Every finding on record at Pacific Post Acute

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment by allowing corridors to become narrow and obstructed, thereby impeding resident mobility, reducing independent wheelchair transit, and creating a safety hazard. This deficient practice had the potential to affect residents, staff, and visitors evacuating the unit during an emergency.During a review of Resident 2's admission record indicated that Resident 2 was admitted on [DATE] with diagnoses Including displaced comminuted (broken, splintered, or crushed into three or more pieces) fracture (broken) of left patella (kneecap), chronic embolism (sudden blockage in a blood vessel) and thrombosis (a blood clot that forms inside a blood vessel) of left lower extremity, and hypertension (HTN-high blood pressure). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 7/27/2026, the MDS indicated Resident 2 had moderate cognitive impairment (slight, noticeable decline in memory and thinking skills that is greater than normal aging). The MDS indicated Resident 2 required between supervision or touching to substantial/maximal assistance from staff for all Activities of Daily Living (ADLs such as eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, putting on/taking off footwear, sit to stand, toilet transfer, sit to lying, sit to stand, toilet transfer, chair/bed-to-chair transfer. walk 10 feet, and personal hygiene). During an interview with Resident 2 on 8/3/2026 at 11 am, Resident 2 stated that she (Resident 2) that the hallways and the back emergency were not accessible because they were cluttered with stuff. Resident 2 stated that she felt unsafe because of the if an emergency arose she as well as other residents had to quickly evacuate the building could prove challenging. Resident 2 stated that she had spoken with administration and nothing had been done about it. During a concurrent observation of Exit 1 (E1) and interview with the Maintenance Supervisor (MS) on 8/3/2026 at 12:09 pm, the hallway at the end of the unit leading to the exit was about 10 feet long leading up to two glass doors with an emergency exit door above. To the right side of the hallway were equipment which included two wheelchairs, one roll aider, one patient transfer lift, one therapy wooden steps with three steps on either side, a 6-foot walking platform with metal handrails, a mobile 3-foot-tall air conditioner, and a sit to stand lift. The space between the equipment and the wall on the other side measured five feet and 75 inches. The MS stated that hallways must be accessible in case of a disaster which required residents to exit emergently. MS stated that confirmed that E1 appeared crowded and that the equipment needed to be removed. During a follow-up interview with MS on 8/3/2026 at 12:19 pm, MS provided their facility policy and procedure (P&P) titled, Means of Egress - Corridors and Exits, reviewed 4/22/2026 indicated the corridors must not be reduced to less than 6 feet. During a review of the facility' policy and procedures (P&P) titled, Means of Egress - Corridors and Exits, reviewed 4/22/2026, the P&P indicated, Means of egress are continuously maintained free of all obstructions in order to use safely and fully in case of an emergency. The same P&P defined the following: Egress refers to the action of going out of or leaving a place.Means of egress is a continuous and unobstructed way of travel from any point in a building or structure to a public way consisting of three separate and distinct parts: (1) the exit access, (2) the exit, and (3) the exit discharge. The P&P included the following indications under policy explanation and compliance guidelines:Furniture placement shall not narrow means of egress and/or impede evacuation. It shall not reduce the corridor width to less than 6 feet and shall be located only on one side of the corridor.No furnishings, decorations, or other objects shall obstruct exits or their access, egress from, or visibility of the exits.

Based on interview and record review, the facility failed to ensure the policy and procedures for resident discharge and discharge planning were followed, for one of three sampled residents (Resident 1).This failure resulted in Resident 1's discharge planning documentation to be incomplete.During a review of Resident 1's admission Record , dated 7/17/26, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including pain in left and right hips, presence of left artificial hip joint, chronic pain syndrome, lack of coordination, abnormalities of gait and mobility, asthma (chronic lung disease where your airways become inflamed, swell, and produce excess mucus), and arthritis (pain, swelling and stiffness in joints). During a review of Resident 1's History and Physical (H&P) dated 5/29/26 indicated the resident had decision making capacity. During a review of Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 6/18/26 indicated, the resident had intact cognition (function of the mind, related to thinking memory, problem-solving, decision making, judgement) and required setup or clean-up assistance from staff for mobility, transfers and activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), except for eating (the resident was independent). During a concurrent telephone interview and record review with Interim Director of Nursing (IDON) of Resident 1's IDT (interdisciplinary) meeting notes, physician progress notes and discharge planning care plans from 4/1/26 through 6/1/26 were reviewed. The IDON verified there were no IDT meeting notes for discharge planning, no physician progress notes indicating the reason for discharge, nor any discharge planning care plans with discharge goals during this time-period. The IDON stated discharge planning documentation is important, so the resident's needs are met, the resident is included in the discharge planning process and the plan is known to the staff. During a review of the facility's policy and procedures (P&P) titled Discharge Planning Process, reviewed/revised 11/19/25 indicated, Initial information and discharge goals will be included in the resident's baseline care plan. Subsequent assessment information and discharge goals will be included in the resident's comprehensive plan of care. If discharge to community is a goal, an active discharge care plan will be implemented and will involve the interdisciplinary team. During a review of the facility's P&P titled Transfer and Discharge (including AMA, Against Medical Advice), reviewed/revised 11/19/25, indicated Non-Emergency Transfers or Discharges - initiated by the facility, return not anticipated. Document the reasons for the transfer or discharge in the resident's medical record. The physician shall document medical reasons for transfer or discharge in the medical record, when the reason for transfer or discharge is for any reason other than nonpayment.

Based on interview and record review, the facility failed to ensure nursing facility staff verify and confirmed resident's laboratory test result as reported by resident's family member (FM 1) after Resident 1 was hospitalized on [DATE] and was diagnosed with urinary tract infection (UTI - an infection in the bladder/urinary tract) and ESBL (Extended-Spectrum Beta-Lactamase - a special shield or enzyme that certain common bacteria have developed to protect themselves from common antibiotics, because the bacteria can chew up and break down the medicine, standard antibiotics don't work against them), according to facility's policy and procedure for one of four sampled residents, Resident 1. As a result, Resident 1 received the incorrect medication for UTI according to Resident 1's laboratory culture test result (bacteria culture test can determine if you have a bacterial infection and, if so, which type of bacteria is causing it) from 6/3/2026 to 6/8/2026.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including atherosclerotic heart disease (build-up of fats, cholesterol, and other substance in and on the arterial walls), UTI, and metabolic encephalopathy (a chemical imbalance in the blood affecting the brain).During a review of the Minimum Data Set (MDS - resident assessment tool) dated 6/13/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required moderate to maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Progress Notes (PN) dated 6/3/2026, the PN indicated, Resident 1 was sitting in activity area was noted with pale appearance, 911 (the standard phone number you dial to reach emergency services like the police, fire department, or an ambulance) was notified at 10:30 a.m., EMT (Emergency Medical Technician) arrival and resident (1) was transferred to General Acute Hospital 1 (GACH 1).During a review of Resident 1's After Visit Summary (AVS) from General Acute Hospital 2 (GACH 2), dated 6/3/2026, the AVS indicated, a diagnoses of UTI with hematuria (blood in urine) and laboratory test in progress including culture (a two-step laboratory process used to detect infections) blood (a lab test that checks your blood for harmful germs, like bacteria or yeast), and culture, urine (a laboratory test that checks your pee for bacteria or fungi to see if you have an infection).During a review of Resident 1's Urine Culture test result from GACH 2, collected on 6/3/2026 and result dated 6/4/2026, the urine culture test result indicated, organism is an ESBL-producer, resistant clinically to most penicillins (type of antibiotic medication used to treat bacterial infections), cephalosporins (a large, widely used group of antibiotics used to treat bacterial infections like strep throat, pneumonia, and skin issue). During a review of Resident 1's Medication Administration Record (MAR) dated 6/3/2026 to 6/8/2026, the MAR indicated, Resident 1 received cephalexin (a common, first-generation prescription antibiotic used to kill the bacteria causing an infection) oral capsule 500 milligram (mg - unit of measurement) four times a day.During a review of Resident 1's PN dated 6/8/2026, the PN indicated, Resident (1) transferred to GACH 1 for further evaluation of hypotensive episode (sudden drop in blood pressure).During a review of Resident 1's Discharge Summary (DS) from GACH 1, dated 6/11/2026, the DS indicated Resident 1's primary diagnosis was recurrent ESBL UTI.During an interview with Resident 1's FM 1 on 6/24/2026 at 12:15 p.m., FM 1 stated, after Resident 1's hospitalization from GACH 2, she called the facility to notify them that Resident 1's urine culture came back with ESBL and that Resident 1 should be receiving a different antibiotic (prescription medicines used exclusively to treat bacterial infections) medication because ESBL is resistant to cephalexin. FM 1 stated, she (FM 1) had called the facility multiple times to make sure that Resident 1's medication is to be changed to the appropriate medication. FM 1 stated, Resident 1 was sent out to hospital again on 6/8/2026 to GACH 1 due to low blood pressure and when she spoke with the facility staff, she was told that Resident 1 was still on cephalexin antibiotic and the medication was never changed.During an interview with Licensed Vocational Nurse 1 (LVN 1) on 6/24/2026 at 1:52 p.m., LVN 1 stated, he spoke with FM 1 and was notified that Resident 1's urine culture came back and was prescribed wrong antibiotic medication, and medication should be changed to a different antibiotic. LVN 1 stated, he notified Medical Doctor 1 (MD 1) regarding FM 1's report. During an interview with MD 1 on 6/24/2026 at 2:45 p.m., when she was notified of Resident 1's urine culture result came back and to have the medication changed. MD 1 checked the medical record from GACH 1 because she was told that Resident 1 was sent out to GACH 1 on 6/3/2026. MD 1 was unable to see the urine test result from GACH 1 so she asked the facility staff where Resident 1 was sent out on 6/3/2026. MD 1 stated, no staff from the facility knew where Resident 1 was sent out to. MD 1 stated, Resident 1 was actually sent out to GACH 2 and was on cephalexin antibiotic until 6/8/2026.During an interview with Interim Director of Nursing (IDON) on 6/25/2026 at 5:05 p.m., IDON stated, FM1 calls the facility many times. IDON stated, if FM 1 reported urine culture result came back from hospital, facility staff should advocate for residents and verify the report. IDON stated, he was not aware of Resident 1's urine culture result of ESBL because he was on vacation. IDON stated, I don't know what happened, I was on vacation. IDON stated, nurses should be advocates to residents and facility staff should follow up on resident's pending urine culture result. IDON stated, when physician asked where Resident 1 was hospitalized on [DATE], facility staff should have checked on Resident 1's emergency transportation report to find out where Resident 1 was sent out so they could verify and confirm Resident 1's urine culture test result.During a review of facility's policy and procedures (P&P) titled, Antibiotic Stewardship, reviewed date 11/19/2025, the P&P indicated, It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Antibiotic orders obtained upon admissions, whether new admission or readmission, to the facility shall be reviewed for appropriateness. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness. During a review of facility's P&P titled, Abuse, Neglect and Exploitation, reviewed date 11/19/2025, the P&P indicated, Prevention of Abuse, Neglect and Exploitation: the facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation of that achieves:. assuring assessment of the resources needed to provide care and services to all residents is included in the facility assessment; the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen by failing to ensure foods with past use-by dates were not stored in the facility's food refrigerator according to the facility's policy and procedures (P&P) titled, Food Safety and Food Storage dated 11/19/2025. This failure had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness for all the residents who receive and consume food prepared in the facility's kitchen. Findings: During a kitchen tour on 3/31/2026 at 7:51 am, the following foods with past use-by dates were observed to be in the facility's kitchen refrigerator:a. A zip lock plastic bag of bagels dated thawed on 3/11/2026 use-by 3/17/2026 was stored in the refrigeratorb. A clear plastic bag of Swiss cheese dated 3/26/2026 with a use-by date of 3/30/2026 was stored in the refrigeratorc. A clear plastic bag of lettuce with a use-by date 3/27/2026 was stored in the refrigeratord. A clear plastic bag of bell peppers with a use-by date of 3/27/2026 was stored in the refrigerator. During an interview on 3/31/2026 at 7:51 am, the Dietary Supervisor (DS) stated the food with past due use-by dates should not be placed in the refrigerator because they can cause food borne illness if served to the residents. During an interview on 4/3/2026 at 1:50pm, the Interim Director of Nursing (IDON) stated food with past use-by date if served and consumed by Residents could cause food borne illness such as nausea, vomiting, diarrhea, resulting in unnecessary hospitalization and potential poor outcomes for Residents. A review of the facility's policy and procedures (P&P) titled, Food Safety and Food Storage dated 11/19/2025 indicated, Food safety practices shall be followed throughout the facility's entire food handling process. Elements of this process include the following: Storage of food in a manner that helps prevents . contamination of the food including from growth of microorganisms . Practices to maintain safe refrigerated storage including but not limited to use by use-by date.

Based on observation, interview and record review, the facility failed to to ensure residents were treated in a manner that enhanced the resident's dignity and respect in full recognition of residents individuality during meals when:Staff placed towels on the residents chest to protect the residents clothes without obtaining consent for seven of nine sampled residents (Residents 23, 20, 36, 26, 39,14 and 43). Staff referred/called residents requiring assistance with meals feeders for for eight out of eight sampled residents (Residents 10, 13, 20, 22, 23, 26, 29, and 36). This failure had potential to negatively affect Residents 20, 20, 36, 26, 39, 14, 43, 10, 13, 20, 22, 23, 26, 29, and 36 sense of dignity and self-worth. Findings: 1.During the review of Resident 23's admission Record (AR), the AR indicated the facility admitted the resident on 2/9/2026 with diagnoses that included but not limited to dysphagia (difficulty swallowing) due to cerebral infarction (a loss of blood flow to a part of the brain), muscle weakness and dementia (a progressive state of decline in mental abilities). During the review of Resident 23's Minimum Data Set (MDS – a resident assessment tool) dated 2/13/2026, the MDS indicated Resident 23 has severely impaired cognition (The mental ability to make decision of daily living) and the resident needs moderate assistance during meals. During the review of Resident 20's AR, the AR indicated the facility admitted the resident on 3/4/2026 with diagnoses that included but not limited to legal blindness, muscle weakness and lack of coordination (impaired balance and uncoordinated body movements). During the review of Resident 20's MDS, dated [DATE], the MDS indicated Resident 20 has severely impaired cognitive/brain function and the resident needs set up and clean up assistance during meals. During the review of Resident 36's AR, the AR indicated the facility admitted the resident on 1/13/2024 with diagnoses that included but not limited to dysphagia (difficulty swallowing) due to cerebral infarction (loss of blood flow to a part of the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body and hemiparesis (weakness or limited function of one side of the body). During the review of Resident 36's MDS, dated [DATE], the MDS indicated Resident 36 has severely impaired cognitive/brain function and the resident need supervision and/or touching assistance during meals. During the review of Resident 26's AR, the AR indicated the facility admitted the resident on 3/13/2026 with diagnoses that included but not limited to dysphagia (difficulty swallowing) due to cerebral infarction (loss of blood flow to a part of the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body and hemiparesis (weakness or limited function of one side of the body). During the review of Resident 26's MDS, dated [DATE], the MDS indicated Resident 26 has severely impaired cognitive/brain function and the resident needs maximum assistance during meals. During the review of Resident 39's AR, the AR indicated the facility admitted the resident on 6/6/2025 with diagnoses that included but not limited to dysphagia (difficulty swallowing) and muscle weakness. During the review of Resident 39's MDS, dated [DATE], the MDS indicated Resident 39 has moderately impaired cognitive/brain function and the resident need assistance in set up and cleaning up during meals. During the review of Resident 14's AR, the AR indicated the facility admitted the resident on 10/28/2025 with diagnoses that included but not limited to aphasia (a disorder that makes it difficult to speak) and protein-calorie malnutrition (severe form of nutritional deficiency due to inadequate intake of protein and calories in diet). During the review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14 has severely impaired cognitive/brain function and the resident need moderate assistance during meals. During the review of Resident 43's AR, the AR indicated the facility admitted the resident on 2/13/2026 with diagnoses that included but not limited to dysphagia (difficulty swallowing) due to cerebral infarction (loss of blood flow to a part of the brain) and protein-calorie malnutrition (severe form of nutritional deficiency due to inadequate intake of protein and calories in diet). During the review of Resident 43's MDS, dated [DATE], the MDS indicated Resident 43 has severely impaired cognitive/brain function and the resident need supervision and/or touching assistance during meals. During an observation on 3/31/2026 at 1:06 pm, in the facility dining area, 9 residents (Resident 23, Resident 20, Resident 36, Resident 26, Resident 39, Resident 14 and Resident 43) in the dining area were served lunch. Staff covered 7 of 9 residents with white bath towels (like a bib) from neck to waist without asking residents. During an interview on 3/31/2026 at 1:17 pm with Registered Nurse (RN) 1, RN 1 stated the 7 residents who had a towel as a covering on their chest needed assistance with their meals. The facility covers the residents with towels to prevent any food from spilling on resident's' clothes. During an interview on 04/02/2026 at 1:07 PM with Director of Nursing (DON), DON stated putting towel in front of residents who need assistance with feeding during mealtimes, without the resident's consent, can make residents feel embarrassed and staff must ask residents for their consent before covering the residents with towels during mealtimes. During an interview on 04/02/2026 at 1:36 PM Activity Director (AD), AD stated placing a towel on resident without obtaining consent during mealtimes, can make the resident uncomfortable and can make them feel childlike. During the review of the facility's policy and procedures (P&P) titled, Promoting/Maintaining Resident Dignity, dated 11/19/2025, the P&P indicated, Explain care or procedure to the residents before initiating the activity. 2. A review of Resident 10's admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included dysphagia (difficulty in swallowing due to damaged brain areas controlling muscles in the mouth, throat, and esophagus) following cerebral infarction (occlusion of blood flow to part of the brain), type 2 diabetes mellitus (high blood sugar resulting from the body's inability to properly use insulin (insulin resistance)), protein calorie malnutrition (inadequate intake of protein, leading to significant changes in body composition, function, and muscle wasting), and aphagia (the total inability to swallow food or liquids, or the refusal to swallow). A review of Resident 10's MDS dated [DATE] indicated the resident 10's cognition was moderately intact. The MDS indicated Resident 10 required Setup or clean-up assistance for eating and oral hygiene, toileting hygiene, upper body dressing and putting on foot wear, Resident 10 supervision/touching assistance for lower body dressing and personal hygiene and partial/moderate assistance with shower/bathing. A review of Resident 13's admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hemiplegia (severe or complete paralysis on one side of the body,) affecting the right nondominant side, dysphagia, chronic kidney disease (inability to filter waste, toxins, and excess fluid from the blood), adult failure to thrive (rapid decline in physical, cognitive, and functional health) and anxiety disorder (excessive, persistent, and uncontrollable worry or fear that interferes with daily functioning). A review of Resident 13's MDS dated [DATE] indicated the resident 13's cognition was severely impaired. The MDS indicated Resident 13 required substantial maximum assistance with eating, oral hygiene, toileting hygiene, shower/bathing self, upper and lower body dressing, putting on footwear and personal hygiene. A review of Resident 20's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included protein calorie malnutrition, metabolic encephalopathy (temporary or permanent brain dysfunction caused by chemical imbalances in the body), dysphagia, legal blindness (severe visual impairment or low vision), hearing loss, schizoaffective disorder (hallucinations or delusions—and mood disorder symptoms) and dementia (progressive, chronic loss of cognitive functioning—including memory, thinking, reasoning, and behavior). A review of Resident 20's MDS dated [DATE] indicated the resident 20's cognition was severely impaired. The MDS indicated Resident 20 required setup or clean-up assistance with eating and oral hygiene, supervision/touching assistance for oral hygiene, upper body dressing, putting on footwear and personal hygiene, partial/moderate assistance with toileting hygiene, shower/bathing self and lower body dressing. A review of Resident 22's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included pneumonia (infection that inflames the air sacs (alveoli) in one or both lungs), protein calorie malnutrition, dysphagia, chronic kidney disease, heart failure (clinical syndrome where the heart muscle cannot pump blood efficiently enough to meet the body's metabolic needs), muscle weakness, and difficulty in walking. A review of Resident 22's MDS dated [DATE] indicated the resident 22's cognition was moderately intact. The MDS indicated Resident 22 required supervision/touching assistance for eating, oral hygiene and personal hygiene, Resident 22 required substantial maximum assistance with upper body dressing and was dependent for toileting hygiene, shower bathing self, lower body dressing and putting on footwear. A review of Resident 23's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that acute respiratory failure with hypoxia (failure to maintain adequate blood oxygen levels, often causing severe symptoms such as shortness of breath, confusion, and bluish skin), dysphagia following cerebral infarction, protein calorie malnutrition, dementia, muscle weakness and difficulty walking. A review of Resident 23's MDS dated [DATE] indicated the resident 23's cognition was severely impaired. The MDS indicated Resident 23 required partial moderate assistance with eating, substantial maximal assistance with oral hygiene, upper body dressing and personal hygiene, Resident 23 was dependent for toileting hygiene, shower/bathing, lower body dressing and putting on/taking off footwear. A review of Resident 26's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included hemiplegia (complete paralysis of right side of the body) and hemiparesis (weakness on right side of the body) following cerebral infarction, aphasia, dysphagia, protein calorie malnutrition, abnormality of gait and mobility and hypertension A review of Resident 26's history and physical indicated Resident 26 did not have capacity for medical decision making due to CVA. A review of Resident 29's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy, protein calorie malnutrition, dysphagia, following cerebral infarction, osteoarthritis of bilateral knees (degenerative joint disease, causing pain, stiffness, and reduced mobility), hypertension (high blood pressure) and shortness of breath. A review of Resident 29's MDS dated [DATE] indicated the Resident 29's cognition was severely impaired. The MDS indicated Resident 29 required partial moderate assistance with eating, substantial maximal assistance with oral hygiene, upper body dressing and personal hygiene, Resident 29 was dependent for toileting hygiene, shower/bathe, lower body dressing and putting on/taking off footwear. A review of Resident 39's admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, dysphagia, protein calorie malnutrition, hypertension, major depressive disorder and difficulty walking. A review of Resident 36's MDS dated [DATE] indicated Resident 36's cognition was severely impaired. The MDS indicated Resident 36 required supervision/touching assistance for eating, partial/moderate assistance with oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear and personal hygiene Resident 36 required substantial/maximal assistance for shower/bathes. During a meal observation on 3/31/2026 at 12:23 p.m., Residents 10, 13, 20, 22, 23, 26, 29, and 36 were observed seated in the common dining area waiting for lunch to be served. Interim Activities Director (AD) provided a list of Resident room numbers and stated the listed room numbers comprised of feeders (dehumanizing term for elderly individuals needing feeding assistance, can be a derogatory, objectifying term) as Residents requiring assistance with eating. AD stated that all the Residents on the list who needed assistance with feeding, were seated at the table at the back of the dining area is dedicated for feeders- Because they need assistance eating because they (Residents 10, 13, 20, 22, 23, 26, 29, and 36) have mobility issues, poor vision, broken arms. During an interview on 4/3/2026 at 1:50 pm Interim Director of Nursing (IDON) stated Residents requiring assistance with meals should not be called feeders because it a dignity issue where a Residents inherent worth, self-respect or right to be valued is violated, neglected or ignored. A review of the facility's policies and procedures titled Promoting/Maintaining Resident Dignity, dated 11/19/2025, indicated, It is the facility practice 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 residents individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect for residents' rights.

Based on interview and record review, the facility failed to ensure that resident or their representative was notified timely in writing according to the facility's policy & procedures (P&P) titled Bed Hold Prior to Transfer with review date 11/19/2025 for two of two sampled residents, (Resident 2 and Resident 20). This deficient practice resulted in Residents 2 and 20 and/or their representative not being aware of the facility's bed hold policy upon transfer to the hospital from the facility. Findings; A review of Resident 2's admission Record indicated the facility admitted Resident 2 on 2/19/2025 with diagnoses including diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (a form of paralysis that causes severe or complete loss of muscle function, weakness, or stiffness on only one side of the body) affection right nondominant side, and end stage renal disease (ESRD - irreversible kidney failure). A review of Resident 2's Minimum Data Set (MDS - resident assessment tool) dated 3/16/2026, indicated Resident 2 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 2 required partial/moderate to substantial/maximal assistance from staff with Activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) care. A review of resident 2's Bed-hold notice, Transfer date 1/24/2026, indicated notification -Telephone notification .Yellow -resident family. A review of Resident 49's admission Record indicated the facility admitted Resident 2 on 1/18/2026, and readmitted Resident 49 on 2/8/2026 with diagnoses including cognitive communication difficulty (difficulty with communication resulting from underlying cognitive issues-such as memory, attention, or executive function-rather than primary speech or language problems), dementia (a progressive state of decline in mental abilities), and chronic kidney disease (damaged kidneys and slowly lose their ability to filter waste and extra fluid from the blood). A review of Resident 49's MDS dated [DATE], indicated Resident 49 was cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 49 required partial/moderate to substantial/maximal assistance from staff with ADL (such as bathing, dressing and toileting a person performs daily) care. A review of resident 49's Bed-hold notice, dated 2/18/2026, indicated notification -Telephone notification .Yellow -resident family. During an interview, on 4/3/2026, at 8:32 A.M., with Licensed Vocational Nurse (LVN ) 1, LVN 1 stated that the facility's process of a 7-day bed hold is that the facility has provides a 7 day bed to provide a resident or the resident's representative (if the residents is cognitively impaired), to sign a 7-day bed hold acknowledgement consent upon admission and or transfer to a hospital. LVN 1 stated that the 7-day bed hold means the resident can come back to the facility upon discharge from the hospital. LVN 1 stated that if resident has an emergency transfer, or is cognitively impaired, the 7-day bed hold is given to the resident representative via telephone. LVN 1 stated that he has never mailed a 7-day bed hold for a resident that leaves for an emergency to the hospital or was cognitively impaired, only a 7-day bed hold order is obtained from the physician, entered into the resident's physician orders. During an interview, on 4/3/2026, at 12:46 P.M., with the Director of Nursing (DON), the DON stated a 7-day bed hold is given to the residents that go out on acute (of sudden onset), or therapeutic leave because residents are entitled to come back to the facility per regulations. The DON stated that the 7-day bed hold should be given as a written notice, provided to the residents and/or mailed to the resident's representative. A review of the facility's P&P titled Bed Hold Prior to Transfer with review date 11/19/2025, indicated,Policy It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold policies prior to transferring a resident to the hospital or the resident goes on therapeutic leave. in detail: .2. The facility will have policies that address holding the resident's bed during periods of absence, such as during hospitalization or therapeutic leave.3. The facility will provide written information about these policies to residents and/or resident representatives prior to and upon transfer for such absences.

Based on interview and record review, the facility failed to ensure that one of two Certified Nursing Assistant (CNA) 1 received an annual performance review according to the facility's policy and procedures (P&P) titled Evaluation Process, reviewed 11/19/2025. This deficient practice had the potential to result in facility staff that were not competent and safely providing resident care. Findings: During a concurrent interview and record review, on 4/3/2026, at 10:26 A.M., with the Director of Staff Development (DSD), CNA1's employee file and Performance evaluation policy were reviewed. The employee file indicated that CNA 1 was hired on 8/7/2024. The DSD stated that facility's process regarding performance evaluations is done 90 days upon hire and annually to determine if any areas that the staff need improvement on, and it is not done, resident are placed at risk if the employee is not doing the right procedure, has not been updated and may not have current up to date information to perform their duties. The DSD stated that CNA 1 did not have an annual performance evaluation done, it should have been done on 1/2/2025. During an interview on 4/3/2026, at 12:42 P.M., with the Director of Nursing (DON), the DON stated that an annual performance evaluation is a review of the staff performance which is done to determine how well the staff are doing, what their strength/weaknesses are, feedback on the employees so see where there is a need for more training, if needed and feedback on what needs to be improved. The DON stated that performance evaluations are done after 90 days for a new hire and then annually, thereafter. The DON stated that if the performance evaluation is not done, there may not be feedback on what additional training needs to be provided to the staff which can impact the quality of the residents would be receiving. A review of the facility P&P tiled Evaluation Process, reviewed 11/19/2025, indicated the following: Policy:It is the policy of our facility to review the work performance of employees with a formal written evaluation annually. At the time the evaluation is given, the facility may or may not make salary/wage adjustments. There is no guarantee that a salary/wage rate increase will be given automatically each year. Factors that will be considered in making decisions about salary/wage adjustments include, but are not limited to: job performance, achieving preset goals, attendance record, adherence to workplace policies, etc.1. The following procedures will be followed for employee performance evaluations:a. At the end of each month, the Human Resource department will notify the Department Manager of evaluations due for the following month.b. Performance evaluations will be used in determining any promotions, demotions, transfers, terminations, salary/wage rate adjustments, etc. Evaluation forms should be returned to the manager/supervisor at least one (1) week prior to employee's appraisal date whenever possible.c. The Manager/Supervisor is to complete the Employee Evaluation Form based on the following categories and points available to score:i. Failing to meet expectationsii. Needs improvementiii. Meets expectationsiv. Above averagev. Excellent.e. After the evaluation has been reviewed by the Administrator, the manager/supervisor will meet with the employee to review and discuss the evaluation.

Based on observation, interview and record review, the facility failed to labeled a small zip lock bag with multiple white pills found in one of two sampled medication carts (Medication Cart 1). This failure had the potential to cause medication errors and harm to the residents.Findings: During an observation on 4/1/2026 at 11:45 am, in the facility hallway, inside Medication Cart 1, there was a small zip lock bag with multiple white pills found in one of the drawers. The zip lock bag did not indicate the name/s of the white pills inside the zip lock bag. During an interview on 4/1/2026 at 12:12 pm with Registered Nurse (RN) 2, RN 2 stated she could not identify the white pills inside the zip lock bag. RN 2 stated the pills can be accidentally administered to a resident and it could cause harm to the resident. During an interview on 4/2/2026 at 1:07 pm, the Director of Nursing (DON), DON stated any unlabeled medication/s found in the medication cart could accidentally be administered to a resident, posing a risk of harm to the resident/s. During the review of the facility's policy and procedures (P&P) titled Labeling of Medication and Biologicals, dated 11/19/2025, the P&P indicated, Labels for each floor/unit's stock medication must include the original manufacturer's or pharmacy - applies label indicating the medication name, the strength, quality, lot, and control number, the expiration date when applicable, appropriate accessory and precautionary statement and direction for use

Based on interview and record review, facility failed to document an acute change of condition for one out of one sampled Resident 50 according to facility's policy and procedures (P&P) titled Documentation in the Medical Record dated, [DATE]. This deficient practice resulted in incomplete documentation of Resident 50's Healthcare Record and had the potential to cause inconsistent communication among care teams, clinical teams, resulting from inaccuracies in crucial detecting of early health changes in residents that ensure timely interventions to prevent hospitalization, and ensuring regulatory compliance and serves as an early warning system to improve patient safety and quality of care. Findings: A review of Resident 50's admission Record indicated the Resident was admitted to the facility on [DATE] with diagnoses which included protein calorie malnutrition (inadequate intake of protein, calories, or both, leading to significant changes in body composition), type 2 diabetes mellitus (high blood sugar) resulting from the body's inability to properly use insulin (insulin resistance), alcoholic cirrhosis of the liver with ascites (advanced stage of chronic liver (abdominal organ) disease caused by long-term alcohol consumption), hypertension (high blood pressure), major depressive disorder (persistent sadness, low mood, and loss of interest in activities lasting at least two weeks) and dementia (progressive, chronic loss of cognitive functioning-including memory, thinking, reasoning, and behavior-severe enough to interfere with daily life). A review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated, [DATE] indicated Resident 50's cognitive (The mental ability to make decisions for daily living) was severely impaired, Resident 50 required supervision or touching assistance with eating and upper body dressing, moderate assistance with oral hygiene and personal hygiene, Resident 50 required substantial maximum assistance with toileting hygiene, shower bathing and walking up to 10 feet. A review of Resident 50's medical record indicates on [DATE] Resident 50 had a change in condition (COC- a sudden clinical deterioration in the resident's physical or mental condition) that required transfer to a higher level of care on [DATE]. A review of Resident 50's nursing progress note dated [DATE] at 10:52 pm indicated that During the shift Resident 50 was not feeling good (vague generalized expression), Resident 50's blood pressure was normal (no values indicated), she (Resident 50) refused to eat or drink at about 10.36 (time of day not indicated). (Resident 50) vomited (expulsion of stomach and upper digestive tract contents through the mouth) coffee ground colored content with blood. 911 (emergency medical dispatch telephone number) was called. 911 arrived at 10.42 (time of day not indicated) while resident was still vomiting and they (911) transferred Resident 50 to a higher level of care. During an interview on [DATE] 12:57 PM, Licensed Vocational Nurse (LVN) 1 stated that, COC is for non-acute changes to resident baseline such as change in vital signs and falls. LVN 1 stated that A COC is not done for Resident who have an acute incident such as Resident 50 because Nurse Calls 911.During an interview on [DATE] at 1:43pm with Interim Director of Nursing (IDON), IDON stated that Resident 50's responsible party informed facility Resident 50 expired (died) while at a higher level of care (hospital). IDON stated a COC provides timely communication and addresses changes in a residents healthcare to the physician, interdisciplinary team and family. IDON stated a COC should have been documented in Resident 50's electronic health care record to indicate the sequence of events leading up to the Residents transfer to a higher level of care. A review of the facility's policy and procedures (P&P) titled Documentation in the Medical Record dated, [DATE], indicated, Licensed staff. shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. A resident's medical record shall contain a representation of the experiences of the Resident and include enough information to provide a picture of the Resident's progress. Documentation shall be factual, objective and resident centered. Avoid generalizations and vague phrases or expressions.

Based on interview and record review, the facility failed to ensure that one of five sampled residents (Resident 20) was free of unnecessary medication according to the facility's policy and procedure (P&P) titled Unnecessary Drugs -Without Adequate Indication for Use, reviewed 11/19/2025 by failing to adhere to Consultant Pharmacist's medication regimen review recommendation (MRR-a monthly, in-depth checkup of a patient's medicines to ensure they are safe, necessary, and effective, usually in long-term care settings) on 2/17/2026. The deficient practice resulted in the unnecessary use of medication for Resident 20. Findings: A review of Resident 20's admission Record indicated the facility admitted Resident 20 on 3/4/2025 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), dementia (a progressive state of decline in mental abilities) affection right nondominant side, and atrial fibrillation (heart condition characterized by an irregular, often rapid heart rate). A review of Resident 20's Minimum Data Set (MDS - resident assessment tool) dated 3/11/2026, indicated Resident 20 was cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 20 required set up/clean up to partial/moderate assistance from staff with Activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) care. A review of Resident 20's Physicians Order dated 3/20/2026, at 5:37 P.M., indicated Seroquel (second-generation antipsychotic medication, used to treat schizophrenia order) oral tablet 25 milligram (MG -unit of measure) by mouth two times a day for agitation. During a concurrent interview and record review on 4/3/2026, at 9:37 A.M., with Licensed Vocational Nurse (LVN) 1, Resident 20's physician's order on Seroquel was reviewed. LVN 1 stated that Resident 20 Seroquel order 25 mg twice a day for agitation was ordered on 3/20/2026. LVN 1 stated that the indication for Seroquel was agitation, was not the accurate reason. LVN 1 stated that Seroquel needs to have an actual indication which in this case (Resident 20) is auditory hallucinations. LVN 1 stated that inaccurate indication for medication is a regulatory requirement, and can lead to wrong administration of medication. During a concurrent interview and record review on 4/3/2026, at 1:00 P.M., with the Director of Nursing (DON), Resident 20's physician's order for Seroquel was reviewed. The DON stated that a complete physician order contains when the medication is to be given including but not limited to what it is for (indication). The DON stated that Seroquel order with an indication of agitation was not an acceptable diagnosis. The DON stated that an accurate diagnosis needs to have a manifestation of a certain behavior. The DON stated that if the indication is not accurate, the facility may not be able to monitor it's effectiveness. A review of the facility's P&P titled Unnecessary Drugs -Without Adequate Indication for Use, reviewed 11/19/2025, indicated,Policy:It is the facility's policy that each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being free from unnecessary drugs.Indications for use is the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and is consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies, or evidence-based review articles that are published in medical and/or pharmacy journals.2. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents and/or representatives, other professionals, and the interdisciplinary team. Each resident's drug regimen will be reviewed on an ongoing basis, taking into consideration the following elements:a. Dose (including duplicate therapy)b. Duration of usec. Indications and clinical need for medicationd. Adequate monitoring for efficacy and adverse consequencese. Preventing, identifying and responding to adverse consequencesf. Any combination of the reasons stated above.6. Circumstances that may warrant evaluation of the resident and medication(s) include: .g. An irregularity identified in the pharmacist's medication regimen review. A review of the facility's P&P titled Medication Regimen Review, reviewed 11/19/2025, indicated,Policy:The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart.Policy Explanation and Compliance Guidelines:1. Medication Regimen Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes:a. Review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities.f. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.

Based on interview and record review, the facility failed to ensure that one of five sampled residents (Resident 2) was free of unnecessary medication according to the facility policy and procedure (P&P) titled Medication Regimen Review, reviewed 11/19/2025 by failing to adhere to Consultant Pharmacist's medication regimen review recommendation (a monthly, in-depth checkup of a patient's medicines to ensure they are safe, necessary, and effective, usually in long-term care settings) on 3/20/2026. The deficient practice had the potential to result in hospitalization and possible death for Resident 2. Findings: A review of Resident 2's admission Record indicated the facility admitted Resident 2 on 2/19/2025 with diagnoses including diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (a form of paralysis that causes severe or complete loss of muscle function, weakness, or stiffness on only one side of the body) affection right nondominant side, and end stage renal disease (ESRD - irreversible kidney failure). A review of Resident 2's Minimum Data Set (MDS - resident assessment tool) dated 3/16/2026, indicated Resident 2 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 2 required partial/moderate to substantial/maximal assistance from staff with Activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) care. A review of Resident 2's physicians order dated 1/29/2026, at 8:27 P.M., indicated Insulin Aspart (fast-acting, man-made insulin used by people with diabetes to manage blood sugar levels, particularly right after eating) Injection Solution 100 units/millimeter (units/millimeter units of measure) Inject 8 unit subcutaneously (beneath, or under, all the layers of the skin) before meals and at bedtime for DM2. A review of Resident 2's physicians order dated 1/29/2026, at 8:27 P.M., indicated insulin Lispro (fast-acting, man-made insulin used to manage blood sugar) Injection Solution 100 units/millimeter, Inject 2 unit subcutaneously before meals for DM2. A review of Resident 2's Consultant Pharmacist's medication regimen review recommendation on 3/20/2026 indicated: Drug(s): two orders for fast acting insulin before meals (insulin aspart and insulin lispro). Please review and discontinue one of these orders. During a concurrent interview and record review on 4/3/2026, at 10:35 A.M., with Licensed Vocational Nurse (LVN) 1, Resident 2's physician's orders and medication administration record were reviewed. LVN 1 stated that Lispro and Aspart are both fast acting insulins and should not be given together at once. LVN 1 stated that giving Lispro and Aspart insulin together may lead to hypoglycemia (a condition characterized by a low level of sugar in the blood), which could lead to death. LVN 1 stated that Resident 2 had an order for Lispro 2 units before meals and Aspart 8 units before meals and at bedtime with a sliding scale. LVN 1 stated that he saw the pharmacy recommendations from 3/20/2026 yesterday (4/2/2026) after the survey team had left for the day and that the physician has not been notified of the Pharmacy recommendations. LVN 1 stated he would notify the physician of the Pharmacy recommendation today (4/3/2026). LVN 1 stated resident 2 has been taking the insulin Lispro and Apart together since they were ordered 1/29/2026 until now. During an interview on 4/3/2026, at 1:00 P.M., with the Director of Nursing (DON), the DON stated that facility process for medication review is that the DON received recommendations from the Pharmacist, and the DON or designated staff then notifies the physician about the Pharmacist recommendations as soon as the recommendations are done. The DON stated that the Pharmacist recommendations were not relayed to the Physician and that the facility will be notifying the Physician right away. The DON stated that, if a resident is on two short acting insulins, it can be harmful to the resident as they (fast insulin)are the same class of insulin which may lead reactions such as hypoglycemia and/or death. A review of the facility's P&P titled Medication Regimen Review, reviewed 11/19/2025, indicated the following;Policy:The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart.Policy Explanation and Compliance Guidelines:1. Medication Regimen Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes:a. Review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities.f. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. A review of the facility's P&P titled Unnecessary Drugs -Without Adequate Indication for Use, reviewed 11/19/2025, indicated,Policy:It is the facility's policy that each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being free from unnecessary drugs.Indications for use is the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and is consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies, or evidence-based review articles that are published in medical and/or pharmacy journals.2. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents and/or representatives, other professionals, and the interdisciplinary team. Each resident's drug regimen will be reviewed on an ongoing basis, taking into consideration the following elements:a. Dose (including duplicate therapy)b. Duration of usec. Indications and clinical need for medicationd. Adequate monitoring for efficacy and adverse consequencese. Preventing, identifying and responding to adverse consequencesf. Any combination of the reasons stated above.6. Circumstances that may warrant evaluation of the resident and medication(s) include: .g. An irregularity identified in the pharmacist's medication regimen review.

Based on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measurement for space) per resident in multiple resident bedrooms for seven of 25 resident rooms, (Rooms 9, 11, 14 16, 26, 27, and 28). This deficient practice had the potential to result in inadequate useable living space for all the residents and working space for the health caregivers, which could affect the quality of life for the residents. Findings: A review of the Request for Room Size Waiver letter submitted by the Administrator, dated 4/2/2026 indicated 5 resident rooms in the facility have no projections or other obstruction, which may interfere with free movement of wheelchair and/or sitting devices. There is enough space to provide for each Resident's care, dignity and privacy and that the rooms are in accordance with the special needs of the residents and would not have an adverse effect on resident's health and safety or impede the ability of any resident in the rooms to attain his or her highest practicable well-being. The following rooms provided are less than 80 square footages (sq.ft -unit of measure) per resident:Room Room Size Floor Area #of beds9 15.1x 9.3 147.9 211 15.1x9.9 147.4 214 15.1x9.5 143.2 216 15.1x 9.5 143.2 2 26 11.1x 12.8 134.35 227 15.2x 10.3 156.4 228 15.2x 10.3 156.4 2 According to the federal regulation, the minimum square footage for a two bedroom is at least 160 sq. ft. During the recertification Survey on 3/31/2026 to 4/3/2026, staff interviews indicated there were no concerns regarding the size of the rooms. During multiple observations of the residents' rooms from 3/31/2026 to 4/3/2026, the residents had ample space to move freely inside the rooms. There were sufficient spaces to provide freedom of movement for the residents and for nursing staff to provide care to the residents. There were also sufficient spaces for bedside tables, side tables and resident care equipment. During a concurrent observation and interview on 4/1/2026, at 1:10 P.M., with the maintenance Supervisor (MS) a laser room measure after confirming accuracy with a measuring tape to measure the size of the room from the window to the door for the length, then measuring from wall to the wall horizontally for the width. The MS stated, this is how I measure to verify the size of the rooms. During an interview on 4/3/2026 at 12:30 P.M., the Director of Nursing (DON), the DON stated the required square footage per resident is 80 sq.ft, the facility requested for a room waiver requesting for the square footage to be acceptable even if it does not meet the regulatory requirement for residents care to still be provide.

Based on interview and record review, the facility failed to provide an effective discharge for one of three sampled residents, (Resident) 1 with a safe and orderly discharge planning by failing to:1.Ensure the facility's policy and procedure (P&P), titled, Discharge Planning Process, was applied by ensuring an effective discharge planning process that addressed the discharge destination met Resident 1's health and safety needs and preferences.2. Ensure Resident 1's care plan for discharge was implemented.3. Ensure that the discharge notice is provided to the resident's representative and Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) in a language and manner in which they can understand at least 30 days prior to discharging Resident 1.These deficient practices resulted in unsafe discharge setting that led to Resident 1's physical harm and hospitalization, Resident 1 was home alone for six days without any necessary care, Resident 1 was found on the floor with injury and was sent to General Acute Care Hospital 1 (GACH 1) on 9/1/2025.During a review of Resident 1's admission Record, it indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including Parkinson's disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain), infection and inflammation reaction due to internal left knee prosthesis (germs have gotten into the joint, causing the body's immune system to attack), type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), acquired absence of left leg above knee (loss of left leg above the knee due to amputation or other causes), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure). The admission Record also indicated that Resident 1 was discharged home on 8/26/2025.During a review of the medical record from General Acute Care Hospital 2 (GACH 2) indicated the following:i. On 6/30/2025, Resident 1 had a revision left above the knee amputation (to correct any complications that arise after primary amputation surgery).ii. Occupational Therapy Evaluation, dated 7/1/2025, indicated, support available: Friend - has a friend that has historically helped her (Resident 1) as needed but may not be able to provide as much as he used to due to his own health issues; homemaking assistant: needs assistance.iii. Physical Therapy Treatment, dated 7/2/2025, indicated that Resident 1 had a non-weight bearing (you cannot place any of your body weight on an injured limb, such as a leg or arm, for a specific period to allow it to heal) on left lower extremity (left leg).iv. Referral Notes from GACH 2, dated 7/3/2025, it indicated, Resident 1 has physical limitations such as deconditioning (when a person is immobile for an extended period of time), frailty (when your body can't get through and recover from illnesses and injuries on its own), malnutrition (lack of sufficient nutrients in the body) or other physical limitation that impair ability to participate in their care, has poor health literacy (the inability to get, process, and understand basic health information and services needed to make good health decisions) and no patient support with social isolation, absence of support to assist with care, as well as insufficient or absent connection with primary care. During a review of Resident's History and Physical (H&P), dated 7/4/2025, it indicated that Resident 1 does not have a decision-making capacity. The H&P also indicated that, Emergency Contact 1 (EC1) is Resident 1's Durable Power of Attorney (POA - authorizes someone else to handle certain matters, such as finances or health care, on someone's behalf. If the power of attorney is durable, it remains in effect if the person becomes incapacitated for any reason, including illness and accidents).During a review of Resident 1's Durable Power of Attorney, indicated Resident 1's EC1 was Resident's 1 appointed POA, signed and dated on 10/10/2024.During a review of the Minimum Data Set (MDS - resident assessment tool) dated 8/26/2025, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 required moderate assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS also indicated Resident 1 used a manual wheelchair.During a review of Resident 1's Care Plan (CP) for discharge, initiated on 7/9/2025, the CP indicated a goal of, Resident (1) will move to an appropriate lower level of care without complication and when appropriate. The CP included interventions such as, facility will provide education to resident/family regarding referrals, community resources and resident and/or family will be involved in discharge planning.During a review of Resident 1's Progress Notes, dated 8/22/2025, it indicated that, Per resident (Resident 1) request, she will discharge home on 8/26/2025, HHA 1 will follow-up for nursing, physical therapy (PT) and Occupation Therapy (OT) services, documented by Social Services Director (SSD).During a review of Resident 1's Post-Discharge Plan of Care and Summary (PDPOCS), dated 8/27/2025, it indicated that Resident 1 was discharged home with Home Health Agency 1 (HHA 1). The PDPOCS indicated a section for each interdisciplinary team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) that included rehabilitation services, dietary services, social services, activities services and nursing services. Each section of the IDT team included notes of discharge recommendations, in which these sections were blank and did not have any information. The PDPOCS IDT sections were all signed and documented by Licensed Vocational Nurse 2 (LVN 2).During a review of Resident 1's Notice of Proposed Transfer/Discharge indicated the notification was sent to Ombudsman via facsimile transmission dated 8/27/2025.During a review of HHA medical record, titled, Start of Care dated 8/27/2025, it was indicated that Resident 1's home environment was altered with cluttered/soiled living conditions, difficulty buying necessities, lack of caregiver/family support, limited social contact and has poor home environment. The Start of Care also indicated that, Patient (Resident 1) has three cats in her home, home is littered with cat urine and feces. Patient (Resident 1) has a POA who lives one hour away and does not visit frequently. It was suggested to patient (Resident 1) to go to assisted living or low-income housing, patient (Resident 1) stated she doesn't want anyone to pull her out of home, she (Resident 1) wants to pass away in the same home her husband passed away in. Patient (Resident 1) with a left above knee amputation exhibits significant mobility limitations and environmental safety risks. Patient (Resident 1) has difficulty independently propelling her WC and demonstrates limited mobility within the home. The living environment is noted to be unclean, with spider webs, excessive dust, and foul odor. Bed [NAME] is high, creating additional fall risk for an amputee. Multiple arcade machines present further clutter and obstruct safe wheelchair navigation.During an interview with Certified Nursing Assistant 1 (CNA 1) on 9/3/2025 at 12:04 p.m., CNA 1 stated, Resident 1 needs assistance with toileting, showering and transferring from bed to a wheelchair while in the facility. CNA 1 stated, Resident 1 was unable to feel if her incontinent brief was wet as she would verbalize to CNA 1 that it wasn't time for her to be changed but when she checked her incontinent brief, it would be wet.During an interview with Physical Therapist Assistant 1 (PTA 1) on 9/3/2025 at 12:25 p.m., PTA 1 stated that Resident 1 had a non-weight bearing order by the physician on her left lower extremity due to a recent revision of above the knee amputation. PTA 1 stated, during PT exercises, Resident 1 required assistance with transferring from bed to wheelchair and unmotivated during therapy with feeling down. PTA 1 stated, Resident 1's physical therapy goal was to be able to use prosthetic so she may move independently and be functional with ADLs. PTA 1 stated, they could not use her prosthetic as they have not received a clearance from her physician, and her left lower extremity and skin integrity was still recovering from her recent surgery. PTA 1 further stated, Resident 1 did not meet her goal for discharge planning.During an interview with EC 1 on 9/3/2025 at 2:54 p.m., EC 1 stated, he is Resident 1's POA per her (Resident 1)'s request. EC 1 stated, he had a different phone number that was listed on Resident 1's record. EC 1 stated, he was not included in the IDT meeting regarding Resident 1's discharge planning. EC 1 stated, he finally received a call from SSD on the day of Resident 1's discharge on [DATE] in which SSD informed him that Resident 1's was about to be picked up by the transportation to be discharged home and to make sure that he will be in Resident 1's home when she gets dropped off. EC 1 asked SSD why she (Resident 1) was being discharged , as he believed that Resident 1 will not be safe to be discharged home alone. EC 1 rushed to go to Resident 1's home on 8/26/2025 to help her when she gets home but he also left that night. EC 1 stated, he does not live with Resident 1 and Resident 1's home was neglected as no one lived in that house for months and it needs to be fixed and cleaned as her house was being housed by cats and racoons that were able to go in and out of the house due to a broken screen door. EC 1 further stated, Resident 1 does not have any mobile phone or any other phone that she may be contacted. EC 1 stated, HHA 1 contacted him as he was the only contact for Resident 1, so he decided to get Resident 1 a mobile phone so that she could be contacted. EC 1 stated, he visited Resident 1, along with his son on 9/1/2025 to give her mobile phone and that was when they found Resident 1 on the floor on her side, there were bowel movements on the floor, on the blanket and on certain parts of her body and she was unable to move on her own.During a concurrent interview with the Social Services Director (SSD) on 9/3/2025 at 1:07 p.m., SSD stated, she had sent in an application for home maker service, personal care and in-home care as part of her discharge planning during her initial admission but had not received any approval information. SSD stated that she was not aware that Resident 1 had a POA. SSD stated, Resident 1 verbalized of wanting to be discharged home on 8/21/2025 and wanted to leave against medical advice (AMA) so she contacted the physician to get an order for a HH and a WC. SSD stated, she was able to arrange a HH and Resident 1 agreed to stay until she was discharged on 8/26/2025. SSD stated, she tried contacting Resident 1's EC 1 on 8/21/2025 but she was unable to contact EC 1 because the contact information they had on file was a non-working number. SSD further stated, Resident 1 does not have a personal mobile phone and was aware there was no other personal contact when Resident 1 was discharged to home on 8/26/2025.During an interview with Home Health Agency Manager (HHAM) on 9/3/2025 at 1:44 p.m., HHAM stated, Resident 1 was initially evaluated by HHA nurse on 8/27/2025. HHAM stated Resident 1 does not have any mobile phone or any other form of communication, so the HHA nurse waited outside Resident 1's door for 30 minutes until Resident 1's opened the door. HHAM stated, on 8/28/2025, the Physical Therapist from HHA attempted to do their initial evaluation but Resident 1 did not open the door, and they were not able to talk to Resident 1. HHAM stated, he talked to Resident 1's EC 1 in which he recommended Resident 1 to have her own mobile phone so they can contact her. HHAM stated, no other visit was conducted with Resident 1 after 8/27/2025.During an interview LVN 2 on 9/3/2025 at 2:21 p.m., LVN 2 stated, he documented and signed Resident 1's PDPOCS upon discharge on [DATE]. LVN 2 stated, he did not do the discharge teaching and education for Resident 1, and he just documented all IDT sections and signed it so it would be completed. LVN 2 stated, he left the form blank for each IDT services and recommendations because he doesn't know what Resident 1 status upon discharged .During a follow-up interview with SSD on 9/5/2025 at 1:37 p.m., SSD stated, during the initial IDT meeting, Resident 1 verbalized that she wanted to go home during discharge planning. SSD stated, when she asked for a discharge order from the physician, she did not ask the nursing team and rehabilitation team regarding Resident 1's needs for a safe discharge and she thought a home health agency would be able to provide her needs upon discharging to home. SSD stated that she was aware that Resident 1 was not able to use her prosthetic for three months, as ordered by her surgeon, so that her skin will heal after her surgery. SSD stated, she did not talk to Resident 1's EC 1 during her stay in the facility and was not aware of Resident 1's living situation at home with SSD verbalizing, how am I supposed to know those things?.During an interview with Director of Nursing (DON) on 9/5/2025 at 1:52 p.m., DON stated, Resident 1 wanted to go home but she needs a 24-hour care to be safe at home. DON Stated she had not seen EC 1 visit the facility and was not aware that he was given instructions on how to care for Resident 1 upon discharge as a care giver. DON stated, it is up to the nursing department and the whole IDT to determine if Resident 1 can be discharged to home safely, it is not just the decision of the social services department. DON stated, if Resident 1 wanted to go AMA, they cannot stop or refuse but they can refer them to Adult Protective Services (APS - a state-run program that protects vulnerable adults from abuse, neglect, and exploitation) so they may assess resident's home to ensure she will be safe at home. DON stated, APS was not contacted upon Resident 1's discharge to home. DON further stated, the post-discharge summary should be completed by documenting and signing each section by that particular IDT.During an interview with General Acute Care Hospital Social Worker 1 (GACH SW1) on 9/8/2025 at 2:04 p.m., GACH SW 1 stated, Resident 1 was admitted to GACH 2 with an initial diagnosis of ST-elevation myocardial infarction (STEMI - is a type of heart attack that is more serious and has a greater risk of serious complications and death). GACH SW 1 stated, Resident 1 was found on the floor with extensive wound on her right forehead, right elbow, right heel, right hip thigh, right shoulder and the wound on her right shoulder was horrible. GACH SW 1 stated, POA questioned the facility why Resident 1 was being discharged home without proper care and without confirming with him. During a review of the facility's policy and procedure (P&P), titled, Discharge Planning Process, date reviewed/revised by facility on 5/28/2025, the P&P indicated, It is the policy of this facility to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmission.In cases where the resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the IDT will treat this situation similarly to refusal of care: discussed with the resident, (and/or his of her representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location; offer other, more suitable, options of locations that are equipped to meet the needs of the resident. Document any discussions related to the options presented; Document refusals of other options that could meet the resident's needs; At time of discharge, follow policies regarding discharges Against Medical Advice, and refer to Adult Protective Services (or other state entity charged with investigation abuse and neglect,) as necessary. If discharge to community is a goal, an active discharge care plan will be implemented and will involve the IDT, including the resident and/or resident representative. The plan shall be documented. The facility will document any referrals to local contact agencies or other appropriate entities made for the purpose of the resident's interest in returning to the community. The evaluation of the resident's discharge needs and discharge plan will be completely documented on a timely basis in the clinical record. The results of the evaluation and the final discharge plan will be discussed with the resident or resident's representative. Education needs, as identified in the discharge plan, will be provided to the resident and/or family member prior to discharge.

Based on observation, interview, and record review, the facility failed to ensure the staff followed the facility's infection control policy and procedure (P&P) by not labeling the personal hygiene belongings (two emesis basins, two toothbrushes, one toothpaste and two bottles of bath soap) in the shared bathroom for four of 14 sampled residents (Resident 25, Resident 27, Resident 28, and Resident 31). This deficient practice had the potential to result in Resident 25, Resident 27, Resident 28, and Resident 31 getting and spreading infection (the establishment of an infective agent in or on a suitable host, producing clinical signs and symptoms such as fever, redness, heat, etc.). Findings: During an observation on 1/21/2025 at 9:24 a.m. in a shared bathroom (shared by Resident 25, 27, 28, and 31), there were two toothbrushes (inside a wall cabinet on top of the sink) , two emesis basins (one was on top of the paper roll machine, the other was on top of the cabinet), two bottles of body soap (one was in the cabinet, another was on top of the sink), and one toothpaste (inside the cabinet) without resident identification labels. During an interview on 1/21/2025 at 9:26 a.m. with Certified Nurse Assistant (CNA)/Restorative Nurse Assistant (RNA) 1, CNA/RNA 1 stated the facility should not leave residents' personal hygiene belongings unlabeled inside the shared bathroom. CNA/RNA 1 stated the unlabeled used items in the bathroom could cause and spread infection between residents and should be thrown away. During an interview on 1/23/2025 at 9:53 a.m. with the Infection Preventionist (IP), IP stated the facility should follow the infection control policy and procedure and throw away any resident's personal hygiene belongings without labeling in the shared bathroom to prevent resident getting and spreading infection. During a review of Resident 25's Admission Record, the Admission Record indicated the facility admitted Resident 25 on 5/23/2024 with diagnoses including major depression disorders, protein-calorie malnutrition (reduced nutrients leading to changes in body composition and function), gastro-esophageal reflux disease (GERD- a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach), abnormalities a of gait and mobility, and schizophreniform disorder (a mental illness characterized by disturbances in thought). During a review of Resident 25's Minimum Data Set (MDS- a resident assessment tool) dated 12/16/2024, the MDS indicated the resident had intact cognitive (ability to remember things, solve problems, or make decisions) skills for daily decision making. The MDS indicated the resident required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance) to complete personal hygiene activities (including combing hair, shaving, applying makeup, washing/drying face and hands). During a review of Resident 27's Admission Record, the Admission Record indicated the facility admitted Resident 27 on 1/2/2025 with diagnoses including acute respiratory failure with hypoxia (a condition in which the body is unable to adequately oxygenate the blood due to a decline in lung function), chronic pancreatitis (a progressive inflammatory disease characterized by irreversible damage to the pancreas), immunodeficiency (a condition in which the body's immune response was reduced or absent ), fracture (broken bone) of one right side rib, end stage renal disease (ESRD- irreversible kidney failure). During a review of Resident 27's MDS dated [DATE], the MDS indicated the resident had intact cognitive skills for daily decision making. The MDS indicated the resident required partial assistance (staff did less than half the effort) from staff to complete self-care including bathing, dressing, using the toilet, or eating. The MDS indicated the resident required supervision or touching assistance to complete oral hygiene. During a review of Resident 28's Admission Record, the Admission Record indicated the facility admitted Resident 28 on 11/2/2024 with diagnoses including immunodeficiency, type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control), and anxiety disorder (a mental illness caused excessive and uncontrollable feelings of fear and anxiety). During a review of Resident 28's MDS dated [DATE], the MDS indicated the resident had intact cognitive skills for daily decision making. The MDS indicated the resident required supervision or touching assistance to complete oral hygiene. The MDS indicated the resident required partial assistance from staff to complete personal hygiene. During a review of Resident 31's Admission Record, the Admission Record indicated the facility admitted Resident 31 on 7/30/2024 with diagnoses including transient cerebral ischemic attack (a short period of reduced blood flow to the brain), major depressive disorder, hypertension (high blood pressure), and dementia (a progressive state of decline in mental abilities) with anxiety. During a review of Resident 31's MDS dated [DATE], the MDS indicated the resident had moderately impaired cognitive skills for daily decision making. The MDS indicated the resident required partial assistance from staff to complete oral hygiene and personal hygiene. During a review of the facility's policy and procedure titled, Infection Prevention and Control Program, revised 12/9/2024, the P&P indicated the facility should follow guidelines for general infection prevention and control while providing resident care services. The P&P indicated all staff should follow the standard precaution (based on the principle all blood, body fluids, secretions, regardless of whether contain visible blood, non-intact skin, and mucous membranes may contain transmissible infectious agents) for all residents all the time.

Based on observation, interview, and record review the facility failed to dispose of medications in a manner that was not retrievable (able to get back,) in one of one inspected medication room (Medication room [ROOM NUMBER].) This failure had the potential to increase the opportunity for medication diversion (the transfer of a medication from a lawful to an unlawful channel of distribution or use,) and increase the risk that residents in the facility could have accidental exposure to harmful medications possibly leading to physical and psychosocial harm, and hospitalization . Findings: During a concurrent observation and interview on [DATE] at 11:21 a.m. with Licensed Vocational Nurse (LVN) 3 in Medication room [ROOM NUMBER], the pharmaceutical waste bin was open and contained a mixture of intact (unchanged from original form) loose medication tablets and capsules out of their manufacturer packaging, medications in manufacturer bottles, creams/ointments and unopened and unused suppositories and patches in their original manufacturer packaging. LVN 3 stated the pharmaceutical waste bin was open and contained medications that were disposed in original manufacturer packaging and as loose tablets and capsules. During an interview on [DATE] at 11:39 a.m. with Registered Nurse (RN) 1 in Medication room [ROOM NUMBER], pharmaceutical waste bin was open and contained intact lose medication tablets and capsules, medications in bottles, creams/ointments and unopened and unused suppositories and patches. RN 1 stated per the facility policy and procedures (P&P) medications needed to be disposed of in a manner that the medications could not be retrieved by pouring liquid over them to disintegrate (break apart) the medications. RN 1 stated the pharmaceutical bin did not contain liquid poured over the medications, and the medications remained in a form that could be easily retrieved and re-used. RN 1 stated when medications are not disposed properly there could be the potential for accidental misuse and diversion. During an interview on [DATE] at 1:07 p.m., with the Director of Nursing (DON) and in the presence of the Administrator (ADM,) the DON stated the pharmaceutical waste bin contained medications that were disposed in their original manufacturer packaging and as lose tablets and capsules and medications in original manufacturer packaging. The DON stated the pharmaceutical bin did not contain liquid that disintegrated the medications, and the medications remained in their original form, allowing for easy access, retrieval, and potential re-use. DON stated the facility failed to dispose of medications in Medication room [ROOM NUMBER] in a manner to prevent retrieval. The DON stated without proper disposal of medications there was increased potential of accidental misuse and diversion of medication, and exposure of harmful substances affecting the safety of all residents and staff. During a review of the facility's P&P, titled Storage of Medications, last reviewed [DATE], the P&P indicated, Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closure are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. During a review of the facility's P&P titled Medication Destruction, last reviewed [DATE], the P&P indicated, Discontinued medications and medications left in the facility after a resident's discharge, which do not qualify for return to the pharmacy for credit, are destroyed. During a review of the facility's P&P titled Destruction of Unused drugs, last reviewed [DATE], the P&P indicated: All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations.

Based on observation, interview and record review, the facility failed to ensure to protect resident right's to be treated with respect and dignity for one of two sampled resident (Resident 390). 1.Resident 390 was not provided bathroom assistance during mealtimes, was told that she will eat after she was provided incontinence care but was not provided care timely. 2.Resident 390 was not turned and repositioned when requested. These failures of not getting timely assistance resulted in Resident 390 felt she was treated like a child, had to eat with soiled incontinence (inability to control the release of urine or stool) brief, was left uncomfortable, upset, frustrated, and helpless. Findings: a. During a concurrent observation and interview on 1/21/2025 at 4:22 p.m., in Resident 390's room, Resident 390 appeared upset and stated the staff were quick to answer the call light and turn the call light off, but she had to wait a long time for the CNAs to respond to her request for assistance. Resident 390 stated CNA 3 and CNA 4 (unable to recall exact day) would ask her What do you need? in elevated and harsh tone of voice. Resident 390 stated she informed them she just wanted to know who was her CNA and they will tell her Why do you want to know? Resident 390 stated she is not a kid for CNAs to raise their voice at her. During an interview on 1/21/2025 at 4:25 p.m. Resident 390 stated on 1/19/2025 morning, she requested CNA 3 to clean her because she had a bowel movement, but CNA 3 told her she needed to wait for CNA 3 to finish passing meal trays before CNA 3 would clean her. Resident 390 stated this happened several times in December to January 2025. Resident 390 stated the longest time she had to wait to be cleaned was 40 minutes. Resident 390 questioned if passing meal trays was more important than cleaning her. Resident 390 stated the delayed in care made her feel uncomfortable, upset, frustrated, and neglected. Resident 390 stated she felt helpless when CNA 3 and CNA 4 ignored her request for assistance, and she have no choice but to tolerate how they treat her like a child because she was sick, unable to walk and care for herself. During an interview on 1/22/2025 at 2:39 p.m., CNA 1 stated on Sunday (1/19/2025) morning at 8:30 a.m. Licensed Vocational Nurse (LVN) 5, CNA 3 and another CNA (unidentified) were talking about how Resident 390 did not want CNA 3 to clean her. CNA 1 stated she volunteered to take care of Resident 390 for the rest of the day. CNA 1 stated she did not know why Resident 390 refused CNA 3. CNA 1 stated she volunteered to take care of Resident 390 so that the Sunday can be a day of peace. CNA 1 confirmed Resident 390 was incontinent and had large bowel movement when she cleaned Resident 390. During a telephone interview on 1/22/2025 at 2:52 p.m., LVN 5 stated on 1/19/2025 at 8 a.m., CNA 3 was busy passing meal trays, had to feed another resident (unidentified), and was not able to change Resident 390's incontinence brief right away. LVN 5 stated CNA 3 informed her when CNA 3 returned to Resident 390's room to clean the resident, Resident 390 refused to be cleaned. LVN 5 stated she talked to Resident 390 and the resident was upset because she waited too long for CNA 3 to clean her. LVN 5 stated Resident 390 refused CNA 3 to clean her and would rather be cleaned by the next shift 3-11 p.m., or someone else. LVN 5 stated she explained to Resident 390 she cannot keep Resident 390 wet all day and she cannot have her wait for the 3 to 11 p.m. shift. LVN 5 stated she had to reassigned Resident 390 to CNA 1. LVN 5 stated CNA 3 should have asked another CNA to helped pass the meal trays. LVN 5 stated the facility was not short staffed and have enough staff to assist with passing meals trays or cleaning residents. During a telephone interview on 1/23/2025 at 8:30 a.m., CNA 3 stated in an elevated tone of voice, Resident 390 was very demanding, frequently used her call light to request to be cleaned, repositioned, fed, and showered. CNA 3 stated her voice sounded usually rough and strong but when she speaks to the residents, she would tone down her voice. CNA 3 stated on 1/19/2025 at 7:30 a.m., while CNA 3 was passing meal trays, Resident 390 pressed the call light and requesting to change her soiled incontinence brief. CNA 3 stated she asked Resident 390 to wait until she (CNA 3) finished passing the meal trays and she would return back to clean Resident 390. CNA 3 stated she did not know who passed Resident 390's meal tray but told Resident 390 after she clean Resident 390 then she (Resident 390) could eat. CNA 3 stated after passing meal trays to other residents, she went back into Resident 390's room and Resident 390 was already eating and refusing to be cleaned. CNA 3 stated she called LVN 5 (charge nurse) because Resident 390 was refusing to be cleaned and LVN 5 told her the assignment would be changed. CNA 3 stated when they were passing meal tray, they cannot do fecal or urinary incontinence care because of an infection control rule which was no cleaning resident to prevent contamination of food and prevent foul odor during mealtime. CNA 3 stated the food would get cold if there was a delay in passing the meal trays. CNA 3 stated she did not ask help to pass the meal trays or clean Resident 390 because she was assigned to the resident and no one else was going to clean her. During an interview on 1/23/2025 at 9:42 a.m., the Director of Staff Development (DSD) stated, CNA 3 told him on 1/22/2025, CNA 3 was going to distribute the meal trays first on 1/19/2025 before cleaning and changing Resident 390's incontinence brief because of infection control concern and cleaning Resident 390 was dirty and she does not want to contaminate the food. The DSD stated when staff were passing meal trays, they can stop passing meal trays and provide incontinence care to residents. The DSD stated the infection control rule that applies after you perform incontinence care was to ensure to do proper hand washing. The DSD stated resident requests needed to be addressed right away. During an interview on 1/23/2025 at 10:50 a.m., the Director of Nursing (DON) stated she spoke to Resident 390, CNA 1, CNA 3 and LVN 5. The DON stated Resident 390 informed her that on 1/19/2025 at 7:30 a.m., CNA 3 brought the breakfast tray to Resident 390 room but Resident 390 said she needed to be cleaned because she had a bowel movement. The DON stated CNA 3 said she told Resident 390 that she would have to wait to be cleaned after CNA 3 passed the meal trays. CNA 3 said she came back at 8 a.m., saw Resident 390 eating her breakfast and Resident 390 refused CNA 3 to clean the resident. The DON stated they teach the staff if the resident needed to be cleaned, the resident should be cleaned. The DON stated the food temperature was important, but the resident should have been cleaned. The DON stated CNA 3 should have asked for assistance to replace her to pass the meal trays. The DON stated they were not short staffed and have enough staff to assist with meal trays. The DON stated the facility needed to protect residents' dignity. During an interview on 1/23/2025 at 11:14 a.m., the Administrator (ADM) stated Resident 390 should have not been left soiled to pass meal trays. The ADM stated the facility has no infection control rule that prohibit the staff from cleaning the resident during mealtime. The ADM stated an infection control was a concern if the staff did not perform handwashing after doing incontinence care. The ADM stated the facility was not short staffed and CNA3 should have called for help. b. During an interview on 1/21/2025 at 4:36 p.m., CNA 4 stated Resident 390 was very demanding, used the call light a lot and wanted everything to be done promptly. CNA 4 stated Resident 390 was upset when CNA 4 would ask Resident 390 to wait but Resident 390 has to wait when she was busy with other residents. CNA 4 stated the call lights were answered in the order of who pressed the call light first. CNA 4 stated Resident 390 wanted to be repositioned every 30 minutes, was very demanding and would use the call light just to ask what was going on in the activity room (located in front of Resident 390's room) and stated in elevated tone of voice emphasizing That was not an emergency. During an interview on 1/21/2025 at 4:40 p.m., CNA 4 stated she provided incontinence care to Resident 390 before going on break at 7 p.m. (unable to recall date) then after her 30 minutes break, one of the residents (did not specify) requested to be cleaned but at the same time Resident 390 had her call light on. CNA 4 stated she asked what Resident 390 needed, and Resident 390 said she wanted to be repositioned. CNA 4 stated she cancelled Resident 390's call light and told her she would return after answering another resident's call light. CNA 4 stated in her mind Resident 390 was just changed and could wait. CNA 4 stated she did not ask anyone to assist Resident 390 because the other CNAs were busy with their residents. CNA 4 stated it took 10 minutes to do incontinent care for the other resident and then CNA 4 returned to repositioned Resident 390. CNA 4 stated they were not short staff but did not ask anyone for assistance and assumed everybody was busy with their own residents. CNA 4 stated they do not ask for help as they have their own assignment, and the resident would have to wait. During an interview on 1/23/2025 at 9:42 a.m., the DSD stated, the DSD stated the CNA's can call for assistance if there were multiple call lights activated at the same time. The DSD stated that it can take 10-20 minutes to change a resident, so it will be faster for the CNA to turn and reposition Resident 390 first or the CNA can ask for assistance from any staff to turn and repositioned Resident 390, so the resident does not need to wait too long. The DSD stated anyone can turn and reposition the resident including the DSD, LVN or registered nurse (RN). The DSD stated they were not short staff and there should be available help if they asked for help or assistance. The DSD stated that resident requests should be addressed right away. During an interview on 1/22/2025 at 3:18 p.m., the DON stated CNA 4 have a high pitch tone of voice, but staff should tone down their voice and speak to residents respectfully. The DON stated the staff should avoid labeling a resident as Demanding. The DON stated if the resident voiced being uncomfortable and wanted to be repositioned the nurses should check the resident even if they were cleaned 30 minutes ago. The DON stated it would only take few minutes to reposition the resident and CNA 4 should have repositioned Resident 390 as she was probably uncomfortable. The DON stated CNA 4 could have asked for assistance if she cannot reposition Resident 390. The DON stated anybody can assist to help reposition residents and there was no reason for Resident 390 to wait. The DON stated if the resident wanted to know what was going on in the activity area the nurses should inform the resident. The DON stated they were not short staff and there should be enough help to assist Resident 390. During a review of Resident 390's Admission Record (Face Sheet), dated 12/3/2024, the Face Sheet indicated the facility admitted Resident 390 on 12/3/2024 with diagnoses including Parkinson's disease (a progressive disease of the nervous system marketed by tremor, muscular rigidity, and slow, imprecise movements), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), protein-calorie malnutrition (PCM- a condition that occurs when the body does not get enough protein or calories), muscle weakness (a lack of strength in your muscles, making it difficult to move or contract them normally) other abnormalities of gait and mobility (unusual walking patterns that can affect a person's mobility). During a review of Resident 390's Care Plan for Bowel Incontinence, dated 12/5/2024, the Care Plan indicated the resident has bowel incontinence with interventions to check the resident every two hours and assist with toileting as needed. During a review of Resident 390's Minimum Data Set (MDS- a resident assessment tool), dated 12/6/2024, indicated the cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired and required maximum assistance (helper does more than half the effort) for activities of daily living. During a review of Resident 390's Documentation Survey Report (document used by CNA to chart resident's activities of daily living), dated January 2025, the Documentation Survey Report indicated CNA 1 documented on 1/19/2025 that Resident 390 had an incontinent, large bowel movement. During a review of the facility's policy and procedure titled, Promoting/Maintaining Resident Dignity, dated 12/16/2024, indicated, All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. Respond to requests for assistance in a timely manner.

Based on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal his/her need for assistance from staff) was within reach for two of 25 residents (Resident 21 and 390). This failure had the potential to delay the resident's care. Findings: a. During a review of Resident 21's Admission Record, (not dated), the Admission Record indicated, Resident 21 was admitted on [DATE] with the following diagnoses, but not limited to, cerebrovascular accident(CVA- a stroke, loss of blood flow to a part of the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) with left sided weakness, muscle weakness, left elbow contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion). During a review of Resident 21's care plan (CP) for communication issues, dated 9/12/2023, the CP indicated Resident 21 has communication issues related to unclear speech. The CP interventions indicated Resident 21 will be provided with a safe environment, including a call light placed within reach. During a review of Resident 21's Minimum Data Set (MDS, a resident assessment tool), dated 11/1/24, the MDS indicated Resident 21 had severely impaired cognitive skills and required maximal assistance from staff for toileting, dressing, and personal hygiene. During a review of Resident 21's CP for fall risk dated 11/7/2024, the CP indicated Resident 21 was at risk for falls. The CP interventions indicated Resident 21's call light should be within reach and Resident's requests for assistance should be promptly addressed. During an observation on 1/21/25 at 9:30 a.m. in Resident 21's room, Resident 21 was lying in bed with their call light hanging from the right side of the bed, out of reach of the resident while unattended by staff. During a concurrent observation and interview on 1/21/23 at 11:40 a.m. with Certified Nurse Assistant (CNA) 2 in Resident 21's room, Resident 21 was lying in bed with call light cord placed under a pillow elevating Resident 21's upper right arm and shoulder. CNA 2 stated the call light is not within reach of the Resident. CNA 2 also stated it is important for resident to have access to call light to call for assistance when they need care, and to prevent resident injuries such as falls. During an interview on 1/23/25 at 3:42 p.m. with the Director of Nursing (DON), DON stated the call light should be within reach of residents to prevent delay in care and maintain the residents' safety. 49390 b. During an observation and interview on 1/21/2025 at 12:26 a.m., in Resident 390's room, Resident 390 was sitting in a wheelchair beside the left side of the bed while eating lunch. Resident 390 stated she was unable to reach the call light to ask for assistance since it was approximately three (3) feet away from her and was wrapped around the right siderail. Certified Nurse Assistant (CNA) 1 unwrapped the call light that was on the siderail and placed it within reach of Resident 390. CNA 1 stated resident's call lights should always be within reach of the resident so the resident could ask for assistance. During an interview on 1/23/2025 at 10:47 a.m., the Director of Nursing (DON) stated the CNA should ensure to place the call light within resident's reach and check the call light placement during rounds. The DON stated it was important for the call light to be within reach so the residents can communicate their needs and for resident safety. During a review of Resident 390's Admission Record (Face Sheet), dated 12/3/2024, the Face Sheet indicated the facility admitted Resident 390 on 12/3/2024 with diagnoses including Parkinson's disease (a progressive disease of the nervous system marketed by tremor, muscular rigidity, and slow, imprecise movements), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), protein-calorie malnutrition (PCM- a condition that occurs when the body does not get enough protein or calories), muscle weakness (a lack of strength in your muscles, making it difficult to move or contract them normally) other abnormalities of gait and mobility (unusual walking patterns that can affect a person's mobility). During a review of Resident 390's Minimum Data Set (MDS- a resident assessment tool), dated 12/6/2024, the MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired and dependent (helper does all the effort) for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). The MDS indicated Resident 390's bowel and bladder and were always incontinent (no episodes of continent voiding or bowel movements) and required maximum assistance (helper does more than half the effort) for rolling left and right, sit to lying and lying to sitting on the side of the bed. During a review of Resident 390's Care Plan for At Risk for Falls, dated 12/5/2024, the Care Plan indicated to place the resident's call light within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. During a review of the facility's Policy and Procedure (P&P) titled, Call Lights: Accessibility and Timely Response, dated 10/21/2024, indicated staff will ensure the call light is within reach of resident and secured, as needed.

Based on observation, interview and record review, the facility failed to ensure to protect one of two sampled residents' (Resident 390) rights to be free from neglect (the failure of the facility, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress) when Certified Nurse Assistant (CNA) 3 and CNA 4 did not clean Resident 390 after she had bowel movement and did not turn and reposition Resident 390 when she requested to be repositioned. This failure resulted in Resident 390 had to eat with soiled incontinence (inability to control the release of urine or stool) brief, was left uncomfortable, felt upset, frustrated, helpless and neglected. Findings: a. During a concurrent observation, interview on 1/21/2025 at 4:22 p.m., in Resident 390's room, Resident 390 appeared upset and stated CNA 3 and CNA 4 (unable to recall exact day) would speak to her in a harsh and elevated tone of voice when she requested for assistance. Resident 390 stated on 1/19/2025 morning, she requested to be cleaned because she had a bowel movement, but CNA 3 told her she needed to wait for CNA 3 to finish passing meal trays before CNA 3 would clean her. Resident 390 stated this happened several times in December to January 2025. Resident 390 stated the longest time she had to wait to be cleaned was 40 minutes. Resident 390 questioned if passing meal trays was more important than cleaning her. Resident 390 stated the delayed in care made her feel uncomfortable, upset, frustrated, and neglected. Resident 390 stated she felt helpless when CNA 3 and CNA 4 ignored her request for assistance, and she have no choice but tolerate how they treat her because she was sick, unable to walk and care for herself. During an interview on 1/22/2025 at 2:39 p.m., CNA 1 stated on 1/19/2025 at 8:30 a.m., Licensed Vocational Nurse (LVN) 5, CNA 3 and another CNA (unidentified) were talking about how Resident 390 refused CNA 3 to clean her. CNA 1 stated she did not know why Resident 390 refused CNA 3, but she (CNA 1) volunteered to take care of Resident 390. CNA 1 confirmed Resident 390 was incontinent and had a large bowel movement when she cleaned Resident 390. During a telephone interview on 1/22/2025 at 2:52 p.m., LVN 5 stated on 1/19/2025 at 8 a.m., CNA 3 was busy passing meal trays, had to feed another resident (unidentified), and was not able to change Resident 390 incontinence brief right away. LVN 5 stated CNA 3 informed her when CNA 3 returned to Resident 390's room to clean the resident, Resident 390 refused to be cleaned. LVN 5 stated she talked to Resident 390 and the resident was upset because she waited too long for CNA 3 to clean her. LVN 5 stated Resident 390 refused CNA 3 to clean her and preferred to be cleaned by the next shift 3-11 p.m., or someone else. LVN 5 stated she had to reassigned Resident 390 to CNA 1. LVN 5 stated CNA 3 should have asked another CNA to helped pass the meal trays. LVN 5 stated asking for assistance to pass the meal trays was doable because they have enough staff to assist and were not short staffed. During a telephone interview on 1/23/2025 at 8:30 a.m., CNA 3 stated in an elevated tone of voice, Resident 390 was very demanding, frequently used her call light to request to be cleaned, repositioned, fed, and showered. CNA 3 stated on 1/19/2025 at 7:30 a.m., while CNA 3 was passing meal trays, Resident 390 pressed the call light and requesting to change her soiled incontinence brief. CNA 3 stated she asked Resident 390 if she could wait until she (CNA 3) finished passing the meal trays and she would return back to clean Resident 390. CNA 3 stated she did not know who passed Resident 390's meal tray but told Resident 390 after she clean Resident 390 then she (Resident 390) could eat. CNA 3 stated after passing meal trays to other residents, she went back into Resident 390's room and Resident 390 was already eating and refusing to be cleaned. CNA 3 stated she called LVN 5 (charge nurse) because Resident 390 was refusing to be cleaned and LVN 5 told her the assignment would be changed. CNA 3 stated when they were passing meal tray, they cannot do fecal or urinary incontinence care because of an infection control rule which was no cleaning resident to prevent contamination of food and prevent foul odor during mealtime. CNA 3 stated the food would get cold if there was a delay in passing the meal trays. CNA 3 stated she did not ask help to pass the meal trays or clean Resident 390 because she was assigned to the resident and no one else was going to clean her. During an interview on 1/23/2025 at 9:42 a.m., the Director of Staff Development (DSD) stated, CNA 3 told him on 1/22/2025, CNA 3 was going to distribute the meal trays first on 1/19/2025 before cleaning and changing Resident 390's incontinence brief because of infection control concern and cleaning Resident 390 was dirty and she does not want to contaminate the food. The DSD stated when staff were passing meal trays, they can stop passing meal trays and provide incontinence care to residents. The DSD stated the infection control rule that applies after you perform incontinence care was to ensure to do proper hand washing. The DSD stated resident requests needed to be addressed right away because staff not providing care right away was neglecting to provide care and services to the resident. During an interview on 1/23/2025 at 10:50 a.m., the Director of Nursing (DON) stated she spoke to Resident 390, CNA 1, CNA 3 and LVN 5. The DON stated Resident 390 informed her that on 1/19/2025 at 7:30 a.m., CNA 3 brought the breakfast tray to Resident 390 room but Resident 390 said she needed to be cleaned because she had a bowel movement. The DON stated CNA 3 said she told Resident 390 that she would have to wait to be cleaned after CNA 3 passed the meal trays. CNA 3 said she came back at 8 a.m., saw Resident 390 eating her breakfast and Resident 390 refused CNA 3 to clean the resident. The DON stated they teach the staff if the resident needed to be cleaned, the resident should be cleaned. The DON stated the food temperature was important, but the resident should have been cleaned. The DON stated CNA 3 should have asked for assistance to replace her to pass the meal trays. The DON stated they were not short staffed and have enough staff to assist with meal trays. The DON stated denying Resident 390's request to be changed and telling her to eat later after being changed but not cleaning and changing incontinence brief right away was neglecting to provide care and services to resident. During a concurrent interview and record review on 1/23/2025 at 11:14 a.m., the facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, dated 11/4/2024, was reviewed with the Administrator (ADM), the ADM stated the P&P indicated the definition of Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. The ADM stated it was a neglect to care for resident when the employees did not provide incontinence care to Resident 390 when she requested to be cleaned. The ADM stated Resident 390 should have not been left soiled to pass meal trays. The ADM stated the facility has no infection control rule that prohibit the staff from cleaning the resident during mealtime. The ADM stated an infection control was a concern if the staff did not perform handwashing after doing incontinence care. The ADM stated the facility was not short staffed and CNA3 should have called for help. The ADM stated not changing a resident, not answering call light, telling residents we would be doing something and not doing it was neglecting to care for resident. b. During an interview on 1/21/2025 at 4:36 p.m., CNA 4 stated Resident 390 was very demanding, used the call light a lot and wanted everything to be done promptly. CNA 4 stated Resident 390 was upset when CNA 4 would ask Resident 390 to wait but Resident 390 has to wait when she was busy with other residents. CNA 4 stated the call lights were answered in the order of who pressed the call light first. CNA 4 stated Resident 390 wanted to be repositioned every 30 minutes, was very demanding and would use the call light just to ask what was going on in the activity room (located in front of Resident 390's room) and stated in elevated tone of voice emphasizing That was not an emergency. During an interview on 1/21/2025 at 4:40 p.m., CNA 4 stated she provided incontinence care to Resident 390 before going on break at 7 p.m. (unable to recall date) then after her 30 minutes break, one of the residents (did not specify) requested to be cleaned but at the same time Resident 390 had her call light on. CNA 4 stated she asked what Resident 390 needed, and Resident 390 said she wanted to be repositioned. CNA 4 stated she cancelled Resident 390's call light and told her she would return after answering another resident's call light. CNA 4 stated in her mind Resident 390 was just changed and could wait. CNA 4 stated she did not ask anyone to assist Resident 390 because the other CNAs were busy with their residents. CNA 4 stated it took 10 minutes to do incontinent care for the other resident and then CNA 4 returned to repositioned Resident 390. CNA 4 stated they were not short staff but did not ask anyone for assistance and assumed everybody was busy with their own residents. CNA 4 stated they do not ask for help as they have their own assignment, and the resident would have to wait. During an interview on 1/23/2025 at 9:42 a.m., the DSD stated the CNA's can call for assistance if there were multiple call lights activated at the same time. The DSD stated it could take 10-20 minutes to change a resident, so it would be faster for the CNA to turn and reposition Resident 390 first or the CNA can ask for assistance from any staff, so the resident does not need to wait too long. The DSD stated anyone can turn and reposition the resident. The DSD stated they were not short staff and there should be available help. The DSD stated resident requests should be addressed right away because not answering the call light, repositioning resident when the resident request for assistance was neglecting to provide or attend to resident needs. During an interview on 1/22/2025 at 3:18 p.m., the DON stated if the resident voiced being uncomfortable and wanted to be repositioned the nurses should check the resident even if they were cleaned 30 minutes ago. The DON stated it would only take few minutes to reposition the resident and CNA 4 should have repositioned Resident 390 as she was probably uncomfortable. The DON stated CNA 4 could have asked for assistance if she cannot reposition Resident 390. The DON stated anybody can assist to help reposition residents and there was no reason for Resident 390 to wait. The DON stated they were not short staff and there should be enough help to assist Resident 390. The DON stated not answering the call light, not turning and repositioning resident in a timely manner was neglecting to provide care and services to resident that could lead to skin breakdown. During a review of Resident 390's Admission Record (Face Sheet), dated 12/3/2024, the Face Sheet indicated the facility admitted Resident 390 on 12/3/2024 with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), protein-calorie malnutrition (PCM- a condition that occurs when the body does not get enough protein or calories), muscle weakness (a lack of strength in muscles, making it difficult to move or contract them normally) other abnormalities of gait and mobility. During a review of Resident 390's Care Plan for Bowel Incontinence, dated 12/5/2024, the Care Plan indicated an intervention to check the resident every two hours and assist with toileting as needed. During a review of Resident 390's Minimum Data Set (MDS- a resident assessment tool), dated 12/6/2024, the MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired and dependent (helper does all the effort) for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). The MDS indicated Resident 390's bowel and bladder and were always incontinent (no episodes of continent voiding or bowel movements) and required maximum assistance (helper does more than half the effort) for rolling left and right, sit to lying and lying to sitting on the side of the bed. During a review of Resident 390's Documentation Survey Report (document used by CNA to chart activities of daily living), dated January 2025, the Documentation Survey Report indicated CNA 1 documented on 1/19/2025 that Resident 390 had an incontinent, large bowel movement. During a review of the facility's P&P titled, Call Lights: Accessibility and Timely Response, dated 10/21/2024, indicated staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the personnel should be notified. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, dated 11/4/2024, the P&P indicated Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The P/P indicated indicators of abuse and neglect includes failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning & positioning.

Based on observation, interview and record review, the facility failed to ensure two of five Certified Nurse Assistants (CNAs) have the competency to provide care in a respectful and timely manner. This failure resulted in Resident 390's needs not being provided care and services in a timely manner that led to feelings of frustration and disappointment. Findings: a. During a concurrent observation, interview on 1/21/2025 at 4:22 p.m., in Resident 390's room, Resident 390 appeared sad and upset. Resident 390 stated she was told by CNA 3 and CNA 4 (unable to recall exact day) in a harsh and elevated tone of voice that she would need to wait for the CNA to finish taking care of another resident before assisting her with incontinence care. Resident 390 stated that on 1/19/2025 morning, she requested to change her incontinence brief because she had a bowel movement, but CNA 3 told her she needed to wait for CNA 3 to finish passing meal trays before CNA 3 would clean her. Resident 390 stated the CNAs were probably busy but asked if passing meal trays was more important than cleaning her. Resident 390 stated the delayed in providing her incontinence care made her feel uncomfortable, upset, frustrated, and neglected. Resident 390 stated she felt helpless when CNA 3 and CNA 4 would just ignore her request for assistance, and she have no choice but tolerate how they treat her because she was sick, unable to walk and felt sad that they have to treat her like a child. During an interview on 1/21/2025 at 4:36 p.m., CNA 4 stated Resident 390 was very demanding, used the call light a lot and wanted everything to be done promptly. CNA 4 stated sometimes Resident 390 would be upset when Resident 390 was told to wait when CNA 4 was busy with other residents but Resident 390 has to wait. CNA 4 stated the call lights were answered in the order of who pressed the call light first and residents have never complained. CNA 4 stated in her mind Resident 390 was just changed and could wait. CNA 4 stated Resident 390 wanted to be repositioned every 30 minutes, was very demanding and would use the call light just to ask what was going on in the activity room (located in front of Resident 390's room) and stated in elevated tone of voice emphasizing That was not an emergency. CNA 4 stated they were not short staff but did not ask anyone for assistance and assumed everybody was busy with their own patient. CNA 4 stated they do not ask for help as they have their own resident, and the resident would have to wait. During an interview on 1/23/2025 at 9:42 a.m., the Director of Staff Development (DSD) stated, CNA 3 told him on 1/19/2025 CNA 3 was going to distribute the meal trays first before cleaning and changing Resident 390's incontinence brief because of infection control issue and that cleaning Resident 390 was dirty and does not want to contaminate the food. The DSD stated that when staff were passing meal trays, they can stop passing meal trays and provide incontinence care to residents. The DSD stated the infection control rule that applies after you perform incontinence care was to ensure to do proper hand washing. The DSD stated he would need to remind the staff to ensure to clean the residents when the residents requested to be clean even during mealtime. The DSD stated there was no infection control rule that prohibits the staff from cleaning the residents during mealtime. b. During a telephone interview on 1/23/2025 at 8:30 a.m., CNA 3 stated when they were passing meal tray, they cannot do fecal or urinary incontinence care because of an infection control rule which was no cleaning resident to prevent contamination of food and prevent foul odor during mealtime. CNA 3 stated the food would get cold if there was a delay in passing the meal trays. CNA 3 stated she did not know what to do, to pass the meal tray or to clean the resident. CNA 3 stated she did not ask help to pass the meal trays or clean Resident 390 because she was assigned to the resident and no one else was going to clean her. CNA 3 stated she could benefit from an in-service on what they should do in case the residents request to be cleaned during mealtime. During an interview on 1/23/2025 at 9:42 a.m., the DSD stated, the DSD stated the CNA's can call for assistance if there were multiple call lights activated at the same time. The DSD stated that it could take 10-20 minutes to change a resident, so it would be faster for the CNA to turn and reposition Resident 390 first or the CNA can ask for assistance from any staff, so the resident does not need to wait too long. The DSD stated anyone can turn and reposition the resident including the DSD, LVN or registered nurse (RN). The DSD stated they were not short staff and there should be available help if they asked for help or assistance. The DSD stated he would need to do in-service about answering call light timely. During an interview on 1/23/2025 at 10:50 a.m., the Director of Nursing (DON) stated they teach the facility staff that if the resident needed to be cleaned, the resident should be cleaned. The DON stated the food temperature was important, but the resident should have been changed. The DON stated the staff should not labeled the residents such as being demanding and would provide in service about right choice of words. The DON stated the facility expected the CNAs to be competent on their CNAs duties and should know when to ask for help and when to clean the residents. The DON stated the staff should know how to be respectful and protect residents' dignity. The DON stated not turning and repositioning the residents when the residents requested for assistance and not providing bathroom assistance timely demonstrated lack of competencies with CNAs duties and she will make sure to provide staff with inservice. During a review of Resident 390's Admission Record (Face Sheet), dated 12/3/2024, the Face Sheet indicated the facility admitted Resident 390 on 12/3/2024 with diagnoses including Parkinson's disease (a progressive disease of the nervous system marketed by tremor, muscular rigidity, and slow, imprecise movements), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), protein-calorie malnutrition (PCM- a condition that occurs when the body does not get enough protein or calories), muscle weakness (a lack of strength in your muscles, making it difficult to move or contract them normally) other abnormalities of gait and mobility (unusual walking patterns that can affect a person's mobility). During a review of Resident 390's Minimum Data Set (MDS- a resident assessment tool), dated 12/6/2024, the MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was intact. The MDS indicated Resident 390 was dependent (helper does all the effort) for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). The MDS indicated Resident 390's bladder and bowel were always incontinent (no episodes of continent voiding or bowel movements). The MDS indicated Resident 390 required maximum assistance (helper does more than half the effort) for rolling left and right, sit to lying and lying to sitting on the side of the bed. During a review of the facility's policy and procedure titled, Competency Evaluation, dated 10/21/2024, indicated, Definitions: Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual need to perform work roles or occupational functions successfully. Policy Explanation and Compliance Guidelines: 1. The knowledge and skills required among staff to meet residents' needs are determined through the facility assessment process. During a review of the facility's job description titled, Certified Nurse Assistant, dated 2023, indicated the Major Duties and Responsibilities: Assist resident with or perform activities of daily living for resident in accordance with care plans and establish policies and procedures. Additional Assigned Tasks: Treat all residents with dignity and respect. Promotes and protects all residents' rights. Accept certified nursing assistant assignments as staffing needs require. Perform certified nursing assistant duties as assigned, in accordance with facility policies and procedures. Personal Skills and Traits Desired/Physical Requirements/Working Conditions: Ability to make independent decisions when circumstances warrant such action. Ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel and the general public. Must have patience, tact, and willingness to deal with difficult residents, family and staff. 50961

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage preparation practices in the kitchen when: 1. The peas and carrots were not dated, labeled in the walk-in freezer. 2. The waffles and cheese were not correctly labeled, dated and stored in the freezer. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 42 of 42 medically compromised residents who received food from the kitchen. Findings: During a concurrent observation and interview, on [DATE] at 8:11 a.m., in the kitchen, with the Dietary Manager (DM), Freezer 1 had two bags of peas and one bag of carrots that were not dated and labeled. The DM stated the bags of peas and carrots had just been opened by the cook but must have forgotten to label them with the date it was opened and used by date. The DM stated it was important to label food with the date it was opened and the used by date to know when to dispose of expired food and to prevent cooking and serving food that can cause illness to the residents. During a concurrent observation and interview, on [DATE] at 8:19 a.m., in the kitchen with the DM, the overflow freezer had cheese with a use by date of [DATE]. The DM stated the date on the cheese label should have been updated from when it was moved to the freezer which would have extended the use by date. The overflow freezer also had waffles with an open date of [DATE] and used by date of [DATE]. The DM stated the dates were labeled incorrectly since the open date and used by date do not make any sense being opened in November prior to the open date. The DM stated they should label the used by dates correctly. During a review of the facility's Policy and Procedure (P&P) titled, Food Safety and Food Storage, dated [DATE], the P&P indicated labeling, dating, and monitoring refrigerated food, so it is used by its use-by-date, or frozen/discarded.