Every finding on record at Camino Ridge Post-Acute

Based on interview and record review, the facility failed to ensure adequate preparation for a safe and appropriate discharge for one of three sampled residents (Resident 1) when:1. The facility did not follow the acute hospital's discharge plan to have Resident 1 stay in a SNF [skilled nursing facility, is a specialized inpatient facility that provides 24-hour medical, nursing, and rehabilitative care (medical or therapeutic treatment that helps you get back, keep, or improve the skills and abilities )] for long term care but instead discharged her to home with orders for HH [home health, provided by HHA - Home Health Agency, an organization that provides skilled nursing and therapeutic care (any treatment, action, or environment designed to heal an illness, ease pain, or improve mental and physical health) to patients in their homes] for PT (Physical therapy, is treatment that helps you improve how your body performs physical movements), OT (Occupational Therapy, is treatment that helps you improve your ability to perform daily tasks) and RN (registered nurse) services. 2. The social services staff did not follow the physician's orders to discharge Resident 1 with Home Health services, and did not ensure proper referral and coordination for Home Health (services provided by health care provider to residents after discharge to home) such as: HH (home health) PT, OT and RN services , and the availability of DME (durable medical equipment, medical equipment that is durable, can be reused, for resident's home use) 3. Resident 1's discharge care plan did not address and include her discharge needs related to medication management (the process of ensuring prescription drugs and other medications are used correctly to maximize safety and effectiveness). 4. The post-discharge plan of care did not address Resident 1's limitations to care for herself and the supposed caregiver's ability and availability to provide assistance and care for Resident 1. There was no training provided to Resident 1's caregiver on medication management, ADL (activities of daily living, are basic functions - bathing, dressing, eating, transferring, toileting. that we all need to perform each day) care and assistance prior to resident's discharge to home. These failures posed an unsafe discharge and could jeopardize the health and safety of Resident 1 who was discharged from the facility without proper preparation for appropriate placement and/or home health referral, medication management, medical equipment set up and a caregiver to provide her with the needed assistance and care.1. Review of Resident 1's hospital records, physician discharge summary, dated 4/21/26 for indication for admission, it indicated, , multiple ED (emergency department, is a 24/7 medical unit in a hospital or facility that provides immediate, unscheduled care for acute illnesses and severe injuries) visits for reported seizure (a sudden, uncontrolled burst of electrical activity in the brain that changes how a person moves, acts, or feels) due to ASD (autism spectrum disorder, is a brain condition that affects how a person learns, acts, and talks) non-adherence (ailing to follow a set of rules, advice, or medical instructions) presenting after being found down concerning for breakthrough seizure (is when you have a seizure after you haven't had one for an extended period of time while being treated for seizures) . PT (physical therapy) evaluated patient who was found to be functioning below baseline (a basic standard or level). Both PT (physical therapist) and OT (occupational therapist) recommended SNF placement. However, SNF Dispo (disposition) for short term rehab has been challenging given patient has no safe Dispo (disposition) plan after. Patient lives with her mother who was previously incarcerated (being locked up in a jail or prison) during this admission then released. Home with HH (home health) was considered, but patient was previously evaluated by psychology back in January 2026 where she was found to lack capacity for complex decision making .Patient can therefore not be home alone in between HH (home health) care. Mother had previously said that she would care for patient at home. However, after further assessment this plan is not feasible., plan was changed to placing patient in long term SNF. Further review of Resident 1's physician Discharge summary dated [DATE] for hospital course under the detailed by problem below, it indicated,. Patient's mother came at bedside to see the patient. She was in a wheelchair.unable to get out of the chair and required assistance from nursing staff. Their (family friend) also confirmed that mom is chronically wheelchair bound. Patient (Resident 1) had an episode of attempted elopement (running away from the health facility without staff permission) on 4/12/26. Given that she has no capacity and could not demonstrate that she could care for herself outside the hospital.Review of Resident 1's admission record indicated she was admitted to the facility on [DATE] with diagnosis of nontraumatic chronic subdural hemorrhage (is a slow collection of old, liquid blood between the brain and the skull's outer lining), unspecified convulsions (is a specific type of seizure involving violent, involuntary muscle contractions (a sudden, uncontrolled tightening or moving of a muscle, such as muscle cramps, twitches, and spasms)), hypertension (HTN, high blood pressure), cerebral infarction (medical term for an ischemic stroke, which occurs when a blocked blood vessel cuts off blood and oxygen to part of the brain, causing brain tissue to die), dysphagia following cerebral infarction (difficulty swallowing caused by brain damage), chronic kidney disease (CKD, a long-term condition where the kidneys are damaged and slowly lose their ability to filter waste and extra fluid from the blood), abnormalities of gait and mobility (mean the specific way a person walks, while mobility is the overall ability to move freely and easily around your environment), unspecified fall and muscle weakness.Review of Resident 1's social service assessment, dated 4/25/26, indicated, Resident (Resident 1) expressed having depression (mood disorder causing sadness and loss of interest in things you once liked). Bad social life. Resident will participate in discharge planning. Resident representative/family will participate in discharge planning. Resident's prior living arrangements: . apartment, 10 stairs to get into home.Review of Resident 1's IDT (interdisciplinary team, a group of different health professionals-such as doctors, nurses, and therapists-who work together on a patient's care plan) care conference, dated 4/27/26, it indicated, Discharge plan:.RESIDENT TO STAY SHORT TERM THERAPY AND MEDICAL SERVICES.Review of Resident 1's social services progress note, dated 5/13/26, indicated, Inform mom that resident may not qualify as she does not have insurance in place and may have to rent wheelchair and purchase walker.Review of Resident 1's PT Discharge summary, dated [DATE], it indicated PT services provided from 4/23/26 to 5/11/26. Patient intermittently live with mother in 2nd story apt. (apartment) with flight of stairs. Walk-in shower, no shower chair. Standard toilet. Patient was intermittently homeless as per chart.During an interview on 7/15/26, at 9:45 a.m., with the social service director B (SSD B), the SSD B stated that Resident 1's health insurance would not pay for her staying to receive therapies (PT, OT) in the facility. The SSD B further stated Resident 1's mother would like her to be discharged home after informing Resident 1's insurance was discontinued. During a phone interview with Resident 1's mother (RP) on 7/3/1/26 at 3:42 p.m., she stated that the facility had not invited her for any care conference nor involved her in the discharge plan. She confirmed having received a call from the social worker of the SNF (SSD B) one day when she was told that her daughter's insurance ran out and they could not have her in the facility. She stated, where will my daughter go?, they wanted to kick her out on the streets, that is why I said, then bring her home. I did not say to the social worker that I wanted my daughter to be discharged . The (facility) did not provide any training on how to take care of my daughter at all. How can I take care of my daughter if I have a lot of medical condition myself, my daughter still in the hospital and she should be discharged in the nursing home. 2. Review of Resident 1's IDT care conference, dated 4/25/26, it indicated, Discharge plan For A SAFE DISCHARGE . HOMEHEALTH, DME (durable medical equipment, referring to reusable devices like wheelchairs, oxygen tanks, and hospital beds), TRANSPORTATION MAYBE NEEDED. Review of Resident 1's physician's order dated 5/13/26 indicated, Resident (1) may discharge home on 5/13/2026. Resident will have the (HHA, home health agency) home health PT/OT/RN. Review of Resident 1's social services progress note, dated 5/13/26, it indicated, Inform mom that resident may not qualify as she does not have insurance in place and may have to rent wheelchair and purchase walker. Review of Resident 1's social services progress note, dated 5/13/26, it indicated, Inform mom that resident may not qualify as she does not have insurance in place and may have to rent wheelchair and purchase walker.During a telephone interview on 7/17/26, at 2:45 p.m., with the HHA-1's clinical supervisor A (CS A), CS A stated Resident 1 was not in their system as they did not accept or admit her.During a telephone interview on 7/17/26, at 3:02 p.m., with social service director B (SSD B), SSD B stated HHA-1 did not accept this resident during referral, so she handed the referral information to another HHA (HHA-2). SSD B stated that there was no confirmation indicating HHA-2 accepted Resident 1. SSD B further stated because Resident 1 did not have health insurance upon discharge, HHA-2 staff told her that their agency could do a courtesy eval (a preliminary, informal, and free-of-charge assessment) for Resident 1. SSD B could not provide any documentation of any HHA referral.During a telephone interview on 7/17/26, at 3:33p.m., with HHA-2's business development staff C (BD C), BD C stated their agency never accepted Resident 1 for HH and to conduct a courtesy evaluation on her. Their HH agency did not receive any referral documents from the referring SNF, and Resident 1 did not have health insurance for payor source (is the person, company, or government program responsible for paying for a service or medical bill). BD C further stated she was waiting for the facility to give her update about Resident 1's insurance coverage status, but she never received a call from the facility or Resident 1.During a telephone interview on 7/17/26, at 5:23 p.m., with the director of Nursing (DON) regarding Resident 1's discharge order for HH, the DON confirmed the facility did not have the necessary home health referral and coordination with the receiving home health agency. The DON further stated that SSD B should have ensured HHA services were followed-up and coordinated for Resident 1 before her discharge to home.During a telephone interview on 7/28/26 , at 10:23 a.m., with the director of rehabilitation (DOR), the DOR stated before Resident 1's discharge she only performed a simulated assessment of a home environment based on the information gathering from the record and Resident 1. She did not perform an in- home safety assessment.During a review of the facility's policy and procedure (P&P) titled, Physician Orders and Telephone Orders, dated 4/3/26, the P&P indicated, Orders shall be implemented promptly and accurately. During a review of the facility's policy and procedure (P&P) titled, Discharge to Another Post-Acute Care Facility, dated 3/2025, the P&P indicated, Residents being discharged to , home health agency,. are assisted in selecting a post-acute care provider that will meet the resident's needs, goals, and preferences. 3. Review of Resident 1's physician Discharge summary dated [DATE], it indicated the patient active problem list documented including non-adherence to medication, self-care deficit and cognitive deficits (an impairment in any of the mental processes used to think, learn, remember, and process information) as late effect of cerebrovascular disease (a group of medical conditions that affect the blood supply and blood vessels in the brain, leading to issues like strokes, blocked arteries, and bleeding). Review of Resident 1's medication orders dated 4/22/26, it indicated, she was prescribed amlodipine (is used to treat high blood pressure and certain types of anginas (chest pain) and coronary artery disease) 5 milligrams (mg, unit of measurement). Give one tablet by mouth one time a day for HTN. Hold for SBP (systolic blood pressure (pressure in the arteries when the heart contracts)) less than 100 and HR( heart rates) less than 60 and lacosamide (also known by the brand name Vimpat, is used to treat partial-onset seizures (focal onset seizures, are electrical surges in the brain that start in just one specific area or one side of the brain)) oral tablet 200 mg. Give one tablet by mouth two times a day for seizures. Review of Resident 1's discharge care plan dated 5/13/26, it indicated the interventions included caregiver and /or resident care training PRN (as needed). Discuss & Assess the Resident and /or responsible party's attitude regarding d/c (discharge) plan.Review of 7/15/26's complaint intake information sheet (is a simple form used to write down the first details when a person reports a problem) indicated the patient (Resident 1) was in the facility on 4/21/26 and released to home on 5/13/26 and readmitted to hospital on [DATE] for seizures. The mom was disabled and the patient (Resident 1) was confused with no capacity to make decisions and managed her medications at home. Facility was refusing to readmit resident to her long-term bed following hospitalization.Review of Resident 1's acute hospital ED provider notes, dated 6/13/26 , it indicated, 47 yo (years old) women with fall yesterday off a dolly with abrasions to her head and raccoon eyes then had a seizure today while eating burrito and fell over brought in by fire. Patient was activated as an ED trauma given raccoon eye. Patient is well-spoken history provided by EMS (Emergency Medical Services, a system that provides out-of-hospital emergency medical care and transport to definitive care). Patient is alert and oriented but not forthcoming.Review of Resident 1's 6/22/26's (hospital) medicine progress notes indicated, Per patient's mom, patient was discharged from SNF at the end of May due to Medi-cal (a state public health insurance program for people with low income, providing free or low-cost medical care) being canceled citing patient's inability to submit an income report. Since being at home it appears patient had difficulty with self-care and adherence to medications. Patient's mom and surrogate decision maker is unable to care for patient as she is going through her own stressors. She herself needs to go to court going to school for anger management and has multiple medical issues that precludes her from caring for patient. Further review indicated, Patient during this admission noted she does not take her medications regularly however unable to articulate reasons why.During a telephone interview on 7/16/26, at 9:30 a.m., with the assistant director of nursing (ADON), the ADON verified Resident 1's RP did not come to the facility upon resident's discharge on [DATE].The discharge instructions with the list of medications were given to Resident 1.Review of Resident 1's progress notes dated 5/14/26, it indicated, Resident (1) discharged home at approximately 11:38 a.m. This RN went over discharge summary with pt.(patient) at bedside. Discharge summary and inventory list signed. Copies provided. Education/teaching provided on medications. Pt d/c (discharge) with prescribed medications. Resident departed to home with in-house transport in wheelchair. Md (Medical doctor) notified. During a review of the facility's policy and procedure (P&P) titled, Discharge Summary and Plan, dated March 2025, the P&P indicated discharge planning, The discharge plan is based on the resident assessment, . and the resident's capacity for discharge. Discharge planning identifies . and ensures that it meets resident's health and safety needs, as well as preferences. The discharge plan is re-evaluated based on changes in the resident's condition or needs prior to discharge. 4. Review of Resident 1's acute hospital physician Discharge summary dated [DATE], under the indication for admission it was documented patient's mother came to bedside to see the patient. She had just been discharged from the ED. She was in a wheelchair, and nursing staff noted a strong urine odor coming from mom, and Pt's mom was unable to get out of the chair and required assistance from nursing staff for herself while visiting the patient. Their family friend G also confirmed that mom is chronically wheelchair bound, and that patient and mom live on the second floor of their apartment and mom. has to crawl up the stairs to get to her apartment. Review of Resident 1's admission record indicated Resident 1's mother was RP (responsible party, is the individual or entity held accountable for making decisions).Review of Resident 1's discharge summary /post discharge plan of care, dated 5/12/26, it indicated Resident 1 signed the discharge documents and the discharge instructions were handed to her at bedside without RP present.Review of Resident 1's nursing progress notes, dated 5/14/26, it indicated Resident discharged home at approx. (approximately) 11:38 a.m. This RN went over discharge summary with pt. (patient) at bedside. Education/teaching provided on medications. Pt. d/c (discharge) with prescribed medications. Resident departed to home with in-house transport in wheelchair. Md (Doctor of Medicine) notified.Review of Resident 1's minimum data set (MDS, an assessment tool), dated 5/13/26, it indicated her functional abilities for self-care was moderate assistance ((helper does less than half effort) for toileting, shower, upper and lower body dressing, personal hygiene and putting on and off footwear, except eating was set-up assistance and oral hygiene was supervision. Her mobility was moderate assistance for shower transfer, toilet transfer, bed to chair transfer, sit to stand.During an interview on 7/15/26, at 11 a.m. and 7/16/26, at 10:28 a.m., with the DON, the DON first stated Resident 1's RP was very involved with Resident 1's care and would come to visit her daughter at the facility daily. However, during subsequent interviews with the DON on 7/17/26 at 10:28 a.m., the DON admitted providing wrong information as to the frequent visits of Resident 1's mother to the facility. The DON clarified that Resident 1's mother (RP) did not come to the facility prior to and during Resident 1's discharge.During a telephone interview on 7/16/26, at 9:08 a.m., with the Ombudsman, Ombudsman stated she received information from the hospital that Resident 1's RP was in a wheelchair, same as Resident 1. The Ombudsman stated, the discharge was questionable for inappropriate discharge from the facility.During an interview with licensed vocational nurse (LVN) D 7/16/26, at 10:38 a.m. LVN D stated she works AM shift (7:00-3:30PM).During an interview with LVN E on 7/16/26 at 12:10 p.m., LVN E stated that she works PM shift (3:00-11:30PM). Both LVN D and E stated that they have not seen Resident 1's mother ever visited the resident when they were working.During a telephone interview on 7/17/26, at 1:17 p.m., with SSD B, SSD B stated Resident 1's mother (RP) verbalized she was the primary caregiver of Resident 1 during discharge planning. However, there was no documented evidence that SSD B verified Resident 1's mother was able to take care of Resident 1 after leaving the facility since the mother was not involved with Resident 1's care during her facility stay from 4/21/26 to 5/14/26.During interviews on 7/29/26, at 1:12 p.m. and 3:15 p.m., with the certified nursing assistant E and F (CNA E and F), CNA E stated Resident 1 required maximum assistance (helper does more than half effort) to moderate assistance (helper does less than half effort) for her activities of daily living (ADLs, are basic functions - bathing, dressing, eating, transferring, toileting). CNA F stated Resident 1 was able to respond to simple questions by making simple decisions. Both CNA E and CNA F stated Resident 1 used wheelchair most of the time for mobility during her stay at the facility, and it was only during therapy sessions that Resident 1 could walk with the therapist using a walker.During an interview on 7/29/26, at 2:30 p.m., with the DON, the DON stated that Resident 1's mother never came to visit her during her stay in the facility, so all of the consent forms were obtained and signed by Resident 1. The DON and SSD B did not confirm whether the mother would be available and capable of assisting Resident 1 with ADL care, medication management. There was no evidence that a caregiver training was provided to the mother at all.During a telephone interview on 7/30/26, at 12:32 p.m., with the DON, DON confirmed Resident 1's discharge was an unsafe discharge.During a phone interview with Resident 1's mother (RP) on 7/3/1/26 at 3:42 p.m., she stated, I'm handicapped, in a wheelchair and could not take care of my daughter. She further stated that the facility had not invited her for any care conference nor involved her in the discharge plan. She confirmed having received a call from the social worker of the SNF (SSD B) one day when she was told that her daughter's insurance ran out and they could not have her in the facility. She stated, where will my daughter go?, they wanted to kick her out on the streets, that is why I said, then bring her home. I did not say to the social worker that I wanted my daughter to be discharged . The (facility) did not provide any training on how to take care of my daughter at all. How can I take care of my daughter if I have a lot of medical condition, . My daughter still in the hospital and should be discharged to the nursing home. During a review of the facility's policy and procedure (P&P) titled, Discharge Summary and Plan, dated March 2025, the P&P indicated, The purpose of the discharge plan is to ensure a safe transition from the facility to the post-discharge setting. The discharge plan is developed.to meet the resident's discharge goals and needs that must be addressed before the resident can be safely discharged (e.g., caregiver support and education, rehabilitation, etc.). Discharge planning identifies the discharge destination and ensures that it meets resident's health and safety needs.

Based on interview and record review the facility failed to follow its abuse policy to investigate and report any allegations of abuse to appropriate agencies within timeframes as required for one of two sampled residents (Resident 2). This failure resulted in an incident of abuse not being investigated and had the potential to compromise the safety of the residents in the facility.Review of Resident 2's clinical record indicated diagnoses that included mood disorder (a mental health condition that affects emotional state, causing persistent, extreme sadness, elation or anger), schizophrenia (a mental illness that is characterized by disturbances in thought) and schizoaffective disorder (a mental disorder that can affect thoughts, mood, and behavior).Review of Resident 2 's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 6/12/26 indicated a Brief Interview for Mental Status - (BIMS-an assessment tool used by facilities to screen and identified memory, orientation, and judgement status of the resident) score of 10 which meant his cognition (how brains learns, remembers and make decisions) was moderately impaired. He used wheelchair in mobility, and did not have upper and lower extremities impairment. Review of Resident 2's Progress Notes, dated 7/16/26 at 1:10 a.m., indicated Registered Nurse A (RN A) found Resident 2 to be involved in verbal altercation with Resident 1. The Progress Notes indicated Resident 2 made a verbal threat to Resident 1, stating I will kill you in your sleep.During an interview with RN A on 7/21/26 at 12:42 p.m., she confirmed that Resident 2 made a verbal threat against Resident 1 to kill him in his sleep on 7/16/26 at 1:10 a.m. RN A stated that she reported the incident to the Director of Nursing (DON) on 7/16/26 at around 1:15 a.m.During an interview with the DON on 7/21/26 at 1:05 p.m., she confirmed that RN A reported to her the incident that Resident 2 made a verbal threat that Resident 2 will kill Resident 1 in his sleep on 7/16/26. The DON confirmed that she did not report the incident to the Administrator (ADM), who was the facility's abuse coordinator. During an interview the ADM on 7/21/26 at 10:35 a.m., she stated that the way RN A wrote it in her progress notes on 7/16/26 at 1:10 a.m., that Resident 2 made a verbal threat that Resident 2 will kill Resident 1 in her sleep was considered a verbal abuse. The ADM confirmed that no facility staff reported to her regarding the incident of allegation of verbal abuse by Resident 2 toward Resident 1 on 7/16/26. The ADM confirmed that the allegation of verbal abuse between Resident 2 and Resident 1 has not been reported to any appropriate agencies. (i.e. California Department of Public Health (CDPH, State licensing and certification agency, Ombudsman and local police department) as of 7/21/26 at 10:35 a.m. The ADM acknowledged if the incident had been reported to her by any facility staff on 7/16/26, she should have investigated the incident immediately and reported the incident to all appropriate agencies.Review of the revised facility's policy and procedures dated 12/2016 titled, Abuse Prevention Program indicated Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, sexual or physical abuse, and physical or chemical restraint not required to treat the residents' symptoms. As part of the resident abuse prevention, the administration will: .7. Investigate and report any allegation of abuse within the timeframes as required by federal requirementsPursuant to Title 42 CFR section 483.12 (c) (1) for any other reasonable suspicion that does not result in abuse or serious bodily injury, the facility must: Call local law enforcement as soon as possible, but not later than 24 hours after the allegation is made. File a written or electronic report to the Long-Term Care ombudsman (LTC), local law enforcement and District Office (DO) within 24 hours.

Based on interview and record review, the facility failed to provide supervision to 1 out of 3 residents (Resident 1) from leaving the facility, when1. Resident 1 did not have an out-on-pass order (OOP, a temporary leave of absence for a resident, typically for family visits, holidays, or other events, which must be approved by the facility, the resident's physician, and often included in the individual's care plan) before he left the faciity on 9/14/2025.2. The facility did not implement Resident 1's care plan to provide one-person assistance during ambulation (the medical term for walking, which is the ability to walk from place to place) and locomotion (the act or power of moving from place to place).3. The facility did not report this incident to the California Department of Public Health (CDPH) as an unusual Occurrence. These failures had the potential to compromise Resident 1's health, safety, and well-being. A review of Resident 1's face sheet (a summary document containing a patient's key demographic and medical information for quick reference by healthcare providers) indicated he was admitted to the facility on [DATE] with diagnoses including aftercare following joint replacement surgery (a medical procedure where a damaged or diseased joint is replaced with an artificial one to relieve pain, improve function, and restore mobility.), stimulant dependence (a type of substance use disorder characterized by the compulsive use of stimulant drugs like amphetamines and cocaine, leading to clinically significant impairment or distress) schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions), generalized muscle weakness (a widespread feeling of weakness or fatigue in multiple muscle groups throughout the body), abnormal posture (deviations from the ideal body alignment, resulting in musculoskeletal imbalances and potential health issues).A review of Resident 1's minimum data set (MDS, an assessment tool) dated 8/28/2025 indicated his brief interview for mental status (BIMS, assessment for cognition level) score was 13 (cognitive intact). A review of Resident 1's physician orders for August and September 2025 revealed no out-of-pass (a temporary leave of absence for a resident, typically for family visits, holidays, or other events, which must be approved by the facility) orders for Resident 1. 1. A review of Resident 1's nursing progress notes dated 9/14/2025 at 2:45 p.m., indicated Resident 1 left the facility around 11:30 a.m., has not come back to the facility yet. Mountain View police department called.A review of Resident 1's nursing progress notes dated 9/14/2025 16:05 p.m., indicated Resident 1 walked back to our facility at 4:06 p.m., by himself. Resident 1 stated that he went to (pharmacy store) to buy cigarettes, after that he felt tired, slept over the grass, and walked back to the facility. He said he didn't know he needed an MD's (doctor's) approval for OOP.During a concurrent record review and interview with the Director of Nursing (DON) on 10/20/2025 at 3:11 p.m., the DON reviewed Resident 1's physician orders for August and September 2025 and confirmed that Resident 1 did not have an out on pass order (OOP) to leave the facility. The DON stated that Resident 1 should not leave the facility without MD's OOP order.During a phone interview with Registered Nurse (RN) A on 10/27/2025 at 5:03 p.m., RN A confirmed that there was no OOP order for Resident 1 for him to leave the facility. A review of the facility's undated policy and procedure titled Therapeutic Leave (Resident absences for purposes other than required hospitalization) Policy indicated .The nurse will obtain an order from the practitioner specifying approval of a therapeutic leave. 2. A review of Resident 1's care plan of self-care deficit as evidenced by : needs limited to extensive assistance with ADLs (basic self-care tasks like eating, bathing, and dressing etc.) related to C2-C5 laminectomy and fusion [a posterior cervical surgery to relieve spinal cord compression by removing the lamina (the back part of the vertebrae) from C2 to C5], COPD (a progressive lung disease that causes breathing difficulties, leading to symptoms like shortness of breath, chronic cough, wheezing, and fatigue), stimulant dependence, schizoaffective disorder, psychosis, chronic viral hepatitis C, anxiety, chronic pain syndrome, depression, muscle spasms, insomnia, neuralgia/neuritis, BPH. The interventions include one-person physical assist required for ambulation and locomotion. During a concurrent record review and interview with the DON on 10/27/2025 at 4:09 p.m., the DON reviewed Resident 1's care plan and confirmed that Resident 1 needs one person assisting with ambulation and locomotion and that it was not safe for him to walk out of the facility by himself. A review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered, Revised March 2022, indicated .The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 3. During a phone interview with Certified Nursing Assistant (CNA) on 10/23/2025 at 2:44 p.m., CNA D stated that Licensed Vocational Nurse (LVN) B was looking for Resident 1 for his noon medication around 11:30 p.m., and found out that Resident 1 was not in the facility on September 14, 2025. Both of them looked everywhere and could not find Resident 1, and a staff member called the police. During a phone interview with LVN B on October 23, 2025, at 4:07 p.m., LVN B stated he was the nurse on duty that day and provided care for Resident 1. LVN B further stated that he did not know when Resident 1 left the facility and that Resident 1 did not take his scheduled noon medication on September 14, 2025. During a phone interview with the Receptionist on October 28, 2025, at 3:20 p.m., she stated that on September 14, 2025, between 11:00 a.m. and 12:00 p.m., she observed a person wearing an orange shirt walk out of the facility with a wristband (an armband used for positive resident identification) without checking out with her. She immediately attempted to follow the individual but was unable to locate the person outside the facility building. The Receptionist stated she was unsure which resident had left the facility. She also confirmed that it was her responsibility to monitor the front entrance and ensure residents checked out when leaving the facility. During a phone interview with Licensed Vocational Nurse (LVN) A on 10/29/2025 at 11:25 a.m., LVN A stated that staff conducted a room-to-room search to identify which resident wearing an orange shirt was missing. She further stated that she and other staff members also went to nearby stores to search for Resident 1. A review of the Mountain View Police Department Report Receipt dated on 9/14/2025 indicated the type of incident Found Missing Person.During an interview with the DON on 10/27/2025 at 11:40 a.m., the DON confirmed that the facility did not report this incident to CDPH. A review of the facility policy and procedures titled Unusual Occurrence Reporting, Revised December 2007, indicated that . As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors.Other occurrences that interfere with facility operations.

Based on interview and record review, the facility failed to prepare and ensure a safe and appropriate discharge for one of three residents (Resident 1) when:1. Resident 1's fall risk level was not updated;2. Resident 1's discharge minimum data set (MDS, a clinical assessment tool) was not accurately coded;3. The facility did not provide discharge notice (a written notice in advance to the resident and the resident's representative in a language and manner they understand and an opportunity to appeal) to Resident 1 and/or her son (Resident 1's co-health care decision maker). Resident 1 also did not have a discharge care plan and did not have discharge notes on the day of her discharge; and4. The facility did not verify the license and the care capabilities of the discharge placement facility.These failures resulted in Resident 1 who had severe cognitive impairment (a significant decline in a person's ability to think, learn, remember, use judgement, and make decisions that can lead to a point where the individual is incapable of living independently because of the inability to plan and carry out activities of daily living [ADL, the tasks of everyday life] and apply judgment), poor recent memory, poor insight and judgment, mental illness, required a Preadmission Screening and Resident Review Level 2 (PASRR Level 2, a comprehensive, person-centered evaluation conducted for individuals identified by a Level 1 screening as having or potentially having a Serious Mental Illness [SMI], Intellectual Disability [ID, a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently], Developmental Disability [DD, a group of conditions due to an impairment in physical, learning, language, or behavior areas], or related condition), and required moderate to maximal assistance or dependent on the staff for ADL was discharged to an unlicensed Room and Board (Independent Living, living accommodations and dining services) on 5/22/25. Resident 1 fell at the discharge placement facility and was sent to acute care on 6/11/25. Findings:1. Review of Resident 1's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including malignant neoplasm (cancer, an abnormal growth of cells) of left breast, diabetes (high blood sugar levels), protein-calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets), hyperlipidemia (high level of fats in the blood), hypertension (HTN, high blood pressure), reduced mobility (limitations in movement), muscle weakness, osteoporosis (a disease that weakens the bones; it makes the bones thinner and less dense than they should be), and depression (a persistent feeling of sadness and loss of interest and can interfere with the daily life).Review of Resident 1's clinical record indicated she did not have quarterly fall risk assessments from 8/22/24 to the day of her discharge on [DATE] (two quarterly assessments).During an interview with the director of nursing (DON) on 7/28/25, at 4:10 p.m., he reviewed Resident 1's clinical record and confirmed that Resident 1 did not have quarterly fall risk assessments from 8/22/24 to the day of her discharge on [DATE]. The DON stated the resident fall risk assessment should be done every quarter.2. During an interview with certified nursing assistant A (CNA A) on 7/30/25, at 1:40 p.m., CNA A stated before the discharge of Resident 1 was dependent on staff for shower and upper and lower body dressing and needed maximal assistance (the helper does more than half the effort) for personal hygiene.During an interview with certified nursing assistant B (CNA B) on 7/30/25, at 2 p.m., CNA B stated before the discharge Resident 1 was dependent on staff for shower, upper and lower body dressing, and personal hygiene.During an interview with certified nursing assistant C (CNA C) on 7/30/25, at 2:15 p.m., CNA C stated before the discharge Resident 1 was dependent on staff for shower and upper and lower body dressing and needed maximal assistance for personal hygiene.During an interview with certified nursing assistant D (CNA D) on 7/30/25, at 3:20 p.m., CNA D stated before the discharge Resident 1 needed moderate assistance (the helper does less than half the effort) for upper and lower body dressing and needed maximal assistance for shower and personal hygiene.During an interview with certified nursing assistant E (CNA E) on 7/30/25, at 3:50 p.m., CNA E stated before the discharge Resident 1 needed a lot of help; Resident 1 was dependent on staff for shower, upper and lower body dressing, and personal hygiene.Review of Resident 1's 5/2025 Document Survey Report V2 (Resident 1's Daily ADL status reported by the CNAs) indicated that for the last three days of her stay (from 5/20/25 to 5/22/25) at the facility she needed maximal assistance for bathing and needed moderate to maximal assistance for upper and lower body dressing and personal hygiene.However, review of Resident 1's discharge MDS on 5/22/25 indicated it was coded that Resident 1 needed moderate assistance for bathing and supervision for upper and lower body dressing and personal hygiene.During an interview with the MDS director (MDSD) on 7/30/25, at 2:45 p.m., she reviewed Resident 1's 5/2025 Document Survey Report V2 and discharge MDS dated [DATE] and confirmed that Resident 1's discharge MDS on 5/22/25 was not accurately coded.3. Review of Resident 1's clinical record indicated she did not have a discharge notice and discharge care plan before her discharge, and there were no discharge notes on the day of her discharge.During an interview with the social service director (SSD) on 7/30/25, at 4:10 p.m., she confirmed that Resident 1 did not have a discharge care plan. The SSD stated the discharge notice was for short-term residents. Resident 1 was a long-term resident, so she did not have discharge notice.During an interview with the director of nursing (DON) on 7/30/25, at 4:50 p.m., he reviewed Resident 1's clinical record and confirmed that there were no discharge notes on the day of her discharge. The DON stated when the residents were discharged , there should be notes on how the residents were, the residents discharged with whom and to where, and what had been done during discharge.4. Review of Resident 1's MDS, dated [DATE], indicated her cognition was severely impaired.Review of Resident 1's Che Behavioral Health Note (Che-Outside Consultant Note), dated 2/14/25, indicated her recent memory and her insight/judgment were poor.Review of Resident 1's result of PASRR Level 1 Screening (the initial screening tool), dated 7/23/23, indicated it was positive (requires Level 2 evaluation), and a PASRR Level 2 Screening was required for her.Review of Resident 1's admission Record indicated Resident 1 and her son, both were health care decision makers for her.Review of Resident 1's Social Services Notes, dated 5/6/25, indicated that Resident 1's son stated that he didn't remember having any conversation on wanting to move Resident 1 out of the facility.Review of Resident 1's Lease Agreement that the facility asked Resident 1 to sign and not her son on the day of her discharge, 5/22/25, indicated the discharge placement was to provide medication assistance to Resident 1 by medication reminder.Review of Resident 1's Physician's Orders Upon Discharge, dated 5/21/25, indicated her discharge medications were acetaminophen (for left knee pain) 325 milligrams (mg, a metric unit of mass) two tablets every 6 hours as needed, anastrozole (for breast cancer treatment) 1 mg one time day, aspirin (blood thinner) 81 mg one time a day, atorvastatin (for hyperlipidemia) 40 mg one time a day, docusate sodium (for bowel management) 250 mg two times a day, loratadine (for itching) 10 mg one time a day, melatonin (for supplement to maintain the natural 24-hour cycle) 3 mg at bedtime, metformin (for diabetes) 500 mg two times a day, optic-Vites with lutein (for eye health) one tablet one time a day.Review of Resident 1's Physician's Report (Resident 1's primary physician's report/notes for referral to the placement agency) for Residential Care Facilities for the Elderly (RCFE, a non-medical facility that provides housing, meals, supervision, and personal assistance with daily activities to seniors who need help but not 24-hour nursing care; these facilities, also known as assisted living or board and care homes, to help seniors maintain independence in a homelike setting, with services like help with bathing, dressing, and medication management), dated 2/17/25, the physician indicated that Resident 1 could not administer own prescription medications.During an interview with the SSD on 7/28/25, at 3 p.m., she stated she asked the placement agency (an organization that helps to find suitable residential care options for seniors, such as independent living, assisted living, memory care, or skilled nursing facilities) for the license of Resident 1's discharge placement, but she didn't receive it, and she did not verify it. The SSD stated she thought Resident 1's discharge placement was a Board and Care (a small, residential facility, that provides room, board, and assistance with daily living activities for individuals who need non-medical supervision but cannot live independently). She did not know Resident 1's discharge placement was a Room and Board (Independent Living, living accommodations and dining services) until Resident 1 was brought to acute care after her fall.During an interview with the SSD on 8/19/25, at 12:25 p.m., she stated the placement agency came to the facility, assessed Resident 1, and determined that they could provide care to her at their place. The SSD stated she would look for that document or request from the placement agency for that document.During an interview with the SSD on 9/11/25, at 11:45 a.m., she confirmed that she could not find the document on Resident 1's assessment by the placement agency. The SSD also confirmed that she requested it, but the placement agency didn't provide it for her.Review of Resident 1's Social Services Notes, dated 6/11/25, indicated on 5/29/25 Resident 1 had an unwitnessed fall in the bathroom at the discharge placement.Review of Resident 1's acute care History and Physical, dated 6/11/25, indicated Resident 1 was found on the floor sitting against her bed at the discharge placement and was brought into the acute care by ambulance. It also indicated that Resident 1's discharge placement was an unlicensed Room and Board (Independent Living).Review of Resident 1's acute care History and Physical, dated 6/11/25, indicated Resident 1's discharge placement refused to take her back. The acute care also determined that they didn't want to send Resident 1 back to her discharge placement, an unlicensed Room and Board (Independent Living), because it was not appropriate for Resident 1, and it would be liability on them if they sent her back there. The acute care determined that Resident 1 would be appropriate for skilled nursing home placement.Review of the facility's policy, Fall Prevention and Response, dated 8/2023, indicated . 1. Utilizing the Resident Assessment Instrument (RAI- a guide that facility staff use for coding and transmission) 3.0 User's Manual Version 1.19.1, dated October 2024) process, facility will identify and address potential for fall accidents, environmental factors, individual risk factors, need for supervision, care, and assistive devices.Review of the Long-Term Care Facility Resident Assessment Instrument (RAI), indicated, It is important to note that information obtained should be validated for accuracy, what the resident's actual status was during the observation period.Review of the facility's policy, Admissions, Transfer, Discharge and Bed-Holds, dated 12/2016, indicated . Transfer and discharge: . Before a resident is transferred or discharged , the facility will notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. Notice will be made at least 30-days prior to transfer or discharge, or as soon as practical . The facility will provide sufficient preparation and orientation to residents and resident representatives in order to ensure a safe and orderly discharge from the facility.

Based on observation, interview, and policy review, the facility failed to provide the residents with a safe environment when one of 8 resident beds was not stable; 5 of 8 toilet seats were not stable as it was wubly; 5 of 6 toilet-seat risers were not stable; and the toilet tank in room [ROOM NUMBER] did not have a proper size and shape lid. These failures had the potential to compromise the health and safety of the residents.Findings:During an observation with the maintenance director (MD) on 6/17/25, at 1:30 p.m., the following were observed:a. The bed in room [ROOM NUMBER]A was still movable even though its wheels were braked.b. The toilet seats in Rooms 18, 20, 28, 31, and 34 were not stable.c. The toilet-seat risers in Rooms 2, 18, 20, 28, and 40 were not stable.d. A smaller and different shaped lid was lying on top of the open toilet tank in room [ROOM NUMBER].During an interview with Resident 2 on 6/17/25, at 1:50 p.m., she stated her portable toilet-seat riser was not stable. She had to carefully position it again and again to make sure it was stable before she sat down on it.During an interview with the MD on 6/17/25, at 1:55 p.m., he stated the smaller and different shaped lid which was lying on top of the open toilet tank in room [ROOM NUMBER] was an accident hazard for the residents and staff, and it should not be there.During an interview with the MD on 6/17/25, at 2:20 p.m., he acknowledged that unstable bed, unstable toilet seats, and unstable toilet-seat risers were not safe for the residents, and he would fix them.Review of the facility's policy, Safe, Clean, Comfortable, and Homelike Environment, dated 6/2023, indicated In accordance with residents' rights, the facility will strive to provide a safe, clean, comfortable, and homelike environment .Review of the facility's policy, Toileting Equipment Policy, dated 6/11/25, indicated Toilet risers and other adaptive toileting devices . must be maintained in safe working condition, . 5. All equipment must be inspected for cracks, corrosion, loose fittings, or other hazards.Review of the facility's policy, Bed Wheel Locking Policy, dated 6/11/25, indicated To ensure resident safety and prevent falls or unintended bed movement by requiring all beds to be locked (wheel brakes engaged) when not being actively relocated.

Based on observation, interview, and record review, the facility failed to implement infection control practices when:1. Certified nursing assistant B (CNA B) did not remove her gloves and carried Resident 3's soiled linen out of her room and in the hallway;2. A soiled pillowcase was left on the floor in room [ROOM NUMBER]; and3. Certified nursing assistant C (CNA C) did not put on a gown when doing incontinent care for Resident 4 who was on Enhance Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, a germ that is resistant to many antibiotics] in nursing homes).These failures had the potential to spread the infection to residents, staff, visitors, and throughout the facility.Findings:1. During an observation on 6/16/25, at 1:15 p.m., CNA B carried soiled linens out of Resident 3's room with her gloved hands and walked in the hallway. One piece of the soiled linens dropped down on the hallway floor. CNA B picked it up and continued walking in the hallway to the double door beside Resident 5's room, opened the double door to throw the soiled linen in the hamper which was parked outside.During a concurrent interview with CNA B, she stated she should remove her gloves in the resident room and should not carry soiled linens out of the resident room and in the hallway. CNA B stated she should place the soiled linens in a plastic bag and throw the bag in the hamper. 2. During an observation with the maintenance director (MD) on 6/17/25, at 1:45 p.m., a soiled pillowcase was on the floor behind the open door in room [ROOM NUMBER].During a concurrent interview with registered nurse D (RN D), she stated one of the residents in room [ROOM NUMBER] was moved to a different room, and the other resident was discharged . RN D stated the staff prepared the room for new residents this morning, and the soiled pillowcase should not be left on the floor.Review of the facility's undated policy, Glove Use, indicated . B. Used gloves should be discarded into the nearest waste receptacle inside the room.Review of the facility's policy, Handling Soiled Linen, dated 6/11/25, indicated . 3. Linen should not be allowed to touch the uniform or floor . 4. Used or soiled linen shall be collected at the bedside or point of use and placed in a linen bag or designated lined receptacle. 3. During an observation on 6/17/25, at 3:45 p.m., CNA C was cleansing Resident 4 who was on EBP and did not wear a gown. CNA C only had gloves on.During an interview with CNA C on 6/17/25, at 3:50 p.m., he stated Resident 4 had bowel movement, so he cleansed her and changed her brief. CNA C observed the EBP sign that was posted on Resident 4's room door and stated he should put on a gown and gloves when cleansing Resident 4 and changing her brief.During an interview with the infection preventionist (IP) on 6/20/25, at 9:20 a.m., she stated the staff should remove their gloves in the resident room and should not carry soiled linens out of the resident room and in the hallway. The IP stated soiled linens should not be let touch the floor, and the CNAs should put on gowns and gloves when providing incontinent care to residents who were on EBP.Review of the facility's posting sign, Enhanced Barrier Precautions, indicated . Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: . Changing briefs or assisting with toileting .

Based on observation, interview, and record review, the facility failed to ensure an assessment for self-administration of medications was completed for one of 3 residents (1) when Resident 1 administered lidocaine (used to relieve pain) liquid to his right hip himself and did not have a self-administration of medication assessment and did not have an order from the physician to do so. This failure resulted in duplication of administered medications and had the potential for improper, unsafe medication administration and not addressing the clinical condition of the resident. Findings:Review of Resident 1's admission Record indicated he was admitted to the facility on [DATE].Review of Resident 1's Minimum Data Set (MDS, a clinical assessment tool), dated 3/25/25, indicated his cognition was intact.During an observation with registered nurse A (RN A) on 6/17/25, at 4:15 p.m., an Aspercreme Lidocaine Liquid Roll-On applicator was on the floor at the foot of the bed of Resident 1.During a concurrent interview with Resident 1, he stated the Aspercreme Lidocaine Liquid Roll-On applicator was his, and he applied it to his right hip himself.During an interview with RN A on 6/17/25, at 4:20 p.m., she reviewed Resident 1's clinical record and confirmed that Resident 1 did not have physician orders for Lidocaine Liquid Roll-On applicator and for self-administration of medication. RN A also confirmed that currently Resident 1 had a physician order for Aspercreme Lidocaine Patch 4% apply to right hip topically every day, on for 12 hours, off for 12 hours.During an interview with the director of nursing (DON) on 6/17/25, at 4:25 p.m., he stated he would keep Resident 1's Lidocaine Liquid Roll-On applicator and would talk with the physician about Resident 1's self-administration of it.Review of Resident 1's clinical record indicated he did not have an assessment on self-administration of medication.During an interview and review record with the DON on 7/14/25, at 11:35 a.m., the DON reviewed Resident 1's clinical record and confirmed that currently Resident 1 had a physician order for self-administration of Lidocaine External Cream 4% to right hip topically one time a day, starting on 6/18/25, but Resident 1 still did not have an assessment on self-administration of medication.Review of the facility's policy, Resident Self-Administration of Medication, dated 6/26/24, indicated . A resident may only self-administration medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. 4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record.

Based on interview, and document review, the facility failed to ensure the designated Infection Preventionist (IP - infection control nurse) had completed the required specialized training in infection prevention and control. This deficient practice had the potential for inadequate infection control measures and could result in mismanagement of infections among residents, staff, and community. Findings: During a review of IP's credentials titled, CDC TRAIN (a Centers for Disease Control and Prevention accredited program for Nursing Home Infection Preventionist Training Course), it indicated the IP completed Module 1 (Infection Prevention & Control Program) and 2 (The Infection Preventionist) on 12/26/2024 and Module 3 (Integrating Infection Prevention and Control into the Quality Assurance Performance Improvement Program) on 12/27/2024. During a concurrent interview with the IP and document review of the IP's CDC Train certificates on 3/27/2025 at 8:30 a.m., the IP confirmed she only completed three modules of the 15 modules to be certified as an IP. The IP stated she was busy with her orientation at the facility and was not able to complete the whole course of the IP certification. The IP further stated she stopped the training course after she completed Module 3 in 12/2024. The IP confirmed she did not have any other trainings related to her role as an IP. During an interview with the director of nursing (DON) on 3/28/2025 at 8:58 a.m., the DON confirmed he did not know the IP did not complete the training requirements before she assumed the position as the facility's IP. During a review of the facility's undated job description job title, Infection Preventionist, indicated, Must have training in infection prevention and control in accordance with federal requirements. During a review of CDC TRAIN titled, Nursing Home Infection Preventionist Training Course, indicated, Program Description: This course will provide infection prevention and control (IPC) training for individuals responsible for IPC programs in nursing homes so they can effectively implement their programs and ensure adherence to recommended practices by front-line staff. The course will include information about the core activities of an effective IPC program, with a detailed explanation of recommended IPC practices to prevent pathogen transmission and reduce healthcare-associated infections and antibiotic resistance in nursing homes. Additionally, this course will provide helpful implementation resources (e.g., training tools, checklists, signs, and policy and procedure templates) .What Topics Are Addressed? The Nursing Home Infection Preventionist Training Course is made up of 24 modules and submodules addressing a variety of topics including an overview of the IPC program and the role of the infection preventionist, infection surveillance and outbreak management, infection prevention practices such as hand hygiene, and antibiotic stewardship.

Based on observation, interview, and facility's document review, the facility failed to maintain resident's rights to privacy and confidentiality to four of 18 sampled residents when Residents 35, 56, 91 and 2's personal information and care instructions were posted in the room visible to their roommate's visitors. This failure had the potential to compromise resident's rights. Findings: 1. During an observation on 3/24/2025 at 9:12 a.m., inside Resident 35's room, Resident 35 was sharing a room with two other residents. Resident 35 was asleep and there were two care instructions posted at the wall: a. one care instruction was posted at the wall above Resident 35's head of bed (HOB) indicated, Mr. [Resident 35's initials] PLEASE HAVE HIM SIT UP IN WHEELCHAIR DAILY FROM 2 - 4 PM IN ACTIVITIES b. and the second care instruction was posted at the wall located to the left side of Resident 35's bed beside his picture indicated, Attention Staff:) Please assist resident down to Activities on the following days. >Tuesday at 2 pm for social & movie & popcorn. > Fridays at 9:30am for morning social Thank you, Activity Staff:) During a concurrent observation and interview with licensed vocational nurse E (LVN E) on 3/25/2025 at 8:40 a.m., inside Resident 35's room, the care instructions were still posted. LVN E confirmed above observation and stated the postings of Resident 35's care instruction should be covered. 2. During an observation on 3/24/2025 at 9:16 a.m., inside Resident 56's room, Resident 56 was in bed asleep, and observed a posting of his care instruction at the wall above his HOB. The posting indicated, Please Remove the ACE wrap when patient is ready for sleep. Thank you! Treatment Nurses. Resident 56 was sharing a room with two other residents. During a concurrent observation and interview with registered nurse H (RN H) on 3/24/2025 at 12:50 p.m., in Resident 56's room entrance, the posting above his HOB could easily be seen just at his room entrance. RN H confirmed above observation and stated she was not the one who posted the care instruction. RN H further stated the care instruction posted above Resident 56's HOB should be covered. 3. During an observation on 3/24/2025 at 11:25 a.m., inside Resident 91's room, Resident 91 was sharing the room with one resident. Resident 91 was seated on his wheelchair and observed a posting of his care instruction posted at the wall above his HOB. It indicated, [Resident 91's room number and full name], FLUID RESTRICTION. During a concurrent observation and interview with certified nursing assistant I (CNA I) on 3/25/2025 at 8:58 a.m., inside Resident 91's room, Resident 91 was in bed, and CNA I was providing Resident 91's morning care to get him ready for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). CNA I confirmed the care instruction posted and stated, should it be there? During an interview with the director of nursing (DON) on 3/28/2025 at 8:39 a.m., the DON stated resident's care instruction should be covered to provide resident's privacy. 50135 4. During an observation on 3/24/2025 at 11:10 a.m., inside Resident 2's room, Resident 2 was awake and sitting in the wheelchair next to her bed. Resident 2 was sharing a room with two other residents. There were two pink sheets of paper labeled, Care Instructions, posted on the wall above Resident 2's head of bed. There were no care instructions located underneath both pink sheets of paper. There were two white sheets of paper posted on the wall on the right side of Resident 2's bed. One sheet indicated care instructions for enteral tube feedings (deliverance of liquid nutrition directly to the stomach through a tube) for Resident 2 and the second sheet indicated care instructions for positioning of Resident 2 while sitting in the wheelchair. During a concurrent observation and interview on 3/27/25 at 11:11 a.m., in Resident 2's room with the DON, the DON stated it was best practice to cover all care instructions for all residents to protect their privacy. During a review of the facility's policy and procedure titled, Dignity-Promoting/Maintaining Dignity, dated 10/2022, indicated, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .13. Maintain resident privacy .

Based on interview, and record review, the facility failed to complete a comprehensive minimum data set (MDS - a federally mandated resident assessment tool) admission assessment and the required discharge (DC) assessment in a timely manner for two of two residents (Residents 39 and 81). This failure resulted in Residents 39 and 81's admission and discharge assessment not completed within the time requirement and had a potential to result in inappropriate care planning and intervention. Findings: 1.Review of Resident 39's clinical record titled, Admission Record, dated 3/27/2025, indicated Resident 39 was admitted to the facility on [DATE] with diagnoses including encephalopathy (a medical condition that affects brain function, leading to a wide range of symptoms like confusion, drowsiness, difficulty concentrating, seizures, and muscle weakness), type 2 diabetes mellitus (a condition which affects the way the body processes blood sugar), and unspecified dementia (decline in mental capacity affecting daily function), severe, with other behavioral disturbance. Review of Resident 39's list of MDS assessments indicated the following: - Admission/5-day assessment dated [DATE], indicated it was completed and signed by registered nurse (RN) on 12/4/2024; and - DC assessment-return anticipated dated 11/18/2024, indicated it was completed and signed by RN on 12/8/2024. During a concurrent interview with the minimum data set coordinator (MDSC) and record review on 3/26/2025 at 10:23 a.m., the MDSC reviewed Resident 39's Admission/5-day assessment and DC assessment return anticipated. MDSC confirmed both assessments were completed late. The MDSC stated Resident 39's Admission/5-day assessment should have been completed on 11/27/2024, which was the thirteenth day from Resident 39's admission. The MDSC confirmed she should have just completed a combined 5-day and DC assessment return anticipated instead of completing them separately since Resident 39 stayed at the facility for only 5 days. The MDSC stated the DC assessment should have been completed on 12/2/2024, which was the fourteenth day of Resident 39's DC. The MDSC further stated, she was on vacation on November 2024, and it was the other MDS nurse who completed both assessments. 2. Review of Resident 81's clinical record titled, Admission Record, dated 3/27/2025, indicated, Resident 81 was admitted to the facility on [DATE] with diagnoses including hypo-osmolality (refers to a low concentration of solutes [a substance that is dissolved in a solution] in the body's fluids, particularly the blood ), and hyponatremia (when the amount of sodium in the blood is too low), and parkinsonism (a disease that include symptoms of slowness of movements, muscle rigidity, involuntary tremors/shaking and impaired balance and posture). Review of Resident 81's list of MDS assessments indicated the following: - There was no DC MDS assessment completed for Resident 81 when Resident 81 discharged on [DATE]. - Admission assessment dated [DATE] was completed and signed by RN on 11/28/2024. During a concurrent interview with MDSC and record review on 3/25/2025 at 10:31 a.m., MDSC reviewed the list of Resident 81's MDS assessments and confirmed there was no DC MDS assessment completed. MDSC stated there should have been a DC assessment completed and it should be dated on 11/25/2024. MDSC continued to review Resident 81's Admission assessment and confirmed it was completed late. MDSC stated the admission assessment should have been completed on 11/20/2024 which was the thirteenth day from Resident 81's admitted . MDSC stated she was on vacation in November and came back on December 2024. Review of Center for Medicare and Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (CMS's LTCF RAI - a guide for facility staff to existing coding and transmission) Manual 3.0 Version 1.19.1, dated 10/2024, indicated, Admission (Comprehensive) - MDS Completion Date No Later Than - 14th calendar day of the resident's admission (admitted + 13 calendar days) . Discharge Assessment-return anticipated - MDS Completion Date No Later Than - discharge date + 14 calendar days.

Based on observation, interview, and record review, the facility failed to develop and implement individualized, resident-centered, care plans for seven of 18 sampled residents (Residents 62, 11, 68, 91, 40, 59, and 98) when: 1. Resident 62's diagnosis of Post Traumatic Stress Disorder was not addressed; 2. Resident 11's new diagnosis of closed nondisplaced supracondylar fracture of distal end of left and right femur without intracondylar extension (broken thigh bone [femur] just above the knee, where the bone is broken but remains in its normal alignment, and the fracture doesn't extend into the knee joint), was not developed and implemented since 1/17/2025, and fall care plan intervention was not implemented; 3. Bed rail (also known as side rail, a barrier attached to the side of bed, designed to prevent falls or assist with mobility) care plan used for Resident 68 was not developed; 4. Resident 91's fall care plan intervention was not implemented; 5. Resident 40's Left and Right heel pressure injury (also known as bedsores, pressure sores, or pressure ulcers, are areas of skin and underlying tissue damage caused by prolonged pressure, often occurring over bony prominences.) care plans were not developed; 6. Resident 59's care plan for pressure injury was not patient centered; and 7. Resident 98's MASD (MASD (Moisture-Associated Skin Damage, a term referring to inflammation and/or erosion of the skin caused by prolonged exposure to moisture sources) care plan were not developed. These failures had the potential to result in the inability to identify the resident's individualized care issues and implement person-centered care plans to address their respective identified needs. Findings: 1. A review of Resident 62's clinical record indicated she was admitted on [DATE] with diagnosis including Post Traumatic Stress Disorder (PTSD). A review of Resident 62's Minimum Data Assessment (MDS - an assessment tool) dated 3/3/25, indicated PTSD under Psychiatric/Mood Disorder in Section I - Active Diagnoses. A review of Resident 62's care plans indicated there was no care plan developed to address the diagnosis of PTSD. During an interview and concurrent record review with the minimum data set coordinator (MDSC) on 3/8/25 at 1:25 p.m., Resident 62's MDS was reviewed. The MDSC confirmed that Resident 62 had a PTSD diagnosis listed on her admission record facesheet (document containing resident's key information.) The MDSC reviewed Resident 62's care plans and confirmed a PTSD care plan had not been developed and she stated a care plan should have been created. The MDSC stated a care plan should be developed to implement actions and interventions to address Resident 62's psychological needs. 44583 2a. Review of Resident 11's clinical record titled, Admission Record, dated 3/27/2025, indicated Resident 11 was admitted to the facility with diagnoses of nondisplaced supracondylar fracture without intracondylar extension of lower end of left femur, type 2 diabetes mellitus (DM - a condition which affects the way the body processes blood sugar), dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning), other chronic (something that continues over an extended period of time) pain, and retention of urine (a condition in which the patient is unable to empty all the urine from the bladder). Review of Resident 11's clinical record titled, SBAR [Situation, Background, Assessment, Recommendation - an assessment tool used to facilitate prompt and appropriate communication of a problem]-Fall Report of Incident, dated 1/11/2025, it indicated Resident 11 had an un-witnessed fall. Further review, there was an interdisciplinary (IDT, team composed of members from different departments involved in resident's care) follow up which revealed, Resident found lying on the floor inside his room. He said he is trying to get his wallet. Denies hitting head. No injury noted. Review of Resident 11's clinical record titled, ED [emergency department] Provider Notes, dated 1/16/2025, it indicated, Resident 11 was transferred to ED. Further review indicated, BIBA [brought in by ambulance] for c/o [complained of] bilateral [both] femur fractures. Both fractures above the knee Per EMS [emergency medical services] report .Pt [patient] had a fall on Saturday and noted swelling and pain the next morning (Sunday) Xray showed fractures per EMS report . Resident 11 was transferred back to the facility on [DATE] with diagnoses including closed nondisplaced supracondylar fracture of distal end of left and right femur without intracondylar extension and acute (severe, or intense) pain of both knees. During an interview with licensed vocational nurse E (LVN E) on 3/25/2025 at 8:35 a.m., LVN E confirmed Resident 11 used to attend group activities prior to his diagnosis of fracture. LVN E stated they allowed Resident 11 to stay in bed for comfort. During an interview with certified nursing assistant J (CNA J) on 3/26/2025 at 1:39 p.m., CNA J stated Resident 11 used to attend activities in the social dining room. CNA J further stated Resident 11 preferred to stay in bed after the fall. During a concurrent interview with the director of nursing (DON) and record review on 3/27/2025 at 9:43 a.m., the DON reviewed Resident 11's SBAR on 1/11/2025, ED report, and list of care plans. The DON confirmed Resident 11 had a fall on 1/11/2025 and sustained fractures to bilateral lower part of his femur. Further review, the DON confirmed there was no care plan developed for the new diagnosis of fracture when Resident 11 came back from the hospital on 1/17/2025. The DON stated there should have been a new care plan developed for staff to know how to manage Resident 11's new condition. During a concurrent interview with the minimum data set coordinator (MDSC) and record review on 3/28/2025 at 10:30 a.m., the MDSC reviewed Resident 11's list of minimum data set (MDS - a federally mandated resident assessment tool) assessments and care plans. The MDSC confirmed there was no care plan developed for Resident 11's new fracture since 1/17/2025. The MDSC stated the IDT should have discussed Resident 11's new condition when he came back from the hospital for them to develop the care plan. 2b. During a concurrent observation and interview with Resident 11 inside his room on 3/24/2025 at 9:08 a.m., Resident 11 was in bed, with urine bag hanged at the lower part of the bed, and a floor mat was located at the left side of his bed. Resident 11's bed was positioned in a regular height. Resident 11 stated he was okay. During another observation on 3/25/2025 at 8:33 a.m., inside Resident 11's room, Resident 11 was in bed, asleep, urine bag was hanged at the lower part of the bed, floor mat was located at the left side of the bed, and the bed was positioned in a regular height level. During an observation on 3/26/2025 at 1:36 p.m., inside Resident 11's room, Resident 11 was in bed, intermittently (on and off) screaming with eyes closed. Resident 11's bed was positioned about this writer's waist level. During a concurrent observation and interview with registered nurse K (RN K) on 3/28/2025 at 3:32 p.m., inside Resident 11's room, Resident 11's bed was positioned in a regular height level. RN K confirmed above observation and stated Resident 11's bed was not in the lowest level. RN K stated Resident 11 was a fall risk and his bed should always be positioned in the lowest level as planned. During a review of Resident 11's actual fall care plan dated 9/19/2019, one intervention indicated, Bed in the lowest position. 3. Review of Resident 68's clinical record titled, Admission Record, dated 3/26/2025, indicated Resident 68 was readmitted to the facility with diagnoses including dementia, severe, with other behavioral disturbance (unusual, disruptive, or problematic behaviors that deviate from typical patterns and cause distress or impairment in daily functioning), epilepsy (a brain disorder characterized by recurrent, unprovoked seizures) , and delusional disorders (a type of mental health condition in which a person can't tell what's real from what's imagined). Review of Resident 68's clinical record titled, Bed Rail Safety Assessment, dated 11/8/2024, revealed Resident 68 had an indication for bed rail use. During observations inside Resident 68's room on 3/24/2025 at 9:37 a.m., Resident 68 was seated on a wheelchair, and her bed was observed with two upper bed rails installed and in upright position. During a concurrent observation and interview with LVN E on 3/26/2025 at 8:41 a.m., inside Resident 68's room, Resident 68 was in bed with two upper bed rails in upright position. LVN E confirmed above observation and stated Resident 68 used the bed rails for repositioning. During a concurrent interview with DON and record review of Resident 68's list of care plans on 3/28/2025 at 8:24 a.m., DON confirmed there was no care plan developed for Resident 68's bed rail used. DON stated there should have been a care plan developed for Resident 68's bed rail use since it was determined it was indicated to assist in repositioning. 4.Review of Resident 91's clinical record titled, Admission Record, dated 3/27/2025, indicated Resident 91 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD - irreversible kidney failure), type 2 DM with diabetic neuropathy (with nerve damage), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and dependence on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). Review of Resident 91's clinical record titled, Fall Risk Assessment, dated 1/11/2025, it indicated Resident 91 had a score of 55 (Morse Fall Scoring: High Risk 45 and higher; Moderate Risk 25-44 and Low Risk 0-24). Review of Resident 91's clinical record titled, SBAR-Fall Report of Incident, dated 3/5/2025, it indicated Resident 91 had an un-witnessed fall in his room. Further review revealed Resident 91 was found sitting on the floor next to his bed and did not sustain any injury. During a concurrent observation and interview with Resident 91 on 3/28/2025 at 10:50 a.m., inside Resident 91's room, Resident 91 was in bed and was observed he wearing a yellow band to his left wrist which indicated, FALL RISK. Resident 91's bed was positioned in a regular height level, which was about this writer's waist level. Resident 91 stated he fell on e time, and he was okay. During a concurrent observation and interview with registered nurse H (RN H) on 3/28/2025 at 11:01 a.m., inside Resident 91's room, RN H confirmed above observation and stated Resident 91's bed should be in a lowest position. RN H confirmed Resident 91 was a fall risk resident. During a review of Resident 91's care plan titled, At risk for falls and injuries . dated 1/11/2025, one of the interventions indicated, Low Bed. Date Initiated: 03/25/2025. During a review of the facility's policy and procedure titled, Care Plan, Comprehensive, dated 12/2017, indicated, It is the policy of this facility to develop, in conjunction with the resident and/or representative, the Comprehensive Resident Care Plan. The care plan is directed toward achieving and maintaining optimal status of health, functional ability, and quality of life .Care Plans are individualized through the identification of resident concerns, unique characteristics, strengths and individual needs. 50855 5. During a review of Resident 40's clinical record indicated Resident 40 was admitted to the facility with diagnosis including Peripheral artery disease (PAD a condition where the arteries that carry blood away from the heart to the limbs (usually the legs) become narrowed or blocked). During a review of Resident 40's physician's order, it indicated an order for Left heel stage 4: Cleanse w/ Dakins (wound care products ), pat dry, apply Santyl (used to remove damaged tissue from chronic skin ulcers and severely burned areas )to wound bed, cover the eschar w/ betadine soaked gauze and cover the heel with gauze Kerlex (bulky gauze bandage primarily used for wound dressing ) daily, dated 2/27/25 During a review of Resident 40's physician's order, it indicated an order for Right heel stage 4 dressing: Cleanse w/ Dakins, apply Santyl to wound bed, cover w/ ca (calcium) alginate (a water-insoluble, gelatinous substance used in various applications, including wound dressing) wound and eschar area, and pad, kerlex roll daily, dated 2/27/25. During a review of Resident 40's clinical record, it indicated there were no care plans developed for Resident 40's left and right heel pressure injury stage 4. During a concurrent interview and record review on 3/26/25 at 4:11 p.m., with the Director of Nursing (DON), the DON reviewed Resident 40's care plan. The DON confirmed there were no care plan develop for Resident 40's left and right heel stage 4 pressure injury. The DON further stated, Resident 40 should have care plans for left and right heel stage 4 pressure injury. During a review of facility's P&P titled, Care Plan, Comprehensive, dated 12/2017, the P&P indicated, . PROCEDURE; 1. Care Plans are individualized through the identification of resident concerns, unique characteristics, strengths and individual needs .5. Each plan should include measurable goals and associated time-frames and responsibility.6. Individualized Care Plans should be accessible to all caregivers . 6.During a review of Resident 59's clinical record indicated Resident 59 was admitted to the facility with diagnoses including malignant neoplasm (abnormal growth of cells that invade and spread to other parts of the body) and muscle weakness. During a review of Resident 59's physician's order, it indicated an order for Stage 2 pressure injury to R (right) buttock: cleanse w/ (with) NSS (normal saline), part dry and apply triad (Wound Dressing is for the local management of pressure) paste then cover with foam dressing, dated 3/10/25. During a review of Resident 59's clinical record, it indicated a care plan, dated 3/10/25, The resident has stage 2 pressure injury to R buttock the intervention indicated, Treatment per order. During a concurrent interview and record review on 3/28/25 at 9:31 a.m., with the Director of Nursing (DON), the DON reviewed Resident 59's care plan. The DON confirmed there is only one intervention for Resident 59's stage 2 pressure injury to right buttock. The DON stated it's not a patient centered, there should have more interventions on care plan for Resident 59's stage 2 pressure injury to right buttock. During a review of facility's P&P titled, Care Plan, Comprehensive, dated 12/2017, the P&P indicated, . PROCEDURE; 1. Care Plans are individualized through the identification of resident concerns, unique characteristics, strengths and individual needs .5. Each plan should include measurable goals and associated time-frames and responsibility.6. Individualized Care Plans should be accessible to all caregivers . DOCUMENTATION GUIDELINES, Document may include: . Resident specific focus, goals and interventions . 7. During a review of Resident 98's clinical record indicated Resident 98 was admitted to the facility with diagnoses including type 2 diabetes mellitus (a condition which affects the way the body processes blood sugar). During a review of Resident 98's physician's order indicated an order for Sacrococcyx (The sacrum and coccyx are two bones located at the base of the spine) scattered MASD Cleanse w/ NS (normal saline), apply Triad and foam dressing daily, dated 3/13/25. During a review of Resident 98's clinical record indicated there were no care plans developed and implemented for Resident 98's Sacrococcyx scattered MASD. During a concurrent interview and record review on 3/28/25 at 9:34 a.m., with the DON, the DON reviewed Resident 98's care plan. The DON confirmed there was no care plan develop for Resident 98's Sacrococcyx scattered MASD. The DON further stated there should have care plan develop for Resident 59's Sacrococcyx scattered MASD. During a review of facility's P&P titled, Care Plan, Comprehensive, dated 12/2017, the P&P indicated, . PROCEDURE; 1. Care Plans are individualized through the identification of resident concerns, unique characteristics, strengths and individual needs .5. Each plan should include measurable goals and associated time-frames and responsibility.6. Individualized Care Plans should be accessible to all caregivers .

Based on observation, interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice when: 1. Resident 89 did not have documentation for the care of her cast (is a device used to support healing by surrounding and immobilizing the area of the fracture) located in her extremity. 2. Resident 54 and Resident 156 did not have physician orders for PICC ((PICC, a thin, soft, long catheter [tube] that is inserted into a vein in arm, leg or neck and the tip of the catheter is positioned in a large vein that carries blood into the heart) line managment; 3. Residents 62, 73, 89, 153, and 156 did not have physician orders for use of side rails; 4. Resident 68's physician was not notified of resident's phenytoin test (to measure and monitor phenytoin [a drug used to treat or prevent seizures or convulsions that may be caused by epilepsy, brain surgery, or treatment for brain cancer] in the blood and to determine whether drug concentations are in the therapeutic range) result; 5.Resident 68 and Resident 91 did not have physician orders for bed/side rails used; 6. Residents 40, 38, 50, and 98 - did not have physician orders for side rails prior to use; 7. Resident 64 did not have a physician order for side rails. These failures had the potential to compromise the residents' health and well-being. Findings: 1. Review of Resident 89's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including fracture of the lower end of the radius (one of the 2 bones that make up the forearm, located on the thumb side), closed fracture (broken bone does not penetrate the skin) with routine healing, dementia (a decline in mental capacity affecting daily function). During an observation on 3/25/25 at 12:34 p.m., a hard cast was noted on Resident 89's right forearm. The cast extended from Resident 89's right hand, just below the fingers, to her right elbow. The integrity of the cast was compromised with shredded gauze visible, protruding from the edges of the cast along the length of the forearm. Review of Resident 89's Order Summary Report indicated there was no physician order for care and treatment of Resident 89's right forearm cast. Review of Resident 89's clinical record indicated there was no documentation addressing Resident 89's right forearm arm, and there was no care plan developed for the fractured radius and the presence of a cast on Resident 89's forearm. During an interview and concurrent record review with registered nurse G (RN G) on 3/26/25 at 8:30 a.m., she stated Resident 89 has a cast on her right forearm. RN G stated licensed nurses should check circulation, sensation, and color of an extremity that is casted. RN G reviewed Resident 89's physician orders, medication and treatment records and stated there were no orders to monitor Resident 89's casted right forearm. RN G reviewed Resident 89's care plans and stated there was no care plan addressing Resident 89's fractured right radius and presence of a cast. RN G stated there should be physician orders and a care plan for Resident 89's casted right forearm During an observation, interview and concurrent record review with the director of nursing (DON) on 3/26/25 at 8:30 a.m., he inspected Resident 89's casted right forearm and confirmed the cast integrity was compromised with shredded gauze visible protruding from the edges of the cast. The DON stated licensed nurses should monitor the casted extremity for sensation, color, signs and symptoms of impaired circulation and infection. The DON reviewed Residents 89's clinical record and confirmed there was no documentation related to resident's casted right arm: no care plan, no monitoring of the cast, no physician orders for cast care and treatment. The DON stated there should be orders and monitoring in place and a care plan addressing Resident 89's fracture right radius and presence of a cast. Review of the facility policy titled Cast Care, of Resident with Plaster Cast dated 2006, indicated documentation guidelines that included observations for circulation, irritation, pain and edema and notification of physician for any untoward signs or symptoms. The policy further indicated care plan documentation guidelines that included identifying the problem that necessitated application of a cast, indicating infection prevention measures, instructions for care of the cast, and type and frequency of peripheral circulation monitoring. 2a. During an observation on 3/27/25 at 2:48 p.m., Resident 54 had a PICC line with a transparent dressing on her right upper arm that was dated 3/21/25. A review of Resident 54's medication administration record (MAR), it indicated Resident 54 received intravenous Meropenem Solution (antibiotic used to treat infections caused by bacteria) twice a day in February from 2/19/25 to 2/2/25 and twice a day in March from 3/11/25 to 3/25/25. During an observation and concurrent interview with the director of nursing (DON) on 03/27/25 at 3:15 p.m., the DON confirmed the presence of a PICC line in Resident 54's upper right arm. The DON stated residents who have PICC lines require physician orders for insertion and care of the PICC line, and a care plan developed for PICC line care. The DON stated PICC line management included physician orders for changing the dressing every 7 days, monitoring the site for signs and symptoms of infection, and flushing the catheter before and after medications were given. During a concurrent record review of Resident 54's clinical record, the DON confirmed Resident 54 had received intravenous antibiotic as stated on the above dates in February and March. The DON confirmed there was no physician orders in place for Resident 54's PICC line. The DON further stated there were no physician orders for dressing changes, monitoring signs and symptoms of infection, or flushing the PICC line, and no care plan had been developed for Resident 54's PICC line. 2b. During an observation on 3/24/25 at 2:08 p.m., Resident 156 was observed with a PICC line in the right upper arm. The PICC line had a transparent dressing dated 3/23/25. Resident stated she was receiving intravenous antibiotic (drug used to treat infection) one time a day for an infection in her left foot. Review of Resident 156's clinical record indicated she was admitted on [DATE] with diagnoses including surgical amputation with acquired absence of left foot, acute osteomyelitis (infection in the bone) of left ankle and left foot, diabetes mellitus (inadequate control of blood levels of glucose). Review of Resident 156's physician orders indicated ceftriaxone sodium (antibiotic used to treat infections caused by bacteria) 2 Gram (unit of measure) intravenously in the evening for osteomyelitis until 4/11/25. Another physician order indicated to flush PICC with 10 milliliters (ml, a unit of measure) NS (normal saline) after med every shift. Catheter patency must be verified prior to each access. Resident 156's 3/2025 intravenous administration record (IAR) was reviewed. The IAR indicated the physician order to flush the PICC line was not documented as completed for 31 occasions during the month of March. There were no licensed nurse's initials on the IAR: 12 times on the day shift, 15 times on the evening shift, and 4 times on the night shift when the IAR was left blank for the flushing Resident 156's PICC line. During an interview with the DON on 3/27/25 at 2:00 p.m., he reviewed Resident 156's IAR and confirmed the PICC line flushes were not documented as completed on the above dates. The DON confirmed if the nurses performed the flushes, they should have documented in Resident 156's IAR. The DON acknowledged that if the flushes were not documented, they were not done. Review of Resident 156's clinical record indicated she had a PICC line in her right upper arm. There was no physician order to change the PICC line dressing. There was no documentation in Resident 156's clinical record to indicate dressing changes were being done. During an interview and concurrent record review with the DON on 3/27/25 at 2:00 p.m., he stated residents who have PICC lines require physician orders for care of the PICC line which includes changing the PICC line dressing every 7 days. The DON confirmed there were no physician orders to change Resident 156's PICC line dressing every 7 days, and he stated there should be dressing change orders. 3. During initial tour observations on 3/24/25 from 9:25 a.m. to 10:08 a.m., Residents 62, 73, 89, 153, and 156 were observed with upper quarter-length side rails (cover a portion of the bed, typically one fouth the length) on the bed. The side rails were fixed in the upright position. Review of Resident 62's, 73's, 89's, 153's, and 156's clinical records indicated there were no physician orders for the use of side rails. During an interview and concurrent record review with the director of nursing (DON) on 3/28/25 at 8:00 a.m., he confirmed Residents 62, 73, 89, 153, and 156 were using side rails on their beds. The DON confirmed there were no physician orders for the use of quarter-length side rails for Residents 62, 73, 89, 153, and 156 and he stated residents who have side rails in use should have a physician order. 44583 4. Review of Resident 68's clinical record titled, Admission Record, dated 3/26/2025, indicated Resident 68 was readmitted to the facility with diagnoses including dementia, severe, with other behavioral disturbance (unusual, disruptive, or problematic behaviors that deviate from typical patterns and cause distress or impairment in daily functioning), epilepsy (a brain disorder characterized by recurrent, unprovoked seizures[a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) , and delusional disorders (a type of mental health condition in which a person can't tell what's real from what's imagined). Review of Resident 68's clinical record titled, Order Summary Report, date ordered 11/8/2024, indicated an order of Phenytoin Sodium 100 milligrams (mg - unit of measurement) two capsules in the morning and one capsule at bedtime for seizure. Review of Resident 68's recent diagnostic test results, dated 3/17/2025, it indicated Resident 68's phenytoin level was 3.0 (normal value 10.0-20.0) which was low. During a concurrent interview with the DON and record review of Resident 68's phenytoin level on 3/17/2025 and nursing progress notes on 3/26/2025 at 2:17 p.m., the DON confirmed Resident 68's phenytoin level was low and there was no documentation from nurses that the physician was notified. The DON stated nurses should have documented they notified the physician about Resident 68's low phenytoin level and the physician's answer or order, if any. During a review of the facility's policy and procedure titled, Provision of Physician Ordered Services, dated 2/5/2025, indicated, Qualified nursing personnel will receive and review the diagnostic test reports or consults and communicate the results to the ordering Physician, physician assistant, nurse practitioner or clinical nurse specialist within 24 hours of receipt unless the reports fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders. Ordering Provider will be notified or results upon receipt if deemed critical and/or require immediate attention. Documentation of consultations, diagnostic tests, the results, and date/time of Physician notification will be maintained in the resident's clinical record. 5a. During an observation inside Resident 68's room on 3/24/2025 at 9:37 a.m., Resident 68 was seated on a wheelchair, and her bed was observed with two upper bed rails installed and in upright position. During a concurrent observation and interview with licensed vocational nurse E (LVN E) on 3/26/2025 at 8:41 a.m., inside Resident 68's room, Resident 68 was in bed with two upper bed rails in upright position. LVN E confirmed above observation and stated Resident 68 used the bed rails for repositioning. During a concurrent interview with the DON and record review of Resident 68's list of care plans and physician's order on 3/28/2025 at 8:24 a.m., the DON confirmed there was no physician's order for Resident 68's bed rail used. The DON stated the nurses should have obtained an order from Resident 68's physician prior to installation and used of bed rails. 5b. During an observation inside Resident 91's room on 3/24/2025 at 11:25 a.m., Resident 91 was seated on a wheelchair and his bed was observed with two upper bed rails installed and in upright position. During a concurrent observation and interview with certified nursing assistant I (CNA I) on 3/25/2025 at 8:58 a.m., inside Resident 91's room, Resident 91 was in bed, and CNA I was providing Resident 91's morning care to get him ready for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). Resident 91's bed had two upper bed rails installed and in upright position. CNA I confirmed observation and stated Resident 91 held on to the bed rails when she cleaned him. During a concurrent interview with the DON and record review of Resident 91's physician's order on 3/28/2025 at 8:38 a.m., the DON confirmed there was no physician's order for Resident 91's bed rail used. The DON stated there should have been a physician's order obtained first prior to installation and bed rail used. 50855 6a. During an observation in Resident 40's room on 3/24/25 at 10:51 a.m., Resident 40 was in bed. Resident 40's bed had bilateral (both) upper quarter side rails. During a review of Resident 40's clinical record indicated Resident 40 was admitted to the facility on [DATE]. During a review of Resident 40's order summary report, dated 3/27/25 at 09:52 PT (Pacific Time Zone) indicated there were no order for bilateral upper quarter side rails. During a concurrent interview and record review on 3/28/25 at 2:46 p.m., with the Director of Nursing (DON), the DON confirmed Resident 40 was using bilateral side rails. The DON reviewed Resident 40's order summary report and he stated there were no order for bilateral upper quarter side rails. The DON further stated Resident 40 should have a physician's order prior to use of side rails. 6b. During an observation in Resident 38's room on 3/24/25 at 12:23 p.m., Resident 38 was in bed. Resident 38's bed had bilateral upper quarter side rails. During a review of Resident 38's clinical record indicated Resident 38 was admitted to the facility on [DATE]. Review of Resident 38's order summary report dated 3/27/25 at 09:41 PT indicated there were no order for bilateral upper quarter side rails. During a concurrent interview and record review on 3/28/25 at 2:48 p.m., with the Director of Nursing (DON), the DON confirmed Resident 38 has bilateral side rails in bed. The DON reviewed Resident 38's order summary report and he stated there is an order for bilateral upper quarter side rails, dated 3/28/25. The DON stated Resident 38 side rails order was just today. The DON further stated Resident 38 should have a physician's order prior to use of side rails. 6c. During an observation in Resident 50's room on 3/24/25 at 3:57 p.m., Resident 50 was lying in bed. Resident 50's bed had both upper quarter side rails. During a review of Resident 50's clinical record indicated Resident 50 was admitted to the facility on [DATE]. Review of Resident 50's order summary report dated, 3/28/25 at 14:13 PT indicated there were no order for bilateral upper quarter side rails. During a concurrent interview and record review on 3/28/25 at 2:39 p.m., with the Director of Nursing (DON), the DON confirmed Resident 50 has bilateral side rails in bed. The DON reviewed Resident 50's order summary report and he stated there is an order for bilateral upper quarter side rails, dated 3/28/25. The DON stated Resident 50 side rails order was just today. The DON further stated Resident 50's side rails should be in physician's order upon admission. 6d. During an observation in Resident 98's room on 3/25/25 at 9:38 a.m., Resident 98 was lying in bed. Resident 98's bed had bilateral upper quarter side rails. During a review of Resident 98's clinical record indicated Resident 98 was admitted to the facility on [DATE]. Review of Resident 98's order summary report, dated 3/27/25 at 08:52 PT indicated there were no order for bilateral upper quarter side rails. During a concurrent interview and record review on 3/28/25 at 2:44 p.m., with the Director of Nursing (DON), the DON confirmed Resident 98 has bilateral side rails in bed. The DON reviewed Resident 98's order summary report and he stated there is an order for bilateral upper quarter side rails, dated 3/28/25. The DON stated Resident 98 side rails order was just today. The DON further stated the physician's order for Resident 98's side rails should be upon admission. 50135 7. During an observation on 3/24/25 at 9:45 a.m., inside Resident 64's room, 1/4 bilateral side rails were observed on the bed of Resident 64. Medical record review for Resident 64 indicated Resident 64's initial admission to the facility was on 12/19/22 and readmitted on [DATE]. During a concurrent interview and record review on 3/27/25 at 11:35 a.m., with the DON, the DON reviewed Resident 64's physician order and confirmed Resident 64 did not have an order for the use of bed rails prior to installation and use. The DON stated Resident 64 had been hospitalized a several times and the physician orders were not updated upon readmission to the facility. During an interview on 3/28/25 at 1:32 p.m., with the DON, the DON stated residents must be offered alternatives to bedrails, an informed consent for use of bedrails, a care plan, an assessment and a physician's order before bedrails are installed. During a review of the facility's policy and procedure titled Proper Use of Bed Rails, dated October 2022, indicated, Policy Explanation and Compliance Guidelines: .8 .the facility will obtain a physician's order for the use of the specified bed rail and medical diagnosis, condition, symptom, or functional reason for the use of the bed rail.

Based on observation, interview, and record review, the facility failed to inspect and ensure the Sharps container (a puncture-resistant container designed for the safe disposal of sharp medical instruments like needles, syringes, and scalpels, to prevent accidental injuries and ensure proper waste management.) were not overfilled for one of four medication carts (medication cart 4). When medication cart 4 was overfilled with syringes. This failure has the potential to cause injury to staff and residents in the facility. Finding: During an observation on 3/25/25 at 9:49 a.m., medication cart 4 was parked outside in the hallway near room [ROOM NUMBER], where residents were observed walking in the hallway. Medication cart 4's Sharps container was observed overfilled. Two used syringes with needles attached were outside the Sharps container door and the lid was open. During a concurrent observation and interview on 3/25/25 at 9:50 a.m., with Registered Nurse G (RN G), RN G was asked if the Sharps container was overfilled on medication cart 4. RN G checked the Sharps container, tried to close the Sharps container lid, but couldn't close the lid and the used syringes were not falling inside the Sharps container. RN G confirmed the Sharps container was overfilled. During a concurrent observation and interview on 3/25/25 at 9:54 a.m., with the Director of Nursing (DON), in the hallway. The DON checked the Sharps container on medication cart 4, and confirmed it was full of used syringes. The DON stated it is the routine of the medication nurse to check the level of the Sharps container. The DON stated that when the objects inside the Sharps container reaches the indicator line on the container it should be replaced. The DON further stated the Sharps container should not be overfilled. The DON stated this is to protect the staff and residents from needle pricks (a puncture made by a needle or similar sharp object, potentially causing pain or, in the case of a needlestick injury, a risk of infection from bloodborne diseases), especially those residents with dementia who might come in contact with the Sharps container. During a review of the facility's Policy & Procedure (P&P) titled HANDLING OF BIOHAZARDOUS WASTE, Revision date 1/1/14, the P&P indicated, .Containers used for biohazard waste shall be so secured as to deny access to unauthorized persons The following items shall be considered biohazardous and disposed of according to this procedure:. Three-quarters (3/4) full needle and syringe rigid impervious collection containers .

Based on observation, interview and record review, the facility failed to ensure the proper care and treatment services for oxygen (O2, a colorless, odorless gas) use was provided for four of seven sampled residents (Residents 42, 155, 303, and 40) when: 1. Resident 42's O2 concentrator's (a device which concentrates the oxygen from ambient air) filter had a grayish substance build-up and there was no Oxygen in Use/No Smoking sign posted at the entrance or door of Resident 42's room; 2. Resident 155's oxygen concentrator's filters were dusty; 3. Resident 303's door or entance there was no sign posted for Oxygen in Use/No Smoking; and 4. Resident 40's door or entance there was no sign posted for Oxygen in Use/No Smoking. These deficient practices had the potential for the residents to have complication related to improper treatment while receiving O2 therapy. Findings: 1. Review of Resident 42's clinical record titled, Admission Record, dated 3/28/2025, indicated Resident 42 was admitted to the facility with diagnoses including parkinsonism (a disease that include symptoms of slowness of movements, muscle rigidity, involuntary tremors/shaking and impaired balance and posture), sleep apnea (a sleep disorder characterized by pauses in breathing during sleep), heart failure (HF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), unspecified, and shortness of breath. During a concurrent observation and interview with certified nursing assistant M (CNA M) on 3/25/2025 at 9:11 a.m., at Resident 42's bed side, Resident 42 was in bed, receiving O2 therapy at 2 liters per minute (lpm) thru a nasal cannula (a device used to deliver supplemental oxygen or airflow) connected to an O2 concentrator. The O2 concentrator's filter located at the right lower side, was observed to have a grayish substance build-up. CNA M confirmed the observation, and her eyes opened wide when she saw the build-up in the O2 filter. Both this writer and CNA M walked towards Resident 42's entrance door and observed there was no Oxygen in Use/No Smoking sign posted. CNA M confirmed the observation. During a concurrent interview with registered nurse F (RN F) and record review of Resident 42's physician order for O2 use on 3/25/2025 at 9:22 a.m., RN F confirmed Resident 42 had an order for oxygen use, as needed only. RN F stated the O2 filter had to be changed at night shift every 72 hours or as needed. During an interview with the director of nursing (DON) on 3/26/2025 at 2:30 p.m., the DON stated the O2 filter should be changed or washed weekly, or at least every Sunday. The DON confirmed there should be a sign posted by the door indicating, Oxygen in Use for those residents receiving O2 therapy. The DON further confirmed they have smokers (residents). During a review of the facility's policy and procedure titled, Oxygen Safety, date revised 3/19/2025, indicated, It is the policy of this facility to provide a safe environment for residents, staff, and the public. Further review indicated, No Smoking signs will be utilized to clearly identify oxygen is in use before connecting the oxygen supply, and will remain in place until oxygen administration has been discontinued. 2. Review of Resident 155's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a disease that causes airflow blockage and breathing-related problems) and dependence on supplemental oxygen. Review of Resident 155's physician order, dated 3/22/25, it indicated she had an order for oxygen at 2 liters per minute continuously. During an observation on 3/25/25 at 1:55 p.m., Resident 155 was receiving oxygen via nasal cannula (a tubing used to deliver oxygen) being delivered via an oxygen concentrator (a medical device that concentrates oxygen from environmental air and delivers it to a resident in need of supplemental oxygen). The filters on both sides of the concentrator machine were dusty, with an accumulation of whitish gray substances on the filter sponge. During an observation and concurrent interview with registered nurse G (RN G) on 3/25/25 at 2:05 p.m., she confirmed both filters on Resident 155's concentrator were dirty, and she stated the filters should be changed. During an interview with the director of nursing (DON) on 3/26/25 at 8:30 a.m., he stated the concentrator filter should be cleaned every week and replaced as needed. Review of the facility's policy Oxygen Concentrator dated 12/3/24, indicated Care of the Concentrator: a. Follow manufacturer recommendations for the frequency of cleaning filters . Review of the Platinum Series XL, 5, 10 operator's manual indicated the following for routine maintenance of the cabinet filters: Remove each filter and clean at least once a week. 3. During an observation on 3/24/25 at 9:12 a.m., Resident 303 was lying in bed with oxygen concentrator in use at 2L/min (L, metric unit of volume) /minutes via nasal cannula (NC, device placed in the nostril used to deliver oxygen) at the bedside. There was no oxygen signage posted on Resident 303's door. During a review of Resident 303's physician's order, it indicated an order, dated 3/24/25 May give O2 @ (at) 1LPM (Liter per minute) via nasal cannula for SOB (shortness of breath), chest pain, Oxygen saturation (the percentage of oxygen in the blood) less than 90% as needed May titrate up to 4LPM to keep O2 saturation 90% and Notify MD (Medical Doctor). During an interview on 3/25/25 at 4:08 p.m., with the Director of Nursing (DON), the DON confirmed there was no Oxygen in use or No smoking sign posted outside Resident 303's door. The DON further stated they should have sign outside the door if they have oxygen concentrator is inside the room even the order for oxygen is as needed for safety. 4. During an observation on 3/24/25 at 10:51 a.m., Resident 40 was lying in bed with oxygen concentrator in used at 2 LPM via nasal cannula at the bedside. There was no oxygen signage posted on Resident 40's door. During a review of Resident 40's physician's order, dated 3/22/25 indicated Start Oxygen at 2L/min (Liter per minute) for SOB, Chest Pain, O2 sat (saturation) < (less than) 90% and Notify MD. During an interview on 3/25/25 at 4:10 p.m., with the Director of Nursing (DON), the DON confirmed there was no Oxygen in use or No smoking sign posted outside Resident 40's door. The DON further stated there should be a sign outside the door if they have oxygen concentrator is inside the room even the order for oxygen is as needed for safety. During a review of the facility's policy and procedure titled, Oxygen Safety, date revised 3/19/2025, indicated, It is the policy of this facility to provide a safe environment for residents, staff, and the public. Further review indicated, No Smoking signs will be utilized to clearly identify oxygen is in use before connecting the oxygen supply, and will remain in place until oxygen administration has been discontinued.

Based on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 91) who received dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment received care in accordance with professional standards of practice when: 1. Staff did not follow Resident 91's fluid restriction (limiting liquids) order; 2. There was no documentation of Resident 91's fluid intake each shift for staff to determine if Resident 91 have met the fluid restriction order; and 3. There was no record of Resident 91's intake and output (I&O - the measurement of the fluids and food that enter [intake] and leave [output] the body) monitoring. This deficient practice had the potential to result in Resident 91's fluid overload (a condition where there is an excessive amount of fluid in the body) or dehydration (a condition that occurs when the body loses more fluids than it takes in, resulting in a lack of water in the body). Findings: 1. Review of Resident 91's clinical record titled, Admission Record, dated 3/27/2025, indicated Resident 91 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD - irreversible kidney failure), type 2 DM with diabetic neuropathy (with nerve damage), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and dependence on dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). Review of Resident 91's Admission minimum data set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], it indicated Resident 91's brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 13 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). During an observation on 3/24/2025 at 11:25 a.m., inside Resident 91's room, Resident 91 was sharing the room with one resident. Resident 91 was seated on his wheelchair and observed a posting of his care instruction posted at the wall above his HOB. It indicated, [Resident 91's room number and full name], FLUID RESTRICTION. During a concurrent observation and interviews with certified nursing assistant I (CNA I) and Resident 91 on 3/25/2025 at 8:58 a.m., inside Resident 91's room, Resident 91 was in bed, and CNA I was providing his morning care to get him ready for dialysis. A pitcher of water about 3/4 full and a cup of water were observed on top of Resident 91's overbed table. CNA I confirmed the observation and stated she was aware of Resident 91's fluid restriction order, but it was night shift staff who left the pitcher of water on the overbed table. Resident 91 stated he could reach the pitcher of water if he needed to drink. 2. Review of Resident 91's clinical records, titled Medication Administration Record [MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), for 3/2025, it indicated an order on 1/17/2025, Fluid Restriction 1200 ml [milliliters - volume of measurement] Total per 24 hrs. as follows: Dietary Dept: 600 ml on meal trays: (BKFT [breakfast], 240 ml, Lunch 120 ml, Dinner 240 ml) Nursing Dept: 480 ml: (Days 250 ml, PM's [evening shift] 250 ml, Noc [night shift]100 ml) every shift. Further review indicated nurses would just initial their names in each shift without documentation of the exact amount of fluids Resident 91 consumed in each shift. 3. Review of Resident 91's clinical records, titled Order Summary Report, date ordered 1/11/2025, indicated, Bumetanide (a diuretic [medicine that help reduce fluid buildup in the body] medicine) Tablet 2 MG (milligrams - unit of measurement) Give 1 tablet by mouth two times a day for fluid retention (it occurs when part of the body swell due to a build-up of trapped fluid). Further review indicated Resident 91 had an order for dialysis every Tuesday, Thursday and Saturday. During a concurrent interview with the registered dietitian (RD) and record review on 3/26/2025 at 3:25 p.m., the RD reviewed Resident 91's dietary notes and the order summary report and confirmed Resident 91 had an order for fluid restriction, dialysis three days a week and was on bumetanide. The RD admitted Resident 91 was at risk of dehydration and confirmed there was no documentation I&O were being monitored. The RD stated it was not his responsibility to recommend I&O monitoring for residents on dialysis, fluid restriction and taking diuretics. The RD further stated his role was just to let the nurses know about the fluid breakdown of fluid restriction. During a concurrent interview with the director of nursing (DON) and record review on 3/28/2025 at 8:42 a.m., the DON reviewed Resident 91's order summary report, assessments, progress notes, and 3/2025 MAR. The DON confirmed Resident 91 was on dialysis three days a week, fluid restriction and on diuretics. The DON stated Resident 91 should not have a pitcher of water on top of the overbed table and nursing staff should follow the allowed fluids each shift to prevent fluid overload. The DON confirmed nurses did not document the exact amount of fluids Resident 91 consumed on each shift. The DON stated the amount of fluids Resident 91 had consumed should be documented in the MAR. The DON admitted Resident 91 was at risk of dehydration and the I&O should have been monitored and documented. The DON stated RD can recommend getting an order for I&O monitoring during his dietary review on Resident 91 if resident did not have one. During a review of the facility's policy and procedure titled, Hemodialysis, dated 12/2/2024, indicated, This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan .to meet the special medical, nursing .needs of resident receiving hemodialysis. During a review of the facility's policy and procedure titled, Fluid Restriction, dated 3/26/2024, indicated, The nurse will obtain and verify the physician's order for the fluid restriction and an order written to include the breakdown of the amount of fluids per 24 hours to be distributed between the food and nutrition department and nursing department, and will be recorded on the medication record or other format as per facility protocol .Water will not be provided at the bedside unless calculated into the daily total fluid restriction. During a review of the facility's policy and procedure titled, Intake and Output (I&O), dated 8/2014, indicated, BASIC RESPONSIBILITY Nursing Staff POLICY * It is the policy of this facility to monitor intake and output and accurately document when it is determined that monitoring is necessary to evaluate hydration status, compliance with fluid restrictions, or to assist in the assessing and managing fluid needs. Potential resident may include (but are not limited to) .b. Residents who are determined to be at risk for dehydration. c. Residents on fluid restriction .

Based on interview, and document review, the facility failed to ensure the licensed nursing staff employed at the facility had appropriate competencies, and skill sets related to intravenous (IV, to deliver a medication into a vein) therapy to ensure the residents with peripherally inserted central catheter (PICC, a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart, used for long term IV medication administration) lines received safe and appropriate medical care to attain or maintain the highest practicable physical, mental, and psychosocial well-being. There were 2 residents with PICC lines admitted to the facility at the time of the survey. This failure could compromise the safety and quality of care for the two residents. Findings: During an interview on 3/28/25 at 9:07 a.m., the DON stated he had been working at the facility for five weeks. The DON stated he was responsible for competency evaluations and the ongoing education program through in-services for licensed nurses at the facility. However, he had not completed any in-services or competency evaluations regarding IV and PICC line care since he started working at the facility. He also stated there were a few residents with PICC lines at the facility and residents were occasionally admitted to the facility from hospitals to complete their medication therapy. The DON stated it was important and beneficial to evaluate nurses' performance for best nursing practice in providing quality resident care. During a review of the in-service binder titled In-services 2024, indicated that discussions and trainings were provided for the facility's licensed nursing staff. There were no records found to indicate in-services for IV and PICC line management and care were conducted, or any evaluations of the facility staff's competencies and skills sets for these special care treatments. During an interview on 3/28/25 at 10:31 a.m., with the Regional Director of Clinical Operations (RDCO), the RDCO stated the Director of Nursing (DON) was responsible for conducting licensed nurses' competency/skills evaluations and in-services since the Director of Staff Development (DSD) had retired and a new DSD had not been hired at the facility. The RDCO stated she conducted an in-service for the licensed nursing staff a few months prior but did not provide any documentation of in-services, training or competency skills validation for PICC line management/care. During an interview on 3/28/25 at 3:00 p.m., with Registered Nurse O (RN O)), RN O stated she had experience caring for residents with PICC lines from her previous employment but did not have a competency skills validation by the DON or the Director of Staff Development (DSD) when hired at the facility. RN O stated she had not attended any in-services for PICC management since being hired. Review of the facility's assessment policy, titled, Grant [NAME] Nursing and Rehab Center Facility Assessment Policy, revised 1/2025, indicated, .4. The Facility Assessment will be used to: a. Inform staffing decisions to facilitate sufficient numbers of staff with the appropriate competencies and skill sets necessary to care for resident needs as identified through resident assessment and plan of care . 2.4 Staff training/education and competencies: California training requirements for Licensed Nurses upon hire; offered annually; PRN (as needed) based on changes in clinical guidance or staff performance evaluations- PICC line management (site care, dressing changes, flushing, aseptic technique, infection prevention).

Based on interview and record review, the facility failed to ensure accurate accountability of controlled drugs (medications that can be easily abused and are under strict government control) and document medication administration in accordance with the facility policy and procedures (P&P) for three out of four residents (Resident 38, Resident 56, and Resident 59). This failure had the potential for medication errors and controlled drug abuse or diversion (when healthcare providers obtain or use prescription medicines illegally). Findings: 1. During a review of Resident 38's clinical record, it indicated Resident 38 was admitted to the facility with diagnoses including bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making). During a review of Resident 38's physician's order, dated 2/18/25, it inlcuded order for morphine sulfate (controlled medication for pain) tablet 15 mg (milligram, unit of measurement), 1 tablet by mouth every 12 hours as needed for severe pain. During a concurrent interview and record review on 3/26/25 at 3:51 p.m., with the Director of Nursing (DON), a review of Resident 38's Controlled Drug Record (CDR) for morphine sulfate 15 mg tablet and the March 2025 Medication Administration Record (MAR) indicated, on 3/15/25 at 10:18 and 3/23/25 at 2:51 p.m., the nursing staff signed out one tablet on CDR but did not document their administration on the MAR. The DON confirmed the findings and stated the nurse should sign the MAR after the medication administration. 2. During a review of Resident 56's clinical record, it indicated Resident 56 was admitted to the facility with diagnoses including malignant neoplasm of thymus (a cancerous tumor that originates in the thymus gland, located in the upper chest behind the breastbone). During a review of Resident 56's physician's order, dated 7/4/24, it included Percocet (controlled medication for pain) 5-325 mg (milligram, unit of measurement), 1 tablet by mouth every 8 hours as needed for severe pain. During a concurrent interview and record review on 3/26/25 at 3::56 p.m., with the Director of Nursing (DON), a review of Resident 56's Controlled Drug Record (CDR) for Percocet 5-325 mg and the March 2025 Medication Administration Record (MAR) indicated, on 3/16/25 at 10:00 a.m. and 3/23/25 at 8:00 a.m., the nursing staff signed out one tablet on CDR but did not document their administration on the MAR. The DON confirmed the findings and stated the nurse should sign the MAR and CDR after medication administration. 3. During a review of Resident 59's clinical record indicated Resident 59 was admitted to the facility with diagnoses including malignant neoplasm (abnormal growth of cells that invade and spread to other parts of the body) and muscle weakness. During a review of Resident 59's physician's order dated 2/20/2025, it included oxycodone (a potent controlled medication for pain)5 mg (milligram, unit of measurement), 1 tablet by mouth every 4 hours as needed for severe pain During a concurrent interview and record review on 3/26/25 at 4:00 p.m., with the DON, a review of Resident 59's Controlled Drug Record (CDR) for oxycodone and the February and March 2025 Medication Administration Record (MAR) indicated, on 2/26/25 at 0000, 3/2/25 at 2330, and 3/23/25 at 0560, the nursing staff signed out one tablet on CDR but did not document their administration on the MAR. The DON confirmed these findings and stated the nurse should sign the MAR and CDR after medication administration. During a review of facility's Policy & Procedure (P&P) titled, Inventory of Controlled Substances, revised 8/1/24, the P&P indicated, 1 .1.3 .1.3.3 The facility should routinely reconcile the number of doses remaining in the package to the number of doses recorded on the Controlled Substance Verification/shift Count Sheet to the medication administration record.

Based on interview and record review, the facility failed to act upon the facility's Consultant Pharmacist's (CP) recommendations during the Medication Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) to address the recommendation/ irregularities for the month of December 1, 2024 to January 31, 2025's MRR for 2 of 4 sampled residents (Resident 2 and 32). This deficient practice had the potential to result in adverse medication outcomes and for potential unnecessary medications for Resident 2 and Resident 32. Findings: 1. During a review of Resident 2's medical record, it indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making), gout (painful form of arthritis), hyperlipidemia (high levels of fat particles [lipids] in the blood), and atrial flutter (a very fast heart rhythm that can lead to an increased risk of stroke due to blood clot formation). Review of Resident 2's physician order dated 1/1/25 indicated an order for risperidone (drug used to treat bipolar disorder) oral tablet 0.5 mg (milligram-unit of measurement), give 1 tablet at bedtime, and orders dated 12/2/24 for allopurinol (used to treat gout) oral tablet 100 mg give one tablet by mouth in the morning, and atorvastatin calcium (medication used to lower fat levels in the blood) oral tablet 40 mg give one tablet by mouth at bedtime. On 12/2/24 Resident 2 was also prescribed Eliquis (used to prevent and treat blood clots) oral tablet 2.5 mg give 1 tablet by mouth two times a day. During a review of the MRR for Resident 2, dated 12/1/24-1/31/25, the MRR indicated the CP's acknowledgment of Resident 2 receiving risperidone and its association with dyslipidemia (abnormally high levels of fats in the blood) but did not have documentation of a fasting (not eating food or drink for a period of time) lipid panel (a blood test that measures levels of fats in the bloodstream) recorded in the medical records within the previous twelve months. The CP noted the physician's orders for atorvastatin and allopurinol with a fasting lipid panel was last monitored in October 2023. The CP's recommendation for monitoring of uric acid (a waste product left over from normal chemical process in the body), and fasting lipid panel was signed off by the facility's physician but not dated. The CP requested clarification of concerns about the medication administration record, prescriber order sheets and recommendation to monitor bleeding for Resident 2 were also not signed and dated by the facility's physician and/or nursing staff. 2. Review of Resident 32's medical record indicated Resident 32 was admitted on [DATE] with diagnoses including depression disorder (a mood disorder that causes persistent feelings of sadness or loss of interest), and dysphagia (difficulty swallowing food or liquids). Further review of the record indicated Resident 32 had a physician's order dated 2/6/25, for duloxetine (medication used to treat depression) 30 mg one capsule by mouth one time a day. Review of the MRR for Resident 32, dated 12/1/24-1/31/25, it indicated a recommendation to the attending physician to discontinue duplicate orders of glycolax and Miralax, to clarify items on the medication administration record (MAR) and prescriber order sheet, to identify and monitor side effects and target behaviors for duloxetine. The facility's physician and nursing staff did not provide a response to the recommendations. The portions of the report designated for the physician and nursing staff to provide a response were left blank. During an interview and concurrent record review on 3/26/25 at 12:12 p.m. with the Director of Nursing (DON), the DON reviewed the MRR's dated 12/1/24-1/31/25 for Resident 2 and Resident 32. The DON stated the physician and nursing staff did not complete the documents in response to the CP's recommendations. The DON stated the CP's reports are forwarded to the physician for review, but the physician failed to sign and date the reports for both residents. The DON could not provide a MRR binder for the year 2024/2025 for review and stated paper copies of the MRR for 2024 and monthly visits by the CP could not be located anywhere in the facility. The DON also verified CP reports were uploaded into the electronic medical records periodically for residents at the facility during the year of 2024. During an interview on 3/26/25 at 12:30 p.m., with the Regional Director of Clinical Operation (RDCO), the RDCO stated the MRR binder and all the documents of the CP's monthly visits for the year 2024 and previous years were somewhere in the facility but could not find them. During a telephone interview on 3/28/2025 at 1:45 p.m., with the facility's CP, the CP stated medication record reviews and visits were done monthly. The CP stated reports were faxed to the DON and recommended the facility review the monthly MRR report and notify resident's physician of any irregularities and recommendations as indicated on the monthly MRR report. During a review of the facility Policy and Procedure titled, Medication Regimen Review, revised 6/5/2024, indicated: .9. Facility should encourage physician/prescriber or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR. 9.1. For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected, as outlined by the State Operations Manual Appendix PP. 9.2 The attending physician should document in the resident's health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. 9.2.1. If the attending physician/prescriber has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record . 13. The attending physician/prescriber should address the consultant pharmacist's recommendations no later than their next scheduled visit to the facility to assess the resident, per facility policy and state or federal regulations. 14. Facility should maintain readily available copies of MRRs on file in Facility as part of the residents' permanent health record and should be readily available for review. 15. If documentation of the consultant pharmacist's findings is not in the active record, it is maintained within the facility and is readily available for review.

Based on observation, interviews, and record review, the facility failed to ensure two out of 18 sampled residents (Resident 68 and Resident 38) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Resident 68 continued to receive Quetiapine (a type of drug [antipsychotic] used to treat symptoms of psychosis) without an updated abnormal involuntary movement scale (AIMS - a clinical rating scale used to assess the severity and frequency of involuntary movements, such as those that can occur as a side effect of certain medications, such as antipsychotics) completed, and there were no non-pharmacological interventions (treatments or strategies that aim to improve health or manage conditions without using medications, focusing instead on physical, psychological, or behavioral approaches) implemented for Resident 68's Quetiapine use; and 2. Resident 38 received Quetiapine without target behavior monitoring. These failures had the potential for increased risks associated with the use of antipsychotic medications that could negatively affect the residents physical, mental, and psychosocial well-being. Findings: 1a. Review of Resident 68's clinical record titled, admission Record, dated 3/26/2025, indicated Resident 68 was readmitted to the facility with diagnoses including dementia, severe, with other behavioral disturbance (unusual, disruptive, or problematic behaviors that deviate from typical patterns and cause distress or impairment in daily functioning), epilepsy (a brain disorder characterized by recurrent, unprovoked seizures[a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) , and delusional disorders (a type of mental health condition in which a person can't tell what's real from what's imagined). Review of Resident 68's quarterly minimum data set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], it indicated Resident 68 had memory problems with long-term (memory that involves the storage and recall of information over a long period of time [as days, weeks, or years] and short-term memory (capacity to keep a small amount of information in mind in an active, readily available state for a short period of time). Review of Resident 68's clinical record titled Order Summary Report, date ordered 3/10/2025, indicated, QUEtiapine Fumarate Tablet 50 MG Give 1 tablet by mouth two times a day for Mood disorder m/b [manifested by] yelling, striking out. During observations inside Resident 68's room on 3/24/2025 at 9:37 a.m., Resident 68 was seated on a wheelchair, and was talking to self. Another observation and concurrent interview with Resident 68's family member (FM) at 12:38 p.m., Resident 68 was eating lunch with FM's assistance and supervision. FM stated, my mom has grade 7 dementia, During a concurrent observation and interview with certified nursing assistant L (CNA L) on 3/25/2025 at 8:50 a.m., inside Resident 68's room, Resident 68 was seated on a wheelchair and continuously talking. CNA L was observed seated on a chair in front of Resident 68. CNA L stated she was a sitter (a caregiver who provides companionship and supervision to patients who need constant observation or assistance, often due to medical conditions or behavioral issues that could pose a risk) for Resident 68 because she was at risk of falling. During an interview with licensed vocational nurse E (LVN E) on 3/26/2025 at 8:41 a.m., LVN E stated Resident 68 had an aggressive behavior and used to wander at the facility. LVN E confirmed Resident 68 had a sitter to prevent her from wandering and elopement (the act of a patient leaving a healthcare facility without authorization or supervision). Review of Resident 68's assessment titled, Abnormal Involuntary Movement Scale (AIMS) Evaluation, indicated these assessments were completed on 1/31/2023 and 8/3/2024. During a concurrent interview with the director of nursing (DON) and record review of Resident 68's AIMS Evaluation on 3/26/2025 at 2:17 p.m., the DON confirmed Resident 68's latest AIMS Evaluation was completed on 1/31/2023 and 8/3/2024. The DON stated AIMS evaluation should have been completed following the MDS assessment, which was quarterly. The DON confirmed there were no AIMS Evaluation completed in between 1/31/2023 and 8/3/2024 and after 8/3/2024. During a review of the facility's policy and procedure titled, Psychotropic Medication [used to treat mental health disorders like antidepressants, anti-anxiety, anti-psychotic, stimulants, and mood stabilizers] Management, dated 12/2017, indicated, If antipsychotic medications are used, an AIMS assessment will be completed upon admission, at the onset of a new order, every six months, and if medication dose is increased. 1b. Review of Resident 68's clinical records like medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) and nursing progress notes, indicated no documentation that Resident 68 received any non-pharmacological interventions to help managed her behaviors. During a concurrent interview with the DON and record review of Resident 68's MAR and nursing progress notes on 3/27/2025 at 9:15 a.m., the DON confirmed there were no documented non-pharmacological interventions provided to Resident 68. The DON stated non-pharmacological interventions should have been provided to Resident 68 to manage her behavior and it should have been documented in the MAR. During a review of the facility's policy and procedure titled, Use of Psychotropic Medication, dated 8/2024, indicated, Residents who use psychotropic drugs shall also receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. 2. A review of Resident 38's clinical record indicated Resident 38 was admitted to the facility with diagnosis including bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making). Review of Resident 38's physician's order dated 2/19/2025 included an order for Quetiapine 200 milligram (mg, unit of measure), give 1 tablet by mouth at bedtime for bipolar. Review of Resident 38's clinical record indicated there was no monitoring for the target behavior of bipolar disorder. During a concurrent interview and record review on 3/26/25 at 4:14 p.m., with the DON, the DON reviewed Resident 38's clinical record and he confirmed there was no target behavior monitoring for Quetiapine use. The DON further stated Resident 38 should have monitoring for the behavior. During a review of facility's P&P titled, Psychotropic Medication Management revised date 8/2024, the P&P indicated, . 3. When psychoactive medications are prescribed, the clinical records should reflect the diagnosis and specific condition, or targeted behavior being treated .

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. Insulated food covers used for food service were stacked and stored wet; 2. There were unlabeled and undated food items in the reach-in refrigerator. These failures had the potential to cause food contamination and food-borne illness to 89 of 90 residents who received their food from the kitchen. Findings: 1. During an initial tour of the kitchen on 3/24/25 at 9:15 a.m., accompanied by the dietary manager (DM), there were 36 insulated plate covers observed to be stacked on a metal wire rack. The insulated plate covers were stacked inside of one another and were wet inside and outside of the plate covers' surfaces. The DM confirmed the insulated plate covers were wet and she stated they should have been air dried before being stacked and stored. According to the 2022 Food and Drug Administration (FDA) Food Code, Section 4-901.11 Equipment and Utensils, Air-Drying Required, After cleaning and sanitizing, equipment and utensils: shall be air-dried . According to the FDA Food Code 2022 4-903 Storing, Clean equipment and utensils shall be stored in a self-draining position that allows air drying. 2. During an observation on 3/24/25 at 9:29 a.m., accompanied by the DM, there were 3 brown bags that were unlabeled and undated in the reach-in refrigerator. There was the word Tuna marked on the outside of each bag and a blank label affixed to the bags. The bags each contained a tuna sandwich wrapped in plastic wrap with no identified markings or date. The DM stated the lunches were prepared in the morning for dialysis residents who are not in the facility over the lunch meal service. The DM confirmed the label was blank and stated the bag lunch and the tuna sandwich should be dated and labelled. A review of the facility policy titled Food Safety in Receiving and Storage indicated food that is repackaged will be labeled with the name of the contents and dated with the date it was transferred to the new container.

Based on observation, interview, and record review, the facility failed to ensure residents were free of accidents and hazards for one of three sampled residents (Resident 1) when: 1. Resident 1 was not accurately assessed for Fall Risk Assessment and Intradisciplinary team (IDT, a coordinated group of experts from several different fields who work together toward a common business goal) Admission Assessment; 2. Staff did not develop and/or implement individualized interventions to prevent falls; and 3. Staff did not assist Resident 1 during toileting and left Resident 1 unsupervised inside the resident restroom. These failures resulted in Resident 1's unwitnessed fall with left femoral neck fracture (broken hip bone). Findings: Review of Resident 1's clinical record indicated Resident 1 was admitted on [DATE] and had diagnoses including left humerus fracture (broken upper arm bone), unspecified altered mental status, muscle weakness, difficulty in walking, abnormalities of gait and mobility, lack of coordination, reduced mobility, and repeated falls. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 1/26/23, indicated a brief interview for mental status (BIMS, a structured cognitive test) was not conducted because the resident was rarely/never understood. Resident 1 required extensive assistance (staff provide weight-bearing support) with one-person physical assist for bed mobility, transfer, and toileting. The MDS also indicated Resident 1 was not steady and was only able to stabilize with staff assistance for moving from seated to standing position, moving on and off toilet, and surface to surface transfers. Resident 1 had a fall with fracture prior to admission to the facility. Review of Resident 1's Fall Risk Assessment, dated 1/24/23, indicated Morse Fall Score of 25 (Moderate Risk). The assessment had a section that asked, Does the resident have more than one diagnosis on the chart? The answer No was marked in response to this question. The question that asked, What type of gait does the resident exhibit? The answer Normal was marked in response to this question. The question that asked, Does the resident ' s response to the above indicated they know the limits of their abilities to ambulate safely? The answer Knows own limits was marked in response to this question. The IDT Admission assessment dated [DATE], indicated Review for past 100 days: Fall related injury and Resident is: Fall risk were not marked. Review of Resident 1's Admission Note from the physician, dated 1/24/23, indicated She was admitted to the hospital status post fall with left humerus fracture. Resident is high risk of fall. Review of Resident 1's Occupational therapy progress report, dated 2/21/23, indicated, Resident will safely perform toileting tasks . with stand by assist (SBA, being there to help when help needed) and occasional tactile cues (a physical touch to guide) for clothing management . The report included impairments: body awareness deficits, decreased functional capacity, decreased safety awareness, and deficits in judgment. Review of Resident 1's fall risk care plan, dated 1/25/23, indicated she was at risk for falls and injuries related to pain, weakness, advanced age, reduced mobility, history of falling, repeated fall and dizziness. Some interventions on the care plan included keeping the resident's call light within reach, encouraging the resident to use the call light, and instructing the resident to avoid sudden position changes. Review of Resident 1's self-care deficit care plan, dated 1/25/23, indicated she required one-person physical assist with bed mobility, transfer, dressing, and toilet use. Review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation)-Fall Report of Incident, effective date 2/22/23, indicated Patient has unwitnessed fall in the bathroom . patient was brought into the bathroom and sat on the toilet. Certified Nursing Assistant A (CNA A) went to arrange the bed. CNA A found the resident on the floor. According to the SBAR, Resident 1 assessed with extremity deformity or misalignment, external head injury, she complained of pain, and she was transferred to the emergency department (ED) for evaluation. Review of Resident 1's Pelvis X-ray report, dated 2/23/23, indicated Findings demonstrate acute left femoral neck fracture. Review of Resident 1's IDT Post Fall Follow Up, signed date 3/06/23, indicated CNA assisted this resident to the toilet and left the resident for privacy. The CNA was in the resident's room arranging the bed sheets. When CNA heard the noise in the toilet, opened the door, resident was on the floor . The IDT Post Fall Follow Up indicated Reassess Fall Risk was marked for potential interventions evaluation. During an interview with the director of staff development (DSD) on 3/16/23 at 11:30 a.m., the DSD stated one-person physical assistance meant staff should stay with resident and provide supervision/assistance. The DSD further stated staff should not leave residents with one-person physical assist alone to do another task during toileting. During an interview and record review with the director of nursing (DON) on 3/16/23 at 11:45 a.m., the DON confirmed Resident 1 was not accurately assessed for the Fall Risk Assessment and the IDT Admission Assessment. The DON acknowledged the intervention on the fall risk care plan of providing reminders to Resident 1 was not an appropriate intervention because she would not remember. The DON stated staff should have stayed nearby to provide one-person physical assist. During a phone interview with CNA A on 3/16/23 at 1:38 p.m., CNA A stated he brought Resident 1 into the bathroom, told her to use a call device for assistance, and left her alone to fix her bed. CNA A stated he heard a noise and found the resident on the bathroom floor. CNA A further stated he did not stay outside the resident's bathroom and the resident did not ask for privacy. During Resident 1's room tour with the DON on 3/16/23 at 1:50 p.m., the toilet in the resident bathroom was not visible from the resident bed. The DON confirmed the observation. During a phone interview with LVN B on 3/16/23 at 1:57 p.m., LVN B confirmed she completed Resident 1's Fall Risk assessment dated [DATE]. LVN B stated Resident 1 had more than one diagnosis, her gait was not normal, and the resident didn't know her limits to ambulate safely. LVN B acknowledged Resident 1 was not accurately assessed for the Fall Risk Assessment. LVN B further stated she made mistakes. During an interview and record review with physical therapist C (PT C) on 3/16/23 at 2:56 p.m., she stated Resident 1 required a stand by assist during toileting. PT C further stated Resident 1 had decreased safety awareness and impulsiveness. During an interview and record review with registered nurse D (RN D) on 3/16/23 at 3:45 p.m., she stated CNA A brought Resident 1 into the bathroom, left to arrange bed, and the resident was found on the floor. RN D stated Resident 1's hip was deformed and she was transferred to ED. RN D stated Resident 1 was alert to person only and forgetful. RN C stated when staff reminded Resident 1 to use her call device, she would not remember to do so. RN D stated providing reminders to Resident 1 was not an appropriate intervention because she would not remember. RN D further stated staff should have stayed with the resident or stayed outside the bathroom door to provide one-person physical assist during toileting. Review of facility Fall Management dated 8/2014, indicated Purpose, to evaluate risk factors and provide interventions to minimize risk, injury, and occurrences. Assessment guidelines, may include fall risk factors/ fall history . Review of facility Care Plan, Comprehensive dated 2008, indicated The care plan is individualized by identified resident problems, unique characteristics, strengths, and individual needs. The care plan becomes a comprehensive tool for the IDT to utilize as a reference for resident specific problems and approaches to establish guidance on meeting the individual needs of the resident.