Every finding on record at El Encanto Healthcare Center

Based on interview and record review, the facility failed to follow its Policy and Procedure (P&P) titled Advance Directives (AD, a written instruction, recognized under State law relating to the provision of health care when the individual was incapacitated [lacking the ability to meet essential requirements for physical health, safety, or self-care]), for four of six sampled residents (Residents 13, 39, 58, and 63) when: a. Resident 13's AD Acknowledgement Form (ADAF, part of an advance directive, a legal document that allowed a person to specify their medical care wishes and who should make decisions for them if they could not) was not completed.b. Resident 58's ADAF was not completed.c. Resident 39's AD was not in Resident 39's chart.d. Resident 63's ADAF and Physician/Provider Orders for Life-Sustaining Treatment (POLST, a medical form that stated what treatments a person wanted or did not want at the end of life) were not in Resident 63's chart. These failures had the potential for facility staff to provide medical treatment and services against the will of Residents 13, 39, 58, and 63. Findings: a. During a review of Resident 13's admission Record (AR), the AR indicated the facility admitted Resident 13 on 10/1/2025 with diagnoses including type 2 diabetes mellitus (DM, a disease in which the body's ability to produce or respond to the hormone insulin was impaired, resulting in elevated levels of glucose/sugar in the blood and urine), hypertension (HTN, high blood pressure), and generalized muscle weakness. During a review of Resident 13's History and Physical (H&P), dated 10/3/2025, the H&P indicated Resident 13 was alert (awake, responsive, and aware of their environment) and conversant (could speak, understand language, and engage in meaningful, logical dialogue). During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool) dated 4/10/2026, the MDS indicated Resident 13 had intact cognition (the ability to think and process information) for daily decision making. The MDS indicated Resident 13 required setup assistance from staff for eating, oral hygiene, and personal hygiene. The MDS indicated Resident 13 required moderate assistance (helper did less than half the effort) from staff for toileting hygiene, showering/ bathing, and bed-to-chair transferring. During an interview and concurrent record review on 7/1/2026 at 2:54 pm with Social Services Assistant (SSA), Resident 13's ADAF dated 10/6/2025 was reviewed, SSA stated Resident 13's ADAF was not fully completed. SSA stated Resident 13's ADAF was missing the facility representative's signature and date. The SSA stated the ADAF should be completed when the facility representative met with Resident 13. SSA stated SSA was unsure if Resident 13's incomplete ADAF was valid or not. b. During a review of Resident 58's AR, the AR indicated the facility admitted Resident 58 on 6/26/2026 with diagnoses including difficulty in walking, low back pain, and dementia (a progressive state of decline in mental abilities). During a review of Resident 58's History and Physical (H&P), dated 6/27/2026, the H&P indicated Resident 58 did not have the capacity to understand and make decisions due to dementia. During an interview and concurrent record review on 7/1/2026 at 2:24 pm with SSA, Resident 58's ADAF dated 6/30/2026 was reviewed, Resident 58's ADAF did not indicate whom the facility discussed the AD policy with. Resident 58's ADAF did not indicate if Resident 58 had completed a POLST. Resident 58's ADAF did not indicate if Resident 58 / Resident 58's family understood that they had the right to formulate an AD and accept or refuse medical or surgical treatment. Resident 58's ADAF did not indicate if Resident 58 / Resident 58's family desired to initiate an AD or POLST at this time or not. The SSA stated Resident 58's ADAF did not indicate if Resident 58 had any AD. The SSA stated staff would not know if Resident 58 had an AD since Resident 58's ADAF was not completed. During an interview on 7/2/2026 at 10:43 am with the facility's Assistant Director of Nursing (ADON), the ADON stated it was important to keep the completed ADAF in resident's chart, so that staff knew what to do in case of an emergency. During a review of Resident 58's MDS dated [DATE], the MDS indicated Resident 58 had moderately impaired cognition for daily decision making. The MDS indicated Resident 58 required setup assistance from staff for eating and oral hygiene. The MDS indicated Resident 58 required moderate assistance from staff for personal hygiene. The MDS indicated Resident 58 required maximal assistance (helper did more than half the effort) from staff with bed-to-chair transferring. The MDS indicated Resident 58 was dependent (helper did all the effort) on staff for toileting hygiene. During a review of the facility's undated P&P titled, Advance Directive, the P&P indicated the facility should record the resident's wishes in the medical record and to follow those wishes to the extent practicable and allowable under state law. The P&P indicated that upon admission, the facility should present to all residents and their representatives with written information about their rights to accept or refuse medical or surgical treatment and their right to formulate an advance directive (if the resident has capacity to do so). The P&P further indicated that the information could be found in the resident rights portion of the admission packet and in the Preferred Intensity of Care and Advance Directive Acknowledgement forms. c. During a review of Resident 39's AR, the AR indicated the facility admitted Resident 39 on 12/15/2023 with diagnoses including history of falling, anxiety disorder (group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear) and muscle weakness. During a review of Resident 39's MDS dated [DATE], the MDS indicated Resident 39 had moderately impaired cognition for daily decision making. The MDS indicated Resident 39 was dependent (helper does all the effort) on staff for toileting, showering, lower body dressing and personal hygiene. During a concurrent interview on 6/30/2026 at 3:02 pm and record review of Resident 39's POLST with the SSA, Resident 39's POLST indicated Resident 39 executed an AD dated 1/10/2023 that was available and reviewed by the facility. The SSA stated Resident 39's AD was not in the chart and should have been in Resident 39's chart, accessible to staff at all times in case of an emergency. The SSA stated the purpose of the AD was to give instructions to staff about Resident 39's wishes and wants regarding medical management, in case of an emergency. During a review of the undated P&P titled, Advance Directive, the P&P indicated It is the policy of this facility to promote a resident's right to accept or refuse medical or surgical treatment, and the right to formulate and advance directive. Further, the facility's policy is to record the residents' wishes in the medical record and to follow those wishes to the extent practicable and allowable under state law. Upon admission, all residents and their representatives are presented with written information about their rights to accept or refuse medical or surgical treatment and their right to formulate an advanced directive (if the resident has capacity to do so). This information is found in the resident rights portion of the admission packet and in the Preferred Intensity of Care and Advance Directive Acknowledgement forms. d. During a review of Resident 63's AR, the AR indicated the facility admitted Resident 63 on 6/24/2026 with diagnoses including fracture (partial or complete break in the continuity of a bone) of the neck of the left femur (thigh bone), end stage renal disease (ESRD, irreversible kidney failure) and hypertension (HTN, high blood pressure). During a concurrent interview and record review on 6/30/2026 with Licensed Vocational Nurse 2 (LVN 2), Resident 63's chart was reviewed. LVN 2 stated there was no copy of Resident 63's POLST and AD acknowledgement form in Resident 63's chart. LVN 2 stated Resident 63 was admitted to the facility on [DATE] and had been in the facility for six (6) days. LVN 2 stated the POLST and AD acknowledgement form should be filled out upon admission and placed in Resident 63's chart for staff to identify Resident 63's wishes and preferences regarding medical care in the facility and during an emergency. During an interview on 7/2/2026 at 10:46 am with the Assistant Director of Nursing (ADON), the ADON stated a copy of the POLST and AD acknowledgement form should be in the resident's chart upon admission or within forty-eight (48) hours of admission and accessible to staff to address and identify the resident's end-of-life wishes and preferences. During a review of the facility's undated P&P titled, Advance Directive, the P&P indicated, Upon admission, all residents and their representatives are presented with written information about their rights to accept or refuse medical or surgical treatment and their right to formulate an advance directive (if the resident has capacity to do so). This information is found in the resident rights portion of the admission packet and in the preferred intensity of care and advance directive acknowledgment forms. The POLST works in concert with and does not replace the advance directive.

Based on observation, interview, and record review, the facility failed to ensure non-English speaking (refers to an individual who cannot speak or understand or have difficulty speaking or understanding the English language) residents were provided with a communication board/device in a language that the resident understood for two of two sampled residents (Residents 5 and 41). These failures had the potential to affect Residents 5 and 41's communication with staff resulting in a delay in the provision of care, treatment and services to Residents 5 and 41. Findings: a. During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 1/30/2025 with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool) dated 5/28/2026, the MDS indicated Resident 5's preferred language was Mandarin. The MDS indicated Resident 5 needed or wanted an interpreter to communicate with a doctor or healthcare staff. The MDS indicated Resident 5 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 5 required supervision or touching assistance (helper did provide verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene and partial/moderate assistance (helper did less than half the effort) with toileting and upper body dressing. During a concurrent observation inside Resident 5's room and interview on 6/30/2026 at 10:13 am with Certified Nurse Assistant 2 (CNA 2), Resident 5 was lying in bed and smiled when greeted. CNA 2 stated Resident 5 did not speak nor understand the English language. CNA 2 stated Resident 5 did not have a communication board or book with pictures and descriptions of Resident 5's spoken language (Mandarin) in the room. CNA 2 stated Resident 5 should have a communication board/book in the room to communicate basic needs to help staff better understand and meet Resident 5's needs. During an interview on 7/2/2026 at 10:46 am with the Assistant Director of Nursing (ADON), the ADON stated all non-verbal, but alert and oriented residents and non-English speaking residents should have a communication board/book at bedside to be able to communicate their needs and for staff to be able to address the residents' needs appropriately. During a review of the facility's undated Policy and Procedure (P&P) titled, Communication Boards, the P&P indicated the facility will ensure nonverbal and non-native speaking residents always have communication boards available at bedside to use in their communication with staff and for the staff to use to communicate with residents. b. During a review of Resident 41's AR, the AR indicated the facility admitted Resident 41 on 8/26/2025 with diagnoses including heart failure (condition when the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs) and unspecified dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 41's Visit Note (VN) dated 8/26/2025, the VN indicated Resident 41 was Cantonese speaking only and Resident 41's son assisted with translating. During a review of Resident 41's untitled Care Plan (CP) dated 8/27/2025, the CP indicated Resident 41 had impaired cognition and communication as evidenced by short/long term memory problem, impaired decision making, problem understanding others and making self understood, related to aging process. The CP intervention indicated nursing staff to provide communication board to Resident 41 as needed to facilitate understanding. During a review of Resident 41's MDS dated [DATE], the MDS indicated Resident 41's preferred language was Cantonese language. The MDS indicated Resident 41 was dependent (helper does all of the effort) from staff for eating, oral hygiene, toileting, showering, lower body dressing, putting on/taking off footwear and personal hygiene. During an observation on 6/30/2026 at 9:52 am inside Resident 41's room, Resident 41 was talking to Resident Relative 1 (RR 1) in Resident 41's own language. During a concurrent observation and interview on 6/30/2026 at 10:03 am, together with the Assistant Director of Nursing (ADON) inside Resident 41's room, Resident 41 was awake lying in bed, talking using Resident 41's own dialect directly to RR 1 at bedside. There was no communication tool at Resident 41's bedside. The ADON stated the ADON could not understand what Resident 41 stated. The ADON stated there was no communication tool at Resident 41's bedside. The ADON stated a communication tool should be accessible to Resident 41 and staff to use to communicate to Resident 41 to be able to meet Resident 41's needs. During a concurrent observation and interview on 6/30/2026 at 12:50 pm with Certified Nurse Assistant 1 (CNA 1), Resident 41 was speaking in Resident 41's primary language. CNA 1 stated Resident 41 spoke Cantonese language while CNA 1 spoke Mandarin. CNA 1 stated a communication tool should be accessible at Resident 41's bedside to facilitate language translation. During an interview on 7/1/2026 at 8:22 am with the ADON, the ADON stated the ADON used the ADON's personal mobile phone to access a translation when no staff member was available to provide language interpretation. The ADON stated there was no communication tool nor language interpretation hotline available and staff had to contact Resident 41's family members to provide language interpretation. During a concurrent interview on 7/2/206 at 9:17 am with the MDS Coordinator (MDSC) and record review of Resident 41's MDS dated [DATE], the MDSC stated Resident 41 spoke Cantonese. The MDSC stated Resident 41 required an interpreter to translate information into Cantonese to facilitate Resident 41's understanding. During a record review of the facility's undated P&P titled, Communication Boards, the P&P indicated it is the facility's policy to accommodate residents who are nonverbal or who speak a language other than English by providing the said residents with communication boards. Social Service will determine during the initial assessment if a resident requires the need for a communication board. If required, a communication board will be provided in the language of the non-native speaking resident. When it is determined during the social service assessment that resident can communicate by means other than verbal skills the resident will be provided with a communication board.

Based on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) on the use of bed rails/siderails (adjustable metal or rigid plastic bars attached to the bed) for three of three sampled residents (Residents 39, 59 and 62) by failing to:a. Follow the Physician Order (PO) to apply bilateral (both sides) 1/2 side rails at head of bed (HOB) for Resident 39.b. Obtain a PO and an informed consent on the use of bedside rails before its application for Resident 59. c. Ensure Resident 62's informed consent for the use of bilateral one-half (1/2) side rails indicated the name of the person giving the consent and the name of the staff verifying the consent. These failures placed Residents 39, 59 and 62 at risk of entrapment (a resident's body or body part becomes caught, trapped or wedged in or around the bedrails, mattress or bedframe) and serious injury from the use of side rails. Findings: a. During a review of Resident 39's admission Record (AR), the AR indicated the facility admitted Resident 39 on 12/15/2023 with diagnoses including history of falling, anxiety disorder (group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear) and muscle weakness. During a review of Resident 39's Order Summary Report (OSR) dated 12/15/2023, the OSR indicated an order for staff to apply 1/2 side rails at head of bed (HOB) for mobility and improve function for generalized weakness. During a review of Resident 39's untitled Care Plan (CP) dated 12/18/2023, the CP indicated Resident 39 was on side rail management to assist with mobility and transfer. The CP indicated Resident 39 was at risk for possible entrapment due to use of side rails. The CP intervention indicated for nursing staff to check the resident's side rails periodically for safety/security. During a review of Resident 39's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/3/2026, the MDS indicated Resident 39 had moderately impaired cognition (ability to think) for daily decision making. The MDS indicated Resident 39 was dependent (helper does all of the effort) from staff for toileting, showering, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 39 required maximum assistance (helper does less than half the effort) from staff for oral hygiene and upper body dressing. During an observation on 6/30/2026 at 10 am, inside Resident 39's room, Resident 39 was awake, lying in bed. The right side of Resident 39's bed had a quarter (1/4) side rail up at the HOB and 1/4 side rail up on the foot of the bed. The left side of the bed had 1/4 side rail up at the HOB. During a concurrent observation and interview on 6/30/2026 at 10:04 am together with the Assistant Director of Nursing (ADON), inside Resident 39's room, Resident 39 was awake lying in bed. The right side of Resident 39's bed had 1/4 side rail up at the HOB and 1/4 side rail up on the foot of the bed. The left side of the bed had 1/4 side rail up at the HOB. The ADON stated Resident 39 could entrap in the side rails if both rails on the right side of the bed were up and became a restraint since it would prevent Resident 39 from getting out of the bed. During a review of the undated facility's Policy and Procedure (P&P) titled, Siderails, the P&P indicated, Side rails are classified as a restraint when they are used to limit a resident's freedom of movement (prevent the resident from leaving his/her bed). b. During a review of Resident 59's AR, the AR indicated the facility admitted Resident 59 on 7/1/2024 and readmitted on [DATE] with diagnoses including profound intellectual disabilities (a person had very serious limitations in learning, understanding, and daily activities) and epilepsy (unusual electrical activity in the brain resulting in seizures [uncontrollable movement]). During a review of Resident 59's History and Physical (H&P) dated 6/18/2026, the H&P indicated Resident 59 did not follow commands. During a review of Resident 59's Physician's admission Orders ([NAME]) dated 6/26/2026, the [NAME] indicated Resident 59 was not capable of giving informed consent and/or able to participate in treatment plan. During a review of Resident 59's Physicians Orders (PO) dated 6/26/2026-6/29/2026, there was no active PO for bedside rails (adjustable metal or rigid plastic bars attached to bed) use. During an observation on 6/30/2026 at 10:08 am inside Resident 59's room, Resident 59 was in bed with 1/4 bedside rails up on both sides of the bed. Resident 59 was calm in bed. During a concurrent interview and record review on 7/1/2026 at 1:55 pm with the MDS Coordinator (MDSC), Resident 59's medical record (chart) and the undated Consent For Bedside Rail Use were reviewed. The MDSC stated the Consent For Bedside Rail Use for Resident 59 was not completed. During a concurrent interview and record review on 7/1/2026 at 1:55 pm with the MDSC, Resident 59's Physical Restrain Device Assessment (PRDA) dated 6/26/2026 was reviewed. The PRDA indicated Resident 59 was unaware of safety needs. The PRDA indicated Resident 59 had short- and long-term memory impairment. The PRDA indicated Resident 59 was non-verbal (could not talk), unable to make self-understood, and unable to understand others. The PRDA indicated Resident 59 was cooperative/ pleasant. The PRDA indicated Resident 59 required assistance from staff for transferring. The MDSC stated the PRDA indicated there was no restraint currently in use for Resident 59. During a concurrent interview and record review on 7/1/2026 at 1:55 pm with the MDSC, Resident 59's Side Rail Evaluation (SRE) dated 6/26/2026 was reviewed. The SRE indicated Resident 59 could not make needs known. The SRE indicated Resident 59 would not use the call light to ask for help. The SRE indicated Resident 59 was non-ambulatory (not able to walk) and dependent (helper did all the effort) on staff with transferring and bed mobility. The MDSC stated the SRE dated 6/26/2026 indicated bedside rail was not considered to be used for Resident 59. The MDSC stated Resident 59 was at risk of entrapment. During a concurrent observation and interview on 7/1/2026 at 2:05 pm with the MDSC inside Resident 59's room, Resident 59 was in bed with 1/4 bedside rails up on both sides of the bed. The MDSC stated Resident 59 should not have bedside rails because the bedside rails consent needed to be completed before installation. The MDSC stated bedside rails could be used as a restraint. The MDSC stated Resident 59 was unable to make decision, and the facility needed to call the Resident 59's responsible party for consent to use the bedside rail. The MDSC stated the risk of side rail use was injury from entrapment. During an interview on 7/2/2026 at 10:43 am, with the facility's Assistant Director of Nursing (ADON), the ADON stated the facility should not install the bedside rails for residents when the assessment indicated no benefit of using the bedside rails. During a review of the facility's undated Policy & Procedure (P&P) titled, Siderails, the P&P indicated the facility should ensure the safe use of side rails as an assistive device, to aid mobility, or to treat medical symptoms. The P&P indicated side rails were classified as a restraint when they were used to limit a resident's freedom of movement (prevent the resident from leaving his/her bed). The P&P indicated side rails were only permissible if they were used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. The P&P further indicated that prior to placing a side rail on the bed, informed consent would be obtained for bedside rail met the definition of a physical restraint even when it could also be used as an enabler. c. During a review of Resident 62's AR, the AR indicated the facility admitted Resident 62 on 6/29/2026 with diagnoses including hypertension (HTN, high blood pressure) and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control). During a review of Resident 62's Physician Order (PO) dated 6/29/2026, the PO indicated Resident 5 had an order for bilateral one-half (1/2) siderails as enabler to aid in bed mobility. During a review of Resident 62's Consent for Bedside Rail Use (CBRU), dated 6/29/2026, the CBRU indicated bedside rail was ordered for left and right upper 1/2 partial rail for mobility aid to improve functional ability when in bed. The CBRU did not indicate the name of the person giving the consent for the use of bilateral 1/2 siderails and the name of the person verifying the informed consent. During a concurrent interview and record review on 6/30/2026 at 11:24 am with Licensed Vocational Nurse 2 (LVN 2), Resident 62's PO and CBRU, dated 6/29/2026 were reviewed. LVN 2 stated Resident 62 had an order for bilateral 1/2 siderails. LVN 2 stated Resident 62's CBRU did not indicate the name of the person giving the consent and the name of the staff verifying the consent on the use of bilateral 1/2 siderails for Resident 62. LVN 2 stated the CBRU should be accurate and complete for the safety of the residents. During an interview on 7/2/2026 at 10:46 am with the Assistant Director of Nursing (ADON), the ADON stated a CBRU should be complete and accurately document the name of the person giving the consent and the name of the staff member verifying the consent to ensure the risks and benefits on the use of siderails were explained and understood by the resident or responsible party. During a review of the facility's Policy and Procedure (P&P) titled, Informed Consent for Use of Psychotherapeutics, Physial Restraints and Medical Devices, revised 3/2005, the P&P indicated, The attending physician determines capacity of the resident to make decisions and give informed consent on his/her admission orders or progress notes. If the resident is determined to not have the capacity to make informed decisions, a surrogate decision-maker is identified. When a new or significantly changed order for a psychotherapeutic, physical restraint or medical device is obtained, the licensed nurse verifies with the physician that informed consent has been obtained. The nurse documents this verification on the order by stating Verified that informed consent obtained.

Based on observation, interview, and record review, the facility failed to ensure safe food storage and sanitary food storage in one of one facility kitchen by failing to:a. Label a tray with fifteen (15) small, square paper packages (juice box) of cranberry juice and fourteen (14) juice boxes of apple juice inside the kitchen cooler fridge with delivery date and used by (the last date recommended for the product to be used)/best by (when a product will have the best flavor, texture, or quality) date or expiration date (final date set by a manufacturer after which a product should not be used or consumed).b. Discard one (1) big, open plastic container of cranberry juice with date beyond the used by/best by date.These failures had the potential to result in harmful bacteria growth and cross-contamination (transfer of harmful bacteria from one place to another) that would lead to foodborne illness (an illness caused by eating contaminated foods) to the residents (in general).Findings: a. During a concurrent observation inside the facility's kitchen and interview on 6/30/2026 at 8:56 am with the Dietary Supervisor (DS), a tray with 15 small juice boxes of cranberry juice and 14 juice boxes of apple juice inside the kitchen cooler fridge did not have delivery dates and used by/best by dates or expiration dates labeled. The DS stated all food items should be labeled with delivery dates, open dates, used by/best buy dates and expiration dates to make sure food served remained at its best quality and safe for consumption. b. During a concurrent observation inside the facility's kitchen and interview on 6/30/2026 at 9:00 am with the DS, 1 big open plastic container, one-fourth (1/4) filled with cranberry juice had an open date of 6/18/2026 and used by date of 6/21/2026 was in a rack located next to the reach-in fridge. The DS stated food items with dates beyond the used by/best by or expiration dates should be discarded and should not be served to the residents to prevent causing diarrhea and vomiting. During an interview on 7/2/2026 at 10:46 am with the Assistant Director of Nursing (ADON), the ADON stated all food products received and delivered should be labeled with delivery/received date, open date, preparation date, and used by/best by date to make sure all prepared food for the residents were good and safe for consumption to avoid gastrointestinal (GI) problems, and food were not kept for a prolonged period to prevent getting spoiled. During a review of the facility's undated Policy and Procedure (P&P) titled, Food Labeling and Dating Policy, the P&P indicated, Upon delivery, inspect all deliveries immediately upon arrival, verify delivery date matches invoice and check manufacturer dates on all packaged items. Label all bulk items without manufacturer dates with receiving date. Remove any items received on or past expiration dates. Opened packages - label with opening date and discard date. Label all opened containers immediately after opening. Beverages: label with opening date; follow manufacturer guidelines.

Based on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Foods Brought by Family/Visitors, by failing to label outside food for two of two sampled residents (Residents 7 and 58). These deficient practices had the potential to result in food-borne illnesses (food poisoning) for Residents 7 and 58 and could lead to serious medical complications and hospitalization.Findings: a. During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted Resident 7 on 9/11/2024 with diagnoses including type 2 diabetes mellitus (DM, a disease in which the body's ability to produce or respond to the hormone insulin was impaired, resulting in elevated levels of glucose/sugar in the blood and urine) and End Stage Renal Disease (ESRD, irreversible kidney failure). During a review of Resident 7's History and Physical (H&P), dated 9/20/2025, the H&P indicated Resident 7 had the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool) dated 6/19/2026, the MDS indicated Resident 7 had intact cognition (the ability to think and process information) for daily decision making. The MDS indicated Resident 7 required setup assistance from staff for eating, oral hygiene, personal hygiene, and bed-to-chair transferring. The MDS indicated Resident 7 required supervision from staff for walking. The MDS indicated Resident 7 required maximal assistance (helper did more than half the effort) from staff for toileting hygiene and showering/ bathing. During an observation on 6/30/2026 at 10:30 am, in Resident 7 's room, there was a sealed and unlabeled plastic container of mixed nuts at Resident 7 's bedside. During a concurrent observation and interview on 6/30/2026 at 12:31 pm with Resident 7, in Resident 7 's room, there was a sealed and unlabeled plastic container of mixed nuts at Resident 7 's bedside. Resident 7 stated Resident 7's family brought the nuts two to three weeks ago. During a concurrent observation and interview on 7/1/2026 at 2:14 pm with Certified Nurse Assistant 2 (CNA 2) inside Resident 7 's room, there was a sealed and unlabeled plastic container of mixed nuts at Resident 7 's bedside. CNA 2 stated the mixed nuts container was not labeled with resident's name or received date. CNA 2 stated staff should label the outside food with resident's name and the received date using a marker and/or sticker. CNA 2 stated the staff would know who's the outside food belonged to. CNA 2 stated everyone should make rounds and check if any outside food was at resident's bedside and intervene accordingly. During a concurrent observation and interview on 7/2/2026 at 10:25 am with Licensed Vocational Nurse 4 (LVN 4), in Resident 7's room, there was a sealed and unlabeled plastic container of mixed nuts at Resident 7 's bedside. LVN 4 stated the staff should have labeled the container of mixed nuts at Resident 7's bedside with Resident 7's name and received date. b. During a review of Resident 58's AR, the AR indicated the facility admitted Resident 58 on 6/26/2026 with diagnoses including urinary tract infection (UTI, an infection in the bladder/urinary tract [part of the body that carried urine]) and dementia (a progressive state of decline in mental abilities). During a review of Resident 58's H&P dated 6/27/2026, the H&P indicated Resident 58 did not have the capacity to understand and make decisions due to dementia. During an observation on 6/30/2026 at 9:53 am, in Resident 58 's room, the following unlabeled food items were at Resident 58 's bedside: 1. Two clear containers of cookies. 2. A zip-lock bag with four cookies. 3. A bag of coffee cake. During a concurrent observation and interview on 7/1/2026 at 2:15 pm with CNA 2 inside Resident 58 's room, the following unlabeled food items were at Resident 58 's bedside: 1. Two clear containers of cookies. 2. A zip-lock bag with four cookies. 3. A bag of coffee cake. CNA 2 stated Resident 58's outside foods were not labeled and should. During an interview on 7/2/2026 at 10:43 am with the facility's Assistant Director of Nursing (ADON), the ADON stated staff should label residents' outside food with the date and time of receiving the food and resident's name. The ADON stated all staff should make rounds and check residents' bedsides for any outside food. The ADON stated when CNAs saw any outside food, the CNA should report to the charge nurse and intervene accordingly. During a review of Resident 58's MDS dated [DATE], the MDS indicated Resident 58 had moderately impaired cognition for daily decision making. The MDS indicated Resident 58 required setup assistance from staff for eating and oral hygiene. The MDS indicated Resident 58 required moderate assistance (helper did less than half the effort) from staff for personal hygiene. The MDS indicated Resident 58 required maximal assistance from staff with bed-to-chair transferring. The MDS indicated Resident 58 was dependent (helper did all the effort) on staff for toileting hygiene. During a review of the facility's P&P titled, Foods Brought by Family/Visitors, dated 6/2023, the P&P indicated the facility should label the food brought by family/visitors that was left with the resident to consume later with the resident's name, the item, and the use by date.

Based on interview and record review, the facility failed to ensure for one of five sampled residents' (Resident 6) target behavior was monitored for the use of psychotropic medication (medication that alter chemical levels in the brain which impact mood and behavior) as indicated in the facility's policy and procedure (P&P) titled Behavior Management. This deficient practice had the potential to result in the use of unnecessary psychotropic medication that could result in significant adverse (harmful) consequences to Resident 6.Findings: During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on 12/17/2025 with diagnoses including history of falling, anxiety disorder (group of mental disorders characterized by feelings of impulse disorder (disorder characterized by impulsivity, failure to resist a temptation, an urge or an impulse), and hyperlipidemia (high level of fats in the blood). During a record review of Resident 6's Order Summary Report (OSR), dated 12/17/2025, the OSR indicated for nursing staff to administer Abilify (antipsychotic medication to treat serious mental disorder in which people interpret reality abnormally), oral tablet, 15 milligrams (mg, unit of measurement), one (1) tablet by mouth one time a day for psychosis (severe mental disorder in which thought and emotions are impaired and with reality it lost) manifested by responding to internal stimuli constantly yelling, getting up unassisted for no reason, at risk for fall and striking out at staff.During a record review of Resident 6's Order Summary Report (OSR), dated 12/17/2025, the OSR indicated for nursing staff to administer Abilify (antipsychotic medication to treat serious mental disorder in which people interpret reality abnormally), oral tablet, 15 milligrams (mg, unit of measurement), one (1) tablet by mouth one time a day for psychosis (severe mental disorder in which thought and emotions are impaired and with reality it lost) manifested by responding to internal stimuli constantly yelling, getting up unassisted for no reason, at risk for fall and striking out at staff. The OSR did not indicate an order for staff to monitor Resident 6's responding to internal stimuli by constantly yelling for the use of Ability. During a record review of Resident 6's OSR, dated 12/17/2025, the OSR indicated for nursing staff to administer Trileptal (medication primarily used to prevent and control seizures, also used for mood instability and aggressive behavior) oral tablet, 150 mg, 1 tablet by mouth every 12 hours for impulse control manifested by easily agitated, becoming verbally and physically aggressive. During a review of Resident 6's Care Plan (CP) titled Antipsychotic, dated 12/17/2025, the CP indicated Resident 6 was on Abilify for psychosis manifested by constantly yelling. The CP intervention indicated for nursing staff to monitor and record episodes of behavior in the Medication Administration Record (MAR) and/or nursing notes. During a review of Resident 6's untitled CP dated 12/17/2025, the CP indicated Resident 6 was on Trileptal for pool impulse control manifested by being easily agitated and verbally and physically aggressive. The CP intervention indicated for nursing staff to monitor and record episodes of behavior in the MAR and/or nursing notes. During a concurrent interview on 7/1/2026 at 9:44 am with Licensed Vocational Nurse 1 (LVN 1) and record review of Resident 6's Medication Administration Record (MAR) for the month of 6/2026, LVN 1 stated, Resident 6's targeted behavior of constant yelling for the use of Abilify was not monitored. LVN 1 stated Resident 6's targeted behavior of constant yelling for the use of Abilify needed to be monitored by licensed nurses every shift to determine if the medication was effective or not. During a concurrent interview on 7/1/2026 at 9:50 am with Licensed Vocational Nurse 1 (LVN 1) and record review of Resident 6's MAR for the month of 6/2026, LVN 1 stated, Resident 6's targeted behavior of being verbally and physically aggressive for the use of Trileptal was not monitored in the morning shift of 6/26/2026 and 6/30/2026. LVN 1 stated Resident 6's target behavior of being verbally and physically aggressive for the use of Trileptal should have been monitored every 12 hours to determine if the medication was effective or not. During a review of the facility's P&P titled, Behavior Management, revised 7/2013, the P&P indicated, Occurrence of behaviors for which psychotropic medications are in use will be entered with hash marks on the medications administration record every shift.

Based on interview and record review, the facility failed to ensure the resident's Minimum Data Set (MDS, a resident assessment tool) reflected an accurate discharge status assessment for one of one sampled resident (Resident 57). This failure resulted in inaccurate reporting to the Centers for Medicare and Medicaid Services (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency and had the potential for Resident 57 not to receive interventions to address Resident 57's specific care concerns. Findings: During a review of Resident 57's admission Record (AR), the AR indicated the facility admitted Resident 57 on 2/5/2026 with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control) and atrial fibrillation (Afib, irregular heartbeat). During a review of Resident 57's Physician Order (PO) dated 4/7/2026, the PO indicated Resident 57 had an order to be discharged home on 4/11/2026 with home health (HH) Physical Therapy/Occupational Therapy ( PT/OT) for therapeutic exercises, activities of daily living (ADL) training and gait, Registered Nurse (RN) for medication management and overall safety evaluation and Home Health Aide (HHA) for bathing.During a review of Resident 57's Discharge Summary (DS) dated 4/11/2026, the DS indicated Resident 57 was discharged home with family or caregiver and home health. During a review of Resident 57's MDS dated [DATE], the MDS indicated Resident 57 was discharged to home or community. During a concurrent interview and record review on 7/1/2026 at 1:45 pm with MDS coordinator (MDS C), Resident 57's PO dated 4/7/2026, MDS dated [DATE] and DS dated 4/11/2026 were reviewed. The MDS C stated the MDS dated [DATE] was incorrectly coded with Resident 57's discharge destination to home instead of home under care of organized home health service organization. The MDS C stated the MDS should be coded accurately and specific for the services provided for accurate reporting to CMS. The MDS C stated Resident 57 was discharged home with HH PT/OT, RN and HH aide on 4/11/2026. During an interview on 7/2/2026 at 10:46 am with the Assistant Director of Nursing (ADON), the ADON stated the MDS assessment should be coded correctly to reflect the resident's overall current health status and for accurate reporting of information to CMS. During a review of the facility's undated Policy and Procedure (P&P) titled, MDS and Resident Assessment Instrument (RAI) Process, the P&P indicated, It is the policy of the facility to complete a comprehensive assessment that accurately reflects each residents' status. MDS assessment must follow the rules set forth by the Centers for Medicare and Medicaid Services (CMS). These rules dictate how the IDT collects resident information, submit it on time, and fix mistakes as needed, to guarantee quality of care, continuity of medically necessary services and proper payments.

Based on interview and record review, the facility failed to develop and implement specific, comprehensive, and individualized person-centered care plan (CP) to meet the resident's needs for one of one sampled resident (Resident 26) to address Resident 42's use of quetiapine fumarate (medication that helps calm a person's thoughts and mood). This failure had the potential to result in Resident 26 not receiving individualized care to maintain the resident's highest practicable physical, mental, and psychosocial well-being. Findings: During a review of Resident 26's admission Record (AR), the AR indicated the facility admitted Resident 26 on 3/25/2026 with diagnoses including dementia (a progressive state of decline in mental abilities) and personal history of other mental and behavioral disorders. During a review of Resident 26's History and Physical (H&P) dated 3/27/2026, the H&P indicated Resident 26 did not have the capacity to understand and make decisions. During a review of Resident 26's Minimum Data Set (MDS, a resident assessment tool) dated 4/1/2026, the MDS indicated Resident 26 had severely impaired cognition (the ability to think and process information). The MDS indicated Resident 26 required maximal assistance (helper did more than half the effort) from staff with eating, oral hygiene, personal hygiene, and bed-to-chair transferring. The MDS indicated Resident 26 was dependent (helper did all the effort) on staff for toileting hygiene. During a review of Resident 26's Physician Orders (PO) dated 5/26/2026, the PO indicated Resident 26 had an active order to receive quetiapine fumarate 25 milligrams (mg-metric unit of measurement) by mouth at bedtime for senile degeneration of brain paranoia (the person's brain had declined over time, causing serious memory and thinking problems). During a concurrent record review and interview with the Licensed Vocational Nurse 4 (LVN 4) on 7/1/2026 at 12:37 pm, Resident 26's entire care plans were reviewed. There was no CP develop for Resident 26's use of quetiapine fumarate. LVN 4 stated there should be a CP to address Resident 26's quetiapine fumarate and a goal for Resident 26 to have fewer behavioral episodes. LVN 4 stated the licensed nurse who received the quetiapine fumarate order from the physician should have developed a CP for Resident 26's quetiapine fumarate use. LVN 4 stated Resident 26 was at risk of developing side effects (unwanted or unexpected reaction) of quetiapine fumarate without the CP to address the resident's behavior or any change of condition. LVN 4 stated the CP should be specific and resident-centered because different residents had different behaviors, so that staff would have the knowledge how to approach the residents in order to meet their needs. LVN 4 stated all the licensed nurses could develop, update, and revise the residents' CP. During an interview with the Assistant Director of Nursing (ADON) on 7/2/2026 at 11:20 am, the ADON stated there should be a specific and resident centered CP for medication use so that staff could monitor the side effects of the medication and know what to do in the event of adverse side effect of the medication on the resident. During a review of the facility's undated Policy and Procedure (P&P) titled, Person-Centered Care Planning, the P&P indicated the facility should develop a comprehensive person-centered CP for each resident that included measurable goals and time-oriented objectives to meet the resident's medical, nursing, and mental and psychosocial needs.

Based on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Peripheral Catheter Dressing Change, by failing to label the intravenous (IV- medicine or fluid that goes straight into a vein) dressing for one of one sampled resident (Resident 58). This deficient practice had the potential to increase the risk of infection for Resident 58 and could lead to serious medical complications.Findings: During a review of Resident 58's admission Record (AR), the AR indicated the facility admitted Resident 58 on 6/26/2026 with diagnoses including urinary tract infection (UTI, an infection in the bladder/urinary tract [part of the body that carried urine]) and dementia (a progressive state of decline in mental abilities). During a review of Resident 58's Physician Orders For Infusion Therapy (POFIT) dated 6/26/2026, the POFIT indicated Resident 58 had an active order to receive IV medication Ertrapenem (medication to treat bacterial infection) 1 gram (g-metric unit of measurement) every 24 hours for 11 days. The POFIT indicated staff to restart IV site and dressing every 72 hours and as needed complications. During a review of Resident 58's History and Physical (H&P) dated 6/27/2026, the H&P indicated Resident 58 did not have the capacity to understand and make decisions due to dementia. During a review of Resident 58's Minimum Data Set (MDS, a resident assessment tool) dated 7/3/2026, the MDS indicated Resident 58 had moderately impaired cognition (the ability to think and process information) for daily decision making. The MDS indicated Resident 58 required setup assistance from staff for eating and oral hygiene. The MDS indicated Resident 58 required moderate assistance (helper did less than half the effort) from staff for personal hygiene. The MDS indicated Resident 58 required maximal assistance (helper did more than half the effort) from staff with bed-to-chair transferring. The MDS indicated Resident 58 was dependent (helper did all the effort) on staff for toileting hygiene. During an observation and interview with Resident 58 on 6/30/2026 at 9:52 am, in Resident 58 's room, Resident 58's left hand IV dressing had dry blood at the insertion site. There was no date labeled on Resident 58's left hand IV dressing. Resident 58 stated the IV site was painful. During a concurrent interview and pictures review on 7/2/2026 at 9:19 am with the MDS Coordinator (MDSC), pictures dated 6/30/2026 at 9:52 am were reviewed. The MDSC stated the pictures indicated the resident's left hand IV dressing had blood at the IV insertion site with the tape coming off. The MDSC stated the MDSC was unable to read the IV dressing date. The MDSC stated the licensed nurse should put the licensed nurse's initial and date on the small sticker on the IV dressing, after changing the IV site. The MDSC stated it was not acceptable for the IV site dressing without a date or the licensed nurse's initial because staff would not know when the IV site dressing was changed. The MDSC stated the IV site should be dry, clean, and intact. The MDSC stated the IV label should be legible. The MDSC stated all staff taking care of Resident 58 should ensure the IV dressing was dry, clean, and intact. The MDSC stated the certified nursing assistant should report to the licensed nurse for any leaking or drainage at the resident's IV site dressing. The MDSC stated staff should change the IV dressing when soiled because of the risk of infection. During an interview on 7/2/2026 at 10:43 am with the facility's Assistant Director of Nursing (ADON), the ADON stated residents' IV dressing should be dry, clean, and intact, to prevent bacterial growth. The ADON stated residents' IV dressing should be labeled with a date and the licensed nurse's initial for infection control. During a review of the facility's P&P titled, Peripheral Catheter Dressing Change, dated 8/15/2028, the P&P indicated the IV site was a potential entry site for bacteria that cause infection. The P&P indicated the licensed nurses caring for residents receiving IV therapy should follow infection control and safety compliance procedure. The P&P further indicated the licensed nurse should label the IV dressing with date, time, and the nurse's initials.

Based on interview and record review, the facility failed to ensure medication regimen review (MRR) irregularity identified by the facility's Pharmacy Consultant was acted upon for one of five sampled residents (Resident 39) in accordance with facility's policy and procedure California Long Term Care Facility Pharmacy Services and Procedures Manual. This deficient practice had the potential for unnecessary and over medication for Resident 39 that could result in harm due to the missed opportunity for a Gradual Dose Reduction (GDR, slow, supervised tapering of psychotropic [psychiatric medicines that alter chemical levels in the brain which impact mood and behavior] to the lowest effective dose or complete discontinuation). Findings:During a review of Resident 39's admission Record (AR), the AR indicated the facility admitted Resident 39 on 12/15/2023 with diagnoses including history of falling, anxiety disorder (group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear), and depression (a feeling of severe sadness or hopelessness).During a review of Resident 39's Order Summary Report (OSR) dated 11/10/2025, the OSR indicated an order for staff to administer Celexa 10 milligram (mg, unit of measurement), one (1) tablet by mouth, 1 time a day every other day for depression manifested by verbalization of sadness with episodes of crying.During a review of Resident 39's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/3/2026, the MDS indicated Resident 39 had moderately impaired cognition (ability to think) for daily decision making. The MDS indicated Resident 39 was dependent (helper does all the effort) from staff for toileting, showering, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated, Resident 39 needed maximum assistance (helper does less than half the effort) from staff for oral hygiene and upper body dressing.During a concurrent record review and review on 7/1/2026 at 1:17 pm, with the facility's Assistant Director of Nursing (ADON), the facility's document titled, Consultation Report (CR), dated 5/1/2026, completed by the facility's pharmacist consultant indicated, Resident 39 has received an antidepressant, Celexa 10 mg every other days since 11/2025 and only 1 x since 7/2025. The CR indicated Please consider trial of discontinuing Celexa. The CR indicated that Resident 39's Primary Physician accepted the Pharmacist's recommendation on 5/20/2026 with the following modifications to reach out to Psychiatrist (a medical doctor who specializes in mental health).During a concurrent interview and record review on 7/1/2026 at 1:17 pm, with the ADON, Resident 39's CR dated 5/1/2025 indicated to obtain a Psychiatrist consultation. The ADON stated, the MRR was a monthly recommendation from the pharmacy consultant that licensed nurses should carry out every month and the ADON oversee to make sure the recommendation from the pharmacy consultant was done and addressed. The ADON stated, she missed referring to the pharmacy recommendation for a psychiatrist consultation. The ADON stated, she should have informed the psychiatrist as soon as possible when the ADON received Resident 39's Physician response to the Pharmacist's recommendation. The ADON stated, the Pharmacist's recommendation was not acted upon.During a concurrent interview and record review on 7/1/2026 at 1:21 pm, with the ADON, a facility document titled Psychotropic Medication Review (PMR), the PMR indicated Resident 39 did not have any episodes of verbalization of sadness with episodes of crying from 12/2025 to 2/2026 and 4/2026. The ADON stated Resident 39 had one (1) episode of verbalization of sadness with episodes of crying on 3/2026 and 5/2026. The ADON stated, Celexa should have been discontinued or GDR because Resident 39 did not have any episodes of depression such as verbalization of sadness.During a review of the Policy and Procedure (P&P) titled, California Long Term Care Facility Pharmacy Services and Procedures Manual, revised 6/5/2024, the P&P indicated, Facility should encourage physician/prescriber or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR. For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why recommendation was rejected. Facility should alert the Medical Director where MRR's are not addressed by the attending Physician in a timely manner.

Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment to help prevent the development and transmission of communicable diseases for one of four sampled residents (Resident 59) by failing to initiate and implement Enhanced Barrier Precaution (EBP, a set of infection control practices that used personal protective equipment [PPE, clothing and equipment used to provide protection] to reduce the spread of multi-drug resistant organisms [MDRO, a bacteria that was resistant to antibiotics-mediations for bacterial infection]. These failures had the potential to expose Resident 59 and other residents in the facility to infection.Findings: During a review of Resident 59's admission Record (AR), the AR indicated the facility admitted Resident 59 on 7/1/2024 and readmitted on [DATE] with diagnoses including dysphagia (unable to swallow), encounter for attention of gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach), and urinary tract infection (UTI, an infection in the bladder/urinary tract [part of the body that carried urine]) . During a review of Resident 59's History and Physical (H&P), dated 6/18/2026, the H&P indicated Resident 59 did not follow command. During a review of Resident 59's Physicians admission Orders ([NAME]) dated 6/26/2026, the [NAME] indicated that Resident 59 was incapable of giving informed consent and/or able to participate in treatment plan. During a review of Resident 59's Physician's Enteral Orders ([NAME]) dated 6/26/2026, the [NAME] indicated Resident 59 had an active order to have enteral feeding with Fibersource HN (a liquid nutrition formula used for enteral feeding) via gastrostomy tube (GT) at 50 cubic centimeter (cc, a small unit used to measure the volume of liquids)per hour over 24 hours due to dysphagia. During a review of Resident 59's Physical Restrain Device Assessment (PRDA) dated 6/26/2026, the PRDA indicated Resident 59 had a GT. The PRDA indicated Resident 59 was unaware of safety needs. The PRDA indicated Resident 59 had short- and long-term memory impairment. The PRDA indicated Resident 59 was non-verbal (could not talk), unable to make self-understood, and unable to understand others. The PRDA indicated Resident 59 required assistance from staff for transferring. During an observation on 6/30/2026 at 10:08 am inside Resident 59's room, Resident 59 was in bed and receiving Fibersource HN via GT. There was no EBP signage nor PPE cart outside Resident 59's room. During an observation on 6/30/2026 at 10:56 am inside Resident 59's room, Resident 59 was in bed and receiving Fibersource HN via GT. There was no EBP signage nor PPE cart outside Resident 59's room. During an interview on 6/30/2026 at 10:58 am with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated residents with GT should be on EBP due to the low immune system. LVN 3 stated residents with GT had open skin with higher risks for infection and needed more protection. LVN 3 stated staff should wear gloves and gowns when providing care to residents with GT for infection control. During a concurrent interview and pictures review on 7/2/2026 at 9:42 am with Infection Preventionist Nurse (IPN), the pictures dated 6/30/2026 at 10:08 am and 10:56 am were reviewed. The IPN stated the pictures indicated no EBP sign outside Resident 59's room. The IPN stated staff should initiate EBP for Resident 59 upon admission and/or within 24 hours of admission after assessments. The IPN stated the facility should place residents with GT on EBP to prevent transmission of infection to other residents, staff, and visitors. The IPN stated there should be EPB sign outside Resident 59's room and a shared PPE cart. The IPN stated it increased risk of infection. During an interview on 7/2/2026 at 11:10 am with the Assistant Director of Nursing (ADON), the ADON stated the ADON did not think the staff put on gowns to provide care to Resident 59 when there was no EBP sign outside Resident 59's room. The ADON stated EBP was to protect residents from staff due to residents being at high risk for getting infection due to the opening on the stomach. The ADON stated the facility should initiate EBP after assessing Resident 59's skin. The ADON stated the facility should put the EBP sign outside the Resident 59's room. The ADON stated it compromised the resident's health when EBP was not initiated and implemented. During a review of the facility's undated Policy & Procedure (P&P) titled, Enhanced Barrier Precaution dated 5/2024, the P&P indicated the facility should use appropriate EBP for the protection of residents, visitors, and health care worker. The P&P indicated EBP were for residents with feeding tubes. The P&P indicated staff should wear gowns and gloves while performing care for EBP residents.

Based on interview, and record review, the facility (Skilled Nursing Facility [SNF] 1) failed to ensure one of three sampled residents (Resident 1) was permitted for readmission to the first available bed in a semi-private room on [DATE] after Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on [DATE] and transferred to Long-Term Acute Care Hospital (LTACH) 1 on [DATE], in accordance with SNF 1's policy and procedure (P&P) titled, Bed-Holds and Returns, dated 10/2022.This deficient practice resulted in Resident 1 remaining in LTACH 1 on [DATE] following an inquiry from LTACH 1 for Resident 1 to be transferred back to SNF 1 and had the potential to cause Resident 1 distress from not being able to return to Resident 1's previous living arrangement.(cross reference F628)Findings:During a review of Resident 1's admission Record (AR), the admission Record indicated SNF 1 originally admitted Resident 1 on [DATE], and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a weakness or partial paralysis affecting one side of the body) following cerebral infarction (damage to brain tissue caused by loss of blood flow to a part of the brain), and dementia (a progressive state of decline in mental abilities).During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated [DATE], the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 1 was severely impaired in cognitive skills (ability to make daily decisions) and required partial/moderate assistance (helper does less than half the effort to complete the activity) for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Physician's Telephone Orders (PTO), dated [DATE] at 6:30 PM, the PTO indicated to transfer Resident 1 to a hospital via 911 (emergency number to request the services of the police, fire department, paramedics, ambulance).During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form, dated [DATE], the SBAR indicated Registered Nurse (RN) 2 received an order from Resident 1's physician to transfer Resident 1 to a GACH via 911 due to altered mental status (AMS-a change in a person's thinking, awareness, or consciousness, causing confusion, reduced alertness, or unusual behavior), and desaturation (a drop in blood oxygen saturation levels below normal, usually falling under 90%) on [DATE] at 6:30 PM.During a review of Resident 1's Progress Notes (PN), dated [DATE], the PN indicated Resident 1 was transferred to GACH 1 by 911 on [DATE] at 7:15 PM due to AMS, increased respiration (rapid and shallow breathing, often resulting from conditions like lung infection, asthma, or anxiety), and desaturation.During a review of Resident 1's H&P from LTACH1, dated [DATE], the H&P indicated Resident 1 was transferred and admitted to LTACH 1 from GACH 1 for further evaluation and therapy on [DATE].During a review of Resident 1's Supportive Care and Palliative Visit Note (SCPVN) from LTACH 1, dated [DATE], the SCPVN indicated Resident 1's discharge goal/plan included transferring Resident 1 back to a skilled nursing facility (SNF).During a review of Resident 1's Psychiatric Consultation (PC- a thorough evaluation, when a psychiatrist assess mental, emotional, and physical health and address the emotional and behavioral issues [persistent and disruptive behaviors that negatively impact an individual's ability to function effectively in daily life and social interactions] to determine a diagnosis and personalized treatment plan ) report from LTACH 1, dated [DATE], the PC indicated Resident 1 was calm, quiet, and manageable with current treatment plan on [DATE].During an interview on [DATE] at 12:51 PM with SNF 1's admission Coordinator Director (ACD), the ACD stated the ACD received the inquiry from LTACH 1 regarding Resident 1's readmission on [DATE]. The ACD stated the facility refused to readmit Resident 1 on [DATE] because Resident 1's behavioral issues were not addressed and evaluated. The ACD stated Resident 1 was calm and had no behavior issues when the ACD assessed Resident 1 in LTACH 1 on [DATE].During an interview on [DATE] at 3:38 PM with SNF 1's Director of Nursing (DON), the DON stated the facility refused to readmit Resident 1 because Resident 1's behavioral issue was not addressed in Resident 1's medical record information from LTACH 1 on [DATE].During a telephone interview on [DATE] at 3:14 PM with LTACH 1's Case Manager (CM 1), CM 1 stated a PC was completed on [DATE] to evaluate Resident 1's behavior issues. CM 1 stated Resident 1's PC report was sent to SNF 1 on [DATE] and SNF 1 declined to readmit Resident 1 because Resident 1 was on hospice (care focused on comfort, pain management, quality of life and dignity as patients near the end of their life) and SNF 1 did not have any available bed for a hospice care resident.During a concurrent interview and record review on [DATE] at 9:02 AM with the Assistant DON (ADON), the facility's Census and Resident Roster, dated [DATE] and [DATE] were reviewed. The ADON stated the facility had 14 available female beds in a semi-private room (317A, 318A, 318B, 319A, 319B, 321A, 329C, 330A, 332B, 333C, 334A, 334B, 335A, and 335B) on [DATE] and on [DATE].During a concurrent interview and record review with the DON on [DATE] at 11:13 AM, Resident 1's PC report from LTACH 1, dated [DATE], was reviewed. The DON stated the facility received the PC report from LTACH 1 on [DATE] and refused to readmit Resident 1. The DON stated Resident 1 should be accepted for readmission to SNF 1 if Resident 1 did not have any behaviors which would endanger the health or safety of Resident 1 or other individuals in SNF 1. The DON stated SNF 1 should have readmitted Resident 1 on [DATE] because SNF 1 could provide the care and meet the needs of Resident 1.During a review of SNF 1's P&P titled, Bed-Holds and Returns, revised 10/2022, the P&P indicated, The requirement that residents be permitted to return to the facility following hospitalization or therapeutic leave applies to all residents regardless of payer source.Following a hospitalization, residents whom staff are concerned about permitting to return due to their clinical/behavioral condition at the time of transfer are evaluated based on their current condition, not their condition when originally transferred.Residents who seek to return to the facility after the state bed-hold period has expired (or when state law does not provide for bed-holds) are allowed to return to their previous room if available or immediately to the first available bed in a semi-private room provided that the resident: a. still requires the services provided by the facility; and b. is eligible for Medicare skilled nursing facility or Medicaid nursing facility services.

Based on interview, and record review, the facility failed to ensure a complete transfer or discharge process for one of three sampled residents (Resident 1) when:1. A Notice of Transfer or Discharge (NTD) was not provided to Resident 1 and/or to Resident 1's representative (RP) when Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 1/3/2026.2. A copy of an NTD was not sent to the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) when Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 1/3/2026.These deficiencies had the potential to violate Resident 1's right to not be inappropriately transferred or discharged and had the potential for the Ombudsman to not be able to advocate for Resident 1 from being inappropriately transferred or discharged .(cross reference F627)Findings:During a review of Resident 1's admission Record (AR), the admission Record indicated SNF 1 originally admitted Resident 1 on 12/10/2024, and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a weakness or partial paralysis affecting one side of the body) following cerebral infarction (damage to brain tissue caused by loss of blood flow to a part of the brain), and dementia (a progressive state of decline in mental abilities).During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 10/6/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 1/3/2026, the MDS indicated Resident 1 was severely impaired in cognitive skills (ability to make daily decisions) and required partial/moderate assistance (helper does less than half the effort to complete the activity) for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Physician's Telephone Orders (PTO), dated 1/3/2026 at 6:30 PM, the PTO indicated to transfer Resident 1 to a hospital via 911 (emergency number to request the services of the police, fire department, paramedics, ambulance).During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form, dated 1/3/2026, the SBAR indicated Registered Nurse (RN) 2 received an order from Resident 1's physician to transfer Resident 1 to a GACH via 911 due to altered mental status (AMS-a change in a person's thinking, awareness, or consciousness, causing confusion, reduced alertness, or unusual behavior), and desaturation (a drop in blood oxygen saturation levels below normal, usually falling under 90%) on 1/3/2026 at 6:30 PM.During a review of Resident 1's Progress Notes (PN), dated 1/3/2026, the PN indicated Resident 1 was transferred to GACH 1 by 911 on 1/3/2026 at 7:15 PM due to AMS, increased respiration (rapid and shallow breathing, often resulting from conditions like lung infection, asthma, or anxiety), and desaturation.During a review of Resident 1's medical record, there was no NTD found in the medical record regarding Resident 1's transfer to GACH 1 on 1/3/2026.During a telephone interview on 2/3/2026 at 11:40 AM with Registered Nurse (RN) 2, RN 2 stated RN 2 should have completed the NTD form and faxed the NTD form to the ombudsman after Resident 1 was transferred to GACH 1 on 1/3/2026.During a telephone interview on 2/3/2026 at 11:13 PM with the Assistant Director of Nursing (ADON), the ADON reviewed Resident 1's medical record and stated the ADON was unable to find an NTD form in Resident 1's medical record. The ADON stated it was important to complete the NTD form, to inform the resident and the resident's family of the resident's transfer or discharge, and to fax the NTD to the ombudsman prior to the resident's transfer or discharge.During a review of the facility's policy and procedure (P&P) titled, Transfer or Discharge, Facility-Initiated, dated 10/2022, the P&P indicated, The Notice of Transfer or Discharge (Emergent or Therapeutic Leave) should be given as soon as it is practicable but before the transfer or discharge if an immediate transfer or discharge is required by the resident's urgent medical needs. The P&P indicated, Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (L TC) ombudsman when practicable. The P&P also indicated, Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge.

Based on observation, interview, and record review, the facility failed to ensure call lights were within reach and were functioning properly for two of three sampled residents (Residents 30 and 18). This failure had the potential for Residents 30 and 18 not to receive necessary care or receive delayed services. Findings: a. During a review of Resident 30's admission Record (AR), the AR indicated Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (paralysis [complete or partial loss of muscle function] on one side of the body), blindness on the left eye, and dementia (a group of conditions, decline in mental ability, that interfere with daily activities). During a review of Resident 30's Care Plans (CPs), dated 9/26/2024, the CPs indicated Resident 30 was at risk for decline in activity of daily living (ADL, term used in healthcare that refers to self-care activities)/range of motion (ROM, full movement potential of a joint), had impaired vision, and was at risk for injury from falls. The CP's interventions included keeping the call light within Resident 30's reach and answering the call light promptly. During a review of Resident 30's Minimum Data Set (MDS, a resident assessment tool), dated 3/29/2025, the MDS indicated Resident 30's cognition (ability to understand and process information) was severely impaired. The MDS indicated Resident 30 was dependent (helper did all the effort, resident did none of the effort to complete the activity) with oral hygiene, toileting, showers, and personal hygiene. During a concurrent observation inside Resident 30's room and interview on 6/10/2025 at 8:39 am with Licensed Vocational Nurse 1 (LVN 1), Resident 30 was lying in bed, on Resident 30's back and the call light was located on top of Resident 30's rolling (bedside) table. The rolling table was located approximately three (3) feet (ft, unit of measurement) away from Resident 30's bed. LVN 1 stated Resident 30 could not reach the call light. LVN 1 stated the rolling table with the call light should be placed next to and close to Resident 30's bed for Resident 30 to call for help [when needed] and prevent injuries like falls. During an interview on 6/11/2025 at 1:44 pm with the Assistant Director of Nursing (ADON), the ADON stated the call light should be placed close to Resident 30's good arm and hand for Resident 30 to be able to use the call light and staff could address Resident 30's needs timely and promptly. b.During a review of Resident 18's AR, the AR indicated Resident 18 was admitted to the facility on [DATE] with diagnoses that included abnormalities of gait (a person's manner of walking) and mobility (the ability to move) and unspecified osteoarthritis (type of joint disease that results from breakdown of joint cartilage [connective tissue] and underlying bone). During a review of Resident 18's CP, dated 9/4/2015, the CP indicated Resident 18 was at risk for injury from falls as evidenced by unsteady gait and balance. The CP's interventions indicated for the nursing staff to have Resident 18's call light within reach and to answer promptly, and to remind Resident 18 to use the call light to call for help as needed. During a review of Resident 18's Fall Risk Assessment (FRA- method of assessing a patient's likelihood of falling), dated 3/17/2025, the FRA indicated Resident 18 was assessed as a high risk for falls due to history of falls in the past 3 months. The FRA indicated Resident 18's vision was impaired, had balance problems, and required assisting devices. During a review of Resident 18's MDS, dated [DATE], the MDS indicated, Resident 18 had intact cognition for daily decision making. The MDS indicated Resident 18 was dependent on staff for eating, oral hygiene, toileting hygiene, showers, upper/lower body dressing, putting on/taking off footwear, and for personal hygiene. During a concurrent observation and interview on 6/10/2025 at 8:30 am, Resident 18 was awake, sitting in Resident 18's bed, and pressing the call light button. Resident 18 stated Resident 18's call light was not working for two days and Resident 18 informed Licensed Vocational Nurse 2 (LVN 2) on 6/9/2025. Resident 18 stated no [staff] came [to check on the light]. Resident 18 stated Resident 18 pressed the call light and no [staff] came to Resident 18's room on 6/10/2025. Resident 18 stated, Resident 18 went out of Resident 18's room to look for the nurse when Resident 18 needed assistance because the call light was not working. During an interview on 6/10/2025 at 10 am with the facility's Assistant Director of Nursing (ADON), the facility's ADON stated, a resident [used the] call light to call for assistance from the staff to [the call light was important to] maintain residents' safety. The ADON stated, call lights needed to be answered by the facility staff within 15 minutes. During a review of the undated facility's Policy and Procedure (P&P) titled, Call Lights, the P&P indicated to instruct the resident to use the call button any time he/she needs to talk with a nurse or be assisted. The P&P indicated for nursing staff to check to see that the system is functioning and if any malfunction, report immediately to [the] maintenance [department]. The P&P indicated to answer all [call] lights promptly, regardless of whose resident it is to ascertain what resident's needs are. The P&P indicated call lights need to be answered within three to five minutes.

Based on observation, interview, and record review, the facility failed to post accurate nurse staffing information of actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift daily for 6/10/25, 6/11/25, and 6/12/25 in accordance with the facility's policy and procedure titled Posting Direct Care Daily Staffing Numbers. This deficient practice of posting inaccurate nurse staffing information could mislead the residents and visitors regarding facility staffing and could affect the quality of nursing care provided to the residents. Findings: During a concurrent observation and interview on 6/13/25, at 2:37 p.m., with the Case Manager (CM), the CM stated the purpose of staff posting was to communicate how many staff were providing care to the residents. The CM stated, the 11pm-7am (night) shift & 7 am -3pm (day) shift, posted dated 6/13/25 was not completed and the staff posting should be completed with staff actual work hours. The CM stated the CM would complete the actual hours on posting the next day. During the same observation, the facility's direct staffing information was not posted in the nurses' station and/or visible areas. During an interview on 6/13/25 at 3:39 p.m. with the Assistant Director of Nursing (ADON), the ADON stated staffing hours needed to be posted at the beginning of the shift and actual hours should be posted. The ADON stated the importance of posting the actual staffing was to determine the number of patients and the number of staff working to take care of the residents. During a record review on 6/13/25, with the CM and the ADON, the Posted Nurse Staffing Information actual total hours was not completed for 6/10/25, 6/11/25, and 6/12/25 for all three shifts. During a review of facility's Policy and Procedure titled, Posting Direct Care Daily Staffing Numbers, dated 2001, the P&P indicated within 2 hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs and NAs) directly responsible for resident care is posted in prominent location (accessible to residents and visitors) and in clear and readable format. The actual time worked during that shift for each category and type of nursing staff, and total number of licensed and non-licensed nursing staff working for the posted shift.

Based on observation, interview, and record review, the facility failed to follow food storage handling practices in accordance with its Policy and Procedure (P&P) by failing to: 1. Remove expired food items from the refrigerator. 2. Label food items with food item name, use by or expired date. 3. Maintain a functional convection steamer (an oven that is designed to steam cook large quantities of food over multiple shelves). These deficient practices had the potential to result in foodborne illness (illness caused by consuming contaminated food or beverages) for the residents. Findings: 1.During initial kitchen observation on 6/10/2025 at 7:50 AM, the kitchen staff did not remove expired food items from the refrigerator. One container of prunes had a use by date of 6/3/25 and one container of puree food was dated 6/9/25 indicating to be used for sack lunch, 4 pieces of half sandwiches). During a concurrent kitchen observation and interview with Food Service Worker (FSW) on 6/10/2025 at 2:21 PM, FSW stated the container of prunes, the container of puree food and four pieces of half sandwiches in the refrigerator were expired and should have been removed from the refrigerator. The FSW stated, the following food items were not properly labeled and should have been labeled with a use by or an expiration date: 1. One container of purple grapes inside the kitchen refrigerator on the bottom shelf. 2. One tray of fruit cups inside the kitchen on the top shelf. 3. One tray of applesauce cups inside the kitchen on the second shelf. 4. One plastic bag containing three green peppers and one orange pepper inside the kitchen on the second shelf. 5. One undated plastic container of fortified milk on top of kitchen table in the fruit and vegetable preparation zone. 6. One undated plastic container of sweetener on top of kitchen table in the fruit and vegetable preparation zone. 7. One undated plastic container of thickener on top of kitchen table in the fruit and vegetable preparation zone. 8. One undated tray of raw chicken inside walk-in freezer on the middle shelf. 9. One undated tray of three pieces of pastrami meat inside the walk-in freezer in the kitchen on the bottom shelf. 10. One tray of 11 fruit cups inside the kitchen refrigerator on the top shelf. The FSW stated properly labeling the food item with a use by or an expiration date would allow the staff to identify when the food items are expiring and when not to serve to the residents. The FSW stated expired food had the potential to cause harm to the residents. 2. During a concurrent kitchen observation and interview with Dietary Aide (DA) on 6/10/2025 at 2:30 PM, the following food items were observed undated or unlabeled: 1. One plastic container of fortified milk on top of kitchen table. 2. One undated plastic container of Sweetener. 3. One undated plastic container of thickener on top of kitchen table in the fruit and vegetable preparation zone. The DA stated, when food items were received, staff must label the food and all food items should have a label indicating received by and use by date to determine when the food would expire. The DA stated, using expred food could get the residents sick. During a kitchen interview with the Dietary Service Supervisor (DSS) on 6/10/25 at 2:41 PM, the DSS stated, labels were used to identify when food was not to be used or was expired. The DSS stated it was important not to use food that was expired because it could make the residents sick. During an interview with the Infection Prevention Nurse (IPN) on 6/11/25 at 10:46 AM, the IPN stated residents' food should be labeled with received date and expiration date because residents should not be served with expired food. The IPN stated, expired food could cause GI issues such as nausea, vomiting and dehydration, causing harm to the residents. If there was no expiration date on the food or if expired food was given to the residents, it could cause food poisoning and harm to the residents. During an interview with [NAME] 1 (C1) on 6/12/25 at 10:54 AM, C1 stated all food items should be labeled with open date and expiration date. C1 stated expired foods should be thrown right away. 3. During a kitchen observation on 6/12/25 at 11:57 AM, [NAME] 2 (C2) opened the facility's convection steamer and screamed of pain when a tray of green beans from inside the commercial convection steamer fell on her and onto the floor. During a follow up kitchen observation of the commercial convection steamer on 6/12/25 at 12:00 PM, the commercial convection steamer had missing five supporting rails on the left side of the steamer. During a concurrent observation and interview with the DSS on 6/12/25 at 12:10 PM, the DSS stated the commercial convection steamer should have been fixed and deemed safe to operate before dietary staff used it to prepare residents meals. The DSS also stated Maintenance Supervisor (MS) was aware of the missing rails and was waiting for the parts to fix it. During an interview with the FSW on 6/12/25 at 12:16 PM, the FSW stated due to the commercial convection steamer accident, the tray of green beans that fell to the floor would have to be remade causing the tray line to be late and the resident meal trays go out later than usual. The FSW also stated that since C1 had left the kitchen area to get medical assistance, the food items for dinner were not being prepared and therefore, dinner for the residents would also be late. During an interview with the DSS on 6/12/25 at 12:21 PM, the DSS stated when the facility does not maintain functional equipment in the kitchen area (the commercial convection steamer) it could lead to the residents' meal trays being served late. During an interview with the MS on 6/12/25 at 1:14 PM, the MS stated, malfunctioning of the commercial convectional steamer in the kitchen had the potential to affect residents' meals served late. During a review of the facility's Policy and Procedure (P&P) titled, Food Labeling and Dating Policy, with effective date of 10/01/1995, the P&P indicated, the facility has standardized procedures for labeling and dating all food items in the dietary department to ensure food safety, prevent foodborne illness, comply with California Department of Public Health regulations, and maintain quality standards for resident care. The P&P indicated, all food items entering, stored within, or prepared in the dietary department must be properly labeled with identification and date information according to established food safety standards and regulatory requirements. B. Storage of Foods 1.Dry Storage -Opened Packages: Label with opening date and discard date -Format: Opened: MM/DD/YY and Discard: MM/DD/YY 2. Refrigerated Storage (32-40F) -Fresh Produce: Label with receiving date and use-by date -Leftovers: Label with preparation date and discard date (maximum 3 days) Frozen Storage (0F or below): Fresh Items Being Frozen: Label with contents, freezing date, and recommended use-by date. Daily Procedures: -Check all labeled items daily for expiration -Remove and discard expired items immediately During a review of the facility's undated P&P titled, Storage, the P&P indicated food, and supplies will be stored in a safe and sanitary manner to ensure that food and supplies are safe to serve and use. Dry Storage: 1. Flour, sugar and dry bulk items will be stored in metal or plastic containers with tight fitting covers .A label will be secured to the container with the name of product and date stored. During a review of the facility's undated P&P titled, Storage, the P&P indicated food, and supplies will be stored in a safe and sanitary manner to ensure that food and supplies are safe to serve and use. Prevention of Contamination Guidelines: 2. Cover, label, date and refrigerate all leftovers as soon as serving is completed. 8. Store all pre-poured beverages and pre-portioned foods in refrigerator, covered and labeled until ready to serve. During a review of the facility's P&P titled, Building Systems General Maintenance Inspection, dated 1/1/99, the P&P indicated to maintain building systems in good working order, inspecting them at intervals which comply with state, federal and company standards to repair as necessary. The P&P indicated weekly inspections are conducted by maintenance staff on the condition of physical plant and equipment for residents and staff .and kitchen equipment, permanent or portable fixtures or equipment within the facility.

Based on interview, and record review, the facility failed to ensure one of three sampled resident's (Resident 39) discharge destination was coded correctly in Resident 39's Minimum Data Set (MDS, a resident assessment tool). Resident 39 was discharge home but the MDS was coded as Resident 39 being discharged short term to the general hospital. This deficient practice resulted in reporting that was not accurate to the Centers of Medicare and Medicaid (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency. Findings: During a review of Resident 39's admission Record (AR), the AR indicated Resident 39 was admitted to the facility 3/14/2025 with diagnoses that included hyperlipidemia (high levels of fats in the blood) and diabetes mellitus type 2 (a disease that results in elevated levels of glucose in the blood). During a review of Resident 39's Physicians Order (PO), dated 3/18/2025, the PO indicated to discharge Resident 39 home on 3/22/2025, per Resident 39's request. During a review of Resident 39's Discharge Summary, dated 3/18/2025, timed at 2:19 pm, the summary indicated Resident 39 was transferred home on 3/22/2025. During a review of Resident 39's MDS, dated [DATE], the MDS indicated Resident 39 was discharged to a short-term general hospital. During a concurrent interview and record review of Resident 39's MDS, with the MDS Coordinator (MDSC) on 6/11/2025 at 9:50 am, the MDSC stated Resident 39 was coded as discharged to a short-term general hospital. The MDSC stated, Resident 39 was discharged home on 3/22/2025 and not to the general hospital. The MDSC stated, Resident 39's MDS assessment needed to be coded as discharged home. The MDSC stated Resident 39's MDS assessment needed to be coded accurately, and CMS needed to be provided with accurate information. During a concurrent interview and record review of Resident 39's medical record (chart) with the Assistant Director of Nursing (ADON) on 6/12/2025, at 9:33 am, the ADON stated Resident 39 was discharged home on 3/22/2025 per Resident 39's request. The ADON stated, Resident 39 was discharged home after dialysis treatment. The ADON stated MDS assessments needed to be coded accurately. During a review of the facility's undated policy and procedure (P&P) titled, MDS and Resident Assessment Instrument (RAI) Process, the P&P indicated, all members of the Interdisciplinary Team (IDT, a team of health care professions who work together to establish plans of care for residents) shared responsibility for accurate completion of the RAI. The P&P indicated RN MDS Coordinator reviewed all sections of the MDS and signed to indicate completion of the assessment.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 17) was provided adequate supervision during activities of daily living (ADL, activities such as bathing, dressing, and toileting a person performs daily) by using a two-person assist to prevent a fall occurrence. This failure resulted in a fall which had the potential to result in severe harm or injury to Resident 17. Findings: During a review of Resident 17's admission Record (Face Sheet), the admission Record indicated the facility admitted Resident 17 on 4/17/2025 with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), morbid obesity (a disorder that involves having too much body fat), generalized muscle weakness (a decrease in muscle strength throughout the body), and lack of coordination (an inability to smoothly and precisely control body movements). During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool) dated 4/24/2025 , the MDS indicated Resident 17 was dependent (helper did all the effort, resident did none of the effort to complete the activity, the assistance of 2 or more helpers are required for the resident to complete the activity) with eating, oral hygiene, toileting, showering, upper/lower body dressing and personal hygiene. The MDS indicated Resident 17 was dependent on staff for rolling to the left and right side. During a review of Resident 17's MDS dated [DATE], the MDS indicated Resident 17 had moderately impaired cognition (ability to understand and process information). During a review of Resident 17's CT (Computed Tomography, a type of specialized x-ray) of the head with no contrast results indicated Resident 17 had no significant abnormality (findings are all normal). During a concurrent observation and interview with Resident 17 on 6/10/2025 at 10:59 a.m., Resident 17 was observed with dark colored areas on the left arm, Resident 17 stated about two weeks ago a lady (resident was unable to identify the staff) turned me to right side, and I slid and fell while the staff was changing my diaper. Resident 17 stated she slid and fell off the bed on her right side. Resident 17 stated she was taken to the emergency room, and had no broken bones. During an interview on 6/11/2025 at 3:23 p.m. with Certified Nursing Assistant 4 (CNA 4). CNA 4 stated Resident 17 needed 2-person assistance for all ADLs and bed mobility such as turning, repositioning, changing, and cleaning. CNA 4 stated she was providing ADL care to Resident 17 when the resident slid very slowly from the bed. CNA 4 stated she was alone providing care at that time. CNA 4 stated she was holding Resident 17's shoulders but the resident was a heavy person and could not prevent the fall. CNA 4 stated she called for assistance and the charge nurse came into the room, while another CNA brought the Hoyer lift (mechanical equipment used to transfer a person support the body from one place to another) to transfer the resident back into bed. During an interview on 6/11/2025 at 3:32 p.m. with Licensed Vocational Nurse (LVN 3), LVN 3 stated Resident 17 should be cleaned and provided ADL with 2-person assistance for the safety of the resident and to prevent fall. During a concurrent interview and record review on 6/11/2025 at 3:46 p.m. with the Assistant Director of Nursing (ADON), Resident 17's nurses' notes dated 6/1/2025 and care plans dated 4/21/2025 were reviewed. The ADON stated based on the documentation, Resident 17 was provided care by only one CNA. The ADON stated Resident 17's ADL should be performed by two CNAs, one to hold the weight of Resident 17 on the other side of the bed to prevent a fall. During a review of the facility's Policy and Procedure (P&P) titled, Activities of Daily Living (ADL) Supporting, revised on 3/2018, the P&P indicated, Appropriate care and services will be provided for residents who are unable to carry out ADL's independently .including appropriate support and assistance with .hygiene (bathing, dressing, grooming and oral care).

Based on observation, interview, and record review, the facility failed to ensure a Foley catheter (FC, a thin, flexible, rubber or plastic tube used to drain urine from the bladder [hollow muscular organ that acts as a reservoir for urine]) was secured on the resident's thigh for one of two sampled residents (Resident 141). This failure had the potential to result in catheter-related complications like tissue trauma and a physical decline to Resident 141. Findings: During a review of Resident 141's admission Record (AR), the AR indicated Resident 141 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (CKD, a progressive condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood), urine retention (inability to fully or partially empty the bladder) and dementia (a progressive state of decline in mental abilities). During a review of Resident 141's Care Plan (CP), dated 6/3/2025, the CP indicated Resident 141 had alteration in urinary elimination and required the use of a Foley catheter. The CP's approaches included to secure catheter tubing to Resident 141's leg to avoid pulling or trauma. During a review of Resident 141's History and Physical (H&P), dated 6/4/2025, the H&P indicated Resident 141 had urinary retention and used an indwelling Foley catheter. The H&P indicated Resident 141 appeared confused During a review of Resident 141's Minimum Data Set (MDS, a resident assessment tool), dated 6/9/2025, the MDS indicated, Resident 141 had an indwelling catheter (Foley catheter). During a concurrent observation inside Resident 141's room and interview on 6/10/2025 at 8:54 am with Licensed Vocational Nurse 1 (LVN 1), Resident 141 was sitting on the wheelchair and had a Foley catheter. LVN 1 stated the Foley catheter tubing was not secured on Resident 141's thigh. LVN 1 stated the Foley catheter's tubing should be secured properly to prevent pulling during movement that could cause trauma and bleeding. During an interview on 6/11/2025 at 1:29 pm with the Assistant Director of Nursing (ADON), the ADON stated, all indwelling catheters should be secured properly on the resident's (in general) thigh to hold the catheter in place and to prevent pulling and injury to the residents during movements and transfers. During a review of the facility's undated Policy and Procedure (P&P) titled, Catheter Care, General, the P&P indicated, Use leg straps to attached catheter tubing to residents' leg to avoid tension on catheter. Be sure [the] strap is attached comfortably and is not too tight.

Based on observation, interview, and record review, the facility failed to label the nasal cannula (NC, a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen [colorless, odorless gas]) tubing for one of one sampled resident (Resident 140). This failure had the potential for Resident 140 to result in infection. Findings: During a review of Resident 140's admission Record (AR), the AR indicated Resident 140 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure (CHF, long term condition that happens when the heart cannot pump blood well enough to give the body a normal supply sometimes resulting in leg swelling), cirrhosis of liver (a condition where the liver is permanently scarred or damaged), and obstructive sleep apnea (a sleep disorder characterized by repeated episodes of upper airway obstruction during sleep). During a review of Resident 140's Physician Order (PO), dated 6/9/2025, the PO indicated, Resident 140 had an order for oxygen at 2 liters (L, unit of measurement) via NC as needed. During a review of Resident 140's History and Physical (H&P), dated 6/10/2025, the H&P indicated, Resident 140 had limited decision-making capacity. During a concurrent observation inside Resident 140's room and interview on 6/10/2025 at 8:31 am, with Certified Nurse Assistant 1 (CNA 1), Resident 140 was lying in bed on his back with oxygen running at 2L via NC. CNA 1 stated the NC tubing was not labeled with a date to indicate when the tubing was last changed. During an interview on 6/11/2025 at 1:28 pm with the Assistant Director of Nursing (ADON), the ADON stated NCs, and other respiratory tubing should be labeled with the date to indicate when [the oxygen] was started or the tubing was changed and for infection control [purposes]. During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration, revised 9/2014, the P&P indicated, Label and date nasal cannula tubing and change every 7 days by Licensed Nurses.

Based on interview, and record review, Certified Nursing Assistant 1 (CNA 1) failed to provide care and services to prevent a fall (unintentionally coming to rest on a lower-level surface) for one of three sampled residents (Resident 1) by failing to: 1. Ensure CNA 1 provided two-person physical assistance (help from two person) when using a Hoyer Lift (mechanical lift, a device used by staff to transfer residents from a bed to a chair or other similar places) to transfer Resident 1 from Resident 1's bed to the Geri chair (large, padded chair with wheeled bases, and are designed to assist seniors with limited mobility/ability to move). 2. Ensure CNA 1 notified Licensed Vocational 3 (LVN 3) to place Resident 1's Low Air Loss mattress (LAL, mattress that operates using a blower-based pump that was designed to circulate a constant flow of air) on a firm mode (set in place and unable or unlikely to move), before CNA 1 turned Resident 1 to the right side of the bed to place the Hoyer lift net/sling (flexible strap used to support or raise the resident) under Resident 1 while the resident was lying on the LAL mattress. 3. Ensure CNA 1 followed the facility's Policy and Procedure (P&P) on Safety and Supervision of Residents, Hoyer Lift, and the Manufacturer's Operations Manual, titled Med Aire Plus 8 Alternating Pressure and Low Air Loss Mattress. As a result, on 12/19/2022 at 8:45 am, Resident 1 fell from the LAL mattress. The facility transferred Resident 1 to a General Acute Care Hospital (GACH) Emergency Department (ED) via ambulance, and was found to have left frontal (forehead) scalp (skin on the top of the head where hair grows) hematoma (collection of blood), periorbital (pertaining to or surrounding the eye) swelling, bilateral (both) nasal (nose) bone fracture (broken bone), and an acute (immediate) nondisplaced (bones broken but the pieces were not moved far enough) transverse fracture (bone is broken perpendicular to its length) through the patella (kneecap). Resident 1 experienced pain (not rated) on her left knee. Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 7/4/1998 and readmitted Resident 1 on 9/1/2022, with diagnoses including aphasia (a disorder that affects how you communicate), hemiplegia (paralysis on one side of the body), and hemiparesis (inability to move on one side of the body) following cerebral infarction (disrupted blood flow to the brain) affecting the right side of the body. A review of Resident 1's History and Physical, dated 9/7/2022, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Care Plan, titled Risk for Fall and Injury, revised on 9/26/2022, indicated for nursing staff to minimize falls and injuries by assisting Resident 1 in all transfers and mobility. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/8/2022, indicated Resident 1 had moderately impaired (poor decisions, cues/supervision required) cognition (ability to think and process information). The MDS indicated Resident 1 was totally dependent (full staff performance) with two or more persons physical assist for transfer (how the resident moves between surfaces including to or from: bed, chair, wheelchair or standing position). A review of Resident 1's Fall Risk Assessment, dated 12/8/2022, indicated Resident 1 was at high risk for falls due to Resident 1 requiring assistance due to visual impairment (eyesight is reduced) , balance problems with sitting, and ambulation (ability to walk. A review of Resident 1's Situation, Background, Appearance, Review (SBAR) and Notify Communication Form, dated 12/19/2022, timed at 2 pm, indicated on 12/19/2022 at 8:45 am, CNA 1 reported to Licensed LVN 3 that Resident 1 was on the floor. The SBAR indicated Resident 1 rolled off Resident 1's bed during morning care. The SBAR indicated LVN 3 found Resident 1 lying on the floor beside Resident 1's bed, facing up with blood flowing from the resident's face. The SBAR indicated Resident 1 had blood noted around and underneath the resident's head. The SBAR indicated Resident 1 had an abrasion (area damaged by scraping/wearing away) on the left knee, and discoloration (changing color in a bad way) on the left eye. Resident 1's nose had 0.8 centimeters (cm-unit of measurement) by 0.2 cm open wound with bleeding and Resident 1's left knee had 1.2 cm by 1 cm abrasion. The SBAR indicated Resident 1 moaned (made a long, low sound expressing physical or mental suffering) and cried. The SBAR indicated LVN 3 notified Resident 1's Primary Physician/Medical Doctor 1 (MD 1) and MD 1 recommended to transfer Resident 1 to a GACH ED for further evaluation. A review of Resident 1's Licensed Nurse Progress Notes, dated 12/19/2022, indicated on 12/19/2022 at around 8:45am, CNA 1 called LVN 3 to Resident 1's room to report a fall. The notes indicated LVN 3 found Resident 1 lying on the floor with blood on the resident's face. The notes indicated Resident 1 had a skin tear to the resident's nasal bridge (the upper, bony part of the human nose), bleeding from the lower lip, an abrasion to the left knee, and a raised area on Resident 1's left forehead. The notes indicated the facility transferred Resident 1 to the GACH ED, at 12:40 pm, via ambulance. A review of Resident 1's GACH Facial Bone's Computed Tomography (CT, a procedure that uses a computer linked to a machine to make a series of detailed pictures of areas inside the body) Report, dated 12/19/2022 at 2:27 pm, indicated Resident 1 fell from the bed, hit her face on the floor, and sustained moderate left frontal scalp hematoma, periorbital swelling, bilateral nasal bone fracture with mild displacement (moving away from the normal location/position) A review of Resident 1's GACH Left Knee X-ray (pictures of the inside of the body) Report, dated 12/19/2022 at 5:37 pm, indicated Resident 1 sustained an acute nondisplaced transverse fracture through the patella. A review of Resident 1's GACH ED Visit Summary, dated 12/19/2022, indicated for Resident 1 to follow-up with Head and Neck Surgery and Orthopedist (a doctor who specializes on injuries and diseases affecting the bones, muscles, and joints) as an outpatient (a patient who receives medical treatment without being admitted to a hospital) in three days, and to take clindamycin (an antibiotic medicine) three times a day for 10 days. A review of Resident 1's Licensed Nurse Progress Notes, dated 12/19/2022 at 10:30 pm, indicated Resident 1 returned to the facility from the GACH ED. A review of the facility's Investigation Report, dated 12/19/2022, indicated CNA 1 was putting the Hoyer lift's net under Resident 1, and Resident 1's LALM slightly slide side off the bed. The report indicated CNA 1 was unable to keep Resident 1 from rolling and falling off the bed. Resident 1 fell on her face, and CNA 1 yelled for help. A review of Resident 1's Physician Follow Progress Note, dated 12/20/2022 at 10:37 pm, indicated Resident 1 had bilateral (both) periorbital ecchymosis (discoloration of skin resulting from bleeding), both nares (nostrils) patent with dried blood. The note indicated Resident 1 groaned (made deep sound in response to pain or despair) in pain to light touch on the left knee. Resident 1's left knee had an immobilizer (a device used to support and protect a broken bone or injury). During an interview with Registered Nurse Manager (RN 1) on 1/5/2023 at 12:05 pm, RN 1 stated, LVN 3 notified her on 12/19/2022 at 8:45 am, that Resident 1 fell and was on the floor. RN 1 stated she immediately went to Resident 1's room and Resident 1's LALM's setting was on. RN 1 stated LVNs (in general) were responsible for the setting of the LALM. RN 1 stated the LALM settings needed to be paused while CNA 1 provided care for Resident 1 when the resident was lying in the bed for safety. RN 1 stated CNAs (in general) could not change, turn on/off the LALM's settings. During an interview with CNA 2 on 1/5/2023 at 1:20 pm, CNA 2 stated on 12/19/2022, he was the assigned Restorative Nurse Assistant (RNA- helps patients to maintain their function and joint mobility) for the facility. CNA 2 stated CNA 1 did not ask him for assistance to transfer Resident 1 via the Hoyer lift. CNA 2 stated it was the responsibility of the LVNs (in general) to change the LALM's settings. During an interview with LVN 1 on 1/5/2023 at 1:30 pm, LVN 1 stated Resident 1's LALM should be on static/pause mode while CNA 1 was changing or moving Resident 1 so that LALM or Resident 1 did not slip or fall off the bed. LVN 1 stated she could not remember when she was in-serviced (training and education) maybe two years ago, on the use of LALM. During an interview with CNA 1, on 1/5/2023 at 2:25 pm, CNA 1 stated on 12/19/2023, she assisted Resident 1 with morning care. CNA 1 stated she was standing on Resident 1's left side and rolled the resident onto the resident's right side while the resident was lying on the bed. CNA 1 stated while Resident 1 was on the resident's right side, CNA 1 placed the Hoyer lift's net/sling under Resident 1 and rolled the resident back on the resident's left side. CNA 1 stated she remained on Resident 1's left side while attempting to place Resident 1 on the Hoyer lift net/sling. CNA 1 stated she was not sure if the LALM was secured to the bedframe. CNA 1 stated she heard a humming, sound coming from the LALM. CNA 1 stated the mattress deflated (having been emptied of air or gas,) the head of the LALM had a bubble, the foot of the LALM was flat, and Resident 1 slid off the LALM and fell to the floor. CNA 1 stated CNAs (in general) were not supposed to touch the LALM controls/settings. CNA 1stated she was not sure if the LALM should be turned on or off while she was providing care to Resident 1. CNA 1 stated she did not ask anyone to turn the LALM's settings off while turning Resident 1 in bed. CNA 1 stated she did not remember if she received any in-services for the use of the LALM. During an interview with Registered Nurse 2 (RN 2) on 1/5/2023 at 4:41 pm, RN 2 stated CNAs (in general) could not operate the LALM controls/settings. RN 2 stated CNAs (in general) needed to inform LVNs (in general) when changing or moving a resident in bed on a LALM to prevent accidents and to keep the residents safe. During an interview with RN 1 on 1/5/2023 at 4:50 pm, RN 1 stated LVNs and CNAs did not receive in-services on the use of the LALM. A review of the facility's Policy and Procedure titled, Safety and Supervision of Residents, revised in July 2017, indicated the facility strives to make the environment as free from accidents hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Employees shall be trained on potential accident hazard and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. A review of the facility's Policy and Procedure titled, Hoyer Lift, dated October 2003, indicated the use of the Hoyer lift will be performed by at least two nursing assistants with the maximum use of safety principles. A review of the undated Manufacturer's Operations Manual titled, Med Aire Plus 8 Alternating Pressure and Low Air Loss Mattress, submitted by the facility, indicated for nursing staff to read the manual in its entirety before using the product. Turning the power switch on/off will start/stop the control unit. The switch lights up when the power is on, and extinguishes when the power is off. Press the auto-firm, button to set auto-firm mode to quickly inflate the air mattress to the maximum pressure which facilitates nursing and caring. The auto-firm indicator lights up (amber) when the system is in auto-firm mode. The system will automatically return to the previous mode 30 minutes after the auto-firm mode is in operation. It is also possible to cancel auto-firm mode by pressing the auto-firm button.

Based on observation, interview, and record review, the facility's Certified Nursing Assistant 1 (CNA 1) failed to prevent a fall accident when CNA1 did not use a gait belt (an assistive device which can be used to help safely transfer a person from a bed to a wheelchair, assist with sitting and standing, and help with walking around) and did not apply on the resident's waist to assist Resident 1 to the wheelchair at the resident's bathroom for one of four sampled residents. Resident 1 was at risk for fall, had balance problem with standing or walking, and required extensive assistance with transfer. This deficient practice resulted in Resident 1 falling and required him to be transferred to General Acute Care Hospital (GACH). Upon admission to the GACH, Resident 1 was having moaning, groaning, not answering questions, had pain on the knee and the urinary catheter site. Resident 1 had nondisplaced (type of fracture in which the bone cracks in only one place and doesn't move to change alignment) C5 (fifth neck bone) fracture (broken). Resident 1 was readmitted to the facility, on 9/29/20, and had to wear a hard-cervical collar (a device to prevent neck movement). Three days after readmission to the facility (10/2/20), Resident 1 developed left sided weakness and left lower extremity numbness (inability to feel), had difficulty with fine motor control of both hands and difficulty with gait. On 10/8/20, Resident 1 developed new onset left sided [MEDICAL CONDITION] (muscle weakness or [DIAGNOSES REDACTED] on one side of the body). Findings: A review of the Admission Record indicates Resident 1 was originally admitted to the facility, on 9/5/2015 with [DIAGNOSES REDACTED]. A review of Resident 1's At Risk for Injury from Falls Care Plan, dated 3/21/19, indicated the resident had unsteady balance, on cardiac (heart) medications (medication not indicated) and possible side effects can lead to falls and requires extensive transfer to use toilet. A review of Resident 1's At Risk for Injury from Falls Care Plan initiated 6/17/19 and revised 3/26/20, indicated Resident 1 was at risk for falls with a history of falls, was forgetful with poor safety judgment, had unsteady balance, on heart medications with falls as a possible side effect, and required extensive assistance from staff during transfers and toilet use. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 6/17/2020, indicated Resident 1 was cognitively (ability to understand, remember and make decisions) intact, uses a wheelchair (wc) for mobility, was able to make self-understood, able to understand others, and required extensive assistance with one person physical assistance for surface transfer and toilet use. The MDS indicated that Resident 1's Care Area Assessment (CAA) Summary indicated Resident 1 triggered for fall. A review of Resident 1's Physical Therapist Progress Notes, dated 7/19/20, indicated Resident 1 can be transferred from bed to and from chair 76 percent (%) to 99 % maximum assistance from staff. The resident and staff training included safety education and fall risk precautions. A review of the Fall Risk Assessment, dated 9/23/20, indicated Resident 1 scored 10 (score of 10 and greater indicates high risk for fall). The same form indicated Resident 1 had balance problems when sitting, standing or walking, on antihypertensive (medication for blood pressure), on anticoagulant (blood thinner) and has [MEDICAL CONDITION] (weak and brittle bones). A review of the Situation, Background, Assessment, Recommendation (SBAR) communication form dated 9/24/20, indicated Resident 1's change of condition included assisted fall and hematuria (blood in urine). The SBAR indicated Resident 1 was found on the floor in the bathroom in a sitting position with head resting on the shower chair. CNA 1 was trying to transfer Resident 1 back onto the wheelchair. Resident 1 was holding onto a side rail and got tired. CNA 1 sat the Resident 1 on the floor. A review of Resident 1's Licensed Nurses Progress Notes, dated 9/24/20 at 11:40 a.m., indicated CNA 1 was pulling the wheelchair when she noticed the resident going down and assisted Resident 1 to the floor. A review of Resident 1's Fall Scene Investigation (FSI) Report, dated 9/25/20, indicated the root cause of fall was due to Resident 1's poor balance and unsteadiness. The FSI report indicated CNA 1 trying to transfer Resident 1 to the wheelchair while Resident 1 was holding on the rail but got tired. CNA 1 assisted Resident 1 to sit on the bathroom floor. A review of Resident 1's Licensed Nurses Progress Notes, dated 9/25/20 at 8:00 am., indicated Resident 1 was confused, yelling but unable to describe the reason. Resident 1 was asked if he was in pain and responded with incomprehensible words. A review of Resident 1's Physician Telephone Order, dated 9/25/20 at 9:40 am., indicated an order to transfer Resident 1 to GACH emergency room for evaluation of altered level of consciousness (ALOC, a change in mental status). A review of the GACH's Internal Medicine H&P, date of service on 9/25/20 at 3:20 p.m. indicated Resident 1's chief complaint was altered mental status, fall, and urinary catheter problem. The H&P indicated the facility reported Resident 1 was noted moaning, groaning, not answering questions, was more altered and complained of pain on the knee and urinary catheter. The H&P indicated Resident 1's CT (Computed Tomography, a scan that provides detailed information about the bones of the spine) Cervical Spine result indicated Resident 1 has nondisplaced (bone crack that not move and maintains its proper alignment) C5 (fifth neck bone) vertebrae (interlocking bones that form the spine. The injury can result in some or total paralysis of wrists, hands, truck, and legs) fracture. Resident 1 had very slight drift (slow movement away from the normal or original position) of right arm. A review of Resident 1's GACH CT Cervical Spine study, dated 9/25/20 at 1:16 p.m., indicated Resident 1 had nondisplaced (type of fracture in which the bone cracks in only one place and doesn't move to change alignment) C5 fracture. A review of Resident 1's Physician Telephone Orders, dated 9/29/20, indicated the facility readmitted Resident 1 with [DIAGNOSES REDACTED]. The physician order [REDACTED]. The hard-cervical collar was to be kept in place on Resident 1's neck at all times. A review of Resident 1's MRI (Magnetic Resonance Imaging, uses a large magnet and radio waves to look at organs and structures inside a body) dated 10/2/20 in comparison with CT C-spine performed on 9/25/20, indicated Resident 1 had C5 to C6 focal (limited to one part of body) spinal stenosis (narrowing of the spaces within your spine). A review of Resident 1's Video Visit- Neurosurgery (surgery of the nervous system) Consultation Progress Notes, dated 10/2/20, indicated Resident 1 had cervical fracture with evidence of possible cord (spinal cord) contusion (bruise) on the MRI. Resident 1 had left sided weakness and left lower extremity numbness (inability to feel) and was evaluated for cervical spine injury. Resident 1 had a decline in his functional status and required extensive assistance for daily activities. Resident 1 had difficulty with fine motor control of his hands and difficulty with gait. A review of Resident 1's physician progress notes [REDACTED]. MRI was negative for stroke. Resident 1 had focal spinal stenosis. The note indicated Resident 1 had some evidence of cord compression (causing an increase in pressure). On 10/13/20 at 2:16 p.m., during an interview, CNA 1 stated she assisted Resident 1 onto a shower chair in the bathroom, on 9/24/20. CNA 1 stated she instructed Resident 1 to grab the side rail and stand. CNA 1 stated Resident 1 started to fall slowly and did not have the strength to hold Resident 1. CNA 1 stated she guided Resident 1 to the floor, and Resident 1's neck/head area ended up against the base of shower chair. CNA 1 stated she used a gait belt, when she transfers Resident 1 all by herself. CNA 1 stated, on 9/24/20, she did not use a gait belt, because she wanted to assist Resident 1 fast. On 10/13/20 at 3:02 p.m., during an observation, Resident 1 was in bed wearing a cervical collar. On a concurrent interview, Resident 1 stated CNA 1 was assisting him, could not hold him, fell on his butt and hit the floor hard. Resident 1 stated that he lost the strength on his legs. The Resident 1 stated he had fallen three times in the facility. Resident 1 complained of a headache. On 10/13/20 at 3:22 p.m., during an interview, CNA 2 stated that Resident 1 required extensive assistance and cannot stand-up by himself. CNA 2 stated she used two persons and a gait belt to transfer the Resident 1 in the bathroom. CNA 2 stated Resident 1 complained of neck pain. On 10/21/20 at 4:34 p.m., during an interview, the Physical Therapist (PT) stated it was a judgement call to use a gait belt when transferring a resident. The PT stated Resident 1, Is a big guy, and required a gait belt for transfers. The PT sated using a gait belt was important because, That would be the safest way. A review of Resident 1's MDS, dated [DATE], indicated Resident 1 had a significant change, had moderate cognitive impairment, used a wheelchair for mobility, was able to make self-understood, able to understand others, and required extensive assistance with two or more persons physical assistance for surface transfer and toilet use. On 10/26/20 at 1:40 p.m., during an interview, CNA 3 stated she was familiar with Resident 1. CNA 3 stated Resident 1 had minimal movement to his arms and legs, moved just a little bit during transfers, and required two people for surface transfers. CNA 3 stated Resident 1 was not able to stand, move, or pull by himself. CNA 3 stated Resident 1 tried to help, but Resident 1 was not steady on his feet. Resident 1 required support from two persons all the time. Resident 1 was at risk for fall. On 10/26/20 at 2:01 p.m., during an interview, CNA 1 stated Resident 1 was able to stand, transfer with one person assist, was steady on his feet, was able to turn from side to side in bed, pull, and grab prior to the fall. A review of the facility's Transfer of Resident from/to Bed revised date 5/1991, indicated to assess a resident's capabilities and provide the form of transfer best suited to his needs and to maintain resident safety during the procedure. The policy indicated that it was the facility's policy to assess and provide appropriate and safe transfer techniques for each resident based on individual need. When assisting a resident to a chair, apply a gait belt around the resident's waist securely enough to prevent sliding up over ribs.