Every finding on record at Buena Park Nursing Center

Based on interview, facility document review, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and/or worsening of pressure ulcer for one of three sampled residents (Resident 1). * The facility failed to check, turn and reposition every two hours Resident 1 as per the resident's plan of care. This failure had the potential for the resident to develop pressure ulcers and/or worsening of the existing pressure ulcer(s).Findings: Review of the facility's P&P titled Prevention of Pressure Ulcers/Injuries revised 5/2019 showed to place the resident on a minimum of a Q 2 hours (every two hours) check and change program. Frequency will be dictated both by facility routine and resident need. A resident who perspires profusely may need to receive more frequent care. Medical record review for Resident 1 was initiated on 7/21/26. Resident 1 was readmitted to the facility on [DATE].Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 was dependent (helper does all the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity) on the following:- Toileting hygiene: the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement; and- Roll left and right: the ability to roll from lying on back to left and right side and return to lying on back on the bed. Review of Resident 1's Plan of Care initiated on 4/26/26 and revised on 6/16/26, showed a care plan problem to address Resident 1's high risk for further skin breakdown related to incontinence of bladder and bowel.and history of Stage 3 pressure ulcer on the sacral. The approaches/interventions included to check, turn and reposition the resident at least every two hours. Further review of Resident 1's plan of care showed a care plan problem initiated on 7/19/26, to address Resident 1's altered skin integrity: MASD on the sacrococcyx extending to left and right buttocks. The approach plan included to keep the area dry and clean. Review of Resident 1's Grievance Form dated 7/9/26, showed Resident 1's Family Member 1 filed a grievance with the SSD expressing frustration regarding the wound care provided to Resident 1. Family Member 1 requested to enhanced supervision and two-hour monitoring checks especially during the 2200-0700 hour shift. The Grievance Form further showed the action taken included utilizing a two-hour monitoring log throughout the shift. Review of Resident 1's Progress Note from the wound physician showed the following:- dated 7/9/26, the H&P of illness section showed Resident 1 had wound: sacrococcygeal MASD with fungal component. The resident had previous Stage 3 pressure injury to the area, consulted for redness and some skin breakdown to the area;- dated 7/14/26, the H&P of illness section showed follow-up reconsultation for fungal dermatitis of the sacrococcyx and MASD; and- dated 7/21/26, the H&P of illness section showed follow-up for MASD of the perianal region and sacrococcyx with fungal dermatitis and some denuded immature scar from resolved sacrococcyx unavoidable pressure injury. Further review of Resident 1' s Progress Note from the wound physician dated 7/9, 7/14, and 7/21/26, showed the recommendation for every two hours turning, frequent diaper changes, no sitting beyond two hours, offloading the wound.turn the resident every two hours to keep the skin clean and dry. Review of Resident 1's Monitoring Log sheets from 6/22/26 through 7/22/26 showed the following blank entries on the sections for the CNA and Charge Nurse Initials and Particulars for the following dates, shifts and times:- dated 6/22/26, 1500-2200 hour shift at 1600, 1800, 2000, and 2200 hours;- dated 6/23/26, 1500-2200 hour shift at 1600, 1800, 2000, and 2200 hours;- dated 6/24/26, 1500-2200 hour shift at 1600, 1800, 2000, and 2200 hours;- dated 6/25/26, 1500-2200 hour shift at 1600, 1800, 2000, and 2200 hours;- dated 6/26/26, 1500-2200 hour shift at 1600, 1800, 2000, and 2200 hours;- dated 6/27/26, 0700-1500 hour shift at 0800, 1000, 1200, and 1400 hours,- dated 6/27/26, 1500-2200 hour shift at 1600, 1800, 2000, and 2200 hours;- dated 6/28/26, 1500-2200 hour shift at 1600, 1800, 2000, and 2200 hours;- dated 6/29/26, 1500-2200 hour shift at 1600, 1800, 2000, and 2200 hours;- dated 6/30/26, 1500-2200 hour shift at 1600, 1800, 2000, and 2200 hours;- dated 7/1/26, 1500-2200 hour shift at 1600, 1800, 2000, and 2200 hours;- dated 7/2/26, 1500-2200 hour shift at 1600, 1800, 2000, and 2200 hours;- dated 7/3/26, 1500-2200 hour shift at 1600, 1800, 2000, and 2200 hours;- dated 7/10/26, 0700-1500 hour shift at 1000, 1200, and 1400 hours;- dated 7/12/26, 1500-2200 hour shift at 1600, 1800, 2000, and 2200 hours;- dated 7/15/26, 1500-2200 hour shift at 1600, 1800, 2000, and 2200 hours;- dated 7/16/26, 1500-2200 hour shift at 1600, 1800, 2000, and 2200 hours;- dated 7/17/26, 0700-1500 hour shift at 0800, 1000, 1200, and 1400 hours,- dated 7/17/26, 1500-2200 hour shift at 1600, 1800, 2000, and 2200 hours;- dated 7/18/26, 0700-1500 hour shift at 0800, 1000, 1200, and 1400 hours,- dated 7/18/26, 1500-2200 hour shift at 1600, 1800, 2000, and 2200 hours;- dated 7/17/26, 0700-1500 hour shift at 0800, 1000, 1200, and 1400 hours,- dated 7/17/26, 1500-2200 hour shift at 1600, 1800, 2000, and 2200 hours;- dated 7/19/26, 1500-2200 hour shift at 1600, 1800, 2000, and 2200 hours;- dated 7/21/26, 1500-2200 hour shift at 1600, 1800, 2000, and 2200 hours;- dated 7/22/26, 0700-1500 hour shift at 0800, 1000, 1200, and 1400 hours, and- dated 7/22/26, 1500-2200 hour shift at 1600, 1800, 2000, and 2200 hours. Further review of the Monitoring Log sheet showed the CNAs were documenting in the Particular section for each time slot the task performed for example diaper changed, drink water, and/or repositioned. On 7/21/26 at 0752 hours, an interview was conducted with CNA 1. When asked how she documented Resident 1's repositioning and brief changes, CNA 1 stated in the binder. On 7/21/26 at 1025 hours, a wound care observation for Resident 1 and concurrent interview was conducted with LVN 1. LVN 1 was observed removing Resident 1's old foam dressing. While LVN 1 was removing the foam dressing, a thin layer of skin was pulling with the dressing. Three open areas were observed on Resident 1's coccyx area and one on the right inner buttocks. LVN 1 stated three days ago the wound looked better, no active bleeding and the redness was better; however, LVN further stated the open areas got bigger. On 7/23/26 at 1137 hours, an interview and concurrent medical record review of the Monitoring Log sheets for Resident 1 was conducted with the DON. The DON stated based on the no entries, there was no proof if Resident 1 was repositioned or changed on the hours indicated. The DON acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for one of three sampled residents (Resident 1). * The facility failed to ensure Resident 1 was changed timely after a bowel movement. In addition, the facility failed to provide a shower when Resident 1 requested to be showered after having a bowel movement. These failures had the potential to result in the resident not receiving necessary care and services and posed a risk for adverse complications. Findings: Review of the facility's P&P titled Activities of Daily Living, Quality of Care, Routine Resident Monitoring, and Scope of Services dated 6/2022 showed it is the policy of the facility that each resident receive, and the facility must provide the necessary care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being consistent with the residents comprehensive assessment and plan of care. Ensure the following ADL functions are monitored, supervised, assisted with and or provided to the resident population at the facility is servicing to included but not limited to bathing showering and or personal hygiene, and toileting. Review of the facility's P&P titled Resident Rights revised 9/2017 showed the following:- to participate in his/her treatment and support the resident by facilitating inclusion of the resident or their representative, including an assessment of the residents strengths and needs incorporating the residents personal and cultural preferences in the development of goals.- to be treated with consideration, respect and full recognition of dignity and individuality, including privacy and treatment and in care of personal needs.- to reside and receive services with reasonable accommodation of residence needs and preferences unless to do so would endanger the health or safety of the resident or other residents. Medical record review for Resident 1 was initiated on 7/3/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's plan of care showed a care plan problem dated 6/8/26, addressing Resident 1's alteration in bowel function. The interventions included to clean the perineal/perianal area with soap and water after each episode of bowel/bladder incontinence. Further review of Resident 1's plan of care showed a care plan problem dated 6/8/26, addressing the resident's ability to shower/bath self. The interventions included to assist the resident to the bath/shower room and assist in bathing as needed. On 7/3/26 at 0936 hours, an interview was conducted with Resident 1. Resident 1 contacted Family Member 1 for an interview. Family Member 1 stated on 6/16/26 at approximately 2005 hours, Resident 1 had soiled himself and requested to be showered, but was not provided one because it was not his scheduled shower time. Family Member 1 stated Resident 1 remained in a soiled brief for approximately 15-18 minutes. On 7/3/26 at 1613 hours, an interview was conducted with CNA 2. CNA 2 stated on 6/16/26, Resident 1 requested a shower after soiling himself. CNA 2 stated he informed Resident 1 that he could not receive a shower in the afternoon since he had already received one in the morning. When asked whether Resident 1 had a shower after the episode of incontinence, CNA 2 stated No, he didn't get a shower. CNA 2 stated it took approximately 30 minutes to change Resident 1's brief after he soiled himself. On 7/3/26 at 1628 hours, an interview was conducted with the MDS Nurse. The MDS Nurse stated if a resident requested a shower, the staff may provide it and could not refuse the resident because it was the resident's right. On 7/7/26 at 1048 hours, a telephone interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent fall for one of four sampled residents (Resident 1). * The facility failed to ensure Resident 1 was adequately assisted when turned and positioned during a diaper change in bed to prevent the resident from sliding off the bed and landed on the floor. This failure had the potential to place the resident at risk for more serious injury and compromised resident safety. Findings: Review of the facility's P&P titled Comprehensive Care Planning dated 3/2019 showed it is the policy of the facility a comprehensive resident - centered care plan be developed for each resident that includes measurable objectives and time frames to meet each residents' medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must include services that are to be provided to attain or maintain the residents' highest level of well-being. Review of the facility's P&P on Fall Risk & Prevention of Injury to Include Pathological Fractures dated 3/2019 showed it is the policy of the facility to identify residents that are at risk for falls and to implement a plan of care in an attempt to prevent falls. If the fall risk assessment is ten or above, the resident is at risk for falls and a plan of care will be developed and with approaches in an attempt to prevent falls, including falls of serious injury. Medical record review for Resident 1 was initiated on 6/3/26. Resident 1 was initially admitted to the facility on [DATE]. Review of Resident 1's CNA Task, Documentation Survey Report showed Resident 1's ability to roll from lying to the left and right side and return to lying back on the bed as follows:* on 3/3/26 and 3/4/26 - day, evening, and night shifts: dependent, CNA does all of the effort, the resident does none of the effort to complete the activity or the assistance of two or more CNA's is required to complete the activity.* on 3/5/26 - for the day shift, the resident needed substantial maximum assistance, CNA performs more than half of the effort. For evening shift, dependent, CNA does all of the effort, the resident does none of the effort to complete the activity or the assistance of two or more CNA's is required to complete the activity and for the night shift, Resident 1 was dependent, CNA does all of the effort, the resident does none of the effort to complete the activity or the assistance of two or more CNA's is required to complete the activity. Review of Resident 1's Care Plan Report on Falls/Injury initiated on 12/8/25, and revised on 3/17/26, showed the goal was to minimize/eliminate risk of fall/injury daily. Review of Resident 1's MDS section GG Functional Abilities dated 3/17/26, showed the code 01 (Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity) for the following:a. Self-Care- toileting hygiene -the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement; and- lower body dressing - the ability to dress and undress below the waist.b. Mobility- roll left and right (the ability to roll from lying on back to left and right side, and return to lying back on bed) Review of Resident 1's Daily Skilled Nurses Notes dated 3/23/36, showed the ADL toileting hygiene was coded as one (1) dependent with two staff assistance. Review of Resident 1's Fall Risk Evaluation dated 4/23/26, showed a score of 19 (high risk for potential falls). Review of Resident 1's Weekly Summary dated 4/2426, for ADL/Self-performance Support showed as dependent in toileting hygiene, shower/ bathing, lower body dressing and personal hygiene and the resident was able to roll left to right with substantial and maximal assist. Review of Resident 1's Progress Notes dated 5/6/26 showed the following:- at 0400 hours, Resident 1 was noted to be sliding from the bed during a diaper change. Resident 1's body was noted sliding off the bed and CNA 1 assisted Resident 1 to slowly slide down the floor in a sitting position on the right side of the bed. Resident 1 was asked and Resident 1 stated fall. The progress note further showed Resident 1 complained of pain, pointing to the left upper quadrant of the abdominal area and was provided with pain medication; and- at 0815 hours, the CNA reported Resident 1 complained of pain to the left side flank (side of the upper body between the lower ribs and hip bone). When the RN supervisor assessed, Resident 1 complained of 10/10 pain level and Resident 1 was provided with pain medication; and- at 0900 hours, the physician was made aware of and ordered for a stat left side x-ray. Reviewed Resident 1's Patient Report for left rib x-ray dated 5/6/26, showed an acute 7th to 8th rib fractures. Review of Resident 1's H&P examination dated 5/11/26, showed Resident 1 had no capacity to understand and make decisions. On 6/4/26 at 0926 hours, an interview and concurrent medical record and facility record review was conducted with the ADON. The ADON stated Resident 1 was assessed as totally dependent, two staff assistance needed in bed mobility and transfers prior to the recent fall. On 6/4/26 at 1302 hours, a telephone interview was conducted with CNA 1. CNA 1 stated, I was turning her to her right side. The bed was at an appropriate height. I had to turn her; she's heavy. After I pulled the dirty diaper out and was sliding the clean diaper under the resident, I had to turn Resident 1 away from me. I saw her leg dangling, and I immediately helped her, assisting her to slide to the floor. I grabbed her, I was solely grabbing the resident to maintain control, and the resident landed on the floor. CNA 1 further stated there were no care plan instructions available for review, and he was not informed how many staff members were required to assist Resident 1 before he provided care. On 6/4/26 at 1323 hours, an interview and concurrent medical record review were conducted with the DOR. The DOR stated Resident 1 was discharged from the rehab with previous status in bed mobility as totally dependent and upon discharge on [DATE], was maximum assistance. The DOR was asked which plan of care for the need of assistance in toileting and bed mobility should the CNAs follow and how this information was imparted to the CNAs. The DOR stated we teach the CNA's depending on how the resident is feeling that day, if the resident is tired, probably we always recommend two staff assist for safety, considering the CNA's different skill levels, it is hard to tell, the nurses also tells them. On 6/4/26 at 1515 hours, an interview was conducted with CNA 6. CNA 6 was asked how many staff are needed in Resident 1's bed mobility, CNA 6 stated, Resident 1 needed 2 staff assistance in pulling up and turning resident side to side, I changed her before, she's heavy. On 6/4/26 at 1645 hours an interview was conducted with the Administrator and DON. The Administrator and DON was made aware and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with the care and services free from accidents and/or injuries. * The facility failed to maintain Resident 1's skin integrity when provided with care. CNA 1 had long nails and scratched Resident 1 during shower . This failure resulted in Resident 1 sustaining multiple scratches on the head and face and posed a risk for the resident's skin to get infected.Findings: Review of the facility's P&P titled Dress Code dated 1/2026 showed nursing staff must keep nails trimmed to 1/8 of an inch to avoid injury to residents. Medical record review for Resident 1 was initiated on 5/7/26. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 5/20/25, showed Resident 1 had no capacity to understand and make his own decisions. Review of Resident 1's Licensed Nurses Progress Note dated 4/29/26 at 1710 hours, showed a CNA reported during shower care, Resident 1 sustained superficial scratch marks to the facial area, forehead, right and left side of the face. Noted linear superficial scratches, no active bleeding, and minimal redness present. On 5/6/26 at 1150 hours, an interview was conducted with RN 1. RN 1 stated on 4/29/26, an incident was reported to her involving Resident 1. RN 1 stated LVN 1 reported that CNA 1 was showering Resident 1 and during the shower, Resident 1 obtained multiple linear scratches on his forehead, cheeks, and chin. RN 1 stated CNA 1 informed her while giving a shower to Resident 1, his tracheostomy [NAME] got disconnected. While CNA 1 was securing the [NAME] with one hand, CNA 1 was trying to rinse Resident 1's head and face with the other hand and her nails caused scratches on Resident 1's face, cheeks and chin. RN 1 stated Resident 1's scratches was assessed and found them to be superficial with no new orders from the physician. RN 1 cleaned the scratches and left them open to air. RN 1 stated CNA 1 was removed from direct resident care pending the police report and ultimately was sent home. RN 1 further stated the facility had a policy for nail hygiene and they should be kept short. RN 1 also stated the facility did not conduct a staff inspections to ensure they were following the facility code. On 5/6/26 at 1239 hours, an interview was conducted with the DON. The DON stated the RN supervisors were the ones who should be conducting uniform inspections to ensure compliance with the facility dress code. On 5/6/26 at 1430 hours, an interview was conducted with RN 2. RN 2 stated it was the responsibility of the DSD to inspect the CNAs for compliance with the dress code; however, the facility did not currently have a full-time DSD. On 5/6/26 at 1458 hours, an interview was conducted with CNA 1. CNA 1 stated while she was showering Resident 1 the resident's [NAME] came loose twice. CNA 1 stated she was focused on keeping the [NAME] connected and was not paying attention to her other hand rinsing Resident 1's head and her long nails were causing scratches to Resident 1's forehead, cheeks and chin. CNA 1 stated she knew she should not have long nails. CNA 1 stated the facility had done multiple in-services about nail grooming and following the dress code, but the policy was never enforced. On 5/6/26 at 1539 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 was observed at the nursing station with long nails appearing to be artificial nails. When asked about her nails, LVN 2 stated her nails were not compliant with the facility's policy but has not taken them off since their last in-service. Review of facility's documents titled Inservice Education Record dated 3/20/26, showed the course title/subject for Nail Hygiene and the subject summary showed proper nail hygiene for nursing staff and prevention of resident injury and infection. The document further showed CNA 1 and LVN 2 attended an inservice education. On 5/7/26 at 0905 hours, an interview was conducted with the DON. The DON was made aware and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure three of five final sampled residents (Residents 3, 14, and 16) reviewed for the unnecessary medications were free from the unnecessary psychotropic medication. * The facility failed to implement and document the nonpharmacological interventions for Resident 14 when the resident experienced behavioral episodes associated with the use of Rexulti (antipsychotic medication) and venlafaxine (antidepressant medication). * The facility failed to ensure the orthostatic blood pressure was accurately monitored for Resident 3 related to the use of the psychotropic medication. These failures had the potential for the residents to have adverse complications from the medications and the potential of not providing the correct data to the prescriber in order to adjust the dose of the psychotropic medications for the residents.Findings: Review of the facility's P&P titled Psychotropic Drug Treatment dated 9/2017 showed the facility to provide psychotropic drug treatment for a resident with a specific condition as diagnosed and documented in the clinical record. The resident has the right to be free from unnecessary drugs/medications and protection from medication errors. When their use is indicated, the facilities would use the least restrictive alternative for the least amount of time and document ongoing evaluation of the need for psychotropic drug treatment. Further review of the P&P showed medication use is not the sole approach for behavior intervention. Other non-pharmacological intervention will be identified and implemented on the plan of care. 1. Medical record review Resident 14 was initiated on 3/11/26. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's H&P examination dated 8/14/25, showed Resident 14 had no capacity to understand and make medical decisions. Review of Resident 14's Order Summary Report showed the following physician's orders: - dated 8/12/25, to monitor episodes of depression as manifested by verbalization of sadness every shift and to record number of episodes every shift; - dated 1/14/26, for Rexulti 1 mg to give one tablet via G- Tube on time a day for dementia with agitation as manifested by responding to internal stimuli leading to resisting care and to monitor episode of responding to internal stimuli leading to resisting care and to record the number of episodes every shift; and - dated 1/30/26, for venlafaxine 25 mg, to give 0.5 tablet via G-Tube three times a day for depression as manifested by verbalization of sadness. Review of Resident 14's MAR for March 2026 showed the Rexulti and venlafaxine medications were being administered as ordered by the physician and the behaviors were monitored as ordered for the medications. The MAR further showed Resident 14 had 17 behavior episodes of responding to the internal stimuli leading to resisting care in the day shift. In addition, Resident 14 had one episode of depression as manifested by verbalization of sadness. Further review of medical record for Resident 14 did not show if a nonpharmacological intervention was provided when the resident had the above behavior episode(s) related to the use of Rexulti and venlafaxine medications. On 3/13/26 at 1447 hours, an interview and concurrent medical record review for Resident 14 was conducted with LVN 6. LVN 6 was unable to show the documentation of the nonpharmacological interventions provided when Resident 14 had the above behavior episode(s) related to the use of Rexulti and venlafaxine medications. On 3/17/26 at 1406 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Medical record review for Resident 3 was initiated on 3/12/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Order Summary Report dated 3/2/26, showed the following physician's order dated: - dated 10/20/25, to administer buspirone (antianxiety medication) 5 mg one tablet by G-Tube every eight hours for anxiety; - dated 11/20/25, to check for orthostatic hypotension by checking the blood pressure in two positions (lying down and sitting) once a day every Sunday related to the use of the buspirone and lorazepam (antianxiety medication); and - dated 1/23/26, to administer lorazepam 1 mg via G-Tube every six hours as needed for anxiety. Review of Resident 3's MAR for March 2026 showed the orthostatic blood pressures (sitting and lying positions) were scheduled to be monitored every Sunday. However, the blood pressure readings for both positions (lying and sitting positions) were the same as follows: - dated 3/1/26, the blood pressure readings were 122/78 mmHg for the sitting position and 122/78 mmHg for the lying position; and - dated 3/8/26, the blood pressure readings were 151/68 mmHg for the sitting position and 151/68 mmHg for the lying position. On 3/17/26 at 0842 hours, an interview and concurrent medical record review was conducted for Resident 3 with RN 6. RN 6 verified Resident 3's physician orders for orthostatic hypotension monitoring for the use of antipsychotic medications once a week every Sunday. RN 6 was informed of the above findings. RN 6 verified and acknowledged the orthostatic hypotension monitoring were inaccurate because of the same blood pressure readings on sitting and lying positions. On 3/18/26 at 0839 hours, an interview and concurrent medical record review for Resident 3 was conducted with the DON. The DON was informed and verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries for two of three final sampled residents (Residents 8 and 110) reviewed for pressure injuries. * The facility failed to ensure the LAL mattress setting was appropriate to the residents' weight for Residents 8 and110. These failures had the potential for the residents to develop pressure injuries or worsening of the existing pressure injuries.Findings: Review of facility's P&P titled Low Air Loss Mattress revised dated 3/2017 showed the manufacturer's guidelines should be reviewed for each individual mattress to ensure this policy is what recommended; if this policy is not in agreement with manufacturer's guidelines, the manufacturer's guidelines will be followed. Review of the DynaRest Airfloat 100 Air Mattress with Pump manual (undated) showed to turn the pressure adjust knot to set a comfortable pressure level by using the weight scale as a guide. 1. Medical record review for Resident 110 was initiated on 3/11/26. Resident 110 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 110's H&P examination dated 3/6/26, showed the resident had no capacity to understand and make decisions. Review of Resident 110's Order Summary Report dated 3/17/26, showed a physician order dated 3/3/26, for LAL mattress for skin and wound management and check for proper setting and function every shift. Review of Resident 110's Weights and Vital Summary showed Resident 110 weighed 128 pounds on 3/8/26. On 3/11/26 at 0906 hours, an observation was conducted for Resident 110. Resident 110 was observed in bed lying on a LAL mattress with the mattress pressure setting passed the 150 pounds mark. On 3/11/26 at 0929 hours, a follow-up observation and concurrent interview was conducted with LVN 1 in Resident 110's room. LVN 1 verified the LAL mattress pressure setting was passed the 150 pounds mark. LVN 1 verified Resident 110 did not weigh more than 150 pounds and verified the resident's current weight was only 128 pounds. LVN 1 stated the mattress pressure setting should be based on the resident's weight to prevent skin breakdown or wound to get worse. On 3/18/26 at 0923 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Medical record review for Resident 8 was initiated on 3/11/26. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's H&P examination dated 8/14/25, showed Resident 8 had no capacity to understand and make decisions. Review of Resident 8's Order Summary Report dated 3/12/24, showed a physician's order dated 8/16/24, for LAL mattress for skin and wound management and check for proper setting and function every shift. Review of Resident 8's Care Plan dated 1/13/26, showed a care plan problem addressing Resident 8's high risk for further skin break down and history of pressure ulcer. The interventions included LAL pressure reduction mattress. Review of Resident 8's Weights and Vital Summary showed Resident 8 weighed 120 pounds on 3/1/26. On 3/11/26 at 1135 hours and 3/12/26 at 1007 hours, an observation was conducted for Resident 8. Resident 8 was observed in bed, lying on a LAL mattress with the mattress pressure setting at the 150 pounds mark. On 3/12/26 at 1134 hours, an follow-up observation and concurrent interview and medical record review for Resident 8 was conducted with LVN 13 in Resident 8's room. LVN 13 verified the LAL mattress pressure setting was at the 150 pound mark. LVN 13 verified that Resident 8 did not weigh 150 pounds, noted the resident's current weight was only 120 pounds. LVN 13 stated the mattress pressure setting should be adjusted according to the resident's weight to prevent skin breakdown. On 3/17/26 at 1406 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observations, interviews, medical record reviews, and facility P&P review, the facility failed to provide the necessary respiratory care services for six of 25 final sampled residents (Residents 3, 4, 7, 21, 69, and 136) and one nonsampled resident (Resident 94 ) reviewed for respiratory care. * The facility failed to ensure the manufacturer's recommendation for cleaning and disinfecting of the ventilator machines was followed for Resident 3, 4, and 7. * The facility failed to ensure Resident 69 received the oxygen therapy as ordered by the physician. Additionally, the facility failed to ensure the staff followed the proper infection control practices when a staff member attempted to place a nasal cannula on the resident after it had been on the floor. * The facility failed to ensure the Oxygen In Use signage was posted outside of Resident 94's room while the resident was on oxygen therapy. * The facility failed to ensure Resident 136's oxygen concentrator did not have a motor like sound. * The facility failed to ensure Resident 21's nebulizer tubing was not touching the floor. These failures had the potential to affect the respiratory health and well-being of the residents in the facility.Findings: 1. Review of the Covidien [NAME] HT70 Ventilator with Accessories Plus Model Operator's Manual (undated), under the Cleaning and Maintenance section, showed the ventilator machine should be clean with the use of a medical detergent or alcohol based cleaning solutions to remove blood, tissue and other residue. Rinse thoroughly with sterile, distilled water and allow to dry. Wipe clean between patients and as needed while in use. The exterior of the ventilator should be wiped clean with a cloth dampened with a medical detergent, disinfectant or alcohol based cleaning solution. a. Medical record review for Resident 7 was initiated on 3/11/26. Resident 7 was admitted to the facility on [DATE]. On 3/11/26 at 1009 hours, an observation was conducted for Resident 7. Resident 7 was observed asleep in bed. Resident 7 was observed with tracheostomy, connected to the ventilator machine and with oxygen supply from concentrator machine. Review of Resident 7's Order Summary Report dated 3/2/26, showed a physician's order dated 12/13/26, for the ventilator setting as follows: AC (Assist Control), VT - 500, rate - 20, 3 liters oxygen, PEEP + 5 four times a day. b. Medical record review for Resident 4 was initiated on 3/11/26. Resident 4 was admitted to the facility on [DATE]. On 3/11/2026 at 1119 hours, an observation was conducted for Resident 4. Resident 4 was observed asleep in bed. Resident 4 was observed with tracheostomy, connected to the ventilator machine and with oxygen supply from concentrator machine. Review of Resident 4's Order Summary Report dated 3/2/26, showed a physician's order dated 1/24/26, for the ventilator machine setting as follows: AC, VT 450, Rate 16, PEEP +5, and 2 liters per minute oxygen four times a day. c. Medical record review for Resident 3 was initiated on 3/12/26. Resident 3 was admitted to the facility on [DATE]. On 3/11/2026 at 1132 hours, an observation was conducted for Resident 3. Resident 3 was observed asleep in bed. Resident 3 was observed with tracheostomy, connected to the ventilator machine and with oxygen supply from concentrator machine. Review of Resident 3's Order Summary Report dated 3/2/26, showed the physician's order dated 3/10/26, for the ventilator setting as follows: daytime: 5 LPM via T-Piece/T-Collar ; Night: SIMV Rate 12, VT 500, PEEP +5, PS 12, 5 LPM four times a day. Further review of the Order Summary Report for Residents 3, 4, and 7 failed to show the physician's order to clean and disinfect the ventilator machine per manufacturer's recommendation were obtained. In addition, further review of the medical record for Residents 3, 4, and 7 failed to show documented evidence of the cleaning and disinfecting of the ventilator machine. On 3/16/2026 at 1054 hours, an interview and concurrent medical record review for Resident 3, 4, and 7 was conducted with RT 1. RT 1 was asked for cleaning and disinfecting of the ventilator machines. RT 1 stated they would use bleach wipes to clean the ventilator machine every day. RT 1 was asked about the physician's order for the cleaning and disinfecting of the ventilator machine per manufacturer's manual and asked if they had documented the cleaning of the ventilator machine everyday. RT 1 verified and acknowledged there were no physician's order and documentation for the cleaning of the ventilator machines. RT 1 was uncertain if they followed the manual from the manufacturer of the ventilator machine. On 3/16/2026 at 1354 hours, an interview and concurrent medical record review for Residents 3, 4, and 7 was conducted with RT 2. RT 2 stated she would inform the facility's contracted company for the ventilator machine yearly maintenance. RT 2 stated she kept a log for the ventilator machine when it was serviced and when would be the next maintenance. RT 2 was asked about the everyday cleaning of the ventilator machine when the resident was using the machine. RT 2 stated the RTs were responsible for the cleaning by wiping the ventilator machines, suction machines, nebulizer machines and concentrator machine using the bleach wipes for everyday cleaning. When asked if there was a log or record when they cleaned the machines, RT 2 verified there was no record of the cleaning of the machines done by RTs. RT 2 was asked if there was a manufacturer's manual of the ventilator machines available, RT 2 verified there was none. RT 2 was asked if they followed the manufacturer's manual of the ventilator machine for cleaning and disinfecting the ventilator machines, RT 2 was uncertain. RT 2 verified and acknowledged the cleaning and disinfecting of the ventilator machines was not followed per manufacturer's recommendation. On 3/17/2026 at 0842 hours, an interview and concurrent medical record review for Residents 3, 4, and 7 was conducted with RN 6. RN 6 verified the RT's were responsible for providing of the respiratory care to the residents who needed respiratory care. RN 6 added the RTs were responsible for the cleaning and maintenance of the ventilator machines. When asked if the cleaning of the ventilator machines were documented, RN 6 verified there was no documentation or recorded evidence if the cleaning of the ventilator machine was performed. RN 6 reviewed the RT flowsheet and verified there was no documentation of cleaning of the vent machine. On 3/18/26 at 0839 hours, an interview and concurrent medical record review for Residents 3, 4, and 7 was conducted with the DON. The DON was informed and verified the above findings Cross reference to F0657, example # 2 a, b, and c. 2. Review of the facility P&P titled Oxygen Administration dated 2/2017 showed to verify that there is a physician order for the oxygen administration. On 3/11/26 at 0826 hours, an observation was conducted for Resident 69. Resident 69 was observed lying in his bed with an oxygen machine positioned on the left side of the bed. The oxygen tubing connected to the machine was observed touching the floor, and the nasal cannula, which was a part of the oxygen tubing, was also touching the floor. The oxygen machine was observed to be off. Medical record review for Resident 69 was initiated on 3/11/26. Resident 69 was admitted to the facility on [DATE]. Review Resident 69's H&P examination dated 2/17/26, showed Resident 69 had no capacity to understand and make decisions. Review of Resident 69's Order Summary Report showed an order dated 2/16/26, for oxygen at a rate of 4 LPM via mask/nasal cannula continuously to keep the oxygen saturation level above 92% for COPD exacerbation. On 3/11/26 at 0836 hours, an observation with a concurrent interview and medical record review for Resident 69 was conducted with LVN 6. LVN 6 was called to Resident 69's room and LVN 6 verified the oxygen tubing and nasal canula was touching the floor. LVN 6 stated the resident should be receiving oxygen at a rate of 4 LPM as per the physician's order. LVN 6 was observed turning on the oxygen machine and was preparing to connect the resident using the same nasal cannula that had been observed on the floor. LVN 6 was stopped and asked whether the oxygen tubing had been on the floor. LVN 6 acknowledged the oxygen tubing for Resident 69 had been on the floor. LVN 6 stated she should have discarded it and used new oxygen tubing before administering oxygen. LVN 6 also stated the oxygen machine needed to be replaced and was observed bringing a new nasal cannula and a new oxygen machine. LVN 6 was observed checking Resident 69's oxygen saturation, which measured 88% without oxygen. After applying oxygen at a rate of 4 LPM, the resident's oxygen saturation increased to 94%. When asked how long the resident had been without oxygen, LVN 6 stated she could not determine the exact time; however, LVN 6 stated she last checked on the resident on 3/11/26 at 0700 hours, and he was receiving oxygen at that time. On 3/17/26 at 1406 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. On 3/11/26 at 0858 hours, during the initial tour of the facility, Resident 94 was observed awake and lying on the bed. Resident 94 was observed wearing a nasal canula and the oxygen concentrator setting was at a rate of 2 LPM. However, there was no signage warning of No Smoking/Oxygen in Use posted inside or outside of Resident 94's room. Medical record review for Resident 94 was initiated on 3/11/26. Resident 94 was admitted to the facility on [DATE]. Review of Resident 94's H&P examination dated 1/19/26, showed Resident 94 had the capacity to understand and make decisions. Review of Resident 94's Order Summary Report showed a physician's order dated 1/16/26, may apply oxygen via nasal cannula at a rate of 2 LPM to keep the oxygen saturation level greater than 92% as needed. On 3/11/26 at 0930 hours, a follow-up observation of Resident 94 and concurrent interview was conducted with the IP. The resident's room was observed with no signage of No Smoking/Oxygen in Use. The IP stated while the resident was on oxygen there should be a No Smoking/Oxygen in Use sign posted by the door outside of the resident's room. The IP verified and acknowledged that there was no sign of No Smoking/Oxygen in Use posted for this resident. On 3/18/26 at 0923 hours, an interview conducted with the DON. The DON was informed and acknowledged the above findings. 4. On 03/11/2026 at 0907 hours, an observation was conducted for Resident 136. A motor like sound was heard out into the hallway, outside Resident 136's room. Resident 136 was observed in bed with a motor like sound coming from Resident 136's oxygen concentrator. Medical record review for Resident 136 was initiated on 3/11/26. Resident 136 was admitted to the facility on [DATE]. Review of Resident 136 H&P examination dated 3/11/26, showed Resident 136 had no capacity to make decision. Review of Resident 136's Order Summary Report showed a physician's order dated 3/10/26, for oxygen at a rate of 2 LPM via nasal cannula to keep the oxygen saturation above 92%. On 3/11/26 at 936 hours, a follow-up observation and concurrent interview was conducted with Resident 136 and LVN 2. LVN 2 verified the motor like sound was coming from Resident 136's oxygen concentrator. LVN 2 stated she noticed the sound but thought it might be related to the oxygen concentrator's position and did not report the sound. When asked if the noise bothered Resident 136, Resident 136 replied yes the sound bothered her. 5. On 3/11/26 1645 hours, an observation was conducted for Resident 21 and concurrent interview was conducted with RN 5. Resident 21's nebulizer tubing was observed touching the floor. RN 5 verified Resident 21's nebulizer tubing was touching the floor. Medical record review for Resident 21 was initiated on 3/12/26. Resident 21 was readmitted to the facility on [DATE]. Review of Resident 21's Order Summary Report showed a physician's order dated 3/7/26, for albuterol solution to be administered via nebulizer every six hours as needed for shortness of breath/wheezing. Review of Resident 21's H&P examination dated 3/9/26, showed Resident 21 was nonverbal and had no capacity to make decisions.

Based on observation, interview, and facility document review, the facility failed to ensure the menu was followed for 10 residents who received pureed food. * The facility failed to ensure the Korean menu was followed during pureed preparation observation when the cook did not puree one food item (roasted [NAME]) posted on menu, and the cook liquified seaweed soup. This failure posed the risk for the residents who received food prepared in the kitchen to not have their nutritional needs met.Findings: Review of the facility's document titled Order Listing Report dated 3/12/26, showed a total of 48 of 124 residents (including 10 on puree diets) received meals prepared in the facility's kitchen. Review of the facility's posted menu for the lunch meal dated 3/12/26, showed the following Korean menu food items were to be served on 3/12/26: Bulgogi (meat), seaweed soup, mixed simple salad, steamed rice, kimchi, and roasted [NAME] (dried seaweed sheets). On 3/12/26 at 0941 hours, a puree food preparation observation and concurrent interview was conducted with [NAME] 1. [NAME] 1 stated he would be doing puree for the Bulgogi and seaweed soup. When asked about the other food items on the menu, [NAME] 1 stated those were pureed in the morning and were currently refrigerated. On 3/12/26 at 1046 hours, [NAME] 1 was observed pouring seaweed soup into a blender. [NAME] 1 showed a liquified version of the seaweed soup. When asked if he (Cook 1) was finished pureeing the seaweed soup to the correct consistency, [NAME] 1 verbalized yes because Koreans liked to drink soup. The Dietary Services Director was called to verify the consistency of the seaweed soup for residents on puree diet. The Dietary Services Director instructed [NAME] 1 to follow the IDDSI Level #4 soup recipe. The directions for pureeing the soup included to add saltine crackers. [NAME] 1 was observed gathering packets of saltine crackers. [NAME] 1 then hesitated and asked the Dietary Services Director. The Dietary Services Director then instructed [NAME] 1 to use thickener and omit the saltine crackers. Per the Dietary Services Director, the RD had instructed her to omit the saltine crackers via telephone. When asked about pureeing the roasted [NAME], [NAME] 1 stated he would not be pureeing this food item, posted on the Korean menu. When asked about how the kimchi was pureed, [NAME] 1 verbalized the kimchi was bought in tubs and was then pureed. The Dietary Services Director was asked for a copy of the puree recipe for kimchi. Per the Dietary Services Director, there was not one specific recipe for kimchi. On 3/13/26 at 1316 hours, an interview and concurrent review of dietary manuals was conducted with the RD. The RD was informed of the above findings. When asked about recipes for the seaweed soup and the kimchi, the RD verbalized the puree recipes provided to the facility were challenging because they were not geared to the specific population Korean and the cultural foods they eat. When asked if she (RD) had done a follow up to the recipes not being geared towards Korean foods, the RD stated she did not do a follow up as the recipes had been approved a long time ago by company's registered dieticians.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed. * The hairnet for one kitchen staff (Tray Line Staff 1) did not completely cover the hair. * There were ten ladles stored above the three compartment sink, above the wash and rinse sinks. * The facility staff (CNA 6) distributed a food tray to Resident 105 without having the licensed nurse check the food tray. * The kitchen staff (Cook 1) failed to wash her hands after touching a trash can during puree preparation observation. These failures had the potential to cause foodborne illnesses to the medically vulnerable residents population who consumed food prepared in the kitchen.Findings: Review of the facility's document titled Order Listing Report dated 3/12/26, showed a total of 48 of 124 residents (including 10 on puree diets) received meals prepared in the facility's kitchen. 1. According to the FDA Food Code Section 2-402.11, Effectiveness, food employees to wear hair restraints (nets, hats, beard nets) to effectively keep hair from contacting exposed food, clean equipment, utensils, linens, and unwrapped single-service items. On 3/11/26 at 0800 hours, an observation in the kitchen was conducted with the Dietary Services Director. Tray line Staff 1 was inside the dishwashing area. Tray line Staff 1 was observed with strands of hair coming out of the side of her hairnet. The Dietary Services Director verified the findings. 2. On 3/11/26 at 0810 hours, an observation in the kitchen was conducted with the Dietary Services Director. There were a total of ten ladles observed stored about two to three feet above the dishwashing and rinse compartments of the three compartment manual dishwash sinks. The findings was verified with the Dietary Services Director. 3. On 3/11/26 at 1155 hours, a dining observation in Station 1 and concurrent interview was conducted with CNA 6. The meal cart was observed delivered to the hallway outside Room A. CNA 6 was observed removing Resident 105's food tray and delivering it to the resident. The food tray was delivered to the resident without being checked by a licensed nurse. CNA 6 verified the findings. 4. Review of the facility's P&P titled Hand Washing Procedure dated 2023 showed hand washing was to be completed after touching a trash can or lid. On 3/12/26 at 0941 hours, a puree food preparation observation was conducted with [NAME] 1. During the food preparation observation, [NAME] 1 was observed removing the gloves and then touched the barrel trash can to dispose of the used gloves. [NAME] 1 put on new gloves without performing hand hygiene and touched the blender used to puree foods. [NAME] 1 touched the barrel of the trash can to dispose of the used gloves, retrieved kimchi from the refrigerator and retrieved a fork without performing hand hygiene in between. When asked about no handwashing after touching the trash can on two separate observations, [NAME] 1 did not acknowledge the findings.

Based on interview and facility P&P review, the facility failed to ensure the personal food policy addressed personal food brought in from the outside for the residents who wanted to store and reheat the foods for later consumption. * The facility failed to ensure the residents were able to store food and reheat brought from outside sources in the facility. This failure posed the risk of the residents not being able to choose to store and/or reheat foods brought from the outside and being able to enjoy foods brought from the outside, at their leisure. Findings: Review of the facility's P&P titled Food and Liquids food From Outside Sources or Other Than the Dietary Department revised 3/2025 showed foods brought from outside could not be reheated or stored in the facility. Review of the facility's document titled Order Listing Report dated 3/12/26, showed a total of 48 of 124 residents (including 10 on puree diets) received meals prepared in the facility's kitchen. On 3/11/26 at 0818 hours, an interview was conducted with the ADON. The ADON stated there was no residents' refrigerator. On 3/13/26 at 1316 hours, an interview was conducted with the RD. The RD stated she was aware of the facility's P&P to not allow the residents to store or reheat foods brought from the outside. The RD stated she was not included in the development of this P&P. On 3/18/26 at 1029 hours, the above findings were shared with the DON and Administrator. The DON stated personal food brought from the outside was not to stored or reheated per the facility's P&P.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control program in accordance with the facility's P&P. * The facility failed to maintain an accurate infection control surveillance program for September 2025 through February 2026. The facility failed to ensure the Surveillance Data was accurate to determine whether the resident's infection met the McGeer's (a standardized surveillance definitions used to detect infections in long-term care facilities, ensuring consistent reporting and monitoring) criteria for true infection. * The facility failed to ensure the facility's water system flowchart identified the risk areas in the facility's water flow system where Legionella may grow as per the facility's P&P; additionally, the facility failed to conduct accurate monitoring of the control area as part of the preventative maintenance plan for Legionnaire's (a severe form of pneumonia, when inhaled as tiny water droplets) disease when the facility failed to conduct monitoring of the temperature for the main water pipe which supplied water to the facility's three water heater tanks. * The facility failed to ensure CNA 1 disinfected Resident 67's call light after picking it up from the ground, and before placing the call light on Resident 67's bed. * The facility failed to ensure CNA 2 performed hand hygiene after changing Resident 137's brief (in Room A ) and before entering Resident 141's room (Room B) to turn off the call light. * LVN 2 was observed with long artificial fingernails. These failures posed the risk of not identifying the residents' infections and controlling the potential transmission of communicable diseases to other residents, staff, and visitors throughout the facility.Findings: 1. Review of the facility's P&P titled Infection Control Program System reviewed 1/2023 showed the facility's infection control program includes a system for preventing, identifying, reporting, investigating and controlling infections and communicable diseases for all the residents, staff, volunteers, visitors, and other individuals providing services under a contractual agreement based upon the facility assessment. The facility maintains written standards, policies and procedures for the infection control program which includes: - The IP collects data and analyzes the information, utilizing the facility's surveillance tools, to develop strategies to prevent further infection transmission. - The IP utilizes the revised McGeer's Criteria for definitions of infection control practices. Review of the facility's monthly Infection Prevention and Control Surveillance Logs from September 2025 through February 2026 showed the following infection surveillance data for HAIs (Healthcare Acquired Infections), CAIs (Community Acquired Infections), and residents who did not meet McGeer's Criteria (DNMC): - September 2025: a total of 37 infections, including 16 HAIs, three CAIs, and 12 DNMCs. - October 2025: a total of 35 infections, including 11 HAIs, 11 CAIs, and nine DNMCs. - November 2025: a total of 42 infections, including 14 HAIs, 10 CAI, and 15 DNMCs. - December 2025: a total of 38 infections, including 14 HAIs, six CAI, and 15 DNMCs. - January 2026: a total of 39 infections, including 15 HAIs, five CAI, and 12 DNMCs. - February 2026: a total of 51 infections, including 17 HAIs, six CAI, and 19 DNMCs. On 3/16/26 at 1400 hours, an interview and concurrent facility document and medical record review for Residents 16, 34, 45, 76, 78, 99, 117, and 143 was conducted with the IP. The IP stated she was responsible for the surveillance and tracking of infections in the facility. The IP stated she tracked the number of infections in the facility to determine the facility's infection rate, and the rate of antimicrobial usage when the infection did not meet the criteria for true infection. The IP stated the facility utilized the McGeer's criteria for all the infections to determine if an infection was a true infection. The IP further stated, if the infection did not meet the criteria for a true infection, it would prompt the facility to reevaluate the antimicrobial therapy to prevent the unnecessary use of antimicrobials and thus contributing to antimicrobial resistance to therapy. Review of the facility's Surveillance Data Collection Form for Residents 16, 34, 45, 76, 78, 99, 117, and 143 was conducted with the IP. The residents' Surveillance Data Collection Form showed the following documentation: * For Resident 45, the report showed the following: - the antibiotic treatment prescribed for Resident 45 was vancomycin (an antibiotic used to treat severe infection) 1 gm every 12 hours for 10 days, started on 9/17/25, for urinary tract infection (UTI). - The criteria for UTI (Urinary Tract Infection) without an indwelling catheter showed both criteria 1 and 2 must be present. For criteria 1b, fever or leukocytosis (high white blood cell count signaling the immune system is responding to an infection) and at least one of the following localizing urinary tract infections: acute costovertebral (connects the ribs and the spine) angle pain or tenderness, suprapubic pain, gross hematuria (blood in the urine), new or marked increase in incontinence, urgency, or frequency; however, only fever was circled and none of the localizing urinary tract sub-criteria were documented. - HAI and CAI were both not selected (however, on the Infection Prevention and Control Surveillance Log for September 2025, showed the infection was selected as HAI). * For Resident 78, the report showed the following: - the antibiotic treatment prescribed for Resident 78 was Zosyn 3.375 gm every six hours for seven days, started on 11/3/25, for leukocytosis. - HAI was selected in the section on the form to indicate whether the infection met the criteria for a true infection, and under addition notes showed the documentation the WBC was 18.32 cells/microliter . - further review of the form showed a blood culture was obtained, however the section for results was blank - Review of the Infection Prevention and Control Surveillance Log for November 2025 showed Resident 78's infection was categorized as a blood infection and the blood culture results were negative. * For Resident 16, the report showed the following: - the antimicrobial treatment prescribed for Resident 16 was fluconazole (antifungal) 100 mg daily for five days, started on 11/11/25. - HAI was selected in the section on the form to indicate whether the infection met the criteria for a true infection. - The criteria for lower respiratory tract infections showed all three criteria must be present. For criteria 2- at least two respiratory sub criteria must be present; however, only one was documented (new or changed lung examination abnormalities). * For Resident 143, the report showed the following: - the antibiotic treatment prescribed for Resident 143 was ceftriaxone (an antibiotic to treat severe infections) 1 gm every 24 hours for 10 days, started on 11/25/25, for leukocytosis. - CAI was selected in the section on the form to indicate whether the infection met the criteria for a true infection, and under addition notes showed the documentation the WBC (White Blood Count) was 17.94 cells/microliter. - further review of the form showed a urine (not blood) culture was obtained and the section for results was blank - review of the Infection Prevention and Control Surveillance Log for November 2025,showed Resident 148's infection was categorized as a blood infection and the urine and blood cultures were negative. * For Resident 76, the report showed the following: - the antibiotic treatment prescribed for Resident 76 was Rocephin (an antibiotic to treat severe infections) 1 gm every 24 hours for seven days, started on 12/4/25. The diagnosis was blank. - HAI was selected in the section on the form to indicate whether the infection met the criteria for a true infection, and under addition notes showed the documentation the WBC was 14.17; and the CXR (chest x-ray) was negative. - further review of the form showed a sputum and urine culture (not blood) were obtained and the section for results was blank - review of the Infection Prevention and Control Surveillance Log for December 2025, showed Resident 76's infection was categorized as a blood infection and the blood culture results were negative. * For Resident 117, the report showed the following: - the antimicrobial treatment prescribed for Resident 117 was Tamiflu 75 mg every 12 hours for five days, started on 1/29/26. - HAI was selected in the section on the form to indicate whether the infection met the criteria for a true infection. - the criteria for respiratory tract infections- influenza like illness showed both criteria 1 and 2 must be present. For criteria 2- at least three of the following influenza-like illness sub criteria: chills, new headache/pain, myalgia/body aches, malaise/loss of appetite, sore throat, or new or increased dry cough; however, only one was documented (chills). * For Resident 34, the report showed the following: - the antibiotic treatment prescribed for Resident 34 was meropenem (an antibiotic used to treat severe infection) 1 gm every 12 hours for seven days, and vancomycin 1 gm daily for seven days, started on 2/2/26, for leukocytosis. - HAI was selected in the section on the form to indicate whether the infection met the criteria for a true infection, and under addition notes showed the documentation the WBC was 45.09 cells/microliter and the heart rate was 110 beats per minute. - further review of the form showed a urine, blood, and sputum culture were obtained, however the section for results was blank - review of the Infection Prevention and Control Surveillance Log for February 2026 showed Resident 34's infection was categorized as a blood infection and the sputum culture was negative, the urine culture and mixed organism, and no documentation of the blood cultures results. * For Resident 99, the report showed the following: - the antibiotic treatment prescribed for Resident 99 was vancomycin 1.25 gm every 48 hours for 10 days, and meropenem 500 mg every 24 hours for 10 days, stated on 2/4/26, for leukocytosis. - HAI was selected in the section on the form to indicate whether the infection met the criteria for a true infection, and under addition notes showed the documentation the temperature was 100.4 degrees F and the heart rate was 145 beats per minute. - further review of the form showed a blood and sputum culture were obtained, however the section for results was blank. - review of the Infection Prevention and Control Surveillance Log for February 2026, failed to showed Resident 99's blood infection on the surveillance log. Additionally, Resident 99 was included on the log for a respiratory infection, however, a surveillance form was not completed to determine whether the respiratory infection met the McGeer's criteria for a true infection. The IP was asked what criteria she used to determine if a blood infection was a true infection. The IP stated she completed the Surveillance Data Collection Form for other infection and if the resident presented with any of the constitutional criteria: fever, leukocytosis, acute mental status change, or acute functional decline, she would select the infection as a true infection. The IP was asked to show the reference literature for the determination of a true infection for the blood infection; however, the IP was unable to provide the reference. The IP reviewed the medical record and Surveillance Data Collection Forms for Residents 16, 34, 45, 76, 78, 99,117, and 143 and verified the Surveillance Data Collection Forms were inaccurate. The IP stated the Surveillance Data Collection Form and the determination of a true infection should be accurate to effectively conduct surveillance and track the prevalence of infections in the facility. On 3/18/26 1008 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings. 2. Review of the facility's P&P titled Legionnaire's Disease (Legionella Pneumophila) reviewed 10/2017 showed it is the policy of the facility to have a plan for the prevention of Legionnaire's disease, recognize signs and symptoms of the disease test as appropriate with a physician's order and report confirmed cases to the local and state health department. The facility will complete a Legionella Risk Assessment to determine their risk for Legionella outbreaks. This assessment will be completed annually. The facility will develop a Water Management Program which will be reviewed annually. The facility will complete the Water Flow Diagram specific to the facility to identify risk areas in which Legionella can grow. The facility will determine risk areas by completing the Building Water System Process Flowchart and implement controls and indicate where these controls are located by completing the Control Area Monitoring Flowchart. During routine inspection of control areas, the facility will attempt to reduce areas if concern with specific pans that have been developed. Preventative maintenance plans have been developed for each control area. Review of the facility's Building Water System Flowchart (undated) showed the flow of water from the main water source through the facility. The facility's water flowchart showed the flow of water into the facility and to the three water heaters tanks that supplied water to the kitchen, laundry, and sinks/showers/nursing stations. Further review of the flowchart showed the legend labeled Potential Hazards with the legend item markers included; however, further review of the facility's flowchart failed to show the identification of areas in the facility's water system (utilizing the legend) where the potential hazards may exist. Review of the facility's Water Management Program updated 10/2025 showed water conditions that tend to promote the growth of legionella included: Stagnation, low water flow, Temperatures between 68 to 122 degrees F (Optimal range 95 to 115 degrees F) Further review of the facility's Water Management Program showed the facility identified a potential hazardous event in the hot water storage would be when the storage temperature would be too low (below 140 degrees F). The Operational Monitoring chart showed the following: - the incoming water would be tested for chlorine residual weekly at the point of entry into the facility, with the critical limit if less than 0.5 mg/L, and recorded in the Chlorine Residual Record sheet, and - the hot water temperature would be tested weekly at the hot water outlet in the kitchen, with the critical limit when the temperature is less than 140 degrees F and recorded in the Weekly Temperature kitchen record sheet. On 3/18/26 at 0915 hours, an observation was conducted in the soiled utility room. Three water heater tanks were observed. The temperature gauge on the left water heater tank showed less than 120 degrees F. The temperature gauges for the other two water heater tanks showed 145 degrees and 155 degrees F. On 3/18/25 at 0918 hours, a concurrent observation, facility document review, and interview was conducted with the Maintenance Director. The Maintenance Director stated he was part of the facility's Water Management Team. When asked about the facility's Water Management Program, the Maintenance Director stated Legionella (a type of bacteria found in water that causes Legionnaires' disease, a severe form of pneumonia, when inhaled as tiny water droplets) could grow when the water temperature was below 140 degrees F and the facility monitored the hot water system by checking the water temperatures daily to ensure the water temperatures were above 140 degrees F. The Maintenance Director stated the main water line supplied the three water heater tanks, and each tank supplied a different part of the facility: the kitchen, laundry room, and showers/sinks/ nursing stations. A concurrent review of the facility's temperature log for March 2026 showed the water temperatures were measured daily in the laundry, kitchen, shower rooms (three), and one resident room per nursing station. Further review of the temperature log showed the documented water temperatures for the shower rooms and resident rooms ranged from 102 to 118 degrees F. When asked how the facility ensured the water supplying the water heater tank for the showers/sinks/resident rooms were within the control limits, the Maintenance Director stated he set the water heater tank which supplied the water to the showers, nursing stations, and resident rooms below 120 degrees for the resident's safety. A concurrent observation of the water pipes which supplied the three water heater tanks (from outside the facility) was conducted with the Maintenance Director. A temperature gauge was observed with the temperature at 120 degrees F. The Maintenance Director verified the above findings. When asked if the water temperature was being monitored and documented in the log, the Maintenance Director stated he was not documenting the water temperature for the pipes leading to the water heater tanks and the temperature had always been 120 degrees F. When asked about the measuring of the chlorine residual level at the point of water entry to the facility, the Maintenance Director stated the chlorine was only tested in the kitchen. A concurrent review of the facility's Building Water System Process Flowsheet and interview was conducted with the Maintenance Director. The Maintenance Director reviewed the flowchart and verified the flowchart only listed the locations of the flow of water through the facility and the potential hazards were not identified and labeled on the flowchart. On 3/18/26 1008 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings. 3. Review of the facility's P&P titled Enhanced Standard Precautions reviewed 5/2024 showed for all the residents regardless of transmission risk or MDRO status: always follow standard precautions, including hand hygiene; use of gowns, gloves, masks, eye shields when contact with moist fluids is likely. Hand hygiene before and touching any resident is critical under all circumstances. On 3/11/26 at 0810 hours, during the initial tour of the facility, Resident 67's call light was observed on the ground. On 3/11/26 at 0813 hours, an observation and concurrent interview was conducted with CNA 1. CNA 1 verified the above findings and was observed picking up the call light and placing the call light on Resident 67's bed. CNA 1 was not observed disinfecting the call light. CNA 1 was interviewed and verified she did not disinfect Resident 67's call light prior to placing it back on the resident's bed. On 3/16/26 at 1430 hours, an interview was conducted with the IP. The IP stated when the resident's call light fell on the ground, the staff were expected to disinfect the call light prior to placing the call light within the resident's reach. On 3/17/26 at 1530 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 4. On 3/16/26 at 0839 hours, CNA 2 was observed in Room A wearing gloves and placing the dirty linen in the hamper located outside of the Room A. CNA 2 was then observed exiting Room A after discarding her gloves and entering Room B to answer and turn off the call light. CNA 2 was not observed performing hand-hygiene after removing her gloves, exiting Room A, and before entering Room B to turn off the call light. On 3/16/26 at 0841 hours, an interview was conducted with CNA 2. CNA 2 stated she was in Room A changing Resident 137's brief. CNA 2 stated after she was done changing Resident 137, she exited the room to answer Resident 141's call light in Room B. CNA 2 verified she did not perform hand-hygiene after removing the gloves and before entering Resident 141's room to answer the call light. CNA 2 further stated she should have performed hand hygiene after the removal of the gloves and before entering another resident's room to prevent contamination and transmission of microorganisms. On 3/16/26 at 1430 hours, an interview was conducted with the IP. The IP stated after changing the resident, the staff should remove the gloves and perform hand hygiene before assisting another resident for infection control purposes. On 3/17/26 at 1530 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Cross Reference to F881. 5. Review of the facility's P&P titled Dress Code dated 2023 showed employee fingernails were to be kept short. On 3/11/26 at 0936 hours, LVN 2 was observed helping to reposition Resident 136. LVN 2 was observed removing her gloves. LVN 2 was observed with artificial long fingernails, extending approximately one half inch in length beyond LVN 2's fingertips. The edge of the nails were observed with a narrow tip, resembling an arrow. When asked about wearing artificial and long fingernails, LVN 2 acknowledged she would need to remove the artificial fingernails.

Based on interview, medical record review, and facility's P&P review, the facility failed to ensure the residents or their representatives were informed in advance of the proposed treatment regarding the use of psychotropic medications (medications affecting brain activity) for one of five residents (Resident 14) reviewed for unnecessary medication. * The facility failed to ensure the informed consent for the venlafaxine (antidepressant medication) indicated the nonpharmacologic measures for Resident 14. This failure had the potential to compromise the resident's and/or their designated representative's right to be fully informed regarding the psychotropic medication and its possible nonpharmacological interventions in order to make an informed decision.Findings: Review of the facility's P&P titled Informed Consent Policy dated 4/2024 showed that the attending physician, PA or NP must obtain the informed consent of the resident or their responsible party for purpose of prescribing, ordering, or increasing an order for a psychotherapeutic medication. The information material to a decision concerning the administration of a psychotherapeutic drug shall include the reasonable alternative treatments and risks, and why this particular treatment is recommended. Review of the AFL 25-38.1 titled Notice of Release of Psychotherapeutic Drug Informed Consent Form dated 2/3/26, showed the facilities may use the CDPH (California Department of Public Health) Psychotherapeutic Drug Informed Consent Form or use their own in-house form as long as the in-house form contains all the data elements on the CDPH form. The form must be in use by January 1, 2026, for new residents, residents being prescribed a new psychotherapeutic drug, and residents having a psychotherapeutic drug dosage change. Review of the CDPH 9168 document titled Psychotherapeutic Drug Informed Consent Form dated 12/2025 showed to include the following psychotherapeutic drug information: drug category, drug name, dosage prescribed, frequency, duration, administration method, caution and earning summary, reason for use of the psychotherapeutic drug and benefits, the probable side effects and significant risks associated with the use of the psychotherapeutic drug, and the reasonable alternative mode(s) of treatment or possible non-pharmacological approaches that could address the resident's needs. Medical record review for Resident 14 was initiated on 3/11/26. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's H&P examination dated 8/14/25, showed Resident 14 had no capacity to understand and make decisions. Review of Resident 14's Order Summary Report showed a physician's order dated 1/30/26, to administer venlafaxine 25 mg tablet, 0.5 tablet via G-Tube three times a day for depression as manifested by verbalization of sadness. Further review of the physician's order showed the informed consent was obtained by the physician with the resident's representative. Review of Resident 14's Informed Consent dated 10/12/25, showed for venlafaxine 25 mg to give 0.5 mg medication, Resident 14's responsible party was informed on 10/12/25. However, further review of the form failed to show the list of possible nonpharmacological approaches that could address the resident's behavior related to the use of the venlafaxine medication. On 3/13/26 at 1444 hours, an interview and concurrent medical record review for Resident 14 was conducted with RN 1. RN 1 verified the Informed Consent for the venlafaxine medication for Resident 14 did not show the list of the possible nonpharmacological approaches that could address the resident's behavior related to the use of the medication. On 3/17/26 at 1406 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility document review, the facility failed to provide the written Notice of Medicare Non-coverage (NOMNC) form CMS-10123 for one of three residents (Resident 139) reviewed for beneficiary notification. * The facility failed to make sure Resident 139 was provided with NOMNC form prior to discharge from the facility. This failure had the potential for Resident 139 and/or the representative to not be aware of the resident's rights and make informed decision regarding Resident 139's care and services.Findings: Medical record review for Resident 139 was initiated on 3/17/26. Resident 139 was admitted to the facility on [DATE]. Review of Resident 139's H&P examination dated 7/7/25, showed the resident had no capacity to make medical decisions. Review of the facility's Beneficiary Notice - Residents discharged Within Last Six Months showed Resident 139 was to be discharged from the Medicare Covered Part A stay on 9/25/25, and would be discharged home, or to a facility for lesser care. Further review of Resident 139's medical record failed to show if Resident 139 and/or the resident's representative were provided with a copy of the NOMNC form when Resident 139 was to be discharged from Medicare Part A services. On 3/17/26 at 1449 hours, an interview was conducted with the Business Office Manager (BOM). The BOM stated they were unable to locate Resident 139's NOMNC form in her chart. On 3/17/26 at 1546 hours, an interview was conducted with the DON. The DON was made aware and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to address the resident's grievance in accordance with the facility's P&P for one of 25 final sampled residents (Resident 81). * The facility failed to address the concern when Resident 81 verbalized the staff was rude and giving attitude when answering his call light. This failure posed the risk for the resident's grievance not being thoroughly addressed, investigated, documented, and resolved.Findings: Review of the facility's P&P titled Grievance Procedure revised 1/2017 showed the resident has the right to and the facility must take prompt efforts to resolve grievances that the resident, responsible party, other family members, or advocates may have and any resident, their responsible party, family member or advocate may file a grievance or complaint concerning resident's treatment, medical care, behavior of other residents or staff members. Medical record review for Resident 81 was initiated on 3/13/26. Resident 81 was admitted to the facility on [DATE]. Review of Resident 81's H&P examination 6/11/15, showed the resident had the capacity to understand and make medical decisions. On 3/17/26 at 1017 hours, an interview was conducted with Resident 81. Resident 81 stated LVN 10 had an attitude and was told he was pressing the call light button too much during the evening shift. Resident 81 stated he told RN 3 about the interaction that transpired. On 3/17/26 at 1113 hours, an interview was conducted with RN 3. RN 3 stated she was made aware of a situation about two weeks ago between Resident 81 and LVN 10. RN 3 stated Resident 81 had said LVN 10 was rude to him and was giving him attitude when answering his call light. RN 3 stated she did not document the interaction between Resident 81 and LVN 10 had occurred and only learned of the incident the following morning. RN 3 further stated if she was working the evening shift when the interaction between Resident 81 and LVN 10 had occurred, she would have handled it differently. On 3/17/26 at 1302 hours, a follow up interview was conducted with RN 3. When RN 3 was asked what the process was when complaints about staff being rude were brought to her attention, RN 3 stated they first would verify with both parties involved to get both sides of the event, and if another incident occurred, they would then file a grievance or give the nurse a write up. On 3/17/26 at 1327 hours, an interview was conducted with the DON. The DON was asked about the process for when the residents would report to staff members about another resident being rude. The DON stated the incidents should be reported to the Social Services, and Social Services would reach out to her and a grievance report would be initiated so they can conduct their own investigation on what happened between the residents and staff members involved. On 3/17/26 at 1546 hours, a follow-up interview was conducted with the DON. The DON was informed and acknowledged the findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 25 final sampled residents (Resident 98) was free from the physical restraints. * The facility failed to implement the least restrictive measures prior to applying a hand mitten to Resident 98's left hand. In addition, the facility failed to follow and document the release of the left hand mittens as per the physician's order. These failures posed the risk of compromising the residents' independence and psychosocial well-being.Findings: Review of the facility's P&P titled Physical Restraints dated 9/2017 showed the restraints will only be used after other alternatives have been tried unsuccessfully and only after a thorough assessment, informed consent from the resident or their responsible party, a physician's order and a care plan to address the use of the restraint. Least restrictive measures shall be assessed prior to the use of an actual restraint. Restraints must be used only as a last resort, and the medical record must indicate the events leading up to their necessity. If restraints are utilized, the opportunity for motion and exercise should be provided for a period of not less than ten minutes during each two hour period in which the restraints are utilized. On 3/11/2026 at 0951 hours and 2/12/26 at 0858 hours, Resident 98 was observed lying in bed with a left hand mitted in placed. Resident 98 was able to move his left arm and was observed touching his body. Medical record review for Resident 98 was initiated on 3/12/26. Resident 98 was admitted to the facility on [DATE]. Review of Resident 98's MDS assessment dated [DATE], showed Resident 98's cognitive skills for daily decision making was severely impaired. Review of Resident 98's Physician Order Summary dated 3/2/26, showed the following physician's orders dated:- to apply left soft hand mitten due high risk for injury related to attempting to pull on medical devices;- to monitor episodes of pulling on medical devices every shift and record number of episodes every shift;- to release left soft hand mitten every two hours for at least 10-15 minutes for ROM, circulation and skin integrity every two hours; and- to check left soft hand mitten for proper fit and placement every shift. a. Review of Resident 98's Restraint Assessment and Reduction Management Program dated 10/27/25, showed for the use of the left hand mitten due to high risk for injury related to attempting to pull on medical devices. However, the assessment did not show the least restrictive interventions were attempted prior to using the left hand mitten devices. b. Review of Resident 98's MAR for March 2026, showed the day and night shift checking of the left soft hand mitten, monitor for signs and symptoms of circulatory impairment related to the left hand mitten use every two hours, and release of the left soft hand mitten every two hours for at least 10 -15 minutes for ROM, circulation and skin integrity every two hours. Further review of the MAR showed the licensed nurses initials when the left hand mitten was released every two hours; however, there was no indication when the left hand mitten was released and what intervention the staff provided to the resident. There were no documented evidence when the left hand mitten was reapplied after the release for at least 10 to 15 minutes. On 3/12/2026 at 1017 hours, an interview was conducted with CNA 5. CNA 5 verified Resident 98 was wearing a hand mitten on the left hand. CNA 5 stated Resident 98 was wearing the mitten because the resident was pulling out his catheter. On 3/12/2026 at 1348 hours, an interview and concurrent medical record review for Resident 98 was conducted with LVN 12. LVN 12 verified the physician's order for the left hand mittens due to behavior of grabbing tubing. When asked about the documentation on what other alternatives they attempted when the left hand mittens was released, LVN 12 stated they just watch the resident making sure he will not grab his tubing. LVN 12 was asked about the documentation on the MAR for the application and releasing of the hand mittens. LVN 12 verified the left hand mittens was released every two hours. LVN 12 was asked about the times when the hand mittens were applied, LVN 12 verified there was no documentation. LVN 12 verified the documentations were not accurate because there was no specific time on when the left hand mittens was reapplied. On 3/12/2026 1403 hours, an interview and concurrent medical record review for Resident 98 was conducted with RN 4. RN 4 verified the physician's order for the left hand mitten restraint of Resident 98 for high risk of injury due to pulling out of medical devices. RN 4 was asked about the restraint assessment and attempts for the least restrictive interventions prior to the application of the left hand mitten, RN 4 verified there were no least restrictive interventions attempted prior to the application of the left hand mitten. On 3/18/2026 at 0839 hours, an interview and concurrent medical record review for Resident 98 was conducted with the DON. The DON was informed and verified the above findings. Cross Reference to F657, example # 1.

Based on observation, interview, and medical record review, the facility failed to ensure the MDS was accurate for one of 25 final sampled residents (Resident 11). * The facility failed to accurately code the functional limitation of the range of motion for Resident 11. This failure posed the risk for the resident to not receive an individualized plan of care based on their specific needs.Findings: On 3/11/26 at 1241 hours, an observation and concurrent interview was conducted with Resident 11. Resident 11 was observed sitting in a wheelchair and using an iPad with his left arm. Resident 11 was observed not moving his right arm. Resident 11 stated he had a stroke that affected the right side of his body, resulting in his inability to move his right arm and right leg. When asked if he had been receiving exercises in the facility to maintain range of motion for the affected areas, he stated he had been this way for a long time and did not want to receive any exercises. Resident 11 added that he did not want to discuss the matter further. Medical record review for Resident 11 was initiated on 3/11/26. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's H&P examination dated 7/18/25, showed Resident 11 had the capacity to understand and make decisions. Review of Resident 11's OT Evaluation and Plan of Treatment dated 7/22/25 to 8/16/25, showed Resident 11 had impaired range of motion on his right upper extremity. Review of Resident 11' PT Evaluation and Plan of Treatment dated 7/20/25 to 8/15/25, showed Resident 11 had impaired right lower extremity, and no impairment in the left lower extremity. Review of Resident 11's admission MDS assessment dated [DATE], showed Resident 11 had impairment in the range of motion on one side of the upper and lower extremity. Review of Resident 11's MDS assessment dated [DATE], showed Resident 11 had no impairment on bilateral upper extremity and had impairment on both sides of lower extremity. On 3/13/26 at 1323 hours, an interview and concurrent medical record review for Resident 11 was conducted with the Director of Rehabilitation. The Director of Rehabilitation stated Resident 11 had a range of motion impairment on his right upper extremity and right lower extremity upon admission to the facility. The Director of Rehabilitation stated Resident 11 had shown improvement in his activities of daily living functioning; however, she was unable to find documentation indicating whether there had been any improvement or decline in the right upper extremity and right lower extremity range of motion. On 3/13/26 at 1340 hours, an observation in Resident 11's room and a concurrent interview was conducted with the Director of Rehabilitation. The Director of Rehabilitation was observed assessing Resident 11's right upper extremity range of motion. The Director of Rehabilitation verified Resident 11 had impaired ROM on the right upper extremity. On 3/13/26 at 0940 hours, an interview and medical record review for Resident 11 was conducted with the MDS Coordinator. The MDS Coordinator stated Resident 11 had ROM impairment on the right upper and lower extremity. The MDS Coordinator verified the MDS assessment on 1/30/26 for Resident 11 was inaccurate. The MDS Coordinator stated MDS assessment should have been coded as impairment on one side of upper and lower extremity. On 3/17/26 at 1406 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview and medical record review, the facility failed to ensure coordination of PASARR and assessments for one of two final sampled residents (Resident 16). * The facility failed to ensure a follow-up was made regarding Resident 16's PASARR level II recommendation for a psychiatric consult and psychotherapy/counseling services for Resident 16 was completed. This failure posed the risk for Resident 16 to not receive the appropriate care.Findings: On 3/11/26 at 1011 hours, Resident 16 was observed in bed, sleeping. Medical record review for Resident 16 was initiated on 03/11/2026. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's H&P examination dated 9/14/24, showed Resident 16's diagnoses included a history of bipolar affective disorder. Review of Resident 16's PASRR Notice of Individual Determination Letter dated 4/12/25, showed the recommended specialized services included psychology consultation and psychotherapy/counseling services. On 3/13/26 at 928 hours, an interview was conducted with CNA 3. When asked about Resident 16, CNA 3 stated Resident 3 had family visits every so often and would get out of bed from time to time to attend the social gatherings. CNA 3 stated Resident 16 would sometimes sleep and sometimes would stay in bed. On 3/13/26 at 1017 hours, a concurrent interview and medical record review was conducted with MDS Coordinator 1. When asked about Resident 16 receiving the PASRR recommended psychology consultation and psychotherapy/counseling service, the MDS Coordinator stated the psychology and psychotherapy recommended services were not completed. Per MDS Coordinator 1 Resident 16 was diagnosed at the acute care hospital prior to being admitted to the facility with bipolar disorder, did not take medications and did not have any behaviors related to bipolar disorder. When asked if MDS Coordinator 1 did a follow up with PASRR staff, MDS Coordinator 1 stated she did not do a follow up to inform the PASRR unit about Resident 16 being diagnosed at the acute care hospital with bipolar disorder and the PASRR unit recommendations.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the level 1 PASRR contained accurate information for one of two final sampled residents (Resident 15) reviewed for PASRR. * Resident 15 had a diagnosis of psychosis; however, the level 1 PASRR showed Resident 15 had no diagnosis of serious mental illness. Additionally, the facility failed to complete a Resident Review when Resident 15's level 2 PASRR evaluation was inaccurate. These failures posed the potential risk for Resident 15 to not receive the necessary care and services as the assessments were inaccurate.Findings: Review of the facility's P&P titled PASRR (Preadmission Screening Resident Review) reviewed 3/2019 showed all admissions to the facility will receive a Preadmission Screening prior to the admission of the resident. If the resident had already been admitted to the facility and the PASRR is being updated because the resident had exceeded the 30-day exempted hospital discharge or there is a significant change according to the MDS, this is considered a resident review (RR) status change. Medical record review for Resident 15 was initiated on 3/11/26. Resident 15 was admitted to the facility on [DATE], and readmitted on [DATE]. a. Review of Resident 15's level 1 PASRR dated 6/9/25, showed Resident 15 had no diagnosis of mental illness and no prescribed psychotropic medications. The form further showed the level 1 screening was negative and a level 2 evaluation was not required for reasons which included Resident 15 did not have a serious mental illness. Review of Resident 15's Order Summary Report showed a physician's order dated 10/8/25, to administer trazadone (antidepressant) 50 mg tablet by mouth at bedtime for as manifested by verbalization of depression leading to inability to sleep. Review of Resident 15's admission MDS assessment dated [DATE], showed Resident 15 had an active diagnosis of psychotic disorder. Review of Resident 15's medical record failed to show a level 1 PASRR Resident Review was conducted (during her initial stay at the facility) for the inaccuracy for the selection of no serious mental illness diagnosis, or when Resident 15 had the new diagnosis of depression and was prescribed the trazodone medication. On 3/12/26 at 1354 hours, an interview and concurrent medical record review for Resident 15 was conducted with the MDS Coordinator. The MDS Coordinator verified the above findings and stated the level 1 screening was inaccurate and a resident review should have been conducted, as well as when Resident 15 had a new diagnosis of depression and was prescribed the antidepressant medication. b. Review of Resident 15's MDS assessment dated [DATE], showed Resident 15 had no functional limitation in ROM in the bilateral upper and lower extremities. Resident 15 was independent for eating and required supervision or touching assistance for rolling left and right, sit to lying, and lying to sitting on the edge of the bed. Review of Resident 15's MDS assessment dated [DATE], showed Resident 15 had functional limitations in ROM in bilateral lower extremities and required partial to moderate assistance (when the helper does less than half the effort) for eating and oral hygiene, and was dependent on staff assistance for toileting, shower/bathe, dressing, rolling left and right and sitting to lying in bed. Review of Resident 15's level 2 PASRR letter titled Notice of Attempted Evaluation dated 12/20/25, showed after reviewing the positive level 1 screening and speaking with staff, a level 2 mental health evaluation was not scheduled for the following reason: the individual had no serious mental illness (SMI) - no functional limitation in the last six months. The case is now closed. To reopen, the facility must resubmit a new level 1 screening. SNFs must submit another screening as a Resident Review (RR). On 3/12/26 at 1550 hours, an interview and concurrent medical record review for Resident 15 was conducted with the MDS Nurse. The MDS Nurse reviewed Resident 15's medical records and verified the above findings. The MDS Nurse stated the level 2 evaluation was inaccurate, and a Resident Review should have been conducted. On 3/17/26 at 1530 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and the facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for two of 25 final sampled residents (Residents 6 and 21). * The facility failed to develop a care plan for Resident 6's use of the blood glucose monitoring device (Dexcom G7). * The facility failed to develop a care plan problem to address Resident 21's IV site. These failures posed the risk of not providing appropriate, consistent, and individualized care to these residents.Findings: Review of facility's P&P titled Comprehensive Care Planning dated 3/2019 showed a comprehensive resident-centered care plan be developed for each resident that includes measurable objectives and timeframes to meet each resident's medical nursing and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will provide specific information to include resident strengths, goals, life history and preferences, discharge planning and will be completed within seven days of the assessment completion. 1. Medical record review for Resident 6 was initiated on 3/12/26. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's Physician Order Summary showed a physician's order dated 2/9/26, to use Dexcom G7 Receiver Device (Continuous Glucose System Receiver). Inject 1 application subcutaneously every day shift every 10 days for DM. Review of Resident 6's comprehensive care plans failed to show documented evidence an individualized care plan problem was developed to address Resident 6's use of blood glucose monitoring device (Dexcom G7). On 3/12/26 at 1428 hours, an interview and concurrent medical record review for Resident 6 was conducted with RN 4. RN 4 verified there was no care plan formulated for the use of the blood glucose monitoring device for Resident 6. On 3/18/2026 at 0839 hours, an interview and concurrent medical record review for Resident 6 was conducted with the DON. The DON was informed and verified the above findings. Cross reference F0684, example number 1. 2. On 3/11/26 at 1039 hours, an observation was conducted of Resident 21 in the resident's room. Resident 21 was in bed with an empty container of vancomycin (antibiotic) hanging from Resident 21's IV pump. Resident 21 had a blanket covering the upper arms. On 3/11/26 1645 hours, an observation of Resident 21 and concurrent interview was conducted with RN 5. RN 5 uncovered Resident 21's blanket to show the right arm. Resident 21 was observed to have a peripheral IV to the right arm. RN 5 verified the resident had an IV to the right arm. Medical record review for Resident 21 was initiated on 3/12/26. Resident 21 was readmitted to the facility on [DATE]. Review of Resident 21's Physician Order Summary showed an order dated 3/7/26, for vancomycin 500 mg via the IV route every 12 hours for nine days. Review of Resident 21's H&P examination dated 3/9/26, showed Resident 21 muscle weakness and hemiplegia. Resident 21 was nonverbal and did not have the capacity to make decisions. Review of Resident 21's comprehensive care plans failed to show documented evidence an individualized care plan problem was developed to address Resident 21's IV site. On 3/13/26 at 0909 hours, an interview and concurrent medical record review for Resident 21 was conducted with RN 3. RN 3 verified a care plan for Resident 21's IV site was not developed.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care was revised to reflect the resident's current care needs and interventions for five of 25 final sampled residents (Residents 3, 4, 7, 73, and 98) reviewed for care plans. * The facility failed to ensure the care plan was revised to include the manufacturer's recommendations for cleaning and disinfecting the ventilator machines for Residents 3, 4, and 7. * The facility failed to ensure Resident 73's care plan interventions for weight loss were revised to reflect Resident 73's NPO status; and failed to ensure the care plan for hydration needs related to NPO status was revised to include the current IV hydration therapy. * The facility failed to ensure Resident 98's care plan for the use of the hand mittens was revised to include the use of least restrictive interventions when the left hand mittens was released every two hours for 15 minutes. These failures posed the risk of not providing the residents with individualized and person-centered care.Findings: Review of the facility's P&P titled Comprehensive Care Planning reviewed 3/2019 showed the care plan must be reviewed and revised periodically, a least quarterly and on an ongoing basis to reflect changes in the resident and the services provided or arranged must be consistent with each resident's written plan. 1. Medical record review for Resident 98 was initiated on 3/12/26. Resident 98 was admitted to the facility on [DATE]. Review of Resident 98's Physician Order Summary showed the following physician's orders: - dated 10/27/25, to apply left soft hand mitten due high risk for injury related to attempting to pull on medical devices; - dated 10/27/25, to monitor episodes of pulling on medical devices every shift and record number of episodes every shift; - dated 10/27/25, to release left soft hand mitten every two hours for at least 10-15 minutes for ROM, circulation and skin integrity every two hours; and - dated 10/27/25, to check left soft hand mitten for proper fit and placement every shift. Review of Resident 98's MDS assessment dated [DATE], showed Resident 98's cognitive skills for daily decision making was severely impaired. Review of Resident 98's plan of care showed a care plan problem dated 10/27/25, addressing Resident 98's use of the left hand mittens to prevent attempting to pull out medical devices. The care plan showed the interventions to check and release mittens every two hours for 15 minutes for skin integrity and circulation. However, the care plan interventions failed to include the use of least restrictive interventions when the left hand mittens was released every two hours for 15 minutes. On 3/12/26 at 1403 hours, an interview and concurrent medical record review for Resident 98 was conducted with RN 4. RN 4 verified the above findings and stated the care plan should have been revised to reflect Resident 98's most current plan of care. 2.a. Medical record review for Resident 7 was initiated on 3/11/26. Resident 7 was admitted to the facility on [DATE]. On 3/11/26 at 1009 hours, Resident 7 was observed in bed asleep. Resident 7 had a tracheostomy connected to a ventilator machine and with oxygen supply from concentrator machine. Review of Resident 7's plan of care showed a care plan problem dated 12/13/25, addressing Resident 7's impaired gas exchange related to ineffective airway. The care plan showed the interventions ventilator management. However, the care plan interventions failed to include the cleaning and disinfecting of ventilator machine per manufacturer's manual were included. b. Medical record review for Resident 4 was initiated on 3/11/26. Resident 4 was admitted to the facility on [DATE]. On 3/11/2026 at 1119 hours, Resident 4 was observed in bed asleep. Resident 4 had a tracheostomy connected to a ventilator machine and with oxygen supply from concentrator machine. Review of Resident 4's plan of care showed a care plan problem dated 1/24/26, addressing Resident 4's impaired gas exchange related to ineffective airway. The care plan showed the interventions ventilator management. However, the care plan interventions failed to include the cleaning and disinfecting of ventilator machine per manufacturer's manual were included. c. Medical record review for Resident 3 was initiated on 3/12/26. Resident 3 was admitted to the facility on [DATE]. On 3/11/2026 at 1132 hours, Resident 3 was observed in bed asleep. Resident 3 had a tracheostomy connected to a ventilator machine and with oxygen supply from concentrator machine. Review of Resident 3's plan of care showed a care plan problem dated 10/20/25, addressing Resident 3's impaired gas exchange related to ineffective airway. The care plan showed the interventions for ventilator management. However, the care plan interventions failed to include the cleaning and disinfecting of the ventilator machine per manufacturer's manual were included. Review of Residents 3, 4, and 7's Order Summary Reports failed to show documented evidence a physician's order was obtained to clean and disinfect the ventilator machine per manufacturer's recommendation were obtained. In addition, further review of Residents 3, 4, and 7's medical records failed to show documented evidence for the cleaning and disinfecting the ventilator machine was recorded. On 3/17/2026 at 0842 hours, an interview and concurrent medical record review for Residents 3, 4, and 7 was conducted with RN 6. RN 6 verified the care plan was formulated for the use of the ventilator machine. RN 6 verified the interventions did not include the cleaning and disinfecting the ventilator machine per manufacturer's manual. On 3/18/2026 at 0839 hours, an interview and concurrent medical record review for Residents 3, 4, and 7 was conducted with the DON. The DON was informed and verified the above findings. Cross Reference F0695, examples # 1a, b and c. 3. Review of the facility's P&P titled Weight Change Protocol dated 2023 showed a care plan is to be developed stating the problems, the goals, and the approached, interventions to accomplish the goals. The care plan must be revised as the goals and interventions change. The goals and interventions in the care plan should match the latest assessment. Medical record review for Resident 73 was initiated on 3/11/26. Resident 73 was admitted to the facility on [DATE]. Review of Resident 73's H&P examination dated 2/2/26, showed Resident 73 had no capacity to understand and make decisions a. Review of Resident 73's Order Summary Report showed the following physician's orders: - dated 2/6/26, to administer Boost VHC (high-calorie nutrition drink) 237 ml four times a day with med pass; and - dated 2/10/26, for Resident 73 to be on an NPO diet, NPO texture, NPO consistency, except for medications and boost if tolerated. Review of Resident 73's plan of care showed care plan problem dated 3/1/26, addressing Resident 73's weight loss of seven pounds in one month. The interventions included to monitor Resident 73's meal intake. b. Review of Resident 73's Order Summary Report showed a physician's order dated 3/10/26, to administer 5% dextrose- 0.9% NaCl IV solution with 20 mEQ potassium chloride at 50 ml/hr intravenously every shift for hydration until 4/2/26. Review of Resident 73's plan of care showed care plan problem dated 2/16/26, addressing Resident 73's hydration needs related to Resident 73's NPO status. The interventions revised on 3/3/26, showed 5% dextrose with 20 mEQ potassium chloride at 50 ml/hr. On 3/17/26 at 1047 hours, an interview and concurrent medical record review or Resident 73 was conducted with RN 2. RN 2 stated the care plans should be developed and individualized to the residents and updated or revised whenever there was a change in the resident's care. RN 2 reviewed Resident 73's medical record and verified the above findings. RN 2 stated Resident 73 was NPO except for medications and boost supplements and was receiving continuous IV hydration therapy of 5% dextrose-0.9% sodium chloride with 20 mEQ of potassium chloride. RN 2 further stated Resident 73 was not eating or receiving meals, therefore the intervention should have been revised. On 3/17/26 at 1530 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility's P&P review, the facility failed to provide the necessary enteral care and services to one of four sampled residents (Resident 1) who had a GJ tube.* The facility failed to ensure Resident 1's enteral feeding was given through the J tube port and medications were given through the G tube port as ordered by the physician. In addition, the facility staff failed to notify the physician when the staff were unable to accurately identify the G and J ports of the GJ tube and provide the in-service training on the care and management of a resident with a GJ tube.* The facility failed to ensure Resident 1 had a physician's order for Resident 1's G tube drainage bag maintenance and discontinuation.These failures resulted in Resident 1's required transfer to an acute care hospital for medical intervention and critical drop in Resident 1's blood sugar level that posed a serious risk for complications such as confusion, seizures, coma, or death. Findings: Review of the facility P&P titled Gastrostomy Tube Feeding via Continuous Pump dated 1/2017, showed it is the policy of the facility to provide nourishment via continuous pump to the residents who are unable to obtain adequate nourishment orally, as ordered by the resident's attending physician.Review of the facility's P&P titled Medication Administration dated 4/2017, under the section procedure showed to verify the tube placement by forcefully injecting 10-30 cc of air into tube while listening with stethoscope to the abdomen for a loud bubbling sound (if no sound heard, notify supervisor immediately). Once placement of the tube is verified, check for residual amounts of feeding by drawing back on the plunger of the bolus syringe. allow each medication to flow down the tube by gravity and to give gentle boots with the plunger if the medication will not flow by gravity and repeat if necessary.Review of the article published in National Library of Medicine titled Percutaneous Gastrostomy and Jejunostomy dated 5/29/23, showed PEG-J tube placement, an extension is placed via the existing PEG tube into the jejunum to allow jejunal feeding. This is particularly useful in patients at high risk of aspiration from gastric feedings such as those with gastroparesis.or those who cannot tolerate gastric feeding. https://www.ncbi.nlm.nih.gov/books/NBK559215/ According to Cleveland Clinic article titled Tube Feeding (Enteral Nutrition) dated 2/21/24, showed Gastrostomy-jejunostomy tube (GJ tube) goes into stomach and passes through Jejunum. These tubes have a G and a J port. The G port drains stomach fluids and allows providers to give medicines. The J port is used for feeding. https://my.clevelandclinic.org/health/treatments/21098-tube-feeding--enteral-nutrition Review of the article in National institute of Diabetes and Digestive and Kidney Disease titled Gastroparesis dated January 2018 showed Gastroparesis, also called delayed gastric emptying, is a disorder that slows or stops the movement of food from stomach to small intestine. Normally, after swallowing food, the muscles in the wall of stomach grind the food into smaller pieces and push them into your small intestine to continue digestion. When gastroparesis, stomach muscles work poorly or not at all, and stomach takes too long to empty its contents. Gastroparesis can delay digestion, which can lead to various symptoms and complications. Complications of gastroparesis may include dehydration due to repeated vomiting malnutrition due to poor absorption of nutrients, blood glucose, also called blood sugar, levels that are harder to control, which can worsen diabetes. https://www.niddk.nih.gov/health-information/digestive-diseases/gastroparesis/definition-facts Review of an article published in National Library of Medicine titled A Study of Variations of the Stomach in Adults and Growth of the Fetal Stomach dated 8/28/22, showed the stomach's capacity varies from 30 ml at birth, increases to 1000 ml at puberty, and 1500 ml in adults https://pmc.ncbi.nlm.nih.gov/articles/PMC9515405/ On 10/23/25 at 1148 hours, a telephone interview was conducted with Resident Representative 1. Resident Representative 1 stated Resident 1's GJ tube was clogged in the facility then Resident 1 was transferred to the acute care hospital where they found his blood sugar dropped to the critical level of 36 where he could have died. Resident Representative 1 further stated the doctor from the acute care hospital told her Resident 1's J tube was clogged with large amount of medications.Closed medical record review for Resident 1 was initiated on 10/23/25. Resident 1 was admitted to the facility on [DATE] and discharged on 10/15/25.Review of Resident 1's H&P examination dated 10/9/25, showed Resident 1 had no capacity to understand and make decisions. Review of the H&P further showed Resident 1 had diagnoses which included diabetes, gastroparesis and ventilator-dependent respiratory failure; and had a tracheostomy tube and GJ tube .Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 was dependent on facility staff for his activities of daily living. Further review of the MDS showed Resident 1 had a feeding tube and received more than 51% calorie through the parenteral or tube feeding.Review of Resident 1's Order Summary Report showed the following physician's orders:- dated 10/8/25, (a) give Nepro (a feeding formula) at 55 ml/hour for 16 hours through the J tube via enteral pump to provide 880 ml/1584 calorie in 24 hours. To start at 1300 hours, and to stop at 0500 hours, or until dose limit is completed, (b) insulin Glargine (an insulin) subcutaneous solution 100 unit/ml, to administer 25 units subcutaneously at bedtime for diabetes mellitus, and (c) insulin lispro (rapid-acting insulin used to manage blood sugar levels in people with diabetes mellitus) injection solution 100 unit/ml, to inject as per sliding scale subcutaneously every six hours for diabetes mellitus if blood sugar:less than 70, to notify medical doctor,70-149 mg/dl, to give 0 units;150-200 mg/dl, to give 3 units;201-250 mg/dl, to give 6 units;251-300 mg/dl, to give 9 units;301-350 mg/dl, to give 12 units;351-400 mg/dl, to give 15 units;401 mg/dl or more, to give 18 units and to notify the MD;- dated 10/9/25, J tube water flush 10 ml per hour via enteral pump to provide 160ml in 24 hours. To start at 1300 hours, and to stop at 0500 hours, or until dose limit is completed; and- dated 10/15/25, to transfer Resident 1 to the Acute Care Hospital for J tube replacement. Review of Resident 1's MAR for October 2025 showed Resident 1 received the insulin Glargine 25 units on 10/14/25 at 2100 hours, and insulin lispro 3 units on 10/15/25 at 0000 hours for the blood sugar of 152 mg/dl. In addition, the MAR showed Resident 1 had a blood sugar level of 84 on 10/15/25 at 0600 hours.Review of Resident 1's Nurses Progress Notes entry by RN 3 dated 10/15/25 showed the following:- at 0720 hours, night shift reported Resident 1's J tube was clogged but the G tube was functional. Upon assessment Resident 1's J tube was clogged and resistance noted when flush. The note showed Resident 1 was awake, alert and responsive through mouth words, had no complaints of pain and discomfort, abdomen was soft, non-tender, no nausea and vomiting. The notes further showed the staff notified the nurse practitioner;- at 0930 hours, the staff received orders from the nurse practitioner to transfer Resident 1 to an acute care hospital; - at 0945 hours, the MD ordered to transfer Resident 1 to the acute care hospital for J tube replacement; - at 1120 hours, Resident 1 was transferred to the acute care hospital; and- at 1530 hours, the contact was made with the acute care hospital via telephone and the facility staff confirmed Resident 1 had been admitted with diagnoses of jejunostomy malfunction and hypoglycemia (low blood sugar). Review of Resident 1's Recent Laboratory results from the acute care hospital dated 10/15/25 at 1239 hours, showed the blood glucose level of 36 mg/dl. Review of Resident 1's ED Notes dated 10/15/25 at 1249 hours, showed the staff attempted to flush Resident 1's J tube with 20 ml of water and unable to flush completely clogged. Review of Resident 1's Order from the acute care hospital dated 10/16/25 at 0840 hours, showed an order for IR Jejunal Feeding Tube Replacement. The order further showed the reason for exam was Resident1 had a clogged GJ J-tube, the G tube was functional but J tube was clogged. On 10/24/25 at 0944 hours, a telephone interview was conducted with LVN 1. LVN 1 stated Resident 1 had a GJ tube with two ports. LVN 1 stated one port was a J tube for the enteral feeding and the other port was a G tube to be used to administer the medications. LVN 1 stated on 10/14/25 at around 2100 to 2200 hours, when she went to administer Resident1's medication, Resident 1's enteral feeding was running through one port and she assumed the other port was the G tube for medication administration. LVN 1 stated when she attempted to pass the medication through the port, she felt a resistance so she reported to RN 2. LVN 1 stated RN 2 attempted to administer the medication through the same port and was able to administer the medication even though she felt some resistance. When asked if LVN 1 was able to identify the correct J and G tube ports of Resident 1's GJ tube, LVN 1 stated the G and J tube ports were not labeled, so she was not able to identify and verify if the feeding was running through the J tube port. LVN 1 stated she did not change the port where Resident 1's enteral feeding was running from. LVN 1 stated when she reported to RN 2, RN 2 also attempted to administer the medication through the same port she had attempted and RN 2 also was not able to verify the correct port. When asked what she could have done to identify and verify if the Resident was receiving the enteral feeding through the correct port, LVN 1 stated she should have called the doctor. LVN 1 further stated she did not call to verify with the doctor if the Resident was receiving the enteral feeding through the correct port. When asked if she received an in-service training before being assigned and care for Resident 1 who had a GJ tube, LVN 1 stated no.On 10/24/25 at 1123 hours, a telephone interview was conducted with RN 2. RN 2 stated Resident 1 was admitted with a GJ tube and had G tube drainage bag attached to one port and the enteral feeding was running on the other port. RN 2 stated on 10/14/25, she was notified by LVN 1 of Resident 1's tube being blocked and LVN 1 could not give the medication. RN 2 stated she went to check Resident 1 and observed Resident 1 was not connected to the G tube drainage bag and one port was connected to the enteral feeding. RN 2 stated when she attempted to administer the medication through the other port, she confirmed the tube was hard to flush but was able to administer the medication. When asked if she was able to correctly identify the two ports of Resident 1's GJ tube, RN 2 stated the two ports of the GJ tube were not labeled and she could not identify the ports. RN 2 stated Resident 1 should receive the enteral feeding through the J tube and she assumed the port connected to the enteral feeding was the J tube, so she attempted to administer the medication through the other port which was blocked. RN 2 stated she did not change the port where the enteral feeding was running from. RN 2 stated she could not verify if Resident 1 was receiving the enteral feeding from the J tube. When asked why Resident 1 required the J tube feeding, RN 2 stated because Resident1 had gastroparesis and Resident 1 could not pass or had delays in passing the feeding from the stomach to the small intestine which could result in nausea, vomiting, risk of aspiration and if he was diabetic, he might have a low blood sugar. RN 2 stated the process was to notify the doctor when she could not identify the correct ports of the GJ tube and make sure Resident 1 was receiving the enteral feeding from the J tube. When asked if she had notified the doctor, RN 2 stated she did not notify the doctor or reach out to the person who could identify the ports correctly to make sure Resident 1 was receiving the enteral feeding through the J port of the GJ tube as ordered by the physician. RN 2 stated she should have notified the doctor right away instead of waiting for next shift to give the report when she could not identify the correct port and could not confirm if the resident received the enteral feeding through the J tube. When asked if RN 2 received an in-service training before being assigned and care for a resident with a GJ-tube, RN 2 stated no.On 10/27/25 at 1100 hours, an interview was conducted with RN 3. RN 3 stated during the night shift on 10/15/25, the nurse reported Resident 1's tube was clogged. She stated she verified with the night nurse that the J tube port of Resident 1's GJ tube was clogged. She stated she was familiar with the GJ tube. RN 3 stated the straight port was the J tube with MIC (a brand name) written on it, and the right port was the G tube. RN 3 stated when she checked, she saw there was a Lopez valve with the enteral feeding connected to the G tube port. RN 3 stated she asked the charge nurse to stop the feeding because that was not the correct port for the enteral feeding. When asked what could happen if Resident 1 receives feeding from the wrong port, RN 3 stated Resident 1 had gastroparesis, and he could not tolerate the feeding in his stomach and could result to nausea, vomiting and hypoglycemia. On 10/28/25 at 0903 hours, a follow up interview and concurrent medical record review for Resident 1 was conducted with RN 3. RN 3 verified Resident 1 was diabetic and had received inulin glargine 25 units on 10/14/25 at 2100 hours and insulin lispro 3 units at 10/15/25 at 0000 hours. RN 3 verified Resident 1's blood sugar on 10/15/25 at 0600 hours was 84 mg/dl. RN 3 was not able to show documentation if Resident 1's blood sugar was checked before he was transferred to the acute care hospital on [DATE] at 1120 hours. RN 3 stated the feeding for Resident 1 was stopped after she found it was connected to the wrong port on 10/15/25 at around 0800 hours. When asked if she received the in-service training regarding taking care of a resident with a GJ tube before she was assigned to Resident 1 who had a GJ tube, RN 3 stated no. RN 3 further stated she thought that was the standard of her nursing practice.On 10/28/25 at 1406 hours, a telephone interview was conducted with the MD. The MD verified Resident 1 was transferred to the acute care hospital due to the J tube being clogged. The MD verified Resident 1 had a GJ tube. When asked which tube Resident 1 should receive his enteral feeding, the MD stated Resident 1 should have received the feeding through his J tube because Resident 1 had gastroparesis which could cause a delay in emptying of the gastric content. When asked what could happen if Resident 1 received the feeding from his G tube, the MD stated giving the enteral feeding through the G tube could cause nausea, vomiting and risk of aspiration for Resident 1. When asked if giving the enteral feeding through the G tube could cause low blood sugar for Resident 1, the MD stated, yes that could cause hypoglycemia. The MD was informed of the night shift licensed nurses not being able to confirm if Resident 1 received the feeding through the correct port, the next shift nurse found Resident 1's enteral feeding was connected to the G tube port of Resident 1's GJ tube, Resident 1 received insulin glargine 25 units on 10/15/25 at 2100 hours and lispro 3 units on 10/14/25 at 0000 hours, the enteral feeding was disconnected on 10/15/25 at 0800 hours and Resident 1 was transferred to the acute care hospital on [DATE] at 1120 hours with a blood sugar level result of 36 mg/dl at 1229 hours. When asked if the above incidents could cause the blood sugar to dropped critically low to 36 mg/dl, the MD stated, yes that could possibly cause low blood sugar.On 10/30/25 at 1115 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON was informed of the above findings and stated Resident 1 should not receive the feeding from the G tube because of his gastroparesis, and licensed nurses should have followed the physician's order for the enteral feeding. The DON further stated if the staff could not identify the correct ports of the GJ tube, they could always reach out to the doctor, clinical coordinator and herself. The DON stated the staff should not assume and should have confirmed Resident 1's enteral feeding was being provided via J tube as ordered by the physician. When asked what could happen if Resident 1 received the feeding form the G tube, the DON stated Resident 1 had gastroparesis, the feeding would stay in his stomach, and could cause discomfort, vomiting, hypoglycemia, and death. The DON was asked if she provided the in-service training to the staff before assigning the residents with a GJ tube, the DON stated she did not provide the in-service training. The DON acknowledged she should have provided the in-service training and made sure the staff were competent to take care of the residents with a GJ tube.On 10/30/25 at1332 hours, an interview was conducted with the Nurse Practitioner. The Nurse Practitioner stated Resident 1 was transferred to the acute care hospital due to his J tube being clogged. The Nurse Practitioner was informed of the above findings, the Nurse Practitioner stated Resident 1 should have received his enteral feeding through the J tube as ordered by the physician, because of his gastroparesis. When asked what could happen if Resident 1 was given enteral feeding from the G tube port, he stated if Resident 1 was not having nausea and vomiting he would think the feeding was being passed down to the small intestine. When asked if he was able to confirm Resident 1's enteral feeding was being passed down to the small intestine on 10/15/25, The Nurse Practitioner stated he could not confirm. When asked what could have caused Resident 1's blood sugar to drop as low as 36 mg/dl on 10/15/25, the Nurse Practitioner was not able to answer.2. Review of Resident 1's Nurses Notes showed the following:- dated 10/8/25 at 1935 hours, showed the routine admission and body check was done. Resident 1 was started on feeding via J tube and G tube with medication and attached to drainage bag for any residual, and- dated 10/9/25 at 1000 hours, Resident 1 was seen and evaluated by the nurse practitioner with new order d/c G tube draining. On 10/24/25 at 1123 hours, a telephone interview was conducted with RN 2. RN 2 stated Resident 1 was admitted to the facility with a drainage bag connected to his G tube port, and he was receiving feeding from his J tube port.Further review of Resident 1's medical record did not show the physician's orders for the G tube drainage bag and how the G tube drainage bag would be managed. In addition, there was no physician's order to discontinue Resident 1's G tube drainage bag. On 10/29/25 at 1012 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 verified this findings. RN 3 stated Resident 1 was admitted with the G tube drainage bag attached; however, she was not able to find if the physician's order was obtained for the maintenance of the G tube drainage bag. RN 3 stated the G tube drainage bag required a physician's order and staff should have obtained the physician's order for the G tube drainage bag maintenance and discontinuation.On 10/30/25 at 1551 hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and acknowledged the above findings.

Based on observation, interview, clinical record review, and review of the facility's infection control program, the facility failed to maintain an effective infection control program to prevent the spread of infections to 10 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) who had symptoms of vomiting and/or diarrhea. Seven of the 10 residents had initial symptoms of vomiting and/or diarrhea on ,[DATE] and [DATE]. In addition, between ,[DATE] and [DATE], seven staff called off sick. However, there was no documented evidence the facility had tracked and/or trended residents' (or staff) symptoms and implemented an affective prevention program, including contacting the local County Public Health Department. This resulted in the spread of the infection to other residents and staff. Findings: On [DATE], an onsite visit was conducted to investigate an anonymous complaint 10 residents had nausea, vomiting and diarrhea. On [DATE] at 0930 hours, an interview was conducted with the DON. She was asked if there are any residents experiencing nausea, vomiting and/or diarrhea. She stated there were only two residents currently experiencing diarrhea; they were diagnosed with [REDACTED]. On [DATE] at 1310 hours, during a tour of the facility, three resident rooms were identified to house residents in isolation. During a concurrent interview with LVN 1, she stated there was one resident with norovirus (a self-limiting infection of the GI tract which causes vomiting, diarrhea, abdominal cramping and is highly contagious) and three residents with [DIAGNOSES REDACTED]. An interview was conducted with RN 1 on [DATE] at 1430 hours. She stated she investigated the GI outbreak according to the Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in California Long-Term Care Facilities dated [DATE]. These recommendations show "when appropriate infection prevention and control measures are not implemented immediately, outbreaks can continue for weeks with many residents becoming ill, resulting in some hospitalization s and occasionally death from dehydration (lack of sufficient fluid intake) and other complications of vomiting and diarrhea." The recommendations also showed viral gastroenteritis should be suspected when two or more residents and or staff develop a new onset of vomiting and diarrhea within one to two days. An outbreak is controlled by immediately reporting any person with a sudden onset of GI symptoms to the IP, who will record new cases daily. In addition, the Medical Director, the County Public Health and the Department should also be informed. The following management interventions should be initiated: 1. limit transmission by controlling resident and staff movement. 2. institute control measures without waiting for diagnostic confirmation. - cancel group activities; - wear PPE (personal protective equipment) and use appropriate hand washing techniques; - create a staff illness policy and create log for tracking symptoms; - manage environment, and - manage visitors. Review of the facility's discharge log and an employee sick call log was conducted. The discharge log showed two residents (Residents 1 and 2) and two nonsampled residents (Residents A and B) who were transferred to the ED with GI symptoms, including nausea, vomiting, diarrhea, dehydration, and altered level of consciousness. The clinical records for these residents were requested for review as well as the clinical records of two residents (Residents 3 and 4) who were identified as being in isolation. Review of a list of employee sick calls on [DATE] and [DATE], showed seven staff had requested a day off for illness including fever, not feeling well and body aches. Staff 1 and 2 had confirmed GI issues, which led them to seek medical treatment. Three more staff were identified to call off with the same symptoms after taking care of the same residents. On [DATE] at 1430 hours, an interview with the DON and RN 1 was conducted. RN 1 stated she had not reported any outbreak of infection to the Orange County Public Health Office, or to the California Department of Public Health, Licensing and Certification (Department). RN 1 further stated an outbreak would be reported when residents had positive laboratory results identifying three of the same illness. When asked, RN 1 could not provide any P&P for the treatment of [REDACTED]. RN 1 stated she investigated the GI outbreak according to the Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in California Long-Term Care Facilities dated [DATE]. Clinical record reviews for 10 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) was conducted. Review of each residents' CNA notes showed the consistency (i.e. diarrhea vs hard) of each resident's bowel movements (BM) were not documented. The flow sheets have space for staff to document bowel habits, including continent, incontinent, colostomy, and the number of BMs during each shift. The DON confirmed there should be an area on the BM record to document the consistency and size of bowel movements. Further review of each resident's clinical record included a review of the paramedics' records, and acute care hospital records, which showed the following: a. Resident 4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the nurses' notes for Resident 4 showed Resident 4 began refusing [MEDICATION NAME] (stool softener) on [DATE], because it was giving her loose stools. Resident 4 had one episode of loose stool. Her physician changed her stool softener back to a fiber supplement. On [DATE], the resident had more episodes of loose stools. The physician discontinued the fiber supplement, added [MEDICATION NAME] (microbes that help repopulate the GI tract) and [MEDICATION NAME] (antidiarrheal medication). In addition, the physician ordered a test for [DIAGNOSES REDACTED] (came back negative on [DATE]). Resident 4 continued to have loose stools from [DATE] through [DATE]. On [DATE], the physician ordered Questran (medication to stop diarrhea by binding bile in the GI tract) and [MEDICATION NAME] (antibiotic) for 10 days. In addition, the physician ordered additional testing for [DIAGNOSES REDACTED], norovirus and C&S (lab test to test for bacterial growth and sensitivity to antibiotics), a CBC (complete blood count) and electrolytes. The physician also ordered IV fluids to treat dehydration and placed the resident on a clear liquid diet for 24 hours. Review of the nurses notes dated [DATE], showed the second [DIAGNOSES REDACTED] test came back negative. However, Resident 4 continued to experience diarrhea. On [DATE], Resident 4's test for norovirus came back positive. On [DATE], the physician ordered to place the resident in contact isolation and encourage oral fluids. The resident continued to have loose BMs. Review of the nurse's note dated [DATE] at 1445 hours, showed Resident 4 was in bed. She was alert, had a loose stool and continued to receive [MEDICATION NAME]. According to the National Institute of Health (NIH) common side effects for [MEDICATION NAME] include GI upset and diarrhea, and antibiotics are not recommended for treating viral infections (norovirus is a virus). On [DATE] at 1355 hours, an interview with Resident 4 was conducted. Resident 4 stated she has been experiencing diarrhea ,[DATE] times per shift for several days. She stated, "I hate it. If I had pills to OD (overdose) and kick the bucket, I'd have taken them." She stated she has not been able to participate in activities and, basically, stays in bed. Resident 4 stated staff do wear PPE each time they enter her room, and she was educated regarding the norovirus. She stated her visitors only wear gloves when they visit her. b. Resident 2 was admitted to the facility on [DATE]. Review of the nurses' notes showed Resident 2 had four loose BMs on [DATE]. Documentation showed Physician 2 was notified and ordered to hold [MEDICATION NAME] (laxative) due to loose BMs. Resident 2 had more episodes of loose stools at 1600 hours. Physician 2 ordered laboratory tests for [DIAGNOSES REDACTED] and C&S, and norovirus. Further review of the nurses' notes showed Resident 2 complained of numbness around his mouth and general weakness on [DATE]. The physician ordered labs and a chest x-ray. Laboratory results showed Resident 2 was dehydrated due to elevated BUN (blood urea nitrogen) and Creatinine (labs reflect kidney impairment) and had an infection, as evidence by elevated white blood cells). Physician 2 ordered IV fluids and an antibiotic for pneumonia. At 1950 hours, Resident 2 was noted with an altered level of consciousness. Paramedics were called. On [DATE], Resident 2 was transferred to acute hospital ED via 911. The resident was admitted to the intensive care unit (ICU) with [DIAGNOSES REDACTED]. Resident 2 received multiple IV medications and was intubated (a tube placed down the windpipe to support breathing). Review of the Cardiology Consultation dated [DATE], showed the family noted Resident 2 had a change of condition (altered mental status and weakness). Documentation showed the family also stated Resident 2's condition has deteriorated rapidly in the last few days (while at the skilled nursing facility). Test results obtained on [DATE], showed Resident 2 tested positive for [DIAGNOSES REDACTED]. On [DATE] at 1853 hours, Resident 2 died in the ICU. Documentation showed the resident suffered cardiopulmonary arrest. On [DATE] at 1530 hours, an interview with the ADON was conducted. The ADON stated she called the acute hospital where their residents were transferred. The hospital staff stated they had not run tests for [DIAGNOSES REDACTED] or the norovirus. When asked if the facility notified the hospital of the outbreak and pending tests upon Resident 2's transfer, the ADON stated, no, she was too embarrassed and would fax a requisition slip to the hospital. c. Resident 7 was admitted to the facility on [DATE]. Review of the nurses' notes dated [DATE], showed Resident 7 had two episodes of vomiting. In addition, from [DATE] through [DATE], documentation showed Resident 7 had multiple episodes of loose stools. On [DATE], the physician ordered to test the resident's stool for [DIAGNOSES REDACTED] three times. A stool sample collected on [DATE], was negative, and tests two and three were canceled. On [DATE], the physician ordered IV fluids for dehydration, due to elevated BUN and Creatinine levels. On [DATE], Resident 7 was noted to have shortness of breath; 911 was called and Resident 7 was transferred to the ED. The resident was admitted to the hospital for acute sepsis, tachycardia (rapid heartbeat) and hypotension (low blood pressure). d. Resident 1 was admitted to the facility on [DATE]. Resident 1's orders for life sustaining treatment included full treatment and CPR. Review of nurse's note dated [DATE] at 0330 hours, showed Resident 1 had three episodes of vomiting and one episode of diarrhea. Two calls were made to Physician 1, but no return call was documented. At 0950 hours, the nurse entered the resident's room and noticed Resident 1 was alert but having difficulty breathing. At 1000 hours, the nurse could not find a pulse, initiated CPR and called the paramedics. Paramedics transported Resident 1 to an acute care hospital's ED. Review of the ED documentation showed Resident 1 was received in full arrest. Paramedics and ED staff were able to revive her. Resident 1 was sent to the ICU with IV heart medications and was placed on a ventilator (a machine that breathes for the resident). Resident 1 was admitted with [DIAGNOSES REDACTED]. Resident 1 died on [DATE] at 1114 hours, with [DIAGNOSES REDACTED]. e. Resident 3 was admitted to the facility on [DATE]. Review of the nurses' notes for Resident 3 showed Resident 3 had two episodes of loose stools on [DATE]. Staff described the BMs as large watery amounts with a foul odor. In addition, Resident 3 had vomited once in the early morning hours. The physician was notified and ordered [MEDICATION NAME] (antidiarrheal medication), and a test for [DIAGNOSES REDACTED], C&S and norovirus. On [DATE], Resident 3 experienced another episode of watery BM. On [DATE], a test result from a stool sample (submitted on [DATE]) showed positive for norovirus. On [DATE], a stool sample was negative for norovirus and Resident 3 was asymptomatic. The CNA notes showed Resident 3 was continent of bowel and used the restroom independently. f. Resident 5 was admitted to the facility on [DATE]. Review of the nurses' notes for Resident 5 dated [DATE], showed the resident had loose stools three times in one hour. The physician ordered an antibiotic, an antidiarrheal medication and a test for [DIAGNOSES REDACTED]. The physician later added a C&S and a test for norovirus, and IV antibiotics due to an elevated white blood cell count (sign of infection). There was no further documentation the resident had diarrhea. On [DATE], the laboratory results showed Resident 5 was positive for norovirus. However, the physician identified the resident did not need isolation because he had been asymptomatic. g. Resident 6 was admitted to the facility on [DATE]. Review of the nurses' notes dated [DATE], through [DATE], showed the resident had multiple episodes of loose stool/diarrhea. On [DATE], laboratory results for [DIAGNOSES REDACTED] were negative. On [DATE] at 1210 hours, a licensed nurse documented they had relayed the negative [DIAGNOSES REDACTED] results to the resident's physician. The physician discontinued further testing for [DIAGNOSES REDACTED]. h. Resident 8 was admitted to the facility on [DATE]. Review of the nurses' notes dated [DATE], showed an episode of loose watery brown stool with foul odor accompanied with abdominal pain. Review of physician's orders [REDACTED]. diff. Resident 8 was placed on isolation and started on an antibiotic when her [DIAGNOSES REDACTED] test was positive. On [DATE], the physician declined a C&S and a norovirus test. Resident 8 continued to have loose stools on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. On [DATE], the physician discontinued the [MEDICATION NAME] and Senna (laxative). i. Resident 9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the nurses' notes dated [DATE], showed Resident 9 had three episodes of vomiting and three episodes of loose, watery, foul smelling stools. physician's orders [REDACTED]. diff three times. On [DATE], Resident 9 had four episodes of loose stools. On [DATE], the lab test for [DIAGNOSES REDACTED] was positive. The resident was placed in isolation and antibiotics were started on [DATE]. On [DATE], the physician discontinued two labs for [DIAGNOSES REDACTED]. Resident 9 continued with episodes of loose stools on ,[DATE], ,[DATE] and [DATE]. j. Resident 10 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of hospital notes showed Resident 10 was positive for [DIAGNOSES REDACTED] prior to her initial admission to this facility. The resident was readmitted to the facility on [DATE], and was to have contact isolation. The resident was discharged to the ED after episodes of vomiting during her dialysis appointment. On [DATE] at 1540 hours, an interview was conducted with the County Department of Public Health officer. She stated the facility initially notified her office on [DATE], and spoke to the person on call because it was after hours. The County Department of Public Health officer's first contact with the facility was [DATE] ([DATE] was a holiday). When asked, the health official stated the County Department of Public Health office should have been notified by the facility on [DATE]. On [DATE] at 1540 hours, an interview was conducted with RN 1, the IP. RN 1 stated the Infection Control Committee includes the Medical Director, several physicians, the IP and various department heads as needed. RN 1 stated the facility requires a doctor's note if an employee misses two to three days of work. RN 1 stated employees are encouraged to not return to work until they have been free of symptoms for two to three days. RN 1 stated she does not ask staff for much information about their particular symptoms/illness. There was no policy and procedure available regarding employee illnesses. RN 1 stated staff is instructed to text or call her if residents have a new infection. RN 1 stated she was not notified of the residents' GI symptoms, but was called into work on [DATE] (Sunday). She stated she noticed a trend of infection symptoms on the Change in Residents log and initiated an investigation. RN 1 stated she called her Infection Control Representative, who instructed her to follow the Centers for Disease Control guidelines. Review of the meeting minutes held on [DATE], showed the meeting lasted 15 minutes. Documentation showed the team decided they would follow the recommendations of the County Department of Public Health, who was notified of the outbreak on [DATE], after the Department's visit. RN 1 stated she thought an outbreak was three or more people with a confirmed diagnosis; therefore, it was not reported to the appropriate authorities. The facility did not identify the outbreak in a timely manner and staff were not reporting acute GI symptoms to the appropriate staff including the IP. Review of the facility's P&P for the Infection Control Program dated ,[DATE] showed the Infection Control Committee will consist of at least the following: the Medical Director, the Administrator, the DON, the IP, Dietary and Housekeeping/maintenance. The P&P further showed the Infection Control Committee will establish P&Ps for the investigation, control and prevention of transmission of disease and infections within the facility. This includes implementing systemic, effective policies and procedures for detecting and reporting infections. The facility was unable to provide an Infection Control P&P to address gastrointestinal outbreaks. In addition, the P&P shows a meeting will contain the following: old business, new business (including: review of infections, review of employee infections, study of departments infection problems and recommendations, review of improvement assurance findings, review of pressure ulcers, review of staff practices and identification of residents at high risk and recommendations), and recommendations and actions to be taken on new problems, including the person responsible and goal dates. The P&P also shows surveillance of employees and volunteers will include illness and absence reporting. Review of P&P titled Significant Change of Condition (undated) showed a resident's change of condition shall be reported to the nursing supervisor, DON, executive director and documented on the 24 hour Change of Condition Report. Observations conducted on [DATE] at 1150 hours, found eight residents in the dining room eating lunch. RN 1 confirmed the facility had not suspended group activities. On [DATE] at 1610 hours, a follow-up interview was conducted with RN 1. She stated some of the doctors did not want to run extensive tests for one episode of diarrhea. She confirmed there was no clarification to the physicians that there was an outbreak going on or that other residents were testing positive for certain diseases. When asked if the facility requested assistance from the Medical Director, RN 1 stated, no.