Every finding on record at Arcadia Care Center

Based on interview, and record review, the facility (Skilled Nursing Facility [SNF] 1) failed to ensure one of three sampled residents (Resident 1) was permitted for readmission to the first available private room on 6/18/2026 after Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 6/8/2026, in accordance with SNF 1's policy and procedure (P&P) titled, Bed-Holds and Returns, dated 3/2025.This deficient practice resulted in Resident 1 remaining in GACH on 6/18/2026 following an inquiry from GACH for Resident 1 to be transferred back to SNF 1 and had the potential to cause Resident 1 distress from not being able to return to Resident 1's previous living arrangement.Findings: During a review of Resident 1's admission Record (AR), the admission Record indicated SNF 1 originally admitted Resident 1 on 2/27/2026, with diagnoses sepsis (a life-threatening complication of an infection) and Dysphagia (difficulty swallowing).During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 2/28/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 6/8/2026, the MDS indicated Resident 1 was intact in cognitive skills (ability to make daily decisions) and required substantial/maximal assistance (helper does more than half the effort to complete the activity) for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Progress Notes (PN), dated 6/8/2026, the PN indicated Resident 1 was transferred to GACH 1 on 6/8/2026 for further evaluation.During a review of Resident 1's Daily Progress notes (DPN) from GACH 1, dated 7/27/2026, at 8:21 AM the DPN indicated Resident 1's was medically stable and pending placement with finished antimicrobials ( a substance that kills tiny living things, like bacteria and fungi, or stops them from growing) and no inpatient needs.During a telephone interview on 8/5/2026 at 11AM with GACH 1's Complex Case manager (CCM1), CCM1 stated Resident 1 was appropriate for SNF placement on 6/18/2026 and a request for return to the facility was initiated. CCM1 stated she made multiple attempts to contact the facility following the initial request. CCM 1stated facility initially reported it could not accept the residents due to isolation requirements/no isolation bed. CCM 1 stated that after isolation was no longer required, additional reasons provided included lack of an appropriate/female bed. CCM 1 reported the facility ultimately stated the resident had been gone too long and would not be accepted back. CCM 1stated antimicrobial therapy was completed on 7/21/26 and the resident was medically stable for SNF placement.During an interview on 8/6/2026 at 10 AM with SNF 1's Director of Nursing (DON), the DON stated she would not accept the resident for readmission and continued to identify the resident's high acuity and wound care needs as the basis for her decision. DON stated that she did not have current hospital wound care documentation identifying the present wound/graft measurements or specific current wound treatment requirements. DON stated that the determination regarding the complexity of the resident's wound care was based on the resident's previous condition and prior care needs rather than current wound care documentation.During a review of facility census records dated 6/18/2026 through 8/6/2026, the records indicated multiple beds available within the facility. The records further indicated the facility admitted other residents into available beds during this time period (6/18/2026 through 8/6/2026).During a review of the facility's policy and procedure titled, Bed-Holds and Returns, revised March 2025, the policy indicated, Residents may return to and resume residence in the facility after hospitalization. The policy further indicated a resident would be permitted to return to the facility immediately upon the first availability of a bed and may be offered an available bed in another area of the facility if the previous room was unavailable.

Based on interview and record review, the facility failed to promptly notify one of three sampled residents (Resident 1's) Responsible Party (RP) regarding Resident 1's increased heart rate and fever on 7/4/2026. This failure resulted in Resident 1's representatives not being informed of Resident 1's change in condition and not making an informed decision (decision based on facts, relevant information, and clear understanding of potential risks, benefits, and alternatives) regarding Resident 1's increased heart rate and fever.Findings: During a review of Resident 1's Face Sheet (FS), the FS indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including left shoulder osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), hypertension (HTN-high blood pressure), and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 5/12/2026, the MDS indicated Resident 1 had moderately impaired cognition (ability to make daily decisions). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) for eating, upper body dressing, oral and personal hygiene. During a review of Resident 1's SBAR Communication Form (SBAR- situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 7/4/2026, the SBAR indicated Resident 1 had tachycardia (a fast heart rate more than 100 beats per minutes [bmp]) around 9:40 AM and fever around 12 PM. During a review of Resident 1's Progress Notes (PN) dated 7/4/2026, the PN indicated Resident 1 had tachycardia with fever and was sent out via 911 (emergency response) to General Acute Care Hospital 1 (GACH 1) on 7/4/2026. There was no documented evidence that Resident 1's RP was notified regarding Resident 1's tachycardia around 9:40 AM and fever around 12 PM on 7/4/2026. During a review of Resident 1's entire medical record, there was no documented evidence that Resident 1's RP was notified regarding Resident 1's tachycardia around 9:40 AM and fever around 12 PM on 7/4/2026. During a concurrent interview and record review on 7/22/2026 at 9:47 AM with Licensed Vocational Nurse 1 (LVN 1), Resident 1's SBAR dated 7/4/2026 was reviewed. LVN 1 stated Resident 1's RP was not notified when Resident 1 had abnormal increased heart rate on 7/4/2026 around 9:40 AM. LVN 1 stated LVN 1 did not notify Resident 1's RP when Resident 1 had a fever of 102.8 degrees Fahrenheit ( F) on 7/4/2026 around 12 PM. LVN 1 stated the Resident 1's RP should have been notified when Resident 1 had any change of condition of tachycardia and fever. During an interview on 7/22/2026 at 4:55 PM with Registered Nurse 2 (RN 2), RN 2 stated RN 2 did not notify Resident 1's RP when Resident 1 had a change of condition of increased heart rate more than 100 bpm on 7/4/2026 around 9:40 AM and a temperature of 102.8 F at 12 PM. During an interview on 7/23/2026 at 10:30 AM with Registered Nurse 3 (RN 3), RN 3 stated RN 3 did not notify Resident 1's RP when Resident 1 had a change of condition of increased abnormal heart rate on 7/4/2026 around 9:40 AM and fever of 102.8 F at 12 PM. RN 3 stated licensed nursing staff should notify the resident's RP promptly for any change of condition During a concurrent interview and record review on 7/23/2026 at 11:45 AM with the Director of Nursing (DON), Resident 1's SBAR dated 7/4/2026 was reviewed. The DON stated the facility should ensure nursing staff notify the resident's RP promptly about any change of condition. During a review of the facility's Policy and Procedure (P&P) titled, Change in a Resident's Condition or Status, revised 3/2025, the P&P indicated the facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The P&P indicated, Unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. The P&P indicated, Notifications will be made to the party responsible when a change occurring in the resident's medical/mental condition or status.

Based on interview and record review, the facility failed to ensure a physician or the facility's Medical Director promptly provided medical care to one of three sampled residents (Resident 1) when Resident 1's attending physician did not respond to Resident 1's change of condition of increased heart rate and fever on 7/4/2026. This failure had the potential for Resident 1 not to receive timely care and treatment and worsen Resident 1's condition. Findings: During a review of Resident 1's Face Sheet (FS), the FS indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including left shoulder osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), hypertension (HTN-high blood pressure), and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 5/12/2026, the MDS indicated Resident 1 had moderately impaired cognition (ability to make daily decisions). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) for eating, upper body dressing, oral and personal hygiene. During a review of Resident 1's SBAR Communication Form (SBAR- situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 7/4/2026, the SBAR indicated Resident 1 had tachycardia (a fast heart rate more than 100 beats per minutes [bmp]) around 9:40 AM and the attending physician was notified but did not respond. The SBAR indicated Resident 1 had chills and fever of 102.8 degrees Fahrenheit ( F) on 7/4/2026 around 12 PM and the attending physician was notified but did not respond. The SBAR did not indicate that the Medical Director or any physician was notified after there was no response from the attending physician. During a review of Resident 1's entire medical record, there was no documented evidence that the facility's Medical Director or any other physician was notified about Resident 1's tachycardia around 9:40 AM and fever around 12 PM after getting no response from Resident 1's attending physician on 7/4/2026. During a concurrent interview and record review on 7/22/2026 at 9:47 AM with Licensed Vocational Nurse 1 (LVN 1), Resident 1's SBAR dated 7/4/2026 was reviewed. LVN 1 stated the facility's Medical Director or any physician was not notified when Resident 1's attending physician did not respond regarding Resident 1's increased heart rate on 7/4/2026 around 9:40 AM. LVN 1 stated LVN 1 did not notify the facility's Medical Director or any other physician when Resident 1's attending physician did not respond regarding Resident 1's fever of 102.8 degrees Fahrenheit ( F) on 7/4/2026 around 12 PM. During an interview on 7/22/2026 at 4:55 PM with Registered Nurse 2 (RN 2), RN 2 stated RN 2 did not notify any other facility physician when RN 2 did not get any response from Resident 1's attending physician regarding Resident 1's change of condition of increased heart rate more than 100 bpm on 7/4/2026 around 9:40 AM and fever of 102.8 F at 12 PM. RN 1 stated it was important to notify the physician of a resident's change of condition. During an interview on 7/23/2026 at 10:30 AM with Registered Nurse 3 (RN 3), RN 3 stated licensed nursing staff should notify the facility's Medical Director immediately if there was no response from the attending physician regarding a resident's significant change of condition. During a concurrent interview and record review on 7/23/2026 at 11:45 AM with the Director of Nursing (DON), Resident 1's SBAR dated 7/4/2026 was reviewed. The DON stated the facility should ensure nursing staff notify the resident's attending physician regarding any change of resident's condition or notify the facility's Medical Director promptly within one hour if there was no response from the attending physician. During a review of the facility's Policy and Procedure (P&P) titled, Change in a Resident's Condition or Status, revised 3/2025, the P&P indicated the facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The P&P indicated, The nurse will notify the resident's Attending Physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. During a review of the facility's P&P titled, Medical Director revised 7/2025, the P&P indicated the medical director functions also include but are not limited to help assure that residents receive adequate services appropriate to meet their needs and provide medical services if the resident's attending physician is not available or does not respond in a timely manner.

Based on interview and record review, the facility failed to ensure the facility reviewed, updated, and/or revised new interventions for one of three sampled residents (Resident 1) care plan (a document that outlines a person's health needs and the care they require) for falls that occurred on 6/19/2026, 6/20/2026, and 6/26/2026. This deficient practices caused subsequent falls to Resident 2, potentially placing Resident 2 at risk for great bodily injury. During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included malignant neoplasm of brain (cancerous brain tumor) and diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). During a review of Resident 2's History and Physical Examination (H&P), dated 5/12/2026, the H&P indicated Resident 2 could make needs known but could not make medical decisions. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 5/11/2026, the MDS indicated Resident 2's cognitive skills for daily decision making was intact. The MDS indicated Resident 2 required supervision for eating. The MDS indicated Resident 2 required moderate assistance (helper does less than half the effort) for oral hygiene and personal hygiene. The MDS indicated Resident 2 required maximal assistance (helper does more than half the effort) for upper body dressing. The MDS indicated Resident 2 was dependent on staff for toileting hygiene, shower/bathing, lower body dressing and putting on/taking off footwear. MDS indicated Resident 2 had falls since admission with no injuries. During a review of Resident 2's Fall Risk Evaluation form, dated 4/29/2026, the Fall Risk Evaluation form indicated a total score of 10 or above represented a high risk for falls. The Fall Risk Evaluation form indicated Resident 2's total score was 12. During a review of Resident 2's Fall Risk Evaluation form, dated 5/8/2026, the Fall Risk Evaluation form indicated a total score of 10 or above represented a high risk for falls. The Fall Risk Evaluation form indicated Resident 2's total score was 21. During a review of Resident 2's Situation, Background, Assessment, Recommendation form ([SBAR] a communication tool used by healthcare workers when there is a change of condition among residents), dated 6/19/2026, the SBAR indicated Resident 2 had an unwitnessed fall on 6/19/2026. The SBAR indicated Resident 2 was found lying on the floor next to Residents 2's bed. The SBAR indicated Resident 2 lost balance as Resident 2 was reaching for an item. The SBAR indicated Resident 2 had no injuries from the fall. During a review of Resident 2's SBAR, dated 6/20/2026, the SBAR indicated Resident 2 had an unwitnessed fall on 6/20/2026. The SBAR indicated Resident 2 was found on floor mat while bending his knees. The SBAR indicated Resident 2 had no injuries from the fall. During a review of Resident 2's SBAR, dated 6/26/2026, the SBAR indicated Resident 2 had an unwitnessed fall on 6/26/2026. The SBAR indicated Resident 2 had an unwitnessed fall while ambulating in the hallway by nurses' station. The SBAR indicated Resident 2 had no injuries from the fall. During a review of Resident 2's Care Plan for falls, dated 5/1/2026, the care plan indicated Resident 2 was at risk for falls related to impaired cognition, lack of coordination, history of falls, and not calling for help. Resident 2's fall risk care plan was not revised after 6/19/2026, 6/20/2026, and 6/26/2026 falls. Resident 2's care plan did not include fall incidents' and new interventions were not developed. During an interview on 6/30/2026 at 10:06 a.m., with Minimum Data Set Nurse 1 (MDS Nurse 1, clinical leader who manages comprehensive patient assessments), MDS Nurse 1 stated a care plan indicated residents' problems, goals and interventions to treat a problem and prevent the problem from getting worse. MDS Nurse 1 stated recurrent falls are part of a long-term goal care plan. MDS Nurse 1 stated long-term goal care plans must be revised after each fall. MDS Nurse 1 stated if care plan did not get revised there would be a risk for resident falling again. MDS Nurse 1 stated MDS Nurse 1 revised Resident 2's fall risk care plan yesterday (6/29/2026). MDS Nurse 1 received Interdisciplinary Team (IDT) notes yesterday (6/29/2026) and added fall incidents and interventions. During an interview on 6/30/2026 at 10:46 a.m., with MDS Nurse 2, MDS Nurse 2 stated a care plan was tailored to each resident's diagnosis with goals and interventions for nursing to practice during resident care. MDS Nurse 2 stated care plans must be revised and updated after a resident had a fall. MDS Nurse 2 stated care plans must get revised to implement new interventions to prevent future falls. MDS Nurse 2 stated MDS Nurse 2 reviewed Resident 2's care plan for falls on 6/29/2026 and the care plan was not updated after Resident 2's falls. MDS Nurse 2 stated MDS Nurse 2 updated Resident 2's fall risk care plan on 6/29/2026. MDS Nurse 2 stated a care plan revision must be completed after each fall and staff must develop new interventions with each revision. During a concurrent interview and record review on 6/30/2026 at 11:16 a.m., with MDS Nurse 2, Resident 2's fall risk care plan, dated 5/1/2026 was reviewed. The care plan indicated no new interventions were developed after Resident 2's fall on 6/19/2026 and 6/20/2026. The care plan indicated Resident 2's fall on 6/26/2026 was not implemented in Resident 2's care plan and new interventions were not developed. The MDS Nurse 2 stated Resident 2's falls should have been care planned with new interventions. MDS Nurse 2 stated all license nurses could have developed new interventions after Resident 2's fall but they did not do it. MDS Nurse 2 stated interventions for a fall risk care plan should be to assign resident to a room close to nurses' station, involve Resident 2 in activities, and answer Resident 2's call light quickly. During an interview on 6/30/2026 at 2:50 p.m., with the Director of Nursing (DON), the DON stated a care plan indicated interventions that nursing staff must practice to care for residents. The DON stated resident's medications, diagnosis, behaviors and change of conditions must get care planned. The DON stated residents needed a care plan for falls to minimize the recurring of falls. The DON stated after a resident had another fall, resident's care plan had to be updated. The DON stated the care plan got updated by developing new interventions. The DON stated if care plan did not get revised after each fall, it created the risk for resident to fall again. The DON stated if new interventions were not developed after a recurring fall, it was a system failure. The DON stated staff needed to review interventions and find out why Resident 2 continued to experience falls. During a review of facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, the P&P indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. The P&P indicated the interdisciplinary team must review and update the care plan:a. When there has been a significant change in the residents' condition.b. When desired outcome was not met. During a review of facility P&P titled, Falls-Clinical Protocol, dated 3/2018, the P&P indicated staff and physician would identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. The P&P indicated if underling causes cannot be readily identified or corrected, staff would try various relevant interventions based on assessments of the nature or category of falling, until falling reduces, stops or until a reason is identified for its continuation. During a review of facility P&P titled, Falls and Fall Risk, Managing, dated 3/2018, the P&P indicated the staff and attending physician would implement resident-centered fall prevention plan to reduce the specific risk factor of falls for each resident at risk or with a history of falls. The P&P indicated if falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant.

Based on interview and record review, the facility failed to ensure nursing staff demonstrated and maintained competency to safely provide care and services in accordance with professional standards for one of three sampled residents (Resident 1) when:1. Licensed Vocational Nurse (LVN) 1 failed to follow Resident 1's doctor's order for oxycodone (a potent, semi-synthetic pain medication prescribed to treat moderate to severe pain) on 5/11/26 to 5/13/26 and on 5/23/26. 2. LVN 1 did not have the knowledge of medication parameters (specific rules, clinical limits, and measurable values that guide how a drug is given, adjusted, or stopped). These deficient practices placed Resident 1 and other residents at risk for unsafe medication administration including complications such as medication over sedation, medication toxicity, and the medication would not help for the medication purpose and residents' diagnosis. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included cervical spinal stenosis (narrowing of the spinal canal in the neck) and diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine. During a review of Resident 1's History and Physical Examination (H&P, physician clinical evaluation and examination of the resident), dated 5/12/2026, the H&P indicated Resident 1 was alert and oriented X 4 (a medical term meaning a patient is fully conscious and correctly aware of four key aspects of their identity and surroundings: person, place, time, and event/situation). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/14/2026, the MDS indicated Resident 1's cognitive skills (reasoning, learning, and problem-solving) for daily decision making was intact. The MDS indicated Resident 1 was independent for all activities of daily living. During a review of Resident 1' s Order Summary Report, dated 5/11/2025, the Order Summary Report indicated Resident 1 had an order to receive oxycodone tablet 5 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) by mouth every three hours as needed for severe pain (7-10 pain level- 0 means no pain, and 10 means the worst pain). During a review of Resident 1' Medication Administration Record (MAR), dated 5/1/2026 - 5/31/2026, the MAR indicated Resident 1 was scheduled to receive oxycodone tablet 5 mg, one tablet by mouth every three hours as needed for severe pain. The MAR indicated on 5/11/2026, 5/12/2026, and 5/23/2026 Resident 1 had a pain scale of 4 and received oxycodone 5 mg. The MAR indicated on 5/13/2026 Resident 1 had a pain scale of 2 and received oxycodone 5mg. During a concurrent observation and interview on 6/29/2026 at 3:37 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 used cellphone to search information to answer the question of what a medication parameter was used for. LVN 1 read off LVN 1's cell phone and stated a medication parameter was used for medication ranges, it provided guidance of when to give certain medications. LVN 1 stated it was not a safe practice not to follow medication parameters. LVN 1 was not able to explain what the medication administration process was when a medication had medication parameters. LVN 1 was not able to explain what LVN 1 would do if a resident was not within a medication parameter. LVN 1 stated the pain scale for medication oxycodone was 5-10 [pain level]. LVN 1 stated if resident were under the medication parameter LVN 1 would administer a medication alternative and LVN 1 stated LVN 1 did not do that. During a concurrent interview and record review on 6/29/2026 at 4:16 p.m. with LVN 1, Resident 1's MAR, dated 5/1/2026 - 5/31/2026 was reviewed. The MAR indicated on 5/11/2026, 5/12/2026, 5/13/2026 and 5/23/2026 Resident 1's pain scale was less than the medication parameter for oxycodone yet medication was administered to Resident 1. LVN 1 stated LVN 1 administered medication to Resident 1 because Resident 1 and Resident 1's family requested the medication. LVN 1 was not able to answer if a pain scale of 2 or 4 was within oxycodone medication parameter. LVN 1 stated a pain scale of 4 was higher than the range of 7 -10 pain scale. LVN 1 stated Resident 1 stated Resident 1 was in excruciating pain. LVN 1 was unable to explain if a pain of 2 and 4 was excruciating pain. LVN 1 stated administering oxycodone to Resident 1 for a pain of 2 and 4 was following doctor orders. During an interview on 6/30/3036 at 3:22 p.m. with the Director of Nursing (DON), the DON stated medication parameters were used for resident safety. The DON stated if medication parameters were not followed it would cause complications, medication toxicity and medication would not help for the medication purpose and residents' diagnosis. The DON stated not following a medication parameter was not following doctor's order because medication was not administered as doctor's order. The DON stated the risk in having staff that were not competent had the potential of harming residents. The DON stated hiring a nurse that did not speak English would increase the risk of miscommunication with residents and doctors and it would create a risk in medication errors. During a review of facility's Policy and Procedure (P&P) titled, Competency of Nursing Staff,, dated 5/2019, the P&P indicated competency in skills and techniques necessary to care for residents' needs include but is not limited to competencies in areas such as: communication, medication management and pain management.

Based on interview and record review, the facility failed to ensure an individualized care plan (a document that outlines a person's health needs and the care they require) was developed and implemented for one of four sampled residents (Resident 1) medical condition of constipation (fewer than three bowel movements per week or experiencing difficult, painful, and incomplete passages of stool). This deficient practice had the risk to negatively affected Resident 1's care and create an immediate risk to Resident 1's health, safety, and quality of life. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included cervical spinal stenosis (narrowing of the spinal canal in the neck) and diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). During a review of Resident 1's History and Physical Examination (H&P, physician clinical evaluation and examination of the resident), dated 5/12/2026, the H&P indicated Resident 1 was alert and oriented x 4 (a medical term meaning a patient is fully conscious and correctly aware of four key aspects of their identity and surroundings: person, place, time, and event/situation). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/14/2026, the MDS indicated Resident 1's cognitive skills (reasoning, learning, and problem-solving) for daily decision making were intact. The MDS indicated Resident 1 was independent for all activities of daily living. During a review of Resident 1's Order Summary Report, dated 5/11/2026, the order summary report indicated Resident 1 had an order for milk of magnesia oral suspension 400 milligrams/5 milliliters, ([mg] one thousand of a gram used for medication dosage and/or amount/[ml] a metric unit of fluid volume used in medicine to measure the total amount of liquid medication), give 30 ml by mouth every six hours as needed for constipation. During a review of Resident 1's Order Summary Report, dated 5/11/2026, the order summary report indicated Resident 1 had an order for polyethylene glycol 3350 oral powder 17 grams ([gm] metric unit of measurement, used for medication dosage and/or amount), give polyethylene 17 gm by mouth one time a day for bowel management (consistent routine to prevent constipation and fecal incontinence [accidental leakage of solid or liquid stool, or gas]). Hold for loose stools. Mix with 8 ounces of water. During a review of Resident 1's Order Summary Report, dated 5/11/2026, the order summary report indicated Resident 1 had an order for senna oral table 8.6 mg, give one tablet by mouth two times a day for bowel management. Hold for loose stools. During a review of Resident 1's Order Summary Report, dated 5/19/2026, the order summary report indicated Resident 1 had an order for polyethylene glycol 3350 oral powder 17 gm, give polyethylene 17 gm by mouth two times a day for bowel management. Hold for loose stools. Mix with 8 ounces of water. During a review of Resident 1's Order Summary Report, dated 5/19/2026, the order summary report indicated Resident 1 had an order for senna oral table 8.6 mg, give two tablet by mouth two times a day for bowel management. Hold for loose stools. During a review of Resident 1's Medication Administration Audit Report (MAR), dated 5/1/2026 - 5/31/2026, the MAR indicated Resident 1 had an order to receive milk of magnesia oral suspension 400mg/5ml, give 30 ml by mouth every six hours as needed for constipation. The MAR indicated Resident 1 received medication on 5/21/2026 and 5/24/2026. During a review of Resident 1's MAR, dated 5/1/2026 - 5/31/2026, the MAR indicated Resident 1 had an order to receive polyethylene glycol 3350 oral powder 17 grams/scoop, give one scoop by mouth one time a day for bowel management. The MAR indicated Resident 1 received medication on 5/12/2026, 5/13/2026, 5/16/2026 - 5/19/2026. During a review of Resident 1's MAR, dated 5/1/2026 to 5/31/2026, the MAR indicated Resident 1 had an order to receive polyethylene glycol 3350 oral powder 17 grams/scoop, give one scoop by mouth two times a day for bowel management. The MAR indicated Resident 1 received medication on 5/19/2026 - 5/25/2026. During a review of Resident 1's MAR, dated 5/1/2026 - 5/31/2026, the MAR indicated Resident 1 had an order to receive [NAME] oral tablet 8.6 mg, give one tablet by mouth two times a day for bowel management. The MAR indicated Resident 1 received medication on 5/12/2026, 5/13/2026, 5/16/2026 - 5/19/2026. During a review of Resident 1's MAR, dated 5/1/2026 - 5/31/2026, the MAR indicated Resident 1 had an order to receive [NAME] oral tablet 8.6 mg, give two tablets by mouth two times a day for bowel management. The MAR indicated Resident 1 received medication on 5/19/2026 - 5/25/2026. During a review of Resident 1's electronic medical record, unable to locate Resident 1's care plan for Resident 1's constipation. During an interview on 6/30/2026 at 10:06 a.m. with Minimum Data Set (MDS) Nurse 1 (clinical leader who manages comprehensive patient assessments), MDS Nurse 1 stated a care plan indicated residents' problems, goals and interventions to treat a problem and prevent the problem from getting worse. MDS Nurse 1 stated residents changes of conditions should be implemented in the care plan. MDS Nurse 1 stated if a resident's medical condition required medication it should be in residents care plan because it would indicate plan of care for residents' medical condition. During an interview on 6/30/2026 at 3:11 p.m. with Director of Nursing (DON), the DON stated a care plan indicated interventions that nursing staff must practice to care for residents. The DON stated resident's medications, diagnosis, behaviors, and change of conditions must get care planned. The DON stated a resident suffering from constipation must have a care plan for constipation. The DON stated it was important to develop a care plan for constipation because constipation can cause sepsis (body's extreme, life-threatening response to an infection), stomach distension (visible swelling, expansion, or increase in the size of the abdomen beyond its normal girth), nausea, vomiting, and could lead to fecal impaction (a serious, potentially life-threatening condition that occurs when severe, chronic constipation causes a large, dry mass of hardened stool to get stuck in the colon [main part of the large intestine, which helps digest food and remove waste from the body] or rectum [final portion of large intestine, temporarily stores stool until expelled from the body]). The DON stated the risk of not having a care plan for constipation was Resident 1 would not be accurately monitored and cared for. During a review of facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, the P&P indicated care plan would include: 1. Measurable objectives and timeframes. 2. Describe services that are to be furnished to attain or maintain the resident's higher practicable physical, mental, and psychosocial well-being. 3. Incorporate identified problem areas. 4. Incorporate risk factors associated with identified problems.

Based on interview and record review, the facility failed to ensure:1.Two of four Certified Nurse Assistants (CNA) met the annual performance evaluation requirements (CNA 2 and CNA 4).2.One of four CNAs met the requirement of full background check before hiring (CNA 4).These deficient practices had the potential to result in lack of knowledge and training among the CNAs, leading to inadequate resident care and the risk for abuse, neglect, and/or exploitation from inadequate background check.Findings: During a review of personnel files (PF) for Certified Nursing Assistant 1 (CNA 1), Certified Nursing Assistant 2 (CNA 2), Certified Nursing Assistant 3 (CNA 3), and Certified Nursing Assistant 4 (CNA 4), the following were identified:CNA 2 did not have a performance evaluation (PE) for 2025. CNA 2's PF indicated CNA 2 was hired on 9/28/23 and the latest PE was dated 9/28/24 signed by CNA 2's supervisor and CNA 2. The PE did not have any comments from CNA 2's supervisor about new goals, objectives, and commitments.CNA 4's PE was dated 7/20/25, signed by CNA 4's supervisor and CNA 4. The PE did not have any comments from CNA 4's supervisor about new goals, objectives, and commitments. CNA 4's date of hire was 6/1/19, which indicated the annual PE was due on 6/1/25 and not 7/20/25.CNA 4's PF did not contain a full background check. The background check was incomplete with only a 7-year criminal court record search for Los Angeles County. CNA 4's PF did not contain an abuse registry check and exclusion list database: Office of Inspection General (OIG) List of Excluded Individuals/Entities (LEIE). During an interview with the Director of Staff Development (DSD) on 3/23/26 at 10:45 a.m., the DSD stated the DSD could only find the PE for 2024 in CNA 2's PF and there was no PE for 2025. The DSD stated PE should be completed annually and the DSD stated annual reviews of CNAs' skills were important to ensure the facility staff provided safe care to the residents. During a review of the facility's undated Policy & Procedure (P&P) titled, Background Screening Investigations, the P&P indicated the facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents ( direct access employees). The P&P further indicated background and criminal checks are initiated within two days of an offer of employment or contract agreement and completed prior to employment. For any individual applying for a position as a Certified Nursing Assistant, the state nurse aide registry is contacted to determine if any findings of abuse, neglect, mistreatment of individuals, and/or theft of property have been entered into the applicant's file. For any licensed professional applying for a position that may involve direct contact with residents, his/her respective licensing board is contacted to determine if any sanctions have been assessed against the applicant's license. Should the background investigation disclose any misrepresentation on the application form or information indicating that the individual has been convicted of abuse, neglect, mistreatment of individuals, and/or misappropriation of property, the applicant is not employed or contracted. During a review of the facility's Policy & Procedure (P&P) titled, Hiring revised January 2008, the P&P indicated the HR director will then conduct any applicable investigations and determine whether the applicant is legally eligible to work in the United States; and an offer of employment may be revoked and employment may be terminated if an investigation reveals that an applicant made misrepresentations about or failed to disclose any fact which might indicate that the applicant is not qualified for the position in question. During a review of the facility's Policy & Procedure (P&P) titled, Staff Development Program revised May 2019, the P&P indicated the primary objective of the facility's Staff Development Program is to ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care. The P&P further indicated, In addition to the in-service training requirements, nurse aides (CNAs) are required to complete no less than 12 hours annually of in-service training that is sufficient to ensure the continuing competency of nurse aides and address any specific areas of weakness identified in performance evaluations and through the facility assessment. During a review of the facility's Policy & Procedure (P&P) titled, Performance Evaluations revised June 2010, the P&P indicated the job performance of each employee shall be reviewed and evaluated at least annually.

Based on interview and record review, the facility's interdisciplinary team (IDT- a group of health care professionals who work together toward the goals of their residents) failed to ensure that a resident would not be allowed to keep medication at the bedside without being assessed to determine the resident's capability to self-administer medications in accordance with the facility's policies and procedures (P&P) for Resident Rights, Administering Medications, Safety and Supervision of Residents and Self-Administration of Medications, for one of four sampled residents (Resident 2). This deficient practice placed Resident 2 at risk of self-medicating inaccurately and had the potential to result in adverse consequences for Resident 2.Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 11/25/25 and readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (respiratory system fails to oxygenate blood) and asthma (chronic respiratory condition causing inflamed, narrowed airways and excess mucus, resulting in wheezing, coughing, and breathing difficulties). During a review of Resident 2's Physician Orders (PO) for December 2025, the POs indicated Resident 2 was prescribed Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath Activated 100-25 MCG/ACT (inhaler treatment to help control the symptoms of asthma and improve lung function), 1 puff inhaled orally one time a day for Asthma unsupervised self-administration. The order was dated 12/8/25 with start date of 12/9/25. During a review of Resident's Medication Administration Record (MAR) for December 2025, the MAR indicated Resident 2 was unsupervised and self-administering Fluticasone-Vilanterol inhaler for the following dates: 12/9/25 - 12/22/25 and 12/24/25-12/31/25. During a review of Resident 2's IDT Care Conference (IDTCC) dated 12/12/25, the IDTCC indicated the care conference was for Resident 2's 12/8/25 admission to the facility. The IDTCC indicated Resident 2's medication list was reconciled and risks and benefits were discussed, but the self-medication administration portion was unmarked (not checked, not discussed) under the items listed as reviewed. Under the IDTCC's Summary of Discussion/Change in Plan of Care, there was no mention of an assessment by the interdisciplinary team to determine if Resident 2 was a candidate to self-administer medication. During a review of January 2026 and February 2026 POs, the POs indicated Resident 2 was prescribed Fluticasone Furoate-Vilanterol inhaler, 1 puff inhale orally one time a day for Asthma unsupervised self-administration. During a review of Resident's Medication Administration Record (MAR) for January 2026 and February 2026, the MAR indicated Resident 2 was unsupervised and self-administering Fluticasone-Vilanterol inhaler for the following dates: 1/1/26 - 1/31/26 and 2/1/26 - 2/28/26. During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 2/27/26, the MDS indicated Resident 2 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 2 was dependent on staff with toileting hygiene, lower body dressing, putting on/taking off footwear; partial/moderate assistance for upper body dressing and personal hygiene, and required substantial/maximal assistance from staff for showering/bathing self. During a review of Resident 2's Nursing Progress Note (NPN) dated 3/2/26 at 8:10 p.m., the NPN indicated, Resident stated the resident has been taking medication on an as needed basis. Informed resident that the current physician order indicates daily administration. Reviewed proper inhaler technique. Resident was instructed to hold breath for a few seconds after inhalation and then exhale slowly. Endorsed to Charge Nurse and RN supervisor to clarify with MD whether medication should be administered daily as ordered or change to PRN as what resident mentioned. During a review of Resident 2's NPN dated 3/2/26 at 10:42 p.m., the NPN indicated, Per MDS endorsement to clarify with MD whether medication should be administered daily as ordered or change to PRN as what resident mentioned. MD clarified it should be once daily routine. Keep current order. Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath Activated 100-25 MCG/ACT (Fluticasone Furoate-Vilanterol) 1 puff inhale orally one time a day for Asthma. During a review Resident 2's Care Plan (CP) for Self-Administration of Medication, initiated and revised on 3/2/26, the CP indicated the resident self-administers Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath Activated 100-25 MCG/ACT. The CP interventions included the following: Physician order for self-administration of medication in place; Resident will be reassessed for ability to self-administer medications quarterly, annually and for significant change of condition. During an interview with Resident 2 and Family Member 1 (FM 1) at bedside on 3/18/2026 at 1:35 p.m., FM 1 stated Resident 2 did not receive Resident 2's inhaler for approximately 2 1/2 months starting on 12/8/25. During an interview with License Vocation Nurse 2 (LVN 2) on 3/23/26 at 11:04 a.m., LVN 2 stated LVN 2 previously monitored Resident 2 when Resident 2 self-administered the Furoate-Vilanterol inhaler. LVN 2 stated, Resident 2 has been self-administering from December 2025 until now [3/23/26]. LVN 2 stated, In PCC (electronic medical record) there should be an assessment for self-medication administration for Resident 2 by the RN supervisor or charge nurse. LVN 2 stated she had not completed a self-medication assessment for Resident 2. During an interview with the Minimum Data Set Nurse (MDSN) on 3/23/26 at 2:20 p.m., the MDSN stated a resident who self-administers medication should have a physician's order and assessment completed by IDT to evaluate the resident's ability to self-medicate. The MDSN stated the MDSN did not have any knowledge that Resident 2 was self-administering medication and only became aware because the MDSN had to do the Quarterly (2/27/26) MDS for Resident 2. During a review of the facility's P&P titled, Resident Rights, revised December 2016, the P&P indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to self-administer medication, if the interdisciplinary care planning team determines it is safe. During a review of the facility's P&P titled, Administering Medications, revised April 2019, the P&P indicated medications are administered in accordance with prescriber orders, including any required time frame. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. During a review of the facility's P&P titled, Safety and Supervision of Residents, revised July 2017, the P&P indicated the interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. During a review of the facility's P&P titled, Self-Administration of Medications, revised December 2016, the P&P indicated residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The P& P further indicated as part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment including (but not limited to) the resident's:a. Ability to read and understand medication labels.b. Comprehension of the purpose and proper dosage and administration time for his or her medications.c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication: andd. Ability to recognize risks and major adverse consequences of his or her medications.If the team determines that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications.

Based on observation, interview, and record review, the facility failed to ensure the call lights be kept within reach for two of five sampled residents (Resident 3 and Resident 5) in accordance with the facility's policy and procedure (P&P), titled, Call Lights.These deficient practices had the potential for Resident 3 and Resident 5 to receive delayed care and services necessary to meet the residents' needs.a. During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 10/3/2025 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a weakness or partial paralysis affecting one side of the body) following cerebral infarction (the blood supply to part of the brain is blocked or reduced, which leading to brain tissue death), generalized muscle weakness, and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing).During a review of Resident 3's Care Plan (CP), dated 11/7/2025, the CP indicated that the resident is at fall risk and the intervention to reduce the risk is to maintain call light within reach.During a review of Resident 3's History and Physical (H&P), dated 11/26/2025, the H&P indicated that the resident had the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 1/9/2026, the MDS indicated Resident 3 was moderate impaired in cognitive skills (ability to make daily decisions). The MDS indicated the resident was dependent (Helper does all of the effort. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, and personal hygiene.During a review of Resident 3's CP, dated 3/1/2026, the CP indicated the intervention to improve functional ability when in bed is to place call light and frequently used items within reach.During a concurrent observation and interview on 3/2/2026 at 1:12 PM with Resident 3 in Resident 3's room, Resident 3 was awake and lying on the bed. Resident 3's call light was hanging on the left side bedrail, and the call light pad was hanging under the bed. Resident 3 stated Resident 3 can barely move hands and arms and cannot reach the call light pad.During a concurrent observation and interview on 3/2/2026 at 1:31 PM with Certified Nursing Assistant (CNA) 2 in Resident 3's room, Resident 3's call light pad was hanging under the bed. CNA 2 stated that Resident 3 was unable to touch the call light pad which was hanging under the bed. CNA 2 stated staff should have placed the call light pad within Resident 3's reach.b. During a review of Resident 5's AR, the AR indicated Resident 5 was admitted to facility on 1/5/2026 with diagnoses including malignant neoplasm of prostate (prostate cancer- is cancer that develops in the prostate, a small, walnut-shaped gland located below the bladder and in front of the rectum in males), secondary malignant neoplasm of bone (bone cancer- aggressive, cancerous growths that destroy bone tissue and can spread to other body parts), difficulty in walking, generalized muscle weakness, and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 5's CP, dated 1/6/2026, the CP indicated the intervention to improve functional ability when in bed is to place call light and frequently used items within reach. The CP indicated that the resident is at fall risk and the intervention to reduce the risk is to maintain call light within reach.During a review of Resident 5's H&P, dated 1/7/2026, the H&P indicated that the resident has the capacity to understand and make decisions.During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5 had intact cognitive skills. The MDS indicated the resident 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, shower/bathe self, and upper and lower body dressing. The MDS indicated the resident required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating, oral hygiene, and personal hygiene.During a concurrent observation and interview on 3/3/2026 at 9:48 AM with Resident 5 in Resident 5's room, Resident 5 was awake and sitting on the left edge of his bed with feet on floor. Resident 5's call light was on the floor next to the right side of the bed. Resident 5 stated Resident 5 cannot use the call light to call for help because he cannot reach the call light.During a concurrent observation and interview on 3/3/2026 at 9:52 AM with Licensed Vocational Nurse (LVN) 1 in Resident 5's room, Resident 5's call light was on the floor. LVN 1 stated that Resident 5 was unable to reach the call light because the call was on the floor and at the other side of bed where the resident was sitting. LVN 1 stated staff should have kept the call light within Resident 5's reach.During an interview on 3/3/2026 at 3:44 PM with the Director of Nursing (DON), the DON stated the facility should ensure the call light was always kept within resident's reach.During a review of the facility's policy and procedure (P&P) titled, Call Light, revised October 2010, the P&P indicated When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, revised March 2021, the P&P indicated, facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. The P&P indicated, The resident's individual needs and preferences are accommodated to the extent possible.

Based on observation, interview, and record review, the facility failed to ensure the physician ordered medication Nystatin (a medication used to treat fungal or yeast infections of the skin, such as diaper rash) not left at bedside for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure (P&P), titled, Storage of Medications.This deficient practice resulted in Resident 1's medication was left at Resident 1's bedside and had the potential for Resident 1 not to receive appropriate medication administration following the physician's orders to meet the residents' needs.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/25/2025 with diagnoses including muscle wasting and atrophy, generalized muscle weakness, liver cell carcinoma (the most common type of liver cancer), secondary malignant neoplasm (is a cancerous tumor, an abnormal growth that can grow uncontrolled and spread to other parts of the body) of other parts of nervous system, and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/28/2025, the MDS indicated Resident 1 had intact cognitive skills (ability to make daily decisions). The MDS indicated the resident was dependent (Helper does all of the effort. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene, shower/bathe self, upper and lower body dressing, and putting on/taking off footwear. The MDS indicated that the resident required substantial/maximal assistance (Helper does more than half the effort) with personal hygiene.During a review of Resident 1's Treatment Administration Record (TAR), dated 3/2026, the TAR indicated Resident 1 had scrotum MASD need to be treated as: cleanse with NS, pad dry, apply Nystatin powder every shift for 14 days and recorded in the TAR. The order date is 2/26/2026.During a concurrent observation and interview on 3/2/2026 at 2:03 PM with Resident 1 and family member at Resident 1's bedside, there was a bottle of physician ordered Nystatin powder with the order label on the top of the bedside drawer. Resident 1 and the family member stated the Nystatin was kept at Resident 1's bedside and everyone can get it.During a concurrent observation and interview on 3/2/2026 at 2:55 PM with Treatment Nurse (TN) 1, the Treatment Cart (a mobile, organized, and lockable unit used by healthcare professionals to store, transport, and administer medical supplies, medications, and equipment) was observed. There was no Nystatin powder, which was ordered on 2/26/2026 to apply for the scrotum MASD every shift for 14 days for Resident 1, in the Treatment Cart. TN 1 stated the Nystatin powder ordered on 2/26/2026 to apply for the scrotum MASD (moisture associated skin damage caused from prolonged exposure to moisture) every shift for 14 days for Resident 1 should be stored in the Treatment Cart instead of at the resident's bedside. TN 1 stated only licensed nurses should get and apply the ordered Nystatin powder to Resident 1.During an interview on 3/3/2026 at 3:44 PM with the Director of Nursing (DON), the DON stated the facility should keep all ordered medications in a locked place and ensure only licensed nurses can access the medication.During a review of Resident 1's Order Summary Report (OSR), dated 3/3/2026, the OSR indicated there was a treatment order to treat scrotum MASD as follow: cleanse with NS (normal saline- a saltwater solution), pat dry, apply Nystatin powder, every shift for 14 days. The order is active on 2/26/2026.During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, revised April 2019, the P&P indicated the facility should store all drugs and biologicals in a safe, secure, and orderly manner. The P&P indicated, Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. The P&P indicated, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 4 completed documentation of the physician's order to perform the bladder scan (a non-invasive, painless ultrasound procedure used to measure the volume of urine in the bladder) and insert a straight catheter (a flexible, single-use, or intermittent tube inserted to the bladder to drain the urine and empty the bladder) for one of three sampled residents (Resident 2) on 12/8/2025.This deficient practice resulted in inaccurate documentation in Resident 2's medical record and had the potential for delaying interventions and services for Resident 2.During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 11/15/2025 with diagnoses which included neuromuscular dysfunction of bladder (nerve damage from disease or injury disrupts communication between the brain, spinal cord, and bladder muscles, causing overactive [leaking/frequency of urination] or underactive [retention of urine] bladder function), and extrarenal uremia (a buildup of waste products in blood that occurs as a result of untreated kidney failure).During a review of Resident 2's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 11/16/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 11/18/2025, the MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort to complete the activity) with toileting hygiene, showering/bathing, and lower body dressing. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort to complete the activity) with eating, oral hygiene, and personal hygiene.During a review of Resident 2's Order Summary Report (OSR), dated 11/15/2025 and 12/1/2025, the OSRs indicated there was no physician's order to perform a bladder scan and insert a straight catheter as needed for Resident 2.During a review of Resident 2's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form, dated 12/8/2025, the SBAR indicated LVN 4 performed a bladder scan on Resident 2, notified Resident 2's physician, and received physician's order to insert a straight catheter as needed for Resident 2 on 12/8/2025 at 12:45 PM.During a concurrent interview and record review on 2/11/2026 at 9:28 AM with LVN 4, Resident 2's OSR, dated 11/15/2025, and SBAR, dated 12/8/2025, were reviewed. LVN 4 stated LVN 4 performed a bladder scan on Resident 2 and received a physician's order to insert straight catheter for Resident 2 to drain urine as needed on 12/8/2026. LVN 4 stated there was no documented order to perform the bladder scan and insert the straight catheter on 12/8/2025. LVN 4 stated LVN 4 should have documented the order to perform the bladder scan and insert straight catheter.During an interview on 2/11/2026 at 2:50 PM with the Director of Nursing (DON), the DON stated the nurse should have obtained and documented a physician's order to perform the straight catheter for Resident 2.During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, undated, the P&P indicated, All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. The P&P indicated, 1. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records. 2. Entries may only be recorded in the residents' clinical record by licensed personnel (e.g. RN, LPN/L VN, physicians, therapists, etc.) in accordance with state law and facility policy. 3. All incidents, accidents, or changes in the resident's condition must be recorded.During a review of the facility's P&P titled, Electronic Signatures and Electronic Orders, revised 4/2021, the P&P indicated, The time and date of orders entered or changed made to electronic records are recorded.

Based on interview, and record review, the facility failed to ensure licensed nurses (in general) monitored the right thigh wound Jackson Pratt drain (JP, a soft, flexible, bulb-shaped suction device that gently draws fluid from a wound to help speed up healing time and reduce risk of an infection), and monitored and changed the right lower quadrant (RLQ) abdominal wound vacuum canister (a medical device that uses continuous or intermittent suction to accelerate healing of wounds) when it was full for one of three sampled residents (Resident 3).These deficient practices resulted in delayed interventions and services for monitoring the wound and JP drain and had the potential to delay Resident 3's wound healing.During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 1/21/2026 with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a weakness or partial paralysis affecting one side of the body) following cerebral infarction (damage to brain tissue caused by loss of blood flow to a part of the brain), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 3's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 1/22/2026, the H&P indicated Resident 3 had the capacity to understand and make decisions. The H&P indicated Resident 3 had undergone surgery on a right thigh tumor and the plan for Resident 3 while in the facility was to receive wound care for right thigh ulcer with monitoring for drainage.During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 1/24/2026, the MDS indicated Resident 3 was dependent (helper does all the effort to complete the activity) on staff for eating, oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, and personal hygiene.During a review of Resident 3's admission Initial Assessment (AIA), dated 1/21/2026 and timed at 5:10 PM, the AIA indicated Resident 3 had a wound vacuum within the RLQ of abdomen to the perineal area (area between the genitals and anus) and a JP drain on the right thigh.During a review of Resident 3's Order Summary Report (OSR), dated 1/21/2026, the OSR indicated there was no physician's order to monitor Resident 3's right thigh JP drain, and to empty and record the output from the JP drain. The OSR indicated there was no order to monitor and to change the canister for Resident 3's RLQ abdominal wound vacuum.During a review of Resident 3's medical record, there was no evidence found in the record that Resident 3's JP drain and wound vacuum were monitored on the evening shift (from 3 PM to 11 PM) on 1/21/2026 and on the night shift (from 11 PM to 7 AM) on 1/22/2026.During a review of Resident 3's Nursing Progress Note (NPN), dated 1/22/2026 and timed at 1:01 PM, the NPN indicated Resident 3's physician ordered to transfer and to admit Resident 3 to General Acute Care Hospital (GACH) 1 for further evaluation of excessive wound vacuum drainage.During a review of Resident 3's NPN, dated 1/23/2026 and timed at 9:34 PM, the NPN indicated Resident 3 was readmitted to the facility from GACH 1.During a review of Resident 3's OSR, dated 2/1/2026, the OSR indicated there was an order to drain and record output for right medial thigh with JP drain, which was ordered and started on 1/22/2026. The OSR indicated there was no order to monitor the wound vacuum and change the canister.During a review of Resident 3's Treatment Administration Record (TAR), dated 1/1/2026 to 1/31/2026, the TAR indicated monitoring for JP drain on right thigh and recording of JP drainage amount every shift started 1/22/2026 and discontinued on 1/22/2026. The TAR indicated there was no monitoring for the JP drain and recording of JP drainage on 1/21/2026 evening shift and on 1/22/2026 night shift. The TAR indicated monitoring for JP drain stoma site on right lateral and medial thigh every shift started 1/22/2026 until 1/27/2026. There is no monitoring for JP drain stoma site on right lateral and medial thigh on 1/21/2026 evening and night shift. The TAR indicated continuing wound vacuum on right quadrants to right inner thigh and monitoring for any adverse change every shift started 1/22/2026 until 1/27/2026. There are no continuing wound vacuum and monitoring for any adverse change on 1/21/2026 evening shift and night shift after the resident's admission on [DATE].During a concurrent interview and record review on 2/9/2026 at 3:11 PM with Treatment Nurse (TN) 1 and TN 2, Resident 3's OSR and TAR were reviewed. TN 1 and TN 2 stated there was no order to monitor, drain, and record the drainage amount of the JP drain and to monitor, continue, and change the wound vacuum canister when it is full on 1/21/2026 upon resident's admission.During a concurrent interview and record review on 2/9/2026 at 4:52 PM with Licensed Vocational Nurse (LVN) 2, Resident 3's OSR was reviewed. LVN 2 stated that there was no order to monitor, drain, and record the drainage amount of the JP drain and monitor and change the wound vacuum on 1/21/2026. LVN 2 stated LVN 2 did not monitor, drain, and record the drainage amount for the JP drain and the wound vacuum on 1/21/2026 evening shift.During an interview on 2/9/2026 at 4:59 PM with Registered Nurse (RN) 1, RN 1 stated RN 1 assessed Resident 3 on 1/21/2026 upon admission and Resident 3 was admitted with JP drain and wound vacuum. RN 1 stated RN 1 did not verify and obtain an order with Resident 3's physician to monitor, drain, and record the drainage amount of the JP drain and monitor and change the wound vacuum on 1/21/2026.During a phone interview on 2/11/2026 at 11:12 AM with LVN 5, LVN 5 stated LVN 5 did not monitor, drain, and record the drainage amount of the JP drain for Resident 3 on 1/21/2026 evening shift.During an interview on 2/10/2026 at 3:42 PM with the Director of Nursing (DON), the DON stated the facility should monitor, drain, and record the drainage amount of the JP drain and monitor, continue, and change the wound vacuum canister after admission for resident who had JP drain and wound vacuum.During a review of the facility's policy and procedure (P&P) titled, admission Assessment and Follow Up: Role of the Nurse, undated, the P&P indicated the admitting nurse needs to contact the resident's Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. The P&P indicated that the orders obtained from the physician should be recorded in the resident's medical records. The P&P also indicated that the nurse should notify the supervisor and the Attending Physician of immediate needs that the resident may have and report other information in accordance with facility policy and professional standards of practice.

Based on interview and record review, the facility failed to ensure therapeutic diets were served as ordered for one of four sampled residents (Resident 1). Resident 1 had a Physician's Order (PO) for no additional salt. This failure had the potential to result in an increased blood pressure (the force of the blood against the artery walls is too high) due to increased salt levels.During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 to the facility on 8/18/2025 with diagnoses that included hypertension (a condition when the force of the blood against the artery walls is too high), epilepsy (cell activity in brain is disturbed), and unspecified dementia (cognitive [ability to understand and process thoughts] decline). During a review of Resident 1's History & Physical Examination -V2 (H&P), dated 8/19/2025, the H&P indicated Resident 1 had the capacity to understand and make medical decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 8/25/2025, the MDS indicated Resident 1 was cognitively intact and required supervision and touching assistance with eating. A review of the Order Summary Report, dated 8/31/2025, the Order Summary Report indicated that Resident 1's diet order was CCHO (Controlled Carbohydrate/NAS (no additional sodium/salt), regular texture, and regular liquid. During a phone interview on 9/9/2025, at 10:40 a.m., with Family (FAM 1), FAM 1 stated the Dietary Supervisor (DS) told FAM 1 that Resident 1 requested additional salt with meals and Resident 1 was provided with salt packets. FAM 1 stated Resident 1 had high blood pressure and should not receive salt. During a phone interview on 9/10/2025, at 1:01 p.m., with FAM 2, FAM 2 stated Resident 1 has a seizure when Resident 1's blood pressure is high. FAM 2 stated Resident 1 should not be given salt. During an interview on 9/10/2025, at 3:08 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated to follow physician diet orders. During an interview, on 9/10/2025, at 4:55 p.m., with the Dietary Supervisor (DS), the DS stated that Resident 1's diet orders were a regular diet, and no added salt. The DS stated Resident 1 always asks for additional salt. The DS stated Resident 1 was so mad. The DS stated Mrs. Dash (salt free seasoning) was offered as an alternative and Resident 1 refused it. The DS stated resident 1's preferences were followed. During a subsequent interview on 9/10/2025, at 5:10 p.m., with the DS, the DS stated that the DS did not have documentation that the DS communicated with FAM 1 or FAM 2 that additional salt packets were provided to resident. The DS stated the DS did not have documentation that the DS informed the physician that Resident 1 requested additional salt packets. The DS stated Resident 1's diet order indicated do not give Resident 1 no additional salt. During a review of the facility's Policy and Procedure (P&P), titled, Diet/Therapeutic Diets, revised October 2017, the policy and procedure indicated diets and therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. If the resident or the resident's representative declines the recommended therapeutic diet, the interdisciplinary team will collaborate with the resident or representative to identify possible alternatives.

Based on interview and record review, the facility failed to ensure that Resident 1, a resident with dementia (loss of thinking, memory, and social abilities), was safely escorted to an outside appointment at GACH 1 for one of five sampled residents.This deficient practice resulted in the resident's safety being put at risk.During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 to the facility on 8/18/2025 with diagnoses that included hypertension (a condition when the force of the blood against the artery walls is too high), epilepsy (cell activity in the brain is disturbed), and unspecified dementia (cognitive [ability to understand and process thoughts] decline). During a review of Resident 1's History & Physical Examination -V2 (H&P), dated 8/19/2025, the H&P indicated Resident 1 had the capacity to understand and make medical decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 8/25/2025, the MDS indicated Resident 1 was cognitively intact and required substantial/maximal assistance with walking 10 feet and was dependent for transfers. During a phone interview on 9/9/2025, at 10:40 a.m., with Family (FAM 1), FAM 1 stated Resident 1 had an appointment on 9/2/2025 at 12:30 p.m. at GACH 1. FAM 1 stated FAM 1 arrived at GACH 1 at 12:20 p.m. FAM 1 stated when FAM 1 arrived at GACH 1, Resident 1 was with provider and Resident 1's wheelchair was there, but no escort was there. FAM 1 stated Resident 1 had another appointment across the street at another office on the same day to have staples removed from Resident 1's head. FAM 1 stated FAM 1 did not see an escort. FAM 1 felt it was unsafe for Resident 1 to be left alone because Resident 1 has dementia. FAM 1 stated Resident 1 was left at the appointment site with Resident 1's medical documents. During an interview on 9/10/2025, at 3:26 p.m., with the Licensed Vocational Nurse (LVN 1), LVN 1 stated the facility will always send an escort, but they also ask the family if family will be available. LVN 1 stated, We don't send them without an escort. LVN 1 stated the only reason that residents will go without an escort is if the family meets them at the appointment or family will meet at the facility and then they go to an appointment. LVN 1 stated it is important to make sure the resident is safe, and that they come back, or there is not an incident of losing the resident and the resident arrives safely. LVN 1 stated LVN 1 is unsure if there is a written Policy stating that, but this is what LVN 1 hopes they're doing it and it's the protocol. During an interview on 9/10/2025, at 4:04 p.m., with the Social Services Director (SSD), the SSD stated staff escort the resident to the appointment and back, if needed. The SSD stated if the resident had a dementia diagnosis, the resident would need an escort. The SSD stated most of the residents in the facility go with an escort. The SSD stated the escort remains at the appointment and returns with the resident unless the family is going to meet them there and the family is okay with taking care of the resident. The SSD stated they must wait for the family before leaving and they can't just leave them there. The SSD stated it is important for safety. The SSD stated that when the Director of Staff Development (DSD) arranges for transportation and an escort, the DSD looks for if the resident needs physical help, a wheelchair, and if the resident is confused or forgetful. During an interview on 9/10/2025, at 4:14 p.m., with the DSD, the DSD stated that Resident 1 was called in to see the doctor and the escort, Escort (ESC 1) stated to the nurse Resident 1's daughter would be coming. During an interview on 9/10/2025, at 5:56 p.m., with Social Services Assistant (SSA), the SSA stated it was determined by email communication, dated 8/28/2025, that Resident 1 needed an escort to ride with her because Resident 1's daughter would meet them at the appointment. The SSA stated that most likely they wait for the family to meet them at the appointment before leaving. The SSA stated if the escort needs to leave, they will call family for an estimated time of arrival (ETA) to the appointment. The SSA stated for the most part escort remains with the patient. The SSA stated it is important for the safety of the resident, so the resident is not alone. During a phone interview, on 9/10/2025, at 6:27 p.m., with ESC 1, ESC 1 stated that Resident 1's daughter was not there. During a review of the facility's Policy and Procedure (P&P), titled, Transportation and Appointments, revised December 2023, the policy and procedure indicated our facility will assist residents in arranging transportation and escort (as indicated for resident with cognitive impairment, diagnosis of Dementia and/or resident's needing physical assistance with transfers and mobility) to/from appointments including when necessary. A member of nursing staff or social services will accompany the resident when the resident's family is not available.

Based on observation, interview, and record review, the facility failed to follow standards of practice and facility protocol for oxygen therapy for four of four sampled residents (Residents 23, 39, 40, and 113) by failing to:a. Ensure Resident 39's nasal cannula ([NC] a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was not touching the floor while in use.b. Ensure Resident 23's NC was safely stored without the nasal prongs touching the back of the oxygen concentrator.c. Ensure Resident 40 received two liters per minute (lpm) of oxygen via NC according to the physician's order.d. Ensure Resident 113's NC was not touching the floor while in use.These failures had the potential to result in the transmission of infectious microorganisms and increased risk of infection for Residents 23, 39, and 113 and had the potential to cause complications associated with oxygen therapy for Resident 40.Findings: a. During a review of Resident 39's admission Record (AR), the AR indicated Resident 39 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included respiratory failure (a condition caused by inadequate supply of oxygen and/or the inability to remove carbon dioxide from the lungs) and pneumonia (an infection/inflammation in the lungs). During a review of Resident 39's History & Physical (H&P), dated 6/19/2025, the H&P indicated the resident had a history of lung cancer and did not have the capacity to understand and make decisions. During a review of Resident 39's Minimum Data Set (MDS, a resident assessment tool), dated 7/2/2025, the MDS indicated Resident 39 had moderately impaired cognition (ability to understand) and used oxygen therapy. During a review of Resident 39's Care Plan (CP), dated 7/20/2025, the CP indicated Resident 39 required continuous oxygen and monitored for shortness of breath, and provided oxygen inhalation as ordered. During a review of Resident 39's Order Summary Report (OSR), dated 7/22/2025, the OSR indicated continuous administration of oxygen at two lpm via NC for respiratory failure, ordered on 7/20/2025. During a review of Resident 39's Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 7/1/2025 to 7/31/2025, the MAR indicated Resident 39 received oxygen via NC on 7/22/2025 during the day shift. During a concurrent observation and interview on 7/22/2025 at 10:44 am with Registered Nurse 3 (RN 3) in Resident 39's room, Resident 39 was lying in bed receiving oxygen through a NC with the NC tubing was touching the floor. RN 3 stated, Resident 39's NC tubing should not be touching the floor because the resident could get an infection, such as pneumonia. During an interview on 7/24/2025 at 4:02 pm with the Director of Nursing (DON), the DON stated the oxygen tubing should not touch the floor when in use because it's an infection control issue. The DON stated, the resident could possibly develop pneumonia from the oxygen tubing touching the floor. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, last revised 12/2024, the P&P indicated to provide safe oxygen administration guidelines and indicated professional standards of practice were followed. During a review of the facility's policy and procedure (P&P) titled, Standard Precautions, Enhanced Barrier Precautions, and Transmission Based Precautions, last revised 5/20/2025, the P&P indicated, its purpose was to provide infection control practices to reduce the potential for transmission of pathogens including COVID-19 and multi-drug resistant organisms and viruses. The P&P indicated, for environmental and equipment protection disinfection of equipment to prevent the spread of COVID-19, MDRO, and other infectious agents. b. During a review of Resident 23's AR, the AR indicated Resident 23 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus type 2 (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine) and anemia (decrease in the total amount of red blood cells in the blood. During a review of Resident 23's MDS dated [DATE], the MDS indicated Resident 23 had moderately intact cognition for daily decision making. The MDS indicated Resident 23 was dependent (helper did all the effort and lifted or held trunk or limbs) to staff for toileting, shower, upper/lower body dressing and putting on/off footwear. During an observation on 7/21/2025 at 9:56 am, Resident 23 was sitting on the shower chair. Resident 23's nasal cannula was hanging on the oxygen concentrator with nasal prongs touching the back of the concentrator. During a concurrent observation and interview on 7/21/2025 at 9:56 am, with the Director of Staff and Development (DSD), the DSD stated Resident 23's nasal cannula was hanging on the oxygen concentrator. The DSD stated, nasal cannula needed to be inside the set-up bag (plastic bag) when not in use for infection control. c. During a review of Resident 40's AR, the AR indicated Resident 40 was admitted to the facility on [DATE] with diagnoses that included pneumonia (an infection/inflammation in the lungs), hypoxemia (low level of oxygen in the blood) and interstitial pulmonary disease (a condition that cause inflammation and scarring (fibrosis) of the lungs.) During a review of Resident 40's MDS dated [DATE], the MDS indicated Resident 40 had moderately intact cognition for daily decision making. The MDS indicated Resident 40 was dependent to staff for eating, oral hygiene, toileting, shower, upper/lower body dressing and putting on/off footwear and personal hygiene. During a review of Resident 40's OSR dated 7/16/2025, the OSR indicated to administer oxygen at two (2) liters per minute (L/min) via nasal cannula continuously for acute respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (high levels of carbon dioxide [waste product that your body gets rid of when you exhale] every shift. During a concurrent observation and interview on 7/21/2025 at 9:23 am, with the DSD, the DSD stated Resident 40's was on oxygen 4.5 LPM via nasal cannula. The DSD stated Resident 40 was receiving oxygen at 4.5 LPM via nasal cannula. During an interview on 7/23/2025 at 10:48 am with Registered Nurse 1 (RN 1), RN 1 stated Resident 40 needed to receive 2 LPM of oxygen via nasal cannula according to the physician's order. RN 1 stated the physician's order needed to be followed to ensure Resident 40 was receiving the correct level of oxygen therapy. During an interview on 7/24/2025 at 11:17 am, with the facility's Director of Nursing (DON), the DON stated the physician's order needed to be followed. The DON stated excessive oxygen could cause dryness in the nose. The DON stated nasal cannula needed to be inside the plastic bag if not in use for infection control to prevent cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). During a review of the facility's P&P titled, Oxygen Administration, revised 12/2024, the P&P indicated to verify that there was a physician's order for this procedure and review the physician's orders or facility protocol for oxygen administration. The P&P indicated, oxygen tubing (cannula/mask) shall be stored in a designated plastic bag when not in use. d. During a review of Resident 113's AR, the AR indicated Resident 113 was admitted to the facility on [DATE] with diagnoses that included pulmonary edema (a condition caused by too much fluid in the lungs causing breathing difficulty) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 113's History & Physical (H&P) dated 6/15/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 113's MDS dated [DATE], the MDS indicated Resident 113 had moderately impaired cognition and used oxygen therapy. During a review of Resident 113's OSR dated 7/24/2025, the OSR indicated continuous administration of oxygen at 2 lpm via NC for hypoxemia (low level of oxygen in the blood), ordered on 6/16/2025. During a review of Resident 113's Care Plan (CP), dated 6/16/2025, the CP indicated Resident 113 required continuous oxygen, monitored for shortness of breath, and provided oxygen inhalation as ordered. During a concurrent observation in Resident 113's room and interview on 7/24/2025 at 2:40 pm, Resident 113 was receiving oxygen through a NC. Resident 113 stated Resident 113 used oxygen, but wished Resident 113 didn't need it. During a concurrent observation and interview on 7/24/2025 at 2:51 pm in Resident 113's room, with Licensed Vocational Nurse 7 (LVN 7) Resident 113 was lying in bed receiving oxygen through a NC with the NC tubing touching the floor. LVN 7 stated Resident 113's NC tubing was touching the floor and should not have touched the floor at all. During an interview on 7/24/2025 at 4:02 pm with the Director of Nursing (DON), the DON stated oxygen tubing should not touch the floor when in use for infection control. The DON stated, the resident could develop pneumonia from the oxygen tubing touching the floor. During a review of the facility's P&P titled, Oxygen Administration, revised 12/2024, the P&P indicated to provide safe oxygen administration guidelines and indicated professional standards of practice were followed.

Based on observation, interview, and record review, the facility failed to provide three of three sampled residents (Residents 10,75 and 119) with dignity and respect, based on the facility's policy and procedure (P&P) titled, Resident Rights, by failing to:a. Ensure Resident 119, who was occasionally (less than seven episodes of incontinence [inability to control the bladder and bowels]) incontinent, was offered alternative means to go to the bathroom. As a result, Resident 119 was instructed by staff to go the bathroom in Resident 119's brief (disposable absorbent garment designed to contain urinary or fecal incontinence). Resident 119 felt pain when having to be turned to be changed and made Resident 119, Feel horrible.b. Ensure Staff do not address Resident 10 as a feeder. As a result, Resident 10 stated Resident 10 felt useless.c. Ensure the Director of Staff Development (DSD) close Resident 75's privacy curtains completely while checking the resident's G Tube site.These deficient practices violated Residents 10,75 and 119's right to privacy and dignity while under the care of the facility.a. During a review of Resident 119's admission Record (AR), the AR indicated the facility admitted Resident 119 on 6/17/2025 with diagnoses that included aftercare following joint replacement surgery, presence of left artificial (fake or manmade) hip joint (where the thigh bone and hip connect), and unspecified chronic kidney disease (damage to the kidneys so they cannot filter blood the way they should). During a review of Resident 119's Minimum Data Set (MDS- a resident assessment tool) dated 6/20/2025, the MDS indicated Resident 119 had moderately impaired cognition (ability to think, remember, and function). The MDS indicated Resident 119 was dependent (helper does all 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 toileting hygiene. The MDS indicated Resident 119 was occasionally incontinent of urine. The MDS indicated Resident 119's bowel continence was not rated due to resident having an ostomy (hole made through the belly that allows fecal matter to pass through) or did not have a bowel movement for the entire seven (7) days. During an interview on 7/24/2025 at 10:45 am, with Resident 119 in Resident 119's room, Resident 119 stated, They (facility staff) make me go to the bathroom in my diaper and I hate it. Resident 119 stated Resident 119 had to go to the bathroom in Resident 119's brief because facility staff would not give Resident 119 a commode (portable toilet) or help Resident 119 up to the restroom. Resident 119 stated, I hate rolling over on the bed (to be changed), it's terribly painful. Resident 119 stated, It makes me feel horrible. During an interview on 7/24/2025 at 11:37 am, with Certified Nurse Assistant 6 (CNA 6), CNA 6 stated Resident 119 was unable to walk without assistance. CNA 6 stated Resident 119 was always incontinent (of bowel and bladder). CNA 6 stated when CNA 6 got Resident 119 up to take a shower, CNA 6 took Resident 119 to the toilet and that Resident 119 was able to hold it (bowel and bladder) until then. CNA 6 stated CNA 6 told Resident 119 to go the bathroom in the brief and CNA 6 will change the brief after. During a concurrent interview and record review on 7/24/2025 at 11:42 am with Licensed Vocational Nurse 5 (LVN 5), Resident 119's MDS dated [DATE] and Bowel and Bladder Assessment (BBA) dated 6/20/2025 were reviewed. LVN 5 stated Resident 119 was occasionally incontinent which meant sometimes Resident 119 was able to hold Resident 119's bowel and bladder and sometimes Resident 119 could not. LVN 5 stated Resident 119 wants to get up all the time to go to the bathroom but was only walking with during physical therapy, and to be safe, a brief was kept on Resident 119. LVN 5 stated it was not a good feeling to be told to go to the bathroom in Resident 119's brief because Resident 119's independence could be hindered. LVN 5 stated this was a dignity issue and could also put Resident 119 at risk for skin breakdown or infection. During an interview on 7/24/2025 at 4:02 pm, with the Director of Nursing (DON), the DON stated it was not acceptable to tell residents who were occasionally incontinent to go to the bathroom in their brief. The DON stated staff needed to either get residents up to go to the toilet, commode, or offer a bed pan (device used as a container for the urine and/or feces of a person who is confined to a bed and therefore not able to use a toilet). The DON stated telling the resident to go to the bathroom in their brief and wait to be changed after, would impact the resident's self-esteem in a negative way, causing issues with dignity, and could offend the resident. During a review of the facility's P&P titled, Resident Rights, revised 3/2025, the P&P indicated employees shall treat all residents with kindness, respect, and dignity. The P&P indicated federal and state laws guarantee certain basic rights to all residents of this facility. The P&P indicated the resident rights included the right to: a dignified existence, be treated with respect, kindness, and dignity, participate in decision-making regarding his or her care, and be informed of, participate in, his or her care planning and treatment. b. During a review of Resident 10's AR, the AR indicated Resident 10 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included multiple sclerosis (disease that affects the brain and nerves causing weakness and problems with movement), protein calorie malnutrition (a condition resulting from insufficient intake of both protein and calories), adult failure to thrive (a decline in older adults characterized by weight loss, decreased appetite, and reduced physical activity, often accompanied by cognitive [mental process involved in knowing, learning, and understanding things] and functional decline), major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest, and a reduced ability to function in daily life) and monoplegia of lower limb (paralysis or weakness affecting the legs) affecting unspecified side. During a review of Resident 10's History and Physical (H&P) dated 5/06/2025, the H&P indicated Resident 10 had the capacity to understand and make decisions. The H&P indicated Resident 10 was at risk for malnutrition, weight loss and falls. During a review of Resident 10's Minimum Data Set (MDS- a resident assessment tool), dated 6/20/2025, the MDS indicated Resident 10 needed substantial/maximal assistance (helper does more than half the effort) from staff with eating, oral hygiene, upper and lower body dressing and personal hygiene. The MDS indicated Resident 10 was dependent (helper does all of the effort) on staff for toileting hygiene, shower, and putting off footwear. During a review of Resident 10's untitled Care Plan (CP) initiated on 1/13/2025, the CP indicated Resident 10 was at risk for social isolation and ineffective coping. The CP interventions indicated for staff to talk to Resident 10 in a calm and non-threatening manner. During a review of Resident 10's untitled CP initiated on 1/23/2025, the CP indicated Resident 10 had little interest or pleasure in doing things, feeling down, depressed or hopeless. The CP interventions indicated for staff to allow Resident 10 to vent feelings and provide a safe environment. During an observation in Resident 10's room on 7/21/2025 at 1:13 PM, Resident 10 was resting in bed. Certified Nurse Assistant 2 (CNA 2) placed the lunch tray on top of Resident 10's side table. As CNA 2 was walking out of Resident 10's room, CNA 2 stated CNA 2 was serving out trays for the feeders (Term feeder can be considered dehumanizing and often discouraged in favor of more respectful language like residents needing feeding assistance or patients requiring assisted feeding). During an interview with CNA 2 on 7/21/2025 at 1:14 PM, CNA 2 stated it was not OK to refer a resident as a feeder because it could affect their dignity. CNA 2 stated labeling the residents as feeders could result in negative emotions such as feeling upset or sad. CNA 2 stated calling a resident a feeder could potentially result in depression or trigger emotional distress. CNA 2 stated, calling a resident a feeder could make them feel degraded. During an interview with Resident 10 on 07/23/2025 at 3:14 PM, Resident 10 stated Resident 10 overheard outside Resident 10's doorway when staff stated they were going to assist the feeders. Resident 10 stated Resident 10 did not like the way the word feeder sounded as it made Resident 10 feel bad because Resident 10 was not able to feed self and needed staff's assistance. Resident 10 stated hearing the staff say the word feeder just reminded her of how useless she had become. During an interview with the Director of Nursing (DON) on 07/24/2025 at 1:06 PM, the DON stated, it was not acceptable to use the word feeder when staff were assigned to a resident who needed assistance with eating. The DON stated the residents' dignity would be affected if staff refer to them as feeder. The DON stated residents could get offended or upset if staff refer to them as feeders. c. During a review of Resident 75's AR, the AR indicated Resident 75 was admitted to the facility on [DATE], with diagnoses that included gastrostomy (creation of an artificial external opening into the stomach for nutritional support), unspecified dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and essential hypertension (high blood pressure). During a review of Resident 75's MDS dated [DATE], the MDS indicated Resident 75 had severely impaired cognition for daily decision making. The MDS indicated Resident 75 was dependent on staff for oral hygiene, toileting, showering/bathing self, lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 75's Order Summary Report (OSR) dated 7/10/2025, the OSR indicated for staff to administer Diabetisource (liquid formula used for G-tube feeding) at 55 milliliter per hour (ml/hr.- unit of measurement) for 20 hours via (through) enteral feeding pump for a total of 1,320 ml per 1,100 kilo calories (kcal, unit of energy) in 24 hours (Pump on at 12 pm and pump off at 8 am if dose was completed). During an observation on 7/21/2025 at 9:01 am with the Director of Staff and Development (DSD), in Resident 75's room. Resident 75 was awake, lying in bed. The DSD pulled the privacy curtain to check Resident 75's G-tube site. The DSD was unable to close the privacy curtain completely leaving approximately 4 feet and 6 inches gap from the wall. The DSD pulled up Resident 75's gown exposing Resident 75's abdominal area to Resident 75's roommate and the hallway. During an interview on 7/21/2025 at 9:04 am with the DSD, the DSD stated the DSD pulled up Resident 75's gown to check Resident 75's G-tube site and was unable to close the privacy curtain with 4 feet and 6 inches gap from the wall exposing Resident 75's body parts to the resident's roommate and passersby. The DSD stated the privacy curtain needed to be closed completely prior to providing care and treatment to the residents to provide privacy. During a concurrent interview on 7/23/2025 at 9:31 am with the DON, the DON stated, the resident's privacy curtain needed to be closed completely to provide privacy and dignity to the resident while staff provided care. The DON stated the residents' body parts should not be exposed during care and treatment. During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights, revised 3/2025, the P&P indicated employees shall treat all residents with kindness, respect, and dignity. During a review of the facility's P&P titled, Quality of Life-Dignity, revised 2/2020, the P&P indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. During a review of the facility's P&P titled, Dining/Assistance with Meals, revised 7/2017, the P&P indicated residents shall receive assistance with meals in a manner that meets the individual needs of each resident. c. Avoiding the use of labels when referring to residents (e.g., feeders). During a review of the facility's P&P titled, Dignity/Privacy, revised 8/2009, the P&P indicated staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observation, interview, and record review, the facility failed to implement the facility's infection control policy and procedure for two of five sampled residents (Residents 83 and 162).a. Certified Nursing Assistant 1 (CNA 1) did not wear the required Personal Protective Equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses like disposable masks, gloves and gowns) and did not perform hand hygiene while taking care of Resident 162 who was on Enhanced Barrier Precaution (EBP- infection control measures implemented in nursing homes to reduce the spread of multidrug-resistant organisms [MDROs- bacteria or other microorganisms that have become resistant to multiple antibiotics]).b. CNA 3 did not wear the required PPE in an EBP room and did not perform hand hygiene before and after touching Resident 83's urostomy bag (a medical device used to collect urine after certain types of bladder surgery).These deficient practices had the potential to result in infection and spread of infection among staff and residents.Findings: a. During a review of Resident 162's admission Record (AR), the AR indicated Resident 162 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of the stomach (a cancerous tumor that develops in the lining of the stomach), other artificial openings of gastrointestinal tract status (a series of organs that work together to digest food, absorb nutrients, and eliminate waste products), pneumonia (an infection of one or both of the lungs) and chronic obstructive pulmonary disease (COPD- a common lung disease causing restricted airflow and breathing problems). During a record review of Resident 162's untitled Care Plan (CP) initiated on 7/11/2025 and revised on 7/23/2025, the CP indicated Resident 162 was on EBP and was at high risk for development of MDRO. The CP interventions indicated to initiate EBP, and staff will perform hand hygiene, wear PPE (gown & gloves) before & after high contact care activities (activities involving close physical contact). During a review of Resident 162's History and Physical (H&P) dated 7/12/2025, the H&P indicated Resident 162 had the capacity to understand and make decisions. During a review of Resident 162's Order Summary Report (OSR) dated 7/12/2025, the OSR indicated EBP every shift for peripheral inserted central catheter (PICC- a thin, flexible tube inserted into a vein in the arm and threaded into a larger vein near the heart) line on the left upper arm. During an observation of Resident 162's room on 7/21/2025 at 9:40 AM, EBP sign was posted outside Resident 162's room. Resident 162 was resting in bed with an ongoing TPN IV formula (a specific mixture of nutrients delivered through a vein to individuals who cannot obtain adequate nutrition through their digestive system) infusing through the left arm PICC line. During an observation of Certified Nurse Assistant 1 (CNA1) on 7/21/2025 at 9:46 AM, CNA1 walked inside Resident 162's room, not wearing PPEs. CNA1 walked over to Resident 162's bed, turned off Resident 162's call light (a device that allows a patient to signal for assistance) and touched Resident 162's hands while Resident 162 handed CNA1 a cell phone and charger. During a concurrent observation of CNA1 and interview on 7/21/2025 at 9:43 AM, CNA1 walked out of Resident 162's room without performing hand hygiene. CNA1 stated CNA 1 should have performed hand hygiene because Resident 162 was on EBP. CNA 1 stated CNA 1 should have worn a gown and gloves when CNA 1 came in contact with Resident 162's hands. CNA1 stated wearing PPEs for a resident on EBP was necessary to prevent the spread of infections and bacteria. During an interview with License Vocational Nurse 1 (LVN1) on 7/21/2025 at 10:00 AM, LVN 1 stated it was important for staff to wear appropriate PPEs when coming into contact with a resident on EBP. LVN 1 stated if staff do not wear the required PPEs when coming into contact with a resident on EBP, there was a high risk of the spread of infection to other residents. During an interview with CNA 2 on 7/22/2025 at 8:15 AM, CNA 2 stated it was important for staff to wear the required PPEs when caring for a resident on EBP to prevent the spread of infection. During an interview with the Director of Nursing (DON) on 7/24/2025 at 1:03 PM, the DON stated, for residents on EBP, staff needed to wear gowns and gloves when providing care or coming into contact with residents. The DON stated staff should wear gloves if the staff touch the resident or resident's belongings. The DON stated it was not acceptable for staff not to follow the EBP precaution because staff can spread infection to themselves or other residents in the facility. During an interview with the facility's Infection Prevention Nurse (IPN) on 7/24/2025 at 9:53 AM, the IPN stated, EBP was a precaution to protect the residents from staff spreading infection to residents. The IPN stated, if a staff member was in contact with a resident that was on EBP and staff do not perform hand hygiene, there was high risk for cross contamination (bacteria from one source is spread to another) and the spread of infection. b. During a review of Resident 83's AR, the AR indicated Resident 83 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm (cancer) of the bladder, dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), and urinary tract infection (UTI- infection that affects part of the urinary tract). During a review of Resident 83's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 6/27/2025, the MDS indicated Resident 83 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 83 needed moderate assistance (helper does less than half of the effort) on staff for oral hygiene, toileting, showering/bathing self, lower body dressing, and putting on/taking off footwear. During a review of Resident 83's OSR dated 7/7/2025, the OSR indicated to place Resident 83 on EBP every shift for the presence of foley catheter (thin, sterile tube inserted into the bladder to drain urine). During a review of Resident 83's CP titled Enhanced Barrier Precautions, dated 7/7/2025, the CP indicated Resident 83 had urostomy (a surgical procedure that creates a new way for your body to get rid of urine) and was high risk for development of MDRO. The CP indicated for nursing staff to initiate EBP and staff will perform hand hygiene, wear PPE (gown and gloves) before and after high contact care activities. During an observation on 7/21/2025 at 9:16 am, Resident 83 was awake lying in bed, with a urostomy bag draining on the right side of bed. During a concurrent observation and interview on 7/21/2025 at 12:52 pm, Resident 83 was lying in bed. Certified Nurse Assistant 3 (CNA 3) entered Resident 83's room and did not perform hand hygiene and did not wear gown and gloves before entering Resident 83's room. CNA 3 held Resident 83's urostomy bag and tube without donning (wearing) gloves. CNA 3 touched Resident 83's blanket and stepped out of Resident 83's room and did not perform hand hygiene. CNA 3 stated she forgot to wear a gown and gloves before entering Resident 83's room. CNA 3 stated she should have sanitized her hands before and after resident care and should have worn gown and gloves to prevent spread of infection. During an interview on 7/22/2025 at 1:38 pm with the Director of Staff and Development (DSD), the DSD stated staff needed to perform hand hygiene before touching the catheter bag and needed to wear gown and gloves before touching Resident 83 who was on EBP to prevent the spread of infection. During a review of the facility's Policy and Procedure (P&P) titled, Standard Precautions, Enhanced Barrier Precautions and Transmission– Based Precautions, revised on 5/20/2025, the P&P indicated EBP primarily is the use of gowns and gloves for specific high contact care activities, based on the resident's characteristics that are associated with a high risk MDRO colonization and transmission: presence of indwelling medical devices (urinary catheter). The P&P indicated the use of PPE will apply following the standard precautions when caring for these EBP residents. The P&P indicated gowns and gloves will be used while performing the following high contact tasks associated with the greatest risk for MDRO contamination of health care personnel's hands, clothes and environment: device care for example urinary catheter or other indwelling devices. Gowns and gloves will be used while performing the following high-contact tasks associated with the greatest risk for MDRO contamination of HCP hands, clothes, and the environment: Any care activity where close contact with the residents is expected to occur Any care activity involving contact with environmental surfaces is likely contaminated by the residents. In multi-bed rooms, each bed space is considered a separate room and change of gowns and gloves and perform hand hygiene when moving form contact with one resident to contact with another resident.

Based on observation, interview, and record review, the facility failed to properly store boiled eggs in one of one facility kitchen. This failure had the potential to result in foodborne illness in the residents who ate the boiled eggs. Findings:During an observation on 7/21/2025 at 8:27 a.m., five eggs without a date and time were observed in a black bowl on the kitchen counter across from the cooking stove.During an interview on 7/21/2025 at 8:28 a.m., with cooking staff, [NAME] 1, the cooking staff stated the eggs were prepared for residents that want their eggs boiled. The cooking staff could not provide an exact date or time the eggs were boiled and placed on the counter. Staff stated the eggs could go bad if I don't know the exact time the eggs were prepared before giving them to a resident.During an interview on 7/23/2025 at 7:59 a.m., with [NAME] 1 and DSS, while in the kitchen, both stated that eggs left out can develop salmonella (a common form of food poisoning) if not dated and timed to determine how long they have been unrefrigerated. If eggs are left out and not labeled with a date and time, they should be thrown out to prevent a resident from contracting salmonella.

Based on observation, interview, and record review, the facility failed to ensure the residents' call light (a device used by patients to call for assistance from hospital staff) was within reach (an arm's length) of four of four sampled residents (Residents 10, 29,114 and 118).These deficient practices had the potential to result in delayed provision of necessary care and services for Residents 10, 29,114 and 118.Findings: a. During a review of Resident 10's admission Record (AR), the AR indicated Resident 10 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included multiple sclerosis (disease that affects the brain and nerves causing weakness and problems with movement), protein calorie malnutrition (a condition resulting from insufficient intake of both protein and calories), adult failure to thrive (a decline in older adults characterized by weight loss, decreased appetite, and reduced physical activity, often accompanied by cognitive [mental process involved in knowing, learning, and understanding things] and functional decline), major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest, and a reduced ability to function in daily life) and monoplegia of lower limb (paralysis or weakness affecting the legs) affecting unspecified side. During a review of Resident 10's History and Physical (H&P) dated 5/06/2025, the H&P indicated Resident 10 had the capacity to understand and make decisions. The H&P indicated Resident 10 was at risk for malnutrition, weight loss and falls. During a review of Resident 10's Minimum Data Set (MDS- a resident assessment tool), dated 6/20/2025, the MDS indicated Resident 10 needed substantial/maximal assistance (helper does more than half the effort) from staff with eating, oral hygiene, upper and lower body dressing and personal hygiene. The MDS indicated Resident 10 was dependent (helper does all of the effort) on staff for toileting hygiene, shower, and putting off footwear. During a review of Resident 10's Care Plan (CP) initiated on 11/11/2024 and revised on 6/16/2024, the CP indicated Resident 10 was at risk for fall and injury due to impaired function (a reduction or loss of an individual's ability to perform daily tasks and activities), bowel/bladder dysfunction (problems with the body's ability to control urination and bowel movements), decreased strength/endurance, weakness/fatigue and lack of coordination. During a review of Resident 10's CP initiated on 1/17/2025 and revised on 6/16/2025, the CP indicated Resident 10 was at risk for falls secondary to debilitated state due to multiple sclerosis. The CP intervention indicated for staff to answer the call light in a timely manner, encouraging the resident to call for assistance and to keep call light and bed controls within easy reach. b. During a review of Resident 118's AR, the AR indicated Resident 118 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including metabolic encephalopathy (a condition where the brain function is impaired), dysphagia (difficulty swallowing), cognitive communication deficit (difficulties with communication) and muscle weakness. During a review of Resident 118's H&P dated 4/30/2025, the H&P indicated Resident 118 does not have the capacity to understand and make decisions. The H&P indicated Resident 118 was at risk for falls. During a review of Resident 118's MDS dated [DATE], the MDS indicated Resident 118 required substantial/maximal assistance (helper does more than half the effort) from the staff for the activities of daily living such as eating, oral hygiene, and upper body dressing. The MDS indicated Resident 118 was dependent (helper does all of the effort) on staff for toileting hygiene, shower, lower body dressing, putting off footwear and personal hygiene. During a review of Resident 118's CP initiated on 4/20/2025 and revised on 7/23/2025, the CP indicated Resident 118 had alteration in physical functioning due to adult failure to thrive. The CP interventions indicated for staff to place the call light and frequently used items within reach and answer the call light promptly. During a review of Resident 118's CP initiated on 5/29/2025 and revised on 7/23/2025, the CP indicated Resident 118 was at risk for falls & injuries related to bowel/bladder incontinence and contractures. The CP interventions indicated for staff to keep the call light within reach. During a review of Resident 118's CP initiated on 5/29/2025 and revised on 7/23/2025, the CP indicated Resident 118 required the use of bilateral grab bar when in bed for mobility and transferring to improve functional ability due to generalized weakness. The CP intervention indicated for staff to keep the call light within easy reach and answer promptly. During an observation of Resident 10's room and interview on 7/21/2025 at 11:09 AM, Resident 10 was resting in bed and the call light was not placed within Resident 10's reach. Resident 10's call light was on the floor and the cord was hanging from the right side of the bed. Resident 10 stated Resident 10 would not be able to reach the call light if Resident 10 needed assistance and Resident 10 did not feel safe. Resident 10 stated Resident 10 would have to wait until someone came in to check on Resident 10 in case Resident 10 needed assistance. During an observation of Resident 118's room and interview on 7/21/2025 at 11:06 AM, Resident 118 was resting in bed and the call light was not within the resident's reach. Resident 118's call light was located on the left top of bed by the pillow. Resident 118 stated Resident 118 could not reach the call light. Resident 118 stated, I can't see it, I can't reach it. I guess if I need help I usually just yell. During concurrent observation of Resident 118's room on 7/21/2025 at 12:16 PM, Resident 118's call light was under multiple blankets under Resident 118's left arm. Resident 118 stated Resident 118 did not know where the call light was and could not find it under all the blankets. During an interview with CNA2 on 7/22/2025 at 8:15 AM, CNA2 stated it was important to answer the call light immediately and to ensure the call light was within reach to use if assistance was needed. CNA 2 stated if the call light was not within reach, residents would get up on their own and could fall. CNA 2 stated, if the call light was on the floor, the call light was not within reach. CNA 2 stated a call light placed by the resident's head was also not within reach. During an interview with the Director of Nursing on 7/24/2025 at 1:33 PM, the DON stated it was not acceptable for a resident's call light to be out of reach because the resident was supposed to be able to call for assistance if they need help. The DON stated if a resident can't use the call light, it can potentially cause the resident harm by not alerting the staff that the resident needed help. The DON stated the resident could suffer a fall and get hurt. The DON stated if a resident had contractures or was unable to use regular button call light, the facility should provide a touch call light that was sensor based which makes it easier for a resident to use. During a review of the facility's Policy and Procedure (P&P) titled Call Light, revised 10/2010, the P&P indicated, The purpose of this procedure is to respond to the resident's requests and needs. During a review of the facility's undated P&P titled, Call System, Residents, the P&P indicated Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. The P&P indicated if the resident has disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan. During a review of the facility's P&P titled, Accommodation of Needs, revised 3/2021, the P&P indicated the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. I. The residents' individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. 2. The residents' individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. c. During a review of Resident 114's AR, the AR indicated Resident 114 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body), muscle weakness and lack of coordination. During a review of Resident 114's untitled CP dated 3/3/2025, the CP indicated Resident 114 was at risk for fall and injury due to impaired cognition and unsteady balance and gait (a person's manner of walking). The CP intervention indicated for the nursing staff placed Resident 114's call light within reach on the dominant side. During a review of Resident 114's Fall Risk Assessment (FRA- method of assessing a patient's likelihood of falling) dated 5/22/2025, the FRA indicated Resident 114 was assessed as high risk for falls due to Resident 114 being chairbound, had poor vision and presence of predisposing disease condition. During a review of Resident 114's MDS dated [DATE], the MDS indicated Resident 114 had severely impaired cognition for daily decision making. The MDS indicated Resident 114 was dependent to staff for oral hygiene, toileting, shower, upper/lower body dressing and putting on/off footwear and personal hygiene. During an observation on 7/21/2025 at 8:42 am, Resident 114 was asleep in bed. During a concurrent observation and interview on 7/21/2025 at 8:46 am with the Director of Staff and Development (DSD), Resident 114's call light was observed on the floor, and not within Resident 114's reach. The DSD stated Resident 114's call light needed to be within reach by the resident to call staff for help or assistance in case of emergency. The DSD stated Resident 114 was high risk for fall. d. During a review of Resident 29's AR, the AR indicated Resident 29 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, bone disorder and abnormalities of gait and mobility (the ability to move). During a review of Resident 29's untitled CP dated 2/20/2025, the CP indicated Resident 29 was at risk for fall and injury due to impaired communication and unsteady balance and gait. The CP intervention indicated for the nursing staff placed Resident 114's call light within reach on the resident's dominant side. During a review of Resident 29's MDS dated [DATE], the MDS indicated Resident 29 had intact cognition for daily decision making. The MDS indicated Resident 29 needed supervision from staff for shower. The MDS indicated Resident 29 needed setup (helper sets up) from staff for eating, oral hygiene, toileting, upper/lower body dressing and putting on/off footwear. During a review of Resident 29's FRA dated 5/14/2025, the FRA indicated Resident 29 was assessed as at risk for falls due to Resident 29 taking one to two medications. During an observation on 7/21/2025 at 8:52 am, Resident 29 was awake, lying in bed and Resident 29's call light was hanging on the right bed side rails. During a concurrent interview on 7/21/2025 at 8:55 am with Resident 29, Resident 29 stated I could not find my call button. Can you please help me find it. During an interview on 7/23/2025 at 10:45 am with Registered Nurse 1 (RN1), RN 1 stated resident's call light needed to be within reach at all times for staff to meet the resident's needs. RN 1 stated, the call light needed to be within reach for the resident to use to call for assistance from the staff to maintain resident's safety. During a review of the facility's P&P titled, Call Light, revised on 10/2010, the P&P indicated when the resident is in bed or confined to a chair, ensure the call light is within easy reach of the resident.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant 3 (CNA 3) fed one of one sampled resident (Resident 40) in a respectful manner by not standing over the resident while assisting with eating during a meal. This deficient practice had the potential for Resident 40 to have decreased feelings of self-worth. Findings: During a review of Resident 40's admission Record (AR), the AR indicated Resident 40 was admitted to the facility on [DATE] with diagnoses that included pneumonia (an infection/inflammation in the lungs), hypoxemia (low level of oxygen in the blood) and dysphagia (difficulty swallowing). During a review of Resident 40s Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/29/2025, the MDS indicated, Resident 40 had moderately intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated, Resident 40 was dependent (helper did all the effort and lifted or held trunk or limbs) to staff for eating, oral hygiene, toileting, shower, upper/lower body dressing and putting on/off footwear and personal hygiene. During a dining observation on 7/21/2025 at 1:33 pm while in Resident 40's room, Certified Nursing Assistant 3 (CNA 3) was observed standing over next to Resident 40's bed while feeding the resident. The CNA 3 stated, Resident 40 needed assistance during meals. The CNA 3 stated she should sit when feeding Resident 40. During an interview on 7/21/2025 at 1:41 pm, with the Director of Staff and Development (DSD), the DSD stated, CNA 3 needed to sit down and maintain eye contact with Resident 40 while assisting meals to provide respect. During an interview on 7/23/2025 at 10:48 am with Registered Nurse 1 (RN 1), RN 1 stated staff needed to sit down in a chair while feeding the residents to give attention and to provide residents with dignity during mealtime. During a review of the facility's P&P titled, Dining/Assistance with Meals, revised on 7/2017, the P&P indicated dining room residents: residents who cannot feed themselves will be fed with attention to safety, comfort and dignity: not standing over residents while assisting them with meals.

Based on interview and record review, the facility failed to provide the laboratory (a room or building equipped for experimental study in science or for testing and analysis) services (laboratory services/laboratory tests included certain blood tests and urinalysis [UA- a medical test that examines a person's urine to detect and diagnose different health conditions], that helped healthcare professionals to detect and treat diseases) for one of three sampled residents (Resident 2) according to the facility's policy and procedures (P&P) titled, Lab and Diagnostic Test Results - Clinical Protocol, by failing to: Ensure assigned licensed nurses (Licensed Vocational Nurses [LVNs] and/or Registered Nurses [RN] carried out (to do or complete) a physician order dated 1/8/2025 for a UA with culture and sensitivity (C&S- a laboratory test that checks for bacteria or other germs in a urine sample that can cause an infection and checks to see what kind of antibiotic [a medicine that stops the growth of or destroys microorganism], will work best to treat the illness or infection) for the treatment of Resident 2's Pseudomonas aeruginosa (Pseudomonas- a type of bacteria that are widely found in the environment that can cause infection on the skin, blood, lungs, and other parts of the body) urinary tract infection (UTI- an infection in any part of the urinary tract, the system of organs that makes urine), as ordered by Resident 2's Primary Care Provider/Medical Doctor (MD) 1. As a result of this failure, Resident 2 did not receive the needed antibiotics therapy to treat Resident 2's Pseudomonas UTI from 1/8/2025 to 1/12/2025. On 1/13/2025, at 1:40 pm, Resident 2 experienced altered mental status (AMS- change in a person's level of consciousness, awareness, or cognitive function [ability to think, process information and make decisions] and was transferred to the General Acute Care Hospital (GACH) 1 for further evaluation and treatment. Cross Reference F684 Findings: During a review of Resident 2's Admission Record (AR), the AR indicated the facility admitted Resident 2 on 1/7/2025, with diagnoses that included UTI and carrier of Carbapenem-resistant Enterobacterales (CRE- a group of bacteria that are resistant to certain antibiotics and can cause serious infections). During a review of Resident 2's Physician Order (PO) dated 1/8/2025, the PO indicated Resident 2 had an order to discontinue ceftazidime-avibactam (Avycaz- medication used to treat a wide variety of bacterial infections) intravenous (IV- a method of delivering fluids or medicine directly into a vein using a needle or tube) solution 2.5 gram (gm- unit of measurement) every eight (8) hours on 1/8/2025, and to repeat urinalysis with C&S on 1/9/2025. During a review of Resident 2's PO, dated 1/8/2025, the PO indicated Resident 2 had an order for urinalysis with C&S on 1/9/2025 (indication was not specified). During a review of Resident 2's PO dated 1/12/2025, the PO indicated Resident 2 had an order to collect urinalysis due to (Resident 2's) confusion. During a review of Resident 2's PO dated 1/13/2025, the PO indicated Resident 2 had an order to transfer Resident 2 to GACH 1 for AMS. During a review of Resident 2's Transfer Form (TF- Transfer to Hospital Form) dated 1/13/2025, timed at 11:27 am, the TF indicated Resident 2 was noted with AMS and would be transferred to GACH 1. During a review of Resident 2's Progress Notes (PN) dated 1/13/2025, timed at 1:40 pm, the PN indicated Resident 2 was transferred to GACH 1 due to AMS. During a review of Resident 2's GACH 1 Emergency Department (ED) Provider Note (EDPN) dated 1/13/2025, timed at 2:01 pm, the EDPN indicated Resident 2 was brought in by emergency medical services (EMS- refers to a system that provides immediate medical care to individuals in emergency situations) due to increased confusion and abnormal laboratory test results. The EDPN indicated Resident 2 was sent to GACH 1 ED to determine alternative antibiotic to treat Resident 2's Pseudomonas UTI. The EPDN indicated Resident 2 was started on ceftazidime-avibactam and discharged from GACH 1 on 1/7/2025 (to Skilled Nursing Facility [SNF] 1) to continue the antibiotics therapy (ceftazidime-avibactam). The EDPN indicated because of the high cost of the antibiotics (ceftazidime-avibactam), SNF 1 had not given the antibiotics (ceftazidime-avibactam) to Resident 2 since Resident 2 was discharged from GACH 1 to SNF 1 (on 1/7/2025). The EDPN indicated Resident 2 would receive a dose of ceftazidime-avibactam in GACH 1 ED. The EDPN indicated MD 1 would coordinate with SNF 1 to ensure Resident 2 received the antibiotics (ceftazidime-avibactam) at SNF 1. During a review of Resident 2's GACH 1 Triage (process by which care providers such as medical professionals determine the order of priority for providing treatment) Note ED (TNED), dated 1/13/2025, timed at 2:15 pm, the TNED indicated Resident 2 was brought in by ambulance for increased confusion that started yesterday (1/12/2024), with elevated white blood cells (cells in the blood that indicate if an infection is present), and UTI. During a concurrent interview and record review on 1/29/2025 at 1:21 pm with RN 1, Resident 2's PN from 1/8/2025 to 1/12/2025 and active PO dated 1/8/2025 were reviewed. The PO dated 1/8/2025 indicated for facility staff to obtain a urinalysis with C&S from Resident 2 on 1/9/2025. Resident 2's PN from 1/8/2025 to 1/12/2025 indicated no documentation facility staff attempted to collect a urine sample from Resident 2 to carry out Resident 2's physician order to obtain a urinalysis with C&S on 1/9/2025. RN 1 stated Resident 2 was admitted to the facility on [DATE] for IV antibiotics (ceftazidime-avibactam) therapy. RN 1 stated RN 1 was Resident 2's admitting nurse. RN 1 stated if MD 1 ordered laboratory tests (labs) for Resident 2, the order needed to be carried out as soon as possible. RN 1 stated there was no documentation in Resident 2's PN indicating Resident 2's urine sample was collected/obtained for the urinalysis with C&S as indicated in Resident 2's physician order. RN 1 stated Resident 2 had a delay in care and did not receive any antibiotics or other treatment at SNF 1 for Resident 2's UTI (from 1/8/2025 to 1/12/2025). During a concurrent telephone interview and record review on 1/29/2025 at 3:59 pm with MD 1, Resident 2's PO dated 1/8/2025 was reviewed. MD 1 stated Resident 2 was admitted to the facility for treatment of Pseudomonas-resistant bacteremia (bacteria in the blood). MD 1 stated MD 1 ordered another urinalysis with C&S the day MD 1 discontinued the ceftazidime-avibactam (Avycaz on 1/8/2025) due to the high cost of the ceftazidime-avibactam (Avycaz). MD 1 stated MD 1 ordered another urinalysis with C&S on the same day (1/8/2025) to see if another antibiotic would be effective. MD 1 stated Resident 2 did not receive any antibiotics or other treatment at SNF 1 for Resident 2's UTI from 1/8/2025 through 1/12/2025 and until 1/13/2025, when Resident 2 was transferred to GACH 1 for AMS. MD 1 stated AMS was a symptom of infection. MD 1 stated Resident 2 was readmitted to SNF 1 on 1/13/2025 with another order for ceftazidime-avibactam (Avycaz) to be given until 1/16/2025. MD 1 stated if MD 1 ordered labs (in general), the labs needed to be obtained as soon as possible so they (MD 1 and facility staff) could appropriately treat Resident 2. MD 1 stated not obtaining Resident 2's urine sample for urinalysis with C&S as soon as possible caused a delay in Resident 2's care which resulted in Residents 2's rehospitalization (readmitted to the hospital for a second time). During an interview and concurrent record review on 1/30/2025 at 11:10 am with LVN 1, Resident 2's PO dated 1/8/2025 was reviewed. Resident 2's PO dated 1/8/2025, indicated Resident 2 had an order for urinalysis with C&S to be obtained on 1/9/2025. LVN 1 stated Resident 2's care was not up to par, and Resident 2 did not receive the needed antibiotics (ceftazidime-avibactam) to treat Resident 2's UTI. During an interview and record review on 1/30/2025 at 11:39 am with the Director of Nursing (DON), Resident 2's PO dated 1/8/2025 was reviewed. Resident 2's PO dated 1/8/2025, indicated Resident 2 had an order for urinalysis with C&S to be obtained on 1/9/2025. The DON stated when MD 1 ordered a urine sample for urinalysis with C&S to be obtained on 1/9/2025, the urine sample needed to be collected that day (1/9/2025), so there was no delay in care. The DON stated Resident 2 experienced a delay in care (did not receive IV antibiotics for 5 days) because Resident 2's urinalysis with C&S was not carried out as ordered by MD 1. The DON stated as a result of missing Resident 2's urinalysis with C&S, Resident 2 did not receive any other treatment to treat Resident 2's UTI. During a review of the facility's P&P titled, Lab and Diagnostic Test Results - Clinical Protocol, revised 11/2018 (most updated), the P&P indicated, The physician will identify and order diagnostic and lab testing on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The P&P indicated, A nurse will try to determine whether the test was done .as a routine screen or follow-up .

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) provided care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of nine sampled residents (Resident 1) by failing to: 1. Ensure CNA 1 provided two-person physical assistance (help from two person) when CNA 1 turned Resident 1 to one side to change the resident ' s adult brief (disposable underwear) on the bed as indicated in Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/18/2023. 2. Ensure CNA 1 notified Licensed Vocational Nurse 4 (LVN 4) or Treatment Nurse 1 (TXN 1) to set Resident 1 ' s Low Air Loss mattress (LAL, mattress that operates using a blower-based pump that was designed to circulate a constant flow of air) on static mode (firm surface set in place and unlikely to move) before CNA 1 turned Resident 1 to one side to change the resident ' s adult brief on the LAL mattress. As a result, on 1/2/2024 at 11:20 AM, Resident 1 fell from her bed to the floor. Resident 1 sustained acute displaced fracture (bone breaks into two or more pieces and move out of alignment) at the neck of the right humerus (upper arm bone) and acute nondisplaced fracture (fracture in which the bone cracks or breaks but remains in proper alignment) at the neck of the right femur (thigh bone) and the sacrum (a structure located at the base of the spine). Resident 1 was transferred and admitted to General Acute Care Hospital 1 (GACH 1) on 1/3/2024 at 1:00 AM for further evaluation. Cross Reference F726 and F656 Findings: During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/16/2016 and readmitted Resident 1 on 12/6/2023, with diagnoses of functional quadriplegia (the complete inability to move all extremities due to severe disability), contracture (a condition of shortening and hardening of muscles, tendons, or other tissue) of muscles on both arms and legs, and dementia (memory loss which interferes with daily functioning). During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 had severely impaired cognition (ability to think and process information), and required extensive assistance (resident involved in activity, staff provide weight-bearing support) from two or more persons with physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed). During a review of Resident 1 ' s Admission/Readmission Assessment (AA), dated on 12/6/2023, the AA indicated Resident 1 was at risk for falls due to Resident 1 had on and off confusion, balance problem while standing and sitting, decreased muscular coordination, and poor vision with or without glasses. During a review of Resident 1 ' s Activities of Daily Living (ADL) Self Care Performance Deficit Care Plan (ADL CP), initiated on 12/6/23, the ADL CP indicated for the staff to assist with ADL and functional mobility (transfer and bed mobility) as needed. During a review of Resident 1 ' s Situation, Background, Appearance, Review Communication Form (SBAR), dated 1/2/2024, the SBAR indicated on 1/2/2024, CNA 1 changed Resident 1 ' s brief, rolled Resident 1 onto Resident 1 ' s right side, and Resident 1 slid off the bed. The SBAR indicated, Resident 1's Primary Physician (PP) was notified and recommended for Resident 1 to have X-ray (pictures of the inside of the body) on the right side of the body. During a review of Resident 1's X-ray report dated 1/2/2024, timed at 6:24 PM, the X-ray report indicated Resident 1 sustained acute displaced fracture at the neck of the right humerus and acute nondisplaced fracture at the neck of right femur. During a review of Resident 1 ' s Progress Notes (PN) dated 1/3/2024, timed at 1 AM, the PN indicated the facility transferred Resident 1 to GACH 1. During a review of Resident 1 ' s GACH 1 Emergency Department Provider Note (ED PN), dated 1/3/2024, timed at 7:25 AM, the ED PN indicated Resident 1 would be admitted to GACH 1 for treatment and would be seen by an orthopedist (a doctor who specializes on injuries and diseases affecting the bones, muscles, and joints). During a review of Resident 1 ' s GACH 1 Computed Tomography scan (CT scan, medical imaging technique used to obtain detailed internal images of the body) of the right hip report dated 1/3/2024, timed at 7:58 AM, the CT scan report indicated Resident 1 had suspicion of an acute nondisplaced fracture of the sacrum. During a review of Resident 1 ' s GACH 1 X-ray of right shoulder report (X-ray report) dated 1/3/2024, timed at 9:58 AM, the X-ray report indicated Resident 1 had fracture of the surgical neck of the right humerus. During a review of Resident 1 ' s GACH 1 Orthopedist Consultation (OC) dated 1/4/2024, timed at 8:56 AM, the OC indicated the plan of care included nonoperative management, sling for comfort, follow up with new x-rays in six weeks, pain control, and non-weight bearing on right upper extremity. During an interview on 1/4/2024 at 4:20 PM with the Director of Nursing (DON), the DON stated, Resident 1 fell on [DATE] at 11:40 AM when CNA 1 was changing Resident 1 ' s brief and turning Resident 1 to Resident 1 ' s right side. The DON stated, X-ray was done on the same day and showed Resident 1 sustained a right humerus fracture. The DON stated Resident 1 ' s PP ordered to transfer Resident 1 to GACH 1. The DON stated, Resident 1 was on a LAL mattress. During an interview on 1/5/2024 at 9:30 AM with TXN 1, TXN 1 stated LAL mattress had to be set on static mode when turning and/or working with Resident 1 on the LAL mattress. TXN 1 stated, Resident 1 was unable to move in bed by herself. TXN 1 stated nursing staff (in general) had to assist Resident 1 with bed mobility. During an interview on 1/5/2024 at 11:15 AM with LVN 4, LVN 4 stated, on 1/2/2024, a CNA (unable to identify) called LVN 4 into Resident 1 ' s room. LVN 4 stated, when LVN 4 entered Resident 1 ' s room, LVN 4 saw Resident 1 on the floor lying on Resident 1 ' s right side. LVN 4 stated, Resident 1 had contractures in all limbs (arms and legs) and required full assistance from staff for cleaning, eating, and turning. LVN 4 stated, the safest way to turn or clean Resident 1 and avoid a fall was to have another staff help when providing care to Resident 1. During an interview on 1/5/2024 at 12:04 PM with CNA 1, CNA 1 stated, CNA 1 provided Resident 1 a bed bath on 1/2/2024 at 11:05 AM. CNA 1 stated, after finishing the bed bath, CNA 1 turned Resident 1 to Resident 1 ' s right side to put a brief on Resident 1. CNA 1 stated, Resident 1 slipped off the bed and fell to the floor. CNA 1 stated, she did not ask for another staff to assist in turning Resident 1 because she had taken care of Resident 1 without assistance in the past. CNA 1 stated, Resident 1 had contracture on both legs. CNA 1 stated, the safest way to change, clean, or reposition Resident 1 was with two staff. CNA 1 stated, Resident 1 ' s fall could have been prevented by having another staff to assist when repositioning, cleaning, or changing Resident 1. During an interview on 1/5/2024 at 2:30 PM with the Director of Staff Development (DSD), the DSD stated, CNAs (in general) were instructed to team up as partners and automatically had another staff to work with in providing care for Resident 1, who needed assistance or dependent on CNAs for care. The DSD stated the expectation would be to have CNA 1 team up with another CNA (any CNA) when providing care to Resident 1. The DSD stated, Resident 1 was dependent on staff for care, turning, and repositioning in bed because Resident 1 had contractures. The DSD stated, Resident 1 needed to be assisted by two staff. The DSD stated, CNA 1 needed to ask for assistance from another staff (any CNA) before CNA 1 turned Resident 1 on the bed to prevent the fall. During an interview on 1/5/2024 at 3:25 PM with CNA 1, CNA 1 stated, she did not notify LVN 4 or TXN 1 to set the LAL mattress on static mode before providing care to Resident 1. CNA 1 stated, the facility trained her that the control panel for the LAL mattress was specifically for the charge nurses (LVNs) or treatment nurses (TXNs) to adjust the setting for LAL mattress. CNA 1 stated CNAs (in general) were not allowed to touch or adjust the setting for the LAL mattress. During an interview on 1/5/2024 at 5:12 PM with the DON, the DON stated, the facility ' s expectation was for CNA 1 to notify the licensed nurses (LVNs or TXNs) to set the LAL mattress on static mode when providing care to Resident 1, so the LAL mattress would not move (air inside the LAL mattress would not shift). The DON stated, when the LAL mattress was not on static mode, the mattress could move, and the distribution of the resident's weight would not be even and could cause the resident to fall out of the LAL mattress. During an interview on 1/5/2024 at 5:49 PM with the DSD, the DSD stated, CNA 1 received special mattress training (on 10/14/2023) which included having the licensed nurse (LVN or TXN) set the LAL mattress on static mode during bed bath or when providing care for any residents (in general) on the LAL mattress. The DSD stated, setting the LAL mattress on static mode prevented the LAL mattress from making sudden movements which could cause a fall. During a review of the facility ' s policy and procedure (P&P) titled, Fall and Fall Risk, Managing, revised in 3/2018, the P&P indicated the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling. During a review of the Manufacturer ' s Manual (MM) titled, DynaRest Airfloat 100, Air Mattress with Pump, undated, the MM indicated in static mode, the LAL mattress provided a firm surface for the patient to transfer or reposition.

Based on observation, interview, and record review, the facility failed to ensure 3 of 19 sample residents (1, 12, and 19) and Randomly Selected Resident (RSR) 21 were provided the necessary care and services to maintain their highest practicable physical well-being. The facility failed to: 1. Provide the needed nutrition and fluids for Resident 19, who was on hospice care (a service that provides support and care for a resident who is terminally ill so that he/she may live as fully and as comfortable as possible) to meet daily requirement as indicated in the resident's advance directive. 2. Administer RSR 21's multivitamin (MVI) tablet as ordered. 3. Ensure Resident 1's bed was in its lowest position and with floor mat placed on both sides of the bed as ordered by Resident 1's physician. 4. Ensure Resident 12's medication order for [MEDICATION NAME] (pain medication) included parameters as to when it was to be administered. Findings: a. During a review of the clinical record for Resident 19, on [DATE], at 9:00 a.m., the undated discharge summary indicated Resident 19 was discharged from the facility on [DATE]. The medical reason indicated Resident 19 expired. There was no documentation on the cause of death. Resident 19's admission record (face sheet) indicated Resident 19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Situation, Background, Appearance and Review Communication Form (SBAR, an effective and efficient way to communicate important information, between members of the health care team, about a patient's condition), dated [DATE], indicated Resident 19 had episodes of desaturation (low oxygen levels) and primary care physician recommended transfer to the general acute care hospital (GACH), via emergency transportation (911), if episode of desaturation continues. The area on the SBAR form for advance care planning information (decisions made by the resident in advance, about the care resident would want to receive if he/she become unable to speak for self) indicated not to attempt resuscitation (DNR, allow natural death) and provide Resident 19 comfort measure. A nursing progress note, dated [DATE], at 11:18 p.m., indicated Resident 19's primary physician was informed of Resident 19's condition along with the health care agent's decisions to change Resident 19's heath care interventions to comfort measures only (no other intervention or medications which are not related to making the patient more comfortable) and to DNR. A nursing progress note, dated [DATE], at 9:30 a.m., indicated Resident 19 was transferred to the GACH with the [DEVICE] in place and supplemental oxygen. A review of the GACH notes, dated [DATE], indicated Resident 19 had a urinary tract infection (infection in any part of the urinary system), and during the stay the health care agent requested for comfort measures and to return Resident 19 to facility on hospice. A nursing progress note, dated [DATE], at 9:56 p.m., indicated Resident 19 was readmitted to the facility from the GACH in no distress, with clear lung sound (breath sounds), stomach soft and non-distended (no information about bowel sounds), and [DEVICE] site clean and intact with no complaints of pain. A review of the physician orders, dated [DATE], indicated Resident 19 was admitted to hospice care with [DIAGNOSES REDACTED]. day, and to provide 200 ml of water every 6 hours. A social services note dated [DATE], at 3:59 p.m., indicated Resident 19's health care agent requested for the Physician Orders for Life-Sustaining Treatment (POLST/a form completed by health care professional based on the resident's preferences and medical indications for cardiopulmonary resuscitation (CPR, an emergency procedure that combines chest compression often with artificial ventilation ), medical intervention and nutrition) to be changed to DNR, comfort measures only (may use medication by any route, positioning, wound care and other measures to relieve pain and suffering; may use oxygen, suction and manual treatment of [REDACTED]. There was no documentation the POLST was revised as requested by the healthcare agent on [DATE]. The nursing progress notes following the social services note, dated [DATE] at 10:17 p.m. to [DATE] at 11:07 a.m., indicated Resident 19 was receiving artificial nutrition via [DEVICE] for 8 days with no signs and symptoms of complications (nausea, vomiting, abdomen distention or residuals) from the [DEVICE] feeding. A review of the interdisciplinary team (IDT, a team representing different disciplines in the healthcare field) conference record, dated [DATE], indicated, under the section of advanced directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), Resident 19 had an advanced directive dated [DATE]. The [DATE] IDT notes also indicated the health care agent requested to change the POLST to DNR, comfort measures only, and no artificial nutrition, and further indicated that her wishes were for Resident 19 to be comfortable as possible. A physician's telephone order, dated [DATE], at 2:00 p.m., indicated to discontinue all [DEVICE] orders and medications. The nursing note, dated [DATE], at 2:14 p.m., indicated Resident 19's hospice physician was informed of the health care agent's decision to change the POLST, and the hospice physician in turn gave the telephone order to change the POLST according to the health care agent's decision. During an interview with the Director of Nursing (DON) and Director of Staff Development (DSD), on [DATE], at 10:05 a.m., when asked to describe Resident 19's mental and physical capacity, the DSD stated Resident 19 was non-verbal to staff and would be up on gerichair (large padded chairs with wheeled bases, and are designed to assist seniors with limited mobility) for activities. The DSD further stated that when Resident 19 was readmitted on [DATE], the following day, Resident 19 was admitted to hospice with her existing [DEVICE] feeding. The DSD verified Resident 19 had her [DEVICE] since [DATE]. When asked why the [DEVICE] feeding was discontinued, the DSD stated the health care agent wished to let Resident 19 go slowly. During an interview with the health care agent, on [DATE], at 11:01 a.m., when asked about the decision to discontinue all [DEVICE] feeding, she stated the recommendation came from the hospice nurse. When further asked if a physician informed her of the risk and benefits of not providing nutrition or an alternative to [DEVICE] feeding for Resident 19, she stated no. A review of the California Power of Attorney for Health Care and Health Care Instruction (advance health care directive), dated [DATE], indicated Resident 19's health care intervention wishes if she was terminally ill and the provision of life sustaining procedures would serve to artificially delay the moment of her death; then she authorized the health care agent to approve the treatment needed to provide her food, water and pain control and to keep her comfortable but otherwise did not authorize active treatment for [REDACTED]. Resident 19 did not sign this choice. The POLST dated [DATE], indicated Resident 19 was DNR, comfort-focused treatment with no hospitalization and no artificial means of nutrition. The area on the POLST for physician signature was blanked. Further review of the directions for the health care provider, indicated the POLST does not replace the Advance Directive, and when available the advance directive should be reviewed and ensure consistency and the update on the form should resolve any conflicts. In addition, the POLST must be completed by a health care provider based on the resident's preferences and medical indications. The directions to the health care provider further indicated a legally recognized decision maker may request to modify the orders, in collaboration with physician, based on the known desires of the resident or, if unknown, the resident's best interests. This POLST for Resident 19 was not complete. During an interview with the Minimum Data Set (MDS) nurse, on [DATE], at 11:20 a.m., she reviewed the telephone order dated [DATE], at 2:00 p.m., for the discontinuation of all [DEVICE] feeding and medication and verified she obtained the telephone order from Resident 19's hospice physician after the care plan meeting with the health care agent, social worker, activities and dietary. When asked if a physician was present during the care plan meeting, she stated no. The MDS nurse further stated when she obtained the order to stop the feeding for Resident 19, she asked the physician about hydration and was instructed to ask the health care agent. The MDS nurse endorsed the information to the next shift to ask the health care agent. The MDS nurse reviewed Resident 19's medical record and verified there was no documentation of the follow up with the health care agent and the alternative intervention. During an interview with the DON, on [DATE], at 11:26 a.m., when asked about her knowledge with the discontinuation order of all feeding for Resident 19, she stated she was not aware of the order. During an interview with the hospice physician, on [DATE], at 11:29 a.m., when asked about how hospice care addresses comfort measures, he stated the care covers personal care, pain and nutrition. The hospice physician was asked the reason why [DEVICE] feeding was discontinued for Resident 19, and he stated Resident 19 was having congestion with nausea and vomiting from the [DEVICE] feeding. The hospice physician was informed there was no documentation from hospice or the facility indicating Resident 19 was congested or had nausea and vomiting. In addition, there was no documentation for the medical justification for the discontinuation of [DEVICE] feeding. The hospice physician stated to speak to the hospice nurse. The hospice nurse then stated she had documentation Resident 19 had nausea and vomiting and will fax the documentation to the facility. On [DATE], at 11:39 a.m., the DON and DSD verified both Resident 19's medical record and the documentation faxed from the hospice agency which does not have any documented evidence Resident 19 had nausea and vomiting or congestion as claimed by the hospice nurse. The DSD verified that during the stay ([DATE] to [DATE]) in the facility, Resident 19 was tolerating the [DEVICE] feeding. Following the days after the discontinuation order of the feeding formula on [DATE], Resident 19's medical record contain documentation of an SBAR, dated [DATE], indicating a weight loss of 15 pounds (lbs.) in one week. Resident 19 on [DATE] weighed 136 lbs. and on [DATE] she weighed 121 lbs. The nursing note on the SBAR for the change in condition indicated the weight loss was due to the discontinuation of the [DEVICE] feeding and water flushes. The note included the weight loss was unavoidable and Resident 19 was at risk of weight loss due to no caloric or fluid intake. A review of the nursing notes, dated [DATE], indicated Resident 19 was observed moaning with facial grimacing and protective body movements. The note further indicated Resident 19 was inconsolable (not able to be comforted) and was medicated with [MEDICATION NAME] (pain medication) 10 milligrams (mg) per one milliliter (ml), with 0.2 ml administered for severe pain. During the time frame from [DATE] to [DATE], Resident 19 was administered pain medication on [DATE], at 11:45 a.m. and [DATE], at 10:30 a.m. A review of the nurses Medication Administration Record [REDACTED] [DATE], at 5:00 p.m., for facial grimacing; [DATE], at 3:00 a.m., for moaning, facial grimacing and inconsolable (cannot be comforted); [DATE], at 10:00 a.m., for facial grimacing; [DATE], at 5:15 p.m., for facial grimacing; [DATE], at 12:00 a.m., for general body pain, moaning and facial grimacing; [DATE], at 4:00 a.m., for general body pain; [DATE], at 3:30 p.m., for general body pain. According to the Centers for Medicare and Medicaid Services guidelines for hospice care, the facility must provide care and services necessary to promote comfort, pain relief, and provide support to meet the needs of the resident at the end of life in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/CMS- -Hospice-End-of-Life.pdf A review of the facility policy and procedure titled Palliative/End-of-Life Care dated ,[DATE], indicated the physician will provide the resident, family and facility staff with pertinent information about the prognosis and overall care plan periodically and when there is a significant change in condition. b. During a medication pass observation on [DATE], at 8:42 a.m., Licensed Vocational Nurse (LVN) was observed as he prepared and administered the morning medications for a Randomly Selected Resident (RSR) 21. LVN prepared and administered a total of 7 medications. A review of RSR 21's physician's order dated [DATE], indicated to administer a multivitamin (MVI) tablet orally once a day. This medication was not prepared and administered during the observed medication administration. During an interview on [DATE], at 10:03 a.m., LVN verified he failed to administer a MVI tablet to RSR 21. c. On [DATE] at 8 a.m., during initial tour and in the presence of registered nurse (RN 1) Resident 1 was observed in bed. The resident was pulling back and forth on the left side bed rail and was attempting to place leg through the bed rail. The bed was observed in a high position and there were no floor mats on either side of the bed. On [DATE], the resident was observed in bed. The bed was in the high position and there were no floor mats on either side of the bed. An admission face sheet indicated Resident 1 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A Fall Risk Evaluation dated [DATE], indicated Resident 1 was a high risk for falls. A care plan titled [MEDICAL CONDITION] dated [DATE] indicated the resident had the potential for injury related to [MEDICAL CONDITION]. Nursing interventions included to adjust the bed to the lowest position and to place floor mats on both sides of the bed. During an interview on [DATE] at 8:55 a.m., RN 1 stated Resident 1 was supposed to have floor mats on both sides of her bed and the bed was supposed to be in a low position to prevent injury. RN 1 acknowledged the bed was not in a low position and stated She is supposed to have floor mats, I don't know what happened. d. An admission face sheet indicated Resident 12 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A physicians order dated [DATE], indicated to administer [MEDICATION NAME] 20 mg (milligram)/1 ml (milliliter) solution give 5 mg sublingual every four hours as needed for pain or shortness of breath. The order did not indicate the pain level when the [MEDICATION NAME] should be administered. During an interview on [DATE] at 8:11 a.m., RN 1 stated the pain level needs to be indicated in the physicians order so that licensed staff is aware of when it is appropriate to administer the [MEDICATION NAME].