Every finding on record at Clear View Sanitarium

Based on interview and record review, the facility failed to report an injury of unknown source (injuries when the source of the injury were not observed by any person and the source of the injury could not be explained by the resident and the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury [e.g., the injury is located in an area not generally vulnerable to trauma]) to the California Department of Public Health (CDPH) for one of three sampled residents (Resident 1), who sustained a right femur (thigh bone) fracture (broken bone) on 7/25/2026.This failure delayed the investigation by the CDPH.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included unspecified (unknown) fracture of right femur, essential (primary) hypertension ([HTN], high blood pressure), hemiplegia (total paralysis of the arm, leg and trunk on the same side of body), hemiparesis (weakness on one entire side of the body) following cerebral infarction (stroke) affecting right dominant side (the side of the body that is preferred and stronger), age-related osteoporosis (a bone disease characterized by weak and fragile bones, increasing the risk of fractures). During a review of Resident 1's History and Physical (H&P), dated 7/30/2026, 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 4/30/2026, the MDS indicated Resident 1's cognitive skills for daily decision making was severely impaired. Resident 1's MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with eating, oral and toileting hygiene, showering/ bathing self, dressing, personal hygiene, bed mobility (rolling left and right side, changing positions from sitting to lying, lying to sitting on side of bed) and transfers. During a review of Resident 1's Situation, Background, Assessment, and Recommendation ([SBAR] a structured way to communicate to the care team about a resident's change in condition), dated 7/25/2026 at 8:44 a.m., the SBAR indicated a Certified Nursing Assistant (CNA) reported that Resident 1 refused to get out of bed due to pain (severity not specified) on the right knee and the skin was slightly hot to touch. At 9:58 a.m., the SBAR indicated Resident 1's right knee pain level was 7/10 (a numerical pain scale with 0 = no pain, 1-3= mild pain, 4-6 moderate pain, 7-8 = severe pain, 9-10 = worst pain possible) and Tylenol 650 (pain reliever) milligram (mg- a unit of measurement) was given. At 12:37 p.m., the Progress Notes indicated Resident 1's primary care provider (PCP) was notified and ordered a STAT (a medical term to mean immediately or at once) radiology (x-ray, process of taking pictures to diagnose and treat diseases) of the right knee. The progress notes indicated Resident 1's PCP ordered to transfer the resident to a general acute care hospital (GACH) for evaluation and treatment. During a review of Resident 1's X-Ray Result, dated 7/25/2026 at 11:42 a.m., the right knee x-ray indicated Resident 1 had an acute (new or sudden) oblique fracture (when the fracture breaks diagonally across its shaft, with the fracture line angled rather than straight or spiraling which is almost always caused by trauma that applies a force to the bone at an angle) of the distal (away from the body) femur with no evidence of osteomyelitis (infection of the bone). There was moderate arthritic (conditions that cause pain, swelling, and stiffness in the joints) changes to the knee with acute distal femur fracture. During an interview on 8/12/2026 at 10:55 a.m. with Resident 1 at the bedside, Resident 1 could not remember what happened to his right leg. During an interview on 8/13/2026 at 10:38 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated on 7/25/2026, they (facility) could not obtain any information from Resident 1 because Resident 1 did not know how and what happened to his right leg. LVN 1 stated staff did not know what caused Resident 1's fracture. During a concurrent interview and record review on 8/18/2026 at 2:09 p.m., with LVN 1, Resident 1's x-ray report dated 7/25/2026, and the physician progress notes dated 8/12/2026, were reviewed. LVN 1 stated Resident 1's fracture had the potential to affect the health, safety and welfare of Resident 1. LVN 1 stated Resident 1's doctor did not indicate that Resident 1 had a spontaneous fracture (a fracture that occurred without trauma). LVN 1 stated unknown cause of fractures were reportable to the CDPH within 2 hours. LVN 1 stated she did not report Resident 1's fracture to CDPH because the Administrator (Admin) and the Director of Nursing (DON) did not instruct her to report it. During a concurrent interview and record review on 8/18/2026 at 3:23 p.m., with the DON, Resident 1's physician progress notes dated 7/30/2026 and 8/12/2026, the x-ray report dated 7/25/2026, and the facility policy and procedures (P&P) titled, Unusual Occurrence, undated, was reviewed. The DON stated the P&P indicated the facility should report unusual occurrences which threatened the welfare, safety, or health of the patients. The DON stated fracture could affect Resident 1's ADLs and placed him at risk for pain and depression. The DON stated unusual occurrence were events that do not usually occur, like a fracture of unknown etiology (cause) and were reportable to CDPH within 2 hours. The DON stated Resident 1's physician did not indicate in the progress notes that the resident sustained a spontaneous fracture. The DON stated they (facility) did not report Resident 1's right femur fracture to CDPH because the Admin was going to report. The DON stated Resident 1's fracture should have been reported to CDPH because the facility could not determine how it happened. The DON stated the facility had no Injury of unknown origin policy. The DON stated the facility relied on the Administrator to know what to do. During interview on 8/18/2026 at 4:44 p.m., with Admin 1, the Admin 1 stated Resident 1's right femur fracture on 7/25/2026 was not reported to CDPH because it was a spontaneous fracture. The Admin 1 stated Resident 1's right femur fracture was not an injury because it was a physiological (normal physical and chemical process of a living body) issue. The Admin 1 stated an injury of unknown origin should be reported to CDPH as an unusual occurrence. During a review of facility's P&P titled, Unusual Occurrence Policy, undated, the P&P indicated, it is the policy of the facility to report unusual occurrences which threaten the welfare, safety, or health of the patients. The policy indicated that the facility would notify the Health Department by email, phone call and fax.

Based on interview and record review, the facility failed to develop written policies and procedures to report injury of unknown source (are injuries when the following criteria are met: when the source of the injury was not observed by any person and the source of the injury could not be explained by the resident and the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury [e.g., the injury is located in an area not generally vulnerable to trauma]) to the California Department of Public Health (CDPH). This failure had the potential to affect 73 residents by delaying the investigation of CDPH.Findings: During a review of facility's undated policy and procedure (P&P) titled, Policy and Procedure for Reporting Suspected Crimes Under the Federal Elder Justice Act, the P&P did not indicate the procedures and guidance for an injury of unknown source. During a review of facility's undated P&P titled, Unusual Occurrence Policy, the P&P did not indicate the procedure for an injury of unknown source. During a concurrent interview and record review on 8/18/2026 at 3:23 p.m., with the Director of Nursing (DON), the facility's P&P titled, Policy and Procedure for Reporting Suspected Crimes Under the Federal Elder Justice Act and the P&P titled, Unusual Occurrence, were reviewed. The DON stated that the facility does not have an Injury of Unknown Source policy. The DON stated the facility's policies did not indicate procedures on how to report injuries of unknown source. The DON stated the policies should have included how to report injuries of unknown source because it's mandated by law. During an interview on 8/18/2026 at 4:41 p.m., with the Administrator (Admin) 1, the Admin 1 stated the facility do not have an injury of unknown source policy. Admin 1 stated, the facility's process would be to report to the Admins and Admins would then discuss with the legal staff to determine what would be reportable to CDPH.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation were practiced in the kitchen when:1 dented can of pineapple chunks was mixed with regular non-dented cans in the dry storage area.6 cups of 8 ounces ([oz.] small unit of weight measurement) of thickened water and 1 cup of 8 oz of orange juice was on the tray with no use by date label.These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) for 70 out of 70 residents who received food from the kitchen. Findings:1. During an observation on 2/24/2026 at 9:24 a.m. in the kitchen's dry storage area, there was one dented can of pineapple chunks mixed with regular non-dented cans. During an interview on 2/26/2026 at 9:15 a.m. with the Dietary Service Supervisor (DSS), the DSS acknowledged there was one dented can of pineapple chunks mixed with regular non-dented cans found in the dry storage area on 2/24/2026. The DSS stated it was unacceptable to put a dented can on the same shelf with the regular non-dented cans. The DSS stated the dented cans should be placed in a designated area. The DSS stated the food inside the dented cans was no longer safe to consume. During a review of the facility's policy and procedure (P&P), titled Food Production and Storage, undated, the P&P indicated A separate defined storage area is provided for dented/rusted cans. 2. During an observation on 2/24/2026 at 9:27 a.m. in the kitchen, there were 6 cups of 8 oz of thickened water and 1 cup of 8 oz of orange juice with a sticker label on the tray indicating it was prepared on 2/23/2026 but there was no label of the use by date. During an interview on 2/26/2026 at 9:00 a.m., with the DSS, the DSS stated prepared food items in the kitchen should be labeled with the date it was prepared and the use by date. The DSS acknowledged there were 6 cups of 8 oz of thickened water and 1 cup of 8 oz of orange juice with no label of used by date identified in the kitchen on 2/24/2026. The DSS stated it was important to put the use by date so the dietary staff would know when the food items expired. During an interview on 2/26/2026 at 10:30 a.m. with the Director of Nursing (DON), the DON stated all food items should be labeled with received date and expiration date or use by date. The DON stated using food items past their use by date could cause abdominal discomfort and food poisoning to the residents. During a review of the facility's policy and procedure (P&P), titled Food Production and Storage, undated, the P&P indicated, All food left over are to be placed in appropriate containers which are covered and labeled. Labels should be attached to the container itself, rather than the lid, and must include the name of the item and the date prepared. The P&P did not disclose the need for and importance of putting a use by date label.

Based on interview and record review, the facility failed to ensure a Minimum Data Set ([MDS] - a resident assessment tool) assessment was completed accurately for one of 18 sampled residents (Resident 3) by failing to ensure Resident 3's use of antibiotic (a drug used to treat infections) was encoded in the recent MDS assessment.This deficient practice resulted in incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the plan of care and delivery of care and services for Resident 3.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and diabetes mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 3's History and Physical (H&P), dated 10/29/2025, the H&P indicated, Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's MDS assessment, dated 2/24/2026, the MDS assessment indicated Resident 3's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS assessment indicated Resident 3 required substantial assistance (helper does more than half the effort) from staff with toileting hygiene, upper and lower body dressing, and personal hygiene.During a review of Resident 3's Physician's Order, dated 2/15/2026, the Physician's Order indicated Resident 3 was prescribed Macrobid (an antibiotic drug) 100 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) by mouth twice (9:00 a.m. and 9:00 p.m.) for 5 days for treatment of urinary tract infection ([UTI] - an infection in the bladder/urinary tract).During a review of Resident 3's medication administration records ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) from 2/16/2026 to 2/20/2026, the MAR indicated, Resident 3 was given Macrobid 100 mg by mouth twice a day for 5 days.During a concurrent interview and record review on 2/27/2026 at 10:39 a.m., with the Minimum Data Set Nurse (MDSN), Resident 3's MDS assessment, dated 2/24/2026, was reviewed. The MDSN stated MDS Section N0415 - Medications (High-Risk Drug Classes: Use and Indication) look back period (the specific time frame within which certain resident conditions and events are assessed) was 7 days before the completion date. The MDSN stated Resident 3's MDS assessment was completed inaccurately. The MDSN stated there should be a checked mark on MDS Section N0415 (F) Antibiotic since Resident 3 received the antibiotic on 2/18/2026, 2/19/2026, and 2/20/2026 which covered the 7 days look back assessment period. The MDSN stated it was an oversight on her part by not encoding the antibiotic in the MDS assessment. The MDSN stated inaccuracy of MDS assessment would affect facility's quality measures (standardized, data-driven metrics derived from CMS-mandated resident assessments to monitor care quality in nursing homes).During a review of the facility's policy and procedure (P&P), titled Record Assessment Instrument/Record Content, undated, the P&P indicated, HealthCare professionals completing portions of the MDS are to certify the accuracy of the section they have completed. The P&P indicated the accuracy of the transcription of the data and computer data entry are important and special attention must be given to correct these errors.

Based on interview and record review, the facility failed to review, update, and revise the care plan to address the use of bolster pads (a soft barrier along the edges of the bed, reducing the risk of rolling out of bed) for one of one sampled resident (Resident 1). This deficient practice has the potential to affect the delivery of necessary care, treatment, and services for Resident 1.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 1's History and Physical (H&P), dated 12/30/2025, 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 standardized assessment and care planning tool), dated 1/2/2026, the MDS indicated the resident was assessed to have severe cognitive (difficulty with thinking) impairment in daily decision making. The MDS indicated Resident 1 was dependent on staff for activities of daily living (ADLs) such as oral hygiene, toileting, showering, dressing and positioning. During a concurrent interview and record review on 2/26/2026 at 2:46 p.m. with Registered Nurse (RN) 1, Resident 1's Fall Care Plans were reviewed. The fall care plan was not revised to show interventions regarding use of bolster pads. RN 1 stated that Resident 1's care plans did not include one for the use of bolster pads. RN 1 stated the care plan should have been revised to reflect the use of bolster pads when the intervention was implemented. During an interview on 2/27/2026 at 11:55 a.m., with the Director of Nursing (DON), the DON stated care plans are revised quarterly and with any change of condition or new physician orders. The DON acknowledged the resident's care plan should have been revised to reflect the use of a bolster pad. During a review of the policy and procedure (P&P) titled, Record Assessment Instrument/Record Content, undated, the P&P indicated, Care plans shall be updated when necessary and as the resident's condition or needs change.

Based on interview and record review, the facility failed to ensure care plan interventions were implemented to ensure a dialysis (a treatment to cleanse the blood of wastes and extra fluid artificially through a machine when the kidney(s) have failed) emergency kit (E-KIT - supplies to help meet the needs of a dialysis resident in the event of an emergency) was always available at bedside for one of one sampled resident (Resident 8).This deficient practice has the potential to result in staff's inability to manage and control the bleeding from Resident 8's dialysis access site in the event of an emergency.Findings:During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 8's diagnoses included End Stage Renal Disease ([ESRD] - irreversible kidney failure), dementia (a progressive state of decline in mental abilities), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality).During a review of Resident 8's History and Physical (H&P), dated 12/22/2025, the H&P indicated Resident 8 did not have the capacity to understand and make decisions.During a review of Resident 8's Minimum Data Set Assessment ([MDS] - a resident assessment tool), dated 1/9/2026, the MDS indicated Resident 8 was independent (decisions consistent and reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated Resident 8 was independent (Resident completes the activity with no assistance from a helper) with oral hygiene, toileting hygiene, and upper and lower body dressing.During a review of Resident 8's Physician's Order, dated 11/3/2022, the Physician's Order indicated Resident 8 was on dialysis treatment 3x/week every Monday, Wednesday, and Friday. The Physician's Order indicated to observe Resident 8's dialysis access site on left forearm for drainage and bleeding.During a concurrent observation and interview on 2/24/2026 at 1:38 p.m. with Registered Nurse 1 (RN 1) in Resident 8's room, RN 1 stated Resident 8's dialysis E-KIT was not available at bedside. RN 1 stated Resident 8's dialysis E-KIT was kept at one of the drawers at the nurse station.During a concurrent interview and record review on 2/24/2026 at 3:29 p.m. with RN 1, Resident 8's care plan, titled ESRD/Dependence on Renal Dialysis, dated 10/14/2025, was reviewed. RN 1 stated the care plan intervention included to make sure the dialysis kit was always available at bedside. RN 1 stated the facility did not follow and implement Resident 8's care plan intervention to keep dialysis E-KIT at bedside. RN 1 stated the dialysis E-KIT should be kept at bedside for the facility staff to easily access in case of an emergency and if the resident has an episode of bleeding when removing the dressing. RN 1 stated it was important to follow and implement care plan interventions to provide proper care and for resident's safety.During an interview on 2/26/2026 at 10:18 a.m., with the Director of Nursing (DON), the DON stated it was very important to follow care plan interventions because the care plan is a set of standardized care the facility staff provides to the residents.During a review of the facility's policy and procedure (P&P), titled Assessments and Care Plan, undated, the P&P did not disclose the importance of implementing care plan interventions.During a review of the facility's P&P titled, Record Assessment Instrument/Record Content, undated, the P&P indicated, Care plans shall be updated when necessary and as the resident's condition or needs change.

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review ([PASARR] - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Level 1 screening (a mandatory preliminary screening required for all individuals seeking admission to a Medicaid-certified nursing facility) was completed and re-submitted for one of four sampled residents (Resident 3).This failure had the potential for Resident 3 not being appropriately identified for further evaluation of serious mental illness leading to resident not receiving necessary specialized services, treatment planning interventions, or appropriate placement.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 3's History and Physical (H&P), dated 10/29/2025, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set Assessment ([MDS] - a resident assessment tool), dated 2/24/2026, the MDS indicated Resident 3's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 3 required substantial assistance (helper does more than half the effort) from staff with toileting hygiene, upper and lower body dressing, and personal hygiene.During a review of Resident 3's Physician's Order, dated 12/23/2025, the Physician's Order indicated Resident 3 was prescribed Seroquel (anti-psychotic drug used for treatment of psychosis) 75 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) by mouth daily at 9:00 a.m. and Seroquel 50mg by mouth at bedtime at 9:00 p.m. for psychosis manifested by aggressive behavior as evidenced by pushing and swinging her hands to staff during care administration.During a concurrent interview and record review on 2/25/2026 at 11:14 a.m., with the Director of Nursing (DON), Resident 3's PASARR Level 1 screening, completed by another facility on 8/14/2023, was reviewed. The DON stated the PASARR Level 1 screening indicated Resident 3 had no serious mental illness diagnoses and was not receiving psychotropic medications The DON stated the PASARR Level 1 screening indicated Resident 3's case was closed, and a PASARR level II (an in-depth, person-centered assessment triggered by a positive Level 1 screen to confirm serious mental illness or intellectual disability) mental health evaluation was not required. The DON stated the facility should have completed and resubmitted a new PASARR Level I screening based on Resident 3's diagnoses of psychosis and depression which were mental illnesses, and Resident 3 was currently taking psychotropic medications. The DON stated a positive PASARR Level 1 screening would trigger a Level II mental health evaluation. The DON stated it was important to complete the PASARR screening accurately to provide specialized treatment and care for residents with mental illness diagnoses, create a treatment plan suited to control resident's behavior, and make sure the resident was appropriately placed at the nursing facility.During a review of the facility's policy and procedure (P&P), titled Preadmission Screening and Resident Review (PASARR), undated, the P&P indicated, The facility participates in the Preadmission Screening and Resident Review screening process (Level 1) for all new and readmissions per requirement to determine if the individual meets the criterion for mental disorders (SMI/SMD), intellectual disability (ID) related condition.

Based on interview and record review, the facility failed to ensure the quarterly (every 3 months) Minimum Data Set Assessment ([MDS] - a resident assessment tool) for one of one sampled resident (Resident 4) was completed within the required timeframe.This deficient practice had the potential to result in a billing error and inaccurate data on Resident 4's care needs.Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own), diabetes mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension ([HTN] - high blood pressure). During a review of Resident 4's History and Physical (H&P), dated 7/19/2024, the H&P indicated Resident 4 did not have the capacity to understand and make decisions. During a review of Resident 4's Minimum Data Set Assessment ([MDS] - a resident assessment tool), dated 7/18/2025, the MDS indicated Resident 4's cognitive (ability to think and reason) skills for daily decision making were moderately impaired (decisions poor, cues and supervision required). The MDS indicated Resident 4 required supervision (helper provides verbal cues as resident completes activity) from staff with upper and lower body dressing and personal hygiene. During a review of the Center of Medicare and Medicaid (CMS) MDS 3.0 NH Final Validation Report, the CMS MDS 3.0 NH Final Validation Report, with an Assessment Reference Date ([ARD] - the specific date used as the endpoint of the observation period when assessing resident's condition) of 7/18/2025, indicated Resident 4's MDS assessment was completed late. The CMS MDS 3.0 NH Final Validation Report indicated a comprehensive or quarterly assessment is due every quarter unless the resident is no longer in the facility. During a concurrent interview and record review on 2/25/2026 at 10:36 a.m., with the Minimum Data Set Nurse (MDSN), Resident 4's MDS assessment, dated 4/16/2025 and 7/18/2025, were reviewed. The MDSN stated Resident 4's quarterly MDS assessment, dated 7/18/2025, was completed for more than 92 days. The MDSN stated MDS quarterly assessment should be completed less than or within 92 days. The MDSN stated the facility did not follow the timeframe for MDS completion as indicated in the Reference Assessment Instrument ([RAI] - a guide that helps nursing home staff use to assess residents and develop care plans). The MDSN stated late completion of MDS assessment would result in facility billing errors and would affect the care provided to the residents. During an interview on 2/25/2026 at 11:37 a.m., with the Director of Nursing (DON), the DON stated late completion of MDS assessment would result in late payment and inaccurate data of resident's condition. During a review of the facility's policy and procedure (P&P), titled Record Assessment Instrument/Record Content, undated, the P&P indicated, Schedule for completion for quarterly assessment should be no less than every 90 days.

Based on interview and record review, the facility failed to ensure written Notice of Proposed Transfer/Discharge contained the required content elements for one of three sampled residents (Resident 75).The deficient practice had the potential to compromise the resident's due process rights related to discharge.Findings:During a review of Resident 75's admission Record, the admission Record indicated Resident 75 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities) with psychotic disturbance, and chronic viral hepatitis C (a viral infection of the liver that leads to illness and can be spread by contact with the contaminated blood). During a review of Resident 75's History and Physical (H&P), dated 10/21/2025, the H&P indicated Resident 75 did not have the capacity to understand and make decisions. During a review of Resident 75's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 1/6/2026, the MDS indicated the resident was assessed to have moderate cognitive (difficulty with thinking) impairment in daily decision making. The MDS indicated Resident 75 required set-up or clean-up assistance from staff for activities of daily living (ADLs) such as eating, oral hygiene, toileting hygiene, and dressing and was independent for positioning, transferring, and walking. During a concurrent interview and record review on 2/27/2026 at 9:30 a.m. with Registered Nurse (RN) 1, Resident 75's Notice of Proposed Transfer/Discharge form, dated 2/12/2026, was reviewed. RN 1 stated the Notice of Proposed Transfer/Discharge did not include the notification date, effective date, discharged location, date the notice was sent to the Long-Term Care Ombudsman, reason for the transfer/discharge, or the signature dates of the facility representative and resident/representative. RN 1 stated the notice should have been fully completed and dated prior to discharge. RN 1 stated she only signed the notice and did not ensure it was complete. RN 1 stated she did not know who was responsible for faxing the notice to the Ombudsman and believed the social worker completed the form. During an interview on 2/27/2026 at 10:00 a.m., with Social Service Assistant (SSA) 1, SSA 1 stated she was not responsible for completing the Notice of Proposed Transfer/Discharge and did not know who was responsible for faxing the notice to the Ombudsman. During a concurrent interview and record review on 2/27/2026 at 10:28 a.m. with RN 1, RN 1 presented an additional Notice of Proposed Transfer/Discharge for Resident 75, dated 2/12/2026, which was reviewed. The new notice that was presented included the discharged location, the discharge date , and reflected an electronic signature by RN 1 on 2/12/2026, the notice did not include the date the notice was sent to the Long-Term Care Ombudsman, reason for the transfer/discharge, or the signature of the resident/representative. RN 1 stated the form was automatically generated from the facility's electronic software system. During an interview on 2/27/2026 at 11:45 a.m. with the Director of Nursing (DON), the DON acknowledged the Notice of Proposed Transfer/Discharge for Resident 75 was incomplete. The DON stated the notice should have been fully completed prior to providing it to the resident and prior to sending it to the Long-Term Care Ombudsman. The DON stated staff discharging the resident were responsible for ensuring the notice was complete. The DON stated that once the notice was completed and electronically signed, it was automatically sent to the Ombudsman through the facility's electronic system. During a review of the policy and procedure (P&P) titled, Transfer/Discharge Policy, undated, the P&P failed to identify the federally required content elements of the written Notice of Proposed Transfer/Discharge and did not include procedures requiring notification to the Long-Term Care Ombudsman at time of a proposed transfer or discharge.

Based on observation and interview, the facility failed to ensure one of the trash dumpsters was closed and not overfilled.This deficient practice has the potential for harboring and feeding of pests.Findings:During an observation on 2/24/2026 at 9:30 a.m. outside of the facility, one of the trash dumpsters lids was observed filled with thrash and the lid was opened.During an interview on 2/26/2026 at 9:25 a.m. with the Dietary Service Supervisor (DSS), the DSS stated the lid of the trash dumpsters should be closed all the time and should not be overfilled. The DSS acknowledged that one of the trash dumpsters was opened and overfilled on 2/24/2026. The DSS stated the risk of having an opened trash dumpsters are that they can attract rodents and insects and provide a place for them to harbor.During an interview on 2/26/2026 at 10:23 a.m. with the Director of Nursing (DON), the DON stated the facility had deficiency five years ago for an opened trash dumpster. The DON stated trash bins that are open attract unwanted pests to the facility.During a review of the 2022 U.S. Food and Drug Administration Food Code, code number 5-501.116 Cleaning Receptacles indicated, Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents.

Based on interview and record review, the facility failed to: 1. Ensure Resident 30 was not prescribed Seroquel (an anti-psychotic medication used to treat mental illness) to control dementia (condition where there is a decline in mental abilities and memory) symptoms. This deficient practice put Resident 30 at risk of an adverse reaction (bad outcome) from taking an anti-psychotic without a diagnosis of a mental illness. Findings: During a review of Resident 30's Admission Record, the Admission Record indicated Resident 30 was admitted to the facility on [DATE] with diagnoses including dementia, diabetes (high blood sugar), and hypertension (high blood pressure). During a review of Resident 30's History and Physical (H&P), dated 4/28/2023, the H&P indicated Resident 30 does not have the capacity to understand and make decisions. During a review of Resident 30's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 10/24/2024, the MDS indicated Resident 30's cognition (ability to gain knowledge and understand) was moderately impaired. Resident 30 does not have indicators of psychosis (symptoms that make it difficult to determine reality). There are no behavioral symptoms. During a review of Resident 30's Physician Orders, dated 11/14/2024, the orders indicated Resident 30 is taking Seroquel 50 mg three times a day for dementia with behavioral disturbances manifested by striking out. During a concurrent interview and record review on 11/15/2024 at 2:13 p.m. with Registered Nurse (RN) 1, Resident 30's medical record was reviewed. The record indicated Resident 30 does not have a diagnosed mental illness. RN1 stated Resident 30 takes Seroquel to control dementia behaviors. RN1 stated giving an anti-psychotic to an elderly person with dementia can be harmful because it increases their risk of falls.

Based on observation and interview, the facility failed to: 1. Ensure the dumpsters were kept closed and all trash was contained. This deficient practice had the potential to attract rodents to the trash area. Findings: During a concurrent observation and interview on 11/12/2024 at 9:05 a.m. with the Dietary Supervisor (DS) at the dumpster area, both dumpsters were open, one was overflowing. Three uncovered gray bins containing loose trash were sitting in front of the dumpsters. The DS stated the dumpsters should be closed at all times. The DS further stated, by leaving the dumpster open could attract animals.

Based on observation and interview, the facility failed to: 1. Ensure the walk-in refrigerator did not contain a spoiled bag of cilantro. This deficient practice had the potential to result in food borne illness (sickness from eating food with harmful bacteria) for any resident consuming the cilantro. Findings: During a concurrent observation and interview on [DATE] at 9:13 a.m. with the Dietary Supervisor (DS) in the walk-in refrigerator, a bag of cilantro was found with brown leaves and brown liquid collecting in the bottom of the bag. The bag of cilantro was labeled with a received date of [DATE]. The DS stated, It's expired. You should remove it. You can't eat it because it's spoiled. The DS cannot state what may happen if a resident eats the expired food.

Based on observation and interview, the facility failed to: 1. Ensure that the medication storage room had a room thermometer that was monitored, and the readings recorded in a room temperature log to ensure a safe temperature range for medication storage. This deficient practice had the potential for harm to residents due to the potential loss of strength of the drugs, and the potential for the residents to receive ineffective drug dosages. Findings: During a concurrent observation and interview, on November 15, 2024, at 9:00 am of the medication room with the Director of Nursing (DON), there was no room thermometer to monitor the temperature. The DON stated there usually is a thermometer in the medication storage room. DON looked around the room and stated, The room was reorganized, and I do not know where it is now. When the surveyor asked if there is a logbook to record room temperatures, the DON stated, We do not have a logbook for room temperatures, only the refrigerator has a log. The DON stated they would request maintenance to come check the room temperature if it felt too warm or cold. During an observation, on November 15, 2024, at 9:22 am, Administrator (ADM) 1, opened a new package containing a room thermometer and hung it on a bulletin board near the medication room door. During a review of the facility's policy and procedures titled Storing Drugs, indicated Keep drugs requiring storage at 'room temperature' at no less than 15 degrees Celsius (59 degrees Fahrenheit) or more than 30 degrees Celsius (86 degrees Fahrenheit).

Based on interview and record review, the facility failed to: 1. Ensure a Pre-Admission Screening and Resident Review (PASRR- a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) assessment was resubmitted for one of 6 sampled residents (Resident 57). This deficient practice had the potential to place the resident at risk of not receiving necessary care and mental health services. Findings: During a review of Resident 57's face sheet, the face sheet indicated Resident 57 was admitted to the facility on [DATE]. The face sheet also indicated Resident 57 had diagnoses which included bipolar disorder (a serious mental illness that causes extreme shifts in mood, energy, activity levels, and concentration), depression (a serious mental health condition that involves a persistent low mood or loss of interest in activities), post-traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) and hypertension (a condition in which the pressure of your blood in your blood vessels is consistently too high). During a review of Resident 57's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/19/2024, the MDS indicated Resident 57's cognitive skills were severely impaired. The MDS also indicated Resident 57 required supervision with toileting hygiene, showering and upper/lower body dressing. During a review of Resident 57's PASRR Level 1 screening, the PASRR indicated Resident 57 did not have a mental health disorder. During a review of Resident 57's diagnosis list, the diagnosis list indicated Resident 57 was diagnosed with bipolar disorder, PTSD, and depression. During a concurrent interview and record review, on 11/14/2024, at 11:58 a.m., with the Resident Care Coordinator (RCC), the RCC stated PASRR's were conducted before admission to the facility or if a resident had a change of condition. The RCC stated Resident 57's PASRR Level 1 results were negative, indicating Resident 57 did not have a mental illness. The RCC stated Resident 57's diagnosis list indicated Resident 57 had a diagnosis of bipolar disorder upon admission on 9/19/2023. The RCC stated a PASRR should had been resubmitted for Resident 57. The RCC stated the risk of not resubmitting a PASRR for a resident could result in a lack of mental health resources that a resident need. During a interview, on 11/15/2024 at 1:03 p.m., with the Director of Nursing, the DON stated the RCC was responsible for completing the PASRR for residents. The DON stated PASRRs are conducted prior to admission and for any change of condition. The DON stated a PASRR should had been resubmitted for Resident 57. The DON stated the risk of not resubmitting a PASRR for a resident could result in not providing the best care possible for the resident and a lack of care. During a review of the facility's policy and procedures, titled Pre-Admission Screening and Resident Review (PASRR) Policy, undated, the policy and procedure indicated, The facility will refer all Level 2 residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or related condition for a Level 2 review upon a significant change in status assessment to the State PASRR representative.

Based on observation, interview, and record review, the facility failed to use one unopened browned turkey breast before its use fresh or freeze by date on 10/6/2023 or throw it after the safe time limit of 14 days of thawing (a process of taking a frozen product from frozen to unfrozen state) and refrigeration storage time on 11/1/2023 in the walk-in refrigerator. This failure had the potential to result in dietary staff serving the browned turkey breast to residents and cause spoiled or unsafely stored food symptoms of vomiting and diarrhea to residents. Findings: During a concurrent observation and interview on 11/07/2023, at 9:26 a.m., with Dietary Supervisor (DS), inside the walk-in refrigerator, there was a Foster Farms Browned Turkey Breast in a gray basin on the second level of the shelf with use fresh or freeze by date on 10/6/2023 and thaw date on 10/19/2023. The Dietary Supervisor stated, it passed the 14 days refrigeration storage time so, he will throw it away upon finding it with the surveyor. During a concurrent interview and record review on 11/9/2023, at 3:05 p.m., with Dietary Supervisor, the facility's policy and procedure (P&P) titled, Food Production and Storage, undated, was reviewed. The P&P indicated, frozen food will be thawed in the refrigerator or according to sanitary standards. The Dietary Supervisor stated, unopened, thawed, cooked food products were usually kept in their walk-in refrigerator up to 14 days. During a concurrent interview and record review on 11/9/2023, at 3:05 p.m., with Dietary Supervisor, the U.S. Food and Drug Administration (FDA) Refrigerator and Freezer Storage Chart, dated 3/2018, was reviewed. The U.S. FDA Refrigerator and Freezer Storage Chart indicated, these short but safe time limits will help keep refrigerated food from spoiling or becoming dangerous. Unopened lunch meats are safe in the refrigerator for 2 weeks (or 14 days). The Dietary Supervisor stated, the Foster Farms Browned Turkey Breast is considered an unopened lunch meat that was thawed on 10/19/2023 based on the written label. The Dietary Supervisor stated, he threw it away upon discovery with the surveyor because it was moved from the freezer to the refrigerator for more than 14 days and it can cause symptoms of vomiting and diarrhea if it was served to the residents.

Based on interview and record review, the facility failed to report an allegation of abuse for two of two sampled Residents (Residents 1 and 2). This deficient practice resulted in a delay for the State Agency to investigate the allegation of abuse. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (group of conditions characterized by impairment in brain function affecting memory and judgment) with mild mood disturbances, major depressive disorder (mood disorder causing persistent feeling of sadness and loss of interest) and generalized anxiety disorder. During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care planning tool) dated 5/18/2023, the MDS indicated Resident 1 had intact cognition (thought process) and required supervision for most of the Activities of Daily Living (ADLs) including bed mobility, transfer, walking, eating and toilet use. During a review of Resident 1's Nurses Notes dated 7/11/2023 at 12:53 a.m., the Notes indicated on 7/10/2023 at 7:25 p.m., Resident 1's roommate (Resident 2) punched Resident 1 on the back of his head and left cheek with a closed fist without reason. During a review of Resident 2's Admission Record, the Admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that causes gradual decline in memory), dementia with psychotic disturbances (false beliefs that make it hard for someone to think clearly) and schizophrenia (severe brain disorder that can cause disorganized thinking). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment and required supervision for most ADL's including bed mobility, transfer, walking and eating. During a review of Registered Nurse' (RNS 2) Statement dated 7/10/2023, the Statement indicated RNS 2 heard a resident (Resident 5) call for help and saw Resident 2 grabbing Resident 1's shoulder from behind with his fist raised ready to hit Resident 1. The statement also indicated Resident 5 claimed Resident 2 had already struck Resident 1 from behind 3 times and that Resident 1 stated he was struck once by Resident 2. During a review of the facility's email correspondence dated 7/11/2023 at 5:27 p.m., the email indicated an SOC 341 (a form to report suspected dependent adult/elder abuse) was sent to the State Agency reporting Resident 2 grabbed Resident 1's shoulder and possibly struck Resident 1. During interviews on 7/18/23 at 9:23 a.m. and 9:50 a.m. with Resident 1, Resident 1 stated on (7/10/2023), he was speaking to his neighbor (Resident 5) when Resident 2 came up behind him and hit him on the left side of his face. Resident 1 stated he did not feel safe. Resident 1 stated Resident 2 also tried to hit a nurse when he did not want to take a shower two days prior to the incident on 7/10/23. During an interview on 7/18/23 at 1:24 p.m. with the Administrator (ADMN), the ADMN stated abuse was any kind of harm presented towards someone which could include neglect, exploitation, sexual, and emotional harm. The ADMN stated he had reported the incident because Resident 1 said he was hit, and it was confirmed that two staff members had to remove Resident 2 away from Resident 1. The ADMN stated it was important for incidents to be reported to the State Agency so that a thorough investigation could be conducted and to keep residents safe. The ADMN also stated any incident resulting in serious harm should be reported to the State Agency within 2 hours and could still report the incident within 24 hours. During an interview on 7/19/23 at 1:42 p.m. with the Director of Nurse (DON), DON stated the facility did not have report the allegation of abuse to State Agency within 2 hours because Resident 1 had no injuries or evidence of abuse. During a review of the facility's undated Policy and Procedure (P&P) titled, Policy and Procedure for Reporting Suspected Crimes Under the Federal Elder Justice Act , the P&P indicated the following: 1. When staff suspect a crime has occurred against a resident, they must report the incident. 2. Staff must report a suspicion of a crime to the state survey agency, local law enforcement, and/or the Ombudsman within a designated time frame by e-mail, fax or telephone. 3. The reporting individual will notify Local Law Enforcement immediately by phone and the LCT Ombudsman, Law Enforcement and Licensing Agency within 2 hours by fax when an incident involves abuse or serious bodily injury. During a review of the facility's undated P&P titled, Reporting Abuse to Facility Management , the P&P indicated the following: When an alleged or suspected case of mistreatment, neglect, injuries of an unknown source, or abuse was reported, the facility administrator, or his/her designee, may notify the following persons or agencies of such incident: a) The State licensing/certification agency responsible for surveying/licensing the facility; b) The local/State Ombudsman; c) The Resident`s Representative (Sponsor) of Record; d) Law Enforcement Officials; e) The Resident`s Attending Physician; and f) The Facility Medical Director

Based on interview and record review, the facility failed to notify the Conservator (person appointed by a judge to act or make decisions on behalf of another person who needed help) of changes in the care or treatment for one of three sampled residents (Resident 1). Resident 1 ' s Conservator designated a Caregiver to assist in feeding Resident 1 during meals and the facility stopped allowing this provision of care by the Caregiver without notifying the Conservator. This deficient practice violated Resident 1 ' s Conservator ' s right to be informed, be an active participant in Resident 1 ' s care planning process and had the potential to cause feelings of rejection and discrimination. Findings: During a record review of Resident 1 ' s Admission Record (AR), The AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including epilepsy (a group of disorders marked by problems in the normal functioning of the brain), visual loss and dysphagia (swallowing difficulties). The AR indicated Resident 1 had a private Conservator. During a record review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care planning tool) dated 3/2/2023, the MDS indicated Resident 1 had unclear speech, limited ability to making concrete requests and responded adequately to simple, direct communication only. The MDS also indicated Resident 1 required extensive assistance with eating, dressing and personal hygiene. During an interview on 3/28/2023 at 11:30 a.m. with the Conservator, the Conservator stated she was very frustrated with the facility for not allowing the caregiver to assist with feeding Resident 1. The Conservator also stated the facility never communicated to her about any issues with the caregiver feeding the resident. During a concurrent interview and record review on 4/10/2023 at 4:35 p.m. with the Caregiver, the Record of Inservice (ROI) was reviewed. The ROI indicated the topic included safe swallowing strategies, small bites, and feeding at a slow rate. The Caregiver stated after she completed the in-service training, she was allowed to feed Resident 1 then the facility changed the rules and had now refused to allow her to feed Resident 1. During interviews on 4/11/2023 at 10:05 a.m. and 4/17/2023 at 1:20 p.m. with the Director of Nursing (DON), DON stated, the change of not allowing Resident 1 ' s Caregiver to assist the resident with feeding during meals, was discussed during the Interdisciplinary Team meeting ([IDT]-structured meeting to address the needs of participants through frequent, organized, and documented communication across disciplines and with the participant) on 12/8/2022 and believed to have notified the conservator at this time however could not find any documentation to indicate the notification was done. During a concurrent interview and record review on 4/17/2023 at 2:37 p.m. with Social Services Director (SSD), Resident 1 ' s Care Conference Notes dated 12/8/2022 and 3/2/2023 were reviewed. SSD stated, Resident 1 ' s Conservator was present during the meeting on 12/8/2022 and was not present during the meeting on 3/2/2023. SSD stated the notes did not indicate the IDT discussed Resident 1 ' s Caregiver not being able to assist in feeding the resident nor did she recall discussing this issue in the IDT meetings. During an interview on 4/13/2023 at 10:05 a.m. and 4/18/2023 at 2:59 p.m., with ADM, ADM stated he decided a couple of weeks ago to stop the caregiver from feeding Resident 1 because she had not completed the required state course. ADM stated he was not sure what date this change was made and was not sure when the Conservator was notified of the change. ADM stated there was no documentation that the facility notified the Conservator. ADM also stated it was important to provide notification to the Conservator to ensure R/P was informed, involved, and understood the plan of care and changes related to the resident. During a review of the facility ' s policy and procedure (P/P) titled, Policy on Resident Rights, undated, The P/P indicated the facility should provide each resident the right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility. This facility should promote the exercise of rights for all residents, including those who face barriers, such as communication problems, hearing problems and cognitive limitations, in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability. In the event a resident is adjudged incompetent under the laws of the State by a court of competent jurisdiction, the rights of the resident are exercised by the person appointed under the State law to act on the resident ' s behalf. During a review of the facility ' s P/P titled, Resident/Family Education, undated, the P/P indicated education was provided by the IDT members to appropriate residents and/or responsible party when applicable if it is felt that it would be efficacious in order to reduce a resident ' s stress or anxiety, or to increase the likelihood of adherence to therapeutic care plans, promote healthy lifestyles, and/or speed the resident ' s return to independence if discharge is appropriate/eminent. The P/P also indicated resident/family was provided with appropriate education and training about illness and care needs.

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach and accessible for three out of twenty-one sampled residents (Resident 20, 27, and 46) who needed assistance. This deficient practice had the potential to result in Residents 20, 27, and 46 not being able to call for help and result in a fall or accident. Findings: During a review of Resident 20's Admission Record (face sheet), the face sheet indicated Resident 20 was originally admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 20's Care Plan titled Potential for Trauma-Falls dated 5/3/2022, the care plan's interventions indicated facility would have a call button in reach. During a review of Resident 20's Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 8/5/22, the MDS indicated Resident 20 usually had the ability to understand and be understood by others. The MDS indicated Resident 20 required set up assistance with bed mobility, transfer, walk in room, walk in corridor, locomotion (moving from place to place), eating, toilet use and one-person assist for dressing, and personal hygiene. During a review of Resident 20's History and Physical (H/P), dated 10/3/2022, the H/P indicated Resident 20 did not have the capacity to understand and make decisions. During a concurrent observation and interview with Licensed Vocational Nurse (LVN 3), on 10/17/2022, at 11:28 a.m., Resident 20 did not have the call light within reach. Resident 20 attempted to get out of bed to use his neighbors call light. LVN3 stated Resident 27 was at risk for falls and could suffer a fracture (broken bone) or hit his head while trying to get up to reach for the call light. During a concurrent observation and interview with LVN 4, on 10/17/2022, at 11:50 a.m., LVN 4 stated Resident 20's call light was not within his reach. LVN 4 stated Resident 20 was not able to call for assistance and could suffer a fall. LVN 4 stated the Resident could feel abandoned and confused when they were unable to use the call light to get assistance when they needed it. During a review of Residents 27's admission record, the admission record indicated the resident was originally admitted on [DATE] and readmitted to the facility on [DATE], diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Residents 27's Care Plan titled Self-Care Deficit dated 11/30/2021, indicated the care plan interventions included to keep the call button in reach. During a review of Resident 27's H/P dated 12/15/2021 indicated Resident 27 did not have the capacity to understand and make decisions. During a review of Resident 27's MDS dated [DATE], indicated Resident 27 usually had the ability to understand and be understood by others. The MDS indicated Resident 27 required set up only for bed mobility, transfer, walk in room, walk in corridor, locomotion (moving from place to place), eating, toilet use, for dressing and personal hygiene. During an observation on 10/17/2027, at 11:00 a.m., Resident 27 did not have a call light and was requesting coffee. Resident 27 attempted to reach for his neighbors call light, lost his balance, and felt down on his bed. During a concurrent observation and interview with Certified Nurse Assistant (CNA 1), on 10/17/2022, at 11:15 a.m., CNA 1 stated Resident 27 did not have the call light within reach all morning because Resident 27 call light clip was broken. CNA 1 stated not having the call light within reach could put Resident 27 at risk for falls. During a review of Residents 46's admission record, indicated Resident 46 was admitted to the facility on [DATE], diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 46's Physician Assessment H&P dated 2/8/2019, indicated Resident 46 was cooperative and alert. During a review of Resident 46's MDS dated [DATE], the MDS indicated Resident 46's usually was able to understand and be understood by others. The MDS indicated Resident 46 requires two- person physical assist with bed mobility, transfer, toilet use, walk in corridor, and walk in room. During a review of Residents 46's Care Plan titled Baseline/Comprehensive Care Plans dated 2/9/2022, indicated the care plan interventions for Resident 46 included call light attached to Resident 46 to alert the nursing staff when resident 46 attempted to get out of bed or slide out of the bed on his own, and call button within reach. During an observation 10/17/22, 10:18AM, Resident 46 was seating on a chair next to his bed and his call light was not within reach. Resident 46 had a contracted left hand and appeared to have difficulty opening and closing both of his hands. During a concurrent observation and interview with Resident 46 and CNA7 on 10/19/22, at 9:14 AM, Resident 46 call light was clamped to Resident 46's left shoulder. The call light had a long string attached to the light switch. Resident 46 demonstrated how he used the call light by leaning forward and moving his left shoulder, but the call light was not triggered. The string attached to the call light was too long. CNA 7 stated Resident 46 used the call light by having the call light clamped was in the room next to Resident 46 and when asked how does Resident 46 call for assistance? CNA 7 explained that the clamped to Resident 46. CNA 7 asked Resident 46 to demonstrate how he use the call light for assistance. Resident 46 leaned forward and tried to move his left shoulder, but the call light did not call for assistance. During a review of the facility's undated policy and procedures (P/P) titled Nursing Policies and Procedures in Answering Call Lights the P/P, indicated a purpose to provide routine or emergency service to patients as needed on request. The policy further indicated the light cords should be within reach of the patient.

Based on observation, interview, and record review, the facility failed to ensure licensed and registered nurses assessed two of 21 sampled residents ((Resident 63 and 25) for the need of restraints prior to placing the residents on physical restraints. This deficient practice had the potential to place the residents at risk for unnecessary prolonged use of restraints. It also had the potential to lead to a decline in physical functioning, residents not being treated with respect and dignity, skin injuries and severe injuries such as strangulation or entrapment. Findings: a. During a review of Resident 63's Admission Record (face sheet), the face sheet indicated Resident 63 was originally admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 63's Minimum Data Set ([MDS] a standardized care assessment and assessment tool), dated 9/23/2022, the MDS indicated Resident 63 sometimes had the ability to understand others and usually was understood by others. The MDS indicated Resident 63 required one-person physical assist for bed mobility, transfer, walking in the room, and corridor, dressing, toilet use and personal hygiene. The MDS indicated Resident 63 required setup for eating. During a review of Resident 63's History and Physical (H/P), dated 10/3/2022, the H/P indicated Resident 63 did not have the capacity to understand and make decisions. During a review of Resident 63's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation in Resident 63's room on 10/17/22 at 1:40 p.m. Resident 63 was sleeping in a wheelchair with pelvic support attached to the back of the resident's wheelchair. During an interview with Certified Nurse Assistant (CNA 5) on 10/19/2022 at 10:32 a.m. CNA 5 stated Resident 63 was always on restraints while in the wheelchair. CNA 5 stated Resident 63 was always sleepy and needed encouragement to wake up during meals. During an interview with the Director of Nursing (DON) on 10/19/2022 at 3:04 p.m. the DON stated Resident 63 was on restraints while in wheelchair. DON stated the facility performed restraint assessment for residents only one time per month. b. During a review of Resident 25's face sheet, the face sheet indicated Resident 25 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 25's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 25's MDS dated [DATE], the MDS indicated Resident 25 sometimes had the ability to understand and be understood by others. The MDS indicated Resident 25 required one-person physical assist for bed mobility, transfer, walking in the room, corridor, dressing, eating, toilet use and personal hygiene. During a review of Resident 25's H/P, dated 10/3/2022, the H/P indicated Resident 20 did not have the capacity to understand and make decisions. During a review of Resident 25's Care plans, there was no care plan for the use of a wheelchair self-release seatbelt. During a review of Resident 25's physician Orders dated 10/16/2022, Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with Licensed Vocational Nurse (LVN 3) on 10/20/2022 at 11:30 a.m., LVN 3 stated Resident 25 had a self-release belt because the resident had fallen several times before and the seatbelt was supposed to prevent Resident 25 from having further falls. LVN 3 stated a restraint assessment was done once a month and discontinued based on each resident's needs. A review of the facility's undated policy and procedure (P/P) titled Restraints/Supports, the P/P indicated restraints/supports will be used only when warranted by a medical condition and ordered by the attending physician, and only when less restrictive measures had been tried and failed. The P/P indicated an ordering physician was required to obtain informed consent. The P/P indicated restraint procedures were used if medically appropriate and possible, used for a maximum of six days a week. The P/P also indicated the facility will practice approaches that will attempt to keep independent functioning to a maximum level.