Every finding on record at West Gardena Post Acute

Based on observation, interview, and record review, the facility failed to maintain and observe infection control measures for two of six sampled residents (Residents 6 and 7) by failing to:1.Ensure Certified Nursing Assistant (CNA) 4 wore an isolation gown (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) while assisting with range of motion (ROM, full movement potential of a joint) exercises to Resident 6's both knees and both ankles which required direct contact with Resident 6 who was on Enhanced Barrier Precautions (EBP- infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug-resistant organisms [microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents]). 2.Ensure CNA 2 wore an isolation gown while assisting with range of motion to Resident 7's both hands and repositioning Resident 7's both legs which required direct contact with Resident 7 who was on EBP. These failures had the potential to transmit infectious microorganisms and increase the risk of infection among the residents and staff members. Findings:1. During a review of Resident 6's admission Record, the admission Record indicated the facility initially admitted Resident 6 on 11/21/2020 and re-admitted on [DATE] with diagnoses including dysphagia (difficulty swallowing) and osteoarthritis (loss of protective cartilage that cushions the ends of your bones). During a review of Resident 6's Order Summary Report, the Order Summary Report indicated a physician's order, dated 4/8/2024, for Resident 6 to be on EBP due to the presence of a gastrostomy tube (G-tube - a tube placed directly into the stomach for long-term feeding). During a concurrent observation and interview on 11/18/2025 at 11:05 a.m., with Resident 6 in Resident 6's room, Resident 6 was lying in bed with blankets covering both legs. CNA 4 entered Resident 6's room, put on gloves and did not put on an isolation gown. CNA 4 removed Resident 6's blankets. Resident 6's both knees and hips were bent and rotated to the right side of the body. Resident 6 stated she was unable to straighten her legs on her own and needed assistance. CNA 4 touched Resident 6's both legs and attempted to straighten Resident 6's both hips, knees, and ankles multiple times. CNA 4 replaced Resident 6's blankets, removed both gloves, performed hand hygiene, and exited the room. During an interview on 11/18/2025 at 11:34 a.m., with CNA 4, CNA 4 confirmed he did not wear an isolation gown while providing care which required direct contact with Resident 6 who was on EBP. CNA 4 stated he should have worn an isolation gown while assisting Resident 6 with ROM of both legs because he had direct contact with Resident 6 who was on EBP. CNA 4 stated it was important to follow infection control protocols to prevent the spread of infection. During an interview on 11/19/2025 at 2:22 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated the purpose of EBP precautions was to reduce the transmission of infection for residents with non-healing wounds (injury to the body that typically involves a laceration or breaking of a membrane) and indwelling devices (medical devices inside the body) such as g-tubes and foley catheters (thin, flexible rube inserted into the bladder to drain urine). The IPN stated all staff providing direct patient care which included repositioning a resident and assisting with ROM to residents on EBP must wear the appropriate personal protective equipment (PPE, equipment worn to minimize exposure to hazards that can cause serious injuries and illnesses) which included an isolation gown and gloves to prevent the spread of infection. During an interview on 11/19/2025 at 4:48 p.m., with the Director of Nursing (DON), the DON stated it was important for staff to follow the proper infection control protocols to prevent the spread of infection. 2. During a review of Resident 7's admission Record, the admission Record indicated the facility initially admitted Resident 7 on 12/7/2020 and re-admitted on [DATE] with diagnoses including type 2 diabetes mellitus ( a disorder characterized by difficulty in blood sugar control and poor wound healing), contractures of both knees, both elbows, and both hands, chronic a chronic diabetic ulcer (persistent open wound that fails to show significant healing) of the left foot and Parkinsons disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). During a review of Resident 7's Order Summary Report, the Order Summary Report indicated a physician's order, dated 1/10/2025, for Resident 7 to be on EBP due to the presence of a G-tube and diabetic ulcers (open sore or wound caused by nerve damage and poor blood flow) on the bottom of Resident 7's left foot and on the fifth metatarsal bone (outer side of the ball of the foot) of Resident 7's right foot. During an observation on 9/30/2025 at 11:01 a.m., in Resident 7's room, Resident 7 was lying in bed with blankets covering the entire body. CNA 2 entered Resident 7's room, put on gloves and did not put on an isolation gown. CNA 2 removed Resident 7's blankets. Resident 7 was wearing splints (a device used to restrict, protect, or immobilize a part of the body to support function and increase ROM) to both elbows, both knees, and the right wrist and hand. Resident 7 had a rolled-up towel in the left hand and was wearing soft boots to both ankles. Resident 7's both knees were bent and rotated to the right side of the body. CNA 2 touched and repositioned Resident 7's both legs. CNA 2 stated Resident 7's left side of the body was stiffer than the right side of the body. CNA 2 removed Resident 7's left towel roll and tried to straighten the fingers of Resident 7's left hand. CNA 2 touched Resident 7's right hand splint and tried to straighten the fingers of the right hand which were wrapped around the splint. CNA 2 removed both gloves, performed hand hygiene, and exited the room. During an interview on 9/30/2025 at 11:10 a.m., with CNA 2, CNA 2 confirmed she did not wear an isolation gown while providing care which required direct contact for Resident 7 was on EBP. CNA 2 stated she should have worn an isolation gown while assisting Resident 7 with ROM and repositioning Resident 7 because she had direct contact with Resident 7 who was on EBP. CNA 2 stated it was important to follow infection control protocols to prevent the spread of infection. During an interview on 11/19/2025 at 2:22 p.m., with the IPN, the IPN stated the purpose of EBP precautions was to reduce the transmission of infection for residents with non-healing wounds and indwelling devices. The IPN stated all staff providing direct patient care, including repositioning residents and assisting with range of motion (ROM) exercises for residents on EBP, must wear appropriate personal protective equipment (PPE), which includes an isolation gown and gloves, to prevent the spread of infection. During an interview on 11/19/2025 at 4:48 p.m., with the DON, the DON stated it was important for staff to follow the proper infection control protocols to prevent the spread of infection. During a review of the facility's policy and procedure (P&P) titled, Standard Precautions, Enhanced Barrier Precautions and Transmission Based Precautions, revised 5/20/2025, the P&P indicated EBP was the use of gloves and gowns for specific high contact care activities based on the resident's characteristics that are associated with high risk of MDRO colonization which included the presence of indwelling medical devices such as G-tubes and chronic and open non-healing wounds. The P&P indicated gowns and gloves would be used while performing high contact tasks associated with the greatest risk for MDRO contamination of the healthcare provider's hands, clothes, and the environment which included any care activity where close contact with the resident is expected and any care activity involving contact with environmental surfaces.

Based on observation, interview, and record review, the facility failed to ensure Restorative Nursing Aides (RNA, nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) accurately documented RNA services provided for two of six sampled residents (Residents 7 and 9) in 5/2025, 6/2025, and 7/2025. This failure had the potential to negatively impact the provision of necessary care and services due to the inaccurate reflection of services provided. Findings: 1. During a review of Resident 7's admission Record, the admission Record indicated the facility initially admitted Resident 7 on 12/7/2020 and re-admitted on [DATE] with diagnoses including type 2 diabetes mellitus ( a disorder characterized by difficulty in blood sugar control and poor wound healing), contractures of both knees, both elbows, and both hands, and chronic a chronic diabetic ulcer (persistent open wound that fails to show significant healing) of the left foot. During a review of Resident 7's 5/2025 RNA flowsheet (daily record of RNA services provided for each month), the RNA flowsheet indicated two RNA orders for: 1. RNA to perform passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 7's both arms and both legs, five times a week and 2. RNA to apply splints (a device used to restrict, protect, or immobilize a part of the body to support function and increase ROM) to Resident 7's right hand, both elbows, both knees, and a towel roll to Resident 7's left hand for four hours, five times a week. The squares on the RNA flowsheet were blank on 5/5/2025 and 5/21/2025. During a review of Resident 7's 6/2025 RNA flowsheet the RNA flowsheet indicated two RNA orders for: 1. RNA to perform PROM exercises to Resident 7's both arms and both legs, five times a week and 2. RNA to apply splints to Resident 7's right hand, both elbows, both knees, and a towel roll to Resident 7's left hand for four hours, five times a week. The squares on the RNA flowsheet were blank on 6/4/2025 and 6/5/2025 for both RNA orders. The square on the RNA flowsheet was blank on 6/26/2025 for the RNA splinting order. During a review of Resident 7's 7/ 2025 RNA flowsheet the RNA flowsheet indicated two RNA orders for: 1. RNA to perform PROM exercises to Resident 7's both arms and both legs, five times a week and 2. RNA to apply splints to Resident 7's right hand, both elbows, both knees, and a towel roll to Resident 7's left hand for four hours, five times a week. The square on the RNA flowsheet was blank on 7/29/2025 for both RNA orders. During a review of Resident 7's Minimum Data Set (MDS, resident assessment tool), dated 10/7/2025, the MDS indicated Resident 7 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 7 was dependent (helper does all the effort) in oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, rolling to both sides, and transfers. The MDS indicated Resident 7 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs. During an observation on 11/18/2025 at 11:53 am in Resident 7's room, Resident 7 was lying in bed with both eyes closed and blankets covering the body from the waist down. Resident 7 was wearing splints to both elbows and holding a rolled-up towel in the left hand. Resident 7's both legs appeared to be bent and rotated to the left side of the body. 2. During a review of Resident 9's admission Record, the admission Record indicated the facility initially admitted Resident 9 on 9/21/2013 and re-admitted on [DATE] with diagnoses including quadriplegia (weakness or paralysis to all four extremities), hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) of an unspecified side of the body. During a review of Resident 9's 5/ 2025 RNA flowsheet, the RNA flowsheet indicated two RNA orders for: 1. RNA to perform PROM exercises to Resident 9's left arm, three times a week and 2. RNA to assist Resident 9 with walking exercises using a front wheeled walker (FWW, mobility device with two wheels in the front used for support when standing or walking) for approximately 30 feet with one person assistance, five times a week. The squares on the RNA flowsheet were blank on 5/5/2025 and 5/21/2025 for both RNA orders. During a review of Resident 9's 6/2025 RNA flowsheet, the RNA flowsheet indicated two RNA orders for: 1. RNA to perform PROM exercises to Resident 9's left arm, three times a week and 2. RNA to assist Resident 9 with walking exercises using a FWW for approximately 30 feet with one person assistance, five times a week. The squares on the RNA flowsheet were blank on the following days: 6/4/2025, 6/5/2025, 6/12/2025, 6/13/2025, 6/16/2025 to 6/20/2025, 6/23/2025 to 6/26/2025, and 6/30/2025 for both RNA orders. During a review of Resident 9's 7/2025 RNA flowsheet, the RNA flowsheet indicated two RNA orders for: 1. RNA to perform PROM exercises to Resident 9's left arm, three times a week and 2. RNA to assist Resident 9 with walking exercises using a FWW for approximately 30 feet with one person assistance, five times a week. The squares on the RNA flowsheet were blank on 7/2/2025 and 7/4/2025 for the RNA PROM exercises order. The squares on the RNA flowsheet were blank on 7/17/2025 and 7/29/2025 for the RNA walking exercises order. During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9 was cognitively intact. The MDS indicated Resident 9 required set up or clean-up assistance (helper sets or cleans up and assists only prior to or following the activity) for eating, partial/moderate assistance for rolling to both sides, sit to stand, and transfers, and substantial/maximal assistance for hygiene, dressing, and bathing. The MDS indicated Resident 9 had functional limitations in ROM in both arms. During a concurrent observation and interview on 9/30/2025 at 2:28 p.m., with Resident 9 in Resident 9's room, Resident 9 was lying in bed. Resident 9's left elbow was bent, and the fingers of the left hand were in a loose fist. Resident 9 stated he was unable to independently move the fingers of the left hand and the left shoulder and needed assistance. Resident 9 lifted his right arm to shoulder height, partially bent and straightened the right elbow, and was unable to actively move all the fingers of the right hand. Resident 9's both legs were straight and resting on a cushion at the end of the bed. Resident 9 minimally bent both knees, bent and straightened both ankles and wiggled all toes. Resident 9 stated staff assisted with exercises almost every day. During an interview on 9/30/2025 at 3:29 p.m., with Restorative Nursing Aide 1 (RNA 1), RNA 1 stated she was the primary RNA for all the residents on an RNA program in the facility. RNA 1 stated two other RNAs, Certified Nursing Assistant 2 (CNA 2) and Restorative Nursing Aide 2 (RNA 2) assist as needed to ensure all residents on the RNA program were seen daily, Monday through Friday. RNA 1 stated that she was able to see all residents in her daily caseload and rarely required assistance. During a concurrent interview and record review on 11/19/2025 at 10:57 a.m., with RNA 1, RNA 1 reviewed Resident 7 and Resident 9's RNA flowsheets for the month of 5/2025, 6/ 2025, and 7/ 2025. RNA 1 stated blank squares on the RNA flowsheet either meant she forgot to document, or she did not provide treatment that day. RNA 1 stated she did not know why there were blank squares in 5/2025, 6/2025, and 7/2025 because there was always RNA coverage Monday through Friday since she had been working. RNA 1 stated that she had not called in sick at any time during the past year she worked at the facility and that coverage was always arranged for days she was scheduled to be off. RNA 1 stated she provided treatment to all residents on the RNA program on the days she worked but forgot to document. RNA 1 stated it was important she documented daily to ensure the facility could monitor if the residents on the RNA program were being seen as ordered. During a concurrent interview and record review on 11/19/2025 at 2:51 p.m., with the Director of Staff Development (DSD), the DSD stated he supervised the RNAs. The DSD stated the facility provided RNA services to the residents in the facility Monday through Friday. The DSD stated RNA 1 was the primary RNA on the floor and CNA 2 and RNA 2 provided back up assistance as needed if RNA 1 was scheduled off or called out sick. The DSD stated RNA 1's daily caseload was very manageable and all residents on the RNA program were seen as ordered. The DSD reviewed Resident 7 and Resident 9's RNA flowsheets for 5/2025, 6/2025, and 7/2025. The DSD stated a blank square on the RNA flowsheet indicated RNA either did not document for the day or RNA treatment was not provided. The DSD reviewed Resident 7's 5/2025 RNA flowsheet and confirmed the squares on the RNA flowsheet were blank on 5/5/2025 and 5/21/2025 for both RNA orders. The DSD reviewed Resident 7's 6/2025 RNA flowsheet and confirmed the squares on the RNA flowsheet were blank on 6/4/2025 and 6/5/2025 for both RNA orders and blank on 6/26/2025 for the RNA splinting order. The DSD reviewed Resident 7's 7/ 2025 RNA flowsheet and confirmed the square on the RNA flowsheet was blank on 7/29/2025 for both RNA orders. The DSD reviewed Resident 9's 5/2025 RNA flowsheet and confirmed the squares on the RNA flowsheet were blank on 5/5/2025 and 5/21/2025 for both RNA orders. The DSD reviewed Resident 9's 6/ 2025 RNA flowsheet and confirmed the squares on the RNA flowsheet were blank on 6/4/2025, 6/5/2025, 6/12/2025, 6/13/2025, 6/16/2025 to 6/20/2025, 6/23/2025 to 6/26/2025, and 6/30/2025 for both RNA orders. The DSD reviewed Resident 9's 7/ 2025 RNA flowsheet and confirmed the squares on the RNA flowsheet were blank 7/2/2025 and 7/4/2025 for the RNA PROM exercises order and on 7/17/2025 and 7/29/2025 for the RNA walking exercises order. The DSD stated there was always at least one RNA on staff Monday through Friday in 5/2025, 6/2025, and 7/2025, and the blank squares likely indicated the RNAs forgot to document the treatments that were provided. The DSD stated the lack of RNA documentation could be mistaken for missed RNA treatments. The DSD stated it was important that RNAs documented accurately to ensure the facility could correctly monitor a resident's progress and tolerance to the RNA program and to ensure all residents on the RNA program were seen as ordered to prevent any functional declines. During an interview on 11/19/2025 at 4:48 p.m., with the Director of Nursing (DON), the DON stated the purpose of the RNA program was to ensure the residents in the facility maintained their function and mobility and to prevent functional declines. The DON stated accurate RNA documentation was important to ensure the facility had an accurate assessment of the type and frequency of services provided, the status of the resident's function, and the resident's tolerance to the RNA program. During a review of the facility's Job Description, titled Restorative Nursing Assistant, dated 5/2017, the Job description indicated one of the responsibilities of the RNA was to maintain accurate restorative progress and documentation records on all patients participating in the restorative program. During a review of the facility's policy and procedure (P&P), titled Charting and Documentation, revised 7/2017, the P&P 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 medical record. The P&P indicated treatment or services performed was to be documented in the medical record. The P&P indicated documentation in the medical record would be objective, completed, and accurate.

Based on observation, interview and record review, the facility failed to maintain an organized medication storage system in the medication room. Medications were found stored in buckets labeled for different medications, and the overall storage lacked a systematic organization (example: alphabetical or by drug class). This deficient practice had the potential to result in medication errors and/or delays in administration if licensed staff were unable to locate the correct medication promptly.Findings: During an interview on 11/18/2025 at 11:05 a.m., with the Director of Nursing (DON), the DON stated the facility had two (2) nursing stations and 1 medication room. During a concurrent observation and interview on 11/18/2025 at 11:30 a.m., with the Licensed Vocational Nurse (LVN 2) in the medication (med) room located between the two nursing stations, observed to contain two walls of shelving with gallon sized buckets. A posted sign read Charge nurses please make sure to maintain organization and cleanliness of this med room. LVN 2 stated the buckets contained over the counter medications and inventory were maintained by central supply personnel. One bucket had two labels: Calcium (a mineral supplement that is essential to our body function) 600 milligrams (mg, an unit to measure mass) and vitamin D3 (an over-the-counter supplement that contained both ingredients in one tablet) and Calcium 500 plus D (a supplement tablet that contained both calcium 500 mg and unspecified amount of vitamin D). Upon closer look at the contents inside the bucket, LVN 2 confirmed there were at least 5 bottles of calcium 500 mg (without vitamin D) and 2 bottles of vitamin D3 50 mg. During a concurrent observation and interview with LVN 2 on 11/18/2025 at 11:38 a.m., with LVN 2, observed another bucket with 4 labels indicated the bucket contained Vitamin D 10 micrograms (mcg, unit to measure mass), Thiamin B-1 (a form of vitamin B) 100 mg, Vitamin D3 10000 international units (IU, an unit to measure concentration of certain vitamins), and Vitamin D3 400 IU. LVN 2 confirmed there were at least 5 bottles of Vitamin D 25 mcg (1000 IU) in this bucket. LVN 2 stated it would be time-consuming to search for a particular medication when there were several types of medications stored in one bucket. LVN 2 stated the buckets system of storing medications were not in any order, not alphabetically, nor by class. During a concurrent observation and interview on 11/18/2025 at 11:40 a.m., LVN 2 confirmed there were three boxes of loperamide HCl (medication to treat diarrhea) 2 mg tablets found in the bucket that was labeled for diphenhydramine (generic for Benadryl, a medication to treat allergies 25 mg and loratadine (a medication to treat allergies) 10 mg. LVN 2 stated the loperamide boxes were misplaced. There was a bucket labeled for loperamide on the top shelf. During an interview on 11/18/2025 at 11:53 a.m., with the DON in the med room the DON stated the current medication storage system in the med room was not organized. The DON stated if nursing could not find the medication they were looking for, nurse would submit a requisition for central supply to order. The DON stated if LVN (in general) could not find the medication, there could be a potential delay in medication administration. During an interview on 11/18/2025 at 3:41 p.m., the DON acknowledged it would be difficult to rotate stocks and prevent expired medications from remaining in circulation. During a review of the facility's policy and procedures P&P) titled Medication Labeling and Storage (revised February 2023), the P&P indicated . The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Medications are stored in an orderly manner.

Based on interview and record review, the facility failed to ensure the prescribers of psychotropic medications (drugs that affect mood, behavior, or mental processes and are used to treat certain mental health conditions) personally provided information and obtained informed consent from the residents and/or their responsible parties for two of five sampled residents (Residents 17 and 45).This failure had the potential to result in miscommunication or misunderstanding between the prescribers and the residents or their representatives regarding the purpose, risks, and benefits of the prescribed medications.Findings: During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including dementia (a condition where there is a decline in cognitive function that affects memory, thinking, and social abilities), psychosis (mental health condition characterized by a disconnection from reality, where individuals may experience symptoms such as hallucinations [false perceptions of sensory experiences], delusions [a mental health condition in which a person has unshakable beliefs in something that's untrue], and impaired insight.During a review of Resident 45's current psychotropic medications (all dated 7/7/2025) included (but not limited to)1.Trazodone (an antidepressant used to treat depression and/or inability to sleep) 100 milligrams (mg, a unit to measure mass), at bedtime for depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) manifested by inability to sleep at night2.Mirtazapine (an antidepressant used to treat depression) 7.5 mg at bedtime for depression manifested by poor oral intake3.Seroquel (quetiapine, an antipsychotic, medication used to treat various types of mental health conditions) 50 mg twice daily for psychosis manifested by visual and auditory hallucinations as evident by resident stating she is talking to small children, and they are waiting for her.4.Seroquel (quetiapine) 50 mg at bedtime (same dx as above)During a concurrent interview and record review on 11/19/2025 at 12:16 p.m., with the Director of Nursing (DON), Resident 45's informed consents for the prescribed psychotropics medications were reviewed. The DON stated the nurse practitioner (NP) who works under the supervision of Resident 45's psychiatrist conducted the in-person psychiatric evaluations, ordered Resident 45's psychotropic medications, provided drug related information, and obtained informed consent from the resident's responsible party. The DON stated she had verified this process During a concurrent interview and record review 11/19/2025 at 12:16 p.m., with the DON, Resident 45's psychotropic medication orders were reviewed which indicated that the NP was not the prescriber of the psychotropic medications. The DON confirmed the psychotropic medications had been prescribed by Resident 45's attending physician and not the NP, as previously stated.During a review of Resident 17's current medications, it was noted that the resident was prescribed the following psychotropic medication including1.Risperdal (risperidone an antipsychotic, medication used to treat various types of mental health conditions) 0.5 mg at bedtime, for bipolar disorder (a mental health condition characterized by extreme mood swings manifested by paranoia [intense feelings of distrust and suspicion]) and delusional as evident by Staff are conspiring against me (dated 9/5/2025) During a concurrent interview and record review on 11/19/2025 at 3:02 p.m., with the Director of Nursing (DON), it was confirmed that the Risperdal 0.5 mg order was prescribed by Resident 17's attending physician. However, the informed consent for the medication was obtained and signed by the psychiatric nurse practitioner (NP), not the prescribing physician. During a review of the facility policy and procedures (P&P) titled Verification of Informed Consent for Psychotherapeutic Medications (revised June 2024), the P&P indicated Before prescribing a psychotherapeutic drug, the physician must personally examine the resident and obtain informed written consent signed by the resident or the resident's representative.

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 10 and 32) received their scheduled 9:00 a.m. medications within the required one-hour administration window.This failure had the potential to result in delays in treatment, which may affect the residents' health conditions. Findings: During a concurrent observation and interview on 9/30/2025 at 10:16 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed in the hallway of Station 1 with a medication cart. LVN 1 stated that she still had two residents waiting to receive their morning medications and pointed to a nearby resident room, which roomed Residents 10 and 32. During an interview on 9/30/2025 at 10:21 a.m., LVN 1 stated she would begin preparing medications for Resident 10. During an observation on 9/30/2025 at 10:34 a.m., LVN 1 was observed obtaining a blood pressure reading for Resident 32 During an interview on 9/30/2025 at 10:35 a.m., LVN 1 stated that Resident 32 would be the last resident to receive medications during the morning medication pass (medication administration process). During a concurrent observation and interview on 9/30/2025 at 10:41 a.m., LVN 1 completed the medication administration process. LVN 1 stated the morning medication pass ran late because she was trying to be extra careful. During an interview on 9/30/2025 at 2:51 p.m., with the Director of Nursing (DON), the DON stated nurses are expected to administer scheduled medications within a two-hour window of one hour before and one hour after the scheduled time. For medications scheduled at 9:00 a.m., this window would be from 8:00 a.m. to 10:00 a.m. The [NAME] stated the administration of medications to Residents 10 and 32 after 10:00 a.m. was outside the acceptable timeframe. During a review of the facility's policy and procedures (P&P) titled, Administering Medications (revised April 2019), the P&P indicated . Medications are administered within one (1) hour of their prescribed time, .

Based on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion (ROM, full movement potential of a joint) for three of six sampled residents (Residents 7, 9, and 39) with ROM concerns by failing to: 1.Objectively measure Resident 7's limited ROM in both hips and both knees during the Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation, dated 11/24/2024. 2.Objectively measure Resident 39's limited finger ROM of the right hand during the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation, dated 5/14/2025. 3.Provide ROM exercises to Resident 9's right hand and right wrist during a Restorative Nursing Aide (RNA, nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) session in accordance with physician's orders. These failures had the potential for Residents 7, 9, and 39 to experience a further decline in ROM resulting in contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) development and have a decline in physical functioning, mobility (ability to move), and activities of daily living (ADL, basic activities such as eating, dressing, toileting). Findings:1. During a review of Resident 7's admission Record, the admission Record indicated the facility initially admitted Resident 7 on 12/7/2020 and re-admitted on [DATE] with diagnoses including type 2 diabetes mellitus ( a disorder characterized by difficulty in blood sugar control and poor wound healing), contractures of both knees, both elbows, and both hands, and chronic a chronic diabetic ulcer (persistent open wound that fails to show significant healing) of the left foot. During a review of Resident 7's PT Evaluation, dated 11/25/2024, the PT Evaluation indicated Resident 7's ROM of both legs were impaired. The PT Evaluation indicated Resident 7's ROM of the right hip, right ankle, left hip, and left ankle were impaired. During a review of Resident 7's Minimum Data Set (MDS, resident assessment tool), dated 10/7/2025, the MDS indicated Resident 7 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 7 was dependent (helper does all the effort) in oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, rolling to both sides, and transfers. The MDS indicated Resident 7 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs. During an observation of a RNA session on 10/1/2025 at 10:42 am, in Resident 7's room, observed Resident 7 was lying in bed wearing splints (a device used to restrict, protect, or immobilize a part of the body to support function and increase ROM) to both elbows, the right wrist, and right hand, a rolled up towel in the left hand, and soft boots (specialized boots placed on the feet and ankles used to treat and prevent pressure sores) on both feet. Restorative Nursing Aide 1 (RNA 1) and Certified Nursing Assistant 2 (CNA 2) removed Resident 7's both knee splints and both soft boots from Resident 7's legs. Resident 7's both legs were bent at the knees. RNA 1 and CNA 2 assisted with passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 7's both knees, both ankles, and all the toes of both feet. RNA 1 and CNA 2 were unable to straighten Resident 7's both hips and both knees. RNA 1 and CNA 2 assisted with ankle ROM and stated both ankles felt stiff during ROM. CNA 2 stated Resident 7's left leg felt stiffer than the right leg. At the end of the session, RNA 1 and CNA 2 replaced both knee splints and soft boots, positioned Resident 7 on the right side of the body and placed pillows in between Resident 7's both knees. During a concurrent interview and record review on 11/18/2025 at 1:42 pm with the Director of Rehabilitation (DOR), the DOR who was a Physical Therapist (PT), stated PTs and OTs used goniometers (instrument used for the precise measurement of angles) to measure joint mobility to objectively (unbiased, based on facts) determine a resident's baseline ROM and detect changes in joint ROM. The DOR reviewed Resident 7's PT Evaluation, 11/24/2024, and confirmed Resident 7's ROM of both hips, both knees, and both ankles were impaired. The DOR stated Physical Therapist 1 (PT 1) completed Resident 7's PT Evaluation and did not use a goniometer to measure the joints of both hips and both ankles but should have because Resident 7 had ROM limitations. The DOR stated Resident 7's baseline ROM of both hips and both ankles were not determined because the ROM limitations were not measured with a goniometer. The DOR stated lack of objective ROM measurements had the potential to negatively impact the staff's ability to detect changes such as improvements or declines in Resident 7's ROM. The DOR stated it was important to provide objective measurements of a limited joint in the PT evaluation to ensure subtle changes of ROM could be detected which would in turn guided the treatments and services provided. During an interview on 11/19/2025 at 4:48 pm with the Director of Nursing (DON), the DON stated the facility provides RNA and Rehabilitation (Rehab) services to maintain, improve, and prevent declines in ROM for the residents in the facility. The DON stated the facility monitored changes in ROM by joint mobility assessments (JMA, a brief assessment of a resident's ROM in both arms and both legs), report from Rehab and/or nursing, and observations during daily care. The DON stated it was important for staff to objectively measure ROM during ROM evaluations to ensure the facility had an accurate assessment of a resident's joints since it affected their ability to effectively monitor changes and provide the appropriate services to address any declines. The DON stated if residents who had ROM limitations did not receive the appropriate treatment and services to maintain their ROM, it could result in a functional decline. 2. During a review of Resident 39's admission Record, the admission Record indicated the facility initially admitted Resident 39 on 5/5/2021 and re-admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty breathing) and peripheral autonomic neuropathy (disorder that affects then nerves that control the body's processes without conscious effort). During a review of Resident 39's OT Evaluation, dated 5/14/2025, the OT Evaluation indicated Resident 39's ROM of both hands were impaired. The OT Evaluation indicated the ROM of Resident 39's ring finger on the right hand was impaired. The OT Evaluation indicated Resident 39's left hand ROM was impaired and described as follows:Index finger: Impaired - tightness and increased risk of deformity, metacarpal phalangeal (MP, knuckle joint) tightness and mild loss of motion notedMiddle finger: Impaired - tightness and increased risk of deformity, distal interphalangeal joint (DIP, joint at the tip of the finger closes to the nail) contracture and loss of motion, proximal interphalangeal joint (PIP, middle joint of the finger between the knuckle and the fingertip) hyperextended (the extension of a body part beyond it's normal limits), MP tightness and mild loss of motion notedRing finger: Impaired - tightness and increased risk of deformity, MP tightness and mild loss of motion notedLittle finger: Impaired - tightness and increased risk of deformity, MP tightness, and mild loss of motion noted. The OT evaluation indicated a goal for Resident 7 to maintain/increase current ROM, decrease stiffness on both hands. During a review of Resident 39's MDS, dated [DATE], the MDS indicated Resident 39 had moderate cognitive impairment. The MDS indicated Resident 39 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity) for eating and oral hygiene, partial/moderate assistance (helper does less than half the effort) for rolling to both sides, sit to stand, and transfers, substantial/maximal assistance (helper does more than half the effort) for toilet hygiene, dressing, and personal hygiene, and was dependent for bathing. The MDS indicated Resident 39 had functional limitations in ROM in both arms. During a concurrent observation and interview on 11/19/2025 at 8:19 am, with Resident 39 in Resident 39's room, observed Resident 39 lying in bed. All the fingers on Resident 39's left hand were bent downwards into the palm of the hand. Resident 39's middle finger on the left hand and the ring finger on the right hand were bent to about 90 degrees at the middle joints of the fingers between the knuckles and the fingertips. Resident 39 stated he was unable to straighten all the fingers on his left hand and the ring finger of the right hand on his own and needed assistance. During a concurrent interview and record review on 11/18/2025 at 2:56 pm with the DOR and Occupational Therapist 1 (OT 1), the DOR stated PTs and OTs used goniometers to measure joint mobility to objectively determine a resident's baseline ROM and detect changes in joint ROM. The DOR and OT 1 reviewed Resident 39's OT Evaluation, dated 5/14/2025, and confirmed Resident 39's ROM of both hands were impaired. OT 1 stated he completed Resident 39's OT Evaluation and did not use a goniometer to measure the joints of Resident 39's fingers but should have because Resident 39 had ROM limitations. OT 1 and the DOR stated Resident 39's baseline ROM of the fingers of both hands were not determined because the ROM limitations were not measured with a goniometer. OT 1 confirmed the OT Evaluation indicated a goal for Resident 39 to maintain and increase joint ROM. OT 1 stated he was unable to determine if Resident 39 made progress and/or met the goal since the evaluation lacked objective ROM measurements of both hands to indicate if Resident 39 maintained, declined, or improved in ROM. OT 1 and the DOR stated the lack of objective ROM measurements in the OT Evaluation had the potential to negatively impact Resident 39's plan of care and staff's ability to detect changes such as improvements or declines in ROM and monitor a resident's progress toward therapy goals. The DOR stated it was important to provide objective measurements of a limited joint in the OT evaluation to ensure subtle changes of ROM could be detected which would in turn guided the treatments and services provided. During an interview on 11/19/2025 at 4:48 pm with the DON, the DON stated the facility provides RNA and Rehab services to maintain, improve, and prevent declines in ROM for the residents in the facility. The DON stated the facility monitored changes in ROM by JMAs, report from Rehab and/or nursing, and observations during daily care. The DON stated it was important for staff to objectively measure ROM during ROM evaluations to ensure the facility had an accurate assessment of a resident's joints since it affected their ability to effectively monitor changes and provide the appropriate services to address any declines. The DON stated if residents who had ROM limitations did not receive the appropriate treatment and services to maintain their ROM, it could result in a functional decline. 3. During a review of Resident 9's admission Record, the admission Record indicated the facility initially admitted Resident 9 on 9/21/2013 and re-admitted on [DATE] with diagnoses including quadriplegia (weakness or paralysis to all four extremities), hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) of an unspecified side of the body. During a review of Resident 9's Order Summery Report, the Order Summary Report indicated a physician's order, dated 8/25/2025, for RNA to provide active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) exercises to Resident 9's right arm, five times a week as tolerated. During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9 was cognitively intact. The MDS indicated Resident 9 required set up or clean-up assistance (helper sets or cleans up and assists only prior to or following the activity) for eating, partial/moderate assistance for rolling to both sides, sit to stand, and transfers, and substantial/maximal assistance for hygiene, dressing, and bathing. The MDS indicated Resident 9 had functional limitations in ROM in both arms. During an observation of Resident 9's RNA session on 10/1/2025 at 10:09 am, in Resident 9's room, observed Resident 9 lying in bed. Restorative Nursing Aide 1 (RNA 1) verbally cued Resident 9 to perform active range of motion (AROM, performance of ROM of a joint without any assistance or effort of another person) exercises to the right shoulder, right elbow, right wrist, and right hand. Resident 9 actively moved the right shoulder and right elbow independently with effort. Resident 9 minimally bent and straightened the right wrist and could not extend all the fingers of the right hand which were bent and curled in toward the palm of the hand. Resident 9 stated he was unable to move his right wrist and fingers well. RNA 1 did not assist with ROM exercises to Resident 9's right wrist and hand. During an interview on 10/1/2025 at 10:31 am with RNA 1, RNA 1 confirmed Resident 9 had RNA orders for AAROM exercises to Resident 9's right arm which meant assisting Resident 9 with ROM exercises to the entire arm, including the shoulder, elbow, wrist, and hand. RNA 1 confirmed she did not assist with ROM exercises to Resident 9's right wrist and hand as ordered. RNA 1 stated Resident 9 required assistance with ROM exercises to the right wrist and hand due to weakness. RNA 1 stated she should have assisted Resident 9 with right wrist and hand ROM exercises as ordered but did not. RNA 1 stated Resident 9 could have a decline in ROM if RNA exercises were not provided as ordered. During an interview on 11/18/2025 at 2:56 pm with OT 1 and the DOR, the DOR stated the purpose of the RNA program was to maintain and improve a resident's functional level and ROM. The DOR stated Rehab determined the types of exercises RNAs were to perform when creating an RNA program. The DOR and OT 1 stated if an RNA order was written for ROM exercises to the right arm, it was expected the RNA provide ROM to the entire arm, which included the shoulder, elbow, wrist, and fingers. The DOR and OT 1 stated if RNA did not provide RNA services as ordered, it could potentially result in a decline in ROM and contracture development. During an interview on 11/19/2025 at 4:48 p.m., the Director of Nursing (DON) stated the purpose of the RNA program was to ensure the residents in the facility maintained their function and mobility and to prevent functional declines. The DON stated it was important for RNA to provide exercises as ordered to prevent potential declines in ROM, function, and to avoid delaying a resident's progress towards goals. During a review of the facility's policy and procedure (P&P) titled, Resident Mobility and Range of Motion, the P&P indicated Residents would not experience an avoidable reduction in ROM and residents with limited ROM would receive the treatment and services to increase and/or prevent a further decrease in ROM. The P&P indicated The care plan would be developed by the interdisciplinary team based on comprehensive assessment and include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and ROM. The P&P indicated The care plan would include the type, frequency, and duration of interventions, as well as measurable goals and objectives.

Based on observation, interview and record review, the facility failed to ensure the reach in freezer for frozen vegetables and frozen meat products in the kitchen were maintained and kept in a safe and operating condition by failing to:1. Follow their policy and procedure titled Freezer Storage which indicated to maintain a temperature of zero-degree Fahrenheit (F- unit of measurement) or lower.This failure had the potential to put residents at risk for food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses or parasites).Findings:During an initial tour of kitchen observation and interview on 9/30/2025 at 8:30 a.m. with [NAME] (CK)1, the reach in freezer had a temperature of 39 degrees F. CK 1 stated the kitchen staff was restocking frozen items in the freezer that was why the freezer's temperature was high.During a concurrent observation and interview on 9/30/2025 at 10:52 with the Dietary Manager (DM), the reach in freezer had a temperature of 12 degrees F. The DM stated the temperature of freezer should be -10 degrees to 0 degrees F to keep the frozen meats and vegetables away from danger zone (temperature range between 40 degrees and 140 degrees F where bacteria can multiply quickly causing food borne illness).During a concurrent observation and interview on 9/30/2025 at 2:45 p.m. with the DM in the kitchen, the reach in freezer temperature read 20 degrees F. There was an observation of frozen deep pizza that started to defrost and an ice cream container that had beads of water on the surface and appeared to be melting. The DM stated the administrator called for a repairman to fix the freezer today.During an interview on 9/30/2025 at 8:41 a.m. and 3:38 p.m. with the DM, the DM stated she did not know the freezer's temperature was greater than zero degrees this morning. The DM stated the facility will discard the frozen food items that were defrosting like pizza, and ice-cream will not be left in the freezer. The DM stated the defrosted frozen food cannot refreeze because defrosted food items had the potential to promote bacterial growth which can cause food borne illnesses if consumed by residents.During a telephone interview on 9/30/2025 at 3:33 p.m. with the Registered Dietician (RD), the RD stated the frozen meats can be thawed in the refrigerator and can still be used for two days. The RD stated the rest of the food will be discarded and whatever the kitchen staff can thaw, will be used. The RD stated residents could get food borne illness if the frozen food items are not stored in a freezer with a temperature of zero degrees F.During an interview on 9/30/2025 at 4:03 p.m. with the Administrator (ADM), the ADM stated she was notified about the freezer not functioning properly on 9/30/2025 at 11:00 a.m. The ADM stated she called the company to fix the freezer, and the kitchen staff will empty the contents of the freezer. During an interview on 11/19/2025 at 2:04 p.m. with the DM, the DM stated maintaining the correct temperature of freezer will keep the freshness and quality of food.During a review of facility's policy and procedure (P&P) titled, Freezer Storage, undated, the P&P indicated the freezer should be maintained at a temperature of zero degrees F.During a review of facility's P&P titled, Food Receiving and Storage, revised 11/2022, the P&P indicated frozen foods are maintained at a temperature to keep the food frozen solid and wrappers of frozen foods must stay intact until thawing.

Based on observation, interview, and record review, the facility failed to ensure food was stored and served in a sanitary manner by failing to:Ensure the freezer's temperature was not greater than zero degrees Fahrenheit (F-unit of measurement) while frozen items were stored.Ensure an open bag of popsicles was dated and labeled with open date and use by date.Ensure an open bag of frozen burritos was dated with open date and stored in a sealed bag.Ensure the cook performed hand hygiene after the removal of used gloves and before removing the baked burritos from the oven.These failures had the potential to put residents at risk for food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites).Findings:1. During an initial tour of kitchen observation and interview on 9/30/2025 at 8:30 a.m. with [NAME] (CK)1, the reach in freezer had a temperature of 39 degrees F. CK 1 stated the kitchen staff were restocking frozen items in the freezer that was why the freezer's temperature was high.During a concurrent observation and interview on 9/30/2025 at 10:52 a.m. with the Dietary Manager (DM), the reach in freezer had a temperature of 12 degrees F. The DM stated the temperature of freezer should be -10 degrees to 0-degree F to keep the frozen meats and vegetables away from danger zone (temperature range between 40 degrees and 140 degrees F where bacteria can multiply quickly causing food borne illness).During an observation on 9/30/2025 at 2:45 p.m. with the DM in the kitchen, the reach in freezer temperature read 20 degrees F. There was an observation of frozen deep pizza started to defrost, and an ice cream container had beads of water on the surface. The DM stated the administrator called for a repairman to fix the freezer today.During an interview on 9/30/2025 at 3:38 p.m. with the DM, the DM stated she did not know the freezer's temperature was greater than zero degrees. The DM stated the facility will discard the frozen food items that were defrosting like pizza and ice-cream and will not leave any food items in the freezer. The DM stated defrosted frozen food cannot refroze because defrosted food items had the potential to promote bacterial growth which can cause food borne illnesses if consumed by residents.During a telephone interview on 9/30/2025 at 3:33 p.m. with the Registered Dietician (RD), the RD stated the frozen meats can be thawed in the refrigerator and can still be used for two days. The RD stated the rest of the food will be discarded and whatever the kitchen staff can thaw will be used. The RD stated residents could get food borne illness if the frozen food items are not stored in a freezer with a temperature of 0-degree F.2.During a concurrent observation and interview on 9/30/2025 at 8:33 a.m. with Dietary Aid (DA) 2, an open box of popsicles not labeled with open date and use by date was observed. DA 2 stated the box of popsicles came from the activity department and should have been labeled and dated with open date and by use date.During an interview on 9/30/2025 at 8:41 a.m. with the DM, the DM stated the dietary staff should have put an open date to determine if the popsicles would still be good to be consumed by the residents.3. During a concurrent observation and interview on 9/30/2025 at 2:45 p.m. and subsequent interview on 9/30/2025 at 4:21 p.m. with the DM, an open, not labeled with date open of burritos was stored in an unsealed bag in the freezer. The DM stated the bags of bean and beef burritos should be stored in a sealed container or bag to prevent freezer burns which can affect the quality of food. The DM stated labeling and dating open food items in the freezer and refrigerator are important so the kitchen staff will know when to discard expired food and to ensure food safety.During an interview on 11/20/2025 at 12:00 p.m. with the Administrator (ADM), the ADM stated labeling and dating of open frozen food is important so the dietary staff would know when the food was open, and is still good to be consumed by residents to ensure food safety.4. During an observation on 11/19/2025 at 12:10 p.m. in the kitchen with [NAME] (CK) 1of the tray line (assembly-line system for preparing and assembling meal trays), CK 1 turned off the stove and removed the bean cheese burritos from the oven with gloves used in plating food. CK 1 was observed removing used gloves and putting on a new pair of gloves without hand hygiene and then proceeded to plate food for the tray line.During an interview on 11/19/2025 at 1:38 p.m. with CK 1, CK 1 stated hand hygiene is practiced before and after preparing food, before putting on a new pair of gloves to avoid cross contamination (unintentional transfer of harmful bacteria, viruses from one food or surface to another). CK 1 stated she should have washed her hands to prevent residents from getting sick of food-borne illnesses.During an interview on 11/19/2025 at 4:15 p.m. with the Director of Nursing (DON), the DON stated not practicing hand hygiene in the kitchen during tray line, and in between tasks can put residents at risk for foodborne illness caused by cross contamination.During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated 11/2022, the P&P indicated foods will be received and stored in a manner that complies with safe food handling practices. The P&P indicated all foods stored in the refrigerator or freezer are covered, labeled and dated with use by date. The P&P indicated frozen foods are maintained at a temperature to keep the food frozen solid.During a review of facility's P&P titled, Procedure for Refrigerated Storage, undated, the P&P indicated the freezer's temperature is 0 degree or lower.During a review of facility's P&P titled, Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, revised 11/2022, the P&P indicated employees should wash hands during food preparation, as often as necessary to remove soil and contamination, to prevent cross contamination when changing tasks and after engaging in other activities that contaminate the hands. The P&P indicated the use of disposable gloves does not substitute for proper handwashing, and handwashing should be practiced after gloves are removed

Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 5 diluted potassium chloride oral solution (a medication used to treat and prevent low potassium levels) prior to administration per physician order for one of three sampled residents (Resident 22).This failure had the potential to cause adverse effects, which may impact the resident's health condition.Findings: During an observation on 9/30/2025 at 9:24 a.m., LVN 5) was preparing medications for Resident 22. LVN 5 poured 30 milliliters (ml, unit to measure volume) of potassium chloride 20 milliequivalents (mEq, unit to measure mass) per 15 ml into a medication cup to a line marked 30 ml. During a medication administration observation on 9/30/2025 at 9:59 a.m., Resident 22 was observed having difficulty taking 30 ml of potassium chloride oral solution directly from a medicine cup. Observed Resident 22 displayed an unpleasant facial expression. During an observation on 9/30/2025 at 10:03 a.m., Resident 22 was observed consuming 30 ml of potassium chloride oral solution. The resident had not yet finished the dose and was observed taking small sips of the potassium chloride, followed by sips of water after each. During a concurrent interview and record review on 9/30/2025 at 10:11 a.m., with LVN 5, reviewed medication label instruction on Resident 22's potassium chloride oral solution bottle. LVN 5 stated the potassium solution bottle label indicated Give 40 mEq by mouth one time a day for hypokalemia (low potassium level in the body), 30ml= 40 mEq. Dilute with four ounces (oz, unit to measure volume) of water (120 ml) before taking medication. LVN stated she did not dilute the potassium chloride solution before administering Resident 22. LVN 5 stated that potassium chloride solution should be diluted before administration due to the taste of the medication. LVN 5 stated that Resident 22 exhibited an unpleasant facial expression while sipping the undiluted solution. During a review of Resident 22's Physician Order, dated 7/19/2025 at 7:27 p.m., the Physician Order indicated Potassium chloride liquid 20 mEq/15 mL, give 40 mEq by mouth one time a day for hypokalemia, 30 mL = 40 mEq. Dilute with 4 oz (120 mL) of water before taking medication. During an interview on 9/30/2025 at 2:55 p.m. with the Director of Nursing (DON), the DON stated nurses should follow the directions on the physician's orders. During an interview on 11/18/2025 at 4:01 p.m., with the DON, the DON stated taking potassium chloride oral solution without diluting it first could cause stomach irritation. During a review of the facility's policy and procedures (P&P) titled Administering Medications (revised in April 2019), the P&P indicated Medications are administered in a safe and timely manner, and as prescribed.

Based on observation, interview, and record review, the facility failed to ensure the lunch meal for one of six sampled residents (Resident 3) was fortified (foods have protein, carbohydrates, and/or fats added to increase the total nutritional value of the food) as ordered by the physician.This failure had the potential to result in inadequate caloric and nutritional intake which could lead to unplanned weight loss, decreased strength, and a decline in overall health status.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted on [DATE] and was readmitted on [DATE] with diagnoses including encephalopathy (any disorder that affects the brain's function or structure), muscle weakness, dysphagia (difficulty swallowing), type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and unspecified protein-calorie malnutrition (poor nutrition).During a review of Resident 3's quarterly Minimum Data Set (MDS - a resident assessment tool) dated 11/15/2025, the MDS indicated Resident 3's had moderate cognitive impairment. The MDS indicated Resident 3 needed supervision or touching assistance with eating. The MDS indicated Resident 3 was dependent on staff for toileting, showering, dressing, and putting on or taking off footwear. The MDS indicated Resident 3 needed partial to moderate assistance from staff with oral and personal hygiene.During a review of Resident 3's Care Plan Report initiated on 2/28/2024 and revised on 11/13/2025, the Care Plan Report indicated The resident has potential nutritional problem and dehydration risk r/t advancing age, mechanically altered diet, on therapeutic diet. The Care Plan indicated interventions included Fortified diet 4-Pureed texture, 2-mildly thick consistency, use plate guard (assistive device used to prevent food from falling off the plate) for meals initiated on 11/3/2025. The Care Plan goals included The resident will maintain adequate nutritional status as evidenced by maintaining weight, no s/sx (signs and symptoms) of malnutrition daily through review date.During a review of Resident 3's Order Summary Report (a comprehensive document that outlines a resident's current medical orders, medications and treatments), dated 11/19/2025, Resident 3 had an order for Fortified diet 4-Pureed texture, 2 - mildly thick consistency, provide inner lip plate for every meal ordered on 11/18/2025 and started on 11/18/2025.During an observation on 11/19/2025 at 12:30 p.m. in Resident 3's room, Resident 3's lunch tray was observed with no sauce, gravy, or margarine.During an interview on 11/19/2025 at 1:52 p.m. with Dietary Aid (DA) 1, DA 1 stated she was responsible for announcing the fortified diet to the cook, but she did not read the diet out loud. DA 1 stated she should have read the meal card carefully and told the cook the diet for Resident 3 was fortified.During an interview on 11/19/2025 at 2:04 p.m. with the Dietary Manager (DM), the DM stated fortified diets were for resident(s) who are losing weight and were ordered by the physician for the resident(s) to gain weight. The DM stated if fortified diet orders were not followed, there would be potential for weight loss.During an interview on 11/19/2025 at 4:15 p.m. with the Director of Nursing (DON), the DON stated the purpose of diet fortification was to add calories to the diet. The DON stated if diets were not fortified, the resident would not meet the additional calorie needs.During a review of the facility's policy and procedure (P&P) titled FORTIFIED DIET dated 2025, indicated .The fortified diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. SAMPLED FORTIFIED MEAL PLAN:. Lunch: Extra sauce or gravy on meat extra margarine on potatoes, rice, or pasta extra margarine on hot vegetables, whipped topping on gelatin, pie, cobblers, and pudding.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 31) humidifier bottle (a medical device used with oxygen therapy to add moisture to dry oxygen) was dated with the last change date.This failure had the potential for Resident 31 to receive oxygen through equipment that may not have been maintained according to infection control standards.Findings:During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including encephalopathy (any disorder that affects the brain's function or structure), muscle weakness, difficulty in walking, acute respiratory failure with hypoxia (low levels of oxygen in your body tissues), and dependence on supplemental oxygen.During a review of Resident 31's quarterly Minimum Data Set (MDS - assessment tool) dated 9/5/2025, the MDS indicated Resident 31 needed oxygen therapy.During a review of Resident 31's Order Summary dated 10/3/2025, the Order Summary Report indicated Resident 31 had an order to change pre-filled humidifier every (Q) seven days and as needed (PRN) when oxygen (O2) was in use. The Order Summary indicated to change the pre-filled humidifier Q seven days starting on 6/13/2025. The Order Summary indicated to change the humidifier every Friday on the day shift, starting 6/20/2025, and PRN when O2 was in use. During an observation on 9/30/2025 at 9:27 a.m. in Resident 31' room, Resident 31 was observed lying in bed with eyes closed, with oxygen at 3 liters per minute via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). The pre-filled humidifier attached to the oxygen setup was not dated. During an observation 10/01/2025 at 10:16 a.m. in Resident 31's room, Resident 31's pre-filled humidifier bottle attached to the oxygen setup was not dated.During a concurrent observation and interview on 10/01/2025 at 10:18 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 31's room, the oxygen tubing and pre-filled humidifier were observed. LVN 1 stated the pre-filled humidifier was not dated. LVN 1 stated the pre-filled humidifier(s) were supposed to be changed weekly. LVN 1 stated if humidifier(s) and oxygen tubing(s) were not dated, there would be a potential for risk for infection.During a concurrent observation and interview 10/01/2025 at 10:21 a.m. with the Director of Nursing (DON) in Resident 31's room, the oxygen tubing and pre-filled humidifier were observed. The DON stated the pre-filled humidifier was not dated. The DON stated the oxygen tubing and humidifier should be changed weekly by the treatment nurse and as needed by charge nurse if they were noticeably soiled or damaged. During a review of the facility's policy and procedure (P&P) titled Oxygen Administration revised October 2010, the P&P indicated .Steps in the Procedure.8. Change and label oxygen tubing weekly and as indicated. The facility's P&P did not indicate procedure for labeling pre-filled humidifier(s).

Based on observation, interview, and record review, the facility failed to ensure that the therapy mat (a padded surface used for therapeutic treatment) in the Rehabilitation Gym (Rehab Gym) was maintained in a clean and unobstructed condition. The mat was observed to be cluttered with various miscellaneous items, including multiple cardboard boxes, a cushion pad, inflatable balls, a large paper towel roll, bags, splints (rigid devices used to support and immobilize a broken bone or impaired joint), a wooden device with plastic rings, folded linen, and personal belongings of staff. This failure had the potential to limit the availability and use of therapeutic equipment, reduce usable treatment space for residents during rehab therapy. Findings: During an observation of the Rehab gym on 9/30/2025 at 4:10 p.m., observed four cardboard boxes, a blue cushion pad, two inflatable balls, a large paper towel roll, a large bag containing splints, two sets of leg splints, a wooden device with plastic rings, folded linen, a personal carrying bag, cell phone, eye glasses, and an eyeglass case were observed on top of the therapy mat. During a concurrent observation and interview on 9/30/2025 at 4:30 p.m., with the Director of Rehabilitation (DOR) in the Rehab gym, the DOR stated the therapy mat was used for residents to work on transfers (moving from one surface to another), sitting balance, and various exercises. The DOR confirmed there were four cardboard boxes, a blue cushion pad, two inflatable balls, a large paper towel roll, a large bag containing splints, two leg splints, a wooden device with plastic rings, folded linen, a personal carrying bag, cell phone, eyeglasses, and an eyeglass case on the therapy mat. The DOR stated the miscellaneous items stored on the therapy mat limited the amount of usable space for residents during therapy sessions. The DOR stated the items on the therapy mat should be stored in their designated areas and not on the therapy mat for resident safety and to ensure the equipment was clear and accessible for resident use. During an interview on 11/19/2025 at 4:48 p.m., with the Director of Nursing (DON), the DON stated all therapy equipment should be accessible for resident use. The DON stated the therapy mat should always be clear and free of clutter to prevent accidents and to ensure residents could access the equipment during therapy. During a review of the facility's undated policy and procedures (P&P), titled, Rehab Space Requirements, the P&P indicated the rehabilitation team would provide skilled rehabilitation services in a safe and suitable environment that encouraged the residents to participate and enabled the treating clinician to address the modalities listed on the plan of care.

Based on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (refers to a set commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) for one of two sampled residents (Resident 64). This deficient practice had the potential for Resident 64 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.Findings:During a review of Resident 64's admission Record, the admission Record indicated Resident 64 was admitted to the facility 10/14/2025 with diagnoses including dementia (a progressive state of decline in mental abilities) and Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 64's Minimum Data Set (MDS- a resident assessment tool) dated 10/21/2025, the MDS indicated Resident 64's cognition (ability to think, understand, learn, and remember) was moderately impaired and was dependent (helper does all the effort) with activities of daily living (ADLs-activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 64's progress note dated 11/6/2025, at 1:33 p.m., the progress note indicated Resident 64 did not have sediment (solid particles found in urine caused by a UTI), hematuria (blood in urine), pain, or foul-smelling odor of the urine. During a review of Resident 64's order details dated 11/6/2025 at 2:26 p.m., the order details indicated an order for Nitrofurantoin (medication to treat urinary tract infections). During a concurrent interview and record review on 11/20/2025 at 7:34 a.m., with the Infection Prevention Nurse (IPN), the IPN indicated Resident 64 was started an oral antibiotic Nitrofurantoin 100 milligrams (mg- unit of measurement) twice a day for 10 days. The IPN stated there was no documentation to determine if there was a urine infection or urine culture done prior to Resident 64's starting on oral antibiotics. The IPN stated I missed this one and the importance of screening residents prior to initiation of antibiotic therapy is to prevent antibiotic resistance and potentially killing good bacteria. During an interview on 11/20/2025 at 9:51 a.m., with the Director of Nursing (DON), the DON indicated the IPN should have done a time-out (a brief pause) when Resident 64 was prescribed the oral antibiotic. The DON stated Resident 64 did not have any symptoms of a UTI and therefore the antibiotic was unnecessary and could lead to resistance if prescribed again in the future. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship, dated 11/2019, the P&P indicated, To optimize use of antibiotics by improving prescribing practices and to reduce inappropriate antibiotic use. The facility will implement an antibiotic stewardship program to promote appropriate use of antibiotics, optimizing the treatment of infection, reducing the threat of antibiotic resistance, reducing adverse events associated with antibiotic use and improving outcomes for residents. The P&P indicated the infection preventionist will track whether the resident met Criteria when the antibiotic is ordered. The P&P indicated the infection preventionist will track if cultures were ordered.

Based on observation, interview and record review, the facility failed to provide dental services for one of two sample residents (Resident 62) in a timely manner by failing to:1. Refer Resident 62 to the dentist for recurrent toothache.2. follow up Resident 62 dental x-rays (a special camera that takes pictures of the inside of the mouth, teeth and jaw) result.These failures had the potential to put Resident 62 for unnecessary pain and increased risk of gum disease.Findings:During a review of Resident 62's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses including myocardial infarction (MI- heart attack), angina pectoris (chest pain caused by reduced blood flow to the heart muscle), heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen) and hyperlipidemia (high level of fats in the blood).During a review of Resident 62's History and Physical (H&P) dated 10/8/2025, the H&P indicated the resident had the capacity to understand and make decisions.During a review of Resident 62's Minimum Data Set (MDS- a resident assessment tool) dated 10/14/2025, the MDS indicated the resident had an intact cognition (ability to think, learn, understand and remember) and required set-up or clean up assistance (helper sets up or cleans up ; resident completes activity and helper assists only prior to or following the activity) with oral hygiene and eating. The MDS indicated the resident had an obvious or likely cavity or broken natural teeth.During a review of Resident 62's Order Summary Report (a comprehensive document that outlines a resident's current medical orders, medications and treatments) dated 10/7/2025, the Order Summary Report indicated an order of dental consult and follow treatment as needed.During a review of Resident 62's Onsite Mobile Dental Note dated 10/24/2025, the Onsite Mobile Dental Note indicated Resident 62's chief complaint was broken teeth on his upper and lower mouth. The Onsite Mobile Dental Note indicated Resident 62 had mostly broken teeth, low oral hygiene (neglecting the practices of keeping teeth and gums clean) and high plaque (a sticky, colorless film that forms on teeth and contributes to tooth decay and gum disease) and tartar (hardened dental plaque). The Onsite Mobile Dental Note indicated teeth extractions and evaluation with dental x-rays for treatment recommendations. The Onsite Mobile Dental Note indicated an order of Amoxiclavunate (medicine used to treat infection) 875 milligrams (mgs. -unit of measurement) by mouth every 6 hours as needed for mild to moderate pain) and Ibuprofen (medicine to treat pain and inflammation) 600 mg for pain.During a review of Resident 62's Order Summary Report dated 10/24/2025, the Order Summary Report indicated a physician order of Amoxicillin-Pot Clavunate 875 mgs - 125 mgs. one tablet by mouth every 12 hours for tooth infection for 10 days.During a review of Resident 62's Order Summary Report dated 10/24/2025, the Order Summary Report indicated an order for Ibuprofen 600 mg 1 tablet for mild to moderate pain (1-7 out of 10 pain levels).During a review of Resident 62's Care Plan titled, Resident noted with broken natural teeth and at risk for oral pain/ discomfort, initiated on 10/8/2025, the Care Plan indicated the resident experienced pain related to toothache to left upper side on 10/12/2025. The Care Plan goal indicated Resident 62 will not exhibit mouth pain through the next review date. The Care Plan interventions included dental consultation due to toothache to the left upper side, and dental evaluation and intervention as needed.During a concurrent observation and interview on 11/18/2025 at 9:40 a.m. with Resident 62, Resident 62 grimaced and pointed to the left upper side of his face. Resident 62 stated he had a toothache 9 out of 10 pain scale (severe pain).During a review of Resident 62's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 11/18/2025 and 11/19/2025, the MAR indicated on 11/18/2025 at 9:52 a.m. Resident 62 had 7 out of 10 on a 0 to 10 numeric pain scale(0= no pain, 1-to 3 numeric pain , 4 to 6 = moderate pain and 7 to 10 = severe pain) and received Ibuprofen 600 mgs one tablet. The MAR indicated on 11/19/2025 at 12:34 p.m. the resident received one tablet of Ibuprofen 600 mgs for 7 out of 10 pain level.During a concurrent interview and record review on 11/19/2025 at 2:33 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 62 's MAR, dated 11/18/2025 and 11/19/2025 and Onsite Mobile Dental Note, for the month of October 2025 were reviewed. LVN 3 stated Resident 62 received Ibuprofen 600 mgs. on 11/18/2025 at 9:52 a.m. and on 11/19/2025 at 12:34 p.m. for toothache of 7 out of 10 pain level. LVN 3 stated there was a dental x-ray performed on 11/12/2025 but there was no result in the chart and no staff followed up the result of Resident 62's dental x-rays. LVN 3 stated the licensed nurses should have followed up the Resident 62's dental x-rays and obtained an order from the physician for a dental consultation because of resident's recurrent toothache. LVN 3 stated licensed nurses would call the physician to obtain a dental consultation, and the social worker would schedule an appointment for the dentist to see the resident. LVN 3 stated Resident 62's could develop a tooth infection, and his toothache could get worse if not addressed.During a concurrent interview and record review on 11/19/2025 at 4:45 p.m. with the Director of Nursing (DON), Resident 62's Order Summary Report, dated 10/24/2025 and Onsite Mobile Dental Note dated 10/2025 were reviewed. DON stated the resident was seen by the dentist and was prescribed an antibiotic (Amoxicillin Pot Clavunate) for tooth infection dated 10/24/2025. DON stated the resident had a dental x-ray on 11/12/2025 and result was not on the electronic chart. DON stated licensed nurses are responsible in following up Resident 62's dental x-ray result and should have notified the physician about the recurrent toothache to obtain a dental consultation. DON stated tooth pain could be an indication of infection and could result in worsening pain if not addressed in a timely manner. DON stated licensed nurses not following up Resident 62's dental x-ray result and not notifying the physician about his toothache could cause delay of care and treatment for Resident 62.During a review of facility's policy and procedure (P&P) titled Dental Services, revised 12/2016, the P&P indicated routine, and emergency dental services are available to meet the resident's oral health services according to the resident's assessment and plan of care.During a review of facility's P&P titled, Quality of Care, revised 8/2009, the P&P indicated quality healthcare should be effective, safe, resident centered (providing care that responds to individual needs) and timely.

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 7) who was assessed as being at risk for pressure ulcer ( localized damage to the skin and/or underlying tissue usually over a bony prominence) development was provided a pressure relieving barrier to be placed between Resident 7's overlapping, contracted (loss of motion of a joint associated with stiffness and joint deformity) toes of the right foot per facility's policy and procedure titled Prevention of Pressure Injuries. This failure had the potential for Resident 7 to develop pressure ulcers on the right foot. Findings: During a review of Resident 7's admission Record, the admission Record indicated the facility initially admitted Resident 7 on 12/7/2020 and re-admitted on [DATE] with diagnoses including type 2 diabetes mellitus ( a disorder characterized by difficulty in blood sugar control and poor wound healing), contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of both knees, both elbows, and both hands, and chronic a chronic diabetic ulcer (persistent open wound that fails to show significant healing) of the left foot. During a review of Resident 7's Minimum Data Set (MDS, resident assessment tool), dated 10/7/2025, the MDS indicated Resident 7 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 7 was dependent (helper does all the effort) in oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, rolling to both sides, and transfers. The MDS indicated Resident 7 had functional limitations in range of motion (ROM (ROM, full movement potential of a joint [limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury]) in both arms and both legs. The MDS indicated Resident 7 was at risk for pressure ulcer development. During a review of Resident 7's Braden Scale (pressure ulcer risk assessment tool), dated 10/7/2025, the Braden Scale indicated Resident 7 was at very high risk for pressure ulcer development due to very limited sensory perception (unable to communicate discomfort, needs to be turned, or had limited ability to feel pain or discomfort in one or two arms or legs), occasionally moist skin, complete immobility (inability to move), and very poor food intake. During a review of Resident 7's care plan, titled Resident 7 was at high risk for impairment to skin integrity due to contractures of both hands, both knees, both elbows, and limited mobility, the care plan indicated a goal for Resident 7 to be free from skin injury. The care plan interventions indicated to identify/document potential causative factors and eliminate/resolve where possible. During a concurrent observation of a Restorative Nursing Aide (RNA, nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) session and interview on 10/1/2025 at 10:42 am, in Resident 7's room, Resident 7 was lying in bed wearing splints (a device used to restrict, protect, or immobilize a part of the body to support function and increase ROM) to both elbows, right wrist, and right hand, a rolled up towel in the left hand, and soft boots (specialized boots placed on the feet and ankles used to treat and prevent pressure sores) on both feet. Restorative Nursing Aide 1 (RNA 1) and Certified Nursing Assistant 2 (CNA 2) removed Resident 7's both knee splints and both soft boots from Resident 7's legs and assisted with passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 7's both knees, both ankles, and all the toes of both feet. Resident 7's middle toe, fourth toe, and small toe of the right foot were hyperextended (extension of a body part beyond its normal limits) at the knuckle joint and overlapping. Resident 7's small toe on the right foot overlapped the fourth toe, and the fourth toe overlapped the middle toe. RNA 1 and CNA 2 stated Resident 7's middle toe, fourth toe, and small toe on the right foot were overlapping and needed to be physically separated by staff because they were on top of each other and creating points of pressure. During a concurrent observation and interview on 10/1/2025 at 11:04 a.m., with Licensed Vocational Nurse 2 (LVN 2) in Resident 7's room, LVN 2 confirmed Resident 7 had contractures of the toes on the right foot causing the middle toe, fourth toe, and small toe to overlap. LVN 2 stated Resident 7's soft boots helped prevent skin breakdown (tissue damage caused by friction, shear [occurs when the skin is pulled in one direction while the underlying bone is pulled in the opposite direction], moisture, or pressure) and pressure ulcers of both heels and feet but caused the overlapping toes to further press against each other when the straps of the soft boots were fastened. LVN 2 stated Resident 7 was at high risk for pressure sore development because she had diabetes and required total assistance for mobility. LVN 2 stated Resident 7's toes on the right foot were overlapping and required staff to physically separate and consistently reposition the toes to prevent areas of pressure. During a concurrent observation and interview on 10/1/2025 at 11:13 am with the Director of Nursing (DON) in Resident 7's room, the DON assessed Resident 7's right foot and confirmed Resident 7 had contractures of the right foot causing the middle toe, fourth toe, and small toes to overlap. The DON stated Resident 7 required a barrier or device to separate the overlapping toes of Resident 7's right foot to offload (reducing or removing pressure) the pressure and prevent pressure ulcers but did not have one. The DON stated the lack of repositioning, prolonged areas of pressure, poor nutrition, and immobility put residents at risk for skin breakdown and pressure ulcers. The DON stated Resident 7 was at high risk for developing skin breakdown and pressure ulcers because Resident 7 required total care for mobility and repositioning and had multiple contracted toes causing areas of constant pressure between the middle toe, fourth toe, and small toe of the right foot with no barrier in-between to offload the pressure. During a review of the facility's P&P titled, Prevention of Pressure Injuries, revised 4/2020, the P&P indicated Staff were to review the care plan and identify the risk factors as well as the interventions designed to reduce or eliminate pressure injuries. The P&P indicated staff inspected skin daily when performing or assisting with personal care or activities of daily living (ADLs) which included the inspection of pressure points, repositioning the resident, and providing support devices and assistance as needed. The P&P indicated skin care and prevention of pressure injuries included the use of facility-approved protective dressings for at risk individuals. The P&P indicated staff were to review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device, monitor regularly for comfort and signs of pressure-related injury, and to consult with current clinical practice guidelines for prevention measures associated with specific devices.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for the assessment and application of splints (a device used to restrict, protect, or immobilize a part of the body to support function and increase ROM) for one of six sampled residents (Resident 27). The facility failed to: 1.Ensure the Director of Rehab (DOR) who was a Physical Therapist (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) performed an assessment to determine the appropriateness, fit, and splint wear time tolerance (length of time and frequency a person can tolerate wearing the splint for safety, comfort, and maximal benefits) of Resident 27's right knee splint. 2.Ensure the Occupational Therapist (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) performed an assessment to determine the appropriateness, fit, and splint wear time tolerance of Resident 27's right elbow and right-hand splints. These failures had the potential to cause Resident 27 to have skin break down (tissue damage caused by friction, shear, moisture, or pressure), pain, discomfort, decreased range of motion (ROM, full movement potential of a joint), joint dislocation (an injury where the joint is forced out of the normal position), deformity (malformation), and/or bone fractures (a crack or break in the bone). Findings:During a review of Resident 27's admission Record, the admission Record indicated the facility initially admitted Resident 27 on 8/20/2024 and re-admitted on [DATE] with diagnoses including right hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body), osteoporosis (condition in which the bones become brittle), and aphasia (loss of ability to understand or express speech, caused by brain damage). During a review of Resident 27's Order Summary Report, the Order Summary Report indicated a physician's order, dated 10/2/2024 with start date of 10/3/2024, for Restorative Nursing Aide (RNA, nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) to apply a right knee splint for three (3) to five (5) hours, every day, 5 times a week. During a review of Resident 27's Order Summary Report, the Order Summary Report indicated a physician's order, dated 10/2/2024 with start date of 10/3/2024, for RNA to apply a right-hand splint for 3 to 5 hours, every day, 5 times a week. During a review of Resident 27's Order Summary Report, the Order Summary Report indicated a physician's order, dated 9/22/2025 with start date of 9/23/2025, for RNA to apply a right elbow splint for 3 to 5 hours, every day, 5 times a week. During a review of Resident 27's Minimum Data Set (MDS, a resident assessment tool) dated 10/7/2025, the MDS indicated Resident 27 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 27 was dependent (helper does all the effort) in eating, hygiene, bathing, dressing, and mobility (ability to move). The MDS indicated Resident 27 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) on both arms (shoulder, elbow, wrist, hand) and one leg (hip, knee, ankle, foot). During an observation on 11/19/2025 at 10:22 am in Resident 27's room, Resident 27 was lying in bed wearing splints to the right elbow, right hand, and right knee. Resident 27's both knees were bent and rotated to the left side of the body. During a concurrent interview and record review on 11/18/2025 at 2:56 pm with the DOR and Occupational Therapist 1 (OT 1), the DOR stated the purpose of splints was to improve or maintain a resident's ROM and prevent contractures. The DOR stated a licensed PT or OT must assess a resident's need for splints if indicated. The DOR stated it was facility's practice for the PTs to assess and determine the necessity of leg splints, while the OTs assessed and determined the necessity of arm splints. The DOR stated the licensed therapist must determine the splint wear tolerance and schedule by periodically assessing the splint for safety, comfort or need for modification. The DOR stated that after the therapist assessed a resident for the correct type of splint and established the wear tolerance, the therapist transitioned the splinting plan of care to nursing and the RNA program. The DOR and OT 1 stated the standard of practice in therapy for a resident requiring a new splint included: an initial evaluation of the resident's ROM, assessment for the type of splint to issue, application of the splint, periodic splint checks to determine the splint wear schedule, tolerance, and if modification was required, training the patient, caregiver, RNA, and nursing on the use of splint and any precautions and documentation of all findings in the clinical record. The DOR and OT 1 reviewed Resident 27's clinical record and confirmed Resident 27 had physician's orders for RNA to apply splints to Resident 27's right elbow, right hand, and right knee. The DOR and OT 1 reviewed Resident 27's therapy records and confirmed there was no documented evidence to indicate splint assessments for Resident 27's right elbow, right wrist, and right knee were completed and determination of the wear time for all splints were evaluated and established by a therapist. The DOR and OT 1 stated if a resident was not properly assessed for the correct splints and wear time tolerance, the resident could potentially have skin breakdown, pain, discomfort, and ROM decline. During an interview on 11/19/2025 at 4:48 pm with the Director of Nursing (DON), the DON stated the Rehabilitation (Rehab) Department was responsible for splint assessments, determining the correct type of splint to issue, and establishing the splint wear time for all residents in the facility. The DON stated that without proper assessment for the correct type of splint and a safe wear time schedule, residents could potentially experience a functional decline, pain, discomfort, and skin breakdown. During a review of a textbook, titled American Physical Therapy Association. (2003). Guide to physical therapist practice (2nd ed.). American Physical Therapy Association pages 76 to 77, the textbook indicated A physical therapist used tests and measures to assess the need for orthotic ( a medical device, often a specialized insole, that is worn inside a shoe or brace to support, align, or correct a body part's function) devices in patients and evaluated the appropriateness and fit of the device. The Guide to Physical Therapy Practice indicated Physical Therapists performed assessments to determine a patient's alignment and fit of the orthotic device, components of orthotic device, level of safety with device, and functional benefit of the device. During a review of a textbook, titled Occupational therapy for physical dysfunction (2014, 7th ed.) pages 429 and 431, the textbook indicated The occupational therapist, as an expert in the adaptive use of upper extremities in occupational performance tasks, has the major responsibility for the recommendation of appropriate orthoses, the testing and training in the use of orthoses, and the selection, design, and fabrication of thermoplastic splints. The Occupational Therapy for Physical Dysfunction indicated The therapist must consider, carefully monitor, and teach the client and caregiver to report any of these problems related to orthotic use: impaired skin integrity, pain, swelling, stiffness, sensory disturbances, increased stress of unsplinted joints, and functional limitations. During a review of the facility's undated policy and procedure (P&P) titled Splinting, the P&P indicated The purpose of splints was to prevent deformity caused by muscle tightness or joint contracture, protect weak muscles from overstretching, prevent increased muscle imbalance, strengthen weak muscles, and provide temporary support for a painful body part. The P&P indicated the charge nurse, or therapist would contact the physician to obtain an evaluation order and treatment sessions for splint application, the monitoring of wear schedule, splint modifications as needed, and instruction for the nursing staff. The P&P indicated the therapist ordered the splints, applied the splint, made any necessary fitting adjustments, placed the resident on a two hour trial wearing period to check for pressure points and assessed the resident's tolerance for the splint, increased the splint wear time throughout the course or treatment, in-serviced the nursing staff on proper application, precautions, and wearing schedule once the therapist determined the splint had reached the maximum benefit to the resident, and documented the instructions and recommendations in the plan of care.

Based on interview and record review, the facility failed to ensure a preadmission screening and annual review of a Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) was accurately documented for two of four residents (Residents 17 and 45).This deficient practice had the potential to result in an inappropriate placement and delay of needed services for Resident's 17 and 45.Findings: A. During a review of Resident 17's admission Record, the admission Record indicated Resident 17 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and major depressive disorder (a mood disorder that causes a persistent feelings of sadness and loss of interest). During a review of Resident 17's Minimum Data Set (MDS- a resident assessment tool) dated 9/5/2025, the MDS indicated Resident 17 was cognitively (ability to think, understand, learn, and remember) intact. During a review of Resident 17's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), for the month of November 2025, the MAR indicated Risperidone 0.5 milligrams (mg- unit of measurement) one tablet by mouth at bedtime for bipolar disorder manifested by paranoia and delusions was ordered on 9/5/2025. During a review of Resident 17's MAR for the month of November 2025, the MAR indicated Trazadone 75 mg at bedtime for depression manifested by the inability to sleep was ordered on 8/19/2025. During a review of Resident 17's Care Plan titled Resident 17 has a behavior problem related to bipolar disorder initiated 3/12/2025, with goals for Resident 17 to have fewer episodes paranoia (a pattern of behavior where a person feels distrustful and suspicious of other people) and delusions (having false or unrealistic beliefs). The Care Plan interventions include approaching him in a calm manner. During a concurrent interview and record review on 11/19/2025 at 12:50 a.m., with the Director of Nursing (DON), Resident 17's PASARR dated 9/5/2025 was reviewed. The PASARR indicated the level one screening was positive and a PASARR level two evaluation was required due to a diagnosis of serious mental illness. The DON stated Resident 17 has bipolar disorder, anxiety, and major depressive disorder and a level two evaluation should have been done but was not because the level two evaluation letter stated Resident 17 does not have a serious mental illness. The DON stated the level two evaluation was documented incorrectly. The DON stated she is responsible for reviewing and completing the PASARR. The DON stated if the PASARR was not documented correctly there will be a delay in resources and care for his mental illness. B. During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder, anxiety (and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 45's MDS dated [DATE], the MDS indicated Resident 45's cognition was severely impaired. During a review of Resident 17's MAR for the month of November 2025, the MAR indicated:a. Mirtazapine 7.5 mg by mouth at bedtime for depression manifested by poor oral intake ordered on 7/7/2025.b. Quetiapine 50 mg by mouth at bedtime for psychosis manifested by visual and auditory hallucinations (sights, sounds, smells, tastes, or touches that a person believes to be real but are not real) ordered on 7/7/2025. c. Trazadone 100 mg by mouth at bedtime for depression manifested by inability to sleep at night ordered on 7/7/2025.d. Seroquel 50 mg by mouth two times a day for psychosis manifested by visual and auditory hallucinations ordered on 7/7/2025. During a review of Resident 45's Care Plan titled Resident 45 has a behavior problem related to psychosis initiated on 10/1/2025 with goals for Resident 45 to have fewer episodes of psychosis. The care plan interventions for Resident 45 include intervening as necessary to protect the rights and safety of others. During a subsequent interview and record review on 11/19/2025 at 1:00 p.m., with the DON, Resident 45's PASARR dated 7/24/2025 was reviewed. The PASARR indicated the level one screening was negative and a PASARR level two evaluation should have been done due to a diagnosis of serious mental illness. The DON stated Resident 45 has psychosis and depression and the PASARR level one evaluation letter was incorrect. The DON stated she will resubmit the PASARR so Resident 45 could receive specialized individualized resources for mental illness. During a review of the facility's policy and procedure (P&P) titled, admission Criteria, dated 3/2019, the P&P indicated, Our facility admits only residents who's medical and nursing care needs can be met. The objectives of our admission criteria policy are to admit residents who can be cared for adequately by the facility. All new admissions and readmissions are screened for mental disorders, intellectual disabilities or related disabilities per the PASARR process. The P&P indicated the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate.

Based on observation, interview, and record review, the facility failed to report a change of condition (COC, major decline or improvement in a resident's status that will not resolve itself without intervention) to the physician for one of six sampled residents (Resident 39) when a decline in range of motion (ROM, full movement potential of a joint) of Resident 39's both hands were identified on the Joint Mobility Assessment (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 3/20/2025. This failure resulted in Resident 39 not receiving the appropriate services and interventions to address and improve ROM, prevent contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness), and improve overall mobility and physical functioning.Findings: During a review of Resident 39's admission Record, the admission Record indicated the facility initially admitted Resident 39 on 5/5/2021 and re-admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty breathing) and peripheral autonomic neuropathy (disorder that affects then nerves that control the body's processes without conscious effort). During a review of Resident 39's JMA, dated 10/17/2024, the JMA indicated Resident 39 had full ROM of both hands. The Findings section of the JMA indicated Resident 39 had a diagnosis or condition that put him at risk for contracture development. The Comment section of the JMA indicated to continue the RNA program as indicated. During a review of Resident 39's JMA, dated 3/20/2025, the JMA indicated Resident 39 had moderate (26 to 50 percent loss of motion) ROM loss to the right hand and severe (greater than 50 percent loss of motion) ROM loss to the left hand. The JMA indicated under findings section, Resident 39 had minimal to severe loss of passive range of motion (PROM, movement at a given joint with full assistance from another person) to the arms and had a diagnosis or condition that put her at risk for contracture development. The JMA indicated under the comment section, Resident 39 had moderate loss in ROM of the middle finger of the right hand in extension of the proximal interphalangeal (PIP, middle joint of the finger between the knuckle and the fingertip) joint, moderate to maximal loss of ROM of the pointer finger of the left hand in the metacarpal phalangeal (MCP, knuckle joint of the finger) joint and distal interphalangeal (DIP, joint at the tip of the finger closes to the nail) joint, and middle finger of the left hand at the DIP joint. The JMA recommendations indicated no skilled Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) evaluation was needed. The JMA under the comment section indicated to continue the RNA program as indicated. During a review of Resident 39's Minimum Date Set (MDS-resident assessment tool) dated 10/16/2025, the MDS indicated Resident 39 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 39 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity) for eating and oral hygiene, partial/moderate assistance (helper does less than half the effort) for rolling to both sides, sit to stand, and transfers, substantial/maximal assistance (helper does more than half the effort) for toilet hygiene, dressing, and personal hygiene, and was dependent for bathing. The MDS indicated Resident 39 had functional limitations in ROM in both arms. During a concurrent observation and interview on 11/19/2025 at 8:19 am, with Resident 39 in Resident 39's room, Resident 39 was observed lying in bed. All the fingers on Resident 39's left hand were bent downwards into the palm of the hand. Resident 39's middle finger on the left hand and the ring finger on the right hand were bent to about 90 degrees at the middle joints of the fingers between the knuckles and the fingertips. Resident 39 stated he was unable to straighten all the fingers on his left hand and the ring finger of the right hand on his own and needed assistance. During a concurrent observation of Resident 39's RNA session and interview on 11/19/2025 at 10:34 am, with Restorative Nursing Assistant (RNA) 1, RNA 1 assisted Resident 39 with active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) exercises to both hands. Resident 39 stated he was unable to straighten the knuckle joints and middle joints of all fingers of the left hand and the ring finger of the right hand and needed assistance. Resident 39 stated he did not recall when both hands became stiff, but thought it was a long time ago. After assisting with ROM exercises to Resident 39's both hands, RNA 1 applied a splint (a device used to restrict, protect, or immobilize a part of the body to support function and increase ROM) to Resident 39's middle finger of the left hand and subsequently applied an additional resting hand splint (splint secured from the hand to the forearm to position the hand in a functional position) on the same hand to include the other fingers and wrist. During a concurrent record review and interview on 11/19/2025 at 1:16 pm with the Director of Rehabilitation (DOR) and Occupational Therapist 2 (OT 2), the DOR stated the facility monitored for changes in ROM by JMAs completed by the Rehabilitation Department (Rehab) upon admission, re-admission, annually and upon a COC. The DOR stated the purpose of the JMAs was to identify any changes in a resident's ROM such as declines or improvements to ensure the residents received the appropriate care and services to prevent further decline and contracture development. The DOR and OT 2 stated any significant declines noted in the JMAs should be investigated, discussed with nursing, and reported to the physician for further intervention. The DOR and OT 2 reviewed Resident 39's JMAs, dated 10/17/2024 and 3/20/2025, and confirmed Resident 39 had a significant decline in ROM of both hands from full ROM to moderate ROM loss in the right hand and severe ROM loss in the left hand. The DOR and OT 2 stated the decline in Resident 39's ROM of both hands was significant and should have been reported to the doctor when the ROM loss was identified on the JMA on 3/20/2025 but was not. The DOR and OT 2 stated it was important staff notified the physician of any changes of condition to ensure the residents received the appropriate treatment and services to prevent further decline. During a concurrent interview and record review on 11/19/2025 at 4:48 p.m. with the Director of Nursing (DON), the DON stated a COC was any new occurrence observed that was different from a resident's normal baseline. The DON stated a significant decline in a resident's ROM was considered a COC and the physician should be notified. The DON reviewed Resident 39's JMAs, dated 10/17/2024 and 3/20/2025, and confirmed Resident 39 had a significant decline in ROM of both hands from full ROM to moderate ROM loss in the right hand and severe ROM loss in the left hand. The DON stated Resident 39's decline in ROM of both hands was significant and should have been reported to the physician but was not. The DON stated that after identifying Resident 39's decline in ROM of both hands on the JMA on 3/20/2025, Rehab should have informed nursing, notified the physician, and re-evaluated Resident 39 to ensure Resident 39 received the appropriate care and services to improve and prevent further ROM decline. The DON stated it was important facility staff notified the physician of declines in ROM to ensure the physician was able to properly direct medical care and implement appropriate interventions to address the issue. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, revised 7/2024, the P&P indicated The facility shall notify the resident, his or her attending physician, and representative (sponsor) of any changes in the resident's medical/mental condition and/or status. The P&P indicated The nurse would notify the physician when there was a significant change in the resident's physical, emotional, or mental condition.

Based on observation, interview, and record review, the facility failed to ensure 24 residents' rooms met 80 square feet (sq. ft- a unit of area measurement) per residents in multibed resident rooms. Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9,10,11,12,14,15,16,17,18,19, 20, 21, 22, 23, 25, and 26 were occupied with at least two residents. rooms [ROOM NUMBERS] were occupied with three residents per room. This deficient practice had the potential to result in inadequate provision of safe nursing care, and privacy for the residents. Findings: During an observation on 9/30/2025 at 10:17 a.m. an initial tour of the facility was done. Residents' rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15,16,17, 18, 19, 20, 21,22. 23, 25, and 26, did not meet the requirement of 80 sq. ft per resident. During an observation on 11/19/2025 at 2:31 p.m., some residents were in their rooms, able to move freely, and open drawers on their nightstand. Nurses were able to perform patient care, and the resident size of room did not affect the privacy of the residents. During a review of the facility's Room Waiver letter, dated 9/15/2025, provided by the Administrator (ADM), the Room Waiver letter indicated that rooms had enough space to provide for each resident's care, dignity. and privacy. The Room Waiver letter indicated the lack of space on the new building code has no adverse effect on the residents' health and safety or on maintaining the wellbeing of the residents. The following rooms were included in the Room Waiver request: Rooms 1, 2, 3, 4, 5, 6, 7. 8, 9, 10, 11, 12, 14, 15,16, 17, 18,19, 20, 21, 22, 23, 25, and 26. During an interview on 11/20/2025 at 12:27 p.m. with the ADM, the ADM stated a letter was sent out every year to ensure the California Department of Public Health was aware of the residents' room sizes. The ADM stated at this time there were no concerns from residents about room size. The ADM stated we can accommodate the residents' needs, provide care and environmental cleaning on a daily basis. During a review of the facility's policy and procedures (P&P), titled Bedrooms, undated, the P&P indicated, .Bedrooms measure at least 80 square feet of space per resident in double rooms, and at least 100 square feet of space in single rooms.

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained when cockroaches were observed in the kitchen. This deficient practice resulted in the facility's kitchen being closed for use to the residents and had the potential to spread bacteria and viruses that cause illness, affecting the population of residents in the facility (44) who resided in there and who received food from the facility's kitchen by consuming potentially contaminated food.Findings: During an observation on 7/11/2025, at 2:19 p.m., of the facility's dry food storage area in their kitchen, in the presence of the Dietary Services Supervisor (DSS), a medium sized dark brown cockroach was seen running out of a box of white powdered thickener that was inside an open plastic bag. During an observation on 7/11/2025, at 2:26 p.m., of the facility's dry food storage area in their kitchen, in the presence of the Dietary Services Supervisor (DSS), a medium sized dark brown cockroach was seen running out of a box of individually packaged crackers. During a review of the facility pest control invoice dated 5/12/2025, the invoice indicated the facility treated Resident 1's room for roaches. During a review of facility pest control invoice dated 5/20/2025, the invoice indicated the facility treated Resident 1's room for American roaches (water bugs). During a review of facility pest control invoice dated 5/28/2025, the invoice indicated the facility treated Resident 1's room for American roaches. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of heart failure ([CHF] a heart disorder which causes the heart to not pump blood efficiently, sometimes resulting in leg swelling). During a review of Resident 1's History and Physical (H&P), dated 6/4/2025, the H&P indicated Resident 1 had capacity to understand and make decisions. During an interview on 7/11/2025 at 2:38 p.m., the Dietary Supervisor (DS) stated the thicker plastic bag should have been closed as part of their infection control practices and so bugs do not get inside. During an interview on 7/11/2025 at 2:40 p.m., the Dietary Aide (DA) 1 stated approximately one month ago, she noticed a few small roaches on a few different occasions in the dry storage area and informed the DS to tell pest control. DA 1 stated pest control came twice in the past month to treat the area. During an interview on 7/11/2025 at 2:44 p.m., the DS stated she had not been informed by anyone that cockroaches were seen in the kitchen, and she had not seen any herself. During an interview on 7/15/2025 at 10:02 a.m., Resident 1 stated approximately one month ago he saw two big roaches in his room but stated he has not seen any since then. During an interview on 7/11/2025 at 12 p.m., the Director of Nursing (DON) stated she had worked at the facility for three years and was not aware there were roaches in the building. The DON stated she found out today (7/11/2025) there were roaches found in the kitchen when the environmental health department came to the facility at approximately 12 p.m. and pointed them out to the DSS. The DON stated the environmental health department staff used a flash light, tapped firmly on a wood shelf in the kitchen and two roaches measuring about one and a half inches came out During review of facility's Policy and Procedure (P/P) titled Pest Control dated 5/2008, the P/P indicated the facility maintains an on-going pest control program to ensure that the building is kept free from insects and rodents.

Based on interview and record review, the facility failed to ensure the resident's physician was notified when the resident had a change of condition (COC) for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) and LVN 2 promptly notified Resident 1's physician when Resident 1 had loose/watery stools for five days as indicated in the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status. 2. Ensure nursing staff implemented Resident 1's Care Plan titled, Resident at Risk for Constipation, by monitoring the amount, consistency, and frequency of Resident 1's bowel movements. This deficient practice resulted in a delay in care and treatment for Resident 1, who was eventually transferred to a General Acute Care Hospital (GACH) on 7/6/24 where she underwent an emergent total colectomy (a surgical procedure to remove the entire colon), a gastric wedge resection (a surgical procedure in which a wedge shaped portion of the stomach is removed), a partial omentectomy (a surgical procedure to remove a portion of the omentum [a fold of tissue that surrounds the stomach and other organs]), and a temporary abdominal (stomach) closure in the setting of fulminant (something that happens suddenly and with great intensity or severity) clostridoides difficile colitis ([C. Diff- results from the disruption of normal healthy bacteria in the colon, often from antibiotics. Can lead to severe damage to the colon and can be fatal). Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses included hypernatremia (high sodium levels in the blood), hypertensive heart disease (a condition in which the blood vessels have persistently raised pressure), chronic kidney disease ([CKD] kidney damage lasting three months or more) heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or paralysis on one side of the body) following a cerebral infarction ([stroke] lack of oxygen to tissues in the brain). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 4/25/2024, the MDS indicated Resident 1's cognition (thinking) was moderately impaired. During a review of Resident 1's History and Physical (H&P), dated 11/17/2023, the H&P indicated, Resident 1 had a fluctuating capacity (situations where a person's decision-making ability varies) to understand and make decisions. During a review of Resident 1's Care Plan, titled Resident at Risk for Constipation, dated 6/18/2024, the Care Plan indicated Resident 1's goal was to maintain passage of soft formed stools at a frequency perceived as normal through 9/16/2024. The Care Plan's intervention included to monitor the amount, consistency, and frequency of Resident 1's bowel movements. During a review of Resident 1's Physician's Order Summary Report dated 6/14/2024, the Physician Orders indicated Resident 1 was to receive Cefuroxime Axetil (an antibiotic used to treat a wide variety of bacterial infections) 250 milligrams ([mg] a unit of measurement) two times a day for a urinary tract infection ([UTI] a bacterial infection in any part of the urinary tract) caused by Escherichia coli ([E. coli] a type of bacteria that can cause severe bloody diarrhea) for seven days. During a review of Resident 1's Medication Administration Record (MAR), dated 6/2024, the MAR indicated Resident 1 received Cefuroxime Axetil from 6/14/2024 through 6/20/2024. During a review of Resident 1's Bowel and Elimination form, dated 7/1/20204 through 7/5/2024, the Bowel and Elimination form indicated the following: 1. On 7/1/2024 at 2:59 p.m. and 10:59 p.m., Resident 1 had two episodes of large loose/diarrhea (loose and watery stools). 2. On 7/2/2024 at 2:30 p.m., Resident 1 had one episode of a large loose/diarrhea. 3. On 7/3/2024 at 11:14 a.m. and 9:14 p.m., Resident 1 had two episodes of large loose/diarrhea. 4. On 7/4/2024 at 6:09 a.m., 1:29 p.m., and 9:46 p.m., Resident 1 had three episodes of large loose/diarrhea.5. On 7/5/2024 at 9:31 p.m., Resident 1 had one episode of a large loose/diarrhea. During a review of Resident 1's Clinical Record, the Clinical Record indicated there was had no documentation to indicate licensed nurses monitored Resident 1's stool, per the Care Plan or that Resident 1's physician was notified of Resident 1's loose/diarrhea. During a review of Resident 1's General Laboratory Work, dated 7/5/2024, the General Laboratory Work indicated Resident 1's Comprehensive Metabolic Panel ([CMP] a blood test that gives doctors information about the body's chemical fluid balance) illustrated Resident 1 had a critically high Creatinine (a waste product that comes from the breakdown of muscle tissue and the digestion of protein in food, [reference range = 0.55 mg/dl- 1.02 mg/deciliter (dl)]) level of 7.6 mg/dl, a critical high blood urea nitrogen ([BUN] a waste product that the kidneys remove from the blood) [reference range = 9.0 mg/dl 23.0 mg/dl) level of 108 mg/dl, and a high sodium (a mineral needed by the body to keep the body fluids in balance, [reference range= 135 milliequivalents per liter (mEq/L - 145 mEq/L]) level of 155 mEq/L. During a review of Resident 1's Progress Notes, dated 7/6/2024, the Progress Notes indicated at 7:15 a.m. (7/6/2024), Resident 1 was awake and refused breakfast and medications. At 12:30 p.m., Resident 1's vital signs ([v/s] measurements of the body's most basic functions such as breathing, heart rate [HR], temperature, and blood pressure [B/P]) were taken. Resident 1's b/p was unobtainable, HR was 51 beats per minute ([bpm] reference range 60-100 bpm), respiratory rate (RR) was 48 breaths per minute (reference range 12-20 breaths per minute), and the resident's Oxygen Saturation level ([O2 Sat] a measure of how much oxygen is circulating in the blood, reference range 95% - 100%) was 91%. The Progress Notes indicated Resident 1 was lethargic (a condition marked by drowsiness) and unresponsive to verbal commands. The Progress Notes indicated 911 was called and Resident 1 was taken by paramedics to a GACH. During a review of Resident 1's Situation, Background, Assessment, and Recommendation ([SBAR] a structured framework that provides communication between members of the health care team about a patient's condition), dated 7/6/2024, the SBAR indicated Resident 1 was lethargic, her B/P could not be obtained, and she was short of breath (SOB) with shallow breathing (when you only draw small amounts of air into your lungs, not using full capacity). During a review of the GACH's Emergency Department (ED) Documentation, dated 7/6/2024, the GACH'S ED Documentation indicated upon admission to the GACH on 7/6/2024, Resident 1 was not alert, her skin was dry, cool, and pale, and her oral mucous membranes (the moist inner lining of some organs and body cavities such as the nose, mouth, lungs, and stomach) were dry. The ED's Documentation indicated Resident 1's B/P was 64/30 millimeters of mercury ([mmHg]the reference range is 120/ 80 mmHg), and her HR was 150 bpm. The ED's Documentation indicated Resident 1 was admitted to the Medical Intensive Care Unit ([MICU] a hospital ward that provides intensive continuous 24-hour care for patients who are critically ill or injured) with a diagnosis of septic shock (a life-threatening condition that happens when your blood pressure drops to dangerously low levels after an infection). The ED's Documentation indicated while in MICU Resident 1's laboratory results on 7/6/2024 indicated the resident had metabolic acidosis (a condition in which the body's fluids have too much acid, resulting in an abnormally low pH [describes the acidity or basicity of a solution]). Resident 1's laboratory results dated [DATE] indicated the following: 1. pH level 7.30 (reference range 7.35- 7.45). 2. Arterial blood carbon dioxide level (indicates how well the lungs remove carbon dioxide [a clear, odorless, and colorless gas] from the blood, reference range 35-45) 20. 3. Bicarbonate level (a form of carbon dioxide, a low level indicates metabolic acidosis) reference range 22-27) 10. 4. [NAME] blood cell count ([WBC] part of the body's immune system that helps the body fight infections and other diseases [reference range 4,000- 11,000 per microliter [cells/ul of blood) 33.4 ul. 5. Creatinine level 9.14 mg/dl. 6. Sodium 153 milliequivalents per liter (mEq/L). 7. Lactate level (a byproduct caused by any type of severe viral or bacterial infection) [reference range= 0.5 mg/dl- 2.2 mg/dl]) 6.9 mg/dl. The GACH's ED Documentation indicated on 7/7/2024, Resident 1 underwent an emergent total colectomy, gastric wedge resection, partial omentectomy, and temporary abdominal closure in the setting of fulminant C. Diff. During a concurrent interview and record review on 7/26/2024, at 3:02 p.m., with a certified nursing assistant (CNA 1), Resident 1's Bowel and Elimination documentation was reviewed. CNA 1 stated on 7/2/2024, she notified the charge nurse (CN 1) whose name she does not recall, that Resident 1 had 2 episodes of watery stools and on 7/4/2024. During an interview on 7/29/2024, at 9:59 a.m., the licensed vocational nurse (LVN 1) stated, no one reported to him that Resident 1 had loose watery stool during the time he worked from 7/1/2024 through 7/4/2024. LVN 1 stated, if he had been notified that Resident 1 had loose watery stool, he would have notified Resident 1's physician, reported this in their morning huddle (a short stand-up meeting 10 minutes or less that is typically conducted at the start of each shift), and completed a COC form. During an interview on 7/29/2024, at 1:31 p.m., LVN 2 stated, she was not notified by anyone that Resident 1 had loose watery stool, if this was reported to her, she would have notified Resident 1's physician. During an interview on 7/29/2024, at 2:19 p.m., Resident 1's Physician stated, no one notified him that Resident 1 had loose watery stool, had he known that Resident 1 had loose watery stool for five days, was not eating or drinking along with his abnormal/critical labs results, he would have suspected C. Diff, colitis (a swelling of the large intestine or colon), or diverticulitis (inflammation or infection of small pouches or sacs called diverticula that form in the wall of a hollow organ such as the colon) and would have given instructions to transfer Resident 1 to the GACH sooner than 7/6/2024. During an interview on 7/29/2024, at 2:45 p.m., the Director of Nursing (DON) stated, the CNAs should have reported when Resident 1 had loose/watery stool to the charge nurse so the charge nurse could call the physician for treatment orders. The DON stated loose/watery stools could lead to dehydration and trigger other medical conditions. According to Medlineplus.gov https://medlineplus.gov (a national library of medicine), Cefuroxime Axetil can cause serious side effects such as watery or bloody stool, stomach cramps or fever during treatment or for up to two or more months after stopping treatment. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, dated 12/2016, the P&P indicated, the facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. The P&P indicated prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider.

Based on interview and record review, the facility failed to ensure a certified nursing assistant (CNA 1) did not turn and reposition a resident (Resident 1), who required a two-person physical assist with bed mobility, by himself, without the assistance of another staff for one of two sampled residents (Resident 1). This deficient practice resulted in Resident 1 falling from bed and sustaining a left parietal (near the back and top of head) scalp hematoma (an injury that causes blood to collect and pool under the skin resulting in a spongy, rubbery, lumpy feel) and laceration (a deep cut or tear in the skin or flesh) with a potential for Resident 1 to sustain more serious consequences such has a brain injury, fractures (a partial or complete break in the bone) and death. On 10/14/2023 Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment of her head wound. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing), contractures (when muscles, tendons, joints, or other tissues tighten or shorten leading to a deformity) of the right and left knee and muscle weakness. A review of Resident 1's History and Physical (H&P), dated 1/22/2023, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 7/10/2023, indicated Resident 1's cognitive skills for daily decision-making were severely impaired. The MDS indicated Resident 1 was totally dependent on staff for bed mobility and required a two or more-persons physical assistance with bed mobility. A review of Resident 1's Situation, Background, Assessment, and Recommendation ([SBAR] a technique which is used to facilitate prompt and appropriate communication within the healthcare team), dated 10/14/2023, and timed at 9 a.m., indicated Resident 1 fell while CNA 1 turned and repositioned Resident 1, while she was in bed, by himself. The SBAR indicated Resident 1 slid off the bed, hit her head on the dresser located beside Resident 1's bed, then landed on the floor. A review of Resident 1's Transfer Form dated 10/14/2023, and timed at 11:33 a.m., indicated Resident 1 was transferred to a GACH for evaluation and treatment related to her fall. A review of Resident 1's GACH Admission Record, indicated Resident 1 was admitted to the GACH on 10/14/2023 at 6:30 p.m. A review of the GACH H&P, dated 10/15/2023, indicated Resident 1 sustained a fall with head trauma resulting in a hematoma and left parietal scalp laceration. A review of Resident 1's head Computed Tomography ([CT] an imaging test used to detect internal injuries by providing cross-sectional images of bones, blood vessels and soft tissues in the body) scan dated 10/15/2023, indicated Resident 1 had a left parietal scalp hematoma. A review of Resident 1's General Surgeon Consultation report, dated 10/15/2023 indicated Resident 1 had a left parietal occipital (back of head) scalp hematoma measuring 3 centimeters ([cm] a unit of measurement) by 3 cm with a small laceration with scabbing and eschar (dead tissue that forms over healthy skin and then, over time, falls off). During an interview on 10/26/2023, at 12:06 p.m., CNA 2 stated, Resident 1 could not get up by herself or move from side to side on her own and required two people to assist when she was turned and repositioned. CNA 2 stated when two people are required to turn and reposition a resident, a staff member should stand on each side of the resident's bed to prevent the resident from falling off the bed. During a concurrent interview and record review with the MDS Nurse on 10/26/2023 at 1:23 p.m., Resident 1's Activities of Daily Living ([ADL] task required to independently care for oneself such as eating, bathing, dressing, grooming and toileting) Performance Self Care Deficit Care Plan dated 12/21/2020, was reviewed. The Care Plan Indicated Resident 1 had muscle weakness and osteoarthritis (mechanical wear and tear on the joints). The Care plan goals included moving Resident 1, while in bed, using a two-person assist. The MDS Nurse stated the purpose of the Care Plan was to assist the nursing staff in providing individualized care to residents based on their needs. The MDS Nurse stated, if the staff had followed Resident 1's care plan to use two people when moving Resident 1 in bed, Resident 1's fall could have been prevented. During a telephone interview on 10/26/2023 at 1:59 p.m., CNA 1 stated he raised Resident 1's bed to the level of his (CNA 1's) waist (approximately three to four feet from the ground), to change Resident 1's bed linens. CNA 1 stated he was standing behind Resident 1, on the left side of Resident 1's bed, with Resident 1's backside facing him (CNA 1), when Resident 1 leaned to her right side. CNA 1 stated Resident 1 rolled off the bed and hit her head on the bedside dresser before she fell to the floor. CNA 1 stated he was not able to prevent Resident 1 from falling off the bed because he was on the opposite side of the bed from where Resident 1 fell and he did not have enough time to prevent Resident 1 from falling. CNA 1 stated it would have been safer if another staff assisted him when he repositioned Resident 1. CNA 1 stated he was not aware Resident 1 required two people to assist with turning and repositioning Resident 1. During a concurrent interview and record review with the Director of Rehabilitation (DOR) on 10/26/2023 at 2:38 p.m., Resident 1's Occupational Therapy Notes for 10/2022 were reviewed. The Occupational Therapy Notes indicated Resident 1 required total assistance with bed mobility and rolling left to right. The DOR stated Resident 1 was a full assist, required two or more persons to roll from left to right because Resident 1 could not roll by herself. The DOR stated Resident 1 does not have a protective reaction (how resident would guard or protect themselves if they were falling) due to her immobility and contractures of her upper and lower extremities. The DOR stated there should have been two staff members assisting with Resident 1's repositioning to prevent her from falling out of bed. During a concurrent interview and record review with the Director of Nursing (DON) on 10/26/2023 at 2:56 p.m., Resident 1's Interdisciplinary Team ([IDT] team members from different departments working together, with a common purpose, to set goals, make decisions that ensure residents receive the best care) notes dated 10/26/2023, and timed at 1:03 p.m., were reviewed. Resident 1's IDT notes indicated Resident 1 had a fall while CNA 1 was turning and repositioning Resident 1 by himself. The IDT notes indicated Resident 1 slid off the bed and hit her head on the dresser that was beside her bed, then landed on the floor. The DON stated CNA 1 reported to her that he was repositioning Resident 1 without assistance when the incident occurred. The DON stated Resident 1's fall should not have happened and could have been avoided if there was another staff member standing with Resident 1 and assisting him (CNA 1) in holding Resident 1 while he (CNA 1) was changing Resident 1's bed linen. During an interview on 10/28/2023 at 12:51 p.m., the Director of Staff Development (DSD) stated when a resident requires two or more people to assist with bed mobility and is totally dependent on staff with moving from side to side in bed, there should always be another CNA assisting to prevent the resident from falling off the side of the bed. A review of the facility's policy and procedure (P/P) titled, Activities of Daily Living (ADL), Supporting, revised 3/2018, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, in accordance with the plan of care, including appropriate support and assistance with mobility. A review of the facility's CNA Job Description revised 10/2020, indicated duties and responsibilities include monitoring and evaluating the resident's response to care plan interventions in accordance with facility policies, and to review care plans daily to determine if changes in the resident's daily care routine have been made on the care plan. A review of the facility's P/P, titled Falls and Fall Risk, Managing, revised 3/2018, indicated the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize the complications from falling.

Based on observation, interview, and record review, the facility failed to promptly notify the physician of the abnormal urinalysis (a test of your urine) results for one of three residents (Resident 4). The facility did not notify the physician until five days after the abnormal urinalysis results had been reported. As a result of this deficient practice there was a delay in diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 4 was transferred to the acute hospital and was diagnosed and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: A review of the Admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's Minimum Data Set ([MDS] a standardized assessment and screening tool) dated 1/18/22, indicated Resident 4 had intact cognition (ability to think, understand, and reason) required extensive assistance with bed mobility, dressing, and personal hygiene, and was totally dependent in toilet use. The MDS indicated Resident 4 had an indwelling suprapubic urinary catheter (a tube placed in the abdomen of the body to drain and collect urine from the bladder). A review of the Nursing Progress Notes dated 4/11/2022 (late entry entered by Licensed Vocational Nurse 5 (LVN 5) indicated, on 2/22/22, Resident 4 verbalized a complaint of lower abdominal pain, and appearance of suprapubic catheter output, urine was noted as cloudy, with leakage at the catheter site. The Nursing Progress Notes indicated the attending physician was notified, and an order was obtained to complete a urinalysis test ([UA] examinations of the physical and chemical properties of urine and its microscopic appearance to aid in medical diagnosis) and orders were noted and carried out. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the results of the UA Laboratory Report dated 2/23/22 at 3:15 a.m. indicated the increased white blood cell count ( WBC, the cells of the immune system that are involved in protecting the body against both infectious disease and foreign invaders) measured 29 WBC per high power field (HPF) (normal range 0-2 WBC per HPF, [the presence of five or more WBCs in the urine indicate a urinary tract infection involving the bladder, kidney or both]) and had the presence of leukoesterase ( a substance that suggest there are WBCS in the urine), [MEDICATION(S)] (substances that suggest [CONDITION(S)]) and small bacteria (microscopic living organisms that can be dangerous and cause infections). The laboratory report results were reported to the facility on [DATE] at 2:12 p.m. The laboratory report indicated the results were reported to the resident's physician on 2/28/22 (handwritten), five days later the result reported and new order to transfer the resident to the general acute care hospital (GACH). A review of the GACH's Discharge Summary dated 3/2/22, indicated, Resident 4 was admitted to the hospital on 2/28/2022, with a chief complaint of urinary tract infection, flank tenderness (discomfort or pain may be present in the back (lower or middle) and/or the suprapubic area), and an elevated WBC. The record further indicated Resident 4 had been complaining of back pain with fever, chills, and shakes. The reason for Resident 4's admission was urosepsis. According to the GACH's course and treatment Resident 4 was found to have a urinary tract infection and was administered the following antibiotics: 1.Empiric [MEDICATION(S)] (antimicrobial therapy directed against an anticipated and likely cause of infectious disease). 2.Tazobactam (Antibiotic, inhibits the growth of or destroys bacteria) 3.375 grams (gm, a unit of measure) intravenously (administer into the vein) once. 3.[MEDICATION(S)] (Antibiotic) 500 milligrams per milliliter (mg/mL, a unit of measure) was started via intravenous (IV) every eight (8) hours. A review of the GACH's Discharge to skilled nursing facility order dated 3/1/22, indicated, Resident 4 was discharged back to the facility on with an order to administer oral [MEDICATION(S)] (antibiotic, works by killing the bacteria that cause urinary tract infections (UTIs) in the urethra, bladder, and/or kidneys) 100 milligrams (mg, a unit of measure) by mouth twice a day for ten days. During an interview on 4/14/22, at 9:14 a.m., with Licensed Vocational Nurse 6 (LVN 6), LVN 6 stated, on 2/28/22, Resident 4 asked for his laboratory result which was collected on 2/23/22. LVN 6 noted there were abnormal laboratory results of the UA test. LVN 6 stated she notified the physician of the resident's results immediately and obtained an order to transfer the Resident 4 to the hospital for possible [CONDITION(S)] (a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues). During an interview on 4/14/22, at 12:43 p.m., with LVN 5, LVN 5 stated, if there was an abnormal finding on a resident's laboratory results, the charge nurse or supervisor needs to inform the attending physician right away. LVN 5 stated the charge nurse was supposed to notify the physician the same day the laboratory results were received. LVN 5 stated if there is a delay in notifying the physician of abnormal laboratory results, there is a potential for harm that could worsen the resident's health. LVN 5 stated, I am not sure why the results for the urinalysis for Resident 4 were reported late. During a concurrent observation and interview on 4/14/22, at 12:27 p.m., with Resident 4, in the resident's room, Resident 4 was observed to have a urinary catheter. Resident 4 stated, on 2/28/22, he was feeling pain in the pit of his stomach and stated that whenever he felt that pain, he knows it's a [CONDITION(S)]. Resident 4 stated that he reported the pain to LVN 5 on 2/22/22 and 2/28/22, but the nursing staff did not inform him of his urinalysis results (test taken on 2/22/22) until he asked LVN 6. Resident 4 stated after he was informed of his urinalysis results (2/28/22), he was transferred to the hospital where he received antibiotics for his [CONDITION(S)]. During an interview on 4/14/22, at 1:21 p.m., with Certified Nurse Assistant (CNA) 4, CNA 4 stated part of his job is to report what the residents' complained about to the charge nurse and there have been several occasions where Resident 4 had expressed he was in pain and LVN 5 did not help him. During an interview on 4/14/22, at 1:50 p.m., with the Director of Nursing (DON), DON stated, when there are abnormal laboratory results or critical laboratory results, the physician is to be informed right away by whoever received the laboratory results. DON stated, Ultimately it is the responsibility of the charge nurse to report abnormal findings, that is why they are the charge nurse because they are in charge of the residents on the shift they are working. During a review of the facility's policy and procedure (P&P) titled, Lab and Diagnostic Test Results - Clinical Protocol dated October 2016, indicated a nurse will review all results. If the staff who first received or reviewed the lab and diagnostic test result 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. The policy further indicated a nurse will identify the urgency of communicating with the Attending physician based on the physician's request, the seriousness of any abnormality, and the individual's current condition. During a review of the facility's policy and procedure (P&P) titled, Lab and Diagnostic Test Results - Clinical Protocol dated October 2016, indicated a nurse will review all results. If the staff who first received or reviewed the lab and diagnostic test result 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. The policy further indicated a nurse will identify the urgency of communicating with the Attending physician based on the physician's request, the seriousness of any abnormality, and the individual's current condition.

Based on observation, interview, and record review the facility failed to implement acceptable infection control practices to prevent the spread and transmission of coronavirus (COVID-19, a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing, and shortness of breath) for seven of 13 sampled residents (Residents 1, 6, 9, 17, 20, 31, 48). The facility failed to: A. Ensure a Certified Nurse Assistant (CNA 1) wore gown and gloves while in Residents 1's and Resident 17's room, who were residing in the yellow zone (zone for residents who are mixed quarantine or symptomatic) to prevent transmission of COVID-19 infection. B. Ensure CNA 1, who was designated to work in the red zone, remained in the red zone (zone for residents that are COVID-19 positive) and was not going to a yellow zone after providing care to Resident 6, 9, 20, 31 and 48, in the red zone. C. Ensure the Maintenance Director (MD) was not going from a red zone to a yellow zone while wearing personal protective equipment [([PPE) equipment designed to protect the wearer from the spread of infection or illness]- used to transfer Resident 31 on bed to the red zone. D. Ensure the Administrator (ADM) and Physical Therapy Assistant (PTA 1) wore a face-shield while in the yellow zone to prevent transmission of COVID-19 infection. These failures placed residents 1, 6, 9, 17, 20, 31, 48, staff, visitors, and the community at a high risk for cross contamination and increased spread of COVID-19 infection. On 1/20/2022, at 5:10 p.m., Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation had caused or was likely to cause serious injury, harm, impairment, or death to a resident) related to the facilities failure to implement acceptable infection control practices was called in the presence of the ADM and the Director of Nursing (DON). On 1/21/2022, at 4:16 p.m., the ADM and DON were informed the IJ situation was lifted after implementation of an acceptable Plan of Action ([POA] a detailed plan outlining actions needed to reach one or more goals) was verified onsite through observation, interview, and record review. Finding: A. During a review of Resident 1's admission record, the record indicated Resident 1 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1 's Minimum Data Set [(MDS), a standardized assessment and care-screening tool], dated 10/18/2021, the MDS indicated Resident 1 had no impairment in cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making, required extensive assistance with bed mobility, dressing, and personal hygiene, and was totally dependent on staff for transfers, toileting, and bathing. During a review of Resident 17's admission record, the record indicated Resident 17 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 17 's MDS, dated [DATE], the MDS indicated Resident 17 had no impairment in cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making, required extensive assistance with bed mobility, dressing, and personal hygiene, and was totally dependent on staff for transfers, toileting, and bathing. During an observation on 1/19/2022, at 12:47 p.m., in the yellow zone, in the east hall adjacent to nursing Station 2, CNA1 was observed entering Resident 1 and Resident 17's room without donning a gown and gloves. CNA1 was observed entering Resident 1 and Resident 17's room with a lunch tray. CNA1 was then observed exiting Resident 1 and Resident 17's room, retrieving another lunch tray from the metal tray cart in the yellow zone and reentering Resident 1 and Resident 17's room without donning gown and gloves. During an interview on 1/19/2022, at 12:50 p.m., CNA1 stated when entering the room in the yellow zone she wore a face shield and a N95 (protective device designed to achieve a close facial fit and filters 95% of airborne particles) mask. CNA1 stated she did not put on gown and gloves because she wanted to distribute the lunch trays quickly. CNA1 stated she was aware of the PPE signs posted outside each resident's room indicating the required PPE before entering the room. CNA1 stated it was important to wear required PPE to prevent the spread of COVID-19 infection to residents and staff. During an interview on 1/21/2021, at 1:46 p.m., the Infection Preventionist (IP) 1 stated due the COVID-19 outbreak staff and visitor entering the facility must wear a face shield and N95 mask. IP 1 stated it is the facility's policy that all staff who was entering a residents' room must also wear gown and gloves in both the yellow and red zones. IP 1 stated it is important to wear the required PPE when entering a resident's room to prevent the spread of pathogens (bacteria, virus, or other microorganism that can cause disease) on clothes which can put resident, staff, and the community at risk of developing COVID-19 infection. During an interview on 1/22/2021, at 3:40 p.m., the DON stated staff was required to wear full PPE, including gown, gloves, face shield, and N95 mask when entering a resident's room in both the yellow and red zones. DON stated to prevent the spread of COVID-19 staff should not enter a resident's room without wearing the proper PPE. A review of the facility's Mitigation Plan (MP), dated 1/10/2022 indicated the facility will train staff on selecting, donning, and doffing appropriate PPE. Signage indicating the required PPE will be posted immediately outside the resident's room indicating appropriate infection control and prevention precautions and required PPE in accordance with California Department of Public Health (CDPH) guidance. The MP indicated the facility will implement a staffing plan to limit transmissions during an outbreak and have dedicated consistent staffing team who directly interacts with residents that are Covid-19 positive. During a review of All Facilities Letter (AFL) 20-74.1 CDPH, Healthcare-Associated Infections Program COVID-19 PPE, Resident Placement/Movement, and Staffing Considerations by Resident Category, dated 7/22/2021, the AFL indicated gowns and gloves must be worn upon room entry in the yellow and red zones. According to the website https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html healthcare personnel must use personal protective equipment appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with a resident or a resident's environment. Donning PPE upon room entry and properly discarding it before exiting a resident room is done to contain pathogens. B. During a review of Resident 31's admission record, the record indicated the resident was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 31's MDS, dated [DATE], the MDS indicated the resident had severe impairment in cognitive (ability to learn remember, understand and decisions) skills for daily decision making, required supervision with eating, extensive assistance with bed mobility, transfers, dressing, personal hygiene, and was totally dependent with toileting and bathing. During a review of Resident 48's admission record, the record indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 48's MDS, dated [DATE], the MDS indicated the resident had moderately impaired cognitive skills for daily decision making, required supervision from staff with bed mobility, transfers, walking in room, dressing, eating, and toileting and needed limited assistance from staff with personal hygiene, and required extensive assistance from staff with bathing. During a review of the Resident 6's admission record, the record indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 6 's MDS, dated [DATE], the MDS indicated the resident had an intact cognitive skill for daily decision making and required staff supervision with bed mobility, transfer, dressing, walk in corridor, toilet use, personal hygiene, and bathing. During a review of the Resident's 9 Admission record, the record indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 9 's MDS, dated [DATE], the MDS indicated the resident had intact cognitive skills for daily decision making and required extensive assistance from staff with bed mobility, dressing, personal hygiene, and was totally dependent on staff for toilet use and bathing. During a review of Resident 20's admission record, the record indicated Resident 20 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 20 's MDS), dated [DATE], the MDS indicated the resident had severe impairment in cognitive skills for daily decision making, required extensive assistance from staff with bed mobility, eating, and toileting, and was totally dependent on staff for transfer, dressing, personal hygiene, and bathing. During an interview on 1/19/2022 at 11:00 a.m., IP 2 stated the facility received COVID-19 response testing (twice a week covid testing of residents and staff) results dated, 1/17/2022 and Residents 31, and 48 were tested positive. IP 2 stated Resident 31, and 48 will remain in their rooms and PPE and red zone signage will be posted on their doors. IP 2 stated she will contact the facility's assigned Public Health Nurse (PHN) for guidance on room change. During an observation on 1/19/2022, at 1:23 p.m. in the East hallway, CNA1 was observed entering Resident 9's and Resident 48's room in the red zone wearing a full PPE. At 1:25 p.m. CNA 1 was observed exiting Resident 9's and Resident 48's room in the red zone. CNA1 removed her gown and gloves before exiting the resident's room and went to the nursing station where she washed her hands. On 1/19/2022, at 1:31 p.m. CNA1 was observed entering Resident 20's and Resident 31's room in the red zone wearing full PPE. At 1:35 p.m. CNA1 was observed exiting Resident 20's and Resident 31's room in the red zone. CNA1 removed her gown and gloves before exiting the residents' room and proceeded to the nursing station where she washed her hands. During a concurrent observation and interview on 1/19/2022, at 1:38 p.m. on the East hallway, CNA1 was observed re-entering Resident 20's room wearing full PPE. CNA1 stated she was going to feed Resident 20 and would be in the room for a while. CNA1 was observed entering Resident 20's room with a lunch tray. On 1/19/2022, at 2:30 p.m. in the east hallway, CNA1 was observed exiting a yellow zone room holding a dirty linen after caring for Residents 9, 20, 31, and 48, in the red zone. During an observation on 1/19/2022, at 2:38 p.m. in the East hallway, CNA1 was observed entering Resident 6's room in the yellow zone holding a clean linen after she previously was caring for Residents 9, 20, 31, and 48, in the red zone. During an interview on 1/21/2022, at 1:46 p.m., IP 1 stated when staff assigned to the red zone they are designated to work only in that area and cannot care for the residents in the yellow zone. IP 1 stated staff can start their day in the yellow zone and end their day in the red zone, but after being in the red zone staff cannot return to the yellow zone. Going from the red zone to the yellow zone staff are placing both the residents and other staff at risk of becoming infected with COVID-19. During an interview on 1/22/2022, at 3:40 p.m., DON stated it was the facility's policy for no going back and forth between the red and yellow zones, when staff is designated to work in the red zone they are not allowed to go back into the yellow zone, staff must end their day in the red zone. DON stated, crossing from the red zone to the yellow zone will affect residents and staff and put everyone at risk of getting COVID-19. According to the website http://publichealth.lacounty.gov/[MEDICATION(S)]/ncorona2019/healthfacilities/snf/prevention/ under special staff considerations, in cohort areas staff assigned to the Red Cohort (area designated for COVID-19 positive residents) should not care for residents in other cohorts if possible. If staff must care for residents in multiple cohorts, they should visit the Red Cohort last and should doff PPE and perform hand hygiene prior to moving between cohorts. C. During an observation on 1/19/2022, at 4:18 p.m., in the red zone, Resident 31 was observed in bed in the hallway awaiting transfer to the room in the red zone. Maintenance Director (MD) was observed pushing Resident 31 on bed to his room in the red zone. MD was observed wearing full PPE including N95 mask, face shield, gown, and gloves. After MD brought Resident 31 into the room MD was observed exiting the red zone room wearing the same PPE, walking down the hall in the red zone, and with gloved hand opened the fire door leading to the yellow zone, and entered the yellow zone. During a concurrent observation and interview on 1/19/2022 at 4:25 p.m., in the red zone, MD was observed re-entering the red zone from the yellow zone through the closed fire door wearing the same PPE used to move Resident 31 to the red zone. MD stated DON informed him that it was OK to leave the red zone and enter the yellow zone without removing PPE. MD stated it was the facility's policy to remove PPE when going from the red zone to the yellow zone and it was OK to return to the yellow zone after working in the red zone. MD stated the reason the facility had red and yellow zones and the requirement to wear PPE was to prevent spreading COVID-19 infection. During an interview on 1/22/2022 at 9:41a.m., the MD stated on 1/19/2022 when he crossed from the red zone to the yellow zone and back to the red zone wearing the same PPE, he was going to transfer Resident 48 from the yellow zone to the red zone. MD stated he was not sure if he should have crossed over zones wearing the same PPE. During an interview on 1/21/2022, at 1:46 p.m., IP1 stated staff should not leave the red zone in full PPE and cross into the yellow zone. IP1 stated if a staff cross from the red zone to the yellow zone wearing the same PPE that staff is cross contaminating the yellow zone. IP1 stated if cross contamination occurs, resident in the yellow zone that are negative for COVID-19 are being exposed to COVID-19 and can become infected with the virus. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention Quality Control Plan, revised 5/2020, the P&P indicated transmission-based precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection. According to the website https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html healthcare personnel must use PPE appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room was done to contain pathogens. D. During a concurrent observation and interview on 1/19/2022, at 1:19 p.m., in the east hall, PTA was observed entering the yellow zone without wearing a face shield. PTA stated she forgot to put on her face shield after leaving the therapy room. PTA stated it was the facility's policy that staff must wear a face shield and N95 mask when in the yellow zone. PTA stated it was important to wear proper PPE to prevent spreading infection to keep everyone safe. During a concurrent observation and interview on 1/20/2022, at 12:55 p.m., ADM was observed entering the yellow zone without the face shield from the courtyard. ADM stated it was the facility's policy that everyone entering the facility must wear a N95 mask and a face shield or goggles due to the current COVID outbreak. During an interview on 1/21/2021, at 1:46 p.m., IP1 stated due to the facility's current COVID-19 outbreak staff must wear a face shield and N95 mask. According to the website http://publichealth.lacounty.gov/[MEDICATION(S)]/nCorona2019/B73COVID/SNF/index.htm once a Covid-19 outbreak has been identified, facility should immediately initiate standard, contact, droplet precautions, plus N95 respiratory and eye protection must be used in both the yellow and red zones. A review of the facility's Mitigation Plan, dated 1/10/2022 indicated the facility will train staff on selecting, donning, and doffing appropriate PPE. Signage will be posted immediately outside resident's room indicating appropriate infection control and prevention precautions and required PPE in accordance with CDPH guidance. The facility will implement a staffing plan to limit transmissions during an outbreak and have dedicated consistent staffing team who directly interact with resident that are Covid-19 positive. e. During an observation on 1/20/22, at 1:55 p.m., observed laundry staff (LS) 1 exited laundry room wearing a gown and gloves, proceeded in entering room [ROOM NUMBER], exited room [ROOM NUMBER] wearing the same gown and gloves, entered room [ROOM NUMBER] wearing the same gown and gloves, walked to the hallway, and entered room [ROOM NUMBER], exited room [ROOM NUMBER] wearing the same gown and gloves. During a concurrent interview on 1/20/22, at 2:00 p.m., with LS 1 and LS 2, LS 2 as an interpreter for LS 1. LS 1 stated that she does not know that she needs to change gowns and gloves when she enters the resident's room. LS 1 stated that nobody shows me. During an interview on 1/22/2022, at 3:30 p.m., with Infection Preventionist (IP) 1, IP 1 stated all staff should don and doff Personal Protective Equipment (PPE) every time they enter and exit resident's room. f. During a review of the Resident's 12 Admission record (Face Sheet), the face sheet indicated Resident 99 was admitted to the facility on [DATE]. Resident 12 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 12 's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/3/2021, the MDS indicated Resident 12 had severe impairment in cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. Resident 12 needs extensive assistance with bed mobility, dressing, personal hygiene, and total dependence with transfer, toilet use and bathing. During an observation on 1/19/2022, at 9:05 a.m., in Resident 12 room, observed syringe used for flushing enteral feeding (liquid food) had a date changed of 1/17/2022. During an interview on 1/20/2022 11:25 a.m., with Licensed Vocational Nurse (LVN) 1, in the Resident 12's room, LVN 1 stated that syringe used for flushing enteral feeding should be changes daily for infection control. During an interview on 1/22/2022, at 3:30 p.m., with Infection Preventionist (IP) 1, IP 1 stated syringes used to flush enteral feeding should be changed daily for infection control

Based on observation of the facility's surveillance video, interview, and record review, the facility failed to follow its policy and a resident's plan of care to provide the necessary care and services, which included a thorough and continuous assessment after a surgical procedure (right arm arteriovenous fistula (AVF) a connection of an artery (carries blood away from the heart) and a vein (carries blood back to the heart)) and provide cardiopulmonary resuscitation timely and accurately ((CPR) C=cardio (heart) P=pulmonary (lung) R=resuscitation) after a resident was found unresponsive for one of three sampled residents (Resident 1). Resident 1 returned to facility lethargic (sluggish; lack of energy) post surgery and was not being monitored for vital signs ((V/S) clinical measurements of blood pressure, heart rate, respiratory rate, and temperature). Resident 1 was found deceased seven hours after returning to the facility post-surgery (cross referenced to F157). This failure of the nurses not continually and thoroughly assessing Resident 1 and performing CPR in a timely efficient manner resulted in a delay in identifying the resident's change in condition and the resident being found unresponsive and expiring. Findings: A review of Resident 1's closed record Admission Face Sheet indicated the resident was initially admitted to the facility [DATE] and re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated [DATE], indicated Resident 1 was able to make needs known had the ability to understand and be understood. The MDS indicated Resident 1 was independent in locomotion on and off the unit using a motorized wheelchair. According to the MDS, the resident's Brief Interview for mental Status (BIMS) scores 15 (score of ,[DATE] means interviewable). A review of Resident 1's physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED].) of infection. The physician's orders [REDACTED]. A review of Resident 1's care plan titled, At Risk for Complications Secondary to receiving [MEDICAL TREATMENT], dated [DATE], indicated the staff interventions included to assess the resident and the right upper chest access site, evaluate pain, numbness/tingling, redness, drainage and/or any S/S of infection of the right upper chest site, and notify the physician and the resident's representative for any change of condition (COC). A review of a nurses' note, dated [DATE], and timed at 7 a.m., indicated Resident 1 went out on pass OOP and stated she had a doctor's appointment and would be having surgery that day. The nurses' note indicated Resident 1 was in stable condition without any complaints of pain, shortness of breath (SOB), skin clear and intact, afebrile (without fever), and the right upper chest catheter was intact without bleeding. The nurses' note did not indicate what type of surgery Resident 1 was having and if and when the resident was returning to the facility. A review of the nurses' notes, dated [DATE], and timed at 11:11 p.m., written by a Licensed Vocational Nurse 1 (LVN 1) indicated Resident 1 returned from the doctor's appointment at 10:15 p.m. on [DATE]. The note indicated Resident 1 denied having pain, but stated she was tired and went straight to bed. LVN 1 documented the resident's vital signs were blood pressure ,[DATE] (normal reference range (NRR) less than ,[DATE] mm/hg (millimeter of mercury)); heart rate at 70 (NRR ,[DATE] bpm (beats per minute)); respiratory rate was at 18 (NRR ,[DATE] breaths per minute) and a temperature of 96.7 (NRR 97XXX,[DATE].5 °F (Fahrenheit)). The note further indicated all needs were met and the call light was within reach. On [DATE] at 11:18 a.m., during an interview and review of the Director of Nursing's (DON) written declaration, the DON stated during her investigation the staff (LVN 1, LVN 2 and the CNAs (CNA 1 and 2) admitted to her that Resident 1's vital signs upon her returned to the facility were not obtained, but falsely charted in the resident's records and they did not assess the resident post surgery. The DON stated LVN 2 did not assess the resident's respiratory status, after Resident 1 called to be elevated in bed, during the early morning (2:20 a.m.) and should have. The DON stated instead of the staff initiating CPR they called her at home and she had to instruct them to start CPR, which was a delay of approximately 15 minutes according to the facility's surveillance video. The DON further stated the staff did not use any artificial manual breathing and administer oxygen to the resident. The DON stated LVN 1, who was on duty when Resident 1 returned to the facility ([DATE]), did not assess the resident upon return to the facility, as indicated in the surveillance video. On [DATE] at 2 p.m., during an interview, the Social Service Director (SSD) the SSD stated he was responsible for scheduling transportation for residents' appointments. The SSD stated he was not sure where Resident 1 went on the morning of [DATE]. On [DATE] at 3:24 p.m., during an interview, Resident 1's roommate (Resident 2), Resident 2 stated Resident 1 looked good that morning, before she left for her procedure. Resident 2 stated Resident 1 returned to the facility at approximately 10:15 p.m. and the staff had to help the resident drive the motorized/electric wheelchair. Resident 2 stated Resident 1 was weak and was leaning over to one side in the wheelchair. Resident 2 stated Resident 1 began moaning when the nurses used the Hoyer lift (mechanical lift used for transferring residents) to put her in the bed and Resident 1's arm was wrapped and it looked like it was bleeding a lot. Resident 2 stated on the morning of [DATE], she heard Resident 1 make a yawning noise. CNA 1 entered the room shortly thereafter and Resident 2 stated, I heard the CNA (CNA1) call the resident's name, run out the room and called the charge nurse. I got into my wheelchair and left the room. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 was alert with her cognition intact and had a BIMS score of 15. According to the MDS, Resident 2's memory was intact and had good recall. At 4:13 p.m., on [DATE], during an interview, a Certified Nursing Assistant 1 (CNA1) stated she was assigned to Resident 1 on the ,[DATE] a.m. shift for [DATE]. CNA 1 stated Resident 1 was sleeping at the start of her shift (11 p.m.) and she was told that the resident had surgery earlier that day. CNA1 stated she checked the resident three times during her shift and on [DATE], at approximately 1 a.m. Resident 1's call light was on. CNA1 stated she entered the resident's room and Resident 1 asked her to adjust her shoulder to elevate the head of bed. CNA 1 stated the resident looked kind of weak and saw blood on the right arm bandage. CNA 1 was asked if she notified LVN 2 of the resident's change in condition and she stated, No. CNA 1 stated she returned to Resident 1's room at approximately 5 a.m. to see if the resident needed anything. When the resident did not respond, CNA1 stated she called the resident by name and asked Are you ok, are you ok while shaking the resident's leg. CNA1 stated she then called for the charge nurse (LVN 2) who came and started CPR. On [DATE], at 4:36 p.m., during an interview, LVN 1 stated Resident 1 went out to the general acute care hospital (GACH) on the morning of [DATE] for a surgical procedure and returned between 9:45 p.m. and 10:15 p.m. that same day. LVN 1 stated she went to the resident's room to checked the blood pressure and the new AVF site for bleeding, charted the resident's arrival, and asked if the resident wanted any pain medications. LVN 1 stated Resident 1 had a dressing to the right arm, which was clean and dry. LVN 1 stated Resident 1 was alert and laughing upon her return to the facility. LVN 1 stated Resident 1 had no discharge papers from the GACH and told the nurse on the next shift (11 p.m.-7 a.m.) to follow-up because the GACH did not call to give a report on the resident. LVN 1 further stated she was going to call the GACH, prior to the resident's return, but saw that Resident 1 had arrived. LVN 1 stated she documented in the facility's communication book for the resident to be monitored for pain and bleeding. On [DATE] at 2 p.m., during an observation of the facility's surveillance video with the Director of Nursing (DON), the DON verified the events and the various staff members on the video, indicated the following occurred on ,[DATE]-[DATE]: At 5:45 a.m., Resident 1 was observed driving her motorized wheelchair in the hallway in an upright position. At 10:01 p.m., An Access van pulled into the facility's parking lot near the rear entrance, and dropped Resident 1 off, the facility's activities director (AD) was present on the video. At 10:06 p.m., the AD was observed maneuvering Resident 1's wheelchair from the parking lot into the facility and down the hallway. Resident 1's head was observed tilted to the left side. LVN 1 was observed on the computer at Nurse's Station 2, when Resident 1 passed the station. LVN 1 stood and observed the resident and the AD passed her and returned to the computer. At 10:16 p.m., LVN 1 entered Resident 1's room for the first time since the resident's return. At 5:10 a.m., CNA1 entered Resident 1's room. At 5:12 a.m., CNA1 was walking out the resident's room and down the hallway towards Nurse's Station 1. At 5:13 a.m., LVN2 and CNA1 were observed entering Resident 1's room. LVN 1 ran out the room to Nurse's Station 2, grabbed a medical chart, looked down the hallway twice towards the direction of Resident 1's room and ran towards Nurse's Station 1. At 5:14 a.m., LVN 2 returned to Station 2 with CNA2. At 5:15 a.m., LVN 2 and CNA2 were observed at Station 2. CNA2 was on her cell phone and LVN 2 was on the computer. At 5:16 a.m., LVN 2 observed pushing a linen cart down the hallway. At 5:17 a.m., LVN 2 and CNAs 1 and 2 were at Nurses' Station 2. At 5:18 a.m., CNA1 was on her cell phone. CNA2 holding her cell phone. LVN 2 seated at Nurse's Station 2. Resident 2 (Resident 1's roommate) observed self-propelling from the room in her wheelchair down the hallway (at the time Resident 1 was unresponsive). At 5:19 a.m., LVN 2 on the facility telephone then retrieved the crash cart with CNA2, after hanging up the phone. At 5:20 a.m., LVN 2 and CNA2 entered Resident 1's room with the crash cart. At 5:24 a.m., LVN 2 exits Resident 1's room. At 5:25 a.m., LVN 2 and CNA2 observed walking down the hallway away from the resident's room. At 5:28 a.m., LVN2 and CNAs 1 and 2 observed out the resident's room. At 5:29 a.m., CNA2 observed running down the hallway with a key in hand. At 5:30 a.m., Paramedics entering the facility on scene. On [DATE], at 3:35 p.m., during an interview, the AD stated Resident 1 did not look like herself when she returned from the surgical procedure on [DATE]. The AD stated the resident was unable to maneuver her wheelchair, so she had to use the controls to drive the resident to her room, because Resident 1 was leaning 'slouched' to one side. The AD stated the resident was dead weight during a transfer with the Hoyer lift, but the AD stated Resident 1 normally helped with the transfer, but was weak. The AD stated she informed the charge nurse (LVN 1) that Resident 1 did not look like herself. The AD stated she thought LVN 1 was going to handle the situation, so she did not call the DON. A review of the facility's policy and procedure titled, Surgery-Related (Pre-and Postoperative) Management- Clinical Protocol, dated ,[DATE], indicated the staff would do the following: After readmission to the facility postoperatively, the physician and staff would maintain appropriate communication with the referring surgeon to ensure that the resident received adequate postoperative care. The policy also indicated the staff would assess the resident for pain and continue to monitor the resident for changes in level of pain; The staff and physician will monitor for, and address, postoperative risks and complications such as infection, [MEDICAL CONDITION], cardiac arrhythmia, bleeding, and failure of the surgical wounds to heal, etc. On [DATE], at 4:17 p.m., during an interview, LVN 2 stated she was the ,[DATE] a.m., charge nurse on [DATE]. LVN 2 stated she made rounds at the beginning of the shift and spoke with Resident 1. LVN 2 stated she received a report from LVN 1, indicating the resident had returned from surgery to the facility at 10:30 p.m., on [DATE]. LVN 2 stated did not receive any aftercare instructions regarding Resident 1. A Nurses' Note written by LVN 2 on [DATE], and timed at 8:12 a.m., as a late entry (L/E) for [DATE] at 11:30 p.m., indicated the resident was in bed, awake and alert, and was able to make needs known. The L/E note indicated Resident 1 denied pain and shortness of breath (SOB); checked the AV Shunt S/P (status [REDACTED]. The review of the facility's surveillance video footage indicated LVN 2 did not enter Resident 1's room throughout her shift until [DATE] at 5:13 a.m., after the resident was found unresponsive, which was verified by the DON watching the facility's surveillance video. A review of the facility's Charge Nurse Job Description indicated nurses were responsible for accurate observations, evaluations and reporting resident's symptoms, reactions and progress to the director of Nurses (DON), Administrator, and others participating in the care and treatment of [REDACTED]. A review of the facility's policy and procedure titled, Rounds/Licensed Staff, dated ,[DATE], indicated the purpose of the policy was to ensure the safety and comfort of the resident, and to assist in continuity of care and to identify possible change in condition by checking the residents every two (2) hours. There were no documentation that Resident 1 was assessed every 2 hours. A Nurses' Note, dated [DATE], and timed at 12 a.m., indicated Resident 1 was sleeping, had no SOB and vital signs were as following blood pressure ,[DATE], temperature 97.2, heart rate 78, respiration 20, and ,[DATE] pain (10 being the worse). No bleeding noted at right AV shunt area. A Nurses' Note, dated [DATE], and timed at 1:30 a.m., indicated CNA1 answered Resident 1's call light and elevated the head of bed (HOB). The note indicated Resident 1 had no complaints of pain or SOB. During an interview on [DATE] at 7:09 a.m., CNA 2 stated on [DATE] between 5 a.m. and 5:30 a.m. she was informed by CNA1 that Resident 1 was having a change of condition (COC). CNA2 stated LVN 2 retrieved the crash cart from the hallway but the cart was locked. CNA2 called another co-worker on her cell phone to help locate the key. CNA2 found the key in nurse's station 1 and gave it to LVN 2 who opened the cart and placed a backboard under the resident and started doing compressions. CNA2 stated she attempted to take the residents vital signs but the numbers were too low, while CNA 1 called the DON and 911. CNA 2 stated there was no AMBU bag in the crash cart, so LVN 2 stopped the CPR, and placed Resident 1 on oxygen. At 7:09 a.m., on [DATE], during an interview, CNA 2 stated she saw Resident 1 on [DATE] at 11 p.m. CNA2 stated she took the resident's vital signs at 11:30 p.m. on [DATE], while she was sleeping. CNA 2 stated she took vital signs on all the residents in facility. However, she was not seen on the video going in and out residents' rooms, as confirmed by the DON. During an interview on [DATE] at 4:17 p.m., LVN 2 stated CNA1 called her between 5 a.m. and 5:15 a.m. because Resident 1 was unresponsive. LVN 2 stated she checked the resident's vital signs, but was unable to obtain. The resident had no heartbeat. LVN 2 went to the crash cart but could not open it and called out to CNA2 for assistance in locating the key. LVN 2 stated she started doing chest compressions on Resident 1. LVN 1 further stated that she was the only licensed nurse on duty so she called 911 and the resident's physician and went back to performing CPR on the resident, but it was unsuccessful. According to an electronic nurse's note, dated [DATE], and timed at 10:48 a.m., Resident 1 was pronounced deceased by the paramedics on [DATE] at 5:30 a.m. A review of the facility's policy and procedure titled, Emergency Procedures, dated ,[DATE], indicated the purpose of the policy was to provide immediate medical care to a resident whose condition indicated a need, which included the following: 1. Do not leave the resident alone. 2. Use the call bell or by calling out for assistance. 3. Check for the ABCs: A - Airway B - Breathing C - Circulation - if indicated, begin CPR procedures 4. Take vital signs. 5. Notify the resident's attending physician or his alternate immediately. 6. If the attending or alternate physician is not available, contact the medical doctor. 7. If the services of the paramedics are needed, activate facility emergency notification system (911).

Based on interview and record review, the facility failed to follow its policy and a resident's plan of care to notify the physician of a change in condition for one of three sampled residents (Resident 1). Resident 1 was brought back to the facility after having surgery at a general acute care hospital (GACH) with a change in condition upon her arrival back to the facility. Resident 1 was lethargic (sluggish; lack of energy) and was bleeding from the surgical wound site (cross referenced to F309). This failure of not notifying Resident 1's physician, per the facility's policy and the resident's plan of care, of the resident's change in condition upon arrival status [REDACTED]. Findings: An unannounced complaint investigation was conducted at the facility on [DATE], to investigate a complaint regarding the lack of quality of care to Resident 1. A review of Resident 1's closed record Admission Face Sheet indicated the resident was initially admitted to the facility [DATE] and re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated [DATE], indicated Resident 1 was able to make needs known and had the ability to understand and be understood. The MDS indicated Resident 1 was independent in locomotion on and off the unit using a motorized wheelchair. According to the MDS, the resident's Brief Interview for Mental Status (BIMS) score was 15 (score of ,[DATE] means interviewable). A review of Resident 1's physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED].) of infection. The orders also stipulated to document and refer to physician if needed, per protocol. A review of Resident 1's care plan titled, At Risk for Complications Secondary to receiving [MEDICAL TREATMENT], dated [DATE], indicated the staff interventions included to assess the resident and the right upper chest access site, evaluate pain, numbness/tingling, redness, drainage and/or any S/S of infection of the right upper chest site, and notify the physician and the resident's representative for any COC (change of condition). A review of a nurses' note, dated [DATE], and timed at 7 a.m., indicated Resident 1 went out on pass (OOP) and stated she had a doctor's appointment and would be having surgery that day. The nurses' note indicated Resident 1 was in stable condition without any complaints of pain, shortness of breath (SOB), skin clear and intact, afebrile (without fever), and the right upper chest catheter was intact without bleeding. The nurses' note did not indicate what type of surgery Resident 1 was having and if and when the resident was returning to the facility. A review of the nurses' notes, dated [DATE], and timed at 11:11 p.m., written by a Licensed Vocational Nurse (LVN 1) indicated Resident 1 returned from the doctor's appointment at 10:15 p.m., on [DATE]. The note indicated Resident 1 denied having pain, but stated she was tired and went straight to bed. LVN 1 documented the resident's vital signs were blood pressure ,[DATE] (normal reference range (NRR) less than ,[DATE] mm/hg (millimeter of mercury)); heart rate at 70 (NRR= ,[DATE] bpm (beats per minute)); respiratory rate was at 18 (NRR= ,[DATE] breaths per minute) and a temperature of 96.7 (NRR =97XXX,[DATE].5 °F). The note further indicated all needs were met and the call light was within reach. On [DATE] at 11:18 a.m., during an interview and review of the Director of Nursing (DON) written declaration, the DON stated during her investigation the staff admitted to her they did not call Resident 1's physician of her change in condition upon her return to the facility from a surgical procedure. On [DATE] at 3:24 p.m., during an interview, Resident 1's roommate (Resident 2), Resident 2 stated Resident 1 looked good that morning ([DATE]), before she left for her procedure. Resident 2 stated Resident 1 returned to the facility at approximately 10:15 p.m. and the staff had to help the resident drive the motorized/electric wheelchair. Resident 2 stated Resident 1 was weak and was leaning over to one side in the wheelchair. Resident 2 stated Resident 1 began moaning when the nurses used the Hoyer lift (mechanical lift used for transferring residents) to put her in the bed and her arm was wrapped and it looked like it was bleeding a lot. Resident 2 stated on the morning of [DATE], she heard Resident 1 make a yawning noise. CNA 1 entered the room shortly thereafter and Resident 2 stated, I heard the CNA (CNA1) call the resident's name, run out the room and called the charge nurse. I got into my wheelchair and left the room so the nurses could do their thing. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 was alert with her cognition intact and had a BIMS score of 15. According to the MDS, Resident 2's memory was intact and had good recall. There was no documentation that Resident 1's physician was called and informed of the resident's change in condition of being weak and lethargic. At 4:13 p.m., on [DATE], during an interview, a Certified Nursing Assistant (CNA1) stated she was assigned to Resident 1 on the ,[DATE] a.m. shift for [DATE]. CNA 1 stated Resident 1 was sleeping at the start of her shift (11 p.m.) and she was told that the resident had surgery earlier that day. CNA1 stated she checked the resident three times during her shift. CNA 1 stated on [DATE], at approximately 1 a.m. Resident 1's call light was on. CNA1 stated she entered the resident's room and Resident 1 asked her to adjust her shoulder. CNA 1 stated the resident looked kind of weak and she saw blood on the bandage to the right arm. CNA 1 was asked if she notified the LVN of the resident's change in condition and she stated, No. CNA 1 stated she returned to Resident 1's room at approximately 5 a.m. to see if the resident needed to be clean or wanted ice water. When the resident did not respond, CNA1 stated she called the resident by name and asked Are you ok, are you ok while shaking the resident's leg. CNA1 stated she then called for the charge nurse (LVN 2) who came and started CPR. On [DATE], at 4:36 p.m., during an interview, LVN 1 stated Resident 1 went out to the GACH on the morning of [DATE] for a surgical procedure and returned between 9:45 p.m. and 10:15 p.m. that same day. LVN 1 stated an ambulance dropped off Resident 1 in the parking lot of the facility and the resident was brought to the nurse's station, while she was charting. LVN 1 stated she followed the resident to the room, checked the blood pressure and the new AVF site for bleeding, charted the resident's arrival, and asked if the resident wanted any pain medications. LVN 1 stated Resident 1 had a dressing to the right arm, which was clean and dry. LVN 1 stated Resident 1 was alert and laughing upon her return to the facility. LVN 1 stated Resident 1 had no discharge papers from the GACH and told the nurse on the next shift (11 p.m.-7 a.m.) to follow-up because the GACH did not call to give a report on the resident. LVN 1 further stated she was going to call the GACH, prior to the resident's return, but saw that Resident 1 had arrived. LVN 1 stated she documented in the communication book to monitor the resident for pain and bleeding. On [DATE], at 2 p.m., during an observation of the facility's surveillance video footage, in presence of the Director of Nursing (DON), who verified the various staff members, indicated the following occurred on [DATE]: At 10:01 p.m., An Access van pulled into the facility's parking lot near the rear entrance, and dropped Resident 1 off, the facility's activities director (AD) was present on the video. At 10:06 p.m., the AD was observed maneuvering Resident 1's wheelchair from the parking lot into the facility and down the hallway. Resident 1's head was observed tilted to the left side. LVN 1 was observed on the computer at Nurse's Station 2, when Resident 1 passed the station. LVN 1 stood and observed the resident and the AD passed her and returned to the computer. On [DATE], at 3:35 p.m., during an interview, the AD stated Resident 1 did not look like herself when she returned from the surgical procedure on [DATE]. The AD stated the resident was unable to maneuver her wheelchair, so she had to use the controls to drive the resident to her room, because Resident 1 was leaning 'slouched' to one side. The AD stated the resident was dead weight during a transfer with the Hoyer lift, but the AD stated Resident 1 normally helped with the transfer, but was weak. The AD stated she informed the charge nurse (LVN 1) that Resident 1 did not look like herself. The AD stated she thought LVN 1 was going to handle the situation, so she did not call the DON. A review of the facility's policy and procedure titled, Surgery-Related (Pre-and Postoperative) Management- Clinical Protocol, dated ,[DATE], indicated the staff would do the following: After readmission to the facility postoperatively, the physician and staff would maintain appropriate communication with the referring surgeon to ensure that the resident received adequate postoperative care. A review of the facility's Charge Nurse Job Description indicated nurses were responsible for accurate observations, evaluations and reporting resident's symptoms, reactions and progress to the Director of Nurses (DON), Administrator, and others participating in the care and treatment of [REDACTED]. A Nurses' Note, dated [DATE], and timed at 1:30 a.m., indicated CNA1 answered Resident 1's call light and elevated the head of bed (HOB). The note indicated Resident 1 had no complaints of pain or SOB. During an interview on [DATE] at 7:09 a.m., CNA 2 stated on [DATE], between 5 a.m. and 5:30 a.m., she was informed by CNA1 that Resident 1 was having a change of condition (COC) and was found unresponsive. At 4:17 p.m., on [DATE], during an interview, LVN 2 stated CNA1 called her between 5 a.m. and 5:15 a.m. because Resident 1 was unresponsive. LVN 2 stated she checked the resident's vital signs but was unable to obtain. LVN 1 stated she started chest compressions (cardiopulmonary resuscitation (CPR) a procedure of maintaining artificial respiration and artificial circulation) on Resident 1 and called 911. According to an electronic nurse's note, dated [DATE], and timed at 10:48 a.m., Resident 1 was pronounced deceased by the paramedics on [DATE] at 5:30 a.m. On [DATE] at 10:15 a.m., during a telephone interview, the facility's charge nurse (LVN 3) stated if there was an emergent change in a resident's condition the physician and 911 should be called immediately. LVN 3 stated she would also check the resident's POLST status and follow the criteria for 911. In regards to Resident 1, LVN 3 stated if a resident returned from the GACH status [REDACTED]. LVN 3 also stated if a resident returned without any aftercare instructions the nurse should call the GACH about the resident's pre and post-op status and request for the aftercare instructions. A review of the facility's policy and procedure titled, Emergency Procedures, dated ,[DATE], indicated the purpose of the policy was to provide immediate medical care to a resident whose condition indicated a need, which included notifying the resident's attending physician or his alternate immediately. A review of the facility's policy titled, Plan of Care for Resident Concern and/or Change in Condition, with a revised date of ,[DATE], indicated for any residents' change of condition the staff should notify the resident's physician and the family immediately.

Based on observation, interview, and record review, the facility failed ensure Family Member 1 (FM 1) a relative of the Director of Nurses did not pour hot sauce into the eye and upper body of one of three sampled;ed resident's (Resident 1). This resulted in Resident 1 having pain in his eye and fear and had the potential to result in post traumatic stress, anxiety. Findings: According to admission records, Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a comprehensive assessment tool and care screening tool), dated May 27, 2016, indicated that Resident 1 was cognitively intact and required extensive assistance for activities of daily living. On July 12, 2016, an unannounced visit was made to the facility to investigate a complaint allegation that Resident 1 was abused by F M 1. During an interview on July 12, 2017 at 2:05 p.m., both the Assistant Administrator and the director of nursing (DON) denied that the facility had any unusual occurrence in the last two months (May and June 2016) and none for the month of July 2016. During an interview on July 12, 2016 at 2:45 p.m., Housekeeper 1 stated on July 7, 2016, she saw Resident 1 push the DON on the abdomen. On the same day at 12:45 p.m., Housekeeper 1 was cleaning the shower near Resident's 1 room when she witnessed the DON's family member (FM 1) go inside Resident's 1 room. FM 1 then left, returned, went inside Resident 1's room again, and left the room quickly. Housekeeper 1 went inside Resident 1's room because the resident was calling for help. The resident was eating lunch. The resident stated that FM 1 had poured salsa on his face. The Housekeeper notified the Maintenance Supervisor. During an interview on July 12, 2016 at 3:00 p.m., the Director of Social Service (DSS), stated the DON informed her that earlier in the day on July 7, 2016, Resident 1 hit her. The DSS stated Resident 1 told the DSS he did not know who at the time, grabbed his wheel chair from the back and he struck out. According to the DSS on July 7, 2016 at 12:30 p.m., the Maintenance Supervisor reported to her that a man went to Resident 1's room and threw salsa on the resident's face. The DSS witnessed salsa on the resident's face and bed linen. There was no documented evidence that the incident was reported to DPH, law enforcement or ombudsman as indicated in the facility's policy and procedure policy titled abuse prohibition. During an interview on July 12, 2016 at 3:15 p.m., Resident 1 stated FM 1 threw salsa in his left eye. The resident also stated he would never forget, he felt pain, and could not see out of his left eye. The resident also stated the facility never took him to general acute care hospital (GACH) and his primary care physician (PCP) did not evaluate his left eye after the incident. During an interview on July 12, 2016 at 3:25 p.m., the Director of Minimum Data Set (DMDS) stated that the Housekeeper 1 witnessed FM 1 go inside Resident 1's room, FM 1 was observed wiping his hands after exiting the resident's room, and Housekeeper 1 heard Resident 1 screaming for the nurse. DMDS also stated that an Administrator in Training informed the Assistant Administrator to notify the Administrator. During an interview on July 12, 2016 at 3:40 p.m., the Assistant Administrator stated that on July 7, 2016, Maintenance Supervisor 1 informed her an urgent incident involving Resident 1 occurred. When she went to Resident 1's room, she observed the resident face with sauce on his left face, shoulder, and bed sheets. The Assistant Administrator stated that the resident stated that a man went inside his room and threw food on him. She further stated that per the facility's observation of a short clip video recorded July 7, 2016 at 12:28 p.m., it was determined that it was FM 1. She further stated the DON had denied knowledge of the incident. The Assistant Administrator stated that the Administrator was not on the premises, she never documented about the incident, never called law enforcement, never notified the Department of Public Health, and never called the Board of Registered Nursing as indicated facility's policy and procedure titled abuse prohibition. The Assistant Administrator further stated that her priority is to protect the residents and did not inform the Administrator of the incident until 4:00 p.m. of the same day. During an interview on July 12, 2016 at 4:00 p.m., the Administrator stated on July 7, 2016, Resident 1 punched the DON in the chest area. The Administrator also stated that based on his interview with Housekeeper 1, the DSS, and Maintenance Supervisor 1, and Resident 1's allegation, FM 1 entered Resident 1's room and threw salsa on the resident's face. The Administrator further stated that he had not reported the incident to the law enforcement, governing agencies, the Department of Public Health, and that the DON and the Assistant Administrator were still providing services at the facility. On July 12, 2016 at 4:30 p.m., during a review of a short clip video recorded July 7, 2016 at 12:28 p.m., a man with shoulder length, dark, straight hair, in a baseball hat, greenish, long sleeved, sweat shirt, and dark pants, was observed standing outside Resident 1's room, entering and exiting the room quickly, and walking towards Housekeeper 1 and Maintenance Supervisor 1. Housekeeper 1 was observed going inside Resident's 1 room, coming out quickly, and calling Maintenance Supervisor 1. During a telephone interview on July 12, 2016 at 5:55 p.m., LVN 2 stated no one told her that Resident 1 had salsa in his eye. During a telephone interview on July 13, 2016 at 10:45 a.m., the PCP stated that he had been at the facility on July 12, 2016 and that the Assistant Administrator never mentioned anything. The PCP also stated that he would have had Resident 1 transferred to GACH for an eye examination had he been notified. According to the facility's policy and procedure titled abuse prohibition, abuse is reported to the resident's attending physician. A review of the facility's policy titled personal visitors dated February 2016, indicated it is the policy of the facility to prohibit employees from having personal visitors while on duty. For liability and safety reasons, visitors are not allowed to the facility without prior approval from the Administrator. All unauthorized persons and those without proper identification may be asked to leave the premises, all personal visitors must register at the reception area or security post and wear the assigned visitor's badge for the duration of the visit. Employees are responsible for making sure that their visitor is wearing a visitor badge and that the visitor returns it upon leaving the facility. There was no evidence the Administrator provided prior approval per the facility's policy and procedure for FM 1. A review of the facility's undated policy and procedure titled abuse prohibition, indicated that the facility would prohibit abuse, and mistreatment, for all residents. The document also indicates that abuse is defined as the willful infliction of physical pain, injury, and mental anguish. The same document also indicates that the notified supervisor would report the suspected abuse immediately to the administrator and other officials in accordance with state law. The abuse would be reported to the resident's family and the attending physician. The document also indicates that upon receiving a report of suspected or alleged abuse, mistreatment, neglect, or exploitation, the administrator or designee would report the incident by telephone within 24 hours to law enforcement agency, provide a written report to to the local ombudsman, the licensing & certification program district office, and the law enforcement agency within 24 hours utilizing the report of suspected adult/elder abuse form. The document also indicated that the licensing boards and registries be notified as applicable, initiate an abuse allegation investigation that focuses on interventions to prevent further injury, and that the investigation would be thoroughly documented on the centers investigation forms/logs. A review of the facility's undated document titled director of nursing resident's rights functions, indicated that the DON would review complaints and grievances made by the resident and or family, make a written or oral report to the administrator indicating action(s) taken to resolve the complaints and grievances. The document further indicates that the DON would report and investigate all allegations of residents abuse and or misappropriation of resident property. A review of the facility's undated document titled Assistant Administrator skilled nursing facility job summary and responsibilities, indicated that the Assistant Administrator would work together with the facility's Administrator and or on behalf of the Administrator in his her absence and must be completely knowledgeable of the facility policies, procedures, job responsibility, bylaws, staff, residents, and activities of the facility. The document also indicated that the person holding the position of an Assistant Administrator, would be delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with the current existing federal and state regulation, established company policies and procedures, and oversee and manage the day to day operations. The document also indicated that the responsibilities of an Assistant Administrator include listens and to properly reacts to complaints or concerns, complete reports. b. During an interview with the DON on July 12, 2016 at 3:15 p.m., she stated that all the incidents reported are in the incident report binder. During concurrent record review in her presence, log indicated no incidents for June and July, 2016. During an interview with Maintenance Supervisor 1 on July 12, 2016 at 3:30 p.m., he stated he was working around Station 2 on July 7, 2016 at 12:00 p.m., when a man came by to ask him where he could find the DON. Maintenance Supervisor 1 stated he told the man the DON was in her office and the man walked away. Maintenance Supervisor 1 stated Housekeeper 1 called him from outside room [ROOM NUMBER], immediately after the man walked away. When Maintenance Supervisor 1 came into the room, he saw Resident 1 with red sauce, like salsa on the left side of his face. When he asked the resident what happened, Resident 1 stated a man came into the room and threw salsa on his face. Maintenance Supervisor 1 stated the resident asked him to assist him to his wheelchair so he could talk to the Supervisor to report the incident. Maintenance Supervisor 1 stated he told the resident to wait and he will let someone know. Maintenance Supervisor 1 stated he then called the Director of Social Services (DSS) and the Director of Minimum Data Set (DMDS) and told them about the incident. Maintenance Supervisor 1 stated he also told the Assistant Administrator about the incident in person on July 7, 2016. During an interview with the DMDS on July 12, 2016 at 3:40 p.m., she stated on July 7, 2016 at 12:15 p.m. Maintenance Supervisor 1 called her and informed her about the incident with Resident 1. DMDS stated that when she interviewed Resident 1, he told her that a man came into his room and threw salsa on his face. DMDS stated Resident 1 said he thought it was FM 1. The DMDS stated she notified the Administrator immediately. Immediate Jeopardy (IJ) was called. The facility failed to provide a safe environment and protect a resident from abuse, permitted involved staff members to continue to render services to the residents, permitted the perpetrator in the facility, failed to notify appropriate governing agencies and law enforcement, failed to notify the attending physician and the psychiatrist, delayed medical attention, and failure to thoroughly investigate the incident for one of three residents (Resident 1). The deficient practice resulted in a staff family member pouring salsa on the resident's face that resulted in left eye pain and becoming fearful for his safety. On July 12, 2016 at 5:10 p.m., the facility administrator, assistant administrator, director of minimum data set (DMDS), and director of social services (DSS) were verbally notified of the IJ situation regarding Resident 1's abuse. The facility provided an acceptable immediate plan of correction (POC) on July 12, 2016 at 6:56 p.m. The remedy for the IJ abatement included: director of nursing (DON) termination, resident's eye assessment, physician and psychiatrist to be notified, facility to call the police, and 72 hour monitoring of the resident initiated. The IJ remedy also indicated that social service designee (SSD) to monitor the resident's feelings and emotions daily, notify department of health and ombudsman, notify California Board of Nursing, and responsible party to ensure resident safety. The POC also indicated that that the facility would post a sign at the main entrance that states all visitors must sign and check in at the nursing station, the security monitor to be repositioned at the nursing desk for easy access to monitor visitors coming in and out, visitors log-in would be moved from the main entrance to the nursing station, and a mandatory in-service to all staff regarding the facility's abuse policy and procedure and facility's visitors log. On July 13, 2016 at 4:45 p.m., the IJ was lifted in the presence of the administrator and corporate direct supervisor.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures to prohibit mistreatment, and abuse of residents for one of three residents (Resident 1) by failing to: 1. Provide a safe environment and protect a resident from abuse 2. Investigate, protect, and respond to abuse incident as indicated in the facility's abuse prohibition policy 3. Ensure staff members involved in the abuse allegation did not continue to render services to the residents, and permit the perpetrator of the abuse in the facility 4. Notify appropriate governing agencies and law enforcement of an allegation of abuse 5. Notify the attending physician and the psychiatrist, of an allegation of abuse and delayed medical and psycological assessment 6. Ensure an allegation of abuse was thoroughly investigated in order to prevent further abuse. The deficient practice resulted in a staff family member (FM1) pouring salsa on Resident 1's face that resulted in left eye pain and become fearful for his safety. Findings: According to admission records, Resident 1 was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a comprehensive assessment tool and care screening tool), dated May 27, 2016, indicated that Resident 1 was cognitively intact, and required extensive assistance from staff for activities of daily living. During an interview on July 12, 2016 at 2:05 p.m., both the Assistant Administrator and the Director of Nursing (DON) denied that the facility had any unusual occurrences in the month of July, 2016. During an interview on July 12, 2016 at 2:45 p.m., Housekeeper 1 stated on July 7, 2016, she saw Resident 1 push the DON on the abdomen. At 12:45 p.m., Housekeeper 1 was cleaning the shower near Resident 1's room when she witnessed the DON's family member (FM 1) go inside Resident 1's room. FM 1 then left, returned, went inside Resident 1's room again and left quickly. Housekeeper 1 went inside Resident 1's room because the resident was calling for help. The resident stated FM 1 had poured salsa on his face. Housekeeper 1 notified Maintenance Supervisor 1. During an interview on July 12, 2016 at 3:00 p.m., the Director of Social Service (DSS), stated the DON had informed her, Resident 1 had hit her. The DSS also stated Resident 1 told her he at the time did not know who had grabbed his wheel chair from the back and he struck out. According to DSS at 12:30 p.m., the Maintenance Director reported to her that a man went to Resident 1's room and threw salsa on the resident's face. The DSS witnessed salsa on the resident's face and bed linen. The Assistant Administrator, DON, Director of Minimum Data Set (DMDS), and Licensed Vocational Nurse (LVN 2) were on duty. There was no documented evidence that the incident was reported to DPH, law enforcement or ombudsman. During an interview on July 12, 2016, at 3:15 p.m., Resident 1 stated the FM 1 went to him while he was in his bed in his room and put salsa in his eye. The resident also stated that he would never forget, he felt pain, and could not see out of his left eye. The resident also stated the facility never took him to general acute care hospital (GACH) and that his Primary Care Physician (PCP) did not evaluate his left eye after the incident. During an interview on July 12, 2016 at 3:20 p.m., Resident 1's roommate refused to speak to the surveyor. He stated he had nothing to say. During an interview on July 12, 2016 at 3:25 p.m., DMDS stated that the Housekeeper 1 witnessed FM 1 go inside Resident 1's room, FM 1 was observed wiping his hands after exiting the resident's room, and Housekeeper 1 heard the resident screaming for the nurse. DMDS also stated that an Administrator in Training informed the Assistant Administrator to notify the Administrator. During an interview on July 12, 2016 at 3:40 p.m., the Assistant Administrator stated on July 7, 2016, Maintenance Supervisor 1 called her and stated an urgent incident occurred regarding Resident 1. When she went to Resident 1's room, she observed the resident with sauce on his left face, shoulder, and bed sheets. The Assistant Administrator also stated the resident stated a man went inside his room and threw food on him. She further stated per observation of the facility's short clip video recording of July 7, 2016 at 12:28 p.m., it was determined that it was FM 1. She further stated the DON had denied knowledge of the incident. The Assistant Administrator stated that the Administrator was not on the premises, she never documented about the incident, never called law enforcement, never notified the Department of Public Health, and never called the Board of Registered Nursing. The Assistant Administrator further stated that her priority is to protect the residents and did not inform the Administrator of the incident until 4:00 p.m. the same day. During an interview on July 12, 2016 at 4:00 p.m., the Administrator stated on July 7, 2016, Resident 1, punched the DON in the chest area. The Administrator also stated that based on his interview with Housekeeper 1, DSS, and Maintenance Supervisor 1, FM 1 entered Resident 1's room and threw salsa on the resident's face. The Administrator further stated that he had not reported the incident to the law enforcement, governing agencies, the Department of Public Health, and that the DON and the Assistant Administrator were still providing services at the facility. On July 12, 2016 at 4:30 p.m., during an observation of the clip video recording dated July 7, 2016 at 12:28 p.m., a man with shoulder length, dark, straight hair, baseball hat, greenish, long sleeved sweat shirt and dark pants, was observed standing outside Resident 1's room, then entered Resident 1's room and exited quickly, and walked toward Housekeeper 1 and Maintenance Supervisor 1. Housekeeper 1 was observed going inside the Resident 1's room, coming out quickly, and calling Maintenance Supervisor 1. During a telephone interview on July 12, 2016 at 5:55 p.m., LVN 2 stated no one told her that Resident 1 had salsa in his eye. During a telephone interview on July 13, 2016 at 10:45 a.m., the PCP stated that he had been at the facility on July 12, 2016 and that the Assistant Administrator never mentioned anything. The PCP also stated that he would have had Resident 1 transferred to GACH for an eye examination had he been notified. According to the facility's policy and procedure titled abuse prohibition, abuse is reported to the resident's attending physician. A review of the facility's document titled welcome to Greenfield Care Center please sign-In , indicated FM 1 never logged in and out between October 18, 2015 and July 11, 2016 while in the facility. A review of the facility's policy titled personal visitors dated February 2016, indicated it is the policy of the facility to prohibit employees from having personal visitors while on duty. For liability and safety reasons, visitors are not allowed to the facility without prior approval from the Administrator. All unauthorized persons and those without proper identification may be asked to leave the premises, all personal visitors must register at the reception area or security post and wear the assigned visitor's badge for the duration of the visit. Employees are responsible for making sure that their visitor is wearing a visitor badge and that the visitor returns it upon leaving the facility. There was no evidence the Administrator provided prior approval per the facility's policy and procedure for FM 1. A review of the facility's undated policy and procedure titled abuse prohibition, indicated that the facility would prohibit abuse, and mistreatment, for all residents. The document also indicates that abuse is defined as the willful infliction of physical pain, injury, and mental anguish. The same document also indicates that the notified supervisor would report the suspected abuse immediately to the administrator and other officials in accordance with state law. The abuse would be reported to the resident's family and the attending physician. The document also indicates that upon receiving a report of suspected or alleged abuse, mistreatment, neglect, or exploitation, the administrator or designee would report the incident by telephone within 24 hours to law enforcement agency, provide a written report to to the local ombudsman, the licensing & certification program district office, and the law enforcement agency within 24 hours utilizing the report of suspected adult/elder abuse form. The document also indicated that the licensing boards and registries be notified as applicable, initiate an abuse allegation investigation that focuses on interventions to prevent further injury, and that the investigation would be thoroughly documented on the centers investigation forms/logs. A review of the facility's undated document titled director of nursing resident's rights functions, indicated that the DON would review complaints and grievances made by the resident and or family, make a written or oral report to the administrator indicating action(s) taken to resolve the complaints and grievances. The document further indicates that the DON would report and investigate all allegations of residents abuse. A review of the facility's undated document titled Assistant Administrator skilled nursing facility job summary and responsibilities, indicated that the Assistant Administrator would work together with the facility's Administrator and or on behalf of the Administrator in his her absence and must be completely knowledgeable of the facility policies, procedures, job responsibility, bylaws, staff, residents, and activities of the facility. The document also indicated that the person holding the position of an Assistant Administrator, would be delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with the current existing federal and state regulation, established company policies and procedures, and oversee and manage the day to day operations. The document also indicated that the responsibilities of an Assistant Administrator include listens and to properly reacts to complaints or concerns, complete reports. Immediate Jeopardy (IJ) was called on July 13, 2016 at 5:10 pm. The facility failed to provide a safe environment and protect a resident from abuse, permitted involved staff members to continue to render services to the residents, permitted FM 1 in the facility, without implementing their policies and procedures, failed to notify Department of Public Health and law enforcement, failed to notify the attending physician and the psychiatrist, delayed medical attention, and failure to thoroughly investigate the incident for one of three residents (Resident 1). The deficient practice resulted in a staff family member pouring salsa on the resident's face that resulted in left eye pain and becoming fearful for his safety. On July 12, 2016 at 5:10 p.m., the facility Administrator, Assistant Administrator, Director of Minimum Data Set (DMDS), and Director of Social Services (DSS) were verbally notified of the IJ situation regarding Resident 1's abuse. The facility provided an acceptable immediate plan of correction (POC) on July 12, 2016 at 6:56 p.m. The remedy for the IJ abatement included: Director of Nursing (DON) termination, Resident 1's eye was assessed, physician, law enforcement, and psychiatrist to be notified, and 72 hour monitoring of the resident. The IJ remedy also indicated that Social Service Designee (SSD) to monitor the resident's feelings and emotions daily, Notify Department of Health and ombudsman, notify California Board of Nursing, and responsible party to ensure resident safety. The POC also indicated that that the facility would post a sign at the main entrance that states all visitors must sign and check in at the nursing station, the security monitor to be repositioned at the nursing desk for easy access to monitor visitors coming in and out, visitors log-in would be moved from the main entrance to the nursing station, and a mandatory in-service to all staff regarding the facility's abuse policy and procedure and facility's visitors log. On July 13, 2016 at 4:45 p.m., the IJ was lifted in the presence of the Administrator and Corporate Direct Supervisor based on receiving the acceptable plan of correction.

Based on observation, interview, and record review, the facility failed to thoroughly investigate and document as indicated in the facility's abuse prohibition policies, an abuse incident that involved the director of nurse's (DON) family member (FM 1) for one of three residents (Resident 1). The deficient practice had the potential to result in further abuse to Resident 1 and all the other residents (census of 32) in the skilled nursing facility. FM 1 had access to Resident 1, while the director of nursing (DON) continued to provide services at the facility, after Resident 1 complained of an abuse by FM 1, and the resident suffered from pain in the left eye and reportedly became fearful for his safety following the abuse. Findings: A review of the admission records, indicated Resident 1 was admitted to the skilled nursing facility on August 13, 2014, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a comprehensive assessment tool and care screening tool), dated May 27, 2016, indicated that Resident 1 was cognitively intact, and required extensive assistance from staff for activities of daily living. During an interview on July 12, 2016, at 2:05 p.m., both the Assistant Administrator and the Director of Nursing (DON) denied that the facility had any unusual occurrence in May, June, and July 2016. During an interview on July 12, 2016 at 2:45 p.m., Housekeeper 1 stated that on July 7, 2016, she saw Resident 1 push the DON on the abdomen. At 12:45 p.m., Housekeeper 1 was cleaning the shower room near Resident 1's room when she witnessed FM 1 go inside Resident 1's room. FM 1 then left the room, returned, went inside Resident 1's room again, and left quickly. Housekeeper 1 went inside Resident 1's room because the resident was calling for help. The resident stated that FM 1 had poured salsa on his face. Housekeeper 1 notified the Maintenance Supervisor, immediately. During an interview on July 12, 2016 at 3:00 p.m., the Director of Social Service (DSS), stated that the DON had informed her, that Resident 1 had hit her. The DSS also stated that Resident 1 when interviewed about the incident, stated he did not know at the time, who grabbed his wheel chair from the back and he struck out. According to DSS on July 7, 2016 at 12:30 p.m., the Maintenance Supervisor reported to her that a man went to Resident's 1 room and threw salsa on the resident's face. The DSS witnessed salsa on the resident's face and bed linen. The Assistant Administrator, DON, Director of Minimum Data Set (DMDS), and Licensed Vocational Nurse (LVN 2) were on duty. There was no documented evidence that the incident was reported to DPH, law enforcement or ombudsman. During an interview on July 12, 2016 at 3:15 p.m., Resident 1 stated on July 7, 2016, he was in bed when FM 1 came inside his room and poured salsa in his eye. The resident also stated that he would never forget, that he felt pain, and could not see out of his left eye. The resident also stated that the facility never took him to general acute care hospital (GACH) and that his Primary Care Physician (PCP) did not evaluate his left eye after the incident. During an interview on July 12, 2016 at 3:40 p.m., the Assistant Administrator stated on July 7, 2016, Maintenance Supervisor 1 called her and stated an urgent incident occurred regarding Resident 1. When she went to Resident 1's room, she observed the resident with sauce on his left face, shoulder, and bed sheets. The Assistant Administrator also stated the resident stated a man went inside his room and threw food on him. She further stated per the facility's investigation and observation of a facility short clip video review of July 7, 2016 at 12:28 p.m., it was determined that FM 1 was the perpetrator. The Assistant Administrator stated she never documented the incident, never called law enforcement, never notified the Department of Public Health, and never called the Board of Registered Nursing. The Assistant Administrator further stated her priority is to protect the residents and she did not inform the Administrator of the incident until 4:00 p.m. of the same day. During an interview on July 12, 2016 at 4:00 p.m., the Administrator stated on July 7, 2016, Resident 1, punched the DON. The Administrator also stated that based on his interview with House Keeper 1, the DSS, and Maintenance Supervisor 1; FM 1 entered Resident 1's room and threw salsa on Resident 1's face. The Administrator further stated that he had not reported the incident to the law enforcement, governing agencies, the Department of Public Health, and that the DON and the Assistant Administrator were still providing services at the facility. On July 12, 2016 at 4:30 p.m., during observation of a short clip video of July 7, 2016 at 12:28 p.m., a man with shoulder length, dark, straight hair, baseball hat, greenish, long sleeved sweat shirt and dark pants, was observed standing outside Resident 1's room, then entered Resident 1's room and exit quickly, and walked towards Housekeeper 1 and Maintenance Supervisor 1. Housekeeper 1 is observed going inside the Resident 1's room, coming out quickly, and calling Maintenance Supervisor 1. During a telephone interview on July 13, 2016 at 10:45 a.m., the PCP, stated that he had been at the facility on July 12, 2016, and the Assistant Administrator never mentioned anything. He also stated that he would have transferred Resident 1 to a GACH for an eye examination, had he been notified. A review of the facility's undated policy and procedure titled abuse prohibition, indicated that the facility would prohibit abuse, mistreatment, neglect, for all residents. The document also indicates that abuse is defined as the willful infliction of physical pain, injury, or mental anguish. The same document also indicated that the notified supervisor would report the suspected abuse immediately to the administrator and other officials in accordance with the state law. The document also indicated that the act of abuse would be immediately reported to the resident's family and the attending physician. The document also indicated that upon receiving a report of suspected or alleged abuse, mistreatment, neglect, or exploitation, the administrator or designee would report the incident by telephone within 24 hours to law enforcement agency, provide a written report to the local ombudsman, the licensing & certification program district office, and the law enforcement agency within 24 hours utilizing the report of suspected adult/elder abuse form. The document also indicated that the licensing boards and registries be notified as applicable, initiate an abuse allegation investigation that focuses on interventions to prevent further injury, and that the investigation would be thoroughly documented on the centers investigation forms/logs. There was no documented evidence submitted to the surveyor during the investigation to indicate the facility reported the incident by telephone within 24 hours to the law enforcement agency, provided a written report to the local ombudsman, the licensing & certification program district office, and the law enforcement agency within 24 hours utilizing the report of suspected adult/elder abuse form. No documented evidence submitted to the surveyor indicating that the licensing boards and registries were notified as applicable, an abuse allegation investigation that focuses on interventions to prevent further injury was initiated, and that the investigation was thoroughly documented on the facilities investigation forms/logs, as the facility policy indicated. Immediate Jeopardy (IJ) was called on July 13, 2016 at 5:10 pm. The facility failed to provide a safe environment and protect a resident from abuse, permitted involved staff members to continue to render services to the residents, permitted FM 1 in the facility, without implementing their policies and procedures, failed to notify Department of Public Health and law enforcement, failed to notify the attending physician and the psychiatrist, delayed medical attention, and failure to thoroughly investigate the incident for one of three residents (Resident 1). The deficient practice resulted in a staff family member pouring salsa on the resident's face that resulted in left eye pain and becoming fearful for his safety. On July 12, 2016 at 5:10 p.m., the facility Administrator, Assistant Administrator, Director of Minimum Data Set (DMDS), and Director of Social Services (DSS) were verbally notified of the IJ situation regarding Resident 1's abuse. The facility provided an acceptable immediate plan of correction (POC) on July 12, 2016 at 6:56 p.m. The remedy for the IJ abatement included: Director of Nursing (DON) termination, Resident 1's eye was assessed, physician, law enforcement, and psychiatrist to be notified, and 72 hour monitoring of the resident. The IJ remedy also indicated that Social Service Designee (SSD) to monitor the resident's feelings and emotions daily, Notify Department of Health and ombudsman, notify California Board of Nursing, and responsible party to ensure resident safety. The POC also indicated that that the facility would post a sign at the main entrance that states all visitors must sign and check in at the nursing station, the security monitor to be repositioned at the nursing desk for easy access to monitor visitors coming in and out, visitors log-in would be moved from the main entrance to the nursing station, and a mandatory in-service to all staff regarding the facility's abuse policy and procedure and facility's visitors log. On July 13, 2016 at 4:45 p.m., the IJ was lifted in the presence of the Administrator and Corporate Direct Supervisor based on receiving the acceptable plan of correction.

Based on observation, interview, and record review, the facility failed to ensure one of 11 sampled residents (Resident 10) was free from physical, verbal and mental abuse as indicated in the facility's policy and procedure. Resident 10 had a basin of hot water dumped on his chest/stomach by Certified Nursing Assistant 1 (CNA 1), and just recently, was subjected to mental/verbal abuse by the same CNA. The facility's failure to prevent, investigate, discipline, and report the CNA's behavior to the Department resulted in Resident 10 experiencing sadness and anger at the treatment he received from CNA 1, and the ongoing potential for mental and physical abuse to other residents who were cared for by CNA 1. Findings: Review of Resident 10's admission record, indicated Resident 10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated April 4, 2014, indicated Resident 10 had no cognitive/decision-making deficits and was able to communicate his needs. The MDS indicated Resident 10 required limited assistance/one-person physical assist with all his activities of daily living (ADLs) including bathing. During the Resident Council group meeting, held on May 24, 2014 at 10 a.m., Resident 10 volunteered that he had been abused by a staff member. Arrangements were made for a private interview with the resident at 3 p.m. on May 24, 2014. During an interview on May 24, 2014 at 3 p.m., Resident 10 stated he had been a resident of the facility for 8 months. He stated he did not remember the exact date, but about four months ago, during the day shift, he felt sick and weak and did not feel like taking a shower. He told CNA 1 he did not wish to take a shower that morning and CNA 1 stated, "OK." The resident stated a short time later, another staff member (unidentified) asked him if he had a shower that morning and he told her no, he had not. Resident 10 stated he then witnessed the unidentified staff member confront CNA 1 in the hallway about having documented that she gave him a shower when she did not. The resident stated CNA 1 got mad at him for telling the unidentified staff member that he had not had a shower that morning. Resident 10 stated CNA 1 then returned to his room to give him a bed bath. He stated he was lying on his back in his bed when CNA 1 soaked a wash cloth in a basin of hot water and wrung it out over his stomach. He stated he screamed out in pain because the water was very hot. He told CNA 1 the water was too hot, and she then dumped the remainder of the water in the basin on his chest and stomach. The resident stated he screamed out in pain and the director of nursing (DON) came into the room. He stated CNA 1 said nothing. Resident 10 stated he told the DON what happened and told her he did not want CNA 1 back in his room ever again. According to Resident 10, CNA 1 was no longer assigned to care for him, but continued to provide care for his roommate (Resident 6), up until about a month ago when his roommate had a problem with CNA 1. Attempts were made to interview Resident 10's roommate (Resident 6), on May 24, 2014 at 4:30 p.m., regarding the incident, but Resident 6 declined interviews. Resident 10 then detailed an incident which occurred the previous Monday (May 19, 2014). He stated he was sitting in the lobby with a fell ow resident and friend, random sample resident 1 (RSR 1), as he did frequently. CNA 1 approached RSR 1, whispered in his ear and turned and left. RSR 1 then turned to Resident 10 and said "&^%k You!" Resident 10 stated he was mad because RSR 1 was his friend and CNA 1 " ...told him something to make him say bad words to me. Then later he (RSR 1) said he was sorry." Resident 10 stated he had not reported the incident to any staff member in the facility. During an interview with the DON on May 24, 2014 at 4 p.m., investigative reports regarding the incident concerning Resident 10 and CNA 1, was requested. The DON stated the incident had not been investigated and was not reported to the Department. The DON stated this was her first position as a DON in a skilled nursing facility. During an interview with CNA 1 on May 25, 2014 at 2:15 p.m., she stated that Resident 10 had refused to shower for 15 days. She stated she reported that to the LVNs (Licensed Vocational Nurses) and the DON. They told her the resident had the right to refuse care if he chose to. She denied having told a co-worker that Resident 10 had already taken a shower and gathered her supplies and went to the resident's room and asked the resident to please let her give him a bed bath. CNA 1 stated that Resident 10 hated her, he cursed her, called her a b----, and said "#@%k You, go back to your country." The CNA further stated: "He was pushing me and fighting. He kicked me. The DON was there and said why are you bathing him if he refused?" Four random staff members, Licensed Vocational Nurse 2 (LVN 2), LVN 3, LVN 4, and CNA 2 were asked to describe Resident 10's personality/behavior. All four staff members agreed that Resident 10 was alert and oriented, non-argumentative, cooperative, quiet, never cursed, never was combative, and never refused care or medications. Review of CNA 1's employee file revealed the following: 1. A Disciplinary Action form, dated June 11, 2013, indicated CNA 1 was "Unable to perform task in job description safely and effectively. As such this could be detrimental or could cause serious problem with residents' health. Staff should be able to perform job written description: do blood pressure accurately, answer call lights within a timely manner, communicate with residents appropriately and report findings to Charge Nurse. After going over plan of correction with CNA 1, she refused to sign it." 2. A Performance Improvement Plan, dated November 19, 2013, indicated CNA 1's performance was unsatisfactory in the following areas and immediate and sustained improvement was required: poor attitude toward co-workers and residents; being argumentative towards co-workers in hallway. Performance improvement objectives included employee will have a good attitude and respect patient's rights. 3. A Disciplinary Action form, dated February 1, 2014, concerned a resident complaint that CNA 1 was disrespectful, threw clothing at a resident and told the resident that she was crazy and her family put her in the nursing home because she was crazy and her family doesn't love her. The corrective action taken included informing the employee the proper way to effectively communicate with a resident. Inservice on communication and interpersonal skills was provided. CNA 1 was removed from providing the resident's care. A written verbal warning was issued for the employee's behavior and performance. During an interview with the administrator/abuse coordinator on May 25, 2014, at 3 p.m., he stated he had never been made aware of the incident involving CNA 1 dumping hot water on Resident 10. According to correspondence from the Administrator, dated June 3, 2014, CNA 1 was placed on suspension, pending investigation May 25, 2014. Based on the results of the facility's investigations, Resident 10's allegations regarding CNA 1 were founded and CNA 1's employment was terminated on May 30, 2014. The facility's policy and procedure titled, "Preventing Resident Abuse," undated, indicated "Our facility will not excuse any form of Resident abuse and will constantly monitor our Facility's policies, procedures, training programs, systems, etc., to prevent Resident abuse." The policy indicated the abuse prevention program included monitoring staff on all shifts to identify inappropriate behaviors, derogatory language, and rough handling of residents.

Based on observation, interview, and record review, the facility failed to investigate allegations of abuse as indicated in the facility's policy and procedure for one of eleven sampled residents (10). Resident 10 had a basin of hot water dumped on his chest/stomach by Certified Nursing Assistant 1 (CNA 1), and on May 19, 2014, was verbally abused/intimidated by the same CNA. The facility's failure to investigate, prevent, correct, and report the CNA's behavior to the Department resulted in Resident 10 experiencing sadness and anger at the treatment he received from CNA 1, and the ongoing potential for mental and physical abuse to other residents who were cared for by CNA 1. Findings: According to the resident admission record, Resident 10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated April 4, 2014, indicated Resident 10 had no cognitive/decision-making deficits and was able to communicate his needs. The MDS indicated Resident 10 required limited assistance/1 person physical assist with all his activities of daily living including bathing. During the Resident Council group meeting held on May 24, 2014 at 10 a.m., Resident 10 volunteered that he had been abused by a staff member. Arrangements were made for a private interview with the resident at 3 p.m. that same day. However, when Resident 10 made mention of the allegedly abusive staff member's name (CNA 1), 4 of the other 5 residents in the meeting all quickly volunteered that CNA 1 had a bad attitude and did not treat residents and fell ow staff members properly. During an interview on May 24, 2014 at 3 p.m., Resident 10 stated he had been a resident of the facility for 8 months. He stated he did not remember the exact date, but about four months ago during the day shift he felt sick and weak and did not feel like taking a shower. He told CNA 1 he did not wish to take a shower that morning and CNA 1 said, "OK". The resident stated that a short time later, another staff member (unidentified) asked him if he had a shower that morning and he told her no, he had not. Resident 10 stated he then witnessed the unidentified staff member confront CNA 1 about having documented that she gave the resident a shower when she did not. The resident stated CNA 1 got mad at him for telling the unidentified staff member that he had not had a shower that morning. Resident 10 stated CNA 1 then came to his room to give him a bed bath. He stated he was lying on his back in his bed when CNA 1 soaked a wash cloth in a basin of hot water and wrung it out over his stomach. He stated he screamed out in pain because the water was very hot. He told CNA 1 the water was too hot, and she then dumped the remainder of the water in the basin on his chest and stomach. The resident stated he screamed out in pain and the director of nursing (DON) came into the room. He stated CNA 1 said nothing. Resident 10 stated he told the DON what happened and told her he did not want CNA 1 back in his room ever again. Resident 10 stated CNA 1 was no longer assigned to care for him, but continued to provide care for his roommate (Resident 6), up until about a month ago when his roommate had an incident with CNA 1. Resident 10 then detailed an incident that occurred the previous Monday (May 19, 2014). He stated he was sitting in the lobby with a fell ow resident and friend (random sample resident 1/RSR 1), as he did frequently. He stated CNA 1 approached RSR 1, whispered in his ear and turned and left. RSR 1 then turned to Resident 10 and said "&^%k You!" Resident 10 stated he was mad because RSR 1 was his friend and CNA 1 " ...told him something to make him say bad words to me. Then later he (RSR 1) said he was sorry." Resident 10 stated he had not reported the incident to any staff member in the facility. Resident 6 declined interview, during an interview with Resident 6's family member on May 25, 2014 at 1:40 p.m., the incident with CNA 1 was described. The family member stated that sometime in January, 2014 (exact date and time unknown,) she was told by Resident 6 that he was in his bed, being tended to by CNA 1. Resident 6 stated that he told the CNA that felt as if he was going to vomit and CNA 1 forcefully pushed him. The family member stated she immediately found CNA 1 in the hallway and sternly and loudly told her she was never to go near Resident 6 again. She stated she also discussed the incident with the DON. The family member stated she had witnessed CNA 1 arguing/confronting other CNAs and staff in the facility, and that CNA 1 had a bad attitude. During an interview with RSR 1 on May 25, 2014 at 4 p.m., when asked about the incident with CNA 1, he stated that the CNA whispered to him that Resident 10 had "...said something bad about me. But I don't believe he did. We are friends and (Resident 10) doesn't go around saying things about people." During an interview with the DON on May 24, 2014 at 4 p.m., investigative reports regarding the incidents concerning Resident 10 and CNA 1, and the incident between Resident 6 and CNA 1 were requested. The DON stated the incidents were not investigated and were not reported to the Department. During an interview with CNA 1 on May 25, 2014 at 2:15 p.m., she stated that Resident 10 had refused to shower for 15 days. She stated she reported that to the LVNs (Licensed Vocational Nurses) and the DON. They told her the resident had the right to refuse care if he chose to. She denied having told a co-worker that Resident 10 had already taken a shower. She stated she gathered her supplies and went to Resident 10's room and asked the resident to please let her give him a bed bath. CNA 1 stated that Resident 10 hated her, he cursed her, called her a b----, and said, "#@%k You, go back to your country " . <mailto:#@%k You, go back to your country." The CNA further stated: "He was pushing me and fighting. He kicked me. The DON was there and said why are you bathing him if he refused?" Regarding the incident with Resident 6, CNA 1 stated she was at the resident's bedside and he was choking. "I called for help. Nobody came to help me. I put the bed up and pushed him on his side and started cleaning him. His mother later told me (Resident 6) told her I was very rough with him and she did not want me near him again." When asked what she had whispered in RSR 1's ear on May 19, 2014, she stated she told him not to drink too much water because he had a problem with his electrolyte balance. Licensed Vocational Nurse 2 (LVN 2), LVN 3, LVN 4, and CNA 2 were asked to describe Resident 10's personality/behavior. The 100% consensus was that Resident 10 was alert and oriented, non-argumentative, cooperative, quiet, never cursed, never was combative, and never refused care or medications. Review of CNA 1's employee file revealed the following: 1. A Disciplinary Action form, dated June 11, 2013, indicated CNA 1 was, "Unable to perform task in job description safely and effectively. As such this could be detrimental or could cause serious problem with residents' health. Staff should be able to perform job written description: do blood pressure accurately, answer call lights within a timely manner, communicate with residents appropriately and report findings to Charge Nurse. After going over plan of correction with CNA 1, she refused to sign it." 2. A Performance Improvement Plan, dated November 19, 2013, indicated CNA 1's performance was unsatisfactory in the following areas and immediate and sustained improvement was required: poor attitude toward co-workers and residents; being argumentative towards co-workers in hallway. Performance improvement objectives included employee will have a good attitude and respect patients' rights. 3. A Disciplinary Action form, dated February 1, 2014, concerned a resident complaint that CNA 1 was disrespectful, threw clothing at a resident and told the resident that she was crazy and her family put her in the nursing home because she was crazy and her family doesn't love her. The corrective action taken included informing the employee the proper way to effectively communicate with a resident. An inservice on communication and interpersonal skills was provided. CNA 1 was removed from that resident's care. A written verbal warning was issued for the employee's behavior and performance. During an interview with the Administrator/Abuse Coordinator on May 25, 2014 at 3 p.m., he stated he had never been made aware of the incidents involving CNA 1 dumping hot water on Resident 10 or rough handling Resident 6. The facility's policy and procedure titled, "Preventing Resident Abuse," undated, indicated " Our facility will not excuse any form of Resident abuse and will constantly monitor our Facility's policies, procedures, training programs, systems, etc., to prevent Resident abuse." The policy indicated the abuse prevention program included monitoring staff on all shifts to identify inappropriate behaviors, derogatory language, and rough handling of residents. All personnel, Residents, family members, visitors, etc. are encouraged to report any suspected incidents of abuse to Facility management instantly. The facility's policy and procedure titled "Abuse Investigations," revised October 2004, indicated all reports of Resident abuse shall be immediately and thoroughly investigated by Facility management. The facility's policy and procedure titled Reporting Abuse to Facility Management" revised October 2004, indicated it is the duty of all employees to punctually report any incident or suspected incident of neglect or Resident abuse to Facility management. According to correspondence from the Administrator, dated June 3, 2014, CNA 1 was placed on suspension pending investigation on May 25, 2014. Based on the results of the facility's investigations, Resident 10's allegations regarding CNA 1 were founded and CNA 1's employment was terminated on May 30, 2014.