Every finding on record at Kaweah Health Skilled Nursing Center

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Pressure Ulcer Prevention and Treatment for one of three sampled residents (Resident 7). This failure had the potential to cause pressure injuries (damaged skin and underlying tissue from prolonged pressure) and had the potential to increase Resident 7's susceptibility to pneumonia.Findings:During an interview on 1/27/26 at 10:03 a.m. with Family Member (FM) 1, FM 1 stated Resident 7 had to go to the hospital every few months for pneumonia.During a concurrent interview and record review on 1/28/26 at 11:22 a.m. with Minimum Data Set (resident assessment tool) Coordinator (MDSC), Resident 7's MDS was reviewed. MDS Section I indicated, Resident 7 had a diagnosis of Chronic Respiratory Failure. MDS Section O indicated, Resident 7 had a tracheostomy (surgical opening in neck to assist in breathing) and was on a ventilator (mechanical method to provide breathing).During a concurrent interview and record review on 1/28/26 at 3:11 p.m. with Charge Nurse (CN), Resident 7's MDS Self-Care Performance indicated, he was dependent on staff for all his Activities of Daily Living (ADL- fundamental care tasks such as bathing, dressing, eating, toileting, moving in and out of bed or chair) needs. CN stated Resident 7 relies on staff for all his care needs.During a concurrent interview and record review on 1/28/26 at 3:33 p.m. with CN, Resident 7's medical record was reviewed. The Care Plan for pressure injury prevention, dated 11/7/25, indicated Resident 7 was to be turned and repositioned every two hours. Resident 7's Turn documentation was reviewed, the following was noted:1/20/26 turned at 6 a.m., 8 a.m., 10 a.m., 12 p.m., 2 p.m., 4 p.m., 7 p.m., and 9 p.m.1/21/26 turned at 6 a.m., 8 a.m., 10 a.m., 12 p.m., 2 p.m., and 4 p.m.1/22/26 turned at 7 a.m. and 7 p.m. 1/23/26 turned at 6 a.m., 7 a.m., 11 a.m., 1 p.m., and 9 p.m. 1/24/26 turned at 8 a.m. and 11 a.m. 1/25/26 turned at 6 a.m., 7 a.m., and 7 p.m.1/26/26 turned at 8 a.m., 10 a.m., and 11 a.m. 1/27/26 turned at 6 a.m., 7 a.m., 9 a.m., 10 a.m., 12 p.m., 2 p.m., 4 p.m., and 6 p.m. 1/28/26 turned at 6 a.m. and 8 a.m. During a concurrent interview and record review on 1/29/26 at 10:13 a.m. with Director of Nursing (DON), DON stated Resident 7 was transferred and admitted to the hospital on [DATE]. The hospital History and Physical (H&P), dated 10/25/25, indicated Resident 7's admission diagnosis was, Health Care Associated Pneumonia. DON stated Resident 7 was discharged from the hospital and returned to the facility on [DATE].During an interview on 1/29/26 at 10:38 a.m. with DON, DON stated that expectation for repositioning dependent residents every two hours is important for skin health and prevention of pneumonia.During a review of the facility's P&P titled, Pressure Ulcer Prevention and Treatment dated 9/20/24, the P&P indicated, B. Patient's position should be changed at least every two hours especially when patient is bedbound.

Based on interview and record review, the facility failed to ensure hygiene Activities of Daily Living (ADL- fundamental care tasks such as bathing, dressing, eating, toileting, moving in and out of bed or chair) were provided timely to one of three sampled dependent residents (Resident 7). This failure had the potential for skin breakdown and to negatively impact Resident 7's dignity.Findings:During an interview on 1/27/26 at 10:03 a.m. with Family Member (FM) 1, FM 1 stated her father does not always receive good care. FM 1 stated she came into the facility to visit him on a Saturday, and he had dried phlegm on his face and his brief was soiled with bowel movement (BM).During an interview on 1/27/26 at 10:22 a.m. with FM 2, FM 2 stated she had concerns with Resident 7's daily needs not being met. FM 2 stated she came to visit Resident 7 and there were a few times when his brief was soiled with BM.During an interview on 1/27/26 at 12 p.m. with Charge Nurse (CN), CN stated Resident 7 received his nutrition via feeding tube (essential nutrition, fluids, and medication are delivered directly into the stomach or small intestine for individuals unable to take in adequate nourishment by mouth).During an interview on 1/28/26 at 9:51 a.m. with CN, CN stated registered nurses (RN) round (checking on the resident's status) on their residents at the odd hours and certified nursing assistants (CNA) round at the even hours. CN stated if the resident had soiled briefs the CNA would be notified to change the resident's briefs. CN stated tube feeding is typically continuous over a 24 hour period and there is not a time when soiled briefs can be expected. CN stated all staff are responsible for ensuring dependent residents are clean, including washing their faces as needed.During an interview on 1/28/26 at 10:22 a.m. with CN, CN stated Resident 7 was dependent on staff for all his ADL needs.During a concurrent interview and record review on 1/28/26 at 11:05 a.m. with CN, Resident 7's ADLs for brief changes were reviewed. The following was noted:1/21/26 brief changed at 5 p.m.1/22/26 brief changed at 3 a.m. and 7 a.m.1/23/26 brief changed 7 a.m.1/24/26 brief changed 8 a.m.1/25/26 no brief change documented.1/26/26 brief changed 10 a.m., 3 p.m. and 5 p.m.1/27/26 brief changed 10 a.m., 1 p.m., 5 p.m. and 6 p.m.1/28/26 brief changed 3 a.m. and 5 a.m.CN stated the expectation was for all brief changes to be documented and when brief changes are not done frequently the resident's skin can begin to break down and result in wounds.A policy and procedure for ADL care for dependent residents was requested, none was provided.

Based on interview and record review, the facility failed to ensure two of 17 sampled residents (Resident 19 and Resident 23) were provided an opportunity to formulate an Advance Directive (legal document that specifies a person's medical care and end of life wishes, should the person become unable to communicate those wishes). This failure had the potential for residents' rights to formulate an advance directive, and medical care wishes and/or end of life issues to not be honored.Findings: During a concurrent interview and record review on 1/28/26 at 3:14 p.m. with Social Worker (SW), Resident 23's Social Services Evaluation (SSE), dated 4/12/24 was reviewed. SW stated there was no documentation Resident 23 had an Advanced Directive completed or if an Advanced Directive was offered. During a concurrent interview and record review on 1/28/26 at 8:18 a.m. with Director of Nursing (DON), Resident 19's medical record was reviewed. DON stated she was unable to find documentation of an Advanced Directive being offered or discussed with Resident 19 or his representative. During a review of the facility's policy and procedure (P&P) titled, Advance Directives dated 10/26/22, the P&P indicated, [The corporation] honors the patient's advance health care directives in inpatient and outpatient areas as they are made known to the organization. Patients admitted to the. skilled nursing units.will be asked if they have executed an Advance Directive designating their health care wishes and/or health care decision maker. Any patients desiring to formulate an Advance Directive with the capacity to do so will be assisted by being given a choice of an approved Advance Directive form. [The corporation] provides education to the Community about Advanced Directives. Under [state] law patients can designate a decision-maker to speak for them even when they are still able to speak for themselves. Procedure: I. Upon admission to. [the] skilled nursing units. all patients will be asked if they have an Advanced Directive or desire more information about Advance Directives.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was provided dignified care when Resident 1's urine collection bag was not covered and was visible to other residents, staff, and visitors. This failure had the potential to result in emotional distress for Resident 1. Findings: During an observation on 1/26/26 at 12:33 p.m. in Resident 1's room, Resident 1 was sitting in his wheelchair. A urine collection bag containing yellow liquid was hanging from the right side of Resident 1's wheelchair. The urine collection bag was uncovered and contents were visible. During a concurrent observation and interview on 1/26/26 at 12:48 p.m. with Licensed Vocational Nurse (LVN) 8, in Resident 1's room. Resident 1 had an uncovered urine collection bag hanging from the right side of his wheelchair. LVN 8 stated he did not put the urine bag in a dignity bag because they did not have any in the facility. LVN 8 stated The Foley [urine collection bag] should be covered. During a current interview and record review with Director of Staff Development (DSD), the facility's orientation book titled, Non-Licensed LTC [long term care] Orientation, (NLO) undated was reviewed. DSD stated the NLO indicated the patient's privacy and dignity is always a priority and the indwelling catheters (IUC) bag must remain in a discreet cover. DSD stated IUCs should be covered with a dignity bag for privacy. During a review of the facility's NLO undated, the NLO indicated, Remember the patient's privacy and dignity is always a priority - the IUC bag must remain in a discreet cover when patient is out of their room-this bag cover must be changed as needed but at least every 30 days. During a review of the facility's policy and procedure (P&P) titled Resident Right and Responsibilities, dated 2025, the P&P indicated, It is the belief of this facility that each resident has a right to a dignified existence, self-determination.

Based on interview and record review the facility failed to ensure the facility Medical Director had oversight over medical services and resident care when the medical director did not attend three quarterly Quality Assurance and Performance Improvement (QAPI- data-driven, comprehensive, and proactive approach to improving safety and quality in healthcare, particularly nursing homes) committee meetings. This failure had the potential to compromise patient safety. Findings:During a concurrent interview and record review on 1/29/26 at 2:47 p.m. with Director of Nursing (DON), the Quarterly Performance Improvement (QPI), committee attendance sign in records dated 6/27/25, 9/19/25, and 1/8/26 were reviewed. The QPI committee attendance sign in records indicated the Medical Director's signature was not documented for the QPI quarterly meetings on 6/27/25, 9/19/25, and 1/8/26. The DON stated the medical director had not attended the last three QPI committee meetings.During a review of the facility's P&P titled, Quality Improvement, dated 3/17/25, the P&P indicated, Membership includes the following personnel: Medical directors.

Based on observation, interview, and record review the facility failed to follow infection control standards when a germicidal (substance that destroys germs) wipe container was left open exposing the germicidal wipes. This failure had the potential for the germicidal solution to be ineffective against germs which could lead to the spread of illness and diseases to residents, staff, and visitors.Findings:During a concurrent observation and interview on 1/29/26 8:05 a.m. with Registered Nurse (RN) 1, at the nurses station, a Germicidal wipes container with wipes sticking out through the open top was on a wall near the nurses station. RN 1 stated the Germicidal container needed to be closed. During a concurrent interview and record review on 1/29/26 at 9:20 a.m. with Infection Prevention Manager (IPM) and Infection Preventionist (IP) the facility's training manual, titled, Infection Prevention (undated) was reviewed. The training manual indicated, Germicidal wipes closed lid=[equals] wet wipes=working disinfectant! Germicidal wipe container lids must be kept closed. Germicidal wipe containers left open dry out. Dried wipes do not disinfect. The IP stated the container needs to be kept closed so it does not create a wick (process of absorbing or drawing away fluid) effect and dries out the germicidal wipes.

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P), titled SNF Storage of Leftover Patient Food. when a refrigerator was not provided for resident's food brought in by family. This failure had the potential to place residents at risk of foodborne illness due to unmonitored food brought in by the family and could limit food choices and options for residents. Findings: During a concurrent interview and record review on 1/27/26 at 2:50 p.m. in a room next to the nurse's station, with Licensed Vocational Nurse (LVN) 9. The refrigerator in the room had a posted sign on the outside of the refrigerator door. The sign indicated No patient food from home allowed in fridge per policy number: FNS. 615. LVN 9 stated resident's food could not be placed that refrigerator. LVN 9 stated she was unaware of a refrigerator at the facility that was used to store residents' food from home. LVN 9 stated she was not aware family could bring in food for the residents to be stored at the facility. During a concurrent interview and record review on 1/27/26 at 2:57 p.m. with LVN 9, the P&P titled, SNF [skilled nursing facility] Storage of Leftover Patient Food was reviewed, LVN 9 stated she was not aware of the SNF Storage of Leftover Patient Food P&P. During a concurrent interview and record review on 1/28/26 at 9:46 a.m. with Director of Rehabilitation (DOR), the P&P titled, SNF Storage of Leftover Patient Food was reviewed. DOR stated the refrigerator that was used for residents to store their food was not working. DOR stated they had not been able to store food brought in for residents and stated the P&P should have been followed. During a review of the facility's P&P titled, SNF Storage of Leftover Patient Food, dated 2025, the P&P indicated, 1. Any food item that is brought from the outside for a resident that is left over and requires cold storage will be labeled by nursing with patient name, room number and date the food was brought in. II. Food items requiring cold storage will be stored in a clearly labeled patient food refrigerator on the unit.

Based on interview and record review, the facility failed to ensure three of three sampled residents (Resident 1, Resident 2, and Resident 3) or their legal representative were provided prior notification of receiving a new roommate. This failure resulted in a violation of residents' rights.Findings:During a review of the Summary of Complaint (SC) dated 12/1/25, the SC indicated, A few weeks ago [Resident 2] was placed on comfort care. We [anonymous complainant] were told she would be moved to a private room as she passed. After being moved to a room by herself a few days later without telling family the facility accepted a new admit into the same room. During a review of Resident 1's Facesheet (FS) undated, the FS indicated Resident 1 resided in room [ROOM NUMBER] starting 12/13/2023.During a review of Resident 2's FS undated, the FS indicated Resident 2 resided in room [ROOM NUMBER] starting 10/3/25.During a review of Resident 3's FS undated, the FS indicated Resident 3 resided in room [ROOM NUMBER] starting 5/1/18.During a review of the Resident List (RL) undated, the RL indicated, (Resident 4) was admitted to room [ROOM NUMBER] (with Resident 1) on 11/7/25 . (Resident 5) was admitted to room [ROOM NUMBER] (with Resident 2) on 11/28/25. (Resident 6) was admitted to room [ROOM NUMBER] (with Resident 3) on 11/21/25.During an interview on 12/3/25 at 11:46 a.m. with Director of Nursing (DON), DON stated she was unable to provide documentation of Resident 1, Resident 2, and Resident 3 receiving notice of receiving a roommate. DON stated that the receiving roommate should be given as much advance notice as possible.During a review of the facility's policy and procedure (P&P) titled In-Room Transfers dated 2/4/25, the P&P indicated, Staff actions: Prior to any in-room transfers, the licensed nurse or social worker service designee shall.inform resident's family or legal representative.

Based on observation, interview, and record review, the facility failed to provide Activities of Daily Living (ADL) care for one of three sampled residents (Resident 1) when Resident 1's fingernails were not cut. This resulted in Resident 1 having long, thick, yellow fingernails and potential for increased risk of nail infection.Findings:During a concurrent observation and interview on 7/9/25 at 10:16 a.m. with Assistant Director of Nurses (ADON) in Resident 1's room, Resident 1 was noted lying in bed. Both hands were contracted (a stiffening/shortening at any joint, that reduces the joint's range of motion), and all ten fingernails were long, thick, and yellow. ADON confirmed Resident 1's fingernails were long, thick, and yellow.During an interview on 7/9/25 at 10:20 a.m. Registered Nurse (RN), RN stated she has been working at the facility for a few years and Resident 1's fingernails has always been thick, long, and yellow.During an interview on 7/9/25 at 10:26 a.m. with Certified Nursing Assistant (CNA 1 and CNA 2), CNA 1 stated she does not recall the last time she had cut or filed (process of smoothing and shortening fingernails) Resident 1's fingernails. CNA 2 stated she has not cut or filed Resident ‘s fingernails. CNA 1 and CNA 2 stated Resident's fingernails were long, thick, and yellow. CNA 2 stated she felt uncomfortable cutting or filling Resident 1's fingernails because he has those fungus (thick and yellow) nails.During a review of the facility's policy and procedure (P&P) titled, Listing of Available Services dated 1/3/2000, the P&P indicated, 1. Covered Services include the following and no additional charges will be made to the resident and/or representative (sponsor): . B. Personal services and supplies for the comfort and cleanliness of the resident. These include, but are not limited to: nail care.

Based on observation, interview, and record review, the facility failed to follow infection control standards of practice when: 1. The vinyl cover on two of four linen carts in the hallway were damaged exposing the clean linen. 2. The Infection Preventionist Nurse (IPN) did not ensure infection control surveillance was being done on a regular basis. 3. A Wound Treatment Nurse (WTN) did not change gloves or wear gown in good repair during a wound care treatment for one of one sampled resident (Resident 5). 4. An used urinal was on a bedside table for one of one sampled resident (Resident 291). 5. The glucometer machine (measures the amount of sugar in the blood) was disinfected with unapproved wipes for two of two sampled residents (Resident 20, Resident 343). These failures had the potential to cause infections and spread of bacteria to residents, staff, and visitors. Findings: 1. During a concurrent observation and interview on 3/18/25 at 4:27 p.m. with Registered Nurse (RN) 4 near room [ROOM NUMBER], one linen cart's vinyl drape was open exposing the clean linen. RN 4 stated the linen cart vinyl cover should have been closed. During a concurrent observation and interview on 3/19/25 at 9:33 a.m. with IPN in the subacute unit, two linen carts were observed in the hallway. Both carts damaged vinyl covers with multiple tears and large holes. IPN stated, I am aware of this, it is unacceptable, clean linen should be covered without exposure. During a review of the facility's policy and procedure (P&P) titled, Linen Carts, dated 9/29/15, the P&P indicated, Laundry staff will monitor the condition of linen carts and cart covers and report issues to the Supervisor for action .III. Cart covers will be checked daily by the linen attendant and replaced as they become soiled or damaged. Covers will be removed when needed and washed, dried and returned to carts .V. Laundry staff will check carts daily and report needed repairs to maintenance department. 2. During an interview on 3/19/25 at 9:45 a.m. with IPN, IPN was unable to provide evidence of infection control monitoring, infection control audits or data collection. IPN stated, I don't document anything about surveillance on paper. I don't have any type of tracking system. During a concurrent interview and record review on 3/20/25 at 10:53 a.m. with IPN and Infection Prevention Manager (IPM), the facility's P&P titled, Healthcare Associated Infection Surveillance Plan, dated 8/19/22, the P&P indicated, VII. Surveillance data will be summarized into a report for review by the Infection Prevention Committee. VIII. Surveillance summaries are included in the IP dashboard. IPN was unable to provide infection control surveillance data. IPN stated the data she reported to Quality Assurance Program Improvement was In my head. 3. During a concurrent observation and interview on 3/17/25 at 11:12 a.m. with WTN in Resident 5's room, Resident 5's wound care was performed by WTN. WTN entered Resident 5's room wearing a cloth gown missing the ties in the back, top, and bottom used to tie the gown closer to the body. WTN put on glovers. WTN removed Resident 5's brief and three soiled dressings from Resident 5's lower back and buttocks. WTN sprayed the lower back and buttock wounds with wound cleaner and removed feces from around the wounds. WTN applied a barrier cream to the wounds and three clean dressings. WTN turned Resident 5 to her back and removed the feeding tube dressing. WTN cleansed the area and placed a new dressing around the feeding tube. WTN did not change her gloves or wash her hands at any time during the procedures. The WTN's gown was falling off her shoulders and fell to her elbows during the procedures. WTN stated she should have changed gloves after moving from dirty (i.e. removing soiled dressing) to clean (i.e. handling clean supplies, applying medication). During a review of Centers for Disease Control and Prevention (CDC) Organization, the CDC indicated, It's crucial to change gloves and perform hand hygiene when moving from a dirty to a clean task or area, and also when gloves become soiled or damaged. During an interview on 3/19/25 at 2:19 p.m. with IPN, IPN stated if a gown is not in good condition and missing the strings that tie in the back, it was no longer a barrier and should not be worn by staff. During an interview on 3/19/25 at 2:20 p.m. with Laundry Manager (LM), LM stated, each building has a reject container for linens and staff gowns that were not in good condition. She stated a gown that is torn or missing the ties should not be worn, it should be placed in the reject container. 50939 4. During a concurrent observation and interview on 3/17/25 at 10:17 a.m. with Resident 291 in Resident 291's room, there was a used urinal on the bedside table near a water pitcher, grapes in an open storage bag, and a denture container. During an interview on 3/17/25 at 10:25 a.m. with Certified Nurses Assistant (CNA) 1, CNA 1 stated Resident 291's urinal should not be placed on Resident 291's bedside table. CNA 1 stated she should have placed the urinal on the urinal holder. During an interview on 3/19/25 at 10:59 a.m. with Director of Nursing (DON) 1, DON 1 stated the facility had a urinal holder that was placed at side of the bed. DON 1 stated Resident 291's used urinal should not have been placed on the bedside table next to his personal belongings. 5. During an observation on 3/18/25 at 12 p.m. at the nurse's station, Registered Nurse (RN) 2 used CAVI wipes (cleaner and disinfectant) to clean the glucometer machine then placed the glucometer machine on the charging port. During an interview on 3/18/25 at 12:01 p.m. with RN 2, RN 2 stated she used the CAVI wipes to clean the glucometer machine after checking residents fingerstick blood sugar. During an interview on 3/18/25 at 12:03 p.m. with Assistant Director of Nursing (ADON), ADON stated the facility used CAVI wipes or alcohol wipes to clean the glucometer machine after each resident use. During an interview on 3/19/25 at 8:32 a.m. with DON 1, DON 1 stated the staff are to clean the glucometer machine after resident use using an alcohol pad or a CAVI wipe. During a concurrent interview and record review on 3/20/2025 at 11:03 a.m. with Infection Preventionist Nurse (IPN), the Nova Biomedical Stat Strip Glucose Hospital Meter System (glucometer) Instructions for Use Manual, (IFUM) dated 2024 was reviewed. The IFUM indicated, Acceptable Cleaning and Disinfecting Materials: Nova Biomedical recommends the use of Clorox Healthcare Bleach Germicidal Wipes. IPN stated the facility's Sani-Cloth and CAVI wipes do not contain bleach. IPN stated she was not aware the glucometer machine required the use of disinfecting wipes which contained bleach for cleaning. During an interview on 3/20/25 at 1:23 p.m. with DON 1, DON 1 stated she did not know that the glucometer manual requires bleach for disinfecting. During a review of the facility's P&P titled, Equipment Cleaning and Low/Intermediate Level Disinfection, dated 6/27/24, the P&P indicated, Policy: All common areas and common equipment will be cleaned appropriately according to standards provided by . the manufactures' manuals/recommendations.

Based on observation, interview, and record review, the facility failed to provide services that meet professional standards when: 1. One of five sampled residents (Resident 343) did not have a physician's order severe pain. This failure resulted in Resident 343's severe pain to not be managed. 2. Four of Four Licensed staff (Registered Nurse [RN] 2, Licensed Vocational Nurse [LVN] 4, and RN 1) were unaware of the process of checking for Gastrostomy Tube (GTube - a tube surgically inserted to the abdomen into the stomach)'s placement for three of three sampled residents (Resident 21, Resident 8, and Resident 15). This failure had the potential for Resident 21, Resident 8, and Resident 15 to aspirate (accidental inhalation of foreign substances into the lungs) and had the potential to cause harm or death. 3. LVN 1 failed to flush the GTube with water between medication administration for one of five sampled residents (Resident 8). This failure had the potential for medications to clog or block the GTube and not reach the stomach for proper absorption. Findings: 1. During a concurrent observation and interview on 3/19/25 at 8:52 a.m. with LVN 1, in Resident 343's room, LVN 1 administered Norco (pain reliever for moderate pain) to Resident 343 for a pain level of 7 of 10 on a pain scale (1. Mild=1-3, 2. Moderate=4-6, 3. Severe=7-10.). During a review of Resident 343's Order Sheet (OS), dated 3/12/25, the OS indicated, Norco 1 tab, by mouth, every 4 hours. PRN [as needed] for pain, moderate (scale 4-6). During a review of Resident 343's Flowsheet Print Request (FPR), dated 3/19/25, the FPR indicated, Norco was administered for Numeric Pain Score above 6 on the following dates and times: 3/13/25 at 10:07 p.m. Numeric Pain Score of 7 3/14/25 at 3:59 p.m. Numeric Pain Score of 7 3/14/25 at 9:49 p.m. Numeric Pain Score of 8 3/15/25 at 3:24 p.m. Numeric Pain Score of 7 3/17/25 at 9:25 a.m. Numeric Pain Score of 9 3/17/25 at 11:18 a.m. Numeric Pain Score of 8 3/17/25 at 7:21 p.m. Numeric Pain Score of 7 3/18/25 at 9:49 p.m. Numeric Pain Score of 7 3/19/25 at 8:52 a.m. Numeric Pain Score of 7 During an interview on 3/19/25 at 2:38 p.m. with LVN 1, LVN 1 stated she did not notify the doctor regarding Resident 343's severe pain level of 7 out of 10. During an interview on 3/19/25 at 2:49 p.m. with Director of Nursing (DON) 1, DON 1 stated there was no severe pain medication order for Resident 343. DON 1 stated the nurse should have contacted the doctor regarding Resident 343's severe pain that was greater than six on the pain scale. DON 1 stated there was no documentation the nurse contacted the doctor regarding Resident 343's pain score of seven. During a review of the facility's P&P titled, Pain Assessment and Reassessment, Standards for, dated 10/20/22, the P&P indicated, Policy: [facility name]recognized and upholds the rights of patients to have pain safely and effectively managed .The presence and intensity of pain will be based on the patient's self-report .indicators in order to balance the need for pain control with the risk of over sedation. Patients will receive the best level of pain control that can be safely provided. All patient care staff will demonstrate competency in the identification and intervention for pain management within the scope of his/her role. Staff will gather data on the patient's level of pain and sedation as the 5th Vital Sign and communicate unexpected findings as appropriate among the healthcare team .VII. PRIOR TO PHARMACOLOGICAL INTERVENTION FOR PAIN: .C. Severity (0-10/10). Numeric values for pain for verbal .are defined as: 1. Mild=1-3, 2. Moderate=4-6, 3. Severe=7-10. 2. During an observation on 3/18/25 at 12:15 p.m. in Resident 21's room, RN 2 placed syringe on Resident 21's GTube port and aspirated (pulled out) to check for residual formula (amount of liquid left in the stomach). During an interview on 3/18/25 at 12:26 p.m. with RN 2, RN 2 stated she aspirated for residual formula to check for correct placement of a GTube During an observation on 3/20/25 at 8:27 a.m. in Resident 8's room, LVN 4 used a syringe to aspirate formula residuals from Resident 8's GTube. During an observation on 3/20/25 at 9:06 a.m. in Resident 15's room, LVN 4 used a syringe to aspirate Resident 15's GTube for residuals. During an interview on 3/20/25 at 9:24 a.m. with RN 1, RN 1 stated nurses can either aspirate with syringe to check for formula residuals or use a stethoscope to check for GTube placement. During an interview on 3/20/25 at 9:31 a.m. with LVN 4, LVN 4 stated we can aspirate the GTube for residual to check for placement. During an interview on 3/20/25 at 11:38 a.m. with DON 2, DON 2 stated nurses should follow the policy for medication administration via GTube. DON 2 stated using a stethoscope to check for placement was not on the policy. During a review of the facility's P&P titled, Medication: Administration, dated 11/2024, the P&P indicated, K. Administration via tube .4. Assessment prior to medication administration, (1) Verify placement of the tube prior to medication administration by checking markings on the tube to make sure it has not migrated. 3. During an observation on 3/20/25 at 8:27 a.m. in Resident 8's room, LVN 4 administered Famotidine (treats excess stomach acid) and then administered Carvedilol (treats high blood pressure) without flushing with 5 ml (milliliters) of water between each medication. During a review of the facility's P&P titled, Medication Administration, dated 11/20/24, the P&P indicated, 5. When administering multiple medications each separate medication must be crushed and dissolved separately and administered separately using 5 ml of water to flush in between each medication.

Based on observation, interview and record review, the facility failed to ensure three of three nutritional products available for resident use were not expired. This failure had the potential for residents to develop food borne illness. Findings: During a concurrent observation and interview on [DATE] at 11 a.m. with Registered Nurse (RN) 3 in Wing A medication room, there were three unopened pro source protein nutrition product that had an expiration date of [DATE]. RN 3 stated the expired pro source products should not have been available for resident use. During a review of the facility's policy and procedure (P&P) titled, Recall & [and] Expired Products, dated 2024, the P&P indicated, Recall and expired food and other nutrition products will not be provided to patients and customers.

Based on observation, interview, and policy review, the facility failed to ensure one of one medication cart (Medication Cart 1) was kept locked or under direct observation by authorized staff. This failure had the potential for residents, unauthorized staff, and visitors to have access to medications. Findings: During an observation on 3/19/25 at 8:25 a.m. outside the medication room, there was an unlocked medication cart (Medication Cart 1). Medication Cart 1 contained insulin vials. During an interview on 3/19/25 at 8:26 a.m. with Director of Nursing (DON) 1, DON 1 stated the medication cart should have been locked. During an interview on 3/19/25 at 8:27 a.m. with Director of Rehabilitation (DOR), DOR stated the medication cart should be kept locked when not in use. During a review of the facility's policy and procedure (P&P) titled, Medication: Security in Patient Care Areas, dated 9/23/19, the P&P indicated, Policy: All medications are to be stored in a secure manner and accessible to authorized staff only.D. Medication Carts 1. Medication carts must be locked when not in use.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 342) were answered with a prolonged delay. This failure had the potential for Resident 342 to experience psychosocial harm when she stated the delay made her feel unimportant. Findings: During a review of Resident 342's History and Physical (H&P), dated 3/15/25, the H&P indicated, Resident 342 had a lumbar laminectomy (the removal of the back part of a lower back bone). and was alert and oriented. During an interview on 3/17/25 at 10:27 a.m. with Resident 342, Resident 342 stated she pressed her call light when she required assistance to the bathroom. Resident 342 stated when she activated her call light prior to shift change, she would wait 45 minutes to an hour for a response. Resident 342 stated the staff would come into her room, turn off the call light, then leave the room. Resident 342 stated the staff help her use the bathroom thirty minutes after shift change. Resident 342 stated she was afraid she might urinate on her self because of the staff's delay in answering her call light when she needed to use the bathroom. Resident 342 stated the staff would come in with sighing noises before assisting her to the bathroom. Resident 342 stated the staff actions made her feel unimportant. During an interview on 3/19/25 at 8:41 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated staff should address the concerns of the resident when turning off the call light. During a review of the facility's policy and procedure (P&P) titled, Nurse Call System, dated 2024, the P&P indicated, D. Staff will respond promptly to ensure resident safety and health needs are met in a reasonable amount of time. During a review of the facility's P&P titled, California Standard Admission Agreement For Skilled Nursing Facilities and Intermediate Care Facilities, undated, the P&P indicated, .(e) Accommodation of needs.(1).receive services in the facility with reasonable accommodation of individual needs and preferences.

Based on observation, interview, and record review the facility failed to ensure: 1. Potentially hazardous food (food capable of supporting microbial growth) was documented on the cool down log. 2. Expired food was removed from the freezer in kitchen 2. 3. Frozen food storage was dated in kitchen 2. 4. The ice machine in kitchen was sanitized in accordance with manufacturer's guidelines. These failures had the potential to result in the spread of foodborne illnesses. Findings: 1. During a concurrent observation and interview on [DATE] at 9:54 a.m. with Certified Dietary Manager (CDM) 1, in Kitchen 2, a large container of cooked pasta was located in the walk-in refrigerator. CDM 1 stated the cooked pasta was for the resident's lunch today. During a concurrent interview and record review on [DATE] at 9:58 a.m. with Cook II (CK) 1, the facility's food cooling log (CL), (undated) was reviewed. CK 1 stated he was the one who cooked the pasta yesterday ([DATE]). CK 1 stated, I hope I documented it. CK 1 reviewed the CL and the pasta noodles were not noted on the log. CK 1 stated he forgot to log his cool down process for the noodles. During an interview on [DATE] at 10:37 a.m. with CDM 1, CDM 1 stated the pasta should have been on the cool down log and was not. During a review of the facility's policy and procedure (P&P) titled, Food Safety HACCP [Hazard Analysis and Critical Control Points], dated [DATE], the P&P indicated, The Food and Nutrition Services Department has a comprehensive food safety and self-inspection system that includes equipment monitoring to ensure the effectiveness and quality of the food safety program for all of our food service customers. 5. Cooling of foods: Internal product temperatures must be recorded of the Food Cool-down log and kept on file for one year for health department inspections and audit purposes. 2. During a concurrent observation and interview on [DATE] at 10:05 a.m. with CDM 1 and Diet Clerk (DC) 3 in Kitchen 2 walk in freezer, a unopened package of Salisbury steak with a used by date of [DATE]. CDM 1 and DC 3 stated that was the correct label. DC 3 stated that it's a use by date and it was expired and should have been tossed out. During a review of the facility's Frozen Storage Life of Foods guidelines, (undated), the guidelines indicated, Discard all items on the expiration date and time. During a review of the facility's policy and procedure (P&P) titled, Food Labeling, dated [DATE], the P&P indicated, It is the policy of the Food and Nutrition Services Department to develop a mechanism to ensure the safe and accurate storage of food and nonfood products. Food storage methods are strictly defined. Food Labeling: Once any food product is opened and not used in its entirety, a Use By sticker shall be placed on the container of the unused portion/product. Product will be discarded at the end of the day from the Use by date placed on the product. 3. During a concurrent observation and interview on [DATE] at 10:05 a.m. with CDM 1 and DC 3 in Kitchen 2 walk in freezer there was a large container of unopened, frozen raw chicken in a large bin that was undated. DC 3 checked for a date and stated there was no date on the container and that it should be dated. During a review of the facility's policy and procedure (P&P) titled, Food Labeling, dated [DATE], the P&P indicated, It is the policy of the Food and Nutrition Services Department to develop a mechanism to ensure the safe and accurate storage of food and nonfood products. Food storage methods are strictly defined. Food labeling: All food products will be labeled with a Received Date. Items once removed from the main box/case will also be manually identified with a Received Date. 4. During a concurrent interview and record review on [DATE] at 2:44 p.m. with Maintenance Employee (MT) 1, the Scotsman Clear 1- Scale remover for Ice Machines bottle was reviewed. MT 1 stated he cleans the ice machine using a cleaner (Scotsman Clear-1) that both descales and sanitizes. MT 1 stated this is the only product that was circulated through the top part of the ice machine. MT 1 stated the product he is using is both a cleaner and a sanitizer. MT 1 stated, I know I saw that somewhere, maybe its on the manufacturers guidelines. MT 1 was unable to find where the ice machine cleaner (Scotsman Clear 1) also indicated the same product was a sanitizer. MT 1 confrmed the findings. During a concurrent interview and record review on [DATE] with MT 1 and CDM 1, Kitchen 2 ice machine Manufacturer's Guidelines (MG) was reviewed. The MG indicated, .7. Allow the ice machine scale remover to circulate in the water system for 10 minutes . 21. Circulate the sanitizer solution for 5 minutes. MT 1 stated the sanitizing step was not being done. CDM 1 stated the ice machine was not sanitized in accordance with ice machine manufacturers guidelines or the dietary policy and procedure on ice machine as is indicates to follow the manufacturers guidelines. During a review of the facility's policy and procedure (P&P) titled, Dispensing Ice, dated [DATE], the P&P indicated, The Food and Nutrition Services Department prepares and dispenses ice in a safe manner to ensure clean machines and handling and prevent cross contamination. Cleaning ice machines: Internal cleaning of the ice producing machinery per manufacturer recommendations are performed by the Plant Operations department.

Based on observation, interview, and record review the facility failed to follow individualized meal tray ticket directions for one of 36 sampled residents (Resident 189) vegetables were not chopped. This failure had the potential to result in meal preferences not being honored. Findings: During an observation on 3/18/24 at 11:54 a.m. in Kitchen 2, Resident 189's lunch plate was prepared by Cook II (CK) 1 and placed in the meal delivery cart by Diet Clerk (DC) 1. Resident 189's lunch plate included mixed vegetables (Cauliflower florets, Broccoli florets, and Carrot rounds) that were not served in a chopped texture. During a concurrent interview and record review on 3/18/24 at 11:54 a.m. with Certified Dietary Manager (CDM) 1, Resident 189's Lunch Meal Tray Ticket (MT), dated 3/18/24 was reviewed. The MT indicated Resident 189's texture request: chopped meats and chopped vegetables. CDM 1 stated the vegetables were not chopped and should have been in accordance with Resident 189's individualized menu directions located on the lunch meal tray ticket. During a review of Resident 189's Physician Orders (PO), dated 3/6/24, the PO indicated, Resident 189 was on a cardiac diet, diabetic, send chopped meats with gravy due to chewing issues per patient request. During a review of the facility's diet manual for chopped diet, (undated), the diet manual indicated, The Chopped/Dysphagia [difficulty swallowing] Level 3 diet is mechanically altered to meet the needs of patients with chewing or swallowing difficulties. Foods served require limited chewing. This diet is designed to maintain or improve the nutritional status of the patient. Food are moist and in bite-size pieces no larger than 1/2 inch. During a review of the facility's policy and procedure (P&P) titled, Tray Assembly Distribution and Cart Delivery, dated 10/14/2021, the P&P indicated, The following steps are used to ensure the accurate and timely distribution and retrieval of trays to patients with prescribed diets: .3. Food service staff member places food items on patient tray during tray line process according to the items listed on the patient tray ticket.

Based on interview and record review, the facility failed to ensure one of 36 sampled residents (Resident 23) significant change in status MDS (Minimum Data Set; Resident Assessment and Care Screening) was accurately completed for section K (Nutritional Status) when Resident 23 received nutrition care for a planned weight gain. This failure had the potential to result in an inaccurate MDS that could impede care planning to meet resident's needs. Findings: During a concurrent interview and record review on 03/20/24 at 09:57 a.m., with the Registered Dietitian (RD), Resident 23's Nutrition Note (NN), completed by RD on 9/2/22 was reviewed. Resident 23's NN, dated 9/2/22, indicated, Weight .: 79.7 kg [175 pounds] . Ideal Body Weight Calculated: 105.2 kg [231 pounds]. RD stated the NN, dated 9/2/22, was Resident 23's admission comprehensive nutrition assessment. RD stated, Resident 23's daily nutritional needs were assessed at 2,700 calories (a unit of energy) a day based on 35 kcal[calories]/kg [per kilogram, a unit of mass, of body weight] of his admission weight of 79.7 kg to promote weight gain. RD stated the goal was for Resident 23 to gain weight due to his underweight status as evidenced by a BMI [body mass index; used as an indicator of obesity and underweight] of 17.5, and he was 75.76% [percent] of his ideal body weight of 105.2 kg. During a concurrent interview and record review on 03/20/24 at 02:25 p.m., with RD in the presence of MDS Coordinator (MDSC), Director of Nursing (DON) and Assistant Director of Nursing (ADON), Resident 23's MDS titled Significant change in status assessment (SCS), dated as complete on 8/31/23 by the MDSC was reviewed. The SCS indicated, K0200. Height and Weight: 75 inches, 211 pounds. RD stated she completed section K (Nutritional Status) of the MDS on 8/31/2023. RD stated for the previous 30 days and six months of the 8/31/23 MDS, Resident 23 was on a planned weight gain tube feeding regimen. RD reviewed K0310. Weight Gain, and RD stated it was coded as 2 meaning Yes [had significant weight gain], not on physician-prescribed weight-gain regimen. RD stated the facility was actively trying to achieve weight gain for Resident 23, and RD stated the tube feeding orders were assessed to provide a planned weight gain. RD stated she was not sure who was responsible for contacting the doctor to get a specific physician order for weight gain to reflect the care and services provided to Resident 23, which was a planned weight gain regimen. RD stated I guess it was me who should have done that. During a concurrent interview and record review on 03/20/24 at 02:35 p.m. with MDSC, MDSC reviewed Resident 23's MDS titled Significant change in status assessment (SCS), dated as complete on 8/31/23. MDSC stated section K0310. Weight Gain was not completed accurately when a 2 was coded that meant Yes, not on physician-prescribed weight-gain regimen. MDSC stated, section K0310. Weight Gain should have been coded as a 1 which meant Yes [had weight gain], on physician-prescribed weight-gain regimen. During a review of the facility's policy and procedure (P&P) titled, RAI Process: Skilled Nursing Care, dated 9/14/23, the P&P indicated, Policy: All disciplines participating in the Resident Assessment Instrument (RAI) process will accurately complete their assessments. Sections to be completed. K . Responsible Discipline: Registered Dietician. After completing a section, the discipline will sign their name, electronically attesting to its accuracy. Then, the RN [Registered Nurse] assessment coordinator signs the assessment (Z0500) verifying assessment completion.

Based on observation, interview, and record review, the facility failed to ensure: 1. One of 36 sampled residents (Resident 190) expired medication was disposed. 2. One of 36 sampled residents (Resident 138) medication was properly labeled with an expiration date. These failures had the potential for residents to receive expired medications which can adversely affect residents health condition. Findings: 1. During a concurrent observation and interview on 3/20/24 at 9:59 a.m. with LVN 2, in medication storeroom one, Resident 190's [NAME] mouth wash (oral medication containing various liquid medications) 120 milliliter (ml)/10 ml had expired on 3/11/24. LVN 2 stated Resident 190 had been discharged from the facility and this medication should have been discarded. During a review of the facility's policy and procedure (P&P) titled Disposal of Unusable Medications, dated 8/24/22, the P&P indicated, Procedure: I. Initial handling of pharmaceutical waste. A. Unused or outdated medications returned to pharmacy shall be evaluated for disposition (disposal, return to stock, or sent to a pharmaceutical waste management company). During a review of the facility's P&P titled Medication: Administration, dated 3/7/24, the P&P indicated, . C. Discharges. 3. All medications specific to a particular patient, which are not being sent home, will be promptly returned to pharmacy for proper disposal. 2. During a concurrent observation and interview on 3/20/24 at 8:19 a.m. with LVN 2, LVN 2 administered Eye relief/refresh eye drops to Resident 138 right and left eye. LVN 2 reviewed the bottle of eye drops and stated there should be an opened date and expiration date on the bottle and there was not. During a concurrent observation and interview on 3/20/24 at 10:22 a.m. with Pharmacist (Pharm), in the medication storeroom, Resident 138 Eye relief/refresh artificial drops were reviewed. Pharm stated Resident 138 eye drops were not properly labeled with an open or expiration date. During a review of the facility P&P titled, Labeling Standards, dated 9/22/23, the P&P indicated, All medications sent to the nursing unit for inpatient use and not available in pyxis will be labeled . and include the following information: Beyond use or expiration date, and lot number when not noted on the original package.

Based on observation, interview, and record review, the facility failed to ensure the head of bed (HOB) of one of 10 sampled residents (Resident 8) was elevated at least 30 degrees while receiving enteral tube (delivery of nutrition via a tube or catheter inserted directly into the stomach through the abdominal wall) feedings. This failure had the potential to result in aspiration (inhaling foreign substance such as food or liquid into the airway and lungs) and lung problems to Resident 8. Findings: During a review of Resident 8's Order Sheet (OS), dated10/10/23, the OS indicated, Tube Feeding Continuous.GTUBE [enteral tube], Jevity 1.5 [formula].55 [milliliters per hour], 24 hours [per day]. During an observation on 3/18/24 at 10:24 a.m. in Resident 8's room, Resident 8 was laying on his left side with the HOB elevated to 15 degrees as indicated by the measuring guide on the side of Resident 8's bed. Resident 8's enteral tube feeding was running at 55 milliliters (ml) per hour. During an interview on 3/18/24 at 10:29 a.m. with Registered Nurse (RN) 1, RN 1 stated according to policy Resident 8's HOB should be elevated at 30 degrees while receiving enteral feeding. During a concurrent observation and interview on 3/18/24 at 10:30 a.m. with Assistant Director of Nursing (ADON) in Resident 8's room, ADON stated Resident 8's HOB was elevated at 15 degrees. ADON stated Resident 8's HOB should have been elevated to a minimum of 30 degrees while receiving enteral feeding. During a review of Resident 8's At Risk for Aspiration IPOC (IPOC-Individual Plan of Care), dated 3/29/19, the IPOC indicated, Elevate Head of Bed during and after Meals.Position Head of Bed to Prevent Aspiration. During a review of the facility's policy and procedure (P&P) titled, Nutrition: Enteral Nutrition, dated 10/30/23, the P&P indicated, To provide best practice guidelines in order to prevent complications and guide the safe management of enteral nutrition in adult inpatients.III.B. Aspiration precautions.HOB elevated to 30-45 degrees.

Based on interview and record review, the facility failed to follow it's policy and procedure on Advance Directive (AD - a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them) for one of 36 sampled resident's (Resident 28). This failure had the potential to result in staff not providing to Resident 28 the appropriate treatment in the event of emergency. Findings: During a review of Resident 28's clinical record it was noted there was no documented advance directive. During an interview on 3/18/24 at 2:47 p.m. with Director of Nursing (DON), DON stated the licensed nurses on the floor go over the admission and ask the patients if they want an AD. DON stated if they mark a yes, the information goes over to the social worker. During a concurrent interview and record review on 3/19/24 at 8:44 a.m. with Registered Nurse (RN) 3, Resident 28's, Electronic Health Record (EHR- an electronic patient chart) was reviewed. Resident 28's EHR indicated, no documented AD. RN 3 stated if the AD is checked yes, then it would go to patient family services. RN 3 stated patient family services would complete the AD. RN 3 stated she is unable to locate AD. During an interview on 3/19/24 at 10:30 a.m. with Resident 28, Resident 28 stated when he was admitted into the facility, he informed staff that he had an AD. During an interview on 3/19/24 at 10:40 a.m. with Social Services (SS), SS stated when the nurses mark the box yes or no on the admission assessment, it generates a clinical order for the AD. SS stated the AD was not followed and the order was not generated. During a review of the facility's policy and procedure (P&P) titled, Advanced Directives (AD), dated 10/16/2022, the P&P indicated, I. Upon admission to (facilty) inpatient units, skilled nursing units . all will be asked if they have an Advanced Directive or desire more information about Advance Directives. B. If a patient at Admission states Yes they have an Advance Directive, but a copy is not readily available, then the following will be done: 1. The Patient Access Registrar will enter Yes in the hospital information system.

Based on observation, interview, and record review, the facility failed to provide continuous mechanical ventilation (a form of life support system; a machine that helps keep the lungs working by pushing air in and out of the lungs via tracheostomy [an opening created at the front of the neck so a tube can be inserted into the windpipe]) as ordered by the physician for one of 13 sampled residents (Resident 1). Resident 1 was without oxygen assistance for more than two hours. This failure resulted in Resident 1 going into respiratory distress (difficulty breathing), requiring Cardiopulmonary resuscitation (CPR -an emergency lifesaving procedure performed when the heart stops beating), and transferred to the acute hospital. Findings: During a review of Resident 1's Face Sheet (FS), undated, the FS indicated, Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included stroke (lack of blood flow to the brain), traumatic brain dysfunction (damage to the brain), traumatic spinal cord dysfunction (loss of muscle function and sensation), respiratory failure (a life-threatening condition where the lungs cannot provide enough oxygen to the body's vital organs [main organs inside the body such as heart, lungs, and brain]), tracheostomy, and dependence on a respirator [ventilator]. During a review of Resident 1's Order Sheet (OS), dated [DATE], the OS indicated, Ventilator-Volume A/C (assist control-the ventilator delivers a fixed tidal volume [amount of air moved into or out of the lungs] at set intervals of time or when the resident initiates a breath delivers a minimum number of preset mandatory breaths by the ventilator; this mode provides full ventilatory support) The OS indicated, Resident 1 had an order for mechanical ventilator to be on continuous mode (continuing without a stop). During a review of Resident 1's ventilator machines manual instruction titled, Instructions for Use (IFU), dated [DATE], the IFU indicated, Standby-A ventilation feature that suspends (discontinue) ventilation [supply of air to the lungs] and keeps current settings when the clinician wants to temporarily disconnect the patient from the ventilator. During a review of the facility Incident Report (IR), dated [DATE], the IR indicated, Resident 1 Was found to be in respiratory distress [difficulty breathing] with a thready [weak] pulse by Nurse Practitioner [NP-works collaboratively with a physician] on [DATE] at [7:23 p.m.] [sic]. Code blue [medical emergency] was called and chest compressions [CPR] and ambu-bag [manual self-inflating-bag] ventilation were initiated immediately. During code activation, Nurse Practitioner identified that the ventilator was on standby mode and corrected the ventilatory support setting. During an interview on [DATE], at 9:45 a.m., with Nurse Manager (NM), NM stated, on [DATE], during shift change between 6:30 p.m. to 7:30 p.m., Resident 1 was in her room, lying in bed and noted to be cyanotic (a bluish or purplish discoloration of the skin, lips caused by lack of oxygen) with respiratory distress. NM stated, CPR was initiated, and Resident 1 was transferred to the acute hospital on [DATE], for evaluation and returned on [DATE]. NM stated, NP noted Resident 1's ventilator machine was on a standby mode and was not giving her [Resident 1] the air she needed. During a concurrent interview and record review on [DATE], at 10:21 a.m., with Director of Nurses (DON), Resident 1's OS, dated [DATE], was reviewed. DON stated, Resident 1 had an order for the ventilator machine to be on continuous mode. DON stated, Resident 1's ventilator machine should never have been placed on a standby mode. DON stated, During the investigation we (management) don't know who put the ventilator on a standby mode. DON stated, Resident 1's code status (full support which includes CPR, if the patient has no heartbeat and is not breathing) was a full code (all procedures will be provided to keep a person alive if the heart stopped beating and/or they stopped breathing). During a concurrent observation and interview on [DATE], at 10:52 a.m., with Certified Nursing Assistant (CNA), in Resident 1's room, Resident 1 was lying in bed. A ventilator machine was at Resident 1's bedside with a plastic breathing tube connected from the ventilator machine to Resident 1 ' s neck area. A rhythmic whoosh, pause, whoosh, pause was heard from Resident 1's ventilator machine. CNA stated, Resident 1 was non-verbal and required two staff assistance for turning and repositioning in bed. During an interview on [DATE], at 10:58 a.m., with Respiratory Technician (RT) 1 and RT 2, RT 1 stated, When the power button located in front of the ventilator machines monitor screen is pressed, a 'standby and a power off' question will appear on the monitor screen. When the standby mode is selected, the machine remains on, but it is not giving out any air. RT 1 stated, The standby mode on a ventilator machine is used when there is an order for weaning (process in decreasing the amount of ventilatory support) a resident off the machine and required an RT to be always at bedside with the resident during the weaning process. RT 2 stated, Resident 1 had an order for the ventilator machine to be on continuously and should not have been placed on a standby mode. During a concurrent interview and record review, on [DATE], at 12:33 p.m., with DON, Resident 1's ventilator machine alarm and button internal log (ventilator machine had its own memory log that record each event or incident), dated [DATE], was reviewed. The log indicated the following: [DATE] at 4:59 p.m. the Start/Stop Key Pressed. [DATE] at 4:59 p.m. (1 second later), the Standby mode was selected. [DATE] at 7:13 p.m. the ventilator machine was turned back on. DON stated, the log indicated Resident 1's ventilator machine was on a standby mode for more than two hours (2 hours and 14 minutes). DON confirmed the ventilator machine was on a standby mode ([DATE]), which resulted in respiratory distress for Resident 1. During an interview on [DATE], at 4:26 p.m., with Registered Nurse (RN) 1, RN 1 stated, on [DATE], at 5 p.m. she administered pain medication to Resident 1 in her room. RN 1 stated, at 5:50 p.m., she returned to Resident 1's room to re-assess Resident 1 and noted her (Resident 1) slight grimacing (frowning). RN 1 stated, at 6:15 p.m., she gave report to the oncoming nurse (Licensed Vocational Nurse-LVN) inside Resident 1's room. RN 1 stated, she went into Resident 1's room three times (no time given) and did not notice Resident 1's ventilator machine was on a standby mode and Resident 1 was not receiving any air. RN 1 stated, Resident 1 Could not breathe without the ventilator machine. During an interview on [DATE], at 9:33 p.m., with RN 2, RN 2 stated, on [DATE], at approximately 6:20 p.m., Resident 1 was in her room with the NP. RN 2 stated, NP noted Resident 1 to be uncomfortable (uneasy). At approximately 7 p.m., RN 2 returned to Resident 1's room with the NP and found Resident 1 was dusky [grayish] color and had a faint (weak) pulse. RN 2 stated, CPR was immediately started. RN 2 stated, the NP noted Resident 1's ventilator machine was on a standby mode ([DATE]). RN 2 stated, Resident 1 needed the ventilator machine to help with breathing. During an interview on [DATE], at 12:39 p.m., with RT 3, RT 3 stated, When a ventilator machine is placed on a standby mode, the machine is on, but it is not giving breath to the resident, not ventilating, not working. RT 3 stated, Resident 1 was dependent on the ventilator machine, was not ready for any type of weaning, the ventilator machine should never have been placed on a standby mode. During an interview on [DATE], at 2:03 p.m., with NP, NP stated, on [DATE], she assessed Resident 1 two times (no time given). NP stated, Resident 1 looked uncomfortable, and she ordered pain medication to be given and a bladder scan (procedure used to detect how much urine is in the bladder). NP stated, she returned to Resident 1's room and noted Resident 1's skin color was different and noted the ventilator machine was on a standby mode. NP stated, she re-started Resident 1's ventilator machine and initiated the CPR. NP stated, Resident 1 had an order for the ventilator machine to be on continuously, There is no reason for her [Resident 1] to be on standby mode. During an interview on [DATE], at 7:23 a.m., with LVN, LVN stated, on [DATE], at approximately 6:20 p.m., he was in Resident 1's room getting verbal report from RN 1. LVN stated, at 6:50 p.m., he went back in Resident 1's room with RN 3 to perform the bladder scan and he noted the lights on Resident 1's ventilator machine was on but was not making any noise. LVN stated, he did not take a closer look at Resident 1's ventilator machine because he thought it was on. LVN stated, Resident 1 had always been on the ventilator since she was admitted ([DATE]). During an interview on [DATE], at 10:08 p.m., with RN 3, RN 3 stated, on [DATE], at approximately 6:50 p.m., she went to Resident 1's room to help with the bladder scan procedure. RN 3 stated, she did not notice Resident 1's ventilator machine was on a standby mode. RN 3 stated, Resident 1 had an order to be on the ventilator machine continuously. RN 3 stated, She [Resident 1] would not be able to tolerate without it [ventilator machine]. During a review of Resident 1's Nursing Narrative Note (NNN), dated [DATE] at 8:23 p.m., the NNN indicated, Approximately [7:23 p.m.] [sic] NP decided to go back and follow up on [Resident 1] and noticed that [Resident 1] was gray/dusky in color and was unresponsive [not reacting or responding] with faint [weak] pulse. [Resident 1] was in respiratory distress and CPR was initiated. During a review of Resident 1's Critical Care Progress Note (CCPN), dated [DATE] at 7:40 p.m., written by the NP, the CCPN indicated Significant Findings: Respiratory arrest (medical emergency where the ability of a resident to breathe stops). CPR started. send to [acute hospital] for evaluation. During a review of Resident 1's EMS (Emergency Medical Services- is a system that provides emergency medical care) narrative note, date [DATE], at 7:25 p.m., the note indicated, RN at scene states she was doing her normal evening rounds, and when she came to this patient [Resident 1], noticed that her ventilator was turned off.Continuously monitored patient during transport and arrived [acute hospital]. During a review of the acute hospital Emergency Documentation (ED), dated [DATE], at 10:30 p.m., the ED indicated, ED Course: [AGE] year-old female. presents to our facility status post [after] CPR. Staff found patient somewhat uncomfortable and realized that her ventilator has been turned off. They turned the ventilator back on, checked her pulse which was reported to be thready [weak]. CPR was initiated and maintained for approximately 10 minutes . Critical Care Note: There was an acute [sudden] impairment of an organ system (a group of organs in the body that work together to perform a specific function) with a high probability of imminent or life-threatening deterioration (a critical illness or injury acutely impairs one or more vital organ systems) in the patient's condition. During a review of the facility's policy and procedure (P&P) titled, Orders: Processing & Notation of Non-Medication Orders, dated [DATE], the P&P indicated, Licensed staff ensure Practitioner orders are followed when delivering care to patients. During a review of the facility's P&P titled, Mechanical Ventilation, dated [DATE], the P&P indicated, Respiratory Care practitioners will safely establish and maintain mechanical ventilatory support resulting in respiratory homeostasis [state of balance] . Procedures: XIII. Automatic Stop Order: Not applicable.