Every finding on record at River Pointe Post-Acute

Based on interview and record review, the facility failed to ensure acceptable parameters of nutritional status were monitored for one of four sampled residents (Resident 1) when Resident 1's weight was not obtained per physician order.This failure decreased the facility's potential to identify, implement, monitor, and modify interventions consistent with Resident 1's needs to maintain acceptable parameters of nutrition.During a review of Resident 1's admission records, the records indicated Resident 1 was admitted to the facility in June 2025 and readmitted in August 2025 with diagnoses that included senile degeneration of brain (loss of intellectual ability), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (condition that cause fear, worry, or panic). Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 5/28/26, indicated Resident 1 had moderate cognitive impairment.During a review of Resident 1's physician order, dated 7/10/25, the order indicated, Vital Signs & weight monthly.During a review of Resident 1's care plan, revised 9/19/25, the care plan indicated, .[Resident 1] has had a WEIGHT LOSS.Monitor weight as ordered.During a review of Resident 1's weight record, the record indicated the following:07/05/2026 - 129 pounds (Lbs, a unit of measurement)05/03/2026 - 126 Lbs09/07/2025 - 131 Lbs08/23/2025 - 135 Lbs08/07/2025 - 135 Lbs08/03/2025 - 140 Lbs07/12/2025 - 146 Lbs07/06/2025 - 148 Lbs06/28/2025 - 160 LbsDuring a concurrent interview and record review on 8/13/26 at 3:23 p.m. with the Assistant Director of Nursing (ADON), the ADON confirmed Resident 1 had a physician order to monitor weight monthly. The ADON further confirmed that Resident 1's weights were not checked monthly contrary to the physician order. The ADON also confirmed that there was no documented evidence that Resident 1 was refusing weight checks. The ADON stated that if there was an order to monitor the weight monthly, the expectation was to follow the order or to clarify with the physician if there was a need to change the order.During a review of the facility's policy and procedure (P&P) titled Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, revised 9/2017, the P&P indicated, .1. The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time.Monitoring.1. The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss.).During a review of the facility's P&P titled Weight Assessment and Intervention, revised 9/2008, the P&P indicated, .The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents.1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter.2. Weights will be recorded in each unit's Weight Record chart or notebook and in the individual's medical record.

Based on interview and record review, the facility failed to ensure complete informed consents (IC, process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention in order to obtain agreement or permission for care, treatment, or services) were in place prior to the initiation and administration of psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) for one of four sampled residents (Resident 1) when there were no consents present in Resident 1's clinical record for Resident 1's use of psychotropic medications.This failure had the potential for Resident 1 or the responsible party (RP) not to be informed of the risk and benefits of the psychotropic medications, and to make an informed decision, before receiving the medications.During a review of Resident 1's admission records, the records indicated Resident 1 was admitted to the facility in June 2025 and readmitted in August 2025 with diagnoses that included senile degeneration of brain (loss of intellectual ability), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (condition that cause fear, worry, or panic). Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 5/28/26, indicated Resident 1 had moderate cognitive impairment.A review of Resident 1's physician order, dated 7/22/26, indicated an order for Lorazepam (used to treat anxiety) 0.5 mg (milligrams, a unit of measurement) one tablet by mouth every four hours as needed for anxiety or agitation manifested by restlessness.A review of Resident 1's physician order, dated 7/23/26, indicated an order for Sertraline (used to treat depression) 100 mg one tablet by mouth one time a day for depression manifested by self-isolation.During a concurrent interview and record review on 8/13/26 at 3:23 p.m. with the Assistant Director of Nursing (ADON), the ADON confirmed that Resident 1 was receiving Lorazepam 0.5 mg and Sertraline 100 mg. The ADON further confirmed that consents were not obtained for both medications and consents should have been obtained before starting psychotropic medications or if there was an increase in the dose. The ADON further stated it was the right of the residents to be informed and that if consents were not obtained before starting the medications, the resident or the responsible party will not be informed of the risks and benefits of the medications.During a review of the facility's policy and procedure (P&P) titled Informed Consent, revised 6/2021, the P&P indicated, .1. The facility shall ensure the resident's rights are maintained and a copy of these rights and pertinent policies are made available to the resident and to any representative of the resident. Among these rights under this section are the right to: a. Receive in advance all information that is material to a decision to accept or refuse treatment.2. Physician's orders related to the use of psychotherapeutic drug, antipsychotic drug, physical restraint, or the prolonged use of a device that may lead to the inability to regain use of a normal bodily function shall not be initiated until the facility is able to verify that the resident or their authorized representative has given informed consent.

Based on interview, and record review the facility failed to protect a resident's right to be free from abuse for one of three residents sampled for abuse (Resident 1) when Resident 2 was observed by Licensed Nurse (LN) 1 inappropriately touching Resident 2's breasts under her shirt.This failure resulted in Resident 1 being sexually abused by Resident 2 and had the potential for Resident 1 to have negative psychosocial health (health related to thoughts, emotions, behaviors, and social life) outcomes.A review of Resident 1's Facesheet (document with personal demographic information) indicated, Resident 1 does not make her own medical decisions and has another person listed as her responsible party. Facesheet further indicated medical diagnoses of encephalopathy (brain disease that alters how the brain works) and dementia (a condition that affects cognition and ability to care for self).A review of Resident 1's Brief Interview for Mental Status (BIMS: a score of cognitive function) dated 4/30/26 indicated a score of 0, indicating Resident 1 had severely impaired cognition (major loss of intellectual and mental capacity that stops a person from living on their own and requires help with daily life).A review of Resident 1's Order Summary Report indicated Resident 1 did not have an order for capacity to make healthcare decisions or ability to give consent.A review of Resident 2's Facesheet indicated Resident 2 had medical diagnosis of degenerative disease of the nervous system (loss of brain cells impacting cognition).A review of Resident 2's BIMS score dated 7/7/26, indicated a score of 6, indicating Resident 2 had severe cognitive impairment.A review of the facility's Report of Suspected Dependent Adult/Elder Abuse dated 7/9/26, indicated, on 7/8/26, at around 3 p.m., Resident 2 was observed to inappropriately touch Resident 1.A review of witness statement signed by LN 1, dated 7/9/26, statement indicated, On July 8th, 2026 at approx. [approximately] 3:15 pm. I [LN 1] witnessed [Resident 2] in the main hallway, sitting in his wheelchair. [Resident 1] was standing in front of [Resident 2]. [Resident 2] was then witnessed putting both of his hands under [Resident 1's] shirt squeezing her breasts. Three attempts to reach LN 1 for an interview were unsuccessful.During an interview on 8/4/26, at 12:15 p.m., with Resident 2, Resident 2 was unable to recall the incident with Resident 1.During an interview with Social Services Director (SSD) on 8/4/26, at 1:47 p.m., SSD stated, she was walking in the hallway on 7/8/26 and heard LN 1 yelling at Resident 2 to stop. SSD stated after the incident she monitored Resident 1 for possible psychosocial decline, and for 72 hours Resident 1 was noted to be at her baseline behavior with no noted decline.A review of the facility's 5-Day Follow-Up Report dated 7/13/26 indicated, the interaction between Resident 1 and Resident 2 on 7/8/26 was directly witnessed by staff.During an interview on 8/4/26, at 3:10 p.m., with Regional Director (RD), Administrator (ADM), and Administrator in Training (AIT), RD stated, the facility follows the Center for Medicare and Medicaid Services (CMS) definition for abuse. When the ADM was asked if a reasonable person would find it appropriate to touch another person's breasts without consent, he stated, no.A review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 2021, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on observation, interview and record review the facility failed to provide adequate supervision to prevent elopement for one resident (Resident 2) of three sampled residents, when Resident 2 left the facility unsupervised and his whereabouts accounted for. This failure resulted in Resident 2 exiting the facility premises, which placed him in a potentially unsafe and perilous place and situation with the risk of being injured or harmed, as he was able to leave the facility without staff being aware. Findings: During a review of Resident 2' s admission Record (AR), the AR indicated Resident 2 was admitted to the facility in October 2025 with diagnoses that included dementia (a progressive state of decline in mental abilities) and Schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 2's Care Plan (CP), dated 10/17/25, the CP indicated, original care plan item. Resident [Resident 2] has exhibited wandering behavior which places him at risk of getting into a dangerous place or encountering a dangerous situation-Related to anger over placement in SNF, has verbalize wanting to leave and wanting to go home- At risk for elopement related to: history of wandering out of facility/history of wandering out of home prior to placement.During a review of Resident 2's CP's interventions, dated 10/17/25, indicated, . Assess/reassess for wandering.Check resident constantly and be aware of resident's whereabouts. Wanderguard (alarm bracelet) for resident's safety.During a review of Resident 2's IDT[interdisciplinary team]-CHANGE OF CONDITION / INCIDENT (IDT) notes dated 7/27/26, the IDT notes indicated, .Resident eloped from the facility on 7/26/26.Between 1:37am and 2:23am, the resident removed the wanderguard and admitted to AIT [Administrator-in-Training] upon pick up that he had thrown it away. Resident planned to elope and had requested his juice be refilled and snacks provided. Resident then sat in the hallway and observed staff. When staff had temporarily left the hallway, resident took his snacks and juice and exited through the ambulance bay door. This door did not alarm upon exit because the wanderguard had been removed by the resident. Staff recognized that the resident was missing at 4:45am .When it was determined that the resident was no longer in the facility, RN supervisor notified 911 and Administrator. This occurred at 5:40am. Review of the medical record demonstrated multiple prior episodes of exit-seeking behavior . Review of Resident 2's IDT notes further indicated, Facility staff began a search party and began walking/driving through the nearby neighborhoods in attempts to locate the resident. Camera footage was reviewed to determine the time and exit route of the resident. It was determined that the resident eloped at 2:23 am through the ambulance bay door. Information was provided to the police who arrived on scene after 6:40am. Police assisted the facility with their search and posted information to twitter for public assistance as well. Facility staff continued to search for the resident until the resident was found at 4:12pm by the local police. Facility staff provided transportation for the resident back to the facility. During transportation resident admitted to removing his wanderguard . During a concurrent observation and interview with Licensed Nurse (LN) on 7/28/26 at 1 p.m., Resident 2 was playing chess with a 1:1 sitter (a person who provides continuous one-on-one supervision, monitoring, and companionship to high-risk patients) in his room. LN confirmed that Resident 2 frequently had exit-seeking behaviors prior to his elopement incident on 7/26/26.During a concurrent interview and record review on 7/28/26 at 3:16 p.m., with Regional Administrator (ADM), the ADM confirmed that Resident 2's whereabouts were unaccounted for from 1:37a.m. to 4:45 a.m. The ADM acknowledged that the care plan was not followed.During a review of the facility policy and procedure (P&P), Wandering and Elopements, undated, indicated, .The facility will identify resident who are at risk of unsafe wandering and strive to prevent harm.the resident's care plan will include strategies and interventions to maintain the resident's safety.

Based on interview and record review, the facility failed to ensure the appropriate food texture was provided for one of three sampled residents (Resident 1), when Resident 1, who was on a puree diet (a diet with food texture of smooth like pudding or mashed potatoes that requires no chewing for one who has difficulty chewing and/or swallowing) received sponge cake. This deficient practice resulted to Resident 1 being hospitalized on [DATE] due to aspiration symptoms (a condition in which food, liquids, saliva, or vomit is breathed into the airway). During a review of Resident 1's admission Record (AR-front page of the chart that contains a summary of basic information about the resident), indicated, Resident 1 was admitted to the facility on [DATE] with multiple diagnoses which included dysphagia (difficulty swallowing).During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 7/9/26, indicated Resident 1 had difficulty swallowing and required a mechanically altered diet (change in texture of food or liquids). During a review of Resident 1's Order Summary Report (OSR, physician [MD] order), dated 7/29/26, indicated, .DIET . Liquified texture . During a review of Resident 1's care plan (CP), dated 11/27/22, the CP indicated, .ADHERE TO.interventions .Diet/MD order. During a review of Resident 1's Physician Progress Note (PPN), dated 6/23/26, the PPN indicated, . On 4/6/2026 he was sent to the ED (emergency department) via 911 for evaluation of nausea, vomiting, and possible aspiration following ingestion of non-pureed food. He was treated for an Aspiration Event and Associated Symptoms. He was transferred to the ED after developing N/V [nausea/vomiting] ,and SOB [shortness of breath] following consumption of pound cake with raisins, despite being on a strict pureed diet due to dysphagia. He was noted to have spitting up of mucus and an episode of vomiting, raising concern for aspiration. During an interview on 7/29/26 at 9:50 a.m. with the Dietary Manager (DM), the DM confirmed that Resident 1 received a different texture (not MD ordered diet) in April 2026. During an interview on 7/29/26 at 10:05 a.m. with the Assistant Director of Nursing (ADON), the ADON stated the expectation was for all diet orders to be followed (therapeutic and textured). The ADON acknowledged there was a risk for aspiration if textured diet orders were not followed. The ADON further confirmed that Resident 1's prescribed diet was not followed. During a review of the facility's policy and procedure ( P&P) titled, Physician Orders, revised July 2016, the P&P indicated, . A resident shall be admitted or accepted for care on the order of a physician.and include .Diet . All orders must be specific and complete with all necessary details to carry out the prescribed order.

Based on observation, interview, and record review, the facility failed to ensure safe administration of supplemental oxygen (a colorless and odorless gas used when a person's body is unable to get enough oxygen from normal air) in accordance with the physician's order for one of three sampled residents (Resident 1), when staff administered supplemental oxygen at 5 liters per minute (L/min, unit of measurement) to Resident 1 continuously without a physician's order.This failure did not reflect Resident 1's treatment needs and placed the resident at risk for oxygen toxicity, worsening of respiratory and cardiac (related to the heart) status, and had the potential to compromise Resident 1's well-being. Findings:A review of admission record indicated the facility admitted Resident 1 early 2026 with multiple diagnoses, including acute respiratory failure with hypoxia (when lungs are unable to pass enough oxygen to the blood, or when fail to remove carbon dioxide (colorless and odorless gas humans breath out) from the blood), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), and ischemic cardiomyopathy (the heart muscle is too weak to pump blood leading to fluid built-up in the lungs or body). Resident 1's clinical records indicated that the resident had obstructive sleep apnea (intermittent airflow blockage during sleep).A review of Resident 1's physician's order dated 3/25/26 indicated, Oxygen: Administer O2 [oxygen] @ [at] 1 L/min [oxygen measured in liters per minute] via NC [Nasal Cannula, a thin plastic tube applied to nostrils to provide supplemental oxygen] at bedtime.Every shift. DX [diagnosis]: Sleep Apnea.A review of the Minimum Data Set (MDS-federally mandated assessment tool) dated 4/1/26 indicated that Resident 1 was cognitively intact and did not experience hallucinations or delusions.During an observation on 5/19/26 at 11:50 a.m., Resident 1 was observed in her bed with supplemental oxygen through NC. Resident 1's oxygen concentrator (OC, a medical device that take in air from the room and filter out nitrogen to provide oxygen) was set at 5 liters/minute. Resident 1 looked at the concentrator and stated, It's at 5 liters, that is way too much for me. Resident 1 denied having shortness of breath and added, They used to have it at 3 liters, not sure when and who increased it for me. Resident 1 explained that she did not want to wear a CPAP (a breathing machine that helps person's breathing by pushing air into lungs through a mask worn over the face) at night and her physician recommended that she used supplemental oxygen at night. Resident 1 stated she was receiving oxygen at night and during daytime.During a concurrent interview and record review with Licensed Nurse (LN 1) on 5/19/26 at 12:05 p.m., LN 1 stated she was overseeing and assisting LN 2 who was a newly hired nurse. LN 1 stated she was not sure if Resident 1 was receiving oxygen continuously. LN 1 reviewed physician order for oxygen administration and stated that Resident 1 was prescribed to have supplemental oxygen at 1 L/min at night only. LN 1 entered Resident 1's room and confirmed that Resident 1 had NC with continuous oxygen flow rate set at 5 L/minute. LN 1 acknowledged that the physician order for oxygen administration was not followed. LN 1 explained that if resident complained of shortness of breath and her oxygen level was too low, the nurse would notify the physician and obtain an order for continuous oxygen administration.During an interview and record review with LN 2 on 5/19/26 at 12:11 p.m., LN 2 stated she received a report from night shift nurse that Resident 1 was on continuous oxygen. LN 2 stated she was not sure of the flow rate of oxygen Resident 1 received and stated she did not check the resident's concentrator and oxygen flow rate since she took over care of Resident 1 earlier this morning. LN 2 confirmed that Resident 1 was supposed to be on oxygen at 1 L/min at night per physician's order.During an interview and concurrent record review on 5/19/26 at 1:50 p.m., the facility's process of oxygen administration was discussed with Director of Nursing (DON). The DON stated that treatment with oxygen required to have a valid physician order with flow rate specified. The DON validated that Resident 1's physician order indicated to administer oxygen at 1 L/min at night. After searching Resident 1's clinical records, the DON stated that the resident did not have an order for continuous oxygen administration. Upon reviewing nurses' documentation for daily oxygen saturation (percentage of oxygen in a person's blood), the DON acknowledged that on multiple days throughout the month of May, nurses documented that Resident 1 was on oxygen during daytime and nighttime contrary to the physician orders. The DON stated that the physician order for oxygen was not followed and if Resident 1 complained of shortness of breath, the physician should be notified and the order for continuous oxygen administration initiated. The DON agreed that administering oxygen at high rate (5 liters/minute) placed Resident 1 at risk for health complications.A review of the facility's policy and procedure (P & P) titled, Oxygen Administration, dated 10/2010, indicated, Purpose .To provide guidelines for safe oxygen administration. The P & P directed nursing, Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident .Adjust the oxygen delivery device so that is comfortable for the resident, and the proper flow of oxygen is being administered.

Based on interview and record review the facility failed to meet the professional standards of quality for one of three sampled residents (Resident 2) when a physician's post-surgical care orders were not implemented for Resident 2. This failure resulted in incomplete post-surgical assessments and monitoring for Resident 2 and placed the resident at higher risk for complications.Findings:Resident 2 was admitted to the facility in early 2026 with diagnoses which included fracture of upper arm bone and sepsis (body's extreme response to an infection).A review of Resident 2's Minimum Data Set (a standardized assessment tool used in nursing homes), dated 2/15/26, indicated Resident 2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident had no cognitive impairment.A review of Resident 2's Order Summary Report (OSR) indicated, Resident [Resident 2] is capable of making her own health decisions.A review of Resident 2's Physician Progress Note (PPN), dated 2/10/26 indicated, .SKILLED admission SNF:.hospitalized [DATE] for septic shock [a serious condition that occurs when a body-wide infection leads to excess inflammation].She [Resident 2] was noted to have dry gangrene [death of body tissue due to a lack of blood flow or a serious bacterial infection] of the left 2nd toe .podiatry was consulted.recommended amputation of that toe outpatient. which indicated that Resident 2 was admitted to the facility with dry gangrene of the left 2nd toe. A review of Resident 2's Nursing Progress Note (NPN), dated 3/3/26 indicated, .pt [patient] out to podiatry, 2nd toe amputated and new orders received.A review of Resident 2's OSR included the podiatrist's post-surgical orders, Amputation of Left 2nd toe Activity: Restrict activities and rest. No heavy lifting, no pushing, no straining until cleared by MD [Medical Doctor]. In the next 2 weeks keep the surgical foot/ankle above the heart as much as possible. For bathing you may use sponge bathe or cover the case/bandage with a trash bag and tape above the knee with duct tape. Do not get the cast/bandage wet. If it gets soaked, it will need to be changed. Amputation of Left 2nd toe operative site: Keep the cast/bandage clean, dry, and intact until follow up with your surgeon. Do not remove the cast/bandage. If bleeding through the bandages is noted. add some more bandages. If the bleeding continues then call: [Hospital Name]: [Phone Number] [Hospital Name and Department] [Phone Number]. Amputation of Left 2nd toe s/s to report to physician Temp >100.4 degrees F or higher, excessive pain not controlled with pain medications, excessive nausea and/or vomiting, increased bleeding from the incision site. These orders were entered in OSR on 3/2/26.A review of Resident 2's SBAR [Situation Background Assessment Recommendation] & INITIAL COC [Change of Condition]/ALERT CHARTING 7 SKILLED DOCUMENTATION 9WCG0-V4 [a structured documentation method used in healthcare] dated 3/10/26, indicated that Resident 2 was transferred to a hospital on 3/10/26 due to abnormal lab results.A review of Resident 2's Treatment Administration Record (TAR, a record that contains physician orders and treatment instructions for nursing staff to implement) for March 2026 did not include the podiatrist's post-surgery care orders on 3/2/26 related to Resident 2's left second toe amputation. During a concurrent interview and records review with the Treatment Nurse (TN) on 4/23/26 at 12:49 p.m., the TN verified Resident 2's March 2026 TAR did not reflect the Podiatrist's orders on 3/2/26 and stated once the physician orders were placed in TAR, wound care nurses and other nurses carried out the orders and documented in the resident's TAR. The TN stated she did not carry out the post amputation orders for Resident 2 since the orders were not in TAR. The TN confirmed that there were no other notes documenting the podiatrist's post amputation orders for Resident 2 were implemented between 3/2/26 through 3/10/26 when the resident was sent out to the hospital. During a concurrent interview and records review with Licensed Nurse (LN) 1 on 4/23/26 at 4:58 p.m., LN 1 stated she worked on morning shifts on 3/4/26 and 3/9/26 and was assigned for Resident 2's care on those days. LN 1 explained that the facility treatment nurses were responsible for wound care and stated, There were no orders on my MAR [Medication Administration Record] or TAR, so I was not able to do it [implement orders].During a telephone interview on 4/24/26 at 11:43 a.m. with LN 2, LN 2 who worked on evening shifts in March stated that he did not implement the podiatrist's post-surgery care orders for Resident 2 because there were no specific post amputation orders for LN 2 to follow.During a telephone interview on 4/27/26 at 3:35 p.m. with LN 4, LN 4 confirmed being assigned to Resident 2 and stated that she was aware Resident 2 had an amputation of the left second toe; however, she did not perform the podiatrist's order for Resident 2 because there was no orders to implement in TAR or MAR. During a telephone interview on 4/27/26 at 4:10 p.m. with LN 5, LN 5 indicated that she took care of Resident 2 in March and stated she was not informed that Resident 2 had an amputation of the left second toe. LN 5 stated that she was not aware of any specific post amputation orders for Resident 2.During a concurrent interview and records review with the Director of Nursing (DON) on 4/23/26 at 3:05 p.m., the DON stated that the admitting nurse was responsible for entering physician and facility orders into PCC (an Electronic Health Record software), and those orders should appear in the resident's MAR or TAR so nurses to carry them out. The DON confirmed that the post amputation care and monitoring orders on 3/2/26 for Resident 2 were not in the resident's TAR and acknowledged that there was no documented evidence that the podiatrist's post amputation care order for the resident had been carried out. The DON emphasized that orders must be completed and documented in the resident's record and failing to correctly follow and document orders could be a significant issue that adversely affects resident care and health.During an interview with the facility Administrator (ADM) on 4/23/26 at 5:39 p.m., the ADM explained that a coding error was made by the nurse who entered the podiatrist's orders for Resident 2 on 3/2/26 which resulted in the orders not appearing in the TAR for nurses to implement. A review of the facility's Policy and Procedure (P&P) titled, Charting and Documentation revised July 2017 indicated, All services provided to the resident.shall be documented in the resident's medical record.The following information is to be documented in the resident medical record. Treatments or services performed.Documentation in the medical record will be.complete and accurate.A review of of the facility's P&P titled, Medication and Treatment Orders, Revised 2016 indicated, Orders for medications and treatments will be consistent.and effective order writing.

Based on observation, interview, and record review, the facility failed to maintain privacy for a census of 110 residents, when the residents' meal tray tickets (paper slips printed for residents' meals detailing names, food allergies, adaptive eating utensils, and therapeutic diet orders) were thrown in the trash.This failure decreased the facility's potential to protect the residents' private health information.Findings:During a concurrent observation and interview on 3/9/26 at 9:54 a.m. with the Interim Dietary Services Supervisor (IDSS), IDSS was observed overseeing the dietary aides cleaning up the breakfast trays. Dietary Aide 1 discarded the residents' meal tickets into a trash bin along with uneaten food. IDSS confirmed kitchen staff discarded the meal tickets into trash bags, which were disposed of in the facility's garbage dumpster. IDSS stated she was unaware of an alternate method to dispose of meal tickets to protect residents' private information. IDSS further stated discarding meal tickets in the trash was a breach of residents' privacy. During an interview on 3/10/26 at 3:45 p.m. with the Registered Dietician (RD), RD stated residents' privacy was breached by discarding meal tickets in trash bins. RD further stated private health information about residents, including allergies and doctor's orders for therapeutic diets, were listed on the meal tickets; therefore it should have been fed into a paper shredder to be discarded correctly. During an interview on 3/12/26 at 8:54 a.m. with the administrator (ADM), ADM stated the residents' private information on meal tickets could easily be exposed to the public. ADM expected all used meal tickets to be shredded.A review of the facility's policy titled, Resident Rights, revised February 2021, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to . privacy and confidentiality .A review of the facility's policy titled, Management of Protected Health Information (PHI), revised April 2014, indicated, PHI shall not be used or disclosed except as permitted by current federal and state laws . It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure.

Based on observation, interview, and record review, the facility failed to store and distribute food in accordance with professional standards for food service safety for a census of 110 residents, when:1. Undated and expired food was stored in the kitchen, and 2. Two wet pans were stored with one pan having brown gel-like smudges inside.These failures decreased the facility's potential to prevent the spread of foodborne illnesses among vulnerable residents.Findings:1. During a concurrent observation and interview on 3/9/26 at 9:06 a.m. with the Interim Dietary Services Supervisor (IDSS) in dry goods storage, a large bin of uncooked macaroni pasta and nine bags of black olives were found undated. IDSS stated each package of olives should have been dated when the box was opened. IDSS further stated serving undated food had the potential for residents to eat food contaminated with bacteria. During a concurrent observation and interview on 3/9/26 at 9:14 a.m. with IDSS, a shallow container with an unfastened lid containing a diet orange drink was found in a refrigerator, with an expiration date of 3/8/26. IDSS confirmed the lid was unfastened and the drink was expired. IDSS stated the lids were to be firmly affixed to beverage containers to avoid spillage and cross contamination. IDSS further stated serving expired juice could expose residents to bacteria.During a concurrent observation and interview on 3/9/26 at 9:20 a.m. with IDSS, an opened undated package of breaded chicken tenders was found in a freezer. IDSS stated the chicken tenders should have had an open date on them, or no one would know if they were appropriate to serve.2. During a concurrent observation and interview on 3/9/26 at 9:11 a.m. with IDSS, two small steam table serving pans were stored wet. IDSS expected the food pans to be air dried before being stored on shelves and stated storing the items wet could cause bacteria or mold to grow.During a concurrent observation and interview on 3/11/26 at 10:40 a.m. with IDSS and [NAME] (C) 1, C 1 was preparing the lunch meal when a steam table pan was found with brown jelly-like splotches inside the bottom of the pan. C 1 stated the pan was dirty with dried food. IDSS confirmed the serving pan had what appeared to be dried food and expected the pan to be clean for residents' food.During an interview on 3/10/26 at 3:42 p.m. with the Registered Dietician (RD), RD expected food to have the received date written on the package and if opened, then the package should have open dates and use by date labels. RD stated serving expired or undated food compromised food safety and could make residents sick. RD further stated heating pans were supposed to be thoroughly cleaned and dried and using dirty or wet pans did not meet expectations; therefore, storing cookware this way could decrease food safety.A review of the facility's procedure titled, Refrigerated Storage, dated 2023, indicated food should be covered, and food packages or containers should be dated.A review of the facility's procedure titled, Freezer Storage, dated 2023, indicated, All frozen foods should be labeled and dated.A review of the facility's policy and procedures (P&P) titled, Food and Supplies: Dry Storage, dated 2023, indicated, Labels should be visible . All food will be dated - month, day, year. P&P further indicated, Food in unlabeled, rusty, leaking, broken containers . shall not be retained or used.A review of the facility's P&P titled, Dishwashing, dated 2013, indicated, All dishes will be properly sanitized through the dishwasher . Gross food particles shall be removed by careful scraping and pre-rinsing in, running water . Dishes are to be air dried in racks before stacking and storing.

Based on observation, interview, and record review, the facility failed to follow the recipe for seven residents of a census of 110, when excess broth and milk and unmeasured amounts of food thickener were added to pureed (a smooth, lump-free, and moist consistency similar to pudding, which does not require chewing and is easily swallowed) meals.This failure decreased the facility's potential to serve residents food that was easy to swallow and retained its nutrient value.Findings:A review of the facility's lunch menu, dated 3/11/26, indicated the menu consisted of sweet and sour chicken, sesame noodles, stir fry vegetables, mandarin Asian salad, and lemon snow bar.A review of the facility's recipe titled, Pureed (IDDSI Level 4 [International Dysphagia Diet Standardization Initiative-Level 4 consists of pureed foods and extremely thick drinks]) Meats, dated 2025, indicated 12 to 24 ounces [(oz.- a unit of measure) 1.5 - 3 cups] of broth was to be added to 12 servings of chicken. The instructions were to thicken the food with 6-12 tablespoons (tbsp- a unit of measure) of food thickener if needed.A review of the facility's recipe titled, Pureed (IDDSI Level 4) Starch (Pasta .), dated 2025, indicated 12 to 24 oz. (1.5 - 3 cups) of warm milk was to be added to 12 servings of noodles, and 6-12 tbsp of food thickener was to be added as needed.During a concurrent observation and interview on 3/11/26 at 10:40 a.m. with [NAME] (C) 1 and Registered Dietician (RD), lunch preparation for pureed food items was observed. C 1 stated she was making 12 servings, then measured 12 servings of cooked chicken and put the food in a blender. C 1 added six cups of broth in increments and added six unmeasured plastic spoonfuls of instant food thickener. C 1 then prepared the noodles for the lunch menu. C 1 added 4.5 cups of milk in increments, and six unmeasured plastic spoonfuls of food thickener. C 1 stated she should have followed the recipe for adding correct amounts of broth, milk, and food thickener.During an interview on 3/11/26 at 11:32 a.m. with RD, RD confirmed C 1 added double amounts of broth to the chicken, added too much milk to the noodles, and did not properly measure the amount of food thickener. RD acknowledged C 1 did not follow the recipe and stated the consistency of the food was inadequate for the residents' swallowing abilities (potential for choking). RD further stated residents on pureed diets might not get essential nutrients if the food had excess liquids.A review of the facility's policy titled, Therapeutic Diets, revised October 2017, indicated, A therapeutic diet is . ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet .A review of the facility's policy and procedure (P&P) titled, Food Preparation, dated 2023, indicated, Food shall be prepared by methods that conserve nutritive value . Recipes are specific as to portion yield, method of preparation, quantities of ingredients . P&P further indicated, Poorly prepared food will not be served-such food is to either be improved, prepared again, or replaced with an appropriated substitution.

Based on observation, interview, and record review, the facility failed to follow proper infection control measures for one of 31 sampled residents (Resident 25), when Licensed Nurse (LN) 1 did not wear proper personal protective equipment (PPE, protective clothing/gown, gloves, face masks/shield to protect from injury or the spread of infection) while providing care to Resident 25 placed on Enhanced Barrier Precaution (EBP, an infection control method).This failure decreased the facility's potential to prevent the spread of infection among residents.Findings:A review of Resident 25's admission Record, indicated she was admitted to the facility in December 2025 with multiple diagnoses including perforated intestine (a hole, tear, or puncture in the wall of the small or large intestine) and protein-calorie malnutrition (a condition caused by a lack of both protein and calories to meet the body's needs).A review of Resident 25's Order Summary Report (OSR), dated 12/17/25, indicated Resident 25 was on EBP due to a central venous catheter (a long, flexible, and thin tube inserted into a large vein usually in the neck or chest that reaches a major vein near the heart to deliver medication or nutrition directly into the bloodstream). The central venous catheter was utilized for total parenteral nutrition (TPN, a specialized high calorie liquid nutrition delivered directly into the bloodstream bypassing the digestive tract). During a concurrent observation and interview on 3/10/26 at 4:29 p.m. with LN 1 in Resident 25's room, LN 1 was observed administering TPN to Resident 25 without wearing a gown. LN 1 stated she should have worn a gown during TPN administration because Resident 25 was placed on EBP.During an interview on 2/11/26 at 10:20 a.m. with the Infection Preventionist (IP), IP stated staff should follow infection prevention and control measures to prevent the spread of infection and for resident safety.A review of the facility's policy titled, Enhanced Barrier Precautions, dated August 2022, indicated, Enhanced Barrier Precautions are used as an infection prevention and control intervention . Gloves and gown are applied prior to performing the high contact resident care activity . EBPs are indicated for residents with indwelling medical devices like central lines . wound care or any skin opening requiring a dressing.

Based on interview and record review, the facility failed to submit in a timely manner a Minimum Data Set (MDS; an assessment tool) for one of 31 sampled residents (Resident 42), when Resident 42's discharge assessment was not submitted since 10/2025.This failure decreased the facility's potential to submit Resident 42's MDS information to the Centers for Medicare and Medicaid Services (CMS) in a timely manner.Findings: A review of Resident 42's admission Record, indicated she was admitted to the facility in 10/25 and discharged on 10/17/25 with a diagnosis of acute and chronic respiratory failure (worsening of breathing function in a patient with pre-existing, long-term respiratory failure).During a concurrent interview and record review on 3/12/26 at 9:23 a.m. with the Minimum Data Set Coordinator (MDSC), MDSC confirmed Resident 42's discharge MDS was not submitted to CMS and was overdue by 134 days. MDSC expected the discharge MDS to be submitted according to the timeframes as indicated in the CMS's Resident Assessment Instrument (RAI - helps facility staff to gather information on a resident's strengths and needs) Manual.During an interview on 3/12/26 at 10:07 a.m. with the Director of Nursing (DON), DON expected staff to follow the required timeframes for MDS submission.A review of CMS's RAI Version 3.0 Manual, dated 10/19, indicated the MDS discharge assessment was to be transmitted to CMS within 14 days of completion.

Based on observation, interview, and record review, the facility failed to follow the plan of care for one of 31 sampled residents (Resident 30), when Resident 30's communication board was not available for use during provision of care.This failure decreased the facility's potential to meet Resident 30's ability to communicate his needs.Findings:A review of Resident 30's admission Record, indicated he was admitted to the facility in October 2025 with a diagnosis of metabolic encephalopathy (a sudden or chronic brain dysfunction due to a chemical imbalance in the body that causes confusion, memory loss, and behavioral changes).A review of Resident 30's Baseline Care Plan, dated 10/19/25, indicated Resident 30's primary spoken language was Spanish.A review of Resident 30's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/13/26, indicated Resident 30 had adequate ability to see and hear.A review of Resident 30's Care Plan, dated 1/29/26, indicated a communication board should be utilized to help Resident 30 express himself to staff and further facilitate effective communication ensuring his needs and preferences were clearly understood and addressed.During an observation on 3/9/26 at 10:54 a.m. in Resident 30's room, Resident 30 appeared anxious and wanted to communicate. Staff members did not utilize a communication board to assist Resident 30 in expressing his concerns at that time.During an observation on 3/9/26 at 12:28 p.m. during lunch time, Resident 30 asked the staff a question in Spanish while pointing to his tray. The staff member replied in English, did not clarify Resident 30's request and stated, just eat.During an observation on 3/12/26 at 12:56 p.m. in Resident 30's room, Case Manager (CM) attempted to wake Resident 30 for lunch. Resident 30 appeared startled and tried to communicate in Spanish. CM continued speaking in English and did not use a communication board to clarify whether Resident 30 wanted to eat then or later.During a concurrent observation and interview on 3/11/26 at 4:50 p.m. with Licensed Nurse (LN) 2 inside Resident 30's room, LN 2 confirmed a communication board was not available for the staff to use when interacting with Resident 30.During a concurrent interview and record review on 3/11/26 at 5 p.m. with the Social Services Director (SSD), Resident 30's care plan, dated 1/29/26 was reviewed. SSD confirmed staff were not given a communication board to help facilitate communications with Resident 30, despite the care plan indicated its use as an intervention tool to support effective communication between Resident 30 and the staff.During an interview on 3/11/26 at 5:15 p.m. with the Director of Nursing (DON), DON expected staff to follow the residents' plan of care to ensure consistent, effective care, minimize issues, and facilitate better communication between residents and caregivers.A review of the facility's policy titled, Translation and/or Interpretation of Facility Services, revised in 2017, indicated, This facility . will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility . The coordinator of this facility's language access program is the Director of Social Services . Staff shall be trained upon hire at least annually on how to provide language access services to LEP residents.

Based on observation, interview, and record review, the facility failed to accommodate the food preferences for one resident (Resident 110) of a census of 110, when [NAME] (C) 1 did not provide a protein substitute of similar nutritive value.This failure decreased the facility's potential to provide Resident 110 with an adequate protein substitute. Findings:A review of Resident 110's admission Record, indicated she was admitted to the facility in 2025 with diagnoses including diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and protein-calorie malnutrition (a severe nutritional deficiency caused by lack of sufficient protein intake, leading to muscle wasting and weight loss).A review of Resident 110's Order Summary Report, dated 8/30/25, indicated she was ordered a consistent carbohydrate diet (CCHO- a diet for managing blood sugar) with pureed texture and thin liquids consistency.A review of Resident 110's Care Plan Report, dated 2/16/25, indicated she was at risk for weight loss and malnutrition, and had several protein-based dislikes: chicken, turkey, and fish. Care plan further indicated to provide Resident 110 with appropriate protein alternatives when serving those meat dishes.A review of the facility's lunch menu, dated 3/11/26, indicated sweet and sour chicken for the main meat dish, with a substitute protein of buttered baked fish.During a concurrent observation and interview on 3/11/26 at 12:23 p.m. with Dietary Aide (DA) 1, DA 2, Registered Dietician (RD), and Interim Dietary Services Supervisor (IDSS), the residents' lunch plating and serving was observed. Resident 110's meal ticket (paper slip printed for resident's meal detailing diet orders, food allergies, and food preferences) indicated she disliked chicken, turkey and fish. Her plate contained only pureed corn and mashed potatoes with gravy. DA 1 placed a yogurt container on her tray. DA 2 stated the facility always gave Resident 110 yogurt as a protein substitute. RD stated Resident 110 needed an adequate protein alternative instead of yogurt. IDSS stated a vegetarian patty would be a suitable protein alternative for meat.During an interview on 3/11/26 at 1:44 p.m. with RD, RD stated the yogurt was an inadequate replacement for Resident 110's protein requirements, as the yogurt's protein amount was below the acceptable protein requirements for a meat substitute. RD confirmed a plant-based veggie patty or another meat alternative that Resident 110 liked should have been available and substituted instead of the yogurt.During a concurrent observation and interview on 3/12/26 at 8:34 a.m. with IDSS, IDSS examined the yogurt container that was served to Resident 110 for protein substitutes. The container indicated the contents of four ounces of raspberry yogurt provided three grams (g- a unit of measure) of protein. IDSS checked the vegetable patties package, which indicated one patty had seven g of protein.A review of the facility's policy titled, Food and Nutrition Services, revised October 2017, indicated, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special diet needs, taking into consideration the preferences of each resident.A review of the facility's policy titled, Substitutions, revised April 2007, indicated, The food services manager, in conjunction with the clinical dietician, may make food substitutions as appropriate or necessary . The food services manager will maintain an exchange list [a meal system that groups foods with similar nutrients (like protein) per serving, allowing items to be swapped to maintain consistent nutritional intake] . Residents' likes and dislikes will be considered when making substitutions.

Based on observation, interview, and record review, the facility failed to ensure call lights were available to use for two of 31 sampled residents (Resident 113 and Resident 121), when:1. Resident 113's call light was not within reach and not suitable to be used; and2. Resident 121's call light was not within reach.These failures decreased the facility's potential to assist residents in a timely manner when needed.Findings: 1. A review of Resident 113's admission Record, dated 3/17/26, indicated Resident 113 was admitted to the facility in July 2025 with diagnoses including multiple sclerosis (MS-a chronic, progressive disease damaging the nerve cells in the brain and spinal cord) and glaucoma (a group of eye diseases causing vision loss and blindness). During a concurrent observation and interview on 3/10/26 at 8:15 a.m. with Certified Nursing Assistant (CNA) 2 and Resident 113, Resident 113 was in bed and a regular call light was observed tied to the left bed rail. Resident 113 was unable to find the call light. Resident 113 explained left hand weakness, partial right hand contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion), and impaired vision. CNA 2 helped Resident 113 to hold the call light in right hand, but Resident 113 was unable to press the button to activate it. CNA 2 confirmed call light was not within reach, not appropriate, and did not meet Resident 113's needs. During an interview on 3/12/26 at 10:09 a.m. with the Administrator (ADM), ADM confirmed Resident 113's call light was not suitable to use with a partial contracture right hand and was not placed within reach. ADM expected staff to provide Resident 113 with a touch pad call light and to place it within reach. ADM stated call lights should be placed within residents' reach to meet their needs in a timely manner. 2. A review of Resident 121's admission Record, indicated he was admitted to the facility in February 2026 with diagnoses including acute respiratory failure (caused by a disease or injury that affects your breathing) and tracheostomy (surgically created hole in your windpipe to allow a tube to be placed to keep it open for breathing). During an observation on 3/9/26 at 8:34 a.m. and 10:31a.m., Resident 121's call light was not within his reach. During an observation on 3/9/26 at 12:43 p.m., a CNA was observed assisting Resident 121 and did not place the call light within his reach. During an interview on 3/12/26 at 9:19 a.m. with CNA 1, CNA 1 stated the call light needed to be within residents' reach, otherwise; they would not be able to call for help if needed. During an interview on 3/12/26 at 9:37 a.m. with the Director of Nursing (DON), DON confirmed Resident 121's call light was not within reach and expected call lights to be within reach, otherwise; residents will be unable to call for assistance if needed. A review of Resident 121's Care Plan Report, dated 2/26/26, indicated staff should ensure resident's call light is within reach . A review of the facility's undated policy and procedure titled, Call Light Policy and Procedure, indicated, . Provide for touch-sensitive call light if resident is contracture and not able to press the call light button . Keep call light within reach of the resident .

Based on interview and record review, the facility failed to ensure a copy of advance directive was obtained for one of 31 sampled residents (Resident 45), when a copy of advance directive was not available in Resident 45's medical records.This failure decreased the facility's potential to honor Resident 45's end-of-life wishes.Findings: A review of Resident 45's admission Record, dated 3/17/26, indicated Resident 45 was admitted to the facility in October 2024 with a diagnosis of nontraumatic subarachnoid hemorrhage (a life-threatening brain bleeding causing physical and mental disabilities). A review of Resident 45's Order Summary Report (OSR), dated 3/17/26, indicated an order to follow the code status per Physician Orders for Life-Sustaining Treatment (POLST-a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) instructions. During a concurrent interview and record review on 3/11/26 at 10:49 a.m. with Minimum Data Set Coordinator (MDSC), Resident 45's POLST and medical records were reviewed. MDSC confirmed Resident 45's POLST, dated 3/3/26, indicated an advance directive created on 3/24/21 was available. MDSC also confirmed a copy of Resident 45's advance directive was not available in the medical records. During an interview on 3/11/26 at 11:59 a.m. with the Director of Nursing (DON), DON confirmed a copy of advance directive was not present in Resident 45's medical records. DON expected staff to obtain a copy of advance directive from the resident or resident representative and to place it in the medical records. DON stated missing a copy of advance directive posed a risk of not honoring Resident 45's preferences and potentially violating resident's rights. A review of the facility's policy titled, Advance Directives, revised in September 2022, indicated, . If the resident or the residents representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff .

Based on observations, interviews, and record review, the facility failed to follow proper infection control practices for one of six sampled residents (Resident 1) when a contracted staff member provided care to Resident 1 without wearing a gown. This failure had the potential to increase the spread of infection for a census of 112. Findings:Resident 1 was admitted to the facility in February of 2026 with diagnoses that included Methicillin Resistant Staphylococcus Aureus Infection (MRSA, an infection caused by antibiotic resistant bacteria). A review of Resident 1's Physician Orders (PO), dated 2/9/26, indicated, CONTACT PRECAUTIONS [infection-control measures used in healthcare settings to prevent the spread of germs transmitted by direct or indirect contact with a patient or their environment. They require wearing gloves and a gown for all room interactions, dedicated equipment usage, and strict hand hygiene] SECONDARY TO DX: Saccral Wound Infection (MRSA) every shift.During a concurrent observation and interview on 2/19/26 at 8:46 a.m. with the Contract Phlebotomist (CP, a licensed healthcare professional who draws blood for lab tests), the CP was observed drawing blood on Resident 1 without having worn a gown. CP then left the room and began touching his phlebotomy equipment without changing his gloves or having performed hand hygiene and returned to Resident 1 to continue drawing blood. When asked about the contact precautions for Resident 1, CP was unable to state what constituted contact precautions and if a gown was required to provide direct care to Resident 1. After the interview, CP went into Resident 2's room to draw blood without cleaning his equipment.During an interview on 2/19/26 at 12:17 p.m. with the Infection Preventionist (IP), the IP confirmed Resident 1 is on contact precautions and, if staff come in and perform direct care such as a blood draw, they should wear a gown. The IP further indicated that wearing a gown during care for a resident on contact precautions was important to prevent the spread of infection to other residents. During an interview on 2/19/26 at 2:12 p.m. with the Director of Nursing (DON), the DON indicated that contact precautions should be followed by all staff including contracted staff. During a review of the facility P&P titled, Isolation - Categories of Transmission-Based Precautions, revised 10/18, the P&P indicated, Contact Precautions.Contact precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment.Staff and visitors will wear gloves (clean, non-sterile) when entering the room.While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage).Gloves will be removed and hand hygiene performed before leaving the room.Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed.

Based on observation, interview, and record review, the facility failed to protect one of three residents (Resident 1) from misappropriation of property, when Certified Nursing Assistant (CNA) 1 solicited and borrowed money from Resident 1, and used Resident 1's debit card for personal use. This failure resulted in Resident 1's emotional distress and loss of property. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted in 10/24/2024 with diagnoses which included anxiety disorder (excessive fear or worry that interferes with daily life to cause significant distress), depression (serious mental condition characterized by persistent sadness or loss of interest in activities), and limitation of activities due to disability. During a review of Resident 1's Activities Care Plan (ACP), revised 7/7/25, the ACP indicated, [Resident 1] has stated a preference for independent self-directed and group activities . During a review of Resident 1's Minimum Data Set (MDS - Federally mandated resident assessment tool), dated 11/25/25, the MDS indicated Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident with a scored range of 0-15,15 with no memory impairment) score of 14, which indicated intact cognition. During a review of Resident 1's Activities Progress Notes (APN), dated 1/22/26, the APN indicated, [Resident 1 verbalized feeling upset and concerned related to recent discovery of financial transactions.[Resident 1] discussed trust placed in CNA and acknowledged difficulty recognizing appropriate financial boundaries with staff. During a review of Resident 1's IDT (Interdisciplinary Team) Notes, dated 1/23/26, the IDT Notes indicated, On 1/22/26.[Resident 1] reported concerns regarding a sudden depletion of funds from her bank account. [Resident 1] stated she was informed by her bank that her account balance was low and expressed that her debit card may have been used inappropriately.Facility staff assisted the resident in reviewing her recent bank transactions.multiple transactions were identified associated with [delivery food services].[Resident 1] stated she is physically unharmed and expressed concern and temporary emotional upset related to the discovery of financial transactions .During the review, staff observed text message communications between the resident and [CNA 1]. During a review of Resident 1's APN, dated 1/23/26, the APN indicated, [Resident 1] stated she's still upset.Her feelings are hurt and she's disappointed in the situation. During a review of Resident 1's APN, dated 1/24/26, the APN indicated, [Resident 1] stated she was emotional, and upset.[Resident 1] stated she doesn't want to see the person the alleged incident is with. During a review of Resident 1's APN, dated 1/27/26, the APN indicated, [Resident 1] responded she is hurt and disappointed in herself and the alleged staff member in the alleged incident. She is finding it hard to understand why would someone do this. [Resident 1] stated it makes it hard to trust others to this point. During a review of Resident 1's APN, dated 1/28/26, the APN indicated, [Resident 1] is still upset .resident stated the alleged staff member has ruined her reputation with her bank. During a review of Resident 1's APN, dated 1/29/26, the APN indicated, [Resident 1] has been asleep all day .The writer has went bye (sic) the room multiple times throughout the day.The writer awoke the resident at last visit and [Resident 1] said she wanted to just sleep and did not feel up to doing anything today. During a review of the facility's investigation binder which included an emailed statement completed by Resident 1 dated 1/22/26, the statement indicated Resident 1 alleged CNA 1 accepted, borrowed, and solicited money from Resident 1, and stated I am physically okay but mentally upset.She's asked me at least five or six times. Resident 1 indicated CNA 1 used Resident 1's debit card without Resident 1's permission. The facility investigation document further confirmed text messages from CNA 1 to Resident 1 requesting money from Resident 1. During a review of Resident 1's Nursing Progress Notes (NPN) dated 1/26/26, the NPN indicated that Resident 1 was emotionally distressed, betrayed and depressed. Resident 1's NPN further indicated Resident 1 experienced sleep disturbances, social withdrawal and lack of interest in activities and remained mostly in her room. During a concurrent interview and record review on 2/10/26 at 9:20 a.m. with the Administrator (ADM), the facilities investigation binder was reviewed. The ADM stated Resident 1 allowed CNA 1 to use Resident 1's debit card to get money and buy her things. and loaned money to [CNA 1]. The ADM further stated Resident 1 was still expressing emotional distress, and the staff receiving money or gifts from residents was against company policy, and that CNA 1 was no longer employed with the facility. During a concurrent interview and record review on 2/10/26 at 2:24 p.m. with Resident 1 in Resident 1's room, Resident 1 reviewed her bank statements and stated CNA 1 had taken thousands of dollars from her bank via debit card and asked her for money via text messages and in person. Resident 1 stated she thought CNA 1 was her friend and sometimes CNA 1 mentioned she would need money because CNA 1 did not get paid until a certain time. Resident 1 stated, I let [CNA 1] use my card, but I never gave her permission to take money like this. Resident 1 stated she felt bad and dumb for giving CNA 1 her debit card and money. Resident 1 indicated she has remained mostly in her room. Resident 1 further stated she felt pressured and gave money to CNA 1 and was never told (by facility) not to give money to a staff. Resident 1's facial expression appeared sad during the duration of the interview. During an interview on 2/11/26 at 10:30 a.m. with Licensed Nurse 1 (LN 1), LN 1 stated, It is the expectation for staff not to ask for or receive money from residents and to follow proper reporting channels and asking a resident for money is a reportable incident. LN 1 further stated, It [asking and receiving money from residents] is not ok and falls in line with financial abuse. We [the facility] do have a protocol not to take money. During an interview on 2/11/26 at 12:37 p.m. with CNA 2, CNA 2 stated, Staff are trained not to take money from residents or buy resident gifts. CNA 2 taking money from residents is against the facilities abuse policy and not good for the residents. During a concurrent observation and interview on 2/11/26 at 12:48 p.m. with Resident 1 in Resident 1's room, Resident 1 was observed lying in bed with lights off. The cell phone text messages from CNA 1 to Resident 1 were reviewed. Resident 1 confirmed the text messages from CNA 1 showed CNA 1 requested money on 11/28/25, 11/29/25, 12/1/25, 12/11/25, 12/29/25,1/6/26,1/9/26 and 1/12/26. Resident 1 stated, I feel dumb for trusting her.still sad about it. During a review of Resident 1's APN, dated 2/12/26, the APN indicated, [Resident 1] was asking about clarification in regards to her debit card. She wanted to make sure her bank was sending her another bank card.[Resident 1] stated she is anxious about receiving her new card and rebuilding her relationship with her bank.building trust in people. During an interview on 2/12/26 at 10:14 a.m. with Social Services Assistant (SSA), the SSA stated Resident 1 was a very social person and after the reported incident with CNA 1, Resident 1 was somewhat depressed after the incident.was isolated in room, and stated, Staff taking or receiving money could be a possible abuse. During an interview on 2/12/26 at 11:05 a.m. with Director of Nursing (DON), the DON stated she expected staff not to borrow money or use residents' property. During a phone interview on 2/13/26 at 10:34 a.m. with CNA 1, CNA 1 confirmed she requested and received gifts and money from Resident 1. CNA 1 stated, I borrowed money from her a couple of times. I did ATM [automated teller machine] withdrawal and no one said I couldn't do that. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, revised 12/2016, the P&P indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.As part of the resident abuse prevention program, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) received adequate assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), when showers were not provided as scheduled. This failure had the potential to result in Resident 2 not attaining his highest practicable physical, mental and psychosocial well-being. Findings: During a review of Resident 2's admission record (AR), the AR indicated Resident 2 was admitted in late winter 2026 with diagnoses which included walking and mobility abnormalities, need for assistance with personal care, and heart failure. A review of Resident 2's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/26/26, indicated Resident 2 had no memory impairment and was totally dependent on shower transfer (getting in and out of shower/tub). A review of Resident 2's ADL care plan, initiated 1/28/26, indicated [Resident 2] has an ADL selfcare performance, and [Resident 2] is at risk for pressure injury development and skin breakdown, and skin discoloration should be noted during baths. A review of Resident 2's shower sheet, the facility was unable to provide a shower sheet for week 1/14/26, which indicated Resident 2 did not receive a shower that week. A review of Resident 2's shower sheet dated 1/22/26, indicated that Resident 2 had received 1 shower that week. A review of Resident 2's shower sheet dated 1/26/26, indicated that Resident 2 had received 1 shower that week. A review of Resident 2's shower sheet dated 2/2/26, indicated Resident 2 had received 1 shower that week. During an interview on 2/10/26 at 10:38 a.m. with Licensed Nurse 2 (LN 2), LN 2 indicated showers were expected to be provided two times per week and should be offered in the evening if resident was not available due to an appointment, and that showers helped residents feel better. LN 2 stated, Shower is important for overall health so [residents] don't get sick. During an interview on 2/11/26 at12:37 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated, Every resident is scheduled for bath twice per week.divided between am and pm shift. No residents are scheduled once per week unless they refuse and we document all refusals.skipped baths and refusals are informed to the nurse. We will try again and make a shower sheet. Everyone has a shower sheet. CNA 2 indicated that showers were important because they kept the resident clean and comfortable. During an interview on 2/11/26 at 11:30 a.m. with Resident 2 and Resident 2's family member (FM) in Resident 2's room, Resident 2 confirmed that he had missed multiple showers and stated that he felt dirty. Resident 2 stated, Sometimes I skip an entire week. Only get a shower. I did not request to get one shower a week. Prefer to get more than one. At home I normally take more than one shower a week. During an interview on 2/11/26 1:52 p.m. with the Assistant Director of Nursing (ADON), the ADON indicated that shower sheets were used to document all showers, and staff were expected to use them. The ADON confirmed showers were scheduled two times per week and staff were expected to document any refusals on the shower sheet and that showers were important for the dignity of the residents so they could feel good and clean. During a review of the facility's policy and procedure (P&P) titled, Abuse and Neglect-Clinical Protocol, revised 3/2018, the P&P indicated, .staff will institute measures to address the needs of residents to minimize the possibility of .neglect. During a review of the facility's P&P titled, Activities of Daily Living (ADLs), Supporting, dated 3/18, the P&P indicated, Residents will provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on interview and record review, the facility failed to ensure food allergies were honored for one of four sampled residents (Resident 1) when during the lunch meal on 12/21/2025 Resident 1 was served Banana Pie that contained a known allergen.This failure resulted in Resident 1 to have a potentially life-threatening allergic reaction.Findings:During a review of Resident 1's clinical record, Resident 1 was admitted in December 2025 with diagnoses that included chronic respiratory failure (a long-term condition where the lungs can't get enough oxygen in or remove enough carbon dioxide), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently), and oxygen dependence. Resident 1's allergies included banana causing anaphylaxis (severe, potentially life-threatening allergic reaction). During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/8/25, Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 1 had intact cognitive.During a review of Resident 1's nutritional assessment, dated 12/1/25, Resident 1's food allergies included banana.During a review of Resident 1's care plan, dated 12/1/25, the care plan indicated that Resident 1 has the potential for complications related to a history of allergic reactions/allergies. Resident allergic to . banana. Interventions included dietary department to review food allergy alerts.During a concurrent review of the facility menu for week three, December 15-21, 2025, and Resident 1's meal ticket for 12/21/25, the menu included banana cream pie for lunch and the meal ticket indicated Resident 1's allergy to banana.During a review of the Change of Condition (COC), dated 12/21/25, Resident 1 reported his throat was closing up after eating bananas. Licensed Nurse (LN) 2 documented Resident 1 was agitated and anxious due to anaphylactic episode, lungs with wheezing upon auscultation, short of breath, a flushed face, with hands on neck gesturing he is having a hard time to breathe. LN 2 documented the Medical Director ordered Epinephrine Injection (a life-saving medication used for the emergency treatment of severe allergic reactions (anaphylaxis) ) 0.3 milligrams (mg-a unit of measurement) intramuscular (IM- in the muscle) now for anaphylaxis. Resident 1 stated the banana dessert was on his lunch tray.During a concurrent review of physician orders, dated 12/21/25, and electronic medication administration record (eMAR) for 12/21/25, Resident 1 was administered Epinephrine 0.3 mg for anaphylaxis.During a review of the facility's kitchen document titled Duties and Responsibilities, undated, indicated that cooks one and two are responsible to tell the dietitian or supervisor for substitutions and alternate food for allergies. Dietary Aide three duties include ensuring all trays are correct per diet.During an interview on 12/29/25 at 1:28 p.m. with the Dietary Supervisor (DS), the DS stated each meal tray is checked against the list of resident allergies and the meal ticket in accordance with the cook and dietary aide job duties. The DS confirmed meal trays should not leave the kitchen with food items residents are allergic to. DS confirmed Banana Cream Pie was on the menu 12/21/25. DS stated she was not sure how Banana Cream Pie was served to Resident 1.During an interview on 12/29/25 at 2:15 p.m. with the Administrator (ADM), the ADM confirmed the expectation is not to serve resident foods they are allergic to. The ADM stated that an allergic reaction can range from a local reaction to life threatening reactions.During an interview on 12/29/25 at 2:23 p.m. with the Director of Nursing (DON), the DON stated the expectation for residents with food allergies is not to serve foods they are allergic to and for the process for checking trays is followed. The DON stated if aresident receives a food item that they are allergic to, and they experience an anaphylaxis reaction, they could die.During a review of the facility's Policy and Procedure (P&P) titled, Food Allergies and Intolerances revised August 2017, the P&P indicated, Residents with food allergies.Steps are taken to prevent resident exposure to the allergen(a) .

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from physical abuse when Resident 2 struck Resident 1 with her fist, hitting her on the left side of her forehead. This failure resulted in Resident 1's bruised left forehead and fear manifested by crying.During a review of Resident 1's admission Record (AR), dated 10/1/24, the AR indicated Resident 1 was admitted to the facility in late 2024 with diagnoses which included aphasia (a disorder that makes it difficult to speak), cognitive communication deficit and right-side body weakness. During a review of Resident 1's Physician's Orders (PO), dated 10/1/24, the PO indicated Resident 1 was incapable of making her own healthcare decisions.During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 11/5/25, the MDS indicated Resident 1 had no mood or behavioral symptoms of crying or verbalization of fear. During a review of Resident 1's hospital emergency department (ED) notes, dated 11/23/25, the ED notes indicated the chief complaint was assault with fist, hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) on forehead, had a bruise to the left forehead. During a review of the SBAR (Situation, Background, Assessment, Recommendations; a form used for urgent resident updates to communicate between healthcare professionals), and initial change of condition (COC) alert charting, dated 11/23/25, the SBAR indicated Resident 1 was punched by Resident 2 in the left side of her head with a closed fist. The SBAR also indicated Resident 1 manifested fear by crying after being struck by Resident 2. During a review of Resident 2's AR, dated 2/21/25, the AR indicated Resident 2 was admitted to the facility in early 2025 with diagnoses which included bipolar (mental health condition causing extreme mood swings) disorder and aggression. During a review of Resident 2's PO dated 2/21/25, the PO indicated Resident 2 was capable of making her own healthcare decisions and was her own responsible party. During a review of Resident 2's Nursing Care Plan (NCP), dated 3/21/25, the NCP indicated, [Resident 2] has demonstrated physical behavior r/t [related to] uncontrolled anger, poor impulse control.aggressive verbal and physical behaviors.assess and anticipate resident's needs, immediately separate any party members involved in confrontation. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had physical behavioral symptoms directed towards others that occurred daily. During a review of the SBAR and COC alert charting dated 11/23/25, the SBAR indicated Resident 2 punched Resident 1, made verbal threats, and displayed physical aggression. The SBAR and COC also indicated Resident 2 punched Resident 1 in the left side of her head with a closed fist. During an interview on 12/4/25 at 12:30 with the Director of Nursing (DON), the DON stated her expectation was that no resident should be hit and no one deserved to be hit. During a concurrent observation and interview on 12/4/25 at 12:52 p.m. inside Resident 1's room, Resident 1 was seated in her wheelchair with no distress. When asked if Resident 1 recalled someone who hit her forehead, she lowered her head to her left shoulder and cried but could not verbalize why she was crying. Resident 1 shook her head and flailed her hands when Resident 2's name was mentioned. During an interview on 12/4/25 at 1:13 p.m. with Certified Nurse Assistant 2 (CNA 2), CNA 2 confirmed Resident 2 hit Resident 1 with her fist. CNA 2 stated Resident 1 feared Resident 2 because Resident 2 cursed, yelled, shouted and said bad words. CNA 2 indicated Resident 1 did not want to stay in her room when Resident 2 was also inside the room and Resident 1 would cry when Resident 2 was present in the room. During an interview on 12/4/25 at 2:03 p.m. with the Social Services Director (SSD), the SSD indicated as reported, Resident 2 hit Resident 1 with her fist. The SSD confirmed Resident 2 was verbally abusive and could hit someone with her temper. SSD stated Resident 2 had this outburst of anger even with little things. SSD stated Resident 1 could not verbally express herself. SSD validated No one deserved to be hit, everybody should be equal here. The SSD indicated, because she was hit, Resident 1 could be traumatized, could be more scared and be more aloof. During an interview on 12/4/25 at 3:01 p.m. with the Administrator (ADM), the ADM indicated Resident 2 was a very difficult and complicated resident and as reported and witnessed by the nurse, Resident 2 hit Resident 1. The ADM stated, No one deserved to be hit, everybody had the right to be safe. During an interview on 12/9/25 at 1:49 p.m. with the Licensed Nurse (LN), the LN confirmed she witnessed Resident 2, with her fist, hit Resident 1 in her left temple. The LN confirmed that when the police came and spoke with Resident 1, Resident 1, because she could not fully verbalize, she demonstrated to the police and said hit, hit with her fist to indicate she was hit by Resident 2. The LN confirmed Resident 1 was very scared of Resident 2. LN stated Resident 1 and the other roommate did not want to stay in the room because of Resident 2. The LN confirmed Resident 2 screamed and yelled and when roommate or Resident 1 watched her television, Resident 2 screamed and said, Shut that television off. The LN confirmed this was the regular behavior of Resident 2, yelling, cursing, screaming at her roommates and striking staff who would come inside her room. The LN confirmed Resident 2 had become very abusive and even threatened the police officer when she was questioned about her hitting Resident 1. The LN indicated she was glad that Resident 1 and her roommate were safe now that Resident 2 was sent out for evaluation because of her very aggressive and abusive behavior, and stated, No one deserved to be abused or hit. During a review of the facility's Policy and Procedure (P&P) titled, Abuse Prevention Program, revised 2018, the P&P indicated, .Resident have the right to be free from abuse . this includes but is not limited to .physical abuse .as part of the abuse prevention program, the administration will protect our residents from abuse by anyone including other residents .

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from neglect, when the facility failed to provide urinary catheter care (a tube inserted into the bladder to drain urine) for 17 days; failed to assess and failed to monitor Resident 1's urine for signs and symptoms of infection for 17 days; and failed to assess for the cause of the resident's symptoms of not feeling well and lack of urine output until one day prior to Resident 1's need for hospitalization . These failures resulted in a delay in promptly identifying and treating Resident 1's urinary tract infection ([CONDITION(S)], an infection involving any part of the urinary system, including urethra, bladder, and kidney) resulting in the resident's transfer to an acute care hospital with septic shock (a life-threatening low blood pressure and organ failure caused by untreated infection). Resident 1 passed away less than 4 hours after arriving to the hospital. Findings: A review of the Admission Record indicated the facility admitted Resident 1 on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission nursing assessment, dated [DATE] at 6:11 p.m., indicated Resident 1 was admitted with an indwelling Foley (name of the catheter used to drain urine from the bladder). A review of Resident 1's admission Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], indicated the resident scored 10 out of 15 on a Brief Interview for Mental Status, where a score of 10 indicated moderately impaired cognitive status. Resident 1 required extensive assistance with bed mobility, toilet use, and personal hygiene. Under the Care Area Assessment (CAA) summary, the indwelling catheter was identified and directed the clinical staff to develop a care plan (a detailed personalized approach to care customized to the resident's concerns and needs and outlining the care and services needed to meet their needs). A review of the 48-hour Baseline Care Plan (a plan that contains the minimum health care information necessary to properly care for a resident immediately upon his/her admission), dated [DATE], indicated Resident 1 had an indwelling catheter. A review of the facility's policy titled, Acute Condition Changes - Clinical Protocol, dated ,d+[DATE], indicated, The physician will help identify individuals with a significant risk for having acute changes of condition during their stay; for example, an individual with an indwelling urinary catheter .or someone with unstable vital signs .In addition, the nurse shall assess and document/report the following .information: Vital signs . The policy indicated that the physician should be contacted regarding resident's change of condition by an adequately prepared nurse who has collected and organized .information, including the resident's current symptoms and status .The physician should request information to clarify the situation; for example, vital signs, physical findings .a description of symptoms .The physician will help the staff monitor a resident with a recent acute change of condition until the problem .has resolved or stabilized . A review of the acute hospital physician's transfer orders, electronically signed on [DATE], indicated Resident 1 was at high risk for readmission and instructed the staff to monitor and assess the resident's vital signs every shift. (Vital signs (vs) are measurements of the body's most basic functions). The five main vital signs routinely monitored by medical professionals include the following: body temperature, heart rate, respiratory rate (rate of breathing), blood pressure, and oxygen saturation level. VS are useful in monitoring medical problems and/or detecting a change of condition (COC). The transfer orders indicated the following: FOLEY [name of the catheter]/URINARY CARE ORDERS: diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The transfer orders documented a set of instructions for catheter care, which included performing hand hygiene when providing catheter care, changing the catheter if it was leaking or clogged, maintaining a closed drainage system to prevent the urine back up into the kidney, keep tubing free of loops or kinks, and empty the urinary bag every shift or if it was full. A review of Resident 1's Order Summary Report, dated [DATE]-[DATE], indicated the resident's physician was notified of the acute hospital admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .consequences. The facility's treatment orders set did not include the order for a urinary catheter and other orders related to urinary catheter care that were addressed in the hospital transfer orders. The clinical records for Resident 1 contained no documented evidence the nursing staff attempted to clarify with the facility physician the order for the urinary catheter and other orders related to urinary catheter care. A review of the facility's physician admission progress notes, dated [DATE], indicated, Patient has chronic urinary retention [difficulty urinating]. Will need [indwelling catheter] to be kept in place .Patient failed multiple voiding trials [a procedure to assess person's ability to empty bladder after removal of indwelling urinary catheter]. The physician indicated that during her visit, Resident 1 was optimistic to do therapy and get better. Under the general appearance the physician documented, Alert, oriented to person, place and time .soft voice .well hydrated .[indwelling catheter] draining clear yellow urine .Assessment and Plan: Patient receiving physical therapy, occupational therapy .Continue .plan of care. Monitor labs [laboratory, blood tests], monitor clinically . A review of Resident 1's clinical record contained no documented evidence the facility developed a personalized comprehensive care plan addressing the indwelling catheter, including catheter care each shift and monitoring resident for signs and symptoms of [CONDITION(S)]. A review of the nursing progress notes and daily nursing alert charting for Resident 1 for the period from [DATE] through [DATE], contained no notes indicating the resident had an indwelling catheter. During the 51 shifts of Resident 1's stay in the facility, one licensed nurse assigned to the resident on [DATE] morning shift documented that she performed catheter care and documented that color of Resident 1's urine was yellow. There was no documented assessment and no documented evidence of the monitoring of Resident 1's urine color, clarity, and odor which could have indicated the presence of infection with the exception of the morning shift on [DATE]. There was no documented evidence the facility assessed if Resident 1 had any discomfort associated with indwelling catheter, including distended bladder and/or burning sensation which could indicate of possible [CONDITION(S)]. A review of Resident 1's clinical records titled Bladder Continence, where Certified Nursing Assistants (CNAs) were required to document the resident's continence each shift, indicated that CNAs were not accurately documenting the resident's continence status. For the period from [DATE] until [DATE], there were 10 shifts where the CNAs documented that the resident was incontinent (unable to hold the urine) and on [DATE], there was no documentation at all. The flowsheet where the CNAs were required to document the amount of urine Resident 1 had in the catheter drainage bag each shift, indicated that on 11 shifts the CNAs did not measure the amount of urine and documented Not Applicable. During an interview with Resident 1's family member (FM) on [DATE], at 9:05 a.m., the FM stated her mother was admitted to the facility for physical and occupational therapy. The FM added, They [facility] totally neglected her .This didn't have to happen .Mom had plans to go home after she got stronger .she died from septic shock due to a [CONDITION(S)] within three hours of arriving to the ED [emergency department]. The FM stated that during her conversation with her mother, mother stated that nobody checked on her and it was extremely difficult to get hold of the staff when she needed help. The FM stated her mother's call light was not working and she had a hand bell, but nobody heard when she rang it because they [staff] shut the door so they couldn't hear when she rang her bell. The FM stated her mother had lost her voice and was whispering and could not call out for assistance. The FM became tearful and stated that one night her mother called her at night and whispered that her oxygen tubing fell off and she could not find it in her bed. The FM stated, I called the nursing station and asked them to send a nurse to check on my mother. The FM added, Mom told me she was without her oxygen for about 45 minutes until someone came to help her. The FM stated, Mom said she felt like a forgotten step-child in this place. The FM stated her mother had a catheter due to her urination issues, her blood sugar was very high, and one week before her death, she [Resident 1] started having symptoms of illness .She was getting sick .They didn't check on her . On [DATE], at 2:15 p.m., Resident 2 was interviewed regarding the facility issues with call lights. Resident 2's MDS, dated [DATE], indicated Resident 2 had no memory impairment and required extensive staff assistance with transferring, personal hygiene, and toileting. Resident 2 stated, Lots of issues with call lights .not working properly for months. They gave us these bells to call for help .Nobody hears them or just don't come. You sit and ring and wait, and ring and wait, and they don't come. Resident 1 stated he needed help from staff and at times he had to lay waiting to have his his incontinence briefs changed for hours. Resident 2 stated he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] .if they don't answer, I don't know what will happen. Resident 2 stated he talked to other residents and they had similar concerns regarding their call lights were not working or that the staff did not hear when they used their hand bells the facility provided to them. Resident 1 stated he complained to the leadership regarding issues with call lights/call bells answering. Resident 1 stated the facility administration kept saying that they were working on replacing the old call light system, but he has heard it for months and nothing has been done. On [DATE] at 4:05 p.m., Resident 3 was interviewed regarding the call lights issues in the presence of the Director of Nursing (DON). The Admission Records indicated Resident 3 was admitted to the facility in the fall of 2021 with [CONDITION(S)] and history of falls. Resident 3's MDS indicated the resident had no memory or cognitive impairment and required extensive staff's assistance for bed mobility, transferring, personal hygiene, and toileting. During a concurrent observation and interview, Resident 3 had her call light in front of her and a small hand bell was observed on the nightstand, behind the resident. Resident 3 stated, Call light [is] not working, [it is] useless. Never worked since I came. Came here 6 days ago .can't walk, need help. I can't reach the bell, but even if I ring it, have to wait a long time, an hour or more. Resident 3 explained that last night she waited to get help to be transferred into bed for ,d+[DATE] hours and nobody came. Resident 3 pointed to the call light and stated,Yes, I pushed my call light and rang a bell. A review of Resident 1's SBAR (Situation, Background, Assessment, and Review communication form used to aid in facilitating communication between facility's staff and physicians), dated [DATE], indicated at 8 a.m., resident experienced a change of condition (COC). The nurse documented that Resident 1 complained of not feeling well, weak, [blood] glucose level 411 (normal blood glucose level is ,d+[DATE]). The nurse documented that the resident had decreased oral intake. The SBAR documentation indicated that the resident's vital signs were not assessed during the documented COC. The resident's blood pressure and heart rate were not checked from 8 a.m., when the resident first complained of not feeling well until 9:31 a.m., and the temperature was not checked for another hour, until 10:34 a.m. The section for documenting [CONDITION(S)] changes, including questions if resident had nausea, vomiting, abdominal distention, or decreased urinary output were left blank. The assessment section directing nurses to describe the resident's condition, including signs of infection or any changes with mental, respiratory, gastrointestinal or urinary status change were left blank and the nurse documented it was N/A [not applicable]. There was no documented evidence of the assessment or description of the status of resident's catheter and the description of urine, including amount, color, and clarity. The nurse documented that the physician was made aware regarding the change of resident's condition at 1 p.m., 5 hours after resident's complained of not feeling well. The nurse documented that change of resident's condition was endorsed to the nurse working afternoon shift. A review of Resident 1's clinical records failed to contain evidence of follow up on resident's change of condition on [DATE], for the afternoon and night shift. There were no nursing progress notes indicating whether the resident was monitored and if her health status improved or worsened. The vs summary indicated that on [DATE], at 7:43 p.m., Resident 1's blood pressure (BP) was ,d+[DATE] mmHg (millimeters of mercury, unit of measurement), which was low for the resident (usually her blood pressure was above ,d+[DATE]). There was no documentation that resident's BP was monitored or rechecked at a later time and the physician was made aware of it. A review of Resident 1's urine output flowsheet (measurement how much urine the resident produced) indicated that on [DATE] at 2:25 a.m., (7 hours after the catheter drainage bag was emptied on [DATE], at 7:20 p.m.), no urine output was documented and the CNA entered Not Applicable. On [DATE], at 2:40 p.m., 19 hours after the bag was last emptied, no urine output was documented and the CNA documented Not Applicable. On [DATE] at 9:29 p.m., resident's catheter drainage bag was emptied and the CNA documented that Resident 1 had 100 ml of urine (milliliters, unit of measurement ). According to the flowsheet, Resident 1 did not produce any urine for over 26 hours (normal urine output is ,d+[DATE] ml in 24 hours). A review of Resident 1's nursing progress notes and alert charting from ,d+[DATE] - [DATE], failed to contain evidence the facility identified that resident had no urine output for over 26 hours, assessed the resident for a distended bladder or the production of urine at all, or that the catheter was clogged and was not draining the urine. There was no documented evidence Resident 1's physician was notified regarding the resident not having urine output for over 26 hours. A review of SBAR communication form, dated [DATE] at 9:23 a.m., indicated, Resident COC [change of condition] not improving, [resident] reports of nausea, appears diaphoretic [extremely sweaty], [CONDITION(S)] [rapid heart beats], c/o [complaining of] not hearing properly and poor appetite .Mental status change .confusion. The SBAR's section 4a., titled Notes (frequency of monitoring, issues, concerns) was blank. The SBAR documentation revealed that Resident 1's most recent documented temperature was taken on [DATE] at 10:34 a.m., which indicated that resident's temperature was not checked for 23 hours, the most recent heart rate and blood pressure were checked on [DATE] at 7:43 p.m., 13 hours prior, and the most recent respiratory rate was checked on [DATE] at 8:27 p.m., more than 12 hours prior to change of resident's condition on [DATE]. A review of the nursing progress notes, dated [DATE] at 10 a.m., indicated Resident 1 was transferred to the Emergency Department (ED) at the family request. A review of the transfer record, dated [DATE], completed by the resident's nurse prior to Resident 1's transfer to ED, indicated the resident was transferred due to change of condition. The transfer record failed to contain information regarding Resident 1's health condition during the transfer. Several sections for documenting resident's assessment, including temperature, pulse rate, respiratory rate, resident's ability to communicate, bowel and bladder control, and the date when the catheter was inserted were left blank. A review of the Resident 1's hospital ED nursing progress note, indicated the resident presented to ED on [DATE] at 10:42 a.m., with critically low blood pressure of ,d+[DATE] (normal range ,d+[DATE]), heart rate 103 (normal rate 60 to 80 beats per minute), and respiratory rate 22 (normal rate is ,d+[DATE] breath per minute). The ED physician's note, dated [DATE], revealed the following, Patient is notably [CONDITION(S)] [heart rate elevated] and hypotensive [low blood pressure] on arrival, given 1 L [liter] NS [Normal Saline, intravenous fluids] immediately for .shock [a widespread infection causing organ failure and dangerously low blood pressure] .Patient has an indwelling Foley .secondary to chronic urinary retention .Concern for possible [CONDITION(S)] [the body's life-threatening response to infection] versus septic shock [a widespread infection from unchecked [CONDITION(S)] causing organs shut down and death] possibly from urinary source as this appears very dirty. Unclear when [name of the catheter] was changed . A review of the Resident 1's laboratory results, dated [DATE], collected at 11:09 a.m., 27 minutes after coming to the ED, indicated the following abnormal results: WBC (white blood cell, indicative of infection) 50.5 K/uL, (thousands per cubic milliliter, unit of measurement; normal range 3.,d+[DATE].1 K/uL) Hgb (hemoglobin, a protein responsible for transporting oxygen in the blood) 6.5g/dL, (grams per deciliter, unit of measurement; normal range 11.5 -15 g/dL) URINALYSIS (urine test): Appearance, urine - turbid (cloudy, foamy; normal is clear) Color, urine - amber (normal color is yellow) Specimen source - catheter URINALYSIS, MICROSCOPY WBC, urine > (greater than) 182 HPF, (high power field, unit of measurement; normal (,d+[DATE]/HPF, increase in WBC may indicate the presence of infection) RBC, urine (red blood cell) 89 HPF, (normal range ,d+[DATE]/HPF) Bacteria, urine HPF 4+, (normal none) Squamous cell count (indicative of [CONDITION(S)]) 220 LPF, (low power field, unit of measurement; normal ,d+[DATE] LPF) [MEDICATION(S)], urine (a cloudy, thick, slimy substance) 4+ LPF, (normal none) A review of the ED physician note, dated [DATE], indicated that despite receiving several strong antibiotics and intravenous fluids, Resident 1's blood pressure continued dropping and her condition worsened. The physician documented, .Laboratory studies show evidence of septic shock, including severely elevated lactic acid at 5.9 mmol/L [millimoles per liter, unit of measurement; a chemical byproduct when a person's oxygen level gets low; levels get higher when person has severe infection, [CONDITION(S)], or septic shock], WBC 50 K [thousand, unit of measurement]; end -organ ischemia [a condition in which the blood flow and oxygen not coming to the organs] .Suspected site (s) of infection: urinary/renal .Patient has septic shock. The physician documented that Resident 1's condition progressively worsened and the resident expressed her wishes to be comfort care (a supportive care focused on comfort and emotional support rather than cure). The physician documented that at 1:45 p.m., Resident 1 was no longer responsive to verbal stimulus and had agonal breathing [gasping for air]. Very pale .bradycardic rhythm [slower than expected heart rate]. The physician documented, Patient [Resident 1] expired [passed away] at 2:10 p.m., which was less than four hours after arrival to ED. During an interview on [DATE], at 4:40 p.m., CNA 1 stated if the resident had an indwelling catheter, generally the CNA would inform the nurse if the resident's urine had odor, blood, or if there was little or no urine in the drainage bag. CNA 1 stated he could not remember if he was assigned to take care of Resident 1. During a concurrent interview and record review on [DATE], at 1:25 p.m., LN 1 stated he was familiar with Resident 1's care. When asked about the indwelling catheter, LN 1 stated Resident 1 was incontinent for bladder and bowel. LN 1 stated, I know for sure, I assessed her, she didn't have Foley when [she] came here .I'm pretty positive she came without a [catheter]. Upon reviewing Resident 1's clinical records, including bladder and bowel assessment and 48 hours baseline care plan, both dated [DATE], and admission MDS assessment, LN 1 acknowledged that Resident 1 was admitted with the indwelling catheter. LN 1 stated the facility should have clarified with resident's physician and obtained orders for the catheter, catheter care, irrigation or changing the catheter if clogged, and monitoring urine for complications every shift. LN 1 stated Resident 1 should have had a Risk for [CONDITION(S)] care plan with measurable interventions, but there was none. LN 1 confirmed there was no documentation that Resident 1's catheter care was done every shift and that her urine was monitored for color, clarity, and sediment for her entire stay in the facility. During a continuing interview [DATE] at 1:25 p.m., LN 1 was asked about the process of monitoring resident for COC. LN 1 stated that during the COC, obtaining resident's vital signs (VS) were the first things that the nurse should be checking and continue monitoring VS frequently. LN 1 stated the nurse should assess resident's catheter frequently and check the amount, color, and clarity of urine and notify the physician if there was no urine output. During an interview on [DATE], at 2 p.m., LN 2 stated catheter care included cleaning the resident's perianal area with soap and water every shift, monitoring and documenting urine output every shift, and informing the physician if there was no urine output. During a concurrent interview and record review on [DATE] at 2:50 p.m., LN 3 stated she was familiar with Resident 1 and took care of her frequently. LN 3 stated she took care of Resident 1 on [DATE], on the evening shift and the [DATE] night shift. LN 3 confirmed that on [DATE], Resident 1's BP of ,d+[DATE] was abnormally low. LN 3 stated she did not notify the physician because the resident's other VS were ok. When LN 3 was questioned regarding the catheter, LN 3 stated, I can't remember if she had it [catheter]. LN 3 stated nursing documentation should indicate if the resident had the catheter and include the urine description, but was unable to find any documentation addressing the catheter and/or urine description. When LN 3 was asked if she assessed Resident 1's urine output on [DATE], LN 3 stated, Nobody reported to me she [Resident 1] had no urine. LN 3 confirmed that Resident 1's vital signs were not monitored the entire night shift on [DATE]. During a concurrent interview and record review on [DATE] at 12:25 p.m., the Director of Staff Development (DSD) acknowledged there was no nursing documentation indicating that Resident 1's change of condition was closely monitored on the evening shift of [DATE], and the night shift of [DATE]. The DSD confirmed there was no frequent vital signs documentation and added, I would expect resident was assessed, I hope she was monitored closely . A review of the facility's policy titled, Catheter Care, Urinary, dated ,d+[DATE], indicated, The purpose of this procedure is to prevent catheter-associated urinary tract infections .Review the resident's care plan to assess for any special needs of the resident .Observe the resident's urine level for noticeable increases or decreases .Maintain an accurate record of resident's daily output .Empty the collection bag at least every eight (8) hours .Check the resident frequently .Observe the resident for complications associated with urinary catheters .Check the urine for unusual appearance .Observe for other signs and symptoms of urinary tract infection .Report findings to the physician or supervisor immediately . The policy provided instructions for the catheter cleaning and directed the staff to document: The date and time the care was given. The name and title of the individual (s) giving the catheter care. All assessment data obtained when giving catheter care .Character of urine such as color (straw-colored, dark, or red), clarity, solid particles, or blood), and odor .Any problems noted .during the perianal care. A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated ,d+[DATE], indicated, A comprehensive, person-centered care plan that includes measurable objectives .to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The interdisciplinary team (IDT) .in conjunction with the resident and his/her family .develops and implements .person-centered care plan for each resident .The comprehensive, person-centered care plan will: include measurable objectives .describe the services that are to be furnished to attain or maintain the resident's highest practicable .well-being .incorporate identified problem areas .incorporate risk factors .reflect treatment goals .aid in preventing or reducing decline in the resident's functional status. During a concurrent interview and record review on [DATE], at 2:15 p.m., the Director of Nursing (DON) stated Resident 1 was well monitored and when the resident's physician saw the resident on [DATE], nothing was wrong with [Resident 1]. The DON confirmed that according to the nursing documentation, Resident 1 started having COC on [DATE] at 8 a.m., but her blood pressure and heart rate were not checked for 1 hour and 30 minutes, the temperature and respirations were not checked for 2 hours and 34 minutes, and oxygen saturation level was not checked until 2:24 p.m., more than 6 hours after resident's complaining of not feeling well. The DON stated during COC, vital signs could indicate what was wrong with the resident and should be monitored more often, at least every 4 hours until resident's condition improved. The DON was unable to find documentation that resident's vital signs and health condition were monitored frequently and acknowledged that the resident did not get better and had to be sent to the hospital in the morning of [DATE]. The DON reviewed resident's clinical records, including SBAR documentation dated [DATE] and [DATE] and was unable to find any documentation that resident had her catheter care done every shift and that her urine was assessed and monitored for [CONDITION(S)]. The DON stated Resident 1 should have had a comprehensive care plan addressing her increased risk for [CONDITION(S)]. The DON stated the purpose of the care plan was to guide the care for resident and to ensure that the resident had the right care for that specific condition. The DON stated he could not find the documentation that the nursing staff clarified and obtained the order for catheter or other catheter-related orders and that the care plan addressing the indwelling catheter was developed. The DON confirmed that Resident 1's clinical records did not contain documentation that her urine output was monitored accurately. The DON did not answer when asked if the nurses identified and reported to resident's physician that resident had no urine for over 26 hours.

Based on observation, interview, and record review, the facility failed to ensure all direct care staff were fit tested annually and upon hire, and provided with the appropriate N95 respirators for use during the care of vulnerable residents in the midst of a facility wide outbreak of COVID-19 (a serious virus that can lead to [CONDITION(S)], hospitalization and death) for a census of 92. This failure placed residents at immediate risk of serious illness or death due to the potential exposure to the COVID-19 virus during a facility wide outbreak where 15 residents and 6 facility staff were positive for COVID-19 at the time of the onsite visit. Findings: During the entrance conference with the Assistant Director of Nursing (ADON) and the Infection Preventionist (IP) on 11/17/21 starting at 8:09 a.m., the IP stated the facility had 15 COVID-19 positive residents in house and 6 positive staff excluded from work. In a concurrent observation and interview on 11/17/21 at 8:52 a.m., the Licensed Nurse (LN) had an N95 and face shield on. The LN stated she was assigned to take care of the residents in the COVID unit. In an interview on 11/17/21 starting at 10 a.m., the Certified Nursing Assistant (CNA) stated she was fit tested for the N95 last year (2020) and she was provided with the N95 respirator available in the facility. In an interview on 11/17/21 starting at 10:35 a.m., the LN stated she was not sure if she was fit tested for the N95. In an interview on 11/17/21 at 12:47 p.m., the Director of Staff Development (DSD) stated there was no N95 fit testing conducted for facility staff in 2021. The DSD further stated the staff were provided with the available N95 supply and not the N95 model the staff were fitted with in 2020. In a concurrent interview and record review on 11/17/21 at 1:17 p.m., the Director of Nursing (DON) stated the fit testing for staff was conducted between May to December 2020. The DON was not able to provide any documented evidence that staff were fit tested in 2021. The facility was unable to provide documentation of staff being provided with the N95 model based on the previous fit testing result. In a follow-up interview on 11/17/21 at 1:46 p.m., the DON stated fit testing should be conducted for newly hired employees and annually. The DON further stated the facility had no policy and procedure for fit testing. In an interview and record review on 11/17/21 at 1:50 p.m., the CNA confirmed the N95 she was currently wearing was provided by the facility. The CNA had a record of a N95 fit test on 6/3/20 and the N95 the facility provided was not the same model of N95 the CNA was fit tested for 17 months ago. The CNA had no record of a fit test for 2021. This finding was confirmed by the DON. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy (IJ, a situation that has threatened or is likely to threaten the health and safety of residents) situation on 11/17/21 at 4:39 p.m. due to the facility's failure to ensure all direct care staff were fit tested annually and upon hire, and provided with the appropriate N95 model respirator for use during the care of vulnerable residents in the midst of a facility wide outbreak of COVID-19. An immediate Plan of Correction (POC) was presented by the facility to the Department which included immediate scheduling of fit testing for all staff and provision of the appropriate N95 models for staff to use during direct resident care. In a concurrent interview and record review on 11/17/21 starting at 7:25 p.m., the DON provided a master list of the newly hired staff showing 136 newly hired staff for 2021. The DON confirmed the newly hired staff from January to November 2021 were not fit tested upon hire and/or rehire. Review of All Facilities Letter 20-15.1 indicated Employers of healthcare and social services workers should follow Centers for Disease Control and Prevention (CDC) guidance and Cal/OSHA regulations for employee respiratory protection when providing direct patient care. This includes, if available, use of a NIOSH-certified respirator at least as protective as an N95 filtering facepiece respirator for routine care of suspected or confirmed COVID patients . According to the Respiratory Protection Information Trusted Source .The Occupational Safety and Health Administration (OSHA) .requires respirator users to be fit tested to confirm the fit of any respirator that forms a tight seal on your face before using it in the workplace. Fit testing is important to ensure expected level of protection is provided minimizing the total amount of contaminant leakage into the face piece through the face seal. https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/respsource3fittest.html A review of OSHA's Respiratory Protection Guidance indicated, .PPE [personal protective equipment], including respirators, will be needed for workers when close contact with someone who is known or suspected of having COVID-19 cannot be avoided. Whenever respirators are required, employers must implement a written, worksite-specific respiratory protection program (RPP), including medical evaluation, fit testing, training, and other elements, as specified in OSHA's Respiratory Protection standard .Ensure that any worker using a tight-fitting respirator (N95) is fit-tested prior to initial use of the respirator, whenever a different respirator size, style, model or make is used, and at least annually thereafter. Passing a fit-test is important because it ensures that the size, make, and model of the respirator can provide a proper facial seal to offer the expected level of protection to the wearer. https://www.osha.gov/sites/default/files/respiratory-protection-covid19-long-term-care.pdf The facility's immediate POC was accepted by the Department on 11/17/21 at 7:43 p.m. and the IJ was lifted on 11/19/21 at 3:55 p.m. after sufficient evidence was provided to ensure all direct care staff had been fit tested and provided with an appropriate model of N95 respirator.