Every finding on record at Huntington Valley Healthcare Center

Based on interview, medical record review, and P&P review, the facility failed to ensure the responsible party was notified of a medication change for one of four sampled residents (Resident 1). * The facility failed to inform Resident 1's responsible party of a new physician's order to administer the apixaban (a blood thinner medication). This failure had the potential of Resident 1's responsible party to not be aware and participate in any decision-making processes.Findings: Review of the facility's P&P titled Advance Directives dated 2001 showed advance care planning, a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions. Upon admission, the interdisciplinary team assesses the residents decision making capacity and identifies the primary decision maker if the resident is determined to not have decision making capacity. Medical record review for Resident 1 was initiated on 8/11/26. Resident 1 was admitted to the facility on [DATE]. Resident 1 had a diagnosis of vascular dementia. Review of Resident 1's MDS assessment dated [DATE] showed, Resident 1's BIMS score was 02, indicating severe cognitive impairment. Review of Resident 1's Face Sheet dated 8/12/26, showed Family Member 1 was the number one emergency contact and the responsible party for Resident 1. Review of Resident 1's Order Summary Report showed a physician's order dated 5/30/26, to administer apixaban oral tablet 5 mg, give two tablets by mouth two times a day for right lower extremity DVT for seven days, a total dose of 10 mg and apixaban oral tablet 5 mg, give one tablets by mouth two times a day for right lower extremity DVT for six months. Review of Resident 1's Nurses Progress Notes dated 5/30/26, showed the resident with order for apixaban oral tablet 5 mg, give two tablets by mouth two times a day for right lower extremity DVT for seven days, total dose of 10 mg. However, further review of the progress notes did not show the responsible party was notified of the new physician's order to administer the apixaban medication. Review of Resident 1's MAR for May 2026 showed on 5/31/26 at 0900 and 2100 hours, Resident 1 was administered the apixaban medication. Review of Resident 1's MAR for June 2026 showed on 6/7/26 to 6/11/26 at 0900 and 2100 hours, Resident 1 was administered the apixaban medication. On 8/12/26 at 1158 hours, an interview and concurrent medical record review for Resident 1 was conducted with LVN 2. LVN 2 verified on 5/30/26, the physician ordered the apixaban medication. LVN 2 verified Resident 1 was administered the apixaban medication from 5/31 to 6/11/26. When asked if Resident 1's responsible party was notified of the new apixaban order, LVN 2 was unable to verify as there were no nurses notes to show the responsible party was notified of the new apixaban medication. On 8/12/26 at 1524 hours, an interview was conducted with the ADON. The ADON was made aware and acknowledged the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to maintain the highest practicable well-being for one of four sample residents (Resident 1). * The facility failed to timely address Resident 1's hypotension and bradycardia. * The facility failed to ensure Resident 1 went for a scheduled gynecology appointment on 5/7/26, due to vaginal bleeding. * The facility failed to notify the physician when Resident 1's apixaban (a blood thinner medication) medication order exceeded the recommended dosing. In addition, the facility failed to monitor the side effects of a blood thinner medication for Resident 1 who was being administered the apixaban medication and had a history of bleeding and anemia. * The facility failed to ensure the physician was timely notified and Resident 1 was provided interventions while waiting for the NP/physician's response for the critical laboratory results. These failures had the potential for the resident to not receive the necessary and negatively affect the residents' health and well-being. Findings: Review of the facility's P&P titled Notification of Medical Appointments (undated) showed the purpose is to establish a standardized procedure for notifying residents' responsible parties about scheduled medical appointments, ensuring transparency, compliance with the California regulations, and the promotion of resident-centered care. This policy applies to all staff members involved in scheduling, coordinating, or facilitating medical appointments for residents within the facility. Review of the facility's P&P titled Change in a Resident's Condition of Status dated 2001 showed the facility promptly notifies the resident, resident's attending physician or provider, and the resident representative of changes in the resident's condition and/or status (e.g., changes in level of care, billing/payments, residents rights, etc.). The nurse will notify the resident's attending physician, provider, or physician on call when there has been a(an):- accident or incident involving the resident;- discovery of injuries of an unknown source;- adverse reaction to medication;- significant change in the resident's physical, emotional, or cognitive condition;- need to alter the residence medical treatment significantly;- refusal of treatment or medications two (2) or more consecutive times;- need to transfer the resident to a hospital/treatment center;- request for discharge against medical advice; and/or; and- specific instruction to notify the physician of changes in the residence condition. Prior to notifying the physician or health care provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the INTERACT SBAR Communication Form. Review of the facility's P&P titled Blood Pressure, Monitoring revised 9/2010 showed a blood pressure reading is represented as a ratio or fraction. The top number is the (systolic pressure) measure the blood pressure during the contractions of the heart (systole). The bottom number (the diastolic pressure) measures the pressure of the blood while the heart is at rest (diastole). The blood pressure is generally defined as normal when the systolic pressure is in the range of 101 to 129 mmHg and the diastolic pressure is in the range of 61 to 84 mmHg. Hypotension is defined as blood pressure less than 100/60 mmHg. Hypotension should be reported to the physician. Staff should record several readings throughout the day, including before and after meals. The following information should be recorded in the resident's medical record:- the date and time the blood pressure was measured;- the name and title of the individual (s), who measured the blood pressure;- the blood pressure reading;- if the resident refused the treatment, the reason(s) why and the intervention taken; and- the signature and the title of the person recording the data. 1. Medical record review for Resident 1 was initiated on 8/11/26. Resident 1 was admitted to the facility on [DATE]. a. Review of Resident 1's Weights and Vitals Summary dated 8/8/25, showed the following vital signs:- at 0848 hours, Resident 1's blood pressure was 81/37 mmHg, with warnings diastolic low of 60 exceeded, systolic low of 90 exceeded, and pulse rate of 51 bpm (beats per minute), with warnings low of 60.0 exceeded, and- at 0957 hours, Resident 1's blood pressure was 85/35 mmHg, the warning indicated diastolic low of 60 exceeded, systolic low of 90 exceeded, and pulse rate was 41 bpm, the warning indicated low of 60.0 exceeded. Review of Resident 1's SBAR Communication Form dated 8/8/25, showed the change in condition, symptoms, or signs observed and evaluated were for episodes of hypotension (BP of 85/35 mmHg), and bradycardia (pulse rate of 41). The form further showed the primary care clinician was notified on 8/8/26 at 0954 hours and gave recommendations to transfer the resident to the acute care hospital. Review of Resident 1's Nurses Progress Notes dated 8/8/25 at 1025 hours, showed the nurse was called to the resident's room. The resident was observed lying in bed, HOB (head of bed) elevated and feet elevated, breathing evenly and unlabored, skin was warm and dry, lethargic, appeared weak, softly answered questions, and denied pain. The BP reading manually was 78/32 mmHg, no noted SOB (shortness of breath), 97% O2 (oxygen) on room air, pulse reading manually was 48 beats per minute, and temperature was 98.1 Fahrenheit. The note further showed 911 was called, arrived at 1047 hours, transported Resident 1 to the acute care facility. Further review of Resident 1's medical records failed show the change of condition was addressed and the physician was notified of the vital signs taken on 8/8/25 at 0848 hours when Resident 1's blood pressure was 81/37 mmHg and the pulse rate was 51 beats per minute. The change of condition was not addressed until approximately one hour later when Resident 1's blood pressure was 85/35 mmHg and pulse rate was 41 beats per minute with the physician notification at 0954 hours. In addition, the paramedics were called and arrived at 1047 hours, another one hour later. On 8/13/26 at 1510 hours, an interview and concurrent medical record review for Resident 1 was conducted with RN 1. When asked what time the first set of vital signs were taken, RN 1 stated on 8/8/25 at 0848 hours. When asked if the physician was notified of Resident 1's blood pressure and pulse rate at 0848 hours, RN 1 stated I don't see anything until 0957 hours. When asked if any interventions were initiated, RN 1 stated I don't see anything documented. When asked if the physician should have been notified at 0848 hours, RN 1 stated yes. RN 1 verified 911 was called at 1025 hours, and the paramedics arrived at 1047 hours. b. Review of Resident 1's Order Summary Report dated 5/1/26, showed Resident 1 had a gynecology appointment due to vaginal bleeding on 5/7/26 at 1430 hours. Review of Resident 1's Progress Notes dated 5/7/26, failed to show any documentation if Resident 1 went to the gynecology appointment or the gynecology appointment had been rescheduled. On 8/13/26 at 0825 hours, an interview and concurrent medical record review for Resident 1 was conducted with the SSD. The SSD verified Resident 1 had a gynecology appointment scheduled for 5/7/26. The SSD stated Resident 1's responsible party was involved and would usually take Resident 1 to the appointments. The SSD stated the social service assistant attempted to remind Resident 1's responsible party on 5/6/26; however, Resident 1's responsible party did not answer, left a voicemail but Resident 1's responsible party did not call back. On 8/13/26 at 0901 hours, a follow-up interview was conducted with the SSD. The SSD stated if the resident did not have means of transportation, the facility would be responsible to set-up the transportation and for a staff member to go with the resident if needed. The SSD verified Resident 1 did not go to the appointment, and there was no follow up attempts to reschedule the appointment when Resident 1 missed the gynecology appointment on 5/7/26. The SSD stated the gynecology appointment for Resident 1 should have been rescheduled. c. Review of Resident 1's Order Summary Report showed the following physicians' order dated 5/30/26:- apixaban oral tablet 5 mg, give two tablets by mouth two times a day for lower extremity DVT for seven days, total dose 10 mg; and- apixaban oral tablet 5 mg, give one tablet by mouth two times a day for lower extremity DVT for six months. Review of Resident 1's MAR for May 2026 showed Resident 1 was administered apixaban 5 mg, two tablets two times a day on 5/31/26 at 0900 and 2100 hours. Review of Resident 1's MAR for June 2026 showed Resident 1 was administered the following medication:- apixaban 5 mg, two tablets two times a day on 6/1 to 6/6/26 at 0900 and 2100 hours; and- apixaban 5 mg, one tablet two times a day on 6/7 to 6/11/26 at 0900, and 2100 hours. * Review of Resident 1's Nurses Progress Notes dated 5/30/26 at 1734 hours, under the Note Text showed This order is outside of the recommended dose or frequency. The note further showed the following:- Apixaban oral tablet 5 mg, give two tablets by mouth two times a day for right lower extremity DVT for seven days, total dose 10mg; - The dosing regimen of two tablets two times per day exceeds the usual dosing regimen of 0.5 to 1 tablet 2 times per day; and- The single dose of two tablets exceeds the maximum single dose of one tablet. The usual dosing regimen is 0.5 to one tablet two times per day. Further review of Resident 1's medical record failed to show the physician was notified when the apixaban medication was outside the recommended dose as documented in Resident 1's progress notes. On 8/13/26 at 1631 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON verified there was no documentation to show the physician was notified when the apixaban was noted to be outside of the recommended dose. * Review of Resident 1's Progress Notes dated 5/30/26 at 2340 hours, showed during incontinent care, the CNA noted a small amount of blood-tinged drainage on Resident 1's brief near the vaginal area. continue to monitor and report any changes. Review of Resident 1's Stool Immunochemical Occult Blood results collected on 6/2/26 and reported on 6/3/26, showed a positive result, indicating blood was present in the stool. Review of Resident 1's Order Summary Report showed a physician's order dated 6/11/26, for anticoagulant/antiplatelet medication, monitor for discolored urine, black tarry stools, sudden severe headache, N&V (nausea and vomiting), diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or VS, SOB, and nose bleeds every shift. Review of Resident 1's MAR for June 2026 showed Resident 1 was monitored for anticoagulant/antiplatelet medication use on 6/11/26, on the evening and night shifts. However, further review of Resident 1's medical record failed to show Resident 1 was monitored for anticoagulant/antiplatelet medication use from 5/31 to 6/10/26 when Resident 1 was administered the apixaban medication. On 8/12/26 at 1125 hours, an interview was conducted for Resident 1 with LVN 1. LVN 1 stated the residents on blood thinners were monitored for bruising, bleeding per shift. On 8/12/26 at 1524 hours, an interview and concurrent medical record review for Resident 1 was conducted with the ADON. The ADON verified Resident 1 was not monitored for signs and symptoms of bleeding when Resident 1 was administered the apixaban medication from 5/31 to 6/11/26 at the morning shift. d. Review of Resident 1's Nurses Progress Notes dated 6/12/26 at 1237 hours, showed the nurse received call from the laboratory. The notes showed critical value of H/H of hgb. (hemoglobin) 6.6 g/dL and hct. (hematocrit) 20.8%. The notes further showed the NP was notified and waiting for response. Review of the eINTERACT SBAR Summary for Providers note dated 6/12/26 at 1415 hours, showed the following:- Blood pressure : 140/75 mmHg;- Pulse rate: 80 beats per minute;- Respiratory rate: 18 breaths per minute;- Temperature: 97.0 Fahrenheit;- Pulse oximetry: 97% in room air. However, the above vital sign reading were obtained on 6/12/26 at 0049 hours. The SBAR further showed the lab with critical results were called, and the NP ordered to send Resident 1 to the emergency room. Further review of Resident 1's medical record failed to show any further attempts to notify the physician or if any interventions were implemented while waiting for the NP's response. On 8/13/26 at 1631 hours, an interview and concurrent medical record review for Resident 1 was conducted with the ADON. When asked when Resident 1's critical laboratory results were reported to the physician, the ADON stated on 6/12/26 at 1237 hours, and waiting for a response. The ADON was asked what the process would be if there was a change in condition and the physician could not be reached. The ADON stated the nurse was to notify the Medical Director. When asked if anything was done to Resident 1 between 1237 to 1432 hours, the ADON stated the Medical Director was not notified and verified there was no documentation on what was done to Resident 1 while waiting for the response. When asked what should have been done, the ADON stated close monitoring, assessment, and vital signs. When asked what assessment would be conducted, the ADON stated for critical labs, the oxygen, blood pressure, skin if pale, mucous membranes, breath sounds, respiratory rate if having trouble breathing, and if extremely tired.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete and accurate for one of four sampled residents (Resident 1). * The facility failed to accurately document Resident 1's change of condition to reflect Resident 1's current condition when Resident 1 had hypotension and bradycardia on 8/8/25, and right leg edema on 5/29/26. In addition, the facility failed to document when Resident 1 was sent out to the acute care facility on 6/12/26. These failures had the potential for the residents' care needs not being met as the clinical information was not complete.Findings: Review of the facility's P&P titled Charting and Documentation dated 2001 showed all services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, or psychosocial condition, shall be documented in the resident's medical record. The medical records should facilitate communication between the interdisciplinary team regarding the residents condition and response to care. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Medical record review for Resident 1 was initiated on 8/11/26. Resident 1 was admitted to the facility on [DATE]. a. Review of Resident 1's SBAR Communication Form dated 8/8/25, showed the change in condition, symptoms, or signs observed and evaluated were for episodes of hypotension (BP of 85/35 mmHg), and bradycardia (pulse rate of 41). Further review of the form showed the symptoms or signs were documented were not clinically applicable to the change of condition being reported for the respiratory evaluation, skin evaluation, and neurological evaluation. Review of Resident 1's SBAR Communication Form dated 5/29/26, showed the change in condition, symptoms, or signs observed and evaluated was for right leg edema (swelling). Further review of the form showed the symptoms or signs were documented as not clinically applicable to the change of condition being reported for the respiratory evaluation, cardiovascular evaluation, skin evaluation, and pain evaluation. On 8/12/26 at 1351 hours, an interview and concurrent medical record review for Resident 1 was conducted with the ADON. The ADON verified the above assessments would be relevant to the changes in conditions. b. Review of Resident 1's Nurses Progress Notes dated 6/12/26 at 1237 hours, showed the nurse received call from the lab. The notes showed critical value of H/H of hgb. (hemoglobin) 6.6 g/dL and hct. (hematocrit) 20.8%. The notes further showed the NP was notified and waiting for response. Review of the eINTERACT SBAR Summary for Providers note dated 6/12/26 at 1415 hour, showed the lab with critical results were called, and the NP ordered to send Resident 1 to the emergency room. Further review of Resident 1's medical record failed to show documentation when Resident 1 was transferred to the acute care facility. On 8/13/26 at 1632 hours, an interview and concurrent medical record review for Resident 1 was conducted with the ADON. When asked when the resident was sent out to the acute care hospital, the ADON stated she did not know the exact time since it was not documented in the progress notes.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed ensure the resident and/or responsible party had access to the resident's personal and medical records for one of four sampled residents (Resident 1). * The facility failed to ensure the medical records were released to Resident 1's responsible party as requested. This failure had the potential to violate the resident's rights to have access to the resident's medical records.Findings: Review of the facility's P&P titled Release of Information dated 2001 showed the resident may initiate a request to release such information contained in his/her records and charts to anyone he/she wishes. Such requests will be honored only upon receipt of a written, signed, and dated request from the resident or representative (sponsor). A resident may have access to his or her records within 24 hours. A resident may obtain photocopies of his or her records by providing the facility with at least a 48 hour (excluding weekends and holidays) advance notice of such request. A fee may be charged for copying services. On 8/11/26 at 0952 hours, a telephone interview was conducted with Responsible Party 1. Responsible Party 1 stated he had requested from the facility for all of Resident 1's medical records but did not receive all the medical records especially when Resident 1 was transferred to the acute hospital. Responsible Party 1 stated he sent emails to follow-up but did not get a response. On 8/11/26 at 1047 hours, a follow-up telephone interview was conducted with Responsible Party 1. Responsible Party 1 stated he received the medical records until May 2026; however, Responsible Party 1 stated he did not receive the copy if the records for the day when Resident 1 went to the emergency room of the acute care hospital in August 2025. Medical record review for Resident 1 was initiated on 8/11/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS assessment dated [DATE] showed, Resident 1's BIMS score was 02, indicating severe cognitive impairment. Review of Resident 1's Face Sheet dated 8/12/26, showed Family Member 1 was the number one emergency contact and the responsible party for Resident 1. Review of Resident 1's Authorization Form for the Release of Health Information dated 4/8/26, Resident 1's responsible party checked the portion which showed wished to have the following records copied, and I will pick them up at the facility. Under the section for the Information Requested showed the request for all medical records from 12/5/24. Further review of the document failed show on what date the requested medical records were released to Resident 1's responsible party. On 8/13/26 at 0852 hours, an interview and concurrent medical record review was conducted with the Medical Records Director (MRD). The MRD stated when she initially released the medical records to the resident representative, the representative returned back a few days later indicating there were some things missing. The MRD stated her process would always be to provide the documents within 48 hours. When asked to show the verification of the release date and what medical records were released to Resident 1's responsible party, the MRD stated she did not have any documentation.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 1) discharge process was followed. * The facility failed to ensure a written copy of the bed hold notice documentation was completed and provided to the Responsible Party at the time of transfer or within 24 hours of transfer to the acute care hospital. * The facility failed to develop a discharge plan for Resident 1 prior to the discharge. * The facility failed to readmit Resident 1 back to the facility when the resident was transferred to an acute care facility. These failures had the potential for Resident 1 to have an inappropriate discharge.Findings: Review of the facility's P&P titled Bed-Holds and Returns revised 1/2026 showed all the residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these polices at least twice:a. notice 1: well in advance of any transfer (e.g. in the admission packet); and b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours). The written bed-hold notices provided to the residents/representatives explain in detail:a. the duration of the stated be-hold policy, if any, during which the resident is permitted to return and resume residence in the facility; b. the reserve bed payment policy as indicated by the stated plan (for Medicaid residents)c. the facility policy regarding bed-hold periods;d. the facility per-diem rate required to hold a bed (for non-Medicaid residents), or t0 hold a bed beyond the stated bed-hold period (for Medicaid residents); ande. the facility return policy. The requirement that residents be permitted to return to the facility following hospitalization or therapeutic leave applies to all residents regardless of payer source. Review of the facility's P&P titled Transfer or discharge date d 2021 showed a transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility. A discharge refers to the movement of a resident from a bed in one certified facility to a bed and another certified facility or other location in the community, when returned to the facility is not expected. Further review of the P&P also showed when the facility transfers or discharges a resident, the following information is documented in the medical record and appropriate information is communicated to the receiving health care institution or provider:a. the basis for the transfer or discharge;b. that an appropriate notice was provided to the resident and/or legal representative;c. the date and time of the transfer or discharge;d. the new location of the resident;e. the mode of transportation;f. a summary of the resident's overall medical, physical, and mental condition;g. disposition of personal affects;h. disposition of medications;i. others as appropriate or as necessary; andj. the signature of the person recording the data in the medical record. Closed medical record review for Resident 1 was initiated on 8/6/26. Resident 1 was admitted to the facility on [DATE], and transferred to an acute care hospital on 6/26/26. On 8/5/26 at 0902 hours, the CDPH L&C Program received a report from the Office of Administrative Hearings and Appeals from the Department of Health Care Services. The report showed Resident 1 was granted an appeal for readmission to the facility. The report further showed the following:- The facility's most recent Discharge Planning Assessment was dated 4/1/26, showed Resident 1 would be discharged to the Responsible Party's residence. Since Resident 1's transfer to Hospital A, the facility had not developed an updated discharge plan that identified Resident 1's post-discharge needs, nor had it documented any arrangements for follow-up care or any necessary medical and non-medical services.- on 6/26/26, Resident 1 was transferred from the facility to the acute care hospital for evaluation per Responsible Party's request. Facility nursing staff attempted to provide a written bed-hold notice to the Responsible Party upon Resident 1's transfer to Hospital A; however, the notice was incomplete, lacking information such as the Responsible Party's signature, hospital name, transfer date, and the facility representative's signature.- on 6/29/26, a case manager at Hospital A requested readmission of Resident 1 to facility.- on 7/2/26, the DON informed the case manager at Hospital A that the facility would not readmit Resident 1. The DON's testimony established that the facility refused Resident 1's readmission based on nonpayment of Resident 1's monthly share of cost and lack of communication from the Responsible Party. - on 7/2/26, the Responsible Party filed an appeal in response to the facility's refusal to readmit Resident 1 back to the facility. Review of Resident 1's Discharge Planning assessment dated [DATE], failed to show the details of the discharge planning as the SSD was unable to schedule an IDT conference with the Responsible Party. Review of Resident 1's Bed Hold Policy and Notification form only showed the Resident's 1 name and date of 6/13/26. The form failed to show complete documentation of the transfer date, location of transfer and the Responsible Party's notification of the bed hold policy. Review of the DON's progress note dated 7/2/26, showed the following regarding facility's reasons as to why the facility was unable to readmit Resident 1 back to facility following the resident's acute care hospitalization:The facility's primary concern was clinical: whether facility can safely, consistently, and appropriately meet resident's increasingly complex care needs under the actual circumstances that exist today. Those circumstances included the resident's need for IV therapies, restrictions placed on the qualified nursing personnel available to provide her care, fragmented communication involving outside non-affiliated clinicians, and the Responsible Party's repeated refusal to meaningfully communicate or collaborate with the DON regarding her mother's clinical condition, care planning, and continuity of care.For a medically complex long-term care resident, safe care required more than the availability of a bed or the technical ability to provide a treatment. It required continuity, clear communication, interdisciplinary collaboration, timely decision-making, and a functional working relationship between the resident's representative and the clinical leaders responsible for overseeing and coordinating that care. That functional relationship did not currently exist.Despite acting as resident's primary representative and potentially holding Power of Attorney or other decision-making authority, the Responsible Party has repeatedly avoided or refused meaningful communication and collaboration with the DON. This has created significant barriers to effective care planning, discussion of changes in resident's condition, coordination of complex clinical services, development of a sustainable plan of care, and consideration of appropriate alternative placement.The DON was responsible for the oversight of the nursing services provided within the facility. When a resident has increasingly complex clinical needs, including IV therapies, meaningful communication between the resident's representative and nursing leadership was essential. A facility cannot safely coordinate complex care when the individual acting as the resident's representative refused to collaborate with the clinical leader accountable for overseeing that care.These concerns were further compounded by the Responsible Party's actions resulting in one of the facility's full-time RN being removed from the participation in the resident's care. This materially restricted the nursing resources available to safely and consistently manage resident's IV therapies and other complex clinical needs. A skilled nursing facility cannot reasonably accept full accountability for complex clinical care while simultaneously being restricted from assigning qualified nursing personnel who would otherwise be available and competent to provide that care.Further fragmenting continuity of care, it has been documented that the Responsible Party consulted and collaborated with the outside physicians and nurses who were not affiliated with the facility and who, to the facility's knowledge, have not established direct communication or a coordinated working relationship with the facility's DON, attending providers, nursing team, or interdisciplinary care team.The facility recognized the Responsible Party's right to seek outside medical opinions. However, a safe long-term care required coordinated clinical decision-making among those responsible for assessing, ordering, implementing, monitoring, and evaluating a resident's care. When outside clinicians provided recommendations, direction, or influence regarding care without communicating with the professionals responsible for actually carrying out and monitoring that care, significant gaps in continuity, communication, and clinical accountability may result.This was particularly concerning for a medically complex resident requiring IV therapies, where the provider orders, medication administration, vascular access, laboratory monitoring, changes in condition, potential adverse reactions, and treatment effectiveness must be consistently assessed and clearly communicated among the responsible clinical team.Taken together, these circumstances created significant barriers to a safe and coordinated care: resident's representative repeatedly refused meaningful collaboration with the DON; a qualified full-time RN has been restricted from participating in the resident's care; and outside non-affiliated clinicians were reportedly consulted without establishing meaningful communication or coordination with the facility's interdisciplinary team.This created a fragmented care environment in which the facility would be expected to assume full clinical accountability for the resident's outcomes without having the unrestricted staffing resources, communication, collaboration, and coordinated decision-making necessary to safely manage her care.These clinical concerns existed within a broader and longstanding history of unresolved financial obligations and unsuccessful efforts by the facility to establish a sustainable plan for resident's long-term care.Resident 1 had a required share-of-cost obligation associated with her long-term care that has remained unpaid despite repeated notices and opportunities to resolve the matter. The outstanding balance has grown to approximately $70,000 and no meaningful payment arrangement has been established.As a result of the continuing nonpayment, the facility issued two separate 30-day notices of discharge. Throughout this process, the facility repeatedly attempted to engage the Responsible Party regarding the resident's financial obligations, care planning, and appropriate alternative placement. These efforts did not result in meaningful cooperation or a sustainable resolution.Following a previous acute care hospitalization, the facility accepted Resident 1 back with the reasonable expectation that her required share-of-cost payments would begin to be addressed. They were not, and the outstanding balance continued to increase.The prolonged failure to pay the resident's required share of cost, despite the continuing availability of long-term care services to her, has raised serious concerns regarding the management and disposition of funds intended for the resident's care. These circumstances have reportedly resulted in an investigation by Adult Protective Services, including concerns regarding possible financial exploitation or misappropriation of the resident's funds and questions concerning the Responsible Party's actual legal authority or Power of Attorney designation.The facility did not represent that these allegations have been finally adjudicated or substantiated unless and until such a determination was made by the appropriate investigating agency or legal authority. However, the existence of the investigation and the underlying documented circumstances were relevant to understanding the broader history of the facility's attempts to resolve the resident's care, financial obligations, and representation. Additionally, the Responsible Party has repeatedly initiated complaints and investigations through the California Department of Public Health regarding the resident's care at the facility. The Responsible Party's allegations have included concerns regarding quality of care, neglect, infection prevention and control, documentation and evidentiary issues, and numerous other aspects of facility's care.The facility fully recognized and respected the right of every resident and representative to raise concerns, file complaints, and seek regulatory review without fear of retaliation. The Responsible Party's exercise of those rights was not the basis for the facility's decision regarding the resident's readmission. However, Resident 1's Responsible Party's position presented a significant inconsistency relevant to this appeal. The Responsible Party has repeatedly alleged that the facility has provided inadequate, neglectful, unsafe, or otherwise deficient care to the resident, yet simultaneously insisted that her mother be returned to that same facility. This contradiction was particularly significant now that resident's clinical needs have become more complex, the facility's ability to assign qualified nursing personnel to her care has been restricted, outside non-affiliated clinicians are reportedly involved without established coordination with the facility's interdisciplinary team, and the Responsible Party continued to refuse meaningful collaboration with the DON responsible for overseeing the resident's nursing care.The facility respectfully submitted that this raised a legitimate question: if the Responsible Party genuinely believed, as reflected by her repeated complaints and allegations, that facility cannot safely and appropriately care for resident, why did she simultaneously insist that the resident be returned to the facility under circumstances that have become even more clinically complex?The facility's position was not retaliatory and was not based upon the Responsible Party's exercise of her rights to make complaints. Rather, these documented circumstances demonstrated a fundamental contradiction between her repeated assertions regarding the facility's alleged inability to safely care for the resident and her current demand that the facility be compelled to readmit Resident 1.The facility has made repeated efforts to address the resident's clinical care, continuity of care, financial obligations, discharge planning, and alternative placement. Those efforts have not resulted in meaningful cooperation or a sustainable plan. Instead, the facility has continued to carry an unpaid balance approaching $70,000 while encountering significant barriers to communication, coordinated care planning, assignment of qualified nursing personnel, and the safe management of resident's increasingly complex clinical needs.Ultimately, the facility's decision must remain centered on whether this facility can safely, consistently, and appropriately meet the resident's current assessed clinical needs under the actual circumstances that existed today. The facility cannot responsibly accept full accountability for complex clinical care while simultaneously facing restrictions on which qualified nurses may provide that care, fragmented communication involving outside clinicians who did not coordinate with the facility's interdisciplinary team, and an ongoing refusal by the resident's representative to meaningfully communicate and collaborate with the DON responsible for overseeing that care.When considered as a whole-including the resident's increased clinical complexity and IV therapy needs; restrictions on qualified nursing personnel; lack of meaningful collaboration with the DON; fragmented involvement of outside, non-affiliated clinicians; two prior 30-day notices of discharge; an unpaid share-of-cost balance approaching $70,000; and an ongoing Adult Protective Services investigation concerning the management of the resident's funds and the Responsible Party's legal authority-the facility respectfully maintained that its decision was reasonable, clinically justified, and based upon the totality of the documented circumstances. On 8/7/26 at 1035 hours, a telephone interview was conducted with the Business Development Director. The Business Development Director stated the DON had been in communication with the Case Manager at the acute care hospital regarding Resident's 1 request for readmission to the facility. It was unclear as to when the initial request was made for readmission for Resident 1. On 8/7/26 at 1250 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the ADON. The ADON verified the Bed Hold Policy and Notification form for Resident 1 was incomplete. The ADON stated the form should be completed at the time of transfer although the resident's representative was informed of the bed hold policy at time of transfer but refused to sign. Additionally, the ADON also verified Resident 1 had no discharge planning during her recent readmission to the facility. On 8/7/26 at 1320 hours, a telephone interview was conducted with the Case Manager at Hospital A. The case manager stated Resident 1 was medically stable for discharge; however, the facility refused to readmit the resident. On 8/7/26 at 1345 hours, an interview was conducted with the Administrator. The Administrator confirmed he has received the result of the Appeal and had consulted with his legal team. At this time, the decision was made not to readmit the resident back to the facility. The Administrator was also informed and acknowledged the above findings related to the discharge process.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to thoroughly investigate an allegation of staff-to-resident abuse for one of four sampled residents (Resident 1). * The facility did not attempt to interview other residents under the care of the alleged CNA and/or other staff members who had contact with Resident 1 during time of the alleged incident. This failure had the potential to place the resident at risk for abuse and jeopardize their safety.Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating revised 1/2026 showed all reports of the resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The P&P also showed to interviews other residents to whom the accused employee provides care or services and to interviews staff members (on all shifts) who have had contact with the resident during the period of alleged incident. Medical record review for Resident 1 was initiated on 7/28/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Change of Condition Report dated 7/17/26, showed at approximately 2300 hours, Resident 1's family member came to the facility and reported the resident had been struck by a CNA. Review of the facility's 5-Day (five days) Follow-up Report dated 7/24/26, showed interview statements for Residents 1 and 2 ( Resident's 1 roommate). Additionally, the staff interviews included only the alleged CNA and two RNs. On 7/29/26 at 1020 hours, a telephone interview was conducted with RN 1. RN 1 stated Resident 1's family member reported the alleged abuse to her on 7/17/26. RN 1 stated after assessing Resident 1, she immediately informed the Administrator, DON, and physician, and completed reporting to the CDPH, Ombudsman, and local law enforcement within the required two hour timeframe. On 7/29/26 at 1209 hours, an interview was conducted with the DON. The DON stated the alleged abuse investigation was initiated immediately after receiving the allegation. The DON verified only the alleged CNA, two RN supervisors, and Residents 1 and 2 were interviewed. The DON stated a thorough abuse investigation should also include interviews with other residents under the care of the alleged CNA, as well as other staff who have worked with Resident 1 and the alleged CNA during the relevant timeframe.

Based on interview, medical record review, document review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for one of three sampled residents (Resident 1). * Resident 1 was assessed as a high fall risk, exhibited ongoing confusion and had multiple unwitnessed falls in the facility. There was no enhanced supervision such as 1:1 (one resident: one staff) monitoring implemented, despite the resident sustaining repeated unwitnessed falls and staff recognition regarding the resident not being able to follow instructions. This failure resulted in Resident 1 experiencing multiple unwitnessed falls, sustaining injuries including skin tears, and ultimately requiring a transfer to the acute care hospital. Resident 1 expired at the acute care hospital due to a traumatic subdural hematoma associated with recurrent mechanical ground-level falls.Findings: Review of facility's P&P titled Falls and Fall Risk, Managing dated 2001 showed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P&P further showed the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.if falling recurs despite initial intervention, staff will implement additional or different interventions or indicate why the current approach remains relevant.if underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable.the staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. Closed medical record review for Resident 1 was initiated on [DATE]. Resident 1 was admitted to the facility on [DATE], and discharged from the facility on [DATE]. Resident 1 was admitted with diagnoses including traumatic subdural hemorrhage with loss of consciousness, history of falling, difficulty in walking, muscle wasting and muscle weakness. Review of Resident 1's Fall Risk assessment dated [DATE], showed a score of 28, indicating the resident had a high risk for falls upon admission. Review of Resident 1's plan of care showed the following care plans initiated on [DATE]:- a care plan for history of falling with interventions including assisting with ambulation and toileting as needed, ensuring the call light and personal items were within reach, keeping the bed in the lowest position with the brakes locked, keeping the environment clutter free and well-lit and providing non-skid footwear;- a care plan for risk for falls with or without injury related to diuretic medication, with interventions including anticipating and meeting resident needs, educating/reminding the resident to call for assistance with all transfers, keeping the bed in low position with the brakes locked, keeping the call light within reach and keeping personal items frequently used within reach; and- a care plan for traumatic subdural hemorrhage with loss of consciousness status known, subsequent encounter with interventions including to implement safety precautions (fall precautions, bed in low position, assist with ambulation) to prevent injury, and to monitor for level of consciousness, orientation, pupil size and reactivity. Review of Resident 1's H&P examination dated [DATE], showed the resident was confused but not in distress. Review of Resident 1's Rehab Status Post Fall Screen dated [DATE], showed the resident had a fall on [DATE] at 1140 hours. Resident 1 had an unwitnessed fall in her room, and was found lying on her back with her knees up on the floor. Recommendations included to confer with the IDT regarding recommendations from therapy. Resident 1's BUE/BLE and AAROM were at baseline, bed in lowest position and call light with reach. Resident 1 received education on fall prevention and the recommendation was for nursing to offer the resident assistance out of bed in the mornings. Review of Resident 1's Fall Risk assessment dated [DATE], showed a score of 20, indicating the resident had a high risk for falls. Review of Resident 1's SBAR Communication Form dated [DATE], showed the change in condition observed was falls. The SBAR showed the resident had falls before and the treatment for the last episode of fall was N/A. The SBAR did not show the dates of the previous falls. Further review of the SBAR showed the following under the Resident/Patient Evaluation section:- under Mental Status Evaluation, Resident 1's status was altered; and- under Functional Status Evaluation, Resident 1's status was falls (one or more). Resident 1 also sustained a skin tear injury and skin discoloration post fall. Review of Resident 1's care plan for unwitnessed fall and is at risk for recurring falls initiated [DATE], showed interventions including keeping the bed in a low position with the brakes locked, keeping the call light within reach, keeping personal/frequently used items within reach and reviewing the medication regimen as indicated. Review of Resident 1's MDS Section C dated [DATE], showed the resident had a BIMS score of 5, indicating severe cognitive impairment. Review of Resident 1's Rehab Status Post Fall Screen dated [DATE], showed the resident had a fall on [DATE] at 1450 hours. Resident 1 had an unwitnessed fall in her room, and was found lying on the right floor side with her head facing the doorway. Recommendations included to confer with the IDT regarding recommendations from therapy and to provide medication review to promote improved sleep patterns and decrease impulsiveness. Review of Resident 1's Fall Risk assessment dated [DATE], showed a score of 26, indicating the resident had a high risk for falls. Review of Resident 1's SBAR Communication Form dated [DATE], showed the change in condition observed was falls. The SBAR showed the resident had falls before and the treatment for the last episode of fall was facility protocol. The SBAR did not further show any details for facility protocol under the treatment section. Further review of the SBAR showed the following under the Resident/Patient Evaluation section:- under Mental Status Evaluation, no changes observed; and- under Functional Status Evaluation, Resident 1's status was falls (one or more). Review of Resident 1's care plan for unwitnessed fall and is at risk for recurring falls initiated [DATE], showed the interventions included non-skid cushion in wheelchair, anticipating and meeting the resident's needs, educating/reminding the resident to call for assistance, encouraging activity as toleration with rest periods between activities as needed, keeping call light within reach and keeping personal/frequently used items within reach. Review of Resident 1's eINTERACT SBAR Summary for Providers dated [DATE], showed at 1350 hours, Resident 1 slid from chair to floor on [DATE]. Resident 1 was assisted into bed after being assessed. No new injuries were noted, IDT recommends to have LAL (low air loss, a specialized therapeutic medical bed designed to prevent and treat bed sores) mattress and non-skid cushion on wheelchair. Primary care provider responded with no new orders at this time. Review of Resident 1's Fall Risk assessment dated [DATE], showed a score of 22, indicating the resident had a high risk for falls. Review of Resident 1's care plan for unwitnessed fall initiated [DATE], showed interventions including a pressure sensitive alarm when resident was in bed, anticipating and meeting the resident's needs, keeping the bed in a low position with the brakes locked, keeping the call light within reach, and reviewing the medication regimen as indicated. Review of Resident 1's Order Summary Report showed a physician's order dated [DATE], for the resident to have bilateral floor mats on the floor next to the bed for every shift. Further review of the medical record failed to show an order for the bilateral floor mats was obtained before [DATE], for the previous falls. Review of Resident 1's SBAR Communication Form dated [DATE], showed the change in condition observed was altered mental status, falls. The SBAR showed the resident's symptoms got worse because of increased confusion and AMS. Further review of the SBAR showed the following under the Resident/Patient Evaluation section:- under Mental Status Evaluation, Resident 1's status was altered;- under Functional Status Evaluation, Resident 1's status was falls (one or more); and- under Behavioral Status Evaluation, Resident 1's status was personality change, due to barely verbally responding and having a fixated stare. Resident 1 also sustained a skin tear injury post fall. Review of Resident 1's care plan for unwitnessed fall initiated [DATE], showed interventions including transfer to the acute care hospital, anticipating and meeting the resident's needs, keeping the bed in a low position with the brakes locked and keeping the call light within reach. Review of Resident 1's IDT Progress Note dated [DATE], showed the following timeline of events:- on [DATE] at 1324 hours, Resident 1 had an unwitnessed fall in her room. Resident 1 had skin tears to UE/LE with scattered discolorations. Resident 1 was assessed and safety transferred to the bed. The physician, treatment nurse and emergency contact was notified;- on [DATE] at 1453 hours, Resident 1 was found in her room on the left side of the bed. Resident 1 was immediately assessed and able to move UE/LE without difficulty. Neuro checks were initiated for 72 hours, and the physician was notified. Resident 1 was non-compliant with safety measures, alert/oriented x 2 with confusion, required redirection. Resident 1 was instructed to use the call light, bed at lowest position, call light within reach, and continue with plan of care;- on [DATE] at 1350 hours, Resident 1 was found on the floor in her room. Resident 1 was noted sitting on her bottom on the floor with both legs extended and the wheelchair behind her. Resident 1 was alert and oriented at baseline, neuro checks initiated, and able to move UE/LE without difficulty. No injuries and vital signs were stable. Resident 1 could not recall what happened, education provided to the resident who verbalized understanding. IDT team recommends having a LAL mattress and non-skid cushion on wheelchair;-on [DATE] at 1525 hours, Resident 1 was found on the floor in her room. Resident 1 was noted lying on her back next to the bed with the bed in the lowest position. Resident 1 was alert and oriented at baseline, neuro checks initiated, able to move UE/LE without difficulty and resident's emergency contact/NP was notified. Resident 1 was educated on using the call light for assistance and the resident verbalized understanding; and- on [DATE] at 0400 hours, Resident 1 was found lying on the side of the bed with a skin tear injury to her right lower leg. Resident 1 had altered mental status and was not verbally responding. Resident 1's NP and emergency contact were notified, and the resident was transferred to the acute care hospital. Further review of the IDT Progress Note dated [DATE], showed prior interventions included anticipating and meeting the resident's needs, keeping the call light within reach and skilled PT/OT services. Current interventions included keeping the bed in a low position with locked brakes, review medications, non-skid cushion while in wheelchair, bilateral mats on the floor, pressure sensitive alarm when the resident was in bed and transfer to the acute care hospital. Review of Resident 1's Death Certificate dated [DATE], showed the resident passed away on [DATE]. Further review of the document showed the cause of death was listed as traumatic subdural hematoma and recurrent mechanical ground level falls. The Death Certificate showed the manner of death was accident, and injury occurred with unwitnessed falls. Review of the Coroner's Investigation Report dated [DATE], showed Resident 1 passed away at the acute care hospital on [DATE], due to traumatic subdural hematoma and recurrent mechanical ground level falls. Further review of the Coroner's Investigation report showed the following:- injury type was listed as falls, unwitnessed;- classification was accident, clinical;- Resident 1 was transported to the acute care hospital on [DATE], for complications of a fall she sustained approximately a week ago. Since her fall, she reportedly remained at her baseline of non-responsiveness;- imaging of her head was significant for a subdural hematoma and she was transferred to a different acute care hospital for higher level of care;- Resident 1 was not responsive to voice commands, and repeat imaging of her head showed a right subdural hematoma and left parietal convexity subdural hematoma. Resident 1 also had skin tears to her bilateral arms and shins;- Despite multiple interventions at the acute care hospital, Resident 1 remained minimally responsive and had a poor prognosis. Resident 1 was transitioned to comfort care measures and ultimately passed away on [DATE]. On [DATE] at 1628 hours, an interview was conducted with LVN 1. LVN 1 stated she was familiar with Resident 1. LVN 1 stated Resident 1 was confused at times, and did not have a 1:1 supervision. LVN 1 stated the resident had one fall on her shift, and believed it occurred the day before she was sent to the hospital. LVN 1 was unsure of the exact date of the fall. LVN 1 stated the staff monitored Resident 1 by doing frequent checks, neuro checks and checking vital signs. LVN 1 stated the resident had a behavior of getting out of bed because she was confused. LVN 1 stated if they saw the resident out of bed, they would go in and educate the resident on asking for assistance with the call light. LVN 1 further stated there were no floor mats on the floor nor any alarms when Resident 1 fell. LVN 1 stated the facility probably could have had a sitter to watch the resident to monitor her at all times. On [DATE] at 1520 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the DON. The DON stated Resident 1's cognitive status was confused and further stated a 1:1 supervision could have been beneficial to avoid the resident from falling. When asked why a 1:1 supervision was not considered, the DON stated she could not speak to that, it could be an intervention but also depended on staffing. The DON stated the facility did not implement floor mats until the fourth fall because other interventions were utilized and they did not want the resident to trip. On [DATE] at 1045 hours, an interview was conducted with the PT 1. PT 1 stated the rehab (rehabilitation) department did not recommend the resident to get out of bed and ambulate on her own. PT 1 further stated the resident was at risk for falls. On [DATE] at 1155 hours, an interview was conducted with LVN 2. LVN 2 stated if a resident could not follow instructions to use the call light for assistance and was a fall risk, the resident might need a sitter or 1:1 supervision. On [DATE] at 1210 hours, an interview was conducted with RN 1. RN 1 stated Resident 1 was confused, high fall risk, with repeated falls, and could not follow instructions. RN 1 stated with other interventions already in place, a sitter might have been the last effective resort. RN 1 verified Resident 1 did not have a sitter. On [DATE] at 1246 hours, an interview was conducted with LVN 3. LVN 3 stated Resident 1 was very confused with zero capacity to follow instructions. LVN 3 stated they tried to reorient her all the time and placed her room close to the nurses station, however as soon as they would talk to her, the resident would attempt to get out of bed again. LVN 3 stated the resident was trying to get up round the clock, and verified there was no sitter for Resident 1. On [DATE] at 1555 hours, an interview was conducted with the Administrator and DON. The Administrator and DON acknowledged the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 1) was readmitted back to the facility. * The facility failed to readmit Resident 1 back to the facility when the resident was transferred to an acute care facility. This failure had the potential for Resident 1 to have an inappropriate discharge.Findings: Review of the facility's P&P titled Transfer or discharge date d 2021 showed a transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility. A discharge refers to the movement of a resident from a bed in one certified facility to a bed and another certified facility or other location in the community, when returned to the facility is not expected. Medical record review for Resident 1 was initiated on 6/4/26. Resident 1 was admitted to the facility on [DATE], and transferred to an acute care facility on 4/7/26. Review of Resident 1's Eligibility Response dated 10/1/25, showed the resident was eligible for long term care. Review of Resident 1's Referral Information Form from the acute care facility dated 6/1/26, showed a referral request for Resident 1 to be transferred back to the facility. The document further showed the resident was projected to be discharged from the acute care facility on 6/2/26. On 6/3/26 at 0902 hours, the CDPH L&C Program received a report from the Office of Administrative Hearings and Appeals from the Department of Health Care Services. The report showed Resident 1 was granted an appeal for readmission to the facility on 5/1/26. The report further showed the following timeline of events: - on 4/7/26, Resident 1 was transferred from the facility to the hospital for treatment;- on 4/17/26, the representative filed an appeal of the facility's refusal to not readmit the resident; - on 4/30/26, the facility attempted to readmit the resident. Review of Resident 1's Social Services Progress Note dated 4/30/26, showed Family Member 1 spoke to the SSD regarding the facility not accepting the resident back today, and will be admitted tomorrow 5/1/26. Review of Resident 1's admission Record (Facesheet) showed the resident was readmitted to the facility on [DATE]. On 6/18/26 at 0921 hours, an interview and concurrent facility document review was conducted with the Business Offices Assistant (BOA). The BOA stated Resident 1 became a long-term custodial resident as of October 2025. On 6/18/26 at 1137 hours, an interview was conducted with the Administrator and DON. The Administrator and DON verified Resident 1 was a long-term custodial resident when she was transferred to the acute care facility on 4/7/26. The Administrator and the DON verified as a result, the resident would be permitted to remain in the facility. The Administrator and the DON acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for six of 27 final sampled residents (Residents 2, 5, 29, 74, 92, and 137) reviewed for oxygen therapy. * The facility failed to ensure Resident 2's oxygen tubing was labeled and dated. * The facility failed to ensure Resident 5's oxygen tubing was labeled and dated and inside a bag when not in use. * The facility failed to ensure a physician's order was obtained for Resident 29's use of the continuous oxygen therapy via the nasal cannula. * The facility failed to follow the physician's order for the administration of continuous oxygen for Resident 74. Resident 74 had a physician's order to receive continuous oxygen at a rate of two LPM; however, Resident 74 received continuous oxygen at a rate of three LPM. * The facility failed to ensure the signage for oxygen use was placed in Resident 92's room and to ensure Resident 92's nasal cannula tubing was labeled and dated. * Resident 137 received continuous oxygen therapy at two LPM via nasal cannula and CPAP at night. The facility failed to ensure the signage for oxygen use was placed outside of Resident 137's room. Additionally, the facility failed to clean the CPAP water chamber as per the user's guide and failed to ensure a care plan was developed for Resident 137's use of the CPAP machine and for the continuous oxygen therapy via the nasal cannula. These failures had the potential for the residents to not receive the appropriate care and may negatively impact the residents' medical conditions.Findings: Review of the facility's P&P titled Oxygen Administration dated 2001 showed to verify there is a physician's order for this procedure and to review the physician's orders or facility protocol for oxygen administration. Assemble the equipment and supplies as needed. Place an Oxygen in Use sign on the outside of the room entrance door. 1. On 5/18/26 at 0826 hours, during the initial tour of the facility, Resident 92 was observed lying in bed with the oxygen on via nasal cannula, which was attached to the oxygen concentrator machine and set at two LPM. In addition, during the observation, the oxygen tubing was not on Resident 92's nares, unlabeled, undated, and there was no oxygen signage posted on the door. On 5/18/26 at 0826 hours, an observation and concurrent interview was conducted with CNA 1. CNA 1 verified the nasal cannula was not on Resident 92's nares, CNA 1 donned gloves and applied the nasal cannula to Resident 92's nares. In addition, CNA 1 verified there was no label and date on the oxygen tubing and there was no oxygen signage on the resident's room. On 5/19/26 at 0900 hours, Resident 92 was observed lying in bed with the oxygen on via nasal cannula, which was attached to the oxygen concentrator machine and set at two LPM. Medical record review for Resident 92 was initiated on 5/18/26. Resident 92 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 92's Order Summary Report dated 5/2026 showed a physician's order dated 5/6/26, to administer oxygen at two LPM via nasal cannula continuously per concentrator or tank every shift. In addition, a physician's order dated 5/11/26 showed, to change oxygen tubing every day shift on Friday. Review of Resident 92's Care Plan Report dated 5/19/26, showed a care plan focus addressing the resident required the use of continuous oxygen. The interventions included to change the humidification and oxygen tubing as indicated. On 5/19/26 at 1603 hours, an interview and concurrent medical record review for Resident 92 was conducted with RN 4. RN 4 verified the above findings and stated CNA 1 should have informed the licensed nurse of the nasal cannula not on Resident 92's nares and the nasal cannula should have been labeled and dated, and the oxygen signage should have been posted in Resident 92's room. On 5/21/26 at 1536 hours, the DON and ADON were informed and acknowledged the above findings. 2. On 5/18/26 at 0700 hours, during the initial tour of the facility, Resident 29 was observed in bed receiving continuous oxygen therapy at two LPM via nasal cannula. Medical record review for Resident 29 was initiated on 5/18/26. Resident 29 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 29's H&P examination dated 4/28/26, showed Resident 29 had the capacity to understand and make decisions. Review of Resident 29's Order Summary Report dated 5/18/26, failed to show a physician's order for the administration of continuous oxygen therapy at two LPM via nasal cannula. On 5/18/26 at 0917 hours, an interview and concurrent observation and medical record review for Resident 29 was conducted with LVN 7. LVN 7 verified Resident 29 was receiving continuous oxygen at two LPM via nasal canula. LVN 7 stated there should be a physician's order for the administration of continuous oxygen therapy. LVN 7 reviewed Resident 29's medical record and verified the above findings. 3. Review of the facility's P&P title CPAP/BiPAP Support revised 1/2026 showed to review the physician's order to determine the oxygen concentration and flow, and the PEEP pressure (CPAP, IPAP, and EPAP) for the machine. Specific cleaning instruction guidelines are obtained from the manufacturer of the PAP device. To obtain a NO SMOKING sign for the resident's room. Review of the User Manual for the [NAME] G3 CPAP dated 2/29/24, showed cleaning the device and its accessories as recommended in the following sections is essential to prevent respiratory infections. Under the section Cleaning the Water Chamber showed to dilute Alconox to 1% with water 113 to 140 degrees F. To soak the water chamber in the detergent for five minutes. Clean the water chamber with a soft bristled brush for one minute. Then rinse the water chamber with running water for five minutes. Wipe it dry with a soft cloth or air dry it away from direct sunlight. WARNING- emptying and cleaning the water chamber daily will help prevent mold and bacteria growth. On 5/18/26 at 0702 hours, during the initial tour of the facility, Resident 137 was observed sleeping in bed and connected to the CPAP machine ([NAME] G3) on her bedside drawer. Resident 137 was also observed receiving continuous oxygen at two LPM via the nasal cannula. An oxygen in-use sign was not observed outside of Resident 137's room door. On 5/18/26 at 0920 hours, Resident 137 was observed resting in bed and receiving continuous oxygen at two LPM via the nasal canula. On 5/18/26 at 0925 hours, an interview and concurrent observation and medical record review for Resident 137 was conducted with LVN 7. LVN 7 stated Resident 137 received continuous oxygen at two LPM via nasal cannula. LVN 7 stated for the resident receiving continuous oxygen there should be a sign outside the door to notify others to prevent any hazards. LVN 7 verified the oxygen signage was not outside of Resident 137's room door. Medical record review for Resident 137 was initiated on 5/18/26. Resident 137 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 137's Order Summary Report dated 5/20/26, showed the following physician's orders: - dated 5/12/26, to administer continuous oxygen at two LPM via nasal cannula, every shift for shortness of breath. - dated 5/12/26, to change the CPAP water chamber every six months during the day shift, starting on the 12th for day one. (However, the physician's orders failed to show how often the water chamber should be cleaned). Review of Resident 137's plan of care with a print date of 5/20/26, failed to show documented evidence a care plan was developed to address Resident 137's use of the CPAP machine or the continuous oxygen therapy at two LPM via nasal cannula. On 5/21/26 at 1123 hours, a follow-up interview and concurrent medical record review for Resident 137 was conducted with LVN 7. LVN 7 stated Resident 137 was placed on the CPAP during the evening shift. LVN 7 reviewed Resident 137's medical record and verified a care plan was not developed to address Resident 137's use of the CPAP machine or her continuous oxygen therapy via NC. On 5/21/26 at 1420 hours, an interview and concurrent medical record review for Resident 137 was conducted with the DON. The DON stated there should be a physician's order for the administration of continuous oxygen therapy and there should be signage outside of the resident's door to prevent any accident hazards. The DON stated there should be a care plan developed for the use of the CPAP machine. The DON stated the care and maintenance for the CPAP machine should be done per the CPAP machine's user guide from the manufacturer. The DON verified the CPAP machine's user guide showed to clean the water chamber daily and verified there were no orders on the cleaning of the water chamber. On 5/21/26 at 1515 hours, an interview was conducted with the Administrator, ADON, and DON. The Administrator, ADON, and DON were informed and acknowledged the above findings. 4. On 5/18/26 at 0718 hours, during the initial tour of the facility, an interview and concurrent observation for Resident 2 was conducted with the ADON. Resident 2 was observed lying in bed, receiving oxygen at two LPM and that the nasal cannula tubing was observed unlabeled and undated. The ADON verified the findings and stated the oxygen tubing needed to be labeled and dated when it was changed; and needed to change every seven days to prevent infection. Medical record review for Resident 2 was initiated on 5/18/26. Resident 2 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 5/10/26, showed Resident 2 had the capacity to understand and make medical decisions. Review of Resident 2's Order Summary Report dated 5/20/26, showed the following physician's order: - dated 5/18/26, to administer oxygen at two LPM via nasal cannula as needed. - dated 5/18/26, to change oxygen tubing every Friday day shift. 5. On 5/20/26 at 0834 hours, during an observation of Resident 5 in his room, Resident 5 was observed lying in bed, with a portable oxygen machine beside Resident 5's bed. The resident's oxygen tubing was unlabeled and undated, coiled, and was hanging on the oxygen machine. On 5/20/26 at 0849 hours, an observation and concurrent interview for Resident 5 was conducted with LVN 3. LVN 3 verified the findings and stated the oxygen tubing needed to be labeled and dated when it was changed; and needed to be inside a bag when not in use to prevent infection. Medical record review for Resident 5 was initiated on 5/18/26. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 5's Order Summary Report, showed the following physician's order: -dated 3/17/26, to administer oxygen at two liters per minute via nasal cannula as needed. -dated 3/17/26, to change oxygen tubing every Monday day shift. Review of Resident 5's MDS admission assessment dated [DATE], showed Resident 5 had a BIMS score of 4 (meaning severe cognitive impairment). On 5/21/26 at 1334 hours, an interview and concurrent medical record review for Residents 2 and 5 was conducted with the DON. The DON verified Residents 2 and 5 had oxygen orders, and the licensed nurses needed to label the oxygen tubing with the date it was changed; and if not being used to make sure it was inside the bag to prevent infection. On 5/21/26 at 1403 hours, an interview was conducted with the Administrator, ADON, and DON. The Administrator, ADON, and DON were informed and acknowledged the above findings. 6. Review of the facility's P&P titled Oxygen Administration dated 2001 showed in preparation for the administration of oxygen, review the physician's order. Medical record review for Resident 74 was initiated on 5/18/26. Resident 74 was admitted to the facility on [DATE]. Review of Resident 74's Care Plan Report revised 4/10/26, showed a care plan focus titled Oxygen Therapy related to pulmonary edema. Review of Resident 74's Order Summary Report showed a physician's order dated 4/9/26, to administer oxygen continuously at a rate of two LPM via nasal cannula. On 5/18/26 at 1010 hours, an observation and concurrent interview was conducted with Resident 74. Resident 74 was observed lying in his bed and was receiving continuous oxygen via an oxygen concentrator and nasal cannula, at a rate of three LPM. Resident 74 stated he required continuous oxygen therapy otherwise he felt short of breath. Resident 74 stated he received oxygen therapy at a rate of three LPM. Resident 74 stated the nurses at the facility adjusted the rate of the oxygen he received. On 5/18/26 at 1015 hours, an observation and concurrent interview for Resident 74 was conducted with LVN 3. LVN 3 verified Resident 74 was receiving continuous oxygen via an oxygen concentrator and nasal cannula at a rate of three LPM throughout the day shift; however, the physician's order showed continuous oxygen was to be administered via nasal cannula at a rate of two LPM. LVN 3 stated she would contact Resident 74's physician to clarify the order. Cross reference F656

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate hemodialysis care was provided for two of four final sampled residents (Residents 29 and 60) reviewed for dialysis services. * The facility failed to ensure Resident 29's hemodialysis communication records were complete and accurate; and failed to ensure the accurate documentation of bruit (a turbulent whooshing sound heard with a stethoscope over a blood vessel) and thrill (the palpable vibration felt with your fingers in the same location). * The facility failed to ensure Resident 60's fluid intake was monitored per physician's order, and the dialysis access site was consistently and accurately assessed as ordered by the physician. These failures had the potential for the residents to not receive the appropriate hemodialysis care and treatment and could negatively affect the residents' well-being. Findings: Review of the facility's P&P titled Dialysis Services revised 11/2017 showed it is the policy of the facility that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice including: - the ongoing assessment of the residents condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility; - ongoing assessment and oversight of the resident before, and after dialysis treatments, including monitoring the resident's condition during treatments, monitoring for complications, implementing appropriate interventions, and using appropriate infection control practices; and - ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. 1. On 5/18/26 at 1250 hours, Resident 29 was observed sitting in the wheelchair with an AV shunt noted in Resident 29's left arm. Resident 29 stated he received hemodialysis treatment every Tuesdays, Thursdays, and Saturdays. Medical record review for Resident 29 was initiated on 5/18/26. Resident 29 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 29's H&P examination dated 4/28/26, showed Resident 29 had the diagnosis of End Stage Renal Disease (ESRD, when the kidneys no longer function well enough to meet a body's needs, treatment involves kidney dialysis or kidney transplant), was on dialysis, and Resident 29 had the capacity to understand and make decisions. Review of Resident 29's Order Summary Report showed the following physician's orders: - dated 4/27/26, for Resident 29's AV fistula shunt (surgically created connection between and artery and vein for hemodialysis) on the left upper arm, to monitor for the presence of bruit (auscultation) and thrill (palpation of vibration) every shift. To document if bruit and thrill is present (+) or absent (-); and to notify the physician if unable to auscultate or palpate, - dated 4/29/26, for Resident 29's hemodialysis treatments every Tuesday, Thursdays, and Saturdays with Dialysis Center A. The chair time: 0900 to 1230 hours, and - dated 5/6/26, for Resident 29's pre and post dialysis weights to be obtained while at the dialysis center. a. Review of Resident 29's Hemodialysis Communication Records showed the following missing and/or inaccurate documentation: - dated 4/8/26, the dialysis access was in the right arm, and the assessment of the dialysis access site was blank; - dated 4/9/26, the post-dialysis weight was not documented; - dated 4/11/26, the post-dialysis weight was not documented, the dialysis access was in the right arm, and the assessment of the dialysis access site was blank; - dated 4/14/26, the assessment for the dialysis access site and for the presence of bruit and thrill were blank; - dated 4/16/26, the thrill was documented as absent; - dated 4/28/26, the assessment for the dialysis access site was blank; - dated 5/9/26, the assessment for the dialysis access site and for the presence of bruit and thrill were blank; - dated 5/14/26, the resident's name was not documented, and the dialysis access- type, location, site assessment, presence of bruit and thrill were blank; - dated 5/16/26, the post dialysis weight and vital signs: temperature, pulse, respirations, BP, and pain, were not documented, and the assessment of the dialysis access site and the dialysis nurse's signature were blank. b. Review of Resident 29's MAR for May 2026 showed the following documentation for the assessment of Resident 29's AV fistula. - on 5/4, 5/5, and 5/11/26, for the day shift, the licensed nurse documented - for the presence of thrill, - on 5/11/26, for the evening shift, the licensed nurse documented - for the presence of thrill, and - on 5/18/26, during the night shift, the licensed nurse documented - for the presence of bruit and thrill. Review of Resident 29's medical record failed to show any documentation the physician was notified of the absence of bruit and thrill for the above dates. On 5/19/26 at 1539 hours, an interview and concurrent medical record review for Resident 29 was conducted with LVN 6. LVN 6 stated Resident 29 had a dialysis access in the left arm and the dialysis access was monitored every shift for the presence of bruit and thrill, and for any bleeding or signs or symptoms of infection. LVN 6 stated upon the resident's return from the dialysis center, the licensed nurse was responsible for checking the Hemodialysis Communication Record to ensure it was completed. LVN 6 reviewed Resident 29's medical record and verified the above findings. On 5/21/26 at 1420 hours, an interview was conducted with the DON. The DON stated the hemodialysis communication record was a form of communication between the facility and the dialysis center. The DON stated upon the resident's return to the facility, the licensed nurse was responsible for reviewing the hemodialysis communication record for any orders and to check for completeness. The DON further stated the hemodialysis communication record should be complete and accurate. The DON stated the licensed nurses were responsible for the assessment of bruit and thrill and if - was documented, the physician should be notified. On 5/21/26 at 1515 hours, an interview was conducted with the Administrator, ADON, and DON. The Administrator, ADON, and DON were informed and acknowledged the above findings. 2. Review of the facility's P&P titled Care of a Resident with End-Stage Renal Disease date revised 1/2026 showed residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. Education and training of staff includes, specifically: the nature and clinical management of ESRD (including infection prevention and nutritional needs); the type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis; signs and symptoms of worsening condition and/ or complications of ESRD; the care of grafts and fistulas. In addition, further review of the facility's P&P titled Fluid Restriction (undated) showed intake and output monitoring shall be completed only when specifically ordered by the physician/ provider or when clinically indicated per facility process. Medical record review for Resident 60 was initiated on 5/18/26. Resident 60 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 60 had a diagnosis of ESRD which required hemodialysis. Review of Resident 60's Quarterly MDS dated [DATE], showed Resident 60 had a BIMS of 13 (8-12 moderately impaired cognition). Review of Resident 60's Order Summary Report dated 5/2026 showed a physician's order dated 11/19/24, to check the right forearm AV fistula for the presence of bruit and thrill every shift, if negative to notify the physician. Monitor for bleeding, drainage, excessive warmth, pain, redness, numbness in fingers, tenderness, or swelling every shift. Further review of Resident 60's Order Summary Report dated 5/2026 showed a physician's order dated 2/17/26, for Renal, double protein diet. Fluid restrictions of 1500 ml per day. Review of Resident 60's care plan report showed a care plan focus dated 6/14/25, addressing Resident 60's hemodialysis treatment and access site location to right upper extremity AVF. Interventions showed to check AVF dressing upon return from dialysis. Monitor AVF for bleeding, drainage, excessive warmth, pain, redness, numbness in fingers, tenderness, or swelling every shift. Report abnormalities to the physician. Monitor for the presence of bruit and thrill every shift. Further review of Resident 60's care plan report showed a care plan focus addressing Resident 60's fluid restriction, dated 11/5/24; however, interventions failed to show to monitor Resident 60's intake and output. Further review of Resident 60's medical record failed to show the fluid intake for Resident 60 was monitored and documented. Review of the Hemodialysis Communication Records for March, April, and May 2026 showed the following: - On 3/7/26, the dialysis access site assessment/ observation was left blank, it was assessed for bruit marked as both present and absent and thrill was left blank. - On 3/21/26, the dialysis access site assessment/ observation was left blank, it was assessed for bruit marked as both present and absent and thrill was left blank. - On 4/4/26, the dialysis access site assessment/ observation was left blank, it was assessed for bruit marked as both present and absent and thrill was left blank. - On 4/11/26, the dialysis access site assessment/ observation was left blank and bruit was left blank. - On 4/18/26, the dialysis access site location was documented as the left arm and the dialysis access site assessment/ observation was left blank, bruit was left blank and it was assessed for thrill marked as both present and absent. - On 4/25/26, the dialysis access site assessment/ observation was left blank and marked as N/A. - On 5/2/26, the dialysis access site assessment/ observation was left blank. - On 5/9/26, the thrill was assessed and marked as both present and absent. - On 5/14/26, the thrill was left blank. On 5/20/26 at 1402 hours, an interview and concurrent medical record review for Resident 60 was conducted with RN 4. RN 4 verified the above findings and stated the purpose of the dialysis communication records was to provide updates on the resident's condition, pre and post dialysis, therefore the dialysis communication form should have been completed accurately. In addition, RN 4 verified the fluid intakes for Resident 60 were not recorded and stated it was informational for staff to be aware how much fluids the resident should consume. On 5/21/26 at 1536 hours, the DON and ADON were informed and acknowledged the above findings.

Based on interview, medical record review, facility document review, and facility's P&P review, the facility failed to ensure the Consultant Pharmacist's recommendation were acted upon for four of five residents (Residents 3, 4, 7, and 60) reviewed for unnecessary medications. * The facility failed to ensure the Consultant Pharmacist's recommendations for March 2026 were followed up for Resident 3's use of the metoclopramide (anti-nausea), pantoprazole, and sucralfate (medication to treat and prevent gastrointestinal ulcers) medications. * The facility failed to ensure the Consultant Pharmacist's recommendations for March 2026 were followed up for Resident 4's use of Lovenox (anticoagulant) and Prednisone (medication used to rapidly reduce inflammation and suppress an overactive immune system) medications. * The facility failed to ensure Resident 7's pantoprazole (medication that reduces the amount of acid produced in the stomach) medication recommendation to lower the frequency from twice a day to everyday was followed up with the physician. * The facility failed to ensure the Consultant Pharmacist's recommendations for February 2026 for phenobarbital (medication to control certain types of seizures, anxiety, and manage withdrawal symptoms from other sedative medications) level was acted upon promptly for Resident 60. These failures had the potential to put residents at risk for adverse consequences related to the medications. Findings: Review of the facility's P&P titled Medication Regimen Reviews (undated) showed a licensed pharmacist reviews the medication regimen of each resident at least monthly. The purpose of the medication regimen review is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. The medication regimen review includes a review of medical records to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities, for example, the use of medication. a. inconsistent with accepted pharmaceutical services, standard of practice; b. not supported by medical evidence; c. that impeded or interfere with achieving the intended outcomes of pharmaceutical services; d. ordered without clinical indication or in excessive dose e. administered without adequate monitoring or in the presence of adverse consequences; and/or f. that appears to be inconsistent with the resident stated preference 1. Medical record review for Resident 7 was initiated on 5/18/26. Resident 7 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 7's MDS quarterly assessment dated [DATE], showed a BIMS score of 13 (meaning cognitively intact). Review of Resident 7's Order Summary Report showed the following physician's order dated 12/27/25, to give pantoprazole 40 mg one tablet by mouth two times a day (30 to 60 minutes before meals) for gastrointestinal protection. Review of the Consultant Pharmacist's Medication Regimen Review between 2/2 to 2/5 and 3/13 to 3/15/26, showed a documentation Resident 7 was taking pantoprazole 40 mg twice a day, typically a proton-pump inhibitor is given once -daily. There was a recommendation for a possible duration of therapy for the twice a day dose and to consider a reduction for once daily. On 5/20/26 at 1415 hours, an interview and concurrent medical record review for Resident 7 was conducted with the ADON. The ADON verified the 2/2026 and 3/2026 Consultant Pharmacist's Medication Regimen Review for Resident 7 was not followed up with the resident's physician. The ADON further stated that when they received the Medication Regimen Review from the Consultant Pharmacist, they needed to follow up with the physician as soon as possible before the next Medication Regimen Review. On 5/21/26 at 1334 hours, an interview and concurrent medical record review for Resident 7 was conducted with the DON. The DON verified Resident 7's Medication Regimen Review recommendation was not follow up with the resident's physician. On 5/21/26 at 1403 hours, an interview was conducted with the Administrator, ADON, and DON. The Administrator, ADON, and DON were informed and acknowledged the above findings. 2. Medical record review for Resident 3 was initiated on 5/18/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's MDS assessment dated [DATE], showed Resident 3 had moderately impaired cognition. Review of Resident 3's Order Summary Report dated 5/21/26, showed the following physician's orders: - dated 1/23/26, to administer metoclopramide 5 mg one tablet by mouth before meals for gastroesophageal reflux disease (GERD, a condition where stomach contents frequently flow back into the esophagus, causing irritation and symptoms like heartburn), - dated 1/23/26, to administer pantoprazole delayed release 40 mg one tablet by mouth two times a day for GERD, and - dated 1/23/26, to administer sucralfate 1 gm/10 ml give 10 ml before meals and at bedtime for GERD. Review of the Consultant Pharmacist's Medication Regimen Review between 3/13 to 3/15/26, showed the following recommendations for Resident 3: - The usual maintenance does of Carafate (brand name for sucralfate) was 1 gm two times a day. Resident 3 was currently on Carafate 1 gm four times a day. Is a dose reduction to 1 gm two times a day clinically warranted? - Resident 3 has orders for both pantoprazole and metoclopramide for GERD. Would it be possible to discontinue one of these orders, as the combination may be considered duplicate therapy? On 5/21/26 at 0954 hours, an interview and concurrent medical record review for Resident 3 was conducted with RN 4. RN 4 stated the Consultant Pharmacist reviewed each resident's medication regimen monthly and made recommendations. RN 4 stated the desk nurses or the RN Supervisors were responsible for following up with the recommendations as soon as possible. RN 4 stated if there were no response from the physician, the desk nurse or RN Supervisors should continue to contact the physician until a response was obtained and should document the attempts. RN 4 reviewed Resident 3's medical record and verified the above findings. RN 4 stated he was unable to find the documentation to show the recommendations were followed up or the physician's response to the recommendations. On 5/21/26 at 1420 hours, an interview was conducted with the DON. The DON stated the recommendations from the Consultant Pharmacist should be communicated to the physician and followed-up on as soon as possible. The DON further stated if there was no response from the physician, the facility should continue to follow-up with the physician and document the physician was made aware and any response from the physician. On 5/21/26 at 1515 hours, an interview was conducted with the Administrator, ADON, and DON. The Administrator, ADON, and DON were informed and acknowledged the above findings. 3. Review of Resident 4's medical record was initiated on 5/18/26. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 4's untitled MDS assessment dated [DATE], showed Resident 4 had a BIMS of 5 (0-7 severely impaired cognition). Review of Resident 4's Order Summary Report for 5/2026 showed the following physician's order dated 3/6/26, for enoxaparin sodium (generic name for Lovenox) injection prefilled syringe kit 40 mg/ 0.4 ml, inject 0.4 ml subcutaneously daily for DVT prophylaxis, rotate site of injection; and prednisone oral tablet 10 mg give one tablet by mouth daily for inflammation. Review of the Consultant Pharmacist's Medication Regimen Review between 3/13 to 3/15/26, showed the following recommendations for Resident 4: - Can we obtain a duration of therapy for Lovenox. This class of medication only has FDA-approved indications for DVT prophylaxis from 7-35 days, or until the risk of DVT has been significantly reduced. - Please clarify the indication for the prednisone as inflammation may be considered too vague. On 5/21/26 at 0954 hours, an interview and concurrent medical record review for Resident 4 was conducted with RN 4. RN 4 stated the Consultant Pharmacist reviewed each resident's medication regimen monthly and made recommendations. RN 4 stated the desk nurses or the RN Supervisors were responsible for following up with the recommendations as soon as possible. RN 4 stated if there were no response from the physician, the desk nurse or RN Supervisors should continue to contact the physician until a response was obtained and should document the attempts. RN 4 reviewed Resident 4's medical records and verified the above findings. RN 4 stated he was unable to find the documentation to show the recommendations were followed up or the physician's response to the recommendations. On 5/21/26 at 1124 hours, an interview and concurrent medical record review for Resident 4 was conducted with the ADON. The ADON verified the above findings and stated the pharmacist came to the facility once a month and pharmacy recommendations were acted upon as soon as possible. The ADON verified Resident 4's medical record failed to show any documentation to show the pharmacy recommendations were addressed. On 5/21/26 at 1536 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 4. Medical record review for Resident 60 was initiated on 5/18/26. Resident 60 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 60's Quarterly MDS assessment dated [DATE], showed Resident 60 had a BIMS of 13 (8-12 moderately impaired cognition). Review of Resident 60's Order Summary Report dated 5/2026 showed a physician's order dated 10/9/22, for phenobarbital tablet 64.8 mg, give one tablet by mouth two times a day for seizures. Review of the Consultant Pharmacist's Medication Regimen Review between 2/2 to 2/5/26, showed the following recommendation for Resident 60: - To comply with CMS regulations which require monitoring of drug-related lab work, please ask the doctor if we can obtain an order for the following lab work for monitoring purposes: phenobarbital recheck. Under recommendation status showed, pending and sent to NP/ MD on 5/17/26 at 1048 hours. On 5/21/26 at 0954 hours, an interview and concurrent medical record review for Resident 60 was conducted with RN 4. RN 4 stated the Consultant Pharmacist reviewed each resident's medication regimen monthly and made recommendations. RN 4 stated the desk nurses or the RN Supervisors were responsible for following up with the recommendations as soon as possible. RN 4 stated if there were no response from the physician, the desk nurse or RN Supervisors should continue to contact the physician until a response was obtained and should document the attempts. RN 4 reviewed Resident 60's medical records and verified the above findings. RN 4 stated he was unable to find the documentation to show the recommendation was followed up or the physician's response to the recommendation sooner. On 5/21/26 at 1108 hours, an interview and concurrent medical record review for Resident 60 was conducted with the ADON. The ADON verified the above findings and stated the pharmacist came once a month and pharmacy recommendations were acted upon as soon as possible. The ADON verified Resident 60's medical records failed to show any documentation to show the pharmacy recommendation was addressed sooner and stated if the lab was not monitored, it can potentially lead for Resident 60 to have a seizure. On 5/21/26 at 1536 hours, and interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to maintain the hood over the stove in a clean and sanitary condition. * The facility failed to ensure the kitchen utensils had smooth, cleanable surfaces and were maintained in good repair. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the cutting boards were maintained in sanitary condition and had smooth, cleanable surfaces. * The facility failed to ensure the heavy-duty blender, and the clear plastic rectangular food-storage containers were air dried prior to storage. These failures had the potential to cause cross contamination and foodborne illness to the residents consuming the food prepared in the kitchen.Findings: Review of the facility's Diet Type Report dated 5/18/26, showed 115 of 121 residents consumed the food prepared in the kitchen. 1. Review of the facility's P&P titled Hood, Vents and Filters dated 2018 showed the hoods must be cleaned every two weeks and must be free of dust and grease. According to the USDA Food Code 2022 Section 4-204.11 Ventilation Hood Systems, Drip Prevention the dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean. On 5/18/26 at 0619 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The kitchen hood over the stove had black, dirty, grease residue. The DSS acknowledged the findings and stated the dietary staff cleaned the hood once a week on Thursdays and the hood was also cleaned by an outside company every six months. The sticker on the hood showed it was last serviced on 2/19/26. 2. Review of the facility's P&P titled Sanitization revised date 11/2022 showed all utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Plastic ware, China, and glassware that cannot be sanitized or are hazardous because of chips, cracks or loss of glaze are discarded. Damaged or broken equipment that cannot be repaired is discarded. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 5/18/26 at 0619 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The following was observed: - One stainless steel slotted spatula with black handle was partially melted. - One stainless steel scoop with blue handle partially chipped and broken. - One rubber spatula with red handle had chipped and cracked edges. - One stainless steel dough cutter with black handle partially melted. The DSS verified the above findings and stated all kitchen utensils and equipment should have been discarded and replaced. 3. Review of the facility's P&P titled Dishwashing dated 2018 showed all the dishes will be properly sanitized through the dishwasher. Gross food particles shall be removed by careful scraping and pre-rinsing in running water. Dishes are to be racked loosely without overlapping. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2022, 4-602.13, Nonfood- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 5/18/26 at 0619 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The following was observed: - Three stainless steel spatulas with white handles had fuzzy films and watermarks. - One stainless steel scoop with white handle had fuzzy films. - Three stainless steel scoops had dry, crusted residue and fuzzy films. - One stainless steel slotted spatula with black handle had dry crusted residue and fuzzy films. - One stainless steel slotted spoon with black handle had watermarks and fuzzy films. - Three stainless steel scoops with blue handles had dry, crusted residue and fuzzy films. - Three stainless steel scoops with gray handles had dry crusted residue and fuzzy films. - Three stainless steel scoops with white handles had dry crusted residue and fuzzy films. - One stainless steel scoop with black handle had dry crusted residue and fuzzy films. The DSS verified the above findings and stated all kitchen utensils and equipment should have been washed properly for infection control purposes. 4. Review of the facility's P&P titled Sanitization date revised 11/2022 showed cutting boards are washed and sanitized between uses. Damaged or broken equipment that cannot be repaired is discarded. According to the USDA Food Code 2022 Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. On 5/18/26 at 0619 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. Green, yellow, blue, red, brown and white cutting boards were observed fuzzy, heavily marred and had deep groves. The DSS verified the findings and stated cutting boards were replaced every three months. 5. Review of the facility's P&P titled Sanitization date revised 11/2022 showed the food preparation equipment and utensils that are manually washed are allowed to air dry whenever practical. Drying food preparation equipment and utensils with a towel or cloth may increase risks for cross contamination. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. On 5/18/26 at 0619 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The following was observed: - One heavy-duty blender stored on the metal rack shelf was observed still wet with visible water inside. - Five rectangular clear bucket containers used for food storage were observed wet with visible water inside and stacked on top of each other. The DSS verified the above findings and stated all kitchen utensils and equipment should have been air dried to prevent bacteria growth. On 5/21/26 at 1536 hours, an interview was conducted with the DON and ADON. The DON and ADON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for five of 27 final sampled residents (Resident 4, 7, 29, 60, and 73) were complete and accurately documented. * Resident 4's POLST showed she had no advance directive; however, Resident 4's medical record showed she had an advance directive and a copy of the advance directive was in her medical record. * The facility failed to ensure Resident 7's blood pressure access site was accurately documented in the resident's medical record with right upper arm AV site. * The facility failed to ensure accurate documentation in the medical record for Resident 29. Resident 29 had the hemodialysis access on the left arm; however the documentation showed Resident 29's blood pressures were obtained in the left arm. * The facility failed to ensure Resident 60's blood pressure access site was accurately documented in the resident's medical record with right upper arm AVF site. * The facility failed to ensure Resident 73 's blood pressure access site was accurately documented in the medical record with left upper arm AV site. These failures had the potential for the residents' care needs not being met as their medical information were inaccurate and incomplete. Findings: Review of the facility's P&P titled End-Stage Renal Disease, Care of a Resident with, revised 1/2026 showed residents with end stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Education and training of staff include, specifically: g. the care of grafts and fistula 1. Medical record review for Resident 7 was initiated on 5/18/26. Resident 7 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 7's MDS quarterly assessment dated [DATE], showed Resident 7 had a BIMS score of 13 (meaning cognitively intact). Review of Resident 7's Order Summary Report showed a physician's order dated 4/13/25, to avoid taking blood pressure, performing venipuncture, giving injections, strenuous activity, or applying restrictive clothing or restraint on the right upper extremity AV site. Review of Resident 7's Weights and Vitals Summary documentation of blood pressure for April and May 2026 showed the following: - On 4/30/26 at 0530 hours, a BP reading of 126/80 mmHg on the right arm; - On 4/30/26 at 0737 hours, a BP reading of 126/80 mmHg on the right arm; - On 5/5/26 at 1240 hours, a BP reading of 137/78 mmHg on the right arm; - On 5/10/26 at 0904 hours, a BP reading of 120/66 mmHg on the right arm; - On 5/10/26 at 0906 hours, a BP reading of 120/66 mmHg on the right arm; and - On 5/18/26 at 1613 hours, a BP reading of 137/71 mmHg on the right arm; On 5/18/26 at 0717 hours, during the initial tour of the facility, Resident 7 was observed awake, lying on the bed with a right upper arm AV shunt. Resident 7 stated he went to dialysis every Tuesday, Thursday, and Saturday. On 5/20/26 at 0816 hours, an interview was conducted with Resident 7. Resident 7 stated he never allowed the licensed nurses to take his BP on the right upper arm. On 5/20/26 at 1426 hours, an interview and concurrent medical record review for Resident 7 was conducted with LVN 1. LVN 1 verified the documentation for the blood pressure reading was on the right upper arm. LVN 1 further stated taking blood pressure on the access site increased the resident risk for infection and blood clot to the left AV shunt. 2. Medical record review for Resident 73 was initiated on 5/18/26. Resident 73 was admitted to the facility on [DATE]. Review of Resident 73's H&P examination dated 4/1/26, showed Resident 73 had the capacity to understand and make medical decisions. Review of Resident 73's Order Summary Report showed a physician's order dated 5/1/26, to avoid taking blood pressure, performing venipuncture, giving injections, strenuous activity, or applying restrictive clothing or restraint on the left upper extremity AV site. Review of Resident 73's Weights and Vitals Summary documentation of blood pressure for May 2026 showed the following: - On 5/5/26 at 1637 hours, a BP reading of 140/76 mmHg on the left arm; - On 5/6/26 at 0950 hours, a BP reading of 131/67 mmHg on the left arm; - On 5/8/26 at 1431 hours, a BP reading of 103/61 mmHg on the left arm; - On 5/13/26 at 0135 hours, a BP reading of 133/73 mmHg on the left arm; - On 5/15/26 at 1430 hours, a BP reading of 143/65 mmHg on the left arm; - On 5/16/26 at 0939 hours, a BP reading of 152/74 mmHg on the left arm;; - On 5/17/26 at 1441 hours, a BP reading of 147/70 mmHg on the left arm; and - On 5/18/26 at 0931 hours, a BP reading of 137/61 mmHg on the left arm; On 5/18/26 at 0659 hours, during the initial tour of the facility, Resident 73 was observed awake, lying on the bed, with Nepro (a specialized, high-calorie, and protein-dense enteral feeding designed specifically for residents with chronic kidney disease on dialysis) at 50 ml/hr running via enteral pump. Resident 73 stated he went to dialysis every Monday, Wednesday, and Friday, with AV site to the left upper arm. On 5/19/26 at 1437 hours, an interview and concurrent medical record review for Resident 73 was conducted with LVN 1. LVN 1 verified the documentation for the blood pressure reading was on the left upper arm. LVN 1 further stated taking blood pressure on the access site increased the resident risk for infection and blood clot to the left AV shunt. On 5/20/26 at 0828 hours, an interview was conducted with Resident 73. Resident 73 stated he never allowed the licensed nurses to take his BP on the left upper arm. On 5/21/26 at 1334 hours, an interview was conducted with the DON. The DON verified the above findings and stated she expected the licensed nurses to follow the MD orders to avoid taking blood pressure on the AV site of the residents who went to dialysis. The DON further stated the pressure from the blood pressure cuff will cause the AV site to clot and burst. On 5/21/26 at 1403 hours, an interview was conducted with the Administrator, ADON, and DON. The Administrator, ADON, and DON were informed and acknowledged the above findings. 3. Review of the facility's P&P titled Charting and Documentation revised 1/2026 showed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record may be electronic, manual, or a combination. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Medical record review for Resident 60 was initiated on 5/18/26. Resident 60 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 60 had a diagnosis of ESRD which required hemodialysis. Review of Resident 60's Quarterly MDS assessment dated [DATE], showed Resident 60 had a BIMS score of 13 (8-12 moderately impaired cognition). Review of Resident 60's Order Summary Report dated 5/2026 showed a physician's order dated 10/10/22, to not take blood pressure, venipuncture, give injections, apply restraints, or restrictive clothing to right upper extremity AV site. Review of the care plan report showed a care plan focus dated 6/14/25, addressing Resident 60's hemodialysis treatment and access site location to right upper extremity AVF. The care plan interventions showed to avoid taking blood pressure, performing venipuncture, giving injections, strenuous activity, or applying restrictive clothing, or restraints on the right upper extremity AV site. Review of Resident 60's Weights and Vitals Summary documentation of blood pressure for March, April, and May 2026 showed the following: - On 3/13/26 at 0829 hours, a BP reading of 112/51 mmHg on the right arm; - On 3/16/26 at 0846 hours, a BP reading of 140/66 mmHg on the right arm; - On 3/22/26 at 1557 hours, a BP reading of 137/71 mmHg on the right arm; - On 3/31/26 at 0838 hours, a BP reading of 144/70 mmHg on the right arm; - On 4/29/26 at 1606 hours, a BP reading of 137/65 mmHg on the right arm; - On 4/30/26 at 1632 hours, a BP reading of 127/63 mmHg on the right arm; - On 5/3/26 at 2019 hours, a BP reading of 141/72 mmHg on the right arm; - On 5/3/26 at 0843 hours, a BP reading of 137/72 mmHg on the right arm; - On 5/5/26 at 1642 hours, a BP reading of 139/78 mmHg on the right arm; - On 5/8/26 at 0824 hours, a BP reading of 123/60 mmHg on the right arm; - On 5/12/26 at 1616 hours, a BP reading of 145/73 mmHg on the right arm; and - On 5/17/26 at 1611 hours, a BP reading of 130/57 mmHg on the right arm On 5/21/26 at 0945 hours, an interview and concurrent medical record review for Resident 60 was conducted with RN 4. RN 4 verified the above findings and stated the staff should not check Resident 60's blood pressure on his right upper extremity and should have been documented accurately for the correct arm used for blood pressure check. On 5/21/26 at 1536 hours, an interview was conducted with the DON and ADON. The DON and ADON were informed and acknowledged the above findings. 4. Review of the facility's P&P titled Advance Directives revised 1/2026 showed prior to or upon admission of a resident, the social services director or designee inquires of the resident, their family members and/or their legal representative, about existence of any written advance directives. If the resident or the resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff. Review of Resident 4's medical record was initiated on 5/18/26. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 4's untitled MDS assessment dated [DATE], showed Resident 4 had a BIMS score of 5 (0-7 severely impaired cognition). Review of Resident 4's POLST dated 4/27/26, showed under Section D, Resident 4 had no advance directive. Further review of Resident 4's medical record showed Resident 4 had formulated an advance directive and a copy of an advance directive was in Resident 4's medical record dated 5/8/25. On 5/21/26 at 1355 hours, an interview and concurrent medical record review for Resident 4 was conducted with the SSD. The SSD acknowledged the above findings and stated the POLST will be revised to reflect Resident 4 had an advance directive to avoid confusion. On 5/21/26 at 1536 hours, an interview was conducted with the DON and ADON. The DON and ADON were informed and acknowledged the above findings. 5. On 5/18/26 at 1250 hours, Resident 29 was observed sitting in the wheelchair and eating his lunch. Resident 29 was observed with a hemodialysis access in the left arm. Resident 29 stated he received hemodialysis treatments every Tuesday, Thursday, and Saturday. When asked, Resident 29 denied the staff taking blood pressures on his left arm. Medical record review for Resident 29 was initiated on 5/18/26. Resident 29 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 29's H&P examination dated 4/28/26, showed Resident 29 had the capacity to understand and make decisions. Review of Resident 29's Order Summary Report dated 5/18/26, showed a physician's order dated 5/6/26, to avoid taking blood pressure, performing venipuncture, giving injections, strenuous activity, or applying restrictive clothing or restraint on the left arm extremity arteriovenous (AV) site. Review of Resident 29's Weights and Vitals Summary from 5/1 to 5/19/26, showed the following documentation for the blood pressure readings: - On 5/1/26 at 0623 hours, a BP reading of 120/76 mmHg on the left arm; - On 5/1/26 at 1456 hours, a BP reading of 93/43 mmHg on the left arm; - On 5/1/26 at 2021 hours, a BP reading of 135/78 mmHg on the left arm; - On 5/2/26 at 0638 hours, a BP reading of 127/74 mmHg on the left arm; - On 5/2/26 at 2045 hours, a BP reading of 115/74 mmHg on the left arm; - On 5/3/26 at 2101 hours, a BP reading of 101/82 mmHg on the left arm; - On 5/4/26 at 0556 hours, a BP reading of 120/66 mmHg on the left arm; - On 5/4/26 at 1300 hours, a BP reading of 122/64 mmHg on the left arm; - On 5/5/26 at 0641 hours, a BP reading of 136/70 mmHg on the left arm; - On 5/5/26 at 2143 hours, a BP reading of 123/77 mmHg on the left arm; - On 5/7/26 at 2304 hours, a BP reading of 101/71 mmHg on the left arm; - On 5/8/26 at 0641 hours, a BP reading of 120/62 mmHg on the left arm; - On 5/9/26 at 2112 hours, a BP reading of 106/73 mmHg on the left arm; - On 5/10/26 at 1145 hours, a BP reading of 101/75 mmHg on the left arm; - On 5/10/26 at 1845 hours, a BP reading of 115/79 mmHg on the left arm; - On 5/10/26 at 2100 hours, a BP reading of 112/76 mmHg on the left arm; - On 5/11/26 at 0555 hours, a BP reading of 122/65 mmHg on the left arm; - On 5/11/26 at 2113 hours, a BP reading of 116/72 mmHg on the left arm; - On 5/12/26 at 2044 hours, a BP reading of 102/71 mmHg on the left arm; - On 5/12/26 at 2259 hours, a BP reading of 120/75 mmHg on the left arm; - On 5/13/26 at 1437 hours, a BP reading of 108/75 mmHg on the left arm; - On 5/13/26 at 2242 hours, a BP reading of 140/117 mmHg on the left arm; - On 5/14/26 at 2138 hours, a BP reading of 116/79 mmHg on the left arm; - On 5/15/26 at 0613 hours, a BP reading of 120/70 mmHg on the left arm; - On 5/18/26 at 0539 hours, a BP reading of 110/66 mmHg on the left arm; and - On 5/19/26 at 0621 hours, a BP reading of 137/97 mmHg on the left arm. On 5/19/26 at 1539 hours, an interview and concurrent medical record review for Resident 29 was conducted with LVN 6. LVN 6 stated Resident 29 had a hemodialysis access in the left arm and the left arm was not used to obtain BP readings. LVN 6 reviewed Resident 29's medical record and verified the above findings. On 5/21/26 at 1515 hours, an interview was conducted with the Administrator, ADON, and DON. The Administrator, ADON, and DON were informed and acknowledged the above findings.

Based on interview, facility document review, and facility P&P review, the facility failed to implement their infection control surveillance program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program for May 2025 through March 2026. The facility conducted surveillance of resident infections based on whether residents were prescribed antimicrobial medications. The facility failed to determine whether the residents who exhibited signs and/or symptoms of infections, and were not prescribed antimicrobial medications, met the facility's criteria for infection (McGeer's Criteria) and thus, failed to include these residents in the facility's infection control surveillance program. These failures posed the risk for not identifying resident infections and controlling the potential transmission of communicable diseases to other residents, staff, and visitors throughout the facility.Findings: Review of the facility's P&P titled Infection Prevention and Control Program (IPCP) dated 1/2026 showed an infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Outcome surveillance (incidence and prevalence of HAIs) is used as a measure of the IPCPs effectiveness. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. The information obtained from infection control surveillance activities is compared with that from other facilities with acknowledged standards and used to assess the effectiveness of established infection prevention and control practices. Standard criteria are used to distinguish CAIs from HAIs. On 5/20/26 at 1005 hours, an interview, facility P&P review, and concurrent facility document review was conducted with the IP. The IP was asked to explain the facility's infection surveillance program. The IP stated when a resident exhibited signs and/or symptoms of infection and was prescribed an antimicrobial medication, the facility would then determine if the resident had met the McGeer's Criteria. The IP stated this information was documented on the facility's monthly Infection Prevention and Control Surveillance Log from 5/2025 to 3/2026. The IP stated in accordance with the facility's Infection Prevention and Control Program P&P, the facility's Infection Surveillance program outcome surveillance included the incidence and prevalence of HAIs, and infection surveillance was used as a measurement of the IPCP's effectiveness. The surveillance tools were utilized by the facility to recognize the occurrence of infections, record their number and frequency, detect outbreaks and epidemics, monitor adherence to infection prevention and control practices, and detect unusual pathogens with infection control implications. Review of the facility's monthly Infection Prevention and Control Surveillance Logs from May 2025 through March 2026 showed the following resident infection surveillance data for HAIs, CAIs, and residents who did not meet McGeer's Criteria (DNMC):- 5/2025: HAI - 54, CAI - 27, and DNMC - 14- 6/2025: HAI - 45, CAI - 17, and DNMC - 19- 7/2025: HAI - 42 , CAI - 26 , and DNMC - 40- 8/2025: HAI - 22, CAI - 10, and DNMC - 25- 9/2025: HAI - 31, CAI - 16, and DNMC - 15- 10/2025: HAI - 18, CAI - 16, and DNMC - 16- 11/2025: HAI -35, CAI -7, and DNMC -12- 12/2025: HAI - 28, CAI - 11, and DNMC - 16- 1/2026: HAI - 30, CAI -26, and DNMC - 22- 2/2026: HAI - 30, CAI - 14, and DNMC - 18- 3/2026: HAI - 33, CAI -17, and DNMC - 14 Further review of the facility's monthly Infection Prevention and Control Surveillance Logs from May 2025 through March 2026 showed documentation all the residents categorized as having an HAI, CAI, or not having met McGeer's Criteria were prescribed antimicrobial medications. There was no documentation showing whether residents who exhibited signs and/or symptoms of infection and were not prescribed an antimicrobial medication, had met McGeer's Criteria. The IP was asked when residents exhibited signs and/or symptoms of an infection and were not prescribed antimicrobial medications, if she determined whether these residents had met the McGeer's Criteria. The IP stated when a resident exhibited signs and/or symptoms of an infection, however was not prescribed antimicrobial medications, the facility did not determine if these residents met McGeer's Criteria. The IP was asked how many residents in the facility from May 2025 through March 2026 who exhibited signs and/or symptoms of infection and were not prescribed antimicrobial medications, met McGeer's Criteria. The IP stated she was uncertain, as the facility did not determine if a resident with signs and/or symptoms of infection met the McGeer's Criteria, unless they were prescribed an antimicrobial medication.

Based on interview, document review, and medical record review, the facility failed to ensure the residents or their representatives were informed in advance of the proposed treatment regarding the use of psychotropic medications (medications affecting brain activity) for one of five residents reviewed for unnecessary medications (Resident 3). * The facility failed to ensure the informed consent for the valproic acid (anticonvulsant) medication included the manifested behaviors for Resident 3. This failure had the potential to compromise the resident's right, or the right of the designated representative, to be fully informed regarding the psychotropic medication in order to make an informed decision. Findings: Review of the AFL 25-38.1 titled Notice of Release of Psychotherapeutic Drug Informed Consent Form dated 2/3/26, showed the facilities may use the CDPH (California Department of Public Health) Psychotherapeutic Drug Informed Consent Form or use their own in-house form as long as the in-house form contains all the data elements on the CDPH form. The form must be in use by January 1, 2026, for new residents, residents being prescribed a new psychotherapeutic drug, and residents having a psychotherapeutic drug dosage change. Review of the CDPH 9168 document titled Psychotherapeutic Drug Informed Consent Form dated 12/2025 showed to include the following psychotherapeutic drug information: drug category, drug name, dosage prescribed, frequency, duration, administration method, caution and earning summary, reason for use of the psychotherapeutic drug and benefits, the probable side effects and significant risks associated with the use of the psychotherapeutic drug, and the reasonable alternative mode(s) of treatment or possible non-pharmacological approaches that could address the resident's needs. Medical record review for Resident 3 was initiated on 5/18/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's MDS assessment dated [DATE], showed Resident 3 had moderately impaired cognition. Review of Resident 3's Order Summary Report dated 5/21/26, showed a physician's order dated 1/24/26, to administer valproic acid 250 mg/5 ml, to give 5 ml by mouth two times a day for unspecified mood disorder manifested by sudden mood swings from calm/pleasant to angry/frustrated and for seizure disorder. Review of Resident 3's Psychotherapeutic Drug Informed Consent Form showed for the valproic acid 250 mg/5 ml medication, Resident 3's responsible party was informed on 1/24/26. However, further review of the form failed to show the behavior manifestations for the use of the valproic acid medication. On 5/21/26 at 1000 hours, an interview and concurrent medical record review for Resident 3 was conducted with RN 4. RN 4 verified Resident 3's informed consent for the valproic acid medication did not include the specific manifested behaviors for the use of the medication. On 5/21/26 at 1420 hours, an interview was conducted with the DON. The DON stated for the residents prescribed the psychotropic medications, the informed consent should include the type of medication, name, dose, route, frequency, indications, and manifested behaviors. On 5/21/26 at 1515 hours, an interview was conducted with the Administrator, ADON, and DON. The Administrator, ADON, and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of one nonsampled resident (Resident 54) was assessed for safe self-administration of medications. * Resident 54 was observed with an Equate nasal spray (medication to relieve allergies) medication at the bedside. This failure had the potential for Resident 54 to administer the medication inaccurately and may negatively impact the health and safety of the resident.Findings: 1. Review of the facility's P&P titled Self-Administration of Medication revised 1/2026 showed the residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. Review of the facility's P&P titled Administering Medication revised 1/2026 showed the medications are administered in a safe and timely manner and as prescribed. Resident may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision - making capacity to do so safely. Medical record review for Resident 54 was initiated on 5/18/26. Resident 54 was admitted to the facility on [DATE]. On 5/19/26 at 0825 hours, an observation, interview, and concurrent medical record review for Resident 54 was conducted with LVN 3. Resident 54 was observed sitting in a wheelchair, and an Equate nasal spray medication was observed on the resident's overbed table. Resident 54 stated the nasal spray was his medication and he used the medication to be sprayed in his nose. LVN 3 stated Resident 54 should have no medication at the bedside, and other residents can get the medication and can use the medication. LVN 3 verified there was no physician order for the nasal spray and to self-administer medication, no self-administration assessment, and no care plan for the use of nasal spray. Review of Resident 54's H&P examination dated 4/2/26, showed Resident 54 had the capacity to understand and make decisions. Review of Resident 54's Order Summary Report for 5/2026 did not show a physician's order for nasal spray medications. Review of Resident 54's Plan of Care with the printed date of 5/20/26, did not show a care plan problem to address Resident 54's safe self-administration of medications. Further review of Resident 54's medical record failed to show a physician's order to self-administer medications, and there was no documentation of an assessment completed for Resident 54 to safely self-administer medications. On 5/21/26 at 1334 hours, an interview and concurrent medical record review for Resident 54 was conducted with DON. The DON verified Resident 54 had no physician's order, assessment, and care plan for the self-administration of any medications. On 5/21/26 at 1403 hours, an interview was conducted with the Administrator, ADON, and DON. The Administrator, ADON, and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to inquire about the existence of an advance directives and failed to inform, provide, and document the written information regarding the rights to formulate the advance directives to one of three final sampled residents (Resident 23) reviewed for Advance Directives. * The facility failed to show evidence that an Advance Directive Acknowledgement was available in Resident 23's medical record. This failure had the potential for the facility to provide treatment and services against the resident's wishes.Findings: Review of the facility's P&P titled Advance Directives date revised 1/2026 showed the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, their family members and/or their legal representative, about the existence of any written advance directives. Upon admission, the resident or representative is provided with written information concerning their rights under state law to make decisions concerning medical care, including the right to refuse or accept medical or surgical treatment and to formulate an advance directive if they choose to do so. Written information is provided in a manner easily understood by the resident or representative. Medical record review for Resident 23 was initiated on 5/18/26. Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's Physician Orders for Life Sustaining Treatment (POLST) dated 4/18/26, showed under Section D, Resident 23 had capacity and had no Advance Directive. Review of Resident 23's Resident Centered Social History and Discharge Planning assessment dated [DATE], failed to show documentation if advance directive formulation was offered to Resident 23 and her responsible party. Review of Resident 23's admission MDS assessment dated [DATE], showed Resident 23 had a BIMS (Brief Interview for Mental Status) score of 12 (8-12 suggests moderate cognitive impairment). Further review of Resident 23's medical record failed to show the existence of an Advance Directive Acknowledgment form. On 5/21/26 at 1341 hours, an interview and concurrent medical record review for Resident 23 was conducted with the SSD. The SSD acknowledged the findings and stated POLST was initiated upon admission by the admitting nurse and the SSD followed through the next business day. When the resident had an advance directive in place, the SSD asked for a copy to be placed in the resident's medical record. If the resident did not have an advance directive, an information on advance directive formulation was provided to the resident. In addition, the SSD verified there was no Advance Directive Acknowledgment form for Resident 23 and stated the advance directive formulation should have been offered to the resident sooner. On 5/21/26 at 1536 hours, an interview was conducted with the ADON and DON. The ADON and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 3) reviewed for unnecessary medications was free from unnecessary psychotropic medications. * The facility failed to ensure Resident 3's orthostatic blood pressure was accurately monitored, as ordered by the physician, for the use of the quetiapine (antipsychotic) medication. This failure had the potential for adverse effects from the psychotropic medication for Resident 3.Findings: Review of the facility's P&P titled Psychoactive/Psychotropic Medication Use dated 4/2025 showed psychotropic medication management for the residents will involve the interdisciplinary [NAME] consideration of the following: indication and clinical need for medication, dose, duration, and adequate monitoring for efficacy and adverse consequences. Management will also include preventing (where possible), identifying, and responding to adverse consequences. Staff will monitor for potential adverse consequences, such as: ii. Cardiovascular: . orthostatic hypotension. Medical record review for Resident 3 was initiated on 5/18/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's MDS assessment dated [DATE], showed Resident 3 had moderately impaired cognition. Review of Resident 3's Order Summary Report dated 5/21/26, showed the following physician's orders:- dated 1/28/26, for the use of the quetiapine medication to monitor Resident 3's orthostatic (measure the blood pressure while laying down or sitting and again upon standing up) blood pressure (BP) in the lying position every Sunday during the day shift,- dated 1/28/26, for the use of the quetiapine medication to monitor Resident 3's orthostatic blood pressure in the sitting position every Sunday during the day shift, and- dated 2/28/26, to administer quetiapine 25 mg by mouth three times a day for unspecified mood disorder manifested by angry outbursts. Review of Resident 3's MARs for April and May 2026 showed the following documentation for the orthostatic BP readings:- on 4/5/26 and 4/12/26, the BP reading was documented as not applicable NA for the lying and sitting positions.- on 4/19/26, the BP reading was documented as 138/84 mmHg for the lying and the sitting positions.- on 4/26/26, the BP reading was documented as 119/76 mmHg for the lying and the sitting positions.- on 5/10/26, the BP reading was documented as 118/67 mmHg for the lying and the sitting positions. On 5/21/26 at 1000 hours, an interview and concurrent medical record review for Resident 3 was conducted with RN 4. RN 4 stated the orthostatic hypotension was a common side effect of the antipsychotic medication. RN 4 stated for the residents on the antipsychotic medications, the orthostatic blood pressure should be checked weekly and the BP readings compared determine if there was a drop. RN 4 reviewed Resident 3's MARs for April and May 2026 and verified the above findings. RN 4 stated the BP readings for the different positions should not be the same. RN 4 further stated NA should not be documented and the licensed nurse should reattempt to obtain the BP readings and/or document in the nurse's progress notes. RN 4 reviewed Resident 3's medical record and verified there were no documentation in the nurse's progress notes for the above dates where the licensed nurse documented NA. On 5/21/26 at 1420 hours, an interview was conducted with the DON. The DON stated the residents prescribed the antipsychotic medications were monitored weekly for orthostatic hypotension. The DON stated the BP readings should not be NA or the same for the different positions. On 5/21/26 at 1515 hours, an interview was conducted with the Administrator, ADON, and DON. The Administrator, ADON, and DON were informed and acknowledged the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to follow their protocol for written notification of transfer or discharge for two of three residents (Residents 29 and 138) reviewed for hospitalizations. * The facility failed to provide written information to Resident 29 about the facility's bed-hold information and failed to ensure a copy of the transfer discharge notification was sent to the Ombudsman when Resident 29 was transferred to the acute care hospital on 4/19/26. * The facility failed to ensure a copy of the transfer discharge notification was sent to the Ombudsman when Resident 138 was transferred to the acute care hospital. These failures had the potential for Residents 29 and 138 to not receive additional protection when the residents were being inappropriately transferred or discharged from the facility. Findings: Review of the facility's P&P titled Transfer or Discharge Notices revised 3/2025 showed residents (or resident representatives) are notified of an impending discharge and the reasons for the move in writing and in a language and manner they understand. Under the section Notice of Transfer or Discharge (Emergency) showed the Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable. The Notice of Facility Bed-Hold and return policies are provided to the resident and representative within 24 hours of emergency transfer. A copy of the notice is sent to the Office of the State Long-Term Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. Review of the facility's document titled Bed Hold Policy and Notification (undated) showed it is the policy of the facility to provide any resident that is transferred to a general acute hospital the right to exercise the bed hold provision. 1. Medical record review for Resident 29 was initiated on 5/18/26. Resident 29 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 29's Bed Hold Policy and Notification dated 4/1/26, showed the section to be completed upon Resident 29's transfer was blank. Review of Resident 29's H&P examination dated 4/28/26, showed Resident 29 had the capacity to understand and make decisions. Review of Resident 29's Order Summary Report dated 5/20/26, showed the a physician's order dated 4/19/26, to transfer Resident 29 to Acute Hospital A emergency room for evaluation: weakness, diaphoretic (excessive sweating), shaking, and malaise (feeling of discomfort or being off). Bed hold for seven days if admitted . Emergency contact notified. Review of Resident 29's medical record failed to show documented evidence the Ombudsman was notified of Resident 29's transfer to the acute-care hospital on 4/19/26. Further review of Resident 29's medical record failed to show documentation Resident 29 was provided with the information on the bed-hold options. On 5/19/26 at 1430 hours, an interview was conducted with the Ombudsman. The Ombudsman stated he wanted the facility to send the notification of the transfer discharge as soon as possible so he could review the notification and determine if the transfer was warranted. On 5/20/26 at 1027 hours, an interview and concurrent medical record review for Resident 29 was conducted with the SSD. The SSD verified Resident 29's bed hold notification was not completed upon Resident 29's transfer to the acute hospital on 4/19/26. When asked for the confirmation the notification of transfer was faxed to the Ombudsman, the SSD stated he was unable to find any documentation. On 5/21/26 at 1420 hours, an interview was conducted with the DON. The DON stated the notification of transfer discharge should be sent weekly to the Ombudsman via email or fax communication. The DON stated the residents were informed of the facility's bed hold policy upon admission to the facility and at the time of the resident's transfer to the acute care hospital. On 5/21/26 at 1515 hours, an interview was conducted with the Administrator, ADON, and DON. The Administrator, ADON, and DON were informed and acknowledged the above findings. 2. Review of the facility's P&P titled Transfer or Discharge Notices revised March 2025 showed in part, the residents (or resident representatives) are notified of an impending transfer or discharge and the reasons for the move in writing and in a language and manner they understand. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman. When a resident is sent emergently to an acute care setting, this is considered a transfer, not discharge, because the resident's return is generally expected. Notice of Transfer is provided to the residents and representative as soon as practicable before the transfer and to the long-term care (LTC) Ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirement). Notice of Facility Bed-Hold and return policies are provided to the residents and representative within 24 hours of emergency transfer. Notices are provided in a form and manner the resident can understand, taking into account the resident's educational level, language, communication barriers, and physical or mental impairments. Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge. Closed medial record review for Resident 138 was initiated on 5/19/26. Resident 138 was admitted to the facility on [DATE], and was transferred to an acute care hospital on 5/15/26. Review of Resident 138's Physician Order summary showed a physician's order dated 5/15/26, to transfer Resident 138 to an acute care hospital ER for further evaluation due to episode of blackish stool. Bed hold for 7 days if admitted . Review of Resident 138's medical record failed to show proof that the Ombudsman was notified of Resident 138's transfer to an acute care hospital. On 5/20/26 at 1443 hours, an interview and concurrent closed record review for Resident 138 was conducted with DON. The DON verified there was no notification to the Ombudsman regarding the transfer to an acute care hospital. The DON stated it was missed and It should have been done upon transfer.

Based on interview and medical record review, the facility failed to ensure the MDS assessment was accurate for two of 27 final sampled residents (Residents 15 and 50) reviewed for MDS. * Resident 15's MDS assessment dated [DATE], showed Resident 15 had a diagnosis of schizophrenia (a chronic and severe brain disorder that affects how a person interprets reality); however, Resident 15 did not have schizophrenia. * Resident 50 was administered lamotrigine (anticonvulsant/mood stabilizer) medication for bipolar (a mental health condition that causes extreme mood swings) disorder. The facility failed to code the diagnosis of bipolar disorder in Resident 50's quarterly MDS assessment dated [DATE]. These failures posed the residents at risk of not receiving an individualized plan of care based on their specific needs. Findings: 1. Medical record review for Resident 15 was initiated on 5/18/26. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's Psychiatric Initial Evaluation dated 3/9/26, showed documentation Resident 15 was not diagnosed with schizophrenia while having resided in the facility, and Resident 15 stated he had no prior diagnosis of schizophrenia. On 5/19/26 at 1123 hours, an interview and concurrent medical record review for Resident 15 was conducted with the MDS Coordinator. Review of Resident 15's MDS dated [DATE], showed Resident 15 had an active diagnosis of schizophrenia. The MDS Coordinator stated having coded Resident 15 with an active diagnosis of schizophrenia was an error. The MDS Coordinator stated Resident 15's physician had assessed Resident 15 at the facility, and Resident 15 did not have a diagnosis of schizophrenia. The MDS Coordinator stated she was familiar with Resident 15 and the resident had not exhibited any signs and/or symptoms of schizophrenia while having resided in the facility. 2. Medical record review for Resident 50 was initiated on 5/18/26. Resident 50 was admitted to the facility on [DATE], and had the diagnosis of Bipolar disorder on 1/9/26. Review of Resident 50's Order Summary Report 4/21/26, showed a physicians order dated 4/16/26, to administer lamotrigine 200 mg one tablet by mouth at bedtime for Bipolar disorder manifested by verbalization of helplessness (bipolar depression). Review of Resident 50's MDS assessment dated [DATE], showed Resident 50 was coded for taking the anticonvulsant medication. However, Resident 50 was not coded for the diagnosis of Bipolar disorder. On 5/21/26 at 1055 hours, an interview and concurrent medical record review for Resident 50 was conducted with LVN 5. LVN 5 stated Resident 50 was administered the lamotrigine medication for Bipolar disorder. LVN 5 reviewed Resident 50's MDS assessment and verified the above findings. On 5/21/26 at 1515 hours, an interview was conducted with the Administrator, ADON, and DON. The Administrator, ADON, and DON were informed and acknowledged the above findings.

Based on interview, medical record review and facility P&P review, the facility failed to provide the necessary skilled nursing care and services for four of eight sampled residents (Residents 1, 3, 4, and 7). * The facility failed to provide continued life-saving measures to Resident 7 when the resident remained unconscious, barely breathing and did not have any blood pressure reading and until the paramedics arrived. This failure resulted to interrupted chest compressions and rescue breathing in an arrest resuscitation and potentially contributed to the resident's death in the acute hospital. * The facility failed to timely and accurately complete a hip/femur x-ray as recommended by the physical therapist due to Resident 1's consistent right hip pain. In addition, the facility failed to obtain a urine sample for testing as ordered by the physician and notify the physician when Resident 1 had an abnormal hemoglobin result. These failures had the potential for the delay in the identification of problems and provision of the necessary interventions which could negatively impact the resident's well-being. * The facility failed to provide Residents 1, 3 and 4 the wound care treatment as ordered by the physician. These failures had the potential to negatively impact Residents 1, 3, and 4's well-being.Findings: 1. Review of the facility's P&P titled Emergency Procedure - Cardiopulmonary Resuscitation and Basic Life Support dated 2001 showed the personnel are certified in CPR (Cardiopulmonary resuscitation for healthcare providers and BLS (basic life support), including defibrillation for victims of sudden cardiac arrest. If an individual is found unresponsive and not breathing normally, a staff member who is certified in CPR for health care providers or BLS will administer CPR unless: a. it is known that a do not resuscitate (DNR) order that specifically prohibits CPR and/ or external defibrillation exist for that individual; or b. there are obvious signs or irreversible death. According to [NAME] A, Singh B, [NAME] PH. Cardiopulmonary Resuscitation. [Updated 2025 Jun 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan from: National Library of Medicine, retrieved 2/6/26, https://www.ncbi.nlm.nih.gov/books/NBK470402/ chest compressions are the cornerstone of CPR. These compressions generate artificial circulation by increasing intrathoracic pressure, which compresses the heart and propels blood forward. Effective compressions maintain coronary perfusion pressure, which is the difference between aortic diastolic and right atrial diastolic pressure during the relaxation phase of compressions. Coronary perfusion pressure is crucial for myocardial blood flow and is a primary determinant of successful return of spontaneous circulation. Ventilations provide oxygen to the lungs and help maintain blood oxygenation. However, positive-pressure ventilation can reduce coronary perfusion pressure by increasing intrathoracic pressure and impeding venous return to the heart. Therefore, the balance between adequate ventilation and minimizing interruptions to chest compressions is critical. The definitive treatment for ventricular fibrillation and pulseless ventricular tachycardia is electrical defibrillation, most commonly administered using an automated external defibrillator. If defibrillation is not performed promptly, brain death can occur in less than 10 minutes. CPR is a critical intervention to provide artificial circulation and ventilation until defibrillation is possible. When performed correctly, conventional manual CPR can deliver up to 33% of normal cardiac output and oxygenation. The cycle of 30 chest compressions followed by 2 rescue breaths should be continued until an automated external defibrillator becomes available or until additional help arrives. Once an automated external defibrillator is on scene it automatically analyzes the cardiac rhythm and advising whether a shock is necessary. If a shock is advised, chest compressions should be paused, and everyone should stand clear while the automated external defibrillator delivers defibrillation. Immediately after the shock, or if no shock is advised, CPR should be resumed without delay, continuing the CAB (Compressions, Airway, and Breathing) sequence until further assistance or advanced care arrives. According to American Heart Association's Hard Hats with Heart undated, retrieved 2/6/26, https://www.heart.org/-/media/Files/Affiliates/WSA/Oregon/CPR-Frequently-Asked-Questions.pdf showed CPR Frequently Asked Questions Toolbox Talks, the section for When do I stop giving Hands-Only CPR? showed to continue pushing hard and fast in the center of the chest until help arrives. If the person speaks, moves, or breathes normally while you're giving chest compressions, Hands-Only CPR can be stopped. Medical record review for Resident 7 was initiated on 2/4/26. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's H&P examination dated 1/29/26, showed the resident had the capacity to understand and make decisions. Review of Resident 7's Order Summary Report dated 2/4/26, showed a physician's order dated 1/27/26, for full code. Review of Resident 7's POLST dated 1/27/26, the CPR section indicated to Attempt Resuscitation/CPR and the Medical Interventions section indicated Full Treatment (primary goal of prolonging life by all medically effective means). Review of Resident 7's eInteract SBAR Communication Form and Progress Notes dated 2/2/26, showed Resident 7 was found on the floor next to the bed, with no response to verbal and tactile stimuli, the assessment revealed asystole and absence of respiration, CPR was initiated and 911 was called. After approximately 20 minutes of CPR, return of spontaneous circulation was achieved and assumed care. The note further showed the fire department arrived, continued CPR and lifesaving measured for another 20 minutes. Further review of Resident 7's medical record failed to show a documentation and/or the vital signs reading when the staff achieved spontaneous circulation. Review of the Resident 7's Electronic Patient Care Report from the Fire Department dated 2/2/26 at 0236 hours, showed the fire department arrived on scene to find resident on the ground surrounded by care staff pulseless, apneic and without compressions being performed. The manual compressions was initiated. BVM (Bag-Valve-Mask) with high flow oxygen was administered. Defibrillation pads were applied at 0239 hours, resident was PEA (Pulseless Electrical Activity). Review of Resident 7's Emergency Department H&P examination dated 2/2/26, the Disposition section showed unfortunately the patient passed away in the Emergency Department. On 2/4/26 at 1435 hours, a telephone interview was conducted with the Fire Captain. The Fire Captain stated he arrived at the facility and found Resident 7 on the ground surrounded by care staff, pulseless and not breathing, and without compressions being performed. The Fire Captain further stated the staff informed him of the CPR provided to the resident for twenty minutes and believed the heart rate was back and stopped the compressions. On 2/4/26 at 1611 hours, a telephone interview was conducted with RN 3. RN 3 stated she walked in Resident 7's room with LVN 5 on the scene. RN 3 stated Resident 7 was unresponsive and had no pulse, then LVN 5 and RN 3 initiated CPR immediately. RN 3 stated LVN 5 provided compressions while RN 3 provided breathing with the use of Ambu bag. RN 3 further stated the pulse was achieved prior to the fire department's arrival at the scene. However, RN 3 further stated Resident 7 had no blood pressure and remained unconscious. On 2/4/26 at 1536 hours, a telephone interview was conducted with LVN 4. LVN 4 stated Resident 7 was unresponsive and had no pulse, and CPR was initiated immediately. LVN 5 provided the compressions while RN 3 provided breathing with the use of Ambu bag. LVN 4 further stated they provided CPR for twenty minutes then the resident's pulse came back, and RN 3 stated to stop the CPR while waiting for the paramedics. On 2/5/26 at 0617 hours, an interview was conducted with LVN 5. LVN 5 stated he found Resident 7 lying on the floor on the left side halfway on prone position. LVN 5 stated Resident 7 had no pulse oximeter reading and RN 3 verified the resident had no pulse and respiration. LVN 5 stated he provided the compressions while RN 3 provided the breathing with the use of Ambu bag. LVN 5 further stated they had performed CPR for 18-20 minutes then obtained carotid pulse as confirmed by RN 3. LVN 5 stated they stopped the compressions with the presence of carotid pulse. LVN 5 further stated Resident 7 remained unconscious, barely breathing and did not have any blood pressure reading for approximately 5-7 minutes while waiting for the paramedics to arrive. On 2/5/26 at 0850 hours, an interview was conducted with the DON. The DON stated the expectation for the licensed nurses was to continue with the CPR until the fire department arrives and takes over the resuscitation. Cross Reference to F726. 2. Review of Resident 1's medical record was initiated on 1/27/26. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 1's H&P examination dated 1/21/26, showed the resident had no capacity to understand and make decision. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1's BIMS score was 3 indicating the resident had severe cognitive impairment. The section GG for Functional Abilities showed Resident 1 required total dependence in activities of daily living and mobility. a. Review of Resident 1's eInteract SBAR Communication Form and Progress Notes dated 7/25/25, showed reported from 2 CNAs, attempted to transfer resident from chair to bed, the resident folded legs in the mid transfer and unable to provide full transfer, gradually assisted resident to the floor with no injuries. Review of Resident 1's Care Plan Report showed a focused problem for fall; resident had an assisted fall and is at risk for injury and recurring falls initiated on 7/25/25. The interventions included to monitor for complications related to the fall such as change in neurological status, evidence of injury, loss of range of motion, pain, and to notify the physician promptly if observed. Review of Resident 1's Rehab-Status Post-Fall Screen dated 7/25/25 at 1639 hours, showed the resident had a fall on 7/25/25 at 1100 hours. The note further showed recommending right hip/ femur and knee x-ray due to consistent right hip pain, nursing notified. Positive [NAME] on right hip. Review of Resident 1's IDT - Fall Progress Notes dated 7/29/25 at 1500 hours, showed Resident 1 had fall on 7/25/25 and had no injury. The current intervention showed for the therapy to re-evaluate. Further review of Resident 1's medical record failed to show a documentation if the facility had notified the physician regarding the PT's recommendation for x-ray right hip/femur and knee due to consistent right hip pain with positive [NAME]. Review of Resident's Order Summary Report dated 1/30/26, showed the following physician's orders:- dated 7/22/25, to provide the non-pharmacological intervention for pain prior to administering the pain medication, 1. Back rub, 2. Repositioning, 3. Warm drink, 4. TV/ Music, 5. Ice Pack; 6. None, and- dated 7/29/25, for the bilateral x-ray of hips/femur to knee per DON due to positive [NAME] test with acute pain. Review of Resident 1's MAR for July 2025 showed Resident 1 was provided with the non-pharmacological interventions for pain on the following dates and shifts:- dated 7/26/25, during day shift with 2. Repositioning;- dated 7/26/25, during evening shift with 2. Repositioning;- dated 7/27/25, during day shift with 1. Back rub, 3. Warm drink, 5. Ice Pack;- dated 7/27/25, during night shift with 1. Back rub, 2. Repositioning, 3. Warm drink;- dated 7/28/25, during night shift with 2. Repositioning; and - dated 7/29/25, during night shift with 1. Back rub, 2. Repositioning, 3. Warm drink. Review of Resident 1's Radiology Interpretation dated 7/29/25, for the bilateral hips examination, the finding showed multiple views of the bilateral hips were reviewed and no acute fracture was identified. Further review of Resident 1's medical record failed to show if the x-ray result for the bilateral femur to knees were completed as ordered by the physician. Review of Resident 1's eInteract SBAR Communication Form and Progress Notes dated 8/1/25 at 0800 hours, showed Resident 1 had an order to be transferred to ER possible blood transfusion. Review of Resident 1's Hospitalist H&P dated 8/1/25, showed the resident presented to ER due to concerns of low hemoglobin. While Resident 1 was in Acute Care Hospital A, an x-ray of the right knee due to right knee pain was done on 8/3/25, the findings showed markedly displaced fractures involving the distal femur. Review of Resident 1's Acute Care Hospital B Internal Medicine H&P dated 8/11/25, showed Resident 1 underwent open reduction and internal fixation (ORIF) of the right distal femur on 8/10/25. On 1/27/26 at 1619 hours, a telephone interview was conducted with family member 1. Family Member 1 stated she was informed Resident 1 fell on 7/25/25. Family Member 1 stated she had observed Resident 1 moaned at times when she visited the facility. According to Family Member 1 the resident does not speak as much because of her condition and she did not see any obvious external deformity. Family Member stated the x-ray was done at the facility which showed negative for fracture. Family Member 1 further stated the nurses had reassured her there were no injury. Family Member 1 stated the x-ray performed at the facility was limited and did not include the Resident's distal femur. Family Member 1 further stated Resident 1 was transferred to the acute care hospital on 8/1/25 due to low hemoglobin. Family Member 1 stated an x-ray was done at the acute care hospital to find out if the resident had any internal bleeding. The x-ray revealed the resident had a fracture of the distal femur and eventually had surgery of the fractured femur which caused the resident to stay in the hospital for 23 days. On 1/30/26 at 1218 hours, an interview and a concurrent record review was conducted with the PT. The PT verified Resident 1 had a fall on 7/25/25, and resident's Rehab-Status Post Fall dated 7/25/25 at 1639 hours, showed the PT had recommended the right hip/femur and knee x-ray due to consistent right hip pain with positive [NAME]. The PT stated recommendations were usually communicated to the nursing department. On 1/30/26 at 1416 hours, an interview and concurrent record review was conducted with RN 2. RN 2 stated the PT would usually have a stop and watch form or verbally inform the nursing staff for any recommendation. RN 1 verified Resident 1's medical record failed to show the physician was informed of the PT's recommendation for x-ray of the right hip/femur to knee. RN 1 verified the order for the bilateral x-ray of hips/femur to knee per DON due to positive [NAME] test with acute pain was ordered on 7/29/25. RN 1 verified Resident 1's medical record failed to show an x-ray result of the bilateral femur and knees as ordered the physician. RN 1 stated the non pharmacological interventions were usually provided to the resident prior administering pain medication for comfort. RN 1 verified Resident 1's MAR showed Resident 1 was provided with the non-pharmacological intervention for pain prior to administering pain medication as above; however, the MAR failed to show if Resident 1 was provided with any pain medication. On 2/5/26 at 0915 hours, an interview was conducted with the DON. The DON stated the expectation regarding the communication of the therapist's recommendation was for the PT to inform the nurse on duty and licensed nurse to report to the physician immediately to prevent delay in treatment. The DON was informed and acknowledged the above findings. b. Review of the facility's P&P titled Lab and Diagnostic Test Results - Clinical Protocol dated 2001 showed when test results are reported to the facility, a nurse will first review the results. If staff who first received or review laboratory and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate in the procedure. A physician can be notified by phone, fax, voicemail, e-mail, pager, or a telephone message to another person acting as the physician's agent. The facility should document information about when, how, and to whom the information was provided and the response. This should be done in the progress notes section of the medical record and not on the laboratory results report. Direct voicemail communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs revies or clarification. A physician should respond within one hour regarding a laboratory test result requiring immediate notification, and by the end of the next office day to a non-emergency message regarding non-immediate laboratory test notification with a request for response. Review of Resident 1's Order Summary Report showed a physician's order dated 7/30/25, for STAT BMP, CBC, and Mag. Review of Resident 1's Test Results dated 7/30/25, showed the resident's hemoglobin level was 6.3 g/dL . The Reference Range for the hemoglobin level was 11.5-15.0 g/dL. Further review of Resident 1's medical record failed to show if the physician and the family member was notified of the resident's low hemoglobin level of 6.3 on 7/30/25. Review of Resident 1's eInteract SBAR Communication Form and Progress Notes dated 8/1/25 at 0800 hours, showed Resident 1 had an order to be transferred to ER possible blood transfusion. Review of Resident 1's Hospitalist H&P dated 8/1/25, showed the resident presented to ER due to concerns of low hemoglobin. The hemoglobin level result was 6.5 g/dL and the Assessment and Plan section showed gastrointestinal hemorrhage, transfuse one unit PRBC (packed red blood cells) while in ED (Emergency Department). On 1/27/26 at 1619 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated the resident's hemoglobin level was 6.3 on 7/30/25. The facility did not notify her of the laboratory results until 7/31/25 and the resident was not transferred to the acute hospital until 8/1/25, 2 days later. c. Review of the facility's P&P titled Acute Condition Changes - Clinical Protocol dated 2001 showed the physician will help identify individuals with a significant risk for having acute changes of condition during their stay. The staff and physician will discuss possible causes of the condition based on factors including resident history, current symptoms, medication regimen, and diagnostic test results. If necessary, the physician will order diagnostic tests and evaluate the patient directly. Review of the facility's P&P titled Laboratory and Diagnostic Test Results - Clinical Protocol dated 2001 showed the physician will identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. Review of Resident 1's MDS assessment dated [DATE] showed in section H, for the Bladder and Bowel Function showed the resident had an indwelling catheter. Review of Resident 1's Care Plan Report showed a care plan focused problem initiated on 8/25/25, to address Resident 1's use of the suprapubic catheter secondary to neurogenic bladder and chronic urine retention; at risk for complications related to dislodgement, infection, skin integrity and urinary output. The interventions included to observe for the signs and symptoms of complications related to suprapubic catheter and notify the physician of the abnormal findings; and laboratory as ordered and report the findings to the physician. Review of Resident 1's eInteract SBAR Communication Form and Progress Notes dated 12/13/25, showed family member reported Resident 1 was observed to be lethargic and had sediments on the urine. The Review and Notify section of the SBAR form showed the recommendation of the primary physician was to collect a urine sample. Review of Resident 1's eInteract SBAR Communication Form and Progress Notes dated 12/17/25, showed family member reported Resident 1 was observed to be lethargic, not taking food and drink. The notes further showed the family member wants to transfer the resident to the acute hospital for further evaluation and the physician was notified. Review of Resident 1's laboratory results failed to show a result for the urine sample testing. In addition, there were no physician's order to collect a urine sample for testing. Further review of Resident 1's medical record failed to show if Resident 1's family member refused for the urine test or any indication why the urine sample was not obtained for laboratory testing. Review of Resident 1's SNF/NF to Hospital Transfer Form dated 12/17/25 at 2125 hours, showed Resident 1 was transferred to the acute care hospital. Review of Resident 1's H&P examination from the acute hospital dated 12/18/25 at 0136 hours, showed the physician reviewed the latest laboratory and imaging results. The examination note further showed Resident 1 had acute kidney injury and catheter associated urinary tract infection and will be started on antibiotic treatment. On 1/27/26 at 1619 hours, a telephone interview was conducted with Family Member 1. Family member 1 stated she reported to the nurse when she had noticed the resident's indwelling catheter had sediments and was lethargic; however, the facility was resisting to take the resident to the hospital. Family Member 1 further stated the resident was eventually got transferred to the acute care hospital on [DATE]. On 1/30/26 at 1418 hours, an interview and a concurrent medical record review for Resident 1 was conducted with RN 2. RN 2 verified Resident 1's eInteract SBAR Communication Form and Progress Notes dated 12/13/25, showed the family member reported Resident 1 was observed to be lethargic and had sediments in the urine. In the Review and Notify section of the form showed the recommendation of the primary physician to collect a urine sample; however, further review of the resident's medical record failed to show the physician's recommendation to obtain urine sample was followed through and no laboratory test was completed for the urine test. RN 2 stated a physician's order should have been written by the nurse as recommended by the physician, a laboratory requisition should have been completed and the family member should have been notified when there was a change in a resident's condition. On 2/3/26 at 0745 hours, an interview was conducted with the DON. The DON stated expectation regarding communicating the change of condition was for the licensed nurses to inform the physician and carry out any laboratory tests recommended to prevent the delay in treatment. On 2/5/26 at 0915 hours, a follow-up interview was conducted with the DON. The DON was informed and acknowledged findings as above. 3. Review of the facility's P&P titled Medication and Treatment Orders dated 2001 showed orders for medications and treatments will be consistent with principles of safe and effective order writing. Review of the facility's Staffing Assignment dated 1/3/26, showed Stations 3 and 4 had a nurse scheduled to provide the treatments; however, the scheduled nurse did not sign the assignment sheet. In addition, review of the Facility's Staffing Assignment dated 1/4/26, showed no assigned treatment nurse for Stations 3 and 4. a. Review of Resident 1's medical record was initiated on 1/27/26. Resident 1 was admitted to the facility on [DATE] and was readmitted on [DATE]. Review of Resident 1's H&P Examination dated 1/21/26, showed resident had no capacity to understand and make decision. Review of Resident 1's MDS assessment dated [DATE] showed Resident 1's BIMS score summary was 3 indicating resident had severe cognitive impairment. Review of Resident 1's order summary dated 2/6/26 showed a physician's order date 12/25/25 for the following:- for the bilateral lower extremity skin discoloration, monitor daily for increase in size, shape, skin breakdown and/ or signs and symptoms of infection until resolved for 30 days;- for the bilateral upper extremity skin discoloration, monitor daily for increase in size, shape, skin breakdown and/ or signs and symptoms of infection until resolved for 30 days;- for the lesion on left thumb, cleanse with normal saline, pat dry apply triple antibiotic ointment and cover with dry dressing every day shift for 30 days; - for MASD (Moisture Associated Skin Damage - is inflammation and erosion of the skin caused by prolonged exposure to moisture, such as urine, stool, sweat, or wound drainage) with excoriation to the left and right buttock, cleanse with normal saline, pat dry, apply skin barrier cream and cover with dry sterile dressing every day shift for 30 days; - to cleanse suprapubic catheter site with normal saline pat dry, apply T-drain sponge dressing everyday as maintenance;- to monitor suprapubic catheter Fr16/10 ml for placement and functioning every day shift;- to monitor for the proper placement, no kinking or compression that could obstruct urine flow to gravity bag during catheter care every shift- for the suprapubic catheter is in privacy bag and catheter leg strap/leg bag on at all times. The Order Summary Report further showed a physician's order date 12/27/25, for the discoloration to left forearm to cleanse with normal saline, cover with dry dressing daily and as needed every day shift for 21 days. Review of Resident 1's TAR for January 2026 failed to showed the nurse' initials for the following treatments on 1/3 and 1/4/26: - for the bilateral lower extremity skin discoloration, monitor daily for increase in size, shape, skin breakdown and/ or signs and symptoms of infection until resolved for 30 days; - for the bilateral upper extremity skin discoloration, monitor daily for increase in size, shape, skin breakdown and/ or signs and symptoms of infection until resolved for 30 days;- for the discoloration to left forearm to cleanse with normal saline, cover with dry dressing daily and as needed every day shift for 21 days;- for the left thumb, cleanse with normal saline, pat dry apply triple antibiotic ointment and cover with dry dressing every day shift for 30 days; - for MASD with excoriation to the left and right buttock, cleanse with normal saline, pat dry, apply skin barrier cream and cover with dry sterile dressing every day shift for 30 days; - to cleanse suprapubic catheter site with normal saline pat dry, apply T-drain sponge dressing everyday as maintenance.- to monitor suprapubic catheter Fr16/10ml for placement and functioning every day shift In addition, the January 2026 MAR failed to show the nurses' initial on the following treatments:- to monitor for the proper placement, no kinking or compression that could obstruct urine flow to gravity bag during catheter care every shift on 1/1/26, during the evening shift; and 1/3 and 1/4/26, during the day shift; and - for the suprapubic catheter is in privacy bag and catheter leg strap/ leg bag on at all times on 1/1/26, during the evening shift; and 1/3 and 1/4/26, during the day shift. On 1/27/26 at 1619 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated Resident 1's catheter was visibly cloudy and the soiled split gauze was filthy. On 1/30/26 at 1502 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated having no assigned treatment nurse on the weekends could happen and the nurses should do the treatments. LVN 2 verified Resident 1's TAR failed to show the initial of a nurse for the above treatments, indicating the treatment was not completed. b. Review of Resident 3's medical records was initiated on 1/30/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's MDS assessment dated [DATE], showed Resident 3's BIMS score was 5 indicating resident had severe cognitive impairment. Review of Resident 3's Order Summary Report dated 2/3/26, showed a physician order dated 8/18/25, to cleanse the gastrostomy tube with normal sterile saline, pat dry and cover with T-Drain dressing and secure with tape every day shift daily. Review of Resident 3's TAR for January 2026 failed to show the nurse' initial on 1/4/24 for the treatment order to cleanse the gastrostomy tube with normal sterile saline, pat dry and cover with T-Drain dressing and secure with tape every day shift daily. On 1/30/26 at 1502 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated having no assigned treatment nurse on the weekends could happen and the nurses should do the treatments. LVN 2 verified Resident 3's TAR failed to show the initial of a nurse for the above treatment, indicating the treatment was not completed. c. Review of Resident 4's medical records was initiated on 1/30/26. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's MDS assessment dated [DATE], showed Resident 4 had a BIMS score of 12 indicating the resident had mild cognitive impairment. Review of Resident 4's Order Summary Report dated 2/3/26 showed a physician order dated 12/24/25, to monitor the discoloration to both lower extremity daily for increase in size, color, odor and the signs and symptoms of infection and for any changes, to notify the physician; and dated 12/25/25, for the following treatments:- face scattered scabs, to cleanse with normal saline, pat dry, apply triple antibiotic ointment and cover with dry sterile dressing every day shift for 14 days; - left ischial region pressure injury, to cleanse with normal saline, pat dry, apply Santyl (wound treatment), calcium collagen (wound treatment) and cover with foam dressing every day shift for 30 days;- left shin scattered scabs, to cleanse with normal saline, pat dry apply triple antibiotic ointment and cover with dry sterile dressing every day shift for 30 days;- provide low air loss mattress for wound care and skin integrity management, set according to resident's weight, check to ensure proper placement and function; - MASD to sacrum, to cleanse site with normal saline, pat dry apply zinc oxide (wound treatment) and leave open to air monitor every day shift for 14 days; - cleanse the posterior neck redness, with normal saline, pat dry and apply nystatin powder (antifungal treatment) and leave open to air; - cleanse the surgical incision with sutures to right lateral neck extending to clavicle, with normal saline, pat dry, and paint with betadine (antiseptic) and leave open to air every day shift for 30 days;- cleanse the upper back spine surgical incision with sutures with normal saline, pat dry, paint with betadine and cover with dry dressing; and - cleanse the right ischial region pressure injury with normal saline, pat dry, apply Santyl, calcium collagen and cover with foam dressing every day shift for 30 days. Review of Resident 4's TAR for January 2026 failed to show the nurses' initials for the following treatments on 1/4/26:- face scattered scabs, to cleanse with normal saline, pat dry, apply triple antibiotic ointment and cover with dry sterile dressing every day shift for 14 days; - left shin scattered scabs, to cleanse with normal saline, pat dry applytriple antibiotic ointment and cover with dry sterile dressing every day shift for 30 days;- for the low air loss mattress for wound care and skin integrity management set according to resident's weight, to check to ensure proper placement and function; - posterior neck redness, to cleanse with normal saline, pat dry and apply nystatin powder and leave open to air; - surgical incision with sutures to the right lateral neck extending to clavicle, cleanse with normal saline, pat dry, and paint with betadine and leave open to air every day shift for 30 days;- upper back spine surgical incision with sutures, to cl[TRUNCATED]

Based on interview, medical record review, and facility document review, the facility failed to ensure the facility staff provided the necessary emergency care and services to Resident 7. * LVNs 4 and 5 and RN 3 failed to provide continued CPR to Resident 7 when the resident remained unconscious, barely breathing and did not have any blood pressure reading. These failures had the potential to put the resident at risk for care not provided in a safe and competent manner.Findings: Review of the facility's P&P titled Competency of Nursing Staff dated 2001 showed all nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law. The staff development and training program is created by the nursing leadership, with input from the medical director, and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents. Competency demonstrations will be evaluated based on the staff member's ability to use and integrate knowledge and skills obtained in training, which will be evaluated by staff already deemed competent in that skill or knowledge. Review of the facility's P&P titled Emergency Procedure - Cardiopulmonary Resuscitation and Basic Life Support dated 2001 showed personnel are certified in CPR (Cardiopulmonary resuscitation for healthcare providers and BLS (Basic Life Support), including defibrillation for victims of sudden cardiac arrest. If an individual is found unresponsive and not breathing normally, a staff member who is certified in CPR for health care providers or BLS will administer CPR unless: a. it is known that a do not resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exist for that individual; or b. there are obvious signs or irreversible death. According to [NAME] A, Singh B, [NAME] PH. Cardiopulmonary Resuscitation. [Updated 2025 Jun 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan from: National Library of Medicine, retrieved [DATE], https://www.ncbi.nlm.nih.gov/books/NBK470402/ chest compressions are the cornerstone of CPR. These compressions generate artificial circulation by increasing intrathoracic pressure, which compresses the heart and propels blood forward. Effective compressions maintain coronary perfusion pressure, which is the difference between aortic diastolic and right atrial diastolic pressure during the relaxation phase of compressions. Coronary perfusion pressure is crucial for myocardial blood flow and is a primary determinant of successful return of spontaneous circulation. Ventilations provide oxygen to the lungs and help maintain blood oxygenation. However, positive-pressure ventilation can reduce coronary perfusion pressure by increasing intrathoracic pressure and impeding venous return to the heart. Therefore, the balance between adequate ventilation and minimizing interruptions to chest compressions is critical. The definitive treatment for ventricular fibrillation and pulseless ventricular tachycardia is electrical defibrillation, most commonly administered using an automated external defibrillator. If defibrillation is not performed promptly, brain death can occur in less than 10 minutes. CPR is a critical intervention to provide artificial circulation and ventilation until defibrillation is possible. When performed correctly, conventional manual CPR can deliver up to 33% of normal cardiac output and oxygenation. The cycle of 30 chest compressions followed by 2 rescue breaths should be continued until an automated external defibrillator becomes available or until additional help arrives. Once an automated external defibrillator is on scene it automatically analyzes the cardiac rhythm and advising whether a shock is necessary. If a shock is advised, chest compressions should be paused, and everyone should stand clear while the automated external defibrillator delivers defibrillation. Immediately after the shock, or if no shock is advised, CPR should be resumed without delay, continuing the CAB (Compressions, Airway, and Breathing) sequence until further assistance or advanced care arrives. According to American Heart Association's Hard Hats with Heart undated, retrieved [DATE], https://www.heart.org/-/media/Files/Affiliates/WSA/Oregon/CPR-Frequently-Asked-Questions.pdf showed CPR Frequently Asked Questions Toolbox Talks, the section for When do I stop giving Hands-Only CPR? showed to continue pushing hard and fast in the center of the chest until help arrives. If the person speaks, moves, or breathes normally while you're giving chest compressions, Hands-Only CPR can be stopped. Review of Resident 7's medical record was initiated on [DATE]. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's Order Summary Report dated [DATE], showed a physician's order dated [DATE], for full code. Review of Resident 7's POLST dated [DATE], the CPR section indicated to Attempt Resuscitation/CPR and the Medical Interventions section indicated Full Treatment (primary goal of prolonging life by all medically effective means). Review of Resident 7's eInteract SBAR Communication Form and Progress Notes dated [DATE], showed Resident 7 was found on the floor next to the bed, with no response to verbal and tactile stimuli, the assessment revealed asystole and absence of respiration, CPR was initiated and 911 was called. After approximately 20 minutes of CPR, return of spontaneous circulation was achieved and assumed care. The note further showed the fire department arrived, continued CPR and lifesaving measured for another 20 minutes. Further review of Resident 7's medical record failed to show a documentation and/or the vital signs reading when the staff achieved spontaneous circulation. Review of the Resident 7's Electronic Patient Care Report from the Fire Department dated [DATE] at 0236 hours, showed the fire department arrived on scene to find resident on the ground surrounded by care staff pulseless, apneic and without compressions being performed. The manual compressions was initiated. BVM (Bag-Valve-Mask) with high flow oxygen was administered. Defibrillation pads were applied at 0239 hours, resident was PEA (Pulseless Electrical Activity). Review of Resident 7's Emergency Department History and Physical examination dated [DATE], the Disposition section showed unfortunately the patient passed away in the Emergency Department. On [DATE] at 1435 hours, a telephone interview was conducted with the Fire Captain. The Fire Captain stated he arrived at the facility and found resident on the ground surrounded by care staff pulseless and not breathing without compressions being performed. The Fire Captain further stated the staff informed him of the CPR provided to the resident for twenty minutes and had believed heart rate was back and stopped the compression. On [DATE] at 1536 hours, a telephone interview was conducted with LVN 4. LVN 4 stated Resident 7 was unresponsive and had no pulse, and CPR was initiated immediately. LVN 5 provided the compressions while RN 3 provided breathing with the use of Ambu bag. LVN 4 further stated they provided CPR for twenty minutes then the resident's pulse came back, and RN 3 stated to stop the CPR while waiting for the paramedics. On [DATE] at 1611 hours, a telephone interview was conducted with RN 3. RN 3 stated she walked in Resident 7's room with LVN 5 on the scene. RN 3 stated Resident 7 was unresponsive and had no pulse, then LVN 5 and RN 3 initiated CPR immediately. RN 3 stated LVN 5 provided compressions while RN 3 provided breathing with the use of Ambu bag. RN 3 further stated the pulse was achieved prior to the fire department's arrival at the scene. However, RN 3 further stated Resident 7 had no blood pressure and remained unconscious. On [DATE] at 0617 hours, an interview was conducted with LVN 5. LVN 5 stated he found Resident 7 lying on the floor on the left side halfway on prone position. LVN 5 stated Resident 7 had no pulse oximeter reading and RN 3 verified the resident had no pulse and respiration. LVN 5 stated he provided the compressions while RN 3 provided the breathing with the use of Ambu bag. LVN 5 further stated they had performed CPR for 18-20 minutes then obtained a carotid pulse as confirmed by RN 3. LVN 5 stated they stopped the compressions with the presence of carotid pulse. LVN 5 further stated Resident 7 remained unconscious, barely breathing and did not have any blood pressure reading for approximately 5-7 minutes while waiting for the paramedics to arrive. a. Review of LVN 4's Licensed Nurse Competency dated [DATE], showed LVN 4 met the competency expectations for the emergency equipment. Review of LVN 4's BLS Provider certificate dated [DATE], showed LVN 4 had successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED) Program. b. Review of LVN 5's Licensed Nurse Competency dated [DATE], showed LVN 5 met the competency expectations for emergency equipment. Review of LVN 5's BLS Provider certificate dated [DATE], showed LVN 4 had successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED) Program. c. Review of RN 3's Competency Skills Checklist dated [DATE], showed RN 3 met the competency expectations for emergency equipment, emergency responses, and CPR. Review of RN 3's RQI (Resuscitation Quality Improvement) Healthcare Provider BLS certificate dated [DATE], showed RN 3 had demonstrated competence in High-Quality CPR Skills and had successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED) Program and RQI Program. However, LVNs 4 and 5, and RN 3 failed to provide the continued life-saving measures to Resident 7 when the resident remained unconscious, barely breathing and did not have any blood pressure reading and until the paramedics arrived. On [DATE] at 0850 hours, an interview was conducted with the DON. The DON stated the expectation for the licensed nurses was to continue with the CPR until the fire department arrives and takes over the resuscitation. Cross Reference F684, Example #1.