Every finding on record at Foothill Heights Care Center

Based on observation, interview, and record review, the facility failed to prevent multiple falls for one (1) of two (2) sampled residents (Resident 1) who was assessed as at risk for fall in accordance with the facility's policy and procedure (P&P) by failing to:Develop and revise the resident-centered care plan (a care plan developed and implemented to meet her or his preferences and goals, and addressed the resident's medical, physical, mental and psychosocial needs) to address Resident 1's fall risk and underlying cause of fall incidents.Initiate and implement the Falling Star Program (a widely used long-term care safety initiative designed to identify residents at a high risk for falls and prevent injuries) after Resident 1's fall on 5/22/2026.Conduct an interdisciplinary team (IDT- a group of healthcare professionals from different disciplines who collaborate to provide comprehensive and coordinated care of a resident) review after Resident 1's fall on 7/16/2026, 7/29/2026 and 8/18/2026 to assess risk factors and implement interventions specific to the underlying causes of each of Resident 1's fall.Closely monitor Resident 1 after the fall on 7/16/2026 as indicated on the IDT review, dated 7/21/2026. These deficient practices have resulted in Resident 1 falling on 7/16/2026, 7/29/2026, and 8/18/2026 and have the potential to result in further falls which could cause harm and injury to Resident 1.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included spinal stenosis (the narrowing of the open spaces within the spine), difficulty in walking, dementia (a brain disorder that results in memory loss, poor judgment and confusion), and history of falling. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 7/22/2026, the MDS indicated Resident 1 was assessed having severely (never/rarely made decisions) impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort; helper lifts, holds, or supports trunk or limbs, but provides half the effort) with toileting hygiene, shower/bathe self, putting on/taking off footwear, rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, and walking 10 feet (ft.- unit of measurement). During a review of Resident 1's Care Plan, initiated on 5/22/2026, the Care Plan indicated Resident 1 had an unwitnessed fall. The care plan interventions indicated to maintain a clutter free and spill free walkways, monitor for complications status post (s/p) fall such as bruising and pain and to report to physician if present, provide proper nonskid socks and footwear when ambulating, and for a STAT (immediately or without delay) x-ray (a photographic image of the internal composition of a part of the body) of bilateral (both) hips and sacrococcyx (bottom part of the spine where the sacrum and coccyx [tailbone] are joined together) area. During a review of Resident 1's Fall Incident Note, dated 7/16/2026, at 10:35 AM, the Fall Incident Note indicated Resident 1 had an unwitnessed fall on 7/16/2026, at 10:35 AM when Charge Nurse (CN) received report from housekeeping staff that Resident 1 was lying in supine position next to her bed. Tylenol (a medication for pain) was administered for moderate pain. The MD (Medical Doctor) was notified and ordered to transfer Resident 1 to General Acute Care Hospital (GACH) for head/neck pain. The Fall Incident Note, under Fall Risk Assessment, indicated Resident 1 was at risk for falls. During a review of Resident 1's IDT Review, dated 7/21/2026, at 1:28 PM, the IDT Review indicated Resident 1 was at risk for recurrent falls due to recent fall resulting in hospitalization and subsequent fall while hospitalized . The IDT Review also indicated Resident 1 was at risk for potential injury, decline in mobility, and changes in functional status. The IDT Report indicated recommendations that included to continue individualized fall prevention interventions per the care plan, follow facility policies and procedures related to fall prevention, resident safety, ongoing care planning, monitor resident closely, and implement fall prevention measures. During a review of Resident 1's Fall Incident Note, dated 7/29/2026, at 3:30 PM, the Fall Incident Note indicated Certified Nursing Assistant (CNA) saw Resident 1 sitting down on the floor. CN went to Resident 1's room and found Resident 1 sitting on the floor beside her bed crying and saying, I slid off and fell on the floor and hurt my head. Resident 1 complained of 2/10 (mild pain) pain in her head. The Fall Incident Note, under Fall Risk Assessment, indicated Resident 1 was at risk for falls. During a review of Resident 1's Change of Condition (COC) Form (late entry), dated 8/20/2026, at 4:32 PM, the COC Form indicated that on 8/18/2026, at 10 PM, CNA 1 called Licensed Vocational Nurse 1's (LVN 1) attention to go to Resident 1's room and found Resident 1 lying on the floor mat near her bed. Resident 1 stated she wanted to attend the graduation and appeared confused and restless. LVN 1 noted pinkish skin discoloration on Resident 1's face near her periorbital (tissues surrounding the eye socket, including the eyelids, eyebrows, and the skin and muscles around the eyes) area. MD was notified and ordered a stat x-ray of the skull. During a review of Resident 1's Progress Note, dated 8/18/2026, at 11:57 PM, the Progress Note indicated Licensed Nurse noted right eye swelling and discoloration around the eye, and some bruises also observed on the arms. Resident 1 alert with intermittent confusion, agitation and restlessness. Resident 1 remained in the room through the night under continuous watch. During an observation on 8/20/2026, at 12:33 PM, in the Activity Room, Resident 1 was observed sitting on her wheelchair, receiving feeding assistance from staff. Resident 1 had a bruise around her right eye. Resident 1 spoke a non-English language but unable to answer questions about her fall and would talk to herself. Resident 1 was observed trying to stand up from her wheelchair while in the Activity Room. Resident 1's wheelchair did not have a red sticker. Resident 1 was not wearing a color-coded wristband. During an observation on 8/20/2026, at 12:40 PM, of Resident 1's room entrance, Resident 1's nameplate did not have a yellow or red star sticker next to Resident 1's name. During an interview on 8/20/2026, at 2:07 PM, with CNA 2, CNA 2 stated Resident 1 had an unwitnessed fall on 8/18/2026. CNA 2 stated she was assigned to Resident 1 on the evening of 8/18/2026. CNA 2 stated on 8/18/2026, at around 9:40 PM, CNA 2 returned to Resident 1's room and saw CNA 1 and LVN 1 picking Resident 1 up from the floor. CNA 2 stated CNA 1 found Resident 1 on the floor when he walked by Resident 1's room. CNA 2 stated Resident 1 was at risk for falls because she could not see very well and liked standing up from her bed. CNA 2 stated she did not know how often Resident 1 needed to be monitored or supervised while in bed. During a concurrent interview and record review on 8/20/2026, at 3:35 PM, with the Director of Staffing Development (DSD), the facility's Falling Star Program binder was reviewed. The DSD stated Resident 1's name was not included in the list of residents at risk for fall (Fall Star List) in the Falling Star Program. During an interview on 8/20/2026, at 4:06 PM, with LVN 1, LVN 1 stated on 8/18/2026 at around 10 PM, LVN 1 was charting at the Nurse's Station when she heard CNA 1 yell outside Resident 1's room that he found Resident 1 on the floor. LVN 1 stated she ran to Resident 1's room and found Resident 1 on the floor next to her bed. LVN 1 assessed Resident 1 and noted that she had red discoloration on the right side of her face. LVN 1 stated Resident 1 was at risk for fall because of previous falls, confusion, poor vision, tried to get out the bed, and did not listen to redirection. LVN 1 stated Resident 1 required staff assistance and supervision when standing because she had difficulty with balance and had poor vision. LVN 1 stated she has observed Resident 1 feeling her surroundings with her hands to know what was around her. LVN 1 stated residents with history of falls should be supervised and monitored every hour. LVN 1 stated Resident 1 should have had a bed pad alarm (safety device to alert staff to help prevent resident falls) ordered or should have been placed under one-on-one supervision before 8/18/2026 because of her history of falls. LVN 1 stated residents who had a history of falls or recent falls were placed in the Falling Star Program and a red or yellow star was placed next to their names on the wall adjacent to the resident's door. During an interview on 8/21/2026, at 10:50 AM, with CNA 3, CNA 3 stated Resident 1 should have been supervised and monitored every hour because she tries to get out of bed and had a history of falls. During an interview on 8/21/2026, at 1:03 PM, with the Director of Rehab (DOR), the DOR stated Resident 1 was a high risk for fall and had actual falls on 5/22/2026, 7/16/2026, 7/29/2026, and 8/18/2026. DOR stated Resident 1 had poor safety awareness and needed assistance with bed mobility, standing, transferring, and walking with a front wheel walker. DOR stated Resident 1 should have been supervised closely because she was confused, unaware of her own strength, and would stand and start walking on her own without assistance. During a concurrent interview and record review on 8/21/2026, at 2:09 PM with MDS Nurse (MDSN), Resident 1's care plans for fall were reviewed. MDSN stated Resident 1's care plan, initiated on 7/16/2026 and revised on 7/29/2026, indicated Resident 1 was at risk for falls related to protein-calorie malnutrition (a condition caused by a lack of enough food, calories, and protein in the diet), difficulty in walking, psychosis (a mental state marked by a disconnect from reality, where a person has trouble telling what is real from what is not), and dementia. MDSN stated Resident 1's care plan interventions, initiated 7/16/2026 and revised 7/29/2026 indicated to:Anticipate and meet Resident 1's needs.Follow facility fall protocolReview information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate Resident/family/caregivers/IDT as to causesMDSN stated Resident 1's care plan interventions were not specific and resident-centered because it did not indicate the specific needs of Resident 1 that had to be anticipated to prevent falls, the cause of the fall, and the education provided to the resident/family/ caregivers. MDSN stated the facility fall protocol that needed to be followed was the Falling Star Program. MDSN stated the interventions indicated in the Falling Star Program policy were not indicated in the care plan's interventions. Furthermore, MDSN stated there was no IDT meeting conducted after Resident 1's fall on 7/29/2026. MDSN stated an IDT meeting should have been conducted to find out the reason for Resident 1's falls and to discuss resident-centered interventions to prevent fall recurrence. During the same concurrent interview and record review on 8/21/2026, at 2:09 PM with MDSN, MDSN stated Resident 1's care plan, initiated on 7/16/2026, indicated Resident 1 had an actual fall with mild redness to the back of the head accompanied by pain to the back of the head radiating to the neck. MDSN stated Resident 1's care plan intervention indicated to continue interventions on the at-risk plan. MDSN stated the interventions on the at-risk plan were Resident 1's care plan interventions from her unwitnessed fall on 5/22/2026. MDSN stated Resident 1's care plan for fall, initiated on 5/22/2026, has not and should have been revised since 5/22/2026. During the same concurrent interview and record review on 8/21/2026, at 2:09 PM with MDSN, MDSN stated Resident 1's care plan, initiated on 7/29/2026, indicated Resident 1 had an actual fall with no major injury. MDSN stated Resident 1's care plan interventions indicated to:Continue interventions on the at-risk planFor no apparent acute injury, determine and address causative factors of the fallMay use wheelchair with a lap buddy (soft cushion or positioning aid placed across a wheelchair to prevent sliding) while awake due to unsteady gait and poor safety awarenessMDSN stated the interventions on the care plan were Resident 1's care plan interventions from her unwitnessed fall on 5/22/2026 which has not been revised since 5/22/2026. MDSN stated Resident 1's care plans for fall were not and should have been revised after each fall. MDSN stated Resident 1's care plan for fall did not and should have indicated specific interventions on how to prevent future falls such as Resident 1's behavior of getting out of bed, supervision, monitoring, lack of safety awareness, vision problems, and moving Resident 's room close to the Nurse's Station. MDSN stated the care plan for fall should have a focus, goal, and detailed resident specific interventions to prevent future falls. During an interview on 8/21/2026, at 3:30 PM, with the Director of Nursing (DON) and the Administrator (ADM), the ADM stated an IDT regarding Resident 1's fall on 7/16/2026 was conducted after Resident 1 returned from the hospital on 7/20/2026. The ADM and DON both stated the IDT recommendations which included monitoring were not included in Resident 1's care plan for fall on 7/16/2026. The ADM and DON both stated that an IDT was not conducted after Resident 1's fall on 7/29/2026. During an interview on 8/21/2026, at 4:32 PM with the DON, the DON stated Resident 1 had a history of falling from her wheelchair and bed but was not ordered with a pad alarm until Resident 1 fell on 8/18/2026. The DON stated that fall prevention interventions for residents with history of falls start with putting the bed in a low position, floor mats (if resident was non-ambulatory [able to walk or move around]), moving the resident close to the Nurse's Station, adding a lap buddy and pad alarms, and one to one supervision. The DON stated a bed pad alarm should have been ordered before 8/18/2026 and could have alerted staff that Resident 1 was trying to get out of bed. The DON stated Resident 1's name was not on the list of residents at risk for falls in the Falling Star binder and should have had a red star next to her name plate to indicate Resident 1 had falls in the last 90 days. The DON stated Resident 1 should have been added to the Falling Star binder. The DON stated Resident 1's care plan should have been resident-centered to ensure proper interventions for fall preventions were communicated to the staff. The DON stated the facility's policy for the Falling Star Program and fall prevention were not followed. During a review of the facility's P&P, titled, Safety and Supervision or Residents, revised 7/2017, the P&P indicated:The facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents.The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.Resident supervision is a core component of the system's approach to safety. The type and frequency of Resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. During a review of the facility's P&P, titled, Falls-Clinical Protocol, revised on 3/2018, the P&P indicated:The staff and practitioner will review each resident's risk factors for falling and document in the medical record. Examples of risk factors for falling include gait and balance disorder, cognitive impairment, confusion, and visual impairment.Falls should be categorized as: those that occur while trying to rise from a sitting or lying to an upright position; those that occur while upright and attempting to ambulate; and other circumstances such as sliding out of a chair or rolling from a low bed to the floor.For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fallBased on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. During a review of the facility's P&P, titled, Falls and Fall Risk, Managing, revised 3/2018, the P&P indicated:Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the Resident from falling and to try to minimize complications from falling.Under Fall Risk Factors, Resident conditions that may contribute to the risk of falls include delirium and other cognitive impairment and visual deficits.The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each Resident at risk or with a history of falls.If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of fallingThe staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.If the Resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. During a review of the facility's P&P, titled, Falling Star Program, revised 1/1/2023, the P&P indicated:After an initial fall or if deemed by the IDT as high risk for fall, Resident will be included on a Falling Star Program.A Red Star will be placed on the resident's door to identify residents with a fall within the last 3 months (90-92 days). The same Red Star will also be placed on the resident's assistive device for locomotion for the staff to easily identify them. A color-coded wristband will be provided to the Resident to alert staff of the falling risk. This Red Star will remain until re-evaluated by the IDT quarterly.A Fall Star List will be kept up to date by IDT members at the nurse's station to be used by staff during huddles.

Based on observation, interview and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections or diseases in the healthcare setting) were followed for one of two sampled residents (Resident 1) when staff did not sanitize the hoyer lift (a mechanical device used by caregivers to safely transfer individuals with limited mobility from one surface to another, such as from bed to wheelchair or the toilet) after use to transfer Resident 1, as indicated in the facility's policy and procedure. This deficient practice had the potential to result in resident developing infections and spreading infection among staff and other residents.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted Resident 1 on 1/18/2024 and readmitted on [DATE] with diagnoses including but not limited to, disorder involving the immune mechanism (any condition where the body's defense mechanism malfunctions). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 4/20/2026, the MDS indicated Resident 1 had severely impaired cognitive (ability to think, learn, remember, use judgment and making decisions) skills for daily decision making. The MDS indicated Resident 1 required partial/moderate assistance (Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with oral and personal hygiene. The MDS indicated Resident 1 required substantial/maximal assistance (Helper lifts or holds trunk or limbs and provides more than half the effort) with eating, upper body dressing, and rolling left to right. The MDS further indicated Resident 1 was dependent (Helper does all the effort or the assistance of two or more helpers is required for the resident to complete the activity) with toileting hygiene, shower/bathing self, lower body dressing, sit to lying, lying to sitting, chair/bed-to-chair transfer, and tub/shower transfer.During an observation on 6/4/2026 at 12:20 PM inside Resident 1's room, Certified Nurse Assistant (CNA) 1 and 2 were observed transferring Resident 1 from the geri chair (geriatric chair, a specialized, multiposition reclining chair with wheels) back to bed using a hoyer lift. Observed a signage by the resident's door indicating Resident 1 was on Enhanced Barrier Precautions (EBP-infection control strategy used in nursing homes and skilled nursing facilities to prevent the spread of multidrug resistant organisms [MDROs-germs that has adapted to survive against multiple types of antibiotic {medicines that fight infections by killing bacteria or stopping them from growing and reproducing} medications]). During a concurrent observation and interview on 6/4/2026 at 12:35 PM inside Resident 1's room, CNA 1 was observed taking the used hoyer lift out of the room to the hallway and plugged the hoyer lift to charge it into a power outlet without sanitizing the hoyer lift. CNA 1 stated he did not wipe the hoyer lift with sani wipes (powerful, disposable wipes designed to clean and disinfect hard, nonporous surfaces to prevent spread of bacteria, viruses, and pathogens [commonly referred to as germs]) because he did not find sani wipes on the PPE cart outside of Resident 1's room. During an interview on 6/4/2026 at 2:50 PM with CNA 1, CNA 1 confirmed that he did not sanitize the hoyer lift after using it to transfer Resident 1. CNA 1 stated he was aware that he needed to sanitize the hoyer lift before and after each resident use. CNA 1 stated not sanitizing the hoyer lift, especially before and after use can cause risk for spread of infection to residents or staff. During a concurrent interview and record review on 6/4/2026 at 3:55 PM with Infection Prevention Nurse (IPN), the facility's policy and procedure (P&P) titled Lifting Machine, Use of Mechanical, review date of 1/29/2026, was reviewed. IPN Nurse stated the P&P indicated to disinfect lift surfaces (hoyer lift). IPN stated sani wipes were to be used to disinfect the hoyer lift. IPN stated if hoyer lift was not sanitized or disinfected after each reisdent use, it can result in the spread of germs and infections to other residents who also needed the hoyer lift during care. IPN stated this can potentially result in illness and hospitalization of the residents. During a concurrent interview and record review on 6/4/2026 at 4:10 PM with the Administrator (ADM), the facility's P&P titled Lifting Machine, Use of Mechanical, review date of 1/29/2026, was reviewed. The ADM stated the P&P indicated to disinfect lift surfaces. The ADM stated the P&P did not indicate to disinfect before and after use. The ADM stated that the policy needed to specify when hoyer lift needed to be disinfected or sanitized.

Based on interview and record review, the facility failed to ensure the physician reviewed and took timely action on a medication regimen review (MRR, consists of a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) irregularity (includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) identified by the facility's pharmacy consultant for three of five sampled residents (Residents 1, 7, and 9) reviewed for unnecessary medications by failing to ensure:Resident 1's March 2026 MRR was addressed by the physician for the use of Benadryl (Diphenhydramine, medication used to relieve allergy symptoms and sometimes to aid sleep).Resident 7's MRR recommendations for appropriate side effect (an unintended or secondary effect) monitoring on 2/16/2026 and 3/17/2026 were followed up on and/or carried out for the medication lamotrigine (Lamictal- anticonvulsant [a medication used to prevent or treat seizures- a sudden disruption of the brain's normal electrical activity accompanied by altered consciousness and/or other neurological and behavioral manifestations] and mood stabilizer).Resident 9's MRR recommendation was addressed by the physician for the use of Ergocalciferol (a dietary supplement and medication used to treat and prevent vitamin D deficiency, helps the body absorb calcium and phosphorous to build strong bones).These deficient practices increased Residents 1, 7, and 9's risk to experience adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to their medication therapy, potentially leading to impairment or decline in their mental, functional, and psychosocial wellbeing.Findings: 1. During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE], with the diagnoses including but not limited to chronic obstructive pulmonary disease (COPD, disease that causes obstructed airflow from the lungs), schizoaffective disorders (a mental illness that causes loss of contact with reality), and schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves). During a record review of Resident 1's Order Summary Report, dated 3/16/2026, the order indicated Benadryl allergy oral tablet 50 milligrams (mg, unit of measurement) by mouth at bedtime for pruritis (itching). During a record review of the Consultant Pharmacist's Medication Regimen Review, dated 3/17/2026, the MRR indicated Resident 1 had an order for Benadryl at bedtime for pruritis. The MRR also indicated that Diphenhydramine, due to its anticholinergic (a substance or drug that blocks the action of acetylcholine, a chemical messenger in the body, reducing certain involuntary body functions) properties, such as dry mouth, blurred vision, urinary retention (condition that makes it difficult to empty the bladder, either partially or completely), etc., this agent is not recommended for use in the elderly population. The MRR further indicated to assess current regimen for a term of therapy (i.e. short-term use), and should current regimen continue to be clinically warranted, suggest documenting an assessment of risk versus benefit in your notes, or on this form, describing that it continues to be appropriate therapy for this resident. During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment and tool), dated 3/19/2026, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were moderately impaired. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) for upper body dressing, roll left and right, and sit to lying. During a concurrent interview with the Director of Nursing (DON) and record review of Resident 1's progress notes and MRR on 5/7/2026 at 3:13 PM, the DON stated Resident 1's MRR for 3/17/2026 was not addressed. The DON stated Resident 1's progress notes did not indicate that the physician was notified and/or that any follow up occurred regarding Resident 1's MRR. The DON stated the MRR should have been addressed within 72 hours of 3/17/2026. The DON further stated following up with the physician on the pharmacist's MRR recommendation was important to ensure Resident 1 received the right medication dosage, and if the medication was no longer needed, it would be discontinued accordingly. 2. During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was admitted to the facility with diagnoses that included schizophrenia, hemiplegia and hemiparesis on the right side of the body and gastro-esophageal reflux disease. During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7 had severely impaired cognitive skills for daily decision making. The MDS also indicated that Resident 7 required partial moderate assistance with oral and personal hygiene and dependent with toileting hygiene, self-bathing/showering, and lower body dressing. During a review of Resident 7's Order Summary Report, the Order Summary Report indicated lamotrigine oral tablet 100 mg and 25 mg, give one tablet (of each to total [=] 125 mg) by mouth at bedtime for mood disorder manifested by angry outbursts. During a concurrent interview and record review on 5/7/2026 at 1:31 PM with the DON, the Consultant Pharmacist's MRRs, dated 2/19/2026 and 3/17/2026, were reviewed. The MRRs indicated that Lamictal was classified as an anticonvulsant (), with a side effect profile that was different from the side effect profile of an antipsychotic (a medication primarily used to manage psychosis [a severe mental condition in which thought, and emotions are so affected that contact is lost with reality]). The MMR further indicated for the side effect monitoring of Lamictal to be updated to more accurately reflect the side effect profile (i.e., as an anticonvulsant). The DON stated MRRs are completed monthly and the pharmacy recommendations are carried out by the doctors and nursing staff. During the same concurrent interview and record review on 5/7/2026 at 1:31 PM with the DON, Resident 7's electronic chart was reviewed for the period of 2/19/2026 through 5/7/2026. Resident 7's electronic chart failed to indicate anticonvulsant side effect monitoring for lamotrigine or documentation on why the recommendation for anticonvulsant side effect monitoring was not being done. The DON stated that no anticonvulsant side effect monitoring was being completed for Resident 7 and that the recommendation was not followed. The DON stated that lamotrigine is an anticonvulsant and it was inappropriate to continue monitoring for antipsychotic side effects because the side effects of anticonvulsants and antipsychotics may differ. The DON further stated that it was important to follow through with the pharmacist's recommendations for anticonvulsant side effect monitoring to ensure the appropriate side effects are monitored, prevent potential harm to the resident, and identify any changes in Resident 7's condition. 3. During a review of Resident 9's admission Record, the admission Record indicated the facility initially admitted Resident 9 on 6/3/2024 and readmitted on [DATE] with diagnoses including, but not limited to protein calorie malnutrition (a severe life threatening condition caused by a lack of enough calories and protein in the diet resulting in weight loss, weak immunity, and reduced functional capacity), osteoporosis (a common bone disease that makes bones weak, brittle, and porous significantly increasing the risk for fractures [break in bones]), and dementia (a progressive state of decline in mental abilities). During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 9 was independent (Resident completes the activity by himself with no assistance from a helper) with eating, oral and toileting hygiene, and upper body dressing. The MDS indicated Resident 9 required set up or clean up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) with lower body dressing, putting on/taking off footwear and personal hygiene. The MDS further indicated Resident 9 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with shower/bathing self. During a review of the Consultant Pharmacist's MRR, dated 3/17/2026, the MRR indicated Resident 9 was on Ergocalciferol 50,000 units (measurement of a medication's biological activity or effect than its physical weight, used to standardize the potency of vitamins, hormones, or certain drugs) weekly. The most recent Vitamin D level was more than (>) 150 (high), which was drawn on 12/10/2025. The MRR indicated the pharmacist's recommendation to consider discontinuing the order at this time since laboratory results have normalized and high dose therapy may no longer be warranted. During a review of Resident 9's Order Summary Report, dated 5/7/2026, the Order Summary Report indicated Ergocalciferol oral capsule 1.25 milligram (mg, a unit of measurement for drug dosage equal to one-thousandth of a gram) (50000UT), give one capsule by mouth one time a day every Tuesday for supplement, with order date of 12/15/2025. During a concurrent interview and record review on 5/7/2026 at 3:27 PM, with the DON, Resident 9's progress notes and MRR dated 3/17/2026, were reviewed. The DON stated there was no physician notification documented in the progress notes addressing Resident 9's MRR. The DON stated the physician was not notified and should have been, within 72 hours after the MRR was done on 3/17/2026. The DON stated that not following the MRR recommendations for Resident 9 could result in an increased calcium (a vital mineral that the body needs to build and maintain strong bones and teeth) level, cause nausea (urge to vomit), vomiting (forceful, involuntary expulsion of stomach contents through the mouth), and weakness for Resident 9. The DON further stated that following up with the physician regarding MRR recommendations is important to ensure residents receive the right dosage of medications and determine if medications need to be discontinued. During a record review of the facility's Policy and Procedure (P&P) titled, Medication Regimen Reviews, dated 1/29/2026, the P&P indicated upon receiving the MRR from the pharmacist, the attending physician reviews and responds to the report. The physician documents in the resident's medical record that the pharmacist's recommendations have been reviewed and what (if any) actions were taken to address them. If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director or (if the medical director is the physician of record) the administrator.

Based on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure (P&P) by failing to:a. Label food in the kitchen with item name and use by date (the last date recommended for the use of the product) and/or open date.b. Keep the refrigerator temperature log updated every shift.c. Discard expired food items in the kitchen.d. Ensure kitchen floor was clean and dry when water overflowed from dishwashing machine onto the floor.e. Ensure the ice machine's drainpipe had an air gap (physical separation between a water supply outlet and the flood-level rim of a receiving vessel like a sink or drain). These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization.Findings: During a concurrent interview and observation on 5/4/2026 at 7:59 AM with the [NAME] (CK) in the kitchen, CK stated the meat in the refrigerator was only labelled with the received on 4/30/2026 and use by date of 4/30/2026. CK stated CK had pulled out the ground beef on 5/3/2026 and forgot to label the food item with name and the use by date of 5/5/2026 since it was being thawed in the refrigerator. During a concurrent interview and record review on 5/4/2026 at 7:59 AM with the Dietary Supervisor (DS) of the Refrigerator Temperature Log for the month of May 2026, DS stated staff were supposed to check the refrigerator temperatures in the morning and afternoon and document the temperature on the log. DS stated the morning temperatures for 5/3/2026 and 5/4/2026 were missing. During a concurrent interview and observation on 5/4/2026 at 8:24 AM with DS, DS stated the mashed potatoes on the kitchen counter had a use by date of 4/31/2026. DS informed CK the mashed potatoes needed to be discarded. During a concurrent interview and observation on 5/4/2026 at 8:37 AM with Dietary Aide (DA), the kitchen floor was observed to be wet with a puddle of water. DA stated the floor gets wet when she washes the dishes in the sink. There was more puddling observed on the kitchen floor when the washing machine strainer was overspilling water and leaking onto the floor. During a concurrent interview and observation on 5/4/2026 at 8:45 AM with DS, DS stated the kitchen floor was wet with water. DS stated water was coming out from the strainer of the washing machine.During a concurrent interview and observation on 5/5/2026 at 2:31 PM with Maintenance Supervisor (MS) of the ice machine, MS stated the ice machine drainage pipe was going directly into the floor and did not know how deep the tube extended past the floor. MS stated the ice machine drainpipe was supposed to have an air gap and there was no air gap since the pipe went through the floor. MS stated an air gap was needed to prevent backflow of bacteria back into the ice machine. During an interview on 5/5/2026 at 2:41 PM with DS, DS stated food items should be labelled with product name and use by date. DS stated when food was thawed, the guideline was for the food item to be labeled and used by the third day. DS stated any food beyond the use by date needed to be discarded due to the growth of germs and bacteria. DS stated the bacteria on the food could harm the residents and staff in the facility. DS stated the kitchen floor should not have pooled water and could cause a safety hazard to the staff. During an interview on 5/6/2026 at 1:43 PM with DS, DS stated the water mopped up from the kitchen floor was discarded in the same utility room shared with housekeeping. During an interview on 5/6/2026 at 5:15 PM with the Infection Prevention Nurse (IPN), IPN stated the food and/or utensils could become contaminated from splatters of water on the floor when there was an overflow of water from the washing machine onto the kitchen floor. IPN stated residents could experience food poisoning or food illness from the splatters of water from the floor. IPN also stated that since there was no water drainage system the water on the floor can become stagnant which could support the growth of bacteria. During a record review of the facility's P&P titled, Refrigerators and Freezers, dated 1/26/2026, the P&P indicated monthly tracking sheets for all refrigerators and freezers are posted to record temperatures; monthly tracking sheets include refrigerator temperature, temperature of food, initials, and action taken; use by dates are completed with expiration dates on all prepared food in refrigerators; expiration dates on unopened food are observed and use by dates are indicated once food is opened; supervisors are responsible for ensuring food items in pantry, refrigerators, and freezer are not past use by or expiration dates. During a record review of the facility's P&P titled, Sanitization, dated 1/26/2026, the P&P indicated the food service area is maintained in a clean and sanitary manner and all kitchens, kitchen areas and dining areas are kept clean. During a record review of the facility's P&P titled, Water Supply, dated 1/29/2026, the P&P indicated approaches to controlling waterborne microorganisms (i.e., water system decontamination) will be consistent with the Food and Drug Administration (FDA). During a record review of the 2022 FDA 2022 Food Code 2022, 5-202.13 titled, Backflow Prevention, Air Gap, indicated an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less then 22 millimeters (mm, unit of measurement) (one inch). https://www.fda.gov/media/164194/download?attachment

Based on observation, interview, and record review, the facility failed to ensure garbage was properly disposed of in accordance with the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal. This deficient practice had the potential to attract pests and rodents and may cause disease and other health issues to residents, staff, and the community.Findings: During a concurrent observation and interview on 5/4/2026 at 8:30 AM with the Dietary Supervisor (DS), in the facility's parking lot, two dumpsters were overfilled with trash bags and left uncovered. DS stated the two dumpsters were overfilled with trash bags and were supposed to be covered with lids. DS stated the dumpsters should be covered with lids to prevent infection control. During a record review of the facility's P&P titled, Food-Related Garbage and Refuse Disposal, dated 1/26/2026, the P&P indicated outside dumpsters provided by garbage pickup services will be kept closed and fee of surrounding litter.

Based on observation, interview and record review, the facility staff failed to obtain an accurate water temperature reading and ensure the water used to wash one load of soiled linens (bedsheets, pillowcases and blankets) were washed at 160 for a minimum of 25 minutes Washer two (2) as indicated in the facility's policy. This deficient practice had the potential to compromise infection control measures to eliminate disease causing germs (microscopic [extremely small and invisible to the naked eye], living organisms including bacteria, viruses, fungi, and protozoa) on linens which could get residents sick and potentially spread infection in the facility.Findings:During a concurrent observation and interview on 5/6/2026 at 11:36 AM with Laundry Staff 1 (LS 1) at the laundry room washer area, one wash load of linen was observed running in Washer 2. LS 1 stated the temperature reading on the thermometer attached to the hot water line behind Washer one (1) and Washer 2 was at 120 degrees Fahrenheit ( -temperature scale used to measure how hot or cold something is). LS 1 stated he does not know why the temperature reading behind Washers 1 and 2 was at 120 which is lower than the temperature reading on the water heater gauge was set at 160 . LS 1 stated the temperature readings from the thermometer attached to the hot water line behind Washer 1 and 2 and water heater gauge should be the same. LS 1 stated the facility Washers 1 and 2'stemperature and should be at 160 . During a concurrent observation, interview, and record review on 5/6/2026 at 12:13 PM with Maintenance Supervisor (MS) and LS 1 in the laundry room dryer area, the dyer temperature log for 5/2026 was reviewed. The dryer temperature log indicated recorded temperatures for Dryer 1 and Dryer 2 from 5/1/2026 to 5/6/2026. LS 1 stated Dryer 1 did not have a built-in thermometer to check the dryer temperature. LS 1 stated the dryer has three settings of low, medium, or high temperature button and he does not know the time (duration the dryer will run) and temperature settings for each selection. LS 1 stated he copied and wrote the temperature readings for Dryer 1 from previous logs as instructed by the previous MS. LS 1 stated staff had been recording the temperature for Dryer 1 without actually measuring it. MS confirmed with LS 1 that temperature was not measured for Dryer 1 because there was no thermometer or temperature gauge to measure Dryer 1's temperature. MS and LS 1 stated recording the temperature without measuring the temperature for Dryer 1 was not acceptable and was not accurate. During a concurrent observation and interview on 5/6/2026 at 1:07 PM with the MS and LS 1 in the laundry room washer section, a laundry cycle for soiled linens were started using Washer 2. MS confirmed the thermometer reading from the hot water line going to Washers 2 was 120 . During a concurrent observation and interview at 5/6/2026 at 1:13 PM at the boiler room with the MS, water heater temperature control panel was set at 160 and confirmed by MS. The hot water temperature reading on the water heater thermometer (gauge) was at 148 . During a concurrent observation and interview on 5/6/2026 at 1:20 PM, in the laundry room washer area, temperature reading from the hot water line leading to Washers 1 and 2's thermometer was at 120 . MS stated the temperature gauge on the water heater in the boiler room and the thermometer attached to the hot water line of Washers 1 and 2 were not working as it was not reading the same temperature. During a concurrent observation and interview on 5/6/2026 at 1:32 PM in the boiler room, water heater gauge reading was at 160 per MS. MS stated the temperature of 160 was not maintained for at least 25 minutes from the start of the wash cycle at 1:07 PM to 1:32 PM because at 1:20 PM the thermometer behind Washer 2 indicated a temperature of 120 . MS stated this was not acceptable as the temperature was not enough to kill the germs in the linens. During a concurrent interview and record review on 5/6/2026 at 4 PM with Infection Prevention and Control Nurse (IPN), the policy and procedure (P&P) titled Departmental (Environmental Services)-Laundry and Linen, revised 1/26/2026 was reviewed. The IPN stated that the P&P indicated that for high-temperature processing, wash linens in water that is at least 160 , for a minimum or 25 minutes. The IPN stated that P&P was not followed when water temperatures from the thermometer behind Washer 1 and 2 OR water line leading to Washers 1 and 2 was observed to be below 160 . IPN stated on the water temperature observed on 5/6/2026 was 120 at 1:07 PM 148 , at1:13 PM 120 at1:20 PM , and 160 ) at 1:32 PM. IPN stated the water temperature for Washer 1 and 2 was not at 160 as soon as the wash cycle started and was not maintained at 160IPN stated this was not acceptable as the temperature and time were not enough to adequately and effectively sanitize the linens used by the residents and could place the residents at risk for infections and spread of infections. During an interview on 5/7/2026 at 9 AM with the Administrator (ADM), the ADM stated there was no specific facility P&P addressing washer and dryer outlining details of temperature and time settings for laundry and documentation or logging of temperatures for washers and dryers. The ADM stated there should be a P&P for this so laundry and maintenance departments will be guided by set standards to effectively manage infection control measures in terms of laundry of linensDuring a review of the P&P titled Laundry and Bedding, Soiled, reviewed 1/29/2026, indicated soiled laundry/bedding shall be handled, transported, and processed according to best practices for infection prevention and control.

Based on interview and record review, the facility failed to ensure that advance directives (a legal document indicating resident preference on end-of-life treatment decisions) were discussed and written information was provided to one (1) of 1 sampled resident (Resident 7) reviewed for advance directive. This deficient practice violated Resident's 7 and/or the resident's responsible party's (RP) right to be fully informed of the option to formulate their advanced directives and had the potential to cause conflict with the residents' wishes regarding health care.Findings:During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness of the arm, leg, and trunk on the same side of the body)on the right side of the body and gastro-esophageal reflux disease (GERD - chronic digestive disease where the contents of the stomach refluxes and irritates the esophagus). During a review of Resident quarterly Minimum Data Set (MDS- a resident assessment tool), dated 4/3/2026, the MDS indicated Resident 7 had severely impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated, Resident 7 was assessed to need partial moderate assistance (helper does less than half the effort) with oral and personal hygiene and dependent with toileting hygiene, self-bathing/showering and lower body dressing. During a concurrent interview and record review on 5/6/2026 at 10:31 AM with the Director of Nursing, Resident 7's Advance Healthcare Directive (AHCD) Acknowledgment Form, dated 3/3/2026 was reviewed. The AHCD Acknowledgment form did not indicate the following:Resident 7's RP received information regarding the right to make an AHCD.If Resident 7 does or does not have an AHCD.If Resident 7's RP did or did not want information regarding formulating an AHCD.The DON stated the AHCD Acknowledgment form should have been completed upon admission of Resident 7 to the facility for staff to know if Resident 7 had an advance directive and that information to formulate an AHCD was given to Resident 7's RP, per facility policy. During an interview on 5/6/2026 at 12:11 PM with the Social Services Director (SSD), the SSD stated per facility protocol, the AHCD Acknowledgement form needs to be completed and signed by the resident or RP with their selection to know if the resident has an advance directive, and or wants additional information to make one so that the resident's wants or wishes with regard to the end-of-life treatment will be known to the staff. During a review of the facility's policy titled Advance Directives, dated 1/29/2026, the policy indicated the resident has the right to formulate an advance directive, and advance directives are honored in accordance with state law and facility policy. The policy also indicated the following:Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives.The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident or representative.If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the residents' legal representative.Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff.

Based on interview and record review, the facility failed to notify the physician regarding the change of condition (COC, tool used by health care professionals when communicating about critical changes in a resident's status) of weight loss for one (1) of two (2) sampled residents (Resident 3) reviewed under nutrition. This deficient practice had the potential to result in delayed provision of necessary care and services.Findings:During a review of Resident 3's admission Record, the admission record indicated Resident 3 was admitted to the facility on [DATE], with the diagnoses including but not limited to protein-calorie malnutrition (a severe condition resulting from inadequate intake of protein and/or calories), thrombocytopenia (abnormally low number of platelets in the blood), and dementia (progressive brain disorder that slowly destroys memory and thinking skills). During a record review of Resident 3's Care Plan, dated 10/20/2025, the Care Plan indicated Resident 3 was at risk for alteration in nutritional status due to being on medication that may alter appetite, malnutrition, needed assistance with meals, and dementia process. The Care Plan goal was Resident 3 will maintain adequate nutrition status as evidenced by stable weight with no significant weight changes (significant weight change defined as greater than or equal to five [5] percent in 30 days, greater than or equal to 7.5 percent in 90 days). The Care Plan interventions for staff were to weigh residents per policy, notify the physician of changes, and monitor weights and refer to weight variance committee if significant change occurs. During a record review of Resident 3's Minimum Data Set (MDS, a resident assessment and tool), dated 4/30/2026, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was severely impaired. The MDS indicated Resident 3 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on eating, toileting hygiene and sitting to lying on the bed. The MDS also indicated Resident 3 did not have a loss of 5 percent or more in the last month or ten (10) percent or more in the last six (6) months. During a record review of Resident 3's Weight Summary dated from 4/1/2026 to 5/4/2026 indicated as follows:On 4/1/2026 the resident's weight was 123.0 pounds (lbs).On 5/4/2026 the resident's weight is 116.0 lbs (-5.69 % weight loss, seven [7] lbs weight loss on 30 days) During a concurrent interview and record review on 5/6/2026 at 9:45 AM with Restorative Nurse Aide 1 (RNA 1), Resident 3's Weight Summary dated from 4/1/2026 to 5/4/2026 was reviewed. RNA 1 stated according to the weight summary, Resident 3 lost 7 lbs within the last month. RNA 1 stated RNAs are responsible for obtaining the resident's weights and to notify the charge nurse when there was a weight loss of five lbs or more.\. RNA 1 stated he did not inform the charge nurse of Resident 1's 7 lbs weight loss noted when he took and recorded Resident 3's weight after 5/4/2026 and should have informed the charge nurse. RNA 1 stated the charge nurse should have been informed to assess the resident for the weight loss and to notify the physician. During a concurrent interview and record review on 5/6/2026 at 10:35 AM with Licensed Vocational Nurse 1 (LVN 1), Resident 3's COC and Nurses Progress Notes dated from 5/4/2026 to 5/6/2026 were reviewed. The COC and progress notes did not have documented evidence that Resident 3's 7 lbs weight loss was assessed, monitored and that the physician was notified. LVN 1 stated the physician needed to be notified immediately when residents experienced a weight loss of four lbs or more in a month since it was a change in the resident's condition. LVN 1 stated there were no notifications to the physician regarding Resident 3's weight loss. During an interview on 5/7/2026 at 2:42 PM with the Director of Nursing (DON), the DON stated the physician should be notified right away when there was a weight loss of three (3) lbs or more within 30 days. The DON stated the facility should have started taking action to prevent any further weight loss and decline of the resident. During a record review of the facility's Policy and Procedure (P&P) titled, Change in a Resident's Condition or Status, dated 1/26/2026, the P&P indicated the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. The P&P also indicated notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. During a record review of the facility's P&P titled, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, dated 1/26/2026, the P&P indicated the staff will report the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake.

Based on interview and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 25) reviewed for beneficiary notification was informed of the changes in Medicare (federal health insurance program) coverage and provided with the Advanced Beneficiary Notice (ABN, written notice provided to Medicare beneficiaries when Medicare payment is expected to be denied for certain services or items) in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential to result in Resident 25's Responsible Party (RP) not being able to exercise their right to file an appeal and had the potential to cause stress to the resident's RP for not being able to make adequate arrangements for charges that may be incurred. Findings:During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted to the facility on [DATE], with the diagnoses including but not limited to encephalopathy (brain disease, damage, or malfunction that results in an altered mental state), Alzheimer's disease (a brain disorder that destroys memory and other important mental functions), and dementia (progressive brain disorder that slowly destroys memory and thinking skills). The admission Record also indicated Resident 25 had RP as the decision maker. During a review of Resident 25's Minimum Data Set (MDS, a resident's assessment tool), dated 2/1/2026, the record indicated Resident 25's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were severely impaired. During a review of Resident 25's Skilled Nursing Facility (SNF) Beneficiary Notification Review form completed on 3/13/2026, the form indicated Resident 25's Medicare Part A Skilled Services episode started on 1/5/2026 and the last day covered day of Part A Service ended on 3/16/2026. The form indicated SNF ABN Form was not provided to Resident 25's RP. During an interview on 5/6/2026 at 11:25 AM with the Business Office Manager (BOM), BOM stated she called Resident 25's RP once on 3/13/2026 to discuss the resident's Part A coverage that will end on 3/16/2026 and left voice message. BOM stated she did not follow up and forgot to call Resident 25's RP again. BOM stated she did not send a copy of the SNF ABN to Resident 25's RP. BOM stated Resident 25 was a long-term resident and had resided in the facility since 1/18/2024 and there was no address for Resident 25's RP on file. BOM stated there should have been an address on file to send the information to the RP. During a follow-up interview on 5/6/2026 at 12:17 PM with BOM, BOM stated the SNF ABN notification via mail to Resident 25's RP would notify Resident 25's RP if there was an out of pocket that was not covered so Resident 25's RP could prepare for the financial responsibility or file an appeal if they did not agree with the decision. BOM stated it was not provided to Resident 25's RP. During a review of the facility's P&P titled, Advance Beneficiary Notice, dated 1/26/2026, the P&P indicated written notices of the likelihood of Medicare payment denial are provided to the resident/beneficiary as soon as the facility makes the assessment that Medicare payment certainly or probably will not be made and before the item or service is furnished.

Based on interview and record review, the facility failed to provide Restorative Nursing Services (a program available in nursing homes to help residents maintain any progress made during therapy treatments, enabling them to achieve their highest practicable level of functioning) treatments (total of 10 missed treatments) for one of two sampled residents (Resident 3) reviewed for limited range of motion (ROM, full movement potential of a joint) in accordance with the physician's order. This deficient practice placed Resident 3 at risk for decline in physical functions and develop contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in the extremities (a limb of the body, such as the arm or leg) for not receiving the ordered exercises. Findings:During a review of Resident 3's admission Record, the admission record indicated Resident 3 was admitted to the facility on [DATE], with the diagnoses including but not limited to muscle wasting (loss of muscle mass) and atrophy (muscle shrinking), contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in the left knee, left shoulder, right shoulder, left elbow and right elbow. During a record review of Resident 3's Joint Mobility Screening, dated 1/20/2026, the screening indicated Resident 3's right and left knees had severe (greater than 50 % loss) loss of mobility. It also indicated Resident 3's right elbow had severe (greater than 50 % loss) loss of mobility and Resident 3's left elbow had moderate (26-50 % loss) loss of mobility. The screening also indicated the current program (RNA program) effectiveness had maintained joint mobility. During a record review of Resident 3's Care Plan, dated 2/7/2026, the Care Plan indicated Resident 3 had an alteration in joint mobility as evidenced by limitations noted to right and left elbow, right and left hip, right and left knee, left wrists, left fingers and was at risk for further unavoidable decline in range of motion. The Care Plan indicated one of the interventions was for staff to provide range of motion exercises as ordered and position the resident to prevent further contractures with pillow or splint. During a record review of Resident 3's Minimum Data Set (MDS, a resident assessment and tool), dated 4/30/2026, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was severely impaired. The MDS indicated Resident 3 had impairment on both sides in the upper and lower extremities. The MDS also indicated Resident 3 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for toileting hygiene, oral hygiene, upper and lower dressing, roll left and right, sit to lying. During a record review of Resident 3's Order Summary Report for the month of May 2026, the order summary report indicated the following: On 2/9/2026- RNA to apply splint (device used to immobilize, protect, and support injured or fractured bones and joints) to both knees, every day five (5) times a week, for four (4) hours or as tolerated.On 3/24/2026- RNA Program, passive range of motion (PROM, the range that can be achieved by external means such as another person or a device) exercises to both upper extremities (UE: shoulders, elbows, wrists, hands) and lower extremities (LE: hips, knees, ankles, and feet) in all planes as tolerated. Every day 5 times a week. During a record review of Resident 3's Joint Mobility Screening, dated 4/28/2026, the screening indicated Resident 3's right and left knees had severe loss of mobility. It also indicated Resident 3's right elbow had severe loss of mobility and Resident 3's left elbow had minimal (less than 25 % loss) loss of mobility. The screening also indicated the current program effectiveness had improved. During a record review of Resident 3's Documentation Survey Report for the months of March and April 2026, it indicated Resident 3's order for RNA services for PROM exercises in both UE and LE in all planes as tolerated every day 5 times a week. It also indicated the order for RNA to apply splints to both knees every day 5 times a week for 4 hours or as tolerated. The documentation survey report indicated 10 missed treatments for the following weeks of the months of March and April 2026: Week 2: 3/9/2026 to 3/15/2026 (three missed treatments)Week 3: 3/16/2026 to 3/22/2026 (three missed treatments)Week 4: 3/23/2026 to 3/29/2026 (one missed treatment)Week 5: 3/30/2026 to 4/5/2026 (one missed treatments) Week 6: 4/6/2026 to 4/12/2026 (one missed treatments) Week 7: 4/13/2026 to 4/19/2026 (one missed treatments) During a concurrent interview and record review on 5/6/2026 at 9:09 AM with Restorative Nurse Aide 1 (RNA 1), Resident 3's Documentation Survey Report for the month of March and April 2026 were reviewed. RNA 1 stated according to the documentation survey report there were 10 missing treatments or RNA services for the month of March and April 2026. RNA 1 stated Resident 3 was supposed to receive RNA services for PROM exercises to both UE and LE and knee splints for both knees. RNA 1 stated RNAs needed to document after performing the RNA services for the resident. RNA 1 stated there were no notes indicating the reasons for the missed RNA services. RNA 1 stated when there was no charting done for the RNA services, then it meant that the RNA services were not provided for Resident 3. RNA 1 stated when RNA services were not done for Resident 3, the resident could get more contracted and/or the contractures could worsen. During a concurrent interview and record review on 5/6/2026 at 10:51 AM with Director of Rehabilitation (DOR) of Resident 3's Joint Mobility Screening, DOR stated according to the resident joint mobility screening, Resident 3 had multiple contractures. DOR also stated RNA services being performed in accordance with the physician's order were needed to maintain the resident's joints and to have a better quality of life. During an interview on 5/7/2026 at 2:39 PM with the Director of Nursing (DON), the DON stated RNAs needed to document the completion of the RNA services or treatments provided to the residents. The DON stated if there was no documentation for RNA services, then it meant the RNA treatment was not done for the resident. The DON stated the importance of providing RNA services as ordered was to improve the resident's activities of daily living and functionality and prevention of contractions. The DON stated when RNA services were not provided to the residents there could be a decline in activities of daily living which can lead to muscle wasting and contractures. During a record review of the facility's Policy and Procedure (P&P) titled, Restorative Nursing Services, revised 7/2017, the P&P indicated residents will receive restorative nursing care as needed to help promote optimal safety and independence. The P&P also indicated restorative goals may include but are not limited to supporting and assisting the resident in maintaining his/her dignity, independence and self-esteem and participating in the development and implementation of his/her plan of care.

Based on observation, interview, and record review, the facility failed to follow its policy to develop and implement a care plan that included strategies and interventions to maintain the safety for one of three sampled residents (Resident 36), reviewed for accidents and assessed as at risk for elopement (the act of leaving a facility unsupervised and without prior authorization) /wandering (moving without any clear purpose or direction). This deficient practice resulted in Resident 36 wandering into Resident 28's room on 5/4/2026, which had the potential to result in harm and injury to both residents.Findings: During a review of Resident 36's admission Record, the admission Record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), unspecified psychosis (a mental health condition characterized by a loss of contact with reality, where a person has difficulty distinguishing what is real from what is not), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 36's Elopement Risk Evaluation, dated 4/18/2026, the Elopement Risk Evaluation indicated Resident 36 was at risk for elopement/wandering. It indicated an appropriate intervention was to conduct frequent visual checks. During a review of Resident 36's Minimum Data Set (MDS- a resident assessment tool), dated 4/24/2026, the MDS indicated Resident 36 with severely impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 36 was supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating, oral and personal hygiene, substantial/maximal assistance (helper does more than half the effort) with toileting hygiene. During a review of Resident 36's Care Plan titled, Resident is at Risk for/has a Behavior Problem Related to Psychosis/Dementia, dated 4/30/2026, the Care Plan indicated Resident 36 had visual/auditory hallucinations (sensing things such as visions, sounds, or smells that seem real but are not) with an intervention for staff to intervene as necessary to protect the rights and safety of others. During an observation on 5/4/2026 at 9:08 AM, inside Room C, Resident 36 was observed entering the room, and Resident 28 was observed lying in bed asleep. Resident 36 was then observed going next to Resident 28's bedside, picking up a pair of shoes from Resident 28's nightstand, and calling Resident 28 Mr. [NAME], while leaning onto his bed and speaking in his language. During an interview on 5/7/2026 at 10:14 AM with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 36 has a behavior of wandering around the facility and asks staff where her son is. During an interview on 5/7/2026 at 11:07 AM with the Director of Staff Development (DSD), the DSD stated Resident 36 was confused due to her dementia and wandered into Room C because she was looking for her son. The DSD stated it was not safe for Resident 36 to wander into Room C because it was a safety issue for both residents that could have resulted in harm. During a concurrent interview and record review on 5/7/2026 at 11:36 AM with the Director of Nursing (DON), Resident 36's electronic medical chart was reviewed from 4/18/2026 through 5/7/2026. The electronic medical chart failed to indicate a care plan developed for Resident 36's behavior of wandering/elopement. The DON stated Resident 36 was assessed to be at risk for wandering/elopement and should have had a care plan developed with interventions that were implemented. The DON stated this was important to ensure Resident 36 did not wander into the rooms of other residents including Resident 28 and for the privacy and safety of the residents. During a review of the facility's P&P titled, Wandering and Elopements, dated 1/29/2026, the P&P indicated the facility will identify residents who are at risk for unsafe wandering and strive to prevent harm. The P&P also indicated when a resident is identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. During a review of the facility's P&P titled, Safety and Supervisions of Resident, revised on 1/29/2026, the P&P indicated Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P also indicated the facility will have an individualized, resident- centered approach to address safety and accident hazards for individual residents and ensure interventions are implemented and documented.

Based on interview and record review, the facility failed to provide nutritional care and services for one (1) of two (2) sampled residents (Resident 44) reviewed for nutrition by failing to monitor and document the resident's meal intake in accordance with the care plan.This deficient practice had the potential to place Resident 44 at risk for further weight loss and negatively affect the resident's overall wellbeing. Findings:During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was originally admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), gastro-esophageal reflux disease (GERD - chronic digestive disease where the contents of the stomach refluxes and irritates the esophagus), and metabolic encephalopathy (a broad term for brain dysfunction caused by systemic illness, chemical imbalances, or organ failure rather than direct physical injury). During a review of Resident 44's Nutrition Assessment Form, dated 1/16/2026, the Nutrition Assessment indicated a weight goal range of 125 pounds (lbs) or greater and with a plan to monitor/evaluate the adequacy of Resident 44's oral (PO) intake. During a review of Resident 44's Registered Dietician (RD)/ Interdisciplinary Team (IDT- a coordinated group of experts from several different fields) Weight Review Skin Review, dated 2/6/2026, the RD/IDT Weight Review indicated that Resident 44 had a significant weight loss likely related to variable PO intake, with a plan to monitor/evaluate the resident's adequacy of PO intake. During a review a Resident 44's Care Plan titled, Resident has the Potential Nutritional Problem/Significant Weight Change Related to Mechanically Altered (moist, soft-textured, and finely chopped or ground foods designed to minimize chewing and safely manage dysphagia Diet Regular Pureed (food that has been blended until smooth and creamy), revised 2/11/2026, the Care Plan indicated a goal for Resident 44 to maintain adequate nutritional status. The care plan interventions were to provide, serve diet as ordered, monitor intake, and record each meal. During a review of Resident 44's Minimum Data Set (MDS- a resident assessment tool), dated, 3/25/2026, the MDS indicated Resident 44 had severely impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 44 was setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, personal and eating hygiene and substantial/maximal assistance (helper does more than half the effort) with shower/bathing self and lower body dressing. The MDS indicated Resident 44 weighed 118 pounds and had swallowing disorder symptoms including coughing or choking during meals or when swallowing meds, holding food in mouth/cheeks or residual food in mouth after meals and loss of liquids/solids from mouth when eating or drinking. During a review of Resident 44's Order Summary Report, the Order Summary Report indicated an order for regular diet- pureed, started 4/3/2026. During a review of Resident 44's Weights and Vitals Summary, the Weights and Vitals Summary indicated had a severe weight loss (a weight loss greater than 10 % in six [6] months), when the resident's weight decreased from 127 pounds (lbs) on 11/3/2025 to 113 lbs on 5/4/2026. During a concurrent interview and record review on 5/7/2026 at 10:09 AM with Licensed Vocational Nurse 2 (LVN 2), Resident 44's Documentation Survey Report, dated April 2026, the Documentation Survey Report failed to indicate Resident 44's amount of PO intake percentage for the following:Breakfast and lunch on 4/7/2026Dinner on 4/12/2026Dinner on 4/13/2026Dinner on 5/16/2026Dinner on 4/23/2026Breakfast and lunch on 4/24/2026Dinner on 4/28/2026LVN 2 stated there was no documented amount of PO intake for Resident 44 on the dates indicated and there should have been. LVN 2 stated staff should have documented Resident 44's daily at each meal to show that staff are monitoring Resident 44's intake as indicated in the care plan because of Resident 44's fluctuating weight and weight loss. LVN 2 also stated staff should monitor Resident 44's intake at every meal to monitor the amount of food she is eating because it could lead to potential nutritional problems including significant weight loss. During an interview on 5/7/2026 at 12:26 PM with the Director of Nursing, the DON stated Resident 44's meal intake should have been monitored and documented every shift to prevent further weight loss. During a review of the facility's policy & procedure (P&P) titled, Nutrition (Impaired)/Unplanned Weight Loss- Clinical Protocol, dated 1/26/2026, the P&P indicated that the nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. The P&P also indicated the staff and physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values), monitor nutritional status, an individual's response to interventions and possible complications of interventions. During a review of the facility's P&P titled, Weight Assessment and Intervention, dated 1/29/2026, the P&P indicated a weight loss of 10 % in 6 months was significant and greater then 10 % was severe.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 5) reviewed for tube feeding received gastrostomy tube (GT, a tube inserted through the belly that brings nutrition directly to the stomach) feeding on 5/4/2026 in accordance with the physician's order. This failure had the potential to cause preventable malnutrition (lack of proper nutrition in the body) and/or weight loss for Resident 5.Findings: During a review of Resident 5's admission Record, the admission Record indicated the facility initially admitted Resident 5 on 10/22/2018 and was readmitted on [DATE] with diagnoses that included but not limited to protein calorie malnutrition (a severe life threatening condition caused by a lack of enough calories and protein in the diet resulting in weight loss, weak immunity, and reduced functional capacity), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and dementia (a progressive state of decline in mental abilities). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 2/18/2026, the MDS indicated Resident 5 had severely impaired cognitive skills (ability to think, learn, remember, reason, and pay attention) for daily decision making. The MDS indicated Resident 5 was dependent (Helper does all the effort. Resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) with eating, oral/toileting/personal hygiene, shower/bathing self, upper and lower body dressing and putting on/taking off footwear. The MDS also indicated Resident 5 received 51% or more of her nutrition and 501 cubic centimeters (cc, a metric unit of volume equal to 1 milliliter [ml]) through a feeding tube (GT feeding). During an observation on 5/4/2026 at 12:24 PM inside Resident 5's room, Resident 5 was observed lying in bed with tube feeding pump on, and GT feeding was not connected to Resident 5's GT and the GT feeding formula (also known as enteral formula, a specialized liquid nutrition designed to be delivered directly into the stomach or small intestine through a feeding tube) was spilling to the floor. During a concurrent observation and interview on 5/4/2026 at 12:33 PM inside Resident 5's room, Licensed Vocation Nurse 2 (LVN) confirmed Resident 5's GT feeding was switched on, it was not connected to the resident and the GT feeding formula was spilling to the floor. LVN 2 stated he did not know what happened. During a review of Resident 5's Order Summary Report dated 5/7/2026, the Order Summary Report indicated Enteral (delivering food or medicine directly into the stomach or small intestine, usually via a tube, rather than through the mouth or veins) Feed Order:Every shift check tube placement before initiation of formula, medication administration, and flushing tube, order start date on 2/18/2026.Every shift continuous water flush at 45 milliliters (ml-a measurement of volume) per hour for 20 hours per GT via dual pump (enteral feeding and flush pump, a medical device designed to deliver liquid nutrition directly into a patient's stomach while automatically managing fluid needs) to provide 900 ml per day, order start date on 4/1/2026.Every shift Jevity (feeding formula) 1.5 at 50 ml per hour x 20 hours per GT via dual pump to provide 1000 ml/1500 kilocalorie (kcal, a unit of energy measuring how much power food provides to the body) per day. During an interview on 5/7/2026 at 12 PM with LVN 2, LVN 2 stated he last saw Resident 5's GT feeding connected to Resident 5 on 5/4/2026 at 11 AM. LVN 2 stated another nurse (does not know who) disconnected the GT feeding from Resident 5 before a Certified Nurse Assistant (CNA) took resident for her (Resident 5) shower. LVN 2 stated when Resident 5 was back to the resident's room another nurse (does not know who) may have heard the tube feeding pump (also called dual pump) beeping and restarted the GT feeding without checking if the tube feeding was connected securely to Resident 5's GT. LVN 2 stated the nurse did not follow the steps in the policy of checking connections before initiating or restarting GT feeding. LVN 2 stated this placed Resident 5 at risk for not receiving the resident prescribed calories and nutrition that could lead to weight loss. During a review of the facility's policy and procedure (P&P) titled Enteral Tube Feeding via Continuous Pump, reviewed 1/21/2026, the P&P indicated the steps in initiating feeding included:Checking the label on the enteral formula against the physician order before administration and the following information:Resident name, ID, and room numberType of formulaRoute of deliveryAccess siteMethod Rate of administration (ml/hr)Verifying placement of tube, attach the administration set to the enteral tube (feeding tube or GT), and press start.

Based on observation, interview, and record review, the facility failed to provide the necessary respiratory care services for one of one sampled resident (Resident 11) reviewed for oxygen by failing to ensure oxygen (O2- a colorless, odorless, and tasteless gas essential for the survival of living things which use it for breathing and respiration) was administered to Resident 11 via nasal cannula (NC- a small plastic tube, which fits into the person's nostrils for providing supplemental O2) according to the physician's order. This deficient practice placed Resident 11 at risk for experiencing complications such as respiratory distress (a condition that occurs when the body needs more O2, resulting in difficulty breathing, rapid breathing, and low blood O2 levels) that can lead to serious illness and/or death.Findings: During a review of Resident 11's admission Record, the admission Record indicated the facility initially admitted Resident 11 on 8/6/2024 and readmitted on [DATE] with diagnosis including, but not limited to hemiplegia (total paralysis on one side) and hemiparesis (partial muscular weakness on one side of the body) of the left side following cerebral infarction (occurs when a blood clot or blockage stops blood from reaching a part of the brain). During a review of Resident 11's Minimum Data Set (MDS-a resident assessment tool) dated 2/11/2026, the MDS indicated Resident 11 had severely impaired cognitive skills (ability to think, learn, remember, reason, and pay attention) for daily decision making. The MDS indicated Resident 11 required partial/moderate assistance (Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with eating and upper body dressing. The MDS indicated Resident 11 required substantial/maximal assistance (Helper lifts or holds trunk or limbs and provides more than half the effort) with oral and personal hygiene and rolling left and right in bed. The MDS further indicated Resident 11 was dependent (Helper does all the effort. The resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. During a review of Resident 11's Order Summary Report, the Order Summary Report indicated a physician's order, dated 5/1/2026 for continuous O2 at 4 liters per minute (LPM-unit of measurement for oxygen a patient receives) via NC to keep O2 saturation (measurement of the percentage of O2 red blood cells are carrying) above 92%. During an observation on 5/4/2026 at 12:50 PM, inside Resident 11's room, Resident 11 was observed awake, lying in bed without his NC on his nostrils. The O2 concentrator (a medical device that filters surrounding air, removing nitrogen [colorless and odorless gas that makes up 78% of the air we breathe] to deliver concentrated, medical grade O2) was observed powered on and the NC and tubing were inside a clear plastic bag. Resident 11 stated he needed his O2 and it was hard to breathe. During a concurrent observation and interview on 5/4/2026 at 12:51 PM, DSD came to assess Resident 11. DSD was observed checking Resident 11's O2 saturation. DSD stated it was 88%. DSD confirmed that the O2 concentrator was on, but the NC was not on Resident 11's nostrils. DSD stated Resident 11's O2 order was continuous to keep his O2 saturation above 92%. DSD stated Resident 11's NC and tubing was stored inside the plastic bag. The DSD stated the doctor's order to administer continuous oxygen was not followed which placed Resident 11 at risk for change of condition and hospitalization. During a concurrent interview and record review on 5/7/2026 at 10:05 AM with Licensed Vocational Nurse 1 (LVN 1), the physician's order for Resident 11 was reviewed. LVN 1 stated Resident 11's O2 order indicated continuous at 4LPM via NC to keep O2 saturation above 92%. LVN 1 stated he changed the humidifier (a small disposable bottle attached to the O2 concentrator that adds moisture to the dry O2 before it is inhaled by the patient), NC and tubing and put the NC on the Resident's nostrils at 8:30 AM on 5/7/2026. LVN 1 stated after 8:30 AM, Certified Nurse Assistant (CNA) 2 and CNA 3 provided morning care to Resident 11. LVN 1 stated neither CNA 2 nor CNA 3 approached him to remove or reapply the O2 NC to Resident 11. LVN 1 stated it was important to follow the doctor's order of administering continuous O2 to Resident 11. LVN 1 stated Resident 11 could be at risk for further desaturation (drop in blood oxygen levels below normal) and respiratory distress and potential transfer to the hospital without the oxygen. During an interview on 5/7/2026 at 10:33 AM with CNA 2 and CNA 3, CNA 2 stated she removed the NC from Resident 11 prior to providing bed bath (cannot remember exact time) and placed the NC and tubing in the plastic bag. CNA 2 and CNA 3 stated they did not know and were not provided education that CNAs cannot touch or remove O2 NC from the residents. During a concurrent interview and record review with the Director of Nursing (DON), the policy and procedure (P&P) titled Oxygen Administration - Respiratory and Pulmonary Conditions, reviewed 1/26/2026, was reviewed. The P&P indicated to verify that there is a physician's order for this procedure. The DON stated the P&P did not specifically indicate who cannot touch the O2 cannulas. The DON stated unlicensed staff cannot remove or put back O2 of residents. The DON stated physician's order was not followed when O2 was taken off Resident 11. The DON stated this placed Resident 11 at risk for desaturation, hypoxemia (a condition where the body's tissues and organs are not receiving enough O2 causing them to function poorly), decline in function, and hospital transfer. During a concurrent interview and record review with the Administrator (ADM), the P&P titled, Oxygen Administration, review date of 1/29/2026, was reviewed. The P&P indicated:All oxygen therapy requires a complete medical order including:Flow rate (L/min)Delivery deviceFrequency/continuous useHumidification, if anyTarget O2 saturation, if ordered Registered Nurse (RN) verifies order accuracy and initiates therapy.CNAs may observe and report changes in breathing, ensure O2 device stays in place, and never adjust O2 flow rates. The ADM stated CNAs are not allowed to remove and reapply O2 device from residents.

Based on interview and record review, the facility failed to provide trauma-informed care (an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of traumas) for one of two sampled resident (Resident 8) reviewed for behavior and diagnosed with post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event).This deficient practice had the potential for Resident 8 to experience re-traumatization, (unintentionally causing harm through practices, policies, and/or activities that are insensitive to the needs of the residents) that could lead to severe psychosocial (dynamic intersection between psychological aspects [thoughts, emotions, and behaviors] and social factors [cultural, environmental, and interpersonal relationships]) harm and negatively affecting his quality of life.Findings:During a review of Resident 8's admission Record, the admission record indicated Resident 8 was admitted to the facility on [DATE], with the diagnoses including but not limited to PTSD, schizoaffective disorders (a mental illness that causes loss of contact with reality), and anxiety disorders (persistent and excessive worry that interferes with daily activities). During a record review of Resident 8's Minimum Data Set (MDS, a resident assessment and tool), dated 1/29/2026, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was intact. The MDS indicated Resident 8 did not have mood or behavior symptoms. The MDS also indicated Resident 8 had a psychiatric (of or relating to the study of mental illness)/mood disorder of PTSD. During a record review of Resident 8's Social Service assessment dated , 1/22/2026 and 4/28/2026, both assessments did not include the history of trauma and what stressors trigger (anything including sound, sight, smell or thought that is a reminder of a traumatic event) an event for the resident. During a record review of Resident 8's Care Plans dated from 1/21/2026 to 5/6/2026, there were no care plans for Resident 8's PTSD. During an interview on 5/6/2026 at 4:33 PM with Social Service Director (SSD), SSD stated SSD was informed by Resident 8 that the resident had PTSD. SSD stated SSD did not document or have an assessment done for Resident 8's PSTD. During an interview on 5/7/2026 at 9:29 AM with Certified Nursing Assistant 5 (CNA 5), CNA 5 stated Resident 8 was not sure if Resident 8 had PTSD. CNA 5 stated he did not know what PTSD was and therefore was not able to provide the best possible care for Resident 8 with a diagnosis of PTSD. During a concurrent interview and record review on 5/7/2026 at 10:43 AM with Licensed Vocational Nurse 2 (LVN 2), Resident 8's Care Plan dated from 1/21/2026 to 5/6/2026 was reviewed. LVN 2 stated Resident 8 had a diagnosis of PTSD. LVN 2 stated Resident 8's Care Plan should contain the information of Resident 8's history related to PTSD, triggers, and trauma informed care interventions. LVN 2 stated Resident 8 did not have a specific care plan for PTSD. LVN 2 stated it was important to know the underlying causes and the triggers for Resident 8's PTSD to avoid the triggers. During a concurrent interview and record review on 5/7/2026 at 2:47 PM with the Director of Nursing (DON), Resident 8's electronic health records dated from 1/21/2026 to 5/6/2026 was reviewed and the facility's Policy and Procedure (P&P) for Trauma-Informed and Culturally Competent Care dated 1/26/2026 were reviewed. The P&P indicated resident assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers; utilize licensed and trained clinicians who have been designated by the facility to conduct trauma assessments, and use assessment tools that are facility-approved and specific to the resident population. The P&P also indicated to develop an individualized care plan that address past trauma in collaboration with the resident and family as appropriate. Resident 8's electronic health records did not indicate assessment, evaluation and care plan regarding the resident's PTSD triggers and there was no care plan. The DON stated she did not know about the history of Resident 8's PTSD such as what triggers it to prevent any outbursts from happening and what interventions works to prevent any triggers for Resident 8's PTSD. The DON stated there was no documentation for an assessment done for an evaluation to Resident 8's trauma and triggers or a care plan for Resident 8's PSTD as indicated on the P&P. The DON stated it was important to know about Resident 8's PSTD so staff could provide trauma informed care, prevent further episodes, and avoid triggers. During a record review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated the interdisciplinary team (IDT, group of healthcare professionals from diverse fields who work in a coordinated manner toward a common goal for the resident), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The P&P also indicated, services provided for or arranged by the facility and outlined in the comprehensive care plan are provided by qualified persons, culturally competent, and trauma- informed.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services for one (1) of six (6) sampled residents (Resident 42) observed for medication administration by failing to ensure Licensed Vocational Nurse 5 (LVN 5) administered Carvedilol (medication used to treat hypertension [high blood pressure] and congestive heart failure [CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling]) with food on 5/5/2026 to Resident 42 as indicated on the physician's order and facility policy. This deficient practice had the potential for Resident 42 to experience gastrointestinal discomfort, nausea, and the risk for side effects such as dizziness, fainting, and sudden low blood pressure.Findings:During a review of Resident 42's admission Record, the admission Record indicated Resident 42 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), leukemia (a cancer of the body's blood-forming tissues), and essential primary hypertension. During a review of Resident 42's Minimum Data Set (MDS- a resident assessment tool), dated 2/12/2026, the MDS indicated Resident 42 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 42 was dependent (helper does all the effort) with toileting, bathing self, personal hygiene and independent (resident completes activity with no assistance) with eating. During a review of Resident 42's Order Summary Report, the Order Summary Report indicated carvedilol oral tablet 3.125 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) give 1 tablet by mouth two times a day related to essential primary hypertension. Give with food. Order started 4/10/2026. During an observation on 5/5/2026 at 4:54 PM in Resident 42's room entry, LVN 5 was observed administering Carvedilol 3.125 mg to Resident 42 without food. During an interview on 5/5/2026 at 4:57 PM with LVN 5, LVN 5 stated she did not administer Carvedilol 3.125 mg to Resident 42 with food. LVN 5 stated she should have administered it with food as indicated on the physician's order. LVN 5 also stated she did not see the resident eating or ask the resident when she last ate before giving her the medication. LVN 5 stated she should have given Resident 42 the medication once she was eating dinner. LVN 5 stated it was important to give the medication as prescribed with food to prevent the medication from [negatively] affecting Resident 42's stomach. During an interview on 5/7/2026 at 11:48 AM with the Director of Nursing (DON), the DON stated medications are to be given as prescribed and Resident 42's carvedilol should have been given with crackers, applesauce or her dinner tray. The DON stated staff are to ensure residents are eating something when the medication is administered, if ordered to give with food. The DON further stated it was important to give as prescribed with food to prevent side effects or harm to the residents. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, dated 1/26/2026, the P&P indicated medications are administered in a safe and timely manner, and as prescribed.

Based on observation, interview, and record review, the facility failed to ensure Medication Cart 1 remained locked while unattended during medication administration on 5/5/2026 as indicated in the facility's policy. This deficient practice had the potential for unauthorized access to medications by residents, staff and visitors which could lead to medication overdose (taking a toxic or poisonous amount of a drug or medicine), unauthorized use, adverse reactions (any unexpected or dangerous reactions to a drug), or harmful drug interactions (a reaction between two or more drugs or between a drug, and a food, beverage, or supplement).Findings: During an observation on 5/5/2026 at 3:48 PM in the facility hallway, Medication Cart 1 was observed unlocked and unattended while Licensed Vocational Nurse 5 (LVN 5) was inside Resident's Room A. During an observation on 5/5/2026 at 4:22 PM, in the facility hallway, Medication Cart 1 was observed unlocked and unattended while LVN 5 was inside Resident's Room B. During an interview on 5/5/2026 at 4:57 PM with LVN 5, LVN 5 stated that per facility protocol, the medication cart should be locked every time staff leave it and go anywhere, for privacy and safety, because anyone could access the medications from an unlocked cart and take them. During an interview on 5/7/2026 at 11:48 AM with the Director of Nursing (DON), the DON stated that medication carts must be locked as soon as the nurse's back is turned to the cart to ensure resident safety and to prevent residents from accessing medications. During a review of the facility's Policy and Procedure (P&P) titled, Medication Labeling and Storage, dated 1/29/2026, the P&P indicated the facility stores all medications and biologicals in locked compartments. The policy also indicated compartments (including carts) containing medications and biologicals (medication that are made using biological substances) are locked when not in use, and carts used to transport such items are not left unattended if open. During a review of the facility's P&P titled, Administering Medications, dated 1/26/2026, the P&P indicated during administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide.

Based on observation, interview, and record review, the facility failed to ensure the nurse staffing information (real-time data regarding the number and types of nursing staff currently on duty) was updated and posted daily on 5/2/2026 and 5/3/2026, according to the facility's policy. As a result, the current resident census, total number of staff and the actual hours worked by the staff were not readily accessible to residents and visitors.Findings:During an observation on 5/4/2026 at 7:49 AM, at the Business Office's door, the staffing information posted indicated the date of 5/1/2026. During an interview on 5/7/2026 at 2:01 PM with the Director of Staff Development (DSD), the DSD stated she is the staff responsible for posting the daily nurse staffing information and it is posted on the door of the Business Office. The DSD further stated she does not work on Saturdays or Sundays, so no daily posting of the nurse staffing information was done on 5/2/2026 and 5/3/2026. The DSD stated she updates and posts the staffing once returning to work on Mondays. The DSD stated daily nurse staffing is posted to ensure staff are aware of the nursing hours and that there is enough staffing for the day. During a review of the facility's policy titled, Posting Direct Care Daily Staffing (nurse staffing informational) Numbers, dated 1/29/2026, the policy indicated the facility will post on a daily basis for each shift nurse staffing data, including the number of personnel responsible for providing direct care to residents. The policy also indicated within two (2) hours of the beginning of each shift, the charge nurse or designee computes the number of direct care staff and completes the Nurse Staffing information form and posts the staffing information in the designated location(s).

Based on interview and record review the facility failed to ensure one (1) of two sampled residents (Resident 1) with history of attempted elopement (occurs when a resident leaves a facility without authorization or supervision) was provided safety protocols, supervision and ensure monitoring to prevent elopement when the front door was left unsupervised on 3/14/2026 around 9 pm. This failure resulted in Resident 1 having a successful elopement and had the potential to lead to endangerment, accident and injury while outside the facility's premises without supervision from staff. Resident 1 was returned to the facility on 3/15/2026 at 1:15 PM.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included but not limited to unsteadiness of feet, other schizoaffective disorders (a mental health problem where a person experiences loss of contact with reality as well as mood symptoms), and other specified anxiety disorders (fear characterized by behavioral disturbances). During a review of Resident 1's Minimum Data Set (MDS- a Resident assessment tool), dated 12/30/2025, the MDS indicated Resident 1 was assessed having moderately impaired (decisions poor; cues/supervision required) cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 was independent with oral/personal hygiene, upper/lower body dressing, and eating. The MDS indicated Resident 1 required setup or clean-up assistance with sit to stand, toilet transfer, and walking 150 feet (ft.- unit of measurement). During a review of Resident 1's Care Plan, initiated on 1/2/2026, the care plan indicated Resident 1 was at risk for wandering/elopement as evidenced by attempts to leave the facility unattended and impaired safety awareness. The care plan indicated Resident 1 drifted away from the smoking group and redirected back to the facility on 1/2/2026. The Care Plan interventions included door monitoring every shift and maintaining a safe and hazard-free environment. During a review of Resident 1's Change of Condition form, dated 1/2/2026, at 12:49 PM, the Change of Condition form indicated on 1/2/2026, at 12:49 PM, Resident 1 attempted to elope while smoking outside. During a review of Resident 1's Elopement Risk Evaluation form, dated 1/2/2026, the Elopement Risk Evaluation form indicated a total elopement risk score of 9 (a total score of 10 or higher indicated at risk for elopement). However, the Elopement Risk Evaluation form also indicated Resident 1 has verbally expressed the desire to go home, packed belongings to go home, or stayed near exit door. The Elopement Risk Evaluation form further indicated, under Summary of Review, that Resident 1 was at risk for elopement/wandering. During a review of Resident 1's Elopement Incident form, dated 3/14/2026, the Elopement Incident form indicated Resident 1 was last observed at approximately 8:40 PM sitting in her wheelchair near the nursing station. At approximately 9 PM Charge Nurse (CN) went to Resident 1's room to administer Resident 1's scheduled nighttime medications. Resident 1 was not present in the room. Immediate attempts were made to locate Resident 1 within the unit and surrounding areas; Resident was not found. A bus was noted in front of the facility, and staff searched for the bus as part of the elopement search; the Resident was not located. Resident 1's Elopement Incident form indicated the elopement occurred by the front door. During the same review of Resident 1's Elopement Incident form, dated 3/14/2026, the Elopement Incident form indicated Resident 1 stated she left the facility through the front door and Resident 1 reported she was going to Oregon. During an interview on 3/26/2026, at 11:58 AM, with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated the front door was always supervised by facility staff because it did not have an alarm. CNA 1 stated the front door was also locked at night for safety reasons. CNA 1 stated she supervised the front door on 3/14/2026 from 8 PM to 8:30 PM. CNA 1 stated Resident 1 was not by the front door or the Nurse's Station while she was supervised the front door. CNA 1 stated at approximately 9 PM, Licensed Vocational Nurse 1 (LVN 1) informed her that Resident 1 was missing in the facility. During an interview on 3/26/2026, at 12:20 PM with CNA 2, CNA 2 stated facility staff supervised the front door to make sure the residents do not leave the facility. CNA 2 stated she last saw Resident 1 in the hallway on 3/14/2026 at approximately 8:40 PM, when she got her lunch. CNA 2 stated at 9 PM, LVN 1 stated Resident 1 was missing and called a Code [NAME] (an emergency code for elopement). During an interview on 3/26/2026, at 2:19 PM with LVN 1, LVN 1 stated there facility staff always supervised the front door to monitor residents and make sure the residents are safe. LVN 1 stated on 3/14/2026, at around 8:40 PM, Resident 1 was sitting in her wheelchair by the Nurse's Station while CNA 3 supervised the front door. LVN 1 stated she left the Nurse's Station soon after 8:40 PM to administer medications and arrived at Resident 1's room at 9PM to administer her medications. LVN 1 stated Resident 1 was not in her room at 9 PM so she went back to the Nurse's Station because that was the last place where she last saw Resident 1. LVN 1 stated when she arrived at the Nurse's Station, Resident 1's wheelchair was there but could not find Resident 1. LVN 1 stated the front door was not supervised by CNA 3 when she went to the Nurse's Station to look for Resident 1. LVN 1 stated she was not sure how Resident 1 was able to leave the facility if the front door was locked because Resident 1 was sometimes unsteady when she stood or walked. LVN 1 stated a Code [NAME] was called because they did not find Resident 1 in the facility. During an interview on 3/26/2026, at 2:31 PM, with Social Services Director (SSD), SSD stated the front door was supervised and monitored by facility staff make sure the residents are safe and do not leave the facility. SSD stated the front door should not be left unattended. SSD stated the residents' safety was the facility's priority. During a concurrent interview on 3/26/2026, at 2:44 PM, with the Director of Nursing (DON), the DON stated the front door was supervised by staff for the safety of the residents because it opens directly to a busy street. The DON stated Resident 1 would not have been able to leave the facility if the front door was supervised on 3/14/2026 at around 9 PM. During a review of the undated facility's policy and procedure (P&P), titled, Wandering and Elopements, the P&P indicated that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. During a review of the facility's P&P, titled, Safety and Supervision of Residents, revised 7/2017, the P&P indicated the following:The facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.Implementing interventions to reduce accident risks and hazards shall include ensuring the interventions are implemented.Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

Based on interviews and record review, the facility failed to maintain accurate documentation of wound care treatments for one (1) of two (2) sampled residents (Resident 1) on the resident's Treatment Administration Record (TAR) in accordance with the facility's policy. This deficient practice had the potential to result in miscommunication among staff and resulted in inaccurate representation of care provided to Resident 1.Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included muscle contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the left and right lower leg. During a review of Resident 1's Care Plan revised on 9/11/2025, the Care Plan indicated Resident 1 had wounds on the base and shaft of the fifth (5th ) metatarsal (long bone on the outer edge of the foot that connects to the smallest toe) and on the left great toe with an intervention that included treatment as ordered. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 11/20/2025, the MDS indicated Resident 1 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 was dependent (helper does all the effort) with eating, oral, toileting, and personal hygiene, shower, upper/lower body dressing and putting on/taking off footwear. During a review of Resident 1's physician's order dated 11/21/2025 timed at 1:45 PM, the physicians order indicated to perform daily dressing changes to Resident 1's left great toe which included cleansing the wounds with normal saline (NS-a saltwater solution), pat dry, paint the peri wound with Betadine solution (an antiseptic used to kill germs and prevent infection particularly on the skin), apply Medi Honey (a medical- grade honey dressing that can be used to treat a variety of wounds), cover with collagen alginate (a light, nonwoven fabrics derived from algae or seaweed), then abdominal pad, and wrap with gauze bandage roll. During a review of Resident 1's physician's order dated 11/21/2025 timed at 2 PM, the physicians order indicated daily dressing changes to Resident 1's left 5th metatarsal head to shaft which included cleansing the wounds with NS, pat dry, paint peri wound with betadine, apply Medi Honey, cover with collagen alginate, then abdominal pad, and wrap with gauze bandage roll. During a concurrent interview and review with the Treatment Nurse (TN) on 12/10/2025 at 1 PM, the TAR for the month of November was reviewed. TN stated there were missing wound treatments for 11/22/2025 and 11/24/2025 which included cleansing the wounds with NS, pat dry, paint peri wound with betadine, apply Medi Honey, cover with collagen alginate, then abdominal pad, and wrap with gauze bandage roll on the following sites:a) Left head metatarsal head to shaft.b) Left great toe. During an interview on 12/10/2025 at 1:13 PM, the TN stated he remembered providing the wound treatments but forgot to document them in the TAR. The TN also stated wound treatments should be documented and signed to indicate it was provided and would not look like it was not done. The TN also stated the TAR should be signed off by the TNs after the wound care treatment was provided. During an interview on 12/10/2025 at 1:47 PM, the Director of Nursing (DON) stated Resident 1's wound treatment should be accurately documented so we can confirm the resident's wound treatment was provided. During an interview on 12/10/2025 at 4:15 PM, the Administrator (ADM) stated that wound care treatment should be accurately documented to ensure wound treatments were provided as ordered. During a review of the facility's undated policy and procedure (P&P) titled, Charting and Documentation, revised 7/2017, the policy indicated that all services provided to the resident, .shall be documented in the resident's medical record. The policy also indicated that documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. The policy further indicated that documentation of the procedures and treatments will include care -specific detail, including date and time the procedure/treatment was provided, name and title of the individual (s) who provided the care, and the signature and title of the individual documenting.

Based on observation, interview and record review, the facility failed to follow its policy and keep the centralized air conditioning (A/C) units in working condition to maintain comfortable and acceptable temperature ranging from 71 to 81 degrees Fahrenheit (F, unit of temperature) for 32 of 32 residents residing in the facility. As a result, Residents 1, 2, 3 and 9 complained the room temperature was hot and uncomfortable. This deficient practice placed Residents 1, 2, 3 and 9 and other residents at risk for dehydration (excessive loss of body water) and/or heat stroke (internal body heat with complications involving the central nervous system that occur after exposure to high temperatures). On August 20, 2020, at 6:25 p.m., an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents) was declared. The facility's Administrator was notified regarding 12 resident rooms temperatures were ranging from 84.4 F to 91.1 F affecting 32 residents in the facility. On August 27, 2020, at 4:03 p.m., the IJ was lifted in the presence of the Administrator after the implementation of the Plan of Action (POA, the action to correct the deficient practices) was verified and confirmed onsite through observation, interview and record review. The Administrator provided an acceptable POA as follow: 1. Facility's Licensed Staff and Certified Nursing Assistants offered water and cold drinks to the residents and keep all 33 residents hydrated (providing plenty of fluid/water) during the daytime. 2. Facility's Licensed Staff checked resident rooms temperature hourly and ensure the residents are comfortable with the temperature. 3. On August 27, 2020, Electrician 1 (ET 1) completed the installation of five extra electrical outlets in Rooms 4, 5, 12, 16, and 20 for five additional portable AC units. Findings: A review of the facility's Certification Information, dated June 15, 2015, indicated the facility was initially certified on June 15, 2015 and was recommended for certification on July 29, 2015. According to https://www.nia.nih.gov/health/hot-weather-safety-older-adults National Institute on Aging, under Hot Weather Safety for Older Adults, dated June 15, 2016, indicated older people can have a tough time dealing with heat and humidity. The temperature inside or outside does not have to reach 100°F to put the residents at risk for a heat-related illness. Headache, confusion, dizziness, or nausea could be a sign of a heat-related illness. High environmental temperatures can be dangerous to the body. In the range from 90 F to 105F, residents can experience heat cramps (painful, involuntary muscle spasms that usually occur during heavy exercise in hot environments) and exhaustion (a state of extreme physical or mental fatigue). A review of Resident 1's Face Sheet indicated the facility admitted the resident on February 16, 2020 with [DIAGNOSES REDACTED]. Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 6/18/2020 indicated the resident had mild impairment in cognition (ability to think and process information). Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) for bed mobility and walking. A review of Resident 2's Face Sheet indicated the facility admitted the resident on October 4, 2020 with [DIAGNOSES REDACTED]. Resident 2's MDS, dated [DATE] indicated the resident had intact cognition. Resident 2 required supervision for bed mobility, walking and personal hygiene. A review of Resident 3's Face Sheet indicated the facility admitted the resident on February 1, 2019 with [DIAGNOSES REDACTED]. Resident 9 required supervision with bed mobility, toilet use and personal hygiene. A review of Resident 9's Face Sheet indicated the facility admitted the resident on February 4, 2020 with [DIAGNOSES REDACTED]. Resident 3's MDS, dated [DATE] indicated the resident had moderate impairment in cognition. Resident 3 required supervision with bed mobility, walking and eating. A review of the facility's floor plan, undated, indicated there were 21 resident rooms with 16 occupied rooms and 5 empty rooms. A review of the facility's census dated August 19, 2020 indicated there were 33 residents in the facility, but one resident left against medical advice (32 residents). A review of the Accu-Weather Forecast for California cities dated August 19, 2020, at 5 p.m., indicated the outside temperature was at 98 F. During an observation and a concurrent checking of Residents' room temperature on August 19, 2020 from 5:45 p.m. to 6:25 p.m., the following temperatures were obtained: a. Outside temperature =97.6 F a. Residents 4's and 5's room (# 3) = 91.5 F b. Residents 2's and 6's room (# 11) = 92.9 F c. Residents 1's, 7's, 8's and 10's room (# 19) = 95.4 F d. Residents 11's, 12's, and 13's room (# 22) = 93.4 F During an observation on August 19, 2020, at 5:50 p.m., Resident 1 was wearing a T-shirt, a pair of shorts, with blush on both cheeks. During a concurrent interview, Resident 1 stated for about one week now, the facility had been hot. Resident 1 stated the Administrator had put a fan in the room a couple of days ago, but it did not help. Resident 1 stated the Administrator knows the AC is not working and his room is hot. During an observation on August 19, 2020, at 6:05 p.m., Resident 2 was lying down in bed. A concurrent interview was conducted with Resident 2; Resident 2 stated it had been hot in the facility for a week. Resident 2 stated the facility put a fan in the room, but it did not cool off. During an interview on August 20, 2020, at 8:35 a.m., the Administrator stated the current owners purchased the facility about two years ago and knew that the facility's central AC system needed to be repaired or replaced. The Administrator stated at the beginning of this year when the weather was getting hot, she purchased some portable AC units and recently purchased some electric fans. The Administrator stated that the facility does not have a maintenance supervisor for one month but did not explain why or who will fix the central AC system. During an interview on August 20, 2020, at 2:32 p.m., the Administrator stated she does not have the temperature log. The Administrator did not provide the temperature log for the month of July and August 2020 for review as requested. During an observation and a concurrent checking of Residents' room temperature with the Administrator using the digital (temperature-sensing instruments) and razor thermometers (instrument for determining temperature by laser) on August 20, 2020 from 2:35 p.m. to 3:05 p.m., the following temperatures were obtained: a. Outside temperature: 96.8 F b. Residents 27's room (# 2) = 90 F c. Residents 4's and 5's room (# 3) = 88.6 F d. Residents 25's and 26's room (# 4) = 88.6 F e. Residents 24's room (# 5) = 84.4 F f. Residents 16's and 17's room (# 9) = 88.9 F g. Residents 14's and 15's room (# 10) = 89.3 F h. Residents 2's and 6's room (# 11) = 91.1 F i. Residents 18's room (# 14) = 88.7 F g. Residents 9's and 19's room (# 15) = 89.4 F k. Residents 20's room (# 16) = 89.4 F l. Residents 21's and 22's room (# 17) = 90.1 F m. Residents 23's room (# 18) = 90.7 F During an interview on August 20, 2020, at 3:30 p.m., Resident 3 stated that it was too hot. The resident stated she had been in the same room for four days; and her room had been this hot the whole time. During an observation and a concurrent checking of the Residents' room temperature with the Administrator on August 21, 2020 from 1:45 p.m. to 2:05 p.m., the following temperatures were obtained: a. Outside temperature: 97.1 F b. Residents 4's and 5's room (#3) = 88.5 F c. Residents 9's and 19's room (# 15) = 86.2 F d. Residents 20's room (#16) = 87.5 F f. Residents 21's and 22's room (#17) = 88.1 F g. Residents 23's room (#18) = 88.7 F During an interview with the Administrator on August 21, 2020, at 3:30 p.m., she stated she would purchase additional portable A/C units and place them inside the resident rooms (did not identify which room) to lower the room temperature. During an observation on August 21, 2020, at 9:10 p.m., the portable A/C units arrived at the facility and were placed in the resident rooms that did not have an A/C unit (Rooms 5, 6, 9, 10, 16 and 20). The circuit breaker boxes tripped the safety switches because the outlets were overloaded as soon as the A/C units were plugged into the electrical wall outlet. The Administrator could not use these outlets to power the additional A/C units in Rooms 5, 6, 9, 10, 16 and 20. During an interview on August 21, 2020, at 9:30 p.m., the Administrator stated she would try to have an electrician come to the facility to add more outlets for the five portable AC units. The Administrator stated it may be difficult to get an electrician to fix the electrical issue since some electricians refuse to work on the weekend and in a nursing home. During an interview on August 22, 2020, at 11:10 a.m., the Administrator stated she will transfer some residents to other rooms so the residents would not be in rooms with temperature above 81 F. During an observation and a concurrent checking of the Residents' room temperatures on August 22, 2020 from 3:15 p.m. to 3:30 p.m., the following room temperatures were obtained: a. Outside temperature: 96.8 F b. Residents 26's room (#4) = 88.1 F c. Residents 24's room (#5) = 87.9 F d. Residents 9's and 18's room (#15) = 85 F e. Residents 21's and 23's room (#17) = 85.6 F f. Residents 23's room (#18) = 86.3. F g. Resident 1's, 7's, 8's, 10's room (#19) = 86.6 F h. Resident 3's and 28's, room (#20) = 89 F i. Resident 30's, 31's, and 32's room (#21) =87.6 F j. Resident 11's, 12's and 13's room (#22) = 88.5 F During an interview on August 23, at 1:35 p.m., the Administrator stated she was able to contact an electrician and he (ET 1) would come to the facility today to fix the circuit breakers for the five additional portable AC units. During an observation and a concurrent checking of Residents' room temperatures on August 23, from 3:40 p.m. and 3:55 p.m., the following room temperatures were obtained: a. Outside temperature: 92.7 F b. Residents 24's room (#5) = 96.8 F c. Residents 21's and 23's room (#17) = 86.3 F d. Residents 23's room (#18) = 87.1 F h. Resident 3's, 27's, and 28's, room (#20) = 89 F i. Resident 30's, 31's, and 32's room (#21) =86.3 F j. Resident 11's, 12's and 13's room (#22) = 89.6 F During an observation and interview on August 24, 2020 at 12:07 p.m., ET 1 came to the facility. The Administrator instructed ET 1 to install five additional electrical outlets and ET 1 started to install the outlets. During a concurrent observation and interview on August 24, 2020 at 1:50 p.m., ET 1 stated he had to stop working and buy more parts to complete installing five electrical outlets. ET 1 stated he would come back today, or tomorrow morning, to continue with his work. Five minutes later, ET 1 left the facility. During an observation and the concurrent checking of Residents' room temperatures on August 24, from 3:42 p.m. and 4 p.m., the following room temperatures were obtained: a. Outside temperature: 89 F b. Residents 9's and 18's room (#15) = 85 F c. Residents 3's 21's and 23's room (#17) = 84 F d. Resident 1's, 7's, 8's, 10's room (#19) = 84 F f. Resident 30's, 31's, and 32's room (#21) = 85 F g. Resident 11's, 12's and 13's room (#22) = 84 F During an interview with Resident 9 on August 24, 2020, at 4 p.m. Residents 9 stated the room was warm. During an interview with Residents 1 on August 24, 2020, at 4:05 p.m., Resident 1 stated they need to fix the AC. During an observation and a concurrent checking of the Residents' room temperatures on August 25, from 2:02 p.m. and 2:17 p.m., the following room temperatures were obtained: a. Outside temperature: 93 F b. Residents 9's and 18's room (#15) = 82 F c. Resident 11's, 12's and 13's room (#22) = 83.9 F During a telephone conference with the Administrator and the facility's Licensee, the District Supervisor and Manager on August 25, 2020 at 3:40 p.m., had informed them the surveyor would not be able to lift the IJ if ET 1 could not complete installing the 5 additional electrical lines for the five portable AC units. During an observation on August 26, 2020 at 5:35 p.m., ET 1 was installing the additional electrical wires and outlets. A concurrent interview was conducted; ET 1 stated he would not be able to complete installing five additional electrical wires and outlets for the portable AC units. During an observation and the concurrent checking of the Residents' room temperatures on August 26, 2020 from 5:40 p.m. and 6 p.m., the following room temperatures were obtained: a. Outside temperature: 90 F b. Residents 23's room (# 18) = 88 F c. Resident 1's, 7's, 8's, 10's room (# 19) = 85 F d. Resident 30's, 31's, and 32's room (# 21) = 87 F e. Resident 11's, 12's and 13's room (# 22) = 90 F During an observation and the concurrent checking of the Residents' room temperatures on August 27, 2020 at 2:57 p.m., ambient temperatures (surrounding temperatures) for all resident rooms were at or below 81 F. Outside temperature was at 97 F. Five additional outlets were installed and functioning properly. A review of the ET 1's report indicated Job is completed on 8/27/20. The report did not contain the description of what was being done to complete the job. A review of the facility's policy and procedure, undated, titled, Maintenance Department, indicated the facility is to provide a clean and safe facility and grounds are maintained through preventive maintenance, corrective maintenance and a comprehensive program of scheduled inspections. A review of the facility's policy and procedure, titled, Air Temperature, indicated prompt response to air temperature complaints is essential for maintaining acceptable levels of temperature, humidity and ventilation. The policy indicated the acceptance range for air temperature is 71 F to 81 F.