Every finding on record at Southland

Based on observation, interview and record review, the facility failed to ensure one of three residents (Resident 1) was supervised while smoking at the smoking patio on 8/9/2026 at 5:30 p.m. and 8/12/2026 at 9:20 a.m. The facility failed to:1.Ensure Resident 1's smoking materials were secured at the nurse's station when not in use during designated smoking times per facility's policy and procedure (P&P) titled Smoking and Safety Measures revised 12/2023.This failure had the potential to increase the risk for fires, burn injuries, and other smoking related accidents to Resident 1 and other residents who might access smoking materials.This failure resulted in Resident 1 being verbally abuse by visitor when he was called the B word in an angry tone while smoking outside on the smoking patio without staff supervision on 8/9/2026 at 5:30 p.m.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 cognitive communication deficit (communication problems caused by underlying thinking and processing difficulties), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty breathing), generalized muscle weakness, and osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/7/2026, the MDS indicated Resident 1's cognition (ability to think or make decisions) was moderately impaired. The MDS indicated Resident 1 needed partial or moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with mobility while in wheelchair and substantial or maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with chair or wheelchair transfers.During a review of Resident 1's Care Plan titled Resident had a potential for injury related to smoking revised on 5/11/2026, the Care Plan indicated goals including Resident 1 would have no injuries related to smoking and be compliant with individual smoking plan. The Care Plan indicated interventions including maintain smoking materials at nurses' station or other designated area, and monitor to assess compliance with facility smoking policy/individual plan.During an interview on 8/12/2026 at 8:55 a.m. with Resident 1 in Activity room, Resident 1 stated on 8/9/2026 at approximately 5:30 p.m., while smoking in the designated smoking patio (which also serves as a pathway leading to the assisted living facility entrance), Visitor ( assisted living resident), approached her in an angry tone, accused her of locking the patio door, called her disrespectful names including B-word. Resident 1 stated no staff, or other residents were present at the smoking patio when the incident occurred. Resident 1 stated she did not report the incident to anyone until the morning of 8/11/2026 since she did not know who the visitor was. Resident 1 stated she felt disrespected when the visitor called her inappropriate names. During concurrent observation and interview on 8/12/2026 at 9:20 a.m., with Resident 1 at the smoking patio, Resident 1 was observed sitting in her wheelchair smoking without smoking apron (protective garment worn by residents who smoke to reduce the risk of burns or fire) on or staff supervision. Resident 1's cigarette and lighter were stored in a plastic container on the side of her wheelchair. Resident 1 stated she had been smoking at the designated smoking area without staff supervision since she was admitted to the facility.During an interview on 8/12/2026 at 11:48 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the importance of smoking supervision while securing cigarettes and lighters in locked area to protect Resident 1 from smoking related accidents. During an interview on 8/12/2026 at 1:08 p.m., with the Director of Nursing (DON), the DON stated Resident 1 was non-compliant with smoking supervision and smoking material storage. The DON stated the importance of keeping residents safe and free from any smoking related accidents. The DON stated Resident 1's unsupervised smoking and unsecured smoking materials posed potential risks including Resident 1 sustaining burn injuries and other residents accessing these items thus creating fire hazards.During an interview on 8/12/2026 at 1:46 p.m., with the Administrator (ADM), the ADM stated Resident 1 received the smoking policy upon admission. The ADM stated the importance of reviewing designated smoking areas and revising facility's smoking policy to ensure Resident 1's safety and protect other residents from smoking related accidents.During a review of the facility's policy and procedure (P&P) titled Smoking and Safety Measures revised 12/2023, the P&P indicated 4. All smoking materials will be secured at the nurse's station when not in use during designated smoking times.6. Smoking may only occur with facility staff present.Cross Reference F600.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from verbal abuse when Resident 1 reported a visitor called her the B word in an angry tone while smoking outside on the smoking patio without staff supervision on 8/9/2026 at 5:30 p.m.This failure had the potential to cause Resident 1 to feel humiliated, fearful, agitated, and sad. Resident 1 stated she felt disrespected when the visitor called her inappropriate names.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 cognitive communication deficit (communication problems caused by underlying thinking and processing difficulties), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty breathing), generalized muscle weakness, and osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/7/2026, the MDS indicated Resident 1's cognition (ability to think or make decisions) was moderately impaired. The MDS indicated Resident 1 needed partial or moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with mobility while in wheelchair and substantial or maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with chair or wheelchair transfers.During an interview on 8/12/2026 at 8:55 a.m. with Resident 1 in Activity room, Resident 1 stated on 8/9/2026 at approximately 5:30 p.m., while smoking in the designated smoking patio (which also serves as a pathway leading to the assisted living facility entrance), Visitor ( assisted living resident), approached her in an angry tone, accused her of locking the patio door, called her disrespectful names including B-word. Resident 1 stated no staff, or other residents were present at the smoking patio when the incident occurred. Resident 1 stated she did not report the incident to anyone until the morning of 8/11/2026 since she did not know who the visitor was. Resident 1 stated she felt disrespected when the visitor called her inappropriate names. During concurrent observation and interview on 8/12/2026 at 9:20 a.m., with Resident 1 at the smoking patio, Resident 1 was observed sitting in her wheelchair smoking without smoking apron (protective garment worn by residents who smoke to reduce the risk of burns or fire) on or staff supervision. Resident 1 stated she had been smoking at the designated smoking area without staff supervision since she was admitted to the facility.During an interview on 8/12/2026 at 11:48 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 8/11/2026 9:00 a.m., Resident 1 approached her as she was passing medications and reported the verbal altercation with the visitor on 8/9/2026 at 5:30 p.m. LVN 1 stated Resident 1 did not report the incident immediately to anybody since she was unsure who the visitor was and felt scared at the time. LVN 1 stated Resident 1 was tearful as she reported the incident to her. LVN 1 stated she reported the incident to the Director of Nursing (DON) as soon as Resident 1 was done talking to her. LVN 1 stated staff must be aware when Resident 1 goes outside the smoking patio to allow adequate supervision and ensure Resident 1's safety. During an interview on 8/12/2026 at 1:08 p.m., with the DON, the DON stated she assessed Resident 1 and found no physical injuries; however, the resident reported feeling discomfort caused by the visitor's unpleasant words. The DON stated she reported the incident to the Administrator (ADM) right away to further investigate. The DON stated the smoking patio was a shared space between the facility and the assisted living. The DON stated it was important to monitor the residents and reassess current smoking practices to ensure Resident 1's safety and avoid future incidents.During an interview on 8/12/2026 at 1:46 p.m., with the Administrator (ADM), the ADM stated he was responsible for investigating any abuse allegations. The ADM stated the DON notified him of the incident prompting him to further investigate. The ADM stated there were no witnesses identified who could provide more information regarding the incident. The ADM stated although the smoking patio was visible from the facility's front desk there was no adequate oversight for residents who go outside the smoking patio. The ADM stated the facility considered a different smoking area away from the shared space with assisted living and review smoking policies to meet residents' safety needs. The ADM stated that not doing so may lead to future resident altercations with possible physical injuries.During a review of the facility's policies and procedures (P&P) titled Abuse: Prevention of and Prohibition Against revised 4/2025, P&P indicated that The facility will provide oversight and monitoring to ensure that it's staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse. The P&P indicated D. Prevention 2. The facility will act to protect and prevent abuse and neglect from occurring within the facility by: Ensuring the health and safety of each resident with regard to visitors. Cross Reference F689

Based on observation, interviews, and record review, the facility failed to implement infection control measures for two of eight sampled residents (Resident 1 and Resident 6). The facility failed to:1.Perform hand hygiene after taking blood pressure and before preparing medications for Resident 6.2.Disinfect the blood pressure cuff and machine before using them on Resident 1.3.Perform hand hygiene before pricking Resident 1's finger for blood sugar testing and disinfect the glucometer (a small portable device used to measure blood glucose) after use on Resident 1.These failures had the potential to increase the transmission of infection among residents, staff, and visitors in the facility.Findings:During a review of Resident 6's admission Record (Face Sheet), the Face Sheet indicated Resident 6 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including cerebral ischemia (brain injury that causes lack of blood flow to the brain), hyperlipidemia (high level of fats in the blood), and spinal stenosis (narrowing of spaces in the spine leading to pain, tingling, numbness or weakness in the neck, back, arms or legs).During a review of Resident 6's History and Physical (H&P) dated 8/3/2026, the H&P indicated Resident 6 had the capacity to understand and make decisions.During a medication pass observation on 8/10/2026 at 9:02 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 6's room, LVN 1 took Resident 6's blood pressure (BP- force of blood pushing against the walls of the arteries as the heart pumps the blood through the body) and returned the BP cuff (a medical tool used to measure blood pressure) on the top of the medication cart. Observed LVN 1 did not perform hand hygiene before preparing Resident 6's medications.During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] to the facility with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), cognitive communication deficit ( a person has trouble communicating because of how their brain processes information) and urinary tract infection(UTI- an infection in the bladder/urinary tract).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 5/21/2026, the MDS indicated Resident had moderately impaired cognition. The MDS indicated Resident 1 required substantial/ maximal assistance (helper does more than half the effort) with toileting hygiene, bathing, and lower body dressing.During a medication pass observation on 8/10/2026 at 9:25 a.m. with LVN 1 in Resident 1's room, LVN 1 took Resident 1's BP without disinfecting the BP cuff and machine after using on Resident 6. Observed LVN 1 did not practice hand hygiene before pricking the finger of Resident 1 to obtain blood for the blood sugar testing. Observed LVN 1 returned the glucometer back in the medication cart without cleaning or sanitizing it.During an interview on 8/10/2026 at 12:59 p.m. with LVN 1, LVN 1 stated hand hygiene should be practiced before entering a resident's room, before and after medication administration. LVN 1 stated licensed nurses should clean and disinfect multi use medical equipment every after use. LVN 1 stated she should have performed hand hygiene in between medication administration tasks and should have disinfected the BP cuff, BP machine after each use on a resident. LVN 1 stated she should have disinfected the glucometer after she used it on Resident 1 and before returning it in the medication cart. LVN 1 stated this kind of practice could spread infection to other residents due to cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products).During an interview on 8/11/2026 at 9:30 a.m. with the Infection Preventionist Nurse (IPN), the IPN stated the licensed nurse should perform hand hygiene before and after in contact with a resident and in between the tasks. IPN stated medical equipment shared by residents should be cleaned and disinfected after each use to prevent spread of infection among the residents, staff members and visitors.During an interview on 8/11/2026 at 12:04 p.m. with the Director of Nursing (DON), the DON stated licensed nurses should practice hand hygiene in between tasks during medication pass and disinfect multi-use medical equipment like bp cuff, and glucometers to prevent the spread of infection in the facility.During a review of facility's policy and procedure (P&P) titled, Hand Hygiene, dated 10/2022, the P&P indicated Hand hygiene is performed before preparing or handling medications, and before and after direct contact with a resident.During a review of facility's P&P titled, IPCP Standard and Transmission-Based Precautions, revised 10/2022, the P&P indicated Patient-care equipment used for multiple patients should be disinfected and cleaned before use on another patient.

Based on interviews and record review, the facility failed to ensure medications were administered safely and in accordance with accepted standards of practice for one of three sampled residents (Resident 1). The facility failed to:1.Ensure medications prepared by nursing students and administered by the Clinical Instructor (CI) were not signed and documented by Licensed Vocational Nurse (LVN) 2.This failure had the potential to create a pattern of inaccurate medication documentation and increase the risk of medication errors, compromising residents' safety.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] to the facility with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), cognitive communication deficit ( a person has trouble communicating because of how their brain processes information) and urinary tract infection(UTI- an infection in the bladder/urinary tract).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 5/21/2026, the MDS indicated Resident had moderately impaired cognition. The MDS indicated Resident 1 required substantial/ maximal assistance (helper does more than half the effort) with toileting hygiene, bathing, and lower body dressing.During a review of Resident 1's Medication Administration Record (MAR) dated 7/28/2026, the MAR indicated LVN 2 documented and signed the medications administered on 7/28/2026 at 9:00 a.m.During an interview on 8/10/2026 at 10:15 a.m. with Nursing Student (NS)1, NS 1 stated the nursing students would come to the facility twice a week. NS 1 stated they administered residents' medications with the Clinical Instructor (CI) and then communicated medications administered to a resident including the vital signs (core measurements of the body's basic functions) to LVN 2. NS 1 stated the nursing students nor the CI do not document or sign the administered medication in the residents' health record. NS 1 stated LVN 2 signed and documented the medications administered by the nursing students with the CI.During an interview on 8/10/2026 at 10:33 a.m., with the CI stated her nursing students prepare the medications, and she and the students administer the residents' medications together. The CI stated she does not sign or document administered medications because she does not have access to the facility's MAR. She stated she reports vital signs, as well as any refused or administered medications, to LVN 2. The CI stated the licensed nurse who prepares and administers the medications should sign the MAR, and a medication error could occur if a licensed nurse signs for medications they did not prepare or administer.During a telephone interview on 8/10/2026 at 11:37 a.m., with LVN 2, LVN 2 stated nursing students and a clinical instructor were present on 7/28/2026. She stated she did not know that the person who prepares and administers the medications should be the one to sign and document in the resident's MAR. LVN 2 stated the nursing students and the CI had been coming to the facility for three years, and it had been the ongoing practice for the students and CI to administer the medications while the licensed nurse signed the medications administered in the resident's MAR. LVN 2 stated she should not sign the MAR if she did not directly observe the nursing students and CI preparing and administering the medications to the residents. She stated this practice could place residents at risk for medication errors, including overdose or underdose, and result in medication parameters (clinical guidelines for administration and monitoring) not being followed.During an interview on 8/11/2026, at 12:04 p.m. with the Director of Nursing (DON), the DON stated LVN 2 should prepare and administer the medications in the presence of the nursing students and Clinical Instructor. The DON stated LVN 2 should document in the resident's MAR after administering the medications. The DON stated the person who prepares and administers the medications to the resident should be the person to document and sign for the administered medications. The DON stated medication error could result if the individual who prepared and administered did not sign and document the administered medicines of a resident.During a review of facility's facility and procedure (P&P) titled, Medication Administration, updated 1/2017, the P&P indicated Medications are administered only by licensed nursing. The P&P indicated The person who prepares the medication is the person who administers the dose and the individual who administers the medication dose should record the administration in the MAR after the medication pass is completed.

Based on observation, and interview, the facility failed to ensure a mattress placed on the floor next to one of three sampled resident's (Resident 1) bed was not damaged. This deficient practice resulted in a visibly damaged mattress placed on the floor next to Resident 1's bed and had the potential for harm to Resident 1 and to affect his sense of dignity.Findings: During a review of Resident 1's admission Record (Face Sheet) the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1 had diagnoses including a cognitive communication deficit (an impaired ability to communicate effectively), and abnormal posture. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 5/22/2026, the MDS indicated Resident 1 's cognition was severely impaired. Resident 1 required supervision/touching assistance with eating, oral hygiene, personal hygiene and was dependent (helper does all the effort) with shower/bathing, and upper body dressing. During an observation of Resident's room on 5/28/2026 at 1:36 p.m., a mattress was noted on the floor next to Resident 1's bed. The mattress was not covered with a sheet or other covering, there was a large white discolored area in the middle of the mattress, the top protective layer of the mattress was worn off, and the right upper side of the mattress was peeled off. During an interview with Certified Nursing Assistant (CNA) 1 on 5/29/2026 at 1:30 p.m., and a concurrent observation of the mattress lying on the floor next to Resident 1's bed, CNA 1 stated the mattress appeared as if it had been cleaned multiple times which caused the top layer of the mattress to be worn off. During a concurrent interview on 5/29/2026 at 3 p.m., the Administrator (ADM) and Director of Nursing (DON) both stated they were aware of the mattress and stated it should not have been there. The DON stated Resident 1's room should be homelike, the mattress on the floor was not pleasing to the eye and could be a dignity issue. During a review of the facility's Policy and Procedure (P/P), dated 11/2021, and titled Residents Rights the P/P indicated it is the policy of this facility that all residents be treated with kindness, dignity and respect.

Based on observation, interview, and record review, the facility failed to ensure staff followed infection control practices for four of thirty sampled residents (Resident 5, 89, 154, and 157) when:Certified Nurse Assistant (CNA) 2 failed to wear proper PPE prior to performing Foley catheter care for Resident 5.Laundry staff (LS) 1 failed to perform hand hygiene before and after distributing linens to Resident 89, 154 and 157.This failure has the potential to result in cross contamination, transmission of infectious organisms, healthcare-associated infections, and overall compromise of resident safety and sanitary conditions to residents. Findings:a. During a review of Resident 5's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted Resident 5 on 6/22/2021 and readmitted on [DATE] with diagnoses including diastolic (congestive) heart failure (weakness of the heart that leads to buildup of fluid in the lungs and other parts of the body), type 2 diabetes mellitus (condition in which the body does not metabolize blood sugar correctly) and obstructive uropathy (when something blocks or makes it hard for urine to flow through this pipe).During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool), dated 2/3/2026, the MDS indicated Resident 5's cognitive (functions your brain uses to think, pay attention, process information, and remember things) was moderately impaired. The MDS also indicated Resident 5 was dependent (helper does all of the effort) on staff with toileting hygiene, required maximal assistance (helper does more than half the effort to complete task) with showering, supervision assistance (helper provides verbal cues and/ or touching/ steadying and/or contact guard assistance as resident completes activity) their personal hygiene.During a review of Resident 5's Order Summary Report, orders as of 5/6/2026, the Order Summary Report indicated starting 3/23/2026, the resident had an indwelling catheter to closed drainage system.During a review of Resident 5's care plan for The resident is on enhanced barrier precautions (EBP- extra safety steps healthcare workers take to protect people in nursing homes from certain hard-to-kill germs called multidrug-resistant organisms), revised 11/7/2025, the care plan's intervention included to direct care staff to utilizes gowns and gloves for all personal care.During a concurrent observation and interview on 5/6/2026 at 10:29 a.m. in Resident 5's room with the Certified Nurse Assistant (CNA) 2, CNA 2 was observed providing indwelling catheter care including emptying the drainage bag without wearing the gown for a resident on EBP precautions. CNA 2 acknowledged not wearing the required gown while providing care.During an interview on 5/7/2026 at 11:40 p.m. with Director or Nursing (DON), the DON stated residents with indwelling catheters are at high risk for infection and required EBP and staff should wear appropriate PPE, including a gown, while providing indwelling catheter care as part of infection control.b. During a review of Resident 89's Face Sheet, the Face Sheet indicated the facility admitted Resident 89 on 3/24/2026 with diagnoses including unilateral inguinal hernia (there is a hole or weak spot in one side of the groin area), Intestinal obstruction (a blockage in the intestine that prevents food, liquid, and gas from passing though normally), and congestive heart failure(when the heart is too weak to pump blood properly, causing fluid to build up in the body)During a review of Resident 89's History and Physical (H&P), dated 3/25/2026, the H&P indicated the resident did not have the ability to understand and make decisions.During a review of Resident 89's Minimum Data Set (MDS- a resident assessment tool), dated 3/31/2026, the MDS indicated the resident's cognitive was severely impaired. The MDS indicated Resident 89 required maximal assistance (helper does more than half the effort to complete task) with eating, oral hygiene, personal hygiene, dependent (helper does all the effort) with toileting hygiene and showering.During a review of Resident 154's Face Sheet, the Face Sheet indicated the facility admitted Resident 154 on 5/4/2026 with diagnoses including intracerebral hemorrhage (bleeding inside the skull that puts dangerous pressure on the brain), left clavicle (the long bone that connects your shoulder to your chest) fracture, and difficulty in walking.During a review of Resident 157's Face Sheet, the Face Sheet indicated the facility admitted Resident 157 on 5/4/2026 with diagnoses including Wedge compression fracture of third lumbar vertebra (when the third bone in your lower back gets crushed and collapses into a wedge shape), History of transient ischemic attack (TIA, a temporary blockage of blood flow to the brain that causes brief stroke-like symptoms) and cerebral infarction (when part of the brain dies due to a blocked blood vessel, commonly known a stroke).During a concurrent observation and interview on 5/05/2026 at 8:55 a.m. in front of Resident 89's room, Laundry staff (LS) 1 was observed handling and distributing clean linen between resident rooms without performing hand hygiene. LS 1 removed clean linen from the linen cart, placed the linen inside Resident 89's wardrobe cabinet, touched the wardrobe doors and linen cart multiple times, then proceeded to the shared room of Resident 154 and Resident157 and handed clean linen to Laundry and House Keeping Staff (LHK) 1 inside without washing or sanitizing hands in between. LS 1 acknowledged the lack of required hand hygiene before and after touching unclean surfaces during the clean linen to prevent cross-contamination and maintain infection control.During an interview on 5/7/2026 at 11:40 p.m. with Director or Nursing (DON), the DON stated handwashing is the number one standard precaution regardless of any situation. The DON stated staff should perform hand hygiene before and after handling and distributing clean linen and before moving between resident rooms to maintain infection control.During a review of the facility's policy and procedure (P&P) titled Infection Prevention and Control Program (IPCP) Standard and Transmission-Based Precautions, revised 3/2024, the P&P indicated Standard Precautions are infection prevention practices that apply to the care of all residents, regardless of suspected or confirmed infection or colonization status and include: Hand hygiene. The P&P also indicated Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE using gown and gloves during high-contact resident care activities.During a review of the facility's P&P titled Infection Control, dated 4/2025, the P&P indicated performing hand hygiene is one of the most effective measures to prevent the spread of infection, based on accepted standards for healthcare workers.During a review of the facility's P&P, titled Infection Prevention-Linen Management, revised 5/2023, the P&P indicated clean linens are to be kept covered and protected from dust and other contaminants prior to use, clean linens are not to come in contact with staff clothing.During the review of the Facility's Assessment titled Staff training/education and competencies, dated, the Facility's Assessment indicated staff confidences included infection control practices such as hand hygiene, standard/ universal precautions, use of personal protective equipment (PPE), Multidrug resistant organisms (MDROs) precautions, and environmental cleaning.

Based on interviews and record reviews, the facility failed to ensure sufficient staff were available to provide care and ensure four out of eight sampled residents' (Residents 35, 60, 63, and 123) needs were met as evidenced by 1.Resident 35 had not been showered for several weeks, and 2.Call lights (device that allows residents to request assistance from nursing staff) for Residents 60, 63, and 123, were not answered in a timely manner.These failures had the potential to resulted in a delay in care and services. Findings:During a review of Resident 35's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 35 was admitted to the facility on [DATE] with diagnoses including difficulty walking, abnormal posture, blindness of the right eye, generalized muscle weakness, and paraplegia (inability to voluntarily move the lower parts of the body). During a review of Resident 35's Minimum data Set ([MDS] a resident assessment tool), dated 3/31/2026, the MDS indicated Resident 35's cognition (ability to make decisions of daily care) was intact. The MDS indicated Resident 35 needed substantial assistance from facility staff (helper does more than half the effort) with showering. During a review of Resident 60's Face Sheet, the Face Sheet indicated Resident 60 was admitted to the facility on [DATE] with diagnoses including aftercare (support, care, and treatment) following joint replacement surgery (procedure replaces damaged joint), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of right knee, difficulty walking, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 60's MDS, dated [DATE], the MDS indicated Resident 60's cognition was moderately impaired, and she had the ability to understand others and make herself understood. The MDS indicated Resident 60 needed set-up assistance with eating, oral hygiene, personal hygiene, needed substantial assistance with toileting hygiene, and was dependent (helper does all the effort to perform the task) on staff with showering. During a review of Resident 63's Face Sheet, the Face Sheet indicated Resident 63 was admitted to the facility on [DATE] with diagnoses including gastrointestinal stromal tumor (cancer in the stomach or small intestine), difficulty walking, and abnormal posture.During a review of Resident 63's MDS, dated [DATE], the MDS indicated Resident 63's cognition was moderately impaired, and he had the ability to understand others and make himself understood. The MDS indicated Resident 63 needed supervision (helper does verbal cues) with eating, partial assistance (helper does less than half the effort to complete the task) with oral hygiene, and personal hygiene, needed substantial assistance with toileting hygiene, and was dependent on staff with showering. During a review of Resident 123's Face Sheet, the Face Sheet indicated Resident 123 was admitted to the facility on [DATE] with diagnoses including, muscle weakness, difficulty walking, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and abnormal posture.During a review of Resident 123s MDS, dated [DATE], the MDS indicated Resident 123's cognition was intact. The MDS indicated Resident 123 was independent with eating, oral hygiene, personal hygiene, and needed supervision with toileting hygiene, and showering. During an interview on 5/4/2026 at 9:18 a.m., Resident 60 stated staff take a long time to respond when she activates her call light to summon help, sometimes she has to wait for 30 minutes.During an interview on 5/4/2026 at 9:21 a.m., with Resident 35, Resident 35 stated he had not showered over couple weeks. Resident 35 also stated call light response time can be slow and sometimes the nurse will answer the call light say they will come back but do not come back. During Resident council meeting on 5/5/2026 at 1:26 p.m., Resident 63 stated the facility was short of nurses. Residents 63 and 123 stated call light response time was a problem, and it was slower than before. Resident 63 and 123 stated the wait times can be as long as 10 minutes and depending on what residents need that 10 minutes can be long. During a concurrent interview and record review on 5/6/2026 at 7:55 a.m. with the Activities Director (AD), the facility's Resident Council Meeting Minutes, 3/4/2026, were reviewed and the AD stated the minutes indicated Resident 60 complained that call lights were not answered in a timely manner. During a concurrent interview and record review on 5/7/2026 at 9:47 a.m. with Licensed Vocational Nurse (LVN) 5, Resident 35's Documentation Survey Report for 4/8/2026 to 5/6/2026 was reviewed and LVN 5 stated Resident 35 showered 5/5/2026 and the last time Resident 35 showered before that was on 4/21/2026, approximately 2 weeks before. LVN 5 stated staff needed to respect residents' preferences to shower for hygiene reasons. During an interview with Registered Nurse Supervisor (RNS) 3, on 5/7/2026 at 12:18 p.m., RNS 3 stated on days where nurses call off absent and no replacement staff were found, the CNAs share the assignment. RNS 3 stated they were understaffed. RNS 3 stated the staff try to help each other but most of the time she's busy taking care of her own assignments. RNS 3 stated Short staffing on the weekends from 3 p.m. to 11 p.m. shift was especially hard on the residents and staff because usually admissions happen during the 3 p.m. to 11 p.m. shift. During an interview on 5/7/2026 at 1:22 p.m., with the Director of Nursing (DON), the DON stated call lights need to be answered immediately so staff can attend to the residents' needs. The DON stated it was important to respect residents' preferences for showers if the resident preferred showers because it was their right. The DON stated staffing the unit should be based on acuity (severity of residents' condition and intensity of nursing care that residents require) and not just census (number of residents in the facility). During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL) care, revised 11/2021, the P&P indicated residents unable to carry out activities of daily living will receive assistance as needed.During a review of the facility's P&P titled, Call Light/Bell, revised 5/2023, the P&P indicated call lights will be answered within a reasonable time. During a review of the facility's Facility Assessment, 2026, the assessment indicated staffing decisions were made at the facility level to ensure there were enough staff to meet residents' needs. Cross Reference: F558

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 104 out of 112 total residents in the facility by not:A. Ensuring Foods were dated, labeled, and discarded before the used by date (expiration dates).B. Ensuring the proper level of the concentration of the Quaternary Ammonium (a type of chemical that is used to kill bacteria, viruses, and mold) in sanitization bucket was monitored and maintained.Findings:A. During a concurrent observation and interview on 5/4/2026, at 8:29 a.m., with the Dietary Supervisor (DS), in dry storage #1, there were food items that were not dated and sealed properly as follows:a. Opened and used dry pasta in a plastic container with no Receiving Date (RD- the day of delivery), no Open Date (OD), and no Used By (UB).b. Opened, used, and unsealed Lasagna dry pasta in a box with RD of 4/23/2026, no OD, and no UB.c. Opened and used marshmallows in a plastic bag with RD or 2/5/2026, no OD, and UB of 5/15/2026.The Dietary Supervisor (DS) stated, all food items should have been labeled with receiving date when the facility got delivery from vendors and used by date (expiration date). The DS stated, it was all the dietary staff's responsibility to check all food items for labels, dates, properly stored and sealed. The DS stated these practices were important to make sure all food items were in good condition because the residents consumed these food items. The DS stated that all opened food items should be closed tightly to prevent contamination. The DS stated, once the food items were opened, there should be different shelf life (the length of time for which an item remains usable, fit for consumption). The DS stated that all staff should refer to Dry Goods Storage Guidelines for shelf life after opening and labeled UB date on food items. The DS stated, opened dry pasta had one year shelf life after opening and the staff should have placed UB date. The DS stated, opened marshmallows had one month shelf life and he would not know when it was opened because there was no OD.During a review of the facility's Policy and Procedure (P&P) titled, Dry Goods Storage Guidelines, dated 2023, the P&P indicated, dry pasta had shelf life of one year after opening and marshmallows had shelf life of one month after opening.During a concurrent observation and interview on 5/4/2025, at 8:59 a.m., with the DS, in walk-in Refrigerator #1, there were food items that were not labeled, dated, and sealed properly as follows:a. Opened, used, unsealed, and unlabeled cream cheese in zip lock bag with no RD, no OD, and UB of 6/26/2026.b. Opened and used sour cream in a plastic container with RD 4/17/2026, no OD, and UB of 5/26/2026.The DS stated, all food items should be dated, and dietary staff should follow the Refrigerator Storage Guide to ensure safety of perishable items that required refrigeration. The DS stated that all opened items should be sealed properly to prevent contamination. The DS stated, opened cream cheese did not have any labels and UB date should be seven days after opening. The DS stated, opened sour cream should be discarded seven days after opening and UB date was incorrect.During a review of the facility's Policy and Procedure (P&P) titled, Refrigerator Storage Guide, dated 2023, the P&P indicated, discard according to follow expiration date or seven days after opening whichever comes first for opened cream cheese and sour cream.During a concurrent observation and interview on 5/4/2025, at 9:09 a.m., with the DS, in walk-in Freezer #1, there were food items that were not sealed properly as follows:a. Opened, used, and unsealed dinner rolls in an opened plastic bag inside of box with RD of 4/23/2026, no OD, and UB of 5/21/2026.b. Opened, used, and unsealed California mixed vegetables in an opened plastic bag inside of box with RD of 3/3/2026, no OD, and UB of 6/2/2026.The DS stated, all food items should be sealed tightly, and dietary staff should follow Freezer Storage guideline to ensure safety of perishable items.During a review of the facility's Policy and Procedure (P&P) titled, Freezer Storage Guidelines, dated 2023, the P&P indicated, frozen vegetable in freezer had shelf life of six months and bread had shelf life of three months.During an interview on 5/5/2026, at 3:47 p.m., with the Regional Registered Dietitian Nutritionist (RRDN), the RRDN stated, all food items should be dated, labeled, and sealed to prevent contamination and food borne illness. The RRDN stated, sanitizing bucket should contain proper level of concentration of chemical to be effective to kill microorganism.During a review of the facility's Policy and Procedure(P&P) titled, Labeling and Dating of Foods, dated 2023, the P&P indicated, Policy: All food items in the storeroom, refrigerator, and freezer need to be labeled and dated based on established procedures for either food safety or product rotation .Procedure: Food delivered to facility needs to be marked with a delivery or received date .The individual opening or preparing a food shall be responsible for date marking at the time of processing and/or storage .When dating, the day of opening or production are counted as Day 1.During a review of the facility's Policy and Procedure(P&P) titled, Storage of Food and Supplies, dated 2023, the P&P indicated, Policy: Food and supplies will be store properly and in a safe manner. Procedures for dry storage: 7. Remove food from the packing boxes upon delivery. 8. Labels should be visible. All food will be dated. All food products will be used per the time specified in the Dry Food Storage Guidelines. 9. Dry food items which have been opened will be tightly closed, labeled and dated. During a review of the facility's Policy and Procedure(P&P) titled, Procedure for Refrigerated Storage, dated 2023, the P&P indicated, 5. Food should be covered .9. All refrigerated foods are to be kept the amount of time per the Refrigerated Storage Guidelines.During a review of the facility's Policy and Procedure(P&P) titled, Procedure for Freezer Storage, dated 2023, the P&P indicated, Procedure: 5. Store frozen foods in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn .9. Refer to Freezer Storage Guidelines for recommended storage time of foods to ensure product rotation.B. During a concurrent observation and interview on 5/4/2026, at 9:22 a.m., with the DS, the DS tested the concentration of the ammonium in the quaternary sanitizer in red sanitizing bucket near the dishwasher sink. The test strip indicated between 150 parts per million (ppm). The DS stated, the test strip should be indicated 200 ppm to kill bacteria and other microorganisms effectively.During a review of the facility's Policy and Procedure (P&P) titled, Quaternary Ammonium Log Policy, dated 2023, the P&P indicated, Policy: The concentration of the ammonium in the quaternary sanitizer will be tested to ensure the effectiveness of the solution. Procedure: The quaternary solution, used for sanitizing clean work surfaces in the kitchen.The concentration will be tested at least every shift or when the solution is cloudy. The solution will be replaced when the reading is below 200 ppm. The replacement solution will be tested prior to usage.

Based on observation, interview and record review the facility failed to ensure one of one resident's (Resident 84) Ativan (a class IV medication for anxiety [mental health condition characterized by pervasive worry and fear affecting daily life]) was properly stored. The medication was not in a locked container.The failure had potential to result in drug diversion (illegal transfer of prescription medications).Findings:During a review of Resident 84's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 84 was admitted to the facility on [DATE] with diagnosis including nonrheumatic aortic stenosis (age related heart problem).During a review of Resident 84's Minimum Data Set ([MDS] a resident assessment tool), dated 3/31/2026, the MDS indicated Resident 84's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) were severely impaired. The MDS indicated Resident 84 was dependent on staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on 5/5/2026 at 3:09 p.m. with Licensed Vocational Nurse (LVN) 1 in the first floor Medication Room, Resident 84's Ativan was found in the medication refrigerator that was without a lock.During a review of the facility's policy and procedure (P/P) titled, Controlled Medication Storage, 2010, the P/P indicated medications in Schedule IV (drugs or chemicals whose manufacture and possession are strictly regulated by the government due to potential of abuse) are stored under separately locked and permanently affixed compartments separate from other medications.

Based on observation, interview and record review, the facility failed to ensure a person-centered care plan was implemented for two of four sampled residents (Resident 13 and Resident 111) when:Resident 13 needed additional time for dental services and refused to comply with dental personnel during the dental visits.Resident 111 received wound treatment on the left knee incision after surgery.These deficient practices had the potential to negatively affect the quality of life and wellbeing for Resident 13 and Resident 111 and personalized goals and interventions for continued care and treatment.Findings:a. During a review of Resident 13's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 13 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral palsy, failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), and benign prostatic hyperplasia ([BPH], age-associated prostate gland enlargement that can cause urination difficulty).During a review of Resident 13's history and physical (H&P), dated 4/26/2025, the H&P indicated Resident 13 was a poor historian and required monitoring of mental status and neurological checks (a rapid assessment of the brain and nervous system function).During a review of Resident 13's Minimum Data Set ([MDS], a resident assessment tool) dated 1/27/2026, the MDS indicated Resident 13 was moderately impaired in cognitive (thought process) functioning for daily decision making. The MDS indicated Resident 13 was dependent (helper does all the effort to complete the task) with self-care abilities such as eating, hygiene and dressing. The MDS indicated Resident 13 was maximal assistance to (helper does more than half the effort) to dependent with mobility such as rolling, sitting, standing and transfers.During a review of Resident 13's Order Summary Report dated 9/8/2025, the Order Summary Report indicated a dental consultation and treatment as indicated.During a review of Resident 13's dental consult note dated 2/17/2025, the dental consult notes indicated additional time required due to cerebral palsy and that resident had poor cooperation and mouth was unable to stay open for short periods of time for treatment, kept closing and spitting.During a review of Resident 13's dental consult note dated 3/20/2026, the dental consult notes indicated additional time required due to the resident condition that resident was confused and moved his head a lot during the cleaning. Resident closed his mouth constantly and could not open wide for extended time.During a review of Resident 13's comprehensive care plan, undated, the comprehensive care plan did not have a focus of resident needing additional time for dental services due to cerebral palsy with no goals and interventions in place to make sure Resident 13's dental visits go smoothly and no issues with treatments being rendered.During a concurrent interview and record review on 05/07/2026 at 11:27 a.m. with Registered Nurse Supervisor (RNS) 3, the dental consult notes dated 2/17/2025 and 3/20/2026 were reviewed. RNS 3 stated Resident 13 had cerebral palsy and that at times, he may not cooperate with dental personnel when treatments are being rendered. RNS 3 stated there should have been a care plan for dental services if Resident 13 was having an issue during the dental visits. RNS 3 stated a care plan was plan of care for residents on how to monitor and treat the residents. The care plan would see if residents were improving and stable and if not, the care plan would need to be revised to meet the care of residents' needs. RNS 3 stated there should have been a care plan in place for the dental consult visit because Resident 13 was being uncooperative and wouldn't open his mouth during the dental visit. RNS 3 stated there should have been a focus with goal and interventions in place focusing on dental consult visits.b. During a review of Resident 111's Face Sheet, the Face Sheet indicated Resident 111 was admitted to the facility on [DATE] with diagnoses including diagnosis of diabetes mellitus ([DM], a chronic disease that affects how the body processes sugar), chronic kidney disease (gradual loss of kidney function to filter waste and excess fluid from the blood), and depressive disorder (a mental health condition marked by a prolonged low mood and a loss of interest or pleasure in everyday activities).During a review of Resident 111's H&P, dated 4/13/2026, the H&P indicated Resident 111 had the capacity to understand and make decisions.During a review of Resident 111's MDS dated [DATE], the MDS indicated Resident 111 had intact cognitive (thought process) functioning for daily decision making. The MDS indicated Resident 111 required supervision (helper provides verbal cues while resident completes task) to moderate assistance (helper does less than half the effort) with self-care abilities such as eating, hygiene and dressing. The MDS indicated Resident 111 was moderate to maximal (helper does more than half the effort) assistance with mobility such as rolling, sitting, standing and transfers. The MDS indicated Resident 111 had a surgical wound for skin conditions.During a review of Resident 111's Order Summary Report dated 4/14/2026, the Order Summary Report indicated: left knee incision site every day shift for 14 days cleanse with normal saline, pat dry, apply xeroform (a sterile, non-adherent, petrolatum-based mesh gauze used as a primary layer for small draining, open wounds) and cover with dry dressing and completed on 4/28/2026.During a review of Resident 111's comprehensive care plan, undated, there was no care plan with the focus on wound treatment on the surgical incision site with goals and interventions to make sure the surgical site was clean, free from infections and daily dressing change.During a concurrent interview and record review on 5/7/2026 at 12:18 p.m. with Licensed Vocational Nurse (LVN) 6, the Order Summary Report dated 4/14/2026 and the comprehensive care plan undated was reviewed. LVN 3 stated Resident 111 had orders to cleanse with normal saline, pat dry, apply xeroform and cover with dry dressing to be done every day, once a day. LVN 6 stated there was no care plan for treatment orders. LVN 6 stated there should have been a care plan for treatments, so all staff are aware of any changes to the wound site, the staff can go back and update the care plan as needed if the previous treatments were not improving the wound site. LVN 6 stated a care plan was a resident record explaining the problems residents are having, their diagnosis and treatments being done for the residents.During an interview on 5/7/2026 at 3:10 p.m. with the Director of Nursing (DON), the DON stated a care plan is to identify the problems that the residents had, create a goal for the problems or diagnosis to be resolved and the interventions that should be for the problems or diagnosis. The DON stated for Resident 13, there should be a care plan in place for Resident 13 having issues with the dental personnel doing the dental services, interventions in place to help the resident and the dental personnel have safe and effective treatment done. The DON stated there should have been interventions in place for Resident 13 for additional time or if nursing staff needed to step in to help the dental personnel so that they can provide the dental treatment. The DON stated Resident 111 should have a care plan for wound treatment to make sure the interventions being done are effective and if it was not, the care plan would need to be revised as needed. The DON stated interventions in place to are to prevent infection, to provide treatment and care. During a review of the facility's policy and procedure (P&P) titled Comprehensive Resident Centered Care Plan, revised 01/2021, indicated development and implementation of a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.During a review of the facility's P&P titled Comprehensive Person-Centered Care Planning, revised 4/2025, indicated a development and implementation of a comprehensive person-centered, culturally competent, and trauma-informed care plan for each resident within seven days of completion of the MDS and will include resident's needs identified in the comprehensive assessment, any specialized services as a result of PASARR recommendation, and resident's goals and desired outcomes, preferences for future discharge and discharge plan. the resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments.

Based on interview and record review, the facility failed to follow through and accurately assess with the Preadmission Screening and Resident Review (PASARR- a comprehensive evaluation that ensures people who have been diagnosed with serious mental illness, intellectual, and/or developmental disabilities are able to live in the most independent settings while receiving the recommended care and interventions to improve their quality of life) level I and level II evaluation for one of five sampled residents (Resident 2) to determine the facility's ability to provide the special needs of the residents.This failure had the potential to result in Resident 2 being at risk of not receiving the necessary care and services Resident 2 needs.Findings:During a review of Resident 2's Face Sheet (front page of the chart that contains a summary of basic information about the resident) , the Face Sheet indicated, Resident 2 was initially admitted to the facility on [DATE] and last readmission was on [DATE] with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), acute respiratory failure (any condition that affects breathing function and result in lungs not functioning properly) and peripheral vascular disease (PVD- a slow, progressive circulation disorder involving damage to, or narrowing, blockage, or spasms of blood vessels outside the heart and brain).During a review of Resident 2's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 2 did not have the capacity (ability) to understand and make decisions.During a review of Resident 2's Minimum Data Set (MDS-resident assessment tool), dated [DATE], the MDS indicated Resident 2 required dependent assistance (Helper does all of the effort) from two or more staff for transfer, bed mobility, maximal assistance (Helper does more than half the effort) from one staff for personal hygiene, shower, dressing, and supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for eating.During a concurrent interview and record review on [DATE], at 12:40 p.m., with the Director of Nursing (DON), Resident 2's Preadmission Screening and Resident Review (PASARR) level I, dated [DATE] was reviewed. The PASARR level I indicated, Resident 2 had serious mental illness and level II evaluation was required. The PASARR level I indicated, Resident had serious mental disorder and was on Duloxetine (a prescription medication used to treat depression, anxiety) and Geodon [a prescription atypical antipsychotic medication (a class of prescription medications primarily used to manage psychosis symptoms like hallucinations, delusions, and severe confusion) used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs)]. The DON stated, Resident 2 should have Level II done based on Level I assessment.During a concurrent interview and record review on [DATE], at 12:45 p.m., with the DON, Resident 2's Notice of Attempted Evaluation, dated [DATE] was reviewed. The Notice of Attempted Evaluation indicated, unable to completed level II evaluation for serious mental illness because Resident 2 had no serious mental illness. The DON stated, this was conflicting information and she should have reassessed the resident. The DON stated, if the PASARR assessment was incorrectly done, the facility should submit the new one or corrected one. The DON stated, she should have followed through it, but she missed it. The DON stated accurate PASARR assessment was important because resident's care and treatment would be changed or delayed according to PASARR assessment which was very crucial for residents with mental illness.During a review of Resident 2's Care Plan Report (CPR) titled, Resident 2 was positive for PASARR Level II and admitted with diagnosis of depression, revised [DATE], the CPR goal indicated, the resident will be encouraged to be involved in socialization, recreation, or any leisure activities while in the facility by [DATE]. The CPR interventions indicated, educate staff on PASARR Level II status and care approaches tailored to resident's diagnosis and support needs.During a review of Resident 2's Order Summary Report (OSR), dated [DATE], the OSR indicated, psychiatry consult (a comprehensive evaluation conducted by a psychiatrist to assess a patient's mental, emotional, and behavioral health) was ordered on [DATE]. The OSR indicated, give Duloxetine HCL one capsule 30 milligram (mg) delayed release by mouth once a day for depression manifested by verbalization of being depressed was ordered on [DATE].During a review of the facility's Policy and Procedure (P&P) titled, Resident Assessment: PASARR, dated 12/2021, the P&P indicated, POLICY: It is the policy of this facility to ensure that each resident is properly screened using the PASARR specified by the State. PROCEDURES: 1. A PASARR shall be completed on every resident upon admission. 2. Based upon the assessment, the facility will ensure proper referral to appropriate state agencies for the provision of specialized services to residents with ID/RC (Intellectual Disability or Related Condition) or SMI (Serious Mental Illness). 3. Social Services shall contact the appropriate State Agency for referral of specialized care and services the resident may require.

Based on interview and record review the facility the facility failed to:a. To define and monitor resident specific, measurable target behaviors related to use of Depakote for one of five residents sampled for unnecessary medications (Resident 7).b. To ensure there were regular Interdisciplinary Team Conferences to assess for continued need/justification and possible gradual dose reduction (stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of psychotropic medications (medications can alter brain chemistry, impact body functions, and modify a person's thoughts, moods, feelings, awareness, and perceptions) for two out of two residents (Resident 60 and 101) as indicated in facility policy.These failures had the potential to result in unnecessary medications which can cause untoward effects to residents. a. During a review of Resident 7's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted the resident on 11/2/2025 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (mental health condition characterized by excessive, persistent, and uncontrollable fear, dread, or worry that interferes with daily life), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and dementia (a progressive state of decline in mental abilities). During a review of Resident 7's History & Physical (H&P), dated 1/1/2026, the H&P indicated Resident 7 had fluctuating capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool), dated 2/2/2026, the MDS indicated Resident 7 had severe cognitive impairment (an individual who has significant cognitive dysfunction in areas of memory, orientation, and attention). During a concurrent interview and record review on 5/6/2026 at 3:36 p.m. with Registered Nurse Supervisor (RNS) 3, Resident 3's Medication Administration Record (MAR), dated 4/2026, was reviewed. The MAR indicated a physician's order for Depakote (divalproex sodium) oral tablet delayed release 250 milligram (mg – unit of weight), give 250 mg by mouth two times a day for mood disorder manifested (m/b) by mood swings. RNS 3 stated, the indication of mood swings was vague and do not provide a measurable resident-specific indicator for monitoring behavior. RNS 3 stated episodes of mood swings were not monitored in the MAR. RNS 3 stated, inadequate monitoring of episodes (observable behaviors that a medication is intended to treat or manage) for Depakote can result in inaccurate data used to guide gradual dose reduction, potentially leading to continued use of a medication that may no longer be necessary. During an interview on 5/7/2026 at 3:47 p.m. with the Director of Nursing (DON), the DON stated mood swings as the indication for Depakote was vague and does not provide a clear, resident specific parameter for monitoring. The DON stated, without adequate indication and monitoring for Depakote, the medication may be administered to the resident inappropriately, potentially affecting the resident's mental status and resulting in physical restraint. During a review of the facility's policy and procedure (P&P) titled Psychotropic Medications, revised 2/2024, the Psychotropic Medications indicated, The facility's Interdisciplinary [NAME] (IDT) will review to ensure. Monitoring for adverse consequences and effectiveness of medications are in place. b. During a review of Resident 60's Face Sheet, the Face Sheet indicated Resident 60 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (mental health disorder characterized by pervasive feeling of worry affecting daily life), and unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) not due to a substance or known physiological condition. During a review of Resident 60's Minimum Data Set([MDS] resident assessment tool), dated 3/13/2026, the MDS indicated Resident 60's cognition was moderately impaired. During a review of Resident 60's Order Summary Report, active orders as of 5/7/2026, the orders indicated: 1. Duloxetine HCl Capsule Delayed Release Particles (medication used to treat depression, anxiety, and pain) 60 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), one capsule by mouth two times a day. 2. Gabapentin Oral Tablet (medication to treat neuropathy [disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet]) 800 mg, one tablet by mouth every 6 hours. 3. Buspirone HCl Oral Tablet 10 MG (medication to treat anxiety), 2 tablets by mouth one time a day. 4. Trazadone (medication to treat depression) 50 milligrams, one tablet by mouth at bedtime. 5. Monitor episodes of depression as evidenced by verbalization of being depressed every shift. 6. Monitor episodes of anxiety as evidenced by verbalization of being anxious. During a review of Resident 101's admission Record, the admission Record indicated Resident 101 was admitted to the facility on [DATE] with diagnoses including major depressive disorder. During a review of Resident 101's MDS, dated [DATE], the MDS indicated Resident 101's cognition was intact. During a review of Resident 101's Order Summary Report, active orders as of 5/7/2026, the orders indicated: 1. Mirtazapine (medication for depression) Oral Tablet 7.5 mg, one tablet by mouth at bedtime. 2. Nortriptyline (medication for depression) 10 mg, four capsules by mouth at bed 3. Monitor for episodes of depression every evening and night shift. During a concurrent interview and record review on 5/6/2026 at 3:19 p.m. with Registered Nurse Supervisor (RNS) 1, Resident 60 and 101's medical records were reviewed. RNS 1 stated we monitored and documented psychiatric behaviors daily. RNS 1 stated no one tally the behaviors at the end of the month. RNS 1 stated the IDT team does not meet to discuss residents' behaviors. RNS 1 stated the IDT should meet to discuss the residents' daily behaviors monthly, so we know how often the behaviors are being observed. During a concurrent interview and record review with the Director of Nursing (DON) on 5/6/2026 at 4:11 p.m. Resident 101 and 60's medical records were reviewed. The DON stated that the IDT does not meet to discuss the psychiatric behaviors resident manifest to see if treatment needs to be changed or medications need to be altered. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medications, revised 2/2024, the P&P indicated quarterly thereafter, or with significant change of condition, the residents will be calendared by Social Services Director for IDT review to assess for continued need/justification and possible gradual dose reduction.

Based on observation, interview and record review:a) The facility failed to discuss and provide written information on the formulation of advanced directives (a legal document indicating a resident preference about end-of-life treatment decisions) for one of one residents (Resident 125) reviewed.b) The facility failed to ensure that advanced directives for two of three residents (Resident 101 and 132) sampled were included in their respective electronic and physical medical records.These deficient practices infringed on residents' right to be fully informed of their options regarding advanced directives and created a potential for care that conflicts with their expressed wishes.a. During a review of Resident 125's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the facility admitted the resident on 8/1/2022 and was re-admitted on [DATE] indicated diagnoses including morbid obesity (having severe excess of body fat), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertensive heart disease (heart damage caused by long-term, unmanaged high blood pressure). During a review of Resident 125's History & Physical (H&P), dated 4/7/2026, the H&P indicated, Resident 125 had the capacity to understand and make decisions. During a review of Resident 125's Minimum Data Set (MDS - a resident assessment tool), dated 4/13/2026, the MDS indicated, Resident 125 was cognitively intact (an individual who has fully preserved mental functions). During a review of Resident 125's Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life), signed on 10/8/2024, the POLST indicated Resident 125 did not have an AD. During a concurrent interview and record review on 5/6/2026 at 11:40 a.m. with the Social Services Director (SSD), Resident 125 did not have a Social Services Assessment/Evaluation completed within the years from 2025 to 2026. The SSD stated, she provides verbal AD education to residents and written education only upon request. The SSD stated that she does not provide a written acknowledgement form to residents to verify when they receive AD education. The SSD stated, if residents are not provided with AD education, their medical decisions may not be honored in the event of an emergency. During a concurrent interview and record review on 5/7/2026 at 3:37 p.m. with the Director of Nursing (DON), the DON stated, the SSD provides only verbal AD education to residents. The DON stated, if the resident is not provided with AD education, the resident's rights may be violated, and the resident's end-of-life wishes may not be honored if the resident were to become unable to make medical decisions and a representative cannot be identified. During a review of the facility's policy and procedure (P&P) titled Advance Directives and Associated Documentation, revised 4/2025, the Advance Directives and Associated Documentation indicated, .it is the policy of this facility to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. b. During a review of Resident 132's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 132 was admitted to the facility on [DATE] with diagnoses including age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), difficulty walking, and hypertensive heart disease (heart damage). During a review of Resident 132's Advanced Skilled Evaluation, 4/30/2026 at 7:44 p.m., the evaluation indicated Resident 132 was alert and oriented to person place and time. During a concurrent interview and record review with the Social Services Director (SSD) on 5/6/2026 at 12:08 p.m., Resident 132's medical records were reviewed. The SSD stated Resident 132's Social Services Assessment/Evaluation, 4/29/2026 at 4:17 p.m., indicated Resident 132 had an advanced directive. A review of Resident 132's electronic records indicated no advanced directives were uploaded. During a concurrent observation and interview on 5/6/2026 at 12:08 p.m., with the SSD, in Nursing station 1, Resident 132's physical chart was reviewed and Resident 132's medical records did not have copies of the advanced directives. The SSD stated the advanced directive copies needed to be in the medical records, so staff know their wishes. During a review of Resident 101's Face Sheet, the face sheet indicated Resident 101 was admitted to the facility on [DATE] with diagnoses including iliac crest spur on the left hip (bony growth, often caused by chronic inflammation or repetitive stress, resulting in sharp hip pain or a dull ache), type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertensive heart disease. During a review of Resident 101's Minimum data Set ([MDS] resident assessment tool), dated 4/1/2026, the MDS indicated Resident 101's cognition was intact. The MDS indicated Resident 101 needed supervision (helper does verbal cues or touching assistance) with personal hygiene and toileting hygiene. During a concurrent interview and record review with the Case Manager (CM) on 5/7/2026 at 9:14 a.m., Resident 101's medical records were reviewed. The CM stated Resident 101's Social Services Assessment/Evaluation, 3/24/2026, indicated Resident 101 had advanced directives. A review of Resident 101's electronic records indicated no advanced directives were uploaded. During a concurrent observation and interview on 5/7/2026 at 9:14 a.m., with the CM, in Nursing station 1, Resident 101's physical chart was reviewed and Resident 101's medical records did not have copies of the advanced directives. The CM stated the advanced directive copies needed to be in the medical records, so staff know their wishes in case of an emergency. During an interview on 5/7/2026 at 1:10 p.m., the Director of Nursing (DON) stated advance directives need to be in the chart, so we know the residents' wishes. During a review of the facility's policy and procedure (P/P) titled, Advance Directives and Associated Documentation, revised 4/2025, the P/P indicated if an advance directive was completed a copy will be obtained and the documents will be placed in the resident health records.

Based on interview and record review the facility failed to meet the needs for four of eight sample residents (Residents 35, 60, 63, and 123). Resident 35 had not been showered for two weeks, and the call lights (device that allows residents to request assistance from nursing staff) for Residents 60, 63, and 123, were not answered in a timely manner.These deficient practices resulted in delays of care and services, which could negatively impact resident outcomes.Findings:A. During a review of Resident 35's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 35 was admitted to the facility on [DATE] with diagnoses including spondylosis with radiculopathy lumbar region (age- related degenerative changes of the lower back can compress or irritate the nerves), difficulty walking, abnormal posture, blindness of the right eye, generalized muscle weakness, and paraplegia (inability to voluntarily move the lower parts of the body).During a review of Resident 35's Minimum data Set ([MDS] a resident assessment tool), dated 3/31/2026, the MDS indicated Resident 35's cognition was intact. The MDS indicated Resident 35 needed substantial assist (helper does more than half the effort) with showering. The MDS indicated Resident 35 stated that while in the facility choosing between a tub bath, shower, bed bath, or sponge bath was very important.During a concurrent interview and record review on 5/7/2026 at 9:47 a.m. with Licensed Vocational Nurse (LVN) 5, Resident 35's MDS for 3/31/2026 was reviewed. LVN 5 stated Resident 35 needed substantial assistance with showering. The MDS indicated Resident 35 stated that while in the facility choosing between a tub bath, shower, bed bath, or sponge bath was very important.During a concurrent interview and record review on 5/7/2026, at 9:47 a.m. with LVN 5, Resident 35's Documentation Survey Report for 4/8/2026 to 5/6/2026 was reviewed and LVN 5 stated Resident 35 showered 5/5/2026 and the last time Resident 35 showered before that was on 4/21/2026, approximately 2 weeks before. LVN 5 stated staff needed to respect residents' preferences to shower for hygiene reasons. B. During a review of Resident 60's Face Sheet, indicated Resident 60 was admitted to the facility on [DATE] with diagnoses including aftercare (support, care, and treatment) following joint replacement surgery (procedure replaces damaged joint), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of right knee, difficulty walking, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 60's MDS, dated [DATE], the MDS indicated Resident 60's cognition was moderately impaired, and she had the ability to understand others and make herself understood. The MDS indicated Resident 60 needed set-up assistance with eating, oral hygiene, personal hygiene, needed substantial assistance with toileting hygiene, and dependent (helper does all the effort to perform the task) on staff with showering.During an interview on 5/4/2026 at 9:18 a.m. Resident 60 stated call light staff response time was a problem and sometimes she had to wait for 30 minutes.During a concurrent interview and record review on 5/6/2026 at 7:55 a.m. with the Activities Director (AD), the facility's Resident Council Meeting Minutes, 3/4/2026, were reviewed and the AD stated the minutes indicated Resident 60 complained that call lights were not answered in a timely manner.C. During a review of Resident 63's Face Sheet, indicated Resident 63 was admitted to the facility on [DATE] with diagnoses including gastrointestinal stromal tumor (cancer in the stomach or small intestine), difficulty walking, and abnormal posture.During a review of Resident 63s MDS, dated [DATE], the MDS indicated Resident 63's cognition was moderately impaired, and he had the ability to understand others and make himself understood. The MDS indicated Resident 63 needed supervision (helper does verbal cues) with eating, partial assistance (helper does less than half the effort to complete the task) with oral hygiene, personal hygiene, needed substantial assistance with toileting hygiene, and was dependent on staff with showering.D. During a review of Resident 123's Face Sheet indicated Resident 123 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (brain problem), muscle weakness, difficulty walking, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and abnormal posture.During a review of Resident 123s MDS, dated [DATE], the MDS indicated Resident 123's cognition was intact. The MDS indicated Resident 123 was independent with eating, oral hygiene, personal hygiene, and needed supervision with toileting hygiene, and showering.During Resident council meeting on 5/5/2026 at 1:26 p.m. Resident 63 and 123 stated call light response time was a problem, and it was slower than before. Resident 63 and 123 stated the wait times can be as long as 10 minutes and depending on what residents need that 10 minutes can be long.During an interview on 5/7/2026 at 1:22 p.m. with the Director of Nursing (DON), the DON stated call lights need to be answered immediately so staff can attend to the residents' needs. The DON stated it was important to respect residents' preferences and shower a resident if they preferred showers because it was their right.During a review of the facility's policy and procedure (P&P) titled, ADL care, revised 11/2021, the P&P indicated residents unable to carry out activities of daily living will receive assistance as needed.During a review of the facility's P&P titled, Call Light/Bell, revised 5/2023, the P&P indicated call lights will be answered within a reasonable time.

Based on interview and record review the facility failed to ensure two of six sampled residents' (Resident 7 and 60) informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for a psychotropic drug (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) was obtained prior to administration.These deficient practices violated Resident 7 and 60's rights to receive advanced information of risks and benefits of proposed care, treatment, treatment alterative, and choose the alterative of choice which includes information for administration of psychotropic drugs.Findings: a) During a review of Resident 7's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 7 was initially admitted to the facility on [DATE] and last readmission was on 12/30/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (constantly feeling worried and nervous), 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 7's History and Physical (H&P), dated 1/1/2026, the H&P indicated, Resident 7 had fluctuating capacity (ability) to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS-resident assessment tool), dated 2/2/2026, the MDS indicated Resident 7 required maximal assistance (helper does more than half the effort) from one staff for bed mobility, transfer, dressing, toilet hygiene, shower, supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for oral hygiene, personal hygiene, and setup or clean-up assistance (Helper sets up or cleans up) from one staff for eating. During a concurrent interview and record review on 5/6/2026, at 3:44 p.m., with Registered Nurse Supervisor (RNS) 3, Resident 7's Psychotherapeutic Drug (prescription substances that affect the mind, emotions, and behavior by altering chemical levels in the brain) Informed Consent Form, dated 12/20/2025 was reviewed. The Psychotherapeutic Drug Informed Consent Form indicated, Depakote (a prescription medication used to treat bipolar disorder) 250 milligrams (mg) by mouth twice a day for mood disorder manifested by sudden angry outburst was ordered. The Psychotherapeutic Drug Informed Consent Form indicated that the section for either consent to treatment or decline the treatment was not documented and there was no information regarding signature of the person gave consent, relationship to the resident, date of the consent given were missing. The Psychotherapeutic Drug Informed Consent Form indicated, there was signature of licensed nurse who obtained telephone consent, but there was no name of the licensed nurse documented. RNS 3 stated that the informed consent for Depakote was not completed because of missing information. RNS 3 stated, the check box for consent or decline the treatment was left blank and she did not know if the resident or RP gave the consent to take Depakote. RNS 3 stated that the consent form should be completed prior to the start of administrating medication. During a concurrent interview and record review on 5/6/2026, at 4:25 p.m., with the Director of Nursing (DON), Resident 7's Psychotherapeutic Drug Informed Consent Form, dated 2/20/2026 was reviewed. The Psychotherapeutic Drug Informed Consent Form indicated, Quetiapine Fumarate [Seroquel- a prescription medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar] 50 mg at bedtime by mouth for psychosis manifested by sudden angry outburst was ordered. The Psychotherapeutic Drug Informed Consent Form indicated, phone consent was obtained from RP, but the check box for consent to treatment or decline the treatment, and the date of telephone consent was not documented. The DON stated, there was old consent for Quetiapine Fumarate on 12/30/2025, but she tried to get new consent due to changes in monitoring target behavior. The DON stated, the consent form was not completed because of missing information, and this would increase the risk that Resident 7 or RP may not be able to exercise the right to opt out of treatment with psychoactive medications. The DON stated this could cause Resident 7 to experience side effects related to psychoactive use which could possibly lead to a decline in Resident 7's quality of life. During a review of Resident 7's Order Summary Report (OSR), dated 5/7/2026, the OSR indicated, give one tablet Quetiapine Fumarate 50 mg by mouth at bedtime for psychosis manifested by sudden angry outburst was ordered on 12/30/2025. The OSR indicated, give 250 mg Depakote tablet by mouth twice a day for mood disorder manifested by sudden angry outburst was ordered on 12/30/2025 and modified on 5/6/2026. During a review of the facility's Policy and Procedure(P&P) titled, Care Treatment: Informed Consent, revised 5/2019, the P&P indicated, POLICY: It is the policy of this facility that resident rights are not violated and a copy of these rights and pertinent policies are made available to the resident and to any representative of the resident . 2. Physician's orders related to the use of psychotherapeutic drug and physical restraints should not be initiated until an informed consent is obtained. During a review of the facility's Policy and Procedure(P&P) titled, Psychotropic Medications, revised 2/2024, the P&P indicated, Procedure: 7. The facility's Interdisciplinary Team (IDT) will review to ensure: Informed consent was obtained prior to medication use and every 6 months thereafter. 8. Upon change of condition or initiation of a new order for psychoactive medications, the facility will obtain consent prior to the initiation of the new medication. b) A review of Resident 60's Face Sheet, the Face Sheet indicated Resident 60 was admitted to the facility on [DATE], with diagnoses including aftercare (support, care, and treatment) following a joint replacement surgery (procedure replaces damaged joint), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (mental health disorder characterized by pervasive feeling of worry affecting daily life), and unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) not due to a substance or known physiological condition. During a review of Resident 60's Minimum Data Set([MDS] resident assessment tool), dated 3/13/2026, the MDS indicated Resident 60's cognition was moderately impaired, and she had the ability to understand others and make herself understood. The MDS indicated Resident 60 needed set-up assistance with eating, oral hygiene, personal hygiene, needed substantial assistance (helper does more than half the effort to complete the task) with toileting hygiene, and was dependent (helper does all the effort to perform the task) on staff with showering. During a review of Resident 60's Order Summary Report, (active orders as of 5/7/2026), the order indicated that starting on 3/6/2026: 1. Duloxetine HCl Capsule Delayed Release Particles (medication used to treat depression, anxiety, and pain) 60 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), one capsule by mouth two times a day. 2. Gabapentin Oral Tablet (medication to treat neuropathy [disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet]) 800 mg, one tablet by mouth every 6 hours. During a concurrent interview and record review with the Director of Nursing (DON) on 5/7/2026 at 4:11 p.m., Resident 60's medical records were reviewed. The DON stated Resident 60 did not have an informed consent for Gabapentin and Duloxetine and indicated that the informed consent should be obtained prior to the administration of psychotropic medications. During a review of the facility's policy and procedure (P/P) titled, Psychotropic Medications, revised 2/2024, the P&P indicated psychotropics were any drugs that affect brain activities associated with mental process and behavior. The P/P indicated a consent will be obtained prior to the initiation of new medication. During a review of the facility's P/P titled, Informed Consent CA, revised 5/2019, the P/P indicated it was the residents right to receive in advance all information that is material to a decision to accept or refuse treatment. The P/P indicated the use of psychotropics should not be initiated until an informed consent was obtained.

Based on observation, interview, and record review, the facility failed to protect resident's privacy and dignity for one of one sample resident (Resident 1) while Resident 1 was urinating.This failure has the potential to result in compromised the resident's dignity and privacy, embarrassment and unwanted expose to others while urinating.Findings:During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted Resident 1 on 7/8/2020 and readmitted on [DATE] with diagnoses including pneumonitis (inflammation of the lungs when the tiny air sacs inside them become swollen and irritated), type 2 diabetes mellitus (condition in which the body does not metabolize blood sugar correctly) and major depressive disorder (mood disorder that causes persistent feeling of sadness and loss of interest).During a review of Resident 1's History and Physical (H&P), dated 12/30/2025, the H&P indicated Resident 1 had the ability to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 2/12/2026, the MDS indicated Resident 1's cognitive (functions your brain uses to think, pay attention, process information, and remember things) was mildly impaired. The MDS indicated Resident 1 required supervision assistance (helper provides verbal cues and/ or touching/ steadying and/or contact guard assistance as resident completes activity) with [NAME], moderate assistance (helper does less than half the effort to complete the task) with personal hygiene, and maximal assistance (helper does more than half the effort to complete task) with toileting hygiene.During an observation on 5/4/2026 at 12:50 p.m. in front of Resident 1's room, the resident was observed sitting in bed using the urinal between his legs. The resident pulled the urinal out, resulting in exposure to the private area while holding the urinal. Certified Nurse Assistant (CNA) 3 entered the room at the time. Resident 1 stated others could not see because there was a table positioned in front of the resident. Resident 1 stated a preference for the room door to remain closed except while eating.During a concurrent interview and record review on 5/6/2026 at 11:12 a.m. with Registered Nurse (RNS, unit manager) 3, Resident 1's Care Plan for activities of daily living (ADL, basic activities such as eating, dressing, toileting) self-care performance deficit, revised 7/14/2025 was reviewed. RNS 3 stated the facility included an intervention on 5/4/2026 which Resident prefers to have privacy curtain open and door while using urinal. RNS 3 stated the care plan was not acceptable, even if a resident prefers to exposure, the facility was still responsible for implementing reasonable interventions to protect the resident's privacy and dignity, as well as the privacy of others, while honoring the resident's preferences.During an interview on 5/6/2026 at 11:31 a.m. with Licensed Vocational Nurse (LVN)3, LVN 3 stated CNA 3 informed her that Resident 1's private area was exposed while urinating on 5/4/26. There is no documentation indicating that alternative interventions were attempted to protect Resident 1's dignity while honoring the resident's preferences.During an interview on 5/6/2026 at 2:56 p.m. with Certified Nurse Assistant (CNA) 3, CNA 3 confirmed Resident 1 did not want others to see his private area, and any reasonable person would likely respond the same way.During an interview on 5/7/2026 at 11 a.m. with the Director or Nursing (DON), the DON stated the facility should provide privacy and dignity while Resident 1 was exposing his private part for urination on the bed. The facility needs to protect residents' privacy and dignity while respecting or honoring their preferences as part of their rights. During a review of the facility's Policy and Procedure (P&P) titled Resident Right, dated 11/2021, the P&P indicated the facility should treat all residents with kindness, dignity and respect. The P&P indicated privacy of a resident's body shall be maintained during toileting, bathing and other activities of personal hygiene, except when staff assistance is needed for the resident's safety.

Based on observation, interview, and record review, the facility failed to ensure proper urinary indwelling catheter care for one of one sampled resident, (Resident 80) by failing to:1.) Ensure the indwelling catheter (a soft, thin tube that goes into your bladder so urine can drain out and into a bag outside your body) drainage bag was off from the floor.2.) Ensure the indwelling catheter drainage bag was below the bladder level during the care.This failure had the potential to cause urine backflow into the resident's bladder, increasing the risk for urinary tract infections (UTI- an infection the bladder/urinary tract) and indwelling catheter-related complications.Findings:During a review of Resident 80's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted Resident 80 on 11/26/2025 and readmitted [DATE] with diagnoses including acute posthemorrhagic anemia (a type of anemia that happens when you lose a lot of blood quickly, and causes a problem in the pee system that stops urine from leaving the body and can cause it to go backward into the kidneys).During a review of Resident 80's History and Physical (H&P), dated 4/1/2026, the H&P indicated the resident did not have the capacity to understand and make decisions.During a review of Resident 80's Minimum Data Set (MDS- a resident assessment tool), dated 4/5/2026, the MDS indicated Resident 80's capacity was severely impaired. The MDS also indicated Resident 80 was dependent (helper does all the effort) on staff with eating, oral hygiene, toileting hygiene, and showering.During a review of Resident 80's Order Summary Report, orders as of 5/4/2026, the Order Summary Report indicated starting 3/30/2026, placing an indwelling catheter to closed drainage system.During a review of Resident 80's Care Plan for Foley Catheter due to Obstructive Uropathy, revised 4/23/2026, the Care Plan indicated Resident 80 was at high risk for UTI and the Care Plan's interventions included to position the indwelling catheter drainage bag and tubing below the bladder level.During a concurrent observation interview on 5/4/2026 at 10:14 a.m. in Resident 80's room, with Certified Nurse Assistant (CNA) 1, Resident 80's urine drainage bag was observed touching the floor. CNA 1 confirmed and stated the urine drainage bag was on the floor; and it should be kept off the floor for infection control.During an observation on 5/6/2026 at 10:13 a.m. in Resident 80's room with Occupational Therapy Assistance (OTA) 1 and Physical Therapist (PT)1, OTA 1 was observed on his right side, holding the resident's urine drainage bag in the air above the resident's bladder level while PT 1 was repositioning the resident, then placed the urine bag between his legs while assisting him to sit up.During an interview on 5/6/2026 at 10:36 a.m. with PT 1 and OTA 1, PT 1 confirmed OTA 1 kept Resident 80's urine drainage back above bladder level when repositioning him.During an interview on 5/7/2026 at 11:40 a.m. with the Director or Nursing (DON), the DON stated staff were expected to always maintain the urine drainage bag off from the floor for infection control and below the bladder level to prevent urine backflow. The DON stated this practice could increase the risk of infection, including UTI.During a review of the facility's procedure and policy(P&P) titled Catheter Care, Indwelling, revised 7/2013, the P&P indicated this P&P is to promote hygiene and decrease risk of infection for catheterized residents. The P&P also indicated staff should keep tubing below level of bladder.

Based on observation, interview and record review the facility failed to:a. Ensure one of four residents received the correct dose of their pain medication (Resident 53). b. Ensure an emergency kit ([E-kit] receptacle that includes medications that need to be administered when pharmacy services are not available) was replaced after being used for Resident 4.These failures have the potential to result in medication errors. a.) During a review of Resident 53's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility originally admitted the resident on 7/3/2016, and was readmitted on [DATE] with diagnosis including fibromyalgia (chronic disorder characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive difficulties), headaches with orthostatic component (headaches that develop within 30 seconds of standing or sitting upright and improve while lying down), age-related osteoporosis without current pathological fracture (a fracture caused by low-trauma, such as a fall from standing height, resulting from weakened bone density), arthropathy (any disease or abnormality affecting a joint, including arthritis, injuries, and degenerative conditions), Unspecified Symptoms of synovitis and tenosynovitis of the right upper arm (inflammation of a tendon and its sheath in the right upper arm, where the specific cause or underlying condition is not explicitly named During a review of Resident 53's Minimum Data Set (MDS), dated [DATE], indicated, Resident 53's cognitive skills for decision making were without impairment. During an observation on 5/7/2026 at 9:21 a.m, in Resident 53's room, Licensed Vocational Nurse (LVN) 2 administered 500 milligram (mg, unit of weight) of Acetaminophen to Resident 53. Resident 53 informed LVN 2 that she was experiencing 9/10 generalized pain and needed medication for pain relief. LVN 2 offered Resident 53 Norco (pain medication ordered for 9/10, moderate to severe pain) for her level of pain. Resident 53 refused and asked for one tablet of Acetaminophen (Tylenol). LVN 2 administered one tablet of Acetaminophen 500 milligrams (mg, unit of weight) per Resident 53's request. During an Interview on 5/7/2026 at 11:58 a.m., with LVN 2, LVN 2 stated she did not follow Resident 53's medication orders for pain. LVN 2 stated because she did not administer the correct dose, Resident 53 could continue to experience pain. During a concurrent interview and record review on 5/7/2026, at 11:58 a.m. with LVN 2, Resident 53's Order Summary Report dated 3/20/2026 was reviewed. Resident 53 had two active medication orders, as needed (PRN) for pain relief. The Order Summary Report indicated, Norco oral tablet 10-325 mg, give one tablet by mouth every 6 hours as needed for severe 8-10 pain, not to exceed 3 grams in 24 hours and Acetaminophen oral tablet give 1000 mg by mouth every 8 as needed for pain 1-3, not to exceed 3 grams in 24 hours from all sources. During a concurrent interview and record review on 5/7/2026, at 11:58 a.m., with LVN 2, Resident 53's Medication Administration Record (MAR) dated 5/7/2026, was reviewed. The MAR indicated LVN 2 administered Acetaminophen (Tylenol) to Resident 53 at 9:18am. LVN 2 stated she should have given Norco to the resident as ordered for a pain level of 8-10 and if the resident refused, she should have notified the physician before administering the incorrect dose to Resident 53. During an interview on 5/7/2026 at 1 p.m. the Director of Nursing (DON) stated following physician orders was important and nurses cannot adjust dosages without physician order. During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration, dated 2010, indicated, Medications are administered as prescribed in accordance with good nursing principles and practices. b.) During a review Resident 4's Face Sheet, the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with a diagnosis including type 2 diabetes (disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 4's Minimum Data Sheet ([MDS] resident assessment tool), 4/4/2026, the MDS indicated the resident's cognition (thought process) was moderately impaired. The MDS indicated Resident 4 needed partial assistance (helper does less than half the effort to complete the task) with eating, oral hygiene, and personal hygiene. During a review of Resident 4's Order Listing Report, the order indicated insulin lispro (medication for diabetes) injection solution 100 units (unit of measurement) inject as per sliding scale (method of dosing insulin based on pre-meal blood glucose levels). During a concurrent observation and interview on 5/5/2026 at 9:03 a.m. with Registered Nurse supervisor (RNS) 2 in the first-floor medication room, an E-kit was observed opened. RNS 2 stated that the E-kit was used for Resident 4. During a concurrent interview and record review on 5/5/2026 at 9:03 a.m. with RNS 2, the E-kit Usage slip was reviewed, RNS 2 stated the E-kit was accessed on 4/28/2026 for Resident 4 and 8 units of insulin lispro removed. During an interview on 5/5/2026 at 9:10 a.m. with RNS 1, RNS 1 stated the E-kit was replaced on 5/4/2026. RNS 1 stated it should have been replaced sooner in case the medication was needed again. During a review of the facility's policy and procedure (P/P) titled, Emergency Pharmacy Service and Emergency Kits, 2012. The P/P indicated that when an E-kit is used the pharmacy needs to be notified and the kit replaced within 72 hours.

Based on interview and record review, the facility failed to address the consultant pharmacist's recommendations to clarify the behavior manifestation for Seroquel [ a prescription medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs)] on 3/6/2026 and to consider a gradual dose reduction (GDR - a periodic attempt to manage a resident's behavioral issues with a lower dose of medication) for Depakote (a prescription medication used to treat bipolar disorder) on 4/19/2026 during the Medication Regimen Review (MRR - a monthly report from the consultant pharmacist identifying any medication irregularities in a resident's current medication regimen) for one of five resident (Resident 7).This failure had the potential to result in failing to ensure the physician evaluated and responded to medication irregularities (potential issues with a resident's medication regimen) identified by the consultant pharmacist during the MRR increased the risk that Resident 7 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to the medication therapy and inadequate monitoring of the behavior possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status.Findings:During a review of Resident 7's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 7 was initially admitted to the facility on [DATE] and last readmission was on 12/30/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (constantly feeling worried and nervous), 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 7's History and Physical (H&P), dated 1/1/2026, the H&P indicated, Resident 7 had fluctuating capacity (ability) to understand and make decisions.During a review of Resident 7's Minimum Data Set (MDS-resident assessment tool), dated 2/2/2026, the MDS indicated Resident 7 required maximal assistance (helper does more than half the effort) from one staff for bed mobility, transfer, dressing, toilet hygiene, shower, supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for oral hygiene, personal hygiene, and setup or clean-up assistance (helper sets up or cleans up) from one staff for eating.During a concurrent interview and record review on 5/7/2026, at 11:16 a.m., with Registered Nurse Supervisor (RNS) 3, Resident 7's Consultant Pharmacist's Medication Regimen Review (MMR), dated 3/6/2026 was reviewed. The MMR indicated, monitoring behavior of sudden angry outburst for Seroquel may be seen as vague and subjective. The MRR indicated that it should be clarified and specific to Resident 7's condition. RNS 3 stated, she was not sure this recommendation was addressed by licensed staff. RNS 3 stated there was no documentation or evidence to prove that it was carried out. RNS 3 stated, the staff were monitoring sudden angry outburst as the target behavior for Seroquel use. RNS 3 stated that the licensed nurse who received the pharmacist recommendation should have acted upon it.During a concurrent interview and record review on 5/7/2026, at 3:17 p.m., with the Director of Nursing (DON), Resident 7's Consultant Pharmacist's Medication Regimen Review (MMR), dated 4/19/2026 was reviewed. The MRR indicated, Resident 7 was on Depakote 250 milligram (mg) twice a day from 12/30/2025 and GDR was required to be attempted. The MRR indicated that if the physician disagreed with the GDR, rational and clinical indication should be documented. The MRR indicated, the physician marked as disagreed and signed without documenting the rational or indication and date of review. The DON stated, the staff or she should have followed through the physician's response regarding consultant pharmacist's recommendation of GDR. The DON stated that the facility did not do behavioral Interdisciplinary team meeting (IDT meeting- a structured, collaborative session where professionals from diverse fields such as medicine, nursing, therapy, and social work interdependently coordinate care, share expertise, and develop a single, integrated plan for residents). The DON stated, GDR and determination of target behaviors were up to psychiatric practitioners (a medical practitioner who specializes in psychiatry-the branch of medicine dedicated to the diagnosis, treatment, and prevention of mental disorders). The DON stated there is no record of a specific response to the pharmacist's request or any other record that addresses the dosage of Depakote specifically and the resident has been on the same dose since December of 2025. The DON stated the facility failed to decrease the dose or document a dosage reduction would be contraindicated for resident-specific reasons. The DON stated the failure to consider a GDR or respond to the pharmacist's request for GDR increased the risk that Resident 7 may have experienced adverse effects of Depakote, such as increased sedation, due to using a higher dose than necessary which could have negatively impacted her quality of life.During a review of Resident 7's Order Summary Report (OSR), dated 5/7/2026, the OSR indicated, give one tablet Quetiapine Fumarate 50 mg (Seroquel) by mouth at bedtime for psychosis manifested by sudden angry outburst was ordered on 12/30/2025. The OSR indicated, give 250 mg Depakote tablet by mouth twice a day for mood disorder manifested by sudden angry outburst was ordered on 12/30/2025 and modified on 5/6/2026.During a review of the facility's Policy and Procedure(P&P) titled, Medication (Drug) Regimen Review (MRR), revised 4/2025, the P&P indicated, Policy: It is the policy of this facility that the drug regimen of each resident will be reviewed at least once a month by a licensed pharmacist. A medication regimen review (MRR) includes a review of the resident's medical chart. Identified irregularities will be documented on a separate written report that includes the resident's name, the relevant drug, and the irregularity identified. The report will be sent to the attending physician, the facility's Medical Director and the Director of Nursing Services (DNS) to be acted upon . Procedure: 1. The pharmacist reviews each resident's medication regimen at least once a month to identify irregularities and to identify clinically significant risks and/or adverse consequences resulting from or associated with medications .3. The MRR includes identification of irregularities, medication-related errors, adverse consequences, and use of unnecessary drugs. 4. a. MRR recommendations to physicians: The report is provided by the Pharmacist or facility to the physician responsible, facility's Medical Director and the Director of Nursing Services within seven (7) working days of review. Communication and physician response will be documented in the clinical record, along with any new orders or changes to medication regimen. The attending physician will document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is no change in the medication, the attending physician will document his or her rationale in the resident medical record . b. Nursing Documentation Review: The report is provided by the Pharmacist within seven (7) working days of review. Nursing personnel will provide a written response to the review.

Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills such as :A. [NAME] (CK) 1 failed to follow the meal ticket for Resident 67 during the trayline (an assembly line system used in nursing homes and institutional food services to prepare and assemble patient or resident meal trays).B. [NAME] (CK) 2 and Dietary Supervisor (DS) failed to verbalize substitute fortified food items for cheese for Resident 67.These failures had potential to result in Resident 67 not receiving fortified diets as prescribed and Resident 67's food preference was not honored to prevent weight loss.Findings:A. During a review of Resident 67's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 67 was initially admitted to the facility on [DATE] and last readmission was on 10/24/2024 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and chronic kidney disease (gradual loss of kidney function to filter waste and excess fluid from the blood).During a review of Resident 67's History and Physical (H&P), dated 4/12/2026, the H&P indicated, Resident 67 had the capacity (ability) to understand and make decisions.During a review of Resident 67's Minimum Data Set (MDS-a resident assessment tool), dated 2/17/2026, the MDS indicated Resident 67 required dependent assistance (Helper does all of the effort) from two or more staff for toilet hygiene, maximal assistance (Helper does more than half the effort) from one staff for shower, moderate assistance (Helper does less than half the effort) from one staff for dressing, personal hygiene, bed mobility, transfer, and independent for eating.During a concurrent observation and interview on 5/5/2026, at 11:51 a.m. during the trayline for lunch, CK 1 placed shredded cheese on Resident 67's plate and extra shredded cheese on small plate as a side dish in Resident 67's tray. The meal ticket indicated, Resident 67 disliked cheese. Resident 67's tray was placed in the lunch cart. CK 1 stated, she failed to check the meal ticket by adding cheese on plate and extra cheese on side plate. CK 1 stated, she should have reviewed and followed the meal ticket.During a review of Resident 67's Order Summary Report (OSR), dated 5/7/2026, the OSR indicated, provide regular texture diet with thin liquids consistency, fortified, Lactose-free (eliminates foods containing lactose, a sugar found in milk and dairy products, primarily to manage symptoms of lactose intolerance like bloating, gas, and diarrhea), extra gravy/sauce with meal was ordered on 4/11/2026.During a review of Resident 67's Care Plan Report (CPR) titled, Resident 67 was at risk for weight loss and dehydration, revised 4/21/2026, the CPR goal indicated, Resident 67 will maintain adequate nutritional status as evidenced by maintaining weight by 6/8/2026. The CPR Interventions indicated, provide and serve diet as ordered by the physician (REGULAR diet, REGULAR texture, THIN LIQUIDS consistency, Fortified).During a review of CK 1's Verification of Job Competency Demonstration, dated 1/28/2026, the Verification of Job Competency Demonstration indicated, CK 1 was able to demonstrate or verbalize use of the meal ticket. The Verification of Job Competency Demonstration checklist did not specifically indicate competencies for follow-through the meal ticket.B. During an interview on 5/5/2026, at 12:26 p.m., with CK 2 in the kitchen, CK 2 stated, today's menu was tacos with beans and cheese, which was the fortified item. CK 2 stated, she was not sure what substitute fortified items could be used if the residents were not able to eat cheese. CK 2 stated, she would use butter as fortified item if the residents were allergic to dairy products. CK 2 stated, she should have known what substitute food items could be used for fortified diet.During an interview on 5/5/2026, at 12:30 p.m., with the DS in the kitchen, the DS stated, he could not recall what substitutes food items for fortified diet could be used instead of cheese. The DS stated, if the residents were allergic to dairy products, he would take out the cheese, but he could not think of the substitutes for cheese. The DS stated, fortified diet was to add extra calories preventing weight loss. The DS stated he should have known the substitutes for cheese because there were residents who could be Lactose intolerant or allergic to dairy products.During an interview on 5/5/2026, at 4:45 p.m., with Resident 67 in her room, Resident 67 stated, she did not like to eat cheese because it caused her stomach to hurt really bad. Resident 67 stated, she could eat some dairy products such as cottage cheese, but most of the dairy products caused her stomach to ache. Resident 67 stated, she received dairy products in tray several times in the past and did not eat the meal. Resident 67 stated, she could not understand why the kitchen staff did not follow the meal ticket which contained her likes and dislikes.During an interview on 5/7/2026, at 11:36 a.m., with the Registered Dietitian Nutritionist (RDN) assigned to the facility, the RDN stated, the meal ticket contained the resident's preference of food, allergies, diet order, and preferred dining location. The RDN stated, staff should have read the meal ticket and follow through to avoid giving food items that might cause adverse health effects or dishonoring resident's preference. The RDN stated it was important to provide fortified diets as ordered to prevent weight loss by adding extra calories. The RDN stated that the staff should have knowledge of substitutes for fortified items according to health conditions and allergies. The RDN stated the staff should have known where they could find information regarding fortified food items at least.During a review of CK 2's Verification of Job Competency Demonstration, dated 1/28/2026, the Verification of Job Competency Demonstration indicated, CK 2 was able to demonstrate or verbalize fortification of food per menu. The Verification of Job Competency Demonstration checklist did not specifically indicate competencies for the list of fortified food item substitutes. During a review of the facility's Policy and Procedure (P&P) titled, Fortification of Food: Increasing Calories and /or Protein in the Diet, dated 2023, the P&P indicated, Purpose: The goal is to increase the calorie and/or protein density of the foods commonly consumed by the resident to promote improvement in their nutrition status. Procedure: Calories and /or protein will be added to selected foods. The facility Registered Dietitian or FNS Director will select the fortification method from the list provided for foods. Adding Calories by extra margarine, extra gravy and sauce, half and half, extra mayonnaise, and high calorie cereal topping.During a review of the facility's Policy and Procedure (P&P) titled, Fortified Diet, dated 2023, the P&P indicated, Description: The fortified diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status . examples of adding calories include: extra margarine, butter, gravy, non-dairy creamer, half and half, mayonnaise, jelly, shipped topping, chocolate sauce, cheese.During a review of the facility's Policy and Procedure (P&P) titled, Job Description Dietitian, dated 12/27/2021, the P&P indicated, Essential Duties and Responsibilities: Review therapeutic and regular diet plans and menus to assure they are in compliance with the physician's orders.During a review of the facility's Policy and Procedure (P&P) titled, Job Description Dietary Supervisor, dated 12/27/2021, the P&P indicated, Essential Duties and Responsibilities: Review the dietary requirements of each resident admitted to the facility, as may be required, and assist the attending physician in planning for the resident's prescribed diet plan. Review diet plans and menus to assure they are in compliance with the physician's orders . Assures all Dietary staff complete required compliance training and processes.

Based on interview, and record review, the facility failed to ensure the resident, who had diagnosis of type 2 diabetes [a disorder characterized by difficulty in blood sugar control and poor wound healing]) and was receiving blood sugar lowering medication, had blood sugar monitoring to ensure the effectiveness of Empagliflozin (medication to lower blood sugar) and to prevent the resident from having hyperglycemia (level of glucose (blood sugar) in the blood is abnormally high) leading to diabetic ketoacidosis (life-threatening complication of diabetes that occurs when the blood sugar levels are too high and untreated for a prolonged length of time) for one of 3 sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 ' s Medical Doctor (MD) ordered Resident 1 ' s blood glucose monitoring to ensure the Empagliflozin (blood sugar level regulating medication) was effective and to prevent Resident 1 from developing hyperglycemia or hypoglycemia (occurs when the blood glucose [simple sugar-body ' s primary source of energy/food] level drops below the level the body can function with normally). 2. Ensure the Nurse Practitioner (NP) had knowledge of Resident 1 ' s diagnosis of type 2 diabetes (diabetes mellitus) and ordered Resident 1 ' s blood glucose (sugar) monitoring. 3. Ensure Licensed Vocational Nurse (LVN) 3 was aware of Resident 1 ' s diagnosis of type 2 diabetes to deliver care, accordingly, including monitoring the resident for signs and symptoms of hyperglycemia or hypoglycemia. 4. Ensure LVN 1 and LVN 3 contacted Resident 1 ' s MD to alert the MD of the lack of an order for Resident1 ' s blood glucose monitoring. 5. Ensure the Director of Nursing (DON) clarified Resident 1 ' s orders with Resident 1 ' s MD and NP to ensure Resident 1 was properly monitored for blood glucose level to prevent the resident from developing hyperglycemia or hypoglycemia. 6. Ensure the licensed nurses developed a plan of care for Resident 1 ' s diagnosis of diabetes and intake of Empagliflozin, blood glucose lowering medication, to have interventions in place for resident ' s glucose monitoring and signs and symptoms of hyperglycemia or hypoglycemia. 7. Ensure staff followed the facility ' s policy and procedure (P&P) titled, Diabetes Mellitus, Resident, Nursing Care of revised November 2017, which indicated the policy of the facility was to recognize and assist in the treatment of complications commonly associated with diabetes. The policy indicated the facility will document pertinent laboratory studies including blood sugar. On 12/17/2024, Resident 1 was transferred via 911 (emergency medical transportation) due to altered level of consciousness (not fully responsive to environment) to the General Acute Care Hospital (GACH) where he was found to have a blood sugar level of 595 milligrams per deciliter ([mg/dl -unit of measurement]; reference range 70 mg/dl to 99 mg/dl) upon admission with the diagnosis of diabetic ketoacidosis (life-threatening complication of diabetes that occurs when the blood sugar levels are too high and untreated for a prolonged length of time). This deficient practice resulted in Resident 1 having an altered level of consciousness due to very high blood sugar levels leading to diabetic ketoacidosis which had the potential to lead to a diabetic coma (a condition when the body is overwhelmed with the amount of blood sugar levels, and the resident cannot wake up or respond purposefully to the environment) and death. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, occlusion and stenosis (blockage) of left carotid artery (vessel that supplies head and neck with blood) and atherosclerotic heart disease (blockages in vessels that supply the heart with blood). During a review of Resident 1's Minimum Data Set ([MDS] -resident assessment tool), dated 12/17/2024, the MDS indicated Resident 1 ' s cognitive (the mental process of thinking, learning, remembering, and using judgement) skills for daily decision-making were moderately impaired. During a review of Resident 1's Order Summary Report (physician ' s orders), dated 12/12/2024, the Order Summary Report indicated an order for Empagliflozin Oral Tablet 10 milligrams ([mg]-unit of measurement) one tablet daily for diabetes mellitus. During a review of Resident 1 ' s Medication Administration Record (MAR) dated from 12/1/2024 through 12/31/2024, the MAR indicated Empagliflozin 10 mg was administered on 12/12/2024, 12/13/2024, 12/15/2024, 12/16/2024 and 12/17/2024 as ordered. During a review of Resident 1 ' s Change of Condition (COC), dated 12/17/2024 and timed at 1:54 p.m., the COC indicated Resident 1 had signs and symptoms of altered mental status (a significant change in mental function), hypotension (low blood pressure [force exerted by your blood pushing against the walls of your arteries as your heart pumps blood throughout your body]) and hyperglycemia . The COC indicated Resident 1 ' s systolic blood pressure [pressure of blood in your arteries when the heart beats] was 90 millimeters of mercury ( [mmHg - unit of measure] reference range 90 -120mm Hg). The COC indicated the facility staff notified Resident 1 ' s NP and the NP ordered for Resident 1 to be transferred to the GACH via 911. During a review of Resident 1 ' s MAR dated 12/17/2024, the MAR indicated a physician ' s order dated 12/17/2024 and timed at 2:04 p.m. to give Lispro Insulin (quick acting medicine used to lower blood sugar) 15 Units (unit of measurement) STAT (immediately) for hyperglycemia one time only. During a review of Resident 1 ' s Follow up Skilled NP Progress Notes, dated 12/17/2024 and timed at 1 p.m., the Skilled NP ' s Progress Notes indicated Resident 1 was hyperglycemic, when the residents ' blood sugar level was checked and 15 units of Lispro insulin was administered but Resident 1 ' s blood sugar remained high (unspecified) after administration and Resident 1 was lethargic (a state of being drowsy and dull, listless, unenergetic, indifferent, sluggish and inactive) with blood pressure at 71/56 mmHg. The Skilled NP Progress Notes indicated nursing staff was advised to transfer Resident 1 via 911 to the GACH. During a review of Resident 1 ' s GACH emergency room Note, dated 12/17/2024 and timed at 2:08 p.m., the GACH emergency room Note indicated Resident 1 was sent to the GACH from the facility due to high blood sugar (unspecified), causing diabetic ketoacidosis and low blood pressure of 81/45. The GACH emergency room Note indicated Resident 1 ' s blood glucose level on 12/17/2024 at 2:30 p.m., was 595 mg/dl (reference range 70 mg/dl to 99 mg/dl). The note indicated Resident 1 was admitted with the diagnosis of diabetic ketoacidosis. During an interview on 1/28/2025 at 11:50 a.m., Licensed Vocational Nurse (LVN) 3 stated, on 12/17/2025 she was assigned to care for Resident 1. LVN 3 stated on 12/17/2024 Resident 1 ' s caregiver called her to Resident 1 ' s bedside. LVN 3 stated upon arrival to Resident 1 ' s room, Resident 1 appeared to have a decreased level of consciousness. LVN 3 stated, the care giver asked her (LVN 3) what Resident 1 ' s blood sugar readings were. LVN 3 stated, she informed the care giver she did not know Resident 1 was diabetic needing blood sugar checks. LVN 3 stated, she told Resident 1 ' s caregiver that the resident ' s blood sugar had not been monitored (since admission on 12/11/2024 [eight days]) because there was no physician ' s order to monitor Resident 1 ' s blood sugar. LVN 3 stated Resident 1 was transferred to the GACH via 911 on 12/17/2024. During an interview on 1/28/2025 at 11:30 p.m., the facility consultant pharmacist (Pharm) stated Empagliflozin is medication used to lower the sugar level in the blood. The Pharm stated residents should have their blood sugar levels monitored regularly (not specified)to determine the residents ' response to Empagliflozin. The Pharm stated failure to monitor resident ' s blood sugar level places residents at risk of having undetected hyperglycemia and hypoglycemia. The Pharm stated without blood glucose monitoring, we cannot adequately assess the effectiveness of blood sugar lowering medication. During an interview on 1/28/2025 at 2 p.m., Resident 1 ' s NP stated she did not order Resident 1 ' s blood glucose monitoring because she did not know he had type 2 diabetes. The NP stated she had limited clinical documentation to review upon Resident 1 ' s arrival and may have missed important information pertaining to Resident 1 ' s medical history. The NP stated the facility nursing staff did not call her to clarify the need for blood sugar checks since Resident 1 was a diabetic. The NP stated she would have ordered blood glucose checks if they had. The NP stated she only found out of Resident 1 ' s diagnosis of diabetes from Resident 1 ' s home care giver, who was at Resident 1 ' s bedside at the time Resident 1 was already hyperglycemic. During an interview on 1/29/2025 at 8:45 a.m., Resident 1 ' s Medical Doctor (MD) stated he did not assess Resident 1 during Resident 1 ' s stay at the facility. The MD stated he delegated Resident 1 ' s care to his NP. The MD stated, on 12/17/2024 upon learning Resident 1 was receiving Empagliflozin he would have ordered blood glucose monitoring to ensure the medication was effective for Resident 1. The MD stated Resident 1 was at risk for hyperglycemia and hypoglycemia which the nursing staff should be assessing for in addition to regular blood glucose level testing. The MD stated failure to monitor for signs and symptoms of hyperglycemia and hypoglycemia placed Resident 1 at risk for a decline of health, diabetic ketoacidosis, diabetic coma, and possible death. During an interview on 1/29/2025 at 11:55 a.m., LVN 1 stated on 12/12/2024 and 12/13/2024, she administered Empagliflozin to Resident 1. LVN 1 stated Empagliflozin is a medication to lower blood sugar. LVN 1 stated it is important to know the resident ' s blood sugar level prior to administering Empagliflozin to ensure the resident is not hypoglycemic or hyperglycemic. LVN 1 stated although it is important to assess Resident 1 ' s blood sugar prior to administrating Empagliflozin, she did not see a physician ' s order to check Resident 1 ' s blood sugar level and did not think to question the lack of physician ' s order for blood sugar testing. During an interview on 1/29/2025 at 4 p.m., the DON stated it was her responsibility to ensure all newly admitted residents ' clinical documents were reviewed to ensure residents receive the appropriate care and treatments. The DON stated she was aware Resident 1 had diabetes and did not have a physician ' s order for blood glucose monitoring. The DON stated, she assumed the physician care team (MD and NP) knew Resident 1 had type 2 diabetes. The DON stated she should have clarified the orders with Resident 1 ' s care team to ensure Resident 1 was properly monitored for complications of hypoglycemia and hyperglycemia. The DON stated upon review of Resident 1 ' s clinical documentation, there was no care plan developed to address Resident 1 ' s diabetic care. The DON stated a diabetic care plan would address monitoring resident ' s blood sugar as directed by the physician, appropriate diabetic diet, monitoring signs and symptoms of hyperglycemia and or hypoglycemia. The DON stated Resident 1 should have had a care plan in place to ensure Resident 1 was being monitored for complications of diabetes. During a review of the Medication Guide for Empagliflozin, undated, the Medication Guide indicated Empagliflozin can cause serious side effects including diabetic ketoacidosis. During a review of the online article from American Diabetic Association (a nonprofit organization the funds research to prevent, cure and manage diabetes) website titled Diabetes and Diabetic Ketoacidosis (DKA), the article indicated DKA is a life-threatening condition that can lead to diabetic coma and even death. The article indicated treatment for DKA takes place in the hospital, but it can be prevented by learning the warning signs and by checking blood glucose regularly. The early symptoms include thirst, frequent urination and high blood sugar level. https://diabetes.org/ During a review of the online article from American Diabetic Association website titled Treatment and Care, check your Blood Glucose (sugar), Diabetic Testing and Monitoring the article indicated blood sugar monitoring is the primary tool used to find out if blood glucose levels are within range. https://diabetes.org/ During a review of the facility ' s policy and procedure (P&P) titled, Diabetes Mellitus, Resident, Nursing Care of revised November 2017, the P&P indicated the policy of the facility is to recognize and assist in the treatment of complications commonly associated with diabetes. The policy indicated the facility will document pertinent laboratory studies including blood sugar. During a review of the facility ' s Job Description Director of Nursing Revised October 2021, the job description indicated the DON would assist in the management and direction of the Nursing Department in accordance with federal, state and local standards, guidelines and regulations that govern the facility and as may be directed by the Administrator and Medical Director, to ensure the highest degree of quality of care is always maintained. The job description indicated the DON would communicate information to nursing personnel regarding new resident admissions and resident discharges and provide oversight. The job description indicated the DON would develop a written plan of care (preliminary and comprehensive) for each resident with identified problems/needs, which indicates the care to be given, goals to be accomplished and which professional service is responsible for each element of care.

Based on observation, interview, and record review, the facility failed to ensure the resident, who was riding in the facility's van while sitting in a wheelchair, had a shoulder seat belt strap on to secure upper body for one of 23 sampled residents (Resident 32). This deficient practice resulted in Resident 32 thrown forward with a wheelchair landing on top of the resident when Driver 1 abruptly stops the vehicle on a yellow light. Resident 32 was admitted to general acute care hospital (GACH) on 3/19/2024 and hospitalized for six days with multiple fractures (broken bone) including fracture to both arms, both legs and neck. On 3/27/2024 Resident 32 was sent back to GACH for anxiety ( a feeling of worry, nervousness, or unease) related to the accident on 3/19/2024. Findings: During a review of Resident 32's Admission Record, the Admission Record indicated Resident 32 was admitted to the facility on [DATE] with diagnoses including right femur ( thigh bone) pathological fracture (a break in a bone that happens without the force of an impact), age-related osteoporosis (causes bones to become weak and brittle) fibromyalgia (a chronic condition that causes pain in muscles and soft tissue all over the body), and dorsalgia (back pain). During a review of Resident 32's Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 3/9/2024, the MDS indicated Resident 32 had the ability to understand others and the ability to express wants and thoughts. The MDS indicated Resident 32 was dependent on staff for toileting, showering, dressing, sitting, lying, and rolling from left to right. The MDS indicated Resident 32 required moderate assistance from staff with washing the face and combing the hair. The MDS indicated Resident 32 required setup and clean up assistance from staff with eating. The MDS indicated Resident 32 did not attempt to walk prior to current illness and did not attempt to use the wheelchair due to medical condition and safety. During a concurrent observation and interview on 3/26/2024 at 11:29 a.m. with Resident 32, the resident was observed to have splints (a removable device that temporarily immobilizes a joint after injury) on both legs wrapped with ace wrap bandages (a compression bandage, a long strip of stretchable cloth that can wrap around) and a cervical collar (used to support spinal cord [a column of nerve tissue that runs from the base of the skull down the center of the back] and head) on her neck. Resident 32 was observed receiving physical therapy (therapy used to preserve, enhance, or restore movement and physical function). During the interview Resident 32 started crying, stated when she was coming back from a doctor's appointment, in the facility's van, she was not strapped in well and when Driver 1 abruptly stopped at a yellow light she flipped forward, and the wheelchair landed on top of her. Resident 32 stated she was on the van's floor for 30 minutes. Resident 32 stated she was wearing a lap belt strap but not the shoulder strap. Resident 32 stated the Administrator (ADMN) had the seatbelts replaced with new equipment and added a seatbelt to go over the stomach and shoulder after her accident on 3/19/2024. Resident 32 stated she came to the facility to get better and get assistance and she end up getting hurt. During an interview on 3/28/2024 at 9:59 a.m. Certified Nurse Assistant (CNA 4) stated Resident 32 called her on 3/19/2024 to informed her she was admitted to GACH due to the accident happened on 3/19/2024 at 7 p.m. going back to the facility after her doctor's appointment. CNA 4 stated Driver 1 made an abrupt stop at a yellow light causing Resident 32 to thrown over from her wheelchair and was on her knees for 30 minutes. CNA 4 stated Resident 32 told her she was going to be admitted to the hospital for broken legs and broken neck. CNA 4 stated Resident 32 currently needed two-persons assistance for bathing, dressing, toileting, and transfer between surfaces, and care must be very slow because Resident 32 was in a lot of pain. During an interview on 3/28/2024 at 10:15 a.m. Licensed Vocational Nurse (LVN 1) stated on 3/19/2024 during the evening shift (3 p.m. to 11 p.m. shift) Resident 32 was riding in the facility van returning from a doctor's appointment when the driver had an abrupt stop, Resident 32 flew from her wheelchair and the wheelchair landed on top of the resident. LVN 1 stated as a result Resident 32 sustained a fracture on both hips, and neck. LVN 1 stated Resident 32 now use a cervical collar and has the splints on both legs wrapped with ace bandages. During an interview on 3/29/2024 at 10:10 a.m. the Assistant Director of Nursing (ADON), stated on 3/19/2024 Resident 32 had an accident while being transported from her doctor's appointment by a van back to the facility and was sent to GACH for further evaluation. ADON stated Resident 32 sustained a displaced fracture (when the bone breaks into two or more parts and moves out of alignment) of fifth (5th) cervical (the neck region of the spine) spine, displaced fracture of the femur non-displaced fracture of the right tibia (shin bone), fractured shaft of the right fibula (leg bone on the lateral side of the tibia), fracture to the upper and lower left fibula, non-displaced fracture (a force causes a bone to crack or break but maintains its alignment) of the left tibia tuberosity (bony part on the upper part of the shin [front part of the leg] ), fracture of the right and left humerus (the long bone in the arm that runs from the shoulder to the elbow), fracture of left femur, and fracture of the right rib. ADON stated Resident 32 has a hard cervical collar brace (a medical device used to support and immobilize the neck) which she must wear while out of bed and soft cervical collar brace to wear while in bed. ADON stated Resident 32 has splints on the left and right leg and non-weight bearing activity (physical exercise or movement that do not put any pressure or load on the joints) on the lower extremities. During an interview on 3/29/2024 at 11:02 a.m. Driver 1 stated on 3/19/2023 at 5 p.m. he went to pick up Resident 32 from the doctor's appointment. Driver 1 stated he parked the van pulled down the ramp, pushed Resident 32 up the ramp, and positioned the wheelchair facing the front of the vehicle. Driver 1 stated he put the brakes on the wheelchair and connected the straps to floor of the vehicle and connected the straps to the frame, then created tension using tensioner (device used for maintaining tension) and connected both back straps and front straps to frame of vehicle and connected the seatbelt. Driver 1 stated he was driving 45 miles per hour and when the traffic light turned yellow, he abruptly stepped on the brakes resulted in Resident 32's wheelchair to tip over. Driver 1 stated when coming to a stop he heard Resident 32 yelling calling for help as her wheelchair tip over and she was on the floor. Driver 1 stated Resident 32 was on the floor of the van still connected to wheelchair on top of her yelling and crying. Driver 1 stated the wheelchair was on top of Resident 32, so he unhooked the straps and unhooked her seatbelt then disconnected the wheelchair. Driver 1 stated he sat Resident 32 up and a bystander called 911 (number used to reach emergency medical, fire, and police services). Driver 1 stated the paramedics (a person trained to give emergency medical care) arrived within 10 minutes and when Resident 32 was on the gurney (a wheeled stretcher used for transporting residents) he noticed Resident 32's left leg was dislocated. Driver 1 stated the facility has started implementing shoulder straps after the accident. Driver 1 stated he was not trained to use the shoulder straps during transport of the residents. Driver 1 stated he have not used the shoulder strap available in the van. Driver 1 stated the shoulder strap could have prevented Resident 32 from being thrown forward, especially on during sudden or abrupt stop. Driver 1 stated the shoulder strap was an extra safety precaution and would have secured Resident 32's upper body. During an interview on 3/29/2024 at 11:49 a.m.the vehicle inspection technician (Tech 1) stated he inspected the facility van on 3/21/2024 and recommended to replace the straps used to secure the wheelchairs. Tech 1 stated the straps were beginning to wear out and there were newer updated straps and updated models. Tech 1 stated the facility followed the recommendation and purchased new straps that were installed on 3/21/2024, after Resident 32's accident on 3/19/2024. During an interview on 3/29/2024 at 12:28 p.m. the Director of Nursing (DON) stated Resident 32 fell forward while sitting in the wheelchair coming back from an appointment with Resident 32's medical doctor on 3/19/2024. DON stated Resident 32 was admitted to the facility with a pathological fracture and after the accident Resident 32 sustained more fractures to the cervical spine, femur, humerus, tibia, and scapula (shoulder blade). During an interview on 3/29/2024 at 1:42 p.m. the Administrator (ADMN) stated he received a text message on 3/20/2024 from the housekeeping supervisor about Resident 32's being transported to the hospital due to the accident on 3/19/2024. The ADMN stated when Driver 1 stopped at the yellow light Resident 32's wheelchair tipped forward. The ADMN stated Resident 32 only had a lap strap on. Driver 1 was not able to get Resident 32 back in the wheelchair. ADMN stated a vehicle inspection was done on 3/21/2024 after the accident and followed Tech 1 recommendations to upgrade and replaced all the straps in the facility's transportation van. ADMN stated the shoulder strap were implemented after the accident to give additional support and more added safety. During a review of Resident 32's GACH records titled, History and Physical (H&P), dated 3/19/2024 indicated Resident 32 presented to emergency department with complain of pain in arm, legs, and back after a fall in a transportation van. The H&P indicated Resident 32 was in her wheelchair in a transport van when the van stopped abruptly, and she fell forward with her wheelchair. Resident 32 was found to have multiple fractures including cervical thoracic spine fracture, bilateral tibia fibula fractures (broken bones in the lower leg), bilateral humeral neck fracture (broken bone in the upper arm), displaced left femur fracture, left elbow fracture, left and right shoulder fracture. During a review of Resident 32's GACH records titled, Neurosurgery Consult dated 3/20/2024, indicated Resident 32 had a diagnosis of osteoporosis and came to the emergency room after not being strapped into a vehicle and falling, hitting her face. During a review of Resident 32's GACH records titled, Physical Therapy Screen, dated 3/22/2024, indicated Resident 32's plan of care was no surgical intervention, soft collar while in bed, hard collar when out of bed for eight weeks, pain control, physical therapy, and occupational therapy (health care provider who helps resident learn or regain skills of activities of daily living) evaluations. During a review of Resident 32's GACH records titled, Physical Therapy Consult, dated 3/23/2024, indicated Resident 32 may benefit from bilateral knee immobilizers (device that does not allow movement of the knee) to stabilize her legs .and non-weight bearing activity to both lower extremities. During a review of Resident 32's Nursing Progress Notes, dated 3/27/2024 at 8:42 a.m., the Nursing Progress Notes indicated, Resident 32 was requesting Ativan (medication used to treat anxiety) for anxiety and verbalizing being anxious. The Nursing Progress Notes indicated Resident 32 received a one-time order for Ativan 0.5 milligrams ([mg]- unit of measurement) for anxiety. During a review of Resident 32's Nursing Progress Notes, dated 3/27/2024 at 8:57 a.m., the Nursing Progress Notes indicated, Resident 32 verbalized feeling anxious and nauseated (feel sick) related to the recent car accident. The Nursing Progress Notes indicated Resident 32 had a physician's orders to receive a psychiatric evaluation (an examination to determine whether an individual has a mental health condition) and Hydroxyzine (medication used to treat anxiety and nausea) 25 mg every 12 hours for anxiety and Zofran (medication to treat nausea and vomiting) 4.0 mg every six hours as needed for nausea. During a review of the facility's vehicle Inspection Invoice (from a company that specializes in servicing wheelchair vans), dated 3/21/2024, the vehicle Inspection Invoice indicated, a recommendation for replacing the old straps with the latest version of straps. The vehicle Inspection Invoice indicated the facility purchased four retractors with four studs fitting flat brackets with the tongue for lap and shoulder belts (strap). During a review of the facility's Investigation Report titled, Final Investigation of Unusual Occurrence, undated, the Investigation Report (IR) indicated, a recommendation was made to upgrade the securing straps to the latest version. The IR indicated the new straps were purchased at that time. The IR indicated, as a measure of increased security to prevent an incident such as this from occurring in the future an additional shoulder restraint seat belt will be used when securing a patient in the van. During a review of facility's policy and procedure (P&P) titled, Wheelchair Securement, the P&P indicated Residents must be secured in their wheelchair and secured in the vehicle before any movements of the vehicle or transportation of any kind was to occur. Most all passenger transportation vehicles will have a securement system. According to the manufacturer recommendations for a wheelchair securements and occupant restraints for transporting individual website article, Always secure the occupant in the vehicle with a complete Occupant Restraint System, consisting of lap and shoulder belts. Secure the wheelchair in the vehicle with a Wheelchair Tie-Down System. https://sure-lok.com/products/occupant-restraints/ During a review of the facility's job description for drivers titled, Job Description: Driver, revised on 10/2017, the driver job description indicated, the primary purpose of your job position is to transport residents to and from appointments and activities in a safe and courteous manner .Secure passengers 'wheelchairs to restraining devices to stabilize wheelchairs during trip. During a review of the facility's Van Driver Skills Checklist dated 1/11 indicated Drives defensively and avoids making abrupt course change. 46036 , 46415

Based on interview and record review, the facility failed to ensure a certified nursing assistant (CNA 1) did not provide perineal care (washing the genital [reproductive organs located on the outside of the body] and rectal [area where a person holds stool before excreting it from the body] areas of the body) by himself without the assistance of another staff to a resident who required a two-persons physical assistance with toileting and personal hygiene for one of two sampled residents (Resident 1). This deficient practice resulted in Resident 1 falling from the bed and sustaining an inner lower lip laceration (a deep cut or tear in the skin or flesh) and a head injury resulting in an acute scalp contusion (any damage to the body that does not break the skin but ruptures (burst suddenly) the capillaries [any of the fine branching blood vessels that form a network between the arterioles [a small branch of an artery leading into capillaries] and venules [a very small vein that collects blood from the capillaries] resulting in discoloration; a bruise). This deficient practice placed Resident 1 at risk to sustain more serious consequences such as brain injury, fractures (a partial or complete break in the bone) and/or death. On 11/2/2023, Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation of her lip wound. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including epilepsy (a brain disorder which causes recurring, unprovoked seizures [a burst of uncontrolled electrical activity between brain cells which causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness]), difficulty in walking, and muscle weakness. A review of Resident 1's ([MDS] a standardized assessment and care screening tool), dated 10/29/2023, indicated Resident 1 had severely impaired cognitive (thinking process) skill for daily decision-making. The MDS indicated Resident 1 required maximum assistance for rolling left to right in bed and required a two or more persons physical assistance with toileting, bathing, upper and lower body dressing, and personal hygiene. The MDS indicated Resident 1 had functional limitations in range of motion ([ROM] the distance and direction a joint can move to its full potential) to both upper and lower extremities. The MDS indicated Resident 1 was frequently incontinent (having no or insufficient ability in holding in urine or stool) of bowel (stool) and bladder (urine). A review of Resident 1's Situation, Background, Assessment, and Recommendation ([SBAR] documentation technique which is used to facilitate prompt and appropriate communication within the care team) form, dated 11/2/2023, and timed at 5:35 a.m., indicated Resident 1 fell from the bed and landed on the floor while CNA 1 was changing Resident 1's incontinence brief by himself. The SBAR indicated Resident 1 sustained a small cut with minimal bleeding on her lower lip. A review of Resident 1's Transfer Form dated 11/2/2023, and timed at 7:51 a.m., indicated Resident 1 was transferred to a GACH on 11/2/2023 for evaluation and treatment related to her fall and injury. A review of the GACH's Emergency Department (ED) Visit Record, indicated Resident 1 was admitted to the ED on 11/2/2023 at 9:52 a.m. A review of the GACH's ED's History and Physical (H&P), dated 11/2/2023, indicated Resident 1 sustained a head injury resulting in an acute scalp contusion. A review of the GACH's Computed Tomography ([CT] an imaging test used to detect internal injuries) scan, of Resident 1's head, dated 11/2/2023, indicated Resident 1 had a left peripheral (area away from the center of the body) cerebellum (back of the head) lesion (an injury to the skin). During a concurrent interview and record review with the MDS Nurse on 11/28/2023 at 1:13 p.m., Resident 1's MDS dated [DATE], was reviewed. The MDS indicated Resident 1 was totally dependent on staff for toileting and required two plus persons physical assistance from staff to complete the task. The MDS nurse stated, when Resident 1 was being repositioned from left to right during perineal care, there should always be another staff member assisting to prevent Resident 1 from falling from the side of the bed. During an interview on 11/2/2023 at 2:33 p.m., Restorative Nursing Assistant 1 ([RNA 1] staff that assist patients in performing tasks which restore or maintain physical function) stated, Resident 1 was not able to get up by herself or move from side to side on her own and required two people to assist when she was turned and repositioned. RNA 1 stated Resident 1 has right side paralysis (the loss of ability to move and sometimes to feel anything, in part or most of the body) from a past stroke. RNA 1 stated when two people are required to turn and reposition a resident, a staff member should stand on each side of the resident's bed to prevent the resident from falling off the bed. During an interview on 11/28/2023, at 2:49 p.m., CNA 1 stated, he raised Resident 1's bed to the level between his (CNA 1) waist and knees (approximately two feet from the ground), to provide perineal care to Resident 1 and change her incontinence brief. CNA 1 stated he was standing behind Resident 1, on the left side of Resident 1's bed, with Resident 1's backside facing him (CNA 1), when Resident 1 leaned to her right side and attempted to grab the frame of the bed with her left arm. CNA 1 stated Resident 1 rolled off the bed and fell to the floor. CNA 1 stated he was not able to prevent Resident 1 from falling from the bed because he was on the opposite side of the bed, and he did not have enough time to prevent Resident 1 from falling. CNA 1 stated it would have been helpful if another staff had assisted him when he was providing perineal care to Resident 1 to prevent Resident 1 from rolling off the bed and falling to the floor. CNA 1 stated he was not aware Resident 1 required two people to assist with perineal care. During an interview on 11/28/2023, at 3:20 p.m., the Director of Staff Development (DSD) stated when a resident requires two or more people to assist with perineal care, there should always be another staff member assisting to prevent the resident from falling from the side of the bed. During a telephone interview on 11/29/2023 at 8:51 a.m., Physical Therapist 1 (PT 1) stated Resident 1 required two-persons assistance for all movements and there should have been two staff members assisting Resident 1 while providing perineal care and repositioning to prevent Resident 1 from falling from the bed. During a concurrent telephone interview and record review with the Assistant Director of Nursing (ADON) on 11/29/2023 at 10:02 a.m., Resident 1's Interdisciplinary Team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) note dated 11/2/2023, and timed at 3:35 p.m., was reviewed. Resident 1's IDT note indicated Resident 1 rolled from the bed to the floor while being changed and sustained a skin tear under her right lip. The IDT note indicated Resident 1 should have been turned by two staff members. The ADON stated CNA 1 reported to her that he was providing perineal care and changing Resident 1's incontinence brief without assistance when the incident occurred. The ADON stated upon assessing Resident 1, she noticed Resident 1 sustained a 0.1 millimeter ([mm] a unit of measurement) laceration to her inner lower lip. The ADON stated Resident 1's fall could have been avoided if there was another staff member standing with Resident 1 and assisting while he (CNA 1) provided perineal care and changed Resident 1's incontinence brief. A review of the facility's undated policy and procedure (P/P) titled, Fall Management System, indicated the facility is committed to providing an environment that remains free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision as appropriate to prevent accidents. It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls. A review of the facility's P/P titled, Activities of Daily Living (ADL) Care, revised 11/2007, indicated maintenance and restorative programs are available to residents in accordance with the resident's comprehensive assessment. The P/P indicated residents who are unable to carry out activities of daily living will receive assistance as needed.

Based on observation, interview and record review, the facility failed to implement interventions to prevent the spread of Coronavirus (a highly contagious virus that causes severe respiratory illness that affects the lungs and airways) which had the potential to affect 78 out of 78 residents currently in the facility and affected 58 out of 192 staff members (certified nurse assistants (CNAs 1, 2, 4, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26), Licensed Vocational Nurses (LVNs 4, 5, 6, 7, 8, 9. 10, 11), Registered Nurse (RN 3), Cook 1, housekeeping (HK) staff (HKs 2, 6, 7, 8, 9), Supervisor of housekeeping (SHK), Dietary Aid (DA 2, 3, 4, 5, 6, 7), Rehab staff 1, 2, 3, 4, 5, 6, 7, 8, the Director of Activity, Maintenance, Social Services (SS 1,2), and Business office staff (BO 1,2)) accordance with the facility's infection control policies and procedures and mitigation plan ((MP) a plan to reduce the spread of infection and loss of life). The facility failed to ensure: 1.There was a full-time infection preventionist ((IP) a nurse in charge of infection prevention and control that provides training for staff and assists with caring for residents) for nine (9) out of 9 months. 2. All staff were fit tested (a test to ensure the respirator was acceptable and correctly fits, the user) prior to the distribution of the N95 masks. The facility failed to provide fit testing for 165 out of 192 staff members (Registered Nurses, Licensed Vocational Nurses, Certified Nurse Assistants, Rehab staff, Housekeepers, Receptionists, kitchen staff, and etc.). 3. Two of five staff members (Housekeeper 1 and Registered Nurse 1) used properly-fitting N95 respirators (respiratory protection device to achieve a close facial fit and with an efficient filtration for airborne particles) when Registered Nurse 1 did not have a proper seal and Housekeeper 1 wore a surgical mask underneath the N95. 4. Proper handwashing techniques were used by one of five staff (Licensed Vocational Nurse 4 (LVN 4)) for infection prevention and control. 5. Housekeeping staff (HKs 2 and 3) follow the five minutes contact time (time a disinfectant was in direct contact with the surface or item to be disinfected) when using a disinfectant to clean. 6. 17 out of 17 trash and soiled linens were properly stored when 15 biohazard bags (disposable red bag that is resistant to moisture and has a strength sufficient to preclude ripping, tearing, or bursting under normal conditions of usage and handling of the waste-filled bag) and two clear plastic bags were observed at the bottom of the stairwell in the Red zone (COVID-19 positive area). 7. Space was clearly designated for all staff entry/exit doors, breakrooms, and bathrooms for infection prevention and control. Green zone (area designated for people who are covid-19 negative or have recovered from COVID-19) and yellow zone (separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick) staff shared the same bathroom and breakroom. Red zone (separates and restricts the movement of people who are confirmed with a contagious disease) staff had accessed to a stairwell that exited in a hallway in the yellow zone. These deficient practices resulted in the spread of COVID-19 infection throughout the facility, affecting 24 residents in the red zone (Residents 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 23, 24, 25, 26, 27, 28) and 58 staff members (CNAs 1, 2, 4, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26; LVNs 4, 5, 6, 7, 8, 9. 10, 11, RN 3, Cook 1, HK staff 2, 6, 7, 8, 9, Supervisor of housekeeping (SHK), DAs 2, 3, 4, 5, 6, 7; Rehab staff 1, 2, 3, 4, 5, 6, 7, 8, Director of Activity, Maintenance, Social Services (SS 1,2), and Business office staff (BO 1,2). This failure had the potential to lead to serious respiratory illness for 54 residents (10 residents in the green zone and 44 residents in the yellow zone),which could result in hospitalization and/or death due to the residents being placed at high risk of COVID-19 exposure. On 12/31/2020 at 6:11 p.m., the administrator (ADM) and the IP, were notified of an Immediate Jeopardy ((IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, a serious injury, harm, impairment, or death to a resident) was called for the facility's staff inability to implement interventions to prevent the spread of COVID-19 infection and threatened the health and safety of residents and staff. On 1/2/2020 at 1:54 p.m., the ADM and DON provided a written acceptable plan of action (POA) as follows: 1.N95 fit testing was completed for all staff working in the facility during the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts. All staff who are schedule to work on 1/1/2021 will have their N95 mask fit testing completed prior to starting to work. The N95 mask fit testing for the rest of the staff on the roster (who are actively on the work schedule) will be completed by January 8, 2021 as part of the plan of correction. 2. The receptionist will distribute an N95 to each staff member when they complete their screening upon arrival to work. A list will be available for the receptionist with each staff member's name and type of N95 they have been fit tested for, and the receptionist will distribute the correct N95 to them for their shift. On the 11 p.m. to 7 a.m. shift: prior to leaving work each day, the receptionist will prepare a bag with the correct N95 each staff member has been fit tested for and leave the bags on the cart at the after-hours screening station. The individual bags will be labelled with each staff member's name and available for them to use. 3. The central supply designee will conduct a weekly inventory of N95 supply. A minimum of a two-week supply will be always maintained, and orders will be placed as needed. If the facility was unable to obtain the N95 respirator that a staff member has been fit tested for, the infection preventionist or designee will conduct a fit test with another available N95 prior to the start of staff's next working shift. 4. The ADM, Director of Nursing (DON), and IP updated their designation of spaces for staff entry/exit, breakrooms, and bathrooms in the red, yellow, and green zones within the facility (see updated floor plan). 5. A full-time infection preventionist (IP) was designated effective 12/31/2020 and a Registered Nurse director of staff development (DSD) will be covering the DSD function until a new DSD is hired. 6. The ADM verified environmental protection agency ((EPA) a governmental agency who creates standards and laws for promoting health of individuals and the environment) certification and registration of the cleaning product. The housekeeping staff were in-serviced by the maintenance supervisor on 1/1/2021 regarding the following: Cleaning and disinfecting, contact time, EPA- approved cleaning products. All staff not currently available will be in-serviced prior to start of their next shift. 7.The facility implemented an updated process on Disposing of Soiled Linen/Trash from the red zone on 1/1/2021. The barrels for dirty linen would be outside the door to the Red zone. Linen will be bagged inside the Red zone and the bags will be placed inside the barrels. Housekeeping will pick up the barrels for transport to laundry. Staff will dispose of trash directly in the dumpster. 8.The infection preventionist (IP) and Director of Nurse (DON) in-serviced all staff currently working during 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts on infection control practices and the updated disposing of soiled linen/trash. Skills competency check was conducted after the in-service training. All staff who are scheduled to work on 1/1/2021 will complete the in-service on infection control and prevention practices, including handwashing techniques. Skills and competency check will be conducted after all in-service training. The infection control and prevention practices in-service for all staff will be completed by 1/8/2021. As part of the plan of correction, skills and competency check for staff will be conducted when they return to work prior to the start of their shift. On 1/2/2021 at 5:46 p.m., the ADM and DON were notified the IJ was lifted after the team conducted an on-site observation, interview and record review and verified and confirmed while onsite the POA was implemented as indicated. Findings: On 12/31/2020 at 10:52 a.m., during an observation while entering the facility the receptionist (Receptionist 1) gave an occupational therapist ((OT 1) a therapist who is trained to treat residents and help maintain skills needed for daily living) a white one size fits all N95 respirator. On 12/31/2020 at 10:56 a.m., during the entrance conference with the director of nursing (DON), she stated the Infection Preventionist ((IP) a nurse in charge of infection prevention for the facility) was not in the facility. On 12/31/2020 at 11:30 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated she was training with the IP nurse. LVN 1 stated the facility had a dedicated bathroom for the staff who worked in the Yellow zone (COVID-19 suspected; separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick). LVN 1 stated the facility had fit test approximately 70 percent (%) of the staff. LVN 1 stated the first COVID-19 confirmed case was a staff member on 11/2/2020. On 12/31/2020 at 11:31 a.m., LVN 4 was observed donning Personal Protective Equipment (PPE) in the hallway of the yellow zone. LVN 4 knocked on a resident's door next to the dining room and was stopped prior to entering and asked about infection prevention protocols at the facility. LVN 4 stated hand hygiene should be performed prior to donning PPE and entering a resident's room. She was asked if hand hygiene was performed prior to her donning the PPE, LVN 4 stated, Well no, not this time. At the conclusion of the interview, LVN 4 entered the resident room in the hallway of the yellow zone without washing her hands. On 12/31/2020 at 11:32 a.m., LVN 4 was observed exiting a resident's room next to the dining room and entered the dining room door. LVN 4 was asked what the dining room was used for and she stated the dining room was only used as a designated handwashing area. On 12/31/2020 at 11:35 a.m., an interview was conducted with Certified Nurse Assistant (CNA 4) and she was asked about the use of the dining room in the yellow zone. CNA 4 stated the dining room was used for handwashing and could also be used as a break room for the Yellow zone staff from the first floor. When asked if the dining room was used to store personal belongings of staff at the facility, CNA 4 stated, Oh, I am not sure. On 12/31/2020 at 11:47 a.m., during an interview, CNA 1 stated staff on the first floor could use the dining room in the yellow zone as a break room. CNA 1 stated staff from the green and yellow zone cold also use the breakroom in the basement. CNA 1 stated the green and yellow zone staff could take their breaks in either dining room. On 12/31/2020 at 11:52 a.m., during an interview, the IP stated she worked 40 hours a week as IP and a director of staff development (DSD), but she was unable to say how many hours a week she worked as an IP. The IP stated she was training LVN 1 to be the IP because she had worked as both an IP and the DSD since March 2020. The IP stated this month was the first case of a resident with COVID-19 on 12/5/2020 and the local public health nurse ((PHN) community health nurse works to promote and protect the health of individuals within a community) recommended the facility to ensure the staff wore the N95 respirators properly. The IP stated the facility in-serviced the staff on how to effectively use the N95 respirator on 12/8/2020. On 12/31/2020 at 12:10 p.m., during an observation and concurrent interview with a central supply ((CS) where the facility kept its supplies, such as personal protective equipment ((PPE) gloves, gowns, masks, respirators, and face shields equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) staff stated she supplied the receptionist with the N95 respirator, and the receptionist distributed the N95 to the staff. The CS staff stated the IP instructed her to give the N95 masks to be distributed by receptionist because she liked a specific respirator brand. The CS staff stated once all the N95 masks of that brand were used, she gave the receptionist a different N95 that was available in the facility's central supply. On 12/31/2020 at 12:20 p.m., during an interview, a dietary aid (DA 1) stated she had an all-white mask that looked like an N95 respirator but did not have a brand name or model on it. DA 1 stated she was wearing an N95 respirators that the receptionist gave to her when they had run out of other N95 respirators. DA 1 stated she had not been fit tested for the N95 she was currently wearing. DA 1 stated she had been recently helping in the kitchen, but her usual assignment was on the floor providing resident's with coffee, juice, hot chocolate, serving the meal trays, and collecting the trash. On 12/31/2020 at 12:24 p.m., during an interview, Registered Nurse 1 (RN 1) in the hallway of the yellow zone on the 1st floor, RN 1 stated the staff were assigned to work on all three floors of the facility, which included the Green, Yellow, and Red zones. RN 1 was asked if there was a protocol in place to control staff movement in between zones, RN 1 stated there was no specific protocol. On 12/31/2020 at 12:30 p.m., during an observation and interview, the basement floor employee lounge had a sign indicating a Yellow Zone breakroom. DA 1 was observed eating in the break room and DA 1 stated it was the kitchen's staff break room. On 12/31/2020 at 12:36 p.m., during an interview, OT 2 stated when she goes to lunch, she keeps her N95 respirator on a paper towel with the outside facing down and the inside open. OT 2 stated that was not what the facility told her to do, but she had forgotten what the facility instructed her to do with the N95 respirator during mealtime. On 12/31/2020 at 12:45 p.m., during an interview with a housekeeper (HK 2), in the Green Zone (area designated for people who are COVID-19 negative or have recovered from COVID-19), stated she used bleach wipes to clean the high touch surfaces. When HK 2 was asked what the contact time was for the bleach wipes, she did not respond. On 12/31/2020 at 12:55 p.m., a concurrent interview and record review with the IP and LVN 1. LVN 1 stated the dining rooms on the first floor, in the Green and Yellow zones, were used for handwashing only and the staff from those zones should take their breaks in the breakroom in the basement. LVN 1 stated Red Zone staff on the third floor should take their breaks in the dining rooms on that floor. LVN 1 was asked which zones were located on the first and second floor and LVN 1 stated green and Yellow Zones were located on those floors and those staff should who worked in the Green Zone take their break in the basement. LVN 1 was asked where the Yellow Zone staff took their breaks and LVN 1 stated, I am not sure. The IP stated infection prevention training was provided to the staff in the month of December 2020. A review of the IP's in-service binder, staff were trained on COVID Updates on 12/1/2020, N95 Seal Check on 12/8/2020, and Hand washing and PPE Usage on 12/17/2020. The IP stated the facility performed a Skills check to assess staff competency. The IP stated the skills check were kept in a binder; but she was unable to provide the skills check competency from the N95 Seal Check training on 12/8/2020, I don't have it. The IP stated that there was no documentation regarding skill checks for staff since June 2020. When asked why there was no documentation, the IP stated, I haven't done any. On 12/31/2020 at 1:01 p.m., during a concurrent observation and interview with LVN 4 in the Green Zone, LVN 4 stated she worked in the Green Zone and the Yellow zone. LVN 4 stated she used the break room on the bottom floor next to the kitchen. LVN 4 also stated she was not fit tested for a N95 respirator. LVN 4 stated the staff who worked in the Red Zone entered through the exit door in the Green Zone to access the stairwell of the Red Zone. On 12/31/2020 at 1:20 p.m., during a concurrent observation and interview, housekeeper (HK 3) was in the Yellow Zone spraying wiping the rails with an orange liquid solution. HK 3 was asked if the product she was using EPA registered and she stated she was not sure. A review of the back of the label on the container did not indicate the product was used for Coronavirus. HK 3 was asked about the contact time (amount time needed for the solution to be effective) of the solution and she stated it was one minute. HK 3 stated she sprays the product and dries it off because the staff did not like to touch wet areas. HK 3 read the product label that indicated a contact time was five (5) minutes to disinfect and stated, Wow 5 minutes. HK 3 was observed wearing a surgical mask under the white N95 respirator. HK 3 stated she had not been fit tested for an N95 and she did not know how to check if the respirator was properly sealed. A review of the EPA website, indicated cleaning product 1 had a contact time of five minutes. On 12/31/2020 at 1:26 p.m., during a concurrent observation and interview, Restorative Nurse Assistants 1 and 2 ((RNA 1 and RNA 2) a certified nursing assistant trained to provide restorative care to residents under the supervision of physical therapist) were in the yellow zone. RNA 1 was on the telephone with a N95 respirator around her neck, and RNA 2 was at the sink. A N95 respirator was lying on top of a table. RNA 2 picked the N95 respirator up from the table. RNA 2 was asked how she knew it was her mask, since it was unlabeled. RNA 2 stated she knew it was her mask because she put the mask on top of the table to take a sip of water. RNA 2 stated the N95 respirator should have not been placed on top of the table because she was told to put the N95 respirator on a paper and cover it. RNA 1 stated she was not supposed to be on the telephone and her N95 respirator was supposed to be covered with a paper to prevent the spread of microorganisms. On 12/31/2020 at 1:39 p.m., during an observation and concurrent interview with registered Nurse (RN 1) in the yellow zone, she stated she was fit tested at her other job at a hospital. RN 1 stated she was fit tested for a different mask then the one she was given and wearing in the facility. RN 1 did a seal check her N95 and when she blew air from her mouth her face shield became foggy (indicating a poorly sealed N95). RN 1 stated the N95 respirator she had been using in the facility was not her size. On 12/31/2020 at 1:45 p.m., during an interview, Receptionist 2 stated she provided all the staff an N95 respirator. Receptionist 2 stated she received the respirator from the central supply and the respirators had one genetic size that was distributed to all the staff. On 12/31/2020 at 2:22 p.m., during an observation and concurrent interview with the Administrator (ADM) and IP, the ADM stated there were designated stairwells for staff to use. The ADM stated the staff who worked in the red zone used a designated staircase to access the second and third floor and the staff from the green and yellow zones used a separate staircase to access the breakroom in the basement on the first and second floor. The ADM explained that two of the four stairwells were used, and staff were instructed not to use the other two stairwells. The first and second floor and the stairwell doors that were not for staff use, did not have assign posted or instructions for accessing the stairwells. The ADM was asked how the staff knew which doors they could enter on each floor the ADM stated, The staff should just know because we've told them. On 12/31/2020 at 2:40 p.m., during an interview, the ADM stated the staff was in-service about fit testing and he thought the staff was fit test in 3/2020. On 12/31/2020 at 2:48 p.m., during an interview with the administrator, he stated the facility had only fit tested four of the staff in 6/2020 when the facility had the first outbreak of COVID-19. On 12/31/2020 at 3:36 p.m., during an interview, LVN 1 stated she was training to be an infection preventionist (IP) but did not have prior experience as infection preventionist and had not completed any training. On 12/31/2020 at 3:38 p.m., during an interview, Licensed Vocational Nurse 3 (LVN 3) at the nurse's station on the first floor, stated the hallways designated as part of the yellow zone should only be used for staff who were working in that same zone. LVN 3 stated staff who worked in the red zone should use a separate entrance and exit to the building. LVN 3 was asked about the exit door at the end of the hallway and she stated it was used as an after-hours entrance for the green and yellow zone staff. On 12/31/2020 at 3:41 p.m., during an observation and concurrent interview housekeeper (HK 1) exited a stairwell door in the yellow zone hallway on the first floor and was asked which area she works, and HK 1 stated, I work in the red zone .I am leaving work now. HK 1 was asked how she normally exited the building after working, HK 1 stated, This is the way I normally go. HK 1 exited the building using the door that was designated as the after-hours entrance for the yellow zone staff. On 12/31/2020 at 3:48 p.m., during an observation, at the bottom of the stairwell, on the first floor, in the yellow zone, with access to the red zone (the same door HK 1 exited prior to leaving the facility), 15 red plastic bags labeled Biohazard/Danger and two clear plastic bags were on the floor. The plastic bags were piled in the walkway, against the wall, on both sides of the stairwell door. A white, milky looking liquid was leaking out of one of the plastic bags. On 12/31/2020 at 4 p.m., during an interview with CNA 2, CNA 3, and LVN 2 in the red zone break room, they were asked what was inside of the bags located at the bottom of the stairwell. CNA 2 stated, One side is trash and one side is dirty linen. When asked if that was the proper way to store trash and soiled linen for the red zone, CNA 2 stated, Well that's how we have been doing it. CNA 3 stated sometimes the barrels were used to hold dirty linen. On 12/31/2020 at 5:04 p.m., during an interview, the IP stated the facility only fit tested some of the staff members in 3/2020 because the facility was unable to get a solution for the fit test kit. The IP stated the facility got the fit test kit in 6/2020 and she did not receive an proper amount of information on how to fit test the employees. The IP stated if the staff were not properly fit tested and staff could spread [MEDICAL CONDITION] to other residents. The IP stated she was working by herself as IP and DSD and it was challenging to monitor infection control and prevention. The IP stated the facility had order different brands of N95 respirators and stated this week the facility had distributed one brand of N95 respirator, but distribution was based on availability of the supply. The IP stated in the beginning of the pandemic (3/2020) she instructed the staff to put their N95 respirator in a paper bag or paper towel when they were eating to prevent contaminating the mask. The IP stated the staff assigned to the Red Zone should not enter the other zones as they had separate entrances. The IP stated she was responsible to supervise infection control practices for the housekeeping as well and stated an improper use of a disinfectant product would not disinfect the surfaces and could keep the surfaces infected. The IP nurse stated that the green and yellow zone staff enter the facility and get screened for COVID-19 in the main lobby. The IP stated the green and yellow zone staff use the same stairwell to access the breakroom in the basement and the facility had two red zones (one on the first floor and the entire third floor). The IP stated the red zone staff should not cross paths with the other staff in the building. The IP was asked how the red zone staff entered the facility and the IP stated, The red zone staff enter the building through a dining room door on the first floor through the dining room and then cross into the yellow zone hallway and enter the red zone stairwell. The IP was asked if it was okay for the red zone staff to cross into the hallway of a different zone the IP stated, It was okay because there was no other entrance. A review of the Employee Time Detail for the IP indicated her job titled was Director of Staff Development and she had worked 8 hours a day five days a week from 9/2020 to 12/2020. A review of the Respirator Fit Test Record and the facility's Education Acknowledgment form, indicated there were only 23 staff fit tested as follow: On 12/11/2020, 10 staff members were fit tested On 12/12/2020, one staff member was fit tested On 12/14/2020, six staff members were fit tested On 12/15/2020, one staff member was fit tested On 12/16/2020, five staff members were fit tested On 6/10/2020, four staff members were fit tested A review of the facility's in-service for N95 Seal check, dated 12/8/2020 indicated the facility had in-serviced 70 staff members of 192 staff members listed on the roster. A review of the in-services for seal check and proper way to wear the N95, dated 12/30/2020 indicated the facility had in-serviced 83 staff of 192 staff members listed on the roster. A review of an email sent to the facility from the local public health department, dated 12/29/2020, from a public health nurse (PHN) indicated a recommendation for the facility to educate the staff on the proper way to wear the N95 respirator. A review of the facility's Coronavirus Disease (COVID-19) Preparedness Plan, dated 3/4/2020 indicated the plan was developed to ensure staff were trained, equipped, and capable of implementing practices to prevent the spread of respiratory diseases, including COVID-19, within the facility. The plan indicated the infection prevention and control policies, guidelines and staff training would provide education and job specific training to staff regarding COVID-19 including correct infection control practices and PPE use and environmental cleaning and disinfection. Staff to receive appropriate training on selection and proper use of PPE, with a required demonstration of competency. Facility to implement a process for auditing adherence to recommended PPE use by staff. Ensure hand hygiene supplies, including alcohol-based hand sanitizer, were readily accessible in patient care areas, including areas where staff removed PPE. Train staff to perform hand hygiene before and after patient contact, contact with potentially infectious material, and before putting on and upon removal of PPE, including gloves. Facility would conduct observations to review adherence to recommended hand hygiene practices by staff. The facility should establish a plan to ensure proper cleaning and disinfecting of environmental surfaces. If the environmental services personnel were given this responsibility, they should be appropriately trained. All housekeeping staff with cleaning responsibilities understood the contact time for selected products. A review of the facility's undated Infection Prevention Position Description indicated the IP would follow all infection control regulations, review guidance and recommendation provided by the center of disease control and prevention (CDC), Department of Public Health (DPH) and/or Local Health Department (LHD) to maintain highly consistent situational awareness with highly evolving nature of COVID-19. IP would monitor and collect all guidance from the LHD, CDPH, and CDC and council all staff on best practices to ensure consistent application of safe IP practices. A review of the California Department of Public Health (CDPH) all facilities letter 20-52, dated 5/11/2020, indicated that due to the higher risk of severe illness and death from COVID-19 among elderly persons and those with chronic medical conditions, CDPH required all Skilled Nurse Facilities to expand their existing infection control policies that must include a full-time, dedicated Infection Preventionist. A review of the State of California- Department Industrial Relations (Cal-Osha) Guidance on COVID-19 for Health Care Facilities dated 8/6/2020, indicated the initial respirator fit testing was required before an employee used a respirator, or when an employee changed to a different model, make, or size respirator. Regardless of respirator availability. Employers must implement work practices that minimize the number of employees exposed to suspected and confirmed COVID-19 patients and infectious aerosols. Employers must ensure that the respirators were kept clean, sanitary, and in good working order always. The respirator must be discarded if at any time it becomes contaminated or does not fit or function correctly. A review of the facility's policy and procedure (P/P), dated 8/2020 and titled, Respiratory Protection Program, indicated according to state and federal regulations, workplaces with workers were required to wear a fit-tested respirator and had an established Respiratory protection program. OSHA requires healthcare workers who are expected to perform patient activities with those suspected or confirmed to be infected with COVID-19 to wear respiratory protection, such as an N 95 respirator .Without an adequate seal, air and small particles leak around the edges of the respirator and into the wearer's breathing zone. To provide proper protection, respirators must be worn correctly, and must be maintained properly. They are prone to leakage, depended on the correct behavior of individual employees and may require management oversight. Respirator fit testing would be repeated in accordance with State and federal Guidance. Respirator used as extended use or limited reuse the staff would be trained on the following steps to reduce contact transmission such as hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses. To minimize potential cross contamination, store respirators so that they do not touch each other and the person using the respirator is clearly identified. Clean hands before and after touching or adjusting the respirator, use a pair of clean gloves after the N95 respirator is donned and any adjustments were made to ensure the respirator was sitting comfortably on the face with a good seal. A review of the Los Angeles LDH Skilled Nursing Facilities - COVID-19 Manual, updated on 12/30/2020 indicated staff working in the quarantine and COVID-19 zones should wear a gown, gloves, eye protection, and a N95 mask. Increase environmental cleaning throughout the facility with emphasis on high touch surfaces and objects. Use EPA registered cleaning and follow the label direction. A review of the facility's undated COVID-19 Mitigation Plan Requirements indicated the Infection preventionist (IP) would work full time for infection prevention. The staff in the yellow and red zones would wear an N95 respirator. A review of the facility's undated P/P titled, Nursing Services indicated the facility would develop staffing assignments in such a way as to limit the risk of COVID-19 transmission by limiting clinical and other staff who have direct contact to specific floor or wings. There should be no rotation of staff between floors and wings during the period they are working each day. A dedicated consistent group of staff would be assigned only to care for COVID-19 positive residents. These staff members would remain separated from other residents and staff.