Every finding on record at Clara Baldwin Stocker Home for Women

Based on observation, interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) who had pressure ulcer/injury (PU/PI- localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) received care and services to promote healing and prevent worsening of pressure injuries in accordance with facility's policies and procedures when:1. Resident 1's and Resident 2's care plan did not include LALM (low air loss mattress, specialized type of medical mattress designed to prevent and treat pressure ulcers [bedsores] while maintaining optimal skin temperature and moisture levels) and APP mattress (alternating pressure pad or pump mattress - specialized medical support surface designed to prevent and treat bedsores) that were used for Resident 1.2. Resident 2 did not have an order for LALM or APP mattress.3. Resident 2's APP mattress was not set according to Resident 2's weight.4. Resident 1 and Resident 2 were repositioned every two hours.These deficient practices had the potential to result in Resident 1 and Resident 2 not receiving the necessary care, treatment and services to promote healing, prevent infection and prevent new pressure ulcer/injury from developing.a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 7/13/2026 with diagnoses which included stage 4 pressure ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of right and left buttocks, stage 2 pressure ulcer of sacral region (Partial-thickness loss of skin, presenting as a shallow open sore or wound), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial weakness or reduced muscle control on one entire side of the body, including the arm, leg, and face) following cerebral infarction (loss of blood flow to a part of the brain), and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 7/14/2026, the H&P indicated Resident 1 had decision making capacities.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/17/2026, the MDS indicated Resident 1 had intact cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all effort to complete the activity) on staff for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and to move around and reposition in bed.During a review of Resident 1's Order Summary Report (OSR), dated 8/26/2026, the OSR indicated the resident had an order starting 7/15/2026 to provide LALM for wound management and to check LALM for proper weight setting and function every day shift. The OSR indicated that the resident had an order starting 8/5/2026 to provide APP mattress for wound management and to monitor APP for proper functioning every day shift.During a review of Resident 1's Care Plan (CP), initiated 7/13/2026, the CP indicated that the resident had potential for pressure ulcer development related to decreased mobility and the interventions included following facility policies and protocols for the prevention and treatment of skin breakdown and frequent repositioning. The CP did not indicate any therapeutic mattress including LALM and APP mattress that were used for Resident 1.During a review of Resident 1's CP, initiated 7/14/2026, the CP indicated that the resident was admitted with right and left buttocks stage 4 pressure injury and sacrococcyx stage 2 pressure injury and the interventions included keeping area clean and dry, providing treatment as indicated in Treatment Administration Record (TAR), and notifying doctor if treatment is ineffective. The CP did not indicate any therapeutic mattress including LALM and APP mattress that were used for the resident.During a review of Resident 1's CP, initiated 8/4/2026, the CP indicated Resident 1 refused LALM for wound management and one of the interventions for this condition is providing APP mattress.During a review of Resident 1's medical record, the medical record indicated that there was no documentation of repositioning Resident 1 every two hours.During a concurrent interview and record review on 8/27/2026 at 12:30 PM with Treatment Nurse (TN) 1, Resident 1's care plan was reviewed. TN 1 stated that care plan regarding the LALM and APP mattress to prevent pressure injury and promote pressure injury healing was not found for Resident 1. TN 1 stated that a care plan should be created to indicate the use of LALM and APP mattress to prevent pressure injury and promote pressure injury healing for residents.During a concurrent interview and record review on 8/27/2026 at 2 PM with the Director of Nursing (DON), Resident 1's care plans were reviewed. The DON stated that care plan regarding the LALM and APP mattress to prevent pressure injury and promote pressure injury healing was not found for Resident 1. The DON stated that it was important to create a care plan to indicate the use of LALM and APP mattress to prevent pressure injury and promote pressure injury healing for Resident 1.b. During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 8/13/2026 with diagnoses which included sacral region pressure ulcer/injury stage 1 (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness), stage 3 pressure ulcer (Full-thickness loss of skin. Dead and black tissue may be visible) of right buttock, encounter for surgical aftercare following surgery on the digestive system, and muscle weakness.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 has moderately impaired cognitive skills. The MDS indicated Resident 2 was dependent on staff) on staff for most activities of daily living and to move around and reposition in bed. The MDS indicated that Resident 2's weight was 89 pounds.During a review of Resident 2's OSR, dated 8/26/2026, the OSR indicated that Resident 2 had an active order for APP mattress for wound management and to check APP mattress for proper weight setting and functioning every day shift, with start date of 8/27/2026. The OSR indicated that there was no order for LALM or APP mattress before 8/26/2026 after Resident 2 was admitted on [DATE].During a review of Resident 2's CP, initiated 8/14/2026, the CP indicated that the resident had potential for pressure ulcer development and the interventions for this condition included following facility policies and protocols for the prevention and treatment of skin breakdown and frequent repositioning. The CP did not indicate any therapeutic mattress including LALM and APP mattress that were used for Resident 2.During a review of Resident 2's CP, initiated 8/17/2026, the CP indicated that the resident was admitted with right buttocks stage 3 pressure injury and the interventions included keeping area clean and dry, providing treatment as indicated in TAR, and notifying doctor if treatment is ineffective. The CP did not indicate any therapeutic mattress including LALM and APP mattress that were used for Resident 2.During a review of Resident 2's TAR, dated 8/2026, the TAR indicated that the resident had APP mattress for wound management and to check APP mattress for proper weight settings and functioning every day shift, which started on 8/27/2026. The TAR indicated there was no documented monitoring for LALM or APP mattress before 8/27/2026.During a review of Resident 2's medical record, the medical record indicated that there was no documentation of repositioning Resident 2 every two hours.During a concurrent observation and interview on 8/26/2026 at 10:55 AM with Resident 2 in Resident 2's room, Resident 2's APP mattress machine indicated that the weight was set between 180 pounds (lb./lbs.- a measurement unit of weight) to 220 lbs. Resident 2 stated that Resident 2's weight was around 90 lbs.During a concurrent interview and record review on 8/26/2026 at 11:50 AM with TN 1, Resident 2's order, dated 8/26/2026 and Resident 2's TAR, dated 8/2026, were reviewed. TN 1 stated that there was no order for using LALM or APP mattress and there were no monitoring and documentation for the LALM or APP mattress's functioning in TAR for Resident 2. TN 1 stated that Resident 2 should have an order for using LALM or APP mattress and the mattresses' functioning should be monitored and documented in TAR. TN 1 stated that APP mattress's setting should have indicated the proper weight according to Resident 2's weight which was 90 lbs., not between 180 lbs. to 220 lbs. due to the APP mattress for Resident 2 having a weight setting. TN 1 stated it was important to set the LALM and APP mattress properly according to the resident's weight and reposition the residents every two hours to prevent pressure ulcers and promote pressure injury's healing.During an interview on 8/26/2026 at 2:35 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated that it was important to turn and reposition the residents who had pressure ulcer on buttocks or sacral area, every two hours and document in the residents' medical record to prevent pressure ulcer and promote pressure injury's healing.During a concurrent interview and record review on 8/27/2026 at 2 PM with the DON, Resident 1's and Resident 2's care plans were reviewed. The DON stated that care plan regarding the LALM and APP mattress to prevent pressure injury and promote pressure injury healing was not found for Resident 1 and Resident 2. The DON stated that it was important to create a care plan to indicate the use of LALM and APP mattress to prevent pressure injury and promote pressure injury healing for the residents. The DON stated that an order for using LALM or APP mattress should be placed for the residents with pressure injury or at risk for developing pressure injury. The DON stated that it was important to set the mattress according to the residents' weight and monitor and document the proper functioning of the mattress in the TAR. During a concurrent interview and record review on 8/27/2026 at 3:25 PM with the Director of Staff Development (DSD), the facility's policy and procedure (P&P), titled, Repositioning, undated, was reviewed. The DSD stated that the staff (nursing staff) should have followed the facility's P&P to document the position in which the resident was placed and the name and title of person who repositioned the resident to show evidence that the repositioning intervention was provided to the residents.During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 10/1/2023, the P&P indicated that the facility should ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs and the comprehensive care plan should include interventions to prevent avoidable decline in function or functional level. The P&P indicated, Document interventions in ADL flowsheet and Kardex as necessary.During a review of the facility's P&P titled, Repositioning, undated, the P&P indicated, Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. The P&P indicated, The following information should be recorded in the resident's medical record: 1. The position in which the resident was placed. This may be on a flowsheet. 2. The name and tile of the individual who gave the care .During a review of the facility's P&P titled, Prevention of Pressure Injuries, revised 4/2020, the P&P indicated that the facility should Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. The P&P indicated that the facility should Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. Select appropriate support surfaces based the resident's risk factors, in accordance with current clinical practice.During a review of the facility's P&P titled, Pressure-Redistribution/Reduction Surfaces, undated, the P&P indicated, New support surfaces are designed and manufactured frequently to meet the needs of residents with chronic and acute skin conditions caused by pressure.To assure effectiveness all products must be used according to the manufacturer's instructions.Dynamic pressure reduction surfaces may be used when a resident cannot be positioned without bearing weight on a pressure ulcer. The P&P indicated, As with all support surfaces, accurate physician's orders, diagnosis, comprehensive assessment, comprehensive care plan and progress documentation are essential for appropriate care of the resident. During a review of the facility's Mattress Manufacturer Manual (MMM) titled, Med Aire Plus 8 Alternating Pressure and Low Air Loss Mattress Replacement System Operator's Manual, dated 2016, the MMM indicated, Drive support surfaces are designed and constructed to reduce the incidence of pressure ulcers while optimizing patient comfort. The MMM indicated that the pressure of the mattress can be adjusted by choosing the patients' corresponding weight setting for weight setting selection.

Based on interview, and record review, the facility failed to complete and document appropriately the transfer summary (document that accompanies a patient when they move between care setting, facility, or provider to another and includes the patient's diagnosis, medications, treatments, dietary requirements, rehabilitation potential, allergies and treatment plan) for one of three sampled residents (Resident 1) by failing to:1. Send a complete transfer summary with Resident 1 upon transfer to General Acute Care Hospital (GACH) 1 on 8/16/2026.2. Indicate the time of transfer for Resident 1 to GACH 1 on 8/16/2026.3. Indicate the name and location of the GACH, where Resident 1 was transferred to on 8/16/2026.4. Complete a skin assessment and document the skin assessment condition upon transfer for Resident 1 on 8/16/2026.These deficient practices resulted in GACH 1 receiving incomplete information regarding Resident 1's care, treatment, and health condition and placed Resident 1 at risk for receiving inadequate and incorrect care and treatment.During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 7/13/2026 with diagnoses which included stage 4 pressure ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of right and left buttocks, stage 2 pressure ulcer of sacral region (Partial-thickness loss of skin, presenting as a shallow open sore or wound), endocarditis (infection of the inside lining of the heart), and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 7/14/2026, the H&P indicated Resident 1 had decision making capacities.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/17/2026, the MDS indicated Resident 1 had intact cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all effort to complete the activity) on staff for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and to move around in bed.During a review of Resident 1's Order Summary Report (OSR), dated 8/26/2026, the OSR indicated there was a physician order, dated 8/16/2026, to send out Resident 1 via 911 (emergency number to request the services of the police, fire department, paramedics, ambulance) for altered level of consciousness.During a review of Resident 1's SBAR Communication Form (Situation, Background, Assessment, Recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 8/16/2026 and timed 9:36 PM, the SBAR indicated on 8/16/2026 Resident 1 had change in level of consciousness, tachycardia (increased heart rate, greater than 100 beats per minute), low grade fever, tremors of extremities and was slow to respond. The SBAR indicated a physician (MD 1) was notified of Resident 1's condition and there was a request to transfer Resident 1 to the GACH.During a review of Resident 1's medical record, the medical record indicated there was no documentation of name and location of the GACH Resident 1 was transferred to and the time when Resident 1 was transferred to GACH on 8/16/2026. The medical record also indicated there was no documentation of skin assessment for Resident 1 upon Resident 1's transfer to the GACH on 8/16/2026.During a phone interview on 8/26/2026 at 3:39 PM with RN 1, RN 1 stated RN 1 did not assess Resident 1's skin when Resident 1 was transferred to GACH 1 on 8/16/2026 because it was an emergency transfer. RN 1 stated RN 1 should have documented the name and location of the GACH Resident 1 was transferred to and the time when Resident 1 was transferred to GACH 1 on 8/16/2026. RN 1 stated RN 1 should have documented the transfer summary completely and appropriately and it was important to reflect Resident 1's health condition upon transfer.During a concurrent interview and record review on 8/26/2026 at 3:10 PM with the Director of Nursing (DON), Resident 1's SBAR, dated 8/16/2026, and Resident 1's medical record was reviewed. The DON stated that the nurse staff should have documented the SBAR completely and properly to indicate the time Resident 1 had a change of condition. The DON stated the nurse staff must document in Resident 1's medical record the time 911 was called, time Resident 1 was transferred out, and the name and location of GACH where Resident 1 was transferred to on 8/16/2026. The DON stated that it was important to document the timeline when resident had change of condition and was transferred to GACH to reflect the resident's health condition upon transfer/discharge.During a concurrent interview and record review on 8/27/2026 at 2 PM with the DON, Resident 1's medical record was reviewed. The DON stated that there was no transfer/discharge summary found including skin assessment documentation when Resident 1 was transferred to GACH 1 on 8/16/2026. The DON stated that it was important to do a skin assessment prior to transfer and give proper skin assessment report to the transfer team. During a review of the facility's policy and procedure (P&P) titled, Transfer or Discharge Documentation, revised 12/2016, the P&P indicated, When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. The P&P indicated, When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: .c. The date and time of the transfer or discharge; d. The new location of the resident; e. The mode of transportation; f. A summary of the resident's overall medical, physical, and mental condition.During a review of the facility's P&P titled, Transfer or Discharge, Emergency, revised 8/2018, the P&P indicated, The resident's medical record must be forwarded to the medical records office within twenty-four (24) hours of the transfer or discharge.

Based on observation, interview and record review the facility failed to ensure renovations for two of four sampled residents' rooms (Resident 1's and Resident 2's shared room) followed State regulations when: 1. Facility did not obtain prior written approval from Department of Healthcare Access and Information (HCAI, state agency that regulates the design, seismic [refers to earthquakes] safety, construction of hospitals and skilled nursing facilities) and from the California Department Public Health (CDPH, the Department) prior to initiating facility renovations. 2. Facility assigned residents in a renovated room prior to written approval from HCAI and CDPH. These deficient practices placed Resident 1 and Resident 2 at risk for unsafe conditions in a renovated room by potentially not having adequate ventilation, a working call light system, electricity, enough room space, and a restroom.During an observation on 7/1/2026 at 11:06 a.m. inside the renovated room (room [ROOM NUMBER]), the room had 2 resident beds, privacy curtains for each bed, chairs next to each bed, a closet for each resident, 1 restroom, 1 sink, a working call light system, electricity, and water sprinklers. During an interview on 7/1/2026 at 11:45 a.m. with the Administrator (ADM), the ADM stated room [ROOM NUMBER] was initially a resident room and then was used as an employee break room. The ADM stated the ADM did not inform HCAI and CDPH prior to initiating renovations in room [ROOM NUMBER] because ADM did know the facility needed to get approval from them prior to renovations. During an interview with Certified Nursing Assistant (CNA) 1 on 7/1/2026 at 12:47 p.m. CNA 1 stated room [ROOM NUMBER] had been the staff break room since CNA 1 started working in the facility four years ago. CNA 1 stated room [ROOM NUMBER] was turned into a resident room couple of months ago (unable to state exact date). During an interview with CNA 2 on 7/1/2026 at 1 p.m., CNA 2 stated the staff break room was converted into a resident room (room [ROOM NUMBER]) six months ago. During an interview on 7/1/2026 at 1:26 p.m. with the Director of Nursing (DON), the DON stated the employee break room was converted into a resident room by removing tables, chairs, and refrigerator from the room and by placing two beds and new curtains in that room. The DON stated the break room already had a restroom, sink, closets, call light system and sliding doors. The DON stated in-house staff did the repairs in the room. During an interview on 7/1/2026 at 1:50 p.m. with Maintenance Assistant (MA), MA stated MA was involved in converting the break room into a resident room. MA stated maintenance staff removed furniture from the room and replaced overbed lights and call light covers and added curtains to the room. MA stated the room was a resident room before it was used as a break room. During a concurrent observation and interview on 7/1/2026 at 2:15 p.m. with Maintenance Director (MD) in room [ROOM NUMBER], MD stated prior to renovating room [ROOM NUMBER], MD did not get approval from HCAI and CDPH because normally they did not require that. MD stated MD was not aware that HCAI and CDPH had to be notified prior to renovating any resident room. The MD stated the ADM did not tell the MD to get prior approval from HCAI and CDPH. During a review of facility's current policy and procedure (P&P) titled Maintenance Service, dated 12/2009, the P&P indicated maintenance service would be provided to all areas of the building, grounds, and equipment. The P&P indicated maintenance staff would maintain the building in compliance with current federal, state, and local laws, regulations and guidelines.

Based on interview, and record review, the facility (Skilled Nursing Facility [SNF] 1) failed to ensure one of three sampled residents (Resident 1) was permitted for readmission to the first available private room on 4/13/2026 after Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 3/21/2026 and transferred to Long-Term Acute Care Hospital (LTACH) 1 on 3/26/2026, in accordance with SNF 1's policy and procedure (P&P) titled, Bed-Holds and Returns, dated 3/2017.This deficient practice resulted in Resident 1 remaining in LTACH 1 on 2/4/2026 following an inquiry from LTACH 1 for Resident 1 to be transferred back to SNF 1 and had the potential to cause Resident 1 distress from not being able to return to Resident 1's previous living arrangement.During a review of Resident 1's admission Record (AR), the admission Record indicated SNF 1 originally admitted Resident 1 on 8/15/2023, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a weakness or partial paralysis affecting one side of the body) following cerebral infarction (damage to brain tissue caused by loss of blood flow to a part of the brain), and dementia (a progressive state of decline in mental abilities).During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 8/16/2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 3/31/2026, the MDS indicated Resident 1 was severely impaired in cognitive skills (ability to make daily decisions) and required partial/moderate assistance (helper does less than half the effort to complete the activity) for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Progress Notes (PN), dated 6/4/2026, the PN indicated Resident 1 was transferred to GACH 1 on 3/21/2026 for further evaluation.During a review of Resident 1's H&P from LTACH1, dated 3/27/2026, the H&P indicated Resident 1 was transferred and admitted to LTACH 1 from GACH 1 for further care on 3/26/2026.During a review of Resident 1's Case management/Social Services notes (CMSSN) from LTACH 1, dated 4/3/2026, the CMSSN indicated Resident 1's discharge goal/plan included transferring Resident 1 back to a skilled nursing facility (SNF).During an interview on 5/22/2026 at 1PM with SNF 1's admission Coordinator Director (ACD), the ACD stated the ACD received the inquiry from LTACH 1 regarding Resident 1's readmission on [DATE]. The ACD stated Resident 1 required a private room due to Candida Auris (C. Auris- is a type of yeast that can cause severe illness and spread easily among very sick patients in healthcare facilities) status and at that time the facility did not have an appropriate bed available. The ACD stated he did not receive additional communication regarding the resident's return and was unaware LTACH 1 continued attempting to return Resident 1 to the facility.During a telephone interview on 5/22/2026 at 3:40 PM with LTACH 1's Social Worker (SW 1), SW 1 stated Resident 1 was appropriate for SNF 1's placement on 4/13/2026 and a request for return to the facility was initiated. SW 1 stated she made multiple attempts to contact the facility following the initial request. SW 1stated messages were left for facility staff and on several occasions, and she was informed the ACD was unavailable. During an interview on 5/22/2026 at 3:55 PM with SNF 1's Director of Nursing (DON), the DON stated she was unaware Resident 1 continued to seek readmission to the facility following the initial inquiry. The DON stated no efforts were made to accommodate Resident 1 through room changes or bed planning because she was unaware the resident remained pending return.During a review of facility census records dated 4/13/2026 through 5/22/2026, the records indicated multiple beds, including private room availability, became available within the facility. The records further indicated the facility admitted other residents into available beds during this time period.During a review of facility admission logs for the month of April and May 2026 the records indicated the facility admitted other residents into available beds during this time period.During a review of the facility's policy and procedure titled, Bed-Holds and Returns, revised March 2017, the policy indicated, Residents may return to and resume residence in the facility after hospitalization. The policy further indicated a resident would be permitted to return to the facility immediately upon the first availability of a bed and may be offered an available bed in another area of the facility if the previous room was unavailable.

Based on interview and record review, the facility failed to maintain a copy of a maintenance schedule for the facility's two of two air conditioner units and the facility's preventative maintenance program failed to include testing water valves (regulate or shut off water flow in plumbing systems) and pneumatic controls (utilize compressed air to measure, transmit, and actuate control signals in systems like HVAC [heating, ventilation, and air conditioning]).This failure had the potential for residents (in general) not to have a comfortable environment while at the facility.Findings:During an interview on 4/24/2026 at 12:04 Pm with the Maintenance Supervisor (MS), the MS stated the facility had two air conditioning (AC) units. The MS stated the front AC unit was currently working but the back AC unit was not working. The MS stated the MS was changing a belt for the back unit. The MS stated the front unit was not working about 2 months ago. During an interview on 4/24/2026 at 1:04 PM with the MS, the MS stated an AC technician came to the facility the last time the AC was not working. The MS stated the AC technician informed the MS the problem with the AC unit was that the water valves on the roof of the facility needed to be exercised (open and closed). The MS stated the only preventative maintenance the maintenance department did for the AC units was a daily visual inspection. The MS stated the facility did not maintain a log or documentation for the daily visual checks. During a telephone interview on 4/24/2026 at 3:02 PM with the AC Technician (AT), the AT stated the AT was called to the facility a couple weeks ago when the facility was having issues with the AC units. The AT stated the facility's AC units needed preventative maintenance monthly to include changing filters, testing water valves, and testing pneumatic controls. During a review of the facility's Policy and Procedure (P&P) titled, Maintenance Service, revised December 2009, the P&P indicated, Maintenance service shall be provided to all areas of the building, grounds, and equipment. The P&P indicated, The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The P&P indicated, Functions of maintenance personnel include, but are not limited to. Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. Providing routinely scheduled maintenance service to all areas. The P&P indicated, The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. The P&P indicated, The Maintenance Director is responsible for maintaining the following records/ reports. Maintenance schedules.

Based on interview and record review, the facility failed to obtain weekly weights for one of three sampled residents (Resident 2) as indicated in the facility's Policy and Procedure (P&P) titled, Weight Change Protocol, undated.This failure had the potential for Resident 2 to experience unexplained/unnoticed weight loss.Findings:During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 10/8/2024 and readmitted Resident 8 on 3/31/2026 with diagnoses that included encephalopathy (brain disease that alters brain function or structure), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and dysphagia (difficulty swallowing foods or liquids).During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 4/3/2026, the MDS indicated Resident 2 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 2 was dependent (helper does all the effort) on staff for bathing, dressing, and toileting hygiene.During a review of Resident 2's Order Summary Report (OSR), dated 4/28/2026, the OSR indicated a physician order dated 3/31/2026 to weigh Resident 2 weekly for 4 weeks.During a review of Resident 2's Weights and Vitals Summary (WVS), dated 4/28/2026, the WVS indicated Resident 2 had not been weighed since 4/3/2026During a concurrent interview and record review on 4/28/2026, at 10 AM with the Director of Nursing (DON), the facility's Weekly Weight Binder was reviewed. The binder contained the names of all residents (in general) who needed to be weighed weekly. Resident 2 was not listed in the binder. The DON stated Resident 2 needed to be weighed weekly for 4 weeks because Resident 2 was recently readmitted to the facility. The DON confirmed the facility had not weighed Resident weekly since readmitted on [DATE].During a review of the facility's Policy and Procedure (P&P) titled, Weight Change Protocol, undated, the P&P indicated, Residents will be weighed on a monthly basis and weekly for those newly admitted .

Based on interview and record review, the facility failed to ensure accurate and complete documentation in the medical records for two of two residents (Residents 5 and 64) by:Failing to include Resident 5's diagnosis for diabetes on Resident 5's admission Record (AR).Indicating a diagnosis of bipolar disorder (BPD, an illness in which the patient goes back and forth between opposite extremes such as high and low levels of mood) for Resident 64 on the AR and the Minimum Data Set (MDS - a federally mandated resident assessment tool) without verification from Resident 64's medical record or confirmation with Resident 64's Medical Doctor (MD).These deficient practices resulted in incomplete/inaccurate medical records for Residents 5 and 64, and had the potential for Resident 5 and 64 to receive inappropriate nursing care and services due to the missing and inaccurate diagnoses on the residents' medical records. Findings: A. During a review of Resident 5's admission Record (AR), the AR indicated the resident was originally admitted to the facility on [DATE] with diagnoses that included encounter for palliative care (a specialized medical care for people living with a serious illness, focused on relieving symptoms, pain, and stress to improve quality of life for both the patient and their families), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), malaise (a general, vague feeling of being unwell, uncomfortable, or off, often described as a lack of energy or the blahs) and neuromuscular dysfunction of the bladder (a condition where damage to the brain, spinal cord, or nerves disrupts the signals required for proper bladder function) among other diagnoses. During a review of Resident 5's History and Physical (H&P), dated 3/25/2025, the H&P indicated Resident 5 had a diagnosis of diabetes mellitus. During a review of Resident 5's Minimum Data Set (MDS – a standardized assessment and care screening tool), dated 11/28/2025, the MDS indicated the resident was severely impaired in cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) skills the daily decision making. The MDS also indicated the resident was totally dependent on staff for transfers, and toilet use and required extensive assistance with bed mobility, dressing and hygiene. During an interview on 1/28/2026 at 10:35 AM with Licensed Vocation Nurse (LVN) 3, LVN 3 stated Resident 5 is receiving insulin with a sliding scale for Humalog Lispro (a fast-acting, man-made insulin used to control high blood sugar in adults and children with diabetes) for diabetes. LVN 3 was not able to see a diagnosis for diabetes for Resident 5 on Resident 5's facesheet. During a concurrent interview and record review on 1/28/2026 at 10:41 AM with the DON, the DON stated, Resident 5 is receiving Humalog Lispro for a diagnosis of diabetes since Resident 5 was admitted to the facility. The DON reviewed Resident 5's facesheet and did not see a diagnosis for diabetes on Resident 5's facesheet. The DON reviewed Resident 5's most recent H&P dated 3/25/2025 and the H&P indicated the resident had a diagnosis of type 2 diabetes. The DON stated it is importance to have the diagnosis of diabetes on Resident 5's facesheet for staff to see the condition of the resident and that the diagnosis could correlate with the medication that the resident is taking. During a concurrent interview and record review on 1/28/2026 at 10:56 AM with the MDS Coordinator (MDSC), the H&P dated 3/25/2025 was reviewed. The MDSC stated Resident 5's H&P listed the diagnosis of diabetes but the MDSC could not recall what happened a year ago and why the diagnosis on diabetes was not on Resident 1's facesheet. The MDSC stated the diagnosis is part of Resident 5's medical record and the nursing team needed to make sure the diagnosis is being addressed as well as managed the plan of care. B. During a review of Resident 64's AR, the AR indicated Resident 64 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease (a condition that occurs later in life and worsens with time in which brain cells degenerate; it is accompanied by memory loss, physical decline, and confusion) and bipolar disorder (BPD, an illness in which the patient goes back and forth between opposite extremes such as high and low levels of mood.) During a review of Resident 64's MDS, dated [DATE], the MDS indicated Resident 64 had severely impaired cognition (ability to understand and process information) and was dependent (helper does all the effort) on staff for activities of daily living. The MDS also indicated a diagnosis of BPD. During a review of Resident 64's History and Physical (H&P) dated 1/17/2026 and signed by Resident 64's Medical Doctor (MD), the H&P did not indicate a diagnosis for BPD. During a review of Resident 64's Order Summary Report (OSR), dated active as of 1/30/2026, the OSR indicated Resident 64 had a physician order for Olanzapine (medication used to treat schizophrenia or bipolar disorder) give 1 tablet by mouth one time a day for BPD manifested by manic episodes with start date 1/19/2026. During an interview on 1/30/2026 at 2:11 PM with Resident 64's Medical Doctor (MD), the MD stated Resident 64 did not have a diagnosis of BPD and the inclusion of the BPD diagnosis was likely entered by the admitting nurse as a mistake. During an interview on 1/30/2026 at 2:26 PM with the MDSC, the MDSC stated Resident 64's BPD diagnosis was included in the MDS and AR based on Resident 64's active medication for olanzapine. The MDSC stated the MDSC was acting in good faith that Resident 64's MD had reviewed the medications and agreed with the indicated diagnoses. The MDSC stated it was important to ensure a resident's diagnoses are correct for the facility to be able to provide for the resident's needs. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 7/2017 the P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.

Based on interview and record review, the facility failed to:(A) follow-up with the MD for the pharmacist drug regimen review recommendation to have the MD assess for Diclofenac gel (a non-greasy, topical medicine used to relieve joint pain caused by arthritis) and Tizanidine's (a medication used to treat muscle spasms, tightness, and cramping caused by spinal cord injuries or diseases like multiple sclerosis) effectiveness and evaluation if dose reduction or adjustment is warranted for one of one sample resident, (Resident 5)(B) indicate the physician's rationale for not following the pharmacist's recommendation in the resident's medication regime review (MMR) for one of one sampled resident (Resident 2).These deficient practices placed the resident at risk for receiving unnecessary medications that can lead to adverse side effects.Findings: (A) During a review of Resident 5's admission Record (AR) indicated the resident was originally admitted to the facility on [DATE] with diagnoses that included encounter for palliative care (a specialized medical care for people living with a serious illness, focused on relieving symptoms, pain, and stress to improve quality of life for both the patient and their families), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), malaise (a general, vague feeling of being unwell, uncomfortable, or off, often described as a lack of energy or the blahs) and neuromuscular dysfunction of the bladder (a condition where damage to the brain, spinal cord, or nerves disrupts the signals required for proper bladder function) among other diagnoses. During a review of Resident 5's History and Physical (H&P), dated 3/25/2025, indicated the resident had the capabilities for decision making. During a review of Resident 5's Minimum Data Set (MDS – a standardized assessment and care screening tool), dated 11/28/2025, indicated the resident was severely impaired in cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) skills the daily decision making. The MDS also indicated the resident was totally dependent on staff for transfers, and toilet use and required extensive assistance with bed mobility, dressing and hygiene. During a review of Resident 5's Medication Regimen Review for the month of December 2025, dated 12/9/2025 indicated the pharmacist recommendation: Resident has been on Diclofenac gel 1% apply 4 grams to affected joints BID for pain management, Tizanidine 2mg BIDF for muscle spasms. Please ensure MD assessment for effectiveness and evaluates if dose reduction or adjustment is warranted. Follow-through: ok. During a review of Resident 5's Medication Administration Record for the month of January 2026 indicated, Diclofenac Sodium External Gel 1% (Diclofenac Sodium (Topical)) Apply to Affected joints topically two times a day for pain management. Apply 4 GM. Non-pharmacological intervention 1. Music 2. Relaxation Techniques 3. Repositioning 4. Cold Compress 5. Respiratory/deep breathing exercises 6. Massage 7. Diet 8. Prayer 9. Exercise 10. Calming Voice. Start date 7/9/2025 at 1700. During a review of Resident 5's Medication Administration Record for the month of January 2026 indicated, tizanidine HCL oral tablet 2 mg (Tizanidine HCL) Give 1 tablet by mouth two times a day for muscle spasms. Start date 7/4/2025 at 0900 During a review of Resident 5's Progress Notes, dated 12/18/2025 indicated, MD was made aware of the pharmacist's medication regimen for Resident 5. The resident has been receiving diclofenac gel 1% (apply 4 grams BID) for pain management and tizanidine 2 mg BID for muscle spasms. MD will be assessing the resident for effectiveness of therapy and will evaluate whether does reduction or adjustments are warranted. NNO as of now. Will continue to monitor. During a concurrent observation and interview on 1/29/2026 at 1:55 PM, with the Director of Nursing (DON), the DON stated she was unable to find the MD assessment for effectiveness and evaluation if the dose reduction or adjustment is warranted as per the MRR pharmacist recommendations. This surveyor observed the DON look through the hospice binder, physical chart and medical records. During an interview on 1/29/2026 at 2:37 PM, with the DON, the DON stated that the importance of the MRR is to know if the medication we are giving is still suitable for the patient and if she is getting the right medication and dose based on the recommendation of the pharmacist. Moving forward we will ask the MD when we should be following up with them or if the recommendation is still no new order. (B). During a review of Resident 2's face sheet, the face sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis including but not limited to dementia (decline in brain function), psychosis (mental health symptom where a person can lose touch with reality), and depression, During a review of Resident 2's History and Physical (H&P), dated 1/10/2026, the H&P indicated Resident 2 is not competent and not able to enter into contract. During a review of Resident 2's MRR, dated 1/10/2026, the MRR indicated the facility's pharmacist recommended the physician review the risk and benefits of keeping Resident 2 on Aricept 5 mg (a medication to treat dementia) and Seroquel 100 mg (a medication to treat mood disorders), due to the risk of mortality in the elderly population. The physician disagreed with the recommendation but did not indicate a rationale. During an interview on 1/29/2026 at 1:20 PM with Director of Nursing (DON), DON stated that the response to the pharmacist's recommendation should have included the physician rationale for not following it. During a record review of the facility's policy and procedure (P&P) titled, Drug Regimen Review not dated, the P&P indicated Physicians will be notified of Pharmacists recommendations and the Physicians response is documented in resident's chart. Per State Operations Manual (SOM) a physician's rationale must be provided as part of Physician's response. During a review of the facility's policy and procedure titled, Drug Regimen Review that is undated, indicated that the Physician's response is documented on the Consultant Pharmacist's review record or elsewhere in the resident's medical record.

Based on interview and record review the facility failed to obtain and maintain copies of advance directives (AD, a legal document explaining a resident's health care wishes when residents cannot speak for themselves) for four of six sampled residents (Residents 3, 6, 43, and 44).This failure had the potential to result in conflict regarding Residents' 3, 6, 43, and 44 health care choices. Findings: a. During review of Resident 3's face sheet. The face sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including but not limited to: arthritis (pain. swelling and stiffness of the joints) right knee infection, muscle weakness, and morbid obesity. During review of the Minimum Data Set (MDS- standardized assessment screening tool) dated 12/11 2025, the MDS indicated Resident 3's cognition was intact. During review of Resident 3's clinical records, the clinical records did not include the resident had an AD. During a concurrent interview and record review on 1/29/2026 at 3:36 PM with the Social Service Director (SSD), Resident 3's clinical records were reviewed. The clinical records indicated Resident 3 had an AD according to the Advance Health Care Directive Acknowledgement Form (AHCD). The SSD stated the AHCD form indicated Resident 3 has an AD, but it is not in their clinical records. The SSD stated it was important to have a copy of the AD in the Residents 3's chart to ensure their choices were honored. During review of the facility's policy and procedure (P&P) titled, Advance Directives dated December 2016, the P&P indicated the facility will comply with state and federal law regarding AD. Upon admission the resident will be provided with written information regarding acceptance or refusal of medical or surgical treatment. If there is an AD it will be placed in the resident's medical record. b. During a review of Resident 43's admission Record (AR), the AR indicated Resident 43 was admitted to the facility on [DATE] with multiple diagnoses including fibromyalgia (long term condition that causes widespread pain, extreme fatigue, and tenderness in muscles and joints throughout the body) and dementia (a gradual decline in mental ability usually caused by a brain disease). During a review of Resident 43's Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 1/8/2026, the MDS indicated Resident 43 had impaired cognition (ability to understand and process information) and was dependent on staff for bathing and toileting. During a concurrent interview and record review on 1/27/2026 at 3:50 PM with Licensed Vocational Nurse (LVN) 5, Resident 43's Advance Healthcare Directive Acknowledgement Form (AHDA), dated 10/24/2024 was reviewed. LVN 5 stated Resident 43's AHDA indicated Resident 43 had a current advanced healthcare directive but there was no copy found in Resident 43's medical chart. The AHDA further indicated if a client has an Advance Health Care Directive, insert a copy into the client's Clinical [medical] Record. c. During a review of Resident 6's AR, the AR indicated Resident 6 was admitted to the facility on [DATE] with multiple diagnoses including metabolic encephalopathy (broad term for temporary or permanent brain dysfunction caused by an underlying condition) and heart failure (the inability of the heart to pump blood effectively). During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had intact cognition and required partial or moderate assistance (helper does less than half of the effort) for toileting and bathing. During a concurrent interview and record review on 1/28/2026 at 2:15 PM with LVN 3, Resident 6's AHDA, dated 12 /3/2025, was reviewed. LVN 3 stated Resident 6's AHDA indicated Resident 6 had a current advance health care directive. LVN 3 stated the form did not indicate whether the facility had a copy of Resident 6's advance health care directive and the copy was not in Resident 6's medical chart. The AHDA further indicated if a client has an Advance Health Care Directive, insert a copy into the client's Clinical Record. During an interview on 1/29/2026 at 4:18 PM with the Social Services Director (SSD), the SSD stated the facility did not have a copy of Resident 6 or Resident 43's advanced health care directives. The SSD stated it was important to have a copy of the advanced health care directives to be able to follow the residents' (in general) wishes for treatment. During a review of the facility's policy and procedure (P&P), titled Advance Directives, dated 12/2016 the P&P indicated advance directives will be respected in accordance with state law and facility policy. d. During a review of Resident 44's AR, the AR indicated the facility admitted Resident 44 on 12/19/2025 with diagnoses including displaced fracture of the upper end of right humerus (a break in the top of the right arm bone), subsequent encounter for fracture with routine healing (a follow up visit after the initial, active treatment of a broken bone) and a history of falling. During a review of Resident 44's H&P dated 12/20/2025, the H&P indicated Resident 44 had decision making capabilities. During a review of Resident 44's MDS dated [DATE], the MDS indicated Resident 44's cognitive skills for daily decision making were moderately impaired (makes poor decisions requiring cues or supervision). The MDS indicated Resident 44 was dependent on transfers, toileting, showering, and lower body dressing, substantial assist with upper body dressing, required moderate assistance with oral hygiene, and supervision with eating. During a review of Resident 44's AHDA dated 12/19/2025, the AHDA indicated Resident 44 had an AD in place. During an interview on 1/28/2026 at 10:16 AM with Resident 44, Resident 44 stated Resident 44 had an AD and no one at the facility had asked for a copy of Resident 44's AD. During an interview on 1/29/2026 at 3:36 PM with the Social Service Director (SSD), the SSD stated Resident 44's AHDA dated 12/19/2025 indicated Resident 44 had an AD. The SSD stated the facility did not have a copy of Resident 44's AD. The SSD stated either the SSD or the admitting nurse (in general) were responsible for reaching out to Resident 44 or Resident 44's representative to obtain copies of the AD. The SSD stated it was important to have a copy of the AD in the residents' chart to ensure Resident 44's choices were honored. During a review of the facility's Policy and Procedure (P&P) titled, Advance Directives, revised December 2016, the P&P's policy statement indicated, Advance directives will be respected in accordance with state law and facility policy. The P&P's policy interpretation and implementation indicated, Prior to or upon admission of a resident, the social services director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.

Based on interview and record review the facility failed to ensure adequate indications for psychotropic medication (medication used to treat mental health disorders [conditions that affect thinking, feeling, mood, and behavior]) use and failed to ensure specific psychotropic medication behavior monitoring (tracking expressions or indications of distress) was completed for two of five sampled residents (Residents 7 and 64).These failures had the potential to result in unmet medical, physical, mental, and psychosocial needs (the emotional and social requirements that individuals must have to feel safe, supported, and capable of functioning well in their environment) to Residents 7 and 64 and had the potential to result in Residents 7 and 64 receiving unnecessary medications.Findings: a.During a review of Resident 7's admission Record (AR), the AR indicated the facility originally admitted Resident 7 on 1/3/2026 with diagnoses including unspecified dementia (a progressive state of decline in mental abilities) and unspecified psychosis (a severe mental health condition in which thought, and emotions are so affected that contact is lost with reality) not due to a substance or known physiological condition (the body's natural, healthy operating state). During a review of Resident 7's History and Physical (H&P), dated 1/4/2026, the H&P indicated Resident 7 did not have decision making capacities. During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool), dated 1/15/2026, the MDS indicated Resident 7's cognitive (the ability to think and process information) skills for daily decision making were moderately impaired (makes poor decisions requiring cues or supervision). The MDS indicated Resident 7 required substantial assistance with lower body dressing, toileting, showering, sitting to lying, and lying to sitting on the side of bed, partial assist with upper body dressing and oral hygiene, supervision assistance with eating, and was dependent with chair and toilet transfers. During a review of Resident 7's Order Summary Report (OSR), dated active as of 1/29/2026, the OSR indicated the following physician orders: 1.Quetiapine fumarate (medication used to treat mental health disorders) 25 milligrams (mg- a unit of measurement) for psychosis manifested by agitation (a feeling of irritability, mental distress, or severe restlessness) with a start date of 1/16/2026 2.Monitor behavior for psychosis manifested by agitation and tally by hashmark (marking vertical lines for each item on the medication administration record) for quetiapine use with a start date of 1/15/2026. During an interview on 1/29/2026 at 11:57 AM with Licensed Vocational Nurse (LVN) 4, LVN 4 stated agitation could be manifested by many different behaviors. LVN 4 stated it was important to monitor specific behaviors [e.g., could include: pacing, fidgeting, irritability, restlessness, muscle tension, shouting, or hostility] for Resident 7 to ensure Resident 7 received the correct amount of medication and if Resident 7 did not exhibit the specific behaviors, the facility could lower the medication's dose. During an interview on 1/30/2026 at 9:21 AM with the Director of Nursing (DON), the DON stated for psychotropic medications, behavior manifestation had to be specific for the resident (in general). The DON stated [manifested by agitation as indicated in the OSR] was not a specific indication for [psychotropic] medication use for Resident 7. The DON stated it was important to address the Resident's specific medical needs to ensure Resident 7 received the proper medical care. During a review of the facility's undated Policy and Procedure (P&P) titled, Antipsychotic Medication [medications used to manage symptoms of psychosis] Use, the P&P's policy statement indicated, Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. The P&P's policy interpretation and implementation indicated, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The attending physician will identify, evaluate, and document with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. b. During a review of Resident 64's AR, the AR indicated Resident 64 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease (a condition that occurs later in life and worsens with time in which brain cells degenerate; it is accompanied by memory loss, physical decline, and confusion). During a review of Resident 64's MDS dated [DATE], the MDS indicated Resident 64's cognition was severely impaired, and Resident 64 was dependent (helper does all the effort) on staff for activities of daily living. During a review of Resident 64's OSR, dated active as of 1/30/2026, the OSR indicated Resident 64 had a physician order for Olanzapine (medication used to treat schizophrenia [a long term severe mental disorder affecting how a person thinks, feels, and behaves, often causing them to lose touch with reality] or bipolar disorder [a long term mental condition characterized by extreme, often disabling, shifts in mood, energy, and activity levels]) give 1 tablet by mouth one time a day for bipolar disorder manifested by manic episodes (periods of abnormally, persistently elevated, or irritable mood and extremely high energy, lasting at least a week or requiring hospitalization) with start date 1/19/2026. During a concurrent interview and record review on 1/30/2026 at 12:15 PM with LVN 3, Resident 64's physician order for Olanzapine was reviewed. LVN 3 stated manic episodes could mean screaming, striking, and acting out of control. LVN 3 stated the order did not indicate a specific behavior presented by Resident 64 and another staff member could have a different idea of how manic episodes were presented. LVN 3 stated the behavior listed in the physician order should be specific to make it clear to all staff what Resident 64 was doing [specific behaviors] and to ensure accurate [behavior] tracking. During an interview on 1/30/2026 at 2:22 PM with the DON, the DON stated Resident 64's order for Olanzapine did not indicate a specific behavior [or indication for use] to monitor. The DON stated it was important to indicate specific behavior [and indication for medication use] for staff to know what to monitor and to help ensure Resident 64 was on the correct medication. During a review of the facility's P&P titled, Antipsychotic Medication Use, undated, the P&P indicated residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medication condition, specific symptoms, and risks to the resident and others.

Based on observation, interview, and record review, the facility failed to ensure the resident did not store medications in their room for one of three residents (Resident 3). This failure had the potential to place Resident 3 at risk for unsafe self-administration of medication, which could result in skin irritation, systemic absorption (the process by which medication is absorbed into the bloodstream) and contamination. Findings: During review of Resident 3's face sheet, the face sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including but not limited to: arthritis (pain, swelling and stiffness of the joints), right knee infection, muscle weakness, and morbid obesity. During a review of Resident 3's Minimum Data Assessment (MDS-standardized assessment screening tool), dated 12/11/2025, the MDS indicated Resident 3 required partial assistance from the nursing staff with bathing, dressing, and using the toilet. During a concurrent observation and interview on 1/28/2026 at 12:15 PM with Resident 3, in Resident 3's room, there were several medication ointments found in the resident's closet: bacitracin zinc (used to prevent infection in skin wounds), Activon (promotes faster healing of the skin), and clotrimazole cream (used to treat fungus infection of the skin). Resident 3 stated the medications were provided by facility and are kept in their closet. During an interview on 1/29/2026 at 9:42 AM with Licensed Vocational Nurse/Treatment Nurse (LVN 2), LVN 2 stated the medications left in the resident's room are not supposed to be there. LVN 2 stated they are unsure why the medications are there and does not know who provided them to Resident 3. During review of the facility's policy and procedure (P&P) titled, Storage of medications, dated November 2020, the P&P indicated drugs and biologicals used at the facility are to be stored in locked compartments. Only authorized staff may have access to locked medications.

Based on observation, interview, and record review the facility failed to administer a zinc ointment (a medication that helps protect and heal the skin) per the physician's order for a pressure ulcer (PU - injury to the skin and underlying tissue caused by constant long term pressure) to the sacral area (the bottom of the back right above the tail bone) for one of three sample residents (Resident 3). This failure has the potential to effect the healing of Resident 3's pressure ulcer. Findings: During review of Resident 3's face sheet, the face sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including but not limited to: arthritis (pain, swelling and stiffness of the joints), right knee infection, muscle weakness, and morbid obesity. A review of Resident 3's Minimum Data Assessment (MDS-standardized assessment screening tool), dated 12/11/2025, the MDS indicated Resident 3 required partial assistance from the nursing staff with bathing, dressing, and using the toilet. During an interview on 1/29/2026 at 9:06 AM with Resident 3, Resident 3 stated medication was not applied to their sacral area yesterday (1/28/2026).During a concurrent interview and record review on 1/29/2026 at 9:41 AM, with Licensed Vocational Nurse/Treatment Nurse (LVN 2), Resident 3's Medication Administration Record (MAR) dated 1/28/2026, was reviewed. The MAR indicated LVN 2 administered the zinc ointment to Resident 3's sacral area. LVN 2 stated they checked off the medication as given, even though it was not given. LVN 2 stated they are not supposed to do that. LVN 2 stated checking off medications that are not given can cause harm to a resident, by delaying care, delaying wound healing, or potentially developing another wound.

Based on interview and record review, the facility failed to revise the Care Plan (CP, a form where one can summarize a person's health conditions, specific care need, and current treatments) related to gastrostomy tube (G-tube, a small flexible tube placed through the skin of the abdomen directly into the stomach) and nutrition for one of one sampled resident (Resident 6) after Resident 6's g-tube was removed.This failure had the potential for Resident 6 not to receive necessary care or services related to the removal of the g-tube. Findings: Based on interview and record review, the facility failed to revise Resident 6's CP related to G-tube and nutrition after Resident 6's g-tube was removed.During a review of Resident 6's admission Record (AR), the AR indicated Resident 6 was admitted to the facility on [DATE] with multiple diagnoses including dysphagia, oropharyngeal phase (a swallowing disorder affecting the mouth and throat) and heart failure (the inability of the heart to pump blood effectively.)During a review of Resident 6's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated [DATE], the MDS indicated Resident 6 had intact cognition (ability to understand and process information) and required partial or moderate assistance (helper does less than half of the effort) for toileting and bathing. The MDS indicated Resident 6 had a feeding tube on admission and received 26-50% of total calories through the feeding tube.During a review of Resident 6's Care Plan Report (CPR) initiated [DATE], the CPR indicated Resident 6 had a nutritional problem or potential nutritional problem related to g-tube feeding and other co-morbidities (two or more illnesses or health conditions existing in the same person at the same time.) The CPR interventions included for staff to explain and reinforce to the resident the importance of maintaining the diet ordered.During a review of Resident 6's Care Plan Report (CPR) dated [DATE], the CPR indicated Resident 6 was admitted to the facility with G-tube site on abdomen. The goal on the CPR indicated the facility will maintain without complications until next review date, [DATE].During a review of Resident 6's Order Summary Report (OSR), dated active as of [DATE] the OSR indicated a physician order for regular diet, soft and bite sized texture, regular consistency, and double protein with start date [DATE]. The OSR also indicated a physician order to have skilled wound care remove gastrostomy tube with order date [DATE].During an interview on [DATE] at 12:03 PM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated LVN 3 could not find a revision for Resident 6's CP related to g-tube. LVN 3 stated Resident 6's CP related to g-tube should have been revised when the g-tube was removed to ensure the g-tube site was monitored for healing and signs of infection. LVN 3 also stated Resident 6's CP related to nutrition should have been revised when Resident 6's g-tube was removed because Resident 6's diet had changed.During an interview on [DATE] at 1:30 PM with the Director of Nursing (DON), the DON stated Resident 6's CPs should have been revised when the g-tube was removed to indicate Resident 6's current nutritional status and help direct Resident 6's treatment.During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, undated the P&P indicated the interdisciplinary team must review and update the care plan: a. when there has been a significant change in the resident's condition.

Based on observation, interview, and record review, the facility failed to ensure a resident's low air loss (LAL - composed of multiple inflatable air tubes that alternately inflate and deflate, mimicking the movement of a patient shifting in bed or being rotated by a caregiver, never leaving the patient in one position for any extended length of time) mattress was set to the correct setting for one of one sample resident (Resident 5).This deficient practice placed Resident 5 at risk for discomfort and the potential for developing pressure ulcers.During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 was originally admitted to the facility on [DATE] with diagnoses that included encounter for palliative care (a specialized medical care for people living with a serious illness, focused on relieving symptoms, pain, and stress to improve quality of life for both the patient and their families), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), malaise (a general, vague feeling of being unwell, uncomfortable, or off, often described as a lack of energy or the blahs) and neuromuscular dysfunction of the bladder (a condition where damage to the brain, spinal cord, or nerves disrupts the signals required for proper bladder function) among other diagnoses.During a review of Resident 5's History and Physical (H&P), dated 3/25/2025, the H&P indicated Resident 5 had a diagnosis of diabetes mellitus.During a review of Resident 5's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/28/2025, the MDS indicated the resident was severely impaired in cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) skills. The MDS also indicated the resident was totally dependent on staff for transfers, toilet use and required extensive assistance with bed mobility, dressing and hygiene.During a review of Resident 5's Order Summary Report (OSR) dated 1/27/2026, the OSR indicated Resident 5 had a physician's order, dated 7/3/2025, for Resident 5's low air loss mattress to be monitored every shift for proper functioning and for offloading and pressure relief.During an observation on 1/27/2026 at 9:24 AM, in Resident 5's room, Resident 5 was asleep in bed. Resident 5's LAL mattress was on and the setting was at 450 pounds (lbs. unit used to measure weight and mass).During a concurrent interview and record review on 1/27/2026 at 9:30 AM, with License Vocational Nurse (LVN) 2, LVN 2 stated that Resident 5 had a physician's order for LAL mattress and for staff to check the LAL for pressure relief and monitoring for proper functioning every shift. LVN 2 stated he had not checked the Resident 5's LAL mattress and he is on his way to check the LAL mattress. LVN 2 checked the LAL mattress and stated it was set for 450 lbs. and locked. LVN 2 stated the red sticker on top of the machine indicates 150 lbs. as the corrected setting. LVN 2 changed the LAL mattress's setting to the weight of 150 lbs. LVN 2 stated that at the setting of 450 lbs., the mattress is too firm for Resident 5 and the firmness can cause pressure injuries and redness to Resident 5's skin. During a review of the facility's Policy and Procedure (P&P) titled, Prevention of Pressure Injuries, revised on April 2020, the P&P indicated to select appropriate support surfaces based the resident's risk factors, in accordance with current clinical practice.

Based on interview and record review, the facility failed to justify a diagnosis of bipolar disorder (BPD, an illness in which the patient goes back and forth between opposite extremes such as high and low levels of mood) for one of one sampled Resident (Resident 64) based on a comprehensive assessment Resident 64 as indicated in the facility's policy and procedure (P&P) titled, Antipsychotic [a class of psychiatric medications primarily used to manage psychosis symptoms] Medication Use.This failure had the potential for Resident 64 to receive unnecessary treatment and/or services and the potential to result in a physical decline to Resident 64.Findings:During a review of Resident 64's admission Record (AR), the AR indicated Resident 64 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease (a condition that occurs later in life and worsens with time in which brain cells degenerate; it is accompanied by memory loss, physical decline, and confusion), dementia (a gradual decline in mental ability usually caused by a brain disease, such as Alzheimer's), and BPD.During a review of Resident 64's Minimum Data Set (MDS - a resident assessment tool), dated 1/23/2026, the MDS indicated Resident 64's cognition (ability to understand and process information) was severely impaired and Resident 64 was dependent (helper does all the effort) on staff for activities of daily living. The MDS indicated a diagnosis of BPD.During a review of Resident 64's History and Physical (H&P), dated 1/17/2026, and signed by Resident 64's Medical Doctor (MD) 1, the H&P indicated Resident 64 had dementia/ Alzheimer's with worsening behavioral issues.During a review of Resident 64's Order Summary Report (OSR), dated active as of 1/30/2026, the OSR indicated Resident 64 had a physician order for olanzapine, give 1 tablet by mouth one time a day for BPD manifested by manic episodes (a period of abnormally high energy, elevated or irritable mood, and increased activity, lasting at least a week, that significantly disrupt daily life and functioning) with start date 1/19/2026.During an interview on 1/30/2026 at 12:15 PM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated upon admission, Resident 64 presented with agitation: screaming, yelling out, and striking at staff. LVN 3 stated Resident 64 was also resistant to care like showering. LVN 3 stated Resident 64 was taking olanzapine for BPD manifested by manic episodes which LVN 3 described as screaming, striking, and acting out of control. LVN 3 stated Resident 64 also had an active urinary tract infection (UTI, common infection in the urine caused by bacteria entering the urinary system) on admission and that could have been a possible cause of Resident 64's behavior. LVN 3 stated Resident 64 is calmer and more cooperative now compared to behavior noted on admission.During an interview on 1/30/2026 at 2:11 PM with Resident 64's physician (Medical Doctor [MD]) 1, MD 1 stated Resident 64 did not have a diagnosis of BPD the facility might have added the diagnosis of BPD by mistake. MD 1 stated Resident 64 was taking olanzapine at home and MD 1 continued the medication at the facility due to Resident 64's history of Alzheimer's with psychosis. MD 1 stated MD 1 planned to discontinue the medication because Resident 64 was doing well at the facility.During an interview on 1/30/2026 at 2:22 PM with the Director of Nursing (DON), the DON stated the medications a resident presented with on admission did not always list the indication for medication use. The DON stated, upon admission, the admitting nurse (in general) tried to find a diagnosis to correlate to the medication if the diagnosis was not already indicated [in the admission records]. The DON stated the admitting nurse (unidentified) made a mistake writing bipolar disorder as the indication for Resident 64's olanzapine medication [in Resident 64's OSR].During a review of the facility's undated P&P titled, Antipsychotic Medication Use, the P&P indicated antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. The P&P indicated diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident.

Based on observation, interview, and record review, the facility failed to inform one of one sampled resident's (Resident 64) physician (Medical Doctor [MD] 1) of Resident 64's change of condition (CoC, an alteration in a resident's physical health that differs from their previous baseline) when Resident 64 was observed with redness on Resident 64's left eye on 1/27/2026. This failure had the potential for Resident 64 not to receive adequate treatment for a potential infection in Resident 64's left eye.Findings: During a review of Resident 64's admission Record (AR), the AR indicated Resident 64 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease (a condition that occurs later in life and worsens with time in which brain cells degenerate; it is accompanied by memory loss, physical decline, and confusion).During a review of Resident 64's Minimum Data Set (MDS- a resident assessment tool) dated 1/23/2026, the MDS indicated Resident 64's cognition (ability to understand and process information) was severely impaired and Resident 64 was dependent (helper does all the effort) on staff for activities of daily living.During a concurrent observation and interview on 1/27/2026 at 1:10 PM with Family Member (FM) 1, Resident 64's left eye was observed. FM 1 stated Resident 64's left eye appeared more red on this day than ever before. FM 1 stated Resident 64's left eye had been pink and/or red a few months ago when Resident 64 had shingles (painful, blistering skin rash caused by the chicken pox virus) on the left side of Resident 64's face.During a concurrent observation and interview on 1/28/2026 at 12:52 PM with FM 1, in Resident 64's room, Resident 64's left eye was observed with redness in the sclera (white outer coating of the eye that surrounds the cornea). FM 1 stated Resident 64's left eye looked red for a couple days and FM 1 informed Resident 64's nurse on 1/27/2026 of the redness. FM 1 stated Resident 64's nurse told FM 1 it would be taken care of, but FM 1 had not received any updates and did not know if there was planned treatment for the redness in Resident 64's left eye.During an observation on 1/29/2026 at 9:23 AM, Resident 64 had redness on Resident 64's left eye and the eye had white discharge (a combination of mucus, oil, skin cells, and debris that accumulate in the eye) on the lower lid.During an interview on 1/29/2026 at 2:37 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated FM 1 mentioned Resident 64's eye redness to CNA 1 on 1/28/2026. CNA 1 stated CNA 1 offered to report Resident 64's eye redness to the Licensed Vocational Nurse (LVN) 6 on behalf of FM 1 but FM 1 declined because FM 1 spoke to the LVN 6 directly on 1/28/2026.During an interview on 1/29/2026 at 2:48 PM with LVN 3, LVN 3 stated LVN 3 had not received any report [from previous shifts] about Resident 64's eye redness and LVN 3 was not sure when the redness started. LVN 3 stated LVN 3 did not see Resident 64's eyes earlier in the shift. LVN 3 stated MD 1 had not been notified of Resident 64's eye redness. LVN 3 stated the nurse [LVN 6] who received the initial report from FM 1 should have notified Resident 64's doctor to rule out a potential infection.During a review of Resident 64's Progress Notes (PN), dated 1/27/2026 to 1/28/2026, there was no documented evidence indicating MD 1 was informed of Resident 64's eye redness.During a review of Resident 64's Situation Background Assessment Recommendation [SBAR] Communication Form and progress note (SBAR), dated 1/29/2026, timed at 2:30 PM, the SBAR indicated Resident 64 had redness and white discharge on the left eye.During a review of the facility's undated policy and procedure (P&P) titled, Change in a Resident's Condition or Status, the P&P indicated the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/ mental condition and/or status. The P&P indicated a significant change of condition, is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting.) Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/ mental condition or status.

Based on interview and record review, the facility failed to develop and implement a comprehensive care plan (CP) for one of one sampled resident (Resident 57), who was on hospice care (care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort and quality of life, rather than a cure).This deficient practice had the potential to result in unmet individualized needs for Resident 57 and the potential to affect the resident's physical and psychosocial well-being.Findings:During a review of Resident 57's admission Record (AR) indicated Resident 57 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease (a long-term condition where the kidneys become damaged and gradually lose their ability to filter waste and extra fluid from the blood, leading to a buildup of toxins), atrial fibrillation (a rapid chaotic, and irregular heartbeat), muscle weakness, hypertension (HTN - high blood pressure), and thrombophilia (a tendency for the blood to clot easily due to an imbalance in clotting proteins).During a review of Resident 57's History and Physical (H&P), dated 11/29/2025, the H&P indicated Resident 57 did not have decision making capacities. During a review of Resident 57's CP, initiated 12/1/2025, the CP indicated Resident 57 had the potential for nutritional problems related to hospice care.During a review of Resident 57's Minimum Data Set (MDS- a resident assessment tool), dated 12/2/2025, the MDS indicated Resident 57's cognitive (the ability to think and process information) was severely impaired. The MDS indicated the Resident 57 was totally dependent on staff for transfers and toilet use, and required extensive assistance with bed mobility, dressing, and hygiene.During a review of Resident 57's Order Summary Report (OSR), dated active as of 12/13/2025, the OSR indicated a physician's order, dated 12/13/2025, for Resident 57 to be admitted to hospice under MD (Medical Doctor) care on routine level of care with primary diagnosis of hypertensive heart disease (various heart conditions caused by long term high blood pressure).During a concurrent interview and record review on 1/30/2026 at 11:58 AM, with the MDS Coordinator (MDSC), the MDSC stated the MDSC could not find a hospice CP for Resident 57 that included the most recent hospice plan of care. The MDSC stated [developing] a hospice CP was important because the CP showed how to care for Resident 57 and [helped with] communication with the staff [to follow the] plan of care for the resident.During a review of the facility's revised policy and procedure (P&P) titled, Hospice Program revised July 2017, the P&P indicated coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental and psychosocial well-being.

F627INTENT These regulations and guidance address inappropriate discharges and:Ensure a facility does not transfer or discharge a resident in an unsafe manner, such as a locationthat does not meet the resident's needs, does not provide needed support and resources, or does notmeet the resident's preferences and, therefore, should nothave occurred. F627Based on observation, interview and record review, the facility failed to ensure Resident 1's discharge location met Resident 1's needs for family support and resources. This deficient practices led to an inappropriate discharge.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/19/2025, with diagnoses that included pneumonia (lung infection) and history of falling.During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/26/2025, the MDS indicated Resident 1 had intact cognition. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds or supports trunk or limbs but provides less than half the effort) with toileting, lower body dressing and personal hygiene. Resident 1 required partial/moderate assistance with the following mobility, rolling left and right, sit to lying, lying to sitting on the side of the bed, sit-to-stand, chair/bed-to chair transfer, toilet transfer, and walking 10 feet.During a review of Resident 1's Physical Therapy Discharge Summary (PTDS) dated 10/2/2025, the PTDS indicated Resident 1 required supervision or touching assistance with bed mobility, transfers, residential mobility.During a review of Resident 1's Progress Notes (PN) dated 10/3/2025, the PN indicated Resident 1 was discharged to an assisted living facility (ALF 1).During an interview on 10/3/2025 at 5 PM, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1's Family member (FM) 1 had stated they will file an appeal because Resident 1 was not ready for discharge.During an interview on 10/3/2025 at 5:31 PM, FM 1 stated, There were no choices offered regarding places to go upon discharge. FM 1 stated FM 1 tried to appeal the discharge decision, but unable to submit the appeal request due to the Federal Shutdown. FM 1 stated, ALF 1 was provided on 10/3/2025, on the day of discharge. FM 1 stated FM 1 went to ALF 1 on 10/3/2025 to check the place and ran out of time so FM 1 agreed to discharge Resident 1 to ALF 1. FM 1 stated Resident 1's Son was sick so it would have been better if there was an ALF closer to Resident 1's Son home so the Son would be able to visit Resident 1.During an interview on 10/7/2025 at 11:43 AM, the Case Manager (CM) stated Resident 1's discharge plan was to discharge Resident 1 to FM 1's home or placement. The CM stated FM 1 had stated it would depend on Resident 1's progress with therapy then Resident 1 could discharge to FM 1's home. The CM stated ALF 1 was the facility that was found for Resident 1 within 48 hours before Resident 1 was discharged .During an interview on 10/7/2025 at 1:40 PM, the CM stated FM 1 toured ALF 1 on 10/3/2025, on the day of Resident 1's discharge and agreed for Resident 1 to be transferred to ALF 1. The CM stated CM informed FM 1 if FM 1 did not agree to the transfer Resident 1 to ALF 1, FM 1 need to pay the facility for additional stay days at the facility until facility staff can find a safe place for Resident 1.During an interview on 10/7/2025 at 4:50 PM, the Social Services Director (SSD) stated it will either be the Senior Placement Agency or the Hospice Agency who would find placement for Resident 1, the SSD stated the SSD did not know what choices of ALF was offered to Resident 1 and FM 1. The SSD stated there was no documentation other options of ALFs were discussed with Resident 1 or FM 1.During an interview on 10/7/2025 at 5 PM, the Director of Nursing (DON) stated the facility needed to offer a list of ALFs to enable Resident 1 and FM 1 to make decision. The DON stated Resident 1's Son was sick and the DON understood why FM 1 would have wanted Resident 1 to be discharged to an ALF closer to this area (near the facility).During a review of the facility's Policy and Procedure (P&P) titled, Discharge Summary and Plan, dated December 2016, the P&P indicated residents transferring to another skilled nursing facility, or who are discharged to a home health agency, long-term care hospital or inpatient rehabilitation facility will be assisted in selecting a post-acute care provider that is relevant and applicable to the resident's goals of care and treatment preferences.

Based on interview and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Abuse Prevention Policy for one of three sampled residents (Resident 1) when the facility did not report a staff to resident abuse allegation (a claim that abuse has occurred) to the State Agency (SA-the state health inspection team that ensures healthcare providers are following federal laws) within two hours.This failure had the potential to result in Resident 1 experiencing abuse and to affect Resident 1's psychosocial (the emotional and social requirements that individuals must have to feel safe, supported, and capable of functioning well in their environment) wellbeing.Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted the resident on 1/12/2024 with diagnoses including hypertensive heart disease (a heart problem resulting in high blood pressure) with heart failure (condition in which the heart cannot pump enough blood to all parts of the body) and rheumatoid arthritis (a disease affecting the joints resulting in painful deformity and immobility).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 7/18/2025, the MDS indicated Resident 1 had severely impaired cognitive skills for daily decision making (problems with ability to think and process information).During an interview on 9/16/2025 at 11:10 AM and 3:40 PM, Licensed Vocational Nurse (LVN) 1 stated on the morning of 9/10/2025 LVN 1 observed a discoloration on Resident 1's right arm. LVN 1 stated Resident 1 stated the discoloration was caused by Certified Nursing Assistant (CNA) 1 during a transfer. LVN 1 stated Resident 1 appeared upset and kept pointing at the discoloration on Resident 1's arm while stating CNA 1's name several times. LVN 1 stated Resident 1 did not have a discoloration on Resident 1's forearm when LVN 1 had assessed Resident 1 earlier the same morning of 9/10/2025. LVN 1 stated discolorations or bruises could be an indication of physical abuse.During an interview on 9/16/2025 at 11:49 AM, LVN 2 stated that on the morning of 9/10/2025, Resident 1 told LVN 2 CNA 1 grabbed Resident 1's arm causing pain when CNA 1 transferred Resident 1 from the bed to the shower chair (a moveable chair). LVN 2 stated LVN 2 observed redness on Resident 1's right forearm. LVN 2 stated Resident 1 appeared upset and frustrated. During an interview on 9/16/2025 at 2:39 PM and 4:24 PM, the Director of Nursing (DON) stated LVN 1 reported the incident involving CNA 1 and Resident 1 to the DON on 9/10/2025. The DON stated that since Resident 1 had stated CNA 1 grabbed Resident 1's right arm causing pain it was possible that CNA 1 had abused Resident 1. The DON stated bruising was a sign of physical abuse. The DON stated it was the policy of the facility to report allegations of physical abuse to the SA within two hours. The DON stated the allegation of physical abuse involving Resident 1 and CNA 1 on 9/10/2025 was not reported to the SA until 9/12/2025. The DON stated it was important to report allegations of abuse within the required timeframe to ensure the resident's safety. During a review of the facility's policy and procedure titled, Abuse Prevention Program, dated 2001, revised December 2016, the P&P indicated, Our residents have the right to be free from abuse.This includes physical abuse. The P&P indicated the facility should identify and assess all possible incidents of abuse and investigate and report any allegations of abuse within the federal requirement timeframe.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled N95 Fit Testing, (N95 respirator, a device designed to protect the wearer from hazardous particles in the air such as fumes gases and viruses) by failing to ensure one of four sample staff [Certified Nurse Assistant 4 (CNA 4)] was fit tested for an N95 respirator mask upon hire. This failure had the potential to result in the spread of Coronavirus 2019 (COVID-2019, a severe respiratory illness caused by a virus and spread from person to person) and other airborne diseases to the residents, staff, and visitors. Findings: During an interview on 2/25/25 at 12:30 pm with CNA 4, CNA 4 stated, CNA 4 began working at the facility on 2/3/25 and CNA 4 has not been fit tested for the N95 mask. During a concurrent interview and record review on 2/25/25 at 12:45 pm with the Director of Staff Development (DSD), the facility's P&P titled, N95 Fit Testing, was reviewed. The P&P indicated All employees to the facility must be in accordance with the provisions of Occupational Safety and Health Administration (OSHA's) Respiratory Protection Standard (29CFR 1910.134) and on the criteria set by the Medical Director of Arbor Environment. Each employee will be fit tested annually and upon hire on the use of the proper N95 respirator. The DSD stated, the DSD should have fit tested CNA 4 before 2/3/25 per P&P titled, N95 Fit Testing. The DSD stated, I did not. During an interview with the Director on Nurse (DON) on 2/25/25 at 1:30 pm, the DON stated each employee will be fit tested annually and upon hire on the use of the proper N95 respirator. During a interview with the IPN on 2/25/25 at 1:50 pm, the IPN stated the importance of fit testing is to prevent transmission of airborne diseases employees to residents or employees to employees and it (fit testing) should had been done before employee was assigned work with the residents.

Based on interview and record review, the facility failed to ensure Resident 1 who had history of intestinal obstruction (blockage of the intestine where food and stools [feces] may not be able to move freely), constipation (occurs when the bowel movements become less frequent and stools become difficult to pass), and bladder (an organ inside the body that stores urine) neck obstruction (blockage) received care and services to prevent and manage constipation for one of three sampled residents (Resident 1) by failing to: 1. Ensure Registered Nurse 2 (RN 2) assessed Resident 1's abdominal bowel (intestine/gut) sounds (sounds made by the movement of the intestines as they push food through) when Resident 1 complained of abdominal pain (unrated) and when RN 2 observed Resident 1 with abdominal distention (swollen beyond its normal size) on 6/29/2023 as indicated in the facility's Bowel Disorders policy and procedure. 2. Ensure Licensed Vocational Nurse 2 (LVN 2) and Medical Doctor 1 (MD 1) assessed Resident 1's abdominal pain and abdominal distention from 6/29/2023 to 7/8/2023 as indicated in Resident 1's untitled Care Plan, dated 5/20/2023. As a result, on 7/8/2023, Resident 1 had abdominal pain (unrated), abdominal and bladder (an organ inside the body that stores urine until it can be emptied) distention (enlarged/inflamed), tachycardia (fast heartbeat), hypotension (low blood pressure), decreased appetite (reduced desire to eat), and required a transfer to General Acute Care Hospital 2 (GACH 2). Resident 1 required an admission to GACH 2 for evaluation for tachycardia and was diagnosed with severe fecal impaction (the result of constant constipation when stools/feces were stuck inside of the rectum [anus]) causing the bladder outlet/neck obstruction (a blockage at the base of the bladder), urinary tract infection (UTI, an infection in any part of the urinary system), and sepsis (the body ' s overwhelming and life-threatening response to an infection which can lead to tissue damage, organ failure, and death). Cross reference F697 Findings: During a review of Resident 1's GACH 1 record titled, Computerized Tomography (CT scan, a medical imaging/pictures technique used to obtain detailed internal images of the body) of the abdomen (belly), dated 5/13/2023, indicated Resident 1 had a very large stool burden (load) in the rectum (the final section of the large intestine), consistent with constipation, hydronephrosis (swelling of the kidney due to build up of urine), and a severely distended bladder (a condition in which the bladder becomes enlarged or inflamed). During a review of Resident 1's Admission Record, indicated the facility admitted Resident 1 on 5/20/2023 with diagnoses that included intestinal obstruction, constipation, and bladder neck obstruction. During a review of Resident 1's untitled Care Plan, dated 5/20/2023, the care plan indicated Resident 1 was at risk for constipation, fecal impaction, and bowel obstruction. The nursing interventions included to document and report signs and symptoms of complications related to constipation such as abdominal distention, changes on bowel sounds, and the necessity of disimpaction (manual removal of feces from the rectum using a lubricated [a substance capable of reducing friction and allow smooth movement] gloved finger) as needed. During a review of Resident 1's History and Physical (H&P), dated 5/23/2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated Resident 1 had a recent hospitalization (unspecified date) due to obstipation (severe or complete constipation). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 6/2/2023, the MDS indicated Resident 1 was severely impaired with cognitive (ability to think and process information) skills for daily decision making. The MDS indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one staff for toilet use and personal hygiene. The MDS indicated Resident 1 had bladder and bowel incontinence (inability to hold urine and stool). During a review of Resident 1's Progress Notes, dated 6/29/2023, timed 7:46 am, the Progress Notes indicated Resident 1 had a distended abdomen, and the abdomen was painful to touch (pain unrated). The Progress Notes indicated nursing staff (unidentified) notified MD 1, and MD 1 ordered to perform a straight catheter (thin tube used to insert into the bladder to pass urine from the body) every six hours as needed. During a review of Resident 1's Progress Notes, dated 6/29/2023, timed 10 am, the Progress Notes indicated Resident 1 had 800 milliliters (ml, unit of measurement) of dark urine. During a review of Resident 1's Subjective, Background, Assessment and Recommendation (SBAR, a communication tool between members of the health care team ) Communication Form, dated 6/29/2023, timed 11:29 am, the SBAR indicated Resident 1 had little to no pee, had decreased urine output, urinary retention (a condition when the bladder does not empty all the way during urination [act of passing urine]), distended abdomen, and the abdomen was tender and painful to touch (pain unrated). During a review of Resident 1's Physician's Progress Record dated 7/1/2023, the Progress Notes indicated Resident 1's abdomen was soft, and Resident 1 was stable for discharge. During a review of Resident 1's Physician's Progress Record dated and 7/5/2023, the Progress Notes indicated Resident 1 had urinary retention. The record indicated Resident 1 was ready to discharge and planning for placement. During a review of Resident 1's SBAR Communication Form, dated 7/7/2023, timed 2:21 pm, the SBAR indicated Resident 1 had tachycardia. Resident 1 had a heartbeat of 105 beats per minute (normal heartbeat 60 to 100 per minute), and decreased appetite. The SBAR indicated MD 1 ordered to give Resident 1 ice cream and fruits. During a review of Resident 1's Nursing Progress Notes, dated 7/7/2023 timed 3:11 pm, the notes indicated Resident 1 had tachycardia (heart rate undocumented) and decreased in appetite. The notes indicated MD 1 ordered a bladder scan. During a review of Resident 1's bladder scan/ultrasound result (imaging test that used sound waves to make pictures of organs), dated 7/8/2023, timed 9:30 am, the bladder scan indicated debris (scattered pieces of waste or remains) were identified. The bladder scan/ultrasound result indicated Resident 1 was uncooperative. During a review of Resident 1's Nursing Progress Notes, dated 7/8/2023, timed 6:41 pm, the notes indicated Resident 1 complained of abdominal pain (pain unrated), and Resident 1 had abdominal distention. The notes indicated Resident 1 became hypotensive (low blood pressure) and had tachycardia (heart rate unrated). The notes indicated Licensed Vocational Nurse 2 (LVN 2) notified MD 1 regarding Resident 1's condition (abdominal pain, abdominal distention, hypotensive, tachycardia) and MD 1 ordered to transfer Resident 1 to GACH 2. During a review of Resident 1's SBAR Communication Form, dated 7/8/2023 timed 6:45 pm, indicated Resident 1 complained of midabdominal (in the middle of the abdomen) pain (pain unrated). The SBAR Communication Form indicated Resident 1 stating hurts - hurts and pointing at Resident 1 ' s mid-abdomen. The SBAR Communication Form indicated Resident 1 ' s abdomen was hard to the touch, and Resident 1 had passed soft brown stool (amount was not indicated). During a review of Resident 1's Nursing Progress Notes, dated 7/8/2023, timed 7:30 pm, the notes indicated Resident 1 was transferred to GACH 2 at 7:20 pm. During a review of Resident 1's GACH 2 records titled, Emergency Department General, dated 7/8/2023, timed 7:43 pm, indicated Resident 1 was brought in by ambulance (BIBA) for evaluation of hypotension, tachycardia, bladder distention, and low appetite. The Emergency Department record indicated Resident 1 was admitted for UTI and sepsis. During a review of Resident 1's GACH 2 records titled CT scan of the abdomen and pelvis (lower part of the trunk, between the abdomen and the thigh) Report, dated 7/9/2023, the CT scan report indicated Resident 1 had a severe fecal impaction of the rectosigmoid colon (the end portion of the large intestine before reaching the rectum). The CT scan report indicated the fecal impaction created a mass-effect (pushing/blocking) on the urinary bladder. During a review of Resident 1's GACH 2 Consultation Records, the consultation records indicated the CT scan of the abdomen and pelvis, dated 7/9/2023 showed Resident 1 had severe fecal impaction of the rectosigmoid colon with mass effect on the urinary bladder. The Consultation Records indicated to clear fecal impaction with enemas (fluid inserted into the rectum and lower colon, to stimulate the elimination of feces from the rectum), suppositories (a small solid medication inserted into the rectum to relieve constipation), and oral laxatives (medication to help empty the bowels). During an interview on 7/12/2023, at 12:10 pm, with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated Resident 1 had been refusing her meals (unable to recall dates). During an interview on 7/12/2023, at 12:43 pm, with CNA 2, CNA 2 stated Resident 1 was incontinent of urine and BM. CNA 2 stated Resident 1 could speak short words like pain, hurt, eat, and was able to point things. During a telephone interview on 7/12/2023, at 1:58 pm, with CNA 4, CNA 4 stated she took care of Resident 1 on 7/8/2023 and Resident 1 pushed the breakfast tray away that morning (7/8/2023). CNA 4 stated Resident 1 drunk some juice and refused lunch. CNA 4 stated Resident 1 was crying. CNA 4 stated Resident 1 was very agitated (feeling troubled), and fidgety (restless). CNA 4 stated Resident 1 ' s cries and agitation were getting worst throughout the morning shift. CNA 4 stated she reported Resident 1's condition (crying, fidgeting and agitation) to LVN 2. CNA 4 stated she recalled Resident 1 had a small BM (unidentified date and time) and Resident 1 was saying hurt, hurt and doctor while Resident 1 was pointing to Resident 1's stomach. During an attempted telephone interview with MD 1 on 7/13/2023 at 1:50 pm, MD 1 was not available. During a concurrent interview with RN 2 on 7/13/2023, at 2 pm, and a review of Resident 1's Progress Notes, dated 6/29/2023, RN 2 stated on 6/29/2023 Resident 1 complained of abdominal pain (pain unrated). RN 2 stated Resident 1 had a painful abdominal distention that was hard to the touch. RN 2 stated her assessment was focused on Resident 1's bladder. RN 2 stated she did not assess the causes for constipation, the bowel sounds nor abdominal pain for Resident 1. During a second attempted telephone interview with MD 1, on 7/13/2023, 2:45 pm, MD 1 was not available. During a telephone interview on 7/13/2023, at 2:50 pm, with LVN 2, LVN 2 stated he took care of Resident 1 on the morning shift of 7/7/2023 and 7/8/2023. LVN 2 stated on 7/7/2023, LVN 2 observed Resident 1 had abdominal pain and abdominal distention. LVN 2 stated he assessed Resident 1's abdominal distention but only focused his assessment on Resident 1 ' s urinary tract issues and not on the constipation issues because a CNA (unidentified) reported to him (LVN 2) that Resident 1 had a BM that morning (amount was not indicated). During a concurrent interview on 7/13/2023 at 3:50 pm, and a review of Resident 1's Progress Notes, dated from 6/29/2023 to 7/8/2023 with the Director of Nursing (DON), the DON stated abdominal concern assessment needed to include bowel sounds assessment. The DON stated Resident 1's Progress Notes dated from 6/29/2023 to 7/8/2023 did not have Resident 1's bowel sound assessments. During a telephone interview with MD 1 on 8/1/2023, at 3:15 pm, MD 1 stated Resident 1 was difficult to manage due to Resident 1's intellectual disabilities (ID, a term used when a person has certain limitations in cognitive functioning and skills). MD 1 stated she (MD 1) was not informed of Resident 1 ' s abdominal distention or constipation. MD 1 stated she could not recall if she was informed of Resident 1's abdominal pain. MD 1 stated she was informed of Resident 1 bladder distention. MD 1 stated whatever was written on her progress record was her assessment. MD 1 stated she did not recall assessing Resident 1's bowel sounds. MD 1 stated the steps in abdominal assessment in order included abdominal inspection, palpation (a method of feeling using fingers or hands during physical examination) and auscultation (the act of listening using a stethoscope (a device to listen to the sounds generated internally by the heart, lungs, and abdomen). During a review of facility undated policy and procedure (P&P) titled, Bowel (Lower GIT) Disorders -Clinical Protocol, indicated the abdominal assessment including for staff to listen for bowel sounds in area of suspected ileus (when the intestines stop functioning properly and food, fluids and gas are not able to pass through normally) or obstruction. The P&P indicated the staff and physician will monitor the overall degree or distress, frequency, severity, and the duration of abdominal pain. During a review of facility undated P&P titled, Change in a Resident's Condition or Status, indicated prior to notifying the physician or healthcare provider, the nurses would make detailed observations and gather relevant and pertinent information for the providers, including information prompted by the SBAR.