Every finding on record at Citrus Heights Health Center

Based on interviews and record review, the facility failed to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of one sampled resident (Resident 1) who was at high risk for falls by failing to:Ensure Certified Nursing Assistant (CNA 1) provided two-person physical assistance (help from two persons) while providing personal care (hands-on assistance with everyday tasks) to Resident 1 as indicated in Resident 1's care plan (CP), titled, [activities of daily living (ADL's - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves)]/Functional Status/Rehab [rehabilitation], dated 7/3/2026. As a result, on 7/5/2026 at around 3:24 am, Resident 1 fell from Resident 1's bed and sustained an open skin flap (a section of skin and underlying tissue that is partially torn or cut away from the body while remaining attached at one edge) on the right forearm, a skin tear and an open skin flap on the left hand, a cut on the left nostril, a cut on the lip area, and abrasions (an injury where the skin rubs off also known as a scrape) on the left anterior (the front) foot.Findings:During a review of Resident 1's Profile Face Sheet (PFS, admission record), the PFS indicated Resident 1 was admitted to the facility 10/12/2025 with multiple diagnoses including hemiplegia (a form of paralysis [complete or partial loss of muscle function in a part of the body] that affects one entire side of the body) following cerebral infarction (commonly known as ischemic stroke, the death of brain tissue caused by prolonged lack of blood flow and oxygen [a colorless gas essential to living organisms]), malignant neoplasm (a cancerous tumor) of specified sites, open wound of unspecified part of the neck, and abnormal posture (the body is out of alignment). During a review of Resident 1's Fall Risk Assessment (FRA), dated 10/12/2025, the FRA indicated Resident 1 was disorientated (feeling confused, lost, or unable to figure out direction, time, or surroundings) at all times. The FRA indicated Resident 1 was at high risk for falls.During a review of Resident 1's History and Physical (H&P), dated 10/13/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Physical Therapy: PT Evaluation & Plan of Treatment (PTEP), dated 10/14/2025 - 11/9/2025, the PTEP indicated Resident 1 was a fall risk and was dependent with all ADLs. The PTEP's assessment summary indicated Resident 1 was at risk for falls and had increased dependency upon caregivers. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 1/5/2026, the MDS indicated Resident 1's cognitive (the ability to think and process information) was severely impaired. The MDS indicated Resident 1 and was dependent (helper does all of the effort, the resident does none of the effort to complete the activity) with oral and toilet hygiene, upper and lower body dressing, chair to bed transfers and with rolling from left to right.During a review of Resident 1's CP titled Fall - History/Risk, related to: requires assistance with transfers, incontinent (involuntary loss of bladder [hollow muscular balloon-like organ that stores urine] or bowel control) of bowel and bladder, weakness, and poor safety awareness, dated 4/14/2026, the CP's interventions indicated to transfer Resident 1 with adequate assistance.During a review of Resident 1's CP titled ADL's/Functional Status/Rehab, dated 7/3/2026, the CP's interventions indicated two-person assistance (assist) with transfers and bed mobility (a person's ability to change body positions while in bed, including rolling, scooting, and sitting up), assisting during transfer with safety, and providing enough support during transfers.During a review of Resident 1's Interdisciplinary Notes (IDT, an alteration in a resident's physical health that differs from his/her previous baseline), dated 7/5/2026, written by Registered Nurse 2 (RN 2), indicated at around 3:24 am, Resident 1 was on the floor laying supine (flat on back) on the left side of Resident 1's bed, with a blanket and linen under the resident. The IDT indicated Resident 1 was noted with blood at the neck area, multiple open skin tear flaps on the right forearm, open skin tear flaps on the left hand, a cut on the left nostril, a cut on the lip area, and an abrasion on the left anterior foot.During a review of Resident 1's Professional Communication (Situation, Background, Assessment, Recommendation [SBAR, a structured four-step communication framework used primarily in healthcare to quickly, clearly, and concisely convey critical resident information]), dated 7/5/2026, timed at 4:00 am, the SBAR indicated Resident 1 had a witnessed fall.During a review of Resident 1's Daily Charting for Sunday, July 05, 2026, documentation completed by CNA 1on 7/4/2026, timed at 11:18 pm, the documentation indicated Resident 1's functional abilities and goals [included]- mobility roll left to right, the ability to roll from lying on back to the left and right side, and returning to lying on the back on the bed. The documentation indicated Resident 1 was fully dependent. The documentation indicated Resident did none of the effort to complete the activity and the assistance of two or more helpers was required for Resident 1 to complete activity.During an interview on 7/22/2026 at 9:35 am, with CNA 3, CNA 3 stated [on 7/5/2026] Resident 1 needed two-person assistance because Resident 1 could not participate with bed mobility and was fully dependent with ADLs. CNA 3 stated when providing care for Resident 1, CNA 3 always asked for assistance from another staff to prevent CNA 3 and Resident 1 from getting hurt.During an interview on 7/22/2026 at 9:56 am, with Registered Nurse (RN) 1, RN 1 stated on 7/5/2026, from 11:00 pm to 6:00 am, RN 1 and CNA 1 were assigned to care for Resident 1. RN 1 stated [on 7/5/2026] Resident 1 was totally dependent [on staff] and needed two-person assistance with bed mobility and during all ADLs. RN 1 stated CNA 1 did not ask RN 1 for assistance with Resident 1 during the duration of RN 1 and CNA's shift. RN 1 stated, on 7/5/2026, CNA 1 assisted Resident 1 with ADLs all by herself and CNA 1 did not ask for assistance from other staff. RN 1 stated if CNA 1 would have asked for assistance, Resident 1's fall could have been prevented.During an interview on 7/22/2026 at 10:22 am, with CNA 2, CNA 2 stated, on 7/5/2026, sometime after midnight (unknown specific time), CNA 2 had a missed call from CNA 1. CNA 2 stated CNA 2 immediately went to CNA 1's unit to Resident 1's room and saw a soiled linen utility cart in front of the room. CNA 2 stated upon entering Resident 1's room, RN 2 and CNA 1 were inside the room. CNA 2 stated Resident 1 was on the floor, facing up on the left side of the bed, and was bleeding. CNA 2 stated Resident 1 needed assistance from two persons because Resident 1 was fully dependent on ADL care.During an interview on 7/22/2026 at 10:47 am, with the Director of Staff Development (DSD), the DSD stated residents who were fully dependent [on staff] required assistance from two staff during personal care, bed mobility, transfers (how the resident moves to and from the bed, chair, or wheelchair), and all ADLs for Resident 1's safety.During an interview on 7/22/2026 at 11:12 am, with RN 2, RN 2 stated on 7/5/2026 at 3:23 am, RN 2 had a missed call from CNA 1. RN 2 stated RN 2 returned CNA 1's call at 3:24 am and CNA 1 notified RN 2 Resident 1 fell out of Resident 1's bed. RN 2 stated RN 2 went to Resident 1's room and Resident 1 was lying flat on the floor. RN 2 stated RN 2 asked CNA 1 what happened and CNA 1 told RN 2 CNA 1 [was providing ADL care to Resident 1] and attempted to turn Resident 1 when Resident 1 slipped off the bed and fell onto the ground. RN 2 stated CNA 1 told RN 2 CNA 1 called CNA 2's phone but CNA 2 did not answer [and proceeded to provide care to Resident 1 without assistance from another staff]. RN 2 stated Resident 1 was totally dependent on staff for personal care involving bed mobility and required two person assist for turning and for Resident 1's safety to prevent falls. RN 2 stated CNA 1 did not ask for RN 2's assistance prior to Resident 1's fall.During an interview and concurrent record review of Resident 1's PTEP, on 7/22/2026 at 3:28 pm, with the Director of Rehabilitation (DOR), the DOR stated Resident 1 was non-ambulatory (unable to walk) and was totally dependent on all ADLs including grooming, hygiene and bed mobility. The DOR stated staff provided 100% of Resident 1's care. The DOR stated Resident 1 always needed assistance from two staff when staff provided ADL for Resident 1's safety. During an interview on 7/22/2026 at 3:47 pm with the Director of Nursing (DON), the DON stated Resident 1 needed two-person assist due to Resident 1's inability to help the nursing staff during personal care and ADLs. The DON stated CNA 1 failed to wait for assistance from another nurse to assist with turning and providing care to Resident 1. The DON stated as a result, Resident 1 fell from the bed and sustained injury on Resident 1's forearm, hand, nostril, and lip. The DON stated if CNA 1 had waited for nursing assistance, the fall could have been prevented. During a review of the facility's follow-up investigation report (FIR), dated 7/9/2026, the FIR indicated Resident 1 was totally dependent on staff for all ADLs and required the assistance of two staff members. The FIR indicated on 7/5/2026 at 3:23 am, Resident 1 experienced a fall from Resident 1's bed while CNA 1 provided personal care to Resident 1 without the assistance of a second staff member. The FIR indicated according to CNA 1's statement, while providing care, CNA 1 pulled Resident 1 toward CNA 1 and turned Resident 1 onto the left side in order to remove soiled linen from beneath Resident 1's body. The FIR indicated during this care, Resident 1 inadvertently rolled off the left side of the bed and fell to the floor. The FIR indicated based on the facility 's investigation, it was determined that CNA 1 failed to wait for prior assistance to provide care for Resident 1 despite knowing Resident 1 required two-person assist during ADLs.During a review of the facility's policy and procedure (P&P), titled Repositioning, dated 5/2013, the P&P indicated to reposition the resident in bed: check the care plan, assignment sheet for communication system to determine resident's specific positioning needs including special equipment, resident level of participation and the number of staff required to compte the procedure. The P&P indicated to use two people and a draw a sheet to avoid shearing while turning or moving the resident up in bed.During a review of the facility's P&P titled Falls and Fall Risk, Managing, dated 3/2018, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P&P indicated unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. The P&P indicated the staff, the input of the attending physician, will implement a resident-centered fall prevention plan to reduce specific risk factor(s) of falls for each resident at risk or with a history of falls.

Based on observation, interview and record review, the facility failed to ensure residents were not allowed to keep medications at bedside without a physician's order and/or without being assessed to determine if the residents were capable of self-administering medications, for two of two sampled residents (Residents 26 and 38). These deficient practices had the potential for Residents 26 and 38 to self-medicate resulting in unsafe medication administration and adverse (harmful) consequences for Residents 26 and 38.Findings: a. During a review of Resident 26's admission Record (AR), the AR indicated Resident 26 was admitted to the facility on [DATE], with diagnoses including pleural effusion (abnormal buildup of excess fluid between the layers of tissue that line the lungs and the inside of the chest cavity) & heart failure (condition when the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs). During a review of Resident 26's Physician's Order (PO) dated 3/13/2025, the PO indicated Resident 26 had an order for Breo Ellipta 100 microgram (mcg-unit of measurement)-25 mcg/dose powder for inhalation [Fluticasone furoate-vilanterol] - 100-25 mcg/d Inhalation, inhale one puff orally once a day, rinse mouth after use, for shortness of breath (SOB). During a review of Resident 26's PO dated 9/7/2025, the PO indicated Resident 26 had an order for Albuterol sulfate HFA 90 mcg/actuation aerosol inhaler [generic] - 90 mcg/actua inhalation as needed, 2 puffs every four hours for SOB. No stop date. During a review of Resident 26's History and Physical (H&P) dated 3/2/2026, the H&P indicated Resident 26 had the capacity to understand and make decisions. During a review of Resident 26's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 5/18/2026, the MDS indicated Resident 26 had moderately impaired cognition (ability to understand). During a review of Resident 26's undated and untitled Care Plan (CP), the CP indicated Resident 26 had the potential for ineffective airway clearance as evidenced by shortness of breath and pleural effusion. The CP goal was for Resident 26 to exhibit adequate respiratory function as evidenced by no shortness of breath, cyanosis (blush or purplish discoloration of the skin, lips, or fingernails) and use of accessory muscle when breathing. The CP interventions included for nursing staff to administer Fluticasone 100 mcg - salmeterol 50 mcg/dose blister powder for inhalation inhale one puff orally twice daily for SOB - Rinse mouth after use and Albuterol sulfate HFA 90 mcg/actuation aerosol inhaler [generic] - 90 mcg/actua inhalation as needed, two puffs every four hours for SOB. During a concurrent observation and interview on 6/22/2026 at 10:49AM with Resident 26 in Resident 26's room, one inhaler and two eyedrop medications (Systane and Visine) were on the bedside table. Resident 26 stated Resident 26 sometimes goes into a coughing spell and would use the inhaler to help the resident. During an interview on 6/22/2026 at 10:55 AM with Certified Nurse Assistant 2 (CNA 2), CNA 2 stated Resident 26 kept the eye drops and inhaler on Resident 26's bedside table. CNA 2 stated CNA 2 has not seen Resident 26 self-administered eye drops but had seen Resident 26 self-administer the inhaler. During an interview on 6/22/2026 at 11:03AM with the Infection Preventionist (IP) nurse, the IP stated Resident 26 had an inhaler and two eye drops on the bedside table and the IP was unaware if Resident 26 was able to self-administer medications. The IP stated the facility kept the residents' inhalers and eye drops in the medication carts unless it was a resident's preference. b. During a review of Resident 38's AR, the AR indicated Resident 38 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. During a review of Resident 38's PO dated 6/20/2026, the PO indicated Resident 38 had an order to apply hydrocortisone cream (cream used to reduce itching, redness and skin irritation) one (1) percent (%), twice a day for 14 days for facial redness. During a review of Resident 38's H&P dated 6/22/2026, the H&P indicated Resident 38 had the capacity to understand and make decisions. The H&P indicated Resident 38 had diagnoses of sepsis (life-threatening condition that arises when the body's response to infection injures its own tissues and organs) and chronic pain. During a review of Resident 38's MDS dated [DATE], the MDS indicated Resident 38 was cognitively intact. During a review of Resident 38's undated CP titled Skin Problem, the CP indicated Resident 38 had facial redness. The CP goal was for Resident 38 to be free from infection. The CP interventions included providing treatment per physician's (MD) orders, observing for signs and symptoms of infection and report to MD promptly; encourage good fluid/meal intake and monitor meal intakes. During a concurrent observation and interview on 6/23/2026 at 9:19AM with Resident 38 in Resident 38's room, one tube of hydrocortisone cream was observed on the bedside table, unsupervised and readily accessible. Resident 38 stated Resident 38's son brought the prescription hydrocortisone cream from home to the facility. Resident 38 stated Resident 38 had been self-applying the cream to Resident 38's face for a mild skin rash that developed after taking antibiotics. Resident 38 stated Resident 38 applied the cream as needed and did not express any concerns regarding its use. Resident 38 stated Resident 38 has not notified the facility about the cream on Resident 38's possession but staff (unidentified) had seen Resident 38 self-applying the cream. During a review of the facility's Policy and Procedure (P&P) titled, Self-Administration of Medications, dated February 2021, the P&P indicated residents have the right to self-administer medications if the interdisciplinary team (IDT) has determined that it is clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.

Based on interview and record review, the facility failed to ensure irregularities identified from the Monthly Drug Regimen Review (MDRR), reported by the facility's pharmacist were acted upon for three of five sampled residents (Resident 2, Resident 16 and Resident 39).For Resident 2, the resident's physician was not informed regarding a GDR (tapering of medication overtime) for the antipsychotic (manage psychosis, including delusions, hallucinations, and disorganized thinking) medications. For Resident 16, the resident's physician was not informed regarding the GDR for Remeron (mirtazapine, a prescription antidepressant used to treat major depressive disorder). For Resident 39, the facility failed to obtain a lipid panel (a blood test that measures the levels of fats/lipids in the blood). These deficient practices had the potential for unnecessary medication administration for Residents 2, 16 and 39.1. During a review of Profile Face Sheet (PFS, admission record), the PFS indicated Resident 2 was re-admitted to the facility on [DATE] with diagnoses that included bipolar disorder (a mental health condition that causes extreme shifts in mood, energy, activity levels, and concentration), urine retention (inability to completely empty your bladder) and obstructive reflux uropathy (blockage prevents urine from flowing normally causing urine to back up and injure the kidneys). During a review of Resident 2's Physician's Orders (PO) for the month of March 2026, the PO indicated Olanzapine (antipsychotic medication used to treat schizophrenia, bipolar disorder) 2.5 milligrams (mg) by mouth (PO) at bedtime (HS) and Lithium Carbonate ER (medication to treat bipolar) 300 mg PO QD (daily) lamotrigine (a medication to stable mood) 1.5 mg po (QD). The PO indicated these medications were ordered on was ordered for Resident 2 on 3/12/2026. During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 4/16/2026, the MDS indicated Resident 2 was cognitively intact (able to think and process information) and needed moderate assistance (helper does less than half the effort) with toilet hygiene, personal hygiene, lower body dressing, sit to stand position, and chair to bed transfers. During a review of Resident 2's document titled Note to Attending Physician/Prescriber ([NAME]), from the facilities pharmacist, dated 4/22/2026, the [NAME] indicated Resident 2 had been on Olanzapine 2.5 milligram (mg) HS, Lamotrigine 150 mg QD, and Lithium ER (Extended release, medication used to treat bipolar) 300 mg QD. The [NAME] indicated to reevaluate if a Gradual Dose Reduction is appropriate at this time. The [NAME] indicated If a GDR is not appropriate at this time, it is recommended that [Resident 2's Physician] address the benefits versus risk of continuing these doses. If GDR is not appropriate (clinically contraindicated) at this time, please document the clinical rational below. The [NAME] indicated no clinical rational and the area for GDR attempt was left blank. During a review of Resident 2's Medication Administration Record (MAR) for June 2026, the MAR indicated Lithium and lamotrigine were administered daily from 6/1/2026 through 6/23/26 and Olanzapine was administered daily from 6/1/2025 to 6/8/2026 and on 6/11/2026 to 6/23/2026 to Resident 2. During an interview and concurrent record review of Resident 2's paper and electronic medical record with the Director of Nursing (DON), on 6/24/2026 at 2:22 pm, the DON stated there was no documentation that indicated Resident 2's physician was informed of the facility's pharmacist (RX) recommendations for a GDR. The DON stated the pharmacist's recommendations needed to be followed for the possibility of giving less medication to the resident. The DON stated antipsychotic GDR was a a must to determine if a medication was working or not and to make changes [to the dosages], if needed. During a review of the facility's Policy and Procedures (P&P) titled, Medication Regimen Review and Reporting (MRR), dated 11/2017, the P&P indicated MRR or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risk associated with medications. The P&P stated Resident-specific MRR recommendations and findings are documented and acted upon by the nursing care center and/or physician. The P&P stated the consultant pharmacist and the nursing care center follow up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days. For those issues that require physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rational of why the recommendation is rejected in the resident medical record. 2. During a review of Resident 16's PFS, the PFS indicated Resident 16 was originally admitted to the facility on [DATE] and was readmitted on [DATE], with a diagnosis that included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and essential hypertension (high blood pressure). During a review of Resident 16's PO, the PO indicated a physician's order, dated 2/18/2026, for Mirtazapine 15 mg tablet by mouth once a night for depression for inability to sleep at night, last dose: 6/24/2026. During a review of Resident 16's History and Physical (H&P), dated 2/20/2026, the H&P indicated Resident 16 had the mental capacity to understand and make decisions. During a review of Resident 16's [NAME], dated 5/6/2026, the [NAME] indicated Resident 16 was on Remeron 15 mg Q Hs. The [NAME] indicated [for the physician] to please evaluate if a GDR was appropriate at the time of the medication review. The [NAME] indicated, if a GDR was not appropriate, [resident 16's physician] had to address the benefits versus risks of continuing the dose. The [NAME] did not indicate a GDR was attempted or a physician's clinical rationale indicating a GDR was not appropriate for Resident 16. The [NAME] indicated a follow-through note was written to a secondary physician. During a review of resident 16's Medication Record (MR), dated May 2026, the MR indicated resident 16 received mirtazapine 15 mg every night at 9 PM from 5/1/2026 to 5/31/2026. During a review of Resident 16's MDS, dated [DATE], the MDS indicated Resident 16's cognition was intact. During a concurrent record review and interview on 6/23/2026 at 1:56 PM with the Infection Preventionist (IP), the IP stated, the IP could not find the note written to the secondary physician in Resident 16's records. During an interview on 6/24/2026 at 3:09 PM with the DON, the DON stated the facility was waiting for the resident's psychologist appointment on 6/23/2026 to have Mirtazapine (Remeron) medication adjusted or left as is in response to the GDR recommendation. The DON stated there was no response from the psychologist after the appointment. The DON stated the facility faxed the GDR for Remeron to the psychologist today and is waiting for a response. The DON stated the importance of medication regimen reviews (MRR) was to see if the resident's medication is working or not working. 3. During a review of Resident 39's PFS, the PFS indicated Resident 39 was originally admitted to the facility on [DATE] and was readmitted on [DATE], with a diagnoses including personal history of other diseases of the circulatory system and major depressive disorder. During a review of Resident 39's MDS, dated [DATE], the MDS indicated Resident 39's cognition was intact. During a review of Resident 39's H&P, dated 5/18/2026, the H&P indicated Resident 16 had the capacity to understand and make decisions. During a review of Resident 39's [NAME], dated 4/23/2026, the [NAME] indicated a recommendation for lipid panel. The [NAME] indicated the physician's response was left blank. During a concurrent record review and interview on 6/23/2026 at 2:49 PM with the Infection IP, the IP stated the IP was unable to find a lipid panel in Resident 39's records. During an interview on 6/24/2026 at 3:39 PM with the DON, the DON stated Resident 39's MMR for April's recommendations included a lipid panel that was overlooked. The DON stated the order was placed yesterday 6/23/2026 and was collected this morning for Resident 39. During a review of the facility's P&P titled, SNF – Nursing Services – Chapter 2 – Clinical Care 09 Psychoactive Medications, dated /6/25/2025, the P&P indicated F. Pharmacist 1. The facility pharmacist shall review the psychotherapeutic medications monthly and make recommendations as appropriate. The P&P indicated the DON/Designee shall follow up on all recommendations from the facility pharmacist.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 16) was free from chemical restraints (a form of medical restraint in which a drug is used to restrict the freedom of movement of a resident) by failing to ensure Resident's 16's consent for Mirtazapine (antidepressant medication to treat major depressive disorders) was signed by the physician. This failure had the potential to negatively impact Resident 16's care and for Resident 16 to experience adverse side effects (unexpected or harmful consequences) from taking Mirtazapine.Findings: During a review of Resident 16's admission Record (AR), the AR indicated Resident 16 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and lack of coordination. During a review of Resident 16's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 5/22/2026, the MDS indicated Resident 16 had intact cognition (ability to understand). During a review of Resident 16's History and Physical (H&P) dated 2/20/2026, the H&P indicated Resident 16 had the capacity to understand and make decisions. During a review of Resident 16's Physician's Order (PO) dated 2/18/2026, the PO indicated for licensed staff to administer Mirtazapine 15 milligrams (mg-unit of measurement) tablet by mouth once a night for depression manifested by inability to sleep at night. During an interview on 6/23/2026 at 1:22 PM with the Infection Preventionist Nurse (IPN), the IPN stated consents were in the physical chart of the resident. The IPN stated Resident 16's Mirtazapine (Remeron) consent was filled out on 5/28/2026 and was pending a physician's signature at the time of the interview. The IPN stated consents were signed when the physician comes to the facility. During an interview on 6/24/2026 at 3:09 PM with the Director of Nursing (DON), the DON stated it could take one week for the consent form to be signed by the physician. The DON stated the Mirtazapine consent was flagged but the physician missed signing the consent. The DON stated Medical Records could fax the consent to the physician but it was not done until 6/23/2026. The DON was unsure of the facility policy how long the doctor had to sign the consent. The DON stated it was important for the consent to be signed so that the physician was aware of what was ordered and that the resident agreed with the medication ordered. During a review of the facility's Policy and Procedure (P&P) titled, SNF - Nursing Services - Chapter 2 - Clinical Care 09 Psychoactive Medications, dated 6/25/2024, the P&P indicated residents do not receive unnecessary or inappropriate psychoactive medications. The P&P indicated facilities must renew the written informed consent every six months. At that time, the facility must provide the resident with any recommended dosage adjustments and the option of revoking consent. If the resident decides to discontinue using the drug, the prescriber is responsible for planning any necessary, gradual dose reduction, as well as possible behavioral interventions.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool) for the 3/16/2026 admission was completed within the required time frame for one of one sampled resident (Resident 7). This deficient practice had the potential to negatively affect the provision of necessary care and services for Resident 7.Findings: During a review of Resident 7's admission Record (AR), the AR indicated Resident 7 was admitted to the facility on [DATE], with diagnoses including secondary malignant neoplasm of the brain (cancer that has spread to the brain from another part of the body) and muscle weakness. During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 was admitted to the facility on [DATE] and discharged on 3/9/2026. During a review of Resident 7's History and Physical (H&P) dated 3/9/2026, the H&P indicated Resident 7 had the capacity to understand and make decisions. During a review of the facility's copy of the Assessment Lookup (AL), the AL under Change ARD or Assessment Type indicated Resident 7's last admission at the facility was on 3/7/2026 and was discharged on 3/9/2026. During a review of Resident 7's Interdisciplinary Notes (IN) dated 3/16/2026, the IN indicated at approximately 8:00 PM, Resident 7 arrived at the facility from General Acute Care Hospital 1 (GACH 1). On 3/16/2026 at approximately 9:15 PM, Resident 7 had shortness of breath and rapid respiration. At approximately 9:45 PM, Resident 7 had respiratory distress, the physician was notified and the physician gave an order to transfer Resident 7 back to GACH. On 3/16/2026 at 10:20 PM, Resident 7 departed the facility for GACH admission. During an interview on 6/24/2026 at 3:30 PM with Registered Nurse 1 (RN 1), RN1 stated RN 1 admitted Resident 7 on 3/16/2026 and transferred Resident 7 back to GACH on 3/16/2026 due to oxygen desaturation (low levels of oxygen). During a concurrent closed record review of Resident 7's clinical record and an interview on 6/24/2026 at 3:55 PM with the MDS Nurse, the MDS Nurse stated Resident 7 was initially admitted to the facility on [DATE], was transferred to GACH on 3/4/2026 and re-admitted on [DATE]. The MDS Nurse stated Resident 7 was discharged again to GACH on 3/9/2026 as an unplanned discharged and was never re admitted . The MDS Nurse stated the MDS Nurse could not find in Resident 7's clinical record an admission MDS completed for the 3/16/2026 re admission. The MDS Nurse stated on 3/9/2026 the MDS coded Resident 7 was discharged to GACH with anticipated return. The MDS Nurse stated the MDS dated [DATE] was the last MDS recorded in the system and there was no MDS completed for the 3/16/2026 admission. During a review of the facility's Policy and Procedure titled, SNF - Chapter 10 - Resident Assessment & Care Planning 013 MDS Completion and Submission Timeframes dated 7/29/2020, the P&P indicated, the following timeframes will be observed by this facility: MDS Completion Date - admission (Comprehensive): admission date + 13 calendar days; Significant Change in Status (SCSA) (Comprehensive): 14th calendar day after determination of significant change in status; Discharge Assessment - return anticipated (Non-Comprehensive): discharge date + 14 calendar days.

Based on interview and record review, the facility failed to ensure the accuracy of Resident 10's Minimum Data Set (MDS, a resident assessment tool) assessment when bipolar disorder was coded as an active diagnosis when bipolar disorder was a historical diagnosis during the assessment's reference period.This deficient practice resulted in an inaccurate reflection of Resident 10's clinical status and the potential to result in improper treatment to Resident 10.Findings:During a review of Resident 10's admission Record (AR), the AR indicated the facility admitted Resident 10 on 4/18/2025, with diagnoses including urinary tract infection (UTI, an infection in the bladder/urinary tract), anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable fear or worry), and migraines (recurring severe headaches that can cause significant pain and discomfort).During a review of Resident 10's History & Physical (H&P), dated 4/20/2026, the H&P indicated Resident 10's active diagnoses included: UTI, Pyelonephritis (infection of the kidneys), chronic (long standing) anxiety disorder, and chronic migraine headachesDuring a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10's cognition (the ability to think and process information) was intact. The MDS indicated Resident 10 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and required substantial/maximal assistance (helper does more than half the effort) with mobility. The MDS indicated Resident 10 had anxiety disorder and bipolar disorder (a mental health condition that causes unusual changes in mood, energy, and activity levels) as active diagnoses.During a review of Resident 10's Initial Psychiatric Evaluation (IPE), dated 6/15/2026, the IPE indicated the psychiatrist (psych, unidentified) identified anxiety disorder as Resident 10's psychiatric diagnosis. The IPE did not indicate bipolar disorder as an active diagnosis.During an interview and concurrent record review on 6/24/2026 at 1:15 PM, Resident 10's H&P, MDS, and IPE were reviewed with the Director of Nursing (DON), the DON stated Resident 10's bipolar disorder was a historical diagnosis and not an active diagnosis. The DON stated the facility failed to ensure the MDS accurately reflected Resident 10's active diagnoses in accordance with the Centers for Medicare & Medicaid Services (CMS, a federal agency that administers major public health insurance programs and sets the regulatory standards for the United States healthcare system) Long-Term Care Facility Resident Assessment Instrument (RAI, standardized framework used in long-term care settings to evaluate a resident's clinical status, functional abilities, and care needs) User's Manual.During a review of the CMS Long-Term Care Facility RAI User's Manual Version 3.0, dated October 2025, section (I) indicates:Active diagnosis are diagnoses that have a direct relationship to the resident's current functional, cognitive, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period.Do not include conditions that have been resolved, do not affect the resident's current status, or do not drive the resident's plan of care during the 7-day look-back period, as these would be considered inactive diagnoses.

Based on observation, interview, and record review, the facility failed to ensure gastrostomy tube (G-tube, is a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding was maintained for one of one sampled resident (Residents 40) as indicated in Resident 40's Care Plan (CP, a structured, personalized roadmap that outlines an individual's health conditions, care needs, and specific goals) and Physician's Order (PO). This deficient practice had the potential for Resident 40 to receive over and/or lack of feeding other than what was ordered by Resident 40's Physician.During a review of Resident 40's Profile Face Sheet, the Profile Face Sheet indicated the resident was re-admitted to the facility on [DATE] with diagnosis that included hemiplegia (paralysis of one side of the body) following cerebral infarction (Stroke) and gastrotomy.During a review of Resident 40's History and Physical (H&P), dated 10/13/2025, the H&P indicated Resident 40 did not have the capacity to understand and make decisions.A review of Resident 40's Minimum Data Set (MDS, a resident assessment and care planning tool) dated 4/3/2026, the MDS indicated Resident 40 had severe impairment in cognitive skills for daily decision making and rarely or never understood others. The MDS indicated Resident 40 required total dependence (full staff performance every time) for transferring, dressing, and personal hygiene.During a review of Resident 40's CP titled, Nutrition/Parenteral (administration of medications, fluids, or nutrients into the body through tubes)/IV (intravenous, inside a vein) Status, dated 4/14/2026, the CP indicated Resident 40 will remain free from complications related to tube feeding by administer tube feeding as ordered by the Physician.During a review of Resident 40's PO dated 6/9/2026, the PO indicated an order for Jevity (calorically dense, fiber-fortified tube feeding) 1.5 to be infused at 50 cubic centimeters (cc, a measure of volume)/hour (hr., a unit of time equal to 60 minutes) for 20 hrs. Water flushes 150 cc every 4 hours. GT feeding to be turned on at 2 pm - 3 pm and turned off at 10 am to 11 am, every shift.During an observation on 6/23/2026 at 11:20 am, inside Resident 40's room, Resident 40 was observed lying in bed, receiving Jevity 1.5 infusing at 50cc/hr. via GT.During an observation and concurrent interview with Registered Nurse 1 (RN 1), on 6/23/2026 at 12:38 pm, Resident 40 was receiving Jevity 1.5 infusing at 50cc/hr. via GT. RN 1 stated Resident 40 had a PO for GT feeding to be turned off at 10 am and turned on at 2 pm. RN 1 stated Resident 40's PO should be followed for the care of Resident 40.During an interview with the Director of Nursing (DON), on 6/23/2026 at 1:22 pm, the DON stated Resident 40's tube feeding should have been turned off at 11:20 am (after 10 am). The DON stated PO order needed to be followed to ensure no possible complications can arise such as fluid overload (too much fluid/blood and water in the body), edema (swelling caused by excess fluid trapped in the body's tissues) or chest congestion (a feeling of fullness, heaviness, or tightness in your chest).During a review of the facility's Policy and Procedure (P&P) titled, SNF - Nursing Services - Chapter 10 - Enteral (in, by way of, or related to the intestines or digestive tract) and Parenteral Nutrition 006 Enteral Nutrition, dated 5/13/2021, the P&P indicated adequate nutritional support through enteral feeding will be provided to residents as ordered.

Based on interview and record review, the facility failed to accurately document the screening result for the Preadmission Screening and Resident Review (PASRR) for one of two sampled residents (Resident 31). Resident 31 had a mental illnesses including schizophrenia (a brain disorder that disrupts how a person interprets reality), bipolar (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks) and depression (mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts) and was receiving psychotropic medication, but the PASRR indicated No under diagnoses of mental disorder. This deficient practice resulted in inaccurate medical record for Resident 31 and had the potential for Resident 31 not to receive special services for treatment of mental illnesses.During a review of Resident 31's Profile Face Sheet (PFS), the PFS indicated the resident admitted to the facility on [DATE] with diagnoses that included schizophrenia, bipolar disorder and major depression.During a review of Resident 31's PASRR Level 1 Screening, dated 12/9/2025, under section III - Serious Mental Illness regarding Resident 31's diagnosed of serious mental illness for individuals who have a serious diagnosed mental disorder such as depressive disorder . schizophrenia/schizoaffective (chronic mental health conditions that cause hallucinations and delusions) disorder . and or mood disturbance; the facility marked No.During a review of Resident 31's History and Physical (H&P), dated 3/2/2026, the H&P indicated the resident could make needs know but could not make medical decisions. During a review of Resident 31's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 3/11/2026, the MDS indicated the resident was cognitively impaired with active diagnosis of psychiatric (medical condition characterized by disturbances in thinking, emotion regulation, or behavior)/mood (mental health disorder causing persistent and severe emotional disturbances) disorder of depression and bipolar disorder. During a review of Resident 31's Physician's Orders (PO), dated 5/27/2026, the PO indicated Fluoxetine (a medication used to treat depression), 20 milligrams taken nightly for major depressive disorder manifested by verbalization of lack of self-worth.During an interview and concurrent record review with the Director of Nursing (DON), at 6/23/2026 at 1:47 pm, the DON stated that Resident 31's PASRR, dated 7/17/19, indicated that Level I was negative and Resident 31 did not need PASRR Level II screening. The DON stated Section III - Serious Mental Illness indicated that Resident 31 did not have a diagnosis of mental illness and Resident 31 did not have prescription for psychotropic medication. The DON stated that the information on Resident 31's PASRR screening was inaccurately reflected Resident 31 because Resident 31 had a diagnosis of bipolar, depression and schizophrenia and was receiving Fluoxetine (a medication used to treat depression). During a review of the facility's Policy and Procedure (P&P) titled admission Criteria, revised on 3/2019, the P&P indicated the facility admits only resident who's medical and nursing care needs can be met. The P&P indicated all new admissions and readmissions are screened for mental disorder (MD, alterations in thinking, mood, or behavior), intellectual disabilities (ID, someone has a harder time learning, understanding, and solving problems compared to others) or related disorders (RD) per the PASRR process. The facility conducts a Level I PASRR screen for all protentional admissions, regardless of payer source, to determine if the individual meets the criteria for MD, ID or RD. The P&P indicated if the PASARR level I screening indicates that the individual may meet the criteria for a MD, ID, or RD, he or she would be referred to the state PASRR representative for the Level II (evaluation and determination) screening process. During a review of the facility's P&P titled, Documentation 001 Charting and Documentation, dated 11/8/2017, the P&P indicated documentation in the medical record ill be objective (not opinionated or speculative) complete and accurate.

Based on observation, interview and record review, the facility failed to provide a call light within reach for one of ten randomly selected residents (Resident 39).This deficient practice had the potential to result in staff delay in meeting Resident 39's needs for hydration, toileting, and activities of daily living.During a review of Resident 39's admission Record (AR), the AR indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE], with a diagnosis of personal history of other diseases of the circulatory system.During a review of Resident 39's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 5/6/2026, the MDS indicated the resident had a BIMS (Brief Interview For Mental Status) Score of 15 (Indicates that the person's cognition is fully intact and they are capable of normal brain function with no or very little impairment).During a review of Resident 39's History and Physical (H&P), dated 5/18/2026, the H&P indicated, Resident 39 had the mental capacity to understand and make decisions.During a concurrent observation and interview on 6/22/2026 at 10:31 AM with Resident 39 in the resident's room, Resident 39 was observed with a call light pad close to Resident 39's head. Resident 39 stated that she used her head to press the call light pad, but she was unable to press it (the call light pad). Resident 39 asked for a tissue to wipe her nose.During a concurrent observation and interview on 6/22/2026 at 10:35 AM with Certified Nurse Assistant (CNA) 2, CNA 2 knocked on the door and asked if Resident 39 needed assistance. Resident 39 asked for a tissue to wipe her nose. CNA 2 tested the call light pad, but Resident 39 was unable able to press the call light pad until after the third try when CNA 2 placed the call light pad closer to Resident 39's head. CNA 2 assisted Resident 39 and cleaned Resident 39's nose. CNA 2 stated that the importance of having a call light within reach is so that when the residents have a need, they would be able to use the call light and get/receive assistance.During a review of the facility's Policy and Procedure (P&P) titled, Answering the Call Light, revised March 2021, the P&P indicated When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident.

Based on interview and record review, the facility failed to ensure appropriate care and services were provided for three of three sampled residents (Resident 8, Resident 3, and Resident 32) by failing to ensure:a. Resident 8, who was on anticoagulant (medication that thins the blood) therapy, was monitored for bleeding in the months of May, June, and July 2025 and Resident 32 who was on anticoagulant therapy was monitored for bleeding in July and August 2025.b. Resident 3's hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) physician orders were followed and/or clarified.c. Resident 32's discharge teaching and instructions included an evaluation of Resident 32 and Resident 32's knowledge about diabetes management (a variety of strategies to control blood glucose [sugar] levels and minimize the risk of complications associated with Diabetes [a disease that results in elevated levels of glucose in the blood]) and provide needed education including but not limited to blood sugar checks, insulin management, and watching for signs and symptoms of hypoglycemia and hyperglycemia.These failures had the potential to result in serious health complications and hospitalization for Resident 8 and Resident 32 and the potential for Resident 3 to inappropriate hospice care.Cross Reference F745 Findings: a. During a review of Resident 8’s “Profile Face Sheet (PFS),” the “PFS” indicated Resident 8 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including pneumonia (an infection/inflammation in the lungs), unspecified organism, heart failure, unspecified, and chronic atrial fibrillation (AFib - rapid, irregular heartbeat for extended periods), unspecified. During a review of Resident 8’s “History and Physical Examination (H&P),” dated 5/5/2025, the “H&P” indicated, Resident 8 could make needs know but could not make medical decisions. During a review of Resident 8’s “Minimum Data Set (MDS – a resident assessment tool),” dated 5/7/2025, the “MDS” indicated Resident 8’s “BIMS (Brief Interview for Mental Status - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident),” was moderately impaired. The “MDS” indicated Resident 8 was taking high-risk drugs including an anticoagulant (e.g. warfarin, heparin, or low-molecular weight heparin). During a review of Resident 8’s “Physician’s Orders (PO),” as of 8/6/2025, the “PO” indicated, a physician’s order, dated 5/27/2025 for Xarelto (an anticoagulant) 20 mg (milligrams – metric unit of measurement) tablet [Rivaroxaban] – one tab by mouth once a day with meals for chronic AFib. During a review of Resident 8’s “Care Plan (CP),” titled, “Resident 8 is at risk for bleeding/development of skin discolorations related to usage of: Xarelto” dated start 7/1/2025, the CP indicated one of the interventions was to monitor for signs and symptoms of bleeding. During a concurrent interview and record review on 8/5/2025 at 1:39 PM with the Infection Prevention Nurse (IPN), Resident 8’s Treatment Record (TAR) and Resident 8’s Medication Record (MAR), dated for the months of May, June, and July 2025 were reviewed. The “TAR” did not indicate a monitoring for bleeding. The MAR indicated monitoring for bleeding, start date of 5/9/2025, but the “MAR” was coded with an “X” for all the dates. The IPN stated when a resident (in general) was on an anticoagulant, staff were to monitor for bleeding and care plan. The IPN stated it was important to monitor because of the risk of bleeding and for the safety of the resident. The IPN stated the monitoring was either documented in the TAR or MAR. The IPN stated the IPN would have to check with Medical Records (MR) what the “X” meant on the “MAR.” During a concurrent interview and record review on 8/5/2025 at 2:02 PM with the MR, Resident 8’s “MAR dated for the months of May, June, and July 2025 were reviewed. The MR stated, the “X” coded on the MAR meant there was no schedule for staff to document. During an interview on 8/5/2025 at 2:05 PM with the IPN, the IPN stated the MAR should not have been coded “X” because the order to monitor for bleeding could get missed or not done. During a concurrent interview and record review on 8/6/2025 at 12:03 PM with the Director of Nursing (DON), Resident 8’s MAR dated for the months of May, June, and July 2025 were reviewed. The DON stated monitoring for bleeding should be documented in the MAR. The DON stated the coding on Resident 8’s MAR was incorrect and the staff should have questioned the code “X. The DON stated it was important to monitor the resident for bleeding when the resident is on an anticoagulant, because the anticoagulant could cause bleeding, anemia (a condition where the body does not have enough healthy red blood cells) and other complications and for the resident’s safety. During a review of the facility’s revised policy and procedures (P&P) dated 11/2018, titled, Anticoagulation – Clinical Protocol, the P&P indicated residents are assessed for evidence of effects related to the subtherapeutic or greater than therapeutic drug level related to that particular drug (for example, a resident with an above therapeutic level of an anticoagulation medication should be assessed for bleeding). b. During a review of Resident 3’s “PFS,” the “PFS” indicated, Resident 3 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia (hemiplegia – total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction, [cerebral infarction or stroke - a condition where brain tissue dies due to a lack of blood supply) affecting right dominant side, cognitive (think, learn, remember, understand and process information) communication deficit, and vascular dementia (a type of dementia [a progressive state of decline in mental abilities] caused by reduced or blocked blood flow to the brain), unspecified severity, without behavioral disturbance/psych (psychosis - a severe mental condition in which thought, and emotions are so affected that contact is lost with reality)/mood/anx. (anxiety - intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 3’s “H&P,” dated 3/28/2025, the “H&P” indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3’s MDS, dated [DATE], the MDS indicated Resident 3 had no speech (absence of spoken words) and Resident 3’s ability to express ideas and wants were rarely/never understood. The MDS indicated Resident 3’s cognitive skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 3 was dependent (helper does all of the effort) self-care and was receiving hospice care (compassionate care for people who are near the end of life provided at the person’s home or within a health care facility). During a concurrent interview and record review, on 8/6/2025 at 12:03 PM with the DON, Resident 3’s medical records were reviewed. Resident 3 had different physicians order for hospice and for the facility. The hospice physicians orders” dated as of 4/22/2025 included an order dated 4/11/2025 for IDT (Interdisciplinary Team - a group of health care professionals with various areas of expertise who work together toward the goals for the residents) every 14 days to review Resident 3’s status and as needed and order for Lorazepam (medicine used to treat anxiety disorders) 2 mg oral every 4 hours as needed. The DON stated the facility did not conduct an IDT for hospice residents. The DON stated the DON had not “seen this kind of order for hospice.” The DON stated the hospice had standard orders, “hospice kit” when they come to the facility, but the staff followed the facility “PO.” The DON stated the facility did not follow hospice orders. The DON stated, the facility should have called the hospice to verify the hospice physician order so the staff would be able to provide the accurate plan of care for Resident 3. The DON stated the different physician order for hospice and for the facility could result in confusion to the staff which physician order to follow and would complicate and affect the care provided to Resident 3. During a review of the facility’s policy and procedure (P&P) titled, “Hospice Program,” revised date 7/2017, the P&P indicated, in general, it was the “responsibility of the facility” to meet the resident’s personal care and nursing needs in coordination with the hospice representative and ensured that the level of care provided was appropriate. c. During a review of Resident 32’s PFS, the PFS indicated the facility admitted Resident 32 on 6/25/2025. During a review of Resident 32’s MDS, dated [DATE], the MDS indicated Resident 32’s cognition (ability to understand and process information) was moderately impaired. The MDS indicated Resident 32 required moderate assistance (helper does less than half the effort. The helper lifts, holds, or supports trunk or limbs but provides less than half the effort) with personal hygiene and toileting hygiene. The MDS indicated Resident 32 had diagnoses that included Diabetes Mellitus (DM, a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose in the blood and urine), and end stage renal disease (ESRD - a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis [procedure to remove metabolic waste products or toxic substances from the bloodstream] or a kidney transplant to maintain life). During a review of Resident 32’s Physician Orders (PO) as of 7/28/2025, the PO indicated an order for Eliquis (medication used to prevent and treat blood clots) 2.5 milligrams (mg) two times a day for atrial fibrillation (AFIB - causes your heart to beat irregularly and sometimes much faster than normal). During a review of Resident 32’s CP titled “Risk for Bleeding/Development of Skin Discolorations,” dated November 2018, related to the use of Eliquis. The CP’s interventions indicated Resident 32 would be monitored for signs and symptoms of bleeding and to report/monitor/document for any presence or formation of skin discolorations. During a concurrent review of Resident 32’s Medication Administration Record (MAR), dated July and August 2025, and interview on 8/6/2025 at 4:15 PM with the Minimum Data Set Nurse (MDSN), the MARs indicated no monitoring for signs and symptoms of bleeding. The MDSN stated there was no monitoring for signs and symptoms of bleeding. The MDSN stated the MAR was the only location to document monitoring for signs and symptoms of bleeding. During an interview on 8/5/2025 at 8:33 AM with the Family Member (FM, Resident 32’s son), the FM stated the plan was to discharge Resident 32 home today, 8/5/2025. During an interview on 8/5/2025 at 11:17 AM with the Social Services Director (SSD), the SSD stated Resident 32 would be discharged [home] on 8/5/2025. The SSD stated the SSD sent a request via fax for a Home Health (HH - medical and supportive services provided in a patient's home to help them manage their health conditions, recover from illness or injury) Registered Nurse (HH RN) to visit Resident 32 [at home]. The SSD stated the SSD would follow up [on the fax requesting services] by calling the HH Agency [prior to Resident 32’s discharge home]. During an interview on 8/5/2025 at 3:05 PM, the SSD stated Resident 32 had left the facility (discharged ) with the FM. The SSD stated the SSD did not call to confirm services with the HH Agency to inquire when the HH RN would visit Resident 32 [at home]. During a concurrent interview and record review on 8/5/2025 at 3:24 PM, with Registered Nurse 1 (RN 1). Resident 32’s “Post Discharge Plan of Care,” dated 8/5/2025, the plan of care’s Special Training/Instructions indicated, accuchecks (monitoring of blood glucose levels). The plan of care indicated Resident 32 was discharged with the following medications: lantus (insulin glargine - a long acting insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication] covers 24 hours or longer) and insulin lispro (a fast-acting insulin that starts to work about 15 minutes after the injection, peaks in about 1 hour, and keeps working for 2 to 4 hours). RN 1 stated Resident 32 was discharged [DATE] and the FM picked up Resident 32. RN 1 stated RN 1 did not know if Resident 32 or the FM knew how to check blood sugars or to administer insulin. RN 1 stated RN 1 would call Resident 32 and the FM to find out. During a follow-up interview on 8/5/2025 at 3:50 PM, RN 1 stated RN 1 was able to call the FM who stated the FM knew how to do accuchecks. RN 1 stated RN 1 was not sure if Resident 32 or the FM knew how to administer insulin. RN 1 stated RN 1 would follow up with the HH Agency to visit Resident 32 on 8/5/2025. During an interview on 8/5/2025 at 4:10 PM with the SSD, the SSD stated SSD was able to get hold of the HH Agency, the HH Agency informed the SSD the HH RN would visit Resident 32 on 8/5/2025. During an interview on 8/5/2025 at 4:15PM with Director of Nursing (DON) 1, DON 1 stated Resident 32 had DM. DON 1 stated Resident 1 required continuity of care at home. DON 1 stated if Resident 32’s blood sugar was not properly managed at home [by an HH RN], Resident 32 could experience low or high blood sugar. DON 1 stated the facility needed to ensure the HH RN visited Resident 32 to ensure continuity of care at home. DON 1 stated coordination of Resident 32’s discharge needs were required. The DON stated [it was important to] evaluate Resident 32’s and the FM’s knowledge pertaining to diabetes management and ensure they understood the teaching and instructions prior to discharge. During a review of the facility’s P&P titled “Discharging the Resident” dated December 2016, the P&P indicated if the resident is being discharged home, ensure that resident and/or responsible party receive teaching and discharge instructions.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in one of one kitchen (Kitchen 1) when five cups of orange colored ice or cream were observed unlabeled and undated in the facility's walk-in freezer. These deficient practices had the potential to result in improper food storage, which could lead to foodborne illnesses. Findings:During an initial tour of Kitchen 1 on 8/4/2025 at 8:42 am, with the Dietary Supervisor (DS), five cups of orange colored ice or cream was observed without a label to indicate what type of food was contained within the cups and a used by or expiration date indicating when the orange substance would expire.During an interview with the DS, on 8/4/25 at 8:43 am, the DS stated the DS was unsure if the five cups contained ice cream or sorbet and did not know when they were prepared. The DS stated the five cups and the tray the cups were placed in did not have a label or a use by date. The DS stated food should always be labeled to ensure the kitchen staff know what kind of food and when the product is edible to avoid infection and for resident food safety. During a review of the facility's policy and procedure titled, Labeling and Dating of Foods, dated 2023, indicated all food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Items can be dated individually or in bulk stored on a tray with a masking tape if going to be used for meal service. During a review of the facility's policy and procedure titled Leftover Foods, dated 2023, the policy indicated leftover foods will be stored and served in a safe manner. Storage of leftovers will be label and dated.

Based on interview and record review, the facility failed to ensure the required direct care staffing (employees and contract staff who, through interpersonal contact with residents or resident care management, provided care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being) information based on payroll data for one of two quarters (Quarter 2) was submitted in the Payroll-Based Journal (PBJ - a system implemented by the Centers for Medicare & Medicaid Services [CMS] that requires nursing homes and long-term care facilities to electronically submit auditable and verifiable staffing and payroll data) on the schedule specified by CMS, but no less frequently than quarterly.This failure had the potential to result in CMS's inability to analyze the facility's staffing patterns, monitor/evaluate adequate staffing levels, evaluate the quality of care, and ultimately inform the public through the Nursing Home Compare website and the Five-Star Quality Rating System (a valuable tool used by CMS to help consumers compare nursing homes and make informed decisions about care) which is essential for ensuring quality care to the residents and accountability within the long-term care industry. Findings:During a review of CMS's PBJ Staffing Data Report (PBJR), dated FY (Fiscal Year) Quarter 2 2025 (January 1 - March 31), the PBJR indicated the Failed to Submit Data for the Quarter was triggered (no data submitted for the quarter).During an interview on 8/6/2025 at 3:52 PM with the Administrator (ADM), the ADM stated the facility's corporate controller office in San Francisco was the one submitting the facility's PBJ data. The ADM stated, the previous (unnamed) controller resigned in March 2025. The ADM stated the facility's PBJ data was not submitted because the State had not given the facility the submitter ID (the unique identifier assigned to the individual or entity submitting the PBJ data file to CMS) yet, to the new Controller (CR), There was a transition. The ADM stated, it was important for the facility to submit the PBJ data so that We know the right staffing, the correct staffing to provide care and services to our residents, and to comply with the requirements. During a review of the facility's policy and procedure (P&P) titled, Payroll Based Journal (PBJ) Reporting, revised date 8/6/2025, the P&P indicated it was the policy of the facility to meet the CMS regulations regarding the reporting of data including PBJ data that were used to assess and improve the accuracy of staff data. The P&P indicated, reports were submitted quarterly within the time frame specified.

Based on interview and record review, the facility failed to obtain and maintain a copy of the Advance Directive (AD - legal document indicating resident preference on end-of-life treatment decisions) in the same section of the resident's medical record readily retrievable by any facility staff for two of two sampled residents (Resident 3 and Resident 13) who had executed an AD.This failure had the potential for Resident 3 and Resident 13 to receive inappropriate or medically unnecessary care and/or treatment or services regarding life-sustaining treatment. Findings:During a review of Resident 3's Profile Face Sheet (PFS), the PFS indicated, Resident 3 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia (hemiplegia - total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarct (infarction), [cerebral infarction or stroke - a condition where brain tissue dies due to a lack of blood supply) affecting right dominant side, cognitive (think, learn, remember, understand and process information) communication deficit, and vascular dementia (a type of dementia [a progressive state of decline in mental abilities] caused by reduced or blocked blood flow to the brain), unspecified severity, without behavioral disturbance/psych (psychosis - a severe mental condition in which thought, and emotions are so affected that contact is lost with reality)/mood/anx (anxiety - intense, excessive, and persistent worry and fear about everyday situations).During a review of Resident 3's History and Physical Examination (H&P), dated 3/28/2025, the H&P indicated, Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 4/18/2025, the MDS indicated, Resident 3 had no speech (absence of spoken words) and Resident 3's ability to express ideas and wants were rarely/never understood. The MDS indicated, Resident 3's cognitive skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated, Resident 3 was dependent (helper does all of the effort) in self-care and was receiving hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility).During a review of Resident 13's PFS, the PFS indicated, Resident 13 was admitted to the facility on [DATE] with multiple diagnoses including unspecified atrial flutter (a type of abnormal heart rhythm that's too fast), essential (primary) hypertension (HTN - high blood pressure), and unspecified sequelae (an aftereffect of a disease, condition, or injury) of cerebral infarction. Resident 13's H&P, dated 3/28/2025, the H&P indicated, Resident 13 had the capacity to understand and make decisions.During a review of Resident 13's MDS, dated 3/29/2025, the MDS indicated, Resident 13 had clear speech (distinct intelligible words) and Resident 13's ability to express ideas and wants were understood. The MDS indicated, Resident 13's BIMS (Brief Interview for Mental Status - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), was intact. The MDS indicated, Resident 13 required partial/moderate assistance (helper does less than half the effort) to supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for self-care.During a concurrent interview and record review on 8/5/2025 at 9:03 AM with the Infection Prevention Nurse (IPN), Resident 3 and Resident 13's Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end of life) filed in the chart (medical record) were reviewed. The POLST indicated, the POLST complemented an AD and was not intended to replace an AD. Resident 3's POLST dated 3/26/2025 indicated, an AD dated 8/19/2013 was available and reviewed. Resident 13's POLST dated 4/1/2025 indicated, an AD dated 8/19/2013 was available and reviewed. The IPN stated, the AD was kept in the resident's (in general) chart. The IPN stated, the IPN could not find a copy of Resident 3 and Resident 13's AD in the chart. The IPN stated, it was important to have a copy of the AD on file so staff would know who to reach out to with regards to resident care and decision and to know what the resident's wishes were especially in the event if life saving measures were needed or not. The IPN stated, it was the Social Services (SSD) who was responsible for obtaining a copy of the AD. During a concurrent interview and record review on 8/5/2025 at 9:39 AM with the SSD, Resident 3 and Resident 13's charts were reviewed. The SSD stated the SSD would conduct an assessment and provide information regarding the AD to the resident or responsible party upon admission and request a copy of the AD if the resident had an AD. The SSD stated, the AD was kept under the AD tab in the chart. The SSD stated, the SSD could not find a copy of Resident 3 and Resident 13's AD in the chart. The SSD stated, it was important to have a copy of the AD on file so staff would know the resident's desires whether to be resuscitated (the process of reviving or restoring a person from a state of apparent death or unconsciousness) or not. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, revised 12/2016, the P&P indicated prior to or upon admission of a resident, the SSD or designee would inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. During a review of the facility's Advance Health Care Directive Form (ADF), effective date 1/1/2019, the ADF indicated, a copy of the signed and completed form was given to the resident's physician, to any other health care providers the resident may have, to any health care institution at which the resident was receiving care, and to any health care agents the resident have named.

Based on observation, interview, and record review, the facility failed to ensure professional standards of nursing practice were followed during a blood draw by venipuncture (a medical procedure that involves inserting a needle into a vein to draw blood) for one of one sampled resident (Resident 1) who had a Peripheral (situated on the edge) Central Catheter (PICC - a type of central venous catheter [CVC, thin flexible tube inserted into a large vein [vessel] typically in the neck, chest, or groin, and threaded into a central vein near the heart to access the bloodstream for administering medications) line for long-term central venous access.This deficient practice had the potential to result in catheter malfunction, an infection, or physical decline to Resident 1.Findings:During a review of Resident 1's Profile Face Sheet (PFS, admission record), the PFS indicated Resident 1 was originally admitted to the facility 4/14/2024 and readmitted [DATE] with diagnoses that included: overactive bladder (hollow muscular organ that acts as a reservoir for urine) and gastro-esophageal reflux disease (GERD; digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the esophagus [muscular tube through which food passes from the throat to the stomach]).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/8/2025, the MDS indicated Resident 1's cognition (ability to understand and process information) was intact. During a concurrent observation and interview on 8/4/2025 at 9:25 AM, Resident 1 had a PICC line on Resident 1's left upper arm and had an antibiotic (medication used to treat infections [harmful microorganisms such as bacteria [living organism that can cause an infection] enter the body and multiply]) running through the line. There was a folded gauze dressing 1 inch below the anterior (situated in front) aspect of the left elbow. Resident 1 stated it was from a blood draw performed early that morning.During an interview on 8/4/2025 at 3:20 PM with Director of Nursing (DON) 1, DON 1 stated for residents (in general) who had PICC lines, if the resident did not want blood drawn on the other [right] arm, the lab needed to communicate with the [nursing] staff because the staff could draw blood directly from the PICC line. DON 1 stated collecting blood by needle stick (needle is used to collect blood from a vein) from the same arm as the PICC line could potentially lead to an infection and catheter damage.During an interview on 8/6/2025 at 4:20 PM with the Infection Prevention Nurse (IPN), the IPN stated the IPN could not find any nursing resources written or online, indicating it was an acceptable nursing practice to draw blood by needle stick from the same arm where the PICC line was located. The IPN stated the facility did not know when laboratory staff drew blood from Resident 1's left arm because laboratory staff did not communicate this action to the facility staff. The IPN stated the facility did not provide laboratory staff with a reminder or cautioned laboratory staff to avoid venipuncture on Resident 1's left arm. During a review of the facility's Policy and Procedure (P&P) titled CVC Dressing Change, dated July 2023, the P&P indicated (in bold and capital letters), NEVER USE SCISSORS OR ANY SHARP OBJECT AROUND THE CATHETER. During a review of the National Institute of Medicine (NIH), undated, guideline for managing central lines, the guideline indicated to avoid venipuncture, peripheral intravenous (a soft flexible tube placed inside a vein, usually in the hand or arm and used to give a person medicine or fluids) catheter insertion, and taking blood pressure on the same arm where the PICC line is located. The guideline indicated to place reminder signs for the healthcare team members. https://www.ncbi.nlm.nih.gov/books/NBK594495/

Based on interview and record review, the facility failed to ensure a follow-up for needed services from a Home Health (HH - medical and supportive services provided in a patient's home to help them manage their health conditions, recover from illness or injury) Agency was completed and the service was confirmed prior to discharge home for one of one sampled resident (Resident 32) who required continuity of care at home by HH services for Diabetes management (a variety of strategies to control blood glucose [sugar] levels and minimize the risk of complications associated with Diabetes [a disease that results in elevated levels of glucose in the blood]). This deficient practice had the potential to result in Resident 32 experiencing complications due to uncontrolled Diabetes while at home and could lead to diabetic emergencies such as hypoglycemia (condition where the level of glucose in the blood is too low), hyperglycemia condition where the level of glucose [sugar] in the blood is too high), and a physical decline for Resident 32.Findings:During a review of Resident 32's Minimum Data Set (MDS - a resident assessment tool), dated 5/15/2025, the MDS indicated Resident 32's cognition (ability to understand and process information) was moderately impaired. The MDS indicated Resident 32 required moderate assistance (helper does less than half the effort. The helper lifts, holds, or supports trunk or limbs but provides less than half the effort) with personal hygiene and toileting hygiene. The MDS indicated Resident 32 had diagnoses that included Diabetes Mellitus (DM, a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose in the blood and urine), end stage renal disease (ESRD - a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis [procedure to remove metabolic waste products or toxic substances from the bloodstream] or a kidney transplant to maintain life). During a review of Resident 32's Profile Face Sheet (PFS), the PFS indicated the facility admitted Resident 32 on 6/25/2025.During an interview on 8/5/2025 at 11:17 AM with the Social Services Director (SSD), the SSD stated Resident 32 would be discharged [home] on 8/5/2025, the SSD stated the SSD sent a request via fax for a Home Health Registered Nurse (HH RN) to visit Resident 32 [at home]. The SSD stated the SSD would follow up [on the fax request for services] by calling the HH Agency [prior to Resident 32's discharge home].During an interview on 8/5/2025 at 3:05 PM, the SSD stated Resident 32 had left the facility (discharged ) with Resident 32's son. The SSD stated the SSD did not call to confirm with the HH Agency when the HH RN would visit Resident 32 [at home].During an interview on 8/5/2025 at 4:10 PM with the SSD, the SSD stated SSD was able to get hold of the HH Agency, the HH Agency informed the SSD the HH RN would visit Resident 32 on 8/5/2025.During a review of Resident 32's Interdisciplinary Notes dated 8/5/2025 at 4:14 PM, the IDT notes indicated the SSD followed up with the HH Agency with confirmation the HH RN would conduct the visit on 8/5/2025 between 6 to 7 PM. During an interview on 8/5/2025 at 4:15PM with Director of Nursing (DON) 1, DON 1 stated Resident 32 had DM. DON 1 stated Resident 1 required continuity of care at home. DON 1 stated if Resident 32's blood sugar was not managed appropriately at home [by an HH RN], Resident 32 could experience low or high blood sugar. DON 1 stated the facility needed to ensure the HH RN visited Resident 32 to ensure continuity of care at home. DON 1 stated coordination of Resident 32's discharge needs were required to ensure Resident 32's discharge teaching and instruction on diabetes management was completed and Resident 32's family members understood the teaching and instructions prior to discharge. During a review of the facility's Position Description (PD) for the Director of Social Services, the PD indicated the Director interacts with all departments and functions as a case manager in terms of coordinating all aspects of discharge and follow up to lower levels of care.During a review of the facility's Policy and Procedure (P&P) titled Skilled Nursing Facility Discharge Plan dated 5/18/2018, the P&P indicated the social services staff shall assist in determining the following: Coordination of care between various caregivers and agencies Follow up medical care and appointments Preparation needed by the resident/family for discharge.

Based on interview and record review, the facility failed to screen one of one of sampled resident (Resident 4) for Preadmission Screening and Resident Review (PASARR). Resident 98 has a mental illnesses including schizophrenia (a mental disorder effecting how a person thinks and feels), bipolar (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks) and depression (mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts) and was receiving psychotropic medication. This deficient practice had the potential to result in Resident 4 to not receive special services for treatment of mental illnesses.Findings: A review of Resident 4's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included schizophrenia, bipolar disorder and major depression. A review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 3/20/2025 indicated the resident was cognitively impaired and required maximal assistance (helper does more than half the effort) for transferring, dressing, oral and toileting hygiene. During an interview and concurrent record review with the Minimum Date Set Coordinator (MDS), on 8/5/2025 at 2:27 pm, the MDSN stated the last PASSAR screening on record for Resident 4 was on 12/31/2024. The MDSN stated there were no records for any type of PASSAR screening other than the one dated 12/31/2024. During an interview and concurrent record review of Resident 4's paper and electronic chart with the Director of Nursing (DON) on 8/5/2025 at 2:33 pm, the DON stated the facility did not submit a PASSAR screening for Resident 4 before and after the resident's admission. DON stated PASSR screenings were important to determine the kind of service the resident needed and to ensure the appropriate care rendered meets Resident 4's individual needs. A review of the facility's policy and procedure titled, admission Criteria for Long Term Care, dated 12/23/2021 indicated all new admission and readmission are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The facility conducts a Level I PASARR screen for all potential admission, regardless of payer source, to determine if the individual meets the criteria for MD, ID or RD.

Based on interview and record review, the facility failed to complete and transmit the initial minimum data set (MDS, a standardized assessment and care-screening tool) assessment in a timely manner for one of one sampled residents (Resident 29) as indicated in the Centers for Medicare & Medicaid Services (CMS is a federal agency that manages health care programs in the United States) Resident Assessment Instrument (RAI, a tool used by nursing homes to assess the needs, strengths, and preferences of residents) manualThis deficient practice resulted in a late completion and transmission of MDS assessment to Centers of Medicare and Medicaid (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. This had the potential to affect the facility's quality monitoring data. Findings: During a review of Resident 29's profile face sheet indicated Resident 29 was admitted to the facility on [DATE].During a review of Resident 29's admission Diagnosis (AD), dated 4/24/2025, the AD indicated diagnoses that included venous thromboembolism (blood clots form in the vein [vessel]), anemia (not enough red blood cells in the body to carry oxygen [colorless, odorless gas]), and insomnia (difficulty sleeping). During a review of Resident 29's Physicians Orders (PO), the physician's order indicated the resident was discharged out of the facility on 5/15/5025.During a record review of Resident 29's MDS initial comprehensive assessment, dated 3/18/2025, the MDS indicated the assessment completion date was completed on 3/28/25. During an interview and concurrent record review of the MDS 3.0 NH Final Validation Report (NHFVR) with the MDS coordinator (MDSC) on 8/6/2025 at 2:46 pm, the MDSC indicated that Resident 29's entry (NT) was submitted late, the submission date is more than 14 days after the entry tracking record. The MDSC stated Resident 4's initial comprehensive assessment was submitted on 5/9/2025 but should have been submitted by 3/29/2025. The MDSC stated it was important to submit the MDS in a timely manner (within 14 days) so CMS will know that Resident 4 was assessed and properly taken care of.During an interview with the Director of Nursing (DON) on 8/6/2025 at 5:25 pm, the DON stated the MDS comprehensive assessment is done 14 days post admission to ensure proper communication is done between CMS and the facility regarding the kind of care that will be provided to Resident 29. A review of the MDS RAI Version 3.0 Manual, Chapter 5: Submission and Correction of the MDS Assessments, dated 10/2024, indicated under Assessment Transmission, . MDS assessments must be submitted within 14 days of MDS Completion Date.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 3), who was unable to carry out activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) received the necessary services to maintain personal and oral hygiene (refers to the maintenance of a healthy mouth, which includes not only teeth, but the lips, gums, and supporting tissues.) This failure had the potential for Resident 3 to develop mildly uncomfortable to severely painful discomfort, pain and/or bleeding from cracked lips. Findings:During a review of Resident 3's Profile Face Sheet(PFS), the PFS indicated, Resident 3 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia (hemiplegia - total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction, [cerebral infarction or stroke - a condition where brain tissue dies due to a lack of blood supply) affecting the right dominant side, cognitive (think, learn, remember, understand and process information) communication deficit, and vascular dementia (a type of dementia [a progressive state of decline in mental abilities] caused by reduced or blocked blood flow to the brain), unspecified severity, without behavioral disturbance/psych (psychosis - a severe mental condition in which thought, and emotions are so affected that contact is lost with reality)/mood/anx. (anxiety - intense, excessive, and persistent worry and fear about everyday situations).During a review of Resident 3's History and Physical Examination (H&P), dated 3/28/2025, the H&P indicated, Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 4/18/2025, the MDS indicated, Resident 3 had no speech (absence of spoken words) and Resident 3's ability to express ideas and wants were rarely/never understood. The MDS indicated, Resident 3's cognitive skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated, Resident 3 was dependent (helper does all of the effort) for self-care and was receiving hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility).During a review of Resident 3's Care Plan (CP - provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan), titled, (Resident 3) is at risk for impaired functional status with selfcare and mobility., date started 7/18/2025, the CP indicated, one of the interventions included to assist with ADLs as necessary.During a concurrent observation and interview on 8/4/2025 at 9:10 AM with Certified Nursing Assistant (CNA) 1, Resident 3 was in bed, awake, nonverbal and did not follow commands. Resident 3 had an enteral feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine) via a G-tube (gastrostomy tube - a tube inserted through the belly that brings nutrition directly to the stomach). Resident 3's lips were dry, chapped, rough looking with small crack areas and pieces of flaking. CNA 1 stated, Resident 3's lips were dry. CNA 1 stated, staff did mouth care after residents (in general) ate. CNA 1 stated, Resident 3 did not eat. CNA 1 stated mouth care was important to prevent chapped lips that could cause bleeding.During an interview on 8/6/2025 at 10:35 AM with the Infection Prevention Nurse (IPN), the IPN stated, Resident 3 was on hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) care and the hospice staff provided personal care to Resident 3 but the facility staff also provided the care including oral care. The IPN stated, Resident 3's lips should not be dry and chapped that could lead to discomfort and pain. The IPN stated, oral care was important for Resident 3's comfort, wellbeing and dignity. During an interview on 8/6/2025 at 12:03 PM with the Director of Nursing (DON), the DON stated, the facility provided care whether a resident (in general) was on hospice care or not. The DON stated it's still the same care, including oral care to prevent cracks and it's a dignity issue. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, revised 3/2018, the P&P indicated residents who were unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. During a review of the facility's P&P titled, SNF - Chapter 12 - Resident Rights 012 Resident Rights, date reviewed/revised 1/10/2022, the P&P indicated employees should treat all residents with kindness, respect, and dignity. The P&P indicated, these rights included the resident's right to a dignified existence.

Based on interview and record review the facility failed to identify a potential chemical restraint for one of one resident (Resident 204) by having a physician order that indicated to give Ativan (used commonly as a sedative and to relieve anxiety) if Resident 204 attempted to get out of bed unassisted. This deficiency had the potential to restrict Resident 204's movement for staff convenience or discipline. Findings: During a review of Resident 204's Detailed Summary, (DS) undated, the DS indicated Resident 204 was admitted to the facility on [DATE] with multiple diagnoses including generalized muscle weakness (lack of physical or muscle strength) and cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). During a review of Resident 204's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated, indicated Resident 204 had moderately impaired cognition (ability to think and reason) and was dependent (helper does all the effort) on staff for bathing and toileting. The MDS also indicated Resident 204 was always incontinent of bowel and bladder. During a concurrent interview and record review on 9/13/2024 at 10:03 AM with the Director of Nursing (DON), Resident 204's Physician's Orders (PO), dated as of 9/12/2024, was reviewed. The PO indicated, May give Ativan if resident tries to get up unassisted, with start date 9/9/2024. The DON stated Resident 204 was a high fall risk and the order indicated to give the medication if resident tried to get out of bed unassisted. The DON further stated the order served to restrict Resident 204's movement and did not indicate a diagnosis or symptom that the medication could relieve. The DON stated the order as written was a chemical restraint and was not an appropriate order for Resident 204 because staff need to find the reason why Resident 204 wants to get out of bed instead of restricting movement. During a review of the facility's policy and procedure (P&P) titled, Identifying Involuntary Seclusion and Unauthorized Restraint, dated 4/2021, the P&P indicated, Chemical restraint is defined as any drug that is used for discipline or staff convenience and not required to treat medical symptoms. The P&P also indicated residents are free from the use of chemical restraints not required to treat their medical condition. The P&P indicated the risk of falling is not considered a medical symptom or self-injurious behavior that warrants the use of restraints.

Based on observation, interview, and record review, the facility failed to develop a comprehensive plan of care for one of two sampled residents (Resident 153) with a limited Range of Motion (ROM - the degree of movement a joint can make). This deficient practice had the potential for a decline in ROM for Resident 153. Findings: During a review of Resident 153's Face Sheet (FS), the FS indicated the facility admitted Resident 153 on 5/2/2024 with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and Alzheimer's disease (irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks). During a review of Resident 153's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 5/8/2024, the MDS indicated the resident rarely/never expressed ideas and wants and rarely/never understood verbal content. The MDS indicated Resident 153 was dependent with all Activities of Daily Living (ADL). The MDS indicated Resident 153 had functional limitation to ROM to both lower extremities. During a concurrent observation and interview on 9/12/2024 at 9 AM, Physical Therapy 1 (PT 1) removed the knee splint (type of brace that supports and stabilizes the knee joint) from Resident 153's knees. During an observation on 9/12/2024 at 10:26 AM, PT 1 assessed Resident 153's joint mobility. Resident 1's both knees would only extend up to 90 degrees, the knees would not extend straight. During a concurrent record review and interview with the facility's Director of Nursing (DON) on 9/12/2024 at 1:04 PM, Resident 153's MDS was reviewed. The DON stated Resident 153 had impaired ROM to bilateral (both) lower extremities. The DON stated there was no care plan developed for Resident 153's impaired ROM. The DON stated if there was a care plan developed for impaired ROM for Resident 153, the interventions to Resident 153 would have included ROM exercises by the RNA after the Physical Therapy (PT) and Occupational Therapy (OT) screening, monitoring the resident for pain, exercise tolerance, skin integrity, and decline in ROM. The DON stated the interventions would help prevent further decline in Resident 153's ROM. The DON stated there was no documented PT/OT evaluation upon Resident 153's admission. The DON stated PT evaluation was completed on 9/11/2024 and ROM exercises for Resident 153 was started on 9/11/2024. During an interview on 9/12/2024 at 1:50 PM, Certified Nursing Assistant 4 (CNA 4) stated Resident 153 had stiffness on both legs since admission. CNA 4 stated PT 1 started training CNAs (in general) on ROM exercises for Resident 153 yesterday (9/11/2024). CNA 4 stated Resident 153 did not receive ROM exercises since admission, until 9/11/24. During a review of the facility's Policy and Procedure (P&P) titled Care Plans, Comprehensive Person-Centered dated March 2022, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet resident's physical, psychosocial and functional needs is developed and implemented for each resident. During a review of the facility's P&P titled Resident Mobility and Range of Motion dated July 2017, the P&P indicated the care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed. The care plan will include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts.