Every finding on record at Harbor Post Acute Care Center

Based on interview, and record review, the facility failed to ensure Certified Nurse Assistant (CNA) 1 did not pinch the face or pull the hair of one of three sampled residents (Resident 1) while providing care to her on 3/23/2026. Following the allegation of abuse Resident 1 was not protected from CNA 1 during the investigation of her allegations. These deficient practices resulted in Resident 1 being fearful of CNA 1 who was then allowed to participate in a meeting where Resident 1 was present to discuss her allegations of abuse. These deficient practices compromised the integrity of the investigation, did not provide protective measures to Resident 1 during the investigation, minimized the severity of the allegations, and placed Resident 1 at risk for continued abuse, intimidation, guilt and fear of retaliation.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 had diagnoses including depression (a mood disorder that causes a persistent feeling of sadness or loss of interest), anxiety (feelings of fear, dread, or unease, often accompanied by physical symptoms like a rapid heart rate or tension) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's the Minimum Data Set ([MDS] a resident assessment tool), dated 2/10/2026, the MDS indicated Resident 1 had moderate cognitive impairment (a brain condition that causes subtle changes in thinking and memory, resulting in more difficulty with these functions than is expected for someone's age). Resident 1 was dependent (helper does all the effort, resident does none of the effort to complete the activity) on staff for toilet hygiene, showering, lower body dressing, and putting on and taking off footwear. During a review of Resident 1's History and Physical (H/P) dated 12/24/2025, the H/P indicated Resident 1 had a fluctuating capacity to understand and make medical decisions. During a review of the facility's undated Incident Investigation document, the Incident Investigation document indicated on 3/22/2026 Resident 1 reported CNA 1 was inappropriate with her during care when CNA 1 possibly rough handled her, pulled her hair and other actions perceived as harmful. During a telephone interview on 4/1/2026 at 10:30 a.m., Resident 1's Responsible Party (RP) stated on 3/23/2026 she notified the Administrator (ADM) by telephone that Resident 1 told her (RP) CNA 1 placed a pillow on her face, pinched her cheek, and covered her nose and mouth with his hands on 3/22/2026, and she (Resident 1) was fearful of CNA 1. On 3/24/2026, Resident 1 called her and allowed her to listen via her (Resident 1) phone to a meeting held with Resident 1, CNA 1, and a staff member (Human Resources [HR] representative). She heard CNA 1 apologize and say the incident (pinching Resident 1's cheek and pulling her hair while repositioning her) was a misunderstanding. Resident 1 sounded upset and said, he is lying. Later during the meeting Resident 1 accepted CNA 1's apology. The RP stated she felt the meeting between Resident 1 and CNA 1 was inappropriate because the facility placed Resident 1 and CNA 1 in the same room and Resident 1 sounded pressured to forgive CNA 1. During an interview on 4/1/2026 at 11:50 a.m., the ADM stated Resident 1's RP called her on 3/23/2026 at approximately 4:30 p.m. and reported that Resident 1 told her (RP) that CNA 1 placed a pillow on her face, pinched her cheek, handled her roughly, and engaged in other actions perceived as harmful. During a telephone interview on 4/2/2026 at 12 a.m., CNA 1 stated he pinched Resident 1's cheek on 3/22/2026 because he wanted to show her endearment because it was her birthday. His intention was to show her a friendly gesture but admitted he did not act professionally. CNA 1 stated he did not explain to Resident 1 what he was doing while providing care to her. When he removed mucus from her nose she may have misunderstood what he was doing. CNA 1 stated when he repositioned Resident 1 in bed, he may have accidentally pulled her hair and caused a pillow to fall on her face. During an interview on 4/2/2026 at 9 a.m., Resident 1 stated CNA 1 pinched her cheek and covered her face with a pillow while providing care (3/22/2026) which made her to feel afraid of CNA 1. The facility held a meeting with her and CNA 1, during which CNA 1 asked for her forgiveness. Resident 1 stated she forgave him but did not want any further trouble and did not want CNA 1 to provide her care anymore. During an interview on 4/2/2026 at 3 p.m., the DSD stated on 3/23/2026 the ADM informed her of the allegation of abuse involving CNA 1 and Resident 1 and directed her to investigate. On 3/24/2026, she, the HR Representative and CNA 1 held a face-to-face meeting with Resident 1 and Resident 1's RP listened via phone. She believed it was important for CNA 1 to apologize and clear up what she felt was a misunderstanding because, in her view, Resident 1 and CNA 1 previously had a good relationship. She did not consider the facility's policy (Abuse Program) which indicated the resident and alleged perpetrator must be separated when she conducted the face-to-face meeting. During a review of the facility's Policy and Procedure (P/P) titled, Abuse Program Policy and Procedure revised 6/25/2025, the P/P indicated the facility has established a system to prevent not only abuse but also those practices and omissions, neglect and misappropriation of property, that if left unchecked can lead to abuse. Residents shall not be subjected to abuse by anyone, including but not limited to facility staff, or other residents. The facility shall make reasonable efforts to protect the residents from harm during the investigation process.

Based on interview, and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH), when on 3/23/2026 one of three sampled resident's (Resident 1) Responsible Party (RP) notified the Administrator (ADM) that Certified Nurse Assistant (CNA) 1 pulled Resident 1's hair, pinched her face and placed a pillow over her head (3/22/2026) causing Resident 1 to be afraid of CNA 1. These deficient practices resulted in a delay in CDPH's investigation and had the potential for information pertinent to the allegations and investigation to be lost and/or forgotten.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 had diagnoses including depression (a mood disorder that causes a persistent feeling of sadness or loss of interest), anxiety (feelings of fear, dread, or unease, often accompanied by physical symptoms like a rapid heart rate or tension) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's the Minimum Data Set ([MDS] a resident assessment tool), dated 2/10/2026, the MDS indicated Resident 1 had moderate cognitive impairment (a brain condition that causes subtle changes in thinking and memory, resulting in more difficulty with these functions than is expected for someone's age). Resident 1 was dependent (helper does all the effort, resident does none of the effort to complete the activity) on staff for toilet hygiene, showering, lower body dressing, and putting on/taking off footwear. During a review of Resident 1's History and Physical (H/P) dated 12/24/2025, the H/P indicated Resident 1 had a fluctuating capacity to understand and make medical decisions. During a review of the facility's undated Incident Investigation document, the Incident Investigation document indicated on 3/22/2026 Resident 1 reported CNA 1 was inappropriate with her during care when CNA 1 possibly rough handled her, pulled her hair and other actions perceived as harmful. During a telephone interview on 4/1/2026 at 10:30 a.m., Resident 1's RP stated on 3/23/2026 she notified the Administrator (ADM) by telephone that Resident 1 told her (RP) that CNA 1 placed a pillow on her face, pinched her cheek, and covered her nose and mouth with his hands on 3/22/2026, and she (Resident 1) was fearful of CNA 1. On 3/24/2026, Resident 1 called and allowed her (RP) to listen via her (Resident 1) phone to a meeting held with Resident 1, CNA 1, and a staff member (Human Resources [HR] Representative) present. She heard CNA 1 apologize and say the incident (pinching Resident 1's cheek and pulling her hair) was a misunderstanding. Resident 1 sounded upset and said, he is lying. Later during the meeting Resident 1 accepted CNA 1's apology. The RP stated she felt the meeting between Resident 1 and CNA 1 was inappropriate because the facility placed Resident 1 and CNA 1 in the same room and Resident 1 sounded pressured to forgive CNA 1. During an interview on 4/1/2026 at 11:50 a.m., the ADM stated Resident 1's RP called her on 3/23/2026 at approximately 4:30 p.m. and reported that Resident 1 told her (RP) that CNA 1 placed a pillow on her face, pinched her cheek, handled her roughly, and engaged in other actions perceived as harmful. The ADM stated she did not report the allegations because she concluded abuse had not occurred and believed the incident was a misunderstanding between Resident 1 and CNA 1 and there was no harm to Resident 1. She felt confident in her decision not to report the allegations to law enforcement, the Ombudsman, or CDPH because she had been in her role for many years and understood the reporting requirements. During a telephone interview on 4/2/2026 at 12 a.m., CNA 1 stated he pinched Resident 1's cheek on 3/22/2026 because he wanted to show endearment for her birthday. His intention was to show her a friendly gesture but admitted he did not act professionally. CNA 1 stated he did not explain to Resident 1 what he was doing while providing care to her. When he removed mucus from Resident 1's nose she may have misunderstood what he was doing. CNA 1 stated when he repositioned Resident 1 in bed, he may have accidentally pulled her hair and caused a pillow to fall on her face. During an interview on 4/2/2026 at 9 a.m., Resident 1 stated CNA 1 pinched her cheek and covered her face with a pillow while providing care (3/22/2026) which made her to feel afraid of CNA 1. Resident 1 stated she reported CNA 1's behavior to her RP but did not report it to anyone at the facility. During an interview on 4/2/2026 at 3 p.m., the DSD stated on 3/23/2026 the ADM informed her of the allegation of abuse involving CNA 1 and Resident 1 (3/22/2026). She did not report the incident to the appropriate agencies because the ADM was the abuse coordinator. During an interview on 4/2/2026 at 3:30 p.m., the Director of Nursing (DON) stated the ADM was the abuse coordinator and was responsible for immediately reporting any allegations of abuse to the appropriate agencies. All allegations of abuse should be reported to the Ombudsman, the CDPH and law enforcement immediately. Failure to report allegations of abuse violates the State and Federal regulations. During a review of the facility's Policy and Procedure (P/P) titled, Abuse Program Policy and Procedure revised 6/25/2025, the P/P indicated the facility. shall ensure. identification of staff members who would be responsible for initial reporting of alleged violations and reporting of results to the facility administrator or facility abuse coordinator, who shall in turn report such an incident to the required agencies.

Based on observation, interview, and record review, the facility failed to ensure that Certified Nurse Assistant (CNA) 1 was not assigned to a resident (Resident 1) after Resident 1 requested not to receive care from CNA 1 for one of three sampled residents (Resident 1). This deficient practice had the potential to upset and cause emotional distress to Resident 1. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including unspecified anxiety disordered (a mental health condition characterized by persistent and extreme worry) and insomnia (trouble falling asleep or staying asleep). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 10/31/2025, the MDS indicated Resident 1 had the capacity to understand and make decisions. The MDS indicated Resident 1 required substantial/maximum assistance (helper does more than half the effort) from staff with toileting hygiene, showering/bathing self, lower body dressing, and putting on/taking off footwear. During an interview on 11/18/2025 at 3:19 p.m., Resident 1 stated on 10/30/2025, CNA 1 was assigned to her during the 3-11 p.m. shift and refused to provide a shower. Resident 1 stated she informed Licensed Vocational Nurse (LVN) 1 that she did not want CNA 1 assigned to her. Resident 1 stated a different CNA (CNA unknown) was subsequently assigned. During a review of the Change of Condition Evaluation (COC), dated 10/30/2025, indicated Resident 1 requested not to be assigned to CNA 1 and asked for a different CNA. The COC indicated CNA 2 was subsequently assigned to Resident 1. During a telephone interview on 11/19/2025 at 9:48 a.m., CNA 1 stated she was assigned to Resident 1 on 11/1/2025 and did not know she was not to be assigned to her. CNA 1 stated her assignment was changed and no longer was assigned to care for Resident 1. During a telephone interview on 11/19/2025 at 12:00 p.m., LVN 1 stated on 10/30/2025 Resident 1 stated she did not want CNA 1 to care for her. LVN 1 stated when a resident does not want a certain staff member to care for them, the request is communicated to everyone (nursing staff) and documented in the communication book. LVN 1 stated he was not aware of Resident 1's preference as it was not documented in the communication book. LVN 1 stated had he had known Resident 1 did not want CNA 1 to be assigned to her, he would have assigned Resident 1 a different CNA. LVN 1 stated it is important to honor Resident 1's request because it is their right.During an interview on 11/19/2025 at 2:21 p.m., Restorative Nursing Assistant (RNA) 1 stated he made the CNA assignment on 11/1/2025 and was not aware of Resident 1's nurse preference until after LVN 1 told him. RNA 1 stated you must honor a resident's preference because it is their right. During an interview on 11/19/2025 at 12:59 p.m., the Director of Nursing (DON) stated she was aware of Resident 1 not wanting CNA 1 to provide care for her. The DON stated that when a resident refuses care from a specific nurse, the information is documented in the communication book. The DON stated that honoring such preferences is important as it relates to resident rights and dignity. During a review of the facility's policy and procedure (P&P), titled Residents Rights, revised 8/2009, the P&P indicated residents are guaranteed the right to voice grievances and to receive a response, as required by federal and state laws.

Based on interview and record review, the facility failed to complete a change in condition (COC a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember), behavioral, or functional status which without immediate intervention, may result in complications or death) for one of one sampled residents (Resident 1), who had an elevated uric acid level (blood test to measure uric acid [natural waste product]) on 3/26/2025.This failure to recognize and respond to the resident's abnormal lab resulted in the lack of necessary care and treatment and had the potential to cause worsening of the resident's left third finger swelling, possibly leading to increased pain, functional decline, or further complications.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 readmitted on [DATE] with diagnoses including cerebral infarction (loss of blood flow to the brain), heart failure (when the heart muscle weakens and cannot pump blood effectively throughout the body), chronic kidney disease (progressive damage and loss of function in the kidneys), gout (type of inflammatory arthritis that causes pain and swelling in your joints) and aphasia (a disorder that makes it difficult to speak). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 8/18/2025, the MDS indicated Resident 1's cognition (ability to think, understand, learn, and remember) was severely impaired and was dependent (helper does all the effort) with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 1's laboratory results dated [DATE], the laboratory results indicated a uric acid level of 10.3 milligram/deciliter (mg/dl-unit of measurement) (Normal uric acid was 1.5 to 6.0 mg/dl). During a review of a Skin/Wound Note dated 3/26/2025 at 8:30 a.m., the Skin/Wound Note indicated Resident 1 had left third finger swelling, tenderness, and pain with touching. The Skin/Wound Note indicated Resident 1's doctor was notified and ordered a uric acid lab to be drawn and an Xray (images that produce pictures of the inside of the body) of the left third finger. During an interview conducted on 10/3/2025, at 1:58 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated that the facility's policy for handling abnormal laboratory results includes notifying the physician and initiating a Change in Condition (COC). RNS 1 stated that a COC should have been completed for Resident 1's elevated uric acid level to ensure appropriate monitoring and communication among staff regarding the resident's condition. During an interview on 10/7/2025, at 3:33 p.m., the Director of Nursing (DON) stated that a COC was required for any significant change in a resident's condition. The DON stated that a COC should have been initiated for Resident 1's elevated uric acid level to allow staff to closely monitor for improvement or deterioration in the resident's status. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, dated 2/2021, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for one of three sampled residents (Resident 1). The facility failed to:1.Develop a care plan to address Resident 1's swollen left third finger. 2.Develop a care plan when Resident 1 had a significant weight loss ( 50 pounds) upon readmission to the facility on These failures had the potential to negatively impact the delivery of necessary care and services, placing Resident 1 at risk for delayed treatment, worsening of physical condition, and further health complications.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 readmitted on [DATE] with diagnoses including cerebral infarction (loss of blood flow to the brain), heart failure (when the heart muscle weakens and cannot pump blood effectively throughout the body), chronic kidney disease (progressive damage and loss of function in the kidneys), gout (type of inflammatory arthritis that causes pain and swelling in your joints) and aphasia (a disorder that makes it difficult to speak). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 8/18/2025, the MDS indicated Resident 1's cognition (ability to think, understand, learn, and remember) was severely impaired and was dependent (helper does all the effort) with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily). During a review of the Skin/Wound Note dated 3/26/2025, timed at 8:30 a.m., the Skin/Wound Note indicated Resident 1 had swelling and pain in the left third finger knuckle, with pain noted upon light touch. During a review of Resident 1's weight records showed that on 7/7, 2025, Resident 1 weighed 200 pounds, and by 8/15/2025, the weight had decreased to 150 pounds, reflecting a 50-pound weight loss upon readmission to the facility on 8/13/ 2025. During a concurrent interview and record review on 10/3/ 2025, at 1:58 p.m., Registered Nurse Supervisor (RNS) 1 stated that there was no care plan developed for either the swollen left third finger noted on 3/26/ 2025, or the significant weight loss observed upon readmission. RNS 1 stated that a care plan should have been developed for both conditions, as care plans serve as a guide for resident care and help staff address and monitor resident problems effectively. During an interview on 10/7/2025 at 3:33 p.m., with the Director of Nursing (DON), the DON stated that a care plan was a critical communication tool used by staff to guide resident care. The DON stated that a care plan should have been developed for Resident 1's swollen finger to ensure proper monitoring of symptoms. The DON stated that regarding the 50-pound weight loss, she was aware of the issue but did not believe a separate care plan was necessary, as it was addressed under the existing tube feeding care plan. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, undated, the P&P indicated, The comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Reflects currently recognized standards of practice for problem areas and conditions. During a review of the facility's P&P titled, Weight Assessment and Intervention, undated, the P&P indicated, Resident weights are monitored for undesirable or unintended weight loss or gain. Individualized care plans shall address the identified cause of weight loss, goals and benchmarks for improvement, and time frames and parameters for monitoring and reassessment.

Based on interview and record review, the facility failed to:a. Ensure a follow up dental appointment was provided for one of one sampled resident (Resident 1). This deficient practice had the potential to result in the delay of necessary care and services for Resident 1 and compromised Resident 1's ability to chew food properly that can lead to weight loss, decreased energy levels, and reduced muscle mass. b. Ensure Resident 1 did not missed scheduled urology follow-up appointment, which was necessary to confirm resolution of a urinary tract infection (UTI- infection in the urine) This deficient practice had the potential to result in delayed identification and treatment of a urinary tract infection (UTI), as well as an increased risk of UTI recurrence.Findings: a.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral infarction (loss of blood flow to the brain), heart failure (when the heart muscle weakens and cannot pump blood effectively throughout the body), chronic kidney disease (progressive damage and loss of function in the kidneys), gout (type of inflammatory arthritis that causes pain and swelling in your joints) and aphasia (a disorder that makes it difficult to speak). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 8/18/2025, the MDS indicated Resident 1's cognition (ability to think, understand, learn, and remember) was severely impaired and was dependent (helper does all the effort) with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily). During an interview on 10/3/2025 at 1:23 p.m., with the Social Services Director (SSD), SSD stated that she did not follow up on Resident 1's authorization for tooth extractions and dentures from 4/2025 until 7/2025. SSD stated she was unable to keep track of all the dental company's recommendations for Resident 1. The SSD stated that while the dental company scheduled appointments she did not verify whether the services were completed. During a subsequent interview on 10/3/2025 at 2:48 p.m., with SSD, the SSD stated that she should have followed up on the authorization for tooth extraction and dentures. The SSD stated that the delay could have impacted Resident 1's comfort and ability to chew food. During an interview on 10/7/2025 at 3:33 p.m., with the Director of Nursing (DON), the DON stated the SSD should have followed up on the dental authorization in a timely manner. The DON stated that the three-month delay resulted in the need to obtain a new authorization and that the lack of follow-up could have affected Resident 1's dignity. During a review of the facility's Social Service Job Description, the Social Service Job Description indicated, The primary function of Social Service Designee is to identify and provide medically related social services which assist residents in maintaining or improving their ability to manage their everyday physical, mental, and psychosocial needs. Make referrals and obtain services from outside entities. During a review of the facility's policy and procedure (P&P) titled, Dental Examination/Assessment, undated, the P&P indicated, Upon conducting a dental examination, a resident needing dental services will be promptly referred to a dentist. b. During a concurrent interview and record review conducted on 10/03/2025 at 11:24 a.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated she could not recall why Resident 1 missed a scheduled urology appointment on 11/04/2024, as there was no documentation available to explain the absence. LVN 1 explained that upon receiving the appointment order from general acute care hospital (GACH), LVN 1 entered the order into the facility's system and provided a copy to the Social Services department. LVN 1 stated that Social Services was responsible for arranging transportation for residents' medical appointments. During a concurrent interview and record review on 10/03/2025 at 12:07 p.m. with Social Services Designee (SSD 1), SSD 1 stated that she was responsible for arranging transportation for Resident 1's urology appointment scheduled for 11/04/2024. SSD 1 stated that she had the appointment order on file but did not know why the resident missed the appointment. SSD 1 stated there were no notes or documentation indicating whether Resident 1 attended the appointment or why transportation did not occur. SSD 1 further explained that her assistant was responsible for contacting the transportation provider but was also unaware of what happened. SSD 1 acknowledged the lack of documentation and stated that the facility has since implemented a tracking system to log all residents scheduled for outside appointments to prevent future occurrences. During an interview and record review on 10/03/2025 at 12:31 p.m. with the Social Services Assistant (SSA), SSA stated that she had texted the transportation company using her personal phone regarding Resident 1's scheduled urology appointment on 11/04/2024. SSA stated that she had no notes or records to verify the contact. SSA acknowledged the absence of documentation and reported that the facility has implemented a new process for documenting and communicating all resident appointments to ensure accountability and prevent future missed appointments. During an interview on 10/03/2025 at 2:13 p.m. with Registered Nurse Supervisor 1 (RNS1), RNS1 stated that she was working on 11/04/2024, the date of Resident 1's scheduled urology appointment but did not know why the resident missed the appointment. RNS 1 confirmed that staff had reviewed Resident 1's chart and were unable to locate any documentation explaining the missed appointment. RNS 1 stated it was important to document all actions in the resident's medical record and stated that, moving forward, the facility has implemented three separate tracking systems to monitor resident appointments. During an interview and record review on 10/07/2025 at 2:23 p.m. with the Director of Nursing (DON), the DON stated that she had interviewed all staff members involved in coordinating appointments, including the social services team, but no one could explain why Resident 1's appointment was missed. The DON stated that she has since conducted multiple in-service training courses and revised the facility's appointment coordination process to ensure all responsible parties were involved and accountable. The DON stated she felt bad over Resident 1's missed appointment. During a review of the facility's dated 12/2016. policy and procedure titled, Resident Rights, indicated The rights include residents right to be notified of his or her condition and of any changes in his or her condition.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:1. 1 box of Boost (nutritional drink)supplement with 19 brick pack remaining were stored in the dry storage area with no date and label.2. 1 box of chocolate fat free ice cream with 26 cups remaining were stored in freezer #1 with no date and label.3. 1 box of [NAME] house honey wheat roll dough were stored in freezer #1 with no date and label.4. 1 box of liquid whole eggs pasteurized with 11 brick pack remaining were stored in refrigerator #1 with no date and label. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 101 out of 106 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 8/12/2025 at 8:22 a.m., with Dietary Aide 1 (DA 1) in the dry storage area, there were 1 box of Boost supplement with 19 brick pack remaining with no date and label. DA 1 stated all food items in the dry storage area should have labeled with the delivery date, the date it was opened, and the best buy date. DA 1 stated the risk for giving expired food items to resident is food poisoning. 2. During a concurrent observation and interview on 8/12/2025 at 8:34 a.m., with the Dietary Service Supervisor (DSS), in the freezer #1, there were 1 box of chocolate fat free ice cream with 26 cups remaining with no open date. The DSS stated 1 box of chocolate fat free ice cream was delivered on 8/5/2025 but it was unknow when the box was opened since it was not labeled with an open date. The DSS stated it is important to label and date so we can keep track of the food items that need to be discarded. 3. During an observation on 8/12/2025 at 8:36 a.m. in the freezer #1, found 1 box of [NAME] house honey wheat roll dough with no label with an open date. 4. During an observation 8/12/2025 at 8:49 a.m., in the walk-in-refrigerator #1, found 1 box of liquid whole eggs pasteurized with 11 brick pack remaining with no label with an open date. During an interview on 8/12/2025 at 8:54 a.m., with the DSS, the DSS stated the acceptable standard of practice was to label and date all the food items in the kitchen. During a review of the facility's undated policy and procedure (P&P) titled, Labeling and Dating of Foods, the P&P indicated, Label with received by date upon receiving, once opened with an open date, and use by date.

Based on interview, and record review, the facility failed to:Ensure a comprehensive water management program was in place.Ensure the Infection Prevention Control Program (IPCP) including standards, polices, and procedures were current, based on national standards, and reviewed at least annually.Ensure gloves were worn while disinfecting the bedside table and prepping wound care supplies for one of one sampled resident (Resident 5).These deficient practices had the potential for staff to follow outdated policies, placing residents and staff at risk for cross contamination and transmission of diseases within the facility.Findings: 1. During a review of the facility’s Water Management Program binder provided by the Infection Prevention Nurse (IPN), the Water Management Program binder only contained the results of randomly selected water samples collected in the facility to test for Legionella (a bacteria that causes a severe form of infection in the lungs). During a review of the maintenance binder from the Maintenance Supervisor (MS), the maintenance binder only had written daily water temperature checks in random residents’ rooms, laundry machine, and dishwasher. During an interview on 8/14/2025 at 10:50 a.m. with the IPN, the IPN stated the facility’s Water Management Program binder and the water temperature checks from the MS are what they have as part of their water management program. During an interview on 8/14/2025 at 3:01 p.m. with the IPN and MS, the IPN stated their water management program plan was to collect water samples from various sources throughout the facility annually and test if there was Legionella. The IPN stated the administrator, the MS, and herself have copies of the report. The MS stated his maintenance binder had daily water temperature checks of two random residents’ rooms sink, the dishwasher, and the laundry machine daily. The MS stated there was nothing else in his binder regarding checks of other areas inside or outside the facility where water may collect or come out of. The MS and IPN stated his binder did not contain paperwork that explained what should be done in the event temperature falls out of range, the areas inside or outside the facility where water comes out of or collects, or diagrams of how hot and cold water flowed throughout the facility. The MS and IPN stated his binder did not contain diagrams of the equipment where water may pass through or an inspection of the equipment. The IPN stated the facility did not have a water management team that met on a routine basis, nor was there a system in place to identify situations that could lead to legionella growth such as the buildup of biofilm and/or sediments. The IPN stated it was important to ensure the water systems in the facility were within acceptable range so the facility would know what corrective action to take to correct it. The IPN stated if the equipment or water were not clean or out of range, it could lead to a growth of waterborne pathogens (microorganisms that could cause disease that are transmitted through water). During a review of the facility’s policy and procedure (P&P) titled “Legionella Water Management Program”, undated, the P&P indicated as part of the infection prevention and control program, the facility had a water management program which is overseen by the water management team and consists of at least the infection preventionist, administrator, medical director, director of maintenance and director of environmental services. The P&P indicated the water management program should include the following elements: an interdisciplinary water management team, detailed description and diagram of the water system in the facility, identification of areas in the water system that could encourage growth and spread of Legionella or other waterborne bacteria, identification of situations that can lead to Legionella growth, specific measures to control introduction and/or spread of legionella, the control limits that are acceptable and monitored, a diagram of where control measures are applied, a system to monitor control limits and the effectiveness of control measures, and a plan for when control limits are not met or control measures are not effective. 2. During a review of the facility’s policies and procedures (P&P) as part of their Infection Prevention Control Program (IPCP), the P&P titled “Vaccination of Facility Staff”, undated, was reviewed. The P&P indicated all staff must be fully vaccinated and received a booster for COVID-19 (a contagious disease caused by a virus) recommended by the World Health Organization and exemptions are made for those with religious beliefs or medical conditions that may be affected by the vaccine and provide a copy of reasonable evidence or claim for the exemption. The P&P further indicated staff who are exempt or incompletely vaccinated, need to test for COVID-19 twice a week and wear an N95 mask (a face mask that filters small particles) at the workplace. During a concurrent interview and record review on 8/15/2025 at 10:15 a.m. of the facility’s IPCP with the administrator (ADMN), the ADMN stated all their policies and procedures are reviewed and approved altogether at one time by the heads of department along with their consultants typically at the beginning of the year. The ADMN stated each department had their own binder of P&P to review that relates to their department and significant changes are discussed together. The ADMN stated, if necessary, an in-service will be held for facility staff to inform them of changes. The ADMN reviewed the P&P titled “Vaccination of Facility Staff” and stated staff members are no longer mandated to receive the COVID-19 vaccine to work, and staff and residents had the right to refuse the vaccine. The ADMN further stated staff who do not want the vaccine do not need to provide evidence why they do not want the vaccine, and those who do not receive the vaccine also did not have to be tested twice a week for COVID-19 or must wear a N95 mask in the facility. The ADMN stated there must have been an oversight as to why this P&P was not updated to reflect the current regulations and it was important to have P&P updated to reflect current practices to ensure the safety of staff and residents. During a review of the facility’s P&P titled “Facility Policy Review”, undated, the P&P indicated a facility process to evaluate the effectiveness and relevance of a specific policy or set of policies and ensures that policies remain current, accurate and aligned with organizational goals and legal requirements. The purpose of policy reviews was to maintain relevance as policies could become outdated due to changes in regulations, technology, or business needs. Reviews ensure policies remain current and applicable. 3. During a review of Resident 5’s face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including an unstageable pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) of the sacrum region, type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities) and quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). During a review of Resident 5’s Minimum Data Set (MDS- a resident assessment tool), dated 7/9/2025, the MDS indicated Resident 5’s cognitive skills were severely impaired. The MDS also indicated Resident 5 was dependent on staff with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent observation and interview, on 8/14/2025, at 9:21 a.m., with Treatment Nurse 1 (TN 1), TN 1 was observed disinfecting Resident 5’s bedside table with Sani-cloth alcohol wipes without wearing gloves. TN 1 performed hand hygiene and began prepping Resident 5’s pressure ulcer medication and supplies without wearing gloves. TN 1 stated gloves should be worn when disinfecting bedside equipment and while preparing supplies for a resident with a pressure ulcer. TN 1 stated she did not wear gloves when she disinfected the bedside table and prepped supplies. TN 1 stated the risk of not wearing gloves while disinfecting the bedside table and prepping pressure ulcer medication and supplies could result in transferring bacteria to Resident 5’s wound, causing an infection. During a review of the facility’s policy and procedures (P&P), titled “Personal Protective Equipment- Using Gloves”, undated, the P&P indicated, “ Use non-sterile gloves primarily to prevent the contamination of the employee's hands when providing treatment or services to the patient and when cleaning contaminated surfaces.”

Based on observation, interview, and record review, the facility failed to:1. Ensure medications were not left at the bedside for one of 24 sampled residents (Resident 1). This deficient practice had the potential to result in Resident 1's not taking his prescribed medications that would lead to medical complications. Findings:During a review of Resident 1's admission Record (front page of the chart that contains basic information of the resident), the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included End Stage Renal Disease ([ESRD] - irreversible kidney failure), hemodialysis ([HD] - a treatment to cleanse the blood of wastes and extra fluids artificially through machine when the kidney(s) have failed), and dementia (a progressive state od decline in mental abilities). During a review of review of Resident 1's History and Physical (H&P), dated 5/28/2025, the H&P indicated, Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool), dated 5/6/2025, the MDS indicated, Resident 1 had the ability to make self-understood and understand others. The MDS indicated, Resident 1 required moderate assistance (helper does less than half the effort) from staff with oral hygiene, upper body dressing, and personal hygiene. During an observation on 8/12/2025 at 11:08 a.m., in Resident 1's room, found 4 medications placed in a cup at bedside table. Resident 1 stated the nurse left those medications when she came and administered his morning medications at around 9:00 a.m. During an interview on 8/12/2025 at 11:18 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she complied with Resident 1's request to leave the medications at bedside. LVN 1 stated the standard of practice is to stay with the resident until he took all his medications. LVN 1 stated the risk of leaving medications at bedside could result in the resident not taking the medication. During an interview on 8/13/2025 at 10:10 a.m., with Registered Nurse 1 (RN 1), RN 1 stated no medications should be left at resident's bedside unattended. RN 1 stated it is important to administer all the prescribed medications to the resident. RN 1 stated the health and safety of Resident 1 would be jeopardized (at risk of harm) if he missed any of his medications. During an interview on 8/14/2025 at 1:40 p.m., with the Director of Nursing (DON), the DON stated Resident 1 is not safe to administer his own medications and the licensed nursing staff should watch the resident taking his medications. The DON stated the physician prescribed medications to residents to treat their existing condition and to prevent any complications. The DON stated there would be an adverse effect (undesirable or harmful outcome) on Resident 1's health condition if he would miss his prescribed medications. During a review of the facility's undated policy and procedure (P&P), titled Standards of Practice, the P&P, indicated Standards ensure nurses provide safe and effective care, minimizing risks and promoting positive patient outcomes. During a review of the facility's P&P, titled Quality of Care,, the P&P indicated, Quality of care is governed by regulations focused on resident well-being and safety.

Based on observation, interview and record review, the facility failed to:1. Ensure care plan intervention was implemented to monitor signs and symptoms of urinary tract infection ([UTI] - an infection in the bladder/urinary tract) for one of four sampled residents (Resident 75) who had a foley catheter (a hollow tube inserted into the bladder to drain or collect urine). This deficient practice placed Resident 75 at risk for unidentified UTI that would lead potentially to life-threatening condition. Findings:During a review of Resident 75's admission Record (front page of the chart that contains basic information of the resident), the admission Record indicated, Resident 75 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 75's diagnoses included obstructive uropathy (a blockage in the urinary tract that prevents normal urine flow), malignant neoplasm of bladder (type of cancer that develops in the bladder, the organ that stores urine), and generalized muscle weakness. During a review of Resident 75's Minimum Data Set ([MDS] - a resident assessment tool), dated 5/21/2025, the MDS indicated, Resident 75 sometimes had the ability to make self-understood and understand others. The MDS indicated, Resident 75's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated, Resident 75 required moderate assistance (helper does less than half the effort) from staff with oral hygiene, toileting hygiene, and upper body dressing. The MDS indicated, Resident 75 had indwelling (inside your body) catheter. During a review of Resident 75's care plan, titled Needs indwelling catheter due to obstructive uropathy, dated 8/19/2024, indicated goal for resident not to develop UTI, until next review in three months. The care plan intervention included to monitor for sign and symptoms of UTI such as chills, fever, note sediments build-up, blood clot, bladder distention, and scanty concentrated foul urine output. During a concurrent observation and interview on 8/13/2025 at 2:26 p.m., with Treatment Nurse 1 (TN 1), in Resident 75's room, TN 1 stated Resident 75 had yellow/white sediments (solid particles which can include crystals and bacteria) in his urine present in the foley catheter tubing. TN 1 stated presence of sediments in the urine is one of the signs and symptoms of UTI. TN 1 stated Resident 75 is at risk for UTI because he has an indwelling foley catheter. TN 1 stated there is no documentation on Resident 75's Treatment Administration Record ([TAR] - a daily documentation record used by a licensed nurse to document treatments given to a resident) indicating he was monitored for signs and symptoms of UTI. During a concurrent interview and record review on 8/13/2025 at 2:52 p.m., with the Director of Nursing (DON), Resident 75's clinical records were reviewed. The DON stated there were no clinical nursing documentation by licensed nursing staff that Resident 75 was monitored for signs and symptoms of UTI. The DON stated it is very important to follow and implement the care plan intervention so resident's UTI could be treated early. The DON stated severe UTI could lead to sepsis (a life-threatening blood infection) that would likely require hospitalization. During a review of the facility's undated policy and procedure (P&P), titled Comprehensive Person-Centered Care Plans, 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.

Based on observation, interview and record review, the facility failed to provide one of one resident (Resident103) with resident-centered activities consistent with the resident's care plan. This deficient practice had the potential to result in Resident 103 expressing feelings of sadness and isolation. Findings:During a review of Resident 103's admission Record, the admission Record indicated the facility admitted the resident on 12/17/2024, and was re-admitted on [DATE] with diagnoses including of cerebral infarction (brain tissue dies due to lack of blood supply), cardiac arrest (loss of heart function, breathing and consciousness), anoxic brain damage (brain deprived of oxygen) aphasia (difficulty speaking) and scoliosis (curvature of the spine).During a review of Resident 103's History and Physical (H&P), dated 6/23/2025, the H&P indicated Resident 103 had the capacity to understand and make decisions.During a review of Resident 103's Activities Care Plan dated 8/04/2025, Resident 103 liked watching TV, joining small groups, listening to music, and exercising. The care plan interventions were for staff to provide 1:1 (one to one ) socialization, providing iPad for music, listening pleasure and sensory stimulation for sound, touch and smell. During a concurrent observation and interview on 8/13/2025 at 10:15 a.m. with Resident 103, Resident 103 was unable to verbalize responses but was able to acknowledge questions via head gestures.During an observation and interview on 8/14/2025 at 2:30 p.m. with the Activity Director (AD), in Resident 103's room, the AD stated Resident 103 watches television (TV), listens to music inside the room via iPad and exercises in room or the Activity Room. There was one TV in Resident 103's room positioned across from Resident 103 facing the roommate. Resident 103 was observed laying on bed staring straight up. The AD stated Resident 103 was not watching TV and would have feelings of sadness if he was unable to watch TV. During an interview on 8/13/2025 at 2:30 p.m. with the Director of Staff Development (DSD), the DSD stated residents are offered resources and activities to be engaged by the Activity Director. The DSD stated nursing staff can assist and engage with residents, but the responsibility with activities was the Activity Director.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 10) had a low air loss mattress on the appropriate setting.This deficient practice had the potential for Resident 10 to develop a pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence).Findings:During a review of Resident 10's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 10 was admitted on [DATE] with diagnoses that included malignant neoplasm of the bladder (bladder cancer), absence of right upper limb below elbow, osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and intervertebral disc degeneration (a condition where the spinal discs, which act as cushions between vertebrae, break down and lose their ability to absorb shock effectively).During a review of Resident 10's History and Physical (H&P), dated 4/10/2025, the H&P indicated Resident 10 did not have the ability to understand and make decisions.During a review of Resident 10's Care Plan, dated 4/14/2025, the Care Plan Report indicated Resident 10 had the potential for skin breakdown and interventions included the use of pressure-redistribution mattress.During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated 5/27/2025, the MDS indicated Resident 10 used a pressure reducing device in bed and required moderate assistance in mobility. The MDS also indicated Resident 10 was usually able to make himself understood and usually able to understand others and had moderately impaired cognition (ability to reason, understand, remember, judge, and learn).During a review of Resident 10's Order Summary Report dated 8/15/2025, the Order Summary Report indicated Resident 10 had an order to apply a pressure foam mattress every day in bed.During a concurrent observation and interview on 8/12/2025 at 12:15 p.m., Resident 10 was observed to be lying on a low air loss mattress (LALM). Resident 10 stated he did not know what the LALM was for. The low air loss mattress dial was set at 320 pound (lb.- unit of weight) and was switched on to the static mode. Resident 10 pointed to a bony area by his elbow and showed his knee and leg and pointed out the bony parts of his body and said he did not have any skin issues, and the bony area is because he had cancer.During a concurrent observation and interview on 8/12/2025 at 3:58 p.m. with Treatment Nurse (TN) 1, TN 1 stated there are various reasons why a resident needs to have a LALM but usually it is because they are at risk of developing a pressure ulcer or already have one. TN 1 looked at LALM setting for Resident 10 and stated it was set at 320 lbs. but that was incorrect because it should be set between 100- 120 lbs. which would be more reflective of Resident 10's weight. TN 1 further stated the LALM is currently set to static mode and not alternating but was unsure which setting he should have been on. TN 1 stated it was important for the settings to be set correctly to reduce pressure ulcers.During an interview on 8/15/2025 at 12:14 p.m. with the Director of Staff Development (DSD), the DSD stated the LALM should be set according to the residents' correct weight to prevent pressure injuries. If it is set at the incorrect weight, it would not be providing the appropriate pressure relief.During a video review of the instructional video by the manufacturing company, Medline, titled A10 and A20 Low Air Loss Mattress System- Instruction for use, dated 6/26/2023, at https://vimeo.com/848769965, the instructional video indicated when preparing the mattress for a resident, turn the dial to the correct weight of the resident. The pump should be in static mode when placing the resident on the mattress. Once placed on mattress, switch from static mode to alternating mode to enable alternating pressure therapy.During a review of the facility's policy and procedure (P&P), titled Support Surface Guidelines, undated, the P&P indicated any individual at risk for developing pressure ulcers should be placed on a redistribution support surface and support surfaces are modifiable and individual resident needs differ.

Based on observation, interview, and record review, the facility failed to: 1. Ensure one of two sampled residents (Resident 34) oxygen delivery equipment was labeled and changed in accordance with the current accepted professional standards of practice. 2. Ensure one of five sampled residents' (Resident 59) tubing for the nebulizer machine (medical device that converts liquid medication into a fine mist, allowing it to be inhaled directly into the lungs) was changed every seven days per facility protocol. These deficient practices had the potential for Resident 34 and Resident 59 to experience complications such as infection associated with oxygen therapy.Findings: 1. During a review of Resident 34’s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 34 was admitted on [DATE] with diagnoses that included end stage renal disease (End Stage Renal Disease-irreversible kidney failure), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 34’s History and Physical (H&P), dated 6/23/2025, the H&P indicated Resident 34 had the capacity to understand and make decisions. During a review of Resident 34’s Minimum Data Set (MDS – a resident assessment tool), dated 6/24/2025, the MDS indicated Resident 34 had the ability to make themselves understood and had the ability to understand others. The MDS further indicated Resident 34 was cognitively intact (ability to reason, understand, remember, judge, and learn) and did not have limitations in range of motion of the upper and lower extremities (related to the arms and legs). During a review of Resident 34’s Care Plan Report dated 6/24/2025, the Care Plan Report indicated Resident 34 had an episode of being short of breath and interventions included to administer oxygen as prescribed. During a review of Resident 34’s Order Summary Report dated 8/15/2025, the Order Summary Report indicated Resident 34 had an order for oxygen via nasal cannula as needed for shortness of breath. During an observation on 8/12/2025 at 1:45 p.m. in Resident 34’s room, an oxygen concentrator (a machine that delivers supplemental oxygen to an individual) with a nasal cannula (a small plastic tube, which fits into the person’s nostrils for providing supplemental oxygen) with a humidifier (a medical device to add moisture to supplemental oxygen) attached were by Resident 34's bedside. The nasal cannula was dated 7/13/2025 and the humidifier did not have a date on it. During an interview on 8/14/2025 at 8:52 a.m. with Resident 34, Resident 34 stated the oxygen machine next to him has been there for several weeks now and did not use it in the past two weeks. During a concurrent observation and interview on 8/15/2025 at 9:09 a.m. with Registered Nurse (RN) 1, Resident 34’s nasal cannula and humidifier was observed at the bedside. RN 1 stated the date on the nasal cannula was dated 7/13/2025 and the humidifier did not have a date on it. RN 1 stated the nasal cannula and humidifier need to be labeled with a date on it and should be changed out at least once a week and if not, it could potentially cause an infection 2. During a review of Resident 59’s admission Record, the admission Record indicated Resident 59 was admitted to the facility on [DATE], with a readmission on [DATE]. Resident 29’s diagnoses included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 59’s History and Physical (H&P), dated 10/22/2024, the H&P indicated Resident 59 did not have a cognitive (ability to reason and understand) impairment. During a review of Resident 59’s Minimum Data Set (MDS – a resident assessment tool), dated 7/15/2025, the MDS indicated Resident 59 is usually able to make herself understood and can usually understand others. Resident 59 was dependent (helper does all the effort) on staff for bathing and dressing the lower body. Resident 59 needed maximal assistance (helper does more than half the effort) with dressing the upper body. During a review of Resident 59’s Order Summary, dated 8/15/2025, the summary indicated on 10/15/2024 the physician entered an order for Budesonide Inhalation Suspension (mediation inhaled into the lungs through a nebulizer to reduce inflammation) to be inhaled two times a day. During a review of Resident 59’s care plan, dated 7/25/2023, the care plan indicated Resident 59 was at risk for infection. The care plan goal indicated the facility would minimize the risks of acquiring a viral infection through infection control precautions During a review of Resident 59’s medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated August 2025, the MAR indicated Resident 59 was given Budesonide Inhalation Suspension at 9:00 a.m. and 5:00 p.m. August 1st- August 12th. During a concurrent observation and interview on 8/14/2025 at 2:25 p.m. with Licensed Vocational Nurse (LVN) 2 at the bedside of Resident 59, Resident 59’s nebulizer tubing was observed with a date of 8/3/2025. The tubing was still plugged into the nebulizer machine. The mask attached to the tubing was dated 8/10/2025. LVN2 stated the nebulizer tubing should be changed every Sunday. The tubing should have been changed on 8/10/2025. The tubing should be changed every 7 days to prevent infection. During a review of the facility’s policy and procedure (P&P), titled “Administering Medications through a Small Volume (Handheld) Nebulizer”, no date, the P&P indicated staff will change equipment and tubing every seven days. The equipment will be stored in a plastic bag with the resident’s name and date on it.

Based on interview and record review, the facility failed to provide an effective pain management on one of one sampled resident (Resident 14) by failing to:1. Ensure Resident 14's pain level was assessed after administering pain medication. This deficient practice placed Resident 14 at risk for inadequate pain relief and delay of care. Findings: During a review of Resident 14's admission Record (front page of the chart that contains basic information of the resident), the admission Record indicated, Resident 14 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 14's diagnoses included chronic (something that continues over an extended period of time) back pain, generalized osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and generalized muscle weakness. During a review of Resident 14's History and Physical (H&P), dated 7/3/2025, the H&P indicated, Resident 14 had the capacity to understand and make decisions. During a review of Resident 14's Minimum Data Set ([MDS] - a resident assessment tool), dated 7/7/2025, the MDS indicated, Resident 14 had the ability to make self-understood and understand others. The MDS indicated, Resident 14 was independent (decisions consistent/reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 14 was totally dependent (helper does all of the effort) from staff with toileting hygiene, upper and lower body dressing. During a review of Resident 14's Order Summary Report (a document containing active orders) dated 8/14/2025, the Order Summary Report indicated, the physician placed a telephone order on 7/15/2025 for Resident 14 to start on Tramadol (controlled pain medication) 50 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) to give one tablet every 12 hours as needed for moderate pain (4-6/10) to severe pain (7-10). During a review of Resident 14's care plan, titled At risk for pain and episode of pain, due to chronic back pain, osteoarthritis, and history of spinal injury, dated 7/3/2025, indicated goals for resident to be comfortable, pain free daily, and pain will be relieved within one hour upon onset, until next review in three months. The care plan interventions included to administer medication as ordered and monitor effectiveness. During a review of Resident 14's Medication Administration Record ([MAR] - a daily documentation record used by a licensed nurse to document medications given to a resident), dated 8/14/2025 at 10:10 a.m. indicated, Resident 14 was given tramadol 50mg one tablet for severe pain (7/10). During an interview on 8/14/2025 at 11:40 a.m. with Resident 14, Resident 14 stated he still has back pain despite receiving tramadol two hours ago. Resident 14 stated his current pain scale is 6/10 (moderate pain), described pain as aching and constant. Resident 14 stated the nurse did not come back to check on him after giving pain medication. During an interview on 8/14/2025 at 12:34 p.m., with Registered Nurse 2 (RN 2), RN 2 stated she administered tramadol 50 mg one tablet to Resident 14 today at 10:10 a.m. RN 2 stated she did not reassess Resident 14's pain level after administering pain medication. RN 2 stated she should have reassessed Resident 14's pain level at least 30 minutes to an hour after administering the tramadol to ensure that the medication was appropriate and effective to the resident and to make necessary adjustment on his pain management plan. RN 2 stated there would be an effect of Resident 14's physical function if his pain is not properly controlled. During an interview on 8/14/2025 at 2:05 p.m., with the Director of Nursing (DON), the DON stated it is very important to assess resident's pain level before and after administration of pain medication to assess the effectiveness of the medication and to observe side-effects (an effect of a drug or other type of treatment that is in addition to or beyond its desired effect). The DON stated ineffective pain management would result to suffering to the resident that would affect his quality of life. During a review of the facility's undated policy and procedure (P&P), titled Pain Assessment and Management, the P&P, indicated The pain management interventions shall be consistent with the resident's goals for treatment, and such goals will be specifically defined and documented.

Based on interview and record review, the facility failed to ensure a resident who received hemodialysis ([HD] - a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment received care in accordance with standards of practice for one of five sampled residents (Resident 1) by failing to:1. Communicate to dialysis center staff regarding Resident 1's change of condition. This deficient practice had the potential to result in a delay or lack of coordination of dialysis care and services to Resident 1. Findings:During a review of Resident 1's admission Record (front page of the chart that contains basic information of the resident), the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included End Stage Renal Disease ([ESRD] - irreversible kidney failure), hemodialysis ([HD] - a treatment to cleanse the blood of wastes and extra fluids artificially through machine when the kidney(s) have failed), and dementia (a progressive state od decline in mental abilities). During a review of review of Resident 1's History and Physical (H&P), dated 5/28/2025, the H&P indicated, Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool), dated 5/6/2025, the MDS indicated, Resident 1 had the ability to make self-understood and understand others. The MDS indicated, Resident 1 required moderate assistance (helper does less than half the effort) from staff with oral hygiene, upper body dressing, and personal hygiene. During a review of Resident 1's Order Summary Report (a document containing active orders) dated 8/1/2025, the Order Summary Report indicated, the physician placed a telephone order on 5/25/2025 for Resident 1 to have dialysis treatment 3x/week every Monday, Wednesday, and Friday. During a review of Resident 1's Change of Condition Evaluation (a communication tool used to communicate a resident's change of condition), dated 8/10/2025, the Change of Condition Evaluation indicated, Resident 1 had an episode of confusion. During a concurrent interview and record review on 8/14/2025 at 12:22 p.m., with Registered Nurse 2 (RN 2), Resident 1's Dialysis Communication Record, dated 8/11/2025 and 8/13/2025, were reviewed. RN 2 stated the licensed nursing staff did not communicate and did not document in the Dialysis Communication Record regarding Resident 1's change of condition for episode of confusion that occurred in the facility on 8/10/2025. RN 2 stated the Dialysis Communication Record is a tool among facility and dialysis staff to communicate resident's condition. RN 2 stated it is very important to communicate and collaborate Resident 1's plan of care and change of condition to dialysis staff so they could manage resident properly during dialysis treatment and to prevent delay of care. During an interview on 8/14/2025 at 1:48 p.m., with the Director of Nursing (DON), the DON stated any change of condition of resident that occurred in the past 24 hours should be communicated immediately to dialysis center staff so they could inform the nephrologist (medical doctor who specializes in the diagnosis, treatment, and management of kidney diseases and conditions) and ask for any treatment recommendation. The DON stated it is essential to maintain an open communication between facility and dialysis staff to meet the needs of the resident and for continuity of care. During a review of the facility's undated policy and procedure (P&P), titled Communication to Dialysis Center, the P&P, indicated Communication between facility and dialysis facilities is crucial for the well-being of residents receiving dialysis. The P&P also indicated a structured process for handoffs during patient transitions between facilities is crucial that includes a documented communication tool that captures essential information like vital signs, medications, any changes in the resident's condition.

Based on observation, interview, and record review, the facility failed to: 1. Ensure one of five sampled residents (Resident 3) received Furosemide ([diuretic]- medication used to remove excess fluid from the body) by the route ordered by the physician.This deficient practice had the potential for Resident 3 to have an adverse effect (bad outcome) after receiving the medication.During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with a readmission on [DATE]. Resident 3's diagnoses included congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and obesity.During a review of Resident 3's History and Physical (H&P), dated 1/30/2024, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 7/22/2025, the MDS indicated Resident 3 had the ability to express ideas and understand others.During a review of Resident 3's Order Summary, dated 8/1/2025, the summary indicated on 7/21/2025 the physician entered an order for Furosemide Oral Solution 2 ml (unit of measure) by mouth one time a day.During a review of Resident 3's care plan, dated 1/27/2024, the care plan indicated Resident 3 had the potential for edema due to heart failure. The interventions indicated staff would administer diuretics as prescribed.During an observation on 8/14/2025 at 8:55 a.m. at the bedside of Resident 3, Registered Nurse (RN) 2 was observed administering Furosemide into Resident 3's feeding tube (a flexible plastic tube placed into your stomach or bowel to help you get nutrition when you're unable to eat). During a concurrent interview and record review on 8/14/2025 at 9:05 a.m. with RN2, Resident 3's physician orders were reviewed. The orders indicated Furosemide was ordered to be given by mouth. RN2 stated if a medication is ordered to be given by mouth, it should given by mouth. If you don't give a medication by the correct route the resident can have ill effects.During a review of the facility's policy and procedure (P&P), titled Administering Medications, no date, the P&P indicated medications are administered in accordance with the prescriber orders.

Based on interview and record review, the facility failed to ensure an accurate Minimum Date Set ([MDS] - a resident assessment tool) was completed accurately for two of 24 sampled residents (Residents 7 and 22) by failing to: 1. Ensure Resident 7's Neurontin (a medication used primarily used as anticonvulsant and for treatment of certain types of nerve pain) were encoded as anti-convulsant in the MDS assessment under Section N (N0415(k) High-Risk Drug Classes) medication. 2. Ensure Resident 22 had accurate documentation in the MDS assessment to reflect the use of Depakote ([anti-convulsant]- medication that controls abnormal electrical activity in the brain). This deficient practice resulted in incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the plan of care and delivery of care and services for Residents 7 and 22).Findings: 1.During a review of Resident 22’s admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE], with a readmission on [DATE]. Resident 22’s diagnoses included dementia (a progressive state of decline in mental abilities), seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and mood disorder. During a review of Resident 22’s History and Physical (H&P), dated 6/19/2025, the H&P indicated Resident 22 did not have the capacity to understand and make decisions. During a review of Resident 22’s Minimum Data Set (MDS – a resident assessment tool), dated 7/24/2025, the MDS indicated Resident 22 had a moderate cognitive (ability to reason and understand) impairment. The MDS indicated Resident 22 was not taking an anti-convulsant. Resident 22 needed maximal assistance (helper does less than half the effort) with bathing, touching assistance with upper body dressing, and moderate assistance with lower body dressing. During a review of Resident 22’s Order Summary, dated 8/1/2025, the summary indicated on 6/18/2025 the physician entered an order for Depakote to be given once a day. During a concurrent interview and record review on 8/14/2025 at 12:51 p.m. with the Minimum Data Set Nurse (MDSN), Resident 22’s MDS was reviewed. The MDS indicated Resident 22 was not taking an anti-convulsant. The MDSN stated the MDS should reflect the residents’ status as of the date it was submitted. Resident 22 initially started taking Depakote on 6/19/2025 and the MDS was completed on 7/24/2025. The MDSN stated Depakote should be coded on the MDS as an anti-convulsant. The MDS submitted on 7/24/2025 was erroneous. During a review of the facility’s policy and procedure (P&P), titled “Certifying Accuracy of Resident Assessment, no date, the P&P indicated any person completing a portion of the MDS must sign and certify accuracy of the portion of the assessment. 2.During a review of Resident 7’s admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 7 was admitted to the facility on [DATE]. Resident 7’s diagnoses included difficulty in walking, neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), and paraplegia (loss of movement and/or sensation, to some degree, of the legs). During a review of Resident 7’s History and Physical (H&P), dated 5/25/2025, the H&P indicated, Resident 7 had fluctuating capacity to understand and make decisions. During a review of Resident 7’s Minimum Data Set ([MDS] – a resident assessment tool), dated 5/29/2025, the MDS indicated, Resident 7 had the ability to make self-understood and understand others. The MDS indicated, Resident 7’s cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated, Resident 7 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity) from staff with eating and oral hygiene. During a review of Resident 7’s Order Summary Report (a document containing active orders) dated 8/1/2025, the Order Summary Report indicated, the physician placed a telephone order on 5/22/2025 for Resident 7 to start on Neurontin (a medication used primarily used as anticonvulsant and for treatment of certain types of nerve pain) 300 milligrams ([mg] – metric unit of measurement, used for medication dosage and/or amount) to give one capsule every three times a day (9 a.m., 1 p.m., and 5 p.m.) for neuropathy. During a concurrent interview and record review on 8/13/2025 at 1:15 p.m., with the Minimum Data Set Nurse (MDSN), Resident 7’s MDS assessment, dated 5/29/2025, was reviewed. The MDSN stated Resident 7’s MDS was completed inaccurately. The MDSN stated Resident 7’s MDS, Section N (N0415(k) High-Risk Drug Classes) should have a checked mark since Resident 7 is on Neurontin which is classified as anticonvulsant medication. The MDSN stated Resident 7 started the Neurontin on 5/22/2025. The MDSN stated Resident 7 received Neurontin on 5/23/2025, 5/24/2025, 5/25/2025, 5/26/2025, 5/27/2025, and 5/28/2025. The MDSN stated the MDS section N (Medications) look back period (the specific time frame within which certain resident conditions and events are assessed) was 7 days before the completion date. The MDSN stated Resident 7’s use of Neurontin as anticonvulsant medication should have been captured and encoded within that assessment period which is 5/29/2025. The MDSN stated the coding of medications in the MDS section N should be based on the drug classification. The MDSN stated it is important to code accurately the MDS section N because it would reflect the correct drug regimen of the resident. The MDSN stated inaccuracy of MDS assessment could affect the care planning of the resident. During a review of the facility’s undated policy and procedure, titled “Certifying Accuracy of Resident Assessment,” the P&P indicated, “Any person completing the portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign the accuracy of that portion of the assessment”.

Based on interview and record review, the facility failed to: 1. Ensure one of five sampled residents (Resident 27) had a Hemoglobin A1C ([HgA1C] - a blood test that measures the average blood sugar level over the past two to three months) completed every three months per physician's order.This deficient practice resulted in inadequate monitoring of Resident 27's diabetes ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was admitted to the facility on [DATE], with a readmission on [DATE]. Resident 27's diagnoses included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 27's Minimum Data Set (MDS - a resident assessment tool), dated 7/25/2025, the MDS indicated Resident 27 was able to express ideas/wants and able to understand others. The MDS indicated Resident 27 was dependent (helper does all the effort) on staff for dressing and bathing.During a review of Resident 27's Order Summary, dated 8/1/2025, the summary indicated on 2/27/2024 the physician entered an order for a HgA1C to be completed every three months.During a review of Resident 27's care plan, dated 11/03/2018, the care plan indicated Resident 27 had a potential for hypoglycemia or hyperglycemia due to diabetes mellitus. The interventions indicated staff would monitor ordered labs and report abnormal results.During a concurrent interview and record review on 8/14/2025 at 2:40 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 27's lab results were reviewed. The results indicated the HgA1C was completed on 8/16/2024 and 3/25/2025. LVN3 stated the HgA1C was not completed as ordered. The HgA1C should have been completed on 6/25/2025. LVN3 stated the physician ordered the test to monitor the status of the resident's diabetes. Since the test was not completed as ordered you don't know the status of the resident's diabetes. The resident may need to have medications adjusted and you wouldn't know.During a review of the facility's policy and procedure (P&P), titled Request for Diagnostic Services, no date, the P&P indicated orders for diagnostic services will be promptly carried out as instructed by the physician's order.

Based on interview and record review, the facility failed to: 1. Ensure beneficiary notices were accurately completed for two of 3 sampled residents (Resident 18 and Resident 30).This deficient practice had the potential to result in residents and/or their responsible parties not being notified of the cost of services per day after benefits expired.Findings:a. During a review of Resident 18's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 18 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing) and osteoarthritis (a common joint disease that involves the breakdown of cartilage and underlying bone in joints). During a review of Resident 18's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated [DATE], the MDS indicated Resident 18's cognitive skills were moderately impaired. The MDS also indicated Resident 18 required maximal assistance with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 18's Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form, dated [DATE], the SNF ABN form indicated Resident 18's last day for Medicare Part A Skilled Services coverage was [DATE]. Resident 18's SNF ABN indicated as of [DATE], Resident 18 would have to pay out of pocket for continuation of care services provided by the facility. The SNF ABN form did not indicate which services Resident 18 received nor indicate the cost of services per day if Resident 18 was to pay out of pocket. b. During a review of Resident 30's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 30 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included anemia (a condition where the body does not have enough healthy red blood cells), type 2 diabetes, end stage renal disease (irreversible kidney failure) and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 30's MDS, dated [DATE], the MDS indicated Resident 30's cognitive (thinking) skills were intact. The MDS also indicated Resident 30 required partial assistance with ADLs. During a review of Resident 30's Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form, dated [DATE], the SNF ABN form indicated Resident 30's last day for Medicare Part A Skilled Services coverage was [DATE]. Resident 30's SNF ABN indicated as of [DATE], Resident 30 would have to pay out of pocket for continuation of care services provided by the facility. The SNF ABN form did not indicate which services Resident 30 received nor indicate the cost of services per day if Resident 30 was to pay out of pocket. During a concurrent interview and record review, on [DATE], at 1:50 p.m., with the admission Coordinator (AC), the AC stated the purpose of the SNF ABN form was to inform residents of the specific care services received and the cost that would need to be paid out of pocket once a resident's Medicare A insurance expired. The AC stated Resident 18 and Resident 30's SNF ABN was incomplete. The AC stated the SNF ABN form was incomplete for Resident 18 and Resident 30 as no specific care areas were checked for each resident and the cost per day was not listed. The AC stated the risk of not completing a SNF ABN form could result in residents being unaware of the termination of their services, benefits and costs of services per day. During a review of the facility's policy and procedures (P&P), titled Beneficiary Notice of Non-Coverage, undated, the P&P indicated, It (SNF ABN) allows the resident (beneficiaries) to make informed decisions about whether to receive the service and potentially pay out-of-pocket, or to decline the service.

Based on interview and record review, the facility failed to recognize severe weight loss that was experienced by one of three sampled residents (Resident 1), when Resident 1 went from 92 pounds (lbs.), on 4/7/2025 to 72.75 lbs. on 5/5/2025 (a weight loss of 19.25 lbs. in less than a month). The facility failed to: 1. Ensure there were no discrepancies in the calculation of the percentage of food Resident 1 consumed between 4/14/2025 and 5/4/2025 when the Weekly Summary Nurse Progress Note indicated Resident 1's food intake was between 51% to 100% versus the Document Survey Report that indicated Resident 1's food intake was 38.9% to 71.4%. 2. Follow Resident 1's Care Plan interventions to monitor Resident 1's weight loss/gain of three lbs. in a week and five lbs. in one month. 3. Notify Resident 1's physician and the facility's Registered Dietician (RD) 1 of Resident 1's poor dietary intake resulting in a severe weight loss of 19.25 lbs. in less than 30 days. 4. Give clear instructions on how to calculate the percentage of food consumed by Resident 1 and other residents. 5. Follow the facility's Policy and Procedure (P/P), titled, Nutritional Screening/Assessment/Resident Care Planning that indicated the facility's RD would be made aware of residents who eat poorly. 6. Follow the facility's P/P, titled, Weight Change Protocol that indicated early identification of a weight problems and possible causes can minimize complications. Residents who experience significant changes in weight or insidious weight loss will be assessed by the facility's RD who will assess, nutritionally diagnose, suggest interventions, monitor, and evaluate the success of the interventions. These deficient practices resulted in Resident 1 experiencing a severe weight loss of 19.75 lbs. in less than 30 days that was unrecognized by facility staff because of a discrepancy in how Resident 1's food intake was documented, which resulted in a delay in care and treatment. Resident 1 was transferred to a General Acute (GACH) where she was diagnosed with failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), severe electrolyte (minerals needed by the body to function) abnormalities, severe protein-calorie malnutrition (occurs when an individual's diet lacks the necessary nutrients needed to maintain health), cachexia (a metabolic condition involving involuntary weight loss due to a loss of muscle and fat mass), and had a nasogastric tube ([NGT] a thin, flexible tube inserted through the nose and down to the stomach to deliver nutrition) was inserted. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including lung transplant status (a surgical procedure where one or both of a resident's diseased or damaged lungs were replaced with healthy lungs from a deceased donor), and diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Physician's Orders, dated 2/19/2025, the Physician's Orders indicated a regular texture diet, thin/regular liquids three times a day. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 2/25/2025, the MDS indicated Resident 1 had mild cognitive impairment (a brain condition that causes noticeable but mild memory and thinking problems). During a review of Resident 1's Nutritional Review Screening, dated 2/27/2025, the Nutritional Review Screening indicated RD 1 recommended a regular texture diet, thin/regular liquids, with an eight ounce (oz) diabetic high protein nutrition ([HPN] a supplemental shake to aide in meeting the daily protein needs in a resident's diet) shake three times a day. The Nutritional Review Screening indicated Resident 1's estimated caloric needs were 1400-1600 kilocalories ([kcals] a unit of measurement used to measure the energy content of food and beverages) daily. The Nutritional Review Screening indicated Resident 1 had an intake of food/fluid of 51% to 100%, an ideal body weight ([IBW] the weight associated with the lowest risk of mortality for a given height, age, sex, and frame size) of 95 lbs., weighed 90 lbs., and needed to gain weight. During a review of Resident 1's Physician's Orders, dated 2/21/2025, the Physician's Orders indicated Resident 1 was to receive a diabetic HPN shake, eight oz three times a day between meals. During a review of Resident 1's untitled Care Plan, dated 2/21/2025, the Care Plan indicated Resident 1 needed a dietary supplement for weight maintenance. The Care Plan's goal indicated Resident 1 would eat 75-100% of each meal and dietary supplements. The Care Plan's interventions included monitoring Resident 1's weight loss/gain of three lbs. in a week and five lbs. in a month. During a review of Resident 1's Weight Summary, dated 4/7/2025, the Weight Summary indicated Resident 1 weighed 92 lbs. During a review of Resident 1's Weekly Summary Nurse Progress Note, dated 4/20/2025 and timed at 5:01 p.m., the Weekly Summary Nurse Progress Note indicated Resident 1's average meal intake for the week (4/14/2025 - 4/20/2025) was 76% to 100%. During a review of Resident 1's Documentation Survey Report, dated 4/2025, the Documentation Survey Report indicated Resident 1 had a total of 21 meals between 4/14/2025 and 4/20/2025 with an average meal intake of 38.9% to 63.1 % which did not match the 4/20/2025 Weekly Summary Nurse Progress Note that indicated Resident 1's average meal intake was 76-100%. During a review of Resident 1's Weekly Summary Nurse Progress Note, dated 4/28/2025 and timed at 3:29 p.m., the Weekly Summary Nurse Progress Note indicated Resident 1's average meal intake for the week (4/21/2025 - 4/28/2025) was 51%-75%. During a review of Resident 1's Documentation Survey Report, dated 4/2025, the Documentation Survey Report indicated Resident 1 had a total of 21 meals between 4/21/2025 and 4/27/2025 with an average meal intake of 47.4% to 71.4%, which did not match the 4/28/2025 Weekly Summary Nurse Progress Note that indicated Resident 1's average meal intake of 51%-75% for the 21 meals. During a review of Resident 1's Weekly Summary Nurse Progress Note, dated 5/4/2025 and timed at 5:36 p.m., the Weekly Summary Nurse Progress Note indicated Resident 1's average meal intake for the week 4/28/2025 -5/4/2025) was 51% to 75%. During a review of Resident 1's Documentation Survey Report, dated 4/2025 through 5/2025, the Documentation Survey Report indicated Resident 1 had a total of 21 meals between 4/28/2025 and 5/4/2025 with an average meal intake of 47.4% to 71.4%, which did not match the 4/28/2025 Weekly Summary Nurse Progress Note that indicated Resident 1's average meal intake for the week was 51% to 75%. During a review of Resident 1's Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 4/2025, the MAR indicated Resident 1 received HPN eight oz three times a day between 4/1/2025 and 4/9/2025, but there was no documentation to indicate the percentage of HPN that Resident 1 consumed. During a review of Resident 1's Physician's Orders, dated 5/5/2025 and timed at 8:54 a.m., the Physician's Order indicated Resident 1 may go out on pass. During a review of Resident 1's Progress Note, dated 5/5/2025 and timed at 9:20 a.m., the Progress Note indicated Resident 1 went out on pass with (FM) 1. During a review of Resident 1's Progress Note, dated 5/5/2025 and timed at 4:49 p.m. the Progress Note indicated FM 1 called the facility and reported Resident 1 was being admitted to the GACH for evaluation due to suspected lung rejection (a condition where the body's immune system attacks the transplanted lung, mistaking it as a foreign body). During a review of the GACH's Conditions of Service Notice, dated 5/5/2025, the Conditions of Service Notice indicated Resident 1 was admitted to the GACH on 5/5/2025 at 11:45 p.m. During a review of the GACH's History and Physical (H&P), dated, 5/6/2025 and timed at 12:30 a.m., the H&P indicated Resident 1 presented with failure to thrive and severe electrolyte abnormalities. During a review of the GACH's Nutritional Assessment, dated 5/6/2025 and timed at 1:44 p.m., the Nutrition Assessment indicated Resident 1 weighed 72.75 lbs. (19.25 lbs. less than her weight of 92 lbs. on 4/7/2025), had a severe protein-calorie malnutrition, and cachexia. During a review of the GACH's Discharge summary, dated [DATE], the Discharge Summary indicated Resident 1 had starvation ketoacidosis (a condition where the body, due to prolonged fasting or inadequate calorie intake, produces excessive ketones [(ketosis) a byproduct of fat breakdown in the body] as an alternative fuel source. Ketosis is a normal response to fasting, starvation ketoacidosis develops when this process is exacerbated, potentially leading to serious health issues) and was placed on an NGT feeding. During an interview on 6/6/2025 at 8:07 a.m., FM 1 stated on 5/5/2025 at approximately 9:30 a.m., she picked up Resident 1 for a follow up appointment for her lung transplant. FM 1 stated Resident 1's lung transplant physician suspected Resident 1 had an infection in her lungs or that her lung transplant was rejecting and planned to admit Resident 1 to the GACH when there was an available bed. FM 1 stated the GACH called her at approximately 10 p.m., (5/5/2025) with an available bed, Resident 1 was admitted to the GACH and diagnosed with dehydration (a condition where the body lacks sufficient water) and was severely malnourished (a poor state of nutrition, where the body does not receive enough essential nutrients, it needs to function properly). During an interview on 6/9/2025 at 12:02 p.m., The Director of Nursing (DON) stated licensed nurses were responsible for monitoring residents' food intake, the CNAs record the percentage of food eaten by residents' each meal and should report food intake below 50% or refusal to eat to the licensed nurses. The DON stated if a resident ate less than 50% in a week or two, they should notify the resident's physician and RD. During an interview on 6/9/2025 at 2:13 p.m., the Director of Staff Development (DSD) stated if a resident eats less than 50% of a meal the CNA should report that to a licensed nurse, if three meals were missed, the licensed nurses should notify the resident's physician and the RD. During an interview on 6/10/2025 at 11:11 a.m., LVN 2 stated she calculated Resident 1's weekly food intake by adding the percentage of the meals she ate (three meals per day times seven [21 meals]) and divided the total percentage by the number of meals (21). LVN 2 stated the average meal intake for Resident 1 between 4/21/2025 through 4/27/2025 was 48% and was inaccurately documented on the Documentation Survey Report, dated 4/2025. During an interview on 6/10/2025 at 12:05 p.m., The DON stated if Resident 1's meal intake had been accurately calculated to indicate that she was eating less than an average of 50% of her food, Resident 1's Physician and RD 1 should have been notified to obtain care instructions. The DON stated the licensed nurses determine the average meal intake of the residents' each week by looking at the trends of the past meals documented by the CNAs. During an interview on 6/10/2025 at 12:36 p.m., Certified Nursing Assistant (CNA) 3 stated they do not calculate the exact amount of what the resident drank, they only estimate if it is 50% or more based on how heavy the bottle is. CNA 3 stated if it seems the resident drank less than half of the HPN shake, they document the resident did not drink it. If it seems the resident drank more than half of the HPN shake, they document the resident drank all of it. During an interview on 6/10/2025 at 2:50 p.m., Resident 1's physician stated he should have been notified if Resident 1 was experiencing poor food intake, he could have evaluated her medications, ordered labs and possibly had her transferred to the GACH for evaluation and treatment. During a review of the facility's Policy and Procedure (P/P) titled Nutritional Screening/Assessment/Resident Care Planning dated 2023, the P/P indicated the facility Registered Dietitian will be made aware of residents who eat poorly. During a review of facility's undated P/P titled Weight Change Protocol the P/P indicated early identification of a weight problems and possible causes can minimize complications. Residents who experience significant changes in weight or insidious weight loss will be assessed by the facility RD who will assess, nutritionally diagnose, suggest interventions, monitor, and evaluate the success of the interventions.

Based on interview and record review, the facility failed to follow a physician's discharge summary order for a prescribed blood thinner medication and a plan of care which indicated the medication should be given as prescribed for one of three sampled residents (Resident 1). Resident 1, who had a history of [REDACTED].'s discharge order for 10 days. This deficient practice resulted in Resident 1 abruptly not receiving [MEDICATION NAME] and having a change of condition (COC) of an altered mental status (AMS), which required a readmission to the GACH 10 days after admission to the SNF. Resident 1 was diagnosed in the GACH with an acute right middle cerebral artery ((MCA) relating to the brain artery) stroke (an obstruction within a blood vessel supplying blood to the brain) after a computed tomography [MEDICATION NAME] ((CTA) non-evasive procedure that enhances anatomic views of vascular structures (pertaining to blood vessels)) was performed and was placed on comfort measures (to ease suffering). Resident 1 expired within 24 hours of admission to the GACH of an ischemic (deficient supply of blood to a body part (such as the heart or brain) that is due to obstruction of the inflow of arterial blood) stroke. Findings: A review of Resident 1's Face Sheet (admission record) indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. pumping chamber), [DIAGNOSES REDACTED] (an irregular, often rapid heart rate that commonly cause poor blood flow), Type 2 diabetes mellitus (high blood sugar), hypertensive [MEDICAL CONDITION] with heart failure (refers to heart problems that occur because of high blood pressure over a long time). During a review of Resident 1's Minimum Data Set (MDS), an assessment and care-screening tool, dated [DATE], Resident 1 had moderate impairment in cognitive skills (thought process) and required extensive assistance for transferring, bed mobility, walking, dressing toilet use and personal hygiene. During a review of Resident 1's GACH discharge summary, dated [DATE] titled Medications to continue taking with no changes indicated Resident 1 was to continue to receive [MEDICATION NAME] 150 milligram ((mg) unit of measurement) one capsule two times daily. During a review of Resident 1's SNF physician order [REDACTED]. During a review of Resident 1's Medication Administration Record (MAR), for the month of ,[DATE] indicated [MEDICATION NAME] 150 mg two times daily was not listed on the MAR and Resident 1 had not received [MEDICATION NAME] for 10 days. During a review of DailyMed, an online pharmacy site, indicated the use of [MEDICATION NAME] was for the reduction in risk of a stroke and systemic embolism (obstruction of an artery, typically by a clot of blood or an air bubble), as it lowers the chance of blood clots forming in the body. According to DailyMed, [MEDICATION NAME] had a Boxed Warning (a warning that appears on the package insert for certain prescription drugs per the U.S. Food and Drug Administration), which indicated premature discontinuation of [MEDICATION NAME] increases the risk of [MEDICAL CONDITION] (the formation of a blood clot inside a blood vessel, obstructing the flow of blood through the circulatory system) events. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?tid=ba74e3c. During a review of Resident 1's care plan, dated [DATE] indicated Resident 1 had a potential for bleeding due to receiving antiplatelet (are medicines that stop cells in the blood (platelets) from sticking together and forming a clot) medications for cardiovascular protection. The staff's intervention included to administer the medication as prescribed, assess for bleeding and notify physician for any unusual observation. During a review of Resident 1's nursing progress note, dated [DATE] and timed at 9:30 a.m., indicated the resident was in bed, lethargic (feeling of tiredness), less responsive and speaking slowly with a right facial droop (loss of facial muscle tone; usually caused by an impairment of nerve function that supply the facial muscles; could be a sign of a stroke) and left upper extremity flaccid (not firm or stiff) and weak. The physician (Physician 1) was made aware of Resident 1's condition and ordered to transfer the resident to the nearest hospital via paramedics. According to the nursing progress note, at 9:32 a.m., 911 (emergency service) was called and the paramedics arrived at 9:42 a.m. and took over the care of Resident 1. During a review of Resident 1's SNF transfer order report, dated [DATE] and timed at 10 a.m. indicated Resident 1 was sent to the GACH due to AMS and lethargy (a state of weariness that involves diminished energy, mental capacity, and motivation). The transfer report indicated Resident 1 had right facial droop. During a review of the Paramedic Run Sheet (Prehospital Care Report Summary) dated [DATE], it indicated the paramedics were dispatched at 9:51 a.m. on [DATE] and arrived at the facility at 9:57 due to Resident 1 having an altered level of consciousness (ALOC) unrelated to low blood sugar and or [MEDICAL CONDITION] (sudden, uncontrolled electrical disturbance in the brain). According to the paramedic run sheet, Resident 1's blood pressures were recorded as ,[DATE] and ,[DATE] millimeters of mercury ((mm Hg) unit of measurement, Normal Reference Range (NRR) ,[DATE] mmHg), had rapid labored breathing with facial droop and an abnormal ECG ((electrocardiogram) records the electrical signals of the heart) of [MEDICAL CONDITION]/flutter (abnormal heart rate, or arrhythmia). Resident 1 was transferred to a comprehensive stroke center to rule out a stroke. During a review of Resident 1's GACH history and physical, dated [DATE] indicated Resident 1 had a history of [REDACTED]. The CTA was positive for a complete occlusion of the right (internal carotid artery) ICA ((Ischemic stroke) occurs when a blood clot blocks or plugs an artery leading to the brain) origin of the right MCA and placed in intensive care unit and due to poor prognosis care was discussed with Resident 1's family for comfort care only and Resident 1 died on [DATE] with family at the bedside. During an interview, on [DATE] at 10:03 a.m., Resident 1's family member (FM 1) stated Resident 1 was not receiving [MEDICATION NAME] 150 mg medication two times daily as prescribed by the GACH physician from [DATE] until [DATE]. During a telephone interview on [DATE] at 3:57 p.m., a supervisor, Registered Nurse 2 (RN 2) stated, Our practice in this facility is to carry out orders that are written in the discharge summary and should be reflected on the MAR, the facility cannot write any order based on what the residents' family are telling us and it should be approved by the admitting doctor. RN 2 stated, If a family persist, we must clarify and verify the order with the doctor. On [DATE] at 4:45 p.m., during a telephone interview, RN 3 stated, When doing admissions, I always verify the discharge summary order to the admitting doctor, and I talk to my director of nursing (DON) before doing anything. RN 3 stated if a resident missed a dose of a blood thinner it could cause a stroke or a [MEDICAL CONDITION]. During a telephone interview on [DATE] at 8:51 a.m., RN 1 stated when the facility admitted new residents from the GACH, the facility must carry out the discharge summary orders. RN 1 stated it was the admitting nurse's responsibility to verify the GACH orders with the physician of which medications to continue or discontinue. During a telephone interview on [DATE] at 3:30 p.m., Resident 1's GACH physician (Physician 2) stated when the resident was discharged from the GACH on [DATE], as per the discharge summary, [MEDICATION NAME] 150 mg twice day was to be continued in the SNF. During a telephone interview on [DATE] at 10:22 a.m., Resident 1's physician assistant ((PA) are advanced practice providers who work under the supervision of a physician to treat residents) stated he works under the direct supervision of Physician 1 who cares for Resident 1 in the SNF. During a telephone interview on [DATE] at 10:45 a.m., RN 1 stated if any resident missed dosages of a blood thinner it can lead to stroke. During a telephone interview on [DATE] at 3:15 p.m., RN 3, who was Resident 1's admission nurse, stated, It's always my practice to clarify and verify physicians order especially if the resident is being discharged from the hospital. When RN 3 was asked why there was no documentation written in the progress notes of Physician 2 (GACH discharging physician) being notified for clarification of Resident 1's medications orders. RN 3 stated, Maybe I did not write it in the progress notes or possibly forgot to properly verify/clarify the admission orders [REDACTED]. RN 3 stated she could not remember. During a telephone interview on [DATE] at 9:11 a.m., RN 1 stated [MEDICATION NAME] medication was not included in Resident 1's SNF admission order, although it was listed as part of Resident 1's home medication to receive from the GACH. RN 1 was asked why [MEDICATION NAME] was not verified and clarified with the admitting physician based on the GACH discharge summary order. RN 1 stated she did not know. During a telephone interview on [DATE] at 11:46 a.m., the SNF Administrator stated, I saw the documentation that our staff spoke to the discharging physician from the hospital (Physician 2) regarding the medication [MEDICATION NAME], as it was put on hold but there was no documentation in the progress notes regarding holding [MEDICATION NAME]. The Administrator confirmed there was no documentation Physician 2 ordered to discontinue [MEDICATION NAME]. During a telephone interview on [DATE] at 9:53 a.m., the facility's Pharmacy Consultant (PC) stated [MEDICATION NAME] was an anti-coagulant (blood thinner) medication. The PC stated if the medication would be discontinued abruptly it could cause [MEDICAL CONDITION] (([MEDICAL CONDITION]) blood clots), stroke and or a [MEDICAL CONDITION] (occurs when the flow of blood to the heart is blocked). During a telephone interview on [DATE] at 3:19 p.m., Physician 2 stated if the medication [MEDICATION NAME] was discontinued abruptly there was a high risk of an ischemic stroke or [MEDICAL CONDITION] could occur. Physician 2 stated it required a physician's orders [REDACTED]. A review of Resident 1's Certification of Death indicated the resident expired on [DATE] at 3:08 p.m. Resident 1's death was listed as an ischemic stroke within days as an onset. A review of the facility's policy and procedure (P/P), dated for the year 2018 and titled, Admission of Resident indicated the facility's purpose was to obtain timely physician admission orders [REDACTED]. The nurse would contact the transferring facility to resolve any questions or to obtain clarification and contact the attending physician's office as needed for orders and/or clarification. According to the P/P, the Licensed Nurse will contact the admitting physician regarding any orders that need clarification and transcribe orders according to facility's policy.

Based on interview and record review, the facility failed to follow its policy and a resident's plan of care to provide adequate assistance of supervision to prevent falls for one of three sampled residents (Resident 1). Resident 1, who was assessed as a high risk for falls and required a two-person assist when transferring from the shower chair to toilet, had a fall in the bathroom when being transferred with a one-person assist. This deficient practice resulted in Resident 1 falling and sustaining a [MEDICAL CONDITION] (broken bone), requiring a transfer to a general acute care hospital (GACH) and a five-day hospitalization . Resident 1 underwent surgery of a left hip hemiarthroplasty (surgical operation used to treat a [MEDICAL CONDITION]) and developed a [MEDICAL CONDITION] embolism (blood clot that travels to the lungs). Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE], and was readmitted [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/23/18, indicated the resident had the ability to understand and be understood, required an extensive one-person physical assist for ambulating in the unit, and a two-person assist with transfer and toilet use. According to the MDS, Resident 1's balance transitions and walking was not steady and required staff's assistance. A review of Resident 1's Fall Risk assessment, dated 12/29/17, indicated Resident 1 was assessed as a high risk for falls, had problems balancing while standing and walking, and used a wheelchair for mobility. A review of Resident 1's care plan titled, High Risk for Falls, dated 12/27/17, indicated Resident 1's propensity (tendency) for injurious falls related to an unsteady gait (walking), unsteady balance, body weakness, and the use of cardiovascular agents (heart medications). The staff's interventions included to monitor Resident 1 and anticipate/intervene for factors causing previous falls such as bowel/bladder urgency, mobility problems, transferring, and walking, and remind resident to ask for assistance. On 3/15/18, at 8:50 a.m., during an interview, Resident 1 was observed sitting up in bed with an abduction pillow between the lower extremities. Resident 1 stated he fell while Certified Nursing Assistant 1 (CNA 1) was assisting him to the restroom via a shower chair to have a bowel movement. Resident 1 stated CNA 1 was alone while assisting him with toileting. Resident 1 stated it was CNA 1's usual routine to assist the resident with toileting and transferring alone. Resident 1 stated CNA 1 usually transferred him to the restroom alone and allowed him to dis-impact (manual removal of stool from rectum) himself. Resident 1 further stated he was a large guy so when he fell , CNA 1 had to go find assistance to help get him off of the floor because he was too heavy (weighing 286 pounds at the time of the fall) to lift alone. During an interview, on 3/15/18, at 9:45 a.m., CNA 1 stated he felt so bad about the incident which caused Resident 1 to fall and sustain a fracture. CNA 1 stated he was alone with Resident 1 at the time of the fall. CNA 1 stated he was familiar with Resident 1's routine and he usually transferred the resident by himself although he was aware Resident 1 required a two- person assist. A review of Resident 1's Nursing Progress Note, dated 3/8/18 and timed at 10:28 a.m., indicated CNA 1 was assisting Resident 1 to the bathroom when the resident slid down and fell on the floor. The progress note indicated Resident 1 was assessed and the physician (MD) was notified. A review of Resident 1's Pain Assessment form, dated 3/8/18 and timed at 12:40 p.m., indicated Resident 1 complained of pain, but there was no score documented on the pain scale assessment (tool used to measure intensity of pain level lowest to highest). The form indicated [MEDICATION NAME] (narcotic pain medication used to treat moderate to severe pain) 10-325 milligrams (mg) one (1) tablet was administered to Resident 1 by mouth. A review of Resident 1's Physicians Order, dated 3/8/18, indicated to transfer Resident 1 to the GACH for further evaluation. A review of Resident 1's Pelvis X-ray exam results, dated 3/10/18, indicated a [MEDICAL CONDITION] femur (thighbone). A review of the GACH's Discharge Summary, dated 3/13/18, indicated Resident 1 had a [DIAGNOSES REDACTED]. The discharge summary indicated Resident 1 required hemiarthroplasty (surgical operation used to treat a [MEDICAL CONDITION]) and developed a [MEDICAL CONDITION] embolism and was started on anticoagulants (medication to dissolve blood clots). A review of the facility's undated policy and procedure titled, Falls and Fall Risk, Managing, 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.