Every finding on record at Lakewood Healthcare Center

Downey, California · CCN 555099

37 findings across 20 inspections, in the inspector's own words, 19 of them at actual harm or above.

Data as of September 30, 2026, released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.

Inspection of June 8, 2026

2 findings

F689D · No harm, potential for more than minimal, isolated

12 findings

F688G · Actual harm, isolated

Based on observation, interview, and record review, the facility failed to provide range of motion ([ROM] full movement potential of a joint) services to one of six sampled residents (Resident 6) with position and mobility (ability to move) concerns after experiencing femoral neck fractures (break in the bone just beneath the rounded bone of the hip) to both hips on 6/6/2025 by failing to: 1. Clarify Resident 6's weight-bearing tolerance ([WB tolerance] amount of weight allowed to put on an injured or surgically repaired limb) and ROM parameters (extent of movement at a joint) to both legs after Resident 6's orthopedic physician's (branch of medicine dealing with the correction or prevention of deformities, disorders, or injuries of the bones and associated soft tissue) appointment on 9/17/2025.2. Provide ROM exercises to both of Resident 6's legs from 9/17/2025 to 12/4/2025.3. Identify and report changes in ROM to Resident 6's legs from 9/17/2025 to 12/4/2025 to the primary care physician and responsible party. 4. Provide Resident 6 with active range of motion ([AROM] performance of an exercise to move a joint without any assistance or effort of another person) exercises to both arms, three times per week, from 10/24/2025 to 12/3/2025, in accordance with the physician's order, dated 10/23/2025. 5. Implement the facility's policy and procedure (P&P) titled, Contracture - Prevention and Management, which indicated to monitor and assess ROM limitation upon admission and quarterly.These failures prevented Resident 6, who used to walk without an assistive device prior to both hip fractures, from receiving ROM exercises to both legs from 9/17/2025 to 12/4/2025 (approximately three months) and resulted in the development of undetected contractures (a stiffening/shortening at any joint that reduces the joint's range of motion) to both knees and abnormal positioning of the lower spine and both hips into rotation toward Resident 6's right side between 9/17/2025 to 12/4/2025. These failures also had the potential for Resident 6 to experience decline in ROM to both arms. Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 6's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), dementia (progressive state of decline in mental abilities), attention to colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body), muscle weakness, and personal history of healed traumatic fracture. During a review of Resident 6's Physical Therapy (PT, therapy that is used to preserve, enhance, or restore movement and physical function impaired or threatened by disease, injury, or disability) Evaluation and Plan of Treatment, dated 5/9/2025, the PT Evaluation indicated Resident 6 was referred to PT after a recent hospitalization for altered mental status, confusion, poor oral intake, and generalized weakness. The PT Evaluation indicated Resident 6's prior level of function (ability prior to therapy intervention) was independent with bed mobility, transfers, and ambulated (walked) 200 feet without an assistive device. The PT Evaluation indicated Resident 6's range of motion (ROM, full movement potential of a joint) in both legs were within functional limits ([WFL] sufficient joint movement without significant limitation) and did not have any contractures limiting function. The PT Evaluation indicated Resident 6 required supervision or touching assistance (helper provides verbal cues and/or touching/steady assistance as resident completes the activity) for rolling to both sides in bed, transferring from lying in bed to sitting at the side of the bed, transferring from chair to bed/chair, sit-to-stand, toilet transfers, and walking 10 feet without an assistive device. During a review of Resident 6's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 6 required supervision or touching assistance for bed mobility, functional transfers, and walking 20 feet without an assistive device. The PT Discharge Summary indicated Resident 6 was discharged to a General Acute Care Hospital (GACH) for X-rays (image of the inside of the body) due to pain in both hips. During a review of Resident 6's Census List (record of hospitalizations, readmissions, room changes, and payer source changes), the Census List indicated Resident 6 was discharged to the GACH on 6/5/2025.During a review of Resident 6's GACH X-ray of the pelvis (large ring of bones at the base of the spine that connects the torso to the legs), dated 6/6/2025, the X-ray indicated Resident 6 had femoral neck fractures (break in the bone just beneath the rounded bone of the hip) to both hips. During a review of Resident 6's Census List, the Census List indicated Resident 6 was readmitted to the facility on [DATE].During a review of Resident 6's PT Evaluation and Plan of Treatment, dated 6/11/2025, the PT Evaluation indicated Resident 6 was referred to PT due to recent hospitalization for body pain with erythema (reddening of the skin) and warmth to both legs. The PT Evaluation indicated Resident 6 had both hip fractures and was referred to PT due to new onset of decreased mobility and strength. The PT Evaluation indicated Resident 6 was non-weightbearing ([NWB] inability to place weight on an injured limb) to both legs due to a pending orthopedic physician appointment (unspecified date). The PT Evaluation indicated Resident 6 had ROM impairments to both hips and knees but was unable to formally assess the ROM due to pain, pain behaviors, and Resident 6's resistance to ROM. The PT Evaluation indicated both of Resident 6's ankles were positioned in negative five (-5) degrees (angle measurement of joints) of dorsiflexion (ankle bent toward the body) and did not have any contractures limiting function. The PT Evaluation indicated Resident 6 had two minus out of five ([2-/5] muscle of the limb moves partially through the range of motion) strength in both hips and knees. The PT Evaluation indicated Resident 6 was dependent on staff (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for rolling to both sides while lying in bed. The PT Evaluation indicated transferring from lying in bed to sitting at the side of the bed, transferring from chair to bed/chair, sit-to-stand, toilet transfers, and walking 10 feet without an assistive device were not attempted with Resident 6 due to medical conditions or safety concerns, including NWB to both legs. Resident 6's PT Evaluation indicated recommendations for the use of a mechanical lift with two-person assistance for transfers. During a review of the physician's order, dated 6/18/2025 and discontinued on 6/22/2025, the physician's order indicated Resident 6 was NWB on both legs until cleared by the orthopedic physician. During a review of the physician's order, dated 6/22/2025, the order indicated NWB on both legs and no ROM until cleared by the orthopedic physician. During a review of Resident 6's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 6 was dependent for rolling to both sides in bed. The PT Discharge Summary indicated transfers from lying on the back to sitting on the side of the bed with feet flat on the floor, and propelling the wheelchair were not attempted due to medical conditions or safety concerns. The PT Discharge Summary indicated Resident 6 was discharged to the GACH. During a review of Resident 6's Census List, the Census List indicated Resident 6 was discharged to the GACH on 6/26/2025 and was readmitted to the facility on [DATE]. During a review of physician's order, dated 7/1/2025, the physician's order indicated Resident 6 was on NWB to both legs with no ROM until cleared by the orthopedic physician. During a review of Resident 6's PT Evaluation and Plan of Treatment, dated 7/2/2025, the PT Evaluation indicated Resident 6 was referred to PT after recent hospitalization for depression and eating feces from the colostomy bag (container that collects waste after a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body). The PT Evaluation indicated Resident 6 was on NWB to both legs due to pending orthopedic physician appointment on 7/17/2025. The PT Evaluation indicated Resident 6 had ROM impairments on both hips, knees, and ankles but was unable to completely assess both legs due to Resident 6's screaming and self-hitting behavior. The PT Evaluation indicated Resident 6 did not have contractures limiting function and was dependent for rolling to both sides while lying bed. The PT Evaluation indicated transferring from lying in bed to sitting at the side of the bed, transferring from chair to bed/chair, sit-to-stand, toilet transfers, and walking 10 feet without an assistive device were not attempted with Resident 6 due to medical conditions or safety concerns, including NWB to both legs. During a review of Resident 6's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 6 was dependent for rolling to both sides while lying in bed. The PT Discharge Summary indicated Resident 6 was discharged to the GACH. During a review of Resident 6's Census List, the Census List indicated Resident 6 was discharged to the GACH on 7/8/2025 and was readmitted to the facility on [DATE]. During a review of Resident 6's PT Evaluation and Plan of Treatment, dated 8/10/2025, the PT Evaluation indicated Resident 6 was referred to PT after a recent hospitalization for shortness of breath, aspiration pneumonia (lung infection from inhaling food or liquid into the lungs), and respiratory failure (serious condition that develops when the lungs cannot get oxygen into the blood). The PT Evaluation indicated Resident 6 was NWB to both legs and no ROM until cleared by the orthopedic physician (unspecified date). The PT Evaluation indicated Resident 6 had ROM impairments to both hips and knees but was unable to formally assess the ROM due to pain, pain behaviors, and Resident 6's resistance to ROM. The PT Evaluation indicated that both of Resident 6's ankles were positioned in -5 degrees of dorsiflexion and did not have any contractures limiting function. The PT Evaluation indicated Resident 6 had 2-/5 strength in both hips, knees, and ankles. The PT Evaluation indicated Resident 6 was dependent for rolling to both sides while lying in bed. The PT Evaluation indicated transferring from lying in bed to sitting at the side of the bed, transferring from chair to bed/chair, sit-to-stand, toilet transfers, and walking 10 feet without an assistive device were not attempted with Resident 6 due to medical conditions or safety concerns. Resident 6's PT Evaluation indicated recommendations for the use of a mechanical lift with two-person assistance for transfers. During a review of Resident 6's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 6 was dependent with rolling to both sides while lying in bed and self-repositioning in bed. The PT Discharge Summary indicated Resident 6 was discharged to the GACH. During a review of Resident 6's Census List, the Census List indicated Resident 6 was discharged to the GACH on 8/19/2025 and was readmitted to the facility on [DATE]. During a review of Resident 6's Minimum Data Set ([MDS] a resident assessment tool), dated 8/26/2025, the MDS indicated Resident 6 had severe impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 6 had clear speech, limited ability to express wants and needs but made concrete requests, responded adequately to simple and direct communication. The MDS indicated Resident 6 required partial/moderate assistance (helper does less than half the effort) for eating, and substantial/maximal assistance (helper does more than half the effort) for oral hygiene and rolling to both sides while lying in bed. The MDS indicated Resident 6 was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for bathing, upper and lower body dressing, and transferring from lying in bed to the side of the bed. The MDS indicated Resident 6 did not have any functional ROM limitation in both arms (shoulder, wrist, elbow, and hand) but had functional ROM limitations in both legs (hip, knee, ankle, and foot).During a review of Resident 6's Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities) Evaluation and Plan of Treatment, dated 8/27/2025, the OT Evaluation indicated Resident 6 was referred to OT after discharge from hospice care (compassionate care for people who are near the end of life which is provided at the person's home or within a healthcare facility) to maximize Resident 6's potential with activities of daily living ([ADLs] basic tasks that individuals perform to maintain their daily lives and independence). Resident 6's OT Evaluation indicated both shoulders had limited AROM to 60 degrees for shoulder flexion (lifting arm overhead; normal movement is 0 to 180 degrees) and had WFL ROM for both elbows, wrists, and hands. The OT Evaluation indicated Resident 6 did not have any contractures limiting function and was dependent on staff for eating, oral hygiene, upper body dressing, and lower body dressing. During a review of Resident 6's PT Evaluation and Plan of Treatment, dated 8/28/2025, the PT Evaluation indicated Resident 6 was referred to PT after discharge from hospice care. The PT Evaluation indicated Resident 6 was NWB to both legs and no ROM due to the pending orthopedic physician appointment (unspecified date). The PT Evaluation indicated both ankles had WFL ROM but both knees were not tested due to Resident 6's refusal despite encouragement and explanation of benefits. The PT Evaluation indicated Resident 6's hip strength was not tested and had 2-/5 strength in both knees and ankles. The PT Evaluation indicated Resident 6 was dependent on rolling to both sides while lying in bed. The PT Evaluation indicated transferring from lying in bed to sitting at the side of the bed, transferring from chair to bed/chair, sit-to-stand, toilet transfers, and walking 10 feet without an assistive device were not attempted with Resident 6 due to medical conditions or safety concerns. Resident 6's PT Evaluation indicated recommendations for the use of a mechanical lift with two-person assistance for transfers. During a review of the physician's orders, dated 9/10/2025, the physician's orders indicated Resident 6 was NWB with no ROM to both legs. During a review of the PT Treatment Encounter Note, dated 9/11/2025, the PT Treatment Encounter Note indicated Resident 6 was appropriate for skilled discharge from PT services due to Resident 6's NWB and no ROM to both legs until cleared by the orthopedic physician. The PT Treatment Encounter Note indicated Resident 6 had an orthopedic physician appointment on 9/17/2025 and would be appropriate for PT services if the orthopedic physician updated Resident 6's NWB and no ROM to both legs. During a review of the PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 6 was dependent for rolling to both sides while lying in bed and self-repositioning in bed. The PT Discharge Summary indicated Resident 6 was discharged from PT due to highest practical level achieved. During a review of the orthopedic physician (MD 2), note, dated 9/17/2025, the physician note indicated Resident 6 had chronic femoral neck fractures to both hips as shown on the X-ray from 6/2025. The physician note indicated Resident 6 had no need for urgent surgical intervention and the plan included contacting Resident 6's responsible party to discuss clinical decision-making as Resident 6 could not make medical decisions independently. The physician note did not indicate Resident 6's weightbearing status and ROM limitations. During a review of the Nursing Progress Notes, dated 9/19/2025 at 9:21 a.m., the Nursing Progress Note indicated RP 2 called the facility after speaking with MD 2's physician assistant. The Nursing Progress Note indicated RP 2 wanted to speak with Resident 6's primary care physician (MD 1) to further discuss Resident 6's plan of care. During a review of the OT Discharge summary, dated [DATE], the OT Discharge Summary indicated Resident 6 required supervision or touching assistance for personal hygiene and upper body dressing. The OT Discharge Summary indicated the Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) demonstrated 100 percent (%) carryover of trained techniques to maintain Resident 6's strength and ROM in both arms. The OT Discharge Summary indicated recommendations for the RNA to provide Resident 6 with active range of motion (AROM, performance of an exercise to move a joint without any assistance or effort of another person) on both arms, three times per week as tolerated. During a review of the physician's orders, dated 10/23/2025, the physician's orders indicated for the RNA to provide Resident 6 with AROM on the right arm and left arm, three times per week as tolerated, every Monday, Wednesday, and Friday. During a review of the MDS, dated [DATE], the MDS indicated Resident 6 had severely impaired cognition. The MDS indicated Resident 6 required set-up or clean-up assistance for eating, and substantial/maximum assistance for oral hygiene, upper body dressing, and rolling to both sides while lying in bed. The MDS indicated Resident 6 was dependent on bathing, lower body dressing, and transferring from lying in bed to the side of the bed. The MDS indicated Resident 6 did not have any functional ROM limitation in both arms but had functional ROM limitations in both legs.During a review of the OT Evaluation and Plan of Treatment, dated 12/13/2025, the OT Evaluation indicated Resident 6 was referred to OT after hospitalization for suicidal ideation and danger to self after Resident 6 engaged in self-harming behavior and not eating for two days. The OT Evaluation indicated Resident 6 had WFL ROM in both arms, impaired strength of three minus out of five (3-/5, the muscle of the limb moves almost fully through the range of motion and unable to sustain any resistance) in both shoulders and elbow, and WFL strength in both wrists. The OT Evaluation indicated Resident 6 was dependent on staff for personal hygiene, bathing, and upper body dressing. During a review of the PT Evaluation and Plan of Treatment, dated 12/13/2025, the PT Evaluation indicated Resident 6 was referred to PT after hospitalization and for decreased mobility and strength. The PT Evaluation indicated Resident 6 was NWB and no ROM in both legs until cleared by the orthopedic physician. The PT Evaluation indicated Resident 6 was positioned with both legs rotated to the right and both hips and knees bent to approximately 120 degrees. The PT Evaluation indicated Resident 6's right knee extended (straightened) to -70 degrees (knee in a bent position of 70 degrees, normal knee extension is 0 degrees) and the left knee extended to -90 degrees (knee in a bent position of 90 degrees). The PT Evaluation indicated Resident 6's right hip/knee had 2-/5 strength, the left hip/knee had zero out of five (0/5, no visible or physical movement) strength without any noted observable movement, both ankles had 2-/5 strength with small movements. The PT Evaluation indicated Resident 6 had contractures in both knees and was dependent on rolling to both sides while lying in bed. During an interview on 12/16/2025 at 11:13 a.m. with the Director of Rehabilitation (DOR), the DOR stated the therapy department (PT, OT, and Speech Therapy [profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders]) did not perform any screens to monitor the residents (in general) for mobility, ROM, and swallowing function. The DOR stated the therapists completed an evaluation on each resident within 24 to 48 hours of admission and nursing contacted the physician for any therapy orders after a change in condition. The DOR stated the facility relied on nursing, including the completion of the MDS assessment, to determine any changes in a resident's ROM, mobility, and self-care. The DOR stated a resident (in general) was discharged from therapy services when the resident reached their highest potential and transitioned to RNA services, if appropriate. The DOR stated the RNA provided ROM exercises, applied splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion), performed sit-to-stand transfers, and ambulation (act of walking). The DOR stated the purpose of ROM exercises (in general) included to prevent any decline in ROM since ROM limitations could increase a resident's risk of contractures, increase pain, and increase pressure injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a body prominence). The DOR defined contractures as the stiffening of muscle and joints making it difficult to stretch the joint. During an observation on 12/16/2025 at 12:32 p.m., in Resident 6's room, Resident 6 was observed lying completely flat in bed. Both hands were resting on the middle of the chest, and the blanket was covering Resident 6's entire body from the chest to the feet. During a concurrent observation and interview on 12/17/2025 at 11:11 a.m. with Licensed Vocational Nurse (LVN) 1 and Certified Nursing Assistant (CNA) 1, in Resident 6's room, Resident 6 was observed awake and lying flat in bed with the blanket covering Resident 6's legs. Resident 6 spoke but the words were not understandable. LVN 1 removed the blanket from Resident 6's legs. Both of Resident 6's legs were rotated toward the right side, both knees were bent, and the left knee was positioned directly on top of the right inner thigh. Resident 6 had cushioned boots covering both feet, preventing the observation of both ankles and feet. CNA 1 stated Resident 6 was monitored every two hours and the resident preferred to lay flat in bed. CNA 1 stated Resident 6 did not allow CNA 1 to place a pillow under Resident 6's head or between the legs. During a concurrent observation and interview on 12/17/2025 at 1:46 p.m. with Physical Therapy Assistant (PTA) 1, in Resident 6's room, Resident 6 was observed lying flat in bed. Resident 6 was initially agreeable to PTA 1 moving both legs. PTA 1 stated Resident 6's legs were rotated to the right side. PTA 1 attempted to assist Resident 6 with rolling to the side, but Resident 6 refused any movement. PTA 1 stated the intention was to attempt to relieve Resident 6's pressure from lying on the back. During a concurrent interview and record review on 12/17/2025 at 4:13 p.m. with the DOR, Resident 6's physician's orders, dated 6/22/2025, OT Evaluation, dated 8/27/2025, PT Evaluation, dated 8/28/2025 and completed by Physical Therapist (PT) 2, PT Discharge summary, dated [DATE], Nursing Progress Notes, dated 9/17/2025 and 9/18/2025, and MD 2's orthopedic physician note, dated 9/17/2025, were reviewed. The DOR stated the OT Evaluation, dated 8/27/2025, indicated Resident 6 had AROM impairments in both shoulders and WFL ROM in both elbows, wrists, and hands. The DOR stated the PT Evaluation, dated 8/28/2025, indicated both of Resident 6's hips were not tested due to safety precautions, including NWB and no ROM to both legs, Resident 6 refused assessments to both knees, and both ankles had WFL ROM. The DOR stated MD 1 wrote orders, dated 6/22/2025, for Resident 6 to remain NWB and no ROM to both legs until cleared by the orthopedic physician. The DOR stated Resident 6 did not receive any ROM exercises to both legs after discharged from PT on 9/11/2025 due to Resident 6's pending orthopedic physician appointment on 9/17/2025. The DOR stated Resident 6 did not attend previously scheduled orthopedic physician appointments after both hip fractures on 6/6/2025 due to Resident 6's multiple hospitalizations. The DOR reviewed MD 2's orthopedic physician note, dated 9/17/2025, and stated MD 2's note did not indicate any WB tolerance and ROM parameters. The DOR stated the facility continued to implement MD 1's order, dated 6/22/2025, for NWB and no ROM to both legs because MD 2 did not clarify Resident 6's WB tolerance and ROM parameters in the orthopedic physician note. The DOR reviewed the Nursing Progress Notes, dated 9/17/2025 and 9/18/2025, and stated the nurses did not clarify Resident 6's WB tolerance and ROM parameters with MD 2. The DOR stated PT and OT did not contact MD 2 to clarify Resident 6's WB tolerance and ROM limitations. The DOR stated Resident 6 has not received any ROM exercises to both legs after the orthopedic physician appointment on 9/17/2025 since the facility did not clarify Resident 6's WB tolerance and ROM limitations. The DOR stated Resident 6 had an increased risk of developing contractures and experiencing a decline in strength to both legs without the provision of ROM exercises. Resident 6's OT Discharge summary, dated [DATE], and Documentation Survey Report for RNA, dated 10/2025, 11/2025, and 12/2025, were reviewed. The DOR stated Resident 6 was discharged from OT services on 10/23/2025 due to reaching the maximal potential. The DOR stated the OT Discharge Summary indicated recommendations for RNA to provide AROM to both arms, three times per week. The DOR stated Resident 6 could develop a decline in ROM and strength to both arms without the RNA's provision of AROM exercises. The DOR reviewed Resident 6's Documentation Survey Report dated 10/2025, 11/2025, 12/2025 and stated the Documentation Survey Report did not have any documentation indicating Resident 6 received RNA for AROM to both arms on the following dates:1) 10/24/2025, 10/27/2025, and 10/29/2025. 2) 11/3/2025, 11/5/2025, 11/7/2025, 11/10/2025, 11/12/2025, 11/17/2025, 11/19/2025, 11/21/2025, and 11/26/2025.3) 12/1/2025 and 12/3/2025.During a concurrent interview and record review on 12/18/2025 at 7:54 a.m., with RNA 2, Resident 6's Documentation Survey Report for 10/2025, 11/2025, and 12/2025 were reviewed. RNA 2 stated the RNAs had a physician's order to provide Resident 6 with AROM exercises to both arms to maintain mobility in both arms. RNA 2 stated Resident 6 preferred the head-of-bed raised for meals. RNA 2 stated he did not see Resident 6 in the wheelchair very often because Resident 6 became agitated while seated in the wheelchair. RNA 2 stated Resident 6's legs were straight most of the time but Resident 2 would tend to position both legs slightly to the right when not eating. RNA 2 stated Resident 6's Documentation Survey Report for 10/2025, 11/2025, and 12/2025 with blank dates indicated the RNA services for AROM were not provided. RNA 2 stated the RNAs in each nursing unit had a designated tablet (small portable computer) to complete their documentation so there was no reason the RNA would be missing documentation. RNA 2 stated the facility would assign RNA 2 to provide residents' care which was normally performed by CNAs and could be a reason for missing RNA documentation. During a concurrent interview and record review on 12/18/2025 at 9:37 a.m., with PT 1, Resident 6's PT Evaluation, dated 5/9/2025, 6/11/2025, 8/10/2025, and 12/13/2025, and physician's order, dated 6/22/2025, were reviewed. PT 1 stated Resident 6 had WFL ROM in both legs during the PT Evaluation, dated 5/9/2025, and walked 20 feet without an assistive device prior to Resident 6's discharge to the GACH on 6/5/2025. PT 1 stated the PT Evaluation, dated 6/11/2025, indicated Resident 6's ROM in both legs were not formally assessed due to pain but strength was informally assessed as 2-/5 in both hips and knees since Resident 6 was observed to spontaneously move at both hips and knees less than 50% of the normal ROM for those joints. PT 1 stated Resident 6's ankles were positioned in 5 degrees of plantarflexion (ankle bent with toes pointing away from the body; joint measurement is the same as -5 degrees of dorsiflexion) and did not have any contractures in both legs. PT 1 stated Resident 6 had physician's orders, dated 6/22/2025, for NWB and no ROM to both legs until cleared by the orthopedic physician. PT 1 stated Resident 6's PT Evaluation, dated 8/1/2025, was grossly assessed as having at least 2-/5 strength since Resident 6 had observable movement in both legs less than 50% of the normal ROM for those joints. PT 1 stated Resident 6's legs were positioned normally on the bed during the PT Evaluation. PT 1 stated PT intervention focused on rolling and self-positioning due to the continued physician's order for NWB and no ROM to both legs until cleared by the orthopedic physician. PT 1 reviewed Resident 6's PT Evaluation, dated 12/13/2025, and stated Resident 6's position included rotation of the lower spine, internal rotation of the left hip (hip joint rotated toward the body), external rotation (hip joint rotated away from the body) of the right hip, and both the hips and the knees were bent while rotated toward the right side. PT 1 stated PT 1 felt really concerned about Resident 6's hips and knees but did not have any clarification on providing ROM to both hips due to the hip fractures. PT 1 stated Resident 6's right knee started at a bent position of 120 degrees and extended to 70 degrees and the left knee started in a bent position of 120 degrees and extended to 90 degrees. PT 1 stated Resident 6's right leg was grossly assessed as having at least 2-/5 strength because Resident 6 could pull the right leg back toward the body from PT 1. PT 1 stated Resident 6's left leg was assessed as having 0/5 strength because PT 1 was unable to feel any muscle movement and Resident 6 was unable to pull the left leg back from PT 1. During an interview on 12/18/2025 at 11:02 a.m. with CNA 7, CNA 7 stated she would occasionally assist CNA 8 with repositioning Resident 6. CNA 7 stated Resident 6 did not like to extend both legs and preferred to position both legs sideways. During a concurrent interview and record review on 12/18/2025 at 11:17 a.m. with Occupational Therapist (OT) 1, Resident 6's OT Evaluation, dated 8/26/2025, physician's orders, dated 6/22/2025, 7/1/2025, and 9/10/2025, and OT Discharge summary, dated [DATE] were reviewed. OT 1 stated Resident 6 received an OT Evaluation on 8/28/2025 after being discharged from hospice care. OT 1 stated Resident 6's AROM in both shoulders were impaired to 60 degrees of shoulder flexion but had WFL ROM in both elbows, wrists, and hands. OT 1 stated nursing could reposition both of Resident 6's legs toward the right or the left side. OT 1 stated Resident 6's knees would be in either a bent or extended position depending on how nursing positioned and repositioned Resident 6's body. OT 1 stated Resident 6 received OT services longer than PT services to work on self-care, including hygiene, grooming, upper body dressing, and ROM training with the RNA, and to monitor Resident 6's ROM and WB tolerance to both legs. OT 1 stated Resident 6 went to the orthopedic physician appointment, but MD 2 wanted to speak with RP 1 and RP 2. OT 1 stated there were no physician's orders for WB tolerance and ROM limitations between 7/10/2025 and 9/10/2025. OT 1 reviewed Resident 6's physician's orders, dated 9/10/2025, for NWB and no ROM to both legs. OT 1 stated this physician's order was discontinued on 12/8/2025. OT 1 stated the facility, including the therapists, did not contact MD 2 for clarification regarding Resident 6's WB tolerance and ROM parameters to both legs.During a telephone interview on 12/18/2025 at 12:19 with RP 1, RP 1 stated Resident 6 had fractures to both hips and did not undergo surgery. RP 1 stated Resident 6 usually had a pillow positioned under both knees to make the resident more comfortable while lying in bed. RP 1

F689G · Actual harm, isolated

Based on interview and record review, the facility failed to provide care and services to prevent a fall for four of 10 sampled residents (Resident 139, Resident 155, Resident 102, and Resident 164) when: 1. Certified Nursing Assistant (CNA) 4 failed to provide two-person assistance prior to providing care to Resident 139.2. CNA 4 failed to place the low-air-loss mattress (LALM, a specialized air mattress that constantly releases air to alternate pressure to shift weight) into static mode (no alternation in pressure), prior to providing care to Resident 139.3. Staff failed to apply a helmet to Resident 155 as ordered by her physician.4. Staff failed to ensure Resident 102 was adequately supervised while in possession of sharpened pencils.5. Smoking precautions were not implemented for Resident 164. These deficient practices resulted in Resident 139 falling from her bed on 11/27/2025, resulting in a left eye orbital floor fracture (a break in the bone at the bottom of the eye socket, often from trauma like a fall or accident) and left orbital proptosis (abnormal bulging or protruding of the eyeball from the eye socket), soft tissue swelling and hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) measuring two (2) centimeters (cm, metric unit of length) to the left eye and left maxillary area (upper jaw bone). Resident 139 also required four (4) total doses of Hydrocodone-Acetaminophen 5-325 (combination medication used to treat moderate to severe pain) during her hospitalization from 11/27/2025 to 12/3/2025. These failures also placed Residents 155, 102, and 164 at risk for avoidable accidents and injuries.Findings: 1. During a review of Resident 139's admission Record, the admission Record indicated Resident 139 was initially admitted to the facility on [DATE], and most recently re-admitted on [DATE]. Resident 139's diagnoses included morbid (severe) obesity (a severe medical condition where excess fat impairs normal bodily functions), generalized muscle weakness, history of falling, and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 139's Minimum Data Set (MDS, a resident assessment tool), dated 11/3/2025, the MDS indicated Resident 139 had severe cognitive impairment (significant trouble with thinking, memory, learning, concentrating, or decision-making). The MDS indicated Resident 139 was dependent on staff (required the assistance of two or more helpers was required to complete the activity) for rolling left and right in bed. The MDS indicated Resident 139 was also dependent on staff for toileting hygiene (cleaning the genital and anal area after voiding or having a bowel movement). During a review of Resident 139's Fall Risk Evaluation, dated 11/3/2025, the evaluation indicated Resident 139 had intermittent confusion and was at risk for falls. During a review of Resident 139's care plan titled Activity of Daily Living (ADLs, activities such as bathing and toileting a person performs daily) self-care performance deficit related to confusion, impaired balance, limited mobility, dated 4/28/2023 and revised 5/12/2025, the care plan indicated Resident 139 was dependent on staff for repositioning and turning in bed. The care plan did not indicate further interventions. During a review of Resident 139's physician's order dated 10/16/2025, the order indicated low-air-loss mattress (LALM) for skin integrity maintenance and prevention. During a review of Resident 139's Change of Condition (COC) assessment, dated 11/27/2025, the COC indicated on 11/27/2025, Resident 139 sustained a fall witnessed by CNA 4. The assessment indicated CNA 4 was providing care to Resident 139 when Resident 139 rolled over and hit her face on the floor. The assessment indicated Resident 139 had bruising around her left eye and a pain score of 6 (moderate pain) on a scale from zero (0) to ten (10) (0 = no pain, 10 = excruciating pain) following the fall. During a review of Resident 139's Medication Administration Record (MAR), dated 11/2025, the MAR indicated on 11/27/2025, Resident 139 received 650 mg of acetaminophen for 6/10 pain after the fall. During a review of Resident 139's progress note, dated 11/27/2025, the progress note indicated Resident 139 was transferred to General Acute Care Hospital (GACH) for further evaluation and treatment following the fall. During a review of Resident's 139's GACH records, dated 11/27/2025 to 12/3/2025, the GACH records indicated Resident 139 was admitted to the GACH on 11/27/2025 following a fall with facial injury, pain, bruising, and swelling to the left eye. The records indicated Resident 139 received 4 total doses of Hydrocodone-Acetaminophen 5-325 from 11/27/2025 to 11/29/2025. During a review of Resident 139's GACH Computed Tomography (CT) scan (a type of medical imaging used to obtain detailed internal images of the body) of the maxillofacial region (face, mouth, and jaw), dated 11/27/2025, the CT scan indicated Resident 139 had a left eye orbital floor fracture, left orbital proptosis and soft tissue hematoma measuring 2 cm overlying the left maxillary facial region. During a review of Resident 139's nursing progress note, dated 12/4/2025, the progress note indicated Resident 139 was re-admitted to the facility on [DATE]. During an interview on 12/16/2025 at 3:42 p.m., with CNA 4, CNA 4 stated on 11/27/2025, he was at Resident 139's bedside performing perineal hygiene (cleansing of the genital and anal area) when the resident fell. CNA 4 stated Resident 139 was on a low air loss mattress (LALM, a specialized air mattress that constantly releases air to alternate pressure to shift weight). CNA 4 stated he did not adjust the LALM settings prior to repositioning Resident 139. CNA 4 stated he was standing to the left of Resident 139 when he rolled the resident onto her left side, facing him. CNA 4 stated while on her left side, Resident 139 was less than six inches from the edge of the mattress. CNA 4 stated he reached behind the resident to adjust her incontinence brief when she began to slide off the mattress. CNA 4 stated Resident 139 did not have side rails on her bed, and he could not stop the fall. CNA 4 stated the left side of Resident 139's face hit the ground first, then the rest of her body followed. CNA 4 stated Resident 139 required two-person assistance with repositioning and incontinence care, but he thought he could perform the task alone. CNA 4 stated he should have asked another staff member to assist him. During an interview on 12/17/2025 at 3:49 p.m., with the Minimum Data Set Nurse (MDSN), the MDSN stated Resident 139 was dependent on staff for rolling left to right in bed, and for toileting hygiene, at the time of the fall. The MDSN stated dependent meant Resident 139 required two staff at the bedside for repositioning and toileting hygiene, with one staff member at each side of the bed while the task was performed. The MDSN stated the main purpose of having two staff members was for the resident's safety. The MDSN stated failure to provide the required level of assistance increased Resident 139's risk for falls and injury. During an interview on 12/18/2025 at 9:50 a.m., with Director of Staff Development (DSD) 2, DSD 2 stated from 10/4/2024 to 10/11/2024 staff were educated to implement two-person assistance when providing care to any resident on a LALM. DSD 2 stated staff were also educated to change the LALM settings to static mode prior to providing care. DSD 2 stated static mode temporarily paused the alternating pressure in the mattress and created a firm, flat surface which prevented the resident from sliding off the bed or being pushed off the bed due to the slanted surface created when each side of the mattress inflated. DSD 2 stated Resident 139's fall could have been prevented. The DSD stated the expectation was that CNA 4 should have asked for a second staff to assist with providing care to Resident 139. During an interview on 12/18/2025 at 1:46 p.m., with the Director of Nursing (DON), the DON stated Resident 139's ADL care plan, dated 4/28/2023 and revised 5/12/2025, indicated she was dependent on staff for repositioning in bed. The DON stated staff were expected to follow the care plan to ensure the resident's care needs were met. The DON stated Resident 139's fall on 11/27/2025 was avoidable. The DON stated CNA 4 should have recruited another staff member to assist him and should have placed Resident 139's mattress into static mode. During a review of the facility's policy and procedure (P&P) titled Fall Management Program, revised 8/28/2025 and effective 11/11/2025, the P&P indicated it was the facility's policy to maintain an environment free of accident hazards. The P&P indicated an avoidable accident occurred when staff failed to implement appropriate interventions. 2. During a review of Resident 155's admission Record, the admission Record indicated Resident 155 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE]. Resident 155's diagnoses included metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance or underlying medical issue), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), inability to move the right side of the body, lack of coordination, abnormalities of gait and mobility, and history of falling. During a review of Resident 155's MDS, dated [DATE], the MDS indicated Resident 155 had severe cognitive impairment. The MDS indicated Resident 155 was dependent on staff for mobility while in bed, and mobility out of bed was not attempted due to safety or medical concerns. During a review of Resident 155's physician order, dated 12/14/2025, the physician order indicated staff were to apply a helmet to Resident 255 at all times. During a review of Resident 155's care plan titled High risk for falls., dated9/23/2025, the care plan indicated the goal for Resident 155 was no serious injury. The care plan interventions indicated to apply a helmet at all times. During observations on 12/15/2025 at 10:53 a.m., 12/16/2025 at 11:08 a.m., and 12/17/2025 at 10:10 a.m., in Resident 155's room, observed Resident 155 lying in bed. Resident 155 was not wearing a helmet. During an interview on 12/17/2025 at 10:15 a.m., with Resident 155's roommate, Resident 155's roommate stated she never observed Resident 155 wearing a helmet. During an interview on 12/17/2025 at 10:19 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 155 was a fall risk. CNA 1 stated Resident 155 did not wear a helmet. CNA 1 stated she never applied a helmet to Resident 155. During a concurrent observation and interview, on 12/17/2025 at 10:20 a.m., at Resident 155's bedside, with CNA 1, observed CNA 1 check Resident 155's bedside dresser and closet for a helmet. CNA 1 stated Resident 155 did not have a helmet in her belongings. CNA 1 stated the Charge Nurse did not tell her Resident 155 needed one. During a concurrent interview and record review, on 12/17/2025 at 10:27 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 155's physician order dated 12/14/2025 was reviewed. The physician order indicated Resident 155 was to have a helmet on at all times. LVN 1 stated she did not know if Resident 155 had a helmet, but as the Charge Nurse, she was responsible for checking the physician orders and ensuring the orders were implemented. LVN 1 stated Resident 155 required a helmet due to her history of falling and injuring herself. LVN 1 stated that the purpose of the helmet was resident safety. During a review of the facility's job description titled Charge Nurse, undated, the job description indicated it was the Charge Nurse's responsibility to ensure that all safety practices were followed. 3. During a review of Resident 102's admission Record, the admission Record indicated Resident 102 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 102's diagnoses included paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), polyneuropathy (damage to many nerves throughout the body, usually starting in hands and feet, causing numbness, tingling and burning sensation), and extrapyramidal (EPS – movement problems such as stiffness, tremors, restlessness caused by certain medications) and movement disorder (a condition that causes uncontrolled and involuntary body movements). During a review of Resident 102's History and Physical (H&P), dated 9/24/2025, the H&P indicated Resident 102 had the capacity to understand and make decisions. During a review of Resident 102's MDS, dated [DATE], the MDS indicated Resident 102's cognition was moderately impaired. The MDS further indicated Resident 102 had fluctuating behaviors of disorganized thinking (rambling conversation, unclear or illogical flow of ideas and unpredictable switching from subject to subject) and delusions (having false or unrealistic beliefs). The MDS indicated Resident 102 required setup or clean-up assistance for eating and oral hygiene and supervision (helper provides verbal cues and/or touching/steadying as the resident completes activity) for toileting, bathing and personal hygiene. During a review of Resident 102's care plan with a focus on behavior problems related to schizophrenia, dated 3/11/2022, the care plan indicated Resident 102 had schizophrenia manifested by paranoid and grandiose delusions (false or unrealistic beliefs) and sudden changes in mood from pleasant to extreme anger outbursts. The care plan indicated Resident 102 had a history of delusional beliefs, which included stating she was a government official and using pencils to write or draw information she believed was provided by the government. The care plan interventions indicated staff were to monitor behavioral episodes, attempt to determine underlying causes, and intervene as necessary to protect the rights and safety of others by approaching the resident in a calm manner, diverting attention, removing the resident from the situation, and redirecting the resident to an alternate location as needed. During a review of Resident 102's Nursing Progress Notes dated 12/15/2025 through 12/17/2025, the Nursing Progress Notes indicated no documented entries of staff supervision or monitoring addressing unsafe items in Resident 102's possession. During an observation on 12/15/2025, at 1:40 p.m., observed Resident 102 standing in the hallway outside of another resident's room holding a bundle of sharpened yellow pencils in her hand. Resident 102 was unsupervised walking through the hallway holding the sharpened pencils. During an interview on 2/15/2024 at 2:10 p.m., with Resident 102, Resident 102 stated she was at the facility on a government assignment and identified herself as a chief advisor for the government. Resident 102 stated she had another identity and believed she was the maker of the Statue of Liberty. Resident 102 stated the pencils in her possession were used to complete logs. Resident 102 stated the pencils were currently kept in a drawer in her room. Resident 102 made multiple statements including stating staff were required to answer to her. Resident 102 stated she was responsible for running the facility and a red book at the nurses' station identified her as being in charge. During a concurrent observation and interview on 12/17/2025 at 9:53 a.m., with CNA 11, in Resident 102's room, observed multiple sharpened pencils in Resident 102's bedside drawer. CNA 11 observed the pencils in the drawer. CNA 11 did not identify the pencils as a safety concern. CNA 11 stated Resident 102 was confused and believed she was the boss of the facility. CNA 11 stated it was acceptable for Resident 102 to have pencils because she was nice, very calm, and independent. CNA 11 acknowledged she could not predict Resident 102's behavior and stated the resident should be checked daily to ensure there were no pencils in her possession. During an interview on 12/15/2025 at 10:05 a.m., with Social Services Assistant (SSA) 1, SSA 1 stated Resident 102 was unpredictable, and pencils should not be in her possession due to safety concerns. During an interview on 12/17/2025 at 10:12 a.m., with LVN 5, LVN 5 stated Resident 102 should not have pencils because she was unpredictable and could use the pencils to harm herself or others. During an interview on 12/18/2025 at 2:01 p.m., with the DON, the DON stated Resident 102 should have supervision while using pencils due to safety for herself, staff, and other residents. During a review of the facility's P&P titled Resident Safety, revised 4/15/2021, the P&P indicated nursing service personnel observed resident safety and wellbeing and conducted resident safety checks at least every two hours around the clock. The P&P indicated staff who identified unsafe situations or practices were to immediately notify their supervisor or charge nurse. 4. During a review of Resident 164's admission Record, the admission Record indicated Resident 164 was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 164's diagnoses included schizoaffective (a serious mental illness with hallucinations, delusions combined with depression or mania), alcohol abuse, anxiety disorder, muscle weakness, lack of coordination and major depressive disorder. During a review of Resident 164's MDS dated [DATE], the MDS indicated Resident 164 cognition was moderately impaired. The MDS indicated Resident 164's mental status fluctuates with disorganized thinking. The MDS indicated Resident 164 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance-as resident completes activity). During a review of the facility's Resident Smokers List dated, 12/15/2025, the Resident Smokers List indicated Resident 164 was a smoker. During a review of Resident 164's Smoking and Safety Assessment (SSA) dated 8/26/2025, the SSA indicated for Resident 164 to utilize a cigarette holder during smoking. During a review of Resident 164's smoking care plan initiated 12/7/2021 and revised on 8/12/2025, indicated Resident 164 is a smoker with supervision and requires a smoking extender to prevent burns to resident's fingers. The care plan indicated an intervention was initiated on 5/31/2022, indicating the resident uses a cigarette extender while smoking. During observations on 12/15/2025 at 10:53 a.m., and 12/17/2025 at 9:42 a.m., Resident 164 was observed in the smoking patio. Resident 164 was observed smoking a cigarette without an extender. During a concurrent observation, interview, and record review on 12/17/2025 at 11:03 a.m., with the Activities Director (AD), Resident 164 was observed in the smoking patio smoking without a cigarette extender. The AD stated certain residents require the use of cigarette extenders to help prevent burns while smoking. The AD stated that smoking precautions, including the use of a cigarette extender, were included in Resident 164's care plan and were required to be followed to prevent injury. The AD stated that cigarette extenders were kept with residents' cigarettes in assigned drawers. The AD stated that there was no cigarette extender in Resident 164's assigned drawer. The AD stated that not having an extender available for Resident 164, while smoking, could increase the risk of burns and/or injury. During a review of the facility's P&P titled Smoking by Residents dated 7/27/2023, the P&P indicated, Facilities that accommodate residents who smoke will take reasonable precautions by providing a safe environment and protecting the non-smoking.

F583F · No harm, potential for more than minimal, widespread

Based on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected by failing to ensure documents, menu ticket and diet type report, containing protected health information ([PHI]- any health information that can be used to identify a specific individual which must remain confidential to prevent harmful consequences) were shredded prior to disposing in the waste container for 295 out of 295 residents. The facility also failed to ensure the privacy curtain was drawn for two of 35 sampled residents (Resident 178 and Resident 188). These deficient practices had the potential to violate 295 of 295 residents' rights for privacy and confidentiality of personal and medical records. These deficient practices also had the potential for Residents 178 and 188 to feel humiliated, emotional distress, and loss of privacy, compromising the residents' dignity.Findings: 1. During an observation on 12/16/2025 at 11:27 a.m., of the trash can by the handwashing sink, observed the diet type report indicating all the resident's name, drug and food allergies, room number, diet, diet texture, diet consistency, diet supplement and additional direction information. During an observation on 12/16/2025 at 1129 a.m. of the dishwashing process, observed the staff throwing the menu ticket in the grey garbage can. During an interview on 12/16/2025 at 11:30 a.m. with the Dietary Supervisor (DS), the DS stated their process of dishwashing was to remove the food and trash including the menu tickets and throw them in the trash. The DS stated the trash is taken out and thrown in the dumpster (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts) outside. The DS stated the menu tickets contained residents' name, diet, room number, likes and dislikes which is protected information. The DS stated the menu tickets also contained resident's diet, diet texture, diet consistency, allergies, food likes and dislikes information. The DS stated they would need a separate container to dispose of the menu tickets so that no one knows where the residents are and where they are located. The DS stated they have been throwing the menu tickets in the trash forever. The DS stated the diet list indicates the residents' name, diet, allergies and medications and it needed to be in the shredder. The DS stated the diet list and menu tickets were in the trash and were not supposed to be in there as somebody could get the resident's information and use it. The DS stated this is Health Insurance Portability and Accountability Act (HIPPA, law that makes your personal health information private and secure with anyone without your permission ensuring you control who sees your sensitive health data.) During a review of the facility's policies and procedures (P&P) titled Notice of Privacy Practices dated 12/1/2012, the P&P indicated, The facility adopts this policy requiring that the facility provide notice of the Facility's privacy practices to facility residents and the public. I. The facility has adopted a Notice of Privacy Practices that describes the Facility's privacy practices (the Privacy Notice), the use and disclosure of Protected Health Information ( PHI) at the facility, and the resident's rights regarding PHI. During a review of the facility's P&P titled Storage and Destruction of Designated Record Set dated 12/1/2025, the P&P indicated To describe the elements of the Designated Record Set and the procedure for approving the content, creation and maintenance of data sources that contains Protected Health Information. I. The facility will maintain accurate and complete medical and billing records for each facility residents in a designated record set, in a secure manner, at locations approved by the facility in accordance with facility policy. II. PHI is kept in locations approved by facility. Any new or additional locations of PHI must be approved by facility administration. II. Storage of Designated Record Set. (A.) The facility will establish the following storage procedures in order to ensure that PHI is accessed by authorized individuals. IV. Destruction of Designated Record Set.(B) The facility records must be destroyed in a manner that ensures the confidentiality of the records and renders the information unrecognizable. i. For PHI in paper records, proper disposal methods may include shredding, burning, pulping or pulverizing the records so that the PHI is rendered essentially unreadable, indecipherable, and otherwise can be reconstructed. ii. For destruction of electronic records PHO see Policy No. HP- 21- Electronic Protected Health Information Security. iii. The facility may not dispose the resident PHI by throwing whole documents in the trash because this is not a method of destruction which ensures the resident information will be recognizable. 2. During a review of Resident 178's admission Record, dated 12/17/2025, the admission Record indicated Resident 178 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 178's diagnoses included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), toxic encephalopathy (any disease, damage, or disorder that affects the brain's function caused by exposure to toxic substances), dementia (a progressive state of decline in mental abilities), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 178's History and Physical (H&P), dated 6/6/2025, the H&P indicated Resident 178 did not have the capacity to understand and make decisions. During a review of Resident 178's Minimum Data Set (MDS - a resident assessment tool), dated 11/23/2025, the MDS indicated Resident 178's cognition (ability to think, remember, and reason) was severely impaired. The MDS indicated Resident 178 required supervision (helper provides verbal cues and/or touching/steadying as the resident completes activity) for eating and upper body dressing and required moderate assistance (helper does less than half the effort) for toileting, bathing, and personal hygiene. The MDS indicated Resident 178 required a wheelchair for mobility (the ability of a resident to move around independently or with assistance). During a concurrent observation and interview on 12/15/2025 at 10:19 a.m., in Resident 178's room, observed Resident 178 sitting on her bed rocking back and forth. Resident 178's privacy curtain was open. The resident was visible from the hallway and to the other residents sharing the room. Resident 178 was observed unclothed with the upper body exposed and a urine-saturated sheet covering the lower extremities. Resident 178's brief was un-taped and falling off, exposing the buttocks. Resident 178 stated she was cold. During a concurrent observation and interview on 12/15/2025 at 10:24 a.m., with Certified Nursing Assistant (CNA) 13, in Resident 178's room, observed Resident 178 unrobed and sitting on the edge of the bed with the privacy curtain open. CNA 13 stated she was not the assigned CNA for Resident 178. CNA 13 stated Resident 178 was confused, anxious, and could become frustrated. CNA 13 stated, She likes to be like this. She takes off her clothes and this is her behavior. CNA 13 pointed to Resident 178's gown on the floor and asked, Don't you see her gown on the floor? CNA 13 stated, So you see she took it off. CNA 13 acknowledged allowing a resident to remain exposed with the privacy curtain open could be a dignity issue. CNA 13 stated staff needed to keep a closer eye on the resident and stated she would get her nurse to assist. CNA 13 did not attempt to dress Resident 178 or provide privacy prior to leaving the room. During an interview on 12/17/2025 at 10:29 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated leaving a resident unclothed with the privacy curtain open was a dignity issue, especially in a shared room. LVN 2 stated Resident 178 should not be exposed in that manner. LVN 2 stated despite Resident 178's behaviors, staff should have protected the resident's privacy and dignity. During an interview on 12/17/2025 at 10:38 a.m., with the Director of Staff Development (DSD), the DSD stated staff must protect resident privacy and dignity. The DSD stated CNA 13 should have closed the curtain, attempted to redirect the resident, and provided privacy. The DSD stated even if the CNA was not assigned to the resident, immediate action should have been taken to protect the resident's privacy and dignity. 3. During a review of Resident 188's admission Record, the admission Record indicated Resident 188 was admitted to the facility on [DATE]. Resident 188's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), Type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), and contracture (a stiffening/shortening at any joint that reduces the joint's range of motion) of multiple muscle sites including both ankles and knees. During a review of Resident 188's MDS, dated [DATE], the MDS indicated Resident 188 had clear speech, expressed ideas and wants, understood verbal content, and had moderately impaired cognition. The MDS indicated Resident 188 had impairments in functional range of motion ([ROM] full movement potential of a joint) in both arms and legs. The MDS also indicated Resident 188 required substantial/maximal assistance (helper does more than half the effort) for toileting, upper body dressing, and lower body dressing. During an observation on 12/17/2025 at 8:34 a.m., observed Resident 188's room door open with a soiled linen cart directly outside the room in the hallway. Resident 188's curtain was drawn, providing privacy between Resident 188's roommate, but was not completely closed around Resident 188's bed. Resident 188 was sitting at the edge of the bed and leaning the torso toward the head of the bed onto the right arm. Resident 188's incontinence brief and both legs were exposed while CNA 9 was placing Resident 188's legs through pants. CNA 9 transferred Resident 188 from the bed to the wheelchair, which was located directly next to the bed. During an interview on 12/17/2025 at 8:39 a.m., while Resident 188 was seated in the wheelchair, Resident 188 stated she did not mind that the curtain was not completely drawn around the bed even if other people walked into the room to see Resident 188 being changed. During an interview on 12/17/2025 at 8:44 a.m. with CNA 9, CNA 9 stated Resident 188's curtain was drawn to the foot of the bed because Resident 188 preferred to see outside while being changed. During a concurrent interview and record review on 12/17/2025 at 8:58 a.m. with the DSD, the DSD reviewed Resident 188's care plans. The DSD stated Resident 188 did not have a care plan for preference to keep the privacy curtain open during care. The DSD stated the staff should completely close the privacy curtain during a resident's care (in general) to prevent anyone from viewing the resident in a vulnerable state. The DSD stated the resident could feel embarrassed or self-conscious if the curtain was not fully drawn during care. During an interview on 12/17/2025 at 9:20 a.m. with the DSD, in Resident 188's room, the DSD stated closing the curtain to the length of the bed did not provide full privacy. During an interview on 12/18/2025 at 3:02 p.m. with the Director of Nursing (DON), the DON stated the privacy curtain should be closed completely to prevent viewing the resident during care. During a review of the facility's P&P titled, Resident Rights, dated 1/1/2012, the P&P indicated the facility staff were to treat all residents with kindness, respect, and dignity. The P&P indicated the residents had a right to privacy. During a review of the facility's P&P titled Resident Rights - Quality of Life, revised 3/2017, the P&P indicated residents were to be cared for in a manner that promoted dignity and respect. The P&P indicated facility staff were to promote, maintain, and protect resident privacy, including bodily privacy, when assisting with personal care.

F755E · No harm, potential for more than minimal, pattern

Based on observation, interview, and record review, the facility failed to remove and separate from current residents' medications 14 discontinued orders for controlled substances (drugs that are regulated by the government because they can be abused or cause addiction) as required by the facility's policy and procedures (P&P), titled, Discontinued Medications and Controlled Medication Storage, affecting nine residents (Residents 24, 29, 45, 59, 63, 127, 237, 257, and 288) in three of five inspected medication carts ([Medcart] (West Station Medcart 1, [NAME] Station Medcart 2, and South Station Medcart 1). This deficient practices increased the risk that Residents 24, 29, 59, 63, 127, 237, 257, and 288, may have received controlled medications without physician orders, more often than prescribed possibly resulting in serious health complications, hospitalization. The availability of discharged Resident 45's controlled medication increased the risk of medication errors, misuse and diversion (when medications are obtained or used illegally).Findings: 1. During an observation of the [NAME] Station Medcart 1, on 12/16/25 at 9:58 a.m., with Licensed Vocational Nurse (LVN) 2, the following discontinued controlled medications labeled for Resident 59 were found inside of the [NAME] Station Medcart 1 stored together with current residents' medications. Resident 59's discontinued controlled medications observed inside of [NAME] Station Medcart 1 were:a. Thirteen tablets of lorazepam 1 milligram (mg, unit of mass or weight in the metric system) for Resident 59 with a fill date of 8/29/2025.b. Fifty-six tablets of lorazepam 1 mg for Resident 59 with a fill date of 9/10/2025. During a current interview and record review on 12/16/2025 at 10:16 a.m., with LVN 2, Resident 59's admission Record was reviewed. The admission Record indicated the resident was hospitalized between 12/5/2025 to 12/10/2025. LVN 2 stated Resident 59 was readmitted to a different nursing station, East Station, on 12/10/2025 with a new order for lorazepam with new directions. LVN 2 stated Resident 59's discontinued controlled medication, lorazepam, should not be in the medication cart when the resident is no longer at the facility and the resident was no longer assigned to the medication cart (West Station Medcart 1). LVN 2 stated discontinued controlled medication should have been removed from the medication cart and given to the Director of Nursing (DON). During an interview on 12/16/2025 at 10:42 a.m., with the Registered Nurse (RN) 1, RN 1 stated discontinued controlled medications go to the DON and the resident's Individual Narcotic Record (a log where each resident's controlled medications are recorded to ensure accurate tracking and accountability) should be signed by the DON and the licensed nurse as soon as possible after the medication is ordered discontinued and/or the resident leaves the facility. During an interview on 12/16/2025 at 10:53 a.m., the DON stated Resident 59's discontinued controlled medication lorazepam should have already been given to the DON for destruction with the facility's consultant pharmacist. The DON stated if the resident's discharge or controlled medications are discontinued on a Friday, and not possible to be given to the DON, then the licensed nurse will keep the medication in the medication cart, continue counting and give the discontinued controlled medication to the DON on Monday, because the DON may not be at the facility on the weekend. During a review of Resident 59's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE], readmitted on [DATE]. The admission Record indicated Resident 59's most recent hospital stay was 12/5/2025 to 12/10/2025. During a review of Resident 59's History and Physical (H&P), dated 8/14/2025, the H&P indicated Resident 59 did not have capacity to make decisions, but can make needs known. During a review of Resident 59's Minimum Data Set ([MDS], a standardized assessment), dated 10/15/2025, the MDS indicated Resident 59's cognition (ability to think, reason, and function) was intact. During a review of Resident 59's Lorazepam orders, the orders indicated the following orders dated:a. 8/23/2025 at 11:39 a.m., telephone order indicated, lorazepam 1 (one) mg by mouth every 6 (six) hours as needed for anxiety for 14 days m/b (manifested by) feelings of losing control, pacing and attempting to strike out.b. 9/9/2025 at 4:39 p.m., telephone order indicated, lorazepam 1 mg by mouth every 6 hours as needed for anxiety for 14 days m/b feelings of losing control, pacing and attempting to strike outc. 12/6/2025 at 8:21 p.m., telephone order indicated, lorazepam, hold date 12/5/2026 through 12/8/2025, reason, transfer to hospitald. 12/8/2025 at 11:56 a.m., telephone order indicated, lorazepam, discontinued date 12/8/2025, reason, discharged to hospital 2. During a concurrent interview and observation of South Station Medcart 1, on 12/16/25 at 11:26 a.m., with LVN 4, LVN 4 stated the South Station Medcart 1 contains both discontinued and residents transferred out of the facility's controlled medications. Observed inside of South Station Medcart 1 were discontinued controlled medications labeled for a total of seven residents (Residents 24, 29, 45, 63, 127, 257, and 288), with one of the seven residents (Resident 45) discharged and was not currently in the facility stored together with current residents' active controlled medication orders. The following resident's discontinued controlled medications observed inside of South Station Medcart 1 included for:a. Resident 24, 53 tablets of lorazepam (treat anxiety, a feeling of worry or nervousness) 1 mg.b. Resident 29, 49 tablets of lorazepam 1 mg.c. Resident 63, 5 tablets of lorazepam 1 mg, one of two medication cards (a type of packaging where each pill is sealed in its own plastic bubble/blister on a sheet).d. Resident 63, 30 tablets of lorazepam 1 mg, two of two medication cards.e. Resident 127, 42 tablets of lorazepam 1 mg.f. Resident 257, 13 capsules of temazepam (treat insomnia, difficulty falling or staying asleep) 7.5 mg.g. Resident 288, 56 tablets of lorazepam 1 mg.h. Resident 45, 9 tablets of lorazepam 1 mg, one of three medication cards.i. Resident 45, 11 tablets of lorazepam 1 mg, two of three medication cards.j. Resident 45, 36 tablets of lorazepam 1 mg, three of three medication cards.k. Resident 45, 12 capsules of temazepam 15 mg. During a concurrent interview and record review on 12/16/2025 at 11:40 a.m., with LVN 4, Residents 24, 29, 63, 127, 257, 288, and 45's admission Records, medication cards, and physician orders between 8/1/2025 to 12/16/2025 were reviewed:a. Resident 29's admission Record indicated the resident was originally admitted to the facility on [DATE], readmitted on [DATE]. Resident 29's telephone order for lorazepam 1 mg was dated 9/18/2025 at 8:34 p.m., order was documented discontinued on 9/22/2025 at 9:01 a.m., with reason, discharged to hospital. LVN 4 stated as of 12/16/2025, Resident 29 did not have a current physician order for lorazepam. Resident 29's monthly Physician Order Summary, dated 12/16/2025, did not include an order for lorazepam for Resident 29.b. Resident 24's admission Record indicated the resident was originally admitted to the facility on [DATE], readmitted on [DATE]. Resident 24's telephone order for lorazepam 1 mg was dated 8/29/2025 at 3:15 p.m., order was documented discontinued on 9/1/2025 at 10:58 a.m., with reason, clarified manifestation. LVN 4 stated as of 12/16/2025, Resident 24 did not have a current physician order for lorazepam. Resident 24's monthly Physician Order Summary, dated 12/16/2025, did not include an order for lorazepam for Resident 24.c. Resident 257's admission Record indicated the resident was originally admitted to the facility on [DATE], readmitted on [DATE]. Telephone order for temazepam 7.5 mg was dated 10/8/2025 at 8:12 p.m., order was documented discontinued on 10/20/2025 at 2:36 p.m., with reason, discharged to hospital. Physician Order Summary, dated 12/16/2025, did not include an order for temazepam for Resident 257. LVN 4 stated as of 12/16/2025, Resident 257 did not have a current physician order for temazepam.d. Resident 63's admission Record indicated the resident was originally admitted to the facility on [DATE], readmitted on [DATE]. Resident 63's admission Record indicated most recent hospital stay was 12/8/2025 to 12/13/2025. Resident 63's telephone order for lorazepam 1 mg was dated 12/8/2025 at 3:21 p.m., order was documented Hold from 12/8/2025 to 12/10/2025, reason, transferred to hospital. Resident 63's lorazepam orders were documented discontinued on 12/10/2025 at 3:48 a.m., with reason, discontinued to hospital. LVN 4 acknowledged that two medications labeled to contain lorazepam 1 mg for Resident 63's was marked as discontinued and stored together with current residents controlled medications inside of the South Station Medcart 1. e. Resident 288's admission Record indicated the resident was originally admitted to the facility on [DATE], readmitted on [DATE]. Resident 288's telephone order for lorazepam 1 mg was dated 11/2/2025 at 5:06 p.m., order was documented discontinued on 11/5/2025 at 11:06 a.m., with reason, discharged to hospital. LVN 4 stated as of 12/16/2025, Resident 288 did not have a current physician order for lorazepam. Resident 288's monthly Physician Order Summary, dated 12/16/2025, did not include an order for lorazepam for Resident 288.f. A review of Resident 127's admission Record indicated the resident was originally admitted to the facility on [DATE], readmitted on [DATE]. Resident 127's telephone order for lorazepam 1 mg was dated 10/30/2025 at 9:45 a.m., with an order to give 1 (one) mg by mouth every 8 hours as needed for anxiety for 14 days, manifested by yelling, angry outburst. LVN 4 stated as of 12/16/2025, Resident 24 did not have a current physician order for lorazepam. Resident 127's Order Listing Report, with an order date range: 8/1/2025 - 12/16/2025, indicated Resident 127's lorazepam order status was documented, Completed. Resident 127's monthly Physician Order Summary, dated 12/16/2025, did not include an order for lorazepam for Resident 127.g. A review of Resident 45's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] and discharged from the facility on 12/12/2025 to the hospital. LVN 4 stated Resident 45 was no longer at the facility and resident's medication cards labeled to contain lorazepam and temazepam, were not marked as discontinued and was stored together with current resident's controlled medications in South Station Medcart 1. During an interview on 12/16/2025 at 12:18 p.m., with LVN 4, LVN 4 stated the facility's policy indicates when resident's controlled medications are discontinued or the resident is discharged from the facility the discontinued controlled medications should be given to the DON for disposal. During an interview on 12/16/2025 at 12:58 p.m., with RN 1, RN 1 stated discontinued controlled medications for Residents 24, 29, 45, 63, 127, 257, and 288 should have been given to the DON to prevent any discrepancies or misuse of controlled medications. During a concurrent interview and review of the facility's policy on 12/16/2025 at 1:09 p.m., with the DON and RN 1, the DON provided a copy of the facility's P&P titled, Discontinued Medications. The DON stated the facility's policy indicated that medications discontinued should be removed from the medication cart and marked and stored separately. The DON acknowledged storing discontinued controlled medication inside of medication carts was not in accordance with the facility's policy. 3. During a concurrent observation, interview and record review of the [NAME] Station Medcart 2, on 12/17/2025 at 10:49 a.m., with LVN 5, inside of the [NAME] Station Medcart 2, was a medication card labeled to contain 27 tablets of lorazepam 1 mg. Resident 237's telephone order dated 10/28/2025 at 12:49 a.m., indicated give lorazepam 1 mg tablet by mouth every 12 hours as needed for anxiety for 14 days. On 10/31/2025 at 1:24 p.m., documentation indicated the facility received an order to discontinue Resident 237's lorazepam medication. LVN 5 stated Resident's 237's discontinued lorazepam medication stored inside of [NAME] Station Medcart 2 should have been marked with a discontinue date and given to the DON to discard. During a review of Resident 237's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE], readmitted on [DATE]. During a concurrent interview and record review on 12/17/2025 at 11:22 a.m., with the DON, Resident 237's physician orders for lorazepam were reviewed. the DON stated Resident 237's discontinued lorazepam medication should not be in the medication cart and should have been separated for disposal. DON reviewed Resident 237's physician orders for lorazepam between 10/28/2025 through 12/16/2025 and stated, Resident 237 did not have a physician order for lorazepam between 11/14/2025 until 12/16/2025. The DON stated there was a potential for Resident 237 to be administered lorazepam without an order or misuse or abuse of controlled medications. During a review of the facility's P&P titled, Discontinued Medications, revised 01/2025, indicated, If a medication expires, or a prescriber discontinues a medication, the discontinued drug container shall be marked or otherwise identified and shall be stored in a separate location designated solely for this purpose. The date the medication was discontinued shall be indicated on the medication container. Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until destroyed.Medications are removed from the medication cart or storage area prior to expiration, and immediately upon receipt of an order to discontinue. During a review of the facility's P&P titled, Controlled Medication Storage, effective date 08/2014, indicated controlled medications remaining in the facility after the order has been discontinued are retained in the facility in a securely double locked area with restricted access until destroyed by the facility's director of nursing or a registered nurse employed by the facility and a pharmacist. The director of nursing in conjunction with consultant pharmacists or designee routinely monitors controlled medication storage, records, and expiration dates during medication storage inspection.

F804E · No harm, potential for more than minimal, pattern

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved appearance and temperature for lunch when: 1. Cinnamon apricot was at 64.9 degrees Fahrenheit ( F, a degree of temperature), country baked beans 103.1 F, roast beef melt on soft roll 104 F, lettuce and tomatoes 92.3 F for regular diet (diet with no restrictions) and soft bite sandwich at 113 F, beans at 110 F, onion soup 106.7 F and milk 47.3 F for soft bite-sized diet (food that are soft and chopped to 1.5 centimeters [cm, a unit of measurement]). 2. Plate presentation for double portion servings and extra food was overflowing and tortilla was touching the beans. 3. The soft bite sized stir-fried vegetables were mushy and mashed. These deficient practices had the potential to result in 280 of 281 facility residents at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.Findings: 1. During a review of the facility's daily cook's spreadsheet (a sheet that contains each diet and what food and portions each diet would get) titled Winter Menus, dated 12/15/2025, the spreadsheet indicated residents on regular diet would include the following foods in the tray:a. French onion soup 8 ounces (oz, a unit of measurement) b. Saltine crackers 1 packetc. Roast beef melt on soft roll 1 pieced. Lettuce and tomatoese. Country baked beans 1/3 cup (c, a household measurement)f. Cinnamon apricots 1/2 cg. Milk 4 oz During a review of the facility's daily cook's spreadsheet titled Winter Menus, dated 12/15/2025, the spreadsheet indicated residents on soft bite-sized International Dysphagia Diet Initiative (IDDSI, [a framework for categorizing food textures and drink thickness]) level 6 would include the following foods in the tray:a. French onion soup 8 oz with chopped vegetablesb. Saltine crackers 1 packet, minced and soak in the soup c. Minced and moist roast beef melt on soft roll 1 pieced. Ketchup 1 tablespoone. Minced and moist country baked beans 1/3 cf. Chopped, soft and drained cinnamon apricots 1/2 cg. Milk 4 oz During a concurrent observation and interview on 12/1/2025 at 11:43 a.m. of the test tray (a process of tasting, temping, and evaluating the quality of food) of the regular diet with the Registered Dietitian (RD), observed the RD take the following temperatures using the facility thermometer: a. Cinnamon Apricot 64.9 Fahrenheit (F, degree of temperature)b. Country baked beans 103.1 Fc. Roast beef melt on soft roll 104 Fd. Lettuce and tomatoes 92.3 F During a concurrent test tray observation and interview on 12/1/2025 at 12:42 p.m. of the soft bite-sized test tray with the RD, the RD took the temperature of the following food using the facility thermometer:a. French onion soup with chopped vegetables 106.7 b. Minced and moist roast beef melt on soft roll 113 Fc. Soft chopped country baked beans 110.1 Fd. Soft chopped cinnamon apricot 64.7 Fe. Milk 47.3 F During an interview on 12/15/2025 at 1:59 p.m. with the RD, the RD stated all the food except for coffee did not meet temperature standards as the expectation is for hot food to be served hot and cold food to be served cold. The RD stated food temperatures could affect the palatability of food and residents would not be satisfied and would not eat the food. The RD stated residents could lose weight overtime as a potential outcome. During a review of the facility's policies and procedures (P&P) titled D16 Food Preparation, dated 9/28/2023, the P&P indicated (4) Acceptable Serving Temperatures a.) Food should be served promptly to maintain safe and palatable temperatures. During a review of the facility's standardized recipe titled Recipe: Roast Beef Melt Sandwich dated 2025, the recipe indicated 3. Serve the sandwich hot. 2. During an observation on 12/15/2025 at 12:51 p.m. of the trayline (an area where foods were assembled from the steamtable to resident's plate), observed double portion tray plate overflowing and the quesadilla was on top of the bowl of beans. During an interview on 12/15/2025 at 2:15 p.m. with the RD, the RD stated plate presentation should be appetizing to the residents and crowded food on the plate is okay for residents requesting extra food and double portions for as long as the tortilla is not going or touching the beans. The RD stated the tortillas could get soft and acceptability could get affected resulting in residents not eating the food. 3. During a review of the facility's daily cook's spreadsheet titled Winter Menus, dated 12/16/2025, the spreadsheet indicated residents on soft bite-sized diet/IDDSI] level 6 would include the following foods in the tray: a. Chopped tender Chinese roasted chicken 2 ozb. Chopped soft-moist fried rice 1/3 cc. Chopped soft stir fry vegetables, 1/3 c d. Chopped mandarin Asian salad, cabbage cooked and serve hot 1/2 ce. Chopped citrus cake, chopped soft drain puree topping 1 pcf. Milk 4 oz During an observation on 12/16/2025 at 11:25 a.m. of [NAME] 1, observed [NAME] 1 mashing the soft bite-sized stir fry vegetables using a whisk (a utensil for whipping eggs and cream) in the steam well. During an interview on 12/16/2025 at 11:36 a.m. with the RD, the RD stated the soft bite-sized stir-fried vegetables were not consistent in size because the zucchini is bigger in pieces and it was not less than 1.5 cm. The RD stated there was already a cart that had stir-fried vegetables with big pieces of zucchini. The RD stated he asked [NAME] 1 to chop it, but the vegetables looked mashed not chopped. The RD stated though the soft bite sized met the texture after [NAME] 1 mashed it, it would not be appetizing to the residents and residents would not eat it as a potential outcome. During a review of the policies and procedures (P&P) titled Food Preparation last reviewed 6/1/2014, the P&P indicated The dietary department has the requisite organization to meet the nutritional needs of residents. The dietary department is responsible for establishing a program that meets the nutritional needs of the residents and accounts for cultural, religious, physical, psychological, and social needs. The primary objectives of the dietary department include: A.) Preparation and provision of nutritionally adequate, attractive, well-balanced meals that are consistent with physicians' orders. C.) Maintenance of standards of quality of food.

F812E · No harm, potential for more than minimal, pattern

Based on observation, interview, and record review, the facility failed to ensure food safety practices and sanitary food storage and food preparation practices when: 1. The refrigerator temperature log indicated temperature at 42 degrees Fahrenheit ( F, a scale of temperature) on 12/10/2025 and freezer temperature log indicated temperature of 10 F on 12/3/2025 and 12/10/2025. 2. Three (3) dented canned foods were stored alongside non-dented canned foods in the dry storage area. 3. The Dietary Supervisor's (DS) was wearing a spiral elastic bracelet touched the plates used in tray line (an area where foods were assembled from the steamtable to resident's plate). 4. Dietary Aide (DA) 1 wore a gold ring with rock while preparing and serving food in the tray line. 5. Ice machine gasket was torn. 6. Two (2) plastic food storage containers on the kitchen shelf had tape and sticker residues. 7. Pots and pans were stacked wet and were not air dried in the storage area. 8. Three (3) cutting boards had scratches. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 280 of 281 medically compromised residents who received food and ice from the kitchen. Findings: 1. During a concurrent observation and interview on 12/15/2025 at 9:13a.m. of the walk-in refrigerator with the DS, observed no thermometer inside the walk-in refrigerator. The DS stated the external thermometer gauge was at 33 F. During an observation on 12/15/2025 at 9:17 a.m. of the walk-in freezer with the DS, observed no thermometer inside the walk-in freezer and the external thermometer gauge was at 2 F. During a review of the facility's logs titled Refrigerator/Freezer Temperature Log posted on the walk-in refrigerator door dated 12/2025, the logs indicated refrigerator temperature was at 42 F on 12/10/2025 and the freezer was at 10 F on 12/3/2025 and 12/14/2025. During an interview on 12/15/2025 at 9:29 a.m. with the DS, the DS stated they maintain the refrigerator temperature at 41 F and below and freezer at 0 F and below to ensure that the food inside it is safe. The DS stated if the temperature was not at the acceptable ranges, freezer could start defrosting and food could start going bad and it could spoil. The DS residents could get foodborne illnesses as a potential outcome if they consumed spoiled food. The DS stated they check the temperatures at 5 AM and 3-4 PM and staff were supposed to document it on the log. During a concurrent interview and record review on 12/15/2025 at 9:39 a.m. with the Assistant Dietary Supervisor (ADS), the Refrigerator/Freezer Temperature Log was reviewed. The refrigerator log indicated a temperature of 42 F on 12/10/2025 and the freezer was at 10 F on 12/14/2025. The ADS stated the staff check the thermometer in the morning and afternoon and the refrigerator should be 41 F and below, and the freezer at 0 F and below. The ADS stated there were temperature entries on 12/10/2025 for 42 F for the refrigerator and 10 F on 12/3/2025 and 12/14/2025 for the freezer with no corrections. The ADS stated the staff was supposed to notify him and write it in the maintenance book or on the corrective action portion of the log, but it was also not documented there. The ADS stated food could become spoiled and not good for consumption if the refrigerator and freezer temperatures were not maintained in the accepted ranges. The ADS stated the residents could potentially get sick of salmonella, virus with diarrhea, nausea and vomiting as symptoms. During a review of the facility's policy and procedure (P&P) titled, Refrigerator/Freezer Temperature Records, dated 11/1/2014, the P&P indicated Purpose: To establish guidelines to record the temperatures of refrigerated and frozen storage areas. Policy: A daily temperature record is to be kept for refrigerated and frozen storage areas. Procedure:I. The dietary manager or designee is to record daily all refrigerator and freezer temperatures on Form A-Refrigerator/Freezer Temperature Log during AM and PM shifts.II. The freezer temperature must be 0 F or below.III. The refrigerator temperature must be 41 F or below.IV. Temperatures above these areas are to be reported to the dietary manager immediately.V. Note on the temperature forms the plan of action taken when temperatures are not in acceptable range.VI. Corrective action should be taken to correct the temperature, or the items should be moved to another storage area to maintain acceptable temperature. During a review of Food Code 2022, the Food Code 2022 indicated, 3-501.16 Time/Temperature for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as a public health control as specified under 3-501.19, and except as specified under (B) and in (C) of this section, Time/Temperature Control for safety food shall be maintained: (2) At 5 C (41 F) or less. 2. During an observation on 12/15/2025 at 9:54 a.m. of the drystorage area, there were two (2) dented cans of green peas and one (1) dented can of baked beans on the same shelf as non-dented food cans. During a concurrent observation and interview on 12/15/2025 at 10:16 a.m. in the dry storage area with the DS, 3 dented cans stored with non-dented canned foods observed. The DS stated dented cans is defined as anything with the dent in the seam or body of the cans. The DS stated they have a separate labeled area of the dented cans in the preparation area to prevent kitchen staff from using them. The DS stated dented cans pose a risk for botulism (a serious illness caused by a toxin that attacks the body's nerves) because air and moisture can enter the container, allowing bacteria to grow and spoil the food. The DS stated residents could get foodborne illnesses as a potential outcome. During a review of the facility's P&P titled, Receiving Food and Supplies, dated 6/22/2023, the P&P indicated Policy: Food and supply items will be received and handled in accordance with recommended sanitary practice. Purpose: To prevent foodborne illnesses. (5) Do not accept and return to supplier, any items that are: (b) dented, rusted, damaged cans. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. 3. During an observation on 12/15/2025 at 12:42 p.m. of the DSassisting the staff during the lunch service, the DS wore a spiral elastic bracelet with a dangling key while assisting in tray line. The key touched empty plates that were then used during lunch tray line. During an observation on 12/15/2025 at 12:51 p.m. in trayline, observed the DS getting the pan of food inside the food warmer and the key the DS was wearing touched the equipment. During an interview on 12/15/2025 at 1:11 p.m. with the Registered Dietitian (RD), the RD stated the key on the DS wrist was not allowed as it could touch the food and could fall on the food. During a review of the facility's P&P titled, Dietary Department - Infection Control, dated 2/29/2024, the P&P indicated, Policy: Dietary employees will follow infection control policies and procedures as established and approved by facility's infection control committee. Purpose: To ensure that the dietary department is maintained in a sanitary condition in order to prevent food contamination and the growth of disease producing organism and toxins. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 - 3-306. 4. During an observation on 12/15/2025 at 12:55 p.m. of the DietaryAide (DA 1) serving food on the trayline, observed DA 1 wearing a gold ring with stone. During a concurrent observation and interview on 12/15/2025 at 1:05 p.m., of DA 1 serving the food in trayline with the DS, DA 1 wore a gold ring with a large stone on her left-hand ring finger while serving food in tray line. DS stated the uniform policy prohibits kitchen staff from wearing dangling earrings and wedding bands because these items can fall into the food. During an interview on 12/15/2025 at 1:09 p.m. with the RD, RD stated kitchen staff are not allowed to wear rings for infection control. During a review of the facility's P&P titled, Dietary Department - Infection Control, dated 2/29/2024, the P&P indicated, Rings, bracelets, and watches are not permitted to be worn while working in the food service area or while preparing food. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 2-303.11 Prohibition. Except for a plain ring such as wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. 5. During an observation on 12/16/2025 at 9:35 a.m. of the internalparts of ice machine in the kitchen, observed a torn gasket. During a concurrent observation and interview on 12/16/2025 at 12:07 p.m. of the internal parts of the ice machine in the kitchen with the DS, the DS stated the black seal was coming off. The DS stated the maintenance department maintains the ice machine and the last time they came was last week. During an interview on 12/16/2025 at 1:30 p.m. with the DS, the DS stated the ice machine gasket was torn and it was not okay as it would not maintain temperature. During a review of the facility's P&P titled Dietary Department - General dated 6/1/2024, the P&P indicated E. Maintenance of accurate records for planning and control of dietary department's food and non-food supply. 6. During an observation on 12/16/2025 at 9:43 a.m. of the pots andpans storage area, observed 2 food containers with tape and sticker residues. During a concurrent observation and interview on 12/16/2025 at 9:49a.m. of the food container with the DS, there was tape residue on the exterior of the food container. The DS stated the tape should have been removed from the container because tape residue can get into resident's food for cross contamination. During a review of the facility's P&P titled, DS48 Pot and Pan Cleaning, dated 6/22/2023, the P&P indicated Pots and pans will be routinely washed, rinsed, and sanitized using the 3-compartment sink and chemicals available. During a review of Food Code 2022, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 7. During an observation on 12/16/2025 at 9:43 a.m. of the pots andpans storage area, observed pots and pans were stacked wet. During a concurrent observation and interview on 12/16/2025 at 9:58a.m. of the pots and pans storage area with the DS, observed the pots and pans were stacked on top of each other. The DS stated pots and pans should not be stacked wet so it can be completely air-dry. The DS stated they could not stack pots and pans wet because of cross-contamination. During an interview on 12/16/2025 at 10:01 AM with the RD, RD stated it was not appropriate to stack wet pans. RD stated wet nesting (when wet dishes, utensils, or cookware are stacked, trapping moisture and creating ideal conditions for bacteria to grow) can occur and bacteria could potentially grow as a potential outcome. During a review of the facility's P&P titled, Pot and Pan Cleaning, dated 6/22/2023, the P&P indicated, 10. Allow items to air dry. Do not use a towel. 11. When items are dry, store them in the proper storage area. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry. 8. During an observation on 12/16/2025 at 10:10 a.m. in thepreparation area, observed scratched brown, green and blue chopping boards. During an interview on 12/16/2026 at 12:10 p.m. with the DS, the DS stated cutting boards that have visible cut marks and scratches should be replaced. DS stated scratched cutting boards can harbor harmful bacteria and could potentially cause cross-contamination. During a review of the facility's P&P titled, Dietary Department - Infection Control, revised 2/29/2024, indicated to maintain sanitary condition to prevent food contamination and the growth of disease producing organisms. During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 4-501.12 Cutting Surfaces. Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may be transferred to foods that are prepared on such surfaces.

F912E · No harm, potential for more than minimal, pattern

Based on observation, interview, and record review, the facility failed to meet the required room size measurement of 80 square feet ([sq. ft.])- a unit of measurement) of room space per resident in rooms with multiple residents. This deficient practice could potentially not provide residents with privacy and could potentially affect residents' health and safety.Findings: During a review of the facility's Room Waiver Request Letter, dated 8/6/2025, the Room Waiver Letter indicated the following rooms did not meet the 80 sq. ft. of space per resident:Room location # of beds Sq. Ft Required Sq. Ft.1. ACU-1A 4 310 3202. ACU-3A 4 310 320 3. ACU-4A 4 310 3204. ACU-4B 2 154 1605. ACU-5B 2 152 1606. ACU-6A 4 310 3207. ACU-7A 4 310 3208. ACU-8A 4 310 320 9. S7 2 141 160 During observations made throughout the course of the survey from 12/15/2025 to 12/18/2025, there were no adverse effects that pertained to the residents' care provided by the facility staff, residents' privacy, health, and safety related to the provided living space of less than 80 sq. ft. per resident. During a concurrent interview and record review, on 12/18/2025, at 2:35 p.m., with the Administrator (ADM), the facility's Room Waiver Request, dated 8/6/2025, was reviewed. The Room Waiver Request indicated the facility normally admitted residents for behavioral and psychological problems. The ADM stated the facility would ensure the residents' health and safety were not adversely affected. The Department will recommend the request for a waiver/variance. During a review of the facility's policy and procedures (P&P) titled Room Waiver, revised 12/1/2015, the P&P indicated the management team consisting of the Administrator, Director of Nurses, and Social Services Director will observe rooms to ensure they are in accordance with the special needs of the residents, and will not have an adverse effect on the residents' health and safety or impede the ability of any resident in the rooms to attain his or her highest wellbeing.

F802E · No harm, potential for more than minimal, pattern

Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and demonstrated competency skills when: a. [NAME] 2 did not follow the recipe when preparing puree (foods that are smooth and pudding like consistency) stir fry vegetables. b. [NAME] 1 did not prepare soft-bite size chopped (foods that can be mashed or broken down with pressure from fork, spoon or chopstick and bite-sized pieces no larger than 1.5 cm [cm., unit of measurement]) stir-fry vegetables in the right size. These deficient practices had the potential to result in 134 of 295 residents on puree/ International Dysphagia Diet Initiative (IDDSI, a framework for categorizing food textures and drink thickness) level 4 and soft bite sized IDDSI level 6 diets at risk of unplanned weight loss, a consequence of difficulty eating and poor food intake, getting food from the kitchen. 1. During a review of the facility's daily cook's spreadsheet (a sheet that contains each diet and what food and portions each diet would get) titled Winter Menus, dated 12/16/2025, the spreadsheet indicated residents on puree diet/IDDSI] level 4 would include the following foods in the tray: a. Puree Chinese roasted chicken 1/3 cup (c, household measurement)b. Puree fried rice 1/3 cc. Puree stir fry vegetables 1/3 c d. Puree mandarin Asian salad 1/3 ce. Puree citrus cake 1/3 c with puree pineapple fluff toppingf. Milk 4 ounces (oz, a unit of measurement) During an observation on 12/16/2025 at 10:20 a.m., of the puree food preparation by [NAME] 2, observed [NAME] 2 preparing puree food. A white perforated scoop was used to measure the vegetables. [NAME] 2 added broth to the vegetables and started using the blender. [NAME] 2 used potato flakes using a measuring cup and one full cup of four cups not leveled and one-half cups of potato flakes (approximately at 2 cups) to make the puree vegetables. During an interview on 12/16/2025 at 10:40 a.m. with [NAME] 2, [NAME] 2 stated he used the broth and followed the recipe for puree vegetables. [NAME] 2 stated he added potato flakes and liquid thickener to achieve the right consistency of the puree vegetables. [NAME] 2 stated he added potato flakes to the puree vegetable until the food was smooth and without lumps. [NAME] 2 stated he would place the puree vegetables back in the oven then check after. [NAME] 2 stated he was doing the puree vegetables recipe for 48 servings. During an interview on 12/16/2025 at 10:48 a.m. with the Dietary Supervisor (DS), the DS stated the Registered Dietitian (RD) trained the staff last November for International Dysphagia Diet Initiative (IDDSI, a framework for categorizing food textures and drink thickness) level 4 guidelines. The DS stated the way to do the puree food was to take food from the regular food and follow the recipe for IDDSI level 4. The DS stated cooks should make sure the puree food is smooth and in the right portion sizes and perform the spoon tilt test (a simple method to check if puree foods are in the correct consistency, thick enough to hold its shape but not sticky by tilting the spoon). The DS stated spoon tilt test is performed to ensure the puree food is not too watery and runny and it's in the right consistency. The DS stated the staff used measuring cups, and it had to be leveled to ensure residents were receiving the right nutrients. The DS stated if the [NAME] did not level the measuring cups, then it would not be accurate, and they did not follow the recipe and could result in increased amount of potato flakes. The DS stated adding too many potato flakes would result in too thick of a product and would increase calorie of the puree food. During an interview on 12/16/2025 at 11:01 a.m. with the RD, the RD stated he provided training to staff for recipes, portion sizes and ingredients for the staff to follow. The RD stated the standardized recipes are important to follow so the food would be cooked the same every time it is prepared. The RD stated the ingredients should be measured to ensure consistency of foods is correct. The RD stated it could affect palatability, appearance and taste and nutritional content if recipes were not followed. During a concurrent observation and interview on 12/16/2025 at 11:56 p.m., of the puree test tray (a process of tasting, temping, and evaluating the quality of food), with the DS and RD, the puree test tray was observed. The DS stated the puree food must be smooth, no lumps, colorful and a baby food consistency. The RD stated puree foods must have no lumps, pudding thick, not too watery, able to hold its shape and pass a standardized fork and spoon test. The DS stated the fork test is used to test the puree mixture for lumps and the spoon tilt test is the test used for puree food to hold its shape, food must fall in one bolus with no dripping liquid. The DS stated a thin film of food left on the spoon was acceptable for spoon tilt test. The RD performed the spoon tilt test for puree salad, puree fried rice and puree Chinese roasted chicken. The RD stated the puree fried rice and puree Chinese roasted chicken were a little thick as it left a thick film when spoon tilt test was performed. The RD stated the puree salad was watery as it fell too quickly during the spoon tilt test. The RD stated the puree foods that were not in the right consistency would not be palatable to the residents and could affect resident's swallowing resulting in decreased nutritional intake. The RD stated the residents could potentially lose weight because of long term decrease in nutritional intake. During a review of the facility's policy and procedure (P&P) titled, Diet Manual Introduction, dated 2025, the P&P indicated Diet manual is intended for use along with the menu system and its corresponding products. The purpose of this manual is to provide common language and a framework for communication among the facility's departments, health care providers, and residents (and their families) when communicating components of their nutritional care and management within the facility. The manual included descriptive overviews of each included diet, allowed foods and those to avoid, nutritional adequacy information, and a simple meal plan, with the goal that this will provide a realistic approach to the diets to make them adaptable to the individual needs of the residents. During a review of the facility's Diet Manual titled IDDSI Level 4: Regular Pureed Diet, dated 2025, the diet manual indicated Description: The pureed diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the prepared pureed food items included on this diet should be smooth and free of lumps, hold their shape, while not being too firm or sticky, and should not weep. Detailed recipes and procedures for pureeing foods may be found in book 1, under the food safety/miscellaneous section. All foods are to be prepared in a food processor or blender. Additional liquids, such as broth, gravy, vegetable or fruit juices, or milk, and potentially food thickeners are added to achieve the appropriate final consistency. Water is not used because it dilutes flavors and results in a poorly accepted product. This diet has texture specifications that must pass IDDSI level#4 testing requirements. TESTING REQUIREMENTS: The finished pureed food item must pass IDDSI Level #4 testing requirements (i.e. appearance, fork drip, and spoon tilt tests). During a review of the facility's P&P titled Standardized Recipe dated 7/1/2014, the P&P indicated To provide the dietary department with guidelines for the use of standardized recipes. Food products prepared and served by the dietary department will utilize standardized recipe. Recipe accuracy concerns will be reported to the Dietitian for evaluation and modification as necessary. During a review of the facility's recipe titled Recipe: Pureed (IDDSI Level 4) Vegetables, dated 2025, the recipe indicated, recipe for 48 serving of puree vegetables would need 1 1/2 - 3 cups instant potatoes as stabilizer. The recipe further indicated (5) the finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished puree items must pass IDDSI Level #4 testing requirements. During a review of the facility's recipe titled Recipe: Pureed (IDDSI Level 4) Meats, dated 2025, the recipe indicated, The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished product must pass IDDSI level 4 testing requirements (i.e. the fork drip, fork pressure, and spoon tilt test). During a review of the facility's recipe titled Recipe: Pureed (IDDSI Level 4) Starch, dated 2025, the recipe indicated, The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished product must pass IDDSI level 4 testing requirements (i.e. the fork drip, fork pressure, and spoon tilt test). During a review of the facility's recipe titled Recipe: Pureed (IDDSI Level #4) Salad, dated 2025, the recipe indicated, The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished product must pass IDDSI level 4 testing requirements (i.e. the fork drip, fork pressure, and spoon tilt test). During a review of the IDDSI guideline website titled IDDSI dated 7/2019, the IDSSI website indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and Fork drip test). During a review of the Job Description titled [NAME] Job Description dated 8/16/2018, the Job Description indicated prepares, in a timely manner, nutritious and attractive meals and supplements for all residents according to Federal, State and corporate requirements. During a review of [NAME] 2's orientation checklist titled Suggested Topics for Orientation Checklist, dated 8/16/2018, the checklist indicated [NAME] 2 was oriented regarding recipe file. During a review of the [NAME] 2's competency titled Dietary [NAME] Competency dated 7/9/2025, the document indicated [NAME] 2 demonstrated competency on serving diet consistency appropriately and following recipes. The competency document was signed by the DS. 2. During a review of the facility's daily cook's spreadsheet titled Winter Menus, dated 12/16/2025, the spreadsheet indicated residents on soft bite-sized/IDDSI] level 6 would include the following foods in the tray: a. Chopped tender Chinese roasted chicken 2 ozb. Chopped soft-moist fried rice 1/3 cc. Chopped soft stir fry vegetables, 1/3 c d. Chopped mandarin Asian salad, cabbage cooked and serve hot 1/2 ce. Chopped citrus cake, chopped soft drain puree topping 1 pcf. Milk 4 oz During an observation on 12/16/2025 at 11:23 a.m. of the soft bite-sized stir fry vegetables in the steam well at the trayline (an area where foods were assembled from the steamtable to resident's plate), observed big chucks of zucchini approximately measuring two (2) to 2.5 cm., in size. During an observation on 12/16/2025 at 11:25 a.m. of [NAME] 1, observed [NAME] 1 mashing the soft bite-sized stir fry vegetables using a whisk (a utensil for whipping eggs and cream) in the steam well. During an interview on 12/16/2025 at 11:36 a.m. with the RD, the RD stated the soft bite-sized stir-fried vegetables were not consistent in size because the zucchini was bigger in pieces and it was not less than 1.5 cm. The RD stated there was already a cart that had stir-fried vegetables with big pieces of zucchini. The RD stated he asked [NAME] 1 to chop it, but the vegetables looked mashed not chopped. The RD stated though the soft bite sized met the texture after [NAME] 1 mashed it, it would not be appetizing to the residents and residents would not eat it as a potential outcome. During a review of the facility's diet manual titled IDDSI Level #6: Soft Bite-Sized dated 2025, the manual indicated Description: The soft and bite-sized is designed for residents who experience biting limitations but are able to chew food items for swallowing. All food prepared for this diet must be soft and chopped into pieces no larger than 1.5 cm to 1.5 cm. This diet has both size and texture specifications that must pass IDDSI level #6 testing requirements. The manual further indicated to avoid cooked vegetables that do not meet size specifications, are tough or fibrous. Definition of chopped: To cut up into small pieces no larger than 1.5 cm x 1.5 cm. During a review of the IDDSI guideline website titled IDDSI dated 7/2019, the IDSSI website indicated, Description and characteristics: bite-sized pieces as appropriate size and oral processing skills: adults, 15 mm = 1.4 cm pieces (no larger than). During a review of the [NAME] 1's orientation checklist titled Suggested Topics for Orientation Checklist, dated 6/18/2018, the checklist indicated [NAME] 1 was oriented regarding recipe file. During a review of the [NAME] 1's competency titled Dietary [NAME] Competency dated 7/9/2025, the document indicated [NAME] 1 demonstrated competency on serving diet consistency appropriately and following recipes. The competency document was signed by the DS. During a review of the facility's in-service records and sign in sheet titled IDDSI transition dated 10/30/2025 and 11/10/2025, the records indicated [NAME] 1 was in attendance and there was no signature for [NAME] 2. The records indicated RD provided in-services for all IDDSI levels, description and testing methods. During a review of the facilities' course in-service records titled Course Completion History dated 12/16/2025, the records indicated [NAME] 2 completed IDDSI comprehensive module, IDDSI designated activities on 11/18/2025 and [NAME] 1 completed the same course on 11/2/2025.

F726E · No harm, potential for more than minimal, pattern

Based on observation, interview, and record review, the facility failed to ensure physician's orders were followed for two of five sampled residents (Resident 18 and Resident 36). This deficient practice placed Residents 18 and 36 at risk for complications due to not receiving their medications, supplements, and not being monitored for signs and symptoms of COVID-19. Findings: 1. During a review of Resident 36's admission Record, the admission Record indicated Resident 36 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 36's diagnoses included hypertension (high blood pressure) and schizophrenia (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 36's History and Physical (H&P), dated 9/24/2025, the H&P indicated Resident 36 did not have the capacity to understand and make decisions due to paranoid (feelings of persecution, anxiety, and a strong sense of threat) schizophrenia. During a review of Resident 36's Minimum Data Set ([MDS] a resident assessment tool), dated 10/14/2025, the MDS indicated Resident 36's cognitive skills for daily decision making was severely impaired (ability to think and reason). The MDS indicated Resident 36 required maximal assistance (helper does more than half the effort) for eating. The MDS indicated Resident 36 was dependent on staff for oral hygiene, toileting hygiene, dressing, shower/bathing, and personal hygiene. During a review of Resident 36's Order Summary Report, dated 9/22/2025, the order summary report indicated the following orders:1. Amlodipine 10 milligrams ([MG] metric unit of measurement, used for medication dosage and/or amount), one time a day, for hypertension. 2. Clonidine 0.2 mg, one time a day, for hypertension.3. Ingrezza 40 mg, daily, for tardive dyskinesia (an uncontrollable condition where the face, body or both make sudden, irregular movements). 4. House supplement/milkshakes, 4 ounces ([oz], unit of weight), three times a day.5. COVID-19 (disease caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death) screening, daily, every shift. During a review of Resident 36's Medication Administration (MAR), for the month of December 2025, the MAR indicated Resident 36 did not receive amlodipine, clonidine, and ingrezza as ordered on 1213/2025. The MAR indicated Resident 36 did not receive the house supplement/milk shake on 12/13/2025 as ordered. The MAR indicated Resident 36 was not monitored/ screened for COVID symptoms during the day shift on 12/13/2025. During an interview on 12/18/2025 at 2:15 p.m. with Registered Nurse (RN) 5, RN 5 stated all residents must receive their medications daily to maintain their highest functional level and help with their health issues. RN 5 stated if residents did not receive their medications, they would not get better and it could be an unsafe situation for them. RN 5 stated licensed nurses were expected to administer all medications to residents. RN 5 stated if a medication was not administered, the licensed nurses had to document the reason why it was not administered in the nursing progress notes. During a concurrent interview and record review on 12/18/2025 at 2:30 p.m. with RN 5, Resident 36's MAR, for the month of December 2025 was reviewed. The MAR indicated on 12/13/2025, for the 9 a.m. administration time, there were no licensed staff initials indicating Resident 36 was administered amlodipine 10 mg, clonidine 0.2 mg, ingrezza 40 mg, or the house supplement/milkshake. The MAR indicated Resident 36 was not monitored/ screened for COVID symptoms on 12/13/2025, during the day shift. RN 5 stated there was no documented evidence Resident 36 received the ordered medication at 9 a.m., the supplement/milkshake or was monitored/screened for COVID on 12/13/2025. RN 5 stated the licensed nurse did not follow the physician orders because the medication was not administered to Resident 36. RN 5 stated this was an unsafe practice because residents need their medications daily. RN 5 stated it was important for residents to receive their medications because it was what the physician ordered to benefit the resident. RN 5 stated licensed nurses must follow all of the physician's orders and document if they were administered or not. RN 5 stated the order for the monitoring/screening of Resident 36 for COVID was a preventative measure and must be followed. 2. During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 18's diagnoses included chronic obstructive pulmonary disease ([COPD], chronic lung disease causing difficulty in breathing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 18's H&P, dated 9/26/2025, the H&P indicated Resident 18 was very confused from severe dementia. During a review of Resident 18's MDS, dated [DATE], the MDS indicated Resident 18's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 18 required setup/clean up assistance for eating. The MDS indicated Resident 18 required maximal assistance for oral hygiene, toileting hygiene, shower/bathing, dressing, and personal hygiene. During a review of Resident 18's Order Summary Report, dated 9/22/2025, the order summary report indicated the following: 1. Donepezil 5 mg, for dementia. 2. Ferrous sulfate 325 mg, for supplement.3. Probiotic one tablet, for supplement.4. Ipratropium albuterol inhalation solution 3 milliliters ([ml] metric unit of measurement, used for medication dosage and/or amount), for COPD. 5. Sugar free house supplement/ milk shake 4 oz at 12 p.m.6. Diabetic snacks at 10 a.m. and 2 p.m. 7. Ensure (a brand of nutritional supplement and meal replacement), as a supplement. 8. Monitor for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar). During a review of Resident 18's MAR for the month of December 2025, the MAR indicated on 12/13/2025 Resident 18 did not receive Donepezil, ferrous sulfate, probiotic, ipratropium albuterol inhalation solution as ordered. The MAR indicated Resident 18 did not receive the supplement/milk shake at 12 p.m. The MAR indicated Resident 18 did not receive diabetic snacks at 10 a.m. and 2 p.m. The MAR indicated Resident 18 did not receive Ensure (a brand of nutritional supplement and meal replacement) at 9 a.m. The MAR indicated Resident 18 was not monitored/screened for COVID symptoms on 12/13/2025 during the day shift. The MAR indicated Resident 18 was not monitored for hyperglycemia and hypoglycemia on 12/13/2025. During an interview on 12/18/2025 at 2:46 p.m. with RN 5, RN 5 stated there was no documentation in the MAR dated 12/13/2025 that indicated Resident 18 received medication at 9 a.m., received supplement/milkshake, ensure or was monitored/screened for COVID, hyperglycemia and hypoglycemia. RN 5 stated the licensed nurses did not follow the physician's order by not providing the scheduled medications, supplements and the monitoring of Resident 18. RN 5 stated it was unsafe not to monitor residents per the physician's order because the licensed nurse would be unaware of the residents health condition and possible decline. During a review of the facility's Policy and Procedure (P&P) titled Medication Administration, dated 10/2017, the P&P indicated medications are administered as prescribed in accordance with good nursing principles. The P&P indicated in no case the individual that administered the medication report off duty without first recording the administration of any medications. The P&P indicated if a medication dose was not administered it must be documented on the MAR. The P&P indicated medications were administered in accordance with written orders of attending physician.

F684E · No harm, potential for more than minimal, pattern

Based on observation, interview, and record review, the facility failed to assess and monitor changes in condition, implement ordered and care-planned interventions, ensure timely administration of medications, and maintain accurate medical records for five of five sampled residents (Residents 18, 36, 130, 155, and 191). These deficient practices resulted in poor quality of care and had the potential to result in delayed identification and treatment of changes in skin condition, worsening of existing skin conditions, unnecessary discomfort, and adverse health outcomes for Residents 18, 36, 130, 155, and 191. Findings: 1. During a review of Patient 36's admission Record, the admission Record indicated Resident 36 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 36's diagnoses included hypertension (high blood pressure) and schizophrenia (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 36's History and Physical (H&P), dated 9/24/2025, the H&P indicated Resident 36 did not have the capacity to understand and make decisions due to paranoid (feelings of persecution, anxiety, and a strong sense of threat) schizophrenia. During a review of Resident 36's Minimum Data Set (MDS, a resident assessment tool), dated 10/14/2025, the MDS indicated Resident 36's cognitive skills for daily decision making was severely impaired (ability to think and reason). The MDS indicated Resident 36 required maximal assistance (helper does more than half the effort) for eating. The MDS indicated Resident 36 was dependent on staff for oral hygiene, toileting hygiene, dressing, shower/bathing, and personal hygiene. During a review of Resident 36' s Order Summary Report, dated 9/22/2025, the order summary report indicated the following orders: 1. Amlodipine (medication used to lower blood pressure) 10 milligrams (mg, metric unit of measurement, used for medication dosage and/or amount), one time a day for hypertension. 2. Clonidine (medication used to lower blood pressure) 0.2 mg one time a day for hypertension. 3. Ingrezza (used to treat involuntary movement disorders) 40 mg in the morning for tardive dyskinesia (an uncontrollable condition where the face, body or both make sudden, irregular movements). 4. Four (4) ounces ([oz], unit of weight) of house supplement/milkshakes three times a day. 5. COVID (disease caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death) screening daily every shift. During a concurrent interview and record review on 12/18/2025 at 2:30 p.m. with Registered Nurse (RN) 5, Resident 36's Medication Administration Record (MAR), for the month of December 2025 was reviewed. The MAR indicated on 12/13/2025 for the 9:00 a.m. administration time, there were no licensed staff initials indicating Resident 36 was administered amlodipine, clonidine, and ingrezza, and provided 4 oz of the house supplement/milk shake. The MAR indicated on 12/13/2025, there were no licensed staff initials indicating Resident 36 was monitored/ screened for COVID symptoms. RN 5 stated there was no documentation in the MAR dated 12/13/2025 that indicated Resident 36 received his routine medications at 9:00 a.m., the supplement/milkshake, or was monitored/screened for COVID. During a concurrent interview and record review on 12/18/2025 at 2:39 p.m. with RN 5, Resident 36's Progress Notes dated 12/13/2025 was reviewed. The progress notes indicated there was no documentation on 12/13/2025 to indicate the reason why Resident 36 did not receive medications. RN 5 stated all licensed nurses must document in the progress notes to indicate the reason why a resident did not receive medication and their physician was notified. RN 5 stated based on the lack of information he did not know why Resident 36 did not receive medications. 2. During a review of Patient 18's admission Record, the admission Record indicated Resident 18 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Resident 18's diagnoses included chronic obstructive pulmonary disease (COPD, chronic lung disease causing difficulty in breathing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 18's H&P, dated 9/26/2025, the H&P indicated Resident 18 was very confused from severe dementia. During a review of Resident 18's MDS, dated [DATE], the MDS indicated Resident 18's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 18 required setup/clean up assistance for eating. The MDS indicated Resident 18 required maximal assistance for oral hygiene, toileting hygiene, shower/bathing, dressing, and personal hygiene. During a review of Resident 18's MAR dated for the month of December 2025, the MAR indicated Resident 18 did not receive or was provided the following on 12/13/2025: 1. Donepezil (used to manage symptoms of dementia) 5 mg. 2. Ferrous sulfate (supplement) 325 mg. 3. Probiotic (help the body digest food or help with symptoms of certain illnesses) 1 tablet. 4. Ipratropium albuterol inhalation solution (used to relax the muscles around the airways and increase airflow to the lungs) 3 milliliters ([ml] metric unit of measurement, used for medication dosage and/or amount). 5. 4 oz sugar free house supplement/milk shake. 6. Diabetic snacks at 10:00 a.m. and 2:00 p.m. 7. Ensure (a brand of nutritional supplement and meal replacement) at 9:00 a.m. 8. COVID monitoring/ screening. 9. Monitoring for hyperglycemia (low blood sugar). During a concurrent interview and record review on 12/18/2025 at 2:46 p.m. with RN 5, Resident 18's MAR, for the month of December 2025 was reviewed. The MAR indicated on 12/13/2025, for the 9:00 a.m. administration time, there were no licensed staff initials indicating Resident 18 was administered donepezil, ferrous sulfate, probiotic 1 tablet, and ipratropium albuterol inhalation solution or provided Ensure. The MAR indicated on 12/13/2025 at 12:00 p.m., there were no licensed staff initials indicating Resident 18 was provided with a house supplement/milk shake. The MAR indicated on 12/13/2025 at 10:00 a.m. and 2:00 p.m., there were no licensed staff initials indicating Resident 18 was provided diabetic snacks. The MAR indicated on 12/13/2025, there were no licensed staff initials indicating Resident 18 was monitored for hyperglycemia or monitored/screened for COVID symptoms. RN 5 stated there was no documentation in the MAR for 12/13/2025 indicating Resident 18 received his routine medication at 9:00 a.m., the supplement/milkshake, ensure or was monitored/screened for COVID and hypoglycemia. During a concurrent interview and record review on 12/18/2025 at 2:52 p.m. with RN 5, Resident 18's Progress Notes dated 12/13/2025 was reviewed. The progress notes indicated there was no documentation on 12/13/2025 to indicate the reason why Resident 18 did not receive medications, supplement/milkshake, ensure, or was monitored/screened for COVID and hypoglycemia. RN 5 stated all licensed nurses must document in the progress notes to indicate the reason why a resident did not receive medication and that the physician was notified. RN 5 stated based on the lack of information he did not know why Resident 18 was not administered medications, supplement/milkshake, ensure, or was monitored/screened for COVID and hypoglycemia as ordered. During a review of the facility's Policy and Procedure (P&P) titled Medication Administration, dated 10/2017, the P&P indicated medications are administered as prescribed in accordance with good nursing principles. The P&P indicated in no case the individual that administered the medication report off duty without first recording the administration of any medications. The P&P indicated if a medication dose was not administered it must be documented on MAR. 3. During a review of Resident 130's admission Record, dated 12/17/2025, the admission Record indicated Resident 130 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 130's diagnoses included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (a mental illness that is characterized by disturbances in thought), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), dementia (progressive state of decline in mental abilities), protein-calorie malnutrition (not getting enough protein and calories to meet the body's needs), and hyperglycemia (high blood sugar levels). During a review of Resident 130's H&P dated 10/30/2025, the H&P indicated Resident 130 had fluctuating capacity to understand and make decisions. During a review of Resident 130's MDS, dated [DATE], the MDS indicated Resident 130's cognition was moderately impaired. The MDS indicated Resident 130 required setup or clean up assistance (helper sets up or cleans up) for eating and supervision (helper provides verbal cues and/or touching/steadying as the resident completes activity) for toileting, bathing, oral and personal hygiene. During a review of Resident 130's Care Plan titled Potential Impairment of Skin Integrity, revised 6/4/2025, the care plan indicated the following interventions: nursing staff were to monitor and document skin conditions and report abnormalities, signs and symptoms of infection, or failure to heal to the physician; and nursing staff were to identify potential causative factors, follow facility protocols for treatment of skin injury, and implement measures to prevent skin injury. During a review of Resident 130's Care Plan addressing Activities of Daily Living (ADLs - outline tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), revised 9/16/2025, the care plan indicated the following interventions: nursing staff were to complete skin inspection every shift, observe for redness, open areas, scratches, cuts, or bruises, and report changes to the nurse. During a review of Resident 130's Nursing Progress Notes dated 12/15/2025 through 12/16/2025, the progress notes did not indicated there was documentation regarding a change of condition (COC - a change in a patient's health status that requires assessment and follow-up) related to Resident 130's rash and no documentation of physician notification. During a concurrent observation and interview on 12/15/2025 at 10:55 a.m., with Resident 130, Resident 130 was observed scratching a rash on both exposed forearms. Resident 130 stated the rash was itchy and nursing staff were not treating the rash. During a concurrent observation and interview on 12/17/2025 at 11:26 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 observed the rash on Resident 130's forearms. LVN 2 stated she was not aware of the rash. LVN 2 stated nurses should assess residents for all conditions, including rashes. LVN 2 stated a rash could be contagious and overlooking a rash could cause an outbreak affecting staff and residents. LVN 2 stated she should have completed a skin assessment and followed up with the treatment nurse regarding the rash. During an interview on 12/17/2025 at 12:29 p.m., with Treatment Nurse (TN) 1, TN 1 stated if Resident 130 had an itchy rash, the rash should have been assessed and the physician contacted. TN 1 stated staff should not have assumed the cause of the rash and should have ensured the rash was assessed, the physician contacted, and a dermatology (a doctor who specializes in diagnosing and treating skin conditions) consultation obtained. TN 1 stated nursing staff, including certified nursing assistants (CNAs), should have assessed Resident 130 for a rash and should have notified the charge nurse or the treatment nurse when the rash was observed. TN 1 stated contacting the physician was important to protect the resident and to prevent the rash from spreading to staff and other residents in case the rash was contagious. During an interview on 12/18/2025 at 2:01 p.m., with the Director of Nursing (DON), the DON stated a rash should have been treated as a COC. The DON stated nursing staff should have notified the physician, followed the physician's orders, and initiated or updated a care plan related to the rash. The DON stated these actions were necessary to maintain skin integrity and prevent skin breakdown. During a review of the facility's P&P titled Change in Condition, effective 8/25/2022, the P&P indicated nursing staff were responsible for reporting, assessing, and documenting changes in a resident's condition and for notifying the resident's physician/advanced practice provider (APP) when a significant change in condition occurred. The P&P also indicated nursing staff were responsible for updating the resident's care plan to reflect the resident's current condition. During a review of the facility's P&P titled Skin Integrity Management, effective 7/31/2024, the P&P indicated a licensed nurse would complete a skin evaluation when there was a change in skin integrity, notify the physician of changes in condition, document treatment in the resident's medical record, and review and update the resident's care plan as necessary. 4. During a review of Resident 155's admission Record, the admission Record indicated Resident 155 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE]. Resident 155's diagnoses included metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance or underlying medical issue), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), inability to move the right side of her body, lack of coordination, abnormalities of gait and mobility, and history of falling. During a review of Resident 155's MDS, dated [DATE], the MDS indicated Resident 155 had severe cognitive impairment. The MDS indicated Resident 155 was dependent on staff for mobility while in bed, and mobility out of bed was not attempted due to safety or medical concerns. During a review of Resident 155's physician order, dated 12/14/2025, the physician order indicated staff were to apply a helmet to Resident 155 at all times. During observations on 12/15/2025 at 10:53 a.m., 12/16/2025 at 11:08 a.m., and 12/17/2025 at 10:10 a.m., at Resident 155's bedside, observed Resident 155 lying in bed. Resident 155 was not wearing a helmet. During an interview on 12/17/2025 at 10:15 a.m., Resident 155's roommate stated she was Resident 155's roommate for more than a month and stated she never observed Resident 155 wearing a helmet. During an interview on 12/17/2025 at 10:19 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was familiar with Resident 155, and knew Resident 155 was a fall risk. CNA 1 stated Resident 155 did not wear a helmet. CNA 1 stated she had never applied a helmet to Resident 155. During a concurrent observation and interview, on 12/17/2025 at 10:20 a.m., at Resident 155's bedside, with CNA 1, observed CNA 1 check Resident 155's bedside dresser and closet for a helmet. CNA 1 stated Resident 155 did not have a helmet in her belongings. CNA 1 stated the Charge Nurse did not tell her Resident 155 needed one. During a concurrent interview and record review, on 12/17/2025 at 10:27 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 155's physician order dated 12/14/2025 was reviewed. LVN 1 stated Resident 155's physician order indicated Resident 155 was to have a helmet on at all times. LVN 1 stated she did not know if Resident 155 had a helmet, but as the Charge Nurse, she was responsible for checking the physician orders and ensuring they were implemented. LVN 1 stated she required the helmet due to her history of falling and injuring herself. LVN 1 stated that the purpose of the helmet was resident safety. During a review of Resident 155's Electronic Medication Administration Record (EMAR), dated 12/2025, the EMAR indicated LVN 1 documented she applied Resident 155's helmet on 12/15/2025, 12/16/2025, and 12/17/2025. During an interview on 12/17/2025 at 12:26 p.m., with LVN 1, LVN 1 stated a check mark logo on the EMAR indicated the order was carried out and/or care was provided. LVN 1 stated she documented in Resident 155's EMAR that she applied Resident 155's helmet even though she did not. LVN 1 stated she made the mistake because she was just clicking and did not pay attention to what she was clicking in the medical record. LVN 1 stated this was not the correct practice for charting in the Resident 155's record. During an interview on 12/17/2025 at 3:40 p.m., with the DON, the DON stated nurses were supposed to accurately document the care provided. The DON stated nurses should only be documenting care that was provided and stated the residents' medical records were supposed to be accurate. During a review of the facility's job description titled Charge Nurse, undated, the job description indicated it was the Charge Nurse's responsibility to ensure that required documentation was complete and in compliance with regulations and standards. 5. During a review of Resident 191's admission Record, the admission Record indicated Resident 191 was initially admitted to the facility on [DATE]. Resident 191's diagnoses included Stage 4 pressure ulcers (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the left and right hip, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (a feeling of uneasiness). During a review of Resident 191's MDS, dated [DATE], the MDS indicated Resident 191's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 191 required supervision or touching assistance for eating, upper body dressing and putting on footwear. The MDS indicated Resident 191 required partial, moderate assistance (helper does less than half of the effort) for toileting and showering. During a review of Resident 191's H& P, dated 2/26/2025, the H&P indicated Resident 191 had the capacity to make and understand medical decisions. During a review of Resident 191's Fungal Rash Care Plan, dated 8/7/2025, the Care Plan indicated Resident 191 had a fungal rash in the pubic area (area around the genitals) that extended to his thighs. The Care Plan interventions indicated to have a dermatologist (a medical doctor who specializes in diagnosing and treating diseases of the skin, hair, nails and mucus membranes) consulted. During a concurrent observation and interview on 12/15/2025 at 10:27 a.m. with Resident 191, Resident 191's legs, back and trunk were observed. Resident 191 had circular, brown to pink-colored rashes spread across his legs, lower back, and lower abdomen. Resident 191 stated that he was told by licensed nursing staff that a physician would evaluate his rash; however, the resident stated this had not occurred since the rash initially developed months ago. During a concurrent interview and record review on 12/17/2025 at 3:53 p.m. with TN 2, all of Resident 191's Nursing Progress Notes, Change of Condition Notes, Consult Visits Documentation, and Physician Orders, dated from 8/6/2025 through 12/17/2025, were reviewed. Resident 191's Change of Condition Note, dated 8/6/2025, indicated Resident 191 reported having mild itchiness to the pubic area, and upon assessment, he was noted with red spots on the pubic area that extended to the lateral thigh. The Change of Condition Note indicated the physician ordered to have a dermatology consult for his re-current skin rash. The Physician Orders indicated Resident 191 was ordered a dermatology consult on 8/6/2025 and 11/21/2025. The Nursing Progress Notes and Consult Visits Documentation lacked documentation to indicate a dermatologist was contacted or a dermatology evaluation was completed. TN 2 stated the normal process to obtain a dermatology consult was for licensed nursing staff to transcribe the physician order, contact the dermatologist, and ensure sufficient documentation was included in the medial record so that other members of the IDT were aware of the resident's medical condition and care needs. TN 2 stated if licensed nursing staff were unable to contact the dermatologist, the order and reason for the consultation should be endorsed to the treatment nurse for follow-up. TN 2 stated he was unaware of the dermatology consult order. TN 2 stated Resident 191's medical record lacked documentation to indicate an attempt was made to contact a dermatologist and that a dermatologist evaluated Resident 191. TN 1 stated this caused a delay in evaluation and treatment of Resident 191's rash. During an interview on 12/17/2025 at 4:25 p.m. with LVN 12, LVN 12 stated he recalled transcribing the physician order for Resident 191's dermatology consult dated 11/21/2025. LVN 12 stated he did not contact the dermatologist to obtain the consultation but endorsed the order to the Registered Nurse Supervisor; however, he did not document the endorsement and did not follow up to ensure the consultation was obtained. LVN 12 stated he also did not follow up on the progression of Resident 191's rash or perform additional assessments. LVN 12 stated the lack of follow-up for Resident 191's consultation led to a delay in assessment, monitoring and specialty evaluation for the skin condition. During a concurrent observation and interview on 12/17/2025 at 3:30 p.m. with TN 2, photographs of Resident 191's legs, abdomen, and back, dated 12/15/2025 and timed at 10:27 a.m., were reviewed. The photos indicated Resident 191 had numerous circular brown to pink-colored rashes present on the legs, lower abdomen, and lower back. TN 2 stated he was not aware Resident 191 had a rash. During a concurrent record review and interview on 12/17/2025 at 3:53 p.m. with TN 2, all of Resident 191's Nursing Progress Notes and Skin Checks, dated 8/6/2025 to 12/17/2025, were reviewed. The Nursing Progress Notes and Skin Checks lacked documentation demonstrating ongoing assessment and monitoring of Resident 191's rash, including evaluation of the rash's progression, response to treatment, or need for modification of interventions. TN 2 stated the lack of documented ongoing assessment, rash progression, or the need for additional treatment modification led to inadequate monitoring of Resident 191's rash that spread from his pubic area to his lower extremities, lower back and abdomen. During a review of the facility's P&P titled, Resident Rights- Quality of Life, revised 3/2017, the P&P indicated the facility was to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident's comprehensive assessment and pIan of care. During a review of the facility's P&P titled, Physician Orders, revised 11/16/2022, the P&P indicated the facility was to ensure Documentation pertaining to physician orders will be maintained the Resident's medical record. During a review of the facility's P&P titled, Skin Integrity Management, revised 6/27/2024, the P&P indicate a Licensed Nurse would complete the skin evaluation weekly and the IDT would review the resident's care plan and update as necessary.

F805E · No harm, potential for more than minimal, pattern

2 findings

F520K · Immediate jeopardy, pattern

Based on observation, interviews, and record reviews, the Quality Assessment and Assurance (QAA) committee failed to monitor the effects of implemented changes, and make needed revisions to the action plans in order to correct the residents potential risks for elopement (when a patient leaves the facility without authorization or appropriate supervision). Resident 1, was admitted to a locked (a health facility providing therapy for substance abuse, mental illness and or other behavioral problems) facility on 5/8/14, with the [DIAGNOSES REDACTED]. On 5/15/14 at 11:20 p.m., Resident 1 used 2 linen barrels stored at the corner of the fence between advanced care unit (ACU which houses independent residents) and special care unit (SCU which houses dementia residents who have loss of brain function that occurs with certain diseases effecting memory, thinking, language, judgment, and behavior.) to jump the fence into the SCU. Resident 1 then used a trash can, jumped the fence next to the activity room wall between SCU and Lakewood gardens parking lot which leads into the streets. Patient 1 eloped from the facility on 5/15/14 by using the linen barrels and trash can as a stepping stool to climbing over the fences. This failure placed Resident 1 and 67 residents out of 281 total resident census, who were also assessed at risk for elopement, at risk for harm and injuries. The facility was also identified with a systems failure by not implementing corrective actions after the facility identified Resident 1 being at risk for elopement and having other residents elope from the same facility. According to the facility's discharge lists, in 2013, there were 3 residents and in 2014, there were 2 residents who eloped from the same facility. On 5/30/14 at 1:38 p.m., an Immediate Jeopardy (IJ) was called. The administrator, the assistant administrator and the DON were immediately notified of the serious findings. The facility developed an action plan in response to the IJ. The facility's action plan included the following: 1. Secure or remove trash containers and soiled clothes containers around the courtyards at ACU and SCU today. 2. Monitoring personnel will be assigned to ACU and SCU grounds effective immediately for 24 hours until the construction of the fences were done. A reliever will be provided to the monitoring persons and log will be done every 30 minutes. 3. Staff will be informed of the residents who are at risk for elopement. 4. On 5/30/14 at 9 p.m., the clinical consultant will give an in-service to all staff in coordination with the Medical Director and the psychiatrist regarding elopement. After verifying the action plan was implemented, the IJ was abated on the same day on 5/30/14 at 5 p.m., and the scope and severity for F323 was reduced to E. Findings: On 5/30/14 at 7 a.m., an unannounced visit was made to investigate an entity self-reported incident regarding quality of care and resident safety. On 5/30/14 at 8 a.m., during a tour of the ACU, resident's room, and the surrounding grounds, the ACU was observed separated from SCU unit by an eight foot metal fence. The fence was recently extended another four feet because Resident 1 had jumped the fence. There were several yellow barrels that were chained to the poles. The barrels were used to store soiled linens in the back of ACU. On 5/30/14 at 8:30 a.m., during the tour the maintenance supervisor stated the extra four foot was added recently to the metal fence in between the ACU and SCU because Resident 1 broke the plastic handles that helped chain the barrels to a pole. He used the two yellow barrels to jump the gait from ACU into SCU. However, on 5/30/14 at 8:45 a.m., during the tour of the ACU, there was 2 gray recycling barrels about three feet tall next to a chained link fence that was not secured or chained to the fence. On 5/30/14 at 8:45 a.m., during the tour and concurrent interview with the Assistant administrator stated once Resident 1 jumped the fence into SCU, he used a trash can to jump the fence into the parking lot in order to leave the facility. However, even though Resident 1 used the trash can to jump over the same fence, next to the fence there was a large plastic trash can, and a metal trash can used for cigarette butts that was not secured or chained. On 5/30/14 at 8:40 a.m., during the tour the activity assistant stated there were ambulatory residents at SCU could probably jump the fence if they wanted to, even without the trash can. In front of the assistant administrator, and maintenance supervisor, the activity assistant demonstrated how one could easily climb the metal fence. He placed one foot on the conduit box (a metal box protecting electrical wires) that was attached next to the fence, used the handle on the gate to place his other foot, and by grabbing the metal rails, he pulled himself to the top of the fence. The activity assistant stated once you're up there (pointing to the top of the fence) you can easily jump the fence over. The assistant administrator also stated at around 10:40 p.m., one of the facility's surveillance cameras did record Resident 1 carrying two yellow soiled linen barrels to the first fence at ACU but it does not show how he jumped the second fence because the camera does not show beyond a certain point. During the tour one camera was observed attached to the back corner of ACU Cottage #6 which was pointing to the direction of SCU. The assistant Administrator stated the facility is in the process of installing more cameras and placing staff members to monitor those cameras. However right now, the facility is only recording and watching the recordings later. He also stated the facility is equipped with an alarm which alerts staff at the nursing station however, the alarm is not installed throughout the 10-acre facility. According to him right now the alarm is not working in the SCU because facility is waiting to recheck the system in order for it to trigger faster. On 5/30/14 at 8:40 a.m., during the tour the maintenance supervisor said he had added an extra three feet of curved inward metal to the already existing railings on top of the concrete walls. He then covered the rails with a solid metal mesh so the residents could not use it as leverage to pull themselves up. However, the exact location where Resident 1 jumped the fence leading to the outside parking lot did not have the curved extension and or the metal mesh covering the rails. The maintenance supervisor said he had done all the work himself but stopped at where Resident 1 jumped because he did not have enough funds. On 5/30/14 at 8:45 a.m., during the observation of the ACU there were two large metal gates that led to the outside parking lot. The gates were eight feet tall with an extra 3 feet of metal railings. The railings did not have the solid metal mesh coverings to prevent the residents from using them as leverage in order to jump the gate. The administrator stated I guess anyone can climb and hold on to the railings and jump over. At the same time a laundry room was also observed in the ACU behind a nine feet fence with an extra 1 foot solid metal added to it. This gate led to another 5 foot gate that led to the outside parking lot. The administrator stated again some of the residents can still jump this fence and leave the facility. A review of Resident 1's clinical records indicated Resident 1 was admitted to the locked facility on 5/8/14, with [DIAGNOSES REDACTED]. The elopement risk assessment form dated 5/13/14, indicated Resident 1 was assessed a total score of 10 (8 or greater the resident should be considered at risk for potential elopement from the facility). On 5/30/14 at 9:08 a.m., after looking at the clinical records the ADON stated there was no plan of care addressing Resident 1's elopement risk, goals and or interventions in order to eliminate and or reduce the resident's elopement. The Minimum Data Set assessment (provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems) dated 5/27/14, indicated short-term and long term memory problems, usually understands, moderately impaired in daily decision making, inattentive, hallucinates (sensing things while awake that appear to be real but instead have been created by the mind), and was delusional (having false or unrealistic beliefs or opinions). A review of the social work progress notes dated 5/13/14, Resident 1 called the police and the social worker designee (SSD) stating someone is out to hurt him. The resident also verbalized wanting to leave and to go back to the skilled nursing facility in Pasadena, where he previously resided. On 5/14/14, the SSD received another call stating Resident 1 wanted to leave the facility and go home The notes further indicated the resident called the SSD several times inquiring about his court hearing on 5/15/14. When SSD called the conservator, she was told the resident did not need to attend the court hearing. According to the notes SSD explained to the resident but it seemed the resident did not understand and he kept calling her on his cell phone. The resident kept telling SSD that someone is hurting him. On 5/15/14, SSD received a call from the Ombudsman stating the resident called her saying someone hurt him. The SSD spoke to the Ombudsman telling them the resident is delusional and that no one hurt him. There was no care plan developed for Resident 1's behavior of verbalizing wanting to go home, being concerned about a court hearing, believing someone was hurting him or out to hurt him, which increased his elopement risks. On 5/30/14 at 9:08 a.m., the ADON stated she could not find a care plan addressing the resident's behaviors. According to the facility's investigation dated 5/15/14, Resident 1 left absent without official leave (AWOL) and was gone until 5/19/14, when he came back to the facility. The resident was re-assessed and transferred to the acute care hospital but did not return. On 5/30/14 at 4 p.m., the facility's medical director said when a resident goes AWOL from the facility, he has recommended for not re-admitting the resident back. When asked what happens to the resident he said, "They have to go to another facility I guess." A review of the facility's policy and procedures for wandering and elopement revised 1/1/12, indicated facility staff must ensure the residents health and safety. If the resident appears likely to elope, the facility staff should provide diversions and increase monitoring of the resident by instituting a one-on-one staffing until the resident's risk of elopement subsides. The nursing staff will update the resident's care plan to include interventions to prevent elopement. A review of the facility's QAA committee minutes dated August, November 2013, and February 2014, only indicated the number of the residents who have AWOL from the facility. The forms indicated to see the attached reports. On 5/30/14 at 4:15 p.m., the assistant administrator and the administrator both stated there were inservices for elopement. When asked how was the inservices were validated to ensure the committees plan was working, they did not answer. The administrator stated he could not find the missing attached reports. Even though the facility was aware of the resident's identified at risk for elopement and the residents who had actually eloped from the facility, there was no documented evidence of committee identifying the irregularities in actions to correct the residents potential risks for elopement, and to monitor the effect of these corrections. On 5/30/14 at 4 p.m., the facility's medical director said when a resident AWOL, his recommendations have been not to re-admit the resident back. When asked what happens to the resident he said they have to go to another facility I guess. A review of the facility's policy and procedures for quality assessment and assurance program revised dated 1/1/12, indicated the facility implements and maintains and ongoing, facility wide QAA program designed to monitor and evaluate the quality of the residents care, pursue methods to improve care and quality, and resolve identified problems. Cross Refer to, F226, F323, and F520

F323K · Immediate jeopardy, pattern

Based on observation, interviews, and record reviews, the facility failed to provide a safe and secure environment and supervision for a resident who was assessed at high risk for elopement (when a patient leaves the facility without authorization or appropriate supervision), who also had short and long-term memory problem, and was experiencing auditory hallucinations (false perceptions of sounds) telling him to kill himself, with no established measures to prevent the resident from eloping. Resident 1, who was admitted to a locked (a health facility providing therapy for substance abuse, mental illness and or other behavioral problems) facility on 5/8/14, with the [DIAGNOSES REDACTED]. On 5/15/14 at 11:20 p.m., Resident 1 used 2 linen barrels stored at the corner of the fence between advanced care unit (ACU which houses independent residents) and special care unit (SCU which houses dementia residents who have loss of brain function that occurs with certain diseases effecting memory, thinking, language, judgment, and behavior.) to jump the fence into the SCU. Resident 1 then used a trash can, jumped the fence next to the activity room wall between SCU and Lakewood gardens parking lot which leads into the streets. Patient 1 eloped from the facility on 5/15/14 by using the linen barrels and trash can as a stepping stool to climbing over the fences. Resident 1 came back on 5/19/14, and was sent out to the acute care hospital for evaluation. Resident 1 was not readmitted back to the facility. This failure placed Resident 1 and 67 residents out of 281 total resident census, who were also assessed at risk for elopement, at risk for harm and injuries. The facility was also identified with a systems failure by not implementing corrective actions after the facility identified Resident 1 being at risk for elopement and having other residents eloped from the same facility. According to the facility's discharge lists, in 2013, there were 3 residents and in 2014, there were 2 residents who eloped from the same facility. On 5/30/14 at 1:38 p.m., an Immediate Jeopardy (IJ) was called. The Administrator, the assistant Administrator and the DON were immediately notified of the serious findings. The facility developed an action plan in response to the IJ. The facility's action plan included the following: 1. Secure or remove trash containers and soiled clothes containers around the courtyards at ACU and SCU today. 2. Monitoring personnel will be assigned to ACU and SCU grounds effective immediately for 24 hours until the construction of the fences were done. A reliever will be provided to the monitoring persons and log will be done every 30 minutes. 3. Staff will be informed of the residents who are at risk for elopement. 4. On 5/30/14 at 9 p.m., the clinical consultant will give an in-service to all staff in coordination with the Medical Director and the psychiatrist regarding elopement. After verifying the action plan was implemented, the IJ was abated on the same day, 5/30/14 at 5 p.m., and the scope and severity for F323 was reduced to E. Findings: On 5/30/14 at 7 a.m., an unannounced visit was made to investigate an entity self-reported incident regarding quality of care and resident safety. On 5/30/14 at 8 a.m., during a tour of the ACU, resident's room, and the surrounding grounds, the ACU was observed separated from SCU unit by an eight foot metal fence. The fence was recently extended another four feet because Resident 1 had jumped the fence. There were several yellow barrels that were chained to the poles. The barrels were used to store soiled linens in the back of ACU. On 5/30/14 at 8:30 a.m., during the tour the maintenance supervisor stated the extra four foot was added recently to the metal fence in between the ACU and SCU because Resident 1 broke the plastic handles that helped chain the barrels to a pole. He used the two yellow barrels to jump the gait from ACU into SCU. However, on 5/30/14 at 8:45 a.m., during the tour of the ACU, there was 2 gray recycling barrels about three feet tall next to a chained link fence that was not secured or chained to the fence. On 5/30/14 at 8:45 a.m., during the tour and concurrent interview with the Assistant administrator stated once Resident 1 jumped the fence into SCU, he used a trash can to jump the fence into the parking lot in order to leave the facility. However, even though Resident 1 used the trash can to jump over the same fence, next to the fence there was a large plastic trash can, and a metal trash can used for cigarette butts that was not secured or chained. On 5/30/14 at 8:40 a.m., during the tour the activity assistant stated there were ambulatory residents at SCU could probably jump the fence if they wanted to, even without the trash can. In front of the assistant administrator, and maintenance supervisor, the activity assistant demonstrated how one could easily climb the metal fence. He placed one foot on the conduit box (a metal box protecting electrical wires) that was attached next to the fence, used the handle on the gate to place his other foot, and by grabbing the metal rails, he pulled himself to the top of the fence. The activity assistant stated once you're up there (pointing to the top of the fence) you can easily jump the fence over. The assistant administrator also stated at around 10:40 p.m., one of the facility's surveillance cameras did record Resident 1 carrying two yellow soiled linen barrels to the first fence at ACU but it does not show how he jumped the second fence because the camera does not show beyond a certain point. During the tour one camera was observed attached to the back corner of ACU Cottage #6 which was pointing to the direction of SCU. The assistant Administrator stated the facility is in the process of installing more cameras and placing staff members to monitor those cameras. However right now, the facility is only recording and watching the recordings later. He also stated the facility is equipped with an alarm which alerts staff at the nursing station however, the alarm is not installed throughout the 10-acre facility. According to him right now the alarm is not working in the SCU because facility is waiting to recheck the system in order for it to trigger faster. On 5/30/14 at 8:40 a.m., during the tour the maintenance supervisor said he had added an extra three feet of curved inward metal to the already existing railings on top of the concrete walls. He then covered the rails with a solid metal mesh so the residents could not use it as leverage to pull themselves up. However, the exact location where Resident 1 jumped the fence leading to the outside parking lot did not have the curved extension and or the metal mesh covering the rails. The maintenance supervisor said he had done all the work himself but stopped at where Resident 1 jumped because he did not have enough funds. On 5/30/14 at 8:45 a.m., during the observation of the ACU there were two large metal gates that led to the outside parking lot. The gates were eight feet tall with an extra 3 feet of metal railings. The railings did not have the solid metal mesh coverings to prevent the residents from using them as leverage in order to jump the gate. The administrator stated I guess anyone can climb and hold on to the railings and jump over. At the same time a laundry room was also observed in the ACU behind a nine feet fence with an extra 1 foot solid metal added to it. This gate led to another 5 foot gate that led to the outside parking lot. The administrator stated again some of the residents can still jump this fence and leave the facility. A review of Resident 1's clinical records indicated Resident 1 was admitted to the locked facility on 5/8/14, with [DIAGNOSES REDACTED]. The elopement risk assessment form dated 5/13/14, indicated Resident 1 was assessed a total score of 10 (8 or greater the resident should be considered at risk for potential elopement from the facility). On 5/30/14 at 9:08 a.m., after looking at the clinical records the ADON stated there was no plan of care addressing Resident 1's elopement risk, goals and or interventions in order to eliminate and or reduce the resident's elopement. The Minimum Data Set assessment (provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems) dated 5/27/14, indicated short-term and long term memory problems, usually understands, moderately impaired in daily decision making, inattentive, hallucinates (sensing things while awake that appear to be real but instead have been created by the mind), and was delusional (having false or unrealistic beliefs or opinions). A review of the social work progress notes dated 5/13/14, Resident 1 called the police and the social worker designee (SSD) stating someone is out to hurt him. The resident also verbalized wanting to leave and to go back to the skilled nursing facility in Pasadena, where he previously resided. On 5/14/14, the SSD received another call stating Resident 1 wanted to leave the facility and go home The notes further indicated the resident called the SSD several times inquiring about his court hearing on 5/15/14. When SSD called the conservator, she was told the resident did not need to attend the court hearing. According to the notes SSD explained to the resident but it seemed the resident did not understand and he kept calling her on his cell phone. The resident kept telling SSD that someone is hurting him. On 5/15/14, SSD received a call from the Ombudsman stating the resident called her saying someone hurt him. The SSD spoke to the Ombudsman telling them the resident is delusional and that no one hurt him. There was no care plan developed for Resident 1's behavior of verbalizing wanting to go home, being concerned about a court hearing, believing someone was hurting him or out to hurt him, which increased his elopement risks. On 5/30/14 at 9:08 a.m., the ADON stated she could not find a care plan addressing the resident's behaviors. According to the facility's investigation dated 5/15/14, Resident 1 left absent without official leave (AWOL) and was gone until 5/19/14, when he came back to the facility. The resident was re-assessed and transferred to the acute care hospital but did not return. On 5/30/14 at 4 p.m., the facility's medical director said when a resident goes AWOL from the facility, he has recommended for not re-admitting the resident back. When asked what happens to the resident he said, "they have to go to another facility I guess." A review of the facility's policy and procedures for wandering and elopement revised 1/1/12, indicated facility staff must ensure the residents health and safety. If the resident appears likely to elope, the facility staff should provide diversions and increase monitoring of the resident by instituting a one-on-one staffing until the resident's risk of elopement subsides. The nursing staff will update the resident's care plan to include interventions to prevent elopement.

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