Every finding on record at Mayflower Care Center

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach and appropriate to the resident's physical ability for three of three sampled residents (Residents 25 49 and 54). These failures had the potential for Residents 25, 49 and 54 not to receive necessary care or receive delayed services to meet Residents 25, 49 and 54's needs. Findings: a. During a review of Resident 25's Face Sheet (FS), the FS indicated the facility initially admitted Resident 25 on 12/24/2015 and readmitted on [DATE] with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities). During a review of Resident 25's untitled Care Plan (CP) dated 4/8/2016, the CP indicated Resident 25 was at risk for falls/injury related to impaired vision, poor body balance/control, history of falls, and Alzheimer's disease. The CP interventions included for nursing staff to keep the resident's call light within easy reach to get assistance. During a review of Resident 25's Minimum Data Set (MDS, a resident assessment tool) dated 6/14/2026, the MDS indicated Resident 25 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 25 was dependent (helper did all the effort) with eating, oral hygiene, toileting, shower, upper/lower body dressing and personal hygiene. During a concurrent observation inside Resident 25's room and interview on 7/14/2026 at 9:54 am with Certified Nurse Assistant 4 (CNA 4), Resident 25 was in bed with a pad sensor (flat call light activated by gross movement) call light hanging on the right side of the bed. CNA 4 stated the pad sensor was not accessible to Resident 25. CNA 25 stated call lights should be accessible and reachable all the time to the residents to use to call staff for assistance whenever help was needed. During an interview on 7/14/2026 at 9:57 am with Registered Nurse Supervisor 1 (RN 1), RN 1 stated call lights should always be accessible to the residents to call staff for help and assistance. During a review of the facility's Policy and Procedure (P&P) titled, Call System, Residents, revised September 2022, the P&P indicated, Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. b. During a review of Resident 49's FS, the FS indicated Resident 49 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia, Alzheimer's Disease and osteoarthritis (deterioration of protective cartilage that cushions the ends of the bones). During a review of Resident 49's untitled CP dated 8/8/2019, the CP indicated Resident 49 was at risk for further unavoidable falls/injuries related to diagnosis of dementia, impaired cognition, osteoarthritis, impaired vision and poor safety awareness/judgement. The CP interventions included for nursing staff to keep Resident 49's call light within easy reach and encourage the resident to use it to get assistance. During a review of Resident 49's History and Physical (H&P) dated 10/25/2025, the H&P indicated Resident 49 did not have the capacity to understand and make decisions. During a review of Resident 49's MDS dated [DATE], the MDS indicated Resident 49 was dependent on staff for oral, toileting and personal hygiene, showers, upper and lower body dressing and putting on/taking off footwear. During an observation of Resident 49 on 7/14/2026 at 9:30 AM, inside Resident 49's room, Resident 49 was wearing a left arm brace and was resting in bed. Resident 49's call light was placed high up on Resident 49's left side rail. During an observation and interview with Restorative Nurse Assistant 1 (RNA1) on 7/14/2026 at 9:34 AM, inside Resident 49's room, RNA1 stated Resident 49's call light was placed on the left side rail. RNA1 stated Resident 1 was wearing a left arm splint and would not be able to reach the call light that was placed on the left side rail. RNA1 stated Resident 49's call light should be within reach and should be placed on Resident 49's right side for easy access. During an interview with License Vocational Nurse 1 (LVN1) on 7/15/2026 at 7:54 AM, LVN1 stated Resident 49's call light should be next to Resident 49's hand on the right side. LVN1 stated Resident 49 was at risk of falls and if the call light was placed on the left side rail, Resident 49 would not be able to reach it to call for assistance. LVN1 stated the call light was important for Resident 49 to have within reach for Resident 49's safety. During an interview with the facility's Director of Nursing (DON) on 7/15/2026 at 10:51 AM, the DON stated call lights should be within the resident's reach. The DON stated the call light needed to be accessible because if the call light was far or placed high up on the side rails, the resident would not be able to reach it. The DON stated the residents needed to use the call light to call for help and also for safety reasons. The DON stated if the call light was hanging on the side rail, Resident 49 would not be able to reach it. The DON stated if Resident 49 could not reach the call light to call for help, the resident was at risk for fall and get injured. During a review of the facilities Policies and Procedures (P&Ps) titled, Call System, Residents, dated 9/2022, the P&P indicated, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. c. During a review of Resident 54's FS, the FS indicated the facility initially admitted Resident 54 on 7/8/2024 and readmitted on [DATE] with diagnoses including muscle weakness, muscle wasting (weakening, shrinking, and loss of muscle) and atrophy (decrease in size or wasting away of a body part or tissue) and Alzheimer's disease. During a review of Resident 54's untitled CP dated 7/8/2024, the CP indicated Resident 54 was high risk for falls/injury related to general weakness and impaired cognition. The CP interventions included for nursing staff to keep Resident 54's call light within easy reach and encourage the resident to use it to get assistance. During a review of Resident 54's MDS dated [DATE], the MDS indicated Resident 54 had moderately impaired cognition. The MDS indicated Resident 54 was dependent on staff for showering and putting on/taking off footwear. upper/lower body dressing. The MDS indicated Resident 54 needed maximum assistance (helper does more than half of the effort) from staff for oral hygiene, toileting hygiene, upper/lower body dressing and personal hygiene. During a review of Resident 54's Fall Risk Assessment (FRA- method of assessing a patient's likelihood of falling) dated 4/17/2026, the FRA indicated Resident 54 was assessed as high risk for falls due to intermittent confusion, bedbound/incontinent (involuntary loss of bladder or bowel control), presence of predisposing disease condition, decreased muscular coordination and required use of assistive devices. During a concurrent observation and interview on 7/14/2026 at 9:56 am inside Resident 54's room, Resident 54 was awake, lying in bed with the call light hanging on the left side bed rails. Resident 54 stated Resident 54 did not know where the call light was. During a concurrent observation and interview on 7/14/2026 at 9:57 am inside Resident 54's room together with Registered Nurse 1 (RN 1), Resident 54's call light was hanging on the left side of the bed. RN 1 stated Resident 54 was unable to reach the call light. RN 1 stated the call light needed to be accessible at all times for Resident 54 to call staff for help or assistance. During an interview on 7/15/2026 at 10:51 am with the facility's DON, the DON stated the residents' call light should be within reach and accessible at all times for the resident to use to call for help from staff and to maintain safety. During a review of the facility's P&P titled, Call System, Residents revised 9/2022. the P&P indicated, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices by failing to ensure food items were dated when they were first opened and prepared in one of one facility freezer. These deficient practices placed the residents at risk for food borne illnesses (infections caused by ingesting contaminated food or beverages). Findings: During initial tour and observation of the facility's kitchen on 7/14/2026 at 9:04 am, together with the Dietary Supervisor (DS), 48 cups of ice cream did not have a label or date when it was first prepared. One bag of waffles was not dated when it was first opened. The DS stated 48 cups of ice cream were not dated to determine when they were prepared by Kitchen Aid 1 (KA 1). The DS stated the bag of waffles should have been dated with used by date and expiration date to determine when it was opened. The DS stated food items should be dated and labeled when they were prepared. During an interview with KA 1 on 7/14/2026 at 9:13 am, KA 1 stated KA 1 prepared 48 cups of ice cream around 8 am and did not indicate the date when they were prepared. During a review of the facility's undated Policy and Procedure (P&P) titled, Dating and Labeling, the P&P indicated, To ensure food safety and prevent contamination within the facility, all food items should be properly covered, dated and labeled in dry storage and refrigerator/freezer areas. All food will be dated according to - month, day and year. Staff should be trained in the importance of food labeling and proper storage procedures to maintain food safety.

Based on interview and record review, the facility failed to develop a specific and individualized care plan to meet the residents' needs for two of two sampled residents (Residents 4 and 5) by failing to:a. Ensure a care plan (CP) was developed for Resident 4 on the use of Buspirone (a medication used to treat anxiety).b. Ensure a CP was developed for Resident 5 on the use of Seroquel (an antipsychotic medication helps to stabilize moods and reduce psychotic symptoms) and Lexapro (a medication used to treat depression and anxiety).These failures had the potential for Residents 4 and 5 not to receive necessary care, treatment, and services. Findings: a. During a review of Resident 4's Face Sheet (FS), the FS indicated the facility initially admitted Resident 4 on 5/21/2025 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety disorder (a mental illness characterized by excessive, persistent, and uncontrollable fear or worry). During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool) dated 5/25/2026, the MDS indicated Resident 4 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 4 required setup or clean-up assistance (helper sets up or cleans up, resident completes the activity) with eating, and substantial/maximal assistance (helper did more than half the effort) with shower and upper/lower body dressing. The MDS indicated Resident 4 was dependent (helper did all the effort, resident did none) with oral hygiene, toileting and personal hygiene. During a review of Resident 4's Order Summary Report (OSR) dated 7/9/2026, the OSR indicated Resident 4 had an order for Buspirone 5 milligrams (mg- unit of measurement) by mouth three times a day for anxiety. During a concurrent interview and record review on 7/16/2026 at 11:25 am with Registered Nurse Supervisor 1 (RN 1), Resident 4's medical record (chart) and electronic medical record (EMR) were reviewed. RN 1 stated there was no CP developed to address Resident 4's use of Buspirone. RN 1 stated a CP should be developed based on the residents' diagnoses, assessment, and medication to be able to plan individualized care, treatment, and services for each resident and monitor its effectiveness. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. b. During a review of Resident 5's FS, the FS indicated the facility initially admitted Resident 5 on 10/29/2021 and readmitted on [DATE] with diagnoses including psychosis (severe mental disorder in which contact with external reality is lost), major depressive disorder (persistent feeling of sadness and loss of interest) and bipolar disorder (mental disorder with periods of depression and elevated mood). During a review of Resident 5's OSR dated 6/23/2026, the OSR indicated Resident 5 had an order for Lexapro 5 mg by mouth one time a day for depression manifested by verbalization of sadness. During a review of Resident 5's OSR dated 6/23/2026, the OSR indicated Resident 5 had an order for Seroquel 25 mg by mouth at bedtime for mood disorder manifested by agitation as evidence by restlessness affecting sleep. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had severely impaired cognition. The MDS indicated Resident 5 was dependent on staff for shower and upper/lower body dressing. The MDS indicated Resident 5 required maximum assistance from staff for oral hygiene, toileting hygiene and putting on/taking off footwear. During a concurrent interview and record review on 7/15/2026 at 10:46 am with the facility's Director of Nursing (DON), Resident 5's medical record (PointClickCare - PCC, a cloud-based software) was reviewed. The DON stated there was no CP developed to address Resident 5's use of Lexapro and Seroquel. The DON stated a CP for Lexapro and Seroquel should have been initiated within 24 hours when the medication was ordered for staff to determine interventions on how to provide care and treatment to Resident 5. During a review of the facility's P&P titled, Care Plan, Comprehensive Person-Centered revised March 2022, the P&P indicated the Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. The P&P indicated the comprehensive care plan is developed within 7 days of the completion of the required MDS assessment and no more than 21 days after admission.

Based on observation, interview, and record review, the facility failed to provide required assistance during activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) for one of one sampled resident (Resident 51). This failure placed Resident 51 at risk for accidents/injury during bed mobility.Findings: During a review of Resident 51's Face Sheet (FS), the FS indicated the facility admitted Resident 51 on 8/29/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), Parkinson's disease (a progressive disease marked by tremors, muscular rigidity, and slow, imprecise movements), and Alzheimer's disease ( progressive decline in mental abilities). During a review of Resident 51's Minimum Data Set (MDS, a resident assessment tool) dated 5/20/2026, the MDS indicated Resident 51 had severely impaired cognition (ability to understand and process information) for daily decision making. The MDS indicated Resident 51 was dependent (helper did all the effort, resident did none) with eating, oral hygiene, toileting, shower, upper/lower body dressing and personal hygiene. During a concurrent observation inside Resident 51's room and interview on 7/14/2026 at 9:23 am with Certified Nurse Assistant 3 (CNA 3), CNA 3 was alone cleaning and turning Resident 51 on Resident 51's right side while in bed. CNA 3 stated Resident 51 was totally dependent on staff for all ADLs. CNA 3 stated Resident 51 could not move from side to side and unable to hold position. During an interview on 7/14/2026 at 9:38 am with the facility's Director of Nursing (DON), the DON stated Resident 51 required 2-person assistance with ADLs, bed mobility and transfers. The DON stated dependent residents should be provided with appropriate assistance during ADLs to ensure safety and for residents to receive adequate care. During a review of the facility's Policy and Procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, revised in 2022, the P&P indicated, Residents who were unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview and record review, the facility failed to prevent unnecessary use of psychotropic medication (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility's policies and procedures (P&P) titled Antipsychotic Medication Use and Psychotherapeutic Medications for one of five sampled residents (Resident 5). This deficient practice had the potential to result in significant adverse (harmful) consequences to Resident 5 for the use of Seroquel (medication used to treat mental health condition).Findings: During a review of Resident 5's Face Sheet (FS), the FS indicated the facility initially admitted Resident 5 on 10/29/2021 and readmitted on [DATE] with diagnoses including psychosis (severe mental disorder in which contact with external reality is lost), major depressive disorder (persistent feeling of sadness and loss of interest) and bipolar disorder (mental disorder with periods of depression and elevated mood). During a record review of Resident 5's Order Summary Report (OSR) dated 6/23/2026, the OSR indicated for licensed staff to administer Resident 5 Seroquel 25 milligrams (mg-unit of measurement) by mouth at bedtime for mood disorder manifested by agitation as evidenced by restlessness affecting sleep. The OSR did not indicate an order for staff to monitor Resident 5's hours of sleep to evaluate the effectiveness of Seroquel use. During a review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 6/27/2026, the MDS indicated Resident 5 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 5 was dependent (helper does all of the effort) from staff for shower and upper/lower body dressing. The MDS indicated Resident 5 required maximum assistance (helper does more than half of the effort) from staff for oral hygiene, toileting hygiene and putting on/taking off footwear. During a concurrent interview on 7/15/2026 at 10:37 am with the facility's Director of Nursing (DON) and record review of Resident 5's medical records (PointClickCare - PCC, a cloud-based software), the DON stated Resident 5 was ordered Seroquel for mood disorder manifested by agitation as evidenced by restlessness affecting sleep. The DON stated agitation and restlessness were not specific indications or target behaviors for the use of Seroquel. The DON stated Seroquel needed to be administered for specific symptoms to avoid unnecessary psychotropic medication. The DON stated Resident 5's hours of sleep was not monitored on the use of Seroquel since 6/23/2026. The DON stated it was important to monitor Resident 5's hours of sleep to determine if Seroquel was effective or not. During a review of the facility's P&P titled, Antipsychotic Medication Use, revised 7/2022, the P&P indicated, Antipsychotic medications will not be used if the only symptoms are one or more of the following:a. Wandering;b. Poor self-care;c. Restlessness;d. Impaired memory;e. Mild anxiety;f. Insomnia;g. Inattention or indifference to surroundings;h. Sadness or crying alone that is not related to depression or other psychiatric disorders;i. Fidgeting;j. Nervousness; ork. Uncooperativeness. During a review of the facility's P&P titled, Psychotherapeutic Medications, revised 3/2025, the P&P indicated, Evaluate the resident's response to psychotropic medication therapy (Antianxiety, Antidepressant, hypnotic and antipsychotic) to determine that the medications are appropriate and resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. The licensed nurse will assess the resident to ensure specific behavior is monitored every shift.

Based on observation, interview, and record review, the facility failed to ensure medications were kept secure by failing to lock one of two medication carts (Med Cart) that contained residents' medications, when not attended to and outside the view of the licensed staff.This deficient practice had the potential for residents' medications to be accessible to others not authorized to have access to the medications and increased the risk for loss of safety and security of all medications necessary to meet the health needs of residents. Findings: During a review of Resident 53's Face Sheet (FS), the FS indicated Resident 53 was admitted to the facility on [DATE] with diagnoses including encephalopathy (a condition that affects the structure or function of the brain), urinary tract infection (UTI- infection that affects any part of the urinary tract) and muscle weakness. During a review of Resident 53's History and Physical (H&P) dated 5/13/2026, the H&P indicated Resident 53 had the capacity to make decisions for activities of daily living. During a review of Resident 53's Minimum Data Set (MDS- a resident assessment tool) dated 6/16/2026, the MDS indicated Resident 53 was dependent (helper does all the effort) on staff for oral, toileting and personal hygiene, showers, upper and lower body dressing and putting on/taking off footwear. During a medication pass observation for Resident 53 on 7/16/2026 at 8:37 AM, with Licensed Vocational Nurse 2 (LVN 2), LVN 2 left the Med Cart outside Resident 53's room in the hallway, unlocked and out of view. During an observation and interview outside Resident 53's room in the hallway with the Treatment Nurse (TN) on 7/15/2026 at 8:53 AM, the TN stated the Med Cart should be locked if left unattended in the hallway. The TN stated anyone who passed by could take medications if the Med Cart was left unlocked. During an observation and interview with LVN 2 in the hallway outside Resident 53's room on 7/15/2026 at 8:56 AM, LVN 2 stated LVN 2 did not lock the Med Cart. LVN 2 stated LVN 2 forgot to lock the Med Cart. LVN 2 stated if the Med Cart was unlocked, anyone could open the Med Cart and take medications and could result in harmful consequences. LVN 2 stated it was LVN 2's responsibility to lock the Med Cart for residents' safety. During an interview on 7/16/2025 at 3:28 PM, with the facility's Director of Nursing (DON), the DON stated, the Med Cart should be locked at all times if the Med Cart was outside the view of the licensed nurse. During a review of the facility's Policy and Procedures (P&P's) titled, Security of Medication Cart dated 3/2023, the P&P indicated, The medication cart shall be secured during medication passes. The cart must be locked before the nurse enters the resident's room. During a review of the facility's P&P titled, Administering Medications dated 3/23, the P&P indicated, During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to the residents or other passing by.

Based on observation, interview, and record review, the facility failed to protect the privacy of one of one sampled resident (Resident 53) when Licensed Vocational Nurse 2 (LVN 2) left the computer screen unattended, exposing Resident 53's medication information. This deficient practice violated Resident 53's right to privacy and confidentiality. Findings: During a review of Resident 53's Face Sheet (FS), the FS indicated Resident 53 was admitted to the facility on [DATE] with diagnoses including encephalopathy (a condition that affects the structure or function of the brain), urinary tract infection (UTI- infection that affects any part of the urinary tract) and muscle weakness. During a review of Resident 53's History and Physical (H&P) dated 5/13/2026, the H&P indicated Resident 53 had the capacity to make decisions for activities of daily living. During a review of Resident 53's Minimum Data Set (MDS- a resident assessment tool) dated 6/16/2026, the MDS indicated Resident 53 was dependent (helper does all the effort) on staff for oral, toileting and personal hygiene, showers, upper and lower body dressing and putting on/taking off footwear. During a medication pass observation for Resident 53 on 7/15/2026 at 8:37 AM, with LVN 2, LVN 2 left the computer screen on and unattended with Resident 53's medication information exposed to other residents and staff who passed by. During a concurrent observation of LVN 2 on 7/15/2026 at 8:48 AM, LVN 2 walked away from the medication cart and left the computer screen on while walking in the hallway to ask Certified Nurse Assistant 1 (CNA1) to get Resident 53 from the Activities Room so that LVN 2 could administer Resident 53's medications. During an interview with CNA1 in the hallway outside of Resident 53's room on 7/15/2026 at 8:50 AM, CNA1 stated LVN 2 left the computer on while walking away to the nursing station to wash LVN 2's hands. CNA1 stated the computer should be turned off/locked due to HIPAA (Health Insurance Portability and Accountability Act - a federal law passed in 1996 that sets national standards to protect sensitive patient medical information from being disclosed without consent) laws and to maintain the resident's privacy. During an observation in the hallway and interview outside Resident 53's room with the Treatment Nurse (TN) on 7/15/2026 at 8:53 AM, the TN stated the computer screen should not be left on if it was displaying Resident 53's medication information. The TN stated the computer screen should be minimized or closed if LVN2 was inside Resident 53's room. The TN stated LVN 2 should not walk away from the computer leaving Resident 53's information on the screen for privacy reasons. During an observation and interview with LVN 2 in the hallway outside Resident 53's room on 7/15/2026 at 8:56 AM, LVN 2 stated, LVN 2 forgot to turn off the computer screen. LVN 2 stated it was LVN 2's responsibility to lock or minimize the computer screen when not in use. During an interview on 7/16/2025 at 3:28 PM, with the facility's Director of Nursing (DON), the DON stated the computer screen should be locked or minimized when it was outside the view of the licensed nurses to protect the resident's confidentiality. During a review of the facility's undated Policy and Procedure (P&P) titled, Electronic Protected Health Information Security, the P&P indicated the facility should ensure the security and integrity of medical records of patients at the facility. During a review of the facility's P&P titled, Resident Rights, dated 2/2021, the P&P indicated the unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues.

Based on interview, and record review, the facility failed to develop and implement a care plan (CP - summary of a person's health condition, care needs, treatments, goals of treatment, and specific interventions for each identified condition or care need) for one of four sampled residents (Resident 1) when: 1. Resident 1 did not have a care plan for Resident 1's diagnosis of multiple myeloma (a type of blood cancer). 2. Resident 1 did not have a care plan for Resident 1's diagnosis of osteopenia (bones are weaker than normal). These failures had the potential for Resident 1 to receive inappropriate care and services. During a review of Resident 1's Face Sheet (FS, document that contains a patient's personal and contact information, diagnoses, and medical history), the FS indicated Resident 1 was readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's History and Physical Examination (H&P, physician's clinical evaluation and examination of the resident), dated 10/1/2025, the H&P indicated Resident 1 was able to make decisions for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/21/2026, the MDS indicated Resident 1's cognitive skills (reasoning, learning, and problem-solving) for daily decision making was severely impaired. The MDS indicated Resident 1 was dependent on staff for most ADLs. During a review of Resident 1's physician's assessment (PA) from General Acute Care Hospital (GACH) 1, dated 9/29/2025, the PA indicated Resident 1 was diagnosed with multiple myeloma and osteopenia. During a review of Resident 1's left shoulder X-ray (picture or digital image of the inside of the body), dated 5/17/2026, the X-ray indicated Resident 1 had osteopenia and lytic lesions (areas of bone destruction that occurs due to diseases such as cancer) from metastasis (spread of cancer cells to other parts of the body) or myeloma. During a review of Resident 1's electronic medical record, there was no care plan for Resident 1's diagnosis of myeloma and osteopenia found in the medical record. During an interview on 5/22/2026 at 1:26 p.m. with the Director of Nursing (DON), the DON stated a care plan was an individualized plan of care for a resident that included interventions to help the resident achieve highest care. The DON stated it was important to develop and implement care plans to set a plan of care for residents' health issues. The DON stated if a resident did not have a care plan for all their health issues there was a risk that the resident might not receive the appropriate care and there was no way to follow up on resident's care. The DON stated care plans are developed on admission, quarterly, with any change of condition, and for new orders or a new diagnosis. The DON stated the DON was not aware that Resident 1 had a diagnosis of myeloma and osteopenia and that was the reason why Resident 1 did not have a care plan. The DON stated during readmission to the facility from the GACH, nursing staff (in general) should have noticed the diagnosis of myeloma and osteopenia and created a care plan for Resident 1. The DON stated with a care plan Resident 1 would have a plan of care for Resident 1's symptoms, pain management and fall precautions. The DON stated the facility did not provide the care Resident 1 required for the diagnosis of myeloma and osteopenia because no one knew Resident 1 had cancer. The DON stated Resident 1 should have been referred to see an oncologist and Resident 1 should have received proper medication for pain management. During a review of facility's Policy and Procedure (P&P) titled The Resident Care Plan, undated, the P&P indicated the objective was to provide an individualized nursing care plan and to promote continuity of resident care. The P&P indicated a care plan included identification of medical, nursing, and psychosocial needs. The P&P indicated it was the responsibility of the licensed vocational nurse to ensure the plan of care was initiated and evaluated.

Based on observation, interview, and record review, the facility failed to ensure the nursing staff assisted with cleaning eye discharge around both eyes and underneath the eyes on the resident's face for one of three sampled residents (Resident 2). This deficient practice had the potential to negatively impact Resident 2's dignity and result in the resident not being treated with respect, kindness, and dignity.Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis following cerebral infarction (the blood supply to the brain is blocked or reduced), heart failure (the heart muscle doesn't pump blood as well as it should), muscle weakness, and dry eye syndrome (eyes do not have enough tears or do not make the right type of tears or tears evaporate too fast). During a review of Resident 2's History and Physical (H&P), dated 5/12/2025, the H&P indicated Resident 2 does not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 10/20/2025, the MDS indicated Resident 2 was severely impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 2 was dependent (helper does all of the effort or the assistance of two or more helpers required for the resident to complete the activity) on eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, and personal hygiene. During a review of Resident 2's Care Plan Report (CP), initiated 5/26/2019, the CP indicated Resident 2 had self-care deficit and needed extensive assistance with Activities of Daily Living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and physical function. The CP indicated goal that Resident 2 will be clean, dry, and well-groomed daily. During a concurrent observation and interview on 1/13/2026 at 9:42 AM with Resident 2, Resident 2 had discharge around both eyes and beneath the eyes on the face. Resident 2 stated that Resident 2 had discharge around both eyes and under the eyes and felt uncomfortable with eyes and needed help to clean the eyes. During a concurrent observation and interview on 1/13/2026 at 9:51 AM with the Activities Assistant (AA) in the activities room, Resident 2 had discharge around both eyes and underneath the eyes. The AA stated that the nurse should have cleaned Resident 2's eye discharge on face and ensured Resident 2 was well-groomed prior transferring Resident 2 to the activities room. The AA stated it is important to ensure residents are well-groomed to maintain residents' dignity. During an interview on 1/13/2026 at 12:20 PM with the Certified Nursing Assistant (CNA) 4, CNA 4 stated that it was nurses' responsibility, and that it was important to help residents with good personal hygiene to keep residents' dignity. During an interview on 1/14/2025 at 11:41 AM with the Director of Nursing (DON), the DON stated it is important for nurses to treat residents with respect, kindness, and dignity to keep residents clean and well-groomed, and to ensure residents' dignity. During a review of the facility's Policy and Procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, revised in 2022, the P&P indicated that the facility should provide residents who are unable to carry out activities of daily living independently the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights, revised in 2/2021, the P&P indicated that the facility should guarantee the residents' rights to a dignified existence and to be treated with respect, kindness, and dignity.

Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 3 developed and implemented a person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) for one of three sampled residents (Resident 2) after Resident 2 was observed with skin discoloration on the left upper extremities, the left side of the body, and the right forearm on 12/1/2025. This deficient practice had the potential for Resident 2 to receive inadequate and inappropriate care.Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness in the arm, leg, and face on one side of the body) following cerebral infarction (stroke, damage to brain tissue caused by loss of blood flow to a part of the brain), and current use of anticoagulants (medicines to help prevent blood clots). During a review of Resident 2's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 5/12/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 10/20/2025, the MDS indicated Resident 2 had severely impaired in cognitive skills (ability to make daily decisions) and was dependent on others (helper does all of the effort to complete the activity) for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS also indicated Resident 2 was dependent on others to move around in bed and for transfers. During a review of Resident 2's Change of Condition (COC) form, dated 12/1/2025, the COC indicated Resident 2 had skin discoloration on the left upper arm, the left side of the body, and the right forearm which a certified nursing assistant (unidentified) reported to LVN 3 on 12/1/2025 at 5 AM. During a concurrent interview and record review on 1/13/2026 at 2:08 PM with LVN 2, Resident 2's COC, dated 12/1/2025 and Resident 2's care plans were reviewed. LVN 2 stated there was no care plan regarding Resident 2's skin discoloration on the left upper arm, the left side of the body, and the right forearm which were identified on 12/1/2025. LVN 2 stated LVN 3 should have developed a care plan immediately after LVN 3 noticed Resident 2's skin discolorations and after LVN 3 created the COC. During a concurrent interview and record review on 1/14/2025 at 11:41 AM with the Director of Nursing (DON), Resident 2's COC, dated 12/1/2025 and Resident 2's care plans were reviewed. The DON stated there was no care plan regarding Resident 2's skin discoloration on the left upper arm, the left side of the body, and the right forearm which were identified on 12/1/2025. The DON stated the facility must develop and implement a care plan for Resident 2 to monitor Resident 2's physical and psychosocial condition right after Resident 2 was observed with skin discoloration on the left upper arm, the left side of the body, and the right forearm on 12/1/2025. The DON stated that it was important to develop a care plan to monitor the resident's healing process and to monitor any complications which could arise after noticing the skin discoloration on Resident 2. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated that the facility should develop and implement a comprehensive resident-centered care plan that includes measurable objectives and timetables to meet each resident's physical, psychosocial and functional needs. The P&P indicated, The comprehensive, person-centered care plan reflects currently recognized standards of practice for problem areas and conditions. The P&P indicated, Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition.

Based on observation, interview, and record review, the facility failed to follow proper food storage and sanitation standards by failing to: a. Ensure there were no expired items stored in the refrigerator: one bag of tortillas, four cheese sandwiches, and seven peanut butter and jelly sandwiches. b. Ensure one tray of apple sauce (20 individual serving containers), and one tray of fruit cocktail (26 individual serving containers) were stored with a preparation date label. c. Ensure monitoring and documenting logs for the Dish machine temperature log, Quat Sanitizer log, and the Refrigerator & Freezer temperature logs for June 2025 were completed. These failures had the potential to result in foodborne illness (illness caused by consuming contaminated food or beverages). Findings: a. During a concurrent observation and interview of the initial kitchen tour on 6/24/2025 at 8:47 a.m. with the Dietary Supervisor (DS) while in the walk-in refrigerator, one bag of tortillas in a clear storage bag had a past best buy date of 6/18/2025, four cheese sandwiches had a past best buy date of 6/18/2025, and seven peanut butter and jelly sandwiches had a best buy date of 6/21/2025. DS stated that the refrigerator was checked by the cooks for expired food items and if a resident received expired food, it could make them ill. b. During a concurrent observation and interview of the initial kitchen tour on 6/24/2025 at 8:47 am with the Dietary Supervisor (DS) while in the walk-in refrigerator, one tray of apple sauce (20 individual serving containers) and one tray of fruit cocktail (26 individual serving containers) were stored without a preparation date label. The DS stated the trays should have been labeled when made, otherwise kitchen staff wouldn't know when they were produced for the residents. c. During a concurrent interview and record review 6/24/2025 at 9:09 a.m. with the Dietary Supervisor (DS) the Dish Machine Temperature Log dated June 2025 was reviewed. The Dish Machine Temperature Log indicated there was missing data on 6/20/2025, 6/21/2025 and 6/22/2025. The DS stated the log was completed by the dishwasher and should have been done to ensure the dishes were coming out sanitized for the residents. During a concurrent interview and record review 6/24/2025 at 9:13 a.m. with the Dietary Supervisor (DS) the Quat Sanitizer (quaternary sanitizer-disinfectant used to sanitize surfaces) Log dated June 2025 was reviewed. The Quat Sanitizer Log indicated, missing data on 6/19/2025, 6/21/2025, 6/22/2025, and 6/23/2025. The DS stated the log was his responsibility and should have been completed to ensure the sanitizer was disinfecting the kitchen appropriately. During a concurrent interview and record review 6/24/2025 at 9:13 a.m. with the Dietary Supervisor (DS) the Refrigerator & Freezer Temperature Log dated June 2025 was reviewed. The Refrigerator & Freezer Temperature Log indicated, missing data on 6/21/2025 and 6/22/2025. The DS stated that the cook should have checked the temperatures. The DS stated, the temperature checks needed to be done to confirm food stayed at the proper temperatures to prevent bacteria growth. During a review of the facility's undated policy and procedure (P&P) titled, Refrigerator/Freezer Storage, indicated no food item that is expired or beyond the best buy date are in stock. The P&P indicated, leftover food or unused portions of packaged foods should be covered, dated, and labeled to ensure they will be used first. The P&P indicated, dietary staff will check and record temperatures of all refrigerators and freezers to ensure the equipment is within appropriate temperatures for food storage and handling and record and initial the temperature log at the beginning of the shift. During a review of the facility's undated policy and procedure (P&P) titled, Dish Washing Procedures-Dish Machine, indicated, a temperature and chlorine log will be kept and maintained by the dish washer to ensure that the dish machine is working properly. During a review of the facility's undated policy and procedure (P&P) titled, Sanitizing Equipment and Surfaces, indicated sanitizing solution will be used to sanitize equipment and surfaces after each use or as often as needed. The P&P indicated, sanitizer levels will be checked and recorded at least once per shift to ensure equipment and surfaces are sanitized appropriately and dietary staff are to record PPM (parts per million) at least once per shift.

Based on observation, interview, and record review, the facility failed to implement its policy and procedures (P&P) titled, Physical Restraint, for four of four sampled residents (Residents 29, 57, 7 and 49) by failing to: a. Ensure to obtain an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) before the installation of side rails. b. Ensure appropriate alternative interventions to side rails/bed rails (adjustable metal or rigid plastic bars attached to the bed) were attempted and did not meet the needs of Resident 57 and ensure the side rails/bed rails pads for Resident 57 were free from damage and wear and tear. c. Ensure Resident 7 had padded bedside rails for seizures as ordered by the physician. d. Ensure Resident 49 had padded bedside rails for seizures as ordered by the physician These failures placed Residents 29, 57, 7, and 49 at risk for entrapment (an event in which residents were caught, trapped, or entangled in a tight space around the bed) and injury from the use of side rails. Findings: a.During a review of Resident 29's admission Record (AR), the AR indicated Resident 29 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness on one side of the body) and muscle weakness (lack of muscle strength). During a review of Resident 29's Minimum Data Set (MDS, a resident assessment tool), dated 5/14/2025, the MDS indicated Resident 29 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 29 was dependent (helper did all the effort, resident did none of the effort to complete the activity) with eating, oral hygiene, toileting, shower, upper and lower body dressing and personal hygiene. During a review of Resident 29's Order Summary Report (OSR), dated 6/9/2025, the OSR indicated Resident 29 had an order for bilateral upper half side rails up and locked up when in bed for activities of daily living (ADLs, activities such as bathing, dressing, and toileting a person performs daily) changes, mobility, positioning, and as enabler. During a concurrent observation while inside Resident 29's room and interview on 6/24/2025 at 9:14 a.m. with Certified Nurse Assistant 3 (CNA 3), Resident 29 was lying in bed and on her back with side rails up on both sides of the bed. CNA 3 stated Resident 29 was confused. During a concurrent interview and record review on 6/25/2025 at 1:59 p.m. with Licensed Vocational Nurse 2 (LVN 2), Resident 29's medical record (chart) and electronic medical record (EMR) were reviewed. LVN 2 stated there was no informed consent obtained and signed for the use of bilateral upper half side rails in Resident 29's chart and EMR. LVN 2 stated staff need to obtain an informed consent from Resident 29 or Resident 29's responsible party (RP) to make sure Resident 29 and/or RP understood and educated on the risks and benefits of using side rails/bed rails. During an interview on 6/27/2025 at 10:05 a.m. with the Director of Nursing (DON), the DON stated signed informed consent should be obtained and a copy retained in the chart before the use and installation of side rails/bed rails indicating the risks and benefits were explained and understood. b. During a review of Resident 57's admission Record (AR), the AR indicated Resident 57 was admitted to the facility on [DATE] with diagnoses that included muscle weakness and abnormalities of (a person's manner of walking) and mobility (the ability to move). During a review of Resident 57's Order Summary Report (OSR) dated 12/20/2024, the OSR indicated an order for staff to apply bilateral upper side rails up and lock when in bed for ADL changes, mobility, positioning and as enabler. During a review of Resident 57's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 3/29/2025, the MDS indicated Resident 57 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 57 needed set up or clean-up assistance (helper sets up or cleans up) by staff for showers, upper/lower body dressing and putting on/off footwear. The MDS indicated Resident 57 was independent (resident completes the activity by himself with no assistance from a helper) to roll left and right (ability to roll from lying on back to left and right side and return to lying on back on the bed), sitting to lying, and lying on side of bed. During a concurrent observation and interview on 6/24/2025 at 10:57 a.m., while in Resident 57's room, Resident 57 was sitting up on the side of the bed and the bilateral side rails were observed to be ripped and damaged. The damaged padded bilateral side rails on the bed were up. Resident 57 stated I do not use the rails (referring to side rails). I do not need it. During a concurrent observation and interview on 6/24/2025 at 9:04 a.m. with the Director of Staff and Development (DSD), the DSD stated the padded side rails were ripped and damaged. The DSD stated the pads needed to be replaced to prevent Resident 57 from injury. During a concurrent interview and observation on 6/25/2025 at 11:04 a.m. while inside Resident 57's room, together with the Director of Nursing (DON), Resident 57 stated I want the side rails out. During a concurrent interview and record review on 6/27/2025 at 10:06 a.m.) with the DON, Resident 57's medical records (PointClickCare - PCC, a cloud-based software used in long-term and post-acute care facilities and chart) was reviewed. The DON stated there was no clinical documentation that appropriate alternatives were attempted before bedrail/siderails were used on Resident 57. The DON stated appropriate alternatives needed to be attempted before installation of side rails. The DON stated, padded side rails needed not to be ripped or damaged for the Residents safety and dignity. The DON stated padded side rails needed to be presentable. During a review of the facility's Policy and Procedure (P&P) titled, Homelike Environment, dated 2/2021, the P&P indicated residents are provided with a safe, clean, comfortable and homelike environment. During a review of the facility's Policy and Procedure (P&P) titled, Physical Restraint, revised 3/2022, the P&P indicated siderails are an enabler to assist with repositioning, transfers or safety. The P&P indicated side rail padding is used to protect the resident from potential injuries due to involuntary movements, fragile skins, osteoporosis (a condition that causes bones to become less solid and less dense which gradually makes them weaker and more brittle) /degenerative joint disease (also known as osteoarthritis, type of joint disease that results from breakdown of joint cartilage [connective tissue] and underlying bone), striking out behavior, etc. The P&P indicated if other interventions such as lowering bed using pillows, alarms, wedge cushions, etc. did not work, a physical restraint assessment shall be completed by the licensed nurse with input from the interdisciplinary team (IDT). The P&P indicated, during an observation period, one or many less restrictive measures shall be attempted such as lowering the bed, using pillows alarms, trapeze, verbal cueing, non-skid mat, wedge cushion, etc. the duration of application, residents' response and effectiveness of less these restrictive measures is to be documented. The P&P indicated informed consent is to be obtained from resident or from surrogate decision maker. c. During a review of Resident 7's admission Record (AR), the admission Record indicated Resident 7 was admitted on [DATE] with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and convulsions (involuntary, rapid muscle spasms that cause uncontrollable shaking and limb movements). During a review of Resident 7's History & Physical (H&P), dated 2/25/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment, dated 4/7/2025, the MDS indicated Resident 7 was severely cognitively impaired (ability to think). During a review of Resident 7's Order Summary Report, dated 6/27/2025, the Order Summary indicated Resident 7 had an active order for foam circle padded side rails for safety precautions due to diagnosis of a seizure disorder, ordered on 11/7/2021. The Order Summary also indicated an active order to monitor for seizure activity, ordered on 11/18/2021. During a concurrent observation and interview on 06/24/2025 at 10:56 a.m. with Licensed Vocational Nurse 2 (LVN 2) in Resident 7's room, both of Resident 7's bedside rails lacked any foam padding. LVN 2 stated, he had an order for the foam circle padded rails which were not present on both rails. LVN 2 stated, Resident 7 had a history of seizures and needed the padding for safety to protect his head and prevent any injuries if a seizure occurred. During an interview on 6/27/2025 at 11:10 a.m. with the Director of Nursing (DON), the DON stated, Resident 7 had a convulsion disorder, and it was important to pad the resident's bedside rails to prevent further injury during seizures. During a review of the facility's policy and procedure (P&P) titled, Seizure Management and Prevention, last revised March 2023, indicated, its purpose is to ensure residents with seizure diagnosis will receive proper care. The P&P indicated, to follow physician orders and pad the side rails if the physician orders. d. During a review of Resident 49's admission Record (AR), the admission Record indicated Resident 49 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and seizures. During a review of Resident 49's History & Physical (H&P), dated 10/2/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 49's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment, dated 4/10/2025, the MDS indicated Resident 49 was cognitively intact and had an active diagnosis (in the last seven days) of a seizure disorder or epilepsy. During a review of Resident 49's Care Plan (CP), last revised on 6/23/2025, the CP indicated Resident 49 had a seizure disorder with an intervention for padded side rails if indicated. During a review of Resident 49's Order Summary Report, dated 6/26/2025, the Order Summary indicated Resident 49 had an active order for levetiracetam (a medication used to treat certain types of seizures) oral tablet 1000 milligrams (mg) and was to receive 1.5 tablets by mouth every 12 hours for seizures, ordered on 10/1/2024. The order summary indicated Resident 49 also had an active order for foam circle padded side rails for safety precautions due to a seizure diagnosis, ordered on 10/8/2024. During a concurrent observation and interview on 06/24/2025 at 11:10 am with Licensed Vocational Nurse 2 (LVN 2) while in Resident 49's room, both of Resident 49's bedside rails lacked any foam padding. LVN 2 stated that the bedside rails would be padded by maintenance for the resident's seizures and were needed as a preventative measure for his safety during a seizure. During an interview on 6/27/2025 at 11:07 a.m. with the Director of Nursing (DON), the DON stated, Resident 49 had a history of seizures and one of the interventions used was padded side rails. The DON stated that the bedside rails should have been padded to prevent any injury to the resident from seizures. During a review of the facility's policy and procedure (P&P) titled, Seizure Management and Prevention, last revised March 2023, indicated, its purpose is to ensure residents with seizure diagnosis will receive proper care. The P&P indicated, to follow physician orders and pad the side rails if the physician orders.

Based on observation, interview, and record review, the facility failed to ensure policies and procedures for oxygen administration were implemented for two of two sampled residents (Resident 49 and Resident 46) by failing to: a. Ensure Resident 49's nasal cannula tubing was not touching the floor when in use. b. Ensure Resident 46's nasal cannula tubing was labeled and was receiving oxygen according to physician's order. These failures had the potential to result in contamination of Resident 49's and Resident 46's care equipment, placing the residents at risk for infection and could have caused complications associated with oxygen therapy for Resident 46. Findings: a. During a review of Resident 49's admission Record (AR), the admission Record indicated Resident 49 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and heart failure. During a review of Resident 49's History & Physical (H&P), dated 10/2/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 49's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment, dated 4/10/2025, the MDS indicated Resident 49 was cognitively intact. During a review of Resident 49's Order Summary Report, dated 6/26/2025, the Order Summary indicated Resident 49 had an active order for oxygen to be administered at two liters per minute (L/min) via nasal cannula (may titrate to five L) as needed for shortness of breath or wheezing, ordered on 10/1/2024. During a concurrent observation and interview on 06/24/2025 at 11:14 a.m. with Licensed Vocational Nurse 2 (LVN 2) while in Resident 49's room, Resident 49 was receiving oxygen through a nasal cannula and the oxygen tubing was touching the floor. LVN 2 stated Resident 49 was on continuous oxygen and the oxygen tubing should not be touching the floor because the resident could acquire an infection. During an interview on 6/27/2025 at 11:13 am with the Director of Nursing (DON), the DON stated, Resident 49 received oxygen continuously for COPD and his heart failure. The DON stated oxygen tubing touching the floor while in use was an infection control risk for the residents. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, last revised March 2022, the P&P indicated oxygen tubing should be used in a manner that prevents it from touching the floor. b. During a review of Resident 46's admission Record (AR), the admission Record indicated Resident 46 was admitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 46's History & Physical (H&P), dated 2/25/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 46's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment, dated 5/16/2025, the MDS indicated Resident 46 was rarely or never understood. During a review of Resident 46's Order Summary Report, dated 6/27/2025, the Order Summary indicated Resident 46 had an active order to administer oxygen at two L/min via nasal cannula for shortness of breath -with titration up to five L/min for oxygen saturation less than 91% as needed for shortness of breath, ordered on 3/12/2025. The Order Summary also indicated an active order to monitor Resident 46's oxygen saturation every shift, ordered on 11/13/2024. During a concurrent observation and interview on 6/24/2025 at 10:14 a.m. with Licensed Vocational Nurse 2 (LVN 2) while in Resident 46's room, Resident 46 was receiving oxygen through a nasal cannula that was unlabeled and set at 1.5 L of oxygen. LVN 2 stated, Resident 46's tubing should have been labeled for infection control, stating if it was old, it could accumulate moisture and build bacteria. LVN 2 further stated, the physician's order was for 2 L of oxygen and changed the oxygen concentration. During an interview on 6/27/2025 at 11:14 a.m. with the Director of Nursing (DON), the DON stated, Resident 46 received oxygen as needed. The DON stated that oxygen tubing should be labeled to prevent the risk of infection. The DON stated, oxygen requires a physician's order and if the oxygen is not at the correct setting the nurses are not following the physician's order. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, last revised March 2022, the P&P indicated oxygen tubing should be changed weekly and as needed with a date, time and initials noted on the oxygen equipment when initially used and when changed. The P&P indicated, oxygen should be administered as ordered by the physician.

c. During a review of Resident 24's admission Record (AR), the AR indicated Resident 24 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and osteoarthritis (OA, a progressive disorder of the joints, caused by gradual loss of cartilage). During a review of Resident 24's Minimum Data Set (MDS, a resident assessment tool), dated 5/4/2025, the MDS indicated, Resident 24 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 24 was dependent (helper did all the effort, resident did none of the effort to complete the activity) with eating, oral hygiene, toileting, shower, upper and lower body dressing and personal hygiene. During a concurrent interview and record review on 6/24/2025 at 1:08 p.m. with Medical Records (MR), Resident 24's chart, EMR and AD Acknowledgement form, dated 8/16/2024, were reviewed. MR stated Resident 24's AD Acknowledgement form indicated Resident 24 had executed an AD. MR stated there was no copy of the AD found in Resident 24's chart and/or uploaded in Resident 24's EMR. During an interview on 6/27/2025 at 10:03 p.m. with the Director of Nursing (DON), the DON stated a copy of the AD should be in the chart and/or EMR and accessible to the staff to address and identify the resident's end-of-life wishes and preferences. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, last revised September 2022, the policy and procedure indicated prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The P&P indicated information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff. b. During a review of Resident 57's admission Record (AR), the AR indicated Resident 57 was admitted to the facility on [DATE] with diagnoses that included muscle weakness and abnormalities of (a person's manner of walking) and mobility (the ability to move.) During a review of Resident 57's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 3/29/2025, the MDS indicated Resident 57 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 57 needed set up or clean-up assistance (helper sets up or cleans up) on staff for shower, upper/lower body dressing and putting on/off footwear. During an interview and concurrent record review on 6/24/2025 at 11:07 p.m., with the Licensed Vocational Nurse 1 (LVN 1) of Resident 57's medical records (PointClickCare - PCC, a cloud-based software used in long-term and post-acute care facilities and chart), LVN 1 stated the AD Acknowledgement Form needed to be signed and initialed completely to follow the residents wishes and wants and needed to be discussed with the resident or responsible party upon admission. During an interview on 6/27/2025 at 11:29 a.m., with the facility's Director of Nursing (DON), the DON stated the AD Acknowledgement Form needed to be filled out completely upon admission by Social Services to assess if the resident executed an AD or wanted to execute. The facility's DON stated there was no clinical documentation that Social Services attempted to reach out to the responsible party or Resident 57 to offer information regarding an AD. During a review of the facility's Policy and Procedure (P&P) titled, Advance Directives, dated 9/2022, the P&P indicated the resident has the right to formulate an advance directive including the right to accept or refuse medical or surgical treatment. The P&P indicated advance directives are honored in accordance with state law and facility policy. The P&P indicated prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The P&P indicated the resident, or representative is provided with written information . to formulate an advance directive if he or she chooses to do so. The P&P indicated information about whether or not the resident has executed an advance directive is displayed prominently in the medical record that is retrievable by any staff.Based on interview and record review, the facility failed to ensure policies and procedures (P&P) regarding Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) were implemented for three of three sampled residents (Residents 24, 46 and 57) by failing to: a. Ensure Resident 46's medical record had information about whether or not the resident executed an AD displayed prominently in the medical record. b. Ensure Resident 57 was provided with information regarding an AD and a copy was in the resident's medical record (chart) and/or uploaded to the resident's electronic medical record (EMR). c. Ensure Resident 24's copy of AD was in the resident's chart and/or uploaded in the resident's EMR. These failures had the potential to result in the facility staff to provide medical treatment and services against the will of the residents. Findings: a. During a review of Resident 46's admission Record (AR), the admission Record indicated Resident 46 was admitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 46's History & Physical (H&P), dated 2/25/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 46's Minimum Data Set assessment, dated 5/16/2025, the MDS indicated Resident 46 was rarely or never understood. During a review of Resident 46's Medical Record, there was no record of a Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) or Advance Directive Acknowledgement Form within the chart to indicate if Resident 46 had an Advance Directive. During a review of Resident 46's Progress Notes, dated 6/24/2025 to 6/25/2025, the progress notes indicated nursing staff attempted to call family regarding Resident 46's AD and POLST. During a concurrent interview and record review on 6/26/2025 at 2:56 p.m. with Licensed Vocational Nurse 2 (LVN 2), Resident 46's Advance Healthcare Directive Acknowledgment (ADA) form was reviewed. The ADA Form was not completed and indicated that Resident 46's doctor and family member were contacted on 6/24/2025. LVN 2 stated that the Resident was admitted to the facility on [DATE] and the ADA form should have been completed already. LVN 2 stated, this information was important for nursing to have during an emergency to allow them to know what treatment the resident should have, whether a full code or if they should not attempt to resuscitate. During an interview on 6/27/2025 at 11:21 a.m. with the Director of Nursing (DON), the DON stated the ADA form allowed them to know the resident's wishes and provide the resident with the desired care. The DON stated that the ADA form was completed by Social Services and should have been followed up on, but did not find any documentation of previous follow-up attempts prior to this week. The DON stated Resident 46 was not clinically stable and it was very important to have the ADA and POLST forms completed to allow nursing staff to provide the proper emergency care for her.

Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for two of two sampled residents (Residents 24 and 1). These failures had the potential to result in Residents 24 and 1 to not receive necessary care or receive delayed services. Findings: a. During a review of Resident 24's admission Record (AR), the AR indicated Resident 24 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and osteoarthritis (OA, a progressive disorder of the joints, caused by gradual loss of cartilage). During a review of Resident 24's Minimum Data Set (MDS, a resident assessment tool), dated 5/4/2025, the MDS indicated, Resident 24 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 24 was dependent (helper did all the effort, resident did none of the effort to complete the activity) with eating, oral hygiene, toileting, shower, upper and lower body dressing and personal hygiene. During a review of Resident 24's Care Plan (CP), dated 6/26/2025, the CP indicated Resident 24 was at risk for falls and injury related to generalized weakness, impaired cognition and poor safety awareness and judgement. The CP interventions included keeping the call light within easy reach and encouraging the resident to use the call light to receive assistance. During a concurrent observation while inside Resident 24's room and during an interview on 6/24/2025 at 9:05 a.m. with Certified Nurse Assistant 3 (CNA 3), Resident 24 was lying in bed, on Resident 24's back and the call light was tucked under the pillow. CNA 3 stated Resident 24 was confused and disoriented. CNA 3 stated Resident 24 did not know where Resident 24's call light was. CNA 3 stated the call light should be placed next to Resident 24 and Resident 24 should be aware of the call light's location to use and be able to call for help when needed. During an interview on 6/27/2025 at 10:30 a.m. with the Director of Nursing (DON), the DON stated the call light should be placed where the resident could see it, access it and reach it. The DON further started the call light should be placed on the strong arm and hand of the resident to use and call for help every time assistance was needed. b. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included muscle weakness, lack of coordination and parkinsonism (a progressive disease marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 1's untitled Care Plan (CP) dated 12/7/2023, the CP indicated Resident 1 had scheduled toileting plan to prevent falls related to attempts to go to bathroom secondary to incontinence (involuntary loss of bladder or bowel control) related to dementia ( long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). The CP intervention indicated for the nursing staff have Resident 1's call light within reach. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 6/5/2025, the MDS indicated Resident 1 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 needed set up pr clean-up assistance (helper sets up or cleans up) on staff for shower, upper/lower body dressing and putting on/off footwear. During a review of Resident 1's Fall Risk Assessment (FRA- method of assessing a patient's likelihood of falling) dated 6/13/2025, the FRA indicated Resident 1 was assessed as high risk for falls due to intermittent confusion, history of falls in the last 12 months, unable to stand without assistance and presence of predisposing disease condition. During an observation on 6/24/2025 at 8:58 am, Resident 1 was awake, sitting in bed with the call light hanging on the wall. Resident 1 stated Resident 1 cannot find Resident 1's call light. During an interview on 6/25/2025 at 12:45 pm with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated resident's call light needed to be within reach at all times to call staff for help or assistance. LVN 1 stated Resident 1 was high risk for fall. During an interview on 6/27/2025 at 10:31 am with the facility's Director of Nursing (DON), the DON stated, a residents' call light needed to be within reach at all times and easily accessible for residents to use to call for assistance from staff and to keep residents safe. During a review of the facility's undated Policy and Procedure (P&P) titled, Call Light, the P&P indicated to ensure that the call light was within the resident's reach when in his/her room or when on the toilet.

Based on observation, interview, and record review, the facility failed to ensure Certified Nurse Assistants 1 and 2 (CNA 1 and CNA 2) donned (put on) the required personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) while providing care to one of one sampled resident (Resident 10) who was on Enhanced Barrier Precaution (EBP, an approach for the use of PPE to reduce transmission of multidrug-resistant organisms [MDRO] between residents in skilled nursing facilities). This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for the residents and the staff that could result in a widespread infection in the facility. Findings: During a review of Resident 10's admission Record (AR), the AR indicated Resident 10 was admitted to the facility on [DATE], with diagnoses that included encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for nutritional support) and dysphagia (difficulty swallowing). During a review of Resident 10's Care Plan (CP) titled Enhanced Standard Precaution, initiated on 12/4/2024, the CP indicated Resident 10 was at high risk for infection due to feeding tubes. The CP interventions indicated for staff to provide enhance standard precaution such as gloves, gown and masks. During a review of Resident 10's Order Summary Report (OSR) dated 12/16/2024, the OSR indicated for staff to place Resident 10 on EBP every shift. During a review of Resident 10's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 4/4/2025, the MDS indicated Resident 10 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 10 was dependent (helper does all of the effort) on staff for oral hygiene, toileting, showering/bathing self, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 10's OSR dated 5/8/2025, the OSR indicated for staff to administer Glucerna 1.2 (liquid formula used for G-tube feeding) at 50 cubic centimeters per hour (cc/hr.- unit of measurement) for 20 hours via pump (medical device used to deliver tube feeding) to provide 1,100 cc per 1,320 kilo calories (kcal, unit of energy) per day. During an observation on 6/25/2025 at 8:32 a.m. while inside Resident 10's room, CNA 1 and CNA 2 were cleaning and changing Resident 10. CNA 1 and CNA 2 were only wearing gloves and did not wear a gown while handling Resident 10. During an interview on 6/25/2025 at 8:36 a.m. with CNA 1, CNA 1 stated, I did not wear a gown while doing resident care for Resident 10, it completely slipped my mind. CNA 1 stated, she needed to wear a gown to protect the residents and staff from spreading infection. During an interview on 6/27/2025 at 9:45 a.m. with the Infection Prevention Nurse (IPN, a healthcare professional who specializes in preventing the spread of infections in healthcare settings), the IP stated Resident 10 was placed on EBP and staff needed to wear gloves and gowns while providing care especially for resident's who had a gastrostomy tube (a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications). During an interview on 6/27/2025 at 11:04 a.m. the facility Director of Nursing (DON), the facility DON stated staff needed to wear gowns and gloves when providing care to residents who are on EBP to prevent the spread of infection and to avoid cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect.) During a review of the facility's undated policy and procedure (P&P) titled, Enhanced Barrier Precautions, the P&P indicated, Enhanced Barrier Precautions involve gown and glove use during high contact resident care activities for residents known to be infected or colonized with a MDRO as well as those at increased risk of MDRO acquisition. The P&P indicated to perform hand hygiene, wear gowns and gloves while performing the following tasks associated with residents who require EBP: device care for example . feeding tube and any care activity where close contact with the resident is expected to occur such as bathing, peri-care, assisting with toileting, changing incontinence briefs, transferring, respiratory care.

Based on observation, interview, and record review, the facility failed to provide supervision to a resident who used a plate guard (a dining aid that can help people with limited control, grip, or dexterity eat with one hand and reduce the risk of spills) during meals for one of one sampled resident (Resident 39). This failure had the potential to result in Resident 39's decline in nutritional status and inability to maintain independence during mealtimes. Findings: During a review of Resident 39's admission Record (AR), the AR indicated Resident 39 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included muscle weakness (lack of muscle strength), osteoarthritis (OA, a progressive disorder of the joints, caused by a gradual loss of cartilage) and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 39's Care Plan (CP), dated 8/19/2022, the CP indicated Resident 39 had an alteration in nutritional status. The CP interventions indicated for Resident 39 to have a plate guard and two (2) handled cup to prevent spillage while eating. During a review of Resident 39's Minimum Data Set (MDS, a resident assessment tool), dated 4/30/2025, the MDS indicated Resident 39 had impaired cognition (ability to understand and process information). The MDS indicated Resident 39 required setup or clean-up assistance (helper sets up or cleans up, resident completes the activity) with eating and substantial/maximal assistance (helper did more than half the effort) with oral hygiene, toileting, shower, upper and lower body dressing and personal hygiene. During a concurrent observation while inside the dining room and interview on 6/24/2025 at 12:51 p.m. with Assistant Director of Staff Development (ADSD), Resident 39 was eating lunch by himself using a plate guard. The plate guard opening was in the front and facing Resident 39. There was a moderate amount of food spilled in front of Resident 39's tray and clothes. ADSD stated Resident 39 was right-handed. The ADSD stated the opening of the plate guard should be positioned on Resident 39's dominant hand and arm for the hand to have access on the plate guard, push food on the wall of the plate guard which served as guard when scooping food and keep the food on the plate and off the table and Resident 39's clothes. During an interview on 6/27/2025 at 10:33 a.m. with the Director of Nursing (DON), the DON stated the opening of the plate guard should be positioned on the strong arm/hand of the resident to have access on the plate guard, scoop food better and minimize spilling of food on the tray and clothes to maintain the resident's independence during mealtime. During a review of the facility's undated policy and procedure (P&P) titled, Adaptive Equipment, the P&P indicated, Resident will have the adaptive equipment as indicated to maintain/improve their functional level. A specific Medical/Adaptive Device shall be obtained such as splint, brace, plate guard, sippy cup, Rocker knife, sling, etc. The staff will observe resident tolerance /effectiveness and notify the physician if there are any signs/symptoms of complications. Provide training on the proper use of equipment as needed.

Based on observation, interview, and record review, the facility failed to ensure residents were provided with a communication device in a language that the resident understood for one of one sampled resident (Resident 30). This failure had the potential to affect Resident 30's communication with the staff and had the potential to result in a delay in the provision of care, treatment, and services to the residents. Findings: During a review of Resident 30's admission Record (AR), the AR indicated Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and anxiety (characterized by excessive, persistent worry and fear that can interfere with daily life). During a review of Resident 30's Care Plan (CP), dated 3/22/2023, the CP indicated Resident 30 had a cognitive and communication deficit related to Resident 30 speaks Cantonese. The CP indicated Resident 30 needed translator/communication devices. During a review of Resident 30's Minimum Data Set (MDS, a resident assessment tool), dated 3/24/2025, the MDS indicated Resident 30's preferred language was Cantonese (a form of Chinese spoken mainly in southeastern China) and needed or wanted an interpreter to communicate with a doctor or healthcare staff. The MDS indicated Resident 30 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 30 needed setup or clean-up assistance (helper sets up or cleans up, resident completes the activity) with eating, oral hygiene, upper and lower body dressing and personal hygiene. During a concurrent observation and interview while inside Resident 30's room on 6/24/2025 at 9:16 a.m. with Licensed Vocational Nurse 2 (LVN 2), Resident 30 was lying in bed and on her back. Resident 30 was responding in Chinese language when asked. LVN 2 stated Resident 30 did not have a communication board inside the room. LVN 2 stated Cantonese speaking staff were not always available in the facility. LVN 2 stated all non-English speaking residents should have a communication board to be able to communicate their needs better to the staff. During an interview on 6/27/2025 at 10:01 a.m. with the Director of Nursing (DON), the DON stated staff identified the language spoken by the residents and provide a communication board to be able to communicate and express their needs and staff address the residents' needs appropriately. During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs Related to Communication, revised May 2023, the P&P indicated, The facility will take reasonable steps to ensure that the staff will communicate with residents to accommodate residents with limited English proficiency and disabilities. Provide communication board with written translation as indicated.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 46), Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment related to respiratory treatments - oxygen therapy was accurately documented to reflect the resident's use of oxygen. This failure had the potential to negatively affect Resident 46's plan of care and delivery of necessary care and services. Findings: During a review of Resident 46's admission Record (AR), the admission Record indicated Resident 46 was admitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 46's History & Physical (H&P), dated 2/25/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 46's Minimum Data Set assessment, dated 5/16/2025, the MDS indicated Resident 46 was rarely or never understood and no oxygen therapy was indicated for continuous or intermittent. During a review of Resident 46's Order Summary Report, dated 6/27/2025, the Order Summary indicated Resident 46 had active orders to administer oxygen at two liters per minute via nasal cannula for shortness of breath -with titration up to five liters per minute for oxygen saturation less than 91% as needed for shortness of breath, ordered 3/12/2025 and to monitor oxygen saturation every shift, ordered on 11/13/2024. During an observation on 6/24/2025 at 9:55 a.m. in Resident 46's room, Resident 46 was observed awake in bed receiving oxygen via nasal cannula. During an interview on 6/26/2025 at 10:56 a.m. with Minimum Data Set Coordinator (MDSC), MDSC stated Resident 46 was not on oxygen at the time of assessment and did not see any documentation showing Resident 46 used oxygen during that time and within the seven-day look back period. During an interview on 6/26/2025 at 11:16 a.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 46 used oxygen as needed for shortness of breath, and it was only removed for showers. LVN 2 stated Resident 46 used oxygen every day, consistently ever since a desaturation (a decrease in oxygen) episode that occurred in March 2025. During a review of Resident 46's Weights and Vitals Summary (summary of resident weights and vital signs) for May 2025, the summary indicated oxygen use for Resident 46 every day from 5/2/2025 to 5/31/2025. During a concurrent interview and record review on 6/26/2025 at 3:04 p.m. with MDSC, Resident 46's Weights and Vitals Summary showed Resident 46 utilized oxygen via nasal cannula every day during the assessment period. MDSC stated that the oxygen saturations showed she used oxygen via nasal cannula, and he failed to review the oxygen saturation summary data. The MDSC stated, the MDS was used to provide better care for the residents and when submitted to The Centers for Medicare and Medicaid Services (CMS) should be coded as accurately as possible. During an interview on 6/27/2025 at 10:10 a.m. with Certified Nurse Assistant 5 (CNA 5), CNA 5 stated Resident 46 was always on oxygen when seen by her and did not utilize it during shower time. During an interview on 6/27/2025 at 11:26 a.m. with the Director of Nursing (DON), the DON stated, Resident 46 received oxygen as needed. The DON stated residents need to be assessed properly and when data is submitted to CMS it should be coded accurately and properly. During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, last revised March 2022, the P&P indicated anyone who completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information.

Based on observation, interview, and record review, the facility failed to provide privacy for one of one sampled resident (Resident 10) when staff did not close the privacy curtain while changing Resident 10's clothes. This deficient practice violated Resident 10's right to bodily privacy and resulted in unnecessary exposure of Resident 10's upper chest area. This deficient practice had the potential to affect Resident 10's psychosocial (mental and emotional) well-being, self-esteem, and self-worth. Findings: During a review of Resident 10's admission Record (AR), the AR indicated Resident 10 was admitted to the facility on [DATE], with diagnoses that included encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for nutritional support) and dysphagia (difficulty swallowing). During a review of Resident 10's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 4/4/2025, the MDS indicated Resident 10 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 10 was dependent (helper does all of the effort) on staff for oral hygiene, toileting, showering/bathing self, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 10's Order Summary Report (O) dated 5/8/2025, the OSR indicated for staff to administer Glucerna 1.2 (liquid formula used for G-tube feeding) at 50 cubic centimeters per hour (cc/hr.- unit of measurement) for 20 hours via pump (medical device used to deliver tube feeding) to provide 1,100 cc per 1,320 kilo calories (kcal, unit of energy) per day. During a review of Resident 10's Care Plan (CP) initiated on 4/22/2022, the CP indicated Resident 10 required assistance with activities of daily living (ADL) as needed. The CP interventions indicated for staff to maintain Resident 10's privacy and respect Resident 10's rights. During a concurrent observation and interview on 6/24/2025 at 8:45 a.m. with the Certified Nurse Assistant 4 (CNA 4, while in Resident 10's room, Resident 10 was awake, sitting in shower chair with upper chest exposing to roommate and possible the hallway. The CNA 3 stated, privacy curtain needed to be closed while doing ADLs to provide resident privacy. During an interview on 6/24/2025 at 8:47 a.m. with the Director of Staff and Development (DSD), the DSD stated the privacy curtain was not closed while the CNA was proving care to Resident 10 and exposing Resident 10's upper chest area. The DS stated staff needed to pull the curtain close to provide privacy while giving care and treatment to residents. During an interview on 6/27/2025 at 10:27 a.m. with the Director of Nursing (DON), the DON stated Resident 10's privacy curtain needed to be closed during care and ADL's to maintain Resident 10's dignity and privacy and not exposing residents body parts. During a review of the facility's policy and procedure (P&P) titled, Dignity, revised 2/2021, the P&P indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated staff would promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observation, interview, and record review, the facility failed to provide supervision and a functioning sensor pad alarm (an assistive electronic device that makes a loud sound to warn caregivers when the resident tries to get up from the bed or the wheelchair) to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of three sampled residents (Resident 1) who was assessed at high risk for falls, by failing to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) and Certified Nursing Assistant 1 (CNA 1) monitored the working condition of Resident 1's sensor pad alarm on 1/22/2023 while Resident 1 was sitting on the wheelchair per the facility's policy on Personal Alarm, and Resident 1's nursing intervention in the Care Plan for Fall. 2. Ensure CNA 1 kept Resident 1 within her visual field (area of space that you can see) on 1/22/2023 per Resident 1's nursing intervention in Resident 1's Care Plan for Fall. As a result, on 1/22/2023, at 1:55 pm, Resident 1 got up from the wheelchair unnoticed by staff, fell from the wheelchair and sustained a fracture (broken bone) on the left hip. Resident 1 required transfer to a General Acute Care Hospital (GACH) via emergency services where Resident 1 had a surgery on 1/23/2023 to repair a left hip fracture. Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 11/1/2016 and readmitted the resident on 9/12/2022, with diagnoses that included dementia (loss of memory and other mental abilities severe enough to interfere with daily life), and hypertension (the force of blood flowing through the blood vessels, is consistently too high). A review of Resident 1's Care Plan for Fall, dated 10/5/21, indicated Resident 1 required the use of a sensor pad alarm when Resident 1 was sitting in a wheelchair and in bed to alert staff (unidentified) of unassisted (not helped by anyone) transfer (moves between surfaces including to or from bed, chair, wheelchair) to prevent a fall incident. The nursing interventions included to use a sensor pad alarm, keep Resident 1 within visual field, monitor the alarm for good working condition, proper placement, and to respond promptly (unidentified time) to Resident 1 once the alarm activated. A review of Resident 1's Fall Risk Assessments, dated 9/12/2022 and 12/15/2022, indicated Resident 1 was at high risk for fall due to Resident 1 had history of fall in the last twelve months, unsteady gait, poor sitting or standing balance, and unable to stand without assistance. A review of Resident 1's Physician Orders, dated 10/13/2022, timed 10:05 am, indicated to apply a pad alarm when Resident 1 was on a wheelchair and in bed to alert staff of unassisted transfers. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/15/2022, indicated Resident 1 had severely (very seriously) impaired cognition (ability to think and reason). The MDS indicated Resident 1 required extensive assistance (staff provide weight bearing support) in transfer, and with locomotion on unit (how the resident moves between locations in his/her room and adjacent corridor on the same floor) with one-person physical assist. A review of Resident 1's Change of Condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) Assessment notes, dated 1/22/2023, at 1:55 pm, indicated a Certified Nursing Assistant (unidentified) reported Resident 1 fell out of the wheelchair onto the floor in the hallway. The notes indicated Resident 1 cried out in pain (unidentified pain level) of the left hip. The notes indicated LVN 2 notified Resident 1's physician (Doctor of Medicine, MD 1) of Resident 1's fall incident. The notes indicated MD 1 ordered a STAT (immediately) x-ray (a test that produces images of the structures inside the body such as the bones) of the left femur (thigh bone) and left hip. A review of Resident 1's Radiology Results Report (official record of medical images that contains the interpretations and images), dated 1/22/2023, timed 8:15 pm, indicated Resident 1 had left femoral intertrochanteric fracture (broken thigh bone). A review of Resident 1's Licensed Nurse Progress Notes, dated 1/22/2023, timed 9:28 pm, indicated the facility transferred Resident 1 via 911, (paramedic transport) to a GACH due to left femur fracture and pain (unidentified level). A review of Resident 1's Orthopedic Operative Report from GACH, dated 1/23/2023, indicated Resident 1 sustained a ground level fall (begins when a person has his or her feet on the ground) and was found to have an intertrochanteric left hip fracture. The report indicated Resident 1's operative limb (leg) was slightly abducted (away from the midline) and internally rotated (rotation towards the center of the body) and had longitudinal traction (leg by contact between the skin and adhesive tape, to maintain the proper alignment of a leg fracture) placed to achieve a satisfactory reduction (surgery of the bone). The report indicated Resident 1 underwent a general endotracheal anesthesia (introduction of a gaseous mixture to keep the resident from fell ing pain through a tube inserted into the trachea [windpipe]) for intramedullary nailing (a metal rod is inserted into the innermost part of the bone) of left intertrochanteric hip fracture operation on 1/23/2023. During an observation and interview on 2/3/2023 at 2:35 pm, Resident 1 was awake and had difficulty standing up. Resident 1 stated she did not remember how she sustained a fractured left hip. During an interview on 2/3/2023 at 3:32 pm and a concurrent review of the facility's Investigation of Incident/Accident, dated 1/26/2023, the Director of Nursing (DON) stated she conducted the investigation of Resident 1's fall incident on 1/22/2023. The DON stated CNA 1 reported Resident 1 had a sensor pad alarm in the wheelchair, but the sensor pad alarm did not go off when Resident 1 stood up then fell on the floor in the hallway. The DON stated there was no documented evidence that facility's nursing staff (in general) monitored and checked Resident 1's sensor pad alarm for proper functioning every day and on 1/22/2023. During an interview on 2/3/2023 at 3:40 pm, LVN 1 stated on 1/22/2023, at 1:55 pm, CNA 1 reported to her that Resident 1 fell out of the wheelchair in the hallway. LVN 1 stated CNA 1 informed LVN 1 Resident 1's sensor pad alarm did not go off when Resident 1 attempted to stand up unassisted from the wheelchair. LVN 1 stated CNA 1 told LVN 1 that her (CNA 1's) back was turned away from Resident 1 since she was monitoring other residents (unidentified). LVN 1 stated she did not check Resident 1's sensor pad alarm for proper functioning on 1/22/2023. During a telephone interview on 2/3/2023 at 4:25 pm, CNA 1 stated on 1/22/2023 from 1:45 pm through 2 pm, she was assigned to monitor ten residents (unidentified) including Resident 1. CNA 1 stated Resident 1 was sitting in the wheelchair in the hallway. CNA 1 stated after she checked Resident 1's sitting position, she turned her back and walked away from Resident 1 to check other residents (unidentified). CNA 1 stated while she was walking towards another resident (unidentified) who was sitting in the wheelchair across the nursing station, five feet away from Resident 1, she heard a loud yelling and groaning sound of pain. CNA 1 stated when she turned around, she saw Resident 1 was already down on the floor. CNA 1 stated she was not aware Resident 1 had attempted to stand up from the wheelchair because Resident 1's sensor pad alarm did not go off. CNA 1 stated she did not check Resident 1's sensor pad alarm for proper functioning on 1/22/2023. CNA 1 stated, I should be looking at the residents the whole time to prevent a fall from the wheelchair. A review of the facility's undated policy and procedure titled, Personal Alarm, indicated nursing staff will monitor proper functioning and positioning of personal alarm and check the alarm system every day for proper functioning. The policy indicated the facility would use a sensor pad alarm that would sound an audible alarm when the sensor detects a resident was rising out of the bed or wheelchair reminding the resident to return to a safe position while alerting staff to a potential fall.

Based on observation, interview and record review, the facility failed to provide a safe and sanitary living environment to prevent the spread of Coronavirus (COVID-19, a respiratory illness that can spread through respiratory droplet from an infected person a non-infected to person) for 24 of 36 residents as indicated in the facility's infection control policies and COVID-19 mitigation plan (plan to reduce loss of life and limit the impact of COVID-19 in the facility) during the COVID-19 pandemic (spread of a disease worldwide) by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) donned (worn) proper Personal Protective Equipment (PPE, gowns, gloves, N95 masks, and face shields worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) while providing incontinent care to Resident 5 in the Yellow Zone (area for residents who have been in close contact with known cases of COVID-19, newly admitted or readmitted residents, residents who have symptoms of possible COVID-19 pending test results and for residents with indeterminate tests). 2. Ensure Restorative Nursing Assistant 1 (RNA 1) and Housekeeper 1 (HK 1) were designated for the Red Zone and followed Infection Control Protocol by working in the Yellow Zone first and then the Red Zone at the end of the shift. 3. Ensure CNA 2 and CNA 3 donned proper PPE while feeding Resident 1 and Resident 2 in the Yellow Zone. 4. Ensure CNA 2 performed hand hygiene between residents in the Yellow Zone. 5. Ensure CNA 4 & CNA 5 completed self-screening (assessing yourself for COVID symptoms) prior to beginning of the shift. These deficient practices had the potential to result in the spread of COVID-19 to Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 25 and staff. The deficient practices also placed staff and residents at risk for COVID-19 infection that could lead to severe respiratory illness, hospitalization and/or death. On January 28, 2022 at 6:25 p.m., the facility's Administrator was notified of the Immediate Jeopardy (IJ, a situation in which a facility's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death to a resident). The IJ was identified due to the facility's staff failure to implement infection control practices according to local Public Health Guidelines, the facility's policies, and facility's MP for COVID-19 to prevent the spread of a contagious disease caused by a severe acute respiratory syndrome Coronavirus. On January 30, 2022 at 6:30 p.m., the Immediate Jeopardy was lifted after an acceptable Plan of Action (POA) was submitted to the Department. The following corrective plans were developed and implemented by the facility: 1. The RN/IPN notified RNA 1 and the HK1 of the findings and gave in services regarding COVID-19 policy. During the in-services, the IP emphasized the importance of these considerations in cohort areas. Staff assigned to the Red Zone should not care for residents in other cohorts if possible. If staff must care for residents in multiple cohorts, they should visit the Red Zone last. 2. The RN/IPN notified the staff of the findings and gave in services regarding COVID-19 policy. During the in services, the IP demonstrated hand hygiene and proper use of PPE during patient care, especially during mealtimes in Yellow Zone and Red Zone with return demonstration. 3. The RN/IPN notified the staff of the findings and gave an in service regarding COVID-19 policy. During the in service, the RN explained the importance of temperature check before the start and at the end of each shift. 4. The administrator and the DON have checked the staff assignments for the next 10 days to ensure that staff assigned to Red Zone are not assigned to other cohorts. The following measures to Prevent Recurrence were developed by the facility: The DON and the IPN notified the staff of the findings stated in the IJ template and gave in services regarding COVID-19 policy. During the in services, the DON and the IP have educated the staff: 1. Staff assigned to the Red Zone should not care for residents in other cohorts if possible. If staff must care for residents in multiple cohorts, they should visit the Red Zone last. 2. Perform hand hygiene in between caring for residents 3. Proper donning/doffing of PPE during patient care, especially while assisting resident to eat 4. Complete COVID-19 screening prior to the start of shifts and conduct temperature check before and after each shift. All screening information including actual temperature checks will be documented on the daily employee screening log. Findings: During a concurrent interview and observation on 1/29/2022, the Registered Nurse Supervisor stated there were 36 residents in the Yellow Zone and 20 residents in the Red Zone. There was a plastic barrier in (clear barrier that is widely used to stop the spread of COVID) between the Red Zone and Yellow Zone. 1. During a concurrent observation and interview on 1/29/2022 at 1:31 pm in the Yellow Zone, CNA 1 was inside room [ROOM NUMBER]A (Resident 5's room in the Yellow Zone), she was wearing an N95 mask, face shield, and gloves. CNA 1 was not wearing an isolation gown. CNA 1 stated she just cleaned the resident and provided peri-care to Resident 5 and stated there was no need to wear an isolation gown because Resident 1 did not have COVID-19. CNA 1 stated room [ROOM NUMBER] is in the Yellow Zone. During an interview and review of CNAs' assignment on 1/29/2022 at 1:35 pm, CNA 1 stated she was assigned to take care Residents 3, 4, 5, 6, 7, 8, 9, 10. The CNAs' assignment indicated CNA 1 was assigned to take care Residents 3, 4, 5, 6, 7, 8, 9, 10. During an interview on 1/29/2022 at 5:40 pm, the Administrator stated facility staff should wear an isolation gown when providing care in the Yellow Zone. A review of the local Guidelines for Preventing & Managing COVID-19 in Skilled Nursing Facilities, updated 1/2/2022, indicated isolation gowns should be used for each resident encounter in the Yellow and Red cohorts for COVID-19 precautions. A review of the facility's Policy titled COVID-19, dated 9/6/2021, indicated Healthcare Personnel should wear full PPE (mask, face shield, gloves and gown) for the care of all residents irrespective of COVID-19 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This policy will be updated based on guideline changes and facility needs. A review of the facility's Mitigation Plan, dated 9/7/2021, indicated If there are COVID-19 cases identified in the facility, health care professionals are provided and are wearing recommended PPE for care of all residents, in line with the most recent CDPH PPE guidance. 2-A. During an observation on 1/29/2022 at 1:34 pm in the Yellow Zone, there was a plastic barrier separating the Red Zone and Yellow Zone with an opening in the middle of the barrier. There was a cart placed in front of the barrier to prevent residents from going through the opening. RNA 1 was inside the Red Zone. During an observation on 1/29/2022 at 1:57 pm through an opening in the barrier between the Yellow Zone and Red Zone, RNA 1 was inside Red Zone. During a concurrent observation and interview on 1/29/2022 at 2:28 pm, RNA 1 was in the Yellow Zone. RNA 1 stated he assisted 2 residents in the Yellow Zone (Residents 6 and 18) and Resident 26 who was in the Red Zone. During an interview on 1/29/2022 at 2:40 pm, RNA 1 stated he provided RNA services to 2 residents in the Red Zone in the morning and then came back to the Yellow Zone to assist with lunch. RNA 1 stated he had to go back and forth the Red Zone and Yellow Zone because he had to get isolation gowns that were kept in the two closets in the Red Zone. A review of the Line Listing indicated Resident 26 was positive for COVID-19 from a swab collected on 1/26/2022. A review of the Census dated 1/29/2022, indicated the resident was in a room located in the Red Zone. 2-B. During an observation on 1/29/2022, Housekeeper 1 (HK 1) was observed in the Yellow Zone picking up trash from resident rooms. During an interview on 1/29/2022 at 5:15 pm in the Yellow Zone, Housekeeper 1 stated she went inside the Red Zone in the morning to pick up linens, trash and when staff would call for cleaning in the Red Zone. HK 1 stated there were 2 housekeepers that day and they were both cleaning in the Yellow Zone. On 1/29/2022 at 5:30 pm, during an interview, the Administrator stated the facility discouraged moving in between Red Zone and Yellow Zone but if it is unavoidable for staffing shortage then facility staff might have to enter the Red Zone. The Administrator stated it is best practice to care for residents in the Yellow Zone first then go to the Red Zone last. A review of the local Guidelines for Preventing and Managing COVID-19 in Skilled Nursing Facilities updated 1/2/2022, indicated staff assigned to the Red cohort should not care for residents in other cohorts if possible. If staff must care for residents in multiple cohorts, they should visit the Red Cohort last and should doff PPE and perform hand hygiene prior to moving between cohorts. A review of the facility's COVID-19 Mitigation Plan, dated 9/7/2021, indicated there will be no rotation of staff between floors or wings during the period they are working each day. A review of the facility's Policy, title COVID-19, dated 9/6/2021, indicated one housekeeper will be assigned for the designated area. 3. During an observation on 1/29/2022 at 12:58 pm in the Yellow Zone, CNA 2 was feeding Resident 1. CNA 2 was wearing an N95 mask and face shield without an isolation gown and her scrubs touching Resident 1's bed. During an observation on 1/29/22 at 1:00 pm in the Yellow Zone, CNA 3 was feeding Resident 2. CNA 3 was wearing an N95 mask and face shield, she was not wearing gloves and gown while feeding Resident 2. During a concurrent observation and interview on 1/29/22 at 1:03 pm in the Yellow Zone, Licensed Vocational Nurse 1 (LVN 1) verified that CNA 3 was not wearing gloves and isolation gown while feeding Resident 2. LVN 1 stated facility staff were supposed to don proper PPE when providing care in the Yellow Zone, LVN 1 stated proper PPE would be N95 mask, face shield/goggles, gown, and gloves. During an interview on 1/29/22 at 1:04 pm, CNA 3 stated she would only use an isolation gown when providing direct patient care. During an interview on 1/29/2022 at 1:10 pm, CNA 2 stated she was assigned to Residents 1, 2, 11, 12, 13, 14, and Resident 16. A review of the local Guidelines for Preventing & Managing COVID-19 in Skilled Nursing Facilities, updated 1/2/2022, indicated isolation gowns should be used for each resident encounter in the Yellow and Red cohorts for COVID-19 precautions. A review of the facility's Policy, title COVID-19, dated 9/6/2021, indicated Healthcare Personnel should wear full PPE for the care of all residents irrespective of COVID-19 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This policy will be updated based on guideline changes and facility needs. A review of the facility's Mitigation Plan, dated 9/7/2021, indicated If there are COVID-19 cases identified in the facility, health care professionals are provided and are wearing recommended PPE for care of all residents, in line with the most recent CDPH PPE guidance. 4. During an observation on 1/29/2022 at 12:58 pm in the Yellow Zone, CNA 2 was feeding Resident 1. CNA 2 was wearing an N95 mask and face shield, she was not wearing an isolation gown and her scrubs touching Resident 1's bed. CNA 2 removed her gloves and left the room without performing hand hygiene. CNA 2 then approached Resident 25 who was not eating. CNA 2 took Resident 25's tray and left to open the door towards the kitchen. CNA 2 brought the tray to the kitchen. During an interview on 1/29/2022 at 1:10 pm, CNA 2 stated she washed her hands when she went inside the kitchen, she stated she was supposed to sanitize her hands after feeding Resident 1. A review of the local Guidelines for Preventing & Managing COVID-19 in Skilled Nursing Facilities, updated 1/2/2022, indicated Healthcare Personnel (HCP) and all other staff members should perform hand hygiene before and after all resident encounters. All staff, residents, and visitors should perform hand hygiene frequently including every time they enter and exit the facility, resident rooms, and common areas; before and after eating; after using the restroom etc. A review of the Policy on COVID-19, dated 9/6/2021, indicated the facility is utilizing guidance from CDC and Department of Public Health. 5. A review of the Employee Screening for COVID-19, dated 1/29/2022, indicated CNA 4 was working in the Yellow Zone and CNA 5 was working in the Red Zone on 1/29/22 and they did not complete the self-screening for COVID-19 symptoms. During an interview on 1/29/2022 at 12:26 pm, CNA 4 stated she reported to work late so she just checked her temperature and she did not complete the self-screening process. CNA 4 stated facility staff just screen themselves. During a concurrent review of the Employee Screening Log and interview with the Registered Nurse Supervisor on 1/29/2022 at 11:50 am, she stated it was difficult to be on the floor and screen staff at the same time because it could get very busy. During a concurrent interview and review of CNAs' assignment, on 1/29/2022 at 1:25 pm, CNA 4 stated she was assigned to care for Residents 17, 18, 19, 20, 21, 22. A review of CNA 5's assignment indicated she was assigned to care for residents in the Red Zone. A review of the Staffing Assignment and Screening Log indicated the following: a. CNA 4 was assigned in the Yellow Zone and there was no documentation she was screened for COVID-19. b. CNA 5 was assigned in the Red Zone and there was no documentation she was screened for COVID-19. A review of the local Guidelines for Preventing & Managing COVID-19 in Skilled Nursing Facilities, updated 1/2/2022, indicated all staff should be checked for symptoms and fever at least once per shift, including at the beginning of shifts. The facility should screen all Healthcare Personnel for symptoms of COVID-19 prior to start of shifts. A review of the facility's Policy on COVID-19, dated 9/6/2021, indicated the facility shall conduct daily temperature checks for staff. All staff should be checked twice daily, once prior to coming to work and second at the end of each shift. Staff working double shifts will be checked again prior to reaching their 12th hour of work.

Based on observation, interview, and record review the facility failed to develop and implement an individualized (resident-specific) care plan to manage identified poor nutritional intake and weight loss in one out of three sampled residents (Residents 1). The care plan did not identify resident- specific type of treatment, frequency and duration, measurable objective, and individualized resident goals. This deficient practice led to the inadequate management of care and the decline in Resident 1's nutritional status, leading to a decline in strength, activity, and overall health placing Resident 1 at risk for injury or death. Resident 1's condition deteriorated requiring hospitalization . Findings: A review of Resident 1's Face sheet dated 5/05/20, indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 8/12/20, indicated the resident required extensive assistance with eating. A review of Resident 1's physician's orders [REDACTED]. The orders indicated that based on physician assessment the resident did not have the capacity to understand and actively participate in decision making. The orders indicated Resident 1 was to receive Vitamin C and Vitamin D supplements by mouth daily. A review of Resident 1's Interdisciplinary Team (IDT, a team of health care professions, who work together to establish plans of care for residents) meeting record dated 7/09/20, indicated the meeting was conducted due to Resident 1's weight loss concern. The record indicated Resident 1 had lost 4 pounds (lbs.) in one month. The record indicated food preferences and food substitutes were discussed. The record did not indicate what the food preferences were or what the food substitutions were. A review of Resident 1's care plan for recent weight loss dated 7/10/20, indicated a goal of no unplanned weight loss or gains, the resident will consume 80-100% of planned diet, and adequate nourishment and hydration to optimal level without complications. The care plan goals and interventions did not indicate the planned diet, type of nourishments, and amount of hydration to meet optimal level. The interventions did not indicate Resident 1's specific diet. The care plan indicated to offer substitutes for food refused by Resident 1. The care plan did not indicate Resident 1's food preferences for the facility staff to offer an appropriate food substitute. A review of Resident 1's care plan for risk of weight loss dated 7/29/20, indicated the resident was at risk for weight loss due to poor intake. The care plan indicated interventions which included diet as ordered; the resident-specific diet was not indicated. A review of Resident 1's IDT record notes dated 8/13/20, indicated the meeting was held due to a quality of care concern. The record indicated Resident 1's family concerns about his current weight and plan of care. The IDT record indicated Resident 1 was admitted on [DATE] with a weight of 166 lbs. Resident 1's weight at the time of the IDT meeting was 150 lbs (16 lbs weight loss from admitted ). The IDT record indicated Resident 1 preferred Mexican food and the resident would be offered food substitutions. The IDT record also indicated Resident 1 would be offered salsa and avocado with meals when available. The record indicated Resident 1's family continued to provide the resident with snacks (chips/orange juice). A review of Resident 1's care plan dated 8/19/20, indicated the resident continued to be at risk for weight loss due to poor appetite. The care plan identified interventions which included diet as ordered. The care plan did not indicate the resident-specific diet. Other interventions indicated included following nutrition and hydration standards of care and providing food substitutions. The care plan did not indicate the resident-specific substitutions. The care plan did not have any indication about the resident's family providing snacks. A review of the facility's Menu dated 6/29/20 to 9/6/20, indicated Mexican food was offered for one meal per week in that time frame. A review of the facility's Meal service Alternative choices dated Summer 2020, indicated the alternative meal choices were Deli Meat Sandwich, Chicken Patty on a Bun, and Chicken Caesar Salad (no Mexican food). During an interview on 8/19/20 at 7 am, Resident 1 was observed to be sitting up in bed with his eyes closed. Resident 1's breakfast tray was at his bedside with pureed eggs, oatmeal, milk, juice, and water. 15 % of the breakfast was eaten. Resident 1 stated the food was okay and the nurses helped him eat when he needed it. During an interview on 8/19/20 at 7 am, Certified Nursing Assistant (CNA) 1 stated they usually left resident 1's food tray with him for 30 minutes and if he did not eat, he would be given a sandwich. During an interview on 8/19/20 at 8:20 am, CNA 2 stated Resident 1 used to use a wheelchair but had a change of condition two weeks prior and required feeding assistance. CNA2 stated no outside food is allowed due to COVID 19 pandemic. CNA 2 stated Resident 1's family used to bring Resident 1 home cooked food. A review of Resident 1's Change of condition form dated 8/28/20, indicated an identified situation of poor oral intake, weight loss, weakness, and increase confusion. The form did not indicate the resident's weight or amount of weight loss. The assessment/evaluation section of the form was not completed. A review of Resident 1's Licensed progress notes dated 8/28/20 timed at 8 am, indicated the resident continued to have poor oral intake and a decrease in weight of two pounds, weakness, and an increase in confusion. The progress note indicated Resident 1's physician and family were notified. A review of Resident 1's Licensed progress notes dated 8/28/20 timed 10:15 am, indicated orders were received to transfer the resident to the acute hospital for further evaluation. A review of Resident 1's Licensed progress notes dated 8/28/20 timed 1 pm, indicated Resident 1 was transferred to the acute hospital. During a telephone interview on 10/05/20 at 12:57 pm, the dietary supervisor (DS) stated menus are premade by registered dieticians and sent to the facility. The DS stated special preferences are accommodated and documented in the dietary departments Kardex (index card with handwritten information). The DS stated the Kardex was for dietary staff communication only and was not a part of the resident's medical record. During a concurrent telephone interview and record review on 10/06/20 at 1:50 pm, the director of nursing (DON) stated resident care plans were initiated on admission by the admission nurse and the Minimum Data Set (MDS, a standardized assessment and care planning tool) nurse was in charge of the comprehensive care plan. The DON stated the purpose of the care plan was for consistency of care and a communication tool for staff to know the specific needs of each resident. The DON stated the care plan needed to be resident specific and individualized. The DON stated the IDT meetings should assist in identifying issues with the resident's current plan of care and to revise the care plans when needed. During that same concurrent telephone interview and record review on 10/06/20 at 1:50 pm, the DON reviewed Resident 1's IDT meeting dated 7/09/20. The DON stated the care plan indicated Resident 1's needs for specific food preferences and substitutions. However, the care plan did not indicate resident specific food preferences and susbstitution offered. The DON stated Resident 1's care plan interventions for recent weight loss dated 7/10/20 were not resident specific and was not revised based on the identified issues during the facility's IDT meeting. The DON stated Resident 1's care plan remained generic and not resident specific throughout the resident's continued weight loss. The DON stated that important interventions for Resident 1 had the potential to have been missed, which could have contributed to the resdent's health decline and continued weight loss. A review of Resident 1's acute hospital face sheet dated 8/28/20, indicated the resident was admitted to the hospital with [REDACTED]. A review of Resident 1's hospital discharge summary dated 9/02/20, indicated the resident was treated for [REDACTED]. The discharge summary indicated the resident's swallowing ability was assessed and found to be normal. A review of the facility's policy titled Nutritional assessment and Resident Care Plan Documentation with a revision date of Year 2019, indicated nutritional assessment and resident care plan documentation would be provided for all residents and entered in the medical record. This is performed to integrate nutrition in the resident care plan, to identify residents at risk for poor nutritional status, to facilitate communication. A review of the facility's policy titled The Resident Care plan (undated), indicated that care plans are considered comprehensive in nature, and should be reviewed in its entirety. The policy indicated the objective of the care plan was to provide an individualized nursing care plan and to promote continuity of resident care. The policy indicated supplementary information, e.g., diets, fluids, mobility, hygiene, intake and output, etc., should be included. The policy also indicated that the nursing care plan acts as a communication instrument between nurses and other disciplines. It contains information of importance for all nurses concerning nursing approach and problem solving.

Based on interview and record review, the facility failed to implement, monitor and revise treatment and interventions for one of three sampled residents (Resident 1) who had persistent rashes. The facility failed to: a. Identify the cause of the rashes and accurately assess Resident 1's skin condition. b. Revise Resident 1's treatment orders when no improvement of the rashes were observed. These failures led to Resident 1 developing infected scabs [MEDICAL CONDITION] (a potentially life threatening infection in which the body has a severe, [MEDICAL CONDITION] response to bacteria or other germs) of the skin due to the resident scratching herself and was transferred to a general acute care hospital (GACH) for evaluation and treatment. Upon readmission from the GACH, Resident 1 continued to have the rash and the same treatments were reordered with no marked improvement, with continued scratching and itching, until assessed by a Dermatologist (physician who specializes in skin diseases) six months later. Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (standardized assessment and care planning tool) dated February 21, 2017, indicated Resident 1 was severely cognitively impaired, was sometimes able to understand others and make herself understood, and required extensive assistance with one person physical assistance with dressing, personal hygiene and bathing. A review of Resident 1's admission skin assessment dated [DATE] indicated Resident 1 had skin tears to the right and left arms, and swelling to the second toe due to [MEDICAL CONDITION]. The skin assessment did not indicate that Resident 1 had any rashes. This was verified during a phone interview with the director of nursing (DON) on June 3, 2017 at 2:22 p.m. a. A review of Resident 1's Multidisciplinary Progress Record dated November 28, 2016, indicated Resident 1's physician ordered [MEDICATION NAME] (cream used to treat itching) cream 1% apply daily for 30 days. A review of Resident 1's Non pressure Sore Skin Problem Report indicated the following: 1. On November 28, 2016, indicated Resident 1 had scattered rash to the back, chest, arms and trunk. 2. On December 1, 8, 15, and 22 indicated Resident 1 had scattered body rash and complained of itching on and off, continue with treatment. 3. On December 28, 2016, a new order for scattered body rash. Apply [MEDICATION NAME] (cream to reduce redness, swelling and itching) 0.1 % cream daily for 30 days to scattered body rash. 4. On January 12 and 19, 2016, indicated Resident 1 still had scattered body rash and complains of itching and scratching constantly. 5. On January 26, 2016 and February 2, 2017, indicated Resident 1 still had scattered body rash and itching on and off. A review of Resident 1's Short Term Goals care plans indicated the following: 1. December 28, 2016 Scattered body rash will resolve within 30 days. Approaches included: Treatment done as ordered. Keep affected area clean and dry. Notify physician if condition worsens. 2. January 28, 2017 Scattered body rash will resolve within 30 days. Approaches included: Treatment as ordered. Assess for skin integrity. Notify physician if conditions worsens. A review of Resident 1's Multidisciplinary Progress Record indicated the following: 1. On January 28, 2017, at 9 a.m., Resident 1's body rash was reassessed, treatment in progress but not completely healed. Resident 1's physician ordered to continue with same treatment ([MEDICATION NAME]). 2. On February 6, 2017, Resident 1's physician came in and evaluated the resident. The physician ordered Resident 1 to be transferred to the GACH 1 for a skin evaluation. A review of Resident 1's Multidisciplinary Progress Record dated February 7, 2017 at 10 a.m., indicated a body assessment done prior to transfer to the GACH noticed that Resident 1 had multiple skin rashes from head to toe. Resident noted (sic) scratching on skin, educated pt. to stop scratching. which led to the physician being notified and to the transfer of Resident 1 to the GACH. No documentation was found which indicated Resident 1 had infected scab areas on her body. A review of Resident 1's GACH History and Physical dated February 7, 2017 indicated the following: 1. Resident 1's chief complaint was: Complaint of abdominal wall infected scabs and keeps on scratching skin. 2. Abdomen Comments: Has diffuse [MEDICAL CONDITION] infected. 3. Medical Impression and Plan included: Problem 1: Skin rash Problem 2: Infected skin scabs/[MEDICAL CONDITION] A review of GACH 1 infectious disease physician consultation of Resident 1 indicated the following: 1. Generalized tiny, pinkish rash involving the face, back, abdomen and limbs. 2. Rash suggested with distant possibility of scabies. 3. May try [MEDICATION NAME] lotion, consider skin biopsy. A review of Resident 1's Discharge Summary from the GACH 1 indicated Resident 1 was in GACH 1 from February 7, 2017 to February 15, 2017. Resident 1 was admitted to GACH 1 with general weakness and generalized itchiness. The generalized itchy rash involved the face but not the palms or soles. The resident was noted with abdominal wall infected scabs, where the resident kept scratching. A review of Resident 1's final [DIAGNOSES REDACTED]. 1.[MEDICAL CONDITION] (a potentially life threatening infection in which the body has a severe, [MEDICAL CONDITION] response to bacteria or other germs) 2. Acute kidney failure 3. Alzheimer's dementia 4. Scabies 5. [MEDICAL CONDITION]. There was no documentation that GACH 1 had performed the skin biopsy or treated Resident 1 with [MEDICATION NAME]. b. Resident 1 was readmitted to the SNF on February 15, 2017. A review of Resident 1's History and Physical dated February 17, 2017 indicated Resident 1 was admitted from GACH 1 due to generalized skin rash with [DIAGNOSES REDACTED]. A review of Resident 1's physician's orders [REDACTED]. 1. Administer [MEDICATION NAME] (an [MEDICAL CONDITION] medication, primarily used for the treatment of [REDACTED]. 2. [MEDICATION NAME] 1% cream twice a day and as needed for itching (Same medication that was used on Resident 1 prior to the GACH.). 3. [MEDICATION NAME] (medication used to treat allergies and itching) 50 mg tablet every 8 hours as needed for itching. A review of Resident 1's care plan for Scattered Body Rash dated February 17, 2017, goal will resolve in 14 days. Approaches included: Treatment as ordered. Keep affected area clean and dry. Notify physician if worsens. A review of Resident 1's Change of Condition (COC)/Interact Assessment Form, dated February 26, 2017 at 12:00 a.m., indicated Resident 1 was at the nursing station and did not want to go to bed. Resident 1 complained of itching on her arms and her right forearm was observed to be bleeding. Resident 1 had been scratching her arms and tore the skin off her arm. Resident 1's physician was notified and the resident's arm was cleaned with normal saline, triple antibiotic ointment was applied and the wound covered with gauze. A review of Resident 1's physician's orders [REDACTED].). A review of Resident 1's Multidisciplinary Progress Record dated March 10, 2017, at 9:00 a.m. indicated Resident 1 was assessed with [REDACTED]. Resident 1's physician was notified and a new order was received. A review of Resident 1's physician's orders [REDACTED]. (This was the same treatment Resident 1 had been receiving since February 26, 2017.) A review of Resident 1's Multidisciplinary Progress Record indicated the following: 1. On March 23, 2017, at 1:05 p.m., the facility nursing staff left a message with Resident 1's physician regarding the [MEDICATION NAME] for scattered rash since 2/17/17. 2. On April 8, 2017, at 2:00 p.m. the nurse practitioner of Resident 1's physician examined the resident and had no new orders. 3. On April 10, 2017, at 9:00 a.m., Resident 1's scattered body rash was reassessed and was not responding to the treatments. Resident 1's physician was made aware and ordered to continue [MEDICATION NAME] 0.5% twice a day for another 30 days, and then reevaluate. The physician also ordered a dermatology (physician who specializes in diseases of the skin) consult. A review of Resident 1's Dermatology Consultation dated April 16, 2017, indicated the following: Diagnosis: [REDACTED]. [MEDICAL CONDITION] can have many causes and occurs in many forms. It usually involves an itchy rash on swollen, reddened skin.) unspecified body rash. Treatment: [MEDICATION NAME], Ivermectin (antiparasitic (organism that live off another organism) medication, used to treat scabies) and Contact Isolation (Procedures that reduce the risk of spread of infections through direct or indirect contact.) A review of Dermatologist's Order Sheet dated April 16, 2017, indicated the Dermatologist ordered: 1. [MEDICATION NAME] 0.1% cream (a topical medicine used to treat psoriasis, [MEDICAL CONDITIONS], and other skin conditions) apply to affected area twice a day for four weeks. 2. Ivermectin 9 mg take one dose once a week for four weeks. 3. [MEDICATION NAME] ([MEDICATION NAME]) 5% cream apply from neck down to toes, leave for 12 hours, then rinse. Repeat once a week for four weeks. 4. Contact Isolation. A review of the Treatment Administration Record (TAR) for the month of April 2017, indicated [MEDICATION NAME] was applied and Ivermectin was administered on April 16, 2017. On May 3, 2017 at 2:27 p.m., an interview was conducted with Certified Nursing Assistant 1 (CNA 1). CNA 1 stated Resident 1 was forgetful and sometimes confused, and had rashes on the arms, back of the legs, and on the stomach. Resident 1 would scratch from the itchiness and required redirection in order to stop or else she would cause injury to her skin. In an interview on May 3, 2017 at 2:50 p.m., the licensed vocational nurse (LVN 1) stated Resident 1 was confused. According to LVN 1 she had scattered rashes all over her body. LVN 1 stated Resident 1 would often pick at her skin and would have to be told to stop. On June 3, 2017 at 1:05 p.m., a telephone interview was conducted with the Dermatologist. The Dermatologist stated he examined Resident 1 on April 16, 2017, for the first time. According to the Dermatologist he ordered Resident 1 be placed in contact isolation and treated with [MEDICATION NAME] and Ivermectin. The Dermatologist stated when a resident has persistent rashes and is immunocompromised often it is one of three things: 1. An allergic reaction. 2. [MEDICAL CONDITION] (a group of medical conditions that cause the skin to become inflamed or irritate). 3. Scabies. According to the Dermatologist residents with any of the three conditions are treated aggressively with [MEDICATION NAME]/Ivermectin and if necessary skin biopsy would be performed. During a phone interview on June 22, 2017 at 9:16 a.m., Resident 1's physician stated We always suspected scabies. She had multiple admissions to the acute hospital. She should have been treated for [REDACTED]. During a telephone interview with the DON on June 29, 2017, at 3:10 p.m., the DON stated that Resident 1 did not have any [MEDICATION NAME] treatment until April after the Dermatologist had seen Resident 1.