Every finding on record at Pasadena Grove Health Center

Based on observation, interview and record review, the facility failed to provide appropriate supervision and resident-centered interventions for wandering (the act of moving [walking or locomotion in a wheelchair] from place to place with or without a specified course or known direction) and elopement (the act of leaving a facility unsupervised and without prior authorization), for one (1) of two (2) sampled residents (Resident 1) by failing to:Ensure hand-off rounding (a process occurring within the flow of nursing care, through which nurses exchange patient-related information and responsibility during transitions of care) was done on 7/22/2026, between Licensed Vocational Nurse 1 (LVN 1) and Licensed Vocational Nurse 2 (LVN 2).Ensure staff responded to the sounding courtyard gate alarm (a small device mounted next to the door to monitor the movement of the door) per facility protocol.Ensure Resident 1's care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) intervention for frequent rounding was clear and specific for Resident 1's assessed behavior of wandering.These failures had the potential to prevent Resident 1 from an elopement on 7/22/2026 at 9:20 PM. Resident 1 left the facility through the courtyard gate, and the resident was back at the facility on 7/23/2026 at 4:51 AM (missing for approximately 7 hours) with a facial laceration (a deep cut or ragged tear in the skin and soft body tissues).Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 1's quarterly MDS, dated [DATE], the MDS indicated Resident 1 had moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, toileting and personal hygiene and independent (resident completes activity with no assistance) with oral hygiene and walking. The MDS indicated Resident 1 with the behavior of wandering daily. During an interview on 8/4/2026 at 11:55 AM with MDS Registered Nurse (MDSRN), MDSRN stated he usually observed Resident 1 wandering throughout the facility from the activity room, nursing stations and outside patio. During a continued interview on 8/4/2026 at 12:00 PM with MDSRN, MDSRN stated all facility doors including the outside courtyard gate [located in the back of the facility] had an alarm that can be heard from inside the facility so that staff can hear and respond. The MDSRN stated all nursing staff are expected to go and check when the alarm sounds to see if it is staff or a resident exiting or coming in. During a review of Resident 1's Change in Condition Evaluation, dated 7/22/2026, and timed 11:30 PM, the Change in Condition Evaluation indicated on 7/22/2026 Resident 1 eloped/ went out the facility without telling anyone and did not come back. During a review of Resident 1's Progress Notes, dated 7/23/2026, the Progress Notes indicated on 7/23/2026, Resident 1 returned to the facility around 4:53 AM and stated he left the facility [on 7/22/2026] around 9 PM. The Progress Note also indicated that Resident returned with a laceration to the resident's right eyebrow. During a review of the facility's Director of Staff Development (DSD) Department Investigation Report, dated 7/23/2026, the DSD Department Investigation Report indicated an incident involving Resident 1 on 7/22/2026 between 3 PM to 11 PM and 11 PM to 7 AM shift on 7/23/2026. The DSD Department Investigation Report also indicated a [facility] camera review was done and the following were observed:At 9:21:21 PM, on 7/22/2026, Resident 1 left the facility premises [back patio door], while LVN 1 was seen on the facility camera at Nursing Station A, using her (LVN 1's) phone.At 10:50 PM, on 7/22/2026, LVN 2 was observed arriving for shift (11 PM to 7 AM).At 11:03 PM, on 7/22/2026, LVN 1 left the facility premises.Neither LVN 1 nor LVN 2 conducted endorsement rounds (hand-off round).At 4:51 AM, on 7/23/2026, Resident 1 walked straight to Nursing Station A, from his room. During an interview on 8/4/2026 at 12:16 PM with LVN 1, LVN 1 stated she was assigned to Resident 1 on 7/22/2026, during the evening shift (3 PM to 11 PM). LVN 1 stated Resident 1 went to the resident's room around 9:00 PM, closed his door and LVN 1 did not round to visualize Resident 1 for the remainder of her shift. LVN 1 stated per facility protocol, she and the oncoming nurse (LVN 2) should have conducted a hand-off report at Resident 1's room at around 11 PM, but they (LVN 1 and 2) did not. LVN 1 further stated visual checks including hand-off reporting should have been done on 7/22/2026 during endorsement or before 11 PM, but she was familiar with Resident 1's nighttime routine and that caused her to get comfortable, and not do rounding. LVN 1 also stated she did not hear the courtyard alarm when Resident 1 left the facility premises, but if she did, facility protocol would have been for her to go check to see who triggered the alarm. During an interview on 8/4/2026 at 12:34 PM with LVN 3, LVN 3 stated she worked on 7/22/2026 during the 3 PM to 11 PM shift. LVN 3 stated she did not hear the courtyard alarm that night when Resident 1 left the premises on 7/22/2026 around 9:21 PM. LVN 3 stated if she or any staff would have heard the alarm, per facility protocol, the facility staff should have responded to intervene and redirect Resident 1 back into the facility and assess him to address any needs he may have had as well as inform his physician. During an interview on 8/4/2026 at 12:39 PM with LVN 2, LVN 2 stated she was assigned to Resident 1 on 7/22/2026 and 7/23/2026 during the 11 PM to 7 AM shift. LVN 2 stated she and LVN 1 did not conduct hand-off rounds at the start of the shift on 7/22/2026 (11 PM) and never laid eyes on Resident 1. LVN 2 stated it was not until around 11:30 PM that she realized Resident 1 was not in the resident's room and checked the facility premises, including the courtyard area. LVN 2 stated while checking the facility for Resident 1, she exited the courtyard gate and the alarm sounded, so it was functioning when Resident 1 left the facility. LVN 2 stated she did not conduct hand-off rounds with LVN 1 because she got busy doing other things (was not able to specify) but should have done a visual check of Resident 1 during endorsement. LVN 2 stated Resident 1 returned during the morning of 7/23/2026 to the facility, with a laceration on the resident's face. During an interview on 8/4/2026 at 1:39 PM with Registered Nurse Supervisor (RNS), RNS stated the courtyard gate has an alarm that can be heard from the nurse's station, including Station A, for anytime it is opened and facility protocol is after the alarm is heard sounding, staff are to go respond, to see if it was residents, visitors or staff that triggered the alarm. RNS also stated when a resident has a care plan intervention to check frequently, that means to visually check on the resident at least every 1 to 2 hours. RNS also stated hand-off rounding is when 2 nurses, the nurse ending the shift and the nurse starting their shift, go to the resident's room together to visualize the resident and endorse what is going on with that resident. During a concurrent interview and review of the facility's surveillance video recording of the facility hallways, nursing stations, courtyard and driveway areas of the facility with Administrator (ADM) and Medical Records Director (MRD) on 8/4/2026 at 3:19 PM, the surveillance video recording showed Resident 1 walking out of the courtyard gate on 7/22/2026 at 9:20:58 PM, towards the left side of the back parking lot. The surveillance video then showed Resident 1 walking down the exit driveway towards Boulevard 1 at 9:21:24 PM. ADM stated the video surveillance showed Resident 1 exiting the facility through the courtyard gate, alone and independently. ADM stated no staff are seen responding to the courtyard while Resident 1 while exiting the facility and leaving the facility premises. During an interview on 8/5/2026 at 9:19 AM with MDSRN, Resident 1's Low Risk for Elopement care plan, revised 3/1/2026, the care plan indicated the intervention to check residents where abouts frequently. MDSRN stated he interpreted frequently to mean every once in a while. MDSRN stated the intervention does not include a measurable and specific timed interval indicated and frequently can be interpreted differently by every nurse that provides the intervention. MDSRN further stated this intervention is subjective and not resident specific enough. MDSRN stated Resident 1 had a behavior pattern to wander and should have defined the rounding times to have consistent care and to ensure Resident 1 received the right supervision to prevent elopement. During an interview on 8/5/2026 at 10:50 AM with the Director of Nursing (DON), the DON stated per facility protocol, nurses are to conduct hand-off rounds at each room to discuss any changes or updates and to visualize the residents. The DON stated LVNs 1 and 2 should have conducted a hand-off report on 7/22/2026 to all residents including Resident 1, but they (LVN 1 and 2) did not. The DON also stated the facility does not have a policy for hand-off rounds even though it is the facility's protocol and should since it is done by staff. During a continued interview on 8/5/2026 at 10:55 AM with the DON, the DON stated Resident 1's care plan intervention to check whereabouts frequently, meant to check the Resident at least twice during the eight (8) hour shift. The DON stated frequently, was broad and not specific to ensure consistent implementation and care from nursing staff and that nurses can create different meanings. The DON stated it was important to make sure all care plan interventions were resident-centered to ensure the right care is being provided to maintain the resident's safety. During a continued interview on 8/5/2026 at 11:00 AM with the DON, the DON stated the facility's courtyard gate has an alarm that is triggered whenever anyone, (including residents, visitors and staff) enters or leaves and that staff are to visualize the door to ensure residents are not trying to leave the facility. The DON stated the staff working 7/22/2026 during the 3 PM to 11 PM shift should have heard and responded to the courtyard alarm when Resident 1 was leaving the facility on 7/22/2026 around 9:20 PM to intervene, assess and potentially prevent Resident 1 from eloping and prevent the resident from obtaining an injury while missing. During a review of the facility's Policy & Procedure (P&P) titled, Wandering and Elopement, revised 11/1/2017, the P&P indicated the facility will identify residents at risk for elopement and minimize and possible injury because of elopement, with the policy purpose to enhance the safety of the residents. The facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. The facility's P&P titled, Care Planning, revised 10/24/2022 was reviewed. The P&P indicated the purpose was to ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs. The P&P also indicated each resident's comprehensive care plan will describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on interview and record review, the facility failed to maintain accurate and complete medical records in accordance with the facility's policy by failing to accurately document the wandering history and episodes for one (1) of two (2) sampled residents (Resident 1), for the resident's Discharge Minimum Data Set (MDS- a resident assessment tool) and Elopement (the act of leaving a facility unsupervised and without prior authorization) Risk Assessments dated 5/29/2026 and 7/23/2026. These failures resulted in inaccurate clinical data, with the potential for delays in the development and implementation of accurate or adequate interventions, which could negatively affect Resident 1's overall well-being and safety.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 1's quarterly MDS, dated [DATE], the MDS indicated Resident 1 had moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, toileting and personal hygiene and independent (resident completes activity with no assistance) with oral hygiene and walking. The MDS indicated Resident 1 with the behavior of wandering (the act of moving [walking or locomotion in a wheelchair] from place to place with or without a specified course or known direction) daily. During an interview on 8/4/2026 at 11:55 AM with MDS Registered Nurse (MDSRN), MDSRN stated he (MDSRN) usually observed Resident 1 moving throughout the facility from the activity room, nursing stations and outside patio. The MDSRN stated per the MDS, wandering does not have to be aimless and may be the pursuit of pleasurable activities, and Resident 1 had wandering behavior. During an interview on 8/5/2026 at 7:56 AM with Social Worker (SW), SW stated Resident 1 had a wandering behavior as a baseline (a normal state of functioning) and was independent with most activities since assessing him for his quarterly MDS on 5/29/2026. SW further stated Resident 1 would wander in the facility and outside for smoking activities four times a day. During a concurrent interview and record review on 8/5/2026 at 9:19 AM with MDSRN, Resident 1's quarterly Elopement Risk Assessment, dated 5/29/2026, was reviewed. The Elopement Risk Assessment indicated Resident 1 did not have a history of wandering. The MDSRN stated that he completed this assessment and triggered Resident 1 with no history of wandering, but the Elopement Risk Assessment should have indicated Resident 1 with a history of wandering and consistent with the quarterly MDS dated [DATE]. MDSRN further stated this assessment was inaccurate and needed to be documented accurately because it was used to help the clinical/nursing staff, and it determines what intervention to provide to ensure Resident 1's safety. During a review of Resident 1's Change in Condition Evaluation, dated 7/22/2026, the Change in Condition Evaluation indicated on 7/22/2026 Resident 1 eloped. During a concurrent interview and record review on 8/5/2026 at 10:50 AM with the Director of Nursing (DON), Resident 1's significant change Elopement Risk Assessment, dated 7/22/2026, was reviewed. The Elopement Risk assessment dated [DATE] indicated Resident 1 did not have a history of wandering and that Resident 1 did not have an episode of wandering in the past 3 months. The DON stated he (DON) completed this Elopement Risk assessment dated [DATE] and it was not accurate since Resident 1 had a history and recent episode of wandering. During a continued concurrent interview and record review on 8/5/2026 at 10:58 AM with the DON, Resident 1's discharge MDS, dated 7/23/2026, the MDS indicated Resident 1 did not have the behavior of wandering. The DON stated the discharge MDS dated [DATE] should have indicated Resident 1 with the behavior of wandering but the form did not, so it was inaccurate. The DON further stated it was important for Resident 1's discharge MDS to be accurate because it was used for staff to determine how to take care of Resident 1, and it would ensure the accurate interventions and care are provided. The DON further stated inaccurate documentation of Resident 1's assessments [MDS and/or Elopement Risk Assessment] that leads to inaccurate or inappropriate interventions, can cause negative health effects for Resident 1. During a review of the facility's Policy and Procedure (P&P) titled, Documentation- Nursing, dated 11/1/2017, the P&P indicated nursing documentation will be concise, clear and accurate. The P&P also indicated the procedure for nursing documentation MDS completion as per Centers for Medicare & Medicaid Services (CMS- a U.S. federal agency that runs public health programs, sets national billing and coding rules, and checks quality standards in hospitals and nursing homes) guidelines. During a review of the facility's P&P titled, Resident Assessment Instrument (RAI- a standardized clinical tool used in nursing homes and long-term care facilities to evaluate a resident's health, functional capacity, and care needs), dated 5/19/2025, the P&P indicated the facility will utilize the RAI process as the basis for the accurate assessment of each resident's functional capacity and health status, as outlined in the CMS RAI Manual. The P&P also indicated that all information recorded within the MDS Assessment must reflect the resident's status at the time of the Assessment Reference Date (ARD).

Based on interview and record review the facility failed to ensure the resident's rights regarding formulating an Advanced Health Care Directive (AHCD- is a legal document that outlines a person's medical care preferences and name a trusted person to make medical decisions if the patient becomes incapacitated [being completely unable to manage one's affairs or makes decisions due to a physical or mental limitation]) were honored for one of two sampled residents (Resident 1) by failing to verify the resident's capacity to make decision, the facility did not involve the legally recognized decision-maker and did not ensure proper witnessing for an AHCD executed inside a skilled nursing facility. These failures resulted in an invalid AHCD and jeopardized the resident's right to have healthcare decisions made according to their expressed preferences.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/5/2023 with diagnoses including, but not limited to Alzheimer's disease (a progressive brain disorder that slowly destroys memory, thinking skills, and the ability to perform simple tasks), chronic kidney disease (long term condition where the kidneys are damaged and lose the ability to filter waste and fluid out of the body), and neuromuscular dysfunction of the bladder (also called neurogenic bladder-a loss of bladder control caused by nerve damage). During a review of Resident 1's Social Work (SW) Initial Assessment (the first meeting and evaluation between a social worker and a patient) dated 5/8/2023, it indicated, responsible party designation indicated that Family 1 was the agent and emergency contact. During a review of Resident 1's History and Physical (H&P-foundational medical document and clinical process used by healthcare providers to evaluate a patient), dated 5/12/2023, the H&P indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 5/18/2023, the MDS indicated Resident 1 had moderately impaired cognitive (mental processes that take place in the brain, including thinking, attention, language learning, memory, and perception) skills for daily decision making. The MDS also indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight bearing support) with eating, dressing, personal hygiene, bed mobility, and walking in the room and corridor. The MDS further indicated Resident 1 was totally dependent (full staff performance every time during entire 7-day period) with toilet use, transfer, bathing, and locomotion on and off the unit. During a concurrent interview and record review on 7/9/2026 at 12:10 PM with Social Services Designee (SSD), the Advance Directive Acknowledgement form dated 5/8/2026, was reviewed. The Advance Directive Acknowledgment form indicated Resident 1 had not executed an Advance Directive and was signed by Family 1. SSD stated the Advance Directive Acknowledgment form was discussed by the former SSD (SSD 2) with Family 1 at the time of Resident 1's admission to the facility. SSD stated during admission, a resident is asked if the resident has or does not have advance directives and if there was none, if resident wanted or does not want information regarding formulating an advance directive. SSD stated if the resident wants to formulate an advance directive, the SSD provides information and assists the resident in filling out the form. SSD stated once form is completed, the ombudsman (a skilled nursing facility Ombudsman is an independent, trained advocate who protects the rights of nursing home residents) is notified so the Ombudsman can meet with the resident to determine if the resident's choices were accurate and the resident was not forced or pressured to execute the advance directive. SSD stated the Ombudsman needed to sign the AHCD form as a witness. During a concurrent interview and record review on 7/9/2026 at 12:25 PM with the SSD, the Durable Power of Attorney (DPOA-a legal document that lets a person name a trusted person to make financial or medical choices if one becomes unable to do so), dated 6/14/2023, and the AHCD form, dated 6/14/2023, were reviewed. SSD stated the DPOA indicated Family 2 as the agent (Attorney-in-Fact, a trusted person appointed to act on another's behalf for legal or financial matters), was signed and initialed by Resident 1. and was notarized by a Notary Public. SSD stated the AHCD indicated Family 2 as the designated agent, and it was signed by Resident 1 and had two (2) witness signatures. SSD stated the AHCD Part 6: Special Witness Requirement/Statement of Patient Advocate or Ombudsman was blank. The AHCD Part 6 indicated that it is required only if one is a patient in a skilled nursing facility and the patient advocate or ombudsman must sign the statement of declaration under penalty of perjury under the laws of California that he/she is serving as a witness as required by Section 4675 of the Probate Code. During the same concurrent interview and record review on 7/9/2026 at 12:25 PM with SSD, SSD stated she does not know if the Ombudsman was notified of Resident 1's execution of AHCD on 6/14/2023 as she was not the SSD at that time. SSD confirmed the AHCD Part 6: Special Witness Requirement/Statement of Patient Advocate or Ombudsman was blank and that if the Statement of Patient Advocate or Ombudsman was blank, it meant that the Ombudsman was not notified and the Ombudsman did not meet with Resident 1. SSD stated if the Ombudsman did not sign the Statement of Patient Advocate or Ombudsman as required by law, the AHCD is not valid. SSD stated she was not aware if the SSD 2 or former Director of Nursing (DON 2) verified if Resident 1 had the capacity to understand and make decisions or why Family 1 was not aware or involved. SSD stated, SSD cannot determine a resident's capacity to make decisions, only a medical doctor (MD-Doctor of Medicine) can determine a residents' capacity to make decisions. SSD confirmed that Resident 1's H&P indicated that Resident 1 did not have the capacity to understand and make decisions. During a phone interview on 7/9/2026 at 4:18 PM with the Ombudsman, the Ombudsman stated the facility's SSD provides resources and assists the residents that have capacity to make decisions in filling out the AHCD form. Ombudsman also stated once the AHCD form is filled out by a resident, the SSD notifies the Ombudsman that the form is ready to be reviewed. Ombudsman further stated that the Ombudsman assigned then goes to the facility, meets with the resident in private to again go over the AHCD that was filled out to ensure that it is according to the resident's wishes, ensure that there was no coercion or pressure involved in formulating/executing an AHCD. Ombudsman added, when the resident is comfortable with the choices made, the Ombudsman signs as the first witness and signs and dates the Statement of Patient Advocate or Ombudsman (Part 6 Special Witness Requirement, page 6 of the AHCD form) which is required only if the person is a patient/resident in a skilled nursing facility. Ombudsman stated a second witness also signs but cannot be a resident's family or facility staff. Ombudsman stated Resident 1's AHCD dated 6/14/2023 does not have to be notarized but the Ombudsman must sign the AHCD Part 6 for the AHCD to be valid. During a concurrent interview and record review on 7/9/2026 at 4:35 PM with the DON, Resident 1's Social Service Initial assessment dated [DATE], Resident 1's H&P dated 5/12/2023, Resident 1's MDS dated [DATE] and, Resident 1's AHCD and DPOA both dated 6/14/2023, were reviewed. The DON confirmed the Social Service Initial Assessment Responsible party designation indicated that Family 1 was the agent and emergency contact. The DON stated that were no other SSD notes that indicated there was a change or update to this information and that Resident 1 had moderate cognitive impairment and the H&P indicated that Resident 1 did not have capacity to understand and make decisions. The DON stated he does not know how or if the SSD 2 and DON 2 verified if Resident 1 had the capacity to make decisions and was verified prior to formulation of the AHCD and DPOA on 6/14/2023. The DON confirmed, the AHCD and DPOA signed and initialed by Resident 1 and that Resident 1 should not have been made to sign the AHCD and DPOA based on the MD's determination that Resident 1 had no capacity to understand and make decisions. The DON stated that the AHCD and DPOA were not valid. During a phone interview on 7/9/2026 at 4:50 PM with Administrator (ADM), ADM stated he does not remember how the process went through for Resident 1's formulation/execution of AHCD and DPOA dated 6/14/2023, who facilitated it and if Resident 1's capacity to make decisions was first verified prior to formulating/executing Resident 1's AHCD and DPOA. ADM stated Resident 1's AHCD and DPOA were not valid since Resident 1 who had no capacity to make decisions signed the AHCD and DPOA. During a concurrent interview and record review on 7/9/2026 at 4:55 PM with the DON, the facility's policy and procedure (P&P) titled Advance Directives, revised 4/30/2021, was reviewed. The P&P indicated:The purpose is to provide residents with the opportunity to make decisions regarding their health care.If no Advance Directives exists, the facility provides the resident with an opportunity to complete the Advance Directive Form upon resident request.Assistance is provided as necessary to execute an Advance Directive.Upon admission, the admission Staff or designee will inform the resident of their right to execute an Advance Directive Form, if one does not already exist.If the resident is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an Advance Directive, the facility may give Advance Directive information to the resident's representative in accordance with state law.The DON stated the Advance Directive Acknowledgement was signed by Family 1 on 5/8/2023 but the AHCD and DPOA in Resident 1's medical records were signed by Resident 1 who was assessed to have no capacity to understand and make decisions designating Family 2 as the agent on 6/14/2023. The DON stated Resident 1's AHCD and DPOA being invalidated, these did not ensure Resident 1's right to have healthcare decisions made according to the resident's wishes/preferences, were followed. During a review of the facility's P&P titled Decision Making Capacity, revised 11/30/2020, the P&P indicated:Residents have a right to make their own health care decisions when possible.The Attending Physician (also called MD) is responsible for determining the resident's capacity to make health care decisions upon admission, upon any significant change in condition, and during the monthly review of ordersThe Attending Physician will document the resident's capacity to make informed decisions. The documentation will make a clear determination whether the resident has the capacity to consent to medical care and if not, will identify a surrogate decision maker.

Based on interview and record review the facility failed to promote dignity and respect for one (1) of nine (9) sampled residents (Resident 1) when Certified Nursing Assistant 1 (CNA 1) stated he had repeated a derogatory word (saying or doing something that is insulting, disrespectful, or meant to belittle someone) in Resident 1's language to the resident and had tossed a pillowcase onto resident's face while playing with Resident 1 on 6/8/2026.This failure had the potential to affect Resident 1 experiencing psychosocial effects (a person's mental, emotional, social and spiritual health) and had the potential to affect the resident's self-esteem, self-worth and violated Resident 1's right to be treated with dignity. Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of dementia (a progressive state of decline in mental abilities) with mood and psychotic disturbance (a mood disturbance affects how you feel [e.g. (for example), extreme sadness or uncharacteristic mania] and a psychotic disturbance affects how you perceive reality) and encephalopathy (any disease, damage, or malfunction that affects the brain's normal structure or function). During a review of Resident 1's Activities Initial Review dated 2/20/2026, Resident 1's Activities Initial Review indicated Resident 1 enjoyed coloring, painting, listening to older music, sitting in the patio and enjoyed wheeling around in the hallway.During a review of Resident 1'S Minimum Data Set (MDS - a resident assessment tool), dated 5/25/2026, the MDS indicated the resident was severely impaired with cognitive (ability to think, remember, and reason) skills for daily decision making. The MDS indicated Resident 1 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with personal hygiene and toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). It also indicated, Resident 1 needed partial/moderate assistance (helper does less than half the effort) with walking 50 feet with two turns, chair/bed-to-chpillowcasers, going from sitting to standing, putting on/taking off footwear and lower body dressing (the ability to dress and undress below the waist) and the resident needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with upper body dressing (the ability to dress and undress above the waist) and eating.During an interview on 6/22/2026 at 3:30 PM with CNA 1, CNA 1 stated on 6/8/2026 he (CNA 1) was playing with Resident 1 in the resident's room by throwing a pillow case up in the air and allowing it to fall onto the resident for the resident to throw back to CNA 1. CNA 1 stated at one point, the pillowcase fell onto the resident's face and at the same time, Resident 1 was saying a derogatory word in the resident's language that CNA 1 did not understand. CNA 1 stated, he knew it was not a good word and had asked Resident 1 to stop saying the derogatory by repeating the word back to the resident. CNA 1 further stated the interaction was witnessed by Licensed Vocational Nurse (LVN) 1 who was walking by in the hallway outside of Resident 1's room.During an interview on 6/23/2026 at 10:10 AM with LVN 1, LVN 1 stated on 6/8/2026 she was walking in the middle hallway and as she was passing by Resident 1's room LVN 1 heard CNA 1 call Resident 1 a derogatory word in the resident's language. LVN 1 stated she then witnessed CNA 1 place a pillowcase on Resident 1's face. LVN 1 stated she did not hear the conversation prior to passing the room and only heard CNA 1 called Resident 1 the derogatory word. LVN 1 further stated CNA 1 had told LVN 1 that CNA 1 was just playing with the resident and explained that is not how a resident should be treated or played with.During an interview on 6/23/2026 at 1:28 PM with Activities Assistant 1 (AA 1) and Activities Assistant 2 (AA 2), both AA 1 and AA 2 stated Resident 1 enjoyed participating in activities such as nail painting, coloring, watching documentaries on the television (TV), playing bingo as well as tossing an inflatable balloon or volleyball in the air. AA 1 and AA 2 stated they focus on age appropriate activities that follow Resident 1's preferences and also stated that throwing a pillowcase in the air to play with the resident is not an age appropriate activity and does not provide Resident 1 with a dignified experience.During an interview on 6/23/2026 at 2:16 PM with the Director of Nursing (DON), the DON stated it is important to provide residents with age appropriate activities that meet the resident's preferences and also take into account the resident's current diagnoses and any behavioral issues the resident might have. The DON stated, tossing a pillowcase up into the air to fall onto the resident is not an activity that is age appropriate for Resident 1 and is not dignified for the resident.During an interview on 6/23/2026 at 2:36 PM with the DON, the DON stated Resident 1 has a behavior of saying a derogatory word in the resident's language to staff, however, it was not okay for CNA 1 to have repeated the word back to the resident even if CNA 1 was telling the resident to stop because whether Resident 1 understood or not, it could have potentially affected Resident 1 emotionally by the resident thinking CNA 1 was saying that word to the resident.During a review of the facility's policy and procedure (P&P) titled, Activities Program, revised 4/1/2021, the P&P indicated its purpose is to encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain the highest attainable social, physical and emotional functioning.During a review of the facility's P&P titled, Resident Rights, revised 5/1/2023, the P&P indicated: All residents have a right to a dignified existence.The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance of enhancement of his or her quality of life, recognizing each resident's individuality.During a review of the facility's P&P titled, Privacy and Dignity, revised 5/1/2025, the P&P indicated its purpose is to ensure that care and services provided by the Facility promote and/or enhance privacy, dignity and overall quality of life. The P&P also indicated, the facility promotes resident care in a manner and an environment that maintains or enhances dignity and respect, in full recognition of each residents' individuality, and further indicated under its procedure:Staff promotes residents' self-esteem and self-worth.Staff treat residents with respect including respecting their social status, speaking respectfully, listening carefully.

Based on observation, interview, and record review, the facility failed to protect one of two residents (Resident 1) from abuse (the willful infliction or injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) when Resident 2 allegedly threw a blanket over Resident's 1's head and hit Resident 1 with a metal object on 5/28/2026. This deficient practice resulted in Resident 1 having an abrasion (injury where top layer of skin is scraped or rubbed away due to friction against a rough surface) on the left cheek and a cut on the left upper lip with the potential for emotional and psychosocial (combined influence of psychological factors and the surrounding social environment on physical, emotional, and/or mental wellness) harm.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/3/2026 with diagnoses including but not limited to epilepsy (brain condition that causes a person to have repeated, unprovoked seizures [sudden, uncontrolled surge or electrical activity in the brain causing changes in behavior, body movements, sensations, or levels of awareness]), chronic obstructive pulmonary disease (COPD-common lung disease causing restricted airflow and breathing problems), legal blindness (severe vision impairment), psychosis (mental health symptom where a person loses touch with reality), and mood disorder (mental health condition that primarily disrupts a person's emotional state, causing long periods of extreme sadness, extreme happiness, or both). During a review of Resident 1's Minimum Data Sheet (MDS-a resident assessment tool), dated 4/7/2026, the MDS indicated Resident 1 had moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with eating, oral hygiene, upper body dressing, and rolling left to right. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers were required for the resident to complete the activity) with toileting and personal hygiene, shower/bathing self, lower body dressing, putting on/taking off footwear, sit to lying, and lying to sitting on the side of the bed. During a review of Resident 1's Change in Condition Evaluation (COC-a clinical assessment used to track, measure, and understand any sudden or significant shift in a person's health, behavior, or physical abilities), dated 5/28/2026, the COC indicated Resident 2 threw a blanket over Resident 1 then hit Resident 1 with two wheelchair foot rests. The COC also indicated Resident 1 sustained minor skin abrasion on the left cheek with minimal bleeding and the resident During a review of Resident 1's Care Plan, dated 5/28/2026, the care plan indicated Resident 1 was at risk for emotional harm and emotional distress related to the altercation and physical trauma from another resident. During a review of Resident 1's Skin Observation Tool, dated 5/29/2026, the Skin Observation Tool indicated Resident 1 had left face abrasion, right posterior hand trauma, and a cut on the left upper lip. During a review of Resident 2's admission Record, the admission Record indicated the facility initially admitted Resident on 10/14/2025 and readmitted on [DATE] with diagnoses including, but not limited to unspecified psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what is real and what is not), anxiety disorder (persistent and excessive worry that interferes with daily activities), schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), and mood disorder (a mental health condition that primarily affects a person's emotional state). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 2 had delusions (misconceptions or beliefs that are firmly held, contrary to reality). The MDS also indicated Resident 2 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity) with eating, oral hygiene, rolling left to right, sit to lying, lying to sitting on the side of the bed. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with toileting and personal hygiene, showing/bathing self, putting on/taking off footwear, upper and lower body dressing, sitting to standing, chair/bed to chair transfer, toilet transfer, and walking 10 feet (unit of measurement) and walking 50 feet with two turns. During a review of Resident 2's Progress Notes/SBAR (an acronym for Situation-Background-Assessment-Recommendation is a technique used to provide a framework for communication between members of the health care team), dated 5/28/2026, the SBAR indicated the COC reported were behavioral symptoms, physical aggression towards Resident 1, increased agitation towards others: threw a blanket over Resident 1's head and hit her (Resident 1) with two footrests, ran out of the room to the back gate. The progress notes also indicated that Resident 2 was escorted back inside the facility, Resident 2 threw linen carts and kitchen carts to the floor while screaming and spitting at staff. The progress notes further indicated the police arrested resident for assault with a deadly weapon (unable to confirm if referring to footrest). During a review of Resident 3's admission Record, the admission Record indicated the facility initially admitted Resident 3 on 9/3/2024 and readmitted on [DATE] with diagnoses including but not limited to congestive heart failure (a serious condition in which the heart does not pump as effectively as it should), COPD, chronic pulmonary edema (a long-term condition where excess fluid slowly builds up in the lungs' air sacs, making it progressively harder to breathe), and malignant neoplasm of the vulva (uncontrolled growth of abnormal cells on the external female genitalia). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 3 required supervision or touching assistance with eating and required partial/moderate assistance with oral/toileting/personal hygiene, upper/lower body dressing, putting on/taking off footwear, roll left to right, sit to lying, lying to sitting on the side of the bed, chair/bed to chair transfer, toilet transfer, and tub/shower transfer. During a concurrent observation and interview on 6/11/2026 at 12:30 PM, inside Resident 1's room, Resident 1 was observed in bed and resting. Resident 1 stated on 5/28/2026 in the evening (cannot recall time), she was getting ready to sleep when she heard Resident 2 grunt and groan and suddenly a fabric material like a blanket was thrown over her head. Resident 1 stated she got hit with something hard like a metal object on the left cheek and she was able to block the second blow with her right hand and yelled for help. Resident 1 stated when she started yelling for help, Resident 2 stopped hitting her. Resident 1 stated she felt something like metal rods on top of her chest to her lap/legs. During the same interview on 6/11/2026 at 12:30 PM with Resident 1, Resident 1 stated she did not really feel safe right after the incident. During an interview on 6/11/2026 at 2:44 PM with Certified Nurse Assistant (CNA) 1, CNA 1 stated she was at the South Nurses' Station across Resident 1 and 2's room and she last saw Resident 1 and 2 around 9:50 PM to 10:05 PM. CNA 1 stated Resident 2 would scream at staff but has not hit someone before. CNA 1 stated on 5/28/2026, another CNA informed her that Resident 1 was screaming and CNA 1 went to Resident 1 and 2's room and when CNA 1 got into the room, Resident 2 was no longer in the room, and she called the Charge Nurse/Licensed Vocational Nurse (LVN) 1. During an interview on 6/11/2026 at 2:50 PM with Registered Nurse Supervisor (RNS), the RNS stated the incident between Resident 1 and 2 happened on 5/28/2026 around 10 PM to 10:15 PM when CNA 1 reported to LVN 1 that Resident 2 hit Resident 1. RNS stated Resident 2 was not in the room when she got there but saw two wheelchair footrests on top of Resident 1's chest. RNS stated Resident 1 had a small cut on the resident's left cheek and left upper lip with small amount of blood. RNS stated Resident 2 went out the patio door and another staff found Resident 2 by the back gate when the alarm went off. RNS stated when Resident 2 was brought back inside the facility and was later taken by the police officer to the police station. During an interview on 6/11/2026 at 4:24 PM with LVN 1, LVN 1 stated CNA 2 notified her that she heard yelling from Resident 1's room and Resident 1 told CNA 2 that Resident 2 hit Resident 1. LVN 1 stated she immediately went to check and observed wheelchair footrests were on top of Resident 1's chest and there was blood on Resident 1's left upper lip and left cheek. LVN 1 stated Resident 2 remained quiet while being asked about the incident then suddenly became agitated, cursed staff and started spitting at them. LVN 1 stated Resident 2 was uncooperative and verbally aggressive to the police officers and Resident 2 was then taken to the police station. During a concurrent interview and record review on 6/11/2026 at 5:21 with the Director of Nursing (DON), Resident 2's Medication Administration Record (MAR-legal document that tracks medications given to a patient, including dosage, time, route, and who administered it) for 5/2026 and progress notes dated 5/17/2026 to 5/18/2026, 5/25/2026, 5/27/26 to 5/28/2026 were reviewed. The MAR indicated the following medications were refused by Resident 2: On 5/25/2026 for 5 PM dose, 5/27/2026 for the 9 AM and 5 PM doses and 5/28/2026 for the 9 AM dose of Zyprexa (used to treat schizophrenia, bipolar I disorder, and treatment-resistant depression) 5 milligrams (mg-a commonly used on medication labels to measure the weight of ingredients) and give one tablet by mouth two times a day for schizophrenia manifested by auditory hallucinations (false perception of hearing a sound in the absence of an external acoustic stimulus) On 5/25/2026 for the 5 PM dose, 5/27/2026 for the 9AM and 5 PM doses and 5/28/2026 for the 9 AM dose of Depakote (prescription medication primarily used as an anticonvulsant and mood stabilizer) 500 mg, give one tablet by mouth two times a day for mood disorder as evidenced by irritable mood. On 5/17/2026 for the 9 AM dose; 5/18/2026 for the 9 AM dose; 5/27/2026 for the 9 AM dose; and 5/28/2026 for the 9 AM dose of aripiprazole (sed to treat mental health conditions like schizophrenia, bipolar disorder, and major depressive disorder) 5 mg. Give one tablet by mouth daily for schizophrenia manifested by disorganized thinking Resident 2's progress notes dated 5/17/2026, 5/18/2026, 5/27/2026 to 5/28/2026 indicated documentation for administration notes as refused x 3 or refused x 3, risk and benefits discussed. The DON stated that there was no documentation that either Resident 2's physician (MD) or psychiatrist (medical doctor who diagnoses and treats mental, emotional, and behavioral disorders) was notified about the resident's refusal to take the medication in accordance with the facility's policy and procedure (P&P). The DON stated that MD notification was very important, especially since Resident 2 had been refusing three medications on multiple times leading to the day of the incident. The DON stated that the MD could have ordered other treatment alternatives to manage and control Resident 2's behaviors which could have potentially prevented the physical abuse by Resident 2. During a concurrent interview and record review on 6/11/2026 at 5:40 PM with the DON, the P&Ps titled Refusal of Treatment, revised 11/1/2017 and Care and Services, revised 11/1/2017, were reviewed. The P&P titled Refusal of Treatment indicated:The Charge Nurse of DON interviews the resident to determine what and why the resident is refusing treatment.The Attending Physician will be notified in a time frame determined by resident's condition.The P&P titled Care and Services indicated:Licensed Nurse or designee documents and notifies the Attending Physician of COC, including progress and/or decline in physical or mental function and refusal of care and services.The DON stated the P&Ps were not followed because the licensed nurses did not notify the MD when Resident 2 refused his Zyprexa, Depakote and aripiprazole on several occasions from 5/17/2026 to 5/28/2026, and if they were followed, it could have potentially prevented the abuse incident. During a concurrent interview and record review on 6/11/2026 at 5:54 PM with the DON, the Care Plan dated 3/2/2026 was reviewed. The Care Plan indicated Resident 2 has a mood problem related to schizophrenia and mood disorder. The care plan indicated intervention includes administering medications as ordered and monitor/document for side effects and effectiveness; notify MD. The DON stated the care plan was not followed as Resident 2 has been refusing medications and MD was not notified of the refusal leading to missed doses of the medications. During a concurrent interview and record review on 6/11/2026 at 6 PM with the DON, the facility's P&P titled Room or Roommate Change, revised 3/14/2018 was reviewed. The P&P indicated that when making a change in room or roommate assignment, the resident's needs and preferences are considered and will be accommodated to the extent practical. The DON stated Residents 1, 2 and 3 were occupying the same room. The DON stated room assignment for Resident 2 who had behavioral problems such as being aggressive, was inappropriate as Resident 1 was legally blind, cannot clearly see who comes in or goes in the room and Resident 3 who was nonverbal at times and bed bound could not effectively protect themselves. The DON stated the P&P was not followed as Resident 1 and 3's needs for safety and protection form potentially being abused were not considered. During a review of the P&P titled Abuse Prevention and Prohibition Program, revised 8/1/2023, the P&P indicated:Each resident has the right to be free from abuse.The facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services under arrangement, family members, legal guardians, surrogates, sponsors, friends, and visitors.

Based on interview and record review, the facility failed to prevent misappropriation of property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) for one (1) of six (6) sampled residents (Resident 1). This failure resulted in the loss of Resident 1's cell phone and laptop, the transfer of funds from Resident 1's bank account to Certified Nurse Assistant 2's (CNA 2) bank account and a credit card account being opened and mailed to CNA 2's address.During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD; a chronic lung disease causing difficulty in breathing) with acute (short-term) lower respiratory infection (inflammation of the large airways of the lung), and pneumonia (an infection of one or both lungs that causes the tiny air sacs [alveoli] to become inflamed and fill up with fluid or pus). During a review of Resident 1'S Minimum Data Set (MDS - a resident assessment tool), dated 4/10/2026, the MDS indicated the resident was moderately impaired with cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 1 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity) with putting on/taking off footwear and lower body dressing (the ability to dress and undress below the waist). MDS also indicated Resident 1 needed substantial/maximal assistance (helper does more than half the effort) with going from lying to sitting at the side of the bed, rolling left and right in bed and upper body dressing (the ability to dress and undress above the waist) and needed supervision or touching assistance (helper provides verbal cues and/or touching steadying and/or contact guard assistance) with eating. During a review of Resident 1's Progress Note, dated 5/4/2026, Resident 1's Progress Note indicated on 5/4/2026, the Social Services Director (SSD) reported an allegation involving potential financial exploitation (the act of treating someone unfairly or taking advantage of them for one's own personal, financial, or selfish benefit) of a deceased resident (Resident 1). The note indicated a friend of Resident 1 informed the facility that an employee appears to have made two unauthorized [NAME] (money transfer company) transactions from the resident's bank account and additionally, a new credit card was also reportedly ordered under that employee's name. During an interview on 5/13/2026 at 11:40 AM with the Administrator (ADM), ADM stated on 5/4/2026, the ADM was notified by Resident 1's friend over the phone that a few days after the resident's death on 4/20/2026, she noticed some [NAME] transactions on the resident's email that were sent to a phone number and a name she did not recognize. ADM stated he spoke with the facility's Business Office Manager (BOM) and confirmed the name, and phone number was CNA 2's. Resident 1's friend also mentioned there was a credit card application that was submitted under Resident 1's name and approval was being sent to an address that was near the facility's address. ADM stated upon checking CNA 2's records, it was found the mailing address was CNA 2's address as well. ADM further stated that upon interviewing CNA 2, CNA 2 verified her phone number and mailing address as the same that were used in the [NAME] transactions and the credit card application. ADM stated CNA 2 had told himself, the Director of Nursing (DON), Human Resources (HR), Director of Staff Development (DSD), and SSD, that there was an instance where she allowed Resident 1 to use her personal phone, and she had stated that she did not notify any supervisor of the incident. During an interview on 5/13/2026 at 1:56 PM with DSD, DSD stated facility's policy is to prevent financial abuse. DSD stated staff are not to take anything they receive from the residents such as gifts. DSD further stated that the nursing department was instructed never to handle any money or deal with residents' financial matters or bank accounts. DSD stated if a resident attempts to hand money to staff when the BOM or SSD is not in the facility, they are to keep it locked and secured inside the nurse's cart. DSD stated they are not to handle any amount over $20.00.During an interview on 5/13/2026 at 4:06 PM with Resident 1's Friend, Resident 1's Friend stated she first noticed an email sent to Resident 1 from Resident 1's bank on 4/26/2026 indicating [NAME] had been set up and CNA 2 was added as a [NAME] recipient, with a $200.00 [NAME] payment sent to CNA 2 on the same day. Resident 1's friend further stated that on 4/27/2026, there was another email from the bank indicating a [NAME] payment of $120.00 was sent to CNA 2. Additionally, Resident 1's Friend stated that a credit card had been opened under Resident 1's name with his bank and the card was being mailed to CNA 2's address. During an interview on 5/13/2026 at 4:23 PM with CNA 2, CNA 2 stated that her only relationship with Resident 1 was as his CNA and nothing more. CNA 2 stated Resident 1 never asked her to buy anything for him other than chips from the vending machine and that she never handled more than $2.50 in cash, which was the cost of the chips Resident 1 requested. CNA 2 also stated she never had access to Resident 1's phone information but admitted that on one occasion she allowed Resident 1 to use her personal phone to help her with a phone backup (making a copy of one's phone data) and to download the TikTok (a global social media platform where users create, watch, share short-form videos and purchase products) application onto her personal phone. CNA 2 stated she has Resident 1's personal phone number so the resident could contact her at any time. CNA 2 stated there were [NAME] transactions transferred to her account from Resident 1's account for $200.00 and $120.00 on 5/5/2026. CNA2 stated she called her bank to report that she was not expecting those transactions and to have them removed from her account. CNA 2 verified her current phone number and address and stated she did not apply for any credit card under Resident 1's name and had not received any credit card in the mail.During an interview on 5/13/2026 at 4:42 PM with ADM, ADM stated during their interview with CNA 2 on 5/4/2026, CNA 2 had told them there was an instance where Resident 1 had downloaded the TikTok application onto CNA2's personal phone. ADM stated according to CNA 2, besides providing activities of daily living (ADL) care for Resident 1, she would also order food from outside source and get him items such as vitamins from a store outside the facility. The ADM stated that staff are permitted to purchase items for a resident if the resident has no family or friends available to do so; however, all transactions must be handled in cash and must be logged and witnessed by the SSD or DON during the cash exchange and again when the goods and change are returned. During the same interview and record review on 5/13/2026 at 4:42 PM with ADM, the Facility's policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, revised 8/1/2023, was reviewed. ADM stated it is the facility, as an entity's responsibility to protect and prevent abuse to a resident.During an interview on 5/13/2026 at 5:18 PM with SSD, SSD stated on 4/20/2026 when Resident 1 passed away, his belongings were inventoried (the process of taking a documented catalog of a resident's personal belongings) by a Restorative Nursing Assistant (RNA, a CNA with specialized training in rehabilitation). The RNA packed up Resident 1's belongings and placed them inside the closet in the resident's room. SSD stated once the RNA finished completing the inventory of Resident 1's belongings, the only item given to her was a yellow envelope containing Resident 1's identification card (ID), Social Security card, Medicare and Medi-Cal insurance cards, and his bank debit card. SSD stated the rest of Resident 1's belongings were packed into a box and placed in the closet inside Resident 1's room, an area accessible to other people, including staff. SSD stated Resident 1's box of belongings was not brought to her office for secure storage until 5/4/2026, when Resident 1's friend contacted the facility. Additionally, SSD stated the inventory of Resident 1's belongings completed on 4/20/2026 accounted for Resident 1's cell phone and laptop; however, during another inventory conducted on 5/4/2026, Resident 1's cell phone and laptop were found to be missing.During a concurrent interview and record review on 5/13/2026 at 5:28 PM with SSD, Resident 1's Inventory List, dated 4/20/2026, was reviewed. Resident 1's Inventory List accounted for Resident 1's cell phone and laptop. SSD stated when she went through the 2 boxes where Resident 1's belongings were stored, everything was accounted for from the Inventory List on 4/20/2026 with the exception of the resident's cell phone and laptop.During a concurrent observation and interview on 5/13/2026 at 5:29 PM with SSD inside her office, the 2 boxes of Resident 1's belongings were observed to be missing the resident's cell phone and laptop as listed on the resident's inventory list on 4/20/2026. SSD stated that the usual procedure after a resident expires is to inventory their belongings and pack them into a box, which is typically stored in the SSD office. However, Resident 1's boxed belongings were left in the room's closet, an area that was unfortunately accessible to others, including staff. During an interview on 5/13/2026 at 5:31 PM with the ADM, ADM stated the normal procedure after a resident expires is to store their belongings in the SSD's office and contact the family to arrange pickup. However, in Resident 1's case, his belongings were left in his room. The ADM stated the facility did not become aware that Resident 1's phone was missing until 5/4/2026, when his friend reported it. The ADM stated Resident 1's belongings should not have been left in the resident's room's closet, as this exposed them to unauthorized access and placed Resident 1's phone and its information at risk. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, revised 8/1/2023, the P&P indicated its purpose is To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. The P&P also indicated:Each resident has the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property.The facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other agencies providing services under arrangement, family members, legal guardians, surrogate, sponsors, friends and visitors.During a review of the Facility's P&P titled, Theft/Loss Prevention, revised 11/1/2017, the P&P indicated its purpose, To assist residents in safeguarding their personal property. The P&P also indicated:The facility is committed to preventing the misappropriation of resident property. The facility will exercise reasonable care for the protection of the resident's property from theft or loss.

Based on interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 2) was free from unnecessary psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) as indicated in the facility's policy and procedure by failing to ensure Resident 2 had a specific indication for the use of Buspirone Hydrochloride (HCL) (a prescription medication used to treat symptoms of generalized anxiety disorder[emotion characterized by feelings of tension, worried thoughts and physical changes]). This deficient practice had the potential to increase the risk of Resident 2 to experience adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to psychotropic medication (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), which may lead to an overall negative impact on the residents' physical, mental, and psychosocial well-being.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE]. Resident 2's diagnoses included chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe), unspecified atrial fibrillation, (a diagnosis confirming an irregular, rapid heart rhythm), and difficulty in walking, not elsewhere classified. During a review of Resident 2's Minimum Data Set (MDS, resident assessment tool), dated 4/7/2026, the MDS indicated Resident 2 had moderately impaired cognitive skills (mental processes that allow people to think, learn, and solve problems) for daily decision making. The MDS indicated Resident 2 needed supervision or touching assistance, (helper provides verbal cues and /or touching/steadying and/or contact guard assistance as resident completes activity) for eating and oral hygiene. Resident 2 needed partial or moderate assistance, (helper does less than half the effort) with upper, lower body dressing, putting on/taking off footwear and sit to lying. The MDS also indicated Resident 2 needed substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunks or limbs but provides more than half the effort) with toileting hygiene, shower/bath self and personal hygiene. MDS indicated Resident 2 had behavior symptoms. During a review of Resident 2's Medication Administration Record (MAR) dated from 4/1/2026 to 4/30/206 was reviewed. Resident 2's April 2026 MAR indicated Buspirone HCL oral tablet 2.5 milligrams (mg, unit of measurement) by mouth three times a day for anxiety manifested by restlessness, ordered on 4/4/2026 and discontinued on 4/15/2026. During a concurrent interview and record review on 5/13/2026 at 2:55 PM with the Licensed Vocational Nurse 1 (LVN 1), Resident 2's April 2026's MAR was reviewed. LVN 1 stated the indication and manifestation of restlessness for the medication of Buspirone can be interpreted as Resident 2 pressing on his call light without stopping. LVN 1 stated restlessness can be interpreted differently by other LVNs and the indications and manifestations of use for this medication were not specific. During a concurrent interview and record review on 5/13/2026 at 4:28 PM with the LVN 2, Resident 2's April 2026's MAR was reviewed. LVN 2 stated the indication and manifestation of restlessness for the medication of Buspirone can be interpreted as Resident 2 expressing frequent complaints for his stay at other convalescent homes. LVN 2 stated restlessness was not specific. During an interview on 5/13/2026 at 5:10 PM with the Director of Nursing (DON), the DON stated it was important to have a specific and accurate indication and manifestation for use of any psychotherapeutic medication to ensure the resident receives the correct medication for the correct indication. The DON stated psychotropic medication orders should have the resident's specific behavior manifestation in order for staff to observe the same behavior and be able to evaluate if the medication was effective or not. This would also ensure that the medication is necessary for the treatment of the resident. The DON stated Resident 2's Buspirone medication did not have specific indications and manifestations for his treatment. During a review of the facility's Policy and Procedure (P&P) titled, Psychotherapeutic Drug Management, Revised on 1/5/2026. The P&P indicated, 'Unnecessary drugs are any drug when used in excessive close (including duplicate drug therapy); for excessive duration; without adequate monitoring; or without adequate indications for its use; in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the afore listed reasons. Procedure:The psychotherapeutic medication order will include the following information:Indications and manifestations of the disorder treated (i.e., auditory hallucinations, hitting others, refusing to eat, etc.)

Based on interview and record review, the facility failed to meet professional standards of quality for one of two sample residents (Resident 1) by failing to follow up with the physician when the physician discontinued Atorvastatin (Lipitor, a statin [a class of drugs] medication used to lower cholesterol and reduce the risk of heart disease, heart attack and stroke) due to a possible cross allergic risk (the potential for an allergic reaction to occur when the immune system recognizes proteins in one substance as similar to proteins in another). This deficient practice had the potential to result in Resident 1 having unintended problems related to cholesterol management which could lead to further cardiovascular complications. Findings: During a record review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE], with the diagnoses including but not limited to limited transient cerebral ischemic attack (a blockage of blood flow to the brain), hypertensive heart disease (long-term high blood pressure which causes structural and functional damage to the heart) with heart failure (a lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), and combined systolic (congestive - unable to pump blood efficiently) (a condition where the left ventricle of the heart is weakened and cannot contract effectively) and diastolic (congestive) (a type of congestive heart failure affecting the heart's ability to fill with blood leading to fluid buildup in the body) heart failure. During a record review of Resident 1's History and Physical (H&P, the initial clinical evaluation and examination of the resident), dated 4/4/2026, the H&P indicated Resident 1's diagnosis is hyperlipidemia (a common condition characterized by high levels of lipids [fats], such as cholesterol [a waxy substance in the blood, often caused by poor diet, lack of exercise, and genetics, which can cause severe heart disease] and triglycerides [the most common type of fat in the body, storing unused calories to provide energy], in the blood, often leading to atherosclerosis a, slow, progressive disease characterized by the buildup of plaque, fat, cholesterol, and other substances within artery walls, causing them to narrow and harden). During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment and tool), dated 4/7/2026, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was moderately impaired. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for toileting hygiene, shower/bathe self, and lying to sitting on side of bed. During a record review of Resident 1's facility Order Summary Report dated 4/3/2026, the order indicated Atorvastatin (commonly known as Lipitor is a prescription statin medication that lowers bad cholesterol [LDL- low-density lipoprotein] and triglycerides while raising good cholesterol [HDL- High-density lipoprotein] to prevent cardiovascular disease, including heart attacks and strokes.) Oral Tablet 20 mg - Give one tablet by mouth at bedtime for hyperlipidemia. During a record review of Resident 1's Drug Regimen Review (DRR, a review of all medications the resident is currently using in order to identify any potential adverse effects and reactions including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy), dated 4/4/2026, the Drug Regimen Review indicated Resident 1 was allergy to Simvastatin (a statin medication used to help lower cholesterol levels in the blood) and a question if resident was able to tolerate Atorvastatin. On 4/6/2026, DRR indicated the physician discontinued the Atorvastatin. During a concurrent interview and record review on 4/22/2026 at 4:19 pm with the Director of Nursing (DON) of Resident 1's DRR, the DON stated the DRR did not indicate stop taking the Atorvastatin. The DON stated the DRR was questioning if Resident 1 was able to tolerate Atorvastatin since Resident 1 was allergic to Simvastatin. The DON stated the Atorvastatin was for Resident 1's high cholesterol levels. The DON stated for the Atorvastatin medication was usually not abruptly stopped. The DON stated stopping Atorvastatin could result in high cholesterol levels which could lead to heart disease or liver problems. During a concurrent interview and record review on 4/22/2026 at 4:36 pm with the Registered Nurse (RN) Supervisor of Resident 1's Progress Notes, RN Supervisor stated Atorvastatin was discontinued on 4/6/2026. After stopping cholesterol medications staff should contact the physician for laboratory orders to determine the resident's baseline levels and ask if new order is needed to replace discontinued order. RN Supervisor stated she should have contacted the physician to ask if the physician wanted to order labs and place new order for Resident 1. RN Supervisor stated there was no follow up after Atorvastatin was discontinued on 4/6/2026. RN Supervisor stated the follow up for discontinuing Atorvastatin had gone through the cracks. During a follow up interview on 4/23/2026 at 11:57 am with RN Supervisor, RN Supervisor stated she contacted the physician yesterday (4/22/2026) and the physician ordered labs and asked RN Supervisor to contact the pharmacist for a recommendation for discontinued Atorvastatin. During an interview on 4/23/2026 at 1:38 pm with the Medical Doctor (MD), MD stated the plan was to start Pravastatin (a prescription statin medication used to lower high cholesterol and triglycerides, reducing the risk of heart attacks, stroke, and heart disease) if Atorvastatin was not a real allergy. MD stated Resident 1's plan was not to discontinue taking cholesterol medication. MD stated he wanted to look at Resident 1's laboratory results and Resident 1 still needed to take a statin with caution. During an interview on 4/23/2026 at 4:10 pm with the Consultant Pharmacist (CP), CP stated the majority of physicians would follow up with the labs and check for alternatives to use another class of medication that control the same symptoms. CP stated there was no reason to stop giving the statin and not start another class of medication because of a cross allergy. CP stated the physician can start a new medication as soon as the resident needs it and labs could be started right away. CP stated if the resident already had the condition and if they needed the medication, then the medication should not wait to be changed right away. CP stated when there was a cross allergy, the license nurses should not wait to contact the physician to switch the medication. CP stated the medication should not just be discontinued because of a possible cross allergy and the licensed nurse should have asked the physician what the plan was after Atorvastatin was discontinued. During a record review of the facility's Policy and Procedure (P&P) titled, Medication Ordering and Receiving Medications from the Dispensing Pharmacy, dated 1/2022, the P&P indicated a licensed nurse should verify medications received and directions for use with the medication order form and/or physician's orders. Promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor. During a record review of the facility's P&P titled, Compliance with Laws and Professional Standards, revised 11/1/2017, the P&P indicated facility staff will provide services in compliance with federal, state, and local laws, regulations, codes and professional standards. Facility staff perform their duties in accordance with the policies and procedures adopted by the Facility.

Based on observation, interview, and record review, the facility failed to administer a medication as indicated on the physician's order for one of two sampled residents (Resident 1) by failing to administer Symbicort Inhalation Aerosol 160-4.5 microgram/actuation (mcg/act, indicates the amount of medication delivered in a single puff from an inhaler) to Resident 1 from 4/4/2026 to 4/23/2026 (did not admit medication for 20 days and total 39 doses missed). This deficient practice had the potential to worsen breathing and increase risk of respiratory exacerbations (a sudden worsening of chronic symptoms, most commonly associated with chronic obstructive pulmonary disease [COPD a progressive, incurable lung disease that causes obstructed airflow, making it difficult to breathe] or asthma, characterized by increased breathlessness, cough, and mucus production) and lead to possible irreversible outcome for Resident 1. Findings: During a record review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE], with the diagnoses including but not limited to COPD, pulmonary fibrosis (a lung disease where the tissue around the air sacs in the lungs becomes damaged), and obstructive sleep apnea (sleep disordered caused by repeated interruptions in breathing during sleep). During a record review of Resident 1's Order Summary Report, dated 4/3/2026, the order indicated Symbicort Inhalation Aerosol 160-4.5 mcg/act - Two puff inhale orally two times a day for COPD. During a record review of Resident 1's Respiratory Treatment Record (RTR, a medical record used by healthcare providers to document the administration of a medication or treatment) for the month of April 2026, the RTR indicated from 4/4/2026 to 4/23/2026 Symbicort was not administered and other/see progress notes twice a day. During a record review of Resident 1's Progress Notes for the month of April 2026 for dates 4/4/2026 to 4/23/2026 the progress note indicated medication was not available. During a record review of Resident 1's Care Plan, dated 4/6/2026, the Care Plan indicated Resident 1 was at risk for altered respiratory status/difficulty breathing related to obstructive sleep apnea, COPD, and pulmonary fibrosis. The care plan interventions for staff were to administer medication/puffers as ordered and monitor for effectiveness and side effects. During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment and tool), dated 4/7/2026, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was moderately impaired. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for toileting hygiene, shower/bathe self, and lying to sitting on side of bed. The MDS also indicated Resident 1 received oxygen therapy. During a concurrent interview and record review on 4/23/2026 at 2:07 pm with the Director of Nursing (DON) of Resident 1's RTR, the DON stated Symbicort was ordered to be administered twice a day. The DON stated Symbicort was to help with respiratory conditions. The DON stated if the Symbicort was not given to Resident 1, Resident 1's COPD could worsen and lead to a decrease in Resident 1's oxygen saturation (amount of oxygen in the blood or how well a resident is breathing). The DON stated Resident 1's Symbicort had not been administered from 4/4/2023 to 4/23/2026. The DON stated Respiratory Therapist (RT) stated the Symbicort was not covered by Resident 1's insurance. The DON stated RT did not communicate with RN, pharmacy, nor MD to seek alternative medication that was covered by insurance During an interview on 4/23/2026 at 2:22 pm with RT, RT stated the Symbicort was ordered on 4/4/2026 but was not received from pharmacy. On 4/10/2026, the pharmacy was notified and the pharmacy stated the medication was not covered by Resident 1's insurance. RT stated as of today (4/23/2026), Resident 1 still had not received the Symbicort. RT stated the only inhaler scheduled for Resident 1 was Symbicort. During an interview on 4/23/2026 at 2:35 pm with RN Supervisor, RN Supervisor stated upon admission to the facility if the Symbicort is not covered by insurance, staff should follow up with pharmacy right away. RN Supervisor stated RT staff should follow up by contacting the pharmacy or notifying the RN supervisor. RN Supervisor stated Symbicort was used for exacerbation and prevention of breathing problems. RN Supervisor stated the Symbicort was Resident 1's maintenance medication to prevent exacerbation of respiratory symptoms which could lead to hospitalization if not taken. During a record review of the facility's undated P&P titled, Respiratory Therapist Job Description, undated, the P&P indicated Respiratory Therapist job duties include determining respiratory therapy treatment plan in consultation with physicians and by prescription, administers respiratory therapy treatments, and keep the RN Supervisor informed about the status of residents, staff and related matters. During a record review of the facility's Policy and Procedure (P&P) titled, Medication - Administration, revised 11/1/2017, the P&P indicated the medication will be administered by a Licensed Nurse per the order of an Attending Physician. During a record review of the facility's P&P titled, Medication Ordering and Receiving from Pharmacy, dated 01/2022, the P&P indicated, medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. A licensed nurse should verify medications received and directions for use with the medication order form and/or physician's orders. Promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor. Assures medications are incorporated into the resident's specific allocation prior to the next medication pass.

Based on observation, interview and record review, the facility failed to provide a safe environment that is free from accident hazards for two (2) of three (3) sample residents (Residents 44, and 9) reviewed for accident hazards by failing to ensure:A black synthetic gait belt (a type of belt used to support, steady, or assist a resident during movement), approximately five (5) feet long, was not left on the floor near Resident 44's bed.Resident 9's feet were not dangling while sitting in the wheelchair.The base of the Hoyer lift (a mechanical device designed to safely transfer individuals with limited mobility between surfaces, such as a bed, chair, or wheelchair) stored in the hallway was not left wide open. The lint trap was cleaned on 4/3/2026 at 8AM, 10AM, and 12PM from the facility's two of two dryer's machines (Dryer 1 and 2). These deficient practices placed Residents 44 and 9 and other residents at risk for serious injury. In addition, it placed the facility and the residents at risk for fire from Dryers 1 and 2. Findings: 1. During a review of Resident 44's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves) and difficulty in walking. During a review of Resident 44'S Minimum Data Set (MDS – a resident assessment tool), dated 2/11/2026, the MDS indicated the resident had moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 44 used a walker and wheelchair as mobility devices. The MDS also indicated Resident 44 needs substantial / maximal assistance (helper does more than half the effort to walk 10 ft. (once standing, the ability to walk at least 10 ft in a room, corridor, or similar space). During a record review of Resident 44's Care Plan, dated 11/26/2024, the Care Plan indicated the resident had moderate risk for falls. The care plan indicated the environment should be adapted to meet the resident's safety needs. During a record review of Resident 44's Fall Risk Assessment, dated 2/6/2026, it indicated Resident 44 was assessed to be at moderate risk for fall. During an observation on 3/31/2026 at 9:55 AM in Resident 44's room, a black synthetic gait belt, approximately 5 ft. long, was observed on the floor near Resident 44's bed. During a concurrent observation and interview on 3/31/2026 at 10 AM with the Licensed Vocational Nurse (LVN 3), in Resident 44's room, LVN 3 stated the black gait belt was on the floor near Resident 44's bed. During an interview on 4/2/2026 at 2:54 PM with Restorative Nurse Assistant (RNA 1), RNA 1 stated RNA 1 forgot the black synthetic gait belt on the floor. RNA 1 stated, sorry about that. The resident might fall. I will not do it again. RNA 1 also stated the black synthetic gait belt was approximately 5 ft. long and it is an accident hard for the resident since the resident my trip and fall. During a concurrent interview and record review on 4/3/2026 at 1:36 PM with the Director of Nursing (DON), the facility's Policy and Procedures (P&P) titled Fall Management Program, dated 11/1/2017 was reviewed. The DON stated the P&P indicated that it is the policy of the facility to provide the highest quality care in the safest environment for the residents residing in the facility. The DON stated the P&P also indicated to keep walkway obstruction and spill free. The DON also stated the facility must remain clutter free to prevent accidents. 2. During a review of Resident 9's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included difficulty in walking and history of fall. During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9 had severe impairment in cognitive skills for daily decision making. The MDS also indicated Resident 9 was dependent (helper does all the effort) with toileting, shower, lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 9 required substantial/maximal assistance with oral hygiene and upper body dressing. During an observation in the resident's room on 4/1/2026 at 9:30 AM, Resident 9 was observed sitting in her wheelchair with the resident's feet dangling and were far away from the wheelchair's footrest with Certified Nursing Assistant 2 (CNA 2) watching the resident. During an observation on 4/1/2026 at 9:40 AM, Resident 9 was seen being wheeled by CNA 2 out in the hallway with the resident's feet still dangling and not resting on the wheelchair's footrest. During an interview on 4/1/2026 at 2:28 PM, Occupational Therapist (OT) stated Resident 9's feet should not be hanging while sitting on the wheelchair and should be on the footrest to prevent leg spasm. The OT also stated Resident 9's footrest should be adjusted to the resident's height and foot distance to the footrest. During an interview on 4/2/2026 at 2:53 PM, the DON stated Resident 9's wheelchair was too high for the resident and Rehabilitation Department (RD) should have evaluated Resident 9's for right and appropriate wheelchair height to prevent the resident's feet from dangling off the floor or the footrest of the wheelchair. The DON also stated Resident 9's feet should not be dangling for proper body alignment and to prevent the resident from falling which could result in injuries while the resident is sitting in the wheelchair. During a review of the facility's P&P titled, Positioning and Body Alignment, revised 11/1/2017, the P&P indicated that the residents' legs are positioned with feet placed firmly on the floor or wheelchair footrest when in a sitting position. The P&P also indicated when positioning the resident on a wheelchair that the footrest is adjusted so that the resident's thighs are parallel with supporting surface. 3. During a concurrent observation and interview on 4/2/2026 at 1:58 PM, the Hoyer Lift was parked in the hallway unplugged and with the base wide open. CNA 3 stated they always park the Hoyer lift in the hallway and that was where they are being charged. CNA 3 also stated the staff were not using the Hoyer lift right now but the facility does not have a storage area to place them. During an interview on 4/2/2026 at 2:06 PM, RNA 2 stated the base of the Hoyer lift should be closed and not left open because anyone can trip and have a fall accident if the base was left open. RNA 2 also stated they leave the Hoyer lift at the hallway because they do not have a storage area to put them in. During an interview on 4/2/2026 at 3:08 PM, the DON stated the facility staff should have placed the Hoyer lift in the area where there was no traffic and residents and staff do not frequently pass by. The DON also stated the facility normally keeps the Hoyer lift in the hallway while it is being charged but the base of the Hoyer lift should be closed to prevent staff and residents from trip and fall accidents. The DON further stated Hoyer lift could pose an accident hazard if the base was left open. During a review of the facility's P&P titled, Resident Rooms and Environment, revised 11/1/2017, the P&P indicated that the facility was to provide residents with a safe, clean, and comfortable and homelike environment. The P&P also indicated that the facility was to ensure the resident could receive care and services safely and that the physical layout of the facility maximizes residents' independence and does not pose a safety risk. 4. During an observation and interview on 4/3/2026 at 1:32 PM, the facility's laundry room had two washers (Washer 1 and 2) and two dryers (Dryers 1 and 2). Laundry Staff (LS) stated she did not know how to open the dryer's front compartment. LS called the Maintenance Supervisor (MS) for assistance and at 1:42 PM, MS came into laundry and opened the Dryers 1 and 2's compartment. MS and LS observed a thick layer of lint around an internal compartment located between the lint screens and the lint vent of Dryer 1 and 2's lint. LS proceeded to remove the lint from the lint trap screen and sweep the internal compartment's bottom surface. MS stated the laundry staff last cleaned the lint compartment was around 6 AM. MS stated the lint present in this internal compartment was a fire hazard and it should have been cleaned ever two (2) hours. During an interview on 4/3/2026 at 1:50 PM with LS, LS stated she had not removed the dryer lint from Dryer 1 and 2 at 8 AM, 10 AM, and 12 PM. LS stated the lint compartment was supposed to be cleaned every 2 hours. During a record review on 4/3/2026 at 1:57 PM with the LS, the facility's Dryer Lint Cleaning Log (DLCL) was reviewed. DLCL indicated Dryers 1 and 2 shall be cleaned every two hours and staff must write the initials at the date and time when the lint traps have been cleaned. DLCL was blank on 4/3/2026 at 8 AM, 10 AM, and 12 PM. A review of the facility's policy and procedure titled, Interior Maintenance Laundry Room/ Water Temperature, effective 1/1/1999, indicated maintenance of the clothes dryer included to check that the laundry personnel were cleaning filters every two hours, vacuum areas around filters, and to make sure equipment was free of lint.

Based on observation, interview, and record review, the facility failed to maintain the food service area in a clean and sanitary condition and failed to follow its proper food - handling policy procedure by failing to ensure: A container of lentils was properly covered with a lid.The can opener was sanitized and free of dry food residue. These deficient practices have the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization.Findings: During a concurrent kitchen observation and interview on 3/31/2026 at 12:46 PM, with the Dietary Supervisor (DSS 1), DSS 1 stated that the clear container of lentils did not have its lid properly closed. During a concurrent observation in the kitchen and interview on 4/1/2026 at 8:18 AM with the Dietary Supervisor (DDS 2), DSS 2 stated that the can opener contained dry food residue, including a white unknown residue and brown- black gunk (an accumulation of greasy or dirty buildup commonly found on dishes, in sinks, or kitchen appliances). During an interview on 4/2/2026 at 12:44 PM with Dietary Aide (DA 1), DA 1 stated all containers should be properly closed to prevent insects and dust from entering, as these can contaminate food and potentially cause illness. During an interview on 4/2/2026 at 12:45 PM, DA 1 also stated that the can opener should be cleaned after each use. During a concurrent interview and record review on 4/2/2026 at 3:27 PM with the DSS2, the facility's P&P titled Food Storage, revised on 11/1/2017, was reviewed. DSS 2 stated the P&P indicated that Any open products should be placed in storage container with tight fitting lid. DSS2 stated they did not follow the P&P for food storage. During a concurrent interview and record review on 4/2/2026 at 3:30 PM with the DSS 2, the facility's P&P titled, Can Opener Use and Cleaning, revised date 11/1/2017 was reviewed. DSS 2 stated the P&P indicated the can opener will be sanitized between uses. DSS 2 stated the P&P for food storage and can opener sanitation was not followed. DSS 2 also stated that failure to sanitize the can opener between uses, and not closing container lids properly, can lead to food contamination and has the potential to cause illnesses such as stomachache and diarrhea.

Based on observation, interview, and record review the facility failed to maintain safe, clean, comfortable sanitary and home-like environment for two (2) of five (5) sampled residents (Resident 11 and 18) reviewed for environment by failing to:Ensure Resident 11's bedside rails (safety devices or barriers attached to the sides of a bed to prevent falls, assist with repositioning, and provide support for getting in and out of bed) foam padding was in good condition. The facility failed to ensure two wash basins and three hand towels were not placed in the toilet tank in Resident 18 's restroom. These deficient practices caused an unsanitary and had potential for residents to be placed at risk for serious illness and/ or injury.Findings: 1.During a review of Resident 11's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of acute respiratory failure (an inability to maintain adequate oxygenation for tissues or adequate removal of carbon dioxide from tissues) and type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel). During a review of Resident 11'S Minimum Data Set (MDS – a resident assessment tool), dated 3/19/2026 the MDS indicated the resident was assessed to have severe impairment with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 11 needed partial moderate assistance (helper does less than half the effort) on eating, oral hygiene (the ability to use suitable items to clean teeth) and substantial maximal assistance (helper does more than half the effort) on sit to lying (the ability to move from sitting on the bed to lying flat on the bed). During a record review of Resident 11's Order Summary Report dated 4/1/2026, the order summary report indicated an order for quarter bedside rails up times two (two half bedside rails up [head of bed]) as an enabler to promote bed mobility, functional mobility and transfer, with an order date of 8/26/2025. During an observation on 3/31/2026 at 9:21 AM in Resident 11's room, Resident 11's black foam padding on the left bedside rails was damaged, with multiple tears visible and a section ripped off in the middle. During a concurrent observation and interview on 4/1/2026 at 2:05 PM with the Environmental Services (EVS 1) in Resident 11's room, EVS 1 stated the black foam padding attached to the left bedside rails was damaged and falling apart. EVS1 stated, when the foam padding shows wear and tear, it should have been replaced. During an interview on 4/1/2026 at 2:16 PM with the License Vocational Nurse (LVN 1), LVN 1 stated the black foam padding on the resident's bedside rails are required to be in good condition to ensure residents' protection, and that foam padding that is falling apart from the bedside rails could potentially cause harm or injury to a resident. During a concurrent interview and record review on 4/3/2026 at 1:39 PM with the Director of Nursing (DON), the facility's Policy and Procedures (P&P) titled Resident Rooms and Environment dated 11/1/2017 was reviewed. The DON stated the facility's P&P indicated, it is the policy of the facility to provide residents with a safe, clean, comfortable and homelike environment. The DON also stated that the black foam padding on the bedside rails of Resident 11 that was falling apart was not acceptable. The DON stated, it was not safe, comfortable and not giving the resident a homelike environment, and the facility's P&P was not followed. 2. During a review of Resident 18's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included chronic kidney disease (gradual loss of kidney damage where kidneys cannot filter the blood the way they should), history of falling, and bradycardia (a low heart rate, when resting heart rate below 60 beats per minute). During a review of Resident 18's Minimum Data Set (MDS- a resident assessment tool), dated 3/16/2026, the MDS indicated Resident 18 had severe impairment in cognitive skills for daily decision making. The MDS also indicated Resident 18 was dependent (helper does all the effort) with toileting and required partial/moderate assistance with eating, oral hygiene, and putting on/taking off footwear. During an observation on 4/3/2026 at 11:12 AM in the Resident 18's room. CNA 3 was observed placing two (2) wash basins and three (3) hand towels over the toilet tank and walking out of the restroom. CNA 3 stated the wash basins and hand towels were used to provide morning care for Resident 18 and should never be placed on the toilet tank. CNA 3 stated the toilet tank should not be considered as a clean surface for placing morning care supplies. During an interview on 4/3/2026 at 3:03 PM with Infection Preventive Nurse (IPN), IPN stated putting wash basins and towels over the toilet tank were unsanitized because during toilet flushing, aerosolized particles would spew into the air and contaminate the wash basins and towels with bacteria.

Based on observation, interview, and record review, the facility failed to ensure the call light (a communication device in hospitals and nursing homes that allows patients to alert staff for assistance) was within arm's reach for one (1) of four (4) sampled residents (Resident 7) reviewed for environment in accordance with the facility's policy and procedure (P&P) titled, Communication - Call System: This deficient practice had the potential for Resident 7 not to be able to call the facility staff for help or assistance, especially during an emergency.Findings:During a review of Resident 7's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), type 2 diabetes mellitus (a condition in which the body cannot regulate blood sugar levels in the blood), and difficulty in walking. During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool), dated 3/3/2026, the MDS indicated Resident 7 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 7 required substantial/maximal assistance (helper does more than half the effort) with eating and was dependent (helper does all the effort) with oral hygiene, toileting hygiene, lower body dressing and putting on/taking off footwear. During an observation and interview on 3/31/2026 at 8:41 AM with Resident 7 in the room, Resident 7 's call light was under the mattress behind the resident's bed. Resident 7 stated she did not know where the call light was. During an interview on 4/1/2026 at 01:21 PM, Certified Nursing Assistant 1 (CNA 1) stated call light was not within Resident 7 reach, and the resident will not be able to use the call light to alert the staff when the resident needed help. During an interview on 4/3/2026 at 4:06 PM, the Director of Nursing (DON) stated the call lights should be within reach of the resident so the resident can use it to call for help and get assistance if desired. During a review of the facility's P&P titled, Communication - Call System, revised 11/1/2017, the policy indicated that the facility provides a mechanism for residents to promptly communicate with nursing staff. The policy also indicated the call cords (call light) will be placed within the resident's reach in the resident's room.

Based on observation, interview and record review, the facility failed to secure the residents personal and medical records when the facility did not destroy identifiable information on the resident's discarded oxygen humidifier (bottle device attached to an oxygen concentrator [a medical device that provides supplemental oxygen to people with breathing disorders], tank, or liquid system to add moisture to dry medical oxygen, reducing nasal dryness, nosebleeds, and throat irritation) container for one (1) of 17 sampled residents (Resident 6). This deficient practice has the potential for unauthorized release of resident's personal information.Findings: During a review of Resident 6's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), depression (a common and serious medical illness that negatively affects how the person feels, the way they think and how they act), and type two (2) diabetes mellitus (a condition in which the body cannot regulate blood sugar levels in the blood). During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool), dated 3/9/2026, the MDS indicated Resident 6 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 6 required substantial/maximal assistance (helper does more than half the effort) with eating and was dependent (helper does all the effort) with oral hygiene, toileting hygiene, lower body dressing and putting on/ taking off footwear. During an observation on 3/31/2026 at 8:01 AM in Resident 6's room, an oxygen humidifier container was labeled with resident's full name and room number was found inside the trash bin in the resident's room. During a concurrent observation on 3/31/2026 at 8:13 AM in Resident 6's room with the Infection Prevention Nurse (IPN), IPN confirmed that the oxygen humidifier container labeled with Resident 6's full name and room number was in the trash bin. IPN stated the resident's identifiable information must be destroyed before discarding in the trash bin. During an interview on 4/1/2026 2:17 PM with Director of Staff Development (DSD), DSD stated with the resident's identifiable information must be removed before throwing any medical equipment or supply in a regular trash bin, and that is in accordance with Health Insurance Portability Accountability Act (HIPAA, a law designed to provide privacy standards to protect patient's medical record and other health information) law. The DSD also stated, Resident 1's oxygen humidifier found inside the trash bin clearly showed identifiable resident's information. DSD stated resident information should not be visible to unauthorized individuals. During a review of the facility's admission Packet (information given to each resident admitted into the facility) includes Resident [NAME] of Rights dated May 2011, indicated the resident has the right to personal privacy and confidentiality of his or her personal clinical records. During a review of the facility's policy and procedure (P&P) titled Privacy and Dignity, dated 11/1/2017. The P&P indicated rights to privacy are a part of the admission agreement and the resident is informed of these rights during the admission process which includes residents are afforded a right to privacy and confidentiality. The P&P also indicated resident rights to privacy and confidentiality of medical information and the clinical record is provided upon admission and explained to the resident during the admission process.

Based on interviews, and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that every resident entering a Medicaid Certified Nursing Facility [NF] receives a Level I screening and if necessary a Level II Evaluation to ensure that the NF residence is appropriate and to identify what specialized services the resident may need) for one (1) of three (3) sampled residents (Resident 10) reviewed for PASRR care area, in accordance with the facility's policy. This deficient practice had the potential to result in inappropriate placement of Resident 10 and had the potential for the resident not to receive the necessary care and services the resident needs. Findings:During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (a mental illness that is characterized by disturbances in thought), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 10's Minimum Data Set (MDS- a resident assessment tool), dated 1/27/2026, the MDS indicated Resident 10 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 10 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene and shower and required supervision (helper provides cues) with eating, oral and personal hygiene, upper and lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 10 has an active diagnosis of depression, psychotic disorder, and schizophrenia. During a review of Resident 10's Medical Records, Residents 10's Medical Records did not indicate that there was a PASARR 1 screening on 11/23/2025 re-admission. Resident 10's medical records indicated a positive PASARR 1 screening on 8/4/2023 and was unable to complete level 2 evaluation on 8/8/2023 as it indicated the resident has no serious mental illness. Resident 10's medical records indicated a diagnosis of depression on 7/21/2025 and 10/28/2025 as indicated on MDS. During a concurrent interview and review of Resident 10's Electronic Medical Record (EMR, an electronic version of the resident's medical history that is maintained by the provider over time) on 4/2/2026 at 12:24 PM with the MDS coordinator, the MDS coordinator stated Resident 10's EMR did not have PASARR level 1 screening from the hospital where the resident was transferred from. The MDS coordinator also stated there should be a PASSAR level 1 screening to check if Resident 10 has mental illness and coordinated with the state agency for further evaluation and proper placement of the resident if the screening is positive. During an interview on 4/2/2026 at 3:00 PM, the Director of Nursing (DON) stated resident 10's PASSAR level 1 screening should have been done if there was none completed at the hospital upon the resident's readmission to ensure the resident was being placed appropriately. During a review of the facility's Policy and Procedure (P&P) titled, Preadmission Screening and Resident Review Reports (PASRR), revised 7/1/2023, the P&P indicated that the facility must ensure that PASARR level 1 is completed either by the transferring general acute care hospital (GACH) or by the facility for all applicants, regardless of payor, prior to admission to determine if they have serious mental illness and/or intellectual disability, developmental disability or related conditions.

Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LAL mattress, a specialized medical bed mattress designed to prevent and treat pressure ulcers [localized damage to the skin and/or underlying tissue usually over a bony prominence] by constantly blowing a tiny amount of air through small holes in its surface) was at a correct setting for one (1) of two (2) residents (Resident 21) reviewed for pressure ulcer , in accordance with the facility's policy and procedure. This deficient practice placed Residents 21 at risk for development of new pressure ulcers and prevent healing of the resident's existing Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) on the sacrococcyx (pertains to both large triangular shaped bone in the lower spine that forms part of the pelvis and the tailbone).Findings: During a review of Resident 21's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included pressure ulcer (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). During a review of Resident 21's Minimum Data Set (MDS- a resident assessment tool), dated 1/16/2026, the MDS indicated Resident 21 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 21 was dependent (helper does all the effort) with toileting and required partial/moderate assistance (helper does less than half the effort) with oral hygiene, shower, lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 21 required supervision (helper provides cues) with eating, upper body dressing and personal hygiene. During a review of the Physician's Order, dated 1/15/2026, at 1:38 PM, the Physician's Order indicated use of LAL mattress for skin maintenance treatment with instructions to check for setting and functionality. During a review of Resident 21's Care Plan, dated 1/16/2026, the Care Plan indicated the resident has LAL for wound management with setting range of 150 to 160 pounds to minimize the risk of further tissue breakdown and a proposed plan to keep LAL mattress on the correct setting according to the resident's weight and comfort. During a review of Resident 1's Wound Weekly Observation Tool (a structured, standardized documentation form used by healthcare professionals to measure, and track the healing progress of pressure injuries, ulcers or surgical sites at least once a week), dated 3/18/2026, the Wound Weekly Observation Tool indicated a wound assessment to the Sacro-coccyx stage 4 pressure injury, measuring 2.2 centimeters (cm, unit of measurement) by 1.22 cm by 1 cm (length and width) and a tunneling depth of 2.4 cm. During an observation on 4/1/2026 at 10:23 AM, Resident 21 was lying in bed with the LAL set at 180 pounds. Resident 21 stated she weighs around 150 pounds. During a concurrent interview and review of Resident 21's Electronic Medical Record (EMR, an electronic version of the resident's medical history that is maintained by the provider over time) on 4/2/2026 at 8:08 AM, Licensed Vocational Nurse 2 (LVN 2) stated Resident 21's weight in the EMR was 158 pounds. During a concurrent observation, interview on 4/2/2026 at 8:12 AM, LVN 2 stated Resident 21's LAL setting was set at 180 pounds. LVN 2 also stated Resident 21's LAL setting should be based on the resident's current weight and not at 180 pounds to prevent creating pressure on the resident's sacral area where she had pressure injury and to promote wound healing. During an interview on 4/2/2026 at 3:01 PM, the Director of Nursing (DON) stated LAL was used to prevent further development of pressure injuries and help with the healing of pressure injuries. The DON also stated the LAL mattress should be set based on the weight of Resident 21 to prevent development of another pressure injuries. During a review of the facility's Policy and Procedure (P&P) titled, Wound Management, revised 11/1/2017 indicated that the facility provides a system for the treatment and management of residents with wounds including pressure and non-pressure ulcers. The P&P also indicated that a resident who has a wound will receive necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers from developing. During a review of the facility's P&P titled, Pressure Reducing Mattress, dated 4/2022 indicated that a specialty mattress which included the LAL mattress or bed will be obtained for pressure relief of residents that have pressure injury or at risk for pressure injury. The P&P also indicated for setting the pressure reducing mattress according to resident's height and weight, to consider referring to manufacturer's guidance.

Based on observation, interview, and record review, the facility failed to ensure the oxygen via nasal cannula (NC, a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels) was administered for one (1) of three (3) sampled residents (Resident 66) reviewed for respiratory services in accordance with the facility's policy. This deficient practice had the potential for Resident 66 not being able to receive the benefits of the supplemental oxygen ordered and had the potential to compromise the resident's respiratory function which could lead to complications. Findings: During a review of Resident 66's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and pulmonary edema (the buildup of excess fluid in the lungs air sacs making it hard to breath). During a review of Resident 66's Minimum Data Set (MDS- a resident assessment tool), dated 1/19/2026, the MDS indicated Resident 66 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 66 required substantial/maximal assistance (helper does more than half the effort) with shower and required partial/moderate assistance (helper does less than half the effort) with oral, toileting and personal hygiene, upper and lower body dressing and putting and taking off footwear. The MDS further indicated Resident 66 required supervision (helper provides cues) with eating. During a review of Resident 66's Care Plan initiated on 5/2/2025 and revised on 5/12/2025, the Care Plan indicated the resident has impaired gas exchange related to increased oxygen demand with a goal to improve the resident's oxygenation and an approach plan to administer oxygen as ordered. During a review of Resident 66's physicians order dated 3/6/2026 at 2:44 PM, the physicians order indicated they may provide Resident 66 with supplemental oxygen at 2 liter per minute (LPM - unit of flow rate) via NC as needed (prn). The physician's order also indicated may titrate (to slowly and carefully adjust until desired result is achieved) 5 LPM to keep oxygen saturation above 90 percent as needed. During an observation on 3/31/2026 at 9:44 AM, Resident 66 was lying in bed with oxygen at 2 LPM and NC prongs not in the resident's nose but were seen on the left side of the resident's face. CNA (unable to get the name) who entered the room after being called by the surveyor confirmed that Resident 66's NC was not correctly placed in the resident's nose. During an interview on 4/2/2026 at 3:39 PM, Licensed Vocational Nurse 4 (LVN 4) stated Resident 66's NC prong should be in the resident's nostril so that the resident would get the benefit of receiving oxygen. During an interview on 4/3/2026 at 7:47 AM, LVN 1 stated Resident 66 would not be getting the oxygen ordered if the NC prong was not correctly placed in the resident's nose. LVN 1 also stated Resident 66 could develop shortness of breath (SOB, difficulty breathing) and desaturate (low blood oxygen level) if the resident is not getting the ordered oxygen. During an interview on 4/3/2026 at 7:51 AM, the Director of Nursing (DON) stated Resident 66's breathing could get affected and the resident desaturate if the oxygen NC prongs were not correctly placed in the resident's nose. During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration, revised 11/1/2017, the P&P indicated its purpose was to prevent or reverse hypoxemia (abnormally low level of oxygen in the blood) and provide oxygen to the tissues. The P&P also indicated that the facility was to check that the oxygen is flowing through the tubing and placed the NC prongs into the nares (nose) and adjust plastic slide under the chin until the nasal cannula fits snugly.

Based on observation, interview, and record review, the facility failed to ensure one (1) of two (2) dumpsters (a movable waste container) were closed and not overflowing, in accordance with the facility's Garbage and Trashcan Use and Cleaning Policy and Procedure (P&P). This deficient practice had a potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species), increasing the risk of disease transmission and health issues for residents, staff, and the surrounding community.Findings: During a concurrent observation and interview on 3/31/20226 at 8:05 AM with the Dietary Supervisor (DSS1) in the facility parking lot, DSS1 stated that 1 dumpster was overflowing with trash, emitted a foul odor, and had its lid left open. During an interview on 4/2/2026 at 12:44 PM, Dietary Aide (DA 1) stated that dumpsters should not overflow to prevent odors and the attraction of rodents and insects, which could potentially cause illnesses such as stomachache and diarrhea. During a concurrent interview and record review on 4/2/2026 at 3:27 PM with the DSS 2, the facility's P&P titled, Garbage and Trash Can Use and Cleaning, revised11/1/2027 was reviewed. DSS1 stated the P&P requires that food waste be placed in covered garbage and trash cans.

Based on interviews and record review, the facility failed to maintain a complete and accurate medical records for three (3) of 17 sampled residents (Residents 12, 21, and 9) in accordance with the facility's Charting and Documentation policy and procedure (P&P) by failing to ensure: 1. Resident 21's sacro-coccyx (pertains to both large triangular shaped bone in the lower spine that forms part of the pelvis and the tailbone) wound care treatment in the Treatment Administration Record (TAR) on 3/15/26, 3/16/2026 and 3/17/2026.2. Resident 9's physician order for Seroquel (drug used to treat schizophrenia) included an indication for use.3. Resident 12's pneumonia (an infection that inflames the air sacs (alveoli) in one or both lungs, causing them to fill with fluid or pus) vaccine consent and Covid-19 (a severe respiratory illness caused by virus and spread from person to person) vaccine consent form included Resident 12's signature.This deficient practice resulted in the medical records inaccurate representation of care provided to Residents 12, 21, and 9 and had the potential to result in delayed communication between care teams.Findings: 1. During a review of Resident 21's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included pressure ulcer (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). During a review of Resident 21's Minimum Data Set (MDS- a resident assessment tool), dated 1/16/2026, the MDS indicated Resident 21 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 21 was dependent (helper does all the effort) with toileting and required partial/moderate assistance (helper does less than half the effort) with oral hygiene, shower, lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 21 required supervision (helper provides cues) with eating, upper body dressing and personal hygiene. During a concurrent interview and record review on 4/2/2026 at 3:22 PM with Treatment Nurse 1 (TN 1), Resident 21's TAR for the month of March 2026 was reviewed. The TAR indicated a wound treatment for Resident 21's Sacro-coccyx pressure injury with normal saline (NS-a saltwater solution), apply collagen powder (a wound dressing that can be used to treat a variety of wounds), and pack loosely with iodoform (compound used as wound dressing to prevent infection) 1/4 packing strips, then cover with super absorbent dressing daily. TN 1 stated the wound treatment for 3/15/2026, 3/16/2026, and 3/17/2026 were provided to Resident 21 but it was not reflected on the TAR. TN 1 stated the TAR should have been signed after giving the wound treatment. During an interview on 4/2/2026 at 3:34 PM, Licensed Vocational Nurse 4 (LVN 4) stated Resident 21's wound treatment should be consistent and followed according to the doctor's order to prevent the wound from getting worse and documented as evidence the wound care was provided. LVN 4 also stated the wound treatment should be documented to help track the healing progress of Resident 21's pressure ulcer. During an interview on 4/2/2026 at 3:46 PM, LVN 2 stated she was doing the wound treatment for Resident 21 on 3/17/2026 but forgot to sign the TAR. LVN 2 also stated Resident 21's TAR did not have accurate documentation of the wound treatments provided and should be accurate to ensure the wound treatments were being communicated to other TNs. During an interview on 4/2/2026 at 3:54 PM, Registered Nurse 1 (RN 1) stated she provided the wound care treatment for Resident 21 on 3/15/2026 and 3/16/2026 but should have made sure it was documented in the TAR. RN 1 also stated Resident 21's TAR was not accurate and wound treatments provided should be documented to prove and validate treatments were done. 2. During a review of Resident 9's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis that included psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and dementia (a progressive state of decline in mental abilities). During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9 had severe impairment in cognitive skills for daily decision making. The MDS also indicated Resident 9 was dependent on toileting, showering, lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 9 required substantial/maximal assistance with oral hygiene and upper body dressing and required partial/moderate assistance (helper does less than half the effort) with eating. During a review of Resident 9's Physician's Order, dated 3/10/2026, the Physician's Order indicated Seroquel 25 milligrams (mg, units of measurement) twice a day. During a concurrent interview and record review on 4/3/2026 at 9:41 AM, with the Director of Nursing (DON), Resident 9's medication reconciliation from General Acute Care Hospital (GACH) dated 3/10/2026, the physician's order and psychiatrist notes were reviewed. The DON stated Resident 9's Psychiatrist notes indicated Resident 9 has a diagnosis of psychosis. The DON stated Resident 9's Physician's Order was incomplete since it should have included a diagnosis for the use of Seroquel. The DON stated this should have been clarified with the Psychiatrist to ensure the medication is appropriate for the resident. During an interview on 4/3/2026 at 11:03 AM, RN 1 stated the Seroquel order should be clarified with the psychiatrist if it did not have an indication on the medication order to ensure the medication is being used for the right diagnosis. During a review of the facility's P&P titled, Psychotherapeutic Drug Management, revised 1/5/2026, the P&P indicated Attending Physician/Licensed Healthcare Professional responsibility was to ensure the psychotherapeutic medication order will include the indications and manifestations of the disorder treated. 3.During a review of Resident 12's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included chest pain, lack of coordination, and pain in bilateral knees. During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12 had mild impairment in cognitive skills for daily decision making. During a concurrent interview on 4/3/2026 at 11:12 AM with Resident 12, Resident 12 stated Infection Prevention Nurse (IPN) offered her pneumonia vaccine and covid-19 vaccine, however, IPN did not asked her to sign any consent. During a concurrent interview and record review on 4/3/2026 at 3:03 PM with IPN, Resident 12's pneumonia vaccine consent and Covid-19 vaccine consent forms were reviewed. IPN stated vaccines were offered to Resident 12 on 1/3/2026, however, the consent forms were not signed. IPN stated consent forms should be signed after offering the vaccines. IPN stated this was important for accurate tracking of vaccine in case recall occurs and reduced duplicate vaccination. During a review of the facility's P&P titled, Informed Consent, revised 1/5/2026, the P&P indicated the informed consent must be signed by the resident or the resident's representative and the physician who provided the material information. i. copies of the signed informed consent form shall be given to the resident or the resident's representative. ii. residents who are conserved but retain the legal power to consent or refuse will be informed and asked for consent. During a review of the facility's P&P titled, Documentation - Nursing, revised 11/1/2017, the P&P indicated its purpose was to provide documentation of residents' status and care given by nursing staff. The P&P also indicated that nursing documentation will be concise, clear, pertinent, and accurate.

Based on observation, interview, and record review, the facility failed to ensure the call light was within resident's arm's reach for one (1) of five (5) sampled residents (Resident 21) reviewed for environment in accordance with the facility's policy. This deficient practice had the potential for Resident 21 not to be able to call the facility staff for help or assistance, especially during an emergency.Findings: During a review of Resident 21's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included anxiety disorder (a mental health disorder characterized by feeling of worry, or fear that are strong enough to interfere with one's daily activities) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 21's Minimum Data Set (MDS- a resident assessment tool), dated 1/16/2026, the MDS indicated Resident 21 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 21 was dependent (helper does all the effort) with toileting and required partial/moderate assistance (helper does less than half the effort) with oral hygiene, shower, lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 21 required supervision (helper provides cues) with eating, upper body dressing and personal hygiene. During an observation on 3/31/2026 at 8:38 AM, Resident 21 was in bed sleeping. Resident 21's call light was observed out of reach, located at the back of the bed and on the floor. During an interview on 4/2/2026 at 10:13 AM, Licensed Vocational Nurse 1 (LVN 1) stated call lights should be within the residents' arms reach so they can use them to call whenever they needed help. During an interview on 4/2/2026 at 3:06 PM, the Director of Nursing (DON) stated the call light should be within reach of Resident 21 so she could use it when she needs assistance or has concerns that require attention. During a review of the facility's Policy and Procedure (P&P) titled, Communication - Call System, revised 11/1/2017, the P&P indicated that the facility provides a mechanism for residents to promptly communicate with nursing staff. The policy also indicated the call cords will be placed within the resident's reach in the resident's room.

Based on interviews and record reviews, the facility failed to immediately inform the physician of one of two sampled residents (Resident 1), who had a diagnosis of hypertension (high blood pressure) and cerebral infarct (the death of brain tissue from a sudden blockage of blood flow, depriving brain cells of oxygen and nutrients) of Resident 1's change of condition by failing to: 1. Ensure the physician was notified by licensed nurse when Resident 1 was reported by Certified Nurse Assistant (CNA) 1 that Resident 1 was sleepier than usual on 12/7/2025 and 12/8/2025.2. Ensure Licensed Vocational Nurse 1 (LVN 1) notified Resident 1's physician timely within 15 minutes from when Resident 1 had a change of condition when Resident 1 was assessed to have a blood pressure (BP) of 153/91 millimeters of mercury (mmHg - a standard unit of measuring blood pressure. Normal blood pressure for adults is generally considered less than 120/80 mm Hg) on 12/8/2025 at 8:07 AM. As a result, Resident 1's BP went up to 210/92 mmHg (it is considered hypertensive emergency [a severe, sudden spike in blood pressure over 180/120 mmHg that can cause damage to organs like the brain such as intracranial hemorrhage {brain bleed- this is a life-threatening neurological emergency, often called a hemorrhagic stroke, where uncontrolled high blood pressure damages arteries, leading to bleeding into the brain tissue}] because the extreme pressure overwhelms brain blood vessels, causing them to weaken, rupture, and leak blood), was assessed to be lethargic (lack of energy and decrease in consciousness), and was unable to respond verbally on 12/8/2025 at 1 PM. Resident 1 was then transferred to General Acute Care Hospital (GACH) via 911 emergency services (EMS - provides emergency medical care) on 12/8/2025 at 2 PM and was admitted to the GACH's Emergency Department (ED). While in GACH, Resident 1 underwent Computerized Tomography scan (CT scan - imaging using x-ray [a photographic or digital image of the internal composition of a part of the body] technique to create detailed images of the body) of the head in GACH and result showed bleeding in the cerebral hemisphere (half of a brain, right or left) of 7.4 centimeters (cm- unit of measure) in craniocaudal (measuring from the head down) by 2.7 cm by 3.5 cm in the transverse dimension (a measurement or direction across). Resident 1 was intubated (breathing tube has been inserted into the windpipe to keep the airway open) in the GACH's ED and admitted to the intensive care unit (ICU - a department in the hospital in which patients who are dangerously ill are kept under constant observation) with acute intracranial hemorrhage. Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted at the facility on 4/18/2025 with the following but not limited to diagnoses of hypertension, anxiety (feeling of worry or fear, but when it is excessive, persistent, and interferes with daily life) and cerebral infraction. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/1/2025, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, walking 10 feet, eating and upper body dressing. The MDS indicated Resident 1 is dependent (Helper does all of the effort. The resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with oral hygiene, toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. During a review of Resident 1's Weights and Vitals Summary dated 12/8/2025 indicated Resident 1's BP read 153/91 mmHg at 8:07 AM. During a review of Resident 1's Progress Notes, dated 12/8/2025 from 10:11 AM to 10:12 AM, the progress notes indicated Resident 1 refused medication, offered three times, physician made aware. The progress notes did not specify the physician was made aware regarding Resident 1's elevated BP of 153/91 mmHG. During a review of Resident 1's Progress Notes, dated 12/8/2025 at 1:00 PM, the Progress Notes indicated the resident was sleepy and refused to open his mouth. During a review of Resident 1's Weights and Vitals Summary dated 12/08/2025 at 1:00 PM, it indicated Resident 1's BP was 210/92 mmHg. During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition [is a significant, sudden shift in a person's physical, mental, behavioral, or functional state from their baseline, requiring clinical attention] among the residents), dated 12/8/2025, the SBAR indicated the resident refused lunch and was sleepy. The SBAR indicated Resident 1 refused to open mouth when given medication at 1 PM and was very lethargic and was unable to respond verbally. During a review of Resident 1's Progress Notes, dated 12/8/2025 at 2:10 PM, the progress notes indicated Resident 1 was transferred to GACH at around 2 PM. During a review of Resident 1's GACH Emergency Department (ED) Hospital admission notes, dated 12/8/2025 at 4:31 PM, the notes indicated Resident 1 had an altered mental status, and blood pressure is elevated. The notes also indicated Resident 1 was very lethargic and confused. During a review of Resident 1's GACH ED Hospital admission notes, dated 12/8/2025 at 5:16 PM, the notes indicated a CT of the brain was done with a result of bleeding in the cerebral hemisphere of 7.4 cm in craniocaudal by 2.7cm by 3.5cm. During a review of Resident 1's GACH ED Hospital admission notes, dated 12/8/2025 at 5:20 PM, the notes indicated Resident 1 had a diagnosis of intracranial hemorrhage and hypertensive emergency. During a review of Resident 1's GACH Discharge Summary Note, dated 12/8/2025, the Summary Note indicated Resident 1 arrived at the ED completely unresponsive, did a CT scan which showed a large left cerebral hemisphere parenchymal (tissue of the brain) hemorrhage. Resident 1 was intubated in the ED and was admitted to the ICU. During an interview on 12/11/2025 at 4:43 PM, Certified Nursing Assistant 1 (CNA 1) stated Resident 1 was sleepier than usual and did not open his mouth to eat his lunch on 12/7/2025 on 7 AM to 3 PM shift and reported it to Registered Nurse 1 (RN 1) at noon on 12/7/2025. CNA 1 also stated Resident 1 is normally active. During an interview with Resident 1's Responsible Party (RP) on 12/12/2025 at 11:15AM, RP stated when she went to go see Resident 1 on 12/7/2025 around 5 PM to 5:30 PM at the facility, RP was unable to wake Resident 1 up and reported it to the facility staff. During a phone interview on 12/12/2025 at 11:33 AM, Licensed Vocational Nurse 3 (LVN 3), who works 3PM to 11PM shift, stated Resident 1 is usually active but was more sleepy than usual on 12/7/2025. LVN 3 stated she did not notify the physician but endorsed the resident about being unusually sleepy to 11-7 shift licensed nurse (unable to recall who). During an interview on 12/12/2025 at 12:05 PM, RN 1 stated, on 12/7/2025 from 7 AM to 3 PM shift, CNA 1 stated Resident 1 was more sleepy than usual, but RN 1 did not notify the physician. During an interview on 12/12/2025 at 12:26 PM, CNA 2 stated Resident 1 did not eat his breakfast and lunch on 12/8/2025 and was unusually sleepier. CNA 2 also stated this is not Resident 1's normal behavior and CNA 2 did not report it to the licensed nurse. During an interview on 12/12/2025 at 1:35 PM, Resident 1's current Care Plan dated 4/22/2025 to 12/11/2025, were reviewed. The care plan indicated a care plan with focus hypertension and chest pain was initiated on 4/22/2025. The care plan to monitor vital signs (key measurements of your body's most basic functions, including temperature, pulse (heart rate), respiratory (breathing) rate, and blood pressure) and report any abnormal findings to the physician. The Director of Nursing (DON) stated Resident 1 is sleepy more than the resident's usual level of consciousness, is considered a change of condition and the physician should have been notified timely after RP reported it to the facility on [DATE] and when Resident 1's BP was 153/91 mmHG on 12/8/2025 around 8:07 AM. During an interview on 12/12/2025 at 2:09 PM, Nurse Practitioner (NP) stated he was not informed of Resident 1's change of condition of sleepiness and of the resident's elevated BP on 12/8/2025 at 8:07 AM. NP also stated Resident 1's BP of 153/91 mmHg should have been reported and if not, that can delay care for Resident 1. NP stated if the BP of 153/91 mmHg was addressed to him, he would order the resident to be transferred to GACH. During an interview on 12/12/2025 at 2:15 PM, with the DON, the DON stated Resident 1's BP of 153/91 mmHg is a change of condition. The DON stated the license nurse should have notified the physician/ NP regarding Resident 1's elevated BP of 153/91 mmHg to obtain an order. The DON also stated Resident 1's change of condition should be reported in a timely manner, and timely manner in the policy means 15 minutes and Resident 1's change of condition was not reported timely. During an interview on 12/12/2025 at 3:15 PM, LVN 1 (who worked a 7AM-3 PM shift when the incident happened) stated Resident 1's elevated BP pf 153/91 mmHg and sleepier than usual is considered a change of condition and the physician needs to be notified within 15 minutes. LVN 1 also stated the physician was not notified within 15 minutes from when Resident 1's BP was assessed to be at 153/91 mmHg on 12/8/2025 at 8:07AM. LVN 1 stated she should have notified Resident 1's physician so the facility could have provided interventions and prevented Resident 1's BP progressing to 210/92 mmHg and avoiding the resident's hospitalization. During an interview on 12/15/2025 at 1:16 PM, the facility's Medical Director (MD) stated if the resident's BP is elevated, the nurse should report it to the physician timely, and the resident should have been sent to the hospital. MD stated the resident was sleepy more than usual and elevated BP on 12/8/2025 at 8:07AM, it should have been reported to the physician timely and not wait until the BP was 210/92 mmHg in the afternoon. During a review of the facility's P&P titled Change of Condition Notification, revised 11/1/2017, was reviewed. The P&P indicated the facility will promptly inform the resident's attending physician when the resident endures a change in condition which included the physical status.