Every finding on record at Del Mar Convalescent Hospital

Based on interview and record review, the facility failed to maintain documentation related to current Coronavirus 2019 (COVID-19, infectious respiratory disease easily spread from person to person) vaccination status for staff. This deficient practice had the potential to result in the facility's staff and residents contracting, transmitting, and experiencing complications related to COVID-19 such as difficulty breathing, persistent pain or pressure in the chest, or diarrhea. During a concurrent interview and record review of staff vaccination logs with the Director Staff Development (DSD) on 12/17/2025 at 11:30 PM, the DSD stated the only COVID-19 Vaccination log for the staff was from 2022. The DSD stated the last COVID-19 outbreak at the facility was in 10/2025 and he could not find an updated log of staff who consented to receive, or had been administered, the COVID-19 vaccine for 2025 - 2026 from the Infection Prevention Nurse (IPN). During the same interview on 12/17/2025 at 11:55 AM, the DSD stated the importance of maintaining an updated list of staff vaccinations was to know which employees to offer the COVID vaccine to and to prevent the spread of COVID. A review of the facility's policy and procedure (P&P) titled Employee COVID-19 Vaccinations revised on 3/13/2023 indicated the facility will track and securely document the vaccination status of each staff member (current and as new employees are onboarded). The P&P indicated each staff member's specific vaccine received, and the dates of each dose received, or the date of the next schedule dose for a multi-dose vaccine, and any staff member who has obtained any booster doses (include the specific vaccine booster received and the date of the administration of the booster).

Based on observation, interview, and record review, the facility failed to properly store foods as evidenced by One open bag of dice broccoli in a freezer was not labeled and dated Two open cartons of milk in a refrigerator were not labeled and dated These deficient practices had the potential to result in residents being exposed to food borne illnesses (illnesses when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) and a widespread infection in the facility. During a concurrent observation and interview on 12/15/2025 at 8:50 AM, one open bag of diced broccoli did not have a label with date in the facility kitchen freezer. The Dietary Supervisor (DS) stated the dietary staff opened and used the diced broccoli, but it was not labeled and dated on the bag. During a concurrent observation and interview on 12/15/2025 at 8:51 AM, two open cartons of milk did not have a label with date in the facility kitchen refrigerator. The DS stated the dietary staff open and used these two cartons of milk, but there was no label or dated on the cartons. During an interview on 12/15/2025 at 8:55 AM with the DS, the DS stated the dietary staff did not label and dated the open the bag of diced carrots and the two cartons of milk. The DS stated it was important to label and date the open items when they were first opened, so other staff would know for how long the food items had been open and how long they would be good to prevent the spread of foodborne illness to the residents. During a review of the facility's policy and procedure (P&P) titled, Food Safety and Food Storage, dated 11/4/2024, the P&P indicated the practices to maintain safe refrigerated storage include labeling, dating refrigerated food.

Based on observation, interview, and record review, the facility failed to ensure medication label for one of one resident (Resident 3) had an expiration/use by date. This deficient practice had the potential for Resident 3 to be administered expired medication. 1. During a review of Resident 3's admission Record (AR), the AR indicated an admission on [DATE] with hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (brain tissue death) affecting left non-dominant side, neoplasm (abnormal mass of tissue from uncontrolled cell growth) of unspecified behavior of brain, and hypertensive heart disease (problems with the heart that can develop if one has high blood pressure) with heart failure. During a review of Resident 3's History and Physical assessment dated [DATE], the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's Order Summary Report, the reported indicated a physician order dated [DATE], for Linzess Oral Capsule (Linaclotide, a prescription medication used to treat chronic constipation conditions such as irritable bowel syndrome with constipation [IBS-C, a chronic gut disorder causing abdominal pain, bloating, cramping, and hard, lumpy stools, where constipation is the main bowel issue]) give 145 micrograms (mcg, unit of measure) by mouth one time a day for chronic constipation, provided by family, give 30 minutes before first meal, may open capsule, do not crush or chew the contents. During a concurrent observation of medication cart storage 2 with Licensed Vocational Nurse (LVN) 3 on [DATE] at 10:33 AM, LVN 3 was observed verifying Resident 3's medication stored in the medication cart. LVN 3 stated she could not find the expiration/use by date on the medication label for Resident 3's Linzess medication. LVN 3 stated she would verify the order with the pharmacy and physician. LVN 3 stated the importance of checking medications for expiration/use by date was to make sure staff does not give resident expired medication. LVN 3 stated the medication would not be as effective if it was expired. During an interview with the Director of Nursing (DON) on [DATE] at 12:01 PM, the DON stated it was important to check medications expiration date prior to administering the medication to a resident because the medication could have less effectiveness or there might be side effects when a resident was administered an expired medication. A review of the facility's policy and procedure (P&P) titled Medication Administration dated [DATE] indicated the medications are administered by licensed nurses, or other staff who are legally authorized to do so in the this state as ordered by physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The P&P indicated to identify expiration date, if expired to notify nurse manager.

Based on observation, interview and record review, the facility failed to: 1.Ensure that the physician's order for docusate sodium included the prescribed dosage and that nursing staff clarified the missing dosage prior to administration. As a result, Resident 17 received docusate sodium without a verified dosage from 12/10/2025 to 12/16/2025. This deficient practice had the potential to cause medication errors, including constipation if underdosed or diarrhea if overdosed. 2. Ensure the accuracy of the Antibiotic and Controlled Drug Record Count log for Resident 33, who was receiving Cephalexin (Keflex, an antibiotic used to treat bacterial infections in various parts of the body). 3. Ensure the Controlled Substances Shift Count log was completed and signed for 12/17/25. These deficient practices related to the facility's controlled drug records resulted in inaccurate shift count documentation and created a potential risk for medication diversio Findings: 1.During a review of Resident 17's admission Record (AR), the AR indicated that the facility originally admitted Resident 17 on 8/13/2025 and readmitted on [DATE] with diagnoses that included unspecified atrial fibrillation (A. FIB, abnormal heartbeat) and diabetes mellitus (a group of diseases that result in too much sugar in the blood). During a review of Resident 17's History and Physical Examination (H&P), dated 9/16/2025, the H&P indicated that Resident 17 did not have the capacity to understand and make decisions. During a review of Resident 17's Physician's Order, dated 12/9/2025, the order indicated that the physician ordered docusate sodium oral tablets, two tablets via gastrostomy tube, once daily for bowel management for Resident 17. The physician's order did not indicate the dosage of the tablets to be administered. During a review of Resident 17's Medication Administration Record (MAR), dated 12/2025, the MAR indicated that nurses administered docusate sodium oral tablets, two tablets via gastrostomy tube, once daily from 12/10/2025 to 12/16/2025. The MAR did not indicate the dosage of the tablets administered. During an observation of medication administration on 12/16/2025 at 8:33 AM, Licensed Vocational Nurse (LVN) 2 checked Resident 17's physician's order for docusate sodium and took out two tablets of docusate sodium from the facility's house supply bottle, which was labeled as 100 milligrams (mg) per tablet. LVN 2 crushed the two 100 mg tablets of docusate sodium. During an observation on 12/16/2025 at 8:54 AM, LVN 2 administered the two crushed tablets of docusate sodium (100 mg per tablet) to Resident 17. During a concurrent interview and record review on 12/16/2025 at 10:02 AM with LVN 2, Resident 17's Physician's Order, dated 12/9/2025, and Resident 17's MAR, dated 12/2025, were reviewed. LVN 2 stated that the Physician's Order did not indicate the dosage for docusate sodium for Resident 17 and that there were two available dosages of docusate sodium in the facility's house supply: 100 mg per tablet and 250 mg per capsule. LVN 2 stated that because the Physician's Order indicated administration in tablet form, she had been administering two tablets of docusate sodium (100 mg per tablet) to Resident 17. LVN 2 stated she thought nurses did not need to write down the dosage for docusate sodium in the Physician's Order as long as the number of tablets was indicated. LVN 2 stated she was not sure why the dosage was not required and did not ask the DON about it. During a concurrent interview and record review on 12/16/2025 at 10:10 AM with the DON, Resident 17's Physician's Order, dated 12/9/2025, and Resident 17's MAR, dated 12/2025, were reviewed. The DON stated that the nurse did not clarify the dosage for Resident 17's docusate sodium upon receiving the physician's order. The DON stated that the nurse who administered docusate sodium to Resident 17 did not clarify the dosage before administration. The DON stated that the nurse should clarify the dosage of docusate sodium with the physician to prevent medication errors. The DON stated that the medication error had the potential to cause constipation for Resident 17 if underdosed or diarrhea if overdosed. During a review of the facility's P&P titled Medication Administration, dated 12/19/2022, the P&P indicated that nurses should compare the medication source with the MAR to verify resident name, medication name, form, dose, route, and time. 2. A review of Resident 33's admission Record (AR) indicated Resident 33 was admitted to the facility on [DATE] with diagnoses of encephalopathy (an alteration in consciousness caused due to brain dysfunction), traumatic subdural hemorrhage (a type of bleeding inside the head, blood collects beneath dura mater [outermost membrane surrounding the brain]) with loss consciousness, and Parkinson's Disease (movement disorder of the nervous system that worsens over time) with dyskinesia (involuntary uncontrolled muscle movements). A view of Resident 33's History and Physical Assessment (H&P) dated 10/30/2025, indicated Resident 3 had fluctuating capacity to understand and make decisions. A review of Resident 33's Minimum Data Set (MDS, a resident assessment tool), dated 3/19/2024, indicated, Resident 33 had moderately impaired cognition (mental process of acquiring knowledge and understanding through perception, attention, thought, and memory). A review of Resident 33's Order Summary Report, dated 12/8/2025 indicated a physician order for Keflex Oral Capsule (Cephalexin- antibiotic medication that inhibits the growth of or destroy microorganisms) give 500 milligram (mg, unit of measure) by mouth three times a day for abnormal urinalysis (test for urine that looks at appearance of urine, checks for blood cells, proteins, and other substances in the urine) for 10 days. During a review of Resident 33's Medication Administration Record (MAR) dated 12/2025 indicated Keflex Oral Capsule 500 mg was last given to Resident 33 on 12/17/2025 at 9 AM. During a concurrent observation of medication cart storage, interview and record review of Resident 33's Antibiotic or Controlled Drug Count log on 12/17/2025 at 10:48 AM, the Controlled Drug Record indicated the last dose of Keflex was administered on 12/17/2025 at 9 AM and signed by Licensed Vocational Nurse (LVN) 4. The Controlled Drug Record indicated a count of 4 remaining doses. Resident 33's Keflex Bubble pack was observed with 5 remaining doses. LVN 4 stated she would discuss with another nurse and indicate an error was made on the count log and then they would both sign the log. LVN 4 stated another nurse documented a dose was held on 12/15/2025 at 1 PM, which was why there was a discrepancy. LVN 4 stated the nurse should not have documented on the count log because signing the count log indicates medication was given. 3. During the same observation of medication cart storage, interview and record review of Medication Cart 1's Controlled Substances Shift Count log on 12/17/2025 at 10:55 AM, the log indicated shift count was not completed for 12/17/2025. The log instructions indicated licensed nurses coming on to shift must verify count of all controlled substances with the off-going shift or anytime medication cart keys are exchanged. The log instructions indicated licensed nurses must count the total number of cards/container and total number of count sheets. The log instructions indicated any discrepancies must be reported immediately to the Director of Nursing (DON) and Administrator (ADM). LVN 4 stated every shift change count is done between licensed nurses of the station. LVN 4 stated it was important for both nurses (off-going and oncoming) to sign the log to ensure the count is correct. LVN 4 stated she forgot to sign when she and the off-going nurse counted this morning. During an interview with the DON on 12/17/2025 at 2:35 PM, the DON stated LVN 4 verified with Resident 33's physician regarding the discrepancy of Keflex doses. The DON stated the count log for Keflex should not have been signed by the nurse if the medication was held. During the same interview with the DON, the DON stated controlled medications should be counted every shift and closely monitored. The DON stated the nurses should sign when they come and leave so that every medication was accounted for. The DON stated it should be done and signed when 2 nurses (off-going and oncoming) verify it is correct. A review of the facility's policy and procedure (P&P) titled Controlled Substance Administration & Accountability, dated 6/5/2023 indicated the facility would promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The P&P indicated the facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. The P&P indicated all controlled substances obtained from a non-automated medication cart or cabinet are record on the designated usage form, the written documentation must be clearly legible with all applicable information provided. The P&P indicated in all cases, the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record. The P&P indicated the Controlled Drug Record (or other specified form) serves the dual purpose of record both narcotic disposition and patient administration. The P&P indicated inventory verification for areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift.

Based on interview and record review, the facility failed to ensure a nutritional assessment was completed one of one sampled resident (Resident 4) when a significant weight loss (losing more than 5% of your body weight [around 10 pounds for many adults]within 6 to 12 months without trying) and a change in diet was identified. This deficient practice had the potential to result in Resident 4 to not receive the appropriate diet and nutritional needs required to address Resident 4's weight loss. A review of Resident 4's admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (brain tissue death) affecting right dominant side, dysphagia (difficulty swallowing), and aphasia (communication disorder from brain damage that impairs speaking, understanding, reading, or writing). A review of Resident 4's History and Physical Assessment (H&P) dated 9/7/2025 indicated Resident 4 did not have the capacity to understand and make decisions. A review of Resident 4's Order Summary Report indicated the following orders: On 10/15/2025, a physician prescription indicated NPO (nothing by mouth) diet, NPO texture, NPO consistency, discontinued. 2. On 10/15/2025, a physician prescription indicated regular diet pureed (pu4) texture, moderately thick (mo3) consistency, small portion of puree and moderately thick liquid at lunch and dinner for oral gratification 3. On 11/1/2025, a physician prescription indicated regular diet pureed (pu4) texture, moderately thick (mo3) consistency, small portion of puree and moderately thick liquid for breakfast lunch and dinner. 4. On 11/3/2025, a physician prescription indicated regular diet pureed (pu4) texture, moderately thick (mo3) consistency, regular portions, three times a day (TID). 5. On 11/6/2025, a physician prescription indicated to discontinue all Enteral Feed Orders (GT) due to family refusal to reinsert GT. 6. On 11/10/2025, a physician prescription indicated regular diet pureed (pu4) texture, moderately thick (mo3) consistency, regular portions, TID. A review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 9/29/2025, indicated Resident 4 had moderately impaired cognitive (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making. The MDS indicated Resident 4 weighed 147 pounds (lbs, unit of measure). The MDS indicated Resident 4 was on a physician-prescribed weight loss regimen due to a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. A review of Resident 4's Weights and Vitals Summary dated 9/2025 to 12/2025 indicated the following weekly weights: On 9/27/2025, a weight of 147 lbs via mechanical lift. 2. On 10/6/2025, a weight of 150 lbs via Hoyer lift. 3. On 10/11/2025, a weight of 144 lbs via Hoyer lift. 4. On 10/18/2025, a weight of 143 lbs via Hoyer lift. 5. On 10/26/2025, a weight of 141 lbs via Hoyer lift. 6. On 11/2/2025, a weight of 142 lbs via Mechanical lift. 7. On 11/5/2025, a weight of 146 lbs via Hoyer lift. 8. On 11/12/2025, a weight of 145 lbs via Hoyer lift. 9. On 11/19/2025, a weight of 144 lbs via Hoyer lift. 10. On 11/26/2025, a weight of 144 lbs via Hoyer lift. 11. On 12/2/2025, a weight of 143 lbs via Hoyer lift. 12. On 12/10/2025, a weight of 140 lbs via Hoyer lift. 13. On 12/17/2025, a weight of 139 lbs via Hoyer lift. A review of Resident 4's care plans indicated an active care plan for alteration in nutritional status related to impaired physical/cognitive functions and disease process as evidenced by mechanically altered diet, therapeutic diet, and gastrostomy tube (GT, feeding tube placed directly into the stomach through the abdomen [belly wall] to deliver nutrition, fluids, and medication) initiated on 9/8/2025 and a revision date of 12/17/2025. The care plan indicated an intervention of a registered dietitian consult due to risk of malnutrition (an imbalance in nutrient intake). A review of Resident 4's Interdisciplinary Team (IDT) Care Conference indicated the following Weight Variance Care Conferences: On 10/9/2025, indicated Resident 4 weighed 147 lbs on 10/9/2025. The IDT indicated Resident 4 had a diet of NPO, tube feeding. The IDT indicated the resident was consistently pulling out GT. The IDT indicated a recommendation to continue GT feedings and weekly weights. 2. On 11/7/2025, indicated Resident 4 weighted 146 lbs on 11/5/2025. The IDT indicated Resident 4 had a regular diet, pureed (PU4) thin (TN0) liquid consistency with an average of 60% of meals eaten. The IDT indicated Resident 4 pulled out GT on 11/6/2025 and Resident 4's family member (FM) 1 did not want GT placement. The indicated recommendations for psychological consultation, family to help during meal time and weekly weights. 3. On 11/17/2025, indicated Resident 4 weighed 145 lbs on 11/12/2025. The IDT indicated Resident 4 had a regular diet, pureed (PU4) with mildly thick (MT2) liquid consistency with an average of 60% of meals eaten. The IDT indicated FM 1 requested not to insert GT and to continue current interventions. 4. On 12/8/2025, indicated Resident 4 weighed 143 lbs on 12/2/2025. The IDT indicated Resident 4 had a regular diet, pureed (PU4) with mildly thick (MT2) liquid consistency with an average of 90% of meals eaten. The IDT indicated there was no change in diet or condition. The IDT indicated recommendations of oral nutritional supplement of Boost daily and to continue current interventions. During a concurrent interview and record review of Resident 4's Nutritional Assessments on 12/17/2025 at 12:41 PM, Minimum Data Set Nurse (MDS) stated and confirmed only one Nutritional Assessment was completed for Resident 4 on 9/27/2025. MDS stated there was no other Nutritional Assessment done when Resident 4's diet changed or when his GT was discontinued. MDS stated Nutritional Assessments should be completed on admission, quarterly, and as needed when there is a change in nutritional status. During a concurrent interview and record review of Resident 4's Nutritional Assessments on 12/17/2025 at 1:02 PM, the Dietary Supervisor (DS) stated Nutritional Assessments are to be completed by the Registered Dietitian. The DS stated the purpose of a nutritional assessment was to provide medical staff a current picture of the resident. The DS stated nutritional assessments are done on admission and when there was any change in diet which should be completed immediately. The DS stated she could not find a current nutritional assessment for Resident 4. During an interview with the Director of Nursing (DON) on 12/17/2025 at 2:39 PM, the DON stated the RD completed a progress note for Resident 4. The DON stated the RD did not complete a nutritional assessment and that the nutritional assessment should have been completed. The DON stated she spoke with the RD to complete an assessment since Resident 4 had the GT pulled it out and his diet was changed. The DON stated she explained to RD to assess Resident 4 to give recommendations. The DON stated the importance of a nutritional assessment was to make sure if any nutrition affected resident's weight loss. A review of the facility's policy and procedure (P&P) titled Nutritional Management, dated 12/19/2022 indicated the facility provides care and services to each resident to ensure resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. The P&P indicated a Registered Dietitian will complete a comprehensive nutritional assessment within 14 days post-admission, corresponding to the MDS in progress sheet, annually, and upon significant change in condition. The P&P indicated the assessment shall clarify the resident' current nutritional status and individual risk factors for altered nutrition/hydration. The P&P indicated the dietitian shall use data gathered from the nutritional assessment to estimate the resident's calorie, nutrient, and fluid needs and whether intake is adequate to meet those needs

Based on observation, interview and record review the facility failed to ensure the Minimum Data Set (MDS, a federal mandated resident assessment tool) assessment was accurate for one of five sampled residents (Resident 43). Resident 43's MDS did not reflect Resident 43's current diagnosis of Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities). This deficient practice resulted in lack of monitoring Resident 43's signs and symptoms of depression. During a record review of the admission record (AR), the AR indicated that Resident 43 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included Neuropathy (damage to the nerves outside your brain and spinal cord (peripheral nerves) that disrupts signals to your body, causing symptoms like numbness, tingling, weakness, and pain), Major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities). During a review of Resident 43's MDS dated [DATE], the MDS indicated Resident 43 had a Brief Interview for Mental Status (BIMS - a tool used to screen and identify the cognitive condition) score of 12 which indicated to be moderately impaired (problems with thinking/memory, may need assistance). During a review of Resident 43's Psychiatry Progress Notes (PPN) dated 10/12/2025, the PPN indicated Resident 43 had a history of Depression with an adjustment disorder diagnosis with the treatment plan to continue with Cymbalta (a prescription medication that is used to treat depression. During an interview and concurrent record review on 12/16/2025 at 3:29 PM of Resident 43's MDS with the MDS coordinator (MDSC), Resident 43's MDS dated [DATE] indicated Resident 43 had feelings of feeling down, depressed, or hopeless, trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy, poor appetite or overeating, feeling bad about himself, trouble concentrating on things with a total severity score of 10. The MDSC stated Resident 43's diagnosis of Depression should have been entered on Resident's 43 MDS. MDSC stated the reason Resident 43's diagnosis was not entered on the MDS was because Resident 43 was not receiving antidepressant medication for depression. MDSC reviewed the RAI manual instructions and stated that the diagnosis should have been entered on Residents 43's MDS Assessment. During an interview on 12/17/2025 at 2:42 PM with the Director of Nurses (DON), the DON stated the MDS identifies potential residents' problems and should be accurate to direct and develop resident care planning. During a review of the facility's Policy and Procedure (P&P) titled, Resident Assessment - RAI dated 12/19/2022, the P&P indicated that the facility will make a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences and that the assessment will include disease diagnosis and health conditions.

Based on observation, interview and record review the facility failed to ensure that two of two sampled residents (Resident 8 and Resident 43) reviewed for comprehensive care plans had their care plan interventions implemented by failing to: Implement Resident 8's antiplatelet care plan interventions for monitoring for bleeding or bruising. 2. Implement Resident 43's mood problem care plan interventions for monitoring feeling of sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite/eating habits; change in sleep patterns' dimmish ability to concentrate; change in psychomotor skills. These deficient practices had the potential to negatively affect the resident's well-being and delay delivery of care and services to Residents 8 and 43. a. During a review of Resident's 8 admission Record (AR), the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction (a stroke, loss of blood flow to a part of the brain), Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control ), Pancytopenia (having low levels of red blood cells, white blood cells and platelets). During a review of Resident's 8 Minimum Data Set (MDS - a resident assessment tool) dated 11/16/2025, The MDS indicated Resident 8's Brief Interview for [NAME] Status (BIMS - a tool used to screen and identify the cognitive condition) score was of 6 which is severely impaired (Severe problems with thinking and memory). The MDS indicated that Resident 8 needs substantial/maximal assistance (helper does more than half the effort) with toileting, shower, lower body dressing, putting on/taking off footwear. The MDS indicated that Resident 8 required partial/moderate assistance (helper does less than half the effort) with upper body dressing. During a review of Resident's 8 Medication Administration Record (MAR) for the month of November and December, the MAR indicated Resident 8 had received Plavix (a medication used to prevent blood clots) 75 milligrams (mg - a unit of measurement), every day from 11/10/2025 to 12/17/2025. During a review of Resident's 8 care plan for Altered Cardiovascular Status, dated 11/10/2025, the Care Plan indicated to monitor/document/report adverse reactions of antiplatelet therapy such as skin discolorations/bruises, blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. During an observation on 12/15/2025 at 2:58 PM in Resident 8's room, Resident 8 was observed with a purplish discoloration and bruises on his bilateral forearms of irregular shape. When Resident 8 was interviewed he did not know or remember how he got the purplish discolorations on his upper extremities. During an interview and concurrent record review on 12/17/2025 at 9:26 AM with the MDS Coordinator (MDSC), the MDSC confirmed that there had been no documented evidence of monitoring for the possible side effects of Plavix (Clopidogrel) on Resident 8's medical record as indicated in Resident 8's care plan. b. During a record review of the admission record (AR), the AR indicated Resident 43 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Neuropathy (damage to the nerves outside your brain and spinal cord), Major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities). During a record review of Resident 43's MDS dated [DATE], the MDS indicated Resident 43 has a Brief Interview for Mental Status (BIMS - a tool used to screen and identify the cognitive condition) score of 12 moderately impaired (Problems with thinking/memory, may need assistance). The MDS indicated that Resident 43 had episodes of feeling down, depressed, or hopeless, trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy, poor appetite or overeating, feeling bad about himself, trouble concentrating on things, such as reading the newspaper or watching television. During a record review of Resident 43's care plan Resident Has a Mood Care Plan Report dated 9/22/2025, the Care Plan indicated as an intervention to monitor/record/report to MD (medical doctor) acute episodes feelings or sadness, loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills. During a review of Resident 43's Psychiatry Progress Notes (PPN) dated 10/12/2025, the PPN indicated Resident 43 has a history of Depression. Currently stable with an adjustment disorder diagnosis. During an interview on 12/17/2025 with Director of Nurses (DON), the DON stated that it is important for Resident 43 and all residents to have a comprehensive care plan and for interventions such as monitoring feeling of sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite/eating habits; change in sleep patterns' dimmish ability to concentrate; change in psychomotor skills to be monitored by staff to prevent decline in residents' health status. During a review of the facility's Policy and Procedure (P&P) titled Comprehensive Care Plan dated 12/19/2022, the P&P indicated qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out interventions. The interventions listed on Resident's 8 and Resident's 43 care plan were not monitored.

Based on observation, interview, and record review, the facility failed to promote dignity and respect for one of one sampled resident (Resident 5) when certified nurse assistant (CNA) 3 was observed standing over Resident 5 and assisting Resident 5 to eat. This deficient practice had the potential to cause a decline in the resident's individuality, self-esteem, and self-worth. A review of Resident 5's admission Record (AR) indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (long-term condition when the kidneys are damaged and lose the ability to filter waste and fluid out of the blood), Alzheimer's Disease (type of dementia [loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life] that affects memory, thinking and behavior), and dementia. A review of Resident 5's Minimum Data Set (MDS, an assessment and screen tool) dated 11/17/2025, indicated the resident had moderately impaired cognitive skills for daily decision making. A review of Resident 5's Physician Orders dated 10/13/2025 indicated Resident 5 was ordered a regular diet liquidized (LQ3) texture and thin (TN0) consistency. During a dining observation on 12/15/2025 at 12:32 PM, CNA 3 was observed standing over Resident 5 and assisting Resident 5 eat lunch. Resident 5's bed was below CNA 3's waist and CNA 3 were not at eye level with the resident. During an interview with CNA 3 on 12/15/2025 at 12:35 PM, CNA 3 stated she was standing because she had back pain. CNA 3 stated it was important to feed resident at eye level so that the person assisting the resident to eat could see how the resident was while eating, and to make sure the resident was not choking while eating. During an interview with licensed vocational nurse (LVN) 2 on 12/15/2025 at 12:39 PM, LVN 2 stated the importance of being at eye level while feeding the resident was to have more contact with resident and to communicate with eyes. During an interview with the Director of Nursing on 12/17/2025 at 2:33 PM, the DON stated staff assisting to feed resident should be at eye level or seated with the resident to observe the resident while eating and to prevent the resident from aspirating (choking). A review of the facility's policy and procedure (P&P) titled Promoting/Maintaining Resident Dignity, dated 12/19/2022 indicated the practice of the facility was to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. The P&P indicated all staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights.

Based on observation, interview and record review the facility failed to ensure that one of five sampled residents (Resident 8) was free from unnecessary drugs by failing to adequately monitor Resident 8's continuous need of Plavix (clopidogrel) (a medication used to treat and prevent blood clots) a medication that may increase the risk of bleeding. This deficient practice placed Resident 8 at risk of uncontrolled bleeding. During a review of Resident's 8 admission Record (AR), the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction (a stroke, loss of blood flow to a part of the brain), Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Pancytopenia (a blood condition where there's a significant drop in all three blood cell types: red blood cells, white blood cells, and platelets, often due to issues with bone marrow function, causing symptoms like fatigue, frequent infections, and easy bruising or bleeding. During a review of Resident's 8 Minimum Data Set (MDS - a resident assessment tool) dated 11/16/2025. The MDS indicated Resident 8's Brief Interview for [NAME] Status (BIMS - a tool used to screen and identify the cognitive condition) score of 6 severely impaired (Severe problems with thinking and memory). The MDS indicated that Resident 8 needs substantial/maximal assistance (helper does more than half the effort) with toileting, shower, lower body dressing, putting on/taking off footwear. The MDS also indicated that Resident 8 required partial/moderate assistance (helper does less than half the effort) with upper body dressing. During a review of Resident's 8 History and Physical Examination (H&P) dated 11/11/2025, the H&P indicated that Resident 8 does not have the capacity to understand and make decisions. During a review of Resident's 8 Medication Administration Record (MAR) for the month of November and December 2025, the MAR indicated Resident 8 had received Plavix (clopidogrel) 75 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) once a day from 11/10/2025 to 12/17/2025. During a review of Resident's 8's Care Plan for Altered Cardiovascular Status, dated 11/10/2025, the Care Plan indicated to monitor/document/report Resident 8's adverse reactions of antiplatelet therapy such as skin discolorations/bruises, blood tinged or red blood in urine. During an observation on 12/15/2025 at 2:58 PM in Resident 8's room, Resident 8 was observed with a purplish discoloration and bruises on his bilateral forearms of irregular shape. When Resident 8 was interviewed he did not know or remember how he got the purplish discolorations on his upper extremities. During a concurrent record review and interview with the MDS Coordinator (MDC) on 12/17/2025 at 9:26 AM, the MDC confirmed that there was no documented evidence of monitoring or reassessment for the side effects of Plavix (Clopidogrel) on Resident 8's medical record since the Resident 8's admission. The MDC stated that ongoing medication Plavix (Clopidogrel) monitoring had not been followed for Resident 8's use of the medication. During a concurrent observation, interview on 12/17/2025 at 9:40 AM with the Director of Staff Development (DSD), the DSD stated he observed Resident 8 during physical therapy sitting on his wheelchair with bruise to left forearm. During a concurrent interview and record review on 12/17/2025 at 9:41 AM with the Director of Staff Development (DSD) of Resident 8's Skin Inspection Forms for the month of December, the DSD stated Resident 8's skin Inspection form was last completed on 12/11/2025, and there should have been a recent one completed but was not able to locate a recent skin inspection form. The DSD stated Resident 8's 12/11/2025 skin inspection form indicated no skin issues. The DSD stated this form should be completed by the Certified Nurse Assistants who are in assigned to the Residents on shower days or when there is a change in skin condition. During an interview on 12/17/2025 at 9:54 AM with Certified Nurse Assistant (CNA 1), CNA 1 stated that she provided care to Resident 8 on 12/16/2025 and 12/17/2025 7 AM - 3 PM. CNA 1 stated she did not remember seeing any skin discolorations on Resident's 8 forearms. CNA 1 stated that on 12/16/2025 the physical therapy department assisted Resident 8 to put his sweater on. CNA 1 stated that Resident 8 sometimes has marks on his arms and that could be the reason she (CNA 1) did not notice the bruises on Resident 8 on 12/16/2025. CNA 1stated that it is important to report skin discolorations or other skin conditions observed in a resident to the license nurses. During an interview on 12/17/2025 at 10:08 AM with CNA 2, CNA 2 stated that on Monday 12/15/2025 he provided care to Resident 8 from 7 AM - 3 PM. CNA 2 stated that he showered Resident 8 on 12/15/2025 and that he forgot to complete a skin inspection form. CNA 2 stated that he does not remember observing any skin discolorations or bruising on Resident's 8 skin. During an interview on 12/17/2025 at 10:38 AM with Occupational Therapist (OT 1), OT 1 stated that on 12/16/2025 she assisted Resident 8 to put his sweater on and did not observe any bruises on his arms. During an interview on 12/17/2025 at 2:42 PM with the Director of Nurses (DON), DON stated it is the facilities to monitor residents who are on anticoagulant medications. DON stated all residents who are on anticoagulants need to have a care plan that includes specific goals and interventions for possible side effects such as bruising or bleeding. DON stated that it is important for staff to monitor the effects of anticoagulant medication to prevent internal bleeding which can be a potential problem of these medications. The DON stated it is important for all of the CNAs to report skin changes to prevent decline in residents' health condition. During a review of the facility's Policy and Procedures (P&P) titled Skin Assessment, dated 12/19/2022, the P&P indicated that there will be a weekly or after a change of condition a skin assessment of full body, or head to toe skin assessment done by a licensed or registered nurse. During a review of the facility's Policy and Procedures (P&P) titled Notification of Changes, dated 12/19/22, the P&P indicated that the facility promptly notifies the resident, physician, resident's representative when there is a change in condition requiring notification.

Based on observation, interview, and record review, the facility failed to ensure resident bedrooms accommodate no more than four residents for seven (7) of eighteen (18) rooms (Rooms 16, 19, 20, 21, 22, 25, and 26) did not have more than four residents in one shared room. This deficient practice had the potential to limit care and services, and the ability to move easily in the room for residents and staff. Findings: During an interview on 12/15/2025 at 2:09 PM, Administrator (ADM) stated the facility had rooms with variances and will continue to apply for the Room Waiver. During a review of the room waiver letter submitted by the ADM on 12/15/2025, indicated rooms 16, 19, 20, 21, 22, 25, and 26, had adequate space for nursing care and multiple beds per room would not adversely affect the health and safety of the residents. During a review of the Client Accommodation Analysis form submitted by the facility on 12/15/2025 indicated the following rooms had more than four beds: room [ROOM NUMBER] with 5 beds, room [ROOM NUMBER] with 5 beds, room [ROOM NUMBER] with 5 beds, room [ROOM NUMBER] with 5 beds, room [ROOM NUMBER] with 5 beds, room [ROOM NUMBER] with 5 beds, and room [ROOM NUMBER] with 5 beds. On 11/8/2024 to 11/10/2024, during the recertification survey, the following were observed: room [ROOM NUMBER] had 5 beds with 5 residents (0 unoccupied beds) 2. room [ROOM NUMBER] had 5 beds with 4 residents (1 unoccupied beds) 3. room [ROOM NUMBER] had 5 beds with 5 residents (0 unoccupied beds) 4. room [ROOM NUMBER] had 5 beds with 5 residents (0 unoccupied beds) 5. room [ROOM NUMBER] had 5 beds with 3 residents (2 unoccupied beds) 6. room [ROOM NUMBER] had 5 beds with 5 residents (0 unoccupied beds) 7. room [ROOM NUMBER] had 5 beds with 5 residents (0 unoccupied beds) During an interview on 12/17/2025 at 12:17 PM, Certified Nursing Assistant (CNA) 4 stated she had enough room in room [ROOM NUMBER] to get around and provide care to the residents. During an observation on 12/17/2025 at 12:37 PM, Family Member (FM) stated that room [ROOM NUMBER] had a total of 5 residents and there was enough space for staff to take care of his father. During a review of the facility's policy and procedure (P&P) titled Resident Rooms, revised on 12/2/2024 indicated resident bedrooms must be designed and equipped for adequate nursing care, comfort and privacy of residents.

Based on observation, interview and record review, the facility failed to follow their policy and procedures to prevent food contamination and the spread of foodborne illness for one of one kitchen in the facility, when multiple food items in the kitchen ' s refrigerator were not labeled with the date and time the food was opened or prepared. This deficient practice had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead hospitalization . Findings: 1. During an observation on [DATE] at 4:13 PM in the facility ' s kitchen, the following food items inside the kitchen ' s refrigerator were observed unlabeled: 4 Cups of Fruit Mix 1 Bowl of Fruit Mix During a concurrent observation and interview on [DATE] at 4:16 PM in the facility ' s kitchen with Assistant Kitchen Manager (AK), the AK stated that prepared and opened food items must be labeled with the date the item was opened and when the item is set to expire. The AK stated he is unsure of when the food items were opened or prepared. During a follow up interview on [DATE] at 12:45 PM with the Dietary Supervisor (DS), the DS stated opened items must have a label that indicated the product name, opened date, and the expiration date. The DS stated not following the facility ' s policy could cause harm in residents because the unlabeled foods could be expired. A review of the facility ' s policy and procedure (P&P) titled, Date Marking for Food Safety, revised [DATE], indicated the individual opening or preparing a food shall be responsible for date marking the food at the time the food was opened or prepared. The P&P also indicated the marking system shall include the date of opening, and the date the item must be consumed or discarded.

Based on observation, interview, and record review, the facility failed to ensure the resident bedrooms accommodate no more than four residents for seven (7) of eighteen (18) rooms (Rooms 16, 19, 20, 21, 22, 25, and 26) and did not have more than four residents in one shared room. This deficient practice had the potential to limit care and services, and the ability to move easily in the room for residents and staff. Findings: During the facility ' s Recertification Survey Entrance Conference, on 11/8/2024 at 5 PM, in the presence of the Administrator (ADM), the ADM stated the facility had rooms with variances and will continue to apply for the Room Waiver. During a review of the room waiver letter submitted by the ADM on 11/8/2024, the letter indicated Rooms 16, 19, 20, 21, 22, 25, and 26, had adequate space for nursing care and multiple beds per room would not adversely affect the health and safety of the residents. During a review of the Client Accommodation Analysis form submitted by the facility on 11/9/2024, the Client Accommodation Analysis form indicated the following rooms had more than four beds: room [ROOM NUMBER] with 5 beds, room [ROOM NUMBER] with 5 beds, room [ROOM NUMBER] with 5 beds, room [ROOM NUMBER] with 5 beds, room [ROOM NUMBER] with 5 beds, room [ROOM NUMBER] with 5 beds, and room [ROOM NUMBER] with 5 beds. On 11/8/2024 to 11/10/2024, during the recertification survey, the following were observed: room [ROOM NUMBER] had 5 beds with 5 residents (0 unoccupied beds) room [ROOM NUMBER] had 5 beds with 5 residents (0 unoccupied beds) room [ROOM NUMBER] had 5 beds with 5 residents (0 unoccupied beds) room [ROOM NUMBER] had 5 beds with 5 residents (0 unoccupied beds) room [ROOM NUMBER] had 5 beds with 4 residents (1 unoccupied beds) room [ROOM NUMBER] had 5 beds with 5 residents (0 unoccupied beds) room [ROOM NUMBER] had 5 beds with 5 residents (0 unoccupied beds) During an interview on 11/8/2024 at 5:33 PM, Family Member (FM) 1 stated that room [ROOM NUMBER] had a total of 5 residents and there was enough space for staff to take care of Resident 42. During an observation on 11/9/2024 at 11:08 AM, Resident 1 was observed being pushed in a wheelchair from room [ROOM NUMBER] ' s resident bathroom to his bed with no issues. During a review of the facility ' s policy and procedure (P&P) titled Resident Rooms, dated 12/19/2022 indicated resident bedrooms must be designed and equipped for adequate nursing care, comfort and privacy of residents. The P&P indicated resident bedrooms will not accommodate more than four residents.

Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 44) is free from significant medication errors when Resident' 44 ' s medication Droxidopa Oral Capsule (medication used to treat symptoms dizziness, lightheadedness or fainting sensation) route of administration did not match Physicians order on Resident 44 ' s Medication Administration Record (MAR) with route of administration (this means by which medication is introduced in the body such as orally, injection or topical application). This deficient practice had the potential to result in Resident 44 to receive medications through the wrong route. Findings: A review of Resident 44 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated the resident was admitted to the facility on [DATE], with diagnoses that included Parkinson ' s ( a progressive brain disorder that causes nerve cells in the brain to deteriorate) disease without dyskinesia (a movement disorder tat causes involuntary, abnormal or repeated muscle movements), Dysphagia (difficulty swallowing) following unspecified cerebrovascular disease ( a group od conditions that affect blood flow to the vessels in the brain). During a review of Resident 44 ' s History and Physical [H&P] dated 12/12/2023, indicated Resident 44 does not have the capacity to understand and make medical decisions. During a review of Resident 44 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/28/2024, the MDS indicated the resident was dependent (helper does all of the effort) for activities such as eating, oral hygiene, toileting, shower, upper and lower body dressing and personal hygiene. During a review of Resident 44 ' s Order summary report dated October indicated an order for the resident to receive Droxidopa Oral Capsule (Droxidopa) 200 milligrams (a unit of measure) via G-tube(a gastrostomy tube surgically inserted into the stomach used to deliver nutritional fluids, medications) three times a day for Neurogenic orthostatic hypotension (a condition that causes a drop in blood pressure when standing up ) with an order date of 5/06/2024. During a medication pass observation, on 11/10/2024, from 8:48 AM to 9:36 AM, Licensed Vocational Nurse (LVN) 3 was observed removing two capsule of Droxidopa Oral Capsule 100 mg opening the capsules and pouring powder medication from the capsule into a clear plastic medication cup and dissolving with water. LVN 3 was then observed proceeding to Resident 44 ' s bedside to administer medication. During a concurrent interview and record review on 11/10/2024 at 9:46 AM with LVN 3 of Resident 44 ' s Medication of Droxidopa Oral Capsule 200 mg verifying Resident 44 ' s medication bottle and Resident 44 ' s MAR. LVN 3 verified Resident 44 ' s instructions for Droxidopa Oral Capsule administration medication label on Resident 44 ' s medication bottle did not match the physician ' s order on the Resident 44 ' s MAR. During an interview with Director of Nursing (DON) on 11/10/2024 at 1:45 PM, DON stated the Resident 44 ' s Primary physician was notified of the indication and route of administration for Resident 44 ' s medication that was brought into facility by Resident 44 ' s family. DON stated Primary physician was unaware of the discrepancy and changed the order for the medication that was able to be administered via G-tube for Resident 44. DON stated pharmacy was notified of new order an order was placed and scheduled to be delivered that day. DON stated it was important to clarify orders and make sure the matches the physician orders route of administration so that the nurses won ' t have any mistakes when administering the medications. DON stated all nurses should always check medication bottles and Physicians orders to make sure they match before administering medications to prevent any complications when giving medications to residents. A review of the facility ' s policy revised on 12/29/2022 titled Medication administration, indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.11. Compare medication source (bubble pack, vial etc.) with MAR to verify resident name, medication name. form, dose, route, and time.

Based on observation, interview, and record review, the facility failed to accommodate the needs two of three sampled residents (Resident 21 and Resident 23) by ensuring the residents ' call lights (a device used to alert staff to the resident ' s room) were placed within the resident ' s reach, in accordance with the facility ' s policy and procedure [P&P] titled Call Lights: Accessibility and Timely Response. This deficient practice had the potential for the residents not to receive care and services that could result in accidents and falls. Findings: 1. During a review of Resident 21 ' s Admission Record, the Admission Record indicated the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (total or partial paralysis of one side of the body), hemiparesis (weakness or an inability to move on one side of the body), and paralytic syndrome (a condition that causes weakness, muscle wasting, and loss of reflexes in the body) During a review of Resident 21 ' s History and Physical (H&P), dated 3/15/2024, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 21 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/16/2024, the MDS indicated the resident has severely impaired cognition (ability to reason and thought process). The MDS indicated the resident was dependent (helper does all of the effort) for activities such as toileting and lower body dressing. The MDS also indicated the resident required substantial assistance (helper does more than half the effort; helper lifts or holds trunk or limbs and provides more than half the effort.) for bed mobility such as rolling left and right, sitting, and transferring from bed to chair. During a review of Resident 21 ' s care plan for falls, initiated on 3/14/2024, the care plan indicated Resident 21 was at risk for falls. The care plan included interventions for staff to ensure the resident ' s call light is within reach and encourage the resident to use if for assistance as needed. The resident needs prompt response to all requests for assistance. During a review of Resident 21 ' s care plan for Impaired communication Function, initiated on 3/14/2024, the care plan indicated Resident 21 has impaired communication due to having impaired cognition. The care plan interventions included to provide a safe environment such as ensuring the call light [is] in reach. During a concurrent observation and interview on 11/08/2024 at 5:58 PM with Certified Nursing Assistant (CNA) 1, Resident 21 ' s call light was observed hanging on the left side of the resident ' s bed and not within Resident 21 ' s reach. CNA 1 stated Resident 21 ' s call light is not within the resident ' s reach because it was hanging on the left side of the bed. CNA 1 stated the call light must be within reach of the resident. During an interview on 11/10/2024 at 12:07 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated call lights are used by residents to call for help. LVN 1 stated residents would not be able to call for help if they cannot reach the call light. During an interview on 11/10/2024 at 2:07 PM with the Director of Nursing (DON), the DON stated staff must ensure call lights are within resident ' s reach. The DON stated the facility ' s fall prevention interventions include making sure residents are taught to use their call lights and that the residents ' call lights are within their reach. The DON stated residents could fall if they get up without asking for help using their call light. A review of the facility ' s policy and procedure (P&P) titled, Call Lights: Accessibility and Timely Response, revised 12/19/2022, indicated staff will ensure the call light is within reach of resident and secured, as needed. The P&P also indicated the call system will be accessible to residents while in their bed. 2. During a review of Resident 23 ' s Admission Record indicated the resident was admitted on [DATE] with diagnoses that included traumatic subdural hemorrhage (a type of bleeding near the brain that can happen after head injury) without loss of consciousness, dysphagia (difficulty swallowing), and hemiplegia (total or partial paralysis of one side of the body), hemiparesis (weakness or an inability to move on one side of the body) During a review of Resident 23 ' s History and Physical (H&P), dated 8/13/2024, indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 23 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 11/5/2024, indicated the resident had moderately impaired cognitive skills for decision making. During a review of Resident 23 ' s care plan for falls, initiated on 7/31/2024, indicated Resident 23 was at risk for falls. The care plan included interventions for staff to place the resident ' s call light within reach and encourage the resident to use it for assistance as needed. The care plan indicated the resident needed prompt response to all requests for assistance. During an observation in Resident 23 ' s room on 11/9/2024 at 10:50 AM, Resident 23 was observed sitting in his wheelchair next to the window. Resident 23 ' s call light was observed on resident ' s bed, more than 3 feet away from Resident 23. Resident 23 was unable to reach the call light. During a concurrent observation and interview in Resident 23 ' s room on 11/9/2024 at 11 AM, Certified Nursing Assistant (CNA) 2 stated she placed Resident 23 by the window. CNA 2 stated Resident 23 ' s could not reach the call light. CNA 2 stated it was important for Resident 23 ' s call light to be within reach so residents could call for help if they needed anything. CNA 2 placing the call light within reach was for resident safety. During an interview with the Director of Nursing (DON) on 11/10/2024 at 4:25 PM, the DON stated the importance of placing call lights within resident ' s reach was for residents to call for assistance when residents required help. The DON stated in cases such as resident discomfort or change in condition, the call light should be easily accessible for residents to call for assistance. 48854

Based on interview and record review, the facility failed to ensure: 1. Resident 37 ' s Physician Orders for Life Sustaining Treatment (POLST) and Advance Directive Acknowledgment Form reflected Resident 37 ' s Advance Directive. 2. Resident 30 ' s POLST reflected Resident 30 ' s Advance Directive wishes and failed to provide Resident 30 with an Advance Directive Acknowledgment form. This deficient practice had the potential to result in misinformation of medical care and treatment and not honoring resident ' s wishes in cases where the resident and/or responsible party was unable to participate in making healthcare decisions. Findings: 1. During a review of Resident 37 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated a readmission to the facility on [DATE] with diagnoses that included of spinal stenosis (spaces inside the bones of the spine get too small), encounter of orthopedic (branch of surgery concerned with conditions involving the musculoskeletal system) and surgical aftercare, and Parkinson ' s Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and a slow, imprecise movements). During a review of Resident 37 ' s History and Physical [H&P] dated 9/9/2024, the H&P indicated the resident was not able to make his own decisions. During a review of Resident 37 ' s POLST dated 5/28/2024, the POLST indicated the resident had an Advance Directive dated 12/29/2023. During a review of Resident 37 ' s Advance Directive Acknowledgement form dated 9/10/2024, the form indicated Resident 37 did not have an Advance Directive. During a review of Resident 37 ' s medical chart on 11/9/2024 at 12:31 PM, an Advance Directive dated 12/29/2023 was found. During a concurrent interview and record review of Resident 37 ' s medical chart with the Social Services Assistant (SSA) on 11/9/2024 at 12:44 PM, the SSA stated he assists with resident admissions with the Admission Coordinator and licensed nurses. The SSA stated he translates and explains the forms in the presence of the Admission Coordinator and licensed nurses. The SSA confirmed Resident 37 ' s POLST and Advance Directive Acknowledgment form did not match. The SSA stated it was important to make sure all the dates and documents reflected Resident 37 ' s wishes in the case of an emergency the staff would know what to do. The SSA stated because the acknowledgment form dated 9/10/2024 indicated there was no Advance Directive and Resident 37 had an Advance Directive on file, the facility should clarify with the family what they want and update the chart. During a concurrent interview and record review of Resident 37 ' s medical chart with the Director of Nursing (DON) on 11/10/2024 at 8:20 PM, the DON confirmed Resident 37 ' s POLST dated 5/28/2024 and Advance Directive Acknowledgment form dated 9/10/2024 did not reflect resident ' s Advance Directive. The DON stated medical information should match and a medical records audit will be done. The DON stated if there was any discrepancy, the facility would call the family to clarify the use of resident ' s Advance Directive. 2. During a review of Resident 30 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included traumatic subdural hemorrhage without loss of consciousness, hemiplegia and hemiparesis (a severe or complete loss of strength or paralysis on one side of the body) following a cerebral infraction (a condition that occurs when blood flow to the brain is blocked, causing brain tissue to die) affecting right dominant side, end stage renal disease (a chronic kidney disease that reached a point where the kidneys can no longer function on their own). During a review of Resident 30 ' s History and Physical Assessment [HPA] dated 10/31/2024, the HPA indicated Resident 30 has the capacity to understand and make medical decisions. During a review of Resident 30 ' s Minimum Data Set (a federally mandated resident assessment tool) dated 9/16/2024 indicated Resident 30 ' s cognition was moderately impaired During a review of Resident 30 ' s Physician Orders for life sustaining treatment (POLST), the POLST did not indicate if Resident 30 had an Advance directive. During an interview and concurrent record review on 11/09/2024 with the Social Services Assistant (SSA), the SSA stated there was no advance directives or evidence that indicated an Advance Directive acknowledgment form was offered to Resident 30 or the responsible party [RP]. The SSA stated advance directives is completed on admission as part of the resident ' s admission paperwork and it should be in the paper chart to indicate Resident 30 ' s wishes. The SSA stated it was important to get this information, so the facility know what the resident ' s or the RP ' s wishes are in case of an emergency. During a review of the facility ' s policy and procedure titled Resident Rights Regarding Treatment and Advanced Directives with a revision date of 12/19/2022, indicated It is the policy of this facility to support and facilitate a resident ' s right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. 1. On Admission the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident, if cognitively able to, would like to formulate an advanced directive. 42878

Based on observation, interview and record review for two of three sampled residents (Resident 24 and 54) the facility failed to ensure: 1. Ensure Resident 24 ' s family representative received a written notification of proposed transfer and/or discharge notification upon resident ' s transfer to the General Acute Care Hospital (GACH) in accordance with the facility ' s policy and procedure and have documented evidence Resident 30 ' s notice was sent to the Ombudsman 2. For Resident 54, the facility did not have documented evidence that notice of transfer was sent to the Ombudsman. This failure violated the resident ' s and resident representative ' s rights to make informed decisions and receive transfer/discharge information of their rights to appeal the transfer/discharge. Findings: 1.A review of Resident 24 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated the resident was originally admitted to the facility on [DATE] and then readmitted on [DATE], with diagnoses that included Chronic respiratory failure with hypoxia (a condition where you don ' t have enough oxygen in the tissue in your body), Alzheimer ' s disease unspecified (a brain disorder that slowly destroys the memory and thinking and other skills). During a review of Resident 24 ' s History and Physical [H&P] dated 8/28/2024, indicated Resident 24 does not have the capacity to understand and make medical decisions. During a review of Resident 24 ' s Notice of Proposed Transfer/discharge date d 8/12/2024, the Notice indicated Resident 24 ' s Responsible Party (RP1) was notified of Resident 24 ' s transfer to the acute hospital on 8/12/2024.The Notice of Proposed Transfer/Discharge indicated the transfer/discharge was necessary for the welfare and the needs cannot be met in the facility. The Notice indicated the resident ' s and the resident representative ' s rights to appeal the transfer/discharge if they believed transfer/discharge was inappropriate/involuntary. The Notice indicated the addresses and contact numbers of the Departments to file the appeal, including the timeframes and deadlines in filing the appeal. During the review of the Notice of Proposed Transfer/Discharge, the Notice had two signature lines: one line was for resident/representative that was observed blank, the other line was for the facility representative had a signature observed dated 8/12/2024. During a review of Resident 24 ' s telephone order dated 8/12/2024 timed at 6:20 P.M., the order indicated may transfer resident via paramedics to the acute hospital. For further evaluation related to respiratory distress, oxygen desaturation. During a review of Resident 24 ' s transfer form dated 8/12/2024 at 6:30 P.M., the form indicated At 6:05 PM, Resident 24 was heard wheezing with congestion, suction with received dark brown fluid, VS temperature 97.2, Blood pressure 126/58, Heart Rate 93, Respirations 26, Oxygen saturation 80% on 2 Liters per min via nasal canula (a device that provides supplemental oxygen to a patient through their nose), titrated oxygen to 15 Liters per minute via mask still wheezing and congested. Spoke to Resident Representative regarding condition and Physician said Resident request no resuscitation but wants emergency treatment if necessary to save life. Doctor aware with orders carried out. Paramedics arrived at 6:20 PM and transferred Resident 24 to acute hospital. Physician and Responsible party made aware. During a concurrent interview and record review of Resident 24 ' s Notice of Proposed Transfer/Discharge form with the Director of Nursing (DON) on 11/10/2024 at 7:15 PM, the DON stated she could not find any documented evidence that Resident 24 ' s Notice of Proposed Transfer/Discharge form was sent to the Ombudsman or to the Resident Representative. The DON stated the Notice should be signed by the Resident ' s Representative or indicate on the Notice that the resident representative was notified. The DON stated it is important for the facility staff to notify and provide in writing the 24 ' s Notice of Proposed Transfer/Discharge form to the residents and their representatives so that they may be informed of their rights when a resident gets transferred. 2. During a review of Resident 54 ' s Face Sheet (FS- front page of the chart that contains a summary of basic information about the resident), the FS indicated a readmission to the facility on [DATE] with diagnoses that included of intrahepatic bile duct (tiny canals that connect some of the organs in the digestive system) carcinoma (cancer that forms in the bile ducts), obstruction of bile duct, and other retroperitoneal (space behind the peritoneum [membrane that lines the inside of the abdomen and pelvis] abscess (pocket of pus). During a review of Resident 54 ' s History and Physical [H&P] dated 10/2/2024, the H&P indicated the resident had the capacity to understand and make her own decisions. During a review of Resident 54 ' s Minimum Data Set (MDS, a federally mandated resident assessment) dated 11/3/2024, the MDS indicated resident had moderately impaired cognition. During a concurrent interview and record review of Resident 54 ' s Notice of Proposed Transfer/Discharge form with the Director of Nursing (DON) on 11/10/2024 at 7 PM, the DON stated this was the form that was sent to the Ombudsman and should be signed by the Resident ' s representative. The DON stated Resident 54 ' s family member was notified of the resident ' s transfer and would sign the form when resident returns to the facility. During an interview with the DON on 11/10/2024 at 7:14 PM, the DON stated there was no fax confirmation for receipt of Resident 54 ' s Notice of Proposed Transfer/Discharge form. The DON stated she was not sure if the notice was sent to the Ombudsman. The DON stated Resident 54 was transferred out of the facility on 11/6/2024 and there was still time to send notice to the Ombudsman. During a review of the facility ' s policy and procedure (P&P) titled Transfer and Discharge, dated 12/19/2022, indicated generally, the notice must be provided at least 30 days prior to a facility-initiated transfer or discharge of the resident. The P&P indicated exceptions to the 30-day requirement apply when the transfer or discharge is effected because: (a) the health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident; (b) the resident ' s health improves sufficiently to allow a more immediate transfer or discharge; (c) an immediate transfer or discharge is required by the resident ' s urgent medical needs; or (d) a resident has not resided in the facility for 30 days. The P&P indicated in these exceptional cases, the notice must be provided to the resident, resident ' s representative if appropriate, and long term care (LTC) ombudsman as soon as practicable before the transfer or discharge. The P&P also indicated the facility will maintain evidence that the notice was sent to the Ombudsman. 42878

Based on observation, interview and record review, the facility failed to ensure residents assessed at risk for falls received care and services, in accordance with their individualized level of risk to minimize the likelihood of falls, as indicated with the facility ' s policy and procedure [P&P] titled Fall prevention program for two of three sampled residents (Resident 6 and 30) by failing to: 1. Ensure the facility staff place the motion alarm on the bed when transferring Resident 6 from the wheelchair to the bed as indicated in Resident 6 ' s care plan for Falls. 2. Ensure to monitor the function and placement of Resident 30 ' s motion alarm when in bed and wheelchair. On 11/08/2024, Resident 30 ' s motion alarm was observed disconnected while in bed. These failures had the potential to result in multiple falls with injuries for both Resident 6 and 30 who were assessed as high risk for falls. Findings: 1. During a review of Resident 6 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the resident was admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (Type 2 diabetes is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), Alzheimer ' s disease unspecified (a brain disorder that slowly destroys the memory and thinking and other skills). During a review of Resident 6 ' s History and Physical Assessment [HPA] dated 2/24/2024, the HPA indicated Resident 6 did not have the capacity to understand and make decisions. During a review of Resident 6 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 9/20/2024, the MDS indicated Resident 6 ' s cognition was severely impaired. The MDS further indicated Resident 6 requires supervision (helper provides verbal cues) with eating, oral hygiene. The MDS indicated Resident 6 required partial (helper does less than half the effort) with toileting, shower and lower body dressing. During a review of Resident 6 ' s Order Summary Report indicated an order to monitor motion alarm function and placement every shift with a start date of 7/11/2024. During a review of Resident 6 ' s Order Summary Report, the Report indicated an order to have Motion alarm when in bed or wheelchair to alert resident not to get out of bed or wheelchair unassisted and to remind resident to wait for assistance with a start date of 7/11/2024. During a review of Resident 6 ' s care plan for falls, initiated on 2/24/2024, the care plan indicated Resident 6 risk for falls related to impaired physical/cognitive functions. The care plan goals indicated Resident 6 would be free from falls through the review date. The care plan interventions included: Monitor motion alarm function and placement every shift, motion alarm when in bed or wheelchair to alert resident not to get out of bed or wheel unassisted and to remind the resident to wait for assistance with initiation date of 7/11/2024. During an observation on 11/08/2024 at 5:31 PM in Resident 6 ' s bedroom, Resident 6 was observed being wheeled into his room by the facility receptionist with a portable motion alarm attached to the Resident 6 ' s wheelchair. The facility receptionist was observed assisting Resident 6 back to his bed, then placed the wheelchair across Resident 6 ' s bed before leaving the room. During the observation, the portable motion alarm was still attached to the wheelchair while Resident 6 was in bed. During a concurrent observation and interview on 11/08/2024 at 5:35 PM with LVN 2, LVN 2 stated Resident 6 was assessed at high fall risk due to the resident ' s lack of safety awareness. LVN 2 stated Resident 6 had a habit of getting up unassisted that was the reason he needed to have a motion alarm when in bed to remind the resident to call for help and alert facility staff. LVN 2 stated facility staff should always transfer Resident 6 ' s portable motion alarm from his wheelchair to his bed when Resident 6 returns to bed. LVN 2 stated the facility receptionist should not have left Resident 6 ' s motion alarm on the wheelchair, after assisting the resident back to bed. LVN 2 stated that the facility receptionist should have notified a nurse before leaving the Resident 6 ' s bedside. 2. During a review of Resident 30 ' s Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE], and recently readmitted on [DATE], with diagnoses that included traumatic subdural hemorrhage without loss of consciousness, hemiplegia and hemiparesis (a severe or complete loss of strength or paralysis on one side of the body) following a cerebral infraction (a condition that occurs when blood flow to the brain is blocked, causing brain tissue to die) affecting right dominant side, end stage renal disease (a chronic kidney disease that reached a point where the kidneys can no longer function on their own). During a review of Resident 30 ' s HPA dated 10/31/2024, the HPA indicated Resident 30 had the capacity to understand and make decisions. During a review of Resident 30 ' s MDS dated [DATE], the MDS indicated Resident 30 ' s cognition was moderately impaired. The MDS indicated Resident 30 required partial/moderate assistance (helper does less than half the effort) with eating, oral hygiene. The MDS indicated Resident 30 was dependent (helper does all of the effort) with toileting, shower and lower body dressing. During a review of Resident 30 ' s Order Summary Report, the Report indicated an order to monitor motion alarm function and placement every shift with a start date of 10/30/2024. During a review of Resident 30 ' s Order Summary Report, the Report indicated an order to have Motion alarm when in bed or wheelchair to alert resident not to get out of bed or wheelchair unassisted and to remind resident to wait for assistance with a start date of 10/30/2024. During a review of Resident 30 ' s initial Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated Resident 30 ' s fall risk score was 10 which indicated Resident 30 was at Risk for falls. During a review of Resident 30 ' s initial Fall risk assessment dated [DATE], indicated Resident 30 ' s fall risk score was 18 which indicated Resident 30 was at high risk for falls. During a review of Resident 30 ' s care plan for falls, initiated on 7/11/2024, the care plan indicated Resident 30 risk for falls related to impaired physical/cognitive functions. The care plan interventions included: Monitor motion alarm function and placement every shift, motion alarm when in bed or wheelchair to alert resident not to get out of bed or wheel unassisted and to remind the resident to wait for assistance with initiation date of 8/06/2024. During an observation on 11/08/2024 at 5:25 PM, Resident 30 was observed laying in bed. Resident 30 ' s bedside alarm was observed hanging from Resident 30 ' s bedframe and a white cable was observed laying on the floor under the bed alarm. During a concurrent interview and observation on 11/08/2024 at 5:26 PM with Licensed Vocational Nurse (LVN 2), LVN 2 stated Resident 30 ' s motion alarm in bed was disconnected. LVN 2 was observed picking up the white cable and connected it to the bed alarm, once connected, a green flashing light was observed coming from Resident 30 ' s motion alarm. LVN 2 stated the flashing green light indicated Resident 30 ' s motion alarm in bed was on and working. LVN 2 stated she did not notice how long Resident 30 ' s motion alarm in bed had been disconnected but it should be connected and on at all times as Resident 30 is a high fall risk with a history of falling from his bed. During an interview on 11/10/2024 at 4:10 PM, with the Director of Nursing (DON), the DON stated it is important for Resident 6 and Resident 30 to have their bed alarms in place and on at all times to alert the resident and staff when the residents attempt to get up unassisted to prevent any falls or injuries to the residents. During a review of the facility ' s P &P titled, Fall prevention program with a revision date of 12/19/2023, the P&P indicated each resident would be assessed for fall risk and receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.

Based on observation, interview and record review, the facility failed maintain a homelike environment by ensuring the facility's wall clocks in the resident's bedroom were set in the current time for 2 of two sampled residents (Resident 1 and 105). This deficient practice had the potential for Resident 1 and105 to get disoriented with time, which could affect the resident's participation with daily activities and over all wellbeing. Findings: 1. A review of Resident 1's Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis that included paraplegia (paralysis or unable to move the lower part of the body), Type 2 diabetes mellitus (a disease in which your blood glucose, or high blood sugar levels). A review of Resident 1's History and Physical, dated 7/26/2022, indicated the resident had the capacity to understand or make decisions. 2. A review of Resident 105's Admission Record indicated Resident 105 was initially admitted to the facility on [DATE] with a diagnosis that included Type 2 diabetes mellitus. Unspecified Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 105's History and Physical, dated 11/04/2023, indicated the resident did not have capacity to understand or make decisions. During an observation and initial facility tour on 11/10/23 at 10:31 AM, the facility, the wall clock in Resident 1's room showed the time of 9:35 AM. In a concurrent interview Resident 1 stated he notified the nurses that his room clock had the wrong time, but no one fixed it. Resident 1 stated he sometimes gets confused with having two clocks with two different times as he uses his personal electronic tablet to see the time as well. Resident 1 stated he likes to know what the correct time because he relies on the time on the wall clock for his daily activities. During an observation and initial facility tour on 11/10/2023 at 11AM, the facility wall clock on the wall in Resident 105's bedroom showed the time of 10AM. In a concurrent interview Resident 105 stated she sometimes gets confused with the time. Resident 105 stated she liked to know what the correct time because she relies on the time for knowing when it's time to get up and for breakfast and lunch. During an observation and concurrent interview on 11/20/2023 at 11:20 AM, the Maintenance Supervisor (MS) was observed entering Resident 105's room taking down the wall clock in front of Resident 105's bed and putting the correct time. MS stated he had forgotten to fix the clocks to display the correct time on three residents' rooms. The MS stated any staff member could have fixed the clocks to display the correct time since the time changed (daylight saving time) about a week ago. During an interview on 1/11/2022 at 5 P.M, the Assistant Director of Nursing (ADON), stated it was important for the facility to maintain the clocks in residents' room in good working condition, so the residents were aware of the current time and day, especially for the residents who has dementia. The ADON stated ensuring that the wall clocks in the resident's room have the right time will help the residents with the orientation of time. A review of the facility's policy and procedure titled, Maintenance Inspection, revised on 12/19/ 2022, indicated It is the policy of this facility to utilize maintenance inspections to assure a safe, functional, sanitary and comfortable environment for residents, staff and the public.

Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of resident's admission to the facility for one of 3 sampled residents (Resident 105) with a diagnosis of Type 2 Diabetes Mellitus (DM-an adult-onset disease in which the blood glucose or sugar levels are too high). This deficient practice had the potential for Resident 105 not to receive the appropriate interventions and treatments for DM and lead to complications such as hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar). Findings: A review of Resident 105's Admission Record indicated Resident 105 was initially admitted to the facility on [DATE] with a diagnosis that included Type 2 DM. Unspecified Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life.). A review of Resident 105's History and Physical, dated 11/04/23, indicated the resident did not have capacity to understand or make decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/9/2023, indicated Resident 105's has an active diagnosis of DM. During an interview and concurrent record review on 11/11/2023 at 10:39 AM with the MDS nurse, the MDS nurse stated Resident 105 was admitted to facility with a diagnosis of Type 2 DM that was not addressed or included in Resident 105's baseline care plan. The MDS nurse tated the care plan should had been initiated during Resident 104's admission to the facility. During an interview on 11/13/2023 at 4:58 PM, with Assistant Director of Nursing (ADON), the ADON stated, the resident's care plans should be initiated within 48 hours upon admission for of all residents with pertinent diagnosis such as Type 2 DM. The ADON stated Resident 105's care plan for DM should had been initiated by the nurses when the Resident 105 was admitted to the facility no later than 48 hours of admission. The ADON stated since Resident 105 had no baseline care plan for DM, this could result in the resident not receiving appropriate interventions and monitoring for complications of DM such as hyperglycemia or hypoglycemia. A review of the facility's policy revised on 12/29/2022 titled Baseline Care Plan, indicated, the facility will develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care. The baseline care plan will be initiated within 48 hours of a Resident's admission.

Based on observation, interview and record review, the facility failed to reasonably accommodate the resident's needs as indicated in the facility's policy and procedure titled, Call Lights: Accessibility and Timely Response for 1 of two residents (Resident 104) who was observed with call lights (device used by a resident to signal his or her need for assistance from professional staff) not within the resident's reach. This deficient practice had the potential to in Resident 104 receive delayed care or not receive services and emergency care when needed. Findings: A review of Resident 104's Admission Record indicated Resident 104 was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnosis that included dysphagia (difficulty swallowing foods or liquids) and type 2 diabetes mellitus (a disease in which your blood glucose, or high blood sugar levels). A review of Resident 104's History and Physical (H&P), dated 10/27/2023 indicated, Resident 104 had the capacity to understand and make decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/03/2023, indicated Resident 104 was cognitively (relating to the mental process involved in knowing, learning, and understanding things) intact. The MDS indicated Resident 104 uses a wheelchair for ambulation. During an observation in Resident 104's room on 11/10/2023 at 10:20 AM, Resident 104 was observed sitting in the wheelchair next to his bed. Resident 104 asked the surveyor Can you get my call light, they brought me back from PT (Physical Therapy-a therapy to strengthen weakened muscle) and left me here, I don't know where my call light is. Resident 104's call light was observed on the floor behind Resident 104's bedside drawer that resident could not reach. During a concurrent interview and observation in Resident 104's room with Licensed Vocational Nurse (LVN1) on 11/10/2023 at 10:28 AM, LVN stated, Resident 104's call light was on the floor behind the bedside drawer that was not withing arm reach of the resident. LVN 1 stated the call light should always be within the resident's reach to prevent an accident or injury reaching for the call light, and to be used when the resident need assistance. During an interview on 11/11/2023 at 4:58 PM with Assistant Director of Nursing (ADON), the ADON stated it was the facility's practice to always leave the call lights within reach of the residents. The ADON stated everyone in the facility was responsible for making sure the residents call lights within the residents reach. The ADON stated it was important for all residents to have their call lights within reach to ensure they get assistance from the staff when in distress, or when the residents need assistance to prevent accident and to ensure we meet the residents' needs. A review of the facility's policy and procedure titled, Call Lights: Accessibility and Timely Response, revised on 12/19/2022, indicated the staff will ensure the call light is within reach of the residents and secured, as needed.