Every finding on record at Cedar Pine Post Acute

Based on observation, interview, and record review, the facility failed to provide the necessary proper care and services for two (2) of two sampled residents (Resident 7 and Resident 48) reviewed for indwelling catheter (a tube that allows urine to continuously drain from the bladder) as indicated in the facility's policy and procedure (P&P) by failing to ensure:Resident 7's indwelling catheter drainage tubing (connects a flexible tube inside the body to an external collection bag) has no sediments (a build-up of waste that collect in the urine tube or drainage bag) and catheter care was provided in accordance with the physician's order.Indwelling catheter care was provided for Resident 48 for 12 days in accordance with the resident's care plan and physician's order.This deficient practice increased the risk of blockage and urinary tract infections (UTI- an infection in any part of the urinary system) for Resident 7 and placed Resident 48 at risk for developing discomfort, urine leakage, infection, and a decreased quality of life Findings: 1. During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included retention of urine, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and absence of right and left leg below knee. During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool), dated 6/15/2026, the MDS indicated Resident 7 has independent (decisions consistent/reasonable) cognition (thought process and ability to reason or make decisions) for daily decision making. The MDS indicated Resident required supervision (helper provides verbal cues) with eating. The MDS indicated Resident 7 required partial/moderate assistance (helper does less than half the effort) with oral hygiene, upper body dressing and personal hygiene. The MDS indicated Resident 7 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower and lower body dressing. The MDS also indicated Resident 7 had an indwelling catheter. During a review of Resident 7's Care Plan focusing on Resident 7's risk for UTI related to indwelling foley catheter use, initiated on 6/8/2026, the Care Plan interventions included the following: Foley care every shift and after each bowel movement. Observe urine output for foul odor, sediments, color, amount, note abdominal pain and distention. During a review of Resident 7's Order Summary Report, dated 6/24/2026, the Order Summary Report indicated the following physician orders: Indwelling catheter care: wash with water and soap around urinary meatus (the opening at the tip of the penis) every shift and as needed, ordered on 6/8/2026. Flush foley catheter (a thin, flexible tube threaded through the urethra into the bladder to continuously drain urine) with 50 milliliters (ml, unit of measurement) normal saline (a saltwater solution) weekly (Monday) and as needed, ordered on 6/15/2026. During an observation on 6/23/2026 at 12:08 PM, in the dining room, Resident 7's indwelling catheter tubing was observed with sediments. During a concurrent observation and interview on 6/24/2026 at 9:56 AM, in Resident 7's room, Resident 7's indwelling catheter tubing was observed with sediments. Resident 7 stated they (facility staff) check and clean it sometimes. During a concurrent record review and interview on 6/26/2026 at 11:22 AM, with Registered Nurse 2 (RN 2), Resident 7's treatment administration record (TAR) for June 2026 was reviewed. RN 2 stated Resident 7's indwelling catheter care was not completed every shift in accordance with the physician's order. RN 2 stated that the following dates and shift have no documentation in the TAR under the indwelling catheter care: 6/9/2026 night shift (11 PM – 7 AM) 6/10/2026 evening shift (3 PM – 11 PM) and night shift. 6/14/2026 day shift (7 AM – 3 PM) and night shift. 6/15/2026 night shift. 6/21/2026 day shift. RN 2 stated Resident 7's TAR has missing documentation for indwelling care for total of five shift for the month of June 2026, RN 2 stated if it was not documented, it was not done. RN 2 stated that it is important for Resident 7's indwelling foley to be cared for every shift to prevent infection. During the same interview record review and interview on 6/26/2026 at 11:22 AM, with RN 2, Resident 7's treatment administration record (TAR) for June 2026 was reviewed. RN 2 stated that Resident 7's foley catheter has a documentation in the TAR that it was flushed on 6/22/2026 (Monday) and has no documentation of as needed flushing. RN 2 verified Resident 7's indwelling foley catheter tubing has sediments on 6/23/2026, and it should have been flushed to prevent blockage. During an interview on 6/26/2026 at 3 PM with Director of Nursing (DON), the DON stated Resident 7's indwelling catheter tubing should be free from sediments, and it should have been flushed in accordance with the physician's order. The DON stated the licensed nurses are responsible for providing indwelling catheter care and the DON did not know why there are multiple days and shifts that indwelling catheter care was not provided to Resident 7 as indicated in the TAR. During a review of the facility's P&P, titled, Incontinent Care, revised on January 2025, the P&P indicated to remove urine or feces from skin, to cleanse and lubricate skin, and to provide dry, odor free perineal care system. During a review of facility's P&P titled Policy and Procedure on Urinary Tract Infection,, revised on January 2025, the P&P indicated facility will provide the needed care and services to resident with diagnosis of UTI, and minimize, if possible, reoccurrence of the same. During a review of facility's P&P titled Catheter Care,, revised on January 2025, the P&P indicated to improve hygiene, and reduce infection by ensuring that catheter care is done every shift to residents who are using foley catheter, The P&P also indicated to observe the urine for any sediments or change in color and to notify Doctor for any sediments noted in the urine flow. 2. During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), disorder of kidney (organ that removes waste and extra water from the blood) and ureter (one of two muscular tubes that carry urine from the kidneys to the bladder [an organ that stores urine]) and UTI During a review of Resident 48's MDS, dated [DATE], the MDS indicated Resident 48 had moderately impaired cognitive for daily decision making. The MDS indicated Resident 48 required substantial/maximal assistance with toileting hygiene, shower/bathing self, supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity and setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating. The MDS also indicated Resident 48 had an indwelling catheter. During a review of Resident 48's Order Summary Report, dated 11/24/2025, the Order Summary Report indicated an indwelling catheter size 16 French (Fr- a scale used that measures the external diameter of the foley catheter tube) with seven (7) to 10 cubic centimeters (cc- a measurement of volume) balloon attached to gravity drainage bag for retention of urine. The Order Summary Report also indicated indwelling catheter care: wash with water and soap around urinary meatus (the external opening where urine exits the body from the urethra) every shift and as needed. During a review of Resident 48's Risk for UTI Related to Foley Catheter (indwelling catheter) Use, revised 11/24/2025, the care plan indicated for indwelling catheter care every shift and cleanse with soap and water around the urinary meatus. During a concurrent interview and record review on 6/25/2026 at 12:57 PM wit Treatment Nurse (TN), Resident 48's Treatment Administration Records (TAR), dated 5/1/2026 through 5/31/2026 and 6/1/2026 through 6/25/2026 were reviewed. The TARs indicated no catheter care was provided every shift on 5/9/2026, 5/20/2026, 5/22/2026, 5/26/2026, 5/27/2026, 5/31/2026, 6/3/2026, 6/9/2026, 6/14/2026, 6/20/2026, 6/21/2026 and 6/24/2026. TN stated Resident 48 has an indwelling catheter and the resident needs to receive catheter care every shift to prevent UTIs. TN stated Resident 48 is at a high risk to develop a UTI, and the catheter care decreases the bacteria that can enter the resident's bladder and/or indwelling catheter and cause a UTI. TN also stated if catheter care is not documented as done, the facility cannot ensure it was provided. During an interview on 6/26/2026 at 11:44 AM with the Director of Nursing (DON), the DON stated catheter care is provided to prevent infections. The DON stated a UTI can cause drainage, fever, confusion and hospitalization, so catheter care was very important and needed to be done every shift as in accordance with the physician's order. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person – Centered, revised 1/2025, the P&P indicated a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident

Based on observation, interview and record review, the facility failed to ensure three (3) of three sampled residents (Residents 57, 76 and 82) reviewed for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) were provided care and services to maintain independence, functional status, good grooming and personal hygiene by failing to:1. Provide feeding assistance to Resident 57 on 6/24/2026, during lunch meal. 2. Ensure Resident 76's fingernails on both hands were not long.3. Ensure Resident 82's fingernails on both hands were not long, jagged, and dirty. These deficient practices have the potential for Residents 57, 76 and 82 to develop skin issues/complications and had the potential to result in a negative effect on residents' quality of life and wellbeing.Findings: 1. During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was originally admitted to the facility on [DATE]. The admission record also indicated Resident 57's diagnoses included dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable fear or worry). During a review of Resident 57's Minimum Data Set (MDS – a resident assessment tool), dated 6/13/2026, the MDS indicated Resident 57 has severely impaired (never/rarely made decisions) cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 57 required partial/moderate assistance (helper does less than half the effort) with eating and oral hygiene. The MDS indicated Resident 57 required substantial/maximal assistance (helper does more than half the effort. helper lifts or holds trunks or limbs and provides more than half the effort) with upper body dressing. The MDS indicated Resident 57 was dependent (helper does all the of the effort) with toileting, showering, lower body dressing, and putting on/taking off footwear. During a review of Resident 57's care plan focusing on Resident 57's risk for further decline in Activities of Daily Living (ADL), initiated on 6/9/2026, the care plan interventions indicated encourage to continue participating in performing ADLs within capability including but not limited to combing hair, dressing, and feeding. During a review of Resident 57's care plan focusing on ineffective airway clearance related to chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), initiated on 6/11/2026, the care plans intervention indicated to keep head of bed elevated to 90 degrees to facilitate breathing. During an observation on 6/23/2026 at 1:35 PM, in Resident 57's room, Resident 57 was observed sitting on wheelchair, currently watching television (TV) with lunch tray on top of a bedside table in front of Resident 57. During a concurrent observation on 6/24/2026 at 12:50 PM and interview with Physical Therapist Assistant (PTA), in Resident 57's room, Resident 57 was observed eating lunch meal in bed without a staff assisting the resident. Resident 57 was observed having hard time reaching out the lunch meal that is on top of the bedside table across the bed. The head of the bed was observed to be low and should have been positioned higher to have a better positioning during meals. PTA stated the head of bed was not raised to 90 degrees to have a sitting position. During a concurrent observation on 6/24/2026 at 12:54 PM and interview with Certified Nurse Assistant 2 (CNA 2), in Resident 57's room, Resident 57 was observed eating lunch meal in bed without a facility staff assisting the resident. CNA 2 stated Resident 57 is alert and that CNA 2 can leave the resident alone because the resident can eat by herself. During an interview on 6/26/2026 at 8:08 AM with MDS Nurse (MDSN), the MDSN stated Resident 57 required partial assistance during meals. MDSN stated Resident 57 was not positioned correctly and should have been positioned 90 degrees in bed on 6/24/2026 during lunch meal. MDSN also stated when Resident 57 was only being given the lunch tray without ensuring Resident 57 was properly positioned, the staff really did not provide the needed assistance for Resident 57. During an interview on 6/26/2026 at 8:50 AM with Physical Therapist (PT), he (PT) stated all residents should be assisted with proper positioning during meals as part of the care the resident needed from staff members. PT stated Resident 57 needs to maintain an upright posture during meals promotes easier swallowing and prevents aspiration (accidentally breathing food, liquid, saliva, or stomach contents into the airway and lungs rather than swallowing them). During a review of the facility's P&P titled, Assisting the Resident with in-room meals, revised on January 2026, the P&P indicated the resident should be positioned so his or her head and upper body are as upright as possible and with the head tipped slightly forward. If the resident is served his or her meal in bed, use wedges and pillows to achieve a nearly upright position. 2. During a review of Resident 76's admission Record, the admission Record indicated Resident 76 was admitted to the facility on [DATE], Resident 76's diagnoses included cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area) affecting left non-dominant side, major depressive disorder (or also called clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems) and hypertension (high blood pressure) During a review of Resident 76's MDS), dated [DATE], the MDS indicated Resident 76 had intact cognitive skills for daily decision making. The MDS indicated Resident 57 required substantial/maximal assistance in toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, and sit-to- stand. The MDS also indicated Resident 76 needed partial moderate assistance in upper body dressing, personal hygiene, roll left and right, sit to lying, and lying to sitting on side of bed. During an observation on 6/23/2026 at 9:31AM inside Resident 76's room, Resident 76 was lying on his bed, with the head of the bed (HOB) elevated 60-degree angle (a unit for measuring angles, where a full circle is 360 degrees ) while reading a newspaper. Resident 76's left hand was contracted (a condition where the fingers or palm of the hand become permanently bent or curled). Resident 76's fingernails on both hands were long. During an observation and interview on 6/24/2026 at 9:03 AM inside Resident 76's room, Resident 76 was awake and lying on his bed and watching the news on the resident's cellphone. Resident 76 showed his long fingernails on his both hands and stated, I wanted it to be cut. During a concurrent observation and record review on 6/24/2026 at 2:50 PM with CNA 4, inside Resident 76's room. CNA 4 stated Resident 76 has long fingernails on both hands. CNA 4 stated they facility staff need to cut it so the residents will not scratch themselves and have a skin breakdown. CNA 4 also stated the facility staff have to keep the resident's fingernails short so microorganisms will not be living under their nails and it must be done every week or as needed. CNA 4 stated the facility needs to keep Resident 76 fingernails short so the resident cannot hurt himself because the resident has a contracted left hand and might accidentally poke or scratch himself. During an interview on 6/26/2026 at 10:11 AM with Director of Staff Development (DSD), DSD stated Resident 76's fingernails on both hands were really long and if Resident 76's left hand has long fingernails, it can cause skin breakdown because the resident has contracture on that hand. DSD also stated the facility staff should make sure the staff trims the residents' fingernails to prevent infection and skin breakdown. During a concurrent interview and record review on 6/26/2026 at 1:04 PM with the Director of Nursing (DON), Resident 76's Care Plan (CP) for ADLs dated 8/7/2025 was reviewed. The CP interventions did not indicate providing grooming and personal hygiene. The DON stated Resident 76's CP interventions were incomplete because it is missing to provide the resident grooming and personal hygiene. The DON stated the staff needs to trim the resident's fingernails at least twice per week to maintain cleanliness and prevent infection. The DON also stated Resident 76's long fingernails can cause skin breakdown and the resident can have infection. 3. During a review of Resident 82's admission Record, the admission Record indicated Resident 82 was admitted to the facility on [DATE]. Resident 82's diagnoses included lymphedema (a chronic disease marked by the increased collection of lymphatic fluid in the body, causing swelling, which can lead to skin and tissue changes), cellulitis (a bacterial infection that enters your skin and tissue through a wound) on bilateral lower extremities, gastroenteritis (inflammation of the stomach and intestines, causing pain, vomiting and diarrhea) and generalized muscle weakness. During a review of Resident 82's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 82 requires supervision or touching assistance (helper provides verbal cues and/or touching/ steadying and/or contact guard assistance as resident completes activity) when eating, oral hygiene, and personal hygiene. The MDS indicated Resident 82 also needed partial/ moderate assistance in upper body dressing, roll left and right, sit to lying, and lying to sitting on the side of the bed. The MDS indicated Resident 82 requires substantial/maximal assistance with toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, sit to stand, and chair/ bed-to-chair transfer. During a concurrent observation and interview on 6/23/2026 at 9:41 AM inside Resident 82's room, Resident 82 was sitting up on his bed and watching videos on his cellphone. Resident 82 showed his fingernails, they were long, jagged, with yellowish discoloration with blackish brown debris under the fingernails. Resident 82 stated I wanted to cut my long fingernails. They were dirty and discolored. It had dirt and it was long. I told the staff last Friday, but they told me they did not have the fingernail cart, which was not available on the weekend. During a concurrent observation and interview on 6/24/2026 at 9:07 AM inside Resident 82's room, Resident 82 was sitting up on his bed. Resident 82 stated my fingernails were still the same, they were still long and dirty. During a concurrent observation and interview on 6/24/2026 at 2:58 PM with CNA 4 inside Resident 82's room, Resident 82 showed his fingernails, they were long, jagged, with yellowish discoloration with blackish brown debris underneath the fingernails. CNA 4 stated Resident 82's fingernails were very dirty, the fingernails were long, jagged and discolored, and also had blackish debris under the fingernails. CNA 4 stated the facility staff need to cut Resident 82's fingernails short because there might be microorganisms living under the resident's fingernails. During an interview on 6/26/2026 at 10:10 AM with the DSD, DSD stated Resident 82's fingernails were long, jagged and dirty, they have brownish debris under the nails. DSD stated the staff did not check the resident's fingernails daily the staff should have offered to cut Resident 82's fingernails because it was dirty and it could cause infection. During a concurrent interview and record review on 6/26/2026 at 12:52 PM with DON, Resident 82's Care Plan (CP) for ADLs dated 6/22/2026 was reviewed. The CP interventions did not indicate providing grooming and personal hygiene. The DON stated the CP was incomplete because it is missing interventions such as grooming and offering to cut Resident 82's long fingernails as part of the resident's personal hygiene. The DON stated, Resident 5's fingernails were long and dirty; it can cause infection because microorganism/ bacteria can live under the resident's fingernails and the staff should have checked it daily. During a concurrent interview and record review on 6/26/2026 at 12:55 PM with DON, the facility's Policy and Procedure (P&P) titled, Nail Care dated 1/2025 was reviewed. The P&P indicated to promote cleanliness, safety, and neat appearance of all residents. The DON stated the staff did not follow the policy because Resident 82's fingernails were long and dirty, and the staff did not promote cleanliness for the residents. During a review of the facility's P&P titled, Activities of Daily Living, supporting dated 2001, the P&P indicated, residents will be provided with care, treatment, and services as appropriate to maintain or improve the resident's ability to carry out ADL. The P&P also indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, including appropriate support and assistance with hygiene, mobility (the capacity to move or be moved freely and easily) and dining.

Based on interview and record review, the facility failed to develop an individualized resident-centered care plan (CP, a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs)for four (4) of 23 sampled residents (Residents 16, 22, 35 and 73) in accordance with the facility's policy and procedure (P&P) by failing to have a care plan for:Resident 22's use of Montelukast (Singulair, a medication used to treat lung inflammation which has potentially dangerous side effects)Resident 73's use of a low air loss mattress (LALM, mattress overlay used to relieve pressure from a resident's back and help wounds heal).Resident 35 to have activities in accordance with the resident's activity assessment.Resident 16's noncompliance (when a resident does not follow a prescribed treatment plan) with fluid restriction as indicated on the physician's order by collecting water at his bedside. This deficient practice had the potential to cause Resident 16, 22, 35 and 73's care goals to not be met and care needs not be addressed, which could negatively affect the residents' overall well-being. Findings: 1. During a review of Resident 73's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness and stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the sacrum (lower end of the spinal area at the base of the spine). During a review of Resident 73's Minimum Data Set (MDS- a resident assessment tool), dated 5/26/2026, the MDS indicated Resident 73 had intact cognitive (ability to think and process information) skills for daily decision making. The MDS indicated Resident 73 was dependent (helper does all the effort) for showering, toileting hygiene, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 73 required supervision (helper provides verbal cues) for eating, and oral hygiene. The MDS indicated Resident 73 required substantial assistance (helper does more than half the effort) for upper body dressing. During a concurrent observation and interview on 6/23/2026 at 9:34 AM with Licensed Vocational Nurse 1 (LVN) 1, Resident 73 was observed in his room lying on a LALM. LVN 1 verified Resident 73 was lying on a LALM. During a concurrent interview and record review on 6/23/2026 at 9:40 AM with LVN 1, Resident 73's CPs, dated 4/1/2026 to 6/23/2026 were reviewed. LVN 1 stated Resident 73 does not have a CP for the use of LALM. LVN 1 stated that Resident 73 should have a CP for the use of LALM to monitor and determine whether the interventions are effective towards reaching a care goal. During a concurrent interview and record review on 6/26/2026 at 11:57 AM with the Director of Nursing (DON), the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised 1/2025 was reviewed. The P&P indicated: A comprehensive, person-centered CP that includes measurable objectives and timetables to meet the resident's physical and functional needs is developed and implemented for each resident. The comprehensive, person-centered CP describes the services that are to be furnished to attain or maintain the resident's highest practicable well-being. The CP reflects currently recognized standards of practice for problem areas and conditions. The DON stated it was important to follow the resident's plan of care of a resident and meet the needs of a resident. The DON stated that a LALM should have a CP to let licensed staff know how to care for a LALM, monitor its effectiveness and ensure it is used properly to prevent wounds. 2. During a review of Resident 22's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and cardiomegaly (enlarged heart). During a review of Resident 22's MD dated 6/7/2026, the MDS indicated Resident 22 had intact skills for daily decision making. The MDS indicated Resident 22 was independent for eating, oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 22 required supervision for showering. During a review of Resident 22's Order Summary Report, dated 4/19/2026, the Order Summary Report indicated Resident 22 was ordered Singulair. During a review of Resident 22's Medication Regime Review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication), dated 5/1/2026 to 5/18/2026, the MRR indicated that Resident 22 was receiving montelukast and required monitoring for a black box warning (BBW; serious, life threatening side effects). The MRR indicated to monitor for these behaviors in the care plan. During a concurrent interview and record review on 6/26/2026 at 8:39 AM with Registered Nurse Supervisor 1 (RNS 1), Resident 22's CPs, dated 2/28/2026 to 6/26/2026 were reviewed. RNS 1 stated Resident 22 does not have a CP for monitoring the BBW side effects of montelukast. RNS 1 stated that Resident 22 should have a CP for BBW monitoring to prevent Resident 22 from experiencing life-threating side effects that could lead to worsening conditions and possible hospitalization. During an interview on 6/26/2026 at 12:11 PM with the DON, the DON stated that a medication with a BBW needs a CP to monitor for side effects and to ensure the resident does not experience serious side effects. 3. During a review of the admission Record, the admission Record indicated Resident 35 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to encounter for attention to gastrostomy (a medical visit or procedure focused on the care, maintenance, or management of a gastrostomy tube [G-tube-an artificial opening in the stomach used for feeding or medication delivery]), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35 was severely impaired (never/rarely made decisions) with cognitive skills for daily decision making. The MDS indicated Resident 35 was dependent on the staff for the activities of daily living such as eating, oral hygiene, toilet hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 35's Activity Assessment (evaluates a resident's background to design personalized, person-centered activity programs), dated 3/10/2026, the Activity Assessment indicated Resident 35 has adequate vision and hearing. The Activity Assessment indicated Resident 35's past activity interests were to listen to music. The Activity Assessment indicated Resident 35's activity interest includes music, watching television (TV) and talking/conversing. During observation in Resident 35's room on 6/23/2026 at 12:09 PM, Resident 35 was observed asleep, in bed, no TV or radio was observed near Resident 35. During observation in Resident 35's room on 6/23/2026 at 1:26 PM, Resident 35 was observed awake, in bed, no TV or radio was observed near Resident 35. During a concurrent record review on 6/26/2026 at 10:52 AM, an interview with MDS nurse (MDSN), Resident 35's care plan was reviewed. MDSN stated Resident 35 did not and should have had a care plan regarding the specific activities appropriate for Resident 35. MDSN stated that it was important to reflect the specific activities and appropriate interventions on the care plan for the entire care team to know the specific activities for Resident 35. During an interview on 6/26/2026 at 10:55 AM with Activity Director (AD), the AD verified Resident 35 has no care plan for activities. The AD stated Resident 35's care plan for activities should include in-room activities such as providing TV or radio to listen to music and talking/conversing activities. During a review of Facility's P&P titled, Care Plan - Comprehensive Person- Centered), revised in January 2025, the P&P indicated facility develops and implements a comprehensive, person-centered care plan for each resident. The P&P also indicated the ca re plan interventions are derived form a thorough analysis of the information gathered as part of the comprehensive assessment. 4. During a review of Resident 16's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and end stage renal dialysis (ESRD - irreversible kidney failure) and dependence on renal (kidney) dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed). During a review of Resident 16's Order Summary Report, dated 5/20/2025, the Order Summary Report indicated fluid restriction of 1,000 cubic centimeters (cc- a measure of volume in the metric system) per day: Nursing: 260 cc total 60 cc – 11 PM to 7 AM 100 cc – 7 AM to 3 PM 100 cc – 3 PM to 11 PM Dietary: 740 cc total Breakfast - 300 cc Lunch - 240 cc Dinner – 200 cc During a review of Resident 16's MDS, dated [DATE], the MDS indicated Resident 16 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 16 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathing self, partial/moderate assistance (helper does less than half the effort) with personal and oral hygiene and setup or clean-up assistance (helper sets up or cleans up) with eating. The MDS also indicated Resident 16 was on a therapeutic diet (a specialized meal plan prescribed by a healthcare provider or registered dietitian to manage, treat, or prevent a specific medical condition). During an observation in Resident 16's room on 6/23/2026 at 12:22 PM, six (6) full cups (a small, round open container used for drinking liquids; a measure of volume equal to approximately 236.59 cc) of water and a bottle of soda were observed on Resident 16's bedside table. During an observation in Resident 16's room on 6/24/2026 at 12:41 PM, four (4) full cups of water and a bottle of soda were observed on Resident 16's bedside table. During a concurrent observation in Resident 16's room and interview on 6/25/2026 at 10:53 AM with Registered Nurse Supervisor 1 (RNS 1), 4 full cups of water and 1 bottle of soda were observed on Resident 16's bedside table. RNS 1 stated Resident 16 is on a fluid restricted diet, and he should not have more than the prescribed amount of water at his bedside for him to drink. RNS 1 stated the 4 cups of water should not be there, but Resident 16 was noncompliant and kept more than the prescribed amount of fluid at his bedside. RNS 1 also stated when Resident 16 receives fluid from the kitchen with his meals, he does not send them and keeps them at bedside and that is why they accumulate (gradually collect) at his bedside. During a concurrent observation in Resident 16's room and an interview on 6/25/2026 at 10:53 AM with RNS 1, 4 full cups of water and 1 bottle of soda were observed on Resident 16's bedside table. RNS 1 stated Resident 16 is on a fluid restricted diet and should not have more than the prescribed amount of fluid accessible at his bedside. RNS 1 stated the 4 cups of water should not have been present at bedside but explained that Resident 16 has been noncompliant with his fluid restriction and keeps more than the prescribed amount of fluid at his bedside. RNS 1 further stated that when Resident 16 receives fluids from the kitchen with his meals, he does not return them and instead keeps them at his bedside, which leads to an accumulation (gradually collection) of fluids. During a concurrent interview and record review on 6/25/2026 at 11:15 AM with RNS 1, Resident 16's electronic medical chart, dated 5/20/2025 through 6/25/2026, was reviewed. The electronic medical chart failed to indicate a care plan for Resident 16's noncompliance of keeping more than the prescribed amount of fluid at his bedside. RNS 1 stated there was no care plan developed for Resident 16's behavior of noncompliance but one should be in place. RNS 1 stated a care plan was needed to implement interventions to prevent Resident 16 from drinking excessive amounts of fluid at any time, which could put his health at risk for fluid overload (a condition when there is too much fluid in your body). During an interview on 6/26/2026 at 11:26 AM with the DON, the DON stated Resident 16 needed a care plan for keeping more than the prescribed amounts of fluid at bedside. The DON stated the care plan would include interventions of educating Resident 16 of risks and informing the dialysis staff and doctor when Resident 16 is noncompliant with fluid restrictions. During a review of the facility's P&P titled, Care Plans, Comprehensive Person- Centered, dated 1/2025, the P&P indicated a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P also indicated the comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment. The P&P also indicated assessments or residents are ongoing and care plans are revised as information about the resident and the residents' conditions change.

Based on interview and record review, the facility failed to ensure three (3) of 3 sampled residents (Resident 6, 16 and 18) reviewed for dialysis (a lifesaving treatment for residents with a kidney failure), who were receiving hemodialysis (process of removing waste products and excess fluid from the body) treatment were provided dialysis care and services in accordance with the facility policy by failing to ensure: Resident 6's dialysis arteriovenous (AV) fistula (vascular access in patients receiving regular hemodialysis) was assessed on 6/10/2026, 6/12/2026, 6/17/2026, and 6/19/2026 (4 days).Resident 16's urine output was monitored and recorded every shift.Resident 18's output was monitored and recorded every shift and the resident's weekly laboratory test was completed as ordered by the physician. These deficient practices have the potential for unnoticed or missed excessive bleeding and infection on Resident 6 dialysis AV fistula and placed Residents 16 and 18 at risk to experience complications of ESRD and negatively affect their physical, mental and psychosocial (the dynamic, interlocking relationship between an individual's psychological state and their social environment) health. Findings: 1. During a review of Resident 6's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was re-admitted on [DATE], with diagnosis of end stage renal disease (ESRD, irreversible kidney failure), anemia (a condition where the body does not have enough healthy red blood cells), and dementia (a progressive state of decline in mental abilities). During a review of Resident 6's Care Plan focused on the resident's diagnosis of ESRD, risk for complications related to hemodialysis, initiated on 4/23/2026, the Care Plan indicated staff intervention included the following: Assess access site on left upper arm AV shunt. Assess skin around access site, noting redness, swelling, local warmth, exudate and tenderness. Check for bruit (whooshing sound heard over an artery, usually with a stethoscope, indicating turbulent blood flow, often due to a narrowing or obstruction) and thrill (palpable vibration felt over an artery, also indicating turbulent blood flow). Monitor signs and symptoms of bleeding from the access site. Palpate skin around shunt (AV fistula) for warmth. During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool), dated 5/5/2026, indicated Resident 6's cognitive (ability to think and reason) skills for daily decision making was modified independence (some difficult in new situations only). The MDS indicated Resident 6 required supervision (helper provides verbal cues) with eating and oral hygiene. The MDS indicated Resident 6 required partial/moderate assistance (helper does less than half the effort) with upper body dressing and personal hygiene. The MDS indicated Resident 6 required substantial/maximal assistance (helper does more than half the effort) with shower, lower body dressing and putting on/taking off footwear. The MDS also indicated Resident 6 is on hemodialysis while a resident in the facility. During a review of Resident 6's Order Summary Report dated 6/24/2026, the Order Summary Report indicated hemodialysis, every Tuesday, Thursday, and Saturday, ordered on 6/7/2026. During a concurrent record review and interview on 6/24/2026 at 2:34 PM, with Licensed Vocational Nurse 2 (LVN 2), Resident 6's Nurse's Dialysis Communication Record, dated 6/10/2026, 6/12/2026, 6/17/2026, and 6/19/2026 were reviewed. The form indicated under the post dialysis check which included dialysis access site, AV shunt check was not completed on 6/10/2026 and 6/12/2026. LVN 2 stated the Nurse's Dialysis Communication Record was not filled out completely when the resident returned from dialysis on 6/10/2026, 6/12/2026 afternoon The form indicated under pre dialysis assessment which included access site, AV shunt was not completed on 6/17/2026 and 6/19/2026. LVN 2 stated the dialysis communication record's post dialysis check for Resident 6 should be completed by the charge nurse upon resident's return from dialysis to know the status of the resident and the resident's AV shunt. LVN 2 stated dialysis communication record's pre dialysis assessment for Resident 6 should be completed by the charge nurse who is assigned to Resident 6 before leaving the facility for dialysis to know the status of the resident and the resident's AV shunt. LVN 2 stated it was important to properly assess resident, document accurately, and complete the Nurse's Dialysis Communication Record to make sure that residents will receive the proper care. LVN 2 added charge nurses need to check vital signs (clinical measurements of pulse rate, temperature, respiration rat and blood pressure) and the resident's dialysis access site such as the AV shunt needs to be observed or assessed and document it in the nurse dialysis communication form. During a concurrent record review and interview on 6/24/2026 at 3:27 PM, with Registered Nurse Supervisor 1 (RNS 1), Resident 6's Nurse's Dialysis Communication Record, dated 6/10/2026, 6/12/2026, 6/17/2026, and 6/19/2026 were reviewed. RNS 1 stated the Nurse's Dialysis Communication Record was not filled out completely on 6/10/2026, 6/12/2026, 6/17/2026, and 6/19/2026. The post dialysis check which included dialysis access site, AV shunt check was not completed on 6/10/2026 and 6/12/2026. RNS 1 stated assessing resident before and after dialysis is important to make sure Resident 6's dialysis AV shunt is not bleeding, no signs of infection and it is working well. RNS 1 stated, it was important to properly assess the residents and complete the Nurse's Dialysis Communication Record to ensure that residents will receive proper care. During a review of facility's Policy and Procedure (P&P) titled, Dialysis, dated January 2015, the P&P indicated the facility shall maintain an ongoing communication with the dialysis center's staff to coordinate the care and services of each resident receiving dialysis treatment with ESRD. The P&P indicated communication method to coordinate the resident's condition, treatment plan and response, with the dialysis center's staff shall be dialysis communication form. The P&P also indicated that licensed nurses shall document condition prior to treatment, and upon resident's return from the treatment. 2. During a review of Resident 16's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), ESRD and dependence on renal (kidney) dialysis. During a review of Resident 16's Order Summary Report (active as of 6/24/2026), the Order Summary Report indicated for Resident 16 to receive dialysis one time a day every Tuesday, Thursday, Saturday related to ESRD, ordered on 2/1/2025. During a review of Resident 16's Care Plan for Risk for Complication related to Hemodialysis, initiated on 2/1/2025, the care plan indicated to monitor intake and output every shift. During a review of Resident 16's MDS, dated [DATE], the MDS indicated Resident 16 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 16 required substantial/maximal assistance with toileting hygiene, shower/bathing self, partial/moderate assistance with personal and oral hygiene and set-up or clean-up assistance (helper sets up or cleans up) with eating. The MDS also indicated Resident 16 was on a therapeutic diet (a specialized meal plan prescribed by a healthcare provider or registered dietitian to manage, treat, or prevent a specific medical condition) and received dialysis. During a concurrent record review and interview on 6/24/2026 at 2:42 PM with LVN 1, Resident 16's Intake & Output Record, dated 5/22/2026 through 6/23/2026, and Resident 16's electronic medical chart from 5/22/2026 through 6/23/2026 were reviewed. Both records did not indicate Resident 16's urine output was monitored and recorded on 5/28/2026 for the 11 PM to 7 AM shift. LVN 1 stated there was no documented urine output for Resident 16 during this shift and there should have been per facility policy and the resident's care plan. 3. During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was originally admitted to the facility on [DATE] with diagnoses that included ESRD, dependence on renal dialysis and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 18's Risk for Complication related to Hemodialysis care plan, revised 8/26/2025, the care plan indicated to monitor intake and output every shift and laboratory as ordered. During a review of Resident 18's Order Summary Report, (active orders as of 6/25/2026), it indicated for Resident 18 to receive dialysis one time a day every Monday, Wednesday, and Friday related to ESRD, ordered 10/1/2025.The Order Summary Report also indicated for complete blood count (CBC- a standard blood test used to evaluate your overall health and detect a wide range of disorders) and basic metabolic panel (BMP- a routine blood test that measures your body's fluid balance, electrolyte levels, metabolism, and kidney function) every Thursday for ESRD, starting 1/22/2026. During a review of Resident 18's MDS, dated [DATE], the MDS indicated Resident 18 had intact cognitive skills for daily decision making. The MDS indicated Resident 18 was independent (resident completes the activity by themselves with no assistance from a helper) with eating, oral, toileting and personal hygiene, dressing and shower/bathing self. The MDS also indicated Resident 18 was on a therapeutic diet and received dialysis. During a concurrent record review and interview on 6/24/2026 at 2:51 PM with LVN 1, Resident 18's Intake & Output Record, dated 5/22/2026 through 6/23/2026, and Resident 18's electronic medical chart from 5/22/2026 through 6/23/2026 were reviewed. Both records did not indicate Resident 18's output was monitored and recorded from 11 PM to 7 AM shift on 5/27/2026, 5/28/2026, 6/2/2026, 6/4/2026 and from 7 AM to 3 PM shift on 5/31/2026. LVN 1 stated there was no documented urine output for Resident 18 during these shifts and there should have been per facility policy. During an interview on 6/25/2026 at 10:53 AM with RNS 1, RNS 1 stated for per facility policy, all residents who receive dialysis should have their intake and urine output (I&O) monitored and documented in the resident's medical records each shift. RNS 1 stated it was necessary to monitor the I&O of these residents to ensure they residents are not receiving too much fluid, coordinate with dialysis staff the status of the resident and ensure the appropriate care is provided. During an interview on 6/26/2026 at 11:20 AM with the Director of Nursing (DON), the DON stated Resident 18receiving dialysis should have I&O monitoring every shift to ensure Resident 18 is receiving the fluid restriction as ordered and the monitoring needs to be documented and recorded in the resident's medical record. The DON stated if I &O monitoring was not done, the resident would be at risk for fluid overload (occurs when the body retains too much water and sodium) where the resident may experience congestion (refers to an abnormal or excessive accumulation of bodily fluids. This could be localized inflammation in the nasal passages, or fluid retention in organs like the lungs), edema (swelling) and distress. During an interview and record review on 6/25/2026 at 3:21 PM with RNS 1, Resident 18's laboratory test records dated 1/1/2026 through 6/25/2026 were reviewed. Resident 18 laboratory test records indicated a CBC and BMP was completed monthly for Resident 18 and did not indicate it was done weekly. RNS 1 stated Resident 18's CBC and BMP were done monthly and not as ordered by the physician which is weekly. RNS 1 stated the order should have been followed or clarified with a new order. RNS 1 stated laboratory test should have been done as ordered because Resident 18 received dialysis and his labs can fluctuate due to the resident's kidneys not working properly. During an interview on 6/26/2026 at 11:32 AM with the DON, the DON stated Resident 18 had an order for weekly laboratory test (CBC and BMP) that were not completed by the facility. The DON stated it was important for Resident 18's laboratory test to be done as ordered to make sure the resident's blood levels are addressed, assessed and reported to the MD as necessary. The DON added, if the laboratory tests are not completed, the staff would not know if there were any problems that needed to be addressed and the residents could experience symptoms related to abnormal laboratory levels. During a review of the facility's P&P titled, Dialysis, revised 1/2015, the P&P indicated licensed nurses shall document the intake monitoring of fluid restriction if ordered. During a review of the facility's policy and procedure (P&P) titled Intake and Output (I&O), revised 8/2025, the P&P indicated it was the policy of the facility to maintain an intake and output record when needed to monitor residents for adequate fluid balance and dialysis residents I&O monitoring is indefinite unless ordered by the medical doctor (MD) to discontinue. The P&P also indicated licensed staff will document fluids consumed in appropriate area of I&O sheet for each shift.

Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM- a specialized medical mattress designed to prevent and treat pressure ulcer [wound that occurs as a result of prolonged pressure on a specific area of the body] by maintaining a cool, dry environment through constant airflow, which helps regulate temperature and moisture) was on the correct setting for two (2) of four (4) sampled residents (Resident 5 and 35) in accordance with the physician's orders and LALM operator's manual instructions. This deficient practice placed Residents 5 and 35 at risk of development of new pressure ulcers, poor wound healing and deterioration (something once in good condition is now weakened, worn out, or otherwise in decline) of current pressure ulcers. Findings: 1. During a review of the admission Record, the admission record indicated Resident 35 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to encounter for attention to gastrostomy (a medical visit or procedure focused on the care, maintenance, or management of a gastrostomy tube [G-tube-an artificial opening in the stomach used for feeding or medication delivery]), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 35's Minimum Data Set (MDS- a resident assessment tool), dated 3/30/2026, the MDS indicated Resident 35 was severely impaired (never/rarely made decisions) with cognitive skills for daily decision making. The MDS indicated Resident 35 was dependent (helper does all of the effort) from the staff for the activities of daily living such as eating, oral hygiene, toilet hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 35's weight summary dated from 4/1/2026 to 6/23/2026, the resident's weight indicated the resident's weight on 6/10/2026 is 158 pounds (lbs.). During a review of Resident 35's Braden scale for predicting pressure sore risk (a tool used in healthcare to assess a resident's risk of developing pressure ulcers by evaluating six factors: sensory perception, moisture, activity, mobility, nutrition, and friction/shear), dated 3/21/2026, timed at 8:53 AM, it indicated Resident 35 was moderate risk for developing pressure ulcer. During an observation in Resident 35's room on 6/23/2026 at 12:09 PM, observed Resident 35 resting in bed with LALM setting at approximately 225 lbs. During an observation in Resident 35's room on 6/23/2026 at 1:26 PM, observed Resident 35 resting in bed with LALM setting at 225 lbs. During a concurrent observation and interview with Treatment Nurse (TN) in Resident 35's room on 6/24/2026 at 2:58 PM, observed Resident 35 resting in bed with LALM setting at 225 lbs. TN verified, the LALM setting was incorrect because Resident 35's weight is not 225 lbs. TN stated Resident 35 is high risk on developing pressure ulcer, and Resident 35 would benefit from the use of LALM if it is in the correct setting. TN stated the CNAs do not touch the settings for the LALM because that responsibility falls on the licensed nurses since the reason for the LALM is to help reduce the pressure on the resident's skin and prevent pressure ulcer from getting worse or developing a new pressure ulcer. TN stated, LAL mattress settings are set by the treatment nurse, but the charge nurses check it too. We know how to place the settings because it is according to the resident's weight. During an interview on 6/24/2026 at 3:26 PM with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated LALM setting should be based on the resident's weight. RNS 1 stated not setting the LALM correctly according to the directions in the LALM manual or physician's orders will not help the residents' wounds or skin condition since the LALM was to prevent skin damage or relieve pressure from the resident's skin. RNS 1 stated, If the settings are off, the LALM may not have enough pressure relief and that will cause more harm than good to the resident. It does not help the resident to have a hard mattress, that can cause skin breakdown, and it can be a potential for infection, especially if the resident is incontinent. The whole use for the LALM is to prevent any further damage to the resident's skin. During a record review of Facility's Brand 2's LALM manual, the manual operation guide indicated to set according to the weight of the patient. 2. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE]. The admission record indicated Resident 5's diagnoses included cirrhosis of the liver (is permanent scarring that damages your liver and interferes with its functioning) and history of stage II pressure ulcer (is one that has progressed to affect both the top and bottom layers of the skin but has not yet affected the fatty tissue beneath) of the left buttock, and anxiety disorder (mental health condition marked by persistent excessive worry, fear, or nervousness that interferes with daily life), During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 5 was dependent in oral hygiene, toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, personal hygiene, roll left and right, sit to lying, lying-to-sitting on the side of the bed, and chair/ bed-to-chair transfer, and tub/ shower transfer. The MDS also indicated Resident 5 was at risk for pressure ulcers. During a record review of Resident 5's weight summary dated 6/10/2026, the summary indicated Resident 5's weight was 152 lbs. During an observation on 6/23/2026 at 10:14 AM inside Resident 5's room, Resident 5 was sleeping, and lying on a LALM which was set at 260 lbs. During an observation on 6/23/2026 at 12:52 PM inside Resident 5's room, Resident 5 was awake and lying on a LALM which was set at 260 lbs. During a concurrent observation and interview on 6/24/2026 at 8:59 AM inside Resident 5's room, Resident 5 was awake and watching television while lying on the LALM which was set at 260 lbs. Resident 5 stated the bed (LALM) was hard and it hurts his back a little bit. During a concurrent observation and interview on 6/24/2026 at 1:02 PM inside Resident 5's room, Resident 5 was lying on the LALM set at 260 lbs. Licensed Vocational Nurse 3 (LVN 3) stated, the LALM was set incorrectly because the LALM was set up 260 lbs. and not according to Resident 5's weight. During a concurrent observation and interview on 6/24/2026 at 1:04 PM with RNS 1 inside Resident 5's room, Resident 5 was lying on the LALM set at 260 lbs. RNS 1 stated Resident 5's LALM was set at 260 lbs., the LALM was too firm for Resident 5. RNS 2 stated, Resident 5 weight last 6/10/2026 was 152 lbs. and the LALM should be set according to the resident's weight so the LALM is not too firm for the resident. RNS 1 stated, Resident 5 can develop pressure ulcers if LALM set incorrectly and it defeats the purpose of avoiding pressure on the residents' pressure points (bony areas of the body). During a concurrent interview and record review on 6/24/2026 at 3:03 PM with TN, Resident 5's Braden Scale Assessment (BSA) dated 4/21/2026 was reviewed. The BSA indicated Resident 5 was at high risk for developing pressure ulcers. TN stated Resident 5 was high risk for developing pressure ulcers and if the resident's LALM was set incorrectly and higher than Resident 5's weight the LALM will be too hard, and the resident can develop new pressure ulcers, and can contribute to the worsening of the resident's current pressure ulcer. During a concurrent interview and record review on 6/26/2026 at 12:23 PM with the Director of Nursing (DON), Resident 5's Physician Order (PO) dated 5/24/2026 was reviewed. The PO indicated may have LALM for skin maintenance. The DON stated the PO was incomplete, it should have included LALM set up should be based on the resident's weight. During a concurrent interview and record review on 6/26/2026 at 12: 23 PM with the DON, Resident 5's Care Plan (CP) for left buttock stage II pressure ulcer, dated 4/5/2026, was reviewed. The CP indicated in the interventions, may have LALM for skin maintenance. The DON stated Resident 5's CP interventions were incomplete because it should have included the use of LALM, indication for use and LALM set up based on Resident's weight, and this is to ensure that interventions were properly implemented. During a concurrent interview and record review on 6/26/2026 at 12:25 PM with the DON, the facility's Policy and Procedure (P&P) titled Air Loss Mattress revised on 7/2012 was reviewed. The P&P indicated: Air pressure of the air loss mattress will be adjusted based on the resident's weight to serve the purpose. The facility staff will maintain the air pressure that will suit and meet the needs of the Resident to serve the purpose of healing enhancement. The DON stated the licensed staff were not following the policy if the LALM of Resident 5 and 35 was set up incorrectly, it defeats the purpose to maintain the skin integrity of the residents and the residents can develop a new pressure ulcer.

Based on observation, interview, and record review, the facility failed to maintain an accurate and complete medical records for one (1) of 23 sampled residents (Resident 73) in accordance with the facility's policy and procedures (P&P) by failing to document Resident 73's use of low air loss mattress (LALM, designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown).This deficient practice has the potential to cause Resident 73 to receive inappropriate care. Findings:During a review of Resident 73's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness and stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacrum (lower end of the spinal area at the base of the spine). During a review of Resident 73's Minimum Data Set (MDS- a resident assessment tool) dated 5/26/2026, the MDS indicated Resident 73 had intact cognitive (ability to think and process information) ability. The MDS indicated Resident 73 was dependent (helper does all the effort) for showering, toileting hygiene, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 73 required supervision (helper provides verbal cues) for eating, and oral hygiene. The MDS indicated Resident 73 required substantial assistance (helper does more than half the effort) for upper body dressing. The MDS did not indicate Resident 73 was using a pressure reducing device for bed. During a concurrent observation and interview on 6/23/2026 at 9:34 AM with Licensed Vocational Nurse (LVN) 1, Resident 73 was observed in his room on a LALM. LVN 1 stated Resident 73 is on a LALM. During a concurrent interview and record review on 6/23/2026 at 9:36 AM with LVN 1, Resident 73's Order Summary Report dated 4/1/2026 to 6/22/2026 and Resident 73's Nursing Progress Notes dated 4/1/2026 to 6/22/2026 were reviewed. LVN 1 stated Resident 73 does not have an order for LALM and the progress notes did not indicate LALM was used for the resident, but the resident is using a LALM (LVN 1 unable to recall since when). LVN 1 stated LALM use requires an attending physician (MD) order because it is a special treatment for pressure ulcer prevention. During a concurrent interview and record review on 6/26/2026 at 12:05 PM with the Director of Nursing (DON), the facility's P&P titled, Policy and Procedure on Air Loss Mattress, revised 7/2012 was reviewed. The P&P indicated:The purpose of this procedure is to ensure that resident skin integrity is maintained and to aid in healing pressure ulcer.LALM will be applied on the resident's bed as MD order.The DON stated that the policy indicated the use of a LALM requires an MD order. The DON stated it is important to have an order for the LALM so it can be used properly and prevent wounds from getting worse. During a concurrent interview and record review on 6/26/2026 at 12:08 PM with the DON, the facility's P&P titled, Physician Orders and Telephone Orders, revised 8/2025 was reviewed. The P&P indicated:Physician's orders shall be obtained prior to the initiation of any medication or treatment.All orders must be specific and complete.All orders must be specific and complete will all the necessary details to carry out the prescribed order without any questions.The DON stated LALM order should have been obtained for Resident 73 prior to starting the resident on the treatment and the use of the LALM should have been documented in the resident's medical records whether in the resident's progress notes or in the treatment administration record from when the resident was placed on LALM. During a review of the facility's P&P titled, Policy and Procedure on Documentations, revised 1/2025, indicated:It is the policy of the facility to document all pertinent data and information of each resident in their respective medical record.Approaches and interventions are documented in order to help residents minimize problems and in the final course achieve resident goals.

Based on observation, interview, and record review, the facility failed to provide oxygen therapy (treatment that provides supplemental, or extra oxygen) as indicated in the physician's order for one (1) of one sampled residents (Resident 5) reviewed for respiratory and oxygen in accordance with the facility's policy and procedures (P&P). This deficient practice had the potential to place Resident 5 at risk for shortness of breath (SOB) or hyperoxia (breathing excess oxygen) which could trigger oxygen toxicity (or poisoning, is damage to the lungs that happens from breathing in too much oxygen. It can cause coughing, trouble breathing, and even death in severe cases) that can lead to irreversible damages of health and/or death.Findings:During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE]. The admission record indicated Resident 5's diagnoses included cirrhosis of the liver (is permanent scarring that damages your liver and interferes with its functioning) and history of stage II pressure ulcer (is one that has progressed to affect both the top and bottom layers of the skin but has not yet affected the fatty tissue beneath) of the left buttock, and anxiety disorder (mental health condition marked by persistent excessive worry, fear, or nervousness that interferes with daily life). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool) dated 4/13/2026. The MDS indicated Resident 5 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 5 was dependent in oral hygiene, toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, personal hygiene, roll left and right, sit to lying, lying-to-sitting on the side of the bed, and chair/ bed-to-chair transfer, and tub/ shower transfer. During a review of Resident 5's Physician Orders dated 4/1/2026, the PO indicated Oxygen at 2 liters per minute (lpm, unit of measurement) via nasal cannula (a lightweight, flexible tube used to deliver supplemental oxygen to people with breathing difficulties) continuously for SOB, respiratory distress, can titrate to 5 lpm via nasal cannula or mask, to monitor for oxygen saturation (SpO2, is a measurement of how much oxygen your blood is carrying as a percentage of the maximum it could carry. Normal value is 95% to 100%) if greater than (>) 92% to check oxygen saturation every shift. During an observation on 6/23/2026 at 10:15 AM inside Resident 5's room, Resident 5 was sleeping and using an oxygen machine (oxygen concentrator, a medical device that gives extra oxygen by taking and filtering air from the surroundings) that was set at more than (>) 5 lpm via nasal cannula. During a concurrent observation and interview on 6/23/2026 at 10:20 AM with Licensed Vocational Nurse 3 (LVN 3) inside Resident 5's room, oxygen machine was set at more than 5 lpm, and the oxygen machine was beeping and had an orange light on. LVN 3 came inside the room and looked at Resident 5's oxygen machine and stated Resident 5's oxygen level was higher than 5 lpm. During an interview on 6/24/2026 at 12:58 PM with LVN 3, LVN 3 stated Resident 5's oxygen machine was set incorrectly yesterday (6/23/2026 at 10:20 AM), and it was set up more than 5 lpm. LVN 3 did not answer when asked what would happen to Resident 5 if the resident was receiving oxygen for >5lpm. During an interview on 6/24/2026 at 1:01 PM with Registered Nurse Supervisor RNS 1 (RNS 1), RNS 1 stated the oxygen setting was higher than 5 lpm, Resident 5 will possibly feel drowning from receiving too much oxygen. During a concurrent observation and interview on 6/24/2026 at 1:03 PM with the Director of Nursing (DON) inside Resident 5's room, the DON stated Resident 5's oxygen machine was set up incorrect, it was more than 5 lpm. The DON stated Resident 5's lungs can possibly collapse from receiving too much oxygen. The DON also stated the licensed staff should check the oxygen machine every time they do rounds, when they give medicine and every 2 hours. During a concurrent interview and record review on 6/26/2026 at 12:35 AM with the DON, Resident 5's Treatment Administration Record (TAR, is a structured document used to track the administration of medications, treatments, or interventions, ensuring accuracy, safety, and compliance in patient care) dated 6/1/2026 to 6/26/2026 was reviewed. The TAR indicated no documentation of Resident 5's oxygen saturation and level of oxygen administered every shift on the following dates:6/7/2026, 6/9/2026, 6/10/2026, 6/14/2026, 6/15/2026 for the night shift, 6/8/2026, 6/9/2026, 6/10/2026 for evening shift and6/14/2026 for morning shiftThe DON stated the licensed staff should be monitoring Resident 5's oxygen saturation and level of oxygen administered every shift and should be documented it in the TAR. The TAR had incomplete documentation from the staff, the TAR was missing oxygen saturation documentation and the level of oxygen administered to the resident. If the TAR was inaccurate and incomplete, the licensed staff did not follow the physician's order. If the licensed staff were not following PO, they did not monitor Resident 5's oxygen saturation every shift, and there's no documentation that the correct amount of oxygen was being given to the resident. During a concurrent interview and record review on 6/26/2026 at 12:41 PM with the DON, Resident 5's Care Plan (CP) for continuous oxygen therapy dated 4/1/2026 was reviewed. The CP interventions did not include goals and interventions such as assessments, monitoring signs and symptoms (s/s) respiratory distress like shortness of breath and monitoring oxygen saturation every shift. The DON stated the CP interventions were incomplete because they were missing goals and interventions. The DON stated the CP interventions should include assessments, monitoring signs and symptoms (s/s) respiratory distress like shortness of breath, monitoring of the resident's oxygen saturation every shift and checking oxygen setting. During a concurrent interview and record review on 6/26/2026 at 12:46 PM with the DON, the facility's Policy and Procedure (P&P) titled Oxygen Administration revised on 10/2010 was reviewed. The P&P indicated after completing oxygen set up or adjustment, the following information should be recorded in the resident's medical record:the rate of oxygen flow, route and rationalethe frequency and duration of the treatment.All assessment data obtained before, during and after the procedure.The DON stated the licensed staff did not follow the policy because there were no documentation and monitoring of Resident 5's oxygen saturation and level of oxygen administered to the resident every shift.

Based on observation, interview and record review, the facility failed to provide podiatry (prevention, diagnosis, and treatment of disorders affecting the foot, ankle, and lower limb) services for one (1) of 1 sampled resident (Resident 82) as indicated in the physician's order and facility's policy and procedure. This deficient practice had the potential for Resident 82 to develop foot and skin issues/complications and had the potential to negatively affect the resident's quality of life and self-esteem.Findings:During a review of Resident 82's admission Record, the admission Record indicated Resident 82 was admitted to the facility on [DATE]. Resident 82's diagnoses included lymphedema (a chronic disease marked by the increased collection of lymphatic fluid in the body, causing swelling, which can lead to skin and tissue changes), cellulitis (a bacterial infection that enters the skin and tissue through a wound) of the bilateral lower extremities, gastroenteritis (inflammation of the stomach and intestines, causing pain, vomiting and diarrhea), and generalized muscle weakness During a review of Resident 82's Minimum Data Set (MDS, a resident assessment tool), dated 6/29/2026, the MDS indicated the resident's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making were moderately impaired. The MDS indicated Resident 82 required supervision or touching assistance (helper provides verbal cues and/or touching/ steadying and/or contact guard assistance as resident completes activity) with eating, oral hygiene, and personal hygiene. The MDS indicated Resident 82 also needed partial/ moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs but provides less than half the effort) with upper body dressing, roll left and right, sit to lying, and lying to sitting on the side of the bed. The MDS indicated Resident 82 required substantial/maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) with toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, sit to stand, and chair/ bed-to-chair transfer. During a concurrent observation in Resident 82's room and interview on 6/23/2026 at 9:39 AM, Resident 82 was sitting up in bed watching videos on his cellphone. Resident 82 showed his bilateral lower extremities, which showed thick, yellowish toenails on both feet. Resident 82 stated, I wanted to see a podiatrist. I informed all the staff. I wanted him (podiatrist) to check my feet and cut my toenails; they are long, thick, and growing upward. I cannot reach them. During an interview on 6/23/2026 at 9:45 AM, Resident 82 stated that a podiatrist visited the facility on 6/20/2026. The podiatrist saw his roommate but did not speak with Resident 82. Resident 82 stated that he asked Registered Nurse Supervisor 2 (RNS 2) if the podiatrist could speak with him, but RNS 2 said no, which made him feel frustrated. Resident 82 stated he simply wanted the podiatrist to examine his feet and provide information. During an interview on 6/25/2026 at 11:03 AM, RNS 2 stated the podiatrist came to the facility on Saturday, 6/20/2026. Resident 82 asked her to request that the podiatrist check his feet and speak with him. RNS 2 asked the podiatrist, but Resident 82 was not on the list of residents scheduled to be seen. RNS 2 stated she did not endorse Resident 82's request to the next shift and did not inform Resident 82 that he was not included on the podiatry list for that day. Resident 82 had thick, long, yellowish toenails on both feet. During an interview on 6/25/2026 at 11:09 AM, RNS 2 stated she did not inform any other staff of Resident 82's podiatry request and did not document it in the communication book. RNS 2 stated she did not initiate a podiatry consultation request for Resident 82 and did not follow up with the Social Services Director (SSD). RNS 2 stated that if a resident requests a consultation, it must be endorsed to the SSD, or the resident will not be seen by the podiatrist. During a concurrent interview and record review on 6/26/2026 at 12:58 PM with the Director of Nursing (DON), Resident 82's Care Plan (CP) for podiatry consult dated 6/18/2026 was reviewed. The CP interventions indicated:Provide evaluation for referralPodiatry consult, as neededInstruct/show resident the proper techniqueUtilize medication for infection as orderedPerform with assist The DON stated the licensed staff should have left a follow-up note for the SSD in the communication book for Resident 82 to be seen by the podiatrist to avoid delay of treatment. During a concurrent interview and record review on 6/26/2026 at 1:01 PM with the DON, the facility's Policy and Procedure (P&P) titled, Ancillary Services dated 8/2024 was reviewed. The P&P indicated to ensure that all ancillary services provided to residents are safe, appropriate. timely, and compliant with applicable federal, state0 and local laws and regulations. These services may include but are not limited to:Physical therapy (PT, is a medical treatment used to restore functional movements, such as standing, walking, and moving different body parts),Occupational therapy (OT, use of self-care and work and play activities to promote and maintain health, prevent disability, increase independent function, and enhance development) Speech therapy (evaluates and treats communication disorders, cognitive-communication issues, and swallowing difficulties)Pharmacy Services (compounding and dispensing of medications. It also includes more modern services related to health care including clinical services, reviewing medications for safety and efficacy, and providing drug information with patient counselling)Laboratory Services Radiology/ImagingPodiatryOptometry (the practice or profession of examining the eyes for visual defects and prescribing corrective lenses),and Dental (the care and treatment of teeth) ServicesThe P&P also indicated ancillary services must be provided within reasonable time frames. The DON stated there was a miscommunication among staff and that RNS 2 did not timely communicate the information, resulting in a delay in podiatry services for Resident 82. This delay negatively affected Resident 82's emotions and self esteem.

Based on observation, interview, and record review the facility failed to provide a clean, comfortable, sanitary, and homelike environment for one (1) of three (3) sampled residents (Resident 57) reviewed for environment. On 6/23/2026, Resident 57's room was observed with a pillow and clothes on the floor near the trash can, a used/soiled diaper on the floor in front of Resident 57, and a green hairbrush on the resident's lunch tray. This deficient practice caused an unsanitary and unsafe environment and had the potential for Resident 57 to be placed at risk of infection and/ or injury.Findings:During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was originally admitted to the facility on [DATE]. The admission record also indicated Resident 57's diagnoses included dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable fear or worry). During a review of Resident 57's Minimum Data Set (MDS - a resident assessment tool), dated 6/13/2026, the MDS indicated Resident 57 has severely impaired (never/rarely made decisions) cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 57 required partial/moderate assistance (helper does less than half the effort) with eating and oral hygiene and Resident 57 required substantial/maximal assistance (helper does more than half the effort. helper lifts or holds trunks or limbs and provides more than half the effort) with upper body dressing. The MDS indicated Resident 57 was dependent (helper does all the of the effort) with toileting, showering, lower body dressing, and putting on/taking off footwear. During a review of Resident 57's care plan focusing on Resident 57's risk for further decline in Activities of Daily Living (ADL), initiated on 6/9/2026, the care plan indicated an intervention to provide safe and uncluttered environment. During a review of Resident 57's care plan focusing on medications of schizoaffective disorder, manifested by throwing food and utensils at staff/floor, initiated on 6/11/2026, the care plan indicated an intervention to monitor behavior of throwing food/utensils at staff/floor every shift. During dining observation on 6/23/2026 at 1:35 PM, in Resident 57's room, Resident 57 was observed sitting on wheelchair, watching television (TV) with lunch tray on top of a bedside table in front of Resident 57. Scattered clothes and a pillow were observed on the floor near a trashcan on the front right side of Resident 57's. Used/soiled diaper that is coiled with Resident 57's pants on the floor was observed in front of Resident 57's wheelchair, and a green hairbrush was observed on top of Resident 57's lunch tray. During an interview on 6/24/2026 at 1:06 PM, with Registered Dietitian (RD), RD stated Resident 57 did not have a clean and clutter free environment on 6/23/2026 and the resident should have a clean and clutter free environment. RD stated all residents should be provided with clean and safe environment because it could potentially be a hazard and is not homelike for the resident. During an interview on 6/26/2026 at 8:06 AM with Registered Nurse 2 (RN 2), RN 2 stated all residents' rooms should always be clean and sanitary to prevent infection. RN 2 stated Resident 57 was not clean and should have been provided with a clean and homelike environment during lunch meal on 6/23/2206. There were a pillow and clothes scattered on the floor near the trashcan, Resident 57's used diaper was on the floor in front of Resident 57's wheelchair, and a hairbrush was on Resident 57's lunch tray. During a review of Facility's Policy and Procedure (P&P) titled Homelike Environment, dated 2001, the P&P indicated residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The P&P indicated the facility staff, and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The characteristics included the following:Clean, sanitary, orderly environment.Clean bed and bath linens that are in good condition.

Based on observation, interview, and record review, the facility failed to ensure the call light (device used by residents to call staff for assistance) was within reach for one (1) of three (3) sampled residents (Resident 43) reviewed for environment in accordance with the facility's policy and procedure (P&P).This deficient practice has the potential to place Resident 43 at risk of not having his needs met and not receiving medical care in an emergency. Findings:During a review of Resident 43's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness, human immunodeficiency virus (HIV; a virus that compromises the body's ability to fight diseases), and dementia (a progressive state of decline in mental abilities). During a review of Resident 43's Minimum Data Set (MDS- a resident assessment tool) dated 4/14/2026, the MDS indicated Resident 43 had severely impaired cognitive (ability to think and process information) skills for daily decision making. The MDS indicated Resident 43 was dependent (helper does all the effort) for toileting hygiene, showering, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 43 required substantial assistance (helper does more than half the effort) for upper body dressing and personal hygiene. The MDS indicated Resident 43 required partial assistance (helper does less than half the effort) for eating and oral hygiene. During a concurrent observation in Resident 43's room and interview on 6/23/2026 at 9:04 AM, Resident 43 was observed lying on his bed. Resident 43 stated that he cannot find his call light. During a concurrent observation and interview on 6/23/2026 at 9:05 AM with Certified Nursing Assistant 1 (CNA1), Resident 43 was observed in bed with his call light tucked behind his back. CNA 1 stated that the call light was tucked under Resident 43's back. CNA 1 stated that if Resident 43 cannot locate his call light, he is unable to call for help when in distress. CNA 1 stated that Resident 43 could experience a medical emergency, such as difficulty breathing, and would not receive timely assistance if his call light is not within reach. CNA 1 stated that Resident 43's condition could worsen if he is unable to call for help. During a concurrent interview and record review on 6/26/2026 at 11:54 AM with the Director of Nursing (DON), the facility's P&P titled, Call Light/Bell, revised 1/2025 was reviewed. The P&P indicated:It is the policy of this facility to provide the resident a means of communication with nursing staff.The call light is to be immediately within reach when a resident is in bed.The DON stated that the policy indicated the call light must be in reach while the resident is in bed. The DON stated that it is important for the call light to be in reach of residents so they may be able to call for help and get assisted, especially during an emergency.

Based on interview and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 57) were free from unnecessary drug (any drug when used without adequate indications for its use by failing to have accurate indication for the use of donepezil hydrochloride (prescription medication used to treat the symptoms of dementia [a progressive state of decline in mental abilities]). This deficient practice had the potential to place Residents 57 at risk for significant adverse (harmful) consequences from the use of unnecessary drug.Findings: During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was originally admitted to the facility on [DATE]. The admission record also indicated Resident 57's diagnoses included dementia, schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable fear or worry). During a review of Resident 57's Minimum Data Set (MDS - a resident assessment tool), dated 6/13/2026, the MDS indicated Resident 57 has severely impaired (never/rarely made decisions) cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 57 required partial/moderate assistance (helper does less than half the effort) with eating and oral hygiene. The MDS indicated Resident 57 required substantial/maximal assistance (helper does more than half the effort. helper lifts or holds trunks or limbs and provides more than half the effort) with upper body dressing. The MDS indicated Resident 57 was dependent (helper does all the of the effort) with toileting, showering, lower body dressing, and putting on/taking off footwear. The MDS indicated a diagnosis of dementia. During a review of Resident 57's Order Summary Report dated 6/25/2026, timed 4:31 PM, the Order Summary Report indicated an order on 6/9/2026 for donepezil hydrochloride (HCL) (Aricept) oral tablet 5 milligrams (mg, unit of measurement), give 1 tablet by mouth at bedtime for cognitive impairment (problems with memory, learning, concentration, or decision-making). During a concurrent record review and interview on 6/26/2026 at 8:33 AM with Registered Nurse 2 (RN 2), Resident 57's donepezil HCL order dated 6/9/2026 was reviewed. RN 2 verified Resident 57 has an order for donepezil for cognitive impairment, ordered on 6/9/2026. RN 2 stated the diagnosis of cognitive impairment as an indication for the use of donepezil HCL was incorrect because it should have been for Resident 57's diagnosis of dementia. RN 2 stated that it was important to have the correct diagnosis or use of a medication to ensure it is being administered appropriately. During a concurrent record review and interview on 6/26/2026 at 11:50 AM with Registered Nurse Supervisor 1 (RNS 1), Resident 57's donepezil order dated 6/9/2026 was reviewed. RNS 1 verified Resident 57 has an order for donepezil HCL for cognitive impairment, ordered on 6/9/2026. RNS 1 stated that having an accurate diagnosis as the indication for any medication is essential to ensure the resident receives the correct medication for the correct purpose. During a review of Facility's Policy and Procedure (P&P) titled, Policy and Procedures on Unnecessary Drugs, revised on July 2012, the P&P indicated to carry out medications as Doctor's order with medication dosage, route, frequency and diagnosis to justify medication used.

Based on observation, interview, and record review, the facility failed to promote dignity and respect for two (2) of 23 sampled residents (Resident 71 and 72) reviewed for dignity, in accordance with the facility's policy when: On 6/23/2026 and 6/24/2026, facility staff did not ensure Resident 71 was not drooling while in the dining room and hallway, where the resident was visible to the visitors and other residents while the resident is in the dining room and in the hallway. 2. On 6/24/2026 and 6/25/2026, facility staff did not ensure Resident 72's meal trays were served within the facility's scheduled mealtimes. These deficient practices have the potential to affect Residents 71 and 72 sense of self-worth and self-esteem, which could negatively impact their emotional and mental well being Findings:1. During a review of Resident 71's admission Record, the admission Record indicated Resident 71 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included hemiplegia (paralysis of one side of the body) hemiparesis (weakness on one side of the body) cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area) affecting left non-dominant side, dysphagia (difficulty swallowing), diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose levels), and hypertension (high blood pressure) During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 5/3/2026, the MDS indicated Resident 2 has severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 2 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in eating, toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, roll left and right, sit to lying, lying to sitting on side of bed and tub/ shower transfer. During a review of Resident 71's Minimum Data Set (MDS, a resident assessment tool) dated 5/15/2026, the MDS indicated Resident 71 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 71 needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds the trunk or limbs, and provides more than half the effort) when eating, oral hygiene, upper body dressing, roll left and right, sit to lying, lying to sitting on the side of the bed. It also indicated Resident 71 also was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, personal hygiene, chair/ bed-to-chair transfer and tub/ shower transfer. During an observation on 6/23/2026 at 12:35 PM in the dining room, Resident 71 was sitting on her wheelchair while at the back of the dining room. Resident 71 was drooling on her shirt and holding a rolled hand towel on her contracted (a condition where the fingers or palm of the hand become permanently bent or curled) left hand. Licensed Vocational Nurse 4 (LVN 4) stated Resident 71's shirt was already wet from the resident's' drool. Resident 71 lunch tray was not on the table while other residents were already eating their lunch. During an observation on 6/24/2026 at 1:09 PM in the hallway, Resident 71 was sitting in her wheelchair, and the resident was drooling and dripping on the resident's chin. There were visitors and residents passing by in the hallway while Resident 71 was sitting in the hallway. During a concurrent observation and interview on 6/24/2026 at 1:12 PM in the hallway with Certified Nursing Assistant (CNA 4), CNA 4 stated Resident 71 was drooling. CNA 4 stated it was not okay that Resident 71 was drooling in the hallway because of dignity, and the facility staff need to make sure Resident 71 is always clean. During an interview on 6/26/2026 at 10:09 AM with Director of Staff Development (DSD), DSD stated the staff were not supposed to let Resident 71 drool on the resident's shirt, particularly when the resident is in the dining room and/ or hallway. DSD stated the staff should wipe the resident's mouth frequently to maintain Resident 71's dignity. 2. During a review of Resident 72's admission Record, the admission Record indicated Resident 72 was admitted to the facility on [DATE]. Resident 72's diagnoses included diabetes, hypertension, left foot hallux valgus (bunion- is a condition in which the big toe migrates laterally toward the second toe) and dysphagia (difficulty swallowing). During a review of Resident 72's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making were intact. The MDS indicated Resident 72 was independent (resident completes the activity by themself with no assistance from a helper) when eating. The MDS indicated Resident 72 also needed partial/ moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs but provides less than half the effort) in toileting hygiene, upper and lower body dressing, putting on/ taking off footwear, roll left and right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair/ bed-to-chair transfer, and walking 10 feet. During an interview on 6/24/2026 at 12:44 PM with Resident 72, Resident 72 stated Where is my food, it is almost 1 PM. It was never on time, never. The meal trays were always late. My breakfast arrived at 8:05 AM this morning, it was not on time. Some of the residents received their meals at 7:30 AM. During a concurrent observation and interview on 6/24/2026 at 12:48 PM with CNA 5 inside Resident 72's room, CNA 5 stated for the resident's lunch time the facility staff started giving out trays around 12:15 PM. CNA 5 stated Resident 72's lunch tray was served at 12:48 PM, and it was considered late. CNA 5 stated Resident 72 complained that the resident's meal tray was late and if the meal tray was always late, the resident can feel disrespected and feel frustrated. During an interview on 6/25/26 at 8:01 AM inside Resident 72's room, Resident 72 stated that she received her meal tray for breakfast at 8 AM. Resident 72 stated she ate dinner at 5:25 PM last night and it was almost 15 hours from her last meal. During an interview on 6/25/2026 at 8:02 AM with CNA 6, CNA 6 stated Resident 72 just got the resident's breakfast tray around 8 AM. CNA 6 stated the breakfast tray has to be served around 7:15 AM or the residents will feel hungry and to ensure the food is kept warm. If Resident 72's meal tray was always late, Resident 72 would feel left out and upset. During a concurrent observation and interview 6/25/2026 at 1:16 PM with Resident 72 inside Resident 72's room, Resident 72 was eating her lunch tray. Resident 72 stated she just received her lunch tray less than 10 minutes ago, and whatever system the facility has in the kitchen it was not working, because the resident's meal tray was always late. During an interview on 6/25/2026 at 1:21 PM with Dietary Supervisor (DTS), DTS stated if meal trays were served to the residents later than the posted time the residents can feel hungry, angry or upset. During an interview on 6/26/2026 at 1:10 PM with the Director of Nursing (DON), the DON stated Resident Mealtimes are from 7:15 AM to 7:45 AM for breakfast and 12:15 PM to 12:45 PM for lunch. he DON stated that if residents' meal trays are served after the allotted mealtime, the food can become cold and residents may feel disrespected. The DON explained that delays can cause residents to feel hungry and upset, and Resident 72 could feel frustrated while waiting for her tray. During an interview and record review on 6/26/2026 at 1:12 PM with the DON, the facility's Policy and Procedure (P&P) titled, Meal Times, revised on 12/2014 was reviewed. The P&P indicated the dietary department will provide accurate, efficient and consistent meal service with attractive food served at the appropriate temperature and in a pleasant atmosphere. The DON stated the staff were not following the policy because Resident 72 meal trays were always served late, the food can get cold. During a review of the facility's P&P titled, Quality of Life- Dignity/ Privacy, revised 8/2025, the P&P indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated residents are treated with dignity and respect at all times and staff are expected to promote dignity and assist residents.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of two (2) of six (6) sampled residents (Resident 23 and 2) observed during medication administration as indicated on the physician's order and facility policy and procedure (P&P) when:1. Licensed Vocational Nurse 3 (LVN) 3 failed to administer Resident 23's levetiracetam (Keppra, medication used to prevent seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), metformin (medication used to control blood sugar levels), and escitalopram (Lexapro; medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) on time.This deficient practice had the potential to cause Resident 23's medical conditions to not be treated effectively.2. LVN 2 failed to administer Resident 2's metoprolol (medication to treat or prevent hypertension [high blood pressure]) with breakfast on 6/25/2026.This deficient practice had the potential to result in damaging Resident 2's esophagus (muscular tube that connects the throat to the stomach) and irritating the resident's stomach lining which may cause nausea, cramps, vomiting, or diarrhea (condition of having loose, watery stool at least three or more times in a single day, or more frequently). Findings: 1. During a review of Resident 23's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). During a review of Resident 23's Minimum Data Set (MDS- a resident assessment tool), dated 5/25/2026, the MDS indicated Resident 23 had intact cognitive (ability to think and process information) skills for daily decision making. The MDS indicated Resident 23 was dependent (helper does all the effort) for eating, oral hygiene, toileting hygiene, showering, upper/lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 23's Physician's Orders, dated 1/31/2025 to 6/26/206 the Physician's Orders indicated the following: Keppra 750 milligrams (mg, unit of measure for medications) 2 times a day for epilepsy, ordered on 2/25/2026. Lexapro 10 mg one time a day for major depressive disorder, ordered on 4/8/2025. Metformin 500 mg one time a day for diabetes, ordered on 10/24/2025. During a review of Resident 23's Medication Administration Record (MAR; a record of medications ordered for a resident which includes time medications are due), dated 6/1/2026 to 6/30/2026, the MAR indicated Resident 23 was ordered Keppra, metformin and Lexapro and they are to be administered at 9 AM every day. During a concurrent observation and interview on 6/25/2026 at 10:12 AM with LVN 3, LVN 3 was observed getting ready to administer medications to Resident 23 in Resident 23's room. LVN 3 stated that Resident 23's Keppra, Lexapro and metformin were due at 9 AM but she is going to give them late. LVN 3 stated that medications can be given one hour after the time they are due and that it has been over an hour since the medications were due. LVN 3 stated that medications will not treat the resident's conditions effectively if they are given late. During a concurrent interview and record review on 6/26/2026 at 12:14 PM with the Director of Nursing (DON), the facility's P&P titled, P&P in Medication Administration, revised 1/2025 was reviewed. The P&P indicated: Medications shall be administered in accordance with our established P&P Medications must be administered within one hour before or after administration time per MD order. The DON stated medications must be administered at the latest, one hour after they are due. The DON stated that a resident's medical conditions will not be controlled if medications are given late. The DON stated that if a resident has DM, their blood sugar might not be controlled. The DON stated that if a resident has epilepsy, they may have seizures. The DON stated that if a resident has depression, they may feel more depressed. 2. During a review of Resident 2's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE], with diagnosis of muscle weakness, hypertension (high blood pressure), and atherosclerotic heart disease (ASHD, occurs when fat builds up restricts blood flow to the heart). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had modified independence (some difficulty in new situations only) with cognitive skills for daily decision making. The MDS indicated Resident 2 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) with oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 2 was dependent on toileting hygiene, shower, lower body dressing, and putting on/taking off footwear. During a review of Resident 2's Order Summary Report, dated 6/24/2026, the Order Summary Report indicated a physician's order, dated 4/16/2026 for metoprolol extended release 25 milligrams (mg, unit of measurement), by mouth, one time a day for hypertension, hold for systolic blood pressure (top or higher number in blood pressure reading) less than 110 and heart rate less than 60. It also indicated to give with breakfast. During a review of Resident 2's Nurse Progress Notes, dated 6/25/2026 timed 2:58 PM, documented by Licensed Vocational Nurse 2 (LVN 2), the Nurse Progress Notes indicated metoprolol was administered at 9:44 AM instead of 7:15 AM. Awaiting response from doctor. During a medication administration observation in Resident 2's room on 6/25/2026 at 9:44 AM, LVN 2 administered metoprolol 25 mg oral tablet to Resident 2 without breakfast or any food. During an interview on 6/25/2026 at 9:50 AM with LVN 2 , LVN 2 stated she did not administer Resident 2's metoprolol medication with breakfast meal and did not offer food or snack during metoprolol medication administration to Resident 2. During an interview on 6/25/2026 at 11:13 AM with Registered Nurse 2 (RN 2), RN 2 stated that LVN 2 did not administer Resident 2's, metoprolol medication with breakfast. RN 2 stated it was important to administer medication as ordered to get the full benefit of the medication and to prevent stomach upset. During an interview on 6/25/2026 at 2:50 PM with RNS 1, RNS 1 stated medications that were ordered to be given with food should be followed because these medications might cause stomach upset or medication might not be effective. RNS 1 stated Resident 2's metoprolol medication order should have been given with breakfast meal at 7:15 AM. During a review of the facility's Policy and Procedure (P&P) titled, Policy and Procedure in Medication Administration, revised on January 2025, the P&P indicated all medications will be administered following the scheduled medication administration routine unless otherwise specified by doctor which is different from routine medication administration schedule.

Based on observation, interview and record review, the facility failed to follow its policy and procedure (P&P) to ensure two (2) of six (6) sampled residents (Resident 23 and 2) observed during medication administration were free from significant medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles, which may have cause the resident discomfort or jeopardize health and safety) when:1. Licensed Vocational Nurse 3 (LVN) 3 failed to administer Resident 23's levetiracetam (Keppra, medication used to prevent seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), metformin (medication used to control blood sugar levels), and escitalopram (Lexapro, medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) on time on 6/25/26 as indicated on the physician's order.This deficient practice had the potential to cause Resident 23's medical conditions to not be treated effectively.2. LVN 2 failed to administer Resident 2's metoprolol (medication to treat or prevent hypertension [high blood pressure]) with breakfast on 6/25/2026 as indicated on the physician's order. This deficient practice had the potential to result in damaging Resident 2's esophagus (muscular tube that connects the throat to the stomach) and irritating the resident's stomach lining which may cause nausea, cramps, vomiting, or diarrhea (condition of having loose, watery stool at least three or more times in a single day, or more frequently). Findings:1. During a review of Resident 23's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). During a review of Resident 23's Minimum Data Set (MDS- a resident assessment tool), dated 5/25/2026, the MDS indicated Resident 23 had intact cognitive (ability to think and process information) skills for daily decision making. The MDS indicated Resident 23 was dependent (helper does all the effort) for eating, oral hygiene, toileting hygiene, showering, upper/lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 23's Physician's Orders, dated 1/31/2025 to 6/26/206 the Physician's Orders indicated the following:Keppra 750 milligrams (mg, unit of measure for medications) 2 times a day for epilepsy, ordered on 2/25/2026.Lexapro 10 mg one time a day for major depressive disorder, ordered on 4/8/2025.Metformin 500 mg one time a day for diabetes, ordered on 10/24/2025. During a review of Resident 23's Medication Administration Record (MAR; a record of medications ordered for a resident which includes time medications are due), dated 6/1/2026 to 6/30/2026, the MAR indicated Resident 23 was ordered Keppra, metformin and Lexapro and they are to be administered at 9 AM every day. During a concurrent observation and interview on 6/25/2026 at 10:12 AM with LVN 3, LVN 3 was observed getting ready to administer medications to Resident 23 in Resident 23's room. LVN 3 stated that Resident 23's Keppra, Lexapro and metformin were due at 9 AM but she is going to give them late. LVN 3 stated that medications can be given one hour after the time they are due and that it has been over an hour since the medications were due. LVN 3 stated that medications will not treat the resident's conditions effectively if they are given late. During a concurrent interview and record review on 6/26/2026 at 12:14 PM with the Director of Nursing (DON), the facility's P&P titled, P&P in Medication Administration, revised 1/2025 was reviewed. The P&P indicated:Medications shall be administered in accordance with our established P&P.Medications must be administered within one hour before or after administration time per MD order.The DON stated medications must be administered at the latest, one hour after they are due. The DON stated that a resident's medical conditions will not be controlled if medications are given late. The DON stated that if a resident has DM, their blood sugar might not be controlled. The DON stated that if a resident has epilepsy, they may have seizures. The DON stated that if a resident has depression, they may feel more depressed.

Based on interview and record review, the facility failed to ensure infection prevention measures (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for two (2) of 23 sampled residents (Residents 9 and 43) by failing to:1. Ensure Certified Nurse Assistant 3 (CNA 3) performed hand hygiene (cleaning hands with the use of alcohol-based hand rubs containing 60%-95% alcohol or hand washing with soap and water) during meal assistance with Resident 43.2. Ensure Resident 9's gastrostomy tube (G-Tube- a surgical opening fitted with a tube to allow feedings to be administered directly to the stomach common for people with swallowing problems) feeding pump (an electronic or battery-powered medical device designed to deliver liquid nutrition, hydration, or medications directly into a resident's stomach) was clean and sanitary during feeding administration. These failures have the potential for Residents 9 and 43 to be at risk for preventable infections related to cross contamination (the physical transfer of harmful bacteria, viruses, or allergens from one person, object, or food to another) from contaminated equipment and/or supplies during provided care and services.Findings:1. During a review of Resident 43's admission Record, the admission Record indicated Resident 43 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), generalized muscle weakness and type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 43's Minimum Data Set (MDS- a resident assessment tool), dated 4/14/2026, the MDS indicated Resident 43 had severely impaired (never/rarely made decisions) cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 43 required partial moderate assistance (helper does less than half the effort) with eating and oral hygiene, and dependent (helper does all the effort to complete activity) with toileting, shower/bathing self and lower body dressing. During an observation on 6/23/2026 at 12:32 PM in the facility dining room, Certified Nurse Assistant 3 (CNA 3) was observed moving her (CNA 3's) eyeglasses from her eyes and raising them on her head and then pulling them from her head and down to her head without performing hand hygiene. CNA 3 was then observed grabbing Resident 43's food tray, taking it to Resident 43 and then removing the resident's food container lid and saran wrap (a thin, transparent plastic cling film used to seal and cover food) off the resident's 2 drinking cups. During an interview on 6/23/2026 at 1:07 PM with CNA 3, CNA 3 stated she moved her eyeglasses from her face and head and did not perform hand hygiene before assisting Resident 43 with the resident's food tray and should have performed hand hygiene. CNA 3 stated it was important to ensure hand hygiene is done for infection control to prevent infections or illness form bacteria that may spread. CNA 3 further stated, per facility protocol, hand hygiene should be done between each resident and if the facility staff touch themselves, including touching their hair and eyeglasses. During an interview on 6/26/2026 at 11:49 AM with the Director of Nursing (DON), the DON stated staff need to complete hand hygiene after touching residents, themselves (staff) or anything to prevent cross contamination with a resident's food, which could cause food borne illness (any illness resulting from eating contaminated/spoiled foods) with symptoms including nausea, vomiting, fever, abdominal pain, confusion and diarrhea. During a review of the facility's policy and procedure (P&P) titled, Preventing Foodborne Illness- Food Handling, dated 2001, the P&P indicated food will be stored, prepared and handled and served so that the risk of foodborne illness is minimized. 2. During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing), chronic kidney disease (CKD- a progressive condition where your kidneys are damaged and gradually lose their ability to filter waste and excess fluid from your blood) and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 9's Physician's Order, dated 6/11/2026, the Physician Order indicated Jevity 1.2 calories (cal) oral liquid (a nutritional supplement), give 60 milliliters (ml- a metric unit of measurement for volume)/ hour via G-tube related to encounter for attention to gastrostomy. 60ml/hr x 20 hours on at 2:00 PM off at 10:00 PM. During a review of Resident 9's MDS, dated 6/16/2026, the MDS indicated Resident 9 had severely impaired cognitive skills for daily decision making. The MDS also indicated Resident 9 was dependent with oral, personal and toileting hygiene, shower/bathing self and dressing. The MDS also indicated Resident 9 had a feeding tube. During a concurrent observation and interview on 6/25/2026 at 9:18 AM with Registered Nurse Supervisor (RNS) at Resident 9's bedside, Resident 9's G-Tube pump was observed with dried tan drops on the top and sides of the machine. RNS stated Resident 9's G-Tube pump had dried stains, the same color as the resident's Jevity feeding and the G-Tube pump should not have stains. RNS also stated Resident 9's G-Tube pump was dirty, but per facility policy, the G-Tube pump needed to remain cleaned to prevent bacteria from going to Resident 9. During an interview on 6/26/2026 at 11:29 AM with the DON, the DON stated staff need to maintain cleanliness of the G-Tube pump to prevent cross contamination from the dirty pump into the feeding and/or GT site of the resident. During a review of the facility's P&P titled, Enteral Nutrition (a method of delivering specialized liquid food directly into the gastrointestinal tract): General Guidelines, undated, the P&P indicated the pump, and pump stand should be kept clean by washing with a cloth and nonstaining germicidal agent.

Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Four (4) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 27 total opportunities (observed administered medications) for error, to yield an overall medication error rate of 14.81 % for two (2) of six (6) sampled residents (Resident 2 and Resident 23) observed for medication administration.1. Licensed Vocational Nurse 3 (LVN) 3 failed to administer Resident 23's levetiracetam (Keppra, medication used to prevent seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), metformin (medication used to control blood sugar levels), and escitalopram (Lexapro, medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) on time on 6/25/2026 in accordance with the physician's order and facility's policy and procedure (P&P).This deficient practice had the potential to cause Resident 23's medical conditions to not be treated effectively.2. LVN 2 failed to administer Resident 2's metoprolol (medication to treat or prevent hypertension [high blood pressure]) with breakfast on 6/25/2026 in accordance with the physician's order and P&P. This deficient practice had the potential to result in damaging Resident 2's esophagus (muscular tube that connects the throat to the stomach) and irritating the resident's stomach lining which may cause nausea, cramps, vomiting, or diarrhea (condition of having loose, watery stool at least three or more times in a single day, or more frequently). Findings: 1. During a review of Resident 23's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). During a review of Resident 23's Minimum Data Set (MDS- a resident assessment tool), dated 5/25/2026, the MDS indicated Resident 23 had intact cognitive (ability to think and process information) skills for daily decision making. The MDS indicated Resident 23 was dependent (helper does all the effort) for eating, oral hygiene, toileting hygiene, showering, upper/lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 23's Physician's Orders, dated 1/31/2025 to 6/26/206 the Physician's Orders indicated the following: Keppra 750 milligrams (mg, unit of measure for medications) 2 times a day for epilepsy, ordered on 2/25/2026. Lexapro 10 mg one time a day for major depressive disorder, ordered on 4/8/2025. Metformin 500 mg one time a day for diabetes, ordered on 10/24/2025. During a review of Resident 23's Medication Administration Record (MAR; a record of medications ordered for a resident which includes time medications are due), dated 6/1/2026 to 6/30/2026, the MAR indicated Resident 23 was ordered Keppra, metformin and Lexapro and they are to be administered at 9 AM every day. During a concurrent observation and interview on 6/25/2026 at 10:12 AM with LVN 3, LVN 3 was observed getting ready to administer medications to Resident 23 in Resident 23's room. LVN 3 stated that Resident 23's Keppra, Lexapro and metformin were due at 9 AM but she is going to give them late. LVN 3 stated that medications can be given one hour after the time they are due and that it has been over an hour since the medications were due. LVN 3 stated that medications will not treat the resident's conditions effectively if they are given late. During a concurrent interview and record review on 6/26/2026 at 12:14 PM with the Director of Nursing (DON), the facility's P&P titled, P&P in Medication Administration, revised 1/2025 was reviewed. The P&P indicated: Medications shall be administered in accordance with our established P&P Medications must be administered within one hour before or after administration time per MD order. The DON stated medications must be administered at the latest, one hour after they are due. The DON stated that a resident's medical conditions will not be controlled if medications are given late. The DON stated that if a resident has DM, their blood sugar might not be controlled. The DON stated that if a resident has epilepsy, they may have seizures. The DON stated that if a resident has depression, they may feel more depressed. 2. During a review of Resident 2's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE], with diagnosis of muscle weakness, hypertension (high blood pressure), and atherosclerotic heart disease (ASHD, occurs when fat builds up restricts blood flow to the heart). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had modified independence (some difficulty in new situations only) with cognitive skills for daily decision making. The MDS indicated Resident 2 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) with oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 2 was dependent on toileting hygiene, shower, lower body dressing, and putting on/taking off footwear. During a review of Resident 2's Order Summary Report, dated 6/24/2026, the Order Summary Report indicated a physician's order, dated 4/16/2026 for metoprolol extended release 25 milligrams (mg, unit of measurement), by mouth, one time a day for hypertension, hold for systolic blood pressure (top or higher number in blood pressure reading) less than 110 and heart rate less than 60. It also indicated to give with breakfast. During a review of Resident 2's Nurse Progress Notes, dated 6/25/2026 timed 2:58 PM, documented by Licensed Vocational Nurse 2 (LVN 2), the Nurse Progress Notes indicated metoprolol was administered at 9:44 AM instead of 7:15 AM. Awaiting response from doctor. During a medication administration observation in Resident 2's room on 6/25/2026 at 9:44 AM, LVN 2 administered metoprolol 25 mg oral tablet to Resident 2 without breakfast or any food. During an interview on 6/25/2026 at 9:50 with LVN 2, LVN 2 stated she did not administer Resident 2's metoprolol medication with breakfast and did not offer food or snack during metoprolol medication administration to Resident 2. During an interview on 6/25/2026 at 11:13 AM with Registered Nurse 2 (RN 2), RN 2 stated that LVN 2 did not administer Resident 2's, metoprolol medication with breakfast. RN 2 stated it was important to administer medication as ordered to get the full benefit of the medication and to prevent stomach upset. During an interview on 6/25/2026 at 2:50 PM with Registered Nursing Supervisor 1 (RNS 1), RNS 1 stated medications that were ordered to be given with food should be followed because these medications might cause stomach upset or medication might not be effective. RNS 1 stated Resident 2's metoprolol medication order should have been given with breakfast meal at 7:15 AM. During a review of the facility's Policy and Procedure (P&P) titled, Policy and Procedure in Medication Administration, revised on January 2025, the P&P indicated all medications will be administered following the scheduled medication administration routine unless otherwise specified by doctor which is different from routine medication administration schedule.

Based on observation, interview, and record review, the facility failed to ensure a Medication Regimen Review (MRR, also known as a Drug Regimen Review-is a structured, comprehensive evaluation of all medications a resident is taking, conducted typically by a pharmacist to ensure medications are appropriate, safe, effective, and used correctly) to identify and follow up on an irregularity (includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) for two (2) of five (5) sampled residents (Resident 22 and Resident 57) reviewed for unnecessary medications in accordance with the facility's policy and procedure (P&P) by failing to ensure: 1. Resident 22 was monitored for the use of montelukast (a medication to treat lung inflammation), including required monitoring for its black box warning (BBW, serious, life-threatening side effects). 2. Resident 57's Donepezil hydrochloride (HCL) (Aricept, a medication used to treat the symptoms of dementia [a progressive state of decline in mental abilities]) order had the correct indication for use. These deficient practices increased Residents 22 and 57's risk to experience adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to their medication therapy, potentially leading to impairment or decline in their mental, functional, and psychosocial wellbeing. Findings: 1. During a review of Resident 22's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and cardiomegaly (enlarged heart). During a review of Resident 22's Minimum Data Set (MDS- a resident assessment tool), dated 6/7/2026, the MDS indicated Resident 22 had intact cognitive (ability to think and process information) skills for daily decision making. The MDS indicated Resident 22 was independent for eating, oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MD indicated Resident required supervision (requires oversight, encouragement, or cueing from staff) for showering. During a review of Resident 22's Order Summary Report, dated 4/19/2026, the Order Summary Report indicated Resident 22 was ordered montelukast. During a review of Resident 22's MRR, dated 5/1/2026 to 5/18/2026, the MRR indicated that Resident 22 was receiving montelukast and required monitoring for a black box warning. The MRR indicated to monitor for these behaviors in the care plan. During a concurrent interview and record review on 6/26/2026 at 8:39 AM with Registered Nurse Supervisor 1 (RNS 1), Resident 22's care plans, dated 2/28/2026 to 6/26/2026 were reviewed. RNS 1 stated Resident 22 does not have a CP for monitoring the BBW side effects of montelukast. RNS 1 stated that Resident 22 should have a CP for BBW monitoring to prevent Resident 22 from experiencing life threating side effects, worsening conditions and possible hospitalization. During a concurrent interview and record review on 6/26/2026 at 12:11 PM with the Director of Nursing (DON), the facility's P&P titled, Medication Regimen Reviews (MRR), dated 2001 and the facility's P&P titled, Black Box Warning (BBW), (undated) was reviewed. The MRR P&P indicated: The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medications errors and other irregularities such as inadequate monitoring for adverse consequences and potentially significant medication related adverse consequences or actual signs and symptoms that could represent adverse consequences. The BBW P&P indicated: The BBW is utilized for safe drug prescribing and administration to residents. A BBW means that medical studies indicate that the drug carries a significant risk of serious or even life-threatening adverse effects. The DON stated that MRR recommendations for BBW side effects monitoring must be followed to prevent the resident from having serious life-threatening side effects as mentioned in the policy. 2. During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was originally admitted to the facility on [DATE]. The admission record also indicated Resident 57's diagnoses included dementia, schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable fear or worry). During a review of Resident 57's MDS, dated [DATE], the MDS indicated Resident 57 has severely impaired (never/rarely made decisions) cognitive skills for daily decision making. The MDS indicated Resident 57 required partial/moderate assistance (helper does less than half the effort) with eating and oral hygiene. The MDS indicated Resident 57 required substantial/maximal assistance (helper does more than half the effort. helper lifts or holds trunks or limbs and provides more than half the effort) with upper body dressing. The MDS indicated Resident 57 was dependent (helper does all the of the effort) with toileting, showering, lower body dressing, and putting on/taking off footwear. The MDS indicated a diagnosis of dementia. During a review of Resident 57's Order Summary Report dated 6/25/2026, timed 4:31 PM, the Order Summary Report indicated an order on 6/9/2026 for Donepezil HCL oral tablet 5 milligrams (mg, unit of measurement), give 1 tablet by mouth at bedtime for cognitive impairment (problems with memory, learning, concentration, or decision-making). During a review of a facility's record titled, Consultant Pharmacist's Medication Regimen Review, dated 6/24/2026, the record indicated listing of residents reviewed with no pharmacy consultant (PC, provides expert guidance on medication therapy, facility operations, and regulatory compliance) recommendation between 6/1/2026 and 6/24/2026. Resident 57 was included in the list of residents reviewed without any pharmacy consultant recommendations. During a concurrent record review and interview on 6/26/2026 at 8:34 AM with Registered Nurse 2 (RN 2), Resident 57's donepezil HCL order dated 6/9/2026 was reviewed. RN 2 verified Resident 57 has an order for donepezil for cognitive impairment, ordered on 6/9/2026. RN 2 stated the diagnosis of cognitive impairment as an indication for the use of donepezil HCL was incorrect because it should have been for Resident 57's diagnosis of dementia. RN 2 stated the facility's PC conducted the medication regimen review with no recommendation for Resident 57. RN 2 stated, Resident 57's donepezil HCL order did not and should have a clarification of order recommendation from the PC. During a concurrent record review and interview on 6/26/2026 at 11:51 AM with RNS 1, Resident 57's donepezil order dated 6/9/2026 was reviewed. RNS 1 verified Resident 1 has an order for donepezil HCL for cognitive impairment, ordered on 6/9/2026. RNS 1 stated that having an accurate diagnosis as the indication for any medication is essential to ensure the resident receives the correct medication for the correct purpose. RNS 1 stated This should have been captured in the MRR. The pharmacy consultant should have a recommendation to clarify the order, to indicate the diagnosis of dementia. During a concurrent record review and interview on 6/26/2026 at 11:54 AM with the facility PC, Consultant Pharmacist's Medication Regimen Review, dated 6/24/2026 and Resident 57's donepezil order dated 6/9/2026 was reviewed. PC verified that he reviewed Resident 57's medication orders with no recommendation. PC stated that Resident 57 has diagnosis of dementia, and not cognitive impairment. PC stated that he should have had a recommendation to clarify the order of donepezil, to indicate the diagnosis of dementia. During a review of Facility's P&P titled, Medication Regimen Review, dated 2001, the P&P indicated MRR report contains the identified irregularity and the pharmacist recommendation. The P&P also indicated an irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences. During a review of Facility's P&P titled, Policy and Procedures on Unnecessary Drugs, revised on July 2012, the P&P indicated to carry out medications as Doctor's order with medication dosage, route, frequency and diagnosis to justify medication used.

Based on observation, interview and record review, the facility failed to maintain clinical records in accordance professional standards and practices and facility's Policy and Procedure (P&P) for one (1) of six (6) sampled residents (Resident 1) by failing to accurately document the administration of narcotics (drug or controlled substance that affects the mood or behavior and if consumed for nonmedical purposes or not prescribed by the doctor can cause serious harm) count in the narcotic drug record (narcotic count sheet is a document used to document and track the administration of controlled substance to ensure accurate dispensing and administration of medications, as well as to provide a record of how much of a controlled substance has been used and when).This deficient practice had the negative impact on the delivery of services and lead to potential harm or irreversible harm to the residents.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of right shoulder rotator cuff tear (involves damage to the muscles and tendons holding the shoulder joint in place, causing pain, weakness, and limited motion, particularly when lifting the arm or sleeping), anxiety(a normal, temporary response to stress or danger, often causing feelings of apprehension, tension, and physical symptoms like a racing heart) and depression (a common, serious medical illness causing persistent sadness, loss of interest, and decreased energy, affecting how you feel, think, and behave).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/16/2026, the MDS also indicated the resident is moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunks or limbs but provides less than half the effort) with toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear but required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with upper body dressing and personal hygiene. The MDS indicated the resident receives scheduled and as needed medication. The MDS also indicated that the resident has occasional pain.During a review of Resident 1's Physician Order, dated 4/3/2026, the Physician Order indicated Oxycodone Hydrochloride (HCL) (a potent, semi-synthetic opioid analgesic medication used to treat severe, ongoing pain) Oral Tablet 5 milligrams (mg - unit of measure) Give 1 tablet by mouth every 6 hours as needed for pain of (5-10/10 pain rating scale; 0 being no pain and 10 being the worst pain) unrelieved by non-opioids.During a review of Resident 1's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 5/2026, the MAR indicated Oxycodone HCL was not given on 5/5/2026.During a concurrent observation and interview on 5/5/2026 at 12PM of Cart 1, Licensed Vocational Nurse 1 (LVN 1) and Surveyor 1 were doing a narcotic count. LVN 1 stated the narcotic count for Resident 1's Oxycodone HCL is not correct and there was a discrepancy in the counting done that morning. Observed was 18 tablets in the bubble pack and the narcotic sheet indicated there should be 19 tablets left.During a concurrent observation and interview on 5/5/2026 at 12:05PM of Resident 1's Oxycodone narcotic count, Director of Nursing (DON) stated the count does not match and there is one missing.During an interview on 5/5/2026 at 1:10PM in Resident 1's room, Resident 1 stated he got his Oxycodone HCL pain medication around 6am this morning. Resident 1 also stated it was given by a male nurse.During an interview on 5/5/2026 at 3:19PM, LVN 2 stated Resident 1's pain was 10/10 on the pain scale and LVN 2 gave Resident 1 his Oxycodone pain medication 6 am this morning, LVN 2 also stated he forgot to document in the MAR and narcotic sheet that Resident 1 received his oxycodone pain medication but he should have documented in the MAR and narcotic sheet when administering Oxycodone HCL to Resident 1.During an interview on 5/5/2026 at 3:30PM, DON stated LVN 2 should have documented in the MAR and narcotic sheet but LVN2 did not document in the MAR or narcotic sheet. DON also stated documentation is to ensure no narcotics are missing and the narcotic count is accurate.During a review of the facility's P&P titled Policy and Procedure in Medication Administration, revised 1/2025, the P&P indicated medications must be immediately charted following the administration by the license nurse who administered the medication.During a review of the facility's P&P titled Charting and Documentation, revised 1/2025, the P&P indicated entries in the clinical record must be accurate, legible, clear and timely. Documentation of procedures and treatments will include care-specific details such as the assessment data obtained during the treatment, how the resident tolerated the procedure/treatment and the signature and title of the individual documenting.During a review of the facility's P&P titled Policies and Procedures on Controlled Drugs Count Records, revised 1/2025, the P&P indicated nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document in the controlled drugs-count record.

Based on observation, interview, and record review, the facility failed to reconcile the General Acute Care Hospital's (GACH) Discharge Medications List and carry out a physician's order to administer long-acting insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) for one (1) of two (2) sampled residents (Resident 2) as indicated on the facility policy and procedure (P&P). This deficient practice resulted in Resident 2 experiencing hyperglycemia (a condition where there's too much glucose in the blood) placing Resident 2 at risk for various serious complications such as ketoacidosis (DKA, a complication of diabetes in which acids build up in the blood to levels that can be life-threatening), dehydration (a condition occurs when the body loses more fluids than it takes in, leading to an insufficient amount of water for normal bodily functions), confusion (a state of reduced awareness and impaired thinking), and coma (a state of prolonged unconsciousness where a person is alive but unresponsive to their surroundings) and transfer to GACH on 4/10/2026. Findings: During a review of Resident 2's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control) with hyperglycemia (high blood sugar), End Stage Renal Disease (ESRD-irreversible kidney failure), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 3/27/2026, the MDS indicated Resident 2's cognitive skills for daily decision making was modified independence. The MDS indicated Resident 2 required supervision or touching assistance (helper provided verbal cues) with eating. The MDS indicated Resident 2 required partial/moderate assistance with oral hygiene. The MDS indicated Resident 1 was dependent on toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. The MDS also indicated Resident 2 received insulin injections. During a review of Resident 2's GACH's Discharge Medications List, dated 2/23/2026, the GACH's Discharge Medications List indicated an order of insulin glargine (long-acting, man-made insulin used once daily to control high blood sugar in adults and children with diabetes), inject 20 units (unit of measurement) subcutaneously (method of administering medication into the fatty tissue layer just below the skin) every 24 hours. During a review of Resident 2's Order Summary Report as of 3/15/2026, the Order Summary Report indicated an order of insulin lispro (insulin used to treat diabetes that is designed to work quickly-usually within 15 minutes of injection-to manage blood sugar spikes immediately before or after meals), inject nine (9) units SQ before meals for DM, hold if blood sugar is less than 100 milligrams per deciliter (mg/dl, unit of measurement), rotate sites of injection. Ordered on 3/14/2026. During a review of Resident 2's Order [NAME] report as of 4/21/2026, indicated an order of insulin glargine SQ, inject 10 unit SQ at bedtime for DM, ordered on 4/17/2026. During an interview on 4/22/2026 at 1:47 PM with Resident 2, in resident's room, Resident 2 stated he's been taking long-acting insulin for more than 20 years now. Resident 2 stated he's been managing his diabetes at home for a while now. Resident 2 stated that at home, he has been injecting himself with a long-acting insulin together with a short acting insulin depending on his blood sugar result. Resident 2 stated here in the facility, he was only receiving the short acting insulin which is being injected to him after the staff checked his blood sugar and this is before meals. Resident 2 added the facility had recently started giving him the long-acting insulin days after his readmission on [DATE]. During a concurrent record review and interview on 4/23/2026 at 10:45 AM with RN 1, Resident 2's medication administration records for March and April 2026 were reviewed. RN 1 verified Resident 2 did not have an order for long-acting insulin which is glargine since admission of 3/14/2026 and was only ordered on 4/17/2026. RN 1 stated that she noticed Resident 2's blood sugar was always high as reflected on the electronic medication administration record (EMAR) for the month of March and April 2026, that is why RN 1 notified Resident 2's Doctor on 4/17/2026. During an interview on 4/23/2026 at 11:55 AM with the DON, the DON stated Resident 2's Discharge Medications List from GACH on 3/14/2026 of insulin glargine was not and should have been carried out upon admission to the facility. The DON stated insulin glargine is a long-acting insulin that works with maintaining blood sugar levels within normal limits, in addition to an order of short acting insulin of lispro. The DON stated Resident 2 did not have insulin glargine order on 3/14/2026, and it was only ordered on 4/17/2026. The DON stated the licensed nurse who admitted Resident 2 to the facility on 3/14/2026 did not completely follow the Discharge Medications List order from GACH. During a review of Facility's P&P titled, Admission, revised on 1/2025, the P&P indicated under the licensed nurse procedure, to notify physician of admission and verify transfer and admission orders. During a review of Facility's P&P titled, Medication Administration, revised on 1/2025, the P&P indicated drugs must be administered in accordance with the written orders of the attending physician.

Based on interview, and record review, the facility failed to administer the intravenous (IV, administering fluids or medications directly into a vein using a needle or tube, allowing for immediate entry into the bloodstream) hydration (the process of supplying water to maintain adequate fluid levels in the body) for one (1) of two (2) sampled residents (Resident 1) on 4/10/2026, in accordance with the physician's order, care plan, and facility policy. This failure had the potential to put Resident 1 at risk for dehydration (a condition occurs when the body loses more fluids than it takes in, leading to an insufficient amount of water for normal bodily functions) and complications that can lead to hospitalization and death. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including malignant (harmful, or dangerous to health) neoplasm (an abnormal, new growth of tissue in the body) of lungs and bones, neoplasm related pain and malnutrition. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 4/11/2026, the MDS indicated Resident 1's cognitive (ability to think and reason) skills for daily decision making was modified independence (some difficulty in new situations only). The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with eating and oral hygiene. The MDS indicated Resident 1 required substantial/moderate assistance (helper does less than half the effort) with upper body dressing and personal hygiene. The MDS indicated Resident 1 was dependent on toileting hygiene, shower, lower body dressing, and putting on/taking off footwear. During a review of Resident 1's Physician's Order, dated 4/10/2026, the Physician's Order indicated peripheral IV hydration of normal saline (NS, a saltwater solution), give over four hours, on 4/10/2026, 4/11/2026, and 4/12/2026. During a concurrent record review and interview on 4/23/2026 at 8 AM with Registered Nurse 1 (RN 1), Resident 1's medical records were reviewed. RN 1 stated the order on 4/10/2026 of IV hydration was not administered until 4/11/2026 at around 11 AM. RN 1 stated she initiated the peripheral IV line on 4/11/2026 because when she started her shift (7 AM to 3 PM), it had been endorsed to her that the order last night had not been carried out. RN 1 stated that Resident 1 did not have an IV line in place when she started her shift on 4/11/2026. During an interview on 4/23/2026 at 11:48 AM with the Director of Nursing (DON), the DON stated she was not aware that the IV hydration on 4/10/2026 was not administered until 4/11/2026. The DON stated the IV hydration order was important because Resident 1 has a change of condition of hypotension (abnormally low blood pressure) on 4/9/2026. The DON stated administering IV hydration would have increased Resident 1's blood pressure. During a review of undated Facility's P&P titled Policy and Procedure for IV, the P&P when an IV order is received, call or fax pharmacy with IV orders. The P&P also indicated, of the fluids and medications ordered are available from emergency kit (e-kit) supply, initiate infusion therapy as ordered in timely manner.

Based on interview and record review, the facility failed to provide the appropriate treatment and service to prevent urinary tract infection (UTI- infection of the urinary tract) to one (1) of two (2) sampled residents (Resident 1) who was admitted at the facility with indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine when a person is unable to urinate on their own) by failing to: 1. Monitor and document Resident 1's change of condition (COC) that was observed by facility staff on 8/14/2025 and on 8/21/2025 of dark/ brown colored urine (normal urine color is clear and yellow) in the indwelling catheter bag. 2. Notify Resident 1's physician (MD 1) of the resident's (COC) of dark/ brown colored urine noted on 8/14/2025 and 8/21/2025 in accordance with the resident's Care Plan for at risk for UTI. These failures resulted in Resident 1 to continue having dark/ brown urine color and experience shortness of breath with an oxygen saturation (O2sat- the amount of oxygen you have circulating in your blood) of 89 percent (normal value is between 95% to 100%), heart rate of 143 beats per minute (bpm- normal value is 60 to 100 bpm), and temperature of 101 Fahrenheit (temperature scale, which is used to measure body temperature. Normal value is between 97 to 99) on 8/22/2025. On 8/22/2025, Resident 1 was transferred to General Acute Care Hospital (GACH) via 911 (the number that you call to contact the emergency services) and in GACH's Emergency Department (ED- medical facility that provides immediate care for patients with serious or life-threatening conditions), Resident 1 was noted to have dark turbid urine in indwelling catheter bag, and the resident was intubated (placing a breathing tube through the mouth and down the throat into the lungs) in GACH's ED. Resident 1 was subsequently admitted to GACH's Intensive Care Unit (ICU- a specialized hospital department for patients with life-threatening illnesses or injuries requiring constant monitoring and advanced life support) with diagnosis of septic shock (a dangerously low blood pressure occurs, preventing vital organs like the heart, brain, and kidneys from receiving enough blood and oxygen, leading to potential organ failure and death) due to UTI associated with indwelling urinary catheter.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE], with diagnosis which included UTI, dysphagia (difficulty or discomfort in swallowing), severe intellectual disability.During a review of Resident 1's admission Nursing assessment dated [DATE], it indicated Resident 1 has an indwelling urinary catheter, and with urine color of yellow and clear. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 8/11/2025, the MDS indicated Resident 1's cognitive skills (processes of thinking and reasoning) for daily decision making was severely impaired (never/rarely made decisions). The MDS also indicated Resident 1 was dependent on personal hygiene, toileting hygiene, shower bath self. The MDS also indicated, the resident is with an indwelling urinary catheter.During a review of Resident 1's Order Summary Report, indicated an order dated on 7/30/2025 for Resident 1 to have indwelling catheter French 16 (size) with 10 cubic centimeters (the volume of sterile water, expressed in cubic centimeters (cc) used to inflate the retention balloon of a indwelling catheter to hold it in place inside the bladder) attached to gravity urine drainage bag (bag attached to the indwelling urinary catheter to collect the urine) for urinary retention (not being able to urinate). During a review of Resident 1's Care Plan Report date initiated on 7/30/2025, the care plan report indicated focus is at risk for UTI related to indwelling urinary catheter use. The care plan report indicated intervention included, observe urine output for foul odor, sediments (solid particles found in urine), color, amount, abdominal pain and distention (a condition where the abdomen appears swollen or enlarged). The care plan report also indicated to notify physicians as needed for any signs and symptoms of UTI present. During a review of Resident 1's Output: Urine dated 8/14/2025 to 8/22/2025, Resident 1's output: urine indicated, on 8/14/2025 at 2:31 PM and 8/21/2025 at 6:59 AM and 8/22/2025 at 6:59 AM, Resident 1's urine characteristic was noted to be brown /dark in color.During a review of Resident 1's electronic medical charts (EMC) dated from 8/14/2025 to 8/22/2025, Resident 1's EMC did not indicate documented evidence that MD 1 was notified of Resident 1's brown/ dark urine color on 8/14/2025 and 8/21/2025 and that the COC was monitored for the urine color and for signs and symptoms of UTI. During a review of Resident 1's Progress Notes, dated 8/22/2025 at 8:57AM, the progress note indicated Resident 1 was noted with shortness of breath, with O2sat of 89 percent, with temperature of 101 Fahrenheit, and with heart rate of 143 bpm. The progress notes also indicated Resident 1 was transferred to GACH via 911. During a review of Resident 1's Order Summary Report, indicated on 8/22/2025, to transfer Resident 1 to GACH via 911. During a review of Resident 1's GACH ED Provider Note dated 8/22/2025 entered by ED doctor at 3:21 PM, the GACH ED provider note indicated Resident 1 was brought in by 911 from the facility with chief complaint of shortness of breath, respiratory distress, tachypnea (elevated heart rate) and hot to touch. The ED provider notes also indicated at 11:17 AM (on 8/22/2025) Resident 1's heart rate is 136 bpm and respiratory rate of 34 breaths per minute. In addition, the ED provider note indicated, Resident 1 has Foley (indwelling catheter) with dark turbid (urine that appears cloudy or opaque. It is caused by the presence of various substances in the urine such as bacteria) urine in bag. The ED provider note indicated Resident 1's lactic acid (activates immune cells and promotes inflammation. increased production of lactic acid or a decreased ability of the body to break it down due to severe infection) level was 2.8 millimole per liter (mmol/L- unit of measurement. Normal value is 0.5 to 1.9mmol/L) and urinalysis (UA, a medical test that analyzes a urine sample to assess the health of the urinary system and other organs) showed Resident 1's urine is cloudy with white blood cell (WBC- type of blood cell that plays a crucial role in the body's immune system. Elevated level indicated infection) level of 686 per high- powered field (HPF. Normal level is less than 0.2/HPF) and moderate bacteria. During a review of Resident 1's GACH ED Provider Note dated 8/22/2025, it indicated under Medical Decisions Making, Resident 1 was intubated and placed on ventilator (a machine or device used medically to support or replace the breathing of a person who is ill, injured), the resident was given 3 Liters (L) of intravenous fluids (solutions administered directly into a patient's veins through a small plastic tube called a catheter), and broad- spectrum antibiotics (antibiotics that are effective against a wide range of bacteria). The ED Provider Note also indicated, 45 minutes of critical care was provided to Resident 1 to manage life threatening critical condition including respiratory failure (a medical condition where the lungs are unable to adequately exchange oxygen and carbon dioxide, leading to low oxygen levels in the blood and other parts of the body) and septic shock. In addition, the ED provider note indicated, date and time of disposition (final decision) is on 8/22/2025 at 2:14 PM and Resident 1's diagnosis is septic shock - UTI associated with indwelling urinary catheter and the resident was admitted to ICU. During a concurrent interview and record review on 8/27/2025 at 3:59 PM with the License Vocational Nurse (LVN 1), Resident 1's EMC dated on 8/14/2025 to 8/22/2025 and Resident 1's Output: Urine for the month of 8/14/2025 to 8/22/2025 were reviewed. LVN 1 stated Resident 1's urine output characteristic on 8/14/2025 at 2:31 PM, 8/21/2025 at 6:59 AM and 8/22/2025 at 6:59 AM, was noted to be brown /dark in color. LVN 1 stated, dark/ brown urine color was not normal for Resident 1 and may indicate possible dehydration (a condition that occurs when the body loses too much water and other fluids that it needs to work normally. It is usually caused by fever or urinating more than normal) or infection. LVN 1 stated, Resident 1's COC of dark/ brown urine color noted on 8/14/2025 and 8/21/2025 should have been reported to MD 1 to obtain orders. LVN 1 also stated, the COC should have been monitored and documented in the resident's progress notes and Resident 1's care plan for at risk for UTI should have been revised. In addition, LVN 1 stated there was no documented evidence in Resident 1's EMC that Resident 1's COC noted on 8/14/2025 and 8/21/2025 was reported to MD1 and that the COC was monitored for progress. During an interview on 8/28/2025 at 6:14 AM with LVN 2, LVN 2 stated, on 8/14/2025 at 2:31 PM and 8/21/2025 at 6:59 AM, there was no monitoring and COC notes/ documentation initiated for Resident 1's dark/ brown urine color found in the resident's EMC. LVN 2 also stated she was the LVN assigned to Resident 1 on 8/21/2025 and 8/22/2025 and that she did not assess Resident 1's urine characteristic and monitored the resident for signs and symptoms of UTI. LVN 2 also stated for residents with indwelling urinary catheter, the licensed nurses should monitor the resident for signs and symptoms of UTI and document the amount of urine, color, and smell. LVN 2 also stated Resident 1's brown/ dark urine color should have been reported to MD 1.During an interview on 8/28/2025 at 6:46 AM with the Certified Nursing Assistant (CNA 1), CNA 1 stated she observed and documented Resident 1's urine color was dark/ brown on 8/21/2025 at 6:59 AM and 8/22/2025 6:59 AM. CNA 1 further stated she did not report it to the licensed nurse. CNA1 stated dark brown urine may indicate infection and that the licensed nurse should be notified of this COC.During an interview on 8/28/2025 at 10:14 AM with Registered Nurse (RN 1), RN 1 stated there was no documentation in Resident 1's medical chart that MD1 was informed regarding Resident 1's urine output was noted to be brown/ dark in color last 8/14/2025 at 2:31 PM and 8/21/2025 at 6:59AM. RN 1 stated the charge nurse/ licensed nurse should have reported it to MD1 to know the underlying reason for the dark/ brown colored urine and to obtain orders to treat and/ or prevent worsening of the condition. RN 1 stated the dark/ brown urine color of Resident 1 could be one of the signs and symptoms of UTI. During an interview on 8/28/2025 at 1:32 PM with the Director of Nursing (DON), the DON stated Resident 1 dark/ brown urine color was not monitored for possible UTI on 8/14/2025 at 2:31 PM and 8/21/2025 at 6:59 AM. The DON stated Resident 1 should have been assessed and monitored for COC noted on 8/14/2025 at 2:31 PM and 8/21/2025 at 6:59 AM. The DON stated that brown/ dark urine color could indicate a possible infection and part of Resident 1's Care Plan for at risk of UTI is that the licensed nurses were supposed to observe and assess the urine output of the resident. The DON also stated any COC such as Resident 1's abnormal urine color should be communicated to MD 1. The DON stated the facility did not follow its policy to implement the resident's care plan because the facility failed to notify MD 1 of Resident 1's COC noted on 8/14/2025 at 2:31 PM and on 8/21/2025 at 6:59 AM. During an interview on 8/28/2025 at 2:40 PM with MD1, MD1 stated, Resident 1's COC of dark/ brown urine color on 8/14/2025 and 8/21/2025 were not reported. MD 1 stated if it had been reported, MD1 would have ordered US to check for infection. During a record review of the facility's Policy and Procedures (P&P) titled Catheter Care date revised 6/2012, the P&P indicated it is the policy of this facility to improve hygiene and reduce infection by ensuring that catheter care is done every shift to residents who are using foley catheter (indwelling catheter). The P&P also indicated the following steps will be observed and implemented in providing the foley catheter care:> Observed urine for any sediments or change in color> Notify MD as well as resident's representative for any sediments noted in the urine flow and for any other significant condition. During a record review of the facility's P&P titled Change in Condition date revised 8/2025, the P&P indicated It is the policy of this facility that all changes in residents' condition will be communicated to the physicians. The P&P also indicated the P&P is to clearly define guidelines for timely notification of a change in resident condition for immediate intervention. The P&P also indicated all nursing actions / interventions will be documented in the license progress notes as soon as possible after residents' needs have been met. The P&P indicated sudden or change in a resident's condition will be communicated to the physician immediately within 30 minutes to 1 hour. During a record review of the facility's P&P titled Care Plan Comprehensive Person Centered, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs to be developed and implemented for each resident. The P&P also indicated each resident's comprehensive person-centered care plan is consistent with residents' rights to participate in the development and implementation of his or her plan of care, including the right to receive the services and / or items included in the plan of care.

Based on observation, interview, and record review the facility failed to ensure one (1) of 1 sampled resident (Resident 1) who was assessed at risk for elopement (a resident who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected) did not elope after going out- on- pass (OOP, temporary permission of a resident to leave the facility in a specified time) on 4/15/2025 at 6 PM by failing to: 1. Develop a care plan and interventions to address Resident 1's risk for elopement. 2. Implement procedures based on the facility's Elopement Risk policy to search for Resident 1 when Resident 1 did not return to the facility while OOP. 3. Ensure facility staff implement its elopement policy by failing to report to local police, administrator, and resident representative within two (2) hours and to California Department of Public Health (CDPH) within 24 hours from when Resident 1 eloped on 4/15/2025. 4. Ensure the facility has a system in place to identify risks for residents who independently go OOP such as wandering, falling, and/or injuries. As a result, Resident 1 left the faciity on OOP unsupervised on 4/15/2025 and did not return. This had the potential to be exposed to harsh environmental conditions including excessive heat and or cold, potential of being hit by a car and medical complications including malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat), dehydration (body loses too much water and other fluids that it needs to work normally), heat stroke (a life-threatening condition where the body's temperature rises dangerously high), and death. On 4/17/2025 at 10:16 PM, while onsite at Facility 1, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) was called in the presence of Director of Nursing (DON) and Administrator ( ADM) due to the facility's failure to supervise Resident 1 to prevent Resident 1's elopement from the facility. On 4/19/2025 at 4:35 PM the facility submitted an acceptable IJ removal plan (IJRP). After verification of IJRP implementation through observation, interview, and record review, the IJ was in the presence of the DON and ADM The IJ Removal Plan dated 4/19/2025, included the following: A. On 04/18/2025, all seven residents with out on pass order was reviewed and updated including the duration, purpose, and companion. If the resident will not return after specified duration, facility will call resident/family/companion for update on whereabouts and the time of return. If resident request to go out on pass independently, resident must meet all of the following criteria to be considered eligible and Interdisciplinary Team will review request to go out unaccompanied and document in Interdisciplinary notes. a. Cognitive Competency (Recent BIMS) b. Behavioral Stability (No recent history of elopement) c. Medical Stability (Medically cleared by Attending Physician) d. Functional Mobility B. MDS Coordinator and Registered Nurse Supervisor, re-assessed all seven residents with out on pass order and baseline care plan was updated. Elopement Risk Assessment was done for all 56 residents. Of those, 54 residents were identified as low risk for elopement and two residents were identified as high risk. C. Elopement Risk Policy and Procedures was revised and updated on 04/18/2025. The license personnel were in-serviced and educated on 04/18/2025 regarding timely assessment and identification of residents with high risk of elopement. Any episode of elopement reported and communicated to the Director of Nursing and Administrator so the facility leadership will be able to inform residents family, physician, regulatory Police Department, Ombudsman, California Department of Public Health and other regulatory agencies. D. Director of Staff Development/Director of Nursing in-service the license personnel regarding Policy and Procedure for elopement to emphasize in reporting to local police, administrator, and residents' representative within 2 hours and to California Department of Public Health within 24 hours when resident elopement. E. All residents with out on pass order was reviewed and updated including the duration, purpose, companion, and return time within four hours. A log was available to both nursing stations, regarding the time out and estimated time to return to the facility. Other residents who have potential to be affected by the deficient practice: A. Residents on high risk for elopement are potentially affected by the deficient practice. There were two residents identified as high risk after reviewing clinical records. The identified residents were re-assessed, care plan was developed and implemented, including monitoring every two hours. Log was available in the nursing station. B. An in-service was provided to License Nurses and direct care giver on 04/18/2025 by the Director of Staff Development and Social Service Director pertaining to: How to alert staff about resident elopement or missing How to locate or search the resident Reporting to governing agencies within 2 hours and CDPH within 24 hours. Measures that will be put in place to ensure that a deficiency will not occur A. The Director of Nursing/ Designee and Director of Staff Development conducted in-service to License Nurses and Certified Nursing Assistants on 04/18/2025 pertaining to the following: 1. Revised Policy and Procedure for Out on Pass Physician order for out on pass Duration and companion Protocol if the resident did not return after Specific duration Resident's decision against medical advice 2. Policy and Procedure for Elopement B. During daily angel rounds the Department Managers will check the out on pass log and discuss in the daily stand-up meeting. Monitoring A. The Director of Nursing Services/Registered Nurse Supervisor is responsible for monitoring the residents on a daily basis to ensure that the deficient practice will not be impacted. Results of the findings will be submitted and discussed to QAPI Committee during the monthly/quarterly QAPI meeting of its effectiveness. Findings: During a review of Resident 1's admission record, the admission record indicated the facility admitted Resident 1 on 3/11/2025. Resident 1's diagnoses of psychoactive substance abuse(drug addiction, is a disease that affects a person's brain and behavior and leads to an inability to control the use of a legal or illegal drug or medicine), unspecified alcohol- induced disorder (a medical condition characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences), generalized muscle weakness (a decrease in muscle strength), and unsteadiness on feet (the person is walking in an abnormal, uncoordinated, or unsteady manner). During a record review of Resident 1's Elopement Risk Assessment, dated 3/11/2025, the elopement risk indicated Resident 1 was at risk for elopement. During a review of Resident 1's Order Summary Report, dated 3/18/2025, the Order Summary Report indicated Resident 1 may go out on pass two times a week. During a review of Resident 1's Minimum Data Set (MDS, standardized care and screening tool), dated 3/24/2025, the MDS indicated Resident 1 had an intact cognitive (process of thinking and reasoning) skills for daily decision making. The MDS also indicated Resident 1 required partial moderate assistance (Helper does less than half the effort. Helper lifts, holds or support trunk or limbs, but provides less than half the effort) with walking 10 feet (ft., a unit to measure the length or distance) once standing and walking 50 ft. with two turns (once standing, the ability to walk at least 50 ft. and make 2 turns). During a concurrent review of Resident 1's Out on Pass (OOP)/ Leave of Absence log and interview with Registered Nurse 1 (RN1) on 4/17/2025 at 2:04 PM, RN1 stated Resident 1 left the facility by himself to go to the store and did not return at the expected time on 4/15/2025 at 9PM. During a review of Resident 1's nurses progress notes, dated 4/15/2025 at 11:08 PM, the progress notes indicated resident has not returned from OOP. The progress notes also indicated Licensed Vocational Nurse 1 (LVN1) called Resident 1 on his cellular phone, but the resident did not answer. During a review of Resident 1's nurses progress notes, dated 4/16/2025 at 5:58 AM, the progress notes indicated Resident 1 had not returned to the facility. During a review of Resident 1's nurses progress notes on 4/16/2025 from 10:33 AM to 1:27 PM, the nurses progress notes indicated Resident 1 was OOP. During a review of Resident 1's nurses progress notes from 4/16/2025 at 1:28 PM to 4/17/2025 at 7:59 AM, the nurses progress notes did not have any further documentation on the resident's whereabouts. During a review of Resident 1's nurses progress notes, dated 4/17/2025 at 8AM, the progress notes indicated, a late entry for 4/16/2025 at 8:30 AM that Resident 1 had not returned to the facility. Registered Nurse 1 (RN1) attempted to call Resident 1 but there was no response. RN 1 informed the medical doctor (MD1, primary physician), the Director of Nursing (DON), Administrator (ADM) and Social Service Director (SSD) that Resident 1 was not back from OOP. There were no new orders received from MD1. During a concurrent interview and record review on 4/17/2025 at 2:10 PM with RN1, Resident 1's Order Summary Report was reviewed. RN 1 stated order summary report dated 3/18/2025 indicated may go out on pass two times a week. RN1 stated Resident 1's OOP order was not specific because it did not indicate who will accompany the resident and for how long the resident may go OOP. During an interview on 4/17/2025 at 4:35 PM with LVN 1, LVN1 stated Resident 1 left the faciity on [DATE] at 6PM for OOP and was expected to return at 9PM the same night (4/15/2025). LVN 1 stated Resident 1 was not back at 9PM (4 hours after Resident 1 left) so LVN 1 called Resident 1 on his cellular phone to verify the resident's whereabouts but did not get a reply. LVN1 stated he did not inform the DON, ADM or the police department. LVN 1 also stated he did not search for Resident 1 when he did not return as expected at 9PM or throughout his shift (3PM to 11PM on 4/15/2025). During an interview on 4/17/2025 at 4:40 PM with RN1, RN1 stated she notified MD1, DON, ADM and SSD on 4/16/2025 at 8:30 AM (11 hours and 30 minutes after) that Resident 1 has not been back at the facility since Resident 1 had gone OOP on 4/15/2025 at 6PM and was expected to return on 4/15/2025 at 9PM. RN1 also stated the facility did not search for the resident and neither did RN 1 report to the police nor to the department of public health about the Resident 1 not being back to the facility after OOP on 4/15/2025. During a review of Resident 1's Social Service Notes, dated 4/17/2025 at 5:42 PM, the Social Service notes indicated Resident 1 went OOP on 4/15/2025 at 4PM according to the signed OOP log. Resident 1 has not been back to the facility since 4/15/2025. During an interview on 4/17/2025 at 4:55 PM with the DON, the DON stated the facility did not search the facility and surrounding streets for Resident 1 on 4/15/2025 to 4/16/2025 because her understanding is that Resident 1 was not returning to the facility and did not consider it as an elopement. The DON confirmed that Resident 1 was in fact missing. The DON stated RN 2 reported to the police on 4/17/2025 at 3:15 PM (45 hours and 15 minutes from when resident left the facility) that Resident 1 has not been back to the facility since 4/15/2025 when resident went OOP. The DON stated she along with the IPN and SSD started calling hospitals and searched the facility surroundings on 4/17/2025 at 1:40 PM. During an interview on 4/17/2025 at 4:48 PM, the DON stated Resident 1 was at risk for elopement according to the elopement risk. The DON stated Resident 1 should have a care plan for elopement to ensure resident safety. During a concurrent interview and record review on 4/18/2025 at 12:45 PM with RN1, Resident 1's care plan was reviewed. RN1 stated Resident 1 does not have care plan for OOP and risk for elopement. RN 1 stated Resident 1 should have a care plan when going OOP and for risk for elopement. During an interview on 4/17/2025 at 6:48 PM with the DON, the DON stated any resident can go OOP even at nighttime if the resident is alert and oriented times four (4) and based on the resident's assessment such as if the resident is able to walk and can go by themselves. During a review of the facility's OOP policy, revised 7/2024, the policy indicated the resident may go out by him /herself if he/she is self-responsible depending upon physician's order. During a concurrent interview and record review on 4/17/2025 at 6:50 PM with the Administrator, Resident 1's Order Summary Report, dated 3/15/2025 was reviewed. The ADM stated Resident 1's order to may go out on pass two times a week was a blanket order because it is not specific. The ADM stated the order did not indicate how long was Resident 1 allowed to be OOP and did not indicate if Resident 1 can go OOP independently or be accompanied by a responsible person while OOP. During a concurrent interview and record review on 4/17/2025 at 6:55 PM with the Administrator, the Policy and Procedure titled, Out on Pass/ Against Medical Advice (AMA)/ Doctors Appointment, revised 7/20/2024 was reviewed. The ADM stated the policy did not have a timeframe indicating a duration of time for when the resident can be OOP. The ADM further stated facility staff should know procedures to follow when the resident does not return from OOP that include searching for residents if residents have not returned within a 4-hour timeframe, report to the responsible party, MD, ADM, DON, local police, and California Department of Public Health. During a concurrent interview and record review on 4/17/2025 at 7 PM with the Administrator, the Policy and Procedure titled, Elopement Risk Precautions and Procedures revised 7/2024 was reviewed. The ADM stated according to the policy, if the resident is not found within 2 hours, notify the local police, administrator, and resident representative and to notify California Department of Public Health (CDPH) within 24 hours from when Resident 1 eloped. The ADM confirmed that IPN reported Resident 1 missing to the local law enforcement on 4/17/2025 at 3:15 PM. During a review of the facility's Policies and Procedure (P&P) titled, Out on Pass/ Against Medical Advice/ Doctors Appointment, revised 7/2024, the P&P indicated to provide opportunity for the resident to participate in family and community life to maintain optimal functioning, the facility will respect resident's rights to be OOP unless otherwise contraindicated to the resident's medical needs. The P&P indicated the resident may go out by him /herself if he/she is self-responsible depending upon physician's order. During a review of the facility's P&P titled, Care Plan, revised 4/2024, the P&P indicated a care plan is a summation of the residents' concerns, goals, approaches and interventions in order to meet the goals and help minimize if not totally eradicate residents' problem. The P&P also indicated the resident care plan is developed within 7 days upon resident's admission, reviewed quarterly, annually or as often as needed as there is a change in condition. The evidence of a care plan that has been reviewed should include but not limited to the new interventions that have been added in addition to the current ones. These interventions should be in chronological order as implemented and carried out. During a review of the facility's P&P titled, Elopement Risk Precautions and Procedures, revised 7/2024, indicated the facility to identify residents who are wanderers or who are a threat to leaving the facility unattended without the knowledge of the facility staff. The P&P indicated to ensure the resident's safety utilizing the least restrictive means available. It also indicated when a resident believed to be missing, the following steps will be implemented: 1. The charge nurse shall be alerted that the resident is missing 2. The charge nurse of designee shall alert staff about the resident elopement or missing. All employees are to report to the nurse station. The charge nurse/ supervisor will explain the situation and designate where each staff person is to search. 3. Search the building: closet, shower, bathrooms and ground thoroughly. 4. If the facility search is unsuccessful, the surrounding streets and yards will be searched. 5. If the resident was not found within 2 hours, notify local police, administrator and responsible party. 6. Give the police a description and current photo of the missing resident. 8. If resident is not found within 24 hours even with the assistance of the police department of if found and resident sustains injury, department of public services will be notified in 24 hours.

Based on observation, interview and record review, the facility failed to follow safe food handling practices for two of two sampled residents (Resident 1 and 2) to prevent an unknown gastrointestinal (GI) outbreak (a sudden rise in the number of cases of an infectious disease) by: 1. Failed to ensure Kitchen Staff 1 (KS 1) did not work in the facility kitchen and prepare food for the residents on [DATE] and from [DATE] to [DATE] while KS 1 was experiencing diarrhea (the passage of three or more loose or liquid stools per day) abdominal pain, vomiting, nausea, fever, and loss of appetite. 2. Failed to store refrigerated food items in accordance with professional standards for food service. Facility kept food items with unclear expiration dates and past used by dates in the refrigerator on [DATE]. These deficient practices placed the residents, facility staff and visitors at risk for contracting gastrointestinal (GI) infection and resulted to 21 residents (Residents 1,2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 and 21) and 5 facility staff (KS 2, Certified Nurse Assistant (CNA) 1, CNA 2, CNA 3, and CNA 4) to experience diarrhea, abdominal pain, vomiting, nausea, fever, and/ or loss of appetite. Resident 3, who experienced nausea, vomiting and diarrhea, was sent to the general acute care hospital (GACH) on [DATE]. Resident 4, who also experienced nausea, vomiting and diarrhea, was sent to the GACH on [DATE]. On [DATE] timed at 6:55 PM an Immediate Jeopardy (IJ: a situation in which the facility's' noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADM), Administrator In Training (AIT), and the Director of Nursing (DON) regarding the facility's failure to ensure KS 1 was not working in the facility kitchen and prepare food for the residents on [DATE] and [DATE] to [DATE]. On [DATE] at 5:36 PM, the IJ was removed after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyor verified and confirmed the implementation of the Plan of Action (POA) while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM and DON. The acceptable IJ Removal Plan included the following: 1. On [DATE], ADM, provided counseling to KS 1 member that reported to work without informing her supervisor or any other department head that she was experiencing symptoms. 2. Facility has done in-service to dietary staff on [DATE], given by back-up Infection Preventionist (IP) nurse, and DON, regarding the following topics: 2.a Employee screening: the importance of notifying the department heads when they are feeling sick and/or are experiencing any symptoms such as cough, fever, sore throat, chills, headache, diarrhea, muscle pain, fatigue (condition marked by extreme tiredness and inability to function due to lack of energy), nausea, vomiting, new loss of taste or smell, congestion, or runny nose 2.b Personal Hygiene, Safe Food Handling, Safe Food Handling/Handwashing, and the seriousness of food borne illness regarding how quickly it spreads, the potential and actual harm it can cause residents, and that it could lead to death. 3. The Supervisor of Dietary Services (DSS) and Manager of the Day (MOD) will monitor the new employee screening form which asks the staff member if they have experienced diarrhea, vomiting, nausea, stomach pain, cramping in the past ,d+[DATE] hours. as well as supervisors will randomly ask staff how they feel. Anyone who complains about sign or symptoms will immediately be asked to leave the premises until no longer experiencing signs and symptoms and a release letter has been issued from the physician. Department heads will inform the DON, ADM, and AIT if any of the above symptoms occur. 4. On [DATE], the back-up Infection Preventionist nurse (IP) 2 and DON have in service to dietary staff on [DATE] regarding the importance of notifying the department heads when they are feeling sick and/or are experiencing any symptoms such as cough, fever, sore throat, chills, headache, diarrhea, muscle pain, fatigue, nausea, vomiting, new loss of taste or smell, congestion, or runny nose. 5. The DSS and any other department heads will randomly ask dietary staff how they are feeling and if they are experiencing any symptoms every week. The Department heads will inform the DON, ADM, and the AIT if any of the above symptoms occur. 6. Counseling provided to Director of Dietary Services, on [DATE], regarding requiring anyone who complains about signs or symptoms to immediately be asked to leave the premises until no longer experiencing signs and symptoms and a release letter has been issued from the physician. 7. Separate screening form, regarding GI symptoms, will be provided for the dietary department for them to complete on a daily basis to be monitored by the DSS or MOD and will report the findings to the ADM. All collected information will be taken to the Quality Assurance and Performance Improvement (QAPI) meeting and discussed for recommendations by the team to be implemented every month times 3 and then quarterly times 3. All in- services to be completed prior to the start of employee's next shift. Findings: 1. During an interview on [DATE] at 2:45 PM, KS 1 stated, she first experienced symptoms of abdominal pain, diarrhea, vomiting, nausea, fever, and loss of appetite on [DATE]. KS 1 stated she worked at the facility as a dishwasher on [DATE] and did not report her symptoms to DSS. KS 1 stated from [DATE] to [DATE] she was still having the same symptoms of abdominal pain, diarrhea, vomiting, nausea, fever, and loss of appetite. KS 1 stated she worked as a kitchen cook at the facility and prepared meals for the residents from [DATE] to [DATE] and she did not report to DSS or any of the facility staff that she was experiencing GI symptoms. A review of KS 1's Time and Attendance - Employee Punch History (timecard) dated [DATE] to [DATE], indicated KS 1 worked at the facility on [DATE] from 9:38 AM to 6:14 PM. The timecard also indicated, KS 1 worked at the facility on [DATE] to [DATE] on different shifts (morning between 5 AM to 2:30 PM] or afternoon shift [between 2 PM to 7 PM]). During an interview on [DATE] at 2:49 PM, Dietary Service Supervisor (DSS) stated that KS 1 did not report feeling sick on [DATE] or on [DATE] to [DATE]. The DSS stated, on [DATE] after KS 1 finished working her entire shift KS 1 told DSS that she felt sick experiencing diarrhea. During an interview on [DATE] at 3:50 PM, the DON stated, the staff identified to have first experienced the GI symptoms was KS 1. The DON stated, KS 1 had GI symptoms of abdominal pain, diarrhea, vomiting, nausea, fever, and loss of appetite which started on [DATE] but KS 1 did not report being sick until [DATE] at the end of her shift. The DON stated KS 1 was supposed to report her symptoms to DSS before coming to work on [DATE]. The DON stated it is important to report feeling sick if staff work in the kitchen to prevent the food from being contaminated, the residents from getting sick and from unknown GI outbreak to occur. A review of the facility's Acute Gastroenteritis (inflammation of the stomach and intestines resulting from bacterial toxins or viral infection and causing symptoms such as diarrhea, abdominal cramps, nausea, vomiting and fever) Surveillance Line List dated [DATE] indicated on [DATE], KS 1 experienced abdominal pain, diarrhea, nausea, vomiting, fever, and loss of appetite. A review of Resident 1's Admission Record (AR) indicated the Resident 1 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes (a disease in which a person's blood glucose, or blood sugar, levels are too high). A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care-screening tool) dated [DATE], indicated Resident 1's cognition (mental processes, ability to understand and make decision) was intact. A review of Resident 1's Situation Background Assessment Recommendation (SBAR - written communication tool) dated [DATE], indicated, Resident 1 had three (3) episodes of yellow- colored loose bowel movement (LBM). A review of Resident 2's AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included convulsions (a condition in which muscles contract and relax quickly and cause uncontrolled shaking of the body). A review of Resident 2's MDS dated [DATE], indicated Resident 2's cognition was severely impaired. A review of Resident 2's SBAR dated [DATE], indicated, Resident 2 had episodes of nausea, vomiting and LBM. A review of Resident 3's AR indicated the resident was initially admitted to the facility on [DATE], with diagnoses that included type 2 diabetes (a disease in which a person's blood glucose, or blood sugar, levels are too high). A review of Resident 3's MDS dated [DATE], indicated Resident 3's cognition (ability to understand and make decision) was intact. A review of Resident 3's SBAR dated [DATE] timed at 4:02 PM, indicated Resident 3 noted to have loose bowel movement (LBM/ diarrhea) with nausea and vomiting (not indicated how many times). A review of Resident 3's Nurses Progress Note (NPN) dated [DATE] timed at 9:37 PM indicated Resident 3 had 1 episode of LBM (diarrhea) in moderate amount. A review of Resident 3's Acute Gastroenteritis Surveillance Line List dated [DATE], indicated, on [DATE] Resident 3 experienced diarrhea, nausea, and vomiting. A review of Resident 3's NPN dated [DATE] times at 2:31 PM, indicated LBM (diarrhea) was noted at this time. A review of Resident 3's physician order dated [DATE] indicated an order to transfer Resident 3 to GACH. A review of Resident 3's NPN dated [DATE] times at 8:20 AM, indicated resident sent to GACH via 911 at 2:35 AM. A review of Resident 4's AR indicated the resident was initially admitted to the facility on [DATE], with diagnoses that included anemia (a condition in which the number of red blood cells within body is lower than normal). A review of Resident 4's MDS dated [DATE], indicated Resident 4's cognition was intact. A review of Resident 4's SBAR dated [DATE], indicated, Resident 4 was experiencing nausea, vomiting and LBM (diarrhea). A review of Resident 4's SBAR dated [DATE], indicated, Resident 4 was transferred to GACH. A review of the facility's Acute Gastroenteritis Surveillance Line List dated [DATE] indicated as follows for residents: a. On [DATE], Resident1 and 2 experienced diarrhea, nausea, and vomiting. b. On [DATE], Resident 3 and 13 experienced diarrhea, nausea, and vomiting. c. On [DATE], Resident 4, 5, 6, 7, 8, 9, 10, 11, and 12 experienced diarrhea, nausea, and vomiting. d. On [DATE], Resident 14 experienced diarrhea, nausea, and vomiting, and Resident 15 experienced diarrhea and nausea. e. On [DATE], Resident 16 experienced vomiting and loss of appetite, Resident 17 experience diarrhea, nausea, and vomiting, and Resident 18 and 19 experienced nausea and vomiting. f. On [DATE], Resident 20 experienced nausea, vomiting, and loss of appetite. g. On [DATE], Resident 21 experienced diarrhea. A review of the facility's Acute Gastroenteritis Surveillance Line List dated [DATE] indicated as follows for staff: a. On [DATE], KS 2 experienced diarrhea and vomiting. b. On [DATE], CNA 1 experienced abdominal pain and nausea. c. On [DATE], CNA 2 experienced abdominal pain, diarrhea, nausea and vomiting, CNA 3 experienced diarrhea and CNA 4 experienced nausea and vomiting. A review of the facility's P&P for Outbreak Investigation revised [DATE], indicated the facility will recognize and contain infectious disease outbreaks and outbreak measures will be instituted whenever there is evidence of an outbreak as outlined: - Goals of outbreak investigation and management are for prompt identification that an outbreak exits and to implement prompt resident placement, transmission- based precautions, and PPE in order to prevent the spread of outbreak. - The Infection Preventionist or designee will review details of signs or symptoms of infection for employee's call in sick and develop line listing of cases with signs or symptoms, onset date and details of illness for residents and employees. - To contain, control and prevent more cases facility will investigate potential cause of outbreak. 45099 2. During a concurrent observation in the kitchen and interview with KS 3 on [DATE] at 10:10 AM, a large container of cottage cheese with a best by date of [DATE] and a large container of sour cream with concealed expiration date were stored inside the kitchen refrigerator. KS 3 stated cottage cheese was supposed to be discarded after the best by date and the sour cream should show the expiration date, so kitchen staff know when to discard it. During an interview on [DATE] at 10:20 AM, the DSS stated expired and past the used by dates in the refrigerator should be discarded to prevent the items from being used and residents from getting sick. During an interview on [DATE] at 2 PM, KS 4 stated it is important to check expiration and use by dates on the ingredients used for cooking and discard them if labels are unclear and past the used by dates, so they do not give out food to residents that's expired and get them sick. A review of the facility's Policy and Procedure titled, Refrigerated Storage Practice, revised [DATE], indicated to check expiration dates of milk and other dated foods.

Based on observation, interview, and record review the facility failed to implement their policy and procedure for infection control to prevent infectious disease outbreak (a sudden rise in the number of cases of an infectious disease) for two of two residents (Resident 1 and 2) by: 1. Failed to ensure Kitchen Staff 1 (KS 1) did not work in the facility kitchen and prepare food for the residents on 3/27/2023 and from 3/30/2023 to 4/3/2023 while KS 1 was experiencing diarrhea (the passage of three or more loose or liquid stools per day) abdominal pain, vomiting, nausea, fever, and loss of appetite. 2. Facility failed to recognize an unknown gastrointestinal (GI, stomach and intestines) outbreak, identify organism/ source of infection, monitor, and control the spread of infectious disease when Resident 1 and Resident 2 had symptoms of diarrhea and vomiting on 4/2/2023 in accordance with the facility's policy and procedure. 3. Facility failed to ensure three (3) staff (Certified Nurse Assistant [CNA] 6, Treatment Nurse [TN, licensed nurse in charge of performing wound care] and CNA 5) were wearing Personal Protective Equipment (PPE) when working with residents on contact isolation (used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled) precautions. 4. Facility failed to ensure supplies (gloves) necessary for the care of residents on contact precautions are accessible and available for staff and visitors use. These deficient practices placed all the other 34 residents in the facility, facility staff and visitors at risk for contracting gastrointestinal (GI) infection and resulted in 21 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 and 21) and 5 facility staff (KS 2, Certified Nurse Assistant (CNA) 1, CNA 2, CNA 3, and CNA 4) experiencing vomiting and diarrhea. Resident 3, who developed symptoms of diarrhea, nausea, and vomiting, was sent to general acute care hospital (GACH) on 4/7/2023, and Resident 4 who also developed symptoms of diarrhea, nausea, and vomiting, was sent to GACH on 4/5/2023. On 4/14/23 timed at 6:55 PM an Immediate Jeopardy (IJ: a situation in which the facility's' noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADM), Administrator In Training (AIT) and the Director of Nursing (DON) regarding the facility's failure to ensure KS 1 was not working in the facility kitchen and preparing food for the residents from 3/27/2023 and 3/30/2023 to 4/3/2023, failure to recognize an unknown GI outbreak, identify organism or source of infection, monitor, and control the spread of infectious disease when Resident 1 and 2 experienced diarrhea and vomiting on 4/2/2023 and facility failed to report the unknown GI outbreak to the local public health (PHN) and district office / California Department of Public Health (CDPH) when Resident 1 and Resident 2 had diarrhea and vomiting on 4/2/2023. On 4/16/2023 at 5:36 PM the IJ was removed after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyor verified and confirmed the implementation of the Plan of Action (POA) while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM and DON. The acceptable IJ Removal Plan included the following: 1. On 4/15/2023, ADM, provided counseling to KS 1 member that reported to work without informing her supervisor or any other department head that she was experiencing symptoms. 2. Facility has done in-service to dietary staff on 4/15/2023, given by back-up Infection Preventionist nurse (IP) 1, and DON, regarding the following topics: 2.a Employee screening: the importance of notifying the department heads when they are feeling sick and/or are experiencing any symptoms such as cough, fever, sore throat, chills, headache, diarrhea, muscle pain, fatigue (a condition marked by extreme tiredness and inability to function due to lack of energy), nausea, vomiting, new loss of taste or smell, congestion, or runny nose 2.b Personal Hygiene, Safe Food Handling, Safe Food Handling/Handwashing, and the seriousness of food borne illness in regarding how quickly it spreads, the potential and actual harm it can cause residents, and that it could lead to death. 3. Separate screening form, regarding GI symptoms, will be provided for the dietary department for them to complete daily. Dietetic Service Supervisor (DSS)/weekend Manager of the Day (MOD) will monitor and will report the findings to the ADM. 4. The facility's consultant, Registered Dietician provided an in-service on 4/18/2023 to the dietary department, for safe food handling, coming to work sick, and the seriousness of food borne illness, pertaining to seriousness and negative impact on resident's wellbeing. 5. On 4/15/2023, the ADM re-educated the DON on the policy and procedure of infection prevention and control. On 4/15/2023, IP 1 was in-serviced via telephone by ADM, on our in-house Outbreak Policy and Procedure, with specific emphasis on monitoring and recognizing signs of infection and the requirement to report two or more incidents of GI symptoms to the Department of Health completed using information from interviews of affected residents and staff, in order to find a root cause. 6. In-service was given by IP 1, on 4/15/2023, to licensed staff regarding change of condition (COC), recognizing symptoms of a potential viral outbreak, according to our in-house Outbreak Policy and Procedure, and how to report timely to the DON, ADM, and AIT. In-services will be completed prior to licensed staff next shift. 7. PHN was contacted 4/17/2023 to request reinforcement in-service on GI symptoms, Outbreak Management, and recognizing all symptoms that can lead to outbreak. 8. PHN requested the facility to add polymerase chain reaction (PCR) Biofire (a test used to identify pathogens [microorganisms that cause disease] associated with gastroenteritis [inflammation of the stomach and intestines, typically resulting from bacterial toxins or viral infection and causing vomiting and diarrhea]) laboratory test for Resident 21 (the last resident affected), who is 27th on the Line List since the resident was the last resident to come down with symptoms (diarrhea and vomiting), PHN felt that the sample would be most viable. The facility's laboratory cannot do the test, the facility is waiting for the laboratory to inform the facility whether the laboratory's out of -state- branch can assist with the test request. If the laboratory out- of- state branch is unable to provide the test facility will contact PHN department for further instructions and guidance. On 4/17/2023, facility will contact Laboratory 1 to see if they are able to do the PCR Biofire test. 9. IP 2 will compile data gathered during the outbreak and examine for improvement opportunities in identification and management of the disease. IP will develop a written report of the outbreak detail which will identify strategies that could be implemented to prevent future outbreaks or improve the process. Facility will implement the following strategies: - Re-educate staff on proper handwashing techniques, PPE (equipment worn to protect against infections) usage, initiate enhanced barrier protection (an approach of targeted gown and glove use during high contact resident care activities), contact isolation precautions (methods used for individuals with suspected infections to prevent the spread of it), disinfection, encourage fluid intake for residents, notifying facility/ supervisor when symptoms occur. - Interview all staff, from all departments, including department heads if any have GI signs or symptoms. - The physician of all symptomatic residents will be notified and requested to order stool culture (a test on a stool sample to find germs such as bacteria or a fungus [yeasts or molds] that can cause an infection). - Will be in close contact with the medical director - Utilize disinfectant cleaning solution as approved by the U.S. Environmental Protection Agency (EPA) - We will follow the recommendations from PHN in regards to activities and communal dining, and visitation. - Educate residents on handwashing and use of hand sanitizer - Residents with suspected symptoms of GI infection will be added to the line list to begin the tracking process. - Reinforce all departments on being observant when going into resident room, for COC. - Implement cleaning solutions in compliance with List G products (cleaning products used for Norovirus [very contagious virus that causes vomiting and diarrhea. You can get it from having direct contact with an infected person, consuming contaminated food or water and/ or touching contaminated surfaces and then putting your unwashed hands in your mouth. Outbreak can occur anytime but occur most often from November to April]). This information will be collected by medical records taken to the Quality Assurance and Performance Improvement (QAPI) meeting and discussed for recommendations by the team to be implemented every month x 3 and then quarterly x3. 10. Residents 1 and 2 had stool cultures done (Resident 1 on 4/2/2023 and Resident 2 on 4/5/2023) and Resident 1 also had complete blood count (CBC, a blood test that measures different parts of the blood) & complete metabolic panel (CMP, a test that measures several different substances in the blood) test on 4/2/2023. Findings: 1. During an interview on 4/14/2023 at 2:45 PM, KS 1 stated, she first experienced symptoms of abdominal pain, diarrhea, vomiting, nausea, fever, and loss of appetite on 3/27/2023. KS 1 stated she worked at the facility as a dishwasher on 3/27/2023 and did not report her symptoms to DSS. KS 1 stated from 3/30/2023 to 4/3/2023 she was still having the same symptoms of abdominal pain, diarrhea, vomiting, nausea, fever, and loss of appetite. KS 1 stated she worked as a kitchen cook at the facility and prepared meals for the residents from 3/30/2023 to 4/3/2023 and she did not report to DSS or any of the facility staff that she was experiencing GI symptoms. A review of KS 1's Time and Attendance - Employee Punch History (timecard) dated 3/27/2023 to 4/14/2023, indicated KS 1 worked at the facility on 3/27/2023 from 9:38 AM to 6:14 PM. The timecard also indicated, KS 1 worked at the facility on 3/30/2023 to 4/3/2023 on different shifts (morning between 5 AM to 2:30 PM] or afternoon shift [between 2 PM to 7 PM]). During an interview on 4/14/2023 at 2:49 PM, DSS stated that KS 1 did not report feeling sick on 3/27/2023 or on 3/30/2023 to 4/2/2023. The DSS stated, on 4/3/2023 after KS 1 finished working her entire shift KS 1 told DSS that she felt sick experiencing diarrhea. During an interview on 4/14/2023 at 3:50 PM, the DON stated, the staff identified to have first experienced the GI symptoms was KS 1. The DON stated, KS 1 had GI symptoms of abdominal pain, diarrhea, vomiting, nausea, fever, and loss of appetite which started on 3/27/2023 but KS 1 did not report being sick until 4/3/2023 at the end of her shift. The DON stated KS 1 was supposed to report her symptoms to DSS before coming to work on 3/27/2023. The DON stated it is important to report feeling sick if staff work in the kitchen to prevent the food from being contaminated, the residents from getting sick and the unknown GI outbreak that occurred. A review of the facility's Acute Gastroenteritis (inflammation of the stomach and intestines resulting from bacterial toxins or viral infection and causing symptoms such as diarrhea, abdominal cramps, nausea, vomiting and fever) Surveillance Line List dated 4/5/2023, indicated, on 3/28/2023 (as per KS 1 her GI symptoms started on 3/27/2023), KS 1 experienced abdominal pain, diarrhea, nausea, vomiting, fever, and loss of appetite. A review of the facility's Policy and Procedure (P&P) titled Norovirus Prevention and Control, revised August 2011, indicated the facility personnel who work with, prepare, or distribute food will be excluded from work if they develop symptoms of acute gastroenteritis and personnel will not return to work until 48 hours after the resolution of symptoms or longer as required by local health regulations. 2. A review of Resident 1's Admission Record (AR) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes (a disease in which a person's blood glucose, or blood sugar, levels are too high) and atrial fibrillation (a serious abnormal heart rhythm). A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care-screening tool) dated 4/4/2023, indicated Resident 1's cognition (mental processes, ability to understand and make decision) was intact. A review of Resident 1's Situation Background Assessment Recommendation (SBAR - written communication tool) dated 4/2/2023, indicated that Resident 1 had three (3) episodes of yellow- colored diarrhea. A review of Resident 1's physician telephone order dated 4/3/2023 indicated an order for stool culture to rule out (R/O) Clostridium difficile (C. diff - a germ [bacteria] that causes life-threatening diarrhea). A review of Resident 1's Order Summary Report dated 4/6/2023, indicated, on 4/6/2023 (4 days from GI symptoms onset) resident was to be placed on contact isolation (the creation of barriers and other protection such as gloves, masks, or gowns to prevent the spread of an infection). A review of Resident 2's AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included convulsions (a condition in which muscles contract and relax quickly and cause uncontrolled shaking of the body). A review of Resident 2's MDS dated [DATE], indicated Resident 2 cognition was severely impaired. A review of Resident 2's SBAR dated 4/4/2023, indicated, Resident 2 was experiencing nausea, vomiting and loose bowel movement (LBM/ diarrhea). A review of Resident 2's physician telephone order dated 4/4/2023 indicated an order for stool culture. A review of Resident 3's AR indicated the resident was initially admitted to the facility on [DATE], with diagnoses that included type 2 diabetes. A review of Resident 3's MDS dated [DATE], indicated Resident 3's cognition was intact. A review of Resident 3's SBAR dated 4/4/2023 timed at 4:02 PM, indicated Resident 3 noted to have LBM (diarrhea) with nausea and vomiting (not indicated how many times). A review of Resident 3's Nurses Progress Note (NPN) dated 4/4/2023 timed at 4 PM indicated Resident 3 had LBM (diarrhea)) with nausea and vomiting. A review of Resident 3's NPN dated 4/4/2023 timed at 9:37 PM indicated Resident 3 had 1 episode of LBM in moderate amount. A review of Resident 3's Gastroenteritis Surveillance Line List dated 4/5/2023, indicated on 4/3/2023 (not consistent with Resident 3's SBAR dated 4/4/2023) Resident 3 experienced diarrhea, nausea, and vomiting. A review of Resident 3's NPN dated 4/6/2023 timed at 2:31 PM, indicated LBM was noted at this time. A review of Resident 3's physician order dated 4/7/2023 indicated an order to transfer Resident 3 to GACH. A review of Resident 3's NPN dated 4/7/2023 times at 8:20 AM, indicated resident sent to GACH via 911 at 2:35 AM. A review of Resident 3's physician's order dated from 4/4/2023 to 4/6/2023, did not indicate resident was to be placed on contact isolation. A review of Resident 4's AR indicated the resident was initially admitted to the facility on [DATE], with diagnoses that included anemia (a condition in which the number of red blood cells within body is lower than normal). A review of Resident 4's MDS dated [DATE], indicated Resident 4 cognition was intact. A review of Resident 4's SBAR dated 4/4/2023, indicated, Resident 4 was experiencing nausea, vomiting and LBM (diarrhea). A review of Resident 3's physician's order dated from 4/4/2023 to 4/6/2023, did not indicate resident was to be placed on contact isolation. A review of Resident 4's SBAR dated 4/5/2023, indicated Resident 4 was transferred to the GACH. A review of the facility's Acute Gastroenteritis Surveillance Line List dated 4/5/2023 indicated the following: a. On 4/2/2023, Resident 1 and 2 experienced diarrhea, nausea, and vomiting. b. On 4/3/202, Resident 3 (not consistent with SBAR when Resident 3 had GI symptoms onset on 4/4/2023) and Resident 13 experienced diarrhea, nausea, and vomiting. c. On 4/4/2023, Resident 4, 5, 6, 7, 8, 9, 10, 11, and 12 experienced diarrhea, nausea, and vomiting. d. On 4/5/2023, Resident 14 experienced diarrhea, nausea, and vomiting, and Resident 15 experienced diarrhea and nausea. e. On 4/6/2023, Resident 16 experienced vomiting and loss of appetite, Resident 17 experienced diarrhea, nausea, and vomiting, and Resident's 18 and 19 experienced nausea and vomiting. f. On 4/7/2023, Resident 20 experienced nausea, vomiting, and loss of appetite. g. On 4/8/2023, Resident 21 experienced diarrhea. A review of the facility's Acute Gastroenteritis Surveillance Line List dated 4/5/2023 indicated the following: a. On 4/6/2023, KS 2 experienced diarrhea and vomiting. b. On 4/8/2023, CNA 1 experienced abdominal pain and nausea. c. On 4/9/2023, CNA 2 experienced abdominal pain, diarrhea, nausea, and vomiting. It also indicated, CNA 3 experienced diarrhea and CNA 4 experienced nausea and vomiting. During an interview on 4/14/2023 at 4 PM, DON stated she cannot explain the reason as to why the contact isolation precautions were not done for Resident 1 and Resident 2 from 4/2/2023 to 4/5/2023. The DON stated the order should have been obtained from the resident's attending physician and implemented on 4/2/2023. The DON stated it was important to place residents (resident 1 and 2) on contact isolation to stop the spread of the infection. During a concurrent interview and record review on 4/14/2023 at 4:10 PM, ADM stated per facility's policy and procedure for outbreak investigation when two (2) or more residents are experiencing GI symptoms (diarrhea, vomiting, nausea, abdominal pain and/ or fever), outbreak control measures should be implemented. The ADM stated the facility's unknown GI outbreak which started on 4/2/2023 was reported to CDPH (via electronic notification) late on 4/5/2023. The electronic notification sent by the facility to CDPH, indicated the report of 14 cases (13 residents and 1 staff) with GI symptoms was sent on 4/5/2023. During an interview on 4/14/23 at 4:20 PM, DON stated the unknown GI outbreak was reported via electronic notification to CDPH on 4/5/2023 when a total of 14 cases: 1 Staff (KS 1) and 13 residents (Residents 1 to 13) were experiencing symptoms. The DON stated only a few symptomatic residents (Resident 1, 2, 3, 7, 10, 12, 13, 16,17, 20 and 21) were tested for stool culture that were experiencing GI symptoms (diarrhea and/ or nausea and vomiting). The DON stated she only got 4 stool culture test result from the 11 residents. The DON stated the 10 residents (Residents 4, 5, 6, 8, 9, 11, 14, 15, 18 and 19) have not been tested and the DON was unable to explain as to why the remaining 10 resident stool culture was not done. The DON stated, it was important to ensure correct laboratory test was done to ensure facility have recognized the source of infection and/ or type of bacteria or virus the facility need treat and prevent the spread. During the same interview on 4/14/2023 at 4:20 PM, DON stated outbreak was reported to PHN and CDPH (via electronic notification) on 4/5/2023 (3 days after the first 2 symptomatic residents). The DON stated, the IPN did not communicate with her why the GI outbreak was not reported until 4/5/2023 when it should have been reported on 4/2/2023. The DON stated it was important to ensure the facility report their outbreak to ensure they get guidance from PHN and to help control and manage the unknown GI outbreak. During an interview on 4/14/23 at 4:30 PM, DON stated she cannot explain the reason as to why there were inaccurate information in the facility's Acute Gastroenteritis Surveillance Line List dated 4/5/2023 such as the date when KS 1 first experienced symptoms of diarrhea, vomiting and fever. The DON stated, the line list indicated KS 1 symptoms started on 3/28/2023 wherein it should be 3/27/2023. The DON stated it was also inaccurate for Resident 3's onset of GI symptoms it should be 4/4/2023 instead of 4/3/2023. The DON stated, it is important to ensure the facility investigate, have an accurate monitoring and tracking of symptomatic residents and staff to be able to see trend and/ or possible source of infection in that way facility can provide the appropriate treatment and or control the spread of infection. A review of the facility's P&P for Outbreak Investigation revised January 2023, indicated the facility will recognize and contain infectious disease outbreaks and outbreak measures will be instituted whenever there is evidence of an outbreak as outlined: - Goals of outbreak investigation and management are for prompt identification that an outbreak exits and to implement prompt resident placement, transmission- based precautions, and PPE in order to prevent the spread of outbreak. - The Infection Preventionist or designee will review details of signs or symptoms of infection for employee's call in sick and develop line listing of cases with signs or symptoms, onset date and details of illness for residents and employees. - To contain, control and prevent more cases facility will investigate potential cause of outbreak. A review of the facility's P&P for Outbreak Investigation revised January 2023, indicated the facility will recognize and contain infectious disease outbreaks and outbreak measures will be instituted whenever there is evidence of an outbreak as outlined: Facility will notify State and local health officials as required by State Law, Public Health Codes or Ordinances, report reportable disease, illnesses, and new or unusual infections to public health agencies as soon as possible. 45099 3. A review of Resident 12's Admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included paraplegia (paralysis affecting your legs, but not your arms) and stage 4 pressure ulcer (deep wound reaching the muscles, ligaments, or bones) of sacral (a large, flat, triangular shaped bone nested between the hip bones and positioned below the last lumbar vertebra) region. A review of Resident 12's MDS dated [DATE] indicated Resident 12 has no cognitive impairment. A review of Resident 8's Admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest) and unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). A review of Resident 8's MDS dated [DATE] indicated Resident 8 has moderately impaired cognitive status. During a concurrent observation and interview on 4/6/2023 at 12:25 PM, CNA 6 entered Resident 12's room, set up the resident's lunch tray then touched the bed control at the foot of the bed without using gloves. CNA 6 proceeded to come out of Resident 12's room and puts his hands in his pockets performing hand hygiene. CNA 6 stated, he forgot to wear his gloves before he entered Resident 12's room who was on contact isolation and forgot to perform hand hygiene before exiting the resident's room. CNA 6 also stated gloves should be worn and hand hygiene should be done to prevent from contracting the infection. During an interview on 4/6/2023 at 12:40 PM, the LVN 1 stated staff are supposed to wear gloves when performing residents care to prevent the spread of the microorganism to other staffs and residents. During an observation on 4/6/2023 at 1 PM, the Treatment Nurse (TN) provided wound care and dressing change to Resident 1's wound on left foot with gloves on and TN was not wearing isolation gown. TN acknowledged she should have worn an isolation gown to protect herself from the infection that Resident 1 might have while performing wound care. During a concurrent observation and interview on 4/6/2023 at 1:40 PM, CNA 5 touched Resident 8 (who was observed with vomit all over the bed, clothes, and hands) and the call light system (device used by residents to call facility staff when they need help) without wearing gloves then immediately touched her (CNA 5) hair without performing hand hygiene. CNA 5 stated she should have used an isolation gown and gloves before touching the resident and performed hand hygiene to prevent getting the infection and spreading them to other residents and staffs. During an interview on 4/6/2023 at 4:45 PM, the DON stated staffs were advised to wear gowns and gloves before entering isolation rooms and touching the residents with suspected infections especially now with the unknown GI outbreak to prevent from spreading and getting the infections. During a concurrent observation and interview on 4/6/2023 at 5 PM, CNA 5 entered Resident 8's room without performing hand hygiene and without wearing isolation gown and gloves. CNA 5 stated she should have worn her PPE (isolation gown and gloves) and performed hand hygiene before and after going in and out of the room to prevent cross contamination to other residents and staff. 4. During an observation outside Resident 7's room on 4/6/2023 at 1:15 PM, there was no trash bin designated to discard used PPEs inside Resident 7's room. During an observation outside Resident 8's room on 4/6/2023 at 1:30 PM, Resident 8's room did not have a contact isolation sign posted outside the resident's room visible to facility staff and visitors to warn the residents, facility staff and/ or visitor on what PPE to use prior to entering the room. During an interview on 4/6/2023 at 4:45 PM, the DON stated contact isolation signs should be posted outside the isolation rooms to let the facility staff know what precautions to use before entering the room. The DON also stated trash bins to discard used PPEs inside isolation room is necessary for infection control so germs does not spread and will be confined in the trash can. The DON further stated if staff throws the PPEs they used in the resident's bathroom, other uninfected residents using the bathroom can possibly get exposed to whatever germs that is in the used PPEs. A review of the facility's policy and procedure titled, Infection Control, Standard Precautions, revised March 2001, indicated that standard precautions (set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin) will be used in the care of regardless of their diagnosis or presumed infection status. The policy indicated to perform hand washing after touching , body fluids, , and contaminated items, whether gloves are worn or not. The policy also stated to wear gloves when touching contaminated items and to wear a gown to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of , body fluids, secretions, or excretions. A review of the facility's policy and procedure titled, Categories of Infection Precautions, revised July 2012, indicated that along with the standard precautions, implement contact precautions for individuals assessed, known, or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environment surfaces or patient-care items in the resident's environment. The facility also stated Gastrointestinal infections as one of the infections requiring contact precautions.

Based on interview and record review, the facility failed to ensure personnel provided basic life support (BLS - activation of the emergency response system, early cardiopulmonary resuscitation (CPR)) to one of three sampled residents (Resident 1) who required such emergency care prior to the arrival of emergency medical personnel, as per physician's orders [REDACTED].>1. Failure to continuously monitor Resident 1's heart and respiratory rate to ensure implementation of immediate Basic Life Support (BLS - includes activation of the emergency response system, cardiopulmonary resuscitation (CPR) and rescue breathing). 2. Failure to implement Resident 1's physician's orders [REDACTED]. 3. Failure to implement the facility's policy on Emergency Care, to ensure licensed nurses gave CPR when Resident 1 was suddenly found to be in cardiac or respiratory arrest. As a result, on [DATE], at 10:24 a.m., upon arrival to the facility, paramedics found Resident 1 not breathing and with no pulse (heart rate). Paramedics provided CPR, revived Resident 1 and transferred her to General Acute Care Hospital 1 (GACH 1). Findings: On [DATE] at 1:15 p.m., an unannounced visit was conducted to the facility to investigate a complaint regarding Resident 1's quality of care. A review of the Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the History and Physical (H&P) Examination, dated [DATE], indicated that Resident 1 has the capacity to understand and make decisions. A review of the POLST (a form with physician's orders [REDACTED]. A review of the Minimum Data Set (MDS - standardized assessment and care-planning tool) dated [DATE] indicated Resident 1 was able to make decisions, was alert and oriented, and was able to communicate needs. A review of Nurses' Notes dated [DATE], timed at 10:15 a.m., indicated Resident 1 was observed with shallow breathing (superficial breathing, drawing minimal air into the lungs) and did not respond to verbal and touch stimuli. The blood pressure was ,[DATE] mmHg (millimeters of Mercury, low blood pressure below ,[DATE], normal range ,[DATE] - ,[DATE]), the oxygen saturation level (a measure of how much oxygen the red blood cells are carrying. Normal range is between ,[DATE]%) could not be obtained. Resident 1's bed was elevated and was provided with oxygen at eight liters per minute (8 L/min) with a mask (facemask used to deliver oxygen). Resident 1's physician and 911 (emergency responders) were called. The Nurses' Notes timed at 10:30 a.m., indicated 911 arrived. Paramedics were unable to obtain Resident 1's blood pressure, Resident 1 was not breathing, and the Paramedics started CPR. A review of the paramedics' report notes, dated [DATE], indicated the arrival time was at 10:24 a.m. Resident 1 was found lying on her back with no heartbeat and no respiration. An empty tube of oral glucose (high sugar concentration used when there is low blood sugar level) was next to Resident 1 and the time of administration was unknown by the staff. At 10:25 a.m., CPR was initiated and medications were given. At 10:39 a.m. Resident 1 responded to life-saving interventions. At 10:53 p.m., Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1). A review of GACH 1 Discharge Note - Physician Final Report, dated [DATE], indicated Resident 1 developed worsening kidney injury. Resident 1 remained on mechanical ventilator (a breathing machine), had poor neurological function. Resident 1 had a [MEDICAL CONDITION] and was pronounced death at 8:44 a.m. A review of Resident 1's Certificate of Death dated [DATE] indicated immediate cause of death was cardiogenic shock (a condition in which the heart suddenly stops pump enough blood to the body). The death certificate indicated the secondary cause of death included [MEDICAL CONDITION] (the heart suddenly stop beating). On [DATE] at 1 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated on [DATE], at approximately 10 a.m., Resident 1 was observed pale, with labored (difficult) breathing. LVN 1 stated Resident 1 was cold and clammy (sweaty skin) and was not responsive. LVN 1 stated she checked Resident 1's blood sugar and it was 68 milligram per deciliter (mg/dl). LVN 1 stated she did not check Resident 1's pulse. LVN 1 stated she did not know if Resident 1 had a pulse and was needed CPR. On [DATE] at 1:20 p.m., during an interview, LVN 2 stated on [DATE] before 10 a.m., Certified Nurse Assistant 1 (CNA 1) mentioned to her that Resident 1 was observed different and did not eat much of her breakfast. LVN 2 stated went and observed Resident 1 was pale skin color, with labored breathing and unresponsive. LVN 2 stated LVN 1 checked Resident 1's blood sugar and was 68. LVN 2 stated she placed the pulse oximeter (an oximeter that measures the proportion of [MEDICATION NAME] hemoglobin in the blood in pulsating vessels, especially the capillaries of the finger or ear) on Resident 1's finger but she could not get any reading for the heart rate (pulse) or oxygen saturation level on the pulse oximeter. LVN 2 stated she tried to place the pulse oximeter on Resident 1's ear lobe and again she could not obtain the pulse or oxygen saturation on Resident 1. LVN 2 stated she elevated Resident 1's head of bed and administered oxygen to Resident 1. LVN 2 stated she did not manually check Resident 1's pulse because the pulse oximeter showed that the resident did not have a pulse. LVN 2 stated We (LVN 1 and LVN 2) don't know what to do so we just wait for 911. On [DATE] at 5:20 p.m., during an interview, the Director of Nursing (DON) stated licensed personnel should know to provide CPR when needed, and while waiting for 911 to arrive. On [DATE], at 5:25 p.m., during a telephone interview, Resident 1's Physician stated CPR should be initiated right way when the resident had no pulse regardless of the resident's condition. The Physician stated, CPR is always significant for survival. A review of the facility's policy and procedure titled Emergency Care revised date ,[DATE] indicated; it is the policy of this facility that all staff member must know what to do in the event of an Emergency. It is the policy of this facility to give quality patient care. This includes emergency care services. All of the Licensed staff are trained in cardiopulmonary resuscitation and are instructed to give CPR where and when it is indicated. If a patient is suddenly found to be in cardiac or respiratory arrest, CPR will be administered. Either another licensed staff member, if on duty at the time or nurse assistant will be instructed to call the paramedics and the attending physician once CPR has been instituted.

Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services as ordered by the physician for one sampled resident (Resident 1). The resident's gastrostomy tube (([DEVICE]) a feeding tube placed through the skin and the stomach wall to provide nutrition) became dislodged and was not reinserted as ordered by the physician. This failure resulted in the resident not receiving medication or feedings for 48 hours and contributed to a 2 lbs (pounds) weight loss from 129 lbs to 127 lbs. During a complaint visit on February 27, 2015, at 11:00 a.m., the evaluator was informed Resident 1's [DEVICE] had dislodged on February 25, 2015 (2 days prior). After three attempts to interview registered nurses (RN 1 and RN 2) the evaluator was informed the facility did not have a director of nursing (DON), nor an administrator. Both the DON and the administrator resigned on February 26, 2014. During an interview with RN 1 stated RN 2 was the nursing supervisor. RN 2, stated he was a recent graduate (August 8, 2014) and a new employee (hired on February 10, 2015), and was not familiar with Resident 1. According to RN 2 he was aware the [DEVICE] had become dislodged on February 25, 2015, but he did not know if there had been any follow-up for the [DEVICE] replacement. On February 27, 2015, at 12:05 p.m., an immediate jeopardy (IJ) was called in the presence of, the Ombudsman, and the facility's Trustee due to Resident 1's [DEVICE] was dislodged and the resident not receiving [DEVICE] feedings and medications for at least 48 hours. The IJ was abated on February 27, 2015, at 1:50 p.m. in the presence of the newly appointed director of nursing (DON) after submitting the following plan of correction: An assessment of the resident was done which included vital signs, and assessment of the [DEVICE] site for pain. physician's orders [REDACTED]. Resident ' s responsible party was informed of the resident's transfer to hospital. Copies of medical records needed for transfer to hospital were completed. Licensed nurses were in-serviced regarding policy and procedures on [DEVICE] management. In addition the facility trustee, a DON and an administrator had been hired and would be assuming responsibilities effective immediately. Findings: An admission face sheet indicated Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. The residents [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), a comprehensive standardized assessment and care screening tool, dated December 17, 2014, indicated the resident was rarely able to make herself understood and rarely able to understand others. According to the MDS the resident was receiving nutrition through a feeding tube ([DEVICE]). The [DEVICE] was placed on April 19, 2011, and was present upon resident's admission to the facility. Review of a nutritional assessment, dated September 10, 2014, indicated the resident was being administered [MEDICATION NAME] (a calorically dense formula with a unique fiber blend that provides complete, balanced Nutrition for tube feeding) 1.2 calories to infuse for 20 hours at 50 milliliters (ml, cc) per hour. The Nutritional Assessment indicated the residents caloric needs were 1375 calories per day, 55 grams of protein, and 1437cc of water per day. On February 6, 2015, the resident's weight was 129 pounds. There was no other weight taken after February 6, 2015 until February 27, 2015, which was 127 pounds. During an observation on February 27, 2015 at 11:33 a.m. Resident 1 was observed lying in bed on her back. The resident had an intravenous ((IV)( infusion of liquid substance infusing directly into a vein line) to the left hand infusing [MEDICATION NAME] ([MEDICATION NAME] is used chiefly as a fluid and nutrient replenisher, and also as a diuretic) in half normal saline (is a general phrase referring to a sterile solution of sodium chloride (NaCl, more commonly known as table salt) in water) 5% in normal saline 0.045% at 60 milliliters per hour. The facility staff received an order from the physician to start the IV at 8:45 p.m. on February 25, 2015. According to Medicine Online www.medicineonline.com: intravenous solutions containing [MEDICATION NAME] and sodium chloride are indicated for [MEDICATION NAME] (administered to the body through a route other than the mouth) [MEDICATION NAME] of fluid, minimal carbohydrate calories, and sodium chloride. Excessive administration of potassium-free solutions may result in significant [DIAGNOSES REDACTED] (low potassium level which is critical to the functioning of nerve and muscle cells, especially in the heart). The intravenous administration of these solutions can cause fluid and or solute overloading resulting in dilution of serum electrolyte concentrations (Electrolytes are the salts and metallic components that are dissolved within the blood stream), over hydration, congested states, [MEDICAL CONDITIONS] (fluid accumulation in the air spaces of the lungs). Review of an undated "Resident Transfer Record" indicated the resident's [DEVICE] became dislodged on February 4, 2015 and the physician ordered to replace the catheter temporarily with a urinary catheter. The physician ordered the resident be transferred to the GACH (general acute care hospital) for [DEVICE] replacement. According to the Resident Transfer Record the GACH would not accept the resident due to an insurance issue. Another entry on the same "Resident Transfer Record" indicated on February 25, 2015, the urinary catheter, which had been placed as a temporary [DEVICE], became dislodged. The physician ordered the resident to be transferred to GACH with [DIAGNOSES REDACTED]. Review of the "Licensed Personnel Progress Notes", dated February 25, 2015, indicated the following: At 1pm, the resident was observed with a dislodged [DEVICE]. There was no order from the physician to replace the dislodged [DEVICE] with a urinary catheter on February 25, 2015. At 4:24 p.m., an order was received to transfer the resident to the GACH for [DEVICE] replacement. At 4:30 p.m., the GACH was called to arrange for transfer of the resident for [DEVICE] replacement. GACH informed the facility staff there would be a call back when a bed was available. At 7:30 p.m., the GACH informed the facility staff the resident could not be accepted due to insurance issues. At 8:45 p.m., a new order was received from the physician to administer IV fluids for hydration until the [DEVICE] was replaced. There was no further documentation the facility staff made any attempt to have the resident transferred to the GACH until the evaluator intervened on February 27, 2015. Review of a letter dated February 28,2015, written by the facility's former administrator, indicated she had made arrangements to have the resident transferred to the GACH on February 19, 2015, after being told by the court Trustee who was assigned on February 18, 2015, that the cost of the [DEVICE] replacement would be covered by the facility. According to the former administrator the resident was scheduled for a [DEVICE] replacement to be done on February 27, 2015. The former administrator stated she was informed the temporary urinary catheter had become dislodged on February 25, 2015, and attempts were made to have the resident transferred for [DEVICE] replacement at that time. According to the former administrator the resident transfer to the GACH was again denied at that time. The former administrator resigned on February 26, 2015. The physician's orders [REDACTED]. A physician's orders [REDACTED]. During an interview on February 27, 2015 at 11:39 a.m., RN 2 was asked about the status of Resident 1. RN 2 stated he had been made aware about the dislodged [DEVICE] by the charge nurse on shift February 25, 2015, but did not know why the [DEVICE] had not been replaced. RN 2 stated " I'm new I don't really know the resident." After reviewing the resident's medical record, RN 2 stated the reason the [DEVICE] had not been replaced was due to a health insurance issue. RN 2 did not know if there had been any further follow-up after February 25, 2015, for transfer of the resident to the GACH for [DEVICE] replacement. During an interview on February 27, 2015 at 11:47 a.m., the director of social services stated (DSS) stated the resident had not been transferred to the GACH on February 25, 2015, because of a health insurance problem. When asked if anybody had followed up on having the resident transferred for [DEVICE] replacement, the DSS stated she did not know. On February 27, 2014, at 12:03 p.m., licensed vocational nurse (LVN 1) stated the resident's [DEVICE] had become dislodged on February 4, 2015, and it had been temporarily replaced with a urinary catheter. According to LVN 1 the temporary catheter became dislodged on February 25, 2015, and had not been replaced. When asked why the [DEVICE] was not replaced with a temporary urinary catheter LVN 1 was unable to answer. According to LVN 1 nurses are able to replace [DEVICE]s if they are trained. During a phone interview on March 2, 2015, at 9:16 a.m., the DON stated the resident was readmitted back to the facility from the GACH on March 1, 2015. Review of the "History and Physical" (H&P) from the GACH "Authored", on February 28, 2015, indicated the resident was admitted for [DEVICE] malfunction and [DEVICE] replacement. According to the medical record the resident was in " Mild distress at the time of the examination. "The "History and Physical", indicated the resident was admitted for a dislodged [DEVICE] three days earlier and the resident had not received medication or feeding for at least 48 hours. Review of laboratory results from the GACH dated February 27, 2015, indicated the following results were low: red blood cell count was 3.66 (normal 4.20-5.40), hemoglobin 10.5 (normal 12.0-16.0 g/dL), hematocrit 33.0 (normal 36.0-48.0%). The [DEVICE] was replaced and the resident was readmitted to the skilled nursing facility (SNF) on March 1, 2015.