Every finding on record at Monterey Park Conv Hosp

Based on observation, interview, and record review, the facility failed to prevent physical abuse (willful infliction of injury which includes, but is not limited to, hitting, slapping, punching, biting, and kicking) for two (2) of three sampled residents (Resident 1 and 2) by implementing the facility's Policy and Procedure (P&P) titled, Abuse, Neglect, and Exploitation revised 12/19/2022 and P&P titled, Accidents and Supervision revised on 12/19/2022. This failure has resulted in Resident 2 hitting Resident 1 on the head on 8/12/2026, leaving Resident 2 with head injury, left scalp laceration, and left upper lip laceration while Resident 2 suffered from a right-hand abrasion and potentially put both residents at risk for mental and emotional distress. Findings1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including but not limited to metabolic encephalopathy (ME, occurs when problems with your metabolism cause brain dysfunction), End-stage renal disease (ESRD, irreversible decline in a person's own kidney function), dementia (a progressive state of decline in mental abilities), psychosis (a mental disorder characterized by a disconnection from reality), anxiety disorder (mental health condition marked by persistent excessive worry, fear, or nervousness that interferes with daily life) and repeated falls. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 8/4/2026, the MDS indicated Resident 1 had severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) when eating, oral hygiene, toileting hygiene, upper body dressing, lower body dressing, and putting on/taking off footwear, personal hygiene, sit to lying and sitting on the side of the bed, sit to stand, chair /be-to-chair transfer, toilet transfer, tub/shower transfer and walk 10 feet. During a record review of Resident 1's Care Plan (CP) for psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) - Quetiapine (antipsychotic medication that treats several kinds of mental health conditions including schizophrenia [a serious mental illness that affects how a person thinks, feels, and behaves] and bipolar disorder [a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration]), for dementia and psychosis revised on 8/1/2026 was reviewed. Resident 1's CP interventions were the following:-Monitor for episodes of dementia with psychotic features manifested by sudden outburst of anger tally with hashmarks and record the number of times the behavior was manifested every shift for use of quetiapine medication.- Administer psychotropic medications as ordered by the physician. Monitor for side effects.-Discuss with physicians and family the ongoing need for use of medication. Review behaviors/ interventions and alternate therapies attempted and their effectiveness as per facility protocol.- Educate the Resident/ family/ caregivers about risks, benefits and the side effects and toxic symptoms of Quetiapine.- May see psychiatrist- Monitor common adverse reactions of Psychotropic therapy. During a review of Resident 1's Physical Aggression Report (PAR) , dated 8/12/2026 , the PAR indicated Resident 1 had a Resident-to-Resident altercation with roommate (Resident 2).Resident 1 claims that Resident 2's television was loud, Resident 1 stated I cannot sleep. He (Resident 2) hit me Resident 2 stated Resident 1 went to him because his TV was loud.Resident 2 thought that Resident 1 might hit him, so Resident 2 hit Resident 1 first.Registered Nurse 1 (RNS 1) 15 minutes before the incident, RNS 1 passed by their room. The door was open, no commotion heard inside.Certified Nursing Assistant 1 (CNA 1) CNA 1 was passing trays and heard a sound similar if somebody fell down. CNA 1 went to check inside Resident 1 and 2's room. CNA 1 saw Resident 2 on top of Resident 1. The Residents were located by their door entrance. CNA 1 separated both Resident1 and Resident 2. CNA 1 summoned other staff to notify the Registered Nurse Supervisor 1 (RNS 1). During a review of Resident 1's GACH 1 Records- emergency department (ED, also known as an emergency room [ER], is a specialized hospital facility that provides 24/7 unscheduled acute care for people with serious, sudden illnesses or injuries), ER Note dated 8/12/2026, Resident 1's ER Note indicated Resident 1 chief complaint was head injury. Resident 1 was brought to the ER by Basic Life Support transport ( BLS transport, which is a non-invasive level of ambulance service for medically stable patients who still require professional monitoring and care during a transfer) from the facility for evaluation of laceration to left scalp and left upper lip status post assault at the convalescent home today. Per EMS Emergency Medical Services (EMS, is a system that responds to emergencies in need of highly skilled pre-hospital clinicians) patients are involved in a physical altercation with another resident after an argument on what to watch on the television. Resident 1 had a laceration on his left parietal skull, repaired with one staple. Length was 1 centimeter (cm, unit of measurement) During a review of Resident 1's Change in Condition (COC) , dated 8/12/2026, the COC indicated at around dinner time, when the CNA 1 delivered their dinner trays, Resident 1 and his roommate (Resident 2) were found sitting on the floor and noted Resident 1 had a laceration on left parietal part of the head with slight bleeding, a cut on the left upper inner lip, and skin tear on the left elbow. During a review of Resident 1's Interdisciplinary Care Conference (ICC) , dated 8/12/2026, the ICC indicated Resident altercation. Resident 1 claimed Roommate (Resident 2) hit him. Resident 1 was noted with a cut on the left upper inner lip, left elbow skin tear, and a laceration on the left parietal area with minimal bleeding noted. During a review of Resident 1's Psychiatry Evaluation dated 8/13/2026, the evaluation indicated, the facility requested an urgent psychiatry evaluation because the patient had an argument with another resident and was hit by the other resident yesterday. According to the nurse report, the patient had an argument with his roommate yesterday and was then hit by his roommate. After that, both patients were sent out to the hospital and then readmitted later that night. During an interview on 8/24/2026 at 9:57AM with Resident 1, inside Resident 1's room. Resident 1 stated someone did hurt him before in the facility. Resident 1 could not remember who that person was, but they shared the same room and pointed to the other bed parallel to his bed. Resident 1 stated Resident 2 hit him on his mouth, and he had a cut on his left lip. Resident 1 remembered he bled a little bit from his head and his mouth, but it does not hurt anymore. It was his roommate (Resident 2), Resident 1 stated Resident 2 did not say anything to him when the incident happened. Resident 1 stated he cannot remember the details, but they did end up on the floor. Resident 1's roommate hit him first on his mouth and then Resident 2 hit him on the face, it was near his eyes. Resident 1 held the side of his face. There were no staff in the room, only the two of them. When the staff came in, they were on the floor. Resident 1 went to the hospital and they treated his lips. 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including but not limited to metabolic encephalopathy, end-stage renal disease (ESRD, irreversible decline in a person's own kidney function), dementia, and anxiety disorder (mental health condition marked by persistent excessive worry, fear, or nervousness that interferes with daily life). During a review of Resident 2's MDS dated [DATE] indicated Resident 2 had moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 2 needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) when toileting hygiene, shower / bathe self, upper and lower body dressing, putting on/taking off footwear, and tub/ shower transfer. The MDS also indicated Resident 2 needed partial/ moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs but provides less than half the effort) in eating, oral hygiene, toileting hygiene, personal hygiene, roll left and right, sit to lying and sitting on the side of the bed, sit to stand, chair /be-to-chair transfer, toilet transfer, and walk 10 feet. During a review of Resident 2's GACH 2 Records- emergency department (ED, also known as an emergency room [ER], is a specialized hospital facility that provides 24/7 unscheduled acute care for people with serious, sudden illnesses or injuries), History and Physical (H&P) dated 8/12/2026, The H&P indicated Resident 2 was presented in the ED via emergency medical technician (EMT, is a medical professional that provides emergency medical services and are most commonly found serving on ambulances and in fire departments) from Skilled Nursing Facility for evaluation after getting in to an altercation with his roommate, Resident 2 does have some superficial abrasion to his right hand. During a review of the facility's Summary of Investigation (SOI), dated 8/12/2026, indicated the following:On 8/12/2026 at 5:20 PM, CNA 1 reported hearing a commotion originating from Resident 1 and Resident 2's room. Upon responding, CNA 1 observed both residents on the floor, Resident 1 stated Resident 2 had hit him.Staff intervened and separated the residents, both Resident 1 and Resident 2 were transferred to General Acute Care Hospital (GACH) for further evaluation.The investigation confirmed that a Resident-to-Resident altercation occurred. During an interview on 8/24/2026 at 12:10 PM with Responsible Party 1 (RP 1), RP 1 stated According to Resident 2, Resident 1 keeps on yelling that night. Resident 2 did not understand what Resident 1 was saying. RP 1 stated there was probably a language barrier between the two Residents. RP1 stated Resident 1 got up from his bed and opened the curtain to see what was going on, but when Resident 2 opened his curtain, he caught Resident 1's fist and Resident 1 was about to hit him (Resident 2) so while Resident 2 was holding Resident 1's fist, Resident 2 hit Resident 1 on the face. RP 1 stated Resident 2 hit Resident 1 to defend himself. Resident 2 stated there was no staff in the room during the incident. RP 1 also stated According to Resident 2, Resident was 1 was agitating her family member (Resident 2) RP 1 also stated according to Resident 2, the man (Resident 1) was vicious. Resident 2 told the psychiatrist that he felt threatened by Resident 1. Resident 2 also stated that Resident 1 was bothersome. RP 1 also stated the volume of the television loud because Resident 2 has a hard of hearing. During an interview on 8/24/2026 at 2:52 AM with CNA 1, CNA 1 stated he found Resident 2 on top of Resident 1 on 8/12/2026. According to CNA 1, he was passing tray for dinner then he heard noise like something fell on the floor. I tried to enter Resident 1 and 2's room, but he cannot open the Residents' door. CNA 1 went to use the adjacent restroom from Room A to enter their room. CNA 1 went inside the Residents' room and found Resident 2 was on the top of Resident 1 on the floor near the door entrance. CNA 1 found both Residents yelling at each other. Resident 1 speaks his language and yelling at Resident 2, CNA 1 cannot understand what Resident 1 was saying. Resident 2 was also yelling at Resident 1 and Resident 2 was louder. CNA 1 reported everything to Registered Nurse Supervisor 1 (RNS 1). During a continued interview on 8/24/2026 at 3:01 PM with CNA 1, CNA 1 stated he saw blood on the floor. CNA 1 saw Resident 1 had an open wound on the right side of his head and his lips were bleeding. CNA 1 also stated When he found Resident 2 is on top of Resident1, that was possible physical abuse. During an interview on 8/24/2026 at 3:17 PM with RNS 2, RNS 2 stated the staff heard a thud sound which is similar sound if someone fell on the room. CNA 1 ran inside Resident 1 and 2's room. When they entered the room, Resident 2 was on top of Resident 1 which was at the back of their room door, and they were at the front of the door of their restroom. Both Residents were lying on the floor. If they were found in that position, they were possibly fighting. During an interview on 8/24/2026 at 3:50 PM with CNA 2, CNA 2 stated she heard a sound that was similar, as if something fell on the floor. CNA 1 is trying to go inside Resident 1and 2's room, but they cannot open the Residents' door. CNA 2 went around the adjacent room and when he entered the Residents' room he saw both Resident 1 and 2 lying on the floor. Resident 1 had blood on the left side of his head and his lips were bleeding. Resident 1 said he was bleeding because Resident 2 had hit him. Resident 1 was complaining about Resident 2's television volume being so loud. Resident 1 was walking towards Resident 2's side of the bed. Resident 2 thought Resident 1 would hit him, so Resident 2 hit Resident 1. Resident 1 cannot communicate with Resident 2, because they do not speak the same language. During a continued interview on 8/24/2026 at 4 PM with CNA 2, CNA 2 stated it is possible that both Residents were fighting because Resident 1 is bleeding and Resident 1 stated Resident 2 was hitting me. When Resident hits another Resident, it is considered physical abuse. We heard commotion inside their room. Resident 1 stated he told Resident 2 that his television was too loud. Resident 2 did not understand him. Resident 1 started to walk towards Resident 2's bed. Resident 2 thought Resident 1 was going to hit him. Resident 1 stated he just wanted to tell Resident 2 to lower the volume of his television, because Resident 1 cannot sleep. Resident 1 decided to get up and walked towards Resident 2 to tell him again to lower the volume of his television, but Resident 2 thought Resident 1 was going to hit him, so Resident 2 hit him on the face. During a concurrent interview and record review on 8/24/2026 at 4:13 PM with the Director of Nursing (DON), the DON stated according to CNA 1, Resident 2 was found on top of Resident 1. The incident was considered physical altercation, because both Residents had injuries from the incident. Resident 1 had a cut on his left upper lip, left elbow abrasion, had a small laceration on his left parietal head, that required 1 staple. Resident 2 stated I thought he was trying to hit me, so I hit him. Resident 1 walked towards Resident 2's personal space. Resident 1 stated he was going to Resident 2 to tell him that his television was loud and Resident 1 wanted to sleep. During a concurrent interview and record review on 8/24/2026 at 4:21 PM with the Director of Nursing (DON), Resident 2's Care Plan (CP) for physical aggressive behavior revised on 7/27/2026 was reviewed. Resident 2's CP interventions were the following:-Assure resident that he is in a safe and secure environment with caringprofessionals. Explain that psychosocial adjustment is often facilitated by developing a trusting relationship with another person (i.e., social worker, nurse, CNA, peer) and by verbalizing thoughts, needs and feelings.-Assure the Resident that staff members are available to help, and department heads maintain an open door policy.- Establish a counseling schedule with the residents. Encourage resident to verbalize/share thoughts, anxieties, fears, concerns and general feelings.- May see psychiatrist- May see psychologist- Observe Resident-signs of fear and insecurity during delivery of care. Take steps to calm resident and help resident feel safe, indicated behavior exacerbation.DON stated interventions were incomplete. Resident 2 mistakenly assumed that Resident 1 would hit him, that is his reason why he hit Resident 1. This incident could have been prevented if we had included in the interventions: provide Resident 1 a 1:1 monitoring or closed supervision. We should have done frequent monitoring by the staff every 15 minutes to 30 minutes, and the staff should keep the door open. During an interview on 8/24/2026 at 4:55 PM with RNS 1, RNS 1 stated she made her rounds at 4:40 PM, approximately 15 minutes before dinner which is at 5 PM. During the PM shift RN rounds, both residents were lying on their beds. Resident 2 was watching television, when I passed by their room it was not that loud. But RNS 1 did not go inside the Residents' room. RNS 1 went to the nurse station. According to CNA 1, he saw the residents on the floor. When the CNAs called me and I entered the room, both Residents were already seated on the floor. Resident 2 was in front of restroom and Resident 1 was sitting leaning at the back of their room door. There was blood on Resident 1's mouth. We provided treatment for Resident 1 because he was bleeding. Resident 2 stated Resident 1 was coming towards him and thought that Resident 1 was about to hit him, that was why I hit Resident 1. Resident 1 stated he just wanted to tell Resident 2 to turn down the volume of his television, but Resident 2 misunderstood Resident 1. Residents 1 and 2 do not speak the same language. During a concurrent interview and record review on 8/24/2026 at 5:20 PM with DON, the facility's policy and procedure (P&P) titled, Accidents and Supervision revised on 12/19/2022, The P&P indicated Supervision is an intervention and a means of mitigating accident risk/ The facility will provide adequate supervision to prevent accidents. Adequacy of supervision:Defined by type and frequencyBased on the individual Resident's assessed needs and identified hazards in the Resident environmentDON stated they could have prevented the incident if they had provided adequate supervision, 1:1 monitoring or closed supervision to the residents, and frequent monitoring by the staff every 15 mins to 30 minutes, keep the residents' door open at all times, and they should have done roommate compatibility on the residents. During a review of the facility's P&P titled, Abuse, Neglect, and Exploitation revised 12/19/2022, The P&P indicated,III. Prevention of Abuse, Neglect and ExploitationThe facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves:A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship;B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms;C. Assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment;D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect;E. Ensuring the health and safety of each resident with regard to visitors such as family members or resident representatives, friends, or other individuals subject to the resident's right to deny or withdraw consent at any time and to reasonable clinical and safety restrictions;F. Providing residents, representatives, and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed;G. Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur; andH. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors.VI. Protection of ResidentThe facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:A. Responding immediately to protect the alleged victim and integrity of the investigation;B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed;C. Increased supervision of the alleged victim, and residents;D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator;E. Protection from retaliation;F. Providing emotional support and counseling to the residents during and after the investigation, as needed;G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.

Based on observation, interview, and record review, the facility failed to follow proper food handling procedures and to maintain the food service area in a clean and sanitary manner in accordance with the facility's policy and procedure (P&P) when: The clear container of mashed potatoes was not closed properly.The food blender (Blender 1) pitcher had a lingering vegetable smell, and the top cover was peeling off and with food residue.The classic peanut butter jar had peanut butter smeared on the outside of the jar's red lid.The can opener had dry crusted food residue.A bag containing beef patties, cinnamon rolls, and chocolate chip cookies was torn, exposing its contents and the label on the bag was unreadable.The food grater had dry food residue.Blender 2 with a gray plastic insert paddle was chipped, calcified, and had dried food residue. These deficient practices have the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization. Findings: During a concurrent observation and interview on 06/29/2026 at 7:37 AM in the kitchen with the Dietary [NAME] (DC1), a clear container of mashed potato was not closed sealed off. DC1 stated the clear container of mashed potatoes was not closed properly. During a concurrent observation and interview on 06/29/2026 at 7:38 AM in the kitchen with DC1, Blender 1 has lingering vegetable smell, and the top cover was peeling off and with food residue. DC1 stated Blender 1 pitcher smelled like vegetables from the pureed food. DC1 also stated they used Blender 1 for breakfast, lunch, and dinner. DC1 also stated the top cover of Blender 1 was peeling off and had dry food residue. During a concurrent observation and interview on 06/29/2026 at 7:39 AM in the kitchen with DC1, classic peanut butter jar had peanut butter smeared on the outside of the jar's red lid. DC1 stated the classic peanut butter jar had peanut butter smeared on the outside of the jar's red lid. During a concurrent observation and interview on 06/29/2026 at 7:40 AM in the kitchen with DC1 can opener had dry crusted food residue. DC1 confirmed the can opener had dry, crusted food residue. During a concurrent observation and interview on 06/29/2026 at 7:45 AM to 7:50 AM in the kitchen with DC1, plastic bag containing beef patties, a plastic bag containing cinnamon rolls and chocolate chip cookies in the freezer was torn, exposing the beef patties. DC1 stated the plastic bag containing beef patties, cinnamon rolls and chocolate chip cookies in the freezer were torn, exposing the food items. DC1 stated the label on the plastic bag containing 8 patties in the freezer was not readable whether it is the food item name or the use by date. During a concurrent observation and interview on 06/29/2026 at 8:00 AM in the kitchen with DC1, food grater had dry food residue. DC1 stated confirmed, the food grater inside the kitchen drawer had dry food residue on it. During a concurrent observation and interview on 06/29/2026 at 8:02 AM in the kitchen with DC1, Blender 2 with a gray plastic insert paddle was chipped, calcified, and had dried food residue. DC1 stated Blender 2 gray plastic paddle was chipped, calcified, and had dry food residue. During an interview on 07/01/2026 at 2:14 PM with the Dietary Aide (DA1), DA1 stated all food containers in the kitchen should be labeled and properly closed. DA1 also stated the blenders (Blenders 1 and 2) should not have any smell and should be in good condition, with no peeled off, chipped off part or calcification. DA 1 added the can opener should not have any dry food residue, and food containers should be clean with no food residue to prevent food contamination, which can cause sickness such as diarrhea. During a concurrent interview and record review on 7/1/2026 at 2:41 PM with the Dietary Supervisor (DS), the facility's P&P titled Date Marking for Food Safety, revised on 12/19/2022, was reviewed. DS stated the P&P indicated that the food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. During a concurrent interview and record review on 07/01/2026 at 2:42 PM with the DS, the facility's P&P titled Food Safety and Food Storage, revised on 12/19/2022, was reviewed. DS stated the P&P indicated that food should be stored, prepared, distributed, and served in accordance with professional standards for food service safety. DS also stated the P&P indicated that labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, must be done so it can be used by its use-by date or frozen/discarded, and that foods should be kept covered or in tightly sealed containers. DS stated the P&P indicated all equipment used in the handling of food must be cleaned and sanitized and handled in a manner to prevent contamination. DS further stated the P&P was not followed, and that the P&P was supposed to be followed to prevent food contamination that can possibly cause foodborne illness such as stomachache and diarrhea.

Based on observation, interview, and record review, the facility failed to observe infection control measures for two (2) of 2 sampled residents (Residents 9 and 13), reviewed for bowel and bladder, as indicated on the facility policy by failing to ensure:1. Certified Nursing Assistant 7 (CNA 7) performed hand hygiene (cleaning hands to prevent germs) after doffing (take off) gloves when providing incontinence (incontinent- a person is unable to voluntarily control their bladder or bowels) care for Resident 9 and before repositioning the resident and touching clean bed sheets.2. CNA 8 doff gloves and performed hand hygiene after providing incontinent care to Resident 13 and before repositioning Resident 13 and touching clean bed sheets.These failures had the potential to result in an increased risk for the spread of bacteria, viruses and pathogens (harmful microorganisms) to the residents, visitors and staff.Findings:1. During a review of Resident 9's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted to the facility on [DATE] with the diagnoses that included gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) status, gastro-esophageal reflux disease (a chronic digestive condition where stomach acid repeatedly flows back into the tube connecting your mouth and stomach [esophagus]), interstitial pulmonary disease (a large group of disorders that cause progressive inflammation and scarring of the tissue between the air sacs in the lungs) and dementia (a progressive state of decline in mental abilities). During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 3/30/26, the MDS indicated the resident is severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated, the resident is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated the resident is always incontinent in both bladder and bowel. During a concurrent observation in Resident 9's room and interview on 7/1/2026 at 9:20 AM, CNA 7 was observed providing incontinent care for Resident 9. CNA 7 was observed cleaning feces off Resident 9 and then doff gloves while touching the outside of the dirty gloves. CNA 7 was then observed putting on a new set of gloves without performing hand hygiene. CNA 7 was later observed touching Resident 9's when repositioning the resident and then touching the clean bed sheets. CNA 7 stated she should have performed hand hygiene after doffing gloves and before putting on a new set of gloves. CNA 7 also stated it is for infection control. 2. During a review of Resident 13's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of benign prostatic hyperplasia (enlarged prostate) and encounter for palliative care (relieving physical pain, stress, and other symptoms to improve your overall quality of life). During a review of Resident 13's MDS, dated [DATE], the MDS indicated the resident is severely impaired in cognitive skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with eating, oral hygiene, upper body dressing and personal hygiene but is dependent with toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. During a concurrent observation in Resident 13's room and interview on 7/1/2026 at 11 AM, CNA 8 was observed providing incontinent care for Resident 13. CNA 8 was observed using the same gloves after providing incontinent care for Resident 13 and touching the resident when repositioning and then touching the resident's bed sheets and side rails (safety/assist guards attached to beds). CNA 8 stated she should have changed her gloves and performed hand hygiene after incontinent care and before repositioning for infection control reasons. During an interview on 7/2/2026 at 3:12 PM, the Infection Preventionist Nurse (IP) stated the CNA is supposed to perform hand hygiene after the removal of gloves and before putting on a new set of gloves because that is cross contamination and infection control. IP also stated after incontinence care, the CNA should change gloves and perform hand hygiene for infection control reasons. During an interview on 7/2/2026 at 3 PM, the Director of Nursing (DON) stated the CNAs should change glove and perform hand hygiene after providing incontinent care to a resident. The DON also stated it is to prevent the spread of infection. During a review of the facility's Policy and Procedure (P&P) titled Personal Protective Equipment, revised 12/19/2022, the P&P indicated perform hand hygiene before donning gloves and after removal. The P&P also indicated gloves are not a substitute for hand hygiene. During a review of the facility's P&P titled Hand Washing, revised 12/19/2022, the P&P indicated the staff must wash their hands before and after patient care as well as before application of gloves after removal of gloves.

Based on interview and record review, the facility failed to revise the care plan for risk for fall for (one) 1 of two (2) sampled residents (Resident 41) reviewed for falls after the resident had an actual fall on 6/7/2026. This deficient practice has the potential for Resident 41 to have further falls, which could result in harm and/ or death.Findings:During a review of Resident 41's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of repeated falls, dementia (a progressive state of decline in mental abilities), muscle weakness and difficulty in walking. During a review of Resident 41's Care Plan with focus Risk for falls, date initiated 3/12/2025 and revised 2/24/2026, the care plan did not indicate it was revised after the fall on 6/7/2026. The care plan did not indicate interventions such as frequent visual check were added after 6/8/2026. During a review of Resident 41's Minimum Data Set (MDS - a resident assessment tool), dated 5/13/2026, the MDS indicated the resident is severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts, holds, or supports trunk or limbs and provides more than half the effort) with oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on/ taking off footwear and personal hygiene but is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with shower/bathe self. During a review of Resident 41's Change in Condition (COC - an alteration in an individual's physical, mental, or functional baseline) Evaluation, dated 6/7/2026, the COC indicated Resident 41 had a fall and was crying intermittently. During a review of Resident 41's Progress Notes, dated 6/7/2026 at 6:20AM, the Progress Notes indicated Resident 41 was on the floor and was witnessed by Certified Nursing Assistant (CNA) at 6:10 AM. During a review of Resident 41's Interdisciplinary Team (IDT; a group of healthcare professionals from complementary fields who work in tandem to treat a resident) fall incident care conference, dated 6/8/2026 at 9:33 AM, the IDT care conference indicated Resident 41 had a fall in the resident's room where the resident slide off her bed due to poor safety awareness. The IDT care conference also indicated that the resident is confused and recommend the following but not limited to frequent visual checks, and assist the resident in maintaining her position in bed. During an interview on 7/2/2026 at 8:23 AM, Resident 41's Care Plans, dated 6/7/2026 to 6/19/2026, were reviewed. RN 2 stated whenever there is a COC such as the fall on 6/7/2026, the risk for fall care plan should be revised. RN 2 also stated there is no care plan created nor revised for the resident's fall on 6/7/2026. RN 2 further stated it is important to revise the care plan because of the need to implement new interventions to help prevent further falls for the resident. During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Care Plans, revised 12/19/2022, the P&P indicated all care assessment areas triggered by the MDS will be considered in developing the plan of care and other factors identified by the IDT team, will also be addressed in the plan of care. During a review of the facility's P&P titled, Fall Prevention Program, revised 4/20/2026, the P&P indicated each resident risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care:a. Interventions will be monitored for effectiveness b. The plan of care will be revised as needed.

Based on observation, interview, and record review, the facility failed to provide assistance with toileting and perineal care (gentle cleaning of the genitals which involves washing, rinsing, and drying the perineum to maintain hygiene, prevent infection, and protect skin integrity) for one (1) of two (2) sampled residents (Resident 1) reviewed for Activities of Daily Living (ADL - activities such as bathing, dressing and toileting a person performs daily) in accordance with the facility's policy. This deficient practice had the potential to result in skin breakdown, incontinence-associated dermatitis (IAD, skin irritation and damage caused by long-term contact with urine or stool, which makes the skin red, sore, and weakened, and can lead to infection), urinary tract infection, and affect resident's self-esteem.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of generalized muscle weakness and other signs and symptoms involving the musculoskeletal system (the combined network of bones, muscles, and joints that gives the body its shape and allows it to stand, walk, and perform daily physical tasks). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 3/28/2026, the MDS indicated Resident 1 had a moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 was dependent (helper does all the effort) with toileting hygiene, shower, lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with oral hygiene, and upper body dressing and required partial/moderate assistance (helper does less than half the effort) with eating and personal hygiene. During a review of Resident 1's Care Plan revised on 3/28/26, the Care Plan indicated Resident 1 has Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily) self-care deficit and a proposed plan requiring the resident 1 staff extensive assistance with personal hygiene. During a concurrent observation and interview on 6/29/2026 at 8:59 AM, Resident 1 was observed lying in bed and stated that one of the Certified Nursing Assistants (CNAs) (resident did not know the staff member's name) told her on Thursday night (6/25/2026) not to use the call light and to just pee on her diaper because she has a lot of things to do when Resident 1 attempted to call for assistance to use the restroom. Resident 1 also stated that the same CNA did not clean on the night of 6/29/2026 or the morning of 6/30/2026 before placing a new diaper on her. During an interview on 6/29/2026 at 9 AM, Resident 1's roommate (Resident 48) stated she heard her roommate (Resident 1) on Thursday night close to 12 midnight (MN) pressing the call light multiple times. Resident 48 also stated the CNA told Resident 1 not to use and turn on the call light because she has other things to do and for Resident 1 to wait. Resident 48 stated when the CNA finally removed Resident 1's wet diaper, Resident 1 asked the CNA if she was going to wipe her, but the CNA said no because she was too busy. Resident 48 also stated that close to 10 minutes before 7 AM the next morning, which is Friday 6/30/2026 Resident 1's diaper was changed by the same CNA and Resident 1 asked the CNA again if she was going to clean her, but she did not. During an interview on 7/1/2026 at 9:31 AM, CNA 5 stated Resident 1 required assistance to go to the restroom. CNA 5 also stated the CNA staff should assist residents to go to the restroom to ensure residents do not have an accident themselves and to keep them comfortable. CNA 5 also stated Resident 1's wet diaper should have been changed and cleaned to remove the traces of urine from the resident before putting a clean diaper to prevent the resident from developing rashes and skin breakdown. During an interview on 7/1/2026 at 9:45 AM, the Director of Nursing (DON) stated CNA staff should assist the residents to ensure the residents' needs are met. The DON also stated the CNA staff should have offered to bring Resident 1 to the restroom and not tell the resident to urinate on her diaper to maintain the resident's dignity. The DON further stated Resident 1 had the right to be treated with dignity and respect. During an interview on 7/2/2026 at 10:44 AM, Licensed Vocational Nurse 2 (LVN 2) stated Resident 1 required assistance to use the restroom and the CNA staff should have assisted the resident to use the restroom to prevent the resident from wetting herself in her diaper. LVN 2 also stated Resident 1 had the right to be treated with respect and should not have been told by the CNA to urinate on her diaper because the CNA was busy. During a review of the facility's P&P titled, Activities of Daily Living (ADL), revised 12/19/2022, the P&P indicated that the facility's care and services on activities of daily living included toileting. The P&P also indicated a resident who is unable to carry out ADL will receive the necessary services to maintain good personal hygiene. During a review of the facility's P&P titled, Promoting/Maintaining Resident Dignity, revised 12/19/2022, the P&P indicated that it is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.

Based on observation, interview and record review, the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions to meet the resident's impaired hearing needs for one (1) of 1 sampled residents (Resident 33) reviewed for hearing/vision. This deficient practice has the potential to delay in the necessary care and services for Resident 33's impaired hearing which can result in ineffective communication.Findings:During a review of Resident 33's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of dementia (a progressive state of decline in mental abilities), muscle weakness and abnormality in gait and mobility. During a review of Resident 33's History and Physical (H&P), dated 5/9/2026, the H&P indicated the resident has a history of hard of hearing. During a review of Resident 33's Minimum Data Set (MDS - a resident assessment tool), dated 6/5/2026, the MDS indicated the resident is moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides less than half the effort) with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing and putting on/taking off footwear but required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with eating. The MDS indicated the residents have minimal difficulty in hearing. During a concurrent observation in the resident's room and interview on 6/29/2026 at 9:07 AM, Resident 33 was observed lying in bed. Resident 33 stated he cannot hear the surveyor during a normal conversation. Resident 33 also stated he is hard of hearing and he refuses to use his hearing aid. During an interview on 6/30/2026 at 2:55 PM, Social Service Director (SSD) stated Resident 33 does have difficulty hearing and the resident refuses to use his hearing aid. SSD also stated there is no care plan initiated for Resident 33's impaired hearing. During an interview on 7/1/2026 at 12:46 PM, Resident 33's care plans, dated 5/12/2026 to 6/30/2026, were reviewed. Registered Nurse 2 (RN 2) stated there is no care plan for Resident 33's impaired hearing and there should be one. RN 2 stated Resident 33 needs a care plan to address the resident's impaired hearing and refusal to use the resident's hearing aid, so the resident is able to communicate effectively during care. During an interview on 7/2/2026 at 2:54 PM, the Director of Nursing (DON) stated a resident with impaired hearing would need to be care planned according to the facility's policy. The DON also stated if hearing impairment was triggered in the MDS, then it would need to be care planned. The DON further stated it is important to have a care plan for the resident's hearing impairment including resident's refusal to use the resident's hearing aid so the staff can communicate with the resident effectively. During a review of the facility's Policy and Procedure (P&P) titled Hearing and Vision Services, revised 12/19/2022, the P&P indicated the facility will utilize the comprehensive assessment process for identifying and assessing a resident's hearing ability in order to provide person-centered care which includes care plan development and implementation. During a review of the facility's P&P titled Comprehensive Care, revised 12/19/2022, the P&P indicated to develop and implement a comprehensive person-centered care plan for each resident. The P&P indicated the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial (the intersection between psychological processes [thoughts, emotions, behavior] and the social environment [relationships, cultural norms, community structures]) well-being.

Based on observation, interview, and record review, the facility failed to ensure that the call light device (one of the major communication technologies that link nursing home staff to the needs of residents) was within reach (an arm's length) of one (1) of 1 sampled resident (Resident 78) reviewed for call devices under the environment care area . This failure had the potential to cause a delay in care for Resident 78 and prevent the resident from receiving the necessary care and services, which could lead to illness or serious injury.Findings: During a review of Resident 78 's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis [loss of motor function in one or more muscles] on one side of the body), hemiparesis (weakness on one side of the body), contracture(permanent tightening or shortening of muscles, tendons, skin, or other tissues that causes joints to become stiff and restricts normal movement) of the left shoulder, and type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel) . During a review of Resident 78 's Minimum Data Set (MDS-a resident assessment tool), dated 4/13/2026, the MDS indicated the resident had moderate cognition (ability to think, remember, and reason) with cognitive skills for daily decision making. Resident 78 needed partial moderate assistance (helper does less than half the effort) on eating, dependent (helper does all the effort) on personal hygiene (the ability to maintain personal hygiene), roll left and right (the ability to roll from lying on back to left side and right side and return to lying position). During a review of Resident 78's Care Plan, revised on 4/5/2025, the Care Plan indicated Resident 78 has an alteration in musculoskeletal status (current health, strength, and functional capability of the body's movement system, which includes muscles, bones, joints, ligaments, and tendons) related to left knee contractures, left shoulder internal rotator contracture, and degenerative changes of the thoracic spine (middle part of the backbone). The care plan indicated staff interventions were to anticipate and meet needs, ensure the call light is within reach, and respond promptly to all requests for assistance. During a concurrent observation and interview on 6/29/2026 at 10:03 AM with the Certified Nursing Assistant 4 (CNA4) in Resident 78's room, Resident 78's call light was coiled on the left side of the resident's bed rails (adjustable metal or rigid plastic bars attached to the sides of a medical or home-care bed) and hanging facing towards the floor. CNA 4 stated the call light was on the contracted side of Resident 78, and the resident is not able to reach the call light and use it to call for staff when assistance is needed. During an interview on 1/23/2026 at 5:07 PM with the Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 78's call light should be on the resident's right side, the dominant side of the resident (refer to the side of the body a person naturally uses more often and has better control, strength, or coordination with), where the resident can reach the call light so the resident can use it to call or to ask for help. LVN 1 also stated the call light is for the safety and needs of the residents and the resident might feel helpless if unable to access or use the call light. During a concurrent interview and record review on 7/1/2026 at 10:51 AM with the Registered Nurse 2 (RN 2), the facility's Policy and Procedures (P&P) titled, Call Lights: Accessibility and Timely Response, revised on 12/19/2026, was reviewed. RN 2 stated the policy indicated that the purpose of the policy is to ensure the facility is adequately equipped with call lights. RN 2 also stated, the P&P indicated staff are required to ensure the call light is within reach of the resident and secure as needed. RN 2 stated that the P&P was not followed and the call light should be within the resident's reach at all times for safety.

Based on observation, interview and record review, the facility failed to inform the physician for one (1) of two (2) sampled residents (Resident 71) reviewed for behavior, when Resident 71 had a change of condition (COC - a sudden, clinically important deviation form a resident's baseline in physical, cognitive, behavioral, or functional domains) on 6/29/2026.This deficient practice had the potential to result in a delay in the necessary care and services for Resident 71.Findings:During a review of Resident 71's admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and depression (a serious mood disorder that causes persistent sadness, loss of interest in activities, and a lack of energy). During a review of Resident 71's Minimum Data Set (MDS - a resident assessment tool), dated 6/15/2026, the MDS indicated the resident is moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with eating, oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene but is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with shower/bathe self. The MDS indicated Resident 71 behavior status, care rejection or wandering is worse compared to prior assessment. During an observation on 6/29/2026 at 11:40AM, Surveyor 1 attempted to interview Resident 71. Resident 71 was observed pinching the surveyor on the surveyor's left arm. During a concurrent observation Resident 71's room and interview on 6/29/2026 at 11:47AM, Resident 71 was observed grabbing Activities Director's (AD) left arm. AD stated this is the first time Resident 71 has done this and it is a new behavior of the resident. During a concurrent observation in the facility's dining room and interview on 6/29/2026 at 12:15 PM, Speech Therapist (ST) was observed being pinched by Resident 71, while ST was feeding Resident 71. ST stated a Certified Nursing Assistant (CNA) was feeding Resident 71 initially, but CNA got scared when Resident 71 started grabbing/pinching the CNA, so ST took over to assist Resident 71 with feeding. During an interview on 7/1/2026 at 2 PM, Registered Nurse 2 (RN 2) stated Resident 71 behavior of pinching/grabbing behavior is a new behavior and considered a significant COC. RN 2 also stated the behavior requires a doctor to be notified but the doctor was not notified when it was noted on 6/29/2026. RN 2 further stated Resident 71 behavior can get worse and can affect other residents/staff who are around Resident 71if it was not addressed promptly. During an observation on 7/2/2026 at 1:30 PM, Resident 71 was observed lying in bed. Resident 71 was also observed attempting to grab/pinch the surveyor. During an interview on 7/2/2026 at 2:49 PM, the Director of Nursing (DON) stated Resident 71's pinching/grabbing behavior is a significant COC. The DON also stated a COC form should have been done as well as monitoring the resident's behavior and calling the physician of the new COC. The DON further stated staff need to inform the licensed nurse when there is a COC so the nurses can address it. During a review of the facility's Policy and Procedure (P&P) titled Notification of Changes, revised 12/19/2022, the P&P indicated to ensure the facility promptly consults the resident's physician and the resident representative when there is a change requiring notification. The P&P also indicated significant change in the resident's physical, mental, or psychological (anything relating to the human mind, mental processes, or behavior) condition such as deterioration in health, mental or psychosocial (the intersection between psychological processes [thoughts, emotions, behavior] and the social environment [relationships, cultural norms, community structures]) status.

Based on interview and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 12) reviewed for unnecessary medications (medication prescribed or consumed without a valid clinical indication for an excessive duration, at too high a dose, or when their potential risks outweigh the benefits) had a specific indication for the use of Buspirone (a medication used to treat anxiety disorder [a group of mental health conditions characterized by persistent, excessive, and uncontrollable fear, worry, or dread that interferes with daily life]), in accordance with the facility's Policy and Procedure (P&P) titled, Use of Psychotropic Medications (drugs that affect a person's mind, emotions, or behavior).This deficient practice had the potential to increase Resident 12's risk to experience adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to psychotropic medication (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), possibly leading to impairment or decline in the resident's mental, functional, or psychosocial (the dynamic intersection between psychological processes [internal thoughts, emotions, and behaviors] and the social environment [relationships, cultural norms, and community structures]) status. Findings:During a review of Resident 12's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of anxiety and depression (a common and serious mood disorder that causes persistent feelings of sadness, hopelessness, and a loss of interest in activities). During a review of Resident 12's Physician Orders, dated 6/2/2026, the Physician Order indicated Buspirone Hydrochloride (HCL) Oral Tablet 15 milligrams (mg - unit of measure) to give 1 tablet by mouth two times a day for anxiety as manifested by restlessness/inability to relax. The order did not indicate specific behavior of the resident's restlessness/ inability to relax. During a review of Resident 12's Minimum Data Set (MDS - a resident assessment tool), dated 6/5/2026, the MDS indicated the resident is moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs and provides more than half the effort) with eating, oral hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated, the residents have anxiety and depression. During an interview on 7/2/2026 at 8:31 AM, Registered Nurse 2 (RN 2) stated Resident 12 restlessness would be pacing and asking about appointments. During an interview on 7/2/2026 at 8:46 AM, RN 1 stated Resident 12 restlessness is complaining of pain and inability to sleep. During an interview on 7/2/2026 at 8:51 AM, Licensed Vocational Nurse 1 (LVN 1) stated Resident 12's restlessness would be walking around and asking for pain medication. During an interview on 7/2/2026 at 8:56 AM, Certified Nursing Assistant 2 (CNA 2) stated she does not know Resident 12's signs and symptoms of restlessness. During an interview on 7/2/2026 at 9:48 AM, RN 2 stated on 6/30/2026 Resident 12's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) should have reflected Resident 12's anxiety level but it does not. During an interview on 7/2/2026 at 9:50 AM, Resident 12's Responsible Party 1 (RP 1) stated Resident 12's sign of restlessness is isolating himself. RP also stated, on 6/30/2026, Resident 12 kept texting RP and stating he (Resident 12) was having an anxiety. RP further stated Resident 12 was texting her from 10:30 AM until 7 PM on 6/30/2026. During a concurrent interview on 7/2/2026 at 10:17AM with the Director of Nursing (DON) Resident 12's MAR, dated 6/2026, was reviewed. The Director of Nursing (DON) stated Resident 12's MAR is not accurate because everyone has a different aspect or behavior of what restlessness is. The DON also stated the staff do not have the same idea of what Resident 12's specific behavior or signs and symptoms of restlessness are. The DON further stated Resident 12 should have the correct manifestation of resident's anxiety, and it should have been reflected in the physician's order and the resident's MAR. In addition, the DON stated the indications for Buspirone need to be more specific such as indicated for anxiety as manifested by resident whether it is isolating himself or pacing so the staff can be consistent on how to monitor the resident properly. During a review of the facility's Policy and Procedure (P&P) titled, Use of Psychotropic Medication(s), revised 3/17/2025, the P&P indicated psychotropic medications are to be used only when a practitioner determines that the medication is appropriate to treat the resident's specific, diagnosed, and documented condition. The P&P also indicated adequate indications for use refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition.

Based on observation, interview, and record review, the facility failed to ensure the facility was free from accident hazards when the facility failed to ensure:1. Proper disposal of a used vacutainer needle (a specialized, double-ended medical needle used for multi-sample blood collection) when the vacutainer was observed not fully placed into the sharp's container.This deficient practice had the potential to result in accidental needlestick injuries (accidental skin punctures caused by used needles or sharp medical instruments) and possible exposure to bloodborne pathogens (infectious microorganisms present in human blood that can cause disease in humans).2. The wheelchair of one (1) of five (5) sampled residents (Residents 85) reviewed for accidents was locked while the resident was left seated in it and left unattended in the hallway.This deficient practice placed Resident 85 at risk of injury and serious harm. Findings: 1. During a concurrent observation and interview on 6/29/2026 at 9:45 AM with the Licensed Vocational Nurse 1 (LVN 1) in the hallway, LVN 1 stated that a vacutainer was not fully inserted into the sharps container attached to the Medication Cart ( Medication Cart A, a mobile storage unit used in hospitals, nursing homes, and clinics to securely organize, store, and transport medications and supplies ) located in the hallway in front of Room A. LVN 1 stated that the clear tubing contained blood residue. LVN 1 also stated that staff, residents, and visitors were passing through the hallway. During an interview on 7/2/2026 at 8:13 AM with LVN 1, LVN 1 stated that the vacutainer should have been disposed of properly to prevent accidents and ensure the safety of residents, staff, and visitors. During a concurrent interview and record review of the facility's Policy and Procedures (P&P) on 7/2/2026 at 2:51 PM with Registered Nurse (RN1), the P&P titled Bloodborne Pathogens/Contaminated Sharps Occupational Exposure, revised on 12/19/2022, was reviewed. RN 1 stated that the P&P indicated it is the policy of this facility to outline procedures in the event of occupational exposure to body fluids or contaminated sharps, in accordance with federal, state, and local guidelines as well as the facility's exposure control plan. The P&P also indicated that universal precautions will be observed to prevent contact with blood or other potentially infectious materials. During a concurrent interview and record review of the facility's P&P on 7/2/2026 at 2:55 PM with RN1, the P&P titled, Standard Precautions Infection Control, revised on 12/19/2022, was reviewed. RN1 stated that the P&P indicated for injection and medication safety, licensed staff who administer injection medications must do so in a safe manner to prevent sharps injuries and contamination of medications and injection equipment. Recommended practices include proper disposal of injection equipment in a sharp container. RN1 stated that the vacutainer should have been fully inserted into the sharp container for the safety of the residents, to prevent needlestick injuries that can possibly cause illness. 2. During a review of Resident 85's admission Record, the admission Record indicated Resident 85 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included history of falling, Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 85's Fall Risk Assessment (a nursing tool that uses a scoring system to evaluate resident's risk of fall), dated 2/1/2025, the Fall Risk Assessment indicated Resident 85's was at risk for fall due to intermittent confusion and use of assistive device such as wheelchair. During a review of Resident 85's Minimum Data Set (MDS- a resident assessment tool), dated 5/4/2026, the MDS indicated Resident 85 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 85 normally used wheelchair in the last seven (7) days and was dependent (helper does all the effort) with shower and putting/taking off footwear. The MDS further indicated Resident 85 required substantial/maximal assistance (helper does more than half the effort) with oral, toileting and personal hygiene and lower body dressing and required partial/moderate assistance (helper does less than half the effort) with upper body dressing and required supervision (helper provides cues) with eating. During an observation on 6/29/2026 at 8:04 AM, Resident 85 was observed sitting on the wheelchair, unattended in the hallway. Resident 85's wheelchair was observed unlocked. During an interview on 7/1/2026 at 12:32 PM, Licensed Vocational Nurse 2 (LVN 2) stated Resident 85's wheelchair brakes should be locked on both sides as safety precautions to prevent fall and injury to the resident. LVN 2 also stated Resident 85 was at risk for fall. During an interview on 7/1/2026 at 12:40 PM, the Director of Nursing (DON) stated Resident 85's wheelchair brakes should be on locked position to keep the wheelchair steady and not roll in case Resident 85 stands up, preventing a fall incident. During a review of the facility's P&P titled, Accidents and Supervision, revised 12/19/2022, the P&P indicated the resident environment will remain as free of accident hazards as is possible which included implementing interventions to reduce hazards and risks.

Based on observation, interview, and record review, the facility failed to ensure one (1) of 1 sampled Resident (Resident 9) reviewed for tube feeding (medical device used to provide liquid nourishment, fluids, and medications by bypassing oral intake) received appropriate gastrostomy tube (GT, tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) care by failing to confirm GT placement when Licensed Vocational Nurse 5 (LVN 5) did not check the resident's gastric residual volume (GRV, the amount of fluid that remains in the stomach and can be withdrawn through a feeding tube before giving additional feedings or medications. It helps determine how well the stomach is emptying and whether the resident is tolerating tube feedings) prior to medication administration on 7/1/2026. This deficient practice placed Resident 9 at risk of aspiration (feeding could enter the windpipe and lungs) that could lead to lung problems such as pneumonia (an infection/inflammation of the lungs).Findings: During a review of Resident 9's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted to the facility on [DATE] with the following but not limited to diagnoses of gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) status, gastro-esophageal reflux disease (a chronic digestive condition where stomach acid repeatedly flows back into the tube connecting your mouth and stomach [esophagus]), interstitial pulmonary disease (a large group of disorders that cause progressive inflammation and scarring of the tissue between the air sacs in the lungs) and dementia (a progressive state of decline in mental abilities).During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 3/30/26, the MDS indicated the resident was severely impaired with cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 9 was dependent (helper does all of the effort. Residents do none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 9 has a feeding tube and was receiving a therapeutic diet (a personalized meal plan prescribed by a healthcare provider or dietitian to treat a specific medical condition). During a review of Resident 9's Physician Orders, dated 2/21/2026, the Physician Orders indicated enteral feeding (a medical method used to deliver liquid nutrition directly into the stomach) for every shift continuously: Jevity (liquid, fiber-fortified nutritional formula, designed for oral or tube feeding when a person cannot meet their nutritional needs via regular food) 1.2 at 40 milliliters (ml - unit of measure)/hour for 20 hours via GT to provide 800 ml/960 kilocalorie (Kcal - the amount of energy food provides to your body )/24 hours. Start between 11 AM to 12PM and continue until total volume is infused. During a concurrent observation and interview of a medication administration on 7/1/2026 at 9:51AM, LVN 5 was observed preparing and administering medications to Resident 9. LVN 5 did not confirm Resident 9's GT placement prior to medication administration. LVN 5 stated she did not but should have confirmed Resident 9's GT placement by checking residuals prior to administering resident's medications. LVN 5 stated this was important to prevent aspiration. During an interview on 7/1/2026 at 1:14PM, the facility's Policy and Procedure (P&P) titled Medication Administration via Enteral Tube, revised 12/19/2022, was reviewed. Registered Nurse 2 (RN 2) stated prior to medication administration GT placement and residuals should be checked. RN 2 also stated GRV should be checked to prevent aspiration. RN 2 stated checking GRV prior to medication administration was not but should be in the policy.During an interview on 7/2/2026 at 1:02PM, the facility's Policy and Procedure (P&P) titled, Medication Administration via Enteral Tube, revised 12/19/2022, was reviewed. The P&P indicated that it is the facility's policy to ensure safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines. It also indicated to verify tube placement prior to administering any fluids or medications. The Director of Nursing (DON) stated checking GT residuals prior to medication administration is not but should be in the policy. The DON also stated it is important to check GT residuals to prevent aspiration and ensure the residents are tolerating their medications and tube feedings.

Based on observation, interview, and record review, the facility failed to ensure oxygen was administered for one (1) of 1 sampled resident (Resident 44) reviewed for respiratory care in accordance with the physician's order and facility policy. This deficient practice placed Resident 44 at risk for hypoxia (a condition that occurs when the lungs cannot get enough oxygen to the blood) causing serious harm. Findings: During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (a sudden, life threatening emergency where the lungs cannot get enough oxygen into the blood, or they cannot remove enough carbon dioxide from the body) with hypoxia and encephalopathy (a brain disease, disorder, or damage that affects brain function). During a review of Resident 44's Minimum Data Set (MDS- a resident assessment tool), dated 5/28/2026, the MDS indicated Resident 44 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 44 was on oxygen therapy while in the facility. The MDS further stated Resident 44 was dependent (helper does all the effort) with eating, oral, toileting and personal hygiene, shower, upper and lower body dressing and putting on/taking off footwear. During a review of Resident 44's Physicians Order, dated 6/4/2026 at 5:05 PM, the Physicians Order indicated oxygen via nasal cannula (NC, a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at two (2) to five (5) liters per minute (LPM - unit of flow rate) to maintain oxygen saturation (the amount of oxygen circulating in the blood) greater or equal to 95 percent (%) every shift. During a review of Resident 44's Care Plan. revised on 6/4/2026, the Care Plan indicated the resident was on oxygen therapy related to acute respiratory failure with hypoxia and interventions included humidified (moistened) oxygen via NC at 2 to 5 LPM to maintain oxygen saturation greater or equal to 95 % every shift. During a concurrent observation in Resident 44's room with Registered Nurse 3 (RN 3) on 6/29/2026 at 10:33 AM, Resident 44 was lying in bed with the NC on the left side of the resident's face while the oxygen concentrator (a medical device that gives extra oxygen by taking and filtering air from the surroundings) was set at 2.5 LPM. During an interview on 7/1/2026 at 11:19 AM, RN 3 stated Resident 44's oxygen NC should be placed correctly in the resident's nose for the resident to receive oxygen to prevent oxygen desaturation (blood oxygen level had dropped below normal). During an interview on 7/1/2026 at 11:26 AM, the Director of Nursing (DON) stated Resident 44's oxygen NC should always be in the resident's nose to help maintain the resident's oxygen saturation at 95 % and above to prevent respiratory distress (trouble breathing). During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration, revised 5/20/2024, the P&P indicated oxygen is administered to residents who need it, consistent with professional standards of practice and comprehensive person-centered care plans. The P&P also indicated oxygen is administered under orders of the physician.

Based on interview and record review, the facility failed to maintain an accurate clinical record in accordance with the facility's policy by failing to accurately document the meal percentage on 6/29/2026 for one (1) of two (2) sampled residents (Resident 41).This deficient practice had the potential to affect Resident 41's nutritional assessment, care planning, monitoring of intake trends, and timely identification of nutritional risks or decline. Findings: During a review of Resident 41's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of repeated falls, dementia (a progressive state of decline in mental abilities), muscle weakness and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 41's Minimum Data Set (MDS - a resident assessment tool), dated 5/13/2026, the MDS indicated the resident was severely impaired with cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 41 required substantial/maximal assistance (helper does more than half the effort. Helper lifts, holds, or supports trunk or limbs and provides more than half the effort) with oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on/ taking off footwear and personal hygiene. Resident 41 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with shower/bathe self. The MDS indicated Resident 41 was on a mechanically altered (food that has been changed in texture) and therapeutic diet (specialized diet prescribed for a medical condition). During an observation on 6/29/2026 at 12:49PM, Resident 41 was observed eating three (3) bites of food (Chicken, Vegetables and Bread) with 90% of food still left on the plate. The Speech Therapist (ST, trained professional who helps people improve their speech, language, voice, cognition, and swallowing abilities), who was assisting another resident on the same dining table as Resident 41, stated Resident 41 took a couple bites of food and consumed 10% of her meal. During a review of Resident 41's meal percentage, dated 6/29/2026 at 1:01PM, the meal percentage indicated the resident ate 51 to 75% of her meal. During a concurrent review and interview on 7/1/2026 at 1:10 PM, Resident 41's meal percentage, dated 6/29/2026 at 1:01PM, was reviewed. Certified Nursing Assistant 6 (CNA 6) stated she did not see how much Resident 41 ate for lunch on 6/29/2026. CNA 6 also stated Resident 41 usually eats 50 to 60% of her meals, so CNA 6 documented that Resident 41 ate 51 to 71% of her meal. CNA 6 further stated she did not but should have checked how much Resident 41 ate on 6/29/2026 for lunch prior to documenting the resident's meal intake in the medical records. During an interview on 7/1/2026 at 1:10PM, Registered Nurse 2 (RN 2) stated it is important to document Resident 41's meal percentage correctly because if there are any changes in Resident 41's eating habits, the facility can address it. During an interview on 7/2/2026 at 2:50PM, the Director of Nursing (DON) stated CNA should not have documented 51 to 75% if the CNA did not see how much Resident 41 ate. The DON also stated documentation should be accurate. During a review of the facility's Policy and Procedure (P&P) titled, Documentation in Medical Record, revised 12/19/2022, the P&P indicated false information shall not be documented. The P&P also indicated documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.

Based on observation, interview, and record review, the facility failed to maintain essential laundry equipment in safe operating condition by failing to remove the lint as scheduled from the lint trap of one of two (2) dryers in accordance with Policy and Procedure (P&P) This deficient practice resulted in lint buildup within the dryer, creating a fire hazard that placed residents and staff at risk of harm.Findings:During a laundry tour on 7/1/2026 at 2:48 PM, one of the two dryers (Dryer 2) was operating without any items in it. Laundry Aid 1 (LA 1) opened the lint door located underneath the dryer and observed lint build up on the lint trap. During an interview on 7/2/2026 at 9:51 AM, the Maintenance Service Supervisor (MSS) stated the dryer lint trap should be cleaned by every 2 hours as scheduled for fire safety and prevention. During an interview on 7/2/2026 at 12:30PM, LA 2 stated she forgot to clean the lint trap of Dryer 2 on 7/1/2026 at 2 PM. LA 2 also stated the dryer should be regularly cleaned and be free from lint build up to prevent fire. During a review of the facility's P&P titled, Laundry, revised 12/19/2022, the P&P indicated laundry equipment will be used and maintained according to manufacturer's instructions. During a review of the facility's P&P titled, Preventative maintenance program, revised 12/19/2022, the P&P indicated the maintenance director is responsible for developing and maintaining a schedule of maintenance services that the buildings, grounds, and equipment are maintained in a safe and operable manner.

Based on observation, interview, and record review, the facility failed to maintain safe, clean, comfortable, sanitary and home-like environment for one (1) of two (2) sampled residents (Resident 17) reviewed for environment by failing to ensure Resident 17's gastrostomy tube (G-tube pump, an electronic, battery-powered medical device that delivers liquid nutrition, fluids, or medication at a controlled rate directly into a person's stomach through a surgically placed abdominal tube) was free of dried milk residue and the flooring in Resident 17's room was free of dry milk residue. These deficient practices created an unsafe and unsanitary environment for Resident 17 and had the potential to result in accidents and risk of contamination and infection. Findings: During a review of Resident 17's admission Record, the admission Record indicated the resident was initially admitted ), and facility on 8/8/2025 with diagnoses of Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel), and lack of coordination. During a review of Resident 17's Minimum Data Set (MDS-a resident assessment tool), dated 4/9/2026, the MDS indicated the resident had moderately impaired cognitive (ability to think, remember, and reason) skills for daily decision-making. Resident 17 needed partial to moderate assistance (helper does less than half the effort) with personal hygiene (the ability to maintain personal hygiene) and sit-to-stand (the ability to come to a standing position from sitting in a chair). During an observation in Resident 17's room on 6/29/2026 at 9:27 AM, Resident 17 was sleeping in bed comfortably. The resident was connected to G tube pump which was noted to be turned off. Resident 17's G-tube pump was observed with visible dried milk drippings. Resident 17's room flooring was also observed with visible dried milk drippings. During a concurrent observation and interview on 6/30/2026 at 7:31 AM with Certified Nursing Assistant 1 (CNA1) in Resident 17's room, CNA1 stated that Resident 17's G-tube pump was dirty, with visible dry milk on it. CNA1 also stated there was dried milk on the floor. During an interview on 7/2/2026 at 8:25 AM with the Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that the G-tube pump and the floor were supposed to always be clean. LVN 1 stated food or milk drippings should be cleaned right away for safety and infection control. During a concurrent interview and record review on 7/2/2026 at 2:58 PM with Registered Nurse 1 (RN 1) of the Resident 17's care plan, dated 5/22/2026, RN 1 stated that the care plan indicated that Resident 17 was at risk for fall related to Parkinson's disease, hypertension (high blood pressure), and depression (severe feelings of sadness and hopelessness). RN 1 stated the care plan interventions indicated to keep the resident's environment safe by having a floor free from spills and clutter. During a concurrent interview and record review on 7/2/2026 at 3:10 PM with RN 1, the facility's Policy and Procedure (P&P) titled, Resident Environmental Quality, revised on 12/19/2022 was reviewed. RN 1 stated that the P&P indicated that it is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During a concurrent interview and record review on 7/2/2026 at 3:12 PM with RN 1, the facility's P&P titled, Cleaning and Disinfection of Resident Care Equipment, revised on 12/19/2022 was reviewed. RN 1 stated that the P&P indicated that the resident care equipment can be a source of indirect transmission of pathogens. Reusable resident care equipment will be cleaned and disinfected in accordance with the Centers for Disease Control and Prevention (CDC, the primary United States federal public health agency tasked with protecting public health and safety by preventing and controlling disease, injury, and disability) recommendations in order to break the chain of infection. RN 1 also stated that the facility did not follow the P&P.

Based on interview and record review, the facility failed to follow its Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) policy to ensure the residents receive information to formulate an advance directive for two (2) of two sampled residents (Resident 139 and 141). This deficient practice had the potential for Resident 139 and 141 to not have their wishes met regarding life-sustaining treatment (any treatment that serves to prolong life without reversing the underlying medical condition) or health care. Findings: 1. During a review of Resident 139's Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of immunodeficiency (failure of the immune system to protect the body adequately from infection) and schizoaffective disorder (a mental illness that is characterized by disturbances in thought). During a review of Resident 139's Minimum Data Set (MDS - a resident assessment tool), dated 5/11/2025, the MDS indicated the resident was moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with oral hygiene and upper body dressing, but required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathe self, lower body dressing and personal hygiene. During a record review of Resident 139's medical chart and electronic health record on 5/13/2025 at 8:42 AM, there was no advance directive acknowledgement in the resident's medical chart and electronic health record . During a concurrent record review of Resident 139's chart and interview on 5/14/2025 at 9:34 AM, the Social Services Director (SSD) stated the advance directive acknowledgement was not and should have been done within 72 hours of admission. The SSD also stated it is important to provide the resident with information to formulate an advance directive; in case of an emergency, the facility will know what type of care to provide for the resident. 2. During a review of Resident 141's Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of sepsis (a life-threatening blood infection), acute respiratory failure (condition making it difficult to breathe on your own) and immunodeficiency. During a review of Resident 141's History and Physical (H&P), dated 5/9/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a record review of Resident 141's chart/electronic record on 5/13/2025 at 9:31 AM, there was no advance directive acknowledgement in the chart/electronic record. During a concurrent record review of Resident 141's medical chart and electronic health record and interview on 5/14/2025 at 9:40 AM, the Social Services Director (SSD) stated the advance directive acknowledgement was not and should have been done within 72 hours of admission. The SSD also stated it is important to provide the resident with information to formulate an advance directive; in case of an emergency, the facility will know what type of care to provide for the resident. During a concurrent record review and interview on 5/14/2025 at 10:20 AM, the DON, the facility's Policy and Procedure (P&P) titled Resident Rights Regarding Treatment and Advance Directive, revised 12/19/2022 was reviewed. The P&P indicated on admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident/resident representative would like to formulate an advance directive. The DON stated the advance acknowledgment form should be done within 72 hours of admission as indicated in the policy, so the facility may know the type of care to provide for the resident.

Based on observation, interview, and record review, the facility failed to ensure the proper use and follow the physician's order for use of bed rails (are adjustable metal or rigid plastic bars that attach to the bed) for six (6) of 6 sampled residents (Resident 1, 2, 17, 26, 56 and 69), as indicated in the facility's policy and procedure. This deficient practice had the potential to place Residents 2, 17, 26, 56 and 69 at risk for entrapment (residents becomes caught or trapped in spaces around a bed rail) which could result in injury and death. This deficient practice resulted in Resident 1 getting trapped on the bed rails on 3/25/2025, wherein Resident 1's stomach was caught on the side rail (middle section of the bed) with the resident's upper body off the bed with his head touching the floor, while his lower body was on the bed, and Resident 1 sustaining a half centimeter (cm, unit of measure) cut on the nose bridge. Findings: 1. During a review of Resident 56's Admission Record, the Admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses of dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety (a feeling of fear, dread, and uneasiness). During a review of Resident 56's Care Plan with focus on Side Rails Management, revised 1/30/2025, the Care Plan indicated to check bed, mattress and rail for appropriateness. During a review of Resident 56's Minimum Data Set (MDS - a resident assessment tool), dated 4/24/2025, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 56 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, and chair/bed to chair transfer (the ability to transfer to from a bed to a chair or wheelchair) During a review of Resident 56's Physician's Order, dated 5/5/2025, the Physician's Order indicated bilateral quarter length side rails up per family request. Monitor resident every shift for appropriate position/movement while in bed that may contribute for possible entrapment. During an observation on 5/12/2025 at 8:55 AM, Resident 56 was lying in bed with the right and left side rails up in the middle section of the bed. During a concurrent interview and record review on 5/14/25 at 12:08 PM, RN 2 stated Resident 2's physician's order which indicated use of bilateral quarter length side rail was not followed. RN 2 stated a doctor's order is needed for the use of right and left side rails up in the middle section of the bed. 2. During a review of Resident 2's Admisison Record, the Admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses of dementia and osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 2's Physician's Order, dated 6/1/2022, the Physician's Order indicated Side Rails Length: 1/4 Location: Bilateral, right side, left side. Monitor resident every shift for appropriate position/movement while in bed. During a review of Resident 2's Care Plan with focus on Side rails management, revised 11/18/2023, the Care Plan indicated to check bed, mattress and rail for appropriateness. During a review of Resident 2's MDS, dated [DATE], the MDS indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS also indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, personal hygiene and chair/bed to chair transfer. During an observation on 5/12/2025 at 9:44 AM, Resident 2 was lying in bed with the right and left side rails up in the middle section of the bed. 3. During a review of Resident 69 Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of dementia and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 69's Physician Orders, dated 1/22/2025, the Physician Orders indicated bilateral quarter length bed rails up to assist with mobility, turning and repositioning by providing a grasp every shift check resident for position or movement in bed that may contribute to possible entrapment. During a review of Resident 69's MDS, dated [DATE], the MDS indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS also indicated Resident 69 was dependent with eating oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off foot wear, personal hygiene and chair/bed to chair transfer. During a review of Resident 69's Care Plan with focus on Side Rails Management, revised 5/11/2025, the Care Plan indicated to check bed, mattress and rail for appropriateness. 4. During a review of Resident 1's Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of dementia and sepsis (a life-threatening blood infection). During a review of Resident 1's Physician Orders, dated 4/25/2025, the Physician Orders indicated bilateral quarter length assist side rails to assist to turn and reposition by providing a grasp every shift monitor resident for appropriate position/movement while in bed that may contribute to possible entrapment. During a review of Resident 1's MDS, dated [DATE], the MDS indicated the resident is severely impaired in cognitive skills for daily decision making. The MDS also indicated Resident 1 required substantial/maximal assistance with toileting hygiene, lower body dressing, putting on/taking off footwear, personal hygiene and chair/bed to chair transfer but is dependent with shower/bathe self. During a review of Resident 1's Care Plan with focus on Side rails management, revised 5/13/2025, the Care Plan indicated check bed, mattress and rail for appropriateness. During an interview on 5/14/2025 at 8:15 AM, RN 5 stated on 3/21/2025 at 3pm when doing rounds, RN 5 found Resident 1 with his stomach caught on the side rail (middle section of the bed) with the resident's upper body off the bed with his head touching the floor, while his lower body was on the bed. RN 5 also stated Resident 1 sustained a half centimeter (cm, unit of measure) cut on the nose bridge. During an interview on 5/14/2025 at 4:10 PM, RN 2 stated Resident 1, 2, 56 and 69's physician order was not followed because the bed side rails were 1/2 up when the order says 1/4 up. 45099 5. During a review of Resident 17's Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included repeated falls, fracture of left femur (thigh bone) and multiple fractures of the pelvis (bony structures that support the hips and lower body). During a review of Resident 17's MDS, dated [DATE], the MDS indicated Resident 17 had severe impairment in cognitive skills for daily decision making. The MDS also indicated Resident 17 was dependent (helper does all the effort) eating, oral, toileting and personal hygiene, shower, upper and lower body dressing and putting on/taking off footwear. During a review of Resident 17's physicians order, dated 2/10/2025 at 9:11 PM, the physicians order indicated bilateral quarter length assist siderail up to assist to turn and reposition by providing a grasp. During an observation on 5/12/2025 at 7:58 AM, Resident 17 was in bed sleeping with both right and left half side rail located in the middle section of the bed During a concurrent interview and record review on 05/14/25 at 12:32 PM, Registered Nurse 3 (RN 3) stated the physicians order for Resident 17 was to use a quarter side rail not half side rail. RN 3 stated the physicians order should be followed. RN 3 also stated Resident 3 would be more prone to injuries if the resident tries to climb out of the side rails. RN 3 also confirmed the bed rail assessment does not address the risk for entrapment and should be included. During an interview on 5/15/2025 at 9:37 AM, RN 4 stated the facility staff did not follow the physicians order for Resident 3 to use quarter side rails. 6. During a review of Resident 26's Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis of Dementia (a progressive state of decline in mental abilities). During a review of Resident 26's physicians order dated 4/6/2022 at 4:46 PM, the physicians order indicated an order for bilateral quarter length side rail. The physicians' order also indicated its use was to assist Resident 26 to turn by providing a grasp. During a review of Resident 26's MDS, dated [DATE], the MDS indicated Resident 26 had severe impairment in cognitive skills for daily decision making. The MDS also indicated Resident 26 was dependent on shower and required substantial/maximal assistance (helper does more than half the effort) with eating, oral, toileting and personal hygiene, upper and lower body dressing and putting on/taking off footwear. During an observation on 5/12/2025 at 3:16 PM, Resident 26 was in bed sleeping with both right and left half side rail located in the middle section of the bed were used. During a concurrent interview and record review on 5/14/25 at 3:03 PM, the Director of Nursing (DON) confirmed that half side rails were used for Resident 17 and 26 instead of quarter side rails as ordered. During a concurrent observation and interview on 5/15/25 at 9:54 AM, Certified Nursing Assistant 8 (CNA 8) did not know what the quarter side rail from the half side rail was. CNA 8 identified the quarter side rail as half side rail and the half side rail as full side rail. During a review of the facility's Policy and Procedure (P&P) titled, Proper Use of Bed Rails, revised 12/19/2022, indicated that it is the policy of the facility to utilize a person-centered approach when determining the use of bed rails. The policy also stated that if the bed rails were used, the facility was to ensure correct installation, use, and maintenance of the rails. During a review of the facility's P&P titled Provision of Physician Ordered Services, revised 5/15/2023, the P&P indicated to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality.

Based on observation, interviews, and record review, the facility failed to ensure Dietary Aide 1 (DA 1) wore hair restraint (worn by food handlers to avoid hair getting into the food) to cover mustache and beard while in the kitchen and food storage areas. This deficient practice had the potential to result in cross contamination (transfer of harmful bacteria [tiny, single-celled living things that are found everywhere, including in and on your body] from one place to another) and harmful bacterial growth that could lead to illness for 69 of 80 medically compromised residents who receive food from the kitchen. Findings: During a concurrent observation and interview on 5/14/2025 at 10:35 AM in the kitchen, with the Dietary Service Supervisor (DSS) and DA 1, DA 1 was observed with mustache and beard and was not wearing beard mask. DA 1 stated he forgot to wear a beard mask today. DSS and DA 1 stated hair could fall into the food and could cause food contamination. DSS and DA 1 stated it was important to wear a beard mask while in the kitchen and storage areas to prevent the spread of germs (a microorganism that causes disease or illness). DSS stated that residents could get sick and potentially lead to hospitalization . During a review of the facility's Policy and Procedures (P&P) titled Food Safety and Food Storage revised 11/4/2024, the P&P indicated, staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. The P&P further indicated that Dietary staff must wear hair restraints (e.g., hair net, hat, and/or beard restraint) to prevent hair from contacting food.

Based on observation, interview, record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for five (5) of seven (7) residents sampled for infection control care areas (Resident 49, 50, 56, 69 and 141) and in accordance with the facility's policy and procedure when: 1.a Licensed Vocational Nurse (LVN) 3 failed to don (putting on) an isolation gown prior to entering Resident 49's room who was on a Transmission Based Precaution (TBP - refers to actions [precautions] implemented in addition to standard precautions that are based upon the means of transmission [airborne, contact, and droplet] to prevent or control infections). 1.b Resident 49 who was on TBP was transported and left in the dining room area for activities on 5/12/2025 by Certified Nursing Assistant 9 (CNA 9). 2.a. LVN 2 failed to change gloves and perform hand hygiene (the process of cleaning and disinfecting hands to remove dirt, and germs) after touching multiple surfaces of Resident 50 who was on enhanced barrier precautions (EBP-refers to an infection control intervention designed to reduce transmission of multidrug resistant organisms [MDROs-bacteria that have become resistant to multiple antibiotics, making it difficult to treat infections they cause] that employs targeted gown and glove use during high contact resident care activities). 2.b. LVN 2 failed to change gloves and perform hand hygiene after giving medications via gastrostomy tube (GT-a surgical opening fitted with a device to allow feedings, fluids, and medications to be administered directly to the stomach common for people with swallowing problems)and before administering insulin (a hormone that helps regulate blood sugar levels, typically administered via subcutaneous injection [given into the layer of fat just below the skin]) injection. 3.4., and 5. Facility failed to ensure facility staff doff (take off) Personal Protective Equipment (PPE; protective clothing, goggles, or other garments to prevent or minimize exposure to and spread of infection or illness) and perform hand hygiene (cleaning hands to prevent germs) after providing peri-care (cleaning the genitals and anal area) to Residents 56, 69, and 141). These deficient practices have the potential to spread infection to staff and residents. Findings: 1.a. During a review of Resident 49's Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis that included scoliosis (sideways curve of a spine) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 49's Minimum Data Set (MDS- a resident assessment tool), dated 2/5/2025, the MDS indicated Resident 49 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 49 required partial/moderate assistance (helper does less than half the effort) with toileting, shower, lower body dressing and putting on and taking off footwear and required supervision (helper provides cues) with eating, oral and personal hygiene, and upper body dressing. During a review of Resident 49's Care Plan initiated on 5/10/2025, the Care Plan indicated the Resident has ESBL of the urine with an approach plan to use contact isolation. During a review of Resident 49's physicians order dated 5/11/2025 at 1:22 PM, the physicians order indicated contact isolation for the resident until 5/17/2025 at 11:59 PM for extended-spectrum beta-lactamase (ESBL, are enzymes produced by some bacteria's that may make them resistant to some antibiotics) of the urine. During an observation on 5/13/2025 at 10:55 AM, Licensed Vocational Nurse 3 (LVN 3) entered Resident 49's room without wearing an isolation gown. During an interview on 5/14/2025 at 12:58 PM, the Infection Prevention Nurse (IPN) confirmed Resident 49 has ESBL of the urine. The IPN stated LVN 3 should have worn an isolation gown before going inside the resident's room to protect her and other residents from contracting the infection. During an interview on 5/14/2025 at 1:06 PM, LVN 3 stated she should have used an isolation gown because the resident is a contact isolation for ESBL of the urine and to prevent the spread of infection to others. During an interview on 5/15/2025 at 9:49 AM, the Director of Nursing (DON) stated that LVN 3 should have worn an isolation gown to protect herself from getting the infection and to prevent spreading the infection to other residents. 1.b During an observation on 5/12/2025 at 10:29 AM, Resident 49 was taken by CNA 9 to the dining room area for activities from the resident's room by wheelchair. During an interview on 5/14/2025 at 12:58 PM, the IPN stated Resident 49 should not have been brought to the dining room by CNA 9 to prevent potential spread of her infection to other residents, staff, and/ or visitors. During an interview on 5/15/2025 at 9:49 AM, the DON stated Resident 49 should not have been brought to the dining room with other residents since the resident could infect other people in the dining room. During a review of the facility's Policy and Procedure (P&P) titled, Transmission -Based Precautions, revised 7/18/2023, the P&P indicated that the facility was to take appropriate precautions to prevent transmission of pathogen, based on the pathogens' mode of transmission. The policy also indicated that residents on TBP should remain in their rooms except for medically necessary care. The policy further indicated that healthcare personnel caring for the residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. 49537 2.During a review of Resident 50's Admission Record, the Admission Record indicated the facility admitted Resident 50 on 9/25/2020 with diagnoses including, but not limited to, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), long term use of insulin, malnutrition (a condition that occurs when the body does not receive enough nutrients or calories to function properly), and presence of GT to administer the medications and water flush. During a review of Resident 50's MDS, dated [DATE], the MDS indicated Resident 50 had severe impairment with cognitive (the mental process that takes place in the brain, including, thinking, attention, language learning, memory, and perception) skills for daily decision making. The MDS also indicated Resident 50 required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provide less that half the effort) with upper body dressing. The MDS indicated Resident 50 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunks or limbs and provides more than half the effort) with eating, oral and personal hygiene, lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 50 was dependent (Helper does all the effort. Resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) with toileting hygiene and shower or bathing self. During a review of Resident 50's Care Plan focused on GT site and continuous GT feeding, and EBP due to use of GT, initiated on 1/24/2025, the Care Plan indicated interventions which included applying enhanced barrier to prevent spread of infections for specific care activities such as caring for devices and giving medical treatments. The Care Plan also indicated following facility policy and procedures on EBP, follow EBP for the duration of use of the GT initiated on 5/24/2024. During an observation on 5/14/2025 at 8:22 AM outside Resident 50's room, LVN 2 was observed preparing Resident 50's medications. LVN 2 entered Resident 50's room with the medications. LVN 2 then grabbed the privacy curtain located between Bed A and Bed B. LVN 2 was then observed grabbing the privacy curtain by Bed A without changing gloves and performing hand hygiene. LVN 2 then proceeded to touch Resident 50's GT feeding pump (a device that delivers liquid formula or medication through a GT. It controls the rate and amount of the delivery, ensuring the patient receives the correct dosage and prevents complications) to turn it off, took out the GT feeding syringe (used to feed a resident quickly, introducing a fairly large bolus per swallow or for water flushing) from its plastic cover, touched Resident 50's gown to access the GT, placed the stethoscope's (a medical instrument that allows healthcare providers to listen to sounds produced inside the body, such as heartbeat, lung and bowel sounds, for diagnostic purposes) earpiece to LVN 2's ears and stethoscope diaphragm (circular end of the chest piece) to Resident 50's abdomen to check GT patency (condition of being unobstructed) and placement. LVN 2 proceeded to administer medications via the GT and reconnected the feeding tube. LVN 2 was then observed to administer the insulin that has been prepared to Resident 50's abdomen without changing gloves and performing hand hygiene. During an interview on 5/14/2025 at 9 AM with LVN 2, LVN 2 stated she forgot to change her gloves and perform hand hygiene after touching multiple surfaces and prior to and after administering Resident 50's medications via GT and prior to administering the resident's insulin. LVN 2 stated it was important to remove used gloves and perform hand hygiene after touching multiple surfaces and donning new gloves prior to proceeding with another task. LVN 2 stated it was important to follow standard precautions and EBP to prevent the spread of MDROs to other residents and staff. LVN 2 stated that residents could become infected and get sick because of not observing standard precautions and EBP. During a review of the facility's P&P titled, Enhanced Barrier Precautions, revised 4/22/2024, the P&P indicated: The facility is to implement EBP for the prevention of transmission of multidrug resistant organisms. EBP are indicated for residents with indwelling medical devices such as feeding tubes. High contact resident care activities include device care or use. EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. 42223 3. During a review of Resident 56's Admission Record, the Admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses of dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 56's Minimum Data Set (MDS - a resident assessment tool), dated 4/24/2025, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 56 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, and chair/bed to chair transfer (the ability to transfer to from a bed to a chair or wheelchair). During an observation on 5/15/2025 at 9:08 AM, Certified Nursing Assistant 1 (CNA 1) was observed providing peri-care to Resident 56. CNA 1 did not change gloves and did not perform hand hygiene after providing peri-care to Resident 56. CNA 1 using the same set of gloves was observed touching Resident 56's bed sheets and the resident's body. During an interview on 5/15/2025 at 9:16 AM, CNA 1 stated she should have removed her gloves, performed hand hygiene and changed gloves prior to touching Resident 56's bed sheets and body to prevent the spread of infection. 4. During a review of Resident 69 Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of dementia and immunodeficiency (failure of the immune system to protect the body adequately from infection). During a review of Resident 69's MDS, dated [DATE], the MDS indicated the resident was severely impaired with cognitive skills for daily decision making. The MDS also indicated Resident 69 was dependent with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, and chair/bed to chair transfer. During an observation on 5/15/2025 at 8:16 AM, CNA 1 was observed providing peri-care to Resident 69. CNA 1 did not change gloves and did not perform hand hygiene after providing peri-care to Resident 69. CNA 1 using the same set of gloves was observed applying lotion to Resident 69's whole body. During an interview on 5/15/2025 at 9:16 AM, CNA 1 stated she should have removed her gloves, performed hand hygiene and changed gloves prior to touching Resident 69 and applying lotion to the resident. CNA 1 stated it is to prevent the spread of infection. 5. During a review of Resident 141's Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of sepsis (a life-threatening blood infection), acute respiratory failure (condition making it difficult to breathe on your own) and immunodeficiency. During a review of Resident 141's History and Physical (H&P), dated 5/9/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a concurrent observation and interview on 5/14/2025 at 9:28 PM, CNA 4 was observed providing peri-care to Resident 141. CNA 4 did not change gloves and did not perform hand hygiene after providing peri-care to Resident 141. CNA 4 using the same set of gloves was observed touching Resident 141's bed sheets, hand and body. CNA 4 stated she should have removed her gloves, performed hand hygiene and changed gloves prior to touching Resident 141's bed sheets, hand and body to prevent the spread of infection During an interview on 5/15/2025 at 11:19 AM, the Infection Preventionist Nurse (IP) stated the CNAs should have removed her gloves, perform hand hygiene, and put on new gloves. IPN also stated the CNAs should not have touched the residents bed sheets, surfaces, and body after providing peri-care to a resident because it can spread infection. During a review of the facility's Policy and Procedure (P&P) titled Hand Hygiene, revised 12/19/2022, the P&P indicated hand hygiene is indicated and will be performed under the conditions listed in, but not limited to: 1. After assistance with personal body functions such as elimination. The P&P also indicated the use of gloves does not replace hand hygiene. If the task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based on observation, interview, and record review, the facility failed to ensure the facility was safe and sanitary by failing to: 1. The kitchen ceiling was free from water leak stains, bubbling and paint that was peeling off. 2. One of four dumpsters was completely closed and not overflowing. This deficient practice resulted in an unsanitary and unhomelike environment and had the potential for residents to be placed at risk for serious illness and hospitalization . Findings: During a concurrent observation and interview on 5/12/2025 at 8:09 AM by the dumpster area, one of four dumpsters was observed overflowing with boxes and dumpster cover was not completely closed. The Maintenance Director stated the company that picks up the garbage has not arrived yet and they were scheduled to be picked up early this morning. During a concurrent observation and interview on 5/12/2025 at 8:13 AM inside the kitchen, with the Dietary Service Supervisor (DSS), the ceiling was observed with water stains, paint patches, bubbling and paint that was peeling off. The DSS stated that the water stains appeared after the rain two weeks ago. DSS stated it still needs to be repaired. The Maintenance Director was already informed but unable to remember the date and time of notification. During a concurrent interview and record review on 5/15/2025 at 9:30 AM with the Maintenance Director, the Policy and Procedure (P&P) titled, Disposal of Garbage and Refuse and Resident Environment Quality, both revised on 12/19/2022 were reviewed. The P&P titled, Disposal of Garbage and Refuse, indicated the facility shall properly dispose of kitchen garbage and refuse. The P&P also indicated that refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. The P&P titled, Resident Environmental Quality, indicated that it was the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. The Maintenance Director stated that one dumpster was overflowing with cartons/boxes, and the lid was not completely closed. The Maintenance Director stated that if the dumpster remained open, insects/animals can get into the trash and make a mess. The Maintenance Director stated the animals, or small insects can get into the facility and spread germs and disease to the residents and staff. During an interview on 5/15/2025 at 9:40 AM with the M Maintenance Director, the Maintenance Director stated that there was water leaking into the air conditioning unit when it rained two weeks ago. The Maintenance Director stated the leak was repaired and he inspected the ceilings around the area of the leak, and he did not see any water stains or bubbling of the paint. The Maintenance Director stated the kitchen ceiling was about five to six feet approximately from the source of the water leak. The Maintenance Director stated that he did not inspect the kitchen ceiling. The Maintenance Director stated that he was not aware of the water leak stain (yellow in color) in the kitchen and was only notified yesterday. The Maintenance Director stated that the peeling paint was due to the water leak damage and could fall into the food being prepared in the kitchen. The Maintenance Director stated that this could result in food contamination and residents could sick from it. The Maintenance Director stated that the facility policy was to fix what needed to be fixed right away. During a review of the P&P titled, Disposal of Garbage and Refuse, the P&P indicated that dumpsters shall be emptied according to the facility contract. The P&P further indicated that the schedule for garbage pick-up should be revised, as needed, based on the volume or refused. During a review of the P&P titled, Resident Environmental Quality, the P&P also indicated preventative maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment.