Every finding on record at Temecula Healthcare Center

Based on interview, and record review, the facility failed to complete the blood culture, (a laboratory test that checks a blood sample for disease-causing germs), for one of three residents (Resident 1), in accordance with the physician order.This failure has the potential to result in delayed treatment which could negatively affect the already fragile health of Resident 1. Findings: On June 17, 2026, at 10:11 a.m., an unannounced visit to the facility was conducted to investigate two complaints on quality care issues. A review of Resident 1's admission Record indicated the resident was admitted on [DATE], and discharged on May 24, 2026, with diagnoses which included encounter for surgical aftercare for incision and drainage (I &D - a minor surgical procedure where a healthcare professional makes a small cut into a localized skin infection to release and drain built-up pus, which immediately relieves pressure and promotes healing) to right and left groin, cellulitis (infection of the skin and the tissues beneath the skin) of groin, and sepsis (occurs when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body, that can lead to death). A review of Resident 1's History and Physical dated May 19, 2026, indicated resident was alert and oriented X 4 (person, place, time, and situation). A review of Resident 1's Change in Condition dated May 21, 2026, at 00:28, indicated . 3 x [times] checked elevated HR [heart rate] using VS [vital sign] machine. 128, [normal resting heart rate a minute between 60-100] 132 and 130. A review of Resident 1's Progress Notes dated May 21, 2026, at 3:36 p.m., indicated [name of doctor] reviewed CBC W/AUTO DIFF [complete blood count with automated differential - a routine blood test that measures red blood cells, white blood cells, and platelets, while using an advanced machine to sort the white blood cells by type] CMP [comprehensive metabolic panel - a routine blood test measuring 14 different substances to check liver and kidney health, blood sugar, and fluid balance]. dated 5/20/2026 with an order for UA [urinalysis] with CS [culture and sensitivity] and (sic) blood cs [cultures] today and repeat cbc in 1 week.Order carried out.A record review of Resident 1's Order Summary Report dated May 21, 2026, indicated CULTURE, BLOOD #2 ** SENT Uncollected On June 17, 2026, at 4:13 p.m., an interview and concurrent record review were conducted with Registered Nurse (RN) 3. RN 3 stated that when the shift started at 3 p.m. she was told that Resident 1 was being transferred out to the hospital. RN 3 stated that Resident 1 had an order for blood cultures dated May 21, 2026, and RN 3 confirmed that there were no results in Resident 1's chart. RN 3 stated that the specimen was uncollected and RN 3 was unsure why the order was not completed. On June 17, 2026, at 4:27 p.m., an interview was conducted with Assistant Director of Nursing (ADON). The ADON confirmed that the blood cultures were not drawn for Resident 1 and should have been collected. A review of the facility's policy and procedure titled Lab and Diagnostic Test Results - Clinical Protocol, revised November 2018, indicated, 1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests.3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. Review by Nursing Staff .4. A nurse will try to determine whether the test was done .

Based on interview and record review, the facility failed to ensure effective discharge planning when the facility did not provide caregiver training on the necessary care required by Resident 1 prior to discharge on [DATE].This failure had the potential to cause anxiety to the resident and the resident's caregiver which could lead to inadequate home care and possible rehospitalization. Findings: A review of Resident 1's admission Record dated February 19, 2026, indicated an admission date of January 12, 2026, with diagnoses which included hypertensive heart disease with heart failure (long term high blood pressure has damaged the heart so it cannot pump blood as well as it should) and morbid obesity (extremely overweight). A review of Resident 1's Minimum Data Set (MDS - an assessment tool) dated February 13, 2026, indicated a Brief Interview for Mental Status (an assessment tool for cognitive functioning) score of 14 (cognitively intact). A review of Resident 1's MDS Section GG dated January 19, 2026, indicated Resident 1 required partial/moderate assistance (the resident can do part of the activity but needs help from another person for less than half of the effort) for toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, rolling left and right, sit to lying, and toilet transfer. A review of Resident 1's progress notes titled Case Manager Note, dated February 3. 2026, indicated, .Spoke with (Name of Resident 1's friend), designated DPOA [Durable Power of Attorney], to review and further discuss the patient's discharge plan. (Name of Resident 1's friend) confirmed that the patient will be returning home upon discharge and stated that his (Friend's family member), along with a close friend, will assist with the patient's ADL needs, including support with mobility, personal care, meals, and supervision as needed.The patient was also engaged in discussion and clearly expressed his preference to return home, stating he does not want placement in a board and care setting at this time. A review of Resident 1's physician order dated February 4, 2026, indicated, Benefit Exhaust 2/6/26 (February 6, 2026) discharge 2/7/26 (February 7, 2026) to (home address) . Further review of Resident 1's record indicated there was no documented evidence that caregiver training was provided to the party responsible or any designated caregiver prior to the planned discharge date for February 7, 2026. In addition, there was no documented evidence that the facility rescheduled the caregiver training when the caregiver training was not completed prior to the planned discharge date on February 7, 2026. On February 7, 2026, at 9 a.m., Certified Nursing Assistant (CNA 1) was interviewed. CNA 1 stated Resident 1 required assistance with daily activities. On February 7, 2026, at 9:10 a.m., an interview was conducted with the Responsible Party (RP) for Resident 1. The RP indicated that the facility intended to discharge Resident 1 on that day (February 7, 2026). Additionally, the RP expressed uncertainty regarding the ability to provide the necessary care for Resident 1 following discharge. On February 23, 2026, at 2:25 p.m., the Director of Rehabilitation (DOR) was interviewed. The DOR stated Resident 1's ability to ambulate and work with therapy varied. The DOR stated there was no documentation indicating a caregiver training was provided or appointments were made to coordinate with the caregiver for training. The DOR stated for Resident 1, the physical therapist recommended home health, caregiver, bariatric front wheel walker, wheelchair, and oxygen upon discharge. On February 25, 2026, at 10:55 a.m., the Case Manager (CM) was interviewed. The CM stated Resident 1 wanted to be discharged home. The CM stated Resident 1 was expected to be discharged home on February 7, 2026, when the state agency came. The CM stated caregiver training was offered to Resident 1's RP but was not completed and no caregiver training was completed for Resident 1's designated caregiver. On February 25, 2026, at 11:50 a.m., the Director of Nursing (DON) was interviewed. The DON stated that the rehabilitation department was responsible for providing caregiver training which included the activities of daily living. The DON stated, Resident 1's caregiver should have been provided caregiver training or any other designated caregiver which would be involved in the resident's care to ensure the resident is safe at home. The DON stated, if the caregiver training was not completed, the resident should not be discharged home and would not be considered a safe discharge. A review of the facility policy titled, Discharge Summary and Plan, dated March 2025, indicated, .Discharge Planning.to ensure a safe transition from the facility to the post-discharge setting.based on resident assessment.Discharge planning identifies the discharge destination, and ensures that it meets the resident's health and safety needs.Discharge to the Community.facility determines if appropriate and adequate support is in place.may include the capacity of the resident's caregivers at home.

Based on interview and record review, the facility failed to provide the resident or resident representative, and the Ombudsman with a new written notice of proposed transfer or discharge when a resident originally scheduled for discharge to home was instead discharged to a board and care facility. This failure had the potential to result in Resident 1 and his representative not receiving adequate notification of the change in discharge destination, nor the opportunity to appeal, potentially impacting their rights and the discharge process. Additionally, the Ombudsman not receiving the new proposed discharged notice led to a missed opportunity for the Ombudsman to advocate for the resident's safe discharge.Findings: A review of Resident 1's admission Record dated February 19, 2026, indicated an admission date of January 12, 2026, with diagnoses which included hypertensive heart disease with heart failure (long term high blood pressure has damaged the heart so it cannot pump blood as well as it should) and morbid obesity (extremely overweight). A review of Resident 1's physician order indicated the following: -Dated February 4, 2026, Benefit Exhaust 2/6/26 (February 6, 2026) discharge 2/7/26 (February 7, 2026) to (home address) . -Dated February 13, 2026, .discharge .board and care. A review of Resident's 1 document titled Notice of Proposed Transfer/Discharge, dated February 4, 2026, indicated .Effective Date: 2/7/26 (February 7, 2026) .Transfer/Discharge to. (home address) . There was no documented evidence that a new written notice of proposed transfer/discharge reflecting the new destination of board and care on February 13, 2026, was provided to the resident/representative party (RP) and the Ombudsman. A review of Resident 1's Discharge/Transfer Summary, dated February 13, 2026, indicated resident was discharged to a board and care. On February 23, 2025, at 4:10 p.m., the Case Manager (CM) was interviewed. The CM stated that a written notice of proposed discharge or transfer was given once she was aware of resident's discharge. The CM stated that the Social Service Designee (SSD) was responsible for providing the written notice of proposed transfer/discharge form to the Ombudsman, resident and the resident representative. The CM stated she would provide a new form when there were changes in the discharge plan. The CM stated she did not provide a new copy to the Ombudsman, for Resident 1. The CM stated, providing a written notice would allow the resident to appeal the discharge decision and help ensure safe discharge. On February 25, 2026, at 11:50 a.m., the Director of Nursing (DON) was interviewed. The DON stated that either the Social Services Director (SSD) or the Case Manager (CM) should review the notice with the residents and/or their representative to discuss the new plan, ensure a safe discharge, and provide the opportunity for an appeal. The DON stated the written notice of proposed transfer/discharge should be completed by the SSD or CM and sent by fax to the Ombudsman. Additionally, the DON stated that a new notice of transfer/discharge should have been prepared for the discharge date of February 13, 2026, for Resident 1. The DON indicated that there was no documentation confirming that this new form had been provided to the resident, the resident representative, or the Ombudsman, for Resident 1. A review of the facility policy titled, Transfer or Discharge Notices, dated March 2025 indicated, .Residents (or resident representatives) are notified of an impending transfer or discharge.in writing.A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman.given as soon as it is practicable but before the transfer or discharge.For significant changes, such as a change in the transfer or discharge destination, a new notice will be given.

Based on interview and record review the facility failed to ensure an alleged incident of physical abuse involving two of seven residents reviewed (Resident 1 and Resident 2), was reported to the state survey agency (SSA) within two hours of the incident. On January 4, 2026, Resident 1 was observed pushing Resident 2, who subsequently claimed to have been choked by Resident 1. The alleged physical abuse occurred on January 4, 2026, at 6:30 p.m., and was not reported to the SSA until 9:15 a.m., on January 5, 2026.This failure had the potential for further abuse and a delay in the investigation of the event.Findings:On January 27, 2026, at 11:22 a.m., an unannounced visit to the facility was conducted to investigate allegations of abuse. A review of Resident 1's (alleged perpetrator) admission record indicated the resident was admitted on [DATE], with diagnoses which included peripheral vascular disease (PVD - condition in which arteries outside the heart become narrowed or blocked), anxiety disorder, (a chronic condition characterized by an excessive and persistent sense of apprehension), right below the knee amputation (BKA), Diabetes Mellitus type 2 (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough insulin to maintain normal sugar levels), encounter for orthopedic aftercare following surgical amputation, acquired absence of other left toe(s), acute osteomyelitis (inflammation of bone or bone marrow, usually due to infection), left ankle and foot, cellulitis (infection of the skin and the tissues beneath the skin), of left lower limb, and methicillin resistant staphylococcus aureus infection (MRSA - a bacteria with antibiotic resistance).A review of Resident 1's History and Physical, dated January 1, 2026, indicated resident had no neuro focal deficits, (Speech, vision, and hearing problems).A record review of Resident 1's eINTERACT SBAR (Situation, Background, Appearance, Review) Summary for Providers, dated January 4, 2026, at 5:41 p.m. indicated .Nursing observations, evaluation, and recommendations are: Writer was notified of an incident that occurred at around 18:30 at hallway of Station 3. Writer promptly interviewed al (sic) parties involved. [Resident 2] reported that he encountered LVN [name of Licensed Vocational Nurse 2] and admitted to using profanity towards the LVN [LVN 2] related to an incident on [DATE]. [Resident 1] witnessed the verbal altercation between LVN [name of LVN 2] and [Resident 2] and intervened.A record review of Resident 1's Progress Notes, dated January 4, 2026, at 7:15 p.m., indicated, [Resident 1] stated that [Resident 2] came very close to his face, prompting him to push [Resident 2] away.A review of Resident 2's (alleged victim) admission record indicated resident was admitted on [DATE], and discharged on January 15, 2026, with diagnoses which included opioid use, anxiety disorder, displaced (the bone fragments are separated or misaligned), bicondylar fracture of left tibia (severe, high-energy injury where the upper part of the left shin bone is broken into two or more pieces, involving both the inner and outer sides), subsequent encounter for closed fracture with routine healing status post open reduction and internal fixation (ORIF - a surgical procedure to fix broken bones by realigning the fragments and holding them together with hardware like plates, screws, or rods), and pedestrian on foot injured in collision with car, pick-up truck or van in nontraffic accident, subsequent encounter.A review of Resident 2's History and Physical, dated January 5, 2026, indicated resident was oriented to person, place, and time.A review of Resident 2's Progress Notes, dated January 4, 2026, at 5:50 p.m., indicated, [Resident 2] stated, He [referring to Resident 1] choked me, but I managed to get out. LVN [name of LVN 2] stated that he intervened to separate two patients in order to prevent further escalation. treatment staff assessed [Resident 2] for skin issues or injuries; refer to skin assessment notes. MD was notified and ordered a psychiatric evaluation and monitoring for emotional distress. Writer also notified the patient's [family member] of the incident. Writer and Social Services interviewed [Resident 1], denied choking [Resident 2]. [Resident 2] came very close to his [Resident 1] face, prompting him to push [Resident 2] away.A record review of Resident 2's eINTERACT SBAR Summary for Providers, dated January 4, 2026, at 7:48 p.m., indicated, .Writer was notified of an incident that occurred around 18:30. I promptly interviewed all parties involved. [Resident 2] reported that he had an encounter with LVN [name of LVN 2] and admitted to using profanity toward the LVN [name of LVN 2] related to an incident on Jan. 3, 2026. Another patient [Resident 1] witnessed the verbal altercation between LVN [name of LVN 2] and patient [Resident 2] and intervened.On January 27, 2026, at 2:42 p.m., an interview was conducted with LVN 1. LVN 1 stated that when two residents have a physical altercation the Registered Nurse should be notified immediately. LVN 1 confirmed that physical altercations should be reported within two hours of the event.On January 27, 2026, at 2:57 p.m., an interview was conducted with the Social Services Director (SSD). The SSD stated that the physical altercation between Resident 1 and Resident 2 occurred on January 4, 2026, at 6:30 p.m. The SSD confirmed that the SSA was notified on January 5, 2026, at 9:15 a.m.On January 27, 2026, at 3:02 p.m., an interview was conducted with Resident 1. Resident 1 stated that he observed that Resident 2 was trying to tell a lie about LVN 2 on January 4, 2026, unable to recall the time. Resident 1 stated that he was standing up for LVN 2, and he (Resident 1) denied that LVN 2 had asked for Resident 1's assistance. Resident 1 stated that Resident 2 got into his face, so he pushed Resident 2 away from him. Resident 1 denied that he choked Resident 2.On January 27, 2026, at 3:43 p.m., an interview was conducted with LVN 2. LVN 2 stated that Resident 2 was up on crutches out in the hallway and started verbally yelling at him (LVN 2). LVN 2 stated that Resident 1 came out of his room and approached Resident 2 who got very close to Resident 1's face, and Resident 1 pushed Resident 2 away.On January 27, 2026, at 4:29 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated that the altercation between Resident 1 and Resident 2 occurred on January 4, 2026, at 6:30 p.m. The DON stated that the incident was reported to the SSA on January 5, 2026, at 9:15 a.m. The DON confirmed that the altercation which is considered abuse and should have been reported to the SSA immediately and was not.On March 2, 2026, at 2:59 p.m., a telephone interview was conducted with the DON. The DON confirmed that the altercation between Resident 1 and Resident 2 on January 4, 2026, was reported to the SSA due to physical abuse.A review of the facility's policy and procedure titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, indicated, .1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility. 3. Immediately'' is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury. 4. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone.

Based on interview and record review, the facility failed to ensure for one of seven residents (Resident 3), that the correct laboratory test was carried out and completed. The physician ordered a stool culture for C-diff (a highly sensitive, specialized laboratory test used to detect the presence of Clostridioides difficile bacteria in feces, usually in patients with persistent, antibiotic diarrhea); however the facility carried out a stool culture (a laboratory test that detects disease-causing bacteria, viruses, or fungi in a stool sample to diagnose infections causing diarrhea, fever, or abdominal pain). This failure had resulted in undiagnosed and untreated underlying cause of diarrhea leading to Resident 3 to continuously experience diarrhea until December 31, 2025. This ongoing condition substantially contributed to an elevated white blood cells (WBC-essential immune system cells produced in the bone marrow that protect the body against infections, viruses, and foreign invaders) count of 36.91(normal reference range 4.0 to 11.0). The resident was subsequently transferred to the general acute care hospital (GACH) on January 1, 2026, at 2:12 a.m., and later passed away. Findings: On January 27, 2026, at 11:22 a.m., an unannounced visit was conducted at the facility to investigate quality care issues.A review of Resident 3's admission Record indicated resident was admitted on [DATE], with diagnoses of encounter for surgical aftercare following surgery on the digestive system, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and bipolar disease (a mental health condition that causes extreme mood swings that include emotional highs and lows). A review of Resident 3's History and Physical, dated December 22, 2025, indicated resident had no neuro focal deficits (speech, vision, and hearing problems).A review of Resident 3's Physician Orders for Life -Sustaining Treatment (POLST), dated December 19, 2025, indicated, .Comfort-Focused Treatment .Relieve pain and suffering with medication by any route as needed; use oxygen, suctioning, and manual treatment of airway obstruction .Request transfer to hospital only if comfort needs cannot be met in current location .A review of Resident 3's SBAR Situation Background Appearance Review Communication Form, dated December 25, 2025, indicated, .The change in condition, symptoms, or signs observed and evaluated is/are: Diarrhea This started on 12/25/2025.Recommendations of Primary Clinicians (if any): stool culture for C-diff. A review of Resident 3's Order Summary, dated December 25, 2025, at 9:35 p.m., indicated, CULTURE, STOOL ** SENT .A review of the Order Summary dated December 25, 2025, and the SBAR dated December 25, 2025, indicated the laboratory test carried out for Resident 3 was stool culture and not the laboratory test ordered by the physician as indicated in the SBAR which was stool culture for C-diff.A review of Resident 3's Bowel Continence/Movements, indicated the following:December 26, 2025, at 4:17 a.m., indicated 1, (incontinent) 4, (large), 4, (loose). December 26, 2025, at 5:25 p.m., indicated 1, (incontinent), 3 (medium), 5, (watery).December 27, 2025, at 7:03 p.m., indicated 1, (incontinent), 4, (large), 5, (watery). December 28, 2025, at 7:33 a.m., indicated 0, (continent), 4, (large), 5, (watery).December 29, 2025, at 6:29 a.m., indicated 0, (continent), 3, (medium), 4, (loose). December 29, 2025, at 10:54 a.m., indicated 0, (continent), 4, (large), 4, (loose).December 29, 2025, at 6:04 p.m., indicated 0, (continent), 2, (small), 5, (watery). December 30, 2025, at 6:49 a.m., indicated 1, (incontinent), 3, (medium), 4, (loose). December 30, 2025, at 9:44 p.m., indicated 1, (incontinent), 4, (large), 5, (watery).December 31, 2025, at 1:36 p.m., indicated 0, (continent), 3, (medium), 4, (loose).December 31, 2025, at 10:35 p.m., indicated 1, (incontinent), 4, (large), 5, (watery).Further review of the Bowel Continence/Movement reports from December 26 to December 31, 2025, indicated Resident 3 was having loose, watery stool for seven days (starting December 25, 2025, to December 31, 2025).A review of the Stool culture results dated December 28, 2025, indicated there was no salmonella/shigella. A review of the progress notes did not indicate that the physician was notified that the stool culture for C-diff was not completed as he ordered on December 25, 2025, and that the resident continued to have loose stool since December 25, 2025. Further review of the progress notes did not indicate documentation of treatment for the resident's loose stool.A review of Resident 3's SBAR (Situation, Background, Appearance, Review) Communication Form, dated December 31, 2025, at 4:23 p.m., indicated .Patient reported to have weight loss of -13.2 lbs./-8.1% x 1 week . drowsiness/always sleeping. RD [Registered Dietician] recommends assists with meals, cbc [complete blood count]/cmp [complete metabolic panel] .A review of Resident 3's Laboratory Results, indicated the following:December 23, 2025, WBC 8.44; andDecember 31, 2025, WBC 36.91 flagged as a critical result.A review of Resident 3's SBAR Communication Form, dated December 31, 2025, at 11:39 p.m., indicated, .Received a critical lab result: Elevated WBC - 36.91 . Further review of the document did not indicate any recommendations or interventions from the primary physician. On January 27, 2026, at 3:59 p.m., a telephone interview was conducted with the Registered Nurse (RN 1). RN 1 stated that on December 31, 2025, at approximately 11:30 p.m., she recalled that Resident 3 had a critical laboratory value for WBC of 36.91. RN 1 stated that she texted the doctor with critical laboratory value, and the doctor responded requesting when Resident 3 was admitted to the facility. RN 1 stated that Resident 3's admission date was provided to the doctor with no response. RN 1 stated that she endorsed the critical laboratory value to Licensed Vocational Nurse (LVN 3). RN 1 stated that on January 1, 2026, at approximately 2 a.m., Resident 3's vital signs became unstable and they called 911. RN 1 stated that Resident 3 had a pulse when the paramedics rendered care and transferred. RN 1 stated that the paramedic came into the facility and informed RN 1 that Resident 3 had passed away in the ambulance, time of death 2:38 a.m.On January 28, 2026, at 1:14 p.m., during an interview and concurrent record review, Licensed Vocational Nurse (LVN) 4 stated that if a resident had loose watery stool, they would notify the physician. LVN 4 stated that an order for a stool culture for Clostridioides difficile is a different test than a stool culture. LVN 4 verified that Resident 3's SBAR Communication Form dated December 25, 2025, indicated that the primary clinician recommendation indicated a stool culture for C-diff which was a different laboratory test from what was indicated in the order summary dated December 25, 2025. LVN 4 stated that the physician should have been notified when the wrong laboratory test was completed.On January 28, 2026, at 2:40 p.m., an interview was conducted with RN 2. RN 2 stated if a resident had laboratory results of a WBC at 36.91, the staff would notify the doctor immediately and follow any new orders.On January 28, 2026, at 3:16 p.m., an interview was conducted with the Assistant Director of Nursing (ADON), and she stated the following: Resident 3 had loose stool, and the physician recommended a C-diff panel (referring to stool culture for C-diff), so the staff should have completed a C-diff test. The ADON confirmed that a stool culture for C-diff should have been completed in accordance with the physician recommendation on December 25, 2025. A resident with a laboratory test result for WBC at 36.91 would be a critical laboratory value; and confirmed that the physician should have been notified; and Confirmed that when RN 1 received a response from the physician asking for the admission date, RN 1 should have followed up with the physician again on the resident's critical laboratory value.On February 20, 2026, at 2:53 p.m., a telephone interview was conducted with LVN 3. LVN 3 confirmed that he was in charge of Resident 3 from 11 p.m. to 7 a.m. on December 31, 2025. During this period, RN 1 instructed LVN 3 to monitor Resident 3 due to a critical laboratory value. LVN 3 explained that he performed visual checks on Resident 3 every 30 minutes to ensure normal breathing. He noted that critical laboratory value is considered an emergency and requires an immediate phone call to the physician rather than a text message. He also performed a bladder scan on Resident 3, during which she was easily aroused. However, when he checked on her again later, her breathing had become labored. Subsequently, he notified RN 1 and the Certified Nursing Assistant (CNA). LVN 3 stated RN 1 then proceeded to call 911.On March 2, 2026, at 3:47 p.m., a telephone interview was conducted with Resident 3's physician. Resident 3's physician stated that he was not informed that the c-diff culture that was ordered on December 25, 2025, had not been performed. Furthermore, the physician stated that if the resident was still having loose watery stool, a C-diff culture would have been important as if it was positive, he would have ordered antibiotics. In addition, he stated he ordered the staff for Resident 3 to be transferred to the GACH, but he was unaware that there was a delay in transferring the resident (Resident 3).A review of Resident 3's SBAR Communication Form dated January 1, 2026, at 2:05 a.m., indicated, .Blood Pressure 76/50 [normal range 110/70 to 120/80].Pulse 58 [normal range 60 to 100].Respirations 28 [normal range 16 to 20]. Pulse Oximetry [a small sensor, typically clipped to the fingertip, earlobe, or toe, uses light to detect how well oxygen is being delivered to the body's extremities] 68% [normal range 95% to 100%]. at around 12:45 am writer checked on the roommate and the resident while in the room. Resident no (sic) SOB [shortness of breath] or in distress, at around 2 am during rounds writer noticed resident have (sic) fast and labored breathing, immediately called the RN supervisor and taken (sic) vitals, RN supervisor assessed the resident and called 911, was offered oxygen therapy. MD notified about the residents (sic) condition. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: send resident to [name of hospital].A review of Resident 3's Progress Notes dated January 1, 2026, at 6:59 a.m., indicated .At around 12 am charge nurse was able to perform bladder scan with resident's permission, No SOB noted, able to respond to the writer, not in distress, at around 12:45 am writer checked on the roommate and the resident while in the room. Resident no (sic) SOB or in distress, at around 2 am during rounds writer noticed resident have (sic) fast and labored breathing, immediately called the RN supervisor and taken (sic) vitals, RN supervisor assessed the resident and called 911, was offered oxygen therapy. MD notified about the residents (sic) condition.A review of Resident 3's Progress Notes dated January 1, 2026, at 07:01 a.m., indicated, At 0205, this writer was notified by the charge nurse to assess the patient's oxygen and level of consciousness. This writer immediately went to assess the patient and noted that she was experiencing difficulty with labored breathing. The head of bed was elevated, and oxygen at 15 L[liters]/min [minute] via non-rebreather mask was initiated. The patient was also noted to have an altered mental status at this time. The patient remained responsive but continued to have labored breathing. 911 was called at approximately 0212. Paramedics arrived and assessed the patient; report and all paperwork were given by the charge nurse, including the patient's POLST [physician's order for life sustaining treatment] indicating DNR [do not resuscitate] status. The paramedics then left to transport the patient to [name of hospital]. At 0240, the patient's [family member] wasnotified (sic) of the transfer. At approximately 0245, one of the paramedics returned and informed staff that the patient had passed away at 0238 in the ambulance.Further review of the progress notes and SBAR from December 31, 2025, to January 1, 2026, indicated that resident was not transferred to the GACH until January 1, 2026, at 2:12 a.m., (2 hours after the WBC critical value of 36.91 was received by the facility on December 31, 2025, and 7 days after the resident was first observed with loose stool). Resident 3 passed away on January 1, 2026, at 2:38 a.m., in the ambulance.A review of the facility's policy and procedure titled Change in a Resident's Condition or Status, revised February 2021, indicated .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an). d. significant change in the resident's physical/emotional/mental condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) . 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form.A review of the facility's policy and procedure titled, Lab and Diagnostic Test Results - Clinical Protocol, revised November 2018, indicated, .1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. 3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. Review by Nursing Staff 1. When test results are reported to the facility, a nurse will first review the results. a. If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. 2. Before contacting the physician, the person who is to communicate results to a physician will gather, review, and organize the information and be prepared to discuss the following (to the extent that such information is available): a. The individual's current condition and details of any recent changes in status, including vital signs and mental status. c. Why the lab and diagnostic tests were obtained (for example, as a routine screen or follow-up; to assess a condition change or recent onset of signs and symptoms, or to monitor a serum medication level); d. How test results may relate to the individual's current condition and treatment; and e. Any concerns and questions the physician will be expected to address regarding the resident. 3. A nurse will identify the urgency of communicating with the Attending Physician based on physician request, the seriousness of any abnormality, and the individual's current condition. Identifying Situations that Warrant Immediate Notification. 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results .Options For Physician Notification. 1. A physician can be notified by phone, fax, voicemail, email, mail, pager, or a telephone message to another person acting as the physician's agent .b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. Physician Responses .a. A physician should respond within one hour regarding a lab test result requiring immediate notification.b. If the attending or covering Physician does not respond to immediate notification within an hour, the nursing staff should contact the Medical Director for assistance .

Based on observation, interview, and record review, the facility failed to ensure professional standards of practice for ostomy care were provided to one of three sampled residents (Resident 2), when the Licensed Vocational Nurse (LVN 1) used a wound cleanser ([NAME] Dermal Wound Cleanser) containing sorbitol (a sugar alcohol) to cleanse the peristomal skin (the area of skin around a stoma [opening] for a colostomy [a surgical procedure that creates an opening in the abdomen connecting part of the large intestine [colon] to the outside of the body, allowing stool and gas to exit through it into a collection bag). This failure caused Resident 2 to suffer pain and had the potential to irritate and damage fragile peristomal skin. Findings:On December 10, 2025, at 10:07 a.m., an unannounced visit to the facility on a complaint and Facility Reported Incident were initiated. A review of Resident 2's medical records indicated the resident was admitted on [DATE], with diagnoses of encounter for surgical aftercare following surgery on the digestive system, pneumonitis (infection) due to inhalation of food and vomit, pressure ulcer, (bed sore) of sacral region, (lies between the fifth segment of the lower spine and the tailbone), type 2 diabetes mellitus, (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough insulin to maintain normal sugar levels), encounter for encounter for attention to colostomy.On December 10, 2025, at 11:59 a.m., an interview was conducted with the Licensed Vocational Nurse (LVN 1). LVN 1 stated he was working on December 10, 2025, and provided care to Resident 2. LVN 1 stated that he changed Resident 2's colostomy bag, cleansed the area with warm water and gauze, and applied a new colostomy bag at approximately 8 p.m. LVN 1 further stated that after returning from a break, a Certified Nursing Assistant (CNA) informed him that Resident 2's colostomy bag was leaking. LVN 1 stated that upon assessment, he observed some redness, where the adhesive contacted the skin, used a wound cleanser to clean the skin and applied a new colostomy bag. On December 10, 2025, at 12:19 p.m., during an interview with the Registered Nurse (RN), the RN stated that on December 6, 2025, she received a call from the Assistant Director of Nursing (ADON) to check on Resident 2. The RN stated that Resident 2 reported that during the colostomy bag change on December 5, 2025, LVN 1 sprayed a liquid on the site that caused severe pain that he had to cover his mouth to avoid screaming out in pain. The RN stated that she reported the incident to the facility administrator. On December 10, 2025, at 12:26 p.m., an interview was conducted with Resident 2. Resident 2 stated on December 5, 2025, at approximately 8:25 p.m., the colostomy bag was leaking and needed to be changed. Resident 2 stated that on December 5, 2025, approximately 9:20 p.m., LVN 1 removed the leaking colostomy bag and used a spray that smelled very strong and burned so badly he had to bite down on his knuckles to keep from screaming. Resident 2 stated that the spray felt like alcohol. Resident 2 stated that on Saturday, December 6, 2025, he reported the incident to ADON by telephone. On December 10, 2025, at 1:30 p.m., an interview was conducted with the Director of Nursing, (DON). The DON stated that Resident 2's physician orders indicated to change the colostomy bag as needed when 3/4 full. The DON stated that usually they would cleanse the peristomal area with normal saline. On December 10, 2025, at 1:48 p.m., during an interview with the Treatment Nurse, the TN stated that Resident 2 had a colostomy bag and would require colostomy bag changes as needed. The TN stated that the peristomal skin would be cleansed with gauze soaked with normal saline. The TN stated that wound cleanser would not be used on the peristomal skin, as it would cause burning. On December 10, 2025, at 2:31 p.m., during an interview with LVN 1, LVN 1 confirmed that [NAME] Dermal Wound Cleanser was used on Resident 2's peristomal skin on December 5, 2025. A review of the listed ingredients indicated sorbitol was the second ingredient listed. A review of Resident 2's Summary Order Report dated November 13, 2025, indicated .Change colostomy bag PRN [as needed] if soiled or dislodgement. Cleanse stoma area & dry gently. Apply ointment as ordered.A review of Resident 2's Health Status Note dated December 5, 2025, at 10:25 p.m., indicated Patient noted with leaking colostomy appliance during PM shift. Colostomy bag was changed twice at 20:00 and 21:50 due to leaking brown BM. Stoma assessed during each change; stoma pink, moist, and intact. Peristomal skin cleansed with warm water, dried thoroughly, and new appliance applied with proper seal. No redness or skin breakdown noted.A review of Resident 2's eINTERACT SBAR Summary for Providers dated December 6, 2025, at 12:54 p.m., indicated .Pt reported an alleged physical abuse against a staff member. Pt explained that it happened while charge nurse was changing his colostomy bag and cleaning his surgical site. Pt reported that a liquid was sprayed that felt like alcohol to his open wound. Pt stated that the pain caused by the spray was unbearable and he had to cover mouth from screaming. Patient further stated the work had to be re-done during the next shift.A review of the Wound, Ostomy, and Continence Nurses Society guidelines titled Basic Ostomy Skin Care published July 2024, indicated .Cleaning the Skin Around the Ostomy. Clean the skin around the ostomy with warm water and a washcloth or soft paper towel and pat dry. Do not use alcohol or any other harsh chemicals to clean the skin around the ostomy. They can cause the skin to get sore.

Based on observation, interview, and record review, the facility failed to ensure use of the Hoyer lift (a portable total patient lifting tool to assist in transferring patients in and out of bed) was operated with two persons for one of four residents (Resident 1). This failure placed Resident 1 at risk for falls and physical injury due to lack of adequate staff support during mechanical lift transfer. Findings:On September 9, 2025, at 2:12 p.m., observed the Physical Therapist (PT) operating the Hoyer lift to transfer Resident 1 from bed to wheelchair without a second staff member assisting. The PT roll the Hoyer lift over towards the wheelchair, with Resident 1 in the Hoyer lift. On September 9, 2025, at 2:17 p.m., during an interview with the CNA, the CNA stated that the Hoyer lift was to be used with two people to ensure resident safety. On September 9, 2025, at 2:51 p.m., during an interview with the PT, the PT stated that Resident 1 required maximum assistance for bed transfers. The PT stated that the Hoyer lift should be operated with two people, and he was operating the Hoyer lift by himself with Resident 1.Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (paralysis of one side of the body) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity and imprecise movement).A review of Resident 1's care plan dated October 3, 2023, indicated, .ADL (activities of daily living) Self-Care Performance Deficit .Interventions .Provide appropriate self-performance and support needed during ADL care .A review of Resident 1's Functional Abilities and Goals, dated August 8, 2025, indicated .Mobility .Chair/bed-to-chair transfer .substantial/maximal assistance [resident does 25-49% of the effort] .A review of the facility's policy and procedure titled Lifting Machine, Using a Mechanical revised July 2017, indicated The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. 2. Mechanical lifts may be used for tasks that require b. Transferring a resident from bed to chair.

Based on observation, interview, and record review, the facility failed to ensure accurate documentation of an incident for one of four sampled residents (Resident 3), when the facility did not document a verbal altercation and related behaviors in the medical record.This failure had the potential for events to go unreported, increasing the recurrence, inadequate monitoring, and poor resident outcomes.Findings:On September 9, 2025, at 11:13 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse.A review of Resident 3's medical records indicated resident was admitted on [DATE], with diagnoses of monoplegia, (paralysis restricted to one limb or region of the body), of lower limb following cerebral infarction, (stroke), affecting left non-dominant side.A review of Resident 3's History and Physical dated June 28, 2025, indicated .doing well overall. In goodspirits (sic).A review of Resident 4's medical records indicated resident was admitted on [DATE], with diagnoses of displaced intertrochanteric fracture of right femur, (broken hip), subsequent encounter for closed fracture with routine healing, diabetes mellitus type 2, (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough insulin to maintain normal sugar levels), and major depressive disorder, (a mood disorder that causes a persistent feeling of sadness and loss of interest).A review of Resident 4's History and Physical dated August 3, 2025, indicated resident had the capacity to make decisions.On September 9, 2025, at 11:47 a.m., during an interview with Resident 4, Resident 4 stated Resident 3 was bumping her wheelchair into everything and appeared agitated. Resident 4 stated that she overheard Resident 3 on the phone threatening to beat someone up. Resident 4 stated she put on her call light, and staff removed Resident 3 from the room. On September 9, 2025, at 1:24 p.m., during an interview with Resident 3, Resident 3 admitted that she wanted to beat up Resident 2, her previous roommate. Resident 3 denied intending to beat up Resident 4. On September 9, 2025, at 1:35 p.m., during an interview with the Licensed Vocational Nurse, (LVN), the LVN stated that when a resident is involved in a verbal altercation, they document a Change of Condition in the medical records. On September 9, 2025, at 1:38 p.m., during an interview with the Assistant Director of Nursing, (ADON), the ADON stated that Resident 3 had a verbal altercation with Resident 2 and was moved to a new room with Resident 4. The ADON stated that Resident 4 overheard Resident 3 on the phone talking about the altercation with Resident 2, earlier in the day. On September 9, 2025, at 3:23 p.m., during an interview with the Certified Nursing Assistant, (CNA 1), CNA 1 stated that on September 4, 2025, Resident 3 was moved from another room due to an altercation. CNA 1 stated that Resident 3 was upset, cursing and yelling from the previous altercation with Resident 2. CNA 1 stated she stepped away from the room and noticed Resident 4 had put on her call light, responded to the call light, and found Resident 4 crying, stating that she overheard Resident 3 was going to beat her ass CNA 1 notified the Registered Nurse and moved Resident 4 to a different room. On September 9, 2025, at 4:38 p.m., during an interview and record review with the Director of Nursing, (DON), the DON reviewed Resident 3's progress notes and confirmed there was no documentation of the incident with Resident 4. There was no evidence of documentation in Resident 3's medical records regarding the incident with Resident 4.A review of Resident 4's eINTERACT SBAR Summary for Providers dated September 4, 2025, indicated .Nursing observations, evaluation, and recommendations are: [Resident 4's room number] Call light was on and attended call light noted patient emotionally distress and crying r/t [related to] new room mate, (sic). According to [Resident 3], roommate went to her bed andtouch [sic] her bed. Roommate was on the phone saying I am gonna beat her up. Separated patient and have a CNA watch them to prevent further incident while CN [charge nurse] informed RN [Registered Nurse] that [Resident 4] and roommate [Resident 3] are not compatible. Case Manager talked to [Resident 3] and said that she was talking on the phone about her old roommate in [room number].A review of Resident 4's IDT Note dated September 4, 2025, at 8 p.m., indicated Late Entry: Clinical Event Type:: Alleged Verbal AltercationDate and Time of Event:: 9/4/25 at around 6pm. Root Cause Analysis (RCA). Include Potential Underlying Cause(s)/Contributing Factor(s):: At around 6pm, the assigned LN [licensed nurse] and CNA reported to the writer that patient and her roommate are not compatible. Patient was crying after hearing her roommate on the phone saying she's going to beat her up. Writer went to the room, saw CM [case manager] speaking with theroommate (sic) and also social services speaking with the patient to get her statement. DON, [Director of Nursing], ADON, [Assistant Director of Nursing], Administrator, and Social Services notified. LN also reported that patient stated that her roommate slapped her bed, however roommate denied this. Patient's roommate clarified that she was on the phone talking about her previous roommate. Shortly after, patient was moved to a different room and station.Resident Description of Event:: Nursing staff and writer have been informed that patient had an alleged verbal altercation with her room mate (sic) who was moved into the room.[Resident 4] stated that she overheard a phone conversation of her room mate (sic) stating I will punch her and felt threatened by the comment. Prior to the comment, new room mate (sic) [Resident 3] alleged pushed her wheelchair into patients wheelchair who was sitting in bed at the time. Per [Resident 4] did not like that behavior but did not say anything.A review of the facility's policy and procedure titled Charting and Documentation revised July 2017, indicated .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 2. The following information is to be documented in the resident medical record. d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident.

Based on interview, and record review, the facility failed to ensure an injury of unknown origin involving one of five residents, (Resident 2) was reported to the State Survey Agency, (SSA), within two hours. Resident 2 was found by staff on April 22, 2025, visibly distressed, and verbally expressing severe pain with a bleeding wound on the right posterior scalp, which the resident could not explain the cause. This failure had the potential for a delay in the SSA investigation, which could result in missed opportunities for safety improvement and implementation of corrective actions. Findings: On April 22, 2025, at 4:38 p.m., the state survey agency received a call from the facility ' s Director of Nursing (DON), to report Resident 2 ' s injury of unknown origin that occurred on April 22, 2025, at approximately 3 a.m. A review of Resident 2 ' s admission record indicated Resident 2 was admitted on [DATE], with diagnoses of displaced (the bone fragments are not properly aligned) intertrochanteric fracture of left femur (a break in the upper part of the thigh bone), aneurysm of artery (a bulge or ballooning in the wall of a blood vessel) of lower extremity, and rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility). Further review of the record indicated Resident 2 was transferred to the general acute care hospital (GACH) on April 22, 2025. A review of Resident 2 ' s History and Physical dated March 17, 2025, indicated no focal deficits (problem with nerve, spinal cord, or brain function). On April 24, 2025, at 1:50 p.m., during an interview with the Licensed Vocational Nurse (LVN), the LVN stated that on April 22, 2025, at approximately 3 a.m., Resident 2 was found in her room with blood dripping from her head. The LVN stated they were unable to determine what had happened and Resident 2 was unable to verbalize what had happened. The LVN stated that they should report an injury of unknown origin to the DON or the Administrator right away. On April 24, 2025, at 3:36 p.m., during an interview, the Assistant Director of Nursing (ADON) stated Resident 2 had an injury of unknown origin that happened on April 22, 2025, at 3 a.m. The ADON stated that the facility is required to report injuries of unknown origin within two hours to the SSA, the Ombudsman, and law enforcement. The ADON stated the facility reported Resident 2 ' s injury of unknown origin after twelve hours. On April 24, 2025, at 5:06 p.m., during a telephone interview, the Certified Nursing Assistant (CNA) stated she was caring for Resident 2 on April 22, 2025. The CNA stated on April 22, 2025, at 2:52 a.m., as she was walking by Resident 2 ' s room, she observed Resident 2 thru the open door, leaning over her over-bed table. The CNA stated she noticed the resident ' s walker was turned over on the side, and there was a large pool of blood in the middle of the floor. The CNA stated she called for assistance, and the facility called 911; and transferred Resident 2 to the hospital. A review of Resident 2 ' s eINTERACT SBAR, dated April 22, 2025, at 3:31 a.m., indicated .Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Bleeding (other than GI) . Nursing observations, evaluation, and recommendations are: Patient (sic) was observed standing in her room, using her bedside table for support, and repeatedly yelling to call her (family member). Blood was noted on the floor, as well as on the patient ' s jacket (sic) and the right posterior side of her head. Upon assessment, a wound was identified on the right posterior scalp. The patient was visibly distressed, verbally expressing severe pain and yelling. She complained of an intense headache. When asked why and how she started bleeding patient is unable to recall. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Transfer to acute hospital for further eval due to bleeding from the back of head . A review of Resident 2 ' s Progress Notes, dated April 22, 2025, at 8:24 a.m., indicated Late Entry: Writer called and faxed SOC 341 to CDPH and Ombudsman Office. (Name of City) Police was notified (sic) . A review of Resident 2 ' s Progress Notes, dated April 22, 2025, at 12:52 p.m., indicated Late Entry . resident was last seen by the CNA at around 1:40 am on 4/22/25 and observed to be asleep in bed. CNA stated: Throughout the night, I checked on the patient three times prior to the incident—each time to assist with her bedpan. On all three occasions, she appeared to be in a deep sleep and required waking to respond. The first time I had checked her was about 11:30 pm, while the last time I had went into her room (before the fall) was around 1:30/1:40 am before I went to my lunch. Shortly after returning from my lunch break around 2:52 am, I was walking past her room when I noticed the patient had just opened the door, same time as I was walking by. I found the patient (sic) hunched over her bedside table (at around 2:52 am). I immediately observed her walker knocked over on the floor, a significant amount blood in the middle of room on the ground, and bleeding from a head wound. I tried asking her what had happened but did not get a response until the nurse came in who speaks the same language as her. I quickly approached to support her and called out for the nurse on duty. We promptly assisted her back to bed, notified the RN supervisor, and contacted emergency services (911). During this time, the patient appeared confused, repeatedly asked for her son, and expressed head pain. LVN stated: Upon assessment, the patient was noted to have an open wound on the right side of the back of her head. When asked if she had fallen, (sic) the patient stated, I don't know what happened to me, and was unable to recall the event . A review of Resident 2 ' s Hospital History and Physical, dated April 22, 2025, at 6:05 p.m. indicated .Patient was found to have trace pneumocephalus, (the presence of air or gas within the skull), SAH, (subarachnoid hemorrhage - bleeding in the area between the brain and the thin tissues that cover and protect it), and SDH, (subdural hematoma - a collection of blood that forms between the brain and the inner layer of the protective tissue surrounding the brain), and will be admitted to ICU (Intensive Care Unit), for further monitoring with trauma team as primary. A review of the facility ' s policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised October 2022, indicated . Reporting Allegations to the Administrator and Authorities . If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law . 2. The administrator and/or designee or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury .

Based on interview and record review, the facility failed to ensure a copy of the discharge notice was sent to the Long-Term Care (LTC) Ombudsman at the same time the notice was provided to one of four sampled residents (Resident 1). This failure had the potential for the LTC Ombudsman not to be able to advocate for the resident in protecting their rights from inappropriate transfer and discharge. Findings: On April 30, 2025, at 9:14 a.m., an unannounced visit to the facility was initiated to investigate an admission, transfer, and discharge rights concern. A review of Resident 1 ' s History and Physical, dated April 3, 2025, indicated Resident 1 was alert and oriented to person, place, and time. On April 30, 2025, at 10:29 a.m., during an interview, the Social Services Designee (SSD 1) stated that the discharge notice for Resident 1 should be sent to the LTC Ombudsman office at the same time the discharge notice is sent to the resident or the resident representative, which should have been on April 22, 2025, for Resident 1. On April 30, 2025, at 10:54 a.m., an interview was conducted with SSD 2. SSD 2 stated that the discharge notice for Resident 1 was provided to Resident 1 ' s family member over the phone and a copy was provided to Resident 1, on April 22, 2025. SSD 2 stated that they sent the discharge notice to LTC Ombudsman on April 25, 2025, by fax. A review of Resident 1 ' s Notice of Transfer / Discharge, issued on April 22, 2025, indicated .Notification Date: 4/22/25 .Effective Date:: 4/25/25 .This notice to inform you that transfer/discharge is necessary for the following reasons .The transfer or discharge is appropriate because your health has improved sufficiently so you no longer require services by this facility .Copy of State LTC Ombudsman Office date: 4/25/25 . A review of Resident 1 ' s Progress Notes, dated April 25, 2025, at 3 p.m., indicated .Patient with an order to Discharge to home . Patient left the facility at around 3 pm pickup by [name of transportation company] . A review of the facility policy and procedure titled Transfer or Discharge Notices, revised March 2025, indicated .Notice of Transfer or Discharge (Anticipated) . 4. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative .

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices when: 1. One sandwich snack was observed to be expired; 2. One dispensing scoop was left inside the container and not stored outside or on top of the mashed potato powder; 3. The kitchen door located near the garbage container area was left open for 20 minutes; and 4. Three garbage containers did not have covers. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) among a vulnerable population of 112 out of 115 residents who received food prepared in the facility's kitchen. Findings: 1. On [DATE], at 9:20 a.m., during an initial kitchen observation, with the Assistant Dietary Supervisor (ADS), one peanut butter and jelly sandwich was found in the snacks refrigerator with a label that read Expired on [DATE], readily available. During a concurrent interview with the ADS, the ADS stated the sandwich was prepared on [DATE], and should have been discarded on [DATE]. The ADS stated, the sandwich should not have been found in the refrigerator. The ADS further stated, if the sandwich had been served to a resident, it could have caused illness. On [DATE], at 1:25 p.m., during an interview with the Registered Dietician (RD) 1, the RD 1 stated the sandwich was past its expiration date, should have been discarded, and was not safe to serve to residents. A review of the facility policy and procedure titled, Food Safety Product Labeling and Dating Guide, dated [DATE], indicated, .clearly marked with use by date (day or date product must be discarded) . 2. On [DATE], at 9:27 a.m., a dispensing scoop was observed stored inside a container, in direct contact with mashed potato powder. During a concurrent interview with the ADS , the ADS stated the scoop should not be in contact with the powder and should be stored in its designated place. On [DATE], at 1:25 p.m., during an interview with Registered Dietician (RD) 1, RD 1 stated a dispensing scoop should be hanging and not touching the product, to prevent cross-contamination. A review of the professional reference U.S. FDA (Food and Drug Administration) Food Code 2022, Section ,d+[DATE].12 In-Use Utensils, Between-Use Storage. indicated, .During pauses in FOOD preparation or dispensing. FOOD preparation and dispensing UTENSILS shall be stored: .in the food with their handles above the top of the food . 3. On [DATE], at 9:47 a.m., the kitchen door leading to the garbage area was observed to be open. During a concurrent interview with the ADS, he stated, the door was propped open for approximately 20 minutes. The ADS stated, the door should not have been left open due to risk of insects and dust entering the kitchen, which could lead to cross-contamination. A review of the professional reference U.S. FDA Food Code 2022, Section ,d+[DATE].14 Outer Openings, Protected. indicated, .The outer openings of a FOOD ESTABLISHMENT shall be protected against the entry of insects and rodents by Solid, Self-closing, tight fitting doors . 4. On [DATE], at 9:51 a.m., three large dumpsters were observed without a tight fitting covers. During a concurrent interview with the ADS, the ADS stated the dumpsters should be covered to prevent insects and rodents infestation. A review of the facility policy titled, .Dispose of Garbage and Refuse, dated [DATE], indicated .Garbage and refuse containers are maintained in good condition .and waste is properly contained in dumpsters .with lids covered .

Based on interview and record review, the facility failed to ensure, 11 of 14 residents reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) (Residents 13, 17, 19, 70, 78, 84, 90, 97, 319, 320, and 322) a copy of the AD was available and the resident or their resident representative (RP) had been provided follow up information regarding the formulation of an AD. These failures had the potential to result in the ADs for Residents 13, 17, 19, 70, 78, 84, 90, 97, 319, 320, and 322 not being readily accessible to staff and physicians, which could lead to the residents' wishes regarding medical treatment being unknown and ultimately not honored. Findings: 1. On April 14, 2025, at 3:58 p.m., an interview was conducted with Resident 70. Resident 70 stated that he was unsure of having an AD and unsure if asked if he would like to formulate one. Resident 70's record was reviewed. Resident 70 was admitted to the facility on [DATE]. A review of the Advance Directive Acknowledgment form, dated March 19, 2025, indicated, .I have not executed any advance directives . A review of Resident 70's Physician Orders for Life-Sustaining Treatment (POLST), dated March 19, 2025, did not indicate Resident 70 had an AD. A review of Resident 70's Minimum Data Set (MDS - an assessment tool), dated March 26, 2025, indicated Resident 70 had Brief Interview of Mental Status (BIMS - a tool to assess cognitive function of an individual) score of 15 (intact cognitive response). A review of the Resident Care Conference dated March 20, 2025, indicated, .Advance Directive/POLST/code status order .(check marked). There was no documented evidence the resident or (RP) was provided information about the right to formulate an AD. On April 17, 2025, at 9:40 a.m., a concurrent interview and record review was conducted with the Social Service Director (SSD) 1. Resident 70's Care Conference dated March 20, 2025, was reviewed with the SSD 1. SSD 1 stated, upon admission, residents in the facility are provided an acknowledgement form indicating whether they have an AD. SSD 1 stated, if a resident has an AD, they would request a copy for facility records; if not, the resident is provided with education on how to create one. SSD 1 further stated a review of the AD should be conducted during the resident care conference. SSD 1 stated that there was no documentation showing Resident 70 or the RP was informed of the right to formulate an AD. SSD 1 stated, it should have been documented and followed up during the resident care conference. SSD 1 stated without an AD on file there was a risk the facility may not be able to honor the resident's care. 2. On April 14, 2025, at 4:00 p.m., an interview was conducted with Resident 90. Resident 90 stated that he was unsure of having an AD and unsure if asked if he would like to formulate one and would like to know more about it. Resident 90's record was reviewed. Resident 90 was admitted to the facility on [DATE]. A review of the Advance Directive Acknowledgment form, dated November 27, 2024, indicated, .I have not executed any Advance Directives . A review of Resident 90's POLST, dated October 10, 2024, indicated, .No advance Directive . A review of Resident 90's the MDS, dated [DATE], indicated Resident 90 had a BIMS score of 15. A review of the Resident Care Conference dated November 28, 2024, indicated, .Advance Directive/POLST/code status order .(check marked). There was no documented evidence the resident or (RP) was provided follow up information about the right to formulate an AD. On April 17, 2025, at 9:43 a.m., a concurrent interview and record review was conducted with SSD 1. Resident 90's care conference dated November 28, 2024, was reviewed SSD 1. SSD 1 stated that there was no documentation showing Resident 90's or the RP were informed about their right to formulate an AD and that it should have been documented and followed up during the resident care conference. 3. On April 14, 2025, at 3:50 p.m., an interview was conducted with Resident 97. Resident 97 stated that she was unsure of having an AD and unsure if asked if she would like to formulate one. Resident 97's record was reviewed. Resident 97 was admitted to the facility on [DATE]. A review of the Advance Directive Acknowledgment form, dated March 19, 2025, indicated, .I have not executed any advance directives . A review of Resident 97's POLST, dated March 13, 2025, did not indicate Resident 97 had an AD. A review of Resident 97's MDS, dated [DATE], indicated Resident 97 had BIMS score of 11 (moderate cognitive impairment). A review of the Resident Care Conference dated March 13, 2025, indicated, .Advance Directive/POLST/code status order .(check marked). There was no documented evidence the resident or (RP) was provided follow up information about the right to formulate an AD. On April 17, 2025, at 9:54 a.m., a concurrent interview and record review was conducted with SSD 1. Resident 97's care conference dated March 13, 2025, was reviewed with SSD 1. SSD 1 stated that there was no documentation indicated Resident 97 or the RP were informed about their right to formulate an AD and that it should have been documented and followed up during the resident care conference. 4. On April 14, 2025, at 3:46 p.m., an interview was conducted with Resident 84. Resident 84 stated that he was unsure of having an AD and unsure if asked if he would like to formulate one. Resident 84's record was reviewed. Resident 84 was admitted to the facility on [DATE]. A review of the Advance Directive Acknowledgment form, dated October 10, 2024, indicated, .I have not executed any advance directives . A review of Resident 84's POLST, dated October 10, 2024, indicated, No advance Directive. A review of Resident 84's MDS, dated [DATE], indicated Resident 84 had BIMS score of 12 (moderate cognitive impairment). A review of the Resident Care Conference dated January 9, 2025, indicated, .Advance Directive/POLST/code status order .(check marked). There was no documented evidence the resident or (RP) was provided follow up information about the right to formulate an AD. On April 17, 2025, at 9:57 a.m., a concurrent interview and record review was conducted with SSD 1. Resident 84's care conference dated January 9, 2025, was reviewed with SSD 1. SSD 1 stated that there was no documentation indicated Resident 84 or the RP were informed about their right to formulate an AD and that it should have been documented and followed up during the resident care conference. 51063 5. During an interview on April 15, 2025 at 4:15 p.m. with Resident 13, Resident 13 stated she believed she had an AD and the facility should have a copy. A review of Resident 13's Admission Record indicated Resident 13 was admitted [DATE]. A review of Resident 13's POLST, dated March 18, 2025, did not indicate Resident 13 had an AD. A review of Resident 13's MDS, dated [DATE], indicated Resident 13 had a BIMS score of 15 - (intact cognitive response). There was no documented evidence the resident or (RP) were provided follow up information or education about the right to formulate an AD and that a copy was available for reference. A review of the Advance Directive Acknowledgment form, dated March 18, 2025, indicated, .I have not executed any advance directives . A review of the Resident Care Conference dated March 19, 2025, indicated, .Advance Directive/POLST/code status order .(check marked). On April 17, 2025 at 10 a.m., during a concurrent interview and record review of Resident 13's Care Conference dated March 19, 2025, with Social Service Director (SSD) 1, SSD 1 stated upon admission, residents in the facility are provided an acknowledgement form indicating whether they have an AD. SSD 1 stated if a resident had an AD they would request for a copy to have available in the facility or will provide them with education on how to formulate one. SSD 1 further stated a review of the AD should be conducted during the resident care conference. SSD 1 stated that there was no documentation showing Resident 13 or the representative parties were informed about their right to formulate an AD and should have been documented and followed up during the resident care conference. SSD 1 stated if there was no AD on file there was a potential for the facility to not be able to honor their wishes for care. 6. During an interview on April 15, 2025 at 4:30 p.m. with Resident 320, Resident 320 stated she does not have an AD and would like to have one. Resident 320 stated she was unsure if it was offered and if it was followed up. A review of Resident 320's Admission Record indicated Resident 320 was admitted [DATE]. A review of Resident 320's POLST, dated April 4, 2025, did not indicate Resident 320 had an AD. A review of Resident 320's MDS, dated [DATE], indicated Resident 320 had a BIMS score of 14 - (intact cognitive response). There was no documented evidence the resident or (RP) were provided follow up information or education about the right to formulate an AD. A review of the Advance Directive Acknowledgment form, dated April 4, 2025, indicated, .I have not executed any advance directives . A review of the Resident Care Conference dated April 5, 2025, indicated, .Advance Directive/POLST/code status order .(check marked). On April 17, 2025 at 10:03 a.m., during a concurrent interview and record review of Resident 320's Care Conference dated April 5, 2025, with Social Service Director (SSD) 1, SSD 1 stated that there was no documentation showing Resident 320 or the representative parties were informed about their right to formulate an AD and should have been documented and followed up during the resident care conference. 7. During an interview on April 15, 2025 at 3:55 p.m. with Resident 322, Resident 322 stated he did not have an AD and was not interested at this time. Resident 322 stated he could not remember if it was offered. A review of Resident 322's Admission Record indicated Resident 322 was admitted [DATE]. A review of Resident 322's POLST, dated January 25, 2025, indicated Resident 322 did not have an AD. A review of Resident 322's MDS, dated [DATE], indicated Resident 322 had a BIMS score of 10 - (moderately impaired cognitive response). There was no documented evidence the resident or (RP) were provided follow up information or education about the right to formulate an AD. A review of the Advance Directive Acknowledgment form, dated January 25, 2025, indicated, .I have not executed any advance directives . A review of the Resident Care Conference dated January 27, 2025, indicated, .Advance Directive/POLST/code status order .(check marked). On April 17, 2025 at 10:06 a.m., during a concurrent interview and record review of Resident 322's Care Conference, dated January 27, 2025, with Social Service Director (SSD) 1, SSD 1 stated that there was no documentation showing Resident 322 or the representative parties were informed about their right to formulate an AD and that it should have been documented and followed up during the resident care conference. SSD 1 stated if there was no AD on file there was a potential for the facility to not be able to honor their wishes for care. 8. During an interview on April 15, 2025 at 4:35 p.m. with Resident 319, Resident 319 stated she did not have an AD but was interested and was unsure if the facility followed up with her. A review of Resident 319's Admission Record indicated Resident 319 was admitted [DATE]. A review of Resident 319's POLST, dated April 9, 2025, did not indicate Resident 319 had an AD. There was no documented evidence the resident or (RP) were provided follow up information or education about the right to formulate an AD. A review of the Advance Directive Acknowledgment form, dated April 9, 2025, indicated, .I have not executed any advance directives . A review of the Resident Care Conference dated April 10, 2025, indicated, .Advance Directive/POLST/code status order .(check marked). On April 17, 2025 at 10:10 a.m., during a concurrent interview and record review of Resident 319's Care Conference, dated April 10, 2025, with the Social Service Director (SSD) 1, SSD 1 stated that there was no documentation showing Resident 319 or the representative parties were informed about their right to formulate an AD and that it should have been documented and followed up during the resident care conference. SSD 1 stated if there was no AD on file there was a potential for the facility to not be able to honor their wishes for care. 9. During an interview on April 16, 2025 with Resident 19, Resident 19 stated he did not have an AD but is interested in formulating one and was unsure if the facility followed up. A review of Resident 19's Admission Record indicated Resident 19 was admitted on [DATE]. A review of Resident 19's POLST, dated February 13, 2025, did not indicate Resident 19 had an AD. A review of Resident 19's MDS, dated [DATE], indicated Resident 19 had a BIMS score of 11 - (moderately impaired cognitive response). There was no documented evidence the resident or (RP) were provided follow up information or education about the right to formulate an AD. A review of the Advance Directive Acknowledgment form, dated April 3, 2024, indicated, .I have not executed any advance directives . A review of the Resident Care Conference dated March 18, 2025, indicated, .Advance Directive/POLST/code status order .(check marked). On April 17, 2025 at 10:14 a.m., during a concurrent interview and record review of Resident 19's Care Conference, dated March 18, 2025, with the Social Service Director (SSD) 1, SSD 1 stated that there was no documentation showing Resident 19 or the representative parties were informed about their right to formulate an AD and that it should have been documented and followed up during the resident care conference. SSD 1 stated if there was no AD on file there was a potential for the facility to not be able to honor their wishes for care. 10. During an interview on April 14, 2025 at 12:45 p.m. with Resident 17, Resident 17 stated she did not have an AD but would like to have one and was unsure if it was offered or followed up. A review of Resident 17's Admission Record indicated Resident 17 was admitted on [DATE]. A review of Resident 17's POLST, dated January 17, 2025, did not indicate Resident 17 had an AD. A review of Resident 17's MDS, dated [DATE], indicated Resident 17 had a BIMS score of 15 - (intact cognitive response). There was no documented evidence the resident or (RP) were provided follow up information or education about the right to formulate an AD. A review of the Advance Directive Acknowledgment form, dated January 17, 2025, indicated, .I have not executed any advance directives . A review of the Resident Care Conference dated April 10, 2025, indicated, .Advance Directive/POLST/code status order .(check marked). On April 17, 2025 at 10:16 a.m., during a concurrent interview and record review of Resident 17's Care Conference dated April 10, 2025, with the Social Service Director (SSD) 1, SSD 1 stated that there was no documentation showing Resident 17 or the representative parties were informed about their right to formulate an AD and that it should have been documented and followed up during the resident care conference. SSD 1 stated if there was no AD on file there was a potential for the facility to not be able to honor their wishes for care. 50309 11. On April 15, 2025, at 10:36 a.m. an interview was conducted with Resident 78. Resident 78 stated initially he did not execute an AD but would like to complete one now. Resident 78 further stated, he could not recall being asked about it again and would like more information. A review of Resident 78's Admission Record indicated Resident 78 was admitted to the facility on [DATE]. A review of Resident 78's Physician Orders for Life-Sustaining Treatment (POLST), dated February 6, 2025, indicated resident did not have an AD. A review of Resident 78's MDS dated [DATE], indicated Resident 78 had a BIMS score of 15 (cognitively intact). A review of the Advance Directive Acknowledgment form, dated August 1, 2024, indicated, .I have not executed any advance directives . A review of the Resident Care Conference dated March 27, 2025, indicated, .Advance Directive/POLST/Code Status Order (check marked) . There was no documented evidence Resident 78 or RP were provided follow up information or education about the right to formulate an AD. On April 17, 2025, at 10:22 a.m. a concurrent interview and record review of Resident 78's Care Conference was conducted with the Social Service Director (SSD) 1. SSD 1 stated residents in the facility are provided an acknowledgement form upon admission and if they had an AD, they would request a copy to be available in the facility. SSD 1 stated if they did not have one, they would provide a handout with information and provide education on how to formulate one. SSD 1 further stated during a resident's Care Conference, which was done quarterly, a follow up with the resident or RP about AD would be conducted. She stated there was no documentation which indicated Resident 78 and/or RP were provided follow up information during the care conference. The SSD stated if there was no AD on file there was a potential for the facility to not be able to honor their wishes for care. A review of the facility's policy and procedure titled, Advance Directives, revised September 2022, indicated, .the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment .advance directives are honored in accordance with state law and facility policy .Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his legal representative, about the existence of any written advance directives .The resident or representative is provided with written information concerning the right to refuse .and to formulate an advance directive if he or she chooses to do so .If the resident does not have an advanced directive .the facility staff will offer assistance in establishing advance directive .staff will document in the medical record the offer to assist and the residents decision to accept or decline assistance .Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retreivable by any staff .

Based on observation, interview, and record review, the facility failed to follow the policy and procedures for oxygen use for two of two sampled residents (Resident 17 and 70) when: 1. Resident 70 was observed receiving continuous oxygen at an incorrect flow rate, without proper documentation or assessment; and 2. Resident 17 had an unlabeled nasal cannula (oxygen tubing - a device that delivers oxygen). These failures had the potential to result in unnecessary or unsafe oxygen administration and increased risk of infection for Residents 17 and 70. Findings: 1. On April 14, 2025, at 2:21 p.m., a concurrent observation and interview was conducted for Resident 70. Resident 70 was alert, oriented and able to verbalize his needs. Resident 70 was observed with oxygen on at six liters per minute (a unit of measure) via nasal cannula. Resident 70 stated he had been on oxygen since the early morning. On April 14, 2025, Resident 70's record was reviewed. Resident 70 was admitted to the facility on [DATE], with diagnosis which included Chronic Obstructive Pulmonary Disease (COPD -a lung disease that makes it difficult to breathe). A review of Resident 70's physicians order dated April 1, 2025, indicated, .Oxygen: at 2-4 L/Min (liters per minute) via NC (nasal cannula) PRN (as needed) to keep O2 sats (oxygen saturation) greater then 90% as needed . A review of Resident 70's Care Plan initiated on March 19, 2025, indicated, .resident has a medical diagnosis of COPD .Goal .the resident will display optimal breathing patterns daily .Approaches .administer oxygen therapy as ordered by physician . On April 14, 2025, at 2:44 p.m., during a concurrent interview and record review, Licensed Vocational Nurse (LVN) 3 stated, Resident 70's oxygen was set at six liters. LVN 3 stated, Resident 70 should not be on six liters. LVN 3 stated, the resident's oxygen use that early morning had not been assessed or documented, and the nurses had not reported the higher oxygen level. LVN 3 stated she should have checked on Resident 3. On April 15, 2025, at 3:51 p.m., during an interview with Registered Nurse Supervisor (RN) 1, RN 1 stated she was not informed that Resident 70 had shortness of breath or any change in condition. RN 1 stated, if there is a physician's order for oxygen, the correct amount should be monitored and maintained. RN 1 stated, staff should report any changes in a resident's condition. RN 1 stated, giving more oxygen than ordered could lead to adverse effects, such as over-oxygenation. On April 17, 2025, at 9:20 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated, all nurses are responsible for proper resident assessments, which included monitoring of vitals signs, identifying changes in condition, and following physicians orders. The DON stated, if a resident is not in respiratory distress and has a as needed oxygen order, nurses must follow the physician's specified rate and frequency. The DON stated, Resident 70 should not have been on six liters of oxygen and should have been receiving oxygen at the rate between two and four liters as needed. The DON further stated, providing too much oxygen could worsen the resident's breathing. A review of the facility policy and procedure titled, Oxygen Administration, dated 2001, indicated, .Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following .signs or symptoms of oxygen toxicity .tracheal irritation, difficulty breathing, or slow, shallow rate of breathing .adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered .observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated .documentation .the rate of oxygen flow, route, and rationale .the frequency and duration of the treatment . 51063 2. During an observation on April 13, 2025 at 9:45 a.m., Resident 17 was observed in bed using oxygen via nasal cannula at two liters per minute. The nasal cannula tubing was unlabeled. On April 13, 2025 at 9:45 a.m. during a concurrent observation and interview with RN Supervisor (RN) 2, RN 2 acknowledged and stated Resident 17's nasal cannula tubing was not labeled with the date and it should have been. RN 2 further stated there is a risk of infection if oxygen tubing was unlabeled. A review of Resident 17's Admission Record indicated Resident 17 was admitted [DATE], with the diagnoses which included acute respiratory failure (a sudden condition when there is not enough oxygen or too much carbon dioxide in the body) and pleural effusion (collection of fluid around the lungs). A review of the Physician Orders dated January 18, 2025, the orders indicated, .Oxygen: Change Oxygen tubing to include NC and/or Mask and Storage Bag every week and prn .every night shift every Sun. During an interview on April 16, 2025 at 10:05 a.m. with the Assistant Director of Nursing (ADON 1), ADON 1 stated staff are expected to label all oxygen tubing with the date to prevent infection. The ADON 1 stated the tubing must be changed every Sunday on the night shift and as needed. A review of the facility's policy and procedure titled, Oxygen Administration, dated October 2010, indicated, .Oxygen tubing and humidifier (if in use) will be changed and labeled every 7 days and as needed.

Based on observation, interview, and record review, the facility failed to ensure the dietary staff were adequately trained to carry out duties in a sanitary and safe manner when one dietary staff did not follow the manufacturer's instructions for the testing of Quaternary (Quaternary ammonium compounds [quats]are a group of chemicals used for disinfectants) sanitizer. This failure had the potential to result in inaccurate readings of the sanitizing solution, which could lead to cross-contamination. Findings: On April 15, 2025, at 10:23 a.m., during an observation of a Dietary Aide (DA) testing the sanitizing solution in the three-compartment sink, the DA was observed dipping the Quat strip into the sanitizing solution for four seconds before comparing the strip to the color comparator chart. A review of the Directions for use Quat-10 Testing Paper indicated .Dip paper for 10 seconds then compare to colors on test strip package . During a concurrent interview with the DA, he stated he should have waited for 10 seconds before comparing the test strip to the color chart. The DA stated, failing to follow the correct procedure could result in inaccurate readings, leading to ineffective sanitization, and increasing the risk for food borne illness (stomach illness acquired from ingesting contaminated food) as well as compromised cleanliness of kitchen surfaces and utensils. On April 15, 2025, at 1:30 p.m., during an interview with Registered Dietician (RD) 1, the RD 1 stated the DA should have followed the manufacturer's instructions when testing the sanitizing solution. A review of the facility policy and procedure titled, Policy & Procedure Manual Resource-Sanitation of Dishes/Manual Washing - Quaternary Ammonium Compound Solutions - Concentration as indicated by manufacturer .

Based on observation, interview, and record review, the facility failed to accommodate the needs for one of three sampled residents (Resident 275), when the call light button was observed on the floor and not within reach. This failure had the potential for Resident 275 not to be able to call staff for assistance which could result in needs of the resident not being met as well as a delay in the provision of care. Findings: Resident 275's record was reviewed. Resident 275 was admitted to the facility on [DATE], with diagnoses which included right below knee amputation (removal of leg). A review of Resident 275's Minimum Data Set (an assessment tool), dated April 9, 2025, indicated, Resident 275 had a Brief Interview of Mental Status (BIMS - a tool to assess cognitive function of an individual) score of 12 (moderate cognitive impairment). A review of Resident 275's Care Plan, initiated on April 2, 2025, indicated, .ADL (Activities of Daily Living) Self-Care Performance Deficit .Encourage the use of call light for assistance - Ensure call light is within reach . On April 13, 2025, at 3:54 p.m., during an observation and concurrent interview with Resident 275, the resident's call light button was on the floor and not within reach. Resident 275 stated, he could not reached it and needed the call light to be closer in order to call the nurse. On April 13, 2025, at 3:57 p.m., an observation in Resident 275's room and concurrent interview were conducted Licensed Vocational Nurse (LVN) 1. LVN 1 stated Resident 275's call light was on the floor and not within reach. LVN 1 further stated, the call light should not be on the floor and should be within the resident's reach to ensure the resident could call for assistance as needed and have their needs met. On April 13, 2025, at 4:10 p.m., an interview was conducted with Director of Staff Development (DSD). The DSD stated Resident 275's call light should not have been on the floor and should have been within reach. The DSD stated without the call light, he would not be able to get assistance in an emergency and his needs would not be met. On April 14, 2025, at 9:25 a.m., an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated it is the facility's practice to ensure resident's call lights are kept within reach. ADON 1 stated the Resident 275's call light should have been within reach and not on the floor. ADON 1 further stated not having the call light within reach could delay the resident's care and result in unmet needs. A review of the facility's policy and procedure titled Answering the Call Light, revised September 2022, indicated .The purpose of this procedure is to ensure timely responses to the resident's request and needs .ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor .

Based on interview and record review the facility failed to ensure one of three residents reviewed for accidents (Resident 40) was free from exposure to chemical hazards when a housekeeper (HK) left a toilet bowl cleaning solution within the resident's reach. This failure had the potential for Resident 40 to be exposed to chemical poisoning or chemical burn if the substance was ingested or mistakenly taken. Findings: On April 16, 2025, at 12:57 p.m., during an interview with Resident 40's Family Member (FM), she stated, on April 15, 2025, at 11 a.m., she found a white cup containing a pink solution with a brush inside, placed on the bedside table near Resident 40's drinking cup. The FM stated, the nurse told her that the brush was a toilet brush and the pink solution was a toilet cleaner. A review of Resident 40's Admission record, indicated, Resident 40 was admitted to the facility on [DATE], with diagnoses which included dementia (forgetfulness). A review of Resident 40's History and Physical Examination dated February 6, 2025, indicated, Resident 40 can not make medical decisions . On April 16, 2025, at 1:12 p.m., during an interview with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she found the toilet cleaning solution near Resident 40's water bottle. LVN 2 stated, there was a potential risk the resident could have accidentally ingested the cleaning solution, which could have caused poisoning. She further stated, this situation was unsanitary, and the cleaning solution should not have been near the resident. LVN 2 stated, it should have been properly secured away from Resident 40's room. On April 16, 2025, at 2:57 p.m., during an interview with Housekeeping Supervisor (HS), the HS stated, residents should not have access to chemical cleaning agents. The HS stated, housekeeping staff are expected to secure all cleaning solutions safely and away from resident areas. On April 17, 2025, at 10:31 a.m., during an interview with the Housekeeper (HK), she stated, she left the cleaning solution inside Resident 40's room. The HS stated, there was a potential for Resident 40 to access the cleaning solution and be harmed. The HK further stated, she should have stored the cleaning solution in the proper storage area before leaving the room. A review of the facility policy and procedure titled, Storage Area-Environmental Service, dated July 1, 2020, indicated .cleaning supplies .maintained in safe manner .

Based on interview and record review, the facility failed to effectively utilize its Quality Assessment and Performance Improvement (QAPI) program to address an ongoing issue involving missing covers on all three dumpsters. This failure resulted in the facility to not implement timely preventative measures and increased potential risk of cross-contamination. Findings: A review of facility document titled Food & Nutrition Services: Daily Supervisor Rounds Checklist, dated March 2, 2025, to April 17, 2025, indicated that the task Trash Lids closed and clean . was not checked off on any day. On April 17, 2025, at 8:37 a.m., during a concurrent interview and record review with the Administrator (ADM), the ADM stated, one of the current QAPI projects was replacing the covers for the three dumpster bins. The ADM stated, they have not been able to check off the task because the dumpster bins remained uncovered. The ADM stated, the facility made multiple attempts to contact the waste management company to replace or repair the bins, but appointments were repeatedly canceled. The ADM stated, while they considered temporary measures such as placing metal mesh over the openings, no interim solutions were implemented. The ADM stated, they should have taken action to prevent animal access and potential contamination while awaiting a resolution. The facility's policy and procedure titled, Quality Assurance and Performance Improvement (APIA) Plan, revised April 16, 2021, indicated, .This facility shall develop, implement and maintain an ongoing, facility-wide Quality Assurance and Performance Improvement (QAPI) Plan designed to monitor and evaluate the quality of resident care, pursue methods to improve quality of care and resolve identified problems .

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when a licensed nurse did not clean and disinfect a shared blood pressure (BP-pressure of blood in blood vessels) cuff according to the manufacturer's recommended contact time (the required duration the equipment must remain wet with the disinfectant to effectively kill microorganisms [germs]). This failure had the potential to expose vulnerable residents to cross-contamination and increase the risk of infections. Findings: On April 15, 2025 at 9:30 a.m., during a medication pass observation, LVN 3 was observed wiping a shared manual blood pressure cuff with a (brand name) disposable wipe after removing it from Resident 223's right upper arm. LVN 3 was not observed leaving the blood pressure cuff surface visibly wet for at least one minute. LVN 3 stated, she should have allowed the cuff to air dry for three minutes. LVN 3 reviewed the manufacturer's instructions and stated the required contact time was one minute. On April 15, 2025 at 10:31 a.m., during an interview with the Infection Preventionist (IP), the IP stated the facility's expectation was for nursing staff to clean shared resident equipment, such as blood pressure cuffs and stethoscopes, before and after each use. The IP stated nursing staff should read and follow the manufacturer's instructions printed on the (brand name) disposable wipe container to ensure the item remains wet for the full recommended contact time. The IP stated, following these instructions is critical to prevent the spread of organisms and infections. On April 17, 2025 at 9:10 a.m., during an interview with Assistant Director of Nursing (ADON) 2, ADON 2 stated the expectation was for nursing staff to disinfect shared resident equipment according to the (brand name) disposable wipe manufacturer's instructions. The ADON 2 stated nursing staff should have followed the manufacturer's instructions to ensure the effectiveness of the product and prevent cross contamination and infection. A review of the facility's policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated March 2021, the P&P indicated, .reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturer's instructions. A review of the manufacturer's instructions for contact time for the (brand name) disposable wipes provided by the facility, the manufacturer's instructions indicated, .Contact time .Allow surface to remain wet for 1 full minute .

Based on interview and record review the facility failed to provide access to personal and medical records within two working days upon request by the resident's legal representative, for one of three sampled residents (Resident 1). This failure has the potential to delay care and treatment, affecting the resident's physical well-being. Findings: On March 3, 2025, at 9:05 a.m., an unannounced visit to the facility was conducted to investigate a resident's rights issue. A review of Resident 1's Admission Record, indicated, Resident 1 was admitted to the facility on [DATE], and was discharged from the facility on January 29, 2025. A review of Resident 1's Release of Medical Information, request, dated February 11, 2025, indicated, .(name) requester .Please consider this as (Resident 1 name) request, by and through this office as legal representative, that all writings related to her within your care, custody and control .that be made available within two working days from the receipt of this correspondence . On February 3, 2025 at 1:02 p.m., during a concurrent interview and review of Resident 1's release of medical information request form with the Medical Records Director (MRD), she stated the process for handling requests for a resident's medical records from a law firm, requires such request to be sent to the facility's legal team. The MRD stated, the facility's legal team either releases the records to the requester or provides approval before any records are released. The MRD further stated the records would be released to the requester within the time specified by the requester or within 15 days, in accordance with facility policy. The MDR stated on February 11, 2025, at 1:08 p.m., she received the request and forwarded it to the facility's legal team, requesting Resident 1's medical records be released to Resident 1's legal representative within two working days. The MRD stated on February 14, 2025, at 12:15 p.m., Resident 1's legal representative contacted the facility to follow up on Resident 1's medical records request. The MRD further stated she contacted the facility's legal team who requested additional records for review. The MRD stated she did not provide an update to the legal representative and had not followed up with the legal team since February 14, 2025. The MRD stated Resident 1's medical records had not been released to the requester. The MRD stated Resident 1's medical records should have been provided within two working days as specified by the requester or within 15 days, in accordance with the facility policy. On February 3, 2025 at 2 p.m., during an interview with the Assistant Director of Nursing (ADON), she stated, medical records could be requested by residents, their representatives or legal representative, and should be provided within two days after the facility received the request. During a review of the facility policy and procedure titled, Resident/Personal Representative Access To Protected Health Information, dated June 2016, indicated, .The facility shall allow an adult resident or his/her personal representative to .receive copies of his/her protected health information (PHI) in a designated record set with an oral or written requests .The requested PHI shall be provided timely .discharged Residents: Within 15 calendar days after the receipt of written request .

Based on interview and record review the facility failed to ensure for one of three sampled residents (Resident 2) had a physician order prior to hospital transfer. This failure had the potential to affect Resident 2's overall health and wellbeing. Findings: On March 3, 2025, at 9:05 a.m., an unannounced visit to the facility was conducted to investigate a complaint incident. A review of Resident 2's Admission Record, indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses which included atrial flutter (an abnormal heart rhythm that can cause an individual to faint). A review of Resident 2's Health Status Note, dated February 19, 2025, indicated, .Was helping patient to use the bathroom, while sitting on toilet patient was straining and eyes rolled back and proceeded to pass out .AMR (American Medical Response) was called and arrived on scene where he (Resident 2) was then transported to (name of hospital) for further assessments . A review of Resident 2's SNF/NF to Hospital Transfer Form, dated February 19, 2025, indicated, .Sent to (name of hospital) .Date of transfer: 2/19/2025 17:50 (5:50 p.m.) .Reason for Transfer: Unresponsive . Further review of Resident 2's medical records, indicated Resident 2 was transferred to the hospital without a physician order. On March 3, 2025, at 9:50 a.m., during a concurrent interview and review of Resident 2's Health Status Note with Registered Nurse (RN) 1, he stated the process when a resident has a change in condition includes notifying the physician and obtaining a transfer order prior to hospital transfer. RN 1 stated, on February 19, 2025, Resident 2 was transferred to the hospital without a physician's order. RN 1 stated an order should have been in place prior to Resident 2 transfer to the hospital. On March 3, 2025, at 2 p.m., during a concurrent interview and review of Resident 2's Health Status Note with the Assistant Director of Nursing (ADON), the ADON stated prior to a hospital transfer, the physician should be notified, and an order must be in place. The ADON stated, Resident 2 was transferred on February 19, 2025, without a physician's order. The ADON stated, an order is essential to ensure resident safety and appropriateness of the transfer. A review of the facility policy and procedure titled, Change in a Resident's Condition or Status, dated 2001, indicated, .The nurse will notify the resident's attending physician or physician on call when there has been a .need to transfer the resident to a hospital/treatment center .discharge without proper medical authority .

Based on document reviews, interviews, review of the Centers for Disease Control and Prevention (CDC) guidelines/recommendations, and the facility policy, the facility failed to maintain an infection prevention and control program to prevent the transmission of Coronavirus Disease 2019 (COVID-19) to staff and residents on 4 of 4 units. Specifically, the facility failed to conduct contact tracing (identification and monitoring of individuals who have been exposed to a disease to prevent further spread) for staff during an outbreak of COVID-19. The facility determined usage of N95 respirators (source control) negated the CDC recommendation/guidelines for testing individuals' exposure to COVID-19. Subsequently, the facility failed to test all residents and staff who had been in close contact with others who had COVID-19. The facility further failed to conduct broad-based COVID-19 testing when contact tracing failed to halt transmission of COVID-19 per the facility's policy. The failed practices had the potential to affect all 111 residents who resided in the facility. As of 02/22/2024, the facility had eight residents and two staff that tested positive for COVID-19. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.80 (Infection Control) at a scope and severity of L. The IJ began on 01/26/2024 when Resident #76 tested positive for COVID-19 and the facility failed to do appropriate contact tracing and testing of everyone that had contact with Resident #76. Subsequently, Resident #63, Resident #45, Resident #81, Resident #251, Resident #252, and Resident #288, who resided on different units of the facility, tested positive for COVID-19 through 02/22/2024. The Administrator and Director of Nursing (DON) were notified of the IJ and provided the IJ template on 02/23/2024 at 6:20 PM. A Removal Plan was requested. The Removal Plan was accepted by the state survey agency on 02/24/2024 at 5:50 PM. The IJ was removed on 02/25/2024 at 11:35 AM, after the survey team performed onsite verification of the Removal Plan implementation. Noncompliance for F880 remained at the lower scope and severity of widespread, with actual harm that was not immediate jeopardy for F880. Findings included: A review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 05/08/2023, revealed Responding to a newly identified SARS-CoV-2-infected [severe acute respiratory syndrome coronavirus 2] HCP [health care personnel] or resident. - A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. - The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. A review of the facility policy titled, COVID-19 Policies and Procedures COVID-19 Mitigation Plan, revised 09/01/2023, revealed Post Exposure and Response Testing * Immediate investigation of potential outbreak should be performed when one (or more) COVID-19 positive individuals (resident or HCP) is identified in a facility. SNFs [skilled nursing facilities] should perform contact tracing within the facility to identify any HCP who have had a higher-risk exposure or residents who may have had high-risk close contact with the individual with SARS-CoV-2 infection: All HCP who have had a higher-risk exposure without source control and residents who have had close contacts, regardless of vaccination status, should be tested promptly (but not earlier that 24 hours after the exposure) and, if negative, again at 3 days and at 5 days after the exposure. The policy revealed, If testing of close contacts reveals additional HCP or residents with SARS-CoV-2 infection, contact tracing should be continued to identify residents with close contact or HCP with higher-risk exposures to the newly identified individual(s) with SARS-CoV-2 infection. A facility-wide or group level approach with quarantine for exposed groups should be considered if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. A review of the facility COVID-19 Outbreak Log, dated 01/24/2024, revealed Resident #77 was positive for COVID-19 upon admission to the facility on [DATE]. Further review revealed four days later, Licensed Vocational Nurse (LVN) #1 had cold symptoms and tested positive for COVID-19 on 01/26/2024. In addition, Resident #76, who resided on the same unit as Resident #77 had shortness of breath and tested positive for COVID-19 on 01/26/2024. There was no documented evidence the facility conducted contact tracing when LVN #1 tested posted for COVID-19 to determine whether residents had been exposed to LVN #1. During an interview on 02/23/2024 at 9:15 AM, the Infection Preventionist (IP) stated LVN #1 cared for residents the day before (01/25/2024) the nurse tested positive for COVID-19. According to the IP. the facility did not test any of the residents LVN #1 cared for as LVN #1 wore an N95 respirator. A review of the facilityCOVID-19 Outbreak Log, dated 02/07/2024, revealed Resident #63 had a cough and tested positive for COVID-19 on 02/05/2024, Resident #45 had a cough and shortness of breath and tested positive for COVID-19 on 02/06/2024, Resident #81 had a cough and tested positive for COVID-19 on 02/06/2024, and the Director of Environmental Services had a fever, headache, body aches, and cough and tested positive for COVID-19 on 02/07/2024. There was no documented evidence the facility conducted contact tracing when the Director of Environmental Services tested positive for COVID-19 to determine whether residents had been exposed to the Director of Environmental Services. A review of the facility COVID-19 Outbreak Log, dated 02/11/2024, revealed Resident #251 had a headache, nausea, and fatigue and tested positive for COVID-19 on 02/11/2024. There was no documented evidence the facility completed contact tracing when Resident #251 tested positive for COVID-19 to determine who had been exposed to the resident. A review of the facility COVID-19 Outbreak Log, dated 02/19/2024, revealed Resident #252 had shortness of breath and tested positive for COVID-19 on 02/16/2024. A review of the facility COVID-19 Outbreak Log, dated 02/22/2024, revealed Resident #288 tested positive for COVID-19 on 02/21/2024. During an interview on 02/23/2024 at 9:15 AM, the IP stated the facility did not test any staff during the COVID-19 outbreak because staff woreN-95 respirators, and the facility did not consider the staff to have been exposed to COVID-19. During an interview on 02/23/2024 at 5:10 PM, Clinical Care Coordinator (CCC) #3 stated she was the IP at the facility for two years prior to the current IP. According to CCC #3, the facility believed staff usage of N95 respirators prevented exposure to COVID-19. During an interview on 02/23/2024 at 11:27 AM, the DON stated facility staff had been wearing N95 respirators since December 2023. During an interview on 02/23/2024 at 3:17 PM, a representative from the local health department stated the facility should complete contact tracing for any resident or staff that were exposed, whether the staff wore an N95 respirator or not. During a follow up interview on 02/23/2024 at 4:16 PM, the DON stated he did not believe staff needed to complete COVID-19 testing because staff wore N95 respirators. During an interview on 02/24/2024 at 9:45 AM, the IP stated she was not able to determine how each resident contracted COVID-19. During an interview on 02/23/2024 at 11:24 PM, the Administrator stated the facility did not test staff after a resident tested positive for COVID-19 if staff wore source control (N95 respirator). During an interview on 02/23/2024 at 6:32 PM, the Administrator stated the staff usage of the N95 respirators negated their need to be tested for COVID-19. On 02/24/2024 at 5:50 PM, a Removal Plan was submitted by the facility and accepted by the state survey agency. It read as follows: 1. How corrective action was taken for identified resident. On February 23, 2024, the Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Preventionist (IP), Quality Assurance Nurse (QAN) immediately tested those on scheduled PM shift on the 23rd, NOC [night] shift on the 24th and AM shift on the 24th. In addition, the Department Heads reached out to staff not scheduled yesterday or today to check their availability to come in and be tested and have an in-service. The scheduled staff and a large portion of the unscheduled staff who were available were tested and available residents and staff for COVID-19 exposure even if they were near the positive resident or not, and no additional residents or staff had positive covid test results. The DON, ADON, IP and QA Nurse reviewed and updated care plans based on residents needs for all those identified within the Immediate Jeopardy (IJ) documentation. In addition, they reviewed current practices during the PM shift on February 23, 2024, to ensure staff are exercising appropriate infection control procedures. The Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Preventionist (IP), Quality Assurance Nurse (QAN) were in-serviced and instructed, by the Corporate Nurse Consultant, on what was needing to be updated in the facility mitigation plan dated February 23, 2024 as well as general infection control and transmission based precautions to include but not limited to following: immediate investigation of potential outbreak should be performed when one or more COVID-19 positive individuals (resident or staff) is identified in the facility, immediate contact tracing by the infection preventionist or designee within the facility to identify any health care provider who have had higher risk exposure or residents who may have had high-risk close contact with the individual with SARS-CoV-2 infection, testing of residents and staff during an outbreak of COVID-19, on days 1, 3, and 5 following exposure, screening of all visitors and staff prior to entering the care area, correct donning and doffing of personal protective equipment of all staff and visitors in the COVID-19 unit and in rooms under transmission-based precaution, and how to recognize and report signs and symptoms of COVID-19 infection to prevent transmission. In consultation with the DON, IP, Director of Staff Development (DSD) and ADON began in-service of all staff verbally and in writing on February 23, 2024, through February 24, 2024. The in-service will be provided to all staff, prior to starting their shift. As the staff report to work for their shift after the 23rd of February, they will be in-serviced prior to starting their shift. This will be done in the Director of Staff Development (DSD) or area that accommodates the number of staff being in-serviced. The in-service will include the facility's revised new mitigation plan and guidelines dated February 23, 2024, general infection control and transmission based precautions to include but not limited to following: immediate investigation of potential outbreak should be performed when one or more COVID-19 positive individuals (resident or staff) is identified in the facility, immediate contact tracing by the infection preventionist or designee within the facility to identify any health care provider who have had higher risk exposure or residents who may have had high-risk close contact with the individual with SARS-CoV-2 infection, testing of residents and staff during an outbreak of COVID-19, on days 1, 3, and 5 following exposure. screening of all visitors and staff prior to entering the care area, correct donning and doffing of personal protective equipment of all staff and visitors in the COVID-19 unit and in rooms under transmission-based precaution, and how to recognize and report signs and symptoms of COVID-19 infection to prevent transmission. The record of education was filed and placed in the education binder by the Director of Nursing (DON). The Quality Assessment and Performance Improvement (QAPI) Committee met on February 24, 2024, to review and approve the QAPI which was created to address this issue. The Medical Director was made aware on February 23, 2024, regarding the IJ and the direction we were taking in the removal plan. The QAPI is part of our Plan of Correction (POC) as we move forward and includes system changes, monitoring and education as needed. The following QAPI Committee members were involved: Administrator Ast. [Assistant] Administrator/Admissions Director Business Office Manager Central Supply Coordinator Director of Staff Development Dietary Supervisor Resident Care Coordinator Station 1 Resident Care Coordinator Station 2 Resident Care Coordinator Station 3 Director of Enviro Services Infection Preventionist Director of Medical Records MDS Director of Rehabilitation Services Social Services Social Services Director of Activities Director of Nursing Assistant Director of Nursing QA Nurse/ADON Nurse Consultant Specific Staff involved in implementing the corrective action: Administrator, DON, ADON, IP, and DSD shall immediately provide education and training to residents, visitors, physicians and staff about the facility's new mitigation plan and policies and procedures as it relates to infection prevention and control by [DATE]. 2. Other residents at risk: All other residents and staff have the potential to be affected by the deficient practice. DON, IP, ADON and the DSD completed COVID-19 testing using antigen testing/POC {Point-Of-Care Test) of all residents on February 23rd into the 24th of February and for all scheduled and available staff on the 23rd into the 24th. No additional positive cases and other reportable incidents were observed. The DON, IP and DSD conducted a random assessment on the 23rd through 24th of February, of staff competency in screening all visitors entering the facility, and staff wearing appropriate personal protective equipment to prevent the spread of infection. No other reportable incidents were found. 3. Systemic Changes: The DON, IP, ADON and DSD began in-service of all staff verbally and in writing on February 23, 2024 in groups held in the DSD office, and at the nurses' station and presented a copy of the facility's new mitigation plan revised February 23, 2024, titled Mitigation Plan Policies and Procedures to include but not limited to the following: improvement plan as listed on the QAPI, contact tracing of residents and staff during an outbreak of the COVID-19 and immediate testing of residents and staff with close contact exposure to an individual who is COVID-19 positive, all visitors shall be screened utilizing the coronavirus screening tool, ensure screening of all who enter the facility for fever, and COVID 19 symptoms, visitors should not go to the designated visitation area to see the resident or enter any of our resident care areas until screening is completed and proper orientation regarding facility protocol is provided. The receptionist or assigned front desk shall provide visitors with coronavirus screening questionnaire form for them to complete, receptionist or assigned staff shall inform and explain to visitors that checking of temperature is also part of our screening process, receptionist or assigned staff shall review the form and not allow entrance to the facility if they answer at least one yes on the questionnaire. 4. Monitoring The DON, IP, ADON, and DSD and other nursing leadership will conduct rounds throughout the facility daily during an outbreak that will encompass all shifts, to ensure staff are exercising appropriate infection control procedures particularly in screening all visitors entering the facility, staff are wearing appropriate personal protective equipment to prevent the spread of infection. The supporting documentation will be kept within the QAPI minutes and reviewed monthly by the QAPI Committee to ensure compliance. Additional monitoring on what measure will be used, and the frequency, as listed under monitoring on the QAPI audit tool shall be performed by the DON, IP, ADON and the DSD weekly. Findings shall be discussed during standup and presented to the Quality Assurance (QA) committee monthly until significant compliance has been demonstrated for three consecutive months. 5. All corrections were completed on 2/24/2024. 6. The immediacy of the IJ was removed on 2/24/2024. Onsite Verification: The IJ was removed on 02/25/2024 at 11:35 AM, after the survey team verified the implementation of the Removal Plans as follows: A review of facility Sars-Cov2 Rapid Antigen Testing (POC) forms revealed all residents were tested on [DATE] or 02/23/2024 and all were negative for COVID-19. On 02/24/2024 at 6:00 PM, all staff listed on a facility working assignment sheet were verified to have been tested . A review of sign-in sheets revealed the Nurse Consultant instructed the DON, ADON, IP, and QAN on needed updates to the facility's mitigation plan. Interviews with the DON, ADON, IP and QAN revealed they had received education regarding the updated plan. A review of a facility document revealed the DON had a telephone conversation with the medical director regarding the IJ and the removal plan. A review of the facility's updated COVID-19 Mitigation Plan for Testing, Quarantine, Isolation, and Vaccination of Health Care Personnel (HCP) and Residents revised 02/23/2024 revealed it was up to date with current CDC guidelines. The facility's mitigation plan was revised to include all HCP who had a higher-risk exposure and residents who had close contact, regardless of vaccination status, should be tested promptly (but not earlier than 24 hours after exposure) and, if negative, again at day three and day five after the exposure. A review of In Service Compliance Training Record revealed staff sign-in sheets dated 02/23/2024 and 02/24/2024 revealed staff were educated on the updated mitigation plan and testing requirements following exposure. Interviews with staff from all three shifts and all disciplines revealed staff were able to verbalize the testing requirements for COVID-19 after being exposed to a resident or staff that had confirmed COVID-19. A review of a facility Random Assessment of Staff Competency dated 02/23/2024, revealed the facility randomly audited staff donning and doffing personal protective equipment, handwashing, visitor screening, and signage. The facility developed a form titled Rounding Tool for COVID-19 to be used for daily rounds and quality assurance and performance improvement (QAPI) audit tools were reviewed. A review of a facility QA/QAPI Committee Meeting Sign-In revealed the facility held a QAPI meeting on 02/24/2024.