Every finding on record at Courtyard Care Center

Based on interviews and record reviews, the facility failed to ensure sufficient staff were available to provide care To ensure one of two residents (Resident 2) had documented evidence of receiving feeding assistance for breakfast and lunch on 2/22/2026.To ensure call lights were answered in a timely manner.These deficient practices had the potential to result in worsening conditions and a delay in care and services.Findings: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 fracture of medial malleolus of left tibia (a break in the bony bump on the inner side of the left ankle), gastroesophageal reflux disease (chronic condition where stomach acid frequently flows back into the esophagus), dementia (a progressive state of decline in mental abilities), and muscle weakness.During a review of Resident 2's Minimum data Set ([MDS] a resident assessment tool), dated 1/14/2026, the MDS indicated Resident 2's cognition (ability to make decisions of daily living) was moderately impaired. The MDS indicated Resident 2 was dependent on staff for all activities of daily living ([ADL] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2's Order Summary report, active as of 3/4/2026, the report indicated an order for Fortified diet (foods enriched with added nutrients not naturally abundant in them) mechanical soft texture (foods that are soft, moist, and easy to chew and swallow), thin consistency. Resident 2 also had an order for Restorative Nursing Assistant (a certified nursing assistant with specialized training to help patients with limited mobility regain or maintain physical function) feeding program starting on 12/9/2025.During a review of Resident 2's Documentation Survey Report for February 2026, the report indicated the amount eaten by Resident 2, there was no documented evidence Resident 2 was assisted with meals three times a day on 2/22/2026. During a review of the facility's Resident council (a group of facility residents who meet to share concerns and give feedback about their care and daily life) meeting minutes, for 2/3/2026 and 1/8/2026, the minutes indicated that call lights were not being answered in a timely manner. During a phone interview with Family Member (FM) 1, on 3/3/2026 at 1:36 p.m., FM 1 stated the facility did not have enough nurses to help the residents, especially on the weekends, and it delayed care and services for the residents.During a concurrent interview and record review on 3/4/2026 at 12:50 p.m., with Registered Nurse Supervisor 1(RNS 1) Resident 2's Documentation survey of amount eaten was reviewed for February 2026. RNS 1 confirmed and stated there was no documented evidence Resident 2 was assisted with meals three times a day on 2/22/2026.During an interview and record review on 3/4/2026 at 1:47 p.m., with the Director of Nursing (DON), the facility's Census and Direct Care Service Hours Per Patient Day ([DHPPD] a critical staffing metric in healthcare represents the total actual hours of direct nursing care provided to patients divided by the daily patient census) for 2/21/2026, 2/22/2026, 2/28/2026 were reviewed. The DON confirmed metrics for Certified Nurse Assistants were below the required 2.4 hours per patient day. The DON stated short staffing affected resident care. On 2/22/2026, the day there was no documented evidence Resident 2 was assisted for breakfast and lunch the facility was short staffed.During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, dated 2024, the P&P indicated the facility provides enough nursing staff to provide nursing and related care service for all residents.

Based on interviews and record review, the facility failed to implement infection control policies when the facility failed to ensure two out of four residents sampled (Resident 3 and 4) were tested for influenza (a highly contagious infectious illness) and Covid-19 (contagious respiratory illness) as soon as respiratory symptoms (warning signs including cough, fever, sore throat, runny nose, congestion, muscle aches) manifested.The deficient practices had the potential to result in the spread of infections in the facility and cause undue harm to the residents' health and well-being. FindingsDuring a review of Resident 3's admission Record, the admission Record indicated Resident 3 was readmitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and pulmonary fibrosis (chronic, progressive lung disease where deep lung tissue becomes scarred, thick, and stiff).During a review of Resident 3's Minimum data Set ([MDS] a resident assessment tool), dated 2/25/2026, the MDS indicated Resident 3's cognition was moderately impaired. The MDS indicated Resident 3 needed set-up assistance with eating, oral hygiene, and was dependent on staff for showering and toileting hygiene.During a review of Resident 3's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form and progress notes. 2/14/2026 at 9:30 p.m., the form indicated Resident 3 presented with shortness of breath, coughing, and congestion.During a review of Resident 3's order, 2/18/2026 at 8:33 p.m., Resident 3 was placed on transmission-based precautions ([TBP] specialized infection control measures used in addition to standard precautions for patients suspected or confirmed to have highly transmissible diseases based on route of transmission).During a review of Resident 3's Lab Results Report, 2/19/2026 at 5 a.m., the report indicated Resident 3 was tested for respiratory pathogen panel (test that identify the specific germ causing respiratory symptoms).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 acute pulmonary edema (life-threatening, sudden buildup of fluid in the lung's air sacs) and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognition was moderately impaired. The MDS indicated Resident 4 needed set-up assistance with eating, oral hygiene, and was dependent on staff for showering and toileting hygiene.During a review of Resident 4's SBAR Communication Form and progress notes. 2/21/2026 at 8:29 p.m., the form indicated Resident 4 presented with a productive cough. During a review of Resident 4's Lab Results Report, 2/23/2026 at 3:30 a.m., the report indicated Resident 3 was tested for respiratory pathogen panel.During a concurrent interview and record review on 3/4/2026 at 9:25 a.m., with the Infection Prevention Nurse (IPN), Resident 3's medical records were reviewed. The IPN confirmed and stated Resident 3 manifested respiratory symptoms on the 2/14/2026 and should have been tested for respiratory pathogen panel or at least flu and Covid-19 right away and not 4 days later 2/18/2026. The IPN stated Resident 3 should have been placed on TBP right away and not 4 days later to prevent the spread of infection.During a concurrent interview and record review on 3/4/2026 at 10 a.m., with the IPN, Resident 4's medical records were reviewed. The IPN confirmed and stated Resident 4 manifested respiratory symptoms on the 2/21/2026 and should have been tested for respiratory pathogen panel or at least flu and Covid-19 right away and not 2 days later 2/23/2026 to prevent the spread of infection.During an interview on 3/5/2026 at 1:47 p.m., with the Director of Nursing (DON), the DON stated we need to follow LA Department of Public Health (LADPH) guidelines to prevent the spread of infections. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control, dated 2025, the P&P indicated the facility will maintain a safe environment to prevent and manage the spread of infections. The P&P indicated the facility will follow current best practicesDuring a review of LADPH Influenza and other Respiratory Virus Diseases Outbreak Toolkit, 12/2025, the toolkit indicated to immediately test residents for Covid-19 and flu when the residents manifest with signs or symptoms of respiratory illness. The toolkit indicated while awaiting test results on symptomatic residents, implement empiric Transmission-Based Precautions for COVID-19.

Based on interviews and record reviews, the facility failed to ensure two of four sampled residents (Resident 1 and 2) medications were administered as ordered.This deficient practice had the potential to result in worsened conditions and higher hospitalization risks.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), gastroesophageal reflux disease (chronic condition where stomach acid frequently flows back into the esophagus), bilateral primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the hip, and disorder of bone density (measures the calcium and mineral amount in bones, determining strength) and structure.During a review of Resident 1's Minimum data Set ([MDS] a resident assessment tool), dated 1/16/2026, the MDS indicated Resident 1's cognition (ability to make decisions of daily living) was severely impaired. The MDS indicated Resident 1 required set-up assistance with eating, oral hygiene, substantial assistance (helper does more than half the effort to complete the task) with personal hygiene, and was dependent (helper does all the effort to complete the task) on staff for showering and toileting hygiene. During a review of Resident 1's Order Summary report, active as of 3/4/2026, the report indicated orders for 1. Alendronate Sodium tablet 70 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) one time a day every Sunday (medication for osteoporosis [weak and brittle bones due to lack of calcium and Vitamin D]), 2. Omeprazole tablet delayed release 20 mg by mouth one time a day (medication for acid indigestion), and3. Synthroid (medication for hypothyroidism [the thyroid gland doesn't make enough thyroid hormone]) oral tablet 75 micrograms ([mcg] metric unit of measurement, used for medication dosage and/or amount) in the morning.During a review of Resident 1's Medication Administration Record (MAR), 3/2026, Resident 1's MAR indicated:1. On 3/1/2026 at 6 a.m., no documented evidence of the administration of Alendronate Sodium tablet and Omeprazole. 2. On 3/1/2026 and 3/3/2026 at 6:30 a.m., no documented evidence of the administration of Synthroid.3. On 3/3/3036 at 6 a.m., Resident 1's MA indicated no documented evidence of the administration of Omeprazole. 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 fracture of medial malleolus of left tibia (a break in the bony bump on the inner side of the left ankle), dementia (a progressive state of decline in mental abilities), and muscle weakness.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was moderately impaired. The MDS indicated Resident 2 was dependent on staff for all activities of daily living (activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2's Order Summary report, active as of 3/4/2026, the report indicated an order for Visine Dry eye relief Ophthalmic Solution 1%, (medication for dry eyes) instill one drop in both eyes three times a day.During a review of Resident 2's Medication Administration Record (MAR), 3/2026, Resident 2's MAR indicated no documented evidence of the administration of Visine on 3/3/2026 at 6 a.m.During a concurrent interview and record review on 3/4/2026 at 12:44 p.m., with Registered Nurse Supervisor 1(RNS 1) Resident 1's MAR was reviewed. RNS 1 confirmed and stated there were medications that were not administered to Resident 1. On 3/1/2026 at 6 a.m., Resident 1's MAR indicated no documented evidence of the administration of Alendronate Sodium tablet and Omeprazole. On 3/1/2026 and 3/3/2026 at 6:30 a.m., Resident 1's MAR indicated no documented evidence of the administration of Synthroid. On 3/3/3036 at 6 a.m., Resident 1's MAR indicated no documented evidence of the administration of Omeprazole. During a concurrent interview and record review on 3/4/2026 at 12:47 p.m., with RNS 1 Resident 2's MAR was reviewed. RNS 1 confirmed and stated there were medications that were not administered to Resident 2. Resident 2's MAR indicated no documented evidence of the administration of Visine on 3/3/2026 at 6 a.m.During an interview on 3/5/2026 at 1:47 p.m., with the Director of Nursing (DON), the DON stated medications should be administered as physician ordered and if MAR was not signed then it means the medication was not administered. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 2024, the P&P indicated medications as administered as prescribed. The P&P indicated as required the individual administering the medication documents in the residents' MAR the date, time, dosage, route of medication administered and the signature and title of the person who administered the drug.

Based on interviews and record review, the facility failed to ensure two of two sampled residents (Resident 2 and 8) had documented evidence that Residents 2 and 8 were assisted with their meals at least three times a day.This deficient practice had the potential to result in worsened conditions, weight loss, and higher hospitalization risks.Findings: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 fracture of medial malleolus of left tibia (a break in the bony bump on the inner side of the left ankle), gastroesophageal reflux disease (chronic condition where stomach acid frequently flows back into the esophagus), dementia (a progressive state of decline in mental abilities), and muscle weakness.During a review of Resident 2's Minimum data Set ([MDS] a resident assessment tool), dated 1/14/2026, the MDS indicated Resident 2's cognition (ability to make decisions of daily living) was moderately impaired. The MDS indicated Resident 2 was dependent on staff for all activities of daily living ([ADL] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2's Order Summary report, active as of 3/4/2026, the report indicated an order for Fortified diet (foods enriched with added nutrients not naturally abundant in them) mechanical soft texture (foods that are soft, moist, and easy to chew and swallow), thin consistency. Resident 2 also had an order for Restorative Nursing Assistant (a certified nursing assistant with specialized training to help patients with limited mobility regain or maintain physical function) feeding program starting on 12/9/2025.During a review of Resident 2's Documentation Survey Report for February 2026 and March 2026, the report indicated the amount eaten by Resident 2, there was no documented evidence Resident 2 was assisted with meals three times a day on 2/12/2026, 2/14/2026, 2/15/2026, 2/22/2026, 2/25/2026, and 2/27/2026. During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), kidney transplant status (individual has undergone surgery to replace failing kidneys with a healthy donor kidney), dementia, anemia (a condition where the body does not have enough healthy red blood cells), and morbid obesity (severe weight of being 100 pounds over ideal weight). During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8's cognition was severely impaired. The MDS indicated Resident 8 was dependent on staff for all ADLs. During a review of Resident 8's Order Summary report, active as of 3/4/2026, the report indicated orders for Fortified diet, pureed texture (consists of smooth, pudding-like foods requiring no chewing), mildly thick consistency.During a review of Resident 8's Documentation Survey Report for February 2026 and March 2026, the report indicated the amount eaten by Resident 8, there was no documented evidence Resident 8 was assisted with meals three times a day on 2/6/2026, 2/13/2026, 2/14/2026, 2/15/2026, 2/16/2026, 2/25/2026, and 2/27/2026.During a concurrent interview and record review on 3/4/2026 at 12:50 p.m., with Registered Nurse Supervisor 1(RNS 1) Resident 2's Documentation survey of amount eaten was reviewed for February and March 2026. RNS 1 confirmed and stated there was no documented evidence facility staff assisted Resident 2 with meals three times a day on 2/6/2026, 2/13/2026, 2/14/2026, 2/15/2026, 2/16/2026, 2/25/2026, and 2/27/2026.During a concurrent interview and record review on 3/4/2026 at 12:58 p.m., with RNS 1 Resident 8's Documentation Survey Report was reviewed for February 2026 and March 2026. RNS 1 confirmed and stated there was no documented evidence Resident 8 was assisted with meals three times a day on 2/6/2026, 2/13/2026, 2/14/2026, 2/15/2026, 2/16/2026, 2/25/2026, and 2/27/2026. RNS 1 stated need to ensure meals were recorded and that residents eat at least three times a day.During a review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services, dated 2025, the P&P indicated each resident is provided with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs.

Based on observation, interview, and record review the facility failed to ensure one of four sampled residents' (Resident 2) call light (device that allows residents to request assistance from nursing staff) was accessible and within reach.This deficient practice resulted in a delay in care and services.Findings: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 fracture of medial malleolus of left tibia (a break in the bony bump on the inner side of the left ankle), dementia (a progressive state of decline in mental abilities), and muscle weakness.During a review of Resident 2's Minimum data Set ([MDS] a resident assessment tool), dated 1/14/2026, the MDS indicated Resident 2's cognition (ability to make decision of daily living) was moderately impaired. The MDS indicated Resident 2 was dependent (Helper does all the effort to complete the task) on staff for all activities of daily living (activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on 3/4/2026 at 11:55 a.m., in Resident 2's room Resident 2's switch adaptive call light (an assistive device allowing individuals with limited mobility or disabilities to alert caregivers by using specialized switches instead of a standard button) was on the floor away from Resident 2. Certified Nurse Assistant (CNA) 1 confirmed Resident 2's call light was out of Resident 2's reach.During an interview on 3/4/2026 at 11:55 a.m., Resident 2 stated she needed the call light under her forearm so she could press it when she needed assistance from facility staff.During an interview on 3/5/2026 at 1:47 p.m., with the Director of Nursing (DON), the DON stated all residents must have an accessible call light that is within reach to ensure residents can call for help. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, dated 2024, the P&P indicated the call light need to be within the residents' reach.

Based on interview and record review the facility failed to develop and implement a Water Management Plan (plan that identifies hazardous conditions and steps to take to minimize the growth and spread of bacteria[germs]) for 56 out of 56 residents. This deficient practice had the potential to expose residents and staff to Legionella (bacteria that can cause serious lung infections) resulting in pneumonia (lung infection), hospitalization or even death. Findings: During an interview on 12/10/2025 at 9 a.m., with the Maintenance Supervisor (MS), the MS stated he just measures water temperatures, makes sure the ice machine was clean, and there were no other tasks regarding the water management plan. During a concurrent interview and record review on 12/10/2025 at 9 a.m., with the Infection Prevention Nurse (IPN), the facility's water management plan was reviewed. The IPN stated there were missing elements to the water management plan. During an interview on 12/10/2025 at 11 a.m. with the Administrator (ADM) the ADM stated the facility should complete the water management assessment because it was required. The ADM stated the water management had no control measures (things you do in the building water systems to limit growth and spread of legionella such as heating, adding disinfectant or cleaning) applied and how to monitor them, there were no interventions created if control measures were not met, there was no documentation of all the activities of the program. During a review of the facility's policy and procedure (P&P) titled, Legionella Water Management Program, revised 7/2017, the P&P indicated water management plan will have the following elements: a. An interdisciplinary water management team. b. A detailed description and diagram of the water system in the facility, including the following:(1) Receiving (where water enters)(2) Cold water distribution (where does cold water go)(3) Heating.(4) Hot water distribution; and(5) Waste (where waste is discarded) c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including:(1) Storage tanks.(2) Water heaters.(3) Filters.(4) Aerators (device attached to faucet)(5) Showerheads and hoses.(6) Misters (fire suppression systems that use very small water droplets to extinguish or control fires), atomizers (device changes water to mist), air washers (air purification), and humidifiers (device adds moisture to air).(7) Hot tubs.(8) Fountains; and(9) Medical devices such as CPAP machines (Continuous Positive Airway Pressure machine that treats breathing problems), etc. d. The identification of situations that can lead to Legionella growth, such as:(1) Construction(2) Water main breaks(3) Changes in municipal water quality (4) The presence of biofilm or slime (Germs and the slime they secrete that stick to and grow on any continually moist surface provides housing, food, and security for many different types of germs, including Legionella), (5) scale or sediment (the mineral build-up in a water system that uses up disinfectants and supports germ growth and/or survival)(6) Water temperature fluctuations(7) Water pressure changes(8) Water stagnation (When water does not flow well; areas of stagnant water encourage biofilm growth and reduce temperature and level of disinfectant)(9) inadequate disinfection. e. Specific measures used to control the introduction and/or spread of legionella (e.g., temperature, disinfectants).f. The control limits or parameters that are acceptable and that are monitored.g. A diagram of where control measures are applied.h. A system to monitor control limits and the effectiveness of control measures.i. A plan for when control limits are not met and/or control measures are not effective; andj. Documentation of the program. The P&P indicated the Water Management Program will be reviewed at least once a year, or sooner if any of the following occur:a. The control limits are consistently not met.b. There is a major maintenance or water service change.c. There are any disease cases associated with the water system; ord. There are changes in laws, regulations, standards or guidelines.

Based on interview and record review the facility's Quality Assurance and Performance Improvement (QAPI) Committee (group responsible for identifying and responding to quality deficiencies in the facility), the facility failed to implement the action plan for the performance improvement project (structured efforts to systematically identify and resolve issues) regarding staff call light response for 56 out of 56 residents.The deficient practice placed the residents at risk for not receiving the quality treatment necessary to adequately meet their highest practicable well-being.Findings: During a record review of the facility's QAPI plan, initiated 8/1/2025, the plan indicated that the facility's call light response was a system issue and an area of improvement. The QAPI's Program action plan indicated that the Administrator (ADM) and managers will ask residents about call light response to measure performance improvement. During a concurrent interview and record review on 12/12/2025 at 9:24 a.m., with the ADM, the facility Angel Daily Room Rounds were reviewed. The ADM stated the rounds did not indicate the staff interviews of residents regarding call light response. The ADM stated there was no documented evidence of interviews conducted that will measure performance improvement. The ADM stated there were missing elements of the project that indicate QAPI program was being implemented.During a record review of the facility's policy and procedure (P&P) titled, Quality assurance performance Improvement Program, revised 2/2022, the P&P indicated the QAPI committee will address specific care and quality issues and implement actions plan to resolve these issues. The P&P indicated the following:1) QAPI Program is focused on indicators of the outcomes of care and quality of life for our residents.2) The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include:a. Tracking and measuring performance.b. Establishing goals and thresholds for performance measurement.c. Systematically analyzing underlying causes of systemic quality deficiencies.d. Implementing corrective action e. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed.f. The committee meets to review reports, evaluate data, and monitor results and adjust the plan.

Based on observation, interview, and record review, the facility failed to dispose of garbage and recyclables properly by not completely covering two of two trash dumpsters (a large trash container designed to be emptied into a truck).This deficient practice had a potential to attract flies, insects, and other animals to the dumpster area placing 56 of 59 facility residents at risk for cross-contamination (a transfer of harmful bacteria from one place to another) and had the potential to cause nausea, vomiting and diarrhea. findings:During a concurrent observation and interview on 12/9/2025 at 9:45a.m. with the Dietary Supervisor (DS) of the garbage area located outside the facility near the kitchen, the DS stated two of two dumpsters were not completely closed and covered. The DS stated the trash had not been picked up from Monday 12/8/2025 was still there. The DS stated the trash lids should be closed and indicated if the trash lid is no closed, bugs can come in and bags can break creating an unsanitary environment. During a review of Food Code 2017, indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment.During a review of the facility's Policy and Procedure (P&P), titled Garbage and Trash, undated, the P&P indicated all food waste must be placed in sealed containers (i.e., plastic bag).

Based on interview and record review the facility failed to provide documented COVID-19 (contagious disease) 2025 to 2026 vaccination (medications used to prevent diseases usually given by injection or by mouth) status, evidence of provision of education on benefits and potential side effects for all employees, including physicians. This failure had the potential to result in staff and residents contracting COVID-19 which could cause serious illness, hospitalization, and death. Findings: During a concurrent interview and record review on 12/10/2025 at 8:10 a.m., with the Infection Prevention Nurse (IPN), the facility's Covid Staff Vaccination Status, undated, was reviewed. The IPN stated there was no documented evidence for all staff of education on benefits and side effects was provided and the offering of 2025 to 2026 Covid-19 booster vaccine. The IPN stated the roster did not include physicians and it should include everyone that has direct access to the residents. During an interview on 12/12/2025 at 7:55 a.m. with the Director of Nursing (DON), the DON stated all staff need to be educated and offered the current COVID-19 booster. During a review of the facility's policy and procedure (P&P) titled, Covid-19 Vaccine Immunization for Residents and HCP, revised 9/2025, the P&P indicated the following:a. The policy is to provide guidance to the facility in meeting the immunization requirements for educating and administering COVID-19 Vaccine and boosters to healthcare personnel (HCP).b. HCP were provided with education regarding the benefits of COVID vaccination and booster potential side effects and adverse events associated with COVID-19 Vaccine and booster.c. The facility keeps a line listing of resident and HCP COVID-19 vaccination status.d. HCP includes physicians.

Based on observation and interview, the facility failed to food was stored in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from food spoilage or contaminated food) for 56 out of 59 residents by failing to:1. Discard unknown resident's tray that had once left the kitchen.2. Date and label frozen items, produce, and stored goods. 3. Discard expired food items in the dry storage.4. Remove wristwatch while being in the kitchen. 5. Implement safe food handling and sanitation.6. Properly perform hand hygiene and wear gloves when handling the thermometer.These deficient practices had the potential to result in residents being exposed to germs and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications and hospitalization.During an initial kitchen tour and interview on 12/9/2025 at 8:36 a.m., with [NAME] (CK) 1, CK 1 stated brown bag with date 12/8/2025, and no residents name on it, in the refrigerator was for a resident (unknown) that goes to dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). There was a plate with a lid on it in the kitchen refrigerator, and it was observed with no resident identifier or date. CK 1 stated the plate with the lid is a fruit plate, and indicated that plate was a resident's (unknown) plate that was sent given to the resident, and was placed back into the refrigerator since the resident (unknown) wanted to eat the fruit plate around later. During a concurrent observation and interview on 12/9/2025 at 8:42 a.m., with CK 1, CK 1 stated the unopened small milk cartons and the container with individual pats of butter, did not have a received on date. During a concurrent observation and interview on 12/9/2025 at 8:59 a.m., with the Dietary Supervisor (DS), the DS stated in the dry storage area:There were no dates on six tapioca mix bags, Cinnamon Streusel, one box of tea bags, a box of iced tea mix and a container of packets of relish.A container of dry peas, and a box of dry lentils were dated 5/11/2023Two panko bags labeled with an expiration date of 7/9/2025. The lids of the brown rice tub and white rice tub were switched and were not dated. During a concurrent observation and interview on 12/9/2025 at 9:29 a.m., with the DS, of the freezer, the DS statedOne Chef [NAME] pumpkin pie with no box was not dated.Two chocolate flavored cream pies with no box were not dated. A bag of tatter tots was not dated. A bag of meatballs was not dated andAn opened bag of barbeque pork rib patty had no open date. During a concurrent interview and record review on 12/9/2025 at 9:49 a.m., with the DS, the DS stated the date is required to know when the items came in and to calculate the use by date. The DS stated if the food items were undated, they will not know when the food item expires and the residents may get sick. The DS stated they should not have any expired items in the dry storage and freezer, and should be tossed if they are expired. The DS stated on the guidelines they utilize (Dietary Directions, Inc./Nutrition Therapy Essentials, Inc. Food Service Policy and Procedures Manual 2018), dry beans are good for one year and indicated the dried peas and lentils are both expired. During a concurrent observation of pureeing (blended food so it does not require chewing) food items and interview on 12/10/2025 at 11:33 a.m., with [NAME] (CK 2) 2, CK 2 was observed preparing a pureed version of seasoned white beans with ham, and wiping his hands on his clothing. CK 2 was observed storing three black plastic spoons in the upper left arm pocket and handed me a spoon from the said pocket from his arm. CK 2 was observed moving onto the next task (pureeing seas greens) after pureeing the seasons beans with ham without performing hand hygiene. CK 2 stated hand washing between tasks was done to prevent contamination as the residents can get sick from cross contamination. During an observation on 12/10/2025 at 11:44 a.m., in the kitchen, the DS was observed wearing a watch that was directly touching/rubbing against the top counter area of where the hot foods were stored to keep warm. During a concurrent observation during food temperature check and interview on 12/10/2025 at 11:46 a.m., with CK 2, CK 2 was going to start doing temperature checks without performing hand hygiene. CK 2 stated after pureeing the corn bread (task after pureeing seas greens), he did not wash his hands and indicated he was supposed to wash his hands. CK 2 stated gloves are worn when you touch food and prepare other food to avoid contamination. CK 2 was observed doing the following preparation to take the temperature of the food items: Wore a glove on the left hand, held the thermometer in the gloved left hand, and with the non-gloved right hand grabbed a few alcohol wipes.With the non-gloved right hand, CK 2 opened the alcohol wipe, proceeded to wipe the thermometer with the non-gloved right hand, and stuck the thermometer in the seasoned beans and ham with the gloved left hand. CK 2 grabbed a new alcohol wipe with the non-gloved right hand, cleaned the thermometer with the non-gloved right hand, and proceeded to put the thermometer with the gloved left hand into the potatoes. CK 2 grabbed the used alcohol wipe that was previously used to clean the thermometer before putting it into the potatoes with the non-gloved right hand, proceeded to clean the thermometer with the non-gloved right hand, and placed the thermometer into the seas greens with the gloved left hand. CK 2 grabbed a new alcohol wipe with the non-gloved right hand, cleaned the thermometer with the non-gloved right hand, and proceeded to put the thermometer with the gloved left hand into the corn bread. During a concurrent observation and interview on 12/10/2025 at 12:19 p.m. with the DS, the DS stated dietary staff were not supposed to wear jewelry and indicated she had a watch on and should not be wearing it as particles can fall into the food. The DS stated hand washing should be done as much as possible, when removing gloves, touching something, and before picking something up. The DS stated spoons should not be kept in the upper arm pocket due to cross contamination. The DS stated when checking the temperature of foods, the staff is supposed to have gloves on both hands and should be wearing gloves when they open the alcohol wipes to sanitize the thermometer. The DS stated with the thermometer should be cleaned each time the temperature is being taken. During an interview on 12/11/2025 at 2:11p.m. with the DS, the DS stated if a tray goes out to the resident, even if the resident does not touch the tray, the items that were on the tray cannot go back into the fridge.During an interview on 12/11/2025 at 2:54p.m. with the Director of Nursing (DON), the DON stated hand hygiene is done before doing a procedure, before putting and after removing gloves, or when handling food before and after. The DON stated hand hygiene is done to prevent the spread of infection and hands should be completely dry. The DON stated if your hands were wet, you do not wipe your hands on clothes as the clothes might have unwanted bacteria, before putting and after removing gloves. The DON stated the lids of the trash should be closed to prevent unwanted flies and smell. The DON stated food items should be dated as you want to make sure that the food is stored during the appropriate duration of time and expired food should not be left as it can put the resident's health at risk. During a review of the facility's Policy and Procedure (P&P), titled Labeling/Date Marking and Safe Storage of Refrigerated & Frozen Foods revised date 1/1/2018, the P&P indicated any foods removed from original container will be properly labeled as follows: the name of the food item being stored and the date the food was removed from its original container and stored. During a review of the facility's P&P Introduction to the Food & Nutrition Services Department (FNS) undated, the P&P indicated proper sanitation shall be maintained during all stages of food delivery, storage, preparation, and service. During a review of the facility's P&P Dietary Directions, Inc. / Nutrition therapy Essentials, Inc. Food Service Policy and Procedures Manual dated 2018, the P&P indicated under miscellaneous, dry beans are good for 1 year. During a review of the facility's P&P Hand washing undated, the P&P indicated each employee will wash his or her hands frequently to eliminate visible dirt and reduce the bacterial load. When to wash: After touching hands to the face, hair, or clothing, between working with raw foods and ready to eat foods, after working with or cleaning dirty equipment or utensils, between glove changes, between any dirty to clean task. During a review of the facility's P&P Safety and Sanitation undated, the P&P indicated Food & Nutrition Services employees shall perform job responsibilities in a safe and sanitary manner. Employees are not allowed to bring personal items including but not limited to cell phones, purses, make-up bags, etc., into the food service production areas.

Based on observation, interview and record review, the facility failed to: a. Ensure the opened UTI -Stat (supplement support urinary health) bottle used for one of one resident (Resident 15) was labeled with a open date. b. Ensure the insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) pen for one of five residents (Resident 10) was labeled with an open date and expiration date. c. Ensure an open bottle of Multivitamins with minerals (supplement) for one of two residents (Resident 24) was labeled with an open date These deficient practices had the potential to result in medication errors. Findings: a. During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was admitted to the facility on [DATE] with diagnosis including Diabetes Mellitus ([DM]a disorder characterized by difficulty in blood sugar control), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and gout (a painful inflammatory arthritis). During a review of Resident 15's Minimum Data Set ([MDS] a resident assessment tool), dated 11/1/2025, the MDS indicated Resident 15 had intact cognition (ability to think and reason) and needed assistance with eating. During a review of Resident 15's Order Summary report, starting 1/2/2025, the order indicated UTI-Stat Oral Liquid administer 30 milliliters (ml) by mouth one time a day. During a concurrent observation and interview on 12/9/2025 at 8:45 a.m., Licensed Vocational Nurse (LVN) 1 was preparing Resident 15's UTI-Stat medication and LVN 1 stated there was no open date for the already opened UTI-Stat supplement. During a concurrent interview and record review 12/9/2025 at 8:47 a.m., with LVN 1, the UTI-Stat label was reviewed and the label indicated to discard after 3 months of opening. LVN 1 stated that the bottle need an open date so we can discard it after three months of opening. b. During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE] with diagnosis including DM. During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 had severely impaired cognition and Resident was dependent (helper does all the effort) on staff for all Activities of Daily Living ([ADLs] activities such as bathing, dressing and toileting a person performs daily) During a review of Resident 10's Order Summary report, starting 11/30/2025, the order indicated Lantus SoloStar 100 unit/ milliliter Solution Pen-Injector (medication that treats DM), inject 12 units subcutaneously (under the skin) two times a day. During a concurrent observation and interview on 12/10/2025 at 8:44 a.m., with the Registered Nurse Supervisor (RNS) of the medication cart for station 1, Resident 10's Lantus SoloStar pen-Injector was reviewed. The Lantus SoloStar pen-Injector was not dated and labeled with the new expiration date. The RNS stated the medication needed the date it was opened because it is only good for a prescribed time frame. During a review of the Lantus Prescribing information handout, revised 5/2025, the handout indicated that the insulin pen was good for 28 days after opening and stored at room temperature. During an interview on 12/12/2025 at 7:55 a.m. with the Director of Nursing (DON), the DON stated medications should be stored separately and need the date open indicated in the multi-use bottles or containers for residents' safety. c. During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and dementia (a progressive state of decline in mental abilities). During a review of Resident 24's H&P dated 10/17/2025, the H&P indicated Resident 24 did not have the capacity to understand and make decisions. During a review of Resident 24's MDS dated [DATE], the MDS indicated Resident 24 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment and was dependent when eating, oral hygiene, upper and lower body dressing, toileting hygiene, and bathing. During a review of Resident 24's Physician Order Summary dated 12/12/2025, the Order Summary indicated an order for multivitamin with minerals give one time a day for supplement. During a concurrent observation and interview on 12/11/2025 at 9:15 a.m. with LVN 4, LVN 4 was observed preparing medications for Resident 24. The multivitamin with minerals medication was observed with no open date indicating when the medication was opened. LVN 4 stated the multivitamin with minerals medication is not labeled with an open date, and medications should be labeled with an open date. During an interview on 12/12/2025 at 7:55 a.m. with the Director of Nursing (DON), the DON stated medications should be stored separately and need the date open indicated in the multi-use bottles or containers for residents' safety. During a review of the facility's P&P titled, Medication Storage in the Facility, revised 5/2022, the P&P indicated medications were stored following manufacturer's recommendations. The P&P indicted when the original seal of manufacturer's container is initially broken the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (NOTE: the best stickers to affix contain both a date opened and expiration notation line). The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating. During a review of the facility's P&P titled, Administering Medication, revised 12/2024, the P&P indicated when opening a multidose container, the date opened shall be recorded in the container.

Based on observation, interview and record review the facility failed to ensure Licensed Vocational Nurse (LVN) 1 administered two medications for one of two resident (Resident 15) with food as ordered by the physician. This resulted in the medication administration error rate of 7.41percent.Findings:During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was admitted to the facility on [DATE] with diagnosis including Diabetes Mellitus ([DM]a disorder characterized by difficulty in blood sugar control), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and gout (a painful inflammatory arthritis).During a review of Resident 15's Minimum Data Set ([MDS] a resident assessment tool), dated 11/1/2025, the MDS indicated Resident 15 had intact cognition (ability to think and reason) and needed set up assistance with eating.During a review of Resident 15's Order Summary report, starting 11/14/2024, the order indicated:1) Indomethacin Oral Capsule (medication for gout) 25 milligrams (mg), one capsule by mouth two times a day with instructions to take with food. 2) Metformin Oral Tablet (medication for DM) 500 mg, one tablet by mouth two times a day with instructions to take with food. During a concurrent observation and interview on 12/9/2025 at 8:45 a.m., LVN 1 administered Indomethacin and Metformin to Resident 15 and LVN 1 stated Resident 15 had breakfast earlier because there was no more breakfast tray at the bedside and the medications were not administered with food.During an interview on 12/9/2025 at 8:50 a.m., with Resident 15, Resident 15 stated she finished eating breakfast at 7:40 a.m.During an interview with the Director of Nursing (DON) on 12/12/2025 at 7:55 a.m. the DON stated medication error rate needs to be no greater than 5 percent. [KB1] The DON stated if the instructions indicate to give with food, then the medication needs to be administered with food otherwise it was an error. During a review of the facility's Policy and Procedure (P/P) titled, Medication-Administration, revised 12/2024, the P/P indicated the P/P was to ensure safe, timely medication administration as ordered.Cross reference: F755

Based on interview and record review, the facility failed to ensure one of five employees (Licensed Vocational nurse-LVN 3) had an active basic life support certification ([BLS] essential emergency care for cardiac/breathing arrest) . This failure had the potential to result in providing ineffective cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is performed when the heart stops beating) to a resident who is in cardiac arrest.Findings: During a concurrent interview and record review on [DATE] at 2:54 p.m. with the Director of Staff Development (DSD), LVN 3's employee file was reviewed. The DSD stated LVN 3 does not have an active BLS certification on file. During an interview on [DATE] at 11:29 a.m. with the Director of Nursing (DON), the DON stated all nursing staff including Certified Nurse Assistants (CNA)s, LVNs, and Registered Nurses (RNs) are required to have active, not expired, BLS certifications to ensure their skills are up to date with current standards. The DON stated, if nursing staff does not have active BLS certifications, there is a risk that they will provide ineffective cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is performed when the heart stops beating). The DON stated BLS certifications should be maintained in the employee's file. During a review of the facility's policy and procedure (P&P), titled Emergency Procedure - Cardiopulmonary Resuscitation, revised [DATE], the P&P indicated personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support), including defibrillation, for victims of sudden cardiac arrest. The P&P indicated the facility is to obtain and/or maintain America Red Cross or American Heart Association certification in basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel.

Based on interview and record review, the facility failed to inform the physician when a dialysis treatment was missed for one of two sampled residents (Resident 39). This failure had the potential to result in a delay of treatment, fluid overload and possible deterioration of the resident.Findings: During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening blood infection), osteomyelitis (inflammation of bone or bone marrow, usually due to infection), end stage renal disease (ESRD-irreversible kidney failure), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 39's History and Physical (H&P), dated 11/19/2025, the H&P indicated Resident 39 had the capacity to understand and make decisions. During a review of Resident 39's Minimum Data Set (MDS - a resident assessment tool), dated 11/20/2025, the MDS indicated Resident 39 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required setup assistance when eating and for oral hygiene, required moderate assistance (helper does less than half the effort) for upper and lower body dressing, required maximal assistance (helper does more than half the effort) for toileting hygiene, and was dependent for bathing. During an interview on 12/10/2025 at 12:20 p.m. with Resident 39, Resident 39 stated they missed a dialysis session one time. During a concurrent interview and record review on 12/11/2025 at 11:19 a.m. with Registered Nurse Supervisor (RNS) 1, Resident 39's medical record was reviewed. RNS 1 stated Resident 39 had orders for scheduled dialysis every Tuesday, Thursday, and Saturday at 8:00 a.m. RNS 1 stated there was no documentation indicating that Resident 39 received their scheduled dialysis on Tuesday 11/25/2025, and it was possible Resident 39 missed dialysis. RNS 1 stated there was no documentation indicating that the physician was notified that Resident 39 missed dialysis. RNS 1 stated the missed dialysis should have been communicated to the physician so that Resident 39 could have been determined if the resident required an additional dialysis session or evaluation. RNS 1 stated a missed dialysis puts Resident 39 at a risk for fluid overload. During an interview on 12/12/2025 at 11:20 a.m. with the Director of Nursing (DON), the DON stated it is important that the physician is notified of a missed dialysis session so that the physician can intervene and determine the next step. The DON stated if the physician is not notified, there is a risk of a delay of treatment or possible deterioration. During a review of the facility's policy and procedure (P&P), titled Change in a Resident's Condition or Status, revised February 2025, 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. During a review of the facility's policy and procedure (P&P), titled Physician Orders and Physician Notification, undated, the P&P indicated the facility ensures that all resident care is provided in accordance with timely, complete, and authenticated physician orders, and that physicians are promptly notified of significant changes in a resident's condition. The P&P indicated all orders and notifications shall be documented accurately to ensure continuity of care and regulatory compliance.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 63) received the Notice of Medicare Non-Coverage (NOMNC- a written notice that informs the resident of their last date of covered services and their right to appeal the decision) at least 48 hours prior to the last covered date. This failure had the potential for the resident to not receive the skilled treatment they may need and violate the residents' right to appeal the decision.Findings: During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including wedge compression fracture (when the front part of the bones of the spine body creating a wedge shape) of lumbar vertebra (lower back bones) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing).During a review of Resident 63's History and Physical (H&P), dated 9/23/2025, the H&P indicated Resident 63 had the capacity to understand and make decisions. During a review of Resident 63's Minimum Data Set (MDS - a resident assessment tool), dated 9/24/2025, the MDS indicated Resident 63 had no cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required setup assistance when eating and oral hygiene, required supervision for showering, and required moderate assistance (helper does less than half the effort) for toileting and upper and lower body dressing. During a review of Resident 63's Discharge instructions dated 10/14/2025, Resident was discharged home on [DATE]. During a concurrent interview and record review on 12/11/2025 at 2:40 p.m. with the Minimum Data Set Coordinator (MDSC) 1, Resident 63's Notice of Medicare Non-Coverage (NOMNC) dated 10/10/2025 was reviewed. The MDSC 1 stated Resident 39's inpatient skilled nursing services end date was 10/14/2025, and Resident 39 signed that they received the notice on 10/14/2025. MDSC 1 stated the resident should have received the NOMNC at least 48 hours prior to 10/14/2025. During an interview on 12/12/2025 at 11:26 a.m. with the Director of Nursing (DON), the DON stated residents should received the NONMC at least 2 days before discharge of skilled services to be informed of the changes to the care of services and inform the resident of their right to appeal. If the resident does not receive the NOMNC prior to discharge, it would violate the residents' right to appeal the decision, and the resident may not receive the skilled treatment they need.During a review of the facility's policy and procedure (P&P), titled Notice of Admission/Medicare Non-coverage (NAMNC) Policy, undated, the P&P indicated termination of skilled coverage is issued at least 2 days before medicare coverage ends or as soon as the decision is made.

Based on interview and record review the facility failed to ensure one of one resident's (Resident 3) Minimum data Set ([MDS] resident assessment tool), dated 11/28/2025, was coded accurately. This deficient practice resulted in an inaccurate assessment of Resident3's current health status and Resident 3's MDS erroneously indicated that Resident 3 received insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) because Resident 3 did not receive any insulin.Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 3's Minimum Data Set ([MDS] resident assessment tool), dated 11/28/2025, the MDS indicated Resident 3 had severe cognitive impairment. The MDS indicated Resident 3 received insulin injections for three days during the last 7 days or since admission. During a review of Resident 3's Medication Administration Record (MAR) for 11/2025 , the MAR did not indicate Resident 3 received insulin injections. During a review of Resident 3's Physician Orders dated 11/2025, the physician orders did not indicate Resident 3 received orders for insulin administration. During a concurrent interview and record review on 12/11/2025 at 11:58 a.m. with the Minimum Data Set Coordinator (MDSC)1, Resident 3's medical records were reviewed. The MDSC 1 stated Resident 3 did not have any orders for insulin, or receive insulin injections. The MDSC 1 stated Resident 3's MDS was inaccurately coded that the resident received insulin injections and should be amended because it was important to have an accurate picture of resident status.During an interview on 12/12/2025 at 7:55 a.m. with the Director of Nursing (DON), the DON stated assessments should be accurate and reflect the residents' plan of care and orders. During a review of the facility's policy and procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, undated, the P&P indicated any person completing a portion of the MDS must attest to the accuracy of the assessments.During a review of Resident Assessment Instrument (RAI - a standardized evaluation that helps healthcare providers assess a resident's needs, strengths, and preferences) manual, Chapter 1, dated October 2019, the RAI indicated the assessment accurately reflects the resident's status.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 39) received dialysis as ordered. This failure had the potential to result in a possible deterioration, fluid overload or even death.Findings: During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening blood infection), osteomyelitis (inflammation of bone or bone marrow, usually due to infection), end stage renal disease (ESRD-irreversible kidney failure), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 39's History and Physical (H&P), dated 11/19/2025, the H&P indicated Resident 39 had the capacity to understand and make decisions. During a review of Resident 39's Minimum Data Set (MDS - a resident assessment tool), dated 11/20/2025, the MDS indicated Resident 39 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required setup assistance when eating and for oral hygiene, required moderate assistance (helper does less than half the effort) for upper and lower body dressing, required maximal assistance (helper does more than half the effort) for toileting hygiene, and was dependent for bathing. During an interview on 12/10/2025 at 12:20 p.m. with Resident 39, Resident 39 stated they missed a dialysis session one time. During a concurrent interview and record review on 12/11/2025 at 11:19 a.m. with Registered Nurse Supervisor (RNS) 1, Resident 39's medical record was reviewed. RNS 1 stated Resident 39 had orders for scheduled dialysis every Tuesday, Thursday, and Saturday at 8:00 a.m. RNS 1 stated there was no documentation indicating that Resident 39 received their scheduled dialysis on Tuesday 11/25/2025, and it was possible Resident 39 missed dialysis. RNS 1 stated a missed dialysis puts Resident 39 at a risk for fluid overload. During an interview on 12/12/2025 at 11:20 a.m. with the Director of Nursing (DON), the DON stated it is important that for a resident who is dependent on dialysis, to receive dialysis as scheduled because it is the only way for the resident to expel the toxins in their body. The DON stated if the resident missed a session of dialysis, it places the resident at risk for a health deterioration or death. During a review of the facility's policy and procedure (P&P), titled Physician Orders and Physician Notification, undated, the P&P indicated the facility ensures that all resident care is provided in accordance with timely, complete, and authenticated physician orders, and that physicians are promptly notified of significant changes in a resident's condition. All orders and notifications shall be documented accurately to ensure continuity of care and regulatory compliance.

Based on interview and record review, the facility failed to ensure two of five employees (Certified Nurse Assistant [CNA] 2 and Restorative Nurse Assistant (RNA) 1) received a performance evaluation annually. This failure had the potential to result in employees not being at current skill level of care which could result in poor health outcomes.Findings: During a concurrent interview and record review on 12/11/2025 at 2:58 p.m. with the Director of Staff Development (DSD), CNA 2 and RNA 1's employee files were reviewed. The DSD stated CNA 2 and RNA 1 did not receive performance evaluations in the last twelve months. The DSD stated performance evaluations should be completed every year and filed in their employee file. The DSD stated if the staff do not receive performance evaluations annually, there is a risk the employee will underperform. During an interview on 12/12/2025 at 11:30 a.m. with the Director of Nursing (DON), the DON stated performance evaluations should be completed once a year or every twelve months. The DON stated if performance evaluations are not completed annually, there is a risk that employees skills are not up to the current standard level of care. During a review of the facility's policy and procedure (P&P), titled Performance Evaluations, revised 12/11/2025, the P&P indicated a performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter.

Based on interview and record review, the facility failed to implement the antibiotic stewardship program (effort to measure and improve how antibiotics are prescribed by clinicians) for one of three sampled residents (Resident 39).This deficient practice had the potential to increase antibiotic resistance and provide antibiotics without justification. Findings: During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening blood infection), osteomyelitis (inflammation of bone or bone marrow, usually due to infection), end stage renal disease (ESRD-irreversible kidney failure), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 39's History and Physical (H&P) dated 11/19/2025, the H&P indicated Resident 39 had the capacity to understand and make decisions. During a review of Resident 39's Minimum Data Set (MDS - a resident assessment tool), dated 11/20/2025, the MDS indicated Resident 39 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required setup assistance when eating and for oral hygiene, required moderate assistance (helper does less than half the effort) for upper and lower body dressing, required maximal assistance (helper does more than half the effort) for toileting hygiene, and was dependent for bathing. During a review of Resident 39's Physician Order Summary dated 12/12/2025, the Order Summary indicated an order for Ceftriaxone Sodium Solution (an antibiotic used to treat bacterial infections) 2 grams (GM- a unit of measurement), use 2 GM intravenously (IV-given through the vein) one time a day for right foot infection for 27 days, with a start date of 11/19/2025. During an interview on 12/10/2025 at 12:20 p.m. with Resident 39, Resident 39 stated they are currently receiving antibiotics for the right foot. During a concurrent interview and record review on 12/11/2025 at 1:34p.m. with the Infection Prevention Nurse (IPN), Resident 39's Individual Surveillance Form for Possible Infection and medical record was reviewed. The IPN stated the purpose of the surveillance form was to determine if the antibiotic meets the criteria and to prevent the growth of antibiotic resistant organisms. The IPN stated the screening for Mcgeer's criteria is determined on the paper form titled Individual Surveillance Form for Possible Infection. The IPN stated if a resident does not meet Mcgeer's criteria, the facility contacts the physician to inform them. The IPN stated the Individual Surveillance Form for Possible Infection for Resident 39 dated 11/18/2025 was incomplete and did not indicate whether Resident 39's Ceftriaxone sodium solution usage met Mcgeer's guidelines for a true infection or indicate that the physician was notified. The IPN stated a complete screening is done for all residents on antibiotics. The IPN stated it was unnecessary to inform the physician that the Mcgeer's criteria was not met if the infection was community acquired and the antibiotic was prescribed by the hospital. The IPN stated if they do not meet criteria, and the physician decides to continue the antibiotics, there should be documentation or a note. During an interview on 12/11/2025 at 11:24 a.m. with the Director of Nursing (DON), the DON stated it is important that all residents on antibiotics are screened using Mcgeer's criteria on admission for antibiotics stewardship including residents who are prescribed antibiotics from the hospital. The DON stated if Mcgeer's criteria was not met, the physician should be notified to prevent unnecessary usage of antibiotics. The DON stated if the physician decides to continue the antibiotic, there should be documentation that the physician was notified that a resident did not meet Mcgeer's criteria. During a review of the facility's policy and procedure (P&P), titled Antibiotic Stewardship Policy, undated, the P&P indicated the facility will implement an antimicrobial stewardship program which will promote appropriate use of antimicrobials.IP will be responsible for infection surveillance and MDRO tracking. IP will collect and review data, such as type of antimicrobial ordered and route of administration, ordering physician, whether appropriate tests such as cultures were obtained prior to antimicrobial being ordered.

Based on interview and record review the facility failed to ensure two of two residents (Resident 1 and 3) neurological checks (Neuro check -series of tests performed by healthcare providers to evaluate the function of the brain) were completed as indicated in the policy. This deficient practice had the potential to result in the delay of care and services which could result in poor health outcomes. Findings: A. During a review of Resident 1's admission record, the admission Record indicated the facility admitted Resident 1 originally on 3/14/2025 with a diagnosis including acute respiratory failure (a condition where you don't have enough oxygen in the tissues in your body or when you have too much carbon dioxide in your blood), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS), a resident assessment tool, dated 4/12/2025, the MDS indicated Resident 1 had severely impaired cognition. The MDS indicated Resident 1 needed set up assistance when eating, substantial assistance (helper does more than half the effort) with personal hygiene, and was dependent (helper does all the effort to complete the task) on staff with bathing, showering, and toileting hygiene. During a review of Resident 1's COC/Interact Assessment Form (SBAR), dated 4/25/2025 at 2:21 a.m., the SBAR (Situation Background Assessment Request - a communication tool used by healthcare workers when there is a change of condition among the residents) indicated Resident 1 had an unwitnessed fall at 2:20 a.m. During a review of Resident 1's Care plan report (untitled) a care plan for Resident actual all was initiated on 4/25/2025. The care plan interventions were to complete neuro checks as ordered. B. During a review of Resident 3's admission record, the admission Record indicated the facility admitted Resident 3 originally on 3/26/2025 with a diagnosis including Pneumonia (an infection/ inflammation of the lungs), meningitis (infection and inflammation of the brain and spinal cord), and abnormalities of gait and mobility. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had severely impaired cognition. The MDS indicated Resident 3 substantial assistance with eating and oral hygiene, and was dependent on staff with bathing, showering, toileting hygiene, personal hygiene, and dressing. During a review of Resident 3's COC/Interact Assessment Form (SBAR), dated 4/19/2025 at 6:02 p.m., the SBAR indicated Resident 3 had an unwitnessed fall at 3:20 p.m. During an interview and record review on 6/27/2025 at 1:43 p.m., with the Director of Nursing (DON), Resident 1 and 3's Neurological assessment Checklist were reviewed. The instructions on the form indicated, for the first 24 hours, complete the assessments every 30 minutes times (x) 2, then every hour x2, then every 2 hours x3, and then every 4 hours x4. The DON stated Resident 1's neuro checks for the first 24 hours were checked every 30 minutes x2, every hour x2, then every three hours x3. The DON stated Resident 3's neuro checks were completed every 30 minutes x2, then every 2 hours x2, then every 3 hours x2, every 4 hours x4. The DON stated the neuro checks were not completed at correct frequencies for both residents. The DON stated that neuro checks need to be completed as instructed. During a review of the facility's policy and procedure (P&P) titled, Neurological Assessment, revised 2/2025, the P&P indicated Neurological assessment will be completed following an unwitnessed fall. The P&P indicated neurological assessment will be performed with the frequency as per falls protocol.

Based on interview and record review, the facility failed to ensure a resident, who was assessed to have a cognitive (the mental process of thinking, learning, remembering, being aware of surroundings and using judgement) impairment and the inability to make medical decisions, was not allowed to leave from the facility against medical advice ([AMA] when a patient chooses to leave a hospital before the doctor recommends discharge) and they failed to ensure discharge planning was conducted for one of three sampled residents (Resident 1) when the facility was made aware that Resident 1's significant other had intentions of taking Resident 1 from the facility AMA. The facility failed to: 1. Ensure a plan for Resident 1's safe discharge was developed when the facility was made aware of Resident 1's significant other's desire to leave the facility, five days before Resident 1's significant other took Resident 1 from the facility without the facility's knowledge or permission. 2. Ensure Resident 1 was not taken from the facility by an unauthorized person (significant other) without the facility's knowledge or permission, resulting in Resident 1's whereabouts being unknown for two days, and upon location of Resident 1 at a homeless encampment, Resident 1 and the significant other were asked to discharge from the facility by signing an AMA form. 3. Ensure Resident 1 was assessed by facility staff, documenting Resident 1's medical condition when he was located at a homeless encampment two days after being taken from the facility, then asking Resident 1 and the significant other to sign the facility's AMA form, without prior discharge planning to ensure Resident 1 was safe and care was provided. 4. Ensure emergency medical services (911) were called to assess Resident 1's medical status and determine if Resident 1 required transport to a General Acute Care Hospital (GACH) for evaluation and treatment as needed instead they asked Resident 1 and the significant other to sign the facility's AMA form, discharging the from the facility without prior discharge planning to ensure Resident 1 was safely discharged . 5. Ensure Resident 1 and/or the significant other, who took him from the facility without the facility's knowledge or permission, was able provide care for Resident 1 before they (Resident 1 and the significant other) were asked to sign AMA discharge documents. These deficient practices resulted in Resident 1, who was incontinent (involuntary voiding of urine and stool), non-ambulatory (inability to walk) with medical conditions/diagnoses that required medication, and whose cognition was severely impaired, being removed from the facility by an unauthorized person without the facility's knowledge or permission. Resident 1's whereabouts were unknown to the facility for two days before he was found residing in a homeless encampment approximately two miles from the facility. Resident 1 was found lying on the floor in a dark tent on a thin mattress and was subjected to poor weather conditions, unsanitary environmental conditions, he was without medication, discharge instructions, caregiver training or provisions necessary to properly care for himself. These deficient practices placed Resident 1 at risk for deterioration of his medical condition, and death. On 12/11/2024 at 3:35 p.m. an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM) and Director of Nursing (DON) due to the facility's failures identify Resident 1's Responsible Party (RP), develop a safe discharge plan to facilitate Resident 1's discharge, and failure to ensure Resident 1's physical and mental status was assessed to determine his need for hospitalization following Resident 1's unknown whereabouts for two day. On 12/13/2024, the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 12/13/2024 at 5 p.m. in the presence of the facility's ADM, DON, and Director of Staff Development (DSD). The facility's IJPR included the following immediate actions: 1. Facility staff went to a homeless encampment at a park, located two miles from the facility, on 12/11/2024, at approximately 5 p.m. The Resident (Resident 1) and his tent were no longer at the same location. On 12/12/2024, at approximately 8:15 a.m., the DON drove by the local area park again where Resident 1 and his Responsible Party (significant other) were found. The DON confirmed that this was Resident 1. Resident 1 was not in any distress and had no signs of diminished cognitive response. Resident 1 was sitting in a wheelchair, his breathing was even and unlabored, he was asked his full name and date of birth, and he was able to respond appropriately. The DON called 911 and the paramedics arrived while the DON remained at the park. The paramedics asked Resident 1 if they could assess him, and he refused. The paramedics offered to take the Resident 1 to the hospital, he and the significant other refused. The paramedics informed the ADM and the DON that they could not force Resident 1 to go to the hospital against and they (Resident 1 and the significant other) had a right to refuse. Resident 1 refused transport with the paramedics and refused an offer to return to the facility. The facility offered Resident 1 and the significant other supplies, but Resident 1 and the significant other told facility representatives to stop bothering them. The DON attempted to notify the Resident 1's Physician at 10:30 a.m., and 3:30 p.m., on 12/12/2024. The Physician called back at 5:45 p.m., he was notified that Resident 1 refused to come back to the facility or go to the hospital to be evaluated. The Physician stated, Well, there is nothing we can do. They have the right to refuse. 2. The facility reviewed Resident 1's medical records, which were available during Resident 1's admission and confirmed the significant other was listed as his Responsible Party in his previous hospital records and his facility history and physical (H&P). The facility also confirmed that Resident 1 and the significant other once resided at the same address. The significant other refused to provide any identifying information to the paramedics or facility representatives on 12/12/2024, because the significant other said that information was personal. The significant other introduced herself to the paramedics as Resident 1's wife and caretaker. 3. On 12/12/2024 the facility Social Services Director (SSD), DON and Minimum Data Set ([MDS] resident assessment tool) nurse reviewed documents for all residents discharged in the past months from 11/12/2024 to 12/12/0224 (12 records), no deficient practices were identified. No other residents left the facility AMA in the past 3 months. 4. On 12/12/2024 the Continuous Quality Improvement (CQI) Nurse Consultant in-serviced all licensed nurses who were present and the Interdisciplinary Team ([IDT] a collaborative group composed of professionals from different disciplines who work together to achieve a common goal ) on the facility's policy and procedure pertaining to the discharge process, discharge planning, AMA, and care for residents with cognitive impairment and physical limitations. In-services were done with licensed nurses who were present on 12/11/2024, 12/12/2024 and 12/13/2024 on all shifts. Staff who were not present for the in-services will be in-serviced via phone and will be asked to sign the in-service form upon return to the facility. If unable to in-service via phone, staff will be in-serviced upon returning to work. Staff will not be returned to the floor until in-serviced. 5. On 12/12/2024, the DON and CQI Nurse Consultant reviewed all current residents' records (53) for presence of information about the responsible party, including contact information and followed up to request information for any residents missing this information. No discrepancies were found. 6. The facility will initiate discharge planning with the resident or resident's representative if the resident has no capacity to make decisions during initial social service assessment and discuss the discharge process and plan during the initial IDT care conference within one week of admission if the resident or representative agree and are available. 7. When a resident or resident's representative expresses the desire to leave the facility, the social service will call for a discharge plan meeting to discuss the resident's post discharge needs unless the plan is already in place. If a resident or representative expresses the desire or intention to leave facility AMA and the physician determines the resident is not ready for discharge and will not issue a discharge order, the facility will present the resident or the representative with information regarding the risks and the consequences of leaving and request that they sign an AMA form. The Physician will be notified regarding the AMA. 8. In the event that a resident leaves the facility without notice, the facility staff will assess the resident for any signs of injury or change of condition once located. The facility may transfer the resident to the emergency department (ED) for further evaluation if needed and the resident will be returned to the facility if the resident or the representative agrees. The facility will involve emergency services personnel as necessary. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a change in how the brain works due to an underlying condition that causes confusion, memory loss and loss of consciousness), status post (after or following) a stroke with right side hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a slight paralysis or weakness on one side of the body), functional quadriplegia (the lack of ability to use one's limbs or to ambulate due to extreme debility or frailty caused by another medical condition without physical injury or damage to the spinal cord), hypertension ([HTN] high blood pressure [BP]), dysarthria (speech that is slurred slow and difficult to understand), benign prostatic hypertrophy ([BPH] a condition in which the prostate is enlarged causing slow urine flow or blockage of urine from the bladder), a urinary tract infection ([UTI] an infection that affects all or part of the urinary tract including the bladder and kidneys), hypothyroidism (a condition when there is not enough hormones in the body to control the body's use of energy), generalized weakness and a history of repeated falls. The Face Sheet indicated there was no responsible person listed only a contact person (the significant other). The contact person listed had no documented contact information, such as address or telephone number. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 was not able to make decisions for himself, was incontinent of bladder and bowel functions, was non ambulatory, and was totally dependent on two or more staff to complete his activities of daily living ([ADLS] routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's H&P dated 11/23/2024, the H&P indicated Resident 1 was able to make his needs known but could not make medical decisions. During a review of Resident 1's Physician's Order, dated 11/22/2024, the Physician's Order indicated Resident 1 was incapable of giving informed consent (a process where a patient is given clear and comprehensive information about a particular action, procedure, or situation, to ensure they understand the risks, benefits, alternatives, and potential consequences of medical interventions) and he was unable to participate in his plan of care. During a review of Resident 1's Physician's Order, dated 11/22/2024 the Physician's Order indicated the following medications were prescribed to Resident 1: 1. Norvasc (a medication used to treat high blood pressure) 2.5 milligrams ([mg] a metric unit of measurement, used for medication dosage and/or amount) one tablet daily for HTN hold for systolic BP (the top number in a BP reading) of less than 100. 2. Doxazosin Mesylate (a medication used to treat urinary problems caused by an enlarged prostate, which includes difficulty urinating) 2.0 mg one tablet daily for BPH. 3. Lipitor (a medication that lowers cholesterol) 20 mg 1 tablet by mouth at bedtime for hyperlipidemia (abnormally elevated levels of any or all lipids [fats] in the blood). 4. Hydrocodone Acetaminophen (a pain medication) 5/325 mg one tablet every four hours as needed for moderate to severe pain 5. Levoxyl (a medication that contains and replaces a hormone) 50 micrograms ([mcg] a metric unit of measurement, used for medication dosage and/or amount) one tablet daily for hypothyroidism. 6. Protonix (a medication that treats gastroesophageal reflux ([GERD] a condition in which the stomach contents leak backwards from the stomach into the esophagus [the tube from the mouth to the stomach], and stomach ulcers) 40 mg one tablet daily for GERD. During a review of Resident 1's Physician's Progress Notes dated 11/27/2024, the Physician's Progress Notes indicated Resident 1 was admitted to the facility on [DATE] with a chief compliant of weakness and an altered level of consciousness ([ALOC] a condition of not being alert, awake or able to understand) for skilled rehabilitation (care that can help a person get back, keep, or improve abilities needed for daily life) with a goal of retraining Resident 1 to improve his coordination/balance, self-care abilities, pain management, and to monitor his cognition to reduce the risk of falls and accidents. During a review of Resident 1's untitled Care Plan, dated 11/25/2024, the Care Plan indicated Resident 1 needed retraining in skills to enable his return to community. The Care Plan's goal was for Resident 1 to be safely discharged to an appropriate level of care with interventions including collaboration with Resident 1, his RP and physician to ensure Resident 1's appropriate placement. The Care Plan indicated to follow up with home health services such as physical therapy ([PT] treatment that helps improve how the body performs physical movement), occupational therapy ([OT] treatment that focuses on helping individuals improve their ability to engage in meaningful ADLs) and nurse services, to provide education and training to Resident 1, and his RP as needed for safety, discharge instructions and a detailed summary of Resident 1's care upon discharge to assure his continuity of care. During a review of Resident 1's Nurses Progress Notes dated 11/25/2024 and timed at 4:14 p.m., and 5:43 p.m., and a subsequent Nurses Progress Notes dated 11/27/2024 and timed at 3:15 p.m., the Nurses Progress Notes indicated Resident 1's significant other (who was identified only as Resident 1's contact without any contact information provided) refused to sign Resident 1's admission documents, treatment plan and refused to provide her contact information. The Nurses Progress Notes indicated Resident 1's significant other wanted to take Resident 1 out of the facility. During a review of Resident 1's Social Services assessment dated [DATE] and timed at 3:39 p.m., the Social Services Assessment indicated Resident 1's significant other stated she would take Resident 1 out of the facility. During a review of Resident 1's Skilled Charting dated 11/28/2024 and timed at 1:14 p.m., the Skilled Charting indicated Resident 1's significant other threatened to take Resident 1 out of the facility AMA because she felt Resident 1 was not making any progress. During a review of Resident 1's Situation, Background, Assessment, Recommendation ([SBAR] a communication tool used by healthcare workers when there is a change of condition among the residents) dated 11/30/2024 and timed at 3:24 p.m., the SBAR indicated at 2:30 p.m., on 11/30/2024, the facility did not find Resident 1 in his bed and Resident 1's roommate reported Resident 1's significant other took Resident 1 for a walk. During a review of Resident 1's Social Service Note dated 12/2/2024 and timed at 5:48 p.m., the Social Service Note indicated Resident 1 and the significant other was located at a homeless encampment, paramedics were called for a wellness check but only a police officer arrived. The Social Service Note indicated Resident 1's significant other stated to the police officer, in the presence of the SSD, that Resident 1 would be okay with her because she had a hex on Resident 1. The Social Service Note indicated Resident 1 was able to state his name and birthdate and that he wanted to stay with the significant other, they (Resident 1 and the significant other) signed the facility's AMA form. During an interview on 12/4/2024 at 11 a.m., Resident 2 stated he was Resident 1's roommate and Resident 1 was not able to express himself and would only mumble. Resident 2 stated Resident 1 had a female visitor, referring to the significant other, that would visit him every other day. Resident 2 stated, on a Saturday afternoon (11/30/2024) he overheard the female visitor telling Resident 1 they were going for a walk, and they left the room with the female visitor pushing Resident 1 in a wheelchair. During an interview on 12/4/2024 at 5:21 p.m., the SSD stated the DON and other licensed nurses were aware (11/25/2024) that Resident 1's significant other voiced her intention of taking Resident 1 out of the facility AMA. The SSD stated on 11/30/2024 the significant other took Resident 1 out of the facility without staff knowledge or permission. The SSD stated on 12/2/2024 (two days after Resident 1 was taken from the facility) after 3 p.m., Resident 1 was found in a homeless encampment with the significant other, two miles away from the facility, they were living in a dark tent, and Resident 1 was lying on a thin mattress on the ground. The SSD stated she called the paramedics, but a police officer showed up. The SSD stated the police officer spoke to Resident 1 and determined Resident 1 was in no distress because he (Resident 1) knew his name, his date of birth and voiced he (Resident 1) wanted to stay at the homeless encampment with the significant other. The SSD stated Resident 1's significant other when questioned, stated not to worry about Resident 1 because she had a hex on him, and he would be okay. The SSD stated the DON had Resident 1 and the significant other signed the facility's AMA form. The SSD stated Resident 1's discharge was unsafe, and it was not the discharge process that the facility encouraged. The SSD acknowledged that Resident 1's significant other took the risk and put Resident 1 in a dangerous situation. During an interview on 12/4/2024 at 6:05 p.m., and a subsequent interview on 12/10/2024 at 2:30 p.m., the DON stated she and other members of the facility were aware of Resident 1's significant other's intention to take Resident 1 out of the facility AMA. The DON stated they did not notify Resident 1's physician of the requested AMA and there was no change of condition (COC), or care plan created to address the significant other's intention. The DON stated Resident 1's physician should have been notified of Resident 1's and/or the significant other's intention to leave the facility AMA so the physician could have had an opportunity to speak to Resident 1 and the significant other about the risks of leaving the facility AMA. The DON stated the goal of the facility was to discharge the residents properly to prevent any decline in health or other complications, but the decision was made to allow Resident 1 and the significant other to sign the AMA form because they could not force Resident 1 to come back to the facility. The DON stated she understood it was an unsafe discharge, but she felt the facility did everything they could for Resident 1. The DON acknowledged she did not assess Resident 1's health status when they found him at the homeless encampment after he was missing from the facility for two days, prior to allowing Resident 1 and the significant other to sign the AMA form, nor did they call the paramedics to transport Resident 1 to the GACH for an in-depth medical evaluation, but she could not answer why this was not done. During an interview on 12/9/2024 at 11:50 a.m., Certified Occupational Therapy Assistant (COTA 1) stated Resident 1 would only respond yes or no to questions, he needed a lot of cueing to stay on task and required maximal assist to complete his ADLs. COTA 1 stated Resident 1 and the significant other should have been trained prior to discharge from the facility to ensure Resident 1 would be assisted at home in a safe and effective manner. During an interview on 12/9/2024 at 2:06 p.m., and a subsequent interview on 12/10/2024 at 3:05 p.m., the ADM stated Resident 1 and the significant other were allowed to sign the AMA form because Resident 1 was able to state his name and birthdate three times and the significant other was Resident 1's family member. The ADM stated she and the other facility staff did not call the paramedics when they found Resident 1 at the homeless encampment because the police officer did not find Resident 1 to be in distress. The ADM stated she determined Resident 1 was not in distress based on his appearance and from the wellness check that the police officer did. During an interview on 12/10/2024 at 1:30 p.m., the Minimum Data Set Nurse (MDSN) stated she and the other members of the facility together with a police officer found Resident 1 at a homeless encampment with the significant other. The MDSN stated Resident 1 was living inside of a dark tent, lying on top of a thin mattress on the ground, there was no electricity, no water supply, and no means to dispose of their waste. The MDSN stated she and the DON did not assess Resident 1's health condition when they found him, nor did they call the paramedics to assess Resident 1's overall health condition. The MDSN stated they should have called 911 to ensure Resident 1 was taken to a GACH for evaluation and treatment as needed. During a telephone interview on 12/12/2024 at 6:09 p.m., Resident 1's Physician stated Resident 1 had no capacity to give consent, he was not able to participate in his plan of care, and he had no capacity to make medical decisions. The Physician stated, although he was not sure if Resident 1's significant other had a sound mind and mental capacity to make decisions or care for Resident 1, she was the person who visited Resident 1 at the GACH, and the facility assumed she was Resident 1's RP. The Physician stated Resident 1's discharge AMA was unsafe because Resident 1 was not properly prepared to transition to the community and he was living in a dire (a situation or event that causse great fear and worry) situation with no proper assistance with his ADLs, no medication, no electricity, unsafe/unsanitary living conditions and exposure to poor weather conditions. During a review of the facility's P/P titled Leaving Against Medical Advice/Without a Discharge Order/Elopement revised 3/25/2023 the P/P indicated the resident who can make their own decisions, has the right to decide whether or not to submit to medical treatment and rehabilitation services and if the resident wants to leave the facility and the physician concurs, the resident may be discharged and if the resident who can make their own decisions decides to leave the facility against the recommendation of the physician, the resident may sign out AMA. The P/P indicated residents who cannot make their own decisions, the conservator and/or the resident's representative will be contacted if she/he wishes to leave the facility and the resident's representative and/or conservator will be informed of the risks related to discharge. The P/P indicated, the resident's representative may make the decision on behalf of the resident and if the facility has concerns regarding the release of the resident, the facility's recourse is through the courts. The P/P indicated the physician or designee will attempt to provide the resident information regarding potential consequences of the action of risk of leaving and the benefits of staying in the facility, and any alternatives. The facility's P/P, titled Discharging the Resident revised 11/2023 indicated the facility must follow the guidelines of discharge process as follows: 1. Documentation of where the new location is 2. Determine who will provide for the resident's care and if the resident is discharged home, ensure the resident and/or responsible party receive teaching and discharge instructions, and 3. Conduct an assessment of the resident condition at discharge, including skin assessment and documentation

Based on observation, interview, and record review, the facility failed to ensure a newly hired licensed vocation nurse (LVN) was able to competently operate the portable oxygen equipment (the cylinder tank containing compressed oxygen and the regulator that controls the amount of oxygen flow) to prevent an accident for one of 14 sampled residents (Resident 8). Resident 8 fell on the floor when she was startled by LVN 4 when LVN 4 improperly opened the oxygen tank. As a result, Resident 8 sustained dark purple discoloration on the right side of the face and neck; a laceration on the upper right eyelid; right raccoon eye (dark purple discoloration around the eye, giving an appearance similar to that of a raccoon); red spots on the sclera (the white part of the eye), fracture of the right maxillary sinus (the area under the eye and above the upper teeth), and fracture of the right arm requiring the use of a sling (a device to immobilize an injured arm). Resident 8 was transported to the acute care hospital via 911 emergency services. Findings: On 12/18/14 at 8:25 p.m., during the initial tour in the presence of Registered Nurse (RN) 1, Resident 8 was observed lying in bed. The right side of the resident's face (from the right eyebrow to the jaw) and neck had dark and light purple discoloration. The area around the resident's right eye was swollen and had dark purple discoloration. The sclera of the resident's eye had red spots. On 12/18/14 at 8:28 p.m., during an interview, RN 1 stated, "The resident was readmitted last night (12/17/14) and had a right humerus (a long bone in the arm that runs from the shoulder to the elbow) fracture." On 12/19/14 at 7:50 p.m., during an interview, Resident 8 stated the purple discoloration on her face was caused by a fall in the dining room. Resident 8 stated LVN 4 was replacing the empty oxygen tank behind her (the resident) wheelchair. The resident stated she did not know if LVN 4 knew what she (LVN 4) was doing because she (the resident) could not see what was happening behind her wheelchair. During the interview with Resident 8, she stated that when the oxygen from the tank started escaping from the tank, a loud noise occurred. The resident stated the loud noise made her scared so she stood up from her wheelchair and fell on the floor. Resident 8 stated there were two people who tried to help LVN 4, but it took them awhile to turn off the sound from the tank. On 12/19/14 at 10 p.m., during an inspection of the oxygen tank storage room with LVN 3, there were 15 portable tanks that were full of oxygen observed. LVN 3 took an oxygen regulator (a device that adjust the precise air flow from the oxygen tank that has been prescribed by the doctor) from the storage cabinet and stated, during an interview, only the licensed nurses were allowed to set up and operate the portable oxygen equipment (the cylinder tank and the regulator). On 12/19/14 at 10:10 p.m., during an observation, LVN 3 attached the regulator to the top area of the oxygen cylinder tank (the cylinder post), opened the oxygen tank valve (a device that controls the flow of oxygen out of the tank) slowly, and then opened the liter flow rate meter (a device that controls how fast oxygen flows to the resident as ordered by the physician) on the regulator slowly. There was no loud hissing sound that came out from the oxygen tank. LVN 3 stated, during an interview, that if the oxygen equipment was set up properly and the oxygen tank valve was opened slowly, the pressure released from the oxygen tank would not create a loud sound. During the interview with LVN 3, he stated he had been working in the facility for about a year and he learned how to set up and operate the portable oxygen equipment prior to his employment to the facility. LVN 3 stated he did not remember if he received an orientation when he was newly hired at the facility and an in-service after his new hire orientation regarding how to correctly set up and operate the portable oxygen equipment. On 12/20/14 at 8:45 a.m., during an interview, the director of staff development (DSD) stated that during the new hire orientation, she would show the newly hired licensed nurse the oxygen storage room, but sometimes she would not conduct a demonstration of how to properly attach the oxygen regulator to the oxygen tank and then operate the equipment. During an interview with the DSD on 12/20/14 at 8 p.m., she stated LVN 4 started working in the facility on 9/18/14 and her previous nursing experience was in home health services. On 12/20/14 at 9:10 a.m., during an interview, the director of nursing (DON) stated she expected the licensed nurse to know how to set up and operate the portable oxygen equipment. The DON stated a newly hired licensed nurse would receive a two day orientation with the DSD and a one-to-one (1:1) training with a licensed nurse in the unit. The DON stated LVN 4 had been working in the facility for four months. During the interview with the DON, she stated the loud sound that startled Resident 8 was created by the leakage (released pressure) of the compressed gas (oxygen) from the oxygen tank that was full. The DON stated she had always informed the licensed nurses to explain to residents what they were about to do before executing a procedure. On 12/20/14 at 12:20 p.m., the DON stated the loud sound that the oxygen tank released occurred when LVN 4 opened the oxygen tank valve. On 12/20/14 at 1:25 p.m., during an interview, the director of rehab stated Resident 8 was receiving physical therapy (PT) and occupational therapy (OT) and had two to three weeks more of therapy remaining at the time the resident had a fall. The director of rehab stated that prior to the fall, Resident 8 was already able to walk about at least 200 feet using a walker before she would feel tired and would sit down. The director of rehab stated that after the accident, Resident 8 could not walk. During the interview with the director of rehab, he stated Resident 8 had a big decline in her function. According to the director of rehab, Resident 8 needed only stand by assist in bed mobility (turning) and transfer (such as sitting to standing), but currently, the resident was totally dependent on staff for bed mobility and transfer. The director of rehab stated, "She (Resident 8) had to stay longer here now." On 12/20/14 at 6:30 p.m., during an interview, LVN 5 stated the portable oxygen tank would release pressure when the valve is opened. In order for the pressure from the tank not to create a loud sound, LVN 5 stated, the oxygen regulator should be tightly placed on the oxygen tank and the valve should be opened slowly. LVN 5 stated she had trained new nurses in the evening shift and she would have the new nurse conduct a return demonstration because some new nurses had not set up and operated portable oxygen equipment before. A review of Resident 8's clinical record indicated the resident was admitted to the facility on [DATE] and she was transferred to the hospital on [DATE]. Resident 8 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was receiving oxygen continuously at two liters per minute via nasal cannula. According to the admission assessment Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/14/14, Resident 8 was alert, able to make her needs known and understand others, and required extensive assistance in bed mobility, transfer, walking in the corridor, dressing, and eating. A review of Resident 8's Fall Risk Evaluation, dated 10/7/14, the resident had a score of 14 (total score of 10 or above represents high risk). A review of the Licensed Personnel Progress Notes, dated 12/13/14, indicated Resident 8 was in the activity room at 2 p.m. when the resident requested to have her oxygen tank replaced. While being assisted by the charge nurse (LVN 4), the oxygen tank started releasing oxygen. Resident 8 panicked and stood up from the wheelchair and attempted to walk away from the wheelchair. Resident 8 lost her balance and fell on the floor on her right side. According to the licensed nurse progress notes, Resident 8 had a laceration on the right eyebrow and ice was applied right away. The resident did not have a change in level of consciousness and behavior. Upon physical assessment conducted by LVN 4, Resident 8 was noticed to have decreased mobility on her right arm. The resident complained of right should pain, 10/10 pain level (10 being severe pain using the pain scale from zero as no pain to 10). 911 emergency services were called and the resident was transported to the emergency room at 2:30 p.m. A review of the hospital's History and Physical, dated 12/13/14, indicated Resident 8 had a fall at the facility. Resident 8's physical examination indicated the resident had right raccoon eye with a small laceration in the upper eyelid with sutures intact. There was surrounding ecchymosis (bruising) in the right periorbital (around the eye) area, with minimal focal tenderness in the orbital (eye) floor area as well as the right maxillary sinus (the area under the eye and above the upper teeth). The History and Physical indicated Resident 8 also had moderate tenderness to palpation (a method of clinical examination using gentle pressure of the fingers) on the right lateral (side) aspect of the right shoulder, with limited range of motion (refers to the distance and direction a joint can move to its full potential) due to pain. Shoulder sling is in place. Resident 8 complained of intermittent diplopia (double vision) on the right eye. According to the History and Physical, the CT scan (x-ray computed tomography, a technology that uses computer-processed x-rays to produce images allowing the user to see inside the object without cutting) of Resident 8's brain indicated there was a fracture of the right maxillary sinus with hemorrhage (bleed) extending through a non-displaced (a break in a bone in which the bone remains aligned properly, despite being broken) right orbital (eye) floor fractures. Orbit (eye) is intact. The x-ray of Resident 8's right shoulder showed an impacted (a fracture in which the bone breaks into multiple fragments which are driven into each other) right humeral head and neck fracture (a break in the upper arm bone). A review of the facility's untitled document, dated 12/15/14, indicated Resident 8's laceration on her right eyebrow measured 1 centimeter (length) x 2 centimeters (width) x ? centimeter (depth) and first aid was provided. A review of the Licensed Personnel Progress Notes, dated 12/17/14, indicated Resident 8 was admitted back to the facility. On 12/18/14, Resident 8 was noted with difficulty feeding self due to limited use of her right upper extremity because of the recent fracture. A recommendation was made to provide the resident with a chopped diet to increase with self feeding using her left hand until the right upper extremity is healed. The rehab therapist recommended a plate guard to increase self feeding. A review of the initial Joint Mobility Assessment, dated 10/8/14, indicated Resident 8 was able to move her right shoulder within her functional limitations (WFL). After the fall on 12/13/14, the Joint Mobility Assessment, dated 12/18/14, indicated Resident 8's right shoulder had a severe joint mobility limitation (a reduction in the ability to move or perform the range of motion (ROM, refers to the distance and direction a joint can move to its full potential) from full ROM or WFL to zero thru 25% ROM). A review of the physician's orders [REDACTED]. A review of the Dietary Order Form, dated 12/18/14, indicated Resident 8 would need her food cut (chopped) in order to increase her self-feeding using her left hand until her right upper extremity is healed. A review of the facility's policy and procedure titled "Oxygen Therapy," undated, indicated "...Explain the procedure to the resident ...Connect flowmeter in the oxygen outlet. Be certain flowmeter is locked in place properly ..." The facility's policy and procedure did not indicate an instruction to guide the licensed nurses on how to open an oxygen tank valve that would prevent or minimize the release of a loud hissing sound.