Based on interview and record review, the facility failed to implement its abuse prevention policy when they did not report an unusual occurrence of an acute new distal femur fracture (a break in the lower part of the thighbone, near the knee joint) of unknown cause to the State Survey Agency (California Department of Public Health - CDPH) within 24 hours of the occurrence, for one of the three sampled residents (Resident 1). This failure had the potential for resident harm and/or death, due to CDPH ' s inability to promptly investigate the possibility of resident abuse in the facility. This delayed CDPH response to ensure Resident 1 was safe and free from possible abuse and/or mistreatment in the facility and had the potential for other unusual occurrences to go unreported. Findings: During a review of Resident 1 ' s admission Record (the front page of the chart that contains a summary of basic information about the resident), dated 5/19/2025, the admission Record indicated, the facility originally admitted Resident 1 on 2/28/2024, then re-admitted Resident 1 on 5/8/2025, with diagnoses that included age-related osteoporosis (weak and brittle bones due to lack of calcium and vitamin D) without current pathological fracture (broken bone caused by disease), dementia (a progressive state of decline in mental abilities), and contracture of the right knee (the tissues around the joint have become stiff or tight, limiting the knee's ability to move freely). During a review of Resident 1 ' s History and Physical, dated 5/9/2025, the H&P indicated Resident 1 did not have the capacity to understand nor make decisions. During a review of Resident 1 ' s Minimum Data Set, (MDS — a federally mandated resident assessment tool), dated 2/24/2025, the MDS indicated, Resident 1 was dependent on assistance (helper performs all the effort. Resident did none of the effort to complete the activity. Or the assistance of two or more helpers was required for the resident to complete the activity). During a review of Resident 1 ' s Radiology Result Report X-ray (a photograph of the internal composition of a body part) of the right knee, dated 5/4/2025, the report indicated Resident 1 had an acute mildly displaced supracondylar fracture of the distal femur. During a review of Resident 1 ' s Progress Notes, dated 5/6/2025, the documentation indicated the results of Resident 1 ' s X-ray were reported to the facility on 5/4/2025. During a review of the facility ' s fax transmittal document, dated 5/7/2025, the document indicated the facility reported the unusual occurrence regarding Resident 1 to CDPH on 5/7/2025 at 8:51 p.m. During an interview on 5/19/2025 at 3:27 p.m. with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated the results of Resident 1 x-ray should have been reported to CDPH within 24 hours of the facility becoming aware of the results. RNS 1 stated the failure to report unusual occurrences or test results within the required timeframe could have further jeopardized Resident 1 ' s well-being. During a concurrent interview and record review on 5/19/2025 at 3:27 p.m. with the Director of Nursing (DON), the fax transmittal document, dated 5/7/2025, and Resident 1 ' s Radiology Result Report X-ray, dated 5/4/2025, were each reviewed. The DON stated Resident 1 ' s x-ray results should have been reported to CDPH as soon as the facility became aware of the results and no later than 24 hours. The DON stated unusual occurrences should be reported as soon as possible, but not later than 24 hours. The DON stated the results of Resident 1 ' s x-ray were not reported to CDPH until 5/7/2025 but should have been sent on 5/5/2025 instead. During a review of the facility ' s policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation — Reporting and Investigating, revised 3/24/2025, the P&P indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported: . 5. Immediately is defined as:a. within two hours of an allegation involving abuse or resulting in physical harm/serious bodily injury; orb. within 24 hours of an allegation that does not involve abuse or result in physical harm/serious bodily injury. During a review of the facility ' s policy and procedure titled, Unusual Occurrence Reporting, revised 12/2007, the P&P indicated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors: . 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call light device was within reach for one of five sampled residents (Resident 8). This failure had the potential to prevent Resident 8 from receiving the necessary care and services timely. Findings: During a review of Resident 8's admission Record, the admission Record indicated, Resident 8 was initially admitted to the facility on [DATE] and the last readmission was on 9/20/2024 with diagnoses including left leg above knee amputation (surgical removal of the portion of the left leg above the knee joint), muscle weakness, dependence on supplemental oxygen (a colorless, odorless gas element that sustains life), and pressure ulcer/injury (damage to skin and tissue underneath the skin caused by unrelieved pressure) stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible) of sacral region (the portion of the spine between lower back and tailbone). During a review of Resident 8's History and Physical (H&P), dated 10/9/2024, the H&P indicated, Resident 8 had the capacity to understand and make decisions. During a review of Resident 8's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/11/2024, the MDS indicated Resident 8 required maximal assistance (Helper does more than half the effort) from one staff for toileting transfer, sit to stand, and moderate assistance (Helper does less than half the effort) from one staff for roll left and right, sit to lying, lying to sitting on side of bed. During a concurrent observation and interview on 10/29/2024, at 12:10 p.m., with Resident 8 in Resident 8's room, Resident 8 was sitting on a wheelchair next to the right-side of the foot of the bed and her nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was connected to a portable oxygen tank that was behind her wheelchair. Resident 8 was hyperventilating (rapid or deep breathing) and seemed very anxious (experiencing worry, unease, or nervousness). Resident 8's call light was clipped on the left side of her bed near the upper siderail, and Resident 8 was unable to reach the call light. Resident 8 stated, she believed her oxygen was almost out because she was barely feeling air coming out from her nasal cannula. Resident 8 stated, she was afraid because she was having shortness of breath (difficulty breathing) and she was not able to reach the call light. Resident 8 stated, she was has been hospitalized multiple times due to breathing issue. Resident 8 stated, she felt helpless not being able to call for help. During an interview on 10/29/2024, at 12:13 p.m., with Licensed Vocational Nurse (LVN) 1 in Resident 8's room, LVN 1 stated, the call light was not placed within reach, and it should have been within reach at all times. LVN 1 stated, Resident 8's oxygen tank indicated 400 pounds per square inch (PSI- the pressure that results when a 1-pound force is applied to a unit area of 1 square inch) which was low pressure and needed to be changed. LVN 1 stated, Resident 8 has had many episodes of difficulty breathing and nursing staff should have placed the call light within reach in case of emergency. During an interview on 11/1/2024, at 10:23 a.m., with the Director of Staff Development (DSD), the DSD stated, the call light should be within reach to accommodate residents' needs in a timely manner. The DSD stated, Resident 8 could have gone into respiratory distress (a person having trouble breathing or not getting enough oxygen) if she was not able to reach call light to alert someone that her oxygen supply is running out. During an interview on 11/1/2024, at 11:12 a.m., with the Director of Nursing (DON), the DON stated call lights should always be accessible and within the resident's reach. The DON stated that if the call light was not within the resident's reach, the resident would be unable to call for assistance to get his or her needs met. During a review of Resident 8's untitled Care Plan (CP), revised 9/3/2024, the CP Focus indicated, Resident 8 was at risk for fall related to impaired balance and poor safety awareness. The CP Interventions indicated, keep call light and bed controls within easy reach. During a review of the facility's policy and procedure (P&) titled, Answering the Call Light, revised 10/2010, the P&P indicated, Purpose: The purpose of this procedure is to respond to the resident's requests and needs. General Guidelines . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor range of motion ([ROM] full movement potential of a joint [where two bones meet]) in both legs for one of eight sampled residents (Resident 49) with limited range of motion and mobility (ability to move) by failing to perform an annual Joint Mobility Screen ([JMS] brief assessment of a resident's range of motion in both arms and both legs) on 4/18/2024 in accordance with the facility's policy titled, Resident Mobility and Range of Motion. This failure had the potential for Resident 49 to develop further ROM limitations in both legs due to the lack of monitoring for potentially 21 months from Resident 49's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) discharge on [DATE] to 4/2025 (next annual JMS). Findings: During a review of Resident 49's admission Record, the admission Record indicated the facility initially admitted Resident 49 on 12/11/2019 and re-admitted the resident on 7/15/2023. The admission Record indicated Resident 49's diagnoses included dementia (a progressive state of decline in mental abilities), functional quadriplegia (paralysis from the neck down, including the arms and legs), and contractures (stiffening/shortening at any joint that reduces the joint's range of motion) in both shoulders, left elbow, and both hands. During a review of Resident 49's PT Evaluation and Plan of Treatment, dated 7/19/2023, the PT Evaluation indicated Resident 49's ROM in both hips, knees, and ankles were impaired. The PT Evaluation indicated Resident 49's ROM limitations included right hip flexion (bending the leg at the hip joint toward the body) 0 to 35 degrees (0-35 degrees, normal 0-120 degrees), left hip flexion 10-60 degrees, right knee flexion (bending the knee) 0-10 degrees (normal 0-135 degrees), left knee flexion 10-60 degrees, both ankles dorsiflexion (bending the ankle toward the body) 0-5 degrees (normal 0-20 degrees), both ankles plantarflexion (bending the ankle away from the body) 0-10 degrees (normal 0-45 degrees). The PT Evaluation indicated Resident 49 had rigid (stiff) muscle tone (amount of tension in the muscle) in both legs, including the right knee which was difficult to bend. During a review of Resident 49's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) provided a 100 percent [%] return demonstration for performing passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) exercises to Resident 49's left leg, right hip, and right ankle. The PT Discharge Summary Recommendations indicated for the RNA to provide PROM to both legs. During a review of Resident 49's physician orders, dated 7/25/2023, the physician orders indicated for the RNA to perform PROM to both legs except the right knee, five times per week as tolerated. During a review of Resident 49's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 1/18/2024, the MDS indicated Resident 49 had no speech, rarely/never expressed ideas and wants, rarely/never understood verbal content, and was severely impaired for daily decision making. The MDS indicated Resident 49 had ROM impairments in both arms and legs. The MDS also indicated Resident 49 was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for dressing, showering, toileting, rolling to both sides in bed, and chair/bed-to-chair transfers. During a review of Resident 49's annual JMS, dated 4/18/2024, the JMS indicated Resident 49 had moderate (26-50% ROM loss) ROM limitations in the left elbow and severe (more than 50% ROM loss) ROM limitations in both shoulders, right elbow, and both hands. The JMS was blank (no assessment) for both legs. During a review of Resident 49's MDS, dated [DATE], 7/12/2024, and 10/11/2024, the MDS indicated Resident 49 had ROM limitations in both arms and legs. The MDS also indicated Resident 49 was dependent for dressing, showering, toileting, rolling to both sides in bed, and chair/bed-to-chair transfers. During an interview on 10/30/2024 at 9:36 a.m., with the Director of Rehabilitation (DOR), the DOR stated the JMS was performed upon a resident's (in general) admission, readmission, change of condition, and annually. The DOR stated the JMS were performed to assess a resident's ROM. During a concurrent observation and interview on 10/31/2024 at 9:42 a.m., in Resident 49's room, Resident 49 was awake while lying in bed with the head-of-bed elevated. Resident 49 was observed with a fully bent right elbow, right wrist bent downward, and both hands were positioned in closed fists. Resident 49's legs were resting straight on the bed. Restorative Nursing Aide 1 (RNA 1) provided PROM to both arms and legs except the right knee. RNA 1 stated Resident 49's right knee did not bend. During a concurrent interview and record review on 10/31/2024 at 1:29 p.m., with the Director of Rehabilitation (DOR), Resident 49's PT Evaluation, dated 7/19/2023, and PT Discharge summary, dated [DATE], were reviewed. The DOR stated the PT Evaluation indicated Resident 49 had spasticity (stiffness) into extension on both legs, making it difficult to bend both legs. The DOR stated the PT Discharge summary, dated [DATE], included recommendations to perform PROM to the left leg, right hip, and right ankle, five times per week. The DOR stated the recommendation did not include Resident 49's right knee since it remained in extension. The DOR stated the PT did not provide Resident 49 with any intervention since discharge from PT on 7/25/2023. During a concurrent interview and record review on 11/1/2024 at 1:30 p.m., with the MDS Coordinator (MDSC) and the MDS Assistant (MDS 2), Resident 49's MDS, dated [DATE], was reviewed. The MDSC stated Resident 49's MDS indicated Resident 49 had ROM impairments in both arms and legs. The MDSC stated Resident 49's MDS did not indicate the location and severity of Resident 49's ROM impairments. During an interview on 11/1/2024 at 1:32 p.m. with the MDSC and MDS 2, the MDSC stated the facility could not use the MDS (in general) to track a resident's ROM limitations since the MDS indicated the presence of ROM limitations but did not indicate the location and severity. During a concurrent interview and record review on 11/1/2024 at 2:47 p.m., with the DOR and the Director of Nursing (DON), Resident 49's annual JMS, dated 4/18/2024, was reviewed. The DOR stated the JMS (in general) was completed to track any decline in ROM to prevent the development of contractures, pressure injuries (pressure-related damage to skin and/or underlying tissue), and pain. The DOR reviewed Resident 49's annual JMS, dated 4/18/2024, and stated Resident 49's ROM in both legs were not assessed. The DOR stated Resident 49 had an increased potential for decline in ROM since both legs were not assessed since discharge from PT services (on 7/25/2023). During a concurrent interview and record review on 11/1/2024 at 2:57 p.m., with the DOR and the Director of Nursing (DON), Resident 49's annual JMS, dated 4/18/2024, was reviewed. The DON stated it was the facility's policy to perform the JMS annually for each resident. The DOR stated Resident 49's next annual JMS would have been in 4/2025 in accordance with the facility's policy. The DON stated Resident 49 would have gone 21 months (7/25/2023 to 4/2025) without an assessment of both legs, which the DON stated was a long period of time. During a review of the facility's policy and procedure (P&P) titled, Resident Mobility and Range of Motion, revised 7/2017, the P&P indicated resident with limited ROM and mobility will receives appropriate services, equipment and assistance to maintain or improve mobility. The P&P further indicated the rehabilitation screening will be completed upon admission and yearly.

Based on observation, interview and record review, the facility failed to provide prompt dental services after dentures were lost on 9/10/24 and provide documentation of what they did to ensure resident could still eat and drink adequately while awaiting dental services for one of two sample residents (Resident 30). This deficient practice resulted in Resident 30 not being able to eat the mechanical soft diet without the dentures until replacement was delivered on 10/31/24. During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility under Hospice (that provides medical, emotional, and spiritual support for people who are terminally ill and nearing the end of their life) on 8/2/2024 with diagnoses included dementia (a progressive state of decline in mental abilities), anemia (a condition where the body does not have enough healthy red blood cells), heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), palliative care (specialized medical care for people living with a serious illness providing relief from the symptoms and stress of the illness). During a review of Resident 30's Minimum Data Set ([MDS], a federally mandated resident assessment tool), dated 8/8/2024, the MDS indicated Resident 30 was severely impaired in cognitive skills (thought process) skills for daily decision-making and was dependent (helper does all of the effort to complete activities, the assistance of two or more helpers is required) on self-care abilities such as eating, oral hygiene, toileting, shower/bathing, upper and lower body dressing and mobility functions such as rolling left and right, sitting to lying, lying to sitting, bed to chair transfers and shower transfers. During a review of Resident 30's Order Summary Report, the Order Summary Report indicated there was no dental consult ordered. During a review of Resident 30's Order Summary Report, the Order Summary Report indicated fortified diet (foods that have been enhanced with additional nutrients, such as vitamins, minerals, protein, carbohydrates, or fats), mechanical soft texture (foods that are soft and easy to chew, less chewing than regular foods), regular liquid consistency ordered on 8/15/2024. During a review of Resident 30's Social Services Note dated 9/11/2024, the Social Service Note indicated Resident 30 was referred to a Dentist today 9/11/2024. The social Service note indicated that family was made aware and will follow up as needed. During a review of Resident 30's Dental Progress Notes, dated 9/25/2024, the Dental Progress Notes indicated Resident 30 has full lower dentures (FLD) only and no treatment indicated due to Resident 30's medical condition. During a review of Resident 30's Social Services Note dated 9/30/2024, the Social Service Note indicated Resident 30 was seen the Dental Care agency on 9/25/2024 to continue with treatment plan. Resident did not express having any trouble eating or drinking, or pain or discomfort. Will follow up as needed. Family also made aware of visit. During a review of Resident 30's Interdisciplinary Team (IDT-team members from different departments working together with a common purpose to set goals and make decisions that ensure the resident received the best care) Care Conference Summary dated 10/16/2024, the IDT Care Conference Summary indicated Resident 30's diet remained the same as mechanical soft consistency since 8/15/2024 and resident was last seen by dentist on 9/25/2024 for new dentures. The IDT Care Conference Summary indicated Resident 30 had poor oral intake of 25-50%, there was significant weight loss noted in two months, Dietary team will continue to monitor, and Registered Dietitian as needed. During a review of Resident 30's Dental Progress Notes dated 10/16/2024, the Dental Progress Notes indicated Resident 30 had missing full upper dentures (FUD), new FUD requested by facility. Resident 30 was informed of new FUD, impressions (imprints of your teeth and mouth) taken with Resident 30's consent. During a review of Resident 30's Social Services Note dated 10/16/24, the Social Service Note indicated Resident 30 was seen on 9/25/2024 and on 10/16/2024 for dental services to continue with treatment. Family made aware and was very thankful. During a review of Resident 30's Dental Progress Notes dated 10/24/24, the Dental Progress Notes indicated try in new FUD, recommend repair for lower denture. During an observation and interview on 10/29/2024 at 12:55 p.m., with Certified Nursing Assistant (CNA) 2 in Resident 30's room, CNA 2 stated the dentures at Resident 30's bedside did not fit the resident anymore. CNA 2 stated Resident 30 cannot really talk without her dentures. Resident 30 was observed eating lunch with no dentures. Resident 30 was observed eating potatoes but only ate one small bite and did not want to eat anymore. During a telephone interview on 10/30/2024 at 10:45 a.m., with Resident 30's Responsible Party (RP), the RP stated the facility lost Resident 30's upper dentures. The RP stated the dental consult saw Resident 30 last week to take impressions of her mouth. During a review of Resident 30's Dental Progress Notes dated 10/30/24, the Dental Progress Notes indicated delivered new FUD. During a concurrent interview and record review on 10/31/2024 at 2:00 p.m. with the Social Service Director (SSD), the SSD stated Resident 30's date of lost dentures was on 9/10/2024 and dental services came to see Resident 30 on 9/25/2024. The SSD stated there was an IDT Care Conference meeting on 10/16/2024, Resident 30's lost dentures were discussed during the meeting, but interventions were already in place to replace the lost dentures. There was no discussion about Resident 30's diet consistency even though there was weight loss and no dentures so no ability to chew. The SSD stated the replacement dentures arrived today and will check to see if it fits Resident 30's mouth. During a review of Resident 30's Social Services Note dated 10/31/2024, the Social Service Note indicated that the Social Service Director (SSD) met with Resident 30 to see how she was doing and how her new dentures were fitting. Resident 30 stated that she is doing fine and that they fit okay. Resident 30 did not express any concerns or discomfort. The SSD will follow up as needed. During a concurrent telephone interview and record review on 10/31/2024 at 2:19 p.m. with the Registered Dietitian (RD), the RD stated she did not get informed that Resident 30 did not have her dentures. The RD stated if Resident 30 had a chewing problem, the RD would have downgraded the diet to lower-level diet consistency like a puree diet which did not require chewing. The RD stated if a resident cannot consume the diet consistency, the outcome when a diet was not tolerated by a resident was weight loss. The RD stated that Resident 30 did not verbalize any chewing or swallowing issues during visits the RD made with Resident 30 but since Resident 30 had diagnosis of dementia, what Resident 30 says might not be valid. During an interview on 11/1/2024 at 5:04 p.m. with the Director of Nursing (DON), the DON stated she was aware Resident 30 did not have her dentures. The DON stated Resident 30 did not want to wear dentures during meals. The DON stated she does not know how the dentures got lost when Resident 30 did not want to wear the dentures during meals. The DON stated there was no discussion to change the diet consistency during the time Resident 30 did not have her dentures. The DON stated the replacement dentures arrived yesterday. During a review of the facility's policy and procedure (P/P) titled Availability of Services, Dental, revised August 2017, the P/P indicated oral healthcare and dental services will be provided to each resident dental services are available to all residents requiring routine and emergency dental care . social services will be responsible for making necessary dental appointments .all requests for routine and emergency dental services should be directed to Social Services to assure that appointments can be made in a timely manner .residents with lost or damaged dentures will be promptly referred to a dentist.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 30) received food according to her preferences. This deficient practice resulted in Resident 30 not eating her preferred diet potentially resulting in decrease meal intake, weight loss, and malnutrition (lack of proper nutrition, caused by not eating enough). Findings: During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility under a Hospice (an agency that provides medical, emotional, and spiritual support for people who are terminally ill and nearing the end of their life) agency on 8/2/2024 with diagnoses included dementia (a progressive state of decline in mental abilities), anemia (a condition where the body does not have enough healthy red blood cells), heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), palliative care (specialized medical care for people living with a serious illness providing relief from the symptoms and stress of the illness). During a review of Resident 30's Minimum Data Set ([MDS], a federally mandated resident assessment tool), dated 8/8/2024, the MDS indicated Resident 30 was severely impaired in cognitive skills (thought process) skills for daily decision-making and was dependent (helper does all of the effort to complete activities, the assistance of two or more helpers is required) on self-care abilities such as eating, oral hygiene, toileting, shower/bathing, upper and lower body dressing and mobility functions such as rolling left and right, sitting to lying, lying to sitting, bed to chair transfers and shower transfers. During a review of Resident 30's Order Summary Report, the Order Summary Report indicated fortified diet (foods that have been enhanced with additional nutrients, such as vitamins, minerals, protein, carbohydrates, or fats), mechanical soft texture (foods that are soft and easy to chew, less chewing than regular foods), regular liquid consistency (unmodified for thickness), ordered on 8/15/2024. During an observation and interview on 10/29/2024 at 12:55 p.m., with Certified Nursing Assistant (CNA) 2 in Resident 30's room, CNA 2 stated Resident 30 liked the potatoes on the meal tray. CNA 2 stated the potatoes were soft and started cutting Resident 30's potatoes into smaller pieces. Resident 30 had no teeth, took one small bite of the potatoes, and did not want to eat anymore after that. CNA 2 stated that Resident 30 liked the soups that the family would bring in for her. During an interview on 10/29/2024 at 1:00 p.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Resident 30 tends to not eat solid food and preferred to eat puree food (food that have a soft, pudding-like consistency) and gets a nutritional Supplement. The LVN 5 stated Resident 30 was admitted with a mechanical soft diet on hospice. LVN 5 stated there was no discussion about possibly changing Resident 30's diet to a puree diet, the hospice team kept the same diet consistency since admission to the facility. LVN 5 stated Resident 30 ate about 25% of her meals and that Resident 30's intake was very low. During a concurrent telephone interview and record review on 10/31/2024 at 2:19 p.m. with the Registered Dietitian (RD), the RD stated there were no notes from the CNA or LVN about Resident 30's preferred diet consistency of puree diet. The RD stated if Resident 30 had a chewing problem, the RD would have downgraded the diet to lower-level diet consistency like a puree diet. The RD stated if a resident cannot consume the diet, because the diet cannot be tolerated by a resident, the resident was at risk for weight loss. The RD stated that Resident 30 did not verbalize any chewing or swallowing issues but since Resident 30 had a diagnosis of dementia, what Resident 30 says might not be valid. During an interview on 11/1/2024 at 2:30 p.m., with CNA 1, CNA 1 stated Resident 30 does not eat a lot during mealtimes. CNA 1 stated Resident 30 ate well this morning with breakfast, over 50% of food eaten since breakfast was puree diet and it was Resident 30's favorite meal, oatmeal. CNA 1 stated Resident 30 did not eat too much food when the diet was mechanical soft diet but Resident 30 ate a lot more with this puree diet. During an interview on 11/1/24 at 5:04 p.m. with the Director of Nursing (DON), the DON stated she did not know Resident 30 preferred a puree diet and if that was what Resident 30 preferred to eat, the speech language pathologist ([SLP], a professional who assesses and treats communication disorders) would have been consulted right away to evaluate Resident 30 and the RD can get the diet order changed to what Resident 30 wanted. A review of facility's policy and procedure (P/P) titled, Resident Food Preferences, revised July 2017, the P/P indicated staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes .nursing staff will document the resident's food and eating preferences in the care plan the dietitian and nursing staff will identify any nutritional issues and dietary recommendations that might be in conflict with the resident's food preferences the dietitian will discuss with the resident or representative the rationale of any prescribed therapeutic diet. The physician (another term for medical doctor, a health professional who practices medicine) and dietitian will communicate the risk and benefits of specialized therapeutic versus liberalized diets therapeutic diets will be ordered only after the resident/representative agrees with and consents to such diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the clinical records were complete and accurately documented by: a. failing to ensure the documentation for one out of six sampled residents (Resident 84) related to Resident 84's intravenous (IV, administered into a vein) access and IV fluids (liquids that are injected into a vein to prevent or treat dehydration [occurs when the body loses more fluids than it takes in]) was accurate. This deficient practice had the potential to reflect inaccurate hydration for Resident 84 b.failing to ensure one of eight sampled residents (Resident 49) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns had complete clinical records for the provision of Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) services. This failure resulted in Resident 49's records being incomplete regarding the provision of RNA in April 2024. Findings: a.During a review of Resident 84's admission record, the admission record indicated Resident 84 was admitted to the facility 8/9/2024 with diagnoses of seizures (a temporary episode of abnormal electrical activity in the brain that causes a sudden change in behavior, movement, or consciousness), acute kidney failure (a sudden loss of kidney function that can be life-threatening if left untreated), and nontraumatic intracerebral hemorrhage (bleeding in the brain). During a review of Resident 84's minimum data set (MDS, a federally mandated resident assessment tool) dated 8/13/2024, the MDS indicated Resident 84 had severe cognitive (ability to make decisions of daily living) impairment. During a review of Resident 84's Situation, Background, Assessment, and Recommendation (SBAR) Communication Form dated 10/28/2024, the SBAR indicated Resident 84 had inadequate hydration with elevated blood urea nitrogen (BUN, a blood test related to kidney function) and creatinine (a blood test related to kidney function). During a review of Resident 84's Physician's orders, the Physician's orders indicated IV fluids and IV site access was ordered on 10/28/2024, the orders read: 1). 1/2 Normal Saline (a solution used to treat cellular dehydration) at 40 milliliters (ml, a unit of measurement of volume) per hour for 500 ml only, for elevated BUN and creatinine every shift for 1 day. 2.) monitor IV access site based on phlebitis scale (measures any signs of irritation at the IV access site). The Physician's orders indicated the 1/2 NS hydration solution to be completed on 10/29/2024 at 8:49 a.m. During a review of Resident 84's Post change of condition (COC)/ SBAR note dated 10/30/2024 at 9:54 p.m., the note indicated Resident 84 was on monitoring for elevated BUN/ creatinine and Resident 84 continued to have 1/2 NS running at 40 ml/ hr. in the left upper arm (LUA) and it was infusing well. The note indicated Resident 84's IV site was intact (in place) and was not swollen or bleeding. There was another COC/SBAR note dated 10/31/2024 at 7:10 a.m., indicating Resident 84 was still on IV fluids for hydration and the IV site in the LUA was intact, this information was struck out (removed from documentation) on 10/31/2024 at 11:24 p.m. due to error in documentation. During a review of Resident 84's Nurse Progress Note dated 10/31/2024 at 11:55 a.m., the progress note indicated it was a late entry note (entered at a later time) for 10/29/2024 at 11:00, the note indicated Resident 84's IV fluids were completed, and the treatment nurse (TXN 1) removed the IV site from the LUA. During an observation on 10/30/2024 at 9:33 a.m., Resident 84 was in bed with no IV fluids infusing at bedside and no IV access. During an observation on 10/31/2024 at 10:20 a.m., Resident 84's body was assessed by licensed vocational nurse (LVN 6), LVN 6 stated Resident 84 did not have IV access and there was only a gauze (a thin, loosely woven fabric) dressing covering the old IV access site. During a concurrent interview and record review on 10/31/2024 at 10:28 a.m., with registered nurse supervisor (RNS 1) of Resident 84's post COC/SBAR notes from 10/20/2024 and 10/31/2024, RN 1 stated Resident 84 completed his IV fluid infusion on 10/29/2024 and his IV access was removed the same day. RNS 1 stated Resident 84's post COC/ SBAR notes from 10/30/2024 and 10/31/2024 documentation was inaccurate because he did not have IV access or IV hydration anymore. RNS 1 stated it was important to have accurate documentation because if he still had IV access it was a risk for infection (IV access only good for 72 hours before needing to change site) and it was important to reflect accurate hydration. RNS 1 stated the inaccurate documentation suggested that the licensed nurses were not doing a complete assessment on Resident 84's body. During an interview on 11/1/2024 at 3:51 p.m., the director of nursing (DON) stated the importance of accurate documentation was to reflect the residents actual care and needs. b.During a review of Resident 49's admission Record, the admission Record indicated the facility initially admitted Resident 49 on 12/11/2019 and re-admitted the resident on 7/15/2023. The admission Record indicated Resident 49's diagnoses included dementia (a progressive state of decline in mental abilities), functional quadriplegia (paralysis from the neck down, including the arms and legs), and contractures (stiffening/shortening at any joint that reduces the joint's range of motion) in both shoulders, left elbow, and both hands. During a review of Resident 49's physician orders, dated 7/25/2023, the physician orders indicated for the RNA to perform passive range of motion (PROM) to both legs except the right knee, five times per week as tolerated. A review of Resident 49 physician orders, dated 7/31/2023, indicated for the RNA to perform PROM to both arms, five times per week, to apply both elbow extension splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) for four to six hours, five times per week, and to apply carrot splints (hand splint shaped like a carrot to position the fingers away from the palm for severe hand contractures) to both hands for four to six hours, five times per week. During a review of Resident 49's MDS, dated [DATE], the MDS indicated Resident 49 had no speech, rarely/never expressed ideas and wants, rarely/never understood verbal content, and was severely impaired for daily decision making. The MDS indicated Resident 49 had ROM impairments in both arms and legs. The MDS also indicated Resident 49 was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for dressing, showering, toileting, rolling to both sides in bed, and chair/bed-to-chair transfers. During an observation on 10/31/2024 at 9:42 a.m., in Resident 49's room, Resident 49 was awake while lying in bed with the head-of-bed elevated. Resident 49 was observed with a fully bent right elbow, right wrist bent downward, and both hands were positioned in closed fists. Resident 49's legs were resting straight on the bed. Restorative Nursing Aide 1 (RNA 1) performed PROM to both arms, applied both elbow splints, and applied both carrot splints. RNA 1 then performed PROM to both legs except the right knee. During a review of Resident 49's Restorative Nursing (RNA) flow sheets (record of RNA sessions) from 12/2023 to 11/2024, the RNA flow sheet for 4/2024 was not included in Resident 49's clinical record. During a concurrent interview and record review on 11/1/2024 at 2:47 p.m., with the Director of Rehabilitation (DOR) and the DON, Resident 49's RNA flow sheets were reviewed. The DOR and DON were unable to locate Resident 49's RNA flow sheet for 4/2024. The DON stated the RNAs were supposed to submit the residents' RNA flow sheets to the facility's Director of Medical Records (DMR). The DON stated Resident 49's clinical records were incomplete since the RNA flow sheets were missing for 4/2024. During a review of the facility's undated policy and procedure (P&P) titled, Charting and Documentation, the P&P indicated all services provided to the resident shall be documented in the resident's medical record. The P&P indicated the resident's medical record should be complete and accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement infection control measures by failing to: A. Ensure Resident 260's visitor was wearing Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) and Licensed Vocational Nurse (LVN) 2 and LVN 3 were doffing (removing PPE in a way that avoids self-contamination) PPE properly without self-contamination after caring for Resident 260 who was on Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms). B. Ensure LVN 1, LVN 4, and Certified Nurse Assistant (CNA) 1 were wearing proper PPE during the care of Resident 8 who was on EBP. C. Ensure the duct tape (a water resistant tape that is not waterproof and will eventually break down and allow water to pass) placed on 4 out of 22 sampled resident's (Resident 16, Resident 54, Resident 59, and Resident 84) beds' padded side rails (a raised side fitted to a bed) was not cracked or pealing, revealing the foam (a soft porous material, and the degree of porosity can vary depending on the type of foam) underneath the duct tape to ensure proper disinfection of the side rails. These deficient practices resulted in facility staff not following infection prevention protocols and had the potential to spread infection amongst residents, staff, and visitors. Findings: A. During a review of Resident 260's admission Record, the admission Record indicated, Resident 260 was admitted to the facility on [DATE] with diagnoses including gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and pressure ulcer/injury (damage to skin and underlying tissue caused by unrelieved pressure) unstageable (full thickness tissue loss but is either covered by extensive dead tissue) of sacral region (the portion of the spine between lower back and tailbone). During a review of Resident 260's History and Physical (H&P), dated 10/28/2024, the H&P indicated, Resident 260 had the capacity to understand and make decisions. During a review of Resident 8's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/31/2024, the MDS indicated Resident 260 required dependent assistance (Helper does all of the effort) from two or more staff for roll left and right, sit to lying, and lying to sitting on side of bed. During a concurrent observation and interview on 10/29/2024, at 10:21 a.m., with Visitor 1 in Resident 260's room, there was signage that indicated Resident 260 was on EBP. Visitor 1 was not wearing a gown or gloves. Visitor 1 was stroking Resident 260's hair and fixing his blanket with bare hands. Visitor 1 was leaning over the left bed siderail. Visitor 1 stated, she did not know about EBP and did not know she needed to wear PPE. Resident 260 pressed the call light to be re-positioned. LVN 2 and LVN 3 answered the call light and donned PPE, but they did not ask Visitor 1 to wear PPE. Visitor 1 stated, nursing staff saw her not wearing PPE, but they did not say anything to her. During a concurrent observation and interview on 10/29/2024, at 10:24 a.m., with LVN 2 and LVN 3 in Resident 260's room, LVN 2 and LVN 3 were doffing their PPE after providing direct care for Resident 260. LVN 2 and LVN 3 were still wearing their gloves when they untied their gowns. LVN 2 and LVN 3's gloves were touching the back side of their work uniforms near the necks. They took off the gowns then took off the gloves last. LVN 2 stated, she always took off her gloves last. LVN 2 stated, she did not realize that there was signage for how to remove PPE and the gloves should be off before removing other PPE. LVN 2 stated, she should have taken off her gloves first to prevent self- contamination. LVN 3 stated, she also realized they were doffing PPE incorrectly and had contaminated themselves without knowing. LVN 2 and LVN 3 stated, incorrect donning and doffing of PPE would spread infection to the vulnerable residents of the facility. During a review of Resident 260's untitled Care Plan (CP), revised 10/28/2024, the CP Focus indicated, Resident 260 was on EBP. The CP Interventions indicated, Care team to provide teaching and education regarding care. Staff will perform hand hygiene, wear PPE before and after high contact care activities. According to the Centers for Disease Control (CDC a national public health agency), a review of a document titled, How to safetly remove personal protective equipment (CS250672-E), indicated to remove PPE before leaving the resident's room, and to remove gloves first because the outside of the gloves are contaminated. (https://www.cdc.gov) B. During a review of Resident 8's admission Record, the admission Record indicated, Resident 8 was initially admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses including aquired absence of left leg above the knee, gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dependence on supplemental oxygen (odorless colorless gas that sustains life), and pressure ulcer/injury stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible) of sacral region (the portion of the spine between lower back and tailbone). During a review of Resident 8's H&P, dated 10/9/2024, the H&P indicated, Resident 8 had the capacity to understand and make decisions. During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 required maximal assistance (Helper does more than half the effort) from one staff for toileting transfer, sit to stand, and moderate assistance (Helper does less than half the effort) from one staff for roll left and right, sit to lying, lying to sitting on side of bed. During an observation on 10/29/2024, at 12:13 p.m., in Resident 8's room, there was signage that indicated Resident 8 was on EBP. Resident 8 was sitting in a wheelchair next to her bed and was complaining that her oxygen tank needed to be replaced. LVN 1 came in to Resident 8's room without wearing PPE . LVN 1 grabbed the handle of Resident 8's wheelchair and pulled out the portable oxygen tank from the back of Resident 8's wheelchair. LVN 1 called Certified Nursing Assistant 1(CNA 1) to bring a new oxygen tank. CNA 1 brought the new oxygen tank and did not donn PPE before entering the room. LVN 1 changed the oxygen tank and adjusted Resident 8's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) without wearing gloves while CNA 1 was helping Resident 8 to adjust her posture. LVN 1 asked LVN 4 who was assigned to Resident 8 to adjust the oxygen flow level. LVN 4 donned gloves, but he did not wear the gown. LVN 4 adjusted Resident 8's oxygen level and re-adjusted Resident 8's nasal cannula. LVN 4's uniform was touching Resident 8's wheelchair while he was providing care. During an interview on 10/29/2024, 12:17 p.m., with LVN 1, LVN 1 stated, they should have worn PPE before providing care for Resident 8 to prevent spreading infection. LVN 1 stated, wearing proper PPE was important to protecting residents and staff from infection. During a review of Resident 8's untitled CP, revised 10/21/2024, the CP Focus indicated, Resident 8 was on EBP due to gastrostomy and open wounds. The CP Interventions indicated, Care team to provide teaching and education regarding care. Staff will perform hand hygiene, wear PPE before and after high contact care activities. During an interview on 11/1/2024, at 10:23 a.m., with the Director of Staff Development (DSD), the DSD stated, he mentioned to staff that glove should be the last PPE to put on and first one to take off after providing care during the in-service. The DSD stated, following proper donning and doffing of PPE could protect residents and staff both. During an interview on 11/1/2024, at 10:49 a.m., with the Infection Preventionist Nurse (IPN), IPN stated, PPE should have worn before caring the resident who was on EBP to prevent cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another). IPN stated, LVN 4 was wearing gloves, but he did not realize that he had indirect contact with Resident 8. IPN stated, PPE was applicable to the visitors and EBP signage indicated wearing PPE was for everyone. IPN stated, staff should have asked Visitor 1 to wear PPE and provided education. During an interview on 11/1/2024, at 11:12 a.m., with Director of Nursing (DON), the DON stated, the staff should follow EBP guidelines and wear proper PPE when indicated for infection control to protect themselves and vulnerable residents. During a review of the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precautions, revised 8/2022, the P&P indicated, Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation: 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room) .3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include . g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing) . 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of [NAME] colonization . 12. Residents, families and visitors are notified of the implementation of EBPs throughout the facility. During a review of the facility's Policy and Procedure (P&P) titled, Personal Protective Equipment, revised 10/2018, the P&P indicated, Policy Interpretation and Implementation . 5. Training on the proper donning, use and disposal of PPE is provided upon orientation and at regular intervals. 6. Employees who fail to use personal protective equipment when indicated may be disciplined in accordance with personnel policies. 7. Visitors and residents who are asked to comply with transmission-based precautions are educated on the proper use of PPE and provided with equipment at no charge. C. During a review of Resident 16's admission record, the admission record indicated Resident 16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of quadriplegia (unable to move all four limbs), dementia (a chronic condition that causes a decline in cognitive abilities, such as thinking, remembering, and reasoning, that interferes with daily life), and osteoporosis (weak bones). During a review of Resident 16's MDS dated [DATE], the MDS indicated Resident 16 had severe cognitive impairment (a condition that makes it very difficult for a person to remember things, learn new things, concentrate, or make decisions). During a review of Resident 16's physician's orders dated 9/22/2024, the Physician order indicated Resident 16 may have padded bilateral grab bars (smaller side rails) as an enabler for positioning and supporting during care. During a review of Resident 54's admission record, the admission record indicated resident 54 was admitted to the facility 4/29/2019 with diagnoses of hemiplegia (can not move one side of the body) affecting the right side and epilepsy (a chronic brain disorder that causes seizures, which are episodes of abnormal electrical activity in the brain). During a review of Resident 54's Physician's orders dated 11/2/2023, the physician order indicated Resident 54 may have left side ½ padded side rails as enabler for bed mobility and for seizure precaution. During a review of Resident 54's MDS dated [DATE], the MDS indicated Resident 54 had severe cognitive impairment. During a review of Resident 59's admission record, the admission record indicated Resident 59 was admitted to the facility on [DATE] with diagnoses of dementia and history of falling. During a review of Resident 59's physician orders dated 5/16/2024, the physician order indicated Resident 59 may have bilateral (both sides) grab bars as enablers for bed mobility. During a review of Resident 59's MDS dated [DATE], the MDS indicated Resident 59 had severe cognitive impairment. During a review of Resident 84's admission record, the admission record indicated Resident 84 was admitted to the facility on [DATE] with diagnoses of seizures, history of falling, and nontraumatic intracerebral hemorrhage (bleeding in the brain). During a review of Resident 84's MDS dated [DATE], the MDS indicated Resident 84 had severe cognitive impairment. During a review of Resident 84's physician's orders dated 10/17/2024, the physicians order indicated Resident 84 may have bilateral padded grab bars up as enablers for turning and repositioning and for seizure precaution. During an observation on 10/29/2024 at 9:40 a.m., Resident 16's bilateral grab bars were wrapped with duct tape, the duct tape was cracked exposing the black foam padding underneath the duct tape. During an observation on 10/29/2024 at 10:05 a.m., Resident 59's bilateral grab bars were covered in duct tape with some sections of duct tape that had pealed off exposing the black foam padding underneath. During an observation on 10/29/2024 at 10:19 a.m., Resident 54's right side ½ padded side rail was covered with duct tape that was cracked and pealing exposing the black foam padding underneath. During an observation on 10/29/2024 at 10:35 a.m., Resident 84's bilateral grab bars only had duct tape wrapped around the top of the grab bars and the rest of the black foam padding was exposed. During an interview on 10/29/2024 at 3:21 p.m., the maintenance supervisor (MS) stated they wrapped the grab bars with duct tape to secure the foam padding to the bed rails. The MS stated the purpose of the duct tape was so housekeeping could clean and sanitize the bed rails because they couldn't clean the foam and they couldn't find a cover, so the facility decided to use duct tape. The MS stated the manufacture fo the bed did not recommend for the bed rails to be wrapped in duct tape. The MS stated nursing staff was to alert him when the tape was cracked or pealing so he could fix it because the black foam padding should not be exposed because it could not be sanitized. The MS checked the duct tape on the bed rails for Resident 16, Resident 54, Resident 59, and Resident 84. The MS stated that the duct tape on both siderails of Resident 16's bed was cracked, exposing the black foam. The MS stated that Resident 84's grab bars were not fully covered in duct tape. The MS stated Resident 54's tape on the right-side rail was cracked and pealing and Resident 59's duct tape on the bilateral grab bars was cracked. The MS said the duct tape should not be that way and it needed to be fixed. During an interview on 11/1/2024 at 2:23 p.m., the housekeeping supervisor (HKS) stated they used a brand name disinfectant for all cleaning in the facility including the bed rails with padding and duct tape. The HKS stated if the black foam padding was exposed under the duct tape there was a risk for infection because bacteria (microscopic organisms that can make you sick) can live in the cracks (pores) of the foam. The HKS stated the duct tape was not a hard, nonporous surface. During an interview on 11/1/2024 at 4:45 p.m., the IPN stated there was a potential for bacteria to grown and build up if the duct tape was broken or missing exposing the black foam padding on the bed rails. During a review of the literature for brand name disinfectant used by the facility, undated, the literature indicated the product was to be used as part of a simple and effective cleaning and disinfection program for facilities on hard, non-porous surfaces.

Based on observation, interview, and record review the facility failed to ensure kitchen staff including the dietary supervisor assistant (DSA) and dietary aide (DA 1) were competent regarding their food thawing policies. These deficient practices had the potential to result in pathogen (germ) exposure and placed 99 out of 106 total residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps (a type of abdominal pain that feel like contractions and can vary in intensity, nausea (a feeling of sickness or discomfort in the stomach that may come with an urge to vomit), vomiting (stomach pain with urge to expel contents through the mouth) , diarrhea (Loose, watery stools that occur more frequently than usual), and fever (elevated body temperature indicating illness) and can lead to other serious medical complications and hospitalization. Findings: During an observation on 10/30/2024 at 11:02 a.m., there was a box of frozen chicken sitting by the food preparation sink in the kitchen, the chicken appeared to have soft pliable skin and appeared partially thawed. The cardboard box had become wet from the thawing chicken juice. The dietary supervisor assistant (DSA) informed dietary aide (DA 1) that they were no longer going to use the chicken for the next day. The DSA instructed DA 1 to place the chicken back into the main freezer located outside of the kitchen. During an observation on 10/30/2024 at 11:09 a.m., DA 1 placed the partially thawed box of chicken back into the facility's main freezer. During an observation on 10/30/2024 at 11:18 a.m., the DSA instructed staff to remove the partially thawed chicken from the facility's main freezer and place it back into the food preparation sink for thawing. During an observation on 10/30/2024 at 11:27 a.m., the chicken that was thawing in the food preparation sink on 10/30/2024 at 11:02 a.m., for thawing, was now sitting in the food preparation sink again to continue thawing without running water over it. During an observation on 10/30/2024 at 11:30 a.m., the DSA walked over to the food preparation sink and turned the water on to run over the thawing chicken. During an observation on 10/30/2024 at 11:31 a.m., the dietary supervisor (DS) came into the kitchen and stated, I told you people that you can't refreeze chicken. During an interview on 10/30/2024 at 11:33 a.m., the DS stated when the kitchen staff decided they were no longer going to use the chicken for the intended meal they should have placed the partially thawed chicken into the refrigerator to continue thawing (good for 3 days) instead of placing the chicken back into the freezer. During an interview on 11/1/2024 at 1:51 p.m., DA 1 stated thawed items should never be put back in the freezer but she did not want to question her supervisor (DSA)'s orders. During an interview on 11/1/2024 at 1:59 p.m., the DSA stated they were not allowed to put partially thawed items back in the freezer (unknown reason why it was done on 10/30/2024). The DSA stated food could not just sit in the sink to thaw, it had to be under running water. The DSA stated if food was not thawed properly there was the potential outcome of food contamination because bacteria begin to grow on the food. During a review of the facility's policy and procedure (P/P) titled Food Receiving and Storage dated 11/2022, the P/P indicated refrigerated foods were to be labeled, dated and monitored so they are used by their use-by date. Frozen foods were to be maintained at a temperature to keep food frozen solid. During a review of the facility's P/P titled Food Preparation and Service dated 11/2022, the P/P indicated food was not to be thawed at room temperature and food being thawed by water need to be completely submerged in cold running water that is running fast enough to agitate and remove loose ice particles. During A review of the 2022 U.S. Food and Drug Administration food Code, Code # 3-501.11 Frozen Food; 3.501.12 Time/Temp Control for Safety Food, Slacking and 3-501.13 Thawing, Indicated, Freezing prevents microbial growth in foods, but usually does not destroy all microorganisms. Improper thawing provides an opportunity for surviving bacteria to grow to harmful number and produce toxins. If the food is then refrozen, significant number of bacteria and toxins are preserved.

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope [a scientific magnifying device]) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated [something that has been made impure or unfit for use by contact with something harmful] food for 99 out 106 total residents in the facility by not ensuring: a.Cottage cheese in the reach-in refrigerator was not past the use by date. b.The temperature log for the walk-in refrigerator was filled out twice daily c. Food such as raw chicken and frozen waffles were not thawed and then returned to the freezer. d.Proper thawing techniques by not having running water over thawing chicken in the sink. e.The facility ice machine was maintained in a clean and sanitary way. f. There was a cleaning log kept for the upper portion of the ice machine. These deficient practices had the potential to result in pathogen (an organism that can cause illness) exposure and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps (a type of abdominal pain that feel like contractions and can vary in intensity, nausea (a feeling of sickness or discomfort in the stomach that may come with an urge to vomit), vomiting (stomach pain with urge to expel contents through the mouth) , diarrhea (Loose, watery stools that occur more frequently than usual), and fever (elevated body temperature indicating illness) and can lead to other serious medical complications and hospitalization. Findings: During an observation on 10/29/2024 at 8:47 a.m., with the dietary supervisor (DS), the reach in refrigerator contained a container labeled cottage cheese and labeled with a use by date of 10/27/2024. During an observation and concurrent interview on 10/29/2024 at 8:52 a.m., with the DS, the facility's main freezer located outside of the kitchen contained frozen Waffles that were thawed for breakfast that morning and then placed back in the refrigerator after not being used. The DS stated it was not facility procedure to put thawed items back into the freezer. During an observation on 10/30/2024 at 11:02 a.m., there was a box of frozen chicken sitting by the food preparation sink in the kitchen, the chicken was partially thawed. The cardboard box had become wet from the thawing chicken juice. The dietary supervisor assistant (DSA) informed dietary aide (DA 1) that they were no longer going to use the chicken for the next day and if DA 1 could place the chicken back into the main freezer located outside of the kitchen. During an observation on 10/30/2024 at 11:09 a.m., DA 1 placed the partially thawed box of chicken back into the facility's main freezer. During an observation on 10/30/2024 at 11:18 a.m., the DSA instructed staff to remove the partially thawed chicken from the facility's main freezer and place it back into the food preparation sink for thawing. During an observation on 10/30/2024 at 11:21 a.m., the temperature log for the walk-in refrigerator was missing the documented temperature for the morning of 10/30/2024. During an observation on 10/30/2024 at 11:27 a.m., the chicken that was thawing in the food preparation sink for thawing was now sitting in the food preparation sink to continue thawing without running water over it. During an observation on 10/30/2024 at 11:30 a.m., the DSA walked over to the food preparation sink and turned the water on to run over the thawing chicken. During an observation on 10/30/2024 at 11:31 a.m., the DS came into the kitchen and stated, I told you people that you can't refreeze chicken. During an interview on 10/30/2024 at 11:33 a.m., the DS stated when the kitchen staff decided they were no longer going to use the chicken for the intended meal they should have placed the partially thawed chicken into the refrigerator to continue thawing (good for 3 days) instead of placing the chicken back into the freezer. During an observation and concurrent interview on 10/31/2024 at 12:10 p.m., the maintenance supervisor (MS) opened the top panel of the ice machine. There was dust around the edges of the ice machine behind the upper panel and covering the inside of the upper portion of the ice machine. A black substance was growing where condensation (water which collects as droplets on a cold surface when humid air is in contact with it) was collecting on the water lines in the upper portion of the ice machine. The MS stated it was a black substance growing in the upper portion of the ice machine and there was a layer of dust in there. The maintenance supervisor stated he cleaned the upper portion of the ice machine every 6 months, but he did not keep record of the cleaning log when he performed the cleaning. During an interview on 11/1/2024 at 1:51 p.m., DA 1 stated all items in the refrigerator past the use by date needed to be thrown out and it was everyone's responsibility to check the dates. DA 1 stated thawed items should never be put back in the freezer but she did not want to question her supervisor (DSA)'s orders. During an interview on 11/1/2024 at 1:59 p.m., the DSA stated she saw the upper portion of the ice machine when the MS opened it on 10/31/2024 and it was dirty, she saw dust and dark colors in there. The DSA stated it was facility policy to clean the upper portion of the ice machine at least every 6 months and there should have been a log to keep track of the cleaning frequency because if there was no record they would not know how frequently the ice machine was being cleaned. The DSA stated there was a potential that cross-contamination for the ice if the upper portion of the ice machine was dirty. The DSA stated it was important to ensure items were not past the use by date to protect the residents from food poisoning. The DSA stated it was important to check the temperature logs for the refrigerator to ensure it was functioning properly and the food would not spoil. The DSA stated they were not allowed to put partially thawed items back in the freezer (unknown reason why it was done on 10/30/2024). The DSA stated food could not just sit in the sink to thaw, it had to be under running water. The DSA stated if food was not thawed properly there was the potential outcome of food contamination because bacteria begin to grow on the food. During an interview on 11/1/2024 at 4:45 p.m., the infection preventionist nurse (IPN) stated if the upper portion of the ice machine was not clean, there was a potential that residents could get sick. The IPN stated if there was no cleaning log for the upper portion of the ice machine, there was no evidence that it had ever been cleaned. During a review of the facility's policy and procedure (P/P) titled Ice Machines and Ice Storage Chests undated, the P/P indicated information regarding the cleaning and care of the ice machine was to be obtained in the owner's manual. During a review of the user's manual for the Ice Machine Installation and User's Manuel undated, the user's manual indicated the ice machine should be cleaned and sanitized every six months or more frequently as needed. During a review of the facility's P/P titled Food Receiving and Storage dated 11/2022, the P/P indicated refrigerated foods were to be labeled, dated and monitored so they are used by their use-by date. Frozen foods were to be maintained at a temperature to keep food frozen solid. During a review of the facility's P/P titled Food Preparation and Service dated 11/2022, the P/P indicated food was not to be thawed at room temperature and food being thawed by water need to be completely submerged in cold running water that is running fast enough to agitate and remove loose ice particles. During A review of the 2022 U.S. Food and Drug Administration food Code, Code # 3-501.11 Frozen Food; 3.501.12 Time/Temp Control for Safety Food, Slacking and 3-501.13 Thawing, Indicated, Freezing prevents microbial growth in foods, but usually does not destroy all microorganisms. Improper thawing provides an opportunity for surviving bacteria to grow to harmful number and produce toxins. If the food is then refrozen, significant number of bacteria and toxins are preserved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record, the facility failed to ensure an injury of unknown origin was reported to the California Department of Public Health (CDPH) for one of five sampled residents (Resident 1) when Resident 1 sustained a moderately displaced (a break in the bone where the bones does not always crack all the way through) fracture (a break in the bone) of the distal (farther end) diaphysis (shaft; or a long tubular structure of the bone) of the femur (thigh bone). This deficient practice resulted in the inability of CDPH to investigate Resident 1 ' s injury of femur fracture in a timely manner and had the potential for facts related to the injury to be forgotten by staff. Findings: During a review of Resident 1 ' s admission Record (Face sheet), the Face sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including encephalopathy (damage or disease that affects the brain leading to the person to be confused), dementia (a condition of loss of cognitive functioning such as thinking, remembering, and reasoning that it interferes with a person ' s daily life and activities) and generalized weakness. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 5/31/2024, the MDS indicated Resident 1 was not able to make decisions that were consistent and reasonable. During a review of Resident 1 ' s SBAR dated 5/20/2023 and timed at 10:38 a.m., the SBAR indicated Resident 1 was groaning and screaming while facility staff assisted her with lower body dressing (pulling Resident 1 ' s pants up). The SBAR indicated Resident 1 was noted with swelling to her right knee, Resident 1 ' s physician was informed and an order for a Stat (immediate) right knee X-ray was obtained. During a review of Resident 1 ' s X-ray report dated 5/20/2024, the X-ray report indicated Resident 1 sustained a moderately displaced fracture of the distal diaphysis of the femur of indeterminate age with moderate degenerative change of the knee with narrowing of the lateral joint compartment (the area on the outside portion of the knee joint). During a review of Resident 1 ' s Transfer Form dated 5/20/2024 at 5:05 p.m., the Transfer Form indicated Resident 1 was transferred to General Acute Care Hospital (GACH) for evaluation and treatment due to her femur fracture. During an interview on 6/7/2024 at 11:55 a.m., the Director of Nursing Services (DON) stated Resident 1 was transferred to the GACH because she (Resident 1) sustained a fracture to her right femur. The DON stated she did not report this injury to CDPH because Resident 1 ' s physician documented Resident 1 ' s fracture was unavoidable due to Resident 1 ' s diagnoses of osteoporosis (brittle bones). During an interview on 6/7/2024 at 12:55 p.m., the Administrator (ADM) stated the facility should have reported to CDPH when Resident 1 sustained an injury of an unknown. During a review of the facility ' s policy and procedure (P/P), titled, Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, revised 4/2021, the P/P indicated if an injury of unknown source is suspected, the suspicion must be reported immediately to the Administrator and to other officials according to the State law. The Administrator or the individual making the allegation immediately reports his or her suspicion to the State licensing/certification agency responsible for surveying/licensing the facility within two hours of an allegation involving abuse or result in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record, the facility failed to ensure an injury of unknown origin was investigated for one of five sampled residents (Resident 1) when Resident 1 sustained a moderately displaced (a break in the bone where the bones does not always crack all the way through) fracture (a break in the bone) of the distal (farther end) diaphysis (shaft; or a long tubular structure of the bone) of the femur (thigh bone) and the cause of the fracture was unknown to the resident and staff. This deficient practice resulted in the inability of the facility to determine what might have been the cause of Resident 1 ' s injury and had the potential to recur. Findings: During a review of Resident 1 ' s admission Record (Face sheet), the Face sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including encephalopathy (damage or disease that affects the brain leading to the person to be confused), dementia (a condition of loss of cognitive functioning such as thinking, remembering, and reasoning that it interferes with a person ' s daily life and activities) and generalized weakness. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 5/31/2024, the MDS indicated Resident 1 was not able to make decisions that were consistent and reasonable. During a review of Resident 1 ' s SBAR dated 5/20/2023 and timed at 10:38 a.m., the SBAR indicated Resident 1 was groaning and screaming while facility staff assisted her with lower body dressing (pulling Resident 1 ' s pants up). The SBAR indicated Resident 1 was noted with swelling to her right knee, Resident 1 ' s physician was informed and an order for a Stat (immediate) right knee X-ray was obtained. During a review of Resident 1 ' s X-ray report dated 5/20/2024, the X-ray report indicated Resident 1 sustained a moderately displaced fracture of the distal diaphysis of the femur of indeterminate age with moderate degenerative change of the knee with narrowing of the lateral joint compartment (the area on the outside portion of the knee joint). During a review of Resident 1 ' s Transfer Form dated 5/20/2024 at 5:05 p.m., the Transfer Form indicated Resident 1 was transferred to General Acute Care Hospital (GACH) for evaluation and treatment due to her femur fracture. During an interview on 6/7/2024 at 11:55 a.m., the Director of Nursing Services (DON) stated she did not investigate Resident 1 ' s injury of unknown origin because, per Resident 1 ' s physician it was unavoidable due to Resident 1 ' s diagnosis of osteoporosis (brittle bones). During an interview on 6/7/2024 at 12:55 p.m., the Administrator (ADM) stated the facility should have investigated Resident 1 ' s fracture to determine the root cause of Resident 1 ' s injury. During a review of the facility ' s Policy and Procedure (P/P), titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised 4/2021, the P/P indicated all reports of resident abuse, including injuries of unknown origin, are thoroughly investigated by facility management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update and document belongings brought by the family on the inventory list for three of four sampled residents (Resident 1, 4, 5). This failure resulted in residents losing items due to not having them written down on the inventory list. Findings: a. During a record review of Resident 1 Face Sheet (admission record), the Face Sheet indicated Resident 1 was initially admitted on [DATE] and was readmitted on [DATE] with diagnosis including hypertensive heart (chronic blood pressure elevation) and chronic kidney disease (CKD: gradual loss of the kidney function), history of falling, and dementia (impaired ability to think, make decisions) with other behavioral disturbance (verbal and physical aggression, wandering). During a record review of Resident 1 ' s Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 1/10/2024, the MDS indicated Resident 1 ' s cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were severely impaired. The MDS indicated Resident 1 is dependent on bathing and transferring from chair/bed to chair transfer and required substantial/maximal assistance in performing activities of daily living (ADL: hygiene, dressing, eating) and utilizes a wheelchair. During a record review of Resident 1 ' s Inventory List (list of resident ' s belongings), it indicated Resident 1 was missing a green Christmas sweater, blue adidas suit, two radios, black and yellow pants outfit, black and white dress with hood, and a blue sweatshirt. During a record review of Resident 1 ' s Theft/Loss Report (document that indicates missing item information), Resident 1 ' s green sweater was seen on another resident and other items that have not been seen for month. During an interview on 2/13/2024 at 11:22am with Resident 1 ' s daughter, the daughter indicated Resident 1 has been missing some of her clothing ' s and stated she does Resident 1 ' s laundry at home to prevent items going missing at the facility and is not sure why the items are missing as she writes Resident 1 ' s name on the inside and outside of Resident 1 ' s clothes. The daughter indicated she has seen some of the residents wearing her Resident 1 ' s clothes. The daughter stated when she brings in new clothes, she notifies the staff to have the item listed on the inventory list. The daughter stated she does Resident 1 ' s laundry every two days and brings back whatever was washed. The daughter stated she will notify the staff if an item was thrown away so that it can be updated on the inventory list. b. During a record review of Resident 4 Face Sheet (admission record), the Face Sheet indicated Resident 4 was admitted on [DATE] with diagnosis including seizures, hypertension (high blood pressure), and dementia without behavior (not acting out), psychotic (disconnection from reality), mood disturbances (feelings of distress, sadness, depression) and anxiety (uneasiness). During a record review of Resident 4 ' s MDS, dated [DATE], the MDS indicated Resident 4 ' s cognitive skills were intact. The MDS indicated Resident 4 is dependent on bathing, dressing the lower part of the body (pants), wearing shoes, required moderate assistance on toilet, shower, and chair to bed transfer, and personal hygiene. The MDS indicated Resident 4 has an impairment on the upper extremities (arms) and utilizes a wheelchair. During a record review of Resident 4 ' s Inventory List it does not indicate Resident 4 had a cell phone on 9/6/2024. During a record review of Resident 4 ' s Theft/Loss Report, Resident 4 had lost a Nokia (cell phone brand) cell phone on 1/16/2024 and indicated the cell phone was not on Resident 4 ' s inventory list. Additionally, it indicated Resident 4 does not remember and none of the staff has seen Resident 4 with a cell phone since the day of admission on [DATE]. c. During a record review of Resident 5 Face Sheet (admission record), the Face Sheet indicated Resident 5 was admitted on [DATE] with diagnosis including anemia (not having healthy red blood cells to carry oxygen throughout the bodymuscle contracture of the right upper arm, and history of falling. During a record review of Resident 5 ' s MDS, dated [DATE] the MDS indicated Resident 5 ' s cognitive skills were mildly impaired. The MDS indicated Resident 5 is dependent on most of the aspect of activities of daily living and required partial assistance in personal and oral hygiene and dressing the upper (. The MDS indicated Resident 5 has an impairment on one side of the upper extremities (arms) and has impairments on both of the lower extremities. During a record review of Resident 5 ' s Inventory List, it does not indicate Resident 5 had a long yellow sleeve sweater on 10/15/2023. During a record review of Resident 5 ' s Theft/Loss Report, Resident 5 had lost a long yellow sleeve sweater on 12/18/2023 and indicated the sweater was not found. During a record review of the Lost and Stolen Property Log, in January, five residents reported to have missing items, December there were three residents that reported having missing items, and in November there were four residents that reported missing items. During a concurrent interview and record review on 2/1/2024 at 2:49p.m. with Social Service Director (SSD), SSD stated the inventory list is initiated at admission and is updated every year or when the family comes and brings new items in the facility for the resident. SSD stated when an item is lost, laundry will be notified, get the description of the missing item, check the residents room, and if the item does not show up within a day or two, the Administrator (ADMN) will determine whether to replace or reimburse the missing item. SSD stated not all of Resident 1 ' s items are missing; however, two or three items were not found. SSD stated the family does not notify the staffs at time when a new item is brought in and will have the family put the residents name on their clothing in case the belonging is laundered at the facility. SSD stated the blue adidas suit, two radios, and black and yellow pants outfit were on Resident 1 ' s inventory list, but the green Christmas sweater, black and white dress with hood, and a blue sweatshirt was not listed. SSD stated ADMN agreed to replace the missing items. SSD stated the inventory list is created to know whose belongings they belong to and is kept as a record in case the item gets lost. SSD stated personal items missing may upset the resident. During a concurrent interview and record review on 2/1/2024 at 3:48p.m. with Director of Nursing (DON), DON stated the inventory list has a list of the clothes the residents brought, so when there are new items, it will be written in the inventory list to track and update the items are there. DON stated when the family brings new item to the facility staff will update the inventory list. DON stated when an item goes missing, they will look at the inventory list and investigate where the item could be such as the laundry. DON stated when an item cannot be found, the item will be replaced or reimbursed. DON stated Resident 1 gets her laundry done at home, so the items that is allegedly missing might not have even been brought into the facility. DON stated there are only two residents that gets their clothing laundered at home. DON stated the family of Resident 1 is doing the laundry and they never tell them when they bring a new item. DON stated the items the family brings for Resident 1 does not have to be included on the inventory list since the laundry is done by the family, Resident 1 ' s item goes in and out of the facility and does not know whether the items that are missing were in the facility. DON stated the inventory list items and the theft/loss report should mirror one another as you would need to verify and confirm with the allegedly missing item on the inventory list. DON stated she did not see the long yellow sleeve missing item for Resident 5 listed on the inventory list. During a review of the facility ' s P&P titled, Residents ' Personal Property, revised December 2023, the P&P indicated the inventory will list the resident ' s clothing and other personal items brought to the facility and retained by the resident. The IDT will also review the resident ' s inventory for accuracy during the resident ' s quarterly care conference. Any changes of additions to the inventory will be made at this time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a dignity or privacy bag (a urinary drainage bag holder that restores the dignity of catheterized [insertion of a tube into the bladder to allow urine to drain for collection] residents by covering urinary drainage bags from the public view) for one of 20 sampled residents (Resident 307) indwelling catheter (a tube that drains urine from the body into a bag outside the body). This failure had the potential to result in Resident 307's low self-esteem and privacy being violated. Findings: During a review of Resident 307's admission Record (Face Sheet ), indicated Resident 307 was admitted to the facility on [DATE] with the diagnoses including acute kidney failure (a medical condition in which the kidneys can no longer adequately filter waste products from the blood), urine retention (the inability to completely empty the bladder), and benign prostatic hyperplasia (a noncancerous increase in size of the prostate gland (a gland of the male reproductive system) with lower urinary tract (consists of kidneys, ureters, bladder and the urethra) symptoms. During a review of Resident 307's Physician Orders, dated 9/22/2023, the Physician Orders indicated, Resident 307 had an order for an indwelling catheter for urinary retention. During a review of Resident 307's History and Physical (H&P) dated 9/23/2023, the H&P indicated, Resident 307 did not have the capacity to make decisions. During a review of Resident 307's Minimum Data Set(MDS - a standardized assessment and care screening tool), dated 10/2/2023, the MDS indicated, Resident 307 required partial to moderate assistance with eating, oral hygiene, toileting, positioning from sitting on the side of the bed to lying flat on the bed, to move from lying on the back to sitting on the side of the bed with no back support, to come to a standing position from sitting in a chair, wheelchair or on the side of the bed, to transfer to and from a bed to a chair, to get on and off a toilet or commode, and walking. During a concurrent observation and interview on 11/27/2023 at 11:45 am, with Certified Nursing Assistant (CNA) 4, in Resident 307's room, observed Resident 307 had an indwelling catheter without a dignity or privacy bag covering the indwelling catheter bag. CNA 4 stated Resident 307 does not have a privacy bag on. CNA 4 stated it was important for Resident 307 to have a dignity/privacy bag to cover the drainage bag from the public view for privacy and residents 'dignity. During an interview on 11/30/2023 at 10:07 am with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the dignity bag maintains the resident's privacy. LVN 1 stated the dignity bag should be used at all times. LVN 1 stated after providing care the dignity bag should be placed back over the indwelling catheter bag. LVN 1 stated the dignity bag was used for the resident's well being for privacy and dignity. During an interview on 11/30/2023 at 12:44 pm with the Director of Nursing (DON), the DON stated all staff were responsible to ensure Resident 307 had dignity bag over the indwelling catheter drainage bag to maintain privacy while the resident was up in a chair or in the bed. During a review of the facility's policy and procedure (P&P) titled, Emptying a Urinary Drainage Bag/Use of Privacy Bag revised on 11/2010, the P&P indicated to, Place the urinary bag in a dignity/privacy bag when in bed or wheelchair to ensure resident's privacy is maintained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of seven sampled resident (Resident 256) responsible party (RP) was notified when the hemoglobin (a red protein responsible for transporting oxygen in the blood) dropped significantly to 7.3 grams/deciliter (g/dcl-normal levels 11.6-15) This failure violated the Resident 256's rights of notification of responsible parties of the care services provided and had the potential to result in a lack of proper care and treatment. Findings: During a review of Resident 256's admission Record (Face Sheet) indicated Resident 256 was admitted to the facility on [DATE], with diagnoses including iron deficiency anemia (a condition in which blood lacks adequate healthy red blood cells), falls, and dysphagia (difficulty in swallowing). During a review of Resident 256's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 11/19/2023, the MDS indicated Resident 256 was severely cognitively impaired (a person who has trouble remembering, learning new things, concentrating, or making decisions). During a review of Resident 256's history and physical (H&P) dated 11/16/2023, the H&P indicated Resident 256 does not have the capacity to make decisions. During a review of Resident 256's care plan (CP) dated 11/28/2023, the CP indicated Resident 256 was at risk for low hemoglobin. The CP indicated the facility will educate the family on signs and symptoms of iron deficiency anemia. During a review of Resident 256's Change of Condition form (COC) dated 11/25/2023, the COC indicated Resident 256 had a low hemoglobin level of 7.3 (normal levels 11.6-15). The COC indicated that Resident 256 responsible party (RP) was not notified. During an interview on 11/28/2023 at 9:30 a.m. with the RP, the RP stated no one from the facility called to notify that Resident 256 hemoglobin blood levels have dropped. During an interview on 11/28/2023 at 9:41 a.m. with the Registered Nurse (RN) 1, RN 1 stated she did not notify Resident 256's RP of low hemoglobin level of 7.3 g/dcl. RN 1 stated it was important to notify the RP so they will be aware of Resident 256 condition. RN 1 stated it should be documented on the COC that the RP was notified but it was not done. During an interview on 11/30/2023 at 12:43 p.m. with the Director of Nurses (DON), the DON stated any change of condition of a resident including a low hemoglobin should be reported to Resident 256's responsible party and documented in the medical record. DON stated it was important to inform RP of any change in condition, so they were aware of resident's condition and plan of care. During a review of the facility policy and procedure (P&P) titled Change in a Resident's Condition or Status dated 2/2021, the P&P indicated the facility will promptly notify the RP of changes in the resident medical/mental condition and or status. The P&P indicated except in medical emergencies, the RP will be notified within twenty-four hours of change in condition. During a review of the facility P&P titled Resident Rights dated 12/2016, the P&P indicated that the resident has the right to be informed of his or her medical condition and of any changes in his or her condition.

Based on interview and record review, the facility failed to develop a comprehensive care plan (a resident-specific plan with defined clinical goals and interventions used to manage identified medical issues or other areas of concern) regarding the use of Depakote (a medication used to treat mood problems) to treat a behavioral problem of sudden outbursts of anger in one of five residents sampled for unnecessary medications (Resident 74.) This failure to develop and implement a care plan with measurable objectives for the use of Depakote may result in not meeting Resident 74's medical, nursing, and mental and psychosocial needs to maintain or attain Resident 74's highest practicable, physical, mental, and psychosocial well-being. Findings: During a review of Resident 74's admission Record (Face Sheet), indicated Resident 74 was admitted to the facility originally on 7/1/23 with diagnosis including unspecified dementia (loss of memory, language, problem-solving and other thinking abilities) with other behavioral disturbance. During a review of Resident 74's Order Summary Report, dated 11/29/23, the Order Summary Report indicated the physician prescribed the following medication on the following date: 1.On 10/25/23 - Depakote 125 milligrams (mg - a unit of measure for mass) by mouth two times a day for mood stabilizer manifested by sudden outburst of anger. During a review of Resident 74's available care plans, last revised October 2023, indicated there were no care plans to address Resident 74's behavioral issues of sudden outbursts of anger that identified the use of Depakote as a targeted intervention. During an interview on 11/29/23 at 11:25 a.m. with the Director of Nursing (DON), the DON stated that the facility was responsible to create a new care plan concerning any medications used to treat behavioral issues. DON stated the facility failed to create a new care plan regarding the use of Depakote to treat the behavioral issue of sudden outbursts of anger for Resident 74. DON stated the care plan creates the therapeutic goal of the facility to treating the resident's problem and there was a risk that the resident's care may not be reviewed and revised as needed without a care plan to establish therapeutic goals leading to a possible decrease in physical, mental, and psychosocial well-being. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated December 2016, the P&P indicated, The comprehensive, person-centered care plan will include measurable objectives and timeframes; describe the services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being; reflect treatment goals, timetables and objectives in measurable outcomes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility staff failed to ensure resident received radiation treatments (cancer treatment that uses radiation (usually high-powered X-rays) to kill cancer cells.) for basal cell carcinoma (type of skin cancer) of the left eye for one of seven sampled residents (Resident 48) by: 1.Failing to send Resident 48 to the correct outpatient department for a scheduled radiation treatment on 11/22/2023. 2.Failing to provide transportation for an outpatient scheduled radiation treatment on 11/27/2023. These failures resulted in a delay of services/treatments and the potential for Resident 48 to be exposed to radiotoxicity for back-to-back radiation treatments. Findings: During a review of Resident 48's admission Record (Face Sheet), indicated Resident 48 was admitted to the facility on [DATE]with diagnoses of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), basal cell carcinoma of the skin, and impaired vision of the left eye. During a review of Resident 48's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 11/9/2023, the MDS indicated Resident 48 has severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions). During a review of Resident 48's History and Physical (H&P) dated 5/9/2023, the H&P indicated Resident 48 had a lesion (an abnormal change in structure of an organ or part due to injury or disease) of the left upper eyelid and cancer (abnormal tissue growth) of the left eyelid. During a review of Resident 48's care plan (CP) dated 11/20/2023, the CP indicated Resident 48 was receiving radiation therapy for basal cell carcinoma of the left eye. The CP indicated the facility will assist with transportation arrangements to radiation appointments. During a review of Resident 48's Physician Order dated 11/20/2023, indicated Resident 48 had an appointment with radiology (a branch of medicine that uses imaging technology to diagnose and treat disease) treatment appointment on 11/22/2023 at 10:45 a.m. at the General Acute Care Hospital (GACH) and transportation to be provided by the Social Worker (SW). Resident 48's physician order was for an appointment in the radiation department. During a review of Resident 48's Social Service Progress Note dated 11/14/2023, indicated the SW set up transportation for Resident 48 to go to the radiology department at the GACH on 11/22/2023. During a review of Resident 48's transportation request dated for 11/22/2023, the transportation request indicated Resident 48 had a request to a radiology appointment, not a radiation appointment. During a review of Resident 48's radiation treatment calendar for November 2023, the calendar indicated Resident 48 had radiation treatments scheduled on 11/22/2023, 11/27/2023 and 11/30/2023 at the GACH. During a review of Resident 48's Nurses Progress Note dated 11/22/2023 at 11:55 a.m., indicated Resident 48 came back from his appointment and the charge nurse (CN) received a call from the radiation oncology department at the GACH and stated Resident 48 did not show up for his radiation treatment appointment. The Nurses Progress Note indicated Resident 48 was taken to the radiology department and not the radiation department by the facility escort. The Nurses Progress Note indicated Resident 48 will need to add another treatment to complete the five radiation sessions. During a review of Resident 48's Psychology notes dated 11/23/2023, the Psychology note indicated Resident 48 expressed frustration about not going to his radiation appointment. During a review of Resident 48's Nurses Progress Note dated 11/27/2023 at 10:56 a.m., indicated there were issues with transportation and Resident 48 radiation treatment had to be cancelled for 11/27/2023. During an interview on 11/28/23 at 12:30 p.m. from the GACH radiation department staff member (SM), the SM stated Resident 48 missed his radiation appointments on 11/22/2023 and 11/27/2023 because the facility sent him to the wrong department on 11/22/2023 and did not provide transportation for Resident 48 appointment on 11/27/2023. During an interview on 11/28/2023 at 1:25 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 48 missed his radiation treatment appointment on 11/22/2023 because he was taken to the wrong department by the facility staff. LVN 3 stated Resident 48 missed his radiation treatment on 11/27/2023 because he did not have transportation. LVN 3 stated it was important for Resident 48 to have his radiation treatments to improve the condition on his left eye and make it better. LVN 3 stated Resident 48 has basal cell carcinoma of the left eye. During an interview on 11/28/2023 at 2:03 p.m. with the Social Worker Assistant (SWA), the SWA stated Resident 48 missed his radiation treatment appointment on 11/22/2023 because the facility escort took him to the wrong department. During an interview on 11/28/2023 at 2:06 p.m. with the facility escort (FE), the FE stated she was told by the charge nurse (CN) to take Resident 48 to the radiology department on 11/22/2023. FE stated she did not know Resident 48 was supposed to go to the radiation department. During an interview on 11/29/2023 at 9:56 a.m. with the SWA, the SWA stated it was the responsibility of the social service department to set up and confirm transportation for the residents. During an interview on 11/29/2023 at 11:02 a.m. with the Director of Nurses (DON), the DON stated Resident 48 orders were entered incorrectly for his radiation treatment appointments. The DON stated it was important that the order was entered correctly so the resident could make it to his radiation appointments so his left eye will heal and not affect his eyesight. During a review of the facility's policy and procedure (P&P) titled Transportation and Appointments dated 12/2008, the P&P indicated the social service department will be responsible for arranging transportation. During a review of the facility's P&P titled Registered Nurse (RN) job description dated 10/2020, indicated the RN transcribe telephone, verbal, and telemedicine orders from providers as appropriate. The Registered Nurse (RN) job description indicated the RN initiates requests for consultations or referrals as requested. The Registered Nurse (RN) job description indicated the RN is to provide oversight of Certified Nurse Assistants (CNA) and licensed nurses as directed by the DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to act on one recommendation from the consultant pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) from 10/5/23 regarding lowering of the dose of esomeprazole (a medication used to treat stomach acid problems) from twice daily to once daily in one of five residents sampled for unnecessary medications (Resident 74.) This failure of failing to respond to recommendations from the consultant pharmacist could have resulted in Resident 74 receiving a higher than necessary dose of esomeprazole possibly resulting in medication side effects (a secondary, typically undesirable effect of a drug or medical treatment). Findings: During a review of Medication Regimen Review (MRR - a monthly evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication), dated 10/5/23, the review indicated the consultant pharmacist recommended reducing Resident 74's esomeprazole maintenance dose from 40 milligrams (mg - a unit of measure for mass) twice daily to 40 mg once daily before breakfast. During a review of Resident 74's admission Record (Face Sheet) indicated Resident 74 was admitted to the facility on [DATE] with diagnoses including Gastroesophageal reflux disease ([GERD] a stomach problem involving the production of too much stomach acid.) During an interview on 11/29/23 at 11:25 a.m. with the Director of Nursing (DON), the DON stated when consultant pharmacist makes recommendations regarding a resident's medication therapy, it was the facility's responsibility to follow up on those recommendations within 30 days. The DON stated the consultant pharmacist made a recommendation to decrease the dose of esomeprazole for Resident 74 on 10/5/23 but facility staff failed to follow up on the recommendation. The DON stated Resident 74 may have experienced more side effects than necessary because of their failure to follow up with the physician regarding the proposed dosage reduction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one expired fluticasone/salmeterol (a medication used to treat breathing problems) inhaler for Resident 22, was removed from the medication cart in one of two inspected medication carts (Medication Cart 2.) This failure could have resulted in Resident 22 experiencing preventable episodes of shortness of breath and troubled breathing possibly leading to hospitalization. Findings: During a review of Resident 22's admission Record (Face Sheet), indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a lung disease that causes restricted airflow from the lungs and breathing problems). During a concurrent observation and interview on 11/28/23 at 1:42 p.m. of Medication Cart 2 with Licensed Vocational Nurse (LVN) 2, the following medication was found expired: 1.One opened fluticasone/salmeterol inhaler device for Resident 22, with opened date of 10/25/23. During a review of manufacturer's product labeling, fluticasone/salmeterol inhalers should be discarded one month after removal from foil pouch. During a concurrent interview with LVN 2 stated the medication was only good for 30 days once the foil pack was opened. LVN 2 stated this inhaler was opened on 10/25/23 and would have expired on 11/24/23. LVN 2 stated this medication was now considered expired, was not safe to administer to Resident 22, and should have been removed from the medication cart on the day it expired. LVN 2 stated, if expired medications were not removed from the medication cart, there was a chance they could still be administered to the resident once they have expired. LVN 2 stated that if a resident was administered an expired breathing treatment, it could be ineffective which might cause respiratory issues or other medical complications for the resident possibly resulting in hospitalization. During a review of the facility's policy and procedure (P&P) titled Medication Storage in the Facility, dated 2008, the P&P indicated, Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to honor food preference of one of two sampled residents (Resident 356) by ensuring vegetables are not overcooked. This failure had the potential for Resident 356 to not receive their nutritional needs and food preferences. Findings: During a review of Resident 356's admission Record (Face Sheet), indicated Resident 356 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (irregular and often rapid heartbeat that can cause poor blood flow), difficulty in walking, hemiplegia (paralysis on one side of the body), and hemiparesis (weakness on one side of the body) following a cerebral infarction (damage to the brain from interruption of its blood supply) and diabetes (a condition in which the body fails to metabolize (process) glucose (sugar) correctly). During a review of Resident 356's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 11/20/2023, the MDS indicated Resident 356 had an intact cognition (ability to think and reason) and required substantial assistance with bed mobility, toileting, bathing, and dressing. During a review of Resident 356's meal tray ticket dated 11/28/2023, the meal tray ticket indicated Resident 356 was on a regular, controlled carbohydrate diet ([CCHO]diet that limits or controls consumption of carbohydrate to help keep blood sugar levels stable), liked green beans, spinach and disliked overcooked vegetables. During a subsequent interview on 11/28/23, at 1:45 p.m. and on 11/30/2023, at 10:46 a.m. with Resident 356, Resident 356 stated vegetables served were always overcooked. Resident 356 stated the green peas on the lunch tray was not tasty and overcooked. Resident 356 stated an unnamed kitchen personnel came and asked her about her food preferences and was aware of her dislike for overcooked vegetables. Resident 356 stated she felt helpless and frustrated for not getting the food she wanted and how vegetables were cooked and prepared. During an observation on 11/28/2023, at 1:30 p.m. test tray for lunch consisted of chicken, green peas, and diced red potatoes. Observed neon green colored peas, mushy and overcooked. During an interview on 11/30/2023, at 8:30 a.m. with Dietary Supervisor (DS), DS stated she asked Resident 356 about her food preferences and Resident 356 had mentioned to her about her dislike for overcooked vegetables. DS stated Resident 356 would not eat and get disappointed if her vegetables were overcooked because her food preference was not followed. During a review of facility's policy and procedure (P&P) titled Food Preferences undated, the P/P indicated resident's food preferences will be adhered to within reason. During a review of facility's P&P titled Food and Nutrition Services revised 10/2017, the P&P indicated residents are provided with a nourishing, palatable and well-balanced diet that will meet his or her nutritional, special dietary needs and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to observe infection control measures on two of six sampled residents (Resident 27 and Resident 43) when Certified Nursing Assistant 3 placed a plastic bag with soiled linens on the fall mat (cushioning pad placed on the floor along the side of the bed that can reduce injury due to fall) of Resident 43 while providing care to the residents. This failure had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents at risk for infection. Findings: During a review of Resident 27's admission Record (Face Sheet), indicated the Resident 27 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dementia (loss of cognitive functioning such as thinking, remembering, and reasoning which can affect and interfere with daily life and activities), and unspecified osteoarthritis (wearing down of the protective tissue at the ends of the bones which occurs gradually and worsens overtime). During a review of Resident 27's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 11/2/2023, the MDS indicated the Resident 27 had severely impaired cognitive skills (ability to learn, remember, understand, and make decision) and required full assistance from staff members with bed mobility, toileting, personal hygiene, and transfer from bed to wheelchair. During a review of Resident 43's Face Sheet, indicated the Resident 43 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dementia, contracture (shortening and hardening of muscles, tendons, and other tissue causing deformity and rigidity of joints) of right elbow and right hand and osteoarthritis. During a review of Resident 43's History and Physical (H&P) dated 8/16/2023, indicated Resident 43 did not have the capacity to understand and make decisions because of dementia. During a review of Resident 43's MDS dated [DATE], the MDS indicated Resident 43 required full assistance from the staff members with eating, toileting, bathing, dressing, personal hygiene, and transfer. During a concurrent observation and interview on 11/27/2023, at 10:00 a.m. with Certified Nursing Assistant (CNA) 3, observed plastic bag of linens was laying on the fall mat of Resident 43. CNA 3 stated the plastic bag filled with linens was dirty and came from Resident 27 whom she just provided care. During an interview on 11/29/2023, at 11:06 a.m. with CNA 3, CNA 3 stated she should have taken the bag of dirty linens from Resident 27 to the hamper as soon as it was wrapped in the plastic bag because there could be a risk of cross contamination and spread of infection if it was left on the fall mat of Resident 43. During an interview on 11/29/2023, at 3:01 p.m. with Infection Preventionist Nurse (IPN), IPN stated dirty linens should be disposed to the proper receptacle and not placed on the floor or floor mat of another resident to prevent spread of infection. During an interview on 11/30/2023, at 12;44 p.m. with Director of Nursing (DON), the DON stated dirty linens should be placed in the hamper or receptacle outside the door of a residents' room and should not be placed on the floor or fall mat because of the risk of contamination and spread of infection. During a review of facility's policy and procedure (P&P) titled Linen (Laundry) Management revised 12/2022, the P/P indicated soiled linen should be placed in a designated container to protect residents and staff from exposure to potentially infectious materials during handling of clean and contaminated linens. Appendix D: Linen and Laundry Management | Environmental Cleaning in Global Healthcare Settings | HAI | CDC During a review of an online article from CDC titled Linen and laundry Management reviewed 5/4/2023, indicated never carry soiled linen against the body, always place in a designated container and do not transport soiled linen by hand outside the specific patient care area from where it was removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement their antibiotic stewardship program (measures used by the facility to ensure antibiotics [drug to treat infection] are used only when necessary and appropriate) on one of two sampled residents (Resident 26) by prescribing an antibiotic without meeting the criteria of their protocol (checklist or guide to initiate antibiotic) for urinary tract infection([UTI] infection in the urine). This failure had the potential to put Resident 26 at risk for antibiotic resistance (not effective to treat infection) and inappropriate use of antibiotic. Findings: During a review of Resident 26's admission Record (Face Sheet), indicated Resident 26 was admitted on [DATE] with diagnoses including schizophrenia ( mental illness that affects how a person thinks, feels and behaves), transient ischemic attack(occurs when the blood supply to a part of the brain is briefly interrupted), benign prostatic hyperplasia ([BPH] enlarged prostate) and acute kidney failure(kidneys are no longer able to adequately remove waste from the blood and control the level of fluid in the body). During a review of Resident 26's Minimum Data Set ([MDS] standardized assessment and screening tool) dated 11/8/2023, the MDS indicated Resident 26 had severely impaired cognition (person had trouble remembering things, making decisions, concentrating, or learning) and required supervision with transfer, bed mobility, and toileting. During a review of Resident 26's Nurses Progress Notes dated 11/27/2023, at 1:16 p.m., indicated Resident 26 was transferred to general acute care hospital (GACH) via 911 because of altered mental status (change level of consciousness, behavior, mood or alertness). During a review of Resident 26's Nurses Progress Notes dated 11/27/2023 timed at 6:40 p.m., indicated Resident 26 returned to the facility in a stable condition and no complaint of dysuria (painful urination). During a review of Resident 26's Nurses Progress Notes dated 11/27/2023, at 10:24 p.m. indicated Cephalexin (antibiotic) 500 milligrams([mgs] unit of measurement) every six hours for 10 days was ordered from GACH and the facility's physician ordered to continue Cephalexin 500 mgs. twice a day for 7 days. The Nurses Progress Notes indicated Resident 26 was exhibiting swelling, or tenderness of testes (male organ), or prostate (gland that produces some of the fluid) with a diagnosis of BPH. During a review of Resident 26's Laboratory Results, the laboratory results indicated no urinalysis (urine test to check the appearance, concentration, or content) or urine culture and sensitivity (urine test that can identify the bacteria causing the infection) was sent to the laboratory to rule out (confirm) UTI. During a review of Resident 26's Physician Order, the Physician Order indicated Cephalexin (antibiotic) oral tablet 500 mgs. one tablet one time only for UTI until 11/27/2023 11:59 p.m. initial dose taken from emergency kit and then one tablet by mouth two times a day for UTI for 7 days. During a review of Resident 26's Medication Administration Record (MAR), the MAR indicated the Resident 26 received Cephalexin oral tablet 500 mgs. on 11/27/2023 at 11:38 p.m., 11/28/2023 at 9:00 a.m. and 5:00 p.m. and 11/29/2023 at 9:00 a.m. During a concurrent interview and record review on 11/29/2023, at 3:01 p.m. with Infection Preventionist Nurse (IPN), IPN stated the facility used McGeer Criteria (guide used to initiate antibiotic) for protocol and Resident 26 used of antibiotic did not meet the criteria for antibiotic. IPN stated Resident 26 came back from GACH with diagnosis of UTI but there was no urine test done in the hospital to confirm resident's diagnosis of UTI or complaint of any pain or fever. IPN stated GACH did not do any urine tests before initiating the antibiotic and according to their protocol Resident 26 should have two criteria before initiating an antibiotic for UTI. IPN stated Resident 26 would be at risk for developing resistant organisms and could have potential side effect from the use of antibiotic. During an interview on 11/30/2023, at 12:44 p.m. with the Director of Nursing (DON), the DON stated the facility should ensure the residents' usage of antibiotic would meet the McGeer Criteria because residents could develop multi-drug resistant organism ([MDRO] germ that is resistant to many antibiotics and can be difficult to treat) and could be considered unnecessary medication. During a review of facility's job description of an Infection Preventionist revised 10/2020, the job description indicated the Infection Preventionist will review, summarize and report data related to infection prevention and control initiatives including antibiotic stewardship, immunization programs, outbreaks and healthcare acquired infection. During a review of facility's policy and procedure (P&P) titled Antibiotic Stewardship revised 12/2016, the P&P indicated antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The P&P indicated the purpose of facility's antibiotic stewardship program is to monitor the use of antibiotics in the facility.

Based on observation, interview, and record review, the facility failed to handle and store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food) for 99 out of 99 total residents in the facility by failure to: 1. Ensure enriched Farina hot wheat cereal have a received date label. 2 Ensure Dietary Aide (DA) 1, DA 2, DA 3, DA 4 and [NAME] 2 did hand hygiene (hand washing ) and don gloves when handling food during the tray line (a process of preparing and setting food for the residents in the facility). 3 Ensure ice machine maker door lining was kept clean. 4 Ensure freezer thermometer was calibrated and in working condition. These failures had the potential for growth of microorganisms (an organism that can be seen only through a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 99 out of 99 total residents in the facility. Findings: 1. During the initial facility kitchen tour observation on 11/27/2023 at 8:30 a.m., observed enriched Farina hot wheat cereal inside the facility food pantry (a room or closet in which food, groceries, and other provisions and dry goods are kept) was not labeled with received date. During an interview on 11/27/2023 at 8:53 a.m., with the DA 1 stated there was no received date for enriched Farina hot wheat cereal that was stored inside the facility food pantry. 2.During a tray line observation on 11/28/2023 at 11:47 a.m., the DA 3 touched the food on the plate with her fingers without gloves on. During a tray line observation on 11/28/2023 at 11:53 a.m., the DA 1 reached to the bin to get utensils with her hands and provided the utensils to [NAME] 1 without wearing gloves. During a tray line observation on 11/28/2023 at 11:52 a.m., DA 4 reached to the bin to get utensils with her hands and provided the utensils to [NAME] 1 without wearing gloves. During a tray line observation on 11/28/2023 at 11:57 a.m., DA 1 touched the food on the plate with her fingers without gloves on. During a tray line observation on 11/28/2023 at 12:10 p.m., DA 2 touched the food on the plate with her fingers without gloves on. During a tray line observation on 11/28/2023 at 12:15 p.m., DA 1 with oven mitt on both hands and brought puree green peas without putting gloves. During a tray line observation on 11/28/2023 at 12:29 p.m., DA 3 touched the food cart and the plate inside the food cart and comes back to the tray line without wearing gloves. During a tray line observation on 11/28/2023 at 12:37 p.m., DA 4 opened the walk-in refrigerator and took six butter and place it on the tray without washing hands and wearing gloves. During a tray line observation on 11/28/2023 at 12:40 p.m., DA 2 took a plate and put it to the tray line area without washing hands and wearing gloves. During an interview on 11/28/2023 at 2:11 p.m. with DA 4, DA 4 stated when doing the tray line preparation, it was important to wear gloves and wash your hands before and after handling of food for infection control. During an interview on 11/28/2023 at 2:17 p.m., with DA 1, DA 1 stated all staff from the kitchen must wash their hands and wear gloves before handling foods in the kitchen for infection control and prevent any food borne illnesses. During an interview on 11/28/2023 at 02:21 p.m. with [NAME] 2, [NAME] stated he should have worn gloves when taking utensils from the bin and handing it to [NAME] 4 who was doing the tray line preparation for infection control. During an interview on 11/28/2023 at 2:23 p.m., with DA 2, DA 2 stated staff should wear gloves during tray line preparation as they were handling food. 3. During a facility kitchen tour observation on 11/27/2023 at 8:48 a.m., observed ice maker machine dirty around the opening area. During an interview on 11/27/2023 at 8:50 a.m., with DA 1, DA 1 stated the opening door inside of the ice machine maker was dirty as evidenced by the paper towel used to wipe the lining inside the ice maker machine became dirty. During an interview on 11/28/2023 at 8:30 a.m., with the Dietary Supervisor (DS), DS stated the icemaker machine must be kept clean to prevent from harboring micro-organisms and for infection control. 4.During an observation on 11/27/2023 at 2:21 p.m., the thermometer inside the facility freezer located outside the kitchen near the exit of the facility backdoor where the frozen goods are kept was malfunction and does not provide accurate reading of the temperature inside the freezer. During an interview on 11/27/2023 at 2:26 p.m. with the DS, DS stated the thermometer inside the freezer was malfunctioning and not working properly. During a review of the facility's policy and procedure (P&P) titled Food Handling dated 2018, indicated Food will be prepared and served in a sanitary manner. All food and nutrition service personnel will wash their hands prior to handling all food, hands should be washed before and after handling. During a review of the facility's P&P titled Ice Machine Cleaning Procedure dated 2018, indicated, The ice machine needs to be cleaned and be sure special attention is paid to cleaning the door molding and the lid of the machine. During a review of the facility's P&P titled Thermometer Use and Calibration dated 2018, indicated, Food thermometers are to be used properly and calibrated to ensure accurate temperature reading.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure one of three sampled residents (Resident 1) call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was answered in a timely manner and helped in toileting by Certified Nursing Assistant (CNA) 4. This failure had the potential to negatively affect Resident 1's physical comfort and psychosocial well-being. Findings: During a review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including osteoarthritis ( a joint disease, in which the tissues in the joint break down over time), heart failure (is a condition that develops when your heart doesn't pump enough blood for your body's needs), and edema (swelling caused by fluid trapped in your body's tissues). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and screening tool), dated 11/3/23, indicated Resident 1 had ability to makes self-understood and understand others. The MDS indicated Resident 1 required limited assistance (resident highly involved in activity) with bed mobility, transferring, dressing, toilet use, and personal hygiene. During an interview on 11/16/23 at 2:00 pm with Resident 1's Representative ([RR] an individual chosen by the resident to act on behalf of the resident to support the resident in decision-making), RR stated at approximately 7 pm or 8 pm on 11/3/2023, Resident 1 asked Certified Nurse Assistant (CNA) 4 for assistance to the restroom. CNA 4 told Resident 1 that she has a diaper on, and she could go inside her diaper because she was almost done with work. RR stated Resident 1 informed her that it took 15-20 minutes for CNA 4 to respond after she pressed the call light. RR stated Resident 1 had become depressed (a constant feeling of sadness and loss of interest, which stops you doing your normal activities) since being at the facility. During an interview on 11/17/23 at 11:20 am with CNA 2, stated that not answering call light in a timely manner and not responding to Resident 1's needs was considered neglect. CNA 2 stated residents can feel helpless, hopeless and feel facility staff does not care of their wellbeing. CNA 2 stated not answering the call light within 10 to 15 minutes would be considered not answering it in a timely manner. During an interview on 11/20/23 at 10 am with CNA 4, CNA 4 stated Resident 1 had put on her call light and when she went into the room, Resident 1 requested to be changed. CNA 4 stated she had already cleaned Resident 1 twice during her shift (11 pm - 7 am shift). CNA 4 stated she told Resident 1 she had already clocked out for her break, and she would change her when she returned from her break. CNA 4 stated her break was 15 minutes. CNA 4 stated Resident 1 claimed it was longer than 15 minutes. CNA 4 stated she did not ask any other staff to assist Resident 1 at that time because her break was only 15 minutes. CNA 4 stated, Resident 1 should not have waited to be assisted with toileting or diaper changed. CNA 4 stated Resident 1 could have developed skin redness, a rash, or a bedsore by not being toileted in a timely manner and make her feel depressed or helpless. During an interview on 11/20/23 at 9:50 am with Director of Staff Development (DSD), DSD stated, it was not good for Resident 1 to wait to be changed, because she could have experienced skin breakdown, dignity issues. DSD stated neglect was not providing care or not providing assistance in a timely manner. During an interview on 11/20/23 at 10:30 am with Director of Nursing (DON), the DON stated, call light should be answered in a timely manner which was less than five minutes. The DON stated, by Residents 1's needs not being met in a timely manner she could develop a skin rash, bedsore, and feel embarrassed if she had to urinate or had a bowel movement in her incontinence brief (diaper). DON stated CNA 4 should have asked another staff to assist Resident 1, while she went on her break, to ensure Resident 1 did not have a delay in care. DON stated Resident 1 could have felt embarrassed, and ashamed. During an interview on 11/20/23 at 11:00 am with Administrator (Admin), the Admin stated, by Resident 1 not receiving care in a timely manner that could be considered neglect. The Admin stated neglect was failure to provide care, willfully and knowingly refusing to provide care. The Admin stated Resident 1 could have experienced a negative outcome such as skin breakdown, a feeling of hopelessness, and embarrassment. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 2016, the P&P indicated Employees shall treat all residents with kindness, respect, and dignity. During a review of the facility's P&P titled, Abuse Prevention, dated 2018, the P&P indicated, The facility assures that residents are free from neglect by having the structures and processes to provide needed care and services. During a review of the facility's P&P titled, Dignity, dated 2021, the P&P indicated, Demeaning practices and standards of care that compromise dignity is prohibited. Staff are expected to promote dignity and assist residents: for example. Promptly responding to a resident's request for toileting assistance. During a review of the facility's P&P titled, Answering the Call Light, dated 2010, the P&P indicated, The purpose of this procedure is to respond to the resident's requests and needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Polymerase Chain Reaction ([PCR] a test used to detect the smallest amount of COVID-19 (a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing, and shortness of breath [SOB]) test was conducted to confirm negative COVID-19 test results obtained via a Point of Care Antigen test ([Antigen] a rapid test that quickly detects the presence or absence of an antigen [a foreign substance] but is less accurate than a PCR test) test, when one out of two sampled residents (Residents 1) continued to exhibit signs and symptoms (s/s) of COVID-19, after his Antigen COVID-19 test results were negative. As a result of this deficient practice Resident 1 tested positive 10 days after his initial (9/1/2023) Antigen test result was negative and continued to exhibit s/s of COVID-19 the entire 10 days prior to being positive for COVID-19, potentially spreading the COVID-19 virus throughout the facility and placing other residents, staff, and visitors at risk for acquiring the COVID-19 virus. Findings: a. During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including congestive heart failure ([CHF] a chronic condition in which the heart doesn ' t pump blood as well as it should), type 2 diabetes mellitus ([DM] a chronic condition which affects the way the body processes blood sugar [b/s]) and chronic obstructive pulmonary disease ([COPD] a group of diseases which cause airflow blockage and breathing-related problems). During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 7/10/2023, the MDS indicated Resident 1 ' s cognitive skills for daily decision-making were moderately impaired and he had the ability to understand and be understood by others. During a review of Resident 1 ' s Order Summary Report ([OSR] physician ' s orders), dated 3/29/2023, the Physician ' s Order indicated an order for Ipratropium-Albuterol Inhalation Solution (a medication used to help alleviate wheezing [breathing with a whistling or rattling sound in the chest]) 0.5-2.5 milligrams ([mg] a unit of measurement)/3 milliliters ([mL] a unit of measurement) every four hours as needed for SOB and wheezing. During a review of Resident 1 ' s Physicians Orders, dated 8/31/2023 and timed at 5:55 p.m., the Physician ' s order indicated an order for Promethazine Hydrochloride ([HCL] a medication used to treat cough) oral syrup 5 ml every four hours as needed for a non-productive cough (dry cough) for seven days. During a review of Resident 1 ' s Medication Administration Record (MAR), dated 8/2023, the MAR indicated Resident 1 received Ipratropium-Albuterol Inhalation Solution for wheezing on 8/31/2023 at 5:37 p.m. During a review of Resident 1 ' s Order Administration Note, dated 8/31/2023, the Order Administration Note indicated Resident 1 received Ipratropium-Albuterol Inhalation Solution for wheezing at 7:13 p.m. During a review of Resident 1's Situation Background Assessment and Recommendation ([SBAR] a communication tool used between members of the healthcare team regarding a patient's condition), dated 8/31/2023 and timed at 4:47 p.m., the SBAR indicated Resident 1's physician was notified of Resident 1's wheezing and a non-productive cough. During a review of Resident 1 ' s MAR dated 9/1/2023, the MAR indicated Resident 1 received Promethazine HCL for coughing on 9/1/2023 at 8:55 a.m., 3/2023 at 8:38 a.m., 9/4/2023 at 8:26 a.m., and 9/7/2023 at 8:47 a.m. During a review of Resident 1 ' s Order Administration Note dated 9/2023, the Order Administration Note indicated Resident 1 received Promethazine HCL on 9/1/2023 at 12:06 p.m., 9/3/2023 at 1:15 p.m., 9/4/2023 at 1:16 p.m., and 9/7/2023 at 2:18 p.m. During a review of Resident 1 ' s COVID-19 Antigen test results, dated 9/1/2023, 9/7/2023 and 9/9/2023, the Antigen test results indicated Resident 1 was negative for COVID-19 During a review of Resident 1 ' s COVID-19 Antigen test results, dated 9/11/2023, the Antigen test results indicated Resident 1 tested positive for COVID-19 (10 days after his initial test results indicated he was negative for COVID-19). During a review of Resident 1's Nursing Progress Notes, dated 9/11/2023, the Nursing Progress Notes indicated Resident 1 was sent to a GACH for worsening blisters and due to being COVID-19 positive. The Nursing Progress Notes indicated Resident 1 had congestion upon transfer to the GACH. During a review of Resident 1 ' s Healthcare Facility Transfer Form, dated 9/11/2023 and timed at 2:46 p.m., the Facility Transfer Form, indicated Resident 1 was transferred to a GACH. During a review of the GACH H&P dated 9/12/2023, the H&P indicated Resident 1 was admitted to the GACH (9/11/2023) with complaints and history of coughing associated with intermittent (occurring at irregular interval, not continuous or steady) SOB. During an interview on 9/14/2023 at 1:10 p.m., Licensed Vocational Nurse 1 (LVN 1) stated she was not aware that if a resident exhibited symptoms of COVID-19 and continued to test negative for COVID-19 using an Antigen test, a PCR test should be done. During an interview on 9/13/2023 at 4:55 p.m., the Director of Nursing (DON) stated they did not conduct a PCR test to confirm if Residents 1 was negative for COVID-19. The DON stated a PCR test should have been conducted when Resident 1 continued to exhibit symptoms of COVID-19. The DON stated a delay in conducting PCR testing on Resident 1, could have caused an increase in COVID-19 cases in the facility due to Residents 1 continuing to be symptomatic despite multiple negative Antigen testing. The DON stated the PCR test is better for early detection of COVID-19. During a review of Centers for Medicare & Medicaid Services QSO (Quality, Safety and Oversight) 20-38-NH, revised 9/23/2022, the QSO indicated an antibody (POC) test does not identify an active COVID-19 infection; therefore, conducting a POC test on a staff or residents does not meet the requirements under this regulation and PCR testing should be done. During a review of the facility ' s COVID-19 Mitigation Plan (MP), revised 8/16/2023, the MP indicated if COVID-19 Antigen (POC) testing is used, confirmation testing will be conducted with PCR testing when a symptomatic individual tests negative via an Antigen (POC) test.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the clinical records were accurately documented for two of 4 sampled residents ( Resident ' s 2, 3) by failing to clarify Physician ' s orders for Life Sustaining Treatment (POLST) end of life wishes for Resident 2 and 3. This deficient practice had the resulted in incomplete resident medical care information and placed residents at risk for confusion in the provision of care in an emergency situation. Findings: A. During a review of the admission record dated [DATE], the admission record indicated that Resident 2 was admitted to the facility for dementia (loss of intellectual functioning), depression (mental health disorder characterized by lowering or elevation of one ' s mood) and hypertension (high blood pressure). During a review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and screening tool) dated [DATE], the MDS indicated, Resident 2 was severely impaired on making daily life decisions. Section S indicated, Resident 2 had a completed POLST and it was selected, Do Not Resuscitate for end of life wishes. During an interview on [DATE] at 8:14 a.m. with Resident 2 ' s son, the son stated, he did not want any drastic life saving measures done for Resident 2. He stated, he had a meeting with his sister ' s and they all agreed that Resident 2 would be a DNR. Resident 2 ' s son stated, he communicated this information to the facility. During an interview and record review on [DATE] at 12:00 p.m. with LVN 2, LVN 2 stated, the POLST are kept on the resident ' s chart. LVN 2 confirmed that Resident 2 POLST order was DNR in the chart. LVN 2 stated, it means no CPR, not giving life support just comfort measures like keep the head up and make sure the resident is not in pain. LVN 2 stated, the POLST was implemented on [DATE]. During an interview and record review on [DATE] at 1:00 p.m. with the RN, the RN stated, Resident 2 POLST indicated she was a DNR. The RN stated, the orders in the chart indicated that Resident 2 was a full code and these were conflicting orders. During an interview and record review on [DATE] at 1:05 p.m. with the ADM, the ADM stated, the orders for Resident 3 should have been clarified and corrected during the IDT (Interdisciplinary Team) meeting. The ADM confirmed, Resident 3 has two different orders for DNR and full code. The ADM stated, if Resident 3 went into cardiac arrest, the facility will follow the orders on the POLST, even if they are not correct. During a review of Resident 2 ' s POLST physician order dated [DATE], the POLST indicated, Resident 2 had an order to be DNR. This POLST was signed by Resident 2 ' s son and attending physician. During a review of Resident 2 ' s Physicians Orders dated [DATE] and [DATE], the physician orders indicated, Resident 2 was a Full Code. B. During a review of Resident 3 ' s admission record dated, [DATE], the admission record indicated, Resident 3 was admitted to the facility for hypertension (high blood pressure), urinary tract infection (bacteria in the urine) and atrial fibrillation (heart condition that causes an irregular and often abnormally fast heart rate). During a review of the Minimum Data Set (MDS - a standardized assessment and screening tool) for Resident 3 dated [DATE], the MDS indicated, Resident 3 had a BIMS score of 4 (Brief Interview for Mental Status [ evaluates memory and orientation]) which indicated, Resident 3 was severely cognitively impaired. During a concurrent interview and record review on [DATE] at 12:52 p.m. with the ADM and RN, they both stated, Resident 3 is on the facility DNR list and the resident current status is a DNR. The ADM and RN both confirmed the date of Resident 3 DNR was [DATE]. During the record review with the ADM, the ADM confirmed that POLST order in the chart stated Resident 3 is a full code dated [DATE]. The ADM and RN both stated, the full code order and POLST order are conflicting and would cause confusion to the staff if Resident 3 went into cardiac arrest. During an interview and record review on [DATE] at 12:55 p.m. with the RN, the RN stated, Resident 3 is a full code according to the POLST order and in an emergency, the staff will go to the chart and look at the POLST and follow the orders on the POLST. The RN stated they would try to call the family if the facility wasn ' t sure of the code status. The RN stated, the resident could be brain dead in 2 minutes without oxygen and it would take more than 2 minutes to contact the family for clarification. During a review of Resident 3 ' s POLST order dated [DATE], the POLST indicated, Resident 3 was a Full Code and wanted all life saving measures to be performed during an emergency. During a review of Resident 3 ' s Physician Order dated [DATE], the physician order indicated, Resident 3 code status was a DNR. The POLST Form is a set of medical orders, similar to the do-not resuscitate (allow natural death) order. POLST is not an advance directive. POLST does not substitute for naming a health care agent or durable power of attorney for health care. The POLST Form is completed as a result of the process of informed, shared decision-making. During the conversation, the patient discusses his or her values, beliefs, and goals for care, and the health care professional presents the patient's diagnosis, prognosis, and treatment alternatives, including the benefits and burdens of life-sustaining treatment. Together they reach an informed decision about desired treatment, based on the person's values, beliefs and goals for care. (POLST.org) During a review of the facility Policy and Procedure (P&P) titled Do Not Resuscitate Order dated revised [DATE], the P&P indicated, the facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. It also indicated, if the resident needs to be transferred to the hospital, a photocopy of the DNR order form must be provided to the personnel transporting the resident to the hospital. The P&P indicated, the resident's Attending Physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effort to, clarify and adhere to the resident's wishes and the Attending Physician must be informed of the resident request to cease the DNR order. During a review of the facility P&P Charting and Documentation, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Based on observation, interview, and record review the facility failed to implement infection control practices to prevent the spread and transmission of the coronavirus ([COVID-19] a potentially severe respiratory illness, caused by a Coronavirus, characterized by fever, coughing, and shortness of breath) during a current COVID-19 outbreak at the facility. By failing to: 1. Ensure a Licensed Vocational Nurse (LVN 1) and the facility's Medical Doctor (MD) wore an N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) while in an isolation area designated for residents positive for COVID-19. 2. Ensure a Certified Nurse Assistant (CNA 1) donned (put on) an N95 mask upon entering the facility as mandated by the current Public Health Guidance. These deficient practices had the potential to result in the spread of COVID-19 infection and placed residents, staff, visitors, and the community at an increased risk of contracting COVID-19. Findings: a. During an observation on 3/2/2023 at 6:05 a.m., in the North/East Hall, LVN 1 was observed in the isolation area standing next to an isolation cart donning a gown and gloves but not wearing an N95 mask. During an interview on 3/2/2023 at 6:15 a.m., with LVN 1, LVN 1 stated he was asked by the Registered Nurse Supervisor (RNS) to care for a resident in the isolation area. LVN 1 stated he removed his N95 mask before entering the isolation area and he was not able to locate a new N95 mask in the non-isolation area. LVN 1 stated he entered the isolation area without wearing a N95 mask and he was aware of the facility's policy indicating all staff entering the facility must wear a N95 in all areas of the facility most importantly in the isolation area. LVN 1 stated it is important to wear N95 mask in the designated isolation area to prevent contracting and transmitting COVID-19 to residents, staff, and visitors. During a concurrent observation and interview on 3/2/2023 at 6:50 a.m., at the entrance to the isolation area next to the social service office, an MD was observed wearing a blue surgical mask. The MD removed the partition separating the isolation area from the non-isolation area and entered the isolation area not wearing an N95 mask. The MD stated he was aware of the facilities current COVID-19 outbreak and the required Personal Protective Equipment ([PPE] equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses.) he must wear while in the facility and the isolation area. b. During an observation on 3/2/2023 at 7:05 a.m., CNA 1 was observed entering the facility through the front entrance not wearing a face mask or later donning an N95 mask when in the facility. CNA 1 proceeded to walk down the hall and entered the employee breakroom. During a concurrent observation and interview on 3/2/2023 at 7:09 a.m., CNA 1 exited the employee breakroom without wearing an N95 mask. CNA 1 proceeded to the receptionist area retrieved and donned an N95 mask. CNA 1 stated she was running late for work, so she did not stop and put on an N95 mask before walking down the hall. CNA 1 stated she was aware of the COVID-19 outbreak in the facility, and she was informed by the Infection Preventionist Nurse (IPN), all staff must wear an N95 mask while at work. CNA 1 stated it is important to wear an N95 mask to prevent exposing and transmitting COVID to residents, coworkers, and visitors. During an interview on 3/2/2023 at 7:50 a.m., with the IPN, the IPN stated, the facility is in a COVID-19 outbreak and there were 12 residents in the isolation area positive for COVID-19. The IPN stated all staff and visitors must wear an N95 mask upon entering the facility. The IPN stated it is important for staff and visitors to wear an N95 mask to while in the facility to prevent the spread of COVID-19. The IPN stated by not wearing an N95 mask in the isolation area, staff and visitors could contract and spread COVID-19 throughout the facility and the Corona virus can be detrimental (cause serious harm) to residents with compromised immune systems. During an interview on 3/2/2023 at 8:30 a.m., with the RNS, the RNS stated all staff and visitors must always wear an N95 mask while in the facility. The RNS stated, if LVN 1 needed to change his N95 mask, he should have changed it before entering the isolation area. The RNS stated, extra N95 masks are kept in the receptionist area and at both nursing stations. The RNS stated, staff and visitors entering the isolated area without wearing an N95 mask, have a high chance of contracting COVID-19 and could spread the virus to residents' staff, and visitors. The RNS stated, MDs are not exempt from wearing an N95 mask in the isolation area and they must also follow the infection control guidelines. During a review of the facility's policy and procedure (P/P), titled, COVID-19 Prevention and Control, dated 2023, the P/P indicated, the facility follows current guidelines and recommendations for the prevention and control of COVID-19, and all staff must wear fit tested N95 mask in any indoor space where there are residents who are in isolation. During a review of the facility's P/P, titled COVID 19 Mitigation Plan, dated 2023, the P/P indicated, the facility will implement a universal masking plan and all staff are required to wear N95 mask while in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure to inform and consult with the residents' physician and psychiatrist (a medical doctor who specializes in mental health) when a resident experienced a change of condition ([COC] a clinical deviation from a resident's baseline) for one of three sampled residents (Resident 1) when Resident 1 verbalized feeling down, depressed (serious mood disorder), hopeless, feeling bad about self, was a failure, have let himself or family down for nearly every day for the past five months. This deficient practice of not notifying the physician and psychiatrist of the resident's COC resulted in a delay of evaluation, care, treatment, and lack of guidance for Resident 1, who was exhibiting signs of depression (serious mood disorder) for over five (5) months. Findings: During a review of Resident 1's admission Record (face sheet), dated 3/21/2023, the face sheet indicated Resident 1 was admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses including delusional disorder (characterized by one or more firmly held false beliefs that persist for at least one month), cardiac arrhythmia (irregular heartbeat), presence of cardiac pacemaker (a small device that was placed in the chest to help control the heartbeat to prevent the heart from beating slowly), and hypertension (high blood pressure). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/20/2023, MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was mildly impaired, and required supervision for activities of daily living. MDS indicated Resident 1 had no active diagnosis of depression. During a concurrent interview and record review of MDS section D (Mood) on 3/26/2023 at 10:00 a.m., with Social Service Assistant (SSA1), SSA 1 stated that she conducted Resident Mood Interview using PHQ9 (nine [9] item Patient Health Questionnaire- a validated interview that screens for symptoms of depression) questionnaires with Resident 1. SSA 1 stated she asked Resident 1 if over the last two weeks, was he bothered by any of the following problems listed on the PHQ 9 questionnaire: a. Little interest or pleasure in doing things. b. Feeling down, depressed, or hopeless. c. Trouble falling or staying asleep or sleeping too much. d. Feeling tired or having little energy. e. Poor appetite or overeating. f. Feeling bad about your self- or that you are a failure or have let yourself or your family down. g. Trouble concentrating on things, such as reading the newspaper or watching television, h. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual. i. Thoughts that you would be better off dead or hurting yourself in some way. The MDS PHQ-9 from 10/2022 to 2/20/2023 indicated the following: On 10/25/2022, indicated Resident 1 was feeling down, depressed, or hopeless for 7-11 days nearly half or more of the days. The MDS indicated Resident 1 was feeling bad about self or that he was a failure or have let himself or family down for 12-14 days nearly every day. On 1/23/2023 and 2/20/2023 indicated Resident 1 was feeling down, depressed, or hopeless for 12-14 days nearly every day. The MDS also indicated Resident 1 was feeling bad about self or that he was a failure or have let himself or family down for 12-14 days nearly every day. During a review of Resident Assessment Instrument (RAI) Manual for Long Term Care Facility 3.0 User's Manual Version 1.17 dated October 2019, RAI indicated Responses to PHQ-9 can indicate possible depression. Responses can be interpreted as follows: Minor Depressive Syndrome is suggested if, of the 9 items, (1) feeling down, depressed or hopeless, (2) trouble falling or staying asleep, or sleeping too much, or (3) feeling tired or having little energy are identified at a frequency of half or more of the days (7-11 days) during the look-back period and at least one of these, (1) little interest or pleasure in doing things, or (2) feeling down, depressed, or hopeless is identified at a frequency of half or more of the days (7-11 days). During a record review of Resident 1's Social Service (SS) Assessment -Type Quarterly, dated 10/31/2022 and 1/23/2023, SS Assessment indicated Resident 1 spent most of his time alone or watching television, and naps regularly throughout the day. SS Assessment indicated over the last two weeks, Resident 1 had been bothered by feeling or appearing down, depressed, or hopeless, feeling bad about himself, feeling of failure, or letting self or family down, expressed adjustment issues, expresses difficulty coping with current health status and rejection of care occurred daily. Social Service Plan indicated the following: a. Establish/continue a positive, trusting relationship with resident and family. b. Communicate with resident, family, interdisciplinary team to assess for home care needs upon discharge and coordinate appropriate referrals c. Participate in ongoing communication with the interdisciplinary team to identify and accommodate resident specific needs. d. Address psychosocial needs (mood, behavior, communication, and mental status), invite to resident-to-resident council meetings e. Invite resident to care plan meetings. f. Covert/open conflict with or repeated criticism of staff. During an interview on 3/26/203 at 10:15 a.m., with the SSA 1, SSA 1 stated she was not sure if she mentioned Resident 1's increasing symptoms of depression to the nurses and said she might have mentioned the result of Social Service Assessment to the Social Service Director (SSD) 1 but SSD 1 no longer work at the facility. The SSA 1 stated she did not document she notified the SSD 1 or any nurses and does not recall notifying the physician or psychiatrist to regarding Resident 1's symptoms of depression. SSA 1 was unable to say or provide documentation how Resident 1's symptoms of depression were addressed including social service plan. During an interview on 3/26/2023 at 10:45 a.m., with the Director of Nursing (DON), the DON stated SSD 1 last worked physically at the facility on 12/15/2022. The next SSD was SSD 2, who was hired on 1/19/2023 and last worked at the facility on 2/24/2023. The next SSD was SSD 3, who just started working on 3/20/2023. During a concurrent interview and record review on 3/26/2023 at 11:00 a.m., with SSA1, MDS Coordinator (MDSC 1), and the DON. Resident 1's clinical record from January 1, 2022, to March 26, 2023, were reviewed including care plan, IDT notes, physician notes, nurses progress notes, Change of Condition ([COC] a clinical deviation from a resident's baseline), psychiatrist, and psychosocial notes. SSA1, MDSC 1, and the DON all verified and stated there were no documentation in Resident 1's electronic or paper clinical record that indicated Resident 1 depression was communicated and addressed by the physician, psychiatrist, or psychologist. Social Service, MDSC 1 and the DON verified that the referral for psychiatrist and psychologist were for refusing medications and was not a referral to addressed Resident 1's symptoms of depression. During a review of Resident 1's Psychiatrist Note, dated 11/22/2022, Psychiatrist Note indicated Resident 1 continued to refuse to be seen by psychiatry, per nursing no acute problematic or concerning behaviors and Resident 1 was not on a psychotropic (drugs that affect a person's mental state) regimen. Resident 1 was receiving Depakote for seizures. During a review of Resident 1's Psychiatrist Note, dated 1/11/2023, Psychiatrist Note indicated Resident 1 was refusing assessment and no behavioral concerns per nursing. During a review of Resident 1's Psychiatrist Note, dated 2/8/2023, Psychiatrist Note indicated Resident 1 does not wish to be seen by psychiatry and per nursing no acute problematic behaviors or concerns. The psychiatrist will remain available if Resident 1 was willing to be interviewed. Psychiatric Note indicated staff aware of emergent option to call for Psychiatric Emergency Teams ([PET] mobile teams operated by psychiatric hospital to perform evaluations for involuntary detention of individuals determined to be at risk of harming themselves or others or who are unable to provide food, clothing, or shelter because of a mental disorder) if needed. During a review of Resident 1's Psychiatrist Note, dated 3/8/2023, Psychiatric Note indicated evaluation was requested by staff to see Resident 1 but Resident 1 refused psychiatric evaluation and Resident 1 had no acute problematic behaviors present. Psychiatric Note indicated per staff Resident 1 had been over all stable despite refusing care from psychiatry and advised staff that psychiatry to remain available for changes in behavior or to call PET team for any crisis if Resident 1 refuses to be evaluated. During an interview on 3/23/2023 at 12:05 p.m., with Family 1, Family 1 stated that Resident 1 had some issues with depression and anxiety. During a review of Psychiatric Evaluation Team (PET) Assessment Form, dated 3/18/2023, PET assessment indicated that on 3/18/2023 at 5:02 p.m., Resident 1 was seen and assessed via face-to-face video conference by a peace officer/ mental health professional. PET assessment form indicated there was a probable cause to believe that Resident 1, as a result of mental health disorder, a danger to others, or to himself, or gravely disabled because of history of delusional disorder, being angry, and easily agitated. PET assessment indicated Resident 1 should be transferred to a 5150 designated facility for up to 72 hours assessment, evaluation, and crisis intervention or placement for evaluation and treatment at a designated facility pursuant to section 5150. During a review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, communication form) dated 3/18/2023, SBAR indicated that on 3/18/2023 at 1:20 p.m., Resident 1 had episode of agitation, kicking, screaming, and striking out staff. Resident 1 left the facility and when staff attempted to stopped him, he became combative. SBAR indicated Resident 1 got agitated while RN 1 was talking to Resident 1 and Resident 1 suddenly took out a bread knife and flagged the bread knife in front of him and seemed that he was ready to strike whoever got close to him. RN 1 and staff (unspecified) was able to get the breadknife from Resident 1. During an interview on 3/26/2023 at 3:20 p.m., with RN 1, RN 1 verified that after Resident 1 was evaluated by the PET, Resident 1 suddenly took out a bread knife, was holding the knife in front of him, knife directed to the staff, and threatening the staff not to come close to him. RN 1 stated they panicked and was afraid that Resident 1 could hurt himself or others. RN 1 stated they (CNA, LVN 1 and RN 1) were able to forcedly take the bread knife from Resident 1. RN 1 stated the PET, nor the law enforcer were not made aware Resident 1 threatened the staff with a bread knife because the incident happened after law enforcer came and after the PET spoke to Resident 1. During a review of Resident 1's Physician Order, dated 3/18/2023, the physician order indicated an order to transfer Resident 1 to a designated 5150 General Acute Care Hospital (GACH) for 5150 Hold. During an interview on 3/23/2023 at 11:47 a.m. with Resident 1's Psychiatrist (Psychiatrist 1), Psychiatrist 1 stated Resident 1 was notified of the situation with Resident 1 on 3/18/2023 and he ordered for resident to be transfer to GACH general acute care hospital) under 5150. Psychiatrist 1 stated that Psychiatrist Nurse Practitioner 1 was the one who saw Resident 1 while at the facility. During an interview on 3/29/2023 at 09:24 a.m., with Resident 1's Psychiatric Nurse Practitioner (NP) 1, NP1 stated she was not aware that Resident 1 was verbalizing he was depressed, and the nurses were telling her that Resident 1 had no concern and refusing psychiatric assessment. NP 1 stated she remembered Resident 1 being irritable, but no one mentioned about him verbalizing he was depressed and relied so much on the nurses' communication because the nurses were the one who saw the resident every day. NP 1 stated it was important for the nurses to report to the psychiatrist what the residents' daily behaviors were so the NP, physicians or psychiatrist can make the correct recommendations or prescriptions. NP 1 stated if she was informed that Resident 1 was verbalizing being depressed, she could have addressed Resident 1's concern and could have made recommendations even if Resident 1 was refusing to be seen. During an interview on 3/30/2023 at 09:02 a.m. with Resident 1's Psychiatrist (Psychiatrist 1), Psychiatrist 1 stated he never saw Resident 1 at the facility and Psychiatrist Nurse Practitioner 1 was the one who saw Resident 1 while at the facility. Psychiatrist 1 stated he was never informed that Resident 1 was verbalizing any symptoms of depression and that Resident 1 threatened the staff with a knife. Psychiatrist 1 stated the staff should have been more assertive of notifying the Physicians including the Psychiatrist of the changes in residents' behavior so they could provide proper intervention. During a review of the facility's policy and procedure (P&P) titled, Behavioral Assessment, Intervention and Monitoring, dated revised March 2019, the P&P indicated, 1. the facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practical physical, mental, and psychosocial wellbeing in accordance with the comprehensive assessment and plan of care. 2. behavioral symptoms will be identified using facility approved behavioral screening tools and the comprehensive assessment. 3. Behavioral services will be provided by qualified staff who have the competencies and skills necessary to provide appropriate services to the residents. 4. residents will have minimal complications associated with the management of altered or impaired behavior. 5. As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations: a. the resident's usual patterns of cognition, mood, and behavior. b. the resident's typical or past response to stress, fatigue, fear, anxiety, frustration and other triggers; and the residents' previous patterns of coping with stress, anxiety and depression. 6. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior and cognition including: a. onset, duration, intensity, and frequency of behavioral symptoms. b. any recent precipitating or relevant factors or environmental triggers. c. appearance and alertness of the resident related observations. 7. New onset or changes in behavior that indicate newly evident or possible serious mental disorder, intellectual disability, or a related disorder will be referred for a PASARR level II (comprehensive evaluation required as a result of a positive Level I Screen. A Level II is necessary to confirm the indicated diagnosis noted in the Level I Screen and to determine whether placement or continued stay in a Nursing Facility is appropriate) evaluation. 8. The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition including: a. Physical or medical changes. b. emotional, psychiatric, and or/ psychological stressors (for example depression, boredom, loneliness, anxiety and or fear.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure ([PASARR] a screening for mental illness and treatment to ensure the facility coordinates with the appropriate State-designated authority to ensure that individuals with a mental disorder, intellectual disability or a related condition receives care and services in the most integrated setting appropriate to their needs) screening form for one of one sampled residents (1). This deficient practice resulted in Resident 1 who did not receive the necessary care, services, and interventions to address his emotional, behavioral and psychosocial needs. Resident 1 became aggressive, threatened staff with a knife and committed suicide on 3/19/2023. Findings: During a review of Resident 1 ' s admission Record (face sheet), dated 3/21/2023, the face sheet indicated Resident 1 was admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses including delusional disorder (characterized by one or more firmly held false beliefs that persist for at least one month), cardiac arrhythmia (irregular heartbeat), presence of cardiac pacemaker (a small device that's placed in the chest to help control the heartbeat to prevent the heart from beating slowly), hypertension (high blood pressure). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/20/2023, MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was mildly impaired, and required supervision for activities of daily living. MDS indicated Resident 1 had no active diagnosis of depression (serious mood disorder). During a concurrent interview and record review of MDS section D (Mood) on 3/26/2023 at 10:00 a.m., with Social Service Assistant (SSA1), SSA 1 stated that she conducted Resident Mood Interview PHQ-9 (9 item Patient Health Questionnaire- a validated interview that screens for symptoms of depression. It provides a standardized severity score and a rating for evidence of a depressive disorder) with Resident 1. The SSA 1 stated she asked Resident 1 if over the last two weeks if he was bothered by any of the problems listed on the PHQ 9 questionnaire and documented Resident 1 ' s response on MDS. The MDS PHQ-9 dated 5/4/2022, 6/8/2022, 7/26/2022 and 8/1/2022, indicated Resident 1 had no symptoms of depression. The MDS PHQ-9 dated 10/25/2022, indicated Resident 1 was feeling down, depressed, or hopeless for 7-11 days nearly half or more of the days. The MDS indicated Resident 1 was feeling bad about self or that he was a failure or have let himself or family down for 12-14 days nearly every day, Resident 1 was moving or speaking so slowly that other people could have noticed or the opposite being so fidgety or restless that Resident 1 have been moving around a lot more than usual. The MDS PHQ-9 dated 1/23/2023 and 2/20/2023 indicated Resident 1 was feeling down, depressed, or hopeless for 12-14 days nearly every day. The MDS also indicated Resident 1 was feeling bad about self or that he was a failure or have let himself or family down for 12-14 days nearly every day. During a review of RAI Manual for Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User ' s Manual Version 1.17 dated October 2019, RAI indicated Responses to PHQ-9 can indicate possible depression. Responses can be interpreted as follows: Minor Depressive Syndrome is suggested if, of the 9 items, (1) feeling down, depressed or hopeless, (2) trouble falling or staying asleep, or sleeping too much, or (3) feeling tired or having little energy are identified at a frequency of half or more of the days (7-11 days) during the look-back period and at least one of these, (1) little interest or pleasure in doing things, or (2) feeling down, depressed, or hopeless is identified at a frequency of half or more of the days (7-11 days). During a record review of Resident 1 ' s Social Service (SS) Assessment -Type Quarterly, dated 10/31/2022 and 1/23/2023, SS assessment indicated Resident 1 spent most of his time alone or watching television, naps regularly throughout the day. SS assessment indicated over the last two weeks, Resident 1 had been bothered by feeling or appearing down, depressed, or hopeless, feeling bad about himself, feeling of failure, or letting self or family down, expressed adjustment issues, expresses difficulty coping with current health status and rejection of care occurred daily. During an interview on 3/26/203 at 10:15 a.m., with the SSA 1, the SSA 1 stated she was not sure if she mentioned Resident 1 ' s increasing symptoms of depression to the nurses and said she might have mentioned the result of social service assessment to the Social Service Director (SSD) 1 but SSD 1 no longer work at the facility. The SSA 1 stated she did not document she notified the SSD 1 or any nurses and does not recall notifying the physician or psychiatrist to consult for Resident 1 ' s symptoms of depression. The SSA 1 was unable to say or provide documentation how Resident 1 ' s symptoms of depression were addressed. During an interview on 3/26/2023 at 10:45 a.m., with Director of Nursing (DON), DON stated SSD 1 last worked physically at the facility on 12/15/2022. The next SSD was SSD 2 who was hired on 1/19/2023 and last worked at the facility on 2/24/2023. The next SSD was SSD 3 who just started working on 3/20/2023. During a review of CAA (Care Area Assessment-provide guidance to focus on key issues identified in comprehensive MDS. Direct staff to evaluate triggered areas) worksheet dated 11/8/2022, CAA indicated Resident 1 ' s mood interview total severity score, and frequency was greater than the prior assessment and triggered mood state as potential problem. CAA indicated to assess and refer accordingly, psychiatry consults as needed and proceed to care planning to focus on safety, nutritional status, health activity pattern, and was not a danger to self or others. During a review of CAA worksheet dated 11/8/2022, CAA indicated behavioral symptoms was triggered potential problem due to Resident 1 rejected evaluation of care daily, changed in behavior, care rejection or wandering has gotten worse since prior assessment. Resident 1 rejected care that was necessary to achieve his goals for health and well-being and had episodes of refusing nursing care including medications. CAA indicated to proceed to care planning to focus on resident ' s safety, nutritional status, behavior approach, health activity pattern, and was not a danger to self and others. During a concurrent interview and record review on 3/26/2023 at 11:00 a.m., with SSA1, MDS Coordinator (MDSC 1), and DON. Resident 1 ' s clinical record from 2022 to 2023 were reviewed including care plan, IDT ([Interdisciplinary team] comprises professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological needs.) notes, physician notes, nurses progress notes, Change of Condition ([COC] a clinical deviation from a resident's baseline), psychiatrist, and psychosocial notes. SSA1, MDSC 1, and DON all verified and stated there were no documentation in Resident 1 ' s electronic or paper clinical record that indicated Resident 1 depression was addressed and that physician, psychiatrist nor psychologist were notified. Social Service, MDSC 1 and DON verified that the referral for psychiatrist and psychologist were for refusing the medications and was not a referral to addressed Resident 1 ' s symptoms of depression. During a review of Resident 1 ' s PASRR Level 1 screening, dated 6/16/2021, PASRR level 1 screen indicated negative and no need for PASRR level II evaluation. During a review of Resident 1 ' s PASRR I level screening, resident review status change dated 8/29/2022, PASRR level 1 screen indicated positive suspected mental illness. Resident has diagnosis of mental disorder and was taking Depakote (used to prevent migraine headaches, seizures, or to treat manic episodes related to bipolar disorder [condition that causes extreme mood swings that include emotional highs mania or hypomania and lows depression]). During a review of Resident 1 ' s Medication Administration Record (MAR) for March 2023, MAR indicated an order to for Depakote Sprinkles capsule 125 mg (milligram-unit of measurement) two (2) capsules by mouth three times a day for seizure disorder. Record indicated Resident 1 refused 20 times out of 54 scheduled times of medication administration in March 2023. During a review of Resident 1 ' s PASRR Level II evaluation letter, dated 9/7/2022, letter indicated after reviewing the positive Level I Screening and speaking with staff, a level II Mental health evaluation was not scheduled due to Resident 1 does not have serious mental illness. The case was closed and to reopen, submit a new level 1 screening. During a review of Resident 1 ' s PASRR Level 1 screening, from 10/2022 to 3/20/2023, the facility unable to provide document of any PASRR reevaluation after Resident verbalized feeling depressed During an interview on 3/26/2023 at 11:00 a.m., with the DON, the DON stated she was responsible for making the referral for PASRR. DON stated she was not aware that Resident 1 had history or symptoms of depression and was not aware about the result of the PHQ9. DON stated she should have followed up and ensure that PASSR Level II was done. DON stated new onset or changes in behavior that indicated newly evident or possible serious mental disorder, intellectual disability, or a related disorder should be referred for a PASRR level II to find out if Resident 1 should stay at the facility or could get the necessary services and treatment to address depression. During an interview on 3/27/2023 at 11:00 a.m., with the DON, DON stated that PASRR level II was evaluated not necessary because on 9/2023 when the PASRR level II has been evaluated, Resident 1 was not yet verbalizing symptoms of depression. DON stated that they should have initiated another PASRR reevaluation for change of condition when resident 1 continued to verbalize being depressed. During an interview on 3/23/2023 at 12:05 p.m., with Family 1, Family 1 stated that Resident 1 had some issues with depression and anxiety and on a lot of medications and thought that Resident 1 managed his depression and anxiety well. During an interview on 3/26/2023 at 3:12 p.m., with Registered Nurse (RN 1), RN 1 stated that Resident 1 became agitated on 3/18/2023 around 1:20 p.m., while trying to elope the facility. RN 1 stated Resident 1 spoke to PET team via videoconference due to aggressive behavior, striking out and kicking staff, eloping the facility and uncooperative to go back to the facility and PET team evaluated Resident 1 was required to be transferred to a designated 5150 (allows for a medical facility or law enforcement agency to place a 72 hour involuntary hold on an individual who they believe is danger to himself or others as a result of a mental illness or condition) facility. During a review of Psychiatric Evaluation Team (PET) Assessment Form, dated 3/18/2023, PET assessment indicated that on 3/18/2023 at 5:02 p.m., Resident 1 was seen and assessed via face-to-face video conference by a peace officer/ mental health professional. PET assessment form indicated there was a probable cause to believe that Resident 1, as a result of mental health disorder, a danger to others, or to himself, or gravely disabled because of history of delusional disorder, being angry, and easily agitated. PET assessment indicated Resident 1 should be transferred to a 5150 designated facility for up to 72 hours assessment, evaluation, and crisis intervention or placement for evaluation and treatment at a designated facility pursuant to section 5150. During a review of Resident 1 ' s Situation, Background, Assessment, and Recommendation (SBAR, communication form) dated 3/18/2023, SBAR indicated that on 3/18/2023 at 1:20 p.m., Resident 1 had episode of agitation, kicking, screaming, and striking out staff. Resident 1 left the facility and when staff attempted to stopped him, he became combative. SBAR indicated Resident 1 got agitated while RN 1 was talking to Resident 1 and Resident 1 suddenly took out a bread knife and flagged the bread knife in front of him and seemed that he was ready to strike whoever got close to him. RN 1 and staff (unspecified) was able to get the breadknife from Resident 1. During an interview on 3/26/2023 at 3:20 p.m., with RN 1, RN 1 verified that after Resident 1 was evaluated by the PET, Resident 1 suddenly took out a bread knife, was holding the knife in front of him, knife directed to the staff, and threatening the staff not to come close to him. RN 1 stated they panicked and was afraid that Resident 1 could hurt himself or others. RN 1 stated they (CNA, DSD and RN 1) were able to forcedly take the bread knife from Resident 1. RN 1 stated the PET, nor the law enforcer were not made aware Resident 1 threatened the staff with a bread knife because the incident happened after law enforcer came and after the PET spoke to Resident 1. During an interview on 3/27/2023 at 6:30 a.m., with RN 2, RN 2 stated at around 1 am, Resident1 ' s door was found by CNA 1 to be closed, door blocked by a wheelchair and Resident 1 ' s foot was observed dangling on the closet and Resident 1 was found hanging in the closet with a shoelace like rope/string on his neck. At 1:57 a.m. Resident was pronounced dead. During an interview on 3/29/2023 at 09:24 a.m., with Resident 1 ' s Psychiatric Nurse Practitioner (NP) 1, NP1 stated she was not aware that Resident 1 was verbalizing he was depressed, and the nurses were telling her that Resident 1 had no concern and refusing psychiatric assessment. NP 1 stated she remembered Resident 1 being irritable, but no one mentioned about him verbalizing he was depressed. NP 1 stated if the nurses informed her that Resident 1 was verbalizing being depressed, she could have looked Resident 1 ' s concern and could have made recommendations even if Resident 1 was refusing to be seen like being transferred for further evaluation or maybe encouraged Resident 1 to take antidepressants since he was verbalizing being depressed. During an interview on 3/26/2023 at 1:00 p.m. with NP 2, NP 2 stated if resident was having emotional distress, verbalizing feeling of depression, having behavioral health crisis ( a disruption in an individual ' s mental or emotional stability or functioning resulting in an urgent need for immediate outpatient treatment in an emergency department or admission to a hospital to prevent a serious deterioration in the individual ' s mental or physical health, the nurses should send the resident to GACH immediately for further evaluation and not wait for psychiatrist because the psychiatrist only comes once a month. NP 2 stated that Resident 1 was severely depressed for him to commit suicide. During an interview on 3/30/2023 at 09:02 a.m. with Resident 1 ' s Psychiatrist (Psychiatrist 1), Psychiatrist 1 stated he never saw Resident 1 at the facility and NP 1 was the one who saw Resident 1 while at the facility. Psychiatrist 1 stated he was never informed that Resident 1 was verbalizing any symptoms of depression and staff should have been more assertive of notifying the Physicians including the Psychiatrist team of the changes in residents' behavior so they could provide proper intervention. During a review of the facility ' s policy and procedure (P&P) titled, Behavioral Assessment, Intervention and Monitoring, dated revised March 2019, the P&P indicated, 1. the facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practical physical, mental, and psychosocial wellbeing in accordance with the comprehensive assessment and plan of care. 2. behavioral symptoms will be identified using facility approved behavioral screening tools and the comprehensive assessment. 3. Residents will have minimal complications associated with the management of altered or impaired behavior. 4. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual ' s mental status, behavior and cognition including a. onset, duration, intensity, and frequency of behavioral symptoms. b. any recent precipitating or relevant factors or environmental triggers. c. appearance and alertness of the resident related observations. 5. New onset or changes in behavior that indicate newly evident or possible serious mental disorder, intellectual disability, or a related disorder will be referred for a PASARR level II evaluation. During a review of the facility ' s policy and procedure (P&P) titled, admission Criteria dated revised March 2019, P&P indicated all new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid PASSR process. 1. The facility conducts a level I PASSR screen for all potential admissions regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASRR representative for the Level II (evaluation and determination) screening process. The admitting nurse notifies the social services department when a resident is identified as having possible (or evident) MD, ID or RD. The social worker is responsible for making referrals to the appropriate state designated authority. 2. Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. The state PASARR representative provides a copy of the report to the facility. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation. 3. Once a decision is made, the state PASRR representative, the potential resident and his or her representative are notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an individualized plan of care to address resident ' s emotional, mental, behavioral and psychosocial wellbeing was developed for one of three sampled residents (Resident 1) when Resident 1 verbalized feeling depressed, hopeless and feeling bad about self for nearly every day for the past five months and when the CAA (Care Area Assessment-provide guidance to focus on key issues identified in comprehensive Minimum Data Set [MDS-a standardized assessment and care screening tool] which direct staff to evaluate triggered areas) indicated the need for a care plan to address Resident 1 ' s increasing behavioral changes and mood state. These deficient practices resulted in a lack of care plan interventions to address Resident 1 ' s increasing symptoms of depression (serious mood disorder) and did not receive the necessary care, services, and intervention to addressed Resident 1 ' s emotional, behavioral, and psychosocial needs. Resident 1 had aggressive behavior, threatened staff with a knife, eight hours later, Resident 1 committed suicide by hanging himself in the closet with a shoelace like rope/string wrapped around his neck and was pronounced dead on 3/19/2023 at 1:57 a.m. Findings: During a review of Resident 1 ' s admission Record (face sheet), dated 3/21/2023, the face sheet indicated Resident 1 was admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses including delusional disorder (characterized by one or more firmly held false beliefs that persist for at least one month), cardiac arrhythmia (irregular heartbeat), presence of cardiac pacemaker (a small device that's placed in the chest to help control the heartbeat to prevent the heart from beating slowly), hypertension (high blood pressure). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/20/2023, MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was mildly impaired, and required supervision for activities of daily living. MDS indicated Resident 1 had no active diagnosis of depression. During a concurrent interview and record review of MDS section D (Mood) on 3/26/2023 at 10:00 a.m., with Social Service Assistant (SSA1), SSA 1 stated that she conducted Resident Mood Interview PHQ-9 (9 item Patient Health Questionnaire- a validated interview that screens for symptoms of depression. It provides a standardized severity score and a rating for evidence of a depressive disorder) with Resident 1. The SSA 1 stated she asked Resident 1 if over the last two weeks if he was bothered by any of the problems listed on the PHQ 9 questionnaire and documented Resident 1 ' s response on MDS. The MDS PHQ-9 dated 10/25/2022, indicated Resident 1 was feeling down, depressed, or hopeless for 7-11 days nearly half or more of the days. The MDS indicated Resident 1 was feeling bad about self or that he was a failure or have let himself or family down for 12-14 days nearly every day, Resident 1 was moving or speaking so slowly that other people could have noticed or the opposite being so fidgety or restless that Resident 1 have been moving around a lot more than usual. The MDS PHQ-9 dated 1/23/2023 and 2/20/2023 indicated Resident 1 was feeling down, depressed, or hopeless for 12-14 days nearly every day. The MDS also indicated Resident 1 was feeling bad about self or that he was a failure or have let himself or family down for 12-14 days nearly every day. During a review of RAI Manual for Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User ' s Manual Version 1.17 dated October 2019, RAI indicated Responses to PHQ-9 can indicate possible depression. Responses can be interpreted as follows: Minor Depressive Syndrome is suggested if, of the 9 items, (1) feeling down, depressed or hopeless, (2) trouble falling or staying asleep, or sleeping too much, or (3) feeling tired or having little energy are identified at a frequency of half or more of the days (7-11 days) during the look-back period and at least one of these, (1) little interest or pleasure in doing things, or (2) feeling down, depressed, or hopeless is identified at a frequency of half or more of the days (7-11 days). During a review of Resident 1 ' s Social Service (SS) Assessment, dated 10/31/2022, SS assessment indicated Resident 1 spent most of his time alone or watching television, naps regularly throughout the day. SS assessment indicated over the last two weeks, Resident 1 had been bothered by feeling or appearing down, depressed, or hopeless, feeling bad about himself, feeling of failure, or letting self or family down, expressed adjustment issues, expresses difficulty coping with current health status and rejection of care occurred daily. During a record review of Resident 1 ' s Social Service (SS) Assessment -Type Quarterly, dated 1/23/2023, SS assessment indicated Resident 1 spent most of his time alone or watching television, naps regularly throughout the day. SS assessment indicated over the last two weeks, Resident 1 had been bothered by feeling or appearing down, depressed, or hopeless, feeling bad about himself, feeling of failure, or letting self or family down, expressed adjustment issues, expresses difficulty coping with current health status. Social Service Plan indicated the following: a. Establish/continue a positive, trusting relationship with resident and family. b. Communicate with resident, family, interdisciplinary team to assess for home care needs upon discharge and coordinate appropriate referrals c. participates in ongoing communication with the interdisciplinary team to identify and accommodate resident specific needs. d. address psychosocial needs (mood, behavior, communication, mental status), invite to resident-to-resident council meetings e. invite resident to care plan meetings. f. covert/open conflict with or repeated criticism of staff. During an interview on 3/26/203 at 10:15 a.m., with the SSA 1, the SSA 1 stated she was not sure if she mentioned Resident 1 ' s increasing symptoms of depression to the nurses and said she might have mentioned the result of social service assessment to the Social Service Director (SSD) 1 but SSD 1 no longer work at the facility. The SSA 1 stated she did not document she notified the SSD 1 or any nurses and does not recall notifying the physician or psychiatrist to consult for Resident 1 ' s symptoms of depression. The SSA 1 was unable to say or provide documentation how Resident 1 ' s symptoms of depression were addressed. During an interview on 3/26/2023 at 10:45 a.m., with Director of Nursing (DON), DON stated SSD 1 last worked physically at the facility on 12/15/2022. The next social service director was SSD 2 who was hired on 1/19/2023 and last worked at the facility on 2/24/2023. The next SSD was SSD 3 who just started working on 3/20/2023. During a review of CAA worksheet dated 11/8/2022, CAA indicated the resident mood interview total severity score, and frequency was greater than the prior assessment and triggered mood state as potential problem. CAA indicated to assess and refer accordingly, psychiatry consults as needed and proceed to care planning to focus on safety, nutritional status, health activity pattern, and was not a danger to self or others. During a review of CAA (Care Area Assessment-provide guidance to focus on key issues identified in comprehensive MDS. Direct staff to evaluate triggered areas) worksheet dated 11/8/2022, CAA indicated Behavioral symptoms was triggered potential problem due to Resident 1 rejected evaluation of care daily, changed in behavior, care rejection or wandering has gotten worse since prior assessment. Resident 1 rejected care that was necessary to achieve his goals for health and well-being. Resident 1 had episodes of refusing nursing care including medications. CAA indicated to proceed to care planning to focus on resident ' s safety, nutritional status, behavior approach, health activity pattern, and was not a danger to self and others. During a concurrent interview and record review on 3/26/2023 at 11:00 a.m., with SSA1, MDS Coordinator, and DON. Resident 1 ' s clinical record including care plan, IDT notes, physician notes, nurses progress notes, Change of Condition (COC), psychiatrist, and psychosocial notes from 2022 to 2023. SSA1, MDSC, and DON all verified and stated there were no documentation in Resident 1 ' s electronic or paper clinical record that indicated Resident 1 depression was addressed. SSA1, MDSC 1, DON and ADM were reminded multiple times during the survey to keep looking for documents that indicated Resident1 ' s symptoms of depression were address but no additional documentation was provided despite CAA indicated to proceed to care planning to focus on resident ' s safety, nutritional status, behavior approach, health activity pattern, and was not a danger to self and others. During a review of Resident 1 ' s Psychiatric Note, dated 2/8/2023, Psychiatric Note indicated Resident 1 does not wish to be seen by psychiatry and per nursing no acute problematic behaviors or concerns and psychiatrist will remain available if Resident 1 willing to interview. Psychiatric Note indicated staff aware of emergent option to call for Psychiatric Emergency Teams ([PET] mobile teams operated by psychiatric hospital to perform evaluations for involuntary detention of individuals determined to be at risk of harming themselves or others or who are unable to provide food, clothing, or shelter because of a mental disorder.) PET eval if needed. During a review of Resident 1 ' s Psychiatric Note, dated 3/8/2023, Psychiatric Note indicated evaluation was requested by staff to see Resident 1 but Resident 1 refused psychiatric evaluation and that no acute problematic behaviors present. Psychiatric Note indicated per staff Resident 1 has been over all stable despite refusing care from psychiatry and advised staff that psychiatry to remain available for changes in behavior or to call PET team for any crisis if Resident 1 refuses to be evaluated. During an interview on 3/26/2023 at 11:00 a.m., with the DON, the DON stated she was responsible for making the referral for Preadmission Screening and Resident Review ([PASRR] federal requirement to help ensure that individuals with a mental disorder or intellectual disability were not inappropriately placed in nursing homes for long term care). DON stated she was not aware that Resident 1 was verbalizing symptoms of depression and stated new onset or changes in behavior should be referred for a PASRR level II (necessitates an in-depth evaluation of the individual by the state-designated authority evaluation) to find out if Resident 1 should stay at the facility or could get the necessary services and treatment to address depression. During an interview on 3/25/2023 at 09:10 a.m., with Licensed Vocational Nurse (LVN) 2 stated she took care of Resident 1 and was not aware Resident 1 had history of depression or that he was verbalizing feeling sad. LVN 2 stated she did not receive any report that Resident 1 was depressed. LVN 2 stated that Resident 1 will sometimes get mad if he does not get his medication on time but did not display any signs of depression and just kept going around the facility. During an interview on 3/26/2023 at 09:38 a.m., with LVN 3, LVN 3 stated he took care of Resident 1 and was not aware Resident 1 had history of depression. LVN 3 stated they were not monitoring Resident 1 for depression and that Resident 1 was just quiet, liked to be by himself and seemed like he does not want to talk to anyone. LVN 3 stated no one told him that Resident 1 had depression. LVN 3 stated if he knew that Resident 3 was depressed, he would have seen the signs that Resident 1 was depressed like when he was refusing his medications consistently, being isolated, refusing to eat. LVN 3 stated he asked a CNA (unable to remember name) on 3/18/2023 at 09:00 a.m. and he was told Resident1 was just having a bad mood. LVN 3 stated if he knew he was depressed he could have investigated more and see if there was anything he could have done. During an interview on 3/26/2023 at 10:03 a.m., with LVN 4, LVN 4 stated he took care of Resident 1 more than 10 times but was not aware that Resident 1 had history of depression or that he was verbalizing being sad and depressed. LVN 4 stated they were monitoring him for refusal of medication but not for depression. LVN 4 stated that Resident 1 was always upset, liked to be by himself but did not think he was depressed. LVN 4 stated no one mentioned he had history of depression. During an interview on 3/23/2023 at 12:05 p.m., with Family 1, Family 1 stated that Resident 1 had some issues with depression and anxiety and on a lot of medications and thought that he managed it well. During an interview on 3/29/2023 at 09:24 a.m., with Resident 1 ' s Psychiatric Nurse Practitioner (NP) 1, NP1 stated she was not aware that Resident 1 was verbalizing he was depressed, and the nurses were telling her that Resident 1 had no concern and refusing psychiatric assessment. NP 1 stated she remembered Resident 1 being irritable, but no one mentioned about him verbalizing he was depressed. NP 1 stated if the nurses informed her that Resident 1 was verbalizing being depressed, she could have looked Resident 1 ' s concern and could have made recommendations even if Resident 1 was refusing to be seen like being transferred for further evaluation or maybe encouraged Resident 1 to take antidepressants since he was verbalizing being depressed. NP 1 stated she was not invited to participate in care plan meeting for Resident 1. During an interview on 3/30/2023 at 09:02 a.m. with Resident 1 ' s Psychiatrist (Psychiatrist 1), Psychiatrist 1 stated he never saw Resident 1 at the facility and NP 1 was the one who saw Resident 1 while at the facility. Psychiatrist 1 stated he was never informed that Resident 1 was verbalizing any symptoms of depression and staff should have been more assertive of notifying the Physicians including the Psychiatrist team of the changes in residents' behavior so they could provide proper intervention. During a review of the facility ' s policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, dated revised December 2016, the P&P indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure facility staff who provided care to residents, received ongoing training and evaluations of their skills to ensure to take care of vulnerable residents with behavioral and mental health problems for 98 of 98 Residents. 2. Resident 1 who verbalized feeling down, depressed, hopeless, feeling bad about self, was a failure, have let himself or family down for nearly every day for the past five months was not assessed, monitored, and provided intervention to help with Resident 1's depression (serious mood disorder). 3. SSA 1 failed to ensure to communicate with the interdisciplinary team (teams of healthcare providers that work to address multiple patient needs) and ensure Resident 1 received care and services to addressed Resident 1's symptoms of depression. 4. Certified Nurse Assistant (CNA) 1, CNA 2, Licensed Vocational Nurse (LVN) 7, Registered Nurse (RN) 1, and RN 2, failed to demonstrate competency on how to handle residents who have aggressive and violent behaviors. Resident 1 was not provided one to one supervision when Resident 1 was displaying aggressive behavior and threatened to hurt staff with a bread knife and was placed on 5150 hold (California Health and Safety Code section 5150 which allows for a medical facility or law enforcement agency to place a 72 involuntary hold on an individual who they believe is danger to himself or others as a result of a mental illness or condition.) These deficient practices resulted in a lack of interventions to addressed Resident 1's increasing symptoms of depression and Resident 1 did not receive the necessary care, services, and interventions to addressed Resident 1's emotional, behavioral, and psychosocial (the psychological dimension [internal, emotional, and thought processes, feelings, and reactions] and the social dimension [ includes relationships, family and community network, social values and cultural practices] of a person) needs. Findings: During a review of Resident 1's admission Record (face sheet), dated 3/21/2023, the face sheet indicated Resident 1 was admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses including delusional disorder (characterized by one or more firmly held false beliefs that persist for at least one month), cardiac arrhythmia (irregular heartbeat), presence of cardiac pacemaker (a small device that's placed in the chest to help control the heartbeat to prevent the?heart?from beating slowly), hypertension (high blood pressure). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/20/2023, MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was mildly impaired, and required supervision for activities of daily living. MDS indicated Resident 1 had no active diagnosis of depression. During a concurrent interview and record review of MDS section D (Mood) on 3/26/2023 at 10:00 a.m., with Social Service Assistant (SSA1), SSA 1 stated that she conducted Resident Mood Interview PHQ-9 (9 item Patient Health Questionnaire- a validated interview that screens for symptoms of depression. It provides a standardized severity score and a rating for evidence of a depressive disorder) with Resident 1. The SSA 1 stated she asked Resident 1 if over the last two weeks if he was bothered by any of the problems listed on the PHQ 9 questionnaire and documented Resident 1's response on MDS. The MDS PHQ-9 dated 10/25/2022, indicated Resident 1 was feeling down, depressed, or hopeless for 7-11 days nearly half or more of the days. The MDS indicated Resident 1 was feeling bad about self or that he was a failure or have let himself or family down for 12-14 days nearly every day, Resident 1 was moving or speaking so slowly that other people could have noticed or the opposite being so fidgety or restless that Resident 1 have been moving around a lot more than usual. The MDS PHQ-9 dated 1/23/2023 and 2/20/2023 indicated Resident 1 was feeling down, depressed, or hopeless for 12-14 days nearly every day. The MDS also indicated Resident 1 was feeling bad about self or that he was a failure or have let himself or family down for 12-14 days nearly every day. During a review of RAI Manual for Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17 dated October 2019, RAI indicated Responses to PHQ-9 can indicate possible depression. During a record review of Resident 1's Social Service (SS) Assessment -Type Quarterly, dated 10/31/2022 and 1/23/2023, SS assessment indicated Resident 1 spent most of his time alone or watching television, naps regularly throughout the day. SS assessment indicated over the last two weeks, Resident 1 had been bothered by feeling or appearing down, depressed, or hopeless, feeling bad about himself, feeling of failure, or letting self or family down, expressed adjustment issues, expresses difficulty coping with current health status and rejection of care occurred daily. Social Service Plan indicated the following: a. Establish/continue a positive, trusting relationship with resident and family. b. Communicate with resident, family, interdisciplinary team to assess for home care needs upon discharge and coordinate appropriate referrals c. participates in ongoing communication with the interdisciplinary team to identify and accommodate resident specific needs. d. address psychosocial needs (mood, behavior, communication, mental status), invite to resident-to-resident council meetings e. invite resident to care plan meetings. f. covert/open conflict with or repeated criticism of staff. During an interview on 3/26/203 at 10:15 a.m., with the SSA 1, the SSA 1 stated she was not sure if she mentioned Resident 1's increasing symptoms of depression to the nurses and said she might have mentioned the result of social service assessment to the Social Service Director (SSD) 1 but SSD 1 no longer work at the facility. The SSA 1 stated she did not document she notified the SSD 1 or any nurses and does not recall notifying the physician or psychiatrist to consult for Resident 1's symptoms of depression. The SSA 1 was unable to say or provide documentation how Resident 1's symptoms of depression were addressed. During an interview on 3/26/2023 at 10:45 a.m., with the Director of Nursing (DON), the DON stated SSD 1 last worked physically at the facility on 12/15/2022. The next SSD was SSD 2 who was hired on 1/19/2023 and last worked at the facility on 2/24/2023. The next SSD was SSD 3 who just started working on 3/20/2023. During a concurrent interview and record review on 3/26/2023 at 11:00 a.m., with SSA1, MDS Coordinator (MDSC 1), and the DON. Resident 1's clinical record from 2022 to 2023 were reviewed including care plan, IDT (Interdisciplinary team) notes, physician notes, nurses progress notes, Change of Condition ([COC] a clinical deviation from a resident's baseline), psychiatrist, and psychosocial notes. SSA1, MDSC 1, and the DON all verified and stated there were no documentation in Resident 1's electronic or paper clinical record that indicated Resident 1 depression was addressed and that physician, psychiatrist nor psychologist were notified. Social Service, MDSC 1 and the DON verified that the referral for psychiatrist and psychologist were for refusing the medications and was not a referral to addressed Resident 1's symptoms of depression. During a review of Resident 1's Psychiatrist Note (Psychiatrist Note), dated 11/22/2022, Psychiatrist Note indicated Resident 1 continued to refuse to be seen by psychiatry and per nursing no acute problematic or concerning behaviors not on psychotropic regimen. Resident 1 on Depakote for seizures. During a review of Resident 1's Psychiatrist Note, dated 1/11/2023, Psychiatrist Note indicated Resident 1 was refusing assessment and no concerning behavioral concerns per nursing. During a review of Resident 1's Psychiatrist Note, dated 2/8/2023, Psychiatrist Note indicated Resident 1 does not wish to be seen by psychiatry and per nursing no acute problematic behaviors or concerns and psychiatrist will remain available if Resident 1 willing to interview. Psychiatrist Note indicated staff aware of emergent option to call for Psychiatric Emergency Teams ([PET] mobile teams operated by psychiatric hospital to perform evaluations for involuntary detention of individuals determined to be at risk of harming themselves or others or who are unable to provide food, clothing, or shelter as a result of a mental disorder.) PET eval if needed. During a review of Resident 1's Psychiatrist Note, dated 3/8/2023, requested by staff to see Resident 1. Resident 1 refused psychiatric evaluation and no acute problematic behaviors present. Per staff Resident 1 has been over all stable despite refusing care from psychiatry. Advised staff psychiatry to remain available for changes in behavior or to call PET team for any crisis if Resident 1 refuses to be evaluated. During an interview on 3/26/2023 at 11:00 a.m., with the DON, the DON stated she was responsible for making the referral for PASRR ([Preadmission Screening and Resident Review federal requirement] to help ensure that individuals with a mental disorder or intellectual disability were not inappropriately placed in nursing homes for long term care). The DON stated she was not aware that Resident 1 had history or symptoms of depression and was not aware about the result of the PHQ9. The DON stated she should have followed up and ensure that PASSR Level II (necessitates an in-depth evaluation of the individual by the state-designated authority evaluation) was done. The DON stated new onset or changes in behavior that indicated newly evident or possible serious mental disorder, intellectual disability, or a related disorder should be referred for a PASRR level II to find out if Resident 1 should stay at the facility or could get the necessary services and treatment to address depression. During an interview on 3/25/2023 at 09:10 a.m., with (LVN) 2 stated she took care of Resident 1 and was not aware Resident 1 had history of depression or that he was verbalizing feeling sad. LVN 2 stated she did not receive any report that Resident 1 was depressed. LVN 2 stated that Resident 1 will sometimes get mad if he does not get his medication on time but did not display any signs of depression and just kept going around the facility. LVN 2 stated she did not receive any in-services regarding how to handle residents' behavioral concerns including how to handle residents demonstrating behavioral crisis and 5150 situations. During an interview on 3/26/2023 at 09:38 a.m., with LVN 3, LVN 3 stated he was not aware Resident 1 had history of depression. LVN 3 stated they were not monitoring Resident 1 for depression and that Resident 1 was just quiet, liked to be by himself and seemed like he does not want to talk to anyone. LVN 3 stated no one told him that Resident 1 had depression. LVN 3 stated if he knew that Resident 1 was depressed, he would have seen the signs that Resident 1 was depressed like when he was refusing his medications consistently, being isolated, refusing to eat. LVN 3 stated he asked a CNA (unable to remember name) on 3/18/2023 at 09:00 a.m. and he was told Resident 1 was just having a bad mood. LVN 3 stated if he knew he was depressed he could have investigated more and see if there was anything he could have done. LVN 3 stated she did not receive any in-services regarding how to handle residents' behavioral concerns including how to handle residents demonstrating behavioral crisis and 5150 situations. During an interview on 3/26/2023 at 10:03 a.m., with LVN 4, LVN 4 stated he took care of Resident 1 more than 10 times but was not aware that Resident 1 had history of depression or that he was verbalizing being sad and depressed. LVN 4 stated they were monitoring him for refusal of medication but not for depression. LVN 4 stated that Resident 1 was always upset, liked to be by himself but did not think he was depressed. LVN 4 stated no one mentioned he had history of depression. LVN 4 stated she did not receive any in-services regarding how to handle residents' behavioral concerns including how to handle residents demonstrating behavioral crisis and 5150 situations. During an interview on 3/26/2023 at 3:12 p.m., with (RN 1), RN 1 stated that Resident 1 became agitated on 3/18/2023 around 1:20 p.m., while trying to elope the facility. RN 1 stated Resident 1 spoke to PET team via videoconference due to aggressive behavior, striking out and kicking staff, eloping the facility and uncooperative to go back to the facility and PET team evaluated Resident 1 was required to be transferred to a designated 5150 (allows for a medical facility or law enforcement agency to place a 72 hour involuntary hold on an individual who they believe is danger to himself or others as a result of a mental illness or condition) facility. During a review of Psychiatric Evaluation Team (PET) Assessment Form, dated 3/18/2023, PET assessment indicated that on 3/18/2023 at 5:02 p.m., Resident 1 was seen and assessed via face to face video conference by a peace officer/ mental health professional. PET assessment form indicated there was a probable cause to believe that Resident 1, as a result of mental health disorder, a danger to others, or to himself, or gravely disabled because of history of delusional disorder, being angry, and easily agitated. PET assessment indicated Resident 1 should be transferred to a 5150 designated facility for up to 72 hours assessment, evaluation, and crisis intervention or placement for evaluation and treatment at a designated facility pursuant to section 5150. During a review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, communication form) dated 3/18/2023, SBAR indicated that on 3/18/2023 at 1:20 p.m., Resident 1 had episode of agitation, kicking, screaming, and striking out staff. Resident 1 left the facility and when staff attempted to stopped him, he became combative. SBAR indicated Resident 1 got agitated while RN 1 was talking to Resident 1 and Resident 1 suddenly took out a bread knife and flagged the bread knife in front of him and seemed that he was ready to strike whoever got close to him. RN 1 and staff (unspecified) was able to get the breadknife from Resident 1. During an interview on 3/26/2023 at 3:20 p.m., with RN 1, RN 1 verified that after Resident 1 was evaluated by the PET, Resident 1 suddenly took out a bread knife, was holding the knife in front of him, knife directed to the staff, and threatening the staff not to come close to him. RN 1 stated they panicked and was afraid that Resident 1 could hurt himself or others. RN 1 stated they (CNA 2, LVN 1and RN 1) were able to forcedly take the bread knife from Resident 1. RN 1 stated the PET, nor the law enforcer were not made aware Resident 1 threatened the staff with a bread knife because the incident happened after law enforcer came and after the PET spoke to Resident 1. RN1 stated she did not receive any in-services regarding how to handle residents with behavioral concerns including how to handle residents demonstrating behavioral crisis and 5150 situations. During a review of Resident 1's Physician Order, dated 3/18/2023, the physician order indicated an order to transfer Resident 1 to a designated 5150 General Acute Care Hospital (GACH) for 5150 Hold. During an interview on 3/26/2023 at 3:20 p.m., with RN 1, RN 1 stated they could not transfer Resident 1 to a designated 5150 GACH facility because she was informed by ambulance and had verified with GACH that admission closed at 5:30 p.m. RN 1 asked Resident 1 if he would like to go to another hospital and Resident 1 refused. Resident 1 was allowed to refuse to be transferred to another hospital for 5150 even when the PET deemed Resident 1 a threat to others and placed resident on a 5150. During an interview on 3/26/2023 at 3:20 p.m., with RN 1, RN 1 stated while waiting for a transfer to a 5150 designated facility, Resident 1 was placed in q 15 minutes monitoring and was not monitored closely. Resident 1 was left unattended and unsupervised in his room with 2 other residents (Resident 2 and 3) even after being suspected of being a danger to others and displayed aggressive, tangential (erratic) and violent behaviors just few hours ago. RN 1 admitted not inspecting the room for any deadly weapon or anything that Resident 1 can use to harm his self or others. RN 1 admitted she was advised by the DON to place Resident 1 on closed continuous monitoring (one to one monitoring), but RN 1 stated she thought she was following elopement procedure to monitor resident every 15 minutes and was focusing of ensuring Resident 1 will not leave the facility unsupervised. RN 1 stated she endorsed to RN 2 to do frequent monitoring to Resident 1 for 5150 bed hold. RN 1 clarified she did not tell RN 2 to do one to one continuous monitoring. During an interview on 3/27/2023 at 6:30 a.m., with RN 2, RN 2 stated RN 1 told her to do every 15 minutes rounding for 5150 hold for elopement. RN 2 stated she was aware that Resident 1 had aggressive behaviors towards the staff but was not aware that Resident 1 used bread knife to threatened staff. RN2 stated she knew what 5150 but was confused what 5150 hold means. RN 2 stated usually when 5150 was ordered the PET team will come right away to pick up the resident. RN 2 stated 5150 was involuntary and Resident 1 no longer had the right to refused to go to the hospital but since a transfer was already scheduled to take place on 3/19/2023 at 08:30 a.m. Further interview with RN 2, RN2 stated she got preoccupied trying to make the arrangement for transportation, do the staff assignment schedule then she was called to respond to an emergency because Resident 1 was found hanging on the closet. RN 2 stated they did monitor Resident 1 but not one to one. RN 2 stated they just made frequent rounds and ensure Resident 1 will not try to leave the facility unsupervised. RN 2 stated she was not aware Resident 2 had depression because he was just quiet and not really talking about harming himself. RN 2 stated Resident 1 was just in his bed sleeping most of the time. RN 2 stated at around 1 a.m., Resident 1's door was found by CNA 1 to be closed, door blocked by a wheelchair. Resident foot was observed dangling on the closet and Resident 1 was found hanging in the closet with a shoelace like rope/string. At 1:57 a.m. Resident was pronounced dead. RN 2 stated she did not receive any in-services regarding how to handle residents' behavioral concerns including how to handle residents demonstrating behavioral crisis and 5150 situations. During an interview on 3/29/2023 at 09:24 a.m., with Resident 1's Psychiatric Nurse Practitioner (NP) 1, NP 1 stated she was not aware Resident 1 was verbalizing he was depressed, and the nurses were telling her that Resident 1 had no concern and refusing psychiatric assessment. NP 1 stated she remembered Resident 1 being irritable, but no one mentioned about him verbalizing he was depressed. NP 1 stated they relied so much on the nurses' communication because the nurses were the one who see the residents every day. NP 1 stated it was important for the nurses to report to psychiatric team what the residents' daily behaviors were so the NP, physicians or psychiatrist can make the correct recommendations or prescriptions. NP 1 stated if the nursing staff informed her that Resident 1 was verbalizing being depressed, she could have looked Resident 1's concern and could have made recommendations even if Resident 1 was refusing to be seen like being transferred for further evaluation or maybe encouraged Resident 1 to take antidepressants since he was verbalizing being depressed. During an interview on 3/26/2023 at 1:00 p.m. with NP 2, NP 2 stated if resident was having emotional distress, verbalizing feeling of depression, having behavioral health crisis (a?disruption in an individual's mental or emotional stability or functioning resulting in an urgent need for immediate outpatient treatment in an emergency department or admission to a hospital to prevent a serious deterioration in the individual's mental or physical health, the nurses should send the resident to GACH immediately for further evaluation and not wait for psychiatrist because the psychiatrist only comes once a month. NP 2 stated if PET placed resident on 5150 the staff should send the resident in the hospital right away, resident have no right to refused. NP 2 stated while waiting to be transferred to the hospital the resident should have been monitored one to one because the resident could hurt someone or himself. NP 2 stated the hospitals were open 24 hours and the facility was not a psychiatric facility. NP 2 stated that Resident 1 was severely depressed for him to commit suicide. During an interview on 3/30/2023 at 09:02 a.m. with Resident 1's Psychiatrist (Psychiatrist 1), Psychiatrist 1 stated he was never informed that Resident 1 was verbalizing any symptoms of depression and that Resident 1 threatened the staff with a knife. Psychiatrist 1 stated the staff should have been more assertive of notifying the Physicians including the Psychiatrist of the changes in residents' behavior so they could provide proper intervention. Psychiatrist 1 stated the facility should ensure the facility has a policy in place and train the staff how to handle behavioral and mental health problems During an interview on 3/25/2023 at 3:00 p.m., with the DON. The DON admitted there was no in-services provided to the staff how to handle 5150, behavioral crisis and how to handle or take care of residents with behavioral concern. DON stated they do not have a DSD since December of 2022. During an interview on 3/26/2023 at 2:00 p.m., with LVN 1 (acting DSD), LVN 1 stated CNA 1, CNA 2, CNA 4 and unable to provide any in-services regarding how to handle residents with behavioral crisis, aggressive behaviors and how to handle 5150 situations. DSD admitted he also does not have competency checklist and was hired on December 2022 because there was no DSD at the time he started working. During an interview on 3/26/2023 at 3:00 p.m., with the DON. The DON admitted there was no in-services provided to the staff how to handle 5150 situations, behavioral crisis and how to handle or take care of residents with behavioral concerns. DON stated they do not have a DSD since December of 2022. DON unable to provided competency skills checklist for LVN 1, and RN 1. During a review of the facility's policy and procedure (P&P) titled, Behavioral Assessment, Intervention and Monitoring, dated revised March 2019, the P&P indicated: 1. the facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practical physical, mental, and psychosocial wellbeing in accordance with the comprehensive assessment and plan of care. 2. behavioral symptoms will be identified using facility approved behavioral screening tools and the comprehensive assessment. 3. Behavioral services will be provided by qualified staff who have the competencies and skills necessary to provide appropriate services to the residents. 4. residents will have minimal complications associated with the management of altered or impaired behavior. 5. As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations: a. the resident's usual patterns of cognition, mood and behavior. b. the resident's typical or past response to stress, fatigue, fear, anxiety, frustration, and other triggers; and the residents' previous patterns of coping with stress, anxiety and depression. 6. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior and cognition including:a. onset, duration, intensity, and frequency of behavioral symptoms.b. any recent precipitating or relevant factors or environmental triggers. c. appearance and alertness of the resident related observations. 7. New onset or changes in behavior that indicate newly evident or possible serious mental disorder, intellectual disability, or a related disorder will be referred for a PASARR level II (comprehensive evaluation required as a result of a positive Level I Screening. A Level II is necessary to confirm the indicated diagnosis noted in the Level I Screening and to determine whether placement or continued stay in a Nursing Facility is appropriate) evaluation. 8. The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition including: a. Physical or medical changes. b. emotional, psychiatric, and or/ psychological stressors (for example depression, boredom, loneliness, anxiety and or fear. During a review of the facility's P&P, titled, Competency of Nursing Staff, dated revised March 2019, the P&P indicated 1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. 2. Licensed nurses and nursing assistants employed by the facility will a. participate in a facility specific, competencies and skill sets deemed necessary to care for the needs of residents, as identified through residents' assessments and described in the plans of care. 3. The following factors are considered in the creation of the competency-based staff development and training program: a. An evaluation of the current program to ensure basic nursing competencies. b. Any gaps in education or training that may be contributing to poor outcomes. c. Specialized skills or training needed based on the resident population. d. A method to track, assess, plan implement and evaluate the effectiveness of training. e. A method to evaluate critical thinking skills and management of care in a complex environment with multiple interruptions. 4. The facility assessment includes an evaluation of the staff competencies that are necessary to provide the level and types of care specific to the resident population. 5. Training and competency evaluations include elements of critical thinking and process necessary to identify and report resident changes of condition. The type and amount of this training is based on the facility assessment and is specific to the different skill levels and licensure of staff. For example, CNAs are trained for and evaluated on competency in identifying and reporting resident changes of condition to the LPN or RN, while LPNS and RNs are trained for and evaluated on managing and reporting pertinent findings to the provider. 6. Facility and resident specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment. 7. Competency demonstrations will be evaluated based on the staff member's ability to use and integrate knowledge and skills obtained in training, which will be evaluated by staff already deemed competent in that skill or knowledge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and facility document review, the facility failed to conduct and document a facility-wide assessment to determine the resources necessary to care for its residents competently during both day-to-day operations and emergencies. This failure posed the risk of the facility not being able to evaluate its resident population and identify the resources needed to provide the necessary care and services the residents required. The facility failed to: 1.Have a policy and procedure in place to address and provide guidance on how to address residents who are having behavioral crisis including how to handle residents who are deemed a danger to self or others. 2. Ensure facility staff who provided care to residents, received ongoing training and evaluations of their skills to ensure to take care of vulnerable residents with behavioral and mental health problems. 3. Ensure Social service and nursing staff demonstrated competency to address behavioral, emotional and mental needs when a resident (Resident 1) verbalized feeling depressed and hopeless for almost five months and the CAA (Care Area Assessment-provide guidance to focus on key issues identified in comprehensive Minimum Data Set [MDS-a standardized assessment and care screening tool] which direct staff to evaluate triggered areas) indicated the need for evaluation and care plan to address Resident 1 ' s increasing behavioral changes and mood state. 4. Ensure Resident 1 who had history of delusional disorder, received adequate supervision when the Psychiatric Emergency Teams ([PET] mobile team operated by psychiatric hospital to perform evaluations for involuntary detention of individuals determined to be at risk of harming themselves or others or who are unable to provide food, clothing, or shelter as a result of a mental disorder.) deemed, he was a threat to others and placed the resident on a 5150 (allows for a medical facility or law enforcement agency to place a 72 hour involuntary hold on an individual who they believe is danger to himself or others as a result of a mental illness or condition.) These deficient practices had the potential for 98 of 98 residents who resided in the facility not receiving the necessary care and services to addressed behavioral, mental and emotional health needs. Resident 1 who did not receive the necessary care and services to addressed increasing changes in behavior and mood resulted in Resident 1 had aggressive behavior and threatened staff with a knife. Resident 1 was left unattended and unsupervised after being deemed a danger to others (5150) and had placed 98 residents' safety at risk for serious injury or harm and resulted in Resident ' s 1 death by suicide. Findings: During an interview on 3/26/2023 at 11:00 a.m., with Director of Nursing (DON), DON stated they do not have a policy that provided guidance to the staff what to do when resident who was having behaving behavioral crisis was deemed a danger to self or others. DON stated they should have policies to address situations like this to assist staff on what to do and will add that to their plan of correction. During a concurrent interview and record review of Resident 1 ' s MDS, on 3/26/2023 at 10:00 a.m., with Social Service Assistant (SSA1), SSA 1 stated that she conducted Resident Mood Interview PHQ9 (9 item Patient Health Questionnaire- a validated interview that screens for symptoms of depression. It provides a standardized severity score and a rating for evidence of a depressive disorder) with Resident 1. The SSA 1 stated she asked Resident 1 on 10/25/2022, 1/23/2023 and 2/20/2023 if over the last two weeks was Resident 1 was bothered by any of the following problems listed on the PHQ 9 questionnaire and Resident 1 reported verbalizing feeling down, depressed, or hopeless for 7-11 days nearly half or more of the days. The MDS indicated Resident 1 was feeling bad about self or that he was a failure or have let himself or family down for 12-14 days nearly every day. The MDS indicated Resident 1 was moving or speaking so slowly that other people could have noticed or the opposite being so fidgety or restless that Resident 1 have been moving around a lot more than usual. During a concurrent interview and record review on 3/26/2023 at 11:00 a.m., with SSA1, MDS Coordinator (MDSC 1), and DON. Resident 1 ' s clinical record was reviewed including care plan, IDT notes, physician notes, nurses progress notes, Change of Condition (COC), psychiatrist, and psychosocial notes from 2022 to 2023. SSA1, MDSC 1, and DON all verified and stated there were no documentation in Resident 1 ' s electronic or paper clinical record that indicated Resident 1 depression was addressed and that physician, psychiatrist nor psychologist were notified. Social Service, MDSC 1 and DON verified that the referral for psychiatrist and psychologist were for refusing the medications and was not a referral to addressed Resident 1 ' s symptoms of depression. During a review of Resident 1 ' s Situation, Background, Assessment, and Recommendation (SBAR, communication form) dated 3/18/2023, SBAR indicated that on 3/18/2023 at 1:20 p.m., Resident 1 had episode of agitation, kicking, screaming, and striking out staff. Resident 1 left the facility and when staff attempted to stopped him, he became combative. SBAR indicated Resident 1 got agitated while RN 1 was talking to Resident 1 and Resident 1 suddenly took out a bread knife and flagged the bread knife in front of him and seemed that he was ready to strike whoever got close to him. RN 1 and staff (unspecified) was able to get the breadknife from Resident 1. During an interview on 3/26/2023 at 3:20 p.m., with RN 1, RN 1 verified that after Resident 1 was evaluated by the PET, Resident 1 suddenly took out a bread knife, was holding the knife in front of him, knife directed to the staff, and threatening the staff not to come close to him. RN 1 stated they panicked and was afraid that Resident 1 could hurt himself or others. RN 1 stated they (CNA, DSD and RN 1) were able to forcedly take the bread knife from Resident 1. RN 1 stated the PET nor the law enforcer were not made aware Resident 1 threatened the staff with a bread knife because the incident happened after law enforcer came and after the PET spoke to Resident 1. During an interview on 3/26/2023 at 3:20 p.m., with RN 1, RN 1 stated while waiting for a transfer to a 5150 designated facility, Resident 1 was placed in q 15 minutes monitoring and was not monitored closely. Resident 1 was left unattended and unsupervised in his room with 2 other residents (Resident 2 and 3) even after being suspected of being a danger to others and displayed aggressive, tangential (erratic) and violent behaviors just few hours ago. RN 1 admitted not inspecting the room for any deadly weapon or anything that Resident 1 can use to harm his self or others. RN1 admitted she was advised by DON to place Resident 1 on closed continuous monitoring (one to one monitoring), but RN 1 stated she thought she was following elopement procedure to monitor resident every 15 minutes and was focusing of ensuring Resident 1 will not leave the facility unsupervised. RN 1 stated she endorsed to RN 2 to do frequent monitoring to Resident 1 for 5150 bed hold. RN 1 clarified she did not tell RN 2 to do one to one continuous monitoring. During an interview on 3/27/2023 at 6:30 a.m., with RN 2, RN 2 stated RN 1 told her to do every 15 minutes rounding for 5150 hold for elopement. RN 2 stated she was aware that Resident 1 had aggressive behaviors towards the staff but was not aware that Resident 1 used bread knife to threatened staff. RN2 stated she knew what 5150 but was confused what 5150 hold means. RN 2 stated usually when 5150 was ordered the PET team will come right away to pick up the resident. RN 2 stated 5150 was involuntary and Resident 1 no longer had the right to refused to go to the hospital but since a transfer was already scheduled to take place on 3/19/2023 at 08:30 a.m., Further interview with RN 2, RN2 stated she got preoccupied trying to make the arrangement for transportation, do the staff assignment schedule then she was called to respond to an emergency because Resident 1 was found hanging on the closet. RN 2 stated they did monitor Resident 1 but not one to one. RN 2 stated they just made frequent rounds and ensure Resident 1 will not try to leave the facility unsupervised. RN 2 stated she was not aware Resident 2 had depression because he was just quiet and not really talking about harming himself. RN 2 stated Resident 1 was just in his bed sleeping most of the time. RN 2 stated at around 1 a.m., Resident1 ' s door was found by CNA 1 to be closed, door blocked by a wheelchair. Resident foot was observed dangling on the closet and Resident 1 was found hanging in the closet with a shoelace like rope/string. At 1:57 a.m. Resident was pronounced dead. During an interview on 3/30/2023 at 09:02 a.m. with Resident 1 ' s Psychiatrist (Psychiatrist 1), Psychiatrist 1 stated he never saw Resident 1 at the facility and Psychiatrist Nurse Practitioner 1 was the one who saw Resident 1 while at the facility. Psychiatrist 1 stated he was never informed that Resident 1 was verbalizing any symptoms of depression and that Resident 1 threatened the staff with a knife. Psychiatrist 1 stated the staff should have been more assertive of notifying the Physicians including the Psychiatrist of the changes in residents' behavior so they could provide proper intervention. During an interview on 3/29/2023 at 09:24 a.m., with Nurse Practitioner (NP) 1, NP1 stated she was the one following up with Resident 1 ' s mental and behavioral concern. NP 1 stated she was not aware that Resident 1 was verbalizing he was depressed, and the nurses were telling her that Resident 1 had no concern and refusing psychiatric assessment. NP 1 stated she remembered Resident 1 being irritable, but no one mentioned about him verbalizing he was depressed. NP 1 stated they relied so much on the nurses ' communication because the nurses were the one who see the residents every day. NP 1 stated it was important for the nurses to report to the psychiatrist what the residents ' daily behaviors were so the NP, physicians or psychiatrist can make the correct recommendations or prescriptions. NP1 stated she was not informed that Resident 1 threatened the staff with a knife and was not transferred to designated facility right away. NP 1 stated if she was informed Resident 1 was not transferred right away, she would have tried to find a way of transferring the resident out like calling 911, law enforcer or provide proper guidance with the staff because there were 24 hours emergency place to send resident who are deemed danger to others and that Resident 1should have not been left alone by himself. During a concurrent interview and review of Facility assessment dated [DATE] on 3/26/2023 at 4:00 p.m., with the Administrator (ADM), DON and Consultant 1, the DON stated the facility provided care for residents with psychiatric and behavioral needs. Facility assessment indicated facility have four residents with anxiety disorder, 10 with major depressive disorder, 13 with recurrent major depressive disorder, and twelve with unspecified psychosis not due to a substance abuse or known physiological condition. DON and administrator admitted they should determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies but did not identify there was no policy and procedure in placed to provide guidance how to address residents who were having behavioral crisis, how to handle resident who was deemed a danger to self or others. Staff who provided care to residents did not receive ongoing training, evaluations of their skills, to ensure competency to take care of residents with behavioral and mental health problems. During a review of Facility assessment dated [DATE], the facility Assessment indicated the Director of Nursing Services/ and or designee collaborates with facility ' s medical director for guidance and recommendation when admitting clinically complex residents to the facility in addition, the DNS and/ or designee takes it to consideration the skill set of the license nurse if they are able to handle clinically complex resident, if the license staff were not trained to handle this cases, the DON an/ or designee will involve the Regional QM nurse to provide training and education to license nurse or reach out to the QAA physicians/ other practitioners or other clinical specialist to provide the in-service training before admitting the resident to the nursing facility, if the Director of Nursing Services and or designee determines it is not safe to admit the resident in the nursing facility, the DNS will decide not to admit or denied admission to the facility. The facility assessment indicated Staff training/education and competencies are following strictly the guidelines and facility ' s protocol in providing training and education to newly hired facility staff (it starts from the orientation process), current facility staff, registry/ contracted staff, monitoring the training progress and ongoing validation of the training. Required skills and training topics include communication, behavioral health training, person centered care include but not limited to person centered care planning, education of resident and family.

Based on interview, and record review the facility's Quality Assurance Performance Improvement ([QAPI] takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve safety and quality in nursing homes) committee failed to identify resident care issues, develop and implement appropriate plans of action to ensure to systematically implemented and evaluated measures necessary to provide behavioral health care and services for the treatment of the resident ' s emotional and mental condition by ensuring: 1. Facility had a policy and procedure in placed how to handle residents who have behavioral crisis (a disruption in an individual ' s mental or emotional stability or functioning resulting in an urgent need for immediate outpatient treatment in an emergency department or admission to a hospital to prevent a serious deterioration in the individual ' s mental or physical health). 2. Facility staff, who provided care to residents, received ongoing training and evaluations of their skills to take care of residents with behavioral and mental health problems. 3. Social service and nursing staff consult with the residents' physician, psychiatrist and IDT ([Interdisciplinary Team]-comprises professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological needs), and develop a plan of care when Resident 1 was verbalizing feeling depressed, hopeless for almost five months and the CAA (Care Area Assessment-provide guidance to focus on key issues identified in comprehensive Minimum Data Set [MDS-a standardized assessment and care screening tool] which direct staff to evaluate triggered areas) indicated the need for evaluation and care plan to address Resident 1 ' s increasing behavioral changes and mood state. 4. Ensure Resident 1 who had history of delusional disorder (characterized by one or more firmly held false beliefs that persist for at least one month), received one to one monitoring (1:1 monitoring-when an individual staff member is assigned to directly supervise no more than one resident and the staff shall stay within very close proximity to ensure constant supervision and immediate intervention if needed for safety reasons.) supervision when the Psychiatric Emergency Teams ([PET] mobile team operated by psychiatric hospital to perform evaluations for involuntary detention of individuals determined to be at risk of harming themselves or others or who are unable to provide food, clothing, or shelter as a result of a mental disorder) deemed, he was a threat to others and placed the resident on a 5150 (allows for a medical facility or law enforcement agency to place a 72 hour involuntary hold on an individual who they believe is danger to himself or others as a result of a mental illness or condition.) These deficient practices resulted in Resident 1 not receiving the necessary care and services to addressed Resident 1 ' s mental and emotional health needs and resulted in Resident 1 had aggressive behavior and threatened staff with a knife. Resident 1 was left unattended and unsupervised after being deemed a danger to others (5150) and had placed other residents' safety at risk for serious injury or harm and resulted in Resident ' s 1 death by suicide. Findings: During an interview on 3/26/2023 at 11:00 a.m., with Director of Nursing (DON), DON stated they do not have a policy and procedure to provide guidance when resident was having behavioral crisis or was deemed a danger to self or others. DON stated they should have policies to address situations like 5150 to assist staff on what to do. During a concurrent interview and record review of Resident 1 ' s MDS, on 3/26/2023 at 10:00 a.m., with Social Service Assistant (SSA1), The SSA 1 stated she asked Resident 1 on 10/25/2022, 1/23/2023 and 2/20/2023 if over the last two weeks was Resident 1 bothered by any of the listed problems on the PHQ 9 (9 item Patient Health Questionnaire- a validated interview that screens for symptoms of depression [serious mood disorder]) questionnaire and Resident 1 reported verbalizing feeling down, depressed, or hopeless, was feeling bad about self or that he was a failure or have let himself or family down for 12-14 days nearly every day. The MDS indicated Resident 1 was moving or speaking so slowly that other people could have noticed or the opposite being so fidgety or restless that Resident 1 have been moving around a lot more than usual. During a review of CAA (Care Area Assessment-provide guidance to focus on key issues identified in comprehensive MDS. Direct staff to evaluate triggered areas) worksheet dated 11/8/2022, CAA indicated behavioral symptoms was triggered potential problem due to Resident 1 rejected evaluation of care daily, changed in behavior, care rejection or wandering has gotten worse since prior assessment. Resident 1 rejected care that was necessary to achieve his goals for health and well-being. Resident 1 had episodes of refusing nursing care including medications. CAA indicated to proceed to care planning to focus on resident ' s safety, nutritional status, behavior approach, health activity pattern, and was not a danger to self and others. During a concurrent interview and record review on 3/26/2023 at 11:00 a.m., with SSA1, MDS Coordinator (MDSC 1), and DON. Resident 1 ' s clinical record from 2022 to 2023 was reviewed including care plan, IDT notes, physician notes, nurses progress notes, change of condition ([COC] a clinical deviation from a resident's baseline), psychiatrist, and psychosocial notes. SSA1, MDSC 1, and DON all verified and stated there were no documentation in Resident 1 ' s clinical record that indicated Resident 1 ' s depression was addressed, and that physician, psychiatrist nor psychologist were notified. Social Service, MDSC 1 and DON verified that the referral for psychiatrist and psychologist were for refusing the medications and was not a referral to addressed Resident 1 ' s symptoms of depression. During a review of Resident 1 ' s Situation, Background, Assessment, and Recommendation (SBAR, communication form) dated 3/18/2023, SBAR indicated that on 3/18/2023 at 1:20 p.m., Resident 1 had episode of agitation, kicking, screaming, and striking out staff. Resident 1 left the facility and when staff attempted to stopped him, he became combative. SBAR indicated Resident 1 got agitated while RN 1 was talking to Resident 1 and Resident 1 suddenly took out a bread knife and flagged the bread knife in front of him and seemed that he was ready to strike whoever got close to him. RN 1 and staff (unspecified) was able to get the breadknife from Resident 1. During an interview on 3/26/2023 at 3:20 p.m., with RN 1, RN 1 verified that after Resident 1 was evaluated by the PET, Resident 1 suddenly took out a bread knife, was holding the knife in front of him, knife directed to the staff, and threatening the staff not to come close to him. RN 1 stated they panicked and was afraid that Resident 1 could hurt himself or others. RN 1 stated they (CNA, DSD and RN 1) were able to forcedly take the bread knife from Resident 1. RN 1 stated the PET nor the law enforcer were not made aware Resident 1 threatened the staff with a bread knife because the incident happened after law enforcer came and after the PET spoke to Resident 1. During an interview on 3/26/2023 at 3:20 p.m., with RN 1, RN 1 stated while waiting for a transfer to a 5150 designated facility, Resident 1 was placed in q 15 minutes monitoring and was left unattended and unsupervised in his room with 2 other residents (Resident 2 and 3). RN 1 admitted not inspecting the room for any deadly weapon or anything that Resident 1 can use to harm his self or others. RN 1 admitted she was advised by DON to place Resident 1 on one to one continuous monitoring, but RN 1 stated she thought she was following elopement procedure to monitor resident every 15 minutes and focused of ensuring Resident 1 will not leave the facility unsupervised. RN 1 stated she endorsed to RN 2 to do frequent monitoring to Resident 1 for 5150 hold. RN 1 clarified she did not tell RN 2 to do one to one continuous monitoring. During an interview on 3/27/2023 at 6:30 a.m., with RN 2, RN 2 stated RN 1 told her to do every 15 minutes monitoring for 5150 hold for elopement. RN 2 stated she was aware that Resident 1 had aggressive behaviors towards the staff but was not aware that Resident 1 used bread knife to threatened staff. RN2 stated she knew what 5150 means and usually when 5150 was ordered the PET team will come right away to pick up the resident. RN 2 stated 5150 was involuntary and Resident 1 no longer had the right to refused to go to the hospital but since a transfer was already scheduled to take place on 3/19/2023 at 08:30 a.m., RN2 did not question why Resident 1 was not transferred right away. RN 2 stated on 3/19/2023 at approximately 1 a.m., Resident1 ' s door was found by CNA 1 to be closed, blocked by a wheelchair. Resident 1 was found hanging in the closet with a shoelace like rope/string wrapped on his neck and was pronounced dead on 3/19/2023 at 1:57 a.m. During an interview on 3/30/2023 at 09:02 a.m. with Resident 1 ' s Psychiatrist (Psychiatrist 1), Psychiatrist 1 stated he never saw Resident 1 at the facility and Psychiatrist Nurse Practitioner 1 was the one who saw Resident 1 while at the facility. Psychiatrist 1 stated he was never informed that Resident 1 was verbalizing any symptoms of depression and that Resident 1 threatened the staff with a knife. Psychiatrist 1 stated the staff should have been more assertive of notifying the Physicians including the Psychiatrist of the changes in residents' behavior so they could provide proper intervention. During an interview on 3/29/2023 at 09:24 a.m., with Resident 1 ' s Psychiatric Nurse Practitioner (NP) 1, NP1 stated she remembered Resident 1 being irritable but was not aware Resident 1 verbalizing he was depressed, and the nurses were telling her that Resident 1 had no concern and refusing psychiatric assessment. NP 1 stated they relied so much on the nurses ' communication because the nurses were the one who see the residents every day. NP 1 stated it was important for the nurses to report to the psychiatrist what the residents ' daily behaviors were so the NP, physicians or psychiatrist can make the correct recommendations or prescriptions. NP1 stated she was not informed that Resident 1 threatened the staff with a knife and was not transferred to designated facility right away. NP 1 stated if she was informed Resident 1 was not transferred right away, she would have tried to find a way of transferring the resident out like calling 911, law enforcer or provide proper guidance with the staff because there were 24 hours emergency place to send resident who are deemed danger to others and that Resident 1 should have not been left alone by himself. During a concurrent interview and review of the 2022 and 2023 QAPI minutes on 3/26/2023 at 4:00 p.m. with the Administrator (ADM), and DON, the ADM and DON stated the QAPI minutes indicated the QAPI committee did not identify there was no policy and procedure in placed to provide guidance how to address residents who were having behavioral crisis, staff who provided care to residents did not receive ongoing training, evaluations of their skills, and lack the competency to ensure to take care of residents with behavioral and mental health problems. The QAPI committee did not identify the staff were not aware when to consult with the residents' physician, psychiatrist, IDT and when to create and develop a care plan for resident who have behavioral concerns. The facility did not identify there was a lack of knowledge with the type of supervision and monitoring required for resident having behavioral crisis. During a review of the facility ' s policy and procedure (P&P) titled, Quality Assurance and performance Improvement (QAPI) program, dated 4/2013, the P&P indicated: 1. The facility shall develop, implement, and maintain an ongoing, facility -wide Quality Assurance and performance Improvement program that builds on the quality assessment and assurance program to actively pursue quality care and quality of life. 2. QAPI committee will gather and use QAPI data in an organized and meaningful way. Areas that may be appropriate to monitor and evaluate include clinical outcomes, complaints from residents and families; re-hospitalization, staff turnover and assignments, staff satisfaction, care plans, state survey deficiencies, MDS assessment and data. 3. Recognizing patterns in systems of care that can be associated with quality problems. 4. The facility will take systematic action targeted at the root causes of identified problems. This encompasses the utilization of corrective actions that provide significant and meaningful steps to improve processes and do not depend on staff to simply do the right thing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to re-admit one of three sampled residents (Resident 1) to the facility following a hospitalization. This deficient practice resulted in Resident 1 being unnecessarily sent to another facility (a totally new environment) which had the potential to cause psychosocial harm. Findings: During a review of Resident 1 ' s admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included unspecific psychosis (a mental condition that causes one to lose touch with reality), difficulty in walking, dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) and dysphagia (difficulty swallowing). During a review of Resident 1 ' s History and Physical (H&P) dated 2/2/2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 2/4/2023, the MDS indicated Resident 1's cognition (ability to think and reason) was severely impaired. The MDS indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from one staff with bed mobility, transfer, getting dressed, toilet use, personal hygiene, and supervision from one staff for eating. During a review of Resident 1 ' s Physician Order (PO) dated 2/4/2023 at 12:20 a.m., the PO indicated Resident 1 was to be transferred to General Acute Care Hospital (GACH) for possible Gastrostomy Tube ([G-tube] a plastic tube inserted into the abdominal wall to provide nutrition, hydration, and medication) and psychiatric evaluation. During a review of Resident 1 ' s Progress Notes (PN) dated 2/24/2023 at 1:35 a.m., the PN indicated Resident 1 was discharged to GACH. During an interview on 2/14/2023, at 11:15 a.m., with Admissions Director (AD), AD stated the Director of Nursing (DON) and the Administrator (ADM) decided who would be re-admitted to the facility. AD stated that she notified the GACH case manager (CM), on 2/9/2023 that they could not take back Resident 1 because he needed 1:1 supervision (a staff exclusively assigned to resident to ensure resident ' s safety). AD stated she did not communicate with or attempt to contact the CM since 2/9/2023. AD stated in the past the facility has accommodated residents who needed 1:1 supervision due to psychosis. During a review of AD ' s Notes, dated 2/9/2023 to 2/14/2023, AD ' s note on 2/9/2023, at 11: 19 a.m., indicated, Received message to call CM. Called and informed we could not accommodate the resident. AD ' s note on 2/14/2023, at 11:21 a.m., indicated, Received updated clinicals on 2/13/2023, (was not in on 2/13/2023) and spoke CM this morning and told her will have it reviewed. AD notes indicated there was no communication with the GACH ' s case manager between 2/9/2023 and 2/14/2023 (during which time Resident 1 was waiting to be transferred from GACH to the facility). During an interview on 2/14/2023, at 11:23 a.m., with Resident 1 ' s wife who is also his Power of Attorney ([POA] officially appointed authority to make legal and financial decisions on behalf of Resident 1), POA stated, the facility called and notified her their refusal to re-admit Resident 1 to the facility on 2/9/2023. POA stated, the facility had knowledge of Resident 1 ' s mental illness prior to ever admitting him, and she did not understand why the facility could not accommodate Resident 1 all of a sudden. POA stated, the facility staff had not contacted her since 2/9/2023. POA stated, Resident 1 and family members were very upset and felt unwanted and unwelcomed from the facility. During an interview on 2/14/23, at 3:25 p.m., with Social Service Director (SSD), SSD stated, the facility should have re-admitted Resident 1 and then attempted to find out the cause of the underlying behavioral issues instead of refusal to re-admit. SSD stated, there was no obvious reason not to re-admit Resident 1 since the Census (resident count) indicated there were available beds and Resident 1 was still on day five of seven bed hold (a reservation that allows one to stay in, or return to, a care facility for seven days) on 2/9/2023. During an interview with DON and ADM on 2/15/2023, at 8:50 a.m., DON and ADM confirmed that Resident 1 ' s behavior issues were known prior to admission. During a concurrent interview and record review on 2/15/2023, at 9:15 a.m., with DON and ADM, the Facility Assessment (FA), ([FA] an annual review and analysis of the facilities ' resident population; staffing required to care for the resident population, and other needs such as equipment) dated 8/29/22 was reviewed. The FA indicated, Some of the most common diagnoses (Top 25) that the facility typically deals with include the following: Difficulty walking (2) . Anxiety disorder (4), Major Depressive Disorder (10), Major Depressive disorder, recurrent, unspecified (13), unspecified psychosis not due to substance abuse or known physiological condition (12), and Dysphagia oropharyngeal (relating to back of the mouth, and part of the throat) phase (8). The FA indicated, Types of care/services we (or contracted services) provide to the residents: Behavior management, Psychotropic (medications that affect the brain) management, Interdisciplinary team ([IDT] each residents ' care team while at the facility) meeting to identify if the use of psychotropic medications is warranted and medically justifiable, Gradual dose reduction, Behavior modification, collaboration with psychiatrist and psychologist, Medication review by pharmacy consultant, Dementia care, psychiatric illness, intellectual or developmental disabilities, the IDT will develop and implement interventions in managing resident ' s behavior and to help support individuals with issues dealing with anxiety, cognitive impairment, diagnosis of depression and other psychiatric diagnoses. DON and ADM stated the facility had the capacity to provide the needed care for Resident 1 according to FA. During a review of the Facility Census (FC), dated 2/9/2023, the FC indicated there were two unassigned beds available, and one admission. The FC indicated, Resident 1 was still on day five of the seven-day bed hold, so his bed was still available for him to come back to. During an interview on 2/15/2023, at 12:20 p.m., with ADM, ADM stated, Resident 1 was admitted to a different facility on 2/14/2023. ADM stated there was no justifiable reason not to re-admit Resident 1 on 2/9/2023. ADM stated the refusal of re-admit could make Resident 1 and family upset. During a review of the facility ' s Policy and Procedure (P&P) titled Bed-Holds and Returns, Revised 3/2017, the P&P indicated, the resident would be permitted to return to an available bed in the location of the facility that he or she previously resided. If there is not an available bed in that part, the resident will be given the option to take an available bed in another distinct part of the facility and return to the previous distinct part when a bed becomes available. A review of the facility's P&P titled, Resident Rights, revised 10/2010, the P&P indicated employees were to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assure effective pain management for one of three sampled residents (R1). This deficient practice had the potential for residents to not receive effective treatment for their pain management. Findings: During a review of resident 1's face sheet, the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and re admitted on [DATE]. Resident 1's diagnoses included chronic pain syndrome (pain remains long after an illness or injury has healed), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), periprosthetic fracture (fractures that occur in association with an orthopedic implant). During a review of residents 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 1/4/2023, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required limited assistance for bed mobility, transfer, walking, eating, personal hygiene and toileting. During a review of resident 1's Physician Orders dated 12/31/2022, the Physician Orders indicated Buprenorphine (opioid used to treat opioid use disorder, acute pain, and chronic pain) 8 milligrams ([mg] unit of measurement), sublingual (SL) tablet by mouth (PO) two times daily (BID) for chronic pain syndrome/opioid hold if sleepy drowsy or respiratory rate less than 12. During a review of resident 1's Physician Orders dated 1/3/2023, the Physician Orders indicated Buprenorphine 8 mg, SL tablet PO, BID for chronic pain syndrome/opioid hold if sleepy drowsy or respiratory rate less than 12. During a review of resident 1's Physician Orders dated 1/24/2023, the Physician Orders indicated, recommended three times a day (TID) Buprenorphine sublingual. During a review of resident 1's Medication Administration Record (MAR), the MAR indicated: 1. On 1/24/2023 at 9:00 a.m. and 5:00 p.m., Resident 1 received Buprenorphine 8 mg SL PO 2. On 1/25/2023 at 9:00 a.m. and 5:00 p.m., Resident 1 received Buprenorphine 8 mg SL PO 3. On 1/26/2023 at 9:00 a.m. and 5:00 p.m., Resident 1 received Buprenorphine 8 mg SL PO 4. On 1/27/2023 at 9:00 a.m., Resident 1 received Buprenorphine 8 mg SL PO During a review of resident 1's Departmental Notes undated, there was no documentation on 1/24/2023 indicating licensed nurse follow Physician order recommendations in changing pain medications frequency to three times a day. During a concurrent observation and interview, on 1/27/2023 at 1:20 p.m., Resident 1 was observed sitting in her wheelchair, wearing clothes, well groomed, with a left leg immobilizer on placed. Resident 1 stated he fell after Christmas and was transferred to the hospital which required surgery. Resident 1 stated he was still in pain ever since his medication was changed. During a concurrent interview and record review on 1/27/2023 at 4:31 p.m., with Registered Nurse Supervisor (RN) Resident 1's MAR, dated December 2022 was reviewed. The MAR indicated, Buprenorphine 8mg SL TID for chronic pain. MAR dated January 2023 was reviewed. The MAR indicated, Buprenorphine 8mg SL BID for chronic pain. RN stated, on 1/24/2023 at 10:48 p.m., Physician recommended that Resident 1 received pain medications TID. RN stated, Licensed Vocational Nurse (LVN) 2 did not follow up Physicians orders recommendations. LVN 2 must called the pain control physician with recommendations and documented the changes. RN stated, it is not acceptable for Resident 1 to be in pain. RN stated our priority is to manage resident pain. RN stated, Resident 1 just had a left hip surgery, and we need to believed Resident 1 is in pain. Resident 1 can be in a risk of blood pressure increase, suffering and discomfort due to not controlling her pain. During an interview on 1/27/2023 at 5:00 p.m., with Director of nursing (DON) stated, failed to managed residents 1 pain can put resident at risk of decrease activity of daily living, blood pressure and heart rate increase. DON stated the licensed nurses are responsible in follow up with doctors ' orders. DON stated, Resident 1 has a pain control doctor, the doctor comes and see resident every month. DON stated, the LVN 2 had informed me of doctor ' s recommendations, but I am unawarded if the doctor had changed the frequency of medications. DON stated, any changed in residents care, should be documented in a nurse notes or physician progress notes. DON stated, it is important to documented, so it will be a prove of the order carried out. During an interview on 1/27/2023 at 5:20 p.m., with LVN 2. LVN 2 stated, if resident had changed of condition in pain we need to follow up with the doctor. The risk of resident having pain, it can affect the vital signs. The pain is assessed two times a shift. LVN 2 stated, I informed the pain control doctor via text. LVN 2 stated, I informed the DON, and I am not sure if I documented or not, LVN 2 stated I cannot remember. It is very important to document any communications with doctor regarding resident, otherwise if will appeared as, the order was never carried out. During a review of the facility ' s policy and procedure (P/P) titled, Administering Pain Medications and dated 3/2020, the P/P indicated the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan and the residents ' choice related to pain management. During a review of the facility's P/P titled, Charting and Documentation dated 7/2017, the P/P indicated the following information is to be documented in the resident ' s medical record: treatments or services performed; progress toward or changed in the care plan goals and objectives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. During a review of Resident 1's Minimum Data Set (MDS) a standardized assessment and care screening tool, dated 10/27/2022, the MDS indicated Resident had the ability to understand and be understood by others. During a review of Resident 1's Situation Background Assessment Recommendation Communication Form – General ([SBAR] a form of communication between members of a health care team) dated 12/3/2022 and timed at 8:11 a.m., the SBAR indicated Resident 1 was helping Resident 3 retrieve her (Resident 3's) blanket from Resident 2. Per Resident 1, the blue blanket belonged to Resident 3, however, Resident 2 insisted it was hers. The SBAR indicated, Resident 2 screamed, yelled, and scratched Resident 1 on her left arm when Resident 1 pulled the blanket from Resident 2. The SBAR indicated Resident 1 received a superficial scratch/abrasion on her left arm. During an interview and concurrent record review on 12/7/2022 at 11:02 a.m., with the Administrator (ADM), a Report of Suspected Dependent Adult/Elder Abuse (SOC 341) was reviewed. The SOC 341 indicated on 12/3/2022, there was an allegation of resident-to-resident abuse between Resident 1 and Resident 2. Resident 2 scratched Resident 1's left arm while Resident 1 was trying to pull the blanket from Resident 3. The ADM stated, Licensed Vocational Nurse 1 (LVN 1) completed the SOC 341 on 12/3/2022 and it was faxed to the Department of Public Health (DPH) by Registered Nurse 1 (RN 1) on the same day at 5:29 p.m. The ADM stated the abuse allegation occurred on 12/3/2022 at approximately 7:15 a.m. and should have been reported to the DPH within two hours, per their policy. The ADMIN stated the SOC 341 was not faxed within the two-hour time frame because the allegation was still being investigated by staff. During a review of Resident 1's Interdisciplinary Team Meeting (IDT) Progress Note dated 12/4/2022, the IDT indicated, Resident 1 sustained two separate scratches to her left arm from Resident 2, one to her upper back area measuring 3 cubic centimeters ([cm] a unit of measurement) x 0.2 cm and the second to her lower arm measuring 17 cm x 0.5 cm. The IDT Progress Notes indicated Resident 1's scratches did not have any bleeding. During a review of the facility's undated policy and procedure (P/P) titled, Abuse Allegation and Reporting, the P/P indicated the administrator or designated representative will notify the California Department of Public Health (CDPH) by telephone and in writing (SOC 341) within two hours of initial report.

Based on observation, interview and record review the facility failed to ensure frozen ground beef was thawed properly for 96 of 103 residents. This deficient practice had the potential to place residents at risk for foodborne illnesses (Illness caused by ingestion of contaminated food). Findings: During an observation on 11/21/22, at 10:40 a.m. a frozen pack of ground beef was sitting inside a small container which was ¼ full of water in the sink. There was cold water from the faucet trickling into the frozen ground beef. During an interview on 11/21/22, at 11:05 a.m. with [NAME] 1(CK1), CK 1 stated she brought out the frozen ground beef two days ago and put in into the refrigerator and removed the ground beef from the refrigerator into the sink with running water an hour ago. During an interview on 11/21/22, at 11:10 a.m. with Dietary Supervisor (DS), DS stated frozen meat is pulled out from the freezer to refrigerator two to three days prior to the meal and placed in the refrigerator to defrost. DS stated if the frozen meat does not completely thaw, the meat is placed under cold running water until it has thawed. During an interview on 11/21/22, at 2:30 p.m. with [NAME] 2 (CK2), CK2 stated frozen ground beef that was not completely defrosted in the refrigerator should be placed in a deep dish pan with continuous cold water running into the frozen ground beef. CK2 stated putting the frozen ground beef in a small bucket and no cold running water was not the proper way to thaw frozen ground beef. CK 2 stated frozen ground beef should be thawed properly to prevent bad bacteria from growing which could lead to food poisoning among residents. During an interview on 11/21/22, at 1:02 pm with DS, DS stated it was important to thaw frozen ground beef and meat properly to avoid food poisoning. She stated to put the frozen meat in the sink on a shallow pan so the water will continue to run. The temperature of the water must be 70 degrees F or lower to thaw the meat properly. During a record review of the facility ' s undated, policy and procedure (P/P) titled Thawing of Meats, P/P indicated thawing meat properly can be done by submerging the meat under running, potable water at the temperature of 70 degrees Fahrenheit or lower, with a pressure sufficient to flush away loose particles.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide one of five sampled residents ( Resident 8) with opportinity to choose and prefered time to get ready for an acitivity related exercises was honored. This deficient practice made Resident 8 felt frustrated and upset and had the potential to affect Resident 8's quality of life Findings: During a record review of Resident 8's admission Record (face sheet) indicated resident was admitted to the facility on [DATE] with diagnoses that included diabetes (high blood sugar), pressure ulcer(damage to an area of skin caused by constant pressure on the area for a long time) of left heel, presence of cardiac pacemaker( implanted device in the chest that helps control the heartbeat), and pressure ulcer of the other part of left foot, and peripheral vascular disease(blood circulation disorder that causes narrowing of blood vessels and reduction of blood flow to the limbs). During a record review of Resident 8's Minimum Data Set (MDS- standardized screening tool) dated 10/25/22 indicated resident had an intact cognition( mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required limited assistance with bed mobility, transfer, locomotion on unit (how resident moves between locations in his room) locomotion off unit(how resident moves to and from unit location like dining, activities or treatments), personal hygiene and toilet use. During an interview on 11/8/2022, at 1:41 p.m. with Resident 8, Resident 8 stated, he kept telling staff to come and get him ready before 10:00 a.m. because he would like to attend an exercise group activity scheduled at 10:00 a.m. in the dining area. Resident 8 stated that it happened all the time, staff was unable to assist him to get out of bed and transfer to the wheelchair and get him ready for the group activity. Resident 8 stated he wanted to attend the exercise activity so he can build his strength and get better. Resident 8 stated he is frustrated and upset every time he would miss the group activity for exercise. During an interview on 11/9/2022, at 3:12 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated, Resident 8 preferred to get up from bed before 10:00 am but she was not able to get him up on the wheelchair on 11/8/2022 because she was giving another resident a shower. During an interview on 11/9/2022, at 3:17 pm with Restorative Nursing Assistant (RNA) 1, RNA 1 stated, Resident 8 requires extensive assistance and likes to do exercises in the activity room. She stated Resident 8 needed help in getting out of bed into the wheelchair, changing his diaper and getting dressed before the exercise activity. During an interview on 11/9/2022, at 2:22 p.m. with Registered Nurse (RN)1 , RN1 stated Resident 8 communicated to her that he liked to attend exercise activity in the dining area before 10:00 am. RN 1 stated she reminded the nurses and certified nursing assistants about resident's preference. RN 1 stated, some of the staff in Station A where Resident 8 was located were all new and unaware of Resident 8's preferences to go to the activity room for exercises on specific time. During an interview on 11/9/2022, at 2:40 p.m. with Activity Director (AD), AD stated Resident 8 liked attending exercise activity in the dining area because resident was looking forward to getting out of the facility and getting discharged . AD stated the CNAs' should know Resident 8's preferences on when to get ready for an activity because the resident was looking forward on getting stronger and better. During an interview on 11/10/2022, at 2:48 p.m. with Director of Nursing (DON), DON stated it was important resident's preference was followed or met. DON stated,facility tried to accomodate residents' needs, so they will be happy and contented with the care. During a record review of facility's policy and procedure(P/P) titled Resident Rights revised 12/16, the P/P indicated federal and state laws guarantee certain rights to all residents of the facility which include the resident's rights to self -determination, to exercise his rights without interference , a dignified existence and be treated with respect, kindness and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one of eight residents (Resident 83) received mail in a timely manner, within 24 hours after being delivered to the facility through a means other than the postal service as stated in facility's policy and procedure. This deficient practice denied Resident 83 of his resident rights to receive mail in the facility in a timely manner. Findings: During a concurrent observation and interview on 11/7/2021 at 12:17 p.m. with Resident 83, Resident 83 stated he just received a package from the Activities Director (AD) that was delivered on 11/3/22 to the Front Desk Receptionist (FD). During an interview on 11/8/2022 at 1:01 p.m. with the Activities Director (AD), the AD stated, when mail comes to the front door, the front desk receptionist gives it to the business office and the business office sends it to residents' mailbox. The AD stated, the mail usually comes everyday between 3:00 p.m. and 5:00 p.m. and then she delivers it to the residents every day. The AD stated it was the activities department responsibility to deliver the mail to the residents. She also stated, she gave Resident 83 his package on 11/7/22 around 12:00 p.m. The AD stated, Resident 83 was looking for it since last week. During an interview on 11/8/2022 at 2:09 p.m. with the Front Desk Receptionist (FD), the FD stated, Resident 83 mail in question was received yesterday on 11/7/22. The FD stated that, it was a big envelope not a package and it was delivered yesterday around 4:30 or 5:00 p.m. for Resident 83. The FD stated that, residents should get the mail the same day. The FD stated that if residents get their mail late, and it was time sensitive that they would not be able to respond in a timely manner. During an interview on 11/9/2022 at 8:48 a.m. with Resident 83's friend. The friend stated , she came to the facility on [DATE] between 5:45 p.m. to 6:30 p.m. and gave the package to the FD. Resident 83's friend stated, she told FD that it was a very important documents and Resident 83 needs to receive it on 11/3/2022. Resident 83's friend stated, she called the facility on 11/4/2022, 11/5/2022 and 11/6/2022 and was not able to reach Resident 83 to asked if he received his mail. She stated, she finally called the facility back on 11/7/2022 and was able to reach Resident 83. Resident 83's friend stated she told resident she dropped the mail package on 11/3/2022 and asked if he received it. She stated, Resident 83 told her he did not receive the mail and will go to the Activities Director to find out what happened. During an interview on 11/9/2022 at 6:31 p.m. with FD, FD was informed that Resident 83 confirmed the date and time of delivery of Resident 83's mail on 11/3/2022, FD stated, she did finally remember that the package for Resident 83 was delivered to the facility and given to her on 11/3/2022 evening by Resident 83's friend. During a review of the facility's policy and procedure (P&P) titled Resident Rights dated December 2016, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: Be free from misappropriation of property. Have access to a telephone, mail and email. During a record review of the facility's P&P titled Mail and Electronic Communication dated May 2017, the P&P indicated, Mail will be delivered to the resident unopened. Mail and packages will be delivered to the resident within 24 hours of delivery on premises.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two sampled resident, resident representative a notice of transfer and was notified of nonemergency transfer of Resident 68 transfer out of the facility. This deficient practice resulted in Resident 68's resident representative unaware of Resident 68's status and whereabouts. Findings: During a review of Resident 68's admission Record (face sheet) indicated resident 68 was admitted to the facility on [DATE], with diagnoses that included dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities), schizophrenia (a mental disorder that affects a person's ability to think, feel, and behave clearly), epilepsy (seizure disorder - sudden, uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), hypertensive heart disease (heart problems related to high blood pressure), major depression (persistent feeling of sadness and loss of interest). During a review of Resident 68's History and Physical (H&P), dated 10/18/2022, the H&P indicated Resident 68 was confused and did not have the capacity to understand and make decisions. During a review of Resident 68's Minimum Data Set (MDS-comprehensive screening tool), dated 8/24/2022, the MDS indicated Resident 68 had severe cognitive (ability to learn remember, understand, and make decisions) impairment for daily decision making, required limited assistance with ADLs (activity of daily living), and used a wander guard bracelet (a bracelet worn by residents that triggers an alarm if a resident attempts to leave a safe area) daily. During a review of Resident 68's Nursing Progress Note dated, 11/7/2022, the nursing progress note indicated Late entry notified doctor regarding Resident 68 trying to elope (patient who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected) and doctor recommended to find appropriate facility. During a review of Resident 68's Case Management Progress Note (CMP) dated, 11/7/2022, the CMP indicated, Late entry reached out to the sister 3 times and left a voicemail to inform of transfer. The sister did not return the call by the time case manager left yesterday evening. Will follow up on 11/8/2022 to provide details of transfer. During an interview on 11/08/2022 at 9:28 a.m. with Resident 68's family member (FM), FM stated, she spoke with registered nurse (RN) and was informed Resident 68 attempted to leave the facility. FM stated RN informed her, the facility thought it would be best if Resident 68 was transferred to a locked dementia facility. FM stated she was informed by RN there was no definite transfer plan. FM stated she informed RN not to transfer Resident 68 without first talking to her, because she wanted the information of the new facilities before the transfer. FM stated she spoke with admission Director (AM) 2 on 11/8/2022 morning and was never informed Resident 68 was transferred out of the facility on 11/7/2022. FM stated AM 2 informed her the facility found a dementia unit and AM 2 would email the transfer plan and the new facility information. FM stated she was not happy with the facility and how they handled this matter. FM stated she wanted to be involved in choosing a new facility for Resident 68 and wanted to be there when he arrived to help him adjust to his new environment. During an interview on 11/08/2022 at 10:01 a.m., with AM 2, AM 2 stated Resident 68 was transferred out of the facility on 11/7/22. AM 2 stated she called Resident 68's FM and left messages about the transfer but did not talk to sister directly until this morning. AM 2 stated she should have spoken to Resident 68's FM before the transfer. AM 2 stated it was important to communicate with family member prior to a transfer because the FM should know where their relative was going and the FM must be involved in the final decision on placement. During an interview on 11/9/2022 at 2:32 p.m., with Registered Nurse (RN), RN stated Resident 68's doctor and FM was notified of his elopement on 11/7/2022 and the doctor gave an order to transfer Resident 68 to a dementia unit. RN stated she informed resident 68's FM of the doctors order to transfer and at that time Resident 68's FM requested not to transfer Resident 68 before speaking to her first. RN stated it was important for Resident 68's FM to be involved because Resident 68 cannot make his needs known and the family has the right to make decisions about what facility the resident was transferred to. During an interview on 11/10/22 at 3:33 p.m., with Director of Nursing (DON), DON stated the facility failed to notify resident 68's FM of his transfer. DON stated resident 68's FM should have been notified prior to his transfer and FM should have been given the opportunity to approve or disapprove of the new facility. DON stated leaving messages on the FM voicemail was not sufficient notification. DON stated it was important to involve the resident and their family in discharge planning because they must have the final say to where their loved one was being transfer to. During a review of the facility's policy and procedure (P&P) titled, Preparing a Resident for Transfer or Discharge, dated 2016, the P&P indicated, A discharge plan is developed for each resident prior to his or her transfer discharge. This plan will be reviewed with the resident, and /or his or her family, at least twenty-four (24) hours or before the resident's discharge or transfer from the facility.

Based on observation, interview, and record review, the facility failed to provide care that meets professional standards of medication administration for one of eight sampled residents, when Licensed Vocational Nurse (LVN) 4 left Resident 46 medications at bedside, unattended. This deficient practice put Resident 46 at risk of medication errors and had the potential for unsafe medication administration to an incorrect resident. Findings: During a concurrent observation and interview on 11/7/2022 at 9:58 a.m. with Resident 46, observed Resident 46 had a medication cup with six (6) pills sitting on her bedside table without the presence of the medication nurse. Resident 46 stated, LVN 4 left the medication on her bedside table for her to take. Resident 46 stated, her arms, shoulders and hands were sore, and she could barely lift them up to take the medications. Resident 46 stated that the charge nurses' sometimes leave medications at her bedside to take on her own. During a record review of Resident 46 admission Record (face sheet) dated 12/7/2017, the face sheet indicated, Resident 46 was admitted to the facility for glaucoma (increased pressure within the eyeball, causing gradual loss of sight) and spondylosis (abnormal wear on the cartilage and bones of the neck). During a record review of Resident 46 Minimum Data Set (MDS- a comprehensive assessment and screening tool), dated 9/28/22, the MDS indicated, Resident 46 was alert and oriented and able to make her own decisions. During a record review of Resident 46 Medication Administration Record (MAR) dated November 2022, the MAR indicated, Resident 46 was prescribed by the physician the following medications: 1. Aspirin (treat pain, fever, headache) 81 milligram ([mg] unit of measurement ) once a day at 9:00 a.m. 2.Cymbalta (for depression) 60 mg once a day at 9:00 a.m. 3.Hydrocholorothiazide 25 mg (for high blood pressure) once a day at 9:00 a.m. 4.Calcium (mineral supplement) once a day at 9:00 a.m. 5.Colace (stool softener) 100 mg twice a day at 9:00 a.m. and 5:00 p.m. 6.Neurontin (for nerve pain) 600 mg three times a day at 9:00 a.m., 1:00 p.m. and 9:00 p.m. During an interview on 11/7/2022 at 10:04 a.m. with LVN 4, LVN 4, stated, she left the medications at Resident 46 bedside because somebody called her and forgot she left the medication at Resident 46 bedside. LVN 4 stated she was aware medications should not be left at resident beside unattended. LVN 4 stated it was dangerous to leave medication at bedside unattended because she does not know if the resident took the medication or not. During an interview on 11/10/2022 at 9:30 a.m. with Registered Nurse (RN) 1, RN 1 stated that medications should not be left at the bedside. RN 1 stated that if a resident refuses the medication licensed staff needs to take the medications back and dispose the medications properly. RN 1 stated, licensed staff were not allowed to leave any medications at the bedside because there was a risk that confused residents, or any other resident could come and take the unattended medications. RN 1 stated that it was very dangerous for the residents and sometimes there were narcotics (medications for pain) in the medication cups. During a review of facility's policy and procedure (P&P) titled Preparation and General Guidelines dated October 2017, the P&P indicated, that the facility should have sufficient staff to allow administering of medications without unnecessary interruptions, medications are administered at the time they are prepared and the person who prepares the dose for administration is the person who administers the dose. The P&P indicated, the resident is always observed after administration to ensure that the dose was completely ingested (taken). During a review of an online article: https://www.ncbi.nlm.nih.gov/books/NBK560654/ titled Nursing Rights of Medication Administration dated 9/12/2021, indicated Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure the wander guard alarm (an alarm that triggers if a resident attempts to leave a safe area ) on two of six exit doors was triggered as one of two sampled resident (Resident 68) who was at risk for eloping (leaving unsupervised, undetected, without authorization) wore a wanderguard (a bracelet worn by residents that triggers an alarm if a resident attempts to leave a safe area) and had a history of wandering throughout the facility, was not supervised and eloped from the facility. This deficient practice resulted in Resident 68 eloping from the facility while wearing a wander guard bracelet. This deficient practice had the potential for Resident 68 to be seriously harmed or injured while out of the facility alone and unsupervised. Findings: During a review of Resident 68's admission Record indicated Resident 68 was admitted to the facility on [DATE], with diagnoses that included dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform daily activities), schizophrenia (a mental disorder that affects a person's ability to think, feel, and behave clearly), epilepsy (seizure disorder, sudden, uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), hypertensive heart disease (heart problems related to high blood pressure), depression (persistent feeling of sadness and loss of interest). During a review of Resident 68's History and Physical (H&P), dated 10/18/2022, the H&P indicated Resident 68 was confused and did not have the capacity to understand and make decisions. During a review of Resident 68's Minimum Data Set (MDS-comprehensive screening tool), dated 8/24/22, the MDS indicated Resident 68 had severe cognitive (ability to learn remember, understand, and make decisions) skills for daily decision making, required limited assistance with ADLs (activity of daily living), and wore a wander guard daily. During a review of Resident 68's Care Plan, dated 12/12/2021 and revised 11/7/2022, the Care Plan indicated Resident 68 had exit seeking behavior, wandered around the facility, was at risk for elopement, wore a wander guard bracelet, and eloped from the facility on 11/7/2022. During a concurrent observation and interview on 11/7/2022 at 9:39 a.m., in Resident 68's room, Resident 68 was observed sitting in a wheelchair wearing a wander guard bracelet on his right wrist, being supervised by Certified Nurse Assistant (CNA) 1. CNA 1 stated resident 68 had a history of wandering around the facility and he had attempted to exit the facility unsupervised in the pass. CNA 1 stated Resident 68 was previously on one to one [(1:1) one resident to one CNA] supervision but the 1:1 was cancelled, and her assignment was decreased to two rooms (6 residents) so she can keep a close eye on Resident 68. During an observation on 11/7/2022, at 10:25 a.m., in the back hall by room one, Resident 68 was observed exiting the facility unsupervised, through the back door leading to the parking lot, wearing a wander guard bracelet on his right arm. As Resident 68 exited through the back door the wander guard door alarm was not triggered. After Resident 68 was out of the facility for 1-2 minutes a secondary door alarm sounded, (Infection Preventionist Nurse) IPN and several other staff ran out of the building and brought Resident 68 back inside. During an interview on 11/7/2022 at 10:28 a.m. with Director of Nursing (DON), DON stated the wander guard alarm should sound when a resident wearing a wander guard bracelet pass through the door and the second door alarm sound when the door was open for one minute or longer. DON stated the Maintenance Director (MD) was responsible for inspecting and checking the door alarm weekly. During a concurrent observation and interview on 11/7/2022, at 10:31 a.m., next to the back door by room one, IPN stated she does not know why the wander guard door alarm did not sound when Resident 68 exited through the door. IPN pointed to a box and keypad mounted on the south wall next to the back door and stated that was the alarm for the wander guard. With Resident 68 wearing the wander guard bracelet, IPN, CNA 1, and Resident 68 entered and exited the back door three (3) times, and the wander guard alarm did not sound. During a concurrent observation and interview on 11/7/2022 at 10:35 a.m., with MD, MD stated he does not have extra wanderguard bracelets or the equipment to test the wander guard door alarms. Toured the facility with MD, CNA 1, and Resident 68. Three out six entrance doors are equipped with wander guard alarms. One of the three wander guard door alarms sounded (side door near Station A) as Resident 68 passed through the doors. During a concurrent interview and record review on 11/7/2022 at 11 a.m., with MD, reviewed facility's Weekly Door Alarm and Door Panel Check List, dated, 8/15/2022 thru 10/10/2022 indicate the door alarms were checked and working properly. A review of the Weekly Door Alarm and Door Panel Check List, dated, 11/6/2022, 10/31/2022, 10/24/2022, 10/17/2022, did not indicate the alarms are working properly. MD stated he did not remember why he did not write on the weekly forms the alarms are functioning properly. During an interview on 11/9/2022 at 2:32 p.m., with Registered Nurse (RN), RN stated Resident 68's doctor and Responsible Party (RP) was notified of his elopement on 11/7/2022. RN stated when Resident 68 was first admitted in the facility, Resident 68 had an issue with the wander guard alarms, the alarms did not work. During concurrent observation and interview on 11/10/2022 at 4:10 p.m., at the facility back door near room one, with MD and Administrator (ADM), MD presented with a wander guard bracelet and device to check the wander guard alarm. MD was not able to demonstrate how to check the wander guard door alarm and stated he has not been checking the wander guard alarm because he did not have the proper equipment. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 2017, the P&P indicated, resident safety and supervision are facility wide priorities. The care team shall target interventions to reduce individual risk related to hazards in the environment including adequate supervision. During a review of the facility's policy and procedure (P&P) titled, Wander Guard/Code Alert System, dated 2007, the P&P indicated, the facilities Interdisciplinary Team (team members from different disciplines) and or nursing will evaluate the need of a resident for monitoring device (wander guard) to prevent unsafe wandering and/or elopement. The monitors are placed by the exit doors to assist staff in monitoring residents. The transmitter is placed on the wrist or ankle of the resident. If the transmitter is detected in an exit alarm zone and the door is open, an alarm sounds at the exit. Periodic testing is required for all transmitter in use on residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Licensed Vocational Nurse (LVN ) 1 documented the administration of a controlled medication on the Antibiotic or Controlled Drug Record for one of two sampled residents (Resident 199). This deficient practice had the potential for inaccurate record of controlled medication used for Resident 199, and had the potential for loss of accountability, which affected the controls against drug loss, diversion, or theft. Findings: During a review of Resident 199's admission Record (face sheet) indicated, Resident 199 was admitted to the facility on [DATE], with diagnoses that included brain cancer (abnormal cells in the brain), epilepsy ( sudden, uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), hypertension (HTN - high blood pressure), and [NAME] Syndrome [a rare, serious disorder of the skin and mucous membranes (the moist, inner lining of some organs and body cavities)] . During a review of Resident 199's History and Physical (H&P), dated 9/7/2022, the H&P indicated Resident 199 had the capacity to understand and make decisions. During a review of Resident 199's Minimum Data Set (MDS-comprehensive screening tool), dated 9/10/2022, the MDS indicated,Resident 199 had intact cognitive (ability to learn remember, understand, and make decisions) skills for daily decision making, required extensive assistance with ADLs (activity of daily living), and used a wheelchair for mobility. During a review of Resident 199's Order Summary Report dated,11/10/2022, the report indicated Resident 199 was prescribed Lacosamide (a medication used to control seizures that involve only one part of the brain) 200 milligram (mg) tablets, 1 table by mouth every 12 hours. During a review of Resident 199's Medication Administration Audit Report dated, 11/9/2022, the report indicated LVN 1 documented in Resident 199's Medication Administration Report (MAR) Lacosamide was administered on 11/9/2022 at 9:14 a.m. During a concurrent observation, interview, and record review on 11/09/2022 at 12:05 p.m., with LVN 1, at Station A, medication cart 1, an observation of Resident 199's controlled medication card (Lacosamide) and a review of Resident 199's Antibiotic or Controlled Drug Record and MAR indicated the pill count was incorrect. The pill count on the medication card was 25 and the count on the record was 26. LVN 1 stated she forgot to sign the Antibiotic or Controlled Drug Record when she gave the medication to Resident 199 at 9:14 a.m. LVN 1 stated, it was important to sign the controlled record immediately after administering the medication so it will be known that the medication was given. During an interview on 11/10/2022 at 9:38 a.m., with Registered Nurse (RN), RN stated charting the administration of controlled medication must be done at the time the medication was given. RN stated administration of controlled medication must be documented in the MAR and on the controlled medication records. RN stated if it was not charted it was not done. Failure to document on the controlled medication record can lead to medication errors and cause the drug count to be incorrect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to: a. Ensure four oral (taken by mouth) medications Cardizem LA (for high blood pressure), Metoprolol (for high blood pressure), Olanzapine (for schizophrenia), and Multivitamin placed in a medication cup and refused by Resident 197 was labeled and stored on medication cart 1. This deficient practice resulted in unsafe storage of the medication and had the potential to result in medication errors. b.Ensure an open Ozempic pen (injectable prescription medicine for diabetes-condition where blood sugar is elevated) is labeled with expiration date. This deficient practice had the potential for unintentional dispensing of expired medications to residents. Findings: a. During a review of Resident 197's admission Record indicated resident 197 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure (condition in which your blood doesn't have enough oxygen), hypertensive heart disease (heart problems related to high blood pressure), heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), and schizophrenia (a mental disorder that affects a person's ability to think, feel, and behave clearly). During a review of Resident 197's History and Physical (H&P), dated 11/3/2022, the H&P indicated Resident 197 had fluctuating capacity to understand and make decisions. During a review of Resident 197's Medication Administration Record (MAR) dated, 11/2022, the MAR indicated on 11/9/2022 at 9:00 a.m., Resident 197 refused to take medications of Cardizem LA, Metoprolol, Olanzapine, and Multivitamin. During a concurrent observation and interview on 11/09/2022 at 12:05 p.m., with Licensed Vocational Nurse (LVN) 1, at Station A, medication cart 1, observed four medications in a medication cup unlabeled and stored in medication cart 1. LVN 1 stated, the medication in the unlabeled medication cup was Cardizem LA, Metoprolol, Olanzapine, and Multivitamin. LVN 1 stated, Resident 197 refused to take the medication in the morning at 9:00 a.m. LVN 1 stated, the open medications should not be inside the medication cart and the medication should have been disposed off properly. During an interview on 11/10/2022 at 9:38 a.m., with Registered Nurse (RN), RN stated if a resident refused to take their medication, the licensed staff must label the medication cup prior to storing it on the medication cart. RN stated if medication was not labeled and stored on the medication cart it could be mistaken for another resident medication and can lead to medication error. RN stated, if a resident continues to refuse their medication the medication should be discarded properly and not stored or left on the medication cart. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated 2008, the P&P indicated medication and biologicals are stored safely, securely, and properly, following the manufactures recommendation. b. During an observation on 11/9/2022, at 8:28 a.m. at medication storage room in Station A with Registered Nurse (RN) 1, observed a used Ozempic pen with open date of 10/31/2022 but not dated with expiration date was stored in the medication refrigerator. During an interview on 11/9/2022, at 8:55 a.m. with Licensed Vocational (LVN ) 3, LVN 3 stated the Ozempic pen was already used on a resident, and he forgot to date the expiration date after it was opened. LVN 3 stated the Ozempic pen should be dated with expiration date after opening and using it on a resident so other licensed staff will be aware when it should be discarded. During an interview on 11/9/2022, at 9:00 a.m. with RN 1, RN 1 stated injectable pen that was opened should be dated with an expiration date to prevent medication error. During a review of facility's policy and procedure(P&P) titled Medication Storage in the Facility dated 2008, the P&P indicated refrigerated medications are kept in closed and labeled containers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a record review of Resident 56's face sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included hyperlipidemia (high level of fat particles in the blood), dysphagia (difficulty of swallowing), colostomy (a surgical procedure that creates an opening for the large intestine or colon through the abdomen), and hypertension (high blood pressure). During a record review of Resident 56's Minimum Data Set (MDS- standardized screening tool) dated 8/19/2022 indicated the resident had severely impaired cognition (person had hard time remembering, learning new things, concentrating, or making decisions in everyday life), and required extensive assistance with dressing, toilet care and personal hygiene. The MDS also indicated the resident required supervision with transfer, bed mobility, and locomotion on unit (how resident moves between locations in his room). During an observation on 11/7/2022, at 12:40 p.m. in Resident 56's room, observed soiled diapers were on the floor next to the resident's bed. Observed Certified Nursing Assistant (CNA) 3 picked up the soiled diapers on the floor with gloves on and threw the diapers on the trash can. CNA 3 faled to perform hand hygiene and proceeded to assist Resident 56 to get out of bed into wheelchair. CNA 3 did not perform hand hygiene after rendering care to Resident 56. During an interview on 11/10/2022, at 9:43 a.m. with CNA 3, CNA 3 stated hand hygiene should be done after picking up the soiled diapers on the floor, before and after providing care to a resident. CNA 3 stated hand hygiene was important to prevent spread of germs among the residents and staff members. During an interview on 11/10/2022, at 2:48 p.m. with Director of Nursing (DON), DON stated it was important to do hand hygiene in order to minimize infection and staff members should perform hand hygiene before and after caring for a resident. During a record review of facility's policy and procedure (P&P) titled Handwashing/ Hand Hygiene revised 4/12, the P&P indicated all personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents and visitors. The P&P indicated employees must wash their hands for at least twenty seconds using soap and water under the following conditions: a.Before and after direct resident contact. b.After contact with a resident 's mucous membranes and body fluids or excretions (waste matter excreted by residents like sweat, urine or feces). Based on observation, interview and record review, the facility failed to ensure standard infection control practices were followed by: a. Failing to ensure laundry staff had the knowledge and skill to accurately check and record laundry wash and drying temperatures. Thise deficient practice had the potential to place residents at risk for spread of infection to the entire facility. b. Failing to practice hand hygiene on one of five residents (Resident 56) after picking up soiled diapers on the floor and before assisting Resident 56 in getting out of the bed to the wheelchair. This deficient practice had the potential to place Resident 56 at risk for spread of infection. Findings: a. During a concurrent observation and interview on 11/8/2022 at 925 a.m. with the Laundry Supervisor (LS), the LS stated that he did not know how to check the wash or dryer temperatures. The LS also confirmed that he had signed the log that morning and wrote a temperature of 180 degrees Fahrenheit ( temperature scale) but did not actually check the temperature of the wash load. Observed a load of linen in the washer and dryer being laundered. During a record review on 11/9/2022 at 8:45 a.m. with the washer and dryer temperature logs recorded by the LS, the LS recorded a washer temperature of 160 degrees and a dryer temperature of 180 degrees Fahrenheit. It was also recorded by LS dryer temperatures on the following dates: 11/1/2022 (185 degrees) 11/2/2022 (185 degrees) 11/4/2022 (180 degrees ) 11/5/2022 (185 degrees ) 11/6/20-22 (180 degrees) During an interview on 11/10/2022 at 8:15a.m. with the laundry service provider (AM), the AM stated, the LS was responsible for checking the temperature of the washing machines and dryers and logging the temperatures accurately daily. The AM stated that, it was important to check the temperature on each load to make sure the linen was being disinfected because the residents could get an infection and the facility could end up in a full outbreak. During a concurrent interview on 11/10/2022 at 8:49 a.m. with the AM and LS, both confirmed the LS did not know how to check the washer or dryer temperatures. LS stated, if the linen was not cleaned or dried at the proper temperature it could lead to infection from the linen and the residents could get sick or it could be contagious. During an interview on 11/10/22 at 9:30 a.m. with the Registered Nurse (RN) 1, RN 1 stated, the LS was responsible for the laundry and should check the temperatures daily of the washer and dryers. RN 1 stated that, if the laundry was not washed at the right temperature, it was not clean and could still have bacteria. She also stated that if they have Covid 19 ( acute respiratory illness in humans caused by a coronavirus) residents, it could be mixed with the other linens and spread infection to any residents. During a record review of the LS job description revised, October 2020, the job description indicated, the LS should establish and implement operational standards and procedures for the departments,supervised, check and maintain equipment to ensure that it was in working order, assist in developing procedures for performing daily laundry tasks; educated team members on facility policies. During a record review of the facility policy and procedure (P&P) Laundry Water Temperature undated, the P&P indicated, that the laundry personnel will maintain a log of daily laundry water temperatures to ensure that water is maintained at the appropriate temperature to provide proper disinfection of soiled linen, and weekly log of laundry temperatures will be maintained to ensure proper disinfection of soiled linen and the will maintain laundry temperatures of the water at a minimum of 160 degrees Fahrenheit. During a record review of the facility P&P Laundry Safety, undated, indicated that the following procedures are for facilities with in-house laundry should, check all cleaning machines and appliances daily to make sure they are clean, operating correctly and free of defects. P&P indicated, that the facility staff should know the correct and safe procedures when using any cleaning product, device or appliance.