Every finding on record at Imperial Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were followed when: 1.The suction tubing and Yankauer suction tip (a medical tool used to clear blood, saliva, and other fluids from a patient's mouth and throat during procedures or emergencies) with the change date for two of two sampled residents (Resident 5 and Resident 16) and not keeping the suction tip in a clean covering for Resident 5. 2. Staff did not perform hand hygiene between handling meal trays, and beverages between Resident 24 and Resident 87. 3. The water management plan (Water Management Program (WMP, a written, step-by-step plan for buildings to ensure their water system was safe, clean, and efficient was implemented as written) was not implemented when staff did not perform monitoring of cold water temperature, chlorine residual (the amount of active chlorine left in water after a set contact time following disinfection) levels, and pH (measure of acidity or alkalinity of an aqueous solution). 4. Licensed Vocational Nurse (LVN) 1 removed a gown in the hallway and disposed of it in a medication cart trash bin instead of the designated Personal Protective Equipment (PPE - gloves, gowns, masks, and face shields) waste container. 5. An Enhanced Barrier Precaution (EBP) signage was not displayed outside the room of one of six residents (Resident 108), who had a Jackson Pratt (JP - a flexible medical device used after surgery to remove excess fluids like blood and lymph from a surgical site) drain. 6. One of three sampled residents' (Resident 85) restroom door had bowel residue (feces). These deficient practices had the potential to increase the risk of cross-contamination (the transfer of bacteria, viruses, microorganisms or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) and spread of infection among the residents, staff and visitors. Findings: 1. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the partial loss of movement on one side of the body), muscle weakness, diabetes (a disorder characterized by difficulty in blood sugar control), dysphagia (difficulty swallowing), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 5's Minimum Data Set ([MDS], a resident assessment tool), dated 6/19/2026, the MDS indicated Resident 5's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 5 was entirely dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and mobility. During a review of Resident 5's care plan, titled Dysphagia: Risk for choking, aspiration (accidentally inhaling food or liquid into your lungs) or pneumonia (an infection/inflammation in the lungs), initiated 5/17/2026, the care plan indicated to provide oral care as needed. During a review of Resident 5's Physician Order, dated 6/16/2026, the order indicated to suction Resident 5's oral secretions (fluids produced in the mouth or mucus) as needed. During observations made on 8/24/2026 at 9:48 a.m. and 8/25/2026 at 7:43 a.m., in Resident 5's room, two unlabeled suction canisters, each containing approximately 100 milliliters (ml, a unit of measurement) of fluid, were found on Resident 5's nightstand. One of the suction canisters contained clear fluid, while the other contained yellowish to brownish fluid. One canister was connected to unlabeled suction tubing attached to an unlabeled Yankauer suction tip (a medical tool used to clear blood, saliva, and other fluids from a patient's mouth and throat during procedures or emergencies). The Yankauer suction tip was contained in a clear plastic bag, dated 6/22/2026. During an observation on 8/26/2026 at 9:15 a.m., in Resident 5's room, two unlabeled suction canisters, each containing approximately 100 ml of fluid, were found on Resident 5's nightstand. One suction canister contained clear fluid, while the other contained yellowish to brownish fluid. One canister was connected to unlabeled suction tubing attached to an unlabeled Yankauer suction tip. The Yankauer suction tip was not contained in a clean plastic bag or another protective covering and was exposed to the environment. During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was initially admitted to the facility on [DATE]. Resident 16's diagnoses included hemiplegia and hemiparesis, muscle weakness, cognitive communication deficit, and gastrostomy. During a review of Resident 16's MDS, dated [DATE], the MDS indicated Resident 16's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 16 was entirely dependent on staff for activities of daily living and mobility. During a review of Resident 16's care plan, titled Dysphagia: Risk for choking, aspiration or pneumonia, initiated 6/26/2026, the care plan indicated to provide oral care after meals to minimize oral residue. During a review of Resident 16's Physician Order, dated 8/8/2026, the order indicated to suction Resident 16 as needed for excessive oral secretions. During observations made on 8/24/2026 at 9:47 a.m., 8/25/2026 at 7:43 a.m., and 8/26/2025 at 9:15 a.m., in Resident 16's room, there was a suction machine attached to a collection canister that contained approximately 100 ml of clear to yellow-tinged fluid. The canister was connected to unlabeled suction tubing attached to an unlabeled Yankauer suction tip. During an interview on 8/26/2026 at 9:53 a.m. with Infection Prevention Nurse (IPN), the IPN stated the proper care and sanitation of oral suction equipment included emptying and cleaning the canister daily, labeling the suction tubing and the Yankauer suction tip with the date they were changed, and keeping the suction tip in a clean covering. The IPN stated it was important to clean and empty the suction canisters, change the suction tubing and the Yankauer suction tip, to minimize bacterial growth and decrease the likelihood of illness for Residents 5 and Resident 16. The IPN stated that if the canisters were not cleaned and emptied daily, there was a risk for Resident 5 and Resident 16 to develop aspiration pneumonia (a lung infection caused by breathing foreign material—such as food, liquid, saliva, or vomit—into the airways instead of swallowing it) or illness. The IPN further stated the Yankauer suction tip should not be left uncovered because doing so created a risk for contamination. During an interview on 8/26/2026 10:23 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that she was Resident 5 and Resident 16's assigned nurse on 8/25/2026 and 8/26/2026, 7:00 a.m. to 3:00 p.m. shift. LVN 1 stated she did not notice the suction canisters contained fluid. LVN 1 stated the suction equipment should remain labeled with a date to identify when the equipment was last changed, and the Yankauer suction tip should not be left uncovered. LVN 1 stated that if the canisters were not emptied and the equipment was not labeled with the last date changed, there was potential for infection for Resident 5 and 16. LVN 1 stated that if the Yankauer suction tip was left uncovered, there was the potential for infection for Resident 5. During a review of the facility's policy and procedures (P&P) titled, Suctioning, dated 8/2014, the P&P indicated the purpose of the policy was to help prevent nosocomial infections associated with suctioning and to prevent transmission of such infections to residents and staff. The P&P indicated the suction collecting canister should be emptied and cleaned daily and changed or decontaminated as necessary. The P&P indicated to empty the suction collection canister as necessary for repeated use on the same resident (usually at the end of each shift) and at least daily. 2. During an observation on 8/24/2026 at 12:39 p.m., in station 1, Certified Nurse Assistant (CNA) 2 was observed distributing meal trays to residents and not performing hand hygiene between Resident 87 and Resident 24. During an interview on 8/24/2026 at 12:58 p.m., with CNA 2, CNA 2 stated she forgot to perform hand hygiene between distributing meal trays and stated she provided one beverage to Resident 87, and then returned with the second beverage to assist Resident 24 with feeding without performing hand hygiene. During a concurrent interview on 8/26/2026 at 11:03 a.m., with Infection Prevention Nurse (IPN), the IPN stated staff should perform hand hygiene before and after distributing meal trays. The IPN stated hand hygiene for safety because failure to perform hand hygiene could result in cross contamination. During a review of the facility's P&P titled, Handwashing / Hand Hygiene, revised August 2019, the P&P indicated Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations'.Before and after eating or handling food. Before and after assisting resident with meal. 3. During an interview on 8/26/2026 at 12:46 p.m. with the IPN, the IPN stated that Maintenance Supervisor (MS) 1 was responsible for monitoring the water quality. The IPN stated she was unsure whether chlorine residuals and pH were monitored. The IPN stated that following the WMP was important to stop bacterial growth and ensure the safety of the facility's water supply. During a concurrent interview and record review with MS 1 on 8/26/2026 at 12:46 p.m., the facility's Water Management Program folder and August 2026 maintenance logs were reviewed. MS 1 stated that he only tested and monitored the facility's hot water. MS 1 stated he did not test the temperature of cold water, chlorine residuals, or pH levels. MS 1 stated attended the Water Management Program meetings and aware these tests were required, but he did not know how to perform them. MS 1 stated he had not completed these tests and the facility had no forms for documenting pH and chlorine testing. During a review of facility's P&P titled, Legionella Water Management Program, revised July 2017, the P&P indicated, Specific measures used to control the introduction and /or spread of Legionella (e.g., temperature, disinfectant). The control limits or parameters that are acceptable and that are monitored. During a review of facility's P&P titled, Infection Prevention and Control Program, undated, the P&P indicated, the Infection Prevention and Control Program provides a system for preventing, identifying, reporting, investigating, and controlling infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. 4. During an observation on 8/25/2026 at 9:10 a.m, in front of Resident 76's room, LVN 1 was observed doffing her gown and discarded the gown in the medication cart trash bin outside the room. During an interview on 8/25/2026 at 9:40 a.m., with LVN 1, LVN 1 stated the importance of doffing (removing personal protective equipment such as gloves, gowns, masks, and face shields after exposure to a hazardous or infectious environment) correctly was to prevent the spread of infection. LVN 1 stated that when doffing, the gown should be discarded in the trash can inside the resident's room before exiting. During an interview on 8/26/2026 at 9:41 a.m. with the IPN, the IPN stated the importance of discarding personal protective equipment (PPE - gloves, gowns, masks, and face shields) in the designated area was to prevent residents from cross contamination and infection. The IPN stated the PPE should always be discarded in the trash bin before leaving the resident room. During an interview on 8/27/2026 at 10:27 a.m. with the DON, the DON stated the importance of doffing correctly was to prevent the spread of infection and cross contamination. The DON stated the dirty gown should have been disposed of in the trash bin located inside Resident 76's room. During a review of the facility's P&P titled, Personal Protective Equipment revised July 2026, indicated, Gowns shall be doffed prior to exiting resident care areas and re-entering common areas, e.g., hallways. 5. During a review of Resident 108's physician's order dated 8/24/2026 indicated the resident was placed on Enhanced Barrier Precautions. During a review of the care plan Enhanced Barrier Precautions, Resident with presence of JP Drain dated 8/24/2026, the care plan Enhanced Barrier Precautions, Resident with presence of JP Drain (a flexible medical device used after surgery to remove excess fluids like blood and lymph from a surgical site) During an observation on 8/24/2026 at 12:31 p.m. outside Resident 108's room, there was no Enhanced Barrier Precaution (EBP) signage displayed outside the resident's room. During an interview on 8/26/2026 at 9:41 a.m. with the IPN, the IPN stated that Enhanced Barrier Precaution (EBP) signage was essential to inform staff of a resident's infection status and wear appropriate Personal Protective Equipment (PPE) required before entering the room. The IPN stated that Resident 108 had a Jackson Pratt (JP) Drain which increased the risk of infection and potential progression to sepsis (a life-threatening medial emergency that happens when the body has an extreme, overactive immune response to an infection), therefore, having EBP signage would help prevent this risk. During a review of the facility's policy and procedure (P&P) titled, Standard Precautions, Enhanced Barrier Precautions and Transmission Based Precautions, revised 6/8/2026, indicated, Enhanced Barrier Precautions (EBP) – primarily is the use of gowns and gloves for specific high contact care activities, based on the residents characteristics that are associated with a high risk of MDRO colonization and transmission: Presence of indwelling medical devices (e.g. urinary catheter, feeding rube, endotracheal or tracheostomy tube, central/vascular catheters, etc.) 6. During an observation on 8/24/2026 at 9:58 a.m. in Resident 85's room, Resident 85's restroom door was noted to have a thin layer of brown-colored, smeared substance. During a concurrent observation and interview on 8/24/2026 at 10:09 a.m., with LVN 1, LVN 1 stated the brown substance on Resident 85's bathroom door was feces. During an interview on 8/26/2026 at 9:41a.m. with the IPN, the IPN stated the importance of keeping the resident's room clean was to ensure infection was not being spread. During an interview on 8/27/2026 at 10:27 a.m. with the Director or Nursing (DON), the DON stated the maintaining a clean homelike environment prevents contamination which ensures the residents are safe from infection.

Based on observation, interview, and record review, the facility failed to follow the standardized recipe for Spinach Au Gratin for five of five sampled residents (Residents 2, Resident 6, Resident 7, Resident 10 and Resident 98). This deficient practice had the potential for affecting the resident's meal satisfaction and risk for weight loss.Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 6/5/2018 and was readmitted on [DATE] with diagnoses including diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness (loss of muscles strength), hypertensive chronic kidney disease and anemia a condition where the body does not have enough healthy red blood cells). During a review of Resident 2's physician diet order, dated 7/6/2026, the physician order indicated Resident 2 was to receive a regular diet with texture, 0 - thin liquid consistency diet. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted the resident on 10/07/2025, and was readmitted on [DATE], with diagnoses including muscle weakness (loss of muscles strength), dysphagia (difficulty swallowing), gastro- esophageal reflux disease (GERD - a chronic condition where stomach acid flows back up into the tube connecting your mouth and stomach), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 6's physician diet order, dated 8/14/2026, the physician order indicated Resident 6 was to receive a diet with no added salt, soft and bite sized texture and thin liquid consistency. During a review of Resident 7's admission Record, the admission Record indicated the facility admitted the resident on 4/19/2026 with diagnoses including muscle weakness. dysphagia, chronic kidney disease, and anemia. During a review of Resident 7's physician diet order, dated 7/30/2026, the physician order indicated Resident 7 was to receive a diet with no added salt, regular texture and thin liquid consistency. During a review of Resident 10's admission Record, the admission Record indicated the facility admitted the resident on 4/3/2026 with diagnoses including muscle weakness, essential (primary) hypertension and anemia. During a review of Resident 10's physician diet order, dated 7/30/2026, the physician order indicated Resident 10 was to receive a diet with no added salt, regular texture and thin liquid consistency. During a review of Resident 98's admission Record, the admission Record indicated the facility admitted the resident on 6/16/2026 with diagnoses including muscle weakness, dysphagia, GERD, and anemia. During a review of Resident 98's physician diet order, dated 7/27/2026, the physician order indicated Resident 98 was to receive a diet with no added salt, regular texture and thin liquid consistency. During an observation on 8/25/2026, at 12:29 p.m., the [NAME] (Cook) 1 was observed preparing and cooking a batch of spinach (in boiling water). During observation in the kitchen on 8/25/2026, at 12:45 p.m., Resident 2, 6, 7, 10 and 98's lunch trays were observed to contain a side dish of cooked and drained spinach. During an observation in the kitchen on 8/25/2026, at 12:59 p.m., [NAME] 1, was observed cooking (in boiling water) an additional batch of spinach. During a concurrent interview and record review on 8/25/2026 at 1:08 p.m., with [NAME] 1, the lunch menu recipe titled Spinach Au Gratin for 8/25/2026 was reviewed. [NAME] 1 stated the recipe included, spinach (chopped and frozen), margarine and Swiss cheese (grated). [NAME] 1 stated he did not add Swiss cheese to the second and third batch of spinach au gratin. [NAME] 1 stated he was responsible for adding the cheese and following the recipes on the menu. During an interview on 8/26/2026 at 1:10 p.m., with the Dietary Supervisor (DS), the DS stated the calories for the recipes are precalculated. The DS stated by not following the recipe, the residents are at risk of a decrease in caloric intake and nutrition. The DS stated the missing ingredients had the potential to place the residents at risk of being less satisfied with the spinach and their meals. During a review of the facility's policy and procedure (P&P) titled, Food Preparation, dated 2023, indicated, Recipes are specific as to portion yield, method of preparation, quantities of ingredients, and time and temperature guidelines.

Based on observation, interview, and record review, the facility failed to ensure opened and frozen bag of mixed vegetables and frozen turkey meatballs were covered and sealed. These deficient practices had the potential to place 90 of 96 medically compromised and vulnerable residents who received food from the kitchen at risk for compromised food integrity and contamination.Findings:During a concurrent observation and interview on 8/24/2026 at 8:15 a.m. with the Dietary Supervisor (DS), in the kitchen, observed an opened bag of turkey meatballs in the freezer, not fully closed. An opened bag of mixed vegetables was observed in the freezer, not fully closed. The DS stated the bags of turkey meatballs and mixed vegetables should have been sealed to prevent the risk of contamination and freezer burn (when frozen foods are exposed to cold, dry air, causing them to dehydrate, often resulting in ice crystal formation on the outside of food).During an interview on 8/26/2026 at 2:00 p.m. with the Registered Dietician (RD), the RD stated kitchen staff should ensure opened frozen foods should be placed in a bag and resealed to prevent freezer burn and to preserve the quality and texture of food.During a review of the facility's policy and procedure (P&P) titled, Procedure for Freezer Storage dated 2023, the P&P indicated, Store frozen foods in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 50) was appropriately assisted with a plate guard (a curved removable rim that clips onto dining plate to keep food from falling) during lunch. This deficient practice compromised Resident 50's ability to independently feed herself.Findings: During a review of Resident 50's admission Record, the admission Record indicated Resident 50 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 50's diagnoses included dysphagia (difficulty swallowing), dementia (a progressive state of decline in mental abilities) and hypertension (HTN- high blood pressure). During a review of Resident 50's History and Physical (H&P) dated 4/30/2026, the H&P indicated Resident 50 did not have the capacity to understand or make decisions. During a review of Resident 50's Minimum Data Set (MDS- a resident assessment tool) dated 7/23/2026, the MDS indicated Resident 50's cognitive (ability to think and understand) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 50 required substantial assistance from staff for eating, personal hygiene and was dependent for bathing and toileting. During a review of Resident 50's physician orders dated 2/26/2026, the physicians order indicated, Kitchen to provide plate guard for all meals to promote independence in feeding with meals. During a review of Resident 50's care plan titled, Patient is at risk of decreased independence in feeding dated 2/26/2026, the care plan indicated the kitchen was to provide a plate guard for all meals to promote independence in feeding. During an observation on 8/24/2026 at 12:15 p.m. in the dining room, Resident 50 was observed eating lunch. A plate guard was attached to side of the plate opposite from Resident 50's body. Resident 50 was observed feeding herself, with droppings of food on the table. During a concurrent observation and interview on 8/24/2026 at 12:26 p.m. with Certified Nursing Assistant (CNA) 4, Resident 50's plate guard was observed attached to the side of the plate opposite from her body. CNA 4 stated the CNA set up Resident 50's plate guard incorrectly because the plate guard should be attached to the side of the plate closer to her body to prevent food spillage. During an interview on 8/26/2026 at 1:15 p.m. with the Dietary Supervisor (DS), the DS stated feeding assistive devices such as plate guards were typically ordered by the rehabilitation team. The DS stated the purpose of plate guards was to promote resident independence with feeding. During an interview on 8/26/2026 at 1:11 p.m. with the Director of Nursing (DON), the DON stated CNA's were responsible for ensuring appropriate assistance was provided to residents using feeding assistive devices. The DON stated it was important to ensure plate guards were set up correctly to ensure safety and promote resident independence with feeding. During a review of the facility's policy and procedure (P&P), titled, Assistance with Meals last reviewed 5/2026, the P&P indicated, Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. These may include devices such as silverware with enlarged/padded handles, plate guards, and/or specialized cups. The P&P indicated, Assistance will be provided to ensure that residents can use and benefit from special eating equipment and utensils.

Based on observation, interview, and record review, the facility failed to ensure the Station 1 hallway leading to the fire exit remained unobstructed.This deficient practice had the potential to delay or block residents, staff, and visitors during an emergency evacuation.Findings: During an observation on 8/24/2026 at 9:49 a.m., 8/25/2026 at 8:23 a.m., and 8/26/2026 at 8:31 a.m., the Station 1 hallway leading to the fire exit was obstructed by two laundry carts and a large laundry bin. The obstruction reduced clear access to the fire exit and had the potential to delay safe evacuation during an emergency. During an interview on 8/25/2026 at 1:24 p.m., with Certified Nursing Assistant (CNA) 5, CNA 5 stated hallways and fire exits must stay clear to ensure staff could assist residents, and those in wheelchairs to enable quick evacuation during emergencies. During an interview on 8/27/2026 at 11:52 a.m., with Maintenance Supervisor (MS) 2, MS 2 stated the hallway and fire exit pathway should remain clear at all times and laundry carts and bins should not be stored by the exit door. MS 2 stated the obstruction could delay residents using wheelchairs or requiring staff assistance during an emergency evacuation. During an interview on 8/27/2026 at 11:57 a.m., with Administrator (ADM), the ADM stated the facility was responsible for maintaining a safe and unobstructed environment, including all exit pathways. The ADM stated blocked fire exits could endanger residents during emergencies. During an interview on 8/27/2026 at 12:10 p.m., with the Director of Nursing (DON), the DON stated residents need unobstructed emergency exits. The DON stated laundry carts blocking pathways could hinder safe evacuation, and for residents needing mobility assistance. During a review of the facility's policy and procedure (P&P) titled, Emergency Exits, dated 20221, the P&P indicated the facility has emergency exits for evacuation, and shall keep exits unblocked and clear at all times.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 18) was provided with assistance during meals. This deficient practice had the potential to cause Residents 18 to feel disregarded, humiliated, emotionally distressed, and also had the potential to compromise the residents' dignity and quality of life. Findings:During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 18's diagnoses included subdural hemorrhage (a bleeding that occurs between the dura mater and the brain, often caused by head injury) without loss of consciousness, diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and muscle weakness. During a review of Resident 18's Minimum Data Set ([MDS]- a resident assessment tool), dated 6/21/2026, the MDS indicated Resident 18's cognitive skills for daily decision making (the ability to think and process information) was moderately impaired. The MDS indicated Resident 18 was dependent (helper does all the effort) on staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 18's History and Physical (H&P- a record of the resident's health history and doctor's checkup) dated 8/7/2026 indicated Resident 18 did not have the capacity to understand and make decisions. During a review of Resident 18's care plan titled, Resident with self-care and mobility performance deficit., dated 7/20/2026, the care plan indicated Resident 18 required supervision or touching assistance during mealtimes. During an observation and interview on 8/25/2026 at 12:25 p.m., with Resident 18, in Resident 18's room, Resident 18 was observed seated in a wheelchair during lunch. The overbed table was positioned away from Resident 18 and the meal tray placed beyond reach. Resident 18 stated he always feeds himself and did not remember staff assisting him during meals. Resident 18 stated, Sometimes I feel like I don't matter in this facility. During an interview on 8/25/2026 at 1:02 p.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated Resident 18 should not be left unattended during meals and the meal tray should be correctly positioned on the overbed table within reach. CNA 3 stated not following these steps could lead to insufficient nutrition, and a loss of personal dignity. During an interview on 8/27/2026 at 8:21 a.m., with the Director of Nursing (DON), the DON stated staff were expected to follow the resident's care plan and provide care in a manner that maintained dignity and respect. The DON stated staff should provide the resident's required supervision/touching assistance during meals and ensure the overbed table and meal tray were properly positioned within reach. The DON stated failure to ensure assistance and proper positioning may compromise Resident 18's safety, nutritional intake, and dignity. During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Dignity/Respect revised 2021, the P&P indicated residents shall be treated with dignity and respect at all times. The P&P indicated each resident shall be cared for in a manner that promotes and enhance quality of life.

Based on observation, interview, and record review, the facility failed to ensure lunch trays were served in a timely manner for one of six sampled residents (Resident 107). This deficient practice had the potential to negatively affect Resident 107s' psychosocial wellbeing.Findings: During a review of Resident 107's admission Record, the admission Record indicated Resident 107 was admitted to the facility on [DATE]. Resident 107's diagnoses included dysphagia (difficulty swallowing), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 107's History and Physical (H&P) dated 8/22/2026, the H&P indicated Resident 107 had the capacity to understand and make decisions. During a concurrent observation and interview on 8/25/2026 at 1:15 p.m. with Resident 107, Resident 107 was observed eating with furrowed eyebrows. Resident 107 stated she was frustrated because she was very hungry and lunch was served late at 1:10 p.m. Resident 107 stated lunch was usually served around 12:30 p.m and lunch should be served at its scheduled time. During an interview on 8/26/2026 at 1:57 p.m. with [NAME] (CK) 1, CK 1 stated on 8/25/2026, lunch trays were late because the kitchen ran out of the prepared spinach dish and had to cook a new batch. CK 1 stated if he had followed the recipe for spinach, the appropriate amount would have been prepared and lunch trays would have been delivered on time. During an interview on 8/25/2026 at 2:37 p.m. with the Dietary Supervisor (DS), the DS stated CK 1 should have followed the spinach recipe to ensure adequate portions of dishes were prepared for the residents. The DS stated late meal trays could be frustrating for residents and residents should be able to expect meals to be delivered around the mealtimes preset by the facility. During a review of the facility's policy and procedure (P&P), titled, Meal Service dated 2023, the P&P indicated the lunch meal time was at 12:00 p.m. During a review of the facility's P&P titled, Quality of Life - Dignity/Respect last revised 3/2026, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feelings of self-worth and self-esteem.

Based on observation, interview, and record review, the facility failed to ensure resident rooms were clean, sanitized, and presented in a manner that supported a homelike environment for two of two residents (Resident 114 and Resident 72), when: 1. Resident 114's restroom was noted with fecal matter on the toilet and wall upon admission. 2. Resident 72's room was noted with chipped paint on the wall. These deficient practices created an unsanitary and unpleasant living environment for Residents 114 and 72.Findings: 1. During a review of Resident 114's admission Record, the admission Record indicated Resident 114 was initially admitted to the facility on [DATE]. Resident 114's diagnoses included urinary tract infection (UTI- an infection in the bladder/urinary tract), muscle weakness, and unspecified Escherichia Coli (a type of bacteria infection). Resident 114's History and Physical (H&P), dated 8/18/2026, the H&P indicated Resident 114 had the capacity to understand and make decisions. During a review of the facility's Census, dated 8/27/2027, the census indicated Resident 114 was admitted to Room A on 8/17/2026 . During an interview on 8/24/20276 at 2:30 p.m. with Resident 114's Emergency Contact (EC 1), EC 1 stated she accompanied Resident 114 during her admission to the facility. Upon arrival, EC 1 stated the facility did not have a bed prepared for Resident 114, resulting in a wait time of one and a half hours before the room was ready. After Resident 114 was settled, EC 1 stated she inspected the restroom and observed it to be unsanitary with visible fecal matter present on both the wall and toilet. EC 1 stated she informed staff, who initially cleaned the restroom with a rag. EC 1 stated she requested that staff provide appropriate sanitary procedures to thoroughly disinfect the area. During an interview on 8/25/2026 at 11:24 a.m. with Registered Nurse (RN) 2, RN 2 stated the standard procedure prior to admitting a resident involved verifying that both the room and restroom were clean. RN 2 recalled that she did not inspect the restroom before Resident 114 was admitted , and only checked its condition after EC 1 raised concerns regarding cleanliness. RN 1 stated she noted that the toilet bowl was dirty and acknowledged that the restroom should have been inspected prior to Resident 114's arrival. RN 2 stated Resident 114 was entitled to a clean and homelike environment, including a sanitary restroom, and stated that an unclean restroom could potentially make her feel uncomfortable or dissatisfied. During a concurrent interview and record review on 8/27/2026 at 1:25 p.m. with the Director of Nursing (DON), the facility's High Touch Surfaces Cleaning and Sanitation Log, dated 8/2026, was reviewed. The log indicated a single initial marked on 8/17/2026 for Room A. The DON stated the documentation was insufficient to determine the frequency of cleaning performed for Room A on 8/17/2026. 2. During a review of Resident 72's admission Record, the admission Record indicated Resident 72 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 72's diagnoses included aftercare following joint replacement surgery, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and muscle weakness. During a review of Resident 72's Minimum Data Set ([MDS]- a resident assessment tool), dated 2/5/2026, the MDS indicated Resident 72's cognitive skills for daily decision making (the ability to think and process information) was intact. The MDS indicated Resident 72 required moderate assistance (helper does less than half the effort) on staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 72's H&P dated 8/4/2026 indicated Resident 72 has the capacity to understand and make decisions. During an observation and interview on 8/24/2026 at 10:01 a.m., with Resident 72, in Resident 72's room, Resident 72 was observed seated on a wheelchair. Resident 72 stated the chipped paint on the wall made the room look dirty and not well maintained. Resident 72 stated that he did not feel the living environment was dignified or comfortable. During an interview on 8/26/2026 at 1:24 p.m., with Licensed Vocational Nurse (LVN) 1, the LVN 1 stated facility staff were responsible for ensuring requests for dirty walls or repairs were made in the maintenance communication logbook (a notebook where a person writes down important information and requests in order). LVN 1 stated clean walls was important in ensuring residents' rights for a homelike environment. During a concurrent observation and interview on 8/27/2026 at 11:41 a.m., with Maintenance Supervisor (MS) 2, in Resident 72's room, observed chipped paint on the wall with scratches, and surface deterioration. MS 2 stated residents should have clean walls. During an interview on 8/27/2026 at 12:02 p.m., with the Director of Nursing (DON), the DON stated maintaining a homelike environment helped residents feel safe, comfortable, respected and promoted dignity. During a review of the facility's policy and procedures (P&P) titled, Safe and Homelike Environment, dated 3/2026, the P&P indicated the facility was to provide residents with a safe, clean, comfortable and homelike environment. The P&P indicated the facility is committed to maintaining a safe, clean, comfortable, and home-like setting through regular room checks conducted by licensed nurses and ongoing departmental inspections.

Based on interview and record review the facility failed to ensure for one of five residents (Resident 8) had a resident centered care plan for Depakote (drug used to prevent or reduce the severity of seizures).This failure had the potential to result in not having monitoring, assessment, interventions and goals which places the resident at risk for harm. Findings:During a review of Resident 8's admission Record, the admission Record indicated the facility admitted the resident on 4/11/2025 and was re-admitted on [DATE] with diagnoses including metabolic encephalopathy (a general brain malfunction caused by an underlying systemic illness or chemical imbalance in the blood that deprives the brain of energy), unspecified mood disorder, and generalized anxiety disorder.During a review of Resident 8's Minimum Data Set (MDS- a resident assessment tool) dated 7/26/2026 indicated the resident had moderate cognitive (ability to think and understand) impairment. The MDS indicated Resident 8 was taking antipsychotic (prescription drugs used to treat mental health conditions), anti-anxiety and anti-convulsant medications (drug used to prevent or reduce the severity of seizures and other neurological conditions).During a review of Resident 8's physician orders dated 7/25/2026 indicated an order for Depakote tablet delayed release 250 milligrams (mg, unit of weight), give one tablet by mouth three times a day for mood disorder manifested by sudden shifts in mood.During a concurrent interview and record review on 8/26/2026 at 1:59 p.m. with the Minimum Data Set Nurse (MDSN), Resident 8's Care Plan Report, undated, was reviewed. Resident 8's Care Plan Report indicated Depakote was not included in the resident centered plan of care. The MDSN stated care plans are essential for addressing resident needs, and incomplete or inaccurate entries may compromise resident safety. The MDSN stated any medications prescribed to a resident must be documented in the care plan, including associated side effects and required interventions. The MDSN stated care plans must be updated to ensure there are no issues affecting patient safety.During an interview on 8/27/2026 at 10:27 a.m. with the Director of Nursing (DON), the DON stated care plans are essential for focusing on residents' goals and needs. The DON stated depakote was part of the resident's orders and must be included in the care plan, which nurses use to reference appropriate interventions. The DON stated that the omission of depakote from the care plan could potentially result in physical harm to Resident 8.During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated May 2026, indicated, The comprehensive, person- centered care plan will: measurable objectives and timeframes; reflect treatment goals, timetables and objectives in measurable outcomes.

Based on observation, interview, and record review, the facility failed to ensure professional standards of practice were met for two of two residents (Resident 108 and Resident 7) when: 1. Resident 108's Jackson Pratt (JP) drain bulb (a medical-grade, flexible silicone reservoir used in post-surgical wound care to continuously collect and measure excess fluids like blood and lymphatic fluid) remained flat or compressed to allow for adequate suction to pull excess fluid from the surgical wound for one of one sampled residents'. 2. Resident 7's physician's order for midodrine hydrochloride (a prescription medication used to treat low blood pressure when standing up from sitting position) was not followed. These deficient practices had the potential to result in inadequate suction and drainage, fluid accumulation, infection, and impaired wound healing for Resident 108, and result in increased blood pressure for Resident 7. Findings: 1. During a review of Resident 108's admission Record, the admission Record indicated Resident 108 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 108's diagnoses included acute cholecystitis (swelling and irritation, called inflammation, of the gallbladder), dysphagia (difficulty swallowing), and muscle weakness. During a review of Resident 108's History and Physical (H&P), dated 8/19/2026, the H&P indicated Resident 108 had the capacity to understand and make decisions. During a review of Resident 108's admission Progress Note, dated 8/17/2026, the progress note indicated Resident 108 was admitted with a Jackson Pratt (JP) drain (JP drain, medical device used to remove excess fluids, like blood or lymph, from a surgical site) to the right upper quadrant (the upper right section of the human abdomen, located roughly under the ribs) after undergoing a laparoscopic cholecystectomy (a common, minimally invasive surgery to remove the gallbladder). During observations made on 8/24/2026 at 12:32 p.m. and 2:50 p.m.; and 8/25/2026 at 7:53 a.m., and 12:32 p.m., Resident 108's JP drain bulb (a medical-grade, flexible silicone reservoir used in post-surgical wound care to continuously collect and measure excess fluids like blood and lymphatic fluid) was expanded and not providing suction to pull excess fluid from the surgical site. During a review of the facility's Lesson Plan for Care of JP [drain] In-service, dated 8/26/2026, the lesson plan indicated the licensed nurses were expected to completely flatten or squeeze the bulb.to push all the air out, then firmly insert the plug back into the spout while keeping the bulb compressed. The lesson plan also indicated to check suction, and the bulb should stay flat or compressed as it slowly re-expands to create a gentle suction pulling fluid from the site. During an interview on 8/25/2026 at 12:44 p.m. with Licensed Vocational Nurse (LVN 3), LVN 3 stated she was responsible for performing the wound treatments within the facility. LVN 3 stated the practice of the facility was to monitor for any signs and symptoms of infection, monitor the site, the drainage output, and ensure the bulb of the JP drain was compressed after it was drained. LVN 3 stated the JP drain bulb was to remain compressed to allow for adequate wound drainage and to promote adequate wound healing. LVN 3 stated if Resident 108's JP drain bulb was not compressed there was a risk for a wound infection and impaired wound healing. During a review of the facility's policy and procedure (P&P) titled, Jackson Pratt (JP) Drain, dated 3/2019, the P&P indicated licensed nurses were to plug the JP drain bulb when the bulb was flat after emptying the bulb. 2. During a review of Resident 7's admission Record, the admission Record indicated the facility admitted the resident on 4/19/2026, and was readmitted on [DATE] with diagnoses including essential hypertension (HTN- high blood pressure), atherosclerotic heart disease of native coronary artery angina pectoris (plaque buildup in heart arteries reducing blood flow and causing chest pain), and orthostatic hypotension (a sudden drop in blood pressure when standing up from a sitting or lying position). During a review of resident 7's Minimum Data Set (MDS - a resident assessment tool) dated 7/13/2026, the MDS indicated the resident's cognitive skills for daily decision making (ability to think and understand) was intact. During a record review of Resident 7's H&P, dated 7/6/2026, the H&P indicated Resident 7 had fluctuating capacity to understand and make decisions. During a review of Resident 7's physician order dated 7/6/2026, the physician order indicated Midodrine HCL Oral Tablet 10 milligrams (mg, unit of weight), give one tablet by mouth three times a day for orthostatic hypotension. Give if systolic blood pressure (SBP - the top number in a blood pressure reading that measures the force of blood against artery walls when the heart beats) is less than 130. During a concurrent interview and record review on 8/27/2026 at 12:05 p.m., with Licensed Vocational Nurse (LVN) 4, Resident 7's Medication Administration Record (MAR) was reviewed. LVN 4 stated midodrine HCL was administered to Resident 7 on 8/2/2026 and 8/23/2026. LVN stated, I should administer midodrine if the resident's (SBP) is below 130. LVN 4 stated he signed the MAR for the administration of midodrine when Resident 7's SBP was above 130. LVN 4 stated his signature was a documentation error and stated his error could provide other nurses with incorrect information. During an interview on 8/27/2026, at 12:27p.m., with the Assistant Director of Nursing (ADON), the ADON stated the importance of following the physician orders, as they are working hand in hand to care for the residents and cannot make orders on our own. The ADON stated potential mishaps can happen when nurses act on their own accord. The ADON stated licensed nurses are trained by the facility monthly on medication administration and are expected to follow the scope of nursing, and the protocols of the facility and drug administration when administering medications to our residents. During an interview on 8/27/2026, at 12: 33p.m., with the Director of Nursing (DON), the DON stated midodrine should be given when the SBP is below 130 to increase the blood pressure. The DON stated giving midodrine when the SBP is above 130, will increase the residents' blood pressure and could possible cause a stroke. During a review of the facility's policy & procedure (P&P), titled, Charting and Documentation, dated 2001, the P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on interview and record review, the facility failed to ensure oxygen saturation (O2 sat- measurement of blood oxygen level circulating in bloodstream) parameters were ordered for one of three sampled residents receiving continuous oxygen therapy (Resident 47). This deficient practice placed Resident 47 at risk of unidentified respiratory complications such as hypoxia (when the body's tissues and organs do not get enough oxygen to function properly) and respiratory distress (difficulty breathing).Findings: During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 47's diagnoses included congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), dysphagia (difficulty swallowing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 47's History and Physical (H&P) dated 4/1/2026, the H&P indicated Resident 47 did not have the capacity to understand or make decisions. During a review of Resident 47's Minimum Data Set (MDS- a resident assessment tool), the MDS indicated Resident 47 had severe cognitive (ability to think and understand) impairment. The MDS indicated Resident 47 was dependent on staff for toileting, bathing, dressing and personal hygiene. The MDS indicated Resident 47 received oxygen therapy. During a review of Resident 47's physician orders dated 8/202026, the physician order indicated to administer oxygen (O2) at two liters per minute via nasal cannula (thin flexible tube used to deliver oxygen) continuously for shortness of breath (SOB) and CHF every shift. During a concurrent interview and record review on 8/26/2026 at 12:40 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 47's physician orders dated 5/15/2026 were reviewed. Resident 47's physician orders indicated to monitor the resident's oxygen saturation (O2 sat) every shift. The physician orders did not indicate O2 sat parameters. LVN 3 stated ensuring physicians ordered O2 sat parameters was important because diagnoses effect the resident's baseline O2 sat range. LVN 3 stated nursing staff uses O2 sat parameters to determine if additional interventions or physician notification was required. During an interview on 8/27/2026 at 10:43 a.m. with the Assistant Director of Nursing (ADON), the ADON stated it was important for oxygen orders to have O2 sat parameters to ensure residents were being assessed and nursing staff knew when residents desaturate. The ADON stated lack of O2 sat parameters placed residents at risk of unidentified respiratory complications such as hypoxia or respiratory distress. During a review of the facility's policy and procedure (P&P) titled, Pulse Oximetry (Assessing Oxygen Saturation) last revised 10/2010, the P&P indicated if oxygen saturation was less than acceptable for resident's condition, nursing staff were to notify the physician.

Based on observation, interview, and record review, the facility failed to maintain an accurate and readily accessible controlled-substance (drugs are strictly regulated as controlled medications due to high risks of physical dependence, misuse, and drug diversion) accountability record for one of one sampled residents (Resident 66), when the narcotic (drugs are strictly regulated as controlled medications due to high risks of physical dependence, misuse, and drug diversion) record count sheet for Resident 66's discontinued lacosamide (a controlled medication used to treat seizures) oral solution was removed from the narcotic count binder and left wrapped around the medication bottle in the narcotic medication drawer. This deficient practice had the potential to delay identification and reconciliation of a controlled-substance discrepancy and increased the risk for medication diversion (misuse of prescription drugs) for Resident 66.Findings: During a review of Resident 66's admission Record, the admission Record indicated Resident 66 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 66's diagnoses included epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), muscle weakness, and gastrostomy (g-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 66's Minimum Data Set ([MDS], a resident assessment tool), dated 5/18/2026, the MDS indicated Resident 66's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 66 was entirely dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and mobility. During a review of Resident 66's physician orders, dated 5/14/2026, the physician orders indicated to administer lacosamide (a controlled medication used to treat seizures) oral solution 10 milligram per millimeter (mg/ml, a unit of measurement) 20 ml via g-Tube every 12 hours for seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 66's Electronic Medication Administration Record (eMAR), dated 8/2026, the eMAR indicated Resident 66's last administered dose of lacosamide oral solution was on 8/18/2026 at 9:00 a.m. During a concurrent observation, interview, and record review on 8/25/2026 at 1:07 p.m. with Licensed Vocational Nurse (LVN) 4, Resident 66's prescribed bottle of lacosamide oral solution was observed towards the back of the narcotic medication drawer. The Narcotic (drugs are strictly regulated as controlled medications due to high risks of physical dependence, misuse, and drug diversion) Drug Record and Reconciliation sheet was wrapped around the medication rather than maintained in the narcotic count binder. The Narcotic Drug Record and Reconciliation sheet, dated 8/2026, was reviewed and indicated Resident 66's last administered dose of lacosamide oral solution was on 8/18/2026 at 9:00 a.m. LVN 4 stated Resident 66 was transferred to the general acute care hospital (GACH) on 8/18/2026. LVN 4 stated the facility's practice following a resident's discharge or transfer was for the controlled medication to be surrendered to the Director of Nursing (DON) and stored in the DON's office. LVN 4 stated this practice limited access to the controlled medication (drugs are strictly regulated as controlled medications due to high risks of physical dependence, misuse, and drug diversion) and prevented inappropriate use. During an interview on 8/26/2026 at 1:39 p.m. with the Assistant Director of Nurses (ADON), the ADON stated the licensed nurses were expected to surrender controlled medications to the DON following a resident's discharge or transfer. The ADON stated that while a controlled medication remained in the medication cart, the corresponding narcotic record count sheet was expected to remain in the narcotic count binder so licensed nurses could perform the controlled-substance count and account for the medication during shift-to-shift reconciliation. The ADON stated there was potential for the medication to be missed during the controlled-substance count if the Narcotic Drug Record and Reconciliation sheet was wrapped around the medication bottle and placed towards the back of the narcotic drawer. During a phone interview on 8/27/2026 at 2:03 p.m. with Pharmacy Consultant (PC 1), PC 1 stated there was an increased risk for diversion when a controlled medication remained in the medication cart because the medication was exposed to multiple licensed nurses working different shifts. PC 1 stated the preferred practice was to keep the medication in the DON's office when the medication was not being used. PC 1 stated the narcotic count sheets served as a method of communication and accountability between licensed nurses regarding controlled medications. PC 1 acknowleged a discrepancy or missing medication could go unidentified until subsequently discovered by a licensed nurse. During a review of the facility's policy and procedures (P&P) titled, Controlled Substances, dated 11/2022, the P&P indicated the following:1. Controlled substance inventory was monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 2. Nursing staff would count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. 3. Controlled substances that remained in the facility after the order had been discontinued or the resident had been discharged were securely locked in an area with restricted access (narcotic drawer) until destroyed.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Medication Storage in the Facility, which indicated medication refrigerator temperatures were monitored and documented twice daily. This deficient practice had the potential for medications requiring refrigeration in Medication Room A to be stored outside of the required temperature range without timely identification, which could affect medication integrity and efficacy. Findings: During a concurrent interview and record review on 8/25/2025 at 12:19 p.m. with the Assistant Director of Nursing (ADON), the facility's Refrigerator Temperature Log, dated 8/2026, was reviewed. The log did not indicate temperatures for the 7 a.m. to 3:00 p.m. shift on 8/24/2026 and 8/25/2026. The ADON stated the assigned Registered Nurse (RN) supervisor was responsible for checking and documenting the refrigerator temperatures at 12:00 a.m. and 8:00 a.m. The ADON stated monitoring the medication refrigerator temperature was important to ensure medications were stored at the appropriate temperature to maintain their efficacy. During a phone interview on 8/26/2026 at 11:29 a.m. with Registered Nurse (RN) 3, RN 3 stated she was the assigned RN Supervisor on 8/24/2026 during the 7 a.m. to 3:00 p.m. shift, and she forgot to document the temperature on the log. RN 3 stated there was no way to verify that the temperature check was completed because the temperature was not documented. RN 3 stated monitoring the medication refrigerator temperature was important to ensure medications were stored at the appropriate temperature and maintained their efficacy. During a review of the facility's policy and procedures (P&P) titled, Medication Storage in the Facility (undated), the P&P indicated medications requiring refrigeration temperatures between 36 degrees Fahrenheit ( F, a unit of measurement) and 46 F were kept in a refrigerator with a thermometer to allow temperature monitoring. The P&P indicated medication storage conditions were monitored on a regular basis. The P&P indicated the temperature of refrigerators used to store biologicals and/or vaccines, should be monitored and recorded twice a day.

Based on observation, interview, and record review, the facility failed to ensure the bedside table and meal tray were within reach for one of five sampled residents (Resident 18), who required assistance with activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). This deficient practice resulted in Resident 18 being unable to safely reach his nourishment, causing the resident to spill the nourishment on the bedside table, and placed the resident at risk for inadequate fluid and nutritional intake, dehydration, and weight loss.Findings: During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 18's diagnoses included subdural hemorrhage (a bleeding that occurs between the dura mater and the brain, often caused by head injury) without loss of consciousness, diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and muscle weakness. During a review of Resident 18's Minimum Data Set ([MDS]- a resident assessment tool), dated 6/21/2026, the MDS indicated Resident 18's cognitive skills for daily decision making (the ability to think and process information) was moderately impaired. The MDS indicated Resident 18 was dependent (helper does all the effort) on staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 18's History and Physical (H&P) dated 8/7/2026 indicated Resident 18 did not have the capacity to understand and make decisions. During a review of Resident 18's care plan titled, Impaired activities of daily living, weakness., dated 7/20/2026, the care plan indicated Resident 18 required supervision or touching assistance with eating. During an observation on 8/25/2026 at 12:30 p.m., with Resident 18, in Resident 18's room, Resident 18 was observed seated in a wheelchair with the lunch tray placed on an overbed table. Resident 18 was unable to safely access his food, resulting in a spill on the overbed table. The overbed table was positioned at an angle and away from the resident's body, preventing the resident from having direct and comfortable access to the meal. During a concurrent observation and interview on 8/25/2026 at 12:47 p.m., at Resident 18's bedside, with Certified Nursing Assistant (CNA) 3, Resident 18 was observed seated in a wheelchair with the lunch tray placed on an overbed table at an angle away from the resident, preventing the resident from having direct and comfortable access to his meal. CNA 3 stated if Resident 18 did not receive help, he might experience difficulty eating and unable to finish his meal. CNA 3 stated ensuring the table and meal tray were arranged correctly encouraged the resident's independence, dignity, and nutritional well-being. During an interview on 8/27/2026 at 9:22 a.m., with the Director of Nursing (DON), the DON stated residents needing help with ADLs, such as eating, and drinking must be properly set up and assisted by staff. The DON stated staff were expected to ensure residents have access to food and drinks before leaving. The DON stated when this was not done for Resident 18, the resident was unable to obtain nourishment independently, which could lead to insufficient intake and unfulfilled daily living needs. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, revised 2001, the P&P indicated, residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition.

Based on interview and record review, the facility failed to ensure the residents' informed consent for psychotropic medications (a chemical substance that alters brain chemistry to change a person's mood, thoughts, feelings, or behavior) were documented in their medical records for two out of four sampled residents (Resident 8 and Resident 42). This deficient practice had the potential to result in incomplete communication among healthcare providers and an inability to readily verify informed consent for prescribed psychotropic medications for Residents 8 and 42.Findings: 1. During a review of Resident 42's admission Record, the admission Record indicated Resident 42 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 42's diagnoses included major depressive disorder (persistent feelings of sadness, and emptiness), anxiety disorder (overwhelming feelings of worry), and muscle weakness. During a review of Resident 42's Minimum Data Set ([MDS], a resident assessment tool), dated 7/6/2026, the MDS indicated Resident 42's cognitive skills (ability to think and reason) for daily decision making were intact. The MDS indicated Resident 42 required partial to moderate assistance (helper does less than half the effort) for toileting, dressing, and taking off footwear. During a review of Resident 42's physician order, dated 6/29/2026, the physician order indicated Resident 42 was prescribed bupropion hydrochloride (a medication used to treat depression) extended-release (medications designed to release their active ingredient gradually over time) oral tablet 150 milligrams (mg, a unit of measurement) one time at bedtime for depression. The order indicated the facility verified informed consent was obtained by the physician from Resident 42. During a review of Resident 42's physician order, dated 8/4/2026, the physician order indicated Resident 42 was prescribed Xanax (a medication used to treat anxiety) Oral Tablet 0.5 mg one tablet by mouth two times a day for anxiety. The order indicated the facility verified informed consent was obtained by the physician from Resident 42. During a record review of Resident 42's entire electronic and paper medical record, Resident 42's medical records did not indicate consent form was documented for Bupropion Hydrochloride and Xanax. 2. During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was initially admitted to the facility on 4/112025 and readmitted on [DATE]. Resident 8's diagnoses included dementia (a progressive state of decline in mental abilities), generalized anxiety disorder, and insufficient sleep syndrome. During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 8 required partial to moderate assistance for toileting, bathing, dressing and taking off footwear.During a review of Resident 8's physician order, dated 7/23/2026, the physician order indicated Resident 8 was prescribed alprazolam (a medication used to treat anxiety) oral tablet 0.5 mg one tablet by mouth two times a day for anxiety. The order indicated the facility verified informed consent was obtained by the physician from Resident 8's responsible party. During a review of Resident 8's physician order, dated 7/25/2026, the physician order indicated Resident 8 was prescribed Depakote (a medication used to treat mood disorders) tablet delayed release 250 mg one tablet by mouth three times a day for mood disorder. The order indicated the facility verified informed consent was obtained by the physician from Resident 8's responsible party. During a record review of Resident 8's entire electronic and paper medical record, Resident 8's medical records did not indicate informed consent was documented for Alprazolam and Depakote. During an interview on 8/26/2026 at 12:30 p.m. with the Director of Nursing (DON), the DON stated the facility's practice was to maintain psychotropic consent forms in a binder located in her office. The DON stated the psychotropic consent forms should be uploaded or filed in the resident's medical record so that all health care providers could readily verify the documented consent. During a review of the facility's policy and procedures (P&P) titled, Charting and Documentation, dated 2021, the P&P indicated the facility was to ensure 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, would 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.

Based on interview and record review, the facility failed to develop a person-centered care plan to address one of one sampled residents' (Resident 2) refusal to use the call light prior to toileting.This failure resulted in Resident 2 using the bathroom unassisted and sustaining a fall.Findings:During a review of Resident 2's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included ataxia (poor muscle control) following cerebral infarction (loss of blood flow to a part of the brain), generalized muscle weakness, and repeated falls. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 4/12/2026, the MDS indicated Resident 2's cognitive skills for daily decision making (process of thinking) was intact. The MDS indicated Resident 2 required partial assistance (helper does less than half the effort) with toileting, bathing, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 2 had prior falls. During a review of Resident 2's History and Physical (H&P), dated 4/9/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's Fall Risk Assessment, dated 5/29/2026, the Fall Risk Assessment indicated Resident 2 was a high risk for falls.During a review of Resident 2's Interdisciplinary Team (IDT, a group of different disciplines working together for a common goal of a resident) Progress Note, dated 4/16/2026, the IDT Progress Note indicated on 4/16/2026, Resident 2 had an unwitnessed fall and was found lying on the floor on her right side. The IDT Progress Note indicated, The call light was available but not utilized. The IDT Progress Note indicated a recommendation to reinforce education on requesting assistance prior to transfers.During a review of Resident 2's IDT Progress Note, dated 6/1/2026, the IDT Progress Note indicated on 6/1/2026, Resident 2 had an unwitnessed fall in the restroom. The IDT Progress Note indicated, The call light was within reach but was not used. The IDT Progress Note indicated a recommendation to educate of fall incident and reinforced importance of using the call light and waiting for staff assistance before getting up, especially when toileting or performing tasks in the bathroom.During a review of Resident 2's Progress Note, dated 6/9/2026, the Progress Note indicated Licensed Vocational Nurse (LVN) 2 responded to a bathroom call light and observed Resident 2 sliding down into a seated position from the toilet chair [and] no impact to the floor was observed. The Progress Note indicated Resident 2 stated her legs were not getting stronger and continued to buckle during standing and walking attempts.During an interview on 6/11/2026 at 9:15 a.m., with Resident 2, Resident 2 stated, on 6/9/2026, she went to the restroom unassisted and when she attempted to transfer from the toilet to her wheelchair, her knees buckled and slid down the toilet chair. Resident 2 stated she could transfer from her wheelchair to the toilet on her own and does not call for assistance.During a phone interview on 6/11/2026 at 1:34 p.m., with Registered Nurse (RN) 3, RN 3 stated a fall could either be when a resident landed on the floor or if a resident lost their balance and slid down towards the floor. RN 3 stated after a resident falls, the licensed nurse was responsible for assessing the resident and developing a care plan. RN 3 stated care plans were part of the licensed nurses charting to communicate to the rest of the staff and to develop and implement interventions to prevent further falls.During a phone interview on 6/11/2026 at 2:06 p.m., with LVN 1, LVN 1 stated Resident 2 knew how to operate the call light and educated to call for toileting assistance. LVN 1 stated although Resident 2 was educated on the importance of calling for assistance, Resident 2 would still transfer herself from the wheelchair to the toilet chair. LVN 1 stated, on 6/9/2026, he answered Resident 2's call light from the restroom and found her sliding off the toilet and almost hitting the floor. LVN 1 stated Resident 2's legs were on the floor; however, her buttocks did not touch the floor when he assisted her back into the wheelchair. LVN 1 stated he did not consider Resident 2 sliding off the toilet as a fall because she did not make full contact with the floor. LVN 1 stated he assisted Resident 2 back to her wheelchair and assessed Resident 2 for any injuries. LVN 2 stated he did develop a care plan for the incident. During a concurrent phone interview and record review on 6/11/2026 at 2:20 p.m., with LVN 1, the facility's Policy and Procedure (P&P) titled, Falls and Fall Risk, Managing, revised 3/2020, was reviewed. The P&P indicated, A fall is defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. LVN 1 stated according to the facility's P&P, Resident 2's incident on 6/9/2026 was considered a fall because he believed Resident 2 would have completely fallen to the floor if he had not assisted Resident 2 in time. LVN 1 stated he should have developed a care plan to implement interventions to prevent further falls. During an interview on 6/15/2026 at 2:14 p.m., with the Director of Nursing (DON), the DON stated care plans were developed to identify certain behaviors and changes in the resident's condition. The DON stated care plans were necessary to develop the appropriate interventions for Resident 2 to prevent further falls and other occurrences. During a concurrent interview and record review on 6/15/2026 at 2:47 p.m., with the DON, Resident 2's Care Plans, active on 6/15/2026, were reviewed. The care plans did not address Resident 2's refusal to use the call light prior to transfers and toileting. The DON stated Resident 2 did not want to use the call light to ask for assistance. The DON stated Resident 2 was at a high risk for falls and should have had a care plan to address that behavior. The DON stated the care plan was necessary to implement additional interventions such as more frequent visual checks to prevent further falls. During a review of the facility's P&P titled, Safety and Supervision of Residents, revised 7/2017, the P&P indicated, The care team shall target interventions to reduce individuals risks related to hazards in the environment, including adequate supervision and assistive devices. During a review of the facility's P&P titled, Falls and Fall Risk, Managing, revised 3/2020, the P&P indicated, 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 interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, undated, the P&P indicated the interdisciplinary team developed and implemented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs. The P&P indicated, The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) received care in accordance with professional standards of practice when the facility did not:1. Obtain vital signs and conduct 72-hour monitoring after Resident 2 sustained a fall in the restroom on 6/9/2026.2. Conduct 72-hour psychosocial monitoring after Resident 1 alleged his arm was grabbed without his consent on 5/28/2026.These failures had the potential for undetected changes in Resident 2's physical or neurological (how the brain, spinal cord, and nerves work) status and Resident 1's psychosocial condition.Findings:a. During a review of Resident 2's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included ataxia (poor muscle control) following cerebral infarction (loss of blood flow to a part of the brain), generalized muscle weakness, and repeated falls. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 4/12/2026, the MDS indicated Resident 2's cognitive skills for daily decision making (process of thinking) was intact. The MDS indicated Resident 2 required partial assistance (helper does less than half the effort) with toileting, bathing, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 2 had prior falls. During a review of Resident 2's History and Physical (H&P), dated 4/9/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's Fall Risk Assessment, dated 5/29/2026, the Fall Risk Assessment indicated Resident 2 was a high risk for falls.During a review of Resident 2's Progress Note, dated 6/9/2026, the Progress Note indicated on 6/9/2026, Licensed Vocational Nurse (LVN) 2 responded to a bathroom call light and observed Resident 2 sliding down into a seated position from the toilet chair [and] no impact to the floor was observed. The Progress Note indicated Resident 2 stated her legs were not getting stronger and continued to buckle during standing and walking attempts. During a review of Resident 2's Progress Notes, dated 6/9/2026 through 6/15/2026, the Progress Notes did not indicate the licensed nurses monitored Resident 2 for any changes post-fall.During an interview on 6/11/2026 at 9:15 a.m., with Resident 2, Resident 2 stated, on 6/9/2026, she went to the restroom unassisted and when she attempted to transfer from the toilet to her wheelchair, her knees buckled and slid down the toilet chair. During a phone interview on 6/11/2026 at 1:34 p.m., with Registered Nurse (RN) 3, RN 3 stated a fall could either be when a resident landed on the floor or if a resident lost their balance and slid down towards the floor. RN 3 stated after a resident falls, the licensed nurse was responsible for assessing the resident, conducting a complete body check and checking vital signs. RN 3 stated checking vital signs were important because abnormal vital signs, such as low heart rate or blood pressure, could have caused the fall. RN 3 stated not only can abnormal vital signs cause a fall, but the fall could also cause abnormal vital signs from internal bleeding. RN 3 stated any abnormalities would then be reported to the physician. RN 3 stated after a fall, the licensed nurses would monitor the resident for 72 hours because a resident might suffer changes in their physical or neurological (how the brain, spinal cord, and nerves work) status. RN 3 stated during the 72 hours, if any changes were identified, the physician would immediately be notified. During a phone interview on 6/11/2026 at 2:06 p.m., with LVN 1, LVN 1 stated, on 6/9/2026, he answered Resident 2's call light from the restroom and found her sliding off the toilet and almost hitting the floor. LVN 1 stated Resident 2's legs were on the floor; however, her buttocks did not touch the floor when he assisted her back into the wheelchair. LVN 1 stated he did not consider Resident 2 sliding off the toilet as a fall because she did not make full contact with the floor. LVN 1 stated he assisted Resident 2 back to her wheelchair and assessed Resident 2 for any injuries. LVN 1 stated he did not obtain a set of vital signs. LVN 1 stated he endorsed the oncoming shift to keep an eye on Resident 2 but did not specifically say Resident 2 fell on the floor. During a concurrent phone interview and record review on 6/11/2026 at 2:20 p.m., with LVN 1, the facility's Policy and Procedure (P&P) titled, Falls and Fall Risk, Managing, revised 3/2020, was reviewed. The P&P indicated, A fall is defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. LVN 1 stated according to the facility's P&P, Resident 2's incident on 6/9/2026 was considered a fall because he believed Resident 2 would have completely fallen to the floor if he had not assisted Resident 2 in time. LVN 1 stated he should have obtained Resident 2's vital signs and informed the oncoming nurse so the 72-hour monitoring could be conducted. During an interview on 6/15/2026 at 2:32 p.m., with the Director of Nursing (DON), the DON stated obtaining vital signs after a fall was necessary to help determine the cause of the fall such as low blood pressure or low heart rate. The DON stated the vital signs would be reported to the physician, who would give orders to monitor or treat Resident 2. The DON stated monitoring Resident 2 for 72 hours would ensure any changes were identified and reported immediately. During a review of the facility's P&P titled, Acute Condition Changes, undated, the P&P indicated when a resident had a change in condition, the nurse was responsible for assessing, documenting, and reporting the resident's vital signs. The P&P indicated, The staff will monitor and document the resident/patient's progress and responses to treatment.b. During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder (a mental health condition characterized by intense, excessive, and persistent worry or fear about everyday situations), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognitive skills for daily decision making was intact. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) with toileting, bathing, lower body dressing, and putting on/taking off footwear.During a review of Resident 1's H&P, dated 5/23/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) Form, dated 5/28/2026, the SBAR indicated, on 5/28/2026, Resident 1 claimed an unidentified male staff member grabbed his arm without his consent. The SBAR indicated Resident 1 had PTSD and may have associated being touched without consent as a possible trigger.During a review of Resident 1's Progress Notes, dated 5/28/2026 through 6/3/2026, the Progress Notes did not indicate Resident 1's psychosocial well-being was monitored. During an interview on 6/15/2026 at 12:06 p.m., with the Social Services Director (SSD), the SSD stated after an abuse allegation was made, the social services and nursing departments would monitor the resident's psychosocial wellbeing for 72 hours. The SSD stated the social services department was not made aware of Resident 1's abuse allegation until 6/3/2026. The SSD stated Resident 1 psychosocial wellbeing should have been monitored after Resident 1 made his abuse allegation on 5/28/2026. The SSD stated the 72-hour monitoring would ensure Resident 1 felt, necessary resources were offered, and other interventions were implemented. During an interview on 6/15/2026 at 2:59 p.m., with the DON, the DON stated 72-hour monitoring following an abuse allegation was necessary to assess Resident 1's safety. The DON stated the 72-hour monitoring would allow Resident 1 to express any feelings or concerns related to the abuse allegation and for the staff to provide psychosocial support and additional resources. During a review of the facility's P&P titled, Abuse and Neglect, revised 7/2017, the P&P indicated, The staff will monitor individuals who have been abused at least until their medical condition, mood, and function have stabilized.

Based on interview and record review, the facility failed to report one of one sampled resident's (Resident 1) abuse allegation to the State Agency (California Department of Public Health [CDPH]), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local law enforcement when Resident 1 alleged he was grabbed by his right arm without his consent.This failure resulted in a delay of an onsite investigation and had the potential to result in further potential abuse to Resident 1.Findings:During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included anxiety disorder (a mental health condition characterized by intense, excessive, and persistent worry or fear about everyday situations), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/26/2026, the MDS indicated Resident 1's cognitive skills for daily decision making (process of thinking) was intact. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) with toileting, bathing, lower body dressing, and putting on/taking off footwear.During a review of Resident 1's History and Physical (H&P), dated 5/23/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) Form, dated 5/28/2026, the SBAR indicated, on 5/28/2026, Resident 1 claimed an unidentified male staff member grabbed his arm without his consent. The SBAR indicated Resident 1 had PTSD and may have associated being touched without consent as a possible trigger. During an interview on 6/15/2026 at 11:24 a.m., with Registered Nurse (RN) 1, RN 1 stated, on 5/28/2026, Resident 1 informed her a male rehab staff member grabbed his arm without his consent. RN 1 stated the allegation was made towards the end of her shift at 3 p.m. and she endorsed Resident 1's allegation to RN 2. RN 1 stated she entrusted RN 2 with the endorsement and thought RN 2 reported Resident 1's abuse allegation to the Administrator (ADM) because she was at the end of her shift. RN 1 stated physical touch without Resident 1's consent could be seen as abuse and should be reported to the ADM, who was the facility's Abuse Coordinator. During a concurrent interview and record review on 6/15/2026 at 11:30 a.m., with RN 1, Resident 1's Progress Notes, dated 5/29/2026, 5/30/2026, 6/2/2026, and 6/3/2026, were reviewed. The Progress Notes indicated Resident 1 claimed he was assaulted. RN 1 stated Resident 1's allegation of his arm being grabbed and being assaulted had to be reported to the ADM immediately. RN 1 stated once the ADM was notified, the ADM was responsible for reporting the abuse allegation to the State Agency (California Department of Public Health [CDPH]), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local law enforcement. RN 1 stated abuse allegations were also reported to the ADM immediately to ensure a thorough investigation was conducted and to prioritize the residents' safety during the investigation.During a phone interview on 6/15/2026 at 1:36 p.m., with RN 2, RN 2 stated, on 5/28/2026, RN 1 informed her of Resident 1's abuse allegation of Resident 1's arm pulled without his consent. RN 2 stated she did not report Resident 1's abuse allegation to the ADM because she thought RN 1 reported it because Resident 1 initially notified RN 1. RN 2 stated she could have followed up with the ADM to ensure Resident 1's abuse allegation was reported. During an interview on 6/15/2026 at 3:42 p.m., with the ADM, the ADM stated, on 5/28/2026, she was not made aware of Resident 1's abuse allegation. The ADM stated she was not made aware of Resident 1's abuse allegation until 6/3/2026. The ADM stated she expected her staff to notify her of all abuse allegations immediately. The ADM stated she was the Abuse Coordinator for the facility, and she was responsible for reporting all abuse allegations to CDPH, the Ombudsman, and local law enforcement within two hours. The ADM stated there was miscommunication between RN 1 and RN 2 which resulted in the delay in reporting and investigating Resident 1's abuse allegation of nonconsensual touch on his arm, which put Resident 1 at risk for further potential abuse. During a review of the facility's Policy and Procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised 4/2024, the P&P indicated, If a resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 'Immediately' is defined as within two hours involving abuse or result in physical harm/serious bodily injury. The P&P indicated the Administrator or person making the allegation must immediately report to the state licensing agency, Ombudsman, and local law enforcement.

Based on interview and record review, the facility failed to notify the primary physician of Resident 2's fall in the bathroom.This failure had the potential to result in missed or delayed diagnosis and interventions for serious injuries.Findings:During a review of Resident 2's Face Sheet, the Face Sheet indicated the facility admitted the resident on 4/8/2026 with diagnoses including ataxia (poor muscle control) following cerebral infarction (loss of blood flow to a part of the brain), generalized muscle weakness, and repeated falls. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 4/12/2026, the MDS indicated Resident 2's cognitive skills for daily decision making (process of thinking) was intact. The MDS indicated Resident 2 required partial assistance (helper does less than half the effort) with toileting, bathing, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 2 had prior falls. During a review of Resident 2's Progress Note, dated 6/9/2026, the Progress Note indicated Licensed Vocational Nurse (LVN) 2 responded to a bathroom call light and observed Resident 2 sliding down into a seated position from the toilet chair and no impact to the floor was observed.During an interview on 6/11/2026 at 8:09 a.m. with Resident 2, Resident 2 stated that she had fallen approximately about six times in the past. Resident 2 stated that her knee frequently buckles, and during her last fall, while in the restroom her knee buckled, causing her to slide down the toilet to the floor while holding onto the side rails. The resident reported calling out for assistance and activated the call light for help. Resident stated a certified nursing assistant (CNA) came to the room in about five minutes and assisted her up. During a phone interview on 6/11/2026 at 1:34 p.m. with Registered Nurse (RN) 3, RN 3 stated when a resident experiences a fall, nursing staff must assess the resident and report the fall to the physician in accordance with facility protocol. RN 3 stated that timely physician notification was important so the physician can determine whether the resident has sustained any serious injuries.During a phone interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 2 was found in the restroom, almost sliding down to the floor and assisted the resident getting back in her wheelchair. LVN 1 stated that when the resident was found, the resident was leaning back on the toilet with her buttocks off the toilet seat and the resident's legs were touching the floor. LVN 1 stated according to facility policy, the circumstance met the definition of a fall, and the physician should have been notified.During an interview and record review on 6/15/2026 at 2:09 p.m. with the Director of Nursing (DON), the DON stated the last incident Resident 2's knee buckling resulting in a fall met the definition of a fall. The DON stated that after a fall it was necessary to assess the resident and notify the physician. The DON stated that notifying the physician was a required component of the SBAR process and was essential to ensure the physician was informed of the resident's condition, to determine the appropriate orders for follow up care and providing optimal care to the resident.During an interview on 6/15/2026 at 2:28 p.m., with the DON, the DON stated that when Resident 2's knee buckled resulting in a fall the physician should have been notified.During a review of the facility's P&P titled, Falls and Fall Risk, Managing, revised 3/2020, the P&P indicated, 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.

Based on interview and record review, the facility failed to ensure timely physician notification for a significant change in condition for one of three sampled residents (Resident 1). This deficient practice had the potential to delay physician evaluation, timely medical intervention, and result in the deterioration of Resident 1's condition.Findings: During a review of Resident 1's admission Record, dated 12/19/2025, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included acute and chronic respiratory failure (a condition in which the lungs are unable to provide enough oxygen to the body or remove carbon dioxide, occurring suddenly and/or over a long period of time), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), congestive heart failure (CHF- a heart disorder which causes the heart to not pump blood efficiently, sometimes resulting in leg swelling), acute pulmonary edema (a sudden buildup of fluid in the lungs that makes breathing difficult), pleural effusion (a buildup of fluid between the lungs and the chest wall that can interfere with breathing), type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN- high blood pressure), end stage renal disease (ESRD- a condition in which the kidneys no longer function well enough to remove waste and excess fluid from the body), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed), and history of renal transplant (a past medical history of receiving a donor kidney to replace failed kidneys). During a review of Resident 1's Admission/readmission Initial Assessment, dated 8/11/2025 at 7:25 p.m., the admission assessment indicated Resident 1 was readmitted to the facility from the general acute care hospital (GACH). The admission assessment indicated Resident 1 had a normal thought process and was oriented to person, place, and time, was able to follow simple commands, had clear speech, understood verbal content, and was understood upon admission. During a review of Resident 1's History and Physical (H&P), dated 8/12/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 8/15/2025, the MDS indicated Resident 1's cognition (ability to think, remember, and reason) was intact. The MDS indicated Resident 1 could eat independently and required moderate assistance (helper does less than half the effort) for toileting, bathing, and personal hygiene. During a review of Resident 1's care plan titled, Resident at risk for cardiac distress related to A-fib, congestive heart failure, hypercholesterolemia, hypertension, and renal failure/end-stage renal disease, initiated on 8/14/2025, the care plan indicated interventions included to monitor Resident 1 for headache, chest pain, irregular pulse, edema, shortness of breath, elevated blood pressure, dizziness, hypotension (low blood pressure), altered level of mentation and to report findings to the physician promptly. During a review of Resident 1's Nursing Progress Note dated 8/20/2025 at 9:42 p.m., the progress note indicated Resident 1 returned from dialysis alert with confusion. During a review of Resident 1's Nursing Progress Note dated 8/24/2025 at 11:57 p.m., the progress note indicated Resident 1 was alert with episodes of confusion. During a review of Resident 1's nursing progress notes from 8/20/2025 through 10/25/2025, the progress notes indicated there was no documented entries Resident 1's physician was notified of the resident's new onset of confusion. The progress notes indicated there was no documented entries a nursing assessment or monitoring was done addressing Resident 1's new onset of confusion. During an interview on 12/30/2025 at 4:39 p.m., with Resident 1's Attending Physician (AP 1), AP 1 stated he was aware Resident 1's baseline laboratory values were abnormal on 8/19/2025. AP 1 stated it was common for residents to have abnormal laboratory values at baseline. AP 1 stated when laboratory values or a resident's condition changed from baseline, the facility was expected to notify the physician. AP 1 stated Resident 1 was alert and oriented at baseline and new onset confusion represented a change of condition. AP 1 stated on 8/20/2025, he would have wanted to be notified of Resident 1's confusion. AP 1 stated if he had been notified of Resident 1's confusion he would have sent Resident 1 to the emergency room for evaluation immediately. During a concurrent interview and record review on 12/31/2025 at 10:00 a.m., with Registered Nurse (RN) 1, Resident 1's nursing progress notes dated 8/11/2025 and 8/20/2025, were reviewed. Resident 1's nursing progress note dated 8/11/2025, indicated Resident 1 was alert and oriented upon admission to the facility. Resident 1's nursing progress note dated 8/20/2025 at 9:42 p.m., indicated Resident 1 was alert with confusion upon her return from dialysis. RN 1 stated this was a new onset of confusion for Resident 1 and represented a change of condition. RN 1 stated when a resident experienced a change of condition, the resident should have been assessed, the physician should have been notified, and appropriate follow-up initiated in accordance with the facility's policy and procedure (P&P). RN 1 stated Resident 1's medical records did not indicate there was a documented nursing assessment, physician notification, a SBAR (Situation, Background, Assessment, and Recommendation), or 72-hour monitoring related to Resident 1's new onset of confusion. RN 1 stated Resident 1 was becoming less alert and less oriented, and this change of condition was not addressed with appropriate interventions which could lead to the deterioration of Resident 1's condition. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, revised 12/2016, the P&P indicated the nurse was required to notify the resident's attending physician of a significant change in the resident's physical, emotional, or mental condition, complete a comprehensive assessment, document the change in condition, and implement continuous monitoring for 72 hours or longer as indicated.

Based on interview and record review, the facility failed to follow its policy and procedure to notify the physician of a change in condition for one of three sampled residents (Resident 1). Resident 1 had an episode of vomiting with loose stool at the time the facility had a [MEDICAL CONDITION] (tiny organisms that may lead to mild to severe illnesses) gastroenteritis (inflammation of the stomach and the intestines characterized by nausea, vomiting, diarrhea, and cramps) outbreak with many other residents, but the physician was not notified. This failure of not notifying Resident 1's physician, per the facility's policy, resulted in the resident's condition worsening, a delay in diagnosis, care, and treatment. Resident 1 expired in the Emergency Department (ED) six hours later. Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. (a disorder of the nervous system that primarily affects bodily movement), and dementia (a group of symptoms that affects memory, thinking and interfering with daily life). A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated [DATE], indicated Resident 1 had the ability to sometimes understand and be understood by others. The MDS indicated Resident 1 required extensive assistance in most activities of daily living (ADLs). According to the MDS, Resident 1 had dysphagia (difficulty in swallowing) and required the use of a feeding tube (gastrostomy tube ([DEVICE]), a tube placed surgically into the stomach to provide nutrition and hydration). A review of a Physician order [REDACTED].), prepared [DATE], indicated Resident 1 did not want cardiopulmonary resuscitation ((CPR) the action or process of reviving someone from unconsciousness or apparent death). A review of Resident 1's Order Summary Report for the month of ,[DATE], indicated the resident had a physician's orders [REDACTED]. A review of Resident 1's Care Plan, dated [DATE], indicated the resident had the potential risk for diarrhea due to decrease in mobility, pain medications, and [MEDICAL CONDITION] medications (affecting mental activity, behavior, or perception, as a mood-altering drug). The staff's interventions included to observe Resident 1 for episodes of diarrhea (watery stool). A review of a Licensed Nurses (LN) Progress Note, dated [DATE], and timed at 6:30 a.m., indicated Registered Nurse 1 (RN 1) documented that at the beginning of the shift, RN 1 spoke to Resident 1's family member (FM 1) at the bedside. The note indicated FM 1 informed RN 1 that she was going to stay in the facility with Resident 1 because the resident was becoming sick. According to the note, Resident 1 had one episode of vomiting and loose stool with occasional moaning. There was no documentation what the staff's interventions were at that time. The note also did not indicate if any vital signs (signs of life; specifically: the heart rate, respiratory rate (number of breaths per minute), body temperature, and blood pressure of a person) were taken at that time. A review of a LN Progress Note, dated [DATE], and timed at 5 a.m., indicated Charge Nurse 1 (CN 1) observed Resident 1 pale and breathing fast with a respiration rate of 25 (Normal Reference Range (NRR) = ,[DATE]). According to the note, Resident 1's blood pressure was ,[DATE] (NRR for the top number = 90 - 120 and the bottom number = 60 - 80) and the heart rate was 59 beats per minute (NRR = 60 -100). The note indicated that FM 1 requested for Resident 1 to be transferred to the general acute care hospital (GACH) so the facility staff called 911. A review of Resident 1's physician's orders [REDACTED]. A review of the Fire Department's Prehospital Care Report Summary, dated [DATE], indicated a call was received at 5:56 a.m. from the facility. The report summary indicated the chief complaint was altered level of consciousness ((AL[NAME]) means that you are not as awake, alert, or able to understand or react as normal) for a duration of eight hours. The report summary further indicated Resident 1 was unconscious with a blood pressure of ,[DATE]. Resident 1's Glasgow Coma Score ((GCS) a standardized system for assessing response to stimuli by assessing eye opening, verbal response, and motor ability) was [DATE] (1 point = no eye opening response, 1 point = no verbal response, 1 = no motor response). The report summary indicated the facility called 911 due to Resident 1 having low oxygen saturation, low blood pressure, and an AL[NAME]. A review of the GACH's notes in the Emergency Department (ED), dated [DATE], and timed at 7:04 a.m., indicated Resident 1's oxygen saturation while receiving two (2) liters of oxygen via nasal cannula (plastic tubing which runs under the nose and is used to administer oxygen) was 92 percent (%) (NRR = ,[DATE] percent). At 9 a.m., the same date ([DATE]) the ED note indicated that Resident 1 had bloody diarrhea and FM 1 who was at bedside reported that the resident vomited twice the day prior and had diarrhea since early that morning. At 11:11 a.m., on [DATE], the ED note indicated that Resident 1 was asystole (a form of [MEDICAL CONDITION] in which the heart stops beating and there is no electrical activity in the heart) and there was no pulse present. Resident 1 was pronounced dead at that time. A review of Resident 1's Certificate of Death, indicated Resident 1 expired on [DATE] at 11:11 a.m., with cardiopulmonary failure as the immediate cause and septic shock (a life-threatening condition that happens when blood pressure drops to a dangerously low level after an infection) as the underlying cause. On [DATE] at 10:55 a.m., during a telephone interview, RN 1 stated Resident 1 had a Do Not Resuscitate (DNR) order. RN 1 stated FM 1 informed her that Resident 1 was not looking good at that time. RN 1 stated Resident 1 had an episode of vomiting but she did not think it was a significant amount. On [DATE] at 2:54 p.m., during a subsequent telephone interview, RN 1 stated Certified Nursing Assistant 1 (CNA 1) and FM 1 informed her that Resident 1 had an episode of loose stool. RN 1 stated when a resident has an episode of loose stool, they should observe the resident first and if there was more than one episode of loose stool, they should call the physician. RN 1 confirmed that the physician was not notified initially about the episode of loose stool and vomiting and she did not assess and document Resident 1's vital signs and should have. During an interview with the Director of Nursing (DON), on [DATE] at 4:30 p.m., the DON stated RN 1 should have contacted the physician regarding Resident 1's episode of vomiting. The DON confirmed that at the time this happened on [DATE], the outbreak had not yet been cleared. The DON stated the facility was not cleared of the gastroenteritis outbreak until [DATE]. A review of a letter sent by the facility to the Department on [DATE] indicated the facility was reporting a possible [MEDICAL CONDITION] gastroenteritis outbreak in their facility that involved a total of 11 residents on [DATE]. A review of a line list (a table that summarizes information about persons who may be associated with an outbreak) attached to the letter indicated the symptoms associated with the outbreak were vomiting, diarrhea, and fever. The letter indicated that as of [DATE], there were two residents who still continued to show symptoms of vomiting that developed on [DATE]. A review of the facility's policy and procedure, titled, Change in a Resident's Condition or Status, revised on ,[DATE], indicated the Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: a significant change in the resident's physical/emotional/mental condition. A significant change of condition is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting). A review of the facility's policy and procedure, titled, Acute Condition Changes - Clinical Protocol, revised on ,[DATE], indicated before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the physician; for example, history of present illness and previous and recent test results for comparison. The policy indicated phone calls to the attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident's current symptoms and status.

Based on interview and record review, the facility failed to adhere to its policy and procedure for change in condition for one of three sampled residents (Resident 1). Resident 1, who had altered level of consciousness ((AL[NAME]) not as awake, alert, or able to understand or react as normal) and episodes of vomiting and loose stool that was not adequately assessed and reported to the physician timely. This deficient practice resulted in delay in diagnoses, care and treatment and Resident 1 being transferred to a general acute care hospital (GACH) via 911 emergency, which lead to Resident 1 expiring in the GACH's Emergency Department (ED) six (6) hours later. Findings: A review of a letter sent to the Department on [DATE] indicated the facility reported a possible [MEDICAL CONDITION] gastroenteritis (an intestinal infection marked by watery diarrhea, abdominal cramps, nausea or vomiting, and sometimes fever) outbreak in the facility that involved a total of 11 residents on [DATE]. A review of a line list (a table that summarizes information about persons who may be associated with an outbreak) attached to the letter indicated the symptoms associated with the outbreak were vomiting, diarrhea, and fever. The letter indicated that as of [DATE], there were two residents who still continued to have symptoms of vomiting that developed on [DATE]. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. (a disorder of the nervous system that primarily affects bodily movement), and dementia (a group of symptoms that affects memory, thinking and interfering with daily life). A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated [DATE], indicated Resident 1 had the ability to sometimes understand and be understood by others. The MDS indicated Resident 1 required extensive assistance in most activities of daily living (ADLs). According to the MDS, Resident 1 had dysphagia (difficulty in swallowing) and required the use of a feeding tube (gastrostomy tube ([DEVICE]), a tube placed surgically into the stomach to provide nutrition and hydration). A review of a Physician order [REDACTED].), prepared [DATE], indicated Resident 1 did not want cardiopulmonary (relating to the heart and lungs) resuscitation ((CPR) the action or process of reviving someone from unconsciousness or apparent death), only comfort-focused treatments. A review of Resident 1's Order Summary Report for the month of ,[DATE], indicated the resident had a physician's orders [REDACTED]. A review of Resident 1's Care Plan, dated [DATE], indicated the resident had the potential risk for diarrhea due to decrease in mobility, pain medications, and [MEDICAL CONDITION] medications (affecting mental activity, behavior, or perception, as a mood-altering drug). The staff's interventions included to observe Resident 1 for episodes of diarrhea (watery stool). A review of a Licensed Nurses (LN) Progress Note, dated [DATE], and timed at 6:30 a.m., indicated Registered Nurse 1 (RN 1) documented that at the beginning of the shift (11 p.m. on the previous day), RN 1 spoke to Resident 1's family member (FM 1) at the bedside. The note indicated FM 1 informed RN 1 that she was going to stay in the facility with Resident 1 because the resident was becoming sick. According to the note, Resident 1 had one episode of vomiting and loose stool with occasional moaning. There was no documentation what the staff's interventions were at that time. The note also did not indicate if any vital signs (signs of life; specifically: the heart rate, respiratory rate (number of breaths per minute), body temperature, and blood pressure of a person) were taken at that time. Further review of the note indicated at approximately 5 a.m., Charge Nurse 1 (CN 1) observed Resident 1 to be pale and breathing fast with a respiration rate of 25 (Normal Reference Range (NRR) = ,[DATE]). According to the note, Resident 1's blood pressure was ,[DATE] (NRR for the top number = 90 - 120 and the bottom number = 60 - 80) and the heart rate was 59 beats per minute (NRR = 60 -100). The note indicated that FM 1 requested for Resident 1 to be transferred to the general acute care hospital (GACH) so the facility staff called 911. A review of Resident 1's physician's orders [REDACTED]. A review of the Fire Department's Prehospital Care Report Summary, dated [DATE], indicated a call was received at 5:56 a.m. from the facility. The report summary indicated the chief complaint was altered level of consciousness ((AL[NAME]) not as awake, alert, or able to understand or react as normal) for a duration of eight hours. The report summary further indicated Resident 1 was unconscious with a blood pressure of ,[DATE]. Resident 1's Glasgow Coma Score ((GCS) a standardized system for assessing response to stimuli by assessing eye opening, verbal response, and motor ability) was [DATE] (1 point = no eye opening response, 1 point = no verbal response, 1 = no motor response). The report summary indicated the facility called 911 due to Resident 1 having low oxygen saturation, low blood pressure, and an AL[NAME]. A review of the GACH's Emergency Department (ED), dated [DATE], and timed at 7:04 a.m., indicated Resident 1's oxygen saturation while receiving two (2) liters of oxygen via nasal cannula (plastic tubing placed into the nose to administer oxygen) was 92 percent (%) (NRR = ,[DATE] percent). At 9 a.m., on [DATE], the ED note indicated that Resident 1 had bloody diarrhea and FM 1 who was at bedside reported that the resident vomited twice the day prior and had diarrhea since early that morning. At 11:11 a.m., the same day ([DATE]), the ED note indicated that Resident 1 was in asystole (a form of [MEDICAL CONDITION] in which the heart stops beating and there is no electrical activity in the heart) and there was no pulse present. Resident 1 was pronounced dead at that time. A review of Resident 1's Certificate of Death indicated Resident 1 expired on [DATE] at 11:11 a.m., with cardiopulmonary failure as the immediate cause and septic shock (a life-threatening condition that happens when blood pressure drops to a dangerously low level after an infection) as the underlying cause. On [DATE] at 10:55 a.m., during a telephone interview, RN 1 stated Resident 1 had a Do Not Resuscitate (DNR) order. RN 1 stated FM 1 informed her that Resident 1 was not looking good at that time ([DATE]). RN 1 stated Resident 1 had an episode of vomiting, but she did not think it was a significant amount. On [DATE] at 2:54 p.m., during a subsequent telephone interview, RN 1 stated Certified Nursing Assistant 1 (CNA 1) and FM 1 informed her that Resident 1 had an episode of loose stool. RN 1 stated when a resident has an episode of loose stool, they should observe the resident first and if there was more than one episode of loose stool, then they should call the physician. RN 1 confirmed that the physician was not notified initially about the episode of loose stool and vomiting and she did document Resident 1's vital signs. RN 1 stated Resident 1's vital signs should have been assessed and documented during the resident's change in condition. During an interview with the Director of Nursing (DON), on [DATE] at 4:30 p.m., the DON stated RN 1 should have contacted the physician regarding Resident 1's episodes of vomiting. The DON confirmed that at the time of Resident 1's change in condition on [DATE], the facility's [MEDICAL CONDITION] outbreak had not yet been cleared. The DON stated the facility was not cleared of the gastroenteritis outbreak until [DATE]. During a telephone interview with a Licensed Vocational Nurse 1 (LVN 1), on [DATE] at 3:20 p.m., LVN 1 stated during the time of the [MEDICAL CONDITION] outbreak, she documented a Situation, Background, Assessment, Recommendation ((SBAR) used to facilitate prompt and appropriate communication) for every resident who vomited or had diarrhea. LVN 1 stated she does not know or remember why she did not include Resident 1. During a telephone interview, on [DATE] at 3:20 p.m., LVN 2 stated when a resident had a change of condition, the SBAR was started and the physician was notified. LVN 2 stated for episodes of vomiting, an SBAR should be completed right away. A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, revised on ,[DATE], indicated the Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: a significant change in the resident's physical/emotional/mental condition. A significant change of condition is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting). A review of the facility's policy and procedure, titled, Acute Condition Changes - Clinical Protocol, revised on ,[DATE], indicated before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the physician; for example, history of present illness and previous and recent test results for comparison. The policy indicated phone calls to the attending or on-call physician should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident's current symptoms and status.