Care Plan Report (CPR) was reviewed. The CPR indicated the facility failed to initiate or update Resident 3's care plan to address Resident 3's risk of falling again, following Resident 3's falls on 5/31/2025, 8/4/2025, and 10/4/2025. The DON stated the IDT did not review Resident 3's care plan following the falls. The DON stated if a resident (in general) had repeated falls then interventions used to prevent the falls must be changed since the current interventions were not working to prevent the falls. The DON stated if resident's care plan was not updated following a fall, the resident would be more likely to fall again. During a review of the facility's policy and procedure (P&P) titled, Fall Management & Prevention Policy, undated, the P&P indicated, the purpose of the fall management and prevention policy was, To minimize the risk of patient/resident falls and fall-related injuries by implementing assessment, prevention, and management strategies . The P&P indicated the responsibility of the facility's Clinical and Nursing staff (in general) was to: Conduct fall risk assessment on admission, transfer, after a fall, or when there is a significant change in condition. Develop and implement individualized fall prevention plans. Document interventions and patient/resident responses in the care record. Educate patients/residents and families on fall risks, prevention measures and safe mobility. Report all falls and near-falls immediately according to facility incident reporting procedures.The P&P indicated the responsibility of all staff was to . Maintain a safe physical environment: clear walkways, adequate lighting, safe flooring, proper use of equipment and assistive device. The P&P indicated Post Fall (after a resident falls at the facility) Management included: . Update the individual's care plan and risk status if needed. Convene a multidisciplinary fall review committee (e.g., nursing, PT/OT, risk management, quality/safety) to analyze:- The event's chain of events and contributing factors- Whether existing interventions were in place and effective- Recommend and implement corrective actions (e.g., change in intervention plan, staff education, environment modification) .

Based on observation, interview, and record review, the facility failed to ensure the residents right to be free from sexual abuse for one of three sample residents (Resident 2). This deficient practice resulted in Resident 2 being subjected to indecent exposure when Resident 1 masturbated in the room in front of Resident 2, and Resident 2 was afraid to go to sleep because Resident 2 feared for his safety.During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia in other diseases classified elsewhere, severe with psychotic disturbance (refers to the advanced stage of the dementia, where cognitive impairment significantly interferes with daily functioning), unspecified psychosis not due to a substance or known physiological condition (a condition where a person experiences delusions (false beliefs), hallucinations (seeing or hearing things that are not real), disorganized thinking and speech, and changes in behavior), depression (a common and serious mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest), delirium due to known physiological condition (a serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking), hypertensive heart disease without heart failure (a condition where prolonged high blood pressure (hypertension) damages the heart muscle without causing heart failure).During a review of Resident 1's History and Physical (H&P) from General Acute Care Hospital 1 (GACH 1), dated 7/23/25, the H&P indicated, Resident 1 was sent by boarding care for psychiatric evaluation due to bizarre behavior for one week and high blood pressure readings. The H&P further indicated Resident 1 was admitted to GACH 1 for significant cognitive impairment across multiple cognitive domains.During a review of Resident 1's Change of Condition (COC), dated 8/19/25, the COC indicated Resident 1 is openly masturbating outside his room, staff directed him to stay in his room, but he is not compliant. An order to send him back to the hospital was obtained.During a review of Resident 1's Physician Orders (POs) active as of 8/19/25, the POs indicated the following order:1. Transfer to GACH 1 due to increased inappropriate sexual behavior, manifested by increased masturbation in public making patients uncomfortable, for further evaluation and treatment. Bed hold x 7 days.During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included nontraumatic acute subdural hemorrhage (a collection of blood between the brain and the inner lining of the skull (dura mater) that occurs without a previous head injury), and other abnormalities of gait and mobility (walking difficulty). During a review of Resident 2's History and Physical (H&P), dated 5/10/25, the H&P indicated, Resident 2 had the capacity to understand and make medical decisions. During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 5/21/25, the MDS indicated Resident 2 required part/moderate assistance with eating and oral hygiene. Resident 2 also required substantial/maximal assistance with toileting hygiene, shower/bathe self and personal hygiene. The MDS further indicated Resident 2 was dependent with upper/lower body dressing and putting on/taking off footwear.During an interview on 9/17/25 at 10:40 a.m. with RN Supervisor 1 (RN 1), RN 1 stated she completed a COC for Resident 1 due to his hypersexual behavior where he walked around in the hallways with his pants down and exposing himself to staff and residents. RN 1 stated she reported Resident 1's behavior to the previous Director of Nursing. RN1 stated she related inappropriate behavior to Resident 1's diagnosis of dementia and did not believe it was sexual abuse. During an interview on 9/17/25 at 11:45 a.m. with Resident 2, Resident 2 stated Resident 1 took off his pants and underwear [in the room] and played with his private parts. Resident 2 stated when Resident 1 was touching himself it made Resident 2 uncomfortable. Resident 2 stated, I was afraid of what could happen to me. I didn't sleep at all because I didn't feel safe in the room. Resident 2 stated he told his concerns to the nursing staff and all they told him was to use the call light to call them if something happened and then they would come right away. During an interview on 9/17/25 at 12:55 p.m. with RN 1, RN 1 stated Resident 2 did not report being uncomfortable in the room with Resident 1. RN 1 stated she could not remember who the other residents were that got exposed to Resident 1 in the hallways. RN 1 stated, It was reported to me that Resident 1 was walking out of his room with his pants down at his ankles. During a concurrent review of Resident 1's Transfer form, dated 8/19/25 and interview with RN Supervisor 2 (RN 2) on 9/17/25 at 4:35 p.m., RN 2 stated Resident 1 was confused, needed redirection, but continued inappropriate sexual behavior; that's why they transferred him. RN 2 was asked if Resident 2 was safe with Resident 1 who was displaying behavior such as masturbating in the open where other residents could see. RN 2 stated Not safe if Resident 2 is alone in the room with Resident 1. RN 2 stated based on the facility's abuse protocol the previous administrator should have been informed about the incident with Resident 1. During a review of the facility's current Policy & Procedure (P&P) titled, Abuse Investigation and Reporting, revised July 2017, the P&P indicated All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies ( as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.

Cross Reference F600Based on interview and record review, the facility failed to ensure residents the right to be free from sexual abuse for one of three sample residents (Resident 2). Based on interview and record review, the facility failed to provide supervision of Resident 1, when he inappropriately exposed himself and masturbated in the presence of Resident 2, after the facility had knowledge of another incident that had occurred where Resident 1 exposed himself masturbating to other residents in the hallway. This deficient practice had the potential to result in Resident 1's behavior to cause psychosocial harm to Resident 2 and other residents if the facility staff did not monitor Resident 1's whereabouts.During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia in other diseases classified elsewhere, severe with psychotic disturbance (refers to the advanced stage of the dementia, where cognitive impairment significantly interferes with daily functioning), unspecified psychosis not due to a substance or known physiological condition (a condition where a person experiences delusions (false beliefs), hallucinations (seeing or hearing things that are not real), disorganized thinking and speech, and changes in behavior), depression (a common and serious mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest), delirium due to known physiological condition (a serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking), hypertensive heart disease without heart failure (a condition where prolonged high blood pressure (hypertension) damages the heart muscle without causing heart failure).During a review of Resident 1's History and Physical (H&P) from General Acute Care Hospital 1 (GACH 1), dated 7/23/25, the H&P indicated Resident 1 was sent by boarding care for psychiatric evaluation due to bizarre behavior times one week and high blood pressure readings. The H&P further indicated Resident 1 was admitted to GACH 1 for significant cognitive impairment across multiple cognitive domains. During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included nontraumatic acute subdural hemorrhage (a collection of blood between the brain and the inner lining of the skull (dura mater) that occurs without a previous head injury), and other abnormalities of gait and mobility (walking difficulty). During a review of Resident 2's History and Physical (H&P), dated 5/10/25, the H&P indicated, Resident 2 had the capacity to understand and make medical decisions. During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 5/21/25, the MDS indicated Resident 2 required part/moderate assistance with eating and oral hygiene. Resident 2 also required substantial/maximal assistance with toileting hygiene, shower/bathe self and personal hygiene. The MDS further indicated Resident 2 was dependent with upper/lower body dressing and putting on/taking off footwear.During an interview on 9/17/25 at 10:40 a.m. with RN Supervisor 1 (RN 1), RN 1 stated she completed a COC for Resident 1 due to his hypersexual behavior where he walked around in the hallways with his pants down and exposing himself to staff and residents.During a concurrent interview and record review of Resident 1's Nursing Progress Notes (dated 8/19/25) with Licensed Vocational Nurse 1 (LVN 1) on 9/17/25 at 12:34 p.m., LVN 1 stated, Resident 1 always had his hand in his pants touching himself. When I gave him medications, he was displaying that behavior and I told him to stop, then he would accept his medications after being told to stop that behavior. LVN 1 stated, Sexual abuse is reportable if a resident is in the hallways with his pants down and touching himself in front of other residents who feel uncomfortable with what is happening.During a concurrent interview and record review of Resident 1's Nursing Progress Notes (dated 8/19/25) and Change of Condition (dated 8/19/25) with RN 1 on 9/18/25 at 3:04 p.m., RN 1 acknowledged she wrote the Progress note dated 8/19/25 at 2:22 p.m. RN 1 stated she only reported to the previous Director of Nursing (DON) about Resident 1's behavior, she did not report it to the previous administrator. RN 1 stated she associated Resident 1's inappropriate sexual behavior with his dementia diagnosis and did not see it as sexual abuse. RN 1 stated Resident 1's history showed he had inappropriate sexual behavior prior to coming to the facility. RN 1 read her note again and then acknowledged that Resident 1 exposing and touching himself in the hallways where other residents were present is a form of sexual abuse and it should have been reported.During a review of the facility's current Policy & Procedure (P&P) titled, Abuse Investigation and Reporting, revised July 2017, the P&P indicated All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.

Based on interview and record review, the facility failed to initiate a care plan for one of three sampled residents (Resident 1) which addressed Resident 1's behavior of inappropriately exposing himself and masturbating in the presence of Resident 2 and other residents in the hallway. 1. This deficient practice had the potential to result in psychosocial harm to Resident 2 and other residents in the facility. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia in other diseases classified elsewhere, severe with psychotic disturbance (refers to the advanced stage of the dementia, where cognitive impairment significantly interferes with daily functioning), unspecified psychosis not due to a substance or known physiological condition (a condition where a person experiences delusions (false beliefs), hallucinations (seeing or hearing things that are not real), disorganized thinking and speech, and changes in behavior), depression (a common and serious mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest), delirium due to known physiological condition (a serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking), hypertensive heart disease without heart failure (a condition where prolonged high blood pressure (hypertension) damages the heart muscle without causing heart failure).During a review of Resident 1's History and Physical (H&P) from General Acute Care Hospital 1 (GACH 1) dated 7/23/25, the H&P indicated Resident 1 was sent by the boarding care for psychiatric evaluation due to bizarre behavior times one week and high blood pressure readings. The H&P further indicated Resident 1 was admitted to GACH 1 for significant cognitive impairment across multiple cognitive domains. During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included nontraumatic acute subdural hemorrhage (a collection of blood between the brain and the inner lining of the skull (dura mater) that occurs without a previous head injury), and other abnormalities of gait and mobility (walking difficulty). During a review of Resident 2's History and Physical (H&P), dated 5/10/25, the H&P indicated Resident 2 had the capacity to understand and make medical decisions. During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 5/21/25, the MDS indicated Resident 2 required partial/moderate assistance with eating and oral hygiene. Resident 2 also required substantial/maximal assistance with toileting hygiene, shower/bathe self and personal hygiene. The MDS further indicated Resident 2 was dependent with upper/lower body dressing and putting on/taking off footwear.During an interview on 9/17/25 at 10:40 a.m. with RN Supervisor 1 (RN 1), RN 1 stated she completed a COC for Resident 1 due to his hypersexual behavior where he walked around in the hallways with his pants down and exposing himself to staff and residents. RN 1 stated she reported Resident 1's behavior to the previous Director of Nursing. RN 1 stated she related inappropriate behavior to Resident 1's diagnosis of dementia and did not believe it was sexual abuse. During an interview on 9/17/25 at 11:45 a.m. with Resident 2, Resident 2 stated Resident 1 took off his pants and underwear [in the room] and played with his private parts. Resident 2 stated when Resident 1 was touching himself it made Resident 2 uncomfortable. Resident 2 stated, I was afraid of what could happen to me. I didn't sleep at all because I didn't feel safe in the room. Resident 2 stated he told his concerns to the nursing staff and all they told him was to use the call light to call them if something happened and then they would come right away. During a review of Resident 1's medical record, no care plan was initiated for Resident 1's hypersexual behavior while in the presence of Resident 2 or other residents.During an interview with Licensed Vocational Nurse 1 (LVN 1) on 9/17/25 at 12:34 p.m., LVN 1 stated, Resident 1 always had his hand in his pants touching himself. When I gave him medications, he was displaying that behavior and I told him to stop, then he would accept his medications after being told to stop that behavior. LVN 1 stated, Sexual abuse is reportable if a resident is in the hallways with his pants down and touching himself in front of other residents who feel uncomfortable with what is happening. LVN 1 stated, For sexual abuse, a change of condition should be initiated then the MD and family representative are notified. The police, Ombudsman, and CDPH are notified about the event. LVN 1 stated a care plan for sexual abuse or inappropriate sexual behavior should be initiated also.During a review of the facility's current Policy & Procedure (P&P) titled, Change in Resident's Condition or Status, revised February 2021, the P&P indicated Policy Interpretation and Implementation: The nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self -limiting); impacts more than one area of the resident's health status; requires interdisciplinary review and/or revision to the care plan. The P&P further indicated, The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS RAI (Minimum Data Set Resident Assessment Instrument) Instruction Manual. During a review of the facility's current Policy & Procedure (P&P) titled, Care Planning - Interdisciplinary Team, revised March 2022, the P&P indicated Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). The IDT includes but is not limited to a) the resident's attending physician; b) a registered nurse with responsibility for the resident; c) a nursing assistant with responsibility for the resident; d) a member of the food and nutrition services staff; e) to the extent practicable, the resident and/or the resident's representative; and f) other staff as appropriate or necessary to meet the needs of the resident, or as requested by the resident. The interdisciplinary team is responsible for the development of resident care plans.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), received interventions for the risk of elopement (a resident leaves the premises or a safe area without the facility's knowledge) when Resident 1 expressed to RN 1 that Resident 1 wanted to leave the facility. This failure resulted in Resident 1 leaving the facility unsupervised on 9/7/2025 and had the potential for Resident 1 to be injured. Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 5/21/2025 with diagnoses including cirrhosis of liver (chronic liver damage), chronic congestive heart failure (a condition in which the heart cannot pump enough blood to all parts of the body), and hepatic encephalopathy (brain disease that alters brain function or structure). During a review of Resident 1's History and Physical (H&P), dated 5/23/2025, the H&P indicated Resident 1 had the capacity to understand and make own medical decisions. During a review of Resident 1's Progress Notes (PN), dated 9/9/2025, The PN indicated that RN 1 documented the following on 9/7/2025 at 10:20 AM: Activity staff was looking for resident (Resident 1), resident (Resident 1) was not in his room, staff immediately started looking for resident (Resident 1) every where in side and outside the facility, resident was no where to be found, drove around the community looking for him. Per staff resident (Resident 1) was last seen around 9:45am. Around 7:20 am resident (Resident 1) verbalized wanting to leave the facility . Resident (Resident 1) was asked where are you going? Resident (Resident 1) unable to provide us with an address stated going to a friend house. During a telephone interview on 9/9/2025, at 1:33 PM with RN 1, RN 1 stated RN 1 was the supervisor on 9/7/2025 when Resident 1 left the facility. RN 1 stated Resident 1 came to the nurses' station around 9:00 AM on 9/7/2025 and told RN 1 that Resident 1 wanted to leave the facility and go home. RN 1 stated RN 1 explained to Resident 1 the risks of leaving against medical advice (AMA) and RN 1 did notify Resident 1's doctor that Resident 1 wanted to leave. RN 1 stated that at 10:20 AM, the facility discovered Resident 1 was missing from the facility. RN 1 stated Resident 1 did not notify anyone that he was leaving the facility. During a concurrent interview and record review on 9/9/2025 at 3:16 PM with the Director of Nursing (DON), Resident 1's Wander/Elopement Risk Evaluation (EE), dated 5/21/2025 was reviewed. The EE indicated, the EE would be completed by a member of the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident) upon admission, quarterly and with a significant change. The EE indicated that one of the questions used to determine if Resident 1was at risk for eloping was, Verbalization of leaving the facility? This question was checked no. The EE indicated Resident 1 was not an elopement risk on 5/21/2025. The DON stated if Resident 1 verbalized he wanted to leave the facility at any point, Resident 1 would be considered an elopement risk. The DON stated if Resident 1 said Resident 1 wanted to leave the facility, then facility staff (in general) should fill out another EE. The DON stated RN 1 did not complete an EE on 9/7/2025, after Resident 1 told RN 1 that Resident 1 wanted to leave the facility and go home. The DON stated Resident 1 would be considered an elopement risk after expressing Resident 1 wanted to leave the facility. The DON stated the facility staff (in general) should monitor Resident 1 closely and make sure Resident 1 was not packing his belongings to leave the facility. During a review of the facility's policy and procedure (P&P) titled, Elopement & Wandering, undated, the P&P indicated, A Wander/Elopement assessment will be completed on all residents upon admission to the facility. The elopement risk is assessed quarterly or as needed with change of condition.

Based on interview and record review, the facility failed to provide necessary (needed) care and services to one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure (P&P) titled, Changes in Resident Condition, when:a. Registered Nurse (RN) 3 and LVN 1 did not notify Resident 1's physician regarding Resident 1's complaint of pain and not feeling well, and Resident 1's request to be transferred to a General Acute Care Hospital (GACH) on 7/20/2025 during the 3-11 shift (3 PM to 11:30 PM).b. Registered Nurse (RN) 3 and LVN 1 did not document Resident 1's complaint of pain and not feeling well, and Resident 1's request to be transferred to a GACH in Resident 1's medical record on 7/20/2025.c. RN 1 did not notify a physician regarding Resident 1's complaint of pain and Resident 1's and Resident 1's Representative's (RR 1 - someone authorized to make healthcare decisions on behalf of another person) request for Resident 1 to be transferred to a GACH on 7/21/2025 at 2 AM.d. RN 1 did not document in Resident 1's medical record regarding Resident 1's complaint of pain and Resident 1's and RR 1's request for Resident 1 to be transferred to a GACH on 7/21/2025 at 2 AM.These failures resulted in delaying Resident 1's treatment and care for Resident 1's complaint of pain and not feeling well and had the potential for Resident 1 to experience a decline in health and wellbeing.During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 4/23/2025 and readmitted Resident 1 on 5/14/2025 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), hypertension (high blood pressure), and hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles).During a review of Resident 1's History and Physical (H&P), dated 4/25/2025, the H&P indicated Resident 1 had the capacity to understand and make his own decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/22/2025, the MDS indicated Resident had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 required partial/moderate (helper does less than half the effort) assistance from staff for dressing, bathing, and personal hygiene.During a review of Resident 1's GACH H&P, dated 7/23/2025 and timed 10:58 AM, the H&P indicated Resident 1 was admitted to GACH 1 Emergency Department on 7/22/2025 at 12:18 PM with complaint of shortness of breath, cough, and chest pain. The H&P indicated Resident 1 was admitted to GACH 1 for aspiration (when something you swallow enters your lungs) pneumonia (an infection/inflammation in the lungs).During an interview on 7/30/2025 at 10:17 AM with RR 1, RR 1 stated Resident 1 called RR 1 on 7/21/2025 at 2 AM and informed RR 1 that Resident 1 was waiting to go to the hospital because Resident 1 had chest pain and was coughing. RR 1 stated RR 1called and spoke to the Social Services Director (SSD) on 7/21/2025 at 9:45 AM. RR 1 stated RR 1 asked the SSD when Resident 1 would be sent to the hospital. RR 1 stated the SSD informed RR 1 the SSD would speak to the Director of Nursing (DON) about Resident 1 being sent to the hospital. RR 1 stated RR 1 called again at 1:45 PM and was able to speak with the DON. RR 1stated the DON was not aware of Resident 1's complaint of chest pain or that Resident 1 was requesting to be sent to the hospital. RR 1 stated RR 1 called later at 10:30 PM and spoke to Registered Nurse (RN) 1. RR 1 stated RN 1 informed RR 1 that RN 1 was waiting for the doctor to determine which hospital the facility would send Resident 1 to on 7/21/2025 at 2 AM. RR 1 stated RR 1 spoke to another unidentified nurse during the night of 7/21/2025 and was informed the facility would notify RR 1 when the doctor called back. RR 1 stated RR 1 called the facility early in the morning of 7/22/2025 and spoke to RN 2 about Resident 1's complaint of chest pain and asked about the transfer to the hospital. RR 1 stated RN 2 called RR 1 back in 1/2 hour and informed RR 1 that Resident 1 would be transferred to the hospital at 10:30 AM on 7/22/2025.During an interview on 7/30/2025 at 10:55 AM with Resident 1, Resident 1 stated Resident 1 started to feel ill with a cough on 7/20/2025. Resident 1 stated Resident 1 informed the staff (unidentified) the evening of 7/20/2025 that Resident 1 had a cough. Resident 1 stated Resident 1 informed the nurse (unidentified) on 7/21/2025 at around 2 AM that Resident 1 was short of breath (SOB) and that Resident 1's chest hurt whenever Resident 1 took a breath. Resident 1 stated the facility staff (unidentified) just wanted to give Resident 1 medicine for the cough but Resident 1 informed the facility staff (unidentified) Resident 1 needed to go to the hospital. Resident 1 stated Resident 1 felt upset because the facility waited over 24 hours before listening to Resident 1 and before sending Resident 1 to the hospital. Resident 1 stated Resident 1 knew something was wrong. Resident 1 stated Resident 1 knew Resident 1's body. Resident 1 stated Resident 1 spent 7 days at GACH 1 with pneumonia in both lungs.During a concurrent interview and record review on 7/30/2025 at 12:10 PM with RN 2, Resident 1's Change in Condition Evaluation (CIC), dated 7/22/2025 and timed 8:14 AM, was reviewed. The CIC indicated Resident 1 had, Elevated BP (blood pressure), cough and chest tightness. The CIC indicated Resident 1's doctor ordered for Resident 1 to be sent to GACH 1. RN 2 stated Resident 1 had been pushing to go to the hospital for the last two days.During an interview on 7/30/2025 at 12:51 PM with the SSD, the SSD stated RR 1 called the SSD on 7/21/2025 during the day (time unknown) and wanted to speak to the SSD about Resident 1 being transferred to a hospital. The SSD stated RR 1 informed the SSD Resident 1 had a cough and was having pain. The SSD stated RR 1 wanted Resident 1 to be transferred to the hospital. The SSD stated the SSD directed RR 1 to talk to the nursing staff (in general).During an interview on 7/31/2025 at 10:53 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 complained of having back pain and requested to go to the hospital on 7/20/2025 during the evening time (exact time unknown). LVN 1 stated LVN 1 texted Resident 1's doctor but that the doctor did not reply. LVN 1 stated LVN 1 did not try to call the doctor when the doctor did not respond to the text message.During an interview on 7/31/2025 at 2:24 PM with RN 3, RN 3 stated RN 3 was the supervisor on the 3-11 shift on 7/20/2025. RN 3 stated RN 3 was notified by LVN 1 that Resident 1 wanted to go to the hospital. RN 3 stated Resident 1 told RN 3 that Resident 1 was in pain and wanted to go to the hospital. RN 3 stated Resident 1 claimed Resident 1 did not feel good. RN 3 stated LVN 1 notified Resident 1's doctor. RN 3 stated RN 3 was under the impression LVN 1 spoke to Resident 1's doctor about Resident 1's complaint of pain and wanting to be transferred to a hospital. RN 3 stated LVN 1 should have spoken to Resident 1's doctor and completed a CIC in Resident 1's medical record.During a concurrent interview and record review on 7/31/2025 at 2:38 PM with the DON, the facility's 24-hour communication log, undated, was reviewed. The 24-hour communication log indicated RN 1 made an entry regarding Resident 1on 7/21/2025 at 4:39 PM which indicated, Paged (Resident 1's doctor) regarding resident (Resident 1) and (RR 1) requesting to be transferred to (GACH 1) d/t uncontrollable pain. Paged MD twice on our shift. Awaiting for response. The DON confirmed Resident 1's medical record did not contain documentation regarding Resident 1's complaints of pain and requests to go to the hospital until 7/22/2025. The DON stated RN 1 should have filled out a CIC on 7/21/2025 when Resident 1 had uncontrolled pain. The DON stated the DON was not made aware of Resident 1's complaints of pain or request to be transferred to the hospital until 7/21/2025 while the DON was driving home in the evening. The DON stated the DON instructed the facility staff (unidentified) to call Resident 1's doctor. The DON stated the facility staff should have called the DON if they were unable to reach Resident 1's doctor. The DON confirmed the facility staff did not get a hold of Resident 1's doctor until 7/22/2205 at 8:14 AM.During a review of the P&P titled, Changes in Resident Condition, undated, the P&P indicated, A facility must immediately. consult with the resident's physician.when there is: .A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life - threatening conditions or clinical). The P&P indicated, Document in the resident's medical record: Date and time of change of condition - Who (physician/family member/responsible party) was notified regarding the condition change, information communicated, response and/or orders received, assessment of resident condition and ongoing monitoring of resident condition, care provided, document the time emergency personnel arrived and took over the care of the resident, if applicable, and update the care plan as needed.

b. During a review of Resident 93's AR, the AR indicated Resident 93 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease (irreversible kidney failure), hydronephrosis (a condition characterized by excess fluid in a kidney due to a backup of urine) and dependence on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 93's MDS, dated [DATE], the MDS indicated Resident 93 had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 93 required partial/moderate assistance (helper did less than half the effort) with oral hygiene, upper body dressing and personal hygiene. The MDS indicated Resident 93 required substantial/maximal assistance (helper did more than half the effort) with toileting and shower. During a concurrent interview and record review on 5/27/2025 at 10:18 a.m. with the Social Services Director (SSD), Resident 93's medical record (chart) and electronic medical record (EMR) were reviewed. SSD stated there was no copy of an AD or AD acknowledgement form in Resident 93's chart or EMR. The SSD stated a copy of an AD and ADA form should be updated and, in the chart, and/or uploaded into the EMR of the resident with each admission or readmission and accessible for the staff to know the resident's wishes and preferences in case of an emergency and how to care for the resident while residing in the facility. During an interview on 5/28/2025 at 1:54 p.m. with the DON, the DON stated, all residents should have an updated copy of their AD and ADA form in the chart and/or uploaded in the EMR indicating residents and/or the resident's representative were provided with information on their rights to refuse or receive medical treatment and how to formulate an AD upon admission or readmission. The DON stated the AD and ADA forms needed to be filled out completely and signed with each admission and readmission to honor the resident's wishes, preferences and changes in the plan of care while in the facility. During a review of the facility's P&P titled Advance Directives dated 9/2022, the P&P indicated prior to, or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The P&P indicated the resident, or representative will be provided with written information concerning the resident's right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or chooses to do so. Based on interview and record review, the facility failed to ensure Advance Directives (AD, a legal document indicating resident preference on end-of-life treatment decisions) and AD Acknowledgement Forms were filled out completely and correctly and added to the resident's medical record for two of three sampled residents (Residents 3 and 93) in accordance to the facility's policy and procedure (P&P) titled Advance Directives. This deficient practice had the potential to cause confusion among the healthcare workers in the event Residents 3 and 93 required immediate medical care and/treatment and had the potential for the residents to receive inadequate or medically unnecessary care and/or treatment or services regarding life-sustaining treatment. Findings: a. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine) and unspecified dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 3's AD Acknowledgement Form dated 4/29/2025, Resident 3's AD Acknowledgment Form was not filled out completely. During a review of Resident 3's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/1/2025, the MDS indicated Resident 3 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 3 was dependent (helper does all of the effort) to staff for toileting hygiene and shower. The MDS indicated, Resident 3 required partial/moderate (helper does less than half the effort) from staff for oral hygiene and personal hygiene. During an interview with the Social Worker (SW), and concurrent record review of Resident 3's AD Acknowledgement Form on 5/27/2025 at 10:49 a.m., the SW stated, the AD Acknowledgement Form was not filled out completely. The SW stated, the AD Form needed to be filled out completely and accurately because it indicated the residents' medical wants and wishes. During an interview on 5/28/2025 at 1:53 p.m. with the facility's Director of Nursing (DON), the DON stated, the AD Acknowledgement Form needed to be discussed by the SW with the RP and/or resident and completely filled out upon admission. The DON stated the AD Acknowledgement Form needed to be filled out accurately and completely in cases of emergency, it was the residents' right for the facility staff to follow the residents' wants and wishes.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage in one of one facility's kitchen by failing to: a. Ensure leftover food from outside the facility was not stored in the kitchen refrigerator. b. Label food items and supplies in the dry storage area with a date open receipt, opened and used/best by date. c. Discard expired food items in the dry storage area. These failures had the potential to result in harmful bacteria growth and cross-contamination (transfer of harmful bacteria from one place to another) that would lead to foodborne illness (an illness caused by eating contaminated food). Findings: a. During a concurrent observation and interview on 5/27/2025 at 8:11 a.m. with the Lead [NAME] (LC) in the facility's kitchen refrigerator there were two (2) to-go boxes inside a white plastic bag with leftover beef, chicken, macaroni salad and rice in the refrigerator which were not labeled and dated. These were stored together with food for the residents in the facility. The LC stated all food items in the kitchen refrigerator should be labeled with the date received, opened and used by date to make sure the food served in the facility was at the highest quality. LC stated leftover food from outside the facility should not be stored in the kitchen refrigerator for infection control purposes. b. During a concurrent observation and interview on 5/27/2025 at 8:40 a.m., with the Dietary Supervisor while inside the facility's dry storage area, the following food items did not have a delivery date, opened date and used by date: b1. One (1) box of open Nestle Rich Chocolate powder b2. Five (5) boxes of unopened [NAME] Ready Care (Thickened Lemon Flavored Water) b3. One (1) bag of hotdog buns b4. Two (2) cans of Real Fresh Ready to Serve Chocolate Pudding c. During a concurrent observation and interview on 5/27/2025 at 8:54 a.m. with the DS inside the facility's dry storage area, a gallon of opened Teriyaki sauce with use by date of 5/2/2025 was in the rack. The DS stated all food items stored in the kitchen refrigerator, freezer, and dry storage area should be labeled with the delivery date, opened date and used by date to make sure food stored was within the recommended shelf-life. The DS stated all expired food items should be discarded to make sure food served to the residents was maintained at its best quality. The DS stated food from outside the facility should not be stored inside the kitchen refrigerator, freezer and dry storage area to prevent cross-contamination. During a review of the facility's undated Policy and Procedures (P&P) titled, Refrigerators and Freezers, the P&P indicated, All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. Supervisors will be responsible for ensuring food items in the pantry, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes. During a review of the facility's undated P&P titled, Food Receiving and Storage, the P&P indicated, All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). Partially eaten food is not kept in the refrigerator.

Based on observation, interview, and record review, the facility failed to provide privacy for one of one sampled resident (Resident 30) when staff did not close the privacy curtain while checking Resident 30's Gastrostomy tube (G-tube, feeding tube that is surgically placed through an opening into the stomach from the abdominal wall) site. This deficient practice violated Resident 30's right to bodily privacy and resulted in unnecessary exposure of Resident 30's abdominal area and lower extremities. This deficient practice had the potential to affect Resident 30's psychosocial (mental and emotional) well-being, self-esteem, and self-worth. Findings: During a review of Resident 30's admission Record (AR), the AR indicated Resident 30 was admitted to the facility on [DATE], with diagnoses that included encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for nutritional support) and dysphagia (difficulty swallowing). During a review of Resident 30's Physician Order (PO) dated 3/20/2025, the PO indicated for staff to administer Nutren 2.0 (liquid formula used for G-tube feeding) at 60 cubic centimeters per hour (cc/hr.- unit of measurement) for 20 hours to provide 1,200 cc per 2,400 kilo calories (kcal, unit of energy) in 24 hours turn on at 2 p.m., turn off at 10 am or until total volume is infuse via pump (medical device used to deliver tube feeding). During a review of Resident 30's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 4/24/2025, the MDS indicated Resident 30 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 630 was dependent (helper does all of the effort) on staff for oral hygiene, toileting, showering/bathing self, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. During an observation on 5/27/2025 at 8:40 a.m. with the Director of Staff Development (DSD), in Resident 30's room, Resident 30 was awake, lying in bed. The DSD pulled up Resident 30's gown and checked Resident 30's G-tube site. The DSD did not close Resident 30's privacy curtain to provide Resident 30 privacy, exposing Resident 30's abdominal area and lower extremities to Resident 30's roommate and hallway. During an interview on 5/27/2025 at 8:42 a.m. with the DSD, the DSD stated the DSD pulled up Resident 30's gown to check Resident 30's G-tube site and did not close the privacy curtain to provide Resident 30 privacy, exposing Resident 30's abdomen and lower extremities. The DSD stated privacy curtain needed to be closed during ADLs to provide privacy. During an interview on 5/28/2025 at 1:55 p.m. with the Director of Nursing (DON), the DON stated Resident 30s' privacy curtain needed to be closed during care and ADLs to provide dignity by not exposing Resident 30's body parts. During a review of the facility's policy and procedure (P&P) titled, Quality of Life-Dignity, revised 2/2020, the P&P indicated, staff promote, maintain and protect resident privacy, including privacy during assistance with personal care and during treatment procedures.

Based on observation, interview, and record review, the facility failed to maintain the kitchen in a clean, safe, and sanitary condition by not ensuring food was stored, prepared, and served in accordance with professional standards of food service safety. The facility did not: 1. Eradicate (destroy/kill) cockroach (small insects that carry and spread infectious diseases) infestation (presence of an unusually large number of cockroach population) in the kitchen and the janitor's closet. 2. Eliminate harborage conditions (locations and conditions where pests can live, thrive [grow strong], reproduce, and feed) such as holes, gaps, cracks, crevices (narrow openings) inside the kitchen. These deficient practices placed a total of 42 residents (Residents 1-42) in the facility, who received food, fluids, and used tableware from the kitchen, at risk of food-borne illness (eating live bacteria, food containing toxins from bacteria) and vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches) from ingesting (drinking/eating) contaminated food and unsanitary food preparation and storage that could lead to life-threatening complications and death. On 12/7/2021, at 2:43 pm, the SSA 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 or residents), in the presence of the facility's Administrator (ADM). On 12/10/2021, at 11:22 am, three days after identifying the IJ situation, the SSA removed the IJ situation while onsite in the presence of the ADM after the facility submitted an acceptable Plan of Action (POA, action to correct the deficient practices) as follows: 1. The increase of pest control service was conducted, on 12/7/2021, and on 12/8/2021, by the previous pest control company. On 12/9/2021, a new pest control company was contracted to provide pest control service and they administered pest control treatment on this same day. The pest control company will provide service bi-monthly for 30 days and as needed. 2. On 12/7/2021 an in-service to all staff, including the dietary staff, was conducted to report any pests or penetrations in the kitchen walls to the maintenance supervisor or designee for immediate corrective action. 3. On 12/7/2021 the Director of Nursing (DON) conducted assessment of the 42 residents for any presence of gastrointestinal (GI) symptoms such as abdominal pain, nausea, vomiting, and diarrhea/loose stools. None of the residents had GI symptoms. Cross Reference F880 and F925 Findings: On 12/7/2021, at 8:50 am, the State Survey Agency (SSA) received notification from the Los Angeles County (LAC) Department of Public Health (DPH) Environmental Health (EH) District Surveillance and Enforcement (DSE) Branch (department responsible for ensuring food provided for human consumption is safe and free of contamination) reporting cockroach infestation in the facility's kitchen. At 10:58 am, Environmental Health Specialist 1 (EHS 1 - inspector) closed the kitchen. At 9:28 a.m., one live cockroach was observed in the kitchen, specifically in the janitor's closet located inside the kitchen. A review of the Environmental Health Specialist 1 (EHS 1 - inspector) Official Inspection Report, dated 12/7/2021, indicated EHS 1 observed: - Five to six live cockroaches harboring (hiding) in a gap between the interior mop sink room door jamb/base tile coving and the wall in the facility's kitchen. - Two dead cockroaches on the floor, under the automatic dishwashing machine drainboard, next to the wall. A review of the facility's census report, dated 12/6/2021, indicated there were 42 residents residing in the facility. On 12/7/2021, at 9:10 am, the surveyor conducted a kitchen observation with EHS 1. At 9:28 am, there was one live German cockroach (a small species of cockroach that can access food items and carry serious diseases. These cockroaches also spread different forms of gastroenteritis [food poisoning, dysentery, diarrhea, and other illnesses], plus they carry several allergens which may cause people to exhibit skin rashes, watery eyes, sneezing, congestion of nasal passages, and asthma), walking on the kitchen floor. On 12/7/2021, at 9:30 am, during an interview, Dietary Supervisor (DS) stated the pest control company services the facility once a month and applies treatment (pesticides used to kill, repel or control pests). On 12/7/2021, at 10:05 am, during an interview, EHS 1 stated he arrived at the facility, on 12/7/2021 at 7 am, and proceeded to conduct a routine inspection of the kitchen. At 7:10 am, he saw five live German cockroaches inside the janitor's closet, next to the door and two dead German cockroaches on the kitchen floor, under the dishwashing drainboard. During an observation on 12/7/2021, at 10:58 am, EHS 1 posted a county food closure sign on the kitchen door and informed the administrator the sign should not be removed until the EH DSE officially reopened the kitchen. A review of the email from the facility's Infection Preventionist Nurse (IP, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment), dated 12/17/2021, timed at 1:31 pm, indicated the facility did not provide pest in-services prior to the IJ because there was no activity of cockroaches. A review of the facility's Pest Control policy, dated 5/2008, indicated the facility would maintain an on-going pest control program to ensure the building is kept free of insects and rodents and shall maintain an effective pest control program. A review of the facility's Kitchen Sanitation and Infection Control policy, dated 2018, indicated the facility would ensure a pest control program providing monthly inspection, treatment and prevention of vermin and insect infestation. The pest control is designed to maintain a sanitary environment, which prevents contamination, transmission or spread of disease, by insects or rodents. A review of the 2017 U.S. Food and Drug Administration Food Code 6-202.15 indicated, insects and rodents are vectors of disease-causing microorganisms (living thing that is too small to be seen with the naked eye) which may be transmitted to humans by contamination of food and food contact surfaces. Food establishment shall be protected against the entry of insects and rodents by filling or closing holes and other gaps along floors, walls, and ceilings; closed, tight fitting windows and solid self-closing tight fitting doors. A review of the 2017 U.S. Food and Drug Administration Food Code 4-402.11 indicated, the inability to adequately or effectively clean areas under equipment could create a situation that may attract insects and rodents and accumulate pathogenic (disease-causing) microorganisms that are transmissible through food. A review of the Centers for Disease Control and Prevention (CDC), Guidelines for Environmental Infection Control in Health Care Facilities, updated on 7/23/2019, indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control included cockroaches found in health-care facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (carrier that transfers an infectious organism from one host to another). A review of the undated article from the County of Los Angeles, Department of Public Health, Effective Management of Cockroach Infestation, at http://publichealth.lacounty.gov/eh/docs/specialized/vector_management/cockroachmgmt.pdf indicated that cockroaches may become pests in any structure that has food preparation or storage areas. The article indicated cockroaches contaminate food and kitchen utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high numbers. Cockroaches that live outdoors could come into contact with human excrement (waste matter/feces) in sewers or with animal fecal matter and had the potential to transmit bacteria that cause food poisoning when they entered the facility's kitchen. A review of the Centers for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health Care Facilities, updated 7/1/2019 https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html, indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. The guidelines indicated pest included cockroaches from inside the health care facilities that can serve as agents for the mechanical transmission of microorganisms (small living thing/cell), or as active participants in the disease transmissions process by serving as a vector (a live carrier that transfers infectious pathogens/germs) to animal and or human.

Based on observation, interview, and record review, the facility failed to ensure an effective infection prevention and control program, led by the Infection Preventionist [IP] Nurse, to provide a safe and sanitary environment by having: 1. Cockroaches (small insects that carry and spread infectious diseases) infestation (presence of an unusually large number of cockroach population) in the kitchen. 2. Harborage conditions (locations and conditions where pests can live, thrive [grow strong], reproduce, and feed) such as holes, gaps, cracks, crevices (narrow openings) in the walls and floors and on different surfaces in the kitchen. This deficient practice placed a total of 42 residents in the facility, who received food, fluids, and used tableware from the kitchen, at risk of food-borne illness (eating live bacteria, food containing toxins from bacteria) and vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches) from ingesting (drinking/eating) contaminated food and unsanitary food preparation and storage that could lead to life-threatening complications and death. On 12/7/2021, at 8:50 am, the State Survey Agency (SSA) received a verbal notification from the Los Angeles County (LAC) Department of Public Health (DPH) Environmental Health (EH) District Surveillance and Enforcement (DSE) Branch (department responsible for ensuring food provided for human consumption is safe and free of contamination) reporting cockroach infestation in the facility's kitchen. At 10:58 am, Environmental Health Specialist 1 (EHS 1 - inspector) closed the kitchen. At 9:28 a.m., one live cockroach was observed in the kitchen, specifically in the janitor's closet. On 12/7/2021, at 2:43 pm, the SSA 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 or residents), in the presence of the facility's Administrator (ADM). On 12/10/2021, at 11:22 am, three days after identifying the IJ situation, the SSA removed the IJ situation while onsite in the presence of the ADM after the facility submitted an acceptable Plan of Action (POA, action to correct the deficient practices) as follows: 1. The increase of pest control service was conducted, on 12/7/2021, and on 12/8/2021, by the previous pest control company. On 12/9/2021, a new pest control company was contracted to provide pest control service and they administered pest control treatment on this same day. The pest control company will provide service bi-monthly for 30 days and as needed. 2. On 12/7/2021 an in-service to all staff, including the dietary staff, was conducted to report any pests or penetrations in the kitchen walls to the maintenance supervisor or designee for immediate corrective action. 3. On 12/7/2021 the Director of Nursing (DON) conducted assessment of the 42 residents for any presence of gastrointestinal (GI) symptoms such as abdominal pain, nausea, vomiting, and diarrhea/loose stools. None of the residents had GI symptoms. Cross Reference F812 and F925 Findings: A review of the Environmental Health Specialist 1 (EHS 1 - inspector) Official Inspection Report, dated 12/7/2021, indicated EHS 1 observed: - Five to six live cockroaches harboring (hiding) in a gap between the interior mop sink room door jamb/base tile coving and the wall in the facility's kitchen. - Two dead cockroaches on the floor, under the automatic dishwashing machine drainboard, next to the wall. A review of the facility's census report, dated 12/6/2021, indicated there were 42 residents residing in the facility. On 12/7/2021, at 9:10 am, conducted a kitchen observation with EHS 1. At 9:28 am, there was one live German cockroach (a small species of cockroach that can access food items and carry serious diseases. These cockroaches also spread different forms of gastroenteritis [food poisoning, dysentery [infection of the intestines], diarrhea, and other illnesses], plus they carry several allergens which may cause people to exhibit skin rashes, watery eyes, sneezing, congestion of nasal passages, and asthma), walking on the kitchen floor, inside the janitor's closet. On 12/7/2021, at 9:30 am, during an interview, Dietary Supervisor (DS) stated the pest control company services the facility once a month and applies treatment (pesticides used to kill, repel or control pests). DS stated he had not seen any cockroaches in the kitchen. On 12/7/2021, at 9:45 am, during an interview, the four-dietary staff (DS 1, 2, 3, and 4) stated they had not seen any cockroaches in the kitchen. On 12/7/2021, at 10:05 am, during an interview, EHS 1 stated he arrived at the facility, on 12/7/2021 at 7 am, and proceeded to conduct a routine inspection of the kitchen. At 7:10 am, he saw five live German cockroaches inside the janitor's closet, next to the door and two dead German cockroaches on the kitchen floor, under the dishwashing drainboard. During an observation on 12/7/2021, at 10:58 am, EHS 1 posted a county food closure sign on the kitchen door and informed the administrator the sign should not be removed until the EH DSE officially reopened the kitchen. A review of the email from the facility's IP, dated 12/17/2021, timed at 1:31 pm, indicated the facility did not provide pest in-services prior to the IJ because there was no activity of cockroaches. A review of the facility's Pest Control policy, dated 5/2008, indicated the facility would maintain an on-going pest control program to ensure the building is kept free of insects and rodents and shall maintain an effective pest control program. A review of the facility's Kitchen Sanitation and Infection Control policy, dated 2018, indicated the facility would ensure a pest control program providing monthly inspection, treatment and prevention of vermin and insect infestation. The pest control is designed to maintain a sanitary environment, which prevents contamination, transmission or spread of disease, by insects or rodents. A review of the 2017 U.S. Food and Drug Administration Food Code 6-202.15 indicated, insects and rodents are vectors of disease-causing microorganisms (living thing that is too small to be seen with the naked eye) which may be transmitted to humans by contamination of food and food contact surfaces. Food establishment shall be protected against the entry of insects and rodents by filling or closing holes and other gaps along floors, walls, and ceilings; closed, tight fitting windows and solid self-closing tight fitting doors. A review of the 2017 U.S. Food and Drug Administration Food Code 4-402.11 indicated, the inability to adequately or effectively clean areas under equipment could create a situation that may attract insects and rodents and accumulate pathogenic (disease-causing) microorganisms that are transmissible through food. A review of the Centers for Disease Control and Prevention (CDC), Guidelines for Environmental Infection Control in Health Care Facilities, updated on 7/23/2019, indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control included cockroaches found in health-care facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (carrier that transfers an infectious organism from one host to another). A review of the undated article from the County of Los Angeles, Department of Public Health, Effective Management of Cockroach Infestation, at http://publichealth.lacounty.gov/eh/docs/specialized/vector_management/cockroachmgmt.pdf indicated that cockroaches may become pests in any structure that has food preparation or storage areas. The article indicated cockroaches contaminate food and kitchen utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high numbers. Cockroaches that live outdoors could come into contact with human excrement (waste matter/feces) in sewers or with animal fecal matter and had the potential to transmit bacteria that cause food poisoning when they entered the facility's kitchen. A review of the Centers for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health Care Facilities, updated 7/1/2019 https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html, indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. The guidelines indicated pest included cockroaches from inside the health care facilities that can serve as agents for the mechanical transmission of microorganisms (small living thing/cell), or as active participants in the disease transmissions process by serving as a vector (a live carrier that transfers infectious pathogens/germs) to animal and or human.

Based on observation, interview, and record review, the facility failed to remain free of pests by not having an effective pest control. For 42 of 42 (Residents 1-42) residents in the facility, who received food, fluids, and used tableware from the kitchen, the facility failed to: 1. Eradicate (destroy/kill) cockroach (small insects that carry and spread infectious diseases) infestation (presence of an unusually large number of cockroach population) in the kitchen. 2. Eliminate harborage conditions (locations and conditions where pests can live, thrive [grow strong], reproduce, and feed) such as holes, gaps, cracks, crevices (narrow openings) in the walls, floors, and different surfaces in the kitchen. This deficient practice placed a total of 42 residents at risk of food-borne illness (eating live bacteria, food containing toxins from bacteria) and vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches) from ingesting (drinking/eating) contaminated food and unsanitary food preparation and storage that could lead to life-threatening complications and death. On 12/7/2021, at 8:50 am, the State Survey Agency (SSA) received notification from the Los Angeles County (LAC) Department of Public Health (DPH) Environmental Health (EH) District Surveillance and Enforcement (DSE) Branch (department responsible for ensuring food provided for human consumption is safe and free of contamination) reporting cockroach infestation in the facility's kitchen. At 10:58 am, Environmental Health Specialist 1 (EHS 1 - inspector) closed the kitchen. At 9:28 a.m., one live cockroach was observed in the kitchen, specifically in the janitor's closet. On 12/7/2021, at 2:43 pm, the SSA 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 or residents), in the presence of the facility's Administrator (ADM) regarding the failure to remain free of pests, which had the potential to cause harm to Resdients 1-42. On 12/10/2021, at 11:22 am, three days after identifying the IJ situation, the SSA removed the IJ situation while onsite in the presence of the ADM after the facility submitted an acceptable Plan of Action (POA, action to correct the deficient practices) as follows: 1. Pest control service was conducted, on 12/7/2021, and on 12/8/2021, by the previous pest control company. On 12/9/2021, a new pest control company was contracted to provide pest control service and they administered pest control treatment on this same day. The pest control company will provide service bi-monthly for 30 days and as needed. 2. on 12/7/2021, the facility conducted in-service training to all staff, including the dietary staff, was conducted to report any pests or penetrations in the kitchen walls to the maintenance supervisor or designee for immediate corrective action. 3. On 12/7/2021 the Director of Nursing (DON) conducted assessment of the 42 residents for any presence of gastrointestinal (GI) symptoms such as abdominal pain, nausea, vomiting, and diarrhea/loose stools. None of the residents had GI symptoms. Cross Reference F880 and F812 Findings: A review of the Environmental Health Specialist 1 (EHS 1 - inspector) Official Inspection Report, dated 12/7/2021, indicated EHS 1 observed: - Five to six live cockroaches harboring (hiding) in a gap between the interior mop sink room door jamb/base tile coving and the wall in the facility's kitchen. - Two dead cockroaches on the floor, under the automatic dishwashing machine drainboard, next to the wall. A review of the facility's census report, dated 12/6/2021, indicated there were 42 residents residing in the facility. On 12/7/2021, at 9:28 am, during a kitchen observation with EHS 1, there was one live German cockroach (a small species of cockroach that can access food items and carry serious diseases. These cockroaches also spread different forms of gastroenteritis [food poisoning, dysentery, diarrhea, and other illnesses], plus they carry several allergens which may cause people to exhibit skin rashes, watery eyes, sneezing, congestion of nasal passages, and asthma), walking on the kitchen floor, inside the janitor's closet. On 12/7/2021, at 9:30 am, during an interview, Dietary Supervisor (DS) stated the pest control company services the facility once a month and applies treatment (pesticides used to kill, repel or control pests). On 12/7/2021, at 10:05 am, during an interview, EHS 1 stated he arrived at the facility, on 12/7/2021 at 7 am, and proceeded to conduct a routine inspection of the kitchen. At 7:10 am, he saw five live German cockroaches inside the janitor's closet, next to the door and two dead German cockroaches on the kitchen floor, under the dishwashing drainboard. During an observation on 12/7/2021, at 10:58 am, EHS 1 posted a county food closure sign on the kitchen door and informed the administrator the sign should not be removed until the EH DSE officially reopened the kitchen. A review of the email from the facility's Infection Preventionist Nurse (IP, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment), dated 12/17/2021, timed at 1:31 pm, indicated the facility did not provide pest in-services prior to the IJ because there was no activity of cockroaches. A review of the facility's Pest Control policy, dated 5/2008, indicated the facility would maintain an on-going pest control program to ensure the building is kept free of insects and rodents and shall maintain an effective pest control program. A review of the facility's Kitchen Sanitation and Infection Control policy, dated 2018, indicated the facility would ensure a pest control program providing monthly inspection, treatment and prevention of vermin and insect infestation. The pest control is designed to maintain a sanitary environment, which prevents contamination, transmission or spread of disease, by insects or rodents. A review of the 2017 U.S. Food and Drug Administration Food Code 6-202.15 indicated, insects and rodents are vectors of disease-causing microorganisms (living thing that is too small to be seen with the naked eye) which may be transmitted to humans by contamination of food and food contact surfaces. Food establishment shall be protected against the entry of insects and rodents by filling or closing holes and other gaps along floors, walls, and ceilings; closed, tight fitting windows and solid self-closing tight fitting doors. A review of the 2017 U.S. Food and Drug Administration Food Code 4-402.11 indicated, the inability to adequately or effectively clean areas under equipment could create a situation that may attract insects and rodents and accumulate pathogenic (disease-causing) microorganisms that are transmissible through food. A review of the Centers for Disease Control and Prevention (CDC), Guidelines for Environmental Infection Control in Health Care Facilities, updated on 7/23/2019, indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control included cockroaches found in health-care facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (carrier that transfers an infectious organism from one host to another). A review of the undated article from the County of Los Angeles, Department of Public Health, Effective Management of Cockroach Infestation, at http://publichealth.lacounty.gov/eh/docs/specialized/vector_management/cockroachmgmt.pdf indicated that cockroaches may become pests in any structure that has food preparation or storage areas. The article indicated cockroaches contaminate food and kitchen utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high numbers. Cockroaches that live outdoors could come into contact with human excrement (waste matter/feces) in sewers or with animal fecal matter and had the potential to transmit bacteria that cause food poisoning when they entered the facility's kitchen. A review of the Centers for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health Care Facilities, updated 7/1/2019 https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html, indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. The guidelines indicated pest included cockroaches from inside the health care facilities that can serve as agents for the mechanical transmission of microorganisms (small living thing/cell), or as active participants in the disease transmissions process by serving as a vector (a live carrier that transfers infectious pathogens/germs) to animal and or human.

Based on observation, interview, and record review, the facility failed to consult immediately with the physician when there was a significant change in clinical condition and need to alter the treatment significantly or the need to transfer one of two sampled residents (Resident 1) from the facility, including: 1. Failure to implement the facility's policy on Change of Resident's Condition or Status, by the charge nurse (Licensed Vocational Nurse 2 -LVN 2) not notifying Resident 1's attending physician or on call physician on [DATE], at 7 p.m., when Resident 1's respiratory condition declined and there was a need to transfer Resident 1 to a General Acute Care Hospital (GACH). LVN 2 called Physician 1 but Physician 1 did not return the call. 2. Failure to ensure LVN 2 consulted with a Registered Nurse (RN) for guidance on the care of Resident 1 on [DATE] at 7 p.m., when LVN 2 was unable to contact Physician 1 about Resident 1's breathing difficulties and lack of improvement after breathing treatment (giving inhaled medication) was provided. 3. Failure to ensure LVN 2 effectively monitored Resident 1's respiratory condition by using a stethoscope (a medical instrument used for listening to sounds produced in the body, especially those of the heart and lungs) to determine the severity of the congestion and location of the secretions and by checking Resident 1's vital signs and oxygen saturation to determine the severity of Resident 1's respiratory problem and effectiveness of the supplemental oxygen. 4. Failure to recognize Resident 1's need for emergent intervention and transfer to a higher level of medical care to prevent further decline in medical condition and death. 5. Failure to implement the facility's policy on Emergency Procedure for CPR (cardio-pulmonary resuscitation) by not instructing staff member to retrieve the Automatic External Defibrillator (AED - portable device that checks the heart rhythm and can send an electric shock to the heart to try to restore a normal rhythm). The facility did not have AED available for staff to use in emergencies. 6. Failure to implement the facility's policy on Oxygen Administration by not ensuring Resident 1, who was receiving oxygen therapy, was assessed, including vital signs, lung sounds, and oxygen saturation (the amount of oxygen being carried by red blood cells. It can be measured using a pulse oximeter) and the results were recorded in Resident 1's medical record. 7. Failure to implement the facility's policy on Pulse Oximetry (small device that clips to the tip of a finger used to measure oxygen level in the blood) by not assessing Resident 1 for signs and symptoms of impaired oxygen saturation (altered respiration, difficulty breathing, and abnormal breath sounds). As a result, on [DATE], at 10:15 p.m. (three hours and 15 minutes after Resident 1's decline in respiratory condition), Resident 1 was not responsive, was given CPR and paramedics pronounced Resident 1 dead at 10:20 p.m., at the facility. Findings: On [DATE] at 10 a.m., an unannounced visit to the facility was conducted to investigate a complaint regarding quality of care and death. A review of the Admission Record indicated Resident 1 was admitted to the facility, on [DATE], with [DIAGNOSES REDACTED]. A review of the Nursing Admission assessment dated [DATE] timed at 10:25 p.m., indicated Resident 1 was alert, oriented, cooperative, talkative, able to eat without assistance, and required two-person assistance with transfers. A review of the admission physician's orders [REDACTED]. A review of the physician's orders [REDACTED]. A review of the physician's orders [REDACTED]. A review of Resident 1's physician's orders [REDACTED]. A review of the Resident Care Plan, dated [DATE], indicated Resident 1 was at risk for impaired gas exchanged manifested by shortness of breath (SOB), productive cough and thick sputum secondary to [MEDICAL CONDITION]. A review of the nursing Progress Notes Updates, dated [DATE] timed at 6 a.m., indicated Resident 1 was noted with coughing productive white phlegm (mucus) and congestion (accumulation of fluids and mucus in the lungs and/or airway, which results in impaired breathing). Resident 1 had wheezing and crackle breath sounds (abnormal lung sounds characterized by discontinuous clicking or rattling sounds) on both lungs on auscultation (listening the lung sounds with the use of a stethoscope) and the oxygen saturation was 93% (normal rate above 90%. Below-normal oxygen saturation level indicates need of supplemental oxygen). Physician 1 was notified and ordered chest x-rays (a radiology exam to visualize changes in the lungs) stat (immediately) to Resident 1 due to cough and congestion. A review of the Final X-ray Report dated [DATE], indicated Resident 1 had bilateral infiltrates (left and right lung infections) and pleural effusions (an excess of fluid that accumulates around the lung), and dense area of the right perihilar (area of the lung) region due to pneumonia. A review of the Licensed Nurse Progress Record dated [DATE] at 7 a.m., indicated Physician 1 was notified of X-ray result and ordered a repeat chest X-ray on [DATE]. The document did not indicate any new order for oxygen therapy and/or an order to check Resident 1's oxygen saturation for the effectiveness of the resident's oxygen therapy. A review of the Licensed Nurse Progress Record dated [DATE] for the 7 a.m. to 3 p.m. shift, timed at 3 p.m., documented by LVN 1, indicated Resident 1 had regular breathing, normal breath sounds, no cough, and no secretions. LVN 1 did not document Resident 1's oxygen saturation and did not indicate if Resident 1 was receiving the supplemental oxygen as ordered. A review of the Licensed Personnel Progress Notes dated [DATE] timed at 7 p.m., completed by LVN 2, indicated Resident 1 had labored (difficult) breathing, congestion, and received [MEDICATION NAME]-[MEDICATION NAME] 2.5 mg - 0.5 mg 3 ml inhalation solution by nebulizer and Physician 1 was called. There was no documentation indicating LVN 2 spoke with Physician 1. LVN 2 did not document Resident 1's vital signs and the oxygen saturation level. At 8 p.m., LVN 2 documented Resident 1 had pursed lip breathing (a breathing technique done by inhaling slowly through the nose and mouth and exhaling through the pursed lips (tightly pressed mouth) to improve breathing). Resident 1 was administered oxygen at 3 L/min. via nasal cannula. LVN 2 took Resident 1's vital signs and documented them (within normal levels). LVN 2 did not document checking Resident 1's oxygen saturation. LVN 2 did not document calling Physician 1 again for further orders, asking a RN for guidance, or if unable to reach Physician 1, or calling the facility's Medical Director. At 9 p.m., LVN 2 indicated Resident 1 had no changes. The documentation did not include Resident 1's vital signs and oxygen saturation readings. LVN 2 did not document calling Physician 1, the Medical Director or a RN. At 10:10 p.m., the note indicated Resident 1 had labored breathing with a respiratory rate of 15 breaths per minute (normal between 12 to 16 breaths per minute) and, Appeared to have diminished lungs. 911 (emergency services - paramedics) was called. Resident 1's blood pressure, heart rate and the oxygen saturation were not documented as checked. At 10:15 p.m., Resident 1 was administered CPR and paramedics upon arrival continued CPR. There was no documentation LVN 2 used an Automatic External Defibrillator (AED - portable device that checks the heart rhythm and can send an electric shock to the heart to try to restore a normal rhythm). A review of the Certificate of Death, Resident 1 expired on [DATE], at 10:20 p.m. Resident 1's immediate cause of death was cardiopulmonary arrest. Other contributory conditions leading to death were arrhythmia (irregular heart rhythm), [MEDICAL CONDITION] cardiovascular disease (hardening of blood vessel in the heart), and hypertension (high blood pressure). On [DATE] at 10:15 a.m., the emergency crash cart (a wheeled cart carrying medicines and equipment for use during medical emergency) as inspected and it had not AED. On [DATE] at 11:30 a.m., during an interview, the director of nursing (DON) stated the facility was not equipped with AED. On [DATE] at 12 p.m., during an interview with LVN 1 and concurrent record review, LVN 1 stated on [DATE] for the 7 a.m. to 3 p.m. shift, Resident 1 was given breathing treatment at 9 a.m. and again at 1 p.m. LVN 1 stated Resident 1 was monitored for cough since admission and had continuous oxygen. LVN 1 confirmed there was no documentation of the oxygen saturation to determine Resident 1's respiratory status and effectiveness of the supplemental oxygen ordered. On [DATE] at 1:05 p.m., during an interview, LVN 2 stated, on [DATE] for the 3 p.m. to 11 p.m. shift, she was in charge of Resident 1's care. LVN 2 stated at around 7 p.m., she noticed Resident 1 was having trouble breathing. LVN 2 stated she could not recall checking Resident 1's oxygen saturation. LVN 2 stated she called Physician 1 but was no able to contact him. LVN 2 stated Resident 1 was asleep between 8:30 p.m. and 9 p.m Around 10:20 p.m., Resident 1 felt clammy (sweaty), had diminished lung sound, had faint (weak) carotid (neck artery) pulse, was unresponsive, and gasping for breath and she was unable to get a blood pressure reading. LVN 2 instructed Certified Nursing Assistant 2 (CNA 2) to start CPR and LVN 3 called paramedics. LVN 2 stated there were no registered nurse in the facility for the 3 p.m. to 11 p.m. shift on [DATE]. On [DATE] at 2:30 p.m., during an interview, the Director of Nursing (DON) stated licensed nurses are to check the oxygen saturation when a respiratory problem arises and when a resident is using oxygen. On [DATE] at 3:50 p.m., during an interview, CNA 1 stated on [DATE] at 3:30 p.m., Resident 1 was coughing and spitting phlegm. CNA 1 stated before 8 p.m., Resident 1 was in a sitting position and had shallow breathing. CNA 1 stated the LVN 2 was called, and LVN 3 called 911. CNA 1 confirmed CNA 2 was administering CPR, when the paramedics took over care of Resident 1. A review of the facility's policy and procedure titled, Oxygen Administration, revised on ,[DATE], indicated for residents receiving oxygen therapy, the assessment includes vital signs, lung sounds, and oxygen saturation. Record in the resident's medical record the rate of oxygen flow, route, rationale, frequency and duration of treatment. A review of the facility's policy and procedure titled, Pulse Oximetry (a probe with a light used to measure oxygen level in the blood), revised date ,[DATE], indicated to assess the resident for the following signs and symptoms of impaired oxygen saturation for altered respiration, difficulty breathing, and abnormal breath sounds. A review of facility's policy and procedure titled, Emergency Procedure for CPR, revised on ,[DATE], indicated if an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [MEDICAL CONDITION] is likely, begin CPR. Instruct a staff member to retrieve the Automatic External Defibrillator. A review of facility's policy and procedure titled, Change of Resident's Condition or Status, revised on ,[DATE], indicated, The nurse supervisor/charge nurse will notify the resident's attending physician or on call physician when there has been a significant change in the resident's physical/emotional/mental condition; and a need to transfer the resident to a hospital/ treatment center.

Based on observation, interview, and record review, the facility failed to treat, detect and implement transmission-based precautions in addition to standard precautions, to one of one resident (Resident 5) confirmed positive for scabies, failed to prevent, control cross-contamination and assess skin rashes to 3 of 3 Resident 5's roommates (6, 9, and 11), in a sample of 13 and one of one staff (CNA 5) who provided care to these residents. An immediate jeopardy (IJ) was identified for the facility's failure to identify, detect, treat, and develop appropriate infection control practices essential in preventing scabies outbreaks. On 1/5/16, at 10 a.m., an immediate jeopardy (IJ) was called and the facility's administrator and director of nursing (DON) were notified of the findings. On 1/7/16, at 3:30 p.m., the facility submitted a plan of correction as follows: 1. The Public Health Nurse was notified of the scabies outbreak and recommendations from the Public Health Nurse were followed to prevent the spread of scabies. 2. All residents were assessed by the dermatologist with treatment interventions were provided to all residents. 3. An infection control program was developed to include investigation of rashes, reporting outbreaks to the public health, preventing the transmission of scabies infection by administering treatments and [MEDICATION NAME] (preventive treatment) treatment to residents, roommates and the facility staff who may have direct contact with the residents with suspected scabies and isolating residents and surveillance and tracking of scabies. 4. Facility developed a plan to provide [MEDICATION NAME] treatment of [REDACTED]. 5. In-services and training were provided to the staff for infection control including identification of and preventing the spread of scabies. 6. A separate list was developed, identifying each resident and employees with suspected scabies, when one or more than one symptomatic resident was identified. On 1/7/16 at 3:30 p.m., the administrator and director of nursing (DON) were notified the IJ was abated. Findings: a. A review of Resident 5's physician's orders [REDACTED]. The Resident 5's Physician's Report from the acute hospital dated 11/17/15, indicated one of the admitting diagnoses, included rash, scabies cannot be ruled out, empirically (based on observation or experience) treatment with [MEDICATION NAME] (a medication applied to the skin and used to treat scabies, a contagious skin infestation). Further review of the clinical records indicated Resident 5 was treated with [MEDICATION NAME] the night before and was showered prior to transfer to the acute hospital on [DATE]. Resident 5's was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 5's clinical record identified in the licensed nurse's admission note dated 11/18/15, the resident had generalized body rash. The physician's orders [REDACTED]. On 1/4/16, at 7:40 a.m., during an observation with LVN 4 Resident 5's hands were scaly and crusted. The resident ' s upper body and legs, and entire body were covered with raised red papules (solid rounded growth that is elevated from the skin. Papules when scratched may open and become crusted and infected). Resident 5 was vigorously scratching these areas. On 1/4/16, at 7:45 a.m., during an interview with LVN 4 stated Resident 5 was seen by a dermatologist (skin diseases specialist) on 12/10/15 and was currently being treated with [MEDICATION NAME] cream (medication applied to skin to help relieve redness, itching, swelling and other discomfort caused by skin condition). On 1/5/16, at 9:30 a.m., the DON was asked if she was aware of the resident's rash. The DON stated that she did. However, she did not know the type of rash the resident had. The DON stated that she would notify Resident 5's physician right away. On 1/5/16, at 9:40 a.m., when asked for documented evidence of the facility's surveillance and tracking of scabies/rashes (program for early detection of infested patients and staff), the DON stated the facility did not have one. On 1/5/16, at 9:45 a.m., an interview with certified assistant (CNA 1) was conducted. CNA 1 stated the Resident 5's roommates (Residents 6, 9, and 11) also had rashes and were all itching. CNA 1 stated that Resident 5 had been itching as a result of the rashes for a month. Resident 6 (B bed) had the rash and itching for 3 weeks, Resident 9 (C bed) had the rash and itching for 3 weeks, and Resident 11 (D bed) had been itching as a result of the rashes for 3 days. CNA 1 also stated she herself had been itching for 2 weeks and the physician ordered anti itch medication ([MEDICATION NAME]- medication which helps treat the symptoms of allergies and allergic reactions, such as itching, sneezing and sniffling). On 1/5/16, at 9:50 a.m., the administrator and the DON were informed of the findings. The administrator arranged for an immediate Dermatology consultation. At 4 p.m., the DON stated the Dermatologist would see the residents in the evening. On 1/5/16, at 10 a.m., an immediate jeopardy (IJ) was called and the facility's administrator and director of nursing (DON) were notified of the findings. On 1/5/16, at 10:20 a.m., during an interview with the Infection Control Coordinator regarding documented evidence of a surveillance log, she stated that there was none. On 1/6/16, at 11 a.m., during an interview with the DON, she stated that there would be another dermatologist coming to the facility to perform skin scraping on all residents. On 1/7/16, at 7 a.m., the DON provided the Dermatologist consult notes dated 1/6/16, indicating Resident 5's scraping result was positive for Norwegian scabies. According to LOS ANGELES COUNTY DEPARTMENT OFPUBLIC HEALTH, ACUTE COMMUNICABLE DISEASE CONTROL PROGRAM July 2009 - Version 3 Human scabies is caused by an infestation of the skin by the human itch mite. The adult female scabies mites burrow into the upper layer of the skin where they live and deposit their eggs.) The microscopic scabies mite almost always is passed by direct, prolonged, skin to skin contact with a person who is already infected. Institutions such as nursing homes and extended care facilities are often sites of scabies outbreaks. Some immunocompromised, elderly, disabled, or debilitated persons are at risk for a severe form of scabies called crusted or Norwegian scabies. Persons with crusted scabies have thick crusts of skin that contain large numbers of scabies mites and eggs. The mites in crusted scabies are much more numerous (up to 2 million per patient). Because they are infested with such large numbers of mites, persons with crusted scabies are very contagious to other persons. In addition to spreading scabies through brief skin to skin contact, persons with crusted scabies can transmit scabies indirectly by shedding mites that contaminate items such as their clothing, bedding, and furniture. Persons with crusted scabies should receive quick and aggressive medical treatment for [REDACTED]. The most common signs and symptoms of scabies are intense itching (pruritus), especially at night, and a pimple-like (papular) itchy rash. During an interview with the dermatologist on 1/7/16 at 2:30 p.m., he stated that Resident 5's infection was positive for Norwegian scabies. The dermatologist stated that the condition had probably existed for a year or so and that this type of infection occurs in debilitated patients who were not being taken care of. The dermatologist also stated that the licensed nurses should have identified the patient's skin problem sooner and that resident should have received the appropriate treatment and prevent the outbreak. The facility's policy and procedure on Skin Assessment, dated 4/2012, indicated: It is the facility's policy to check and assess resident's skin condition upon admission, once every shift, during shower and upon discharge to determine skin condition and assure that the appropriate treatment is implemented. The undated policy and procedure titled Isolation Measures, indicated: Isolation procedures are designed to help prevent the spread of microorganisms among residents, visitors and personnel. Since the infecting agent (source) and the host factors are more difficult to control, the interruption in the spread of infection is directed at transmission and thus the utilization of special isolation measures. The facility's undated policy and procedure titled Isolation Measures, indicated it is the responsibility of the Infection Control Coordinator or her designee to notify the attending physician for an order to isolate a resident when there is a suspected infectious process occurring. Isolation precaution should be initiated as a precautionary measure by the Nursing Department until the laboratory results are received. Isolation is to be carried out in accordance with an infection control plan consistent with the health department and Centers for Disease Control. b. Resident 6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 10/7/15, indicated that the resident was able to complete the brief mental status interview, understands others, able to make herself understood, and required extensive assistance with bed mobility, transfer, walking in room, dressing, toilet use, hygiene, and bathing. Section M 1040 (D) under Skin condition did not identify skin rashes as evident. During observations with LVN 4 on 1/5/16, at 9:30 a.m., Resident 6 was in bed, awake and lying sideways. During an interview, Resident 6 stated that she was itching on her body. The resident had scattered, multiple, raised reddened papules and red pin point marks on both arms, abdomen, back, and lower legs with itching to both arms, wrists, thighs and legs, chest and back areas. According to LVN 4, the resident was also receiving [MEDICATION NAME] (treat a variety of skin condition) 0.1% cream for the rash since 11/18/15. A review of the clinical records indicated a physician's orders [REDACTED]. A review of the nurses notes dated 11/18/15 indicated, Resident 6 had dermal rash with red color on upper back and right side of the body. The note stated that the physician was made aware and a new order was received as follows: cleanse dermal rash with soap and water to upper back and right side of body, pat dry and apply [MEDICATION NAME] 1% cream two times a day for 14 days, then re-evaluate. On 11/27/15, the staff received a physician's telephone order that stated, discontinue order treatment to skin rash on right and left extremities, resolved. May apply [MEDICATION NAME] 1 % to right and left lower arm for itching tow times a day for 2 weeks as needed (PRN). On 12/2/15, another physician's orders [REDACTED]. There was no documented evidence of a continuing assessment of the skin condition. The physician ordered on [DATE], [MEDICATION NAME] (an antibiotic cream applied to skin) to apply to skin scratch for 7 days. A physician's orders [REDACTED]. On 1/5/16, at 1 p.m., during an interview with CNA 1, she stated that Resident 6 had the rash and itching for about three weeks. During an interview with the DON and LVN 4 on 1/5/16, at 9:40 a.m. they both stated that scabies was not ruled out for Resident 6. LVN 4 stated that the physician had not seen and assessed the resident. He added that the CNAs would report to him about their findings, he would do his assessment and call the physician for orders. LVN 4 stated he did not know how that it could be scabies. The DON stated that they do not track or do surveillance of skin rashes and/or infections. According to Davis Drug Guide for Nurses, Ninth Edition, during [MEDICATION NAME] cream treatment the nurse should assess affected skin before and daily during therapy. Note the degree of inflammation and pruritus. Notify the physician or other health care professional if symptoms of infection (increased pain, [DIAGNOSES REDACTED], purulent exudate) develop. c. Resident 9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].). The latest Minimum Data Set (MDS), dated [DATE], indicated the resident's cognitive skills for daily decision making were severely impaired, and was totally dependent on staff for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. An interview was conducted with CNA 2 on 1/5/15, at 9:45 a.m., she stated she had observed the rash for about 2 weeks. She also stated that she had informed the treatment nurse about it. During a care observation with CNA 2, revealed Resident 9 with scattered, raised papules to her arms, wrist, upper back, left knee and left foot. CNA 2 stated the resident cries whenever she tried to touch her. During a general observation with LVN 4 on 1/5/16, at 9:50 a.m., Resident 9 was lying in bed. Resident 9 was not interviewable but was making a lot of sound. According to LVN 4, the resident was not able to state what she wants. During an interview with LVN 4, he stated the resident was receiving treatment for [REDACTED]. LVN 4 stated he was not aware of any her skin rash. On 1/5/16, at 9:55, the DON went to the resident's room to check on the rashes. During an interview the DON stated she was not aware of Resident 9's rashes. During a record review with the DON and LVN 4 on 1/5/16, at 10:00 a.m., LVN 4 was unable to find any documented evidence that Resident 9 was assessed with [REDACTED]. On 1/5/16, at 10:30 a.m., during an interview, CNA 1 stated she developed a rash for two weeks. It was observed a pin point red rash on CNA's both arms, upper body and back and legs. CNA 1 stated that the itching was more intense during the night. CNA 1 stated that she informed LVN 4 about her rash but she was informed that it was just an allergy. CNA 1 stated that she went to her own physician and was told that it was an allergy and was prescribed [MEDICATION NAME] (used to treat allergies.) During an interview with the DON on 1/6/16, at 11 a.m., she stated that she was not aware of any staff having any skin rash. On 1/6/16, at 2 p.m., the facility's consultant and treatment nurse were observed performing skin scraping to all four residents that were found to have skin rashes. According to the DON, they obtained physician's orders [REDACTED]. The DON also stated that a dermatologist was scheduled to come to the facility in the afternoon. Isolation precaution was still not implemented. On 1/6/16, at 2:30 p.m., the DON stated that CNA 1 was sent to the clinic for evaluation and treatment. The administrator and the DON informed the survey team that the Public Health Nurse of the local health department and the Department of Health Facilities Inspection Division were notified on 1/5/16. The Director of Staff Development (DSD)/ Infection Control Coordinator stated that the DON and the DSD performed skin inspection of all residents and staff on 1/5/16. The DSD presented the survey team a surveillance list of residents and facility staff with rashes. The list indicated an addition of four residents with skin rash. The DON stated that the dermatologist assessed all residents including Resident 5 and diagnosed them with unspecified dermatitis. The dermatologist ordered treatments with Ivermectin (used to treat scabies and is usually taken orally), [MEDICATION NAME] (used to treat the itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various scalp and skin conditions), [MEDICATION NAME] ( used to treat scabies), [MEDICATION NAME] ( medication used to treat allergies), [MEDICATION NAME] ( used to treat itching) and [MEDICATION NAME] (liquid antimicrobial skin soap ). The DON also stated that the skin scraping result was negative on all residents that had skin rash. DON stated that they had contacted another dermatologist to come for a second opinion. At this time the facility had the isolation precaution initiated that included isolation carts outside the resident rooms. The DON stated that the residents' belongings in the room would be placed plastic bags and stored in storage located on the facility grounds for 7 to 10days, all curtains and linens would be removed and washed and the room was deep cleaned. On 1/7/16, at 7:30 a.m., during an interview with the DON she stated the dermatologist performed skin scraping on all residents and found only one resident (Resident 5) positive for Norwegian scabies and all the rest of the residents did not have the scabies. She also stated that the dermatologist continued all the previous orders by the first dermatologist except for Ivermectin. DON stated that all residents and staff who were potentially exposed to the resident with scabies will be offered [MEDICATION NAME] for [MEDICATION NAME] treatment. The DSD stated that all staff will receive in-service and training regarding identifying, reporting and treatment of [REDACTED]. On 1/7/16, at 3:30 p.m., the immediate jeopardy was lifted after receiving the facility's plan of correction, which included the infection control measures and treatment that were implemented. Cross refer to F 309. d. A review of the Admission Record of Resident 11 indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated December 27, 2015, indicated the resident was able to complete the mental status interview, understands others and able to make self understood, and required extensive to total assistance with activities of daily living. During an interview on January 5, 2016, at 10 a.m., Certified Nursing Assistant (CNA) 1 stated that Residents 5, 6, 9 and 11 had a generalized body rash. CNA 1 stated Resident 11 had the body rash for about three days. During an observation on January 5, 2016, at 10:30 a.m., Resident 11 was observed sitting in a wheelchair in the activity room. CNA 1 brought the resident back to her room for a skin assessment. During the skin assessment, Resident 11 was observed with reddened papules (small solid rounded bumps rising from the skin that are each usually less than 1 in diameter) on bilateral hands, wrists, fingers, and ankles. A review of a nurse's note dated January 5, 2016, at 11 a.m., indicated the resident's physician was notified of the rash and new orders for a dermatology consult, skin scraping and contact isolation precaution were received. A review of a physician's orders [REDACTED]. a. [MEDICATION NAME] (for allergy)10 milligrams (mg) every morning for four weeks. b. [MEDICATION NAME] (for allergy, cold remedies) 25 mg every night at bedtime for four weeks. c. [MEDICATION NAME] 0.05% cream to be applied to rash twice a day for four weeks. d. [MEDICATION NAME] 4% wash to be used all over body once a day for four weeks e. [MEDICATION NAME] 5% to be applied from neck down to toes and left for 12 hours then rinse. Repeat above once a week for four weeks. f. Ivermectin (anti-parasitic) 9 mg once a week for four weeks. During an interview on January 6, 2016, at 8:50 a.m., Resident 11 stated she has had the rashes on her arms for about a month and complained of feeling itchy. The resident stated the staff applied cream on her body last night and gave her medications that made her feel better. During an interview on January 6, 2016, at 8:55 a.m., Licensed Vocational Nurse (LVN) 4 stated that the resident's rashes were first assessed and treated on January 2, 2016. However, a review of the clinical record with LVN 4 did not contain documentation that the resident's skin rashes were assessed and treated until January 5, 2016, after the surveyor questioned it. e. A review of the Admission Record of Resident 12 indicated the resident was originally admitted on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated December 16, 2015, indicated the resident was able complete the brief mental status interview, understands others and able to make self understood, and required extensive to total assistance with activities of daily living. During an interview on January 6, 2016, at 8:45 a.m., Certified Nursing Assistant (CNA) 2 stated that Resident 12 has a rash and has been scratching for about two weeks. CNA 2 stated she reported this to the charge nurse. On January 6, 2016, at 9:15 a.m., an assessment of the resident's skin was done with Licensed Vocational Nurse (LVN) 4. During the skin assessment, Resident 12 was observed with scattered rash to bilateral upper arms and right flank area and a some scratch marks. During an interview on January 6, 2016, at 9:16 a.m. LVN 4 stated he was not aware of the resident's rashes and did not see the rashes yesterday when they conducted a skin sweep of all residents in the facility. LVN 4 stated she would notify the physician and obtain treatment. Cross refer to F 309.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to 5 sampled residents (5, 6, 9, 11 and 12) in a sample of 13. The facility staff failed to identify and treat the Norwegian scabies infection, which resulted in severe discomfort for these residents. According to LOS ANGELES COUNTY DEPARTMENT OFPUBLIC HEALTH, ACUTE COMMUNICABLE DISEASE CONTROL PROGRAM July 2009 - Version 3 Human scabies is caused by an infestation of the skin by the human itch mite. The adult female scabies mites burrow into the upper layer of the skin where they live and deposit their eggs.) The microscopic scabies mite almost always is passed by direct, prolonged, skin to skin contact with a person who is already infected. Institutions such as nursing homes and extended care facilities are often sites of scabies outbreaks. Some immunocompromised, elderly, disabled, or debilitated persons are at risk for a severe form of scabies called crusted or Norwegian scabies. Persons with crusted scabies have thick crusts of skin that contain large numbers of scabies mites and eggs. The mites in crusted scabies are much more numerous (up to 2 million per patient). Because they are infested with such large numbers of mites, persons with crusted scabies are very contagious to other persons. In addition to spreading scabies through brief skin to skin contact, persons with crusted scabies can transmit scabies indirectly by shedding mites that contaminate items such as their clothing, bedding, and furniture. Persons with crusted scabies should receive quick and aggressive medical treatment for [REDACTED]. The most common signs and symptoms of scabies are intense itching (pruritus), especially at night, and a pimple-like (papular) itchy rash. Findings: a. A review of Resident 5's clinical records included a physician's orders [REDACTED]. The Physician Report from the acute hospital dated 11/17/15, included an admitting [DIAGNOSES REDACTED]. A review of the clinical record indicated Resident 5 was treated with [MEDICATION NAME] the night before and was showered prior to transfer(1/16/15) to the acute hospital. The licensed nurses progress notes, from 11/23/15 to 1/4/16, did not reveal any documentation of the rash. However, the treatment records, from 11/3/to 1/4/16 indicated the resident was receiving the [MEDICATION NAME] cream (to treat variety of skin condition) two times a day. A review of the Admission Record of Resident 5 indicated the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a standardized assessment tool, dated 11/4/15, indicated Resident 5 had short and long-term memory problems, was severely impaired cognitive (mental) skills for daily decision-making, and required total assistance from the staff with activities of daily living. The licensed nurse's admission note dated 11/18/15, indicated the resident had generalized body rash. The physician's orders [REDACTED]. On 1/4/16, at 7:40 a.m., during an observation with LVN 4 present, Resident 5's hands were scaly and crusted. The upper body and legs, and entire body were covered with raised red papules (solid rounded growth that is elevated from the skin. Papules when scratched may open and become crusted and infected). Resident 5 was vigorously scratching to these areas. During an interview at 7:45 a.m., LVN 4 stated Resident 5 was seen by a dermatologist (skin diseases specialist) on 12/10/15, and was diagnosed with [REDACTED]. LVN 4 also stated the dermatologist prescribed [MEDICATION NAME] cream (medication applied to skin to help relieve redness, itching, swelling and other discomfort caused by skin condition. On 1/5/16, at 9:30 a.m., the DON (Director of Nurses) was asked if she was aware of the resident's rash. She stated she did but she did not know the type of rash the resident had. The DON stated that she would notify Resident 5's physician right away. At 9:40 a.m., when asked for documented evidence of the facility's surveillance and tracking of scabies/rashes (program for early detection of infested patients and staff), the DON stated the facility did not have one. At 10 a.m., an interview with certified assistance (CNA 1) was conducted. CNA 1 stated the Resident 5's roommates (6, 9, and 11) also had rashes and were itching. CNA 1 stated that Resident 5 had been itching for a month. Resident 6 (B bed) had the rash and itching for 3 weeks, Resident 9 (C bed) had the rash and itching for 3 weeks, and Resident 11 (D bed) had been itching for 3 days. CNA 1 also stated she too had been itching for 2 weeks and had seen her physician and was given anti-itch medication ([MEDICATION NAME]- medication which helps treat the symptoms of allergies and allergic reactions, such as itching, sneezing and sniffling). On 1/5/16, at 10 a.m., the administrator and the DON were informed about the findings. The administrator arranged for an immediate Dermatology consultation. At 4 p.m., the DON stated the Dermatologist would see the residents in the evening. On 1/5/16, at 10:20 a.m., during an interview with the Infection Control Coordinator regarding a surveillance log, she stated that there was none. On 1/5/16, at 8:30 a.m. the DON stated that the result of the scraping was not ready yet. She also stated that the Department and the Public Health Nurse were already notified of the scabies outbreak. An interview with LVN 4 was conducted on 1/6/16, at 10 a.m. LVN 4 stated Resident 5 was sent to the Dermatologist clinic on 11/17/15, and was prescribed the [MEDICATION NAME] cream and [MEDICATION NAME] (medication for itching.) LVN 4 stated that he was not sure if skin scraping (a test used to determine the presence of scabies) was performed. He also stated that there was no mention of isolation precautions. LVN 4 stated he did not know that the rash was scabies otherwise he would have taken action sooner. On 1/6/16, at 11 a.m., during an interview with the DON, she stated that there would be another dermatologist coming to the facility to perform skin scraping on all residents of the facility. On 1/7/16, at 7 a.m., the DON presented the Dermatologist consult notes dated 1/6/16, indicating that Resident 5 had a positive result for Norwegian scabies. According to LOS ANGELES COUNTY DEPARTMENT OFPUBLIC HEALTH, ACUTE COMMUNICABLE DISEASE CONTROL PROGRAM July 2009 - Version 3 Human scabies is caused by an infestation of the skin by the human itch mite. The adult female scabies mites burrow into the upper layer of the skin where they live and deposit their eggs.) The microscopic scabies mite almost always is passed by direct, prolonged, skin to skin contact with a person who is already infected. Institutions such as nursing homes and extended care facilities are often sites of scabies outbreaks. Some immunocompromised, elderly, disabled, or debilitated persons are at risk for a severe form of scabies called crusted or Norwegian scabies. Persons with crusted scabies have thick crusts of skin that contain large numbers of scabies mites and eggs. The mites in crusted scabies are much more numerous (up to 2 million per patient). Because they are infested with such large numbers of mites, persons with crusted scabies are very contagious to other persons. In addition to spreading scabies through brief skin to skin contact, persons with crusted scabies can transmit scabies indirectly by shedding mites that contaminate items such as their clothing, bedding, and furniture. Persons with crusted scabies should receive quick and aggressive medical treatment for [REDACTED]. The most common signs and symptoms of scabies are intense itching (pruritus), especially at night, and a pimple-like (papular) itchy rash. During a telephone interview with the dermatologist on 1/11/16, at 2:30 p.m., he stated that Resident 5 was positive for Norwegian scabies. The dermatologist stated that the condition had probably existed for a year or so and that this type of infection would occur in debilitated patients who were not being taken care of. The dermatologist also stated that the licensed nurses should have identified the patient's skin problem sooner; and that the resident should have received the appropriate treatment to prevent the outbreak. The facility's policy and procedure on Skin Assessment, dated 4/2012, indicated: It is the facility's policy to check and assess resident ' s skin condition upon admission, once every shift, during shower and upon discharge to determine skin condition and assure that the appropriate treatment is implemented. The undated policy and procedure titled Isolation Measures, indicated: Isolation procedures are designed to help prevent the spread of microorganisms among residents, visitors and personnel. Since the infecting agent (source) and the host factors are more difficult to control, the interruption in the spread of infection is directed at transmission and thus the utilization of special isolation measures. The facility's undated policy and procedure titled Isolation Measures, indicated it is the responsibility of the Infection Control Coordinator or her designee to notify the attending physician for an order to isolate a resident when there is a suspected infectious process occurring. Isolation precaution should be initiated as a precautionary measure by the Nursing Department until the laboratory results are received. Isolation is to be carried out in accordance with an infection control plan consistent with the health department and Centers for Disease Control. b. On 1/4/16, at 7:30 a.m., a review of the lists of residents receiving skin treatment indicated Residents 5, 6, 9 and 11 were being treated for [REDACTED]. Record review indicated Resident 6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 10/7/15, indicated that the resident was able to complete the brief mental status interview, understands others, able to make herself understood, and required extensive assistance with bed mobility, transfer, walking in room, dressing, toilet use, hygiene, and bathing. Section M 1040 (D) under Skin condition did not identify skin rashes as evident. During observations with LVN 4 on 1/5/16, at 9:30 a.m., Resident 6 was in bed, awake and lying sideways. Resident 6 stated that she was itching on her body. The resident had scattered multiple raised reddened papules and red pin point marks to bilateral arms, abdomen, back, and lower legs with itching to both arms, wrists, thighs and legs, chest and back areas (indicative of scabies infestation). According to LVN 4, the resident was also receiving treatment for [REDACTED]. A review of the clinical records indicated a physician's orders [REDACTED]. The nurses notes dated 11/18/15 indicated Resident 6 had dermal rash with red color on upper back and right side of the body. The note indicated that the physician was made aware and new order was received as follows: cleanse dermal rash with soap and water to upper back and right side of body, pat dry and apply [MEDICATION NAME] 1% cream two times a day for 14 days, then re-evaluate. On 11/27/15, the staff received physician's telephone order to discontinue the treatment to the skin rash on right and left extremities, resolved. May apply [MEDICATION NAME] 1 % to right and left lower arm for itching two times a day for 2 weeks as needed (prn). On 12/2/15, there was another physician's order [REDACTED]. On 12/6/15, the physician ordered [MEDICATION NAME] (an antibiotic cream applied to skin) to apply to skin scratches for 7 days. On 12/16/15, an order for [REDACTED]. Since 11/18/15, there was no documented evidence of a continuing assessment of the skin condition. On 1/5/16, at 1 p.m., during an interview with CNA (Certified Nursing Assistant) 1, she stated that Resident 6 has had the rash and itching for about three weeks. During an interview with DON and LVN 4 on 1/5/16, at 9:40 a.m. they both stated that scabies was not ruled out for Resident 6. LVN 4 stated that the physician had not seen and assessed the resident. He added that the CNAs would report to him about their findings, he would do his assessment and call the physician for orders. LVN 4 stated he did not know that it could be scabies. The DON stated that they do not have a system of tracking or surveillance of skin rashes and/or infections. According to Davis Drug Guide for Nurses, Ninth Edition, during [MEDICATION NAME] cream treatment the nurse should assess affected skin before and daily during therapy. Note the degree of inflammation and pruritus. Notify the physician or other health care professional if symptoms of infection (increased pain, [DIAGNOSES REDACTED], purulent exudate) develop. ( c) Resident 9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].). A latest Minimum Data Set (MDS), dated [DATE], indicated the resident's cognitive skills for daily decision making were severely impaired, and was totally dependent on staff for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. An interview was conducted with CNA 2 on 1/5/15, at 9:45 a.m., CNA 2 stated she had observed the rash for about 2 weeks. She also stated that she had informed the treatment nurse about it. While CNA 2 provided care, Resident 9 was observed with raised papules on her arms, wrist, upper back, left knee and left foot. CNA 2 stated the resident cries whenever she tried to touch her. During a general observation with LVN 4 on 1/6/16, at 9 a.m., Resident 9 was lying in bed. Resident 9 was not interviewable but was making a lot of sounds. According to LVN 4, the resident was not able to state what she wants. He stated the resident was receiving treatment for [REDACTED]. LVN 4 stated he was not aware of any of her skin rashes. On 1/5/16, at 9:45, the DON went to the resident's room to check on the rashes. During an interview, the DON stated she was not aware of Resident 9 ' s rashes. During record review with the DON and LVN 4 on 1/5/16, at 9:45 a.m., they were not able to find any documented evidence that Resident 9 ' s rashes and itching was assessed. The facility failed to assess Resident 9's skin condition resulting to the lack of intervention/treatment. Cross refer to F441 d. A review of the Admission Record of Resident 11 indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated December 27, 2015, indicated the resident was able to complete the mental status interview, understands others and able to make self understood, and required extensive to total assistance with activities of daily living. During an interview on January 5, 2016, at 10 a.m., Certified Nursing Assistant (CNA) 1 stated that all four residents in room [ROOM NUMBER], including Resident 11, has a generalized body rash. CNA 1 stated Resident 11 had the body rash for about three days. During an observation on January 5, 2016, at 10:30 a.m., Resident 11 was observed sitting in a wheelchair in the activity room. CNA 1 brought the resident back to her room for a skin assessment. During the skin assessment, Resident 11 was observed with reddened papules (small solid rounded bumps rising from the skin that are each usually less than 1 in diameter) on bilateral hands, wrists, fingers, and ankles. A review of a nurse's note dated January 5, 2016, at 11 a.m., indicated the resident's physician was notified of the rash and new orders for a dermatology consult, skin scraping and contact isolation precaution were received. A review of a physician's orders [REDACTED]. a. [MEDICATION NAME] (for allergy) 10 milligrams (mg) every morning for four weeks. b. [MEDICATION NAME] (allergy, cold symptoms) 25 mg every night at bedtime for four weeks. c. [MEDICATION NAME] (topical to help redness and itching) 0.05% cream to be applied to rash twice a day for four weeks. d. [MEDICATION NAME] (skin cleanser) 4% wash to be used all over body once a day for four weeks e. [MEDICATION NAME] 5% to be applied from neck down to toes and left for 12 hours then rinse. Repeat above once a week for four weeks. f. Ivermectin (treat infection caused by parasites) ie scabies, lies) 9 mg once a week for four weeks. During an interview on January 6, 2016, at 8:50 a.m., Resident 11 stated she has had the rashes on her arms for about a month and complained of feeling itchy. The resident stated the staff applied cream on her body last night and gave her medications that made her feel better. During an interview on January 6, 2016, at 8:55 a.m., Licensed Vocational Nurse (LVN) 4 stated that the resident's rashes were first assessed and treated on January 2, 2016. However, a review of the clinical record with LVN 4 did not contain documentation that the resident's skin rashes were assessed and treated until January 5, 2016. e. A review of the Admission Record of Resident 12 indicated the resident was originally admitted on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated December 16, 2015, indicated the resident was able to complete the brief mental status interview, understands others and able to make self understood, and required extensive to total assistance with activities of daily living. During an interview on January 6, 2016, at 8:45 a.m., Certified Nursing Assistant (CNA) 2 stated that Resident 12 has a rash and has been scratching for about two weeks. CNA 2 stated she reported this to the charge nurse. On January 6, 2016, at 9:15 a.m., an assessment of Resident12's skin was done with Licensed Vocational Nurse (LVN) 4. During the skin assessment, Resident 12 was observed with scattered rash to bilateral upper arms and right flank area and a some scratch marks. During an interview on January 6, 2016, at 9:16 a.m. LVN 4 stated he was not aware of the resident's rashes and did not see the rashes yesterday when they conducted a skin sweep of all residents in the facility. LVN 4 stated he would notify the physician and obtain treatment.

The facility failed to ensure that the restorative program was fully carried for one out of 14 sample residents (13), to include ambulation as the physician ordered. This resulted in the resident's decline in the ability to ambulate (walk). The facility also failed to determine by an appropriate professional, such as a physical therapist (PT), the reason for the resident's refusal to ambulate. Findings: A review of the clinical record from the acute rehabilitation hospital prior to Resident 13's original admission to the skilled nursing facility (SNF) dated December 14, 2010, indicated that the discharge plan was for the resident to go to the skilled nursing facility (SNF). The resident/caregiver's goal was the resident would like to get better and to walk. The resident was able to ambulate (walk) 10 feet in the parallel bars with moderate assistance, using a right (R) double adjustable ankle joint (DAAJ) which is a ankle -foot orthosis (AFO), an assistive device for walking. On March 11, 2012, at 12:00 p.m., during an observation, Resident 13 was lying in his bed alert, awake, and oriented. There was no adaptive equipment at the resident's bedside. The resident was observed, with a right sided weakness but was able to raise his right arm with the use of his left arm. According to the admission record, Resident 13 was originally admitted to the SNF facility on February 2, 2011, with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), a standardized assessment and care planning tool, dated February 15, 2012, indicated the resident had no cognitive (mental) problems, needed extensive assistance from staff members for all activities of daily living. The MDS indicated that walking in the room and walking in the corridor did not occur, functional limitation in range of motion indicated impairment on one side of upper and lower extremity. There were no mobility devices used by the resident. The resident did not have any splint or brace assistance. The Care Area Assessment (CAA) Summary dated February 15, 2012, indicators of ADLs - Functional Status indicated that the resident had self-care deficit related to physical limitations secondary [MEDICAL CONDITION] right [MEDICAL CONDITION] (weakness) which triggered the need to care plan. The care plan considerations indicated to identify and address the underlying condition and contributing risk factors in order to prevent further decline in ADLs and to maximize the resident's functional potential. The care plan approaches for potential decline in joint range of motion dated February 2, 2011, included; to provided RNA (restorative nurses assistant services) as ordered. The Initial Rehabilitation Screening Form, dated February 7, 2011, conducted by the physical therapist, indicated no PT evaluation was needed at this time. The Initial Joint Mobility assessment dated [DATE], indicated the resident's Restorative Nursing Program was to include: Right upper extremity and right lower extremity AAROM (active assistive range of motion) and PROM (passive range of motion), and to ambulate the resident with left hand-rail and right AFO. The Initial Joint Mobility Assessment problem summary dated February 7, 2011, done by the licensed PT, indicated to ambulate the resident with left hand rail and right lower extremity AFO, QD(every day) as tolerated. There was no documented evidence in the SNF clinical record to indicate that the resident was fully or further assessed for ambulation abilities to include: distance and endurance abilities, or number of persons required to assist for ambulation. The physician orders [REDACTED]. A review of the RNA notes of February 2011 to November 7, 2011, revealed that the resident was ambulating progressively. There was no documented evidence of how far the resident was ambulating. The (SNF) care plan goal dated February 2, 2011, did not include how far the resident will be able to ambulate. The November 15, 2011, Joint Mobility Quarterly Assessment indicated that the resident was unable to tolerate progressive ambulation and there was no documented evidence in the clinical record that the facility staff reassessed the resident to identify and address the underlying condition and contributing risk factors that contributed to the inability of the resident to tolerate progressive ambulation such as pain, in order to prevent further decline and to maximize the resident's functional potential. There was no documented evidence in the clinical record that the facility attempted to ascertain through an appropriate professional, such as a physical therapist, as to why the resident was unable to tolerate progressive ambulation on November 15, 2011, or thereafter. A review of the physician order [REDACTED]. On March 11, 2012, at 12:15 p.m., during an interview with the resident, he stated he saw Physical Therapist (PT) 1 only one time since his admission to the SNF. The resident also stated that he used to walk by swinging his leg before he was admitted to the SNF facility, and he had not walked from the time of his admission to the facility. The resident stated he had pain when he attempted to ambulate with the RNA. On March 13, 2012, at 4:40 p.m., during an interview with PT 1, she stated the resident was not a candidate for rehabilitation because the resident had plateaued from the general acute rehabilitation hospital. When asked if she received an endorsement from the therapists at the rehabilitation hospital, she stated no. The Surveyor asked PT 1 if she has any documented evidence in the clinical record that would show that the resident plateaued from the hospital where she came from, she stated no. According to PT 1, she stated the facility did not receive any papers from the general acute rehabilitation hospital. However, a review of the clinical record revealed there was a history and physical from the rehabilitation hospital with the discharge plan, that included continuation of PT. On March 11, 2012, at 2 p.m., the director of nursing (DON) during an interview could not provide an answer/explanation, when asked how would she would ensure and assess the effectiveness of the RNA program. On March 11, 2012 at 4 p.m. during an interview the director of nursing (DON) could not provide an answer/explanation, when the surveyor asked the DON why the resident stated he had not walked during his stay in the SNF, yet the RNA notes indicated the resident was ambulated from the resident's admission on February 2, 2011, until November 9, 2011. The Joint Mobility Quarterly assessment dated [DATE], also indicated the resident was unable to tolerate progressive ambulation. However, there was no documented evidence that the facility attempted to determine (by an appropriate professional such as a physical therapist) the reason for the resident's refusal to ambulate. The DON was not able to provide an answer/explanation. The RNA notes dated November 7, 2011, indicated that the resident refused to ambulate. There was no documentation on the RNA notes for the reason of the resident's refusal to ambulate. On March 11, 2012, at 5 p.m., during an interview with the administrator, she stated the facility was not able to provide physical therapy (PT) for ambulation of the resident because the resident's insurance carrier had not approved for physical therapy. There was no evidence in the SNF clinical record that the SNF provided a physical therapy evaluation or physical therapy from February 2, 2011 to March 10, 2012. There was no evidence in the SNF clinical record that the facility attempted to obtain approval from the insurance provider for physical therapy services after November 7, 2011, when the resident refused to ambulate with the RNA. However, on March 10, 2012, at 3:50 p.m. after the re-certification survey began, a physician order [REDACTED]. According to the job description of the restorative nursing assistant (RNA) dated September 2011, the RNA is under the supervision of the Rehabilitation Department, director of nursing services, director of staff development and licensed nurses, the RNA is responsible for providing nursing care using the restorative nursing approaches learned through training and actual demonstration. The restorative does not function independently. The general role and responsibilities included were direct nursing care in the form of specialized activity such as range of motion (passive or active), generalized strengthening exercises, ambulation and transfer, reports to the director of nursing, physical therapist, occupational therapist, or speech therapist any changes (significant or not significant) regarding resident's condition including lack of or decrease of motivation. Such significant change may be feeding problems or mobility problems. Document daily or weekly on each resident in the RNA form. The facility's undated policy and procedure titled "Physical Therapy", indicated the therapies ascertain the [DIAGNOSES REDACTED]. If the primary [DIAGNOSES REDACTED]. If the therapist has any concern in this respect, no change in treatment nor discontinuation is affected until the resident's condition has been discussed with the physician.

The facility failed to ensure that the restorative program was fully carried for one out of 14 sample residents (13), to include ambulation as the physician ordered. This resulted in the resident's decline in the ability to ambulate (walk). The facility also failed to determine by an appropriate professional, such as a physical therapist (PT), the reason for the resident's refusal to ambulate. Findings: A review of the clinical record from the acute rehabilitation hospital prior to Resident 13's original admission to the skilled nursing facility (SNF) dated December 14, 2010, indicated that the discharge plan was for the resident to go to the skilled nursing facility (SNF). The resident/caregiver's goal was the resident would like to get better and to walk. The resident was able to ambulate (walk) 10 feet in the parallel bars with moderate assistance, using a right (R) double adjustable ankle joint (DAAJ) which is a ankle -foot orthosis (AFO), an assistive device for walking. On March 11, 2012, at 12:00 p.m., during an observation, Resident 13 was lying in his bed alert, awake, and oriented. There was no adaptive equipment at the resident's bedside. The resident was observed, with a right sided weakness but was able to raise his right arm with the use of his left arm. According to the admission record, Resident 13 was originally admitted to the SNF facility on February 2, 2011, with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), a standardized assessment and care planning tool, dated February 15, 2012, indicated the resident had no cognitive (mental) problems, needed extensive assistance from staff members for all activities of daily living. The MDS indicated that walking in the room and walking in the corridor did not occur, functional limitation in range of motion indicated impairment on one side of upper and lower extremity. There were no mobility devices used by the resident. The resident did not have any splint or brace assistance. The Care Area Assessment (CAA) Summary dated February 15, 2012, indicators of ADLs - Functional Status indicated that the resident had self-care deficit related to physical limitations secondary [MEDICAL CONDITION] right [MEDICAL CONDITION] (weakness) which triggered the need to care plan. The care plan considerations indicated to identify and address the underlying condition and contributing risk factors in order to prevent further decline in ADLs and to maximize the resident's functional potential. The care plan approaches for potential decline in joint range of motion dated February 2, 2011, included; to provided RNA (restorative nurses assistant services) as ordered. The Initial Rehabilitation Screening Form, dated February 7, 2011, conducted by the physical therapist, indicated no PT evaluation was needed at this time. The Initial Joint Mobility assessment dated [DATE], indicated the resident's Restorative Nursing Program was to include: Right upper extremity and right lower extremity AAROM (active assistive range of motion) and PROM (passive range of motion), and to ambulate the resident with left hand-rail and right AFO. The Initial Joint Mobility Assessment problem summary dated February 7, 2011, done by the licensed PT, indicated to ambulate the resident with left hand rail and right lower extremity AFO, QD(every day) as tolerated. There was no documented evidence in the SNF clinical record to indicate that the resident was fully or further assessed for ambulation abilities to include: distance and endurance abilities, or number of persons required to assist for ambulation. The physician orders [REDACTED]. A review of the RNA notes of February 2011 to November 7, 2011, revealed that the resident was ambulating progressively. There was no documented evidence of how far the resident was ambulating. The (SNF) care plan goal dated February 2, 2011, did not include how far the resident will be able to ambulate. The November 15, 2011, Joint Mobility Quarterly Assessment indicated that the resident was unable to tolerate progressive ambulation and there was no documented evidence in the clinical record that the facility staff reassessed the resident to identify and address the underlying condition and contributing risk factors that contributed to the inability of the resident to tolerate progressive ambulation such as pain, in order to prevent further decline and to maximize the resident's functional potential. There was no documented evidence in the clinical record that the facility attempted to ascertain through an appropriate professional, such as a physical therapist, as to why the resident was unable to tolerate progressive ambulation on November 15, 2011, or thereafter. A review of the physician order [REDACTED]. On March 11, 2012, at 12:15 p.m., during an interview with the resident, he stated he saw Physical Therapist (PT) 1 only one time since his admission to the SNF. The resident also stated that he used to walk by swinging his leg before he was admitted to the SNF facility, and he had not walked from the time of his admission to the facility. The resident stated he had pain when he attempted to ambulate with the RNA. On March 13, 2012, at 4:40 p.m., during an interview with PT 1, she stated the resident was not a candidate for rehabilitation because the resident had plateaued from the general acute rehabilitation hospital. When asked if she received an endorsement from the therapists at the rehabilitation hospital, she stated no. The Surveyor asked PT 1 if she has any documented evidence in the clinical record that would show that the resident plateaued from the hospital where she came from, she stated no. According to PT 1, she stated the facility did not receive any papers from the general acute rehabilitation hospital. However, a review of the clinical record revealed there was a history and physical from the rehabilitation hospital with the discharge plan, that included continuation of PT. On March 11, 2012, at 2 p.m., the director of nursing (DON) during an interview could not provide an answer/explanation, when asked how would she would ensure and assess the effectiveness of the RNA program. On March 11, 2012 at 4 p.m. during an interview the director of nursing (DON) could not provide an answer/explanation, when the surveyor asked the DON why the resident stated he had not walked during his stay in the SNF, yet the RNA notes indicated the resident was ambulated from the resident's admission on February 2, 2011, until November 9, 2011. The Joint Mobility Quarterly assessment dated [DATE], also indicated the resident was unable to tolerate progressive ambulation. However, there was no documented evidence that the facility attempted to determine (by an appropriate professional such as a physical therapist) the reason for the resident's refusal to ambulate. The DON was not able to provide an answer/explanation. The RNA notes dated November 7, 2011, indicated that the resident refused to ambulate. There was no documentation on the RNA notes for the reason of the resident's refusal to ambulate. On March 11, 2012, at 5 p.m., during an interview with the administrator, she stated the facility was not able to provide physical therapy (PT) for ambulation of the resident because the resident's insurance carrier had not approved for physical therapy. There was no evidence in the SNF clinical record that the SNF provided a physical therapy evaluation or physical therapy from February 2, 2011 to March 10, 2012. There was no evidence in the SNF clinical record that the facility attempted to obtain approval from the insurance provider for physical therapy services after November 7, 2011, when the resident refused to ambulate with the RNA. However, on March 10, 2012, at 3:50 p.m. after the re-certification survey began, a physician order [REDACTED]. According to the job description of the restorative nursing assistant (RNA) dated September 2011, the RNA is under the supervision of the Rehabilitation Department, director of nursing services, director of staff development and licensed nurses, the RNA is responsible for providing nursing care using the restorative nursing approaches learned through training and actual demonstration. The restorative does not function independently. The general role and responsibilities included were direct nursing care in the form of specialized activity such as range of motion (passive or active), generalized strengthening exercises, ambulation and transfer, reports to the director of nursing, physical therapist, occupational therapist, or speech therapist any changes (significant or not significant) regarding resident's condition including lack of or decrease of motivation. Such significant change may be feeding problems or mobility problems. Document daily or weekly on each resident in the RNA form. The facility's undated policy and procedure titled "Physical Therapy", indicated the therapies ascertain the [DIAGNOSES REDACTED]. If the primary [DIAGNOSES REDACTED]. If the therapist has any concern in this respect, no change in treatment nor discontinuation is affected until the resident's condition has been discussed with the physician.