Every finding on record at Heritage Manor

Based on interview and record review, the facility failed to ensure a safe and appropriate discharge for two of 2 sampled residents (Resident 1 and 2) who required peritoneal dialysis (PD, a type of dialysis [a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed] that uses the lining of the abdomen [peritoneum] as a natural filter to remove waste, toxins, and extra water from the body]) service. The facility admitted Residents 1 and provided PD services to the residents without obtaining license and reporting to the State Agencies since 2/2026. The facility initiated Resident 1 and 2 to discharge to the hospital on 4/29/2026 which was not the choice of the residents. The deficient practice resulted in Resident 1 and 2 being transferred to the hospital with was not their feeling displaced and reported feeling disappointed that affected their psychological wellbeing. Findings: 1.During a review of review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 2/8/2026 and readmitted on [DATE] with diagnoses that included end stage renal disease (ESRD, a condition that the kidneys [an organ that filters waste, excess fluids, and toxins from the blood to create urine] no longer function well enough to meet a body's needs) and infection (the invasion and multiplication of microorganisms in body, causing tissue damage and disease) and inflammatory reaction (body's defense mechanism against harmful stimuli) due to PD. During a review of Resident 1's History and Physical (H&P), dated 3/23/2026, indicated Resident 1 had the capacity to understand and make decisions, and was receiving PD for ESRD. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/22/2026, indicated Resident 1's had no cognitive impairment (ability to understand and make decisions). The MDS indicated Resident 1 required PD. The MDS indicated Resident 1 required partial/moderate assistance with eating, oral hygiene, and substantial/maximal assistance. During a review of Resident 1's Interdisciplinary Care Conference (IDT), dated 4/29/2026, timed at 12:43 PM, the IDT indicated the facility informed Resident 1 that the facility was unable to provide PD and unable to safely meet the resident's clinical needs at this level of care. The IDT indicated after reviewing all available options, the resident decided to transfer to a GACH capable of providing PD and continued rehabilitation services. During a review of Resident 1's Order, dated 4/29/2026, the order indicated the physician ordered to transfer the resident to General Acute Care Hospital (GACH). During a review of Resident 1's Progress Notes (PN), dated 4/29/2026 timed at 4:12 PM, the PN indicated Resident 1 was transferred to GACH. During a review of Resident 1's Notice of Transfer/Discharge, dated 4/29/2026, the notice indicated the transfer, or discharge is necessary for the resident's welfare and needs could not be met in the facility. 2. During a review of Resident 2's AR, the facility admitted Resident 2 on 2/24/2026 with diagnoses on ESRD and dependence on renal dialysis. During a review of Resident 2's H&P, dated 2/27/2026, indicated that Resident 2 had the capacity to understand and make decisions and was receiving PD for ESRD. During a review of Resident 2's MDS, dated [DATE], indicated that Resident 2's cognitive skills was intact. The MDS indicated that Resident 2's received PD upon admission to the facility. During a review of Resident 2's Interdisciplinary Care Conference (IDT), dated 4/29/2026 timed at 12:37 PM, the IDT indicated the facility informed Resident 2 that the facility was unable to provide PD and unable to safely meet the resident's clinical needs at this level of care. The IDT indicated after reviewing all available options, the resident and the responsible party decided to transfer to a GACH capable of providing PD and continued rehabilitation services. During a review of Resident 2's Order, dated 4/29/2026, the order indicated the physician ordered to transfer the resident to General Acute Care Hospital (GACH) for dialysis covered needed. During a review of Resident 2's Progress Notes (PN), dated 4/29/2026 timed at 4:23 PM, the PN indicated Resident 2 was transferred to GACH. During a review of Resident 2's Notice of Transfer/Discharge, dated 4/29/2026, the notice indicated the transfer or discharge is necessary for the resident's welfare and needs could not be met in the facility. During a telephone interview on 4/30/2026 at 2:13 PM with Family Member (FM) 1, FM 1 stated on 4/28/2026, the facility staff informed him that the facility could not provide PD for Resident 2 in the facility anymore and the resident needed to go somewhere else. FM 1 stated the facility did not spend time looking for another place for Resident 2. FM 1 stated Resident 2 was transferred to a GACH's emergency room (ER) on 4/29/2026 afternoon and the ER staff was surprised because they did not understand why the facility would send a resident who was fine to an ER. FM 1 stated Resident 2 was admitted into the GACH late at night on 4/29/2026 and he did not receive his daily PD on 4/29/2026. FM 1 stated Resident 2 and him wanted to continue to stay in the facility and did not want to be transferred to a hospital, but they did not have a choice. During a telephone interview on 4/30/2026 at 2:15 PM with FM 2, FM 2 stated she felt Resident 1 was kicked out by the facility. FM 2 stated Resident 1 was transferred to a GACH on 4/29/2026 afternoon, but the GACH could not do PD for her yesterday and the GACH was planning to send the resident to a different GACH. FM 2 stated Resident 1 relied on the facility to find a right place for her to continue PD treatment and rehabilitation service. FM 2 stated Resident 1 wanted to stay in the facility because they were providing PD treatment and rehab services for her. FM 2 stated Resident 1 was currently in a bad situation and did not know what she could do. During a telephone interview on 5/1/2026 at 9:55 AM with the Administrator (ADM), the ADM stated after the facility staff realized the facility did not obtain the license to provide PD services in the facility during the recent recertification survey, the IDT conducted meetings to discuss discharge options with Resident 1 and 2 and their responsible parties, later, the facility transferred the two PD residents to a GACH on 4/29/2026. The AMD stated he did not have control over the admission process and treatment plan in the GACH after the residents were transferred. During a telephone interview on 5/1/2026 at 11:49 PM with Resident 1, Resident 1 stated the facility staff informed her that the facility was not licensed to provide PD treatment for the residents in the facility a couple days ago, so she had to move to a different place. Resident 1 stated the facility offered four options and she decided to be transferred to the hospital because she had no other choice. Resident 1 stated at the hospital where she is currently staying, she could not sleep well because the nurses in the hospital were not competent at providing PD treatment, so she had to stay up at night to watch the nurses. Resident 1 stated she only received limited rehabilitation services in the hospital which hindered her from regaining her mobility and strength to go back home. Resident 1 further stated transferring to a hospital from the facility was not her preferred choice and she did not want to stay in the hospital. During an interview on 5/1/2026 at 12:08 PM with the Director of Nursing (DON), the DON stated the facility admitted and had retained Resident 1 and 2, who required PD service in the facility, since 2/2026, but the facility could not provide the PD service for these two residents due to lack of license to provide PD service. The DON stated as a result, the facility had to discharge them, even though it was not the residents' choice to be discharged from the facility. During a review of the facility's policy and procedure (P&P) titled, Transfer and Discharge, dated 12/19/2026, the P&P indicated The facility will evaluate and determine the level of care needed for the resident prior to admission to ensure the facility's ability to meet the resident's needs and Once admitted , the resident has the right to remain at the facility, except in limited circumstances. During a review of the facility's policy and procedure (P&P) titled, Facility Assessment Tool, dated 2/18/2026, indicated services and care the facility offered based on the resident's needs did not include peritoneal dialysis. During a review of the California Department of Public Health (CDPH) All Facility Letter (AFL) titled Updated Guidance for the Provision of Home Dialysis Services in a SNF (Skilled Nursing Facility), revised on 3/8/2021, the AFL indicated that the Centers of Medicare and Medicaid Services (CMS) requires the dialysis facility to notify CDPH of any arrange between CNS and SNF by submitting FORM CMS 3427 End Stage Renal Application and Survey and Certification (PDF) to CDPH. During a review of the same CDPH AFL titled Updated Guidance for the Provision of Home Dialysis Services in a SNF, revised on 3/8/2021, the AFL indicated that SNFs seeking to provide peritoneal or hemodialysis services must apply for approval of the optional services. The AFL indicated any SNF seeking to initiate the provision of dialysis services in a SNF must submit a change of application to CDPH's Centralized Application Branch (CAB) to request state approval to add the service to the facility's license.

Based on interview and record review, the facility failed to ensure two of two sampled resident (Resident 1 and 2) received services in accordance with the facility's capabilities and available resources when the facility admitted and retained the residents requiring peritoneal dialysis (PD, a type of dialysis [a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed] that uses the lining of the abdomen {peritoneum} as a natural filter to remove waste, toxins, and extra water from the body]) services without having an established peritoneal dialysis program and the necessary services to safely provide PD care as approved by the State Agency. These deficient practices had the potential for the residents to experience complications related to PD such as infections (peritonitis, catheter exit-site infections), mechanical issues (hernias, dialysate leaks, catheter blockage), and metabolic changes like weight gain or high blood sugar that can lead to hospitalization. Findings: 1.During a review of review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 2/8/2026 and readmitted on [DATE] with diagnoses that included end stage renal disease (ESRD, a condition that the kidneys [an organ that filters waste, excess fluids, and toxins from the blood to create urine] no longer function well enough to meet a body's needs) and infection (the invasion and multiplication of microorganisms in body, causing tissue damage and disease) and inflammatory reaction (body's defense mechanism against harmful stimuli) due to PD. During a review of Resident 1's History and Physical (H&P), dated 3/23/2026, indicated Resident 1 had the capacity to understand and make decisions, and was receiving PD for ESRD. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/22/2026, indicated Resident 1's had no cognitive impairment (ability to understand and make decisions). The MDS indicated Resident 1 required partial/moderate assistance with eating, oral hygiene, and substantial/maximal assistance with toileting hygiene, shower/bathe self and chair/bed-to-chair transfer. The MDS indicated that Resident 1 received PD since admission. During a review of Resident 1's Order Recap Report, order date 2/21/2026, indicated Resident 1 was to received PD using Dianeal with 1.5% Dextrose (a dialysis solution used for PD) 2000 milliliters (mL, unit of weight) per hour. The order began 2/21/2026 and ended 3/4/2026. During a review of Resident 1's Order Recap Report, order date 3/4/2026, indicated Resident 1 was to receive PD using 1.5% Dextrose Solution (a dialysis solution used for PD). The treatment was prescribed for 10.5 hours with five cycles with a fill volume of 2000 mL, starting at 7 PM each evening. The PD treatment began 3/4/2026 and ended 4/3/2026. During a review of Resident 1's Physician Order Summary (POS), dated 4/26/2026, indicated Resident 1 was to receive PD using Extraneal (a dialysis solution used for PD), The treatment was prescribed for 10.5 hours with five cycles of 2000 mL fills and a final 1500 mL fill, starting at 7 PM each evening. The PD treatment began on 4/17/2026. During a review of Resident 1's SNF (Skilled Nursing Facility) PD Patient Treatment Log, dated February 2026 to March 2026 indicated that Resident 1 received daily PD treatments from 2/21/2026 to 3/29/2026. During a review of Resident 1's Medication Administration Record (MAR) for April 2026 indicated that Resident 1 received PD treatments from 04/1/2026 to 04/4/2026 and 4/17/2026 to 4/26/2026. 2. During a review of the Resident 2's AR, the facility admitted Resident 2 on 2/24/2026 with diagnoses on ESRD and dependence on renal dialysis. During a review of Resident 2's H&P, dated 2/27/2026, indicated that Resident 2 had the capacity to understand and make decisions and was receiving PD for ESRD. During a review of Resident 2's MDS, dated [DATE], indicated that Resident 2's cognitive skills was intact. The MDS indicated that Resident 2's received PD upon admission to the facility. During a review of Resident 2's POS, dated 4/2/2026, indicated Resident 2 was to receive PD using 2.5% Dextrose solution (a dialysis solution used for PD). The treatment was prescribed for 9.5 hours with five cycles and a fill volume of 2700mL, starting at 7 PM each evening. The PD treatment started 4/2/2026. During a review of Resident 2's MAR for February, March, and April 2026 showed that the resident received PD treatments from 2/25/2026 - 2/28/2026, 3/1/2026 - 3/14/2026, and 4/16/2026 - 3/31/2026. During a review of Resident 2's SNF - PD Patient Treatment Log, indicated Resident 1 received daily PD treatments from 3/4/2026 to 4/25/2026. During a telephone interview on 4/30/2026 at 2:13 PM with Family Member (FM) 1, FM 1 stated the facility admitted Resident 2 and the nurses provided PD treatment for the resident everyday in the facility. FM 1 stated he and Resident 2 did not know the facility did not have the license and could not provide PD treatment in the facility as the state regulation when Resident 2 was admitted to the facility. During a telephone interview on 4/30/2026 at 2:14 PM with FM 2, FM 2 stated the facility admitted Resident 1 and the nurses provided PD treatment for the residents everyday in the facility. FM 2 stated Resident 1 agreed to stay in the facility because she was told that the facility was able to provide PD treatment. During a telephone interview on 5/1/2026 at 11: 49 AM with Resident 1, Resident 1 stated she agreed to be admitted into the facility because the facility could provide PD treatment and she did not know the facility did not have a license and was not allowed to provide PD for the residents in the facility. During a review of the Facility Assessment, it indicated PD services were not included in the services to be provided by the facility. During a remote meeting conducted on 4/28/2026 at 11:30 AM with the facility Administrator (ADM), in the presence of the CDPH Program Managers (PMs) and Supervisors, the ADM stated that there were two residents currently residing at the facility who were receiving PD treatment and services. The ADM also stated that the facility's nursing staff assisted these residents with initiating and disconnecting their PD treatments in the facility. During the same interview on 4/28/2026 at 11:35 AM with the ADM, CDPH PM, and Supervisors, the ADM stated that it happened several years ago when he noticed that residents discharged from the hospital had PD or HD. The ADM stated that he believed offering PD was a nice service to offer to help the overall healthcare eco care system. The ADM also stated that he spoke with [Clinic 1], his legal counsel, and his consultants regarding offering PD in the facility. The ADM further stated that it was his understanding that PD [did not] require the same level of requirements as HD. During the same interview on 4/28/2026 at 11:40 AM with the ADM, CDPH PM, and Supervisors, the ADM stated that he was aware of the All Facilities Letter (AFL, an official notice from CDPH sent to all healthcare facilities such as clinics, hospitals, and skilled nursing homes) that indicated the facility needed to notify CDPH prior to the start of PD services in the facility. The ADM stated that, according to the regulatory reference ESRD obligation and Title 22 (California Code of Regulations aimed at protecting the health, safety, and well being of residents in licensed care facilities; regulations that act as the baseline licensing requirements for health facilities), PD was not specifically identified under optional services. During the same interview on 4/28/2026 at 11:50 AM with the ADM, CDPH PM, and Supervisors, the ADM stated that the facility's nursing staff received training from Clinic 1. The ADM also stated that the facility has all the [dialysis] solutions and equipment to perform the procedure on hand. During an interview on 5/1/2026 at 12:08 PM with the Director of Nursing (DON), the DON stated the facility should not have admitted Resident 1 and Resident 2 into the facility. The DON stated admitting these two PD residents and providing PD service to them could put them at risk for infection and other complications. During a review of the facility's policy and procedure (P&P) titled, Transfer and Discharge, dated 12/19/2022, the P&P indicated The facility will evaluate and determine the level of care needed for the resident prior to admission to ensure the facility's ability to meet the resident's needs. During a review of the facility's policy and procedure (P&P) titled, Facility Assessment Tool, dated 2/18/2026, indicated services and care the facility offered based on the resident's needs did not include peritoneal dialysis. During a review of the California Department of Public Health (CDPH) All Facility Letter (AFL) titled Updated Guidance for the Provision of Home Dialysis Services in a SNF (Skilled Nursing Facility), revised on 3/8/2021, the AFL indicated that the Centers of Medicare and Medicaid Services (CMS) requires the dialysis facility to notify CDPH of any arrange between CNS and SNF by submitting FORM CMS 3427 End Stage Renal Application and Survey and Certification (PDF) to CDPH. During a review of the same CDPH AFL titled Updated Guidance for the Provision of Home Dialysis Services in a SNF, revised on 3/8/2021, the AFL indicated that SNFs seeking to provide peritoneal or hemodialysis services must apply for approval of the optional services. The AFL indicated any SNF seeking to initiate the provision of dialysis services in a SNF must submit a change of application to CDPH's Centralized Application Branch (CAB) to request state approval to add the service to the facility's license.

Based on observation, interview, and record review, the facility failed to ensure that the accurate and current staffing data sheet (total number of actual hours worked by licensed [Registered Nurses (RNs), Licensed Vocational Nurses [LVNs], and unlicensed nurses [Certified Nurse Assistants (CNAs)] ) was posted on 4/25/2026 for the 7 AM - 3 PM shift when the annual recertification survey team entered the facility on 4/25/2025 at 8:30 AM. This deficient practice had the potential to delay recognition of inadequate staffing levels, which may lead to delayed response times, unmet resident needs, and decreased supervision, particularly for residents who require assistance with activities of daily living (ADLs), such as bathing, dressing, and toileting, or who require ongoing safety monitoring. This deficient practice also had the potential to prevent residents, families, and visitors from accurately assessing staff availability, which may affect their ability to raise concerns, request assistance, or make informed decisions regarding the resident's care environment. Findings: During an observation on 4/25/2026 at 8:35 AM, a Census and Direct Care Services Hours per Patient Day (DHPPD, a CMS issued document used to record direct care service hours over a 24-hour period), dated 4/25/2026 was observed posted by the Nurse's Station. The document indicated that the facility's patient census was 91. During the same observation on 4/25/2026 at 8:38 AM, a Nursing Staff Projection document, dated 4/24/2026 was observed posted by the Nurse's Station. The document indicated that the facility's patient census for each shift (11 PM - 7 AM, 7 AM - 3 PM, and 3 PM to 11 PM) was 89. During a concurrent interview and record review on 4/28/2026 at 3 PM with the Director of Staff Development (DSD), a photo of the facility's Nursing Staff Projection sheet, dated 4/26/2026 timed at 8:45 AM, was reviewed. The DSD stated, the Nursing Staff Projection was not updated by the 11 PM - 7 AM RN supervisor for the 7 AM - 3 PM shift on 4/25/2026. The DSD stated that during the weekends and holidays, the RN supervisor of the 11 PM - 7 AM shift was responsible for completing the CHHPD and the Nursing Staff Projection sheet. During the same interview on 4/28/2026 at 3:05 PM, the DSD stated it was important to accurately update and post the Nursing Staff Projection sheet each day to inform residents, families, and visitors of how many CNAs, LVNs, and RNs were projected to work on the current day. The DSD stated that when the Nursing Staff Projection sheet was not accurate, residents, families, and visitors may not be aware of the actual staffing availability. This lack of information could affect their ability to request assistance with residents' ADLs, make informed decisions regarding a resident's plan of care, or address concerns about the resident's physical environment, which may result in delays in care. During a review of the facility's policies and procedures (P&P) titled Nurse Staffing Posting Information, dated 9/16/2024, the P&P indicated that the Nurse Staffing Sheet will be posted on a daily basis and will contain the following information but not limited to the current date and the facility's current resident census. The P&P indicated that the facility will post the Nurse Staffing Sheet at the beginning of each shift.

Based on observation, interview and record review the facility failed to implement the facility's policy and procedure for infection control for 5 of 5 sampled residents Residents 43, 46, 62, 67 and 106. The facility failed to: 1.Resident 106's nasal canula (NC-a lightweight, flexible tube used to deliver supplemental oxygen) was properly stored when not in use to prevent contamination in accordance with Oxygen Administration facility policy. 2.Appropriately cohort Resident 62 who was on peritoneal dialysis (PD, a home-based treatment for kidney failure) with Resident 46 who had active infection with Escherichia coli Extended-Spectrum beta-lactamase (ESBL E. coli, bacteria resistant to many common antibiotics, making infection harder to treat) in urine in the same room. 3. Ensure Resident 43's intravenous site (IV- catheter inserted into the vein) was labeled with a date and initialed by the registered nurse (RN) who last changed the IV site dressing. 4. Ensure Resident 67's personal items located in a three-drawer plastic bin at Resident 67's bedside was not expired. These deficient practices had the potential to spread infection to Residents 43, 46, 62, 67 and 106, other residents in the facility. Findings 1.During a review of Resident 106's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including essential hypertension (high blood pressure), acute congestive heart failure (the heart can't pump enough blood). During a review of Resident 106's History and Physical (H&P), dated [DATE], the H&P indicated Resident 106 did not have the capacity to understand and make decisions. During a review of Resident 106's Order Summary Report dated [DATE] indicated a Physicians order for: Oxygen via NC at 2 liters (a unit of measurement) per minute as needed, may titrate Oxygen up to 5 liters per minute to maintain Oxygen saturation greater or equal to 93% with a start date of [DATE]. During an observation on [DATE] at 9:39 AM, Resident 106's NC was observed laying on the floor next to Resident 106's head of bed. During a concurrent interview and observation on [DATE] at 9:41 AM of Resident 106's room with Registered Nurse 2 (RN 2), RN 2 stated she did not know why resident 106's NC was laying on the room floor. RN 2 stated Resident 106's NC should be stored in a plastic clear bag when not in use to prevent it from being contaminated. During an interview on [DATE] at 1:41 PM with Director of Nursing (DON), the DON stated all resident Oxygen NC should be stored properly inside clear plastic bag that is labeled when not in use. The DON stated it can make a resident sick if it falls on the floor and then is used by the resident as the NC can become contaminated. A review of the facility's Policy and Procedure (P&P) titled Oxygen Administration, revised [DATE], indicated 4. Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include keep delivery devices covered in plastic bag when not in use. 2.During a review of Resident 62's admission Record (AR), the AR indicated the facility admitted Resident 62 on [DATE] and readmitted on [DATE] with diagnoses that include end stage renal disease (ESRD, a condition that the kidneys [an organ that filters waste, excess fluids, and toxins from the blood to create urine] no longer function well enough to meet a body's needs) and infection (the invasion and multiplication of microorganisms in body, causing tissue damage and disease) and inflammatory reaction (body's defense mechanism against harmful stimuli) due to peritoneal dialysis catheter(a tube for PD access). During a review of Resident 62's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated [DATE], indicated Resident 62's had no cognitive impairment (ability to understand and make decisions). The MDS indicated Resident 62 was receiving PD. The MDS indicated Resident 62 required partial/moderate assistance with eating, oral hygiene, and substantial/maximal assistance with toileting hygiene, shower/bathe self and chair/bed-to-chair transfer. During a review of Resident 62's Physician Order Summary dated [DATE] indicated that starting [DATE], the resident was to receive peritoneal dialysis (PD) using Extraneal (a dialysis solution used for PD). The physician ordered treatment consisted of five cycles totaling 10.5 hours, with fill volumes of 2000 mL for each cycle and a final fill of 1500 ml. The PD treatment was scheduled to begin at 7 PM and continue until completion each evening. b. During a review of Resident 46's AR, the AR indicated the facility admitted Resident 46 on [DATE] with diagnoses that include urinary tract infection (UTI, an infection in any part of the urinary system (organs that produce and release urine, caused by bacteria). During a review of Resident 46's MDS, dated [DATE], the MDS indicated Resident 46's had moderately impaired cognition and memory. The MDS indicated Resident 46 required partial/moderate assistance with eating, oral hygiene and personal hygiene, and was dependent on toileting hygiene, shower/bathe self and chair/bed-to-chair transfer. During a review of Resident 46's Order Summary Report, dated [DATE], the report indicated the physician ordered Resident 46 to be placed on contact isolation precautions (precautions to prevent the spread of infections transmitted by direct or indirect contact with a patient or their environment) starting on [DATE] due to presence of ESBL E. coli. During an observation on [DATE] at 1:18 PM, Residents 62 and 46 reside in the same room and were roommates. During an observation and concurrent interview on [DATE] at 4:13 PM with the Infection Preventionist (IP), the IP stated Resident 46 was placed on contact isolation due to presence of ESBL and E. coli in the urine on [DATE]. The IP stated the facility staff should not have cohort Resident 62 with Resident 46 together because Resident 62 was at high risk for contracting infection due to having kidney failure and receiving peritoneal dialysis. The IP stated she did not notice Resident 62 had been in the cohort with Resident 46 who had active infection since [DATE]. During an interview on [DATE] at 2:01 PM with the Director of Nursing (DON), the DON stated Resident 62 was at high risk for contracting infection because she was receiving PD. The DON stated Resident 46 had an active infection with ESBL E.coli. The DON stated the facility should not place these two residents in the same room to prevent potential infection for Resident 62. The DON stated the facility staff did not check the residents' status and did not ensure these two residents were not cohort in the same room. During a review of the facility's policy and procedure (P&P) titled, Peritoneal Dialysis, dated [DATE], the P&P indicated the facility will establish policies/procedures based upon current standard of practice to include transmission-based precautions including placement/location (Cohorting). During a review of the facility's P&P titled, Transmission-Based (Isolation) Precautions, dated [DATE], the P&P indicated when implementing transmission-based precautions, the facility will consider sharing a room with a roommate with limited risk factors (without indwelling or invasive devices, without open wounds, and not immunocompromised) as appropriate based on the pathogen and method of transmission. 3.During a review of Resident 43's admission Record (AR), the AR indicated the facility originally admitted Resident 43 on [DATE] and readmitted her on [DATE] with diagnoses that include pneumonia (infection of lungs) and hypertension (high blood pressure). During a review of Resident 43's Minimum Data Set (MDS, a resident tool), dated [DATE], the MDS indicated Resident 43 had severely impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 43 was dependent on oral hygiene and personal hygiene, toileting hygiene, shower/bathe self and chair/bed-to-chair transfer. During a concurrent observation and interview on [DATE] at 12:53 PM with Registered Nurse (RN) 2, Resident 43 was lying on the bed, and she had an intravenous catheter (IV catheter, a flexible plastic tube inserted into a vein to deliver fluids, medications, or blood products directly into the bloodstream) inserted in her right foot. The IV site was covered with a transparent dressing that was unlabeled. There was not date or initial of who last changed Resident 43's IV site dressing. RN 2 stated she inserted the IV catheter two days ago and she put a label sticker with the date and initial on the IV site transparent dressing, but she could not find the label sticker at this time. RN 2 stated the reason the IV was labeled and initialed with the nurse who changed the IV site dressing was so other nurses would know when the IV was inserted and when the dressing required changing. RN 2 stated the date and the initial on the IV site should be visible at all times and changed every 72 hours in accordance with the facility's policy to prevent infection. During an interview on [DATE] at 1:53 PM with the Director of Nursing (DON), the DON stated the as the standard of practice, the RNs should label the date and initial when they insert a new IV catheter into the resident and monitor the IV site. The DON stated the date and initial must be visible at all times, so they would know when to change the IV catheter to prevent infection for the resident. During a review of the facility's policy and procedure (P&P) titled, Intravenous Therapy, dated [DATE], the P&P indicated IV sites are changed every 72 hours unless otherwise by the physician. 4.During a review of Resident 67's AR, the AR indicated the facility originally admitted Resident 67 on [DATE] and readmitted her on [DATE] with diagnoses that include dementia (a progressive, irreversible syndrome characterized by a decline in memory, thinking, behavior, and daily function, commonly affecting older adults) and hyperlipidemia (a common condition characterized by high levels of fats). During a review of Resident 67's MDS, dated [DATE], the MDS indicated Resident 67's had severely impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 67 was dependent on oral hygiene and personal hygiene, toileting hygiene, shower/bathe self and chair/bed-to-chair transfer. During a concurrent observation and interview on [DATE] at 10:07 AM, the Infection Preventionist (IP) was observed was moving a three-drawer plastic storage bin that was in Resident 67's room out of the room. The storage cart drawers have the following: a. four (4) opened bottles of normal saline (a mixture of water and salt) and one (1) of the bottles was labeled with an open date of[DATE] b. 4 opened, used tubes of Medihoney (a medical-grade honey used to treat wound and burns) in a gloves box c. 1 opened, used tube of Bacitracin Zinc Ointment (a topical ointment used to treat and prevent infection in a wound). d. three (3) opened, used Medihoney, 1 opened, used tube of Silverhoney (a medical-grade honey used to treat wound and burns) and 1 opened and used Bacitracin Zinc ointment were inside a Ziploc bag e. 3 opened, half-full bottles of ultrasound gel (a gel used during a ultrasound test [a test used a sound wave to capture the image inside the body]) f. 1 opened bottle of Artificial Teas lubricant eye drops (eye drops used to treat dry, scratchy, or burning eyes) g. multiple linen sheets, diapers and towels The IP stated the plastic storage bin was at Resident 67's bedside and she was removing it from the room because the items should not be stored at the bedside because of infection control concerns. The IP stated she was not sure for how long the resident had these items kept in the plastic storage cart. During an interview on [DATE] at 4:05 PM with the Treatment Nurse (TXN), the TXN stated Resident 67 did not have any skin issues except requiring g-tube site care. The TXN stated she saw the plastic storage bin at Resident 67's bedside but she did not know what was stored inside the cart. The TXN stated the facility had never provided the NS, Bacitracin Zinc ointment, Medi Honey and ultrasound gem to Resident 67. The TXN stated the family members were the ones who brought those items from outside into the facility. The TXN stated she saw the family members use NS to clean Resident 67's hands before. During an interview on [DATE] at 10:55 AM, the IP stated the items in Resident 67's plastic storage bin at bedside were contaminated and expired. The IP stated when the FM continued to use these items on Resident 67, the resident was at risk for infection. The IP stated the facility staff did not check the items that were stored inside Resident 67's plastic storage bin and did not address the potential infection issue with FM and other staff. During an interview on [DATE] at 2:33 PM with Certified Nursing Assistant (CNA) 3, CNA 3 stated she took care Resident 67 before and she noticed that there was a plastic storage bin was at Resident 67's bedside, but she did not know what was inside the cart. During an interview on [DATE] at 1:55 PM with the Director of Nursing (DON), the DON stated the facility staff did not check what was stored inside Resident 67's plastic storage cart and did not talk to the family members to address proper storage of residents' personal items. The DON stated properly storing resident's items was important so the resident would not receive contaminated and expired solution, gel, ointment and eye drops. The DON stated the nurse should report any improper storage issue at residents' bedside and prevent infection to the residents. During a review of the facility's P&P titled, Infection Prevention and Control Program, dated [DATE], the P&P indicated the facility to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of infections.

Based on observation, interview and record review, the facility failed to ensure to store and serve food for 69 residents receiving food from the kitchen in accordance with professional standards for food service safety, and the facility's policy and procedure titled, Food Safety and Food Storage, revised 12/19/2022. This deficient practice had the potential for the residents to acquire food-borne illness (a life-threatening infection due to consuming contaminated food) from ingesting expired food. Findings: During an observation on 4/25/2026 at 8:45 AM in the kitchen with the dietary staff there were open and expired food items in the freezer as listed: One open bag full of mixed vegetables store in the freezer Ten (10) cups of expired ice cream store in the freezer Ice scoop stored inside the ice container machine During a concurrent observation and interview on 4/25/2026 at 8:45 AM with the Kitchen staff (KS 1) stated that the vegetable bag that was slightly opened was overlooked by staff and should have been disposed. KS 1 stated the ice cream cups expired on 4/24/2026 and should have been discarded and not store in the freezer. During a concurrent observation and interview on 4/25/2026 at 9:00 AM, the Dietary Supervisor (DS 1) acknowledged that the ice scoop should not have been left inside the ice machine. DS 1 explained that there were plans to install a hook outside the ice machine to properly store the ice scoop, but this task had not yet been completed. During an interview on 4/28/2026 at 2:42 PM with the Registered Dietitian (RD 1), RD 1 stated that the ice scoop should never be stored inside the ice machine, additionally RD 1 stated that expired food should never be stored in the freezer and open bags in the freezer can be exposed to the elements of the freezer and can affect the taste of the food. During a review of the facility's policy and procedure (P&P) titled, Food Safety and Food Storage date revised 12/19/2022, indicated that food safety practices shall be followed throughout the facility's entire food handling process. Food should be stored in a manner that helps prevent deterioration or contamination of the food. Equipment used in the handling of the food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with food.

Based on observation, interview, and record review, the facility failed to ensure residents receiving anticoagulant or antiplatelet medications (blood thinner) were monitored for medication side effects, in accordance to the resident's care plan and failed to obtain the correct safe dose for a prescribed anti nausea medication, in accordance to professional standard of practice and pharmaceutical recommendation for four of six sampled residents (Residents 3, 40, 75, and 65) by failing to: 1. The facility did not monitor Resident 3 for signs and symptoms of bleeding while receiving Eliquis (a blood thinner medication).2. The facility did not monitor Resident 40 for signs and symptoms of bleeding while receiving Eliquis. 3. The facility did not monitor Resident 75 for signs and symptoms of bleeding while receiving Brillinta (a medication that prevents blood from sticking together) and Aspirin (medication that prevent blood clot to form). 4. For Resident 65, the facility failed to include a maximum daily dose for ondansetron (Zofran-medication to relieve nausea and vomiting) in the physician's order for 8 mg every 8 hours as needed, which could allow administration of up to 32 mg in 24 hours and place Resident 65 at risk for adverse reactions. These deficient practices placed Residents 3, 40, and 75 at increased risk for preventable complications associated with anticoagulant or antiplatelet use, including internal bleeding or bruising, which could result in serious injury or death. The failure to ensure the correct Ondansetron dose also placed Resident 65 at risk for medication related harm. Findings: 1. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] with included diagnoses of acute respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide) with hypoxia (low levels of oxygen), cachexia (loss of muscle and fat), Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 3's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated on 3/27/2026, the MDS indicated Resident 3's cognition (the ability to process thoughts) was severely impaired. During a review of Resident 3's Order Summary Report dated 4/28/2026, indicated Resident 3 had a physician order of Aspirin (medication that prevents the blood from sticking together) 81 milligrams (mg - unit of measurement), once a day for prophylaxis (preventative) for cerebrovascular accident (CVA - a stroke, loss of blood flow to a part of the brain) stop if bleeding. Eliquis 2.5 mg one tablet two times a day for CVA prophylaxis. During a record review of Resident 3's care plan titled The Resident is on Anticoagulant dated on 3/26/2026, the care plan indicated to monitor for any of the following: blood in the urine, blood in the stool, unusual bleeding from shaving, bleeding from the gums, nose, excessive bleeding from the wounds, large hemorrhagic area, petechiae, if I've observed signs and symptoms, hold anticoagulant/antiplatelet dose and notify MD if my initial is N it signifies the absence of listed signs and symptoms. During an interview on 4/26/2026 at 1:53 PM with the Registered Nurse 3 (RN 3), RN 3 stated no monitoring is being done because it is in the care plan, RN 3 stated that she was told not to add a physician order for monitoring because it is in the care plan. During an interview on 4/6/2026 at 1:57 PM with the Director of Nurses (DON), the DON stated that there were no physician orders for monitoring for adverse reactions to anticoagulant/antiplatelet medication stated that the facility removed it from the physician orders because she was told by the facility's nurse consultant that monitoring was not needed as long as they had it in the care plan. During a concurrent record review, the resident's records did not indicate documented evidence that the facility staff had monitored Resident 3 for adverse reactions brought about by the use of anticoagulants such as blood in the urine, blood in the stool, unusual bleeding from shaving, bleeding from the gums, nose, excessive bleeding from the wounds, large hemorrhagic area, petechiae, if I've observed signs and symptoms, hold anticoagulant/antiplatelet dose and notify MD if my initial is N it signifies the absence of listed signs and symptoms. 2. During a review of Resident 40's admission Record (AR), the AR indicated Resident 40 was admitted to the facility on [DATE] with diagnoses which included dementia (a progressive state or decline in mental abilities), Diabetes Mellitus (DM a disorder characterized by difficulty in blood sugar control and poor wound healing), Atrial Fibrillation (heart rhythm disorder where the heart beats irregularly and rapidly). During a review of Resident 40's MDS dated [DATE], the MDS indicated Resident 40's cognition was severely impaired. During a review of Resident 40's Order Summary Report dated 4/28/2026 indicated that on 3/21/2026 the physician order Eliquis 2.5 mg two times a day to prevent deep vein thrombosis (blood clot forms in a vein). During a review of Resident 40's Medication Administration Record dated 3/21/2026 - 4/28//2026 Resident 40 received daily dose of Eliquis. During a review of Resident 40's care plan titled The Resident is on Anticoagulant dated 3/23/2026 indicated to monitor/document/report as necessary adverse reactions of anticoagulant therapy such as blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs, bleeding gums, nosebleed, unusual bruising, fall levels in lab results, fall in blood pressure, and blood clot. During a record review, the resident's records did not indicate documented evidence that the facility staff had monitored Resident 40 with adverse reactions of anticoagulant therapy such as blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs, bleeding gums, nosebleed, unusual bruising, fall levels in lab results, fall in blood pressure, and blood clot, in accordance to the written care plan. 3. During a review of Resident 75's AR, the AR indicated Resident 75 was admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses which included Diabetes Mellitus, kidney failure (kidneys fail to filter waste, regulate blood pressure, and maintain proper red blood cell levels). During a review of Resident 75's MDS dated [DATE] indicated Resident 75's cognition was moderately impaired. During a review of Resident 75's Order Summary Report dated 4/29/2026, the AR indicated Resident 75 on 10/6/2025 had a physician order for Brillinta 60 mg two times a day for Myocardial Infarction (MI - heart attack). On 2/2/2025 Resident 75 had a physician order for Aspirin Delayed Release 81 mg for CVA prophylaxis. During a review of Resident 75's Medication Administration Record dated 2/1/2026 - 4/29/2026 Resident 75 received daily dose of Brillinta. Resident 75 received daily dose of Aspirin 3/7/2026 - 4/30/2026. During a review of Resident 75's care plan titled The Resident is on Antiplatelet Agent dated 11/12/2021 with a revision date on 4/26/2026 indicated to monitor for any of the following: blood in the urine, blood in the stool, unusual bleeding after shaving, bleeding from the gums, bleeding from the nose, excessive bleeding from wounds, large hemorrhagic area, petechiae. Monitor/document/report as necessary adverse reactions of antiplatelet agent such as blood tinged, red blood in the urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in the vital signs. During an observation on 4/26/2026 at 1:04 PM, a large bruise was observed covering the left anterior hand area dark purple in color, Resident 75 stated he probably bumped his hand on the doorway. During an interview on 4/26/2026 at 2:32 PM with RN 3 stated that the bruise on Resident 75's left hand has not been reported to the physician because nursing was not aware of the condition and the need to monitor the resident for bruising or bleeding due to use of antiplatelets. RN 3 stated that the attending Certified Nurse Assistant 5 (CNA 5) assigned to Resident 75 had not reported to the licensed nurses that Resident 75 had a bruise. During a concurrent record review of Resident 75's records, the bruising was not documented anywhere in the resident's records. During an interview on 4/26/2026 at 2:41 PM with CNA 5, CNA 5 stated that she did not report the bruise today because she noticed the bruise three days ago. CNA 5 stated that she reported it to a nurse on Thursday but could not remember who she told to. During an interview on 4/26/2026 at 2:57 PM with the DON and CNA 5. The DON brought in CNA 5 to interview in front of surveyor. CNA 5 stated that she did not report the bruise today because she did not see it today and it must have just happened. The DON stated that she talked to Resident 75 and Resident 75 told the DON that he did not report the hand bruise to anyone. CNA 5 stated that Resident 75 had bruises three days ago. The DON stated that there was no change of condition and physician notification for the bruises observed three days ago. The DON stated that the physician was going to be made aware and that the facility was going to initiate a care plan for the bruising. During a concurrent record review, the resident's records did not indicate documented evidence that the facility staff had monitored Resident 75 with adverse reactions of antiplatelet agent such as blood tinged, red blood in the urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in the vital signs, in accordance to the written care plan. 4. During a review of Resident 65's admission Record (AR), the AR indicated that Resident 65 was admitted on [DATE], with diagnoses that included muscle wasting and atrophy (the wasting or loss of muscle tissue caused by reduced protein and increased degradation), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing). During a review of Resident 65's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 4/7/2026, the MDS indicated that Resident 65 has severely impaired cognition (the ability to process thoughts). During a review of Resident 65's Order Summary Report dated 4/22/2026, the Report indicated a physician order to administer Ondansetron 8 mg every 6 hours as needed for nausea/vomiting for 14 days. The physician order did not indicate the adult maximum dose for Ondasetron by mouth, according to manufacturer's guidelines. During an interview on 4/28/2026 at 11:45 AM with RN 1, RN 1 stated that Resident 65 had vomiting and was administered Ondansetron 8 mg on 4/27/2026 at 9:25 PM and 4/28/2026 at 7:55 AM. RN1 stated that a change of condition was done on Resident 65. Medication dosing review with RN 1 per dosing guidelines for Ondansetron the maximum daily allowance is 24 mg per day. RN 1 stated that she was going to call and verify the dosage with pharmacy. Exceeding 24 mg of Ondansetron per day can lead to severe side effects including cardiac issues. During a concurrent interview and record review of Resident 65's MAR on 4/28/2026 at 12:24 PM with RN 1, RN 1 stated that the physician order for Ondansetron was clarified on 4/28/26 timed at 12:15 PM, with the pharmacist and the physician to administer Ondasetron 8 mg and added the parameter according to guidelines not to exceed dosing 24 mg in 24 hours. During an interview on 4/29/2026 at 9:25 AM with the DON, the DON stated that the dosage for Ondansetron exceeded the recommended dosage and this was a potential for overdosing. During a review of facility's policy and procedure (P&P) titled, High Risk Medications - Anticoagulants revised date 12/19/2022, indicated that anticoagulant medications are associated with greater risks of adverse consequences than other medication. The policy indicates that the residents plan of care shall alert staff to monitor for adverse consequences. During a review of the facility's P&P titled Provider Pharmacy Requirements revised date 1/2025, indicated that the pharmacy will provide medication information and consultation to the facility's nursing staff. During a review of the Mayo Clinic Side effects and dosage of Ondansetron is used to prevent nausea and vomiting that is caused by cancer medicines (chemotherapy) or radiation therapy. It is also used to prevent nausea and vomiting that may occur after surgery. Ondansetron works in the stomach to block the signals to the brain that cause nausea and vomiting. For oral dosage forms (oral disintegrating tablets, solution, or tablets): For prevention of moderate nausea and vomiting after treatment with cancer medicines: Adults and children [AGE] years of age and older-At first, 8 milligrams (mg) taken 30 minutes before starting cancer treatment. The 8-mg dose is taken again 8 hours after the first dose. Then, the dose is 8 mg every 12 hours for 1 to 2 days. Ondansetron (oral route,oromucosal route) - Side effects & dosage - Mayo Clinic.com Document last updated: April 30, 2026

Based on observation, interview and record review, the facility failed to ensure to 2 of 2 sampled residents ( Residents 6 and 62) who required peritoneal dialysis (PD, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed]that uses the lining of the abdomen [peritoneum] as a natural filter to remove waste, toxins, and extra water from the body) receive such services, consistent with professional standards of practice and the Federal and State Department requirements prior to providing PD Services to the residents. The facility failed to: 1.For Resident 6 failed to receive ongoing assessment and oversight before, during, and after PD treatments. In addition, no documentation on the PD logs, MAR (Medication Administration Record, and TAR (Treatment Administration Record) to indicate Resident 6's vital signs, cardiac, respiratory, and skin assessments before, during, and after PD treatments were monitored. 2. For Resident 62's the resident was not assessed for competency for self-administration and self-disconnection of peritoneal dialysis. In addition, the physician order for PD solution was not specific when to administer Dextrose 1.5% (fluid with sugar) or Dextrose 2.5%. to the resident. These deficient practices had the potential for the residents to experience complications related to PD such as infections (peritonitis, catheter exit-site infections), mechanical issues (hernias, dialysate leaks, catheter blockage), and metabolic changes like weight gain or high blood sugar that can lead to hospitalization. Cross reference to F880 Findings: 1.During a review of Resident 6's admission Record (AR), the AR indicated that the facility admitted Resident 6 on 2/24/2026 with diagnoses that included End Stage Renal Disease (ESRD, irreversible kidney failure) and dependence on renal dialysis, During a review of Resident 6's history and physical (H&P), signed and dated on 2/27/2026, the H&P indicated that Resident 6 had the capacity to understand and make decisions. The H&P indicated that Resident 6 was diagnosed with ESRD on PD treatments. During a review of Resident 6's Minimal Data Set (MDS, a resident's assessment), dated 2/27/2026, the MDS indicated that Resident 6's cognitive (a person's thought process) was intact. The MDS indicated that Resident 6's active diagnoses included ESRD, and Resident 6 experienced shortness of breath when lying flat in bed. The MDS indicated that Resident 6 received PD treatments upon admission. During a review of Resident 6's Order Summary Report, an order, dated 2/24/2026, indicated that Resident 6 received PD treatments with Low Calcium 2.5% solution (type of dialysis solution used in PD) five times a day. The treatment started 2/25/2026 and ended 3/3/2026. During a review of Resident 6's care plan, revised 3/2/2026, the care plan indicated that Resident 6 required PD related to ESRD. The care plan's interventions included identifying changes in Resident 6's behavior that may impact PD administration before and after treatment and assessing resident's condition before and after treatments for complications. The care plan's interventions included monitoring and documenting signs and symptoms of renal insufficiency (kidneys no longer filter waste products from blood) such as changes in level of consciousness, skin elasticity, and changes in heart and lung sounds, monitoring and documenting worsening peripheral edema (swelling of arms and legs), and monitoring for bleeding and signs of symptoms of bacteremia (bacteria in the blood) or septic shock (life-threatening infection). During a review of Resident 6's Order Summary Report, an order, dated 4/2/2026, indicated that Resident 6 received PD treatment with 2.5% Dextrose for 5 cycles with a fill volume of 2700 mL. The treatment was prescribed for 9.5 hours and started each evening at 7 PM. The treatment started 4/2/2026. During a review of Resident 6's care plans, revised 3/9/2026, the care plan indicated that Resident had chronic renal failure due to ESRD and dependence on PD. The care plan's interventions included to monitor for changes in mental status such as lethargy, fatigue, tremors, or seizures, to monitor for signs and symptoms of infection, urinary tract infections, and to monitor for neck vein distension (visible bulging of the large veins of the neck due to fluid overload), difficulty breathing, and lung sounds for crackles (abnormal lung sounds). During an observation on 4/25/2026 at 11:19 AM in Resident 6's room, Resident 6 was observed lying in bed and using his phone. There was a white machine with the words Homechoice Claria noted on the screen and Baxter noted on the bottom left of the machine with two antenna-like objects was noted on the left side of Resident 6's bed on top of the bedside table. There was a urinal bottle (portable, handheld plastic container used to collect urine) hanging on the handle of the second drawer of the bedside table. There was a paper towel taped to the handle of the top drawer of the bedside table with the written instructions as follows: At the end of therapy to: Push the down arrow to see I-Drain, total UF [ultrafiltration], average dwell time. Push the down arrow until you see 'Manual Drain' and press the enter button. This will tell machine to drain patient. It will stop when it senses no more fluid left. You might sit patient up to facilitate fluid to drain easier. During the same observation on 4/25/2026 at 11:22 AM in Resident 6's room, on the left side of Resident 6's bed with one opened packet of 4x4 gauze dressing, one opened packet of 2x2 gauze dressing, one open box of gloves, and 2 solutions noted on top of the overbed table (an adjustable and mobile table with lockable wheels designed to slide over a bed or a chair to create a stable surface). One solution was labeled Alcavis, which was a high level disinfectant compatible with catheters, caps, and connections. The second solution was labeled ExSept plus which was an antimicrobial exit site, skin, and wound cleanser. During the same concurrent observation and interview on 4/25/2026 at 11:22 AM in Resident 6's room Resident 6 stated he has been in the facility for almost three months and received home dialysis 7 days a week for 10 hours a day. Resident pointed to the white machine with the words Homechoice Claria on it, and Resident 6 stated that was his PD machine. Resident 6 stated that the nurses from the facility set up and connect his dialysis machine to his PD catheter around 6 PM or 7 PM before he goes to bed, and the nursing staff disconnects his PD catheter from the PD machine around 5 AM the next morning. During an observation on 4/25/2026 at 6:38 PM in Resident 6's room with Licensed Vocational Nurse (LVN) 2, LVN 2 was observed sanitizing and preparing Resident 6's PD machine. LVN 2 was observed using PPE and removing three dialysis solution bags from the boxes inside Resident 6's in-room closet. Resident 6's in-room closet was observed with about 10 boxes of dialysis supply equipment stacked on top of each other. Then LVN 2 connected the PD tubing to the three dialysis solution bags, inserted the PD cassette into the PD machine, and turned on the PD machine. LVN 2 changed her gloves, placed the connected PD drainage tubing on the floor, bringing the open end of the PD drainage tubing into the in-room bathroom, and taped the PD drainage tubing to the toilet to drain. LVN 2 changed her gloves without using hand sanitizer, then the PD machine automatically began to prime the PD cassette and tube and cleaned the PD catheter with the disinfectant solution. Once the PD completed the internal set up, LVN 2 was observed connected the PD tubing to Resident 6's PD catheter and the PD treatment began. During the concurrent interview and record review on 4/25/2026 at 7:30 PM with LVN 2, Resident 6's Skilled Nursing Facility (SNF)-PD Treatment Log, Medication Administration Record (MAR), and Treatment Administration Record (TAR), dated for February, March, and April 2026 were reviewed. LVN 2 stated, there was documentation on the PD logs, MAR, and TAR to continuously monitor Resident 6's vital signs, cardiac, respiratory, and skin assessments before, during, and after PD treatments. During the same concurrent observation and interview on 4/25/2026 at 7:50 PM with LVN 2, in Resident 6's room, Resident 6's in-room closet was observed with 10 boxes on the floor stacked on top of each other. There were LVN 2 stated, Resident 6's PD dialysis solutions and accessories were stored in his closet. LVN 2 stated, Resident 6 did not have any more PD tubing available and hopes that more tubing will come tomorrow. During an observation on 4/26/2026 at 5:34 AM with Registered Nurse (RN) 1 in Resident 6's room, RN 1 was observed recording Resident 6's drainage output total from the PD machine, performing hand hygiene, and removing the PD tubing cassette from the PD machine. RN 1 was observed changing gloves, disconnecting Resident 6's PD catheter from the PD tubing, disinfecting Resident 6's PD catheter before covering the catheter with a sterile white cap and taped gauze over Resident 6's PD catheter site. During a concurrent interview and record review 4/29/2026 at 11:02 AM with Certified Nurse Assistant (CNA) 6, Resident 6's CNA Nutrition – Amount Eaten record, dated for April 2026, was reviewed. CNA 6 stated that there was no separate documentation to monitor the specific amount of liquid intake Resident 6 had at mealtimes. CNA 6 stated, she was not aware that Resident 6 was on fluid restrictions. During a concurrent interview and record review on 4/29/2026 at 11:32 AM with LVN 5, Resident 6's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2026 was reviewed. LVN 5 stated that there was no monitoring documented on the MAR and TAR related to Resident 6's fluid restriction. LVN stated, she was not aware that Resident 6 had any fluid restriction orders. During an interview on 4/29/2026 at 3:15 PM with the Director of Nursing (DON), the DON stated, since Resident 6 was a PD patient, it was important to monitor his fluid intake and verify that he was compliant with the fluid restrictions because he was at risk for fluid overload. During an interview on 4/29/2026 at 3:25 PM with the Director of Nursing (DON), the DON stated, it was important to use hand sanitizer in-between changing gloves while performing PD because the PD exit catheter site was an opening into the body. The DON stated it was important to use hand sanitizer to prevent the spread of infection. During the same interview on 4/29/2026 at 3:28 PM with the DON, the DON stated, it was especially important to perform good hand hygiene when performing PD treatments because the PD catheter exit site was an open surgical site, and improper hand hygiene may lead to infection of the PD catheter exit site or peritonitis. During a concurrent interview and record review on 4/29/2026 at 3:30 PM with the DON, the facility's policy and procedure (P&P) titled Peritoneal Dialysis, dated 12/19/2022, was reviewed. The DON stated, the P&P indicated the facility will assure that each resident receives care and services for the provisions of peritoneal dialysis consistent with professional standards of practice. This will include: the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at the facility, and the ongoing assessment and oversight of the resident before, during, and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation, of appropriate interventions, and using appropriate infection control practices. During the same concurrent interview and record review on 4/19/2026 at 3:40 PM with the DON, Resident 6's MAR and TAR, dated for April 2026, was reviewed. The DON stated, there was no documented evidence of ongoing monitoring for Resident 6's mental status, cardiac status, respiratory status, or skin assessment before, during, or after PD treatments. The DON stated, PD residents required increased oversight and monitoring because they were already clinically unstable prior to PD, and these residents become even more clinically unstable during PD treatments. The DON stated that continuous monitoring was important to see the whole picture of the resident's condition and to identify whether the resident was improving or declining so the staff could intervene appropriately. During a review of the facility's P&P titled Peritoneal Dialysis, dated 12/19/2022, the P&P indicated that before, during, and after receiving the peritoneal dialysis, the facility must, based on the physician's orders and professional standards of care, do the following: 1.obtain vital signs, weights, assess the resident's stability, level of consciousness, and comfort or distress, 2.monitor for post-dialysis complications and symptoms such as, but not limited to dizziness, nausea, fatigue, or hypotension. . 2.During a review of Resident 62's admission Record (AR), the AR indicated the facility admitted Resident 62 on 2/8/2026 and readmitted on [DATE] with diagnoses that include end stage renal disease (ESRD, a condition that the kidneys [an organ that filters waste, excess fluids, and toxins from the blood to create urine] no longer function well enough to meet a body's needs) and infection (the invasion and multiplication of microorganisms in body, causing tissue damage and disease) and inflammatory reaction (body's defense mechanism against harmful stimuli) due to peritoneal dialysis catheter(a tube for PD access). During a review of Resident 62's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 4/22/2026, indicated Resident 62's had no cognitive impairment (ability to understand and make decisions). The MDS indicated Resident 62 was receiving PD. The MDS indicated Resident 62 required partial/moderate assistance with eating, oral hygiene, and substantial/maximal assistance with toileting hygiene, shower/bathe self and chair/bed-to-chair transfer. During a review of Resident 62's Physician Order Summary dated 4/26/2026 indicated that starting 4/17/2026, the resident was to receive peritoneal dialysis (PD) using Extraneal (a dialysis solution used for PD). The physician ordered treatment consisted of five cycles totaling 10.5 hours, with fill volumes of 2000 mL for each cycle and a final fill of 1500 ml. The PD treatment was scheduled to begin at 7 PM and continue until completion During an observation on 4/26/2026 at 6:24 AM in Resident 62's room, Resident 62 disinfected and disconnect her PD catheter from the dialysis machine by herself in the presence of Licensed Vocational Nurse (LVN) 1. During an interview on 4/26/2026 at 6:45 AM with LVN 1, LVN 1 stated Resident 62 disconnected the PD catheter from the dialysis machine after her dialysis cycles completed most of the time and the nurse let the resident do it herself. LVN 1 stated she was endorsed by other nurses that Resident 62 could disconnect herself and the nurse just stayed at bedside to provide assistance as needed. During an interview on 4/26/2026 at 8:38 AM, the Director of Nursing (DON) stated indicated the resident was alert and oriented. The DON reported that Resident 62 informed the facility staff that she performed her peritoneal dialysis (PD) independently at home and knew how to do it, so the facility allowed her to self-administer her PD treatment. The DON stated the facility did not maintain documentation confirming Resident 62 was trained and competent to self-administer or self-disconnect her PD treatment. The DON also stated the facility did not develop a care plan or conduct an IDT meeting to address Resident 62's self-administration and self-disconnection of her PD treatment. During an interview on 4/29/2026 at 2:03 PM with the DON, the DON stated the facility should have assessed the competency of self-administration of PD, developed a care plan, and conduct an interdisciplinary Team (IDT, a structured, collaborative session where healthcare professionals meet regularly to develop and update holistic care plans) meeting with the resident and the IDT and maintain the documentation to ensure safety, prior to allowing Resident 62 to self-administer and self-disconnect her PD treatment. During a review of the facility's P&P titled, Peritoneal Dialysis, dated 12/19/2022, the P&P indicated This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving peritoneal dialysis. The P&P also indicated The facility will identify who is allowed to provide peritoneal dialysis treatments to residents, in accordance with State licensing rules, and The facility will maintain documentation of completion of competency/training for staff or other individuals providing the dialysis treatments. 2. During a concurrent observation and interview on 4/25/2026 at 6:25 PM with LVN 4, LVN 4 indicated that the fluid she administered for PD for Resident 62 was not transcribed to the physicians order and that the administered fluid dextrose 2.5% was the only fluid available for the resident at the time, LVN 4 could not explain when it was indicated to use Dextrose 1.5% or Dextrose 2.5%. During a review of Resident 62's Physician Order Summary dated 4/26/2026 indicated that starting 4/17/2026, the resident was to receive peritoneal dialysis (PD) using Extraneal (a dialysis solution used for PD). The physician ordered treatment consisted of five cycles totaling 10.5 hours, with fill volumes of 2000 mL for each cycle and a final fill of 1500 ml. The PD treatment was scheduled to begin at 7 PM and continue until completion each evening. During a review of Resident 62's PD Treatment Order Form dated 4/16/2026 indicated a PD order for PD 2000 for five cycles total 10.5 hours and last fill volume of 1500 milliliters (ml) with dextrose 1.5% or 2.5% with solution different Extraneal. During an interview on 4/26/2026 at 8:17 AM with Hemodialysis (a type of dialysis that removes toxins and extra fluid in the blood that uses specialized catheter inserted into the vein with the use of machine) Nurse (HDN) stated that the physician order should have included the percentage of the dextrose fluid as well as the indication of when to use Dextrose 1.5% or Dextrose 2.5% per HDN the type of fluid is based on the residents current weight and lab results. HDN stated that the order was incomplete and not completely transcribed to the physician orders. During an interview on 4/29/2026 at 1:45 PM with the Director of Nurses (DON) stated that it is important to transcribe orders correctly to the physician orders to ensure that residents receive the correct order. During a review of the facility's P&P titled, Peritoneal Dialysis, dated 12/19/2022, the P&P indicated This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving peritoneal dialysis. 2b. During an observation on 4/26/2026 at 6:24 AM in Resident 62's room, Resident 62 disinfected and disconnect her PD catheter from the dialysis machine by herself in the presence of Licensed Vocational Nurse (LVN) 1. During an interview on 4/26/2026 at 6:45 AM with LVN 1, LVN 1 stated Resident 62 disconnected the PD catheter from the dialysis machine after her dialysis cycles completed most of the time and the nurse let the resident do it herself. LVN 1 stated she was endorsed by other nurses that Resident 62 could disconnect herself and the nurse just stayed at bedside to provide assistance as needed. During an interview on 4/26/2026 at 8:38 AM, the Director of Nursing (DON) stated indicated the resident was alert and oriented. The DON reported that Resident 62 informed the facility staff that she performed her peritoneal dialysis (PD) independently at home and knew how to do it, so the facility allowed her to self-administer her PD treatment. The DON stated the facility did not maintain documentation confirming Resident 62 was trained and competent to self-administer or self-disconnect her PD treatment. The DON also stated the facility did not develop a care plan or conduct an IDT meeting to address Resident 62's self-administration and self-disconnection of her PD treatment. During an interview on 4/29/2026 at 2:03 PM with the DON, the DON stated the facility should have assessed the competency of self-administration of PD, developed a care plan, and conduct an interdisciplinary Team (IDT, a structured, collaborative session where healthcare professionals meet regularly to develop and update holistic care plans) meeting with the resident and the IDT and maintain the documentation to ensure safety, prior to allowing Resident 62 to self-administer and self-disconnect her PD treatment. During a remote meeting conducted on 4/28/2026 at 11:30 AM with the facility Administrator (ADM), in the presence of the CDPH Program Managers (PMs) and Supervisors, the ADM stated that there were two residents currently residing at the facility who were receiving PD treatment and services. The ADM also stated that the facility's nursing staff assisted these residents with initiating and disconnecting their PD treatments in the facility. During the same interview on 4/28/2026 at 11:35 AM with the ADM, CDPH PM, and Supervisors, the ADM stated that it happened several years ago when he noticed that residents discharged from the hospital had PD or HD. The ADM stated that he believed offering PD was a nice service to offer to help the overall healthcare eco care system. The ADM also stated that he spoke with [Clinic 1], his legal counsel, and his consultants regarding offering PD in the facility. The ADM further stated that it was his understanding that PD [did not] require the same level of requirements as HD. During a review of the facility's P&P titled, Peritoneal Dialysis, dated 12/19/2022, the P&P indicated This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving peritoneal dialysis. The P&P also indicated The facility will identify who is allowed to provide peritoneal dialysis treatments to residents, in accordance with State licensing rules, and The facility will maintain documentation of completion of competency/training for staff or other individuals providing the dialysis treatments. A review of the CDPH AFL titled Updated Guidance for the Provision of Home Dialysis Services in a SNF, revised on 3/8/2021, the AFL indicated that the Centers of Medicare and Medicaid Services (CMS) requires the dialysis facility to notify CDPH of any arrangements and by submitting FORM CMS 3427 End Stage Renal Application and Survey and Certification (PDF) to CDPH. A review of the same CDPH AFL titled Updated Guidance for the Provision of Home Dialysis Services in a SNF, revised on 3/8/2021, the AFL indicated that SNFs seeking to provide peritoneal or hemodialysis services must apply for approval of the optional services. The AFL indicated any SNF seeking to initiate the provision of dialysis services in a SNF must submit a change of application to CDPH's Centralized Application Branch (CAB) to request state approval to add the service to the facility's license. A review of the same CDPH AFL titled Updated Guidance for the Provision of Home Dialysis Services in a SNF, revised on 3/8/2021, the AFL indicated, that the facility must contact the HCAI for certification of the building standards. The AFL indicated that the facility must submit their application and have an onsite survey conducted prior to providing services.

Based on observation, interview, and record review, the facility failed to provide care and services based on Professional Standard of Practice for two of two sampled residents (Residents 38 and 43). The facility failed to: 1.For Resident 38 with diabetes (a condition of having high blood sugar) Registered Nurse (RN) 3 transcribed in a physician order to administered IV (intravenous or administered into the vein) 5% Dextrose Normal Saline (solution with salt and glucose) to the resident without a physician order. This deficient practice had the potential to result in inaccurate treatment and inappropriate IV fluid administration and result in serious complications that included hyperglycemia (high blood glucose levels) fluid overload (the body retaining and unable to remove excess fluids) or need of hospitalization. 2. For Resident 46, who had a foley catheter (a flexible tube used to drain urine from the bladder continuously into a bag) the Treatment Nurse (TXN) reinserted the foley catheter without a physician order after the physician ordered to removed the foley catheter on 4/10/2026. The deficient practice had potential to received unnecessary use of foley catheter. Findings: 1.During an observation on 4/25/2026 at 9:29 AM in Resident 38's room, Resident 38 was observed alone, sleeping in bed with the 5% Dextrose 0.9% Normal Saline was hanging from an IV pole (a metal stand used to hold IV solutions and IV medications) with an unlabeled IV solution bag of 5% Dextrose Normal Saline at a rate of 200 mL/hr infusing into Resident 38's IV catheter site (the specific spot where a small, flexible tube is inserted into the vein to deliver fluids or medication) in her right hand. During a review of Resident 38's admission Record (AR), the AR indicated that the facility admitted on [DATE] and readmitted Resident 38 on 10/9/2025 with diagnoses included Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar), lumbar spinal stenosis (narrowing of the space within the spine causing pressure on the nerves), and chronic viral Hepatitis B (chronic liver infection caused by the hepatitis B virus). During a review of Resident 38's history and physical (H&P), signed and dated 2/23/2026, the H&P indicated that Resident 38 did not have the capacity to understand and make decisions. During a review of Resident 38's Minimal Data Set (MDS, a resident assessment tool), dated 2/26/2026, the MDS indicated that Resident 38's cognitive (a resident's thought process) skills were severely impaired. The MDS indicated that Resident 38's active diagnoses included DM. During a review of Resident 38's Weight and Vitals Summary report, dated from 4/1/2026 to 4/30/2026, the report indicated on 4/25/2026 timed at 7:35 AM, Resident 38's blood pressure was 86/50 mmHg. During a review of Resident 38's telephone order (TO, a verbal order prescribed by a physician or other authorized prescribing provider and transcribed by a nurse or other authorized personnel), dated 4/25/2026 timed at 8 AM, the TO indicated that Physician 1 ordered IV 5% Dextrose in Normal Saline (solution with salt and glucose) at 50 milliliters per hour (mL/hr, rate of infusion) for three days for low blood pressure. During a review of Resident 38's electronic physician orders, dated 4/25/2026 timed at 9:45 AM, the physician's order indicated that Physician 1 ordered IV 5% Dextrose in Normal Saline at 50 mL/hr for low blood pressure and poor intake for 3 days. During a review of Resident 38's electronic physician orders, another order was entered dated 4/25/2026 timed at 10:45 AM, the physician's order indicated Physician 1 ordered to administer IV 45% Sodium Chloride Solution (solution with salt) at 50 mL/hr for low blood pressure and poor oral intake. During a concurrent interview and record review conducted on 4/26/2026 at 3:10 PM with Registered Nurse (RN) 1, Resident 38's electronic Active Orders were reviewed. RN 1 stated that the telephone (TO) order had been written by RN 3. RN 1 further stated that she electronically transcribed the TO order, dated 4/25/2026, and backdated the time to 8:00 AM for the 5% Dextrose Normal Saline at 50 mL/hr as indicated in the TO order written by RN 3. RN 1 stated she entered this order into Resident 38's electronic medical record on 4/25/2026 at 9:45 AM. During the same concurrent interview and record review on 4/26/2026 at 3:15 PM with RN 1, Resident 38's electronic Active Orders, was reviewed. RN 1 stated, she received the phone call from Physician 1 for the order of 45% Normal Saline solution at 50 mL/hr. RN 1 stated, she disconnected the 5% Dextrose Normal Saline solution and administered the IV 45% Normal Saline solution ordered by Physician 1 to Resident 38. During a concurrent interview and record review on 4/26/2026 at 3:24 PM with RN 3, RN 3 reported that on 4/25/2026 at 8 AM, she observed Resident 38 was more drowsy than usual and decided to proactively start IV fluids without notifying Physician 1 first before initiating the IV therapy. RN 3 stated she wrote the telephone order herself and timed it at 8 AM to reflect when she began the IV. RN 3 stated she selected the IV 5% Dextrose in Normal Saline because Resident 38 was diabetic, and she believed dextrose-containing fluids typically raise blood pressure more quickly. RN 3 stated that after initiating the IV therapy, she called Physician 1's office and left a voicemail to notify Physician 1 of Resident 38's change of condition. RN 3 stated she did not document Resident 38's change in condition of low blood pressure and poor intake in the resident's records on 4/25/2026. During an interview on 4/28/2026 at 9:30 AM with Physician 1, Physician 1 stated he did not prescribe IV solutions of 5% Dextrose Normal Saline at a rate of 200 mL/hr to be administered to Resident 38. Physician 1 stated, if the [licensed] nurses see a change of condition [in a resident], he expected the nurses to call me and notify me first. Physician 1 stated, he did not know why the 5% Dextrose Normal Saline Solution was administered to Resident 38 because Resident 38 was a known diabetic resident. Physician 1 stated, the 5% Dextrose Normal Saline Solution would increase her blood glucose levels but he did not know by how much Resident 38's blood glucose levels would had increased because her blood glucose levels were not checked before or after the 5% Dextrose Normal Saline Solution was infused. During an interview on 4/28/2026 at 1:55 PM with the Director of Nursing (DON), the DON stated, RN 3 should not have administered the IV fluids without physician orders. The DON stated, it was nursing standards for RN 3 to notify Physician 1 of Resident 38's change in condition and to follow the physician's recommendation prior to initiating treatment. During a review of the facility's policies and procedures (P&P) titled Intravenous Therapy, dated 12/19/2022, the P&P indicated that a physician's order is obtained before starting IV therapy. During a review of the facility's P&P titled Medication Administration, dated 12/19/2022, the P&P indicated that medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician. During a review of the same facility's P&P titled Notification of Changes, dated 12/19/2022, the P&P indicated that circumstances that require notification include significant changes in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental, or psychosocial status. During a review of the facility's P&P titled Documentation in Medical Record, dated 12/19/2022, the P&P indicated that the principles of documentation included that false information shall not be documented and to record descriptive and objective information based on first-hand knowledge of the assessment, observation, or service provided. During a review the same facility's P&P titled Documentation in Medical Record, dated 12/19/2022, the P&P indicated that the documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. The P&P indicated that documentation shall be timely and in chronological order, and record date and time of entry. During a review of the California Nursing Practice Act, as codified in the Business and Professions Code and [NAME] Regulations, Registered Nurses (RNs) do not have authority to prescribe medications—their role is limited to administering medications and therapeutic agents only under the order of an authorized prescriber. During a review of the facility's job description titled Registered Nurse, date unknown, the job description indicated that the Registered Nurse's major duties and responsibilities included observing for changes in residents' status, notifying the physician and resident's family or representative and documenting accordingly. During a review of the same facility's job description titled Registered Nurse, date unknown, the job description indicated that the Registered Nurse's major duties and administrations included transcribing physician orders to medical record and carries out orders as written, and preparing and administering medication as per physicians' orders and observes for adverse effects. 2. During a review of Resident 46's admission Record (AR), the AR indicated the facility admitted Resident 46 on 3/22/2026 with diagnoses that include urinary tract infection (UTI, an infection in any part of the urinary system (organs that produce and release urine, caused by bacteria) and Parkinson's disease (a progressive condition that affects movement). During a review of Resident 46's MDS, dated [DATE], the MDS indicated Resident 46's had moderately impaired cognition (ability to understand and make decisions) and memory. The MDS indicated Resident 46 required partial/moderate assistance with eating, oral hygiene and personal hygiene, and was dependent on toileting hygiene, shower/bathe self and chair/bed-to-chair transfer. During a review of Resident 46's Order Summary Report, dated 4/26/2026, the report indicated the physician ordered to insert a Foley catheter on 4/1/2026. During a review of Resident 46's Physician's Order (PO), dated 4/7/2026, the PO indicated the physician ordered to discontinue Foley catheter on 4/10/2026 at 7 AM, then, obtain a bladder scan (a quick, painless, and non-invasive procedure used to measure the volume of urine in the bladder [an organ that hold urine], assessing how well it empties) every eight hours, if residual was greater than 250 milliliter (ML, a measurement unit), then, do in and out catheterization (a single-use, flexible tube inserted into the urethra to empty the bladder and then removed immediately). During a review of Resident 46's Change in Condition Evaluation (COC), dated 4/10/2026 timed at 9:30 AM, the COC indicated Resident 46's Foley catheter was discontinued per physician's order. The COC indicated the physician's recommendation was to monitor for urine output. Bladder scan, if residual is >250 ml do in and out catheter. During a concurrent observation and interview on 4/25/2026 at 1:23 PM, Resident 46 was lying on the bed with a Foley drainage bag hanging on the bed frame. Resident 46 stated she had a Foley catheter inserted for urination. During a concurrent interview and record review on 4/26/2026 at 11:33 AM with Licensed Vocational Nurse (LVN) 3, Resident 46's medical record was reviewed. LVN 3 stated there was an order to discontinue Resident 46's Foley catheter on 4/10/2026 and her Foley catheter was discontinued on 4/10/20206, but she currently has Foley catheter again. LVN 3 stated there was no documentation recording that physician ordered the re-insertion of foley catheter. LVN 3 stated it was confusing to the nurses what order to follow. During a concurrent interview and record review on 4/26/2026 at 12:04 PM with the Treatment Nurse (TXN), Resident 46's Physician Orders, dated 4/1/2026 to 4/26/2026, were reviewed. The TXN stated there was no documentation of a physician order to re insert a Foley catheter after Resident 46's Foley catheter was removed on 4/10/2026. The TXN stated the Foley catheter was removed on the morning of 4/10/2026, but three hours later the resident reported she was unable to void and requested that the Foley catheter be re inserted, so the TXN re inserted a Foley catheter. The TXN stated Resident 46 had a Foley catheter in place prior to the removal on 4/10/2026, and the facility staff were aware of Resident 46's condition; therefore, she felt they did not need a new physician order for re insertion of the Foley catheter on 4/10/2026. During an interview on 4/29/2026 at 1:43 PM with the Director of Nursing (DON), the DON stated that if a resident's Foley catheter was discontinued, the nurse should obtain a new physician order prior to re insertion. The DON stated the nurse who obtained the physician order for the re insertion of Resident 46's Foley catheter on 4/10/2026 did not transcribe the order into Resident 46's medical record. The DON stated it was a nursing standard of practice to transcribe all physician orders into the resident's medical record to ensure accurate documentation and to ensure the resident received consistent care while in the facility. During a review of the facility's policy and procedure (P&P) titled, Appropriate Use of Indwelling Catheters, dated 12/19/2022, the P&P indicated The use of an indwelling urinary catheter will be in accordance with physician orders. During a review of the facility's policy and procedure (P&P) titled, Registered Nurse Job Description, dated 2023, the P&P indicated registered nurse's major duties and responsibilities including transcribing physician orders to medical record. During a review of the facility's P&P titled, Licensed Vocational Nurse Job Description, dated 2023, the P&P indicated licensed vocational nurse's major duties and responsibilities including transcribing physician orders to medical record.

Based on observation, interview and record review, the facility failed to ensure call light was within reach for five of five sampled residents (Resident 46, . The deficient practices had potential for Resident 46 not being able to call the facility staff to ask for help or assistance, especially during emergencies. During a review of Resident 46's admission Record (AR), the AR indicated the facility admitted Resident 46 on 3/22/2026 with diagnoses that included displaced fracture of base of neck of right femur (right hip fracture) and Parkinson's disease (a progressive condition that affects movement). During a review of Resident 46's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 3/26/2026, indicated Resident 46's had moderately impaired cognition (ability to understand and make decisions) and memory. The MDS indicated Resident 46 required partial/moderate assistance with eating, oral hygiene and personal hygiene, and was dependent on toileting hygiene, shower/bathe self and chair/bed-to-chair transfer. During a concurrent observation and interview on 4/25/2026 at 1:20 PM, Resident 46 was in her room with the door closed, making her not visible from the hallway. Resident 46 was sitting in bed with the head of the bed elevated more than 60 degrees. Resident 46 stated she needed a tissue but could not reach it, and she was unable to call staff because she did not know where her call light was. The call light cord was observed hanging over the headboard, out of her reach. During a concurrent observation and interview on 4/25/2026 at 1:21 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated she forgot to put Resident 46's call light within the resident's reach after she showered her in the morning. CNA 1 stated it was important to keep the call light within residents' reach to ensure they get the help they needed. During an interview on 4/292026 at 1:49 PM with the Director of Nursing (DON), the DON stated the call light should be within residents' reach at all times to ensure their needs were met and their safety. During a review of the facility's Policy and Procedure (P&P) titled, Call lights: Accessibility and Timely Response, dated 12/19/2022, the P&P indicated The call system will be accessible to residents while in their bed .within the resident's room.

Based on interview and record review, the facility failed to ensure that the arbitration agreement (AA, a written contract where parties agree to settle disputes privately through a neutral third party [an arbitrator] rather than in a public courtroom) was adequately explained so the resident or their responsible party (RP) could understand its terms for one of three sampled residents (Resident 65) by failing to inform Resident 65's RP that he had 30 days after signing to fully review the agreement and rescind any agreement if it was not understood at the time of admission. This deficient practice has the potential to affect Resident 65's and the resident's RP's right to make informed decisions and choices about important aspects of the resident's health, safety and welfare. Findings: During a review of Resident 65's admission Record (AR), the AR indicated that Resident 65 was admitted on [DATE], and Resident 65's RP was Family Member (FM 1). The AR indicated that Resident 65 was admitted with diagnoses that included encephalopathy (a temporary brain dysfunction caused by a chemical imbalance in the body). During a review of Resident's 65 History and Physical Examination (H&P), dated 4/4/2026, the H&P indicated that Resident 65 does not have the capacity to understand and make decisions. During a review of Resident 65's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 4/7/2026, the MDS indicated that Resident 65 has severely impaired cognition (the ability to process thoughts). The MDS indicated that Resident 65 was dependent (helper does all the effort) in toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, and needed substantial/maximal assistance in personal hygiene, upper body dressing, oral hygiene, and eating. During a review of Resident 65's Arbitration Agreement (AA), dated 4/9/2026, the AA indicated that FM 1 signed the agreement. During an interview on 4/29/2026 at 10:50 AM with FM 1, FM 1 stated that he signed the AA but did not receive a copy of the AA. FM 1 stated that the facility did not inform him that the AA was not required for admission and that he could rescind within 30 days after signing it. FM 1 stated that he thought that it was part of the admission agreement. During an interview on 4/29/2025 at 12:35 PM with Business Office Assistant (BOA 1), BOA 1 stated that he explains to the residents and their RPs that the AA is a [NAME] who decides the outcome instead of a jury (a group of ordinary people chosen from the community to hear evidence during a trial and decide the truth). BOA 1 stated that they (the resident and RP) normally understand and BOA 1 did not have to explain further. BOA 1 stated he did not know and did not inform the residents and their RPs that the AA can be rescinded within 30 days. During an interview on 4/29/2026 at 12:39 PM with the Business Office Manager (BOM), the BOM stated that BOA 1 is expected to explain the purpose of the AA, inform residents and their RPs that signing the AA is optional and not required for admission, and clarify that they have 30 days to change their mind and cancel the agreement. The BOM stated that she was not aware that BOA 1 did not know that the AA could be rescinded within 30 days. The BOM added that it is important for BOA 1 to be knowledgeable when explaining the AA to the residents or their RPs, so they fully understand what they are signing. During a review of the facility's policy and procedure (P&P) titled Binding Arbitration Agreement revised 12/19/2022, the P&P indicated that when explaining arbitration agreement, the facility shall explicitly inform the resident of his or her representative of his or her right not to sign the agreement as a condition of admission or that is a requirement to receive care at the facility.

Based on observation, interview, and record review, the facility failed to ensure to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, sufficient fluid intake to maintain proper hydration and health to two of two sampled residents (Residents 6 and 65) by failing to: 1.For Resident 65, who has had weight loss, the staff failed to monitor and document the percentage of intake of nourishments/snacks to indicate if the snacks were consumed or not as ordered by the physician and recommended by the Registered Dietician. 2.For Resident 6, who required peritoneal dialysis (PD, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) was not monitored to restrict fluid intake to 1500 milliliters (mL, unit of measure) as indicated in the Nutritional Assessment on 3/3/2026. These failures had the potential to place Resident 6 and Resident 65 to be at risk for altered nutritional or hydration status which may lead to severe dehydration or fluid overload which may result in a hypotensive (low blood pressure) or hypertensive (high blood pressure) blood pressure emergency, edema (swelling), shortness of breath, heart failure (heart cannot effectively pump blood to the rest of the body), unplanned weight loss or gain and may lead to hospitalization. Cross Reference with F698 Findings: 1.During a review of Resident 65's admission Record (AR), the AR indicated that Resident 65 was admitted on [DATE], with diagnoses that included muscle wasting and atrophy (the wasting or loss of muscle tissue caused by reduced protein and increased degradation), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), and protein-calorie malnutrition (a condition caused by not eating enough food [calories] and protein to meet the body's needs). During a review of Resident 65's care plan (CP) titled The Resident Has Nutritional Problem dated 4/5/2026, the CP indicated the CP interventions for staff to provide, serve Resident 65 diet as ordered, monitor and record the resident's intake after every meal, and for the Registered Dietitian (RD) to evaluate and make diet change recommendations as necessary. During a review of Resident 65's Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 4/7/2026, the MDS indicated that Resident 65 has severely impaired cognition (the ability to process thoughts). The MDS indicated that Resident 65 was dependent (helper does all the effort) in toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, and needed substantial/maximal assistance in personal hygiene, upper body dressing, oral hygiene, and eating. During a review of Resident 65's weight record for April 2026, the record indicated Resident 65 weighed 125 pounds (lbs., unit of weight) on 4/3/2026, and 122 lbs. on 4/24/2026, indicating that Resident 65 lost 3 lbs. in weight (2.4 % weigh loss) in 22 calendar days. During a record review of Resident 65's Order Summary Report (OSR), indicated a physician order on 4/15/2026 for Resident 65 to have dietary supplement snack two times a day between meals. During a review of Resident 65's Nutrition Nourishment intake documentation regarding the intake of snacks two separate occasions were documented given by Certified Nurse Assistants on 4/10/2026 and 4/21/2026. (documented by CNAs/RNAs) During an interview on 4/27/2026 at 9:32 AM with Registered Nurse 1 (RN 1), RN 1 stated that the weight loss of 3 lbs. was not reported to the physician because they still have another week to monitor weight loss and that it was also not reported to the Registered Dietitian. RN 1 stated that she does not know why the Certified Nurse Assistants (CNA's), Restorative Nurse Assistants (RNA's) are not recording the percentage intake of the snacks. During an interview on 4/27/2026 at 10:32 AM with CNA 6 stated that they do not document the percentage of intake of nourishments/snacks. During record review, there was no documented evidence that Resident 65's percentage intake for nourishments/snacks was monitored and documented. During an interview on 4/27/2026 at 10:34 AM with CNA 7 stated that CNAs do not document the percentage of intake or snacks stated that the CNA's do not give them to the residents stated the RNAs are the ones that give them to the residents. During an interview on 4/27/2026 at 10:36 AM RNA 1 stated that the RNAs are the ones responsible to pass out the snacks to the residents but do no document the intake. RNA 1 stated that most residents don't even like the snacks. RNA 1 stated that they do not report to the License Nurses when residents don't like or refuse snacks. During a record review of Resident 65's Dietary Preference, dated 4/27/2026 timed at 10:52 AM, the RD wrote that she interviewed Resident 65 and Resident 65 stated that he would like to have health shakes with his meals and fortified foods to help him not to lose weight. During an interview on 4/28/2026 at 2:42 PM with RD 1, RD 1 stated that her expectation is to be made aware when a resident is refusing or does not like snack. RD 1 stated that she expects nursing to be aware of the amount of intake of the snack. RD 1 stated that she needs to be made aware of issues with the snacks for early intervention. During an interview on 4/29/2026 at 9:18 AM with Director of Nurses (DON), DON stated that the expectation that staff assist residents with snacks and if not consuming to let nursing know with the purpose to prevent weight loss. DON stated that the CNA should document the amount of intake of the snack. During a review of the facility's policy and procedure (P&P) titled Weight Management Policy revised date 11/1/2024 indicated that the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as body weight. Interventions will be monitored and modified as appropriate consistent with choices, preferences, goals to maintain acceptable parameters of nutritional status. 2.During a review of Resident 6's admission Record (AR), the AR indicated that the facility admitted Resident 6 on 2/24/2026 with diagnoses that included End Stage Renal Disease (ESRD, irreversible kidney failure) and dependence on renal dialysis. During a review of Resident 6's history and physical (H&P), signed and dated on 2/27/2026, the H&P indicated that Resident 6 had the capacity to understand and make decisions. The H&P indicated that Resident 6 was diagnosed with ESRD on PD treatments. During a review of Resident 6's Minimal Data Set (MDS, a resident's assessment), dated 2/27/2026, the MDS indicated that Resident 6's cognitive (a person's thought process) was intact. The MDS indicated that Resident 6's active diagnoses included ESRD, and Resident 6 experienced shortness of breath when lying flat in bed. The MDS indicated that Resident 6 received PD treatments upon admission. During a review of Resident 6's care plan, revised 3/2/2026, the care plan indicated that Resident 6 needed PD related to ESRD. The care plan's interventions included a fluid restriction of 1500mL, with nursing providing 780 mL of fluids and dietary providing 720 mL and monitoring his intake and output. During a review of Resident 6's Nutritional Assessment record, dated 3/3/2026, the record indicated that Registered Dietitian (RD) indicated Resident 6's fluid restriction of 1500 mL each day. During a review of Resident 6's Order Summary Report, an order, dated 3/5/2026, indicated that Resident 6 had a fluid restriction of 1500 mL. The order indicated that Resident 6's total nursing fluid amount was 780 mL and total dietary fluid amount was 720 mL with meals. During a review of Resident 6's Order Summary Report, an order, dated 4/2/2026, indicated that Resident 6 received PD treatment with 2.5% Dextrose for 5 cycles with a fill volume of 2700 mL. The treatment was prescribed for 9.5 hours and started each evening at 7 PM. The treatment started 4/2/2026. During a concurrent observation and interview on 4/25/2026 at 11:19 AM in Resident 6's room, Resident 6 was observed lying in bed and his water pitcher and cup on top of his overbed table (portable table with lockable wheels designed to slide over the bed or chair) on the right side of his bed. Resident 6 stated that he receives PD 10 hours a day, 7 days a week in the facility. Resident 6 stated that he was able to drink 1000 mL to 2000 mL of fluids a day. Resident 6 stated, he does not know how much liquids he drinks and only takes sips here and there really. During an interview on 4/28/2026 at 2:55 PM with RD 1, RD 1 stated that residents with fluid restrictions were expected to be monitored by nursing. RD 1 stated that nursing was aware of the total fluid intake per day calculation done by the RD. RD 1 stated, it was important for nursing to know the fluid intake of the resident and to verify that the resident was compliant with the fluid restrictions. RD 1 stated that if a resident was not compliant with the fluid restrictions, the resident was at risk for complications such as fluid retention and fluid overload. During a concurrent interview and record review 4/29/2026 at 11:02 AM with Certified Nurse Assistant (CNA) 6, Resident 6's CNA Nutrition – Amount Eaten record, dated for April 2026, was reviewed. CNA 6 stated, the only documentation to monitor for Resident 6's food and liquid intake collectively was in the CNA Nutrition – Amount Eaten record. CNA 6 stated that there was no separate documentation to monitor the specific amount of liquid intake Resident 6 had at mealtimes. CNA 6 stated, she was not aware that Resident 6 was on fluid restrictions. During a concurrent interview and record review on 4/29/2026 at 11:32 AM with Licensed Vocational Nurse (LVN) 5, Resident 6's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2026 was reviewed. LVN 5 stated that there was no monitoring on the MAR and TAR related to Resident 6's fluid restriction. LVN 5 stated, Resident 6 was able to drink as much fluid as he wanted. LVN 5 stated, she was not aware that Resident 6 had any fluid restriction orders. During an interview on 4/29/2026 at 3:15 PM with the Director of Nursing (DON), the DON stated, since Resident 6 was a PD patient, it was important to monitor his fluid intake and verify that he was compliant with the fluid restrictions. The DON stated, if a resident was not compliant with the fluid intake, the resident was at risk for fluid overload. During the same concurrent interview and record review on 4/29/2026 at 3:20 PM with the DON, Resident 6's MAR and TAR, dated for April 2026, was reviewed. The DON stated that there was no monitoring of Resident 6's fluid intake by nursing. During a review of the facility's policies and procedures (P&P) titled Fluid Restrictions, dated 12/19/2022, the P&P indicated that it is the policy of this facility to ensure that fluid restrictions will be followed in accordance with physician's orders. The P&P indicated that the restriction of fluids may be due to underlying medical conditions that may cause fluid build-up such as ESRD and electrolyte imbalance disorders. During a review of the same facility's P&P titled Fluid Restrictions, dated 12/19/2022, the P&P indicated that the fluid restriction distribution will take into consideration the amount of fluid to be given at mealtimes, snacks, and medication passes. The P&P indicated that water will not be provided at bedside unless calculated into the daily total fluid

Based on observation, interview and record review, the facility failed to store drugs and destruct biologicals in accordance with the facility's policy and procedure titled Medication Storage and Destruction of Unused Drugs when unknown white medication tablet was found on the floor in one of the two medication rooms. This deficient practice resulted in unsafe storage of the medication and had the potential to result in medication errors and misuse. During an observation Medication Room (MR) and concurrent interview with Licensed Vocational Nurse (LVN) 2 on [DATE] at 5:22 AM, a white round unknown medication tablet was found on the floor. LVN 2 stated she did not know what medication it was and why the tablet was on the floor. LVN 2 stated nurses should check the MRs for any loose tablets and discard medication tablet into the Medication Disposable bin to prevent medication errors. During an interview on [DATE] at 1:46 PM with the Director of Nursing (DON), the DON stated that nurses are required to check the medication rooms each shift to ensure no loose medications are present. The DON explained that any loose or unknown tablets found on the floor should be discarded in the Medication Disposal bin for distraction according to facility's policy to prevent contamination and medication errors. During a review of the facility's policy and procedure (P&P) titled, Medication Storage, dated [DATE], the P&P indicated the facility to ensure all medications housed on the premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. During a review of the facility's P&P titled, Destruction of Unused Drugs, dated [DATE], the P&P indicated All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations. The P&P also indicated Unused, unwanted and non-returnable medications should be removed from their storage area and secured until destroyed.

Based on observation, interview, and record review, the facility failed to maintain or enhanced a resident's dignity, in accordance with the facility's policy and procedure titled Promoting/Maintaining Resident Dignity, for two of six sampled residents (Residents 1 and 49) by failing to: 1.Cover Resident 1's urinary collection bag (a bag where urine drains from the bladder) with a privacy bag. 2.Provide privacy to Resident 49 while being assisted after a shower. Resident 49 was left in a shower chair with no clothes or covering from the waist down in the middle of her room while the door was open exposed to the facility hallway. These deficient practices had the potential for lowering the resident's self-esteem and self-worth. Findings: 1.During a review of Resident 1's admission Record (AR), the AR indicated that Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with included diagnoses of Dementia (a progressive stated of decline in mental abilities), lack of coordination, anxiety disorder. During a review of Resident 1's Medical Summary dated 1/28/2026, the Summary indicated that Resident 1 has atonic bladder status post suprapubic catheter. During a review of Resident 1's Minimum Data Set (MDS – a federally mandated resident assessment tool) dated on 2/9/2026, the MDS indicated that Resident 1 has moderately impaired cognition (the ability to process thoughts). During a review of Resident 1's Order Summary Report dated 4/28/2026. The Report indicated Resident 1 had a physician order dated 3/6/2026 to maintain suprapubic catheter size 16, change for blockage, leaking, pulled out, excessive sedimentation, and change catheter drainage bag as needed. During a concurrent observation and interview on 4/25/2026 at10:21 AM, Resident 1 was observed sitting on the side of his bed with an indwelling catheter with the drainage bag hanging on the side of his right-side bed rail without a privacy bag. Resident 1 did not answer when asked if he was comfortable exposing his urinary drainage bag. Resident answered with other past life stories when asked questions. During an interview on 4/28/2026 at 11:24 AM with Treatment Nurse (TXN), TXN stated that all staff are responsible to ensure that a dignity bag is covering the urinary bag unless the resident refuses the dignity bag. TXN unsure why Resident 1 did not have a dignity bag present. During an interview on 4/29/2026 at 9:00 AM with Director of Nurses (DON) stated that residents with a foley bag should have a dignity bag unless they refused as well as a basin underneath it to protect the bag from touching the floor. 2. During a review of Resident 49's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including cirrhosis of liver (a condition in which a liver stops functioning normally), fronto-temporal neurocognitive disorder (a mental health condition characterized by abnormal shrinkage in two parts of the brain). During a review of Resident 49's History and Physical (H&P), dated 1/27/2025, the H&P indicated Resident 49 does not have the capacity to understand and make decisions. During a review of Resident 49's Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 1/29/2026, the MDS indicated Resident 49 requires maximal assistance (helper does more than half the effort, helper lifts, holds, or support). During an observation on 4/25/2026 at 8:30 AM in Resident 49's room, Resident 49 was observed sitting in the shower in the middle of the room chair wearing no clothes or cover from the waist down. Resident 49's bedroom door was open. During an interview and concurrent observation on 4/25/2026 at 8:32 AM with Certified Nursing Assistant (CNA8), CNA 8 stated she was Resident 49's CNA that morning and was in the middle of dressing Resident 49 when the RN supervisor told her to go assist another resident in the restroom. CNA 8 stated she left and forgot to cover Resident 49 before leaving. During an interview on 4/28/2026 at 2:35 PM with the Director of Nursing (DON), the DON stated facility nurses should never [NAME] a resident undressed and exposed in the middle of the room. The DON stated doing this violates a resident's dignity and right to privacy. During a review of the facility's policy and procedure (P&P) titled, Promoting/Maintaining Resident Dignity , with a revision date of 12/19/2022, the P&P indicated It is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances residents quality of life by recognizing each resident's individuality.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure titled, Call Lights: Accessibility and Timely Response for three out of six sampled residents (Resident 1) to ensure that the residents had the call system within reach and were able to use it if desired. This deficient practice placed the residents at risk of not having their needs met timely, especially during an emergency or accident. Findings: 1. During a review of Resident 65's admission Record (AR), the AR indicated that Resident 65 was admitted on [DATE], with diagnoses that included muscle wasting and atrophy (the wasting or loss of muscle tissue caused by reduced protein and increased degradation), and chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing). During a review of Resident 65's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 4/7/2026, the MDS indicated that Resident 65 has severely impaired cognition (the ability to process thoughts). The MDS also indicated that Resident 65 was dependent (helper does all the effort) in toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, and needed substantial/maximal assistance in personal hygiene, upper body dressing, oral hygiene, and eating. During a review of Resident 65's care plan (CP) with the focus on ADL (Activities of Daily Living, the basic tasks that people do every day to take care of themselves) Function, dated 4/20/2026, the care plan included the intervention for staff to keep call light within easy reach of Resident 65. During an observation on 4/25/2026 at 9:27 AM, a call light was hanging on the side of Resident 65's roommate's bed, which was not reachable to Resident 65 the call light was hanging on the wall behind the roommate's bed. During an interview on 4/26/2026 at 12:53 PM with Certified Nurse Assistant (CNA 2), CNA 2 stated Resident 65 is able to use his call light. CNA 2 stated CNA 2 has been busy and did not realize that the call light was out of Resident 65's reach. b. During a review of Resident 3's AR, the AR indicated that Resident 3 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide) with hypoxia (low levels of oxygen), cachexia (loss of muscle and fat), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 3's MDS dated on 3/27/2026, the MDS indicated that Resident 3 has severely impaired cognition (the ability to process thoughts). The MDS also indicated that Resident 3 was dependent (helper does all the effort) in personal hygiene, putting on and off footwear, lower body dressing, upper body dressing, shower/bathe self, toileting hygiene, oral hygiene. During a review of Resident 3's CP with the focus on ADL Function, dated 4/9/2026, the CP included the intervention for staff to keep the call light within easy reach of the resident. During an observation on 4/25/2026 at 10:17 AM, Resident 3's call light was on the floor near the resident's oxygen concentrator. During an interview on 4/26/2026 at 11:25 AM with CNA 3, CNA 3 stated that it is important to have the call light within the reach of the resident to be able to assist the resident with their needs. c. During a review of Resident 1's AR, the AR indicated that Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included dementia (a progressive stated of decline in mental abilities), lack of coordination, anxiety disorder (mental health conditions involving excessive, uncontrollable, and persistent fear or worry that interferes with daily life). During a review of Resident 1's MDS dated [DATE], the MDS indicated that Resident 1 has moderately impaired cognition (the ability to process thoughts), the MDS also indicated that Resident 1 was dependent (helper does all the effort) in putting on/taking off footwear, lower and upper body dressing, shower/bathe self, toileting hygiene, oral hygiene, eating. During an observation on 4/25/2026 at 10:21 AM, Resident 1's call light was covered under the resident's blanket and was hanging off the side of the bed nearly touching the floor unreachable to Resident 1. During an interview on 4/29/2026 at 9:03 AM with CNA 8, CNA 8 stated that the call light must always be within reach with the purpose to assist resident. CNA 8 stated that not having the call light within reach can potentially cause an injury such as a fall. During an interview on 4/29/2026 at 1:52 PM with the Director of Nurses (DON) stated that the call light must be within residents reach and answered timely to prevent potential falls or injury. During a review of facility's policy and procedures (P&P) titled Promoting/Maintaining Resident Dignity indicated that it is the practice of the facility to protect and promote residents' rights and treat each resident with respect. Staff are required to respond to residents' request for assistance in a timely manner. During a review of facility's policy and procedure (P&P) titled Call lights: Accessibility and Timely Response dated 12/29/2022, indicated that staff will be educated on the proper use of the resident call light system, ensuring resident access to the call light. Staff will ensure that the call light is within reach of resident and securely position.

Based on observation, interview, and record review, the facility failed to inform Physician 1 of the significant change in condition of one of three sample residents (Resident 38) on the morning of 4/25/2025 when Registered Nurse (RN) 3 assessed Resident 38, diagnosed with Diabetes Mellitus [DM, a disorder characterized by difficulty in blood sugar control and poor wound healing], with a blood pressure (the force blood pushes against the arteries; normal reading is 120/80 milliliters of mercury [mmHg, unit of measure]) of 85/50 mmHg and was drowsier than usual and RN 3 administered IV (Intravenous or administered into the vein) 5% Dextrose Normal Saline (solution with salt and glucose) without the physician's order. This deficient practice resulted in Resident 38 receiving 5% Dextrose Normal Saline for 1 hour at a rate of 200 milliliters per hour (mL/hr, unit of rate) without a physician's order. This deficient practice had the potential to result in Resident 38 experiencing worsening hyperglycemia (high blood sugar levels), edema (swelling), and electrolyte imbalance, and fluid overload that could lead to hospitalization. Cross Reference with F757 Findings: During a review of Resident 38's admission Record (AR), the AR indicated that the facility admitted on [DATE] and readmitted Resident 38 on 10/9/2025 with diagnoses included Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar), lumbar spinal stenosis (narrowing of the space within the spine causing pressure on the nerves), and chronic viral Hepatitis B (chronic liver infection caused by the hepatitis B virus). During a review of Resident 38's history and physical (H&P), signed and dated 2/23/2026, the H&P indicated that Resident 38 did not have the capacity to understand and make decisions. During a review of Resident 38's Minimal Data Set (MDS, a resident assessment tool), dated 2/26/2026, the MDS indicated that Resident 38's cognitive (a resident's thought process) skills were severely impaired. The MDS indicated that Resident 38 required maximal assistance (helper does more than half the effort) for activities of daily living (ADLs, activities such as bathing, dressing, and toileting a person performs daily) such as eating and oral hygiene, and required maximal assistance for mobility such as transfers from lying to sitting at the edge of the bed and transferring from sitting to standing position. The MDS indicated that Resident 38's active diagnoses included DM. During a review of Resident 38's Weight and Vitals Summary report, dated from 4/1/2026 to 4/30/2026, the report indicated on 4/25/2026 timed at 7:35 AM, Resident 38's blood pressure was 86/50 mmHg. During a review of Resident 38's telephone order (TO, a verbal order prescribed by a physician or other authorized prescribing provider and transcribed by nurse or other authorized personnel), dated 4/25/2026 timed at 8 AM, the TO indicated that Physician 1 ordered IV 5% Dextrose Normal Saline (solution with salt and glucose) at 50 milliliters per hour (mL/hr, rate of infusion) for three days for low blood pressure. During an observation on 4/25/2026 at 9:29 AM in Resident 38's room, Resident 38 was observed sleeping in bed with the 5% Dextrose 0.9% Normal Saline was hanging from an IV pole (a metal stand used to hold IV solutions and IV medications) with an unlabeled IV solution bag of 5% Dextrose Normal Saline at a rate of 200 mL/hr infusing into Resident 38's IV catheter site (the specific spot where a small, flexible tube is inserted into the vein to deliver fluids or medication) in her right hand. During a concurrent interview and record review on 4/26/2026 at 3:24 PM with RN 3 , RN 3 reported that on 4/25/2026 at 8 AM, she observed Resident 38 drowsier than usual and decided to proactively start IV fluids without notifying Physician 1 before initiating the IV therapy. RN 3 wrote the telephone order herself and timed it at 8 AM to reflect when she began the IV. RN 3 stated she selected 5% Dextrose in Normal Saline because Resident 38 was diabetic, and she believed dextrose-containing fluids typically raise blood pressure more quickly. During an interview on 4/28/2026 at 9:30 AM with Physician 1, Physician 1 stated he did not prescribe IV solutions of 5% Dextrose Normal Saline at a rate of 200 mL/hr to be administered to Resident 38. Physician 1 stated, if the nurses see a change of condition [in a resident], he expected the nurses to call me and notify me first. During an interview on 4/28/2026 at 1:55 PM with the Director of Nursing (DON), the DON stated, RN 3 did not notify Physician 1of Resident 38's change of condition before starting the IV solutions. The DON stated that Physician 1 needed to be aware of Resident 38's change of condition in order to prescribe the most appropriate intervention for Resident 38. During a review of the facility's policies and procedures (P&P) titled Notification of Changes, dated 12/19/2022, the P&P indicated that the facility must inform the resident, consult the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. During a review of the same facility's P&P titled Notification of Changes, dated 12/19/2022, the P&P indicated that circumstances that require notification include significant changes in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental, or psychosocial status. During a review of the facility's job description titled Registered Nurse, date unknown, the job description indicated that the Registered Nurse's major duties and responsibilities included observing for changes in residents' status, notifying the physician and resident's family or representative and documenting accordingly.

Based on interview and closed record review, the facility failed to ensure the required Notice of Proposed Transfer/Discharge (a written notification to the resident or responsible party (RP) was fully completed and sent to the Long Term Care Ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities) for two of two sampled residents (Resident 7 and Resident 101). The required notice, which provides written information to the resident or responsible party regarding the reason for the transfer or discharge, was not completed in full before being sent to the Ombudsman. This deficient practice failed to ensure the residents' rights to have the Long Term Care Ombudsman notified and able to advocate on behalf of Resident 7 and Resident 101 regarding their proposed transfer/discharge. Findings: 1 During a review of Resident 7's admission Record (AR), the AR indicated that the facility admitted Resident 7 on 9/5/2022 and readmitted Resident 7 on 4/5/2026 with diagnoses that included sepsis (a life threatening blood infection), acute respiratory failure (condition where the lungs cannot supply oxygen-rich blood to the body) with hypoxia (condition where the body tissues do not have enough oxygen rich-blood, and Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar). During a review of Resident 7's history and physical (HP), signed and dated 4/7/2026, the HP indicated that Resident 7 did not have the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS), dated [DATE], the MDS indicated that Resident 7's cognitive skills (a resident's thought process) were severely impaired. The MDS also indicated that Resident 7 was dependent (the helper performs all of the effort) for activities of daily living (ADLs) and functional mobility, including repositioning in bed and transferring from bed/chair to chair. During a concurrent interview and record review on 4/28/2026 at 9:30 AM with the Medical Records Director (MRD), Resident 7's Notice of Transfer/Discharge, dated 3/9/2026, was reviewed. The MRD stated the record indicated Resident 7 was transferred/discharged because Resident 7's health had improved sufficiently such that he no longer required the services provided by the facility. The MRD stated the record showed that Resident 7 was transferred on 3/6/2026 to a General Acute Care Hospital (GACH). During the same concurrent interview and record review on 4/28/2026 at 9:32 AM with the MRD, Resident 7's SBAR (Situation, Background, Assessment, Recommendation, a communication tool used by healthcare workers when there is a change of condition among the residents) record, dated 3/9/2026, was reviewed. The MRD stated that the SBAR record indicated that Resident 7 had a change of condition that required him to be transferred to the GACH via 911. During the same concurrent interview and record review on 4/28/2026 at 9:34 AM with the MRD, Resident 7's Notice of Transfer/Discharge, dated 3/9/2026, was reviewed. The MRD stated the record did not indicate the appropriate reason for Resident 7's transfer to the GACH. The MRD stated it was important to document the most appropriate reason for transfer/discharge so that the Ombudsman would be accurately informed of Resident 7's location. The MRD stated Resident 7 experienced a change of condition that could not be managed by the facility and therefore required transfer to a higher level of care. During a concurrent interview and record review on 4/28/2026 at 9:40 AM with Registered Nurse (RN) 2, Resident 7's Notice of Transfer/Discharge, dated 3/9/2026, was reviewed. RN 2 stated she was the licensed nurse who completed the document. RN 2 stated she did not select the correct reason for Resident 7's transfer to the GACH. RN 2 acknowledged that the Ombudsman was not accurately informed of Resident 7's reason for transfer. During a review of the facility's policies and procedures (P&P) titled Transfer and Discharge (including AMA), dated 12/19/2022, the P&P indicated that the facility's transfer/discharge notice will be provided to the resident and the RP and will provide the specific reason and basis for transfer or discharge. 2.During a review of Resident 101's admission Record (AC), the AC indicated the resident was originally admitted to the facility on [DATE], with diagnoses that included pancytopenia (abnormally low amounts of all three types of blood cells), heart failure (a condition in which the heart muscle can't pump enough blood). During a review of Resident 101's Order Summary Report dated 3/12/2026, the Order Summary Report indicated an order for: May discharge on [DATE]. Request ultra-light wheelchair, 3 in 1 commode with home health with an order date of 2/13/2026 timed at 12:11 PM. During a review of Resident 101's facility provided document Transmission of verification report of Resident 101's Notice of Transfer/Discharge, the document indicated it was faxed to the Ombudsman on 2/13/2026. The document did not indicate the reason for Resident 101's transfer/discharge. During an interview and record review on 4/26/2026 at 1:10 PM with Medical Record Director (MRD) of Resident 101's Notice of Transfer/discharge date d 2/13/2026, the MRD stated when a resident was transferred or discharged the facility must send a completed copy of the Transfer/ Discharge form to the ombudsman with the reason for Resident 101's discharge/transfer and keep a copy of the fax confirmation as part of their medical records. The MRD stated she had not noticed the copy the facility had sent to the ombudsman was not filled out and did not include a reason why Resident 101 was discharged from the facility. During a review of the facility's policy and procedure (P&P) titled Transfer and Discharge (Including AMA), dated with a revision 12/19/ 2022, the P&P indicated The facility's transfer/discharge notice will be provided to the resident and the resident representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided A. The specific reason and basis for transfer or discharge. The P&P further stated, The notice must be provided to the resident, resident representative and Long-Term Care Ombudsman as soon as practicable before the transfer or discharge.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food production practices were implemented by failing to: Dispose of one sandwich, with a use by date of 2/23/26, stored in the facility's refrigerator in the conference room. Ensure kitchen towels used to wipe food contact surfaces were stored in the sanitizer solution bucket and ensure hair nets were readily available in the conference room where food was served. Ensure temperature of Time/Temperature control for safety food (TCS foods that can support bacterial growth that can result in food borne illness unless stored, prepared and served safely) foods were not above 41 degrees Fahrenheit (F). The temperature of milk held for cold storage served during lunch service was measured at 52.5F. 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 food borne illnesses in 89 out of 93 residents who received food from the facility. Findings: During an observation in the conference room on 2/24/2026 at 10:30 AM there was one turkey sandwich with date 2/22/26 -2/23/2026 stored within reach inside the refrigerator. During an interview with the Dietary Supervisor (DS) on 2/24/2026 at 11:05 AM, DS stated that sandwiches were prepared the day before and served the next day. DS stated if the sandwich was not served by the use by date, the sandwich was discarded. The DS stated the turkey sandwich observed in the conference room refrigerator was expired and should be discarded. DS stated the upstairs conference room was the temporary food serving area since the elevator was not working. During a review of the facility's policy and procedures (P&P) titled Food Safety and Food Storage the P&P indicated, Refrigerated storage -Practices to maintain safe refrigerated storage include: iv. Labeling, dating and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by-date, or frozen/discarded. During a review of the 2022 U.S. Food and Drug Administration Food Code titled Ready to Eat, Time/Temperature control for safety food, Date Marking Code#3-501.17, indicated, Ready to eat, time temperature control for safety food prepared and packaged by food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed, sold, or discarded. 2. During an observation of the tray line (a system of food preparation, in which trays move along an assembly line) for lunch service, located in the upstairs conference room on 2/24/206 at 11:30AM, there was no hair net available to wear. During a concurrent observation and interview with DS, the DS stated that staff had hair nets on already from the kitchen located in the basement, and then went to the conference room, wearing the same hair net to serve food. The DS stated that the conference room was a temporary food serving area and that there should be hair nets readily available in the conference room instead of leaving the premises to go and obtain a hair net in the kitchen located in the basement. The DS stated hair nets are important, so food does not get contaminated with hair. During the same observation in the conference room at 11:40 AM, [NAME] 1 was observed wiping food contact surfaces with a kitchen towel, then stored the kitchen towel on the counter. During a concurrent observation and interview with [NAME] 1 on 2/24/2026 at 11:40 AM, [NAME] 1 stated, kitchen towels should be stored in a sanitizer solution when not in use. [NAME] 1 stated the kitchen towel was from the kitchen and they do not have a sanitizer solution in the conference room to store the towels. [NAME] 1 stated it is important to clean the counters with kitchen cloth and sanitizer because it sanitizes the counters so there is no contamination. During an interview with DS on 2/24/2026 at 11:45 AM, DS stated a sanitizer solution bucket should be in the conference room. DS stated the sanitizer solution bucket was left in the kitchen. DS returned with sanitizer solution in a red bucket. During the same interview with DS on 2/24/2026 at 11:50 AM, the DS stated kitchen staff could not check the sanitizer solution since there were no sanitizer strips in the conference room, therefore staff could not tell if the sanitizer solution was effective. DS stated it was important to have the sanitizer solution test strips to monitor the effectiveness of the sanitizer and to make sure food contact surfaces are sanitized. During a review of facility's P&P titled, Food Safety and Food Storage, revised 11/2024, the P&P indicated, staff shall adhere to safe hygienic practices to prevent contamination of foods from hands on physical objects. Dietary staff must wear hair restraints (e.g. hairnet, hat and or beard restraint) to prevent hair form contacting food. During a review of facility P&P titled, Sanitizer use concentrations for food service and food production facilities, revised 4/2020, the P&P indicated, sanitation buckets must be established with appropriate sanitizing solution.sanitizing cloths should be placed in the sanitizing buckets to be used for sanitizing all work surfaces and equipment. Dietary should change these buckets at least 3 times a day and test with the appropriate test strips each time the solution is changed to ensure accurate levels of sanitizer.Some corporations require red sanitizing buckets. A review of the 2022 U.S. Food and Drug Administration Food Code, Code 3-304.14 Wiping Cloths, use Limitation, indicated, (B) Cloths in-use for wiping counters and other EQUIPMENT surfaces shall be:(1) Held between uses in a chemical sanitizer solution at a concentration specified under S 4-501.114; 3. During an observation of the lunch service in the conference room on 2/24/2026 at 11:30 AM, a temperatures check of the milk was conducted using the facility's thermometer. The obtained temperature registered the milk temperature at 52.5 degrees Fahrenheit (F). During a concurrent observation and interview with DS and dietary aide (DA) 1, DA 1 stated the beverages were stored in the freezer in the kitchen to ensure they were very cold when brought up to the conference room. DS stated the conference room gets warm during meal service and temperatures of cold beverage did not stay at 41degrees F or lower. DS stated there was no ice in the conference room to store the beverages on ice before meal services. DS stated if room temperature milk was served to residents, residents would complain, and if milk was left out too long, the milk would go bad. During a review of the facility's P&P titled food Safety and Food Storage, revised 11/2024, the P&P indicated, when preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce or eliminate potential hazards.Holding - staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained. Staff shall refer to the current FDA Food Code. Foods and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger zone. During a review of the 2022 U.S. Food and Drug Administration Food Code 3-501.16 titled Time/Temperature control for safety food, hot and cold holding indicated, except during preparation, cooking or cooling, time/temperature control for safety food shall be maintained at 135degrees F or above, and at 41 degrees F or below.

Based on observation, interview and record review the facility failed to ensure a QA/QAPI (Quality Assurance/Quality Assurance and Performance improvement, a date driven proactive approach to improvement used to ensure services are meeting quality standards) plan was developed on how to monitored interventions put in place related to the inoperable elevator from and to the kitchen and food service in the conference room by failing to: 1. Safe and sanitary food storage and distribution practices in the conference room. 2. Staff received ongoing training and evaluations of their skills and knowledge to ensure safe food receipt and delivery procedure, safe and sanitary food distribution to residents and reduced risk of injury. 3.Food items were received and handled in a safe and sanitary manner from suppliers. This deficient practice had the potential for unsanitary and unsafe food storage and distribution practices that can result in food poisoning or foodborne illnesses (gastrointestinal infection due to consumption of contaminated food with toxins from bacteria, virus or parasites). Cross reference to F812 and F921Findings: During a concurrent observation and interview with Assistant Administrator (AADM) and Maintenance Supervisor (MS) on 2/24/2026 at 10:30AM, The facility conference room was used as a food distribution and serving area. During a concurrent interview with AADM and MS on 2/24/2026, AADM stated that the elevator has been broken since the last quarter of 2024. AADM stated kitchen is in the basement and food is being delivered by staff through the stairwell and into the conference room. During the same observation in the conference room on 2/24/2026 at 10:30AM there was one sandwich with a date of 2/22/26- 2/23/2026 expired stored in the reach in refrigerator. During an observation in the kitchen located in the basement on 2/24/2026 at 11:00AM, Dietary Aide (DA1) was carrying beverages including juices and milk in cups on a tray up the stairs. During a concurrent observation and interview with Dietary Supervisor (DS) on 2/24/2026 at 11:05AM, DS stated elevator broke down in October 2024 and since then, they have been using the stairwell to carry food and receive the deliveries that are left in the parking lot. DS stated during this time only one staff member was injured, DS stated no in-service related to fall injuries and fall prevention were provided. During an observation in the basement on 2/24/2026 at 11:08AM Cook1 and DA2 are taking large pans of food upstairs. During an observation in the conference room for lunch service on 2/24/2026 at 11:30AM, Food and beverages temperatures were checked using facility thermometer. The temperature of the cold beverage apple juice was 46.9 degrees Fahrenheit ( F). The temperature of the milk was 52.5 F. During a concurrent observation and interview with DS on 2/24/2026 at 11:30AM, DS stated the conference room is warm during service time, there is no ice in the conference room to store the beverages while serving. DS stated cold food and beverages should have a temperature of 41 F degrees and below. During a concurrent observation and interview with DA3 and DS in the basement on 2/24/2026 at 1:00 PM DS stated food and supplies are delivered 2-3 times week. DS stated the food delivery vendors used to bring all the food deliveries through the elevator to the kitchen. DS stated that now food vendors leave the food in the parking lot and kitchen staff bring it to the basement using the stairwell. During an interview with the Administrator (ADM) on 2/26/2026 at 10:30AM, the ADM stated the facility meets monthly for the QA meeting and since the elevator broke on 10/2024, the QA meeting has discussed the replacement of the elevator. The ADM stated the committee talks about the elevator outage during QA meetings but could not show me documentation that they had a performance improvement project or have been monitoring the sanitation and infection control in the upstairs conference room where food is being served. The ADM stated they take every injury seriously but have not implemented routine ongoing training to assess skills and risk of injury of staff who transport food through the stairwell. ADM stated it is very important to monitor the new procedures to make sure if the temporary food service system needs improvement or change. The ADM stated elevator repair takes a long time and it is a slow approval process, also to monitor data of different quality measures takes time and they have not done it as part of their QAPI. During an interview with Dietary Supervisor (DS) on 2/26/2026 at 11:30AM, DS stated facility Registered Dietitian does a monthly sanitation audit in the kitchen which includes making sure food is stored safely, and staff are following good hygiene practices. DS stated the monthly audit does not include the conference room where food is temporarily being served due to the elevator outage. DS stated staff are not routinely trained in injury risk prevention while delivering food through the stairwell. DS stated while we make sure delivered food items that are cold and perishable are brought downstairs to the kitchen and stored first; we have not established a monitoring and audit system to make sure cold food stays cold during delivery. During a review of facility policy and procedures (P&P) titled, Quality Assessment and Assurance Committee (dated 12/19/2022), the p&p indicated, the facility will maintain a quality Assessment and Assurance (QAA) committee to identify quality issues and develop appropriate plans of action to correct quality deficiencies thought an interdisciplinary approach. The committee will: c: identify and respond to quality deficiencies thought the facility; d: develop and implement corrective plans of action and monitor to ensure performance goals or targets are achieved and sustained; e: Revise corrective action as necessary, based on QAA committee monitoring and evaluation.

Based on observation, interview and record review, facility failed to maintain safe and functional environment by ensuring the elevator from the kitchen was maintained in functioning condition to maintain sanitary and safe food service for all residents in the facility and staffs. As a result, resident food was carried by the staff from basement through the stairwell, food distribution and service is relocated to the conference room, food vendors leave food deliveries in the parking lot to be carried by kitchen staff through the stairwell. This deficient practice had the potential to result in unsafe and unsanitary food storage and distribution practice and place staff at risk of injuries.Findings: During a concurrent observation and interview with Assistant Administrator (AADM) and Maintenance Supervisor (MS) on 2/24/2026 at 10:30AM, the facility conference room was being used by the facility as a food distribution and serving area for the residents. During the same observation on 2/24/2026 at 10:30AM, in the conference room, there was a steam table (used to hold precooked food at safe temperatures >135 degrees F; has multiple stainless-steel compartments (wells) that use heated water to produce steam and keep food warm), a plate warmer, one refrigerator (vertical commercial refrigerator with a from opening doors) meal carts (carts with shelves to transport food) and a fan. During a concurrent interview with AADM and MS on 2/24/2026 at 10:40 AM, the AADM stated that the elevator has been broken since last quarter of 2024. AADM stated the kitchen was in the basement and food was being delivered by staff through the stairwell and into the conference room. AADM stated the facility have tried different places and different methods to serve food, and the conference room has been the location that works out the best to serve food for the residents. AADM stated food delivery service has been relocated to the conference room to set up the trays, because the elevator was not working and the kitchen is in the basement. During the same interview on 2/24/2026 at 10:40 AM, the MS stated before the elevator broke in 2024, there were problems with the elevator, and the repair company was always providing maintenance. The MS stated, the repair company informed the facility that the elevator should be replaced. MS stated after 10/2024 no repair was done for this elevator. MS stated has copies of all the repairs reports from the elevator repair company. During an observation in the kitchen located in the basement on 2/24/2026 at 11:00AM, Dietary Aide (DA1) was carrying beverages including juices and milk in cups set up on a tray up the stairs. Observed DA1 going up and down stairs 4 times to deliver the trays of beverages. DA1 was observed breathing fast and observed sweat on forehead, face and neck. During a concurrent observation and interview with DA1 on 2/24/2026 at 11AM, DA1 acknowledged being warm and sweating from going up and down the stairs. During a concurrent observation and interview with Dietary Supervisor (DS) on 2/24/2026 at 11:05AM, DS stated elevator broke down in October 2024 and since then, the facility have been using the stairwell to carry food and receive food deliveries from vendors. DS stated during this time one staff member was injured, DS stated the facility had not provided in-services related to safety in deliver food and prevent fall injuries and fall prevention. During an observation in the basement on 2/24/2026 at 11:08AM Cook1 and DA2 are taking large pans of food via stairway to the conference room upstairs. During an observation in the conference room for lunch service on 2/24/2026 at 11:30AM, Food and beverages temperatures were checked using facility thermometer. The temperature of the cold beverage apple juice was 46.9 degrees Fahrenheit ( F)The temperature of the milk was 52.5 F. During a concurrent observation and interview with DS on 2/24/2026 at 11:30AM, DS stated the conference room is warm during service time, there was no ice in the conference room to store the beverages while serving. DS stated cold food and beverages should have a temperature of 41 F and below during holding time (hold time-time when food is stored before and during service). During a concurrent observation and interview with DA3 and DS in the basement on 2/24/2026 at 1:00 PM DS stated food and supplies are delivered 2-3 times week. DS stated the food delivery vendors used to bring all the food deliveries through the elevator to the kitchen. DS stated that now food vendors leave the food in the parking lot and kitchen staff bring it to the basement using the stairwell. During a concurrent interview with DA3 on 2/24/2026 at 1:00PM, DA3 states after food vendor delivers the food in the parking lot, DA3 brings the perishable food such as milk and dairy products first to the kitchen. DA3 states takes 3 gallons of milk at a time and brings it down the stairs to the kitchen. DA3 states takes 2 hours to bring supplies when working alone. DA3 states when dairy products left outside for long time, they can go bad. During an interview with ADM on 2/26/2026 at 10:30AM ADM stated they tried to fix the elevator several times, but then it was not repairable and needed to be replaced. ADM stated they did not try to repair it further since they were told by elevator repair company that it needed to be replaced. ADM stated the elevator failed in October 2024. ADM stated notified HCAI (department of healthcare access and information) on 10/2025 of the elevator replacement project but did not notify the district office of the existing inoperable elevator. During a review of a report from the elevator company titled Maintenance Time Ticket dated 4/4/2024 the maintenance report indicated, recommend replacing oil, cleaning valves, change [NAME], packing and doing 5-year load test During a review of the Maintenance Time Ticket dated 5/23/24, 7/26/24; 7/31/24; 8/2/2024 report did not indicate the recommended services from previous months were done. During a review of the Maintenance Time Ticket dated 8/21/2024 indicated, report due emergency alarm bell not working found broken wire replaced and checked return to service. During a review of the Maintenance Time Ticket dated 9/9/2024 indicated a routine maintenance was completed. There is no other maintenance completed on the elevator after 9/9/2024. During a review of facility Program Flexibility request dated 2/23/2026, the program flexibility indicated, A temporary meal staging area has been established in the upstairs conference room to support service during the elevator outage. During a review of the 2022 U.S. Food and Drug Administration Food Code 3-501.16 titled Time/Temperature control for safety food, hot and cold holding indicated, except during preparation, cooking or cooling, time/temperature control for safety food shall be maintained at 135degrees F or above, and at 41 degrees F or below. During a review of facility policy and procedure(P&P) titled, Food safety and Food Storage (revised 11/2024) the P&P indicated, When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards. Holding: staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained. During a review of facility policy and procedure(P&P) titled, Food safety and Food Storage (revised 11/2024) the P&P indicated, Foods and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the danger zone. Strategies include Timely distribution of all meals/snacks. During a review of facility policy and procedure(P&P) titled, Food safety and Food Storage (revised 11/2024) the P&P indicated, refrigerated storage-foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. During a review of facility policy and procedures titled Receiving Food and Supplies (revised 2/2019) the policy and procedure indicated, Food items should be received and handled in accordance with good sanitary practice. Keep cold food at room temperature for a minimum length of time. Do not allow cold foods to rise greater than 41degrees F or frozen foods to thaw.

Based on interview and record review, the facility failed to provide the necessary diabetic care and services for one of three sampled residents (Resident 1), who had a diagnosis of type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control), by failing to coordinate services for diabetic care and management for Resident 1 that included checking blood sugar with an accu-check machine (checking blood sugar level with the use of a machine, by pricking the finger and collecting a small blood sample on a test strip, which would be read by the machine) in accordance with Physician 1's H&P treatment plan. This deficient practice resulted in Resident 1 experiencing hyperglycemia (a condition where there's too much glucose in the blood) placing Resident 1 at risk for various serious complications, in ketoacidosis (DKA, a complication of diabetes in which acids build up in the blood to levels that can be life-threatening), dehydration (a condition occurs when the body loses more fluids than it takes in, leading to an insufficient amount of water for normal bodily functions), confusion (a state of reduced awareness and impaired thinking) and coma (a state of prolonged unconsciousness where a person is alive but unresponsive to their surroundings). Cross reference to F656, F726, F756.Findings: During a review of Resident 1's GACH 1's Lab (prior to admission to the facility), dated 7/10/2025, the Lab report indicated Resident 1's hemoglobin A1C (HA1C, a blood test that reflects average blood sugar levels over the past two to three months) was 7.1, which was higher than the normal range. During a review of Resident 1's GACH 1's Nursing Narrative Note, dated 7/10/2025, the Note indicated the nurse notified Physician 1 the result of HA1C and Physician 1 ordered metformin (a medication used to treat Type 2 DM) 500 milligrams (MG, a unit of measurement) twice a day. During a review of Resident 1's GACH 1's Orders, dated 7/10/2025, the Orders indicated Physician 1 ordered metformin 500 MG one table orally twice per day before meals on 7/10/2025. During a review of Resident 1's General Acute Care Hospital (GACH) 1's Medication Tasks-Scheduled (MT), dated 7/11/2025 to 7/14/2025, the MT indicated Resident 1 received metformin 500 MG one table orally twice per day before meals from 7/11/2025 and 7/14/2025. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnosis of type 2 diabetes with hyperglycemia. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/18/2025, indicated Resident 1 had severely impaired cognitive (ability to think and reason) skills for daily decision making was moderately impaired memory and cognition (ability to think and reasonably). During a review of Resident 1's H&P, dated 7/15/2025 indicated Physician 1's plan was for Accu-check daily, continue DM meds. During a review of Resident 1's care plan titled, The resident has diabetes mellitus, initiated on 7/15/2025, the care plan goals indicated the following: The resident will be free from signs and symptoms of hyperglycemia. The resident will be free from signs and symptoms of hypoglycemia (low blood sugar). The resident will have no complications related to diabetes. The care plan's interventions included the following: Diabetes medications as ordered by doctor. Monitor/document/report as needed for any signs and symptoms of hyperglycemia. Monitor/document/report as needed for any signs and symptoms of hypoglycemia. During a review of Resident 1's Medication Administration Record (MAR), from July 2025-August 2025, indicated Resident 1 did not get daily accu-check and did not receive any diabetes medication from 7/14/2025 to 8/8/2025. During a review of Resident's SBAR, dated 7/22/2025 at 2:52 PM, the SBAR indicated Resident 1 had weight loss of six pounds per week related to edema decreased and the physician recommended Complete Blood Count (CBC, a common blood test that analyzes the three main types of blood cells), Comprehensive Metabolic Panel (CMP, a blood test that measures 14 different substances in the blood that includes blood sugar level), lipid panel ( a blood test that measures different types of fats in the blood), and thyroid-stimulating hormone (TSH, a blood test to check thyroid [a gland that regulating energy, growth and organ function] function) During a review of Resident 1's laboratory CMP result dated collection date dated 7/23/2025 indicated Resident 1's blood sugar level was 289 milligram per deciliter (MG/DL, a unit of measurement) which was high according to reference range (70-110 MG/DL). During a review of Resident 1's Situation, Background, Appearance, Review and Notify Communication Form (SBAR, a form to communicate about a resident's change of condition), dated 8/9/2025 at 9:50 AM, the SBAR indicated Resident 1 complained about weakness and not feeling well. The SBAR indicated the resident's blood sugar was at 557 milligram per deciliter (MG/DL, a unit of measurement). The SBAR indicated the physician ordered regular insulin with sliding scale and metformin. During a review of Resident 1's MAR, dated 8/9/2025 at 11:30 AM, Resident 1's blood sugar level was 358 mg/dl and Insulin Regular (a medicine that helps the body use or store the blood sugar) was administered to Resident 1 per sliding scale. During a review of Resident 1's Order Summary Report, dated 8/11/2025, the report indicated the physician ordered for the resident to receive Regular insulin injection subcutaneously as per sliding scale, starting on 8/9/2025 and Lantus (a brand name for insulin) 10 unit injection subcutaneously in the morning for DM, starting on 8/11/2025. During an interview with RN 3 on 8/13/2025 at 2:25 PM, RN 3 stated she texted a picture and faxed Resident 1's laboratory results to Physician 1 on 7/23/2025, but did not inform Physician 1 that Resident 1 was not on a routine (daily) accu-check and was not on any diabetes medications or management for the blood sugar levels. During an interview with the Director of Nursing (DON) on 8/13/2025 at 4:15 PM, the DON stated Resident 1's H&P indicated Physician 1's plan was to perform Accu-check daily, continue DM meds. The DON stated there was no order of daily accu-check and diabetes medications for Resident 1 from 7/14/2025 to 8/9/2025, and the MRD did not inform the nursing staff that the H&P was available for review when she put it in the resident's paper chart. The DON further stated the nurses did not review the H&P and did not know the physician's treatment plan for the resident which was to perform daily accu-check monitoring and for the resident to receive diabetic medications. The DON stated the MRD should have informed the nurses the H&P was available, so the nurse could review it timely. The DON stated if the nurses reviewed the H&P timely, then, the nurse should have clarified with the physician to get the orders for accu-check and diabetes medications to prevent the resident from experiencing hyperglycemia. During a concurrent interview and record review on 8/14/2025 at 1:08 PM with MDSN 1, Resident 1's H&P, dated 7/15/2025, was reviewed. MDSN 1 stated Resident 1's H&P was not reviewed during the IDT meeting on 7/24/2025. MDSN 1 stated they should have reviewed and discuss the H&P during IDT, so they would notice the orders for accu-check daily and diabetes medication were missing and notified the physician for clarification. During an interview on 8/14/2025 at 4:05 PM with Physician 1, Physician 1 stated he was informed and made aware by nursing staff of Resident 1's blood sugar level at 289 mg/dl, on 7/23/2025, but the nurse did not inform him that the resident was not on any diabetes medications. Physician 1 stated if he knew Resident 1 was not on any diabetes medications, he would have ordered for the resident to have daily accu-check and diabetes medications to treat his DM. During an interview on 8/15/2025 at 4:39 PM with the DON, the DON stated the nurses should review Resident 1's H&P and orders to make sure the physician's treatment plan and orders were consistent, and the nurse should notify the physician when there was a discrepancy between the treatment plan and the orders. The DON stated if the nurses reviewed the H&P, they would have been able to notice the discrepancy and obtain the orders for accu-check and diabetes medications earlier. During an interview on 8/15/2025 at 4:41 PM with the DON, the DON stated when the nurse reported Resident 1's abnormal blood sugar level to the physician on 7/23/2025, the nurse should check the resident's regular blood sugar level and what diabetes medications Resident 1 was taking, and provide the pertinent information to the resident's physician to better manage the resident's blood sugar level, but the nurse did not notify the physician that there was no daily accu-check and diabetes medications for Resident 1 who had a diagnosis of DM and his blood sugar was high, as result, there was lack of communication and coordination between nursing staff and physician notification to ensure appropriate diabetic care and services were provided to the resident. During a review of the facility's policy and procedure (P&P) titled, Provision of Quality of Care, revised 12/19/2022, the P&P indicated the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices, Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being, and A comprehensive care plan will be developed for each resident in accordance with procedures for development of the care plan. During a review of the facility's P&P titled, Nursing Care of the Resident with Diabetes Mellitus, revised 12/9/2025, the P&P indicated the facility to help the resident control his/her diabetes with diet, exercise, and insulin (as ordered), prevent recurrent hyperglycemia/hypoglycemia, recognize, manage, and document the treatment of complications commonly associated with diabetes. The P&P indicated glucose monitoring as the management of individuals with DM should follow relevant protocols and guidelines, including physician to order the frequency of glucose monitoring, monitoring resident's blood sugar with accu-check. The P&P indicated HA1C should be less than seven in a diabetic individual. The P&P also indicated medication management of type II diabetes may include oral hypoglycemic agents (medication that can lower the blood sugar level) with or without insulin. During a review of the facility's P&P titled, Registered Nurse-Job Description, dated 2023, the P&P indicated the RN participates in the admission of residents as required, observes for changes in residents ‘status, notifying the physician and resident's family or representative and documenting accordingly, transcribes physician orders to medical record and carries out orders as written, collaborates with other members of the interdisciplinary team as needed to ensure residents' needs are holistically met, initiates, reviews and updates care plans as required.

Based on interview, and record review, the facility failed to provide the necessary respiratory care and interventions in accordance with the resident's respiratory care needs, care plan, facility policy and professional standards of practice, the physician's order and facility's policy and procedure for one of three closed record sampled residents (Resident 98) diagnosed of acute respiratory failure with hypoxia (a life-threatening condition where the lungs fail to deliver enough oxygen to the blood, leading to dangerously low oxygen levels in the body), chronic obstructive pulmonary disease exacerbation (worsened COPD, sudden severe symptoms of a lung disease characterized by poor airflow to the lungs that results in shortness of breath, difficulty breathing and respiratory distress) and pulmonary hypertension [a condition characterized by high blood pressure (BP, the measurement of the pressure or force of blood inside the blood vessels) in the arteries of the lungs which makes the heart work harder to pump blood through the narrowed or damaged blood vessels in the lungs that causes shortness of breath and difficulty breathing] by failing to: 1. Monitor Resident 98 for respiratory distress (life-threatening condition that causes severe difficulty breathing. It occurs when the lungs become inflamed and damaged, making it difficult for oxygen to reach the bloodstream) and change in respiratory condition, in accordance with the resident's care plan for COPD and physician orders, when Certified Nurse Assistant (CNA) 1 found Resident 98 with weakness, labored breathing, and an oxygen saturation (blood oxygen level) of 88% (normal range ,d+[DATE]%) while receiving oxygen via nasal cannula (NC- a plastic flexible tubing used to deliver oxygen into the nose) at 2 LPM [Liters (unit of volume) Per Minute (unit of time)] and reported his findings to Licensed Vocational Nurse (LVN) 1. 2. Follow physician orders to titrate (adjust) Resident 98's oxygen therapy to ,d+[DATE] LPM via mask to maintain oxygen blood levels of 94% and above, when Resident 98's oxygen saturation decreased to 70% on [DATE] at 5:50 AM, while receiving 2 LPM of oxygen via NC. 3. Ensure LVN 1 monitored and documented Resident 98's vital signs (measurements of the body's most basic functions, including temperature, pulse rate, breathing rate, and BP, used to assess a person's overall health), treatments rendered, and reported to the physician, in accordance with the physician orders. 4. Ensure LVN 1 immediately notified the physician and called 911 (an emergency number) emergency services, when CNA 1 reported to LVN 1 that Resident 98 was experiencing labored breathing with his oxygen saturation decreased to 88% on [DATE] at around 5:30 AM, and when LVN 1 assessed Resident 98 with findings of weakness and oxygen saturation continued to decrease to 70% on [DATE] at 5:50 AM. 5. Ensure LVN 1 implemented Resident 98's Physician Orders for Life-Sustaining Treatment (POLST, a portable medical order that communicates a patient's wishes for end-of-life care and treatment interventions) according to the resident's preferences. These deficient practices resulted in the delay in diagnosis, care, and respiratory services for Resident 98's change in respiratory condition. Resident 98 expired at the facility on [DATE] with the cause of death as cardiac dysrhythmia (abnormal or irregular heartbeat), acute respiratory distress and pulmonary hypertension. On [DATE] at 3:09 PM, while onsite at the facility, the California Department of Public Health (CDPH) an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) was identified and called regarding the facility's failure to notify the physician regarding significant changes in Resident 98's respiratory conditions and provide the necessary respiratory care and monitoring. On [DATE] at 7:52 PM, the IJ was removed in the presence of the Administrator (ADM) and the Director of Nurses (DON) after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and while onsite at the facility, the surveyors verified/confirmed the facility's implementation of the IJ Removal Plan and the IJ situation was no longer present. The IJ Removal Plan dated [DATE], included the following: 1. On [DATE], the Director of Nursing (DON) and Registered Nurse (RN) supervisor evaluated current residents with oxygen order (12 residents) and/or with diagnosis of COPD (32 residents) for appropriate assessment and interventions. 2. On [DATE], the Regional Nurse Consultant (RNC) provided one on one education to DON and Director Staffing Development (DSD) related to respiratory care, assessment and documentation, monitoring for any change of condition, oxygen administration as ordered by the physician, notification of the physician, escalation of emergent medical services (911) if needed, and implementation of POLST per resident preference. 3. On [DATE], the Regional Nurse Consultant (RNC) conducted an interview with LVN 1 and CNA 1 regarding the death incident of Resident 98. The RNC investigated for the licensed nurse documentation, monitoring of change of condition and the reason for not calling 911 and for the possible root cause. 4. On [DATE], the RNC provided one on one education to LVN 1 related to respiratory care, assessment and documentation, monitoring for any change of condition, oxygen administration as ordered by the physician including skills competency, notification of the physician, escalation of emergent medical services (911) if needed, and implementation of POLST per resident preference. 5. On [DATE], the DON or designee conducted re-education for licensed nursing staff on the following topics: documentation, oxygen administration, compliance with individualized interventions in each resident's care plan, implementation of POLST and notification of the physician and following physician orders. 6. On [DATE], the DON or designee started auditing residents with COPD and or Oxygen order 3 times weekly (Monday - Wednesday- Friday) for 4 weeks to ensure physician's orders were carried out, resident specific care plans were implemented, and necessary respiratory equipment/supplies were in place, and monitor if change of condition occurred. Upon identification, the DON or designee would immediately address concerns and remedy any audit deficiencies with the licensed nursing staff immediately. 7. On [DATE], A Quality Assurance and Performance Improvement (QAPI, a data-driven approach to improve the quality of care and services in healthcare settings) Plan was implemented to track and report on above audit findings. The findings will be presented on the last Wednesday of the month for the monthly Quality Assessment and Assurance (QAA, an integrated system of management activities involving planning, implementation, assessment, reporting, and quality improvement to ensure that a process, or service is of the type and quality needed and expected) meeting for a minimum of three months. After the initial three months, the QAA Committee will decide regarding the continued frequency of audits and subsequent reporting, with audits continuing at least monthly to sustain compliance. 8. On [DATE] the RNC discussed regarding Chronic Obstructive Pulmonary Disease (COPD) and pulmonary hypertension with post-test to LVN 1 to ensure understanding of the medical condition. 9. On [DATE], the DON or designee provided education to licensed nurses regarding COPD and pulmonary hypertension with post-test to ensure understanding of the medical condition. Cross reference to F580 and F867. Findings: During a review of Resident 98's Admission Record (AR), the AR indicated the facility admitted Resident 98 on [DATE] with diagnoses that included acute respiratory failure with hypoxia, COPD with exacerbation (worsened symptoms), pulmonary hypertension, type 2 diabetes mellitus with hyperglycemia (DM, a chronic condition that happens when the body has persistently high blood sugar levels), and atrial fibrillation (afib a common type of irregular heartbeat). During a review of Resident 98's Order Summary Report (OSR), indicated on [DATE], Resident 98 had a physician order to monitor temperature and oxygen saturation every shift for suspected/confirmed Covid-19 (Coronavirus disease, an infectious disease caused by the SARS-CoV-2 virus), and to call the physician if oxygen saturation is newly below 91%, or if the resident's usual oxygen saturation is lower or is 3% or more lower than their baseline. During a review of Resident 98's Care plan (CP), dated [DATE], indicated Resident 98 had COPD exacerbation. The goal was that the Resident 98 would display optimal breathing patterns (a respiratory rate of 12 to 20 breaths per minute with regular, rhythmic inhalations and exhalations) daily with the interventions that included monitoring for signs and symptoms of acute respiratory insufficiency such as shortness of breath at rest, cyanosis (a bluish or purplish discoloration of the skin, typically caused by a lack of oxygen in the blood), and somnolence (lethargy, weakness, and difficulty thinking), and to administer oxygen via NC at ,d+[DATE] LPM continuously, may titrate oxygen to ,d+[DATE] LPM via mask to maintain oxygen saturation greater or equal to 94%. During a review of Resident 98's CP, dated [DATE], indicated Resident 98 was at risk for Covid-19 related to diagnosis of COPD exacerbation, DM, and afib. The interventions included to follow Resident 98's POLST, monitor temperature and pulse oximetry (a test used to measure oxygen levels of the blood) per physician's order and report abnormal findings to the physician. During a review of Resident 98's CP, dated [DATE], indicated Resident 98 had altered cardiovascular (related to heart and blood vessels) status related to afib, hypertension (high BP), and hyperlipidemia (high level of fats in the bloodstream). The interventions included to monitor Resident 98's vital signs and notify the physician of significant abnormalities, monitor/document/report to the physician for changes in capillary refill (a quick test to assess blood flow to tissues by observing how quickly color returns to the nail bed after pressure is applied) and color/warmth of extremities. During a review of Resident 98's History and Physical, dated [DATE], indicated Resident 98 had the capacity to understand and make decision. During a review of Resident 98's OSR, indicated on [DATE], for Resident 98 to receive oxygen via NC at ,d+[DATE] LPM continuously, may titrate oxygen to ,d+[DATE] LPM via mask to maintain oxygen saturation greater or equal to 94%. During a review of Resident 98's OSR, indicated on [DATE], the physician ordered to follow the instructions in Resident 98's POLST. During a review of Resident 98's POLST, dated [DATE], indicated if Resident 98 was found with a pulse and/or is breathing, the healthcare provider may, in addition oxygen treatment, use a non-invasive positive airway pressure (a method of breathing support that delivers pressurized air or oxygen through a mask without inserting a tube into the windpipe) which included continuous positive airway pressure (CPAP, a machine that uses mild air pressure to keep breathing airways open), bi-level positive airway pressure (BiPAP, a type of device that helps with breathing), and bag valve mask (a handheld device used to provide emergency breaths to someone who is not breathing or not breathing adequately) assisted respirations. During a review of Resident 98's Minimal Data Set (MDS-a federally mandated resident assessment), dated [DATE], indicated Resident 98's cognition (ability to think, remember, and reason) was moderately impaired and needed moderate assistance (helper does less than half the effort) in eating and oral hygiene. During a review of Resident 98's Weights and Vitals Summary, indicated Resident 98's last vital signs was taken on [DATE] at 1:09 AM with the resident's BP at ,d+[DATE] mmHg (millimeters of mercury, a unit of measurement for pressure), oxygen saturation of 93% while the resident was on room air, heart rate at 100 beats per minute, and temperature of 98.7 degrees Fahrenheit (a scale for measuring temperature). There was also no documented evidence that Resident 98 was monitored for vital signs on [DATE] at 5:50 AM when Resident 98 responded to touch only by opening his eyes, and had slow breathing. During a review of Resident 98's Progress Notes, dated [DATE], indicated at 5:50 AM during CNA morning care, Resident 98 responded only by opening his eyes, breathing slowing down with oxygen saturation at 70% via NC until the resident passed away. There was no documented evidence in the report that Resident 98 was provided with increased oxygen level to increase oxygen saturation to 94% as ordered by the physician. There was also no documented evidence that Resident 98 was monitored for vital signs, provided with ,d+[DATE] LPM oxygen via mask per physician's order on [DATE] at 5:50 AM when Resident 98 responded to touch only by opening his eyes, had slow breathing, and oxygen saturation at 70 % while on 3 LPM oxygen via NC. During a review of Resident 98's SBAR Communication Form (a structured approach to healthcare communication, standing for Situation, Background, Assessment, and Recommendation to ensure clear and concise information exchange, especially in critical situations) and clinical records on [DATE], indicated that there was no documented evidence that the physician was notified when Resident 98's condition changed by responding only by opening his eyes, breathing slowing down with oxygen saturation at 70% via NC on [DATE] at 5:50 AM until the resident expired on [DATE] at 5:59 AM. During a review of Resident 98's Record of Death, dated [DATE], indicated Resident 98 expired on [DATE] at 5:59 AM with the final diagnosis that included COPD, hypoxia and respiratory failure. During a review of Resident 98's Physician's Discharge Summary, dated [DATE], indicated Resident 98 was admitted on [DATE] and was discharged from the facility due to resident expired on [DATE] at 5:59 AM. During a review of Resident 98's Death Certificate dated [DATE], indicated Resident 98 expired on [DATE] with the primary cause of death as cardiac dysrhythmia and secondary cause of death that included acute respiratory distress and pulmonary hypertension. During an interview on [DATE] at 6:38 AM with CNA 1, CNA 1 stated, he took care of Resident 98 from 11 PM on [DATE] until the resident expired on the morning of [DATE]. CNA 1 stated, when he was caring for Resident 98 at the beginning of his shift, Resident 98 was alert and oriented, with the vital signs including BP and oxygen saturation was within normal limits, though he could not recall the results of the vital signs and time they were taken. CNA 1 stated, around ,d+[DATE]:30 AM during his rounds in the facility, he noticed that Resident 98 did not respond when he called Resident 98's name, and breathing very slow but his skin was warm when touched and the resident was very weak with his oxygen level at around 88%. CNA 1 stated, he immediately reported to LVN 1 that Resident 98's oxygen blood level was low and then LVN 1 went to assess Resident 98. CNA 1 stated, they (LVN 1 and CNA 1) checked Resident 98's vital signs about four times, but he could not recall the results and time the vital signs were taken. CNA 1 stated, he could only recall that Resident 98's oxygen level was at 88% when he first found the resident around ,d+[DATE]:30 AM and notified LVN 1. CNA 1 then stated Resident 98 slowly died in about 1 hour while receiving oxygen via NC. During a concurrent record review and interview on [DATE] at 6:52 AM with LVN 1, Resident 98's Weights and Vitals Summary, SBAR Communication Form, and clinical records on [DATE] and [DATE] were reviewed. LVN 1 stated, there was no records indicating Resident 98 was assessed and monitored for vital signs, Resident 98's physician was notified, or interventions were provided related to Resident 98's slow breathing with oxygen saturation at 70% on [DATE] at 5:50 AM. During an interview on [DATE] at 7 AM with LVN 1, LVN 1 stated, he was the charge nurse that took care of Resident 98 from 11 PM on [DATE] until the resident expired on [DATE] at 5:59 AM. LVN 1 stated, Resident 98 was alert, oriented and responsive at the beginning of his shift on [DATE], with oxygen saturation above 90% while receiving oxygen supplement at 3 LPM. LVN 1 stated, Resident 98 was able to make his needs known. LVN 1 stated, when LVN 1 provided Resident 98 with his scheduled breathing treatment (treatment to prevent difficulty breathing and shortness of breath) at 4 AM, Resident 98's oxygen saturation was about 93% and Resident 98 was placed back on ,d+[DATE] LPM oxygen via NC after the breathing treatment. LVN 1 stated around 5:30 AM, CNA 1 told him Resident 98 had a change in condition and breathing very slow and was very weak. LVN 1 stated he went to Resident 98's room, and Resident 98 opened his eyes but was very weak. LVN 1 stated he checked Resident 98's vital signs a few times but could not recall the results of the VS and he did not document the vital signs in Resident 98's clinical record. LVN 1 stated, he did not report Resident 98's change of condition to the Registered Nurse (RN) who was working during his shift on [DATE]. LVN 1 stated, he did not increase Resident 98's oxygen level as per physician's order because the resident had diagnosis of COPD. LVN 1 stated, he did not inform the physician when Resident 98's condition changed with oxygen saturation down to 88% and 70%. LVN 1 stated he informed Resident 98's physician after the resident passed away on [DATE]. LVN 1 stated, he supposed to notify Resident 98's physician, call for help or call 911 when CNA 1 reported to him that Resident 98 was weak with slow breathing and a decrease in the resident's oxygen saturation. LVN 1 stated, Resident 98 expired less than one hour after he was notified by CNA 1 for Resident 98's weakness and slow breathing. During a review of LVN 1's statement provided by the facility, dated [DATE] not timed, indicated on [DATE] at 11 PM, Resident 98 was laying comfortably in bed with oxygen via delivered via NC at 3 LPM with no sign and symptoms of respiratory distress. The statement indicated on [DATE] at 4 AM, LVN 1 administered the routine breathing treatment, Resident 98 was sleepy in bed, then at 5:50 AM, CNA 1 called LVN 1's attention and informed him that Resident 98 was only responding by opening his eyes. The statement indicated LVN 1 checked Resident 98's oxygen saturation that was 70 %. While Resident 98 was receiving oxygen supplement at 3 LPM. The statement indicated, LVN 1 elevated the Resident 98's head of the bed then suddenly Resident 98 became weak and unresponsive, like the resident last breath. During a review of CNA 1's statement provided by the facility, dated [DATE] not timed, indicated on [DATE] at 5:30 AM, CNA 1 came to change Resident 98's diaper and noticed a change in his condition and immediately reported his findings to LVN 1. The statement indicated, Resident 98's oxygen saturation was at 89%, then went down to 88%, and suddenly dropped down to 70%. LVN 1 and CNA 1 checked Resident 98's BP which was lower than the limit, then CNA 1 and LVN 1 elevated Resident 98's head of the bed higher and the resident became unresponsive. The statement indicated, Resident 98's breathing was slowing down until his last breath. During an interview on [DATE] at 9:40 AM with the DON, the DON stated when CNA 1 reported to LVN 1 that Resident 98's oxygen saturation was trending down and the resident was weak, LVN 1 should have immediately assessed, monitored and documented Resident 98's vital signs in the resident's clinical record. The DON stated, when LVN 1 found Resident 98's oxygen saturation of 70%, LVN 1 should have immediately called for help or Code Blue (an emergency code indicating a patient is experiencing a life-threatening medical emergency, typically a cardiac or respiratory arrest, requiring immediate medical attention and resuscitation efforts). followed the physician order to titrate Resident 98's oxygen therapy, followed Resident 98's POLST, called 911, and notified the physician to prevent a delay in treatments and interventions. During an interview on [DATE] at 1:02 PM with Resident 98's Primary Physician (PP) 1, PP 1 stated when Resident 98's oxygen saturation of ,d+[DATE]% went down to 88%, it was a sudden drop of oxygen saturation or a sudden change in condition, PP 1 stated LVN 1 was supposed to follow the physician's orders and notified him (PP1) right away, followed Resident 98's POLST, called 911 and notified the physician again. PP 1 stated, he was not notified of Resident 98's significant change in respiratory status on [DATE]. PP 1 stated, he was notified only after Resident 98 already expired on [DATE]. During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration, revised [DATE], indicated the following: - Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. - The equipment needed for oxygen administration will depend on the type of delivery system ordered. Type of delivery systems include nasal cannula, non-rebreather mask, CPAP mask, BiPAP mask. - Staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen. During a review of the facility's P&P tiled, Notification of Changes, revised [DATE], indicated the facility consult with the resident's physician when there is a change requiring such notification. Circumstances requiring notification include significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status, which may include life-threatening conditions. During a review of the facility's P&P titled, Medical Emergency Response, revised [DATE], indicated the following: - The employee who first witnesses or is first on the site of a medical emergency will initiate immediate action, basic first aid and summon for assistance. - A nurse will assess the situation and determine the severity of the emergency, designate a staff member to announce a Code Blue (a medical emergency alert, usually indicating a person has experienced cardiac or respiratory arrest requiring immediate resuscitation efforts) if necessary, notify the physician and call 911 as needed. - All available staff will respond to the emergency accordingly. - The RN Supervisor or Charge Nurse of the unit will take the Emergency Cart to the code site, ensure accurate documentation of the event and delegate any other duties or tasks needed.

Based on interview and record review the facility failed to ensure one (1) of five (5) sampled residents (Resident 1), who was assessed at risk for falls and diagnoses of dementia (a progressive state of decline in mental abilities) and age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) was free from falls and injury in accordance with the resident ' s care plan by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 prevented Resident 1, who was assessed as totally dependent to staff for bathing/showers, from falling in the Shower Room while sitting on the shower chair. On 11/30/2024, Resident 1 fell on her left side when the resident opened the arm rest of her shower chair while CNA 1 bent over to fix the hem (an edge that is folded over and stitched down to prevent threads coming loose) of her [CNA 1] pants. 2. Ensure CNA 1 notified Registered Nurse (RN) 1 when Resident 1 fell from the shower chair and placed the resident back on the shower chair, after the resident fell on [DATE] timed at 10:30 AM. 3. Ensure CNA 1 did not move and transfer Resident 1 back to the shower chair, prior to a licensed nurse assessing the resident for injuries in accordance with the facility ' s Policy and Procedure (P&P) on Incidents and Accidents. As a result of this deficient practice, on 11/30/2024 at around 11:10 AM, RN 1 heard Resident 1 screaming and yelling from the resident's room and observed Resident 1 with left upper arm swelling (the enlargement of organs, skin, or other body parts), moaning and grimacing in pain, with sad/frightened/frown. The X-ray (electromagnetic [relating to the electrical and magnetic forces produced by an electric current] waves that create pictures of the inside of your body) report taken at the facility indicated the resident had a moderately displaced oblique (having a slanting direction or position/angle) fracture (a broken bone that happens suddenly due to a traumatic injury) of the distal diaphysis (the main or midsection of a long bone) of the left humerus (upper arm bone), consistent with an acute fracture (a broken bone that happens suddenly due to a traumatic injury, like a fall causing immediate pain and noticeable damage to the bone). Resident 1 was transferred to the general acute care hospital (GACH) on 11/30/2024 at 8:11 PM for further treatment. It was determined in the GACH that Resident 1 was not a good candidate for surgery and therefore received non-operative treatment (medical treatment that does not involve surgery) at the GACH that included medication management for pain control. A left humerus fracture splint [a brace that supports and immobilizes the shoulder or arm to help with healing after an injury] was placed to the resident ' s left arm and to continue with non-weight bearing (you are not allowed to put any weight on a specific body part) to the left upper extremity. Findings: During a review of Resident 1 ' s Admission Record [AR], the AR indicated the facility admitted the resident on 6/22/2021, with diagnoses including history of falling, age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) without current pathological fracture (a broken bone that occurs when a disease weakens the bone, making the bone more likely to break than normal), and abnormalities in gait (a person ' s manner of walking) and mobility (a change to a person ' s walking pattern). During a review of Resident 1 ' s Fall Risk form dated 6/20/2024, the Fall Risk form indicated the resident had intermittent (fluctuating) confusion. The Fall Risk form indicated the resident was assessed at risk for falls. During a review of Resident 1 ' s History and Physical (H&P) dated 6/23/2024, the H&P indicated additional diagnosis that included dementia. The H&P indicated Resident 1 was dependent to staff for all activities of daily living [ADL, basic tasks people need to do to take care of themselves that included eating, bathing]. The H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Care Plan for Self-Care Deficit: Bathing revised on 6/28/2024, the Care Plan indicated interventions that included facility staff would evaluate the resident ' s ability to perform ADLs. During a review of Resident 1 ' s Care Plan for Age-related Osteoporosis revised on 6/28/2024, the care plan indicated the goal for the resident was to remain free of injuries or complications related to Osteoporosis. The Care Plan interventions included to monitor/document for risk of falls to reduce risk of falls. During a review of Resident 1 ' s Care Plan for Risk of Falls revised on 6/28/2024, the care plan indicated a goal for the resident to be free of falls and minor injury. The Care Plan interventions included anticipating the resident ' s needs, reminding the resident to call for help when needed, and educating the resident about safety reminders and what to do if a fall occurs. During a review of Resident 1 ' s Minimum Data Set (MDS - a federally mandated [a law or court ruling that the federal government imposes on state and local governments to address issues that affect the United States] resident assessment tool) dated 9/19/2024, the MDS indicated the resident had severe cognitive impairment (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 1 ' s speech was unclear and was sometimes able to understand and be understood. During further review of the MDS, the MDS indicated under Self-Care, that assessed the resident ' s safety and quality of performance, Resident 1 was assessed as dependent (helper did all of the effort and the resident did none of the effort to complete the activity; or the assistance of two or more helpers was required for the resident to complete the activity) to facility staff with showering/bathing. The MDS indicated shower transfers (the ability to get in and out of a tub/shower) was not applicable (not attempted and the resident did not perform this activity prior to the current illness). During a review of Resident 1 ' s Care Plan for an Actual Fall that happened to the resident, dated 11/20/2024, the care plan indicated Resident had an actual fall on 11/20/2024 [10 days prior to Resident 1 ' s fall in the shower room on 11/30/2024]. The Fall care plan goal for Resident 1 was to provide a safe environment that minimizes complications associated with falls. During a review of another Fall Risk evaluation form for Resident 1, dated 11/20/2024, the Fall Risk form indicated Resident 1 continued to be at risk for falls. During a review of Resident 1 ' s Situation, Background, Assessment, and Recommendation (SBAR) dated 11/30/2024 timed at 2:11 PM, the SBAR indicated the resident had a left upper arm swelling and was moaning and grimacing when moving the left upper arm. The SBAR indicated the resident had pain with non-verbal signs of occasional moan or groan (make a deep inarticulate [not able to express yourself clearly or effectively] sound in response to pain), low-level of speech with a negative or disapproving quality, and sad/frightened/frown. The SBAR indicated the resident ' s family (FM) was at the bedside during the assessment and the physician was notified with an order for a STAT (is derived from the Latin word statim, which means instantly or immediately) left shoulder upper arm X-ray. During a review of Resident 1 ' s Physician ' s Order dated 11/30/2024, the Physician ' s Order indicated left upper arm X-ray STAT due to pain and swelling. During a review of Resident 1 ' s Final X-ray Report taken at the facility on 11/30/2024, the X-ray Report indicated the exam was for the left humerus due to swelling, mass/lump (a noticeable bump or swelling on the body) of unspecified site. The X-ray report indicated the resident had a moderately displaced oblique fracture of the distal diaphysis of the left humerus, consistent with an acute fracture. The X-ray Report indicated clinical follow-up was recommended. During a review of Resident 1 ' s Physician ' s Order dated 11/30/2024, the Physician ' s Order indicated to administer Acetaminophen (a pain reliever) oral tablet 325 milligrams (mg, a unit of measurement of weight), two (2) tablets by mouth every four (4) hours as needed (PRN) for mild pain (one [1] to three [3]/10) for 30 days. During a review of Resident 1 ' s Medication Administration Record (MAR) dated 11/30/2024 at 2:17 PM, the MAR indicated the resident received two 325 mg Acetaminophen tablets by mouth for mild pain. During a review of Resident 1 ' s Nurses Progress Note dated 11/30/2024 timed at 8 PM, the Note indicated the resident was in bed complaining of pain and swelling on the left upper arm and an x-ray done at 4 PM, that showed a left upper arm fracture. The Nurses Progress Note indicated the family requested the resident be transferred to the GACH. The Nurses Progress Note indicated the facility staff gave report to the GACH at 5 PM, the ambulance arrived at the facility on 11/30/2024 at 7:50 PM, and the resident was sent to the GACH at 8:11 PM. During a review of Resident 1 ' s GACH emergency room (ER) Triage (the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) Notes dated 11/30/2024 timed at 8:54 PM, the ER Triage Notes indicated the resident had left upper arm swelling, tenderness, and the resident was in a left arm sling (a device that supports and immobilizes an injured body part) upon arrival to the GACH ER. During a review of Resident 1 ' s GACH Left Humerus Computed Tomography (CT - a medical imaging technique that uses X-rays and a computer to create detailed pictures of the inside of the body) Radiology Report dated 11/30/2024, the CT Radiology Report indicated there was a complete displaced fracture involving the distal humeral diaphysis. The CT report indicated there was posterior displacement of the distal humeral diaphyseal (relating to the diaphysis of a bone) fragment. During a review of Resident 1 ' s GACH Left Humerus X-ray Radiology Report resulted on 12/1/2024, the X-ray Radiology Report indicated there was a complete oblique displaced fracture of the distal humeral diaphysis and a posterior displacement of the distal humeral fragment. During a review of Resident 1 ' s GACH Orthopedic (the branch of medicine dealing with the correction of deformities of bones or muscles Consult) H&P dated 12/1/2024, the GACH H&P indicated the resident ' s affected side revealed intact thin skin, swelling and edema (a condition that occurred when fluid builds up in the body ' s tissue and caused swelling), significant ecchymosis (a bruise), and tenderness (pain or discomfort) along the left upper extremity. The GACH H&P indicated Resident 1 ' s left humerus x-ray was a spiral fracture (a type of fracture characterized by a complete break in a bone that occurs when a twisting force causes the bone to split into at least two pieces) of the distal humerus. The GACH H&P indicated the original plan was to perform an open reduction internal fixation (ORIF, to realign broken bone pieces and secure them) of the humerus but decided against surgery due to comorbidities (condition of having two or more disease at the same time). The GACH H&P indicated Resident 1 would receive non-operative treatment that included medication management for pain control application, a left humerus fracture splint (a brace that supports and immobilizes the shoulder or arm to help with healing after an injury) was placed to the resident ' s left arm and to continue daily with non-weight bearing to the left upper extremity. During an interview on 12/3/2024 at 2:47 PM, RN 1 stated on 11/30/2024, CNA 1 was providing care to Resident 1 inside the resident ' s room around 11 AM, and she heard the resident screaming and yelling. RN 1 stated at around 11:10 AM, when she entered Resident 1 ' s room, she observed the resident ' s left arm was swollen but the skin was intact and there was no discoloration. RN 1 stated Resident 1 would not move her left arm or let the facility staff touch the left arm. RN 1 stated the attending physician was notified around 12 PM and ordered a STAT x-ray. RN 1 stated CNA 1 did not inform her that Resident 1 had a fall on 11/30/2024. During an interview on 12/3/2024 at 3:54 PM, CNA 2 stated Resident 1 required total care (providing a person with all the necessary support and assistance they need to manage their health and daily life, including medical care, personal hygiene, and other needs) and could also use hands to gesture what the resident wants. CNA 2 stated Resident 1 usually sits down in the wheelchair. CNA 2 stated on 11/30/2024 during the 3 PM to 11 PM shift, Resident 1 was sitting in the wheelchair and was not moving her left arm. CNA 2 stated Resident 1 ' s x-ray was performed around dinner time and shortly after the resident was sent to the GACH. During an interview on 12/4/2024 at 7:18 PM, the Administrator (ADM) stated CNA 1 contacted the Director of Staff Development (DSD) on 12/3/2024 at 9:18 PM and stated she did not provide accurate information when CNA 1 witnessed Resident 1 falling from the shower chair in the Shower Room and did not tell any staff. The ADM stated that according to CNA 1, on 11/30/2024 at 10:30 AM, CNA 1 took Resident 1 to the Shower Room and as CNA 1 was turning on the shower, Resident 1 opened the safety arm to the shower chair and fell . The ADM stated, CNA 1 took Resident 1 back to the resident ' s room and noticed swelling and informed RN 1 of the swelling. The ADM stated CNA 1 did not inform RN 1 of the fall and what actually happened on 11/30/2024. During a telephone interview on 12/4/2024 at 7:39 PM, CNA 1 stated on 11/30/2024 Resident 1 was sitting on the shower chair in the Shower Room. Resident 1 opened the arm rest of the shower chair, while CNA 1 was bending over to tuck the hem of CNA 1 ' s pants into her socks, to avoid her pants from getting wet. CNA 1 stated while she was bending over, Resident 1 opened the arm of the shower chair and fell to the left side with the shower chair to the floor. CNA 1 stated the shower chair arm rest was secured prior to the resident falling but Resident 1 was still able to open the arm rest to the shower chair. CNA 1 stated that when she saw Resident 1 getting up, CNA 1 tried to get to Resident 1 but was not able to catch the resident because by the time she could get to the resident, Resident 1 already touched the ground. CNA 1 stated she had her hand on the resident ' s stomach when she attempted to get to her, to make sure the resident ' s head does not hit the ground. During the same telephone interview on 12/4/2024 at 7:39 PM, CNA 1 stated after Resident 1 fell , she attempted to call another CNA to assist her, but nobody came, so CNA 1 picked up Resident 1 by herself, along with the shower chair. CNA 1 stated another CNA [CNA 3] came after Resident 1 was already back up in the shower chair, to ask what happened, but she told CNA 3 that nothing happened and did not mention Resident 1 fell . CNA 1 stated she proceeded to take Resident 1 back to bed. CNA 1 stated when she put Resident 1 back to bed, she noticed the resident ' s left arm was swollen. CNA 1 stated when RN 1 came to the resident ' s room and asked if Resident 1 fell , CNA 1 did not tell RN 1 that the resident fell from the shower chair to the floor. CNA 1 stated she told RN 1 that Resident 1 ' s left arm was already swollen when she came to assist the resident that morning [11/30/2024]. CNA 1 stated she did not tell anyone in the facility what actually happened [Resident 1 falling from the shower chair in the shower room] on 11/30/2024, because she was scared. During an interview on 12/5/2024 at 2:17 PM, CNA 3 stated when CNA 1 called for help because the resident ' s arm looked different on 11/30/2024, Resident 1 was already back in the room and observed the resident ' s arm was swollen. CNA 3 told CNA 1 to inform RN 1, and both walked out of the room. CNA 3 stated if a resident would have an incident of fall and the resident was on the floor, it is the facility ' s policy to not move the resident and instead call for help and report to the licensed nurse to assess the resident. During an interview on 12/5/2024 at 2:38 PM, Licensed Vocational Nurse (LVN) 1 stated if a resident fell , she would call the RN Supervisor to help assess the resident for any swelling, pain, or injury. LVN 1 stated not moving the resident was important to see the position the resident was in and to avoid further harm to the resident. During an interview on 12/5/2024 at 3:17 PM, the DSD stated unlicensed staff like CNAs were expected to ask for help and should not have moved or lifted a resident until help arrived because the licensed nurse would need to do an assessment. The DSD stated the CNAs must wait before moving the resident for safety issues because moving the resident would cause more harm to the resident. During an interview on 12/5/2024 at 3:30 PM, RN 2, who was assisting the Director of Nursing at the facility, stated she expects the facility staff to call for assistance and not do anything by themselves, if a resident falls because the facility staff may not be knowledgeable to assess the resident. RN 2 stated CNA 1 should have called for help/assistance from a licensed nurse to be able to assess if Resident 1 was safe to move, after the resident fell on [DATE]. RN 2 stated CNA 1 should have called for help instead of moving Resident 1 back to the shower chair and to bed. During an interview on 12/13/2024 at 3:54 PM, the DSD stated since Resident 1 was totally dependent to staff for shower/bathing, CNA 1 should not have taken her eyes off Resident 1 and should not have left Resident 1 in the shower chair while she reached down to tuck her pants in to her socks. The DSD stated CNA 1 informed her during her post-interview with CNA 1 that on 11/30/2024, Resident 1 was being resistant when she placed the resident on the shower chair. The DSD stated CNA 1 should have asked another CNA to assist her on 11/30/2024, since Resident 1 was being resistant so CNA 1 would not have to take her eyes off [Resident 1]. The DSD stated that CNA 1 should have followed the facility ' s policy for Incidents and Accidents that indicated not to move a resident after a fall to prevent further harm because a licensed nurse need to know and assess the resident and notify the physician. During a review of the facility ' s P&P titled, Incidents and Accidents, dated 12/19/2022, the P&P indicated the purpose of reporting an incident which is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization, assures that appropriate and immediate interventions are implemented, and corrective actions are taken to prevent recurrences. The P&P further indicated, Any injuries would be assessed by the licensed nurse or practitioner and the affected individual would not be moved until safe to do so. During a review of the facility ' s P&P titled, Comprehensive Care Plans, dated 12/19/2022, indicated the facility would Develop and implement a comprehensive person-centered care plan for each resident consistent with resident ' s rights that include measurable objectives and timeframes to meet the resident ' s medical, nursing, mental, and psychosocial needs that are identified in the resident ' s comprehensive assessment. During a review of the facility ' s P&P titled, Accidents and Supervision, dated 12/19/2022, indicated, Each resident would receive adequate supervision and assistive devices to prevent accidents including identifying hazards and risks, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. The P&P indicated, Resident-directed approaches may include implementing specific interventions as part of the plan of care. The P&P indicated, Monitoring and modification processes include ensuring interventions are implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed, and evaluating the effectiveness of new interventions. During a review of the facility ' s P&P titled, Fall Prevention Program, dated 12/28/2023, indicated, Each resident would be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.