Every finding on record at Presbyterian Intercomm Hosp Dp/Snf

Based on observation, interview and record review the facility failed to monitor the medication room temperature to keep between 59-86 degrees Fahrenheit ( F) for all drugs and biologicals stored in the medication room such as, an intravenous (IV -fluids given directly into the blood stream), medications Xalatan (eye medication), diltiazem (a prescribed medication that slows down a fast heart rate), amoxicillin (a prescribed antibiotic) were stored. store in the medication room in accordance with the facility's policy and procedure titled Temperature Monitoring and Medication Storage Conditions. This deficient practice had the potential for intravenous fluids and medications which could affect the integrity and the effectiveness of the medications and intravenous solutions. Findings: During an observation on 8/13/2026 at 9:45 AM in the medication storage room, there was no temperature-monitoring log available. The medication room contained a variety of medications including Xalatan (a prescription eye drop used to lower high pressure inside the eye drops, intravenous (IV) fluids, including Sodium Chloride 0.9%. The manufacturer label indicated the solution should be stored at room temperature not to exceed 77 . During a concurrent interview on 8/13/2026 at 9:45 AM with Registered Nurse1 (RN 1) stated the facility had no temperature-monitoring log in the medication room to indicate the temperature in the medication room daily where all the medications and IV bags are stored. During an interview on 8/13/2026 at 11:35 AM with the Facility's Manager (FM 1), FM 1 stated the facility did not monitor the temperature of the medication room where medications where stored. FM 1 stated the facility did not maintain a log for monitoring room temperature. During an interview on 8/13/2026 at 11:40 AM with the Director of Nurses (DON), DON stated the medication room contained temperature sensitive medications that should be stored within the proper temperature range. During a review of the facility's policy and procedure (P&P) Temperature Monitoring and Medication Storage Conditions revised on 12/24/2025, indicated, medication shall be stored in an orderly manner in well lighted cabinets, and manufacture's recommendation.

Based on observation, interview and record review, the facility failed to store food in a sanitary manner to prevent foodborne illness in accordance with the facility's policy and procedure (P&P) for Purchasing, Receiving and Storing Food and Supplies. The facility failed to ensure: A carton of Lactaid (real, farm-fresh cow's milk that has been treated to breakdown lactose (a natural sugar found in dairy products)) was not discarded on or before the expiration date in the kitchen's Dairy Walk-in Refrigerator. Resident's snacks were disposed by the disposal date labeled. This failure had the potential to result in residents developing a foodborne illness such as food poisoning with symptoms including upset stomach, stomach cramps, nausea, vomiting, and/or diarrhea. 1. During an interview on 8/11/2026 at 9:30 AM with the Executive Chef (EC), the EC stated there was no separation between the facility's kitchen and the hospital's kitchen. The EC stated all food stored, prepared, served and delivered is from the same place. During a concurrent observation and interview on 8/11/2026 at 9:39 AM with the EC in the hospital Dairy Walk-in Refrigerator, a carton of Lactaid milk was labeled with a use by date of 8/17/2026 and carton had an expiration date of 8/9/2026. EC stated the Lactaid milk should have been discarded on the expiration date 8/9/2026 and the label should have had the expiration date printed on the carton. Eating or drinking expired food could cause stomach upset and residents could get sick. During an interview on 8/13/2026 at 12:49 PM with the Food Services Director (FSD), the FSD stated the importance of discarding food before the expiration date is to prevent residents from consuming spoiled food because they can get sick. During a review of the facility's P&P titled Purchasing, Receiving, and Storing of Food and Supplies - E.83200.024, dated 9/27/2023, the P&P indicated, all food held in refrigerated areas will be appropriately covered, clearly labeled, if not readily identifiable, and dated. The P&P also indicates to label with the expiration/best used by date. Products are dated, as necessary, to ensure that the First in - First out (FIFO) procedure is followed. 2. During a concurrent observation and interview on 8/13/2026 at 12:49 PM with Food Services Director (FSD) in the facility's nourishment room, two snacks were labeled to be disposed by 8/12/2026. The FSD stated the food service worker, or nursing staff should have thrown away the snacks prior to the disposal date. The FSD stated the food service worker checks the temperature and ensures facility refrigerator was cleaned daily. The FSD stated the importance of discarding food before the expiration date is to prevent residents from consuming spoiled food because they can get sick. During a review of the facility's dietary worker Daily Task Routine, dated 4/6/2026, it indicated the dietary worker will stock and clean the facility refrigerator at least once during their shift. During a review of the facility's P&P titled Purchasing, Receiving, and Storing of Food and Supplies - E.83200.024, dated 9/27/2023, the P&P indicated, all food held in refrigerated areas will be appropriately covered, clearly labeled, if not readily identifiable, and dated. The P&P also indicates to label with the expiration/best used by date. Products are dated, as necessary, to ensure that the First in - First out (FIFO) procedure is followed. Foods are regularly inspected to discard any expired or spoiled food items.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained for two of five sampled resident (Resident 31 and 35) by failing to ensure: 1. Resident 31's urinal was placed on the bedside rail and bedside table beside the resident's drinks. 2. Respiratory Tech 1 (RT1) don (put on) Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) while inside the room of Resident 35 who was placed on contact isolation (a set of infection control practices used to prevent the transmission of infectious agents that spread by direct or indirect contact with a patient or their environment) for infection in the urine, in accordance with the facility's policy and procedure titled Transmission-Based Precautions. These failures had the potential to result in cross-contamination (transfer of harmful germs, bacteria, or allergens from one object, surface, or food to another) and place the resident at risk for illness.2. During a review of Resident 35's Face Sheet, the face sheet indicated the resident was admitted to the facility on [DATE]. During a review of Resident 35's History and Physical (H&P) dated 8/3/2026, indicated Resident 35 had Enterococcus Faecium Bacteria (a type of bacteria that can become resistant to common antibiotics) in the urine. A review of the The H&P indicated Resident 35 was placed on contact isolation due to Methicillin-resistant Staphylococcus aureus (MRSA - a type of staph bacteria that cannot be killed by many common antibiotics), and vancomycin-resistant enterococcus (VRE -a bacteria that are resistant to vancomycin (medication use to treat infections caused by bacteria) in the urine. During an observation on 8/13/2026 at 1:25 PM, a contact precautions sign was posted at the entrance to Resident 35's room. Respiratory Technician 1 (RT1) was observed inside Resident 35's room leaning against the wall and conversing with a staff member while holding a personal water bottle. During an interview on 8/13/2026 at 1:25 PM with RT 1, RT 1 stated Resident 35 was on contact isolation, and stated PPE should be worn while inside the resident's room. RT 1 stated she had just finished removing her PPE and was in the process of leaving Resident 35's room. During an interview on 8/13/2026 at 3:35 PM with the Respiratory Therapy Director (RTD), RTD stated that for any resident that is on contact isolation all staff inside the room should have PPE and upon removal of the PPE RT 1 should have exit Resident 35's room. During a review of the facility's policy and procedure (P&P) titled Transmission-Based Precautions revised on 7/2/2024, indicated contact precautions were used for residents with organisms that can be transmitted through direct contact with the resident and indirect contact with environmental surfaces. Findings: 1. During a review of Resident 31's Face Sheet (FS), the FS indicated the facility admitted Resident 31 on 8/2/2026 with a diagnosis that included left distal femur fracture (a broken bone in the lower part of the thighbone, right above the knee joint). During a review of Resident 31's Minimum Data Set (MDS- a resident assessment tool), dated 8/9/2026, the MDS indicated Resident 31's cognitive skills (ability to think and reason) for daily decision-making were intact. The MDS indicated Resident 31 required substantial/maximal assistance (helper does more than half the effort) from staff for toileting hygiene and lower body dressing. During a review of Resident 31's History and Physical (H&P), dated 8/2/2026, the H&P indicated Resident 31 was admitted to the facility with diagnoses that included infection of prosthesis (bacteria or other microorganisms infect the area in and around a joint implant), hypertension (high blood pressure), and benign prostatic hyperplasia (enlargement of the prostate gland that can cause urinary symptoms such as a weak urine stream, frequent urination, and difficulty urinating). During a concurrent observation and interview on 8/11/2026 at 10:27 a.m. with Resident 31 in Resident 31's room, a urinal was observed hanging on the bedside rail and another urinal with yellow urine was placed on the bedside table with a cup and pitcher next to it. Resident 31 stated he was afraid the urinal would fall, but he had nowhere else to place it. During an interview on 8/12/2026 at 11:20 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated the placing urinal on the bedside table where the resident eats could cause cross-contamination and the resident could become sick. During an interview on 8/12/2026 at 11:28 a.m. with the Infection Preventionist Nurse (IP Nurse), the IP Nurse stated the facility's practice was to place the urinal on the bedside rail for easy access. The IP Nurse stated placing the urinal on the bedside table was not the facility's practice. The IP Nurse stated when the resident ate from the same table where the urinal was placed, contamination could get into the resident's food or drinks, and the resident could become sick or develop an infection. During a review of the facility's policy and procedure (P&P) titled, Environmental Services Cleaning, dated 7/1/2026, the P&P indicated, Standard precautions: is the foundation for preventing transmission of disease during patient care in all healthcare settings, regardless of suspected or confirmed presence of an infectious agent. It applies to all patients and all situations, regardless of diagnosis or presumed infection status and when interacting with blood, body fluids, secretions and excretions.

Based on interview and record review the facility failed to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an Advance Directive (AD - a legal document indicating resident preference on end-of-life treatment decisions) for one of four sampled residents (Resident 7) in accordance with the facility's policy and procedure titled Advance Directive for Healthcare Information. As a result of this deficient practice, the resident had the potential not exercise the right to receive care and services according to the residents' wishes and choices in the event the resident becomes incapable of making decisions regarding their care. Findings: During a review of Resident 7's Face Sheet, the Face Sheet indicated Resident 7 was admitted to the facility on [DATE]. During a review of Resident 7's History and Physical (H&P) dated 7/25/2026, the H&P indicated Resident 7 was admitted to the facility with the diagnosis cerebrovascular accident (CVA - stroke, loss of blood flow to a part of the brain), atrial fibrillation (A-Fib - heart rhythm disorder where the heart beats irregularly and rapidly), left hemiplegia (total paralysis of the arm, leg and truck on the same side of the body). During a review of Resident 7's Minimum Data Set (MDS - an assessment tool), dated During a review of Resident 7's Initial Adult assessment dated [DATE], indicated Advance Directive information was provided to Resident 7. During an interview on 8/13/2026 at 10:23 AM with Social Worker 1 (SW 1), SW 1 stated Resident 7 was provided with AD information and had interest in executing AD, however SW 1 stated she did not follow-up with Resident 7. SW 1 stated when residents expressed interest in executing advance directive SW 1 follows up with the resident and family to assist with executing an advance directive if the resident or the family wishes to proceed. During an interview on 8/13/2026 at 5:26 PM with the Director of Nurses (DON), DON stated advance directive information is provided when a resident expresses interest in executing an AD. The DON stated that if Resident 7 expressed interest in executing an AD, the social worker should have followed up with Resident 7. During a review of the facility's policy and procedure (P&P) titled Advance Directive for Healthcare Information revised on 4/3/2026, the P&P indicated that if a resident wishes to formulate an advance directive the nurse will contact the social worker to provide a blank copy of the advance directive form and educate the resident or residents family regarding the process. The social worker will document in the medical record.

Based on interview, and record review the facility failed to ensure one of five sampled residents (Resident 8) was free of unnecessary medication when the resident's physician ordered Resident 8 to receive escitalopram a psychotropic (medications to manage mood, behavior and perception) used to treat depression (a feeling of severe sadness and hopelessness affecting the daily life) without an indication for its use in accordance to the facility's policy and procedure titled Psychotherapeutic Medication. This deficient practice had the potential to result in Resident 8 receiving unnecessary medication leading to adverse reaction (undesired effect of medication). Findings: During a review of Resident 8's Face Sheet, the face sheet indicated Resident 8 was admitted to the facility on [DATE]. During a review of Resident 8's History and Physical (H&P) dated 7/24/2026, the H&P indicated Resident 8 had diagnoses that included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), anxiety (a feeling of fear, dread, and uneasiness that is more intense and persistent than normal and can interfere with daily life), depression. During a review of Resident 8's Minimum Data Set (MDS - a resident assessment tool) dated 8/4/2026 indicated Resident 8 had received an antidepressant medication during the seven-day look back period. During a review of Resident 8's Medication Administration Record (MAR) indicated Resident 8 was administered escitalopram (medication used to treat depression and generalized anxiety disorder) on 8/8/2026, 8/9/2026, 8/10/2026, 8/11/2026, 8/12/2026, no clinical indication for use was included with the physician order. During a review of Resident 8's care plan titled Psychotropic Medications dated 7/24/2026, indicated to monitor behavioral manifestations. During an interview on 8/13/2026 at 5:54 PM with the Director of Nurses (DON), DON stated the facility had a list of mood descriptions that nursing staff selected based on the resident's current mood. The DON stated the resident was not being monitored for specific behavior related to the use of antidepressant medication. The DON further stated the facility continued the medication because the resident had been receiving it at home. During a review of the facility's policy and procedure (P&P) titled Psychotherapeutic Medication revised on 7/20/2026, indicated, symptom management will be documented in the medical record. Furthermore, the P&P stated the psychotherapeutic medication will be ordered with indication for use by the provider.

Based on observation, interview, and record review, the facility failed to ensure a hearing aid was maintained in working condition for one of one sampled resident (Resident 19) when Resident 19's right hearing aid was not functioning. This failure had the potential to result in ineffective communication, inability to hear and understand information regarding medications and care provided by facility staff.Findings: During a review of Resident 19's Face Sheet (FS), the FS indicated the facility admitted Resident 19 on 7/31/2026 with diagnoses that included urinary tract infection (an infection of the urinary tract). During a review of Resident 19's Minimum Data Set (MDS- a resident assessment tool), dated 8/12/2026, the MDS indicated Resident 19's cognitive skills for daily decision-making were moderately impaired. The MDS indicated Resident 19 had minimal hearing difficulty in some environments, such as when a person spoke softly or when the setting was noisy, and used hearing aids. During a review of Resident 19's History and Physical (H&P), dated 8/2/2026, the H&P indicated Resident 19 had diagnoses that included hypertension (high blood pressure), diabetes mellitus (a condition affecting the body's ability to control blood sugar), and chronic obstructive pulmonary disease (a chronic lung disease that causes difficulty breathing). During a concurrent observation and interview on 8/11/2026 at 10:09 a.m. with Resident 19 in Resident 19's room, Resident 19 was wearing a hearing aid in the left ear. Resident 19 stated she was unable to hear from her right side because the right hearing aid was not working and needed to be cleaned. Resident 19 stated she had been at the facility for approximately two weeks. During an interview on 8/11/2026 at 10:14 a.m. with Registered Nurse (RN) 2, RN 2 stated she was aware Resident 19 was having difficulty with the hearing aid. During an interview on 8/12/2026 at 11:56 a.m. with Resident 19, Resident 19 stated, I have trouble hearing. My right side hearing aid is not working. I am only wearing the left side hearing aid. Resident 19 stated she informed the nurses when she first arrived at the facility approximately two weeks earlier. During an interview on 8/12/2026 at 12:30 p.m. with the Director of Nurses (DON), the DON stated the importance of having a functional hearing aid was because Resident 19 depended on the hearing aid to be able to hear clearly. The DON stated without a functional hearing aid, Resident 19 could experience a communication barrier and might not understand the nurse when receiving care or medications. During a review of the facility's policy and procedure (P&P) titled, Reasonable Accommodations for Individuals with Disabilities, dated 10/2/2025, the P&P indicated the facility was committed to serving all patients according to their individual needs. If a hospital employee recognized or had reason to believe a patient had special needs, the employee must advise the individual that appropriate auxiliary aids and services would be provided when necessary for effective communication.committed to providing appropriate auxiliary aids and services to ensure individuals who were deaf or hard of hearing received the same level of care and had effective communication.

Based on observation, interview and record review, the facility failed provide respiratory care (medical services prescribed to assess, diagnose, treat, manage, and monitor residents who have breathing or heart-lung function problems) and services to ensure one of three sampled residents (Resident 50) received care consistent with professional standards of practice and in accordance with the facility's policy and procedure (P&P) on Oxygen Therapy Protocol E.77200.306. This failure had the potential to result in Resident 50 receiving more oxygen than required, unnecessary treatment, and lung tissue damage from oxygen toxicity (cellular and tissue damage caused by breathing too much extra oxygen at higher-than-normal pressures or concentrations).During a review of Resident 50's Facesheet (FS), the FS indicated Resident 50 was admitted to the facility on [DATE] with esophageal stricture (an abnormal narrowing of the esophagus (muscular tube that carries food and liquid from your mouth to your stomach)), and aspiration pneumonia (a lung infection that happens when you breathe food, liquid, vomit, or spit into your lungs instead of swallowing safely). During a review of Resident 50's History and Physical (H&P) dated 8/8/2026, the H&P indicated Resident 50 has a history of obstructive sleep apnea (a common sleep disorder where the upper airway repeatedly collapses or becomes blocked during sleep) and uses a continuous positive airway pressure (CPAP) machine (a non-invasive way to supply air pressure using a mask). During a review of Resident 50's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 8/13/2026, the MDS indicated Resident 50 has little to no cognitive (ability to process thoughts and information) impairment. During a review of Resident 50's Adult Plan of Care, dated 8/7/2026, the plan of care indicated to monitor, manage, improve oxygenation needs and to manage and maintain a patent airway (path for air to move from mouth or nose down to the lungs are free from obstruction, clear and open). During an observation on 8/11/2026 at 12:15 PM in Resident 50's room, Resident 50 had nasal cannula (a light plastic tube with two small prongs to deliver oxygen through a person's nose) on but resting on left side of face. The oxygen was turned on to two liters (a unit of measurement). Certified Nursing Assistant (CNA) 1 arrived in room and phoned the Licensed Vocational Nurse (LVN) 1 to adjust nasal cannula and reposition resident. During a concurrent interview and record review on 8/13/2026 at 3:18 PM with the Director of Nursing (DON), Resident 50's Active Orders (a physician's order) were reviewed. The Active Orders indicated for Resident 50 to receive oxygen at two liters per minute per respiratory protocol. The DON stated Resident 50's physician order indicated to administer up to two liters per minute of oxygen and keep the oxygen saturation (the indirect measurement of arterial oxygen saturation using a sensor placed on a person's finger, reported as a percentage) above 93% (normal range 95%-100%). Resident 50's physician order did not indicate to titrate (slowly change the amount up or down to reach desired outcome) the oxygen down or to remove the oxygen, a separate order would be written for that. The DON also stated Resident 50 has been receiving two liters of oxygen since admission to the facility. During a concurrent interview and record review on 8/13/2026 at 4:35 PM with the Respiratory Therapy Director (RTD), the facility's P&P titled, Oxygen Therapy Protocol E.77200.306, dated 1/27/2025 was reviewed. The P&P indicated, to wean the oxygen down to room air (normal, unassisted ambient air in an everyday environment) or to the oxygen level the resident was receiving at home. The RTD stated titrating the oxygen up or down, doing room air trials, and weaning residents off oxygen are part of the respiratory protocol. The RTD stated, not following the protocol means that the resident may be receiving therapy that they do not need, receive too much oxygen and the resident might be going home on oxygen therapy they do not need. The RTD further stated the licensed nurses from the facility work together with respiratory therapists to carry out the respiratory protocol. During a review of the facility's P&P titled, Oxygen Therapy Protocol E.77200.306, dated 1/27/2025, the P&P indicated the purpose of the protocol is to provide a framework to standardize and ensure the treatment of patients requiring supplemental oxygen, as well as the response to their clinical decompensation. During a review of the facility's P&P titled, Transitional Care Unit Standards of Care - E.69010.020, dated 7/1/2026, the P&P indicated oxygen therapy and pulse oximetry (a simple, accurate, and non-invasive technique used to monitor arterial oxygen saturation) to maintain an oxygen saturation greater than 92% or per provider order.

Based on interview and record review, the facility failed to accurately document the freezer temperature to zero degrees Fahrenheit (0 F) on the resident's freezer temperature log in the facility's nourishment room in accordance with the facility's policy and procedure (P&P) Purchasing, Receiving, and Storing of Food and Supplies - E.83200.024. This failure had the potential to result in misinterpreting temperatures leading to food not stored not in proper temperature that could lead to food borne illnesses (an infection or irritation of the digestive tract caused by eating or drinking food and beverages contaminated with harmful germs like bacteria, viruses, parasites, or toxic chemicals). Findings: During a concurrent observation and interview on 8/13/2026 at 12:49 PM with FSD in the facility's nourishment room, food refrigerator log showed 8/12/2026 and 8/13/2026 with the freezer temperature outside of acceptable temperature (0 to -18 degrees). The FSD stated the food service worker may have left out the negative sign. The FSD stated accuracy of the temperature log helps ensure that the refrigerator and freezer are working appropriately and food inside was always kept within desired temperature. During a concurrent interview and record review on 8/13/2026 at 1:15 PM with Food Services Worker (FSW), the facility's Temperature Log for Patient Food Refrigerator/Freezer, dated August 2026 was reviewed. The log indicated freezer temperature for 8/12/2026 was two (2 F) and on 8/13/2026 the freezer temperature was 4 F. When asked what the normal range for the freezer temperature was, FSW stated it was below zero degrees (0 F). FSW stated he should have written the negative sign (-4 F) on the log. During an interview on 8/19/2026 at 2:59 PM with the Accreditation and Licensing Coordinator (ALC), the ALC stated there is no explicit policy that addresses the correctness and accuracy of documentation, it is generally understood that any task involving the recording or documenting of records should be performed accurately. During a review of the facility's dietary worker Daily Task Routine, dated 4/6/2026, it indicated the dietary worker will stock and clean the facility refrigerator at least once during their shift. The dietary worker is also responsible for checking the refrigerator and freezer temperatures. During a review of the facility's P&P titled, Purchasing, Receiving, and Storing of Food and Supplies - E.83200.024, dated 9/27/2023, the P&P indicated, all refrigerators, freezers, and storerooms used for perishable food will have working, reliable thermometers and temperatures will be recorded daily. Frozen foods will be stored at zero degrees Fahrenheit (a unit of measurement for temperature) or below.

Based on observation, interview and record review, the facility failed to promote dignity and respect when a care view camera (a specialized camera designed for patient monitoring in healthcare setting that allows healthcare professionals to remotely observe residents and intervene if necessary, typically for safety purposes like fall prevention) was placed in the resident's room for four (4) of eight (8) sampled residents (Residents 33, 49, 60 and 64). This failure resulted in Resident 33, 49, 60 and 64 experiencing feelings of discomfort and not having any personal privacy.1. During a review of Resident 49’s admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of septic discitis (infection discitis; a serious condition where the intervertebral [a flat, round “cushion” located between each vertebra {small, bony segments that make up the spine or backbone} in the spine, acting as a shock absorber and allowing for movement] disc spaces in the spine become inflamed due to infection) and lumbar stenosis (a condition where the spinal canal in the lower back narrows, compressing the spinal cord and nerves).During a review of Resident 49’s Minimum Data Set (MDS – a resident assessment tool), dated 7/1/2025, the MDS indicated the resident had an intact cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 49 needed substantial/maximal assistance (helper does more than half the effort) with going from a sitting to a standing position and going from lying down to sitting on the side of the bed and needed partial/moderate assistance (helper does less than half the effort with putting on/taking off footwear. Resident 49 needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for personal hygiene and eating. During a review of Resident 49’s Patient Transfer Orders dated 7/17/2025, Resident 49’s Patient Transfer Orders indicated an order from 6/24/2025 for remote monitor camera.During a concurrent observation in Resident 49’s room and interview on 7/17/2025 at 8:20 AM with Certified Nursing Assistant 2 (CNA 2), Resident 49 was observed lying down in bed watching television. A care view camera was observed on the wall, directly across from Resident 49. There was no posted signage observed outside or inside the room directly in front of or around Resident 49 indicating there was a video surveillance. CNA 2 stated there was no posted signage in the room and that there is usually a sign indicating there is video surveillance but not in this room. During a concurrent observation and interview on 7/17/2025 at 8:40 AM with Resident 49 in his room, a sign indicating video monitoring was in progress was observed on the wall directly across from the resident under the care view camera. Resident 49 stated the camera has been up for about three (3) to 4 weeks and it was the first time he had ever seen the sign indicating video monitoring was in progress. Resident 49 stated the staff have never spoken to him about the camera prior to it being utilized and that he feels as if it is an invasion of his privacy and stated he would equate it to putting a camera in a bathroom.During an interview on 7/18/2025 at 9:32 AM with Resident 49, Resident 49 stated he is not a fan of cameras and has no real privacy other than when staff are assisting him with being changed and they call to let the technician know to turn the camera off. Resident 49 stated he did not sign or agree to sign a consent and feels as if the facility just gave him the run around and does not know who is watching him. Resident 49 stated that whoever is watching him can use what they see against him.During an interview on 7/18/2025 at 11:57 AM with Resident 49, Resident 49 stated before yesterday, there was no sign to let himself, his family or visitors know that there was video surveillance in his room and stated he understand the use of cameras in hallways and the hospital entrance but not in the room. 2. During a review of Resident 60’s admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of acute kidney injury (AKI; a rapid decline in kidney function, typically indicated by an increased in serum creatinine [a waste product produced by the body from the normal breakdown of muscle tissue and the digestion of protein] or a decrease in urine output) and acute (sudden/short duration) metabolic encephalopathy (a condition where brain dysfunction arises from metabolic or chemical imbalances in the body).During a review of Resident 60’s MDS, dated [DATE], the MDS indicated the resident had an intact cognitive skills for daily decision making. Resident 60 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with toilet transfers (the ability to get on and off a toilet or commode) and showers/bathing self (the ability to bathe self, including washing, rinsing, and drying self [excludes washing or back and hair], and needed substantial/maximal assistance with putting on/taking off footwear and lower body dressing. Resident 60 needed partial/moderate assistance with chair/abed-to-chair transfers, going from sitting to a standing position, personal hygiene and eating.During a review of Resident 60’s Patient Transfer Orders dated 7/17/2025, the Patient Transfer Orders indicated an order on 7/7/2025 for remote monitor camera.During a concurrent observation in Resident 60’s room and interview on 7/17/2025 at 8:20 AM with CNA 2, Resident 60 was observed lying down in bed and CNA 2 was setting up to provide the resident with morning care. A care view camera was observed on the wall, directly across from Resident 60. There was no posted signage observed outside or inside the room directly in front of or around Resident 60 indicating there was a video surveillance. CNA 2 stated there was no posted signage in the room and that there is usually a sign indicating there is video surveillance but not in this room.During an interview on 7/18/2025 at 10:38 AM with Resident 60’s Family Representative (FR 1), Resident 60’s Family Representative stated on 7/3/2025 when Resident 60 was transferred to the unit, the care view camera was already up. FR 1 further stated both she & the resident were not educated about the camera prior to it being utilized. 3. During a review of Resident 64’s admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of left foot fracture (a break in one of more bones in the foot) and gastroesophageal reflux disease (GERD; a condition where the stomach contents flow back up into the esophagus [a muscular tube that acts as a passageway for food and liquids, transporting them form the throat to the stomach], causing irritation and discomfort).During a review of Resident 64’s MDS, dated [DATE], the MDS indicated the resident had an intact cognitive skills for daily decision making. Resident 64 was dependent with putting on/taking off footwear and lower body dressing. Resident 64 needed substantial/maximal assistance with chair/bed-to-chair transfers and going from a sitting position to a standing position and needed setup or clean-up assistance (helper sets up or cleans up; resident completes the activity) with personal hygiene and eating. During a review of Resident 64’s Patient Orders dated 7/18/2025, the Patient Orders indicated an order from 7/2/2025 for remote monitor camera. During a concurrent observation in Resident 64’s room and interview on 7/18/2025 at 9:38 AM, Resident 64 was observed lying down in bed. A Care View Camera was observed on the wall across from the resident. Resident 64 stated she did not know anything about the camera and did not think it was on. Resident 64 stated she hoped it was not on because she would not want someone watching her at all and if she found out someone was watching her it would not be a happy day for her. Resident 64 also stated that it is important that whoever lies in the bed she is in knows about the camera and whether it is on or not. Resident 64 stated she did not remember if anyone had spoken to her about the camera and did not sign any consent for it. During an interview on 7/17/2025 at 9:25 AM with the Director of Nursing (DON), the DON stated there is no official consent obtained for the use of the care view camera other than patient or family representative education that is to be initiated prior to the camera being utilized. The DON also stated that prior to the care view camera being initiated, a sign is supposed to go up in the room to make patients and visitors aware that the room is under the care view safety video surveillance remote monitoring. During an interview on 7/18/2025 at 11:02 AM with DON, the DON stated the care view cameras were implemented around July 2023, which were utilized for residents who were usually confused and/or forgetful. The DON stated the staff check with the residents throughout the day to see how they are in general. The DON added if there are any conversations that come up regarding the residents being uncomfortable with the care view camera, they would gather more information and provide the residents with a refusal form. The DON further stated a follow-up assessment should be done especially when a resident’s mentation improves and that it would be an opportunity to check in on the resident regarding this area. 4. During a review of Resident 33's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included pancytopenia (a condition in which there is lower than normal number of red and white blood cells and platelets in the blood) and chronic lymphocytic leukemia (a type of cancer where the bone marrow [soft spongy tissue inside the bone] makes too much abnormal white blood cells called lymphocytes). During a review of Resident 33’s Physician’s Order, dated 6/29/2025, timed at 1:59 AM, the Physicians Order indicated to place a remote monitor camera in the resident’s room. During a review of Resident 33's Minimum Data Set (MDS, a resident assessment tool), dated 7/9/2025, the MDS indicated Resident 33 had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 33 required supervision (helper provides cues) with toileting and personal hygiene, shower, upper and lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 33 was independent (resident completes the activity by themselves with no assistance from helper) with eating and oral hygiene. During an observation in Resident 33’s room on 7/15/2025 at 4:28 PM, Resident 33 was lying in bed with a video camera inside the room located on top of the ceiling facing the resident. During an observation and interview on 7/17/2025 at 8:37 AM, Resident 33 was lying in bed with no sign posted inside or outside the resident’s room indicating the room is under surveillance while video camera was in use. Resident 33 stated, “It was an off feeling knowing I was being watched 24/7 (24 hours and 7 days).” Resident 33 stated he had not seen a sign posted indicating that there was video surveillance in his room since the camera went up. During concurrent observation at Resident 33’s room and interview on 7/18/2025 at 8:26 AM, the Clinical Nurse Manager (CNM) confirmed that a video surveillance camera was in use for Resident 33. The CNM stated there should have been a sign outside Resident 33’s room indicating a surveillance camera was in use, so the family would be aware that the resident has a video camera on. During a review of the facility’s policy and procedure (P&P) titled, “Continuous Video Monitoring System,” revised 7/3/2023, the P&P indicated its purpose, “To provide guidelines for continuous video monitoring of patients utilizing a remote video monitoring system.” The P&P further indicated: a. Staff Roles and Responsibilities i. Ensure signs regarding video monitoring are posted in patient’s rooms. ii. Continue reassessment of patient appropriateness for video monitoring throughout patient’s stay. During a review of the facility’s P&P titled, “Patient Rights and Responsibilities,” revised 7/1/2025, the P&P indicated its purpose to assure that a patient is informed of his or her rights and responsibilities upon receiving care and service from General Acute Care Hospital (GACH), to assure that staff, physicians, volunteers and other health care providers are informed of these rights and responsibilities and are respectful of them. The P&P further indicated: a. The list of patient rights includes the following (but is not limited to) the patient’s right to: a. Considerate and respectful care, and to be made comfortable. b. Make decisions regarding medical care and receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or refuse a course of treatment. Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved, alternate courses of treatment or non-treatment and the risks involved in each, and the name of the person who will carry out the procedure or treatment. c. Request or refuse treatment, to the extent permitted by law. d. Have personal privacy respected.

Based on interview and record review, the facility failed to complete and transmit a discharge tracking assessment (a type of assessment conducted when a resident leaves a nursing home, which includes clinical items for quality monitoring as well as discharge tracking and is transmitted to the Centers for Medicare and Medicaid Services [CMS; a United States government agency that administers healthcare programs]) for one (1) of five (5) sampled residents (Resident 57). This failure had the potential to result in the facility's inaccurate quality monitoring data at transition points, such as when residents enter or leave the facility. During a review of Resident 57's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of pyelonephritis (a type of urinary tract infection [UTI; an infection in the bladder/urinary tract] that specifically affects one or both kidneys) and chronic respiratory failure (a long-term condition where the respiratory system cannot adequately exchange oxygen and carbon dioxide leading to low blood oxygen levels and/or high carbon dioxide levels) with hypoxia (a condition in which there is an inadequate supply of oxygen to the body's tissues).During a concurrent interview and record review on 7/17/2025 at 4:36 PM with Minimum Data Set (a resident assessment tool) Nurse 2 (MDS Nurse 2), Resident 57's Electronic Medical Record (EMR; a digital collection of a patient's health information that is stored and accessed electronically) was reviewed. MDS Nurse 2 stated Resident 57's Electronic Medical Record indicated there was no MDS discharge tracking assessment completed and therefore was not transmitted 14 days after Resident 57 was discharged from the facility on 6/20/2025. MDS Nurse 2 stated Resident 57 was discharged on 6/20/2025 and the discharge MDS would have been due on 7/4/2025. MDS Nurse 2 stated the discharge MDS assessment was not and should have been done. MDS Nurse 2 stated it is important that a discharge MDS is completed and transmitted to CMS because its purpose is to show the resident's progress of the time the resident was admitted to the facility and how they were when they were discharged . During a review of the facility's policy and procedure (P&P) titled Resident Assessment Instrument (RAI) Process revised 7/3/2025, the P&P indicated, The RAI is a process that assists in the Transitional Care Unit (TCU) staff to consistently and accurately gather information regarding the resident's functional status, strengths, weaknesses, and preferences, as well as offering guidance on further assessment once problems have been identified through the use of Minimum Data Set (MDS). The information gathered will be used to formulate an individualized interdisciplinary plan of care for the resident during their stay in TCU. The P&P also indicated, The RAI is a comprehensive assessment that consist of three major sections: MDS, Care Area Assessments (CAAs) and Utilization Guidelines. The P&P further indicated:a. The MDS i. The MDS must be completed timely and accurately with appropriate signatures form the interdisciplinary team.b. The RAI assessments consist of two types: i. Omnibus Budget Reconciliation Act (OBRA) Assessments are Federally mandated, and must be completed timely and accurately on all residents regardless of payor source by the assigned due date:1. discharge: discharge date + 14 calendar days. ii. Medicare Prospective Payment Systems (PPS) Assessments1. Part A PPS Discharge Assessment.

Based on observation, interview, and record review, the facility failed to have accurate and complete medical records for one (1) of seven (7) sampled residents (Residents 60) by failing to document the Nurse Practitioner (NP, a registered nurse with advanced education and training, holding a master's or doctoral degree in nursing) notification of Resident 60's refusal to take Atenolol (drug used to treat high blood pressure) in accordance with the facility's policy. This deficient practice resulted in the inaccurate representation of care provided which could delay the provision of necessary care and services needed for Resident 60's wellbeing.Findings: During a review of Resident 60's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included urinary retention (a condition in which the resident is unable to empty all the urine from his bladder) and acute kidney injury (sudden and rapid decline in kidney function). During a review of Resident 60's Minimum Data Set (MDS, a resident assessment tool), dated 7/15/2025, the MDS indicated Resident 60 had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 60 was dependent (helper does all the effort) with toileting and shower and required substantial/maximal assistance (helper does more than half the effort) with lower body dressing and putting on and taking off footwear. The MDS further indicated Resident 60 required partial/moderate assistance (helper does less than half the effort) with eating, oral hygiene, and upper body dressing. During a review of Resident 60's Physician's order summary, the Physicians order summary indicated an order for Atenolol 50 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount daily and to hold for Systolic Blood Pressure (SBP, the pressure in the arteries when the heart beats) below 100 -millimeter mercury (mmHg, units used to measure blood pressure). During a medication pass observation with Registered Nurse 1 (RN 1) on 7/17/2025 at 9:30 AM, Resident 60's SBP indicated a reading of 108 mmHg. Resident 60 refused the Atenolol 50 mg daily dose offered by RN 1 and stated his SBP was ok. During a review of Resident 60's Medication Administration Record (MAR) on 7/18/2025, the MAR indicated to hold Atenolol for SBP below 100 mmHg. The MAR did not indicate the reason Resident 60's Atenolol was not administered and the NP notification of the refusal. During a concurrent record review and interview on 7/18/2025 at 9:03 AM, RN 1 stated Resident 60's medical records did not reflect that she notified the NP of the resident's refusal for Atenolol. RN 1 stated she did not but should have documented the NP notification of the resident's refusal for Atenolol in the resident's medical records. RN 1 stated it was important to document the NP notification since it would be considered not done if it was not documented. During an interview on 7/18/2025 at 9:09 AM, the Clinical Nurse Manger (CNM) stated that because it was an ordered medication for certain treatments, there could be risks from missing the medication and so it needs to be documented that the physician was made aware. During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration in Adults and Pediatrics, revised 9/27/2023, the P&P indicated that medications not administered should have the reason for not administering documented in the MAR. The P&P also indicated that if the patient refuses the medication, ordering physician will be notified and documented in the MAR.

Based on interview and record review, the facility failed to administer a medication for one (1) of seven (7) sampled residents (Resident 5) as indicated on the physician's order. This failure had the potential to place Resident 5 at risk for developing a Urinary Tract Infection (UTI; an infection in the bladder/urinary tract) due to not receiving her Estradiol (hormone medication used for regulating various bodily processes). During a review of Resident 5's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD; a chronic lung disease causing difficulty in breathing) and coronary artery disease (CAD; a condition where the blood vessels that supply the heart become narrowed or blocked). During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated (date), the MDS indicated the resident had intact cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 5 needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with walking 10 feet, car transfers (the ability to transfer in and out of a car or van on the passenger side), chair/bed-to-chair transfers and lower body dressing (the ability to dress and undress below the waist). Resident 5 was independent with going from lying down to sitting on the side of the bed, upper body dressing (the ability to dress and undress above the waist), personal hygiene and eating.During a review of Resident 5's Patient Transfer Orders, dated 7/16/2025, the Patient Transfer Orders indicated an order on 7/2/2025 for Estradiol vaginal cream, 1 application daily at bedtime for genitourinary syndrome of menopause (GSM; a condition in postmenopausal [12 months after the final menstrual period] women where the genital and urinary tracts are affected due to hormonal changes and encompasses a range of symptoms such as urinary discomfort and increased risk for urinary tract infections). During a review of Resident 5's Medication Administration Report, dated from 7/1/2025 to 7/16/2025, the Medication Administration Report indicated on 7/10/2025 at 6:13 AM Resident 5's Estradiol was not given due to not being available.During an interview on 7/15/2025 at 10:49 AM with Resident 5, Resident 5 stated the facility lost her Estradiol medication and did not receive it for two nights in a row. Resident 5 stated she needs to use this medication to prevent her from getting a UTI. During a concurrent interview and record review on 7/16/2025 at 3:23 PM with Clinical Nurse Manager (CNM), Resident 5's Electronic Medical Record (EMR; a digital version of a patient's health information that is stored and accessed electronically) was reviewed. Resident 5's EMR indicated the resident had an order for Estradiol every night at bedtime and that it was not given on the night of 7/9/2025 due to it not being available. CNM stated if a medication is not available, they would send a dose request to pharmacy. During the same concurrent interview and record review on 7/16/2025 at 3:23 PM with CNM, CNM stated if a dose is missed, the resident's physician (MD) should be notified. The CNM stated there was no documentation of the MD being notified of Resident 5 missing her Estradiol dose on 7/9/2025. CNM stated it is important to notify the MD since it is a prescribed medication that was ordered to be given and was not received by the resident. During a concurrent interview and record review on 7/17/2025 at 4:41 PM with MDS Nurse 2 (MDS Nurse 2), Resident 5's EMR was reviewed. MDS Nurse 2 stated Resident 5's EMR indicated Resident 5 did not receive her Estradiol cream as ordered on 7/9/2025 at bedtime due to it not being available. MDS Nurse 2 stated normally if a medication is not available, they would send a message to pharmacy for either an anticipated dose or if they need another dose, which would in turn be delivered into the resident's bin. MDS Nurse 2 stated the MD should be notified if a dose is missed. MDS Nurse 2 further stated the documentation found in Resident 5's EMR only indicated it was not given on 7/9/2025 due to it not being available and no documentation could be found of the medication being requested from pharmacy or that the MD was notified. During an interview on 7/17/2025 at 4:49 PM with the Director of Nursing (DON), the DON stated their process for a medication that is not available is to use the pharmacy messenger request to have it delivered and if the medication is marked off as not given regardless of what the reason may be, the MD needs to be notified. The DON stated it is important to notify the MD so the MD could decide if an alternative could be given and for the staff to know what the next step in the process would be. During a concurrent interview and record review on 7/18/2025 at 9:08 AM with CNM, the facility's policy and procedure (P&P) titled, Medication Administration in Adults and Pediatrics, revised 9/27/2023 was reviewed. The P&P indicated, If missing or delayed administration of medication has altered treatment plan or posed realized or unrealized harm to patient, the prescribing physician will be notified prior to administering any additional doses. CNM agreed with the P&P and stated this is their process indicating the MD should be notified when a medication is missed or not given.During a review of the facility's P&P titled, Medication Administration in Adults and Pediatrics, revised 9/27/2023, the P&P indicated, Medication will be administered by type of order obtained.

Based on observation, interview, and record review, the facility failed to ensure one (1) of 1 sampled Resident (Resident 65) who was receiving nutrition by nasogastric tube feeding (NGT - a method of providing nutrition and medication directly into the stomach through a tube inserted through the nose) was provided care to prevent aspiration by failing to ensure the resident's head of the bed was elevated during feeding in accordance with the facility's policy. This deficient practice placed Resident 65 at risk of aspiration (feeding could enter the windpipe and lungs) that could lead to lung problems such as pneumonia (an infection/inflammation of the lungs). Findings:During a review of Resident 65's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 65's Care Plan, initiated on 7/3/2025, the Care Plan indicated staff intervention included was to keep resident's head of bed (HOB) over 30 degrees while on NGT feeding. During a review of Resident 65's Physicians order, the Physicians order indicated tube feeding, continuous drip, Glucerna (tube feeding formulas for residents with diabetes) 1.2 1 liter 40 milliliters (ml, unit of measure per liquid)/hour. During a review of Resident 65's Minimum Data Set (MDS- a federally mandated assessment tool), dated 7/9/2025, the MDS indicated Resident 65 had severe cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision and functional abilities were not attempted. The MDS also indicated Resident 65 had an NGT. During a concurrent observation and interview with Certified Nursing Assistant 3 (CNA 3) on 7/16/2025 at 8:52 AM, Resident 65 was in bed receiving Glucerna 40 ml/hour via NGT. Resident 65 was observed sliding down in bed. CNA 3 stated Resident 65's head was not and should be at 30 degrees. During an interview on 7/16/2025 at 1:46 PM, Registered Nurse 1 (RN 1) stated, Resident 65 HOB should be at least 30 degrees or higher to prevent aspiration of the tube feeding. During an interview on 7/17/2025 at 3:51 PM, the Director of Nursing (DON) stated the HOB of Resident 65 should be at 30 degrees and above during tube feeding to prevent aspiration. During a review of the facility's Policy and Procedure (P&P) titled, Enteral Feedings (a way to provide nutrition directly into the stomach when the person is unable to eat or drink enough on their own) in Adult Patient, the P&P revised 7/3/2023, indicated that the patient should be prepared prior to the initiation of enteral feeding and positioned properly by elevating the backrest to a minimum angle of 30 degree and preferably 45 degrees.

Based on interview and record review, the facility failed to follow its policy titled, Resident Assessment Instrument (RAI - a standardized process used in nursing homes to collect information about residents' needs and strengths, enabling the creation of individualized care plans) Process, for two (2) of six (6) sampled residents (Residents 46 and 57) by not ensuring the comprehensive resident assessment was completed within 14 calendar days of resident's admission. This failure had the potential to result in Residents 46 and 57 not having an individualized care plan, which could negatively affect the residents' over all wellbeing.1. During a review of Resident 46's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of metastatic (the spread of cancerous [a disease in which cells grow and divide abnormally, without control] cells from the original [primary] tumor to other parts of the body, forming new tumors [metastases] in those locations) renal cell carcinoma (kidney cancer) and encephalopathy (a disturbance in brain function). During a review of Resident 46's History and Physical Examination (H&P) dated, 6/13/2025, the H&P indicated Resident 46 was alert and oriented times 3 (a person is awake, alert and aware of their identity, location and the current time) with appropriate affect (when a person's emotional expression) {facial expression, body language, or tone of voice matches the situation and their thoughts or what they are saying}. During a concurrent interview and record review on 7/17/2025 at 9:50 AM with Minimum Data Set (a resident assessment tool) Nurse 2 (MDS Nurse 2), Resident 46's Electronic Medical Record (EMR; a digital collection of a patient's health information that is stored and accessed electronically) was reviewed. MDS Nurse 2 stated Resident 46's EMR indicated that the resident's comprehensive assessment, which was due 14 days after admission, was not done. MDS Nurse 2 stated Resident 46's last admission was on 6/12/2025 and the comprehensive assessment would have been due on 6/26/2025. MDS Nurse 2 stated the purpose of the comprehensive assessment is to evaluate the resident and see how the resident was progressing with things such as physical therapy (PT; a medical treatment used to restore functional movements such as standing, walking and moving different body parts) and occupational therapy (OT; helps people participate in their everyday activities by addressing physical, cognitive, emotional, or developmental challenges). During the same interview on 7/17/2025 at 9:50 AM with MDS Nurse 2, MDS Nurse 2 stated the comprehensive MDS assessment reflects the resident's skin, pain, medication, and cognition. MDS Nurse 2 stated it is a snapshot of how the resident is which could be a reference for the resident's care plan. 2. During a review of Resident 57's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of pyelonephritis (a type of urinary tract infection [UTI; an infection in the bladder/urinary tract] that specifically affects one or both kidneys) and chronic respiratory failure (a long-term condition where the respiratory system cannot adequately exchange oxygen and carbon dioxide leading to low blood oxygen levels and/or high carbon dioxide levels) with hypoxia (a condition in which there is an inadequate supply of oxygen to the body's tissues).During a concurrent interview and record review on 7/17/2025 at 9:54 AM with MDS Nurse 2, Resident 57's EMR was reviewed. MDS Nurse 2 stated Resident 57's EMR indicated that the comprehensive assessment that was due 14 days after the resident's admission was not and should have been done. MDS Nurse 2 stated Resident 57 was admitted on [DATE] and the resident's comprehensive assessment would have been due on 6/20/2025. and was not done.During a review of the facility's policy and procedure (P&P) titled, Resident Assessment Instrument (RAI) Process, revised 7/3/2025, the P&P indicated, The RAI is a process that assists in the Transitional Care Unit (TCU) staff to consistently and accurately gather information regarding the resident's functional status, strengths, weaknesses, and preferences, as well as offering guidance on further assessment once problems have been identified through the use of Minimum Data Set (MDS). The information gathered will be used to formulate an individualized interdisciplinary plan of care for the resident during their stay in TCU. The P&P also indicated, The RAI is a comprehensive assessment that consist of three major sections: MDS, Care Area Assessments (CAAs) and Utilization Guidelines. The P&P further indicated:a. The MDS i. The MDS must be completed timely and accurately with appropriate signatures form the interdisciplinary team.b. The RAI assessments consist of two types: i. Omnibus Budget Reconciliation Act (OBRA) Assessments are Federally mandated, and must be completed timely and accurately on all residents regardless of payor source by the assigned due date:1. admission: (required by 14th calendar day of resident's admission) (admission date + 13 calendar days).c. Care Area Assessments (CAA) i. A CAA is required to be completed accurately and timely with the following Federal OBRA Assessments and Prospective Payment Systems (PPS) Assessments:1. Federal OBRA: admission Assessment (required by Day 14).

Based on observation, interview, and record review, the facility failed to report an allegation of abuse to the Department of Health Services (DHS a government agency that promotes and protects the health of all people and their communities) and the state agencies within the two-hour time frame as indicated in the facility's policy and procedure for one of two sampled residents (Resident 69). The Licensed Vocational Nurse (LVN) 2 did not report to the Director of Nursing (DON) when Resident 69 reported to LVN 2 that a staff member (unknown) yelled and was mean to Resident 69. This deficient practice violated the resident's rights to be free from any form of abuse and the potential for Resident 69 not to be protected and to further experience mental and emotional abuse that could lead to a psychosocial (mental and emotional being) and decline. Findings: During a review of Resident 69 Face Sheet Report indicated Resident 21 was admitted to the facility on [DATE]. During a review of Resident 69's Admission History and Physical record, dated 7/10/2024, indicated Resident 69 was awake, alert and oriented and diagnosis that included acute (severe and sudden in onset) cerebral vascular accident (a loss of blood flow to part of the brain), hypertension (elevated blood pressure) and coronary artery disease (a condition that affects your heart ) , hemiplegia and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke), congestive heart failure (CHF, the heart doesn't pump blood as well as it should) and major depressive disorder (feelings of sadness and/or a loss of interest in activities once enjoyed). During a record review of Resident 69's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 7/13/2024, indicated Resident 69 was cognitively (intellectual activity such as thinking, reasoning, or remembering) intact, had clear speech, had the ability to express ideas and wants and had the ability to understand others. The MDS indicated Resident 69 needed partial assistance (staff provided some support) with self-care (bathing, dressing and using the toilet) and was impaired on one side of the residents upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) extremities. During an observation and interview with LVN 2 on 7/13/2024 at 10:01 AM, Resident 69 was at bedside and reported experiencing leg cramps a few days ago (unknown date). Resident 69 stated he requested from Nurse 1 (N1) (unknown) to assist him in sitting up in a chair next to the resident's bed. Resident 69 stated N1 yelled at him and stated, you are not going anywhere. Resident 69 stated N1 was mean and yelled at him stating You are going to stay where you are at and that was that!. Resident 69 stated he felt disrespected and berated and it was not a pleasant experience. Resident 69 stated being yelled at felt as some type of verbal abuse. During an interview on 7/13/2024 at 10:56 AM with the Director of Nursing (DON), the DON stated LVN 2 informed him about Resident 69's allegation of abuse. During an interview on 7/13/2024 at 1:50 PM with Registered Nurse (RN) 2, RN 2 stated Resident 69 was alert and oriented and was able to make his own decisions. During an interview on 7/13/2024 at 3:19 PM with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated Resident 69 was awake, alert and oriented and had never heard Resident 69 make up stories. During an interview on 7/13/2024 at 4:29 PM, the DON stated abuse was defined as any type of financial, physical, sexual, neglect or verbal abuse. DON stated, he was aware of the allegation of abuse reported by Resident 69, but At this time, the allegation of abuse has not been reported to the Department of Health (DPH) and the state agencies. DON stated it was important to report any allegation of abuse because it needs to be escalated for proper authorities to ensure the safety of the resident and needs were meet so it (abuse) does not happen again. During a review of the facility's policy and procedure titled Abuse, Neglect, and Misappropriation of Property - E69010.001, dated 10/13/2022, indicated each resident has the right to be free from abuse, corporal punishment (physical punishment), and involuntary seclusion (separation of a resident from other residents or locked to her/his room against their will) period. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies service the resident, family member(s), legal guardians, friends, or other individuals. All employees of long-term care facilitys are mandated reporters of elder or dependent abuse as set forth under Section 15655 of the Welfare and Institutions Code and in accordance to State Operations Manual for Long Term Care Facilities 2017. Additionally, 483-13 (b) of the State operations Manual for Long Term Care Facilities, 2017 requires that alleged violations within the facility and the result of internal investigations be reported to the Department of Health Services. Investigation/Reporting: mandated reporters are required to report incidents of known or suspected abuse: all alleged violations - immediately but no after than 2 hours - if the alleged violation involves abuse .

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in the kitchen. During initial tour of the kitchen, an opened container of salad was observed unlabeled with the name of the food item and dated of when the food was prepared or to be discarded. This failure had the potential for improper food storage, which could lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). Findings: During an initial tour of the kitchen, on [DATE] at 5:55 PM, with the Supervisor Food Services (SFS) an opened container of salad, wrapped in clear plastic wrap, was observed in the facility ' s cold production refrigerator. The container was unlabeled with the name of the food item and dated of when the food was prepared or to be discarded. The SFS stated the container of salad might be a staff ' s personal salad. The SFS stated the container should not be stored in the cold production container if it was a staff person ' s salad. The SFS stated all food items should be dated and labeled. The DSD stated the food item could be expired. During an interview on [DATE] at 10:07 AM, with the System Director Infection Preventionist (SDIP), the SDIP stated the food items in the refrigerator should be labeled and dated to know if the food is expired. The SDIP stated residents could be exposed to foodborne illnesses if residents were served expired food. During a review of the facility ' s policy and procedure (P&P) titled, Patient Floor stock Food Supplies, revised [DATE], the P&P indicated, All perishable food will be dated to ensure food safety. The P&P indicates, Items not commercially labeled will have a label affixed stating date and contents . The P&P indicated, Staff food must be kept separate from the patient food. Staff shall not store their food in the patient refrigerator or freezers.

Based on observation, interview, and record review, the facility failed to assess the risk for accidental choking for one of one sampled resident (Resident 116), for the ability to chew food and safely eat a regular textured diet (all food textures that people with no chewing or swallowing issues eat) who had missing top teeth and dentures. This failure had the potential for Resident 116 to choke on her food and result in accidental death. Findings: During a review of Resident 116's Face sheet Report (AR, Admission Record), the AR indicated Resident 116 was admitted to the facility on [DATE] with the diagnosis of chest pain. During a review of Resident 116 ' s TCU History and Physical (H&P), dated 7/8/2024, the H&P indicated, the reason Resident 116 was admitted to the facility was to receive Physical Therapy (PT, therapy that is used to preserve, enhance, or restore movement and physical function impaired, Occupational Therapy (OT, helps you improve your ability to perform daily tasks), and Wound Care (treatment of a wound). During a concurrent observation and interview on 7/12/2024 at 8:02 pm, with Resident 116 ' s Resident Representative (RR) 1 in Resident 116 ' s room, Resident 116 was missing her top teeth. RR 1 stated Resident 116 was also missing the top dentures which was at Resident 116 ' s home. RR 1 stated RR 1 was concern for Resident 116 because the facility was serving Resident 116 meals with meat that was whole (not cut up). RR 1 stated Resident 116 almost choked on the chicken that was not cut up which was served for dinner (on 7/12/2024). During a concurrent interview and record review on 7/13/2024 at 2:44 pm, with Registered Nurse (RN) 1, the electronic medical record (EMR) failed to indicate Resident 116 was missing her top teeth and dentures. RN 1 stated Resident 116 was receiving regular textured meals in which the meat was not cut up. During an interview on 7/13/2024 at 4:05 pm, with the Assistant Director of Nursing (ADON), the ADON stated the reason it was important for the nursing staff to assess resident ' s (in general) teeth was because the assessment would determine the resident ' s (in general) ability to chew food. The ADON stated there was a risk residents (in general) could aspirate if they could not chew the food correctly. The ADON stated if residents (in general) were missing their top teeth, Speech Therapy (ST) should assess the resident to determine they could tolerate their diet. The ADON stated Resident 116 ' s medical EMR failed to indicate Resident 116 was assessed by ST. During an interview on 7/14/2024 at 8:58 am, with RN 2, RN 2 stated RN 2 assessed Resident 116 ' s ability to chew her food on 7/13/24 at 5pm, because the Surveyor had informed facility staff Resident 116 was having difficulty chewing her food. RN 2 stated Resident 116 was not able to gum her food (chewing food without teeth). RN2 stated RN2 ordered a trial tray for Resident 116 to determine what textured diet was safe for Resident 116. RN 2 stated Resident 116 did well with the soft and bite size texture (used if you are not able to bite off pieces of food safely but are able to chew bite-sized pieces down into little pieces that are safe to swallow). RN 2 stated nursing should examine a resident ' s (in general) mouth upon admission. RN 2 stated sometimes residents come without their dentures. RN 2 stated nursing should watch them to monitor if the ordered diet texture is safe for them. During a review of Resident 116 ' s Patient Transfer Orders, the Patient Transfer Orders indicated Resident 116 ' s diet texture was changed to soft and bite-sized on 7/13/2024 at 6:28 pm. During a review of the facility's policy and procedure (P&P) titled, Medical-Surgical Standards of Care, revised 3/28/2024, the P&P indicated, Utilizing nursing process, registered nurse provides a systematic exam assessing patient's condition/needs, identifying actual and/or potential health related problems in order to evaluate, develop and implement an individualized plan of care. The P&P indicated, It is policy that all patients receive quality care which is individualized and appropriate based on developmental level. The P&P indicated, Transitional care unit (TCU) will complete a head-to-toe assessment minimally every 24 hours.

Based on observation, interview and record review, the facility failed to promote care that maintained dignity and respect for one of one sampled residents (Resident 11) by failing to ensure Resident 11's drainage bag (a tube that removes fluid from the body into a collection bag connected to the resident that stored body fluids) from the stomach that was hanging from on the resident's bed frame was not exposed to the public and uncovered. This deficient practice had the potential to affect the resident's psychosocial (emotional and mental status) being and deprive the resident from dignity. Findings: During initial tour of the facility, on 7/12/24 at 6:48 pm, Resident 11 was observed in the room, laying lying in bed, with a catheter bag hanging on the right side of the residents' bed, exposed to the public and un-covered was with cloudy sediments (matter that settles in the bottom of the tube or bag) in the tubing and bag, was observed. During a review of Resident 11's Face Sheet Report (an admission record), indicated Resident 11 was admitted to the facility on [DATE]. During a review of Resident 11's History and Physical dated 7/19/24, indicated Resident 11 had a history of paraesophageal hernia (part of stomach moves up to the chest area) status post [after] repair with gastrojejunostomy (GJ, a feeding device place in the stomach to bypass the mouth, throat and stomach) tube placement. During a review of Resident 11's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 6/25/24, indicated Resident 11's cognition (intellectual activity such as thinking, reasoning, or remembering) was moderately intact, that needed maximal assistance (helper does more than half the effort) with lower body dressing and toilet hygiene. During a review of Resident 11's Patient Transfer Orders Active Orders on 7/14/24, indicated Miscellaneous Nursing: gastrostomy port (a surgical opening through the skin of the abdomen to the stomach) drain to drainage bag (catheter bag) by gravity. Gastrostomy site cleanse with normal saline (electrolyte fluid) and cover with dry dressing daily and as needed. During an observation and concurrent interview with Licensed Vocational Nurse 1 (LVN 1), on 7/12/24 at 7:16 pm, LVN 1 stated Resident 11's catheter bag did not have a dignity cover. LVN 1 stated catheter bags should always have a privacy bag and it was important for Resident 11's dignity. During an interview with the Director of Nursing (DON) on 7/13/24 at 6:37 pm, the DON stated catheter bags should be covered at all times, it did not matter if urine or whatever bodily fluids were contained in the bag, for dignity reasons, the catheter bag should always be covered. A review of the facility's policy and procedure titled Patient Rights and Responsibilities - E.87200.704, approved on 12/16/2021, indicated the facility believed that patients have certain rights and responsibilities while under the care and services (of the facility). Patients had the rights to: considerate and respectful care and to be made comfortable.

Based on interview and record review, the facility failed to ensure one of two closed sampled residents (Resident 13), received notification of the transfer/discharge from the facility and the reasons for the move in writing. As a result of this failure the facility deprived Resident 13 the right to be informed regarding transfer and discharge from the facility. Findings: During a review of Resident 13's Facesheet Report (AR, Admission Record), the AR indicated Resident 13 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation with rapid ventricular rate (a-fib with RVR, an abnormal heart rhythm). The AR indicated Resident 13's was discharged from the facility to General Acute Care Hospital (GACH) on 4/20/2024. During a concurrent interview and record review on 7/14/2024 at 2:44 PM with the Director of Nursing (DON), of the electronic medical record (EMR) indicated Resident 13 was not notified in writing of Resident 13's transfer/discharge to GACH. The DON stated Resident 13 was discharged back to the cardiac unit of the GACH due to the resident experiencing worsening edema (swelling caused by too much fluid trapped in the body's tissues) and A-fib with RVR. The DON stated the facility did not have a discharge/transfer notification document during the time that Resident 13 was discharged from the facility. The DON stated a discharge/transfer notification document had not been developed yet. During a review of the facility's Transitional Care Unit Notice of Proposed Transfer/Discharge (Transfer/Discharge Notice), The Transfer/Discharge Notice indicated the document was created on 6/18/2024. During an interview on 7/14/2024 at 3:11 PM with the DON, the DON stated the facility did not have a policy and procedure (P&P) for providing notification to residents about their transfer/discharge. The DON stated the facility was currently developing that policy.

Based observation, interview, and record review, the facility failed to provide care related to IV sites/therapy (Intravenous is a small plastic catheter placed through the skin into the vein used to give fluids and medications) based on to the professional standard of practice and the facility's policy and procedure for two of two sampled residents (Resident 63 and Resident 66). 1. Resident 63's, IV medication bag was not labeled with the date and time the antibiotic (medication used to treat infection) was administered. Resident 63's IV tubing was not labeled with the date and the tubing was first used. 2. Resident 66's IV site dressing/tape (plastic tape or gauze covering the IV) on the left arm was not labeled with date and time of when the IV site was dressing/tape was change. Resident 66's IV site had not physician order on how to monitor and care for the IV site to prevent infection.e. Resident 66's IV was discontinued by the facility staff without the physician's order. This deficient practice had the potential to increase complications associated with intravenous therapy such as infection. Findings: 1. A review of Resident 63's face sheet (an admission record) indicated the resident was admitted to the facility on [DATE], with a diagnosis of septic arthritis (a painful infection in a joint that can come from germs that travel through the bloodstream from another part of the body). A review of Resident's 63's Patient Transfer Orders (a physician order), dated 7/3/2023, indicated to administer Ceftriaxone (a medication used to treat infection) via IV piggyback (IVPB, medication administered via secondary IV tubing connected to the primary tubing), 2 grams (g-a unit of measure) in 50 milliliters (ml, unit of measure) dextrose (fluid with sugar) to infuse over 30 minutes every 24 hours for septic arthritis. During an observation on 7/7/2023 at 10:49 AM, Resident 63 was observed with an empty antibiotic IV bag hanging on an IV pole at bedside. The IV bag had no label that indicate the date and time of when IV bag was opened and administered. During an interview with Registered Nurse (RN) 2 on 7/7/2023 at 11:23 AM, RN 2 stated Resident 63's IV tubing should be labeled with the date and time to know when it was started. RN 2 stated the IV antibiotic bag should have the date, and time when medication was given. 2. A review of Resident 66's Face Sheet indicated the resident was admitted to the facility on [DATE], with a diagnosis of spondylosis lumbar (degeneration of lumbar vertebrae, a form of low back pain)/posterior spinal diskectomy fusion (surgical procedure used to correct problems with the small bones in the spine) lumbar three to lumbar (lower region of the spine) five. A review of Resident 66's History and Physical Interval Note, dated 7/5/2023, indicated the resident was admitted to the facility for further physical therapy (care that relieve pain and help one move better or strengthen weakened muscles) and medical management. The History and Physical indicated Resident 66 was alert and oriented to person, place, and time. During an observation on 7/7/2023 at 11:50 AM, Resident 66's IV dressing on the left hand was peeling off and without a label that indicated the date and time the IV dressing was last changed. In a concurrent interview, Resident 66 stated he could not recall when the IV dressing was last changed. Resident 66 stated the IV on his left arm was inserted at the hospital but could not recall when the peripheral IV was inserted at the hospital. During an interview on 7/7/2023 at 11:53 AM, RN 3 stated the resident's IV dressing should be labeled with the date and time of when the dressing was changed, and when the IV was inserted. During an interview and concurrent record review of Resident 66's Patient Transfer Orders, with the Clinical Manager (CM) on 7/7/2023 at 5:05 PM, the CM stated, Resident 66's IV was discontinued today. The CM confirmed and stated there was no physician orders on how to maintain and care for the Resident 66's IV, and there was no order to discontinue the IV today. The CM stated it was a part of the facility standard of practice to have a physician's order to maintain, care and discontinue the IV sites. A review of the facility's policy and procedure titled Intravenous Therapy for Adults and Pediatrics Peripheral and Central, revised 7/13/2022 indicated labeling of IV tubing, IV site and IV bags are required when the resident is admitted . The policy indicated all IV sites will be changed only as clinically warranted based on integrity and patency of the site and labeled with initiation date and time. The policy indicated a physician will write orders for the following: insertion or discontinuation of a peripheral IV.