**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary respiratory care and implement interventions in accordance with the resident's needs, care plan, facility policy and professional standards of practice and the physician's order for one of three sampled residents (Resident 77) who had a diagnoses of chronic obstructive pulmonary disease exacerbation (COPD, sudden severe symptoms of a lung disease characterized by poor airflow to the lungs that results in shortness of breath (SOB), difficulty breathing and respiratory distress (a condition that occurs when the body needs more oxygen, resulting in difficulty breathing, rapid breathing, and low blood oxygen levels) and a history of pneumonia (a severe respiratory infection that results in shortness of breath and difficulty breathing) by failing to: 1. Monitor and evaluate if the oxygen provided was effective to relieve the resident's respiratory distress and oxygenation in accordance with the resident's care plan for COPD and physician's orders, when Resident 77 experienced shortness of breath (SOB), labored breathing (taking more effort to breath than usual), and an oxygen saturation (blood oxygen level) decreased to 72% (normal range 90-100%) while receiving oxygen via nasal cannula (NC- a plastic flexible tubing used to deliver oxygen into the nose) at 2 liters per minute (L/min) on [DATE] at 11:05 PM. 2. Follow physician orders to titrate (adjust) Resident 77's oxygen therapy at 2-5 L/min to maintain oxygen blood levels of 92% when Resident 77's oxygen saturation decreased to 72% on [DATE] at 12:10 AM, while receiving 2 L/min of oxygen via NC. 3. Ensure Licensed Vocational Nurse (LVN) 6 monitored and documented Resident 77's respiratory distress, treatments rendered (given), and report Resident 77's change in respiratory condition to the physician, in accordance with the physician orders and the facility's policy and procedure. 4. Ensure to notify the physician and 911 (an emergency number) emergency services immediately, when Resident 77 complained of not being able to breathe and exhibited signs and symptoms of respiratory distress as manifested by labored breathing and oxygen saturation of 72% on [DATE] at 12:10 AM. 5. Ensure the physician was aware that Resident 77 was refusing to go to the hospital while complaining of not being able to breath and exhibited signs and symptoms of respiratory distress as manifested by labored breathing and oxygen saturation of 72% on [DATE] at 12:10 AM. As a result of these deficient practices Resident 77 did not receive immediate respiratory care and interventions on [DATE] from 11:05 PM when the resident was initially observed with respiratory distress, labored breathing, decreased level of oxygenation, until [DATE] at 2:29 AM when the paramedics pronounced Resident 77 dead after providing unsuccessful CPR (cardiopulmonary resuscitation, an emergency treatment for someone who stopped breathing or heartbeat has stopped by providing chest compression [pressing on the chest over the heart] and rescue breathing [mouth-to-mouth resuscitation]) was provided. On [DATE] at 2:02 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the facility's failure to notify the physician regarding significant changes in Resident 77's respiratory conditions and provide the necessary respiratory care and monitoring. On [DATE] at 11:17 AM, the IJ was removed in the presence of the Administrator (ADM) and the Director of Nurses (DON) after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and while onsite at the facility, the surveyors verified/confirmed the facility's implementation of the IJ Removal Plan and the IJ situation was no longer present. The IJ Removal Plan dated [DATE], included the following: 1. On [DATE], the Director of Nursing (DON) conducted a full house audit to identify all residents with a diagnosis of COPD, those on continuous and, PRN (as needed) oxygen. The audit identified 10 residents with COPD and 18 residents receiving oxygen therapy. The DON reviewed the care plans and physician's orders for these residents to ensure appropriate interventions such as following MD (Medical Doctor/physician) orders, oxygen therapy orders, repositioning of patients, checking oxygen saturation, assessment of signs and symptoms of hypoxia (low blood oxygen in the body tissues) respiratory failure (failure of the lungs to meet the body's demand for oxygen) for effectiveness of the intervention and monitoring for signs and symptoms of respiratory distress, verifying respiratory status using objective data such as oxygen saturation were in place. The DON will also review the communication to the Primary Care MD, if no response, the medical director and or emergency services will be called immediately. No additional residents were found to be at immediate risk. 2. On [DATE] a one to one in-service regarding MD notification, Medical Director notification, and emergency services was provided to the Night Shift Licensed Nurse assigned to Resident 77 on [DATE], by the facility's DON. The Licensed Nurse was also suspended pending the facility's investigation. 3. On [DATE] and [DATE] the Pharmacy Consultant initiated Medication Regimen Reviews (review of the medications the residents are receiving) for all residents receiving Oxygen Therapy and with COPD/SOB. 4. On [DATE], the facility conducted a root cause analysis (RCA) which included interviews with involved staff. The RCA revealed the following contributing factors: Lack of staff education on monitoring and reporting changes in respiratory status, and inadequate communication between nursing staff and physicians regarding significant changes in condition. 5. On [DATE] the Certified Nursing Assistant (CNA) assigned to Resident 77 on [DATE] during the night shift was provided a one-to-one in-service regarding Emergency Care Policy and Procedure. 6. On [DATE], the Director of Nursing/ Staff Development Coordinator (DSD) started to provide in- services to all Licensed Nursing staff for all shifts including CNAs, LVNS, RNs on Emergency Medical Response: A. Monitoring and reporting changes in respiratory status B. Following physician orders for oxygen titration and maintaining target oxygen saturation levels, and C. Facility policy and procedure for responding to respiratory distress, including immediate notification of the primary physician, emergency services, and medical director. 7. By [DATE], the DON reviewed the facility's policy and procedure for responding to respiratory distress to ensure clarity and consistency with current standards of practice. 8. By [DATE], the DON created a monitoring tool related to COPD and Oxygen Therapy to ensure clarity and consistency with current standards of practice. Findings: During a review of Resident 77's admission Record (AR), the AR indicated the facility admitted Resident 77 on [DATE] and readmitted on [DATE] with diagnoses that included COPD with exacerbation (worsened symptoms), pneumonia, hypertensive heart disease (high blood pressure), and type 2 diabetes mellitus (condition of having high blood sugar). During a review of Resident 77's Physician Orders for Life-Sustaining Treatment (POLST- a medical order that documents a patient's preferences for end-of-life care), dated [DATE], indicated if the resident was found with a pulse and/or was breathing, full treatment was ordered for medical interventions including intubation (a tube placed in the mouth to the airway to provide oxygenation), advanced airway interventions (a tube place in the airway), mechanical ventilation (assisted breathing provided with the use of a machine), and cardioversion (a medical procedure that restores a normal heart rhythm by using electricity or medication to treat an abnormal heart rhythm). During a review of Resident 77's Order Summary Report (OSR), indicated on [DATE], Resident 77 had physician orders to monitor for sign and symptoms of respiratory distress that included monitoring for pulse oximetry (a device used to monitor oxygen blood level), lethargy (a state of unusual drowsiness, fatigue, and lack of energy and mental alertness), accessory muscle usage (breathing using muscles other than those typically used for breathing to take in and expel air) and to document with hashmarks (or tally marks, a numerical system used to keep track of things by number) in the clinical record of the resident if present and report to the physician. The physician also ordered to titrate (adjust) oxygen at 2-5 L/min via NC continuously to maintain oxygen saturation at 92 % or above, and to notify the physician if oxygen saturation was below 92% for SOB. The OSR indicated in the event of an emergency, the Medical Director may be called if the attending physician or alternate physician are not available. During a review of Resident 77's History and Physical Examinations, dated [DATE], indicated Resident 77 had the capacity to understand and make decisions. During a review of Resident 77's OSR, indicated on [DATE], Resident 77 had a physician order for Full Code (a medical order that instructs the health care team to perform all possible life-saving measures if the resident goes into cardiac or respiratory arrest [when the heart stopped beating or the resident stopped breathing]). During a review of Resident 77's Physician Progress Note, dated [DATE], indicated Resident 77 exhibited alertness and cognitive ability to effectively communicate needs and his language comprehension and response during assessments were appropriate. The notes indicated Resident 77 continued under monitoring for anemia (a condition of not having enough healthy red blood cells to carry oxygen to the body's tissues) and has declined hospitalization despite the recommendation, understanding the associated risks and benefits. During a review of Resident 77's Physician Progress Note, dated [DATE], indicated when confronted with acute medical symptoms or conditions necessitating immediate attention for Resident 77, the staff has received explicit instructions to promptly trigger emergency medical services (EMS- a system that provides emergency medical care to residents after an incident of serious illness or injury) via 911 and direct the resident to the emergency department. These symptoms and conditions encompass, though are not confined to exacerbation (severe symptoms) of asthma (a respiratory disorder that makes it difficult to breath). The note indicated, the data mentioned above is based on information available during the encounter and may change as other data becomes available. During a review of Resident 77's Care plan, dated [DATE], indicated Resident 77 had exacerbation (worsened symptoms) of COPD manifested by wheezing (a high-pitched, whistling sound that occur during breathing when the airways in the lungs become narrowed or blocked) with the goal that the resident would display optimal breathing patterns daily. The care plan interventions included to give aerosol (a substance released in very fine mist) or bronchodilations (a medication that make breathing easier by relaxing the muscles in the lungs and widening the airways [bronchi])as ordered by the physician and monitor/document any side effects and effectiveness, to monitor for difficulty breathing on exertion, and to administer oxygen via nasal cannula at 2 L/min. During a review of Resident 77's OSR, indicated on [DATE], Resident 77 had a physician order for Ipratropium-Albuterol (a medication used to prevent wheezing, difficulty breathing, chest tightness, and coughing) 3 ml (milliliter, unit of volume) inhale (breathing in) orally (by mouth) every 6 hours as needed for SOB/wheezing for 14 days. During a review of Resident 77's Progress Notes, dated [DATE], indicated on [DATE] at 11:05 PM, during an initial assessment Licensed Vocational Nurse (LVN) 6 noted Resident 77 was in bed asleep but responsive to verbal stimuli with no complaint of pain or discomfort. The note indicated on [DATE] at 12:10 AM, Resident 77 was sitting on his bed and verbalized I can't breathe, I need a breathing treatment, breathing was labored with oxygen saturation was at 72%. The note indicated LVN 6 administered a breathing treatment and offered to transfer the resident to the hospital of which Resident 77 declined and on [DATE] at 12:30 AM, Resident 77 verbalized thank you, I'm feeling better. The note indicated at on [DATE] at 1 AM, Resident 77 was asleep with eyes closed and receiving continuous oxygen at 2 L/min, then at 1:55 AM, LVN 6 was alerted to Resident 77's room by Certified Nurse Assistant (CNA) 4, that Resident 77 was unresponsive with no chest movement and no pulse, CPR (cardiopulmonary resuscitation, is an emergency treatment that's done when someone's breathing or heartbeat has stopped by chest compression [pressing on the chest over the heart] and rescue breathing [mouth-to-mouth resuscitation]) was initiated and 911 was called. The notes indicated on [DATE] at 2:10 AM, the paramedics arrived and took over the CPR and Resident 77 was pronounced dead at 2:29 AM and Resident 77's physician was notified via text on [DATE] at 3:16 AM. During a review of Resident 77's Medication Administration Record (MAR) for [DATE], indicated on [DATE] at 12:10 AM, Ipratropium-Albuterol Inhalation Solution medication was given to Resident 77 for SOB/wheezing. During a review of Resident 77's Physician's Discharge Summary, dated [DATE], indicated Resident 77 was discharged from the facility due to resident expired. During a review of Paramedic Run Report, dated [DATE], indicated Resident 77 presented warm, pupils were fixed (indication of no brain activity), in asystole (no heart rhythm) and for the duration of CPR. The report indicated, Resident 77 remained in asystole with no changes after given 3 Epinephrine (the primary drug administered during CPR to reverse cardiac arrest) doses and was pronounced dead at 2:29 AM after 20 minutes of high-quality CPR. The report indicated, staff stated the patient (Resident 77) is being seen at this facility for COPD and possible pneumonia. Pt was advised to go to the hospital by staff numerous times for better care and treatment but declined for a week. Pt was given a breathing treatment by staff at midnight with no improvement and was found not breathing at around on [DATE] at 2 AM. Staff immediately began CPR and called 911. CPR taken over by EMS on [DATE] at 2:09 AM. During an interview on [DATE] at 4:37 PM with CNA 4, CNA 4 stated, when she came to work on [DATE] at around 11:06 PM, Resident 77 did not respond when she tried to greet him, his eyes were closed, and he was breathing very fast. CNA 4 stated, Resident 77 was receiving oxygen supplement with a tube in his nose. CNA 4 stated, LVN 6 told her that Resident 77 was not feeling well and that she should keep an eye on the resident. CNA 4 stated, she checked Resident 77 several times and observed Resident 77's breathing was getting loose and loose to the point of no breathing anymore, and his facial expression was flat. CNA 4 stated, she did not monitor for Resident 77's vital signs (measurement of the blood pressure, heart rate, respiratory rate, and body temperature) or oxygen saturation because it was the charge nurse's responsibility. CNA 4 stated, she asked LVN 6 to Please come and check on Resident 77 because she had to attend another resident. CNA 4 stated, LVN 6 went to see Resident 77 and she went to another resident's room to give care. CNA 4 stated, when she came out of the other resident's room, she saw LVN 4 bringing in a big oxygen tank to Resident 77's room. When she peeked in Resident 77's room, LVN 4 told her that the resident was dead. CNA 4 stated, she recalled LVN 4 was performing CPR on Resident 77, but she did not come to help in Resident 77's room because she was busy with the other resident. During an interview on [DATE] at 5:09 PM with LVN 6, LVN 6 stated, when he first checked on Resident 77 at the start of his shift on [DATE] at around 11 PM, Resident 77's vital signs including the oxygen saturation was around 94-95% while Resident 77 was receiving 2 L/min oxygen via NC. LVN 6 stated, Resident 77 was breathing heavily, and very labored. LVN 6 stated, about an hour later, Resident 77 told him I can't breathe, I want my breathing treatment. LVN 6 stated he checked Resident 77's oxygen saturation and it was at 72%. LVN 6 stated, he asked Resident 77 if he wanted to be transferred to the hospital, but Resident 77 stated No, meaning he didn't want to go the hospital, so LVN 6 gave Resident 77 Albuterol breathing treatment as ordered by the physician. LVN 6 stated, after the treatment, Resident 77's oxygen saturation went up, but not that high, to 75-78%. LVN 6 stated, he asked Resident 77 again if Resident 77 wanted to be transferred to the hospital, Resident 77 stated No. LVN 6 stated, after the breathing treatment was given, he put Resident 77 back to continuous oxygen at 3 L/min via NC. LVN 6 stated, he did not recheck Resident 77's vital signs when Resident 77 had an episode of decreased oxygen saturation of 72%, and he did not recheck and monitor Resident 77's oxygen saturation after giving Resident 77's breathing treatment when the oxygen saturation increased to 75-78%. LVN 6 stated, when communicating with the physicians at the facility, the staffs only text the doctors during the night, the staffs do not call the doctors if they need to report the resident's condition. LVN 6 stated, he did not document Resident 77's (Change of Condition) COC, notify the doctor via text or call, or call 911 regarding Resident 77's labored breathing, low oxygen level, changes in the respiratory and refusal to go to the hospital because Resident 77 had a behavior of refusing to be transferred to the hospital and because LVN 6 believed that Resident 77's breathing was better given that the oxygen saturation went up from 72 % to 75-78%. LVN 6 also stated, he was busy with other residents. LVN 6 stated, he told CNA 4 to keep an eye on Resident 77 for his movement in case Resident 77 was not breathing. LVN 6 stated, when CNA 4 came and told him to come to see Resident 77, he rushed in Resident 77's room, tapped on Resident 77's shoulder but the resident was not responding. LVN 6 stated, Resident 77's chest was not moving up and down, so he ran out of the room to call for help and brought in the bigger oxygen tank. LVN 6 stated, LVN 7 was helping him to call 911 while he went back to Resident 77's room and started CPR. LVN 6 stated, the resident's room did not have any button to activate Code Blue (a code announced through an overhead audio system to alert the staffs in the facility about a medical emergency). LVN 6 stated, he did not call for a Code Blue overhead because he did not want to panic other residents during the nighttime. During an interview on [DATE] at 6:06 PM with LVN 7, LVN 7 stated, he was at his nursing station when he heard LVN 6 running in the hallway, telling him, My patient is not responding. LVN 7 stated, he helped LVN 6 to call 911 at his station, when he finished his call with 911, he walked over to Resident 77's room and believed that there were two to three people in the room and recalled one of them was doing CPR. LVN 7 stated, he did not come in to help because the EMS already came in by that time. During a concurrent record review and interview on [DATE] at 9:14 AM with the Regional Medical Record (RMR), Resident 77's Change of Condition/MD notification and orders for the month of [DATE] were reviewed. The RMR stated, there was no documented evidence that a COC was completed, no indication that the physician was notified, and no physician order to address Resident 77's respiratory distress and decreased oxygenation on [DATE]. The RMR stated, there was no care plan for Resident 77's refusal to go to the hospital and no documented evidence that alternative interventions were discussed with Resident 77 regarding his refusal. There was also no documentation that the DON, Administrator or the facility's Medical Director was informed about Resident 77's change in respiratory condition. During an interview on [DATE] at 10:04 AM with the MDS Nurse (MDSN), the MDSN stated, when Resident 77 desaturated (a drop in blood oxygen level) and was having SOB, LVN 6 should follow the doctor's order to notify the doctor right away about the situation and the resident's low saturation even when the resident refused to be transferred to the hospital. The MDSN stated, the doctor should be notified about the resident's refusal because if the resident was alert enough, the doctor could explain to the resident that if he refused care, it could lead to death. The MDSN stated, it was important to notify the doctor right away so the LVN could have orders for immediate interventions and treatment. The MDSN stated, the doctor might also ask the nurse to just call 911. During an interview on [DATE] at 11:16 AM with the Director of Nurses (DON), the DON stated, at nighttime, the facility doesn't have any registered nurse, only LVNs. The DON stated, depending on the severity of the situation, the doctor could be contacted via calls or text messages. The DON stated, if the primary physician didn't respond, the medical director could be notified. The DON stated, he (DON) was also available 24/7 in case of emergency for guidance. The DON stated, in a situation when the resident's saturation went down to 72% and was having SOB and there was order for breathing treatment, the nurse could send the doctor a text to notify the doctor about the situation. The DON stated, while waiting for the doctor's response, the LVN should monitor for the resident's vital signs including oxygen saturation, put the resident on oxygen and titrate to the maximum oxygen level as ordered, give breathing treatment, and continue to monitor the resident for how the resident was doing with vital signs and document them in the resident's medical record. The DON stated, if the oxygen saturation was at 75-78% after treatment, the treatment was not effective. The DON stated, if the resident refused to be transferred to the hospital, the nurse should notify the doctor right away to report the situation that the oxygen and breathing treatment was given as ordered but the oxygen saturation level did not increase as expected and that the resident refused transferring to the hospital. The DON stated, LVN 6 should have reported Resident 77's desaturation episode and his refusal to the doctor even if LVN 6 respected Resident 77's right and have the doctor decide what to do. The DON stated, 911 should have been called to manage the situation. During an interview on [DATE] at 4:50 PM with Resident 77's primary physician (PMP 1), the PMP 1 stated, on the night of [DATE], he did not receive any text or call from the facility staff regarding Resident 77's desaturation and SOB. PMP 1 stated, he only got a text to notify him that his patient (Resident 77) had passed away early morning of [DATE] because of unresponsiveness and not breathing. PMP 1 stated, when the oxygen saturation went down to 72% and Resident 77 was having SOB, LVN 6 should give breathing treatment and notify him at least via text messages. PMP 1 stated, after breathing treatment, when the oxygen saturation went up to 75-78%, the saturation was still too low, and Resident 77 should have been transferred out to the hospital for higher level of care. PMP 1 stated, even when Resident 77 refused, LVN 6 should have let him know. PMP 1 stated, he would have asked LVN 6 to transfer or call 911. PMP 1 stated, the facility's practice is very aggressive with transferring out in cases of emergency that the patient was not able to be stabilized. PMP 1 stated, if he was aware of the patient's repeated refusal to care, he would consider hospice or discuss with him of changing in code status if Resident 77 was alert able to decide for himself. PMP 1 stated, LVN 6 should not decide by himself without informing the physician whether to not transfer Resident 77 to the hospital or not due to respecting the resident's right because Resident 77 was still a full code. During a review of the facility's Policies and Procedures (P&P) titled, Change of Condition (COC) Notification, revised [DATE], indicated the following: a. An acute COC is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Clinical important means a deviation that, without intervention, may result in compilations or death. b. The Licensed nurse will notify the resident's Attending Physician when there is a significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, life threatening conditions or clinical complications; a need to alter treatment signification; and a decision to transfer or discharge the resident from the facility. c. The Licensed Nurse will assess the resident's COC and document the observations and symptoms. d. The Attending Physician will be notified timely with the residents' COC. Notification to the Attending Physician will include a summary of the condition change, and an assessment of the resident's vital signs. e. In emergency situations (e.g., a resident is experiencing unexpected SOB), the Licensed Nurse will: immediately call the Attending Physician. f. If the Licensed Nurse is unable to reach the Attending Physician or the Physician on call during emergency situations, he/she will notify the Facility's Medical Director. If the resident deteriorates, the symptoms are serious, and the most rapid intervention available by a physician would place the resident in great jeopardy, call 911 for transport to hospital. g. Notify the Nursing Supervisor of emergency. During a review of the facility's P&P titled, Emergency Care - General, revised [DATE], indicated, emergency - Life threatening is the situation that requires prompt intervening actions to maintain physical, mental, and/or emotional health. Summon help and immediately call 911 for medical emergency assistance. These emergency situations would include but are not limited to: cessation (stop) of breathing and document the resident's vital signs including blood pressure, pulse, respirations and temperature. During a review of the facility's P&P titled, Pulse Oximetry (Assessing Oxygen Saturation), revised [DATE], indicated: a. For the safety and comfort of residents, the Facility will utilize pulse oximetry to measure levels of oxygen in the resident's blood when such measurement is ordered by the resident's Attending Physician or as indicated by the resident's condition. b. A normal oxygen saturation is between 90 to 100 percent. Anything below 90 percent should be closely monitored, including the maintenance of a flow chart or documentation record for oxygen saturation level. c. Residents with respiratory distress will have a respiratory assessment completed that may include the use of a pulse oximeter to noninvasively measure the resident's blood oxygen saturation. d. If oxygen saturation is less than 90 percent, if oxygen saturation is at less than an acceptable level fo the resident's condition, notify the Attending Physician. During a review of the facility's P&P titled, Oxygen Administration, dated [DATE], indicated to prevent or reverse hypoxia and provide oxygen to the tissues, the facility will, in an emergency situation or when a physician's order cannot be immediately obtained, oxygen may be initiated by a Licensed Nurse in the presence of acute chest pain or any other acute situation in which hypoxia is suspected. A physician is to be contacted as soon as possible after initiation of oxygen therapy in emergency situations, for verification and documentation of the order for oxygen therapy consultation, and further orders. Oxygen saturations will be measured and documented at a minimum of daily for resident's receiving oxygen therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the attending physician (Medical Doctor [MD] 1) included blood sugar monitoring [an intervention that is essential for managing diabetes that involves checking blood sugar levels using a device] and medications to manage Diabetes Mellitus [DM, a chronic disease where a person has high blood sugar levels because the body does not produce insulin (a hormone made by the pancreas- an organ in the body) normally] for one of three sampled residents (Resident 1) who was diabetic (a person with diagnosis of diabetes) by failing to: 1. Ensure the licensed staff reviewed Resident 1's general acute care hospital (GACH 1) records for all appropriate discharge orders and ensure admission orders from the facility and continuity of care for DM was verified with MD 1, upon admission to the facility, on [DATE]. 2. Ensure the licensed staff verified Resident 1's admission orders from the facility, by reviewing Resident 1's medical history from GACH 1 and addressed the resident's diagnoses of DM. There was no documented evidence diabetes management that included blood sugar monitoring, insulin administration and monitoring to prevent hyperglycemia (high blood sugar level) and hypoglycemia (low blood sugar level) was implemented while the resident resided in the facility from [DATE] to [DATE]. 3. Inform the physician that Resident 1 with DM did not have admission orders from the facility to monitor the resident's blood sugar and if the physician wanted to continue the orders for the resident to receive insulin to manage the resident's diabetes according to GACH 1's Discharge Documentation and in accordance with the facility's policy and procedure titled admission Assessment. 4. Ensure the plan of care for Resident 1's DM was implemented by monitoring the resident for hypoglycemia and hyperglycemia while residing in the facility from [DATE] to [DATE] (a total of 61 days). As a result, Resident 1 was transferred to GACH 2 via 911 emergency services on [DATE] due to altered level of consciousness (a change in a patient's state of awareness [ability to relate to self and the environment]), oxygen desaturation (a decrease in the amount of oxygen in the blood) of 77% (blood oxygen levels drop below a normal range [normal levels are 96 to100 %]) and a blood sugar level of 500 (normal blood sugar levels are between 70 to 100). Resident 1 arrived at GACH 2 Emergency Department (ED) with a blood sugar level of 810 (normal blood sugar levels are between 70 to 100) on [DATE]. Resident 1 was transferred to the Intensive Care Unit (ICU, a specialized unit in a hospital that caters to patients that are critically ill) for management of Diabetic Ketoacidosis (DKA - a serious complication of diabetes that happens when the body does not have enough of a hormone called insulin) and died on [DATE]. According to Resident 1's Certificate of Death (a legal document used by the state and federal government to prove someone has died), Resident 1's immediate cause of death (final disease or condition resulting in death) was Diabetic Ketoacidosis and the underlying cause of death (disease or injury that initiated the events resulting in death) was DM Type 2. On [DATE] at 7:33 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the facility's failure to ensure a resident with a diagnosis of DM Type 2 received the appropriate admission orders from the facility or diabetes care and management provided by a physician. The survey team notified the Administrator (ADM) and the Director of Nursing (DON) of an IJ situation on [DATE] at 7:33 PM, due to the facility's failure to ensure Resident 1 received the appropriate facility admission orders for diabetes care and management provided by a physician. On [DATE] at 3:02 PM, the ADM provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On [DATE] at 3:19 PM, while onsite and after the surveyor verified/confirmed the facility's full implementation of the IJ Removal Plan through observation, interview, and record review, and determined the IJ situation was no longer present, the IJ was removed onsite, in the presence of the ADM and the DON. The IJ Removal Plan dated [DATE], included the following: - On [DATE], the DON provided an in-service (training program while staff are employed) with Licensed Vocational Nurse (LVN) 1 on diabetic medication order clarifications, facility admission orders, implementation of care plans, verification of physician orders, and signs and symptoms of hyperglycemia (high blood sugar levels) and hypoglycemia (low blood sugar levels). - LVN 1 was provided with additional in-service on Diabetic Care Policy and Procedure, diabetic patient management, order clarification, and care planning on escalation (to involve someone of higher position) of interventions if medication list is not provided for residents upon admission. - Starting [DATE], the Director of Nurses (DON)/Designee initiated monthly in-services for three months to reinforce best practices in the admission process, to review all inquiries for newly admitted residents. Registered Nurse [RN]/DON will input all medication orders for newly admitted residents. RN/DON will complete all admission assessments for newly admitted residents. RN/ DON will contact the transferring acute care hospital and primary care provider to clarify all medication orders and compare to the patient's diagnosis/medical condition to ensure that all of the correct medications are ordered for each resident upon admission to the facility and correct any potentially missed medication orders in real time. - On [DATE] and [DATE], the DON provided all licensed nurses with an in-service regarding Diabetes Management including the review of facility admission diagnosis, diabetic medication order clarification, implementation of care plans, verification of physician orders, and proper documentation to ensure that all staff are updated on the current diabetic care policy and procedure. - On [DATE], the Pharmacist Consultant (provides facilities with expert advice and recommendations about resident's medications by performing medication reviews) completed a Medication Regimen Review (MRR, a process conducted by a pharmacist, to review a resident's medications) for all residents with diagnosis of DM at the facility and made recommendations. - On [DATE], the DON and Minimum Data Set (MDS- a comprehensive standardized assessment and screening tool) Nurse reviewed records for all current residents with the diagnosis of DM using a Diabetes Audit Log to identify other residents. All residents with diagnosis of DM were physically assessed, admission orders/documentation were reviewed, monitoring for signs and symptoms of hypoglycemia and hyperglycemia were reviewed, and care plans were reviewed/updated to address DM management. - On [DATE], the DON/MDS Nurse and the Medical Records Director (MRD), conducted an audit of medication administration records and treatment protocols for residents with a diagnosis of DM to ensure adherence to prescribed treatments. - Starting [DATE], the MDS Nurse will conduct an admission chart review audits for newly admitted residents the next day, after their admission to the facility to monitor compliance with diabetes management protocols, physician orders, blood sugar monitoring, and identify areas requiring corrective action. - Starting [DATE], the Interdisciplinary Team [IDT] will develop and implement comprehensive care plans for residents with DM, including regular monitoring, and preventive measures for complications. Care plans will be reviewed by IDT and updated during weekly meetings and as required by changes in the resident's condition by a licensed nurse. - Starting [DATE], the RN or DON will oversee documentation of care plans, assessments, medication orders, monitoring, and physician orders, ensuring that all interventions are properly recorded and that any issues or clarifications are addressed the same day that the residents are admitted . - On [DATE], the Medical Director provided an in-service with Resident 1's attending physician regarding admission orders, DM medication management, medication orders, order for blood sugar checks and monitoring for signs and symptoms of hypoglycemia and hyperglycemia. - On [DATE], the Medical Director provided an in service with the Pharmacist Consultant that reviewed Resident 1's medication regimen during the month of February 2024 to educate the consultant on reconciliation of all resident's diagnosis with medication orders concurrently. - On [DATE], the Medical Director educated the Pharmacist Consultant regarding medication recommendations regarding DM medication management, medication orders, and order for blood sugar checks and monitoring for signs and symptoms of hypoglycemia and hyperglycemia. - Starting [DATE], the DON/Designee will oversee the administration of diabetes-related medications and ensure that physician recommendations are followed daily. - Starting [DATE], the Medical Director will initiate an in-service of the facility's Primary Care Physicians, Nurse Practitioners, and Physicians Assistants on admission orders, DM medication management, medication orders, and order for blood sugar checks. Cross reference with F684, F711, F756 Findings: During a review of Resident 1's GACH 1 record, titled, Inpatient Progress Notes, dated [DATE], indicated Resident 1 had a diagnosis of DM . The GACH 1 record indicated a plan to continue Resident 1's insulin medication to maintain a blood sugar goal of less than 180. During a review of Resident 1's GACH 1 record titled Discharge Documentation dated [DATE], timed at 11:07 AM, indicated Issues to Address on Outpatient Follow Up/Discharge Action Plan which included Resident 1 to have continued diabetes management upon admission in the facility. The Discharge Documentation record indicated Resident 1 received insulin in GACH 1 and will need physician [follow up] for DM care. Further review of the Discharge Documentation indicated Resident 1's last blood sugar result in GACH 1 on [DATE] was 157. During a review of Resident 1's Facility admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included DM, encephalopathy (damage or disease that affects the brain), dementia (a syndrome that causes a decline in cognitive [thought process] abilities, such as thinking, remembering, and making decisions, that can interfere with daily activities), and hypertension (high blood pressure). During a review of Resident 1's Facility Nursing admission Assessment, dated [DATE], timed at 6:03 PM, signed by LVN 1 and LVN 3, indicated the resident was admitted to the facility on [DATE] at around 5:10 P.M. The Nursing admission Assessment indicated Resident 1 had a diagnosis of DM Type 2. During a review of Resident 1's care plan titled, The resident [Resident 1] has DM, initiated on [DATE] and revised on [DATE], indicated a goal for the resident is to not have complications related to diabetes. The care plan interventions included to monitor, document, and report signs and symptoms of hyperglycemia and hypoglycemia. During a review of Resident 1's Order Summary Report (OSR) for all orders during Resident 1's stay at the facility from [DATE] to [DATE], included a physician order to administer Insulin Lispro [a class of insulin hormone] Injection Solution 100 Unit/ML [Unit per milliliter, a unit of measure] Inject as per sliding scale (a guide use to determine how much insulin to give to correct an elevated blood sugar) on [DATE]. The OSR indicated the order for Insulin Lispro sliding scale was discontinued the same date, [DATE]. During a review of Resident 1's facility records titled, Discontinue Order, dated [DATE], timed at 11:17 PM, signed by LVN 1, indicated a telephone order from MD 1 for Insulin Lispro Sliding Scale to be discontinued on [DATE], timed at 11:16 PM. The record indicated the reason for discontinuing was Clarification of Order. During the review of the resident's physician orders, there was no additional orders or justification for Lispro insulin after it had been discontinued. During a review of Resident 1's History and Physical (H&P), dated [DATE], signed by MD 1, indicated the resident did not have the capacity to understand and make decisions. The H&P indicated Resident 1 had a diagnosis of DM. During a review of Resident 1's admission MDS, dated [DATE], indicated the resident had severely impaired [a condition that significantly limits an individual's physical or mental abilities] cognition (ability to remember and process information). The admission MDS indicated Resident 1 did not have an order for insulin and did not include resident's diagnosis of DM. During a review of Resident 1's Change in Condition Evaluation (CIC), dated [DATE], timed at 7:04 PM, the CIC indicated Resident 1 was found to have labored breathing (a non-medical term used to describe when breathing is difficult or impaired) and with a blood sugar level of 500. The CIC indicated Resident 1 had signs and symptoms that included altered mental status, oxygen desaturation, and hyperglycemia. The CIC indicated MD 1 and Resident 1's family were notified. The CIC indicated Resident 1 was transferred via 911 emergency services to GACH 2 on [DATE]. During a review of Resident 1's Transfer Form, dated [DATE], the Transfer Form indicated Resident 1 was transferred to GACH 2 on [DATE]. The Transfer Form indicated the reason for the transfer was due to altered mental status. During a review of Resident 1's GACH 2 Emergency Department [ED] Reports dated [DATE], indicated the resident was admitted to the ED on [DATE] at 6:48 PM with a chief complaint of altered mental status and having a blood sugar of High [a glucometer (a portable device used to measure blood sugar levels) reading that means a very high blood sugar level above 600]. The GACH 2 ED Report indicated At around 5:50 PM, [Resident 1] refused her dinner and threw her juice on the floor and refused to eat. When [Resident 1] was reevaluated they [facility staff], noted that she [Resident 1] was breathing heavily [difficulty breathing] and not speaking. The GACH 2 ED Report indicated the facility staff tried to measure [Resident 1's] [blood] sugar, and the glucometer read as high. The GACH 2 ED Report indicated Resident 1's blood sugar level taken at the GACH 2 upon arrival to the ED was 810. During the same review of Resident 1's GACH 2 ED Report dated [DATE], indicated a diagnosis of DKA. The GACH 2 ED Report indicated the resident was started on insulin drip (insulin that is administered directly through a person's vein) and was admitted to the ICU for management of the DKA. During a review of Resident 1's GACH 2 Medication Administration Record [MAR], the GACH 2 MAR indicated GACH 2 started Resident 1 on insulin drip (insulin given through an intravenous [IV-thorough the vein] to get into the body more quickly to bring down high blood sugar) on [DATE]. During a review of Resident 1's GACH 2 records titled Discharge [DC] Summaries Notes, dated [DATE], timed at 3:11 PM, indicated Resident 1 coded [a medical term which means a person's heart stopped and basic life support was provided] and expired on [DATE] while in the ICU. The GACH 2 DC Summary indicated Resident 1's final diagnoses included DM Type 2, hyperosmolar hyperglycemic state (a serious complication of diabetes that happens when blood sugar levels are very high for a long period of time), DKA, sepsis (a serious condition in which the body responds improperly to an infection), and altered mental status . During a review of Resident 1's Certificate of Death indicated Resident 1 expired on [DATE] in GACH 2. The Certificate of Death indicated the immediate cause of death (final disease or condition resulting in death) as Diabetic Ketoacidosis and underlying cause of death (disease or injury that initiated the events resulting in death) indicated Diabetes Mellitus Type 2. During a concurrent interview on [DATE] at 1:28 PM with the MDS Nurse and record review of Resident 1's clinical records and physician orders provided by the facility from [DATE] to [DATE], the MDS Nurse stated there were no documented evidence that the facility licensed staff called MD 1 to verify the reason for the Clarification of Order for Resident 1's Insulin Lispro Sliding Scale that was discontinued on [DATE]. The MDS Nurse stated there was no additional orders or justification for discontinuing the resident's order for Lispro insulin after it had been discontinued on 2/8.2024. The MDS Nurse stated there was no documented evidence that licensed staff notified MD 1 or other physicians that Resident 1 was receiving insulin while at GACH 1. The MDS Nurse stated there was no documented evidence that licensed staff verified if MD 1 would continue the order for insulin and blood sugar monitoring as a diabetic regimen [course of treatment] for Resident 1. The MDS Nurse stated residents that have a diagnosis of DM should have an order to have their blood sugar monitored. The MDS Nurse stated discontinuing a medication should have a valid reason. The MDS Nurse stated the reason indicated by LVN 1 on [DATE], which read clarification of order, was not a valid reason for discontinuing the Insulin Lispro Sliding Scale on [DATE]. The MDS Nurse stated she did not call or clarify with MD 1 to verify the insulin medication order and blood sugar monitoring, upon completion of the resident's admission MDS [on [DATE]]. The MDS nurse stated there was no documented evidence that Resident 1 was monitored for signs and symptoms of hyperglycemia and hypoglycemia, as indicated in the resident care plan for DM developed on [DATE] and revised on [DATE]. During the same interview, on [DATE], at 1:28 PM, the MDS Nurse stated that she had reviewed the GACH 1 records provided to the facility upon Resident 1's admission on [DATE]. The MDS Nurse stated the GACH 1 records indicated Resident 1 was receiving insulin while at GACH 1. The MDS Nurse stated the facility should have continued Resident 1's blood sugar monitoring and insulin because it was the GACH 1's discharge plans for Resident 1, prior to facility admission. During a concurrent interview and record review of Resident 1's entire facility records, from [DATE] to [DATE], and the facility's policy and procedures on admission Assessment and admission and Orientation of Residents on [DATE] at 2:48 PM, LVN 2 stated there was no documented evidence that another licensed nurse, reviewed Resident 1's medication orders the next day after the resident's admission to the facility. LVN 2 reviewed the policy and procedures on admission and Orientation of Residents, that indicated a registered nurse will conduct the initial assessment of the resident. LVN 2 stated when a resident is admitted during the evening or night shift by an LVN, an RN must re-assess the resident again the next day, which should include the verification of the resident's medication orders. LVN 2 stated there was no documented evidence that another licensed staff (RN or another LVN) conducted a drug review of Resident 1's medication orders and re-assess Resident 1 the next day, which should include verification of the resident's medication orders, as indicated in the facility's policy titled admission Assessment and admission and Orientation of Residents to ensure all the required orders were included. During a phone interview on [DATE] at 4:25 PM with LVN 1, LVN 1 stated when a resident is admitted to the facility, the admitting nurse calls the physician and asks if the attending physician would like to continue everything [medication orders from the GACH]. LVN 1 stated she does not verbally read over the resident's entire medication list to the physician. LVN 1 stated she could not remember if she spoke to MD 1 on [DATE], when she admitted Resident 1 to the facility. LVN 1 stated she could not remember discontinuing any insulin medications or blood sugar monitoring for Resident 1 on [DATE]. LVN 1 stated discontinuing an insulin order required a valid reason such as supporting the discontinuation with laboratory results such as a Hemoglobin [Hb] A1C [a common blood test used to diagnose type 1 (pancreas does not make insulin) and type 2 (the pancreas make less insulin) diabetes] laboratory result. LVN 1 stated the facility practice was for the MDS Nurse to review a newly admitted resident's GACH records and for the RN supervisor to review the admission orders for accuracy. LVN 1 stated she did not know if another licensed staff or an RN reviewed Resident 1's admission orders the next day following admission on [DATE]. During an interview on [DATE] at 6:45 PM with the DON, the DON stated when a resident is newly admitted to the facility, the licensed nurse should verify all the resident's medications with the physician. The DON stated it is the licensed nurse's responsibility to notify the physician if a resident's medical diagnosis was not addressed, such as not having medications for a resident's diagnosis of DM. The DON stated for a resident with a diagnosis of DM, the expectation is for the licensed nurse to ask the physician to add an order for blood sugar monitoring. The DON stated discontinuing insulin must be supported by enough justification such as blood sugar trends or laboratory values like the Hemoglobin A1C. During a review of the facility's P&P titled, admission and Orientation of Residents, revised [DATE], indicated the following: 1. The resident's physician will provide medical orders, including a medical condition or problem associated with each medication. 2. The resident's physician will provide routine care orders to maintain or improve the resident's function. 3. A registered nurse will conduct the initial assessment of the resident. During a review of the facility's P&P titled, admission Assessment, [DATE], indicated the licensed nurse will complete a drug regimen review upon admission or as close to the actual time of admission as possible to identify any potential or actual clinically significant medication issues. During a review of the facility's policy and procedure titled Care Planning dated [DATE], indicated each resident should have a comprehensive person-centered care plan developed and implemented based on individual assessed needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure one of three sampled residents (Resident 1) who had a diagnosis of Diabetes Mellitus [DM, a chronic disease where a person has high blood sugar levels because the body does not produce insulin (a hormone made by the pancreas- an organ in the body) received treatment and services, in accordance with professional standards of practice, the care plan, physician orders, and the facility ' s policies and procedures, for the treatment and care of DM. The facility failed to: 1. Ensure a licensed staff reviewed Resident 1 ' s medical history of DM and discharge orders from GACH 1 that indicated Resident 1 was receiving insulin and blood sugar monitoring, prior to admission to the facility and verify with MD 1 if blood sugar monitoring and/or insulin should be continued while residing at the facility from [DATE] to [DATE]. 2. Implement the facility ' s policy and procedure titled admission Assessment, when another licensed nurse did not complete a drug regimen review on or after Resident 1 ' s admission at the facility to identify any potential or actual clinically significant medication issues. 3. Implement the facility ' s policy and procedure titled Diabetic Care and Resident 1 ' s plan of care for DM, which indicated the facility ' s licensed nurses would monitor Resident 1 for signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), and document in the resident ' s records, from the date of facility admission on [DATE]- [DATE] (a total of 61 days). 4. Ensure the facility ' s Interdisciplinary Team (IDT- a group of professionals with different areas of expertise who work together to achieve a common goal), that included the Director of Nursing (DON) was aware of Resident 1 ' s care plan for DM and reviewed the resident ' s records to ensure the care plan are being followed, in accordance with the DON ' s written job description. 5. Ensure that the facility ' s Pharmacist Consultant (PH) 1 have documented evidence in the facility ' s Medication Regimen Review (MRR, a process conducted by a pharmacist, to review a resident ' s medications) that pharmacy recommendations were provided to address concerns related to Resident 1 ' s diagnosis of DM, in accordance with the Pharmacist Consultant job description. The MRR did not indicate recommendations for blood sugar monitoring or insulin regimen to manage Resident 1 ' s DM. As a result, Resident 1 had a change in condition on [DATE], manifested by altered level of consciousness (a change in a patient's state of awareness [ability to relate to self and the environment]), oxygen desaturation (blood oxygen levels drop below a normal range [normal levels are 96 to100 %]) of 77% and a blood sugar of 500 (normal blood sugar levels are between 70 to 100). Resident 1 was transferred to the general acute care hospital (GACH) 2 via 911 emergency services. Resident 1 ' s blood sugar result from the GACH 2 indicated a blood sugar of 810 on [DATE]. Resident 1 died at the GACH 2 due to Diabetic Ketoacidosis (DKA - a serious complication of diabetes that happens when the body does not have enough of a hormone called insulin [a hormone made by the pancreas- an organ in the body)]) on [DATE]. Resident 1 ' s Certificate of Death (a legal document used by the state and federal government to prove someone has died) indicated the immediate cause of death (final disease or condition resulting in death) as Diabetic Ketoacidosis and underlying cause of death (disease or injury that initiated the events resulting in death) indicated DM Type 2 (a type of DM [chronic condition caused by not producing enough insulin in the body]) . On [DATE] at 7:43 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider ' s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the facility ' s failure to ensure a resident with a diagnosis of Diabetes Mellitus (DM, a chronic disease where a person has high blood sugar levels because the body does not produce insulin normally and required blood sugar monitoring and/or medications to lower blood sugar levels]) Type 2 received treatment and services for diabetes. The survey team notified the Administrator (ADM) and the Director of Nursing (DON) of an IJ situation on [DATE] at 7:43 PM, due to the facility ' s failure to ensure Resident 1 received the appropriate admission orders for diabetes care and management provided by a physician. On [DATE] at 3:02 PM, the Administrator (ADM) provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On [DATE] at 3:19 PM, while onsite and after the surveyor verified/confirmed the facility ' s full implementation of the IJ Removal Plan through observation, interview, and record review, and determined the IJ situation was no longer present, the IJ was removed onsite, in the presence of the ADM and the DON. The IJ Removal Plan dated [DATE], included the following: · On [DATE], the DON provided an in-service (training program while staff are employed) with Licensed Vocational Nurse (LVN) 1 on diabetic medication order clarifications, admission orders, implementation of care plans, verification of physician orders, and signs and symptoms of hyperglycemia (high blood sugar levels) and hypoglycemia (low blood sugar levels). · LVN 1 was provided with additional in-service on Diabetic Care Policy and Procedure, diabetic patient management, order clarification, and care planning on escalation (to involve someone of higher position) of interventions if medication list is not provided for residents upon admission. · Starting [DATE], the Director of Nurses (DON)/Designee initiated monthly in-services for three months to reinforce best practices in the admission process, to review all inquiries for newly admitted residents. Registered Nurse [RN]/DON will input all medication orders for newly admitted residents. RN/DON will complete all admission assessments for newly admitted residents. RN/ DON will contact the transferring acute care hospital and primary care provider to clarify all medication orders and compare to the patient's diagnosis/medical condition to ensure that all of the correct medications are ordered for each resident upon admission and correct any potentially missed medication orders in real time. · On [DATE] and [DATE], the DON provided all licensed nurses with an in-service regarding Diabetes Management including the review of admission diagnosis, diabetic medication order clarification, implementation of care plans, verification of physician orders, and proper documentation to ensure that all staff are updated on the current diabetic care policy and procedure. · On [DATE], the Pharmacist Consultant (provides facilities with expert advice and recommendations about resident ' s medications by performing medication reviews) completed a Medication Regimen Review for all residents with diagnosis of DM at the facility and made recommendations. · On [DATE], the DON and Minimum Data Set (MDS- a comprehensive standardized assessment and screening tool) Nurse reviewed records for all current residents with the diagnosis of DM using a Diabetes Audit Log to identify other residents. All residents with diagnosis of DM were physically assessed, admission orders/documentation were reviewed, monitoring for signs and symptoms of hypoglycemia and hyperglycemia were reviewed, and care plans were reviewed/updated to address DM management. · On [DATE], the DON/MDS Nurse and the Medical Records Director (MRD), conducted an audit of medication administration records and treatment protocols (system of rules) for residents with a diagnosis of DM to ensure adherence to prescribed treatments. · Starting [DATE], the MDS Nurse will conduct an admission chart review audits for newly admitted residents the next day, after their admission to the facility to monitor compliance with diabetes management protocols, physician orders, blood sugar monitoring, and identify areas requiring corrective action. · Starting [DATE], the IDT will develop and implement comprehensive care plans for residents with DM, including regular monitoring, and preventive measures for complications. Care plans will be reviewed by IDT and updated during weekly meetings and as required by changes in the resident's condition by a licensed nurse. · Starting [DATE], the RN or DON will oversee documentation of care plans, assessments, medication orders, monitoring, and physician orders, ensuring that all interventions are properly recorded and that any issues or clarifications are addressed the same day that the residents are admitted . · On [DATE], the Medical Director provided an in-service with Resident 1 ' s attending physician regarding admission orders, DM medication management, medication orders, order for blood sugar checks and monitoring for signs and symptoms of hypoglycemia and hyperglycemia. · On [DATE], the Medical Director provided an in service with the Pharmacist Consultant that reviewed Resident 1's medication regimen during the month of February 2024 to educate the consultant on reconciliation of all resident's diagnosis with medication orders concurrently. · On [DATE], the Medical Director educated the Pharmacist Consultant regarding medication recommendations regarding DM medication management, medication orders, and order for blood sugar checks and monitoring for signs and symptoms of hypoglycemia and hyperglycemia. · Starting [DATE], the DON/Designee will oversee the administration of diabetes-related medications and ensure that physician recommendations are followed daily. · Starting [DATE], the Medical Director will initiate an in-service of the facility's Primary Care Physicians, Nurse Practitioners, and Physicians Assistants on admission orders, DM medication management, medication orders, and order for blood sugar checks. Cross reference to F635, F711, F756 Findings: During a review of Resident 1 ' s GACH 1 record, titled, Inpatient Progress Notes, dated [DATE], indicated Resident 1 had a diagnosis of DM . The GACH 1 record indicated a plan to continue Resident 1 ' s insulin medication to maintain a blood sugar goal of less than 180. During a review of Resident 1 ' s GACH 1 record titled Discharge Documentation dated [DATE], timed at 11:07 AM, indicated Issues to Address on Outpatient Follow Up/Discharge Action Plan which included Resident 1 to have continued diabetes management in the facility. The Discharge Documentation record indicated Resident 1 received insulin in GACH 1 and will need physician [follow up] for DM care. Further review of the Discharge Documentation indicated Resident 1 ' s last blood sugar result in GACH 1 on [DATE] was 157. During a review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included DM, encephalopathy (damage or disease that affects the brain), dementia (a syndrome that causes a decline in cognitive [thought process]) abilities, such as thinking, remembering, and making decisions, that can interfere with daily activities), and hypertension (high blood pressure). During a review of Resident 1 ' s Nursing admission Assessment, dated [DATE], timed at 6:03 PM, signed by LVN 1 and LVN 3, indicated the resident was admitted to the facility on [DATE] at around 5:10 P.M. The Nursing admission Assessment indicated Resident 1 had a diagnosis of DM Type 2. During a review of Resident 1 ' s care plan titled, The resident [Resident 1] has DM, initiated on [DATE] and revised on [DATE], indicated a goal for the resident to not have complications related to diabetes. The care plan interventions included to monitor, document, and report signs and symptoms of hyperglycemia and hypoglycemia. During a review of Resident 1 ' s Order Summary Report (OSR) for all orders during Resident 1 ' s stay at the facility from [DATE] to [DATE], included a physician order to administer Insulin Lispro [a class of insulin hormone] Injection Solution 100 Unit/ML [Unit per milliliter, a unit of measure] Inject as per sliding scale (a guide use to determine how much insulin to give to correct an elevated blood sugar) on [DATE]. The OSR indicated the order for Insulin Lispro sliding scale was discontinued the same date, [DATE]. During a review of Resident 1 ' s facility records titled, Discontinue Order, dated [DATE], timed at 11:17 PM, signed by LVN 1, indicated a telephone order from MD 1, for Insulin Lispro Sliding Scale to discontinue on [DATE], timed at 11:16 PM. The record indicated the reason for discontinuing was Clarification of Order. During a review of Resident 1 ' s admission MDS, dated [DATE], indicated the resident had severely impaired [a condition that significantly limits an individual's physical or mental abilities] cognition (ability to remember and process information). The admission MDS indicated Resident 1 did not have an order for insulin and did not include resident ' s diagnosis of DM. During a review of Resident 1 ' s admission MDS, dated [DATE], indicated the resident had severely impaired cognition (ability to remember and process information). The admission MDS indicated Resident 1 did not have an order for insulin and did not include resident ' s diagnosis of DM. During a review of Resident 1 ' s IDT Conference Record, dated [DATE], signed by different members of the facility ' s IDT from the Nursing Department, Activities Department, and Social Services, participated by Resident 1 ' s family member (FM 1), the IDT Record indicated Resident 1 had a diagnosis that included dementia and DM Type 2. The IDT Record indicated Resident 1 ' s plan of care to receive physical therapy (a healthcare profession that helps an individual ' s body improve and perform physical movements) and occupational therapy (therapy based on engagement in meaningful activities of daily life) while residing at the facility and the discharge goals to go home with FM 1. The IDT Conference Record did not indicate information that IDT addressed Resident 1 ' s plan of care for management of DM. During a review of Resident 1 ' s Change in Condition Evaluation (CIC), dated [DATE], timed at 7:04 PM, the CIC indicated Resident 1 was found to have labored breathing (a non-medical term used to describe when breathing is difficult or impaired) and with a blood sugar level of 500. The CIC indicated Resident 1 had signs and symptoms that included altered mental status, oxygen desaturation, and hyperglycemia. The CIC indicated MD 1 and Resident 1 ' s family were notified. The CIC indicated Resident 1 was transferred via 911 emergency services to GACH 2 on [DATE]. During a review of Resident 1 ' s Transfer Form, dated [DATE], the Transfer Form indicated Resident 1 was transferred to GACH 2 on [DATE]. The Transfer Form indicated the reason for the transfer was due to altered mental status. During a review of Resident 1 ' s GACH 2 Emergency Department [ED] Reports dated [DATE], indicated the resident was admitted to the ED on [DATE] at 6:48 PM with a chief complaint of altered mental status and having a blood sugar of High [a glucometer (a portable device used to measure blood sugar levels) reading that means a very high blood sugar level above 600]. The GACH 2 ED Report indicated At around 5:50 PM, [Resident 1] refused her dinner and threw her juice on the floor and refused to eat. When [Resident 1] was reevaluated they [facility staff], noted that she [Resident 1] was breathing heavily [difficulty breathing] and not speaking. The GACH 2 ED Report indicated the facility staff tried to measure [Resident 1 ' s] [blood] sugar, and the glucometer read as high. The GACH 2 ED Report indicated Resident 1 ' s blood sugar level taken at the GACH 2 upon arrival to the ED was 810. During the same review of Resident 1 ' s GACH 2 ED Report dated [DATE], indicated a diagnosis of DKA. The GACH 2 ED Report indicated the resident was started on insulin drip (insulin that is administered directly through a person ' s vein) and was admitted to the ICU for management of the DKA. During a review of Resident 1 ' s GACH 2 Medication Administration Records (MAR), the GACH 2 MAR indicated GACH 2 started Resident 1 on insulin drip (insulin given through an intravenous [IV-through the vein] to get into the body more quickly to bring down high blood sugar) on [DATE]. During a review of Resident 1 ' s GACH 2 records titled Discharge [DC] Summaries Notes, dated [DATE], timed at 3:11 PM, indicated Resident 1 coded [a medical term which means a person ' s heart stopped and basic life support was provided] and expired on [DATE] while in the ICU. The GACH 2 DC Summary indicated Resident 1 ' s final diagnoses included DM Type 2, hyperosmolar hyperglycemic state (a serious complication of diabetes that happens when blood sugar levels are very high for a long period of time), DKA, sepsis (a serious condition in which the body responds improperly to an infection), and altered mental status . During a review of Resident 1 ' s Certificate of Death indicated Resident 1 expired on [DATE] in GACH 2. The Certificate of Death indicated the immediate cause of death (final disease or condition resulting in death) as Diabetic Ketoacidosis and underlying cause of death (disease or injury that initiated the events resulting in death) indicated Diabetes Mellitus Type 2. During a concurrent interview on [DATE] at 1:28 PM with the MDS Nurse and record review of Resident 1 ' s clinical records provided by the facility from [DATE] to [DATE], the MDS Nurse stated there were no documented evidence that any licensed staff called MD 1 to verify the reason for the Clarification of Order for Resident 1 ' s Insulin Lispro Sliding Scale that was discontinued on [DATE]. The MDS Nurse stated there was no documented evidence that licensed staff notified MD 1 or other physicians that Resident 1 was receiving insulin from GACH 1. The MDS Nurses stated there was no documented evidence that licensed staff verified if MD 1 would continue the order for insulin and blood sugar monitoring as a diabetic regimen [course of treatment] for Resident 1. The MDS Nurse stated residents that have a diagnosis of DM should have an order to have their blood sugar monitored. The MDS Nurse stated discontinuing a medication should have a valid reason. The MDS Nurse stated the reason indicated by LVN 1 on [DATE], which read clarification of order, was not a valid reason for discontinuing the Insulin Lispro Sliding Scale on [DATE]. The MDS Nurse stated she did not call or clarify with MD 1 to verify the insulin medication order and blood sugar monitoring, upon completion of the resident ' s admission MDS [on [DATE]]. The MDS nurse stated there was no documented evidence that Resident 1 was monitored for signs and symptoms of hyperglycemia and hypoglycemia, as indicated in the resident care plan for DM developed on [DATE] and revised on [DATE]. During a concurrent interview on [DATE] at 1:28 PM with the MDS Nurse and record review of Resident 1 ' s clinical records provided by the facility from [DATE] to [DATE], the MDS Nurse stated there were no documented evidence that any licensed staff called MD 1 to verify the reason for the Clarification of Order for Resident 1 ' s Insulin Lispro Sliding Scale that was discontinued on [DATE]. The MDS Nurse stated there was no documented evidence that licensed staff notified MD 1 or other physicians that Resident 1 was receiving insulin from GACH 1. The MDS Nurses stated there was no documented evidence that licensed staff verified if MD 1 would continue the order for insulin and blood sugar monitoring as a diabetic regimen [course of treatment] for Resident 1. The MDS Nurse stated residents that have a diagnosis of DM should have an order to have their blood sugar monitored. The MDS Nurse stated discontinuing a medication should have a valid reason. The MDS Nurse stated the reason indicated by LVN 1 on [DATE], which read clarification of order, was not a valid reason for discontinuing the Insulin Lispro Sliding Scale on [DATE]. The MDS Nurse stated she did not call or clarify with MD 1 to verify the insulin medication order and blood sugar monitoring, upon completion of the resident ' s admission MDS [on [DATE]]. The MDS nurse stated there was no documented evidence that Resident 1 was monitored for signs and symptoms of hyperglycemia and hypoglycemia, as indicated in the resident care plan for DM developed on [DATE] and revised on [DATE]. During the same interview, on [DATE], at 1:28 PM, the MDS Nurse stated that she had reviewed the GACH 1 records, provided to the facility upon Resident 1 ' s admission on [DATE]. The MDS Nurse stated the GACH 1 records indicated Resident 1 was receiving insulin from the GACH. The MDS Nurse stated the facility should have continued Resident 1 ' s blood sugar monitoring and insulin because it was the GACH 1 ' s discharge plans for Resident 1, prior to facility admission. The MDS Nurse stated there was no documented evidence the facility ' s licensed nurses monitored Resident ' s blood sugar from [DATE] to [DATE]. The MDS Nurse stated the only blood sugar result she found for Resident 1 was taken on [DATE], with a blood sugar result of 500. During a concurrent interview and record review of Resident 1 ' s entire facility records, from [DATE] to [DATE], and the facility ' s policy and procedure on admission Assessment and admission and Orientation of Residents on [DATE] at 2:48 PM, LVN 2 stated there was no documented evidence that another licensed nurse, reviewed Resident 1 ' s medication orders the next day after the resident ' s admission to the facility. LVN 2 reviewed the policy and procedures on admission and Orientation of Residents, that indicated a registered nurse will conduct the initial assessment of the resident. LVN 2 stated when a resident is admitted during the evening or night shift by an LVN, an RN must re-assess the resident again the next day, which should include the verification of the resident ' s medication orders. LVN 2 stated there was no documented evidence that another licensed staff (RN or another LVN) conducted a drug review of Resident 1 ' s medication orders and re-assess Resident 1 the next day, which should include verification of the resident ' s medication orders, as indicated in the facility ' s policy titled admission Assessment and admission and Orientation of Residents to ensure all the required orders were included. During a phone interview on [DATE] at 4:25 PM with LVN 1, LVN 1 stated when a resident is admitted to the facility, the admitting nurse calls the physician and asks if the attending physician would like to continue everything [medication orders from the GACH]. LVN 1 stated she does not verbally read over the resident ' s entire medication list to the physician. LVN 1 stated she could not remember if she spoke to MD 1 on [DATE], when she admitted Resident 1 to the facility. LVN 1 stated she could not remember discontinuing any insulin medications or blood sugar monitoring for Resident 1 on [DATE]. LVN 1 stated discontinuing an insulin order required a valid reason such as supporting the discontinuation with laboratory results such as a Hemoglobin [Hb] A1C (a common blood test used to diagnose type 1 and type 2 diabetes) laboratory result. LVN 1 stated the facility practice was for the MDS Nurse to review a newly admitted resident ' s GACH records and for the RN supervisor to review the admission orders for accuracy. During an interview on [DATE] at 6:45 PM with the DON, the DON stated it is the licensed nurse ' s responsibility to notify the physician if a resident ' s medical diagnosis was not addressed, such as not having medications for a resident ' s diagnosis of DM. The DON stated for a resident with a diagnosis of DM, the expectation is for the licensed nurse to ask the physician to add an order for blood sugar monitoring. The DON stated discontinuing insulin must be supported by enough justification such as blood sugar trends or laboratory values like the Hemoglobin A1C. During a concurrent interview and record review of Resident 1 ' s IDT Conference Record dated [DATE], and the resident ' s entire records from [DATE] to [DATE], on [DATE] at 9:55 AM with the DON, the DON stated the IDT Record did not show evidence that Resident 1 ' s DM was addressed. The DON stated the IDT record did not indicate a plan for Resident 1 ' s DM such as adding an order for insulin or blood sugar monitoring. The DON stated he could not find documented evidence the facility ' s IDT addressed Resident 1 ' s DM plan of care interventions on [DATE], to meet care plan goals to prevent complications related to diabetes that included monitoring, documenting, and reporting signs and symptoms of hyperglycemia and hypoglycemia. The DON stated the standard of practice for residents with DM should include blood sugar monitoring or a Hemoglobin A1C result and visual monitoring of signs and symptoms of DM. The DON stated there was no evidence in Resident 1 ' s records that the facility ' s licensed nurses monitored the resident for signs and symptoms of hypoglycemia, hyperglycemia and other signs and symptoms of DM such as frequent urination or increased thirst. The DON stated there was no laboratory order made by the physician (MD 1) that included Hb A1c during the resident ' s stay in the facility from [DATE] to [DATE]. The DON stated that Resident 1 ' s MAR from [DATE] to [DATE] did not indicate Resident 1 was monitored for blood sugar levels and DM signs and symptoms. During a review of the facility ' s MRR for the months of 2/2024, 3/2024, and 4/2024, the MRR did not have documented evidence that Pharmacist Consultant (PH) 1 addressed or provided pharmacy recommendations related to Resident 1 ' s diagnosis of DM. The MRR did not indicate recommendations for blood sugar monitoring or insulin regimen to manage Resident 1 ' s DM. During an interview, on [DATE] at 11:45 AM, PH 1 stated she comes to the facility once a month to review the facility residents ' medications. PH 1 stated she reviews the residents ' current medications only and does not look at a resident ' s diagnoses when making her recommendations. PH 1 stated, she was not part of the medication review when a resident gets admitted to the facility. PH 1 stated, she does not look at admission orders that were not current or had been discontinued. PH 1 stated she would only be able to recommend insulin medication for a resident, if the resident was getting their blood sugars checked and would base her recommendations on the results of the blood sugar checks. PH 1 stated she could not remember Resident 1 and did not check the resident ' s medication records why Resident 1 ' s insulin and blood sugar checks were discontinued on admission ([DATE]). PH 1 stated that if she knew Resident 1 had diabetes and did not have any blood sugar checks, she would have recommended for blood sugar checks or a Hemoglobin A1C laboratory test to be done and would have recommended insulin or oral diabetes medications (medications taken by mouth to manage blood sugar levels). During an interview on [DATE] at 1:19 PM, MD 1 stated that normally the current medications from the acute hospital are continued when a resident is admitted to the facility. MD 1 stated he could not remember Resident 1, but he signed and performed the resident ' s History and Physical assessment on [DATE]. MD 1 stated, generally, unless the discharging physician in the GACH discontinued the GACH medications, the expectation is for current medications to be continued at the facility. MD 1 stated, he reviewed the medications of Resident 1 from GACH 1 and stated that all current medications was supposed to be continued. MD 1 stated Resident 1 ' s insulin medications should not have been discontinued. MD 1 stated Resident 1 ' s insulin should have been continued at the upon admission to the facility on [DATE]. MD 1 stated, he does not discontinue insulin medications, once admitted to the facility, but would review for any dosage changes. MD 1 stated, he was not aware Resident 1 ' s insulin was not continued in the facility and that there was no blood sugar monitoring ordered for the resident. MD 1 stated, if insulin is discontinued, the resident could get hyperglycemic [increase blood sugar levels]. MD 1 stated, Resident 1 should have received insulin while in the facility. MD 1 stated, Resident 1's blood sugar levels could go high if not monitored and complication such as DKA could happen and result in death. MD 1 stated, he was not aware Resident 1 did not have an order for blood sugar monitoring, and if he knew that Resident 1 had a diagnosis of diabetes, he would have placed an order for blood sugar monitoring. MD 1 stated he expected the facility ' s licensed nurses to let him know that Resident 1 did not have blood sugar monitoring for the management of DM. MD 1 stated, discontinuing insulin needs documented justification and could not recall if the facility ' s licensed nurses informed him of Resident 1 ' s blood sugar monitoring. During an interview on [DATE] at 5:25 PM, the DON stated that PH 1 did not have any pharmacy recommendations for Resident 1 for the months of 2/2024, 3/2024, and 4/2024. During a review of the facility ' s policy and procedure (P&P) titled, Diabetic Care, revised [DATE], indicated the following: 1. The purpose of the P&P is to provide a protocol for the immediate treatment of hypoglycemia in residents diagnosed with diabetes. 2. The Licensed Nurse will monitor residents for signs and symptoms (of) hypoglycemia and hyperglycemia. Signs and symptoms will be documented in the resident ' s medical record and the Attending Physician will be notified. 3. Notify the Attending Physician of treatment and results and for any possible changes in insulin or oral diabetes medications. During a review of the facility ' s P&P titled, admission and Orientation of Residents, revised [DATE], indicated the following: 1. The resident ' s physician will provide medical orders, including a medical condition or problem associated with each medication. 2. The resident ' s physician will provide routine care orders to maintain or improve the resident ' s function. 3. A registered nurse will conduct the initial assessment of the resident. During a review of the facility ' s P&P titled, admission Assessment, [DATE], indicated the the licensed nurse will complete a drug regimen review upon admission or as close to the actual time of admission as possible to identify any potential or actual clinically significant medication issues. During a review of the facility ' s policy and procedure titled Care Planning dated [DATE], indicated each resident should have a comprehensive person-centered care plan developed and implemented based on individual assessed needs. During a review of the facility ' s job description titled, Consultant Pharmacist, (undated) indicated the pharmacist is to: 1. Provide physicians, nurses, and patients with therapeutic recommendations and/or medication information. 2. Report any drug regimen irregularities to the attending physician and Director of [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was alert, oriented to name, place, time and person, and able to make needs known was free from sexual abuse (non-nonconsensual touching of one person for the sexual gratification of another) by failing to ensure: 1. Resident 1 was not sexually abused by the Laundry Staff from 8/30/23 to 9/1/23. 2. Resident 1 was protected from sexual abuse from the Laundry Staff. The Licensed Vocational Nurse (LVN 1) and the Director of Nursing (DON) was aware of Resident 1's allegation of sexual abuse when it was reported by Resident 1 on 9/2/23. The Laundry Staff continued to work in the facility until 9/5/23. These deficient practices resulted in Resident 1 experiencing sexual abuse, verbalized feeling unhappy, uncomfortable, disgusted, shocked, and violated (failing to respect someone ' s peace or privacy) from the action and abuse of the Laundry Staff. This deficient practice also had the potential to affect other vulnerable residents in the facility to experience sexual abuse. On 9/12/23 at 2:39 pm, the California Department of Public Health (CDPH) called and was notified of an Immediate Jeopardy situation (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) with regards to the facility ' s failure to protect the residents from sexual abuse, allowing Laundry Staff back to the facility and went into Resident 1 ' s room talking to her. The facility submitted an acceptable IJ Removal Plan (action to correct the deficient practices), to CDPH on 9/13/23 at 5:07 PM. The IJ was removed on 9/13/23, after the surveyors verified and confirmed the facility implemented the facility ' s IJ Removal Plan (a detailed plan to address the IJ findings) while onsite by observation, interview, and record review. The IJ was removed in the presence of Administrator (ADM) and the Director of Nursing (DON). The acceptable IJ Removal Plan included the following information: 1. Administrator provided a 1:1 (one on one) in-service regarding Abuse Prevention and Prohibition and immediately. 2. Terminated Laundry Staff on 9/13/23. 3. DON and Treatment Nurse proceeded to assessed Resident 1 and conduct a body assessment on 9/5/23 at 11:10 AM. Resident body check was noted to be clear and skin intact. 4. Resident was assessed as alert, oriented and no complaint of any pain, discomfort, was noted to be calm and cheerful and no signs and symptoms of any emotional distress such as crying, sadness or being emotional, denied feeling of fear and anxiety. 5. Change of Condition/SBAR (stands for 'Situation, Background, Assessment, Recommendation a communication tool communication between members of the health care team about a patient's condition) was initiated by the DON on 9/5/23 at 11:30 AM, Primary MD (Medical Doctor) and Family 1 made aware of the alleged abuse allegation of Resident 1. Primary MD ordered refers to psychiatrist and continue monitor for signs and symptoms of emotional distress times 14 days. Care plan for Risks for emotional distress and discomfort related to Alleged Abuse allegation by a male laundry employee was initiated on 9/5/23. 6. IDT (Interdisciplinary Team-team of facility staff that work together to develop the plan care of the residents) team met with Resident 1 on 9/5/23 at 12:00 PM to discuss her alleged allegation of abuse regarding the laundry male staff. Resident was informed regarding the Laundry Staff being suspended this morning to provide reassurance and ensure her safety. Resident 1 was informed to report any concern or issues regarding any facility staff to licensed nurses immediately to ensure her safety. 7. On 9/5/23 at 12:30 PM, Regional Clinical Director (RCD) provided in-service training to Administrator and DON regarding Abuse Prohibition and Management specifically on timely reporting of alleged resident abuse and protection of resident who made the allegation of abuse. 8. A physician order for monitoring of Resident 1 for signs and symptoms of emotional distress by the licensed nurse each shift was initiated on 9/5/23 at 1:30 PM and will be ongoing indefinitely to ensure that any resident issue be communicated to primary MD and psychiatrist timely. RCD provide in-services regarding Abuse Prohibition and Management including reporting and prevention to Dietary staff, Housekeeping and nursing staff on 9/5/23 at 1:00 PM. Administrator continued to provide Abuse Prohibition and Management in-service to facility on 9/5/23 3-11 shift and DON provided Abuse Management to nursing staff on 9/6/23 11-7 shift. All facility staff were made aware of Resident 1 allegation of abuse regarding the male Laundry Staff during the abuse in-services. Cross Reference F607 Findings: A review of Resident 1 ' s admission Record indicated the Resident 1 was admitted the facility on 12/11/18 with diagnoses that included unspecified Epilepsy (neurological disorder in which a person has two or more unprovoked seizures that occur more than 24 hours apart), myocardial infarction (partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart muscle), and, muscle weakness (when full effort doesn't produce a normal muscle contraction or movement). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 8/17/23, indicated Resident 1 had the capacity to make needs known and understand others, and with moderate cognitive impairment (ability to understand and make decisions). During an interview on 9/7/23 at 11:20 am, the DON stated she was informed by LVN 1 on 9/3/23 around 2:30 pm on Sunday of Resident 1 ' s sexual abuse allegation. The DON stated Resident 1 ' s allegation was not considered an allegation of abuse since she has dementia (progressive or persistent loss of intellectual functioning). The DON stated she told LVN 1 she will come back tomorrow (9/4/23) to assess the sexual allegation. The DON stated Resident 1 informed her about the allegation of sexual abuse on 9/4/23 at around 6:35 pm. The DON stated she did not report Resident 1 ' s allegation of sexual abuse to the adult protective services, the state survey agency, ombudsman, and the local law enforcement, and did not investigate the allegation of sexual abuse because Resident 1 has dementia. The DON stated the facility ' s Abuse policy indicated the facility ' s abuse coordinator was the ADM who should report any allegation of abuse to the Department, Ombudsman, and local law enforcement within two hours. DON admitted it was her fault she did not inform the ADM and suspend the Laundry Staff when she was informed by LVN 1 about the sexual abuse allegation on 9/3/23. The DON denied that she was informed of the allegation of sexual abuse on 9/2/23 as reported by Resident 1 to the law enforcement and the surveyor. During an interview on 9/7/23 at 11:50 am, the ADM stated he was not informed of Resident 1 ' s sexual abuse allegation on 9/2/2023 as reported by Resident 1. The ADM stated he was notified of the alleged sexual abuse on 9/5/23 around 9 am. The ADM stated DON and LVN 1 did not report Resident 1 ' s allegation of sexual abuse to the adult protective services, the state survey agency, ombudsman, and the local law enforcement. The ADM stated the facility ' s Abuse policy indicated the facility should report any allegation of abuse to the Department, Ombudsman, and local law enforcement within two hours of alleged sexual abuse. During an observation and interview with Resident 1 on 9/7/23 at 12:30 PM, Resident 1 was observed sitting on the bed. In an interview, Resident 1 was alert and oriented to name, place, time and date. Resident 1 stated on 8/30/23 while she was sitting on the bed, the Laundry Staff stood in front of her and said something to her that she could not understand. The Laundry Staff then grabbed her left hand and put her hand under his buckle belt and had her rub his penis five to six times back and forth. Resident 1 stated the Laundry Staff was smiling and kept looking behind him to see if there was anyone watching. Resident 1 stated before the Laundry Staff left her room, he said he was coming back. Resident 1 stated, the next day on 8/31/23, the Laundry Staff went in her room between 10 AM to 11 AM, and again grabbed her hand and rubbed her hand on penis about five to six times and he kept watching the door to see if someone was coming. Resident 1 stated on 9/1/23, the Laundry Staff came into her room again, grabbed and rubbed her hand against his penis. Resident 1 stated she pulled back her left hand and told Laundry Staff Not to do that ever again. Resident 1 stated she felt unhappy, uncomfortable, disgusted, and shocked with the incident. Resident 1 stated she did not know what to do and who to tell. Resident 1 stated she talked to Family 1 (FAM1) about the sexual abuse. Resident 1 stated FAM 1 informed the Licensed Vocational Nurse (LVN 1) about the sexual abuse by the Laundry Staff on 9/2/23. A review of Police Report (PR) from Police Department (PD1) reported dated on 9/5/23 at 11:52 am. PD1 conducted an interview with Resident 1 and the PR indicated the following: 1. Resident 1 stated on 8/30/23 around 1 pm, Laundry Staff went into her room and approached her bedside. Resident 1 was in a sitting position on her bed and Laundry Staff stood on left side of her bed, grabbed her left hand, and pulled towards the bottom portion of his belt buckle. Resident 1 stated the Laundry Staff rubbed the back of her hand approximately five to six times back and forth between his belt-buckle and his penis. Laundry Staff placed her hand over his paints and not under his clothes. Laundry Staff was looking back toward the bedroom door to see if anyone was approaching her bedroom. Resident 1 said Laundry Staff looked at her, touched her face with his other hand. Laundry Staff released her left hand and put his finger to his mouth and said Shh, shh shh, I ' ll be back. 2. Resident 1 stated on 8/31/23 between 10 am to 11 am, Laundry Staff went into her room and approached her left side of bed. Resident 1 was in a sitting position on her bed and Laundry Staff stood on the left side. Laundry Staff grabbed her left hand and pulled it toward his groin area. Resident 1 stated in the manner the Laundry Staff grabbed her hand form a fist position. Resident 1 said Laundry Staff rubbed the back of her hand below his belt buckle over his pants approximately six times back and forth between his belt-buckle and his penis. Laundry Staff was looking back toward the bedroom door to see if anyone was approaching her bedroom. Laundry Staff released her left hand and put his finger to his mouth and said Shh . shh shh, I ' ll be back. 3. Resident 1 stated on 9/1/23 between 10 am to 11 am, Laundry Staff went into her room and approached her left side of bed. Resident 1 was in a sitting position on her bed and Laundry Staff stood on the left side. Laundry Staff grabbed her left hand and pulled it toward his groin area. Resident 1 stated the manner in which the Laundry Staff grabbed her hand form a fist position. Resident 1 said Laundry Staff rubbed the back of her hand below his belt buckle over his pants two times. Resident 1 hand was rubbed back and forth between his belt-buckle and his penis. Resident said she was in shocked the other two times that Laundry Staff assaulted her and now she was angry and pulled her hand away. Resident 1 recalled saying No don ' t ever do that again, Laundry Staff walked away and never returned. 4. Resident 1 stated she notified LVN 1 on 9/2/23. 5. Resident 1 stated on 9/5/23 at around 9 am the Laundry Staff walked in her room and said, Momma, momma, momma, please don ' t. I have a sick daughter in college. Please momma, please don ' t get me fired. I won ' t be able to get work. 6. The report indicated the Resident 1 was coherent and provided detailed statements of the answer to the question and the allegation appeared credible. During an interview on 9/12/23 at 10:35 am LVN 1 stated Resident 1 ' s Family (FAM 1) called him around noon time on 9/3/23 and told him about Resident 1 was sexual abuse by the Laundry Staff on 8/30/23, 8/31/23 and 9/1/23. LVN 1 went to Resident 1 ' s room to gather information from Resident 1. LVN 1 stated at the beginning, on 9/3/23 Resident 1 she was in shocked and hesitated to tell the whole story. LVN 1 stated Resident 1 reported that feeling anxious and afraid to go to nursing station to look for him. LVN 1 stated Resident 1 was able to give detailed information of the sexual abuse incident clearly and was not confused. LVN 1 stated he reported Resident 1 ' s allegation of sexual abuse to DON around 2 pm on 9/3/23. LVN 1 denied that he received Resident 1 ' s allegation of sexual abuse on 9/2/23 as reported by Resident 1 to the police the surveyor. During an interview on 9/12/23 at 12:10 pm with Maintenance and Laundry supervisor (MLS), stated that he was informed by LVN 1 on 9/3/23 about the Resident 1 ' s alleged sexual abuse by the Laundry Staff. Laundry Staff was off on 9/3/23 and 9/4/23. MLS stated Laundry Staff returned to work on 9/5/23. During an interview on 9/13/23 at 3:20 pm with the DON, stated that she talked to the Laundry Staff on 9/5/23 not to go to Resident 1 ' s room. A review of Resident 1 ' s progress note titled Psych evaluation following an alleged sexual abuse, dated 9/8/23, indicated Resident 1 was sexually violated by a facility staff on 8/30/23, 8/31/23 and 9/1/23. The evaluation indicated, on 8/30/23 the Laundry Staff came into to her room and stoked her face with his hand; on 8/31/23 Resident 1 stated the Laundry Staff came to her room and stoked her arms; Resident 1 stated she felt uncomfortable and unhappy by the action of the Laundry Staff; and on 9/1/23 Resident 1 stated Laundry Staff came to her room and held her left hand to rub his groin. Resident 1 reported she felt violated and disgusted by the action of the Laundry Staff. A review of the facility ' s policy and procedure, titled Abuse Prevention and Prohibition Program revised on 10/24/22, indicated the residents had the right to be free from abuse and the facility had zero-tolerance for abuse, neglect, and mistreatment of each resident. The policy indicated the facility was committed to protecting residents from abuse by anyone, including from the facility staff; shall thoroughly investigate; and report resident allegation of abuse no later than two hours after forming the allegation to the ombudsman, law enforcement: adult protective services and state survey agency; protect resident from any harm that could result from investigation; and the facility staff member accused of committing abuse against a resident is suspended until the investigation is complete, and the findings had been reviewed by the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to implement the facility's policy and procedure, titled Abuse Prevention and Prohibition Program Policy for one of three sampled residents (Resident 1) by not protecting, preventing, reporting, investigating an allegation of sexual abuse (non-consensual touching of one person for the sexual gratification of another) from the facility's male Laundry Staff. The facility failed to: 1. Prevent Resident 1 from sexual abuse when the facility's male Laundry Staff grabbed and rubbed Resident 1's hand between his belt buckle and his penis five to six times back and forth while in the Resident 1's room on 8/30/23 and 8/31/23. 2. Protect Resident 1 from sexual abuse on 9/1/23, when the Laundry Staff continued to go into Resident 1's room putting the resident's hand above his penis. Resident 1 pulled away and told the Laundry Staff Not to do that ever again. 3. Protect Resident 1 from sexual abuse when the Laundry Staff remained employed at the facility from 9/2/23 to 9/5/23, for four days after reported to the Licensed Vocational Nurse (LVN 1) 1 and the Director of Nursing (DON) on 9/2/23 by Resident 1 and Family 1 (FAM1). 4. Report Resident 1's allegation of sexual abuse to the Department of Public Health (State Survey Agency), local law enforcement, Ombudsman (state agency that advocates for the residents) and Adult Protective Services (agency that protects the adults and elderly) on 9/2/23 by Resident 1 and FAM 1 to LVN 1 and the DON. 5. Investigate an allegation of sexual abuse when the sexual abuse was reported by Resident 1 to the Licensed LVN 1 and the DON on 9/2/23. The allegation was investigated on 9/5/23 (four days after the alleged abuse occurred). These deficient practices resulted in Resident 1 experiencing sexual abuse, verbalized feeling unhappy, uncomfortable, disgusted, shocked, and violated (failing to respect someone's peace or privacy) from the action and abuse of the facility Laundry Staff. This deficient practice also had the potential to affect other vulnerable residents in the facility to experience sexual abuse. On 9/12/23 at 2:39 pm, the California Department of Public Health (CDPH) notified the facility of an Immediate Jeopardy situation (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) in the presence of the DON and the Administrator (ADM) with regards to the facility's the failure to implement the facility's Abuse prevention and prohibition program. The facility submitted an acceptable IJ Removal Plan (a detailed plan to address the IJ findings) to CDPH on 9/13/23 at 5:07 pm. The IJ was removed on 9/13/23, after the surveyors verified and confirmed that the facility implemented the facility's IJ Removal Plan while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM and DON. The acceptable IJ Removal Plan included the following information: 1. Facility Administrator provided a 1:1 (one on one or one person providing in service to one staff) in-service regarding Abuse Prevention and Prohibition and immediately and suspended the Laundry Staff on 9/5/23 on 10:30 am. 2. Facility Administrator reported Resident 1's alleged sexual abuse allegation to Department of Public Health on 9/5/23 at 11:00 am by telephone. 3. The DON reported Resident 1's allegation of sexual abuse of via telephone to the police on 9/5/23 at 11:40 am. 4. The Administrator called the ombudsman (a state agent that advocates for the residents) on 9/5/23 at 12:00 pm and left message regarding Resident 1 alleged sexual abuse allegation. 5. Facility Administrator completed the SOC (State of California) 314 (form used by the facility to report suspected adult or elderly abuse to the stated survey agency) was faxed to CDPH on 9/5/23 at 4:07 pm and the Ombudsman office on 9/5/23 at 4:09 pm. 6. The local police came to the facility on 9/5/23 at 12:20 pm and interviewed Resident 1 via telephone. 7. On 9/5/23 at 12:00 pm, Regional Clinical Director provided a 1:1 in-service training to the DON regarding timely reporting of abuse to the abuse coordinator (Administrator) and timely initiation of investigation upon knowledge of Resident 1 alleged sexual abuse allegation to ensure Resident 1 safety and prevent psychological (mental) and emotional trauma (traumatizing experiences that leave you feeling unsafe or helpless). 8. On 9/5/23 at 12:30 pm, Regional Clinical Director (RCD) provided in-service training to Administrator and DON regarding Abuse Prohibition and Management specifically on timely reporting of alleged resident abuse and protection of resident who made the allegation of abuse. 9. RCD provided in-services regarding Abuse Prohibition and Management including reporting and prevention to Dietary staff, Housekeeping and nursing staff on 9/5/23 at 1:00 pm. The Administrator continued to provide Abuse Prohibition and Management in-service to facility on 9/5/23 during 3pm-11pm shift, and the DON provided Abuse Management to nursing staff on 9/6/23 11pm-7am shift. All facility staff was made aware of Resident 1 allegation of abuse regarding the male Laundry Staff during the abuse in-services. 10. Abuse binder on each station was initiated by the DON on 9/12/23 at 8:15 pm and provided in-service to the licensed nurses regarding the Abuse binder contents and information on the 3pm-11pm shift and will be ongoing till all licensed nurses will be in-service by 9/13/23. The Abuse binder will contain the following information: 1.) Contact number and fax number for CDPH, Contact Number and Fax number for Ombudsman and contact number for the police district. 2.) Name and Title of the Abuse Coordinator and DON 3.) Copies of SOC 341 form 4.) Facility policy and Procedure for Abuse Prohibition and Management. 11. Facility will continue to provide staff education regarding Abuse Prevention, Investigation and Reporting monthly for the next 6 months starting in the month of October 2023 to ensure facility compliance with facility's policy and procedure on Abuse Prohibition and Management. 12. Facility initiated QAPI (Quality Assurance Program Improvement-program to improve the quality of care at the facility) for Abuse Management on 9/5/23 to prevent recurrence of any late reporting, prevention of abuse and protection of resident including timely investigation of any alleged abuse resident report. Cross Reference to F600 Findings: A review of Resident 1's admission Record indicated the Resident 1 was admitted to the facility on [DATE] with diagnoses that included unspecified epilepsy (a disorder due to disturbed activity in the brain), myocardial infarction (partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart muscle) and, muscle weakness (when full effort doesn't produce a normal muscle contraction or movement). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 8/17/23, indicated Resident 1 had the capacity to make needs known and understand others, and with moderate cognitive impairment (ability to understand and make decisions) that required extensive assistance (resident involved in activity, staff provide weight bearing support) with one-person physical assistance on bed mobility and transfer. A review of Police Report (PR) from Police Department (PD1) report dated, 9/5/23 at 11:52 am. PD1 conducted an interview with Resident 1 and the PR that indicated the following: 1. Resident 1 stated on 8/30/23 around 1 pm, Laundry Staff went into her room and approached her bedside. Resident 1 was in a sitting position on her bed and Laundry Staff stood on left side of Resident 1's bed, grabbed her left hand and pulled towards the bottom portion of his belt buckle. Resident 1 stated the Laundry Staff rubbed the back of her hand approximately five to six times back and forth between his belt-buckle and his penis. Laundry Staff placed her hand over his pants and not under his clothes. Laundry Staff was looking back toward the bedroom door to see if anyone was approaching the resident's bedroom. Resident 1 said Laundry Staff looked at her, touched her face with his other hand. The Laundry Staff released her left hand and put his finger to his mouth and said Shh, shh shh, I'll be back. 2. Resident 1 stated on 8/31/23 between 10 am to 11 am, the male Laundry Staff went into her room and approached her left side of bed. Resident 1 was in a sitting position on her bed and Laundry Staff stood on the left side. Laundry Staff grabbed her left hand and pulled it toward his groin area. Resident 1 stated the way Laundry Staff grabbed her hand form a fist position. Resident 1 said Laundry Staff rubbed the back of her hand below his belt buckle over his pants approximately six times back and forth between his belt-buckle and his penis. Laundry Staff was looking back toward the bedroom door to see if anyone was approaching her bedroom. Laundry Staff released her left hand and put his finger to his mouth and said Shh, shh shh, I'll be back. 3. Resident 1 stated on 9/1/23 between 10 am to 11 am, Laundry Staff went into her room and approached her left side of bed. Resident 1 stated she was in a sitting position on her bed and the Laundry Staff stood on the left side. Laundry Staff grabbed her left hand and pulled it towards his groin area. Resident 1 stated the way Laundry Staff grabbed her hand form a fist position. Resident 1 said the Laundry Staff rubbed the back of her hand below his belt buckle over his pants two times. Resident 1's hand was rubbed back and forth between his belt-buckle and his penis. Resident said she was in shock the other two times that Laundry Staff assaulted her and now she was angry and pulled her hand away. Resident 1 recalled saying No don't ever do that again, Laundry Staff walked away and never returned. 4. Resident 1 stated she notified LVN 1 on 9/2/23. 5. Resident 1 stated on 9/5/23 at around 9 am the Laundry Staff walked in her room and said, Momma, momma, momma, please don't. I have a sick daughter in college. Please momma, please don't get me fired. I won't be able to get work. 6. The report indicated the Resident 1 was coherent and provided detailed statements and the allegation appeared credible. During an interview on 9/7/23 at 11:20 am, the DON stated she was informed by LVN 1 on 9/3/23 around 2:30 pm on Sunday of Resident 1's sexual abuse allegation. The DON stated Resident 1's allegation was not investigated because the allegations was not considered sexual abuse since Resident 1 has dementia (progressive or persistent loss of intellectual functioning). The DON stated she told LVN 1 on 9/3/23 that she will come back tomorrow (9/4/23) to assess the sexual allegation. The DON stated she talked to Resident 1 on 9/4/23 around 6:35 pm. The DON stated she did not report Resident 1's allegation of sexual abuse to the adult protective services, the state survey agency, ombudsman, and the local law enforcement, and did not investigate the allegation of sexual abuse because Resident 1 has dementia. The DON stated the facility's Abuse policy indicated the facility's abuse coordinator was the ADM who should report any allegation of abuse to the Department, adult protective services, ombudsman, and local law enforcement within two hours. The DON admitted it was her fault she did not inform the ADM and suspend the Laundry Staff when she was informed by LVN 1 about the sexual abuse allegation on 9/3/23. The DON denied being informed of the allegation of sexual abuse on 9/2/23 as reported by Resident 1 to the law enforcement and the surveyor. Resident 1 stated FAM 1 informed LVN 1 about the sexual abuse by the Laundry Staff on 9/2/23. During an interview on 9/7/23 at 11:50 am, ADM stated he was not informed of Resident 1's sexual abuse allegation on 9/2/2023. The ADM stated he was notified of the alleged sexual abuse during the morning meeting on 9/5/23 around 9 am. The ADM stated the DON and LVN 1 did not report Resident 1's allegation of sexual abuse to CDPH, adult protective services, ombudsman, and the local law enforcement. The ADM stated the facility's Abuse policy indicated the facility should report any allegation of abuse to CDPH, ombudsman, and local law enforcement within two hours of alleged sexual abuse. During an interview on 9/12/23 at 10:35 am LVN 1 stated Resident 1's Family (FAM 1) called him around noon time on 9/3/23 and told him Resident 1 was being sexually abused by the Laundry Staff on 8/30/23, 8/31/23 and 9/1/23. LVN 1 went to Resident 1's room to gather information from Resident 1. LVN 1 stated at the beginning, on 9/3/23 Resident 1 was in shock and hesitated to tell the whole story. LVN 1 stated Resident 1 reported feeling anxious and afraid to go to the nursing station to look for him. LVN 1 stated Resident 1 was able to give detailed information of the sexual abuse incident clearly and was not confused. LVN 1 stated he reported Resident 1's allegation of sexual abuse to DON around 2 pm on 9/3/23. LVN 1 denied that he received Resident 1's allegation of sexual abuse on 9/2/23 as reported by Resident 1 to the police officer and the surveyor. During an interview on 9/12/23 at 12:10 pm with Maintenance and Laundry supervisor (MLS), stated that he was informed by LVN 1 on 9/3/23 about the Resident 1's alleged sexual abuse by the Laundry Staff. Laundry Staff was off on 9/3/23 and 9/4/23. MLS stated Laundry Staff returned to work on 9/5/23. During an interview on 9/13/23 at 3:20 pm with DON, stated that she talked to the Laundry Staff on 9/5/23 to inform him not to go to Resident 1's room. The DON stated she did not suspend the Laundry Staff on 9/3/23 when LVN 1 reported to her the alleged sexual abuse of Resident 1 by the Laundry Staff. A review of Resident 1's progress note titled Psych evaluation following an alleged sexual abuse, dated 9/8/23, indicated Resident 1 was sexually violated by a facility staff on 8/30/23, 8/31/23 and 9/1/23. The evaluation indicated, on 8/30/23 the Laundry Staff came into to her room and stoked her face with his hand; on 8/31/23 Resident 1 stated the Laundry Staff came to her room and stoked her arms; Resident 1 stated she felt uncomfortable and unhappy by the action of the Laundry Staff; and on 9/1/23 Resident 1 stated the Laundry Staff came to her room and held her left hand to rub his groin. Resident 1 reported she felt violated and disgusted by the action of the Laundry Staff. A review of the facility's policy and procedure, titled Abuse Prevention and Prohibition Program revised on 10/24/22, indicated the residents had the right to be free from abuse and the facility had zero-tolerance for abuse, neglect, and mistreatment of each resident. The policy indicated the facility will: 1. Protect residents from abuse by anyone, including from the facility staff. Protect the resident from any harm that could result from investigation; and the facility staff member accused of committing abuse against a resident is suspended until the investigation is complete, and the findings had been reviewed by the Administrator. 2. Promptly and thoroughly investigate reports of resident abuse. If the ADM receives a report of abuse and mistreatment, the ADM or designee will appoint a member of the facility's management team to investigate the allegation by making an investigation report, interview witnesses, resident (as medically appropriate) and review all relevant documents. 3. Report resident's allegation of abuse no later than two hours after forming the allegation to the ombudsman, law enforcement: adult protective services and state survey agency. The ADM will submit initial and follow up written reports of the result of all the abuse investigation consequences actions to the appropriate agencies. 4. Prevent resident from abuse by ensuring the supervisors immediately intervene, correct, and report identified situation where about is at risk for occurring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to notify the attending physician (Physician 1) and responsible party (Family 1 and 2) promptly when a resident, who tested positive for COVID-19 (coronavirus disease 2019; a disease caused by a very contagious virus and often causes respiratory symptoms) on 8/16/23, had a change in condition (COC) and developed unresolved cough, difficulty breathing, congestion, [an abnormal or excessive accumulation of body fluid]), and shallow breathing (rapid, deep breathing) on 8/17/23 and 8/18/23 for one of four sampled residents (Resident 1), in accordance with the resident ' s plan of care for COPD (chronic obstructive pulmonary disease) and the facility policy on COC Notification. In addition, the facility failed to notify the physician when the resident had faint (weak) heartbeat and facility staff had to place Resident 1 on nonrebreather oxygen mask (a device that gives high concentration of oxygen, usually in an emergency) due to low saturation levels [normal blood oxygen levels are between 95% to 100%]) (actual oxygen saturation level not documented in resident ' s records), on 8/18/23. These deficient practices resulted to a delay in respiratory care, treatment, and services of Resident 1 ' s respiratory condition. Resident 1 passed away on 8/18/23 between the hours of 9:15 PM to 9:30 PM, while in the facility (two days after testing positive for COVID-19). On 8/23/2023 at 3:06 PM, during the facility ' s Focused Infection Control Survey (a focused survey conducted by the California Department of Public Health to Skilled Nursing Facilities associated with the transmission of COVID-19 among staff and residents in facilities), 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 regarding the facility ' s failure to notify Physician 1 regarding significant changes in Resident 1 ' s respiratory conditions (unresolved, congestion, low saturation levels requiring oxygen, use of non-rebreather oxygen mask, faint heartbeat) in accordance with the facility ' s policy on Change of Condition Notification and the plan of care for COPD. On 8/25/2023 at 3:06 PM, the IJ was removed after the surveyors verified and confirmed the facility implemented the facility ' s IJ Removal Plan (a detailed plan to address the IJ findings) while onsite by observation, interview, and record review. The IJ was removed in the presence of the Regional Clinical Director (RCD). The acceptable IJ Removal Plan included the following: 1. On 8/23/2023, the Director of Staff Development (DSD), Minimum Data Set (MDS; an assessment screening tool) Nurse and another licensed staff/designee re-assessed all 56 residents identified to have COVID 19 positive results from rapid testing for any changes in condition and assessments to be completed on 8/24/2023. All 56 residents care plans for COVID 19 were updated and revised on 8/24/2023 for risks of COVID related symptoms by the licensed nurses and communicated to the staff. 2. On 8/23/2023, the facility ' s Medical Director was notified by the Regional Clinical Director (RCD) regarding the 56 residents with positive COVID 19 results. 3. On 8/23/2023, an in-service was provided by the RCD to all licensed nurses present during the 3 PM to 11 PM shift regarding contacting the attending physician as soon as possible for any residents ' change in the condition and decreased oxygen saturation levels. 4.On 8/24/2023, the RCD provided one on one in-service to LVN 2 regarding facility policy for resident change in condition and notification of physician. 5.On 8/24/2023, the RCD provided in-service and education to licensed staff to review the POLST when there is a change of condition for residents to ensure licensed staff follow any directives for life sustaining treatments. 6. On 8/24/2023, the RCD created a mini orientation checklist for registry licensed staff regarding the facility ' s policy/processes at the facility to be provided by the DSD during Monday to Fridays and lead licensed staff for Saturdays and Sundays. 7. The RCD to provide one on one training to the Director of Nurses (DON) upon return to work at the facility as DON is currently on sick leave. Trainings to include resident ' s change of conditions, providing supervision and follow up assessments, prompt communication to physician for new orders, and possible transfer to hospital based on facility policy. Cross Reference to F695. Findings: A review of Resident 1 ' s Face Sheet (admission record) indicated the facility admitted the resident on 5/8/2023 with diagnoses that included vascular dementia (brain damage caused by multiple strokes [occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts]), hyperlipidemia (high level of fat particles in the blood), and hypertension (high blood pressure). A review of Resident 1 ' s POLST signed and dated by Physician 1 on 6/25/2023, indicated the following medical interventions if the resident is found with a pulse and/or is breathing to perform selective treatment (goal of treating medical conditions while avoiding burdensome measures) and additional orders that indicated a handwritten note, Hospital. A review of Resident 1 ' s History and Physical assessment dated [DATE], indicated Resident 1 did not have the capacity to understand and make decisions. The History and Physical Assessment indicated Resident 1 had COPD. A review of Resident 1 ' s care plan for COPD dated 7/30/2023, indicated Resident 1 is at risk for shortness of breath/respiratory distress (a life-threatening lung injury that allows fluid to leak into the lungs) related to COPD. The care plan interventions indicated the staff would monitor the resident for shortness of breath, irregular (abnormal) respiration, wheezing (a high-pitched whistling sound made while breathing, often associated with difficulty breathing), crackles (brief popping when a person breathes, often associated with presence of fluid in the lungs), rhonchi (occur when there are secretions or obstruction in the larger airways of the lungs), excessive secretion, and inform the physician promptly. The care plan interventions indicated to administer oxygen inhalation as ordered, monitor oxygen saturation as needed/ordered, breathing treatment as ordered and monitor the effect of treatment. The care plan indicated to inform the physician if treatment is ineffective. A review of Resident 1 ' s care plan for COVID-19 Positive antigen rapid test dated 8/16/2023, did not indicate physician notification in the nursing interventions for any changes in resident condition related to COVID-19. A review of Resident 1 ' s Minimum Data Set (MDS, an assessment and screen tool) dated 8/11/2023 indicated Resident 1 had moderately impaired cognitive (thought process) skills for daily decision making. The MDS indicated Resident 1 required total dependence (full staff performance every time during entire seven-day period) with bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 1 ' s written Physician order dated 8/16/2023 timed at 10 AM, indicated Transmission Based Precaution (TBP; extra measures centered on a specific mode of transmission for patient with known or suspected infection) contact isolation precautions (use of appropriate protective equipment prior to patient contact) for COVID 19 virus for 14 days . A review of Resident 1 ' s Situation, Background, Assessment, Recommendation (SBAR; a communication document for licensed nurses for residents with change of conditions) Communication Form dated 8/16/23, indicated Resident 1 had a change in condition with signs and symptoms observed COVID + (positive) and coughing that started on 8/16/2023. The SBAR indicated Resident 1 ' s most recent blood pressure was 140/59 millimeters of mercury (mmHg; unit of measurement to measure blood pressure) ., and oxygen saturation level at 95 % on room air (when a resident is not receiving any supplemental oxygen, then the resident is breathing on room air). The SBAR indicated Family 1 and 2, including Physician 1 was notified on 8/16/23 timed at 10 AM. The SBAR did not indicate what specific information was provided to Physician 1 and Family 1 or 2. The SBAR did not indicate any other new physician orders but to monitor vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a person ' s essential body functions). A review of Resident 1 ' s Licensed Personnel Weekly Progress Notes indicated the following information for dates 8/17/2023 to 8/18/2023: 1. On 8/17/2023 timed at 3 PM to 11 PM shift (no specific time written), authored by LVN 2, indicated On monitoring for COVID + (positive), has coughing noted, no signs and symptoms (s/s) of fever, nausea/vomiting (n/v), diarrhea (loose, watery stools three or more times a day), chills, fatigue noted at this time. All needs are met . Vital signs blood pressure (B/P) 117/80, pulse is 70, respiration is 17, temperature is 97.8 . 2. On 8/18/23 timed at 11 PM to 7 AM (no specific time written) authored by LVN 2, indicated Monitoring for COVID + (positive), has coughing noted, no s/s of any fever, n/v, diarrhea, chills noted at the moment. All needs met. B/P 127/80, pulse 67, respiration 17, temperature is 97.8 . 3. On 8/18/2023 timed at 7 AM to 3 PM (no specific time written) authored by LVN 1, indicated Resident 1 on monitoring for COVID 19 positive and no cardiac arrest (occurs when the heart suddenly and unexpectedly stops pumping)/distress noted, no signs/symptoms of pain, or discomfort noted, vital signs within normal limits (WNL) . nonproductive cough noted. 4. On 8/18/2023 timed at 3 PM to 11 PM (no specific time written) authored by LVN 1, indicated Resident 1 passed away at 9:15 PM, family in to visit and say last goodbyes. MD (Physician 1) notified; mortuary (a funeral home) . Resident 1 ' s body warm to touch, heartbeat faint (weak) upon family arrival. No pulse or respiratory noted. Resident 1 was placed on nonrebreather upon low oxygen saturation level (sic). During a telephone interview with Resident 1 ' s family members (Family 1 and 2) on 8/22/2023 at 4 PM, Family 1 stated she called the facility every day to check on Resident 1. Family 1 stated the facility staff did not tell her Resident 1 was not feeling well. Family 1 stated she called the facility in the morning on 8/18/2023 and staff told her Resident 1 was okay but was sleeping. Family 1 stated she called the same day, later in the afternoon, and no one answered. Family 1 stated at around 9:15 PM on 8/18/2023, she received a call from the facility, instructing her to come now, because Resident 1 is dying. Family 1 stated she arrived at the facility at 9:30 PM. Family 1 stated when Family 1 and 2 arrived at Resident 1 ' s room, Resident 1 was receiving oxygen attached to clear balloon. Family 1 stated she did not know what the clear balloon was used for. Family 2 stated there was an oxygen tank in Resident 1 ' s room, but it was not attached to Resident 1 when Family 1 and 2 arrived in Resident 1 ' s room on 8/18/23. Family 1 stated an unknown nurse was also in Resident 1 ' s room. Family 1 stated the unknown nurse in the room did not mention to transfer Resident 1 to the acute hospital. Family 1 stated Resident 1 passed away shortly 15 to 30 minutes after they arrived at the facility. Family 2 stated Resident 1 has had a cough since 8/15/2023. On 8/22/2023 at 5:54 PM, during a concurrent interview and record review of Resident 1 ' s Licensed Nurses Weekly Progress Notes (from 8/16/2023 to 8/18/2023) with the Registered Nurse Supervisor (RNS), the RNS stated Resident 1 passed away on 8/18/2023 at 9:15 PM due to infection (a condition in which bacteria or viruses that cause disease have entered the body) and COVID 19. The RNS stated there was no documented evidence in Resident 1 ' s progress notes and clinical record that Physician 1 was notified of changes in the resident ' s medical condition (unresolved, congestion, low saturation levels requiring oxygen, use of non-rebreather oxygen mask, faint heartbeat) before Resident 1 passed away on 8/18/23. During a concurrent interview and record review of Resident 1 ' s SBAR Communication Forms for the month of August 2023 with the RNS on 8/22/2023 at 5:57 PM, RNS stated the only change of condition with physician notification documented in the resident ' s records were from 8/16/2023, when Resident 1 became positive with COVID 19. During an interview with LVN 1 on 8/22/2023 at 6:51 PM, LVN 1 stated she did not notify Physician 1 of Resident 1 ' s change of condition (low saturation levels, congestion, use of nonrebreather oxygen mask, faint heartbeat), because she expected the DON, who was also in Resident 1 ' s room on 8/18/2023, to notify Physician 1. LVN 1 stated the DON spoke with Resident 1 ' s family and transferring the resident to the acute hospital was not offered to Family 1 and 2. LVN 1 stated she thought the DON would document in Resident 1 ' s SBAR form, which is why LVN 1 did not document Resident 1 ' s change of condition. LVN 1 stated she forgot to document all the vital signs she took from Resident 1 on 8/18/2023 during the 7 AM to 3 PM shift and 3 PM to 11 PM shift. During the same interview, on 8/22/23 at 6:51 PM, LVN 1 further stated she bumped up (increased) Resident 1 ' s oxygen therapy and used a nonrebreather mask instead of a nasal cannula (a medical device that consists of a small, flexible tube with two prongs that sit inside a patient ' s nostrils). LVN 1 stated she increased Resident 1 ' s oxygen therapy up to 8 liters per minute via nonrebreather mask. LVN 1 stated when she noticed that Resident 1 was still unresponsive to 8 LPM of oxygen therapy, LVN 1 stated she called and notified Resident 1 ' s family. LVN 1 stated she did not remember what Resident 1 ' s oxygen saturation level during the time she called Resident 1 ' s family. LVN 1 stated she did not document any of Resident 1 ' s vital signs in the resident ' s records. LVN 1 stated when Resident 1 ' s family arrived, Resident 1 was wearing a nonrebreather mask, and presented with shallow breathing (rapid, deep breathing). LVN 1 stated during the endorsement report from LVN 2 (11 PM to 7 AM night shift licensed nurse) on 8/18/2023, LVN 2 reported that during the night shift, LVN 2 stated that Resident 1 was suctioned (removing mucus and fluids from the nose, mouth or back of the throat with a bulb syringe [a device that is used to inject fluid into, or withdraw fluid from the body]) or a catheter [thin flexible tube]) in the mouth. LVN 1 stated she also suctioned Resident 1 orally on 8/18/2023 but could not recall the time. LVN 1 stated Resident 1 sounded congested (abnormal or excessive accumulation of a body fluid) in his chest. LVN 1 stated she did not listen to Resident 1 ' s lung sounds. LVN 1 stated she looked at Resident 1 and saw Resident 1 ' s oxygen saturation level was low. LVN 1 stated she did not document Resident 1 ' s oxygen saturation level and vital signs on 8/18/2023. LVN 1 stated she could not recall Resident 1 ' s oxygen saturation level and vital signs during that time (8/18/2023). During the same interview, on 8/22/23 at 6:51 PM, LVN 1 stated she worked a double shift from 7 AM to 3 PM and 3 PM to 11 PM shifts on 8/18/23 and was assigned to care for Resident 1. LVN 1 stated the certified nursing assistant (CNA 1) informed her that Resident 1 was not feeling well after dinner on 8/18/2023. LVN 1 stated prior to dinner, Resident 1 did not have any issues. LVN 1 stated after CNA 1 notified her of Resident 1 ' s status (not feeling well after dinner), LVN 1 went to Resident 1 ' s room and took the resident ' s vital signs. LVN 1 stated she did not document and could not recall the results of Resident 1 ' s vital signs on 8/18/2023, after dinner. LVN 1 stated Resident 1 looked like he was transitioning (beginning of the final stage of dying). LVN 1 stated that on 8/18/2023, Resident 1 was transitioning and had a change of condition but could not recall the exact time, after dinner of Resident 1 ' s change of condition. LVN 1 was asked to explain what she meant by Resident 1 was transitioning and stated her definition of transitioning was if I am looking at him (Resident 1), skin was pale, it looks like something was changing that I could not take care of him, it was something he could not recover from. During a telephone interview with the DON on 8/22/2023 at 7:59 PM, the DON stated she was at the Nursing Station when LVN 1 informed her that Resident 1 ' respiratory condition was declining (to deteriorate gradually) due to low saturation levels and difficulty breathing. The DON stated she did not check the entirety of Resident 1 ' s documented POLST which indicated Resident 1 may be transferred to an acute hospital as a form of selective treatment. The DON stated she went to Resident 1 ' s room on 8/18/2023 and checked Resident 1 ' s pulse and oxygen saturation level. The DON stated she could not remember the time she went inside Resident 1 ' s room and what Resident 1 ' s oxygen saturation level was on 8/18/23. The DON stated the oxygen saturation of Resident 1 was 88 % or something. The DON stated she did not write Resident 1 ' s oxygen saturation level down anywhere in the resident ' s medical records. During the same telephone interview, on 8/22/2023 at 7:59 PM, the DON stated, I was thinking LVN 1 was going to notify Physician 1 of resident ' s change of condition (unresolved cough, congestion, low saturation levels requiring oxygen, use of non-rebreather oxygen mask, faint heartbeat). The DON stated she told LVN 1 that if Resident 1 started declining, to notify the family and Physician 1. The DON stated she knew Resident 1 was a DNR but did not check Resident 1 ' s entire POLST document. The DON stated she did not see the additional selective treatments indicated in Resident 1 ' s POLST that Resident 1 could be transferred to an acute hospital. The DON stated she could not find documented evidence in Resident 1 ' s POLST not to transfer Resident 1 to the acute hospital. The DON stated Resident 1 ' s family did not request Resident 1 not to be transferred to an acute hospital and the DON did not ask Resident 1 ' s family if they wanted Resident 1 to be transferred to the acute hospital. The DON stated she did not document anything with regards to the change of condition in Resident 1 ' s medical records, on 8/18/23. During a telephone interview with Physician 1 on 8/23/2023 at 10 AM, Physician 1 stated he was not notified of Resident 1 ' s death, on 8/18/23. Physician 1 stated he went to the facility a few days after Resident 1 ' s death. Physician 1 stated he was not notified of Resident 1 ' s change of condition (difficulty breathing, low saturation levels not improving with oxygen administration) on 8/17/2023 or 8/18/2023. Physician 1 stated he did not know Resident 1 ' s oxygen level was not improving with oxygen administration. Physician 1 stated that Resident 1 had end stage dementia (the stage in which dementia loss of memory, language, problem-solving and other thinking abilities symptoms become severe to the point where a person requires help with everyday activities) but if he was notified of the Resident 1 ' s change in condition (difficulty breathing, low saturation levels not improving with oxygen administration) on 8/18/23, he would have contacted Resident 1 ' s family members (Family 1 and/or 2) and discussed if family members (Family 1 or 2) would have wanted the resident to be transferred to the acute hospital. Physician 1 stated he would have ordered the facility ' s licensed nurses for Resident 1 to be transferred to the acute hospital. During the review of Resident 1 ' s Licensed Personnel Weekly Progress Notes from 8/17/2023 through 8/18/2023 did not indicate documented evidence that Physician 1 was notified and consulted of a decline or abnormal changes (unresolved cough, congestion, low saturation levels, difficulty breathing requiring the use of nonrebreather mask, faint heartbeat) in Resident 1 ' s respiratory status. During a telephone interview with LVN 2 on 8/23/2023 at 11:06 AM, LVN 2 stated she was assigned to Resident 1 on 8/17/2023 during the 3 PM to 11 PM and the next shift on 11 PM to 7 AM. LVN 2 stated that on 8/17/2023, during the 3 PM to 11 PM shift, the DON and the infection prevention nurse (IPN) were present in Resident 1 ' s room when Resident 1 had a change of condition (difficulty breathing, congestion, low saturation level). LVN 2 stated when she came back from her lunch break during the 3 PM to 11 PM shift (unable to recall exact time), on 8/17/2023, she was told by the DON and IPN that Resident 1 was not blinking. LVN 2 stated the DON and IPN told her Resident 1 was breathing, but not breathing well (difficulty breathing) so when they suctioned the resident, LVN 2 that the IPN and DON informed her that Resident 1 Came back to the normal oxygen saturation level. LVN 2 stated the DON, the IPN, and another unknown LVN she could not remember, were all in Resident 1 ' s room and got Resident 1 back to baseline (provides a critical reference point for assessing changes and impact, as it establishes a basis for comparing the situation before and after an intervention, because Resident 1 was unresponsive). LVN 2 stated she did not know what Resident 1 ' s baseline or oxygen saturation levels before and after the resident was suctioned by IPN and the DON. LVN 2 stated that on 8/17/2023, she did not assess or listen to Resident 1 ' s lung sounds because she was on her lunch break. LVN 2 stated there was no documentation of Resident 1 ' s change of condition (difficulty breathing, congestion, low saturation level) on 8/17/2023 during the 3 PM to 11 PM shift, while she was on lunch break. LVN 2 stated she did not call and notify Physician 1 of Resident 1 ' s change of condition on 8/17/2023. LVN 2 stated she was unsure if Physician 1 was notified by any other licensed nurses, regarding Resident 1 ' s change of condition on 8/17/2023. During an interview with the IPN on 8/23/2023 at 2:12 PM, the IPN stated that on 8/17/2023 during the 3 PM to 11 PM shift, she heard a commotion by Resident 1 ' s room. IPN stated she went to Resident 1 ' s room and saw Resident 1 was coughing and having trouble breathing. The IPN stated the DON was also inside Resident 1 ' s room. The IPN stated Resident 1 was not on any oxygen therapy at that time (8/17/23). The IPN stated she saw that there was a suctioning machine set up (a type of medical device that is primarily used for removing or aspirating obstructions - like secretions (discharges), saliva) at Resident 1 ' s bedside. The IPN stated because she saw the suctioning machine set up and saliva fluids in Resident 1 ' s mouth, she told the DON Let ' s suction. The IPN stated she and the DON suctioned Resident 1 (on 8/17/2023). The IPN stated she suctioned Resident 1 ' s saliva and used a yankauer (a firm, plastic suction tip used to suction thick oral secretions). The IPN stated she did not know and did not verify if Resident 1 had physician orders for suctioning. The IPN stated she did not notify Physician 1 of providing suctioning treatment to Resident 1 due to the resident having difficulty breathing. The IPN stated a change of condition should have been completed and documented in Resident 1 ' s medical records. The IPN stated But like I said, the DON was there and another licensed nurse, I assumed they were taking care of everything, I only went in there because I heard a noise and to see if they needed help. A review of the facility ' s policy and procedure titled Change of Condition Notification, dated 6/1/2017 indicated the licensed nurse will notify the resident ' s Attending Physician when there is a significant change in the resident ' s physical, mental or psychological status, deterioration in health, mental or psychosocial status, life-threatening conditions or clinical complications. The policy indicated the licensed nurse will assess the resident ' s change of condition and document the observations and symptoms. The policy indicated the Attending Physician will be notified timely with a resident ' s change in condition. The policy indicated notification to the Attending Physician will include a summary of the condition change and an assessment of the resident ' s vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required. The policy indicated the licensed nurse will review the resident ' s advanced directives (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) and ensure that the Attending Physician is aware of the resident ' s wishes. The policy indicated in emergency situations if the resident deteriorates, the symptoms serious, and the most rapid intervention available would place the resident in great jeopardy, call 911 for transport to the hospital. The policy indicated the licensed nurse will document the time the family/responsible person was contacted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary respiratory care and implement interventions in accordance with the resident ' s needs, care plan, facility policy and professional standards of practice, consistently across all shifts (7 AM to 3 PM, 3 PM to 11 PM, and 11 PM to 7 AM) for one of four sampled residents (Resident 1) by: 1. Not monitoring and informing the attending physician (Physician 1) in accordance with the resident ' s care plan for COPD (chronic obstructive pulmonary disease; a group of lung diseases that block airflow and make it difficult to breathe) when Resident 1 experienced shortness of breath (SOB), irregular respiration, excessive secretion, wheezing (a high-pitched whistling sound made while breathing, often associated with difficulty breathing), crackles (brief popping when a person breathes, often associated with presence of fluid in the lungs), and/or rhonchi (occur when there are secretions or obstruction in the larger airways of the lungs). 2. Not monitoring and informing Physician 1, in accordance with the resident ' s care plan for COPD when Resident 1 was having congestion, difficulty breathing and had low oxygen saturations (amount of oxygen circulating in the blood [normal blood oxygen levels are between 95% to 100%]) on 8/17/2023 and 8/18/2023. 3. Ensuring the facility ' s licensed nurses for all shifts (Licensed Vocational Nurses [LVN] 1 and 2), Infection Preventionist Nurse (IPN), and the director of nurses (DON) monitor and document Resident 1 ' s respiratory changes in conditions, respiratory status and treatments rendered in accordance with professional standards of practice, Resident 1 ' s care plan for COPD, and facility policy on Change of Condition Notification. 4. Not monitoring and documenting Resident 1 ' s signs and symptoms of COVID 19, vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions), including oxygen saturation on 8/17/2023 and 8/18/2023 every four hours consistently, in accordance with the physician ' s order. 5. Not following the facility ' s policy on Oxygen Administration to obtain a physician ' s order for oxygen therapy that includes oxygen flow rate, method of administration, usage of therapy, titration (selection of oxygen delivery system based on level of oxygen support required) instructions when LVN 1 and 2, the IPN, and the DON applied oxygen and a nonrebreather mask (a special medical device that helps provide oxygen in emergencies) to Resident 1 and increase the oxygen flow rate up to 8 liters per minute (LPM; unit of measurement for oxygen therapy) on 8/17/23 and 8/18/23. Resident 1, who was diagnosed with COPD and tested positive for COVID-19 (coronavirus disease 2019; a disease caused by a virus that can be very contagious and often causes respiratory symptoms that may attack more than lungs and respiratory system)on 8/16/2023. These failures resulted in the delay in diagnosis, care, and services of Resident 1 ' s respiratory condition. Resident 1 passed away on 8/18/2023 between the hours of 9:15 PM to 9:30 PM, two days after testing positive for COVID 19, due to difficulty breathing and low saturation levels (actual oxygen saturation level not documented in resident ' s records). On 8/23/2023 at 3:09 PM, during the facility ' s Focused Infection Control Survey (a focused survey conducted by the California Department of Public Health to Skilled Nursing Facilities associated with the transmission of COVID-19 among staff and residents in facilities), 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 regarding the facility ' s failure to provide necessary respiratory care and implement interventions in accordance with the resident ' s needs, care plan, facility policy and professional standards of practice, consistently across all shifts. On 8/25/2023 at 3:06 PM, the IJ was removed after the surveyors verified and confirmed the facility implemented the facility ' s IJ Removal Plan (a detailed plan to address the IJ findings) while onsite by observation, interview, and record review. The IJ was removed in the presence of the Regional Clinical Director (RCD). The acceptable IJ Removal Plan included the following: 1. On 8/23/2023, the RCD contacted the facility Medical Director to discuss appropriate Oxygen orders, parameters (factors or limits that affect the way something can be done), and standard of practice acceptable for a resident with diagnosis of COPD and other respiratory condition. 2. On 8/23/2023, an in-service was provided by the RCD to all licensed nurses to monitor resident ' s vital signs and oxygen saturation per physician ' s order, resident care plan intervention implementation and documentation of specific interventions provided to a resident with diagnosis of COPD, and to review policy and procedure regarding oxygen administration specifically on obtaining a physician order prior to oxygen administration. 3. On 8/24/2023, the RCD developed a respiratory monitoring checklist for licensed nurses each shift to monitor the respiratory changes/status of each resident with a diagnosis of COPD. An in-service regarding the monitoring checklist was given to the 3 PM to 11 PM staff and ongoing. 4.On 8/24/2023, the RCD and Minimum Data Set (MDS; an assessment and monitoring tool) Nurse reviewed residents clinical records, out of 56 COVID 19 positive residents, 11 residents had COPD diagnosis. Four of 11 residents had routine oxygen orders. 5. On 8/24/2023, the MDS Nurse/Director of Staff Development (DSD) and other licensed staff-initiated re-assessments and re-evaluation of residents with COPD with oxygen therapy orders for symptoms of SOB and low oxygen saturation levels. 6. On 8/24/2023, the MDS Nurse/DSD validated the active diagnosis of COVID 19 positive residents with their primary care physician for active monitoring and updated the plan of care. 7. On 8/24/2023, the Medical Records Personnel updated the face sheet for the active diagnoses of all residents identified with COVID 19 in the facility. Cross Reference to F580. Findings: A review of Resident 1 ' s Face Sheet (admission record) indicated the facility admitted the resident on 5/8/2023 with diagnoses that included vascular dementia (brain damage caused by multiple strokes), hyperlipidemia (high level of fat particles in the blood), and hypertension (high blood pressure) A review of Resident 1 ' s History and Physical assessment dated [DATE], indicated Resident 1 did not have the capacity to understand and make decisions. The History and Physical Assessment indicated Resident 1 had COPD. A review of Resident 1 ' s care plan for COPD dated 7/30/2023, indicated Resident 1 is at risk for shortness of breath/respiratory distress (a life-threatening lung injury that allows fluid to leak into the lungs) related to COPD. The care plan interventions indicated the staff would monitor the resident for shortness of breath, irregular respiration, wheezing, crackles, rhonchi, and excessive secretion, and inform the physician promptly. The care plan interventions indicated to administer oxygen inhalation as ordered ., monitor oxygen saturation as needed/ordered, breathing treatment as ordered and monitor the effect of treatment. The care plan indicated to inform the physician if treatment is ineffective. A review of Resident 1 ' s MDS dated [DATE] indicated Resident 1 had moderately impaired cognitive (thought process) skills for daily decision making. The MDS indicated Resident 1 required total dependence (full staff performance every time during entire seven-day period) with bed mobility, dressing, eating, toilet use, and personal hygiene. A review of the facility ' s undated Resident Line List (a template/list for data collection and active monitoring of both residents and staff during a suspected/active outbreak) indicated Resident 1 received a positive COVID 19 test result on 8/16/2023. A review of Resident 1 ' s written Physician ' s order dated 8/16/2023 timed at 10 AM, indicated Transmission Based Precaution (TBP; extra measures centered on a specific mode of transmission for patient with known or suspected infection) contact isolation precautions (use of appropriate protective equipment prior to patient contact) for COVID 19 virus for 14 days . Monitor vital signs every 4 hours for 14 days (blood pressure, temperature, pulse, respiratory rate, oxygen saturation level, and pain) and monitor for COVID 19 virus symptoms every 4 hours (0= none, 1= headache, 2= cough, 3= shortness of breath, 4= increase in temperature, 5= nausea and vomiting, 6= diarrhea, 7= chills, 8= sore throat, 9= fatigue or weakness, 10= new loss of taste or smell). A review of Resident 1 ' s Situation, Background, Assessment, Recommendation (SBAR) Communication Form indicated Resident 1 had a change in condition with signs and symptoms observed COVID + (positive) and coughing that started on 8/16/2023. The SBAR indicated Resident 1 ' s most recent blood pressure was 140/59 millimeters of mercury (mmHg; unit of measurement to measure blood pressure) ., and oxygen saturation level at 95 % on room air. The SBAR indicated Family 1 and 2, including Physician 1 was notified on 8/16/23 timed at 10 AM. The SBAR did not indicate any other new physician orders but to monitor vital signs. A review of Resident 1 ' s Licensed Personnel Weekly Progress Notes indicated the following information: 1. On 8/17/2023 timed at 3 PM to 11 PM shift (no specific time written) authored by LVN 2, indicated On monitoring for COVID +, has coughing noted, no signs and symptoms (s/s) of fever, nausea/vomiting (n/v), diarrhea, chills, fatigue noted at this time. All needs are met . Vital signs B/P (blood pressure) 117/80, pulse is 70, respiration is 17, temperature is 97.8 . 2. On 8/18/23 timed at 11 PM to 7 AM (no specific time written) authored by LVN 2, indicated Monitoring for COVID +, has coughing noted, no s/s of any fever, n/v, diarrhea, chills noted at the moment. All needs met. B/P 127/80, pulse 67, respiration 17, temperature is 97.8 . 3. On 8/18/2023 timed at 7 AM to 3 PM (no specific time written) authored by LVN 1, indicated Resident 1 on monitoring for COVID 19 positive and no cardiac arrest distress noted, no signs/symptoms, pain, or discomfort noted, vital signs within normal limits (WNL) . nonproductive cough noted. 4. On 8/18/2023 timed at 3 PM to 11 PM (no specific time written) authored by LVN 1, indicated Resident 1 passed away at 9:15 PM, family in to visit and say last goodbyes. MD (Physician 1) notified; mortuary (a funeral home) . Resident 1 ' s body warm to touch, heartbeat faint (weak) upon family arrival. No pulse or respiratory noted. Resident 1 was placed on nonrebreather mask upon low oxygen saturation level (sic). During the review of Resident 1 ' s Licensed Personnel Weekly Progress Notes for 8/17/2023 and 8/18/2023 did not indicate documented evidence that Physician 1 was notified and consulted of changes in Resident 1 ' s respiratory condition. During a telephone interview with Resident 1 ' s family members (Family 1 and 2) on 8/22/2023 at 4 PM, Family 1 stated she called the facility every day to check on Resident 1 . Family 2 stated Resident 1 has had a cough since 8/15/2023. Family 1 stated she called the facility in the morning of 8/18/2023 and facility staff told her Resident 1 was okay but was sleeping. Family 1 stated she called the same day, later in the afternoon, and no one answered from the facility. Family 1 stated at around 9:15 PM on 8/18/2023, she received a call from the facility, instructing her to come now, because [Resident 1] is dying. Family 1 stated she arrived at the facility at 9:30 PM. Family 1 stated when Family 1 and 2 arrived at Resident 1 ' s room, Resident 1 was receiving oxygen was attached to clear balloon. Family 1 stated she did not know what the clear balloon was used for. Family 2 stated there was an oxygen tank in Resident 1 ' s room, but it was not attached to Resident 1 when Family 1 and 2 arrived in Resident 1 ' s room on 8/18/23. Family 1 stated an unknown nurse was also in Resident 1 ' s room. Family 1 stated the facility should have sent Resident 1 to the acute hospital. Family 1 stated Resident 1 passed away shortly 15 to 30 minutes after their arrival. On 8/22/2023 at 5:54 PM, during a concurrent interview and record review of Resident 1 ' s Licensed Nurses Weekly Progress Notes (from 8/16/23 to 8/18/23) with the Registered Nurse Supervisor (RNS), the RNS stated Resident 1 passed away on 8/18/2023 at 9:15 PM due to infection (a condition in which bacteria or viruses that cause disease have entered the body) and COVID 19. RNS stated she could not find documented evidence in Resident 1 ' s progress notes that Physician 1 was notified for any changes in condition before Resident 1 passed away on 8/18/2023. On 8/22/2023 at 6 PM, during a concurrent interview and record review of Resident 1 ' s Monitoring for Signs and Symptoms of COVID 19 and Vital Signs every Four Hours form with the RNS, the RNS stated that Resident 1 ' s signs and symptoms of COVID 19 dated 8/17/2023 timed at 4 PM and 8 PM were blank. The RNS further stated that on 8/18/2023 at 12 AM, 4 AM, 8 AM, 12 PM, 4 PM, and 8 PM, Resident 1 ' s COVID 19 Monitoring for signs and symptoms form were also blank. The RNS further stated that Resident 1 ' s vital signs, including oxygen saturation levels on 8/18/2023 timed at 8 AM, 12 PM, 4 PM, and 8 PM were left blank. The RNS stated she could not find documented evidence that Resident 1 ' s signs and symptoms of COVID 19 and vital signs were consistently monitored every four hours on 8/17/2023 and 8/18/2023, according to the physician ' s orders. During an interview with LVN 1 on 8/22/2023 at 6:51 PM, LVN 1 stated she worked a double shift on 7 AM to 3 PM and 3 PM to 11 PM shifts on 8/18/23 and was assigned to care for Resident 1. LVN 1 stated the certified nursing assistant (CNA 1) informed her that Resident 1 was not feeling well after dinner on 8/18/2023. LVN 1 stated prior to dinner, Resident 1 did not have any issues. LVN 1 stated after CNA 1 notified her of Resident 1 ' s status (not feeling well after dinner), LVN 1 went to Resident 1 ' s room and took the resident ' s vital signs. LVN 1 stated she did not document and could not recall the results of Resident 1 ' s vital signs on 8/18/2023, after dinner. LVN 1 stated Resident 1 looked like he was transitioning (beginning of the final stage of dying). LVN 1 stated that on 8/18/2023, Resident 1 was transitioning but could not recall the exact time, after dinner. LVN 1 was asked to explain what she meant by Resident 1 was transitioning and stated her definition of transitioning was if I am looking at him (Resident 1), skin was pale, it looks like something was changing that I could not take care of him, it was something he could not recover from. During the same interview, on 8/22/23 at 6:51 PM, LVN 1 stated she did not notify Physician 1 because she expected the DON to notify the physician of Resident 1 ' s change of condition (difficulty breathing, low saturation levels not improving with oxygen administration, faint heartbeat). LVN 1 stated she thought the DON would document the resident ' s symptoms and change in condition (unresolved, congestion, low saturation levels requiring oxygen, use of non-rebreather oxygen mask, faint heartbeat) in Resident 1 ' s SBAR form. LVN 1 stated she did not document Resident 1 ' s changes in condition (unresolved, congestion, low saturation levels requiring oxygen, use of non-rebreather oxygen mask) and interventions provided on 8/18/2023. LVN 1 stated she forgot to document all the vital signs she took from Resident 1 on 8/18/2023 during the 7 AM to 3 PM shift and 3 PM to 11 PM shift. During the same interview, on 8/22/23 at 6:51 PM, LVN 1 further stated she bumped up (increased) Resident 1 ' s oxygen therapy and used a nonrebreather mask instead of a nasal cannula (a medical device that consists of a small, flexible tube with two prongs that sit inside a patient ' s nostrils). LVN 1 stated she increased Resident 1 ' s oxygen therapy up to 8 liters per minute via nonrebreather mask. LVN 1 stated when she noticed that Resident 1 was still unresponsive to 8 LPM of oxygen therapy, LVN 1 stated she called and notified Resident 1 ' s family. LVN 1 stated she did not remember what Resident 1 ' s oxygen saturation level during the time she called Resident 1 ' s family. LVN 1 stated she did not document any of Resident 1 ' s vital signs in the resident ' s records. LVN 1 stated when Resident 1 ' s family arrived, Resident 1 was wearing a nonrebreather mask, and presented with shallow breathing (rapid, deep breathing). LVN 1 stated during the endorsement report from LVN 2 (11 PM to 7 AM night shift licensed nurse) on 8/18/2023, LVN 2 reported that during the night shift, LVN 2 stated that Resident 1 was suctioned (removing mucus and fluids from the nose, mouth or back of the throat with a bulb syringe [a device that is used to inject fluid into, or withdraw fluid from the body]) or a catheter [thin flexible tube]) in the mouth. LVN 1 stated she also suctioned Resident 1 orally on 8/18/2023 but could not recall the time. LVN 1 stated Resident 1 sounded congested (abnormal or excessive accumulation of a body fluid) in his chest. LVN 1 stated she did not listen to Resident 1 ' s lung sounds. LVN 1 stated she looked at Resident 1 and saw Resident 1 ' s oxygen saturation level was low. LVN 1 stated she did not document Resident 1 ' s oxygen saturation level and vital signs on 8/18/2023. LVN 1 stated she could not recall Resident 1 ' s oxygen saturation level and vital signs during that time (8/18/2023). During an interview with CNA 1 on 8/22/2023 at 7:13 PM, CNA 1 stated when he arrived at the facility for the 3 PM to 11 PM shift at around 3 PM, on 8/18/2023, Resident 1 was wearing an oxygen nonrebreather mask. CNA 1 stated LVN 1 suctioned Resident 1 ' s mouth right before dinner. CNA 1 stated after Resident 1 was suctioned he tried to feed Resident 1, and Resident 1 ate a little and then would not eat anymore. CNA 1 stated prior to dinner, Resident 1 was breathing fast while wearing the nonrebreather mask. CNA 1 stated he went back to Resident 1 ' s room around 8 PM and CNA 1 noticed Resident 1 was not breathing anymore. CNA 1 stated I did not see him breathing and CNA 1 stated he felt Resident 1 ' s pulse was faint (weak), so he called and notified LVN 1. During a telephone interview with the DON on 8/22/2023 at 7:59 PM, the DON stated she was at the Nursing Station when LVN 1 informed her that Resident 1 was declining (to deteriorate gradually). The DON stated she went to Resident 1 ' s room and checked Resident 1 ' s pulse and oxygen saturation level. The DON stated she forgot what Resident 1 ' s oxygen saturation level was on 8/18/2023. The DON stated the oxygen saturation of Resident 1 was 88 % (normal blood oxygen levels are between 95% to 100%) or something. The DON stated she could not remember the time she went inside Resident 1 ' s room and what Resident 1 ' s oxygen saturation level was on 8/18/2023. The DON stated when she walked into Resident 1 ' s room and Resident 1 was wearing a nonrebreather mask, the resident ' s oxygen was at 4 LPM before it was increased to 8 LPM. The DON stated she told LVN 1 to make sure Resident 1 ' s oxygen therapy was increased to 8 LPM. The DON stated she did not write Resident 1 ' s oxygen saturation level down anywhere in the resident ' s medical records. The DON stated she did not document anything with regards to the change of condition (unresolved, congestion, low saturation levels requiring oxygen, use of non-rebreather oxygen mask, faint heartbeat) in Resident 1 ' s medical records, on 8/18/23. The DON stated she did not listen to Resident 1 ' s lung sounds as indicated in Resident 1 ' s care plan for COPD. During a telephone interview with Physician 1 on 8/23/2023 at 10 AM, Physician 1 stated he was not notified of Resident 1 ' s death, on 8/18/23. Physician 1 stated he was not notified by the facility staff of Resident 1 ' s change of condition (unresolved cough, congestion, difficulty breathing, congestion, low oxygen saturation) on 8/17/2023 or 8/18/2023. Physician 1 stated he did not know Resident 1 ' s oxygen level was not improving with oxygen administration. Physician 1 stated if he was notified of the resident ' s change in condition (difficulty breathing, low saturation levels not improving with oxygen administration) on 8/18/23 . Physician 1 would have ordered Resident 1 to be transferred to the acute hospital. On 8/23/2023 at 10:04 AM, during a concurrent interview and record review of Resident 1 ' s COPD care plan with the DON, the DON stated she did not review and implement all of Resident 1 ' s care plan for COPD. The DON stated she did not know she needed to assess and listen to Resident 1 ' s lungs sound. The DON stated she should have assessed Resident 1 ' s lungs. The DON stated she wanted to check on Resident 1 ' s oxygen saturation levels at first and stated that was her fault. During a telephone interview with LVN 2 on 8/23/2023 at 11:06 AM, LVN 2 stated she was assigned to Resident 1 on 8/17/2023 during the 3 PM to 11 PM and the next shift on 11 PM to 7 AM. LVN 2 stated that on 8/17/2023, during the 3 PM to 11 PM shift, the DON and the infection prevention nurse (IPN) were present in Resident 1 ' s room, when Resident 1 had a change of condition. LVN 2 stated when she came back from her lunch break on 8/17/2023, she was told by the DON and IPN that Resident 1 was not blinking. LVN 2 stated the DON and IPN told her Resident 1 was breathing, but not breathing well so when they suctioned him . LVN 2 stated she did not assess or listen to Resident 1 ' s lung sounds because she was on her lunch break. LVN 2 stated she did not know what Resident 1 ' s oxygen saturation levels before and after the resident was suctioned. LVN 2 stated there was no documentation of Resident 1 ' s change of condition on 8/17/2023 during the 3 PM to 11 PM shift, while she was on lunch break. LVN 2 stated she did not call Physician 1 on 8/17/2023. LVN 2 stated she was unsure if Physician 1 was notified by any other licensed nurses, regarding Resident 1 ' s change of condition on 8/17/2023. During an interview with the IPN on 8/23/2023 at 2:12 PM, the IPN stated that on 8/17/2023 during the 3 PM to 11 PM shift, she heard a commotion by Resident 1 ' s room. IPN stated she went to Resident 1 ' s room and saw Resident 1 was coughing and having trouble breathing. The IPN stated the DON was also inside Resident 1 ' s room. The IPN stated Resident 1 was not on any oxygen therapy at that time (8/17/23). The IPN stated she saw that there was a suctioning machine set up (a type of medical device that is primarily used for removing or aspirating obstructions - like secretions [discharges], saliva) at Resident 1 ' s bedside. The IPN stated because she saw the suctioning machine set up and saliva fluids in Resident 1 ' s mouth, she told the DON Let ' s suction. The IPN stated she and the DON suctioned Resident 1 (on 8/17/2023). The IPN stated she suctioned Resident 1 ' s saliva and used a yankauer (a firm, plastic suction tip used to suction thick oral secretions). The IPN stated she did not know and did not verify if Resident 1 had physician orders for suctioning. The IPN stated she did not notify Physician 1 of providing suctioning treatment to Resident 1 due to the resident having difficulty breathing. The IPN stated Resident 1 ' s change of condition should have been documented in Resident 1 ' s medical records to reflect the resident ' s symptoms and treatments provided. The IPN stated But like I said, the DON was there and another licensed nurse, I assumed they were taking care of everything, I only went in there because I heard a noise and to see if they needed help. A review of the facility ' s policy and procedure titled Change of Condition Notification, dated 6/1/2017 indicated the licensed nurse will assess the resident ' s change of condition and document the observations and symptoms. The policy indicated the Attending Physician will be notified timely with a resident ' s change in condition . The policy indicated the licensed nurse will review the resident ' s advanced directives (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) and ensure that the Attending Physician is aware of the resident ' s wishes. The policy indicated in emergency situations if the resident deteriorates, the symptoms serious, and the most rapid intervention available by a physician would place the resident in great jeopardy (danger), call 911 for transport to the hospital. A review of the facility ' s policy and procedure titled Oxygen Administration, dated 6/1/2017 indicated a physician ' s order is required to initiate oxygen therapy, except in an emergency situation, the order shall include oxygen flow rate, method of administration, usage of therapy, titration instructions, and indications for use. The policy indicated that a physician is to be contacted as soon as possible after initiation of oxygen therapy in emergency situations, for verification and documentation of the order for oxygen therapy consultation, and further orders. The policy indicated oxygen saturations will be measured and documented at a minimum of daily for resident ' s receiving oxygen therapy.