Every finding on record at Lemon Grove Care and Rehabilitation Center

Based on interview and record review, the facility's Quality Assurance Agency (QAA) failure to identify, monitor, and address problem areas identified by the State Survey team for their Quality Assurance and Performance Improvement (QAPI) plan, during their annual recertification.This failure put all residents at risk for medication errors and equipment failures.(See F-759, F-761, and F-908)An interview was conducted with the Administrator (ADM) and Director of Nursing (DON) on 12/18/25 at 5:31 P.M. The ADM and DON stated they both started at the facility three months ago. The ADM and DON stated they had reviewed last year's recertification and recognized medication administration and medication storage were both issues. The DON stated she began by monitoring, auditing, and educating staff regarding medication storage and they thought they had corrected the issues, so it was dropped from QAPI. The DON stated based on the current medication error rate during this re-certification, and the medication storage issues, they should have identified improvement was needed prior to survey. The ADM stated the Director Maintenance did not attend their quarterly QAA meetings. The DON stated maintenance issues were discussed every morning in their stand-up meetings. The ADM acknowledged equipment safety issues were identified during recertification, which should have been brought to his attention by the Director of Maintenance, or facility's Safety Committee, prior to survey. A review of the facility's QAPI plan dated 9/10/25 through 12/2025, listed no implementation or monitoring of medication administration, medication storage, or equipment maintenance. According to the facility's policy, titled Quality Assurance and Performance Improvement, dated September 2019, .Purpose: The purpose of the QAPI plan and processes is to continually assess the facility's performance in all service areas, so that systems and processes achieve the delivery of person-centered care, and which maximizes the individuals highest practicable physical, mental and social well-being.2. QAPI Plan Components.c. Feedback, data systems, and monitoring.e. Systemic analysis and systemic action.

Based on observation, interview and record review, the facility failed to implement their own Infection Control Program when: 1. There was no documented evidence regarding vaccine refusal, no documented hand hygiene surveillance and no documented evidence regarding antibiotic surveillance,Cross reference F881 2. Resident 178's oxygen tubing did not have a date, 3. Resident 8's oxygen tubing and nebulizer (liquid medication delivered as a fine mist inhaled into the lungs through a mouthpiece or mask) mask were not dated and stored properly. These failures could potentially contribute to the spread of microorganisms. 2. Resident 178 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia (a condition where the lungs fail to adequately exchange oxygen, leading to low oxygen in the blood) according to the facility's admission Record. During an observation on 12/15/25 at 8:47 A.M., Resident 178 was in bed with an oxygen cannula (oxygen tubing with two open prongs placed in the nose) connected to a humidifier bottle (plastic bottle with distilled water that adds moisture to oxygen being inhaled) and concentrator (machine that provides oxygen). The oxygen tubing did not have a date. A joint observation and interview on 12/15/25 at 10:37 A.M., was conducted with Licensed Nurse (LN) 14. LN 14 checked Resident 178's oxygen tubing. LN 14 stated the oxygen tubing did not have a date when it was last changed. LN 14 stated Resident 178's oxygen tubing should be dated when it was first applied to Resident 178 then changed every Wednesday. LN 14 stated it was important to date and change every Wednesday to keep the tubing clean and to prevent infection. 3. Resident 8 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing) and gastrostomy status (feeding tube in the stomach) according to the facility's admission Record. During an observation on 12/15/25 at 9:15 A.M., a concentrator was observed next to Resident 8's bed. An oxygen cannula was hanging on top of the concentrator. A nebulizer mask connected to a nebulizer machine was on top of Resident 8's bedside table. A review of Resident 8's Order Summary Report indicated, CHANGE OXYGEN NASAL CANNULA and PLASTIC STORAGE BAG EVERY WEDNESDAY NIGHT and PRN [as needed]. A joint observation and interview on 12/15/25 at 10:40 A.M., was conducted with Licensed Nurse (LN) 14. LN 14 checked Resident 8's oxygen tubing and nebulizer mask. LN 14 stated the oxygen tubing and the nebulizer mask were not stored in a plastic bag. LN 14 stated the oxygen tubing and nebulizer mask should be stored in a plastic bag when not in use to keep them clean and prevent resident infection. During an interview on 12/16/25 at 3:54 P.M. with LN 12, LN 12 stated oxygen cannulas and masks were changed every Wednesday and stored in a plastic bag for infection control. An interview on 12/18/25 at 4:50 P.M. was conducted with the Director of Nursing (DON). The DON stated oxygen cannulas and nebulizer masks should be dated when changed and stored in a plastic bag for infection control. A review of the facility's undated policy and procure (P&P) titled, Oxygen Handling and Storage was conducted. The P&P indicated, It is the policy of this facility to provide proper use and handling and storage of respiratory equipment (oxygen tanks, oxygen tubings and nebulizers) in the facility. During a review of the facility's undated P&P titled, Small Volume Nebulizer (SVN) the P&P indicated, Replace and/or clean nebulizer components as per facility guidelines/policy.Tubing may be replaced every week. Findings: 1. On 12/18/25 at 1: 17 P.M., an interview and record review was conducted with the Director of Staff Development (DSD), Director of Nursing in training (DIT), and the Director of Nursing (DON). The DSD stated she started working on April 224 with DSD role and started doing Infection Preventionist (IP) role on 12/11/25. The DON stated we had our transition from 10/16/25. The DSD/IP stated she had no account to California Immunization Registry (CAIR) and she had no access to check residents vaccination status. A random review of resident's vaccination refusals was conducted. There was no documented evidence to indicate a follow up education and care plan related to vaccine refusal. According to the facility's policy titled, Infection Control Prevention and Control Program, revised 11/23/2016 indicated, The Infection Prevention and Control Program is comprehensive in that it addresses detection, prevention and control of infections among resident and personnel.THE MAJOR ACTIVITIES OF THE PROGRAM ARE:.SURVEILLANCE OF INFECTIONS AND REPORTING.REPORTING MECHANISMS FOR INFECTION CONTROL.A. The IP completes the Infection Surveillance monthly form and reports.C. Compliance with Infection Prevention Control practices is monitored and documented by: 1. Staff evaluation .2. Observation of Practices i.e. Hand Hygiene.The IP/Director of Staff Development and Director of Nursing review the compliance monitoring and initiate appropriate action. A review of the facility Healthcare-Associated Infections Program Adherence Monitoring for Hand Hygiene was conducted. There were no documented evidence for the months of August, September and October 2025. In addition, there was decline in the from 92% on July 2025 Adherence Monitoring for Hand Hygiene to 73% of November 2025. The DSD/IP and DIT could not verbalize what action was needed to correct decrease adherence in hand hygiene. There was no documented evidence including in -services related to hand hygiene were provided to show appropriate action related to hand hygiene adherence monitoring. Antibiotic surveillance for October 2025 did not match the case map for October 2025. The October 2025 Antibiotic surveillance had 6 cases of community acquired infection (CAI), 6 cases of healthcare associated infection(HAI) and 5 did not meet criteria. The October 2025 case mapping had 8 entries but did not identify whether CAI or HAI. There was no documented evidence to indicate comprehensive tracking measures with data analysis, length of antibiotic use, appropriate use of antibiotic use and communication with Medical Director and Pharmacist to discuss opportunities of improvement.

Based on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 19.51%. Eight medication errors were observed out of 41 opportunities, during the medication administration process for one of eight randomly observed residents (Resident 8). As a result, the facility could not ensure medications were correctly administered to all residents. In addition this deficient practice had the potential to affect the resident's health and wellbeing.Findings: Resident 8 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing) and gastrostomy status (feeding tube in the stomach) according to the facility's admission Record. During medication administration on 12/17/25 at 9:50 A.M. an observation for Resident 8, Licensed Nurse (LN) 14 administered the following medications:-Tylenol (pain medication) 325mg two tablets by mouth-Allopurinol (for high uric acid in the blood) 100mg one tablet by mouth-Carvedilol (heart medication) 12.5mg one tablet by mouth-Hydralazine hydrochloride (for high blood pressure) 25mg one tablet by mouth-Metformin hydrochloride (for high blood sugar) 850mg one tablet by mouth-MVI (multivitamin) with mineral (supplement) one tablet by mouth-Geri-Kot (for constipation) 8.6mg two tablets by mouth-Juven (nutrition powder) nutrition support 1 packet by mouth, mixed in eight ounces of water by mouth During a review of the Order Summary Report for Resident 8, the Order Summary Report indicated: -Tylenol tablet 325mg give two tablets via G-Tube (gastrostomy tube- tube in the stomach) three times a day-Allopurinol 100mg give one tablet G-Tube one time a day-Carvedilol 12.5mg give one tablet G-Tube two times a day-Hydralazine hydrochloride 25mg one tablet G-Tube two times a day -Metformin hydrochloride 850mg one tablet G-Tube two times a day-Multiple Vitamins-Minerals give one tablet enterally (via feeding tube) one time a day -Senna oral tablet 8.6mg give two tablets via G-Tube one time a day-Juven oral packet give 1 packet enterally two times a day During an interview on 12/17 25 at 3:47 P.M. with Licensed Nurse (LN) 34, LN 34 stated the medication administration record (MAR) should be checked prior to medication administration. LN 34 stated the MAR should be checked to ensure the correct medication, resident, dose, time and route for resident's safety. An interview and joint record review was conducted on 12/18/25 at 10:16 A.M. with LN 14. LN 14 stated the five rights of medication administration were: checking for the right resident, time, medication, route and dose. LN 14 checked physician's orders for Resident 8 in the electronic medical record. LN 14 acknowledged that the physician's orders for the tablets were to be given via Resident 8's G-tube. During an interview on 12/18/25 at 4:50 P.M. with the Director of Nursing (DON), the DON stated she expected nurses to follow the five rights of medication administration. The DON stated it was important to follow the five rights to ensure that physician's orders were followed. A review of the facility's undated policy and procedure (P&P) titled, Medication Administration was conducted. The P&P indicated, It is the policy of this facility to accurately prepare, administer and document oral medications.Verify medication with medication order. The policy did not provide guidance regarding the five rights of medication administration.

Based on observation, interview, and record review, the facility failed to maintain resident equipment in a safe, functional manner for 57 of 159 residents, located in the secured unit, (specialized, secured area for residents with dementia or mental illness, who are prone to wandering), when:1. Handrails in the hallway, ( Station 3), had peeling paint, and;2. A bed remote control had exposed wires.These failures had the potential for peeling paint to be ingested by confused residents and the wires from the bed's remote control to pierce the skin of a resident.Findings:During initial tour on 12/15/25 at 10:07 A.M., an observation was conducted of the handrails outside room [ROOM NUMBER]. The handrails contained numerous layers of paint, and the white paint was peeling off in different areas.An observation and interview was conducted with Director of Maintenance (DM) on 12/16/25 at 3:50 P.M. of the hallway handrails outside Station 3's activity room. The DM was observed removing patches of white peeling paint from the handrails, with attempts of smoothing out the peeling paint patches. The DM stated he tried to check the handrails daily because of the peeling paint. The DM stated the peeling paint could be ingested by confused residents, which could cause harm. An observation was conducted of Station 3's handrails on 12/17/25 at 9:25 A.M. All the handrails on Station 3 had been painted lime green overnight. An observation and interview was conducted with Licensed Nurse 33 (LN 33) on 12/17/25 at 11:30 A.M., of Station 3's handrails, near the nurse's station. LN 33 stated the handrails were painted last night, because the previous paint kept peeling. LN 33 stated the green paint was starting to peel already, because too much paint had already been added. LN 33 stated the harm with the peeling paint was residents could ingest the peeling paint. An observation was conducted of Station 2's hallway handrail on 12/17/25 at 12:11 P.M. The handrail near the nurse's station was painted tan, with a small area of chipped wood exposed. 2. Resident 4 was admitted to the facility on [DATE], with diagnoses which included paranoid schizophrenia (a mental illness marked by intense paranoia, delusions [false beliefs, often persecutory], and auditory hallucinations [hearing voices], per the facility's admission Record. An observation was conducted with Resident 4, while lying in bed on 12/16/25 9:04 A.M. The bed control remote was wrapped around the upper right side rail. The coiled cord to the bed remote was frayed with exposed wires, approximately 6-7 inches down the length of the cord.An observation and interview was conducted with Certified Nursing Assistant 33 (CNA 33) on 12/16/25 at 9:06 A.M., of Resident 4's bed remote control. CNA 33 stated the cord should be replaced, because wires were exposed. CNA 33 stated the exposed wires were a safety issue and could poke the resident. A record review was conducted of Station 3's maintenance book on 12/16/25 at 9:06 A.M. Resident 4's frayed cord for the beds' remote control had not been reported by staff and was not documented in the unit's maintenance book. An interview was conducted with the Director of Maintenance (DM) on 12/16/25 at 9:12 A.M. The DM stated he conducted monthly inspections of resident rooms, to identify issues needing repairs. The DM stated he retrieved his monthly maintenance log to see when Resident 4's room was last inspected.An interview was conducted with CNA 34 on 12/16/25 at 9:39 A.M. CNA 34 stated if equipment issues were identified, she would inform the charge nurse and document the issue in the facility's maintenance book, so repairs could be made. A follow-up interview was conducted with the DM on 12/16/25 at 10:11 A.M. The DM stated he could not identify when Resident 4's room was last inspected in his monthly room maintenance log. The DM stated he was informed today of the exposed wires in Resident 4's room by staff. The DM stated the exposed wires on the bed remote could poke the resident or break her skin.An interview was conducted with the Director of Nursing (DON) on 12/18/25 at 8:50 A.M. The DON stated she expected all resident equipment to be regularly inspected to be safe and functional.According to the facility's policy, titled Physical Environment-Equipment Maintenance, dated May 2007, It is the policy of this facility to establish procedures for routine and non-routine care of equipment and to ensure that equipment remains in good working order for residents and staff safety.Procedures: .3. Electrical. equipment will be inspected.on a routine basis. 5. Routine inspections and maintenance will be recorded using TELS and equipment .

Based on interview and record review, the facility failed to follow its own policy and procedure to establish an antibiotic stewardship program when the Infection Preventionist (IP) did not comprehensively track and monitor appropriate use of antibiotics. This failure had the risk to affect the residents in the facility due to lack of oversight and monitoring that could lead to increased infections and preventable deaths from resistant infections.Cross reference F880Findings: On 12/18/25 at 1: 17 P.M., an interview and record review was conducted with the Director of Staff Development (DSD), Director of Nursing in training (DONIT), and the Director of Nursing (DON). The DSD stated she started working on April 224 with DSD role and doing Infection Preventionist (IP) role on 12/11/25. The DON stated we had our transition from 10/16/25 and the designated IP was no longer working in the facility. The October 2025 Antibiotic surveillance had 6 cases of community acquired infection (CAI) and 6 cases of healthcare associated infection(HAI). The October 2025 case mapping had 8 entries but did not identify whether a CAI or an HAI cases. The Antibiotic surveillance for October 2025 did not match the case map for October 2025. There was no documented evidence to indicate comprehensive tracking measures for antibiotic use to include data analysis, length of antibiotic use or number of days of therapy, and reason of using the antibiotic. In addition, there was no evidence of communication with the Medical Director and Pharmacist to discuss opportunities of improvement. The DSD/IP, the DIT and the DON could not discuss the Infection Control Program. The DON stated the facility should have done accurate and complete infection surveillance to prevent infection. According to the facility's policy, titled Antibiotic Stewardship, revised 9/2017 indicated, .It is the policy [facility name] to implement an Antibiotic Stewardship Program (ASP) that is incorporated in the overall Infection Prevention and Control Program which will promote appropriate use of antibiotics while optimizing the treatment of infections.Nursing home ASP activities should include, at a minimum.leadership, accountability, drug expertise, action to implement recommended policies or practices, tracking measures, reporting data, education for clinicians, nursing staff, residents and families about antibiotic resistance and opportunities for improvement.

Based on observation, interview, and record review, the facility failed to provide assistance for 6 of 6 dependent residents with their Activities of Daily Living (ADLs, activities related to mobility and personal care) when: 1. Resident 23 was not assisted in getting up and out of bed. Cross Reference F- 679. 2. Two residents (Resident 71 and Resident 163) who were cognitively impaired were not cued to perform hand hygiene before meals. 3. Routine nail care was not provided to three residents (Residents 90, 6 and 112). As a result, the residents were at risk for skin injury, infection and overall quality of life. Findings: 1. Resident 23 was readmitted to the facility on [DATE], with diagnoses which included multiple sclerosis (MS, a disease that causes breakdown of the protective covering of nerves, can cause numbness, weakness, trouble walking, vision changes and other symptoms), per the facility's admission Record. On 12/15/25, a review of Resident 23's minimum data set (MDS, a federally mandated resident assessment tool) dated 11/27/25, indicated Resident 23 could make independent reasonable decisions. The MDS of Resident 23's functional abilities indicated he had lower extremities impairment and that he was dependent on staff for his activities of daily living (ADLs, like transferring). On 12/15/25, a review of Resident 23's care plan indicated Resident 23 required total assistance with transfers. On 12/15/25 at 9:06 A.M., an observation and an interview was conducted with Resident 23 in his room. Resident 23 was lying in bed with his legs elevated. Resident 23 stated he had MS and was unable to walk. Resident 23 stated he stayed in bed and no one got him up from bed. On 12/15/25 at 4:55 P.M., a follow-up observation and an interview were conducted with Resident 23 in his room. Resident 23 stated, I want them to get me out of here. Resident 23 stated he could not stand and or walk and needed assistance to get up. On 12/16/25 at 3:20 P.M., another follow-up observation, and an interview were conducted with Resident 23 in his room. Resident was lying in bed. Resident 23 stated he had not gotten up from the previous day (12/15/25) until 12/16/25. On 12/16/25 at 3:53 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated Resident 23 was alert, could make his needs known and was dependent on staff when transferring. On 12/17/25 at 2:59 P.M., a joint record review and interview was conducted with the Activity Coordinator (AC). The AC stated Resident 23 required two person to assist him with transfers from bed to wheelchair. On 12/17/25 at 3:36 P.M., a joint record review and an interview were conducted with Licensed Nurse (LN) 3. LN 3 stated the staff had gotten up Resident 23 a month ago to attend an activity. LN 3 stated Resident 23 required two person assist to transfer him from the bed to the wheelchair and back to bed. LN 3 stated Resident 23 had been in bed a lot and could cause complications like getting wounds, isolation and boredom. On 12/18/25 at 1:19 P.M., an interview was conducted with CNA 3. CNA 3 stated during the time she was assigned to Resident 23, she had not helped Resident 23 get up. On 12/18/25 at 3:19 P.M., a joint review of Resident 23's clinical record and an interview was conducted with the Director of Nursing (DON). The DON stated Resident 23 required assistance from the staff when getting up and out of bed. The DON stated the policy was for the staff to encourage and offer Resident 23 to get up and out of bed to enhance his quality of life. A review of the facility's policy titled, ADL care, revised 11/07, indicated, .2. Residents who are unable to carry out activities of daily living (ADL) will receive assistance as needed. 2a. Resident 71 was admitted to the facility on [DATE] with diagnoses which included dementia (a progressive state of decline in mental abilities) and required assistance with personal care, per the facility's admission Record. On 12/16/25, a review of Resident 71's history and physical (H&P) dated 2/26/25 indicated Resident 71 had severe dementia and was pleasantly confused. On 12/16/25, a review of Resident 71's MDS dated [DATE], indicated Resident 71's functional abilities was supervision and cueing in performing her personal hygiene. 2b. Resident 163 was admitted to the facility on [DATE] with diagnoses which included dementia and required assistance with personal care, per the facility's admission Record. On 12/16/25, a review of Resident 163's MDS dated [DATE], indicated Resident 163 had a brief interview for mental status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 12/15 which meant Resident 163 had moderate cognitive impairment. The MDS of Resident 163's functional abilities indicated he required supervision and cueing in performing his personal hygiene. During dining observation on 12/15/25 at 11:26 A.M., Resident 71 sat alone at the fourth dining table and Resident 163 sat at the opposite table with another resident. No hand hygiene was provided to the residents. On 12/15/25 at 11:46 A.M., meal trays were served to the residents. Resident 71 picked up her food, played with her food with her bare hands and licked her fingers. No supervision was provided to Resident 71. Resident 163 spooned his food and licked his fingers every time the food escaped the spoon. No supervision was provided to Resident 163. On 12/15/25 at 12:16 P.M., an interview was conducted with Restorative Nursing Assistant (RNA) 1. RNA 1 stated the staff should have offered hand sanitizer to the residents after they ate their meal. On 12/16/25 at 1:01 P.M., a follow-up interview was conducted with RNA 1. RNA 1 stated Resident 71 and Resident 163 required supervision and cueing to perform hand hygiene. RNA 1 stated the policy was to provide encouragement and offered the residents to perform hand hygiene before and after meals. RNA 1 stated, Yesterday (12/15/25), it was chaos. I was busy focused on feeding another resident. RNA 1 stated hand hygiene was important for personal hygiene and infection control. On 12/18/25 at 3:42 P.M., an interview was conducted with the DON. The DON stated hand hygiene should have been offered to the residents before and after meals for infection control. A review of the facility's policy titled, Assisting the Resident with In-Room Meals, revised 12/15, indicated, .8. Be sure the resident is prepared to receive the meal (like.hands washed.) 3a. Resident 90 was readmitted to the facility on [DATE] with diagnoses which included multiple sclerosis (MS) and had contractures (stiffening of joints) of his right and left hands, per the facility's admission Record. On 12/16/25, a review of Resident 90's MDS dated [DATE], indicated Resident 90 had a BIMS score of 5/15 which meant Resident 90 had severe cognitive impairment. The MDS of Resident 90's functional abilities indicated he had upper and lower extremities impairment and that he was dependent on staff with his ADLs (activities of daily living), like personal hygiene. On 12/15/25 at 10:17 A.M., an observation and an interview were conducted with Resident 90 in his room. Resident 90 laid in bed with his right hand in a splint with long and sharp fingernails. Resident stated he was unable to lift his left hand, and the fingernails were long. Resident 90 stated he wanted the fingernails to be trimmed short. On 12/15/25 at 10:28 A.M., a joint observation of Resident 90 and an interview with LN 4 was conducted. LN 4 stated Resident 90's fingernails were long and sharp. LN 4 stated Resident 90 was diabetic (high blood sugar) and LNs were to trim his fingernails. LN 4 stated he would have to trim Resident 90's fingernails short for hygiene and prevent him from getting an infection. On 12/17/25 at 4:38 P.M., an interview was conducted with LN 3. LN 3 stated Resident 90 was totally dependent on staff with his ADLs. LN 3 stated for diabetic residents, LNs were to trim and cut the residents' fingernails. LN 3 stated Resident 90 could dig his hands and caused tears to the skin since he had contracted hands. LN 3 stated nail care was important for hygiene and infection control. On 12/18/25 at 3:51 P.M., an interview was conducted with the DON. The DON stated nail care was important to Resident 90 for hygiene and infection control. A review of the facility's policy titled, ADL care, revised 11/07, indicated, .2. Residents who are unable to carry out activities of daily living (ADL) will receive assistance as needed. A review of the facility's undated policy and procedure (P&P) titled, Nail Care was conducted. The P&P indicated, It is the policy of this facility to promote cleanliness, safety, and neat appearance. 3b. Resident 6 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (a chronic autoimmune disease (occurs when the body immune system mistakenly attacks its own healthy cells, tissues, and organ causing inflammation, damage, and dysfunction) affecting the brain and spinal cord causing diverse symptoms like vision problems, numbness, weakness, and balance issues, fatigue, and cognitive difficulties) and need for assistance with personal care according to the facility's admission Record. During an observation and interview on 12/16/25 at 8:36 A.M., Resident 6 stated he had MS. Resident 6 had long fingernails. Resident 6's fingernails had black debris under the nails. Resident 6 stated he would like staff to trim his fingernails because he could not trim them by himself. An interview and joint observation on 12/16/25 at 8:57 A.M. was conducted with Certified Nurse Assistant (CNA) 12. CNA 12 checked Resident 6's fingernails and stated Resident 6's fingernails were long and dirty. CNA 12 stated Resident 6's fingernails should be trimmed for infection control and to prevent Resident 6 from scratching himself. During an interview on 12/16/25 at 3:51 P.M. with Licensed Nurse (LN) 12, LN 12 stated CNAs trimmed fingernails once a week to prevent scratching and the risk of infection. 3c. Resident 112 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (stroke) according to the facility's admission Record. During an observation of Resident 112 on 12/16/25 at 9:38 A.M., Resident 112 was in bed with left arm bent at elbow close to Resident 112's left side of his body. Resident 112's left hand was closed in a fist. Resident 112's right thumb was bent toward the palm of the hand. Resident 112's had long fingernails. During an interview on 12/16/25 at 3:41 P.M. with CNA 11, CNA 11 stated nail care for residents were completed on Sundays. CNA 11 stated nail trimming was important to prevent residents from getting hurt and to prevent infection. An interview with the Director of Staff Development (DSD-a licensed nurse certified for staff training) was conducted on 12/16/25 at 4:20 P.M. The DSD stated an in-service was provided regarding filing and keeping residents' fingernails clean during showers and as needed. The DSD stated CNAs can only file and keep residents' fingernails clean and no trimming was allowed. The DSD stated the licensed nurse could trim residents' fingernails. The DSD further stated it was important to keep residents' fingernails trimmed and clean for good hygiene and infection control. A joint observation of Resident 112 and interview was conducted on 12/16/25 at 4:55 P.M. with Licensed Nurse (LN) 13. LN 13 checked Resident 112's left arm and hand. LN 13 could not straighten Resident 112's left arm and was unsuccessful in attempting to open the left hand. LN 13 checked Resident 112's right hand and fingers. Resident 112's right fingers bent with the thumb close to their palm. LN 13 stated Resident 112's right hand fingernails were long. LN 13 stated CNAs can trim residents' fingernails, but LNs trimmed them if residents had contractures to prevent injury. An interview with the DON was conducted on 12/18/2025 4:50 PM. The DON stated residents' long fingernails should be trimmed because it was a quality of care and infection control issue. A review of the facility's undated policy and procedure (P&P) titled, Nail Care was conducted. The P&P indicated, It is the policy of this facility to promote cleanliness, safety, and neat appearance.

Based on observation, interview, and record review, the facility failed to ensure: 1.Timely assessment, monitoring and immediate physician notification in response to significant clinical changes, including suspected gastrointestinal (referring to the stomach and intestines) bleeding and ongoing nausea or vomiting for one of three sampled residents reviewed for closed record (Resident 1). Cross Reference F 580. 2. A physician's order was obtained from the attending physician prior to blood sugar checks on a resident (Resident 9) who was on insulin (antidiabetic medication). In addition, blood sugar checks was obtained without proper time interval. This deficient practice resulted in a delay in the resident receiving treatment to address Resident 1's necessary care and services and placed Resident 1's health at risk. In addition, Resident 9 had blood sugar checks without physician's order, without appropriate time interval and caused discomfort to Resident 9. Findings: Resident 1 was readmitted to the facility on [DATE] with diagnoses which included pneumonia (infection of the lungs), per the facility's admission Record. A review of Resident 1's history and physical (H&P) dated [DATE] was conducted. Per the H&P, Resident 1's Computed Tomography (CT scan, a type of imaging that uses X-ray techniques to create detailed images) of his chest, abdomen and pelvis at the general acute care hospital (GACH) indicated Resident 1 had left chest wall large hematoma with active extravasation (a collection of blood in the extra thoracic space). The H&P indicated one of Resident 1's active medications was enoxaparin (anticoagulant, blood thinner medication). On [DATE] at 8:38 A.M., a joint record review and interview was conducted with LN 32. LN 32 stated Resident 1 was transferred to the GACH on [DATE] at 10:50 A.M. after a cardiopulmonary resuscitation (CPR, a life sustaining treatment) was initiated at the facility. LN 32 stated Resident 1 was at GACH when he passed away. LN 32 stated per LN 1's nurses progress notes on [DATE] at 1:36 A.M. Resident 1 vomited large amount of coffee ground emesis (medical term for vomiting). LN 32 stated the progress notes indicated, after Resident 1 vomited a coffee ground emesis, Resident 1 received ondansetron (antiemetic medicine to prevent nausea and vomiting). LN 32 stated there was no documentation indicating Resident 1 was assessed before the antiemetic medications were given. LN 32 stated the progress notes indicated there were no documentation to indicate the physician was notified of Resident 1's change in condition (CIC) until 10:50 A.M. on [DATE]. LN 32 stated Resident 1 had CIC at 1:36 A.M. and that was more than nine hours after LN 1 observed Resident 1 had a CIC. LN 32 stated the LNs should have immediately informed the attending physician because Resident 1 was on anticoagulant and vomited a coffee ground emesis. LN 32 stated there was no monitoring documented for Resident 1. LN 32 stated the purpose of monitoring Resident 1 for further bleeding was to notify the attending physician because coffee ground emesis was a sign of bleeding and could be dangerous to Resident 1's health. On [DATE] 4:08 P.M., a joint review of Resident 1's clinical record and an interview were conducted with the Director of Nursing (DON). The DON stated Resident 1 had been receiving and anticoagulant from GACH. The DON stated the timeline was as follows: - - [DATE], Resident 1 was readmitted to the facility, and was on anticoagulant. - - [DATE] at 3 A.M., the LN progress notes indicated Resident 1 had another large ground coffee emesis around 7:45. The DON stated she did not see documentation if this episode was the first time Resident 1 had coffee ground emesis. - - [DATE] at 11:10 A.M., the LN progress notes was reviewed and indicated, the nurse practitioner (NP, a nurse who has advanced clinical education and training. NPs share many of the same duties as doctors) was notified and NP gave diagnostic orders for Resident 1. The DON stated Resident 1 had CIC on [DATE] at 3 A.M., the LNs did not notify the NP until after eight hours of Resident 1's CIC. - - [DATE] at 1:37 A.M., the progress notes indicated Resident 1 vomited a large coffee ground emesis. - - [DATE] at 10:49 A.M., the progress notes indicated Resident 1 had changed in level of consciousness, the NP was notified, NP recommended to send Resident 1 to GACH, CPR was initiated at the facility and was sent out to the hospital and was placed in intensive care unit (ICU, a special area in a hospital or healthcare facility for people who have a life-threatening illness or injury). Resident 1 expired at the hospital. The DON stated she did not see any documentation of notifying the doctor on [DATE] at 1:37 A.M. when LN 1 observed Resident 1 had coffee ground emesis. The DON stated that ondansetron was given to Resident 1 on [DATE] at 1:52 A.M and at 9:55 A.M., there was no documentation of LN 1's observation of Resident 1's condition. The DON stated the NP was notified on [DATE] at 10:20 A.M. and at that time, CPR was initiated to Resident 1. The DON stated the LNs should have notified the physician immediately, meaning as soon as possible after they (LN) observed the resident's CIC. The DON stated Resident 1 passed away at GACH. A review of the facility's policy titled, Change in Condition, revised 2025, indicated, It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being.Procedure.2. The nurse will perform and document an assessment of the resident and identify need for additional interventions.Routine Medical Change, 1. All symptoms and unusual signs will be communicated to the attending physician promptly. A review of the facility's policy titled, Notification, Physician or Responsible Party, revised 2024, indicated, It is the policy of this facility to promptly notify the resident, his/ her attending physician/ NP.of changes in the resident's condition . 2. On [DATE] at 8:45 A.M., a concurrent observation and interview was conducted with Resident 9 and Licensed Nurse (LN) 23. LN 23 obtained blood from the resident to check Resident 9's blood sugar level. Resident 9 stated the LNs took my blood sugar this morning before breakfast. Resident 9 stated she had a routine blood sugar check before breakfast but LNs did not do it logically. A review of Resident 9's current physician's order did not indicate an order for blood sugar checks. On [DATE] at 8: 14 A.M., a concurrent interview and record review was conducted with LN 24. LN 24 stated there was no physician order for blood sugar checks for Resident 9. LN 24 stated she would notify the physician. On [DATE] at 8: 21 A.M., a concurrent interview and record review was conducted with LN 23. LN 23 stated it was a standard operating procedure for LNs to check resident blood sugar. LN 23 stated when Resident 9 returned to the facility, there was no physician order for blood glucose check. In addition, there was documentation in the electronic Medication Administration Record (eMAR) to enter blood sugar checks or results. LN 23 stated she should have clarified with the LN Supervisor when there was no physician order for blood sugar checks. LN 23 stated Resident 9 did not have a physician order for blood sugar checks. On [DATE] at 10:09 A.M., a concurrent interview and record review of Resident 9's Weights and Vitals Summary report of blood sugar checks on the following dates was conducted with the Director of Nursing (DON) indicated: [DATE] at 9 A.M., blood sugar (BS) = 285 mg/dl [DATE] at 5 P.M., = 283 mg/dl [DATE] at 9:07 A.M., = 196 mg/dl [DATE] at 6:17 P.M., = 132 mg/dl [DATE] at 9:42 A.M., = 230 mg/dl [DATE] at 6: 54 P.M., = 211 mg/dl [DATE] at 9 A.M., = 214 mg/dl [DATE] at 5 :49 P.M., = 306 mg/dl [DATE] at 7:11 A.M., = 238 mg/dl A review of Resident 9's time of blood sugar checks and time intervals indicated the following: [DATE] taken at 11: 15 A.M. and 12: 16 P.M. [DATE] taken at 10: 47 A.M and 11: 57 A.M. [DATE] taken at 7 A.M. and 9 A.M. [DATE] taken at 7: 27 A.M and 8:05 A.M. [DATE] taken at 7 A.M and 9 A.M. [DATE] taken at 7: 15 and 8:42 A.M. [DATE] taken at 7 A.M. and 9: 15 A.M. [DATE] taken at 7 A.M. and 8:35 A.M. [DATE] taken at 7 A.M and 9 A.M. [DATE] taken at 7:33 A.M and 9:16 A.M. [DATE] taken at 7:02 A.M. and 9 A.M. [DATE] taken at 7:04 A.M. and 7: 25 A.M. [DATE] taken at 8:39 A.M. and 8:40 A.M. [DATE] taken at 7 A.M. and 8: 48 A.M. [DATE] taken at 7 A.M. and 9 A.M. [DATE] taken at 7 A.M and 8: 49 A.M. [DATE] taken at 7: 15 A.M. and 8: 51 A.M. [DATE] taken at 7:56 A.M. and 9: 51 A.M. [DATE] taken at 7: 35 A.M. and 9: 10 A.M. [DATE] taken at 7: 29 A.M. and 10: 12 A.M. During a concurrent interview and record review with the DON, the DON stated LNs should notify the physician when there was no order of blood sugar check. The DON also stated LNs should not check blood sugar check without a physician order. The DON stated she did not know why the blood sugar check was taken with close intervals. According to the facility policy entitled Physician Orders, revised 2025, indicated, .Physician's orders shall be obtained prior to the initiation of any medication or treatment.When a licensed nurse has questions about an order, the physician will be contacted to ensure follow up and timely implementation of the order.

Based on interview and record review, the facility failed to ensure a resident was free from unnecessary medication when a resident (Resident 5) was receiving rivaroxaban (blood thinner that prevents and treat blood clots, one side effect is bruising or bleeding) and was not monitored for five months for signs and symptoms of bruising/ bleeding for one of two sampled residents reviewed for anticoagulant (AC, medicines that help prevent blood clots). This failure could result in AC medication related untoward side effects from inconsistent and poor management of medication therapy for Resident 5. Cross Reference F 756 Findings: Resident 5 was re-admitted to the facility on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following a stroke, per the facility's admission Record. On 12/15/25, a review of Resident 5's clinical record was conducted. There was a physician's order on 7/31/25 for rivaroxaban (AC) for prevention of stroke. There were no physicians order and documentation of monitoring for signs and symptoms of bleeding or bruising related to rivaroxaban use from 7/31/25 to 12/14/25. On 12/17/25 at 4:02 P.M., a joint review of Resident 5's clinical record and an interview was conducted with Licensed Nurse (LN) 3. LN 3 stated Resident 5 had been receiving rivaroxaban since 7/31/25, the whole month of August, September, October, November, and until 12/14/25. LN 3 stated Resident 5 received the rivaroxaban and she did not see physician's order for monitoring Resident 5 for bleeding and bruising until 12/15/25. LN 3 stated it was five months that there was no documentation of monitoring Resident 5 while on blood thinners. LN 3 stated Resident 5 should have been monitored for bruising and bleeding for resident's safety since the resident was unable to express her symptoms. On 12/18/25 at 4 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation was for the LNs to monitor residents receiving anticoagulants for signs of bleeding and bruising to ensure there were no untoward side effects of the anticoagulant therapy. A review of the facility's undated policy titled, Pharmacy Services/ Medication Management for Anticoagulants, indicated, The facility safely administers and monitors anticoagulant medications based on practitioner orders, resident needs, and accepted standards of practice, using ongoing assessment.Residents are monitored for bleeding.

Based on observation, interview, and record review, the facility failed to provide individualized therapeutic and or social activities that promote the residents' highest physical, mental, and psychosocial well-being, according to their plan of care for one of three reviewed residents (Resident 23). This deficient practice placed Resident 23 at risk for decreased emotional well-being, social isolation, and reduced quality of life due to the lack of meaningful engagement. Cross Reference F 677.Findings: Resident 23 was readmitted to the facility on [DATE], with diagnoses which included multiple sclerosis (MS, a disease that causes breakdown of the protective covering of nerves, can cause numbness, weakness, trouble walking, vision changes and other symptoms), per the facility's admission Record. On 12/15/25, a review of Resident 23's minimum data set (MDS, a federally mandated resident assessment tool) dated 11/27/25, indicated Resident 23 could make independent reasonable decisions. The MDS also indicated Resident 23's functional abilities included lower extremities impairment and that he was dependent on the staff on his activities of daily living (ADLs, like transferring). On 12/15/25, a review of Resident 23's care plan indicated Resident 23 will participate in group activities of choices including playing bingo. On 12/15/25 at 9:06 A.M., an observation and an interview was conducted with Resident 23 in his room. Resident 23 was laying in bed with his legs elevated. Resident 23 stated he had MS and was unable to walk. Resident 23 stated he stayed in bed and no one got him up from bed. Resident 23 stated he wanted to join activities but was unable to get up on his own. On 12/15/25 at 4:55 P.M., a follow up observation and an interview were conducted with Resident 23 in his room. Resident 23 stated he had not gone to the activity and would like to play Bingo. Resident 23 stated the staff had not offered any activities to him and it was boring. Resident 23 stated, I want them to get me out of here. Resident 23 stated he could not stand and or walk and needed assistance to get up. On 12/16/25 at 3:20 P.M., another follow up observation, and an interview were conducted with Resident 23 in his room. Resident 23 was laying in bed. Resident 23 stated he had not gotten up from yesterday (12/15/25) until 12/16/25. Resident 23 stated he wanted to attend activities and it would be great if he could be get up and attend activities. On 12/16/25 at 3:53 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated Resident 23 was alert and could make his needs known. CNA 2 stated Resident 23 was dependent on the staff when transferring. CNA 2 stated Our sup (supervisor) tells us to ask them (residents) to have social activities unless bedbound. On 12/17/25 at 2:59 P.M., a joint record review and an interview was conducted with the Activity Coordinator (AC). The AC stated Resident 23 required two person to assist him to transfer from bed to wheelchair. On 12/17/25 at 3:12 P.M., a joint observation and interview of Resident 23 with the AC was conducted in Resident 23's room. Resident 23 stated to AC, he would love to attend the activity and it would be nice. The AC stated Resident 23 was so happy and he is now smiling. On 12/17/25 at 3:36 P.M., a joint record review and interview were conducted with Licensed Nurse (LN) 3. LN 3 stated the staff had gotten up Resident 23 a month ago to attend an activity. LN 3 stated Resident 23 required two person assist to transfer him from the bed to the wheelchair and back to bed. LN 3 stated Resident 23 had been in bed a lot and could cause complications like getting wounds, isolation and boredom. On 12/18/25 at 11:36 A.M., a follow-up interview and record review of Resident 23's activity quarterly evaluation was conducted with the AC. The AC stated Resident 23 was in the one-on-one activity program from November to December 2025. The AC stated Resident 23 likes bingo. The AC stated bingo was a group activity and contradicted Resident 23's activity quarterly evaluation that indicated Resident 23's activity goal was met when he could not join bingo which Resident 23 liked. The AC stated Resident 23 had no wheelchair to attend the group activity and the information was communicated to nursing. The AC stated she could not locate the documentation indicating Resident 23 needed a wheelchair to attend the group activity. The AC stated Resident 23's evaluation was not accurate; the goal was not met. On 12/18/25 at 1:19 P.M., an interview was conducted with CNA 3. CNA 3 stated during the time she was assigned to Resident 23, she had not gotten up Resident 23 to attend group activity. On 12/18/25 at 3:19 P.M., a joint review of Resident 23's clinical record and an interview was conducted with the Director of Nursing (DON). The DON stated Resident 23 required assistance from the staff when getting up and out of bed. The DON stated there was no documentation of an attempt to encourage Resident 23 to attend activities of choice. The DON stated the policy was for the staff to encourage and offer Resident 23 to attend activities of choice to enhance his quality of life. A review of the facility's policy titled, Quality of Life, Activities Program, revised 3/19 indicated, .It is the policy of this facility to implement an ongoing resident centered activities program that incorporates the resident's interests.which is integral to maintaining and/ or improving a resident's physical, mental, and psychosocial well-being.Procedures, 1. Activities are planned according to the resident's preferences, needs and abilities.

Based on observation, interview, and record review, the facility failed to promote dignity for two of six residents (Resident 4 and Resident 177) when:1. Resident 177 had an uncovered urinary collection bag (when urine drains from the bladder into a clear plastic drainage bag); and,2 . A staff member stood over Resident 4, while assisting with a meal.These failures had the potential for Residents 4 and 177 to feel exposed and undignified. Findings:1. Resident 177 was readmitted to the facility on [DATE], after a hospital diagnosis of bacteremia (a bacterial infection in the bloodstream), per the hospital discharge records, dated 12/11/25.During initial tour on 12/15/25 at 9:42 A.M., Resident 177's bed was empty. According to Licensed Nurse 31 (LN 31), Resident 177 was outside the secured unit (a specialized, controlled environment within a facility, for residents with mental illness or memory loss) attending a physical therapy session.An observation was conducted of LN 32 on 12/15/25 at 2:34 P.M., as she was administering Resident 177 an intravenous antibiotic (medication administered directly into a patient's bloodstream through a vein) in the resident's room. Resident 177 had a urinary collection bag hanging from the right bedframe. The collection bag was a milliliter cylinder type (usually utilized in a hospital setting for closely monitoring the urine output) and was uncovered. The urine was visible in the collection bag. A dignity bag (a dark colored bag utilized to cover urine collection bags) was not covering the collection bag or attached to the resident's wheelchair, which was used earlier to transport Resident 177 to physical therapy. A joint observation and interview was conducted with LN 32 while inside Resident 177's room on 12/15/25 at 2:54 P.M. LN 32 observed visible urine within Resident 177 urine collection bag and stated the drainage bag should have a dignity bag covering it, and there was not one present. LN 32 stated dignity bags were important to protect the resident's privacy and to provide dignity.An interview was conducted with the Director of Nursing (DON ) on 12/18/25, at 8:50 A.M. The DON stated she expected all urinary collection bags to be covered with a dignity bag, to promote a resident's privacy and dignity. According to the facility's policy, titled Resident Rights, Dignity and Respect, dated October 2015, .4. Residents shall be examined and treated in a manner that maintains privacy of their bodies.2. Resident 4 was admitted to the facility on [DATE], with diagnoses which included paranoid schizophrenia (a mental illness characterized by intense paranoia, distrust, and suspicion, often leading to delusions (believing others want to harm you) and auditory hallucinations-hearing voices), per the facility's admission Record.An observation was conducted of Certified Nursing Assistant 31 (CNA 31) on 12/17/25 at 8 A.M., as she assisted Resident 4 with her breakfast within the resident's room. Resident 4 was in bed with the head of the bed elevated. CNA 31 was standing next to the bed, with a spoon in her hand and a meal tray on the bedside table. CNA 31 was observed standing over Resident 4's head, by approximately 2 feet. An interview was conducted with CNA 31 on 12/17/25 at 8:04 A.M. CNA 31 stated, Yes, I know I should not have been standing over her while assisting with her meal, because it was a dignity issue An interview was conducted with Licensed Nurse 31 (LN 31) on 12/17/25, at 8:08 A.M. LN 31 stated staff should be sitting or maintaining eye level while assisting residents with their meals. LN 31 stated if staff were standing, it could be assumed by the resident they were looking down on the residents or standing over them. LN 31 stated it was important to maintain eye level while feeding residents, to show respect and encourage socialization. An interview was conducted with the Director of Nursing (DON) on 12/17/25 at 8:11 A.M., as she entered the secured unit. The DON stated staff should always maintain eye to eye level when assisting residents with their meals. The DON stated staff could sit next to the bed or raise the bed up to obtain an eye to eye level. The DON stated by maintaining eye to eye level, it promotes dignity and respect.According to the facility's policy, titled Assisting the Impaired Resident with In-Room Meal, dated September 2013, .Steps in the Procedure: 1. Place the tray on the overbed table.3. If you are going to be seated during the feeding, position a chair where it will convenient for you and the resident.According to t facility's policy, titled Resident Rights, Dignity and Respect, dated October 2015, It is the policy of this facility that all residents be treated with kindness, dignity and respect.

Based on interview, and record review, the facility failed to ensure a Licensed Nurse (LN 1) notified the physician immediately, when a resident who was on anticoagulant therapy (medicines that help prevent blood clots) experienced episodes of vomiting large amount of coffee ground vomit (coffee ground vomit indicates upper gastrointestinal bleeding), for one of three sampled residents (Resident 1) reviewed for closed record.This deficient practice resulted in a delay in the resident receiving treatment to address Resident 1's significant change in condition and placed Resident 1's health at risk. Cross Reference F 684.Findings: Resident 1 was readmitted to the facility on [DATE] with diagnoses which included pneumonia (infection of the lungs), per the facility's admission Record. A review of Resident 1's history and physical (H&P) dated [DATE] was conducted. Per the H&P, Resident 1's Computed Tomography (CT scan, a type of imaging that uses X-ray techniques to create detailed images) of his chest, abdomen and pelvis at the general acute care hospital (GACH) indicated Resident 1 had chest wall large hematoma with active extravasation (a collection of blood in the extra thoracic space). The H&P indicated one of Resident 1's active medications was enoxaparin (anticoagulant). On [DATE] at 8:38 A.M., a joint record review and an interview was conducted with LN 32. LN 32 stated Resident 1 was transferred to the GACH on [DATE] at 10:50 A.M. after a cardiopulmonary resuscitation (CPR, life sustaining treatment) was initiated at the facility. LN 32 stated Resident 1 was at GACH when he passed away. LN 32 stated per LN 1's nurses progress notes on [DATE] at 1:36 A.M. Resident 1 threw up large amount of coffee ground emesis (medical term for vomiting). LN 32 stated the progress notes indicated she did not see any notes indicating the physician was notified of Resident 1's change in condition (CIC) until 10:50 A.M. LN 32 stated Resident 1 had CIC at 1:36 A.M. and that was more than nine hours after LN 1 observed Resident 1 had a CIC. LN 32 stated the LNs should have had informed the attending physician immediately because Resident 1 was on anticoagulant and threw up coffee ground emesis. LN 32 stated coffee ground emesis was a sign of bleeding and could be dangerous to Resident 1's health. On [DATE] at 4:08 P.M., a joint review of Resident 1's clinical record and an interview were conducted with the Director of Nursing (DON). The DON stated Resident 1 had been receiving an anticoagulant from GACH. The DON stated the timeline was as follows: - - [DATE], Resident 1 was readmitted to the facility, and was on anticoagulant.- = [DATE] at 3 A.M., the LN 1 progress notes indicated Resident 1 had another large ground coffee emesis around 7:45.- - [DATE] at 11:10 A.M., the LN progress notes indicated the nurse practitioner (NP, a nurse who has advanced clinical education and training and share many of the same duties as doctors) was notified and NP gave diagnostic orders for Resident 1. The DON stated Resident 1 had CIC on [DATE] at 3 A.M., the LNs did not notify the NP or the attending physician until after eight hours of Resident 1's CIC. - - [DATE] at 1:37 A.M., the progress notes indicated Resident 1 threw up a large coffee ground emesis.- - [DATE] at 10:49 A.M., the progress notes indicated Resident 1 had changed in level of consciousness, the NP was notified, NP recommended to send Resident 1 to GACH, CPR was initiated at the facility, was sent out to the hospital and was placed in intensive care unit (ICU, a special area in a hospital or healthcare facility for people who have a life-threatening illness or injury). Resident expired at the hospital. The DON stated she also did not see any documentation of notifying the doctor on [DATE] at 1:37 A.M. when LN 1 observed Resident 1 had coffee ground emesis. The DON stated the NP was notified on [DATE] at 10:20 A.M. The DON stated the LNs should have notified the physician immediately meaning as soon as possible after they (LN) observed the resident's CIC. A review of the facility's policy titled, Notification, Physician or Responsible Party, revised 2024, indicated, It is the policy of this facility to promptly notify the resident, his/ her attending physician/ NP.of changes in the resident's condition .

Based on observation, interview, and record review, the facility failed to ensure a thorough investigation was conducted for an allegation of abuse for one of one resident (Resident 162), when Resident 162 reported a male staff (RNA- restorative nursing assistant 1) inappropriately touched her. This failure had the potential to negatively affect Resident 162's psychosocial wellbeing and the potential to expose all residents in the facility to abuse.Findings: On 12/2/25, the Department of Public Health (CDPH) received a facility reported incident for an allegation of RNA 1 inappropriately touched Resident 162's breast. On 12/15/25 at 9:25 A.M., a concurrent observation and interview was conducted with Resident 162 in her room, curled up in bed. Resident 162 stated RNA 1 touched her breast in her room, but could not recall the date and time it happened. Resident 162 stated there were two unwitnessed incidents with the same staff (RNA 1). Resident 162 stated she informed her roommate (Resident 9) about the second incident. On 12/15/25 at 9:36 A.M., an interview was conducted with Resident 9. Resident 9 stated the incident happened a couple of weeks ago after breakfast in the room. Resident 9 stated she heard Resident 162 saying it is not happening. Resident 9 stated she did not not witness the incident. On 12/17/25 at 8:55 A.M., a concurrent interview and a review of Resident 162's clinical records and RNA 1's record was conducted with the Director of Nursing (DON). The DON stated Resident 162's physician History and Physical (H&P) dated 11/3/25 indicated Resident 162 did not have the capacity to understand and make decisions. The DON stated Resident 162's Brief Interview of Mental Status (BIMS - ability to recall) score dated 11/7/25 was 5/15 which meant Resident 162's cognitive level was severely impaired. The DON stated RNA 1 did not have any previous allegations of abuse, was not previously suspended, had no disciplinary actions prior, and he was up to date with his in -services and trainings. On 12/18/25 at 10:30 A.M., a follow up interview and record review was conducted with the DON. The DON stated there were no date and time Resident 9 and Resident 162 were interviewed during the facility investigation. The DON stated there were no date and time when RNA 1 was interviewed. The DON stated there were no other residents interviews to whom RNA 1 provided care or services. The DON stated she should have interviewed other residents and staff members to have a more understanding of the abuse allegation and the investigation would have a more definitive conclusion to make the investigation thorough and complete for prevention and safety of all residents. According to the facility policy entitled Administration, revised 6/2025, indicated .The investigation will include the following:.An interview with staff members (on all shifts) who may have information regarding the alleged incident;.Interviews with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident;.An interview with staff member (on all shifts) having contact with e accused employee; and.A review of all circumstances surrounding the incident.

Based on interviews and record reviews, the facility failed to provide a written notice of transfer and its bed hold policy to a resident and his Responsible Party (RP) at the time of his hospital transfer for one of three residents (18) reviewed for closed record. As a result, Resident 18 and his RP were not fully informed of Resident 18's bed hold rights. Findings: Per the facility's admission Record, Resident 18 was readmitted to the facility on [DATE] with diagnoses to include end stage renal disease (End Stage Renal Disease-irreversible kidney failure). On 12/17/25, a review was conducted of Resident 18's medical record. Resident 18's history and physical dated 6/24/25 indicated Resident 18 did not have the capacity to understand and make decisions and the resident's family member (FM) was the RP. Per the facility's Progress Note, dated 11/24/25 at 12 A.M., Resident 18 was transferred to an acute care hospital for a change in condition. There was no documentation on 11/24/25 or 11/25/25 that Resident 18's RP was provided with a written notice of Resident 18's transfer and the facility's bed hold policy. Per the facility's Bed Hold Notification, signed by Resident 18's RP on 10/6/25 (at the time of admission), the portion of the form titled, Confirmation of Transfer & Bed Hold Provision was not completed. The form was blank for the sections indicating the acute care hospital to which Resident 18 was transferred, the day and time he left, who notified him or his RP of the bed hold option, when he and his RP were notified, and the location for staff to sign. The section of the form that indicated 24-hour notification to Resident 18 and his RP was left blank. On 12/18/25 at 3:58 P.M., a joint review of Resident 18's bed hold notification form and an interview was conducted with the Director of Nursing (DON). The DON stated there was no signature when Resident 18 was transferred out to the hospital. The DON stated written notice of transfer and bed hold should have been provided to Resident 18 and his RP because that was their right. Per the facility's policy, titled Bed Hold, revised 1/22, It is the policy of this facility to inform the resident or resident's representative in writing of the right to exercise the bed hold provisions of (7) days upon admission, before transfer to a general acute care hospital.the duration of the state bed hold policy.that the resident's bed will be held for the duration of (7) days, during which time the resident is permitted to return and resume residence in the facility.

Based on observation, interview, and record review, the facility failed to accurately assess and code two of six residents (130 and 9) for Restorative Nursing Services (RNA-a specially training certified nursing assistant who provides range of motion exercises with residents, in order to maintain mobility and flexibility) on their Minimum Data Set (MDS-a mandated reporting assessment tool) used to inform Centers for Medicare and Medicaid Services (CMS), of residents' current status reviewed for MDS accuracy. This failure resulted in CMS not being informed of Resident 130's and Resident 9's current health status and services being provided.Findings: 1. Resident 130 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke - a medical emergency where blood flow to part of the brain is suddenly blocked or a blood vessel bursts, depriving brain cells of oxygen and nutrients causing them to die within minutes) affecting the left side (weakness of the left extremities), per the facility's admission Record. During initial tour 12/15/25 at 10:53 A.M., an observation and interview was conducted with Resident 130 as he laid in bed. A wheelchair was positioned near the foot of the bed. Resident 130 stated he wanted physical therapy, because he could not walk and he felt he was getting weaker every day. Resident 130 stated he really wanted to walk again. Resident 130's medical record was reviewed on 12/17/25. According to the physician's order, dated 10/22/25 indicated, Program for passive range of motion, left lower extremity, all planes, 10 repetitions, two sets, three times a week as tolerated. According to the quarterly Minimum Data Set (MDS-a clinical assessment tool), dated 12/11/25, Resident 130 had a cognitive score of 15, indicating cognition was intact. The quarterly MDS for Special Treatments, Section O, listed no Restorative Nursing Programs had been provided in the past seven days. A care plan, titled Resident at Risk for decline in Range of Motion, undated, listed RNA services being provided three times a week. The Weekly Restorative Nursing notes were present in the facility's Progress notes. An interview was conducted with certified nursing assistant 32 (CNA 32) on 12/17/25 at 9:58 A.M. CNA 32 stated it was important to recognize and identify residents with deteriorating range of motion, so a referral to physical therapy could be made and an assessment completed. An interview was conducted with Restorative Nursing Assistant 1 (RNA 1) on 12/17/25 at 12:06 P.M. RNA 1 stated Resident 130 was receiving RNA services three times a week to the lower extremities. An interview and record review was conducted with the Minimum Data Set Nurse (MDSN), regarding Resident 130's RNA services. The MDSN stated when reviewing and assessing residents for services, she reviews the physician's orders, nurses' notes, care plans, and administration records. The MDSN reviewed Resident 130's current physician orders, which indicated RNA services were being provided. The MDSN reviewed the 12/11/25 MDS, section O for RNA services which indicated no services were being provided. The MDS then checked the RNA administration record, which had no documented services. The MDSN left to get RNA 1, in order to confirm if RNA services were being provided or not. An interview was conducted with RNA 1 on 12/17/2025 at 12:30 12:23 P.M, with the MDSN being present. RNA 1 stated he documented his services in the nurses' progress notes and he never used the RNA Administration Record. The MDSN stated she completely missed it, by not checking the nursing progress notes for confirmation. The MDSN stated she should have checked with RNA 1 to confirm services were being provided and where they were documented. The MDSN stated that by missing the RNA assessment, CMS was unaware of the resident's current condition and services being provided. An interview was conducted with the Director of Nursing (DON) on 12/18/25 at 8:50 A.M. The DON stated she expected MDS data to be correct and completed in a timely manner. The DON stated CMS needed to be aware of all services being provided to residents. According to the Resident Assessment Instrument, dated October 2019, Section O-0500, .Steps for Assessment; 1. Review the restorative nursing program notes and/or flow sheets in the medical record. 2. For the 7-day look-back period, enter the number of days on which the technique, training or skill practice was performed for a total of at least 15 minutes during the 24-hour period. 3. The following criteria for restorative nursing programs must be met in order to code O-0500: Measurable objective and interventions must be documented in the care plan and in the medical record. 2. According to the facility's admission Record, Resident 9 was admitted to the facility on [DATE] and readmitted on [DATE], was sent out and return to facility on 12/8/25. On 12/17/25 at 3: 27 P.M., a concurrent observation, interview, and record review was conducted with Licensed Nurse (LN) 21. Resident 9 had hemiplegia (paralysis or severe weakness affecting one side of the body [arm, leg, and sometimes face] due to brain damage, often from a stroke, injury, or congenital condition) on the left side of body. Review of the admission notes indicated: On 1/31/24 Resident 9 had history of stroke with left sided hemiplegia (loss of muscle function). The questions were answered with: yes to weakness present, yes to left arm and left leg, yes to paralysis, left side weakness and ROM in arm, hand, leg and foot with limitation on one side. On 5/24/25 readmission assessment for Resident 9 questions were answered: Resident 9 had no weakness, paralysis, and did not indicate any limitation or loss of ROM. On 12/8/25 readmission assessment for Resident 9, the questions were answered: paralysis was marked with a check and ROM impairment on one side. During an interview with LN 21, LN 21 stated Resident 9's record was not accurate. LN 21 stated Resident 9's admission on [DATE] did not indicate any weakness or paralysis on the left side and the License Nurse Initial admission Record did not indicate ROM limitation or loss. On 12/17/25 at 3: 47 P.M., a concurrent observation, interview, and review of the LN initial admission notes was conducted with LN 22. Resident 9 had hemiplegia on the left side. Review of the LN initial admission notes dated 1/31/24 indicated: Resident 9's question were answered with yes to weakness present, yes to left arm and left leg, yes to paralysis and left side weakness and ROM in arm, hand, leg and foot with limitation on one side. On 5/24/25, the admission assessment, Resident 9 no weakness, paralysis and did indicate any limitation on ROM or loss. On 12/8/25, the assessment were answered on Resident 9 questions: paralysis was marked with a check and ROM impairment on one side. During this interview with LN 22, LN 22 stated Resident 9's assessment record was not accurate. LN 22 stated the License Nurse Initial admission Record on 5/24/25 did not indicate ROM limitation or loss. LN 22 stated it was important to have an accurate description of Resident 9. On 12/17/25 at 4: 25 P.M., an interview and record review of Resident 9's MDS (minimum data set- assessment tool) section G was conducted with Minimum Date Set Nurse (MDSN) 21. MDSN 21 stated Resident 9 was assessed today and confirmed Resident 9 had left sided weakness on upper and lower extremity. MDSN 21 stated the MDS assessment was not accurate. MDSN 21 stated Resident 9's records should be accurate to provide accurate care. On 12/18/25 at 10:09 A.M., an interview and review of the LN initial admission assessment and MDS assessment was conducted with the Director of Nursing (DON). The DON stated Resident 9's records was not coded accurately. The DON stated we need accurate MDS coding to provide accurate care. According to the facility policy entitled Resident Assessment Instrument, updated 10/1/19, indicated .The results of the assessment, which must accurately reflect the resident's status and needs.'

Based on observation, interview, and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASSAR 2-a federally mandated process that ensures individuals with serious mental illness (SMI), intellectual disabilities (ID), developmental disabilities (DD), are not inappropriately admitted to Medicaid-certified nursing facilities (NFs) if they can be served in a more integrated, community-based setting) was completed in a timely manner for one of three residents (Resident 129) reviewed for PASSAR.The failure had the potential for Resident 129 to be improperly placed or to miss out on additional services offered for PASSAR II residents.Findings:Resident 129 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought), per the facility's admission Record. An observation and interview was conducted with Resident 129 on 12/16/2025 at 8:15 A.M., in his room. Resident 129 was dressed and neatly groomed. Resident 129 stated he was admitted to the facility a few months ago and has made one or two friends since admission.Resident 129's medical record was reviewed on 12/17/25. A PASARR I was completed on 11/10/25, which was listed as, positive and triggered for a PASSAR II to be conducted by a State official. There was no documented evidence a PASARR II had been completed.On 12/17/25, the Minimum Data Set Nurse (MDSN) was asked to provide proof a PASSAR II had been completed.A review of Resident 129's PASARR II was reviewed on 12/17/25 at 8:16 A.M. The document dated 11/14/25 indicated, Unable to complete evaluation for serious Mental illness.Staff were unresponsive on 2 or more attempts to schedule within 48 hrs. Case close. An interview and record review of Resident 129's PASARR II was conducted with the MDSN on 12/17/25 at 8:30 A.M. The MDSN stated she arranged and scheduled the PASARR II interviews with State evaluators. The MDSN stated once Resident 129's PASARR II document was requested and reviewed, the MDSN realized Resident 129's PASARR II was never completed. The MDSN stated she could not recall ever receiving any calls from the State to schedule the evaluation or ever receiving the PASARR II letter, indicating the case was closed due to being unable to reach the facility to schedule it. The MDSN stated since the PASARR II was never completed it had the potential for a delay in Resident 129 receiving additional services and to ensure he was appropriately placed at the facility An interview was conducted with the Director of Nursing (DON) on 12/18/25 at 8:50 A.M. The DON stated PASSAR II's were important so staff could properly care for the resident and provide all recommended services. The DON stated she expected all PASARR I and PASSR II's to be completed in a timely manner. According to the facility's Policy, titled Resident Assessment: PASRR, dated December 2021, .1 A PASRR shall be completed on every resident upon admission.3. After admission, IDT members will review the assessment for accuracy and the need for PASRR Level II referral. 4. Based on the assessment, the facility will ensure proper referral to appropriate State agencies for the provision of specialized services to residents with ID/RC (Intellectual Disability or Related Condition) or SMI (Serious Mental Illness) .

Based on observation, interview, and record review, the facility failed to complete post fall assessments for one of one resident (Resident 57) reviewed for accidents according to the facility's policy and procedure. This failure had the potential for not identifying the root cause of Resident 57's falls and maintain Resident 57's safety.Findings: Resident 57 was admitted to the facility on [DATE] with diagnoses including vascular dementia (brain damage affecting thinking, memory, judgment and walking), unspecified severity according to the facility's admission Record. During an observation of Resident 57 on 12/15/25 at 9:30 A.M., Resident 57 was in bed with a floor mat on the right side of the bed. An interview and concurrent record review on 12/17/25 at 3:08 P.M. was conducted with Licensed Nurse (LN) 11. LN 11 stated Resident 57 used to walk independently using a front wheel walker but had declined and preferred to stay in bed most of the day. LN 11 reviewed Resident 57's progress notes from September 2025 and stated Resident 57 has had multiple fall incidents. LN 11 stated Resident 57 fell on 9/3/25, 9/16/25, 10/11/25, 11/5/25, 12/8/25 and on 12/11/25. LN 11 stated a fall risk assessment was completed upon a resident's admission and after each fall. LN 11 reviewed fall risk assessments for Resident 57. LN 11 stated the fall risk assessment completed on 9/16/25, 10/11/25 and on 12/11/25 indicated, Resident 57 was high risk for falls.LN 11 stated there was no fall risk assessment completed for the Resident 57's fall incidents on 9/3/25 and 11/5/25. LN 11 stated a fall risk assessment should have been completed to assess the resident's functionality and if fall preventive measures were working. During an interview on 12/17/25 at 3:25 P.M. with Certified Nurse Assistant (CNA) 13, CNA 13 stated Resident 57 had episodes of unsafely getting up from bed unassisted and was a fall risk. CNA 13 stated Resident 57 required one on one monitoring for safety. An interview was conducted on 12/18/25 at 4:50 P.M. with the Director of Nursing (DON). The DON stated post fall assessments were needed to check for the root cause of a fall and to have appropriate interventions. A review of the facility's policy and procedure (P&P) titled, Fall Best Practice Guidelines, dated 7/2016 was conducted. The P&P indicated, It is the policy of this facility to.Investigate the circumstances surrounding each resident fall and implement actions to reduce the incidence of additional fall and minimize potential for injury.Identify the residents who are at risk for fall.Fall risk assessment will be completed within 24 hours of admission, post fall, with the MDS [Minimum Data Set- a clinical assessment tool] required assessment, and quarterly.A Post Fall Assessment including recommendations and care plan changes will be completed for all residents who experienced a fall.Findings: Resident 57 was admitted to the facility on [DATE] with diagnoses including vascular dementia (brain damage affecting thinking, memory, judgment and walking), unspecified severity according to the facility's admission Record. During an observation of Resident 57 on 12/15/25 at 9:30 A.M., Resident 57 was in bed with a floor mat on the right side of the bed. An interview and concurrent record review on 12/17/25 at 3:08 P.M. was conducted with Licensed Nurse (LN) 11. LN 11 stated Resident 57 used to walk independently using a front wheel walker but had declined and preferred to stay in bed most of the day. LN 11 reviewed Resident 57's progress notes from September 2025 and stated Resident 57 has had multiple fall incidents. LN 11 stated Resident 57 fell on 9/3/25, 9/16/25, 10/11/25, 11/5/25, 12/8/25 and on 12/11/25. LN 11 stated a fall risk assessment was completed upon a resident's admission and after each fall. LN 11 reviewed fall risk assessments for Resident 57. LN 11 stated the fall risk assessment completed on 9/16/25, 10/11/25 and on 12/11/25 indicated, Resident 57 was high risk for falls. LN 11 stated there was no fall risk assessment completed for the Resident 57's fall incidents on 9/3/25, 11/5/25 and on 12/8/25. LN 11 stated a fall risk assessment should have been completed to assess the resident's functionality and if fall preventive measures were working. During an interview on 12/17/25 at 3:25 P.M. with Certified Nurse Assistant (CNA) 13, CNA 13 stated Resident 57 had episodes of unsafely getting up from bed unassisted and was a fall risk. CNA 13 stated Resident 57 required one on one monitoring for safety. An interview was conducted on 12/18/25 at 4:50 P.M. with the Director of Nursing (DON). The DON stated post fall assessments were needed to check for the root cause of a fall and to have appropriate interventions. A review of the facility's policy and procedure (P&P) titled, Fall Best Practice Guidelines, dated 7/2016 was conducted. The P&P indicated, It is the policy of this facility to.Investigate the circumstances surrounding each resident fall and implement actions to reduce the incidence of additional fall and minimize potential for injury.Identify the residents who are at risk for fall.Fall risk assessment will be completed within 24 hours of admission, post fall, with the MDS [Minimum Data Set- a clinical assessment tool] required assessment, and quarterly.A Post Fall Assessment including recommendations and care plan changes will be completed for all residents who experienced a fall.

Based on observation, interview, and record review, the facility failed to ensure a resident (Resident 5) was positioned properly while tube feeding (TF-nutrition in liquid form through a tube) was ongoing per the resident's plan of care for one of two residents reviewed for TF. As a result, Resident 5 was at risk for aspiration (back up of fluid from the stomach to the lungs) and other TF complications.Findings: Resident 5 was re-admitted to the facility 7/29/25 with diagnoses which included dysphagia (difficulty swallowing) and a gastrostomy (opening in the stomach created surgically), per the facility's admission Record. On 12/16/25 at 9:38 A.M., an observation of Resident 5 in the room was conducted. Resident 5 was lying flat on bed while a TF was infusing. On 12/16/25 at 10:40 A.M., a joint observation of Resident 5 and an interview was conducted with Licensed Nurse (LN) 32. LN 32 stated Resident 5's TF would have been completed at 10 A.M. LN 32 stated Resident 5's head of bed was flat and should have been elevated to prevent Resident 5 from aspiration that could have led to pneumonia (lung infection). LN 32 stated for residents with ongoing TF, the head of the bed should have been elevated to 30 to 45 degrees angle to prevent the residents from aspiration. A review of Resident 5's plan of care, titled Enteral Feeding, indicated one of the interventions was to elevate Resident 5's head of bed at 45 degrees angle during and thirty minutes after TF. On 12/18/25 at 4 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated facility's policy for residents with ongoing TF, the residents' head of bed should be elevated at 30-45 degrees angle to prevent from aspiration. A review of the facility's policy and procedure (P&P) titled, Gastrostomy Tube Care and Management, dated 1/22 was conducted. The P&P did not provide guidance regarding proper positioning of a resident with TF.

Based on observation, interview, and record review, the facility failed to assess respiratory status during a nebulizer treatment (liquid medication delivered as a fine mist inhaled into the lungs through a mouthpiece or mask) for two of two residents (Resident 178 and Resident 8) reviewed for respiratory care. This failure had the potential for residents to receive inappropriate care and treatment to address their respiratory problems.Findings: 1.Resident 178 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia (a condition where the lungs fail to adequately exchange oxygen, leading to low oxygen in the blood) according to the facility's admission Record. On 12/17/25 at 8:55 A.M. Resident 178's family member notified Licensed Nurse (LN) 14 that Resident 178 had difficulty breathing. LN 14 informed Resident 178's family member that he will administer a nebulizer treatment to Resident 178 to help with the breathing. LN 14 took a medication in a plastic vial from the medication cart. LN 14 poured the liquid medication into a chamber connected to a mask and a machine, placed the mask on Resident 178 and then turned on the machine. LN 14 did not listen to Resident 178's lung sounds, checked respiratory rate and heart rate prior to, during or after the nebulizer treatment. During a review of Resident 178's Order Summary Report, the Order Summary Report indicated, Ipratopium-Albuterol Solution.3 ml [milliliter] inhale three times a day for Acute respiratory failure. An interview was conducted with LN 11 on 12/18/25 at 8:31 A.M. LN 11 stated for nebulizer treatments, the resident's lung sounds, respirations and heart rate should be checked before and after the nebulizer treatment. LN 11 stated an assessment should be conducted in case there was a change in the resident's condition. 2.Resident 8 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing) and gastrostomy status (feeding tube in the stomach) according to the facility's admission Record. A medication administration observation for Resident 8 was conducted on 12/17/25 at 9:52 A.M. with Licensed Nurse (LN) 14. LN 14 stated Resident 8 was due for a nebulizer treatment. LN 14 took a liquid medication in a small plastic vial from the medication cart, poured the medication into a chamber connected to a mask and a machine, applied the mask to Resident 8 then turned on the nebulizer machine. LN 14 did not check Resident 8's lung sounds, respiratory rate and heart rate before, during or after the nebulizer treatment. A review of the Order Summary Report for Resident 8 indicated, Budesonide [a steroid medication used to reduce inflammation] Inhalation Suspension.2 ml [milliliter] inhale orally via nebulizer two times a day for COPD (Chronic Obstructive Disease- lung diseases that block airflow and make it difficult to breathe) Nebulizer treatment. During an interview on 12/18/25 at 10:16 A.M. with LN 14. LN 14 stated he was not instructed to check a resident's respiratory rate and pulse prior to, during or after a nebulizer treatment. An interview on 12/18/25 at 10:29 A.M. with LN 34 was conducted. LN 34 stated the resident's respirations, breathing and pulse should be checked before and after a nebulizer treatment. LN 34 stated it was important to check the resident's heart rate if it was normal after a nebulizer treatment and if the treatment was effective. An interview on 12/18/25 at 4:50 P.M., was conducted with the Director of Nursing (DON). The DON stated she expected nurses to stay with the resident during breathing treatment. The DON stated nurses should check the resident's respirations, listen to their lungs and check heart rate because some medications could increase heart rate. The DON stated an assessment should be done to check for abnormality and effectiveness of the nebulizer treatment. A review of the facility's undated policy and procedure (P&P) titled, Small Volume Nebulizer was conducted. The P&P indicated, Nebulizer treatment is done to improve and promote coughing, to improve distribution of ventilation [process of moving air in and out of the respiratory system], to open up alveoli [air sacs in the lungs], to decrease carbon dioxide [waste product expelled upon breathing out] and to deliver medication [s]. The policy did not provide guidance regarding resident assessment to verify effectiveness of the nebulizer treatment.

Based on interview and record review, the facility failed to address and implement the Consulting Pharmacist's (CP) recommendation during a monthly Medication Regimen Review (MRR) regarding a psychotropic medication (a medication that affects brain function), for one of five residents (Resident 99), for Medication Review. In addition, the CP did not identify monitoring of untoward side effects of anticoagulant (AC, blood thinner medication) for one of two residents (Resident 5) reviewed for AC (Cross Reference F 757). This failure had the potential for Resident 99 not to be monitored appropriately by staff for exhibiting specific behaviors. In addition, Resident 5 was not monitored for untoward side effects of AC for five months.Findings: Resident 99 was admitted to the facility on [DATE], with diagnoses which included paranoid schizophrenia, (a mental illness marked by intense paranoia, delusions [false beliefs, often persecutory], and auditory hallucinations [hearing voices]), according to the facility's admission Record. Resident 99's medical record was reviewed on 12/17/25. According to the physician's order, dated 5/23/24, Ativan 1 milligram tablet, (a medication use to treat anxiety), three times a day by mouth, for anxiety. Monitor episodes of anxiety as exhibited by restlessness every shift. According to undated care plan, titled Anti-Anxiety medication use related to anxiety disorder as exhibited by anxiousness, included an intervention of: Monitor/record occurrences of target behavior. A review of the MRR for October 2025 was conducted on 12/17/25. The CP made the recommendation for Resident 99's Ativan use indicated: Restlessness is vague and subjected, it is not measurable, please change or correct. There was no documented evidence that the recommendation was addressed or acted on. An interview and record review regarding Resident 99 was conducted with Licensed Nurse 33 (LN 33 ) on 12/18/25 at 8:27 A.M. LN 33 stated to administer a psychotropic medication, there needed to be a physician's order, a consent signed by the resident or their responsible party, and a specific behavior to monitoring for. LN 33 reviewed Resident 99's physician order for Ativan behavior monitoring, which listed a behavior of restlessness. LN 33 stated the behavior was too vague and subjective. LN 33 stated the behavior should be more specific like, repeatedly pacing. getting up and down from bed. LN 33 stated the behavior of restlessness should have been captured sooner by staff and changed to a specific targeted behavior. An interview and record review was conducted regarding Resident 99 with LN 31 on 12/18/25 at 8:34 A.M. LN 31 stated specific behaviors needed to be listed by the physician for staff to monitor for, when receiving a psychotropic medication. LN 31 reviewed Resident 99's physicians' order for Ativan behavior monitoring. LN 31 stated the behavior of restlessness was too vague and was unacceptable for monitoring. LN 31 stated the behavior needed to be very specific such as yelling and/or screaming at staff. An interview and record review regarding Resident 99's MRR was conducted with the Director of Nursing (DON) on 12/18/25 at 8:50 A.M. The DON stated specific behavior monitoring should be documented, so staff were aware of what behavior they were monitoring for. The DON reviewed Resident 99's October 2025 MMR and the CP's recommendation regarding the vague behavior of restlessness. The DON stated the recommendation should have been implemented, once it was received and it was not. The DON stated she did not follow through and make the recommended changes. An interview was conducted with the Consulting Pharmacist (CP) on 12/18/25 at 9:51 A.M. The CP stated he made recommendations on a monthly basis and he expected staff to follow the recommendations or offer a written explanation of why they are not being followed. The CP stated if he made a recommendation in October 2025, he expected staff to acknowledge it and make the needed changes that same month. According to the facility's policy, titled Care and Treatment-Medication Regimen Review, dated May 2007, .Procedure: .4. Pharmacist review considers factors such as; Whether the physician and staff have documented objective findings, diagnoses, and/or symptoms to support indications for use. 5.The use of medication without evidence of adequate monitoring.6.B. Nursing Documentation Review: Nursing personnel provide a written response to the review after the report is received. 2. Resident 5 was re-admitted to the facility on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following a stroke, per the facility's admission Record. On 12/15/25, a review of Resident 5's clinical record was conducted. There was a physician's order on 7/31/25 for rivaroxaban (AC) for prevention of stroke. There were no physicians order and documentation of monitoring for signs and symptoms of bleeding or bruising related to rivaroxaban use from 7/31/25 to 12/14/25. On 12/17/25 at 4:02 P.M., a joint review of Resident 5's clinical record and an interview was conducted with Licensed Nurse (LN) 3. LN 3 stated Resident 5 had been receiving rivaroxaban since 7/31/25, whole month of August, September, October, November, until 12/14/25. LN 3 stated Resident 5 received the rivaroxaban, and she did not see physician's order for monitoring Resident 5 for bleeding and bruising until 12/15/25. LN 3 stated it was five months that there was no documentation on monitoring Resident 5 while on blood thinners. LN 3 stated Resident 5 should have been monitored for bruising and bleeding for resident's safety since the resident was unable to express her symptoms. On 12/18/25 at 9:46 A.M., a telephone interview was conducted with the facility's CP. The CP stated Resident 5's physician's order for rivaroxaban was received on 7/31/25. The CP stated the medication regimen review (MRR) for Resident 5's AC therapy should have been done monthly to look for discrepancies. The CP stated there was no monitoring for the untoward side effects like bleeding, for Resident 5's AC therapy from July 2025 to December 2025. The CP stated, It should have been captured during the MRR. I did not capture it. On 12/18/25 at 4 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation was for the LNs to monitor residents on anticoagulant for bleeding and bruising to ensure there was no untoward side effects of the anticoagulant therapy. A review of the facility's undated policy titled, Pharmacy Services/ Medication Management for Anticoagulants, indicated, The facility safely administers and monitors anticoagulant medications based on practitioner orders, resident needs, and accepted standards of practice, using ongoing assessment.Residents are monitored for bleeding.Anticoagulants therapy is reviewed monthly by the consultant pharmacist, with follow-up documented as appropriate. A review of the facility's policy titled, Medication Regimen Review (MRR), revised 5/07, indicated, .1. The pharmacist must review each resident's medication regimen at least once a month.to identify clinical significant risks and or adverse consequences resulting from or associated with medications.

Based on observation, interview, and record review, the facility failed to ensure medications had proper storage and labeling when:1. Two tablets were found loose and unlabeled inside a medication drawer,2. Expired medications were stored inside the medication refrigerator These failures had the potential for medications to be incorrectly administered and decrease medication potency (medication strength) that could compromise the therapeutic effectiveness of stored medications.Findings: 1. A medication storage observation was conducted on 12/17/25 at 7:52 A.M., at station 1. Licensed Nurse 14 (LN 14) opened the second drawer of the medication cart which contained medication cards for residents. A small orange and small white tablet were found loose and unlabeled at the bottom of the drawer. LN 14 stated he was unsure why there were loose tablets in the medication drawer. LN 14 stated the medication cards listed residents' names and drug names. LN 14 stated there should not be any loose and unlabeled medications in the medication cart because staff would not know what the medications were used for. 2. A medication storage observation was conducted on 12/17/25 at 11:56 A.M. at the facility's medication storage room. During a joint observation of the medication refrigerator with LN 32, three bisacodyl suppositories (medication for constipation) were inside the refrigerator. LN 32 checked the expiration dates for each suppository and stated the suppositories had an expiration date of 11/2025. LN 32 stated the suppositories should not be in the refrigerator because they were expired. LN 32 stated expired medications were no longer effective. An interview with the Director of Nursing (DON) on 12/18/25 at 4:50 P.M., the DON stated there should be no loose and unlabeled medications in the medication drawer because it was a safety issue and infection control concern. The DON further stated if a medication was expired, the medication was no longer effective. A review of the facility's policy and procedure (P&P) titled, Labeling and Storage, dated 2/2025 was conducted. The P&P indicated, It is the policy of this facility that medications and biologicals are labeled in accordance with facility requirements, state and federal laws.Drugs shall be stored in appropriate temperatures.Discontinued drug container shall be marked.Discontinued drugs shall be disposed of within ninety (90) days of the date the drug was discontinued, unless the drug is reordered within that time The policy did not provide guidance regarding expired medications.

Based on interview, and record review, the facility failed to ensure one of three residents (Resident 1) did not gain access to illegal substances. As a result, Resident 1 died at the facility. The Medical Examiner's report indicated Resident 1 had fentanyl (a potent synthetic opioid drug) and methamphetamine (a potent central nervous system stimulant) in his system. Findings: A record review of Resident 1's undated Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included low back pain, other psychoactive substance abuse (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), insomnia (the presence of an individual's report of difficulty with sleep), and depression (a serious medical illness that negatively affects how you feel, the way you think and how you act). A record review of Resident 1's Elopement Assessment, dated [DATE], indicated Resident 1 scored 31 of 55, which according to the record, indicated a high risk for elopement. A record review of Resident 1's care plans were conducted. One of Resident 1's care plans dated [DATE], indicated, I am at risk for adverse reaction r/t (related to) potential IV (intravenous - a way of giving a drug or other substance through a needle or tube inserted into a vein) drug use while here at (name of facility). One of Resident 1's care plans dated [DATE], indicated, (Resident 1's name) went out unnoticed with a PICC line (peripherally inserted central line - a flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the right side of the heart) resulting in potential for injury. A record review of the Resident 1's nursing Progress Note written by Licensed Nurse (LN) 1 dated [DATE] was conducted. This record indicated, .noticed resident present with droopy eyes, slurred speech and sluggish like movement with a flush syringe connected to his PICC line, resident has a history of IV drug use and writer called RN (registered nurse) supervisor and charge nurse to assess patient as patient appeared high. When RN's [sic] went to assess resident, resident then got up and started exercising and exhibiting erratic (unpredictable) behavior that is not within baseline (a starting point used for comparison), resident MD (medical doctor) made aware and a N.O. (new order) for a toxicology screen (the scientific study of adverse effects that occur in living organisms due to chemicals) ordered; lab (laboratory) called and made aware. A record review of Resident 1's physician's order dated [DATE] indicated, toxicology lab R/T (related to) potential substance abuse. A record review of Resident 1's Test Request Form dated [DATE] indicated that Resident 1 refused to provide a sample for the ordered toxicology screening. A record review of Resident 1's Test Request Form dated [DATE] indicated that a urine specimen was obtained for toxicology screening. On [DATE] an email was received from medical records at the facility which indicated the lab ran a culture and sensitivity (a culture is a test to find germs that can cause an infection. A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection) instead of a toxicology screen. A record review of Resident 1's nursing Progress Note written by LN 1 dated [DATE] was conducted. This record indicated, Resident was found coming into the building by station one staff from outside the facility; resident has a PICC line for IV abt (antibiotic); st (station) 1 nurses called st 2 and notified staff here; resident approached by charge nurse and writer to ask why the resident was outside, resident replied to get cell service. Resident made aware that due to the PICC line and current drug abuse history, resident should not be stepping out outside [sic] without an order or someone to supervise to prevent injury; resident stated ok . A record review of Resident 1's nursing Progress Note written by LN 4 dated [DATE] was conducted. This record indicated that on [DATE] at 12:55 A.M., Resident found moaning and saying I' m in pain and IV line disconnected from PICC line port and PICC line clamped (had been connected earlier). 103a (1:03 A.M.) resident found gasping for air and nonresponsive. Placed on oxygen 10 liters via non-rebreather mask (a medical device that helps deliver oxygen in emergency situations). 104am (1:04 A.M.) no pulse palpable (capable of being felt) CPR (cardio-pulmonary resuscitation - an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) begun and paramedics called. 110 (1:10 A.M.). Narcan (used for the treatment of life-threatening opioid overdose or suspected opioid overdose) 4 mg (milligrams) given x2 (two times) nasally. CPR continues and paramedics arrive at 112 (1:12 A.M.). 140am (1:40 A.M.) CPR ceased and paramedics pronounced resident deceased . A record review of Death Certificate Amendment Worksheet from the Medical Examiner's Office dated [DATE] at 4:39 P.M. was conducted. The cause of death was listed as complications of acute (something with a sudden onset) and chronic (something that continues over a period of time) substance use disorder. Manner of death: accident. Place of injury: (address of facility). Date and time: [DATE] time unk (unknown). How occurred: self-administered methamphetamine (a potent nervous system stimulant) and recently fentanyl (a potent synthetic opioid pain reliever). The report indicated that central blood (blood near the center of the body, often near the heart) was positive for fentanyl, methamphetamine, oxycodone (an opioid pain reliever), nor fentanyl (substance the body makes as it breaks down fentanyl) and 4-ANPP (an impurity found in fentanyl preparations). The report indicated that peripheral blood (blood away from the center of the body, such as the arms or legs) was positive for oxycodone and nor fentanyl. On [DATE] at 10:39 A.M., An interview and concurrent record review of the nursing Progress Note dated [DATE] was conducted with the Nurse Practitioner (NP). The NP stated Resident 1 had a history of leaving facilities against medical advice. The NP stated, The resident was a big risk for overdose. The NP reviewed Resident 1's nursing Progress Note dated [DATE]. The nursing Progress Note indicated, .noticed resident present with droopy eyes, slurred speech and sluggish like movement with a flush syringe connected to his PICC line, resident has a history of IV drug use and writer called RN supervisor and charge nurse to assess patient as patient appeared high. When RNs went to assess resident, resident then got up and started exercising and exhibiting erratic behavior that is not within baseline, resident MD made aware and a new order for toxicology was ordered. Lab called and made aware. The NP stated a urinalysis for toxicology was ordered on [DATE]. The NP stated, The staff thought the resident was high on drugs. The NP stated no other orders were written in response to Resident 1's change of condition on [DATE]. The NP stated no one to one monitoring was ordered. The NP stated the resident was not transferred to a higher level of care. A concurrent record review of the Social Services note dated [DATE] was conducted. The Social Services note indicated, There had been concerns mentioned due to patient having IVs and PICC line. NP expressed concerns with patient going out on pass while on IV medications . The NP stated he did not feel comfortable granting Resident 1 a one-time pass to leave the facility for a family wedding. The NP stated it was approved by (physician's name, MD 1). On [DATE] at 3:10 P.M., an interview was conducted with Medical Doctor (MD) 1. MD 1 stated, I saw the resident fiddling around with something and he put it in his pockets. I expressed concern about his behavior and SUD (Substance Use Disorder - a disease that affects a person's brain and behavior and leads to an inability to control the use of a legal or illegal drug or medicine). He said I'm not using. If I was you guys wouldn't know. He had vials of white powder or a bag and a needle. He was here for treatment of infection, there was nothing else to treat. This is what drug addicts do. He's not in prison. We can't control everything he did. Just read my notes. He's only here for treatment of IV antibiotics for infection. Someone could have brought him something. He could have gone out and gotten something. We know he left the building once. On [DATE] at 12:02 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated there were no measures put in place to prevent Resident 1 from leaving the facility without the knowledge of the staff. The DON stated Resident 1 leaving the facility put the resident at risk for harm. On [DATE] at 2:45 P.M., an interview was conducted with the DON. The DON stated the resident should not have had access to a syringe. The DON stated there was a duty to keep the resident safe. The DON stated the facility did not do one on one monitoring. The DON stated there was a toxicology lab related to potential substance abuse ordered by MD 1 on [DATE]. The DON stated the resident refused to give a urine sample on [DATE] so the test was reordered. The DON stated there were no notes in the record that the resident refused to provide a urine sample for the toxicology lab. The DON stated there was no facility investigation of the death. Another toxicology lab was ordered on [DATE] which was collected. A record review of the nursing Progress Note written by LN 2 dated [DATE] at 9:03 P.M. was conducted. The record indicated, Resident's (Resident 1) PICC line was noted to be clogged when RN attempted to do initial flushing. RN stopped and notified the MD immediately. A record review of the nursing Progress Note written by LN 3, dated [DATE] at 12:30 P.M. was conducted. The record indicated, Resident's (Resident 1) PICC line was noted clogged when to do [sic] initial flushing prior to the IV medication. Stopped immediately and notified NP. A record review of the Physical Medicine Rehabilitation Consultation/ Initial Evaluation dated [DATE] was conducted. The record indicated, Date of Service [DATE]. (physician's name, MD 2) .Nursing staff notably expressing concerns for possible active drug use given his (Resident 1) PICC line being clogged on numerous occasions. On [DATE] at 8:51 A.M., an interview and joint record review of Resident 1's nursing note dated [DATE] was conducted with LN 1. LN 1 stated she called the RN into the room to show her a flush syringe attached to (Resident 1's name) left arm PICC. LN 1 stated The resident wasn't presenting how he usually presented. LN 1 stated that when the RN came into the room the resident started exercising and his behavior was erratic. LN 1 stated she called the charge nurse and RN supervisor in so they could assess him. LN 1 stated she called the NP and received an order for toxicology. LN 1 stated there were no notes showing increased monitoring or transfer to a higher level of care. LN 1 reviewed Resident 1's nursing note dated [DATE] at 2:17 P.M. LN 1 stated Resident 1 was seen coming back into the facility. LN 1 stated no one knew how long the resident was gone. LN 1 stated there was a potential for injury because Resident 1 had a PICC line. LN 1 stated, That was the only time Resident 1 left on my shift. LN 1 stated she notified the NP and got an order for toxicology. LN 1 stated Resident 1 requested pain medication as soon as he could have it. LN 1 stated Resident 1 could not have been gone more than ,d+[DATE] hours based on the medication administration time. LN 1 stated Resident 1 received a medication between 9 A.M and 10 A.M. on [DATE] and returned to the facility at 2:17 P.M. LN 1 stated she wrote a care plan on [DATE] after Resident 1 returned to the building regarding (resident name) went out unnoticed with PICC line resulting in potential for injury. LN 1 stated that interventions that addressed Resident 1's behavior of leaving the building unattended were not initiated until [DATE]. On [DATE] at 10:00 A.M., an interview was conducted with LN 4. LN 4 stated, .nurses would find his IV disconnected, they would find paraphernalia (equipment used for taking illicit drugs) at the bedside such as syringes. There was a comment made to the nurses not to leave any syringes because we believe he might be using his PICC line to shoot up drugs through, at one point an order for a drug screen was made to look for street drugs. I don't know the results of that test. I found a plastic syringe near the bedside the night of the code, it was one of our 10 cc (cubic centimeter - a unit of measurement) normal saline (sterile salt water for injection) syringes, empty, it appeared to have a white residue in a scant amount. He could get syringes if a nurse carelessly threw the syringe into the trash by his bedside. I dispose of syringes in the sharps container depending on if there's blood or wound irrigation (the steady flow of a solution across an open wound surface to achieve wound hydration, to remove deeper debris, and to assist with the visual examination) it can be thrown in the trash. He'd been there quite a while so it's conceivable that he may have had a surplus of the 10 cc saline syringes . On [DATE] at 11:05 A.M., an interview was conducted with the Medical Director. The Medical Director stated, People come and go all the time, I imagine if he (Resident 1) had any visitors he could have gotten something brought in .There's no indication for methamphetamine so that had to come from an outside source. Fentanyl patches are in the facility, but you can't convert that to another delivery system. I would imagine the methamphetamine was laced with fentanyl. On [DATE] at 12:43 P.M., an interview was conducted with the Administrator (Adm), the DON, and the Clinical Market Leader (CML). A verbal summary of the incident involving Resident 1 was provided to the Adm, the DON, and CML. The CML stated the facility did not do everything they could to keep Resident 1 safe while in the facility. A record review of the undated policy titled Care and Treatment - Medication Access and Storage was conducted. The policy stated, It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .2 .Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. A policy related to the care of a resident with substance use disorder was requested from the DON on [DATE]. The DON stated the facility did not have a policy related to the care of a resident with substance use disorder. A policy related to disposal of facility syringes was requested from the DON on [DATE]. The DON stated the facility did not have a policy related to disposal of facility syringes.

Based on observation, interview and record review, the facility failed to plan and implement nutritional interventions to address an unplanned weight loss for one of 24 sampled residents (Resident 141) which progressed to a clinically significant (Effects, results, or consequences that materially affect or are likely to affect an individual's physical, mental, or psychosocial well-being either positively by preventing, stabilizing, or improving a condition or reducing a risk, or negatively by exacerbating, causing, or contributing to a symptom, illness, or decline in status.) unplanned weight loss (the resident's weight fell below his ideal body weigh) that was identified by the facility as avoidable. As a result, Resident 141 had experienced an unplanned clinically significant compromised nutritional status as evidenced by unplanned significant weight loss, which fell below his ideal body weight. According to accepted standards of practice, Among older people, weight loss is associated with frailty, functional impairments, immune disorders, pressure ulcers, [MEDICAL CONDITION], cognitive impairment, low quality of life, and increased mortality. Research indicates it is critical that any weight loss in older adults be prevented. (Source: Position of the American Dietetic Association: Liberalization of the Diet Prescription Improves Quality of Life for Older Adults in Long Term Care, Journal of the American Dietetic Association, December 2005). Involuntary weight loss can lead to muscle wasting, decreased immunocompetence, depression and an increased rate of disease complications. Various studies have demonstrated a strong correlation between weight loss and morbidity and mortality. One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of [DIAGNOSES REDACTED]. (FEBRUARY 15, 2002 / VOLUME 65, NUMBER 4 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN) Findings: On 3/16/16 at 10 A.M., Resident 141's medical record was reviewed. Resident 141 was born in the year of 1953 ([AGE] years old) was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 141 was re-admitted to the facility on [DATE], after staying in the hospital from 12/30/15 to 1/4/16 (per hospital discharge records, dated 1/4/16) with [DIAGNOSES REDACTED]. According to Resident 141's history and physical, dated 1/7/16, This resident does not have the capacity to understand and make decisions .surrogate decision maker: IDT (the facility's interdisciplinary team) . Resident 141's Weights and Vitals Summary indicated the following weights; 8/29/15 - 144.2 pounds (lbs) 9/6/15 - 144.2 lbs 9/28/15 - 143.2 lbs 10/24/15 - 141 lbs 11/29/15 - 138 lbs 12/27/15 - 136.2 lbs 1/05/16 - 131 lbs 1/10/16 - 133.8 lbs 1/16/16 - 132 lbs 1/23/16 - 130.2 lbs 1/30/16 - 130 lbs 2/07/16 - 131 lbs 2/14/16 - 129 lbs 2/21/16 - 128.2 lbs 2/28/16 - 131 lbs 3/05/16 - 130.2 lbs 3/09/16 - 130.2 lbs 3/13/16 - 126.2 lbs 3/13/16 - 126.2 lbs According to the Minimum Data Set (MDS) Resident Assessment And Care Screening, dated 2/26/16, Resident 141 had a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and was not on physician-prescribed weight-loss regimen. An observation was conducted on 3/15/16 at 7:58 A.M. The posted breakfast schedule time for the dining room was 7:30 A.M. Resident 141 was sitting in his wheelchair in the dining room. His breakfast tray was set on a table in front of him, and included eggs, a muffin, a bowl of oatmeal, a carton of milk that was opened, and a cup of cranberry juice with a plastic cover and a straw. Resident 141 was observed feeding himself independently, using his hand to pick up the muffin. He was observed to take a bite of the muffin. At the time of the dining observation, the oatmeal and eggs appeared untouched, and the cup of juice was full. A dietary quarterly evaluation was completed by a dietary services supervisor (DSS) on 9/10/15. The dietary quarterly note included, Diet Order: NAS (no added salt), fortified, chopped, large portion with entrée X 1.5, Resource 2.0 (oral nutrition supplement for increased calories and protein) 120 ML (milliliters) PO (by mouth) TID (three times a day) with med (medication) pass three times a day, . Food Likes; likes most foods ., weight: 144.2 pounds on 9/6/15, Usual Weight: 140 - 150 (pounds), Desirable Weight Range/Ideal Weight Range 128 - 156 (pounds) . A dietary quarterly evaluation was completed by a DSS on 12/3/15. The dietary quarterly note indicated the same nutrition interventions as listed in the 9/10/15 dietary quarterly note. The weight listed was 138 lbs as of 11/29/15. Usual weight was documented as 140 - 150 lbs. On 3/16/16 at 2:04 P.M., the registered dietitian (RD) 31 reviewed the above dietary quarterly evaluation, and stated, There was a weight loss of six pounds from the time the previous dietary quarterly note was done. It's not a significant weight loss, but it's a change in weight, and changes should be reported to the dietitian and nursing. On 3/16/16 at 2:30 P.M., the facility's current DSS reviewed the dietary quarterly notes, dated 9/10/15 and 12/3/15, and acknowledged that there was a six pound weight loss. The DSS stated there was not a referral provided to the registered dietitian (RD) but I would have expected the DSS to tell nursing, and the RD. The DSS acknowledged the purpose of a dietary quarterly note was to check in on a resident to monitor for, and identify changes, in order to refer to the RD. A dietary quarterly evaluation was completed by a DSS on 3/04/16. The dietary note included, Diet Order: Restricted Concentrated Sweets (RCS), regular texture, regular portion ., Weight: 131 lbs as of 2/28/16 ., P.O. intake 100% most meals, weight 2/28/16 131.0-1/30/16 130 (lbs). Weight stable in 1 mos. (month). 2/28/16 131.0-8/28/15 144.2 down 13.2# (pounds) =9% in 6 mos (9% body weight loss in 6 months) ., I will refer to R.D. (registered dietitian) on next schedule visit for assess. It was noted that there was no documented extra nourishment such as the fortified diet, large portion entrée, and oral nutrition supplement that the previous two dietary quarterly notes had indicated Resident 141 had been provided. On 3/16/16 at 2:04 P.M., the facility's current registered dietitian (RD 31) stated that she was unable to locate a nutrition assessment by an RD since at least 9/10/15. RD 31 and facility staff reviewed physician orders [REDACTED]. The physician order [REDACTED]. On 3/16/16 at 3:50 P.M., the director of nursing (DON) stated it was the assistant director of nursing (ADON) responsibility to address unplanned weight changes, and conduct interdisciplinary weight committee meetings for unplanned significant weight loss. Concurrently, in the presence of the DON, the ADON stated an IDT (interdisciplinary team) committee was conducted for Resident 141 on 2/2/16 due to significant weight loss of 7% in one month. The ADON showed the documentation used for the IDT meeting which included, LN (licensed nurse) -Nutrition Interdisciplinary Team Update ., Weight: 130 (pounds) as of 1/30/16 .Average Meal Percent Intake 20 - 100% .resident tolerated current diet well. No s/s (signs or symptoms) of aspiration noted. Lungs clear. No s/s of dehydration. No skin issues noted. Resident up and OOB (out of bed) in w/c (wheelchair) ad lib (when he wants), resident continue with episodes repetitive standing up from his w/c. Resident is on MVI (multivitamin) with minerals for supplement. Resident IBW (ideal body weight) is 142 (lbs). IDT recommends continue current interventions and f/u prn (follow up as needed.) The IDT for that meeting consisted of three nurses. Concurrently, the ADON stated the IDT team on 2/2/16 determined, He's active. He cannot wheel himself but he is active because he stands up multiple times a day which probably caused the significant unplanned weight loss. It's not a concern because he's active. He was eating between 20 - 100% with the majority of the time eating more than 75%. No interventions were recommended. Record review of the documented meal consumption percentage for Resident 141 from 1/9/16 through 1/29/16 indicated 15 out of 21 days reviewed, the average consumption of the three meals daily were less than 75%. It was documented that he accepted a snack 7 times out of the 21 days. A record review of Resident 141's nutrition care plan which included, Date initiated: 2/22/16 by (name of ADON) . Focus: Alteration in Nutritional Status 2/2 .Goal: Resident to eat greater than 75% PO meals/snacks x 3 mo This same goal was listed on the previous nutrition care plan developed by a registered dietitian dated as in place since 4/16/13. Concurrently, the ADON stated, At that time he only lost 7 pounds in a month. The ADON was asked what the facility's goal was in regard to Resident 141's weight at the time of the IDT weight meeting, on 2/2/16. The ADON reviewed Resident 141's weight and nutrition care plan, and stated, He was stable at 144 pounds as of 9/6/15. The nutrition care plan was to maintain his weight. The ADON acknowledged Resident 141 had lost fourteen pounds as of the time of the IDT weight variance meeting was conducted, from what the facility stated was his stable weight of 144 pounds. The ADON acknowledged at the time the IDT weight variance was conducted the IDT members limited their review of weight loss to 7% of weight loss in a one month period of time. The ADON acknowledged that the nutrition care plan was not met, and that the facility had not recommended interventions to address the unplanned significant weight loss to improve his clinically significant nutritional compromised status, and /or to prevent further unplanned weight loss. Concurrently, the ADON acknowledged Resident 141 used to have nutrition interventions in place (fortified, large portion entrée and Resource 2.0 three times a day) when his weight was stable at 144 pounds. The ADON stated, They probably were stopped when he went out to the hospital after a fall and for [MEDICAL CONDITION] of his leg. According to the hospital's Discharge Summary, dated 1/4/16, Date of Admission: 12/30/15 .brought to the hospital status [REDACTED].date of discharge: 1/04/16 . Concurrently, the DON reviewed Resident 141's physician orders [REDACTED]. The physician order [REDACTED]. A record review of Resident 141's Weights and Vital Summary indicated he weighed 144.2 lbs on 8/29/15 and 129 lbs on 2/14/16 which was a 10.54% loss of body weight, significant (weight loss greater than 10 %) and unplanned. A nursing progress note, dated 3/2/16, completed by a nurse (LN 32) indicated, Resident with 13.2 lbs/10% lost in 6 months. Previous weight is 144.2 lbs 6 mos ago and now down to 131 lbs. Current diet is CCHO (consistent carbohydrate controlled diet for diabetes), regular texture, thin liquids. In the last 7 days resident consumed approximately 40%-100% of meals . There was no documentation of nursing interventions to address the weight loss. A nursing progress note, dated 3/3/16 completed by a nurse (LN 33) indicated, No ill effect noted from having a wt. loss of 13.2 lbs. in 6 mos . There was no documentation of nursing interventions to address the weight loss. A nursing progress note, dated 3/4/16 completed by a nurse (LN 34) indicated, No ill effect noted from wt. loss of 13.2 lbs in 6 months .ate 100% for breakfast and lunch . There was no documentation of nursing interventions to address the weight loss. On 3/16/16 at 4:00 P.M., in the presence of the DON, the ADON acknowledged that there was no further IDT weight variance meeting conducted, after the one and only time on 2/2/16, to address Resident 141's further weight loss. The ADON acknowledged that there were no interventions in place, and stated, He was eating overall good. The RD employed by the facility in January and half the month of February 2016 was not available to interview. The DON stated (name of previous RD; RD 35) was no longer employed at the facility at the time of the survey. Facility staff reported RD 35's last visit to the facility was on 2/17/16. The facility's current RD was employed by the facility on 3/7/16. The DON stated that the ADON was responsible to monitor and address unplanned significant weight loss, and should have assured this resident was placed on weekly weight monitoring. On 3/17/17 at 11:30 A.M., in the presence of the Administrator and the corporate nurse consultant (CNC), the DON acknowledged that Resident 141's significant unplanned weight loss was not effectively addressed by the facility and was avoidable. On 3/21/17 at 10:10 A.M., the ADON reviewed Resident 141's nutrition care plan which included, Date initiated: 2/22/16 by (name of ADON) .Focus: Alteration in Nutritional Status 2/2 .Goal: Resident to eat greater than 75% PO meals/snacks x 3 mo ., serum [MEDICATION NAME] (proteins in the blood it needs to maintain growth and repair tissue) Increase/maintain to/@>3.4 g/dl (gram/deciliter) x 3 mo ., Wt Main-Increase-Decrease @ (at)/to 142-152# (lbs) w/no sig. changes (significant changes) ., Interventions: Diet: Fortified no added salt, large portion entrée (x 1.5), chopped meat, Resource 2.0 120 mL PO TID with medication pass . The ADON acknowledged the above nutrition care plan was not accurate as the document had nourishments listed that were not provided to the resident at the time the nutrition care plan was initiated on 2/22/16. On 3/21/17 at 11:35 A.M., in the presence of the CNC, the ADON stated that she had forwarded a nutrition care plan that the previous registered dietitian (RD 35) had completed and placed it onto her nutrition care plan. A review of the nutrition care plan developed by RD 35, dated 1/25/16 as Diet Care Plan per medical records personnel, under 'Interventions' indicated, Diet: Fortified no added salt, large portion entrée (1.5 x), chopped meat, Resource 2.0 120 mL PO TID with medication pass ., Follow-Up 3/25/16 . Concurrently, the CNC and ADON acknowledged the diet/nutrition care plan was inaccurate as the resident had not been provided the listed nourishments when that care plan was initiated on 1/25/16, as they were discontinued as of 1/4/16. Concurrently, the ADON stated she had the responsibility for verifying the nutrition care plan was accurate. The ADON verified that she was delegated the main responsibility to coordinate nutrition care and a nurse should have been capable for recommending approaches to address unplanned significant weight loss, and had not. Record review of Resident 141's labs indicated on 1/7/16 his [MEDICATION NAME] (the body's major plasma protein) was 3.3 L (low) (reference range for normal was 3.5 - 3.7 g (grams)/dl (deciliter)), and on 2/22/16 his [MEDICATION NAME] was 3.0 L, in which the nutrition care plan goal was to increase/maintain @ 3.4 g/dl x 3 months. The nutrition care plan for [MEDICATION NAME] had not been met, and there lacked an effective intervention to address the unmet nutrition care plan. On 3/21/17 at 11:35 A.M., in the presence of the corporate nurse consultant (CNC), the ADON verified nutrition interventions to address the unplanned significant weight loss had not occurred until 3/14/16, after the resident weighed 126.2 lbs. (a loss of 18 lbs. had occurred). The next IDT weight committee had not convened until 3/17/16 for Resident 141. The facility's undated policy and procedure titled Weight Variance Monitoring indicated, Purpose: To facilitate identification and assessment of residents with unstable, unplanned weight fluctuations and to provide an interdisciplinary approach to resident assessment and intervention in the treatment of [REDACTED]. Policy: It is the policy of this facility to provide weight variance monitoring based on nursing standards, as indicated by individual resident need and/or per physician order. A Weight Variance Committee reviews residents with unstable weights in an interdisciplinary setting. The committee may include the Director of Nursing Services or designee, MDS Coordinator, Dietary Services Supervisor, Charge Nurse, RNA (restorative nursing assistant), Speech Therapist , Procedure ., 10. A. Unusual gain or loss of 5% or more in one (1) month. B. Unintentional gain or loss of 7.5% or more in three (3) months. C. Unintentional gain or loss of 10% or more in six (6) months. C. Gain or loss of 3 or more pounds in one (1) week in residents weighing less than 100 pounds. Unusual or significant weight variances will be reported by the charge nurse to the Weight Variance Committee ., 12. The Weight Variance Committee will evaluate each referred resident within 48 hours. This evaluation may include: . 1) Review food preferences, 2) Review dining preferences ., 3) Discuss abilities and assistance needed, 4) Discuss need for social services intervention, 5) Discuss benefits of nutrition and hydration and risks of poor nutrition and hydration, and undesired weight gain or loss . The facility's policy and procedure titled Care and Treatment; Nutrition (Policy Number: NACT 20; revised 5/07) indicated, Policy: It is the policy of this facility to ensure that all resident maintain acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible. Purpose: To provide care and services including: Assessing the resident ' s nutritional status and the factors that put the resident at risk of not maintaining acceptable parameters of nutritional status; .Defining and implementing interventions for maintaining or improving nutritional status that are consistent with resident needs, goals, and recognized standards of practice, or explaining adequately in the medical record why the facility could not or should not do so; and Monitoring and evaluating the resident's response or lack of response to the interventions; and revising or discontinuing the approaches as appropriate, or justifying the continuation of current approaches ., Weight Loss; Significant weight loss (5% in one (1) month, 7.5% in three (3) months, or 10% in six (6) months), as well as unplanned weight loss that occurs over time that does not meet the guidelines for significant weight loss and does not trigger review of the Nutritional Status RAP (resident assessment plan), should be addressed in the care plan. Facility approaches to address weight loss may include an ongoing search for the cause(s) of weight loss, unless the facility determined that the cause is known or the search for the cause has been exhausted or should be limited ., Once the cause(s) is/are identified, relevant care plan decisions are made and documented. Ongoing interventions are evaluated and modified as needed. Avoidable; .define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate ., Dietary Evaluation; .2. Once the resident has been evaluated for nutrition status, the Nurse Supervisor . will determine if there is a significant change in the resident's condition If so, additional nutrition will be offered to those residents including all high risk residents. Options include, but are not limited to, Super Cereal, large portions, between meal snacks, and commercial nutritional supplements (e.g., Resource, Glucerna, Health Shakes, etc.) ., Clinical Evaluation .3. Update and revise care plan as appropriate, .5. Any resident meeting the criteria for weight loss and any resident at risk will be weighed weekly with the weight entered in the weekly weight progress notes. Weekly weights will be reviewed each week during resident care plan conference ., 7. ADNS (assistant director of nursing services) .will ensure that proper documentation has been completed .