Every finding on record at Culver West Health Center

Based on interview, and record review, the facility failed to complete the Annual Minimum Data Set (MDS-a resident assessment tool) Assessment timely for one of four sampled residents (Resident 4 and Resident 12) according to the facility's policy and procedures (P&P) titled, Resident Assessment Instrument, revised 1/2/2026, This deficient practice had the potential to negatively affect the provision of necessary care and services needed for Resident 4 and Resident 12.Cross Reference F640Findings: During a concurrent interview and record review with Minimum Data Set Coordinator (MDSN) on 7/9/2026 at 3:19 PM, Resident 4 and Resident12's most recent annual MDS assessments were reviewed. MDSN stated Resident 4 and Resident12's MDS was not completed at that time. MDSN stated the annual assessments were started on 6/8/2026 and should have been completed within 14 days (6/22/2026). MDSN stated the MDS delineates all the care services provided to the resident and not completing the MDS within CMS guidelines could lead to the facility not recognizing a change in the resident's condition. During an interview on 7/9/2026 at 3:25 PM, the Director of Nursing (DON) stated MDS assessments should be completed and submitted per CMS guidelines. A review of the facility's policy and procedures (P&P) titled, Resident Assessment Instrument, revised 1/2/2026, indicated the Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conduct timely and appropriate resident assessments and reviews according to the following schedule:a. Within fourteen (14) days of the resident's admission to the facility;b. When there has been a significant change in the resident's condition;c. At least quarterly; andd. Once every twelve (12) months.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a resident assessment tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for one out of the four sampled residents (Resident 4, Resident12) according to the facility's policy and procedures (P&P) titled, Resident Assessment Instrument, revised 1/2/2026, i . This deficient practice had the potential to result in delayed services for Resident 4 and This deficient practice had the potential to result in delayed services for Resident 12.Cross Reference F636Findings: A review of the facility's Centers for Medicare and Medicaid Services (CMS) Submission (transmission) Report dated 7/9/2026, indicated Resident 12's Annual MDS was submitted on 7/9/2026 (31 days after the assessment reference date (ARD), 6/8/2026. During a concurrent interview and record review with Minimum Data Set Coordinator (MDSN) on 7/9/2026 at 3:19 PM, Resident 4 and Resident12's most recent annual MDS assessments were reviewed. MDSN stated Resident 4 and Resident12's MDS was not completed at that time. MDSN stated the annual assessments were started on 6/8/2026 and should have been completed within 14 days (6/22/2026) and submitted within 14 days of the completion date (7/6/2026). During an interview on 7/9/2026 at 3:25 PM, the Director of Nursing (DON) stated MDS assessments should be completed and submitted per CMS guidelines. A review of the facility's policy and procedures (P&P) titled, Resident Assessment Instrument, revised 1/2/2026, indicated the Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conduct timely and appropriate resident assessments and reviews according to the following schedule:a. Within fourteen (14) days of the resident's admission to the facility;b. When there has been a significant change in the resident's condition;c. At least quarterly; andd. Once every twelve (12) months.

Based on observation, interview, and record review, the facility failed to contact and verify with a physician if one of one sampled resident (Resident 17) can continue to take apixaban (a prescription anticoagulant (blood thinner) 2.5 (dose) milligrams (mg - unit of measure) Atrial Fibrillation (AFib-an irregular and often very rapid heart rhythm which can lead to blood clot formation in the heart increasing the risk of stroke, heart failure and other heart-related complications). This deficient practice resulted in Resident 17 not receiving apixaban after 2/2026 and substantially placing Resident 17 at increased to suffer cardiovascular event, hospitalization and death. Findings: A review of Resident 17's medical record indicated Resident 17 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses thank include, type 2 diabetes mellitus (a long term metabolic condition where the body either resists the effects of insulin (a hormone that regulates sugar)), chronic systolic congestive heart failure (medical condition where the heart cannot pump blood efficiently), primary pulmonary hypertension (high blood pressure develops within the blood vessels of your lungs), persistent atrial fibrillation (a continuous, irregular heart rhythm that lasts longer than seven days), chronic kidney disease (a condition in which the kidneys are damaged and gradually lose their ability to filter waste and excess fluid from the blood), anemia (a medical condition where your body lacks enough healthy red blood cells or hemoglobin to effectively carry oxygen to your tissues), abnormalities of gait and mobility (medical condition that changes how you walk or move) and muscle weakness. A review of Resident 17's history and physical (H&P) dated 12/23/2025 indicated, Resident 17 is alert and oriented X4 (the patient is alert and oriented to person, place, time, situation). A review of Resident 17's Minimum Data Set (MDS - a resident assessment tool) dated 4/15/2026 indicated the resident 17's cognition (The mental ability to make decision of daily living) was intact, Resident 17 was independent with eating, required set-up or clean-up assistance for oral hygiene, required supervision with personal hygiene, Resident 17 required partial moderate assistance with toileting hygiene and upper body dressing, substantial maximal assistance with shower/bathe and was totally dependent for lower body dressing and putting on/taking off footwear. During a facility tour on 7/6/2026 at 9:27am Resident 17 stated he told several facility staff on multiple occasions (dates and times unknown) to give him a medication called apixaban (a prescription anticoagulant (blood thinner) 2.5 (dose) mg (unit of measure) that he had been previously prescribed by for his primary care physician for AFIB but has been unsuccessful in convincing them (licensed staff) of his need of medication. Resident 17 stated the last time he received his AFIB medication was 2/2026. During a concurrent interview and record review on 7/7/2026 at 11:02 am, with the Minimum Data Set Nurse -lead (MDSN) nurse stated Resident 17's current electronic medical administration record, indicated he (Resident 17) was not prescribed apixaban and/or any medication for atrial fibrillation. MDSN stated she would call the Resident 17's physician to check if Resident 17 still needed apixaban for atrial fibrillation. A review of Resident 17 electronic medical administration records history indicated an order for apixaban oral tablet 2.5mg for atrial fibrillation was discontinued on 12/21/2025. A review of Resident 17 medical records on 7/7/2026 at 12:08pm indicated an order for Apixaban oral tablet 2.5mg to be given by mouth two (2) times a day resumed on 7/7/2026 at 11:27 am. During an interview on 7/9/2026 at 1:15pm, Licensed Vocational Nurse (LVN) 2 stated, if a resident a medication that he/she has previously been prescribed, LVN2 would ask the resident why the needed the medication, verify the diagnosis, check the electronic medical record and inform the resident's physician of the residents request to have the medication started or resumed. LVN 2 stated stopping crucial medication like apixaban indefinitely exposes a resident to risk of stroke, heart attack, pulmonary embolism which could result in sudden death. During an interview on 7/9/2026 at 1:29pm, Director of Nursing (DON) stated if a Resident requests a medication that is not on his/her current ordered medication, licensed nurses should clarify with the primary care physician (PCP) if the resident needs the medication. DON stated, discontinuing apixaban indefinitely without justification, places a Resident at risk of developing blood clots which could lead to stroke. A review of the facility's policy and procedures (P&P) titled Resident Rights dated 1/12/2026, indicated, Federal and state laws guarantee certain basic rights to all resident of this facility. These rights include the Resident's right to be informed of and participate in, his or her.treatment, . have the facility to respond to his or her grievances.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices in the facility kitchen when: Refrigerator 1's internal temperature indicated 45 degrees Fahrenheit (F- unit to measure temperature - 41 degrees F or lower).Freezer 1's internal temperature indicated 10 degrees Celsius (C- unit to measure temperature - 17 degrees C or lower). These failures had the potential to result in cross contamination (transfer of harmful bacteria from one place to another) and an increased risk of foodborne illness (any illness resulting from eating contaminated or spoiled food) to the resident who consumed food from the facility's kitchen. Findings: During a concurrent observation and interview on 7/6/2026 at 9:05 A.M. with Dietary Aid (DA) 1 in the kitchen, Refrigerator 1's internal temperature indicated 45 degrees F (recommended temperature is 41 degrees F or lower). DA 1 stated 45 degrees F is too warm for the inside of the refrigerator. DA 1 also stated that if the internal temperature of a refrigerator is too warm, then the food could potentially become contaminated, and the residents can become sick. During a concurrent observation and interview on 7/6/2026 at 9:07 A.M. with DA 1 in the kitchen, Freezer 1's internal temperature indicated 10 degrees C (recommended -17 degrees C or lower). DA 1 stated that 10 degrees C is too warm for the inside of the freezer. DA 1 also stated that if the internal temperature of a freezer is too warm, then the food could potentially become contaminated, and the residents can become sick. During an interview on 7/7/2026 at 2:10 P.M. with the Dietary Supervisor (DS), the DS stated that internal temperatures of 45 degrees F (Refrigerator 1) and 10 degrees C (Freezer 1) are too warm. The DS stated that if food storage temperatures are too warm, this can potentially cause the food to be contaminated and result in the residents becoming sick. During a review of the facility's policy and procedure (P&P) titled, Procedure for Refrigerated Storage, dated 2023, indicated: Refrigerator - 41 degrees F or lower Freezer - 0 degrees F (-17 degrees C) or lower During a review of Food Code 2022, dated 1/18/2022, the Food Code 2022 page 105, indicated, Under refrigeration that maintains the food temperature at 5 degrees C (41 degrees F) or less.

Based on observation, interview, and record review, the facility failed to provide services and equipment to improve toileting and toilet transfer abilities for one of four sampled residents (Resident 5) who was continent (having voluntary control of urination and bowel movements) and able to walk and transfer (move from one surface to another) with assistance. This deficient practice resulted in Resident 5 wearing adult briefs (absorbent, disposable garments worn to manage bowel and bladder loss) and toileting in bed instead of walking to the bathroom or using a commode (portable toilet) due to lack of available toileting equipment for safe transfers, feelings of humiliation and low self-worth, and placed Resident 5 at risk for functional decline, skin breakdown (tissue damage caused by friction, shear, moisture, or pressure), and incontinence (having no or insufficient voluntary control over urination or bowel movements). Cross Reference F676 & F690 Findings: During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including, but not limited to end stage renal disease (ESRD, chronic kidney disease that causes gradual loss of kidney function), morbid obesity (chronic disease characterized by excessive body fat), muscle weakness, and benign prostatic hyperplasia with lower urinary tract symptoms (enlargement of the prostate gland causing urinary symptoms such as frequent urination). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 6/1/2026, the MDS indicated Resident 5 was cognitively (mental action or process of acquiring knowledge and understanding) intact. The MDS indicated Resident 5 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene and bathing, supervision or touching assistance with upper body dressing and walking 150 feet, set-up or clean-up assistance with sit to stand, bed to chair transfers, and toilet transfers, and was independent with eating, oral hygiene, rolling to both sides, and lying to sitting on the side of the bed. The MDS indicated Resident 5 was always continent of bowel and bladder. During an observation and interview on 7/7/2026 at 9:07 am with Resident 5, Resident 5 was lying in bed wearing adult briefs. Resident 5 stated he primarily used a bed pan (shallow pan used by immobile individuals to urinate or have a bowel movement while in bed) and urinal (reusable or disposable container designed for urinating without access to a standard toilet) for toileting and wore adult briefs daily for possible accidents because the toilet in the bathroom was too low and he did not have a commode or device that elevated the toilet seat. Resident 5 stated he was over six feet tall and could not safely transfer on and off the toilet in his bathroom because the toilet seat was too low. Resident 5 stated he tried to sit on the toilet in his bathroom in the past, got stuck, and required two staff members to assist him off the toilet. Resident 5 stated he informed staff and requested equipment to elevate the toilet seat or commode that could accommodate his weight and size multiple times, but staff never gave him equipment and instructed him to use a bedpan, urinal, and adult brief instead. Resident 5 stated he was able to walk, tried to be as independent as possible, and felt humiliated and degraded because he had to wear an adult brief and toilet in bed. During an interview and record review on 7/7/2026 at 3:02 pm with Occupational Therapist 1 (OT 1), OT 1 stated OT evaluated a resident's activities of daily living (ADL, basic activities such as eating, dressing, toileting) function and provided treatment and equipment recommendations to improve ADLs, such as toileting and toilet transfers. OT 1 reviewed Resident 5's OT Discharge summary, dated [DATE], and confirmed OT 1 discharged Resident 5 from OT services because Resident 5 was no longer progressing in ADLs and no longer required skilled therapy (services that require specialized training and experience of a licensed therapist or therapy assistant). OT 1 confirmed OT 1 documented Resident 5 required partial/moderate assistance for toilet transfers at the time of discharge from OT services on 3/22/2026. OT 1 stated OT 1 simulated the toilet transfer only in the rehab gym with a chair and therapy mat (padded surface used for therapy treatment) and did not observe or provide treatment to address toilet transfers using a regular toilet. OT 1 stated the chair and therapy mat in the rehab gym were higher than the toilet in Resident 5's room and was not an adequate simulation since they were not the same height. OT 1 stated Resident 5 was very tall and required specialized equipment such as a raised toilet seat (bathroom accessory that attaches over an existing toilet to add height) or commode to safely transfer onto the toilet for toileting because the toilet in his room was very low to the ground. OT 1 stated Resident 5 requested to practice toilet transfers during therapy but refused to practice using a regular shower chair which could be placed over the toilet to elevate the surface as OT 1 suggested. OT 1 stated she did not know why and did not investigate Resident 5's reason for refusal but thought he likely refused because the regular shower chair she suggested was not bariatric (specialized medical and mobility equipment used to support individuals with obesity) and was likely scared to try. OT 1 stated she did not offer to practice toilet transfers with other bariatric equipment and discharged Resident 5 from therapy without further attempts to maximize Resident 5's toileting and toilet transfer abilities because she assumed he would refuse. OT 1 stated she should have investigated Resident 5's reason for refusal, offered and issued alternative equipment to ensure safe toilet transfers, and practiced toilet transfers in Resident 5's room or simulated a transfer on a surface equal to the toilet height in Resident 5's room but did not. OT 1 stated Resident 5 was able to walk and should be walking to the bathroom or using a commode instead of using an adult brief, bedpan, or urinal to promote good hygiene, dignity, and independence. During an interview on 7/7/2026 at 3:25 pm with the Director of Rehabilitation (DOR), the DOR stated residents who are continent and able to walk should be walking to the bathroom for toileting and should not be toileting in bed. The DOR stated that facility staff must notify the Rehabilitation Department (Rehab) when residents require specialized equipment, such as a bariatric raised toilet seat or commode to ensure Rehab properly assessed the resident for safe transfers and provided the necessary equipment to prevent functional decline, prevent skin breakdown, and preserve dignity. During an interview on 7/7/2026 on 4:01 pm with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Resident 5 wore an adult brief and used a bed pan and urinal for toileting in bed. CNA 2 stated Resident 5 was able to walk and requested to use a regular toilet several times in the past but was not evaluated by Rehab and did not have the proper equipment to accommodate his height and weight for safe transfers in his bathroom. CNA 2 stated the toilet in his room was very low and the shower chair in the bathroom was not wide or high enough for safe transfers when placed over the toilet. During an interview on 7/8/2026 at 3:15 pm with the Director of Nursing (DON), the DON stated the facility provided Rehab evaluations, treatments, and nursing services to maintain and improve residents' abilities to perform ADLs. The DON stated that Rehab evaluates whether a resident can safely complete toilet transfers and determines the necessary equipment to ensure safe toilet transfers. The DON stated that if the facility did not provide the necessary opportunities, services, and equipment for residents who are continent and able to walk to maintain or improve ADLs by using a toilet or commode, residents may experience functional decline, skin breakdown, and embarrassment. During a review of the facility's undated Policy and Procedure (P&P) titled Activities of Daily Living (ADLs) Assistance, the P&P indicated the facility .is committed to maintaining and improving each resident's abilities in ADLs to the highest practicable level. Assistance will be provided based on the resident's assessed needs, preferences, and care plan, ensuring: promotion of resident independence and self-care where possible, respect for resident dignity, privacy, and choices, prevention of avoidable declines in ADL function, and timely and appropriate intervention for dependent residents.

Based on observation interview and record review, facility failed to provide a clear and concise policy and procedures (P&P) regarding storage of and accessibility to smoking materials (cigarettes, lighters, matches) for one out of one (1) sampled resident (Resident 17). This deficient practice had the potential to cause inconsistency and confusion for residents and staff by making it difficult to uniformly implement the policy and to ensure safety and compliance.Findings;A review of Resident 11's admission record indicated Resident 11 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that include chronic obstructive pulmonary disease (COPD- a group of progressive, incurable lung conditions that cause long-term breathing difficulties and restricted airflow), chronic pulmonary edema (an abnormal buildup of fluid in the air sacs (alveoli) and tissues of the lungs), alcohol abuse with intoxication (improper, excessive, or non-therapeutic use of a alcohol causing temporary, reversible condition of altered consciousness, judgment, and behavior), major depressive disorder (a persistently depressed mood or a profound loss of interest in activities, lasting at least two weeks), acute respiratory failure with hypoxia (a life-threatening condition where the lungs cannot put enough oxygen into the blood), tobacco use (habitual consumption of the tobacco products-cigarettes), generalized anxiety disorder (excessive, uncontrollable, and persistent worry about everyday events and activities) and, other psychoactive substance dependence (compulsive, uncontrollable need to use a drug or alcohol despite harmful consequences).A review of Resident 11's Minimum Data Set (MDS - a resident assessment tool) dated 6/6/2026 indicated the resident 11's cognition (The mental ability to make decision of daily living) was intact, Resident 11 required set-up or clean-up assistance for eating, required supervision with oral hygiene and upper body dressing, Resident 11 required partial moderate assistance with personal hygiene, substantial maximal assistance with toileting hygiene, shower/bathe and was totally dependent for lower body dressing and putting on/taking off footwear.A review of Resident 11's Smoker's Risk Assessment, dated 5/8/2026, indicated Resident 11 was an independent smoker. During an interview on 7/8/2026 at 1:12 pm, at bedside, Resident 11 stated he kept his own cigarettes with him while in the facility. During an interview on 7/8/2026 at 2:45 pm, the Activity Director (AD) stated Residents who demonstrate independent safe smoking abilities care are allowed to smoke independently without supervision, additionally, Residents are allowed to keep their own cigarettes but not lighters.During an interview on 7/9/2026 at 1:29 pm, Director of Nursing (DON) stated Residents who have been cleared to smoke independently via assessment are not supposed to keep their cigarettes at bedside because of safety and fire hazard.A review of facility's policy and procedures (P&P) provided by medical records while onsite on 7/8/2026 titled Smoking Policy dated 1/12/2026 indicated, the Residents are not permitted to keep smoking materials, lighters, matches or any other related items in their possession. Cigarettes, matches, lighters, and other materials will be kept by the designated staff of the facility.A review of facility's P&P titled provided electronically on 7/9/2026 titled Smoking Policy-Residents dated 1/12/2026 indicated Residents who have independent smoking privileges are permitted to keep cigarettes, pipes, tobacco, and other smoking articles in their possession.

Based on interview and record review, the facility failed to revise the comprehensive care plan for one of four sampled residents (Resident 5) by failing to discontinue the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) plan of care when Resident 5 was discharged from OT services on 3/22/2026. This deficient practice resulted in staff confusion of services provided and had the potential to negatively affect the delivery of necessary care and services.Cross Reference F550, F676, & F690 Findings During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including, but not limited to end stage renal disease (ESRD, chronic kidney disease that causes gradual loss of kidney function), morbid obesity (chronic disease characterized by excessive body fat), muscle weakness, and benign prostatic hyperplasia with lower urinary tract symptoms (enlargement of the prostate gland causing urinary symptoms such as frequent urination). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 6/1/2026, the MDS indicated Resident 5 was cognitively (mental action or process of acquiring knowledge and understanding) intact. The MDS indicated Resident 5 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene and bathing, supervision or touching assistance with upper body dressing and walking 150 feet, set-up or clean-up assistance with sit to stand, bed to chair transfers, and toilet transfers, and was independent with eating, oral hygiene, rolling to both sides, and lying to sitting on the side of the bed. The MDS indicated Resident 5 was always continent of bowel and bladder. During a review of Resident 5's comprehensive care plan, initiated 2/6/2026, the care plan indicated Resident 5 required skilled OT services to address limitations in activities of daily living (ADL, basic activities such as eating, dressing, toileting) participation and generalized weakness. The care plan indicated a goal for Resident 5 to increase safety while participating in ADLs and reduce the level of assistance required for ADLs and functional transfers. The care plan indicated interventions for OT to provide treatment five times a week for four weeks for self-care training, therapeutic exercises, therapeutic activities (functional and goal-oriented tasks designed to help patients regain independence in daily living), and neuromuscular re-education (rehabilitation techniques to restore muscle function and movement). During a review of Resident 5's Occupational Therapy Discharge Summary (OT Discharge Summary), dated 3/22/2026, the OT Discharge Summary indicated OT discharged Resident 5 from OT services on 3/22/2026 due to maximal potential achieved. During an observation and interview on 7/7/2026 at 9:07 am with Resident 5, Resident 5 was lying in bed. Resident 5 stated OT discharged him from therapy several months ago and did not understand the reason for discharge since he felt he was making significant progress and improvement. Resident 5 stated Restorative Nursing Aide (nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) services assisted with walking exercises a few times a week, but it was not enough for his recovery and needed more therapy to make him more independent. During an interview and record review on 7/8/2026 at 11:32 am with the Minimum Data Set Nurse (MDSN) and Minimum Data Set Assistant (MDSA), the MDSN stated licensed staff updated the comprehensive care plans quarterly, upon a change of condition (COC, major decline or improvement in a resident's status that will not resolve itself without intervention), and as needed. The MDSN stated the Rehabilitation Department (Rehab) was responsible for initiating, updating, and discontinuing therapy related services in the comprehensive care plan. The MDSN stated the MDSN and MDSA used information gathered from the OT evaluation and notes to determine the level of assistance and recommendations for interventions a resident required for all ADLs. The MDSN reviewed Resident 5's care plan and confirmed Resident 5 had a care plan for OT services, five times a week for ADLs and weakness. The MDSN stated she was unaware Resident 5 was discharged from OT services and thought OT was providing Resident 5 with OT services because the care plan indicated Resident 5 had OT services, five times a week. The MDSN stated it was important that staff updated the care plan because inaccurate care plans could result in staff confusion and lack of necessary services. During an interview and record review on 7/8/2026 at 12:06 pm with the Director of Rehabilitation (DOR), the DOR stated Rehab was responsible for initiating, updating, and discontinuing therapy related services in the comprehensive care plan upon admission, quarterly, and as needed. The DOR reviewed Resident 5's care plan and confirmed Resident 5 had an active care plan for OT services, five times a week to address ADLs and strengthening. The DOR reviewed Resident 5's OT Discharge summary, dated [DATE], and confirmed OT discharged Resident 5 from OT services on 3/22/2026 and was no longer receiving therapy services. The DOR stated OT should have discontinued the OT care plan when OT discharged Resident 5 from therapy services on 3/22/2026 but did not. The DOR stated that staff must update the care plan to accurately indicate the services being provided. The DOR stated that if staff did not update the care plan, it could result in staff confusion and lack of or delay of necessary care which could lead to functional and ADL decline. During an interview on 7/8/2026 at 3:15 pm with the Director of Nursing (DON), the DON stated staff developed comprehensive and individualized care plans for every resident to identify the type of care to provide the residents in the facility. The DON stated Rehab was responsible for initiating, updating, and discontinuing therapy and Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) care plans upon admission, quarterly, upon a COC, and as needed. The DON stated Rehab should discontinue the therapy care plan and create a new RNA care plan for functional maintenance once a resident was discharged from therapy services to ensure the residents received the proper care and staff were aware of the types of services the resident was or was not receiving. The DON stated staff must review and update care plans to accurately reflect services provided to ensure the facility provided the appropriate care the residents need to prevent decline. During a review of the facility's Policy and Procedures (P&P) titled Care Plans, Comprehensive Person-Centered, revised 1/12/2026, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The P&P indicated the Interdisciplinary Team must review and update the care plan when: there has been a significant change in a resident's condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview, and record review, the facility failed to provide services and equipment to improve toileting and toilet transfer abilities for one of four sampled residents (Resident 5) who was continent (having voluntary control of urination and bowel movements) and able to walk and transfer (move from one surface to another) with assistance. This deficient practice resulted in Resident 5 wearing adult briefs (absorbent, disposable garments worn to manage bowel and bladder loss) and toileting in bed instead of walking to the bathroom or using a commode (portable toilet) due to lack of available toileting equipment for safe transfers, feelings of humiliation and low self-worth, and placed Resident 5 at risk for functional decline, skin breakdown (tissue damage caused by friction, shear, moisture, or pressure), and incontinence (having no or insufficient voluntary control over urination or bowel movements).Cross Reference F550, F657, & F690Findings: During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including, but not limited to end stage renal disease (ESRD, chronic kidney disease that causes gradual loss of kidney function), morbid obesity (chronic disease characterized by excessive body fat), muscle weakness, and benign prostatic hyperplasia with lower urinary tract symptoms (enlargement of the prostate gland causing urinary symptoms such as frequent urination). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 6/1/2026, the MDS indicated Resident 5 was cognitively (mental action or process of acquiring knowledge and understanding) intact. The MDS indicated Resident 5 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene and bathing, supervision or touching assistance with upper body dressing and walking 150 feet, set-up or clean-up assistance with sit to stand, bed to chair transfers, and toilet transfers, and was independent with eating, oral hygiene, rolling to both sides, and lying to sitting on the side of the bed. The MDS indicated Resident 5 was always continent of bowel and bladder. During a review of Resident 5's Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Discharge Summary (OT Discharge Summary), dated 3/22/2026, the OT Discharge Summary indicated Resident 5 required partial/moderate assistance with toilet/commode transfers. The OT Discharge Summary indicated OT discharged Resident 5 from OT services due to maximal potential achieved. During an observation and interview on 7/7/2026 at 9:07 am with Resident 5, Resident 5 was lying in bed wearing adult briefs. Resident 5 stated he primarily used a bed pan (shallow pan used by immobile individuals to urinate or have a bowel movement while in bed) and urinal (reusable or disposable container designed for urinating without access to a standard toilet) for toileting and wore adult briefs daily for possible accidents because the toilet in the bathroom was too low and he did not have a commode or device that elevated the toilet seat. Resident 5 stated he was over six feet tall and could not safely transfer on and off the toilet in his bathroom because the toilet seat was too low. Resident 5 stated he tried to sit on the toilet in his bathroom in the past, got stuck, and required two staff members to assist him off the toilet. Resident 5 stated he informed staff and requested equipment to elevate the toilet seat or commode that could accommodate his weight and size multiple times, but staff never gave him equipment and instructed him to use a bedpan, urinal, and adult brief instead. Resident 5 stated he was able to walk, tried to be as independent as possible, and felt humiliated and degraded because he had to wear an adult brief and toilet in bed. During an interview and record review on 7/7/2026 at 3:02 pm with Occupational Therapist 1 (OT 1), OT 1 stated OT evaluated a resident's activities of daily living (ADL, basic activities such as eating, dressing, toileting) function and provided treatment and equipment recommendations to improve ADLs, such as toileting and toilet transfers. OT 1 reviewed Resident 5's OT Discharge summary, dated [DATE], and confirmed OT 1 discharged Resident 5 from OT services because Resident 5 was no longer progressing in ADLs and no longer required skilled therapy (services that require specialized training and experience of a licensed therapist or therapy assistant). OT 1 confirmed OT 1 documented Resident 5 required partial/moderate assistance for toilet transfers at the time of discharge from OT services on 3/22/2026. OT 1 stated OT 1 simulated the toilet transfer only in the rehab gym with a chair and therapy mat (padded surface used for therapy treatment) and did not observe or provide treatment to address toilet transfers using a regular toilet. OT 1 stated the chair and therapy mat in the rehab gym were higher than the toilet in Resident 5's room and was not an adequate simulation since they were not the same height. OT 1 stated Resident 5 was very tall and required specialized equipment such as a raised toilet seat (bathroom accessory that attaches over an existing toilet to add height) or commode to safely transfer onto the toilet for toileting because the toilet in his room was very low to the ground. OT 1 stated Resident 5 requested to practice toilet transfers during therapy but refused to practice using a regular shower chair which could be placed over the toilet to elevate the surface as OT 1 suggested. OT 1 stated she did not know why and did not investigate Resident 5's reason for refusal but thought he likely refused because the regular shower chair she suggested was not bariatric (specialized medical and mobility equipment used to support individuals with obesity) and was likely scared to try. OT 1 stated she did not offer to practice toilet transfers with other bariatric equipment and discharged Resident 5 from therapy without further attempts to maximize Resident 5's toileting and toilet transfer abilities because she assumed he would refuse. OT 1 stated she should have investigated Resident 5's reason for refusal, offered and issued alternative equipment to ensure safe toilet transfers, and practiced toilet transfers in Resident 5's room or simulated a transfer on a surface equal to the toilet height in Resident 5's room but did not. OT 1 stated Resident 5 was able to walk and should be walking to the bathroom or using a commode instead of using an adult brief, bedpan, or urinal to promote good hygiene, dignity, and independence. During an interview on 7/7/2026 at 3:25 pm with the Director of Rehabilitation (DOR), the DOR stated residents who are continent and able to walk should be walking to the bathroom for toileting and should not be toileting in bed. The DOR stated that facility staff must notify the Rehabilitation Department (Rehab) when residents require specialized equipment, such as a bariatric raised toilet seat or commode to ensure Rehab properly assessed the resident for safe transfers and provided the necessary equipment to prevent functional decline, prevent skin breakdown, and preserve dignity. During an interview on 7/7/2026 on 4:01 pm with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Resident 5 wore an adult brief and used a bed pan and urinal for toileting in bed. CNA 2 stated Resident 5 was able to walk and requested to use a regular toilet several times in the past but was not evaluated by Rehab and did not have the proper equipment to accommodate his height and weight for safe transfers in his bathroom. CNA 2 stated the toilet in his room was very low and the shower chair in the bathroom was not wide or high enough for safe transfers when placed over the toilet. During an interview on 7/8/2026 at 3:15 pm with the Director of Nursing (DON), the DON stated the facility provided Rehab evaluations, treatments, and nursing services to maintain and improve residents' abilities to perform ADLs. The DON stated that Rehab evaluates whether a resident can safely complete toilet transfers and determines the necessary equipment to ensure safe toilet transfers. The DON stated that if the facility did not provide the necessary opportunities, services, and equipment for residents who are continent and able to walk to maintain or improve ADLs by using a toilet or commode, residents may experience functional decline, skin breakdown, and embarrassment. During a review of the facility's undated Policy and Procedure (P&P) titled Activities of Daily Living (ADLs) Assistance, the P&P indicated the facility .is committed to maintaining and improving each resident's abilities in ADLs to the highest practicable level. Assistance will be provided based on the resident's assessed needs, preferences, and care plan, ensuring: promotion of resident independence and self-care where possible, respect for resident dignity, privacy, and choices, prevention of avoidable declines in ADL function, and timely and appropriate intervention for dependent residents.

Based on observation, interview, and record review, the facility failed to provide one of one (1) sampled resident (Resident 17) with the opportunity to make choices about aspects of his (Resident 17's) care planning that is significant to the resident overall health and well-being according to the facility's policy and procedures (P&P) titled Resident Rights dated 1/12/2026. This deficient practice denied Resident 17 the right to be informed of and participate in his treatment plan with the potential to affect Resident 17's ability to attain or maintain his highest practicable physical, mental, and psychosocial well-being. Findings: A review of Resident 17's medical record indicated Resident 17 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses thank include, type 2 diabetes mellitus (a long term metabolic condition where the body either resists the effects of insulin (a hormone that regulates sugar)), chronic systolic congestive heart failure (medical condition where the heart cannot pump blood efficiently), primary pulmonary hypertension (high blood pressure develops within the blood vessels of your lungs), persistent atrial fibrillation (a continuous, irregular heart rhythm that lasts longer than seven days), chronic kidney disease (a condition in which the kidneys are damaged and gradually lose their ability to filter waste and excess fluid from the blood), anemia (a medical condition where your body lacks enough healthy red blood cells or hemoglobin to effectively carry oxygen to your tissues), abnormalities of gait and mobility (medical condition that changes how you walk or move) and muscle weakness. A review of Resident 17's history and physical (H&P) dated 12/23/2025 indicated, Resident 17 is alert and oriented X4 (the patient is alert and oriented to person, place, time, situation). A review of Resident 17's Minimum Data Set (MDS - a resident assessment tool) dated 4/15/2026 indicated the resident 17's cognition (The mental ability to make decision of daily living) was intact, Resident 17 was independent with eating, required set-up or clean-up assistance for oral hygiene, required supervision with personal hygiene, Resident 17 required partial moderate assistance with toileting hygiene and upper body dressing, substantial maximal assistance with shower/bathe and was totally dependent for lower body dressing and putting on/taking off footwear. During a facility tour on 7/6/2026 at 9:27am Resident 17 stated he told several facility staff on multiple occasions (dates and times unknown) to give him a medication called apixaban (a prescription anticoagulant (blood thinner) 2.5 (dose) mg (unit of measure) that he had been previously prescribed by for his primary care physician for AFIB but has been unsuccessful in convincing them (licensed staff) of his need of medication. Resident 17 stated the last time he received his AFIB medication was 2/2026. During a concurrent interview and record review on 7/7/2026 at 11:02 am, with the Minimum Data Set Nurse -lead (MDSN) nurse stated Resident 17's current electronic medical administration record, indicated he (Resident 17) was not prescribed apixaban and/or any medication for atrial fibrillation. MDSN stated she would call the Resident 17's physician to check if Resident 17 still needed apixaban for atrial fibrillation. A review of Resident 17 electronic medical administration records history indicated an order for apixaban oral tablet 2.5mg for atrial fibrillation was discontinued on 12/21/2025. A review of Resident 17 medical records on 7/7/2026 at 12:08pm indicated an order for Apixaban oral tablet 2.5mg to be given by mouth two (2) times a day resumed on 7/7/2026 at 11:27 am. During an interview on 7/9/2026 at 1:15pm, Licensed Vocational Nurse (LVN) 2 stated, if a resident a medication that he/she has previously been prescribed, LVN2 would ask the resident why the needed the medication, verify the diagnosis, check the electronic medical record and inform the resident's physician of the residents request to have the medication started or resumed. LVN 2 stated stopping crucial medication like apixaban indefinitely exposes a resident to risk of stroke, heart attack, pulmonary embolism which could result in sudden death. During an interview on 7/9/2026 at 1:29pm, Director of Nursing (DON) stated if a Resident requests a medication that is not on his/her current ordered medication, licensed nurses should clarify with the primary care physician (PCP) if the resident needs the medication. DON stated, discontinuing apixaban indefinitely without justification, places a Resident at risk of developing blood clots which could lead to stroke. A review of the facility's policy and procedures (P&P) titled Resident Rights dated 1/12/2026, indicated, Federal and state laws guarantee certain basic rights to all resident of this facility. These rights include the Resident's right to be informed of and participate in, his or her.treatment, . have the facility to respond to his or her grievances.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 6), who was assessed as at risk to develop pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) and was admitted without pressure ulcers, received the necessary care and services to prevent pressure ulcer from developing, by failing to:Prevent Resident 6 from developing a right heel pressure injury while residing in the facilityRevise the resident right heel skin impairment care plan interventions These deficient practices had the potential for Resident 6 not to receive the necessary care and services to prevent the development of pressure ulcer.Findings: A review of Resident 6's admission Record indicated the facility admitted the resident on 2/10/2026 and with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), muscle weakness and right hip fracture. A review of Resident 6's Admit/Readmit Assessment, dated 2/10/2026, indicated the resident required extensive assistance with bed mobility and the resident did not have any pressure injuries. A review of Resident 6's Braden Scale (pressure sore risk predictor tool) dated 2/10/2026, indicated Resident 6 had a Braden score of 16 which indicated the resident in the at risk category to develop a pressure injury. A review of Resident 6's History and Physical (H&P), dated 2/11/2026, indicated Resident 6 on had a history of multiple falls and was admitted to the facility on [DATE] after a hospital stay after the resident fell and sustained a right hip fracture. A review of Resident 6's admission Minimum Data Set (MDS- a resident assessment tool) dated 2/13/2026, indicated the resident's cognition (ability to think, understand, and reason) was moderately impaired. The MDS indicated Resident 6 required substantial assistance with bed mobility. The MDS also indicated Resident 6 was dependent upon staff for oral hygiene, showering, dressing and toileting hygiene. The MDS also indicated Resident 6 was always incontinent, was at risk for developing pressure ulcers, and did not have any unhealed pressure ulcers. A review of Resident 6's Quarterly MDS, dated [DATE], indicated Resident 6 had one unstageable pressure injury. A review of Resident 6's Wound Physician Progress Note, dated 2/13/2026, indicated the resident had one wound described as a surgical wound to the right hip. The Wound Progress Note did not indicate the resident had any other wounds. A review of Resident 6's Wound Physician Progress Note, dated 2/20/2026, indicated the wound physician was asked to evaluate and treat the resident's wounds. The progress note indicated the resident had two wounds, a right hip surgical wound and a stage 3 sacral coccyx pressure ulcer (Full-thickness loss of skin. Dead and black tissue may be visible). A review of Resident 6's Wound Physician Progress Note, dated 2/27/2026, indicated the resident had developed a third wound, a right heel (DTI - purple or maroon colored area of discolored intact skin developed due to damage of underlying soft tissue from pressure). A review of Resident 6's physician orders regarding the treatment of the resident's right heel were as follows:-On 2/23/2026 the facility was to cleanse Resident 6's right heel wound cleansed with normal saline, pat dry, paint with betadine, cover with dry dressing then wrap with kerlix (a stretchy fluffy gauze) every day and as needed for 21 days- On 2/27/2026 Resident 6's right heel was to be cleansed with normal saline, pat dry, apply betadine, cover with abdominal pad (ABD - a thick, high absorbent medical bandage), wrap with rolled gauze, secure with tape every day and as needed for 21 days- On 4/21/2026, the resident's right heel pressure ulcer was to be cleansed with normal saline, pat dry, apply hydrogel (a jelly like wound dressing that adds moisture to the wound and doesn't stick to the wound), cover with xeroform (a non-adherent mesh gauze dressing impregnated with Vaseline and a deodorizing and antimicrobial agent apply donut or abdominal pad (ABD) with a hole cut 2 layers, secure with rolled gauze every other day and as needed for 30 days-on 4/28/2026 Resident 6's right heel pressure injury was to be cleansed with normal saline, pat dry, apply Santyl ointment (a prescription ointment used to remove dead tissue from pressure injuries) , cover with ABD pad, secure will rolled gauze every day and as needed for 30 days-on 6/29/2026 the treatment indicated staff were to cleanse with normal saline, pat dry, apply Santyl ointment, calcium alginate, cover with ABD pad and rolled gauze every day; and-On 7/3/2026, the physician ordered Resident 6's right heel to be cleansed with NS, pat dry, apply Santyl ointment, collagen sheet (a soft biodegradable pad that promotes new tissue growth), cover with ABD pad and rolled gauze every day During a record review on 7/7/2026 at 9:57 AM, Resident 6's care plans were reviewed. Resident 6's Actual Impairment to Skin Integrity of the Right Hell care plan indicated the impairment was a deep tissue pressure injury. The goal was for the resident to have no complications from the pressure injury (PI). The care plan interventions included to provide the resident with heel protectors at all times when in bed. The care plan interventions also indicated the treatment for the wound was to cleanse with normal saline (NS - a saltwater solution), pat dry, paint with betadine, cover with dry dressing then wrap with kerlix. The care plan did not address Resident 6 not wearing both heel protectors or the Pressure Relief Ankle Foot Orthosis (Prafo- boot isa highly adjustable brace designed to treat foot drop [is the inability to lift the front part of the foot, causing the foot to drag or slap the ground when walking], manage contractures [are structural changes to your soft and connective tissues that cause them to stiffen, tighten and contract], and offload heel pressure). The care plan also did not include the current physician wound treatment order of cleansing the site with normal saline, applied Santyl ointment, collagen sheet cover with an abdominal pad and wrap with rolled gauze. During a concurrent interview and observation on 7/6/2026 at 10:20 AM, Resident 6 was observed laying in bed. The resident was laying on a low air loss mattress (LALM-mattress designed to treat and prevent pressure ulcers). The resident's feet were bare and there was a kerlix wrapped around the resident's right heel and ankle. Resident 6 stated Licensed Vocational Nurse (LVN) 3 changed the dressing today. During a concurrent interview and observation on 7/8/2026 at 10:16 AM, Resident 6's wound care was observed. Resident 6 was observed wearing a Pressure Relief Ankle Foot Orthosis (PRAFO - a specialized medical device) boot to the right foot. Resident 6's left foot did not have a heel pad or PRAFO boot. LVN 3 removed the dressing that was in place and stated the wound was 50 percent slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps) and 50 percent granulation (new tissue). LVN 3 proceeded to administer the current wound treatment of cleansing the site with normal saline, applied Santyl ointment, collagen sheet cover with an abdominal pad and wrap with rolled gauze. LVN 3 also stated the wound physician determined Resident 6 only needed to wear the PRAFO boot on his right foot. During an interview on 7/8/2026 at 12:14 PM, Certified Nursing Assistant (CNA) 3 stated Resident 6 only wears one PRAFO boot on the right foot. CNA 3 stated it was their understanding that the resident only needed to wear the boot on the right foot. During a concurrent observation at Resident 6 was observed wearing a PRAFO boot on the right foot and the left PRAFO boot was observed in the resident's room closet. During a concurrent interview and record review on 7/09/2026 at 10:17 AM, Resident 6's electronic medical record was reviewed. LVN 3 stated the facility admitted Resident 6 on 2/10/2026. LVN 3 stated Resident 6 developed the right heel pressure injury in the facility on 2/23/2026. During a review of Resident 6's care plans, LVN 3 stated Resident 6's right heel skin impairment care plan was not updated when the physician determined Resident 6 could only wear the PRAFO boot on the right heel and was not updated with the current wound treatment orders until today (7/9/2026) for Resident 6. LVN 3 stated the care plan addresses how a resident's care is to be administered and the goal. LVN 3 stated not updating the care plan could lead to the resident not receiving the care they require. During an interview on 7/9/2026 at 1:24 PM, the Director of Nursing (DON) stated the care plan is part of the nursing process and guides the assessment, planning and decision on the appropriate interventions to provide the resident. The DON also stated a resident's wound care plan should be updated as needed and should include the current treatment order, medications to facilitate wound healing. The DON further stated not updating the care plan may result in the resident receiving the wrong interventions and the wound could worsen. A review of the facility's policy and procedures (P&P) titled, Prevention of Pressure Ulcers/Injuries, revised 1/12/2026, indicated, staff were to review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable and staff were to review the interventions and strategies for effectiveness on an ongoing basis. A review of the facility's (P&P),Care Plans, Comprehensive Person- Centered, revised 1/12/2026, indicated, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion (ROM, full movement potential of a joint) for two of four sampled residents (Residents 9 and 10) with ROM and mobility (ability to move) concerns by failing to: Ensure Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) provided passive ROM (PROM, movement at a given joint with full assistance from another person) exercises to Resident 9's left elbow and left knee in accordance with physician's orders, dated 2/19/2027.Objectively (unbiased, based on facts) measure Resident 10's ROM impairments of both shoulders during the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday activities) evaluation, dated 4/2/2026.These deficient practices had the potential to cause ROM decline leading to contractures (loss of motion of a joint associated with stiffness and joint deformity) and an overall decline in physical functioning and activities of daily living (ADL, basic activities such as eating, dressing, toileting). Findings: 1. During a review of Resident 9's admission Record (AR), the AR indicated Resident 9 initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including, but not limited to left-sided hemiplegia (weakness to one side of the body), contracture of an unspecified joint (where two bones meet), and muscle wasting and atrophy (thinning or loss of muscle tissue). During a review of Resident 9's Order Summary Report (OSR), the OSR indicated a physician's order, dated 2/19/2026, for RNA to provide PROM exercises to Resident 9's both arms and both legs, seven times a week. During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool), dated 5/13/2026, the MDS indicated Resident 9 had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment for daily decision making. The MDS indicated Resident 9 required substantial/maximal assistance (helper does more than half the effort) for rolling to both sides and sit to lying and required dependent assistance (helper does all the effort or required the assistance of two of more helpers for the resident to complete the activity) for hygiene, bathing, dressing, and bed to chair transfers. The MDS indicated Resident 9 had functional ROM limitations (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in one arm and one leg. During an observation of Resident 9's RNA session on 7/8/2026 at 10:40 am, in Resident 9's room, Resident 9 was lying in bed. Resident 9 was wearing a left-hand splint (a firm device used to stabilize and immobilize an injured bone or joint) and the left elbow was fully straight. Resident 9's both hips and knees were straight with both feet pointing downwards towards the foot of the bed. Restorative Nursing Aide (RNA) 2) stood on Resident 9's right side and provided PROM to Resident 9's right shoulder, elbow, wrist, hand, hip, knee, and ankle. RNA) 1 stood on Resident 9's left side and assisted with PROM to Resident 9's left shoulder, wrist, hip, and ankle. RNA 1 did not provide PROM to Resident 9's left elbow, fingers, or knee. During an interview on 7/8/2026 at 10:51 am with RNA 1, RNA 1 confirmed RNA had orders to provide PROM to Resident 9's both arms and both legs which meant assisting Resident 9 with ROM exercises to the entire leg, including the hips, knees, and ankles and to the entire arm, including the shoulder, elbow, wrist, and hand. RNA 1 stated she provided PROM to Resident 9's left wrist and left hand in the morning before applying the left-hand splint and confirmed she did not assist with ROM exercises to Resident 9's left elbow and left knee during the RNA session. RNA 1 stated that staff must perform PROM exercises for Resident 9's arms and legs because Resident 9 could not follow directions and has extremely stiff and contracted joints, especially in the left elbow and left knee. RNA 1 stated she should have assisted Resident 9 with left elbow and left knee ROM exercises as ordered but did not. RNA 1 stated if RNA did not provide exercises as ordered, it could result in ROM decline. During an interview on 7/8/2026 at 12:06 pm with the Director of Rehabilitation (DOR), the DOR stated the purpose of the RNA program was to maintain and improve a resident's functional level and ROM after discharge from therapy. The DOR stated Rehab determined the types of exercises RNAs were to perform when creating an RNA program. The DOR stated if an RNA order was written for ROM exercises to both legs, it was expected the RNA provide ROM exercises to the entire leg, which included the hips, knees, and ankles. The DOR stated if an RNA order was written for ROM to both arms, it was expected the RNA provide ROM exercises to the entire arm, which included the shoulder, elbow, wrist, and hand. The DOR stated if RNA did not provide RNA services as ordered, it could potentially result in a decline in ROM and ADLs and contracture development. During an interview on 7/8/2026 at 3:15 pm with the Director of Nursing (DON), the DON stated it was important for RNA to provide exercises as ordered to ensure the residents in the facility maintained their level of function and to prevent potential declines in mobility, ADLs, and contracture development. During a review of the facility's Policy and Procedures (P&P) titled, Resident Mobility and ROM, revised 1/12/2026, the P&P indicated residents will not experience an avoidable reduction in ROM and residents with limited ROM will receive treatment and services to increase and/or prevent a further decrease in ROM. The P&P indicated the care plan will include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and ROM. During a review of facility's P&P titled, Restorative Nursing Services, revised 1/12/2026, the P&P indicated residents will receive restorative nursing care as needed to help promote optimal safety and independence. 2. During a review of Resident 10's admission Record (AR), the AR indicated Resident 10 initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including, but not limited to chronic obstructive pulmonary disease (COPD, lung disease that causes obstruction of airflow and can limit normal breathing), Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), and weakness. During a review of Resident 10's OT Evaluation and Plan of Treatment (OT Evaluation), dated 4/2/2026, the OT Evaluation indicated Resident 10's ROM of both shoulders were impaired. The OT Evaluation did not indicate objective measurements and degree of ROM movement for Resident 10's both shoulders. During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 had moderate cognitive impairment. The MDS indicated Resident 10 required supervision or touching assistance for eating and rolling to both sides, partial/moderate assistance (helper does less than half the effort) for oral hygiene, upper body dressing, personal hygiene, and bed to chair transfers, and substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, bathing, lower body dressing, and tub/shower transfers. During an observation on 7/7/2026 at 12:48 pm, in Resident 10's room, Resident 10 was sitting in a wheelchair with both elbows bent and resting on the wheelchair armrests. Resident 10 opened and closed both hands and bent and straightened both elbows. Resident 10 did not attempt to move both shoulders or raise both arms overhead when asked. During a concurrent interview and record review on 7/7/2026 at 3:45 pm with the DOR, the DOR stated therapists (in general) measured ROM during OT evaluations to establish a baseline to track changes to the joint since ROM impacts a resident's ability to safely and independently perform ADLs. The DOR stated therapists objectively measured ROM using goniometers (instrument used for the precise measurement of angles) to determine a resident's baseline ROM and detect changes in joint ROM. The DOR stated OT should objectively measure any joint ROM limitations observed during the OT evaluation using a goniometer because it was an objective way of establishing a resident's ROM baseline and monitoring for changes in ROM. The DOR reviewed Resident 10's OT Evaluation, 4/2/2026, and confirmed OT assessed Resident 10's both arms and determined Resident 10's ROM of both shoulders were impaired. The DOR confirmed the OT Evaluation did not indicate specific ROM measurements of Resident 10's shoulder ROM impairments and was not objective. The DOR stated that if the OT evaluation did not indicate objective ROM measurements of a resident's ROM impairments, facility staff cannot effectively monitor and detect ROM changes, which could lead to a decline in ROM, mobility, and ADLs. During an interview on 7/8/2026 at 3:15 pm with the DON, the DON stated the facility monitored for changes in ROM by therapy evaluations, observations, and staff report. The DON stated it was important staff documented objectively during ROM evaluations to establish an accurate baseline assessment of a resident's joints because it enabled facility staff to effectively monitor changes and provide the appropriate services to address any declines. During a review of the facility's P&P titled, Resident Mobility and ROM, revised 1/12/2026, the P&P indicated residents will not experience an avoidable reduction in ROM and residents with limited ROM will receive treatment and services to increase and/or prevent a further decrease in ROM. The P&P indicated the care plan will include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and ROM. The P&P indicated the care plan will include the type, frequency, and duration of interventions as well as measurable goals and objectives. During a review of the facility's P&P titled, Charting and Documentation, revised 1/12/2026, the P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview, and record review, the facility failed to:A. Ensure the facility staff are provided with one clear policy and procedures regarding whether or not, residents who independently smoked cigarettes, could keep smoking materials, lighters, matches or any other smoking related items as evidenced by the following two conflicting and confusing facility policies and procedures titled:1. Smoking Policy dated 1/12/2026 indicated, Residents are not permitted to keep smoking materials, lighters, matches or any other related items in their possession. Cigarettes, matches, lighters, and other materials will be kept by the designated staff of the facility .2. Smoking Policy-Residents dated 1/12/2026 indicated, Residents who have independent smoking privileges are permitted to keep cigarettes, pipes, tobacco, and other smoking articles in their possession. This deficient practice had the potential to cause confusion among staff and residents placing the residents, staff and guests at increased risk for fire related injuries, hospitalization and death. B. Ensure Certified Nursing Assistant (CNA) 1 did not make private arrangements with a private transportation company (PTC) to pick up one of one sampled residents (Resident 99) from the facility and transported Resident 99 to and from a bank in Pasadena 20 miles away from the facility unaccompanied and without supervision, without a physician's order, without facility staff awareness and consent from Resident 99 family members and awareness. This deficient practice placed Resident 99 at increased risk for psychological harm (the mental and emotional harm caused by a highly distressing, threatening, or overwhelming even), accidents and falls with injury, hospitalization, and death. Findings: A. A review of Resident 11's admission record indicated Resident 11 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that include chronic obstructive pulmonary disease (COPD- a group of progressive, incurable lung conditions that cause long-term breathing difficulties and restricted airflow.), chronic pulmonary edema (an abnormal buildup of fluid in the air sacs (alveoli) and tissues of the lungs), alcohol abuse with intoxication (improper, excessive, or non-therapeutic use of a alcohol causing temporary, reversible condition of altered consciousness, judgment, and behavior), major depressive disorder (a persistently depressed mood or a profound loss of interest in activities, lasting at least two weeks), acute respiratory failure with hypoxia (a life-threatening condition where the lungs cannot put enough oxygen into the blood), tobacco use (habitual consumption of the tobacco products-cigarettes), generalized anxiety disorder (excessive, uncontrollable, and persistent worry about everyday events and activities) and, other psychoactive substance dependence (compulsive, uncontrollable need to use a drug or alcohol despite harmful consequences). A review of Resident 11's Minimum Data Set (MDS - a assessment tool) dated 6/6/2026 indicated the resident 11's cognition (The mental ability to make decision of daily living) was intact, Resident 11 required set-up or clean-up assistance for eating, required supervision with oral hygiene and upper body dressing, Resident 11 required partial moderate assistance with personal hygiene, substantial maximal assistance with toileting hygiene, shower/bathe and was totally dependent for lower body dressing and putting on/taking off footwear. A review of Resident 11's Smoker's Risk Assessment, dated 5/8/2026, indicated Resident 11 was an independent smoker. During an interview on 7/8/2026 at 1:12 pm, at bedside, Resident 11 stated he kept his own cigarettes with him while in the facility. During an interview on 7/8/2026 at 2:45 pm, the Activity Director (AD) stated that residents who demonstrate independent safe smoking abilities care are allowed to smoke independently without supervision, additionally, Residents are allowed to keep their own cigarettes but not lighters. During an interview on 7/9/2026 at 1:29 pm, Director of Nursing (DON) stated Residents who have been cleared to smoke independently via assessment are not supposed to keep their cigarettes at bedside because of safety and fire hazard. A review of the facility's policy and procedures (P&P) provided by medical records while onsite on 7/8/2026 titled Smoking Policy dated 1/12/2026 indicated, Residents are not permitted to keep smoking materials, lighters, matches or any other related items in their possession. Cigarettes, matches, lighters, and other materials will be kept by the designated staff of the facility . A review of the facility's P&P titled provided electronically on 7/9/2026 titled Smoking Policy-Residents dated 1/12/2026 indicated, Residents who have independent smoking privileges are permitted to keep cigarettes, pipes, tobacco, and other smoking articles in their possession. B. Cross Reference F808 and F835 During a review of Resident 99's admission record, dated 6/14/2025, indicated Resident 99 was admitted to the facility on 6/14/2025 with diagnoses but not limited to transient ischemic attack (TIA- a temporary blockage of blood flow to the brain causing stroke symptoms), end stage renal disease (kidneys have permanently stopped working), anarthria (inability to speak clearly), dysphagia (difficulty swallowing), and hemiplegia (severe or complete loss of voluntary movement on one entire side of the body) affecting the right side. During a review of Resident 99's physician order, dated 2/5/2026, indicated, (Resident 99) may go out on Therapeutic pass on Monday, Wednesday, and Friday with an outside agency. They will be riding with resident to and from the Fitness gym (gymnasium- is a dedicated indoor or outdoor facility equipped for physical exercise, sports, and athletic training). During a review of Resident 99's Minimum Data Set (MDS- a resident assessment tool), dated 3/16/2026, indicated Resident 99 used a wheelchair (an assistive device) and required total physical assistance transferring from a bed to a chair (wheelchair). The MDS also stated Resident 99's cognitive patterns were moderately impaired (a person's memory or thinking have started to weaken). During a review of Resident 99's history and physical (H&P- a detailed story written by a physician about your medical care), dated 8/12/2025, indicated, This Resident (Resident 99) due to complex medical problems and history of illness is: High Risk for falls. During a review of Resident 99's notarized (a document is one that has been officially verified, witnessed, and authenticated by a neutral public official known as a notary public) Financial Power of Attorney (POA) Packet, the Acknowledgement form, dated 4/26/2026, indicated Resident 99's name. The date of the signed Signature and Acceptance form was illegible. During a review of the facility's Release of Responsibility for Leave of Absence sign in/out form, undated, indicated no documented evidence that Resident 99 signed in or signed out for OOP for the month of April 2026. During a telephone interview on 7/7/2026 at 3:11 P.M. with Family Member (FM) 1, FM 1 stated that between 4/26/2026 to 4/30/2026, CNA 1 organized and paid a PTC to transport Resident 99 to a bank 20 miles away from the facility and to also meet Resident 99's FM 3. FM 1 stated that Resident 99 (FM 1's father) had changed the reside t's financial POA (Power of Attorney) from FM 1 and FM 4 to FM 2. During a telephone interview on 7/8/2026 at 9:15 A.M. with FM 2, FM 2 stated, Resident 99 changed Resident 99's financial Power of Attorney (POA- is a legal document that allows one person (the principal) to designate a trusted person or entity (the agent or attorney-in-fact) to make legal, financial, or medical decisions on their behalf) from FM1 and FM 4 to FM 2 in 4/2026 per Resident 99 and FM 3's requests. FM 2 stated Resident 99 wanted to control over Resident 99's finances. FM 2 stated FM 2 was aware that Resident 99 had traveled to the resident's bank to change over the resident's financial POA but did not know how Resident 99 arrived at the bank or if FM 3 was able to meet Resident 99 at the bank. During an interview on 7/8/2026 at 11:28 A.M. with CNA 1, CNA 1 confirmed and stated CNA 1 was at CNA 1's residence when CNA 1 used an application (app- a software designed to run on handheld devices like smartphones and tablets) on CNA 1's cellular phone to make transportation arrangements with a PTC and also paid the PTC to transport Resident 99 to the bank in Pasadena on 4/2026. CNA 1 did not provide the date and refused to share proof of the PTC records. CNA 1 stated that CNA 1 did not inform the facility Admin, Director of Nursing (DON) or any facility staff. CNA 1 stated that Resident 99 traveled alone to a bank in Pasadena via PTC without adequate supervision which placed Resident 99 at increased risk for physical harm such as a vehicle accident. CNA 1 stated Resident 99 said was to meet FM 3 at the bank in Pasadena, however, CNA 1 does not know if Resident 99 met with FM 3 at the bank. CNA 1 refused to provide/share the month and or the date when CNA 1 paid the PTC to transport Resident 99 to a bank in Pasadena. CNA 1 stated that CNA 1 does not know how and when Resident 99 returned to the facility. On 7/9/2026 at 11:15 A.M., this writer attempted to call FM 3 for interview but was unsuccessful. On 7/13/2026 at 1:41 P.M. this writer made a second attempt to call FM 3 for interview but was unsuccessful. During an interview on 7/9/2026 at 12:36 P.M. with the DON, the DON stated DON was aware that FM 1 was the previous financial POA for Resident 99 and it was changed to FM 2. The DON stated called FM 2 and confirmed that FM 2 was Resident 99's financial POA. The DON confirmed and stated Resident 99 left the facility without adequate supervision on 4/2026 and that CNA 1 paid for a PTC for Resident 99 to go to a bank in Pasadena placing Resident 99 at risk for physical harm such as a vehicle accident. During a review of the facility's P&P titled, Therapeutic Leave Policy, with a review date of 1/12/2026, indicated, Therapeutic Leave: A planned absence of a resident authorized by a physician order. All therapeutic leaves, must sign the Release of Responsibility form with the receptionist for the safety and tracking of all residents. During a review of the facility's P&P titled, Safety and Supervision of Residents, with a review date of 1/12/2026, indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on observation, interview, and record review, the facility failed to provide services and equipment to improve toileting and toilet transfer abilities for one of four sampled residents (Resident 5) who was continent (having voluntary control of urination and bowel movements) and able to walk and transfer (move from one surface to another) with assistance. This deficient practice resulted in Resident 5 wearing adult briefs (absorbent, disposable garments worn to manage bowel and bladder loss) and toileting in bed instead of walking to the bathroom or using a commode (portable toilet) due to lack of available toileting equipment for safe transfers, feelings of humiliation and low self-worth, and placed Resident 5 at risk for functional decline, skin breakdown (tissue damage caused by friction, shear, moisture, or pressure), and incontinence (having no or insufficient voluntary control over urination or bowel movements). Cross Reference F557 and F676Findings: During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including, but not limited to end stage renal disease (ESRD, chronic kidney disease that causes gradual loss of kidney function), morbid obesity (chronic disease characterized by excessive body fat), muscle weakness, and benign prostatic hyperplasia with lower urinary tract symptoms (enlargement of the prostate gland causing urinary symptoms such as frequent urination). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 6/1/2026, the MDS indicated Resident 5 was cognitively (mental action or process of acquiring knowledge and understanding) intact. The MDS indicated Resident 5 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene and bathing, supervision or touching assistance with upper body dressing and walking 150 feet, set-up or clean-up assistance with sit to stand, bed to chair transfers, and toilet transfers, and was independent with eating, oral hygiene, rolling to both sides, and lying to sitting on the side of the bed. The MDS indicated Resident 5 was always continent of bowel and bladder. During a review of Resident 5's Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Discharge Summary (OT Discharge Summary), dated 3/22/2026, the OT Discharge Summary indicated Resident 5 required partial/moderate assistance with toilet/commode transfers. The OT Discharge Summary indicated OT discharged Resident 5 from OT services due to maximal potential achieved. During an observation and interview on 7/7/2026 at 9:07 am with Resident 5, Resident 5 was lying in bed wearing adult briefs. Resident 5 stated he primarily used a bed pan (shallow pan used by immobile individuals to urinate or have a bowel movement while in bed) and urinal (reusable or disposable container designed for urinating without access to a standard toilet) for toileting and wore adult briefs daily for possible accidents because the toilet in the bathroom was too low and he did not have a commode or device that elevated the toilet seat. Resident 5 stated he was over six feet tall and could not safely transfer on and off the toilet in his bathroom because the toilet seat was too low. Resident 5 stated he tried to sit on the toilet in his bathroom in the past, got stuck, and required two staff members to assist him off the toilet. Resident 5 stated he informed staff and requested equipment to elevate the toilet seat or commode that could accommodate his weight and size multiple times, but staff never gave him equipment and instructed him to use a bedpan, urinal, and adult brief instead. Resident 5 stated he was able to walk, tried to be as independent as possible, and felt humiliated and degraded because he had to wear an adult brief and toilet in bed. During an interview and record review on 7/7/2026 at 3:02 pm with Occupational Therapist 1 (OT 1), OT 1 stated OT evaluated a resident's activities of daily living (ADL, basic activities such as eating, dressing, toileting) function and provided treatment and equipment recommendations to improve ADLs, such as toileting and toilet transfers. OT 1 reviewed Resident 5's OT Discharge summary, dated [DATE], and confirmed OT 1 discharged Resident 5 from OT services because Resident 5 was no longer progressing in ADLs and no longer required skilled therapy (services that require specialized training and experience of a licensed therapist or therapy assistant). OT 1 confirmed OT 1 documented Resident 5 required partial/moderate assistance for toilet transfers at the time of discharge from OT services on 3/22/2026. OT 1 stated OT 1 simulated the toilet transfer only in the rehab gym with a chair and therapy mat (padded surface used for therapy treatment) and did not observe or provide treatment to address toilet transfers using a regular toilet. OT 1 stated the chair and therapy mat in the rehab gym were higher than the toilet in Resident 5's room and was not an adequate simulation since they were not the same height. OT 1 stated Resident 5 was very tall and required specialized equipment such as a raised toilet seat (bathroom accessory that attaches over an existing toilet to add height) or commode to safely transfer onto the toilet for toileting because the toilet in his room was very low to the ground. OT 1 stated Resident 5 requested to practice toilet transfers during therapy but refused to practice using a regular shower chair which could be placed over the toilet to elevate the surface as OT 1 suggested. OT 1 stated she did not know why and did not investigate Resident 5's reason for refusal but thought he likely refused because the regular shower chair she suggested was not bariatric (specialized medical and mobility equipment used to support individuals with obesity) and was likely scared to try. OT 1 stated she did not offer to practice toilet transfers with other bariatric equipment and discharged Resident 5 from therapy without further attempts to maximize Resident 5's toileting and toilet transfer abilities because she assumed he would refuse. OT 1 stated she should have investigated Resident 5's reason for refusal, offered and issued alternative equipment to ensure safe toilet transfers, and practiced toilet transfers in Resident 5's room or simulated a transfer on a surface equal to the toilet height in Resident 5's room but did not. OT 1 stated Resident 5 was able to walk and should be walking to the bathroom or using a commode instead of using an adult brief, bedpan, or urinal to promote good hygiene, dignity, and independence. During an interview on 7/7/2026 at 3:25 pm with the Director of Rehabilitation (DOR), the DOR stated residents who are continent and able to walk should be walking to the bathroom for toileting and should not be toileting in bed. The DOR stated that facility staff must notify the Rehabilitation Department (Rehab) when residents require specialized equipment, such as a bariatric raised toilet seat or commode to ensure Rehab properly assessed the resident for safe transfers and provided the necessary equipment to prevent functional decline, prevent skin breakdown, and preserve dignity. During an interview on 7/7/2026 on 4:01 pm with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Resident 5 wore an adult brief and used a bed pan and urinal for toileting in bed. CNA 2 stated Resident 5 was able to walk and requested to use a regular toilet several times in the past but was not evaluated by Rehab and did not have the proper equipment to accommodate his height and weight for safe transfers in his bathroom. CNA 2 stated the toilet in his room was very low and the shower chair in the bathroom was not wide or high enough for safe transfers when placed over the toilet. During an interview on 7/8/2026 at 3:15 pm with the Director of Nursing (DON), the DON stated the facility provided Rehab evaluations, treatments, and nursing services to maintain and improve residents' abilities to perform ADLs. The DON stated that Rehab evaluates whether a resident can safely complete toilet transfers and determines the necessary equipment to ensure safe toilet transfers. The DON stated that if the facility did not provide the necessary opportunities, services, and equipment for residents who are continent and able to walk to maintain or improve ADLs by using a toilet or commode, residents may experience functional decline, skin breakdown, and embarrassment. During a review of the facility's undated Policy and Procedure (P&P) titled Activities of Daily Living (ADLs) Assistance, the P&P indicated the facility .is committed to maintaining and improving each resident's abilities in ADLs to the highest practicable level. Assistance will be provided based on the resident's assessed needs, preferences, and care plan, ensuring: promotion of resident independence and self-care where possible, respect for resident dignity, privacy, and choices, prevention of avoidable declines in ADL function, and timely and appropriate intervention for dependent residents.

Based on observation interview and record review, the facility failed to:1. Provide appropriate monitoring of insulin for one of five sampled residents (Resident 5).2. Initiate a comprehensive care plan that addressed Resident 5's diagnosis of diabetes or the administration of insulin.These deficient practices had the potential to result in complications from the use of insulin such as hypoglycemia and lethargy.Findings: A review of Resident 5's admission Record indicated the facility admitted the resident on 5/26/2023 and readmitted on [DATE] with diagnoses including but not limited to diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), morbid obesity and ESRD (End Stage Renal Disease-irreversible kidney failure). A review of Resident 5's Minimum Data Set (MDS - a resident assessment tool) dated 6/1/2026, indicated Resident 5 has intact cognition (ability to think and reason), required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, bathing and lower body dressing. The MDS also indicated Resident 5 was receiving insulin. A review of the physician order, dated 11/20/2025, indicated to administer Lantus Insulin five units) solution subcutaneously (applied under the skin) at bedtime for diabetes mellitus with hyperglycemia (high blood sugar). A review of the physician order, dated 2/5/2026, indicated the facility was to administer to Resident 5 regular insulin Pen 100 units per mililiter (ml) before meals per sliding scale insulin (refers to the progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges), for diabetes mellitus as follows:Blood sugar less than 60 or greater than 401 to notify physicianBlood sugar 60 - 200 administer = 0 units of insulinBlood sugar 201 - 250 administer = 3 units of insulinBlood sugar 251 - 300 administer = 4 units of insulinBlood sugar 301 - 350 administer = 6 units of insulinBlood sugar 351 - 400 administer = 9 units of insulinBlood sugar 261-280 administer = 5 units of insulin A record review of all Resident 5's physician orders on 7/9/2026 at 8:21 AM, indicated there was no orders for to monitor for hypoglycemia, vomiting or lethargy. A review of Resident 5's June 2026 and July 2026 medication administration records (MAR) indicated that Resident 5 was receiving regular insulin and Lantus insulin. The same MARs also indicated no documented evidence the license nurses monitored the resident's monitoring for the side effects of insulin. During a concurrent interview and record review on 7/09/2026 at 9:13 AM, Resident 5's electronic medical chart was reviewed. Upon review of Resident 5's physician orders, the Director of Nursing (DON) stated Resident 5 was taking Lantus and regular insulin. The DON stated a side effect of insulin included hypoglycemia and the nurses should be monitoring the resident for the signs of symptoms of low blood sugar and this monitoring should have been on the resident's MAR. The DON further stated there was no care plan that addressed Resident 5's insulin medications. The DON stated there should be a care plan and the care plan interventions should include, the administration of insulin and there should be monitoring for the signs and symptoms of hypoglycemia. A review of the facility policy and procedures (P&P), Insulin Administration, revised 1/12/2026, indicated the goal was To provide guidelines for the safe administration of insulin to residents with diabetes. The P&P also indicated nursing staff were to notify the physician if the resident has signs and symptoms of hypoglycemia that are not resolved by following the facility protocol for hypoglycemia management. A review of the facility's P&P, Care Plans, Comprehensive Person-Centered, dated 1/12/2026, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P also indicated the comprehensive, person-centered care plan:a. Includes measurable objectives and timeframes;b. Describes the services that are to be furnished to attain or maintain the resident's highestpracticable physical, mental, and psychosocial well-being, reflects currently recognized standards of practice for problem areas and conditionsg. Incorporate identified problem areas;h. Incorporate risk factors associated with identified problems;k. Reflect treatment goals. timetables and objectives in measurable outcomes.

Based on interview and record review, for one of one sampled residents (Resident 99), the facility failed to ensure Certified Nursing Assistant (CNA) 1 followed/verified a physician's order for minced and moist diet (therapeutic diet-a personalized meal plan prescribed by a doctor or registered dietitian to treat a medical condition or manage symptoms) dated 4/8/2026. CNA 1 brought and gave Resident 99 protein bars (a convenient, ready-to-eat snack designed to deliver a concentrated dose of protein) to eat. Resident 99 has a diagnosis of dysphagia (difficulty swallowing). This failure resulted in Resident 99 eating the protein bar/s placing Resident 99 at increased risk for choking, hospitalization, and death. Findings: Cross Reference F689 and F835 During a review of Resident 99's admission record, dated 6/14/2025, indicated Resident 99 was admitted to the facility on 6/14/2025 with diagnoses but not limited to transient ischemic attack (TIA- a temporary blockage of blood flow to the brain causing stroke symptoms), end stage renal disease (kidneys have permanently stopped working), anarthria (inability to speak clearly), dysphagia, and hemiplegia (severe or complete loss of voluntary movement on one entire side of the body) affecting the right side. During a review of Resident 99's Minimum Data Set (MDS- a resident assessment tool), dated 3/16/2026, indicated Resident 99 used a wheelchair (an assistive device) and required total physical assistance transferring from a bed to a chair (wheelchair). The MDS also stated Resident 99's cognitive patterns were moderately impaired (a person's memory or thinking have started to weaken). During a review of Resident 99 Physician's Order dated 4/8/2026, indicated, Resident 99 diet was downgraded from soft bite-sized diet to minced and moist diet (food that is soft, wet, and cut into small pieces) because of Resident 99's dysphagia (difficulty swallowing). During a review of Resident 99's Care Plan (CP- a personalized roadmap of your health), dated 6/14/2025, indicated, The resident (Resident 99) has a swallowing problem. The resident will not have injury related to aspiration (inhaling something into your lungs by accident) through the review date. The resident will have no choking episodes when eating through the review date. During a review of Resident 99's Speech Therapy Treatment Encounter Notes (Summary of Daily Skilled Services), dated 5/5/2026, indicated, It is not optimal to upgrade pt (Resident 99) to a regular or soft and bite sized diet due to prolonged oral phase and previous weight loss with upgraded diet. During a telephone interview on 7/7/2026 at 3:11 P.M. with FM 1, FM 1 stated that before Resident 99 was discharged from the facility on 5/26/2026, CNA 1 paid for protein bars and brought protein bars and water bottles for Resident 99 while resident was at the facility. During an interview on 7/8/2026 at 11:28 A.M. with CNA 1, CNA 1 confirmed and stated CNA 1 used CNA 1's own money to buy Resident 99 protein bars but did not consult with the facility's dietician (a medical trained food expert), licensed nurses or facility leadership. CNA 1 stated Resident 99 ate the protein bars and was aware Resident 99 was on a minced diet. During an interview on 7/9/2026 at 12:36 P.M. with the DON, the DON stated CNA 1 used CNA 1's own money to buy protein bars for Resident 99 while the resident was at the facility. The DON stated Resident 99 should not be receiving/eating protein bars because Resident 66 is on a puree diet (consists of foods that are blended, whipped, or mashed into a smooth, lump-free consistency similar to pudding). The DON stated that CNA 1 purchased bottled water and protein bars for Resident 99. The DON also stated Resident 99 was at risk for choking from eating the protein bars. During a review of facility's P&P titled, Resident Food Preferences, with a review date of 1/12/2026, indicated, The Dietitian and nursing staff, assisted by the Physician, will identify nutritional issues and dietary recommendations that might be in conflict with the resident's food preferences.

Based on observation, interview, and record review, the facility failed to ensure a garbage dumpster lid completely closed and covered for one of two garbage dumpsters. This failure had the potential to attract pests (any living thing that can spread disease) and spread infection (when harmful germs like bacteria or viruses can enter your body and make you sick) to facility residents. Findings: During a concurrent observation and interview on 7/6/2026 at 9:10 A.M. with Dietary Aid (DA) 1 in the outdoor garbage area, a garbage dumpster was filled with trash bags to the point that the lid could not fully close. DA 1 stated the garbage dumpster lid should be fully closed to prevent pests and vermin (a small animal, bug, or parasite that can spread disease or destroy property) which can potentially make the residents sick. During an interview on 7/7/2026 at 2:10 P.M. with the Dietary Supervisor (DS), the DS stated insects or animals could travel inside the garbage dumpster if the lid is not fully closed and this can result in the residents becoming sick. During a record review of the facility's policy and procedures (P&P) titled, Miscellaneous Areas - Garbage and Trash, dated 2023, indicated: All food waste must be placed in sealed leak-proof, non-absorbent, tightly closed containers (i.e., plastic bags) and shall be disposed of as necessary to prevent a nuisance or unsightliness. Adequate, clean, vermin-proof areas must be provided for storage of garbage and rubbish. During a record review of the facility's P&P titled, Trash Removal, dated 1/12/2026, indicated, Be sure that the trash cart remains covered at all times. During a review of Food Code 2022, dated 1/18/2022, the Food Code page 527, indicated, Outside receptables must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 adhered to the facility's professional code of conduct (rules for how employees should behave at work) by not engaging in an inappropriate romantic relationship with one of one resident (Resident 99) according to the facility's Employee Handbook, dated 3/2025 and evidenced by:1. CNA 1 making arrangements with a private transportation company (PTC) to pick up Resident 99 from the facility, transported Resident 99 to a bank in Pasadena 20 miles away from the facility, and transported Resident 99 back to the facility unaccompanied and without supervised, and without the knowledge of Resident 99's family members, and facility staff. 2. CNA 1 visiting Resident 99 at a general acute care hospital (GACH) 1 on multiple occasions in the months of 5/2026 and 6/2026 when Resident 99 was admitted at GACH 1.3. CNA 1 bringing and giving protein bars (a convenient, ready-to-eat snack designed to deliver a concentrated dose of protein) despite a physician's order for Resident 99 to consume minced and moist diet (therapeutic diet-a personalized meal plan prescribed by a doctor or registered dietitian to treat a medical condition or manage symptoms) dated 4/8/2026. Resident 99 has a diagnosis of dysphagia.4. CNA 1 exchanging romantic text messages with Resident 99. This failure resulted in Resident 99's Family Member (FM) 1 alerting the facility of (CNA 1)'s inappropriate relationship with Resident 99 and placed Resident 99 at increased risk for accidents, falls, injuries, choking, hospitalization and death. Findings: Cross Reference F689 and F808During a review of Resident 99's admission record, dated 6/14/2025, indicated Resident 99 was admitted to the facility on 6/14/2025 with diagnoses but not limited to transient ischemic attack (TIA- a temporary blockage of blood flow to the brain causing stroke symptoms), end stage renal disease (kidneys have permanently stopped working), anarthria (inability to speak clearly), dysphagia (difficulty swallowing), and hemiplegia (severe or complete loss of voluntary movement on one entire side of the body) affecting the right side. During a review of Resident 99's physician order, dated 2/5/2026, indicated, (Resident 99) may go out on Therapeutic pass on Monday, Wednesday, and Friday with an outside agency. They will be riding with resident to and from the Fitness gym (gymnasium- is a dedicated indoor or outdoor facility equipped for physical exercise, sports, and athletic training). During a review of Resident 99's Minimum Data Set (MDS- a resident assessment tool), dated 3/16/2026, indicated Resident 99 used a wheelchair (an assistive device) and required total physical assistance transferring from a bed to a chair (wheelchair). The MDS also stated Resident 99's cognitive patterns were moderately impaired (a person's memory or thinking have started to weaken). During a review of Resident 99's notarized (a document that has been officially verified, witnessed, and authenticated by a neutral public official known as a notary public) Financial Power of Attorney (POA) Packet, the Acknowledgement form, dated 4/26/2026, indicated Resident 99's name. The date of the signed Signature and Acceptance form was illegible. During a review of the facility's Release of Responsibility for Leave of Absence sign in/out form, undated, indicated no documented evidence that Resident 99 signed in or signed out for OOP for the month of April 2026. During a review of Resident 99's Discharge summary, dated [DATE], indicated Resident 99 was discharged to GACH 1 on 5/26/2026 at 4:25 P.M. During a review of Resident 99's Physician's Order dated 4/8/2026, indicated, Resident 99 diet was downgraded from soft bite-sized diet to minced and moist diet (food that is soft, wet, and cut into small pieces) because of Resident 99's dysphagia (difficulty in swallowing). During a review of Resident 99's Speech Therapy Treatment Encounter Notes (Summary of Daily Skilled Services), dated 5/5/2026, indicated, It is not optimal to upgrade pt (Resident 99) to a regular or soft and bite sized diet due to prolonged oral phase and previous weight loss with upgraded diet. During a review of an e-mail (electronic mail) from FM 1 to the facility, dated 6/3/2026, indicated, Please forward this message to the appropriate staff members at (the facility). Since leaving (the facility) to (GACH 1), (CNA 1) has followed (Resident 99) to (GACH 1) visiting him frequently and I've observed that the care for him is not within the realm of a professional manner. (CNA 1) should not have continued engagement with (Resident 99) after his stay at (the facility). During a telephone interview on 7/7/2026 at 3:11 P.M. with FM 1, FM 1 stated that between 4/26/2026 to 4/30/2026, CNA 1 organized and paid a PTC to transport Resident 99 to a bank 20 miles away from the facility and to also meet Resident 99's FM 3. FM 1 stated that Resident 99 (FM 1's father) had changed his financial POA (Power of Attorney) from FM 1 and FM 4 to FM 2. FM 1 stated that on 5/2026 (unable to recall the date), Resident 99 was admitted at GACH 1 and while FM 1 was visiting Resident 99 at GACH 1, CNA 1 came to visit Resident 99 at GACH 1 on 5/2026 and 6/2026 (unable to state dates). FM 1 stated that before Resident 99 was discharged from the facility on 5/26/2026, CNA 1 paid for Resident 99's protein bars and brought the protein bars and water bottles for Resident 99 while resident was at the facility. FM 1 also stated Resident 99 had given FM 5 a birthday card with $25 cash inside. FM 1 stated when FM 1 asked CNA 1 about the birthday card, CNA 1 stated, (Resident 99) asked me to get the card, so I got the card for (Resident 99). FM 1 stated that while visiting Resident 99 at GACH 1, FM 1 had access to Resident 99's personal cellular phone. FM 1 stated that either 5/2026 or 6/2026, while Resident 99 was admitted at GACH 1, FM 1 stated FM 1 started noticing CNA 1 having an inappropriate relationship with Resident 99. FM 1 also stated that FM 1 read the inappropriate text messages on Resident 99's phone from Resident 99 to a recipient with the same first name as CNA 1. During a telephone interview on 7/8/2026 at 9:15 A.M. with FM 2, FM 2 stated, Resident 99 changed Resident 99's financial Power of Attorney (POA- is a legal document that allows one person (the principal) to designate a trusted person or entity (the agent or attorney-in-fact) to make legal, financial, or medical decisions on their behalf) from FM1 and FM 4 to FM 2 in 4/2026 per Resident 99 and FM 3's requests. FM 2 stated Resident 99 wanted control over Resident 99's finances. FM 2 stated FM 2 was aware that Resident 99 had traveled to the resident's bank to change over the resident's financial POA but did not know how Resident 99 arrived at the bank or if FM 3 was able to meet Resident 99 at the bank. During an interview on 7/8/2026 at 10:10 A.M. with DSD, the DSD stated DSD was aware that CNA 1 had visited Resident 99 at GACH 1 on 5/2026. DSD confirmed and stated DSD received and read the e-mail dated 6/3/2026 from FM 1 that indicated that CNA 1 was having inappropriate/romantic relationship with Resident 99 since 5/2026 or 6/2026 (not very sure of the month) when Resident 99 was admitted at GACH 1. DSD stated the facility Admin was already aware of the email sent by FM 1 when DSD went to inform the Admin. DSD stated any allegation of abuse must be reported immediately to keep the residents safe at the facility. During an interview on 7/8/2026 at 10:31 A.M. with the Admin, the Admin stated and confirmed that he was aware (did not give dates) of the email FM 1 had sent to the facility regarding CNA 1 and Resident 99. The Admin stated he could not recall if the email from FM 1 indicated that CNA 1 was having inappropriate relationship with Resident 99. The Admin stated he was aware that CNA 1 was visiting Resident 99 at GACH 1. The Admin stated the inappropriate behavior by CNA 1 was a potential for conflict of interest. During an interview on 7/8/2026 at 11:28 A.M. with CNA 1, CNA 1 confirmed and stated CNA 1 was at CNA 1's residence when CNA 1 used an application (app- a software designed to run on handheld devices like smartphones and tablets) on CNA 1's cellular phone to make transportation arrangements with a PTC and also paid the PTC to transport Resident 99 to the bank in Pasadena on 4/2026. CNA 1 did not provide the date and refused to share proof of the PTC records. CNA 1 stated that CNA 1 did not inform the facility Admin, Director of Nursing (DON) or any facility staff. CNA 1 stated that Resident 99 traveled alone to a bank in Pasadena via PTC without adequate supervision which placed Resident 99 at increased risk for physical harm such as a vehicle accident. CNA 1 stated Resident 99 said was to meet FM 3 at the bank in Pasadena, however, CNA 1 does not know if Resident 99 met with FM 3 at the bank. CNA 1 refused to provide/share the month and or the date when CNA 1 paid the PTC to transport Resident 99 to a bank in Pasadena. CNA 1 stated that CNA 1 does not know how and when Resident 99 returned to the facility. CNA 1 confirmed and stated CNA 1 gave FM 5 a birthday card with cash inside per Resident 99's request. CNA 1 stated the cash given to FM 5 inside the birthday card was from Resident 99's room. CNA 1 confirmed and stated that when Resident 99 was admitted at GACH 1, CNA 1 wore work scrubs (two-piece uniforms worn by healthcare staff) and no identification badge when CNA 1 went to visit Resident 99 at GACH 1 on 5/2026 and 6/2026. CNA 1 stated that CNA 1 went to help feed Resident 99 but did not wear an identification badge. CNA 1 further stated that CNA 1 used CNA 1's own money to buy Resident 99 protein bars but did not consult with the facility's dietician (a medical trained food expert), licensed nurses or facility leadership. CNA 1 stated Resident 99 ate the protein bars and was aware Resident 99 was on a minced diet. CNA 1 denied having a romantic relationship with Resident 99 but when asked to confirm if inappropriate text messages were exchanged between CNA 1 and Resident 99, CNA 1 did not respond. During a review of text messages on Resident 99's cellular phone provided by FM 1 on 7/9/2026 at 7:48 A.M., one of the text messages between Resident 99 and CNA 1 dated 5/13/2026 indicated, an individual with CNA 1's first name wrote, Hi [NAME], how are you today? I can't wait to see you. I miss you. During an interview on 7/9/2026 at 12:36 P.M. with the DON, the DON stated that beginning of 6/2026, staff member from facility Admissions office (did not name the staff member) forwarded the DON the email from FM 1 was concerned about CNA 1 not within the realm of professional manner. The DON confirmed and stated Resident 99 left the facility without adequate supervision on 4/2026 and that CNA 1 paid for a PTC for Resident 99 to go to a bank in Pasadena. The DON further stated that CNA 1 visited Resident 99 at GACH 1 on 5/2026 approximately 3-4 times after CNA 1 completed work at the facility work. The DON stated that CNA 1 used CNA 1's own money own money to buy Resident 99 protein bars while the resident was at the facility. The DON stated Resident 99 should not be receiving/eating protein bars because Resident 66 is on a puree diet (consists of foods that are blended, whipped, or mashed into a smooth, lump-free consistency similar to pudding). The DON stated that CNA 1 and Resident 99 had an inappropriate relationship by exchanging romantic text messages, CNA 1 visiting Resident 99 at GACH 1, purchasing bottled water and protein bars for Resident 99. The DON also stated that this relationship had the potential to cause physical harm to Resident 99 such as a vehicle accident or choking from the protein bars provided. During a review of the facility's Employee Handbook, dated 3/2025, indicated the following: Employees must avoid situations involving actual or potential conflict of interest. If employees are involved in any of the types of relationships or situations described in this policy, they should immediately and fully disclose the relevant circumstances to their immediate supervisor, or any other appropriate supervisor, for a determination about whether a potential or actual conflict exists. Employees are expected to conduct their personal affairs in a manner that does not adversely affect the Facility's or their own integrity, reputation, or credibility. During a review of the facility's P&P titled, Therapeutic Leave Policy, with a review date of 1/12/2026, indicated, Therapeutic Leave: A planned absence of a resident authorized by a physician order. All therapeutic leaves, must sign the Release of Responsibility form with the receptionist for the safety and tracking of all residents. During a review of the facility's P&P titled, Safety and Supervision of Residents, with a review date of 1/12/2026, indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on observation, interview, and record review, the facility to ensure the medical record contained sufficient information for one of four sampled residents (Resident 10) was complete by failing to indicate the recommendations and plan of care on the Joint Mobility Assessment (JMA, a brief assessment of a resident's range of motion [ROM, full movement potential of a joint] in both arms and both legs), dated 4/2/2026, for Resident 10, who was identified as having a decline in ROM of both shoulders compared to the previous JMA, dated 9/9/2025. This deficient practice had the potential to delay and negatively affect the delivery of necessary care and services and result in ROM decline leading to contracture (loss of motion of a joint associated with stiffness and joint deformity) development and functional decline for Resident 10. Findings: During a review of Resident 10's admission Record (AR), the AR indicated Resident 10 initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including, but not limited to chronic (ongoing) obstructive pulmonary disease (COPD, lung disease that causes obstruction of airflow and can limit normal breathing), Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), and weakness. During a review of Resident 10's Joint Mobility Assessment (JMA), dated 9/9/2025, the JMA indicated Resident 10's ROM of both shoulders was Within Functional Limits (WFL, variance due to normal aging process allowed up to 25 percent). The JMA indicated for Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) to evaluate and treat Resident 10. During a review of Resident 10's Joint Mobility Assessment (JMA), dated 4/2/2026, the JMA indicated Resident 10's ROM of both shoulders was moderately impaired (resident has 50 to 75 percent available ROM in the joint). The following portions of the JMA form were blank:Patient/Resident was reviewed for rehabilitative needs on this date:Physical Therapy, Occupational Therapy, Speech Therapy Evaluation orders requested (check appropriate boxes)No skilled therapy intervention is needed at this time (check box blank)Additional comments/Notes: During a review of Resident 10's Minimum Data Set (MDS, a resident assessment tool), dated 6/4/2026, the MDS indicated Resident 10 had moderate cognitive impairment. The MDS indicated Resident 10 required supervision or touching assistance for eating and rolling to both sides, partial/moderate assistance (helper does less than half the effort) for oral hygiene, upper body dressing, personal hygiene, and bed to chair transfers, and substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, bathing, lower body dressing, and tub/shower transfers. During an observation on 7/7/2026 at 12:48 pm, in Resident 10's room, Resident 10 was sitting in a wheelchair with both elbows bent and resting on the wheelchair armrests. Resident 10 opened and closed both hands and bent and straightened both elbows. Resident 10 did not attempt to move both shoulders or raise both arms overhead when asked. During a concurrent interview and record review on 7/8/2026 at 3:08 pm with the Director of Rehabilitation (DOR), the DOR stated the Rehabilitation Department (Rehab) conducted detailed JMAs which included a ROM assessment of each resident's both arms and legs upon admission, quarterly, and upon a change of condition (COC, major decline or improvement in a resident's status that will not resolve itself without intervention) to monitor for changes in a resident's ROM. The DOR stated the purpose of JMAs was to monitor ROM changes, identify any improvements or declines in a resident's ROM, and determine whether the current services were effective or if a resident required skilled therapy (services delivered by a licensed therapist or therapy assistant who has specialized training and experience) services. The DOR reviewed Resident 10's JMA, dated 9/9/2025, and confirmed Resident 10's ROM of both shoulders was WFL. The DOR reviewed Resident 10's JMA, dated 4/2/2026, and confirmed Resident 10's ROM of both shoulders was moderately impaired, which was a decline compared to the previous JMA, dated 9/9/2025. The DOR stated Resident 10's JMA, dated 4/2/2026, was incomplete because the portion of the JMA which included the interpretation of the ROM results, whether skilled therapy services were recommended, and comments/notes section were blank. The DOR stated the evaluating therapist must complete all sections of the JMA to include an interpretation of the findings to indicate if the resident maintained, improved, or had a decline in ROM, recommendations, and plan of care to ensure the resident had the appropriate services to prevent further decline. The DOR stated if staff did not complete all sections of the JMA, it could result in ROM and functional decline, lack of effective treatment and services, and inability or missed opportunities to detect declines. During an interview on 7/8/2026 at 3:15 pm with the Director of Nursing (DON), the DON stated the facility monitors for changes in ROM by staff report and therapy assessments, which included JMAs which were done upon admission and quarterly by Rehab. The DON stated it was important that staff completed all portions of the JMA to ensure the facility promptly identified any ROM changes and provided appropriate services to address any declines and prevent contractures. During a review of the facility's Policy and Procedures (P&P) titled, Charting and Documentation, revised 1/12/2026, the P&P indicated the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview and record review the certified nursing assistant (CNA) 3 failed to put on personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) before entering a room identified with signage as enhanced barrier precautions() to transfer Resident 3 from bed to chair for one of three sampled residents, Resident 3.This deficient practice placed other residents at risk of transmission of possible bacteria.A review of Resident 3's admission Record indicated the facility admitted this [AGE] year-old male on 12/17/2025 most recently with diagnoses including Chronic Obstructive Pulmonary Disorder (COPD-a chronic lung disease causing difficulty in breathing) dysphagia (difficulty swallowing), Congestive Heart Failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), Hypertension (HTN-high blood pressure), glaucoma, atrial fibrillation (irregular heartbeat), emphysema, asthma (condition causing narrowing and swelling of the airways in the lungs), gastroesophageal reflux (GERD-heartburn), gout (arthritis), chronic kidney disease (damaged kidney function for more than 3 months), dependent on oxygen and benign prostatic hypertrophy (BPH-enlarged prostate gland).A review of Resident 3's physician order dated 2/3/2026 indicated Indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) for BPH, chronic kidney disease, stage 3A.A review of Resident 3's physician order dated 2/11/2026 indicated enhanced barrier precaution r/t urinary catheter.A review of Resident 3's minimum data set (MDS-a resident assessment tool) dated 2/16/2026 indicated Resident 1's cognition (mental ability to make decisions for daily living) was moderately impaired. Resident 3 was dependent (helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting, personal hygiene, and transfers (moving between surfaces) from bed to chair.A review of Resident 3's care plan titled, I am on Enhanced Standard Precautions r/t urinary catheter; I am at risk for acquiring or being source of MDRO (multidrug-resistant organisms). The care plan included the intervention my nurse will render enhanced barrier precaution procedures in accordance to facility infection control plan.During a concurrent observation and interview on 4/1/2026 at 10:51 am with the licensed Vocational Nurse (LVN) 1, outside of Resident 3's room; we witnessed CNA 3 inside of Resident 3's room touching surfaces, touching the resident while in bed removing the blankets while not wearing gloves, gown or mask. LVN 1 stated, I believe one of the Resident's has a gastrostomy tube (g tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) so anyone handling Resident 3 should put on gown, mask and gloves before entering the room. LVN 1 then asked CNA 3 to exit the room and put on PPE.During an interview on 4/1/2026 at 11:52am with CNA 3. CNA 3 stated, When the sign says enhanced barrier precaution I am supposed to put on a gown and gloves before entering the room if I am going to do anything with the resident. CNA 3 was going into the room to transfer Resident 3 from bed to chair and prepare Resident 3 for lunch. Lastly, CNA 3 stated, I should have put on the gown and gloves before I went into the room to transfer Resident 3 to the wheelchair.A review of the facility's policy and procedure titled, Enhanced Barrier Precautions, reviewed 1/2026 indicated,1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug-resistant organisms (MDROs) to residents.2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room).b. Personal protective equipment (PPE) is changed before caring for another resident.c. Face protection may be used if there is also a risk of splash or spray.3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include:a. dressing;b. bathing/showering;c. transferring;d. providing hygiene;e. changing linens;f. changing briefs or assisting with toileting;g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); andh. wound care (any skin opening requiring a dressing).4. EBPs are indicated (when contact precautions do not otherwise apply) for residents infected or colonized with a CDC targeted or epidemiologically important [NAME], including:a. Pan-resistant organisms;b. Carbapenemase-producing carbapenem-resistant Enterobacterales;c. Carbapenemase-producing carbapenem-resistant Pseudomonas spp;d. Carbapenemase-producing carbapenem-resistant Acinetobacter baumannii;e. Candida auris;f. Methicillin-resistant Staphylococcus aureus (MRSA);g. ESBL-producing Enterobacterales;h. Vancomycin-resistant Enterococci (VRE);i. Multidrug-resistant Pseudomonas aeruginosa; andj. Drug-resistant Streptococcus pneumonia.5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of [NAME] colonization.a. Wounds generally include chronic wounds (i.e., pressure ulcers, diabetic foot ulcers, venous stasis ulcers, and unhealed surgical wounds), not shorter-lasting wounds like skin breaks or skin tears.b. Indwelling medical devices include central lines, urinary catheters, feeding tubes and tracheostomies. Peripheral IV catheters are not considered an indwelling medical device for purposes of EBPs.

Based on observations, interview and record review the facility failed to ensure the call light was accessible for one of three sampled residents, (Resident 1).This deficient practice caused Resident 1 to sit in wet diaper from 12:30 am to 6:30 am and further cause burning sensation to buttocks.A review of Resident 1's admission Record indicated the facility originally admitted this [AGE] year old male on 6/14/2025 and most recently on 9/21/2025 with diagnoses including Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (total weakness of the arm, leg, and trunk on the same side of the body) of the right side, end stage renal disease(ESRD-End Stage Renal Disease-irreversible kidney failure), 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), essential hypertension (HTN-high blood pressure), hyperlipidemia (fat in the blood), cerebral infarction(CI-stroke, loss of blood flow to a part of the brain, generalized weakness, dysphagia (difficulty swallowing), aphasia (a disorder that makes it difficult to speak) and anemia (a condition where the body does not have enough healthy red blood cells.A review of Resident 1's History and Physical (H&P- a physician assessment and treatment plan) dated 8/21/2025 indicated Resident 1's cognition (mental ability to make decisions for daily living) was intact.A review of Resident 1's Minimum Data Set (MDS-resident assessment tool) dated 3/16/2026, indicated Resident 1 was dependent (helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting, personal hygiene, and transfers (moving between surfaces) from bed to chair.A review of Resident 1's care plan titled, I have functional and ADL self-care performance deficit, revised 3/20/2026 included the following interventions: turn and reposition every 2 hours, call light within reach and attend to needs promptly, encourage resident to call nurse for help.A review of Resident 2's admission Record indicated the facility admitted this [AGE] year-old male on 1/19/2026 with diagnoses including Rhabdomyolysis (breakdown of muscle causing kidney damage), hypokalemia (low potassium), HTN, venous insufficiency (poor circulation in legs), cataract (cloudy lens) of right eye and chronic kidney disease (long term kidney failure).A review of Resident 2's H&P dated 1/20/2026 indicated Resident 2's cognition was intact.A review of the Daily Assignment Sheet dated 4/1/2026 11:00pm to 7:00am indicated CNA 2 was assigned to Resident 1.On 3/24/2026 The California Department of Public Health (CDPH) received a complaint alleging Resident 1's call light was not accessible causing Resident 1 to contact family when help is needed. During an interview on 4/2/2026 at 10:34 am The Certified Nursing Assistant (CNA) 1 assigned to Resident 1 stated Resident 1 went to dialysis at 9:00 am. CNA 1 stated, I changed Resident 1 after breakfast; Resident 1 was not soaking wet because the night shift had just changed Resident 1. Resident 1 should be back between 12:00pm and 1:00pm.During an interview on 4/2/2026 at 10:39 am with Resident 2; the roommate of Resident 1. Resident 2 stated, Last night it was pretty quiet between 2:00am and 6:00am I don't recall anyone coming into the room. I have seen them come in and change Resident 1 at night, Resident 1 uses the button, and they come but last night was pretty quiet.During an interview on 4/2/2026 at 11:17am with Resident 1. Resident 1 was found on the patio near the front nursing station using communication board to communicate. Resident 1 types out on board that no one came to check on Resident 1 last night between 12:30am and 6:30 a.m. Resident 1 stated, I needed to be changed at 12:30am but my call light was on the floor. I did not sleep much because my bottom was burning, I was not repositioned, I have told all shifts about my bottom burning, I have learned to just tolerate it because no one cares started to cry. CNA 2 changed me at 6:30am this morning and that is the only time I have been changed today since last night. During an interview on 4/2/2026 at 1:49 pm with CNA 2. CNA 2 stated that Resident 1 slept all night long and Resident 1 was changed once at 6:30 am. Resident 1 had an appointment this morning, so I changed and got Resident 1 dressed this morning. When I started my shift at 11:00pm I saw that Resident 1 was asleep and I saw what I thought was the call light coming out of the wall. Resident 1 usually calls during the night between 1:00am and 2:00am but last night Resident 1 did not call for a change. When I went into the room this morning what I thought was the call light was the phone charger cord. When I came in this morning, I did see the call light dangling on the right side of the bed out of Resident 1's reach; Maybe that's why Resident 1 did not call last night. Lastly, CNA 2 stated, That's probably why Resident 1 was more wet than usual when I changed him this morning.During a concurrent observation and interview on 4/2/2026 at 2:39pm with CNA 1 inside of Resident 1's room. Resident 1's call light was on the floor on the right side of the bed. CNA 1 opened Resident 1's diaper and intact skin was observed on Resident 1's bottom. CNA 1 raised the head of bed, placed bedside table in front of resident with communication board, went to trash can to take off gown and attempted to exit the room. CNA 1 stated, Do you have everything you need and Resident 1 looked and smiled Surveyor stopped CNA 1 from exiting the room and stated, Where is the call light? CNA 1 then walked over and picked up call light from the floor and pinned it onto the bed linen.During an interview on 4/2/2026 at 4:16pm with the Director of Nursing (DON), The DON stated the call light should always be in reach. A review of the facility's policy and procedure titled, Call Light Answering revised 1/12/2026 indicated:NURSING ACTION1. Upon admission, the nurse call system will be demonstrated to the resident. To acquaint resident with a system he/she can use to communicate. 2. Instruct the resident to use the call button any time he/she needs to talk with a nurse or be assisted. To make resident feel secure that his/her needs will be met.3. Check to see that the system is functioning. If any malfunction, report immediately to maintenance.4. If resident is able to ambulate, instruct him/her on bathroom emergency call button.5. Keep constant watch on all call lights.6. Answer all lights promptly, regardless of whose resident it is.7. Turn off call light as soon as you enter room before complying with resident's request.9. Always check with the charge nurse before doing anything of an unusual nature for the resident.10. Report to charge nurse if the task is beyond your authority to perform.11. Reposition call light within resident's To assure resident can call for help.DOCUMENTATIONThe licensed nurse will document in the resident's care plan any needed intervention for the resident to use the call light system (e.g. - quad light, positioning on right or left side, etc.).A review of the facility policy and procedure titled, Routine Resident Checks reviewed 1/12/2026 indicated1. To ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each unit at least once per each 8-hour shift.2. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc.3. The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the resident's condition and medical needs.4. The Nursing Supervisor/Charge Nurse shall keep documentation related to these routine checks, including the time, identity of the person making checks, and any outcomes of each check. (Note: CNAs may also record this information and provide it to the Nurse Supervisor/Charge Nurse.)

Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards to maintain skin integrity for one of 10 sampled residents (Resident 1) by failing to: 1. Implement the Comprehensive Care Plan for diabetic ulcer (a slow-healing wound that commonly appears on the feet) interventions on monitoring Resident 1 ' s blood sugar to help with wound healing. 2. Ensure that a recommendation of a vascular consult (a doctor who specializes in the treatment of arteries and veins) by the Wound Care Specialist/Nurse Practitioner (WCS) was followed up with the physician to obtain an order after Resident 1 ' s left heel wound size changed from 8/8/2023 with a measurement of 4.2 centimeters (cm, unit of measurement) length by 4.7 cm width and increased size of 4.4 cm length by 5 cm width on 8/15/2023. 3. Conduct an Interdisciplinary (IDT - team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) care conference when Resident 1 ' s left heel wound increased from 8/8/2023 to 8/15/2023 and WCS recommended for a vascular consult. 4. Implement the facility ' s policy and procedures (P&P) titled, Pressure Ulcer [injuries to skin and underlying tissue resulting from prolonged pressure on the skin] and Wound Management to evaluate and document the status of the skin conditions weekly and ensure the accurate assessment of the wound was provided for Resident 1. 5. Ensure Resident 1 did not receive Fibersource (formulated with fiber to meet the nutritional needs for tube feeding patients with normal or elevated calorie and/or protein requirements and has higher carbohydrate content) tube feeding (TF- a method of supplying nutrients directly into the stomach) via gastrostomy tube (GT- a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) in accordance with a physician ' s order. The facility was aware Resident 1 had diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and administered Diabetisource TF (a unique carbohydrate blend includes pureed fruits and vegetables to help with the nutritional management of patients with diabetes or stress-induced hyperglycemia [high blood sugar]) to Resident 1. These deficient practices resulted in Resident 1 being transferred to the general acute care hospital 1 (GACH 1) on 8/23/2023, needing intravenous (IV - administering fluid medication through a needle or tube inserted into a vein) antibiotics (medication that fight bacterial infection) and left below the knee amputation (BKA, removal of the limb) was performed. GACH 1 reported maggots (small, wormlike fly larva [a worm-like creature, which emerges from an egg]) were found in Resident 1 ' s left heel wound upon admission in the Emergency Department (ED). On 9/12/2023 at 2:46 p.m., while at the facility, an Immediate Jeopardy (IJ, a situation in which the facility ' s non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of facility ' s Administrator (ADM), Director of Nursing (DON) and Quality Assurance Nurse (QAN) regarding the facility ' s failure to ensure the comprehensive care plan for diabetic ulcer was implemented, an IDT conference was conducted, a follow-up recommendation by WCS was implemented and a correct order of TF formula was given to Resident 1. These deficient practices resulted in Resident 1 having a below the knee amputation. On 9/15/2023 at 2 p.m., the IJ was removed in the presence of the ADM, DON and QAN after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and the surveyor verified and confirmed through observation, interview, and record review onsite the facility ' s implementation of the IJ Removal Plan. The acceptable removal plan included the following actions: 1. On 9/13/2023, Resident 1's care plan was updated. Resident 1's wound progress was reviewed, and a weekly IDT wound progress was completed on 9/13/2023. A physician order to monitor Resident 1 for any signs and symptoms (s/sx) of infection on the wound was placed on 9/13/2023 including to notify Medical Doctor 1 (MD 1) if symptoms were noted. On 9/13/2023, the Registered Nurse (RN 1) reviewed all the blood sugar readings of Resident 1, and MD 1 was notified and obtained an order for insulin (regulate the body ' s energy supply) sliding scale (a chart of how much insulin dosages to take before each meal) every six hours. 2. On 9/12/2023, an IDT meeting was conducted with the Resident 1's daughter to discuss the plan of care including the wound progress update. 3. On 9/12/2023, Treatment Nurse (TXN) received a 1 on 1 education from the DON to make sure all recommendations from the WCS were ordered and carried out. The in-service emphasizes making sure the DON was notified of any recommendation to ensure that orders are discussed with MD 1 and implemented to ensure there is no delay on the care and services. 4. On 9/12/2023, RN 1 immediately checked the tube feeding order including the flushing (water) order for Resident 1 and hung the feeding according to the physician's order. 5. On 9/12/2023, a change in condition (COC) was initiated to monitor Resident 1 for any adverse reaction, the blood sugar level for Resident 1 was also checked; no adverse reaction was noted. MD 1 was notified as well as the daughter. 6. On 9/12/2023, two ways checked of all enteral feeding orders was done by the DON and RN 1 to ensure that the feeding administered matches the physician's order for all residents with enteral feeding. 7. On 9/12/23, RN 1 identified all current residents with diabetes and review of plan of care for diabetic management. RN 1 obtained physician order to draw hemoglobin A1C (HbA1C-a blood test that indicates average blood glucose level over the past two to three months) and reported to their attending physician. HbA1C laboratory test (lab) was drawn on 9/13/2023 for all diabetic residents. 8. On 9/12/2023, the DON initiated an in-service to all licensed nurses on the following topics: A. Diabetic care emphasizes making sure each residents with diabetes received proper monitoring of blood sugar level as well as proper notification of physician for any s/sx of hypoglycemia (low blood sugar)/hyperglycemia (high blood sugar). The emphasis of the in-service is to make sure there is no delay in the care and services to the residents. B. Enteral tube feeding, gastrostomy (a surgically created opening in the belly) care and diabetic care and management and proper documentation and reporting of lab test results. C. Wound prevention - turning and repositioning and including all special devices and other special mattresses. (in-service for licensed nurses and certified nurse assistants - CNA) D. In-service on Comprehensive Care plan emphasizes making sure the licensed nurses updates and follows the plan of care for diabetic residents. As of 9/14/2023 - 60 percent (%) completion of in-services for licensed nurses. All licensed nurses on vacation or off days will be required to attend the in-service upon return. 9. On 9/13/2023, the WCS conducted a training on wound assessment and documentation to licensed nurses. Completed on 9/13/2023, (70% of licensed nurses). All licensed nurses on vacation or off days will be required to attend the in-service upon return. 10. On 9/13/2023, RN 1 and the TXN conducted a full skin sweep on all 21 DM residents to identify any skin breakdown/diabetic ulcers. 11. All physicians order were reviewed to make sure there was no delay in the care and services to residents who have a change of condition due to diabetic complications. No other resident was identified with a new diabetic wound on 9/13/2023. 12. All 21 residents with DM were reviewed by RN 1 to make sure there is a clear order on how blood glucose monitoring will be done on 9/13/2023. All 21 resident's physician's order were reviewed, obtained, clarified, and implemented by RN 1 on 9/13/2023. Cross reference: F693 Findings: A review of Resident 1 ' s Admission Record indicated that Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type II DM, sepsis (a life-threatening condition that arises when the body ' s response to infection causes injury to its own tissues and organs) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure). During a review of Resident 1 ' s Physician Order Summary Report (POSR), dated 2/23/2023 indicated, wound consult and treatment as indicated with Skilled Nursing Facility (SNF) wound care. During a review of Resident 1 ' s Care Plan for DM initiated on 5/27/2023, had a goal of, will have no complications related to diabetes, with interventions included, finger stick (blood tests conducted on capillary blood [sample of blood is obtained by pricking the skin's surface to obtain a drop or several drops of blood for laboratory testing] obtained by fingerstick) blood sugar check every six hours ., and fasting serum blood sugar (measures blood sugar after not eating) as ordered. During a review of Resident 1 ' s POSR, active order and discontinued as of 5/27/2023 indicated, there was no order for monitoring Resident 1 ' s blood sugar level via fingerstick every six hours. During a review of Resident 1 ' s Care Plan for diabetic ulcer of the left heel initiated on 6/14/2023, indicated a goal of, resident will have no complications related to ulcer, with interventions to, monitor blood sugar levels .monitor/document wound size, depth, margins, periwound tissue surrounding a wound] [skin, document progress in wound healing on an ongoing basis, notify medical doctor as indicated . monitor/document/report as needed changes in wound color, temperature, sensation, pain or presence of drainage and odor . During a review of Resident 1 ' s Non-Pressure Ulcer Skin Report, completed by TXN, indicated from 8/2/2023 to 8/21/2023, no weekly progress report was documented regarding Resident 1 ' s non-pressure ulcer skin by the TXN. A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 8/14/2023, indicated Resident 1 has moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and required extensive assistance from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, dressing, toileting, and personal hygiene). The same MDS also indicated that Resident 1 was at risk for developing pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin). During a review of Resident 1 ' s SNF Wound Care Notes dated 8/15/2023, completed by WCS indicated, i. Wound: left heel, diabetic wound . ix. Plan: cleanse with NS [normal saline]and apply Santyl (used to remove dead tissue from wound) daily, also recommended a vascular consult for this left foot. During a review of Resident 1 ' s SNF Wound Care Notes dated 8/22/2023, completed by WCS indicated, i. Wound: left heel diabetic wound . [NAME]. Overall wound condition: declined. xii. Plan: cleanse with Dakin ' s solution (strong topical antiseptic widely used to clean infected wounds, ulcers, and burns) and apply Santyl (medicine that removes dead tissue from wounds) to the wound bed and vascular consult is needed. During a review of Resident 1 ' s POSR, active order as of 8/23/2023 indicated, there was no order for monitoring Resident 1 ' s blood sugar level via fingerstick every six hours. During a review of Resident 1's Medical Records from GACH 1 indicated the following: a. Resident 1 presented in the Emergency department (ED) on 8/23/2023 with diagnosis of osteomyelitis (infection in the bone), abscess (buildup of a pus), sepsis, bacteremia (bacteria present in the bloodstream). b. Necrotic ulceration [ the death of cells in living tissue caused by external factors such as infection] to the left heel with presence of maggots and malodor (unpleasant smell) c. Left foot x-ray (use of invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs on film or digital media) on 8/23/2023 resulted in an extensive subcutaneous gas with osseous erosion (the loss of bone from disease processes) of the posterior (back side) and inferior (below) calcaneus (large bone forming the heel) consistent with osteomyelitis. d. Resident 1 ' s infection was too severe and a BKA had to be performed per orthopedic surgeon (examines, diagnoses, and treats diseases and injuries to the musculoskeletal system) on 8/25/2023. e. On 8/23/2023, Resident 1 ' s glucose level test result was 213 milligram/deciliter (mg/dL) (high - normal glucose test is between 70 mg/dL - 100 mg/dL). During an interview with the WCS on 8/29/2023 on 12:07 p.m., WCS stated, Resident 1 has a diabetic ulcer on her left foot in which he assesses and monitors once a week. WCS stated Resident 1 ' s left foot wound had drastically changed and declined on 8/15/2023. WCS stated, as a result, he recommended for a vascular consult and communicated it to the TXN. WCS further stated, a vascular consult would be able to further examine Resident 1 ' s left heel wound as she (Resident 1) may have some blockage in the arteries or veins. WCS further stated, since Resident 1 has a DM, her (Resident 1) blood sugar level would also be a factor why the wound was not healing. WCS stated, there was no blood sugar level monitoring ordered for Resident 1. During an interview with the TXN on 8/29/2023 at 12:42 p.m., TXN stated they first noted Resident 1 developed redness on her left heel while doing rounds with the WCS on 6/13/2023, skin was intact, no drainage was noted, no s/sx of infection and no odor was noted. TXN stated, Resident 1 ' s left heel was not getting better and the WCS recommended a vascular consult on 8/15/2023, but he did not follow up on it as he had forgotten to obtain an order from MD 1. TXN further stated, he did not do any skin weekly assessment on Resident 1 ' s left heel after 8/2/2023 until 8/22/2023. During an interview and a concurrent record review with RN 1 on 8/30/2023 at 11:37 a.m., Resident 1 ' s care plan regarding blood glucose was reviewed. RN 1 stated, Resident 1 ' s care plans indicated to monitor blood glucose via fingerstick every six hours to aid in wound healing. RN 1 stated and confirmed, Resident 1 does not have any blood glucose levels monitoring via fingerstick every six hours since 5/27/2023 and were unable to provide documentations if they have called the doctor for an order so they can monitor her blood glucose levels. RN 1 stated, Resident 1 ' s left heel wounds were not getting better, it was not healing and was getting bigger. RN 1 further stated, if a wound was not getting better, they need to consult with the physician and have an IDT meeting for further recommendations. During a concurrent interview and record review of Resident 1 ' s IDT Care Conference Record with RN 1 on 8/30/2023 at 11:37 a.m., RN 1 verified, as of 8/15/2023, there was no IDT care conference conducted when Resident 1 ' s left heel wound increased from 8/8/2023 to 8/15/2023 in which WCS recommended for a vascular consult. RN 1 stated, she was aware of the GACH 1 ' s report of finding maggots in Resident 1 ' s wound. RN 1 stated, the maggots came from a fly but unable to answer how the maggots got into Resident 1 ' s wound. RN 1 further stated, she had also seen flies around the facility at times. RN 1 further stated, she was unaware of the WCS recommendation for a vascular consult on 8/15/2023 but it should have been followed up. RN 1 stated, licensed nurses are responsible for obtaining an order from the physician, calling for a vascular surgeon to make an appointment and arrange transportation for an appointment. RN 1 stated, if a vascular surgeon was consulted, it would have helped with Resident 1 ' s wound healing. A review of Resident 1 ' s POSR, dated 8/30/2023 indicated, enteral feed - order every shift continuous feeding of Diabetisource via GT . During an observation of Resident 1 on 9/12/2023 at 10:25 a.m., Resident 1 was observed receiving enteral TF of Fibersource via GT. During a concurrent observation, interview, and record review with RN 1 on 9/12/2023 at 11:01 a.m., RN 1 observed Resident 1 was receiving Fibersource enteral TF with the surveyor. RN 1 stated, physician ordered Diabetisource for Resident 1 but was receiving the incorrect TF of Fibersource. RN 1 stated, Resident 1 ' s was not receiving the correct nutrition and at risk of high blood sugar due to a higher carbohydrates content of Fibersource. A review of the facility ' s P&P titled, Pressure Ulcer and Wound Management (includes non-pressure ulcer wounds), with review date ofn 9/12/2022 indicated, it is the policy of this facility to ensure that resident ' s skin status is assessed and appropriate interventions are developed and implemented to maintain skin integrity, assist in wound healing and or prevent avoidable skin breakdown . skin assessment: the licensed nurse may assess resident ' s skin integrity at the minimum the following intervals: licensed nurse weekly progress review, upon completion of nursing weekly summary, the skin assessment is documented in the resident weekly summary . evaluation: a licensed nurse on a weekly basis evaluates and documents the status of the pressure ulcers condition on the skin breakdown progress report and licensed nurse weekly progress notes and notifies the physician of pressure ulcer deterioration or lack of pressure ulcer progress. A review of the facility ' s P&P titled, Foot Care, with reviewed date of 9/12/2022 indicated, the purpose of foot care is to cleanse, prevent infection, control odor and stimulate peripheral circulation. A review of the facility ' s P&P titled, Nursing Care of the Resident with Diabetes Mellitus, with review date of 9/12/2022 indicated, glucose monitoring: the management of individuals with diabetes mellitus should follow relevant protocols and guidelines . medication management: the nurse will closely monitor the diabetes management of cognitively impaired residents, assist the resident with his or her specific medication regimen, as ordered and as needed. A review of the facility ' s P&P titled, Care Plans, Comprehensive Person-Centered, with review date of 9/12/2022 indicated, a comprehensive, person-centered care plan must include measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident, . each resident ' s comprehensive person-centered care plan will be consistent with the resident ' s rights to participate in the development and implementation of his or her plan of care, including the right to: . receive the services and/or items included in the plan of care, . the IDT must review and update the care plan: when there has been a significant change in the resident ' s condition; when the desired outcome is not met . A review of the facility ' s P&P titled, Interdisciplinary Team Care Conference, with review date of 9/11/2023 indicated, to provide an interdisciplinary discussion of residents ' individualized status for integration into care plan approaches and goals . The resident care coordinator is responsible for the timely and efficient facilitating of the IDT care conferences . A review of the facility ' s P&P titled, Tube Feeding, with review date of 9/12/2022 indicated, the purpose of a tube feeding is to administer specially prepared nutrients into the stomach . the tube feeding procedure will be performed by the licensed nurse according to the physician ' s order .

Based on observation, interview and record review, the facility failed to ensure two of seven sampled residents (Residents 1 and 2), who were at risk of elopement (leaving the facility unsupervised, presenting an imminent threat to the resident's health and safety because resident was too impaired to make a decisions), had wandering behavior (occurs when a person roams around and becomes lost or confused about their location) and had high risk for falls, were provided a safe environment with supervision as indicated in the plan of care and the facility ' s policies. As a result: 1. On 4/27/2022 around 8:30 pm, Resident 1 eloped from the facility, missing all his needed medications, food and fluids until a good Samaritan (one who voluntarily renders aid to another in distress although under no duty to do so) found Resident 1 and called the facility the next day, 4/28/2022, at 12:00 pm. The facility ' s administrator picked up Resident 1 at 0.7 miles from the facility. Resident 1 sustained abrasions (superficial rub or [NAME] off the skin) to the tip of the nose, left nostril (openings at the end of the nose), both knees and right lower leg, and an open wound on the right plantar (bottom) of the foot. 2. On 6/7/2022 at 9:30 am, Resident 2 eloped from the facility and emergency medical services (EMS) found the resident the following day, 6/8/2022, laying under a tree too weak to get up on his own. EMS took Resident 2 to General Acute Care Hospital (GACH 1) Emergency Department (ED) at 4:25 pm, where the resident was diagnosed with generalized weakness, dehydration, acute kidney injury (AKI, a condition where the kidneys have stopped working properly), possible pneumonia (lung infection), urinary tract infection, and [CONDITION(S)] (low level of red blood cells in the blood). Findings: 1. A review of Resident 1 ' s Admission Record indicated the facility admitted the resident, an [AGE] years-old male, on 8/30/2021 with diagnoses including [CONDITION(S)] (A disorder that affects a person's ability to think, feel, and behave clearly), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), diabetic retinopathy (an eye condition that can cause vision loss and [CONDITION(S)] in people who have diabetes), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily functioning) and polyneuropathy (a damage to the peripheral nerves in the body that can result to pain, discomfort or mobility difficulties). A review of Resident 1 ' s History and Physician Examination dated by the attending physician (Physician 1) on 8/31/2021, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 3/8/2022, indicated the resident had severely impaired cognition (unable to remember, making decisions, concentrating, or learning). A review of Resident 1 ' s Care Plan, initiated on 8/30/2021 and last reviewed on 3/16/2022, indicated Resident 1 was a wanderer and at risk for elopement due to his impaired safety awareness and cognition. The goal was for Resident 1 not to leave the facility unattended through the next review date of 6/8/2022. The interventions included distracting the resident from wandering by offering pleasant diversions, structured activities; and monitoring and documenting wandering behavior and attempted diversional interventions in behavior log. A review of Resident 1 ' s Care Plan, initiated on 8/30/2021 and last reviewed on 3/16/2022, indicated Resident 1 was a high fall risk and injury due to his impaired cognition, poor safety awareness, medication used that could affect balance, history of dizziness and an unwitnessed fall on 3/22/2022. The interventions included monitoring unsafe behaviors such as restlessness (the inability to remain still or at rest), climbing out of bed, and getting up from the wheelchair unassisted. A review of Resident 1 ' s Care Plan, initiated on 8/31/2021 and last reviewed on 3/16/2022, indicated Resident 1 had visual impairment related to diabetic retinopathy. A review of Resident 1 ' s Care Plan initiated on 8/31/2022 and last reviewed 3/16/2022, indicated Resident 1 had diabetes mellitus. The goal was for the resident to be free from signs and symptoms of [CONDITION(S)] (high blood sugar) and [CONDITION(S)] (low blood sugar). The interventions included giving diabetes medication as ordered. A review of Resident 1 ' s Wandering Risk Assessment, dated 3/13/2022, indicated Resident 1 was a moderate risk for wandering related to disorientation, not understanding his surroundings or what is being said, recent experience of room changes, transfer from one unit to another caregiver/staff change, and medications. A review of Resident 1 ' s Status Post Fall Rehab Assessment, dated 4/12/2022, indicated Resident 1 had a recent fall on 4/8/2022 at 7:30 am. The assessment indicated Resident 1 had poor safety awareness. A review Resident 1 ' s Nursing Progress Note, dated 4/27/2022 at 11:23 pm, indicated at 8:30 pm, Resident 1 could not be found in the facility and the surrounding neighborhood. A review of Resident 1 ' s nursing Progress Note, dated 4/28/2022 at 3:17 pm, indicated the facility received a telephone call, time not indicated, from a good Samaritan (one who voluntarily renders aid to another in distress although under no duty to do so) to inform them finding Resident 1 on a local street. The Administrator picked Resident 1 up and brought him back to the facility at 12:15 pm. Resident 1 was noted with multiple injuries. A review of Resident 1 ' s Skin Assessment, dated 4/28/2022, indicate the following injuries: 1. Tip of nose abrasion 2.5 centimeters (cm) in length by 3 cm in width by undetermined (UTD) depth. 2. Left nostril abrasion 0.5 cm by 0.5 cm by UTD 3. Right knee abrasion Site #1 3.5 cm by 3.5 cm by UTD 4. Right Knee Abrasion Site #2 2 cm by 2 cm by UTD 5. Right lower leg abrasion 4 cm by 3.5 cm by UTD 6. Left knee abrasion 3 cm by 3 cm by UTD 7. Right plantar foot open wound 3 cm x 3 cm x 0.1 cm. A review of the Physician ' s Orders for Resident 1 ' s injuries, dated 4/28/2022, indicated to cleanse tip of nose abrasion, left knee abrasion, left nostril, right knee abrasion site #1, right knee abrasion site #2 and right lower leg abrasion with NS (normal saline, a salt solution), pat dry, apply triple ATB (antibiotic, medication used to treat or prevent bacterial infections on the skin) and leave open to air. Cleanse the right plantar foot open wound with NS, pat dry, apply triple ATB, cover with dry dressing, and wrap with kerlix (a wound dressing / bandage). A review of the facility ' s Investigation Report dated 5/2/2022, indicated Resident 1 was seated in the lobby on 4/27/2022 at 6:30 pm. The licensed nurse (unnamed) noted Resident 1 was not in his room at 8:30 pm. The report indicated Resident 1 was found nearby the facility, was transferred back to the facility, and the resident did not have major injuries. On 5/16/2022 at 11:42 am, during an interview, the Director of Nursing (DON) stated Resident 1 might have left through the front door because both back doors were locked and had alarms. The DON stated there was no alarm in the front door. The DON stated the front receptionist ends her shift at 3:00 pm. After 3:00 pm., it is a community effort between the nurses to monitor the front door. On 5/16/2022 at 12:05 pm, during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 walked up and down the facility hallway a lot prior to his elopement. During a concurrent observation and interview on 5/16/2022 at 12:30 pm, Resident 1 had a bandage on the plantar area (sole) of his right foot. Resident 1 stated he did not remember what happened. On 5/16/2022 at 1:56 pm, during an interview, the Administrator stated a stranger found Resident 1 and contacted the facility based on Resident 1 ' s wrist band. The Administrator stated he picked up Resident 1 at 0.7 miles from the facility and brought him back. The Administrator stated after the receptionist leaves the facility between 3:00 pm to 5:00 pm, the nursing staff is in-charge of monitoring the front door. On 5/16/2022 at 2:26 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated she was assigned to Resident 1 on the evening he eloped. CNA 1 stated she gave Resident 1 his dinner tray around 5 pm and when she picked up the tray at around 7:00 pm, she noticed Resident 1 was gone, which she reported to the charge nurse. CNA 1 stated staff looked for the resident but were unable to find him. On 5/16/2022 at 2:40 pm, during an interview, Registered Nurse 1 (RN 1) stated she was the RN Supervisor on duty that assessed Resident 1 on 4/28/2022 when he came back to the facility. RN 1 stated Resident 1 was tired and slept until the next day. On 5/17/2022 at 10:18 am., during an interview, RN 2 stated she was the RN supervisor the night Resident 1 eloped from the facility (4/27/2022). RN 1 stated she generally sits in the nursing station and monitors the front door at night; however, the night Resident 1 eloped, she had two admissions and had to go back and forth from the front to the back of the facility to assess the newly admitted residents. RN 1 stated at around 8:30 pm, LVN 5 informed her that Resident 1 could not be found in the facility. On 5/17/2022 at 2:06 pm, during an interview, LVN 3 stated she noted Resident 1 with abrasions to his nose and legs when he came back to the facility on [DATE]. LVN 3 stated Resident 1 verbalized he was hungry but was unable to remember what happened to him. On 5/17/2022 at 4:03 pm, during an interview, LVN 5 stated he was the charge nurse the night Resident 1 eloped. LVN 5 stated he was passing medications at around 8:00 – 8:30 pm, and he could not find Resident 1. On 6/14/2022 at 12:23 pm, during a telephone interview, the DON stated she could not provide documentation the care plan intervention of monitoring and documenting wandering behavior and attempted diversional interventions in a behavior log was performed prior to Resident 1 ' s elopement. 2. A review of Resident 2's Admission Record indicated the facility originally admitted the resident on 7/23/2020 and readmitted him on 1/31/2021, with diagnoses including [CONDITION(S)] (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain) with behavioral disturbance (agitation including verbal and physical aggression, wandering, and hoarding), hypertensive [CONDITION(S)] (heart problems that occur because of high blood pressure that is present over a long time) with heart failure, and long-term and current use of anticoagulants (blood thinners). A review of the Physician ' s order for Resident 2, dated 2/8/2021, indicated to apply a bed alarm (devices that can detect the patient's movements and sound an alarm if he/she tries to get up from the bed on their own). A review of Resident 2 ' s Care Plan developed on 3/16/2022 for the resident ' s risk for Wandering/Elopement related to wandering aimlessly stating I want to go to the bank and an episode of elopement on 6/7/2022. The interventions included always securing the exit door and gate alarms and frequently monitoring the alarms were operating or turned on. A review of Resident 2 ' s MDS dated [DATE], indicated the resident had memory problems, required limited to extensive assistance with walking and locomotion. The same MDS further indicated no history of falls or falls during admission. A review of Resident 1 ' s Nursing Note written by LVN 6 on 6/7/2022 indicated at 11:24 am staff was unable to locate Resident 2. At 11:35 am Police was notified and at 11:55 am a police officer at facility took a missing person report. On 7/6/2022 at 12:16 pm, during an interview, the Maintenance Assistant (MA) stated all alarms for the exit doors must be turned off and on with a key. All housekeeping and maintenance staff have a key and there is a key at the nursing station for each exit door. On 7/6/2022 at 12:34 pm, during an interview, LVN 6 stated on 6/7/ Resident 2 left through the back exit door of the North Nursing Station. The door had an alarm and staff need to check who opens the doors before turning off the alarm. LVN 6 could not remember if the door alarm went off when Resident 2 left. On 7/6/2022 at 2:14 pm, during an interview, the Administrator stated the facility had video surveillance but currently it only went back to 6/11/2022. The Administrator further stated after the incident he observed the video footage, and on 6/7/2022 at 9:30 am Resident 2 was seen exiting the North Nursing Station back exit door and out the back delivery door to the alley. The Administrator stated the video did not have sound, so he could not determine if the doors alarm went off. On 7/6/2022 at 2:38 pm, during an interview, CNA 2 stated that on 6/7/2022, she last saw Resident 2 around 9:30 am sitting in his wheelchair outside his room. Later, she saw Resident 2 ' s wheelchair empty, she checked in the bathroom and other resident ' s rooms and informed the nursing supervisor about not finding Resident 2. On 7/8/2022 at 9:06 am, during a telephone interview and a concurrent record review with the DON, Resident 2 ' s Elopement Risk assessment dated [DATE] was reviewed. The DON confirmed and stated Resident 2 ' s Elopement Risk assessment dated [DATE], indicated Resident 2 had a low risk for elopement, which was not accurate. The DON further stated Resident 2 had a history of elopement, therefore the Elopement Risk Assessment should have been documented as high risk. A review of the facility ' s policy and procedures titled, Fall Prevention and Incident Management, dated 1/1/2015, indicated It is the policy of this facility to assess residents for fall and accident risk to plan and implement interventions to reduce the risk for incidents and injuries, in addition, the facility will assess, treat, investigate and document incident investigations findings. A review of the facility ' s policy and procedures titled, Resident Elopement, dated 1/1/2015, indicated the purpose of the policy was to identify residents at risk for elopement and to prevent any possible injury because of elopement. The residents ' risks for elopement are assessed by the Licensed Nurse upon admission and re-admission by completing the form. The resident ' s risks for elopement and preventive interventions will be documented in the resident ' s medical record and will be reviewed and re-evaluated by the Interdisciplinary Team (IDT) upon admission, re-admission, quarterly, annually, and upon identified significant change of condition according to the Resident Assessment Instrument (RAI) guidelines. Residents with a history of wandering, have been determined to be at risk of wandering or leaving the facility will have a photograph or alternate means of identification. Ensure the residents are able to move about freely, are monitored and remain safe. A review of the facility's policy and procedures titled, 'Wandering & Elopement revised 7/2017, indicated, the Licensed Nurse, in collaboration with the IDT, will assess residents upon admission, readmission, quarterly, and upon identification of significant change in condition according to the RAI guidelines to determine their risk of wandering/elopement. The resident's risk for elopement and preventative interventions will be documented in the resident's medical record and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly and upon change in condition according to the RAI guidelines.

Based on interview and record review, the facility failed to consult immediately with the physician when there was a significant change in clinical condition and need to alter the treatment significantly for one of four sample residents (Resident 1). Resident 1 arrived to the facility on (MONTH) 25, (YEAR) at 7:40 p.m. without respiratory distress. At 11:45 p.m., Resident 1 was congested and coughing, requiring suctioning and respiratory treatment but the licensed nurse did not notify Resident 1's physician of the change of condition. At 1:45 a.m., six hours after admission, Resident 1 was unresponsive, cardiopulmonary resuscitation (CPR) was initiated, and paramedics (911) were called. Paramedics pronounced Resident 1 dead at the facility at 2:30 a.m. Findings: On (MONTH) 9, (YEAR), at 8:40 a.m., an unannounced visit to the facility was conducted to investigate a complaint regarding quality of care. A review of the Admission Record indicated Resident 1 was admitted to the facility, from General Acute Care Hospital 1 (GACH 1), on [DATE]. Resident 1's [DIAGNOSES REDACTED]. to think clearly, manage emotions, make decisions and relate to others); and hypertension (high blood pressure). A review of GACH 1 Clinical Record sent with Resident 1 indicated in the History and Physical (H&P) exam dated [DATE], Resident 1 had episodes of aspiration (refers to the accidental sucking in of food particles or fluids into the lungs) events and altered mental status. Resident 1's code status was full code (resuscitation if needed). A review of Physician 1's Orders on admission included: -Oxygen at two to three liters per minute (L/min) continuously through a nasal cannula (flexible tube placed under the nose with two prongs that go inside the nostrils) for shortness of breath. -[MEDICATION NAME] nebulization solution 0.5% 2.5 milligrams (mg), inhale orally via nebulizer every four hours as needed (PRN) for shortness of breath. -[MEDICATION NAME] solution 0.02% 500 micrograms (mcg) inhale orally via nebulizer every four hours PRN for shortness of breath. -Suction PRN A review of Resident 1's nursing Progress Notes, Admission Summary dated (MONTH) 25, (YEAR), timed at 7:40 p.m., indicated Resident 1 was admitted from General Acute Care Hospital 1 (GACH 1), awake and oriented to self, able to follow commands and mumbled when talking. Physician 1 verified all transfer physician's orders [REDACTED]. Resident 1 had a GT delivering the feeding formula Nepro, at 45 cubic centimeters (cc) per hour (hr) (45 cc/hr). Resident 1 received all ordered medications, was noted with oral secretions, was suctioned as ordered, the vital signs taken were within normal levels. Resident 1's oxygen saturation (blood oxygen level is a measure of how much oxygen the red blood cells are carrying. Normal range is between ,[DATE]%) was 95%. A review of a nursing progress note dated [DATE], timed at 10:50 p.m., indicated Resident 1 was awake, able to follow commands, had the head of the bed elevated, and required suctioning due to oral secretions. The oxygen saturation was 95%. Resident 1's care was endorsed to the next shift (11 p.m. - 7 a.m.) A nursing progress note documented [DATE] at 5:02 a.m., indicated on [DATE], at 11:30 p.m., Resident 1 was alert, oriented to self, and had no difficulty breathing. At 11:45 p.m., Resident 1 was coughing and congested, had raised the head of the bed, and was suctioned. The oxygen saturation was 95% and vital signs were within normal ranges. At 1 a.m., Resident 1 was congested and the licensed nurse administered breathing treatment. Resident 1 remained congested. At 1:30 a.m., the licensed nurse suctioned Resident 1. At 1:45 a.m., Resident 1 was not responsive, CPR was initiated and paramedics were called and was pronounced dead at 2:30 a.m. Further record review disclosed no documented evidence Resident 1's GT feeding was stopped when there was increased congestion. There was no evidence the lungs where checked with stethoscope to assess the status of the lungs. There was no evidence Physician 1 was called for further orders when Resident 1's had increased secretion needing several suctioning and did not improve with suctioning or breathing treatment. During an interview on [DATE] at 12:30 p.m., Physician 1 stated she did not have a chance to see Resident 1 in the facility. Physician 1 stated the Resident 1 had multiple episodes of aspiration at GACH 1 and was sent to ICU every time he had aspiration. During an interview on [DATE] at 3:30 p.m., Licensed Vocational Nurse (LVN 1), who worked the evening shift 3 p.m. to 11:p.m. stated Resident 1 received GT feeding and was placed on aspiration precaution. LVN 1 stated she would call the physician if Resident 1 continued to have congestion or coughing. During an interview on [DATE] at 7:30 a.m., Certified Nursing Assistant (CNA 1) stated when she made rounds around 11:10 p.m. LVN 1 was still in the facility and told her to keep close eyes on Resident 1 because he was very sick. CNA 1 stated Resident 1 looked pale and did not respond verbally. On [DATE], at 7 a.m., during an interview, LVN 2, who worked the 11 p.m. to 7 a.m. shift, stated she did not call Physician 1 because she did not notice a change in Resident 1's condition. Resident 1 looked very sick and had secretions, which needed suctioning. During an interview on [DATE] at 11:30 a.m., the Director of Nursing (DON) stated Resident 1 was very sick since admission and the licensed nurses should have called Physician 1 for transfer to a GACH. A review of facility's policy and procedure on Change of Condition Management Guideline, effective [DATE], indicated a change of condition may be subtle and slow to develop, severe and develop quickly, and could be physical, mental and/or psychosocial in nature.

Based on observation, interview, and record review, the facility failed to develop a system between the nurses and the dietary staff to ensure one of 17 residents (random selected residents (RSR) 18) on Insulin therapy was administered a meal or a snack at least 5-10 minutes just prior to the administration of rapid acting [MEDICATION NAME] Insulin and long acting [MEDICATION NAME]. This resulted in the resident developing [DIAGNOSES REDACTED] and consequently receiving an intravenous push of [MEDICATION NAME] 50% and being transferred to the general acute care hospital (GACH), where he was diagnosed with [REDACTED]. This practice resulted in RSR 18's turning pale in color, sweating heavily, and having a drop in blood sugar from 186 milligrams per deciLiter (mg/dl) at 6:30 a.m. to 33 mg/dl at 7:16 a.m. Findings: A review of the Medication Administration Record [REDACTED]. Consequently, two (2) units of [MEDICATION NAME] Insulin and 25 units of [MEDICATION NAME] were administered at 6:30 a.m. by registered nurse (RN) 1. During a room observation on April 7, 2016, at 7:16 a.m., RSR 18 was observed lying in bed with his eyes closed, sweating heavily, and his face was pale in color. RSR 18 was arouseable, but not verbally responding, but was shaking his head up and down when asked if he was okay. Licensed Vocational Nurse (LVN 1) stated that she was alerted by a certified nursing assistant (CNA 1) that RSR 18 was sweating. LVN 1 was observed with a glucometer machine (medical device to measure the amount of sugar in the blood) in her hand and she stated that RSR 18's blood sugar was checked and the reading measured 33 milligrams per deciLiter (mg/dL) (normal range is between 70-100 mg/dl). During an observation on April 7, 2016 at 7:18 a.m., the director of nursing (DON) was observed to administer [MEDICATION NAME] (a medication used to quickly increase blood sugar) by injection into RSR 18's left arm as a result of the resident's low blood sugar reading of 33 mg/dL. At 7:26 a.m., after the [MEDICATION NAME] was administered, LVN 1 was observed rechecking RSR 18's blood sugar, and the reading measured 35 mg/dL. The physician's orders [REDACTED]. The evaluator also observed at 7:33 a.m., the paramedics arrived on the scene. A peripheral intravenous (IV) (a small catheter inserted into a vein to immediately deliver medications and fluids into the bloodstream) was inserted to RSR 18's right arm. [MEDICATION NAME] 50 percent (%) (Medication used to restore blood sugar levels) was administered through the IV. At 7:41 a.m., during an observation, RSR 18's blood sugar was rechecked by LVN 1 and the reading was measured at 271 mg/dl. At 7:52 a.m., during an observation, RSR 18 was transferred to the general acute care hospital (GACH) via paramedics for further evaluation and returned to the facility at 12:35 p.m. Record review of RSR 18's discharge summary from the GACH indicated a [DIAGNOSES REDACTED]. According to the admission record, RSR 18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the minimum data set (MDS) (a standarized assessment tool) dated March 20, 2016, indicated RSR 18 had severe cognitive impairment and required limited assistance by staff for activities of daily living (ADLs). The MDS indicated RSR 18 had an active [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. the blood) insulin per sliding scale (administering a certain amount of fast-acting insulin based on the blood sugar) coverage as follows: If blood sugar is 70-140 mg/dl = no insulin 141-180 mg/dl = 1 unit 181-220 mg/dl = 2 units 221-240 mg/dl = 3 units 241-260 mg/dl = 4 units 261-280 mg/dl= 5 units 281-300 mg/dl = 6 units 301-350 mg/dl = 7 units If blood sugar is greater than 351mg/dl, administer 8 units, and notify the physician. According to Mosby's Nursing drug reference, 23rd edition, 2010, [MEDICATION NAME] has an onset (the length of time before insulin reaches the blood stream and begins to lower the blood sugar)) of 10-20 minutes and peaks (the time period when it best lowers the blood sugar) at 1-3 hours and has a duration (how long insulin continues to work) of 3-5 hours and should be administered just prior to the beginning of a meal. A physician's orders [REDACTED].m According to Mosby's Nursing drug reference, 23rd edition, 2010, [MEDICATION NAME] has an onset of 1.5 hours. The MAR indicated [REDACTED]. However, there was no documented evidence RN 1 made arrangements to ensure a meal or snack was served to him prior to the administration of the insulin, to ensure the resident did not have a hypoglycemic episode after the administration of insulin in accordance to professional standards and the manufactures insert. During an interview on April 8, 2016 at 7:16 a.m., the dietary supervisor stated that the first breakfast cart leaves the kitchen at 7:15 a.m. in no particular order of who is served first. She further stated RSR 18's tray is one of the trays on the first cart that leaves the kitchen. During an interview on April 7, 2016 at 1:10 p.m., the DON stated the nurse on the night shift (11 p.m., - 7 a.m. shift) is responsible for checking the resident's blood sugar. The DON stated the night shift licensed nurse will administer the Insulin in accordance to the physician order [REDACTED]. RSR 18 never received a tray. On April 7, 2016, at 5:35 p.m., during an interview with the 11 p.m., - 7 a.m. shift registered nurse (RN 1), he stated he checked RSR 18's blood sugar around 6:30 a.m. and administered insulin around the same time. RN 1 stated that [MEDICATION NAME] is short acting insulin. RN 1 stated that he observed breakfast trays in the hallway at 7 a.m. and food should be served within thirty (30) minutes of insulin administration. RN 1 worked for the facility for one year and had been a RN for almost [AGE] years. During an interview on April 8, 2016, at 7:38 a.m., the DON stated the facility did not have a policy for insulin administration, and did not have a policy as to how soon resident's meals should be served. The DON further stated that the nurses just follow the physician orders. An inservice training dated January 27, 2016, indicated that licensed nurses were provided training on insulin administration, including the types and the monitoring of the resident's food intake. RN 1's name was not included in the training attendance log. The DON obtained a new physician order [REDACTED]. According to the Insulin package insert, [MEDICATION NAME] should generally be administered immediately (within 5-10 minutes) prior to the start of a meal.

Based on interview and record review, the facility failed to ensure the resident received food in a form designed to meet her individual needs for one of one sampled residents (Resident 1). Resident 1, prescribed a mechanical soft diet, received chopped chicken that contained chicken bones. This resulted in Resident 1 choking on chicken bones contained in the mechanically chopped chicken that was served to her on January 12, 2013, which necessitated a [MEDICATION NAME] maneuver (an emergency method for treating choking that uses an upward thrust immediately below the breastbone to expel food or another blockage from the windpipe) by facility staff to dislodge the chicken bones and allow the resident to breathe freely. Findings: Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The "physician's orders [REDACTED]. A care plan dated April 3, 2010, last reviewed on October 2012 (no specific date), for self-care deficit indicated Resident 1 was totally dependent on staff for all activities of daily living, including eating. Another care plan, dated March 27, 2012, last reviewed October 2012 (no specific date) for nutritional risk related to chewing difficulty. The interventions included diet as ordered and feed resident. According to the Minimum Data Set (MDS) an assessment and care screening tool dated January 7, 2013, Resident 1 was severely impaired in her cognitive skills for daily decision-making and was totally dependent on staff for all her activities of daily living, including eating. On February 14, 2013, at 1:20 pm, a review of Interdisciplinary Progress Notes dated January 12, 2013, at 6:30 pm, revealed an entry that read, "Called by the family member and family member reported while mom is eating piece of chicken, family stated "she choked and vomited ". The documentation indicated the certified nursing assistant (CNA 1) was asked what happened and she stated "the same thing". "Resident choked and vomited." There were no subsequent entries in the "Interdisciplinary Progress Notes" after January 12, 2013, indicating Resident 1 was monitored for safety of swallowing, consequences related to the resident's choking incident on January 12, 2013, or any subsequent choking episodes. The facility menu for January 12, 2013, indicated that chicken was not planned to be served during the dinner meal on that day, but beef tacos were. However, chicken was indicated as the menu item for the lunch meal on January 12, 2013. Resident 1 had multiple documented food dislikes, including beef, and was therefore served chicken as an alternate menu item for dinner on January 12, 2013. Review of several recipes for the preparation of chicken menu items designed to be served on the facility's menu (including Baked Chicken, Barbecue Chicken and Golden Chicken), indicated the use of chicken thighs and chicken breast fillets. The recipes indicated, "Dysphagias (difficulty swallowing) and Mechanical Softs (mechanical soft): Debone 2 oz (ounces) meat per portion. Chop or grind to desired texture." On February 13, 2013, at 1:00 pm, and February 22, 2013, at 9:22 am, in an interview with Resident 1's family member, it was stated that on January 12, 2013, during the dinner meal, Resident 1 was served chopped chicken pieces that were approximately 1 inch in diameter. The family member stated Resident 1 was feeding herself, and suddenly started choking. A certified nursing assistant (CNA 1), present in the dining room during the dinner meal attempted to help, but did not know how to perform [MEDICATION NAME] maneuver. The licensed vocational nurse (LVN 1) who was in the hallway was called to come and assist Resident 1. LVN 1 proceeded to perform the [MEDICATION NAME] maneuver, at which time Resident 1 vomited, releasing chicken bones that had become lodged in her airway. The family member stated there were several chicken bones noted. The facility cook who prepared the food on January 12, 2013, at dinner time was not available for interview. On February 14, 2013, at 12:30 p.m. the Dietary Service Supervisor (DSS) was interviewed regarding this incident. She insisted that boneless chicken was purchased specifically for the preparation and service of mechanically altered diets. She was not aware what was served to Resident 1 on January 12, 2013. During a telephone conversation with the resident's family member on March 29, 2013, at 2 p.m., she stated after the incident Resident 1 was afraid to eat, but since then Resident 1 was back in her normal eating pattern.