Every finding on record at Alhambra Healthcare & Wellness Centre, LP

Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for two (2) of three (3) sampled residents (Residents 2 and 3) in accordance with the facility's policy and procedure (P&P) by failing to ensure: Licensed Vocational Nurse 1 (LVN 1) perform hand hygiene /change gloves before administering medications to Resident 2 and in between tasks. 2. LVN 1 changed gloves in between tasks before checking Resident 3's blood sugar (or glucose, is the sugar found in your blood that serves as your body's primary source of energy) These deficient practices have potential to place the residents and staff at risk of infection.Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 2's diagnoses included diabetes (a condition that happens when the blood sugar [glucose] is too high), gastrostomy tube (G-tube, is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications), and dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 6/16/2026, the MDS indicated Resident 2 has severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 2 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in putting on/ taking off footwear, chair/bed- to chair transfer, and tub/shower transfer. Resident 2 also needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in toileting hygiene, shower/ bathe self, lower body dressing, roll left and right, sit to lying, and lying to sitting on side of the bed. During an observation right outside Resident 2's room on 8/13/2026 at 11:37 AM, LVN 1 was standing outside Resident 2's room and looking at the electronic medication administration record (eMAR, is the digital version of the traditional paper medication administration records used in healthcare facilities) on top of his cart. LVN 1 touched the laptop keyboard, touched the med cart keys before opening his medication cart and pulled middle drawer to get Resident 2's medication. LVN 1 did not perform hand hygiene before preparing Resident 2's medication. LVN 1 dispensed Resident 1's medication from the bubble pack into a medication cup with his bare hands. LVN 1 then transferred the medication into a medication pouch and crushed it. During an observation on 8/13/2026 at 11:40 AM with LVN 1 inside Resident 2's room, LVN 1 put on disposable gloves then knocked on the door before entering Resident 2's room. Resident 2 was awake and lying on his bed with head of the bed (HOB) elevated to 45-degree angle (a unit for measuring angles, where a full circle is 360 ). LVN 1 spoke to Resident 2, then LVN 1 pressed the bed control to raise the resident's HOB to 75-degree angle. LVN 1 pulled the privacy curtains to cover Resident 2, then touched Resident 2's gown and towel. LVN 1 proceeded to connect the syringe (a cylindrical, hollow tube, or barrel of a syringe which is medical device used to inject or withdraw fluids) to resident's G-tube to check for gastric residual (or residual volume, is the amount of formula and stomach fluids left in the stomach between feedings). LVN 1 flushed the G-tube then administered Resident 2's medication then flushed the G-tube. LVN 2 once again touched Resident 2's gown and towel. LVN 1 did not change his disposable gloves or perform hand hygiene in between tasks while administering Resident 2's medications. During an interview on 8/13/2026 at 11:47AM with LVN 1, LVN 1 stated he did not perform hand hygiene before starting to prepare Resident 2's medication. LVN 1 stated he should have performed hand hygiene to prevent infection. During an interview on 8/13/2026 at 11:48AM with LVN 1, LVN 1 stated he was wearing disposable gloves during the medication administration and did not change gloves in between tasks. LVN 1 stated he should have changed his gloves in between tasks because of infection control. During an interview on 8/13/2026 at 4:12 PM with the Director of Nursing (DON), the DON stated the licensed staff should always change gloves, during medication administration to G-tube residents, they should change gloves during medication preparation, change gloves before checking G-tube placement and change gloves in between tasks, every time they touch other things like clothing, or curtain to make sure they will not contaminate or can introduce bacteria to the G-tube site or cause cross contamination or cause infection. The Licensed staff should change gloves when changing tasks. During an interview on 8/13/2026 at 4:12 PM with the Director of Nursing (DON), the DON stated that licensed staff should always change gloves during medication administration for residents with G tube. The DON stated the licensed staff should change gloves during medication preparation, before checking G tube placement, and between tasks. The DON added that licensed staff must change gloves every time they touch other items, such as clothing or curtains, to ensure they do not contaminate or introduce bacteria to the G tube site or cause cross contamination (is the physical movement or transfer of harmful bacteria from one person, object or place to another) or infection. 2. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 3's diagnoses included diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose levels), chronic kidney disease (CKD, is a condition in which the kidneys are damaged and cannot filter blood as well as they should), and acute respiratory failure (occurs when you do not have enough oxygen in your blood) with hypoxia (a dangerous condition that happens when the body does not get enough oxygen). During a review of Resident 2's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 3 was dependent on toileting hygiene, shower/bathe self, lower body dressing, and putting on/ taking off footwear, roll left and right, sit to lying, lying to sitting on the side of the bed, sit to stand, and chair/ bed-to-chair transfer. Resident3 also needed partial/ moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs but provides less than half the effort) in eating, oral hygiene, and personal hygiene. During an observation on 8/13/2026 at 11:54 AM inside Resident 3's room, LVN 1 put on a pair of disposable gloves and then knocked on the door before entering Resident 3's room. Resident 3 was observed sitting in a wheelchair positioned near the foot of her bed. LVN 1 pulled Resident 3's privacy curtain. LVN 1 wiped Resident 3's right ring finger with an alcohol pad, waited for the alcohol to dry, and then pricked the resident's finger with a lancet (a small, disposable, double-edged needle or blade used to prick the skin-usually on the finger-to obtain a tiny blood sample for checking blood sugar levels). LVN 1 placed another alcohol pad on the resident's pricked finger with another alcohol pad. LVN 1 did not change his gloves between tasks. During an interview on 8/13/2026 at 12:02 PM with LVN 1, LVN 1 stated he should have changed his gloves before checking Resident 3's blood sugar check. LVN 1 stated he should have changed his gloves in between tasks for infection control. During a concurrent interview and record review on 8/13/2026 at 4:28 PM with the DON, the facility's P&P titled, Hand Hygiene, revised 9/1/2020 was reviewed. The P&P indicated to establish the use of appropriate hand hygiene for all facility staff, healthcare personnel (HCP), residents, volunteers and visitors while at the facility. The facility considers hand hygiene as the primary means to prevent the spread of infections. Hand hygiene means cleaning your hands by handwashing (washing hands with soap and water), antiseptic hand wash or antiseptic hand rub (i.e. alcohol-based hand rub (ABHR) including foam or gel). The following situations require appropriate hand hygiene:iii. After contact with blood, other body fluids, secretions, excretions, mucous membranes, non-intact skin, wound drainage and soiled dressing.vi. Before donning and after doffing Personal Protective Equipment (PPE)vii. Immediately upon entering and exiting a resident roomThe DON stated the licensed staff should perform hand hygiene- ABHR or handwashing before preparing the medications, when entering a room with isolation like Enhanced Barrier (EBP, refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) to prevent spread of bacteria and cross-contamination. During a concurrent interview and record review on 8/13/2026 at 4:32 PM with the DON, the facility's P&P titled, Personal Protective Equipment revised 1/1/2012 was reviewed. The P&P indicated Gloves (sterile, non-sterile, heavy-duty and/or puncture-resistant)Facility Staff wear gloves whenever there is touching blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin.iii. Gloves are used only once and are discarded into the appropriate receptacle located in the room in which the procedure is being performed.The DON stated the licensed staff should always change their disposable gloves every time they change their tasks. The Licensed Staff should have changed their gloves prior to touching curtains or other high touch areas surfaces, different tasks and when in contact with the residents because of infection control. The DON stated if Licensed Staff were using dirty gloves, they could cause cross contamination, or they could be the source of spreading bacteria.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, administering of drugs and biologicals to meet the needs for one (1) of three (3) sampled residents (Residents 2) by failing to ensure the licensed staff used two (2) identifiers (the individual's name, an assigned identification number, date of birth or another person-specific identifier) prior to administering medications on 8/13/2026 in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential for medication errors (any preventable event that may cause or lead to inappropriate medication use) and result in harm to Resident 2.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 2's diagnoses included diabetes (a condition that happens when your blood sugar [glucose] is too high), gastrostomy tube (G-tube, is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications), and dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 6/16/2026, the MDS indicated Resident 2 has severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 2 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in putting on/ taking off footwear, chair/bed- to chair transfer, and tub/shower transfer. Resident 2 also needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in toileting hygiene, shower/ bathe self, lower body dressing, roll left and right, sit to lying, and lying to sitting on side of the bed. During an observation on 8/13/2026 at 11:42 AM with Licensed Vocational Nurse 1 (LVN 1), inside Resident 2's room, LVN 1 checked Resident 2's gastric residual (or residual volume, is the amount of formula and stomach fluids left in the stomach between feedings) and flushed Resident 2's G-tube and administered Resident 2's medication via G-tube. LVN 1 did not check Resident 2's armband prior to administering Resident 2's medication. During an interview on 8/13/2026 at 11:45 AM with LVN 1, LVN 1 stated he did not check Resident 2's armband before administering his medications because he was in a rush and he forgot to do it. LVN 1 stated he should have checked Resident 1's arm band to verify the resident and avoid medication error. During a concurrent review and interview on 8/13/2026 at 4PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Medication - Administration revised on 6/26/2025 was reviewed. The P&P indicated that the licensed nurse will verify the Resident's identity before administering the medication using the six (6) rights of medication administration which included the right resident by confirming with two identifiers. The DON stated the licensed staff should always check 2 identifiers prior to medication administration. The DON stated the licensed nurse needs to check the resident's armband for the resident's name or date of birth (DOB). The DON also stated to check the electronic medication administration record (e-MAR, is the digital version of the traditional paper medication administration records used in healthcare facilities) for the Resident's name, date of birth and correct medication order . The DON also stated if the licensed staff did not check the resident's armband, there is a risk for the medication to be administered to the wrong resident. The DON added that the licensed nurse should always verify the residents before medication administration. During review of the facility's P&P titled, Medication - Administration, revised 6/26/2025, the P&P indicated all medications shall be administered by licensed nursing staff according to physician orders, current best practices, and federal and state regulations, The facility shall ensure residents receive the correct medications in a timely, safe and documented manner.Residents are identified before medications are administered. Methods of identification include:a. checking identification bandb. checking photographs attached to medical record; andc. if necessary, verifying resident identification with other facility personnel.

Based on observation, interview, and record review, the facility failed to ensure a bed rail (side rails - metal or plastic bars attached to the sides of a bed to help prevent falls, provide support and assist patients with moving or getting out of bed) assessment was completed to assess for risk for entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about) for three (3) of 3 sampled Residents (Residents 7, 59 and 104) reviewed for accidents as indicated on the facility policy and procedure (P&P). This failure had the potential to result in the inappropriate use of bed rails for Residents 7, 59 and 104, which could pose a safety risk and result in injury or harm. Findings: 1. During a review of Resident 7's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of unspecified sequelae (the aftereffects, complications or secondary conditions that follow a prior disease, injury or trauma) of cerebral infarction (also known as ischemic stroke – brain tissue damage and death caused by a sudden loss of blood supply and oxygen) and generalized muscle weakness (widespread loss of physical strength affecting the entire body, making everyday tasks such as standing, lifting, or moving require extra effort). During a review of Resident 7'S Minimum Data Set (MDS – a resident assessment tool), dated 5/12/2026, the MDS indicated the resident had severe impairment (difficulty with or unable to make decisions, learn, remember things) with cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 7 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for resident to complete the activity) with tub/shower transfers (the ability to get in and out of a tub/shower), putting on/taking off footwear and lower body dressing (the ability to dress and undress below the waist). MDS indicated Resident 7 needed substantial/maximal assistance (helper does more than half the effort) with chair/bed-to-chair transfers, rolling left and right in bed, going from lying down to sitting on the side of the bed, upper body dressing (the ability to dress and undress above the waist) and personal hygiene. The MDS also indicated Resident 7 needed partial/moderate assistance (helper does less than half the effort) with eating. During a review of Resident 7's Care Plan, dated 6/11/2026, the Care Plan indicated Resident 7 had a potential for injury (e.g. [for example] bruises, skin tears, entrapment) related to the use of bilateral 1/3 bed rails used as an enabler when in bed to assist with ADLs (activities of daily living – the fundamental self-care tasks required for basic survival and independent functioning, including bathing, dressing and eating), transfers, repositioning, per resident/RP (resident representative) request. The Care Plan also indicated interventions included were to evaluate the ongoing need for bedrail use at least quarterly, during change in condition and/or as deemed necessary, and to evaluate the resident's risk of entrapment prior to the use of bed. During an observation on 7/21/2026 at 10:07 AM inside Resident 7's room, Resident 7 was observed asleep in bed with his bilateral (both) upper 1/3 bed rails up.During an observation on 7/22/2026 at 2:57 PM inside Resident 7's room, Resident 7 was observed asleep in bed with his bilateral 1/3 bed rails up.During a concurrent interview and review on 7/22/2026 at 3:32 PM with Registered Nurse 1 (RN 1) Resident 7's Electronic Medical Record (EMR, an electronic medical record including information about a patient's health history), dated 5/5/2026 to 7/22/2026 was reviewed. Resident 7's EMR indicated an order dated 6/12/2026 for bilateral 1/3 bed rails up used as enabler when resident in bed to assist with ADLs, transfers, repositioning per resident/RP request. Monitor bed rails for proper placement and condition every shift. Monitor safe use of bed rails every shift for possible entrapment. Resident 7's EMR also indicated a bed rail evaluation dated 5/21/2026 that was not filled out and still in progress. RN 1 stated Resident 7 did have an order for the use of his bilateral 1/3 bed rails and had a bed rail evaluation that was not completed and should have been completed so that they could determine if the use of bed rails was appropriate for Resident 7 to use. 2. During a review of Resident 104's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis on one side of the body affecting an arm, a leg and face muscles) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction affecting the left dominant side and generalized muscle weakness.During a review of Resident 104's History and Physical Examination (H&P), dated 7/16/2026, the H&P indicated Resident 104 did not have the capacity to understand and make decisions, had a fair prognosis for rehabilitation and was on fall precautions. During a concurrent observation with Certified Nursing Assistant 1 (CNA 1) inside Resident 104's room on 7/21/2026 at 9:34 AM, Resident 104 was observed lying down in bed with her bilateral 1/3 bed rails up. During an observation on 7/22/2026 at 8:03 AM inside Resident 104's room, Resident 104 was observed lying down in bed with her bilateral 1/3 bed rails up.During an observation on 7/22/2026 at 2:50 PM inside Resident 104's room, Resident 104 was observed lying down in bed with her bilateral 1/3 bed rails up.During a concurrent interview and record review on 7/22/2026 at 3:24 PM with RN 1, Resident 104's EMR dated 7/15/2025 to 7/22/2026 was reviewed. Resident 104's EMR indicated an order dated 7/17/2026 for bilateral 1/3 bed rails used as an enabler when in bed to assist with ADLs, transfers, repositioning per resident/RP request. Monitor bed rails for proper placement and condition every shift. Monitor safe use of bed rails every shift for possible entrapment. Resident 7's EMR failed to indicate a bed rail evaluation or assessment and care plan for the use of Resident 104's bilateral 1/3 bed rails. RN 1 stated because Resident 104 had an order for the use of her bilateral 1/3 bed rails, a bed rail evaluation should have also been done and a care plan for the bed rails should have been initiated. RN 1 verified that Resident 104 did not have a bed rail evaluation or assessment and did not have a care plan for the use of her bilateral 1/3 bed rails. RN 1 also stated the purpose of a bed rail evaluation is to verify the appropriateness of using bed rails for the resident. RN 1 further stated the purpose of a care plan is to guide the nurses with how to deal with a certain problem or focus regarding resident's care. During an interview on 7/24/2026 at 12:47 PM with the Director of Nursing (DON), the DON stated before implementing bed rails for a resident, a bed rail evaluation or assessment needs to be done to know if they are applicable and suitable for the residents to use. The DON stated because every resident is unique, if the resident needs to use a bed rail, they need to identify the resident's mobility, cognitive status and medical condition and explain the risks and benefits since the use of a bed rail has a risk for entrapment. The DON also stated if no bed rail assessment is done, the risk for entrapment could lead to major injury or fracture in the case the resident gets trapped in the bed rail if they are agitated or moving abruptly. The DON further stated it is important to have a care plan for the use of bed rails because they need to make sure it is individualized and resident centered so that they can promote safety and provide quality care for the residents according to their individualized needs. 3. During a review of Resident 59's admission Record, the admission Record indicated Resident 59 was admitted to the facility on [DATE] with history of falling and bone density disorder (the bones are losing their strength and minerals, making them thin, fragile, and easily breaks). During a review of Resident 59's MDS, dated [DATE], the MDS indicated Resident 59 had moderate impairment in cognitive skills for daily decision making. The MDS also indicated Resident 59 required setup assistance (helper sets up; resident completes activity) with toileting hygiene, shower, lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 59 was independent (resident completes the activity by themselves with no assistance from helper) with eating, upper body dressing, oral and personal hygiene. During an observation on 7/22/2026 at 9:10 AM, Resident 59 was in bed sleeping with both 1/3 padded bed rails up. During a concurrent interview and record review on 7/22/2026 at 3:51 PM with the MDS Nurse, Resident 59's Medical Records were reviewed. The MDSN stated Resident 59 had a physician's order for the 1/3 bed rail on 7/7/2026 readmission but did not have a nursing bed rail evaluation prior to installing the bed rail. During a concurrent interview and record review on 7/23/2026 at 2:55 PM with RN 1, Resident 59's nursing bed rail evaluation was reviewed. RN 1 stated Resident 59 did not have nursing bed rail evaluation completed upon the 7/7/2026 readmission and, therefore, was not evaluated for risk for entrapment upon readmission. RN 1 stated a nursing bed rail evaluation was necessary to ensure the bed rails were appropriate for Resident 59 and to assess the resident's risk of entrapment. RN 1 further stated the admitting nurses should conduct bedrail screening and evaluation during admission and each readmission. During an interview on 7/23/2026 at 3:33 PM, the Maintenance Services Director (MSD) stated a resident should have a bedrail evaluation completed by the nurses before he is informed to install a bed rail, to ensure the bed rail is appropriate for the resident. The MSD also stated the nursing bedrail evaluation was done to prevent injuries such as bed entrapment. During a review of the facility's Policy and Procedure (P&P) titled, Bed Rail Screening and Implementation, dated 4/22/2026, the P&P indicated that the facility was to evaluate risks, benefits, and the need for bed rail use prior to installation. The P&P also indicated that the bed rail evaluation will be completed by the licensed nurse in collaboration with the Inter Disciplinary Team (IDT, comprised of team members from different disciplines working together, with a common purpose, to set goals, make decisions, and share resources and responsibilities), prior to the use and/or installation of any bed rail upon: 1. Admission 2. Readmission 3. Change in bed or mattress, or 4. Following any significant change of condition, including mobility, cognition behavior, and medical status.

Based on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with the facility's policy and procedure titled Food Storage and Handling by failing to ensure:1. The chopped lettuce salad in a small styrofoam container was prepared fresh on the same day and labeled with the resident's name.2. Dietary staff washed her hands prior to touching clean food containers and plate covers after touching the floor. 3. A tray with three (3) small cups of watermelon and 3 cups of Jell-O pudding with strawberry sauce inside walk-in refrigerator was labeled with its preparation date. These deficient practices have the potential to result in foodborne illness (illness that comes from eating contaminated food) in a population of 79 residents who consume the food prepared by the facility every day. Findings:During a kitchen tour on 7/21/2026 at 7:47 AM with the Assistant Dietary Services Supervisor (ADSS) a small styrofoam container with chopped lettuce salad inside dated 7/20/2026 was observed inside the walk-in refrigerator. ADSS stated it could have been for 1 of the residents but was not labeled with the resident's name. During another interview with the ADSS on 7/21/2026 at 8:44 AM, the ADSS stated vegetable salads should be prepared fresh on same day to ensure they are still crisp and palatable for the resident. During dinnerware sanitization and storage observation on 7/23/2026 at 9:04 AM, the Dietary Aid (DA) stooped down and touched the floor with the rubber mats to check the low temperature dishwasher gauge, took a fresh chlorine test strip (a small piece of chemical paper used to measure the amount of chlorine bleach in the water during a commercial low-temperature wash cycle), opened the dishwasher cover and removed the clean food covers to check the Parts Per Million (PPM, concentration of chemical sanitizer) then touched the clear plastic food container sitting on the clean cart to dry without washing her (DA) hands. During an interview on 7/23/2026 at 9:10 AM the ADSS stated she should have washed her hands after touching the floor and before touching clean food covers and the plastic food container to prevent potential spread of infection because staff walk all over the floor and there could be all kinds of bacteria on them. During an interview on 7/23/2026 at 9:16 AM, Dietary Service Supervisor (DSS) stated the clear plastic containers are used to store cut vegetables. DSS also stated the DA should have washed her (DA) hands after she touched the floor and before touching anything that has been washed to prevent contaminating the clean food containers. During another kitchen observation with the DSS on 7/23/2026 at 12:19 PM, a tray with three (3) small cups of chopped pieces of watermelon covered with a plastic wrap and 3 covered cups of Jell-O pudding with strawberry sauce inside the walk-in refrigerator was not labeled with a preparation date. DSS stated the tray with 3 small cups of watermelon and 3 cups of Jell-O pudding with strawberry sauce inside the walk-in refrigerator should be labeled with the date when they were prepared so the kitchen staff would know when they were made and when to toss them away before they go bad to prevent food borne illness to the residents. During a review of the facility's Policy and Procedure (P&P) titled, Food Storage and Handling, revised 2/29/2024, the P&P indicated, food items will be stored, thawed, and prepared in accordance with standard sanitary practices and that all items will be correctly labeled and dated including fresh fruits and vegetables to avoid foodborne illnesses. During a review of the facility's P&P titled, Infection Control, revised 2/29/2024, the P&P indicated that dietary employees would follow infection control policies and procedures as established and approved by the facility's infection control committee. The P&P also indicated its purpose was to ensure that the dietary department is maintained in a sanitary condition to prevent food contamination and the growth of disease producing organism and toxins (natural or man-made harmful substances that could make someone sick).

Based on observation, interview, and record review, the facility failed to ensure the call light (a cord with a button next to the bed which turns on a light or makes a sound when pushed to alert staff) was within resident's arm's reach for two (2) of (2) sampled residents (Residents 11 and 59) reviewed for environment in accordance with the facility's policy. This deficient practice had the potential for Resident 11 and 59 not to be able to call the facility staff for help or assistance, especially during an emergency.Findings: 1. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), generalized muscle weakness and history of falling. During a review of Resident 11's Minimum Data Set (MDS, resident assessment tool), dated 4/21/2026, the MDS indicated Resident 11 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 11 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower, lower body dressing and putting on/taking off footwear and required partial/moderate assistance (helper does less than half the effort) with upper body dressing. The MDS further indicated Resident 11 required supervision (helper provides cues) with oral and personal hygiene and required setup assistance (helper sets up; resident completes activity) with eating. During a review of Resident 11's Care Plan, revised on 5/8/2026, the Care Plan indicated the resident has an Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily) self-care performance deficit due to weakness and Parkinson's disease and included an intervention to ensure the resident's call light is within reach and functioning properly. During a review of Resident 11's Care Plan, revised on 5/8/2026 Resident 11's Care Plan also indicated the resident was at risk for fall related to poor balance, unsteady gait and history of falls and included an intervention to ensure the resident's call light is within reach. During an observation on 7/21/2026 at 4:37 PM, Resident 11 was lying in bed with the resident's call light seen on the floor on the right side of the resident's bed. 2. During a review of Resident 59's admission Record, the admission Record indicated Resident 59 was admitted to the facility on [DATE] with history of falling, and bone density disorder (the bones are losing their strength and minerals, making them thin, fragile, and easily breaks). During a review of Resident 59's MDS dated [DATE], the MDS indicated Resident 59 had moderate impairment in cognitive skills for daily decision making. The MDS also indicated Resident 59 required setup assistance (helper sets up; resident completes activity) with toileting hygiene, shower, lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 59 was independent (resident completes the activity by themselves with no assistance from helper) with eating, upper body dressing, oral and personal hygiene. During a review of Resident 59's Care Plan, revised on 6/3/2026, the Care Plan indicated the resident was at risk for injury related to use of side rail (a long or short protective bars attached to the side of the bed to prevent falls, or assist with movement) as an enabler to assist with ADL and included an intervention to ensure the resident's call light is within reach. During an observation on 7/21/2026 at 8:53 AM, Resident 59 was sitting in her wheelchair on the left side of the resident's bed with the resident's call light hanging on the wall hooked on the head part of the resident's bed. During an interview on 7/22/2026 at 2:28 PM, Certified Nursing Assistant 3 (CNA 3) stated the resident's call light should be within the residents' reach to ensure the resident can call if there is an emergency and whenever they needed something. CNA 3 also stated the call light would not be within the resident's reach if the call light is left hanging on the wall or if it is on the floor. During an interview on 7/22/2026 at 2:39 PM, Licensed Vocational Nurse 3 (LVN 3) stated call lights should be placed by the side of the bed where residents could reach the call light to call for the staff when assistance is needed and during emergencies. LVN 3 also stated Resident 11 and 59 would not be able to reach the call light if the resident's call light is on the floor or hanging on the wall by the head of the bed. During a review of the facility's Policy and Procedure (P&P) titled, Communication- Call System, revised 8/29/2024, the P&P indicated the facility will maintain a communication system to allow residents to call for staff assistance from their rooms. The P&P also indicated the call alert device will be placed within the resident's reach.

Based on observation, interview, and record review, the facility failed to ensure the wheelchair was at the right height to ensure the resident's feet were resting on the foot pedals (the flat platform at the front of a wheelchair where a user places their feet) for one (1) of two (2) sampled residents (Residents 72) reviewed for positioning according to the facility policy. This deficient practice placed Resident 72 at risk for poor posture and poor body alignment and potential for fall due to unsafe weight shifts during transfers.Findings:During a review of Resident 72's admission Record, the admission Record indicated Resident 72 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with generalized muscle weakness and history of falling. During a review of Resident 72's Minimum Data Set (MDS, resident assessment tool), dated 7/3/2026, the MDS indicated Resident 72 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 72 was dependent (helper does all the effort) with eating, oral, toileting and personal hygiene, shower, upper and lower body dressing and putting on/taking off footwear. During an observation on 7/21/2026 at 8:50 AM, Resident 72 was seated on the wheelchair with the resident's feet dangling and not resting on the wheelchairs foot pedals while the resident was outside the resident's restroom. Certified Nursing Assistant 2 (CNA 2) later transported Resident 72 to the activity room using the same wheelchair and the resident's feet dangling and not resting on the wheelchair's foot pedals. During an interview on 07/22/2026 at 2:50 PM, Registered Nurse 2 (RN 2) stated Resident 72 could develop footdrop (inability to lift the front part of the foot due to nerve damage or muscle weakness) if the resident's feet were not resting on the wheelchair's foot pedals. RN 2 also stated Resident 72 should be re-evaluated for proper wheelchair use by the Physical Therapist (PT, a trained health expert who helps residents recover strength, manage pain and improve movement). During an interview on 7/22/2026 at 2:57 PM, Director of Rehab (DOR) stated Resident 72's feet should be resting on the wheelchair's foot pedals to support the resident's feet when the resident is sitting on the wheelchair so the resident's feet would not be dangling. DOR also stated Resident 72's feet should be resting on the wheelchair's foot pedals for proper sitting positioning to prevent the resident from sliding. During an interview on 7/23/2026 at 2:06 PM, the Director of Nursing (DON) stated wheelchairs should be properly fitted for Resident 72 because the resident could slip off the wheelchair if the wheelchair was too high for the resident and the resident's feet were not touching the foot pedals. During a review of the facility's Policy and Procedure (P&P) titled, Positioning in Chair, revised 1/1/2012, the P&P indicated that the residents are positioned to maintain correct body alignment when seated. The P&P also indicated footrests are adjusted so that the resident's thighs are parallel with supporting surfaces and feet are flat on the foot pedals with the backs of the heels against the heel loops and the toes pointed straight ahead while on the wheelchair

Based on interview and record review, the facility failed to develop an individualized resident-centered care plan (CP, a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) for one (1) of two (2) sampled residents (Resident 19) reviewed for pain, as indicated on the facility policy by failing to have a care plan for Resident 19's use of pain medication, tramadol hydrochloride (Hcl, a drug used to treat moderate to severe pain in adults). This deficient practice had the potential to result in medication misuse, or failure to achieve optimal pain relief for Resident 19.Findings: During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was initially admitted to the facility on [DATE]. Resident 19's diagnoses included malignant neoplasm of unspecified part of unspecified bronchus or lung (lung cancer happens when harmful cells in your lungs grow unchecked) and secondary malignant neoplasm of bone (a cancer that has started in another part of the body and has spread to the bone via the bloodstream or lymph nodes). During a review of Resident 19's Minimum Data Set (MDS, resident assessment tool), dated 5/19/2026, the MDS indicated Resident 19 had moderately impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 19 needed partial or moderate assistance, (helper does less than half the effort) with toilet hygiene, shower/bathe self, upper and lower body dressing and putting on/taking off footwear. Resident 19 needed supervision or touching assistance, (helper provides verbal cues and /or touching/steadying and/or contact guard assistance as resident completes activity) for oral and personal hygiene. Resident 19 needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) for eating. The MDS also indicated Resident 19 received scheduled pain medication regimen. During a review of Resident 19's Physician Orders, dated 7/6/2026, the Physician's Order indicated tramadol Hcl tablet 50 milligrams (mg, a unit of measurement for weight) give 1 table by mouth every eight (8) hours for pain management (a multidisciplinary medical approach to diagnosing, treating, and alleviating acute or chronic discomfort) for 30 days. During a concurrent interview and record review on 7/24/2026 at 1:04 PM with the Registered Nurse Supervisor 1 (RNS1), Resident 19's pain management plan of care (a structured, individualized document that outlines the medical and supportive services a patient needs to address their specific health conditions and goals) was reviewed. RNS 1 stated Resident 1 was prescribed with tramadol Hcl, but it was not and should have been included in the resident's pain management plan of care. RNS 1 stated it is important to include tramadol in Resident 1's pain management plan of care to ensure resident was provided effective pain treatments. During an interview on 7/24/2026 at 1:23 PM with the Director of Nursing (DON), the DON stated it is very important to include Resident 1's pain medication, tramadol, in the care plan so that staff can ensure the medication is working properly to control Resident 19's pain. During a review of the facility's Policy and Procedure (P&P) titled, Pain Management, effective 5/26/2023, the P&P indicated:A pain assessment will be completed for each resident upon admission, quarterly, when there is a new onset of pain, exacerbation of pain, or when there is a significant change in status. The IDT will review the residents' Pain Management and make changes to the care plan as needed. Documentation, the Licensed Nurse will update the Care Plan for pain management with any change in treatment and/or medication.

Based on observation, interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 11) reviewed for Activities of Daily Living (ADL - activities such as bathing, dressing and toileting a person performs daily) was provided care and services to maintain good grooming and personal hygiene by failing to ensure Resident 11's long and jagged fingernails (rough and uneven nails) were cleaned and trimmed. This deficient practice resulted in multiple scattered scratch marks on Resident 11's left lower flank area, across right outer arm and upper right side of the resident's body.Findings:During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with dementia (a progressive state of decline in mental abilities) and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) During a review of Resident 11's Minimum Data Set (MDS, resident assessment tool), dated 4/21/2026, the MDS indicated Resident 11 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 11 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower, lower body dressing and putting on/taking off footwear and required partial/moderate assistance (helper does less than half the effort) with upper body dressing. The MDS further indicated Resident 11 required supervision (helper provides cues) with oral and personal hygiene and required setup assistance (helper sets up; resident completes activity) with eating. During a review of Resident 11's Care Plan revised on 4/28/2026, the Care Plan indicated a goal to keep the resident's skin intact with a proposed plan to keep the resident's fingernails short and clean. During an observation on 7/21/2026 at 4:37 PM, Resident 11 was lying in bed with jagged and untrimmed fingernails on both hands. In addition, there was yellowish-brown discoloration on top of the nailbeds and dark brown dirt built up under the fingernails. During an observation on 7/22/2026 at 8:20 AM, Registered Nurse 2 (RN 2) was doing skin checks on Resident 11 while the resident was lying in bed and observed scratch marks on the resident's left lower flank (the side of the body between the top hip bone and the lower ribs, closer to the lower back) area, across right outer arm and upper right side. Resident 11 was also observed scratching the right side of his body while RN 2 was doing skin checks on the resident. During an interview on 7/22/2026 at 1:50 PM, Certified Nursing Assistant 3 (CNA 3) stated the residents' fingernails should be cleaned and trimmed when the resident's fingernails look outgrown and dirty to prevent the residents' from hurting themselves and others. CNA 3 also stated the residents' nails should be filed after cutting them to prevent any jagged or sharp edges. During an interview on 7/22/2026 at 2:42 PM, Licensed Vocational Nurse 3 (LVN 3) stated CNAs should report any fingernail trimming that needed to be done for diabetic (a disorder characterized by difficulty in blood sugar control and poor wound healing) residents to the licensed staff but for all other residents that are not diabetic, any of the CNAs could do the nail trimming. LVN 3 also stated scratching the skin with dirty and untrimmed nails could break or scratch the resident's skin and could cause an infection to the broken skin. During an interview on 7/24/2026 at 12:30 PM, the Director of Nursing (DON) stated it is important to maintain good grooming and hygiene to the residents to prevent contaminating their food when eating with their hands during meals. The DON further stated long, dirty, and untrimmed fingernails could cause skin injuries to the residents if the resident scratches themselves and if the same area of the skin gets scratched it could break and could lead to complications such as skin infection or bleeding. During a review of the facility's Policy and Procedure (P&P) titled, Grooming Care of the Fingernails and Toenails, revised 10/21/2021, the P&P indicated nail care is given to clean the nail bed and keep the nails trimmed. The P&P also indicated procedures to include gently removing the dirt from around and under each nail, trim fingernails into an oval shape and smooth the nails with a nail file or emery board.

Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LAL mattress, a specialized medical bed mattress designed to prevent and treat pressure ulcers [localized damage to the skin and/or underlying tissue usually over a bony prominence] by constantly blowing a tiny amount of air through) for one (1) of three (3) sampled residents (Residents 97) reviewed for pressure ulcers was set according to the residents' current weight as indicated on the Physician's order and facility policy. This deficient practice placed Resident 97 at risk for development of new pressure ulcer and progression of moisture associated skin damage (MASD, caused from prolonged exposure to moisture) to Sacro-coccyx (pertains to both large triangular shaped bone in the lower spine that forms part of the pelvis and the tailbone) area.Findings: During a review of Resident 97's admission Record, the admission Record indicated Resident 97 was admitted to the facility on [DATE] with type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 97's Minimum Data Set (MDS, resident assessment tool), dated 4/29/2026, the MDS indicated Resident 97 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 97 was dependent (helper does all the effort) with toileting hygiene, shower, lower body dressing and putting on/taking off footwear and required substantial/maximal assistance (helper does more than half the effort) with eating, upper body dressing, oral and personal hygiene. During a review of Resident 97's Physician's Order, dated 7/1/2026 at 1:11 PM, the Physician's Order indicated LAL mattress for skin management. The Physician's Order also indicated LAL setting according to Resident 97's current weight. During a review of Resident 97's Braden Scale (used for predicting pressure ulcer risk) with an effective date of 7/10/2026, the Braden Scale indicated Resident 97 was high risk for developing pressure ulcer. During a review of the residents 97's Weight Record, the Weight Record indicated Resident 97's weight on 7/13/2026 was 150.8 pounds (lbs). During a review of Resident 97's Wound Assessment and Plan Record dated 7/14/2026, the Wound Assessment and Plan Record indicated Resident 97 had an MASD on the Sacro-coccyx area extending to the right/left buttocks and posterior thighs. During an observation on 7/21/2026 at 11:51 AM, Resident 97 was lying in bed with the LAL set at 200 lbs. During a concurrent observation and interview on 7/22/2026 at 3:04 PM, Registered Nurse 1 (RN 1) stated Resident 97's LAL mattress was set at 200 lbs. RN 1 also stated Resident 97's LAL mattress should be set based on the resident's current weight and according to the Physician's order. RN 1 further stated LAL mattress is used for skin maintenance to help redistribute pressure and promote wound healing. During an interview on 7/24/2026 at 9:09 AM, the Assistant Director of Nursing (ADON) stated LAL should be set correctly based on the resident's weight so the mattress can inflate properly to relieve pressure and used as preventive measures to prevent further skin breakdown to the resident. During a review of the facility's Policy and Procedure (P&P) titled, Mattresses, revised 6/27/2024, the P&P indicated that the facility provides a mattress appropriate to the residents' needs. The P&P also indicated that the facility provides pressure reduction mattress to residents at risk for skin breakdown and help to distribute body weight relieving areas of pressure. P&P also indicated an air mattress is used under the direction of an attending physician's order or when the resident's clinical condition warrants pressure reducing devices. During a review of the P&P titled, Pressure Injury Prevention, revised 6/27/2024, the P&P indicated its purpose was to prevent the development of pressure injury in residents identified at risk. The P&P also indicated that the facility would implement interventions identified in the plan of care which ay include but are not limited to pressure redistributing devices for the bed.

Based on observation, interview, and record review, the facility failed to administer gastrostomy tube (G-tube, a tube inserted through the abdomen to deliver nutrition directly to the stomach) feeding for one (1) of two (2) sampled residents (Resident 5) reviewed for tube feeding in accordance with the physician's order and facility's policy. This failure had the potential to result in Residents 5 experiencing fluid overload (when the body has too much water which can raise the blood pressure, force the heart to work harder and make it hard to breathe) which could then also lead to aspiration (when food, liquid or other material enters a person's airway and eventually the lungs by accident which can happen as a person swallows or when food comes back up from the stomach).Findings: During a review of Resident 5's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of protein-calorie malnutrition (refers to various degrees of nutritional disorders caused by inadequate quantities of protein and energy in the diet) and dysphagia (difficulty swallowing). During a review of Resident 5'S Minimum Data Set (MDS - a resident assessment tool), dated 5/13/2026, the MDS indicated the resident was moderately impaired with cognitive (ability to think, remember, and reason) skills for daily decision making. MDS indicated Resident 5 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with chair/bed-to-chair transfers, rolling left and right in bed, upper and lower body dressing (the ability to dress and undress above and below the waist), and putting on/taking off footwear. MDS also indicated Resident 5 needed substantial/ maximal assistance (helper does more than half the effort) with personal hygiene and had a feeding tube.During a review of Resident 5's Order Summary Report, dated 7/23/2026, Resident 5's Order Summary Report indicated a physician's order, dated 5/18/2026 for Jevity 1.5 (type of feeding formula) at 60 cubic centimeters (cc equal to 1 milliliter [ml]; a measure of fluid volume)/hour (hr) using Kangaroo pump (a medical device used to deliver liquid food, nutrients, or water directly into a person's stomach or small intestine through a feeding tube) via (by) G-tube for 20 hours to provide 1200 ml or 1800 kilocalorie (kcal, a unit of energy). On at 2 PM and off at 10 AM or until complete volume is infused.During a concurrent observation on 7/21/2026 at 10:09 AM with Registered Nurse 1 (RN 1) inside Resident 5's room, Resident 5 was observed sitting up in his wheelchair at bedside with his G tube connected to a Kangaroo pump. The pump displayed a rate of 60 mL/hr, with 144 minutes remaining, 143 mL of formula left, and a total of 2,165 ml delivered. RN 1 stated Resident 5 should have only received 1,200 ml and the feeding exceeded the amount ordered by 965 ml. RN 1 further stated receiving more than the ordered amount places Resident 5 at risk for aspiration and upset stomach due to overfeeding. RN 1 further stated when starting a new feeding, the Kangaroo pump settings should be cleared and correctly programmed according to the physician's order to ensure the displayed volume accurately reflected what the resident received.During a concurrent observation and interview on 7/21/2026 at 10:09 AM with the Director of Nursing (DON) inside Resident 5's room, Resident 5 was observed sitting up in his wheelchair at bedside with his G-tube connected to a Kangaroo pump. The pump displayed a rate of 60 mL/hr, with 144 minutes remaining, 143 mL of formula left, and a total of 2,165 ml delivered. The DON stated the Kangaroo pump's display showed the residents had received more volume than ordered, indicating the resident was overfed. The DON stated staff must follow the procedure of resetting the Kangaroo pump before starting a new feeding so the volume the resident receives accurately follows the order. The DON further stated that if a resident receives too much feeding, it could potentially lead to fluid overload, and for a resident who already has a condition such as edema (swelling caused by excess fluid trapped in the body's tissues), overfeeding can negatively affect the resident. During a review of the facility's policy and procedure (P&P) titled, Enteral Feedings, revised 8/24/2023, the P&P indicated:Review order for the enteral feeding.Administer enteral feeding formula per physician order.Set pump settings according to the physician order.Set dose limit on machine and start, if applicable.

Based on observation, interview, and record review, the facility failed to monitor the fluid restriction (a dietary change that limits the amount of liquid a person can consume in a day) for one (1) of three (3) sampled residents (Resident 10), reviewed and receiving dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney/s have failed) as indicated on the physician order and facility's policy. This deficient practice had the potential for Resident 10 to have fluid overload (harmful amount of fluid in the body) which could cause complications such as swelling, high blood pressure, shortness of breath, and pulmonary edema (an accumulation of fluid in the lungs) or fluid deficit (condition where fluid output exceeds the fluid intake) which could cause complications such as low blood pressure, electrolyte imbalances (occurs when levels of essential minerals in the body are too high or too low disrupting normal bodily functions), reduced dialysis efficiency, or cardiac arrest (sudden and unexpected cessation of heart function causing the heart to stop pumping blood to the brain and other vital organsFindings: During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 10's diagnoses included end stage renal disease (ESRD - the final, irreversible stage of kidney [vital for filtering waste, excess fluid, and toxins from the blood to produce urine] failure where kidney function declines to below 15% of normal), dependence on renal dialysis (a person's kidneys have failed, requiring a machine or medical process to clean waste and extra fluid from their blood to stay alive), and pleural effusion (an abnormal buildup of excess fluid in the space between the lungs and the chest cavity), During a review of Resident 10's Minimum Data Set (MDS, resident assessment tool), dated 6/26/2026, the MDS indicated Resident 10 had moderate cognitive impairment with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 10 was dependent (helper does all of the effort) with oral hygiene, toileting hygiene, shower/bath self, upper and lower body dressing, putting on/taking off footwear, personal hygiene, sit to stand and toilet transfer. Resident 10 needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) for eating and oral hygiene. During a review of Resident 10's Physician Orders, dated 7/10/2026, the Physician's Order indicated fluid restriction of 1200 milliliters (ml-unit of measure) per day. During a concurrent interview and record review on 7/23/2026 at 10:51 AM with Licensed Vocational Nurse (LVN 2), Resident 10's Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 7/23/2026, was reviewed with LVN2. MAR did not indicate Resident 10's oral intake to ensure fluid restriction of 1200 ml per day. During a concurrent review of Resident 10's medical records and interview on 7/23/2026 at 11:04 AM with the Registered Nurse Supervisor 1 (RNS1), RNS 1 stated she cannot find any documentation of oral intake monitoring for Resident 10. RNS1 also stated Resident 10 did not have a care plan indicating the resident's fluid restriction of 1200 ml as indicated on the physician order, dated 7/10/2026 either. During an interview on 7/23/2026 at 12:56 PM with the Director of Nursing (DON), the DON stated it was important for licensed nurses to monitor and document the oral intake of a resident receiving dialysis in order to prevent fluid overload, protect heart health, and ensure effective dialysis treatments. During a review of the facility's Policy and Procedure (P&P) titled, Fluid Restriction, effective 5/26/2026, the P&P indicatedResidents on fluid restrictions will be monitored for intake and output and will receive appropriate interventions to alleviate discomfort from the fluid restrictions for the duration of the Providers' order.Residents on fluid restrictions must have a provider order and a plan of care for the restriction which indicates the amount of fluid allowed within a 24-hour timeframe.The Licensed Nurse will: complete intake and output documentationDuring a review of the facility's P&P titled, Dialysis Management, effective 3/27/2026, the P&P indicatedThe facility should assure that each resident receives care and services consistent with professional standards of practice.Diet and fluid restrictions will be followed as ordered.All documentation concerning dialysis services and care of the dialysis resident will be maintained in the resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure a container of 18 ounces (oz, unit of measurement used to describe weight or volume) perishable (spoils quickly) raw organic kraut (uncooked, naturally fermented cabbage grown without chemical compound used to control pests) stored in the residents' refrigerator was properly labeled with the storage and expiration dates. This deficient practice had the potential to result in food borne illnesses (any illness resulting from eating contaminated/spoiled foods) to Resident 83 if the food was consumed.Findings: During a review of Resident 83's admission Record, the admission Record indicated Resident 83 was admitted to the facility on [DATE] with unspecified protein calorie malnutrition (a condition that occurs when a person's body does not get the right amount of nutrients it needs to function properly). During a review of Resident 83's Minimum Data Set (MDS, resident assessment tool), dated 6/2/2026, the MDS indicated Resident 83 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 83 was dependent (helper does all the effort) on toileting hygiene, shower, lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 83 required partial/moderate assistance (helper does less than half the effort) with oral hygiene and upper body dressing and required supervision (helper provides cues) with eating. During a concurrent observation and interview on 7/21/2026 at 1:54 PM with Licensed Vocational Nurse 3 (LVN 3) in the employee lounge where the residents' refrigerator was located, inside the residents' refrigerator was a thermal bag with boxed food items labeled with Resident 83's name. Inside Resident 83's thermal bag was an 18 oz dented plastic container of perishable raw organic kraut without an expiration date. There was also an approximately 1/4 left of light-yellow liquid in a container inside the thermal bag without a storage date. LVN 3 stated the food stored inside the residents' refrigerator should all be labeled with storage and expiration dates because the unlabeled food can spoil and pose a risk of foodborne illness to Resident 83 if consumed. During an interview on 7/23/2026 at 12:09 PM, the Dietary Services Supervisor (DSS) stated nurses should label food items stored in residents' refrigerators with the resident's name and the date the food was stored to ensure food safety. The DSS stated the proper labeling allows staff to determine when the food was stored and when it should be discarded to prevent foodborne illness. During a concurrent observation and interview on 7/24/2026 at 8:42 AM with Resident 83, the resident was observed lying in bed and stated his family brought him food and often buys his own food. Resident 83 also stated he has a thermal bag where the staff puts his food and places it in the residents' refrigerator. Resident 83 further stated the facility has a policy where they throw the food away in two to three days if not consumed. During a review of the facility's Policy and Procedure (P&P) titled, Food Brought in by Visitors, revised 4/24/2025, the P&P indicated that the facility would store food by placing the food in a food container that is clearly labeled with the resident's name and date received and stored in the refrigerator designated for this purpose. The P&P also indicated that refrigerated perishable food will be labeled, dated and discarded after 48 hours if not consumed.

Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for one (1) of seven (7) sampled residents (Resident 52) reviewed for infection control in accordance with the facility's policy and procedure (P&P) when:The facility failed to ensure trash bag was not placed on top of Resident 52's bed, next to Resident 52's right leg while Licensed Vocational Nurse (LVN) 1 was providing the resident's wound dressing change. 2. Housekeeping (HK) 1 used her feet with a small towel to clean a large puddle of liquid leaks coming out of the broken trash bag inside Rooms A and B. These deficient practices have the potential to contaminate clean items and can place Resident 52 and other residents at risk of infection. Findings: 1. During a review of Resident 52's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and muscle weakness. During a review of Resident 52's Minimum Data Set (MDS- a resident assessment tool) dated 7/10/2026, the MDS indicated Resident 1 had moderately impaired cognitive (ability to think and process information) ability. The MDS indicated Resident 52 required partial assistance (helper does less than half the effort) for toileting hygiene, showering, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 52 required supervision for eating, oral hygiene, upper body dressing and personal hygiene. During a review of Resident 52's Order Summary Report (list of doctor's orders) dated 7/16/2026, the Order Summary Report indicated Resident 52 had an order for dressing changes to a right forearm skin tear. During an observation on 7/23/2026 at 9:37 AM in Resident 52's room, LVN 1 was observed placing a trash bag on top of Resident 52's bed, next to the resident's right leg. LVN 1 was observed removing Resident 52's right arm dressing and throwing into the trash bag that was placed on Resident 52's bed. LVN 1 was observed cleaning the wound with gauze and throwing the gauze into the same trash bag. During a concurrent observation and interview on 7/23/2026 at 9:42 AM with LVN 1, a trash bag containing soiled gauze from wound care was observed on top of Resident 52's bed next to Resident 52's right leg. LVN 1 stated the trash bag with gauze that has bodily fluids should not be on the resident's bed next to the resident's right leg because the resident's leg can touch the dirty contents and the resident's bed should be maintained clean and to prevent spread of infection. During a concurrent interview and record review on 7/24/2026 at 10:14 AM with Infection Prevention Nurse (IPN), the facility's P&P titled, Infection Prevention and Control Program Description, dated 3/8/2024 was reviewed. The P&P indicated: The Infection Prevention and Control Program (IPCP) is a set of comprehensive processes that address the prevention and control of infections. Infection Prevention and Control Risk areas will be assessed. The spread of infections will be prevented. IPN stated the trash bag should not be placed on the resident's bed next to the resident because the trash from a wound dressing change is contaminated by infectious bodily fluids and can spread infection if the resident touches it or if it touches the resident's bed. IPN stated that the policy indicated that the facility would prevent the spread of infections and identify risks for infections. During an interview on 7/24/2026 at 11:11 AM with the Director of Nursing (DON), the DON stated that trash bags should not be placed on top of a resident's bed because the trash may contaminate clean areas and touch the resident which may spread infection. 2. During an observation on 7/22/2026 at 9:33 AM, HK 1 was observed inside the residents' room remove a large clear plastic trash bag from the black trash bin located between Rooms A and B. A large puddle of liquid spilled on the floor was observed coming from the large clear plastic trash bag. HK 1 discarded the trash outside the room in the trash container, wiped the puddle of liquid spilled on the floor with a small towel using her (HK 1) feet then came out and grabbed the mop to clean remaining liquid. HK 1 was then seen enter Room C afterwards. During an interview on 07/22/2026 at 1:55 PM, HK 1 stated she was supposed to use the mop and not used her feet and a small towel to clean the liquids spilled from the trash bag between Room A and Room B to prevent getting germs on her shoes and spreading them to other rooms. During an interview on 7/22/2026 at 2:09 PM, the Maintenance Assistant (MA) stated HK 1 should be using the floor mop when cleaning out spills from the clear plastic trash bag and not use a small towel and wipe the floor with her feet. MA also stated we do not know what type of germs are in that liquid spilled on the floor from the trash bag and HK 1 could spread the germs on the floor including the rest of the rooms. During an interview on 7/22/2026 at 2:20 PM, IPN stated HK 1 should have used the mop right away to clean the liquid spills from the clear plastic trash bag instead of using HK 1 feet to wipe the liquid spills from the trash bag to prevent contaminating HK 1's shoes with potential germs and bacteria's and spread them everywhere and in other residents' rooms. During an interview on 7/24/2026 at 8:55 AM, the Assistant Director of Nursing (ADON) stated HK 1 should have mopped and sanitized the floor because the staff would not know what kind of bacteria's that was mixed in the liquids that spilled from the trash, and if you use your shoes to wipe the spills those bacteria's could get to your shoes and the staff could spread those bacteria's as she walks around. ADON also stated residents could potentially pick up those germs if they do not wash their hands after picking up items on the floor. During a review of the facility's P&P titled, Housekeeping – General, revised 1/1/2012, the P&P indicated to ensure that the facility is clean, sanitary at all times so as to promote the health and safety of residents, staff and visitors. The P&P also indicated that the housekeeping department uses safe and proper methods for cleaning, disinfecting, and sterilizing all areas, surfaces, and equipment as required by law. During a review of the facility's P&P titled, Infection Control – P&P, revised 1/1/2012, the P&P indicated the facility infection control P&P are intended to facilitate maintaining a safe, sanitary environment and to help prevent and manage transmission of diseases and infections.

Based on interview and record review, the facility failed to maintain a complete record for one (1) of two (2) sampled residents (Resident 1) as indicated in the facility's policy and procedure. This deficient practice had the potential for delayed or unnecessary treatment which could negatively affect the overall wellbeing of Resident 1. 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 cardiovascular accident (CVA, commonly known as a stroke, a loss of blood flow to part of the brain, which damages brain tissue caused by blood clots and broken blood vessels in the brain), major depressive disorder (or also called clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems), and dementia (a progressive state of decline in mental abilities) During a review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 10/28/2025, the MDS indicated Resident 1 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 needed partial/ moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs but provides less than half the effort) in toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, roll left and right, sit to lying, lying to sitting on the side of the bed, sit to stand and chair/ bed-to-chair transfer and with walking for 10 feet.During a review of Resident 1's Order Summary Report (OSR) dated 10/20/2025, the OSR indicated Lorazepam 0.5 milligrams (mg, metric unit of measurement, used for medication dosage and/or amount) give 1 tablet by mouth every six hours as needed for 14 days for anxiety disorder for manifested behavior episodes of easily gets anxious, start to tremble, and hands are shaky.During a review of Resident 1's informed consent (legal and ethical requirement that ensures residents understand and voluntarily agree to medical treatment after being fully informed of its risks, benefits, and alternatives) documentation for the use of Lorazepam (medication for anxiety [emotion characterized by feelings of tension, worried thoughts and physical changes]), dated 10/21/2025, the informed consent was not marked to indicate that the facility staff obtained informed consent from the resident or responsible party.During a concurrent interview and record review on 11/25/2025 at 1:10 PM with the Director of Nursing (DON), Resident 1's Nurses Progress Notes (NPN), dated 10/21/2025 was reviewed. The NPN did not indicate any information that licensed staff spoke to the resident or responsible party. The DON stated that there was no documentation that licensed staff obtained consent from the responsible party.During an interview on 11/25/2025 at 2:36 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated he spoke to Resident 1's responsible party. (family member [FM1]) to obtain consent over the phone. LVN 1 stated he did not and should have documented this conversation with FM1 on the progress notes and consent form. During a concurrent interview and record review on 11/25/2025 at 2:41PM with LVN 1, the informed consent documentation dated 10/21/2025 was reviewed. LVN 1 stated I forgot to write FM 1's name on the verification of informed consent form. LVN 1 stated the consent form was incomplete.During a concurrent interview and record review on 11/25/2025 at 4:14 PM with the DON, the informed consent dated 10/21/2025 was reviewed. The DON stated the licensed staff should have completed the informed consent after obtaining the consent with the resident's responsible party /family member over the phone. The DON added that the licensed staff should also have documented the discussion regarding the consent obtained from the resident's responsible party in the nurse's progress notes.During a concurrent interview and record review on 11/25/2025 at 4:18PM with the DON, the facility's policy and procedure (P&P) titled, Completion & Correction, revised 1/2012 was reviewed. The P&P indicated, entries will be complete, legible, descriptive and accurate. The DON stated if the licensed staff did not have complete and accurate documentation, the licensed staff did not follow the facility's policy.During a record review of the facility's P&P titled, Completion & Correction revised 1/2012, the P &P indicated to ensure that medical records are complete and accurate. The Facility will work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation.

Based on observation, interview, and record review, the facility failed to ensure two (2) of two sampled residents (Resident 23 and 59) were treated with respect and dignity in accordance with the facility policy by failing to ensure: 1. Resident 23's clothes were clean and free of food particles. 2. Resident 59 was called by preferred name. This deficient practice has the potential to affect the residents' self-worth and self-esteem. Findings: 1. During a review of Resident 23's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses of dementia (a progressive state of decline in mental abilities) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool), dated 4/22/2025, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required supervision/ touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene but required set up or clean up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) with eating. During an observation on 6/23/2025 at 9:09 AM in Resident 23's room, Resident 23 was observed with brown and yellow food particles on her gown and bed linen. During an interview on 6/23/2025 at 1:40 PM, Certified Nursing Assistant 1 (CNA 1) stated Resident 23 was not cleaned up after her meal. CNA 1 also stated that when picking up the resident's tray, staff are also to ensure the residents are clean from food particles because it is the resident's right and dignity. During an interview on 6/25/2025 at 10:16 AM, Director of Nursing (DON) stated Resident 23 should not have food particles left on her gown and bed linen because that is the resident's dignity. During a review of the facility's Policy and Procedure (P&P) titled Accommodation of Needs, revised 1/1/2012, the P&P indicated residents individual needs are accounted for in the facility's provision of a clean comfortable bed. The P&P also indicated the facility environment is designed to assist the resident in achieving independent functioning and maintaining the resident's dignity and well-being. 2. During a review of Resident 59's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of spinal stenosis (a condition where the spaces within your spine narrow, potentially compressing the spinal cord and nerves) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 59's MDS, dated [DATE], the MDS indicated the resident was moderately impaired in cognitive skills for daily decision making. The MDS also indicated the resident required set up or clean up assistance with toileting hygiene, shower/bathe self, and personal hygiene but is independent (resident completes the activity themselves with no assistance from the helper) in eating, oral hygiene, upper body dressing, lower body dressing, and putting on/taking off footwear. During an observation on 6/23/2025 at 11:01 AM, Receptionist (RC) was observed calling Resident 59 grandma. During an interview on 6/24/2025 at 1:28 PM in Resident 59's room, Resident 59 stated she does not like being called grandma, but the staff calls her anything they want. Resident 59 also stated she likes to be called Miss. During an interview on 6/25/2025 at 10:25 AM, RC stated I did, and I should not have called Resident 59 grandma because it is the resident's dignity. During an interview on 6/26/2025 at 11:45 AM, DON stated RC should not have called Resident 59 grandma because the facility staff would have to refer the resident by her name due to the resident's dignity. During a review of the facility's P&P titled Quality of Life Resident Rights, revised 3/2017, the P&P indicated the facility staff to always speak respectfully to residents, including addressing the resident by his or her name of choice.

Based on observation, interview, and record review, the facility failed to implement proper gastrostomy tube (GT - a tube that is surgically inserted into the resident's stomach to allow access for food, fluids, and medications) practices and procedures for two of three sampled residents (Residents 61 and 69) by failing to ensure: 1. Resident 69's head of bed was elevated at least 30 degrees while receiving enteral feeding (a method of providing nutrition directly to the gastrointestinal tract when a person cannot eat by mouth) in accordance with the facility's policy and physician's order. 2. The GT feeding was connected to Resident 61, allowing all feeding to be given as prescribed by the physician These deficient practices placed Resident 69 at risk for aspiration (accidental inhalation of foreign material [like food, liquid, or stomach contents] into the airways and lungs) and had the potential to place Resident 61 to receive an incorrect total feeding amount received in a day that can lead to malnutrition (lack of proper nutrition in the body). Findings: 1. During a review of Resident 69's admission Record, the admission Record indicated Resident 69 was initially admitted to the facility on [DATE], with the diagnoses including but not limited to hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis [loss of motor function in one or more muscles] on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a stroke, damage to tissue in the brain due to loss of oxygen to the area) affecting left non-dominant side, acute respiratory failure (an inability to maintain adequate oxygenation for tissues or adequate removal of carbon dioxide from tissues) with hypoxia (lack of oxygen in the tissues to sustain bodily function), and dementia (progressive brain disorder that slowly destroys memory and thinking skills). During a record review of Resident 69's Physician Order Summary Report, dated 4/25/2025, the order indicated every shift Glucerna 1.2 (a meal replacement or supplement made specifically for individuals with diabetes) at 60 cubic centimeter/hour (cc/hr, measurement of volume flow rate) using Feeding Pump (a medical device designed to deliver enteral nutrition directly into gastrointestinal tract) via GT for 20 hours to provide 1200 cc/1440 kilocalorie (kcal, equal to one calorie) until complete volume infused. Start pump at 2 PM. During a record review of Resident 69 Minimum Data Set (MDS, a resident assessment and tool), dated 5/12/2025, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were severely impaired. The MDS indicated Resident 69 required substantial/maximal assistance (helper does more than half the effort) for sitting to lying, sitting to standing, and chair-bed-to-chair transferring. The MDS indicated Resident 61 had a feeding tube. During a record review of Resident 69's Care Plan, revised on 5/20/2025, the care plan indicated Resident 69 required a GT related to dysphagia (difficulty swallowing). The care plan interventions for staff were to keep the head of the bed elevated to 45 degrees during and thirty minutes after tube feeding and listen to lung sounds every shift and as needed. During a record review of Resident 69's Physician Order Summary Report, dated 7/17/2024, the order indicated every shift elevate head of bed 30 - 45 degrees during feedings. During an observation on 6/23/2025 at 9:38 AM in Resident 69's room, Resident 69 was lying awake on his back in bed. Resident 69's head of bed was elevated around 20 degrees while the Glucerna enteral feeding was infusing at 60 cc/hr. During a concurrent observation and interview on 6/25/2025 of Resident 69's bed position on 6/23/2025 with the Director of Nursing (DON), the DON stated Resident 69's head of bed was less than a 30-degree angle. During review of Resident 69's care plan revised on 5/20/2025 with the DON, the DON stated Resident 69's care plan indicated Resident 69 should be positioned at 45 degrees during enteral feedings. The DON stated the head of bed of residents receiving enteral feedings should be positioned at 35-45 degrees. The DON stated residents could aspirate when the head of the bed was not elevated to at least 35 degrees. The DON stated pneumonia (lung inflammation caused by bacterial or viral infection) and hospitalization could result when residents aspirated the enteral feedings. During a record review of the facility's policy and procedure titled, Enteral Feedings, revised 8/24/2023, the policy indicated the head of bed should be elevated 30 degrees during enteral feedings. 2. During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was admitted to the facility on [DATE] with diagnoses that included gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dementia (a progressive state of decline in mental abilities) and dysphagia. During a review of Resident 61's MDS, dated [DATE], the MDS indicated Resident 61 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 61 was dependent (helper does all effort needed to complete activity) with toileting hygiene and lower body dressing and substantial/maximal assistance with oral and personal hygiene, eating and bathing/showering. The MDS also indicated Resident 61 received 51% or more of his nutrition through a feeding tube (GT). During a review of Resident 61's Order Listing Report, dated 6/26/2025, the Order Listing Report indicated Enteral Feed Order: a. Every shift check for placement and patency, revised 6/3/2025. b. Every shift continuous water via GT- administer 30 milliliters (mL - a measurement of volume) /hour x 20 hours to provide 600 cc, revised 6/3/2025. c. Every shift Glucerna 1.2 at 75 ml/ hour (hr) via pump x 20 hours = 1500 ml/24h via GT, revised 6/11/2025. During an interview on 6/24/2025 at 8:38 AM with Licensed Vocational Nurse (LVN) 3 at Resident 61's bedside, Resident 61 was observed with Glucerna that leaked into Resident 61's bed, creating a pool of the Glucerna feeding next to Resident 61 and spilling onto floor. LVN 3 stated the GT feeding had leaked out of the GT tubing and/or GT and should not be leaking. LVN 3 stated staff are to check to make sure all tubing is connected to Resident 61 to ensure the resident is getting the nutrition the resident needed and not spilling on the floor or bed. During an interview on 6/25/2025 at 1:39 PM with the DON, the DON stated nurses are to make sure the GT feeding is properly connected and running as ordered per the facility's policy because if the GT Feeding is leaking, that means the resident is not receiving the full prescribed amount of GT feeding and is at risk of preventable weight loss. During a review of the facility's policy and procedure (P&P) titled Enteral Feeding- Closed, revised 1/1/2012, the P&P indicated enteral feeding will be administered via pump as ordered by the Attending Physician. The P&P also indicated the procedure to review order, check resident for tube placement and to connect container and tubing.

2. During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness one side of the body), dementia (a progressive state of decline in mental abilities), 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 dysphagia (difficulty swallowing). During a review of Resident 61's Order Listing Report, revised 3/26/2025, the Order Listing Report indicated an order to swab/suction every shift as appropriate. During a review of Resident 61's MDS, dated [DATE], the MDS indicated Resident 61 had moderately impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 61 was dependent (helper does all effort needed to complete activity) with toileting hygiene and lower body dressing and substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with oral and personal hygiene, eating and bathing/showering. During a review of review of Resident 61's Medication Administration Record (MAR), dated 5/31/2025, the MAR indicated an order to suction as needed for excessive secretion for seven (7) days. The MAR also indicated suction was only administered to Resident 61 on 6/3/2025. During a concurrent observation at Resident 61's bedside on 6/24/2025 at 8:54 AM and interview with LVN 3, the following suction equipment was observed: a. A suction yaunker in open packaging, dated 5/31/2025 b. Suction tubing dated 5/31/2025 c. A collection canister dated 5/31/2025 with white sections/ fluid seen inside. LVN 3 stated all of Resident 61's suction equipment should have been discarded and changed. LVN stated it was important to discard and change the equipment per policy because bacteria (harmful microorganisms) can build up and cause contamination (the introduction of harmful or undesirable substances or microorganisms) with the equipment, leading to the worsening of Resident 61's respiratory infection and the spread of bacteria. During a concurrent interview and record review on 6/25/2025 at 1:39 PM with the DON, the facility's policy and procedure (P&P) titled, Cleaning & Disinfection of Resident Care Equipment, revised 1/1/2012, the P&P indicated: a. Semi-critical items consist of items that come in contact with mucous membranes or non-intact skin (e.g. respiratory therapy equipment). b. Single resident-use items are cleaned/disinfected between uses by a single resident and disposed of afterwards. c. Single-use items are disposed of after a single use. d. Semi-critical items are sterilized/disinfected in a processing location and stored appropriately until use. The DON stated suction equipment including Resident 61's yaunker, suction tubing and collection canister are considered single use items, according to the facility's protocol and is discarded after each use. The DON stated Resident 61's collection canister should not have been at the bedside for more than 24 hours after use and should have been discarded and replaced, along with the yaunker and tubing. The DON stated it is important to ensure suction equipment is discarded and changed per policy for single use items to prevent infections and/or the spread of infections to other residents. During an interview on 6/26/2025 at 11:53 AM with the infection Preventionist Nurse (IPN), the IPN stated it is important for suction equipment to be changed because bacteria (harmful microorganisms) can grow in the equipment and then transferred back to the residents' mouth during suctioning and negatively affect the residents by becoming sick or sepsis (a life-threatening blood infection). Based on observation, interview, and record review, the facility failed to ensure two (2) of three (3) sampled residents (Residents 76 and 61) received respiratory care in accordance with the facility's policy by failing to ensure: 1. Resident 76 had a physician's order for the use of oxygen therapy. This deficient practice had the potential for Resident 76 to receive the incorrect amount of oxygen which could lead to shortness of breath (SOB), worsening conditions, and hospitalization. 2. The suction equipment including yankauer (a curved tube with a large opening, used for suctioning fluids and debris from a resident's airway [mouth and/or throat], suction tubing and collection canister (a temporary container used to collect secretions or fluids removed from the body such as saliva) was discarded and replaced. This deficient practice had the potential to cause preventable respiratory infections to Resident 61. Findings: 1. During a review of Resident 76's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included type 2 Diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), cerebral infarction (loss of blood flow to a part of the brain) and dependence on oxygen. During a review of Resident 76's Minimum Data Set (MDS, a care assessment and screening tool) dated 4/18/2025, the MDS indicated the resident was assessed to have severely impaired cognition (capable of remembering, learning new things, concentrating, or making decisions that affect everyday life) and was dependent (helper does all effort) when showering, lower body dressing, putting on footwear and personal hygiene. The MDS also indicated Resident 76 was assessed to require substantial/maximal assistance (helper does more than half the effort) for eating, oral hygiene, toileting hygiene, and upper body dressing. The MDS also indicated Resident 76 required oxygen therapy. During an observation on 6/23/2025 at 9:43 AM, Resident 76 was observed in his room receiving oxygen at two (2) liters per minute (LPM, dose measurement for delivery of oxygen). During a concurrent record review and interview on 6/23/2025 at 10 AM with Licensed Vocational Nurse 1 (LVN 1), Resident 76's Order Summary Report (OSR) was reviewed. The OSR indicated that Resident 76 did not have an order to receive oxygen therapy. LVN 1 stated that Resident 76 is receiving oxygen but does not have a doctor's order to receive oxygen. LVN 1 stated that the resident may have respiratory distress (difficulty breathing), and SOB if they receive too much oxygen. LVN 1 stated this may cause the resident to be sent to the hospital. During a concurrent interview and record review on 6/25/2025 at 9:53 AM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Oxygen Therapy, dated 11/2017, was reviewed. The P&P indicated: 1. The purpose of the policy is to ensure the safe administration of oxygen in the facility. 2. Administer oxygen per physician orders. The DON stated that the P&P indicated that it is necessary to have a physician's order to administer oxygen. The DON stated that if a resident gets oxygen without an order they may receive too much oxygen and their condition may worsen. The DON stated that this may lead to hospitalization.

Based on observation, interview and record review, the facility failed to dispose of expired vegetables stored in the facility kitchen's refrigerator during a kitchen observation conducted on 6/23/2025. This deficient practice had the potential to cause food-borne illnesses. Findings: During a concurrent observation and interview on 6/23/2025 at 8:10 AM with Dietary Aide (DA) 2, the following foods were found in the kitchen's refrigerator: lettuce with expiration date 6/21/2025, cilantro with expiration date 6/19/2025, parsley with expiration date 6/19/2025 and cucumbers with expiration date 6/22/2025. DA 2 stated that the vegetables are expired and residents can get sick if they eat expired food. During a concurrent interview and record review on 6/25/2025 at 9:16 AM with Registered Dietitian (RD) the facility's policy and procedure (P&P) titled, Food Storage and Handling dated 6/4/2024 was reviewed. The P&P indicated that fresh vegetables should be checked and sorted for ripeness and should be labeled and dated. RD stated that the labels on the vegetables found in the kitchen's refrigerator indicate that they are expired and should have been thrown away. RD stated that the vegetables were not checked before the expiration date. RD stated that it is important to properly label foods to ensure that expired foods are not used. RD stated that residents can get sick if they eat expired foods.

Based on observation, interview and record review, the facility failed to dispose of garbage properly in the facility's garbage disposal area during kitchen observation conducted on 6/23/2025. This deficient practice had the potential to attract pests and spread disease. Findings: During an observation on 6/23/2025 at 8:26 AM, the facility's trash was observed with trash bins overflowing with trash, trash bins with lids that were not completely closed, trash bags on the floor, a hamper used as a trash can and uncovered trash cans. During a concurrent interview and observation on 6/23/2025 at 8:31 AM with Dietary Aide (DA) 1, the facility's garbage disposal area was observed. DA 1 stated that trash bags should not be on the floor, trash should be covered, and hampers should not be used as a trash can. DA 1 stated that animals can get into the trash if it's not covered and they may spread disease. During a concurrent interview and record review on 6/25/2025 at 9:12 AM with Dietary Supervisor (DS) the facility's policy and procedure (P&P) titled, Waste Management dated 4/21/2022 was reviewed. The P&P indicated: 1. The purpose of the policy is to reduce the risk contamination from regulated waste and maintain appropriate handling and disposable of all waste. 2. Waste containers must closable. 3. Waste must be disposed of in appropriate, non-combustible (burnable) waste containers 4. Waste bags must be disposed of into covered waste bin. DS stated that it is important to dispose of trash in a closable container to keep pests away because trash can attract more pests and they may transmit disease. DS stated that hampers should not be used as trash cans. DS stated that trash should not be on the floor.

2. During a review of Resident 38's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of exposure to COVID and bullous pemphigoid (a chronic autoimmune skin disorder characterized by itchy, blistering skin lesions, most commonly affecting older adults). During a review of Resident 38's Minimum Data Set (MDS, resident assessment tool), dated 4/8/2025, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 38 was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with putting on/taking off footwear The MDS also indicated Resident 38 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathe self and lower body dressing. The MDS indicated Resident 38 required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort) with toileting hygiene. During an observation on 6/23/2025 at 10:26 AM, CNA 1 was observed coming out of Resident 38 's room with a set of gloves on. CNA1 closed the door of Resident 38 before doffing his gloves. During an interview on 6/23/2025 at 10:55 AM, CNA 1 stated he provided peri-care to Resident 38. CNA 1 also stated he should not have used the same gloves to close the resident's room door. CNA 1 stated he should have doffed the gloves and performed hand hygiene prior to exiting the resident's room to prevent the spread of infection. During an interview on 6/25/2025 at 11:21 AM, the IPN stated CNA 1 should have doffed his gloves and performed hand hygiene before exiting Resident 38 's room to prevent the spread of infection. IPN also stated CNA 1 can spread COVID since the facility is currently in an outbreak. During an interview on 6/26/2025 at 1:15 PM, the Director of Nursing (DON) stated it is not acceptable for CNA1 to use dirty gloves to close Resident 38's room door because that can spread infection. The DON also stated CNA1 should have doff gloves and perform hand hygiene before exiting the resident's room. During a review of the facility's P&P titled, Personal Protective Equipment, revised 01/01/2012, the P&P indicated the facility staff are required to wear PPE when performing a task that may involve exposure to body fluids. The P&P also indicated gloves are used only once and are discarded into the appropriate receptacle located in the room in which the procedure is done, and hands are washed before and after removing of gloves. During a review of the facility's P&P titled, Hand Hygiene, revised 9/1/2020, the P&P indicated situations that require hand hygiene are not limited to the following: 1. After contact with body fluids 2. After doffing PPE 3. Immediately exiting a resident's room Based on observation, interview and record review, the facility failed to maintain infection control (methods used to prevent, control, or stop the spread of infections) and prevention as indicated in the facility's policy by failing to ensure: 1. Certified Nurse Assistant 1 (CNA 1) and Family Member 2 (FM 2) wore personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) as indicated while inside of novel respiratory isolation (separation of residents with a suspected or confirmed Coronavirus [COVID-19, a severe infection mainly respiratory disease that could spread from person to person]) infections rooms, Room A and Room B. 2. CNA 1 doff (remove an item or clothing) and dispose PPE and perform hand hygiene (cleaning hands to prevent germs) after providing peri-care (cleaning the genitals and anal area) to Resident 38. These failures had the potential to result in an increased risk for the spread of bacteria, viruses and pathogens (harmful microorganisms) to residents, visitors and staff throughout the facility, while increasing the risk of [preventable] infections. Findings: 1. During an observation on 6/23/2025 at 8:51 AM on Room A's wall near the doorway, a Novel Respiratory Precautions sign was observed that indicated, on room entry, to clean hands, wear a gown, an N-95 ( disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) and face shield or goggles and gloves and then to clean hands when exiting [the room]. CNA 1 was observed entering the room without a face shield. During an interview on 6/23/2025 at 8:56 AM with CNA 1, CNA 1 stated Room A is an isolation room that requires the PPE of a face shield. CNA 1 stated he should have worn one while inside of the room. CNA 1 also stated according to the policy, he needs to wear all required PPE including the face shield and apply it before entering the residents' rooms to prevent spreading a virus. During an observation on 6/23/2025 at 12:08 PM outside of Room B, FM 2 was observed putting on PPE with Licensed Vocational Nurse 2 (LVN 2) for novel respiratory precautions. FM 2 was observed with an N-95 mask upside down and the metallic strip under the chin instead of the nose. FM 2 then entered Room B. During a concurrent interview and record review on 6/23/2025 at 12:24 PM with LVN 2, the N95 Particulate Respirator Wearing Instructions and Fit Check (undated) was reviewed. The wearing instructions indicated to wear the mask with the metallic strip facing up, adjust metallic strip over the bridge of the nose and to press down until there is a close fit. The Fit check indicated to tighten the metallic strip over the as needed until a tight seal is achieved to ensure a proper fit. LVN 2 stated that FM 2 was wearing the N-95 incorrectly and the metallic strip should have been on the nose instead of the chin area to make sure it was a tight fit. LVN 2 also stated if the fit for the N95 is not proper or tight, COVID-19 could spread to other visitors, residents and/or staff. During an interview on 6/26/2025 at 11:53 AM with the Infection Preventionist Nurse (IPN), the IPN stated per facility protocol, novel respiratory precautions require anyone entering the room to wear an N-95, face shield, gown and gloves and to put them on before entering the room. IPN stated the N-95 is to be worn correctly with the metal strip across the nose to ensure it seals and works correctly. IPN also stated wearing all of the necessary PPE and wearing it correctly is important to prevent exposure and spreading of the virus to others, possibly causing a widespread outbreak Covid-19. During a review of the facility's policy and procedure (P&P) titled, Management of COVID-19, revised 10/11/2022, the P&P indicated the standard and transmission-based precautions (TBP) will be implemented for patients suspected or confirmed to have COVID-19, facility will follow local/county public health and state regulations when applicable, and for confirmed or undiagnosed respiratory infections in residents, staff follows isolation precautions of facemask, gloves, isolation gown and eye protection to prevent the development and transmission of COVID-19. During a review of the facility's P&P titled, Resident Isolation- Categories of Transmission - Based Precautions, revised 1/1/2012, the P&P indicated transmission-based precautions are used when caring for residents who are documented or suspected of having communicable diseases or infections that can be transmitted to others, whenever measures more stringent than standard precautions are needed to prevent or control the spread of infection.

Based on interview and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 1) was provided with cardiopulmonary resuscitation (CPR-a lifesaving emergency procedure for a victim who has signs of cardiac arrest [a situation when a victim becomes unresponsive, no normal breathing, and no pulse]), in accordance with the standard of practice on basic life support and the facility's cardiopulmonary resuscitation policy by failing to: 1. Ensure facility staff immediately start CPR when Resident 1 was found unresponsive (no movement or response to stimuli and no pulse or respirations). Instead, Licensed Vocational Nurse 1 (LVN 1) walked to the nurses' station, which was about 30 feet away from the resident to check on the resident's code status (type of emergent treatment a resident would or would not receive if their heart or breathing were to stop) before starting CPR. 2. Ensure facility staff immediately start CPR when Resident 1 was found unresponsive. Instead, Resident 1 was moved from outside his room to the resident's room, which was about 10 feet away, and placed on the bed prior to starting CPR. As a result of these failures, Resident 1 did not receive immediate CPR and was pronounced dead by the paramedics (healthcare professional that respond to emergency calls and performs CPR to the victims) on [DATE] at 9:23 PM, 35 minutes after Resident 1 became unresponsive, due to cardiac and respiratory arrest (heart and lungs stopped functioning) related to asphyxia (the state or process of dying from not having enough air or unable to breathe). Findings: On [DATE] at 11:50 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding quality-of-care services. The survey team notified the Director of Nursing (DON), the Administrator (ADM), the [NAME] President of Operation (VPO), and Quality Assurance (QA) consultant of the IJ situation due to delay in the initiation of CPR to Resident 1. On [DATE] at 9:52 PM, the IJ was removed in the presence of the ADM, VPO, Chief of Business Development (CBD), QA, and the DON after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and the surveyor verified/confirmed onsite the facility's implementation of the IJ Removal Plan and the IJ situation was no longer present. The IJ Removal Plan dated [DATE], included the following: 1. On [DATE], the DON/Designee immediately provided an in - service education to the Nursing Staff regarding Aspiration/Choking Precautions. 2. On [DATE], DON initiated an in - service education to the Nursing Staff, and sitters regarding meals/snacks distribution, aspiration/choking precautions, emergency response - code blue, supervision, validation of diet prior to distribution. This in-service will be completed by [DATE]. Nursing Staff and sitters on leave or unscheduled will receive education upon return to work. 3. On [DATE], an American Heart Association accredited outside vendor for CPR Classes (CPR-911), came to the facility and provided an in - service education and competency assessment for Licensed Nurses, CNAs, and other staff on CPR and Heimlich Maneuver. 4. On [DATE], an American Heart Association accredited outside vendor for CPR Classes (CPR-911), came to the facility and initiated an in - service education and competency assessment for Licensed Nurses, CNAs and other staff on CPR and Heimlich Maneuver. This in-service will be completed by [DATE] to ensure that a CPR certified staff is available at all times to provide CPR immediately when needed. 5. On [DATE], the DON provided an in - service education to the Licensed Nurses regarding Emergency Response, Change of Condition, Unusual Occurrence, and Resident Supervision. 6. On [DATE], the DON provided an in - service education to the Licensed Nurses, CNAs, and other staff from other departments regarding the policy and procedures for Cardiopulmonary Resuscitation/Emergency Response. 7. On [DATE], the DON provided an in - service education to the Licensed Nurses, CNAs, and other staff from other departments regarding the policy and procedures for Cardiopulmonary Resuscitation/Emergency Response. Staff on leave or unscheduled will receive education upon return to work. 8. On [DATE], the DON/Designee conducted an audit of residents who had code blue emergencies and became unresponsive after choking within the last 30 days, to ensure that licensed nurses-initiated CPR immediately without delay. There were no other residents identified to have been affected by the same deficient practice. 9. On [DATE], the DON/Designees conducted an audit and observation of current residents during meals to ensure that residents received accurate diet texture as ordered. 10. On [DATE], the DON/Designees conducted an audit and observation of current residents that received HS snacks to ensure that residents received accurate food texture as ordered. There are 30 residents that received HS snacks and all residents identified received accurate diet texture. 11. On [DATE], the DON/Designees conducted an audit of current residents and reviewed the most recent MDS, ST Notes/Discharge Summaries within the last 30 days to identify residents' required level of assistance with eating, residents at risk for aspiration/choking, to ensure that a care plan for risk for aspiration/choking are developed and implemented accordingly. 35 residents out of total current census of 94 were identified to be at risk for aspiration/choking based on their current diagnoses, diet orders, recent changes of condition, and/or speech therapy evaluation and discharge summary. 12. An ADHOC (for this) meeting is scheduled to be conducted on [DATE], with Administrator and QAA Members, to review the recent incident of choking, current practices and policies related to aspiration, and emergency response. 13. On [DATE], the DON/Designee conducted an audit and observation of current residents with resident/family preference of being assisted with eating by private caregivers to ensure that the private caregiver(s) have received adequate training. There are six other residents identified to have the preference of being assisted with eating by private caregivers and none were affected by the same deficient practice. 14. The Speech Therapist (ST) is scheduled to initiate an in-service education to the nursing staff regarding different diet textures. This in-service will be completed by [DATE]. Nursing Staff on leave or unscheduled will receive education upon return to work. 15. Upon identification or request by a resident or caregiver/family member to provide assistance with eating, the ST will provide training to the interested caregiver and document the training in residents' records. PROCESS: a. Evening (3 PM-11 PM) Shift Nursing Supervisor will print a copy of diet orders and dietary supplements to be used in validation of meals and snacks served for the day. Any new orders/changes in orders will be communicated by the receiving licensed nurse to the CNA, and a new copy of diet orders will be printed out for reference. b. The Dietary Supervisor/Designee will print and place a copy of Diet Orders in a folder in the meal cart during mealtimes for reference. c. Licensed Nurses will check and validate meal trays and snacks prior to distribution to residents. d. Any snacks or food items picked up by CNAs will be checked by a Licensed Nurse prior to distribution to residents. e. Meal Trays and snacks will be distributed to the residents by nursing staff. f. Diet Orders, Dietary Supplement Orders, and Required Level of Assistance with Eating will be made available in the Diet Binder at each nurse's station and dining room for reference. The DON/Designee will be responsible for updating these lists. g. Snacks provided by the kitchen that are not resident-specific will be sorted and labeled according to texture (i.e., Regular, Mechanical Soft, Puree, etc.) h. On [DATE], the DON/Designee conducted competency assessments to nursing staff to ensure that residents receive their prescribed diet orders with appropriate verification of food texture and fluids consistency prior to meal distribution. CPR Procedure: Responding to Cardiopulmonary Emergency 1. Check the victim for responsiveness, respiration, and pulse. a. If the victim responds but is injured, follow the facility protocol for first aid or call 911. b. Verify, or instruct a staff member to verify the code status of the individual. c. If the resident shows signs of irreversible death, cardiopulmonary resuscitation may be withheld. The physician shall be contacted immediately. 2. If the victim is unresponsive (no movement or response to stimuli, and no pulse or respirations, activate the Emergency response team). a. Call for help and send someone to contact the EMS or 911 for emergency medical assistance. b. Send someone for the emergency cart and supplies, and to announce your facility code for medical emergencies. c. Initiate CPR in accordance with AHA guidelines. d. CPR will be initiated at the place of incident if area is safe; if area is not safe, resident will be moved to a safe area immediately and CPR will be initiated. e. Continue CPR until the EMS arrives and assumes care of the resident. 16. The DON/DSD will conduct Code Blue Drills every 3 months to ensure that staff are aware and trained in all emergency procedures, administering CPR, and responding to Residents who are choking and who become unresponsive. 17. The DON/Designee will conduct a review of residents weekly for 4 weeks then bi-monthly for 2 months who had code blue emergencies and became unresponsive after choking to ensure that licensed nurses-initiated CPR immediately without delay. Identified concerns will be immediately addressed and reported to DON for follow-up and resolution as warranted. 18. The DON/Designee will conduct an audit of residents' records and observation of current residents with resident/family preference of being assisted with eating by private caregivers, weekly for 4 weeks then bi-monthly for 2 months, to ensure that the private caregiver(s) have received adequate training. 19. The Administrator will conduct a review and audit of CODE Blue Drill Records monthly for 3 months to ensure that current staff have participated in the drills. Any issues identified will be addressed by the Administrator immediately. 20. The DON will present the results of CODE Blue Emergency Response audits, and Caregiver Training audits to the Quality Assurance and Performance Improvement for review and recommendations monthly for 3 months or until substantial compliance is achieved. 21. The Administrator will present the results CODE Blue Drill records audits to the Quality Assurance and Performance Improvement for review and recommendations monthly for 3 months or until substantial compliance is achieved. 22. The Administrator and DON will be responsible for monitoring and sustaining compliance. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included dysphagia oropharyngeal phase (difficulty transferring food from the mouth into the pharynx [passage leading from the mouth and nose to the esophagus {organ that food travels through to reach the stomach for further digestion] and the larynx [voice box]) and esophagus to initiate an involuntary swallowing process) and generalized muscle weakness. A review of Resident 1's Physician's Order, dated [DATE], indicated a diet order for no added salt (NAS, food is seasoned as regular food), consistent (or controlled) carbohydrate (one of several substances such as sugar or starch that provide the body with energy) diet (CCHO, a restrictive diet that involves eating the same numbers of carbohydrate daily) mechanical soft texture (food item that has been blended, mashed, mixed, or processed into a smooth and uniform texture), nectar thick consistency (easily pourable and are comparable to heavy syrup found in canned fruits). A review of Resident 1's Physician's Order, dated [DATE], indicated a CPR order. A review of Resident 1's History and Physical (H&P), dated [DATE], indicated Resident 1 does not have the capacity to understand and make decisions. A review of Resident 1's ST Notes, dated [DATE], included diet precautions for the resident to receive NAS CCHO mechanical soft texture, nectar thick consistency. A review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated [DATE], indicated the resident had severely impaired cognitive skills (ability to understand and make decision) for daily decision making. The MDS indicated Resident 1 required supervision (helper provides verbal cues) with eating and oral hygiene and required substantial assistance (helper does more than half the effort) with toileting, hygiene, shower, lower body dressing, and putting on/taking off footwear. Resident 1 required partial assistance (helper does less than half the effort) with upper body dressing. A review of Resident 1's Change in Condition (COC) Evaluation, dated [DATE] at 1:20 AM, indicated on [DATE] at 8:48 PM, CNA 1 called for assistance to check on Resident 1 who had a COC. COC evaluation indicated Resident 1 did not have a pulse. CPR was initiated by facility staff until paramedics arrived. Resident 1 was pronounced dead by the paramedics on [DATE] at 9:23 PM. During an interview on [DATE] at 2:25 PM, Certified Nurse Assistant 1 (CNA 1) stated on [DATE] at around 8:40 pm, she was sitting next to Resident 1, just outside of his room. Resident 1 was on a recliner wheelchair eating a sandwich when the resident started coughing. CNA 1 stated she saw a third of the sandwich inside Resident 1's mouth so CNA 1 removed it. CNA 1 stated she asked Uncertified Assistive Personnel 1 (UAP 1) who was sitting near her to assist in getting Resident 1 up so CNA 1 can perform the Heimlich maneuver (a procedure used to force a foreign object from a choking victim's airway [organ that allow airflow to the lungs] by performing abdominal thrusts) because Resident 1 did not respond when CNA1 asked him if he was okay. CNA 1 stated she then performed the Heimlich maneuver to Resident 1. CNA 1 stated Registered Nurse 1 (RN 1) arrived and saw the resident unresponsive with his lip turning blue. CNA 1 stated Resident 1 was moved back to room onto the bed, which was 10 feet away from the hallway, in accordance with RN 1's instructions. During an interview on [DATE] at 2:57 PM, UAP 1 stated, CNA1 instructed her to pick up a sandwich for Resident 1 from the residents' refrigerator around 8:15 PM on [DATE]. UAP 1 stated she grabbed extra sandwiches to hand out to other residents. UAP 1 stated she gave Resident 1's sandwich of regular texture with unknown content to CNA 1. UAP 1 stated CNA 1 gave Resident 1 the sandwich. UAP 1 further stated she saw Resident 1 eating the sandwich and after a few minutes, saw Resident 1 coughing. UAP 1 stated CNA 1 removed a piece of sandwich from Resident 1's mouth and performed the Heimlich maneuver because the resident was unresponsive. During an interview on [DATE] at 3:54 PM, LVN 1 stated she rushed to check on Resident 1 who was just outside his room. LVN 1 stated Resident 1 was unresponsive, so she went back to the nurses' station to check on Resident 1's code status. LVN 1 stated as soon as she found out that Resident 1 was a full code (if a resident's heart stopped beating or stopped breathing, all resuscitation procedures will be provided to keep the resident alive), she went back to the resident who was being wheeled by the staff back to his room. LVN 1 stated she called 911 (number to contact for emergency services) at this time. LVN 1 stated as soon as Resident 1 became unresponsive and without a pulse, CPR should have been initiated by the staff because every second counts. LVN 1 stated staff should have left Resident 1 where he was, which was outside his room, instead of moving him back in his room on to his bed. During an interview on [DATE] at 3:56 PM, LVN 1 stated Resident 1 was on dysphagia (difficulty swallowing) mechanical soft diet with nectar thick consistency and should not have been given a sandwich because of the resident's difficulty with swallowing. LVN 1 stated Resident 1 could not swallow a sandwich because it is considered a regular texture. LVN 1 also stated, according to CNA 1, UAP 1 gave the sandwich to Resident 1. During an interview on [DATE] at 5 PM, RN 1 stated on [DATE] around 8:48 PM, LVN 1 called her to check on Resident 1 due to change of condition. RN 1 stated that when she arrived outside Resident 1's room, RN 1 observed Resident 1 was already cyanotic (bluish skin color due to inadequate oxygen in the blood) and unresponsive. RN 1 further stated she tried to check Resident 1's mouth but did not see any obstruction or foreign body and instructed CNA 1 and the other CNAs helping out to transfer Resident 1 back to his room and placed on to his bed. RN 1 stated she then instructed LVN 1 to get Resident 1's chart at the nurses' station to check on the resident's advanced directives (a legal document that indicates resident's wishes about receiving medical care if the resident is no longer able to) and to verify code status. RN 1 stated she then initiated CPR to Resident 1 after LVN 1 arrived in the resident's room confirming Resident 1 was a full code. During an interview on [DATE] at 5:03 PM, RN 1 stated they did not initiate CPR outside Resident 1's room, where he was found unresponsive but instead initiated it when Resident 1 was moved back in his room to his bed, for privacy because there were other residents around watching. During an interview on [DATE] at 10:26 PM, CNA 1 stated Resident 1 turned blue and became unresponsive while she was doing the Heimlich maneuver. CNA 1 stated she was instructed by RN 1 to move Resident 1 back in his room and place on his bed when Resident 1 turned cyanotic and unresponsive. CNA 1 stated RN 1 initiated CPR when Resident 1 was placed back on his bed. During a concurrent observation and interview on [DATE] at 8:10 PM, the Director of Nursing (DON) stated there was about 30 feet from the nurses' station to Resident 1's room. A review of the facility's Policy and Procedure titled, Cardiopulmonary Resuscitation, dated [DATE], indicated steps in responding to cardiopulmonary emergencies to include checking the victim for responsiveness, respirations, and pulse. The policy also indicated that if the victim was unresponsive to activate the emergency response team by: 1. Calling for help and sending someone to contact the Emergency Medical Services (EMS) or 911 for emergency medical assistance. 2. Sending someone for the emergency cart (used to transport and dispense emergency medications and supplies) and supplies, and to announce your facility code for medical emergencies. 3. Initiate CPR in accordance with the American heart Association (AHA) guidelines. A review of Basic Life Support Provider Manual by American Heart Association, dated 2020, indicated: High-quality CPR with minimal interruptions and early defibrillation (administering a controlled electric shock to allow restoration of the normal rhythm.) are the actions most closely related to good resuscitation outcomes. High quality CPR if started immediately after cardiac arrest combined with early defibrillation can double or triple the chances of survival. These time-sensitive interventions can be provided both by members of the public and by healthcare providers. Bystanders who are not trained in CPR should at least provide chest compressions (act of applying pressure to someone's chest in order to help blood flow through the heart in an emergency situation). Even without training, bystanders can perform chest compressions with guidance from emergency telecommunicators over the phone; the signs of severe airway obstruction included clutching the throat with the thumb and fingers, making the universal choking sign, unable to speak or cry, weak/ineffective cough or no cough at all, and the rescuer actions included: to take step immediately to relieve the obstruction, if severe airway obstruction continues and the victim becomes unresponsive, start CPR. A review of Basic Life Support Provider Manual by American Heart Association, dated 2020, indicated: a choking victim's condition may worsen, and the victim may become unresponsive. If the rescuer is aware that a foreign-body airway obstruction is causing the victim's condition, you will know to look for a foreign body in the throat. To relieve choking in an unresponsive adult, follow these steps: 1. Shout out for help. Send someone to activate the emergency response system. 2. Gently lower the victim to the ground if you see that they are becoming unresponsive 3. Begin CPR, starting with chest compressions. Do not check for a pulse. Each time you open the airway to give breaths, open the victim's mouth wide. Look for the object. 4. If you see an object that looks easy to remove, remove it with your fingers 5. If you do not see an object, continue CPR. 6. After about five (5) cycles or two (2) minutes of CPR, activate the emergency response system if someone has not already done so.

Based on interview and record review, the facility failed to follow the physician's order to give mechanical soft texture (food item that has been blended, mashed, mixed, or processed into a smooth and uniform texture) diet for one (1) of three (3) sampled residents (Resident 1) in accordance with the facility's policy on nutrition management of dysphagia (difficulty swallowing) by facility staff failing to : 1. Ensure Certified Nursing Assistant (CNA 1) did not instruct Uncertified Assistive Personnel 1 (UAP 1) to obtain a sandwich from the facility's refrigerator for Resident 1 to consume on [DATE]. 2. Verify Resident 1's diet order for the resident to receive no added salt (NAS, food is seasoned as regular food), consistent or controlled carbohydrate (one of several substances such as sugar or starch that provide the body with energy) diet (CCHO, a restrictive diet that involves eating the same numbers of carbohydrate daily) mechanical soft texture, nectar thick consistency (easily pourable and are comparable to heavy syrup found in canned fruits) prior to handing the resident a sandwich of regular texture and unknown content as a snack on [DATE]. These deficient practices resulted in causing Resident 1 to choke (difficulty breathing because of constricted or obstructed throat or a lack of air) on [DATE] resulting in loss of consciousness. Resident 1 was pronounced dead by the paramedics (trained to give emergency medical care to residents who are injured or ill) on [DATE] at 9:23 PM. Findings: On [DATE] at 11:50 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding food and nutrition services. The survey team notified the Director of Nursing (DON), the Administrator (ADM), the [NAME] President of Operation (VPO), and Quality Assurance (QA) consultant of the IJ situation due to Resident 1 who was on dysphagia (difficulty swallowing) mechanical soft texture, nectar thick consistency diet was served with a sandwich of regular texture and unknown content on [DATE], which caused Resident 1 to choke resulting in loss of consciousness. Resident 1 was pronounced dead on [DATE] at 9:23 PM. On [DATE] at 9:52 PM, the IJ was removed in the presence of the ADM, VPO, Chief of Business Development (CBD), QA, and the DON after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and the surveyor verified/confirmed onsite the facility's implementation of the IJ Removal Plan and the IJ situation was no longer present. The IJ Removal Plan dated [DATE], included the following: On [DATE], the DON/Designee immediately provided an in-service education to the Nursing Staff regarding Aspiration/Choking Precautions. On [DATE], the DON immediately provided an in-service education to the sitter regarding scope of practice/job description. On [DATE], DON initiated an in-service education to the Nursing Staff and sitters regarding meals/snacks distribution, aspiration/choking precautions, emergency response, supervision, validation of diet prior to distribution. This in-service will be completed by [DATE]. Nursing Staff and sitters on leave or unscheduled will receive education upon return to work. On [DATE], the DON provided an in - service education to the Nursing Staff regarding the facility's policy and procedures for Comprehensive Care Planning, with emphasis on implementation of interventions, such as aspiration and choking precautions in cases where the resident is assessed to need supervision and on choking precautions. On [DATE], the DON/Designee developed a list of residents at risk for aspiration/choking, and supervision during meals and placed it in the Special Needs List binder at each Nursing Station and Dining Room. An ADHOC (for this situation) meeting is scheduled to be conducted on [DATE], with Administrator and QAA Members, to review the recent incident of choking, current practices and policies related to aspiration, and emergency response. On [DATE], the DON/Designees conducted an audit and observation of current residents during meals to ensure that residents received accurate diet texture as ordered. On [DATE], the DON/Designees conducted an audit and observation of current residents that received bedtime (HS) snacks to ensure that residents received accurate food texture as ordered. There were 30 residents that received HS snacks and all residents identified received accurate diet texture. On [DATE], the DON/Designees conducted an audit of current residents and reviewed the most recent MDS, Speech Therapy (ST, the treatment of communication and swallowing disorders) Notes/Discharge Summaries within the last 30 days to identify residents' required level of assistance with eating, residents at risk for aspiration/choking, to ensure that a care plan for risk for aspiration/choking are developed and implemented accordingly. 35 residents out of total current census of 94 were identified to be at risk for aspiration/choking based on their current diagnoses, diet orders, recent changes of condition, and/or speech therapy evaluation and discharge summary. On [DATE], the Speech Therapist (ST) was scheduled to initiate an in-service education to the nursing staff regarding different diet textures. This in-service will be completed by [DATE]. Nursing Staff on leave or unscheduled will receive education upon return to work. PROCESS: a. Night Shift Nursing Supervisor will print a copy of diet orders and dietary supplements to be used in validation of meals and snacks served for the day. Any new orders/changes in orders will be communicated by the receiving licensed nurse to the CNA, and a new copy of diet orders will be printed out for reference. b. The Dietary Department will also place a copy of Diet Orders in a folder and made in the meal cart during mealtimes for reference. c. Licensed Nurses will check and validate meal trays and snacks prior to distribution to residents. d. Any snacks or food items picked up by CNAs will be checked by a Licensed Nurse prior to distribution to residents. e. Meal Trays and snacks will be distributed to the residents by nursing staff. f. Diet Orders, Dietary Supplement Orders, and Required Level of Assistance with Eating will be made available in the Diet Binder at each nurse's station and dining room for reference. The DON/Designee will be responsible for updating these lists. g. Snacks provided by the kitchen that are not resident-specific will be sorted and labeled according to texture (i.e., Regular, Mechanical Soft, Puree, etc.) by the dietary department. The snacks will be hand delivered by dietary staff to a licensed nurse and will be stored in the med room. The licensed nurse receiving the snacks from dietary staff will validate the accuracy of texture of snacks provided. h. Licensed Nurses with access to the med room will distribute the snacks to the CNAs to ensure that residents receive the appropriate/accurate snacks as ordered. i. On [DATE], the DON/Designee initiated competency assessments to nursing staff to ensure that residents receive their prescribed diet orders with appropriate verification of food texture and fluids consistency prior to meal distribution. 1. The DON/Designee will conduct rounds and observations during mealtimes and/or during distribution of snacks, seven (7) times/week for four (4) weeks then weekly for two (2) months, to ensure that residents are receiving accurate diet as ordered. Any issues identified will be addressed by the DON immediately. 2. Quality Assurance and Performance Improvement (QAPI) a. The DON will present the results of the Meal/Snacks Observation to the Quality Assurance and Performance Improvement for review and recommendations monthly for 3 months or until substantial compliance is achieved. b. The DON will be responsible for monitoring and sustaining compliance. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included dysphagia oropharyngeal phase (difficulty transferring food from the mouth into the pharynx [passage leading from the mouth and nose to the esophagus {organ that food travels through to reach the stomach for further digestion] and the larynx [voice box]) and esophagus to initiate an involuntary swallowing process) and generalized muscle weakness. A review of Resident 1's Physician's Order, dated [DATE], indicated a diet order for the resident to receive NAS, CCHO, mechanical soft texture, nectar thick consistency. A review of Resident 1's History and Physical (H&P), dated [DATE], indicated Resident 1 does not have the capacity to understand and make decisions. A review of Resident 1's ST Notes, dated [DATE], included diet precautions and for the resident to receive NAS CCHO, dysphagia mechanical soft texture, nectar thick consistency. A review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated [DATE], indicated the resident had severely impaired cognitive skills (ability to understand and make decision) for daily decision making. The MDS indicated Resident 1 required supervision (helper provides verbal cues) with eating and oral hygiene and required substantial assistance (helper does more than half the effort) with toileting, hygiene, shower, lower body dressing, and putting on/taking off footwear. Resident 1 required partial assistance (helper does less than half the effort) with upper body dressing. A review of Resident 1's Care Plan titled, Potential for Nutritional Problem related to Aging, Dysphagia, and Dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a resident's daily functioning), revised [DATE], indicated staff interventions were to monitor, document, report signs and symptoms of dysphagia, explain and reinforce to resident the importance of maintaining the diet ordered, and to provide and serve diet as ordered. A review of Resident 1's Change in Condition (COC) Evaluation, dated [DATE] at 1:20 AM, indicated on [DATE] at 8:48 PM, CNA 1 called for assistance to check on Resident 1 who had a COC. COC evaluation indicated Resident 1 did not have a pulse. CPR was initiated by facility staff until paramedics arrived. Resident 1 was pronounced dead by the paramedics on [DATE] at 9:23 PM. During an interview on [DATE] at 2:25 PM, CNA 1 stated on [DATE] at around 8:40 PM, she was sitting next to Resident 1, just outside of his room. Resident 1 was on a recliner wheelchair eating a sandwich when the resident started coughing. CNA 1 stated she saw a third of the sandwich inside Resident 1's mouth so CNA 1 removed it. CNA 1 stated she asked UAP 1 who was sitting near her to assist in getting Resident 1 up so CNA 1 can perform the Heimlich maneuver (a procedure used to force a foreign object from a choking victim's airway [organ that allow airflow to the lungs] by performing abdominal thrusts) because Resident 1 did not respond when CNA1 asked him if he was okay. CNA 1 stated she then performed the Heimlich maneuver to Resident 1. CNA 1 stated Resident 1 was moved to his bed, which was 10 feet away, when Registered Nurse 1 (RN 1) arrived and saw the resident unresponsive with his lip turning blue. During an interview on [DATE] at 2:57 PM, UAP 1 stated, CNA1 instructed her to pick up a sandwich for Resident 1 from the residents' refrigerator. UAP 1 stated she grabbed a few more sandwiches to hand out to other residents. UAP 1 stated she gave Resident 1's sandwich of regular texture with unknown content to CNA 1. UAP 1 stated CNA 1 gave Resident 1 the sandwich. UAP 1 further stated she saw Resident 1 eating the sandwich and after a few minutes, saw Resident 1 coughing. UAP 1 stated CNA 1 removed a piece of sandwich from Resident 1's mouth and performed the Heimlich maneuver. During an interview on [DATE] at 3:56 PM, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was on dysphagia mechanical soft diet with nectar thick consistency and should not have been given a sandwich because of the resident's difficulty with swallowing. LVN 1 stated Resident 1 could not swallow a sandwich because it is considered a regular texture. LVN 1 also stated, according to CNA 1, UAP 1 gave the sandwich to Resident 1. During an interview on [DATE] at 4:43 PM, the Dietary Service Supervisor (DSS) stated Resident 1's diet order for NAS, consistent or controlled carbohydrate mechanical soft texture, nectar thick consistency was between pureed (smooth, crushed or blended food) and mechanical soft. DSS stated Resident 1 should not have been given a sandwich because sandwiches were not to be given for residents on dysphagia mechanical soft diet. During an interview on [DATE] at 5:57 PM, the DON stated CNA 1 should have checked the diet of Resident 1 before the resident was given a sandwich for the resident's safety. A review of the facility's Snack Spreadsheet indicated that sandwiches was not recommended for residents on dysphagia with thick liquid diet. A review of the facility's Policy and Procedure titled, Dysphagia Diets and Thickened Liquids, revised [DATE], indicated its purpose was to provide appropriate food and fluid consistencies to residents with dysphagia or swallowing problems, to ensure adequate hydration and diminish the risk of asphyxiation (deprivation of oxygen that can result in unconsciousness and often death). A review of the facility's Policy and Procedure titled, Nutrition Management of Dysphagia, dated 2023, indicated that dysphagia mechanical diet is a diet that consists of food that are moist, mechanically altered, easily mashed, or pureed. The policy also indicated that the dysphagia mechanical diet was necessary to form a cohesive bolus (breakdown of solid material into a size suitable for subsequent propulsion through the coordinated actions of the tongue, teeth, and cheeks while mixing the partially prepared matter with saliva) requiring little chewing and food must not be sticky or bulky increasing the risk of airway obstruction.

Based on interview and record review, the facility failed to ensure one of two residents (Resident 1) was not physically abused by a staff member. On 12/9/16, Resident 1 reported to the facility she was abused by someone in the shower. This deficient practice resulted in Resident 1 sustaining a bruise lip and a bruise and skin tear on her left arm. Findings: A review of Resident 1's medical record Face Sheet indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Minimum Data Set (MDS, a resident assessment and care screening tool), dated 10/27/16, indicated Resident 1 had clear speech and was usually understood. Resident 1 displayed some memory problems, did not display any disorganized thinking, altered level of consciousness, hallucinations (seeing or hearing things in the absence of any real external stimuli) or delusions (misconceptions or beliefs, that are firmly held, contrary to reality). According to Section G, functional status, Resident 1 needed extensive assistance (staff provide weight-bearing support) for transferring and bathing. According to Section E, Behaviors, Resident 1 did not have any physical, verbal or other behavioral symptoms not directed towards others. A review of Resident 1's Interdisciplinary Team Conferences (IDT) from 2/5/16 to 10/20/16, there was no documentation of Resident 1 being combative, resisting care or assaultive behaviors. A review of Resident 1's weekly summary from 10/31/16 to 12/11/16 there was no documentation of Resident 1 being combative, resisting care or assaultive behaviors. A review of Resident 1's Alzheimer's/dementia care plan dated 10/22/16 there was no documentation of Resident 1 being combative, resisting care or displaying assaultive behaviors. A review of Resident 1's, Incident and Accident Report Form, dated 12/9/16 at 9:45 a.m., indicated Resident 1 had a swollen upper lip 2 x 3 centimeters (cm) and a left upper arm skin tear 1 x 1 x 0.1 cm. The report indicated Resident 1 stating a girl hit her inside the room. On 12/9/16 at 12 p.m. a police officer arrived to the facility. On 12/9/16 at 1:45 p.m. Resident 1 was able to identify CNA 1 as the girl that hit her and CNA 1 was asked to leave the facility. A record review of Resident 1's physician's orders [REDACTED]. Monitor upper lip for any skin breakdown, swelling, bleeding and complain of pain. During an interview, on 12/28/16 at 10 a.m., with Resident 1 and the social service designee acting as interpreter, Resident 1 stated she remembered being hit by a fist by two women and one was wearing a dress. During an interview, on 12/28/16 at 10:20 a.m., with the administrator (ADM) she stated Resident 1 first reported the alleged abuse to the activity assistant (AA) on 12/9/16 at 9:45 a.m. The ADM stated Resident 1 was unable to tell them who hit her, but stated it happened in the shower. CNA 1 was assigned to her that day and gave Resident 1 a shower that morning. The ADM stated CNA 1 denied hitting Resident 1. CNA 1 did mention Resident 1 was very combative that morning during the shower. The ADM stated on the afternoon of 12/9/16 there was visible swelling of Resident 1's upper lip. Resident 1 also had a bruise and skin tear on her left upper arm that was not present the previous day (12/8/16). The ADM stated due to the Resident 1's statement and the visible injuries, Resident 1's family did not feel it was safe for their family member to be around CNA 1. The ADM stated they terminated CNA 1 effective 12/12/16. During an interview, on 12/29/16 at 9:52 a.m., with family member (FM 1) she stated she visited Resident 1 on 12/9/16 at 11:15 am. FM 1 stated I saw my mom and her lip was swollen. I asked her what happened to her lip and she said someone hit her. I asked who and she couldn't tell me. I knew it was my mom's shower day because she takes showers on Tuesday and Fridays. I asked who her nurse was that day and they told me CNA 1. I asked to speak to CNA 1. I asked her what happened to my mom's lip and she said she didn't know. She did say my mom was not cooperative in the shower that morning. I asked the other CNA that feed her breakfast if her lip was swollen at breakfast and she said no. I think it happened in the shower or when they were transferring my mom. LVN 1 stripped her in front of me to check her body and there was a bruise on her left arm with blood. You could tell it was a fresh because there was blood too. According to the facility's policy and procedure titled, Abuse-Prevention Program, dated 11/2016 indicated the facility is to ensure the health, safety, and comfort of residents by preventing abuse and mistreatment.