Every finding on record at Extended Care Hospital of Riverside

Based on observation, interview, and record review, the facility failed to ensure the radiology report identifying a non-displaced fracture (break in the continuity of the bone) at distal ulnar diaphysis were appropriately communicated to the physician for one of three residents reviewed for falls (Resident 1). This failure had the potential to result in delayed provision of appropriate interventions which could have adversely impacted Resident 1's health status. Resident 1 was transferred to the general acute care hospital (GACH) on July 16, 2026 (2 days after the radiology report came out).Findings:On July 27, 2026, at 12:01 p.m., an unannounced visit to the facility was conducted to investigate a complaint for a quality-of-care issue.A review of Resident 1's admission Record indicated resident was admitted on [DATE], with diagnoses which included aftercare following surgical above the knee amputation left limb, diabetes mellitus type 2 (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough insulin to maintain normal sugar levels), and arthritis (a broad category covering any disorder that damages the smooth cartilage, lining, or tissues surrounding where two bones meet).A review of Resident 1's History and Physical dated July 15, 2026, indicated resident had capacity to make decisions.On July 27, 2026, at 1:23 p.m., during observation, Resident 1 was observed in bed with a sugar tong splint (a long, U-shaped orthopedic device used to immobilize the wrist and forearm) to the left arm, and above the knee amputation (AKA) on the left limb. During a concurrent interview with Resident 1 with a Certified Nursing Assistant (CNA 1) present at bedside to assist in translating in Spanish, Resident 1 stated that she fell in the bathroom, and was unable to reach the call light, but her roommate called for help. She stated that the staff assisted her back to bed and an x-ray of her left arm was taken. Resident 1 stated she did not feel pain until after a couple of hours after the incident and worsened over two days. She stated she informed the nurse and she was taken to the hospital, where a splint and medication were provided for the fracture. A review of Resident 1's Nurses Progress Notes dated July 13, 2026, at 10:04 p.m., indicated, AROUND 7:40 PM PATIENT HAD UNWITNESSED FALL, WAS FOUND SITTING ON THE FLOOR OF HER RESTROOM STATED SHE LOSS BALANCE AND SLIDE ON THE FLOOR. SKIN ASSESSMENT DONE NO BLEEDING NOTED, PATIENT STATED SHE DID NOT HIT HER HEAD. ABLE TO MOVE HER BILATERAL UPPERAND (sic) LOWER EXTREMITY. PATIENT COMPLAINTS OF PAIN 8/10 ON HER LEFT HAND. STATED SHE HIT HER HAND ON THE TOILET BOWL. EDUCATE TO ASK FOR ASSISTANCE WHEN HELP IS NEEDED. NEURO CHECK INITIATED. MD [name] MADE AWARE AND ORDER STAT X RAY OF THE LEFT HAND.A review of the Medication Review Report dated July 28, 2026, indicated, .STAT X RAY OF THE LEFT HAND AND RADIUS ON 7/13/26 DUE TO PAIN S/P FALL.07/13/2026.On July 27, 2026, at 3:42 p.m., an interview was conducted with Registered Nurse (RN 1). RN 1 stated that radiology results are usually available the same day or next day and fractures are considered critical. RN 1 stated that the doctor should be notified immediately of a critical result; and if the physician did not respond within 30 minutes, the physician should be contacted again. A review of Resident 1's Radiology Result Report with a reported date of July 14, 2026, at 1:51 a.m., indicated, .examination completed July 13, 2026, at 8:26 p.m.Examination LEFT HAND.Clinical Indication: status post fall.Impression: Impression:1. Study significantly limited as only frontal view has been submitted for interpretation.2. Acute, obliquely oriented non-displaced fracture at distal ulnar diaphysis.3. Linear lucency across head of 1st proximal phalanx may be entirely projectional - due to radiographictechnique and positioning, although an acute hairline fracture can have this appearance.4. No other acute fracture or dislocation.5. Moderate osteoarthritis - as demonstrated. On July 27, 2026, at 2:39 p.m., during interview with RN 2. RN 2 stated that the Radiology Results would indicate when the results were faxed to the facility. RN 2 confirmed that the radiology report for Resident 1 was reported on July 14, 2026, at 1:51 a.m.On July 27, 2026, at 4:13 p.m., an interview was conducted with the Director of Nursing (DON). The DON confirmed that Resident 1's radiology results were reported to the facility on July 14, 2026, at 1:51 a.m. The DON could not verify that Resident 1's physician was aware of the radiology results. The DON confirmed that Resident 1 was sent to the Emergency Department on July 16, 2026, when Resident 1 had increased left wrist pain.A review of Resident 1's Nurses Progress Note dated July 14, 2026, at 5:05 a.m., indicated, Resident Left hand Xray result is out during the shift and was reported to MD for review awaiting MD responseOn July 28, 2026, RN 3 stated that Resident 1 fell during the evening shift on July 13, 2026. RN 3 stated an X-ray of the left hand was done, with results being available on July 14, 2026. RN 3 confirmed that she had documented sending the results to Resident 1's physician and reported them to the next shift. She stated that follow-up with the physician is necessary if there is no response to critical results but admitted she did not follow up this time. Resident 1 was sent to the Emergency Department on July 16, 2026, and received a splint for the left arm.A review of Resident 1's Change of Condition Evaluation dated July 16, 2026, at 1:39 p.m., indicated, .Abnormal Results.7. XRAY. 1. New or unsuspecting finding (e.g. fracture.) . Summarize your observations, evaluation and recommendations: pt has nondisplaced fracture to left hand.2. Date and time of clinician notification July 16, 2026, 1 p.m 3. Recommendation of Primary Clinician(s): [NAME] (sic) out to [name of hospital] .A review of the facility's policy and procedure titled Radiology and other Diagnostic Services and Reporting revised December 19, 2022, indicated .Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results.

Based on interview and record review, the facility did not accurately assess the fall risk status of one of the three residents reviewed for falls, (Resident 1) when the resident had a fall on July 13, 2026. This failure placed Resident 1 at risk for unprevented falls. Findings:On July 27, 2026, at 12:01 p.m., an unannounced visit to the facility was conducted to investigate a complaint on a quality-of-care issue.A review of Resident 1's admission Records indicated resident was admitted on [DATE], with diagnoses which included aftercare following surgical above the knee amputation left limb, diabetes mellitus type 2 (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough insulin to maintain normal sugar levels), and arthritis (a broad category covering any disorder that damages the smooth cartilage, lining, or tissues surrounding where two bones meet).A review of Resident 1's History and Physical dated July 15, 2026, indicated resident had capacity to make decisions.A review of Resident 1's Fall Risk Assessment dated June 3, 2026, indicated a score of 9 with Risk Category: N/A [not applicable]A review of Resident 1's Nurses Progress Notes dated July 13, 2026, at 10:04 p.m., indicated, AROUND 7:40 PM PATIENT HAD UNWITNESSED FALL, WAS FOUND SITTING ON THE FLOOR OF HER RESTROOM STATED SHE LOSS BALANCE AND SLIDE ON THE FLOOR. SKIN ASSESSMENT DONE NO BLEEDING NOTED, PATIENT STATED SHE DID NOT HIT HER HEAD. ABLE TO MOVE HER BILATERAL UPPERAND (sic) LOWER EXTREMITY. PATIENT COMPLAINTS OF PAIN 8/10 ON HER LEFT HAND. STATED SHE HIT HER HAND ON THE TOILET BOWL. EDUCATE TO ASK FOR ASSISTANCE WHEN HELP IS NEEDED. NEURO CHECK INITIATED. MD [name] MADE AWARE AND ORDER STAT X RAY OF THE LEFT HAND.A review of Resident 1's Fall Risk Assessment dated July 13, 2026 (completed after the fall incident), indicated a score of 9 with Risk Category: N/A.2. History of falls (past 3 months) 1. No falls in past 3 months.On July 27, 2026, at 3:42 p.m., during an interview, Registered Nurse (RN 1) stated that after Resident 1's fall on July 13, 2026, a Fall Risk Assessment was completed. RN 1 stated that the Fall Risk Assessment for Resident 1 was not accurate, and it should have indicated that Resident 1 had one to two falls in the last three months, instead of zero falls in the last three months. On July 27, 2026, at 4:13 p.m., an interview was conducted with the Director of Nursing (DON). The DON confirmed that Resident 1's Fall Risk assessment dated [DATE], indicated that Resident 1 had no falls in the past three months, and should have indicated Resident 1 had one to two falls within the past three months.A review of the facility's policy and procedure titled Fall Prevention Program, revised April 20, 2026, indicated .Each resident will be assess for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of fall. 2. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. The risk assessment will contain the following components:a. Identify environmental hazards and individual risks, including the need for supervisionb. Evaluate and analyze hazards and risks.3. The nurse and/or interdisciplinary team will initiate interventions on the resident's care plan, m accordance with the resident's level of risk.7. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care.8. When any resident experiences a fall, the facility will:a. Assess the resident.b. Complete a post-fall assessment.

Based on observation, interview, and record review, the facility failed to ensure an environment free of accident hazards and to ensure resident receives adequate supervision and assistance devices, for three of three residents reviewed for accidents (Residents 34, 85 and 24) when:1.Resident 34 was found to have cigarettes and a lighter at bedside. This failure had the potential to place Resident 34 and other residents at risk for harm and injuries.2.Resident 85 did not receive adequate supervision and effective fall prevention interventions.This failure resulted in Resident 85 sustaining a fall with facial injuries requiring hospital transfer. 3.Resident 24, assistance device (call light) was not within reach.This failure had the potential to result in the resident being unable to request for assistance, placing her at risk for injury.Findings: 1.On February 9, 2026, at 9:44 a.m., a concurrent observation and interview with Resident 34 was conducted in her room. Resident 34 stated she smokes cigarettes with supervision and was observed to have cigarettes and a lighter at bedside. A review of Resident 34's admission Record dated February 12, 2026, indicated an admission date of December 23, 2025, with diagnoses which included metabolic encephalopathy (brain dysfunction). A review of Resident 34's History and Physical dated December 24, 2025, indicated resident had the capacity to understand and make decisions. A review of Resident 34's Smoking assessment dated [DATE], indicated, .Safety factors.burns skin, clothing, furniture or other.drops ashes on self.Recommendation.smoke with supervision. On February 11, 2026, at 11:13 a.m., a concurrent interview and record review with Licensed Vocational Nurse (LVN) 15 was conducted. LVN 15 stated residents are not allowed to keep cigarettes and lighters at bedside. LVN 15 stated all staff are responsible for ensuring smoking paraphernalia is not kept at bedside without staff knowledge. LVN 15 stated is a resident does not want to surrender smoking paraphernalia to staff, an Interdisciplinary Team (IDT) meeting should be completed and should be care planned. LVN 15 stated there was no documented evidence that an IDT meeting was conducted, or care plan was initiated related to Resident 34 keeping her smoking paraphernalia at bedside. LVN 15 stated she was not aware Resident 34 had cigarettes and a lighter at bedside and Resident 34 should not have had these items at bedside, since an IDT was not done and it was not included in the care plan. LVN 15 stated it was important to follow the facility's protocol for managing smoking paraphernalia to prevent resident harm and risks for safety and fire. On February 12, 2026, at 10:47 a.m., an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated if a resident is alert and oriented times four and requested to have their smoking paraphernalia at bedside, staff should have conducted an IDT meeting, informed the physician, initiated a care plan, and provided education on safety. The ADON stated there was no documented evidence that an IDT meeting was conducted, the physician was notified, and a care plan initiated. The ADON stated Resident 34 should not have had cigarettes and a lighter at bedside. The ADON stated this was important to ensure safety for all residents. A review of the facility's policy and procedures titled, Resident Smoking, dated October 20, 2025, indicated, .provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking.Smoking materials.maintained by designated staff. 2. A review of Resident 85's admission Record dated February 17, 2026, indicated the resident was admitted to the facility on [DATE], with diagnoses including abnormalities of gait and mobility. A review of Resident 85's History and Physical dated October 24, 2025, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 85's Fall Risk Assessment, dated October 23, 2025, indicated Resident 85 was at risk for falls. A review of Resident 85's Minimum Data Set (an assessment tool) dated January 10, 2026, indicated Resident 85 required supervision or touching assistance for chair/bed to chair transfer. A review of Resident 85's SBAR (Situation, Background, Appearance, Review and Notify) Communication Form, dated January 26, 2026, indicated .At approximately 11:15, resident had an unwitnessed fall and was found laying (sic)on the floor in a prone position .Verbal and able to follow commands. No changes to LOC (level of consciousness) .send to ER . A review of Resident 85's Care plan indicated there was no revisions of the care plan addressing the resident's behavior of attempting to transfer independently without supervision after becoming aware of the resident's behavior prior to the fall. On February 11, 2026, at 12:05 p.m., an interview was conducted with CNA 3, CNA 3 stated Resident 85 fell face forward while attempting to transfer from her wheelchair to the bed and sustained facial injuries. CNA 3 stated Resident 85 could perform transfers with supervision. CNA 3 stated Resident 85 was a fall risk, and it was not safe to be left unattended in the wheelchair. CNA 3 stated she previously observed Resident 85 transfer herself from the wheelchair to the toilet without supervision and did not report to the licensed nurse and she should have. On February 11, 2026, at 12:15 p.m., an interview was conducted with CNA 4. CNA 4 stated on January 26, 2026, she heard a noise coming from Resident 85's room and found the resident on the floor. CNA 4 stated the resident had black eyes, swelling to the nose, knot on the head, and nose was bleeding. CNA 4 stated the resident was sent to the hospital. CNA 4 stated Resident 85 had a history of attempting to get up on without staff assistance and that staff were aware of this behavior. On February 11, 2026, at 2:48 p.m., an interview was conducted with CNA 5. CNA 5 stated she was aware Resident 85 would attempt to stand from the wheelchair independently. CNA 5 stated, on January 26, 2026, she was covering for Resident 85's assigned CNA. CNA 5 stated she last saw the resident in the dining room and did not know when the resident returned to her room as she was assisting another resident. On February 12, 2026, at 10:47 a.m., an interview with the Assistant Director of Nursing (ADON) was conducted. ADON stated CNAs were expected to report unsupervised transfer attempts to the licensed nurse so that a fall risk assessment could be completed and the behavior care planned. The ADON stated Resident 85's behavior of attempting to transfer independently should have been reported and addressed through updated care planning. The ADON stated Resident 85 should not have been left unattended in her wheelchair and her attempts to get up without supervision should have been reported to the nurse. The ADON stated this was important to prevent accidents, harm, and falls. A review of the facility's policy and procedure titled, Fall Prevention Program, dated December 28, 2023, indicated, Each resident .will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . provide additional interventions as directed by the resident's assessment . A review of the facility's policy and procedure titled, Fall Risk assessment dated [DATE], indicated, . provides supervision . to each resident to prevent avoidable accidents . risk assessment will be completed by the nurse . when a significant change is identified . risk assessment will contain .individual risks, including the need for supervision .fall care plan will include interventions, including adequate supervision . to reduce the risk of an accident . 3. On February 10, 2026, at 8:35 a.m., Resident 24 was heard yelling from inside her room. Upon entering, Resident 24 was observed in bed with her call light hanging to the side of the bed and not within reach. Resident 24 stated she wanted her bedside table moved. Resident 24 stated she was unable to locate her call light. A review of Resident 24's admission Record, indicated Resident 24 was admitted to the facility on [DATE], with diagnoses which included frequent falls. A review of Resident 24's History and Physical, dated January 20, 2026, indicated Resident 24 does not have the capacity to understand and make decisions. A review of Resident 24's Care Plan dated January 28, 2026, indicated .The resident is at risk for falls r/t (related to) Gait/balance problems, Unaware of safety needs, History of Fall .Place resident's call light is within reach.The resident needs prompt response to all requests for assistance . On February 10, 2026, at 8:37 a.m., during a concurrent observation and interview with Licensed Vocational (LVN) 1, LVN 1 stated Resident 24's call light was not within reach, and it should have been. LVN 1 stated if the call light was not within her reach, the resident would be unable to request assistance, including during an emergency. A review of facility Policy and Procedure titled Call Lights: Accessibility and timely Response, dated December 19, 2022, indicated .Staff will ensure the call light is within reach of resident and secured as needed.

Based on observation, interview, and record review, the facility failed to ensure: 1. Physician orders with parameters were followed when medications were administered without documenting the systolic blood pressure for one of three residents reviewed after medication pass observation. This failure had the potential for residents to inadvertently receive medications when they need to be held according to the physician's orders. 2. medications contained in the medication carts were not discontinued or discharged and not stored in the cart along with active residents' medications. This failure had the potential for discontinued medications to be used as not intended; 3. there was accurate accounting of Scheduled II controlled substances (federal designation of a class/classes of medications with the highest addictive potential) to minimize misuse and abuse when one dose of Resident 58's generic Norco (potent opioid used to treat severe pain) 5 mg was removed from the blister card without documentation of administration in the resident's medical record. 4. Lidoderm (topical patch to treat local pain) 5% patches were applied to Resident 63 for 12 hours as instructed in the physician order. This failure had the potential for the resident to receive inadequate pain control.1. On February 9, 2026, at 10 a.m., during a medication pass observation, LN 15 prepared and administered to Resident 79 eight oral medications including carvedilol (medication to treat high blood pressure) 3.125 mg. It was observed six of the eight medications were crushed and mixed with apple sauce. On February 9, 2026, a review of Resident 79's electronic medical record (EMR) indicated: Resident 79 was [AGE] years old, admitted to the facility on [DATE], with diagnoses which included atherosclerotic (hardening of blood vessels) heart disease of native coronary (heart) artery and essential hypertension (high blood pressure); Resident 79 had a physician order on [DATE], to receive carvedilol (medication to treat high blood pressure and heart disease) 3.125 mg (milligram, unit of measurement) one tablet by mouth two times a day for hypertension and hold if SBP (systolic blood pressure, the top number of the blood pressure reading, maximum pressure in your arteries when your hear contracts and pumps blood) is less than 110 mm Hg (millimeter mercury, blood pressure measurement) or if the heart rate is less than 60 beats per minute; Resident 79's [DATE] the medication administration record (MAR) for carvedilol did not document SBP; and Resident 79's February 2026 the MAR did not document SBP. On February 9, 2026, at 3 p.m., during an interview, LN 15 stated there was no place in the MAR to document SBP. LN 15 stated one would not be able to document SBP since there was no field to document in MAR. The facility's policy and procedure titled, Medication Errors, undated, was reviewed, and it indicated: .To prevent medication errors and ensure safe medication administration, nurses should verify the following information .right documentation . The facility's policy and procedure titled, Medication Administration, effective, [DATE], was reviewed, and it indicated: .Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice .Obtain and record vial signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters . 2. On February 10, 2026, at 1 p.m., during an inspection of the medication cart (Cart 1) located at Nursing Station 1, there was a bottle of megestrol (medication to increase appetite) 40 mg/ml (milligram per milliliter, unit of measurement) and one blister card containing hydroxyzine (medication to treat skin rash or itching) for Resident 17. During a concurrent interview, LN 16 stated both medications were discontinued and not active. LN 16 stated they should not have been in Cart 1 and discarded properly. Resident 17's medical record was reviewed on February 10, 2026, and it indicated hydroxyzine 25 mg was discontinued on [DATE] and megestrol 40 mg/ml was discontinued on [DATE]. The facility's policy and procedure titled, Discontinued Medications, revised, [DATE], was reviewed, and it indicated: .When medications are expired, discontinued by a prescriber .the medications are marked as discontinued or stored in a separate location and later destroyed . 3. On February 10, 2026, at 1:20 p.m., during an inspection of the medication cart (Cart 1) located at Nursing Station 1, there were two blister cards containing generic Norco 5 mg tablets and the corresponding Controlled Drug Record (CDR) for Resident 58's generic Norco 5 mg blister cards. Review of the generic Norco 5 mg CDR indicated one dose was removed and signed out by a licensed nurse on February 4, 2026, at 9 p.m. On February 10, 2026, Resident 58's medical record was reviewed, and it indicated: Resident 58 had a physician order on [DATE] for generic Norco 5 mg with the direction to give one tablet every 6 hours as needed for severe pain; There was a physician order on February 1, 2026 to discontinue the generic Norco 5 mg and there was no new or continuing order for the generic Norco 5 mg; and The Resident 58's medication administration record for generic Norco 5 mg indicated the last day the medication order was active was February 1, 2026, and no documentation of administration of generic Norco 5 mg was present after February 1, 2026. On February 10, 2026, at 2:50 p.m., in an interview, LN 16 confirmed one dose of the generic Norco 5 mg was removed from the blister card, signed out on the CDR by a licensed nurse on February 4, 2026, after the generic Norco 5 mg was discontinued, and no documentation of administration on Resident 58's medical record. LN 16 agreed due to the absence of documentation, there was no way to tell if the medication was administered to Resident 58 or another resident. The facility's policy and procedure, titled, Controlled Substance Administration & Accountability, revised, [DATE], was reviewed, and it indicated: .All controlled substances (Schedule II, III, IV, V) are accounted for .All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided .In all cases, the dose noted on the usage form .must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record . 4. On February 11, 2026, Resident 63's medical record was reviewed, and it indicated: Resident 63 was [AGE] years old, admitted to the facility on [DATE], with diagnoses which included hemiplegia (paralysis of one side) following cerebral infarction (stroke) and symptoms and signs involving musculoskeletal (related to muscles and bones) system; The resident had a physician order on [DATE] for Lidoderm Patch 5% with the direction to apply to lower lumbar (lower back) topically on in AM (morning), off at HS (bedtime) for back pain and remove per schedule; The Resident 63's medication administration record (MAR) for [DATE], indicated Lidoderm patches were applied at 9 a.m. and removed at 6 p.m.; The Resident 63's MAR for February 2026, indicated Lidoderm patches were applied at 9 a.m. and removed at 6 p.m. On February 12, 2026, at 4:05 p.m., in an interview, LN 17 stated dosing time of HS (bedtime) would be 8 or 9 p.m. On February 12, 2026, at 4:10 p.m., in an interview, the ADON stated dosing time of HS would be 9 p.m. On February 11, 2026, at 12:15 p.m., in an interview, the ADON stated the Lidoderm patch order was revised for the patch to be applied for 12 hours for the resident.The manufacturer's prescribing information for Lidoderm Patch 5% indicated, Apply Lidoderm to intact skin to cover the most painful area. Apply the prescribed number of patches (maximum of 3), only once for up to 12 hours within a 24 hour period. The facility's policy and procedure titled, Medication Administration - General Guidelines, effective, [DATE], was reviewed, and it indicated: .Medications are administered as prescribed in accordance with good nursing principles and practices .Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule .

Based on observation, interview, and record review, the facility failed to ensure medications that required refrigeration were not stored outside of the refrigerator at room temperature. This failure had the potential for residents to receive ineffective medications.On February 10, 2026, at 12:40 p.m., during an inspection of the medication cart (Cart 1) located at Nursing Station 1, there was an amber bottle containing approximately 80 ml (milliliter, unit of measurement) of gabapentin (medication to treat seizure) 250 mg (milligram, unit of measurement) per 5 ml solution for Resident 55. The gabapentin bottle had an auxiliary label that indicated, Refrigerate. During a concurrent interview, LN 16 confirmed the bottle was stored in Cart 1 at room temperature and stated it should have been in the medication refrigerator. The facility's policy and procedure titled, Medication Storage, effective, December 19, 2022, was reviewed, and it indicated: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper .temperature .All medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room . According to the manufacturer's prescribing information for gabapentin oral solution indicated, Store refrigerated .

Based on interview and record review, the facility failed to provide a written notice of transfer and failed to provide a written bed-hold notice to one of three residents reviewed for discharges (Resident 111) and or the resident representative at the time of transfer to the hospital.These failures had the potential to deny the resident the right to be informed of transfer and bed-hold rights, including the right to reserve and return to a bed. Findings:A review of Resident 111's admission Record dated February 13, 2026, indicated the resident was admitted on [DATE], with diagnoses including cirrhosis of the liver (irreversible liver damage).A review of Resident 111's History and Physical dated December 8, 2025, indicated the resident had fluctuating capacity to understand and make decisions.A review of Resident 111's Physician Progress Note dated December 18, 2025, indicated, .patient's family recently expressed concerns that she needs a paracentesis (a medical procedure in which a needle is inserted into the abdominal cavity to remove excess fluid) and requested hospital transfer.A review of Resident 111's SNF/NF to Hospital Transfer Form dated December 18, 2025, indicated resident was transferred to hospital for paracentesis.There was no documented evidence that a written notice of transfer was provided to the resident or resident representative (RP).On February 13, 2026, at 3:13 p.m., a concurrent interview and record review were conducted with the Assistant Director of Nursing (ADON). The ADON stated it was the licensed nurse's responsibility to provide the written notice of transfer to the resident and RP prior to the resident leaving the facility. The ADON stated there was no documented evidence that the notice of transfer was provided and stated the notice should have been provided to ensure a safe discharge. A review of the facility's policy and procedure titled, Transfer and Discharge (including AMA), dated December 19, 2022, indicated, The facility's transfer/discharge notice will be provided to the resident and the resident's representative.provided.prior to facility-initiated transfer or discharge.must be provided to the resident, resident's representative if appropriate. 2.A review of Resident 111's admission Record dated February 13, 2026, indicated an admission date of December 7, 2025, with diagnoses including cirrhosis of the liver (irreversible live damage).A review of Resident 111's History and Physical dated December 8, 2025, indicated the resident had fluctuating capacity to understand and make decisions.A review of Resident 111's SNF/NF to Hospital Transfer Form dated December 18, 2025, indicated resident was transferred to hospital for paracentesis and resident representative was notified of transfer.There was no documented evidence that a written bed-hold notice was provided to the resident or representative party (RP) at the time of transfer.On February 13, 2026, at 4:26 p.m., an interview with the Director of Nursing (DON) was conducted. The DON stated the licensed nurse was responsible for completing the bed-hold form and informing the resident or RP prior to transfer to the hospital. The DON stated there was no documented evidence that a bed-hold notice was provided to Resident 111 or the RP. The DON stated a bed-hold notice should have been provided to Resident 111 or the RP to inform the resident of the right to reserve and return to a bed and promote continuity of care.A review of the facility policy and procedures titled, Bed Hold Notice Upon Transfer, dated December 19, 2022, indicated, .At the time of transfer for hospitalization.the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy.the facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file.

Based on interview and record review, the facility failed to ensure appropriate Pre-admission Screening and Resident Review (PASARR) and referral for one of three residents reviewed for PASARR (Resident 5) when the resident was admitted with documented diagnoses of major depressive disorder and psychosis and was not referred to the State-Designated Authority (SDA) for a PASARR Level II evaluation. This had the potential to prevent a determination of the resident's need for specialized mental health services and prevented incorporation of PASARR recommendations into the resident's comprehensive care plan. Findings:On February 11, 2026, Resident 5's record was reviewed. Resident 5 was admitted on [DATE], with diagnoses that included unspecified psychosis (loss of contact with reality) and major depressive disorder (a mood disorder). The document titled, History and Physical, dated December 4, 2025, indicated .Medical History .psychosis .has fluctuating capacity to understand and make decisions. The PASARR Level I, dated November 13, 2025, indicated, . Diagnosed Serious Mental Illness. Does the Individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance .No. The document titled, Adult Psychosocial Assessment. Dated November 12, 2025, indicated, .resident endorses depression.diagnosis.major depressive disorder, recurrent, moderate.difficulties including feeling sad, depressed, feeling overwhelmed, irritability and difficulty concentrating, endorses sleep disturbances, fatigue, stay in bed all day, low motivation, feeling on edge and depressed mood.plan to continue Vilazodone (antidepressive medicine) oral tablet 20 mg (milligrams - a unit of measurement) daily. There was no documented evidence that the facility corrected PASARR screening or referred Resident 5 to the SDA for PASARR level II evaluation upon identifying the mental health diagnoses. On February 11, 2026, at 11:44 a.m. an interview and record review was conducted with the Minimum Data Set Coordinator (MDS). The MDS stated Resident 5 had a negative PASARR level one screening that was completed by the hospital and received by the facility prior to admission. The MDS Coordinator stated the MDS, Section I indicated Resident 5 had a diagnosis of Psychosis and Major depressive disorder entered on November 11, 2026. The MDS Coordinator further stated a new PASARR screening and referral should have been conducted and that it was not. A review of the facility policy and procedure titled, Resident Assessment - Coordination with PASARR Program, dated December 2023, indicated, .The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID or a related condition to the appropriate stated-designated authority for Level II PASARR evaluation and determination.any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review.a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder.

Based on interview and record review, the facility failed to monitor and assess an intravenous (IV - intravenous catheter inserted into the vein to deliver fluids and medication) site for one of one resident reviewed for parenteral (administered by injection) fluids (Resident 124) according to facility policy.This failure had the potential to result in undetected IV-related complications including infection, infiltration, or inflammation of a vein.Findings:A review of Resident 124's admission Record dated February 12, 2026, indicated the resident was admitted on [DATE], with a diagnosis which included urinary tract infection (UTI - an infection in the urinary tract).A review of Resident 124's History and Physical dated February 3, 2026, indicated resident had the capacity to understand and make decisions.A review of Resident 124's Physician Orders dated February 13, 2026, indicated an order for Ertapenem (a broad-spectrum antibiotic used to treat serious bacterial infections) 500 milligrams (mg - a unit of measurement) intravenously every 24 hours for UTI for 7 days and no order for monitoring the IV site.A review of Resident 124's February 2026 Medication Administration Record (MAR) indicated Ertapenem 500 mg intravenously was administered daily from February 4, 2026, to February 9, 2026.There was no documented evidence that the IV site was monitored or assessed during the period the IV antibiotic was administered.On February 12, 2026, at 8:29 a.m., a concurrent interview and record review were conducted with the Registered Nurse Supervisor (RNS). The RNS stated IV sites should be monitored and assessed each shift for complications and documented in the MAR by the RNS. The RNS stated there was no documented evidence that monitoring and assessments were performed for Resident 124's IV site during the course of IV therapy. The RNS stated it was important to monitor and assess the IV site to ensure there were no complications or potential infection to the resident.On February 12, 2026, at 10:47 a.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated it was the responsibility of the RNS to assess IV sites every shift and document the assessment. The ADON stated there was no documented evidence that IV site monitoring or assessments were completed for Resident 124. The ADON stated monitoring the IV site was important to prevent complications and infection. A review of the facility's policy and procedure titled, Intravenous Therapy, dated December 19, 2022, indicated, .IV sites are checked.per facility protocol and PRN for signs and symptoms of infection.nurse will assess for associated risks.IV documentation is recorded in the.Medication Administration Record.

Based on interview and record review, the facility failed to provide required information and follow up with the resident's representative (RP) regarding Advance Directives (AD - written statement of a person's wishes regarding medical treatment) for one of one resident reviewed for AD (Resident 6), who lacked decision-making capacity.This failure had the potential to prevent the resident's representative from participating in medical decision-making and ensuring the resident's treatment preferences were honored. Findings:A review of Resident 6's admission record dated February 12, 2026, indicated Resident 6 was admitted on [DATE], with a diagnoses which included dementia (progressive cognitive impairment).A review of Resident 6's History and Physical dated August 5, 2025, indicated Resident 6 does not have the capacity to understand and make decisions. A review of Resident 6's POLST dated December 7, 2023, indicated there was no documented AD for Resident 6.A review Resident 6's Quarterly Social Service assessment dated [DATE], indicated, .advance directive was not offered at this time the resident is confused.Further review of Resident 6's record indicated there was no documented evidence the facility followed up with the resident's representative to provide information or education regarding AD or conservatorship. On February 11, 2026, at 3:32 p.m., concurrent interview and record review with the Social Service Director (SSD) was conducted. The SSD stated residents were offered to formulate an AD and provided education upon admission and during quarterly assessments. The SSD stated if a resident lacks decision-making capacity, the resident's RP is contacted and informed of their right, including the right to file for conservatorship. The SSD stated Resident 6 did not have an AD since 2023, was not offered to formulate an AD due to confusion, and follow-up with the RP was not conducted as required by facility practice. The SSD stated she should have followed up with the RP to allow participation in decision making.On February 12, 2026, at 10:47 a.m., an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated if the resident is confused and unable to consent to formulate an AD, the SSD should have informed the RP. The ADON stated there was no documentation the resident's representative was contacted regarding advance directives and stated the SSD should have. The ADON stated it was important to follow up with the RP to allow the RP to be involved in decision making and honor the resident's wishes.A review pf the facility's policy and procedure titled, Residents' Rights Regarding Treatment and Advance Directives, dated December 19, 2022, indicated, .In the event the resident is unable to formulate an AD due to cognitive impairment.the facility will provide information and education to the resident representative.The facility will periodically assess the resident for decision-making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capacities.

Based on observation, interview, and record review, the facility failed to provide a diet in accordance with physician's orders for one of 19 residents reviewed during dining observation (Resident 14), when the resident, who had a documented allergy to nuts was served a brownie containing nuts.This failure placed the resident at risk for an allergic reaction.Findings:On February 9, 2026, at 12:32 p.m., Resident 14 was observed eating in the dining room. Resident 14 was served a dessert brownie which contained nuts.Resident 14 stated he did not want to eat the brownie because it contained nuts and further stated he had an allergy to nuts. Resident 14 stated he would not eat anything containing nuts because he would react in a bad way and could developed seizures (convulsions).A review of Resident 14's tray card indicated, .Allergies: Peanuts and Tree Nuts .A review of Resident 14's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD). Resident 14's History and Physical indicated Resident 14 had the capacity to understand and make decisions.Resident 14's Nutritional assessment dated [DATE], indicated .Food Allergies: nuts, nitrates .Resident 14's Physician's order dated January 7, 2026, indicated .Allergy Report: Food Allergy- Peanuts.A review of the recipe titled Turtle Brownie (Mix) Indicated .Ingredients .Nuts, Pecan, pieces medium.On February 12, 2026, at 10:22 a.m., the Licensed Vocational Nurse (LVN) 2 was interviewed. LVN 2 stated he checked trays before they were delivered to residents. The LVN 2 stated he did not know the brownie contained nuts and stated he should have verified the ingredients with dietary staff prior to delivering the tray. LVN 2 further stated the resident could have developed shortness of breath as an allergic reaction. On February 12, 2026, at 10:28 a.m., the Dietary Service Supervisor (DSS) was interviewed. The DSS stated Resident 14 should not have served the brownie because it contained nuts. The DSS stated staff should verify ingredients when a resident has a documented allergy and stated that serving nuts to a resident with a nut allergy could result in hospitalization due to an allergic reaction. A review of the facility Policy and Procedure titled, Resident Food Preferences, dated April 30, 2021, indicated .Food Preferences, allergies should be recorded on the resident's tray card .these.allergies, intolerances should be honored.

Based on observation, interview, and record review, the facility failed to ensure the physician-ordered therapeutic diet (a diet ordered by a physician as part of resident's medical treatment to manage a disease or condition) was followed for one of 19 residents reviewed for nutrition (Resident 90), when the resident was not provided the ordered minced and moist diet texture at lunch on February 12, 2026. This failure had the potential to result in decreased nutritional intake and increased risk for choking due to the resident's dysphagia (difficulty swallowing).Findings:On February 12, 2026, at 12:40 p.m., Resident 90 was observed in the dining room being assisted by Certified Nurse Assistant (CNA) 1 with CNA 2. Resident 90 stated he was not able to chew the chicken breast because it was spongy. Resident 90 stated he could only suck on the chicken and could have finished the meal if it had been a softer consistency. CNA 1 stated the meal served as soft and bite-sized and stated the resident's diet should have been minced and moist consistency. CNA 1 stated Resident 90 consumed approximately 25% of the meal. During a concurrent observation and interview with CNA 2, CNA 2 attempted to cut the chicken with spoon and stated the chicken was not soft enough and could be difficult to chew. A review of Resident 90 's admission Record indicated, the resident was admitted to the facility on [DATE], with diagnoses which included dysphagia. A review of the History and Physical dated January 14, 2026, indicated Resident 90 has fluctuating capacity to understand and make decisions. A review of Resident 90's Minimum Data Sheet (an assessment tool) Section L Oral/ Dental Status indicated .(edentulous) No Natural teeth or tooth fragment(s). A review of Resident 90's Physician's order dated February 3, 2026, indicated .CCHO (Consistent Carbohydrate Control diet- aims to stabilize blood sugar levels) Minced & Moist (MM5- food texture to improve safety for individual with swallowing difficulty) Texture, Thin (TN0) Consistency. The meal served on February 12, 2026, was not minced and moist in texture as ordered. On February 12, 2026, at 2 p.m., during an interview with the Dietary Service Supervisor (DSS), the DSS stated the physician's diet order for Resident 90 should have been followed. The DSS further stated when the order was not followed there was a potential for decrease intake and an increased risk for choking. A review of the facility Policy and Procedure titled Therapeutic Diet Orders, dated May 17, 2023, indicated .The Therapeutic Diet, including mechanically altered diets.will be based on individual needs as determined by resident assessment.in certain situations, such as Swallowing difficulty. The Dietary and Nursing staff are responsible for providing therapeutic diets.

Based on observation, interview, and record review, the facility failed to ensure food safety requirements for food storage and preparation were followed when one expired 12-ounce Tabasco sauce was found in the dry storage room readily available for use. This failure had the potential to place the residents at risk for food-borne illness in a medically vulnerable population of 82 residents who consumed food prepared by the facility. Findings:On February 9, 2026, at 8:35 a.m., during the initial kitchen tour, one 12-ounce bottle of Tabasco sauce was observed on a dry storage shelf readily available for use. The bottle was labeled with an open date of October 26, 2025, and a manufacturer's best-by date of December 2025, which had expired. During a concurrent interview with the Dietary Service Supervisor (DSS), the DSS stated the sauce should have been discarded. The DSS stated there was potential for food borne illness if the expired product were used. On February 12, 2026, at 2:27 p.m., the Registered Dietician (RD) was interviewed. The RD stated expired food items should be discarded, and that consumption of expired products could cause gastrointestinal illness. A review of the facility Policy and Procedure titled Date Marking for Food Safety, dated December 19, 2022, indicated .The facility adheres to a date marking system to ensure the safety of ready-to-eat .food.The discard date may not exceed the manufacturer's use-by-date.

Based on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported to the State survey agency within two hours for two of five residents, (Residents 2 and 3).This failure had the potential for a delay in the investigations and interventions to prevent further incidents of abuse. Findings:On December 9, 2025, at 10:14 a.m., an unannounced visit to the facility to investigate an allegation of physical abuse. A review of Resident 2's medical record indicated the resident was admitted on [DATE], with diagnoses of dementia, (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and pressure ulcer injury stage 4 (PUI - full thickness tissue loss with exposed bone, tendon, or muscle).A review of Resident 2's History and Physical dated September 22, 2025, indicated resident was not capable of understanding and making decisions.A review of Resident 3's medical record indicated the resident was admitted on [DATE], with diagnoses of chronic obstructive pulmonary disease, (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), polyneuropathy, (the simultaneous malfunction of many peripheral nerves throughout the body), and depression, (a mood disorder that causes a persistent feeling of sadness and loss of interest).A review of Resident 3's History and Physical dated November 8, 2025, indicated resident had the capacity to make decisions.On December 9, 2025, at 11:52 a.m., during an observation of Resident 2, the resident was lying in bed on his right side, with eyes slightly opened, respirations were even and unlabored. Resident 2 did not respond to verbal questions. On December 9, 2025, at 12:18 p.m., during an interview with the Licensed Vocational Nurse (LVN 1), LVN 1 stated that Resident 2 was occasionally awake and could not be able to get out of bed. LVN 1 stated allegations of abuse should be reported to the Administrator, Director of Nursing within two hours. LVN 1 stated that an allegation of abuse would require keeping residents apart, physician notification, documentation of a change in condition, and care plan updates. On December 9, 2025, at 12:32 p.m., during an interview with Resident 3, Resident 3 stated that back in November 2025, Resident 2 reached toward the television remote and toward his bed, so he flicked Resident 2 on the head. Resident 3 stated there were no witnesses to the event. On December 9, 2025, at 1:01 p.m., during an interview with Licensed Vocational Nurse (LVN 2), LVN 2 stated that if a resident flicked another resident in the head, she would report the incident right away to the Registered Nurse, the abuse coordinator. A review of Resident 3's Progress Notes dated November 23, 2025, at 8 a.m., indicated Resident hit another resident on the head for being too noisy. Client educated on the importance of hitting or coming into contact with another resident. Resident reported he is lucky I didn't kick his ass. Resident again educated. Resident reported he flick the other resident on the head to quiet him.Further review of Resident 3's Progress Notes dated November 23, 2025, indicated no documentation that the alleged incident was reported to the California Department of Public Health (CDPH) within two hours. On December 9, 2025, at 3:01 p.m., during an interview with the Director of Nursing (DON), the DON stated that on December 1, 2025, the Social Service Director notified him of the November 23, 2025, incident at 8 a.m. The DON confirmed that the incident was considered an allegation of physical abuse and should have been reported within two hours to the CDPH. The DON stated that the incident was not reported within the required timeframe.On December 18, 2025, at 12:38 p.m., during a telephone interview with the Social Service Director (SSD), the SSD stated on December 1, 2025, she was reviewing Resident 3's progress notes, and noted the incident on November 23, 2025, at 8 a.m., and notified the DON. The SSD stated that the incident was reported to the state survey agency on December 1, 2025 (seven days after the incident). On December 18, 2025, at 12:51 p.m., during a telephone interview with LVN 3, LVN 3 stated that on November 23, 2025, at 8 a.m., a certified nursing assistant reported that there was an incident with Resident 3 and Resident 2. LVN 3 stated that during an interview with Resident 3, Resident 3 admitted flicking Resident 2 on the head. LVN 3 stated Resident 2 had no injuries from the incident. LVN 3 stated she was not aware that allegations of abuse were required to be reported within two hours. A review of Resident 2's eINTERACT SBAR Summary for Providers dated December 1, 2025, at 12:06 p.m., indicated The Change In Condition/s reported on this CIC Evaluation are/were. Resident's room mate (sic) allegedly flicked his head on 11/23/2025. He is safe with no injuries. No concerns or worries. room mate's (sic) bed moved to another room. MD and family aware. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: - Continue with POC.A review of Resident 3's eINTERACT SBAR Summary for Providers dated December 1, 2025, at12:45 p.m., indicated Situation: The Change In Condition/s reported on this CIC Evaluation are/were. Alleged physical aggression, flicking roommates head with his fingers one time. This happened on 11/23/25 and was documented but not reported. Resident room changed for his safety and that of room mates (sic) on 12/1/2025. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: - Continue monitoring- Psych consult.A review of the facility's policy and procedure titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation revised December 19, 2022, indicated .Reporting/Response: The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation.When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated.1. The Licensed Nurse will:a. Respond to the needs of the resident and protect him/her from further incident.b. Remove the accused employee from resident care areas.c. Notify the Administrator or designee.d. Notify the attending physician, resident's family/legal representative, and Medical Director.e. Monitor and document the resident's condition, including response to medical treatment or nursing interventions.f. Document actions taken in the medical record.The Administrator or designee will:a. Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than 2 hours after discovery or forming the suspicion.

Based on observation, interview, and record review, the facility failed to ensure care and treatment were provided for four of seven residents reviewed (Residents 1, 4, 5, and 6) when:1. For Resident 1, the licensed nurses did not timely assess and monitor the resident who experienced a change in condition on June 16, 2025. This failure resulted in the hospitalization of Resident 1 on June 20, 2025, with a diagnosis of urinary tract infection (an infection that occurs in any part of the urinary system [how the body gets rid of extra water and waste]). 2. For Residents 4, 5, and 6, peripheral intravenous (IV - administration of fluids or medication through the vein) sites were not documented as assessed or changed for the duration of the admission. This failure had the potential to place Residents 4, 5, and 6 at risk for infection and injury due to prolonged use of the same IV access.Findings: 1 . On July 10, 2025, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses including toxic encephalopathy (a condition of chemical imbalance in the blood) and urinary tract infection. A review of the Care Plan the resident has impaired immunity dated March 26, 2025, indicated, .the resident will remain free from infection through the review date.the resident will not display any complications related to immune deficiency .interventions.monitor/document/report to MD s/sx of delirium: change in behavior, altered mental status, wide variation in cognitive function throughout the day, communication decline, disorientation, periods of lethargy, restlessness, and agitation, altered sleep cycle. A review of Resident 1's Physician Order dated, June 13, 2025, indicated, .U/A (urinalysis) with C/S (a laboratory test used to identify the type of bacteria causing an infection to determine which antibiotics or treatments) for routine lab on Monday AM June 16, 2025. A review of Resident 1's Progress Notes, indicated, -Dated, June 13, 2025, at 9:54 p.m., .Dr.new order for UA with C/S on Monday AM.June 16, 2025 for routine lab.resident aware noted and carried out. -Dated, June 16, 2025, at 2:27 p.m., .patient (Resident 1) refused meds and blood sugar checks this shift.she yelled and attempted hitting at nurse.resident refused to be changed.yelled at nurse when talked to her.patient yelled and tried hitting at nurse.pt was left alone.will endorse to next shift continue to monitor. - Dated, June 20, 2025, at 8:00 a.m., .patient (Resident 1) behavior still not cooperative and refusing meds, treatments, meals, and even supplements ordered and given.also refusing to work with RNA (restorative nursing assistant).MD (Physician) made aware of residents behavior worsening.awaiting call from MD. - Dated June 20, 2025, at 4:23 p.m. indicated, .NP (nurse practitioner) came to visit resident.resident observed to be noncompliant with care.MD ordered to have the resident sent out to hospital for further evaluation including doing the urinalysis as the resident refused to have urine collected last time for UA test. -Dated June 26, 2025, at 10:55 p.m. indicated, .readmit patient from (name of hospital) with DX (diagnosis) of UTI.incontinent of bowel and bladder. Further review of Resident 1's progress note indicated no documentation that Resident 1's change in behavior was monitored and assessed on June 16, 2025. On July 10, 2025, at 1:16 p.m., an interview and record review of Resident 1's progress notes were conducted with LVN 1. LVN 1 stated on June 13, 2025, she documented that Resident 1 refused to provide a urine sample for laboratory testing to rule out a possible urinary tract infection. LVN 1 stated Resident 1 was combative, refused care, and refused to do the labs (ordered tests) on June 16, 2025. LVN 1 was unable to describe or was unaware of the mental effects a urinary tract infection could cause in at risk female residents. LVN 1 stated, Resident 1 had a change in mental status on June 16, 2025, which she should have reported to the physician. LVN 1 stated she should have monitored the resident and documented in the progress note. On July 10, 2025, at 2:08 p.m., an interview and record review of Resident 1's progress notes from June 5 to June 20, 2025, were conducted with the Director of Nursing (DON). The DON stated, Resident 1 had increased confusion and documented refusals of care on multiple occasions. The DON sated, on June 16, 2025, Resident 1 refused and strike staff and that should have been a change in condition. The DON stated, there was no documentation regarding Resident 1's behavior changes. The DON stated there was a risk of further complications for Residents with an infection and it should have been addressed on June 16, 2025, and the staff should not have waited to communicate the change on June 20, 2025. The DON further stated care plans should be revised and updated with changes in condition so that the interventions in place reflect the current status of the residents. 2a. A review of Resident 4's medical record indicated Resident 4 was admitted to the facility on [DATE], with diagnosis which included, metabolic encephalopathy (chemical imbalance in the blood), and urinary tract infection (UTI). The History and Physical Examination, dated June 11, 2025, indicated Resident 4 has fluctuating capacity to understand and make decisions. A review of the hospital Final Discharge Disposition dated June 10, 2025, indicated, .IV (intervascular) access.peripheral.location.R FA (right forearm).date of insertion.June 7, 2025. A review of the skin check note dated, June 10, 2025, at 10:49 p.m. indicated, .noted with iv in right forearm. A review of the physicians order summary dated, June 11, 2025, indicated, .Cefazolin Sodium (antibiotic) injection solution 2 gm (unit of measure), use 2 gram intravenously (into the blood stream) one time a day for sepsis (infection), UTI for 6 weeks. A review of the nurses progress note dated June 12, 2025, at 10:05 p.m., indicated, .On monitoring for new admit, currently on IV antibiotics for UTI. A review of the skilled evaluation dated June 24, 2025, at 6:31 p.m. indicated, .resident currently on antibiotics cefalzolin 2 gm for diagnosis of uti. A review of the Care Plan titled, Resident is on antibiotic therapy (Cefazolin injection r/t sepsis, UTI indicated, .monitor/document/report s/sx (signs and symptoms) of infection r/t diarrhea, itchy, discharge/coating of anus. Further review of Resident 1's progress notes and Medication Administration Record indicated, there was no documented evidence that care, assessment, and monitoring of the IV site to the right hand of Resident 4 was conducted by the staff from June 10, 2025, to June 27, 2025. 2b. A review of Resident 5's medical record indicated Resident 5 was admitted to the facility on [DATE], with diagnosis which included, metabolic encephalopathy (chemical imbalance in the blood), and urinary tract infection (UTI).The History and Physical Examination, dated June 11, 2025, indicated Resident 5 has fluctuating capacity to understand and make decisions. The Progress note dated July 14, 2025, indicated, .Resident on monitoring for IV ABT (antibiotic) E. coli (bacteria) urine. No worsening symptoms noted.will continue to monitor.The Progress note dated July 13, 2025, indicated, .Resident on monitoring for INVanz (antibiotic) injection 1 gram (unit of measure) intravenously one time a day for ESBL (bacterial infection) in urine for 10 days, no discomfort or pain reported.A review of the Physicians Order Summary dated, July 11, 2025, indicated, .Invanz injection 1 gm use 1 gram intravenously one time a day for ESBL in urine for 10 days. Further review of Resident 5's progress notes and Medication Administration Record indicated that the resident's IV site was being monitored or assessed for infection or infusion of antibiotics.2c. A review of Resident 6's medical record indicated Resident 6 was admitted to the facility on [DATE] and readmitted [DATE], with a diagnosis which included UTI, and end stage renal disease (ESRD - a disease of the kidneys).The History and Physical Examination, dated June 13, 2025, indicated Resident 6 did not have capacity to understand and make decisions. The Nursing Progress Note dated July 4, 2025, indicated, .skin assessment done and noted peripheral line on right arm and right hand.A review of the Physicians Order Summary dated, July 4, 2025, indicated, .Cefeprime HCL (antibiotic) intravenous solution use 1 gram intravenously one time a day for PNA (pneumonia - lung infection) for 14 days.Further review of Resident 6's progress notes and Medication Administration Record (MAR) indicated there was no documented evidence of monitoring, assessment, or documentation that the peripheral IV noted upon admission was assessed from June 4, 2025, to June 14, 2025. On July 14, 2025, at 2:53 p.m., an interview and record review of Residents 4, 5, and 6's MAR were conducted with RN 2. RN 2 stated when caring for residents receiving IV medications, she reviews the physician's orders and assessed the IV site for patency and signs of infection before administering the medication. RN 2 stated, IV sites should be labeled with the insertion date and that peripheral IV lines should typically be checked every two or three days. RN 2 stated she was unsure how long the IV lines can remain in place, and they are usually left in as long as they appear to be functioning and uninfected, unless they become dislodged, stop working, or the resident request to keep it in. RN 2 stated there was no documented evidence in Residents 4, 5, 7, and 7's records indicating the IV sites were assessed, removed, or changed. RN 2 stated, documentation should have been completed. RN 2 stated the facility has a standard order set for IV monitoring, but it was not followed for these residents. RN 2 stated, there was no way to confirm whether the required site assessments were performed. On July 14, 2025, at 3:54 p.m., an interview and record review were conducted with the DON. The DON stated upon admission from another facility or the hospital, all residents with a peripheral IV in place should be assessed each shift. The DON stated, the assessment should include looking for signs of infection, patency, and skin changes. The DON stated he was unsure how long a peripheral IV could remain in place, but IV sites should be labeled with the insertion date. The DON stated, IV site assessments should be documented in the MAR and/or in a progress note to confirm that the assessment was completed. The DON stated the order set for four residents were missing and it should have been in place. The DON stated, the lack of documentation of IV site assessments posed a risk for residents to develop infections and for the insertion site to go unchecked. A review of the facility policy titled, Peripheral Intravenous Catheter Insertion, Maintenance, and Removal dated December 19, 2022, indicated, .it is the policy of this facility to ensure that peripheral intravenous catheters are inserted, maintained and discontinued consistent with current standards of practice.peripheral intravenous (IV) catheter.to maintain an IV access to the resident.peripheral IV sites should be changed after 72 hours unless otherwise ordered by the physician, if the site becomes infiltrated, or if the resident exhibits signs of phlebitis or extravasation.if the IV is left in place longer than 72 hours, IV site care will be done every 24 hours.Peripheral IV sites should be checked at least every shift and PRN.Removal of peripheral IV is indicated by the order of the physician when therapy is complete, when clinically indicated, when deemed no longer necessary for the plan of care, or have not been used for 24 hours or more.site care and maintenance.document procedure.

Based on observation, interview, and record review, the facility failed to ensure the physician was notified of a significant change in condition and refusal of treatment for one of seven sampled residents (Resident 1).This failure had the potential for further confusion, aggressive behaviors, and refusal of care, and led to discomfort with the potential for complications related to untreated infection.Findings: On July 10, 2025, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses including toxic encephalopathy (a condition of chemical imbalance in the blood) and urinary tract infection (UTI - an infection that occurs in any part of the urinary system [how the body gets rid of extra water and waste]). A review of Resident 1's Care Plan dated March 26, 2025, indicated, .the resident has impaired immunity .the resident will remain free from infection through the review date.the resident will not display any complications related to immune deficiency .interventions.monitor/document/report to MD s/sx of delirium: change in behavior, altered mental status, wide variation in cognitive function throughout the day, communication decline, disorientation, periods of lethargy, restlessness, and agitation, altered sleep cycle. A review of facility document dated June 13, 2025, indicated, .Patient (Resident 1) is irritable, no distress noted.At baseline mentation. A review of Resident 1's Physician Order dated, June 13, 2025, indicated, .U/A (urinalysis) with C/S (culture and sensitivity - a laboratory test to identify the type of bacteria causing an infection and to determine which antibiotics treatment) for routine lab on Monday AM June 16, 2025. A review of Resident 1's Progress Notes, indicated, -Dated June 13, 2025, at 9:54 p.m., .Dr.new order for UA with C/S on Monday AM.June 16, 2025 .for routine lab.resident aware noted and carried out. -Dated June 16, 2025, at 2:27 p.m., .patient (Resident 1) refused meds and blood sugar checks this shift.she yelled and attempted hitting at nurse.resident refused to be changed.yelled at nurse when talked to her.patient yelled and tried hitting at nurse.pt was left alone.will endorse to next shift continue to monitor. - Dated June 20, 2025, at 8:00 a.m., .patient (Resident 1) behavior still not cooperative and refusing meds, treatments, meals, and even supplements ordered and given.also refusing to work with RNA (restorative nursing assistant).MD (Physician) made aware of residents behavior worsening.awaiting call from MD. - Dated June 20, 2025, at 4:23 p.m. indicated, .NP (nurse practitioner) came to visit resident.resident observed to be noncompliant with care.MD ordered to have the resident sent out to hospital for further evaluation including doing the urinalysis as the resident refused to have urine collected last time for UA test. -Dated June 26, 2025, at 10:55 p.m. indicated, .readmit patient from (name of hospital) with DX (diagnosis) of UTI.incontinent of bowel and bladder. Further review of Resident 1's progress note indicated no documentation that the physician was notified of the resident's behavior changes and refusal to complete the ordered urinalysis on June 16, 2025. Physician notification did not occur until June 20, 2025 (four days after the change in condition). On July 10, 2025, at 1:16 p.m., an interview and record review of Resident 1's progress notes were conducted with LVN 1. LVN 1 stated Resident 1 refused urine collection and had a change in behavior on June 16, 2025. LVN 1 stated, she should have reported Resident 1's refusal and behavior change to the physician. On July 10, 2025, at 1:56 p.m., an interview and record review of Resident 1's progress notes were conducted with Registered Nurse (RN) 1. RN 1 stated the process for treatment refusals was to contact the physician and document in the medical record. RN 1 stated, the physician placed a new order for urinalysis on June 16, 2025. RN 1 stated, the urine sample was not obtained, the refusal should have been documented, and the physician should have been notified. A review of the facility policy titled, Notification of Changes, dated December 2022, indicated, .to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.examples.recurrent episodes of delirium, recurrent UTIs.significant change in the resident's physical, mental or psychosocial conditions such as deterioration in health, mental or psychosocial status.acute condition.exacerbation of a chronic condition.

Based on interview and record review, the facility failed to report an allegation of physical abuse to the California Department of Public Health (CDPH) within two hours after the allegation was made, for one of six sampled residents (Resident A). This failure had the potential to result in psychosocial harm to Resident A and other residents in the facility. Findings: A review of Resident A's admission record indicated, Resident A was admitted to the facility on [DATE], with diagnoses which included osteomyelitis (inflammation of the bone tissue). A review of Resident A's Minimum Data Set (MDS - an assessment tool) dated May 9, 2025, indicated Resident A had a Brief Interview for Mental Status (BIMS - [screener for mental and cognitive status] score of 12 (moderate cognitive impairment). A review of Resident A's Social Service Progress Note, dated May 27, 2025, at 3 p.m., indicated, .This resident (Resident A) is alert able to make needs known .On 5/27/25 [sic] This resident believes ithad been 8 or 8:30 pm, .verbal altercation took place with (Resident B). States he was talking to staff not yelling when he noticed (Resident B) hovering over his side of the bed leaning forward at eye level telling him I told you to keep it down Mother F***** the resident stated that he raised his arm to (Resident B) face telling him 'your not going to tell me what to do' .per resident (Resident B) then grabbed his wrist . On June 3, 2025, at 11:12 a.m., the Administrator was interviewed. The Administrator stated, when an abuse allegation was identified, the staff were expected to report it to him, as the abuse coordinator and to the Director of Nursing (DON) immediately. The administrator stated, the abuse allegation should have been reported to CDPH within two hours. On June 3, 2025, at 3:53 p.m., the Social Service Director (SSD) was interviewed. The SSD stated, on May 27, 2025, at around 11 a.m., she became aware of the altercation between Residents A and B (approximately eleven hours after the incident occurred). On June 3, 2025, at 4:20 p.m., Resident B was interviewed. Resident B stated, Resident A, his roommate, woke him up around 12 a.m. and raised his arm as if to hit him, but there was no physical contact. On June 3, 2025, at 4:23 p.m., Resident A was observed and interviewed. Resident A stated, Resident B was trying to kill him. Resident A stated, Resident B told him to tone down his voice, twisted his arm, and tried to hit him. Resident A stated I was not safe that night. Resident A stated, the incident happened on May 26, 2025, at around 8:30 p.m. Resident A was observed with two scabbed marks about 3 mm in size and the other about 5 mm in size, located approximately two inches above the wrist. On June 5, 2025, at 2:24 p.m., the Licensed Vocational Nurse (LVN) was interviewed. The LVN stated, while exiting another resident's room, she heard a heated argument on May 27, 2025, after 12 a.m. The LVN stated, when she spoke with Resident A, the resident informed her that Resident B had scratched his right hand. The LVN stated, she informed the RN Supervisor and told her to report it to the DON. The LVN stated, this was an allegation of abuse and should have been reported immediately. A review of the facility policy and procedure titled, Abuse, Neglect and Exploitation, dated December 19, 2022, indicated .Reporting/Response .Reporting all alleged violations .Immediately, but no later than 2 hours after the allegation is made .

Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Level I screening accurately reflected the presence of diagnosed mental disorders for one of three sampled residents (Resident A). This failure had the potential to result in the inappropriate admission of residents who may not meet the criteria for nursing facility placement, and in the resident not receiving the appropriate services for their diagnosed mental health conditions. Findings: A review of Resident A's admission Record indicated Resident A was admitted to the facility on [DATE], with diagnoses which included bipolar disorder (mental disorder) and anxiety disorder. A review of Resident A's PASARR Level 1 screening, dated May 20, 2025, indicated .Level 1 negative for SMI (serious mental illness) .Section III- SMI .Does the individual have a serious diagnosed mental disorder such as depressive disorder [persistent feeling of sadness or loss of interest] , anxiety disorder [excessive worry], panic disorder [sudden episodes of intense fear or discomfort], schizophrenia/schizoaffective disorder [chronic severe mental disorder], or symptoms of psychosis [loss of contact with reality], delusions [false fixed belief that are not based on reality], and/or mood disturbance? - No . On June 5, 2025, at 1:30 p.m., during a concurrent interview and review of Resident A's PASARR with Minimum Data Set Nurse (MDSN)1, MDSN 1 stated, she missed the diagnoses and she should have answered yes to the question in Section III. MDSN 1 further stated, when PASARR screening are completed incorrectly, there is a potential the resident could be admitted even if they may not be appropriate for this facility. On June 5, 2025, at 2:10 p.m., during a concurrent interview and review of Resident A's PASARR with MDSN 2, she stated the diagnoses of bipolar disorder could have significantly changed the PASARR result from Level 1 Negative to Level 1 Positive. A review of the facility policy and procedure titled Resident Assessment-Coordination with PASARR Program, dated December 19, 2022, indicated, .PASARR Level 1- initial pre-screening that is completed prior to admission i. Negative Level I Screen- permits admission to proceed and ends the PASARR process .ii. Positive Level I Screen- necessitates a PASARR Level II evaluation prior to admission .

Based on interview and record review, the facility failed to ensure a post discharge follow-up was conducted and documented in the medical records for one of three residents reviewed (Resident 1). This failure had the potential to compromise Resident 1's safety and well-being by not ensuring post-discharge needs were met. Findings: A review of Resident 1's medical record indicated he was admitted to the facility on [DATE], with diagnoses which included left tibia (leg bone) fracture and type 2 diabetes mellitus (abnormal high sugar). Resident 1 was discharged on January 22, 2025. A review of Resident 1's History and Physical, dated September 5, 2024, indicated he had capacity to understand and make decisions. A review of Resident 1's Order Summary, dated January 21, 2025, indicated, .LCD (last cover day) 1.21.25 (January 21, 2025) D.C. (discharge) 1/22/25 (January 22, 2025) at 11:00am, to address (provided) . A review of Resident 1's NOTICE OF PROPOSED TRANSFER/DISCHARGE, effective date of January 22, 2025, indicated .The transfer or discharge is appropriate because your health has improved sufficiently so that you no longer require services provided by the facility . A review of Resident 1's Progress Notes, dated January 22, 2025, at 12:33 p.m., indicated .pt (patient) discharged . A further review of Resident 1's progress notes indicated, there was no documentation showing that the Case Manager (CM) followed-up with the resident after his discharge. On March 5, 2025, at 10:25 a.m., a concurrent interview and record review were conducted with the Social Service Director (SSD). The SSD stated when a patient was discharged , she and/or the CM would call the resident at least 72 hours after discharge to check in and provide additional information as needed. The SSD stated, she maintained a binder containing her post-discharge follow up call logs, while the CM kept track of her own logs. The SSD stated, Resident 1's discharge had been coordinated by the CM, and was unsure whether the CM conducted a follow up call for Resident 1. On March 6, 2025, at 12:35 p.m., a concurrent interview and record review were conducted with the Director of Nursing (DON). The DON stated, per facility policy, the social services and case management departments were responsible for calling and checking in on residents at least 72 hours after discharge and again between 14-28 days post-discharge. The DON stated, there was no documentation showing that Resident 1 was contacted after discharge. The DON stated, Resident 1 should have received a follow up phone call to ensure Resident 1's post discharge care needs were met and the resident remained safe. A review of the facility's policy and procedure titled, Follow Up Discharge Phone Call, revised December 2024, indicated .the purpose of follow up discharge call is .within 72 hours of discharge, as this is the time when most patients will have questions and need reassurance, advice and reinforcement of information provided upon discharge .to check patient's condition and support discharge instructions . A review of the facility's policy and procedure titled, Documentation in Medical Record, revised on December 2022, indicated .each resident's medical record shall contain a representation of the experiences of the resident and include enough information to provide a picture of the resident's progress .licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record .documentation shall be accurate, relevant and complete, containing sufficient details about the resident's care .

Based on interview and record review, the facility failed, for one of four residents (Resident 1), to ensure the Office of the State Long-Term Care Ombudsman (LTC Ombudsman - an advocate for residents to protect residents' rights and ensure quality care) received timely notification of Proposed Transfer/Discharge (a planned or suggested move of a resident from a healthcare facility to another location) when Resident 1 was discharged on [DATE]. This failure has the potential to result in Resident 1 lacking an advocate to protect their rights and ensure an appropriate and safe discharge plan. Findings: Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses including esophageal cancer (a rare cancer that occurs when cells in the esophagus is a muscular tube that moves food and liquids from the throat to the stomach mutate and grow out of control). A review of Resident 1's History and Physical, dated October 14, 2024, indicated Resident 1 had the capacity to understand and make decisions. A review of the Physician Order, dated January 30, 2025, indicated Resident 1 was to be discharged to (Name of facility). A review of the Notice of Proposed Transfer/Discharge, dated January 29, 2025, indicated that Resident 1 had given verbal consent to the Proposed Transfer/Discharge plan. The Notice of Proposed Transfer/Discharge form included a fax transmittal dated February 3, 2025, at 1:22 p.m., sent to the Ombudsman, four days after Resident 1 was discharged . A review of the Nurse Progress Note, dated January 31, 2025, indicated that Resident 1 had been discharged to (Name of Facility). On February 3, 2025, at 1:26 p.m., a concurrent record review and interview was conducted with the SSD. The SSD stated, Resident 1 had given a verbal consent to the Notice of Proposed Transfer/ Discharge on January 29, 2025. The SSD stated she had not notified the LTC Ombudsman until February 3, 2025. The SSD stated she should have faxed the notice to the LTC Ombudsman on January 29, 2025, when Resident 1 received the discharge notice. The SSD stated the protocol for a planned discharge had been to notify the resident and (Named Facility), have the resident or resident responsible person sign and date the Notice of Proposed Transfer/Discharge, and fax a copy of the notice to the LTC Ombudsman. The SSD further stated she did not have an evidence that the LTC Ombudsman was notified on January 29, 2025. The policy titled Transfer and Discharge (including AMA), dated December 19, 2022, was reviewed. The policy indicated, .Policy Explanation and Compliance Guidelines .Generally, the notice must be provided at least 30 days prior to a facility-initiated transfer or discharge of the resident .the notice must be provided to the resident .and LTC ombudsman as soon as practicable before the transfer or discharge .

Based on interview and record review, the facility failed to ensure staff discussed the decisions and the rationale regarding issues or concerns raised by the Resident Council (a group of residents who come together to discuss concerns, make suggestions, and advocate for improvements in their living environment). This failure had the potential to feel that their voices were not heard which could result in dissatisfaction and a decline in quality of life. Findings: On January 22, 2025, at 5:25 p.m., during an interview with Resident 1, she stated the dining room/activity room closes at 7 p.m. and reopens at 9 a.m. Resident 1 further stated the access to the patio and vending machine is only available thru the dining room. On January 22, 2025, at 5:40 p.m., during an interview with Certified Nurse Assistant (CNA) 1, he stated the dining room closes at 6:15 p.m. and the key is held by the Registered Nurse Supervisor (RNS). On January 22, 2025, at 5:40 p.m., during an interview with the Dietary Service Supervisor (DSS), she stated the dining room is closed right after dinner time and the key is held by the Registered Nurse Supervisor (RNS). On January 22, 2025, at 6:55 p.m., during an interview with Resident 2, he stated the dining room closes at 7 p.m Resident 2 further stated that the activity room is the only place available to sit, relax, and socialize with other residents. On January 22, 2025, at 7:45 p.m., during an interview with Resident 3, he stated he wanted to go out to the patio to get fresh air. Resident 3 stated, he attempted multiple times since his admission but was unable to do so because the dining room was closed. On January 22, 2025, at 7:55 p.m., during an interview with Resident 4, she stated she wanted to buy soda at night but was unable to because the dining room was closed. On January 22, 2025, at 8:10 p.m., during an interview with the Registered Nurse Supervisor (RNS), she stated they were instructed to lock the dining room at 7 p.m. and she is the one who holds the key. On January 22, 2025, at 8:30 p.m., during an interview with the Assistant Director of nursing (ADON), she stated the staff were not supposed to lock the dining room, but only to keep it closed. On February 3, 2025, at 2:16 p.m., the Dietary Services Supervisor (DSS) was interviewed. The DSS stated, she had heard residents discussing and complaining about the dining room being closed at night. The DSS further stated that she informed the department heads about these concerns during the morning meetings. A review of facility document tiled, RESIDENT COUNCIL DEPARTMENTAL RESPONSE FORM, dated December 18, 2024, indicated, .Issues Identified by Resident Council .Resident ' s expressed concern of dinning (sic) room door being closed .facility resolved by giving RN (Registered Nurse) key and communicated with staff. The door will remain open breakfast lunch and dinner . Further review of the facility document Resident Council Departmental Response Form, dated December 18, 2024, indicated there was no documentation that the solutions and their rationale were discussed with the Resident Council. On February 5, 2025, at 3:03 p.m., the Administrator was interviewed. The Adm stated, the residents had brought up concerns about the dining room being closed at night during a Resident Council meeting. The Adm stated, the team developed solutions to address the issue, these solutions were not shared or discussed with the Resident Council. The Adm stated that the information should have been disseminated to ensure residents were informed. A review of Resident 1 's Admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included aftercare following surgery of the digestive system (group of organs that work together to digest and absorb nutrients from the food you eat). Resident 1 's History and Physical Examination, dated December 5, 2025, indicated Resident 1 has the capacity to make decisions. A review of Resident 2 's Admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (mental condition). Resident 2 's History and Physical Examination, dated November 30, 2024, indicated Resident 2 has the capacity to make decisions. A review of Resident 3 's Admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included left total knee replacement. Resident 3 's History and Physical Examination, dated January 20, 2025, indicated Resident 3 has the capacity to make decisions. A review of Resident 4 's Admission Record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar). Resident 4 's History and Physical Examination, dated December 29, 2024, indicated Resident 4 has the capacity to make decisions. A review of the facility policy and procedure titled, Resident Council Meetings, dated December 19, 2023, indicated, .The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the Council .