Every finding on record at Gem Tcu

Based on observation, interview and record review, the facility failed to ensure resident rooms were at a comfortable temperature for three (3) of 3 sampled residents (Resident 1, Resident 2 and Resident 3) by failing to ensure the facility's Heating, Ventilation and Air Conditioning (HVAC, a climate control system that keeps indoor areas at a comfortable temperature) was in good repair.This deficient practice had the potential to result in Residents 1, 2 and 3 feeling uncomfortably hot and negatively affect their quality of life. Findings:a). 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 end stage renal failure (ESRD; irreversible kidney failure) which required dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and cellulitis (a skin infection that causes swelling and redness) of both legs. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 4/15/2026, the MDS indicated Resident 1 had intact cognitive (ability to think and process information) skills for daily decision making ability. The MDS indicated Resident 73 was dependent (helper does all the effort) for toileting hygiene, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 1 required supervision (helper provides verbal cues) for eating. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) for upper body dressing. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) for oral hygiene and personal hygiene. b). During a review of Resident 2's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included heart failure and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 5/7/2026, the MDS indicated Resident 1 had moderately impaired cognitive (ability to think and process information) skills for daily decision making ability. The MDS indicated Resident 73 was dependent (helper does all the effort) with toileting hygiene, showering, lower body dressing and putting on and taking off footwear. The MDS indicated Resident 2 required supervision (helper provides verbal cues) with eating. The MDS indicated Resident 2 required substantial assistance (helper does more than half the effort) for upper body dressing. The MDS indicated Resident 2 required moderate assistance (helper does less than half the effort) in oral hygiene and personal hygiene. c). During a review of Resident 3's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included stage four (4) pressure ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the sacrum (lower back area), DM and generalized muscle weakness. During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool), dated 6/5/2026, the MDS was yet to be fully completed. During an interview on 7/17/2026 at 7:29 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated that CNA 1 has heard Resident 1, Resident 2 and Resident 3 complain that their rooms are hot. CNA 1 stated that a hot room can make residents feel stressed and can negatively affect their health conditions. During an interview on 7/17/2026 with Resident 3 at 7:37 PM in Resident 3's room, Resident 3 stated that her room feels hot and very uncomfortable. Resident 3 stated she gets sweaty in bed and feels like the facility does not care about her. During an interview on 7/17/2026 at 7:46 PM with Resident 2, in Resident 2's room, Resident 2 stated that she feels hot and very uncomfortable in her room. Resident 2 stated that this makes her feel less energy and sweaty. During an interview on 7/17/2026 at 7:51 PM with Resident 1. in Resident 1's room, Resident 1 stated that the HVAC is not working and it is hot and very uncomfortable in her room. Resident 1 stated that she feels helpless because she cannot do anything about it even though she has reported it to the facility. Resident 1 stated she feels like the facility is not listening to her and cannot sleep well sometimes because the room is hot. During an interview on 7/17/2026 at 7:56 PM with Licensed Vocational Nurse (LVN) 1, in Resident 1's room, LVN 1 stated that the room feels warmer than other rooms and today is a hot day. LVN 1 stated that the HVAC is not cooling the room well. LVN 1 stated that residents can feel uncomfortable and it can aggravate the health conditions of residents if the room is hot on a hot day. During a concurrent interview and observation on 7/18/2026 at 3:39 PM with the Regional Maintenance Director (RMD) Resident 1 and Resident 2's room temperature was taken with a digital laser thermometer (device used to measure temperatures) by the RMD and observed to be 80.9 degrees Fahrenheit (F, unit of measure for temperature). RMD stated Resident 1 and Resident 2's room temperature was 80.9 and is more hot than other rooms. During a concurrent interview and observation on 7/18/2026 at 3:43 PM with RMD, Resident 3's room temperature was taken with a digital laser thermometer by the RMD and observed to be 81.3 degrees F. RMD stated Resident 3's room temperature is 81.3 and is hotter than other rooms. During a concurrent interview and observation on 7/18/2026 at 3:49 PM with RMD, the facility's room [ROOM NUMBER] 's temperature was taken with a digital laser thermometer by the RMD and observed to be 74.6 degrees F. RMD stated room [ROOM NUMBER]'s temperature is 74.6 degrees F. During a concurrent interview and observation on 7/18/2026 at 3:52 PM with RMD, the facility's room [ROOM NUMBER] temperature was taken with a digital laser thermometer by the RMD and measured to be 73 degrees F. RMD stated room [ROOM NUMBER]'s temperature is 73 degrees F. During a concurrent interview and record review on 7/18/2026 at 4:06 PM with RMD, the facility's P&P titled, Maintenance Service dated 2001 was reviewed. The P&P indicated:Maintenance service shall be provided to all areas of the building.Functions of maintenance personnel include maintaining the heat/cooling system.RMD stated that the policy indicated the cooling system is to be maintained in good working order. RMD stated the HVAC is not in proper working condition since it is only properly cooling some rooms. RMD stated he will call a technician to fix the HVAC. During a concurrent interview and record review on 7/18/2026 at 4:47 PM with Director of Nursing (DON), the facility's P&P titled, Homelike Environment dated 2001 and the facility's P&P titled Quality of Life dated 8/2011 were reviewed.The Homelike Environment P&P indicated:Staff provides person centered care that emphasizes the resident's comfort and preferences.The facility staff and management maximizes the characteristics of the facility that reflect a personalized, homelike setting including comfortable temperature.The Quality of Life P&P indicated:A facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life.The facility's responsibilities toward creating and sustaining and environment that humanizes and individualizes each resident.The DON stated the Homelike Environment policy indicated residents are provided a comfortable and homelike environment with comfortable temperatures. The DON stated that some rooms were not as cool as others and they are working on repairing the HVAC. The DON stated the Quality of Life policy states that the facility will promote maintenance or enhancement of each resident's quality of life and stated that she is aware that some rooms are not being cooled adequately and does not feel that it affects the resident's quality of life or health conditions.

Based on observation, interview, and record review, the facility failed to ensure one (1) of 3 sampled residents (Resident 1) who was dependent with staff for Activities of Daily Living (ADL, are activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) were provided care and services to maintain good grooming, personal hygiene based on the facility's policy and procedure.This deficient practice had the potential for Resident 1 to develop infection and skin breakdown which could result in poor wound healing and the decline of the resident's well-being. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 1's diagnoses including but not limit to hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area) affecting left non-dominant side, diabetes (a chronic condition that happens when your blood sugar [glucose] is too high) with hyperglycemia (a condition where the blood glucose [sugar] levels are abnormally high), and generalized muscle weakness. During a review of Resident 1' s Minimum Data Set (MDS, a resident assessment tool) dated 6/13/2026, the MDS indicated Resident 1 had intact cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 was incontinent with bowel and bladder. The MDS also indicated Resident 1 had one unhealed Stage 4 pressure ulcer (Full-thickness skin and tissue loss with exposed or directly palpable fascia [a thin, fibrous connective tissue that surrounds and supports all the structures in the body, including muscles, organs, bones, and nerves], muscle, tendon, ligament, cartilage or bone in the ulcer and one moisture associated skin damage (MASD, caused from prolonged exposure to moisture). The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does no effort to complete the activity) in toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, chair/ bed-to-chair transfer and tub shower transfer. Resident 1 also requires substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in oral hygiene, upper body dressing, personal hygiene, sit to lying, and lying to sitting on the side of the bed. During an observation and interview on 7/15/2026 at 10:19 AM, Resident 1 was lying on her bed with the head of the bed (HOB) elevated to 60-degree angle (a unit for measuring angles, where a full circle is 360 ). Resident 1 stated she had wound on her butt for six months already. Resident 1 always repositions herself, but her wound would not heal, Resident 1also stated her body is not responding well on healing her wounds. Resident 1 stated she was not being changed as frequently as she liked and needed, that is why she had rashes for 6 months. Resident 1 groin had rashes because of the moisture and heat from the diapers. The staff did not change Resident 1's brief, as frequently as they were supposed to every shift. During an interview on 7/15/2026 at 1:34 PM with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated this is the first time that CNA 1 was going to change Resident 1's brief since Resident 1 left for her dialysis (a life-sustaining medical treatment that performs the natural functions of the kidneys when they fail, such as filtering waste products, toxins, and excess fluid from the blood) appointment around 4:30 AM. During an interview on 7/15/2026 at 1:36PM with Resident 1 inside Resident 1's room, Resident 1 stated she did not ask the staff to be changed earlier when she was back from dialysis, so the staff will not get upset with her, and think that she was being difficult and be mean to her. During an interview on 7/15/2026 at 1:38 PM with CNA 1, CNA 1 stated she should have explained to Resident 1 the risk and benefits of changing her briefs when she was back from the dialysis appointment. If they do not change the Resident brief's frequently, Resident 1 might get soaked and will continue to have rashes because of the moisture. During an interview on 7/15/2026 at 2:15PM with Treatment Nurse (TN), TN stated MASD contributing factors includes soaked diaper and moisture from sweat. If Resident 1's diaper change was not done frequently, the MASD could get worse and Resident 1 might open another wound on her coccyx (tailbone, is the small, triangular bone located at the very base of the spinal column) area. During a concurrent interview and record review on 7/15/2026 at 3:18 PM with Director of the Staff Development (DSD), Resident 1 Bowel and Bladder Elimination Charting (BBEC) dated 6/1/2026 to 7/15/2026 were reviewed. The BBEC indicated the following dates did not have documentation,1. 6/1/2026 - morning (AM) shift, evening (PM) shift2. 6/4/2026 - night (NOC) shift3. 6/13/2026 - NOC shift4. 6/14/2026 - NOC shift5. 6/16/2026 - NOC shift6. 7/4/2026 - NOC shift7. 7/6/2026 - NOC shift8. 7/7/2026 - PM shift9. 7/10/2026 - PM shift10. 7/11/2026 - NOC shift DSD stated BBEC had incomplete documentation, some shifts were blank. If there were no documentation, it meant the CNAs did not monitor the B&B elimination of Resident 1. We would not know how many times Resident 1 voided and how many times the CNAs changed Resident 1's brief for that shift. During a concurrent interview and record review on 7/15/2026 at 3:41 PM with Director of Nursing (DON), Resident 1 Bowel and Bladder Elimination Charting (BBEC) dated 6/1/2026 to 7/15/2026 were reviewed. DON stated the staff documentation in BBEC was incomplete. If there was no documentation, we would not know if Resident 1 was being changed for the shift. If Resident 1's brief was not changed, she can have skin issues and if she already has skin issues, it can get worse. During a concurrent interview and record review on 7/15/2026 at 3:43 PM with the DON, the facility's policy and procedure (P&P) titled, Supporting Activities of Daily Living (ADLs), dated 2001 was reviewed, The P&P indicated Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. DON stated the staff did not provide the appropriate care to Resident 1; they should check if she needed diaper change every 2 hours and as needed. The staff did not provide appropriate care like changing diapers to maintain their skin integrity. During a concurrent interview and record review on 7/15/2026 at 3:58 PM with the DON, the facility's P&P titled, Urinary Incontinence- Clinical Protocol, dated 2001, indicated for incontinent individuals. The nursing staff will identify and document circumstances related to incontinence; for example, frequency, nocturia (waking up two or more times during the night to urinate), dysuria (painful or difficult urination) or relationship to coughing or sneezing. DON stated the staff should be documenting everything on the Resident's chart. The staff were not following policy, because staff were missing documentation on their shift.During a review of the facility's policy and procedure titled, Charting and Documentation dated 2001, the P&P indicated the following information is to be documented in the resident medical record: a. objective observation. The P&P also indicated Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.

Based on observation, interview, and record review, the facility failed to provide a functional call light for two (2) of three (3) sampled residents (Residents 2 and 3) in accordance with the facility's policy and procedure (P&P) titled Call System (an emergency, nurse, or service-oriented communication setup that allows users to push a button to alert staff or caregivers), Resident. These failures had the potential to put Residents 2 and 3 at risk of experiencing delays in receiving assistance from facility staff, which could lead to an accident or injury.Findings: 1.During a review of Resident 2 's admission Record, it indicated, the resident was initially admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel), muscle weakness , and urinary tract infection (UTI, an infection of the bladder and urinary system) and urinary retention (a condition that makes it difficult to empty the bladder, either partially or completely) . During a review of Resident 2 's Minimum Data Set (MDS - a resident assessment tool), dated 4/19/2026, the MDS indicated that the resident had moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 2 required supervision or touching assistance (helper provides verbal cues and/or touching or steadying as the resident completes the activity) for personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing, and drying face and hands). It also indicated, substantial maximal assistance (helper does more than half the effort) was needed for sit-to-stand (the ability to come to a standing position from sitting in a chair). During a review of Resident 2's care plan initiated on 4/19/2026, the care plan indicated that Resident 2 requires the use of bilateral one-fourth (1/4) partial side rails (a pair of short safety rails, one on each side, attached to the upper section of a hospital or care bed, spanning only about a quarter of the bed's total length) as an enabler. The care plan also the intervention was to place the call light and frequently used items within reach and to answer the call light promptly. 2. During a review of Resident 3's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of muscle weakness, cirrhosis (a condition in which the liver is scarred and permanently damaged) and dysphagia (difficulty swallowing). During a review of Resident 3 's MDS, dated [DATE], the MDS indicated that the resident had moderately impaired cognitive skills for daily decision making. Resident 3 required supervision or touching assistance for personal hygiene. It also indicated Resident 3 was dependent (helper does all the effort) for chair-to-bed transfer and tub/shower transfer (the ability to get in and out of a tub or shower). During a review of Resident 3's care plan initiated on 12/24/2026, the care plan indicated Resident 3 requires the use of bilateral one-half (1/2) side rails The care plan also indicated that Resident 3 was at risk for entrapment or injury. the intervention was to place the call light and frequently used items within reach and to answer the call light promptly. During an observation on 5/6/2026 at 6:40 AM at Nursing Station A, the call light the indicator light for Room A was on from the call light indicator panel/ board (panel with resident's room number and light indicator if the call light was switched on), there was no sound heard. Certified Nursing Assistant (CNA 1) was observed standing at the nursing station counter checking a folder, and a Licensed Vocational Nurse (LVN 1) was sitting in front of the computer. Room A's call light indicator by the door was also visibly lit from Nursing Station A. During an interview on 5/6/2026 at 6:45 AM in Room A with CNA 1, CNA 1 stated, When the call light is on, we need to come right away to attend to residents' needs. During an interview on 5/6/2026 at 6:46 AM with Resident 3 in Room A, Resident 3 stated staff do not answer the call light and that it took one hour or more for the call light to be answered. Resident 3 also stated sometimes he had to bang the grabber on the table for staff to come. During an interview on 5/6/2026 at 6:48 AM with Resident 2 in Room A, Resident 2 stated it took one hour or more for staff to answer the call light, and that this happened all the time. During a concurrent observation and interview on 5/6/2026 at 7AM with the Director of Nursing (DON), the DON pressed the call light in Room A for Resident 2 and 3. The DON stated that the call light outside Room A's door for Resident 2 and 3 at Nursing Station A was lit; however, it did not make an alert sound. During an interview on 5/6/2026 at 7:09 AM with the Licensed Vocational Nurse (LVN 1), LVN 1 stated the call lights were answered as soon as possible to attend to residents' needs. LVN 1 also stated the call light in Room A does not have sound when pressed. During an interview on 5/6/2026 at 11:47 AM with LVN 2, LVN 2 stated the call light board located in the nursing station does not have sound, only light. LVN 2 stated the call light was broken because there should be sound to alert the nurses at the station. The call light is a means of resident communication and needs to be answered as soon as possible. During a concurrent interview and record review on 5/6/2026 at 11:48 AM with LVN 2, the facility's P&P titled Call System, Resident, revised date 9/2022, was reviewed. LVN 2 stated the P&P indicated residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. LVN 2 also stated the P&P indicated the call system remains functional at all times and if audible communication is used, the volume is maintained at an audible level that can easily be heard. LVN 2 also stated that calls for assistance are answered as soon as possible. LVN 2 also stated that the P&P for Call System, Resident was not followed. During a concurrent interview and record review on 5/6/2027 at 12:55 PM with LVN 3, the facility's P&P titled Care Plans, Comprehensive Person Centered, dated 2001, was reviewed. LVN 3 stated the P&P indicated that a comprehensive, person-centered care plan including measurable objectives and a timetable to meet the resident's physical, psychosocial (how a person feels emotionally and how they interact with other people), and functional needs is developed and implemented for each resident. LVN 3 stated the care plan for Resident 2 and 3 was not implemented and that the P&P for care plan was not followed since Resident 2 and 3's call light were not answered promptly.

Based on observation, interview, and record review, facility staff failed to revise the care plan (a dynamic, written document outlining a patient's health needs, goals, and customized interventions, formulated through assessment) for the use of mechanical lift (a device used to safely transfer individuals with limited mobility between beds, wheelchairs, and chairs, reducing physical strain on caregivers) for one of two (2) sampled residents (Resident 1) as indicated on the facility policy. This deficient practice had the potential for Resident 1 not to receive resident specific interventions to ensure safety.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 re-admitted to the facility on [DATE]. Resident 1's diagnoses included hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild loss of strength in a leg, arm, or face) following cerebral infarction (a damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, hydrocephalus unspecified (water in the brain, an abnormal buildup of cerebrospinal fluid [ a clear, colorless liquid produced in the brain] in the brain's ventricles without a specified cause), and Guillain-Barre syndrome (a rare neurological disorder in which a person's immune system mistakenly attacks part of the network of nerves that carries signals from the brain and spinal cord to the rest of the body). During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with eating, oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, and sit to lying. During a concurrent observation and interview on 5/4/2026 at 10:16 AM with Certified Nursing Assistant 1 (CNA 1) inside Resident 1's room, observed Resident 1 being transferred from the shower chair back to the resident's bed by CNA 1 and CNA 2. CNA 1 stated since Resident 1 was light weight, the resident can be transferred with two people assistance. CNA 1 and CNA2 stated they have always used two people assist to transfer Resident 1 and have never used a mechanical lift. During a review of Resident 1's comprehensive admission MDS, dated [DATE], the MDS indicated mechanical lift was one of the devices and aids used for the resident. During a review of Resident 1's Care Plan, dated 8/9/2025, the Care Plan indicated intervention for Resident 1's precaution for further falls and injuries was the use of assistive devices such as wheelchair and mechanical lift. During a concurrent interview and record review on 5/5/2026 at 9:55 AM with MDS nurse, Resident 1's Care Plan Report dated 8/9/2025 to 5/4/2026, and the MDS assessment dated [DATE] were reviewed. MDS nurse stated she was not aware that the nursing staff did not use mechanical lift to transfer Resident 1 but instead utilized two people to assist with the resident's transfer. MDS nurse stated she should have reviewed and revised Resident 1's care plans after each MDS assessment was completed to keep the resident's care plan current and updated. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 2001, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan: when the desired outcome is not met;when the resident has been readmitted to the facility from a hospital stay; andat least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview, and record review, facility staff failed to develop and implement a care plan for proper safety precautions for one (1) of two (2) sampled Residents (Resident 1) by failing to identify interventions related to the resident's specific risks which included behavior of kicking his legs while in bed. This deficient practice resulted to Resident 1 sliding off from the bed on 3/24/2026 and potential for further falls which could cause injury and harm to the resident. 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 re-admitted to the facility on [DATE]. Resident 1's diagnoses included hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild loss of strength in a leg, arm, or face) following cerebral infarction (a damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, hydrocephalus unspecified (water in the brain, an abnormal buildup of cerebrospinal fluid [ a clear, colorless liquid produced in the brain] in the brain's ventricles without a specified cause), and Guillain-Barre syndrome (a rare neurological disorder in which a person's immune system mistakenly attacks part of the network of nerves that carries signals from the brain and spinal cord to the rest of the body). During a review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 1/23/2026, the MDS indicated Resident 1 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with eating, oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, and sit to lying. The MDS also indicated Resident 1 did not have any fall episodes. During a review of Resident 1's Situation, Background, Assessment, and Recommendation communication form (SBAR, a structured framework used in healthcare to ensure concise and effective communication during critical situations, patient handoffs, or provider calls), dated 3/24/2026, the SBAR communication form indicated Resident 1 slid off the bed, slowly down to the floor mat. During a concurrent interview and record review on 5/4/2026 at 2:55 PM with Registered Nurse Supervisor (RNS), Resident 1's SBAR communication form dated 3/24/2026 was reviewed. RNS stated Resident 1 slid off the bed unto the floor mat. RNS stated she was not aware how Resident 1 slid off the bed. During an observation on 5/4/2026 at 9:45 AM in Resident 1's room, Resident 1 was awake lying on a low air loss mattress (a special mattress that gently blows air through small holes to help keep the skin dry and reduce pressure, which helps prevent or treat pressure injuries). Resident 1 was unable to speak. Resident 1 had bilateral upper quarter side rails (a safety bar attached to the side of a bed to help prevent a person from falling out and to provide support when moving or repositioning) up. During an interview on 5/5/2026 at 10:16 AM with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated she placed Resident 1 back to his bed after returning from the shower room. CNA 3 stated she raised Resident 1's bilateral side rails. CNA 3 stated she went outside of the resident's room to obtain linen from the linen cart, which was located in front of Resident 1's room. CNA 3 stated by the time she returned to the resident's room, Resident 1 was observed sitting on the floormat with his back against the bed frame. CNA 3 stated Resident 1 tends to kick a lot when in bed, which could contribute to resident falling. CNA 3 stated Resident 1 was kicking a lot during activities of daily living (ADL) care on 3/24/26, and stated she should have stayed with Resident 1 to prevent him from sliding off his bed. During a concurrent interview and record review on 5/5/2026 at 11:33 AM with the Director of Nursing (DON), Resident 1's care plan (a dynamic, written document outlining a patient's health needs, goals, and customized interventions, formulated through assessment), dated 3/24/2026 was reviewed. The DON stated Resident 1's care plan did not include resident - centered safety protocols to prevent falls. The DON also stated Resident 1's care plan did not, but should have, addressed Resident 1's behavior of kicking his legs which could result in sliding off the bed. The DON stated Resident 1 had another fall in 11/2025 which resulted from this same behavior. The DON stated CNA 3 should have stayed inside the room with Resident 1 to prevent him from sliding off the bed. The DON also stated it is very important to prevent Resident 1 from further falls to avoid severe injuries like hip fractures (a break in the upper part of the thigh bone [femur] near the hip joint, which usually happens from a fall and often requires medical treatment). During a review of the facility's Policy and Procedure (P&P) titled, Falls and Fall Risk, Managing, dated 2001, 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. The P&P also indicated that according to the MDS, a fall is defined as: Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). The P&P also indicated Resident-Centered Approaches to Managing Falls and Fall RiskThe staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) 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. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 2001, was reviewed. The P&P indicated:Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.

Based on interview and record review, the facility failed to change the enteral (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine) feeding bag every shift/every 24 hours for one of four sampled residents (Resident 2) in accordance with the physician 's order and facility policy.This deficient practice had the potential for Resident 2 not to get adequate nutrients via enteral feeding which could lead to malnutrition (serious condition that occurs when a resident's diet does not contain the right amount of nutrients) and results in hospitalization and death. Findings: During a review of Resident 2's admission Record, the admission Record indicated that Resident 2 was admitted to the facility on [DATE] with dysphagia (difficulty swallowing), encounter for attention to gastrostomy (a surgically created opening from the abdomen to the stomach for feeding or medication.) and adult failure to thrive (not a specific disease, for inadequate physical growth or a decline in physical and mental function). During a review of Resident 2's Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool), dated 10/26/2025, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were impaired. The MDS indicated Resident 2 required total dependence (full staff performance) on staff for oral hygiene, toilet hygiene, and personal hygiene. The MDS indicated Resident 2 was on feeding tube.During a review of Resident 2's Order Summary, dated 10/22/2025, the Order Summary indicated to change enteral administration set with every bottle of formula, every shift. During a review of Resident 2's Care Plan, initiated on 9/17/2025, the Care Plan indicated Resident 2 was at risks for significant weight loss and risks for dehydration (condition that occurs when the loss of body fluids, mostly water, exceeds the amount that is taken in). The staff interventions included were for the the staff to assist with tube feeding and water flushes and to see orders for current feeding orders. During a Resident 2's family member (R2FM) phone screenshot review and interview on 12/17/2025 at 2:10 PM, R2FM's phone screenshot, dated 11/14/2025 at 12:21 PM, indicated the screenshot of the Resident 2's enteral feeding bottle, dated 11/11 2025 9 PM. R2FM stated Resident 2's enteral administration feeding set had not been changed for three (3) days from 11/11/2025 to 11/14/2025. R2FM stated, My father did not get his nutrition and hydration needed for his body. During an interview on 12/17/2025 at 3:03 PM with the Director of Nursing (DON), the DON stated R2FM validated the screenshot with the DON. The DON stated the licensed nurse did not change the enteral feeding bottle and hydration water bag every shift as indicated in the order. As a result, Resident 2 was at risk of not getting or maintaining adequate nutrition and hydration needed for his body. The DON stated it was facility's procedure to change administration set and formula bottle every 24 hours or followed physician's order.During a review of facility's undated policy and procedure (P&P) titled, Enteral Tube Feeding via Continue Pump, the P&P indicated formulas that had been reconstituted in advance and discard within 24 hours. Discard reconstituted formulas kept at room temperature with four hours. The P&P also indicated to refer to facility procedure for hang times and administration set changes.

Based on interview and record review, the facility failed to complete/and follow through with the Preadmission Screening and Resident Review (PASARR; a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) for two (2) of three (3) sampled residents (Residents 3 and 4) under the PASARR care area by not: Completing a PASARR level 1 screening for Resident 3 upon admission on [DATE]. 2. Conducting a follow up to obtain a PASARR level II (a resident-centered evaluation that is completed for anyone identified by the Level 1 Screening as having, or suspected of having, a PASRR condition, such as serious mental illness [SMI], intellectual disability [ID], developmental disability (DD), or related condition [RC]) evaluation for Resident 4 in accordance with the facility policy. This failure had the potential to result in inappropriate placement and unidentified specialized services for Residents 3 and 4. During a review of Resident 3's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of dementia (a progressive state of decline in mental abilities) and paranoid schizophrenia (a subtype of schizophrenia [a mental illness that is characterized by disturbances in thought]characterized by prominent delusions). During a review of Resident 3'S Minimum Data Set (MDS – a resident assessment tool), dated 9/1/2025, the MDS indicated the resident had severe impairment (difficulty with or unable to make decisions, learn, remember things) with cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 3 was dependent (helper does all of the effort. Resident does none of the effort to complete activity or the assistance of two [2] or more helpers is required for the resident to complete the activity) with chair/bed-to-chair transfers, going from lying to sitting on the side of the bed, upper and lower body dressing (the ability to dress and undress above and below the waist), putting on/taking off footwear, and personal hygiene. Resident 3 needed substantial/maximal assistance (helper does more than half the effort) with eating. During a concurrent interview and record review on 10/1/2025 at 10:14 AM with Social Services Director (SSD), Resident 3's Electronic Medical Record (EMR; a digital version of a patient's paper chart containing the resident's medical history, diagnoses, treatment sand other health information) dated October 2025 was reviewed. SSD stated Resident 3 last had a PASARR level 1 screening done on 9/16/2019 and verified that Resident 3's admission profile indicated she was last admitted to the facility on [DATE]. SSD stated there was no PASSAR level 1 screening done for Resident 3's admission on [DATE] and further stated that the purpose of the PASARR is to screen if a resident has any mental/developmental disabilities and indicated if the resident may have any specific psychiatric (anything related to mental illness or its medical treatment) issues and needs so that the facility may address them. SSD further stated if the PASARR screening is not done, the facility cannot comply with needs that a resident may have. 2. During a review of Resident 4's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 4's PASARR completed on 7/2/2024, it indicated Resident 4's need for Level II PASARR evaluation. During a review of Resident 4'S MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making was independent (decisions consistent/reasonable). The MDS indicated Resident 4 required set up or clean up assistance (Helper sets up or cleans up; resident completes activity) with eating. The MDS indicated Resident 4 required substantial/maximal assistance with oral hygiene, upper body dressing and personal hygiene. The MDS indicated Resident 4 was dependent with toileting hygiene, shower, lower body dressing, and putting on/taking off footwear. The MDS also indicated Resident 4 was receiving antipsychotic (medication primarily used to manage psychosis). During a concurrent record and interview on 11/19/2025 at 9:13 AM, with MDS nurse (MDSN), Resident 4's PASARR dated 7/2/2024 were reviewed. The MDSN stated she was responsible for overseeing PASARR. The MDSN stated she is newly hired in the facility and has not checked all PASARR's yet. The MDSN verified Resident 4's PASARR level I evaluation dated 7/2/2024 indicated level II evaluation is required. The MDSN stated that there was no follow up made with a PASARR representative regarding the need for Resident 4's Level II evaluation. The MDSN stated that Level II evaluation was to determine appropriate placement and/or the need for specialized services. During a review of the facility's Policy and Procedure titled, admission Criteria, revised March 2019, indicated all new admissions and readmissions are screened for MD, ID or related disorders (RD) per the Medicaid PASARR process. It also indicated if the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. (1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID or RD. (2) The social worker is responsible for making referrals to the appropriate state-designated authority.

Based on observation, interview, and record review, the facility failed to ensure proper food handling pas practiced and was provided in accordance with the facility's policy and procedure (P&P) by failing to ensure an open bag with eight (8) chicken patties and a cheesecake in the kitchen's walk-in freezer was labeled with open date and best by (expiration) date. The deficient practice of failing to ensure unlabeled foods are disposed accordingly had the potential to result in growth of bacteria and transmission of foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea (the frequent passing of loose, watery stools), and fever and can lead to other serious medical complications and hospitalization.Findings:During a concurrent observation in the facility kitchen and interview on 9/29/2025 at 7:47 AM with the Dietary Supervisor 1 (DS 1), walk-in freezer was observed. There were eight (8) chicken patties in an open bag, with no label of open date, expiration date, and no best by date. In addition, there was a cheesecake with no label of received date (dates of delivery), expiration date, and no best by date. DS 1 stated she did not know why some of the items were not labeled with open date, received date, expiration date and best by date. DS 1 stated, all items that are being opened in the facility's kitchen should have a label of the date when it was opened or first use and use by date or expiration date. During an interview on 11/18/2025 at 2:04 PM with DS 3, DS 3 stated the food items in the facility's kitchen without a label of open date, received date, and best by date are not safe to use/ to serve to the residents because of uncertainty whether it is still good to use or not. DS 3 stated the 8 chicken patties and the cheesecake observed in the walk-in freezer should be discarded because no one knows how long it has been there, and those foods might cause residents to get sick, or experience stomach issues like diarrhea. During a review of facility's P&P titled Food Receiving and Storage, revised in November 2022, indicated all foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). During a review of facility's P&P titled Refrigerators and Freezers, revised in November 2022, indicated all food is appropriately dated to ensure proper rotation by expiration dates. The P&P indicated Received dates (dates of delivery) are marked on cases and on individual items removed from cases for storage, Use by dates are completed with expiration dates on all prepared food in refrigerators and expiration dates on unopened food are observed and use by dates are indicated once food is opened. It also indicated supervisors are responsible for ensuring food items in pantry, refrigerator and freezers are not past use by or expiration dates.

Based on observation, interview, and record review, the facility failed to implement facility's policy and procedures (P&P) for food brought by family/visitors for five of seven sampled residents (Residents 4, 9, 25, 37 and 32) by failing to ensure:1. A container of rice and noodles for Resident 4 was labeled with use by date.2. Food was removed and discarded from the resident's refrigerator for Resident 9 who was discharged from the facility on 9/26/2025.3. A container of pozole (a kind of soup) and bag of cabbage for Resident 25 was labeled with use by date.4. A box of pizza for Resident 37, dated 9/6/2025 was disposed. 5. Multiple containers of food containing rice fish, bitter melon and beef for Resident 32 was labeled with use by date.6. Food brought by Resident 32's visitor was not left in resident's room for more than 2 hours. These deficient practices had the potential to result in food-borne illnesses (food poisoning) for Residents 4, 9, 25, 37 and 32, with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications and hospitalization.Findings: 1. During a review of Resident 4's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 4's medical records, it indicated a diet order of renal diet (diet plan for people with kidney disease) / Consistent or Controlled Carbohydrate diet (CCHO diet, a dietary approach for managing blood sugar levels) mechanical soft texture (a diet of foods that are modified to be easy to chew and swallow), regular liquid consistency, ordered on 8/22/2025, and discontinued on 11/3/2025. During a concurrent observation and interview on 9/29/2025 at 8:09 AM with Dietary Supervisor 1 (DS 1), the resident's refrigerator was observed. DS 1 stated there is a container of rice, and a container of noodles with Resident's 4 name with no date when it was received and it was not labeled with use by date. 2. During a review of Resident 9's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses of anemia (a condition where the body does not have enough healthy red blood cells), hypertension (HTN-high blood pressure) and dementia (a progressive state of decline in mental abilities). During a review of Resident 9's medical records, it indicated a diet order of CCHO diet, mechanical soft chopped texture, regular liquid consistency, ordered on 7/31/2025, and discontinued on 9/26/2025. During a concurrent observation and interview on 9/29/2025 at 8:10 AM with DS 1, the resident's refrigerator was observed. DS 1 stated there is a container of sour cream, yogurt, pickles and a bottle of prune juice with Resident's 9 name. DS 1 stated all these foods should have been discarded after the resident was discharged from the facility on 9/26/2025. 3. During a review of Resident 25's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was re admitted on [DATE], with diagnosis of end stage renal disease (ESRD, irreversible kidney failure), and paraplegia (loss of movement and/or sensation, to some degree, of the legs). During a review of Resident 25's medical records, it indicated a diet order of double protein renal/CCHO diet, regular texture, regular liquid consistency, ordered on 9/19/2025, and discontinued on 11/3/2025. During a concurrent observation and interview on 9/29/2025 at 8:11 AM with DS 1, the resident's refrigerator was observed. DS 1 stated there is a container of pozole, and a bag of cabbage with Resident's 25 name and not labeled with the date when it was received and not labeled with the use by date. 4. During a review of Resident 37's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was re admitted on [DATE], with diagnosis of hypertension, anemia and muscle weakness. During a review of Resident 37's medical records, it indicated a diet order of regular diet, regular texture, regular liquid consistency, ordered on 9/2/2025, discontinued on 10/8/2025. During a concurrent observation and interview on 9/29/2025 at 8:12 AM with DS 1, the resident's refrigerator was observed. DS 1 stated there is a box of pizza labeled with Resident 37's name, with 2 slices of pizza left inside the box, dated 9/6/2025. DS 1 stated the pizza should have been discarded and not left in the refrigerator for a long time. 5. During a review of Resident 32's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of paroxysmal atrial fibrillation (an irregular heartbeat that starts and stops on its own) and type 2 diabetes mellitus (high blood sugar). During a review of Resident 32'S Minimum Data Set (MDS – a resident assessment tool), dated 10/15/2025, the MDS indicated the resident was cognitively intact (ability to think, remember, and reason) with cognitive skills for daily decision making. It indicated Resident 32 needed supervision or touching assistance (helper sets up or cleans up; resident completes activity) with walking 150 feet, chair/bed-to-chair transfers, personal hygiene and upper body dressing (the ability to dress and undress above the waist). The MDS indicated Resident 32 needed partial/moderate assistance (helper does less than half the effort) with lower body dressing (the ability to dress and undress below the waist) and putting on/taking off footwear and needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating. During a concurrent observation and interview on 9/29/2025 at 8:44 AM with Resident 32 inside his room, a bowl of fish soup on top of a plate with a half-eaten piece of chicken was observed uncovered and unlabeled with the use by date that was placed on top of Resident 32's rolling bedside table. Resident 32 stated Resident 32's visitor brought it for him last night.During a concurrent observation and interview on 9/29/2025 at 8:51 AM with Licensed Vocational Nurse 3 (LVN 3) and Resident 32 inside Resident 32's room, a bowl of fish soup on top of a plate with a half-eaten piece of chicken was observed uncovered and unlabeled with the use by date that was placed on top of Resident 32's rolling bedside table. LVN 3 verified, the uncovered bowl of fish soup on top of a plate of half-eaten chicken had no label of use by date. Resident 32 stated he would like to eat it later & LVN 3 told the resident that she would have someone put it in the refrigerator. During a concurrent observation and interview on 9/30/2025 at 12:28 PM with Resident 32 inside his room, two Tupperware containers were observed on Resident 32's rolling bedside with one containing rice and the other containing soup and were not labeled with use by date or time. Resident 32 stated his friend had brought it in for him earlier that same day. During an interview on 9/30/2025 at 12:30 PM with Registered Nurse 1 (RN 1), RN 1 stated Resident 32's friend had come by around 12:00 PM on 9/30/2025. During a concurrent observation and interview on 9/30/2025 at 3:12 PM with the Director of Nursing (DON) inside Resident 32's room, two Tupperware containers were observed on top of Resident 32's rolling bedside table with one containing rice and the other containing soup with a labeled date of 9/30/2025 and time at 12:00 PM. The DON verified Resident 32's food brought in from the outside at 12:00 PM was still at the resident's bedside at 3:12 PM. During an interview on 11/18/2025 at 2:11 PM with DS 3, DS 3 stated food brought by residents, residents' visitors/family are being stored in facility's resident's refrigerator. DS 3 stated CNAs stored the food in resident's refrigerator, and CNAs should label it with the date when it was received, and the use by date. DS 3 stated that partially eaten food should not be kept in the resident's refrigerator. DS 3 stated it is important to label resident's food with use by date to ensure the resident does not consume the food after the use by date that was labeled on their foods. DS 3 stated residents might get sick for consuming food that is being stored there for a while. During a concurrent interview and record review on 10/1/2025 at 10:38 AM with the DON, the facility's policy and procedure (P&P) titled, Food Brought by Family/Visitors, revised March 2025 was reviewed. The P&P indicated: a. Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility-prepared food. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date. b. The nursing staff will discard perishable foods on or before the use by date. c. Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer than 2 hours will be discarded. The DON stated, since Resident 32's food that was brought in on 9/30/2025 at 12:00 PM was still at the bedside on 9/30/2025 at 3:12 PM, it should have been discarded since their policy indicated foods that are left out for the resident/s without a source of heat or refrigeration longer than 2 hours will be discarded. The DON stated, food brought from outside the facility for the resident should be labeled with use by date and if not properly stored could potentially cause the resident to get sick due to a foodborne illness (a sickness caused by eating food or drinking liquids contaminated with bacteria, viruses, parasites or toxins) or food poisoning (sickness that occurs from eating food or drinking beverages contaminated with germs, toxins or chemicals).

Based on observation, interview and record review, the facility failed to follow their infection control policies & procedures for five (5) of six (6) sampled residents (Residents 10, 18, 40, 61, and 77) by not ensuring:1-4. The availability of environmental Protection Agency (EPA; a United States federal agency that protects human health and safeguards the environment by creating and enforcing environment laws and regulations) registered sanitizing wipes or bleach wipes effective against Clostridium Difficile (C. diff; a highly contagious bacterial infection that causes an infection of the colon [the longest part of the long intestine]) for Residents 10, 18, 61 and 77 on contact isolation (a transmission based precautions to stop germs from spreading through direct touch with a patient or indirect touch with contaminated objects in their environment) for C. diff infection. 5. Used disposable tray, disposable food containers and disposable utensils (single use eating tools, such as forks, knives, and spoons, that are discarded after one use) of Resident 40 who was on contact isolation, were properly disposed. These failures have the potential to result in the spread of infection to other residents in the facility.1. During a review of Resident 10's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of enterocolitis (an inflammation of both the small intestine and the large intestine) due to clostridium difficile and pneumonia (an infection of the lungs). During a review of Resident 10'S Minimum Data Set (MDS – a resident assessment tool), dated 9/5/2025, the MDS indicated the resident was severely impaired (difficulty with or unable to make decisions, learn, remember things) with cognitive skills (ability to think, remember, and reason) for daily decision making. Resident 10 was dependent (helper does all of the effort; resident does none of the effort to complete the activity or the assistance of two (2) or more helpers is required for the resident to complete the activity) with upper and lower body dressing (the ability to dress and undress above and below the waist), putting on/taking off footwear and personal hygiene. Resident 10 needed substantial/maximal assistance (helper does more than half the effort) with going from lying to sitting on the side of the bed and rolling left and right in bed. During a review of Resident 10's Order Summary Report dated 10/2/2025, Resident 10's Order Summary Report indicated an order from 9/21/2025 for contact isolation every shift for stool C. diff. 2. During a review of Resident 18's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of enterocolitis due to clostridium difficile and multiple sclerosis (a chronic autoimmune [a condition where the immune system turns against itself] disease that affects the central nervous system [brain and spinal cord]). During a review of Resident 18'S MDS, dated [DATE], the MDS indicated the resident was moderately impaired cognitive skills for daily decision making. Resident 18 was dependent with chair/bed-to-chair transfers, going from lying to sitting on the side of the bed, putting on/taking off footwear and lower body dressing. Resident 18 needed substantial/maximal assistance with upper body dressing and personal hygiene and needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating. During a review of Resident 18's Order Summary Report, dated 10/2/2025, Resident 18's Order Summary Report indicated an order from 9/23/2025 for contact isolation (stool c. diff).During a review of Resident 18's Care Plan, dated 9/24/2025, Resident 18's Care Plan indicated Resident 18 had C. Difficile. The care plan indicated staff interventions were to put Resident 18 on contact isolation and to disinfect all equipment used before it leaves the room. 3. During a review of Resident 61's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of polyarthritis (a condition where multiple joints experience inflammation) and dysphagia (difficulty swallowing), oropharyngeal phase (a stage of swallowing that involves moving food or liquid from the mouth to the top of the esophagus [a muscular tube that connects the throat to the stomach]). During a review of Resident 61'S MDS, dated [DATE], the MDS indicated the resident was severely impaired with cognitive skills for daily decision making. Resident 61 was dependent with rolling left and right in bed, upper/lower body dressing, putting on/[NAME] off footwear, personal hygiene and eating. During a review of Resident 61's Order Summary Report dated 10/2/2025, Resident 61's Order Summary Report indicated an order from 9/29/2025 for contact isolation precautions for stool C. diff. During a review of Resident 61's Care Plan dated 9/30/2025, Resident 61's Care Plan indicated Resident 61 had C. Difficile. The care plan indicated staff interventions were to put Resident 61 on contact isolation and to disinfect all equipment used before it leaves the room. 4. During a review of Resident 77's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of systemic inflammation response syndrome (SIRS; a widespread inflammatory response throughout the body) and gastro-esophageal reflux disease (GERD; a condition where stomach acid flows back up into the esophagus, causing irritation and discomfort). During a review of Resident 77's History and Physical Examination (H&P), dated 9/26/2025, the H&P indicated Resident 77 had the capacity to understand and make decisions.During a review of Resident 77's Order Summary Report, dated 10/2/2025, Resident 77's Order Summary Report indicated an order from 9/25/2025 for contact isolation until confirmation resident is negative for stool C. diff. During a review of Resident 77's Care Plan, dated 10/1/2025, Resident 77's Care Plan indicated Resident 77 has C. Difficile. The care plan indicated staff interventions were to put the resident on contact isolation and to disinfect all equipment used before it leaves the room.During an observation on 9/30/2025 at 12:26 PM in the hallway outside of Resident 10 and 61's room, a contact isolation was observed indicating to clean and disinfect reusable equipment before use on another person. A supply cart was observed right outside the door with a purple container of Super Sani-Cloth Germicidal (an agent that kills microorganisms like bacteria and viruses) Disposable Wipes on top of the supply cart. During a review of the facility's Super Sani-Cloth Germicidal Wipes container, the Super Sani-Cloth Germicidal Wipes container did not indicate it was effective against C. Diff. During an observation on 10/1/2025 at 9:42 AM in the hallway outside of Resident 18 and 77's room, a contact isolation sign was observed indicating to clean and disinfect reusable equipment before use on another person. A supply cart was also observed right outside the door with a purple container of Super Sani-Cloth Germicidal Disposable Wipes on top of the supply cart. During an interview on 10/1/2025 at 9:42 AM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Residents 18 and 77's room is on contact isolation for C. diff in the stool. LVN 1 stated the Super Sani-Cloth Germicidal Wipes that are located outside the room are what he would use to clean and disinfect the objects inside the room such as the resident's bedside table and chairs. During a concurrent observation and interview on 10/1/2025 at 9:42 AM with LVN 1 in the hallway outside of Residents 18 and 77's room, a supply cart was observed right outside the door with a purple container of Super Sani-Cloth Germicidal Disposable Wipes on top of it. LVN 1 reviewed the Super Sani-Cloth Germicidal Disposable Wipes container and stated it did not name C. diff as an organism it was effective against.During a concurrent observation and interview on 10/1/2025 at 9:48 AM with Infection Preventionist 1 (IP 1) outside of Residents 10 and 61's room, a contact isolation sign was observed indicating to clean and disinfect reusable equipment before use on another person. A supply cart was also observed right outside the door with a purple container of Super Sani-Cloth Germicidal Disposable Wipes on top of the supply cart. IP 1 stated Residents 10 and 61 were on contact isolation for C. diff and the purple container Super Sani-Cloth Germicidal Disposable Wipes outside their room would be used to wipe down the objects in their room. IP 1 reviewed the Super Sani-Cloth Germicidal Disposable Wipes container label and stated it did not indicate C. diff as an organism it was effective against and further stated the wipes that should be used for C. diff isolation were bleach wipes.During a concurrent observation and interview on 10/1/2025 at 9:50 AM with LVN 2 in the hallway outside of Resident's 10 and 61's room, a purple container of Super Sani-Cloth Germicidal Disposable Wipes was observed on the supply cart outside of the room. LVN 2 stated since the purple container of Super Sani-Cloth Germicidal Disposable Wipes was what was supplied outside of the room, they were the wipes she would use to disinfect her pulse oximeter (a device used to measure blood oxygen saturation [SpO2]) that she would use for the residents. LVN 2 stated they were the same wipes she had used yesterday to disinfect the objects in Residents 10 and 61's room. During an interview on 10/1/2025 at 9:53 AM with IP 1, IP 1 stated it's important to provide the correct wipes effective against C. diff because an outbreak of cross contamination with residents in other rooms could occur. IP 1 also stated C. diff spores are able to stay on a surface for three (3) months at a time and if anyone brushes against a surface contaminated with C. diff, they could easily transfer the bacteria to another resident if they are not using proper hand washing, personal protective equipment (PPE; equipment worn to protect against hazards like serious injuries, illnesses or infections) and disinfecting wipes.During a review of the facility's policy and procedure (P&P) titled, Clostridium Difficile, revised October 2018, the P&P indicated, Measures are taken to prevent the occurrence of Clostridium Difficile infections (CDI) among residents. Precautions are taken while caring for residents with C. Difficile to prevent transmission to other residents. The P&P further indicated: a. The primary reservoirs for C. difficile are infected people and surfaces. Spores can persist on resident-care items and surfaces for several months and are resistant to some common cleaning and disinfection methods. b. Steps towards prevention and early intervention include: a. Disinfection of items with potential fecal soiling (e.g. [for example] bedpans, commode chairs, bed rails, etc.) using a disinfecting agent recommended for C. difficile (e.g. household bleach and water solution or an EPA registered germicidal agent effective against C. difficile spores. 5. During a review of Resident 40's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses of enterocolitis due to clostridium difficile, dysphagia, and encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).During a review of Resident 40'S MDS, dated [DATE], the MDS indicated the resident was severely impaired with cognitive skills for daily decision making. The MDS indicated Resident 40 was dependent with eating, oral hygiene, toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear, personal hygiene and rolling left and right in bed. During a review of Resident 40's Care Plan, initiated on 9/16/2025, the Care Plan indicated a focus on Resident 40 requiring contact isolation precautions related to Candida auris (C. auris, a type of yeast that can cause severe illness and spread easily among very sick patients in healthcare facilities) at gastrostomy tube site. The staff interventions indicated the following: Handle and transport lined and waste in a manner that avoids transfer of microorganisms (germ) to residents, staff, and environment. Implement appropriate isolation techniques by staff, resident and visitors. Maintain adequate isolation supplies near the isolation room. Place necessary equipment and supplies in the room needed for isolation. During a concurrent dining observation and interview on 9/30/2025 at 1:05 PM, in the hallway with Certified Nurse Assistant 6 (CNA 6), CNA 6 was observed carrying a disposable tray with disposable bowl, disposable used spoon, used napkin and disposable food container. CNA 6 stated this was the lunch tray from Resident 40 on contact isolation. CNA 6 stated she will be throwing it outside the facility, in the dumpster. During a concurrent interview and record review on 10/1/2025 at 9:20 AM with IP 1, Resident 40's active orders and facility policy were reviewed. IP 1 stated Resident 40 has an active order of contact isolation precautions due to Candida auris (C. auris, a type of yeast that can cause severe illness and spread easily among very sick patients in healthcare facilities) at gastrostomy site since 9/16/2025. IP 1 stated CNA 6 did not and should have thrown all the disposable items inside Resident 40's room for infection control. IP 1 stated contact isolation order should be followed and implemented to protect other residents from infections. IP 1 stated the infection control policy on Disposable Dishes and Utensils did not but should have indicated that the disposable dishes and utensils for any residents on contact isolation should be thrown inside the resident's room or should be placed in an enclosed trash bag to be thrown in the dumpster. During an interview on 11/18/2025 at 1:49 PM with CNA 6, CNA 6 stated she should have not discarded Resident 40's disposable lunch tray outside the contact isolation room on 9/30/2025. CNA 6 stated Resident 40's disposable trays should have been thrown in the trash can inside the resident's room since the resident was on contact isolation to avoid spreading the germs to other residents. CNA 6 also added that anything that Resident 40 used while in contact isolation should be placed in a trash bag before transporting outside the contact isolation room. During an interview on 11/19/2025 at 10:53 AM with IP 2, IP 2 stated disposable trays, disposable food containers and utensils are being used for residents with contact isolation order. IP 2 stated it is important to implement and practice contact isolation precautions to prevent spreading the infection to other residents. IP 2 stated it was important to throw the contaminated disposable meal trays and disposable utensils inside the contact isolation room or placed in a trash bag if they need to be transported outside the room since it could come in contact with another resident and spread the infection. During a review of Facility's P&P titled, Disposable Dishes and Utensils, dated 2001, indicated single-service articles may be used to serve residents in isolation, per facility policy.

Based on observation, interview and record review, the facility failed to promote dignity and respect in accordance with the facility's policy and procedure for one (1) of two (2) sampled residents (Resident 49) under the Dignity Care Area, when Certified Nursing Assistant 3 (CNA 3) was observed standing above Resident 49's eye level while assisting the resident during mealtime. This failure had the potential to affect Resident 49's self-esteem and self-worth.During a review of Resident 49's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of dementia (a progressive state of decline in mental abilities) and dysphagia oropharyngeal phase (a difficulty in the first stage of swallowing, where food is transferred from the mouth to the esophagus [muscular tube that connects the throat to the stomach]). During a review of Resident 49'S Minimum Data Set (MDS - a resident assessment tool), dated 11/5/2025, the MDS indicated the resident had severe impairment (never/rarely made decisions) with cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 49 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with going from sitting to lying down, rolling left and right in bed, upper and lower body dressing (the ability to dress and undress above and below the waist), putting on/taking off footwear, personal hygiene and eating.During an observation on 9/29/2025 at 2:47 PM inside Resident 49's room, Resident 49 was observed sitting up in bed, with her bed in the lowest position and CNA 3 was observed standing next to the resident and attempting to feed her a spoonful of food. During an interview on 9/30/2025 at 1:04 PM with CNA 3, CNA 3 stated on 9/29/2025 she was standing when attempting to feed Resident 49 during mealtime. CNA 3 stated she should not be standing over the resident when assisting her with feeding. CNA 3 added that the correct way to assist a resident with feeding is to be sitting down next to her/him. CNA 3 further stated standing over a resident while assisting her/him with feeding could potentially scare the resident. During a concurrent interview and record review on 10/1/2025 at 10:34 AM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Assistance with Meals, revised March 2022 was reviewed. The P&P indicated, Resident who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: not standing over residents while assisting them with meals. The DON stated not standing over the residents means that the person assisting the resident with feeding should be at her/him eye level so that the resident feels comfortable, respected, and provided with a dignified dining experience. During a review of the facility's P&P titled, Dignity, revised February 2021, the P&P indicated that, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem, and also indicated:a. When assisting with care, residents are supported in exercising their rights. For example, residents are: a. Provided with a dignified dining experience. During a review of the facility's P&P titled, Resident Rights, revised February 2021, the P&P indicated, Employees shall treat all residents with kindness respect and dignity and further indicated: a. Federal and state laws guarantee basic rights to all residents of this facility. These rights include the resident's right to:a. Be treated with respect, kindness and dignity.

Based on observation, interview and record review, the facility failed to ensure three (3) of seven (7) sampled residents (Residents 6, 10 and 43) had their call light (a signaling device, typically a button, used by patients or residents in a healthcare setting to request assistance from staff) placed within reach under the Environment care area. This failure resulted in Residents 6, 10 and 43 not being able to call for help when they were attempting to reach for their call lights and placed them at risk for experiencing a delay in receiving assistance from facility staff which could have potentially led to a fall or accident. Findings: 1. During a review of Resident 6's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of Colles' Fracture (a break in the distal radius [the larger of the two bones in the forearm] near the write, most often caused by a fall onto an outstretched hand) of right radius and osteoarthritis (a degenerative joint disease that causes pain, stiffness, and swelling as the protective cartilage that cushions bones wears down over time). During a review of Resident 6'S Minimum Data Set (MDS - a resident assessment tool), dated 10/15/2025, the MDS indicated the resident was moderately impaired with cognitive (ability to think, remember, and reason) skills for daily decision making. It indicated Resident 6 needed substantial/maximal assistance (helper does more than half the effort) with chair/bed-to-chair transfers, personal hygiene, putting on/taking off footwear and lower body dressing (the ability to dress and undress below the waist). The MDS also indicated Resident 6 needed partial moderate assistance (helper does less than half the effort) with upper body dressing (the ability to dress and undress above the waist) and needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating. During a review of Resident 6's Care Plan dated 10/2/2025, Resident 6's Care Plan indicated Resident 6 had an activities of daily living (ADL; basic self-care tasks necessary for survival such as bathing, dressing, eating, using the toilet and moving around) self-care and/or mobility performance deficits and included an intervention to place call light within reach. During a concurrent observation and interview on 9/30/2025 at 1:01 PM in the hallway outside of Resident 6's room, Resident 6 was observed waving her hand calling for help. Upon entering Resident 6's room, Resident 6 was observed sitting in her wheelchair to the left of her bed with her call light curled up around itself on the right side of her bed out of Resident 6's reach. Resident 6 stated she needed help with being changed and could not reach her call light to call for help. During a concurrent observation and interview on 9/30/2025 at 1:02 PM with Minimum Data Set Nurse (MDSN) inside Resident 6's room, Resident 6 was observed sitting in her wheelchair on the left side of her bed with her call light curled up around itself on the right side of the resident's bed and out of Resident 6's reach. MDSN stated Resident 6's call light was wrapped around itself on top of the right side of Resident 6's bed and out of Resident 6's reach. MDSN stated the purpose of the call light is for residents to call for assistance with any need they may have. 2. During a review of Resident 10's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of enterocolitis (an inflammation of both the small intestine and the large intestine) due to clostridium difficile (a type of bacteria that can cause a severe intestinal infection leading to diarrhea, fever, and abdominal pain) and pneumonia (an infection of the lungs). During a review of Resident 10'S MDS, dated [DATE], the MDS indicated the resident was severely impaired (difficulty with or unable to make decisions, learn, remember things) with cognitive skills for daily decision making. It indicated Resident 10 was dependent (helper does all of the effort; resident does none of the effort to complete the activity or the assistance of two (2) or more helpers is required for the resident to complete the activity) with upper and lower body dressing, putting on/taking off footwear and personal hygiene. The MDS also indicated Resident 10 needed substantial/maximal assistance with going from lying to sitting on the side of the bed and rolling left and right in bed.During a review of Resident 10's Care Plan dated 8/9/2025, Resident 10's Care Plan indicated Resident 10 had an ADL self-care and/or mobility performance deficit and indicated an intervention to place call light within reach. During a concurrent observation and interview on 9/30/2025 at 3:16 PM with Licensed Vocational Nurse 2 (LVN 2) inside Resident 10's room, Resident 10 was observed calling out for help with his call light was observed hanging off the right side of the bed with Resident 10 lying down diagonally on the bed with his back towards the right side of the bed's right half side rail and Resident 10's body turned towards the left bottom corner of the. LVN 2 stated Resident 10's call light was out of Resident 10's reach.During an interview on 9/30/2025 at 3:21 PM with LVN 2, LVN 2 stated earlier on 9/30/2025 at 3:16 PM inside Resident 10's room, Resident 10 was calling out for help and his call light was out of his reach & hanging off the right side of the resident's bed. LVN 2 stated the purpose of the call light is for residents to notify staff that the resident need help and if the call light is not within the resident's reach, it poses a risk for the resident to fall if the resident is not able to call the staff to get the help they need. 3. During a review of Resident 43's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of reduced mobility (limited ability to move around independently due to physical, sensory, or cognitive impairments) and lack of coordination (the inability to perform movements smoothly and controlled leading to clumsiness, unsteadiness and poor balance). During a review of Resident 43'S MDS, dated [DATE], the MDS indicated the resident was cognitively intact with cognitive skills for daily decision making. It indicated Resident 43 was dependent with chair/bed-to-chair transfers and needed substantial/maximal assistance with going from sitting to standing, putting on/taking off footwear and lower body dressing. The MDS also indicated Resident 43 needed partial/moderate assistance with upper body dressing and needed setup or clean-up assistance with personal hygiene and eating. During a review of Resident 43's Care Plan dated 8/10/2025, Resident 43's Care Plan indicated Resident 43 had an ADL self-car and/or mobility performance deficit and indicated an intervention to place call light within reach. During a concurrent observation and interview on 9/29/2025 at 10:06 AM with Resident 43 inside her room, Resident 43 was observed lying down in bed with her call light hanging on the left side of the resident's bed and out of reach of Resident 43. Resident 43 stated she could not reach her call light, and she would like someone to help her. During a concurrent observation and interview on 9/29/2025 at 10:08 AM with Registered Nurse Supervisor 1 (RNS 1) and Resident 43 inside Resident 43's room, Resident 43 was observed lying in bed with the resident's call light hanging off the left side of the resident's bed and out of reach of Resident 43. RNS 1 stated Resident 43 was unable to reach the resident's call light and it was out of Resident 43's reach. Resident 43 stated she could not reach her call light and asked for help to get it. During an interview on 10/1/2025 at 10:37 AM with the Director of Nursing (DON), the DON stated the purpose of the resident's call light is for the residents to use it to call for help from the staff. The DON stated if the call light is out of reach, the resident will not be able to call for any assistance with either being changed, needing water or wanting to be transferred back to bed and is a potential risk for the resident/s to attempt to get up on their own and have an accident. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, revised September 2022, the P&P indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs, and also indicated to, Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and form the floor.

Based on interview and record review, the facility failed to ensure a charge against one (1) of 24 sampled residents (Resident 79) personal funds was not imposed during the resident's stay at the facility from 4/3/2025 to 6/14/2025. This deficient practice had a potential to result in emotional distress brought about by a financial loss due to Resident 79 not receiving the required reimbursement from the facility.Findings: During a review of Resident 79's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (a brain disorder caused by a chemical imbalance in the body) and sepsis (a life threatening medical emergency where the body has an overwhelming and extreme inflammatory [body's response to infection] response to an infection which can cause damage to its own tissues and organs). During a review of Resident 79'S Minimum Data Set (MDS - a resident assessment tool), dated 4/9/2025, the MDS indicated the resident was severely impaired (difficulty with or unable to make decisions, learn, remember things) with cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 79 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two [2] or more helpers is required for the resident to complete the activity) with chair/bed-to-chair transfers, personal hygiene, putting on/taking off footwear, and upper and lower body dressing (the ability to dress and undress above and below the waist, and needed substantial/maximal assistance (helper does more than half the effort) with eating. During a review of Resident 79's Resident Account Detail, dated 4/3/2025 to 6/13/2025, Resident 79's Resident Account Detail indicated an ending balance of $8,170.50.During a concurrent interview and record review on 11/19/2025 at 8:44 AM with Business Office Manager 1 (BOM 1), Resident 79's billing records, dated 4/3/2025 to 6/14/2025 were reviewed. BOM stated Resident 79 was previously at the facility from 4/3/2025 to 6/14/2025 and was admitted under Medicare (the United States [U.S.] federal health insurance program for people age [AGE] and older).During a concurrent interview and record review on 11/19/2025 at 8:51 AM with Business Office Consultant (BOC), Resident 79's billing records dated, 4/3/2025 to 6/14/2025 were reviewed. BOC stated Resident 79 was under Medicare insurance and supplemental insurance (a type of insurance that fills gaps in a primary policy and provides an extra layer of coverage). BOC stated Resident 79 had no share of cost (a monthly dollar amount that some individuals with income over a certain limit must pay towards their medical expenses before their government-sponsored health coverage begins to pay) and her co-payment was covered by her supplemental insurance. During an interview on 11/19/2025 at 8:55 AM with BOM 1 and BOC, BOM stated they were aware that resident 79 was requesting a refund of $8,170.50 and had reached out to the previous owner via (by) electronic mail (email) of the facility since the facility went under new ownership on 8/1/2025. BOC stated the old owner had told them that they would try to get in touch with Resident 79 and her family and take care of Resident 79's refund. BOC stated she does not know what happened after that. During a concurrent interview and record review on 11/19/2025 at 3:17 PM with BOC, an email thread between BOC, Business Office Manager 2 (BOM 2) and the facility's previous biller was reviewed. The email thread indicated BOC first reached out to the facility's previous biller on 8/13/2025 informing them that Resident 79 was requesting a refund and another email was sent out indicating the same thing to the previous biller on 10/10/2025 from BOM 2. No other email or communication was sent out after 10/10/2025. BOC stated they were first notified that Resident 79 needed a refund in the first or second week of August 2025 and provided the information to the previous biller on 8/13/2025. BOC stated the previous biller had told her that she would reach out to Resident 79's family. BOC stated BOM 2 took over afterwards and sent an email to the previous biller on behalf of Resident 79's family on 10/10/2025 and has since not heard of anything else regarding the matter until 11/19/2025 when she was informed that Resident 79 had not yet received any refund. During the same interview on 11/19/2025 at 3:17 PM with BOC, BOC stated the normal process when a resident is newly admitted to the facility is to check and verify the resident's insurance and then speak with either the resident or family representative to explain the benefits, what insurance covers and whether there are any co-payments (a payment made by the beneficiary in addition to that made by insurance) or share of cost. BOC also stated that since the last email sent out to the facility's previous biller on 10/10/2025, another follow-up should have been made to ensure Resident 79 received her reimbursement of $8,170.50. BOC further stated the importance of following up is to make sure the process is being followed and that the residents are getting their requested refunds. During an interview on 11/19/2025 at 3:42 PM with BOM 1, BOM 1 stated on 10/9/2025 she had spoken with Resident 79's family member about the refund and BOM 2 then sent an email to the previous biller on 10/10/2025. BOM 1 stated there was no follow up with Resident 79's family after 10/10/2025 and had assumed the refund was taken cared of. During a concurrent interview and record review on 11/19/2025 at 4:02 PM with BOM 1, Resident 79's billing records, dated 4/3/2025 to 6/14/2025 were reviewed. Resident 79's billing records indicated an over payment of $8,170.50. BOM 1 stated the amount is a total of what Resident 79 was paying for coinsurance (the percentage of costs for a covered healthcare service that is paid after one has met their deductible [the amount of money that must be paid out-of-pocket (spending your own money) for covered services before insurance starts to pay]) out-of-pocket.

Based on observation, interview, and record review the facility failed to provide a clean, comfortable, and home-like environment for one (1) of 24 sampled residents (Resident 25) by failing to ensure that Resident 25's room has no pool of water beside the resident's bed and the resident's electric fan by the resident's room was not dusty. These deficient practices caused an unsanitary environment and had potential for Resident 25 to be placed at risk for infection and injuryFindings: During a review of Resident 25's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was re admitted on [DATE], with diagnosis of end stage renal disease (ESRD, irreversible kidney failure), dependence on renal (kidney) dialysis (process of removing waste products and excess fluid from the body), and paraplegia (loss of movement and/or sensation, to some degree, of the legs). During a review of Resident 25's Minimum Data Set (MDS- a resident assessment tool), dated 9/1/2025, indicated Resident 25 with modified independence (some difficult in new situations only) in terms of cognitive (ability to think and reason) skills for daily decision making. The MDS indicated Resident 25 required setup or clean up assistance (helper sets up or cleans up, resident completes activity) with eating and oral hygiene. The MDS indicated Resident 25 required partial/moderate assistance (helper does less than half the effort) with upper body dressing. The MDS indicated Resident 25 required substantial/maximal assistance (helper does more than half the effort) with shower, lower body dressing and putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 25 was dependent (helper does all of the effort) with toileting hygiene. During a review of Resident 25's Care Plan (CP) focused on residents' allergic rhinitis, initiated on 8/24/2025, it indicated an intervention to keep room cool and free of irritants (smoke, dust and cleaning agents). During an observation on 9/29/2025 at 1:36 PM in Resident 25's room, a dusty electric fan was observed in front of Resident 25's bed. During a concurrent observation and interview on 9/30/2025 at 9:20 AM in Resident 25's room, a dusty electric fan was observed and pool of water next to Resident 25's bed. Resident 25 warned the surveyor about the pool of water next to Resident 25's bed. Resident 25 stated he had a shower 10 minutes ago and Certified Nurse Assistant 4 (CNA 4) left the room after CNA 4 placed Resident 25 in bed. Resident 25 stated CNA 4 did not clean and dry the floor before leaving the room. CNA 5 entered the room and verified that there is a pool of water on the floor next to Resident 25's bed. CNA 5 stated CNA 4 should not have left the room with pool of water on the floor. During a concurrent observation and interview on 10/1/2025 at 9:37 AM in Resident 25's room, with the Housekeeping Supervisor (HS), the electric fan in the resident's room was observed. The HS verified that the electric fan was dusty. The HS stated it is the housekeeping department who needs to check the cleanliness of the electric fan inside resident's room, and if cleaning is needed, it's the housekeepers who need to report to maintenance department. The HS stated dusty electric fan is not good to use in resident's room because the dust can cause the resident to get sick like coughing. During a concurrent observation and interview on 10/1/2025 at 9:45 AM in Resident 25's room, with Registered Nurse Supervisor 1 (RNS 1), the electric fan was observed. RNS 1 stated the electric fan is dirty, and full of dust. RNS 1 further stated the electric fan should have been cleaned and should not have dust on it because the dust will move to the air and to residents when the electric fan is turned on. RNS 1 stated having a dusty electric fan can make Resident 25 sick such as coughing and shortness of breath. During an interview on 10/1/2025 at 9:48 AM with RNS 1, RNS 1 stated resident's room should always be kept clean. RNS 1 stated the floor of resident's room should remain dry to avoid accidents such as slip or fall because of the pool of water by the resident's bedside. RNS 1 stated CNAs should make sure the resident's room is clean and clutter free before leaving the room. RNS 1 stated leaving pooled of water on the floor after giving Resident 25 a shower is not a homelike environment because it is not safe for the resident, and it looks unsanitary. RNS 1 stated CNA 4 should have told housekeeper to dry the floor and not just leave the room with water on the floor next to Resident 25's room. During a follow up interview on 11/19/2025 at 1:30 PM with CNA 5, CNA 5 stated she remembered the day on 9/30/2025 when pool of water was observed on the floor near Resident 25's bed. CNA 5 stated CNA 4 should have dried the floor before leaving the room because it is not safe and it looks dirty having water on the floor. During a review of Facility's Policy and Procedures (P&P) titled Homelike Environment, revised in February 2021, indicated the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting, that included the following: Clean, sanitary and orderly environment. Comfortable and safe temperatures.

Based on observation, interview, and record review, the facility failed to ensure the Low Air Loss mattress (LAL mattress, designed to prevent and treat pressure ulcer [localized damage to the skin and underlying soft tissue caused by prolonged pressure]) for one (1) of four (4) sampled residents (Resident 38) under pressure ulcer care area was set at the correct settings in accordance with the resident's weight. This deficient practice had the potential for Resident to develop new pressure injury. Findings: During a review of Resident 38's admission Record, the admission Record indicated the facility admitted Resident 38 on 10/11/2024. Resident 38's diagnoses included pressure ulcer of unspecified site , lack of coordination, and type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel). During a review of Resident 38's Minimum Data Set (MDS, standardized care and screening tool), dated 10/17/2025, the MDS indicated Resident 38 was dependent (helper does all the effort) on toileting and needed substantial /maximal assistance (helper does more than half of the effort) for personal hygiene. The MDS also indicated Resident 38 was at risk for developing pressure ulcer/ injuries. The MDS also indicated skin and ulcer/ injury treatment included pressure reducing device for bed and application of ointments/medications. During a record review of Resident 38's Order Summary Report dated 11/18/2025, the Order Summary Report indicated a physician's order dated 11/3/2024 for low air loss mattress to maintain skin integrity. During a record review of Resident 38's Care Plan, dated 9/3/2025, the Care Plan indicated the resident has potential/ at risk for impairment to skin integrity related to impaired mobility and fragile skin. The care plan also indicated that the resident's risk for development of further pressure injury/ ulcers will be reduced through implementation of preventative measures through LAL mattress for skin management. During a record review of Resident 38's Weights and Vitals, dated 11/18/2025, the Weights and Vitals indicated on 11/4/2025 at 9 AM Resident 38's weight was 139 pounds (lbs., to measure weight or mass). During a record review of Resident 38's Braden Scale (an assessment tool used for predicting the risk for developing pressure sores), dated 10/22/2925, the Braden Scale indicated a score of 17, meaning resident was at risk for developing pressure injury. During a concurrent observation in Resident 38's room interview and record review on 11/18/2025 at 9:30 AM with the Registered Nurse Supervisor (RNS 1), Resident 38's weight dated 11/4/2025 entered at 9 AM was reviewed. RNS 1 stated the LAL mattress setting was set at 300 lbs. RNS 1 stated the LAL mattress setting should have been set between 140 to 150 lbs. since Resident 38 weighed 139 lbs on 11/4/2025. RNS 1 also stated that when the LAL mattress was not in the correct setting, it defeats its purpose, and it can cause more harm to resident than prevent pressure ulcer. RNS 1 also stated Resident 28 was at risk for developing pressure injury. During an interview on 11/19/2025 at 2:04 PM with the License Vocational Nurse (LVN 4) LVN 4 stated Resident 38's LAL mattress setting was at 300 lbs and the dial should be set between 140 to 150 lbs. to prevent re-opening of the pressure injury on the sacrococcyx (the fused sacrum and coccyx, or tailbone). LVN 4 also stated that Resident 38 was at high risk for developing pressure injury, which is why the LAL mattress was ordered for wound management, to prevent the development and re-opening of the pressure injury on the resident's sacrococcyx area. During a concurrent interview and record review on 11/19/2025 at 3:02 PM with LVN 5, the facilities Policy and Procedures (P&P), dated 2001, titled, Specialty Mattress- Pressure Relieving Device was reviewed. LVN 5 stated the P&P indicated the purpose of this procedure is to provide guidelines for the appropriate pressure -relieving devices or LAL mattress for resident at risk of skin breakdown. LVN 5 also stated under General Guidelines of the P &P indicated to set the mattress according to the residents' weight when a resident is not able to provide the comfort preference. During a concurrent interview and record review on 11/19/2025 at 3:05 PM with LVN 5, the LAL mattress manufacturer's guide, dated 3/15/2016, titled, Med Aire Plus 8 Alternating Pressure and LAL Mattress Replacement System Operational Manual was reviewed. LVN 5 stated the operational manual indicated the weight setting button, plus (+) and minus (-), can be used to adjust the pressure of the inflated cells (the air pockets in the mattress that fill with air to support the resident's body) based on the patient's weight. LVN 5 also stated the facility did not follow its P&P titled, Specialty Mattress- Pressure Relieving Device and the Med Aire Plus 8 Alternating Pressure and LAL Mattress Replacement System Operational Manual LVN 5 also stated this could possibly cause the development of a pressure injury, or re-opening of Resident 38's pressure injury on Sacrococcyx.

Based on observation, interview and record review, the facility failed to identify the environment for potential hazard for one of two sample residents (Resident 12) under accidents care area by failing to ensure the floor was dry. This deficient practice had the potential for Resident 12 to sustain injury in an event of a fall due to the wet floor. Findings:During a review of Resident 12's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was re admitted on [DATE], with diagnosis of end stage renal disease (ESRD, irreversible kidney failure), dementia (a progressive state of decline in mental abilities), and generalized anxiety disorder (GAD, is a chronic condition characterized by excessive, persistent worry about everyday things that is difficult to control). During a review of Resident 12's Minimum Data Set (MDS- a resident assessment tool), dated 8/15/2025, the MDS indicated Resident 12's cognitive (ability to think and reason) skills for daily decision making was independent (decisions consistent/reasonable). The MDS indicated Resident 12 required setup or clean up assistance (helper sets up or cleans up, resident completes activity) with eating, oral hygiene, toileting hygiene, shower, lower body dressing, upper body dressing, putting on/taking off footwear, personal hygiene, sit to stand and chair/bed to chair transfer. During a concurrent observation and interview on 9/30/2025 at 9:25 AM in Resident 12's room, Resident 12 was observed sitting on the wheelchair, Resident 12 was observed approaching his side of the bed where there was a pool of water on the floor. Resident 12 stated that he was going to his bed. During an interview on 10/1/2025 at 9:49 AM with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated it was important to keep Resident 12's floor clean, dry and clutter/ accident hazard free because Resident 12 can transfer independently from wheelchair to bed and vice versa. RNS 1 stated there Resident 12 could slip and fall if the floor was wet or with a pool of water RNS 1 also added that the presence of water on the floor was not safe for anyone walking on the area. During an interview on 10/1/2025 at 10:43 AM with the MDS nurse (MDSN), the MDSN stated Resident 12 can transfer from wheelchair to bed with set up assistance. The MDSN stated the staff should set up and provide Resident 12 with safe environment such as clean and dry floor to be able for Resident 12 to perform the transfer safely. MDSN stated a wet floor could place Resident 12 at risk for accidents such as fall incident. During a review of Facility's Policy and Procedure (P&P) titled, Falls and Fall Risk, Managing, revised March 2018, the P&P indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. It also indicated the following environmental factors that contribute to the risk of falls included wet floors. During a review of Facility's P&P titled Homelike Environment, revised February 2021, the P&P indicated the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting, that included clean, sanitary and orderly environment.

Based on interview and record review, the facility failed to provide dialysis (process of removing waste products and excess fluid from the body) care and services by failing to assess the resident's left upper arm dialysis access site (surgical or medical creations that allow for blood to be cleaned by a dialysis machine and returned to the body) on 11/11/2025, 11/12/2025, and 11/18/2025 for one of two sampled residents (Resident 25) under dialysis care area, in accordance with the facility policy and physician's order. This deficient practice had the potential for complications such as bleeding or infection on Resident 25's left upper arm arteriovenous (AV) fistula (shunt, a surgically created connection between an artery and a vein, most commonly in the arm, that provides access for hemodialysis when kidneys fail) dialysis access. Findings: During a review of Resident 25's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was re admitted on [DATE], with diagnosis of end stage renal disease (ESRD, irreversible kidney failure), dependence on renal (kidney) dialysis, and paraplegia (loss of movement and/or sensation, to some degree, of the legs). During a review of Resident 25's Minimum Data Set (MDS- a resident assessment tool), dated 9/1/2025, the MDS indicated Resident 25 had modified independence (some difficult in new situations only) in terms of cognitive (ability to think and reason) skills for daily decision making. The MDS indicated Resident 25 required setup or clean up assistance (helper sets up or cleans up, resident completes activity) with eating and oral hygiene. The MDS indicated Resident 25 required partial/moderate assistance (helper does less than half the effort) with upper body dressing. The MDS indicated Resident 25 required substantial/maximal assistance (helper does more than half the effort) with shower, lower body dressing and putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 25 was dependent (helper does all of the effort) with toileting hygiene. The MDS indicated Resident 25 was on hemodialysis treatment while a resident at the facility. During a review of Resident 25's Order Summary Report, dated 10/1/2025, the Order Summary Report indicated an order monitor bruit (whooshing sound heard over an artery, usually with a stethoscope, indicating turbulent blood flow, often due to a narrowing or obstruction) and thrill (palpable vibration felt over an artery, also indicating turbulent blood flow) on left arm AV shunt every shift, ordered on 9/19/2025. During a concurrent record review and interview on 11/18/2025 at 9:27 AM, with Registered Nurse Supervisor 1 (RNS 1), Resident 25's Dialysis Communication Record, dated 11/11/2025, 11/12/2025, and 11/18/2025 were reviewed. RNS 1 stated the forms indicated a blank box for the presence of bruit and thrill, and an incomplete dialysis access site assessment might cause confusion when delivering care to Resident 25. During a concurrent record review and interview on 11/19/2025 at 9:50 AM, with MDS nurse (MDSN), Resident 25's Dialysis Communication Record, dated 11/11/2025, 11/12/2025, and 11/18/2025 were reviewed. The MDSN stated the records were not filled out completely when the resident returned from dialysis on 11/11/2025, 11/12/2025, and 11/18/2025. The post dialysis assessment, which included cognitive status, AV shunt, access site, skin assessment and breathing patterns/breath sounds, was not completed on 11/11/2025, 11/12/2025, and 11/18/2025. The MDSN stated the dialysis communication record for Resident 25 should be completed by the charge nurse upon resident's return from dialysis to know the status of the resident. The MDSN stated it was important to properly assess resident, document accurately, and complete the dialysis communication record to make sure that resident will receive the proper care. The MDSN added resident's who's in hemodialysis might have complications after dialysis that might lead to change of condition and hospitalization. The MDSN stated that without the documentation meant the post dialysis assessment was not done. During an interview on 11/19/2025 at 11:03 AM, Quality Assurance nurse (QAN), stated assessing the resident after dialysis was important to make sure Resident 25's dialysis AV shunt was not bleeding, and ensure Resident 25's vital signs were within normal range after dialysis. QAN added that residents who had dialysis sometimes come back with low blood pressure because of fluids that were removed from their body and completing and documenting the post dialysis assessment will ensure an intervention can be done if resident has a change of condition. During a review of the facility's policy and procedure (P&P) titled, Access and Care of Hemodialysis Catheters, dated 2001, the P&P indicated care of AV fistula included the following: Check for signs of infection (warmth, redness, tenderness or edema) at the access site when performing routine care at regular intervals. Check the color and temperature of the fingers, and the radial pulse of the access arm when performing routine care and at regular intervals. Check patency of the site at regular intervals. Palpate the site to feel the thrill, or use a stethoscope to hear the whoosh or bruit of blood flow through the access. The P&P indicated if dressing becomes wet, dirty, or not intact, the dressing shall be changed by a licensed nurse trained in this procedure. The P&P also indicated documentation of the following: Condition of dressing. Any part of report from dialysis nurse post-dialysis being given. Observation post-dialysis.

Based on observation, interview and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 17), under food care area, was provided with a meal tray that did not contain a food the resident was allergic to. This failure had the potential to result in Resident 17 experiencing an allergic reaction such as anaphylaxis (a severe, whole-body allergic reaction that happens quickly and is life-threatening).Findings:During a review of Resident 17's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of morbid (severe) obesity (a chronic condition characterized by an excessive accumulation of body fat that poses a risk to health) due to excess calories (the energy content of food and drink) and lack of coordination (the inability to control and organize the movement of different parts of the body, resulting in movements that are awkward, unsteady and clumsy). Resident 17's admission Record also indicated, Resident 17 had an allergy to eggs. During a review of Resident 17'S Minimum Data Set (MDS - a resident assessment tool), dated 7/18/2025, the MDS indicated the resident was cognitively intact (ability to think, remember, and reason) with cognitive skills for daily decision making. It indicated Resident 17 was dependent (helper does all of the effort; resident does none of the effort to complete the activity) with chair/bed-to-chair transfers (the ability to transfer to and form a bed to chair [or wheelchair]), going from lying to sitting on side of the bed, rolling left and right in bed, lower body dressing (the ability to dress and undress below the waist), and putting on/taking off footwear. The MDS also indicated Resident 17 needed partial/moderate assistance (helper does less than half the effort) with upper body dressing (the ability to dress and undress above the waist) and needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating and personal hygiene. During a review of Resident 17's Care Plan dated 10/4/2025, Resident 17's Care Plan indicated a food allergy to eggs with interventions including:a. Consult with the dietician to make sure foods served to resident are free of allergens.b. Instruct the resident and family in avoiding allergens.c. Make sure the resident's allergies are well documented throughout the chart, medication records, menu cards, dietary records, and all other pertinent documents.d. Make sure that all necessary staff members are alerted to the resident's allergies.e. Observe for signs and symptoms of allergic reaction.f. Offer food alternatives to replace foods resident is allergic to. During a concurrent interview and record review on 9/29/2025 at 9:29 AM with Resident 17 in her room, a picture of Resident 17's meal tray containing a piece of egg on her plate taken on Resident 17's phone dated 8/22/2025 at 7:19 AM was reviewed. Resident 17 stated she notified staff to show them the egg and reminded them that she was allergic to eggs. Resident 17 stated nothing else happened and that she could have died if she consumed it since she is allergic to eggs. During a concurrent interview & record review on 9/29/2025 at 9:31 AM with Resident 17 in her room, a picture of Resident 17's meal tray containing a salad and a hard-boiled egg cut in half taken on Resident 17's phone dated 9/20/2025 at 5:08 PM was reviewed. Resident 17 stated her egg allergy is listed on her meal tray/ card and she notified her Certified Nursing Assistant (CNA) that night and asked her to bring her a fresh plate with no egg.During an interview on 11/18/2025 with Resident 17, Resident 17 stated the incidents that happened where she received her meal tray with egg on 8/22/2025 and 9/20/2025 made her feel like no one cared about her. During a concurrent interview and record review on 11/18/2025 at 12:42 PM with Dietary Supervisor (DS), Resident 17's phone picture dated 8/22/2025 and 9/20/2025 showing Resident 17's meal trays containing eggs were reviewed. DS verified in both pictures, egg was observed on Resident 17's plate. DS stated when residents have an allergy, it is printed on an allergy spreadsheet that is checked for accuracy and there is also a paper indicating the resident's allergy on their meal tray and all meal trays are doubled checked before serving to the resident. DS stated it was not acceptable for Resident 17 to have received egg on both of her meal trays on 8/22/2025 and 9/20/2025 because she could have had an allergic reaction if she had eaten it or any food on the tray that had cross-contamination (the transfer of harmful substances like bacteria or allergens from one surface, food, or person to another).During an interview on 11/19/2025 at 4:55 PM with the Director of Nursing, the DON stated Resident 17 should not have received any tray containing any food the resident was allergic to on her plate because she could have potentially had an allergic reaction. During a review of the facility's policy and procedure (P&P) titled, Food Allergies and Intolerances, revised August 2017, the P&P indicated, Resident with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to allergen(s). The P&P also indicated: a. Meals for residents with severe food allergies are specially prepared so that cross-contamination with allergens does not occur. b. Residents with food intolerances and allergies are offered appropriate substitution for foods that they cannot eat.

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse (disposable material, which includes both recyclable and non-recyclable material) from the kitchen properly when the designated green kitchen dumpster (a movable waste container designed to be brought and taken away by a special collection vehicle) was observed overfilled with a lid covering it halfway. This failure had the potential to result in the attraction and spread of vermin (animals that are believed to be harmful, or that carry diseases, e.g., rodent's parasitic worms or insects) that could potentially infiltrate the facility, affect the resident care areas and pose a threat to residents of the facility.Findings: During a concurrent observation and interview on 9/30/2025 at 10:49 AM with dietary aide 1 (DA 1), a kitchen green dumpster was observed at the back of the facility. The kitchen green dumpster was observed to be overflowing, and the dumpster lid cover was halfway open. DA 1 stated the dumpster's lid was not and should be closed. DA 1 stated, The dumpster is full and overflowing, that is why the lid cannot be closed. During an interview on 11/18/2025 at 2:32 PM with the Dietary Supervisor 3 (DS 3), DS 3 stated that overflowing dumpster was not acceptable. DS 3 stated trash needs to be entirely inside the dumpster, and lid should be properly closed to prevent attraction of rats, insects like ants, or fly. DS 3 stated, Rats and insects that carry diseases might go inside the facility and cause harm to residents. During record review of the facility's Policy and Procedure titled, Sanitation and Infection Control, dated 2011, indicated to keep lids of outside trash dumpsters closed.

Based on observation, interview, and record review, the facility failed to ensure the ice machine drainage has an air gap (a vertical, unobstructed space between the ice machine's drain and the building's drainage system that prevents contaminated drain water from flowing back into the machine's clean water supply. It is a safety feature, often a simple pipe fitting or a dedicated device, that acts as a barrier, with the most common requirement being a 1-2 inch gap to comply with health and plumbing codes) to ensure no contact with outside contaminated (unfit for use, or unsafe) source as indicated in facility's policy and procedures (P&P). This deficient practice had the potential to result in backflow of contaminated water back to the ice machine and had the potential to result in pathogen (germ) exposure to residents, which could place the 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.During an observation on 11/19/2025 at 8 AM, ice machine was observed inside the utility room across nursing station 2. During a concurrent observation and interview on 11/19/2025 at 8:31 AM with Dietary Supervisor 3 (DS 3), ice machine inside the utility room was observed. There was no air gap observed from the ice machine's drainage.DS 3 stated the ice machine's drainage has no air gap because it is connected to other pipes for drain. DS 3 stated usually ice machine drainage host has an air gap to the floor drain to prevent water from backing up from the machine. DS 3 also stated there is water dripping from the pipe. During a concurrent observation and interview on 11/19/2025 at 8:40 AM with the Maintenance Supervisor (MS), the ice machine was observed. MS stated ice machine was moved to the utility room a month ago. MS stated the drain is a closed system, where in the ice machine drainage hose is connected to a water storage bin that collects water, and as soon as it reaches the water level, there is a pump in the water storage bin that will turn on to pump the water up to the black pipe that is four feet (unit of measurement) above the pump. MS stated all the hose, water storage bin and pipes are all connected with no air gap. MS stated the water dripping from the black pipe is a result of condensation (when a gas turns to a liquid) from the water that is inside the pipe. During the exit conference on 11/19/2025 at 5 PM, the facility's Administrator stated, it is the regulation for the ice machine to have an air gap. During a review of facility's P&P titled Ice Handling, dated 2011, it indicated the ice will be dispensed through an ice machine which has no contact with outside contaminated source (human contact or unsanitary water source.) The P&P also indicated water filters on ice machines should be checked and maintained on a routine basis by the maintenance department and the exterior of the ice machine will be cleaned and sanitized weekly. During a review of facility's P&P titled Food Receiving and storage, revised in November 2022, it indicated food services, or other designated staff, maintain clean and temperature/humidity-appropriate food storage areas at all times. It also indicated food may not be stored under leaking water lines, or under lines on which water has condensed.

Based on observation, interview, and record review the facility to provide treatment and services to attain the highest practicable mental and psychosocial well- being of one of two sampled residents (Resident 1) who was diagnosed with depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities) anxiety (a feeling of fear, dread, and uneasiness), and borderline personality disorder (a mental health condition that affects the way people feel about themselves and others, making it hard to function in everyday life) and who was identified as being danger to self and others (DTSO- the probability that a person will inflict serious physical injury upon the person or another person in the near future) on 4/28/2025 by failing to: 1. Ensure 1:1 sitter (provide one to one nursing or observation care to an individual patient for a period of time) intervention were put in place for Resident 1 who refused to be sent to General Acute Care Hospital (GACH) on 4/28/2025 due to DTSO. 2. Monitor and document Resident 1 behavior of verbalizing possibly hurting self or other after the resident was identified to be danger to self and to others on 4/28/2025. 3. Develop and implement a care plan to address Resident 1's refusal to be sent to GACH on 4/28/2025 in accordance with the physician's order. 4. Ensure additional follow up and intervention was developed for Resident 1 to ensure Resident 1's safety and prevent injury and harm to self or to others after resident refused psychiatrist (the branch of medicine concerned with the study, diagnosis, and treatment of mental illness) consultation on 5/8/2025. 5. Develop and implement a care plan when Resident 1 was identified to be DTSO on 4/28/2025 to ensure the resident's safety and security and prevention of injuries. As a result of noncompliance, on 5/12/2025 at 5:20 AM, Resident 1 was found unresponsive by Licensed Vocational Nurse (LVN 1) with two (2) opened prescription plastic containers of doxepin (medication to treat anxiety or depression - unknown dosage) and 1 bottle of ondansetron (medication used to prevent nausea and vomiting- unknown dosage). Resident 1 was sent to GACH via 911 (the telephone number used to reach emergency medical, fire, and police services) and was assessed in GACH' ER with Glascow Coma Scale (GCS- neurological assessment tool used to evaluate a patient's level of consciousness. The score ranges from 3 [deep comatose {state of deep unconsciousness for a prolonged or indefinite period, especially as a result of injury or illness}] to 15 [full consciousness]) of 3. Resident 1 was intubated (a process where healthcare professional inserts a tube into a patient's mouth or nose into the trachea [airway/ windpipe] to help the patient to breath) for poor GCS and was admitted to GACH's Intensive care units (ICU, an organized system for the provision of care to critically ill patients) from 5/12/2025 to 5/14/2025. Resident 1's urine toxicology (screen analyzes a urine sample to identify the presence of drugs or other chemicals) report indicated Resident 1 was positive for tricyclic antidepressant (TCA- a class of medications used to treat anxiety and/ or depression). On 5/14/2025 at 4:51 PM, while onsite at Facility 1, the California Department of Public Health (CDPH) called an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) in the presence of Administrator ( ADM), and Medical Record Director ( MDR) due to the facility's failure to prevent further occurrence of serious harm, serious impairment, and or death of residents with diagnosis of depression, anxiety, and borderline personality disorder and or who were assessed to be DTSO. On 5/16/2025 at 3:16 PM the facility submitted an acceptable IJ removal plan (IJRP- action to correct the deficient practice) to CDPH. The IJ was removed after the surveyor verified and confirmed the facility implemented the facility's IJRP while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM, MRD, and Director of Operations (DOO). The IJ Removal Plan dated 5/16/2025 included the following: 1. Immediate Action Taken on 05/14/5025: o Starting on 05/13/2025 the charge nurse will immediately notify the physician if the resident refused to go to the hospital, refusal of care and treatment for psychiatry and psychologist (someone who studies the human mind and human emotions and behavior, and how different situations have an effect on people). o Starting on 5/14/2025, if a resident has an order to be transferred to the hospital for further evaluation who exhibits any behavior (not specified), and refused to be transferred to the hospital licensed nurse will immediately notify MD. o The Director of Social Services completed (date not indicated) a Psychosocial Assessment of nine (9) identified residents who has a diagnosis of depression, reviewed and updated 9 Care Plan as necessary. There are no other identified residents who has a diagnosis of anxiety, borderline personality disorder and DTSO. o Licensed staff were instructed to document behavioral observations in the monitoring log such DTSO every hour and notify the nurse or RN supervisor and/or designee 2. Ongoing Monitoring and Documentation: o On 5/14/25 the Medical records Director generated an audit of all residents with diagnoses including anxiety disorder, borderline personality disorder, and Depression; and provided the list to the Assistant Director of Nursing (DON) and the Administrator for further review and analysis. o The facility has a total census of 61 on 5/14/2025, there were 9 residents that have a diagnosis of depression, and no other residents have a diagnosis of anxiety and borderline personality disorder. o The Director of Social Services completed a psychosocial assessment of all 9 residents with a diagnosis of depression to identify residents who may be DTSO on 5-14-2025 and o other residents were identified at risk of harming themselves or others. o Starting on 05/13/2025 Situation, Background, Assessment, and Recommendation (SBAR, structured communication framework that can help teams share information about the condition of a patient or team member or about another issue your team needs to address), / Change in Condition (COC change in a resident's condition may mean that he or she is at risk) was implemented, and in-service was conducted by Assistant DON and Clinical Consultant to licensed nurses that the facility promptly notifies the resident, the resident's physician and the resident's representative of any changes in the resident's medical/mental condition and/or status. o On 05/14/2025, 72-hour monitoring including mood/behavioral changes, interactions with staff and peers, response to redirection, and safety observations will be implemented for the resident/s. The Assistant DON and clinical consultant conducted an in-service (starting 5/14/2025) to licensed nurses to include mood/behavioral changes, interactions with staff and peers, response to redirection, and safety observations. 3. Care Plan Development and Implementation: o On 05/14/2025 the care plan was reviewed and updated for 9 identified residents who has a diagnosis of depression. Assistant DON and clinical consultant provided in-service to license nurses regarding Care plan documentation for residents that addressed a psychiatric crisis (any situation in which a person's behavior puts them at risk of hurting themselves or others) and refusal to comply with the physician's recommendation for hospital transfer for resident's safety. o On 05/14/2025 the Administrator conducted 1:1 in-service to SSD regarding Care plan documentation for residents that addressed a psychiatric crisis and refusal to comply with the physician's recommendation for hospital transfer to ensure resident's safety o Crisis Intervention Plan included: o Provide safe and clean environment o Visual check and document monitoring of resident behavior every hour for resident safety o Administer medication as ordered o Diet as ordered o Encourage to verbalize feelings o Always approach in calm and friendly manner and unhurriedly o To ensure all needs are met o Provide emotional support o Maintain comfort and dignity o To call doctor of medicine (M.D) for any noted change of condition 4. Follow-Up after Refusal of Psychiatrist Consultation on 5/8/2025: o Starting on 05/13/2025, Social Services will re-evaluate and update initial psychosocial assessment of the resident when a resident refused for psychiatric consult and licensed nurse will inform MD. o Starting on 05/14/2025, Social services will make daily visits to re-engage the resident and residents who are identified with diagnosis of depression, anxiety and borderline personality disorder and documented in the progress notes and provide resident's education on the importance of psychiatric evaluation. 5. Revised Care Plan for DTSO: o Starting on 05/14/2025, behavioral and Crisis intervention care plan (Crisis intervention Plan under #3) will be implemented to reflect ongoing risk for harm to self and others. Interventions included: o AS needed (PRN) and scheduled psychiatric medication management o Behavior tracking and psychiatric consultation follow-up o Staff re-education on management of residents with psychosocial adjustment difficulties o Development of a crisis intervention care plan to Resident 1's behavior that triggers and de-escalation techniques 6. Systemic Measures to Prevent Recurrence o Starting on 5/13/2025 the ADON and Clinical consultant conducted in-service licensed nurses regarding policy and procedure SBAR/COC with emphasis on immediately reporting resident for any change in the resident medical/mental condition. o Licensed staff in-services will continue until compliance is met. o All licensed nurses and social services staff were in-serviced by Administrator, ADON and Clinical consultant immediately on 05/14/2025 regarding the existing policies and procedures: o Charting and Documentation Policy for management of residents with psychiatric/psychologist who has a diagnosis of depression, anxiety, borderline personality disorder and danger to self and others. o Requesting, Refusing and/or Discontinuing Care or Treatment o Initial Psychosocial Assessment, Intervention and Monitoring Policy and Implementation of Crisis Intervention Policy 7. Monitoring for Sustained Compliance o The Director of Nursing (DON) and/or ADON will audit all residents with behavioral risks for residents who have diagnosis of depression, anxiety, borderline personality disorder and danger to self and others weekly x 4 weeks, then monthly x 3 months. o All refusals of psychiatric care or hospital transfers will be reviewed by the IDT within 24 hours of occurrence and to notify primary care physician. o Results of audits and compliance monitoring will be reported by the DON and/or ADON monthly to the Quality Assurance and Performance Improvement (QAPI) committee. Findings: During a review of Resident 1's admission record indicated the facility admitted Resident 1 on 11/14/2024 with diagnosis which include depression, anxiety, and borderline personality disorder. During a review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 2/1/2025, indicated Resident 1 was assessed to be cognitively intact (process of thinking and reasoning). The MDS also indicated Resident 1 was set up or clean up assistance (helper set up or cleans up; resident complete the activity) on eating, oral hygiene, personal hygiene. During a review of Resident 1's progress notes dated 4/28/2025 at 10:45 PM indicated Resident 1 stated the facility is a sh*thole because the people in the facility make it a shithole. It should have been burned down in the fire so all of us suffering from this d*ck could have somewhere better. The progress notes also indicated an order to transfer the resident to hospital for DTSO. During a review of Resident 1's Order sheet dated 4/28/2025 indicated notes: schedule for psychiatrist and psychologist consult. Frequency: one time daily for one day starting 4/28/2025. During a review of Resident 1's Physicians Order Sheet print date on 5/13/2025 indicated Transfer to acute hospital: transfer resident due to danger to self and others, order date 4/28/2025. During a review of Resident 1's medical records from 4/28/2025 to 5/11/2025, it did not indicate documented evidence Resident 1 was transferred to GACH due to DTSO. During a review of Resident 1's progress notes dated 5/12/2025 at 9:36 AM indicated at 5:20 AM License Vocational Nurse (LVN 1) LVN 1 went to Resident 1's room to check on the resident and LVN 1 found Resident 1 unresponsive, with pulse and breathing normal. The progress notes also indicated 911 transferred Resident 1 to General Acute Care Hospital emergency room (GACH ER) for further evaluation. During a review of Local Police District (LPD1) report dated 5/12/2025 indicated, on 5/12/2025 at approximately 10:17 AM LPD1 were dispatched to the facility to respond to a possible overdose. The LPD1 report indicated Resident 1 was unresponsive and was sent to GACH. LPD1 report also indicated according to the interview with ADM, the ADM received a text from the charge nurse indicating Resident 1 was not waking up possibly due to the medications and alcohol the resident may have consumed. The report also indicated Resident 1 was taken to GACH on 5/12/2025 at approximately 6AM and according to the interview with ADM, the medications found at Resident 1's bedside were not provided by their facility (from Pharmacy 2) but belonged (was labeled under Resident 1's name) to Resident 1. During a review of Reisdent 1's GACH records dated from 5/12/2025 to 5/20/2025 indicated, Resident 1 was admitted at GACH from 5/12/2025 and was discharged to home with Resident 1's family on 5/20/2025. The GACH record indicated, on 5/12/2025 Resident 1 was brought to GACH's ER with chief complaint of altered mental status at SNF with next to empty pill bottles (name of medication not specified) and Resident 1 with GCS of 3. The GACH record also indicated Resident 1 was brought in by ambulance after the resident was found in the facility somnolent (sleepy) and obtunded this morning (5/12/2025). The GACH record also indicated per paramedic's report, Resident 1 was found next to alcohol bottles (not specified) and a bag of pills (not specified) that were unknown and possibly there was a bottle of Klonopin. During a review of the same Resident 1's GACH records dated from 5/12/2025 to 5/20/2025 indicated, Resident 1 was intubated for poor GCS. The GACH records also indicated Resident 1 had intentional TCA overdose +/- (with or without) Kolonopin. The GACH records indicated, Resident 1 was admitted in GACH's ICU from the ER, then downgraded (a reduction in the level of care or status, often in the context of a patient's condition or a medical procedure being changed to a less complex or less expensive) option to Medical Surgical Unit (MSU- a specific area where patients receive care for a variety of medical/ surgical conditions and less critical patient than in ICU) on 5/14/2025. During an interview on 5/14/2025 at 7:05 AM with LVN 3, LVN 3 stated on 5/12/2025 at around 5AM, Resident 1 was unresponsive and LVN 3 tried to wake the resident for 10 minutes, but the resident was not responding. LVN 3 stated, Resident 1 was laying across the bed horizontally and snoring loud. LVN 3 also stated LVN 3 saw 2 opened prescription plastic containers of doxepin (unknown dosage) and 1 bottle of ondansetron (unknown dosage). LVN 3 also stated the medications were not dispensed from the facility's pharmacy (Pharmacy 1). LVN 3 stated the residents are not allowed to have medications from outside the facility and all medications should be prescribed by the primary physicians and medication supplies should be coming from Pharmacy 1. During a concurrent interview and record review on 5/14/2025 at 7:25 AM with LVN 1, Resident 1's progress notes dated 5/12/2025 was reviewed. LVN 1 stated, LVN 1 started her shift on 5/11/2025 at around 11:30 PM making rounds and check Resident 1 and did not check on Resident 1 until 5/12/2025 around 5:20 AM. LVN 1 stated at 5:20 AM Resident 1 was laying across the bed, snoring, and unresponsive to stimuli. LVN 1 also stated, Resident 1 had 2 opened prescription plastic containers of doxepin and 1 bottle of ondansetron on the resident's bedside table. LVN 1 stated, Resident 1 was transferred to GACH ER via 911 around 6 AM and police came approximately 4 to 5 hours after. During a concurrent interview and record review on 5/14/2025 at 3:30 PM with LVN 2, Resident 1's medical chart dated from 4/28/2025 to 5/13/2025 were reviewed. There was no documented evidence of the facility monitored Resident 1 after being assessed as DTSO and when Resident 1 refused to be transferred to GACH. LVN 2 stated no monitoring and documentation from 4/28/2025 to 5/11/2025 regarding resident's danger to self and others on the resident's progress notes. LVN 2 also stated Resident 1 did not have care plan developed to address Resident 1's refusal to be transferred to GACH on 4/28/2025. During a concurrent interview and record review on 5/14/2025 at 3:35 PM with LVN 2, Resident 1's progress notes dated 5/8/2025 at 5:09 PM and Resident 1's medical chart dated from 5/9/2025 to 5/13/2025 were reviewed. The progress notes dated 5/8/2025 indicated offered Psychiatric consult but declined and stated that she (Resident 1) had her own psychiatrist. In addition, there was no documented evidence that the facility made a follow up and provided additional interventions after resident refused psychiatrist consult. LVN 2 stated there was no additional follow up and intervention was made for Resident 1 to ensure Resident 1's safety and prevent injury and harm to self or to others after resident refused psychiatrist consultation on 5/8/2025. During a concurrent interview and record review on 5/14/2024 at 4:35 PM with the Registered Nurse Supervisor (RNS 1), Resident 1's medical chart dated from 4/28/2025 to 5/13/2025 were reviewed. There was no documented evidence the facility monitored Resident 1's behavior of verbalizing wanting or planning to hurt self and/ or others after the resident was identified to be DTSO and after the resident refused to be transferred to GACH on 4/28/2025. RNS 1 stated there was no Interdisciplinary Care Team (IDT, means a group of professional and direct care staff that have primary responsibility for the development of a Service Plan for an individual receiving services) meeting done, no monitoring for Resident 1's behavior of verbalizing wanting or planning to hurt self and/ or others and no care plan initiated regarding residents behavior of DTCO since 4/28/2025. During an interview on 5/16/2025 at 12:05 PM with RNS 1, RNS 1 stated the intervention to monitor Resident 1 closely at least every hour or designate 1:1 sitter for the safety of the residents and staff should have been done immediately for Resident 1. RNS 1 stated most of the staff do not go to check on Resident 1 because of the resident's behavior very mean and yells at staff. During an interview on 5/16/2025 at 12:38 PM with RNS 1, RNS 1 stated the facility should have developed Resident 1's care plan for danger to self and others and document Resident 1's behavior verbalizing wanting to burn the facility and or hurt self or others. During an interview on 5/16/2025 at 12:43 PM with RNS 1, RNS 1 stated Resident 1 refused the psychiatrist consultation on 5/8/2025, the facility did not make additional attempts for psychiatric evaluation or follow up after that. RNS 1 stated RNS 1 checked Resident 1's medical chart, and RNS 1 did not find any documentation regarding additional interventions done after Resident 1 refused. RNS 1 stated, the facility licenses nurse was supposed to monitor Resident 1's behavior of verbalizing wanting to burn the facility and/ or wanting to hurt others or self after being identified as DTSO. RNS 1 also stated, the facility was supposed to have an IDT meeting and care plan developed regarding Resident 1's refusal to be sent to GACH and to be seen by a psychiatrist. During an interview on 5/16/2025 at 12:53 PM with RNS 1, RNS 1 stated Resident 1 was DTSO, and the facility did not ensure Resident 1's safety and provide a safe environment. RNS 1 stated Resident 1 was sent to GACH's ER via 911 and admitted to the GACH's Intensive Care Unit (ICU, specialized treatment given to patients who are acutely unwell and require critical medical care) on 5/12/2025. During an interview on 5/16/2025 at 1:29 PM with LVN 2, LVN 2 stated no documentation in Resident 1's medical chart regarding monitoring of Resident 1's behavior of verbalization of wanting to burn the facility and/ or wanting to hurt others or self, after the resident was identified as DTSO. The care plan for DTSO was not initiated, no SBAR, no change of condition (COC- similar to a SBAR) documentation done and no monitoring of Resident 1 to ensure the resident's safety. During an interview on 5/16/2025 at 2:00 PM with the Administrator (ADM), ADM stated the facility failed to assess, supervise and monitor for being danger to self and others Resident 1 who was identified DTSO on 4/28/2025, and because of all these Resident 1 was found unresponsive on 5/12/2025 and was transferred to GACH and admitted in GACH's ICU. A record review of the facility's Policy and Procedure (P&P) titled Resident Examination and Assessment revised date 2001, it indicated the purpose of this procedure is to examine and assess the resident of any abnormalities in health status, which provides a basis for the care plan. A record review of the facility's P&P titled Change in a Resident's Condition or Status revised date 2/2021 indicated a significant change of condition is a major decline or improvement in the residents' status that requires interdisciplinary review and /or revision to the care plan. The P&P indicated prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Interact SBAR Communication Form. The P&P indicated the nurse will record in the resident's medical record information relative to change in the resident's medical / mental condition status. A record review of the facility's P&P titled Charting and Documentation date 2/2001 indicated all services to the resident, progress toward the care plan goals, or any change in the resident's medical, physical, functional pr psychosocial condition shall be documented in the resident's medical record. A record review of the facility's P&P titled Behavioral Assessment, Intervention and Monitoring dated 3/2019 under assessment indicated the nursing staff will identify, document and inform the physician about specific details regarding change in an individual's mental status, behavior and cognition. The P&P also indicated under Management: 1.The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. a. Atypical behavior will be differentiated from behavior that is dangerous or problematic for the resident(s) or staff, or behavior that signals underlying distress. b. If the behavior is atypical but not problematic or dangerous and the resident does not appear to be in distress, then the IDT will monitor for changes but not necessarily intervene to normalize the behavior. 6. If the resident lacks decision-making capacity and does not have effective family support, the IDT will contact social services to provide assistance to the resident. 7. Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. 8. Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior Monitoring: 1. If the resident is being treated for altered behavior or mood, the IDT will seek and document any improvements or worsening in the individual's behavior, mood, and function. 2. The IDT will monitor the progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported.

Based on observation, interview and record review, the facility failed to provide a safe environment for one (1) of three (3) sample residents by failing to ensure Resident 1 did not possess one bottle of alcoholic beverage and eight (8) medication bottles from Pharmacy 2 (outside pharmacy) labeled with Resident 1's name while the resident is residing in the facility in accordance with the facility's policy titled Restricted Item /Contraband. As a result of noncompliance, on 5/12/2025 at 5:20 AM, Resident 1 was found unresponsive by Licensed Vocational Nurse (LVN 1) with two (2) opened prescription plastic containers of doxepin (medication to treat anxiety or depression - unknown dosage) and 1 bottle of ondansetron (medication used to prevent nausea and vomiting- unknown dosage). Resident 1 was sent to GACH via 911 (the telephone number used to reach emergency medical, fire, and police services) and was assessed in GACH' ER with Glascow Coma Scale (GCS- neurological assessment tool used to evaluate a patient's level of consciousness. The score ranges from 3 [deep comatose {state of deep unconsciousness for a prolonged or indefinite period, especially as a result of injury or illness}] to 15 [full consciousness]) of 3. Resident 1 was intubated (a process where healthcare professional inserts a tube into a patient's mouth or nose into the trachea [airway/ windpipe] to help the patient to breath) for poor GCS and was admitted to GACH's Intensive care units (ICU, an organized system for the provision of care to critically ill patients) from 5/12/2025 to 5/14/2025. Resident 1's urine toxicology (screen analyzes a urine sample to identify the presence of drugs or other chemicals) report indicated Resident 1 was positive for tricyclic antidepressant (TCA- a class of medications used to treat anxiety and/ or depression) and placed other residents in the facility at risk for serious injury and/ or death. Cross reference with F742. Findings: During a review of Resident 1's admission record indicated the facility admitted Resident 1 on 11/14/2024 with diagnosis which include depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities), anxiety (a feeling of fear, dread, and uneasiness) , and borderline personality disorder (a mental health condition that affects the way people feel about themselves and others, making it hard to function in everyday life). During a review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 2/1/2025, indicated Resident 1 was assessed to be cognitively intact (process of thinking and reasoning). The MDS also indicated Resident 1 was set up or clean up assistance (helper set up or cleans up; resident complete the activity) on eating, oral hygiene, personal hygiene. During a review of Resident 1's progress notes dated 5/12/2025 at 9:36 AM indicated at 5:20 AM License Vocational Nurse (LVN 1) LVN 1 went to Resident 1's room to check on the resident and LVN 1 found Resident 1 unresponsive, with pulse and breathing normal. The progress notes also indicated 911(the telephone number used to reach emergency medical, fire, and police services) transferred Resident 1 to General Acute Care Hospital Emergency (GACH) for further evaluation. During a review of Local Police District (LPD1) report dated 5/12/2025 indicated, on 5/12/2025 at approximately 10:17 AM LPD1 were dispatched to the facility to respond to a possible overdose. The LPD1 report indicated Resident 1 was unresponsive and was sent to GACH. LPD1 report also indicated according to the interview with ADM, the ADM received a text from the charge nurse indicating Resident 1 was not waking up possibly due to the medications and alcohol the resident may have consumed. The report also indicated Resident 1 was taken to GACH on 5/12/2025 at approximately 6AM and according to the interview with ADM, the medications found at Resident 1's bedside were not provided by their facility (from Pharmacy 2) but belonged (was labeled under Resident 1's name) to Resident 1. The LPD 1 repot also indicated the following medications (total of 8 bottles) were found in the resident's belongings: 1. One bottle of ondasentron (medication to prevent nausea and vomiting- (miscellaneous [misc] amount and dosage not indicated.) 2. Two bottles of Doxepin (used to treat anxiety or depression - misc amount and dosage not indicated) 3. One empty bottle of Doxepin (misc amount and dosage not indicated) 4. One bottle of Klonopin (used to control seizures [a sudden, abnormal electrical disturbance in the brain that can cause changes in behavior, movements, feelings, and levels of consciousness. It's often characterized by involuntary muscle contractions, convulsions, and sometimes a loss of awareness] in epilepsy [a chronic neurological disorder characterized by recurrent, unprovoked seizures] and for the treatment of panic disorder- misc amount and dosage not indicated) 5. Two empty bottles of Klonopin (misc amount and dosage not indicated) 6. Blue and tan pills (did not indicate name of medication- misc amount) During a review of the facility's Final Investigation Summary Report submitted to the surveyor on 5/16/2025, it indicated, LPD 1 came to the facility at approximately 11 AM (date not specified) and searched Resident 1's room and LPD 1 found pill bottles (bottle of medications) inside a shopping bag and 1.5 Liters bottle of Wine 1. The report also indicated the facility found the following items in Resident 1 belongings on 5/12/2025: 1. Crumpled receipt from Pharmacy 2 shopping bag and the receipt indicated Wine 1 was purchased from Pharmacy 1 on 5/9/2025 at 5:46 PM. 2. Bottle of medications from Pharmacy 2 labeled with Resident 1's name: Klonopin 0.5 milligrams (mg, unit of measurement) which was found empty; 15 pieces of Dilaudid 2 mg; Zpulenz 4 mg sachet with expiry date of 12/2020; 52 capsules of doxepin 100 mg and 10 tablets of Ondasteron 8 mg with expiry date of 3/2025. During a review of Reisdent 1's GACH records dated from 5/12/2025 to 5/20/2025 indicated, Resident 1 was admitted at GACH from 5/12/2025 and was discharged to home with Resident 1's family on 5/20/2025. The GACH record indicated, on 5/12/2025 Resident 1 was brought to GACH's ER with chief complaint of altered mental status at SNF with next to empty pill bottles (name of medication not specified) and Resident 1 with GCS of 3. The GACH record also indicated Resident 1 was brought in by ambulance after the resident was found in the facility somnolent (sleepy) and obtunded this morning (5/12/2025). The GACH record also indicated per paramedic's report, Resident 1 was found next to alcohol bottles (not specified) and a bag of pills (not specified) that were unknown and possibly there was a bottle of Klonopin. During a review of the same Resident 1's GACH records dated from 5/12/2025 to 5/20/2025 indicated, Resident 1 was intubated for poor GCS. The GACH records also indicated Resident 1 had intentional TCA overdose +/- (with or without) Kolonopin. The GACH records indicated, Resident 1 was admitted in GACH's ICU from the ER, then downgraded (a reduction in the level of care or status, often in the context of a patient's condition or a medical procedure being changed to a less complex or less expensive) option to Medical Surgical Unit (MSU- a specific area where patients receive care for a variety of medical/ surgical conditions and less critical patient than in ICU) on 5/14/2025. During an interview on 5/14/2025 at 7:05 AM with LVN 3, LVN 3 stated on 5/12/2025 at around 5AM, Resident 1 was unresponsive and LVN 3 tried to wake the resident for 10 minutes, but the resident was not responding. LVN 3 stated, Resident 1 was laying across the bed horizontally and snoring loud. LVN 3 also stated LVN 3 saw 2 opened prescription plastic containers of doxepin (unknown dosage) and 1 bottle of ondansetron (unknown dosage). LVN 3 also stated the medications were not dispensed from the facility's pharmacy (Pharmacy 1). LVN 3 stated the residents are not allowed to have medications from outside the facility and all medications should be prescribed by the primary physicians and medication supplies should be coming from Pharmacy 1. During a concurrent interview and record review on 5/14/2025 at 7:25 AM with LVN 1, Resident 1's progress notes dated 5/12/2025 was reviewed. LVN 1 stated, LVN 1 started her shift on 5/11/2025 at around 11:30 PM making rounds and check Resident 1 and did not check on Resident 1 until 5/12/2025 around 5:20 AM. LVN 1 stated at 5:20 AM Resident 1 was laying across the bed, snoring, and unresponsive to stimuli. LVN 1 also stated, Resident 1 had 2 opened prescription plastic containers of doxepin and 1 bottle of ondansetron on the resident's bedside table both labeled under Resident 1's name and from Pharmacy 2. LVN 1 stated, Resident 1 was transferred to GACH ER via 911 around 6 AM and police came approximately 4 to 5 hours after. LVN 1also stated, LPD 1 searched Resident 1's belongings and found four (4) additional plastic containers/ bottles of prescription medication labeled under Resident 1's name from Pharmacy 2. LVN 1 stated, the 4 additional plastic bottles of prescription medications were as follows: Klonopin (unable to recall dosage), and Clonazepam (unable to recall dosage- another name for Klonopin-produces a calming effect on the brain and nerves, which helps to reduce anxiety, prevent seizures, and promote relaxation) were inside the plastic bag with a bottle of open Wine 1. During an interview on 5/14/2025 at 10:16 AM with the Registered Nurse Supervisor (RNS 1), RNS 1 stated all medications from outside pharmacy such as Pharmacy 2 were not allowed, it was for residents' safety. RNS 1 stated only Pharmacy 1 (facility's own pharmacy) can deliver/ dispense medication in a bubble pack (an entire week's worth of medications is sorted into a single blister pack, with one blister for each dosing period) for the licensed nurses to give to the resident. During an interview on 5/14/2025 at 12 PM with LVN 2, LVN 2 stated we do not check residents' belongings, the residents usually present whatever they have. During an interview on 5/15/2025 at 12:55 PM with LVN 4, LVN 4 stated Resident 1 was able to bring alcohol and medications from Pharmacy 2 inside the facility and this caused danger to the resident. LVN 4 also stated we did not follow the facility policy and procedures (P&P) to ensure contraband/ prohibited items such as alcoholic beverage to be brought in the facility. During an interview on 5/16/2025 at 2PM with the administrator (ADM), the ADM stated the facility failed to prevent Resident 1 from bringing alcohol to and 7 prescription bottles of medications from Pharmacy 2, because of all this the resident may have overdosed with medications and wine and was found unresponsive on 5/12/2025 and was transferred to GACH, and was admitted at GACH's intensive care units (ICU, an organized system for the provision of care to critically ill patients). During a record review of the facility's P&P titled Restricted Item /Contraband revised on 3/2016, indicated restricted items include any item that is prohibited on the facility grounds. Such items include those that are illegal, or that present a safety risk to residents, staff, visitors, or the facility. The P&P also indicated, all facility staff is responsible for observing environment for potentially unsafe items. The P&P also indicated, Administrator, physician (or other clinical staff with hospital privilege), Nursing leadership or their designee can authorize a search based on reasonable suspicion of the presence of restricted items. The P&P indicated: facility residents and staff will be informed of identified restricted items (this may be done via training, posters, resident handbook or similar means) including: Drugs/medications not prescribed by facility Physicians, or with their knowledge and approval. Alcohol and items containing significant amounts of alcohol that may he abused.

Cross reference F755 and F758 Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) was free of any significant medication error due to missed and incorrect doses of prescribed psychotropic (any drug that affects brain activities associated with mental processes and behavior) medications. This deficient practice resulted in Resident 1 being transferred to the General Acute Care Hospital (GACH) due to exhibiting aggressive behavior and being a danger to self and others such as attempting to kick staff, cursing (use of offensive or impolite language), locking himself in the bathroom, and stating if he wanted to hurt himself, he would do it without telling staff. Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder (a mental illness that causes loss of contact with reality) bipolar (mental disorder characterized by episodes of mania and depression) type, manic episode (abnormally excited mood), and severe major depressive disorder (mood disorder with persistent feeling of sadness and loss of interest causing significant impairment in daily life), with psychotic features (abnormal mental health condition characterized by delusions [an unshakable belief in something untrue] and hallucinations [an experience in which you see, hear, feel, or smell something that does not exist]). A review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 7/30/2022, indicated Resident 1 had cognitively intact (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 did not exhibit any behavior or mood symptoms. The MDS indicated Resident 1 required extensive (resident involved in activity, staff provide weight-bearing support) two or more people assistance for bed mobility (how resident moves to and from lying position, turns side, and positions body while in bed or alternate sleep furniture) and transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position). The MDS indicated Resident 1 required total dependence (full staff performance) for locomotion on (how resident moves between locations in his/her room and adjacent corridor on same floor), locomotion off unit, toilet use, and personal hygiene. A record review of Resident 1's Physician Order Sheet, indicated the following: a. Valproic Acid (a medication used to treat various types of seizure disorders [uncontrolled electrical disturbance in the brain] and manic episodes related to bipolar disorder) 250 milligrams (mg, unit of measurement) capsule (2 capsules = 500 mg) by mouth for mood stabilizer, ordered 7/26/22 (Discontinued on 7/27/2022. New order of Valproic Acid change to liquid form on 7/27/2022) b. Valproic Acid 250 mg/5 milliliters (ml, a unit used in the metric system for measuring capacity) oral solution (500 mg) solution oral four times daily for mood stabilizer, ordered on 7/27/22 (Discontinued: 9/15/2022) c. Valproic Acid 250 mg/5 ml, (5 ml) oral solution (500 mg) four (4) times daily for mood stabilizer manifested by irritable mood, ordered on 9/15/2022 (Discontinued: 10/21/2022) d. Quetiapine (an antipsychotic medication used to treat schizophrenia [disorder that affects a person's ability to think, feel, and behave clearly], bipolar disorder, and depression) 300 mg tablet (2 tablets = 600 mg) by mouth once a day adjunct (added) to Olanzapine for delusional thoughts manifested by talking to self, ordered on 7/26/2022 (Discontinued on 7/27/2022) e. Quetiapine 400 mg tablet (1 tablet) by mouth once a day, adjunct to Olanzapine for delusional thoughts manifested by talking to self, ordered 7/28/22 (Discontinued: 7/29/2022) f. Quetiapine 200 mg tablet (2 tablets) by mouth once a day at bedtime for delusional thoughts manifested talking to self, ordered 7/29/2022 (Discontinued: 10/21/2022) g. Olanzapine (an antipsychotic medication primarily used to manage psychosis [mental disorder characterized by a disconnection from reality]) 20 mg tablet by mouth daily for psychotic behavior manifested by severe agitation, ordered on 7/26/22 (Discontinued on 9/30/22). h. Olanzapine 20 mg tablet (25 mg) oral for psychotic behavior manifested by severe agitation, ordered on 9/30/2022 (Discontinued on 10/13/2022) i. Olanzapine 20 mg tablet, give with Olanzapine 5 mg tablet oral for a total of 25 mg for psychotic behavior manifested by severe agitation, ordered on 10/13/2022 (Discontinued on 10/18/2022) j. Olanzapine 20 mg tablet, give with Olanzapine 10 mg for a total of 30 mg oral at bedtime for psychotic behavior manifested by severe agitation on 10/18/2022 (Discontinued on 10/21/2022) During a concurrent interview with Licensed Vocational Nurse 1 (LVN 1) and record review of the Electronic Medication Administration Report (e-MAR) on 11/9/2022 at 10:41 a.m., LVN 1 stated he gave Resident 1 Valproic Acid 5 ml on 10/12/22, 10/13/2022, and 10/14/2022 for the morning and noon medication pass. During a concurrent interview with LVN 3 and record review of the e-MAR on 11/9/2022 at 3:29 p.m. LVN 3 stated she gave Resident 1 Valproic Acid 5 ml on the following dates and times: 1. 9/5/2022 for the morning (9 a.m.) medication pass 2. 9/6/2022, 9/7/2022, 9/14/2022 for the dinner (5p.m.) and bedtime (HS, 9p.m.) medication pass. 3. 9/15/2022 for the dinner medication pass LVN 3 stated she administered Olanzapine 20 mg on 10/5/2022, 10/6/2022, and 10/11/2022 at bedtime to Resident 1. During a concurrent interview with LVN 4 and record review of the e-MAR on 11/9/2022 at 4:05 p.m., LVN 4 stated she gave Resident 1 the following: 1. Valproic Acid 5 ml on 9/2/2022, 9/3/2022, 9/5/2022, 9/8/2022, 9/9/2022, 9/10/2022, 9/11/2022, 10/1/2022, 10/2/2022, 10/7/2022, 10/8/2022, and 10/10/2022 for the dinner and bedtime medication pass. 2. Olanzapine 20 mg on 10/1/2022, 10/2/2022, 10/7/2022, 10/8/2022, and 10/10/2022 for the bedtime medication pass. During a telephone interview on 11/23/2022 at 11:12 a.m., the facility's Consultant Pharmacist (CPH) stated if Resident 1 received Valproic Acid 250 mg (5 ml) instead of the Valproic Acid 500 mg (10 ml) 4 times a day per doctor's order, Resident 1's behavior would not be controlled and Resident 1's mood behaviors would have manifested itself more. The CPH stated the doctor increased Olanzapine 20 mg to Olanzapine 25 mg on 9/30/2022 to address Resident 1's psychotic behavior. The CPH stated if Resident 1 received Olanzapine 20 mg instead of Olanzapine 25 mg daily per doctor's order, Resident 1's psychotic behavior would be manifested more and Resident 1 would have more episodes of agitation. The CPH stated the Pharmacist who did the recap (to make or be able to make a summary) should have fixed how the medication was written and entered by the admitting nurse. The CPH stated the pharmacist should have clarified the Valproic Acid to make it 10 ml instead of 5 ml. The CPH stated the nurses should calculate the amount of Valproic Acid 500 mg solution ordered and should have given 10 ml because the doctor's order was Valproic Acid 250 mg/5 ml. The CPH stated it was not acceptable for the nurses to give less than what the doctor ordered for the medications. The CPH further stated the nurses were supposed to follow the doctor's orders. During a concurrent interview with the Director of Nursing (DON) and record review of the e-MAR on 11/23/2022 at 12:53 p.m., the DON stated if the medications were not given per doctor's orders, the resident's behavior will not be controlled and resident may develop previous behaviors of being aggressive, irritable, and talking to himself. The DON stated when the resident does not receive the correct dose of a psychotropic medication, this will cause a change in the resident's behavior. The DON stated the Licensed Nurse's signature on the e-MAR indicated medication was administered to the Resident. The DON stated the = on the e-MAR meant the nurses did not give the medication. The DON stated the following medications were not administered to Resident 1 according to the e-MAR: 1. For July 2022 a. Valproic Acid 500 mg - There was one (1) missed dose (7/27/2022) 2. For September 2022 a. Valproic Acid 500 mg - There were 10 missed doses (9/4/22 dinner and HS, 9/5/22 noon, 9/12/22 dinner and HS, 9/16/22 HS, 9/25/22 dinner and HS, 9/27/22 dinner and HS). b. Quetiapine 200 mg (2 tabs) - There were 5 missed doses (9/4/22, 9/12/22, 9/16/22, 9/25/22, and 9/27/22). 3. For October 2022 a. Valproic Acid 500 mg - There were 12 missed doses (10/3/22 dinner and HS, 10/4/22 dinner and HS, 10/9/22 dinner and HS, 10/16/22 dinner and HS, 10/17/22 dinner and HS, 10/18/22 dinner and HS. b. Quetiapine 200 mg (2 tabs) - There were six (6) missed doses (10/3/22, 10/4/22, 10/9/22, 10/16/22, 10/17/22, and 10/18/22). c. Olanzapine 25 mg - There were 5 missed doses (10/3/22, 10/4/22, 10/9/22, 10/16/22, and 10/17/22). d. Olanzapine 30 mg - There was 1 missed dose (10/18/22 ) The DON stated there was no documentation indicating the reason why the following medications were not administered to Resident 1. During a concurrent interview with the DON and record review of the e-MAR on 11/23/2022 at 4:43 p.m., the DON stated when nurses administer medications, they sign the e-MAR. The DON stated the Medical Records Director reviews the e-MAR and would let the DON know if there were any missing signatures which would indicate medication was not administered. The DON stated she was not aware Resident 1 had missing medication doses for the month of July, September, and October. During a telephone interview on 12/5/2022 at 1:40 p.m., the Psychiatrist 1 (PSY 1) stated the facility was giving half the dose of Valproic Acid by mistake as noted on the Physician Order Sheet. The PSY 1 stated Resident 1 was supposed to receive 10 ml (500 mg) of the Valproic Acid four times a day. The PSY 1 stated if Resident 1 received missed and incorrect doses of psychotropic drugs, Resident 1 would become manic and agitated when decompensated (the failure to generate effective psychological coping mechanisms in response to stress, resulting in personality disturbance or disintegration, especially that which causes relapse in schizophrenia). The PSY 1 stated Resident 1 would become very agitated, rambled, and would shut down when not receiving the correct dose of medication. The PSY 1 stated had witnessed Resident 1 experience manic psychosis during Resident 1's GACH admission due to poor compliance with his anti-psychotic medications. A record review of Resident 1's Clinical Notes, dated 10/20/2022 at 12:05 p.m. written by the DON, indicated Resident 1 was extremely aggressive and continued to talk to himself. The Clinical Notes also indicated Resident 1 locked himself inside the bathroom in the morning and did not open the bathroom for the nurses. A record review of Resident 1's Clinical Notes, dated 10/20/2022 at 12:35 p.m. written by the DON, indicated Resident 1 was sitting on the floor, very upset, and stated he would hurt himself without telling anyone. A record review of Resident 1's Discharge/Transfer Notice, dated 10/20/2022, indicated Resident 1 was transferred to GACH because he was a danger to himself and others. A record review of Resident 1's GACH Discharge Summaries Notes, dated 10/24/2022 written by PSY 1, indicated Resident 1 gesticulated (use gestures, especially dramatic ones, instead of speaking or to emphasize one's words) bizarre and hostile manner in attempted conversation engagement. PSY 1's note indicated Resident 1 was not eating or drinking fluids and was transferred to the medical floor to provide intravenous (IV - an apparatus used to administer a fluid [as of medication, blood, or nutrients]) hydration (process of causing something to absorb water) and parental nutrition (intravenous administration of nutrition, which may include protein, carbohydrate, fat, minerals and electrolytes, vitamins and other trace elements for patients who cannot eat or absorb enough food through tube feeding formula or mouth to main good nutrition status) along with medication. PSY 1's note indicated Resident 1 showed no improvement while he was at the behavioral health department. A review of the facility's policy and procedure titled, Administering Medications, revised 12/2012, indicated medications must be administered in accordance with the orders and the individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) was free from an unnecessary drug. An unnecessary drug is any drug when used in the presence of adverse consequences which indicate the dose should be reduced or discontinued. The facility continued to administer aspirin (medication which uses include the prevention of formation of blood clots) to Resident 1, in the presence of Resident 1 having melena (black tarry stools associated with upper [MEDICAL CONDITION] and the presence of blood in the stool). This deficient practice resulted in Resident 1 suffering Hemorrhagic Shock (low blood pressure due to large amount of blood loss), requiring a blood transfusion and surgery to repair an intestinal ulcer (break in the lining of the small intestine). Findings: A review of Resident 1's Admission Face Sheet indicated Resident 1 was admitted to facility on 8/1/2015 with [DIAGNOSES REDACTED]. A review of Minimum Data Set (MDS), a comprehensive assessment and care screening tool, dated 8/13/2015 did not indicate a [DIAGNOSES REDACTED]. A review of Resident 1's physician's orders [REDACTED]. > Regular Diet > Aspirin 325 milligrams (mg) one tablet by mouth every 12 hours [MEDICAL CONDITION]([MEDICAL CONDITION] - stroke) (poor blood flow to brain) [MEDICATION NAME] (preventive measure). During an interview with registered nurse (RN) 1 on 6/21/2016 at 12:30 p.m., RN 1 stated that she admitted Resident 1. She also stated that she verified all the hospital transfer orders to Resident 1's attending physician. A review of Resident 1's history and physical examination [REDACTED]. A review of Resident 1's Physician Telephone Order dated 8/2/2015 indicated to change Resident 1's diet to clear liquid, due to Resident 1's nausea, vomiting and abdominal distention. A review of Resident 1's Physician Telephone Order dated 8/3/2015 indicated to place Resident 1 on NPO (nothing by mouth) except meds (medications). A review of Resident 1's Physician Telephone Order dated 8/4/2015 indicated to discontinue NPO order for Resident 1 and start regular diet. A review of facility Policy and Procedure titled Medication Administration dated 2009 indicated: Other special considerations in medication administration: Give NSAIDs (Non-steroidal Anti-[MEDICAL CONDITION] Drugs) (drugs that provide pain relief, reduce fever and prevent inflammation) (which includes aspirin) with food or antacids and fluids. A review of Resident 1's Medication Record indicated aspirin 325 mg one tablet was given every 12 hours at 9 a.m. and 9 p.m. from 8/2/2015 to 8/13/2015. On 8/14/2015, aspirin 325 mg was given at 9 a.m. A review of Resident 1's Nursing Assistant Daily Flow Sheet-Day Shift dated 8/2015 indicated Resident 1 did not have nourishment (snacks) at 10 a.m., from 8/2/2015 to 8/14/2015. A review of Resident 1's Nursing Assistant Daily Flow Sheet - PM Shift dated 8/2015 indicated Resident 1 did not have bedtime snacks from 8/2/2015 to 8/14/2015. During an interview with the director of nurses (DON) on 6/21/2016 at 11 a.m., the DON stated the facility mealtime is 7 a.m. for breakfast, 12 noon for lunch and 5 p.m., for dinner. The DON also stated Resident 1 was given aspirin from 8/2/2015 to 8/14/2015 without food or antacid. The DON also stated that Resident 1 did not receive nourishment at 10 a.m. and snacks at bedtime because there was no order for Resident 1. The DON further stated that there was no monitoring done by the facility to check for any adverse effects of aspirin. A review of Resident 1's nurse practitioner (NP) 1 notes on the following dates: 8/4/2015, 8/5/2015, 8/6/2015, 8/7/2015, 8/10/2015, 8/11/2015, 8/12/2015 and 8/14/2015 indicated Resident 1 ' s stools were positive for melena. Resident 1's NP notes indicated to continue aspirin. Attempt to interview NP 1 was done but NP 1 refused to be interviewed on 6/21/2016 at 1:00 p.m A review Resident 1's Nurse's Notes dated 8/14/2015, at 9:10 p.m., indicated that Resident 1 had one episode of coffee-ground(presence of coagulated blood) emesis (vomit) about 75 ml (milliliters), blood pressure (BP) of 98/57 (normal 120/80), and a pulse of 106 beats per minute (normal 60-100). Resident 1 was placed on Trendelenburg position (body is laid flat on the back with the feet higher than the head) to increase BP. A review of Resident 1's Nurse's Notes dated 8/14/2015, at 9:30 p.m., indicated Resident 1 had loose watery bloody stool, still complaining of nausea. Resident 1's skin was cool and clammy. BP 111/67, pulse 126. 911 was called to transfer Resident 1 to general acute care hospital (GACH). A review of the GACH Emergency Documentation Report dated 8/14/2015 indicated Resident 1's blood pressure was 108/42, heart rate was 145 beats per minute, and hemoglobin (part of red blood cell that carries oxygen) was 8.3 grams/deciliter (normal 11.5-15.5). Clinical impression included: upper [MEDICAL CONDITION] with hemorrhagic shock (low blood pressure due to bleeding). Resident 1 was started on [MEDICATION NAME] (medicine that stops stomach acid secretion). The GACH physician indicated he advised Resident 1's family that: given the massive nature of the patient's GI (gastrointestinal) bleed, that this is life threatening and there is the potential that the patient may have a bad outcome. A review of the GACH Consultation Notes dated 8/15/2015 indicated Resident 1 was seen by a [MEDICATION NAME] (physician that specializes in the diseases of the digestive system) and assessment indicated Resident 1 most likely had an upper [MEDICAL CONDITION], will do an endoscopy (procedure to look inside a body space using an instrument with a camera), suspect ulcer related to aspirin use. A review of the GACH [MEDICATION NAME] Procedures dated 8/15/2015 indicated Resident 1 underwent EGD procedure(esophagogastroduodenoscopy) (procedure that visualizes the upper part of the gastrointestinal tract up to the duodenum), an ulcer measuring 15 millimeters (mm) was found in the duodenum (upper part of small intestine near stomach) that showed an adherent clot, two clips applied to prevent rebleeding. A review of the GACH Discharge Documentation dated 8/19/2015 indicated Resident 1 received two units (unit=450 ml) of blood transfusion. Aspirin was discontinued and Resident 1 was discharged to home. According to http://www.webmd.com/drugs/2/drug-1082-3/aspirin-oral/aspirin-oral/details#side-effects, Aspirin may cause serious bleeding from the stomach/intestine or other areas of the body. If you notice any of the following rare but very serious side effects, seek immediate medical attention: black/tarry stools, persistent or severe stomach/abdominal pain, vomit that looks like coffee grounds, slurred speech, and weakness on one side of the body, sudden vision changes or severe headache. A review of the aspirin 325 mg house supply medication that was given to Resident 1 indicated on the bottle: Stomach Bleeding Warning: This product contains an NSAID, which may cause severe stomach bleeding. The chance is higher if you are age 60 or older. Stop use and ask doctor if you experience any of the following signs of stomach bleeding: have bloody or black stools. The facility failed to discontinue or reduce Resident 1 aspirin medication, when Resident 1 was displaying adverse reaction to the aspirin. Resident 1 had signs of [MEDICAL CONDITION] daily with bloody or black stools (melena).

Based on observation, interview and record review, the facility failed to provide the necessary services to prevent the formation of pressure ulcers for 1 of 15 sampled residents (Resident 9) who had no history of, but was at risk of developing pressure sores by failing to: 1. Ensure that the pressure reduction mattress was correctly placed on the bed of resident 9, with the nylon material facing up (positioned on top) to reduce pressure and shear (occurs when adjacent surfaces slide across one another, typically when a patient slides down in bed or chair to affected areas of the body). 2. Reposition the resident in such a way as to avoid pressure to the existing affected left hip pressure sore during the survey. Resident 9 developed an unstageable pressure sore (a pressure sore that is covered with slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, and stringy in texture) and/or eschar tissue (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab like) to the left hip which was initially measured as 4 centimeters (cm) by 4 cm, and was described as having a blackish/brown eschar (dead) tissue in the center and [DIAGNOSES REDACTED] (redness of the skin that occurs with skin injuries, infection, or inflammation) around the area of the wound. Findings: A review of the Admission Information Sheet of Resident 9 indicated that the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. results from damage to the parts of the brain that control language). The Admission assessment dated [DATE], indicated the resident had two water blisters on the right upper arm but had no pressure sores. The Minimum Data Set (MDS- a standardized assessment tool) dated May 11, 2010, indicated the resident had a short and long-term memory problem, was severely impaired in his cognitive skills for daily decision making, sometimes made himself understood and sometimes understood others, required extensive assistance with bed mobility, and was totally dependent on the staff for transfer, dressing, eating, toilet use, personal hygiene, and bathing. The MDS indicated the resident had functional limitations in range of motion on both upper and lower extremities, was bedfast all or most of the time and used the bed rails for bed mobility or transfer. According to the MDS, the resident was incontinent of bowel and bladder and did not have pressure sores. A review of the Pressure Sore Risk assessment form indicated that Resident 9 had a high risk of developing pressure sores as evidenced by a score of 10 on December 30, 2010, and a score of 11 on February 11, 2011. A total score of 8 or above represents a high risk for developing pressure sores. A review of the skin integrity care plan dated December 30, 2010, indicated that Resident 9 had a potential for skin breakdown related to bowel incontinence, bladder incontinence, diabetes mellitus, decreased mobility, skin fragility, and impaired cognition. The care plan goal indicated that the resident would be free from tissue injury and skin breakdown for three months. The nursing interventions included to turn and reposition the resident while on the bed at least every two hours, and to provide a pressure relieving mattress as indicated. The quarterly MDS dated [DATE], indicated that the resident had a short and long-term memory problem, was severely impaired in his cognitive skills for daily decision making, rarely/never made himself understood and rarely/never understood others, and was totally dependent on the staff for bed mobility, transfer, dressing, eating, toilet use, personal hygiene, and bathing. The MDS indicated the resident was unsteady, required human assistance to stabilize balance during movement from seated to standing position and surface-to-surface transfers, and had functional limitations on both upper and lower extremities. According to the MDS, the resident was incontinent of bowel and bladder and was at risk for developing pressure sores, but did not have pressure sores. According to the physician's orders [REDACTED]. The physician ordered to cleanse the resident's left hip dry blood blister with normal saline (solution made of salt and water), spray with [MEDICATION NAME] (topical wound spray used to help relieve pain and help the healing of skin <http://www.webmd.com/skin-problems-and-treatments/picture-of-the-skin> wounds, ulcers, and sunburn <http://www.webmd.com/skin-problems-and-treatments/tc/sunburn-topic-overview>), and cover with a dry dressing daily for 14 days. According to the pressure sore care plan dated February 18, 2011, the resident had a deep tissue injury (purple or maroon area of discolored intact skin due to damage of underlying soft tissue damage; the area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) on the left hip. The listed care plan goal indicated that the pressure sore would be resolved in 14 days. The nursing interventions included to use a pressure reducing device on the resident's bed and wheelchair at all times, and to gently reposition the resident every two hours. However, there was no documented evidence the resident was being repositioned every two hours. A review of the Nursing Assistant Daily Flow Sheets for February and March 2011, indicated the resident was totally dependent and required full staff performance for bed mobility and positioning every two hours, each day. However, the documentation did not indicate the times that the resident was repositioned and the side (right, back, left) the resident was turned to. The Weekly Decubitus Report dated February 19, 2011, indicated the resident developed a deep tissue injury on the left hip that was dark red/brown in color with surrounding redness which measured 4 centimeters (cm) by 4 cm, unable to determine (UTD) depth and UTD description of necrotic tissue. On February 24, 2011, the wound size remained the same at 4 cm by 4 cm with dark red/brown color and the depth and description of necrotic tissue was unable to be determined. The report indicated to continue with the treatment as ordered. On March 3, 2011, the report indicated the wound measured 4 cm by 4 cm, was dark red/brown in color with UTD depth and UTD description of necrotic tissue, and to continue treatment as ordered. During a wound treatment observation with Treatment Nurse 1 on March 16, 2011, at 9:50 a.m., the resident was observed with an unstageable pressure sore on the left hip. The pressure sore was observed with a blackish/brown eschar tissue (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab like) on the center and [DIAGNOSES REDACTED] (redness of the skin occurs with skin injuries, infection, or inflammation) around the area of the wound. On March 16, 2011, at 11 a.m., during an observation, the resident was observed positioned on his left side with his left hip (area with pressure sore) resting on the mattress. The resident was awake but nonverbal and unable to reposition himself. On March 16, 2011, at 3:40 p.m., the two evaluators along with the federal surveyor, and Registered Nurse (RN) Supervisor 1 went inside the resident's room. The resident was observed still lying on his left side. There was no control unit or machine observed connected to the mattress. The evaluator instructed RN Supervisor 1 to remove the linen covering the mattress. Upon the removal of the linen, the thick light-gray colored vinyl material was observed facing up where the resident was lying and the thin dark blue colored nylon material was facing down and directly touching the bed frame. During another observation on March 16, 2011, at 4:15 p.m., the resident was observed lying on his left side with his left hip resting on the mattress. The resident's mattress was further inspected by the evaluators, the federal surveyor, and the Director of Nursing (DON). As the DON lifted the linen covering the mattress, the thick light-gray colored vinyl material was observed positioned on top and the thin dark blue colored nylon material was positioned on the bottom. During an interview with the DON on March 16, 2011, at 4:20 p.m., she stated the resident's mattress was considered a pressure redistribution mattress (static) but not a low air loss (LAL) or alternating pressure pad (APP) mattress (dynamic - pressure reducing device designed to change its support characteristics in a cyclical fashion). She stated the facility would only recommend or use a LAL or APP mattress on a resident with a Stage 3 or Stage 4 pressure sore, but since the resident had an unstageable pressure sore, a LAL or APP was not utilized. According to http://www.npuap.org/NPUAP_S3I_TD.pdf, APP mattress is composed of support surface that provides pressure redistribution via cyclic changes in loading and unloading as characterized by frequency, duration, amplitude, and rate of change parameters and LAL mattress is composed of a support surface that provides a flow of air to assist in managing the heat and humidity of the skin. According to the US Department of Health and Human Services publication: "Clinical Practice Guideline for Pressure sore Treatment" (2004), use a static support surface if a patient can assume a variety of positions without bearing weight on a pressure sore and to use a dynamic support surface if the patient cannot assume a variety of positions without bearing weight on a pressure sore. Although some patients with pressure sore improve when cared for on a static support surface, there is evidence that others have a better pressure sore outcome when cared for on a dynamic support surface (Clinical Practice Guideline, Number 15. treatment of [REDACTED].S. Department of Health and Human Services Public Health Service. Agency for Health Care Policy and Research). A review of a physician's orders [REDACTED]. However, the low air loss mattress was recommended and provided to the resident only after the evaluator questioned it. Additionally, during multiple observations on March 17, 2011, at 10 a.m., and 2 p.m., and on March 18, 2011, at 8 a.m.,12 p.m., and 4 p.m., the resident was observed in bed positioned on his left side with his left hip (pressure sore site) directly resting on the mattress. On March 17, 2011, at 10:40 a.m., during an interview with Certified Nursing Assistant 1 (CNA 1), he stated the resident had been on the blue and gray colored mattress since admission on December 2010. He stated the gray part of the mattress had been positioned on top, facing up, and the blue part on the bottom, facing down since admission. The US Department of Health and Human Services publication: "Clinical Practice Guideline for Pressure sore Treatment" (2004), indicated to avoid positioning patients on a pressure sore. Because pressure that is of sufficient intensity and duration to cause soft tissue ischemia (inadequate blood supply) and necrosis (death of living cell or tissue) contributes to the development of pressure sores, it is reasonable to assume that pressure on a sore can delay healing. During another wound treatment observation with Treatment Nurse 1 on March 17, 2011, at 1:40 p.m., the resident was observed with an unstageable pressure sore on the left hip which measured 2.8 cm by 2.8 cm. The depth of the wound could not be determined due to a presence of a blackish/brown eschar tissue on the center. The site was observed with redness around the area of the wound. On March 16, 2011, at 5 p.m., during an interview with the maintenance supervisor and Treatment Nurse 2, in the presence of a co-evaluator and federal surveyor, both staff stated the thin dark blue nylon material of the mattress should have been positioned on top in contact with the resident and the thick light-gray vinyl material should be positioned on the bottom touching the bed frame. During a telephone interview with the manager of the facility's mattress supplier on March 18, 2011, at 3:05 p.m., he stated the dark blue part of the mattress that is made of a thin non-sweat, waterproof, and breathable nylon which help reduce sweating (moisture), prevents and helps with pressure sores goes on top, facing up. He further stated the light gray part of the mattress that is made of vinyl goes on the bottom, facing the bed spring. On March 22, 2011, at 7:10 a.m., the maintenance supervisor provided the surveyor with an invoice for a foam mattress dated January 24, 2007. According to the invoice, the mattress was a pressure reduction mattress named MEV-TM25. A review of the mattress' description indicated that the mattress is a premium quality, high density foam core for users up to 400 pounds with convulated foam layers that allows the user greater comfort and pressure reduction. The mattress is covered with a non-shear, fluid resistant, breathable nylon, and is excellent for regular, replacement, or pressure reduction mattress. According to "http://www.invacare.com/doc_files/06-059_TSS%20catalog.pdf", pressure sores can be caused by four factors, either individually or in combination: a. Pressure: results in compression of soft tissue between a bony prominence and an external surface, such as a bed. When external pressure exceeds capillary blood pressure, the blood supply from the blood vessels to the muscle and skin tissue is impeded, resulting in tissue breakdown. b. Moisture: Over-hydrates skin, resulting in maceration, which lowers its resistance to mechanical stresses such as pressure or friction. c. Shear: Occurs when adjacent surfaces slide across one another, typically when a patient slides down in bed or chair. The skin remains stationary against the bed linens while the underlying tissue shifts. This causes capillaries to stretch and tear, resulting in reduced blood flow. d. Friction: Caused when the skin is pulled across a coarse surface such as bed linens, washcloths, or incontinence pads. When friction is applied to the skin, the outer protective layer is rubbed away. The soft moist layers of skin are exposed which allow bacteria to enter. e. Unstageable Pressure sore - a pressure sore that is covered with slough and/or eschar tissue. f. Eschar- dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab like.