Every finding on record at Long Beach Post Acute

Based on interview and record review, the facility failed to ensure the Social Service Director (SSD) documented services provided to the Emergency Contact (EC) 1 for one of five sampled residents (Resident 1) when EC 1 was assisted and updated in initiating a guardianship (an evaluation conducted to determine whether the individual needs assistance with decision making or with accomplishing activities of daily living) evaluation and completing documents necessary for guardianship.This failure has resulted in undetermined efforts of the facility in assisting EC 1 of the guardianship evaluation and had the potential for EC 1 to miss updates of the process requested.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 was admitted to the facility with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), depression (feelings of constant sadness and loss of interest that affects normal day to day activities) and anxiety (extreme worry). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/9/2025, the MDS indicated Resident 1 was able to make decisions that were reasonable and consistent and required one-person assistance from staff to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's untitled Care Plan, dated 12/3/2025, the Care Plan indicated Resident 1 had the potential for foreseeable complications of clinical or social decline related to non-adherences/refusal/resistive to care. The Care Plan goals indicated Resident 1's right to choose will be honored, staff to assist Resident 1 with making healthcare decisions and the family and/or responsible party to be informed of the risks and consequences of choices that Resident 1 makes daily. The Care Plan interventions indicated involving the family and/or responsible party in coordinating and implementation of Resident 1's plan of care. During a telephone interview on 6/12/2026 at 10 a.m., the EC 1 stated she initiated filing for guardianship for Resident 1 and she gave the court document to the SSD on 2/2026 for a guardianship evaluation of Resident 1, but she did not receive an update from the SSD until the last week of 5/2026, informing her that she (SSD) needed to find another psychiatrist to assist with the evaluation and signing of the court document. EC 1 stated her efforts to contact and/or follow up with the SSD was not reciprocated and it caused her to feel left out and missed the updates. During an interview on 6/12/2026 at 2:14 p.m., the SSD stated she received the court document from EC 1 on 2/2026, but Resident 1 had not been seen by a psychiatrist for a guardianship evaluation. The SSD stated she gave EC 1 a call (did not specify the date) and informed her of the update (did not specify the date) when EC 1 visited Resident 1 the facility, however, did not document the update in Resident 1's medical record. During a review of Resident 1's Medical Records, there was no documentation indicating Resident 1's court document receipt, updates of Resident 1's guardianship evaluation nor communication of updates from the SSD to EC 1. During an interview on 6/12/2026 at 4:26 p.m., the Administrator (ADM) stated the SSD should have documented in Resident 1's medical record to reflect EC 1 was provided updates of the request for guardianship evaluation related to the process of filing for guardianship. The ADM confirmed the medical record of Resident 1 did not indicate any documentation from the SSD in relation to Resident 1's guardianship evaluation nor updates relayed to EC1 since 2/2026. The ADM stated all staff of the facility are responsible to ensure the residents' medical records are accurate and complete to reflect the services and/or assistance provided by the facility to the residents. During a review of the facility's policy and procedures (P&P) titled, Components of a Health Record, dated 1/ 2004, the P&P indicated the facility shall maintain a health record for each resident, including but not limited to social service evaluation and notes.During a review of the facility's P&P titled, Documentation Principles, dated 1/2004, the P&P indicated the following:a. The health records of the residents shall be kept current, accurate and detailed, consistent with good medical and professional practice based on the service provided for each resident, b. The content of the health records of the residents must contain information regarding the residents' stay at the facility and shall be centralized in the residents' medical records, and c. The health records of the resident shall be maintained in compliance with the licensing and certification governmental agency requirements and professional standards.

Based on interview and record review, the facility failed to ensure an informed consent was obtained prior to administering amphetamine-dextroamphetamine ([Adderall] a psychotropic [any drug that affects a person's mental state, emotions, thoughts, or behavior] medication used to treat attention-deficit hyperactivity disorder [ADHD - a condition that makes it difficult to focus, stay organized and control restlessness) for one of four sampled residents (Resident 1).This failure resulted in Resident 1 receiving Adderall without documented informed consent, and without being informed of the medication's purpose, dose, risks, benefits and alternatives prior to administration. This failure had the potential for Resident 1 to receive unnecessary medications. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including generalized anxiety disorder (extreme worry), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), recurrent, severe (serious depression that comes back repeatedly and significantly affects daily functioning) with psychotic symptoms (hearing or seeing things that are not there or having strong false beliefs), and ADHD.During a review of Resident 1's History and Physical (H&P), dated 3/12/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 3/17/2026, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and required supervision or touching assistance (helper provides verbal cues, steadying and/or contact guard assistance as resident completes activity) from staff for eating, oral hygiene, toileting, bathing, upper/lower body dressing and personal hygiene. During a review of Resident 1's Initial Psychiatric Evaluation, dated 3/20/2026, the Initial Psychiatric Evaluation indicated Resident 1 had a diagnosis of ADHD. The Initial Psychiatric Evaluation further indicated Resident 1 was currently receiving Adderall 20 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) daily as a psychotropic medication and the plan was to continue the Adderall 20 mg daily.During a review of Resident 1's Order Summary Report (Physician' s Orders) dated 3/31/2026, the Physician' s Order indicated an order was placed for Resident 1 to receive Adderall 20 mg by mouth one time a day for ADHD ordered on 3/21/2026. During a review of Resident 1's Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 3/2026, the MAR indicated Adderall was administered to Resident 1 every day from 3/21/2026 through 3/31/2026.During a review of Resident 1's MAR dated 4/2026, the MAR indicated Adderall was administered to Resident 1 every day from 4/1/2026 through 4/30/2026.During a review of Resident 1's MAR dated 5/2026, the MAR indicated Adderall as administered to Resident 1 every day from 5/1/2026 through 5/5/2026.During a review of Resident 1's Interdisciplinary Team (IDT] a group of medical professionals from different disciplines who work together to help a resident achieve their goals) Conference Note, dated 3/25/2026, the IDT Conference Note indicated Resident 1 inquired about the next psychiatric visit to discuss the Adderall dosing with the medical doctor. The IDT Conference Note indicated Resident 1 would be notified once the facility was aware of the next psychiatric visit date. During an interview on 4/28/2026 at 11:17 a.m., Resident 1 stated she took Adderall 20 mg three times a day prior to her admission to the facility. Resident 1 stated the facility administered Adderall 20 mg to her once a day. Resident 1 stated she had not been informed why the Adderall dose was changed and requested to speak with the psychiatrist (a medical doctor who diagnoses and treats mental health conditions) regarding the Adderall dose change.During a concurrent interview and record review on 5/4/2026 at 3:53 p.m., with the Registered Nurse Supervisor (RNS) 1, Resident 1's Medical Records was reviewed. RNS 1 stated there was no informed consent for Adderall and stated she was not sure if Adderall was considered a psychotropic medication. RNS 1 stated if Adderall was considered a psychotropic medication, then there should have been an informed consent completed prior to Resident 1 receiving Adderall. RNS 1 stated an informed consent for psychotropic medications was important because the informed consent acknowledged the resident knew the medication, route, potential side effects, and non-pharmacological interventions. RNS 1 stated the informed consent reduced residents' questions about medications because residents knew what they were taking and what to expect from the medication.During an interview on 5/5/2026 at 11 a.m., Resident 1 stated she never signed an informed consent for Adderall or reviewed the Adderall medication dose with a doctor. Resident 1 stated the facility record indicated a diagnosis of stimulant abuse, but the facility prescribed Adderall which was a stimulant. Resident 1 stated she wanted provider clarification regarding the stimulant abuse diagnosis and why she was ordered a stimulant if she was diagnosed with a stimulant abuse. During a review of Resident 1's email, dated 5/5/2026 at 3:05 p.m., the email indicated staff presented Resident 1 with an informed consent form related to stimulant medication. The email indicated Resident 1 did not sign the informed consent form because the medical record contained disputed stimulant-related language while the facility prescribed and administered stimulant medication. The email indicated Resident 1 requested direct provider clarification regarding who ordered the medication and why the current dose and schedule differed from Resident 1's prior prescribed dose and schedule.During a review of the facility's policy and procedure (P&P) titled, Informed Consent, revised 4/2017, the P&P indicated if the attending physician, Physician Assistant (PA), or Nurse Practitioner (NP) prescribed, ordered, or increased an order for a psychotherapeutic medication, the Physician, PA, or NP shall obtain informed consent from the resident. The P&P indicated the facility shall verify informed consent prior to the administration of a psychotherapeutic medication. The P&P indicated the facility could have the licensed healthcare practitioner who ordered the therapy obtain informed consent from the resident or obtain a copy of the current informed consent from the facility where the therapy was started. The P&P indicated it was the responsibility of the physician, PA, or NP who ordered the therapy to obtain informed consent prior to initiation of therapy. The P&P indicated the physician, PA, or NP could not delegate the responsibility to the nurse to obtain consent. The P&P indicated information material to a decision concerning administration of a psychotherapeutic drug included the reason for treatment, nature of the treatment, nature, degree, duration, and probability of side effects and significant risks, reasonable alternative treatments and risks, why the treatment was recommended, and the resident's right to accept or refuse the proposed treatment.

Based on observation, interview, and record review, the facility failed to ensure the grievance process was followed for one of four sampled residents (Resident 1).This failure resulted in Resident 1's grievance regarding food preferences being marked resolved without the identified problem being corrected, without the responsible department being notified, and without follow-up to verify resolution. This failure resulted in Resident 1 continuing to receive unwanted processed deli meats after the grievance was filed and had the potential to negatively impact Resident 1's health and well-being. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including attention-deficit hyperactivity disorder ([ADHD] a condition that makes it difficult to focus, stay organized and control restlessness), functional dyspepsia (ongoing stomach discomfort such as fullness, bloating, or mild pain without a clear medical cause), and constipation (difficulty having bowel movements or having fewer bowel movements than usual).During a review of Resident 1's History and Physical (H&P), dated 3/12/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 3/17/2026, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and required supervision or touching assistance (helper provides verbal cues, steadying and/or contact guard assistance as resident completes activity) from staff for eating, oral hygiene, toileting, bathing, upper/lower body dressing and personal hygiene. The MDS indicated Resident 1 felt it was very important to have snacks available between meals. During a review of the facility's Grievance/Concern Log dated 3/2026, the Grievance/Concern Log indicated Resident 1 had one grievance reported on 3/24/2026. The Grievance/Concern Log indicated the grievance was reported by Resident 1, the incident took place on 3/24/2026, the result was noted as resolved, and the resolution date was 3/25/2026.During a review of Resident 1's Grievance/Concern Form, dated 3/24/2026, the Grievance/Concern Form indicated Resident 1 reported ongoing dietary concerns. The Grievance/Concern Form indicated Resident 1 reported she was served food items she did not request, and Resident 1 had already discussed meal preferences with staff. The Grievance/Concern Form indicated the concern was reported to the Business Development Director and the department addressing the concern was Social Services. The Grievance/Concern Form indicated Resident 1's dietary preferences were reviewed in detail and updated. The Grievance/Concern Form indicated nursing staff were reminded to reinforce and communicate updated dietary preferences to the dietary department promptly. The Grievance/Concern Form indicated the concern was completed on 3/25/2026. The Grievance/Concern Form indicated the dietary department was informed in person on 3/24/2026. The Grievance/Concern Form indicated correct meals were provided to Resident 1, Resident 1 was informed of corrective actions taken and expressed understanding, and the facility would continue to monitor meal accuracy to ensure compliance with Resident 1's preferences.During an interview on 4/28/2026 at 11:17 a.m., Resident 1 stated she was unable to eat the food served by the facility because the facility did not consistently provide food according to her preferences. Resident 1 stated she requested salads with chicken only, but the facility continued to serve salads with processed deli meat. Resident 1 stated she removed the processed deli meat from the salads and returned the processed deli meat to the kitchen. Resident 1 stated she had complained several times, but the kitchen continued to serve processed deli meat on meals after the grievance was filed. Resident 1 stated she understood grievances were filed by sending concerns directly to the Administrator (ADM). Resident 1 stated she sent concerns regarding food, privacy, medications, and dental care directly to the ADM by email.During a concurrent observation and interview on 4/28/2026 at 12:40 p.m., in Resident 1's room, Resident 1's lunch tray was observed with a salad. The salad included cheese, cucumbers, tomatoes, lettuce, carrots, and processed deli meat. Resident 1 stated the processed deli meat on the salad was the same meat she had repeatedly requested not be served.During an interview on 4/29/2026 at 3:30 p.m., with the Social Services Director (SSD), the SSD stated residents could file a grievance by completing a Grievance Form located outside the Social Services office. The SSD stated the facility investigated grievances, developed solutions, and referred grievances to the appropriate department for follow-up. The SSD stated grievances were reported to the Administrator (ADM), who participated in the grievance process. The SSD stated she was informed of Resident 1's dietary grievance and spoke with Resident 1 regarding the grievance. The SSD stated Resident 1 had an Interdisciplinary Team (IDT) meeting with nursing and dietary staff, and the IDT addressed Resident 1's food preferences, including what Resident 1 wanted and did not want in the salad. The SSD stated she followed up with Resident 1 the day after the grievance was filed. The SSD stated Resident 1 was upset and stated she still was not receiving the salad. The SSD stated she checked Resident 1's meal that day, and Resident 1 had received a salad. The SSD stated she did not remember Resident 1 stating she did not want processed meat on the salad.During a concurrent interview and record review on 4/30/2026 at 9:40 a.m., with the Registered Dietitian (RD), Resident 1's Grievance/Concern Form, dated 3/24/2026, was reviewed. The RD stated she was unaware of Resident 1's grievance regarding food preferences. The RD stated Resident 1's food preferences were documented on the Nutrition Services Progress Note, provided to the kitchen, and posted in the kitchen.During a concurrent interview and record review on 4/30/2026 at 11:40 a.m., with the Dietary Supervisor (DS), Resident 1's Grievance/Concern Form, dated 3/24/2026, was reviewed. The DS stated if a grievance involved the dietary department, the DS should receive the Grievance/Concern Form. The DS stated he did not receive Resident 1's Grievance/Concern Form and was not aware Resident 1 had filed a grievance regarding food preferences. The DS stated if he had known Resident 1 filed a grievance regarding food preferences, he would have followed up with Resident 1 to ensure Resident 1's food preferences were followed.During a review of a forwarded email from Resident 1, dated 5/5/2026 and timed at 2:59 p.m., the email included a photo of a plate card (meal ticket) showing chef salads for lunch and dinner with extra meat, chicken only, and no eggs or processed meats in salads. The email indicated there was additional photographs showing facility-served meals and salads with chopped processed/deli-style meat despite the plate card instruction. During a concurrent interview and record review on 5/5/2026 at 4:04 p.m., with the ADM, the facility's Grievance Procedure policy and procedure (P&P) was reviewed. The ADM stated the SSD was the grievance official and responsible for grievances. The ADM stated grievances involving the dietary department were referred to dietary, and dietary followed up with the resident. The ADM stated the RD and DS knew about Resident 1's grievance regarding food preferences. The ADM stated the facility completed the grievance process for Resident 1's grievance but did not provide documentation of the completed grievance process. The ADM stated the facility did not complete the regular grievance process because the facility could not complete an IDT meeting with Resident 1. The ADM stated Resident 1 wanted the grievance by email, and the facility could not complete the grievance process as indicated in the facility's Grievance Procedure P&P.During a review of the facility's policy and procedure (P&P) titled, Grievance Procedure, revised 1/2017, the P&P indicated the resident had the right to and the facility must make prompt efforts to resolve grievances the resident, responsible party, other family members, or advocates may have. The P&P indicated any resident, responsible party, family member, or advocate may file a grievance or complaint concerning the resident's treatment, medical care, behavior of other residents or staff members, without fear of discrimination or reprisal in any form. The P&P indicated grievances should be submitted in writing but may include verbal complaints. The P&P indicated the Grievance Official for the facility was the ADM, who was responsible for overseeing the grievance process. The P&P indicated the resident or person filing the grievance on behalf of the resident would be informed of the findings of the investigation and actions to correct any identified problems, unless the grievance was filed anonymously. The P&P indicated the results of the grievance would be reported within ten working days of filing the grievance or complaint with the facility and would include the date the grievance was received, the summary of steps taken to investigate it, a summary of the resolution with a statement whether the grievance was confirmed or not, and any corrective action taken. The P&P indicated the ADM was responsible for taking appropriate corrective action in accordance with state law if the violation of resident rights was substantiated and would maintain evidence demonstrating the resolution for at least three years. The P&P indicated grievances filed and the resulting investigations by the facility would be reviewed monthly during the monthly Quality Assurance Performance Improvement ([QAPI] a data driven proactive approach to improvement used to ensure services are meeting quality standards) meeting to ensure appropriate measures were taken to investigate the grievance.

Based on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] - a resident assessment tool) accurately reflected the active diagnoses of one of four sampled residents (Resident 1). This failure resulted in inaccurate diagnoses, incomplete nutritional assessments, and Care Plans that did not reflect Resident 1's gastric sleeve surgery (a surgery which permanently reduces stomach size and affects how much and what types of food the resident can tolerate), loose teeth, autism diagnosis (a developmental condition that affects how the resident understands information, communicates, interacts with others, and responds to sensory input), history of eating disorders, chewing problems, or food intolerances. These failures had the potential to negatively affect Resident 1's nutritional management, dietary tolerance, and individualized plan of care. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses generalized anxiety disorder (ongoing excessive worry or nervousness), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) , insomnia (trouble falling asleep or staying asleep), nightmare disorder (repeated bad dreams that disturb sleep), attention-deficit hyperactivity disorder (ADHD - a condition that makes it difficult to focus, stay organized and control restlessness), functional dyspepsia (ongoing stomach discomfort such as fullness, bloating, or mild pain without a clear medical cause), and constipation (difficulty having bowel movements or having fewer bowel movements than usual). During a review of Resident 1's History and Physical (H&P), dated 3/12/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 3/17/2026, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and required supervision or touching assistance (helper provides verbal cues, steadying and/or contact guard assistance as resident completes activity) from staff for eating, oral hygiene, toileting, bathing, upper/lower body dressing and personal hygiene. The MDS indicated Resident 1 felt it was very important to have snacks available between meals. The MDS did not include Resident 1's autism, eating disorder, gastric sleeve surgery, or dental concerns. During a review of Resident 1's General Acute Care Hospital (GACH) Psychiatric Evaluation, dated 2/23/2026, the Psychiatric Evaluation indicated Resident 1 was diagnosed with autism and had eating disorders in the past. During a review of Resident 1's GACH History and Physical (H&P), dated 2/24/2026, the H&P indicated Resident 1 had gastric sleeve surgery in 2017 and had a loose right front tooth (a dental condition that can affect chewing and food intake). During a review of Resident 1's admission Diagnosis List, dated 3/11/2026, the admission Diagnosis List did not include autism, history of eating disorders, gastric sleeve surgery in 2017, a loose right front tooth, toothache, or chewing problems. During a review of Resident 1's Nutrition Risk Assessment, dated 3/11/2026, the Nutrition Risk Assessment indicated Resident 1 had teeth or dentures in good condition and Resident 1 had good food intake. The Nutrition Risk Assessment did not indicate Resident 1 had loose teeth, toothache, gastric sleeve surgery, autism, eating disorder history, food intolerances, chewing problems, or swallowing problems. During a review of Resident 1's Gastrointestinal (GI) Distress Care Plan, dated 3/11/2026, the Care Plan indicated Resident 1 had dyspepsia. The Care Plan did not include Resident 1's gastric sleeve history or intolerance to certain foods related to the gastric sleeve. During a review of Resident 1's Oral/Dental Care Plan, dated 3/11/2026, the Care Plan indicated Resident 1 had loss of appetite, refusal to eat and behavior. The Care Plan's goals indicated Resident 1 will not complain of mouth pain and dental pain related to poor teeth condition. The Care Plan did not include Resident 1's loose teeth, chewing difficulty, or the need for modified textures due to dental status. During a review of Resident 1's admission Diagnosis List, dated 3/12/2026, the Admissions Diagnosis List did not include Resident 1's diagnosis of autism, gastric sleeve surgery, or eating disorder history. During a review of Resident 1's Nutrition Care Plan dated 3/12/2026. The Care Plan indicated Resident 1 was at risk for malnutrition due to anxiety, depression, chronic pain, insomnia, alcohol abuse, and being overweight. The Care Plan's goal indicated Resident 1 will maintain current weight, maintain adequate nutrition, and tolerate diet. The Care Plan's interventions included regular diet and nutritional shakes. The Care Plan did not include Resident 1's gastric sleeve surgery, autism diagnosis, chewing difficulty, food intolerances, or history of eating disorders. During a review of Resident 1's Physician Note, dated 3/13/2026, the Physician Note indicated Resident 1 had gastric sleeve surgery in 2017 and reported difficulty eating and intolerance to certain foods. During a review of Resident 1's admission Nutritional Assessment, dated 3/16/2026, the assessment did not include autism, history of eating disorders, gastric sleeve surgery, loose tooth, toothache, or chewing problems. During a review of Resident 1's Interdisciplinary Team ([IDT] a group of medical professionals from different disciplines who work together to help a resident achieve their goals) Notes, dated 3/26/2026, the IDT Notes did not include Resident 1's gastric sleeve surgery (a surgical procedure that reduces the size of the stomach), autism diagnosis (a developmental condition that affects communication, social interaction, sensory processing, and how a person experiences the environment), chewing difficulty, or past eating disorder history, despite these conditions being documented in Resident 1 GACH discharge notes. During a review of Resident 1's Physician Note, dated 4/17/2026, the Physician Note indicated Resident 1 had gastric sleeve surgery in 2017 and had ongoing toothache requiring dental follow up. During an interview on 4/28/2026 at 11:17 a.m., Resident 1 stated she had difficulty eating food served by the facility. Resident 1 stated she requested salads because salads were something she could eat. Resident 1 stated she requested chicken only on her salads, but the facility served salads with diced deli meat. Resident 1 stated she did not want diced deli meat on her salads because the diced deli meat upset her stomach and became stuck in her loose teeth. Resident 1 stated she had gastric sleeve surgery and could not tolerate certain foods. Resident 1 stated the facility had prepared salads according to her preference before, but the facility did not consistently prepare salads according to her preference. During an interview on 4/30/2026 at 9:40 a.m., the Registered Dietitian (RD) stated she relied on specially the Face Sheet, admission Diagnosis List, and Physician Orders for the admission Nutritional Assessment. The RD stated she did not review the hospital discharge records, or progress notes to complete a nutritional assessment because she thought the admission Diagnosis List and Physician Orders was accurate and complete. During a review of an email from Resident 1 to the facility's Administrator and Social Services Director (SSD), dated 4/30/2026 at 12:43 p.m., the email indicated Resident 1 requested the facility review and correct Resident 1's Medical Record. The email indicated Resident 1 disputed the diagnosis of stimulant abuse and requested clarification regarding who added the diagnosis, what documentation supported the diagnosis, and whether the diagnosis was copied from another facility's record. The email indicated Resident 1 requested the facility include autism in Resident 1's record. The email indicated Resident 1's dietary concerns involved gastric sleeve history, functional dyspepsia, mobile or loose teeth, dental issues, difficulty eating safely, muscle wasting and atrophy, gait and mobility issues, and the need for a consistent tolerable protein and dietary plan. During a concurrent interview and record review on 5/5/2026 at 8:33 a.m., with the MDS Nurse (MDSN), Resident 1's GACH H&P and psychiatric evaluation was reviewed. The MDSN stated he was responsible for adding the diagnoses of all residents to the Admissions Diagnosis List upon admission. The MDSN stated he did not enter the diagnoses of autism, gastric sleeve surgery, or loose tooth into Resident 1's diagnosis list upon admission because he believed the resident was not being monitored for those diagnoses. The MDSN acknowledged the diagnoses mattered and stated leaving them off the diagnosis list affected Resident 1's care. The MDSN stated the diagnoses would have been care planned with interventions if they had been entered upon admission. During a review of the facility's Resident Assessment Instrument (RAI) Version 3.0 Manual, Section I, Active Diagnoses, dated 10/2025, the RAI Manual indicated one important function of the MDS assessment was to generate an updated, accurate picture of the resident's current health status. The RAI Manual indicated active diseases and infections drove the current plan of care. The RAI Manual indicated medical record sources for diagnoses included progress notes, the most recent H&P, transfer documents, discharge summaries, diagnosis/problem list, and other available resources. The RAI Manual indicated active diagnoses had a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, or nursing monitoring. The RAI Manual indicated diseases coded in the categories were not limited to the diseases listed as examples, and if a disease or condition was not specifically listed, the diagnosis was entered in Additional Active Diagnoses.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered Care Plan for Resident 1's autism (a developmental condition that affects how the resident understands information, communicates, interacts with others, and responds to sensory input) and bathing preferences/barriers for one of four sampled residents (Resident 1). This failure resulted in Resident 1's Care Plans not reflecting individualized interventions for cognitive, behavioral, hygiene, and physical care needs. This failure had the potential to negatively affect Resident 1's individualized care, hygiene, and overall well-being.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses generalized anxiety disorder (ongoing excessive worry or nervousness), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) , insomnia (trouble falling asleep or staying asleep), nightmare disorder (repeated bad dreams that disturb sleep) and attention-deficit hyperactivity disorder (ADHD - a condition that makes it difficult to focus, stay organized and control restlessness). During a review of Resident 1's History and Physical (H&P), dated 3/12/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 3/17/2026, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and required supervision or touching assistance (helper provides verbal cues, steadying and/or contact guard assistance as resident completes activity) from staff for eating, oral hygiene, toileting, bathing, upper/lower body dressing and personal hygiene. The MDS indicated Resident 1's preference to choose between a tub bath, shower, bed bath, or sponge bath and to have snacks available between meals were very important. During a review of Resident 1's General Acute Care Hospital (GACH) Psychiatric Evaluation, dated 2/23/2026, the Psychiatric Evaluation indicated Resident 1 was diagnosed with autism (a developmental condition that affects communication, social interaction, learning, and sensory processing) and had eating disorders in the past.During a review of a forwarded email from Resident 1 to the facility's Administrator (ADM) and Social Services Director (SSD), date sent 4/30/2026 at 12:43 p.m., the email indicated Resident 1 requested the facility include autism in Resident 1's record and identify care approaches related to Resident 1's autism. The email indicated Resident 1 requested advance notice, scheduled therapy times, a clear therapy plan before each session, staff identification by name and role, communication in writing, when possible, a private setting for sensitive discussions, and assignment to therapy staff Resident 1 could work safely and calmly.During an interview on 4/30/2026 at 3 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 1 refused her shower. CNA 2 stated CNA 2 did not know why Resident 1 refused her shower. CNA 2 stated CNA 2 asked Resident 1 every couple of hours, and if Resident 1 continued to refuse, CNA 2 reported the refusal to the charge nurse. CNA 2 stated Resident 1's showers were scheduled on Tuesdays and Saturdays, but Resident 1 could get a shower any day, and CNA 2 offered showers to residents every day. CNA 2 stated Resident 1 always refused showers when CNA 2 was assigned to Resident 1. CNA 2 stated when CNA 2 told the charge nurse Resident 1 still did not go take a shower, the charge nurse talked to Resident 1, but Resident 1 still refused.During a concurrent interview and record review on 5/4/2026 at 3:53 p.m., with Registered Nurse (RN) 1, Supervisor, Resident 1's Interdisciplinary Team (IDT) Notes, Care Plans, hospital discharge records, and psychiatric evaluation were reviewed. RN 1 stated Resident 1 declined showers and preferred to complete personal hygiene in Resident 1's room. RN 1 stated Resident 1's showers were not documented as refusals because completing personal hygiene in Resident 1's room was Resident 1's preference. RN 1 stated RN 1 did not know why Resident 1 declined showers. RN 1 stated if Resident 1 refused showers, the care team should have been notified, and the shower refusals should have been addressed in Resident 1's Care Plan. RN 1 stated Resident 1's Care Plans did not include shower refusals. RN 1 stated RN 1 did not know Resident 1 was uncomfortable taking showers or if discomfort was the reason Resident 1 declined showers. RN 1 stated a care plan should have been developed for Resident 1's showers, and staff should have attempted other approaches to get Resident 1 to shower. RN 1 stated, from a nursing perspective, staff needed to ensure Resident 1 had good skin care and prevent potential skin breakdown and infection. RN 1 stated staff should have followed up to ensure Resident 1 provided good hygiene for herself. RN 1 stated if Resident 1 was uncomfortable with a certain staff member, staff could have provided a staff member Resident 1 was more comfortable with. RN 1 stated if Resident 1 refused showers, staff should have attempted to educate Resident 1 regarding the importance of showers and determined why Resident 1 refused showers. RN 1 stated the refusal needed to be addressed to resolve the refusal. RN 1 stated before the investigation, RN 1 was unaware of Resident 1's diagnosis of autism. RN 1 stated Resident 1 did not have a care plan for autism. RN 1 stated the diagnosis for autism should have been completed by the admitting nurses. RN 1 stated if RN 1 had known Resident 1 had autism, staff might have had a different approach to Resident 1's care, and autism should have been care planned. RN 1 stated not knowing a resident's diagnosis could definitely impact the resident's care regarding specific food preferences and concerns being addressed. RN 1 stated Resident 1's care plans were important because care plans guided Resident 1's care. RN 1 stated if Resident 1 had autism, there should have been a different approach to Resident 1's care. RN 1 stated knowing Resident 1 had autism would change how RN 1 related to Resident 1, and RN 1 would add a care plan for the diagnosis.During a concurrent interview and record review on 5/5/2026 at 8:33 a.m., with the MDS Nurse (MDSN), Resident 1's Medical Records, GACH hospital discharge records, and Care Plans were reviewed. The MDSN stated he was responsible for adding diagnoses to Resident 1's medical diagnosis list in the EHR. The MDSN stated he did not add autism or gastric sleeve surgery to Resident 1's medical diagnosis list because the physician did not add the diagnoses to the physician's notes. The MDSN stated autism and gastric sleeve surgery would have been under Resident 1's diagnoses if they had been captured. The MDSN stated if the diagnoses had been captured, the diagnoses would have been care planned with interventions. The MDSN stated leaving diagnoses off the diagnosis list affected Resident 1's care, especially for residents with autism, because there would be a care plan for autism. The MDSN stated Resident 1 had autism and needed a different type of care, and Resident 1's care needed to be tailored to Resident 1, not just in general. The MDSN stated the IDT would be a way to catch diagnoses missed on admission. The MDSN stated when diagnoses were missed, the missed diagnoses affected the care of the resident, and correct diagnoses would change the care of the resident.During a review of the facility's policy and procedure (P&P) titled, Policy for the Interdisciplinary Team, revised 8/2016, the P&P indicated it was the policy of the facility that the Interdisciplinary Team (IDT) was responsible for the development of an individualized comprehensive care plan for each resident. The P&P indicated a comprehensive care plan for each resident shall be started on admission and completed within seven days of completion of the resident assessment. The P&P indicated the care plan was based on the resident's needs and the resident's comprehensive assessment and was developed by a Care Planning/IDT which included, but was not necessarily limited to, the resident's attending physician, the registered nurse who had responsibility for the resident, the dietary manager/dietitian, social services personnel responsible for the resident, the activity director/coordinator, therapists, consultants, the director of nursing, the charge nurse responsible for resident care, nursing assistants responsible for the resident's care, and others as appropriate or necessary to meet the needs of the resident. The P&P indicated the resident, the resident's family, and/or the resident's legal representative/guardian or surrogate were encouraged to participate in the development and revisions to the resident's care plan. The P&P indicated every effort would be made to schedule care plan meetings at the best time of the day for the resident and the resident's family. The P&P indicated the mechanics of how the IDT met its responsibilities in the development of the interdisciplinary care plan, including face-to-face, teleconference, written communication, etc., was at the discretion of the Care Planning Committee.During a review of the facility's P&P titled, Resident Rights, revised 9/2017, the P&P indicated residents had the right to participate in the development and implementation of the person-centered plan of care, including goals and outcomes, to be informed in advance of changes to the plan of care, to request meetings or revisions to the care plan, and to see the care plan and sign after any significant changes to it.

Based on interview and record review, the facility failed to ensure staff consistently identified, documented, and addressed the reasons for one of four sampled residents (Resident 1) repeated refusals of scheduled showers, and implement alternative approaches to provide adequate bathing and hygiene care. This failure resulted in Resident 1 not receiving showers for an extended period and had the potential to affect Resident 1's dignity and increase the risk for poor hygiene, skin breakdown, and infection.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnosis including muscle wasting (weakening, shrinking, and loss of muscle) and atrophy (a decrease in size or wasting away of a body part or tissue), abnormalities of gait and mobility (difficulty walking or moving in a normal, safe, or steady way), generalized anxiety disorder (ongoing excessive worry or nervousness), and attention-deficit hyperactivity disorder (ADHD - a condition that makes it difficult to focus, stay organized and control restlessness). During a review of Resident 1's History and Physical (H&P), dated 3/12/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's History and Physical (H&P), dated 4/21/2026, the H&P indicated Resident 1 had mobility and ADL dysfunction related to muscle wasting and atrophy and abnormal gait/mobility. The H&P indicated Resident 1's medical rehabilitation goal included activities of daily living ([ADLs) activities such as bathing, dressing and toileting a person performs daily) supervision.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 3/17/2026, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and required supervision or touching assistance (helper provides verbal cues, steadying and or contact guard assistance as resident completes activity) from staff for eating, oral hygiene, toileting, bathing, upper/lower body dressing and personal hygiene. The MDS indicated Resident 1's preference to choose between a tub bath, shower, bed bath, or sponge bath was very important. During an interview on 4/28/2026 at 11:17 a.m., with Resident 1, Resident 1 stated she did not take showers because there was no privacy in the shower room and men could be in the shower room with women. Resident 1 stated the shower room was nasty, the shower had multiple showers with curtains which did not close all the way, and dirty linen was kept inside the shower room. Resident 1 stated when she had to take a shower, there was a tall male staff member who watched while residents took showers, and this made Resident 1 feel very uncomfortable. Resident 1 stated the curtains did not provide complete privacy, and the male staff member stared while Resident 1 took a shower. Resident 1 stated she told staff she did not take showers because there was no privacy and she did not want men walking in unannounced. Resident 1 stated when she complained to the facility about the shower situation, staff did not do anything. Resident 1 stated since staff did not do anything about the shower situation, Resident 1 washed up in the bathroom in Resident 1's room with baby wipes. Resident 1 stated when Resident 1 told staff about Resident 1's shower concerns, Resident 1 was told, You can take a shower if you want.During an interview on 4/30/2026 at 3 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 1 refused her shower. CNA 2 stated CNA 2 did not know why Resident 1 refused her shower. CNA 2 stated CNA 2 asked Resident 1 every couple of hours, and if Resident 1 continued to refuse, CNA 2 reported the refusal to the charge nurse. CNA 2 stated Resident 1's showers were scheduled on Tuesdays and Saturdays, but Resident 1 could receive a shower any day, and CNA 2 offered showers to residents every day. CNA 2 stated Resident 1 always refused showers when CNA 2 was assigned to Resident 1. CNA 2 stated when CNA 2 told the charge nurse Resident 1 still did not go take a shower, the charge nurse talked to Resident 1, but Resident 1 still refused.During a concurrent interview and record review on 5/4/2026 at 3:53 p.m., with RN 1, Resident 1's Interdisciplinary Team ([IDT] a group of medical professionals from different disciplines who work together to help a resident achieve their goals) Notes and Care Plans were reviewed. RN 1 stated Resident 1 declined showers and completed personal hygiene in her room. RN 1 stated the showers were not documented as refusals because staff considered the personal hygiene in her room to be her preference. RN 1 acknowledged Resident 1's IDT notes did not indicate shower refusals were addressed. RN 1 acknowledged Resident 1's care plans did not address shower refusals. RN 1 stated she did not know why Resident 1 declined showers. RN 1 stated she did not know Resident 1 was uncomfortable taking showers or if discomfort was the reason she declined showers. RN 1 stated, from a nursing perspective, staff needed to ensure good skin care and prevent potential skin breakdown and infection. RN 1 stated staff should have followed up to ensure Resident 1 provided good hygiene for herself. RN 1 stated if Resident 1 was uncomfortable with a certain staff member, staff could have provided a staff member she was more comfortable with. RN 1 stated if Resident 1 refused showers, staff should have attempted to educate her regarding the importance of showers and determined why she refused. RN 1 stated the refusal needed to be addressed to resolve the refusal.During a review of the facility's policy and procedure (P&P) titled, Certified Nursing Assistant Documentation, revised 10/2015, the P&P indicated it was the policy of the facility that certified nursing assistants document per shift, accurately and consistently. The P&P indicated certified nursing assistants were required to have daily documentation. The P&P indicated activities of daily living included personal hygiene, including how the resident maintained personal hygiene, combing hair, brushing teeth, and shaving. The P&P indicated activities of daily living included bathing, including how the resident took a full-body bath/shower, sponge/bed bath, and transfer. The P&P indicated activities of daily living required a performance code. The P&P indicated additional information required on the 7-3, 3-11, and 11-7 shifts included a check of the resident's skin, which was to be initialed when done, and the signature of the certified nursing assistant to verify delivery of service.During a review of the facility's P&P titled, Resident Rights - Refusal of Care, revised 4/2017, the P&P indicated it was the policy of the facility to implement approaches with a resident who refused care. The P&P indicated the facility had to respect the resident's right to refuse care and/or treatment. The P&P indicated if a resident was resistant to care or refused care, the facility would implement approaches. The P&P indicated if a resident refused care or was agitated, the staff member would leave the resident's room and attempt to gain the resident's cooperation in 10-15-minute increments times three. The P&P indicated if the resident was refusing care from a certified nursing assistant, the licensed nurse would be notified of the resident's refusal. The P&P indicated if a resident refused care or treatment, medications, or food, the resident's attending physician would be notified within a 72-hour time frame.

Based on observation, interview, and record review, the facility failed to ensure the Registered Dietician (RD) and Dietary Supervisor (DS) completed a comprehensive and accurate nutritional assessment for one of four sampled residents (Resident 1) to meet their individualized needs and dietary preferences. This failure resulted in Resident 1 receiving meals which did not align with her stated food preferences and nutritional needs. This failure had the potential to negatively affect Resident 1's nutritional status and dietary management due to autism (a developmental condition that affects how the resident understands information, communicates, interacts with others, and responds to sensory input), gastric sleeve surgery (a procedure which permanently reduces stomach size and affects how much and what types of food the resident can tolerate), loose teeth, history of eating disorders, and documented food preferences.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 was admitted to the facility with diagnoses including attention-deficit hyperactivity disorder (ADHD - a condition that makes it difficult to focus, stay organized and control restlessness), overweight (body weight higher than what is considered health for height), functional dyspepsia (ongoing stomach discomfort such as fullness, bloating, or mild pain without a clear medical cause), and constipation (difficulty having bowel movements or having fewer bowel movements than usual).During a review of Resident 1's History and Physical (H&P), dated 3/12/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 3/17/2026, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and required supervision or touching assistance (helper provides verbal cues, steadying and/or contact guard assistance as resident completes activity) from staff for eating, oral hygiene, toileting, bathing, upper/lower body dressing and personal hygiene. The MDS indicated Resident 1's preference to have snacks available between meals was very important. During a review of Resident 1's General Acute Care Hospital (GACH) Psychiatric Evaluation, dated 2/23/2026, the GACH Psychiatric Evaluation indicated Resident 1 was on disability since 2018 due to depression, autism (a developmental condition that affects how a person communicates, interacts with others, learns, and experiences the world around them), anxiety (extreme worry), and ADHD. The GACH psychiatric evaluation indicated Resident 1 had eating disorders in the past.During a review of Resident 1's GACH H&P, dated 2/24/2026, the GACH H&P indicated Resident 1 had gastric sleeve surgery in 2017. The GACH H&P indicated Resident 1 complained of a recent fall which caused a loose right front tooth. The GACH H&P indicated Resident 1 had not seen a dentist and requested a recommendation for treatment after discharge. The GACH H&P indicated Resident 1 had prediabetes (when blood sugar is higher than normal, but not high enough to be diagnosed as diabetes [a disorder characterized by difficulty in blood sugar control and poor wound healing]).During a review of Resident 1's admission Diagnosis List, dated 3/11/2026, the admission Diagnosis List did not indicate Resident 1 had autism, eating disorders in the past, gastric sleeve in 2017, a loose right front tooth, toothache, or chewing problems.During a review of Resident 1's Nutrition Risk Assessment, dated 3/11/2026, the Nutrition Risk Assessment indicated Resident 1 was lethargic and disoriented. The Nutrition Risk Assessment indicated Resident 1 fed herself, had stable weight within the last three months, had teeth or dentures in good condition, had good food intake, took snacks and supplements as offered, had few food dislikes, and had two to three predisposing conditions. The Nutrition Risk Assessment did not indicate Resident 1 had loose teeth, toothache, gastric sleeve in 2017, autism, eating disorders in the past, many food dislikes or complaints, food-related intolerances, or chewing problems.During a review of Resident 1's Gastrointestinal (GI) Distress Care Plan, dated 3/11/2026, the Care Plan indicated Resident 1 had dyspepsia. The Care Plan's interventions included give diet per physician order, avoid irritants in diet such as coffee, spicy food, and alcohol, administer anti-acid or gas medication per physician order, monitor for signs and symptoms of GI distress (stomach or intestinal discomfort) such as abdominal pain, blood in stool, weakness, and diarrhea, and assess for abdominal distention, bowel sounds, and tenderness. During a review of Resident 1's Oral/Dental Care Plan, dated 3/11/2026, the Care Plan indicated Resident 1 had loss of appetite, refusal to eat, and behavior. The Care Plan's goals indicated mouth, and teeth would be cleaned daily, Resident 1 would not complain of mouth pain, Resident 1 would not have any choking episode daily, and Resident 1 would not complain of dental pain related to poor teeth condition. The Care Plan's interventions included diet as ordered, monitor tolerance of texture of food, monitor appetite and weights and report significant weight loss, monitor percentage of food consumption for each meal, dental consult and follow-up as ordered and needed, follow up dental treatment as needed, encourage Resident 1 to report difficulty chewing food, and staff to monitor for signs and symptoms of chewing difficulty, including taking longer to chew or longer time when eating.During a review of Resident 1's Nutrition Care Plan, dated 3/12/2026, the Care Plan indicated Resident 1 was at risk for malnutrition related to anxiety (extreme worry), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities), chronic pain, insomnia (difficulty sleeping), alcohol abuse, and overweight. The Care Plan's interventions indicated Resident 1's diet was regular diet, regular texture, thin liquids, nutritional shake three times a day as needed, honor Resident 1's reasonable food preferences, RD to evaluate and make nutrition recommendations as needed, monitor for and document signs and symptoms of dysphagia (difficulty swallowing), offer meal replacement if Resident 1 consumed less than 50 percent, and provide assistance during meals as needed.During a review of Resident 1's Physician Note, dated 3/13/2026, the Physician Note indicated Resident 1 had gastric sleeve in 2017. The Physician Note indicated Resident 1 stated, I cannot eat and my system does not accept. The Physician Note indicated Resident 1 requested Ensure. During a review of Resident 1's admission Nutritional Assessment, dated 3/16/2026, the admission Nutritional Assessment did not indicate Resident 1 had autism, eating disorders in the past, gastric sleeve in 2017, a loose right front tooth, toothache, or chewing problems.During a review of Resident 1's Order Summary Report (Physician's Orders), dated 3/31/2026, the Physician's Order indicated and order was placed for Resident 1 to receive a regular diet, regular texture, and thin liquids. The Physician's Orders indicated Resident 1 had an order for nutritional shakes three times a day. During a review of Resident 1's Physician Note, dated 4/17/2026, the Physician Note indicated Resident 1 had gastric sleeve in 2017. The physician note indicated Resident 1 stated, My teeth still hurt. I need a dentist. The Physician Note indicated Resident 1 had a toothache. The Physician Note indicated the plan included a dental consult. The Physician Note indicated acute care hospital, skilled nursing facility, and therapy records were reviewed personally.During a concurrent observation and interview on 4/28/2026 at 11:17 a.m., Resident 1 stated she had difficulty eating food served by the facility. Resident 1 stated she requested salads because salads were something she could eat. Resident 1 stated she requested chicken only on her salads, but the facility served salads with diced deli meat. Resident 1 stated she did not want diced deli meat on her salads because the diced deli meat upset her stomach and became stuck in her loose teeth. Resident 1 stated she had gastric sleeve surgery and could not tolerate certain foods. Resident 1 stated the facility had prepared salads according to her preference before, but the facility did not consistently prepare salads according to her preference. Resident 1 stated no matter how often she complained, the kitchen continued to serve diced deli meat. Resident 1 stated some days the kitchen put chicken on her salads and then served diced deli meat again. Resident 1 stated the facility did not adhere to her preferences and did not consider her gastric sleeve. Resident 1 showed photographs of salads served with diced deli meat. Resident 1 showed a photograph of diced deli meat removed from a salad and wrapped in plastic to return to the kitchen. Resident 1 moved both upper front teeth back and forth with her finger. Resident 1's upper front teeth appeared visibly loose when Resident 1 moved the teeth back and forth.During a review of a forwarded email from Resident 1, dated 4/29/2026 at 1:01 p.m., the forwarded email included photographs of meals Resident 1 received at the facility. The photographs showed several salads with diced processed meat.During a concurrent interview and record review on 4/30/2026 at 9:40 a.m., with the Registered Dietitian (RD), Resident 1's admission Record (Face Sheet), admission Diagnosis List, Physician's Order, hospital discharge notes, physician notes, Nutrition Services Progress Note, and admission Nutritional Assessment were reviewed. The RD stated she used Resident 1's Face Sheet, admission Diagnosis List, and Physician's Order to complete Resident 1's admission Nutritional Assessment. The RD stated she routinely used the Face Sheet, admission Diagnosis List, and Physician's Order to complete nutritional assessments. The RD stated the Face Sheet, admission Diagnosis List, and Physician's Order were sufficient to complete Resident 1's admission Nutritional Assessment. The RD stated she did not use Resident 1's hospital discharge notes to complete Resident 1's admission Nutritional Assessment and was unfamiliar of how to obtain these records in Resident 1's electronic health record (EHR). The RD stated she did not assess Resident 1 for chewing or swallowing difficulties because speech therapy (a service that helps residents improve or maintain their ability to speak, understand language, swallow safely, and communicate their needs) assessed residents for chewing and swallowing. The RD stated she did not know Resident 1 had loose teeth, gastric sleeve surgery, autism, or eating disorders in the past when she completed Resident 1's admission Nutritional Assessment. The RD stated she did not reference Resident 1's loose teeth, gastric sleeve surgery, autism, or eating disorders in the past in the admission Nutritional Assessment. Upon review of Resident 1's physician notes, dated 3/13/2026 and 4/17/2026, the RD acknowledged Resident 1 had gastric sleeve surgery in 2017. The RD stated Resident 1 should have told the RD Resident 1 had gastric sleeve surgery. The RD stated she should not rely totally on Resident 1 for Resident 1's medical history. The RD stated she was surprised she did not mention Resident 1's gastric sleeve surgery. The RD stated she was blown away and frustrated because she did not know Resident 1 had gastric sleeve surgery. The RD stated if she had known Resident 1 had gastric sleeve surgery, she would have asked Resident 1 more questions. The RD stated she should look at more information to ensure she was getting accurate information about Resident 1. The RD stated she should have reviewed Resident 1's hospital discharge records upon admission to ensure Resident 1's information was accurate, but she did not know how to access the records in the electronic health record (EHR). The RD stated after she reviewed Resident 1's hospital records, the Face Sheet and admission Diagnosis List were not complete and did not include gastric sleeve surgery or autism. The RD stated knowing Resident 1 had gastric sleeve surgery would have made a difference. The RD stated she did not think autism affected Resident 1's eating or food preferences because Resident 1 was an adult who could name her food preferences. The RD stated autism could be an issue for a child or teenager because children and teenagers with autism could have food aversions and food preferences, but not adult autistic residents. The RD stated Resident 1 had very specific food likes and dislikes. The RD stated Resident 1's food preferences were documented on the Nutrition Services Progress Note and provided to the kitchen on 3/16/2026. The RD stated she was not aware Resident 1 had filed a grievance regarding food preferences or Resident 1's preference to not have processed meat with meals.During a concurrent interview and record review on 4/30/2026 at 11:48 a.m., with the Dietary Supervisor (DS), Resident 1's admission Nutritional Assessment and Nutrition Services Progress Note were reviewed. The DS stated when a resident was admitted , the DS went to the resident to determine if the resident had chewing difficulty, swallowing difficulty, or food preferences. The DS stated the information was documented on an admission nutritional assessment screening form and transferred to a diet card ([plate card] - a small card or label placed on a resident's meal tray that tells dietary staff exactly how the resident's food should be prepared and served). The DS stated the plate cards were kept in the dietary department and used to identify special requests or resident-specific meal preferences. The DS stated if a resident wanted to speak with the DS regarding meals, preferences, or food issues, nursing staff notified the DS. The DS stated he spoke with the resident and added changes to the plate card. The DS stated he referred issues to the RD, but the plate card was the only place where the information was documented. The DS stated he did not write a note when he referred a resident to the RD and only told the RD verbally. The DS stated he reviewed residents every three months and wrote a progress note. The DS stated he did not complete Resident 1's admission Nutritional Assessment and the RD completed it. The DS stated the dental status section of Resident 1's admission Nutritional Assessment was not completed but should have been completed. The DS stated if Resident 1 had a chewing or swallowing problem, the chewing or swallowing problem should have been circled on the admission Nutritional Assessment. The DS stated there was no circled chewing or swallowing problem on Resident 1's admission Nutritional Assessment, which indicated Resident 1 did not have a chewing or swallowing problem. The DS stated he completed a Nutrition Services Progress Note for Resident 1, dated 3/12/2026, and the Nutrition Services Progress Note indicated Resident 1 did not have complaints of chewing or swallowing difficulties. The DS stated he remembered the Social Services Director (SSD) coming into the kitchen with Resident 1. The DS stated Resident 1 did not mention processed meat and only stated she wanted a salad with extra meat but did not state what type of meat. The DS stated Resident 1 stated she did not want eggs on her salad. The DS stated if he had known Resident 1 wanted regular chicken and did not want processed meat, it would not have been a problem because the request could have been done. The DS stated he did not know Resident 1 filed a grievance regarding dietary preferences and stated if the grievance involved dietary preferences, he should have received a copy of the grievance. The DS stated if he had known there was a grievance regarding Resident 1's food preferences, he would have followed up with Resident 1 to ensure Resident 1's preferences were followed.During a review of a forwarded email from Resident 1 to the facility's Administrator (ADM) and Social Services Director (SSD), date sent 4/30/2026 at 12:43 p.m., the email indicated Resident 1's dietary concern was not a general food preference and involved gastric sleeve history, functional dyspepsia, loose teeth, dental pain, difficulty eating safely, muscle wasting/atrophy, gait/mobility issues, and the need for a consistent tolerable protein/dietary plan.During a concurrent observation and interview on 5/4/2026 at 9:11 a.m., with the Dietary Supervisor (DS), while in the kitchen, a handwritten dietary preference note was observed posted for Resident 1. The note indicated Resident 1 wanted chef's salad for lunch and dinner every day, no egg, extra meats, and chicken only. The note included a handwritten date of 3/20/2026. The words chicken only appeared to be written in black marker and appeared consistent with the handwriting and marker style used for the other dietary preference information on the note. The words chicken only were circled in black ink pen, and a handwritten date of 4/30/2026 appeared in black ink pen next to the circled words. The DS stated the 4/30/2026 date was written because he added chicken only to the posted dietary preference note on 4/30/2026. The DS stated Resident 1's original plate card with preferences was discarded and was not available for review.During a concurrent interview and record review on 5/4/2026 at 3:53 p.m., with RN 1, Resident 1's Interdisciplinary Team ([IDT] a group of medical professionals from different disciplines who work together to help a resident achieve their goals) Notes and Care Plans were reviewed. RN 1 stated she knew Resident 1 had an IDT meeting on 3/26/2026 regarding specific food preferences for breakfast, lunch, and dinner. RN 1 stated the RD was part of the IDT meeting on 3/26/2026 and documented Resident 1's food preferences for breakfast, lunch, and dinner. RN 1 stated she was not aware Resident 1 had a grievance regarding food preferences, which was resolved on 3/25/2026. RN 1 stated this was the first time RN 1 heard about processed meats. RN 1 stated Resident 1 mentioned in the IDT meeting what she would like to eat, as opposed to what she did not want. RN 1 stated with a grievance, staff needed to follow up and reassess to make sure the grievance was resolved. RN 1 stated staff should have checked with Resident 1 to ensure the grievance preferences were addressed. RN 1 stated before the investigation, RN 1 was unaware Resident 1 had diagnoses of autism and gastric sleeve. RN 1 stated if staff knew about autism, staff may have had a different approach to Resident 1's care. RN 1 stated not knowing the diagnoses could affect Resident 1's care regarding Resident 1's specific food preferences and concerns being addressed.During an interview on 5/5/2026 at 8:33 a.m., with the MDS Nurse (MDSN), the MDSN stated he was responsible for entering the diagnoses for all residents upon admission. The MDSN stated he reviewed Resident 1's hospital discharge records upon admission and entered her diagnoses. The MDSN stated he did not enter Resident 1's gastric sleeve surgery, autism, or loose tooth from the hospital discharge record because those diagnoses were not being monitored. The MDSN acknowledged those diagnoses had been captured, the diagnoses would have been care planned with interventions. The MDS Nurse stated it was important for nursing staff and clinicians to review the hospital records themselves and should not rely only on the diagnoses entered by the MDSN. The MDSN stated gastric sleeve history mattered because there could be eating and dietary concerns, absorption issues, need for added vitamins, and food intolerances. The MDSN stated leaving diagnoses off the diagnosis list affected Resident 1's care.During an interview on 5/5/2026 at 1:07 p.m., Resident 2 stated she was Resident 1's roommate. Resident 2 stated she was present when facility staff brought Resident 1's meals into the room. Resident 2 stated she observed facility staff bring Resident 1 salads with chopped meat, and Resident 1 told facility staff she did not want chopped meat. Resident 2 stated Resident 1 refused the chopped meat and facility staff continued to bring chopped meat to Resident 1. Resident 2 stated Resident 1 asked for chicken constantly and Resident 2 observed chopped meat on Resident 1's meals. Resident 2 stated Resident 1's salads looked different each time they were served but always included chopped meat. Resident 2 stated Resident 1 only received chicken on her salad when chicken was on the facility's menu. Resident 2 stated she was present when Resident 1 offered to buy her own chicken for her meals.During a review of a forwarded email from Resident 1, dated 5/5/2026 at 2:59 p.m., the attachment to the email included a photograph of Resident 1's plate card, which indicated Resident 1's lunch and dinner preference was chef salads for lunch and dinner with extra meat, chicken only, and no eggs or processed meats in salads. The attachment also included a photograph of a chef salad dated with an orange label marked 5/2/2026 and served with diced processed/deli-style meat.During a review of the facility's policy and procedure (P&P) titled, Policy for the Interdisciplinary Team, revised 8/2016, the P&P indicated the Interdisciplinary Team (IDT) was responsible for the development of an individualized comprehensive care plan for each resident. The P&P indicated a comprehensive care plan for each resident would be started on admission and completed within seven days of completion of the resident assessment. The P&P indicated the care plan was based on the resident's needs and comprehensive assessment. The P&P indicated the IDT included the resident's attending physician, registered nurse responsible for the resident, dietary manager or dietitian, social services staff, therapists, director of nursing, charge nurse, nursing assistants, and others as appropriate or necessary to meet the needs of the resident.During a review of the facility's P&P titled, Dietary - Menus, Food and Drink, reviewed 1/2017, the P&P indicated the facility's policy was to meet the nutritional needs of residents in accordance with established national guidelines. The P&P indicated the facility would provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. The P&P indicated menus would be prepared in advance and the facility would make reasonable efforts to reflect the religious, cultural, and ethnic needs of the residents. The P&P indicated menus would be reviewed by a registered dietitian (RD) for nutritional adequacy and updated periodically. The P&P indicated the facility would respect the resident's right to make personal dietary choices. The P&P indicated food would be prepared to accommodate resident allergies, intolerances, and preferences. The P&P indicated if a resident refused the meal served or requested a different meal, appealing options of similar nutritive value would be offered. The P&P indicated drinks would be served consistent with the resident's needs and preferences, sufficient to maintain resident hydration.During a review of the facility's P&P titled, Food and Nutrition Preparation and Service, reviewed 1/2017, the P&P indicated the facility's policy was to provide each resident with a nourishing, palatable, well-balanced diet that met the daily nutritional and dietary needs of the resident. The P&P indicated each resident would be provided a nourishing, palatable, well-balanced diet that met daily nutritional and dietary needs while taking into account the preferences of the resident. The P&P indicated the resident-centered care plan would identify preferences of the resident, as well as the resident's religious, cultural, and ethnic needs, if applicable. The P&P indicated the facility would make reasonable efforts to offer meals and snacks to residents outside scheduled or non-traditional times.During a review of the facility's P&P titled, Nutritional Screening/Assessments/Resident Care Planning, dated 2023, the P&P indicated the resident's nutritional status and nutritional needs would be assessed. The P&P indicated a nutritional program specific to the resident's needs would be planned and implemented and reassessed periodically for progress. The P&P indicated information recorded would come from a variety of sources and vary with each resident, including direct resident interview, contact with family and friends, the medical record, direct observation, and resident care conference. The P&P indicated change in eating habits, difference in eating pattern, eating problems, weight, and other problems would be recorded in dietary progress notes and the resident care plan. The P&P indicated the Food and Nutrition Services Director and/or Facility Registered Dietitian would participate in resident care planning to contribute pertinent nutritional information to the medical and nursing team.

Based on interview and record review, the facility failed to ensure staff accurately documented when a resident (Resident 1) refused therapy and when Resident 1 was notified that her therapy services were discontinued for one of four sampled residents (Resident 1). This deficient practice resulted in an incomplete clinical record and had the potential to negatively affect Resident 1's continuity of care, care planning, skilled coverage decision-making, and the facility's ability to evaluate the appropriateness of therapy discontinuation.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including muscle wasting (weakening, shrinking, and loss of muscle) and atrophy (a decrease in size or wasting away of a body part or tissue), abnormalities of gait and mobility (difficulty walking or moving in a normal, safe, or steady way), pain in right leg, chronic pain, muscle spasm (sudden tightening and cramping of a muscle) and attention-deficit hyperactivity disorder (ADHD - a condition that makes it difficult to focus, stay organized and control restlessness).During a review of Resident 1's History and Physical (H&P), dated 3/12/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's History and Physical (H&P), dated 4/21/2026, the H&P indicated Resident 1 had mobility and activities of daily living ([ADL] activities such as bathing, dressing and toileting a person performs daily) dysfunction related to muscle wasting and atrophy and abnormal gait/mobility. The H&P indicated physical therapy/occupational therapy (PT/OT) was requested from 3/12/2026 through 4/9/2026 for muscle wasting and atrophy and abnormal gait/mobility. The H&P indicated to continue PT/OT from 4/7/2026 through 5/5/2026. The H&P indicated Resident 1 had a high risk for functional impairment without therapy.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 3/17/2026, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding though thought, experience, and the senses) was intact and required supervision or touching assistance (helper provides verbal cues, steadying and or contact guard assistance as resident completes activity) from staff for eating, oral hygiene, toileting, bathing, upper/lower body dressing and personal hygiene.During a review of Resident 1's Subjective, Objective, Assessment, Plan ([SOAP] a common format used by healthcare workers to write notes about a resident's condition and care) Note, dated 4/6/2026, the SOAP Note indicated Resident 1 continued PT/OT. The SOAP Note indicated Resident 1 had musculoskeletal hypomobility, muscle wasting and atrophy, and abnormalities of gait and mobility. The SOAP Note indicated the plan included PT/OT exercises and skilled needs for PT/OT.During a review of Resident 1's Licensed Nurses' Notes, dated 4/7/2026, the Licensed Nurses' Notes indicated a telephone order was received from the physician to continue skilled physical therapy (PT) and occupational therapy (OT) treatment.During a review of Resident 1's Licensed Nurses' Notes, dated 4/16/2026, the Licensed Nurses' Notes indicated a telephone order was received from the physician to discontinue skilled OT intervention after that day. The Licensed Nurses' Notes indicated the order was noted and carried out. The Licensed Nurses' Notes did not indicate Resident 1 was notified of the discontinuation of OT services.During a review of Resident 1's History and Physical (H&P), dated 4/21/2026, the H&P indicated Resident 1 had mobility and activities of daily living (ADL) dysfunction related to muscle wasting and atrophy and abnormal gait/mobility. The H&P indicated Resident 1 had a high risk for functional impairment without therapy and adequate pain control. The H&P indicated Resident 1 had a high risk of developing contractures, pressure ulcers, poor healing, or falls if Resident 1 did not receive adequate therapy and pain control. The H&P indicated to continue PT/OT from 4/7/2026 through 5/5/2026.During a review of Resident 1's Physical Therapy (PT) Notes, dated 3/2026 through 5/2026, there was no documentation indicating Resident 1 was notified of documented therapy refusals, that Resident 1 was educated regarding the effect of therapy refusals on continued skilled services. There was no documentation indicating Resident 1 was notified that PT services would be discontinued before the Notice of Medicare Non-Coverage ([NOMNC] a Medicare notice used to inform a beneficiary of the planned end of Medicare-covered skilled services) was issued.During a review of Resident 1's Occupational Therapy (OT) Notes, dated 3/2026 through 5/2026, there was no documentation indicating Resident 1 was notified of documented therapy refusals, that Resident 1 was educated regarding the effect of therapy refusals on continued skilled services. There was no documentation indicating Resident 1 was notified OT services would be discontinued before OT services were discontinued on 4/16/2026.During a review of Resident 1's Clinical Record, dated 3/2026 through 5/2026, there was no documentation indicating an Interdisciplinary Team ([IDT] a group of medical professionals from different disciplines who work together to help a resident achieve their goals) meeting related to Resident 1's therapy refusals was held before OT services were discontinued on 4/16/2026. There was also no documentation indicating an IDT meeting was held related to Resident 1's therapy refusals before the NOMNC was issued.During a review of Resident 1's Licensed Nurses' Notes, dated 4/28/2026, the Licensed Nurses' Notes indicated Resident 1's last covered day (LCD) was 5/1/2026 and Resident 1 was changed to custodial care on 5/2/2026. The Licensed Nurses' Notes indicated this was noted and communicated. The Licensed Nurses' Notes did not indicate who was notified or whether Resident 1 was notified.During a review of Resident 1's Advance Beneficiary Notice of Non-Coverage ([ABN] a notice used to inform a beneficiary Medicare may not pay for listed services), dated 4/28/2026, the ABN indicated Medicare may not pay for physical therapy (PT), occupational therapy (OT), speech therapy (ST), and daily skilled nursing care. The ABN indicated the reason Medicare may not pay was Skilled no longer needed. Goals met. The ABN indicated Resident 1's last covered day was 5/1/2026, and custodial care would begin on 5/2/2026. The ABN did not indicate Resident 1 was notified of documented therapy refusals, educated regarding how therapy refusals affected continued skilled services, or informed of the basis for discontinuation of PT/OT services before the ABN was issued. There was no documentation indicating Resident 1 or Resident 1's Responsible Party (RP) selected an option, signed, or dated the ABN.During a review of Resident 1's NOMNC, the NOMNC indicated Medicare coverage of Resident 1's current skilled nursing services would end on 5/1/2026. The NOMNC indicated, under Additional Information, Skilled is no longer needed. Goals met. There was no documentation indicating Resident 1 was notified of documented therapy refusals, educated regarding how therapy refusals affected continued skilled services, or informed of the basis for discontinuation of physical therapy/occupational therapy (PT/OT) services before the NOMNC was issued. The NOMNC was not signed or dated by Resident 1 or her RP. During an interview on 4/30/2026 at 1:18 p.m., with Occupational Therapist (OT) 1, OT 1 stated Resident 1 received occupational therapy services for activities of daily living (ADLs), therapeutic exercises, and therapeutic activities. OT 1 stated Resident 1's OT services were initiated on 3/12/2026. OT 1 stated Resident 1's goals were self-care, increased independence and strength, and functional reach. OT 1 stated she made the decision to discontinue Resident 1's OT services and informed the physician. OT 1 stated the decision to discontinue therapy was based on Resident 1's participation, level of function, improvement, refusals, and goals being met. OT 1 stated Resident 1's last day of OT was 4/16/2026, according to the physician's order in the chart. OT 1 stated she was not involved in an Interdisciplinary Team (IDT) meeting before Resident 1's OT services were discontinued. OT 1 stated she informed Resident 1 she would be discontinued from OT but did not document the conversation. OT 1 stated the discussion was a conversation in passing. OT 1 stated when she informed Resident 1 she would be discontinued from therapy, Resident 1 said, Okay. OT 1 stated she did not know if Resident 1 was aware therapy was required for continued skilled services. OT 1 stated she did not inform Resident 1 that therapy was required for continued skilled services. OT 1 stated she was not involved in whether Resident 1's discontinuation of therapy affected her skilled level of care because she did not know all of Resident 1's skilled levels and was not involved in the insurance part.During a telephone interview on 5/4/2026 at 9:24 a.m., with the Physical Therapist/Director of Rehabilitation (PT/DOR), the PT/DOR stated Resident 1 was discharged from therapy because Resident 1 had reached her goals. The PT/DOR stated reasons for therapy discharge included a resident achieving goals or being non-compliant. The PT/DOR stated if a resident had three refusals, therapy staff explained to the resident why therapy services were being discontinued and documented the refusal or no treatment on the service log matrix. The PT/DOR stated Resident 1 had no complaints related to certain staff members and stated Resident 1 was busy doing something else when she refused therapy. The PT/DOR stated therapy staff did not complete an interdisciplinary team (IDT) meeting for refusals and did not complete an IDT meeting related to Resident 1 before discontinuing therapy. The PT/DOR stated therapy staff let Resident 1 know before discharge the therapy was ending. The PT/DOR stated Resident 1 was informed through NOMNC when Resident 1's therapy services were being discharged . The PT/DOR stated if Resident 1 wanted to appeal, Resident 1 could appeal the decision. The PT/DOR stated Resident 1 appealed, and the appeal did not reinstate Resident 1's Medicare coverage. The PT/DOR stated therapy services were to continue until the NOMNC end date of 5/1/2026.During a concurrent interview and record review on 4/29/2026 at 2:48 p.m., with the Business Office Manager (BOM) and Resident 1, Resident 1's NOMNC was reviewed. The BOM stated the NOMNC meant the physician reviewed Resident 1's therapy notes and concluded Resident 1 no longer required skilled nursing services. The BOM stated the NOMNC meant Medicare would no longer be billed after the date listed on the NOMNC. The BOM stated Resident 1's Medicare coverage ended on 5/1/2026. The BOM stated Resident 1 had Medi-Cal eligibility as of April 2026. The BOM stated the Advance Beneficiary Notice of Non-Coverage ([ABN] - a notice used to inform a beneficiary of services Medicare may not cover) indicated Resident 1's last covered day was 5/1/2026, and custodial care would begin on 5/2/2026. The BOM stated Resident 1 could remain in custodial care and receive assistance with medications. The BOM stated Resident 1 wanted to go to another facility and wanted her Medicare coverage. The BOM stated the Medicare denial was only for the facility and not for all facilities. Resident 1 stated she did not agree with the assessment to end physical therapy/occupational therapy (PT/OT) services. Resident 1 stated she did not agree with the physician discontinuing PT/OT services. Resident 1 stated the only reason PT/OT services were discontinued was because she refused to be seen by a certain staff member from the therapy department. Resident 1 stated she did not refuse therapy services and only did not want the specific staff member. Resident 1 stated she communicated to the therapy department because she did not want to work with the specific staff member, but her request was not honored. Resident 1 stated she wrote an email to the Administrator on 4/24/2026 regarding this concern.During a review of Resident 1's email titled, Rehab/Skilled-Care Dispute, dated 5/4/2026, the email indicated Resident 1 disputed any record indicating or implying Resident 1 refused rehabilitation, refused skilled care, no longer required skilled care, met all goals, or accepted custodial/lower-level care. The email indicated Resident 1 requested an accommodation not to work with a specific therapy staff member due to prior interactions and communication concerns. The email indicated Resident 1 identified the request as an accommodation/safety request, not a refusal of rehabilitation.During a review of the facility's undated policy and procedure (P&P) titled, Medicare Part A Eligibility for Rehabilitation Services, the P&P indicated the resident must require daily skilled nursing or rehabilitation services. The P&P indicated the treatment modalities, frequency, and duration must be specifically ordered by the physician. The P&P indicated the resident must have potential to reach rehabilitative goals in a reasonable and predictable period. The P&P indicated there must be a change in function and medical condition to support the need for skilled therapy.During a continued review of the facility's undated P&P titled, Medicare Part A Eligibility for Rehabilitation Services, the P&P indicated it was important to have physician documentation of changes in the resident's functional and medical condition to support the need for skilled therapy to restore the resident to the resident's prior level of function. The P&P indicated discontinuation of Medicare Part A occurred when the physician discontinued orders for skilled rehabilitation services, the resident failed to make significant progress in a reasonable period of time, the resident achieved treatment goals, the resident no longer required daily skilled nursing or rehabilitation services, or the resident used all Medicare A days.

Based on observation, interview, and record review, the facility failed to ensure the storage of food was done under sanitary conditions in one of one kitchen by not labeling an opened food item with a date opened and prepared food items with date prepared.These deficient practices had the potential to cause food-borne illnesses (any illness resulting from eating contaminated/spoiled foods).Findings:During a concurrent observation and interview on 1/12/2026 at 8:26 a.m., with the Dietary Supervisor (DS) in the dry storage room, a previously opened gallon container of sesame oil was without a label of open date. The DS stated the oil did not have an open date. There was a serving tray on top of a storage bin that had five prepared bowl containers of dry cereal with no label of date prepared. During an interview on 1/14/2026 at 11:53 a.m., with the Registered Dietician (RD), the RD stated opened food items should be dated and labeledDuring a review of the facility's policy and procedure (P&P), titled Labeling and Dating of Foods, dated 20203 The P&P indicated all food items in the storeroom need to be labeled and dated. Newly opened Food items will need to be closed and labeled with an open date and used by date. All Prepared foods need to be covered labeled and dated. Items can be dated individually or in bulk stored on a tray with masking tape if they are going to be used for meal service. During a review of the facility's P&P, titled Storage of Food and Supplies, dated 2023, The P&P indicated Dry food items which have been opened, such as dry cereal will be tightly closed, labeled and dated.

Based on interview and record review, the nursing staff failed to revise a care plan for impaired communication for one of four sampled residents (Resident 30) who was deaf (condition where an individual has a significant or complete inability to speak) and non-verbal. This deficient practice had the potential for Resident 30's needs not to be met, due to her inability to express them.During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including hearing loss, non-verbal, and idiopathic peripheral autonomic neuropathy (IPAN: nerve damage affecting automatic functions (heart rate, blood pressure [amount of pressure that takes the heart to pump blood in the body], digestion). During a review of Resident 30's History and Physical (H&P), dated 7/25/2025, the H&P indicated Resident 30 had the capacity to understand and make decisions. During a review of Resident 30's Minimum Data Set ([MDS] a resident assessment tool), dated 1/7/2026, the MDS indicated Resident 30's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills were intact. The MDS indicated Resident 30 was independent on all aspects of activities of daily living (ADLs: routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 30 did not have any impairments on the upper (arms/shoulders) and lower (hips/legs) extremities. During a concurrent interview and record review on 1/14/2026 at 1:43p.m., with Registered Nurse Supervisor (RN 1), RN 1 stated Resident 30 did not have a care plan regarding communication/language in her medical record. During an interview on 1/15/2026 at 12:22 p.m., with the Director of Nursing (DON), the DON stated care plans are individualized to ensure the staff know how to take care of the residents individually. The DON stated care plans are updated as needed, quarterly, and upon readmission. The DON stated all active care plans should be in the residents' chart. During a concurrent interview and record review of Resident 30's Impaired Communication dated 7/22/2025 on 1/15/2026 at 12:24p.m. with the DON, the DON stated the target date reflected on the care plan of 10/2025 should have been updated. The DON stated care plans are continuous and without care plans, there would be no guide on how to care for the residents. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Planning, revised 1/2017, the P&P indicated the care plan must be reviewed and revised periodically, at least quarterly, and an ongoing basis to reflect changes in the resident and the services provided or arranged must be consistent with each resident's written plan.

Based on observation, interview, and record review, the facility failed to ensure a person-centered care plan was developed and implemented for Risperdal [anti-psychotic medication (used to manage psychosis symptoms)] for one of four sampled residents (Resident 5). This deficient practice has the potential to result in unnecessary medication use, unmonitored side effects and decline in functional status. Findings:During a review of Resident 5's admission Record (Face Sheet), the admission Record indicated the facility admitted the resident on 5/5/2025 with diagnoses including peripheral autonomic neuropathy (damage to automatic body nerves for unknown reasons), hypotension (low blood pressure), paranoid schizophrenia (brain disorder where a person may hear or see things that are not real), schizoaffective disorder (condition where someone's thoughts get mixed up and their mood swings are very strong and hard to control), and hyperglycemia (high blood sugar).During a review of Resident 25's History and Physical (H&P) dated 5/6/2025, the H&P indicated Resident 25 has fluctuating capacity to understand and make decisions.During a record review of a physician's (MD) order dated on 5/5/2025 at 9:00 p.m., the MD indicated Risperdal 3 milligram (mg, unit of weight), give one tablet by mouth at bedtime for paranoid schizophrenia and auditory hallucination to harm others.During a concurrent interview and record review on 1/12/2026 at 1:17 p.m. with Registered Nurse (RN) 1, there was no documented care plan for Risperdal 2 mg and Risperdal 3 mg, ordered for paranoid schizophrenia and auditory hallucination. RN 1 stated the care plan was not developed and implemented. RN 1 stated a licensed nurse initiates the care plan. RN 1 stated a comprehensive, patient-centered care plan was required to guide staff in identifying Resident 5's diagnosis, understanding the related needs and behaviors, and implementing individualized interventions. RN 1 stated without a care plan, Resident 5's symptoms related to paranoid schizophrenia and auditory hallucinations may be overlooked, resulting in delayed assessment and intervention.During a concurrent interview and record review on 1/14/2026 at 11:40 a.m. with the Director of Nursing (DON), Resident 5's care plan for Risperdal 2 mg and Risperdal 3 mg, ordered for paranoid schizophrenia and auditory hallucination was not found. The DON stated the absence of a care plan limits the nursing staff's ability to recognize changes in condition, provide timely support, and implement the appropriate interventions necessary to meet Resident 5's needs.During a review of the facility's policy and procedure (P&P) titled, Psychotropic Drug Treatment, dated 9/2017, indicated The purpose of this procedure is to provide psychotropic drug treatment for a resident with a specific condition as diagnosed and documented in the clinical record.Nursing services, social services and other members of the interdisciplinary team (IDT) will address the behaviors in progress notes and on the resident centered care plan.

Based on interview and record review, the facility failed to document nursing assessment for the use of Continuous Positive Airway Pressure (CPAP, a machine that delivers air through a mask to keep the airway open during sleep and prevent breathing pauses) for one of three sampled residents (Resident 78). This deficient practice had the potential to result in inaccurate and incomplete resident records and delayed identification of respiratory support needs. Findings:During a review of Resident 78's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 1/9/2026, with diagnoses including alcohol dependence, nicotine dependence, major depressive disorder (mood disorder characterized by persistent sadness and loss of interest in daily activities) and insomnia (trouble falling asleep or staying asleep).During a review of Resident 78's Minimum Data Set (MDS, a resident assessment tool), dated 1/15/2026, the MDS indicated Resident 78 had intact cognition (ability to think and understand). The MDS indicated Resident 78 needed supervision from staff for eating, toileting hygiene, dressing and bathing.During an interview on 1/13/2026 at 4:10 p.m. with Resident 78, Resident 78 stated he informed a licensed nurse on day of admission on [DATE] regarding CPAP needs and his missing mask. Resident 78 stated he had been using CPAP machine daily for 2 years for his sleep apnea (a condition that causes breathing to stop and start several times during sleep).During a concurrent interview and record review on 1/14/2025 at 9:22 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 78's Resident's Clothing and Possessions (Belonging List) for 1/9/2026 and Licensed Nurses Notes for 1/9/2026 were reviewed. LVN 3 stated Belonging List indicated Resident 78 had CPAP machine with him on admission. LVN 3 stated there was no documentation indicating Resident 78 had informed licensed nurse of need for CPAP use on admission day.During a concurrent interview and record review on 1/15/2026 at 10:41 a.m., with LVN 1, Resident 78's Licensed Nurses Notes for 1/9/2026 was reviewed. LVN 1 stated on 1/9/2026, Registered Nurse Supervisor (RN) 1 was made aware of Resident 78's history of CPAP use at home. LVN 1 stated there was no documentation indicating a report was made by LVN 1 to RN 1.During an interview on 1/15/2026 at 11:32 a.m., with Registered Nurse Supervisor (RN) 1, RN 1 stated the RN was responsible for completing the resident admission assessment. RN 1 stated when a medical device was present upon admission, the RN was expected to inquire whether the resident was using the device. RN 1 stated there was no documentation indicating an assessment was completed regarding Resident 78's use of a CPAP machine. RN 1 stated documentation of the medical device was important to ensure resident needs were identified and addressed and symptoms were managed. RN 1 stated failure to assess and document CPAP use could place the resident at risk for complication such as sleep apnea and respiratory compromise while sleeping.During an interview on 1/15/2026 at 12:22 p.m., with Director of Nursing (DON), the DON stated there should have been an interdisciplinary team meeting done for Resident 78 CPAP use and a licensed nurse had to document the history of use of the CPAP. The DON stated no documentation meant care was not done. The DON stated lack of documentation for CPAP use could result in inaccurate medical records and poor communication among staff, which could lead to failure to provide appropriate respiratory support.During a review of facility's policy and procedures (P&P) titled, Documentation Principles dated 1/2004, the P&P indicated Health records shall be kept for each resident and the content shall be in compliance with the licensing and certification government agency requirements and professional standards. All health information regarding a resident's stay shall be centralized in the resident's health record.Resident's health record shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each resident.

Based on interview and record review, the facility failed to ensure a resident, who was newly admitted to the facility, from a psychiatric facility, was supervised, and monitored to prevent one out of three sampled residents (Resident 1) from eloping (leaving a secured institution without notice or permission) from the facility. Resident 1 was last seen in the facility on 10/4/2024 at approximately 8:30 p.m., on the facility ' s patio, smoking. Resident 1 was noted missing on 10/4/2024 at approximately 9 p.m., and found at his family ' s residence, 22 miles away on 10/5/2024 at 5:30 a.m. This deficient practice resulted in Resident 1 eloping from the facility on 10/4/2024 at approximately 9 p.m. and missing for over eight hours. This deficient practice had the potential for Resident 1 ' s whereabouts to continue to be unknown, for Resident 1 to be exposed to excessive drops in temperature, motor vehicle accidents, hunger, dehydration, and death. Findings: During a review of Resident 1 ' s Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and with diagnoses including schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), and anxiety disorder (a mental illness causing persistent fear and/or worry). During a review of Resident 1 ' s History and Physical (H/P), dated 9/23/2024, the H/P indicated, Resident 1 did not have the capacity to make medical decisions. During a review of Resident 1 ' s Minimum Data Set [(MDS), a standardized assessment and screening tool], dated 9/29/2024, The MDS indicated, Resident 1 was admitted from a psychiatric facility. The MDS indicated Resident 1 was able to understand and be understood by others, with moderate cognitive impairment (ability to register and recall information). The MDS indicated Resident 1 had no functional limitations in range of motion ([ROM] the direction a joint can move to its full potential). During a review of Resident 1 ' s Nurse Progress Note, dated 10/4/2024, the Nurse Progress Note indicated Resident 1 was noted missing after a head count was conducted. During a review of Resident 1 ' s Nurse Progress Note, dated 10/5/2024 and timed at 7:50 a.m., the Nurse Progress Note indicated Resident 1 arrived at his family ' s house (located approximately 22 miles away from the facility location) at 5:30 a.m., (eight hours and 30 minutes after Resident 1 was found missing from the facility). During an interview on 10/8/2024 at 4:28 p.m., Registered Nurse 1 (RN 1) stated on 10/4/2024 at approximately 9 p.m., she was notified by a staff person (identity unknown), that Resident 1 could not be located during the headcount. RN 1 stated Resident 1 was last seen on the patio during the smoke break at approximately 8 p.m. to 8:30 p.m. RN 1 stated she did not know how Resident 1 eloped from the facility. During a telephone interview on 10/9/2024 at 9 a.m., Resident 1 ' s Responsible Party (RP) stated Resident 1 arrived at her residence on 10/5/2024 at approximately 5:30 a.m., on foot, he appeared weak and incoherent (not able to express themselves clearly). The RP stated she called the facility and spoke with RN 2, who instructed her to take Resident 1 to a General Acute Care Hospital (GACH) for evaluation and treatment. During an interview on 10/10/2024 at 10:42 a.m., the Activity Assistant (AA 1) stated on 10/4/2024 at approximately 8:30 p.m., he saw Resident 1 on the patio during the smoke break after he gave Resident 1 a cigarette. AA 1 stated he was the only staff person on the patio during that time with about 20 residents and he did not see Resident 1 because he (AA 1) was attending to other residents who were waiting to receive and have their cigarettes lit. AA 1 stated it was not sufficient for one staff person to monitor all the residents during smoke breaks. AA 1 stated once Resident 1 received his cigarette he walked behind him (AA 1) and he (AA 1) lost sight of Resident 1, and he did not know how Resident 1 eloped from the facility but thought he might have climbed over a gate on the smoking patio. During an interview on 10/10/2024, at 2:18 p.m., with the DON, the ADM, the Maintenance Supervisor (MS), and the Director of Staff development (DSD), the DON stated it was important for all residents on the patio to be supervised to ensure the residents were safe and secure. The DON, ADM and DSD stated they felt one person monitoring residents on the patio during the smoke break was sufficient to provide adequate supervision to the residents. The DSD stated CNA 1 and a security guard were assigned to make rounds throughout the facility. The DSD stated the nursing staff who work inside the facility were able to see the residents who were on the patio through the windows that overlooked the patio and they had never had a problem with this system. The DSD stated if additional staff were designated to supervise the patio, it would decrease the amount of staff available to attend to the residents who remained inside the facility. The DON, DSD and the ADM stated they did not know where Resident 1 went after being seen on the patio at approximately 8:30 p.m. The ADM and DON stated they did not know how Resident 1 was able to elope from the facility. During an interview on 10/10/2024 at 3:42 p.m., CNA 1 stated on 10/4/2024 she made rounds and conducted a head count every 30 minutes to ensure all residents were accounted for. CNA 1 stated the last time she saw Resident 1 was at approximately 7:45 p.m. before the 8 p.m., smoke break, and at approximately 8:55 p.m., she inspected Resident 1 ' s room and could not locate him. CNA 1 stated she was assigned to monitor the area near Nursing Station 1, not the patio area and viewing the residents on the patio from inside the building through the windows that overlooked the patio did not provide adequate supervision for the residents because the patio has blind spots and at night, it was dark. During a review of the facility ' s Patio Monitoring Log, dated 10/4/2024, the Patio Monitoring Log indicated at 8 p.m. to 8:30 p.m., one staff person member was assigned on the patio and from 8:30 p.m. to 9 p.m., the Patio Monitoring Log had no designated staff person assigned to the patio. During a review of the facility ' s Follow Up Investigation Report, dated 10/10/2024, the Follow Up Investigation Report indicated Resident 1 possibly scaled the fence and left the facility between 8:45 p.m. to 9 p.m., after the final smoke break. During a review of the facility ' s Policy and Procedure (P&P) titled, Safety and Supervision of Residents, dated 5/2015, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated resident supervision is a core component of the systems approach to safety, the type and frequency of the supervision may vary among residents and over time for the same resident. During a review of the facility ' s, Facility Assessment (a review of a nursing home's resources and capabilities to care for residents), dated 7/21/2024, the Facility Assessment indicated the facility maintains adequate staffing necessary to ensure shift to shift coverage was provided for all needs and services.

Based on observation, interview, and record review, the facility failed to ensure the storage, preparation and distribution of food was done under sanitary conditions for 63 of 63 residents by not: 1. Labeling perishable food items (two open pasta bags) with open date. 2.Thawing diced beef according to facility policy. These deficient practices had the potential to cause food-borne illnesses. Findings: During a concurrent observation and interview on 9/30/2024 at 8:45 a.m., with the Dietary Supervisor (DS) in the dry storage room, two bags of dried pasta (one macaroni and one farfalle) were previously opened without an open date. The DS stated the bags did not have an open date. During an observation on 10/1/2024 at 11:45 a.m., in the kitchen meal prep sink, three bags of meat were sitting in a tray of still (not running) water. The sink faucet was off. During a concurrent observation and interview on 10/1/2024 at 12:13 p.m., with [NAME] 1, [NAME] 1 turned on the sink faucet. [NAME] 1 stated the bagged meat was diced beef for tomorrow's lunch. [NAME] 1 stated the water was running over the diced meat earlier, but does not know when the water was turned off. [NAME] 1 stated thawing meat should be placed under continuous running water and reach a goal of under 40 degrees Fahrenheit (a unit of measure of temperature) in two hours. During an observation on 10/1/2024 at 12:18 p.m., [NAME] 1 removed the thawing meat tray from under the running water, did not take the temperature, covered and labeled the tray, and placed the tray in the refrigerator. During an interview on 10/1/2024 at 12:20 p.m., with the DS, the DS stated when defrosting under running water, the process includes thawing the meat under running water with a goal of below 70 degrees Fahrenheit in two hours. The DS stated if food is not thawed properly, there is a risk for residents to contract a food borne illness. During an interview on 10/3/2024 at 11:26 a.m., with the DS, the DS if there is unlabeled opened food, the staff would not know when it was opened and when the food will expire. The DS stated the quality of food such as the texture would be compromised. During a review of the facility's policy and procedure (P&P), titled Labeling and Dating of Foods, dated 2020, The P&P indicated Newly opened food items will need to be closed and labeled with an open date . During a review of the facility's policy and procedure (P&P), titled Storage of Food and Supplies, dated 2020, The P&P indicated Dry food items which have been opened, such as pudding, gelatin, biscuit mix, pancake mix, dry cereal, spices, coffee, noodles, etc., will be tightly closed, labeled and dated. During a review of the facility's policy and procedure (P&P), titled Food Preparation, dated 2018, The P&P indicated Thawing meat properly can be done in these four ways: 3. Submerge under running, potable water at a temperature of 70?F or lower, with a pressure sufficient to flush away loose particles. a. The food product cannot remain in the temperature danger zone (41degrees Farenheit to 140 degrees Farenheit) for more than four hours, which includes the time the food is thawed. Use immediately.

Based on observation, interview and record review, the facility failed to: a. Ensure one of four sampled residents (Resident 116)'s narcotic (drug that affects mood or behavior) was documented in the narcotic record when it was administered on 9/11/2024 at 5 pm. b. Ensure one of three sampled resident's (Resident 53)'s home medications were documented when facility staff received it. These deficient practices had the potential to result in medication errors and drug diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of narcotics. Findings: a. During a review of Resident 116's Admission Record, the record indicated Resident 116 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental health disorder that affects the mood and behavior), depressive episodes (feeling sad, irritable, and empty), and generalized anxiety disorder (a mental health condition that causes people to experience excessive, persistent, and uncontrollable worry). During a review of Resident 116's Minimum data Set (MDS), a federally mandated assessment tool, dated 7/10/2024, the MDS indicated Resident 116's cognition (ability to make decisions of daily living) was intact, and Resident 116 was independent with all activities of daily living (ADL - tasks related to personal care). During a review of Resident 116's Physician's Order Summary Report, the order summary indicated, starting on 7/23/2024, Ativan (Lorazepam - medication used to treat anxiety) 0.5 milligrams by mouth every six hours as needed for anxiety manifested by panic attack (brief episode of intense anxiety, which causes the physical sensations of fear). During a concurrent observation, interview and record review on 9/30/2024 at 1:55 p.m., at the station 1 medication room, with the Assistant Director of Nursing (ADON), Resident 116's Antibiotic or Controlled Drug Record for Lorazepam 0.5 milligram was reviewed, and the record indicated the last dose was administered on 9/11/2024 at 7:45 a.m. and there should be 18 tablets left in the bubble pack (a card that packages doses of medication within small, clear, plastic bubbles). The ADON counted the Lorazepam and noted 17 tablets in the bubble pack. The ADON stated there was a discrepancy with the count and narcotic record because we are missing one 0.5 milligram tablet of lorazepam. During a concurrent interview and record review on 9/30/2024 at 3:00 p.m. with the ADON, Resident 116's Medication Administration Record (MAR) for 9/2024 was reviewed and the MAR indicated Ativan (Lorazepam) 0.5 milligrams was last administered on 9/11/2024 at 5:00 p.m. The ADON stated the nurse should have recorded the last dose on Resident 116's Narcotic Record for Lorazepam so the nurses know when the resident received it. b. During a review of Resident 53's Admission Record, the record indicated Resident 53 was initially admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, depressive episodes, and generalized anxiety disorder. During a review of Resident 53's MDS, dated [DATE], the MDS indicated Resident 53's cognition was intact, and Resident 53 needed partial assistance (helper does less than half the effort) with ADLs. During a concurrent observation and interview on 9/30/2024 at 2:18 p.m., at the station 1 medication room, with the ADON, Resident 53's sealed, unopened, opaque plastic bag with unidentified medications were noted. The ADON stated we don't know what medications were in the bag because the bag was never opened and there was no home medication list with the medications. The ADON stated there should have been a medication list, so we know what medications Resident 53 was taking. During an interview with the Director of Nursing (DON) on 10/3/2024 at 12:00 p.m., the DON stated the Narcotic record needs to be accurate because we always need to know the disposition of narcotics. The DON stated inventory of all belongings including home medications were important so residents can leave with their personal belongings. During a review of the facility's policy and procedure (P&P), titled, Preparation and General Guidelines, IIA5: Controlled Medications, effective date 8/2014, the P&P indicated medications included in the Drug Enforcement Administration classification as controlled substances were subject to record keeping in the facility in accordance with federal, state, and applicable laws and regulations. When controlled medications were administered the licensed nurse administering the medication immediately enters the information on the accountability record and the MAR: 1. Date and time of administration 2. Amount administered 3. Signature of nurse administering the dose on the accountability record at the same time the medication is removed from the supply. During a review of the facility's P&P titled, Medication Storage in the Facility, ID3: Controlled Medication Storage, effective 8/2014, the P&P indicated at each shift change a physical inventory of all controlled medications, including the emergency supply, is conducted by two licensed nurses and it is documented on the Controlled Medication Accountability Record. Any discrepancy and controlled substance medication counts is reported to the DON immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. During a review of the facility's P&P titled, Medication Ordering and Receiving from Pharmacy, IC 120: Medications brought to the facility by a resident or Family Member, effective 8/2014, the P&P indicated a licensed nurse: a. Receives medication delivered to the facility and documents delivery of the medication on the appropriate form. b. Verifies medications received and directions for use with the original medication order.

Based on observation, interview, and record review the facility failed to ensure to document the visual monitoring for behaviors, every 15 minutes for one of one resident's (Resident 113)'s medical records. The deficient practice indicated an inaccurate account of care and services received by Resident 113, and the inability of the facility to recognize and act on trends of Resident 113's behaviors. Findings: During a review of Resident 113's Admission Record, the record indicated Resident 113 was admitted to the facility on [DATE] with diagnoses including schizophrenia (mental health disorder that can cause people to lose touch with reality), depressive episodes (feelings of sadness, tearfulness, emptiness, or hopelessness), and generalized anxiety disorder (mental health condition that causes people to experience excessive, persistent, and uncontrollable worry). During a review of Resident 113's Minimum data Set (MDS), a federally mandated assessment tool, dated 10/1/2024, the MDS indicated Resident 113's cognition (ability to make decisions of daily living) was moderately impaired, and Resident 113 needed supervision (helper provides verbal cues and touching assistance as resident completes activity) with eating, oral hygiene, dressing, and personal hygiene, and moderate assistance (helper does less than half the effort) with showering and toileting hygiene. During a review of Resident 113's care plan titled, Activities of Daily Living Self Care Deficit, dated 9/25/2024, the care plan goal indicated Resident 113 needed assistance with bed mobility, transfer, walking, dressing, eating, toilet use, personal hygiene, and bathing. The care plan intervention indicated to visually check resident frequently. During an observation and interview on 9/30/2024 at 10:12 a.m., with Certified Nurse Assistant (CNA) 1, at the hallway adjacent to Resident 113's room, CNA 1 was noted to be watching Resident 113 and just sitting in the hallway. CNA 1 stated he was closely monitoring Resident 113 to make sure Resident 113 does not wander in other residents' rooms and take things. CNA 1 stated he visually monitors Resident 113 at least every 15 minutes. CNA 1 stated every 15-minute visual check for behaviors was not documented anywhere in Resident 113's chart. During an observation and interview on 9/30/2024 at 10:52 a.m., with CNA 2, at the hallway adjacent to Resident 113's room, CNA 2 was noted standing in front of Resident 113's room looking at Resident 113. CNA 2 stated she was closely monitoring Resident 113 and making sure she can see Resident 113 continuously. CNA 2 stated they do not document that they were monitoring the resident continuously in the chart. During an interview and record review on 10/1/2024 at 12:05p.m., with the Assistant Director of Nursing (ADON), Resident 113's progress notes, care plans, and medical records were reviewed and there was no documented evidence of the staff closely monitoring and visually checking Resident 113 every 15 minutes. The ADON stated the facility staff closely monitors new admissions to ensure the resident was safe and was acclimated to the environment. The ADON stated it was an intervention in the care plan to visually check resident frequently, but it was not documented anywhere that the CNA's were providing the service. During an interview and record review with the Director of Nursing (DON) on 10/3/2024 at 12:00 p.m., the facility's policy and procedure (P&P) titled, Documentation Principles, revised 2/2018, was reviewed. The DON read a portion the P&P and stated it was the policy of the facility that clinical records shall be current and kept in detail consistent with good medical and professional practice based on care provided to each resident. The DON stated CNA documentation should be accurate. During a review of the facility's policy and procedure (P&P) titled, Documentation Principles, revised 2/2018, the P&P indicated clinical records shall be current and kept in detail consistent with good medical and professional practice based on care provided to each resident. Entries must be accurate, timely, objective, specific, concise, legible, clear, and descriptive. During a review of the facility's P&P titled, Certified Nurse Assistant Documentation, revised 10/2015, the P&P indicated certified nurse assistants document per shift, accurately and consistently.

Based on observation, interview, and record review, the facility failed to serve a snack that was prepared as prescribed by the physician for one of two sampled residents (Resident 33). This deficient practice had the potential to cause the resident to choke on their food. Findings: During a review of Resident 33's Admission Record, dated 9/22/2024, the Admission Record indicated Resident 33 was initially admitted to the facility on [DATE] with diagnoses including Dysphagia (difficulty swallowing). During a review of Resident 33's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/19/2024, the MDS indicated Resident 33 was cognitively (ability to make decisions of daily living) intact and able to recall recent events During a review of Resident 33's physician orders, dated 9/13/2024, the order sheet indicated Resident 33 was prescribed a pureed (consisting of foods that are ground, pressed, or strained until they have a smooth, soft consistency, similar to pudding) texture regular diet. During a review of Resident 33's s Speech Language Pathologist (SLP- a licensed professional who diagnoses and treats speech, language, communication, cognitive, and swallowing disorders in people of all age) Evaluation and Plan of Treatment, dated 9/16/2024, the evaluation indicated the SLP recommends Solids = Puree Consistencies for Resident 33. During an observation on 10/2/2024 at 10:14 a.m., Certified Nurse Assistant 3 (CNA 3) was observed passing snacks that included soft baked chocolate chip cookies and lemon cookies and juice on a cart. During a concurrent observation and interview on 10/2/2024 at 10:28 a.m., with Resident 33, Resident 33 was observed sitting up with one empty cookie wrapper. one cookie still in its packaging, and a cup of juice. Resident 33 stated they had just eaten one cookie and planning to eat the second cookie on the table. There were no other items observed on the table. During an interview on 10/2/2024 at 10:29 a.m., with CNA 3, CNA 3 was unable to state which residents were on pureed diets. and will find out. During an interview on 10/2/2024 at 10:39 a.m., with CNA 3, CNA 3 stated that she found out that Resident 33 was on a pureed diet and they can have yogurt and pudding that comes from the kitchen. CNA 3 stated they gave Resident 33 a yogurt. During a concurrent interview and record review on 10/2/2024 at 2:50 p.m., with Licensed Vocational Nurse 1 (LVN 1), the document titled, Situation-Background-Assessment-Recommendation (SBAR-document that indicates resident's change of condition) dated 10/2/2024 was reviewed. LVN 3 stated Resident 33 was being monitored for aspiration((food or liquid accidentally entering the lungs) because Resident 33 ate a cookie earlier. During an interview on 10/2/2024 at 3:21 p.m., with the SLP, the SLP stated appropriate snacks for a resident on a pureed diet included pudding, applesauce, or pureed fruits. The SLP stated Resident 33's diet recommendation is pureed and cookies are not an appropriate snack for a resident on a pureed diet. During an interview on 10/3/2024 at 11:49 a.m., with the Director of Nursing (DON), the DON stated it is important for staff to follow physician orders. The DON stated if a resident who is prescribed a pureed diet is provided a cookie as a snack, the resident is at risk for aspirating or choking. During a review of the facility's Charge Nurse job description (undated), the job description indicated general duties and responsibilities include, Perform treatments-administer medications, and/or implement other nursing interventions as indicated by the resident care plan r as ordered by the physician.

Based on observation, interview, and record review, the facility failed to follow up and ensure one of eight sampled residents (Resident 7) received follow up dental care recommended by the dentist. This deficient practice had the potential to cause further decline in Resident 7's teeth and dental pain. Findings: During a review of Resident 7's Admission Record, the Admission Record indicated Resident 7 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), generalized anxiety disorder (a mental health condition that causes people to experience excessive, uncontrollable, and irrational worry about everyday things), and depression (a mental state that can affect a person's thoughts, feelings, behavior, and sense of well-being). During a review of Resident 7's Oral/Dental care plan dated 4/7/2024, the care plan indicated Resident 7 needed supervision for oral care. Goals for Resident 7 included Resident 7 would not complain of dental pain related to poor teeth condition with interventions that included dental consult and follow-up as needed and to follow up with dental treatment as needed. During a review of Resident 7's Dental Notes dated 5/29/2024, Resident 7 required dental crowns (a type of dental restoration that completely caps or encircles a tooth) on his two top front teeth (number 8 and number 9 teeth). Resident 7 denied treatment on this day (5/9/2024) but was willing to try a different day. During a review of Resident 7's Dental Notes dated 6/12/2024, Resident 7 refused to be seen that day but Resident 7 agreed to try a different day. There were no further Dental Notes or follow ups for dental care in Resident 7's chart after 6/12/2024. During a review of Resident 7's Resident Care Conference Review form dated 9/10/2024, the form indicated Resident 7 was last seen by the dentist on 6/12/2024. During a review of Resident 7's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/10/2024, the MDS indicated Resident 1 was cognitively intact (the person was able to think, learn, and remember clearly, and to carry out daily activities effectively). During an observation on 9/30/2024 at 2:59 p.m., Resident 7's two top front teeth were broken. During an interview on 10/1/2024 at 2:50 p.m., Resident 7 stated the dentist came to see him three times and took x-rays (imaging creates pictures of the inside of your body) to fix his broken teeth but he never came back to do the crowns. Resident 7 stated he would feel better about himself if his teeth were fixed. During an interview on 10/3/2024 at 11:01 a.m., the social services director (SSD) stated the last time Resident 7 was seen by the dentist was 6/12/2024. The SSD stated the dentist came to the facility as needed or every two months if there wasn't an immediate need. The SSD reviewed her ancillary notes and there were no attempts from the dentist to follow up with Resident 7 since he declined being seen by the dentist on 6/12/2024. The SSD stated she did not have it written down in her notes that Resident 7 was pending dental crowns. The SSD stated Resident 7 had cracked front teeth when she talks to him. During an interview on 10/3/2024 at 11:19 a.m., Resident 7 stated he did not remember declining dental treatment and hopes the dentist comes back soon to do the work because it would help him feel better about himself. During an interview on 10/3/2024 at 11:49 a.m., the director of nursing (DON) stated it was important to track ancillary services (supportive or diagnostic services beyond primary healthcare) and ensure the residents received follow up ancillary care because the facility needed to ensure the residents were getting the care and treatments they needed. The DON stated if a resident refused ancillary treatment, it should have been in the progress notes and the facility should have done an interdisciplinary care plan meeting to ensure they follow up with the resident regarding the treatment. The DON stated it was important to follow up with the resident to reevaluate how the resident was feeling because one day they may decline the treatment, but they may agree the next day or next week and then they could call the dentist to come back and do the work when the resident was up for it. The DON stated the potential outcome of not getting recommended dental treatment done was not good (the DON, did not specify what not good was). During a review of the facility's policy titled Social Services Department- Dental, Optometry, and Audiology Evaluations, undated, indicated dental evaluations were scheduled on annual basis and/ or as needed.

Based on interview and record review, the facility failed to ensure one of two residents (Resident 61), who was diagnosed with post-traumatic stress disorder (PTSD - mental health condition that can develop after someone experiences a deeply distressing or disturbing event), received trauma informed care (a model that aims to provide effective mental health services by taking into account a person's past experiences with trauma). This deficient practice had the potential to result in resident 61's re-traumatization and can be detrimental for the resident's psychosocial status. Findings: During a review of Resident 61's Admission Record, the record indicated Resident 61 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (mental health disorder that can cause people to lose touch with reality), major depressive disorder (mental health condition characterized by persistent sadness or loss of interest in activities), anxiety disorder (mental health condition that causes people to experience excessive, persistent, and uncontrollable worry), and PTSD. During a review of Resident 61's Minimum data Set (MDS), a federally mandated assessment tool, dated 9/19/2024, the MDS indicated Resident 61's cognition (ability to make decisions of daily living) was intact, and Resident 61 needed moderate assistance (helper does less than half the effort) with activities of daily living (ADL), tasks related to personal care. During a review of Resident 61's Brief Trauma Questionnaire and Life Events Checklist, dated 9/13/2024, the list indicated Resident 61 experienced five traumatizing events. Resident 61 experienced a fire, transportation accident, physical assault, sexual assault, and other unwanted or uncomfortable sexual experiences. During an interview on 10/1/2024 at 2:52 p.m., with the Social Services Director (SSD), the SSD stated Resident 61 was assessed for trauma the resident experienced or witnessed by using the Brief Trauma Questionnaire and Life Events Checklist. The SSD stated the care plan and interventions to address the trauma was developed by the nursing staff. During an interview and review on 10/2/2024 at 1:50 p.m. with the Assistant Director of Nursing (ADON), Resident 61's care plans and social services notes were reviewed and there were no trauma informed care plans for Resident 61. The ADON reviewed Resident 61's medical records and stated there was no documented evidence of the identification of triggers that can cause re-traumatization, and there were no personalized trigger specific interventions addressing Resident 61's PTSD. The ADON stated moving forward they would develop and implement a care plan for Resident 61. During an interview with the Director of Nursing (DON) on 10/3/2024 at 12:00 p.m., the DON stated the nurses need to develop individualized trauma informed care for residents who suffered PTSD, so the nurses know exactly how to take care of the resident. During a review of the facility's policy and procedure (P&P) titled, Trauma Informed Care, revised 2/2018, the P&P indicated residents who are trauma survivors will receive culturally competent, trauma informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that may cause re traumatization of the resident. The facility will provide nursing and related services to assure resident safety and attain or maintain the highest well-being of each resident, as determined by resident assessments and individualized plans of care and considering the number, acuity, and diagnoses of the resident population. Based on the comprehensive assessment the resident will receive the appropriate treatment and services to correct the assessed problem to attain the highest level of well-being (as linked to the history of PTSD). treatment and services to correct the assessed problem to attain the highest level of well-being (as linked to the history of PTSD).

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a specialized tool due to its small size) that could cause food borne illness (food poisoning: illness due to consuming spoiled food) for residents in the facility by not: a. ensuring Strawberry ready care shakes (nutritional shake that gets delivered frozen) were dated, when placed in the refrigerator to thaw (once thawed, shelf life is less than 14 days) b. ensuring a salad and bowl of lettuce was labeled and dated in the refrigerator. c.ensuring a bowl of tuna salad, a container of cornflakes, and a tupperware of peaches were not expired. c.ensuring the ice machine was maintained in a clean and sanitary way These deficient practices had the potential to affect residents of the facility and result in pathogen (germ) exposure, and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization . Findings: During an observation on [DATE] at 10:48 a.m., with the dietary supervisor (DS), the dry storage area contained a container of corn flakes with a use by date of [DATE]. The DS removed the corn flakes from the shelf for disposal. During an observation and concurrent interview on [DATE] at 10:54 a.m., with the DS, refrigerator one (1) contained strawberry Ready Care shakes without a date of when they were moved from the freezer to the refrigerator to thaw. The DS stated there was not a date on the Ready Care shakes for when they were brought to the refrigerator to thaw. During an observation on [DATE] at 10:58 a.m., with the DS, refrigerator 2 contained a salad (chicken, egg, lettuce, shredded cheese, and shredded carrots) and lettuce that were not dated. Refrigerator 2 also contained, a bowl of tuna and a Tupperware of peaches dated [DATE] (expired 1 day prior to the observation). The DS removed the tuna and peaches from refrigerator 2 for disposal. During an interview on [DATE] at 2:46 p.m., the DS stated the potential outcome for having undated and expired food items in the kitchen was food borne illness, and need to ensure expired items are not served to their high-risk residents. During an interview on [DATE] at 3:24 p.m., dietary assistant (DA 1) stated it was the job of all kitchen staff to ensure there was no expired or undated food in the kitchen. During an observation and concurrent interview on [DATE] at 10:02 a.m., with the maintenance supervisor (MS), the MS opened the ice machine door and there were brown crusty areas that were chipping on the metal frame of the ice machine. The MS stated the brown crusty areas were rust and he should have requested to have the ice machine replaced since it could contaminate the ice served to the residents. During an interview on [DATE] at 3:39 p.m., the MS stated there was rust on the ice machine and when he cleaned it in [DATE], he saw the rust. The MS stated he did not inform the administrator (admin) or the DS but the outside company that comes and services the ice machine monthly was aware. The MS stated they were going to replace the top portion of the ice machine, but it was not done yet. The MS state the importance of not having any rust on the ice machine was resident safety. During a review of the facility's policy and procedure (P/P) titled Ice Machine Cleaning Procedures dated 2020, the P/P indicated information regarding the operation, cleaning and care of the ice machine was to be obtained in the owner's manual. During a review of the facility's P/P titled Storage of Food and Supplies dated 2020, the policy indicated food was to be stored properly and in a safe manner. The P/P indicated no food will be kept longer than the expiration date on the product. The P/P indicated individual packages of refrigerated or frozen food taken from the original packing box need to be labeled and dated. The P/P indicated supplemental shakes which are taken from the frozen state and thawed in the refrigerator must be dated as soon as they are placed in the refrigerator.

Based on interview and record review, the facility failed to ensure implement Resident 1's rights not to be subjected to physical abuse, mental abuse and or punishment, (2) The facility also failed to implement Resident 2's care plan for physically and verbally aggressive behaviors for the staff to visually monitor Resident 2 periodically for safety, especially when he was with peers. (3) The facility failed to update Resident 2's care plans for physically and verbally aggressive behaviors based on psychotherapist recommendation that the staff should monitor the resident by watch closely due to the resident's anger issues. (4) The facility failed to implement Resident 2's care plan for anti-psychotic drug therapy to monitor the resident for behavior. This deficient practice resulted in Resident 1 sustaining abrasions to his right foot that staff had observed to bleed. Findings: A review of Resident 1's face sheet/ admission record indicated that the resident was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's face sheet/ admission record indicated that the resident was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's psychology consultation from an acute care facility, dated 08/25/2013, indicated that the resident stated that he had been in psychiatric hospitals a few times because of getting into fights with other people and hurting them. The report also indicated that Resident 2's thought content was paranoid and irritable; his behavior was guarded and suspicious; his psychomotor activity (where movements and thought processes are combined) was tense; and his speech was pressured. The report further indicated that Resident 2 had a history of [REDACTED]. A review of Resident 2's care plan for anti-psychotic (medication used to manage [MEDICAL CONDITION]) drug therapy, dated (MONTH) 2013, indicated that the resident was prescribed anti-psychotic medications due to episodes of paranoid delusions (fixed, false belief that one is being harmed or persecuted by a particular person or group of people) related to [MEDICAL CONDITION] (mental disorder) and that the staff were to monitor the resident for behavior. A review of Resident 2's care plan for physically and verbally aggressive behaviors, dated (MONTH) 2013, indicated that Resident 2 was at risk for injuries to himself and to others, related to his habit of being physically and verbally abusive. The care plan also indicated that Resident 2 had goals not to injure himself or others. The plan's intervention approaches indicated that when the resident exhibits verbal and physical abusive behaviors, then the staffs were to find out reasons for the abusive behaviors and to try to resolve the areas of concern. The plan also indicated that for safety, the staffs were to visually monitor Resident 2 periodically for safety, especially when he was with peers. Resident 2's individual psychotherapy progress note, dated 10/14/2013, indicated that Resident 2 was angry and had poor self-control; that the resident's session goals were to treat his confusion, disorganized thinking, anger and aggression; that the resident maybe threatening peers; and that the resident needed to be watch closely for anger issues. Resident 2's social work progress notes, dated 10/15/2013, indicated that Resident 2 was observed in the dining room agitated by another resident's repeated requests coffee, which resulted in an altercation between Resident 2 and the other resident (Resident 1). Resident 1's licensed personnel weekly progress notes, dated 10/15/2013 at 12:45 p.m., indicated that Resident 1 and 2 had an altercation. The progress notes also indicated that Resident 1 was noted not to have any injuries, discolorations, bruises or redness. However, 15 minutes later at 1 p.m., the resident was noted to have bleeding from his right foot. The resident sustained [REDACTED]. Review of witness statement report, dated 10/15/2013, indicated that staff interviewed Resident 1 and the resident reported that he was asking for a cup of coffee when Resident 2 tried to stop him. The report also indicated that Resident 1 said he defended himself; that the incident was all over a cup of coffee; and that Resident 2 was a jerk. Application for 72-hour detention for evaluation and treatment form dated 10/15/2013 indicated that staff reported that Resident 2 Was very aggressive and attacked a peer because he (Resident 1) was repeatedly asking for coffee. This document also indicated that the recorder had interviewed Resident 2 and that Resident 2 said, That man hit me last night, so I hit him. During an interview on 11/13/2013 at 10:50 a.m., certified nurse assistant (#6) stated on 10/15/2013 prior to the confrontation between Residents 1 and 2, she was in the dining room passing out lunch trays to other residents with her back towards Residents 1 and 2. Certified nurse assistant (#6) stated that she was not looking at Residents 1 and 2, but she heard Resident 1 repeatedly ask for coffee, and that she heard Resident 2 loudly tell Resident 1 that he could not get the coffee himself, but he had to wait. Certified nurse assistant (#6) stated that afterwards she heard the sounds of an altercation taking place between Residents 1 and 2. Certified nurse assistant (#6) stated that upon hearing the altercation, she saw that Resident 2 had already left the table he had been sitting at and was at the table where Resident 1 had been sitting, and only then, the staffs separated the two residents from each other. During an interview on 11/13/2013 at 11:10 a.m., certified nurse assistant (#9) stated that on 10/15/2013, while in the dining room, that she did not exactly witness the incident but was there during the incident. Certified nurse assistant (#9) stated that Resident 2 was angry with Resident 1 because Resident 1 had been asking for coffee. Certified nurse assistant (#9) stated that Resident 1 had a habit of always asking for coffee, and that Resident 2 had habits where small things got to him and that he often got upset. Certified nurse assistant (#9) stated that when she heard the commotion, she turned around and saw Resident 1 stood up from his seat and told Resident 2 to get out of his (Resident 1's) face. Certified nurse assistant (#9) stated that was when the staffs stopped them and told them to calm down. Registered Nurse #15 and Certified Nurse Assistant #16's written statements indicated that they were in the dining room on 10/15/2013, at and around the time of the incident, but they were not monitoring Resident 2. During an interview on 11/13/2013 at 11:58 a.m., Resident 1 stated that on the date of incident that another resident had gotten upset with him over a cup of coffee. Resident 1 said that he was getting a cup of coffee when another resident (Resident 2) told him that he could not get the coffee, followed by the other resident punching Resident 1 with a closed fist on the right side of his face, in the area between his (Resident 1's) temple and cheek. Resident 1 also stated that the other resident (Resident 2) had stepped on his right foot during the incident that caused him to sustain the bruises on his foot. Resident 1 said that he felt that the other resident used his full power to hit him and that the punch made him feel hurt, both physically and emotionally. During an interview on 11/13/2013 at 11:58 a.m., with Resident 1, Resident 1's girlfriend was present. The girlfriend said that the Resident 1 still had treatment padding on his right foot due to the bruises that he sustained during the incident. During an interview on 11/13/2013 at 12:07 p.m., Resident 1's girlfriend stated that at or around the time of the incident, Resident 1 had called her with his cell phone, complaining that he was punched in the face and the police had responded. Resident 1's girlfriend also stated that the incident caused the resident to be very anxious and very emotional. Resident 1's girlfriend further stated that Resident 1 had a problem remembering events longer than a week and that she was surprised that the resident still remembered the event at this time. During an interview on 11/13/2013 at 5:43 p.m., the director of nursing stated that around the time of the incident, the police was notified of the altercation between Residents 1 and 2. She stated that the police investigated and wrote a report, but the facility did not obtain a copy of the report and the fact that the police investigated the incident was not reported to the Department. During an interview on 11/13/2013 at 5:43 p.m., the director of nursing stated that Resident 1's licensed personnel weekly progress notes, dated 10/15/2013 at 1 p.m., described the resident had injuries to his right foot and that the foot was bleeding. The director of nursing stated that she did not know how the resident has sustained the injuries because the resident had stated that his foot had just start bleeding. The director of nursing also stated, No when asked if there were any other instance or episode, in which the resident's body (head to toes) had just start to bleed prior to or after the altercation event the resident had with Resident 2 on 10/15/2013. During an interview on 11/13/2013 at 6:05 p.m., the director of nursing stated Resident 2's care plan for physically and verbally aggressive behaviors, dated (MONTH) 2013, was not updated from Staffs were to visually monitor Resident 2 periodically for safety to include information obtained from the assessment as indicated in the resident's individual psychotherapy progress note, dated 10/14/2013, that indicated the resident needed to be watch closely for anger issues. The director of nursing stated that the two monitoring descriptions were not the same and that watch closely could mean that the facility should have providing the resident with one to one supervision. The facility's policy and procedure for patient abuse and prevention, dated (MONTH) 2008, indicated that the facility shall uphold resident's right to be free from any form of verbal, physical and mental abuse, corporal punishment and involuntary seclusion. The policy and procedures also described mental abuse to include but not limited to, humiliation, harassment and threats of punishment or deprivation. Furthermore, the policy and procedures described that the facility shall also institute procedures that allows for identification, correction, and intervention in situations in which abuse, neglect and or misappropriation of resident property is more likely to occur. Areas of identification, correction and intervention may include but not limited to . identification of residents with potential for behavioral symptoms and manifestations that may lead to conflict or anger through comprehensive assessment, care planning and monitoring. The facility failure to ensure Resident 1's rights not to be subjected to physical abuse and the facility failure to implement Resident 2's care plans by failing to monitor and re-direct Resident 1 presented thre risk of serious physical harm to Resident 1.