Every finding on record at West Pico Terrace Healthcare & Wellness Centre LP

Based on observation, interview and record review, the facility failed to ensure:Four residents on the pureed diet (foods that do not require chewing and are easily swallowed. All food should be smooth and pureed to the consistency of pudding) received bread texture in form that meet their needs and in accordance with international Dysphagia Diet Initiative IDDSI (IDDSI- a framework made up of levels and describes food textures and drink thickness) Level Four (pureed foods and extremely thick drinks) when the texture of the pureed bread was lumpy, not smooth and had small pieces of bread crust present requiring chewing before swallowing.Soft and Bite size diet texture was prepared according to the IDDSI-Level 6 (All foods prepared for are soft and chopped into bite size 1/2 inch x 1/2 inch pieces) when 12 resident received minced (ground) texture meats and vegetables instead of chopped into bite size pieces 1/2 inch per diet order. These deficient practices had the potential to result in meal dissatisfaction, decreased nutritional intake and increased choking risk for the residents who received the pureed bread. Findings: During an observation of the tray line (tray line- a system of food preparation, in which trays move along an assembly line) service for lunch on 4/14/2026 at 11:50AM, the pureed bread looked lumpy, and not smooth while in a pan on the steam table (table having openings to hold containers/Pans of cooked food over steam or hot water circulating beneath them). During the same observation and interview with [NAME] (Cook1) and Dietary Supervisor (DS) 1 on 4/14/2026 at 12:00PM, [NAME] 1 said we use the food processor (kitchen appliance designed for quickly chopping, slicing, shredding, grating, pureeing, and mixing foods using interchangeable blades and discs within a closed bowl) to make the pureed bread. Cook1 said added some butter and liquid to bread then pulsed the food processor until soft. DS 1 said we don't add a lot of water so we minimize how much thickener we use (Food thickeners are substances used to increase the viscosity of liquids and foods without changing their taste, examples include starches (cornstarch, potato starch), gums (xanthan, guar), gelatin, and pectin, which work by absorbing water or forming gels). During a concurrent interview and taste test of the pureed bread with DS 1 and [NAME] 1, on 4/14/2026 at 12:40PM, the appearance of the pureed bread had a lumpy texture. There were small pieces of bread, and it was not smooth. During the tasting of the pureed bread, it was grainy and some residue stayed in the mouth requiring chewing. [NAME] 1 stated food processor was used to puree' the bread, [NAME] 1 stated melted butter and liquid was added to the mixture until bread is soft. [NAME] 1 agrees that the pureed bread does not look smooth and said the bread needs to be in the food processor longer and some more liquid to make a smooth puree texture. Cook1 said puree should be smooth with no lumps, and no need for chewing so residents don't have swallowing problems. DS 1 stated the pureed bread is soft but agrees that the texture is not smooth like pudding or mashed potato. During a review of the facility recipe titled Pureed (IDDSI Level 4) Breads, cakes, cookies, pancakes and other bread products (dated 2025) the recipe indicated, puree bread on low speed adding milk gradually.the finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated that Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and Fork drip test. 2.During an observation in the kitchen on 4/14/2026 at 12:00PM, [NAME] 1 served minced or ground roast turkey and minced green beans to residents who were on soft and bite size diet order (IDDSI level 6- food particles are soft and chopped into 1/2 inch pieces). During a concurrent observation and interview with [NAME] 1 and DS 1 on 4/14/2026 at 12:40PM, DS 1 stated our menu does not have a soft and bite size diet, we follow the mechanical soft diet which is ground or minced meats and vegetables. DS stated when doctor orders therapeutic diet for residents on the soft and bite size diet the residents will receive the same food texture as the residents on the minced (ground) and moist diet. During the same interview [NAME] 1 stated we make the minced consistency with the food processor to make sure everyone gets consistent size like ground meat and then we mix some gravy for moisture. During a dining observation in residents' room on 4/14/2026 at 1 PM one resident (Resident 8) refused to eat the lunch. Resident 8 stated the food does not look good and does not like it. During a concurrent observation and review of Resident 8's tray card (a printed sheet that includes resident diet order, preferences and dislikes and placed on the meal tray) for lunch, the tray card indicated residents 8 diet was soft and bite size diet but received minced (ground) roast turkey and green beans instead. During a concurrent interview and taste test of the soft and bite size diet with DS 1 and Regional Dietary Supervisor (DS 2) on 4/15/2026 at 12:00PM DS 1 stated we served cilantro lime chicken and carrots in minced texture to residents on the soft and bite size diet. DS1 stated the chicken and the carrots were in the food processor to make sure they come out small and consistent in size. DS 1 stated we downgrade the diet (Downgrading a diet involves increasing food restriction to improve safety, typically going from Regular to Soft/Bite-Sized to Minced/Moist to Pureed, and to thickening liquids. This reduces choking risk but should be guided by a speech-language pathologist (SLP) to avoid malnutrition or unnecessary restrictions) to make sure everyone gets small and soft pieces. DS 1 stated our menu does not have soft and bite size diet guidelines, so we use mechanical soft diet and ground the meats and vegetables. DS 1 stated we are serving the wrong texture when residents receive a diet that is the wrong texture they will complain and not eat. During the same interview and taste test with DS 2 on 4/15/2026 at 12:00 DS 2 stated soft and bite size diet should be food cut into bite size pieces 1/2 inches and that are soft. DS 2 stated that when the residents on the soft and bite size diet receive a downgraded minced and moist texture diet will be unhappy with food and not eat. During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated that Level 5 Minced and Moist is usually eaten with spoon or fork, for people who cannot bite off pieces of food safely but have some basic chewing ability. It is important that food is not sticky. You should be able to scoop food onto a fork, with no liquid dripping and no crumbles falling off the fork. Size of the food is 4mm, which is about the gap between the prongs of a standard dinner fork. Food testing method: Spoon tilt test and Fork drip test. During a review of facility's diet manual diet titled IDDSI LEVEL #6: SOFT and BITE-SIZED (dated 2025) the diet indicated, is designed for residents who experience biting limitations but can chew food items for swallowing. All food prepared for this diet must be soft and chopped into pieces no larger than 1/2 inch x 1/2 inch. This diet had both size and texture specifications that must pass IDDSI level #6 testing requirements. During a review of facility policy and procedures (P&P) titled, Therapeutic Diets (revised 2014), the P&P indicated, Purpose: to ensure that the facility provides therapeutic diets to residents that meet nutritional guidelines and physician orders. Therapeutic diets are diet that deviate from the regular diet and require a physician order. Therapeutic diet will not be given without a physician order. Therapeutic diets are reflected on the menu extension. The Dietary manager will periodically review the resident's tray card and the physician dietary orders to ensure that the information is consistent.

Based on observation, interview and record review, the facility failed to adhere to infection control practices when certified nursing assistant (CNA) 1 failed to wear a gown while providing direct care to one of five sampled residents (Resident 5). Resident 5 was on enhanced barrier precautions (EBP- are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs)). This deficient practice had the potential to transmit infectious microorganisms to the other residents in the facility. Findings: A review of the admission record indicated the facility admitted Resident 5 on 5/22/2024 and re-admitted the resident to the facility on 1/23/2023, with diagnoses including End Stage Renal Disease (ESRD -irreversible kidney failure), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and dementia (a progressive state of decline in mental abilities). A review of Resident 5's Minimum Data Set (MDS-a resident assessment tool) dated 1/29/2026, indicated Resident 5's cognition (ability to think, understand, and reason) was moderately impaired. The MDS further indicated Resident 5 required substantial assistance from staff for toileting hygiene, bathing and lower body dressing. The MDS also indicated the resident received dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). A review of Resident 5's Order Summary Report, dated 4/15/2026, indicated on 1/8/2026 the physician ordered if bleeding occurred at the resident's left femoral permcath after dialysis, staff to apply pressure with clean gauze for five to 10 minutes. Staff were to repeat until bleeding stopped and to notify the physician if the bleeding did not stop. During an observation on 4/14/2026 at 9:27 AM, the wall next to Resident 5's nameplate outside the resident's room door was signage that indicated staff to observe EBP with Resident 5 when dressing, bathing/showering, providing hygiene, changing briefs or assisting with toileting. During a concurrent observation and interview on 4/14/2026 at 9:28 AM, with the Licensed Vocational Nurse (LVN) 3 inside Resident 5's room, CNA 1 was observed performing morning care (routine hygiene and personal care provided to a resident to start their day feeling clean and comfortable) for Resident 5. CNA 1 was not wearing a gown while providing personal hygiene care to Resident 5. LVN 3 stated CNA 1 should be wearing a gown to prevent the spread of infection amongst other residents and staff. During an interview on 4/14/2026 at 9:42 AM, CNA 1 stated Resident 5 chose to have a bed bath today and he (CNA 1) forgot to put on a gown prior to performing AM care. CNA 1 stated that CNA 1 should have been wearing a gown while providing care to Resident 5. CNA 1 further stated wearing a gown was to help stop prevents the spread of bacteria to other residents. During an interview on 4/17/2026 at 10:57 AM, the Director of Nursing (DON) stated the facility uses Enhanced Barrier Precautions (EBP for residents with multi-drug resistant organisms (MDROs - microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents), or indwelling devices like Feeding Tube or tracheostomy to prevent the spread of infection. The DON also stated staff required to use gown and glow when they are performing high- contact resident care activities like dressing, bathing, shower, providing hygiene, changing linens. The DON further stated enhanced barrier precaution prevents the spread of any infection in the facility. A review of the facility's policy and procedures titled, Enhanced Barrier Precautions, revised 12/15/2024, indicated for residents for whom EBP indicated, EBP is employed when performing the following high-contact resident care activities for those at risk of transmission or acquisition of MDROs:a. Dressingb. Bathing/showeringc. Transferring within the resident roomd. Providing hygienee. Changing linensf. Changing briefs or assisting with toiletingg. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator.

Based on observation, interview and record review, the facility failed to protect the residents rights to privacy when Certified Nursing Assistant (CNA) 1 failed to close the privacy curtain/s while the performing personal care for one of 32 sampled residents (Resident 5) to ensure Resident 5 was not visually exposed to the roommates. This deficient practice violated the resident's right for privacy for Resident 5. Findings: A review of Resident 5's admission record indicated the facility admitted the resident on 6/25/2025 and re-admitted the resident to the facility on [DATE], with diagnoses including End Stage Renal Disease (ESRD -irreversible kidney failure), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and dementia (a progressive state of decline in mental abilities). A review of Resident 5's Minimum Data Set (MDS-a resident assessment tool) dated 1/29/2026, indicated Resident 5's cognition (ability to think, understand, and reason) was moderately impaired. The MDS further indicated Resident 5 required substantial assistance from staff for toileting hygiene, bathing and lower body dressing. During a concurrent observation and interview on 4/14/2026 at 9:28 AM, with the Licensed Vocational Nurse (LVN) 3 inside Resident 5's room, CNA 1 was observed performing morning care (routine hygiene and personal care provided to a resident to start their day feeling clean and comfortable) for Resident 5. Resident 5's privacy curtain was not closed and Resident 5 was in the direct view of the other roommate. LVN 3 stated Resident 5's privacy curtain should have been closed completely to maintain Resident 5's privacy. During an interview on 4/14/2026 at 9:42 AM, CNA 1 stated the resident chose to have a bed bath today and he forgot to close the resident's privacy curtain. During an interview on 4/17/2026 at 10:58 AM, the Director of Nursing (DON) stated the during resident care the privacy curtain is closed to maintain the resident's dignity and privacy. A review of the facility's policy and procedures (P&P) titled, Resident Rights, revised 1/1/2012, indicated, Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights. A review of the facility's P&P titled, Resident Rights - Quality of Life, reviewed 3/2017, indicated, Facility Staff promotes, maintains, and protects resident privacy, including bodily privacy, when assisting with personal care and during treatment procedures.

Based on observation, interview, and record review, the facility failed to ensure one of the three sampled residents' (Resident 4) Preadmission Screening and Resident Review (PASARR - a screening evaluation used to determine whether placement in a long term care facility is appropriate for the resident) Level I (a tool that helps identify possible serious mental illness and/or intellectual/development disability) assessment was accurately completed. This deficient practice of failing to accurately complete PASARR Level I assessment for Resident 4 puts Resident 4 at risk for not receiving the necessary care and services tailored to Resident 4's needs. Findings: During a review of Resident 4's admission record (face sheet - a document containing demographic and diagnostic information) indicated Resident 4 was admitted to the facility on [DATE] with the following diagnoses: unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), depression (a common but serious mood disorder that causes a persistent feeling of sadness and loss of interest), and epilepsy (a long term brain disease that causes repeated seizures due to abnormal electrical signals produced by damaged brain cells). During a review of Resident 4's history and physical (H&P - a physician's complete patient examination) dated 3/24/2026 indicated, Resident 4 had the capacity to make medical decisions. During a review of Resident 4's physician progress notes (a doctor's written record that documents a patient's health status, treatment, and care plan) dated 3/30/2026, indicated, Resident 4's institutionalized status limits patient's ability to independently seek outpatient treatment. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 3/30/2026, indicated, Resident 4 had a moderately impaired decision (make poor decisions, cues and supervisions required). MDS also indicated Resident 4 had little interest or pleasure in doing things and was feeing down, depressed, or hopeless nearly every day. MDS also indicated, Resident 4 used mobility device (helps a person walk or move from place to place when one has a disability or injury) such as a walker to get around. During a review of Resident 4's care plan (CP - a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) with an initiated date of 3/25/2026 and target date of 6/21/2026, the CP indicated, Resident 4 uses psychotropic medications (medications that treat mental health disorders) Vraylar (medication used to treat schizophrenia, bipolar I disorder (manic/mixed/depressive episodes), and major depressive disorder (MDD) as an add-on [optional] treatment in adults) for bipolar disorder. The CP goal indicated that Resident 4 will be free of psychotropic drug related complications including movement disorder (conditions that causes either increase movements or reduced or slow movements), discomfort, hypotension (low blood pressure), gait (walk) disturbance, and behavioral impairment. The CP interventions included monitor and record occurrence of target behavior symptoms as manifested by fluctuation of emotions. During a review of Resident 4's CP with an initiated date of 3/23/2026 and target date of 6/21/2026, the CP indicated, Resident 4 uses antidepressant medications (common prescription medications that help treat depression, anxiety, and obsessive-compulsive disorder) trazodone (treats depressed mood and anxiety) and Wellbutrin (treats major depressive disorder, seasonal affective disorder, and aid in smoking cessation) related to depression, and poor adjustment to admission. The CP goal indicated that Resident 4 will show decreased episodes of signs and symptoms of depression. The interventions included monitor and report adverse reactions to antidepressant therapy such as change in behavior/mood/cognition, hallucinations and delusions, social isolation, suicidal thoughts, withdrawal, and decline in activities of daily living (routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of the Interdisciplinary Team (IDT -a collaborative group of professionals from diverse fields-such as doctors, nurses, therapists, and social workers-who work together, sharing expertise to provide comprehensive, integrated care for a patient's complex physical and psychological needs) Notes dated 3/25/2026 at 12:27 PM, indicated Resident 4 was seen by a physician via facetime (an application for making video and voice calls over the internet). The IDT Notes indicated the physician reviewed Resident 4's current psychotropic medications with Resident 4 and that all medications will continue as ordered. The facility failed to produce an In-Service Education (a professional development for workers aimed to enhance their skills, knowledge, and competence to improve job performance), with a sign-in sheet and lesson plan for PASARR process prior to 4/17/2026. During a review of the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled admission Criteria with a reviewed date of 5/29/2025 indicated, The facility will admit only those individuals whose care needs can be safely and effectively met by the services, staffing, and equipment available at the facility. A registered nurse or physician must complete a pre-admission screening to determine if the facility can safely meet the individual's needs. During a review of the facility's P&P titled Pre-admission Screening Level II Resident Review with a reviewed date of 9/2017 indicated, the PASARR will be completed in accordance with the Pre-Screening Resident Review (PASARR) policy.

Based on interview, and record review, the facility failed to develop an individualized and comprehensive plan that is specific for the of care for one of five sampled residents (Resident 5) with diagnosis of Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). This deficient practice had the potential to result in a ineffective nursing and medical care for Resident 5. Findings: A review of the admission record indicated the facility admitted Resident 5 on 5/22/2024 and re-admitted the resident to the facility on 1/23/2023, with diagnoses including End Stage Renal Disease (ESRD -irreversible kidney failure), DM and dementia (a progressive state of decline in mental abilities). A review of Resident 5's Minimum Data Set (MDS-a resident assessment tool) dated 1/29/2026, indicated Resident 5's cognition (ability to think, understand, and reason) was moderately impaired. The MDS further indicated Resident 5 required substantial assistance from staff for toileting hygiene, bathing and lower body dressing. The MDS also indicated the resident was taking insulin (a hormone that lowers the level of glucose (a type of sugar) in the blood). A review of Resident 5's Diabetes Mellitus care plan, initiated 9/9/2025, indicated the resident was taking insulin. The care plan goal was for the resident to have no complications related to diabetes. The care plan interventions included to avoid exposure to extreme heat or cold, to check for breaks in skin, and to educate the resident and family that diabetes was a chronic disease. A review of the care plan also indicated there were no interventions for specific medications to be given nor was there interventions to be done when the resident's blood sugar was too high or too low. A review of Resident 5's physician's orders, dated 9/16/2025 indicated the resident to receive the following: Hypoglycemia protocol colon if a resident responsive give either 1/2 cup of orange juice comma half cup of soft Drink, 1 cup of milk, half cup of apple juice or other item with the 1530 grams of carbohydrates. Residents with renal failure should not receive orange juice. Monitor the resident closely, checking finger sticks and vitals every 15 minutes until stable as needed on 9/16/2025 If the resident is responsive but unable to swallow: rub a thick form of sugar on the inside of the residence cheek or under the tongue. Monitor the resident closely, checking finger sticks and vitals every 15 minutes until stableIf a resident becomes unresponsive:: emergency services. If ordered by the attending physician or medical director, inject Glucagon 1 milligram while waiting for emergency help. Monitor the resident closely, check finger sticks and vitals every 15 minutes until stable or transfer as needed Monitor/document/report PRN for signs an symptoms (s/sx) of hyperglycemia: increased thirst and appetite, weight loss, fatigue, dry skin, poor healing, muscle cramps, abdominal pain, deep labored breathing (Kussmaul), acetone (fruity) breath, stupor, coma Q shift. Every shift If symptoms exist, assess the resident and report findings to the physician Monitor/document/report PRN s/sx of hypoglycemia: sweating, tremor, Increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, Staggering gait Q shift. every shift If symptoms exist, assess resident and report findings to the physician A review of Resident 5's physician order dated 4/4/2026, indicated to inject Novolog insulin (inject subcutaneously-applied under the skin) sliding scale (refers to the progressive increase in pre-meal or nighttime insulin doses and is based on (fingerstick) blood sugar (FSBS) test levels done at set intervals) coverage for blood sugar (BS) measurement in milligrams per deciliter (mg/dl - unit of measurement) as follows;BS :70 to 150 = 0 unit; BS: 151 to 200 = 2 units, BS: 201 to 250 = 4 units, BS: 251 to 300 = 6 units, BS: 301 to 350 = 8 units, BS: 351 to 400 = 10 units, and for BS greater than; 400 = 12 notify physician twice a day. During a concurrent interview and record review with Registered Nurse Supervisor (RNS) 1 on 4/15/2026 at 10:47 AM, Resident 5's care plans were reviewed. RNS 1 stated Resident 5 was taking insulin for her diabetes. RNS 1 also stated Resident 5's diabetes care plan was not specific. RNS 1 stated the care plan should have included the physician hyperglycemia and hypoglycemia and insulin orders. RNS 1 also stated with insulin it is very important to monitor for signs and symptoms of hypoglycemia. RNS 1 further stated the care plan must be resident centered and specific in order to provide for the proper care of the resident. During an interview on 4/17/2026 at 11:00 AM, the Director of Nursing (DON) stated the care plan guides staff on the resident's care and that the care plan is individualized for the resident and their diagnoses. The DON further stated if a specific and individualized care plan is not in place the care plan will not be appropriate for them. A review of the facility's policy and procedure titled, Person-Centered Care Planning, revised 4/24/2025, indicated, The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: i. The services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial wellbeing. ii. Any services that would otherwise be required under, but are not provided due to resident's exercise of rights, including the right to refuse treatment.

Based on observation, interview and record review, the facility failed to ensure food served was flavorful and/or at the proper temperature for one of one sampled residents (Resident 34). This deficient practice had the potential to impact the resident's nutritional status, quality of life and can lead to insufficient food intake for Resident 34. Findings: A review of the admission record indicated the facility admitted Resident 34 on 8/4/2025 and readmitted the resident on 3/19/2026, with diagnoses that included end stage renal disease (ESRD -irreversible kidney failure), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and muscle weakness. A review of Resident 34's History and Physical 3/20/2026, indicated the resident was at risk for acute exacerbation, decompensation or functional decline. A review of the Minimum Data Set (MDS - a resident assessment tool) dated 3/26/2026, indicated Resident 34 had moderate cognitive impairment. Resident 34 required set-up assistance from staff for eating and oral hygiene. During an interview on 4/14/2026 at 12:35 PM, Resident 34 stated the food was not good. Resident 34 further stated the food looks pretty but it has no taste. Resident 34 also stated she previously weighed 150 pounds when she first came to the facility and now she weighed 111 pounds. Resident 34 also stated no one has spoken with her about her food preferences. On 4/15/2026 at 11:05 AM, during a group interview, three out of four residents in attendance stated the food had no flavor and was often cold to lukewarm. On 4/15/2026 at 12:09 PM, during a test tray tasting with the Regional Dietary Supervisor (DS) 2 and the Dietary Service Supervisor (DS) 1, the fiesta rice tasted very bland. DS 2 stated most of the recipes have a bland taste although the food tasted very fresh. On 4/17/2026 at 10:58 AM, the Director of Nursing (DON) stated the food was often brought up in resident council especially by new residents. A review of the facility's policy and procedures (P&P), P-DS01 Dietary Profile and Resident Preference Interview, dated 11/11/2025, indicated the dietary department will provide residents with meals consistent with their preferences and physician order as indicated on the tray card.

Based on observation, interview, and record review, the facility failed to ensure three of 23 resident rooms (rooms [ROOM NUMBER]) had at least 80 square feet per resident in multiple resident bedrooms. This failure had the potential to have an adverse effect on the health, movement and safety of staff and eight of the nine residents (Residents 3, 9, 15, 16, 18, 20, 39, 46) in rooms [ROOM NUMBER]. Findings: During an observation and concurrent interview on 4/14/2026 with Residents 9, 39, and 46 in room [ROOM NUMBER] at 11:36 AM, 11:42 AM, and 11:58 AM respectively, Residents 9, 39, and 46 stated they had no problems with their room and that there was enough space in the room for their personal belongings and for them to move around. During an observation and concurrent interview on 4/14/2026 with Residents 15, 16, and 18 in room [ROOM NUMBER] at 11:43 AM, 11:47 AM, and 12:09 PM respectively, Residents 15, 16, and 18 stated there are no problems with their room and that there is enough space in the room for their personal belongings and for them to move around. During an observation and concurrent interview on 4/14/2026 with Resident 3 in room [ROOM NUMBER] at 1:29 PM, Residents 3 stated there are no problems with the room and that there is enough space in the room for Resident 3's personal belongings and to move around. A review of the Client Accommodations Analysis form (form that is designed to provide a record of client accommodations approved for licensed care; it identifies the approved use of individual rooms and approved capacities) dated 4/14/2026, indicated the following rooms with their corresponding measurements:The following rooms provided are less than 80 sq.ft. pr resident:Room # Room Size Floor Area (sq.ft.) Number (#) of beds7 19.1 x 10.91 217.21 314 20.1 x 10.83 217.68 3 15 20 x 11 220 3 A review of the Client Accommodation Analysis form indicated that the above rooms measured less than the required 80 square footage per resident in multiple resident bedrooms. For a three-bed capacity room, the square footage requirements would be at least 240 square feet. A review of a room waiver request letter received from the Administrator dated 4/14/2026, indicated the Administrator is requesting a waiver for rooms [ROOM NUMBER]. The letter indicated that the rooms were in accordance with the special needs of the residents and would not have an adverse effect on residents' health and safety or impede the ability of any residents in the rooms to attain his or her highest practicable well-being. During an interview on 4/16/2026 with Licensed Vocational Nurse (LVN) 6 and Rehabilitation Manager (RM) at 3:50 PM and 3:55 PM respectively, LVN 6 and RM stated there are enough space in rooms [ROOM NUMBER] to perform their tasks. During an interview on 4/16/2026 at 3:59 PM with the Director of Nursing (DON), the DON stated the facility has not received any complaints from residents nor from the staff about the room sizes for rooms [ROOM NUMBER]. The DON stated, there is enough space for residents to keep their personal belongings and move around the room comfortably. During an interview on 4/17/2026 at 9:36 AM with Registered Nurse (RN) 1, RN 1 stated there is adequate space to perform all nursing care for the residents in rooms [ROOM NUMBER]. RN 1 stated all residents can move in rooms [ROOM NUMBER]. without problems with the space. A review of the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Room Waiver with a revision date of 12/01/2015 indicated, Residents will be screened for medical and personal needs for placement in waiver room that is slightly smaller room. The residents will be ambulatory (ability to walk and move around despite an illness or injury) or semi-ambulatory (a person with limited mobility who can walk or move independently to a partial extent, but requires mobility aids such as a walker or a wheelchair or assistance from others on a regular basis) residents.

Based on interview and record review the facility failed to ensure the medical records were complete and accurate for two of two sampled residents (Resident 1 and Resident 2). 1.For Resident 1, the facility failed to verify that the physician obtained the informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from Resident 1 on 4/1/25 before starting Resident 1 on Buspirone (medication that treats anxiety) 30 milligrams (mg. - metric unit of measurement, used for medication dosage and/or amount) two times a day. 2. For Resident 2, the facility failed to verify that the physician obtained informed consent from Resident 2 ' s responsible party on 4/9/25 before giving Resident 1 Mirtazapine (medication to treat depression) 15 mg., Quetiapine (medication that treats certain mental condition) 50 mg. and Buspirone 20 mg. This deficient practice resulted in inaccurate and incomplete medical records for Resident 1 and Resident 2. Findings: 1. During a review of the Admission Record indicated the facility admitted Resident 1 on 3/14/25 with diagnoses including anxiety disorder and generalized muscle weakness. During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 3/21/25, indicated Resident 1 had moderately impaired cognitive skills (the mental ability that enables a person to think, learn, remember, and solve problems). Resident 1 was dependent on toileting hygiene, needed maximal assistance (helper does more than half the effort) with shower/bathe self, lower body dressing, needed moderate assistance (helper does less than half the effort) with oral hygiene, upper body dressing, putting on/off footwear, personal hygiene and supervision with eating. During a review of Resident 1 ' s Verification of Informed Consent dated 4/1/25 indicated Resident 1 was on Buspirone 30 mg. two times a day for anxiety. The Verification of Informed Consent did not indicate the physician ' s name that prescribed the Buspirone. The same Verification was signed by Resident 1; however, the Verification did not indicate if the prescriber obtained informed consent from Resident 1. 2.During a review of the Admission Record indicated the facility admitted Resident 2 on 4/9/25 with diagnoses including major depression and dementia (a progressive state of decline in mental abilities). During a review of the Minimum Data Set, dated dated dated [DATE] indicated Resident 2 had severe cognitive impairment. Resident 2 was dependent on shower/bathe self, lower body dressing, putting on/taking off footwear, maximal assistance with oral hygiene, toileting hygiene, personal hygiene and moderate assistance with eating and upper body dressing. During a review of Resident 2 ' s Verification of Informed Consent dated 4/9/25 indicated Resident 2 was on Mirtazapine 15 mg., Quetiapine 50 mg. and Buspirone 20 mg. The Verification of Informed Consent did not indicate the prescriber. The same Verification indicated Resident 2 ' s next of kin (NOK) signed the Verification, however the Verification did not indicate that the prescriber obtained informed consent from Resident 2 ' s NOK. During a concurrent interview and record review on 4/30/25 at 10:47 a.m., Resident 1 ' s Verification of Informed Consent dated 4/1/25 and Resident 2 ' s Verification of Informed Consent dated 4/9/25 were reviewed with the registered nurse supervisor (RNS) 1. RNS 1 stated Resident 1 and Resident 2 ' s Verification of Informed Consent did not indicate if the prescriber obtained consent from Resident 1 and from Resident 2 ' s NOK. RNS 1 stated the Verification Form was incomplete and RNS 1 stated this can lead to miscommunication. During a concurrent interview and record review on 4/30/25 at 1:39 pm., Resident 1 ' s Verification of Informed Consent dated 4/1/25 and Resident 2 ' s Verification of Informed Consent dated 4/9/25 were reviewed with the director of nursing (DON). DON confirmed that Resident 1 and Resident 2 ' s Verification of Informed Consent were incomplete. DON stated the Verification Forms should have a check mark to indicate that the physician obtained informed consent from Resident 1 and Resident 2's NOK. During a review of the facility Policy and Procedures (P&P) titled Completion & Correction reviewed on 6/20/24, indicate, entries will be recorded promptly as the events or observations occur. The same Policy indicated no blank spaces are to be left on forms. If something does not apply to the resident enter N/A so that is clear the category was purposely not answered. During a review of the facility P&P titled Informed Consent reviewed on 6/24, indicated, the facility will confirm that the resident ' s medical record contains documentation that the physician has obtained informed consent prior to initiating medical intervention.

Based on observation, interview and record review, the facility failed to ensure boxed food items were not stored directly on the floor. This deficient practice had a potential to cause food contamination, which placed the residents of the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During a concurrent interview and observation in the dry storage on 2/5/25 at 5:32 PM with [NAME] 1 (CK1), the following food items were observed stacked directly on the floor: a. One box of Thickened dairy drink b. One box of thickened lemon-flavored water c. 25- pound bag of sugar CK1 stated these food items in boxes were delivered earlier in the day and were not placed on the racks. CK1 stated the boxes should be stored at least 6 inches off the floor to prevent contamination and not to spread infection to the residents. During an interview on 2/8/25 at 4:02 PM, the Dietary Supervisor (DS1) stated boxes are to be stored 6 inches off the floor for infection control. During an interview on 2/9/25 at 5:59 PM, the Director of Nursing (DON) stated food in the kitchen is to be stored in sanitary manner. A review of the facility provided storage guidelines, under Section A- Sanitary Conditions in Storage of Food, indicated shelving should be mounted at least 6 inches from the floor, preferably on castors for ease of cleaning and 18 inches from the ceiling and foods should be stored off the floor.

Based on observation, interview and record review, the facility failed to 1. Ensure one of 12 sampled residents (Resident 4) who tested negative for coronavirus (COVID-19 - an infectious disease that can cause respiratory illness in humans) was not cohorted with a resident who tested positive with COVID-19. 2. Ensure the Physician's order for transmission-based precaution was updated for Resident 30. These deficient practices had the potential to transmit infectious diseases and increase the risk of infection to the residents, staff, and visitors. Findings: 1a. A review of the Admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including pneumonia (lung infection that inflames air sacs with fluid or pus), acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), hemiplegia and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left dominant side. A review of the Minimum Data Set (MDS - resident assessment tool) dated 12/20/2024, indicated Resident 4's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 4 required maximal to total dependent from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent observation and interview with Resident 4 on 2/7/2025 at 7:13 p.m., Resident 4 was cohorted and placed in the same room with Resident 29. Resident 4 stated, she tested negative for COVID-19. 1b. A review of the Admission Record indicated Resident 29 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and muscle wasting and atrophy (characterized by a significant shortening of the muscle fibers and a loss of overall muscle mass). A review of the MDS dated [DATE], indicated Resident 29's cognitive skills for daily decisions were severely impaired. A review of Resident 29's COVID-19 antigen (generally a protein on the surface of a virus) test dated 2/6/2025, indicated, Resident 29 tested positive for COVID-19 infection. A review of facility's census on 2/7/2025, 2/8/2025, 2/9/2025 indicated, Resident 4 had been placed in a room cohorted with Resident 29. During an interview with Registered Nurse 1 (RN 1) on 2/8/2025 at 4:23 p.m., RN 1 stated, Resident 29 tested positive for COVID-19 and Resident 4 tested negative. RN 1 stated, both residents (Resident 4 and Resident 29) were placed in the same room but there were no documentations to indicate the reason why they (facility) did not separate Resident 4 and Resident 29. RN 1 further stated, Resident 4 did not want to move to another room, but there were no documentations for explanation of the risk of Resident 29 refusing to be moved. RN 1 stated, if a resident with negative COVID test is placed with a resident who is tested positive for COVID-19, it places the resident at risk of transmitting the infection to another resident. During an interview with Infection Preventionist (IPN) on 2/9/2024 at 3:10 p.m., IPN stated Resident 4 was not moved to another room because the resident refused to be moved. IPN stated, there were no documentation that Resident 4 was offered to be moved as her roommate, Resident 29 who tested positive with COVID-19. IPN stated, this (practice) placed other residents at risk of contracting COVID-19 infection. A review of the facility's Public Health Letter titled, Viral Respiratory Illness Outbreak Notification Letter, dated 2/7/2025 indicated, Based on the preliminary investigation, the Department of Public Health required that the following control measures and actions be implemented, as applicable to the setting: identify symptomatic individuals so that they can be separated from those affected by the illness. A review of the facility's policy and procedure (P&P) titled, Management of COVID-19, reviewed date 6/20/2024 indicated, Centers will have a plan based on CDC/CMS/State/local recommendation to prevent transmission, such as having a dedicated space in the facility for cohorting and managing care for patients with COVID-19 . Cohorting of patient within the Center will be in accordance with the Cohorting Policies. A review of Centers for Disease Control and Prevention (CDC - national public health agency of the United States) titled, Infection Control Guidance: SARS-SoV-2, dated 12/2023, indicated, Placement of residents with suspected or confirmed SARS-CoV-2 infection: Ideally, residents should be placed in a single-person room as described. 2. A review of the Admission Record indicated Resident 30 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute bronchospasm (a sudden narrowing of the airways [bronchi] in the lungs, caused by the contraction of muscles lining the airways), pulmonary embolism (a blood clot gets stuck in an artery in the lung, blocking blood flow to part of the lung), Type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure). A review of the MDS dated [DATE], indicated Resident 30's cognitive skills for daily decisions was intact. The MDS indicated Resident 30 required set-up assistance from staff for ADLs. A review of Resident 30's Order Summary Report dated 1/29/2025, indicated the physician ordered for the resident to be on, Contact/droplet precaution (contact precautions are used for patients with infections that can be transmitted by contact, while droplet precautions are used for patients with infections that can be transmitted by droplet). During a concurrent observation and interview with Resident 30 on 2/7/2025 at 6:03 p.m., Resident 30 stated, he was having some shortness of breath (SOB) and on oxygen therapy. Resident 30 was observed in a room with no transmission-based precaution (TBP) signage outside his door; there were no personal protective equipment (PPE-a barrier precaution which includes the use of gloves, gown, mask, face shield, when anticipating coming in contact with blood, body fluids or other communicable toxins or agents) observed outside the door for staff and visitors to use. During an interview with RN 1 on 2/8/2025 at 4:23 p.m., RN 1 stated, Resident 30 was on TBP room while he was taking antibiotic (ABX) for pneumonia. RN 1 reviewed Resident 30's medical record and confirmed, the Physician's order for contact/droplet precaution is still in place. RN 1 stated, it (the precaution) should have been discontinued as Resident 30 was done with ABX therapy. During an interview with IPN on 2/9/2024 at 9:16 a.m., IPN stated Resident 30 was no longer on TBP room, and they should have discontinued the order for precaution. IPN stated, she did not discontinue the order timely after physician had ordered to discontinue the TBP room. A review of the facility's P&P titled, Infection Control- Policies & Procedures, reviewed date 6/20/2024, indicated, The facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.

Based on interview and record review, the facility failed to ensure two of six sampled residents, (Resident 3 and Resident 29)'s clinical record was updated per facility's policy and procedure by failing to: 1. Ensure Resident 3's Physician Orders for Life-Sustaining Treatment (POLST - is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) were complete and accurate. 2. Ensure Resident 29's Advance Healthcare Directives (AHCD - written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were followed up and discussed with the residents and/or responsible parties. These deficient practices had the potential to cause conflict with resident's wishes regarding health care decisions. Findings: I. During record review, the Admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood) and aphasia (a disorder that makes it difficult to speak). During record review, the Minimum Data Set (MDS - resident assessment tool) dated [DATE], indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 10 required maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During record review, Resident 3's POLST, date prepared on [DATE], the POLST form was incomplete with no documentation regarding Resident 3's wishes such as cardiopulmonary resuscitation (CPR - medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered cardiac arrest), medical interventions and artificially administered nutrition, the POLST does not have signatures of resident and/or legally recognized decisionmaker if the POLST was discussed and reviewed. II. During record review, the Admission Record indicated Resident 29 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and muscle wasting and atrophy (characterized by a significant shortening of the muscle fibers and a loss of overall muscle mass). During record review, the MDS dated [DATE], indicated Resident 29's cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 10 was dependent from staff for ADLs. During record review, Resident 29's Advance Directive Acknowledgement (ADA) Form, dated [DATE], indicated, Yes, I (Resident 29) have executed an Advance Directive, the form did not indicate if facility requested a copy of the actual AHCD. During record review, Resident 29's electronic medical record and paper medical record as of [DATE], there are no ADHD recorded in the chart. During a concurrent interview and record review with Social Services Director Interim (SSDI) on [DATE] at 3:04 p.m., SSDI reviewed Resident 3's medical record and stated and confirmed, the POLST is incomplete and it does not have information if Resident 3 is a Full Code (if a person's heart stopped beating or breathing, the person will allow all medical measures to be taken to maintain and resuscitate life) or DNR (do not resuscitate- a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation (CPR) if breathing stops or the heart stops beating). SSDI 1 also reviewed Resident 29's ADA form and stated and confirmed, Resident 29 has an AHCD but there was no indication if the facility followed up and requested the copy. During an interview with Director of Nursing (DON) on [DATE] at 6:10 p.m., DON stated, facility should have followed up with the actual copy of residents' AHCD they formulated one so they can honor their wishes. DON further stated, the POLST must be completed with information if they are Full Code or DNR. During record review, the facility's policy and procedure (P&P) titled, Advance Directive, reviewed on [DATE] indicated, The Facility will respect a resident's advance directive and will comply with the resident's wishes expressed in an advance directive . Upon admission, the Admission Staff or designee will obtain a copy of a resident's advance directive. If the resident has an Advance Directive, the facility shall obtain a copy of the document and place it in the resident's medical record. During record review, the facility's P&P titled, Physician Orders for Life-Sustaining Treatment (POLST), reviewed [DATE], the P&P indicated, A completed and signed POLST form is a legal physician order that is immediately actionable . Completion of a POLST form will reflect a process of careful decision making by the resident, the resident's legally recognized health care decision maker if the resident lacks decision making capacity, and the attending physician, physician assistance or nurse practitioner, regarding the resident's medical condition and known treatment preferences.

Based on observation, interview, and record review, the facility failed to ensure that one out of three sampled residents (Resident 10) was free from physical restraint by failing to ensure the physician's order for bilateral bed siderails was in placed and the proper use of use rails are appropriate according to facility's policy and procedure. This deficient practice had the potential to result in entrapment and injury with the use of restraints. Cross Reference F656 Findings: During record review, the Admission Record indicated Resident 10 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), Parkinson's disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain), Type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and muscle wasting and atrophy (characterized by a significant shortening of the muscle fibers and a loss of overall muscle mass). During record review, the Minimum Data Set (MDS - resident assessment tool) dated 2/6/2025, indicated Resident 10's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 10 required maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During the initial tour of the facility and observation of Resident 10 on 2/7/2025 at 6:23 p.m., Resident 10 was observed in bed, lying on a bed with a bilateral (both) siderails up. Resident 10 was observed asking staff for assistance on opening food container. During record review of Resident 10's Order Summary Report as of 2/9/2025, indicated there was no physician order for the use of bilateral bed siderails. During record review of Resident 10's Care Plan (CP) as of 2/9/2025, indicated there are no CP developed for the use of bilateral siderails. During an interview with Director of Nursing (DON) on 2/9/2025 at 6:14 p.m., DON stated, the bed side rails are used as an enabler. DON stated there should be a physician's order and CP for the use of bed siderails as it limits resident movements and can be a restraint. During record review of the facility's policy and procedures (P&P) titled, Bed Rails, reviewed on 6/20/2024, the P&P indicated, A bed rail is an assistive device and must be used in accordance with the following regulations: . are classified as a physical restrain when bed rails are used to limit a Resident's freedom of movement . A detailed order by a healthcare provider is required before any restrains can be utilized.

Based on interview, and record review, the facility failed to provide a bed hold notification (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization ) in writing at the time of transfer to the hospital for one of three sampled residents (Resident 38). This deficient practice denied Resident 38 or the Responsible Party (RP) of being informed of resident's right to have the facility hold and reserve his bed while absent from the facility. Findings: During record review of Resident 38's Admission Record (Face Sheet) indicated Resident 38 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses including metabolic encephalopathy (brain damage that causes severe confusion and forgetfulness), bladder cancer and chronic kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood). During record review of Resident 38's Bed Hold Agreement form, dated 12/6/24 indicated the form had three sections, the first was To be Completed upon Admission or Return to Facility, the second was Notification of Bed Hold option upon transfer/therapeutic leave and the third was 24 Hour Notification of Bed Hold Decision. A review of the Bed Hold Agreement form also indicated Under the section To be Completed upon Admission, indicated Resident 38's responsible party (RP) was informed that the resident or RP had the right to request the facility hold the bed for seven days should the resident be transferred to an acute hospital and the resident or RP must notify the facility within 24 hours of transfer/leave if the resident wished to have the bed held. This section of the form was signed by the RP on 12/6/24. A further review of Bed Hold Agreement form indicated the second and third sections were not filled out and were unsigned. During record review, Resident 38's Minimum Data Set (MDS- a resident assessment tool) dated 12/30/24, indicated the resident's cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was intact. The MDS indicated Resident 38 required substantial assistance (helper does less than half to more than half the effort) from staff for toileting hygiene, showering/bathing and lower body dressing. During record review, Resident 38's Physician Order, dated 2/5/25, indicated to transfer Resident 38 to the Emergency Department (ED) via 911 for further evaluation of hypotension (low blood pressure). During record review, Resident 38's Progress Note dated 2/5/25 indicated at 9:10 AM the resident had a blood pressure of 80/60 (normal 120/80) and the nurse practitioner ordered the resident transferred to General Acute Care Hospital (GACH) 1. The progress note also indicated Resident 38 was transferred via 911 (a telephone number used to reach emergency medical, fire, and police services) to GACH 2. During record review of Resident 38's Skilled Nursing Home/Nursing Home (SNF/NF) to Hospital Transfer Form, dated 2/5/25, indicated the resident was transferred to GACH 2. During a concurrent interview and record review on 2/9/25 at 12:38 PM with Registered Nurse Supervisor (RNS) 1, Resident 38's electronic health record was reviewed. RNS 1 stated Resident 38 was transferred to a general acute care hospital on 2/5/25 for low blood pressure and high heart rate. RNS 1 stated the facility did not notify Resident 38 or the responsible party of the resident's right to a bed hold during or after the transfer. RNS 1 stated a bed hold notification is required to be offered upon transfer in order to guarantee the resident has a bed to return to upon readmission. During an interview with on 2/09/25 at 5:59 PM, the Director of Nursing (DON) stated, the policy is to inform the resident of their right to a bed hold upon transfer. During record review, the facility's policy and procedures (P&P) titled, Bed Hold, revised 7/2017, indicated, the facility notifies the resident and/or representative, in writing, of the bed hold option, any time the resident is transferred to an acute care hospital or request therapeutic leave. During record review, the facility's P&P titled, Discharge and Transfer of Residents, revised 2/2018, indicated, the purpose of the policy was to ensure that discharge planning is complete and appropriate and that necessary information is communicated to the continuing care provider. The P&P also indicated upon transfer to the acute hospital the resident/resident representative will be given an opportunity to execute a bed hold.

Based on interview and record review, the facility failed to complete a change of condition (COC -a sudden deviation from person/patient's baseline in physical, cognitive, behavioral or function) in accordance with the facility's policy and procedures (P&P) titled Change of Condition Notification reviewed 6/20/2024 for one out of six residents (Resident 23) This deficiency practice had the potential to result in the delay of care for Resident 23. Findings: During record review, Resident 23's Admission Record indicated the facility admitted Resident 23 on 7/3/2023 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), personal history of transient ischemic attack (TIA - a temporary blockage of blood flow to the brain) and cerebral vascular accident (CVA- Stroke) without residuals, and hypertension (HTN - elevated blood pressure). During record review of Resident 23's Minimum Data Set (MDS - resident assessment tool) dated 1/10/2025, indicated Resident 23 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 23 required extensive staff assistance with activities of daily living (ADL -tasks of everyday life). During a concurrent interview and record review, on 2/9/2025, at 8:45 a.m., with Registered Nurse Supervisor 1 (RNS 1), Resident 23's electronic chart was reviewed. RNS 1 stated there was no documented evidence that a COC was completed for Resident 23 on 9/15/2025. RNS 1 stated A COC is done to see if there is any new or continuous change in the resident's condition and since residents 23 continued to have aggressiveness, combativeness and continuously refused to allow staff to collect the urine sample ordered by the physician, a COC documentation should have been done. RNS 1 stated lack of completion of the coc leads to lack of recommendations needed on how to deal with the changes. During an interview, on 2/9/2025, at 4:04 p.m., with the Director of Nursing (DON), the DON stated that a COC is done to so residents can be monitored, and the Interdisciplinary team can be involved in providing resident with the care needed and if not done no one will know or monitor what is going on. During record review of the facility's P&P, titled, Change of Condition Notification reviewed 6/20/2024, indicated, Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner . A. A need to alter treatment significantly (e.g. based on labs/x-ray results, a need to discontinue an existing form of treatment due to change of condition).

Based on interview and record review, the facility failed to immediately develop and implement a baseline care plan according to their Policy and Procedures (P&P) in accordance with the facility's policy and procedures (P&P) titled Comprehensive Person-Centered Care planning revised 11/2018 for one of four sampled residents (Resident 6), by failing to: 1. Address the inclusion of activity programs that are tailored to Resident 6's interests and to Resident 6's cognitive, physical/functional and social abilities to stimulate and facilitate Resident 6's social engagement. 2. Outline a personalized treatment strategy for Resident 6's hearing loss within 48 hours of admission. These deficient practices had the potential to negatively affect the delivery of necessary care and services for Resident 6. Findings: During record review, Resident 6's Admission Record indicated the facility admitted Resident 6 on 11/23/2024 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), generalized weakness (a feeling of weakness in most parts of the body), and adult failure to thrive (a noticeable decline in health). During record review, the physician order dated 11/23/2024, indicated audiology (a medical study of hearing and balance, and treatment of related disorders) consult with follow up treatment as indicated for Resident 6. During record review, the history and physical (H&P -a physician's examination of the patient) dated 11/25/2024 at 10:46 a.m., indicated .past medical history . hard of hearing for Resident 6. During record review, Resident 6's Minimum Data Set (MDS - resident assessment tool) dated 11/30/2024, indicated Resident 6 had mild cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 6 required extensive staff assistance with activities of daily living (ADL -tasks of everyday life). The MDS further indicated Resident 6 had moderate difficulty with hearing and severely impaired vision. During an interview, on 2/8/2025, at 2:21 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 6 was hard of hearing, and that facility staff have to go very close to her ear and speak very loud for Resident 6 to hear. During a concurrent interview and record review, on 2/9/2025, at 10:04 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 6's electronic chart was reviewed. RNS 1 stated a care plan for activities is for staff to know what interventions to take to achieve the goal for the resident to participate in the activities that the resident prefers. RNS 1 stated Resident 6 did not have documented evidence of an activity care plan in her chart. RNS 1 further stated that lack of an activity care plan for Resident 6, facility staff will not know her activity preference. During a concurrent interview and record review, on 2/9/2025, at 1:47 p.m., with Activities Director (AD), Resident 6's electronic chart was reviewed. AD stated, a care plan provides residents with the services that the residents needs and for other facility staff to know what activities needs the resident has before even meeting the resident. AD stated Resident 6 did not have a documented activity care plan and that and that Resident 6 needed to have one. AD further stated, if the resident does not have a care plan for activities, the team members will nots know how to handle the resident in regard to their activities which may lead to the residents feeling sad and neglected. During an interview, on 2/9/2025, at 4:14 p.m., with Director of Nursing (DON), DON stated base line care plans are supposed to be initiated within 48 hours of admission which includes a personalized activity care plan for the team to know how to take care of the resident. DON stated potential adverse outcome of not having an activity care plan is that the staff may not know the type of activities the Resident prefers and may lead resident to be sad and depressed (sadness, hopeless and loss of interest). During record review, the facility's policy and procedures, titled, Comprehensive Person-Centered Care Planning revised 11/2018, indicated, Purpose: To ensure that a comprehensive person-centered care plan is developed for each resident . 1. Baseline Care plan . b. The baseline care plan will be developed and implemented, using necessary combination of problem specific care plans, within 48 hours of the resident admission . c. The baseline care plan must reflect the resident's stated goals and objectives and include interventions that address his or her needs.

Based on interview and record review, the facility failed to implement a comprehensive care plan (CP) that met the care/services based on the resident's individual assessed needs for one of six sampled residents (Resident 10), by failing to ensure that a comprehensive CP was developed with the use of Resident 10's bilateral (both) bed siderails, when Resident 10 was hospitalized on [DATE], 7/22/2024, and 12/27/2024. This deficient practice had the potential to result in a negative impact on residents' health and safety, as well as the quality of care and services received. Findings: A review of the Admission Record indicated Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), Parkinson's disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain), Type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and muscle wasting and atrophy (characterized by a significant shortening of the muscle fibers and a loss of overall muscle mass). A review of Resident 10's Minimum Data Set (MDS - resident assessment tool) dated 2/6/2025, indicated Resident 10's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 10 required maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During the initial tour of the facility and observation of Resident 10 on 2/7/2025 at 6:23 p.m., observed resident 10 in bed, lying on a bed with a bilateral siderails up. Observed Resident 10 asking staff for assistance on opening food container. A review of Resident 10's CP as of 2/9/2025, indicated there are no CP developed for the use of bilateral siderails. Furthermore, there are no CP when Resident 10 was hospitalized due to altered mental status on 6/29/2024, chest pain on 7/22/2024 and productive cough and generalized weakness on 12/27/2024. During an interview with Registered Nurse (RN) 1 on 2/8/2025 at 3:39 p.m., RN 1 reviewed Resident 10's chart and stated and confirmed, there are no CP developed for the use of bilateral bed siderails. RN 1 further stated, there are also no CP when Resident 10 had a change of condition (COC) and was hospitalized on [DATE], 7/22/2024 and 12/27/2024. RN 1 stated, a CP should be developed when residents had COC, so that they can update the plan of care and manage the problems. During an interview with Director of Nursing (DON), on 2/9/2025 at 6:14 p.m., the DON stated, the bed side rails are used as an enabler. DON stated there should be a physician's order and CP for the use of bed siderails as it limits resident movements and can be a restraint. DON further stated, there should also be CP for each hospitalization and COC so that all staff are on the same page on managing resident's plan of care. A review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, reviewed on 6/20/2024, the P&P indicated, Is it the policy of this facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being . The comprehensive care plan will also be reviewed and revised at the following times: onset of new problems; change of condition.

Based on observation, interview, and record review, the facility failed to revise the enteral feeding care plan to meet the individual needs for one of two sampled residents (Resident 22). This deficient practice had the potential to prevent Resident 22 from receiving care to address specific needs, which could lead to a decline in her nutrition. Findings: A review of Resident 22's Admission Record indicated the facility admitted Resident 22 on 10/9/24 with diagnoses including cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain) dysphagia (difficulty swallowing) and heart failure (a disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). A review of Resident 22's Minimum Data Set [MDS - a resident assessment tool] dated 1/8/25 indicated the resident had severely impaired cognition (never/rarely made decisions) and was totally dependent upon staff for eating, oral hygiene, toileting hygiene, lower body dressing and personal hygiene. The MDS also indicated Resident 22 had a feeding tube. A review of Resident 22's physician order dated 1/16/25, indicated to give Jevity 1.5 at 65 milliliters (ml, unit of measurement) per hour (hr) via gastrostomy tube (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for dysphagia (difficulty swallowing). During an observation on 2/7/25 at 6:08 PM at Resident 22's bedside, Resident 22 was observed lying in bed awake with Jevity 1.5 calorie formula bottle infusing at 65 ml/hr. During a record review on 2/8/25 at 12:22 PM, Resident 22's Requires tube feeding care plan, initiated 10/9/24, was reviewed. The care plan indicated Resident 22's current enteral feeding order was for Jevity 1.5 to infuse at 40 ml/hr. The care plan indicated the goal was for the resident to maintain adequate nutritional and hydration status. A further review of the care plan indicated the care plan did not include the resident's current enteral feeding order. During a concurrent interview and record review on 2/8/25 at 1:08 PM, Resident 22's physician orders and care plans were reviewed with Registered Nurse Supervisor (RN) 1. RN 1 stated Resident 22's current enteral feeding order was Jevity 1.5 at 65 ml/hr. RN 1 stated Resident 22's enteral feeding care plan was not updated with the current physician order. RN 1 stated should have been updated in order for all staff to know the current interventions in place. RN 1 further stated not updating the care plan could lead to the Resident not receiving the proper care. During an interview on 2/9/25 at 5:57 PM, the Director of Nursing (DON) stated the staff update the care plan when the changes in the resident's care, medication or enteral feeding occurs. The DON confirmed the findings and stated the care plan should be updated so the resident receives appropriate care. A review of the facility's policy and procedure (P&P ) titled, Comprehensive Person-Centered Care Planning, revised 11/2018, the P&P indicated, the comprehensive care plan will the comprehensive care plan will be periodically reviewed and revised by the interdisciplinary team (IDT, - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) after each assessment which means after each MDS assessments as required, accept discharge assessments. In addition, the comprehensive care plan will also be reviewed and revised at the following times: i. onset of new problems; ii. change of condition; iii. in preparation for discharge; iv. to address changes in behavior and care; v. other times as appropriate or necessary.

Based on interview and record review, the facility failed to notify the physician when they were unable to collect urine sample for urinalysis, culture and sensitivity (UA [a test to check if the urine has an infection, kidney problem, diabetes or liver disease] and C&S [test to find germs & the type of antibiotics they respond to]) for one of three sampled residents (Resident 23) per physician's orders. This deficient had the potential to result in the delay of the appropriate instructions needed from the physician to prevent infection and hospitalization . Findings: A review of Resident 23's Admission Record indicated the facility admitted Resident 23 on 7/3/2023 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), personal history of transient ischemic attack (TIA - a temporary blockage of blood flow to the brain), and cerebral vascular accident (CVA- Stroke) without residuals, and hypertension (HTN - elevated blood pressure). A review of Resident 23's Minimum Data Set (MDS - a resident assessment tool) dated 1/10/2025, indicated Resident 23 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 23 required extensive staff assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 23's change of condition (COC -a sudden deviation from person/patient's baseline in physical, cognitive, behavioral or function) effective 9/12/2024 at 2:48 p.m., indicated Licensed Vocational Nurse (LVN) documented that on 9/12/2024 Certified Nursing Assistant (CNA) informed LVN that Resident 23 was aggressive/combative during ADL care. The COC indicated that on 9/12/2024 at 2:40 p.m., the LVN relayed Resident 23's condition to the physician who gave an order to collect a urine sample for UA, C&S via straight catheter. A review of the physician order dated 9/15/2024 at 11:04 a.m., indicated transfer to General Acute Care Hospital (GACH) for further evaluation and treatment possible Urinary Tract Infection (UTI-an infection of the urinary tract, which includes the kidneys, ureters, bladder, and urethra). During a concurrent interview and record review on 2/9/2025, at 8:45 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 23's electronic chart was reviewed. RNS 1 stated that the facility's process for an order for a routine (a standard or regular way of doing something) urine sample collection, was that the facility needs to attempt collection of the urine sample three times and if not successful, then they need to notify the doctor. RNS 1 stated the COC on 9/12/2024 indicated that Resident 23 was aggressive and combative while performing ADL care. RNS 1 stated aggressiveness and combativeness maybe a sign (something a doctor, or other person, notices) and symptoms (is what a person/patient feels) of a UTI and if the urine sample was not collected, there would not be any lab results to treat the resident. RNS 1 further stated if the UTI was left untreated, it may lead to sepsis (a life threatening blood infection) and possibly prolonged hospitalization . RNS 1 stated there was no documented evidence that Resident 23's physician was notified when the facility failed to collect the urine sample after three attempts. During an interview with the Director of Nursing (DON), on 2/9/2025, at 4:04 p.m., the DON stated that the urine sample was supposed to be collected as soon as possible when the order was received. The DON stated if the urine sample was not able to be collected after trying three consecutive shifts, then the physician needs to be notified. The DON stated a UA, C&S is a urine sample that is ordered when a resident is suspected of having a UTI. The DON further stated if a UTI was left untreated, it could lead to sepsis. A review of the facility's policy and procedures (P&P), titled, Refusal of Treatment revised 1/1/2012, the P&P indicated, Procedure . IV. The attending Physician will be notified of refusal of treatment in a time frame determined by the resident's condition and potential serious consequences of the refusal. VI. When the residents refusal brings about a significant change in the resident's condition, a reassessment is made, and new information is incorporated into the residents care plan.

Based on interview and record review, the facility failed to provide outside services as required by physician orders in accordance with the facility's policy and procedures (P&P) titled Referral to Outside Services revised on 12/1/2013, by failing to refer one of four sampled residents (Resident 6) to an audiologist (a healthcare professional that specializes in evaluating and treating hearing problems, like hearing loss). This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 6. Findings: A review of Resident 6's Admission Record indicated the facility admitted Resident 6 on 11/23/2024 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), generalized weakness (a feeling of weakness in most parts of the body), and adult failure to thrive (a noticeable decline in health). A review of Resident 6's physician order dated 11/23/2024, indicated audiology (a medical study of hearing and balance, and treatment of related disorders) consult with follow up treatment as indicated. A review of Resident 6's History and Physical (H&P -a physician's examination of the patient) dated 11/25/2024 at 10:46 a.m., indicated .past medical history . hard of hearing. A review of Resident 6's Minimum Data Set (MDS - a resident assessment tool) dated 11/30/2024, indicated Resident 6 had mild cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 6 required extensive staff assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The same MDS further indicated Resident 6 had moderate difficulty with hearing and severely impaired vision. During an interview with Certified Nursing Assistant (CNA) 1, on 2/8/2025, at 2:21 p.m., CNA 1 stated Resident 6 was hard of hearing. CNA 1 further stated that the facility staff had to go very close to Resident 6's ear and speak very loud for Resident 6 to hear. During a concurrent interview and record review, on 2/9/2025, at 10:18 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 6's electronic chart was reviewed. RNS 1 stated Resident 6 had a referral to audiology on 11/23/2024 however, there was no documented evidence in Resident 6's chart that the resident was seen by audiology. RNS 1 further stated that social services was responsible for making the appointment. During a concurrent interview and record review, on 2/9/2025, at 11:09 a.m., with the Social Services Director Interim (SSDI), Resident 6's electronic chart was reviewed. SSDI stated, facility process was that when there was a physician's order for referral to ancillary (extra or supporting services that are added onto the main service) services, the referral to the requested specialty was sent the day of admission or the day that the order was received. SSDI stated Resident 6 had an order for audiology consult on 11/23/2024 however, there was no documented evidence that a referral to audiology was made. SSDI stated Resident has hard of hearing and has a hard time hearing the staff which may lead her to get frustrated. The SSDI confirmed and stated that it had been 13 weeks since the order was given. During an interview with the Director of Nursing (DON), on 2/9/2025, at 4:14 p.m., the DON stated that the facility's process for an audiology or ancillary order, was that the social services was notified, the social services then notifies the audiologist of the order right away. The SSDI then puts the resident on the audiology or ancillary list and the resident will be seen when the audiologist comes into the facility. The DON further stated if the audiologist was not notified of the referral order, there will be a delay in the care and the evaluation of the resident. The DON further stated delaying the evaluation of Resident 6 would ultimately affect the overall communication with the resident, and the resident may end up feeling depressed (sadness, hopeless). A review of the facility's policy and procedures (P&P), titled, Referral to Outside Services revised 12/1/2013, the P&P indicated, To provide residents with outside services as required by physician orders or the care plan .The Director of Social Services coordinates the referral of residents to outside agencies/programs to fulfill resident needs for services not offered by the Facility .

Based on interview, observation, and record review, the facility failed to maintain a safe, functional and comfortable environment for one of six sampled residents (Resident 4), by failing to ensure the exit pathway was clear of geriatric (relating to old people, especially with regard to their healthcare) recliner chairs (geri-chair - large, padded chairs with wheeled bases, and are designed to assist seniors with limited mobility) and clutter. This failure had the potential to place Resident 4 at risk of fire hazards injury and accidents. Findings: A review of the Admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including pneumonia (lung infection that inflames air sacs with fluid or pus), acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), hemiplegia and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left dominant side. A review of Resident 4's Minimum Data Set (MDS - resident assessment tool) dated 12/20/2024, indicated Resident 4's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 4 required maximal to total dependent from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent observation and interview with Resident 4 on 2/7/2025 at 7:13 p.m., Resident 4 stated, her exit door pathway is obstructed with geri-chairs and it's blocking her view to the outside. Resident 4 stated, she asked the staff to have it move because she's scared that if they need to evacuate her due to fire, it will be blocking the way, and she also feels uncomfortable because she doesn't like how it's blocking her view. Observed six geri-chairs outside her door which completely blocked the exit pathway. During an interview with Maintenance Supervisor (MS) on 2/8/2025 at 11:40 a.m., MS stated, they put the geri-chair outside Resident 4's room because of the recent rains. MS stated, he was aware of Resident 4's complaint about the geri-chair and how it is blocking the pathway but he has not moved the equipment away. MS stated the exit pathway is not a storage area and it should be clear of any equipment. During an interview with Director of Nursing (DON) on 2/9/2025 at 6:01 p.m., DON stated, the exit pathway should be clear in case of fire, earthquake and any emergency. DON stated, resident might feel unsafe when the exit pathway is blocked and obstructed. A review of the facility's policy and procedure (P&P) titled, Resident Rooms and Environment, reviewed on 6/20/2024, the P&P indicated, The facility provides residents with a safe, clean, environment, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. A review of the facility's P&P titled, Resident Safety, reviewed on 6/20/2024, the P&P indicated, Purpose: To provide a safe and hazard free environment . Any facility staff member who identifies an unsafe situation, practice or environment risk factor should immediately notify their supervisor or charge nurse.

Based on interview and record review, for one of three sampled residents (Resident 2), the facility failed to: 1. Provide behavioral management care and continuous 1:1 sitter (one person designated to always remain with the resident while assigned) monitoring and supervision to prevent accident for Resident 2 who was on 5150 hold (a 72-hour long involuntary treatment hold in a hospital or mental health facility) for danger to others and gravely disabled a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter). 2. Ensure Resident 2 received an accurate behavioral and mental evaluation after Resident 2 attempted to elope (a patient leaving a facility without notice), had aggressive behavior, and had a fall incident on 2/19/2023. 3. Notify the attending physician (MD 1-Medical Doctor), psychiatrist (MD 2), or the facility's medical director (MD) of Resident 2's aggressive and unmanageable behavior in a timely manner. Resident 2 was not admitted to any General Acute Care Hospital (GACH) due to 5150 hold on 2/17/2023 and returned to the facility on [DATE]. 4. Facilitate transfer of Resident 2 to a facility that could provide the appropriate level of care. 5. Conduct Interdisciplinary Team (IDT - a group of professionals with different functional expertise working toward a common goal) to discuss plan of care regarding Resident 2 on 5150 hold and the Resident 2's aggressive behavior. These deficient practices resulted in Resident 2 falling and hitting his head on the concrete (floor) at the facility, sustaining a head injury, and was transferred to GACH 3 for further evaluation on 2/19/2023, where Resident 2 was diagnosed with left side large subdural hematoma (a pool of blood collecting between the brain and its outermost covering), and an eight centimeter (cm- unit of measurement) right sided scalp (head) laceration (a pattern of injury in which blunt forces result in a tear in the skin and underlying tissue). Resident 2 was admitted in the intensive care unit (ICU- is a designated area of a hospital facility that is dedicated to the care of patients who are seriously ill), intubated (a tube inserted either through the mouth or nose and into the airway to aid with breathing), and connected to a ventilator (a respirator- a machine used to help a patient breathe). On 3/9/2023, at 6:50 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Director of Nursing (DON) and the facility's Manager because of the seriousness related to the facility's failure to: 1. Provide care and continuous supervision to prevent accident for Resident 2 who was on 5150 hold (a 72-hour long involuntary treatment hold in a hospital or mental health facility). 2. Notify MD 1, MD 2, or MD 3 of Resident 2's aggressive and unmanageable behavior in a timely manner. 3. Transfer Resident 2 to a facility that could provide the appropriate level of care. 4. Develop and implement policy and procedures on 5150 hold. 5. Conduct Interdisciplinary Team to discuss plan of care regarding Resident 2 on regarding 5150 hold and the aggressive behavior. On 3/10/2023, at 5:29 p.m., the facility provided acceptable IJ Removal Plan (interventions to correct the deficient practice). While onsite, the survey team confirmed implementation of the IJ corrective actions through observation, interview, and record review, and the SSA removed the IJ in the presence of the DON and Facility Manager On 3/10/2023, at 5:29 p.m. A review of the facility's IJ removal plan included the following: The DON initiated an audit of current residents to identify other residents with ongoing aggressive behavior or exhibiting behaviors that place danger to themselves or others. No other residents were identified. The DON/Designee initiated an in - service education to the staff regarding Behavior Management, 5150 Process, Physician Notification, Fall Management, and documentation. The in - service will also include coordination and communication between the transferring and receiving facilities. This in -service will be completed by 3/17/23. Staff on leave or unscheduled will receive education upon return to work. This in -service will be provided monthly for 3 months and as warranted based on identified needs. Staff understanding of the education will be validated by a post-test. The [NAME] President of Behavioral Health and Social Services was scheduled to provide training to the staff related to Behavior Management, 5150 Process, Physician Notification, Documentation, and coordination and communication between the transferring and receiving facilities. During daily clinical meetings on Monday to Friday, the DON/Designee and IDT will conduct a review and audit of current residents with changes of condition related to aggressive behavior to ensure that adequate care and supervision is provided, and the attending physician or the psychiatrist is notified timely. Any concerns identified will be addressed immediately. The Administrator and DON will be responsible in monitoring and sustaining compliance. The Director of Nursing will present the results of the changes of condition related to Aggressive Behavior Audit to the Quality Assurance and Performance Improvement Committee for review monthly for the next three months and quarterly thereafter. The Administrator notified the Medical Director of the facility's current issues on F689, aggressive behavior management, and fall incident with injury. The Medical Director will visit the facility for review and actions as warranted, related to current QAPI (Quality Assurance and Performance Improvement). Findings A review of Resident 2's Admission Record indicated the facility originally admitted Resident 2 on 1/10/2023 and readmitted Resident 1 on 2/13/2023 with diagnoses including type 2 diabetes mellitus (a long term condition that causes an impairment in the way the body regulate and uses sugar), end stage renal disease (ESRD - a medical condition in which a person's kidneys stop functioning permanently), dependance on renal dialysis (a process of removing excess water solutes and toxins from the blood in people whose kidneys can no longer perform these functions naturally), history of falls, major depressive disorder( a mental condition characterized by a persistently depressed mood and long term loss of pleasure or interest in life), hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and hemiparesis (weakness or the inability to move on one side of the body), and cerebral infarction (brain tissue death as of lack of circulation to the brain tissue from a clotted blood vessel) affecting the left side. A review of Resident 2's history and physical (H&P) completed by MD 1 dated 1/16/2023, indicated the facility admitted Resident 2 after a fall that resulted in left knee pain and a left femur fracture (break of the thigh bone), and Resident 2 had left lower extremity (LLE - left leg) brace (a device that supports or holds in correct position a part of the body). The H&P indicated Resident 2 had the capacity to understand and make decisions and to monitor laboratory results and obtain psychiatry (medical specialty devoted to the diagnosis, prevention, and treatment of mental conditions) consult for Resident 2. A review of Resident 2's Minimum Data Set (MDS - a standardized assessment ability to make decisions of daily living) was moderately impaired. The MDS indicated Resident 2 did not have any physical or verbal behaviors directed towards staff and did not wander or attempt to leave the facility. The MDS indicated Resident 2 required extensive one person assist for bed mobility, dressing, toilet use and personal hygiene, used a wheelchair for mobility, and did not ambulate (walk). A review of Resident 2's at risk for fall secondary to generalized weakness, gait (a manner of walking) problem, . hemiplegia and hemiparesis, muscle weakness, and history of fall care plan initiated 2/7/2023, indicated Resident 2 had an actual fall on 2/6/2023 and 2/14/2023. The interventions included to determine and address causative factors of fall and monitor/document/report . change in mental status, new onset . agitation times 72 hours to MD (medical Doctor). A review of Resident 2's nursing progress notes dated 2/14/2023 timed at 9 p.m., indicated Licensed Vocational Nurse 1 (LVN 1) documented Resident 2 was agitated and attempted to hit staff members, was screaming and shouting get out of my way, I'm leaving the facility. Resident 2 was destructive, grabbed any available item to throw at staff, and did not listen to staff. A review of Resident 2's change in condition (COC) dated 2/14/2023 timed at 10:50 p.m., indicated Resident 2 had a witnessed fall, placed himself on the ground, was insisting to go home, . inability to walk and care for himself. The COC further indicated MD 1 notified and X-ray ordered for the right hip, right shoulder, sacrum (triangular bone in the lower back formed from fused bones between the two hip bones), coccyx (small triangular bone at the base of the spine) and Resident 2 to receive Ativan 0.5mg (milligrams- unit of measurement) one time only for aggressive behavior. A review of Resident 2's Xray request dated 2/14/2023, indicated Resident 2 refused Xray to the right hip, right shoulder, sacrum, and coccyx on 2/15/2023 at 12:37 a.m. A review of Resident 2's at risk for elopement care plan initiated 2/15/2023, indicated Resident 2 verbalized wanting to go home, was yelling, throwing things, and refusing medications. Interventions included to monitor Resident 2's location every two hours and document behavior of trying to leave the facility. A review of Resident 2's nursing progress notes dated 2/15/2023 timed at 10 a.m., indicated the Director of Social Services (DSS) documented Resident 2's family member 1 (FM 1) was notified of Resident 2's behavior and attempting to leave the facility. A review of Resident 2's physician order dated 2/15/2023 timed at 9:54 p.m., indicated to transfer Resident 2 to GACH 1 for aggressive behavior. A review of Resident 2's nursing progress note dated 2/15/2023 timed at 11:34 p.m., indicated LVN 1 documented Resident 2 was agitated, and the police was called because Resident 2 was attempting to hurt staff members. The nursing progress note indicated Resident 2 will be transferred to GACH 1 for mental evaluation per MD 1's order. A review of Resident 2's nursing progress note dated 2/16/2023 timed at 11:49 a.m., indicated MD 1 cancelled transfer to GACH 1 and stated MD 2 would go to the facility and evaluate Resident 2. A review of Resident 2's physician progress note dated 2/16/2023, indicated MD 1 documented Resident 2 gets easily agitated/anger/irritable, had poor coping skills, and paranoid ideations (thought processes involving persistent suspiciousness and beliefs of being persecuted, harassed, or treated unfairly by others) and to increase Lexapro (a medication used to treat certain mental/mood disorders) and start Seroquel (a medication used to treat certain mental/mood disorders). A review of Resident 2's COC evaluation form dated 2/17/2023 timed at 7:30 a.m., indicated Resident 2 displayed aggressive behaviors evidenced by yelling and throwing items towards staff members, refused to take insulin (a medication that lowers blood sugar level in the blood) and morning medications and MD 1 was notified on 2/17/2023 at 8:10 a.m. MD 1 ordered to transfer Resident 2 to an unnamed GACH/health facility. A review of Resident 2's Application for 72 hour Detention for Evaluation and Treatment completed by a police officer dated 2/17/2023, indicated at approximately 8:15 a.m., officers responded to a rapid call at . regarding a male patient (Resident 2) very aggressive, throwing items at nursing staff. Upon arrival we (officers) observed subject (Resident 2) yelling and throwing items inside his room. Subject yelled that it was no need for him to stay at the above facility . Subject must have dialysis x3 a week . suffers from depression and his condition has been deteriorating. Based on . mental condition, not realizing he needs . officers placed subject on 5150 hold for danger to others and gravely disabled adult. A review of Resident 2's nursing progress note dated 2/17/2023 timed at 8:25 a.m., indicated LVN 2 documented Resident 2 was agitated, cursing at staff, and throwing objects toward staff. MD 1 was notified and ordered to transfer Resident 2 to GACH 1 on a 5150 hold. The nursing progress note indicated police were called, arrived, wrote a 5150 hold for Resident 2, and remained with Resident 2 until transportation arrived on 2/17/2023 at 10:20 a.m. Resident 2 was transferred to GACH 2. A review of Resident 2's physician order dated 2/17/2023 timed at 8:52 a.m., indicated to transfer Resident 2 on 5150 hold due to danger to others and danger to self. A review of Resident 2's nursing progress note dated 2/17/2023 timed at 11:30 a.m., indicated LVN 3 documented, she called report to GACH 1 regarding Resident 2. However, during the report call, LVN 3 was informed by GACH 1 staff that GACH 1 could not accept Resident 2 because Resident 2 was on a 5150 hold and LVN 3 informed MD 1. The nursing progress note further indicated MD 1's case manager contacted/communicated with LVN 3 and confirmed that Resident 2 should be transferred to GACH 2. Resident 2 was transferred to GACH 2 on 2/17/2023. A review of Resident 2's nursing progress note dated 2/17/2023 timed at 1:33 p.m., indicated LVN 3 documented, GACH 2 contacted and informed the facility that GACH 2 was not expecting Resident 2 and that Resident 2 will be returning to the facility. Resident 2 returned to the facility on [DATE] at 2:25 p.m., was agitated, yelling, and continued to throw items at staff. A review of Resident 2's nursing progress note dated 2/17/2023 at 8:36 p.m., indicated LVN 7 documented, that LVN 7 met with FM 1 regarding Resident 2's behavior and that the facility assigned Resident 2 a 1:1 sitter for safety and supervision to prevent accident for Resident 2 who was on 5150 hold. A review of Resident 2's nursing progress note dated 2/18/2023 at 10:28 a.m. and at 4:24 p.m., indicated LVN 4 documented, Resident 2 remained aggressive, tried to open the facility's hallway door but was stopped by staff. The Police was called because Resident 2 was a risk to harm self and others, and that MD 1 was informed. The nursing progress note did not indicate if MD 1 gave any orders or recommendations. A review of Resident 2's physician order dated 2/19/2023 timed at 1:29 p.m., indicated to transfer Resident 2 to GACH 4 due to severe backache and mental evaluation. However, Resident 2 refused to go. A review of Resident 2's nursing progress note dated 2/19/2023 timed at 6:57 a.m., indicated LVN 1 documented, AGAIN!!!! resident becomes more agitated trying to hurt staff screaming and shouting asking for the police. LVN 1 further documented the sitter (1:1) could not handle the situation and please have this resident (Resident 2) out of this facility. We are in great danger there are three of us trying to stop this resident from hurting staff. The nursing progress note did not indicate if LVN 1 notified MD 1 or MD 2 of Resident 2's aggressive and unmanageable behavior. A review of Resident 2's nursing progress note dated 2/19/2023 timed at 4:47 p.m., indicated LVN 5 documented Resident 2 was at the nursing station sitting in wheelchair yelling and throwing objects at staff. The nursing progress note further indicated Receptionist 1 (RCPT 1) left the facility through the front door and Resident 2 in his wheel chair, attempted to follow RCPT 1. Resident 2 began to kick the door and tried to exit the facility. Resident 2 threatened RCPT 1 and told RCPT 1 that he was going to kick RCPT 1 down the stairs when Resident 2 got up from his wheelchair. The nursing progress note indicated LVN 5 left to call 911 and upon return, found Resident 2 on the ground at the bottom of the steps outside the facility on 2/19/2023 at 4:53 p.m. LVN 5 documented Resident 2 was alert with moderate bleeding noted to the back side of his (Resident 2) head and LVN 3 applied a pressure (to stop bleeding) dressing. The paramedics arrived on 2/17/2023 at 4:59 p.m. and transported Resident 2 to GACH 3. A review of Resident 2's GACH Department of Emergency (ED) Medicine Treatment record dated 2/19/2023 timed at 7:49 p.m., indicated Resident 2 . sent over for trip and fall with confusion. He had a large bleeding laceration to his right occiput (back of head). Patient states he was in a bicycle accident. He is not clear as to what happened to him. He has no significant extremity (leg or arm) pain. Patient (Resident 2) sent over from the facility . He has been combative and assaulting staff over the past several days, disruptive, and . he fell down and hit his head . The ED notes indicated Resident 2's blood pressure (BP) on 2/19/2022 was recorded as follows: - 178/73 Mmhg (millimeters of mercury - unit to measure pressure). Reference range is between 90/60 Mmhg and 120/80 Mmhg) - 187/76 Mmhg at 7:22 p.m. The ED notes further indicated He (Resident 2) is in acute distress and has bleeding laceration eight cm long and five millimeters (mm- unit to measure distance) to the right occipital region . Patient (Resident 2) is awake and not oriented to date, time or place . The ED notes indicated emergent consent was obtained, skin repair (to laceration) was completed with sutures (stitches- is a medical device used to hold body tissues together and approximate wound edges after an injury or surgery) after administering bupivacaine 2.25% (anesthesia - medication causes a loss of feeling or awareness caused by drugs or other substances). The ED notes indicated computed tomography (CT- multiple x-rays of the head, including the skull, brain, eye sockets, and sinuses) brain result date of 2/19/2023, indicated post (after) traumatic hemorrhages (bleeding). The ED notes indicated Resident 2 received desmopressin (DDAVP - medication to treat diabetes insipidus [a rare disorder that causes the body to make too much urine]). The ED notes indicated Resident 2 was on Aspirin (medication that reduces pain, fever, inflammation, and blood clotting) and Plavix (medication that prevents platelets [blood cells] from sticking together to form an unwanted blood clot[s]). The ED notes indicated Resident 2 was admitted to neurosurgery ICU (unit devoted to the care of patients with immediately life-threatening neurological problems). The ED notes indicated the diagnostic impression included . subdural hematoma (a pool of blood between the brain and its outermost covering) with a midline shift (when something pushes this natural centerline of the brain to the right or to the left which may occur following traumatic brain injury) . A review of Resident 2's GACH CT Brain dated 2/19/2023 and timed at 7:13 p.m., indicated There is a Left frontoparietal subdural hemorrhage measuring 1.9 cm in thickness and with intraventricular (clear fluid filled cavity in the brain) extension. There is right lateral ventricular extension of hemorrhage involving the mid right lateral ventricle and occipital horn. Rightward midline shift measuring 3 mm. A review of Resident 2's GACH CT Brain dated 2/20/2023 and timed at 1;40 p.m., indicated Slight midline shift to the right is seen measuring 1-2 (one to two) mm . There is a slight increase in intraventricular blood products noted. On 2/22/2023 at 8:23 a.m., Resident 2's FM 1 stated Resident 1 has been very aggressive, cursing, tried to hit staff and was throwing objects. It just started this past week. He went to the hospital on 2/11/2023 and on 2/12/2023 he was different and was more agitated. FM 1 stated Resident 1 was never happy with the staff and did not want to be in the facility. FM 1 stated Resident 1 was super aggressive on 2/17/2023 and was throwing objects at staff and his roommate. They (facility) tried to place him on 5150 hold. On 2/22/2023 at 12:39 p.m., during an interview, LVN 3 stated the police were at the facility on 2/17/2023 because Resident 2 was aggressive and throwing things at staff. LVN 3 stated LVN 2 informed her there was an order dated 2/17/2023 timed at 8:52 a.m., to transfer Resident 2 to a GACH on a 5150 hold. On 2/22/2023 at 3:15 p.m., during an interview, LVN 2 confirmed and stated she received an order from MD 1 on 2/17/2023 to transfer Resident 2 to GACH 1 on a 5150 hold. LVN 2 stated she called GACH 1 to give report and GACH 1 case manager told her that GACH 1 did not accept patients (residents) on 5150 hold and suggested to LVN 2 to send Resident 2 to GACH 2. LVN 2 stated GACH 1 case manager told her and the DON that it was ok to send Resident 2 to GACH 2 without calling report about Resident 2. LVN 2 confirmed and stated she did not call report to GACH 2 prior to sending Resident 2. On 2/24/2023 at 10:58 a.m., during an interview, LVN 6 stated on 2/19/2023 at 4:40 p.m. he was passing (administering) medications when witnessed Resident 2 throw a cup of juice from his dinner tray near the facility's main entrance by the receptionist desk. Resident 2 had no 1:1 sitter at this time. LVN 6 stated he continued to pass medications and 10 minutes later, LVN 5 called him to help at the facility's front entrance. LVN 6 stated he witnessed a CNA leave through the facility's front door and Resident 2 attempted to exit as well. LVN 6 stated Resident 2 was in a wheelchair, had a leg brace on the left leg, was kicking the door, making verbal threats and attempting to hit LVN 6 by swinging his (Resident 2) elbows. LVN 6 stated he was behind Resident 2's wheelchair and was trying to stop Resident 2 from exiting the building. LVN 6 stated Resident 2 told the staff member who was outside the building, that he (Resident 2) was going to get up out of his chair and kick her down the stairs if she did not get out of his (Resident 2) way. LVN 6 stated he then instructed the staff member to move out of the way and LVN 5 simultaneously stepped away to call for help. LVN 6 further stated Resident 2's wheelchair was lodged (stuck) in the doorway and he could not get on the other side of the doorway. LVN 6 stated that within the next five to six seconds, Resident 2 stood up and grabbed the steps handrail outside the main door entrance, walked down six steps unassisted to the ground level, turned to the right, fell and hit his head on the concrete. LVN 6 stated Resident 2 was bleeding from the back of the head, was alert and answering questions, and the paramedics arrived three minutes later and transported Resident 2 to GACH 3. On 2/24/2023 at 5:01p.m., during an interview, LVN 5 stated Resident 2 had complained of back pain earlier in the day on 2/19/2023 and was supposed to transfer to GACH 1 for the back pain and a psychiatric evaluation. LVN 5 stated she witnessed Resident 2 attempt to go out of the facility after a staff member exited the building. LVN 5 stated Resident 2 was in his wheelchair and was kicking the door and she called LVN 6 to come and assist with Resident 2. LVN 5 stated she then went to the nursing station to call 911. LVN 5 stated by the time she got back to the front door; Resident 2 was on the ground at the bottom of the steps, and that everything happened quickly. On 2/25/2023 at 11a.m., during a telephone interview, MD 2 confirmed and stated that on 2/16/2023, she saw Resident 2 because the facility staff were concerned about Resident 2's behavior. MD 2 stated Resident 2 was showing paranoid behavior, was very aggressive and the staff were afraid of Resident 2 and thought Resident 2's behavior was a manifestation of depression. MD 2 further stated Resident 2 later agreed to take medication to control his (Resident 2) mood, increased the dose of Lexapro, and started Resident 2 on Seroquel. MD 2 further stated on 2/16/203, the facility's evening staff (unnamed) informed her that Resident 2 was aggressive again and was trying to hurt the staff members. MD 2 stated she asked the staff if Resident 2 was administered the aforementioned the medications but could not recall the staff member's response. MD 2 stated she remembered she told the facility's staff to send Resident 2 to GACH 1 because she was able to admit and visit patients there. MD 2 stated the facility contacted her on 2/17/2023 and reported that Resident 2 was agitated still and had refused to go to GACH 1. MD 2 stated the facility asked for her assistance to transfer Resident 2 to a GACH on a 5150 hold ordered by MD 1. MD 2 confirmed and stated she gave a nurse (unidentified) at the facility, phone numbers to four different GACHs to send a psychiatric evaluation team (PET - a unit that provides psychiatric evaluations of suspects who appear to be in some form of mental crisis) staff to evaluate and place Resident 2 on a 5150 hold. MD 2 stated a few hours later the facility contacted and informed her that GACH 2 was sending Resident 2 back to the facility. MD 2 stated she was unaware that the facility had transferred Resident 2 to GACH 2. MD 2 stated the order to transfer Resident 2 to GACH 2 was appropriate because Resident 2 was agitated and had other medical conditions including hemodialysis (a treatment to filter wastes and water from your blood). MD 2 stated she was unaware GACH 2 did not offer dialysis services, unaware a PET team did not evaluate Resident 2 at the facility and was also unaware the police placed Resident 2 on a 5150 hold. MD 2 stated she assumed GACH 2 accepted Resident 2 because Resident 2 was already on 5150 hold. On 2/27/2023 at 10:47 a.m., during an interview and record review with the DON, Resident 2's transfer order on 5150 dated 2/17/2023 was reviewed. The DON confirmed and stated the facility did not have a policy and procedures on 5150 hold. On 2/27/2023 at 1:31 p.m., during an interview, MD 1 confirmed and stated the facility notified him that Resident 2 was not transferred to GACH 1 on 2/17/2023 because GACH 1 did not accept residents on 5150 hold. MD 1 stated he then instructed the facility to contact MD 2 to assist with Resident 2's transfer. MD 1 also confirmed and stated the facility did not notify him of Resident 2's transfer to GACH 2 on 2/17/2023. MD 2 stated he was not familiar with GACH 2 and did not practice at GACH 2. MD 2 stated, I just saw him (Resident 2) in the hospital in Intensive Care Unit (ICU - a designated unit of a hospital dedicated to care for patients who are seriously ill) on a ventilator. On 3/9/2023 at 4:55 p.m. the DON confirmed, and stated Resident 2 returned to the facility on [DATE] and had a copy of the 5150 hold. The DON stated she informed MD 2 of Resident 2's return and MD 2 instructed the DON to continue to encourage Resident 2 to take Seroquel and Lexapro. The DON stated she was not sure because they (the facility) have never been in this situation when asked what the facility should have done when Resident 2 returned still on 5150 hold. The DON confirmed and stated the facility's IDT team did not meet to discuss Resident 2's plan of care or how to manage Resident 2's behavior after Resident 2 returned from GACH 2 on a 5150 hold. The DON stated she informed only MD 2 that Resident 2 had returned to the facility and that MD 2 did not give further orders. On 3/10/2023 at 2:36 p.m., during an interview, the facility's MD stated the facility should have contacted him to assist with Resident 2's transfer because the MD is affiliated with GACH 3. The MD further stated, after reviewing the facility's documentation regarding Resident 2's incident, the facility needed to educate staff on 5150 hold, how to the manage residents with aggressive behavior, and revise some policies. The MD stated, This (Resident 2's incident) could have been avoided if the facility called (contacted) me. A review of the facility's policy and procedures titled Resident Safety, revised on 4/15/2021, indicated a resident will be evaluated on admission, quarterly and whenever there is a change in condition to identify circumstances that pose a risk for safety and wellbeing of the Resident. The IDT will establish a person-centered observation or monitoring systems for the resident to address the identified risk factors identified. A review of the facility's policy and procedures titled Behavior Management revised on 1/16/2022, indicated the facility will ensure that when a resident displays a mental disorder, psychosocial adjustment difficulties (e.g., crying, yelling, hitting, etc.) ., they will receive appropriate treatment to address the problem or attain the highest practicable mental and psychosocial wellbeing. Efforts will be made by the Interdisciplinary Team (IDT) to implement non-pharmacological interventions to alleviate behavior symptoms before initiating any psychoactive medications. B). The IDT will convene to discuss care plan interventions and document the IDT recommendations and interventions in the medical record. IV). Drug interventions: A). If the attending physician determines that the resident requires psychoactive medication(s), they will follow the facilities informed consent policy .

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who was at risk of falls and was on a low air loss mattress (LALM, an air mattress covered with tiny holes designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture as well as to relieve pressure), was provided side rails in bed for safety and prevent falls as requested by Resident 1's Responsible Party 1 (RP 1) as Resident 1 was able to move in bed and could roll out of bed. As a result, on 5/17/2022 at 1:30 p.m., two days after admission to the facility for rehabilitation, Resident 1 fell from bed onto the floor, requiring transfer to General Acute Care Hospital 1 (GACH 1) by Emergency Medical Services (EMS, paramedics). Resident 1 was diagnosed with acute cervical (neck) facture (bone break) of C5-C6 vertebrae (the neck bones number 5 and 6) and laceration (cut) on the right side of the forehead. After fracture repair surgeries, Resident 1 remained quadriplegic (paralyzed [unable to move] from the neck down and required a [CONDITION(S)] (an incision in the windpipe made to relieve an obstruction to breathing) and needed a ventilator (a breathing machine that moves air in and out of the lungs) for breathing. Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident, a [AGE] year-old female, from GACH 1 on 5/14/2022, with diagnoses including non-traumatic intracerebral hemorrhage (stroke, bleeding into the brain) in cerebellum (back section of the brain), facial weakness, [CONDITION(S)] (paralysis [inability to move] one side of the body), Stage IV (four) pressure ulcer (also named pressure sores or bedsores, deep wound that involves muscle, tendons, ligaments, and bone) of the sacrum (the portion of the spine between the lower back and tailbone), end stage [CONDITION(S)] ([CONDITION(S)], total loss of kidney function), and dependence on renal [CONDITION(S)] (a treatment that takes over a person ' s kidney function when the kidney stops working). A review of Resident 1's Inter-Facility Transfer Report sent by GACH 1 with the resident on admission, dated 5/14/2022, indicated the resident was a high fall risk. A review of Resident 1's nursing Clinical Admission Evaluation, dated 5/14/2022, indicated the resident had impaired range of motion (ROM, joint movement) on both arms and both legs. A review of Resident 1's Fall Risk Evaluation, dated 5/14/2022, indicated Resident 1 scored 9 for fall risk. The fall risk evaluation also indicated the resident had decreased muscular coordination and use of assistive devices (cane, wheelchair, or walker) for gait and balance. However, Resident 1's fall risk evaluation did not include any documentation on how to interpret the score for fall risk. A review of the facility's undated blank copy for Fall Risk Evaluation, indicated If the total score is 10 or greater, the resident should be considered at High Risk for potential for potential falls. However, the fall risk evaluation form did not indicate how to interpret scores less than 10. A review of the Physician's Order for Resident 1, dated 5/15/2022, indicated the use of a LALM and verify functioning every shift. A review of Physician's Order for Resident 1, dated 5/16/2022, indicated to provide the resident physical therapy (PT) and occupational therapy (OT) treatment five times a week for four weeks for therapeutic exercises, bed mobility, transfers, gait/stairs management, A review of Resident 1's PT Treatment Encounter Note, dated 5/16/2022, indicated the resident required fall risk precautions. The PT note did not include the specific fall precautions. A review of Resident 1's OT Treatment Encounter Note, dated 5/16/2022, indicated Resident 1 required fall risk precautions. The OT note did not include the specific fall precautions. A review of Resident 1's OT Treatment Evaluation & Plan of Treatment, dated 5/16/2022, indicated Resident 1 stated being worried about falling. A review of Resident 1's Care Plan, initiated on 5/16/2022, indicated Resident 1 was at risk for falls related to diagnoses. The goals was for Resident 1 not falling through the review date of 8/14/2022. The interventions included placing the bed in the lowest position with LALM and providing a safe environment such as slide fails (side rails) as ordered. A review of Resident 1's Active Orders as of 5/20/2022, did not indicate a physician ' s order for bed side rails. A review of Resident 1's Change of Condition (COC) Evaluation completed by Licensed Vocational Nurse 3 (LVN 3), dated 5/17/2022 and timed at 3:24 a.m., indicated the resident fell from bed at around 1:30 a.m. Resident 1 had blood in the forehead, was helped back to bed. LVN 3 called paramedics and they transferred Resident 1 back to GACH 1. On 6/2/2022 at 2:28 p.m., during an interview, LVN 1 stated Resident 1 did not move but one time she observed the resident leaning towards the left side of the bed so she (LVN 1) repositioned Resident 1 to the middle of the bed. On 6/2/2022 at 3:37 p.m., during an interview, the Maintenance Supervisor (MS) stated on 5/16/2022, he changed Resident 1's regular mattress to a LALM and installed Resident 1's side rails on 5/17/2022 after Resident 1's fall. On 6/2/2022 at 4:19 p.m., during an interview, the Director of Nursing (DON) stated the facility relies on the documentations from the transferring facility to provide care to the resident. The DON stated RP 1 requested on 5/16/2022 to have side rails in the resident's bed and put them up for safety. The DON stated she did not grant RP 1's request because the nursing staff needed to first assess if Resident 1 needed side rails up. The DON stated she believed Resident 1 was unable move in bed without assistance and did not need side rails. On 6/9/2022 at 10:15 a.m., during a telephone interview, Occupational Therapist 1 (OT 1) stated he evaluated Resident 1 on 5/16/2022. OT 1 stated Resident 1 had movements on both sides of her body, but one side was significantly weaker than the other. On 6/9/2022 at 2:00 p.m., during a telephone interview, Speech Therapist 1 (ST 1) stated she evaluated Resident 1 on 5/16/2022, who was able to move from side to side and the bed did not have side rails. ST 1 stated RP 1 pointed out to her on 5/16/2022 that Resident 1 did not have side rails and RP 1 requested side rails up in bed because Resident 1 could move and roll out of bed. ST 1 stated Resident 1's bed should be lowered to the floor or side rails should be applied to the bed. ST 1 stated she facilitated a conversation between RP 1 and the DON on 5/16/2022 and witnessed RP 1 verbalize to the DON about the need of side rail and the DON told him they would take care of it. ST 1 stated anyone with a stroke was at risk for falls. On 6/14/2022 at 10:15 a.m., during a telephone interview, Physical Therapist 1 (PT 1) stated she evaluated Resident 1 on or about 5/15/2022 and the Resident 1 was able to turn from side to side. PT 1 stated Resident 1 needed minimal assistance to get to vertical position (to rise straight up). However Resident 1 declined to stand up because the resident was not comfortable. PT 1 stated it was agreed to try to stand Resident 1 on the next visit. On 6/14/2022 at 3:48 p.m., during a telephone interview, LVN 3 stated on 5/17/2022 at 1:30 a.m., he found Resident 1 on the floor, on the right side of the resident's bed, facing down. LVN 3 stated Resident 1 was on a LALM without side rails. LVN 3 stated LALM are slippery. LVN 3 stated Resident 1 ' s bed was in the lowest position and the LALM was on top of the bed. LVN 3 stated Resident 1 did not move, the resident did not have side rails on the bed, and there were no have floor mats. On 6/14/2022 at 4:27 p.m., during a telephone interview, LVN 4 stated Resident 1 was able to move her upper body. LVN 4 stated she once observed Resident 1's legs positioned towards the edge of the left side of the bed, and she repositioned Resident 1 to the middle of the bed. LVN 4 stated Resident 1 could have benefited from the side rails because of the LALM that are slippery. LVN 4 stated the height of Resident 1's bed was Minimum. Was not high. LVN 4 stated she could not remember if Resident 1's bed had side rails. LVN 4 stated RP 1 did not like that Resident 1's room was All the way at the end. He wanted a room change. Social service has to change rooms. On 7/6/2022 at 12:30 p.m., during a telephone interview, RP 1 stated upon Resident 1's admission to the facility he requested bed side rails up multiple times to prevent the resident from falling out of bed. RP 1 stated Resident 1's bed was narrow and needed bed rails to prevent her from falling. RP 1 stated he requested for bed side rails multiple times but received push back from staff who told him that that they needed a direct order from the doctor to install bed side rails. RP 1 stated he asked the facility staff to read Resident 1's chart from GACH 1 which indicated the resident needed close monitoring. RP 1 stated Resident 1 was still in GACH 1 as of 7/6/2022. RP 1 stated Resident 1 is now quadriplegic and on a ventilator for artificial life support. RP 1 stated he was now placed in a position to pull the plug (remove from life support). RP 1 stated he felt Resident 1 was robbed of her ability to rehabilitate after her miraculous rehabilitation from GACH 1 prior to going to the facility. On 7/18/2022 at 11:44 a.m., during a telephone interview, LVN 3 stated and confirmed Resident 1's neck was not immobilized (to fix/support part of a body part to reduce or eliminate motion) when she was placed back in bed after the fall. A review of GACH 1 Neurocritical Care Attending Addendum note for Resident 1, dated 5/17/2022, indicated the resident had acute cervical spinal cord injury and the four extremities (legs and arms) were flaccid (paralyzed, unable to move) and with complaints of some difficulty breathing. Resident 1 was placed on a ventilator. The neurologist (a physician specialized in the branch of medicine dealing with disorders of the nervous system) documented, At the time of my involvement, the patient ' s condition was critical with high potential for death and/or physiologic deterioration secondary to acute spinal cord injury (and) acute [CONDITION(S)]. A review of GACH 1 Hospitalist Progress Note for Resident 1, dated 5/18/2022, indicated Resident underwent a C6 - C7 Anterior Cervical Discectomy and Fusion (ACDF, a surgery to remove damage disk or bone spurs in the neck), C3 - C7 laminectomy (a spinal surgery that removes a portion of a vertebra called lamina), and C2 - T2 posterior spinal fusion. A review of GACH 1 Hospitalist Progress Note for Resident 1, dated 5/27/2022, indicated Resident 1 underwent [CONDITION(S)] on 5/26/2022. A review of the facility's policy and procedures (P&P) titled, Resident Rights, revised 1/1/2012, indicated the following: 1. The facility will promote and protect the residents' rights. Residents have freedom of choice, as much as possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules and regulations and applicable state and federal laws governing the protection of resident health and safety. 2. State and federal laws guarantee certain basic rights to all residents of the facility. These rights include, but are not limited to, a resident right to .Choose a physician and treatment and participate in decisions and care planning .Voice grievances and have the facility respond to those grievances in a prompt manner. 3. The facility makes every effort to assist each resident in exercising his/her rights by providing the following services: A. The facility's staff encourages residents to participate in planning their daily care routines (including ADLs, activities of daily living) . 4. In order to facilitate resident choices, facility staff will inform (and regularly remind) the resident and family members of the resident's right to self-determination and participation in preferred activities; gather information about the resident's personal preferences on initial assessment and periodically thereafter and document these preferences in the medical record; and include information gathered about the resident's preferences in the care planning process. A review of the facility's P&P titled, Bed Rails, revised 12/4/2020, indicated that it is the facility's policy to review the risks and benefits of bed rails with the resident or resident's representative and obtain informed consent prior to installation. A review of the facility's P&P titled, Fall Management Program, revised on 3/13/2021, indicated the facility will implement a fall management program that supports providing an environment free from fall hazards. The Interdisciplinary Team (IDT) and/or licensed nurse will develop a care plan according to the identified risk factors and root cause(s) per Care Area Assessment (CAA) guidelines. The policy also indicated IDT will initiate, review, and update the Resident ' s fall risk status and care plan at the following intervals: on admission, quarterly, annually, upon identification of significant change of condition, post fall and as needed. A review of an undated LALM Owner ' s Manual provided by the facility, indicated a warning that this device (LALM) is designed to help provide pressure redistribution and may require other equipment. This may include but is not limited to; 1. Bedrails for repositioning and fall prevention .

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of COVID-19 (Coronavirus disease 2019, a highly contagious [MEDICAL CONDITION] infection that spread from person-to-person affecting the respiratory system) for one of three residents (Residents 9) in the Yellow Zone (area of the facility reserved for residents who have been exposed to Covid-19 and are potentially COVID-19 positive but have not yet tested positive for the infection and are to be monitored closely for 14 days) out of a total of 21 residents in the facility, for three Kitchen Staff, and five nursing staff. The facility failed to: a.Ensure Kitchen Staff 1, 2, and 3 donned (put on) Personal Protective Equipment (PPE - protective clothing, goggles, head/shoe covers, mask, gown, gloves or other garments or equipment designed to protect the wearer's body from infection) and performed hand hygiene before entering and exiting the Yellow Zone. b. Ensure that signage indicated the requirement for Hand Hygiene and the use of PPE was visible and prominent at the doors between the facility's Yellow Zone and the assisted living facility (Facility 2) next door, which kitchen staff used to deliver meals between the two facilities. c. Ensure Staff 2 removed her PPE and performed hand hygiene before leaving the room of Resident 9 in the Yellow Zone, and then proceeding to handle items on the medication cart in the hallway of the Yellow Zone. d. Ensure the facility had a functioning Red Zone (an area of the facility reserved for residents who have tested positive for Covid-19, where they are grouped together for 14 days in order to prevent them from spreading Covid-19). e. Ensure staff (Staff 3, Staff 4, Staff 6 and Staff 7) donned N95 particulate respirator masks according to the manufacturer's instructions. An N95 mask is a specialized mask capable of filtering out 95% of particles from the air, thereby protecting the wearer from breathing in those particles, including Covid-19 particles. These deficient practices had the potential to result in the spread of COVID-19 placing all 27 residents in the facility and the staff at risk to be infected with COVID-19 and becoming seriously ill, leading to hospitalization and/or death. On 12/10/2020 at 4:20 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADM), and the Regional Quality Management Consultant (RQMC) for the facility's failure to implement measures to prevent the transmission of COVID-19 infection that threatened the health and safety of the residents and staff. On 12/14/2020 at 3:11 p.m., the IJ situation was lifted after the facility submitted an acceptable Plan of Action (POA, interventions to correct the deficient practices); the surveyor verified and confirmed the implementation of the POA while onsite through observations, interviews and record review. The IJ situation was removed in the presence of the Administrator and Regional Quality Management Consultant. The accepted POA included the following actions: a. In-service education to Kitchen Staff 1, 2, and 3 including all staff on 12/12/2020 regarding infection control prevention with emphasis on regulations pertaining to, proper use of PPE, Hand Hygiene, maintaining a Red Zone where residents who test positive for Covid-19 can be grouped together and cared for such that Covid-19 does not spread to residents who are negative for [MEDICAL CONDITION]. b. Proper signages were posted at the doorway used by the kitchen staff between the facility and the healthcare facility next door. Hand sanitizer and infection control carts with the necessary supplies and PPEs were placed near the doors. On 12/12/2020, In-service education was provided to all staff regarding infection control prevention and proper signage of the Yellow Zone. c. On 12/11/2020, the facility provided in-service education to Staff 2 regarding the proper donning and doffing of PPE and hand hygiene when leaving the rooms of residents in the Yellow Zone. d. The Administrator contacted nurse staffing agencies to acquire additional staff, and enough permanent staff returned from sick leave, such that the facility could provide care for residents who have tested positive for Covid-19, in the facility's Red Zone. -The facility removed the extra beds and equipment that were stored in the rooms of the Red Zone that were meant for residents infected with Covid-19. -The facility ensured that all resident beds of the Red Zone are clean and have linens on them and that the rooms and resident beds are prepared to receive residents who test positive for Covid-19. -The facility ensured that the staff who care for residents of the Red Zone have a bathroom and break area where they can take their breaks without leaving the Red Zone and entering other areas of the facility and possibly spreading Covid-19 to other residents. e. On 12/11/2020 and 12/12/2020, the facility in serviced Staff 3, Staff 4, Staff 6 and Staff 7 regarding proper donning, wearing and doffing of N95 particulate respirator masks, according to the manufacturer's instructions. Findings: A review of the facility's census dated 12/2, 12/8, 12/10, and 12/14/2020 indicated the facility had 21, 12, 11, and 10 residents in-house, respectively. a. During an observation on 12/2/2020 at 1:12 pm, Kitchen Staff 1 (KS 1) and Kitchen Staff 2 (KS 2), entered the facility's Yellow Zone from Facility 2, next door, through the double doors that allow passage between the skilled nursing facility and Facility 2. Upon entrance both kitchen staff did not wash their hands or use hand sanitizer. Kitchen Staff 1 and 2 were observed not wearing PPE (gloves) upon entrance to the Yellow Zone. Both Kitchen Staff were pushing a meal cart in front of them and along a hallway to a nurse's desk where they left the meal cart, touched multiple objects around the nursing station while conversing with other staff, and then walked back down the hallway and exited the facility's yellow zone. Kitchen Staff 1 and 2 did not perform hand hygiene upon exiting the Yellow Zone. During an interview, on 12/2/2020 at 1:19 pm, Licensed Vocational Nurse (LVN) 1 stated Kitchen Staff 1 and Kitchen Staff 2 should have used hand sanitizer or washed their hands when entering the facility. During an observation, on 12/8/2020, at 2:13 pm, Kitchen Staff 3 entered the facility's Yellow Zone from Facility 2, next door, through the same set of double doors that allow passage between the buildings and did not wash his hands or don PPE. Kitchen Staff 3 retrieved a meal cart from the hallway of the Yellow Zone, passed through the double doors again, leaving the facility and entering Facility 2 next door. During observation, a hand sanitizer dispenser was posted near the double doors, Kitchen Staff 3 did not perform hand hygiene or wipe down the meal cart with a cleaning agent upon exiting. b. During an observation on 12/2/2020 at 1:12 pm, near the set of double doors that separated the facility from Facility 2 (next door), there was no signage indicating the need for staff who enter the facility through these double doors, to don or doff PPE, or practice hand hygiene. There was no hand sanitizer or equipment cart of PPE posted near the double doors for staff to use when entering of leaving the facility through the double doors. During an interview, on 12/8/2020 at 2:46 pm, the Administrator (ADM) stated staff who enter the facility's yellow zone from Facility 2 next door should be washing their hands or using hand sanitizer. During an interview on 12/8/2020 at 2:47 pm, the ADM stated and acknowledged that Facility 2 next door to the facility had an ongoing outbreak of Covid-19 amongst its residents and staff. The ADM stated staff passing back and forth between the two facilities to provide kitchen services can spread Covid-19 back and forth between the residents and staff of the facility. A review of a letter written by ADM, dated 12/10/20, indicated, As of November 27 and up until today's date, we have had 24 staff test positive for covid-19. During an interview on 12/17/2020 at 2:53 pm, the Infection Preventionist (IP) agreed Facility 2, next door had an active Covid-19 outbreak, and staff who entered the facility from Facility 2, without washing their hands or wearing PPE, could have exposed the 11 residents of the Yellow Zone to Covid-19. c. During an observation on 12/8/2020 at 2:21 p.m., Staff 2 donned PPE, entered the room of Resident 9, exited the room while still wearing PPE, and approached the medication cart in the hallway. Staff 2 was observed handling items on the medication cart while still wearing gloves and other PPE, and then returned to the room of Resident 9. During an interview on 12/8/2020 at 2:28 pm, Staff 2 stated that she should have removed her gloves and PPE and either washed her hands or used hand sanitizer between leaving the resident room and touching the medication cart or items on the medication cart. Staff 2 stated that not washing her hands can cross contaminate objects with Covid-19 which can then be spread to residents and other staff. A review of a letter written by ADM, dated 12/8/20, indicated, the facility had an outbreak of covid-19 amongst its residents and staff starting on 11/27/20 and since then the facility had a cumulative amount of 27 positive (for Covid-19) residents since 11/27/20. During an interview on 12/17/2020 at 2:53 pm, the Infection Preventionist (IP) stated the staff who did not take off her ppe when she left a residents room and then touched objects on the medication cart, could have contaminated the medication cart which could have exposed other residents in the Yellow Zone to Covid-19 possibly resulting in their hospitalization s and deaths. d. During an observation on 12/10/2020 at 2:35 pm, with the ADM, the facility's red zone consisted of three rooms next to Facility Exit 3. One room had an old, undated and open bottle of liquid nutrition hanging from a pole by a bed and two resident beds had no pillows, sheets or blankets, or other indication whether they were clean or not. Another room that was meant for two residents in it, had three resident beds, none of which had pillows, sheets or blankets or other indications of if they were clean or not. The third room, which was supposed to be for staff that were working in the Red Zone to use as a breakroom, was full of resident beds, a medication cart, and two equipment poles and other forms of equipment. There was no room for a person to stand or sit, or to reach the bathroom. During an interview on 12/10/2020 at 3:38 pm, the ADM stated he did not know why the extra equipment was stored in the rooms of the Red Zone and that extra equipment should not be stored in the resident rooms of the break room. The ADM stated there should not be old, undated and open bottles of liquid nutrition left hanging by a pole beside a resident bed, that the resident beds should have clean pillows, sheets and blankets on them to indicate they were clean and ready for residents. During an interview on 12/17/2020 at 3 pm, ADM stated that the purpose of having a Red Zone is to prevent the spread of Covid-19 to residents who are negative for Covid-19. During an interview on 12/17/2020 at 3:05 pm the IP stated having a functioning Red Zone is important to stop the spread of Covid-19 among residents, but the facility could not maintain a Red Zone and so the Covid-19 negative residents were put at risk for contracting Covid-19. During an interview on 12/17/2020 at 3:10 p.m., ADM stated that the facility did not follow its mitigation plan to obtain additional staff from Nurse Registry agencies, and as a result the facility could not maintain a Red Zone, which could have resulted in Covid-19 negative residents contracting covid-19 from resident who had tested positive for Covid-19. During an interview on 12/17/2020 at 3:13 p.m., DON stated that the facility's mitigation plan does include plans for acquiring additional staff if needed, but the plan was not followed as evidenced by the fact the facility could not keep its Red Zone staffed or care for residents that tested positive for Covid-19, which resulted in the facility transferring Covid-19 positive residents to another facility. During an interview on 12/17/2020 at 3:15 pm, the IP stated that the facility staff are trained to work in the Red Zone, but so many were on sick leave at the same time that the facility did not have enough staff to care for both covid-19 positive and negative residents separately. As a result, Covid-19 negative residents were at risk for Covid-19 spreading to them. e. During an observation on 12/10/2020 at 3:45 pm, four staff (Staff 3, Staff 4, Staff 6 and Staff 7) were observed in the hallway of the Yellow Zone, wearing N95 masks that were modified, contrary to the instructions of the manufacturer. (An N95 mask is a specialized mask capable of filtering out 95% of particles from the air, thereby protecting the wearer from breathing in those particles, including Covid-19 particles.) During an interview on 12/10/2020 at 3:46 p.m., Staff 3 stated she had cut the elastic bands of her N95 mask with scissors to make it more comfortable by retying the bands around her ears instead of having them behind her head and neck because, It's easier to take on and off. During an interview on 12/10/2020 at 3:47 p.m., Staff 4 stated she had used scissors to cut the elastic bands and retied the ends of the elastic bands such that the elastic bands looped around her ears instead of behind her neck and head as intended by the manufacturer because, It's more comfortable. During an interview on 12/10/2020 at 3:48 p.m., Staff 6 stated he had cut the elastic bands of the mask so that he could retie them and loop them around his ears. During an interview on 12/10/2020 at 3:49 p.m., Staff 7 stated he had altered his N95 mask to make it more comfortable by securing it around his ears instead of around the back of his head and neck. During an interview on 12/17/20 at 3:19, ADM stated he had reviewed the manufacturer's instructions for the wearing and use of the N95 mask that the facility has approved for use by its staff and stated that if the N95 mask is not worn according to the manufacturer's instructions, the staff can become infected with covid-19 and spread it to residents who are negative for covid-19 which can result in the resident becoming infected with Covid-19, being hospitalized and even dying. During an interview on 12/17/20 at 3:21 p.m., DON stated that cutting the elastic bands of the N95 masks can result in a poor fit of the mask to the face of the wearer, which can result in the wearer becoming infected with Covid-19 and spreading Covid-19 to other residents and staff which can result in serious complications such as hospitalization s and even death. During an interview on 12/17/20 at 3:33 p.m., the IP stated that altering the N95 approved for use by staff within the facility is not allowed because it can result in staff becoming infected with Covid-19 and infecting other staff and residents, which can result in hospitalization and death. A review of the website https://www.byd.care/products/n95-respirator, dated 2020, authored by the manufacturer of the N95 masks approved by the facility to be worn by facility staff while caring for residents, indicates, Failure to properly use and maintain this product could result in injury or death. Never substitute, modify, add, or omit parts. A review of the website https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html, authored by The Centers for Disease Control and Prevention (The CDC), dated 12/1/2020, indicated adults of any age with certain underlying medical conditions were at increased risk for severe illness from [MEDICAL CONDITION] that causes COVID-19. Severe illness from COVID-19 is defined as hospitalization , admission to the ICU, intubation or mechanical ventilation, or death. A review of the website http://publichealth.lacounty.gov/acd/ncorona2019/covidcare/, authored by The Los Angeles County Department of Public Health, dated 10/28/2020, indicated older adults and people who have underlying medical conditions like heart or lung disease or diabetes are at higher risk for developing more serious complications from COVID-19. A review of the facility's policy and procedure titled Hand Hygiene, dated 9/1/2012, indicated hand hygiene will be performed before donning and after doffing Personal Protective Equipment (PPE) and also immediately upon entering and exiting a resident room. A review of the facility's Covid-19 Mitigation Plan, dated 11/30/20, indicated Cohorting Residents, Residents will be cohorted in one of three distinct areas of the facility; green, yellow or red. Residents who test negative for COVID-19 and have no signs or symptoms of the illness are kept in the GREEN area. Residents who are under investigation for COVID-19 are kept in the YELLOW area and those who are positive for COVID-19 are kept in the RED area. Additional Cohorting Requirements, Residents who tested positive for COVID-19 should be separated from all residents who test negative and all residents under investigation for COVID-19. The Mitigation Plan indicated all residents who test positive for COVID-19 should be located in a single area within the facility; red area. The Mitigation Plan indicated the facility can demonstrate that there was advanced planning, in alignment with its emergency preparedness plans, for backup staffing using all resources (e.g., corporate resources, temporary staffing agencies, hospital partnerships or other resources). The facility had a plan for expediting training of new HCP brought in from other locations to provide resident care if the facility reaches a staffing crisis. The Mitigation Plan indicated staffing hours may be expanded as needed to address staffing needs. A staff member has been assigned responsibility for conducting a daily assessment of staffing status and needs and has implemented or is ready to implement backup plans as needed. A review of the facility's policy and procedure titled, Infection Control - Policies & Procedures, dated 1/1/2012, indicated the facility's infection control policies and procedures were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infection.