Every finding on record at San Marino Healthcare Center

Based on observation, interview, and record review, the facility failed to maintain resident room temperatures within the required range of 71 to 81 degrees Fahrenheit ( F, a scale used to measure temperature) for three (3) of four (4) sampled residents (Residents 2, 3, and 4) in accordance with the facility's policy. This deficient practice had the potential to adversely affect Residents 2, 3, and 4's health, comfort, and overall quality of life. Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included polyneuropathy (conditions affecting nerve function in various parts of the body, leading to symptoms such as weakness, numbness, and burning pain), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 8/6/2026, the MDS indicated Resident 2 had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with upper and lower body dressing and putting on/ taking off footwear and required supervision (helper provides cues) with shower, oral, toileting, and personal hygiene. The MDS further indicated Resident 2 required setup assistance (helper sets up; resident completes activity) with eating. During a concurrent observation and interview on 8/12/2026 at 2:40 PM, Resident 2 was lying in bed inside the room with a floor fan turned on. Resident 2 stated the room gets a little warm around 3 PM to 4 PM. During another interview on 8/12/2026 at 4:45 PM, Resident 2 was out of bed standing inside his room with the floor fan turned on and stated it was warm in his room. 2. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included asthma (a long term lung problem where the tubes that carry air in and out of your chest becomes swollen, tight, and filled with sticky mucus, making it hard to breathe), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had moderate impairment in cognitive skills for daily decision making. The MDS also indicated Resident 3 required setup assistance with toileting and personal hygiene, shower, lower body dressing and putting on/ taking off footwear. During a concurrent observation and interview on 8/12/2026 at 4:08 PM, Resident 3 was inside his room standing and stated he was sweating because it was hot in his room. Resident 3 was observed going out of the room wiping his face with a small towel and on his way to take a shower. 3. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities) and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 had severe impairment in cognitive skills for daily decision making. The MDS also indicated Resident 4 required substantial/maximal assistance (helper does more than half the effort) with oral, toileting and personal hygiene, shower, upper and lower body dressing and putting on/ taking off footwear and required supervision with eating. During a concurrent observation and interview on 8/12/2026 at 4:40 PM, Resident 4 was observed inside his room seated at the edge of his bed with family members standing nearby inside the room. The room was observed without a floor fan and without a water pitcher. Family stated it was warm inside the room. During a concurrent observation and interview on 8/12/2026 at 4:50 PM, Registered Nurse (RN) stated resident rooms should have a safe temperature between 71 to 81 degrees Fahrenheit to keep the residents comfortable and prevent heat strokes (severe body overheating). RN also stated Resident 4 did not have a water pitcher and a fan in his room. RN further stated water hydration should be provided to Resident 4 to prevent dehydration (losing more water than you take in). During an interview with the Maintenance Service Supervisor (MSS) on 8/12/2026 at 3:22 PM, the MSS stated the staff sometimes turn down the thermostat (an automatic device that senses the temperature of a system and controls heating or cooling to keep the temperature close to a set level) when it is hot outside. The MSS also stated when the staff turns the thermostat down, it overloads the pipe outside. The MSS further stated the facility had to turn the Heating, Ventilation, and Air Conditioning (HVAC, is a mechanical system that regulates the temperature, humidity, and air quality in indoor environments to provide thermal comfort and remove contaminants which is essential for maintaining environmental temperatures within safe and acceptable ranges) system off on Monday 8/10/2026 and Tuesday 8/11/2026 for a few hours (no more than 2 hours) to defrost it. During an interview on 8/12/2026 at 3:27 PM, Licensed Vocational Nurse (LVN) stated at the start of 3 PM to 11 PM shift, it usually becomes warmer in the Station 1 resident rooms where the sun hits and the temperature cools down as the evening progresses. During a concurrent observation on 8/12/2026 at 3:57 PM, MSS checked the room temperatures with the temperature gun and showed Resident 2, 3, and 4's room temperature was 82 degrees Fahrenheit. During another interview with the MSS on 8/12/2026 at 4:15 PM, MSS stated the resident room temperature should be between 71 to 81 degrees F range for the safety and well-being of the residents. During a room temperature check by the MSS with the use of a temperature gun on 8/12/2026 at 4:35 PM, the room temperature showed the following:a.) Resident 2 - 82b.) Resident 3 - 85c.) Resident 4 - 84 During an interview on 8/12/2026 at 5:09 PM, the Administrator (ADM) stated residents' rooms should be between 71 to 81 degrees Fahrenheit to keep the residents comfortable and safe from dehydration and/or anything that would compromise the health of the residents due to excessive heat. During a review of the facility's Policy and Procedure (P&P) titled, Maintenance Services, revised December 2009, the P&P indicated maintenance services shall be provided to all areas of the building, grounds, and equipment. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. During a review of the facility's P&P titled, Homelike Environment, revised February 2021, the P&P indicated residents are provided with a safe, comfortable and homelike environment. The P & P also indicated the facility staff, and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting which included a comfortable and safe temperatures (71 to 81 degrees Fahrenheit).

Based on observation, interview, and record review, the facility failed to develop and implement an individualized resident-centered care plan (CP, prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions to the meet the residents' needs for one (1) of three (3) sampled residents (Residents 1), assessed as at risk for falls as indicated on the facility's policy and procedure (P&P) This deficient practice had the potential for Resident 1 to fall and suffer from injury.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of stroke (occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts or ruptures), aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension) Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and dementia (impaired ability to remember, think, or make decisions that interfere with everyday activities) During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 6/26/2026, the MDS indicated Resident 1 had severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 was dependent (helper does all of the effort, Resident does none of the effort to complete the activity) in oral hygiene, toileting hygiene, shower/bathe self, upper/ lower body dressing, putting on/ taking off footwear and personal hygiene. The MDS also indicated Resident 1 needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, walk 50 to 150 feet. The MDS indicated Resident 1 did not have any incidents of fall. During a review of Resident 1's CP, dated 4/23/2026, the CP indicated Resident 1 was at risk for falls, injury, and accidents related to confusion, deconditioning, gait/ balance problems, incontinence, poor communication, comprehension, unaware of safety needs, vision /hearing problems, antihypertensive use, antipsychotic (a type of drug used to treat symptoms of psychosis [(a severe mental condition in which thought, and emotions are so affected that contact is lost with reality]) use , antidepressant (a class of medications primarily used to treat depression [a serious condition that significantly impacts a person's ability to function], it helps lift a sad or low mood) use, history of stroke, aphasia, Alzheimer's Disease, dementia, and mental illness. The CP interventions indicated the following:Anticipate and meet the resident's needs.Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The Resident needs prompt response to all requests for assistance.Encourage and assist the resident to participate in activities that promote exercise physical activity for strengthening and improved mobilityEnsure that the resident is wearing appropriate footwear.Follow facility fall protocol.Keep environment free from clutter hazardsOrient to room & facility as needed.Encourage to ask for assistance.Monitor any changes in condition and refer to physician as needed.Physical therapy (PT, is a medical treatment used to restore functional movements, such as standing, walking, and moving different body parts) evaluation and treat as ordered or as needed. During a review of Resident 1's Fall Risk Evaluation, dated 6/21/2026, the Fall Risk Evaluation indicated Resident 1 scored 14.0, which meant Resident 1 is at risk of falling. During an observation on 8/5/2026 at 8:26 AM in the hallway, Resident 1 was assisted by two (2) staff members toward her room. Resident 1was frowning and was wearing a hospital gown. Resident 1 had Steri-Strips (are thin adhesive skin closure tapes used to pull the edges of shallow cuts together or support surgical incisions after stitches or staples are removed placed) on her forehead and on the bridge of her nose. There was a red- purplish discoloration noted on Resident 1's bilateral orbital area (or orbital region, is the face area around the eye) During a concurrent observation and interview on 8/5/2026 at 9:15 AM with Certified Nurse Assistant 2 (CNA 2) inside Resident 1's room, Resident 1 was awake and lying in her bed. CNA 2 was seated in a chair placed next to Resident 1's bed. CNA 2 stated Resident 1 had been trying to get up from the bed, so he sat down to watch her. During an interview on 8/5/2026 at 1:31 PM with LVN 1, LVN 1 stated, on 8/2/2026 at 11:40 AM, LVN 1 went to check on Resident 1 who was seated in a wheelchair alone in the activity room. LVN 1 stated while she was walking in the hallway toward the Medication Room at around 11:45 AM, she heard a thumping noise. LVN 1 ran back to the activity room and saw Resident 1 lying face down on the floor in the middle of the room. During a concurrent interview and record review on 8/5/2026 at 1:52 PM with LVN 1, Resident 1's CP for fall was reviewed. LVN 1 stated, the care plan interventions were missing supervision and frequent monitoring for Resident 1. LVN 1 stated Resident 1 could not use the call light because she was non-verbal and her cognition was severely impaired. LVN 1 stated the care plan should have included monitoring every hour and supervision to prevent Resident 1 from falling.LVN 1 further stated the care plan interventions needed to be updated to accommodate Resident 1's needs. The current interventions were not resident-centered and were not applicable to the resident. LVN 1 stated because of Resident 1's recent fall, the Resident's needs ongoing supervision and monitoring every hour to prevent resident from falling again. During a concurrent interview and record review on 8/5/2026 at 2:27 PM with the MDS Nurse (MDSN), Resident 1's CP for falls was reviewed. MDSN stated that the CP interventions were not resident centered because Resident 1's cognition was severely impaired. MDSN stated Resident 1's care plan did not and should include essential interventions, such as providing frequent visual monitoring and constant supervision of Resident 1 every hour. During a concurrent interview and record review on 8/5/2026 at 2:35 PM with MDSN, the facility's policy and procedure (P&P) titled, Care Plans- Comprehensive, revised on 9/2010, the P&P indicated, Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. It is recognized that care planning individual symptoms or Care Area Triggers in isolation may have little, if any, benefit for the residents. MDSN stated they should revise the CP to accommodate Residents 1's needs and provide interventions applicable to Resident 1. They need to make sure Resident 1 was provided with supervision and monitor every hour to prevent her from falling. During a concurrent interview and record review on 8/5/2026 at 2:36 PM with MDSN, the facility's P&P titled, Safety and Supervision of Residents, revised on 9/2010, the P&P indicated, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. MDSN stated they should have provided supervision to monitor Resident 1 every hour. During a concurrent interview and record review on 8/5/2026 at 3 PM with the Director of Nursing (DON), Resident 1's CP for risk of falls, dated 4/23/2026 was reviewed. The DON stated that Resident 1's CP should have updated after the actual fall on 8/2/2026. The DON stated the CP should include Resident 1 to be in line of sight of staff at all times to ensure Resident 1's safety and prevent falls. During a review the facility's P&P titled, Care Plans- Comprehensive, revised on 9/2010, the P&P indicated the following:5. Care plan interventions are designed after careful consideration of the relationship between the residents' problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers.6. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. No single discipline can manage the task in isolation.8. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition changes.

Based on interviews and record review, the facility failed to provide a written investigative summary of the grievance (a formal complaint) filed for one of two sampled residents (Resident 1) in accordance with the facility's policy and procedures (P&P) titled, Grievances/Complaints, Filing.This failure had the potential for a delay of action needed with regard to the resident's grievance and to causing psychosocial harm (mental or emotional stress) to Resident 1.Findings:During a review of Resident 1's admission record, dated 6/8/2026, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses but not limited to chronic obstructive pulmonary disease (COPD- a long-term lung disease causing difficulty in breathing), major depressive disorder (mental condition of deep sadness, loss of interest in life), bipolar disorder (mood swings of low depression to emotional highs), and hypothyroidism (thyroid gland makes too little of hormone). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 6/15/2026, indicated Resident 1 had a major loss in brain function (cannot remember things, learn new tasks, or make choices). During an interview on 8/3/2026 at 3:57 P.M. with Family Member (FM) 1, FM 1 stated Resident 1 refused to remove their jewelry while at the facility even when Resident 1 showered. FM 1 stated FM 1 and FM 2 visited Resident 1 at the facility on 6/25/2026 and Resident 1 was wearing all (2 pair yellow earrings, 1 yellow metal bracelet, 1 yellow metal necklace) the resident's jewelry. FM 1 stated FM 1 and FM 2 visited Resident 1 at the facility on 7/3/2026 and Resident 1 was not wearing 3 jewelry items (1 pair of yellow earrings, 1 yellow metal bracelet, 1 yellow metal necklace). During an interview on 8/5/2026 at 1:27 P.M. with FM 2, FM 2 stated FM 1 and FM 2 filed a grievance and reported Resident 1's missing jewelry to facility staff on 7/3/2026. FM 2 stated FM 2 contacted Administrator (Admin) on 7/4/2026 and FM 2 told Admin they felt the jewelry was stolen by facility staff and that Admin told FM 2 the facility is aware of Resident 1's missing jewelry, and the facility was conducting a search. FM 2 stated FM 2 contacted Admin on 7/10/2026, Admin told FM 2 the facility did not find the missing jewelry, and it was the facility's responsibility to reimburse Resident 1 if items are not found. FM 2 stated FM 2 contacted Admin on 7/17/2026 and 7/21/2026, and Admin told FM 2 the facility could not find the missing jewelry, and the facility's Human Resources (a department that helps with hiring, pay, and solves problems) is following up. During a concurrent interview and review on 8/3/2026 at 1:01 P.M. with Licensed Vocational Nurse (LVN) 1, Resident 1's Inventory List on admission and Discharge, dated 6/8/2026 and 7/3/2026 were reviewed. The Inventory List on admission dated 6/8/2026 indicated hand-written items, 2 pair yellow earrings, 1 yellow metal bracelet, 1 yellow metal necklace. Resident 1's Inventory List on Discharge, dated 7/3/2026, did not indicate 2 yellow earrings, and the 1 yellow metal bracelet, 1 yellow metal necklace in the list of belongings returned to the resident. LVN 1 stated FM 1 wanted to take Resident 1's belongings home early and not wait until the resident is discharged from the facility on 7/22/2026 and so they completed the inventory list discharge on [DATE]. Resident 1's 2 yellow earrings, 1 yellow metal bracelet, and 1 yellow metal necklace were missing on 7/3/2026. During a review of the facility's Theft/Loss Monitoring Report, dated 7/7/2026, indicated, (Resident 1) was found on right side laying down in her bed sleeping. (Resident 1) was found to be missing her jewelry (not specified). The only jewelry found was on her right side two earrings. During an interview on 8/3/2026 at 4:42 P.M. with the Director of Nursing (DON), the DON stated Resident 1 refused to remove the resident's jewelries. The DON also stated if a resident's belongings were missing or stolen while in the facility, this had the potential for the resident to feel upset and sad. During an interview on 8/3/2026 at 5:01 P.M. with Admin, Admin stated the facility were notified of Resident 1's missing jewelry on 7/2026 but does not remember the exact date. Admin stated the facility does not have a plan how to resolve or address the concern of Resident 1's missing jewelry and the facility did not provide Resident 1 nor FM 1 and FM 2 a written investigative summary of Resident 1's missing jewelry. Admin stated if a resident had lost a belonging item, this had the potential of the resident to feel upset. During a review of the facility's P&P titled, Grievances/Complaints, Filing, with a review date of 4/2017, the P&P indicated: Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint.A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office. During a review of the facility's job description titled, Administrator, undated, indicated: Ensure that the resident's rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage complaints, are well established and maintained at all times.Review resident complaints and grievances and make written reports of action taken. During a revie of the facility's P&P titled, Theft and Loss Policy Procedure, undated, indicated, The Administrator is responsible for seeing that action is taken on all reports of theft and loss. During a review of the facility's P&P titled, Quality of Life - Dignity, with a review date of 2/2020, indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for one of two sampled residents (Resident 1) when Certified Nursing Assistant 2 (CNA 2) grabbed and pulled Resident 1's hair on 6/10/2026 in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential to affect Resident 1's psychosocial (combined influence of psychological factors and the surrounding social environment on physical, emotional, and/or mental wellness) well-being. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including but not limited to metabolic encephalopathy (abnormalities of water, electrolytes, vitamins, and other chemicals that adversely affect the brain function), cognitive (mental action or process of acquiring knowledge and understanding) communication deficit, and dementia (progressive brain disorder that slowly destroys memory and thinking skills). During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment and tool), dated 4/29/2026, the MDS indicated the resident had severe impairment with cognitive skills for daily decision making. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) for toileting hygiene, upper and lower body dressing, and sit to stand. The MDS also indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steading and/or contact guard assistance as resident completes activity) for sit to lying and lying to sitting on side of bed. During a record review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR) Communication Form (a technique used to provide a framework for communication between members of the health care team), dated 6/10/2026, the SBAR Communication Form indicated at approximately 9:24 PM, Licensed Vocational Nurse 1 (LVN 1) received a call from Director of Staff Development (DSD) stated CNA 1 called her and reported and witnessed an alleged abuse toward a resident, from another staff. During a record review of Resident 1's Interdisciplinary Team (IDT, group of healthcare professionals from diverse fields who work in a coordinated manner toward a common goal for the resident) Conference Record, dated 6/12/2026, the record indicated CNA 1 stated I was walking in the hallway, I heard a loud noise as I was passing by near Resident 1's room. I saw Resident 1 on the floor with her pants pulled down and saw CNA 2 grabbed Resident 1's hair. Resident 1 said ouch. I asked CNA 2 if she needs help, but she just ignored me. The record also indicated CNA 2 stated she was trying to change Resident 1. Resident 1 was combative and almost fell out of bed. CNA 2 tried to hold Resident 1's head and shoulder so she could not get hurt but Resident 1 was pushing CNA 1 back. CNA 1 was on the left side of Resident 1's back so she accidentally grabbed Resident 1's head and hair. During a record review of the facility's Five-Day Letter, dated 6/14/2026, the letter indicated CNA 1 reported while walking past Resident 1's room, he heard a loud noise and observed CNA 2 holding what appeared to be Resident 1's hair. CNA 1 further reported that he assisted CNA 2 in returning the resident to bed and subsequently reported his concerns to the DSD. During an interview on 6/25/2026 at 12:03 PM with CNA 2, CNA 2 stated while changing Resident 1's brief (protective underwear to prevent leakage), Resident 1 was sitting at the edge of the bed and started kicking as she slid onto the floor from the bed. CNA 2 stated she held Resident 1 with her leg as Resident 1 was sliding down. CNA 2 stated she used her left hand to hold Resident 1's head and her right hand was trying to cut the brief to easily tear off Resident 1's brief. CNA 2 stated that CNA 1 passed by twice offering help, but she declined both times. CNA 2 stated when CNA1 passed by the second time, Resident 1 was sitting on the floor and then stood up on her own. During an interview on 6/25/2026 at 12:26 PM with CNA 1, CNA 1 stated he heard some commotion in Resident 1's room and as CNA 1 walked by, he saw Resident 1 lying on the floor between the two beds. CNA 1 stated Resident 1 was lying down and propping her head higher than the rest of her body. CNA 1 stated he saw CNA 2 walk towards Resident 1 from behind the curtain and reached down and grabbed Resident 1's hair in a fist against her scalp. CNA 1 stated he saw Resident 1's head tilt back from CNA 2 grabbing Resident 1's hair. CNA 1 stated Resident 1 said ouch and her face was scrunched up and expressed pain. CNA 1 stated CNA 2 then noticed CNA 1 looking into the room and CNA 2 immediately stopped what she was doing. CNA 1 stated he put on gloves and went inside the room and asked CNA 2 if she needed help, but CNA 2 did not respond. CNA 1 stated when he went inside Resident 1's room and Resident 1 said that CNA 2 was rough. CNA 1 stated he remained with Resident 1 while CNA 2 changed Resident 1's bed. CNA 1 stated he was shocked after witnessing CNA 2 grab Resident 1's hair and therefore felt it was safer for him to remain with Resident 1 while CNA 2 was in the room. CNA 1 stated he then spoke with the DSD and LVN 1 to report CNA 2 pulling Resident 1's hair since he was a mandated reporter. During an interview on 6/25/2026 at 12:54 PM with LVN 1, LVN 1 stated CNA 1 reported that as he was passing by Resident 1's room and saw Resident 1 on the floor, CNA 1 saw CNA 2 holding Resident 1's hair in her hand. LVN 1 stated CNA 2 said that she helped Resident 1 not to hit herself when falling and ended up grabbing Resident 1's hair. During an interview on 6/25/2026 at 2:28 PM with DSD, DSD stated CNA 1 called her on 6/10/2026 before 9:30 PM. DSD stated CNA 1 stated he witnessed an abuse and saw CNA 2 grabbing Resident 1's hair. During an interview on 6/25/2026 at 4:41 PM with DSD, DSD stated that when a resident falls, staff are expected to use proper body mechanics, such as bending their knees and lifting residents by supporting them under the arms. DSD stated that staff should not hold a resident's head during a fall, as this could result in pulling the resident's hair or causing a head injury. DSD further stated that if a resident is already on the ground after a fall, the CNA should not assist the resident to get up. Instead, the CNA must call the licensed nurse first so the licensed nurse can assess the resident for injuries before the resident is assisted to stand. During a concurrent interview and record review on 6/25/2026 at 5:12 PM with the Director of Nursing (DON) of the facility's P&P titled, Preventing Resident Abuse, revised 01/2011, the P&P indicated the facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse and the facility's goal is to achieve and maintain an abuse-free environment. The DON stated Resident 1 was on the floor and CNA 2 was trying to pull Resident 1's hair. The DON stated that when CNA pulled Resident 1's hair, it was a failure to ensure the resident's right to be free from abuse.

Based on interview and record review, the facility failed to maintain accurate (being completely free from mistakes, errors, or defects) resident medical records for two (2) of 2 sampled residents (Resident 1 and 2) by failing to ensure:Resident 1's Fall risk evaluation (a simple, straightforward check-up used to determine how likely you are to fall and get hurt) dated 3/29/2026 and 5/24/2026 were accurate.Resident 2's Fall risk evaluation dated 4/13/2026 and 4/21/2026 were accurate. This deficient practice had the potential for Resident 1 and 2 not to identify and address fall risk factors and interventions to minimize and prevent future falls.Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included depression (a serious mood disorder that causes a persistent feeling of sadness and a loss of interest in activities you usually enjoy), atrial fibrillation (AFib, is an irregular and often very rapid heart rhythm), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/23/2026, the MDS indicated Resident 1's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching assistance) with eating. It also indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with upper body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with oral hygiene and lower body dressing. In addition, it indicated Resident 1 was dependent (helper does all of the effort) with toileting hygiene, shower, and personal hygiene. The MDS indicated Resident 1 is taking antipsychotic (prescription medications used to treat mental health conditions), antianxiety (prescription drugs designed to calm the nervous system), antidepressant (medications that treat mental health conditions), anticoagulant (blood thinners), diuretic (drugs that cause your kidneys to make more urine), hypoglycemic (drug used to lower and control high blood sugar levels) and anticonvulsant (drugs used to calm abnormal electrical activity in the brain) medications. During a review of Resident 1's Fall Risk Evaluation, dated 3/29/2026, the Fall Risk Evaluation indicated Resident 1 requires use of assistive devices (cane, wheelchair, walker, and furniture) for gait/balance assessment. The Fall Risk Evaluation indicated to respond based on the following types of medications:Anesthetics (medication used by doctors to temporarily block pain and sensation).Antihistamines (medication that stops or reduces allergy symptoms).Antihypertensives (medication designed to prevent or treat high blood pressure).Antiseizures (anticonvulsant, medication used to calm abnormal electrical activity in the brain).Benzodiazepines (medication that slows down activity in your brain).Cathartics (medication used to empty the bowels).DiureticsHypoglycemicsNarcotics (substance that dulls the senses, relieves pain, and induces sleep).Psychotropics (drugs that alter brain chemistry, affecting how you think, feel, and behave).Sedatives/Hypnotics (medications that slow down your brain and nervous system activity).The Fall Risk Evaluation indicated Resident 1 takes one (1) to 2 of these medications and/or within the last seven days. During a review of Resident 1's Fall Risk Evaluation, dated 5/24/2026, the Fall Risk Evaluation indicated Resident 1 requires use of assistive devices (cane, wheelchair, walker, and furniture) for gait/balance assessment. The Fall Risk Evaluation indicated to respond based on the following types of medications:Anesthetics.Antihistamines.Antihypertensives.Antiseizures.Benzodiazepines.Cathartics.DiureticsHypoglycemicsNarcotics.Psychotropics.Sedatives/Hypnotics.The Fall Risk Evaluation indicated Resident 1 takes one (1) to 2 of these medications and/or within the last seven days. During a concurrent record review and interview on 5/27/2026 at 1:48 PM with Licensed Vocational Nurse1 (LVN 1), Resident 1's Fall Risk Evaluation dated 3/29/2026 and 5/24/2026, and active medication orders were reviewed. LVN 1 stated Resident 1's Fall Risk |Evaluation dated 3/29/2026 and 5/24/2026 are exactly similar. LVN 1 stated, Resident 1 had a fall incident on 5/24/2026, that is why Fall Risk Evaluation was done for that day. LVN 1 stated when a resident had a fall incident, the Fall Risk Evaluation should already indicate a history of fall and the form completed on 5/24/2026 did not indicate resident has a history of fall. LVN 1 stated the Fall Risk Evaluation has inaccurate documentation for Resident 1's gait/balance assessment. LVN 1 stated the box indicating Resident 1 requires assistive device is not enough, there should be a check mark on the boxes indicating that Resident 1 has balance problem while standing and walking. LVN 1 also, stated Resident 1 is currently taking Ativan (medication for anxiety) which is a type of benzodiazepine and narcotic medication, Cymbalta which is psychotropic, Lasix which is a diuretic, metoprolol which is an antihypertensive. LVN 1 stated Resident 1 takes 3 to 4 medications under the types of medications that was indicated in the Fall Risk Evaluation. LVN 1 stated the assessment answer indicating Resident 1 takes 1 to2 of the medications under the listed types of medications was a wrong documentation because it did not reflect that Resident 1 is taking 3 to 4 medications. LVN 1 stated maintaining accurate medical records, including Fall Risk Evaluations, is important to avoid confusion. During a concurrent record review and interview on 5/27/2026 at 3:15 PM with MDS nurse (MDSN), Resident 1's Fall Risk Evaluation dated 3/29/2026 and 5/24/2026, and nurse progress notes dated 5/24/2026, timed 10:30 PM were reviewed. MDSN stated Resident 1's Fall Risk Evaluation dated 3/29/2026 and 5/24/2026 were documented similar to each other, with the same inaccurate documentation. MDSN stated Resident 1's Fall Risk Evaluation, dated 3/29/2026, was done for Resident 1's quarterly assessment, and the licensed nurse who was taking care of Resident 1 on 5/24/2026 copied the Fall Risk Evaluation dated 3/29/2026. MDSN also stated the documentation for the Fall Risk Evaluation on 5/24/2026 should reflect Resident 1's fall incident and 1 history of fall should have been documented because Reisdent 1 had a fall in the facility. MDSN stated Resident 1 had a fall on 5/24/2026 around 8:30 PM, where in Resident 1 was observed crawling on the floor near the foot of the bed as indicated in nurse progress notes dated 5/25/2026, timed 10:30 PM. 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) with current fracture (a broken or cracked bone), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had modified independence (some difficulty in new situations only) cognitive skills for daily decision making. The MDS indicated Resident 2 required supervision or touching assistance with eating, oral and toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. It also indicated Resident 2 was independent (resident completes the activity by themselves with no assistance from a helper) with walking and Resident 2 is taking antipsychotic, antidepressant, diuretic, and anticonvulsant medications. During a review of Resident 2's Fall Risk Evaluation, dated 4/13/2026, the Fall Risk Evaluation indicated Resident 2 had a 1 to 2 history of falls from the past three (3) months. The Fall Risk Evaluation indicated Resident 2 was chairbound (being unable to walk and relying on a chair or wheelchair) and has incontinent elimination status (lacks voluntary control over their bladder or bowels, resulting in involuntary leakage or accidental loss of urine or stool). The Fall Risk Evaluation indicated Resident 2 has balance problem while standing and walking, has decreased muscular coordination, has change in gait pattern when walking through doorway, has jerking or unstable when making turns, and requires use of assistive devices (cane, wheelchair, walker, and furniture) for gait/balance assessment. The Fall Risk Evaluation indicated to respond based on the following types of medications:AnestheticsAntihistamines.Antihypertensives.Antiseizures.Benzodiazepines.Cathartics.DiureticsHypoglycemicsNarcotics.Psychotropics.Sedatives/Hypnotics.The Fall Risk Evaluation indicated Resident 2 takes 3 to four (4) of these medications and/or within the last seven days. During a review of Resident 2's Fall Risk Evaluation, dated 4/21/2026, the Fall Risk Evaluation indicated Resident 2 had no history of falls from the past 3 months. The Fall Risk Evaluation indicated Resident 2 was ambulatory (able to walk or move around instead of being confined to a bed or chair) and has incontinent elimination status. The Fall Risk Evaluation indicated to respond based on the following predisposing (suffer from a specific condition) conditions:Seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).Osteoporosis (a condition that weakens your bones).Fractures (broken bone).The Fall Risk Evaluation indicated Resident 2 has decreased muscular coordination and requires use of assistive devices for gait/balance assessment. The Fall Risk Evaluation indicated to respond based on the following types of medications:AnestheticsAntihistamines.Antihypertensives.Antiseizures.Benzodiazepines.Cathartics.DiureticsHypoglycemicsNarcotics.Psychotropics.Sedatives/Hypnotics.The Fall Risk Evaluation indicated Resident 2 takes 1 to 2 of these medications and/or within the last seven days. During a concurrent record review and interview on 5/27/2026 at 2 PM with LVN 1, Resident 2's Fall Risk Evaluation dated 4/13/2026 and 4/21/2026, and active medication orders were reviewed. LVN 1 stated Fall Risk |Evaluation dated 4/13/2026 and 4/21/2026 documentations were different. LVN 1 stated that Resident 2 had a fall incident on 4/13/2026, that is why Fall Risk Evaluation was done for that date. LVN 1 stated the Fall Risk Evaluation dated 4/21/2026 has inaccurate documentation since it was documented that Resident 2 has no history of falls for the past 3 months. LVN 1 stated the Fall Risk Evaluation dated 4/13/2026 has inaccurate documentation for Resident 2's ambulation and elimination status, since Resident 2 was ambulatory and not chairbound. During the same concurrent review and interview on 5/27/2026 at 2 PM, Resident 2's Fall Risk Evaluation dated 4/21/2026 was reviewed. LVN 1 stated the Fall Risk Evaluation dated 4/21/2026 has inaccurate documentation for Resident 2's gait/balance assessment, the checked off boxes indicating Resident 1 has decreased muscular coordination and requires assistive device is not enough, there should be check marks on the boxes indicating that Resident 1 has balance problem while standing and walking. LVN 1 stated Resident 2 has multiple medications that are categorized as psychotropics, diuretics, narcotics, cathartics, sedatives, and antiseizures. LVN 1 stated Resident 2's Fall Risk Evaluation dated 4/21/2026 was a wrong documentation since it indicated Resident 2 takes 1 to 2 medications instead of 3 to 4 medications under the types of medications. During a concurrent record review and interview on 5/27/2026 at 3:20 PM with MDSN, Resident 2's Fall Risk Evaluation dated 4/13/2026 and 4/21/2026, and medical records were reviewed. MDSN stated Resident 2's Fall Risk Evaluation, dated 4/13/2026, was done because Resident 2 had a fall incident. MDSN stated Resident 2's Fall Risk Evaluation, dated 4/13/2026 has inaccurate documentation when the licensed nurse documented that Resident 2 was chairbound, because Resident 2 was ambulatory. MDSN stated Resident 2's Fall Risk Evaluation, dated 4/21/2026 has inaccurate documentation because it was documented that Resident 2 has no history of fall, but Resident 2 just had a fall incident 1 week prior to the evaluation. MDSN also stated Resident 2's Fall Risk Evaluation, dated 4/21/2026 indicated Resident 2 has only 1 to 2 predisposing diseases, but Resident 2 has 3 or more predisposing diseases such as seizures, osteoporosis, and fracture. MDSN stated that inaccurate documentation might lead to confusion in the delivery of care. MDSN added it is very important to maintain accurate documentation with residents' Fall Risk Evaluation because it is used as part of the assessment process to ensure residents' safety. During a review of Facility's Policy and Procedure (P&P) titled, Charting Errors and/or Omissions (leaving something out), revised in December 2006, the P&P indicated accurate medical records shall be maintained by the facility. During a review of Facility's P&P titled, Charting and Documentation, revised in July 2017, the P&P indicated documentation in the medical record will be objective (not opinionated), compete and accurate.

Based on interview and record review, the facility failed to monitor every, one (1) to two (2) hours the whereabouts of 1 of 2 sampled residents (Resident 2) who wander (to move around different places usually without having a particular purpose or direction) in accordance with the facility's policy and procedure. This deficient practice had the potential to result in Resident 2 wandering into another resident's room, which placed the resident at risk for another injury and potential serious harm.Findings:1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 3/23/2026, the MDS indicated Resident 1 had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 required supervision (helper provides cues) with oral, toileting, and personal hygiene, shower, upper and lower body dressing, and putting on /taking off footwear. The MDS further indicated Resident 1 required setup assistance (helper sets up; resident completes activity) with eating. During an interview on 5/8/2026 at 12:16 PM in Resident 1's room, Resident 1 stated the night of 4/23/2026 he was sleeping looking and facing towards the wall hugging his radio when he felt the blanket come off him, he woke up and saw Resident 2 standing beside his bed and grabbed the radio he was holding and Resident 2 started walking towards the door. Resident 1 also stated he went after Resident 2 and grabbed his (Resident 2) shirt in the hallway to stop Resident 2. Resident 1 further stated Resident 2 stopped in front of Room A after he felt the tugging of his shirt then Resident 2 turned towards Room A and went inside. Resident 1 stated both (Resident 1 and 2) were tugging on the radio and then Resident 1 fell on the floor on top of Resident 2 who had hit his (Resident 2) head on the floor. Resident 1 denied hitting Resident 2 and stated the radio he had was borrowed from someone, so he felt responsible for it. 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included paranoid schizophrenia and major depressive disorder. During a review of Resident 2's Elopement (a resident leaving a care facility or hospital unit without authorization or notifying the staff. It typically involves vulnerable individuals such as those with mental health conditions) Evaluation (a tool used to determine if an individual requires an alarmed, delayed exit door as a necessary safety intervention), dated 1/27/2026, the Elopement Evaluation indicated Resident 2 wanders and was at risk for elopement. During a review of Resident 2's Care Plan initiated on 1/27/2026, the Care Plan indicated the resident was at risk for injuries secondary to wandering behavior with an approach plan to monitor resident's location with visual checks every 2 hours. During a review of Resident 2's Minimum Data Set, dated [DATE], the MDS indicated Resident 2 had moderate impairment in cognitive skills for daily decision making. The MDS also indicated Resident 2 required supervision with toileting, shower, and personal hygiene and required setup assistance with oral hygiene, upper and lower body dressing. The MDS further indicated Resident 2 was independent with eating and putting on/taking off footwear. During a review of Resident 2's Care Plan initiated on 4/26/2026, the Care Plan indicated the resident was at risk for injuries secondary to wandering behavior with an approach plan to monitor resident's location with visual checks every 2 hours. During a review of the facility's Head Count and Call Light Check for Resident 2 dated 5/4/2026 to 5/8/2026, the head count and call light check were not signed (not done) on the following dates and shift: 5/4/2026 - day, evening and night shifts (7-3 PM, 3-11 PM, and 11-7 PM).5/5/2026 - night shift (11-7 PM)5/6/2026 - evening shift (3-11 PM)5/7/2026 - evening shift (3-11 PM)5/8/2026 - day and evening shift (7-3 PM and 3-11 PM) During an interview on 5/8/2026 at 12:53 PM, Certified Nursing Assistant 1 (CNA 1) stated he was working the night of 4/23/2026 and heard a commotion in Room A, went to the room and saw both Residents 1 and 2 on the floor. During an interview on 5/8/2026 at 1:33 PM, Resident 3 who was in Room A stated, on 4/23/2026, Resident 2 went to his room and was followed by Resident 1, Resident 1 grabbed Resident 2's shirt and took out the radio from him (Resident 2). Resident 3 also stated both Resident 1 and 2 fell towards the bed of his roommate and one of the CNA tried to get Resident 2 off the floor while Resident 1 left his room. During an interview on 5/8/2026 at 3:21 PM, Licensed Vocational Nurse 1 (LVN 1) stated, on the night of 4/23/2026 she was in the medication room when she heard a commotion in Room A and saw both Residents 1 and 2 struggle on something. LVN 1 also stated both Residents 1 and 2 lost their balance while Resident 1 was trying to get the radio from Resident 2. LVN 1 further stated Resident 1 fell on top of Resident 2 and caused Resident 2 to hit his head on the bottom part metal frame of Resident 3's roommate's bed. During a concurrent interview and record review on 5/8/2026 at 4:18 PM, CNA 2 stated the facility had a head count and call light check to log the resident's whereabouts which needed to be filled out once done by the staff to ensure we are aware of the resident's location or whereabouts. CNA 2 also stated there was no valid proof or documented evidence that Resident 2 was being supervised and monitored for the resident's whereabouts every hour on 5/4/2026 to 5/8/2026. CNA 2 further stated Resident 2 walks around and goes to other residents' rooms and the resident should have been monitored. During an interview on 5/8/2026 at 4:48 PM, LVN 2 stated Resident 2 wanders and walks a lot and there are multiple occasions the resident goes to other residents' rooms. LVN 2 also stated the staff are supposed to do head counts and check the residents' location or whereabouts every 1 to 2 hours and as needed to ensure the staff know where the residents are and for the residents' safety. LVN 2 added, if it was done it should have been documented in the resident's head count and call light check. LVN 2 further stated the incident with Resident 1 and 2 would have been prevented if the staff knew where Resident 2 was at that time and they could have prevented Resident 2 wandering into another resident's room. During an interview on 5/8/2026 at 5:16 PM, the Director of Staff Development (DSD) stated Resident 2's Care Plan for wandering behavior dated 4/26/2026 did not indicate any new approach for Resident 2's wandering behavior. DSD also stated the facility had to ensure new interventions were added since the previous intervention (care plan for wandering behavior dates 1/27/2026) was not effective to prevent same incident of Resident 2 wandering into another resident's room from happening again. DSD further stated Care Plan help guide the staff on how to take care of the residents. During a concurrent interview and record review on 5/8/2026 at 5:23 PM, Resident 2's Care Plan for the wandering behavior dated 4/26/2026 and head count and call light check dated from 5/4/2026 to 5/8/2026 were reviewed. The Director of Nursing (DON) stated Resident 2's Care Plan should have been revised and updated after the wandering incident on 4/23/2026 to add new interventions to prevent the same problem of Resident 2 wandering into another resident's room from happening again. The DON also stated monitoring of Resident 2's location or whereabouts was not done from 5/4/2026 to 5/8/2026 every 1 to 2 hours. The DON further stated there is a tendency that Resident 2 could wander into another resident's room again and have another incident and altercation with another resident. The DON also stated the head count and call light check was used to check all the residents' location/whereabouts every hour including those who wander around. During a review of the facility's Policy and Procedure (P&P) titled, Wandering & Elopements, revised 3/2019, the P&P indicated the facility would identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. During a review of the facility's P&P policy titled, Safety and Supervision of Residents, revised on 7/2017, the P&P indicated that residents' safety and supervision and assistance to prevent accidents are facility wide priorities. The P&P also indicated an individualized, resident-centered approach to safety by ensuring that the interventions are implemented correctly and consistently. The P&P further indicated resident risks and environmental hazards included unsafe wandering.

Based on observation, interview, and record review, the facility failed to promote dignity and respect for three (3) of three residents (Resident 8, 7, and 39) reviewed under dignity care area when:Certified Nursing Assistant 1 (CNA 1) used labels to address Resident 8 on 1/6/2026.CNA 1 used labels to address Resident 7 and was standing over while assisting the resident during meals on 1/6/2026. Facility staff used labels when addressing Resident 39 on 1/6/2026, 1/7/2026 and 1/8/2026. These deficient practices had the potential to affect Resident 8,7, and 39's sense of self-worth and self-esteem which could negatively affect the residents' emotional and mental well-being.Findings:1. During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE]. Resident 8's diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral vascular accident (CVA, or stroke is an interruption in the flow of blood to cells in the brain) of the left non-dominant side, anxiety disorder (a disorder characterized by nervousness characterized by a state of excessive uneasiness and apprehension, typically with compulsive behavior [repetitive, persistent, and often uncontrollable actions that a person feels driven to perform] or panic attacks), and major depressive disorder (or also called clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems). During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated 12/3/2025, the MDS indicated Resident 8 had intact cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 8 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, roll left and right, sit to lying, and lying to sitting on the side of the bed. During an observation on 1/6/2026 at 12:29 PM in Resident 8's room, Resident 8 stated Did you (referring to CNA 1) get me some ice for my water? CNA 1 stated, Yes, my dear. Resident 8 got upset and screamed at CNA 1 and Resident 8 stated Just put down my ice water in front of me! During an observation on 1/6/2026 at 1:25 PM in Resident 8's room, Resident 8 called CNA 1 to turn on her fan. CNA 1 replied to Resident 8 and stated, Yes, my dear. During an interview on 1/8/2026 at 12:31 PM with CNA 1, CNA 1 stated they were not supposed to address residents using labels such as my dear. CNA1 stated that the staff should address residents by the names they prefer in order to maintain dignity and respect. During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Dignity revised on 2/2020, the P&P indicated Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. 2. During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 7's diagnoses included ataxia (poor muscle control that causes clumsy or awkward movements, having trouble walking or balancing), dementia (a progressive state of decline in mental abilities), and dysphagia (difficulty swallowing) During a review of Resident 7's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 7 was dependent on eating, oral hygiene, toileting hygiene, shower/bathe self, upper body and lower body dressing, putting on/ taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub shower transfer. During the dining observation on 1/6/2026 at 12:44 PM in Resident 7's Room, Resident 7 was seated in her wheelchair. CNA 1 was observed initially sitting on a chair then observed standing over Resident 7 while feeding the resident. During an interview on 1/6/2026 at 1:33 PM. CNA 1 stated, Sometimes it takes time to assist the feeders. I have two feeders. The other feeder was transferred to the hospital. During an interview on 1/8/2026 at 12:29 PM with CNA 1, CNA 1 stated staff need to be at resident's eye level when assisting residents during meals to promote dignity and respect. CNA 1 stated that she is petite and usually sits on a low folding chair. CNA 1 stated that she kept standing while assisting Resident 7 with her meal because she could not adjust the chair height to be at eye level with Resident 7. During an interview on 1/8/2026 at 2:58 PM with CNA 1, CNA 1 stated staff were not supposed to call the residents who were dependent on staff for eating as feeders because it does not promote respect and dignity. During a review of the facility's P&P titled, Assistance with Meals, revised 7/2017, the P&P indicated Residents requiring full Assistance: residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example:Not standing over residents while assisting them with meals.Avoiding the use of labels when referring to residents (e.g. feeders) 3. During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 39's diagnoses included metabolic encephalopathy (ME, occurs when problems with your metabolism cause brain dysfunction), dysphagia, dementia, and history of falling. During a review of Resident 39's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 39 was dependent on oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, toilet transfer and tub/shower transfer. During an observation on 1/6/2026 at 1:27 PM in Resident 39's room, Resident 39 was seated in her wheelchair when CNA 6 entered the room to ask if Resident 39 was ready for activities. CNA 1 stated, Yes, she's finished eating. See, she understood me! Right, girl! Give me two thumbs up. During an observation on 1/7/2026 at 12:37 PM in Resident 39's room, Resident 39 was seated in her wheelchair. CNA 5 stated, Hi sweetie (to Resident 39), she (the surveyor) wants to speak to you. During an observation on 1/7/2026 at 12:44 PM in Resident 39's room, CNA 5 stated, Hold on sweetie (to Res 39). CNA 5 stated, We should not call residents 'sweetie'. We should address them by their names because we need to respect them. We should call them Miss or use their first or last names. During an observation on 1/8/2026 at 12:20 PM in Resident 39's room, Resident 39 was seated in her wheelchair eating her lunch. CNA 4 stated, Mama [NAME] (to Resident 39) are you hungry? Mama, Look.During an interview on 1/8/2026 at 12:25 PM with CNA 4, CNA 4 stated it was not appropriate to call Resident 39 Mama [NAME]. CNA 4 stated that the staff should address residents by their first or last names to maintain dignity. During a review of the facility's undated P&P titled, Quality of Life - Dignity, the P&P indicated Residents are treated with dignity and respect at all times.

Based on observation, interview, and record review, the facility failed to follow its policy to maintain a safe, clean, comfortable, and homelike environment for three (3) of five (5) sampled residents (Residents 2, 4, and 44) under environment task, when the facility failed to ensure:Resident 2's room was free of trash on the floor, and the wall did not have splattered brownish colored stains.Resident 4's wheelchair was in good condition, with no peeling armrests.Resident 44's wheelchair was in good condition, with no peeling armrests.These deficient practices had the potential to negatively affect Residents 2, 4, and 44 well-being and quality of life. Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], Resident 2's diagnoses included hydronephrosis (swelling of the kidney) with renal and ureteral calculous (kidney stones) obstruction (preventing urine flow), cirrhosis of the liver (is permanent scarring that damages your liver and interferes with its functioning) and pancytopenia (a lower-than-normal count of all three types of blood cells: red blood cells [anemia], white blood cells [leukopenia], and platelets [thrombocytopenia]) During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 11/21/2025, the MDS indicated Resident 2 had moderately impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 2 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, sit to stand, and chair/ bed-to-chair transfer. During a concurrent observation and interview on 1/7/2026 at 12:53 PM in Resident 2's Room, Resident 2 was lying on his bed eating cookies. The floor had multiple used tissues scattered, and the wall had splattered brownish stains. Resident 2 stated that he dropped the used tissues on the floor because he could not find the trash can. During a concurrent observation and interview on 1/7/2026 at 12:59 PM with Housekeeper 1 (HSK 1) in Resident 2's room, the wall was observed to have splattered brownish colored stains. HSK 1 stated that the stains might be from juice or coffee. HSK 1 added that the wall needed to be cleaned to prevent bacteria growth and to reduce the risk of Resident 2 becoming ill. During a concurrent observation and interview on 1/7/2026 at 1:01 PM with Certified Nursing Assistant 2 (CNA 2) in Resident 2's room, multiple used tissues were still on the floor. CNA 2 picked up the garbage can from the corner of the room, then used gloved hands to collect the tissues and placed the garbage can near Resident 2's bed. CNA 2 stated that the room needed to be kept clean and trash removed from the floor to maintain infection control. During a concurrent observation and interview on 1/7/2026 at 1:02 PM with Licensed Vocational Nurse 1 (LVN 1) in Resident 2's room, the wall was observed to have splattered brownish stains. LVN 1 stated that the stains were from coffee and that the wall was dirty. LVN 1 added that housekeeping should clean the wall to maintain infection control. During an interview on 1/7/2026 at 1:03PM with Resident 2, Resident 2 stated he did not throw coffee on the wall. Resident 2 stated that he did not throw coffee on the wall. Resident 2 stated that he was trying to place his coffee cup on the corner of the table in front of him, but he missed, and the cup fell on the floor, causing a mess. Resident 2 stated the housekeeper mopped the floor but did not clean the wall. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Environmental Surfaces. revised 8/2019, the P&P indicated, 9. Housekeeping surfaces (e.g. floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 11. Walls blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. 2. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 8/1/2025. Resident 4's diagnoses included dementia (progressive brain disorder that slowly destroys memory and thinking skills), schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a review of Resident 4's MDS, dated [DATE]. The MDS indicated Resident 4's cognitive (processes of thinking and reasoning) skills for daily decision making were moderately impaired. The MDS indicated Resident 4 required partial moderate assistance (helper does less than half the effort) on toilet hygiene, shower bathe self (the ability to bathe self), personal hygiene (the ability to maintain personal hygiene. The MDS also indicated Resident 4 used manual wheelchair as mobility device. During an observation on 1/6/2026 at 12:10 PM, Resident 4 was in the hallway sitting in her wheelchair. The wheelchair's left armrest black leather covering was cracked and torn, exposing the foam padding. During a concurrent observation and interview on 1/7/2026 at 2:40 PM with the Social Services Director (SSD), the SSD stated that the armrest of Resident 4's wheelchair was ripped, and the foam was exposed. During an interview on 1/7/2026 at 2:45 PM, Resident 4 stated, I want a new wheelchair. 3. During a review of Resident 44's admission Record indicated the facility admitted Resident 44 on 1/15/2025. Resident 4's diagnoses included major depressive disorder, seizure (a sudden and temporary change in the electrical and chemical activity in the brain which leads to a change in a person's movement, behavior, level of awareness and/or feelings), muscle weakness. During a review of Resident 44's MDS, dated [DATE]. The MDS indicated Resident 44's cognitive skills for daily decision making were cognitively intact (skills for daily decision making were intact). The MDS indicated Resident 44 required substantial maximal assistance (helper does more than half the effort) on toilet hygiene, shower bathe self, personal hygiene. The MDS also indicated Resident 44 used manual wheelchair as mobility device. During a concurrent observation and interview on 1/6/2026 at 9:54 AM with Resident 44, while seated in his room in his wheelchair, Resident 44 stated that the wheelchair armrests were old, peeling, and rough on the skin. During a concurrent observation and interview on 1/7/2026 at 2:53 PM with the SSD, the SSD stated that the armrest of Resident 44's wheelchair was peeling. The SSD stated that residents could possibly feel discomfort, which could cause skin tears, and that peeling armrests can harbor bacteria. The SSD also stated that wheelchairs should be in good condition. During a concurrent interview and record review on 1/8/2026 at 8:31 AM with Licensed Vocational Nurse (LVN 2), the facility's policy and procedure (P&P) titled, Maintenance Services, revised in 12/2009 was reviewed. LVN 2 stated that the P&P indicated maintenance services shall be provided to all areas of the building, grounds, and equipment. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. LVN 2 also stated that the facility did not follow the P&P, as the wheelchair armrest was not in good condition.

Based on observation, interview, and record review, the facility failed to provide grooming services for two (2) of three (3) sampled residents (Resident 9 and 22) under activities of daily living (ADLs- are activities related to personal care that include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) care area, in accordance with the facility's policy. This deficient practice resulted in Resident 9 and 22 having long and jagged (having rough, sharp points protruding) fingernails, potentially leading to skin injury, infection, and scarring (mark left on the skin after a wound or injury has healed).Findings: 1. During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] with diagnosis which included lack of coordination, type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During review of Resident 9's Minimum Data Set (MDS, a resident assessment tool), dated 11/7/2025, the MDS indicated Resident 9's cognitive skills (processes of thinking and reasoning) for daily decision-making skills were moderately impaired (decisions poor, cues supervision required). The MDS indicated Resident 9 required partial moderate assistance ( helper does less than half the effort) with eating, oral hygiene (the ability to use suitable items to clean teeth, dentures if applicable), shower bathe self ( the ability to bathe self), personal hygiene ( the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing and drying face and hands). During a review of Resident 9's Care Plan, dated 11/5/2025, the Care Plan indicated the resident has an ADL self-care performance deficit and was at risk for further decline in functional abilities. The care plan intervention indicated to assist with ADLs as needed, and to assist with grooming and trimming fingernails. During an observation on 1/6/2026 at 12:28 PM in Resident 9's room, Resident 9's fingernails had visible food debris around the nail edges. The fingernails were discolored with a yellowish-black substance underneath and were chipped and jagged. During a concurrent observation and interview on 1/7/2026 at 2:22 PM with the Social Service Director (SSD), the SSD stated Resident 9's fingernails were dirty and had yellowish- black to brownish spots. The SSD also stated the nurse should wash the resident's hands before and after eating for hygiene and sanitation. The SSD stated that poor hand hygiene can possibly cause illnesses like diarrhea and stomach upset. 2. During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was initially admitted to the facility on [DATE] with diagnosis which included depression (severe feelings of sadness and hopelessness), schizoaffective disorder (a mental illness that causes loss of contact with reality), dementia (progressive brain disorder that slowly destroys memory and thinking skills). During review of Resident 22's MDS, dated [DATE], the MDS indicated Resident 22's cognitive skills for daily decision-making skills were moderately impaired. The MDS indicated Resident 22 required partial moderate assistance with oral hygiene, shower bathe self and personal hygiene. During a review of Resident 22's Care Plan, dated 3/7/2025, the Care Plan indicated the resident has an ADL self-care performance deficit and was at risk for further decline in functional abilities related to impaired mobility, weakness and difficulty in walking. The care plan intervention indicated to assist with ADLs as needed, and to assist with grooming and trimming fingernails. During an observation on 1/6/2026 at 10:07 AM in the hallway, Resident 22's fingernails were observed to be jagged with visible black residue underneath. During a concurrent observation and interview on 1/7/2026 at 2:28 PM with the SSD, the SSD stated Resident 22's fingernails were dirty and jagged with black debris on the nails. The SSD stated Resident 22's nails need to be trimmed, cleaned and smoothed to prevent skin injuries. During a concurrent interview and review on 1/8/2026 at 3:20 PM with the Licensed Vocational Nurse (LVN 3), the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL) Support, dated 2/2018, was reviewed. LVN 3 stated the P&P indicated residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. LVN 3 stated the P&P was not followed. LVN3 stated Resident 9 and 22's fingernails were long, dirty, and not smooth. LVN 3 stated both Residents 9 and 22 require assistance with nail care and that nails should be kept clean for infection control purposes. LVN 3 stated residents can touch surfaces or fecal matter and may scratch themselves, which can result in cuts and increase risk of skin infections, diarrhea, and stomachache. During a concurrent interview and review on 1/8/2026 at 3:23 PM with LVN 3, the facility's P&P titled, Care of Fingernails / Toenails, dated 2/2018, was reviewed. LVN 3 stated the purpose of this procedure was to clean the nail bed, to keep nail trimmed and to prevent infections. LVN 3 stated the P&P indicated nail care includes daily cleaning and regular trimming. LVN 3 also stated the P&P was not followed. During a review of the facility's P&P titled, Care of Fingernails / Toenails, dated 2/2018, the P&P indicated to clean the resident's nail bed, to keep nail trimmed to prevent infections.

Based on observation, interview, and record review, the facility failed to provide a safe environment for three (3) of six (6) sampled residents (Residents 6, 44, and 45) reviewed under accidents care area, as indicated on the facility policy by failing to: Ensure electrical cords were properly organized and were not wrapped around the metal bed frame of Resident 44.Implement interventions to address Resident 6's wandering behavior, who entered another resident's room.Implement interventions to address Resident 28's wandering behavior, who entered another resident's room. This deficient practice placed Resident 44, 6, and 28, as well as other residents in the facility, at risk for serious injury and/or death.Findings: 1. During a review of Resident 44's admission Record, the admission Record indicated the facility admitted Resident 44 on 1/15/2025. Resident 4's diagnoses included major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), seizure (a sudden and temporary change in the electrical and chemical activity in the brain which leads to a change in a person's movement, behavior, level of awareness and/or feelings), and muscle weakness. During a review of Resident 44's Minimum Data Set (MDS, a resident assessment and tool), dated 11/21/2025, the MDS indicated Resident 44's cognitive skills for daily decision making were cognitively intact (skills for daily decision making were intact). The MDS indicated Resident 44 required substantial maximal assistance (helper does more than half the effort) on toilet hygiene, shower bathe self, personal hygiene. During observation on 1/6/2026 at 9:59 AM at Resident 44's room, multiple electrical cords were observed coiled on the metal base of the bed and are lying loosely on the floor below the bed creating clutter area. During an observation on 1/6/2026 at 9:59 AM in Resident 44's room, multiple electrical cords were observed coiling around the metal base of the bed and lying loosely on the floor below the bed, creating a cluttered area. During a concurrent observation and interview on 1/7/2026 at 2:45 PM with the Social Services Director (SSD) in Resident 44's room, the SSD stated that a white extension cord was wrapped around the metal base of the bed. The bed's plug and cellphone charger were connected to the extension cord. The SSD stated that this created accident hazards that could cause fire, sparks, and electric shock. The SSD also stated that the resident's room was supposed to be safe, clean, and comfortable. During a concurrent interview and record review on 1/8/2026 at 8:31 AM with Licensed Vocational Nurse (LVN 2), the facility's policy and procedure (P&P) titled, Maintenance Services, revised in 12/2009, was reviewed. LVN 2 stated that the P&P indicated maintenance services shall be provided to all areas of the building, grounds, and equipment. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. LVN 2 also stated that the facility did not follow the P&P. LVN 2 stated that extension cords are not supposed to be wrapped around the metal base of the resident's bed, as this can increase the risk of falls, fire, and possible electric shock. During an interview on 1/8/2026 at 10:06 AM with the Maintenance Director (MD), the MD stated that octopus wiring (multiple electrical cords, plugs, power strips, and extension cords connected in a cluttered or overloaded way) was not acceptable and could cause accidents. The MD stated, We will change. During a concurrent interview and record review on 1/8/2026 at 3:42 PM with LVN 3, the facility's P&P titled, Safety and Supervision of Residents, revised 7/2017, was reviewed. LVN 3 stated that the P&P indicated the facility strives to make the environment as free from accident hazards as possible. LVN 3 stated that resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. 2. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on 7/14/2015. Resident 6's diagnoses included dementia (progressive brain disorder that slowly destroys memory and thinking skills), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), hypertension (high blood pressure). During a review of Resident 6's MDS, dated [DATE]. The MDS indicated Resident 6's cognitive skills for daily decision making were severely impaired (never/ rarely made decisions). The MDS indicated Resident 6 was independent (resident completes the activity by themselves) on eating, oral hygiene and personal hygiene. The MDS also indicated Resident 6 was independent on walking 50 feet (ft. unit of measurement) with two turns (once standing, the ability to walk at least 50 ft. and make two turns), and walking 150 ft. (once standing, the ability to walk at least 150 ft. in a corridor or similar space. During a concurrent observation and interview on 1/7/2026 at 8:38 AM with Certified Nursing Assistant (CNA 10), CNA 10 stated that Resident 6 was wandering around the hallway and entering Room A. During a concurrent observation and interview on 1/7/2026 at 1:20 PM with the Dietary Supervisor (DST), the DST observed Resident 6 enter Room A, take a glass of soda from the bedside table of Resident 30, and drink it. During an interview on 1/7/2026 at 1:25 PM with CNA 11, CNA 11 stated that Resident 6's room was not Room A. CNA 11 also stated that this was not acceptable because Resident 6 could take other residents' belongings or eat other residents' food, which may result in an allergic reaction or cause harm. During a concurrent interview and record review on 1/8/2026 at 3:45 PM of Resident 6's care plans with LVN 3, LVN 3 stated that no specific care plan for wandering from room to room was found in Resident 6's chart. LVN 3 stated that Resident 6 was a wanderer and that residents are not supposed to go into other residents' rooms for safety reasons. During a concurrent interview and review on 1/8/2026 at 3:47 PM with LVN 3, the facility's policy and procedures (P&P) titled, Care Plan Comprehensive Person-Centered, dated 3/2022, was reviewed. LVN 3 stated that the P&P indicated a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial (combined influence of psychological factors and the surrounding social environment on physical, emotional, and/or mental wellness), and functional needs, and is developed and implemented for each resident. During a concurrent interview and review on 1/8/2026 at 3:49 PM with LVN 3, f the facility's P&P titled Wandering and Elopements, dated 3/2019, was reviewed. LVN 3 stated that the P&P indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. LVN 3 stated that if a resident is identified as at risk for wandering, elopement, or other safety issues, the care plan will include strategies and interventions to maintain the resident's safety. LVN 3 stated that the P&P was not followed, as there should have been someone in the hallway to monitor and redirect residents. LVN 3 also stated that Resident 6 is a wanderer. 3. a. During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was admitted to the facility on [DATE], Resident 28's diagnoses included dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), anxiety disorder (a disorder characterized by nervousness characterized by a state of excessive uneasiness and apprehension, typically with compulsive behavior [repetitive, persistent, and often uncontrollable actions that a person feels driven to perform] or panic attacks), During a review of Resident 28's Minimum Data Set (dated 11/4/2025, the MDS indicated Resident 28 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 28 needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, sit to stand, chair/bed-to-[NAME] transfer, toilet transfer, tub/shower transfer, and walk 10 feet. a. During medication administration observation on 1/8/2026 at 8:30 AM in the hallway, Resident 28 was observed propelling his wheelchair and trying to get inside multiple Residents' rooms multiple times. During a medication administration observation in Resident 21's room on 1/8/2026 at 8:36 AM with Licensed Vocational Nurse 1 (LVN 1), Resident 28 came inside Resident 21's room while LVN 1 was administering medication to Resident 21. During a concurrent observation on 1/8/2026 at 8:37 AM in the hallway, with the Quality Assurance Nurse (QAN) and LVN, Resident 28 was observed getting out of another Resident's room. During a medication administration observation in Resident 21's room on 1/8/2026 at 8:56 AM with LVN 1, Resident 28 came inside Resident 21's room while LVN 1 was administering medication to Resident 21 During an observation on 1/8/2026 at 9:02 AM in the hallway, Resident 28 went inside another female resident's room. There were no staff observed watching Resident 28 During an observation on 1/8/2026 at 9:05 AM in the hallway, Resident 28 was propelling his wheelchair and went inside another residents' room. During an interview on 1/8/2026 at 9:05 AM with LVN 1, LVN 1 stated it was not acceptable for Resident 28 to enter other residents' room because this could be an invasion of privacy. During an interview on 1/8/2026 at 9:28 AM with Certified Nurse Assistant 7 (CNA 7), CNA 7 stated Resident 28 wanders in the hallway and into other Resident's, which is a privacy issue. CNA 7 stated the staff needed to redirect and supervise Resident 28 because he is confused and wandering. During an interview on 1/8/2026 at 9:38 AM with QAN, QAN stated another resident might hit Resident 28 because he was in another Resident's room. QAN stated Facility staff should always supervise and redirect Resident 28. 3b. During a review of Resident 28's History and Physical Exam (H&P), dated 11/10/2025, the H&P indicated Resident 28 had a fluctuating mental capacity with a dementia cognitive impairment. H&P indicated a plan to monitor for safety/function. During a review of Resident 28's Impaired Cognitive Function and Impaired Thought Processes. care plan, dated 12/8/2025, the care plan indicated the staff interventions included were to cue, reorient, and supervise as needed. During a review of Resident 28's Nursing Skilled Evaluation, dated 1/5/2026, the Nursing Skilled Evaluation indicated under safety note that Resident 28 needs visual monitoring while up in wheelchair and in bed. The Nursing Skilled Evaluation also indicated Resident 28's room was Room A. During an observation on 1/8/2026 at 12:34 PM in Resident 45's room (Room B) with CNA 7, Resident 28 was observed unsupervised in his wheelchair, entering Room B. Resident 45 was observed stating for Resident 28 to get out his room. During an observation on 1/8/2026 at 12:42 PM in Room B, Resident 28 was observed unsupervised in his wheelchair, reentering Room B and Resident 45 stated, Here he goes coming in again. During an observation on 1/8/2026 at 12:49 PM in the facility hallway, Resident 28 was observed unsupervised in wheelchair, entering Room B. Resident 45 was observed grabbing Resident 28's wheelchair and pushing Resident 28 out of Room B and back into the hallway. There were no staff observed in the hallway or in Room B to intervene and ensure the safety, redirection and or re-cue Resident 28. During an interview on 1/8/2026 at 1:07 PM with LVN 1, LVN 1 stated Resident 28 has Alzheimer's disease and needs to be redirected. LVN 1 stated it was unsafe for Resident 28 to enter Room B and for Resident 45 to push his wheelchair out of the room. LVN 1 stated Resident 28 could have fallen or been hit or pushed by Resident 45. LVN 1 also stated Resident 28 needed to have 1 to 1 supervision to ensure his safety because redirection does not always work because he continues to enter other resident's rooms. During an interview on 1/9/2025 at 3:03 PM with the Director of Nursing (DON), the DON stated that Resident 28 has a tendency to wander and that a CNA is usually assigned to frequently monitor him. However, the DON stated that Resident 28 should be on one-to-one supervision to ensure his safety and prevent him from entering other residents' rooms. During a review of the facility's P&P titled, Safety and Supervisions of Resident, revised on 7/2017, the P&P indicated Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P also indicated the facility will have an individualized, resident- centered approach to address safety and accident hazards for individual residents and ensure interventions are implemented.

Based on observation, interview, and record review, the facility failed to monitor the use of anticoagulant therapy ( AC,a medical treatment using drugs, called blood thinners, to prevent or treat dangerous blood clots [thrombi] by slowing down the blood's clotting process, stopping existing clots from growing, and preventing new ones from forming) for two (2) of 2 sampled residents (Residents 2, and 39) under AC care area, as indicated on the facility's policy when facility failed to:1. Monitor Resident 2 for signs and symptoms of bleeding while receiving Heparin injection (is an anticoagulant used to decrease the clotting ability of the blood and help prevent harmful clots from forming in blood vessels) on 11/16/2025 to 11/18/2025.2. Monitor Resident 39 for signs and symptoms of bleeding for the use of Apixaban (Eliquis, a medication used to help prevent strokes or blood clots in people who have atrial fibrillation [afib, a condition in which the heart beats irregularly, increasing the chance of clots forming in the body and possibly causing strokes]) on 8/28/2025 as indicated in the comprehensive person-centered care plan.This deficient practice had the potential for Residents 2 and 39 to suffer excessive bleeding which could lead to complications such as organ damage, severe anemia (a condition in which the body does not have enough healthy red blood cells. [red blood cells provide oxygen to body tissues]), or death. Findings:1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], Resident 2's diagnoses included hydronephrosis (swelling of the kidney) with renal and ureteral calculous (kidney stones) obstruction (preventing urine flow), cirrhosis of the liver (is permanent scarring that damages your liver and interferes with its functioning) and pancytopenia (a lower-than-normal count of all three types of blood cells: red blood cells [anemia], white blood cells [leukopenia], and platelets [thrombocytopenia]) During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 11/21/2025, the MDS indicated Resident 2 had moderately impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 2 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, sit to stand, and chair/ bed-to-chair transfer. During a concurrent observation in Resident 2's room and an interview on 1/6/2026 at 10:32 PM, Resident 2 was sitting up in his bed, and multiple areas of discoloration were noted on his bilateral upper extremities. Resident 2 stated that he was taking an anticoagulant and had bruises on his arms as well as his legs. During a concurrent interview and record review on 1/8/2026 at 3:44 PM with MDS Nurse (MDSN), Resident 2's Physician Orders (PO) dated 11/16/2025 to11/17/2025 were reviewed. The PO indicated the following:On 11/15/2025, Heparin Sodium Injection Solution 5000units/milliliter (ml, measure of volume) Inject 1 vial subcutaneous (SQ, is a shot that delivers medicine into the fatty tissue layer just under the skin, above the muscle, using a short, small needle for slow, steady absorption) every eight (8) hours for deep vein thrombosis (DVT, a blood clot in a vein located deep within the body, usually in the leg) prophylaxis (prevention) until 12/6/2025, discontinued on 11/17/2025. On 11/17/2025, Heparin Sodium Injection Solution 5000 units/ml Inject 1 vial subcutaneously two times a day for DVT Prophylaxis until 12/6/2025, discontinued on 11/18/2025.MDSN stated the PO had no order for monitoring for signs and symptoms of bleeding on 11/16/2025 to 11/18/2025. MDSN stated the staff needed to have an order for monitoring signs and symptoms of bleeding, so that the staff can monitor Resident 2's signs and symptoms of bleeding every shift while on Anticoagulant use. MDSN stated the staff did not and should have monitored Resident 2 for bleeding due to Heparin use. During a concurrent interview and record review on 1/8/2026 at 3:46 PM with MDSN, Resident 2's Medication Administration Record (MAR) dated 11/1/2025 to 11/30/2025 was reviewed. MDSN stated Heparin was administered to Resident 2 on 11/16/2025, 11/17/2025, 11/18/2025. MDSN also stated the MAR did not have documented evidence that Resident 2 was monitored for signs and symptoms of bleeding. During a concurrent interview and record review on 1/8/2026 at 3:50 PM with MDSN, Resident 2's Care Plan (CP) dated 11/1/2025 to 1/8/2025 was reviewed. MDSN stated there was no CP formulated for Resident 2 when he was on Anticoagulant. MDSN also stated if Resident 2 was started on Anticoagulant, the staff should have a care plan right away, to include interventions to monitor Resident 2 for signs and symptoms of bleeding and side effects of the medication. During a concurrent interview and record review on 1/8/2026 at 4:07 PM with MDSN, the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated, a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each Resident. MDSN stated a care plan should be formulated to monitor bleeding, to make sure Resident 2 will not have any bleeding episodes. During an interview on 1/9/2026 at 11:35 AM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated if there was an order for Heparin and there was no monitoring for bleeding, the staff should have followed up with the physician and obtained an order. LVN 1 stated this was important to ensure Resident 2 will be monitored for bleeding episodes by the staff. During an interview on 1/9/2026 at 11:38 AM with LVN 1, LVN 1 stated if there were no care plans, it means there were no interventions for the use of anticoagulant such as monitoring Resident 2 for signs and symptoms of bleeding. 2. During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 39's diagnoses included metabolic encephalopathy (ME, occurs when problems with your metabolism cause brain dysfunction), Afib, and hypertension (high blood pressure) During a review of Resident 39's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 39 was dependent on oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, toilet transfer and tub/shower transfer. During a concurrent interview and record review on 1/8/2026 at 4:16 PM with MDSN, Resident 39's PO dated, 6/5/2025 was reviewed. The PO indicated Eliquis oral tablet 2.5 milligram (mg, a unit of weight/mass) Give 1 tablet by mouth two times a day for afib. MDSN stated Resident 39 did not have an order to monitor for bleeding while using anticoagulant. MDSN also stated if there was no order for monitoring for bleeding while Resident 39 was on anticoagulant therapy, it means the resident will not be monitored for it. During a concurrent interview and record review on 1/8/2026 at 4:22 PM with MDSN, Resident 39's CP on Anticoagulant therapy, dated 8/28/2024, was reviewed. The CP Interventions indicated:Administer anticoagulant medications as ordered by physicians. Monitor for side effects and effectiveness every shift.Monitor signs and symptoms of bleeding every shift. Document: Y if monitored and N if no of the above was observed. If monitored progress notes and notify the MD if any signs and symptoms of side effects noted.MDSN stated the CP interventions were not implemented because there was no documented evidence on the MAR or anywhere in Resident 39's chart. During a concurrent interview and record review on 1/8/2026 at 4:23 PM with MDSN, Resident 39's MAR dated 6/5/2025 to 1/8/2026 was reviewed. MDSN stated there was no documentation that Resident 39 was monitored for signs and symptoms of bleeding. During a concurrent interview and record review on 1/8/2026 at 4:31 PM with MDSN, Resident 39's Nurse's Progress Notes dated 6/1/2025 to 6/30/2025 was reviewed. MDSN stated there was no documentation that Resident 39 was monitored for signs and symptoms of bleeding in the nurses' progress notes. MDSN stated, If it was not documented, it was not done, During a concurrent interview and record review on 1/8/2026 at 4:33 PM with MDSN, Resident 39's NPN, dated 1/1/2026 to 1/8/2026 was reviewed. MDSN stated there was no documentation in the nurses' progress notes of the staff monitoring Resident 39 for signs and symptoms of bleeding, as indicated in the care plan. During a concurrent interview and review on 1/8/2026 at 4:37 PM with MDSN, the facility's P&P titled, Care Plans, Comprehensive Person-Centered revised 3/2022 was reviewed. The P&P indicated,The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.The comprehensive, person-centered care plan:a. includes measurable objectives and timeframesb. describes the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being.MDSN stated the staff did not follow the policy by not implementing Resident 39's care plan interventions. During a review of the facility's P&P titled, Anticoagulation- Clinical Protocol revised 11/2018, the P&P indicated, the physician and staff will identify individuals who are currently anticoagulated; for example, those with a recent history of deep vein thrombosis (DVT), or heart valve replacement, atrial fibrillation or those who have had recent joint replacement surgery.a. Assess any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications.Monitoring and follow up1. The physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications.5. The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems.a. If an individual in anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety in accordance with the facility's policy and procedure (P&P) titled Glove Use Policy by failing to:Ensure dietary staff (Cook 1, Kitchen Staff 1 and 2) performed hand hygiene (is the act of cleaning the hands with soap or handwash and water to remove viruses/bacteria/microorganisms, dirt, grease, or other harmful and unwanted substances stuck to the hands). Change gloves during cooking and tray line assembly. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness (-food poisoning- with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization.FindingsDuring an observation of the tray line assembly on 1/8/2026 at 11:37AM, [NAME] 1 touched her kitchen facemask with her left hand while wearing disposable gloves and then began scooping food for the tray line assembly. During an observation of the tray line assembly on 1/8/2026 at 11:39AM, [NAME] 1 put on the oven mittens while wearing the same disposable gloves observed at 11:37 AM, then pulled the tray of bread from inside the oven, removed the oven mittens, touched the serving plates wearing the same disposable gloves, and removed the foil that was covering the food trays. During a concurrent observation of the tray line assembly and interview on 1/8/2026 at 11:42 AM with [NAME] 1, [NAME] 1 put on mittens while wearing the same disposable gloves observed at 11:37 AM, then touched tray of bread, then grabbed another food tray, and then started scooping food from food tray to the serving plates. [NAME] 1 stated they need to change gloves if they touch different utensils and they need to wash their hands after removing the disposable gloves and changing the gloves in between changing of task (cooking/ serving/ preparing the plate) because of infection control. During an observation of the tray line assembly on 1/8/2026 at 11:47 AM, [NAME] 1 was wearing disposable gloves and touched her hairnet, then held the food scooper while using the same gloves. During an observation of the tray line assembly on 1/8/2026 at 11:56 AM with [NAME] 1, [NAME] 1 was wearing disposable gloves then touched the blender and continue serving food without changing gloves. During an observation of the tray line assembly on 1/8/2026 at 11:57 AM,KS 1 was wearing disposable gloves, then touched the refrigerator handle, took food items from the refrigerator, and touched the serving plate without changing gloves. During an observation of the tray line assembly on 1/8/2026 at 12 PM, KS 2 was wearing disposable gloves, then touched the refrigerator handle, took two (2) glasses of chocolate milkshakes and placed it on the resident's tray, and pushed the serving tray cart to the dry storage room without removing the disposable gloves and performing hand hygiene. During an interview on 1/8/2026 at 12:05 PM with [NAME] 1, [NAME] 1 stated the staff were not supposed to wear the disposable gloves inside the mittens because of cross contamination. [NAME] 1 stated, I should have removed my disposable gloves before using the oven mittens and when I was changing tasks, when I used the blender, because I can contaminate the food and the residents can get sick. During an interview on 1/8/2026 at 12:08PM with KS 1, KS 1 stated she did not change gloves after she changed her tasks during train line assembly today (1/8/2026). KS 1 stated she should have removed her gloves and washed her hands to prevent food contamination because residents can get sick. During an interview on 1/8/2026 at 12:13 PM with KS 2, KS 2 stated she should have washed her hands before using the serving/ pushcart because it can contaminate the other kitchen items used to serve the residents food, and it can cause the residents to get sick. During a concurrent interview and record review on 1/8/2026 at 12:16 PM with Dietary Supervisor (DTS), the facility's P&P titled, Glove Use Policy revised in 2023 was reviewed. The P&P indicated, gloves needed to be changed before beginning a different task and after touching bare skin or hair. DTS stated the staff should have changed gloves in between tasks or after touching their clothing/ mask or hairnet because of infection control issues that can arise, and the residents can get sick. During a review of the facility's P&P titled, Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices revised on 10/2017, the P&P indicated employees must wash their hands:Before coming in contact with any food surfaces.After handling soiled equipment or utensils.During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/orAfter engaging in other activities that contaminate the hands.

Based on interview and record review, the facility failed to ensure the antibiotic (a drug that kills or stops the growth of harmful bacteria) stewardship (the effort to measure and improve how antibiotics are prescribed by and used by residents) was completed for two (2) of 2 residents (Residents 20 and 2) while receiving antibiotic treatment in the facility.This deficient practice had the potential for Residents 20 and 2 to develop antibiotic resistance (when bacteria, viruses, fungi, and parasites no longer respond to antimicrobial medicine and become ineffective making infections difficult or impossible to treat increasing the risk of disease spread, severe illness, disability, and death) and suffer adverse side effects (an undesired harmful effect resulting from a medication or other intervention) from unnecessary or inappropriate antibiotic use.Findings:1. During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease (heart complications caused by high blood pressure that is present over a long time) with heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure), and generalized muscle weakness.During a review of Resident 20's Minimum Data Set (MDS, resident assessment tool), dated 10/30/2025, the MDS indicated Resident 20 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 20 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with toileting and personal hygiene, shower/bathing, dressing, partial/moderate assistance with eating and substantial/maximal assistance with oral hygiene.During a review of Resident 20's Physician Order, dated 11/9/2025, the order indicated doxycycline hyclate (a broad-spectrum tetracycline antibiotic used for bacterial infections) 100 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) give one (1) tablet by mouth every 12 hours for pneumonia (an infection/inflammation in the lungs) for five (5) days.During a review of Resident 20's Medication Administration Record (MAR), dated 11/1/2025 through 11/30/2025, the MAR indicated Resident 20 received doxycycline hyclate 100 mg by mouth from 11/9/2025 through 11/14/2025.2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included urinary tract infection (UTI- an infection in the bladder/urinary tract), hydronephrosis (swelling of the kidney) with renal and ureteral calculous (kidney stones) obstruction (preventing urine flow), and cirrhosis of the liver (permanent scarring that damages your liver and interferes with its functioning).During a review of Resident 2's MDS dated , 11/21/2025, the MDS indicated Resident 2 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 2 was dependent on toileting hygiene, shower/ bathe self, lower body dressing, and substantial/maximal assistance (helper does more than half the effort) with personal and oral hygiene.During a review of Resident 2's Physician Order, dated 11/17/2025, the order indicated neomycin sulfate (an antibiotic used orally and topically to treat a wide variety of infections in the body) oral tablet 500 mg, give 1 tablet by mouth two times a day for UTI for 10 days.During a review of Resident 2's MAR, dated 11/1/2025 through 11/30/2025, the MAR indicated Resident 2 received neomycin sulfate 500 mg by mouth from 11/17/2025 through 11/27/2025.During an interview on 1/9/2026 at 8:46 AM with the Infection Preventionist Nurse 1 (IPN 1), IPN 1 stated per facility protocol, when antibiotics are ordered, the IP nurse completes a Surveillance Data Collection Form that evaluates if Loeb's criteria (a set of clinical guidelines for long-term care [LTC] facilities, providing a minimum checklist of signs and symptoms to help decide when to start antibiotics that aims to reduce unnecessary antibiotic use) and/or McGreer's criteria (standardized definitions for identifying infections in LTC facilities that provides clear guidelines for surveillance, research, and antibiotic stewardship) are met for continued use of the prescribed antibiotics. IPN 1 stated this evaluation is documented in addition to monitoring during therapy for any adverse reactions or changes to stop antibiotic use. The IPN 1 also stated it was important to ensure the antibiotic stewardship program including evaluations and monitoring was completed for residents to prevent unnecessary medication use and create antibiotic resistance.During a concurrent interview and record review on 1/9/2026 at 12:21 PM with the IPN 1, the facility's Order Listing Report, dated 9/1/2025 through 11/30/2025 was reviewed. The Order Listing Report indicated Resident 20 completed her doxycycline hyclate therapy for PNA on 11/9/2025 and Resident 2 completed his neomycin sulfate therapy for UTI on 11/17/2025. The IPN 1 stated the facility had no antibiotic surveillance tracking forms or antibiotic reviews documented for Resident 20 and/or Resident 2 during antibiotic administration. IPN 1 stated there should be documented reviews and tracking per facility policy. IPN 1 further stated that without documentation, she cannot ensure the antibiotic use for Residents 20 and 2 was evaluated and monitored appropriately, and that the antibiotic stewardship program was followed.During an interview on 1/9/2026 at 2:35 PM with the Director of Nursing, the DON stated the antibiotic use for Residents 20 and 2 should have been evaluated and tracked according to the facility's policy. The DON further stated, it was important to ensure residents receive the appropriate antibiotic and that antibiotic use was appropriately evaluated and monitored.During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship, revised 12/2016, the P&P indicated that antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program and the purpose of the Antibiotic Stewardship Program is to monitor the use of antibiotics in the residents.During a review of the facility's P&P titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, revised 12/2016, the P&P indicated:Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship.As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee.All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include:a. Resident name and medical record number;b. Unit and room number;c. Date symptoms appeared;d. Name of antibiotic (see approved surveillance list);e. Start date of antibiotic;f. Pathogen identified (see approved surveillance list);g. Site of infection;h. Date of culture;i. Stop date;j. Total days of therapy;k. Outcome; andl. Adverse events

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable, and home like environment for two (2) of five sampled residents (Resident 8 and 20) under environment care area, when the facility failed to ensure air vents ( openings in buildings for air passage, essential for ventilation, air circulation, and maintaining indoor air quality) inside the resident's rooms were free from dust particles. This deficient practice had the potential for the residents to feel discomfort and suffer from respiratory problems which could negatively affect the residents' well-being and quality of life. Findings:1. During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE], Resident 8's diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral vascular accident (CVA, or stroke is an interruption in the flow of blood to cells in the brain) of the left non-dominant side, anxiety disorder (a disorder characterized by nervousness characterized by a state of excessive uneasiness and apprehension, typically with compulsive behavior [repetitive, persistent, and often uncontrollable actions that a person feels driven to perform] or panic attacks), and major depressive disorder (or also called clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems) During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool) dated 12/3/2025, the MDS indicated Resident 8 had intact cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 8 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, roll left and right, sit to lying, and lying to sitting on the side of the bed. During an observation on 1/7/2026 at 8:48 AM in Resident 8's room, the air vent directly on top of Resident 8 was full of dust. Resident 8 stated The air vent on top of me is so filthy! During a concurrent observation and interview on 1/8/2026 at 10:09 AM with Maintenance Assistant 1 (MTA 1) in Resident 8's room, Resident 8's air vent was full of dust. MTA 1 stated Resident 8's air vent was dirty, and it was necessary to move Resident 8's bed so it could be cleaned. MTA stated the air vents should be cleaned at least once a month because it was connected to other residents' rooms. MTA stated it was important to clean it because the dust can affect Resident 8's breathing causing respiratory problems. 2. During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was admitted to the facility on [DATE], Resident 20's diagnoses included metabolic encephalopathy (ME, occurs when problems with your metabolism cause brain dysfunction), anemia (a condition where the body does not have enough healthy red blood cells) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest. During a review of Resident 20's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 20 was dependent on toileting hygiene, sit to stand, chair/bed-to-chair transfer, and toilet transfer. During a concurrent observation and interview on 1/8/2026 at 9:15 AM in Resident 20's room, Resident 20 was observed lying on her bed and the air vent above her was dusty. During a concurrent observation an interview on 1/8/2026 at 10:12 AM with MTA 1 in Resident 20's room, Resident 20 was lying on her bed and air vent above her was dusty. MTA 1 stated Resident 20's air vent was also dirty. MTA stated they need to clean the residents' air vents at least once a month because those are connected to other residents' rooms and residents can get sick. During a review of the facility's policy and procedure (P&P) titled, Inspection of Heat/Air-conditioning system, revised 5/2008, the P&P indicated, the facility's heating and air-conditioning system shall be inspected at lease semi-annually. Prior to the beginning of each heating/cooling season our facility's heating and air-conditioning systems shall be inspected for possible gas leaks, lines that have burst, etc. During a review of the facility's P&P titled, Quality of Life - Homelike Environment revised 5/2017, the P&P indicated,2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:a. Clean. sanitary and orderly environment. During a review of the facility's P&P titled, Cleaning and Disinfection of Environmental Surfaces revised 8/2019, the P&P indicated,14. Horizontal surfaces will be wet dusted regularly (e.g., daily, three times per week) using clean cloth moistened with an EPA-registered hospital disinfectant (or detergent). The disinfectant (or detergent) will be prepared as recommended by the manufacturer.

Based on interview and record review, the facility failed to notify the medical doctor (MD) of changes with the residents' condition for two (2) of 22 sampled residents (Residents 57 and 20) as indicated in the facility's policy and procedures (P&P):Resident 57's refusal of medications and meals from 11/5/2025 to 11/10/2025.Resident 20's new complaint of itching on bilateral hands and feet on 1/6/2026.These failures resulted in delayed treatments and interventions for Residents 20 and 57 with the potential for inadequate care, services and a preventable decline in Resident 20's and 57's mental, physical and psychosocial well-being.Findings:1. During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and type 2 Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 57's Minimum Data Set (MDS - a resident assessment tool), dated 11/10/2025, the MDS indicated Resident 57 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS also indicated that Resident 57 was dependent (helper does all of the effort to complete the activity) with toileting, bathing/shower, lower body dressing, substantial/maximal assistance (helper does more than half the effort) with oral and personal hygiene and partial/moderate assistance (helper does less than half the effort) with eating. During a review of Resident 57's Medication Administration Record (MAR), dated 11/1/2025 through 11/30/2025, the MAR indicated Resident 57 did not receive all prescribed doses of 12 medications from 11/5/2025 through 11/12/2025 due to Resident 57's refusals. The MAR also indicated Resident 57 had 10 refused meals from 11/5/2025 - 11/12/2025. During a concurrent interview and record review on 1/9/2026 at 2:42 PM with the Director of Nursing (DON) and Licensed Vocational Nurse 4, Resident 57's electronic medical chart dated from 11/5/2026 to 11/10/2025 was reviewed. Resident 57's medical chart failed to indicate any MD notification of refused medications and/or meals from 11/5/2025 to 11/10/2025. The DON stated the MD should have been made aware/ notified of Resident 57's refusals by the licensed nurse to coordinate with the MD on the next plan of care and interventions for Resident 57. During a review of the facility's P&P titled, Requesting, Refusing, and/or Discontinuing Care or Treatment, revised 5/2017, the P&P indicated when a resident refuses care or treatment, the healthcare practitioner (MD) must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the request. For example, a resident's refusal to take a diuretic while experiencing acute congestive heart failure should be reported immediately, while a refusal to take a blood pressure medication while the blood pressure is well controlled can be reported within 24 hours. The P&P defined treatment as services provided for purposes of maintaining/restoring health, improving functional level, or relieving symptoms and the refusal of treatment documentation must be done and include the date and time the practitioner was notified and the practitioner's response. 2. During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease (heart complications caused by high blood pressure that is present over a long time) with heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure) and generalized muscle weakness. During a review of Resident 20's MDS, dated [DATE], the MDS indicated Resident 20 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 20 was dependent on toileting and personal hygiene, shower/bathing, dressing, partial/moderate assistance with eating and substantial/maximal assistance with oral hygiene. During a concurrent interview and observation on 1/6/2026 at 8:43 AM at Resident 20's bedside, Resident 20 was observed telling Certified Nursing Assistant 9 that both of her hands were itchy. CNA 9 then stated he would inform Resident 20's licensed nurse. During an interview on 1/8/2026 at 8:57 AM, CNA 9 stated he informed Licensed Vocational Nurse 5 (LVN 5) regarding Resident 20's itchiness on both hands on 1/6/2026. During a concurrent observation and interview on 1/8/2026 at 9:10 AM with LVN 1 and Resident 20, at Resident 20's bedside, LVN 1 was observed preparing medication administration for Resident 20. Resident 20 stated she had itching in both her hands and has now moved to both of her feet as well. Resident 20 stated she has had itching in her hands since 1/6/2026 and in her left and right foot for a day. LVN 1 stated she just became aware of the itching and Resident 20 did not have any prescribed treatments for the itching on hands and feet. During an interview on 1/8/2026 at 9:38 AM with LVN 5, LVN 5 stated she was made aware of dry skin only by CNA 9 and did not inform the doctor about Resident 20's itching hands. During an interview on 1/9/2026 at 2:03 PM with LVN 1, LVN 1 stated she became aware of Resident 20's itching on hands and feet on 1/8/2026 but did not inform the MD because she thought LVN 5 would have done it. LVN 1 stated a change in condition evaluation with MD notification should have been done the day it occurred per facility policy. During a concurrent interview and record review on 1/9/2026 at 2:54 PM with the DON and LVN 4, Resident 20's electronic medical chart from 1/6/2026 through 1/9/2026 were reviewed. Resident 20's medical chart failed to indicate a change of condition evaluation and an MD notification for Resident 20's bilateral (left and right) hand itching that started on 1/6/2026 and bilateral feet itching that started on 1/8/2026. The DON stated the MD should have been notified with documentation of the date and time of notification, a revised care plan created and monitoring by nursing staff of the resident's change of condition for 72 hours according to facility policy. The DON also stated it was important to communicate with the MD regarding Resident 20's itching so that an order can be given and the itching can be treated. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, revised 5/2017, the P&P indicated the facility will promptly notify the resident's attending physician of changes in the resident's medical/mental condition. The P&P also indicated except in medical emergencies, notifications will be made within 24 hours of change occurring in the resident's medical/mental condition or status

Based on observation, interview, and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 39) under activities of daily living care area was provided a communication board (pre-printed board that has pictures, numbers, and user defined images that allows a resident to point or indicate on the board what he/she wants communicated) with the language that the resident was able to understand and speak (primary language) in accordance with the facility policy and procedure. This deficient practice prevented Resident 39 from communicating with the staff and had the potential to delay receiving appropriate care/treatment that the resident needed.Based on observation, interview, and record review, the facility failed to ensure resident with language barrier was provided a communication board (pre-printed board that has pictures, numbers, and user defined images that allows a resident to point or indicate on the board what he/she wants communicated) with the language that the resident was able to understand and speak (primary language) for one (1) of three (3) sampled residents (Resident 39) in accordance with the facility policy and procedure. This deficient practice prevented Resident 39 from communicating with the staff and had the potential to delay receiving appropriate care/treatment that the resident needed. Findings:During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included metabolic encephalopathy (ME, occurs when problems with your metabolism cause brain dysfunction), atrial fibrillation (Afib, is an irregular and often very rapid heartbeat), and hypertension (high blood pressure) During a review of Resident 39's Minimum Data Set (MDS, a resident assessment tool), dated 10/31/2025, the MDS indicated the resident's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making were moderately impaired. The MDS indicated Resident 39 was dependent (helper does all of the effort, resident does no effort to complete the activity) on oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, toilet transfer and tub/shower transfer. During a concurrent observation and interview on 1/6/2026 at 12:25 PM with Resident 39 inside Resident 39's room, Resident 39 was sitting up in her wheelchair and eating lunch. Resident 39 was speaking to the surveyor in the resident's primary language. The surveyor asked Resident 39 questions in English and Resident 39 responded in her primary language. There was no communication board provided in Resident 39's room or at the bedside. During an observation on 1/7/2026 at 9:19 AM inside Resident 39's room, there was no communication board provided in Resident 39's room or at the bedside. During a concurrent observation and interview on 1/7/2026 at 12:37 PM with Certified Nursing Assistant 5 (CNA 5) inside Resident 39's room, Resident 39 was sitting in her wheelchair and there was no communication board in Resident 39's room or at the bedside. CNA 5 stated there was no communication board provided for Resident 39. CNA 5 communicated with Resident 39 using in English, and Resident 39 responded in her primary language. During a concurrent observation and interview on 1/8/2026 at 12:20 PM with CNA 4 in Resident 39's room, Resident 39 was sitting in her wheelchair. CNA 4 stated CNA 4 does not speak Resident 39's primary language. CNA 4 stated Resident 39 did not have a communication board and having one would be useful to help Resident 39 express needs and receive assistance promptly. During an interview on 1/8/2026 at 12:21 PM with Director of Social Services (DSS) inside Resident 39's room, DSS stated she just placed the communication board at Resident 39's bedside yesterday (1/7/2026) after lunch, as Resident 39 did not have it before. DSS stated promoting communication such as providing the communication board is part of accommodation of the resident's needs in accordance with the facility's policy. DSS stated it is important to have communication board at the resident's bedside for non-English-speaking residents so the resident/s can effectively communicate their needs to the staff. During a review of the facility's policy and procedure (P&P) titled, Translation and/or interpretation of Facility Services, revised 11/2020, the P&P indicated, the facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. The P&P indicated it is understood that in order to provide meaningful access to services provided by the facility, translation and/or interpretation must be provided in a way that is culturally relevant and appropriate to the LEP individual. The P&P also indicated staff shall be trained upon hire and at least annually on how to provide language access services to LEP residents. During a review of the facility's P&P titled, Accommodation of Needs, revised 1/2020, the P&P indicated, the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. The P&P also indicated staff will interact with the residents in a way that accommodates the physical or sensory limitations of the residents, promotes communication, and maintains dignity.

Based on interview and record review, the facility failed to provide appropriate discharge planning (the process of preparing a resident to safely transition from a hospital or care facility to the next level of care) as indicated in the Director of Social Services job duties and the resident's care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) for one (1) of 1 sampled resident (Resident 45) from the discharge care area. This failure resulted in a delay in discharge planning for Resident 45, with the potential for a delayed discharge from the facility.Findings:During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was admitted to the facility on [DATE] with diagnoses that included (difficulty swallowing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). The admission Record also indicated Resident 45 had a public guardian (PG- a court-appointed individual responsible for managing the affairs of people who are unable to do so themselves due to mental and/or physical inabilities). During a review of Resident 45's quarterly Minimum Data Set (MDS - a resident assessment tool), dated 12/4/2025, the MDS indicated Resident 45 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 45 was independent (resident completes activity by themselves with no assistance from a helper) with eating and supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with bathing, dressing, oral, toileting and personal hygiene. During a review of Resident 45's Discharge Plan- care plan, initiated 6/2/2025, the care plan indicated Resident 45 was expected to be discharged to the community, board and care (B&C- a small residential facility that provides housing, meals, and assistance with activities of daily living [ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves]) or assisted living facility (a residential facility that provides housing, meals, and support for ADLs), with a goal to be discharged to community. The care plan indicated the Social Services Director (SSD) will intervene for appropriate and necessary follow up[s] as indicated. During a review of Resident 45's Interdisciplinary Team (IDT - a coordinated group of experts from several different fields) Conference Record, dated 12/3/2025, the IDT Conference Record indicated Resident 45's discharge plan to lower level of care at an assisted living facility. During an interview on 1/8/2026 at 11:34 AM with Resident 45, Resident 45 stated he asked for a discharge repeatedly, but facility is not telling me anything. Resident 45 stated he wanted to leave the facility and go live at home. During an interview on 1/9/2026 at 8:36 AM with the SSD, the SSD stated Resident 45 had an expected discharge date next month (February), but the facility needed to get Resident 45 approved with waivers to assist with housing and the resident's medical insurance switched. The SSD stated Resident 45's PG signed an application, but unable to recall when. During a concurrent interview and record review on 1/9/2026 at 12:43 PM with the SSD, the following records for Resident 45 were reviewed: Agency 1 Patient Consent to Receive Services and Certification, dated 8/20/2025 and signed by Resident 45's PG. The Patient Consent indicated Resident 45's PG consent for admission and treatment, with authorization of Agency 1 Home Health and associates to provide transition care and/or case management services per policy of the Assisted Living Waiver Program (ALWP- provides Medicaid funding for seniors and people with disabilities who need nursing-level care but prefer to live in a home-like assisted living community, rather than a skilled nursing facility, covering personal care, health services, meals, and activities, though participants typically pay for room & board) care coordination. Agency 1 Consent to be Placed on the Assisted Living Waiver Program Waitlist, dated 8/20/2025 and signed by Resident 45's PG. The Consent indicated Resident 45's PG consented and authorized Agency 1 to submit Resident 45's medical information to the state for the purpose of being placed on a waitlist for the ALWP.The SSD stated she received the consents the same day they were signed on 8/20/2025 but as of today, nothing further has been done. The SSD stated it was not until she checked her documents on 1/9/2026 that she found the consents and must have overlooked them. The SSD stated her role was to assist the residents in finding the proper placement and financial programs as needed to get them discharged into another facility, and from 8/20/2025 to 1/9/2026, there had been no submission of the signed consents back to Agency 1 for the continued processing towards discharge planning for Resident 45. The SSD stated she should have been aware of the signed consents to ensure a follow up so that Resident 45 was assisted with his discharge planning and does not get lost in the bunch, in which Resident 45 would not get an opportunity to discharge and go to the community or meet the resident's discharge goal. During a review of the facility's form titled Director of Social Services job description/duties, (undated), the form indicated the primary purpose of the job position is to plan, develop and direct the Social Serves Department in accordance with current federal, state, and local standards, guidelines and regulations, established facility policies and procedures, and as may be directed by the Administrator, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. The form also indicated that the Director of Social Services will participate in discharge planning, development and implementation of social care plans and resident assessments.

Based on observation, interview and record review, the facility failed to ensure that an alternative meal was offered and provided to one (1) of 1 sampled resident (Resident 45) from the choices care area, after his lunch meal was refused, as indicated in facility policy. This failure resulted in Resident 45 having preventable hunger with the potential risks for decreased feelings of well-being and/or malnourished (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat).Findings:During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was admitted to the facility on [DATE] with diagnoses that included (difficulty swallowing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 45's Order Summary Report dated 11/26/2025, the Order Summary Report indicated an order for a regular diet (a balanced, unrestricted eating plan with a variety of foods from all major groups). During a review of Resident 45's quarterly Minimum Data Set (MDS - a resident assessment tool), dated 12/4/2025, the MDS indicated Resident 45 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 45 was independent (resident completes activity by themselves with no assistance from a helper) with eating and supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with bathing, dressing, oral, toileting and personal hygiene. During a review of Resident 45's Potential Nutritional Problem care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs), revised 1/9/2026, the care plan indicated a goal for Resident 45 to maintain adequate nutritional status daily. During a review of the facility's Meal Schedule (undated), the Meal Schedule indicated lunch is scheduled daily at 12:00 PM. During a concurrent observation and interview on 1/8/2026 at 12:39 PM with Resident 45 and Certified Nurse Assistant 7 (CNA 7) at Resident 45's bedside, Resident 45's lunch meal tray was observed uneaten. Resident 45 stated the food is terrible. CNA 7 stated she would inform dietary staff Resident 45 of his refused lunch. During a concurrent observation and interview on 1/8/2026 at 1:16 PM with Resident 45 at Resident 45's bedside, Resident 45's uneaten lunch tray was observed. Resident 45 stated he has not been offered a substitute meal but is hungry and wants to eat. During an interview on 1/8/2026 at 2:25 PM with CNA 7, CNA 7 stated she did not inform any additional staff (including dietary and/or licensed) regarding Resident 45's refused lunch meal and did not offer Resident 7 alternative meal items. CNA 7 stated Resident 45 should have been offered an alternative lunch tray, and it is important to make sure resident meal refusals are communicated to the charge nurse and kitchen staff and then follow up with the resident to ensure Resident 7 gets an alternative lunch tray. During an interview on 1/8/2026 at 2:46 PM with the Dietary Supervisor (DTS), the DTS stated dietary staff was not aware of Resident 45's lunch meal refusal on 1/8/2026 so no alternative meal was offered to the resident. During an interview on 1/8/2026 at 3:04 PM with the DTS, the DTS stated according to the facility's policy, when a resident refuses a meal, either nursing staff or dietary staff will offer alternative menu choices/ meal tray and then it would be provided to the resident. The DTS also stated Resident 45 should have been offered an alternative meal after he refused the lunch tray on 1/8/2026. DTS stated it is important to ensure alternative meals are offered to residents when they refuse the delivered meal to ensure they receive balanced and nourished meals to prevent malnutrition. During a review of the facility's policy and procedure (P&P) titled Food Substitutions for Residents Who Refuse the Meal, (undated), the P&P indicated residents will be provided a suitable nourishing alternate meal after the planned, served meal has been refused. The P&P also indicated nursing personnel will ask any resident who does not eat his meal or food item as to why he is not eating and offer a food substitution in accordance with the resident's diet order. The P&P indicated food and nutrition services staff (FNS) will deliver the substituted item(s) to the resident after other residents have been served.

Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) for two of five sampled residents (Residents 21 and 2) from the infection control care area were followed in accordance with the facility's policy and procedure when: 1. a. Certified Nurse Assistant 1 (CNA 1) and CNA 8 failed to wear proper Personal Protective Equipment (PPE, is specialized clothing or equipment worn by an employee for protection against infectious materials, such as gowns, gloves, masks, and goggles) for Enhanced Barrier Precautions (EBP, refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) room while repositioning Resident 21 and CNA 1 did not perform hand hygiene after removing CNA 1's gloves. b. Licensed Vocational Nurse 1 (LVN 1) failed to change her gloves in between tasks during medication administration via gastrostomy tube (G-tube, is a tube inserted through the belly that brings nutrition directly to the stomach) to Resident 21. 2. CNA 1, CNA 9 and CNA 4 failed to wear proper PPE in the EBP room while assisting Resident 2 on his Activities of Daily Living (ADLs, are activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). These deficient practices have potential to contaminate clean items or to cross contaminate (the physical movement or transfer of harmful bacteria from one person, object or place to another) and can place Resident 21 and Resident 2 at risk for infection. Findings:1. During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures [are brief episodes of abnormal electrical activity in the brain that can cause a variety of symptoms, including involuntary movements, loss of consciousness, and changes in behavior]), dysphagia (difficulty swallowing) and dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities). During a review of Resident 21's Minimum Data Set (MDS, a resident assessment tool) dated 12/10/2025, the MDS indicated Resident 2 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 21 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting, sit to stand, chair/ bed-to-chair transfer, toilet transfer, and tub/shower transfer. During a review of Resident 21's current Physician Order dated 10/30/2025. The physician's order indicated Enhanced Barrier Precautions secondary to G-tube use every shift. During an observation on 1/8/2026 at 8:30 AM inside Resident 21's room, Resident 21 was sitting on a wheelchair. CNA 1 and CNA 8 entered Resident 21's room wearing disposable gloves and was not wearing gown. CNA 1 and CNA 8 lifted and repositioned Resident 21 in the wheelchair. During an observation on 1/8/2026 at 8:31 AM inside Resident 21's Room, CNA 1 removed her disposable gloves and immediately left the room without performing hand hygiene, then entered another resident's room (Room A) that is not on isolation precaution (used in healthcare, that create barriers to stop germs from spreading from a sick person to others (staff, visitors, other patients) by separating them and requiring specific PPE and practices, like hand hygiene, based on how the germ spreads). During a medication administration observation on 1/8/2026 at 8:34 AM with LVN 1, LVN 1 was wearing gown and gloves. LVN 1 pulled the curtain, touched Resident 21's clothes, and then checked Resident 21's G-tube placement. LVN 1 did not remove her gloves before administering Resident 21's medications via the resident's G-tube. During medication administration observation on 1/8/2026 at 8:44 AM with LVN 1, LVN 1 washed and dried Resident 21's flush syringe (a cylindrical, hollow tube, or barrel of a syringe which is medical device used to inject or withdraw fluids) using the same disposable gloves and in the bathroom sink that is shared and being used by two (2) other residents. During an interview on 1/8/2026 at 8:48 AM with LVN 1, LVN 1 stated she did not change her gloves after she checked Resident 21's G- Tube placement and before administering Resident 21's medications. LVN 1 stated she should have changed her gloves because of risk of cross contamination and she can introduce infection the Resident 21. During an interview on 1/8/2026 at 8:49 AM with LVN 1, LVN 1 stated she should have removed her gloves and used a new one before cleaning Resident 21's flushed syringe because when LVN 1 finished rinsing Resident 21's flush syringe the dirty gloves can contaminate the clean flush syringe. During an interview on 1/8/2026 at 10:07 AM with CNA 1, CNA 1 stated Resident 21 was on EBP and that CNA 1 should wear gown and not only gloves when transferring or pulling Resident 21 up in the wheelchair. CNA 1 also stated she should have performed hand hygiene after removing gloves and before going into another resident's room to prevent spread of infection. During a concurrent interview and record review on 1/9/2026 at 3:01 PM with Infection Preventionist Nurse 1 (IPN 1), the facility's policy and procedure (P&P) titled Infection Control revised 5/2025 was reviewed. The P&P indicated, EBP requires staff to wear gloves and gown during moments of providing direct care with the EBP resident. The direct care moments are:> Transferring residents from bed, changing bed linens> Direct contact with the environmentIPN 1 stated, the staff should have worn the gown and gloves in EBP Rooms. IPN 1 stated any activity that they will have contact with the residents. IPN 1 also stated, the staff should wear gowns and gloves because the staff's clothes can get contaminated, and they can spread the infection when they go to other residents. During a review of the facility's P&P titled, Standard Precautions revised 10/2018, the P&P indicated: > Gloves are changed as necessary, during the care of a resident to prevent cross-contamination from one body to another (when moving from a dirty site to a clean one).> Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident.> After gloves are removed, wash hands immediately to avoid transfer of microorganisms to other residents or environments. 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], Resident 2's diagnoses included hydronephrosis (swelling of the kidney) with renal and ureteral calculous (kidney stones) obstruction (preventing urine flow), cirrhosis of the liver (is permanent scarring that damages your liver and interferes with its functioning) and pancytopenia (a lower-than-normal count of all three types of blood cells: red blood cells [anemia], white blood cells [leukopenia], and platelets [thrombocytopenia]). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 11/21/2025, the MDS indicated Resident 2 had moderately impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 2 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, sit to stand, and chair/ bed-to-chair transfer. During a review of Resident 2's current Physician Order dated 11/25/2025, the physician's order indicated may have EBP secondary to indwelling catheter (a thin, hollow tube that's inserted into the bladder through the urethra to drain urine. During an observation on 1/8/2026 at 9:42 AM inside Resident 2's room, Resident 2 was lying on his bed. CNA 1 was wearing disposable gloves and was not wearing gown while assisting Resident 2 to remove the resident's clothes. CNA 1 then wiped Resident 2's face with a wet washcloth. During an observation on 1/8/2026 at 9:44 AM inside Resident 2's room, CNA 9 was wearing disposable gloves and was not wearing gown while shaving Resident 2's beard. During an observation on 1/8/2026 at 9:53 AM inside Resident 2's room, CNA 4 was wearing disposable gloves and was not wearing gown while assisting Resident 2 get dressed. During an observation on 1/8/2026 at 9:54 AM inside Resident 2's room, CNA 1 was wearing disposable gloves and was not wearing gown when assisting Resident 2 on his sponge bath. During an interview on 1/8/2026 at 10:02 AM with CNA 4, CNA 4 stated they were supposed to wear gowns and gloves in EBP room and they (CNA 9 and 4) forgot to wear gown while assisting Resident 2 with the resident's ADLs. CNA 4 also stated they should wear PPE when doing high contact activities with residents on EBP. During an interview on 1/8/2026 at 10:04 AM with CNA 1, CNA 1 stated they did not wear gown inside the EBP room while providing Resident 2's morning care. CNA 1 stated they were supposed to wear gowns and gloves when providing care to residents with EBP because of infection control. During a concurrent interview and record review on 1/9/2026 at 3:31 PM with IPN 1, the facility's P&P title Infection Control revised 5/2025 was reviewed. The P&P indicated, EBP requires staff to wear gloves and gown during moments of providing direct care with the EBP resident. The P&P indicated, the direct care moments are:> Bathing or providing AM and PM care> Toileting and changing briefs> Direct contact with the environment> Managing indwelling medical devicesIPN 1 stated if the staff were performing ADLs with a resident with indwelling catheter like Resident 2. IPN 1 stated the staff should wear proper PPE which are gown and gloves because there is a possibility of having splatters of urine when cleaning Resident 2, and it could cause cross contamination if it got into the staff's scrub suit/ uniform and it can spread infection when the staff were also taking care of other residents. During a review of the facility's P&P titled, Standard Precautions revised 10/2018, the P&P indicated gowns (clean, non-sterile) are worn to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids secretions, or excretions or cause soiling of clothing.

Based on observation, interview, and record review, the facility failed to protect one of two residents (Resident 1) from physical abuse (intentional bodily injury such as pinching, slapping and hitting) when Resident 2 hit, slapped, and scratched Resident 1 on 7/1/2025 in accordance with the facility's policy and procedure (P&P) titled, Abuse Prevention Program,. This deficient practice resulted in, abrasions (wound where skin rubs off due to friction) on Resident 1's left face, left upper cheek and left side of the forehead; abrasion on the middle left outer forearm; bruising on the distal (location on the body farther away from the center of the body) left outer wrist; and an abrasion on the right Achilles (back of the lower leg connecting the calf muscles to the heel bone) and placed the resident at risk for psychosocial (combined influence of psychological factors and the surrounding social environment on physical, emotional, and/or mental wellness) harm. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with the diagnoses including but not limited to metabolic encephalopathy (abnormalities of water, electrolytes, vitamins, and other chemicals that adversely affect the brain function), dementia (progressive brain disorder that slowly destroys memory and thinking skills), and difficulty in walking. During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 6/9/2025, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were severely impaired. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident [NAME] none of the effort to complete the activity) for sitting to lying, lying to sitting on side of bed, sitting to standing, and chair-bed-to-chair transferring. During a record review of Resident 1's SBAR (an acronym for Situation-Background-Assessment-Recommendation is a technique used to provide a framework for communication between members of the health care team), dated 7/1/2025, the SBAR indicated Resident 1 was involved in an altercation with her roommate. The SBAR indicated at approximately 4 AM, after staff reported the altercation, noted Resident 1 sitting on the floor and Resident 2 attempting to hit Resident 1. Residents 1 and 2 were separated and noted scratches on Resident 1's left upper cheek, left side of the forehead, left forearm, and anterior aspect of the right heel. During a record review of Resident 1's Nursing Note, dated 7/1/2025, the note indicated Resident 1 had four new wounds acquired in-house as follows: - Skin issue #1: left face, left upper cheek and left side of the forehead abrasions.- Skin issue #2: Middle left outer forearm abrasion.- Skin issue #3: Distal left outer wrist bruising.- Skin issue #4: Right Achilles abrasion. During a record review of Resident 1's care plan, dated 7/1/2025, the care plan indicated physical altercation with resident's roommate (Resident 2), Resident 1 is the victim, and Resident 1 sustained scratch marks on the left arm, left cheek, left side of the forehead and right anterior aspect of the ankle and right anterior aspect of the ankle. During a record review of Resident 1's Interdisciplinary Team (IDT, group of healthcare professionals from diverse fields who work in a coordinated manner toward a common goal for the resident) Conference Record, dated 7/2/2025, the IDT record indicated Resident 1 was seen by staff being attacked by the resident's roommate (Resident 2). The IDT also indicated when charge nurse arrived both residents (Resident 1 and 2) were on the floor and Resident 2 was attempting to continue to hit/scratch/slap Resident 1. The IDT also indicated upon assessment Resident 1 was noted with scratch marks on the left arm, left cheek, left side of the forehead, and right anterior aspect of the ankle. During a record review of Resident 1's Physician Order Summary Report, dated 7/3/2025, the orders indicated as follows:- Cleanse left cheek scratch with normal saline (NS, mixture of salt and water used to replenish fluid and electrolyte), pat dry, apply triple antibiotic (used to reduce the risk of infections following minor skin injuries) and leave open to air every day shift for 30 days.- Cleanse left forearm scratch with normal saline, pat dry, apply triple antibiotic and leave open to air every day shift for 30 days.- Cleanse right heel abrasion with normal saline, pat dry, apply triple antibiotic and leave open to air every day shift for 30 days. 2. During a record review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with the diagnoses including but not limited to metabolic encephalopathy, schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), and personal history of other mental and behavioral disorders. During a record review of Resident 2's Physician Order Summary Report, dated 3/3/2025, the order indicated Risperidone (an antipsychotic [drugs that work by altering brain chemistry to help reduce psychotic symptoms like hallucinations, delusions, and disordered thinking] medication that alters the effects of chemicals in the brain) 0.5 milligrams (mg, unit of measurement): Give one tablet by mouth one time a day for Schizophrenia manifested by rapid mood cycling as evidence by sudden shifts in mood from pleasant to extreme anger as evidenced by yelling/screaming at others. During a record review of Resident 2's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort, helper lifts or holds trunk or limbs but provides less than half the effort) for sitting to lying, sitting to standing, and walking ten feet. The MDS also indicated Resident 2 had daily verbal behavioral symptoms (e.g., threatening others, screaming at others, cursing at others) directed toward others. During a record review of Resident 2's SBAR, dated 7/1/2025, the SBAR indicated Resident 2 had behavioral symptoms. The SBAR indicated at approximately at 4 AM staff reported Resident 2 was hitting Resident 1. The SBAR indicated LVN 1 arrived in Residents 1 and 2' room with both residents sitting on the floor and Resident 2 was attempting to hit/slap/scratch Resident 1. During a record review of Resident 2's care plan, dated 7/1/2025, the care plan indicated Resident 2 had a physical altercation with roommate Resident 1, at risk for injury to self or others, and at risk for repeat altercation with other residents. During a record review of the facility's final investigation report, dated 7/3/2025, the report indicated at approximately 4 AM (date not indicated), Resident 1 was seen by staff attacking Resident 2 in their room. During an observation on 7/16/2025 at 11:10 AM with Resident 1, Resident 1 was sitting in her wheelchair with scratch marks noted on the left arm. During an interview on 7/16/2025 at 11:24 AM with the Administrator (ADM), ADM stated there was a physical altercation between Resident 1 and Resident 2. ADM stated Resident 1 had scratches from the physical altercation and Resident 2 was the aggressor. During an interview on 7/16/2025 at 12:30 PM with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated on 7/1/2025 from 3:30 AM to 4 AM Room A's (Resident 1 and 2's room) lights were on, the door was closed, and CNA 2 heard a big thump. CNA 2 stated she went to Room A and saw Resident 1 was on the while Resident 2 was in front of, on top of, and hitting Resident 1. CNA 2 stated Resident 2 was hitting Resident 1 while Resident 1 was putting her hands up and trying to protect herself. CNA 2 stated Resident 1 had scratches on one of her arms from Resident 2. During an interview and record review on 7/16/2025 at 2:10 PM with LVN 2, LVN 2 stated Resident 2's mood changes. LVN 2 stated Resident 2 would scream, yell and if close by Resident 2 she could grab you when she was in a bad mood. LVN 2 stated Resident 1 did not have behavior problems. During a concurrent record review and interview on 7/16/2025 at 2:24 PM with LVN 2 the facility's policy & procedure (P&P) titled, Abuse Prevention Program, revised December 2016 was reviewed. The policy indicated the facility's residents have the right to be free from abuse which includes physical abuse. LVN 2 stated the facility's resident has the right to be free from abuse. LVN 2 stated when a resident hits another resident that is not being free from abuse. LVN 2 stated Resident 1 was physically abused by Resident 2.

Based on observation, interview, and record review, the facility failed to maintain an ongoing pest control service twice a month to prevent presence of rodent droppings (mice feces, usually black, and the blacker the dropping the fresher and about 1/4 inch in length, or the size of a grain of rice, and have pointed ends) in the facility's kitchen for 54 out of 54 residents in the facility. This deficient practice resulted in the facility kitchen closure, on [DATE], due to the 54 residents were at risk of vector-borne diseases (diseases that result from an infection transmitted to human by animal such as rabbits, rodents, and reptile) and also had the potential to experience food infection from ingesting live bacteria, food intoxication from ingesting food containing toxins from bacteria, and disease transmission that can lead to life threatening health complications and death. On [DATE] at 3:35 p.m., the Los Angeles County Environmental Health Department notified the Department regarding the presence of rodent droppings found by the Registered Environmentalist Health Specialist (REHS - performs inspections of various facilities and properties to determine conformance with applicable State laws and County Ordinance Code sections) in the facility's kitchen The REHS closed the facility's kitchen at 4:17 p.m. On [DATE] at 4:25 p.m. and at 4:30 p.m., the Health Facility Evaluator Nurse (HFEN) observed rodent droppings in the facility's kitchen. On [DATE], at 6:41 p.m., an Immediate Jeopardy (IJ-as 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) was declared and the facility's administrator and the director of nursing were notified of rodent feces in the facility kitchen. Rodent droppings can be reservoirs of a variety of dangerous diseases [MEDICAL CONDITION]. The droppings, saliva and urine of certain rodent species are known to transmit Hantavirus [MEDICAL CONDITION] syndrome (HPS). Disturbance of the droppings causes [MEDICAL CONDITION] to go airborne that may enter your nasal passages, causing infection. (retrieved [DATE]20 at https://www.orkin.com/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 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. (retrieved [DATE]20 at https://www.fda.gov/media/ 2/download) On 1/11/2020 at 9:55 a.m., the IJ was removed in the presence of the administrator after onsite verification of the facility implementation of the acceptable plan of actions. The facility's submitted acceptable plan of actions as follows: 1. Facility called a new pest control service to provide service to the facility on [DATE]. 2. The facility's pest control service will provide service from once a month to every week for one month then two times a month until the infestation is resolved. 3. Dietary Supervisor (DS) with the Administrator will conduct their own inspections daily of the kitchen to report any unusual findings and findings will be recorded on a log and corrected promptly. 4. Department Heads will be provided an in-service by the Administrator. DON was to conduct facility rounds of all areas that included residents' rooms, hallways, and activity room. 5. Department Heads will conduct room rounds to identify if any rooms have rodent droppings. The Director of Nursing and/or Designee will review resident's charts for change of condition related to food borne illnesses and infections. 6. The Maintenance Supervisor will seal all openings in the kitchen walls and areas with opening to prevent rodents from coming inside the facility's kitchen. Findings: A review of the facility's Census report, dated [DATE], indicated there were 54 residents residing in the facility. On [DATE] at 3:35 p.m., the Los Angeles County Environmental Health Department notified the Department regarding the presence of rodent droppings found by the REHS. A review of the Retail Food Official Inspection Report by the REHS, on [DATE] with in time at 11:40 a.m. and out time at 5:30 p.m., indicated the REHS found the following: A) 70 rodent feces on the floor and under a drainpipe that was under the mechanical ware wash machine and rodent feces were determined to be fresh at the time of the inspection. B) 15 rodent feces on the floor directly between the two stoves and the wall behind the stoves. Inspector and facility staff were unable to retrieve these rodent feces due to the location (it would require that the stoves be moved to access the 15 rodent feces). C) Three rodent feces under a food preparation table and immediately adjacent to the two stoves. D) Three rodent feces under a food preparation sink. E) Two rodent feces on a 1-inch x 14 inches metal bar that was five feet above the ground and behind kitchen equipment that exists at the same wall as the stoves. The REHS observed an approximate two inches by three inches hole at the bottom half of a drainpipe that was exiting into the wall that was under the mechanical ware wash machine. The REHS also reported the facility had to close the kitchen at 4:17 p.m. On 1/9/20 at 4:20 p.m., during an interview, the REHS stated the rodent droppings were found in five areas in the facility's kitchen. The REHS stated the facility had already cleaned areas on the floor under the drainpipe, the food preparation table, and the food preparation sink. The REHS stated the facility had covered the two inches by three inches hole at the bottom half of the drainpipe that was exiting into the wall under the mechanical ware wash machine. On [DATE], at 4:25 p.m., during an observation of the facility's kitchen, rodent droppings were observed behind the facility's refrigerator on a wall ledge and on the floor. On [DATE], at 4:30 p.m., during an observation and concurrent interview, the DS confirmed there were about 13 rodent droppings behind the facility's refrigerator on a wall ledge and on the floor. On [DATE] at 4:36 p.m., during an observation and concurrent interview, the DS confirmed there were about 20 or more rodent droppings on the floor behind the facility stove on the left side and 10 or more rodent droppings on the floor behind the facility stove on the right side. The DS stated the rodent droppings were small elongated black substance. On [DATE], at 4:44 p.m., during an observation and concurrent interview, the DS stated the hole found by the RHES was covered at about 2 p.m. to 3 p.m. today. The DS confirmed there were three rodent droppings on the floor at the corner near the covered hole, and about four rodent droppings on the floor under the dish washer machine. On [DATE]20, at 6:20 a.m., during an observation and concurrent interview, the DS confirmed new rodent droppings observed on the floor in front of the facility refrigerator. A review of the facility's Pest Control Quality Assurance Reports indicated the following visits made by the pest control company and action taken or recommendation done by the pest control service: 1/2/2019 - treat the interior of the kitchen for control of roaches. 1/16/2019 - treat the interior for control of roaches. 2/6/2019 - treat the interior for control of roaches. 5/15/2019 - treat the exterior for control of rats or mice. 5/30/2019 - treat the interior for control of roaches. 6/10/2019 - treat the interior for control of roaches. 6/19/2019 - threat the interior for control of roaches. 7/10/2019 - treat the exterior for control of roaches. 8/14/2019 - treat the interior for control of general pest. 8/21/2019 - treat the exterior for control of general pest and treated 6 rooms for ants and roaches. 9/18/2019 - treat the interior for control of general pest. [DATE] - treat the interior for control of roaches. 12/18/2019 - treat the interior for control of roaches. 12/31/2019 - place trap in the kitchens and also in the room for control of rats or mice. On [DATE] at 5:45 p.m., during an interview, the administrator stated the facility's pest control company came to service the facility building on 12/31/19 to control roaches, rodent, and ants. The administrator stated the facility pest control service provided a full service to treat and control pest that included roaches, ants, and rodents. The administrator stated the pest control service came to the facility monthly and sometimes twice a month. The administrator stated the pest control company was contacted on 1/2/2020 to check the facility for openings and gaps for rodents to come in. The administrator stated the dietary staff had seen movement (did not specify) early in the morning when coming in. On [DATE] at 5:54 p.m., during an interview with the administrator and concurrent record review of the facility's Pest Control Quality Assurance Reports from 6/2019 to 1/2020 provided by the administrator, the administrator confirmed the pest control service did not provide service to the facility on [DATE]. A review of the [STATE] Invoice - Service Slip by the new facility pest control service, dated [DATE]20, indicated a special service was provided to the facility's kitchen - dishwasher. The pest control service placed twelve glue board (trays coated with an extremely sticky adhesive to trap rats or mice) and four T-Rex (a spring-loaded rats or mice trap). The pest control service indicated traps to be inspected in the morning by the pest control service. A review of the facility's Pest Control contract, dated 2/22/1990, indicated the pest control company was to provide service to the facility twice monthly at 9 a.m. and last approximately one and a half hours per service. The service included sanitation report, pesticides use, structural problems, housekeeping, and storage practices. A review of the facility's Pest Control policy and procedure, revised on 5/2008, indicated the facility shall maintain an effective pest control program and maintains an on-going pest control program to ensure that the building was kept free of insects and rodents. 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 microorganisms that are transmissible through food. Effective measures must be taken to eliminate their presence in food establishments. Ensure that fixed equipment is installed in a way that: allows accessibility for cleaning on all sides, above, and underneath the units or minimizes the need for cleaning due to closely abutted surfaces; ensures that equipment that is subject to moisture is sealed; prevents the harborage of insects and rodents and provides accessibility for the monitoring of pests. (retrieved [DATE]20 at https://www.fda.gov/media/ 2/download)

Based on interview and record review, the facility failed to: 1. Identify and report to the local health department a possible outbreak (defined as two or more clinically suspect or confirmed cases identified in residents, healthcare workers, volunteers and/or visitors during a six-week time period) of scabies (an itching skin irritation caused by the microscopic human itch mite, which burrows into the skin's upper layers and eventually causes itching, tiny irregular red lines just above the skin and an allergic rash) when three of five residents (Residents 53, 44, and 45) were treated with anti-scabies medication on 3/1/19. 2. Develop and implement its Infection Prevention and Control Program for four of five residents (Residents 53, 44, 45, and 20) who presented with signs and symptoms of scabies when contact isolation precautions (used to prevent the spread of diseases that can be spread through contact), line listing (a table that summarizes information about persons who may be associated with an outbreak), and decontamination (process of removal of the infectious agent) of the residents' rooms were not conducted. 3. Conduct an ongoing system of surveillance designed to identify possible infections before they can spread to other persons in the facility. These deficient practices resulted in the spread the scabies to the residents and had the potential to spread to other residents or staff members who were exposed with the residents being treated with scabies medications. The lack of an ongoing system of surveillance to identify possible infections had the potential to result in a delay in providing the necessary services to prevent or control a possible infection. Findings: 1a. A review of Resident 53's Face Sheet indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review of Resident 53's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 6/27/19, indicated the resident had severe impairment in cognitive skills. Resident 53 required extensive assistance (resident involved in activity, staff provide weight bearing support) for toileting and personal hygiene. On 7/18/19 at 5:44 p.m., during an interview and record review, the Director of Nursing (DON) stated Resident 53's Nurses Notes dated 8/18/18 indicated the resident had a dermatology (branch of medicine concerned with the [DIAGNOSES REDACTED]. A review of Resident 53's Nurse's Notes did not indicate a skin assessment related to the generalized itchiness of the resident. A review of Resident 53's Physician's Progress Notes dated 9/12/18 indicated the resident had generalized itchiness for one month concentrated on the arms, stomach and feet. The Physician's assessment indicated suspected scabies. The Physician's plan included [MEDICATION NAME] (medication used to treat scabies) cream to be applied to the neck down to feet, wash off in the morning, and repeat every week for four weeks. A review of Resident 53's Physician order [REDACTED]. Repeat every week for 4 weeks for scabies. A review of Resident 53's Physician's Progress Notes dated 10/17/18 indicated an assessment of Scabies, Improving. The Physician's progress notes indicated a plan to repeat [MEDICATION NAME] cream at night and the next week. On 7/18/19 at 5:50 p.m., during a concurrent interview and record review of Resident 53's Nurses Notes from 9/12/18 to 3/2/19, the DON stated there was no documentation indicating whether Resident 53's scabies was improving or worsening. The DON stated that there was no documentation indicating contact isolation and/or decontamination of the environment was conducted. A review of Resident 53's Dermatology Preliminary Notes dated 3/1/19 indicated a treatment plan of [MEDICATION NAME] cream as [MEDICATION NAME] (measure taken to maintain health and prevent the spread of disease) treatment for [REDACTED]. A review of Resident 53's physician's orders [REDACTED]. On 7/18/19 at 5:55 p.m., during an interview, the DON stated the facility did not conduct a skin sweep of all the residents and start a line listing of other residents and staff in (MONTH) (YEAR). The DON stated Residents 53 and 45 were roommates. The DON also stated there were three residents (Residents 53, 44 and 45) who presented with rashes in (MONTH) 2019 and were given medications used to treat scabies. The DON also stated three night shift Certified Nursing Assistants (CNA) 5, 6 and 7 told her that they (the CNAs) complained of itching. The DON further stated the facility did not have a line listing of staff who were exposed and complained of symptoms of scabies. CNAs 5, 6 and 7 did not return a call to the facility when they were attempted to be interviewed. 1b. A review of Resident 44's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review of Resident 44's MDS (MDS, a standardized assessment and screening tool) dated 6/21/19, indicated the resident had severe impairment in cognitive skills. Resident 44 required total dependence (full staff performance) from staff for activities of daily living that includes transferring, dressing, eating, toileting, and personal hygiene. A review of Resident 44's physician's orders [REDACTED]. A review of Resident 44's physician's orders [REDACTED]. A review of Resident 44's Nurses Notes dated 2/25/19 indicated the resident's physician examined the resident and had a new order for a dermatologist (a physician who specializes in the [DIAGNOSES REDACTED]. A review of Resident 44's Dermatologist Notes dated 3/1/19 indicated a [DIAGNOSES REDACTED]. The orders included: - Ivermectin (medication used to treat scabies) 12 mg (milligrams), take 4 tablets once a week for 4 weeks. - [MEDICATION NAME] cream 5%, apply from neck to toes, leave for 12 hours then rinse. Repeat once a week for 4 weeks. - Contact isolation precautions. On 7/17/19, at 11:30 a.m., during an interview, the Dermatologist stated he prescribes Ivermectin and [MEDICATION NAME] together when it is highly suspicious if a resident has scabies. The Dermatologist also stated when he prescribes Ivermectin and [MEDICATION NAME], the facility should start line listing, conduct a skin sweep (skin inspection of all residents), provide daily shower to the affected residents and place the residents treated for [REDACTED]. During a concurrent interview and record review on 7/18/19 at 5:50 p.m., the DON stated there was no nursing documentation from 2/15/19 to 3/8/19 indicating the resident was placed on contact isolation or daily shower, no documented line listing, skin sweep and decontamination of the environment was conducted. A review of Resident 44's Physician's Progress Note dated 5/14/19 indicated the resident was diagnosed with [REDACTED]. 1c. A review of Resident 45's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 45's MDS dated [DATE] indicated the resident had severe impairment in cognitive skills. Resident 45 required extensive assistance for toileting and personal hygiene. A review of Resident 45's Dermatologist notes dated 3/1/19 indicated a [DIAGNOSES REDACTED]. The orders included: - Ivermectin 9 mg (take 3 tablets) PO once a week for 4 weeks - [MEDICATION NAME] 5% cream, apply from neck to toes, leave for 12 hours then rinse. Repeat once a week for 4 weeks. - Contact isolation precautions. During a concurrent interview and record review on 7/18/19 at 5:53 p.m., the DON stated there was no nursing documentation indicating the resident was placed on contact isolation and/or decontamination of the environment was conducted. 2. A review of Resident 20's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 20's MDS dated [DATE] indicated the resident had severe impairment in cognitive skills. Resident 20 required extensive assistance for dressing, toileting, and personal hygiene. A review of Resident 20's Dermatologist notes dated 5/10/19 indicated a [DIAGNOSES REDACTED]. - Ivermectin 15 mg (take 5 tabs) PO once a week, for 4 weeks. - [MEDICATION NAME] (anti [MEDICAL CONDITION] medication) 20 mg (1 tab) PO twice a day (BID) for 5 days. - [MEDICATION NAME] 5% cream, apply from neck to toes, leave for 12 hours, then rinse, repeat once a week for 4 weeks. There was no order of contact isolation precautions included. On 7/18/19 at 6:05 p.m., during an interview, the DON stated [MEDICATION NAME] and Ivermectin are medications used to treat scabies. The DON also stated Ivermectin is used to treat scabies to kill the bug from inside the body because the topical treatment may not be effective. The DON stated Ivermectin is a strong oral medication and is harmful to the residents' liver and that laboratory tests should be done to ensure the safety of the residents. The DON also stated when there are two suspected residents with scabies and/or being treated with medications for scabies, it should have been reported to the department because it is considered an outbreak. The DON further stated there is no documentation indicating the following were completed: - Report to the department of public health of a possible outbreak when Residents 53, 44, and 45 were treated with anti-scabies medications on 3/1/19. - Conduct a skin sweep and start a line listing of all other residents with rashes. - Place Residents 53, 44, 45 and 20 on contact isolation who were ordered for medications to treat scabies. - Perform a decontamination of Resident 53, 44, 45 and 20's rooms per facility's policy and procedure (P&P). A review of the facility's P&P titled, Scabies, revised on (MONTH) 2012 indicated the purpose of this procedure is to treat residents infected with and sensitized to scabies and to prevent the spread of scabies to other residents and staff. The facility's Scabies P&P indicated to obtain or verify the existence of a physician's orders [REDACTED]. The facility's Scabies P&P indicated that [DIAGNOSES REDACTED]. Failure to identify scrapings as positive does not necessarily exclude the diagnosis. It is difficult to obtain a positive scraping because only one or two mites may cause multiple [MEDICAL CONDITION]. Often [DIAGNOSES REDACTED]. The facility's Scabies P&P indicated that affected residents should remain on Contact Precautions until twenty four (24) hours after treatment. The facility's Scabies P&P indicated the following equipment and supplies will be necessary when performing this procedure: - [MEDICATION NAME] (or other treatment lotion) or Ivermectin (oral dosage). - Disinfectant (a chemical agent used to destroy harmful microorganisms such as bacteria and mold) - Personal protective equipment (for example, gowns, gloves, mask, etc., as needed). The facility's Scabies P&P indicated the Infection Preventionist (experts on methods of preventing and controlling the spread of infectious diseases) or Committee is responsible for the following: - During a scabies outbreak among residents and/or personnel, the Infection Prevention or Committee will coordinate interdepartmental planning to facilitate a rapid and effective treatment program. - Control of an epidemic depends on treating all residents at risk. Specific drug selection for each resident will depend on that individual's risk factors, possible medication interactions, etc. - The use of Ivermectin PO should be considered during widespread outbreak and/or when treatment with topical medication is unsuccessful. The facility's Scabies P&P indicated cleaning protocols for days 1, 7 and 8 under environmental services that include: - Remove privacy curtains - Remove all bed linens except the pillow. Strip the resident's bed carefully. Place bed linen in bag and take it to laundry. - Disinfect the mattress. A review of the Acute Communicable Disease Control Program, Scabies Prevention and Control Guidelines for Healthcare Settings of Los Angeles County Department of Public Health revised 7/2019, indicated, .Outbreak definition .Two (2) or more clinically suspect or confirmed cases of scabies identified in patients/residents, healthcare workers, volunteers and/or visitors during a six (6) week time period . All outbreaks of scabies are required to be reported to the County of Los Angeles Department of Public Health . Long term care facilities and home health agencies should report to .LAC Department of Public Health, Health Facilities Inspection Division, Licensing and Certification . A review of the Centers for Disease Control and Prevention (CDC the leading national public health institute whose goal is to protect public health and safety through the control and prevention of disease), long term surveillance for scabies is imperative to eradicate scabies from an institution. The local health department and neighboring institutions should be notified of the outbreak and of any residents who may have been transferred to or of staff who may have worked in other institutions. (https://www.cdc.gov/parasites/scabies/health_professionals/control.html) 3. On 7/18/19 at 3:19 p.m., during an interview and record review the Director of Staff Development (DSD) stated she was the infection control nurse. The DSD stated that she has a log for residents who are receiving antibiotics only. The DSD stated that there is no log to track other residents with potential signs and symptoms of infection (for example coughing, fevers, or redness/rashes). The DSD stated she did not know there was a difference between antibiotic stewardship and infection control program. The DSD stated before (MONTH) 2019 there is no documentation of an infection surveillance log. A review of the facility's undated policy and procedure titled, Infection Control Program, indicated that the facility shall establish an infection control program designed to provide a safe, sanitary, and comfortable environment for residents and staff to help prevent the development and transmission of disease and infection .it will include statistical analysis such as: infection reports, infection-related reports, and regular review of the infection control program.

Based on interview and record review, the facility failed to prevent falls for 1 of 4 sampled residents (Resident 1). Resident 1 fell fourteen (14) times, from 12/16/16 to 8/21/17 (8-month period) due to the facility's failure to: 1.Provide interventions addressing Resident 1's specific physical and behavior problems (unsteady gait (person's manner of walking), wandering, and poor judgement when sitting down) in the care plans, and initiated short term care plans that lasted 72 hours after every fall without measurable target goals. 2. Provide interventions for individualized supervision after each fall. 3. Discuss interventions for preventing future falls, during Resident 1's Care Conference Review/ Interdisciplinary Team Conference Records (IDT, used interchangeably), 4. Follow their policy and procedure for Fall Program and Fall Procedure, by not updating Resident 1's care plans after every fall and did not contain new/individualized interventions to help decrease the number of falls. 5. Complete a change in condition assessment and the fall risk assessments after each fall. These deficient practices resulted in a right arm fracture, hospitalization , and pain for Resident 1. Findings: On 9/6/17 at 2:25 p.m., during an interview, Resident 2 (Resident 1's roommate) stated, when Resident 1 fell and broke her arm, Resident 1 was crying, sobbing, and she felt bad for her. A review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility, on 6/23/14, with [DIAGNOSES REDACTED]. A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/13/17, indicated Resident 2's cognitive skills (memory and thinking skills) were intact (made decisions regarding tasks of daily life independently and decisions were consistent/reasonable). On 9/6/17 at 2:35 p.m., during an interview, a licensed vocational nurse (LVN 1) stated Resident 1 was always ambulatory and her gait (person's manner of walking) was not that steady. LVN 1 stated Resident 1's baseline was to get up early in the morning and start walking around the hallways. LVN 1 stated after every fall that Resident 1 suffered, a short-term care plan was initiated. The short-term care plans were discontinued after 72 hours. On 10/18/17 at 3:11 p.m., during an interview, the director of nursing (DON) stated examples of interventions for residents who had suffered falls were low bed, wheelchair part time with monitoring, supervised ambulation, a walker, and appropriate shoes. The DON stated Resident 1 was a fall risk from admission and was supervised like all other residents and that staff was around the facility at all times. The DON stated the facility did not develop an individualized supervision for Resident 1 and was supervised like all other residents. On 12/1/17 at 12:30 p.m., during an interview, LVN 2 stated that when a resident sustained [REDACTED]. LVN 2 stated that Resident 1's problem was her judgement, because she would attempt to sit down on a chair and half of her butt cheek touched the chair. LVN 2 stated Resident 1 would slide off, and she would miss the chair. During the interview, LVN 2 stated, when the facility's staff noticed Resident 1 was attempting to sit down, they would guide her to sit. LVN 2 stated that Resident 1 was supervised just like all other residents and supervision in the facility was the same for all residents. LVN 2 stated for example, if Resident 1 was walking in the hallway and staff noticed her to have an unsteady gait, then the staff would assist her. LVN 2 did not state any other interventions provided to Resident 1. A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility, on 8/15/15, with [DIAGNOSES REDACTED]. A review of Resident 1's MDS, dated [DATE], indicated Resident 1's cognitive skills (memory and thinking skills) were severely impaired and required supervision for bed mobility, transfers, walk in room and/or corridor, and locomotion in the units. Resident 1 was assessed to wander in the facility on a daily basis. Resident 1 had two or more falls with injuries (skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the resident to complain of pain). A review of Resident 1's Order Summary Report, active orders as of 9/1/17, indicated a physician order, dated 9/30/15, that resident may ambulate as she desired (ad lib) inside the facility and with supervision. On review of Resident 1's Nursing Notes from 12/16/16 to 9/5/17, indicated that Resident 1 fell fourteen times: 1. On 12/16/16 at 3:15 p.m., Resident 1 was found on the floor in a supine (lying face upward) position and next to the Christmas tree. This incident was not witnessed by the staff. 2. On 12/20/16 at 10:30 a.m., Resident 1 was found sitting on the floor with both legs extended and in front of room 23. 3. On 1/18/17 at 7:13 a.m., a certified nursing assistant reported that Resident 1 was pushed by another resident (Resident 1's roommate) and fell to the floor. Resident 1 had a bump on the back of the head and ice was applied. Resident 1's roommate admitted to pushing Resident 1, because Resident 1 was trying to get into the roommate's bed. There was no documented evidence that a care plan was developed for this incident. 4. On 1/19/17 at 4:15 p.m., the charge nurse was called to the television room, because Resident 1 was sitting on a chair and in an attempt to get up, lost balance. Resident 1 put one foot over the other foot and fell back on her buttocks. 5. On 2/10/17 at 9:10 a.m., Resident 1 was walking on the hallway, suddenly lost control and balance, and was found sitting on the floor. Due to memory problems, Resident 1 was unable to give a reason for the fall. 6. On 3/16/17 at 11:30 a.m., Resident 1 was found sitting on the floor by room 6 and had redness to the left elbow. 7. On 3/24/17 at 4:30 p.m., the charge nurse was notified by the Director of Nursing (DON) that staff heard a noise in the front television room. Resident 1 was found sitting on the floor. Resident 1 was attempting to sit on a chair and missed the chair. 8. On 4/2/17 on the 11 p.m. to 7 a.m. (11-7), a certified nursing assistant called a charge nurse to check Resident 1, because she was found lying on the floor in her room. The charge nurse went to Resident 1's room and found the resident on the floor on her right side. 9. On 4/9/17 at 10:10 a.m., Resident 1 tripped and lost her balance on the patio ground. Resident 1 suffered a bump on the right side of her forehead, small abrasion, and small amount of bleeding was noted. 10. On 4/10/17 at 2:30 p.m., Resident 1 was found sitting on the floor in her room. 11. On 6/23/17 at 2:50 p.m., Resident 1 was walking around the front dining room and lost her balance. Resident 1 was sitting on the floor and unable to verbalize what had happened. 12. On 7/22/17 at 3:00 p.m., Resident 1 was found lying on the floor in room 10 and was unable to explain what happened due to a poor cognitive status and memory. Resident 1 had not Change in Condition Assessment record for 7/22/17. 13. On 8/2/17 at 8:45 p.m., the charge nurse found Resident 1 to have left side discoloration on the forehead. Resident 1 was unable to state what had happened. 14. On 8/21/17 at 6:00 a.m., a certified nursing assistant called the charge nurse to station two. Resident 1 was found seated on the floor and could not explain what had happened. Resident 1 had pain and discomfort to her right arm. At 1:21 p.m., Resident 1 stayed in bed during day shift (7 a.m. to 3 p.m.) and complained of pain to her right arm. During the evening shift (3 p.m. to 11 p.m.), Resident 1 was in bed and appeared to be in discomfort, pain medication was administered. Due to the complaint of pain and discoloration to the right shoulder, the physician was called for an order to transfer Resident 1 to the hospital for evaluation. A review of Resident 1's physician's orders [REDACTED]. At 4:20 p.m., the physician wrote an order that indicated Resident 1 was to be transferred to the hospital for evaluation of the right arm. A review of Resident 1's Nursing Note, dated 8/22/17 at 1:30 a.m., indicated the hospital called the facility and made them aware that Resident 1 had a fracture on the right arm and would be back to the facility with a sling (a bandage used to support an injured arm) in place. A review of Resident 1's physician's orders [REDACTED]. Another physician order [REDACTED]. A review of Resident 1's Nursing Notes, dated 8/22/17 at 7:15 p.m., indicated Resident 1 was back at the facility and had right arm pain 4/10 (pain scale of 0 to 10) and medication was administered. GACH 2 discharge instructions indicated Resident 1's right arm fracture was inoperable. A review of Resident 1's Nursing Notes, dated on 8/23/17 at 2 p.m., indicated Resident 1 had a right shoulder sling and the right arm was immobilized and had discoloration. Resident 1 had slight swelling to right arm and right upper chin area. On 8/23/17, during the evening shift (3 p.m. to 11 p.m.), Resident 1 complained of 3/10 pain. A review of Resident 1's Nursing Notes, dated 8/24/17 during night shift (11 p.m. to 7 a.m.), indicated Resident 1 had facial grimace of pain and discomfort. A 400 mg tab of Ibuprofen was administered. On 8/24/17 at 2 p.m., during care, Resident 1 had facial grimacing. The physician was called and made aware that Resident 1 required stronger pain medication. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's Nursing Notes, dated 8/25/17 at 3:00 p.m., indicated Resident 1 had 6 out of 10 pain and swelling with discoloration to the right arm. At 6:30 p.m., swelling was noted on the right arm and at middle of Resident 1's chest area. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's Nursing Notes, dated 9/1/17 at 2 p.m., indicated Resident 1 went out of the facility premises for an orthopedic appointment. Resident 1 did not return to the facility. A review of Resident 1's Discharge Summary indicated date discharged was 9/2/17. A review of Resident 1's Fall Risk Assessment records indicated that Resident 1 was a high risk for falls. Resident 1's score ranged from 20 to 24 (a total score above 10 represented a high risk for falls). Resident 1 had no Fall Risk Assessment for the falls that occurred on 1/18/17, 4/10/17, 6/23/17, 7/22/17, and 8/2/17. A review of Resident 1's Resident Care Conference Reviews, dated 12/21/16, indicated two licensed nurses and the social service director attended the conference. Resident 1's increased episodes of falls were discussed but the document did not indicate how the facility would attempt to prevent future falls. The Care Conference Review, dated 2/27/17, indicated one licensed nurse, the activity director, a dietary supervisor, and the social service director attended the conference. This document did not indicate Resident 1's four falls, occurred since the last conference, and did not indicate a new approach to prevent future falls. A review of Resident's Care Conference Review, dated 6/26/17, indicated two licensed nurses, the activity director, a dietary supervisor, and the social service director attended the conference. The Care Conference Review indicated that Resident 1 was a fall risk and had four falls within the last three months but did not indicate the facility's interventions to prevent future falls. On review of Resident 1's medical records, the facility was not able to provide any other Care Conference Review records from 12/16/16 to 8/21/17 (8 months period). The Care Conference Reviews by the facility team did not indicate discussion of interventions to prevent future falls for Resident 1. A review of Resident 1's Risk for Falls long term care plan, dated 8/15/15 and updated on 11/28/16, indicated Resident 1 had the following problems: history of falls, poor safety awareness, missed the chair when tried to sit down, and impaired cognition. The care plan indicated interventions for the nursing staff that included visual checks at intervals and providing redirection with reality orientation as needed. These interventions did not specify when or how often the nursing staff should perform the interventions. The facility updated the care plan on 1/26/17, 2/21/17, 2/27/17, 5/2017, 6/26/17, and 9/2017. Throughout these updates, the facility did not include the increase number of falls into the problem section or incorporate new interventions to prevent Resident 1 missing the chair during an attempt to sit down. On 5/2017 and 9/2017 the care plan care reviewed and updated with no changes made. A review of Resident 1's Short Term Problems (short-term care plans) indicated the facility did not develop a care plan for the fall that occurred on 1/18/17. The Short Term Problem for Resident's fall on 8/21/17 was initiated on 8/22/17. The short term care plans that were developed for all other falls, did not include an individualized plan or interventions that addressed Resident 1's specific physical and behavior problems of unsteady gait, wandering, and poor judgement when sitting down. These care plans were only active for 72 hours and then discontinued. The care plans did not address scheduled increased or individualized supervision for Resident 1. A review of facility's policy and procedure with revised date 9/20/17, titled Resident Care Planning, indicated a written plan is developed to meet the individual needs of the resident. The procedure indicated the development of an individualized written care plan for the resident that indicates the care to be given, the objectives to be accomplished, and the professional discipline responsible for each element of care. The objectives should be measurable and time-limited. The facility would review, evaluate, and update the resident's care plan, as necessary, by the nursing staff and other professional personnel involved in the care of the resident at least quarterly, and more often if there is a change in the resident's condition. After information has been gathered, the data is analyzed to determine what problems and needs exist. The policy and procedure indicated the guidelines for identifying, selecting and recording problems that included objectives/goals within the resident's abilities, which can be reached realistically. Each problem should have an objective/goal that is simple, specific and measurable within a specified time-frame. When selecting appropriate actions or approaches toward resolving the resident's problems, actions must be clearly stated and be specific as to How. Although specific actions may be performed by an individual responsible discipline, the interdisciplinary team's collective actions provide the most effective effort toward resolution of the resident's problems. The policy and procedure indicated, each discipline should be aware of all of the resident's care, document resolution of the problem, and evaluate the plan by considering: a. Are the resident's problems still current? Are current problems worsening? b. Are the actions/approaches appropriate and effective? If the problem is not resolving, new approaches are essential. c. Are the interventions being followed by all staff members responsible? d. Are all appropriate members of the interdisciplinary team involved in the plan of care as needed? A review of facility's policy and procedure, dated 8/28/17, titled, Fall Program and Fall Procedure, indicated if a resident fell , the following paperwork to be completed were change of condition, care plan, and update the fall assessment. The policy and procedure indicated adding any intervention that is new to help decrease falls in the future. The facility attempts to put in place as soon as possible something to assess with fall reduction as it relates to the fall assessment (examples: low bed, side rails, check resident shoes, check for items they may trip over, instruct assigned nurse aide to monitor resident more closely). The policy and procedure indicated paperwork is to be completed immediately after fall and completed by the end of shift.

Based on observation, interview and record review the facility failed to maintain safe and comfortable temperature levels for four sample residents (Resident 1, 2, 3 and 13) in a sample of 14 and seven randomly selected residents (RSR 15, 16, 17, 18, 21, 22, and 23) totaling 11 residents after the air conditioning unit malfunctioned in Rooms 27 to 31 for two days. Resident 2 who had a gastrostomy ((GT) a surgical opening through the abdomen into the stomach used for feeding and medications) was in room [ROOM NUMBER], with a room temperature reading at 87.8 degrees Fahrenheit (°F). RSR 17 who had a GT was in room [ROOM NUMBER], with a room temperature of 88.6 °F. Residents 1, 3, 13 and RSR 15, 16, 18, 21, 22, and 23) residing in Rooms 27-31 had room temperature readings between 84.3 °F to 90.2 °F. There were no adequate cooling interventions provided to these residents in these rooms for two days. According to the Weather Underground temperature on 8/3/17 the hottest temperature outside that day was 98 °F. This deficient practice placed residents at risk for dehydration (reduction in the amount of water in the body) and skin breakdown due to lack of cool air circulating and moisture-associated skin damage ((MASD) is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus). On 8/3/17, at 9 p.m., an immediate jeopardy (IJ) was called for the failure of the facility to maintain safe and comfortable temperature levels by not having adequate ventilation, and cooling systems and cooling measures which placed eleven residents, whose medical status were already compromised at risk for dehydration and complications. The administrator and director of nursing (DON) were notified of the immediate jeopardy findings. On 8/4/17, the facility submitted an acceptable plan of correction and the IJ was abated on 8/4/17, at 5:25 p.m., for the following reasons: (a). Hourly rounds on residents in Rooms 27-31 until air conditioning (AC) unit is fixed. Checking temperatures in the rooms every hour. If above 90 °F notify administrator (ADM). (b). Offer fresh cool water to all residents in Rooms 27-31 every two hours. (c). Maintain water stations and have them changed every four hours. (d). Cancel activities involving exercise and repetitive motion. (e). Notify the primary physician if residents with GTs have elevated temperatures and ask to increase water flush by 100 cubic centimeters (cc). (f). Utilize fans safely to circulate air in hallways/rooms, and use curtains in the rooms to block direct sun. (g) Relocate residents, from 7 a.m., to 9 p.m., to other areas where it is cooler. (h). Offer moistened cool towels to body of residents. (i). A technician was sent out to look at the heating, ventilation and air conditioning (HVAC) unit on 8/4/17 at 9:30 a.m., and replaced the thermostat which lowered the temperatures in all five rooms ranged from 74.6 to 81 °F. (j). the facility also bought portable AC units if it was needed. Findings: 1. During the initial tour of the hallway which housed Rooms 27-31, on 8/3/17 at 7:30 p.m., with licensed vocational nurse (LVN 1), LVN 1 stated it felt warm. The following temperatures were taken with a thermocouple (measures temperatures) with LVN 1 present: Hallway of rooms 27-31 was 87.8 °F; room [ROOM NUMBER], which had one resident (RSR 17 with a GT), was 88.6 °F; room [ROOM NUMBER], which had three residents (Resident 1, Resident 13, and RSR 16), was 87.7 °F room [ROOM NUMBER], which had two residents (RSR 21 and 18), was 84.3 °F room [ROOM NUMBER], which had three residents (Resident 3, RSR 15 and 22), was 87.8 °F room [ROOM NUMBER], which had two residents (Resident 2 with a GT, and RSR 23), was 90.2 °F During these observations there were portable electric fans in each of these five rooms. The air that was circulating was hot/warm air. The windows were open one to two inches and were not able to open any further to allow cooler air from the outside to circulate to the inside of the resident rooms. During an observation and concurrent interview, on 8/3/17 at 7:40 p.m., RSR 15 (room [ROOM NUMBER]-B) was sitting on his bed with his T-shirt half up his back. RSR 15 stated the temperature in the facility was always hot. During an observation, on 8/3/17 at 8:50 p.m., Resident 2 was in bed lying on his back with his GT running with Glucerna (nutritional supplement) 1.2 calorie (cal) at 65 cc per hour (hr). Resident 2 was non-interviewable. During the initial tour of the facility, on 8/3/17, from 7:30 p.m. to 9 p.m., Residents 1, 3, 13 and RSR 15, 16, 18, 21, 22 and 23 were ambulatory and were not in their rooms. Residents 1, 3, 13 and RSR 16, 18, 21, 22 and 23 were non-interviewable. A review of Resident 2's admission record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/24/17, indicated Resident 2 had unclear speech and was sometimes able express ideas and wants. Resident 2 needed extensive assist (staff providing weight-bearing support) on the staff for transferring and eating. According to the Abbott titled, Glucerna 1.2 cal, dated 12/2016 to administer at room temp. Prolong exposure to temperatures below 32 °F or above 95 °F could affect the physical consistency of the product and is not recommended. https://abbottnutrition.com/faq. According to the Weather Underground temperature on 8/3/17 the hottest temperature outside that day was 98 °F. During observation, on 8/3/17 at 9:20 p.m., RSR 17's was lying on his back in bed with his GT running with Jevity (supplement nutrition) 1.2 calories at 55 cc/hr. Resident 17 was non-interviewable. A review of RSR 17's admission record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RSR 17's MDS, a standardized assessment and care screening tool, dated 2/23/17, indicated RSR 17 had unclear speech and was sometimes understood. RSR 17 was totally dependent on the staff for transferring and eating. According to Abbott titled, Jevity 1.2 cal, administer at room temp. Prolong exposure to temperatures below 32 °F or above 95 °F could affect the physical consistency of the product and is not recommended. https://abbottnutrition.com/faq. According to the Weather Underground temperature on 8/3/17 the hottest temperature outside that day was 98 °F. During an interview, on 8/3/17 at 7:25 p.m., with certified nursing assistant (CNA 1), she stated the hot temperatures in Rooms 27-21 started today. CNA 1 stated she was off yesterday. During an interview, on 8/3/17 at 7:40 p.m., with LVN 1 she stated she was off the last two days and not aware of the hot temperatures. LVN 1 knew maintenance had problems with the AC unit recently. LVN 1 stated she thought someone fixed it already. During an interview, on 8/3/17 at 7:42 p.m., with the ADM he stated they just installed a new HVAC unit and have been having problems with it off and on since June 2017. The ADM stated they had ordered a new motor for the unit that was supposed to arrive on Wednesday (8/2/17) has not arrived. The ADM stated he had provided fans to residents and increased hydration to those residents affected. During an interview, on 8/3/17 at 8:21 p.m., with the director of nurses (DON) she stated it has been hot, in the hallway where Rooms 27-31 are, for about two days. Another observation of the rooms temperatures were conducted, on 8/3/17 at 8:45 p.m. and revealed: room [ROOM NUMBER] - 86.4 °F room [ROOM NUMBER] - 86.5 °F room [ROOM NUMBER] - 81.9 °F room [ROOM NUMBER] - 87.7 °F room [ROOM NUMBER] - 86.8 °F During an observation, on 8/3/17 at 9:38 a.m., with the ADM while using his own temperature gun in hallways and Rooms 27-31 it was observed reading 90 °F and above. During an interview, on 8/4/17 at 5:40 p.m., with the maintenance supervisor (MS) he stated the HVAC completely stopped working since Wednesday (8/2/17). The MS stated they put fans in the resident's rooms to help cool the rooms down. The MS stated he checked the temperatures in the rooms every day, but does not keep a log. The MS was unable to give any documentation of monitoring for the days the HVAC was broken. According to Weather Underground for the temperatures in El Monte, CA on 8/2/17 the maximum temperature was 98 °F. On 8/3/17 the maximum temperature that day was 98 °F. https://www.wunderground.com/history/airport/KEMT/2017/8/2/DailyHistory.html?req_city=San+Gabriel&req_state=CA&req_statename=&reqdb.zip= &reqdb.magic=1&reqdb.wmo= During an interview, on 8/5/17 at 2 p.m., with the ADM he stated he has no policy and procedure for what the temperatures in the resident's rooms are supposed to be. The ADM stated he knows the regulation states it was between 71-81 °F.

Based on observation, staff interviews and document review the facility failed to ensure food was served in a sanitary manner to nine of 51 residents eating breakfast when unpasteurized (not exposed to an elevated temperature for a period of time) shell eggs were used for the preparation and service of fried eggs to residents. This had the potential of subjecting the residents to acquiring Salmonella, a foodborne illness commonly associated with the service of unpasteurized, undercooked eggs, especially to a highly susceptible population such as the elderly. On 12/18/13 at 8:30 a.m., the facility Administrator and the Dietary Service Supervisor (DSS) were notified Immediate Jeopardy was declared in response to the potential of foodborne illness associated with the service of undercooked, unpasteurized eggs to facility residents. The Immediate Jeopardy was abated on 12/18/13 at 5:30 p.m., following a review of the facility's immediate plan of correction for the removal of the Immediate Jeopardy, review of the resident's clinical record and staff interview. The facility Administrator was informed the Immediate Jeopardy was abated. In addition to the Immediate Jeopardy situation, the facility also failed to ensure: 1) Leftover food stored in the refrigerator was maintained at or below a temperature of 41 degrees F and that the food cooling temperatures were recorded on the Cooling log in accordance to the facility ' s policy and procedure. 2) The dry storage room was maintained at a temperature of 50 degrees to 70 degrees F as indicated in the facility ' s policy and procedure. 3) The scoop of the food thickener was not stored in the product. 4) The can opener blade had no metal shavings 5) Kitchen cabinets are a cleanable surface, and 6) Expired foods products were discarded. This has the potential to result in food contamination and the growth of microorganisms that can lead to injury or illness of the residents. Findings: 1. According to the Center for Disease Control and Prevention (CDC) report for 1993 - 1997, "Surveillance for Food-borne Disease Outbreaks - United States," identified the most significant factors to food borne illness. Improper cooking and improper holding temperatures are two of several categories identified as contributing factors directly relate to food safety concerns. According to the Food and Drug Administration (FDA) Food Code 2013, Section 3-801.11 Pasteurized Foods, Prohibited Re-Service, and Prohibited Food, "In a food establishment that serves a highly susceptible population: (B) Pasteurized eggs or egg products shall be substituted for raw eggs in the preparation of: (1) Foods such as Caesar salad, hollandaise or Bearnaise sauce (a sauce made of butter, egg yolks, vinegar and flavored with herbs), mayonnaise, meringue, eggnog, ice cream and egg-fortified beverages, and (C) The following foods may not be served or offered for sale in a ready-to-eat form: (2) A partially cooked animal food such as lightly cooked fish, raw meat, soft-cooked eggs that are made from raw eggs, and meringue." On 12/17/13 at 3:10 p.m., during an inspection of the facility kitchen, only unpasteurized shell eggs were observed to be available for the preparation of items such as over easy eggs. Pasteurized shell eggs are uniquely identified via a red letter "P" that is stamped on each egg. There was no red letter "P" stamped on any of the shell eggs observed in the facility kitchen nor did the carton in which the eggs were delivered identify the eggs as pasteurized. On 12/18/13 at 7:19 a.m., during an observation of the breakfast tray line, cooked fried eggs were in the steam table. A concurrent interview was conducted at this time with Cook B regarding the preparation of the eggs. Cook B stated the eggs have to be cooked until a temperature of 146 degrees F and took the temperature of the eggs in the steam table which showed they were 145 degrees F. Cook B stated the yolks cannot be runny unless they were pasteurized eggs and they did not have pasteurized eggs. On 12/18/13 at 7:35 a.m., 7:43 a.m. and 7:46 a.m., the Dietary Services Supervisor (DSS) told Cook B to make more fresh eggs on the griddle. Cook B washed his hands and during this time the DSS took over cooking the eggs. The DSS flipped the eggs over and placed them in the steam table on the tray line. On 12/18/13 at 7:43 a.m., the surveyor took the temperatures of the freshly cooked eggs. The temperatures ranged between 128.5-130.5 degrees F. At 7:46 a.m. more temperatures were taken by the surveyor of the freshly cooked eggs on the plate and they ranged from 121.7 to 123.8 degrees F. At 7:52 a.m. one egg was taken off the griddle then placed on the plate with a temperature of 128.3 degrees F. On 12/18/13 at 8:05 a.m., an observation of the breakfast meal in the back dining area/hallway was conducted. Nine random residents were served and consumed the over easy eggs, characterized by runny yolks that smeared the plates. On 12/18/13 at 8:25 a.m., the cart was taken back into the kitchen and an interview was conducted at this time with the DSS. The DSS stated when the eggs are cooked they must be served right away and the temperatures are supposed to be 140 degrees F. The DSS looked at all the nine residents' plates and acknowledged that there should not be the runny yolk on them. The DSS stated she used pasteurized eggs when she worked at other facilities. The DSS stated this facility did not have them here when she started and she never ordered them. On 12/18/13 at 8:30 a.m., the Administrator and the DSS were notified the Immediate Jeopardy was declared in response to the potential of foodborne illness associated with the service of undercooked, unpasteurized shell eggs to facility residents. On 12/18/13 at 4:10 p.m., in an interview with the Registered Dietitian (RD), she stated she has not done an inspection of the kitchen since she had started in May. The RD stated she did not have enough hours to do both clinical and the kitchen. The RD stated she had 10 hours each month and had been asking for more. The RD stated starting in December she was given 12 hours but was not sure if that would be enough. The RD stated the unpasteurized eggs should be cooked to 145 degrees F. On 12/18/13, at 4:30 p.m., the facility provided an acceptable plan of correction in response to the immediate jeopardy declared, that included: a. The removal of all unpasteurized shell eggs from the facility, and the purchase of pasteurized shell eggs through the facility's food vendor. b. The DSS will check the tray line temperature to ensure appropriate temperature on a daily basis. c. All identified residents who ate eggs during the visit will be put on 72 hour alert charting to assure no signs and symptoms of salmonella (a type of bacteria that causes food poisoning), are present every four hours; if any resident shows symptoms check will take place every two hours. d. In service training on the proper manner to prepare eggs to the staff members involved in the cooking of eggs by the RD. e. The RD will oversee compliance by monitoring staff procedures to prevent recurrence every two weeks for 90 days. f. Facility Administrator/Assignee will cover compliance of alleged deficiencies on daily stand up meeting. g. Measures adopted for Systematic Change to prevent Recurrence: h. All residents will be monitored on a daily basis by nurses to observe for salmonella symptoms. i. Findings will be brought to the attention of the QA committee at a minimum of quarterly and as deemed necessary for further intervention and corrective action. j. RD hours will be increased from 10 hours to 24 hours per month for 90 days starting on 12/18/13 to allow for proper monitoring of the kitchen. Once the 90 day period is completed, the level of compliance will be re-evaluated and the RD hours will be re-assessed. On 12/18/13 at 4:15 p.m., the in-service training and the availability of pasteurized eggs were validated. 2. On 12/17/13 at 3:10 p.m., during a tour of the kitchen the following items were observed in the walk-in refrigerator: chicken parmesan dated 12/16/17 at 50.3 degrees F, cooked noodles dated 12/16/13 was 42.8 degrees F, meatloaf dated 12/17/13 was 65.8 degrees F, and cooked carrots dated 12/17/13 were 60.3 degrees F. At this time the DSS threw out the chicken parmesan. On 12/17/13 at 4:30 p.m., the following items were observed in the walk-in refrigerator: cooked noodles dated 12/16/13 was 45.1 degrees F, meatloaf dated 12/17/13 was 61.3 degrees F, and cooked carrots dated 12/17/13 were 57.2 degrees F. On 12/18/13 at 9:50 a.m., an interview was conducted with Cook B regarding cool down of food items. Cook B stated they usually prepare large roasts the day they are served but they do cool down leftovers. Cook B stated they put the food in an ice bath in the refrigerator and then put on the cooling log. On 12/18/13 at 10:10 a.m., an interview was conducted with the DSS. The DSS stated they throw away leftovers. The DSS acknowledged the food items seen on 12/17/13 should have been thrown away. A concurrent interview at this time was conducted with the Cook B. Cook B stated he did not use the cooling log for any of the leftovers in the refrigerator. The DSS stated they had thrown away those leftovers and they had not served to anyone. Review of the cooling logs dated December 2013, showed no items were written. Further review of the cooling logs dated 2013, indicated for 11/13, 10/13, 9/13, 7/13, 5/13, and 1/13 that there was no temperature for the two hour indicator, there was only a temperature for one and a half hours then hourly after that. It indicated for 6/13 there was one food item on the cooling log with a temperature of 80 F after two hours. It indicated for 5/13 and 1/13 there were three food items on the cooling log with a temperature of 75 F after two hours. On 12/18/13 at 10:25 a.m., an interview was conducted with the DSS while reviewing the cooling logs dated 2013. The DSS stated the cool down procedure would be to cool down the food to 70 F within two hours and then to 40 F within four hours. The DSS stated if after two hours, the food temperature is greater than 70 F then they should just put it on an ice bath then keep cooling down to reach 40F. The DSS acknowledged the cooling logs had times for an hour and a half instead of two hours. On 12/18/13 at 4:10 p.m., an interview was conducted with the RD. The RD stated that the staff should not continue to cool down the food item if it did not reach 70 F in two hours. The RD stated that after two hours if the food does not reach 70 F then the staff should reheat the food to 165 F and then start the cooling process over. According to the Food and Drug Administration (FDA) Food Code 2013, Section 3-501.14 Cooling "(A) Cooked time/temperature control for safety food shall be cooled: (1)Within 2 hours from 135F to 70F; and (2) Within a total of six hours from 135F to 41F or less." 3. On 12/17/13 at approximately 3:27 p.m., the temperature of the dry storage room was over 70 degrees Fahrenheit (F). The pin on the thermometer which indicated the temperature had moved past the numbered areas on the thermometer. The red colored pin was in a blank area with no numbers. The thermometer range was -20 to 70 degrees F. The surveyor thermometer in the room measured 75.6 degrees F. The recommended temperature of a dry storage room according to the Food and Drug Administration is between 50 and 70 degrees F. The facility policy and procedure titled "Receiving and Storage" under the subtitle "Dry Storage Areas" states "Storerooms should have good ventilation and temperature should be 50 degrees to 70 degrees F." According to the Cooperative Extension of the University of North Dakota, "Maintaining food at the appropriate room temperature would prevent spoilage due to high temperature and prolong the quality of food. The risk of spoilage jumps sharply as storage temperatures rise" and "prolonged temperatures above 75 degrees F, the rate of nutrient loss in canned food increases." 4. On 12/17/13 at 6:15 p.m., an observation was conducted of the scoop being in the can of food thickener. An interview was conducted at this time with the Dietary Aide 1. Dietary Aide 1 stated the scoop is always in the can of thickener. On 12/17/13 at 6:20 p.m., an interview was conducted with the DSS. The DSS stated the scoop should not be in the can of the thickener. 5. On 12/17/13 at 4:15 p.m., an observation was conducted of the can opener. It was observed the blade was worn down and exposed of bare metal. On 12/17/13 at 6:25 p.m., an interview was conducted with the DSS. The DSS acknowledged the blade was worn with metal shavings. The DSS stated she could not remember when the blade was changed last. The DSS stated the staff should tell her when it is worn down. The DSS stated there was no policy and procedure on the can opener but it was on their daily cleaning list. 6. Observation of the kitchen cabinetry on 12/17/13, showed the cabinets were constructed with wood and painted in white or off-white. Several shelves had exposed wood and chipping paint. These surfaces were therefore absorbable. According to the 2013 Food Code Section 4-101.19 "nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material." 7. The facility kept on-hand food items and ingredients that had exceeded the recommended storage times on shelves in the kitchen. For example, cooking sherry dated "9/17/12" with an expiration date of 03/05/13. Item had expired nine months earlier. There was a gallon of soy sauce with a date of 9/1/13. According to the facility policy titled Food Storage charts for Opened Foods dated 12/10/10, the recommended storage time or "use by date" for soy sauce is three months. In addition the chart recommended the item be stored covered in a refrigerator 38 to 41 degrees F.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to residents for two of 14 sample residents (5, 12). For Resident 5, who was non-communicative, the facility staff failed to identify and treat his Norwegian scabies infection, which resulted in severe discomfort for the resident and put every other resident, staff, and visitor to the facility at risk for infection (outbreak). For Resident 12 the facility failed to obtain necessary information regarding the pacemaker as indicated on the facility policy and procedure to ensure the proper functioning of the pacemaker (12). Findings: a. According to the CDC (Centers for Disease Control): 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]. Resident 5 was admitted to the skilled nursing facility (SNF) on November 2, 2011, with [DIAGNOSES REDACTED]. According to the MDS (minimum data set, an assessment tool) dated November 15, 2011, the resident was totally dependent on staff assistance for all activities of daily living, was incontinent of bowel and bladder, and had impaired range of motion to all extremities, and had no rash. Resident 5 was rarely/never able to make his needs understood and rarely/never understood others. During a wound care observation on November 26, 2011 at 2:15 p.m., Resident 5 was sleeping in his bed. He was the only resident living in the room. LVN 1 and CNA 1 donned gloves after entering the resident's room with the surveyor. When the Treatment Nurse (LVN 1) awakened the resident, he immediately began vigorously scratching his chest and arms. The skin on the resident's hands was scaly and crusted. When LVN 1 exposed the resident's upper body and legs, the resident's entire body was covered with raised red papules indicative of scabies infestation. The resident became combative while CNA 1 held the resident's hands to reposition him. During the observation, LVN 1 stated she did not know what scabies infestation looked like. The clinical record for Resident 5 had been reviewed on November 26, 2011 at 2 p.m. The nurses note dated November 25, 2011 at 9:30 p.m. indicated the resident was noted to have a generalized body rash with itching of skin, the resident's physician was called, and the physician issued new orders. The physician's orders [REDACTED]. ([MEDICATION NAME] cream does not eradicate scabies). On November 26, 2011 at 3 p.m., the DON was asked to accompany the surveyor to Resident 5's room. The crusted, scaly skin on the resident's hands and the raised red papules all over his body were compared to pictures contained in Health Department literature regarding scabies/atypical scabies infestation. The DON agreed that the resident's skin condition matched the photos in the literature. The DON stated he would call Resident 5's physician right away. The DON did not grasp the severity of the situation, even though the DON had been made aware that the resident's skin condition was suspected to be a scabies infestation, Isolation precautions were not implemented. On the same day, at approximately 3:30 p.m., the DON stated that he had spoken to Resident 5's physician, and the physician stated he would visit the resident the next morning. The DON was informed that the facility had a serious problem with infection control regarding the resident's skin condition and needed to arrange for a Dermatology consultation (to ensure quick and aggressive medical treatment) immediately, or risk infecting other residents, staff and visitors. The DON agreed to arrange for an immediate Dermatology consultation. At approximately 6 p.m., the DON stated the Dermatologist would see the resident "in about 2 hours". Isolation precautions were not implemented at this time. The nurses note dated November 26, 2011 at 8:15 p.m., indicated the resident was seen by the Dermatologist, skin scrapings (a test used to determine the presence of scabies) were taken, and new orders were received. The note indicated that at 9 p.m. [MEDICATION NAME] (a topical cream used to treat scabies infections by destroying the mites which cause scabies) was applied as ordered. There was no mention made of isolation precautions being in effect. A physician's (Dermatologist) order dated November 26, 2011 at 8:20 p.m. indicated to apply [MEDICATION NAME] cream from neck to toes tonight and wash off in a.m. Repeat in 7 days and in 2 weeks; Contact isolation (per facility's policy and procedure: place patient in a private room; don gown and gloves upon entry to the room; remove gown and gloves before leaving the room and wash hands immediately with an antimicrobial agent or waterless antiseptic agent and do not touch potentially contaminated environmental surfaces or items in the patient's room; after gown removal, ensure clothing does not contact potentially contaminated environmental surfaces. Contaminated linen and trash carts were not addressed in the policy) and discontinue [MEDICATION NAME] cream. During an observation on November 27, 2011, at 7:30 a.m. Resident 5's room was being cleaned by gowned and gloved housekeeping staff. No isolation cart was in place outside the resident's room so staff/visitors could don gowns and gloves before entering the room. No trash/linen carts were observed inside the resident's room. At 8:30 a.m. the DON stated that Resident 5 was back in his disinfected room after being showered. During an observation at that time no isolation cart was in place outside the resident's room and no trash/linen carts were observed inside the room. CNA 1 was observed inside the resident's room removing a disposable gown and gloves at 8:35 a.m. CNA 1 placed them in a plastic red hazardous materials waste bag, which she set on an upholstered chair in the room. CNA 1 then tied the red bag and placed it in the resident's closet. CNA 1 then walked out of the room, carrying the resident's breakfast tray back to the kitchen. CNA 1 was not observed to have washed her hands. On the same day at 9 a.m., the DON was asked where the gowns and gloves required for isolation precautions were being kept. The DON went to the medical records office and returned with a package of disposable gowns. At that time, LVN 1 stated that the gowns and gloves were in the resident's bedside table. In order to prevent further spread of infection, the DON was informed that staff/visitors needed to don gowns and gloves outside the isolation room and remove gowns and gloves before exiting the room. Shortly afterwards, an isolation cart containing gowns and gloves was placed outside Resident 5's room, and 2 large plastic barrels, one for trash, one for linens were placed inside the room. During an interview with the DON on 11/27/11 at 3 p.m., he stated that the nursing staff had not notified him of Resident 5's skin condition. Otherwise, the DON stated, he would have taken action sooner. On November 28, 2011 at 3 p.m., the facility faxed the results of the skin scrapings done by the Dermatologist to the Surveyor. The scrapings revealed mites, which confirmed the clinical [DIAGNOSES REDACTED]. During an interview with the dermatologist on 11/30/11 at 10:15 a.m., he stated that Resident 5's infection was an early case of 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 stated that it was a lack of common sense on the part of the nursing staff to not identify the patient's skin problem. The facility's policy and procedure for skin checks was requested from the DON. The DON stated skin checks were logged on a separate form and that he had the forms and would provide the requested copies. However, the policy and skin check documents were not submitted to the survey team. The DON stated he could not locate them. The facility's policy and procedure titled "Isolation Measures: General Policy Statement" undated, indicated it is the policy of this facility to utilize a disease specific system of isolation precautions in addition to standard precautions. Isolation procedures shall be initiated as a precautionary measure by the Nursing Department. The facility's staff failed to recognize the signs and symptoms of Resident 5's skin condition, such as the itching and scratching, the crusted skin on the resident's hands and the raised red papules all over his body, as suspicious for scabies. As a result the resident was not provided treatment necessary to resolve the scabies infestation, until after the survey team notified the DON that the resident required quick and aggressive medical treatment. Additionally, although the resident had been residing in the facility for over three weeks, with scabies, the facility staff did not identify that the resident had a rash until November 25, 2011. The facility's undated policy and procedure titled "Transmission-Based Precautions, Contact Precautions", indicated in addition to standard precautions, the facility staff will use contact precautions for specified patients known or suspected to be infected with microorganisms that can be transmitted by direct contact with the patient (hand or skin to skin contact that occurs when performing patient care activities that require touching the patient's dry skin) or indirect contact (touching) with environmental surfaces or patient care items in the patient's environment. Wear gloves when entering the room and remove gloves before leaving the patient's environment and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. After glove removal and hand washing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient's room to avoid transfer of microorganisms to other patients or environments. Wear a gown when entering the room if it is anticipated that your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room. Remove the gown before leaving the patient's environment. After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other patients or environments. These policies were not followed, and as a result, the entire resident population, and all staff and visitors to the facility were exposed to scabies infection and at risk for infection. b. On 11/26/11, a review of the clinical record revealed Resident 12 an [AGE] year old male, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. There was no information in the clinical record regarding the pacemaker type or date of insertion. A review of the care plan for pacemaker dated 8/9/11, indicated to monitor if pulse is below 60 and /or resident becomes symptomatic- short of breath, dizziness, altered level of consciousness, [MEDICAL CONDITION], chest pains, and notify physician promptly. Keep resident from running microwaves. A review of the facility's policy and procedures for Permanent Pacemaker, revealed upon admission during the head to toe assessment the licensed nurse should determine if the resident is with a permanent pacemaker. Obtain plastic card that comes with the pacemaker and affix or place in the resident's clinical record (inside of front cover). Include information on the plan of care regarding the type of pacemaker date of insertion, pacemaker check lab and phone number. Record vital signs every month and include rate and rhythm of apical pulse. Monitor resident for any signs and symptoms of dizziness and weakness, if he/she is not able to communicate condition and keep the resident away from any electrical appliances (i.e. microwave ovens).