Every finding on record at La Mesa Healthcare Center

Based on interview and record review, the facility failed to develop and implement individualized, person-centered discharge care plans that reflected each individualized, person-centered discharge for three of five sampled residents (Resident 1, 3 and 4) with the same generic and identical goals and interventions for each resident.These deficient practices placed three residents (Resident 1, 4 and 5) at risk for unmet healthcare needs, poor coordination of care, ineffective discharge planning, interruption in continuity of care, and avoidable health complications after discharge. Cross Reference F627 and F628. Findings:1. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body)/Hemiparesis weakness on one side of the body) following cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain). A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 6/2/26 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 7 points out of 15 possible points which indicated Resident 1 had severe cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 7/22/26 a record review was conducted on Resident 1's discharge care plan that indicated, .Discharge/Transfer Planning Preference: [] Resident [] Resident's Responsible Party/Family Members indicates preference to discharge to: [BLANK] Date Initiated: 06/02/2026 Goals: Current level of care is appropriate considering current physical/social/emotional status Date Initiated: 06/02/2026 Revision on: 06/11/2026 Target Date: 09/02/2026 Improve independence with ADLs and/or mobility to allow for safe discharge to (enter). Date Initiated: 06/02/2026 Revision on: 06/11/2026 Target Date: 09/02/2026 Medical condition(s) will improve to extent possible to allow for safe discharge to (enter). Date Initiated: 06/02/2026 Revision on: 06/11/2026 Target Date: 09/02/2026 Pain will be managed to allow for safe discharge to (enter). Date Initiated: 06/02/2026 Revision on: 06/11/2026 Target Date: 09/02/2026 Risk for (specify: Isolation, decreased appetite, increased mood problems, signs, and symptoms of anxiety) will be minimized as the resident becomes comfortable with current environment while discharge planning takes place. Date Initiated: 06/02/2026 Revision on: 06/11/2026 Target Date: 09/02/2026 Will be comfortable in their environment. Date Initiated: 06/02/2026 Revision on: 06/11/2026 Target Date: 09/02/2026 Will be discharged to [ ] appropriate placement [ ] (enter) which will meet individualized health objectives. Date Initiated: 06/02/2026 Revision on: 06/11/2026 Target Date: 09/02/2026 Will meet resident/resident representative discharge goal/plan of [ ] return to community [ ] remain in this facility [ ] transfer to another long-term care facility [ ] Hospice care services [] Respite care services [ ] Other (specify). Date Initiated: 06/02/2026 Revision on: 06/11/2026 Target Date: 09/02/2026 Coordinate DME, pharmacy, home health, and/or in-home support services. Date Initiated: 06/02/2026 Social services to document changes to discharge goal per resident/resident representative preference as indicated. Date Initiated: 06/02/2026 Social services to schedule IDT care plan meetings upon admission, quarterly, and as needed. Date Initiated: 06/02/2026. On 7/22/26 at 10:47 A.M., an interview and record review was conducted with the Social Services Assistant (SSA). The SSA read out loud (Resident 1, 4, and 5) discharge care plan. The SSA stated I should have updated the care plans for all three residents (Resident 1, 4, and 5). The SSA stated the discharge care plans was not updated and for all three discharges. The SSA stated It is important to update the care plan to identify their needs upon discharge and should be personalized that works for the resident for safety and for continuum of care otherwise they can decline overall and it would not be a successful discharge. The SSA stated the discharge care plans for all three residents were cut and paste. On 7/22/26 11:34 A.M., an interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated all three residents (Resident 1, 4, and 5)had the same discharge care plans and generic. LN 1 stated it's important for a personalized discharge care plan so that we are addressing the health and safety needs of the residents to prevent re-admissions and health decline. It is important. On 7/22/26 12:14 P.M., an interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON read out loud (Resident 1, 4, and 5's) discharge care plan. The ADON stated that all three residents (Resident 1, 4, and 5's) discharge care plan was basically all the same and generic. It is not personalized and it is a copy and paste for the discharge care plans. The ADON stated we need to have personalized discharge care plan as a means to communicate with each other as well as have the resident/family involved that is personalized to prevent health declines, safety and re-admissions when they discharge. That way it makes sure that we meet all their discharge needs. Discharge care plans are needed to ensure safe and orderly discharges to prevent further health decline and safety. On 7/22/26 at 12:29 P.M., an interview and record review was conducted with the Social Service Director (SSD). The SSD read out loud (Resident 1, 4, and 5's) discharge care plan. The SSD stated all three residents (Resident 1, 4, and 5's) discharge care plans was not personalized and generic because we have not been revising them. The SSD stated discharge planning takes time to plan so that nothing gets missed and addressed appropriately so supplies, medications, MD/Social services concerns are discussed plus we need t o order DME's we need to know ahead of time what the role is to what we need to do to have a proper safe transition to their discharge location to prevent hospitalizations, and complications when they leave. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-centered dated March 2022, indicated .The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MOS assessment(Admission, Annual or Significant Change in Status), and no more than 21 days after admission 2. A review of Resident 4's admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses which included history of Diabetes Mellitus Type II (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).A record review of Resident 4's minimum data set (MDS - a federally mandated resident assessment tool) dated 7/3/26 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 12 points out of 15 possible points which indicated Resident 4 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 7/22/26 a record review was conducted on Resident 4's discharge care plan indicated, .Discharge/Transfer Planning Preference: [] Resident [] Resident's Responsible Party/Family Members indicates preference to discharge to: [BLANK] Date Initiated: 06/01/2026 Revision on: 07/05/2026 Cancelled Date: 07/05/2026 Goals: Current level of care is appropriate considering current physical/social/emotional status Date Initiated: 06/02/2026 Date Initiated: 06/01/2026 Revision on: 07/05/2026 Target Date: 08/28/2026 Cancelled Date: 07/05/2026 Improve independence with ADLs and/or mobility to allow for safe discharge to (enter). Date Initiated: 06/01/2026 Revision on: 07/05/2026 Target Date: 08/28/2026 Cancelled Date: 07/05/2026 Medical condition(s) will improve to extent possible to allow for safe discharge to (enter). Date Initiated: 06/01/2026 Revision on: 07/05/2026 Target Date: 08/28/2026 Cancelled Date: 07/05/2026 Pain will be managed to allow for safe discharge to (enter). Date Initiated: 06/01/2026 Revision on: 07/05/2026 Target Date: 08/28/2026 Cancelled Date: 07/05/2026 Risk for (specify: Isolation, decreased appetite, increased mood problems, signs, and symptoms of anxiety) will be minimized as the resident becomes comfortable with current environment while discharge planning takes place Date Initiated: 06/01/2026 Revision on: 07/05/2026 Target Date: 08/28/2026 Cancelled Date: 07/05/2026 Will be comfortable in their environment Date Initiated: 06/01/2026 Revision on: 07/05/2026 Target Date: 08/28/2026 Cancelled Date: 07/05/2026 Will be discharged to [ ] appropriate placement [ ] (enter) which will meet individualized health objectives Date Initiated: 06/01/2026 Revision on: 07/05/2026 Target Date: 08/28/2026 Cancelled Date: 07/05/2026 Will meet resident/resident representative discharge goal/plan of [ ] return to community [ ] remain in this facility [ ] transfer to another long-term care facility [ ] Hospice care services [] Respite care services [ ] Other (specify). Date Initiated: 06/01/2026 Revision on: 07/05/2026 Target Date: 08/28/2026 Cancelled Date: 07/05/2026 Coordinate DME, pharmacy, home health, and/or in-home support services. Date Initiated: 06/01/2026 Revision on: 07/05/2026 Cancelled Date: 07/05/2026 Social services to document changes to discharge goal per resident/resident representative preference as indicated. Date Initiated: 06/01/2026 Revision on: 07/05/2026 Cancelled Date: 07/05/2026 Social services to schedule IDT care plan meetings upon admission, quarterly, and as needed. Date Initiated: 06/01/2026 Revision on: 07/05/2026 Cancelled Date: 07/05/2026.On 7/22/26 at 10:47 A.M., an interview and record review was conducted with the Social Services Assistant (SSA). The SSA read out loud (Resident 1, 4, and 5) discharge care plan. The SSA stated I should have updated the care plans for all three residents (Resident 1, 4, and 5). The SSA stated the discharge care plans was not updated and for all three discharges. The SSA stated It is important to update the care plan to identify their needs upon discharge and should be personalized that works for the resident for safety and for continuum of care otherwise they can decline overall and it would not be a successful discharge. The SSA stated the discharge care plans for all three residents were cut and paste. On 7/22/26 11:34 A.M., an interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated all three residents (Resident 1, 4, and 5)had the same discharge care plans and generic. LN 1 stated it's important for a personalized discharge care plan so that we are addressing the health and safety needs of the residents to prevent re-admissions and health decline. It is important. On 7/22/26 12:14 P.M., an interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON read out loud (Resident 1, 4, and 5's) discharge care plan. The ADON stated that all three residents (Resident 1, 4, and 5's) discharge care plan was basically all the same and generic. It is not personalized and it is a copy and paste for the discharge care plans. The ADON stated we need to have personalized discharge care plan as a means to communicate with each other as well as have the resident/family involved that is personalized to prevent health declines, safety and re-admissions when they discharge. That way it makes sure that we meet all their discharge needs. Discharge care plans are needed to ensure safe and orderly discharges to prevent further health decline and safety. On 7/22/26 at 12:29 P.M., an interview and record review was conducted with the Social Service Director (SSD). The SSD read out loud (Resident 1, 4, and 5's) discharge care plan. The SSD stated all three residents (Resident 1, 4, and 5's) discharge care plans was not personalized and generic because we have not been revising them. The SSD stated discharge planning takes time to plan so that nothing gets missed and addressed appropriately so supplies, medications, MD/Social services concerns are discussed plus we need t o order DME's we need to know ahead of time what the role is to what we need to do to have a proper safe transition to their discharge location to prevent hospitalizations, and complications when they leave. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-centered dated March 2022, indicated .The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MOS assessment(Admission, Annual or Significant Change in Status), and no more than 21 days after admission 3. A review of Resident 5's admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses which included history of Wedge (front of back bone) Compression Fracture (a squashed spine bone where the front part collapses into a wedge or doorstop shape while the back stays the same height) of the fourth lumbar vertebrae (lower back bone).A record review of Resident 5's minimum data set (MDS - a federally mandated resident assessment tool) dated 3/26/26 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 11 points out of 15 possible points which indicated Resident 5 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 7/22/26 a record review was conducted on Resident 5's discharge care plan indicated, .Discharge/Transfer Planning Preference: [] Resident [] Resident's Responsible Party/Family Members indicates preference to discharge to: [BLANK] Date Initiated: 03/22/2026 Revision on: 06/02/2026 Cancelled Date: 06/02/2026 Goals: Current level of care is appropriate considering current physical/social/emotional status Date Initiated: 03/22/2026 Revision on: 06/02/2026 Cancelled Date: 06/02/2026 Improve independence with ADLs and/or mobility to allow for safe discharge to (enter). Date Initiated: 03/22/2026 Revision on: 06/02/2026 Cancelled Date: 06/02/2026 Medical condition(s) will improve to extent possible to allow for safe discharge to (enter). Date Initiated: 03/22/2026 Revision on: 06/02/2026 Cancelled Date: 06/02/2026 Pain will be managed to allow for safe discharge to (enter). Date Initiated: 03/22/2026 Revision on: 06/02/2026 Cancelled Date: 06/02/2026 Risk for (specify: Isolation, decreased appetite, increased mood problems, signs, and symptoms of anxiety) will be minimized as the resident becomes comfortable with current environment while discharge planning takes place Date Initiated: 03/22/2026 Revision on: 06/02/2026 Cancelled Date: 06/02/2026 Will be comfortable in their environment 03/26/2026 Date Initiated: 03/22/2026 Revision on: 06/02/2026 Cancelled Date: 06/02/2026 Will be discharged to [ ] appropriate placement [ ] (enter) which will meet individualized health objectives Date Initiated: 03/22/2026 Revision on: 06/02/2026 Cancelled Date: 06/02/2026 Will meet resident/resident representative discharge goal/plan of [ ] return to community [ ] remain in this facility [ ] transfer to another long-term care facility [ ] Hospice care services [] Respite care services [ ] Other (specify). Date Initiated: 03/22/2026 Revision on: 06/02/2026 Cancelled Date: 06/02/2026 Coordinate DME, pharmacy, home health, and/or in-home support services. Date Initiated: 03/22/2026 Revision on: 06/02/2026 Cancelled Date: 06/02/2026 Social services to document changes to discharge goal per resident/resident representative preference as indicated. Date Initiated: 03/22/2026 Revision on: 06/02/2026 Cancelled Date: 06/02/2026 Social services to schedule IDT care plan meetings upon admission, quarterly, and as needed. Date Initiated: 03/22/2026 Revision on: 06/02/2026 Cancelled Date: 06/02/2026. 7/22/26 10:47 AM SSA ([NAME], [NAME] I/RR) Admit [DATE] DC [DATE] Dx DM type II w/o complications MDS 7/3/26 BIMS 12 Resident dc'd w/ caregiver he went home with PT/OT/RN DME. Discharge careplan in place but not locations updated. Date initiated 6/1/26. We have a NOMNOC on 6/29/26 I should have updated the care plan (read out loud at the same time with the undersigned for [NAME], [NAME] and [NAME] it was a cut/paste) The discharge careplan was not updated and personalized (all three of them [NAME], [NAME] and [NAME]). It is important to update the care plan to identify their needs upon discharge and should be personalized that works for the resident for safety and for continuum of care otherwise they can decline overall and it would not be a successful discharge. 7/22/26 10:50 AM SSA ([NAME], [NAME] I/RR) DxDischarge CP initiated [DATE]. The care plan was not revised or personalized (read out loud at the same time with the undersigned for [NAME], [NAME] and [NAME] it was a cut/paste). She was with Tri-care. It is important to update the care plan to identify their needs upon discharge and should be personalized that works for the resident for safety and for continuum of care otherwise they can decline overall and it would not be a successful discharge. 7/22/26 11:34 AM [NAME] RN ( [NAME]-I/RR) Yes, she had a Gtube. On the 14th the 2 daughters came and were educated by [NAME] LVN. He teach them about TF using the Kangaroo pump, syringe, and everything how to do the machine and they were understanding of instructions by return demonstration. One of the daughters was even more interested than the other daughter. The discharge care plan we didn't personalize to put the teaching that we did. It's the same as the other care plans ([NAME], [NAME] and [NAME]).[NAME] there is no dc care plan. It should be initiated within 48H and revised. It's important for a personalized discharge care plan so that we are addressing the health and safety needs of the residents to prevent re-admissions and health decline. It is important. [NAME] is not here but we can call him. 7/22/26 12:14 PM ADON (I/RR)- [NAME], [NAME] and [NAME] (Read care plans at the same time with the undersigned and it was copy and paste no personalization). Well, I guess I can't talk my way out of that. It's basically all the same and generic. It is not personalized and it is a copy and paste for the discharge care plans. For [NAME] there is no discharge care plan and there should be one because discharge planning starts on admission. We need to have personalized discharge care plan as a means to communicate with each other as well as have the resident/family involved that is personalized to prevent health declines, safety and re-admissions when they discharge. That way it makes sure that we meet all their discharge needs. Discharge care plans are needed to ensure safe and orderly discharges to prevent further health decline and safety. 7/22/26 12:29 PM [NAME] SSD (I/RR) I will tell you I'm still having a lot of fixing up to do with our department. I've been for 6 months and I realize that our discharge care plans are not personalized and/or revised on timely. The IDT meeting have not been scheduled since I got here. I usually do progress notes and options on what they decided. - [NAME], [NAME] and [NAME] (Read care plans at the same time with the undersigned and it was copy and paste no personalization). The discharge care plans are not personalized and generic because we have not been revising them. [NAME] there is no discharge care plan at all and it should be initiated within 48 hours and revised. I know it will take time to fix our department. DC planning takes time to plan so that nothing gets missed and addressed appropriately so supplies, medications, MD/Social services concerns are discussed plus we need t o order DME's we need to know ahead of time what the role is to what we need to do to have a proper safe transition to their discharge location to prevent hospitalizations, and complications when they leave. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-centered dated March 2022, indicated .The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MOS assessment(Admission, Annual or Significant Change in Status), and no more than 21 days after admission

Based on interview and record review, the facility failed to prepare a safe and coordinated discharge for one of five sampled residents (Resident 1) by not providing necessary equipment for a continuous tube feeding(TF-way to give liquid food, water, and medicine directly into the stomach or small intestine through a soft plastic tube when a person cannot safely chew or swallow) order and/or necessary teaching to administer a bolus (a way to give liquid food or formula through a feeding tube like a meal, using a large syringe several times a day) feeding as revised due to no feeding pump (machine used to deliver tube feedings).These deficient practices placed Resident 1 at risk for missed needed nutrition, delayed feeding, poor nutritional status, dehydration, re-hospitalization, and complications related to not receiving prescribed TFs after discharge.Cross Reference F628 and F656. Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body)/Hemiparesis weakness on one side of the body) following cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain). A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 6/2/26 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 7 points out of 15 possible points which indicated Resident 1 had severe cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 7/22/26 at 8A.M., an interview with Resident 1's Family Member (FM) was conducted via telephone. FM stated that the facility had discharged her mother (Resident 1) without a Kangaroo (a portable medical machine used to feed liquid nutrition and water directly into a person's stomach or small intestine through a feeding tube ) pump that was necessary to give Resident 1 her nutritional needs via tube feeding. FM stated she gave the Social Services Assistant (SSA) the number to call for the home health (HH) company to include needing an order for the TF and to notify them that they did not get a Kangaroo pump and it needed to be ordered prior to the day of discharge. FM stated her mother (Resident 1) did not receive her TF the following day at home after discharge and went without nutrition when it was supposed to be hung in the morning (8AM-9AM). FM stated that her sister went back to the facility the next day (July 17, 2026) which they gave her 3-4 feeding solutions with tubing without no pump and an updated order for a bolus instead of continuous feeding via the Kangaroo pump. FM stated she and her sister did not get any instructions and/or special training to administer a bolus feed. FM stated she thought the facility was going to give her sister a Kangaroo pump but instead gave her protein shakes and TF supplies without the Kangaroo pump, however Resident 1 did not want to eat or drink anything and went without her nutritional intake. FM stated about noon that day (July 17, 2026) they received a fax from the facility with the order for the bolus feed to be given every four hours. FM stated they (HH, FM and FM sister) requested for other documents (no H&P, no face sheet, no discharge care plan, no advanced directive (AD-a legal document indicating resident preference on end-of-life treatment decisions) , no progress notes, no discharge summary, & no special instructions or precautions for ongoing care for TF or wounds. FM stated she nor her sister was taught how to administer TF via bolus and only was taught using the Kangaroo pump upon discharge. On 7/22/26 at 8:22 A.M., an interview with the HH Registered Nurse (HHRN) conducted via telephone (HHRN was at Resident 1's residence at the time of the interview). The HHRN stated the facility discharged Resident 1 without ensuring a safe transition of care. The HHRN stated the facility faxed only a HH physical (PT) and occupational (OT) order on the afternoon of the discharge (7/16/26). The HHRN stated the following day (7/17/26), she only received an order for the TF bolus that was changed from the original discharge orders for continuous feeding. The HHRN stated she did not receive Resident 1's History and Physical (H&P), face sheet (FS), discharge summary, discharge care plan, AD, progress notes, or instructions for ongoing TF and wound management. The HHRN stated Resident 1 arrived home without the required feeding pump, the family had not been instructed on how to administer the prescribed bolus TF, and Resident 1 was unable to receive the ordered nutrition because the necessary equipment (Kangaroo pump) and complete discharge information had not been provided. On 7/22/26 at 9:48 A.M., an interview and record review was conducted with the Social Services Assistant (SSA). The SSA stated she initiated Resident 1's discharge care plan on 6/2/26 but failed to update and individualize the care plan before discharge to reflect Resident 1's discharge destination, caregiver support, TF needs, required durable medical equipment (DME), and ongoing services. The SSA stated the discharge care plan was not personalized and should have been revised to identify Resident 1's return home with her daughter and son, Resident 1's prescribed TF regimen, caregiver education needs, and equipment necessary for a safe discharge. The SSA stated the facility failed to order the required Kangaroo Pump before discharge, despite knowing Resident 1's nutritional needs. The SSA admitted she forgot to order the feeding pump and left TF education to nursing without confirming with Resident 1's family had been instructed before discharge. The SSA stated Resident 1's daughter later reported that Resident 1's feeding was delayed because the feeding pump had not been provided. The SSA further stated that the interdisciplinary team (IDT- a group of different experts, such as doctors, therapists, nurses and social workers, who work closely together) was responsible for identifying discharge needs, coordinating with nursing, therapy, HH, Resident 1, and family, arranging caregiver education, and ensuring all services and supplies were in place before discharge. The SSA stated these processes were not completed for Resident 1. The SSA also stated that the facility did not routinely conduct formal IDT discharge planning meetings and relied on informal communication among staff/ The SSA stated HH should have received Resident 1's FS, physician orders, H&P, discharge summary, pro9gress notes, rehabilitation notes, and other documents as requested for continuum of care however, she acknowledged she only faxed HH order on 7/15/26 and the revised bolus TF order on 7/16/26 after Resident 1 had already discharged home. The SSA stated she had no documentation identifying what records were transmitted and only retained fax confirmation reports showing that only 2 pages were sent on each date. On 7/22/26 a record review was conducted on Resident 1's clinical chart with diet orders that included an order for TF started 6/3/26 .Enteral [into the stomach] Feed Order every shift TUBE FEEDING FORMULA: Fibersource HN [TF brand] @ [at] 60 [milliliters]/HR [hour] x 20 HRS, TV [total volume] 1200 ML (1440 kcal [kilocalories], 65 g [gram] pro [protein], 972 ml free water). and 6/23/26 .Enteral Feed Order every shift TUBE FEEDING FORMULA: Fibersource HN@ 60 ML/HR x 15 HRS, TV 900 ML (1080 kcal, 49g pro, 729 ml free water). On 7/22/26 a record review was conducted on Resident 1's clinical chart that included an order started on 7/17/26 (day after discharge) that indicated, .Bolus Feeding: Fiber source HN [TF Brand] 225 ml via g-tube [gastrostomy tube-is a soft, flexible tube placed through a small hole in the belly directly into the stomach to deliver liquid food, fluids, and medicines]. On 7/22/26 a record review was conducted on Resident 1's clinical chart. There was no records to indicate that FS, POS, progress notes, discharge summaries, special instructions, AD, rehab notes and H&P notes for continuum of care was sent to the HH. On 7/22/26 at 11:18 A.M., an interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated the facility discharged Resident 1 with orders for continuous TF and failed to obtain and communicate the revised bolus TF until after Resident 1 had already returned home. The ADON stated the facility did not order the required Kangaroo pump before discharge and acknowledged Resident 1'/s daughter contacted the facility upset because Resident 1 missed her scheduled morning TF due to the lack of equipment. The ADON stated Resident 1 had poor oral intake during her stay and relied on TF to meet her nutritional needs. The ADON stated that delaying TF placed Resident 1at risk for continued nutritional decline, weight loss, and worsening health status. On 7/22/26 at 11:34 A.M., an interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 1 had a G-tube and confirmed Resident1 's two daughters received instructions on administrating TF using the Kangaroo pump, syringe (a device used to inject fluids into or withdraw them from the body), and return demonstration before discharge but not for the TF bolus feed. LN 1 acknowledged the discharge care plan was not updated or individualized to reflect Resident 1's TF regimen, caregiver education, equipment needs, or specific discharge instructions and was essentially the same as the other sampled residents' (Resident 4 and Resident 5) discharge care plans. LN 1 stated an individualized discharge care plan is necessary to communicate Resident 1's specific health and safety needs, guide caregivers after discharge, promote continuity of care, and reduce the risk of re-hospitalization and further health decline. On 7/22/26 at 11:41 A.M., an interview was conducted with LN 2 via telephone. LN 2 stated he provided Resident 1's daughters with education on G-tube carem including recognizing signs and symptoms of infection, verifying tube placement before initiating feedings, checking gastric (stomach) residuals (left over TF fluid), operating the Kangaroo pump for continous TF, and notifying physician when residual volumes exceed 100 ml. LN 2 stated he did not teach Resident 1's daughters how to do a bolus TF because that was the active order at the time of discharge (7/16/26) for continuous TF and not a bolus. LN 2 acknowledged that if a bolus TF order had been received prior to discharge, he would have instructed Resident 1's daughters on the revised feeding method. LN 2 stated missing prescribed TF could place Resident 1, who had poor oral intake and depended on TF for nutrition, at risk for weight loss, nutritional decline, and worsening health status. On 7/22/26 12:14 PM ADON an interview and record review was conducted with the ADON. The ADON reviewed Resident 1's discharge care plan (along with Resident 4 and Resident 5) and acknowledged the discharge care plans were generic, contained copied information, and were not individualized to reflect each resident's (Resident 1, Resident 4 and Resident 5) specific discharge needs. The ADON stated discharge planning begins on admission and discharge care plan should be updated throughout a resident's (all facility residents) stay to communicate the resident's (all facility residents)stay to communicate resident's (all facility residents) individualized needs to the IDT, all residents, family, caregivers, and post discharge providers. The ADON stated an individualized discharge care plan is necessary to coordinate services, identify required equipment, provide caregiver education, promote continuity of care, reduce the risk of rehospitalization, and prevent further heath decline. The ADON stated that Resident 1's revised order for the bolus TF was not discussed or provided education to Resident 1's daughters upon discharge. The ADON stated Resident 1 left the facility without a Kangaroo pump and had to miss her feeding because of the lack of equipment to administer the discharge TF instructions. The ADON stated that Resident 1's discharge process did not ensure Resident 1's discharge plan, physician orders, caregiver education, and necessary equipment were coordinated and implemented before discharge. On 7/22/26 at 12:29 P.M., an interview and record review was conducted with the Social Services Director (SSD). The SSD stated the facility's discharge care plans were not consistently revised or individualized to reflect residents' (all facility residents) specific discharge needs. The SSD stated the IDT had not conducted routine discharge planning meeting since her employment began 6 months earlier and admitted that discharge care plans for (Resident 1, Resident 4 and Resident 5) contained generic, copied information rather than resident-specific discharge interventions. The SSD stated effective discharge planning requires advance coordination among nursing, therapy, social services, physicians, residents (all facility residents) and caregivers to identify equipment needs, arrange DME, coordinate medications and supplies, address psychosocial concerns, and ensure a safe transition to the discharge location. The SSD stated these processes were intended to prevent complications, avoid rehospitalization, and promote continuity of care. On 7/22/26 at 12:36 P.M., an interview and record review was conducted with the Social Services Director (SSD) specifically for Resident 1. The SSD stated the facility knew before discharge that Resident 1 required TF's and HH services; however, the facility failed to arrange the required Kangaroo pump before discharge. The SSD stated it wasw the facility's responsibility to coordinate with the HH agency for obtaining the feeding pump (Kangaroo pump) and admitted the facility should have ordered the equipment before Resident 1 returned home. The SSD stated the facility mistakenly assumed Resident 1's daughter or the HH agency would arrange the feeding pump, resulting in Resident 1 missing prescribed TF after discharge because the equipment was not ordered and unavailable to function Resident 1's continuous TF orders. The SSD further stated the facility cannot assume another provider will coordinate essential discharge equipment or services and stated that failure to provide the required feeding pump and coordinate discharge services placed Resident 1 at risk for interrupted nutrition, weight loss, worsening health status, and re-hospitalization. On 7/29/26 at 10:25 A.M., an interview was conducted via telephone with Resident 1's FM. FM stated the HH agency had still not received Resident 1's clinical records from the facility needed to provided ongoing care. FM stated the HH agency planned to contact the facility directly to request for missing records necessary for continuity of care. RM stated the delay in transmitting Resident 's clinical information continued after discharged and interfered with coordination of Resident 1's post-discharge services. A review of the facility's policy and procedure titled, Discharge Summary and Plan dated March 2025, indicated The discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and the representative to develop interventions to meet the resident's discharge goals and needs that must be addressed before the resident can be safely discharged (e.g., caregiver support and education, rehabilitation, etc.) . Discharge planning identifies the discharge destination, and ensures that it meets the resident's health and safety needs, as well as preferences.c. needed medical and non-medical services (including medical equipment).

Based on interview and record review, the facility failed to coordinate a safe and effective discharge for one for five sampled residents (Resident 1) by ensuring caregivers received education on prescribed tube feeding (TF-way to give liquid food, water, and medicine directly into the stomach or small intestine through a soft plastic tube when a person cannot safely chew or swallow), providing necessary equipment for TF feeding pump (machine used to deliver tube feedings) before discharge, communicating updated physician orders to the receiving Home Health Agency (HHA), and transferring complete clinical information necessary for continuity of care.These deficient practices placed Resident 1 at risk for interruption of prescribed TF feedings, inadequate nutrition, weight loss, dehydration, worsening health status, delayed continuity of care, and avoidable rehospitalization. Cross Reference F627 and F656. Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body)/Hemiparesis weakness on one side of the body) following cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain). A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 6/2/26 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 7 points out of 15 possible points which indicated Resident 1 had severe cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 7/22/26 at 8A.M., an interview with Resident 1's Family Member (FM) was conducted via telephone. FM stated that the facility had discharged her mother (Resident 1) without a Kangaroo (a portable medical machine used to feed liquid nutrition and water directly into a person's stomach or small intestine through a feeding tube ) pump that was necessary to give Resident 1 her nutritional needs via tube feeding. FM stated she gave the Social Services Assistant (SSA) the number to call for the home health (HH) company to include needing an order for the TF and to notify them that they did not get a Kangaroo pump and it needed to be ordered prior to the day of discharge. FM stated her mother (Resident 1) did not receive her TF the following day at home after discharge and went without nutrition when it was supposed to be hung in the morning (8AM-9AM). FM stated that her sister went back to the facility the next day ([DATE]) which they gave her 3-4 feeding solutions with tubing without no pump and an updated order for a bolus (a way to give liquid food or formula through a feeding tube like a meal, using a large syringe several times a day) instead of continuous feeding via the Kangaroo pump. FM stated she and her sister did not get any instructions and/or special training to administer a bolus feed. FM stated she thought the facility was going to give her sister a Kangaroo pump but instead gave her protein shakes and TF supplies without the Kangaroo pump, however Resident 1 did not want to eat or drink anything and went without her nutritional intake. FM stated about noon that day ([DATE]) they received a fax from the facility with the order for the bolus feed to be given every four hours. FM stated they (HH, FM and FM sister) requested for other documents (no H&P, no face sheet, no discharge care plan, no advanced directive (AD-a legal document indicating resident preference on end-of-life treatment decisions) , no progress notes, no discharge summary, & no special instructions or precautions for ongoing care for TF or wounds. FM stated she nor her sister was taught how to administer TF via bolus and only was taught using the Kangaroo pump upon discharge. On 7/22/26 at 8:22 A.M., an interview with the HH Registered Nurse (HHRN) conducted via telephone (HHRN was at Resident 1's residence at the time of the interview). The HHRN stated the facility discharged Resident 1 without ensuring a safe transition of care. The HHRN stated the facility faxed only a HH physical (PT) and occupational (OT) order on the afternoon of the discharge ([DATE]). The HHRN stated the following day ([DATE]), she only received an order for the TF bolus that was changed from the original discharge orders for continuous feeding. The HHRN stated she did not receive Resident 1's History and Physical (H&P), face sheet (FS), discharge summary, discharge care plan, AD, progress notes, or instructions for ongoing TF and wound management. The HHRN stated Resident 1 arrived home without the required feeding pump, the family had not been instructed on how to administer the prescribed bolus TF, and Resident 1 was unable to receive the ordered nutrition because the necessary equipment (Kangaroo pump) and complete discharge information had not been provided. On 7/22/26 at 9:48 A.M., an interview and record review was conducted with the SSA. The SSA stated she initiated Resident 1's discharge care plan on 6/2/26 but failed to update and individualize the care plan before discharge to reflect Resident 1's discharge destination, caregiver support, TF needs, required durable medical equipment (DME), and ongoing services. The SSA stated the discharge care plan was not personalized and should have been revised to identify Resident 1's return home with her daughter and son, Resident 1's prescribed TF regimen, caregiver education needs, and equipment necessary for a safe discharge. The SSA stated the facility failed to order the required Kangaroo Pump before discharge, despite knowing Resident 1's nutritional needs. The SSA admitted she forgot to order the feeding pump and left TF education to nursing without confirming with Resident 1's family had been instructed before discharge. The SSA stated Resident 1's daughter later reported that Resident 1's feeding was delayed because the feeding pump had not been provided. The SSA further stated that the interdisciplinary team (IDT- a group of different experts, such as doctors, therapists, nurses and social workers, who work closely together) was responsible for identifying discharge needs, coordinating with nursing, therapy, HH, Resident 1, and family, arranging caregiver education, and ensuring all services and supplies were in place before discharge. The SSA stated these processes were not completed for Resident 1. The SSA also stated that the facility did not routinely conduct formal IDT discharge planning meetings and relied on informal communication among staff/ The SSA stated HH should have received Resident 1's FS, physician orders, H&P, discharge summary, pro9gress notes, rehabilitation notes, and other documents as requested for continuum of care however, she acknowledged she only faxed HH order on 7/15/26 and the revised bolus TF order on 7/16/26 after Resident 1 had already discharged home. The SSA stated she had no documentation identifying what records were transmitted and only retained fax confirmation reports showing that only 2 pages were sent on each date. On 7/22/26 a record review was conducted on Resident 1's clinical chart with diet orders that included an order for TF started 6/3/26 .Enteral [into the stomach] Feed Order every shift TUBE FEEDING FORMULA: Fibersource HN [TF brand] @ [at] 60 [milliliters]/HR [hour] x 20 HRS, TV [total volume] 1200 ML (1440 kcal [kilocalories], 65 g [gram] pro [protein], 972 ml free water). and 6/23/26 .Enteral Feed Order every shift TUBE FEEDING FORMULA: Fibersource HN@ 60 ML/HR x 15 HRS, TV 900 ML (1080 kcal, 49g pro, 729 ml free water). On 7/22/26 a record review was conducted on Resident 1's clinical chart that included an order started on [DATE] (day after discharge) that indicated, .Bolus Feeding: Fiber source HN [TF Brand] 225 ml via g-tube [gastrostomy tube-is a soft, flexible tube placed through a small hole in the belly directly into the stomach to deliver liquid food, fluids, and medicines]. On 7/22/26 a record review was conducted on Resident 1's clinical chart. There was no records to indicate that FS, POS, progress notes, discharge summaries, special instructions, AD, rehab notes and H&P notes for continuum of care was sent to the HH. On 7/22/26 at 11:18 A.M., an interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated the facility discharged Resident 1 with orders for continuous TF and failed to obtain and communicate the revised bolus TF until after Resident 1 had already returned home. The ADON stated the facility did not order the required Kangaroo pump before discharge and acknowledged Resident 1'/s daughter contacted the facility upset because Resident 1 missed her scheduled morning TF due to the lack of equipment. The ADON stated Resident 1 had poor oral intake during her stay and relied on TF to meet her nutritional needs. The ADON stated that delaying TF placed Resident 1at risk for continued nutritional decline, weight loss, and worsening health status. On 7/22/26 at 11:34 A.M., an interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 1 had a G-tube and confirmed Resident1 's two daughters received instructions on administrating TF using the Kangaroo pump, syringe (a device used to inject fluids into or withdraw them from the body), and return demonstration before discharge but not for the TF bolus feed. LN 1 acknowledged the discharge care plan was not updated or individualized to reflect Resident 1's TF regimen, caregiver education, equipment needs, or specific discharge instructions and was essentially the same as the other sampled residents' (Resident 4 and Resident 5) discharge care plans. LN 1 stated an individualized discharge care plan is necessary to communicate Resident 1's specific health and safety needs, guide caregivers after discharge, promote continuity of care, and reduce the risk of re-hospitalization and further health decline. On 7/22/26 at 11:41 A.M., an interview was conducted with LN 2 via telephone. LN 2 stated he provided Resident 1's daughters with education on G-tube carem including recognizing signs and symptoms of infection, verifying tube placement before initiating feedings, checking gastric (stomach) residuals (left over TF fluid), operating the Kangaroo pump for continous TF, and notifying physician when residual volumes exceed 100 ml. LN 2 stated he did not teach Resident 1's daughters how to do a bolus TF because that was the active order at the time of discharge ([DATE]) for continuous TF and not a bolus. LN 2 acknowledged that if a bolus TF order had been received prior to discharge, he would have instructed Resident 1's daughters on the revised feeding method. LN 2 stated missing prescribed TF could place Resident 1, who had poor oral intake and depended on TF for nutrition, at risk for weight loss, nutritional decline, and worsening health status. On 7/22/26 12:14 PM ADON an interview and record review was conducted with the ADON. The ADON reviewed Resident 1's discharge care plan (along with Resident 4 and Resident 5) and acknowledged the discharge care plans were generic, contained copied information, and were not individualized to reflect each resident's (Resident 1, Resident 4 and Resident 5) specific discharge needs. The ADON stated discharge planning begins on admission and discharge care plan should be updated throughout a resident's (all facility residents) stay to communicate the resident's (all facility residents)stay to communicate resident's (all facility residents) individualized needs to the IDT, all residents, family, caregivers, and post discharge providers. The ADON stated an individualized discharge care plan is necessary to coordinate services, identify required equipment, provide caregiver education, promote continuity of care, reduce the risk of rehospitalization, and prevent further heath decline. The ADON stated that Resident 1's revised order for the bolus TF was not discussed or provided education to Resident 1's daughters upon discharge. The ADON stated Resident 1 left the facility without a Kangaroo pump and had to miss her feeding because of the lack of equipment to administer the discharge TF instructions. The ADON stated that Resident 1's discharge process did not ensure Resident 1's discharge plan, physician orders, caregiver education, and necessary equipment were coordinated and implemented before discharge.On 7/22/26 at 12:29 P.M., an interview and record review was conducted with the Social Services Director (SSD). The SSD stated the facility's discharge care plans were not consistently revised or individualized to reflect residents' (all facility residents) specific discharge needs. The SSD stated the IDT had not conducted routine discharge planning meeting since her employment began 6 months earlier and admitted that discharge care plans for (Resident 1, Resident 4 and Resident 5) contained generic, copied information rather than resident-specific discharge interventions. The SSD stated effective discharge planning requires advance coordination among nursing, therapy, social services, physicians, residents (all facility residents) and caregivers to identify equipment needs, arrange DME, coordinate medications and supplies, address psychosocial concerns, and ensure a safe transition to the discharge location. The SSD stated these processes were intended to prevent complications, avoid rehospitalization, and promote continuity of care. On 7/22/26 at 12:36 P.M., an interview and record review was conducted with the Social Services Director (SSD) specifically for Resident 1. The SSD stated the facility knew before discharge that Resident 1 required TF's and HH services; however, the facility failed to arrange the required Kangaroo pump before discharge. The SSD stated it wasw the facility's responsibility to coordinate with the HH agency for obtaining the feeding pump (Kangaroo pump) and admitted the facility should have ordered the equipment before Resident 1 returned home. The SSD stated the facility mistakenly assumed Resident 1's daughter or the HH agency would arrange the feeding pump, resulting in Resident 1 missing prescribed TF after discharge because the equipment was not ordered and unavailable to function Resident 1's continuous TF orders. The SSD further stated the facility cannot assume another provider will coordinate essential discharge equipment or services and stated that failure to provide the required feeding pump and coordinate discharge services placed Resident 1 at risk for interrupted nutrition, weight loss, worsening health status, and re-hospitalization. On 7/29/26 at 10:25 A.M., an interview was conducted via telephone with Resident 1's FM. FM stated the HH agency had still not received Resident 1's clinical records from the facility needed to provided ongoing care. FM stated the HH agency planned to contact the facility directly to request for missing records necessary for continuity of care. RM stated the delay in transmitting Resident 's clinical information continued after discharged and interfered with coordination of Resident 1's post-discharge services. A review of the facility's policy and procedure titled, Discharge Summary and Plan dated March 2025, indicated .The discharge summary provides necessary information for continuing care providers pertaining to the course of treatment while the resident was in the facility and the resident's plans for care after discharge. 3. By the time the resident leaves the facility, the discharge summary is furnished to the provider who is assuming responsibility for care of the resident after discharge The discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and the representative to develop interventions to meet the resident's discharge goals and needs that must be addressed before the resident can be safely discharged (e.g., caregiver support and education, rehabilitation, etc.). 4. The discharge plan is based on the resident assessment, the goals for care, the desire for discharge andthe resident's capacity for discharge. 5. Discharge planning identifies the discharge destination, and ensures that it meets the resident's health and safety needs, as well as preferences.c. needed medical and non-medical services (including medical equipment).

Based on interview and record review, the facility failed to complete a comprehensive person-centered discharge care plan for one of five sampled residents (Resident 2) within the required timeframe following the comprehensive assessment and failed to develop, implement, or revise Resident 2's discharge care plan before discharge.These deficient practices placed Resident 2 at risk for inadequate discharge planning, poor communication among the Intradisciplinary Team (IDT- a group of different experts, such as doctors, therapists, nurses and social workers, who work closely together) and post-discharge providers, interruption of needed services, and avoidable health decline or re-hospitalization. Findings:A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included history of Diabetes Mellitus Type II (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A record review of Resident 2's minimum data set (MDS - a federally mandated resident assessment tool) dated 2/17/26 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 2 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 7/22/26 at 10:24 A.M., an interview and record review was conducted with the Social Service Assistant (SSA). The SSA stated that Resident 2 did not have a discharge care plan and acknowledged that one was never developed during Resident 2's stay at the facility. The SSA stated discharge planning should begin upon admission and the discharge care plan should have been initiated when Resident 2 was admitted to the facility. The SSA stated the IDT was actively seeking placement for Resident 2; however, Resident 2's care plan was never developed to identify Resident 2's discharge goals, anticipated discharge location, ongoing placement needs, or services required after discharge. The SSA stated the discharge care plan should have been updated throughout Resident 2's stay and finalized before discharge to ensure continuity of care and a safe transition to the assisted living facility that Resident 2 was discharged to. On 7/22/26 at 11:34 A.M., an interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 2 did not have a discharge care plan. LN 2 stated the discharge care plan should have been initiated within 48 hours of admission and revised throughout Resident 2's stay to reflect Resident 2's individualized discharge needs. LN 2 stated an individualized discharge care plan is necessary to communicate Resident 2's healthcare needs, coordinate discharge services, promote continuity of care, and reduce the risk of rehospitalization and health decline. On 7/22/26 at 12:14 P.M., an interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated we didn't even have a discharge care plan in place when it should have. Discharge care plans are needed to ensure safe and orderly discharges to prevent further health decline and safety. On 7/22/26 at 12:29 P.M., an interview and record review was conducted with the Social Services Director (SSD). The SSD stated Resident 2 did not have a discharge care plan and acknowledged the facility failed to initiate one within the required timeframe. The SSD stated discharge planning should beg8ni on admission and be revised on a continuous basis throughout Resident 2's stay to reflect Resident 2's individual needs. The SSD stated the discharge care plan is intended to identify and coordinate medications, Durable Medical Equipment (DME), social services needs, discharge goals, and the responsibilities of the IDT to ensure a safe transition to the discharge location. The SSD stated that without a timely, individualized discharge care plan, important discharge needs could be missed, resulting in poor coordination of care, delays in necessary services, or equipment, complications after discharge, and an increased risk of hospitalization. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-centered dated March 2022, indicated .The comprehensive person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment(Admission, Annual or Significant Change in Status), and no more than 21 days after admission.

Based on observations, interviews, and record reviews, the facility failed to develop a comprehensive, person-centered care plan to address the resident's need for a Hoyer lift for transfers for one of one sampled residents (Resident 6) reviewed for transfer assistance. This failure led to inconsistent transfer practices for Resident 6. Findings:A review of Resident 6's admission record indicated Resident 6 was readmitted to the facility on [DATE] with diagnosis that included muscle weakness, spinal stenosis (the narrowing of the spaces inside your backbone, which pinches your spinal cord and nerves) and obesity (unhealthy amount of excess body fat.)A review of Resident 6's care plan did not indicate the use of a Hoyer lift.On 7/13/26 at 9:40 A.M., an observation and interview was conducted with Resident 6 in her room. Resident 6 was lying supine (lying flat on your back, facing upward) with head of bed elevated and her overbed table positioned in front of her. Resident 6 stated that staff use a Hoyer lift to transfer her from the bed to the shower chair on her scheduled shower days. On 7/14/26 at 8:20 A.M., an interview was conducted with certified nurse assistant (CNA) 1. CNA 1 stated Resident 6 preferred to use a Hoyer lift for transfers from the bed to the shower chair. CNA 1 stated she received this information from physical therapy.On 7/15/26 at 8:50 A.M., an interview and record review was conducted with Rehabilitation Director (RD). The RD stated Resident 6 preferred to transfer from the bed to the shower chair using a Hoyer due a to fear of falling. On 7/15/26 at 9:11 A.M., an interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON reviewed Resident 6's care plan and stated there was no care plan regarding the use of the Hoyer lift, that required two-person assistance. The ADON stated a care plan should have been in place to ensure Resident 6 was transferred safely.On 7/15/26 at 10:24 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated a care plan should be developed for residents who use a Hoyer lift. The DON stated because it was a durable medical equipment (DME), it should be care-planned to ensure patient safety.A review of the facility care plan policy titled Care Plan, Comprehensive, Person-Centered, revised March 2022, indicated .4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care

Based on interviews and record review, the facility failed to follow through on a physician's order for a hospice (special medical care for people facing a terminal illness) evaluation for one of three residents (Resident 94) reviewed for a close record. This failure had the potential to delay appropriate care for Resident 94. Findings: Per the facility's admission record, Resident 94 was admitted to the facility on [DATE] with diagnoses that included human immunodeficiency virus (HIV - a virus that attacks the body's immune system, specifically the white blood cells that fight off infections). On [DATE], at 9:45 A.M., a concurrent interview and record review was conducted with the social services director (SSD). A review of Resident 94's physician's orders indicated that hospice evaluations were ordered on [DATE] and [DATE]. Further review of Resident 94's clinical records indicated there was no follow-through regarding these hospice evaluations. As a result, the physician's orders for hospice evaluations were not carried out before Resident 94's death on [DATE]. The SSD stated that hospice evaluations should be done within 24 to 48 hours of being ordered by a physician to ensure residents can receive the appropriate care they need. On [DATE], at 11:50 A.M., a concurrent interview and record review of Resident 94's clinical record was conducted with the director of nursing (DON). The DON stated that the hospice evaluation orders should have been followed through by the staff. The DON stated it was her expectation that all physician orders be done as ordered by the physician to ensure proper and appropriate care can be provided to the residents.

Based on observation, interviews, and record review, the facility failed to measure the external length of peripherally inserted central catheter's (PICC line - a long, thin, flexible tube that delivers treatments through a vein) for one resident (16) during dressing changes.This failure had the potential for Resident 16 to result in intravenous (IV- medical method used to send fluids, medicines, or nutrition directly into a person's bloodstream through a tube) therapy complication. Findings: Per the facility's admission record, Resident 16 was admitted to the facility on [DATE] with diagnoses that included left foot and ankle osteomyelitis (bone infection). On 7/12/26, at 9:50 A.M., a concurrent observation and interview was conducted with Resident 16 in his room. Resident 16 was observed to have a right upper arm PICC line. Resident 16 stated it was used for his IV antibiotics. When asked about the dressing changes, Resident 16 stated he cannot remember if the licensed nurse (LN) measures his arm or the external catheter. On 7/13/26, at 10:20 A.M., a concurrent interview and record review was conducted with the assistant director of nursing (ADON) of Resident 16's clinical records. A review of Resident 16 IV medication administration record (MAR - a legal document that tracks medications and treatments given to a patient) indicated Resident 16's PICC line's external catheter was not measured 6/18/26. 6/21/26 and on 7/5/26 during dressing changes. The ADON stated that the external length of the PICC line must be measured to ensure it was intact and the catheter was in the right place for the resident safety. On 7/14/26, at 11:00 A.M., an interview was conducted with the director of nursing (DON). The DON stated it was her expectation that the LNs measure the external length of the PICC lines during all dressing changes. The DON stated it was important to ensure the resident's IV medications were administered safely. A review of the facility policy titled Vascular Access Devices and Infusion Therapy Procedures (PICC), dated 10/24, indicated that the facility must .Measure external length of PICC catheter .with each dressing change .

Based on interviews and record review, the facility failed to manage Resident (55) pain when licensed nurse (LN 11) did not reassess Resident 55's pain after administering pain medication. This failure had the potential for Resident 55's pain to be unrelieved and not managed properly. Findings:Per the facility's admission record, Resident 55 was admitted to the facility on [DATE] with diagnoses that included bladder cancer.On 7/14/26, at 10:13 A.M., a concurrent interview and record review of Resident 55's clinical record was conducted with LN 11. According to Resident 55's progress notes, on 7/7/26 at 7:05 P.M., LN 11 administered Acetaminophen (a common medicine used to lower fevers and relieve minor aches and pains) for 10/10 (pain scale that indicates the absolute worst, most agonizing pain you can imagine) pain on his lower abdomen. LN 11 stated she did not reassess Resident 55's pain, but she should have. LN 11 stated that it was important to reassess a resident's pain after administering pain medications to ensure the pain has been relieved.On 7/15/26, at 11:00 A.M., an interview was conducted with the director of nursing (DON). The DON stated that it was her expectation that all nurses manage residents' complaints of pain appropriately and that they must reassess the pain to ensure the pain has been controlled.A review of the facility policy titled Pain Assessment and Management, dated Aril 2025, indicated that nurses must .Monitor.to determine if the resident's pain is being adequately controlled.

Based on observation, interview, and record review, the facility failed to follow appropriate infection prevention and control practices when expired food items and food items with no dates were left in a dedicated refrigerator for the residents.This failure had the potential to result in a foodborne illness for an already vulnerable population.Findings: On 7/15/26 at 9:05 A.M., a concurrent observation and interview was conducted with the Assistant Director of Nursing (ADON). The ADON observed the residents refrigerator at the west wing nurses' station. ADON stated foods stored for residents should have a name and a date on the food item and should be discarded after 72 hours. The ADON observed that a 32-ounce container of creamer dated 7/10/26 should have been discarded. The ADON observed a container of undated food that should have been labeled. The ADON stated there should not be any expired foods in the residents' refrigerator. The ADON stated eating expired foods could cause food borne illnesses or create stomach upset like nausea and/or vomiting. 7/15/26 at 10:24 A.M. An interview was conducted with the Director of Nursing (DON). The DON stated her expectations were for all staff to follow the Food Brought by Family or Visitor policy. A review of the facility policy titled Food Brought by Family/Visitors dated 5/28/2025 indicated .8.Containers are labeled with the resident's name, the item and the use by date

Based on interviews and record review, the facility failed to offer the influenza (a highly contagious respiratory illness caused by viruses that infect the nose, throat, and lungs) vaccine (medication that reduces the risk of contracting influenza) to one of five sampled residents (74) reviewed for infection control. This failure had the potential for Resident 74 to contract influenza. Findings: Per the facility admission record, Resident 74 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD - a long-term lung disease that makes it hard to breathe). On 7/14/26, at 11:00 A.M., a concurrent interview and record review of Resident 74's clinical record was conducted with the infection preventionist nurse (IPN). A review of Resident 74's immunization record indicated that the influenza vaccine was not offered or given for the 2025 -2026 flu season (the yearly time-between December and February, mostly fall and winter-when the contagious lung and throat illness called influenza spreads easily). The IPN stated the influenza vaccine should have been offered to all residents. On 7/15/26, at 11:15 A.M., an interview was conducted with the director of nursing (DON). The DON stated that it was her expectation that all residents be offered the influenza vaccine. The DON stated this was important to prevent outbreaks among highly vulnerable elderly residents and to reduce severe illness. A review of the facility policy titled Influenza Vaccine, dated 08/2025, stated that Between October 1st and March 31st each year, the influenza vaccine is offered to residents .

Based on interview and record review, the facility failed to develop a care plan to protect Resident 1 from further claims of lost personal funds when the resident alleged his cash was stolen from his personal locked safe.As a result, Resident 1 was potentially exposed to feeling decreased sense of security.Findings:On 5/5/26 at 12:25 P.M., an onsite investigation was conducted to investigate a Facility Reported Incident (FRI) regarding an alleged stolen cash of $3000 from Resident '1 personal safe. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with PTSD (Post-Traumatic Stress Disorder - a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening event). A review of Resident 1's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated 3/5/26, indicated the resident's BIMS (Brief Interview for Mental Status) was 15 out of 15, indicating the resident was cognitively intact (no memory, focus, or judgment issues).On 5/5/26 at 1:10 P.M., an observation and interview were conducted with Resident 1. The resident was observed sitting at the edge of the bed, eating lunch. Resident 1 stated he had lost cash a few times at the facility and this time. In response, the facility provided a personal safe with a lock and key for his room. However, despite multiple offers and education from staff about the risks of keeping cash on hand, Resident 1 adamantly refused to use the facility's safe, stating that he did not trust anyone with his money. After receiving his personal safe, Resident 1 stated he went to the bank to withdraw his money and placed them in the safe. Resident 1 pointed out a black box located on the floor between his nightstand and his bed and explained he hid the safe in the nightstand and kept the key in an open-top glass pouch. Resident 1 stated he could not find his key to the safe and discovered the safe was open and empty. Resident 1 stated that this time, he had $2,500 in cash stolen, adding to two previous thefts at the facility. Resident 1 repeatedly stated that he did not trust anyone with his money, yet he did not keep a record of the amount of money kept in his safe. Resident 1 stated stated he could not remember how much money he withdrew prior to placing the cash in his safe or which date he withdrew the money. On 5/5/26 at 2:08 P.M., an interview was conducted with the Certified Nursing Assistant (CNA). The CNA stated he would accompany Resident 1 to his bank to withdraw money using Uber as their transportation. The CNA stated he did not have the knowledge of how much money Resident 1 withdrew each time they visited the bank. The CNA stated the facility's policy for personal funds was to keep it in the facility's safe or to send it home with the family. On 5/5/26 at 3:33 P.M., an interview was conducted with the ADM and the Director of Nursing (DON). The ADM stated Resident 1 was very skeptical of others and would not even let the housekeeping clean his room without his presence. The ADM stated Resident 1 refused to put his money in the facility's safe or count it after returning from the bank, despite multiple educational efforts and being informed of the risks of losing the money. The ADM stated the facility decided to utilize the personal safe for Resident 1 since the resident reported he had lost his cash a few times at the facility but continued to refuse to use the facility's safe. A review of Resident 1's care plan Resident prefer to keep his money and decline to keep it in the safe dated 2/17/26 indicated, Continue to Offer to use safe at social services office to keep his money Reeducate resident to risk and consequences of keeping money at bedside. No other care plans were found regarding his personal funds, including his visits to the bank and inventory of the money he withdrew, and his use of the personal safe. On 5/6/26 at 10:37 A.M., an interview and record review was conducted with the Assistant Social Worker (ASW). After reviewing Resident 1's care plans, the ASW stated she failed to develop Resident 1's personalized care plan surrounding his personal funds. The ASW stated the care plan should have been more specific and personalized because she was aware that Resident 1 made trips to the bank to withdraw his money with the CNA, the resident's refusal to count the money and use the facility's safe after his bank visits, and the presence of his personal safe. On 5/6/26 at 10:50 A.M., an interview and record review was conducted with the Licensed Nurse (LN). The LN reviewed Resident 1's care plan. The LN stated the facility should have developed a clear care plan for Resident 1's money withdrawals, inventory of the money, and use of the safe. On 5/6/26 at 11:10 A.M., an interview was conducted with the DON and the ADM. The ADM and the DON acknowledged that the facility did not develop personalized care plans for Resident 1 regarding the use of the personal safe and the expectations surrounding its use, a clear process of Resident 1's trip to the bank with the CNA, and a protocol for after the resident returns with the money from the bank. The DON stated those should have been developed as part of Resident 1's care plan.A review of facility's policy titled Personal Property revised August 2022, did not indicate protection plan for residents after they encounter accidents while out on pass. A review of facility's policy titled Care Plans, Comprehensive Person-Centered revised March 2022, indicated, .1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review, the facility failed to ensure staff adhered to infection prevention and control practices for one of three sampled residents (Resident 2) when:Resident 2's urinary catheter and tubing (a flexible, hollow tube inserted into the bladder to drain and collect urine) was touching the floor and was not placed inside the catheter bag (fabric bag used to conceal urinary collection bag). This failure had the potential for cross-contamination (spread of germs and bacteria) and posed an infection to residents, staff, and visitors.Findings:A review of admission Record for Resident 2 indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis that included Acute Kidney Failure (kidneys suddenly can't filter waste products from the blood). During a facility tour on 4/29/26 at 11:10 A.M., Resident 2 was observed inside the room with a Foley catheter drainage bag touching the floor beside the bed where it remained for an undetermined amount of time. On 4/29/26 at 11:50 A.M., an observation and interview was conducted with Certified Nurse Assistant (CNA 1) in Resident 2's room. CNA 1 stated the Foley catheter, and tubing should not touch the floor and that the urine bag must be placed inside the catheter bag. CNA 1 stated this was to prevent infections to the resident. On 4/29/26 at 2:25 P.M., an interview with an Infection Preventionist (IP) was conducted. The IP stated Foley catheters should be hung on the low side of the residents' bed and not touch the floor. The IP stated the urine bag should be placed inside a catheter bag. The IP stated his expectation was for all nursing staff to adhere to infection control practices. On 4/29/26 at 4:30 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated Foley catheters should never touch the floor and should be maintained in urine catheter bag to prevent cross-contamination. The DON stated her expectations was for nursing staff to strictly adhere to infection control practices. A review of the facility's policy titled Catheter Care, Urinary, dated 2001, indicated .2. Be sure the catheter tubing and drainage bag are kept off the floor

Deficient Practice StatementBased on observation, interview, and record review, the facility failed to ensure staff report an allegation of financial abuse one of two residents (Resident 1) reviewed for abuse. As a result, Resident 1's report of stolen money was not reported to the Department in a timely manner, which delayed the investigation. Findings:On 8/15/25 at 11:52 A.M., The department received a complaint regarding Resident 1's money for the amount of $ 4700 dollars stolen by an unknown certified nursing assistant (CNA) and that the facility Administrator (ADM) told Resident 1 the facility was not responsible.On 8/15/25 a review of the Facility's admission Record (AR) was conducted. The facility AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included Aftercare following Joint Replacement.On 8/21/25 at 12 noon, an interview with Resident 1 was conducted. Resident 1 stated he took out his $ 3200 dollars total in large $100 bills from the business office on 5/30/25 and signed the document. Resident 1 stated it was his lifelong money from social security and that he wanted it back. Resident 1 stated he told the Administrator (ADM) on 8/7/25 that the money was missing from his room. Resident 1 stated he wondered why the investigation on the missing money was just started on 8/21/25 when Resident 1 had reported the money missing on 8/7/25. Resident 1 stated when he came back to his room, he found his bedding and everything on his bed, all tossed away.On 8/21/25, A review of Resident 1's Minimum Data Set (MDS - a federally mandated assessment tool) dated 6/2/25, indicated a brief interview for mental status (BIMS) score of 11, which indicated Resident 1's cognition (thought process) was mildly impaired. A cognitively intact has a score of 13-15.On 8/21/25 at 1:20 P.M., an interview with the Administrator (ADM) was conducted. The ADM stated, I did not know that we had to report the incident since no one was accused of stealing the money until the surveyor came to the facility and started to investigate, including interviewing Resident 1. The ADM could not provide evidence that the incident was reported to the Department. On 8/21/25 at 1:30 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the facility should have reported any forms of abuse, in a timely manner as required by state laws. On 8/21/25 at 2:18 P.M., a second interview with the DON was conducted. The DON confirmed that the facility reported the incident on 8/21/25. This was 14 days later after Resident 1 had informed the ADM of the allegation. On 8/22/25, A review of the facility's record titled, Investigating Incidents of Theft and/ or Misappropriation of Resident Property dated April 2021, indicated .6. If an alleged or suspected case of theft , exploitation or misappropriation of resident property is reported, the facility administrator , or his designee, notifies the following person or agencies within twenty-four (24 ) hours of such incident as appropriate: a. State licensing & certification agency. A review of the facility's policy dated January 2011 indicated, .2. within 5 working days of the alleged incident, the facility will give the resident, resident representative, the ombudsman, the state survey and certification agency. written report of the findings of the investigation and summary of corrective action.

Based on observation, interview, and record review, the facility staff failed to consistently monitor and document urine output (UO) per the facility's policy, for four of six sampled residents (7, 10, 11 and 12) with a urinary catheter (a tube inserted into the bladder to aid in urine flow). In addition, there was no urinary catheter care order for Residents 7, and 12. These failures had the potential for residents 7, 10, 11 and 12 to have urinary retention and develop urinary tract infection (UTI). Findings: 1a. Resident 7 was readmitted to the facility on [DATE], with diagnoses which included sepsis (a serious condition in which the body responds improperly to an infection), per the facility's Admission Record. Resident 7's attending physician completed Resident 7's history and physical (H & P) dated 2/13/25. The H & P indicated, Resident 7 was not able to make own decisions. On 3/24/25 at 9:32 A.M., an observation and an interview of Resident 7 was conducted in her room. A urinary catheter was attached to Resident 7's wheelchair. Resident 7 stated she was in pain and will go to the nurse's station. A review of the physician's order dated 2/12/25, indicated for the staff to measure Resident 7's urine output for 30 days. On 3/26/25 at 9:53 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 21. CNA 21 stated Resident 7 had a urinary catheter, and one responsibility of the CNAs was to measure residents' urine output. CNA 21 stated the measurement would be in milliliter (ml, metric of measurement) and should be documented in the resident's clinical record. On 3/26/25 at 11:15 A.M., a review of Resident 7's clinical record and an interview was conducted with Licensed Nurse (LN) 23. LN 23 stated Resident 7 was alert with moments of confusion. LN 23 stated Resident 7 had a urinary catheter and Resident 7's urine output should be monitored every shift and documented in her clinical record. LN 23 stated there were missed documentation of urine output for Resident 7 in March 2025: 3/9, 3/14, 3/17 through 3/19, 3/21, and 3/23/25 in the evening shifts. LN 23 stated Resident 7's urine output should have been monitored and documented consistently to ensure she was not retaining urine and prevent UTI. On 3/26/25 at 3:24 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation for residents with urinary catheter was, the nurses should have consistently measured the residents' urine output and documented in the residents' clinical record. The DON stated it was important to identify if the resident was retaining any fluid to prevent resident from acquiring UTI. A review of the facility's policy, titled Catheter Care, Urinary, revised 8/2022, indicated, The purpose of this procedure is to prevent urinary catheter associated complications, including urinary tract infections .Input/ Output, 1. Observe the resident's urine level for noticeable increases or decreases .2. Follow the facility procedure for measuring and documenting .output . A review of the facility's policy, titled Output, Measuring and Recording, revised 10/2010, indicated, The purpose of this procedure is to accurately determine the amount of urine that a resident excretes in a 24-hour period .Steps in the Procedure .8. Record the amount noted on the output side of the .output record. Record in mls . 1b. On 3/24/25 at 9:32 A.M., an observation and an interview of Resident 7 was conducted in her room. A urinary catheter was attached to Resident 7's wheelchair. Resident 7 stated she was in pain and will go to the nurse's station. On 3/26/25 at 9:53 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 21. CNA 21 stated Resident 7 had a urinary catheter, and the responsibility of the CNA was to empty the urine bag. On 3/26/25 at 11:15 A.M., a review of Resident 7's clinical record and an interview was conducted with Licensed Nurse (LN) 23. LN 23 stated Resident 7 was alert with moments of confusion. LN 23 stated Resident 7 had a urinary catheter. LN 23 stated the physician's order indicated to change and irrigate the urinary catheter. There was no catheter care order for Resident 7. On 3/26/25 at 3:24 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation for the residents with urinary catheter was, the nurses should have verified the residents' physician for urinary catheter care order. The DON stated there should be a documentation that catheter care was provided to residents with urinary catheter to prevent infection. The DON stated the expectation was the LNs were responsible to clean the insertion site. A review of the facility's policy, titled Catheter Care, Urinary, revised 8/2022, indicated, The purpose of this procedure is to prevent urinary catheter associated complications, including urinary tract infections .Perineal care, 1. Use soap and water or bathing wipes for routine daily hygiene .Documentation, The following information should be recorded in the resident's medical record, 1. The date and time that catheter care was given . 2. Resident 10 was readmitted to the facility on [DATE], with diagnoses which included UTI, per the facility's Admission Record. Resident 10's attending physician completed Resident 10's history and physical (H & P) dated 2/12/25. The H & P indicated, Resident 10 did not have the capacity to understand and make decisions. On 3/24/25 at 9:36 A.M., an observation of Resident 10 was conducted in her room. Resident 10 laid in bed with eyes closed and did not respond to her name. There was a urinary catheter hanged at Resident 10's bed rails. A review of the physician's order dated 3/4/25, indicated for the staff to measure Resident 10's urine output in mls (milliliter, metric of measurement) every shift for 30 days. On 3/26/25 at 9:41 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 21. CNA 21 stated Resident 10 was confused, had a urinary catheter, and one responsibility of the CNAs was to measure residents' urine output. CNA 21 stated the measurement would be in mls and documented in the resident's clinical record. On 3/26/25 at 11:10 A.M., a review of Resident 10's clinical record and an interview was conducted with Licensed Nurse (LN) 23. LN 23 stated Resident 10 was alert with moments of confusion. LN 23 stated Resident 10 had a urinary catheter and Resident 10's urine output should be monitored every shift and documented in her clinical record. LN 23 stated there were missed documentation of urine output for Resident 10 in March 2025: 3/13, 3/14, 3/18 through 3/21, and 3/24/25 for the whole 24-hour shift. LN 23 stated, in addition, there were missed monitoring and documentation of urine output for Resident 10 in the following dates and shifts. 3/15/25 night shift, 3/16/25 night and morning shifts, 3/17/25 morning and evening shifts, 3/22/25 night and morning shifts, 3/23/25 morning shift, 3/25/25 night and morning shifts, and 3/26/25 night shift. LN 23 stated Resident 10's urine output should have been monitored and documented to ensure she was not retaining urine and prevent UTI. On 3/26/25 at 3:24 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation for residents with urinary catheter was, the nurses should have consistently measured the residents' urine output and documented in the residents' clinical record. The DON stated it was important to identify if the resident was retaining any fluid to prevent resident from acquiring UTI. A review of the facility's policy, titled Catheter Care, Urinary, revised 8/2022, indicated, The purpose of this procedure is to prevent urinary catheter associated complications, including urinary tract infections .Input/ Output, 1. Observe the resident's urine level for noticeable increases or decreases .2. Follow the facility procedure for measuring and documenting .output . A review of the facility's policy, titled Output, Measuring and Recording, revised 10/2010, indicated, The purpose of this procedure is to accurately determine the amount of urine that a resident excretes in a 24-hour period .Steps in the Procedure .8. Record the amount noted on the output side of the .output record. Record in mls . 3. Resident 11 was readmitted to the facility on [DATE], with diagnoses which included sepsis (a serious condition in which the body responds improperly to an infection), per the facility's Admission Record. Resident 11's attending physician completed Resident 11's history and physical (H & P) dated 9/30/24. The H & P indicated Resident 11 was able to make own decisions. On 3/24/25 at 10:13 A.M., an observation and an interview of Resident 11 was conducted in his room. Resident 11 laid in bed watching TV. There was a urinary catheter hanged at Resident 11's bed rails. Resident 11 stated he did not have concerns at the moment. A review of the physician's order dated 3/4/25, indicated for the staff to measure Resident 11's urine output in mls (milliliter, metric of measurement) every shift for 30 days. On 3/26/25 at 9:56 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 21. CNA 21 stated Resident 11 knew what was going on and oriented, had a urinary catheter, and one responsibility of the CNAs was to measure residents' urine output. CNA 21 stated the measurement would be in mls and documented in the resident's clinical record. On 3/26/25 at 11:35 A.M., a review of Resident 11's clinical record and an interview was conducted with Licensed Nurse (LN) 21. LN 21 stated Resident 11 was alert, oriented and knew what was going on. LN 21 stated Resident 11 had a suprapubic catheter (a urinary catheter that is inserted into the bladder from a small cut in your tummy, just above your pubic bone). LN 21 stated Resident 11's urine output should be monitored every shift and documented in his clinical record. LN 21 stated there were missed documentation of urine output for Resident 11 in the following dates and shifts: 2/28/25, 3/2/25, 3/7/25, 3/8/25, 3/12/25, 3/24/25 night shifts, and 3/3/25 evening shift. LN 21 stated the purpose of monitoring the urine output for the resident with urinary catheter was to make ensure the resident did not retain fluids to prevent UTI. LN 21 further stated it was important to know if the catheter was patent. On 3/26/25 at 3:24 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation for residents with urinary catheter was, the nurses should have consistently measured the residents' urine output and documented in the residents' clinical record. The DON stated it was important to identify if the resident was retaining any fluid to prevent resident from acquiring UTI. A review of the facility's policy, titled Catheter Care, Urinary, revised 8/2022, indicated, The purpose of this procedure is to prevent urinary catheter associated complications, including urinary tract infections .Input/ Output, 1. Observe the resident's urine level for noticeable increases or decreases .2. Follow the facility procedure for measuring and documenting .output . A review of the facility's policy, titled Output, Measuring and Recording, revised 10/2010, indicated, The purpose of this procedure is to accurately determine the amount of urine that a resident excretes in a 24-hour period .Steps in the Procedure .8. Record the amount noted on the output side of the .output record. Record in mls . 4a. Resident 12 was readmitted to the facility on [DATE], with diagnoses which included UTI, per the facility's Admission Record. Resident 12's attending physician completed Resident 12's history and physical (H & P) dated 3/5/25. The H & P indicated, Resident 12 can make needs known but could not make medical decisions. On 3/24/25 at 9:27 A.M., an observation and an interview of Resident 12 was conducted in her room. Resident 12 laid in bed watching TV. A urinary catheter was hanged at Resident 12's bed rails. Resident 12 stated she felt good. A review of the physician's order dated 3/3/25, indicated for the staff to measure Resident 12's urine output in mls (milliliter, metric of measurement) every shift for 30 days. On 3/26/25 at 9:34 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 21. CNA 21 stated Resident 12 was alert with period of confusion, had a urinary catheter, and one responsibility of the CNAs was to measure residents' urine output. CNA 21 stated the measurement would be in mls and documented in the resident's clinical record. On 3/26/25 at 11:04 A.M., a review of Resident 12's clinical record and an interview was conducted with Licensed Nurse (LN) 23. LN 23 stated Resident 12 was able to make her needs known. LN 23 stated Resident 12 had a urinary catheter and Resident 12's urine output should be monitored every shift and documented in her clinical record. LN 23 stated there were missed documentation of urine output for Resident 12 in March 2025: 3/3 through 3/7, 3/10 through 3/12, 3/13 through 3/24, 3/17 through 3/21, and 3/24/25 for the whole 24-hour shift. LN 23 stated, in addition, there were missed monitoring and documentation of urine output for Resident 12 in the following dates and shifts. 3/8, and 3/9 night and evening shifts, 3/15, 3/16, 3/22, and 3/25 night and morning shifts, and 3/23 morning shift. LN 23 stated Resident 12's urine output should have been monitored and documented to ensure she was not retaining urine and prevent UTI. On 3/26/25 at 3:24 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation for residents with urinary catheter was, the nurses should have consistently measured the residents' urine output and documented in the residents' clinical record. The DON stated it was important to identify if the resident was retaining any fluid to prevent resident from acquiring UTI. A review of the facility's policy, titled Catheter Care, Urinary, revised 8/2022, indicated, The purpose of this procedure is to prevent urinary catheter associated complications, including urinary tract infections .Input/ Output, 1. Observe the resident's urine level for noticeable increases or decreases .2. Follow the facility procedure for measuring and documenting .output . A review of the facility's policy, titled Output, Measuring and Recording, revised 10/2010, indicated, The purpose of this procedure is to accurately determine the amount of urine that a resident excretes in a 24-hour period .Steps in the Procedure .8. Record the amount noted on the output side of the .output record. Record in mls . 4b. On 3/24/25 at 9:27 A.M., an observation and an interview of Resident 12 was conducted in her room. Resident 12 laid in bed watching TV. A urinary catheter was hanged at Resident 12's bed rails. Resident 12 stated she felt good. On 3/26/25 at 9:34 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 21. CNA 21 stated Resident 12 was alert with period of confusion, had a urinary catheter, and the responsibility of the CNA was to empty the urine bag. On 3/26/25 at 11:04 A.M., a review of Resident 12's clinical record and an interview was conducted with Licensed Nurse (LN) 23. LN 23 stated Resident 12 was able to make her needs known. LN 23 stated Resident 12 had a urinary catheter. LN 23 stated there was no urinary catheter care order for Resident 12. LN 23 stated the wound care nurse (WCN) was responsible for providing the catheter care to the residents with catheter. LN 23 further stated, I don't know how to do that foley (urinary catheter) care. On 3/26/25 at 2:20 P.M., an interview was conducted with the WCN. The WCN stated the LNs who passed medications were responsible in providing catheter care to residents with urinary catheter. On 3/26/25 at 3:24 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation for the residents with urinary catheter was, the nurses should have verified the residents' physician for urinary catheter care order. The DON stated there should be a documentation that catheter care was provided to residents with urinary catheter to prevent infection. The DON stated the expectation was the LNs were responsible to clean the insertion site. A review of the facility's policy, titled Catheter Care, Urinary, revised 8/2022, indicated, The purpose of this procedure is to prevent urinary catheter associated complications, including urinary tract infections .Perineal care, 1. Use soap and water or bathing wipes for routine daily hygiene .Documentation, The following information should be recorded in the resident's medical record, 1. The date and time that catheter care was given . 4b. On 3/24/25 at 9:27 A.M., an observation and an interview of Resident 12 was conducted in her room. Resident 12 laid in bed watching TV. A urinary catheter was hanged at Resident 12's bed rails. Resident 12 stated she felt good. On 3/26/25 at 9:34 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 21. CNA 21 stated Resident 12 was alert with period of confusion, had a urinary catheter, and the responsibility of the CNA was to empty the urine bag. On 3/26/25 at 11:04 A.M., a review of Resident 12's clinical record and an interview was conducted with Licensed Nurse (LN) 23. LN 23 stated Resident 12 was able to make her needs known. LN 23 stated Resident 12 had a urinary catheter. LN 23 stated there was no urinary catheter care order for Resident 12. LN 23 stated the wound care nurse (WCN) was responsible for providing the catheter care to the residents with catheter. LN 23 further stated, I don't know how to do that foley (urinary catheter) care. On 3/26/25 at 2:20 P.M., an interview was conducted with the wound care nurse (WCN). The WCN stated the LNs who passed medications were responsible in providing catheter care to residents with urinary catheter. On 3/26/25 at 3:24 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation for the residents with urinary catheter was, the nurses should have verified the residents' physician for urinary catheter care order. The DON stated there should be a documentation that catheter care was provided to residents with urinary catheter to prevent infection. The DON stated the expectation was the LNs were responsible to clean the insertion site. A review of the facility's policy, titled Catheter Care, Urinary, revised 8/2022, indicated, The purpose of this procedure is to prevent urinary catheter associated complications, including urinary tract infections .Perineal care, 1. Use soap and water or bathing wipes for routine daily hygiene .Documentation, The following information should be recorded in the resident's medical record, 1. The date and time that catheter care was given .

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations, according to standards of practice when: 1. One outdated container of sour cream was not discarded and still stored for use and consumption. 2. Personal clothing items that belonged to staff were hanging on the food container carts. These failures had the potential to expose residents to unsafe and unsanitary food practices that could lead to widespread foodborne illnesses. Findings: 1. On 3/24/25 at 8:19 A.M., a concurrent observation and interview was conducted with the Certified Dietary Manager (CDM). One container of sour cream was labeled with a use by date (when food should be consumed) of 3/22/25. The CDM stated the sour cream container should have been thrown away on or before the use by date to prevent residents from developing any foodborne illness if they consumed food items past the use by date. On 3/25/25 at 10:01 A.M., an interview was conducted with the Registered Dietitian (RD). The RD acknowledged that the sour cream container should have been discarded per label, to avoid using outdated food items. A review of the Food and Drug Administration (FDA; United States (US) government agency that ensures safety of food) 2022 indicated 3-501.18 Ready to Eat, Disposition (A) A food shall be discarded if it . (3) Is inappropriately marked with a date or exceeds a temperature and time 2. On 3/24/25 at 8:28 A.M., a concurrent observation and interview was conducted with the Certified Dietary Manager (CDM). Personal clothing items were observed hanging on the food storage container carts. The CDM stated that personal clothes should have been kept inside the lockers to maintain food safety in the kitchen. An interview was conducted with the Registered Dietitian (RD) on 3/25/25 at 10:07 A.M. The RD acknowledged that all kitchen staff's personal belongings should be kept away from food items and equipment. The facility's policy titled Employee Personal Items dated 2023, indicated, Policy: Personal items brought in by staff from outside will not be kept in the kitchen.

Based on observation, interview, and record review, the facility failed to address resident's needs for one of three sampled residents (Resident 2) when Resident 2's lower denture was not applied during meals. This failure had the potential to affect Resident 2's well-being, comfort, and safety while dining. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses which included a history of dementia (loss of memory), muscle weakness, and communication deficit, per the Admission Record. A review of Resident 2's nursing care plan (NCP; document that outlines the nursing care required for a specific patient) dated 12/21/21, indicated that Resident 2 had upper and lower dentures that needed to be worn during meals, and removed at night. An observation was conducted on 3/24/25 at 9:34 A.M. inside Resident 2's room. Resident 2 was eating without her dentures in place. A lower denture was observed inside a denture cup placed on the table. A follow-up observation and interview was conducted with licensed nurse (LN) 2 on 3/25/25 at 9:01 A.M. Resident 2 was eating breakfast without a denture on. LN 2 stated that Resident 2's lower denture was inside the denture cup that was on the bedside table. LN 2 further stated that a nursing staff should have applied the denture inside Resident 2's mouth so that Resident 2 may chew and eat properly. An interview was conducted with the Director of Nursing (DON) on 3/26/25 at 4:05 P.M. The DON stated that NCPs should be implemented by the health care team. The DON acknowledged that Resident 2's dentures should have been applied during meals, as instructed on the care plan. The facility's policy titled Dentures, Cleaning and Storing revised 3/2018, indicated, .Preparation .2.1. Review the resident's care plan to assess for any special needs of the resident General Guidelines 4' Encourage the resident to keep dentures in his or her mouth .

Based on observation, interview, and record review, the facility failed to ensure the central venous catheter (a tube inserted into a large vein near the heart to allow for long-term access to the bloodstream for medications, fluids, blood draws, and other treatments) was changed and monitored for two of two sampled residents (292 and 297). This failure had the potential for complications related to intravenous (IV - method of delivering fluids, medications, or nutrients directly into the bloodstream through a vein) therapy. Findings: Per the facility's admission record, Resident 292 was admitted on [DATE] with diagnoses that included right ankle and right foot osteomyelitis (infection of the bone). A review of Resident 292's physician's orders indicated, on 3/20/25 an order was made to change IV dressing every day every Sunday. On 3/24/25 at 10:45 A.M., an observation and interview were conducted with Resident 292 in her room. Resident 292 had an IV line on the right upper arm. Resident 292 stated a nurse changed the dressing yesterday. Resident 292 could not recall if the nurse measured her arm or the IV catheter. On 3/24/25 at 11:15 A.M., an observation and interview were conducted with Resident 297 in his room. Resident 297 had an IV line on the right upper arm. Resident 297 stated a nurse changed the dressing yesterday and he could not recall if the nurse measured his arm or the IV catheter. On 3/26/25 at 8:38 A.M., a concurrent interview and record review was conducted with LN 3. A review of the Peripherally Inserted Central Catheter (PICC) line dressing change documentation dated 3/23/25 in the IV Medication Administration Record (MAR) for both Residents 292 and 297 indicated, measurements of arm circumference and catheter length were not done. LN 3 stated the importance of measuring arm circumference and the catheter length for a central venous catheter was to ensure proper placement and prevent complications. On 3/27/25 at 2:25 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated that measuring arm circumference and the catheter length for a central venous catheter during the dressing change was a standard of practice and should have been done. A review of the facility's policy titled Central Venous Catheter Care and Dressing Changes, dated 2001, indicated .6. Measure the length of the external central vascular access device with each dressing .measure arm circumference .

Based on observation, interview and record review, the facility failed to provide interventions to prevent the redevelopment of pressure injuries (skin damaged by lack of movement for staying in a position for too long) and accurately assessed residents for skin injury for two of three residents reviewed for pressure injuries (Resident 16 and Resident 20). As a result, Resident 16 redeveloped a pressure injury on her left buttock and Resident 20 developed a new pressure injury on her left buttock. Findings: 1. A review of Resident 16's Admission Record indicated Resident 16 was readmitted to the facility on [DATE], with diagnoses which included generalized muscle weakness. Resident 16's attending physician completed Resident 16's history and physical (H&P) dated 6/14/24. The H & P indicated Resident 16 was able to make own decisions. Resident 16's minimum data set (MDS - a federally mandated resident assessment tool), completed on 1/30/25, indicated Resident 16's brief interview for mental status (BIMS, ability to recall) score was 13/15 (a score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). Resident 16's MDS for functional abilities from lying on back to roll to left and right side indicated Resident 16 needed moderate staff assistance which meant the helper (staff) lifts, holds or supports resident's trunk or limbs. During an observation and an interview of Resident 16 in her room on 3/24/25 at 10:22 A.M., Resident 16 laid in bed, with low air loss mattress (designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown). Resident 16 stated she had no concerns. A review of the facility's matrix (used to identify pertinent care categories) indicated, Resident 16 had a stage 3 (extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) facility acquired pressure injury on her left buttock. A review of Licensed Nurses (LN) progress notes dated 3/7/25, 3/8/25, 3/9/25, and 3/10/25 indicated, Resident 16 had a small open wound at the buttock and was placed on alert charting. There was no physician order and no documentation from the treatment nurse. A review of LN's weekly summary notes completed by LN 22, dated 3/13/25 and 3/20/25 indicated, Resident 16 had no skin injury. A review of Resident 16's skin assessment completed by the wound care nurse (WCN) on 3/17/25, indicated, Resident 16 had stage 3 pressure injury on her left buttock and measured as follows: - Area 0.7 centimeter (cm, metric of measurement), - Length 0.9 cm. - Width 1.1 cm. - Depth 0.2 cm. The WCN's skin assessment notes for Resident 16 indicated, Resident 16's onset of her pressure injury was unknown. The skin assessment notes indicated, the pressure injury had moderate serosanguinous (type of wound drainage) exudate. During an observation and an interview of Resident 16 in her room on 3/25/25 at 3:58 P.M., Resident 16 was slightly lying on her right side. Resident 16 stated she had open wound on her buttocks. During a record review of Resident 16's clinical record and a joint interview with the Wound Care Nurse (WCN) on 3/26/25 at 2:20 P.M., the WCN stated she was familiar with Resident 16. The WCN stated Resident 16 needed some help from the staff when turning or repositioning herself in the bed. The WCN stated Resident 16 had history of stage 3 pressure injury on her left buttock and was resolved. The WCN stated night shift CNAs notified her about Resident 16's open wound on her left buttock on 3/17/25. The WCN stated, It was already stage 3. The WCN stated she was not aware Resident 16 had an open wound from 3/7/25 and she was notified on 3/17/25. The WCN stated there was no documentation that Resident 16 was receiving treatment on her open wound on her left buttock. The WCN stated the nurses should have informed her or the doctor so treatment could have been started for Resident 16's open wound. The WCN stated it can be preventable. During an interview with the Director of Nursing (DON) on 3/26/25 at 3:24 P.M., the DON stated the LNs should have done the treatment, it was not only monitoring and alert charting. The DON stated the LNs should have followed it up with the physician and informed the wound care nurse so treatment should have been started. The DON further stated the staff should have repositioned the resident every two hours especially Resident 16 had history of open wounds on her left buttock. The DON stated, This is preventable. A review of the facility's policy, titled Prevention of Pressure Injuries, revised 4/2020, indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors .Skin Assessment, 1. Conduct a comprehensive skin assessment .with each risk assessment, as identified according to the resident's risk factors .3. Inspect the skin on a daily basis when performing or assisting with personal care .Monitoring, 1. Evaluate, report .potential changes in the skin . 45909 2. Resident 20 was admitted to the facility on [DATE] with diagnoses which included a history of muscle weakness, abnormal mobility, and fracture of the vertebra (spine), per the Admission Record. A review of Resident 20's nursing care plan (NCP- document that outlines the nursing care required for a specific patient) dated 11/10/23, indicated that Resident 20 was at risk for skin breakdown. A wound observation and interview was conducted with the Wound Care Nurse (WCN) on 3/25/25 at 9:55 A.M. inside Resident 20's room. Resident 20's left buttock was purple in color. The WCN stated that a deep tissue injury (DTI- skin breakdown caused by prolonged pressure) was identified on Resident 20's left buttock when Resident 20 was assessed on 1/6/25. The WCN stated that Resident 20's left buttock DTI would have been prevented with accurate skin assessment and appropriate skin treatment. A concurrent interview and record review was conducted with Licensed Nurse (LN 3) on 3/25/25 at 2:30 P.M. Resident 20's nursing weekly summary (NWS- detailed nursing documentation completed by the LN every week; included a summary of assessment and comprehensive care that was provided to the resident) dated: 12/26/24 included documentation that Resident 20 had no skin breakdown. 1/1/25 included documentation that Resident 20 had no skin breakdown. 1/8/25 included documentation that Resident 20 had skin breakdown that was discovered on 1/6/25. LN 3 stated that Resident 20's DTI on the left buttock would have first appeared as a stage 1 (skin redness). LN 3 acknowledged that Resident 20's DTI would have been prevented with accurate nursing assessment, prompt communication, and skin treatment. An interview was conducted with the DON on 3/26/25 at 4:09 P.M. The DON acknowledged that LNs should accurately assess and document a resident skin condition to prevent further skin breakdown. The facility's policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 3/2014 indicated, Assessment and Recognition .2.In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length

Based on observation, interview and record review, the facility failed to provide a safe environment related to activity of daily Living (ADL - everyday task) for one of three sampled residents (Resident 59) when Resident 59 used a disposable razor while unsupervised. This failure had the potential to affect Resident 59's safety and well- being. Findings: Resident 59 was admitted to the facility on [DATE] with diagnoses which included right eye vision loss and heart failure. A review of Resident 59's physician order dated 4/17/24 indicated, Aspirin (ASA- medication that can cause bleeding) one tablet by mouth, every day for cerebrovascular accident (CVA-blockage of the brain) prophylaxis (prevention). A concurrent observation and interview was conducted on 3/24/25 at 9:23 A.M with Resident 59. Resident 59 was observed shaving her chin with a disposable razor. Resident 59 stated that she shaved her chin everyday by herself. An interview and record review was conducted with licensed nurse (LN) 1 on 3/25/25 at 3:53 P.M. LN 1 stated that per Resident 59's physician order for ASA, Resident 59 was at risk for bleeding. LN 1 further stated that Resident 59 should had been supervised or assisted by staff while she shaved her chin. An interview was conducted with the Director of Nursing (DON) on 3/26/25 at 4:07 P.M. The DON stated that staff should assist residents to prevent accidents. The DON acknowledged that Resident 59 had right eye vision loss and was on ASA. The DON stated that Resident 59 should have not shaved her chin by herself to prevent accidental cut and bleeding. The facility's policy titled Shaving the Resident revised 2018, indicated, .Preparation 1. Review the resident's care plan to assess for any special needs of the resident

Based on observation, interview, and record review the facility failed to ensure oxygen (O2) was administered per physician's order for one of three sampled residents (Resident 19) reviewed for O2 therapy. This failure had the potential to affect Resident 11's respiratory health. Findings: A review of Resident 19's Admission Record indicated Resident 19 was readmitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD, respiratory illness that limits airflow into and out of the lungs). A review of Resident 19's history and physical (H &P) dated 6/19/24 was conducted. Resident 19's attending physician documented Resident 19 had severe COPD and required to continue O2 therapy. Per the H&P, Resident 19 had history of cognitive impairment. A review of Resident 19's physician order dated 2/14/25 indicated the following order: Continuous O2 at 2 liters per minute (LPM) via nasal cannula (NC, a tubing that delivers O2 connected to the O2 tank or O2 concentrator through the resident's nose). During an observation and an interview of Resident 19 in her room, on 3/24/25 at 10:45 A.M., Resident 19 laid in bed, with O2 at 4 LPM/ NC connected to the O2 concentrator. Resident 19 stated she was fine. During an observation and an interview of Resident 19 in her room on 3/25/25 at 3:52 P.M., Resident 19 laid in her right side, with O2 at 4 LPM/ NC connected to the O2 concentrator. Resident 19 did not respond when her name was called. During an interview with Certified Nursing Assistant (CNA) 22 on 3/26/25 at 10:10 A.M., CNA 22 stated Resident 19 had her O2 therapy all the time and the Licensed Nurses (LNs) were responsible for Resident 19's O2 therapy. During a record review of Resident 19's clinical record, a photo taken of O2 administered to Resident 19, and an interview with LN 21 on 3/26/25 at 11:57 A.M., LN 21 stated Resident 19 had a physician order that indicated Resident 19's O2 therapy was at 2 LPM/NC. LN 21 stated the LNs were supposed to follow the physician's order to make sure Resident 19 would not develop O2 toxicity (lung damage that happens from breathing in too much extra [supplemental] oxygen, also called O2 poisoning). During an interview with the Director of Nursing (DON) on 3/26/25 at 3:24 P.M., the DON stated LNs should have followed the physician order to prevent Resident 19 from developing O2 toxicity. A review of the facility's policy titled, Medication and Treatment Orders, revised 7/2016, indicated, Orders for medications and treatments will be consistent with principles of safe and effective order . A review of the facility's policy titled, Oxygen Administration, revised 10/2010, indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration .Review the physician's order .for oxygen administration .