Every finding on record at Rosewood Post Acute

Based observation, interviews, and record review, the facility failed to ensure infection prevention and control practices were followed for five of six sampled residents (Residents 1, 2, 3, 4, and 5) when:1. Two soiled dressings were observed on Resident 1 and Resident 2's nightstands during two separate occasions.2. One licensed nursing staff member failed to clean and disinfect the glucometer (a handheld device used to measure a person's blood sugar level) after using it for Resident 3 and subsequently used the same contaminated device for Residents 4 and 5 without sanitizing it.These failures had the potential to increase the risk of bacterial transmission, expose residents to cross-contamination (germs are accidentally transferred from one person, object, or surface to another person or surface), and result in infection. A review of Resident 1's admission Record (AR), printed on 8/4/26 indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses of stroke, gastrostomy (a medical device inserted through the abdominal wall directly into the stomach. It is used for people who can't eat or swallow food normally, allowing for direct delivery of nutrition, fluids, and medications into the stomach) status, respiratory failure (lungs are not working well enough to provide the body enough oxygen), and dependence on respirator (also call ventilator, a machine that helps a person breath when they cannot breathe on their own).A review of Resident 1's facility document, Order Summary Report (OSR), indicated physician orders to clean gastrostomy tube (GT) site with normal saline (salt-water solution) and cover with T-drain (a 4x4 inch gauze dressing with a slit cut from the edge to the center) dressing every day and to change the tracheostomy (a surgical procedure where the doctor makes an incision in the front of neck to create an opening into the trachea) dressing every shift.A review of Resident 2's AR, printed on 8/4/26 indicated that Resident 2 was admitted to the facility on [DATE] with diagnoses of stroke, gastrostomy status, respiratory failure and tracheostomy status.A review of Resident 2's facility document OSR indicated physician orders to change GT dressing every day and to change tracheostomy dressing every shift.A review of Resident 3's AR printed on 8/4/26 indicated that Resident 3 was admitted to the facility on [DATE] with a diagnosis of Diabetes Mellitus (DM, a condition that blood sugar is too high).A review of Resident 3's facility document OSR indicated a physician order to administer insulin (medication used to decrease blood sugar) according to the resident's blood sugar level before meals and at bedtime.A review of Resident 4's AR printed on 8/4/26 indicated that Resident 4 was admitted to the facility on [DATE] with a diagnosis of DM.A review of Resident 4's facility document OSR indicated a physician order to administer insulin according to the resident's blood sugar level before meals and at bedtime.A review of Resident 5's AR printed on 8/4/26 indicated that Resident 5 was admitted to the facility on [DATE]with a diagnosis of DM.A review of Resident 5's facility document OSR indicated a physician order to administer insulin according to the resident's blood sugar level before meals. The order also specified that insulin should be withheld if the resident skips a meal or if the blood sugar level is less than 100mg/dl.During a concurrent observation and interview on 8/3/26 at 10:27 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 1's room, a T drain dressing with a small amount dried, dark-brown matter at the center was observed lying on the top of the nightstand next to an opened oral suction device (Yankauer, a rigid plastic suction tube used to remove saliva, mucus, or other fluids from a person's mouth). LVN 1 removed the soiled dressing and stated that it should be tossed in the trash can immediately. LVN 1 further stated that leaving soiled dressing on the nightstand could potentially cause contamination of other equipment, including the suction machine, nebulizer, and Yankauer.During a concurrent observation and interview on 8/3/26 at 12:18 p.m. with LVN 2, in Resident 2's room, a T drain dressing with a small amount of dried, dark-brown material at its center was observed on the nightstand, positioned between the suction machine and the nebulizer. LVN 2 removed the soiled dressing and explained that soiled dressings should be disposed of in the trash can immediately after removal from the patient.During an observation on 8/3/26 at 12:22 p.m., LVN 3 was observed exiting Resident 3's room wearing gloves and holding a glucometer. Without sanitizing and disinfecting the glucometer, LVN 3 placed the glucometer in a black rectangular basket containing alcohol pads, lancets and a bottle of blood glucose (BG) test strips. After removing their gloves, LVN 3 recorded the BG result into the computer and proceeded to Resident 4's room to check BG using the same unsanitized glucometer. LVN 3 took the unsanitized glucometer into Resident 4's room and placed it on Resident 4's bed, by their side. After checking the BG and removing the test strip from the glucometer, LVN 3 returned the contaminated glucometer to the black basket located on the top of the medication cart without sanitizing. LVN 3 then proceeded to Resident 5 to continue BG checks using the same glucometer previously used for Resident 3 and 4 without sanitizing.During an interview on 8/3/26 at 12:28 p.m., LVN 3 stated they were unaware that the glucometer should be cleaned and disinfected after each use, especially when it is used for multiple residents.During an interview on 8/3/26 at 2:44 p.m. with the Infection Preventionist (IP), the IP stated that all soiled dressings, whether heavily soiled or not, should be disposed of in the red biohazard bag. The IP stated leaving soiled dressings on the nightstands poses a risk for transmitting bacteria, especially among residents who are medically complex, such as residents with tracheostomy, on dialysis, or receiving tube feeding. IP stated the glucometer must be cleaned and disinfected with specific wipes after each use to prevent cross-contamination.During a review of the facility's Policy and Procedure (P&P), titled Dressing, Soiled/Contaminated, no revision date, stated Disposable items such as bandages, applicators, gauze pads, etc , that are soiled or contaminated with infective material, blood, or body fluids must be placed in a plastic bag and removed from the resident's room upon completion of any procedure. No. 2. Soiled dressings that are not heavily soiled with exudate may be placed in a plastic bag and placed in regular waste.During a review of the facility's P&P, titled Glucometer Cleaning, no revision date, indicated All glucometers that will be shared by multiple patients will be thoroughly wiped with disinfectant and allowed to air dry after each use and between every patient.

Based on observation, interview and record review the facility failed to ensure one of three residents (Resident 1) maintained an acceptable weight. This failure resulted in Resident 1 having a 20.6 % weight loss.During a review of Resident 1's admission Record (AR), dated 5/8/26, the AR indicated Resident 1 was admitted from an acute care hospital where Resident 1 was treated after sustaining several fractured bones. During a review of Resident 1's Multi Data Set (MDS- an assessment tool used to plan a resident's care) Section C - Cognitive Patterns, dated 4/30/26, MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS - an assessment which measures thinking ability) received a score of 6 out of a possible 15, which indicated impaired thinking ability. During an interview on 5/5/26 at 9:15 a.m. with Resident 1, Resident 1 stated, Resident 1 often did not feel like eating. Resident 1 stated, the food was not bad, she just did not feel like eating. Resident 1 also stated, staff brought her food that she requested to eat. During an interview on 5/5/26, 2026 at 10:55 a.m. with Registered Dietitian (RD), RD stated, Resident 1 lost a lot of weight. RD stated, Resident 1 was very anxious and this anxiety caused her to burn up more calories than she took in. RD stated, Resident 1 was on 1:1 staffing during meals, a fortified diet, nutritional supplements and daily weights.During an interview on 5/5/26 at 11: 20 a.m. with Restorative Nursing Assistant 1 (RNA- a certified nursing assistant who has received specialized training to help patients recover, maintain physical mobility and prevent physical decline through therapeutic rehabilitation) RNA 1 stated, RNA 1 worked with Resident 1 four days a week. RNA 1 stated, RNA 1 stayed with Resident 1 during breakfast and encouraged her to eat. RNA 1 stated, Resident 1 fed herself, ate small amounts and at times refused meals. RNA 1 stated, Resident 1 was often very anxious. During an interview on 5/5/26 at 11:58 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 1 was highly anxious. LVN 1 stated, Resident 1's anti- anxiety medication, Buspar, had not been very effective, but seemed to be more effective since a recent dose increase. LVN 1 stated, Resident 1 continued to refuse some meals and also did not eat all of the meals Resident 1 did eat. LVN 1 stated, the staff helped Resident 1 by setting up her meals and remaining with her and giving her encouragement while she ate. LVN 1 also stated, staff asked Resident 1 what she wanted to eat when she refused meals or ate a small amount and would obtain what she wanted from the kitchen.During an interview on 5/5/26 at 12:18 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated, Resident 1 continued not eating all of her meals. CNA 1 stated, Resident 1 ate small amounts and continued to refuse food, even with a lot of encouragement to eat. During an interview on 5/5/26 at 1:40 p.m. with Director of Nursing (DON), DON stated, Resident 1's anxiety was treated with anti-anxiety medication. DON stated, Resident 1 had not been evaluated or treated by a mental health professional. DON stated, Resident 1 had not been seen by a mental health professional regarding Resident 1's anxiety.During an interview on 5/13/26 at 8:53 a.m. with Social Service Director (SSD), SSD stated, there had been no discussion with the family regarding artificial feeding and the use of a feeding tube. During an interview on 5/15/26 at 8:58 a.m., with RD, RD stated, no discussion of artificial nutrition, including use of a feeding tube had occurred. RD stated, Resident 1 would be at increased risk of aspiration with a NG tube (a tube that is inserted through the nose down into the stomach and is used for feeding liquid formula) and therefore, would need a gastrostomy tube (a tube surgically inserted into the stomach that is used for feeding liquid formula), which needed to be put in the stomach during a surgical procedure. RD also stated, Resident 1 was able to swallow and therefore, a feeding tube had not been considered. During an interview on 5/15/26 at 12:21 p.m. with DON, DON stated, artificial nutrition via a feeding tube was not considered as an intervention for Resident 1 because Resident 1 could swallow. DON stated, the physician was referring Resident 1 to mental health due to her anxiety. During a review of Resident 1's POLST, dated January 30, 2026, the POLST indicated, Attempt Resuscitation .Full Treatment . Trial period of artificial nutrition, including feeding tubes . During a review of Resident 1's Weights and Vitals Summary (WVS), dated May 8, 2026, WVS indicated, Resident 1 weighed as follows: 106 pounds (lbs.) on 1/31/26, 95.8 lbs. on 2/28/26, 90.4 lbs. on 3/31/26, 85.8 lbs. on 4/30/26 and 84.8 lbs. on 5/7/26. WVS also indicated, 05/05/2026 . -7.5% change [Comparison weight 02/04/2026. 106.6 lbs. -20.6%, -22lbs] MDS: -5% change over 30 day(s) [Comparison Weight 04/04/2026, 90 lbs., -5.6% -5lbs]. During a review of an email, dated 5/18/26, from admission Assistant (AA), email indicated, Resident 1 weighed 83.2 lbs. on 5/18/26. During a review of Resident 1's Order Listing Report (ORD 1), dated 04/01/2026 - 04/30/2026, ORD 1 indicated, 1:1 feeder with all meals .Revision Date 04/29/2026.During a review of Resident 1's ORD 1, ORD 1 indicated, buspirone HCL (medication used to treat anxiety) Oral Tablet 5 mg (Buspirone HCL) Give 10 mg by mouth one time a day for Anxiety for 3 days . Revision Date 04/27/2026.During a review of Resident 1's ORD 1, ORD1 indicated, buspirone HCL Oral Tablet 5 mg (Buspirone HCL) Give 5 mg by mouth three times a day for anxiety until 04/27/2026 . Revision Date 04/27/2026.During a review of Resident 1's ORD 1, ORD 1 indicated, buspirone HCL Oral Tablet 5 mg (Buspirone HCL) Give 5 mg by mouth two times a day for anxiety for 3 days . Revision Date 04/27/2026.During a review of Resident 1's Order Listing Report (ORD 2), dated 05/01/2026 - 05/31/2026, ORD 2 indicated, BusPIRone HCL Tablet 5 mg Give 2 tablet by mouth every 8 hours for anxiety.During a review of Resident 1's Medication Administration Record ([DATE]) dated, 3/1/26 to 3/31/26, [DATE] indicated, Resident 1 received a regular diet with thin liquids from 1/31/26 to 3/23/26.During a review of Resident 1's [DATE], [DATE] indicated, Resident 1 received Ensure after meals if Resident 1 ate less than 60% of meals starting 3/20/26 at 0900 and ended 3/23/26 at 2029.During a review of Resident 1's [DATE], [DATE] indicated, Resident 1 received Ensure after meals - 4 ounces house supplement/MedPass 2.0 with meals starting 2/28/26.During a review of Resident 1's Medication Administration Record ([DATE]), dated 4/1/26 to 4/30/26, [DATE] indicated, Resident 1 was ordered to have 1:1 staffing during meals starting 4/29/26.During a review of Resident 1's [DATE], [DATE] indicated, Resident 1 was ordered to have a regular fortified diet with thin liquids and health shakes starting 3/24/26.During a review of Resident 1's [DATE], [DATE] indicated, Resident 1 received 4 ounces of House Supplement (high protein and calorie liquid meal supplement) after meals and MedPass 2.0 (fortified nutritional shake) six ounces starting 4/24/26 0900.During a review of Resident 1's [DATE], [DATE] indicated, Resident 1 received House Supplement and MedPass2.0 six ounces at 2 p.m. and bedtime starting 4/28/26 1700.During a review of Resident 1's [DATE], [DATE] indicated, Resident 1 received Pro-stat Oral Liquids (protein supplement) 30 ml by mouth three times a day on trays starting 4/4/26. During a review of Resident 1's [DATE], [DATE] indicated, Resident 1 was ordered to receive Lorazepam (a medication used to treat anxiety) 0.5 mg tablet by mouth as needed every eight hours for anxiety from 1/30/26 through 3/25/26. MAR indicated, Resident 1 received the Lorazepam as follows: 3/1/16 - 2 doses; 3/2/26 -1 dose; 3/3/26 - 3 doses; 3/4/26 - 2 doses; 3/5/26 - 3 doses; 3/6/26 - 1 dose; 3/7/26 - 3 doses; 3/8/26 and 3/9/26 - 2 doses; 3/10/26 - 3 doses; 3/11/26 and 3/12/26 - two doses; 3/13/26 and 3/14/26 - three doses; 3/15/26 through 3/17/26 - two doses; 3/18/26 and 3/19/26 - two doses; 3/20/26 - three doses; 3/21/26 - two doses; 3/22/26 - three doses; and no doses on 3/23/26 and 3/24/26.During a review of Resident 1's [DATE], [DATE] indicated, Resident 1 received Buspirone HCL 5 mg tablet by mouth two times a day, for anxiety, starting 3/25/26 at 1700 and ending 3/28/26 at 2100.During a review of Resident 1's [DATE], [DATE] indicated, Resident 1 received Buspirone HCL 5 mg tablet by mouth three times a day, for anxiety, starting 3/29/26 at 0900.During a review of Resident 1's [DATE], [DATE] indicated, Resident 1 received Buspirone HCL 10 mg by mouth once a day for three days for anxiety, starting on 4/28/26.During a review of Resident 1's [DATE] and 2, [DATE] and 2 indicated, Resident 1 received Buspirone 5mg by mouth three times a day for anxiety from 3/29/26 through 4/27/26.During a review of Resident 1's [DATE], [DATE] indicated, Resident 1 received Buspirone HCL 5 mg by mouth twice a day for anxiety from 4/28/26 through 4/30/26.During a review of Resident 1's SBAR Communication Form (SBAR 1), dated 3/18/26, SBAR 1 indicated, Resident 1 weighed 92 pounds (lbs.) on 3/18/26. SBAR 1 indicated, notified Kaiser MD by fax waiting for orders.During a review of Resident 1's SBAR Communication Form (SBAR 2), dated 4/3/26, SBAR 2 indicated, Resident 1 weighed 88.8 (lbs.) on 4/3/26. SBAR 2 indicated, primary care clinician notified refer to RD.During a review of Resident 1's SBAR Communication Form (SBAR 3), dated 5/1/26, SBAR 3 indicated, Resident 1 weighed 85.8 lbs. on 4/30/26. SBAR 3 indicated, primary care clinician notified refer to RD.During a review of Resident 1's SBAR Communication Form (SBAR 4), dated 5/5/26, SBAR 4 indicated, Resident 1 weighed 84.6 lbs. on 5/4/26. SBAR 1 indicated, primary care clinician notified will send to Kaiser advise.

Cross Reference F689Based on interviews and record reviews, the facility failed to report Resident 1's elopement to the California Department of Public Health (CDPH). During the incident, the resident suffered a left knee laceration but was unable to explain how it occurred.This failure had the potential to put the resident's safety at risk and delay the investigation of CDPH. On 5/28/26 at 12:10 p.m., an unannounced visit was conducted at the facility to investigate a complaint. During a review of Resident 1's Departmental Notes indicated that the resident was discovered missing on 5/25/26 at approximately 5:00 a.m. and was later located at the 7-Eleven store across the street from the nursing home at 5:30 a.m. During an interview on 5/28/26 at 1:44 p.m. with Registered Nurse (RN) 1, RN1 stated on 5/25/26 at 5:00 a.m., the facility staff was unaware that the resident had left the building and explained that the front lobby door automatically allowed anyone inside to exit. RN1 also added, the resident was found at 5:30 a.m. by Certified Nursing Assistant (CNA 1) in the 7-eleven store across the street and when he assessed the resident, the resident had a left knee skin laceration and was unable to explain how he obtained the laceration.A review of Resident 1's Face sheet indicated that the resident was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, muscle weakness and cognitive communication deficit (cerebral infarction is medical term for stroke meaning when blood flow to the brain is stopped causing brain injury, cognitive communication deficit means someone struggles to communicate effectively, because their brain has trouble processing or organizing information. It affects a person's ability to pay attention, remember details, reason, and understand social cues).During a review of Resident 1's MDS (an assessment tool) dated 5/8/26 under Section C, it indicated Resident 1's cognition was severely impaired. During an interview on 5/28/26 at 4:07 p.m. with the Director of Nursing (DON), the DON stated that Resident 1's elopement incident should have been reported to the department. During an interview on 5/28/26 at 4:43 p.m. with the Administrator (Adm), ADM stated Resident 1 eloped on 5/25/26 and stated the incident of elopement was not reported to the department.During a review of the facility's policy and procedure (P&P) titled, Accidents and incidents investigating and reporting, dated 2001, the P&P indicated, Policy Statement: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator.S483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

Cross Reference F609Based on interview and record review, the facility failed to provide adequate supervision when Resident 1 eloped from the facility.This failure had the potential to put the resident's safety at risk. A review of Resident 1's Departmental Notes indicated that the resident was discovered missing on 5/25/26 at approximately 5:00 a.m. and was later located at the 7-Eleven store across the street from the nursing home at 5:30 a.m.During an interview with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 5/25/26 at 5:00 a.m., Resident 1 was missing from the facility. CNA 1 stated the resident was last seen lying in bed in his room at approximately 4:30 a.m. CNA 1 further stated that at 5:30 a.m., she found the resident inside the 7-Eleven store across the street from the facility sitting in a wheelchair and Resident 1 told CNA 1 he wanted to go home.A review of Resident 1's Face sheet indicated that the resident was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, muscle weakness and cognitive communication deficit (cerebral infarction is medical term for stroke meaning when blood flow to the brain is stopped causing brain injury, cognitive communication deficit means someone struggles to communicate effectively, because their brain has trouble processing or organizing information. It affects a person's ability to pay attention, remember details, reason, and understand social cues). A review of Resident 1's MDS (an assessment tool) dated 5/8/26 under Section C, it indicated Resident 1's cognition was severely impaired. The MDS Section GG titled, Functional Abilities indicated, Resident 1 only needed supervision or touching assistance from a helper to ambulate. The MDS also indicated that the resident only needed supervision or touching assistance from a helper when wheeling himself with a manual wheelchair to a distance of at least 50 feet and partial assistance from a helper when wheeling himself to a distance of at least 150 feet.During an observation on 5/28/26 at 2:15 p.m., Resident 1 was observed to be sitting in his wheelchair and was independently propelling himself down the hallway where he was residing.During a review of Resident 1's nursing progress note dated 1/6/26, it indicated that the resident attempted to stand from wheelchair stated, .I want to go home. leave me alone, I want to go home.During a review of Resident 1's nursing progress note dated 4/14/26, Resident 1 stood up from wheelchair and said he wanted to walk so he could go home. During an interview on 5/28/26 at 3:04 p.m. with Responsible Party (RP), RP stated on 5/4/26, the facility informed her that Resident 1 fell in the hallway where the resident lived. RP also stated she was worried about the resident wandering around the building and potentially getting out of the facility.During a review of Resident 1's SBAR (SBAR stands for Situation, Background, Assessment and Recommendation, a standardized communication tool used in healthcare to share information quickly and clearly) dated 5/4/26, it indicated the resident had a fall in another hallway from where the resident's room was located. During an interview on 5/28/26 at 1:44 p.m. with Registered Nurse (RN)1, RN 1 stated on 5/25/26 at 5:00 a.m., the facility staff was unaware that the resident had left the building and explained that the front lobby door automatically allowed anyone inside to exit. Stated the resident was found at 5:30 a.m. by CNA 1 in the 7-eleven store across the street and when he assessed the resident, the resident had a left knee skin laceration and was unable to explain how he obtained the laceration. RN 1 also stated that Resident 1 was observed wandering throughout the facility frequently.During an interview on 5/28/26 at 4:07 p.m. with the Director of Nursing (DON), the DON stated the facility did not expect that the resident would go out of the facility.During an interview on 5/28/26 at 4:43 p.m. with the Administrator (Adm), ADM stated Resident 1 eloped on 5/25/26 and stated the incident of elopement was not reported to the department.During a review of the facility's policy and procedure (P&P) titled, Leave of Absence Without Notice(LAWN), dated 1/16/26, the P&P indicated, Policy: The interdisciplinary team members (IDT) are recommended to evaluate if a resident is deemed at risk of leaving the facility without notice and identify resident-specific measures in a least restrictive environment. Definitions. Elopement occurs when a resident leaves the premises or a safe area without notice/authorization.

Based on interview and record review, the facility failed to ensure the facility assessment (an assessment of the resources and staffing that the facility needs to competently care for the specific patient population) was complete when the following required components were not included. 1. Staffing plan 2. Staff training/education and competencies This failure had the potential to negatively affect a vulnerable population.Findings: 1. During a record review of the facility assessment dated 3/23/26, there was no documented evidence that the facility assessment included the following required component: a. Staffing plan During a review of the facility's, Program Flex (a waiver that allows a Skilled Nursing Facility to deviate from state requirements using alternative methods), with a start date of 7/1/2025, the program flex indicated, Workforce Shortage Waiver, (an exemption that allows the facility to temporarily operate below staffing requirements). There was no documented evidence that the facility assessment addressed how the program flex would meet the needs of the residents, how the facility determined the required number of staff, or described the required staff qualifications to meet the needs of the residents in the facility. During an interview with the Director of Nursing (DON) on 5/14/2026 at 4:38 p.m., the DON stated, I was unaware the facility assessment was incomplete. 2. During a record review of the facility assessment dated 3/23/2026, the facility assessment did not indicate training/education and competencies required to meet the needs of the residents including the specialty population. A review of the facility's Resident Matrix. (a tool used to identify all residents and pertinent resident care areas) that was provided upon entrance, the Resident Matrix showed the following: 5 residents who received dialysis (a medical treatment that filters waste products and excess fluid from the blood) 25 residents with tracheostomies (a surgically created opening in the front of the neck that leads directly into the windpipe to help a person breathe) 14 residents who were on ventilators (a medical device that pushes air into and out of the lungs to help a person breathe) During an interview on 5/11/2026 at 2:35 p.m. with the Administrator (Admin), the Admin confirmed the facility provided care and services for residents receiving dialysis, residents with tracheostomies and residents on ventilators. During an interview with the Director of Nursing (DON) on 5/14/2026 at 4:38 p.m., the DON stated, I was unaware the facility assessment was incomplete.

Based on observation, interview, and record review, the facility failed to ensure cold drinks were held at 41 degrees Fahrenheit or below during lunch tray line.This failure had the potential to result in the growth of bacteria, placing the residents at risk for contracting a food borne illness.Findings:During a concurrent observation and interview on 5/13/26 at 11:53 a.m. with the Registered Dietitian (RD), RD stated that the temperature checks were going to be performed and logged. The cold drinks were taken out of the refrigerator, placed on a cart in a plastic tub of ice, and placed next to the tray line to be placed on the meal trays. The juice temperature was registered at 45 degrees Fahrenheit (F) (unit of temperature), and the milk temperature was registered at 43 degrees F. RD was observed pouring more ice into the plastic tubs that the drinks were sitting in. The drinks were then placed on meal trays and placed into the carts for delivery to the units.During an interview on 5/13/26 at 2:25 p.m. with the RD, RD stated that the required temperature for cold drinks was 41 degrees F or lower. RD verified that the temperatures for the cold drinks in tray line for lunch were above the required temperatures. The RD stated a potential concern for the cold drinks being above the required temperature would be a risk for bacteria to grow and potential illness for the residents. During a review of the facility's policy and procedures (P&P) titled Food: Preparation, dated February 2025, the P&P indicated . All foods will be held at appropriate temperatures, greater than 135 degrees F (or as state regulation requires) for hot holding, and less than 41 degrees F for cold food holding.

Based on observation, interview, and record review, the facility failed to ensure two of 23 sampled residents received ordered Restorative Nursing Assistant services (RNA-services to help regain and maintain functional abilities through rehabilitative care) when:1.Resident 65 did not receive passive range of motion (PROM-movement of a joint through its full range by external force) or RNA services three days a week, as ordered by the physician, for approximately 8 months.2.Resident 30 did not receive RNA services as ordered by the physician.These failures had the potential to result in a decrease in mobility, decrease in muscle tone, and functional decline for Resident 65 and Resident 30.Findings:1. During a review of Resident 65's Face Sheet (Resident Demographics), the Face Sheet indicated Resident 65 was admitted to the facility on [DATE] with diagnoses which included intracerebral hemorrhage (type of stroke that occurs when a blood vessel in the brain ruptures or leaks) and muscle weakness.During an observation on 5/12/2026 at 8:56 a.m. with Resident 65, Resident 65 was laying in his bed. Resident 65 had a tracheostomy (a surgically created opening in the front of the neck that goes directly into the windpipe to help a person breathe) that was connected to an oxygen concentrator (a medical device that delivers purified oxygen to people with breathing difficulties). During a review of Resident 65's Medical Doctor Orders (MD Orders), dated 8/26/2025, the MD Orders indicated, RNA: PROM to all joints BUE/BLE as tolerated to maintain joint integrity. 3d/wk. Started on 8/26/25.During a review of Resident 65's Care Plan, dated with an initiation date of 7/31/2025 and target date of 7/20/2026, the Care Plan indicated, Resident 65 had a care plan for will remain free of complications related to immobility, including contractures . The Care Plan further indicated that Resident 65 had a care plan for RNA services for three days a week to maintain joint integrity and it was to be started on 8/26/2025.During an interview on 5/14/2026 at 9:01 a.m. with the Director of Staff Development (DSD), the DSD confirmed that Resident 65 had a doctor's order for RNA services that started on 8/26/2025. The DSD stated that there was no documentation of RNA services for Resident 65 because he had not received RNA services. The DSD further stated that Resident 65's doctor, Medical Doctor (MD) 1, was not aware that Resident 65 had not received RNA services for the past 8 months.During an interview on 5/14/2026 at 9:39 a.m. with the Director of Rehabilitation (DOR), the DOR stated that every Monday she met with the DSD and RNAs to discuss the residents that were currently receiving RNA services. The DOR further stated that Resident 65 was not receiving RNA services and had not been discussed in previous Monday meetings with the DSD and RNAs.During a review of Resident 65's medical chart, Resident 65's chart did not have any RNA services documented. (Total of 8 months after RNA services were ordered.)During an interview on 5/14/2026 at 2:26 p.m. with the MDS Nurse, the MDS Nurse stated that when a resident did not receive RNA services, the resident was at risk for contractures, skin issues, and muscle wasting (progressive loss, thinning, or shrinking of muscle mass).During an interview on 5/14/2026 at 4:52 p.m. with the Director of Nursing (DON), the DON stated that Resident 65's RNA services should have been started right after being ordered on 8/26/2025. The DON also stated that the Sub Acute Director and herself performed monthly reviews of the doctor's orders and it should have been noticed that Resident 65 had not received RNA services. During an interview on 5/14/2026 at 5:52 p.m. with MD 1, MD 1 stated that Resident 65 should have received RNA services for range of motion and he was not aware that RNA services were not performed.During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Services, undated, the P&P indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence.2. During a review of Resident 30's Face Sheet (Resident Demographics), the Face Sheet indicated Resident 30 was admitted to the facility on [DATE] with diagnoses which included absence of the right and left leg above the knee and muscle weakness.During a record review of Resident 30's Annual Minimum Data Set (MDS- standardized assessment tool), dated 4/24/2026, the Annual MDS indicated, Resident 30 had a BIMS (brief interview for mental status- standardized cognitive screening test) score of 14 out of 15, cognitively intact.During a concurrent observation and interview on 5/11/2026 at 5:12 p.m. with Resident 30, Resident 30 was laying in his bed with his bedside table positioned in front of him. On Resident 30's bedside table was a pair of hand weights. Resident 30 stated he had above the knee amputations (removal of a limb or body part) for both his legs. Resident 30 stated that he was supposed to receive rehabilitation therapy three times a week, however, he had not received any services. Resident 30 also stated that his brother brought him the hand weights on his bedside table so he could work out his arms while he was in his bed. Resident 30 further stated that if he received rehabilitation services, he would be able to go out of the facility with his family.During an interview on 5/13/2026 at 2:28 p.m. with the Director of Staff Development (DSD), the DSD stated that Resident 30 should have received RNA services three times a week. The DSD further stated that when a resident did not receive RNA services when ordered, it can affect their mobility and muscle tone.During a review of Resident 30's Restorative Assessment/Referral, dated 2/11/2026, the Restorative Assessment/Referral indicated, Resident 30 was at risk for decline in upper and lower extremities, range of motion, and strength, and the goal was to maintain upper and lower extremity strength and range of motion. The Restorative Assessment/Referral further indicated that the treatment plan was RNA services three times a week for upper and lower extremities.During a review of Resident 30's Documentation Report, Intervention/Task, for February 2026 through 5/13/2026, the Documentation Report, Intervention/Task indicated, Resident 30 did not receive scheduled RNA services on the following dates: 2/27/2026, 4/10/2026, 4/22/2026, and 5/8/2026 (a total of 4 times since 2/11/2026).During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Services, undated, the P&P indicated, Restorative goals may include, but are limited to supporting and assisting the resident in:.Developing, maintaining or strengthening his/her physiological and physiological resources;.maintaining his/her dignity, independence and self-esteem.

Based on interview and record review, the facility failed to ensure the responsible party (a representative who may exercise the resident's rights) (RP) for one of three sampled residents (Resident 1) had sufficient notice of the care planning conference. This failure resulted in RP not being able to attend the care planning conference, not being informed of proposed treatment and not being included in making treatment decisions regarding Resident 1's care. Findings:During an interview on 2/10/26 at 11:33 a.m. with Resident 1's RP, RP 1 stated, he was Resident 1's son and RP. RP also stated, RP was a medical doctor and worked full time. RP stated, facility called him on 11/13/25 and left a message, which stated a care planning conference was scheduled for later that same day. RP stated, he was unable to attend due to short notice. RP also stated, he had difficulty getting his calls returned by facility staff and had been unsuccessful in the past in getting care conferences scheduled at times he was able to attend. RP stated, RP was not kept informed of Resident 1's care and treatment and was not included in making decisions regarding treatment.During an interview on 2/11/26 at 2:35 p.m. with Social Service Assistant (SSA) 1, SSA 1 stated, SSA 1 telephoned Resident 1's RP in the morning to inform him a care conference was scheduled for later the same day. SSA 1 stated, Resident 1's RP did not answer and SSA 1 left a message. SSA 1 stated, SSA 1 thought Resident 1's RP had not returned the call. SSA also stated, SSA 1 usually had not written a note in the chart when SSA 1's calls were returned. SSA 1 stated, SSA knew the RP was a doctor who worked full time.During a concurrent interview and record review on 2/11/25 at 2:40 p.m. with SSA, Resident 1's Social Service Progress Note (SSN), dated 11/13/2025 was reviewed. The SSN indicated, SSA attempted to contact RP/son to schedule a care conference. No answer, left message requesting a return call. SSA stated, the SSN was dated 11/13/2025 at 9:02 a.m. During a concurrent interview and record review on 2/11/25 at 2:42 p.m. with SSA, Resident 1's Progress Note (PN), dated 11/13/2025 was reviewed. The PN indicated as follows: Type: Interdisciplinary Care Conference (meeting of Resident 1's health care providers to discuss Resident 1's condition and to plan Resident 1's care); .Name and Title of Attendees C. [NAME], CCC E. Rentoria, SSD M. [NAME], MDS C. [NAME], RN Supervisor R. Silva, AD M. [NAME], DM [NAME], Son/RP via phone was invited but did not attend . Copy of the care plan. Resident/Resident representative refused. SSA stated, the PN was dated 11/13/2025 at 2:47 p.m., which was the date and time when the Care Conference was held. During an interview on 2/11/26 at 2:48 p.m. with Social Services Director (SSD), SSD stated, SSA 1 telephoned Resident 1's son and RP on 11/13/25 to invite him to the Interdisciplinary Care Conference scheduled for 11/13/25. DDS stated, it was short notice to call the son on the same day as the Care Conference. SSD also stated, the son would be given five days' notice of future care conferences. During a review of the facility's policy and procedure titled, CARE PLANNING - INTERDISCIPLINARY TEAM, dated 08/25/2021, the P&P indicated, . Our Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. 3. The resident, the resident's family and/or the resident's representative are encouraged to participate in the development of and revisions to the resident's care plan.4. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family.

Based on interview and record review, the facility failed to ensure the responsible party (a representative who may exercise the resident's rights) (RP) for one of three sampled residents (Resident 1) had sufficient notice of the care planning conference. This failure resulted in RP not being able to attend the care planning conference and not being involved in planning Resident 1's care. Findings:During an interview on 2/10/26 at 11:33 a.m. with Resident 1's RP, RP 1 stated, he was Resident 1's son and RP. RP also stated, RP was a medical doctor and worked full time. RP stated, facility called him on 11/13/25 and left a message, which stated a care planning conference was scheduled for later that same day. RP stated, he was unable to attend due to short notice. RP also stated, he had difficulty getting his calls returned by facility staff and had been unsuccessful in the past in getting care conferences scheduled at times he was able to attend. RP stated, RP was not kept informed of Resident 1's care and treatment.During an interview on 2/11/26 at 2:35 p.m. with Social Service Assistant (SSA) 1, SSA 1 stated, SSA 1 telephoned Resident 1's RP in the morning to inform him a care conference was scheduled for later the same day. SSA 1 stated, Resident 1's RP did not answer and SSA 1 left a message. SSA 1 stated, SSA 1 thought Resident 1's RP had not returned the call. SSA also stated, SSA 1 usually had not written a note in the chart when SSA 1's calls were returned. During a concurrent interview and record review on 2/11/25 at 2:40 p.m. with SSA, Resident 1's Social Service Progress Note (SSN), dated 11/13/2025 was reviewed. The SSN indicated, SSA attempted to contact RP/son to schedule a care conference. No answer, left message requesting a return call. SSA stated, the SSN was dated 11/13/2025 at 9:02 a.m. During a concurrent interview and record review on 2/11/25 at 2:42 p.m. with SSA, Resident 1's Progress Note (PN), dated 11/13/2025 was reviewed. The PN indicated as follows: Type: Interdisciplinary Care Conference (meeting of Resident 1's health care providers to discuss Resident 1's condition and to plan Resident 1's care); .Name and Title of Attendees C. [NAME], CCC E. Rentoria, SSD M. [NAME], MDS C. [NAME],, RN Supervisor R. Silva, AD M. [NAME], DM [NAME], Son/RP via phone was invited but did not attend . Copy of the care plan. Resident/Resident representative refused. SSA stated, the PN was dated 11/13/2025 at 2:47 p.m., which was the date and time when the Care Conference was held.During an interview on 2/11/26 at 2:48 p.m. with Social Services Director (SSD), SSD stated, SSA 1 telephoned Resident 1's son and RP on 11/13/25 to invite him to the Interdisciplinary Care Conference scheduled for 11/13/25. DDS stated, it was short notice to call the son on the same day as the Care Conference. SSD also stated, the son would be given five days' notice of future care conferences. During a review of the facility's policy and procedure titled, CARE PLANNING - INTERDISCIPLINARY TEAM, dated 08/25/2021, the P&P indicated, . Our Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. 3. The resident, the resident's family and/or the resident's representative are encouraged to participate in the development of and revisions to the resident's care plan.4. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family.

Based on observation, interview and record review, the facility failed to protect one of four sampled residents (Resident 1) from physical abuse when Resident 2 hit Resident 1 on the left side of his face.This failure resulted in Resident 1 having pain, swelling and redness near the left eye.During a record review of Resident 1's admission record, the record indicated Resident 1 was admitted to the facility on [DATE]. The record indicated Resident 1 had diagnoses which included dementia (a loss of brain function affecting memory, thinking, language, judgment, or behavior). During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used in identifying problems to be addressed in plan of care), dated 1/14/26, the record indicated Resident 1 was rarely/ never understood, had a memory problem, and never/rarely made decisions regarding tasks of daily life. The assessment indicated Resident 1 used a wheelchair and was able to wheel/propel himself independently. During a record review of Resident 2's admission record, the record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included anxiety (a feeling of fear, dread, and uneasiness that acts as a natural reaction to stress) and aphasia (disorder that lessens ability in speaking, understanding, reading or writing). During a record review of Resident 2's MDS assessment dated [DATE], the assessment indicated Resident 2's Brief Interview for Mental Status (BIMS, short-term memory screening tool) score was zero (0) out of 15, indicating severe loss of ability with memory and thinking. During an observation on 2/17/26 at 10:48 a.m. Resident 1 was wheeling himself along the hallway in the facility. During an observation on 2/17/26 at 10:52 a.m. Resident 2 was sitting in his wheelchair inside his room. Resident 2 stated Please! Please! with a loud, high tone of voice, while shaking his head left to right, when asked about any memory regarding the incident between him and Resident 1. During a phone interview on 2/17/26 at 12:05 p.m. with Restorative Nurse Assistant (RNA), RNA 1 stated on 1/15/26, at around 10:30 a.m., while he was with another resident, he heard someone yelling. RNA 1 stated he rushed to Resident 2's room. RNA 1 stated he saw Resident 1 and Resident 2, both were sitting in their wheelchairs in Resident 2's room. RNA 1 stated he saw Resident 2 swinging his arm and hitting Resident 1 on the left side of his face. RNA 1 stated he had to separate both residents. During a record review of Resident 1's progress notes dated 1/15/26, Registered Nurse (RN 1) documented, resident had physical altercation with another resident. It was reported that [Resident 1] was struck on his left eye by [Resident 2] .[Resident 1] with mild pain to [left] eye and surrounding outer area. Area with redness and mild swelling .cool compress provided to area .Tylenol (medication for pain) was provided for pain . During a record review of Resident 2's progress notes dated 1/15/26. RN 1 documented, resident [Resident 2] physically struck another resident [Resident 1] in the L (left) eye. [Resident 2] refused to speak with staff about incident . [Resident 2] was angry . During an interview on 2/17/26 at 1:01 p.m. Licensed Vocational Nurse (LVN 1) stated Resident 1 was wheelchair bound and goes around the facility by himself. LVN 1 stated Resident 1 was confused and would go inside other resident's rooms. During an interview with Registered Nurse (RN 1) on 2/17/26 at 2:27 p.m. RN 1 stated she was on duty on the day of the incident. RN 1 stated the abuse incident between Resident 1 and Resident 2 could have been avoided by ensuring that Resident 1 was kept in line of sight. RN 1 also stated that it was even more important to protect residents with severe cognitive impairment (difficulty with thinking, memory, and understanding, preventing them from living independently) from abuse, as they are the vulnerable population (people who are easily harmed physically and emotionally). During a review of facility's Policy and Procedure (P&P) titled, Abuse Prohibition dated 10/25/24, P&P indicated, Health Care Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. Physical abuse includes hitting, slapping, pinching, kicking, etc.

Based on interview and record review, the facility failed to ensure for one out three sampled residents (Resident 1), there was no personal belongings inventory form filled out. Resident 1's personal inventory form was not filled out during admission. This failure resulted in an inaccurate inventory f resident's personal belongings. Findings:A review of the facility's admission Record indicated Resident 1 was admitted on [DATE] with diagnoses that included Nonrheumatic tricuspid valve disorder, (a type of heart valve disease, when the two right heart chambers doesn't close as it should. Blood flows backward through the valve into the upper right chamber). Resident 1 was discharged home from the facility on 08/18/2025.During a concurrent interview and record review on 01/05/2026 at 12:42 p.m., with Administrator (ADM), ADM reviewed Resident 1's Inventory of Personal Effects, ADM stated the form was not filled out.During a review of facility's Inventory of Personal Effects form, it indicated Resident 1's list of personal belongings was not filled out, the Certification of Receipt during admission or discharge had no signatures from Resident 1 or responsible party, and facility staff representative.During a review of facility's policy and procedures titled Resident's Personal Property with effective date 08/25/2021 it read: Purpose: To protect the Resident right to retain his/her personal belongings and preserve the Resident individuality and dignity. Policy: Personnel will identify and record the Resident belongings upon admission to a Facility. Procedure: 3. All items brought into the Facility will be listed on the Inventory of Personal Effects form and kept in the Resident clinical chart. Any additional items brought into the Facility after admission must be added to this list. Obtain the following signatures on the Inventory of Personal Effects: Resident or resident representative/date, Employee/date. 5. Resident or resident representative will sign the Inventory of Personal Effects again at discharge to acknowledge receipt of personal property.

During an interview on 7/31/25 at 9:31 a.m., with Resident 1's family member (RFM) 1, RFM 1 stated Resident 1 told her that LVN 1 hit Resident 1 in his right leg when LVN 1 told the resident to scoot back to his bed. RFM 1 stated she spoke to LVN 1 about the incident and LVN 1 denied the allegation. RFM 1 stated she could not remember the date of the incident.Review of Resident 1's departmental notes did not indicate an incident when resident accused LVN 1 of hitting his right leg.During a review of Resident 1's admission Record, dated 7/31/25, indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included muscle weakness.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) dated 5/18/25 under Section C, it indicated a score of 13, meaning Resident 1 was cognitively intact. During an interview on 8/4/25 at 5:15 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she remembered an incident when Resident 1 accused LVN 1 of hitting his right leg when she was trying to assist the resident to get back to his bed. LVN 1 further stated that RFM 1 called the facility on the phone and asked LVN 1 if she hit Resident 1's leg. LVN 1 stated she denied the allegation, but she did not report the alleged abuse incident to her supervisor. LVN 1 stated she should have reported the incident to her supervisor and the Administrator per facility's abuse policy so the incident would have been investigated. LVN further stated that there were no other staff that knew of the incident, and she could not remember the date when the incident happened.During an interview on 8/6/25, at 12:30 p.m., with the Administrator (Adm), stated LVN 1 should have reported the alleged abuse incident to the Adm.During a review of the facility's undated policy and procedure (P&P) titled, Abuse Prohibition Policy and Procedure, the P&P indicated, . 7.3 Report allegations involving neglect, exploitation or mistreatment (including injuries or unknown source) . within 24 hours if the event does not result in serious bodily injury. 7.4 notify local law enforcement, Ombudsman, Licensing District Office, Licensing Boards .7.6 Initiate an investigation within 2 hours of an allegation of abuse.7.7 The investigation will be thoroughly documented.

Based on interview and record review the facility failed to ensure the Responsible Party (RP is the person designated as being responsible for another person's medical and financial decisions) of Resident 1 ' s change of condition (COC). This failure resulted in Resident 1 ' s RP being uninformed and unaware of Resident 1 ' s COC. Findings: During a review of Resident 1's admission Record, dated 5/21/25, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit (communication difficulties)and aphasia (a language disorder that affects the ability to communicate). Review of Resident 1 ' s Minimum Data Set (an assessment tool) dated 4/22/25, indicated he had a brief interview for mental status or BIMS of 0 (BIMS score of 0-7 indicates severe cognitive impairment). During a review of the clinical record for Resident 1, the progress notes documented by Registered Nurse (RN) 1 dated 2/19/25 at 8:46 a.m., indicated, Right foot big toe have a foul smell. Will be referred to Podiatry( Podiatry is a branch of medicine that focuses on the diagnosis, treatment, and prevention of disorders of the feet, ankles and lower legs). During a concurrent joint interview and record review with the Director of Nursing (DON) and RN 1 on 5/21/25 , at 1:16 p.m., RN 1 and DON could not find the documentation that Resident 1 ' s RP was informed of the resident ' s foul smelling right big toe. RN 1 acknowledged she could not recall that she informed Resident 1 ' s RP about the the resident's toe. During an interview with the DON on 5/21/25 at 1:36 p.m., DON stated the facility had to notify the physician and the RP if there was a COC. During a review of the facility's policy and procedure (P&P) titled, Change of Condition: Notification of, dated 8/25/21 the P&P indicated, I. Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident ' s condition. II. Policy: A facility must immediately inform the resident, consult with the Resident ' s physician . and notify, consistent with his/her authority, Resident Representative where there is: . A significant change in the Resident ' s physical, mental or psychosocial status . A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment .or to commence a new form of treatment) .

Based on interview and record review the facility failed to ensure the Responsible Party (RP is the person designated as being responsible for another person's medical and financial decisions) of Resident 1 ' s change of condition (COC). This failure resulted in Resident 1 ' s RP being uninformed and unaware of Resident 1 ' s COC. Findings: During a review of Resident 1's admission Record, dated 5/21/25, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit (communication difficulties)and aphasia (a language disorder that affects the ability to communicate). Review of Resident 1 ' s Minimum Data Set (an assessment tool) dated 4/22/25, indicated he had a brief interview for mental status or BIMS of 0 (BIMS score of 0-7 indicates severe cognitive impairment). During a review of the clinical record for Resident 1, the progress notes documented by Registered Nurse (RN) 1 dated 2/19/25 at 8:46 a.m., indicated, Right foot big toe have a foul smell. Will be referred to Podiatry( Podiatry is a branch of medicine that focuses on the diagnosis, treatment, and prevention of disorders of the feet, ankles and lower legs). During a concurrent joint interview and record review with the Director of Nursing (DON) and RN 1 on 5/21/25 , at 1:16 p.m., RN 1 and DON could not find the documentation that Resident 1 ' s RP was informed of the resident ' s foul smelling right big toe. RN 1 acknowledged she could not recall that she informed Resident 1 ' s RP about the the resident's toe. During an interview with the DON on 5/21/25 at 1:36 p.m., DON stated the facility had to notify the physician and the RP if there was a COC. During a review of the facility's policy and procedure (P&P) titled, Change of Condition: Notification of, dated 8/25/21 the P&P indicated, I. Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident ' s condition. II. Policy: A facility must immediately inform the resident, consult with the Resident ' s physician . and notify, consistent with his/her authority, Resident Representative where there is: . A significant change in the Resident ' s physical, mental or psychosocial status . A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment .or to commence a new form of treatment) .

Based on observation, interview and record review, the facility failed to provide necessary care to maintain good grooming and personal hygiene to four of six sampled residents (Residents 56, 90, 97, 59) who were dependent on staff to carry out activities of daily living (ADL). This failure resulted to Residents 56, 90, 97 and 59 having long and dirty fingernails. Findings: A review of Resident 56's admission Record revealed that resident was admitted on [DATE] (original admit date was 10/9/2020) with diagnoses which included persistent vegetative state ( a state of brain dysfunction in which a person shows no signs of awareness). Resident required total assistance with all activities of daily living. During an observation on 2/25/25 at 10:30 a.m., Resident 56 had long and dirty fingernails. A review of Resident 90's admission Record revealed that resident was admitted on [DATE] with diagnoses which included cognitive communication deficit (a communication disorder that makes it hard for someone to think and communicate effectively due to brain injury, stroke or other neurological conditions). Resident required total assistance with all activities of daily living. During an observation on 2/25/25 at 10:40 a.m., Resident 90 had long and dirty fingernails. A review of Resident 97's admission Record revealed that resident was admitted on [DATE] with diagnoses which included anoxic brain damage (death or damage of brain cells due to the oxygen deprivation of the brain for an extended period of time), and limitation of activities due to disability. During an observation on 2/25/25 at 10:55 a.m., Resident 97 had long fingernails. A review of Resident 59's admission Record indicated that resident was admitted [DATE] (original admit date was 6/8/22) with diagnoses which included persistent vegetative state and limitation of activities due to disability. During an observation on 2/25/25 at 11:10 a.m., Resident 59 had long, jagged fingernails. During an interview with Licensed Vocational Nurse (LVN)1 on 2/26/25 at 11:10 a.m., LVN 1 stated the CNAs should trim and file the fingernails of residents when they are long and jagged, The charge nurses are responsible for trimming the fingernails of residents with diagnosis Diabetes Mellitus. The podiatrist visits the facility monthly to trim the toenails of the residents. A review of the facility's Policy & Procedure titled: Fingernails/Toenails, Care of, Revised February 2018, it revealed .1. Nail care includes daily cleaning and regular trimming .4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

Based on interview and record review, the facility failed to provide preventive treatment and services to maintain and improve range of motion (ROM) for two of 20 sampled residents (Resident 13, Resident 97) when the physician order for PROM (Passive Range of Motion) exercises for Resident 97 was not implemented and Resident 13 had no physician order for ROM (Range of motion is one aspect of exercise important for increasing or maintaining joint function . Passive range of motion is movement applied to a joint solely by another person or persons or a passive motion machine). This deficient practice had the potential to result in the residents' increased and worsening of a contracture (contracture is the shortening and hardening of muscles and joints which limit and interfere with daily functioning) Findings: 1. A review of the face sheet of Resident 13 indicated he was admitted on [DATE] but was originally admitted on [DATE] with diagnoses that included paraplegia, contracture of muscle, contracture of joint, and muscle weakness. During an observation on 2/24/25 at 10 a.m., Resident 13 was lying in bed, both upper and lower extremities were contracted. A review of Resident 13's Minimum Data Set (MDS - an assessment tool to evaluate the health status of a resident), dated 1/27/25, indicated, Resident 13 was moderately impaired with his cognitive skills, and ROM on both sides of the upper and lower extremities were impaired and required assistance with activities of daily living such as bathing, dressing, toilet use, eating [through a gastrostomy tube (GT)- a thin flexible tube inserted through the abdominal wall and into the stomach] A review of Resident 13's Physician Order dated for February 2025 indicated no orders for Restorative nursing care/ROM exercises. During an interview on 2/26/25 at 9:07 a.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 13 was fully dependent on staff for his care. When asked, CNA 4 stated she was unsure if Resident 13 was on any PT (physical therapy)program. CNA 4 stated they were just supporting Resident 13's contracted extremities with pillows. During a review of Resident 13's care plan (old) dated/revised 3/14/17 it indicated Resident 13 had limited physical mobility with interventions dated/revised 12/7/23 to monitor, document/report to MD PRN (pro re nata - as the need arises) [NAME] and symptoms of immobility: contractures forming or worsening . No current care plan related to Resident 13's limited mobility/contractures were listed. There was no documented evidence to show that Resident 13 was having ROM exercises which were provided by a Restorative Nursing Assistant (RNA) program. 2. During an observation on 2/24/25 at 11:30 a.m. Resident 97 was lying in bed, sleeping, and had contractures on both hands and legs. During an interview with CNA 5 on 2/25/25 at 9:30 a.m. outside room [ROOM NUMBER], CNA 5 stated she was new and not very familiar with the residents in the room. CNA 5 stated Resident 97 was the only resident that had contractures out of the three residents. A review of Resident 97's face sheet, it indicated he was admitted on [DATE] with diagnoses that included anoxic brain damage, limitation of activities due to disability, and muscle weakness. A review of Resident 97's MDS dated [DATE] indicated Resident 97 was severely impaired with no cognitive skills for decision making. It also indicated Resident 97 as totally dependent on staff for dressing, transfer, eating (through a GT), personal hygiene, toilet use, and bathing. The MDS indicated Resident 97 had limited range of motion in both upper and lower extremities. During a review of Resident 97's physician orders dated February 2025, indicated active orders with start date 12/4/25, perform passive range of motion exercises (PROM) to bilateral upper and lower extremities in all places of movement 3-5X/week as tolerated to maintain joint mobility, prevent contractures and skin integrity issues every shift every Mon, Wed, Thu, Fr, Sat. There was no documented evidence that Resident 97 was receiving PROM as ordered. During an interview on 2/25/25 at 4:12 p.m. with the RNA (Restorative Nursing Assistant, a person trained to provide specific treatment to residents to restore and maintain strength, coordination, and skills to perform functional activities of daily living), RNA stated Rehab has the list of those on the RNA program (exercises or activities designed to maintain or improve residents' abilities to the highest practicable level such as: range of motion exercises, splint or brace assistance, training and skills practice in bed mobility, transfers, walking, dressing, grooming, eating, communication). During a concurrent interview and record review on 2/26/25 at around 10:50 a.m. with the director of Rehab (DOR), DOR acknowledged that Residents 13 and 97 were not on the RNA program. When asked regarding the importance of RNA program for the residents with contractures, DOR stated it was important to prevent decline in contractures. DOR provided the list of residents on the RNA program and the RNA weekly schedules. Residents 13 and 97 were not on the list of the residents getting RNA program. DOR stated Resident 97 completed Physical Therapy (PT) in November of last year. During a review of Resident 97's care plan dated/initiated 10/25/24, the care plan indicated Resident 97 required occupational therapy due to impaired ROM with interventions for OT clarification order: 5 days/week x 4 weeks. No current care plan was provided. During an interview on 2/27/25 at 9:30 a.m. with the Director of Nursing (DON), DON stated the RNA has a schedule for the patients and RNA is the one that does ROM. DON stated the therapy/Rehab would evaluate, make recommendations, and give referrals to the RNA. DON stated the doctor gives the order. During a review of the facility policy and procedure (P&P) titled, Range of Motion Exercises Rehabilitative and Restorative, dated October 2010, the P&P indicated, Range of Motion Exercises Purpose .to exercise the resident's joints and muscles .when exercises are complete .the following information should be recorded, date time exercises performed .type of ROM exercise given .whether the exercise was active or passive .

Based on observation, interview, and record review, the facility failed to store and prepare food under safe and sanitary conditions when: 1. Dry food items were stored less than six inches from the floor. 2. [NAME] (CK) 1 did not wear a beard restraint while preparing resident food. 3. Expired yogurt was stored in the resident refrigerator. 4. Two ice scoops were stored uncovered and open to air. These failures had the potential for contamination of food resulting in food borne illness for the 63 residents who received food from the kitchen, 25 residents who received ice from unit three and two residents who received ice for unit one. During an observation on 2/24/25, at 9:47 a.m., in the dry food storage area, one bulk container of powdered milk, one bulk container of sugar and one bulk container of flour were stored approximately 4.5 inches above the floor. During an interview on 2/27/25, at 12:17 p.m., with Registered Dietician (RD), RD stated it was important to store food no less than six inches above the floor to prevent contamination. During a concurrent observation and interview on 2/24/25, at 9:27 a.m., with CK 1, in the kitchen, CK 1 was observed wearing a surgical face mask that did not cover his entire beard while cutting potatoes for residents' lunch. CK 1 stated that he should have been wearing a beard restraint. During an interview on 2/24/25 at 9:50 a.m., with RD, RD stated it was important for cooks to wear beard restraints when they prepared resident food because their hair could drop on the food. During a concurrent observation and interview on 2/24/25, at 10:06 a.m., with Registered Nurse (RN)1, the resident refrigerator had yogurt that expired on 2/14/25 in one of its shelves. RN 1 threw it in the trash and stated it was a risk for food borne illness. During a concurrent observation and interview on 2/26/24 at 2:03 p.m., with Certified Nursing Assistant (CNA) 1, in unit 3 nurses' station hallway, the resident ice scoop was observed stored in a plastic bag that was open to air. CNA 1 stated they stored the ice scoop in the plastic bag and used it for residents that wanted ice with their water. CNA 1 stated they could not close the plastic bag. During a concurrent observation and interview on 2/26/25, at 3:12 p.m., with CNA 2, on unit one, a sub-acute unit (a unit for patients who need more intensive care than home but not as critical as a full hospital stay, often focusing on rehabilitation and recovery after a serious illness or injury), the resident ice scoop was observed beside an ice chest on a cart in the resident hallway. The ice scoop was in an plastic bag contained in a lidless plastic container. CNA 2 stated the ice scoop was for the two sub-acute residents that liked ice. During an interview on 2/26/25, at 4:41 p.m. with Infection Preventionist (IP), IP stated the resident ice scoops should have been in a covered container to prevent the possible risk for contamination. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, undated, The P&P indicated, Food in designated dry storage areas are kept at least six (6) inches off the floor (unless packaged for case lot handling. for example, dollies, pallets, racks and skids) . During a review of the facility's policy and procedure (P&P) titled, Infection Control for Dietary Employees, dated 12/6/24, the P&P indicated, Purpose . To ensure that the dietary department is maintained in a sanitary condition in order to prevent food contamination and the growth of disease producing organisms and toxins. The P&P indicated, Clean hair - covered with an effective hair restraint while in all kitchen and food storage areas. (And beard/ mustache covering when applicable). During a review of the facility's policy and procedure (P&P) titled, Safe Handling of foods from Visitor, revised 3/28/24, the P&P indicated, Items will be thrown out after 48 hours . Items not opened can follow the manufacturer use by date. During a review of the facility's policy and procedure (P&P) titled, Ice Machine Scoop, revised January 2013, the P&P indicated, A covered plastic or stainless steel container holds the scoop.

3. During an observation on 2/26/25 at 9:26 a.m., in the shared bathroom for rooms [ROOM NUMBERS], the toilet bowl was dirty with red substance that appeared like blood around the toilet seat and outside the right side of the toilet bowl. On the floor near the toilet, were three areas of dry dark red substances. Also on the floor was a dry brown substance that looked like feces. There was a trash bin that had no liner near the toilet. During a concurrent observation and interview on 2/26/25 at 9:28 a.m. with Certified Nursing Assistant (CNA) 4, CNA 4 acknowledged that the bathroom (B/R) was dirty, needed to be cleaned for sure, and needed good cleaning. CNA 4 stated housekeeping comes in everyday to clean, usually by 11 a.m. or 10:30 a.m. CNA 4 stated she has not seen it this morning as the resident involved was assisted by the night staff. CNA 4 stated two residents (Residents 50 and 67) out of four residents were using the B/R. During an interview on 2/26/25 at 1:40 p.m. with Resident 50 who was Spanish speaking only, [Licensed Vocational Nurse (LVN) 1 was used as Spanish translator], Resident 50 stated he and Resident 67 used the B/R, and the B/R was always messed up by Resident 67. He stated the bathroom was dirty this morning and every day. He stated he told a staff about it this morning but unable to remember the staff. During an interview on 2/26/25 at 4:33 p.m. with Resident 67, Resident 67 stated whenever he used the B/R, he informed staff, and staff would say they would call housekeeping to clean it. He stated staff would tell him housekeeping only worked till 8 pm. Resident 67 stated sometimes they ran out of toilet paper and no paper seat cover in the B/R for several days. During a concurrent observation and interview on 2/26/25 at 9:36 a.m. with the Infection Preventionist (IP), IP confirmed that the B/R was not clean and the substance around the toilet and three dry dark substances on the floor looked like blood stains and the brownish substance looked like BM (bowel movement). IP stated they told staff if staff saw that a bathroom was dirty, they should call housekeeping to clean it. During a concurrent observation and interview on 2/26/25 at 9:40 a.m.with the Housekeeping Supervisor (HKS) and Director of Maintenance (DOM), HKS stated the B/R should have been cleaned. She stated it should have been cleaned and wiped out first by the nursing staff who should notify housekeeping staff who would clean it and disinfect it. During an interview on 2/27/25 at 9:04 a.m.with IP, IP stated regarding the blood and feces in the bathroom, the CNA was supposed to clean it first, then should call housekeeping to clean and disinfect it. During an interview on 2/27/25 at 9:20 a.m. with the Director of Nursing (DON), DON stated, staff notifies housekeeping when the bathroom is dirty. DON stated houskeeping has a cleaning schedule. DON stated the bathrooms are supposed to be clean all the time. During a review of the facility's policy and procedure (P&P) titled, Restroom Cleaning, dated 3/28/2018, the P&P indicated, Healthcare Services Group (HCSG) is committed to providing a safe, clean, and hygienic environment for residents, staff, and visitors .Visible soil should be removed prior to disinfecting .Nursing staff provides the initial cleanup of blood and body fluids. Environmental Services staff follow by disinfecting surfaces contaminated with a small, residual amount of feces, blood, or other body fluids . Based on observation, interview and record review the facility failed to observe infection control measures for six of 26 sampled residents when: 1. Two opened and uncapped Clotrimazole cream tubes were found at Resident 18's bedside table (Clotrimazole cream is a medicated cream used to treat skin infections). 2. The air filter of the oxygen concentrator for residents 26, 59, and 84 were dirty. 3. The facility did not maintain a clean bathroom for residents 50 and 67. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infections for residents and staff. (Cross Reference F761) Findings: 1. During an initial tour of the facility on 2/24/25 at 11:11 a.m., two opened and uncapped Clotrimazole cream ointment tubes were found at Resident 18's bedside table. When asked, the Director of Nursing (DON) stated, the creams should not be at the bedside and should be locked in the medication cart. Review of Resident 18's admission Record (information containing contact details, brief medical history at-a-glance) indicated, Resident 18 was admitted to the facility on [DATE] with diagnoses that included dysphagia and presence of a gastrostomy. Review of Resident 18's MDS (an assessment tool) dated 11/21/24, indicated the resident was not cognitively intact (Dysphagia is the medical term for swallowing difficulties and a gastrostomy is a surgical procedure that creates an opening in the stomach through the abdominal wall. A tube, called a gastrostomy tube is then inserted through this opening to provide nutrition and medication directly into the stomach). Review of Resident 18's Physician's order dated 12/20/24, indicated an order of Clotrimazole cream 1%, apply to around gastrostomy stoma site topically two times a day for discharge and redness around the stoma site . (gastrostomy stoma site is the skin of the gastrostomy opening where the gastrostomy tube was inserted; topically means apply to the surface). Review of Resident 18's Medication Administration Record (MAR), indicated, Clotrimazole Cream 1% was last applied around the gastrostomy stoma site topically on 2/24/25 at 8:00 a.m. During an interview on 2/27/25 at 9:11 a.m., with Infection Preventionist (IP) , IP stated the two tubes of clotrimazole cream should have a cap and be stored in the medication cart. Further stated the risk of the creams being uncovered was the risk of spread of infection. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 9/18/23, the P&P indicated, Purpose: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . 2. The program is based on the accepted national infection prevention and control standards . 2. During observation on 2/24/25 at 10:15 a.m., the air filter of Resident 26's oxygen concentrator ( a medical device that separates nitrogen from the air around you so you can breathe up to 95% pure oxygen) was covered with a thick layer of brown frizzy material and caked dust particles. This had the potential to lead to reduced oxygen purity. The air filter is used to remove particles and contaminants from entering the lungs while in use. Resident 26 had diagnoses which include acute and chronic respiratory failure, chronic obstructive pulmonary disease ( a lung disease that blocks airflow making it difficult to breath), and Resident 26 was dependent on the oxygen concentrator for ease of breathing. During observation on 2/25/25 at 8:45 a.m., the air filter of Resident 59's oxygen concentrator was covered with a thick layer of brown frizzy material and caked dust particles. This had the potential to lead to reduced oxygen purity. The air filter is used to remove particles and contaminants from entering the lungs while in use. Resident 59 had diagnoses which include respiratory failure (inability of the lungs to exchange gases) and dependence on respirator. Resident 59 required the use of the oxygen concentrator continuously throughout the day. During observation on 2/25/25 at 9:05 a.m., the air filter of Resident 84's concentrator was covered with a thick layer of brown frizzy material and caked dust particles. This had the potential to lead to reduced oxygen purity. The air filter is used to remove particles and contaminants from entering the lungs while in use. Resident 84 had diagnoses which include chronic respiratory failure and required the use of oxygen concentrator to maintain an oxygen saturation (percentage of oxygen in the blood) level above 92 %. During an interview with the Director of Nursing (DON) on 2/25/25 at 1:35 p.m., she stated the air filters of the oxygen concentrators were supposed to be cleaned or replace every week. A review of the facility's Policy and Procedure titled Ventilator and Concentrator Filters dated September 2009 and Reviewed/Revised January 2014 indicated .1. Shall be removed and washed twice per week to clear accumulated dust and dirt. 2. Filter shall then be dried on a paper towel and replaced with a new filter while laundering and drying the dirty filter.

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment when: 1. The toilet seat/cover was loose and was the wrong size for the toilet in rooms [ROOM NUMBERS]'s (shared bathroom). There was a gap between the toilet bowl and the toilet seat when closed. 2. The linoleum flooring in rooms [ROOM NUMBERS]'s bathroom was discolored with patches of black stains. This failure placed Resident 155 at risk for safety and may negatively impact the resident's psychological health when she has to use an unmaintained bathroom that is not safe and clean. Findings: During an initial tour on 2/24/25 at 11:20 a.m., Resident 155 was lying in bed, with a bedside commode by her bed. Resident 155 expressed concerns regarding the toilet being too low, and the toilet seat was the wrong size for the toilet bowl. She stated she was the only resident using the bathroom and she was provided with a bedside commode, but she preferred to use the bathroom. During an observation on 2/24/25 at 11:27 a.m., the toilet seat was loose, and did not cover the entire perimeter of the toilet bowl as it was not the right size. When the toilet seat was down, there was a four inch gap which exposed the inner part of the toilet bowl. The linoleum flooring of the bathroom appeared old, worn, and discolored with patches of black stains. During an interview on 2/26/25 at 9:24 a.m. with CNA 4, CNA 4 acknowledged that the toilet seat was definitely smaller than the toilet bowl and was unsure if maintenance knew about it. CNA 4 acknowledged the areas of black stains on the bathroom floor. When asked, CNA 4 stated she had seen it only in that bathroom. During an interview on 2/26/24 at 9:54 a.m. with the Director of maintenance (DOM) and the Housekeeping Supervisor (HSK), DOM stated it was the wrong toilet seat cover and it was loose. He stated he wasn't aware of it, and the toilet seat poses a risk of accidents to the residents. DOM acknowledged the discolored black areas on the linoleum flooring and used a wet paper towel to attempt to clean off the black stain close to the base of the toilet bowl. DOM stated it was a permanent stain and cannot be scrubbed off. HSK stated the bathroom floor was mopped every day. She stated most of the residents' bathroom floors are old original floor linoleum. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, dated February 2021, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment .Staff provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences .the characteristics of the facility that reflect a personalized, homelike setting .include clean, sanitary and orderly environment . During a review of the facility's P&P titled Work Orders, Maintenance, dated April 2010, the P&P indicated, Maintenance work orders shall be completed in order to establish a priority of maintenance service .work orders must be filled out and forwarded to the Maintenance Director .

Based on observation interview and record review, the facility failed to assure medications were stored in a secure location when two opened and uncapped Clotrimazole cream tubes were found on Resident 18's bedside table (Clotrimazole cream is a medicated cream used to treat skin infections). This deficient practice had the potential for medication misuse and/or ineffective treatment. (Cross Reference F880) Findings: During an initial tour of the facility on 2/24/25 at 11:11 a.m., two opened and uncapped Clotrimazole cream tubes were found on Resident 18's bedside table. When asked, the Director of Nursing (DON) stated, the creams should not be at the bedside and should be locked in the treatment cart. Review of Resident 18's Facesheet (information containing contact details, brief medical history at-a-glance) indicated Resident 18 was admitted to the facility on [DATE] with diagnoses that included dysphagia and presence of a gastrostomy. Review of Resident 18's MDS (an assessment tool) dated 11/21/24, indicated the resident was not cognitively intact (Dysphagia is the medical term for swallowing difficulties and a gastrostomy is a surgical procedure that creates an opening in the stomach through the abdominal wall. A tube, called a gastrostomy tube is then inserted through this opening to provide nutrition and medication directly into the stomach). Review of Resident 18's Physician's order dated 12/20/24, indicated an order of Clotrimazole cream 1%, apply to around gastrostomy stoma site topically two times a day for discharge and redness around the stoma site . (gastrostomy stoma site is the skin of the gastrostomy opening where the gastrostomy tube was inserted; topically means apply to the surface). Review of Resident 18's Medication Administration Record (MAR), indicated, Clotrimazole Cream 1% was last applied around the gastrostomy stoma site topically on 2/24/25 at 8:00 a.m. During an interview on 2/27/25 at 9:30 a.m., with Registered Nurse (RN)1, RN 1 stated, the clotrimazole creams should not have been left unattended at Resident 18's bedside because of the risk of having another staff apply the cream to a wrong resident. RN 1 also stated, because the creams were uncapped or had no cover and were exposed to air and dirt, there was a risk of contaminating the wound which could result to infection During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, revised November 2020, the P&P indicated, . The facility stores all drugs and biologicals in a safe, secure, and orderly manner . 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications .

Based on observation, interview and record review, the facility failed to adequately supervise one of three totally dependent (the resident needs the staff to completely and totally perform the task) on staff residents (Resident 1) after transferring her back to bed. Certified Nursing Assistants (CNA 2 and CNA 3) left her in bed, unattended, and unsupervised resulting in an avoidable fall out of bed. This failure resulted in Resident 1 sustaining a right leg fracture (broken bone), pain, and a transfer to Acute Care Hospital (ACH 1) for follow up care. Findings: During a record review of Resident 1 ' s Admission Record dated 11/14/22, the record showed Resident 1was admitted to the facility in 08/15/2015. During a record review of Resident 1 ' s Annual Minimum Data Set (MDS - an assessment tool used to guide care) assessment dated [DATE], the assessment showed Resident 1 had unclear speech, was sometimes able to understand others and make self-understood. The assessment also showed Resident 1 was totally dependent on staff for Activities of Daily Living (ADLs, Activities related to personal care, such as bathing, bed mobility, transfers, personal hygine, etc.), had limited range of motion in both upper and lower extremities. During a record review of Resident 1 ' s Physician Progress Notes dated 09/23/22, the progress notes showed Resident 1 had diagnosis of Cerebral Palsy (According to Centers for Disease Control and Prevention (CDC), Cerebral Palsy (CP) is a group of disorders that affect a person ' s ability to move and maintain balance and posture), Ankylosing Spondylosis (According to Mayo Clinic it ' s an inflammatory disease that, over time, can cause some of the bones in the spine (vertebrae) to fuse. This fusing makes the spine less flexible and can result in a hunched posture). The Physician progress notes also showed Resident 1 was at a High Risk for Falls. During an interview on 11/14/22, at 10:16 a.m., Licensed Vocational Nurse (LVN 1) stated Resident 1 was at risk for falls and she recently fell in the evening on 10/23/22 causing a fracture in right lower extremity. LVN 1 also stated Resident 1 was not able to move in bed independently and was totally dependent on the staff for Activities of Daily Living (ADLs). During a review of Resident 1 ' s Fall risk assessment dated [DATE], the assessment showed Resident 1 was at risk for falls related to inability to stand, need of assistance to move from place to place, decreased muscle coordination. During a record review of Fall-risk Care Plan ' , revised 10/17/22, showed Resident 1 is high risk for falls [related to] Unaware safety needs, Poor communication/comprehension, Deconditioning, poor trunk control, Incontinence (lack of voluntary control over urination or defecation), Chair bound. The care plan showed, facility ' s goal was The [Resident 1] will not sustain serious injury . and the interventions as Two-person assistance with transfers, bed mobility . During an observation and interview on 11/14/22, at 10:00 a.m., with Certified Nursing Assistant (CNA1), Resident 1 was sitting in a wheelchair in the hallway outside her room. CNA 1 stated Resident 1 had communication difficulties, but staff was able to understand her needs. CNA 1 then walked in Resident 1 ' s room, Resident 1 ' s bed was the first bed next to the door with foot of the bed facing the cabinets and drawers in the room. During a phone interview on 11/14/22, at 12:07 p.m., Certified Nursing Assistant (CNA2) stated she was not assigned staff on 10/23/22 but she helped the assigned staff (CNA 3) to transfer Resident 1 from wheelchair to bed. CNA 2 stated around 09:30 p.m., CNA 3 called her to help with the transfer. During a phone interview on 11/18/22, at 2:36 p.m., CNA 2 stated on 10/23/22 evening, after transferring Resident 1, she moved the wheelchair by the door and closed the curtain, obstructing her view of Resident 1. CNA 2 stated CNA3 was at the closet by the foot end of the bed with her back turned towards Resident 1. CNA 2 stated CNA 3 was facing the closet and the door, searching for incontinence supplies with one hand in the closet and talking to CNA 2., who was standing by the door. CNA 2 stated CNA3 turned around and saw Resident 1 rolling from bed, and asked CNA 2 who was closer to Resident 1 ' s bed, to grab her. CNA 2 stated she did not let Resident 1 go on the floor and grabbed Resident 1 by her belly, while Resident 1 hit her leg with the bed frame or the floor. CNA 2 stated Resident 1 started screaming in pain. CNA 2 stated without notifying the Charge Nurse on duty and completing a post fall assessment, CNA 2 put Resident 1 back to bed by herself. CNA 2 stated it was an avoidable situation, if CNA 3 had put all of Resdient 1's stuff (night gown, briefs) next to Resident 1's bedside and was prepared to complete ADL care, instead of searching for ADL care supplies in the closet where CNA 3 did not have a direct view of Resident 1. During a phone interview on 11/14/22, at 12:28 p.m., Certified Nursing Assistant (CNA3) stated she was the assigned direct care staff for Resident 1 on the evening of 10/23/22. CNA 3 stated she asked CNA 2 to assist her to put Resident 1 back to bed out of the wheelchair. CNA 3 stated she was at the foot of the bed getting briefs from the closet while CNA 2 transferred Resident 1 and put her in bed. CNA 3 stated CNA 2 put Resident 1 on her right side with her legs at the right edge of the bed, and bottom towards the middle of the bed. CNA 3 stated as she was turning around from the closet, she noticed Resident 1 ' s both legs were swinging on the right side of the bed while CNA 2 was by the door leaving the room. CNA 3 stated she yelled grab her, she is going to fall CNA 2 grabbed Resident 1, while Resident 1's both knees touched the floor on the right side of the bed. CNA 3 stated there were no fall protection padded mats on the floor. CNA 3 stated the fall was avoidable because Resident 1 was already at the edge of the bed and weight of her knees made her move . During a record review of Resident 1 ' s Progress Notes dated 10/23/22, Licensed Vocational Nurse (LVN3) documented Reported by CNA, [Resident 1] was in her bed and rolling out of the bed. CNA who was closer to [Resident 1] caught her up to prevent the fall. She was holding [Resident 1] from the back and was not sure if [Resident 1] hit the ground or bed frame. Head to toe assessment was done, [Resident 1] was [complained of] pain to right knee and lower leg skin discoloration noted .able to move all extremities except right lower leg .[physician] was notified with order for stat [immediate] X-Ray [images of internal bones, and organs] to right knee and leg . During a phone interview on 11/14/22, at 12:48 p.m., with Licensed Vocational Nurse (LVN3), LVN3 stated she was the assigned charge nurse for Resident 1 on 10/23/22. LVN 3 stated she thought Resident 1 ' s fall out of bed was questionable as she was not sure if the staff safely transferred and positioned her in bed. LVN3 stated that Resident 1 does not roll, she is always on one side, I have never seen her move, she cannot move, can barely flex, and extend, can only wiggle her toes and fingers . For her to roll to another side, it ' s not possible. LVN 3 also stated after the fall on 10/23/22, Resident 1 was crying in pain in right lower extremity during her post fall assessment and told her, It hurt, it hurt and she gave her Tylenol [pain reliver] 650 milligrams [unit of measurement] for pain at 10:00 pm. During a record review of Radiology Results Report, dated 10/24/2022, showed Resident 1 had malaligned Acute (sudden onset) Proximal Tibia/Fibula ( top/knee end of two long bones in lower leg) Fractures (broken bone). During a record review of nursing Progress Notes, dated 10/24/2022, indicated Resident 1 was transferred to ACH on 10/24/22 for Fracture. During a review of ACH 1 Emergency Department after visit summary dated 10/24/22, the summary showed Resident 1 ' s right lower leg was splinted and was given pain medication for right leg fracture.

Based on resident and staff interview, and record review, the facility failed to ensure that one of three residents (Resident 1) received adequate supervision and ensured that her wheel chair seat belt was secured when she was transported on the bus to school. Resident 1 was dependent on staff for assistance with all care needs and went on a bus in the morning to her school. CNA1 took the resdient to the bus put the seat belt on then took the seat belt off to put a jacket on the resident and forgot to replace the seat belt. During the bus trip when the bus turned a corner, Resident 1 fell out of her wheelchair on her face and sustained a neck fracture. Findings: According to record review on 1/31/14 at 9:15 AM, Resident 1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 3/10/13 showed that the resident was moderate risk for fall related to being unaware of safety needs and poor communication and comprehension. The care plan interventions included anticipate and meet the residents needs, educate residents, family, care givers about safety reminders and what to do if fall occur, and the resident needs prompt response to all requests for assistance. The MDS (Minimum Data Set-an assessment tool) dated 1/17/14 showed that the resident was total dependent on staff for her needs. The MDS further showed that Resident 1 was dependent on staff for repositioning and turning, and Resident 1 used a wheel chair for mobility (move without restrictions). The nurses notes dated 1/17/14 at 3:18 PM showed that the resident per family member and the school had an incident in the morning when in the bus on the way to her school. Resident 1 was transferred to the emergency room and was admitted to the hospital. The emergency room report on 1/17/14 stated that the Resident 1 was on a transport vehicle that turned a corner and she fell out of her chair, hit her head and it was unknown if she had loss of consciousness. The emergency room notes continued to state that it was also unknown whether the resident was strapped into her wheel chair. The emergency room notes further stated in the emergency room Resident 1 was noted to have some midline cervical spine tenderness as well as a forehead abrasion and workups showed evidence of cervical (neck) spine (back) fracture . The x-ray report of the cervical spine dated 1/17/14 showed that Resident 1 had an acute fracture at C3-C4 (Cervical). The discharge summary from the acute hospital dated 1/21/14 showed that Resident 1 had a mechanical fall with C3-C4 cervical displaced fracture and conservative management. The discharge summary continued to state that Resident 1 had a history of [REDACTED]. The discharge summary further stated that Resident 1 was transporting in a bus the morning she was admitted when the bus made a sudden turn, the wheelchair dislodged and Resident 1 fell face first onto the floor. The nurses notes dated 1/29/14 at 5:52 PM showed that Resident 1 was readmitted to the facility at 5:30 PM by ambulance via gurney with [DIAGNOSES REDACTED]. During an interview on 1/31/14 at 9:30 AM Resident 1 was observed lying in her bed with a neck collar in place. Resident 1 stated that she fell on the bus, the CNA (certified nurse aide) forgot to put on her seat belt. On 2/4/14 at 7:30 AM CNA 1 stated that the night shift CNA gets Resident 1 up in chair, day shift CNA feeds the resident and the resident goes off to school. CNA 1 stated that on day of incident he did everything he normally does for the resident. CNA 1 further stated that he took the seat belt off to put a jacket on the resident and forget to put the seat belt back on.