Every finding on record at San Gabriel Valley Medical CTR D/P SNF

Based on observation, interview, and record reviews, the facility failed to maintain safe, clean, comfortable, sanitary and home-like environment for two (2) of three (3) sampled residents (Resident 21 and 30) reviewed for environment by failing to: 1.Ensure that Resident 21's gastrostomy tube (G-tube pump, an electronic, battery-powered medical device that delivers liquid nutrition, fluids, or medication at a controlled rate directly into a person's stomach through a surgically placed abdominal tube) and pole were free of dried milk residue. 2.Ensure that the power strip, with four power cords plugged in, had electrical cables that were not coiled and tangled with Resident 21's G-tube pump base. 3.Ensure Resident 30's television's (TV's) power cord was not plugged into the distant outlet of the room. These deficient practices created an unsafe and unsanitary environment for Residents 21 and 30 and had the potential to result in accidents and the spread of disease and infection.Findings: 1. During a review of Resident 21's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of chronic respiratory failure (long term condition where the lungs cannot properly exchange oxygen and carbon dioxide over time). During a review of Resident 21'S Minimum Data Set (MDS – a resident assessment tool), dated 4/22/2026 the MDS indicated the Resident 21 was assessed to have severe impairment with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were severely impaired. It indicated, Resident 21 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in eating, oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene and roll left and right. During a concurrent observation and interview on 4/25/2026 at 10:10 AM with Nurse Manager (NM) in Resident 21's room, NM stated Resident 21's G-tube pump and G-tube pole base were dirty and had visible dried milk drippings on them. NM also stated the power strip, with four power cords plugged in, had electrical cables that were coiled and tangled with Resident 21's G-tube pump base. 2. During a concurrent interview and record review on 4/26/2026 at 3:57 PM with Registered Nurse (RN) 2, the facility's Policy and Procedures (P&P) titled Environmental Safety, revised on 4/20/2026, were reviewed. RN 2 stated the P&P indicated the purpose of P&P was to ensure a safe physical environment for patients, staff, and visitors. RN 2 also stated the facility did not follow the P&P for environmental safety because of the tangled and coiled power cords was unsafe for the resident and is a trip or fire hazard. RN 2 also stated milk drippings and unorganized electric cords are not acceptable. During an interview on 4/7/2026 at 12:03 PM with the License Vocational Nurse (LVN) 3, LVN 3 stated no milk drippings should be on the G-tube pump and pole, for infection control and cleanliness because this could possibly harbor bacteria that can cause sickness to Resident 21. LVN 3 also stated the coiled electrical cord on Resident 21's G-tube pole was not acceptable because it can cause electrocution to residents and staff. LVN 3 also stated everything needs to be clean and organized. 3.During a review of Resident 30's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of chronic heart failure (a long-term condition where the heart muscle is weakened or damaged and cannot pump blood efficiently, leading to reduced oxygen delivery to body). During a record review of Resident 30's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 30 was dependent with eating, oral hygiene, toileting hygiene, shower, upper and lower body dressing, and personal hygiene. During an observation on 4/25/2026 at 8:30 AM, in Resident 30's room, Resident 30's head- of- bed was close to the wall and there was a space between the foot of the resident's bed and the wall across it for staff, residents or visitors to pass by/ walk through. There was a TV on top of the resident's bedside table, and it was positioned on the left side of the bed. The TV's power cord was plugged in the power outlet located on the distant side of the TV (wall across Resident 30's bed). During a concurrent observation and interview with RN 3 on 4/26/2026 at 3:45 PM, Resident 30 was observed in the room, with a TV on top of the resident's bedside table positioned on the left side of the resident's bed while the TV cord was plugged into the power outlet located on the distant side of the TV and across the resident's bed. RN 3 stated the TV's power cord was an accident or trip hazard for the staff as it is plugged onto wall across the TV and resident's bed (distant from the TV) and facility staff can tripped when walking inside the room. During an interview on 4/27/2026 with Facility's Materials Director (FMD) and Facilities (FC) Coordinator, FMD and FC both stated Resident 30's TV power cord should not be plugged on the distant side where the TV is situated. Both FMD and FC stated maintenance staff should have been informed to provide the nurses where to plug the TV's cord where it is not blocking the way inside the room or going to the resident's right side of the bed. During a review of facility's P&P titled Environment of Care Manual, dated 2/2002, the P&P indicated in order to provide a safe working environment, it is essential that all employees have access to information regarding safe use of electrical equipment.

Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for two (2) of four (4) sampled residents (Resident 12 and 36) in accordance with the facility's policy and procedure (P&P) when:Contact isolation precaution (prevent the spread of infections transmitted by direct or indirect contact with a patient or their environment) signage was not posted outside Resident 12's room who was on contact isolation precaution.Licensed Vocational Nurse 3 (LVN 3) failed to don (put on) and doffed (the safe and orderly removal) personal protective equipment (PPE, such as gowns, masks, goggles, gloves) during medication pass (a structured, routine procedure in healthcare settings, such as nursing homes, where nurses or qualified personnel administer scheduled medications to patients) for Resident 36 who is in contact isolation on 4/27/2026. These deficient practices have the potential to result in a widespread infection in the facility that could compromise the health of the residents, visitors, and staff.Findings:1. During a review of Resident 12's admission Record, the admission record indicated Resident 12 was originally admitted to the facility on [DATE], with diagnosis of respiratory failure (a condition where there's not enough oxygen in your body). During a review of Resident 12's Minimum Data Set (MDS- a resident assessment tool), dated 3/11/2026, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 12 was dependent (helper does all of the effort) with eating oral hygiene, toileting hygiene, shower, upper and lower body dressing, and personal hygiene. During a review of Resident 12's Interdisciplinary Team (IDT, a collaborative group of professionals, including physicians, nurses, therapists, and social workers, who develop a personalized care plan for residents), dated 4/15/2026, indicated a documentation that Resident 12 is on contact isolation. During a review of Resident 12's Care Plan (CP) regarding actual infection, dated 4/17/2026, indicated interventions such as instruct/monitor infection control measures and contact precautions. During an observation on 4/25/2026 8:23 AM, Resident 12's isolation signage outside the room indicated enhanced barrier precaution (EBP, use of PPE beyond anticipated blood and body fluid exposures). During a concurrent observation and interview on 4/25/2026 at 2:15 PM with Registered Nurse 5 (RN 5), RN 5 verified the signage posted outside Resident 12's room is EBP signage. During a concurrent record review and interview on 4/26/2026 2:52 PM with Infection Prevention Nurse (IPN), Infection Control Log for April 2026 were reviewed. IPN stated Resident 12 is on contact isolation for Carbapenem-resistant Enterobacterales (CRE, family of germs that is difficult-to-treat) and Vancomycin-Resistant Enterococci (VRE, a bacteria that normally live in the intestines but have developed resistance to vancomycin [a powerful antibiotic]). IPN stated the isolation signage outside Resident 12's room should be contact isolation sign and not EBP. IPN stated placing a contact isolation signage was important to alert staff and visitors to wear appropriate PPE before entering Resident 12's room. IPN stated contact isolation means to covered up, wear PPE at the doorstep, to prevent and avoid possibility of infection transmission. IPN added that not posting the correct isolation signage is a noncompliance issue and placed the residents, staff and/ or visitors at risk for spread of infection. 2. During a review of Resident 36's admission Record, the admission record indicated Resident 36 was originally admitted to the facility on [DATE], with diagnosis of respiratory failure. During a review of Resident 36's MDS, dated [DATE], the MDS indicated the resident's cognitive for daily decision making was severely impaired. The MDS indicated Resident 36 was dependent with eating oral hygiene, toileting hygiene, shower, upper and lower body dressing, and personal hygiene. During a review of Resident 36's Care Plan (CP) regarding actual infection, dated 5/27/2025, revised on 2/25/2026, indicated interventions such as instruct/monitor infection control measures and contact precautions, hand washing before and after patient care, and PPE (gown, mask, gloves) per facility protocol. During a concurrent medication administration observation and interview on 4/27/2026 at 9:15 AM, LVN 3 walked out of Resident 36's room with PPE and walked across the hallway to return the vital signs machine. LVN 3 stated I did not change PPE because I only check Resident 36's heart rate quickly and have to take the vital signs machine out of the room before I pass medications. During an interview on 4/27/2026 at 11:58 AM with Registered Nurse 3 (RN 3), RN 3 stated Resident 36 has a contact isolation signage outside the resident's room, and that means that everyone going in should use PPE which included isolation gown, gloves and mask, and remove PPE before stepping out of the resident's room. RN 3 stated LVN 3 did not and should have removed PPE before coming out of Resident 36's room and donned a new set of PPE before entering back to Resident 36's room. RN 3 stated what LVN 3 did was an infection breach, other staff and visitors who can be in the hallway might come in contact with LVN 3 who came out from a contact isolation room with soiled PPE. RN 3 stated walking out of a contact isolation room without removing the soiled PPE is not a good practice. During a concurrent record review and interview on 4/27/2026 1:35 PM with IPN, Infection Control Log for April 2026 were reviewed. IPN stated Resident 36 is on contact isolation for CRE, methicillin-resistant staphylococcus aureus (MRSA, a bacteria that does not respond to antibiotics), and Extended-Spectrum Beta-Lactamase (ESBL, a bacteria that is difficult to treat). IPN stated the licensed nurses should doffed PPE before leaving contact isolation room, and to do hand hygiene (the act of cleaning hands) and donned PPE before going back to the same room or to another resident's room. IPN stated LVN 3 coming out of a contact isolation room with the used or soiled PPE is not a good practice. During a review of facility's P&P titled Personal Protective Equipment, dated 3/2003, the P&P indicated all attire and equipment used for the care and treatment of patients in isolation are not to be worn outside of the isolation room. During a review of facility's P&P titled Infection Control, dated 4/2022, the P&P indicated each staff member assigned in the unit is responsible for ensuring that infection prevention and control procedures are followed.

Based on observation, interview, and record review, the facility failed to follow proper food-handling procedures and to maintain the food service area in a clean and sanitary manner, in accordance with the facility's policies and procedures (P&P) when: One can opener was dirty, had peeled metal lining, and was chipped and rusted.One food processor was cracked and had white, crusty buildup.One clear plastic bag of breaded chicken was not labeled with the item name and the open date (date opened or first use).A container of chopped garlic in the refrigerator was not sealed.The rubber seal on the ice machine cover door was cracked and falling apart.A container of ready-mixed mashed potato powder in the kitchen spice rack was not sealed properly. These deficient practices have the potential to expose residents to pathogens (germs), placing them at risk for developing foodborne illness (food poisoning), which may cause symptoms such as upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever.Findings: 1. During a concurrent observation and interview on 4/25/2026 at 7:57 AM in the facility's kitchen with Food Service Worker (FSW) 1, FSW 1 stated the can opener observed on the kitchen table was dirty, had peeled of metal lining, and was chipped and rusted. 2. During a concurrent observation and interview on 4/25/2026 at 7:58 AM in the facility kitchen with FSW 1, FSW 1 stated that the food processor observed was cracked and had white, crusty buildup. 3. During a concurrent observation and interview on 4/25/2026 at 8:00 AM in the facility kitchen with FSW 1, FSW 1 stated a clear plastic bag of breaded chicken was not labeled with the item name and open date. 4. During a concurrent observation and interview on 4/25/2026 at 8:02 AM in the facility kitchen with FSW 1, FSW 1 stated, a container of chopped garlic observed in the produce refrigerator was not sealed. 5. During a concurrent observation and interview on 4/25/2026 at 8:11 AM in the facility kitchen, FSW 1 stated the rubber seal on the ice machine cover door was observed to be cracked and falling apart. 6.During a concurrent observation and interview on 4/26/2026 at 11:00 AM in the facility kitchen with the Dietary Director (DD), the DD stated the container of ready mixed mashed potato powder observed in the kitchen spice rack was not sealed properly. During an interview on 4/26/2026 at 1:49 PM with FSW 1, FSW 1 stated the can opener should be in good condition and should not be dirty. FSW 1 also stated it was not acceptable that the can opener on the kitchen table was dirty, peeling off metal lining, chipped, and rusted because this could cause food contamination. FSW 1 stated the can opener needs to be cleaned after every use. During the same interview on 4/26/2026 at 1:49 PM with FSW 1, FSW 1 stated that all containers with food inside were supposed to be sealed properly and airtight to prevent food contamination and sickness, such as diarrhea or stomachache. FSW 1 added the food containers or food items should have been labeled with an open date (date of first use) and labeled the item name. FSW 1 stated if containers are not sealed properly, tiny particles can get in, which can cause mold, insects, and contamination. FSW 1 also stated this can affect the quality and flavor of the food. During the same interview as above on 4/26/2026 at 1:49 PM with FSW 1, FSW 1 stated the unlabeled plastic bag of breaded chicken should be labeled with the item name and with the open date. FSW 1 explained that it was important to know when the food item was opened so the kitchen staff know until when they can use the food item or serve the food, as serving food past its safe date or expiration date could result in serving spoiled food. During an interview on 4/26/2026 at 1:52 PM with FSW 1, FSW 1 stated the food processor should be in good condition, not cracked, and it should not have white buildup, discoloration, or multiple scratches. FSW 1 stated this is not acceptable because it can cause food contamination. During an interview on 4/26/2026 at 1:55 PM with FSW 1, FSW 1 stated the rubber seal (gasket) on the ice machine cover door was cracked and falling apart and the plastic door on the bottom right corner had an open crack. FSW 1 stated the ice machine was not supposed to be in damaged condition. FSW 1 state there should be no calcification (a buildup of minerals like calcium from water that forms hard, white residue inside the ice machine, which can affect its function) and no cracks. FSW 1 also stated that it was possible that tiny rubber particles could fall into the ice, which could result in contamination and sickness. During a concurrent interview and record review on 4/26/2026 at 2:55 PM with the Clinical Nutritional Manager (CNM), the facility's Policy and Procedures (P&P) titled Infection Control, revised date 1/2025, was reviewed. CNM stated the P&P indicated all counters, shelves, equipment, and utensils are kept clean and maintained in good repair, and are free of breaks, open seams, cracks, or chipped areas. The CNM also stated that the P&P indicated can openers will be washed in hot, soapy water daily. During a concurrent interview and record review on 4/26/2026 at 2:58 PM with the CNM, the facility's P&P titled Food Storage: Left Over, Refrigerator Stock, revised date 1/2025, was reviewed. The CNM stated that the P&P indicated that food is properly covered, refrigerated, and stored appropriately to ensure safe consumption. The P&P also indicated that all foods are to be covered, labeled, and refrigerated. Items are dated, and a clear identification (product label or written label) is placed on containers. The CNM stated that the facility's P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure two (2) of 2 medication carts (Med Cart) were not left unattended and locked at all times in accordance with the facility's medication management policy. This deficient practice had the potential for unauthorized access to medications by staff and visitors which could lead to medication overdose (taking a toxic or poisonous amount of a drug or medicine), unauthorized use, adverse reactions (any unexpected or dangerous reactions to a drug), or harmful drug interactions (a reaction between two or more drugs or between a drug, and a food, beverage, or supplement).Findings: During a concurrent observation and interview of the Nurse's Station, on 4/25/2026, at 3:24 PM, Med Cart 2 was left unattended and unlocked. Medications of residents were observed inside the second and third drawers of Med Cart 2. Licensed Vocational Nurse 1 (LVN 1) stated the medication carts locked automatically once the drawers are pushed in. LVN 1 stated medication carts should always be locked when unattended. During an observation of the Nurse's Station, on 4/26/2026, at 4:49 PM, Med Cart 1 was left unattended and unlocked. During an interview, on 4/26/2026, at 4:46 PM, with the Minimum Data Set Nurse (MDS 1), MDS stated Med Carts should be locked at all times. MDS 1 stated licensed nurses need to push the drawers all the way in and listen for the locking sound before walking away from the medication carts. MDS 1 further stated licensed nurses need to make sure the medication carts are locked before walking away to prevent unauthorized staff or visitors from accessing residents' medications. MDS 1 stated unauthorized staff or visitors can steal or take the medications that are not prescribed to them. MDS 1 stated the facility's medication storage policy was not followed when Med Cart 1 and Med Cart 2 were left unlocked and unattended. During a review of the facility's Policy and Procedure (P&P) titled, Medication Management: General, revised 11/2017, the P&P indicated the following:The facility will assure that storage, administration and documentation of medications are managed to maintain patient safety.The facility will assure that access to medications is only available to appropriate licensed staff per regulatory requirements and accreditation standards.Medications are stored securely until preparation for administration.Storage of Medications in patient care areas: all non-controlled medications (medications that have a low potential for abuse, addiction, or physical dependence including prescription and over the counter medications), including refrigerated medications, will be single locked when unattended.

Based on interview and record review, the facility failed to ensure the medical records were complete and accurately documented for one (1) of 1 sampled resident (Resident 19) reviewed for abuse, (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) by failing to document Resident 19's report of hitting his head on the headboard while getting repositioned up in bed (to move a resident from the foot of the bed back toward the head of the bed) by Licensed Vocational Nurse 4 (LVN 4). This deficient practice had the potential to result in incomplete assessment of Resident 19's needs and could lead to a lack of or delay in delivery of necessary care and services.Findings: During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was admitted to the facility on [DATE]. During a review of Resident 19's History and Physical (H&P), dated 1/19/2026, the H&P indicated Resident 19 had diagnoses that included status post cholecystectomy (previously undergone surgical removal of the bladder), recurrent aspiration pneumonia (repeated episodes of lung infection caused by the recurring inhalation of foreign materials into the airways and lungs), and coronary artery disease status post bypass (previous surgical treatment to bypass blocked arteries in the heart using a vessel taken from another part of the body). During a review of Resident 19's Minimum Data Set (MDS- a resident assessment tool), dated 2/11/2026, the MDS indicated Resident 19 was assessed having intact memory and cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 19 was dependent (helper does all of the effort) with eating, toileting hygiene, upper/lower body dressing, personal hygiene, and rolling left and right. During a concurrent observation and interview, on 4/25/2026, at 10:20 AM in Resident 19's room, Resident 19 was observed awake in bed, wearing a Passy Muir Valve (PMV- a one-way speaking valve placed on a tracheostomy tube to allow patients to speak, swallow, and breathe more naturally), and accompanied by his Responsible Party (RP 1). Resident 19 stated LVN 4 hit him on the head sometime in 11/2025. Resident 19 stated he informed the Nurse Manager (NM) about the incident but could not remember when he informed NM. During an interview on 4/26/2026, at 2:50 PM, with NM, NM stated sometime in 11/2025, Resident 19 and RP 1 informed her that Resident 19 hit his head while getting pulled up on the bed by LVN 4. NM stated she spoke to LVN 4 about the incident and LVN 4 confirmed Resident 19 head hit his head while LVN 4 provided care and pulled Resident 19 up on the bed. NM stated she did not document the incident between Resident 19 and LVN 4 in Resident 19's medical record. During a concurrent interview and record review of Resident 19's medical records on 4/27/2026, at 8:58 AM with the Minimum Data Set Nurse (MDS 1), MDS 1 stated there was no documentation in Resident 19's medical record by LVN 4 or any licensed nurse that Resident 19 hit his head while pulling him up on the bed. During an interview on 4/27/2026, at 10:44 AM, with LVN 2, LVN 2 stated if a resident reported getting hurt while receiving care, the report should be documented in the residents' medical record. LVN 2 stated the facility staff who was involved in the residents' care and who received the report were responsible for documenting the incident in the residents' medical record. During an interview, on 4/27/2026, at 11:30 AM, with Registered Nurse (1) RN 1, RN 1 stated it was standard practice for facility staff to document incidents that involved residents' care in the medical record. RN 1 stated the documentation should include a description of the incident, head to toe assessment (a systemic physical examination used by nurses to evaluate a resident's overall health status), interventions performed, injuries, and if the physician was notified. RN 1 stated the facility's policy for documentation was not followed. During a review of the facility's policy and procedure (P&P), titled, Charting, Guidelines, dated 4/2022, the P&P indicated the following:All charting should be done as soon as possible after a given event.Keep entries factual and specific. They must be accurate and informative. Document any changes in resident condition as well as steps taken in response to the change. Continue to chart on a resident as often as condition warrants until the condition is resolved. During a review of the facility's P&P, titled, Documentation in the Medical Record, Legal, dated 4/2022, the P&P indicated the following:A clear, concise, accurate, legible, and chronological written history of the Resident's stay will be documented, in accordance with state and federal guidelines, and The Joint Commission (JCAHO- an accreditation organization for hospitals, clinics and nursing homes) standards.Entries should be made as soon as possible after clinical events occur, to ensure accuracy and to provide information relevant to the residents' continuing care.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, administering of drugs and biologicals to meet the needs for two (2) of five (5) sampled residents (Resident 19 and Resident 36) reviewed and observed for medication administration, in accordance with the physician's order and facility's Policy and Procedure (P&P) by failing to ensure: Licensed Vocational Nurse 2 (LVN 2) administered Resident 19's ferrous sulfate (a supplement used to increase iron levels to support red blood cell production) not exceeding 2 hours of the scheduled dosing time of 8 AM on 4/27/2026.LVN 3 administered Resident 36's order for doxazosin (Cardura, medication used to treat high blood pressure and symptoms of an enlarged prostate [a small, walnut-sized gland in males that sits just below the bladder and surrounds the urethra, which produces fluid that helps make semen, which carries sperm]). This deficient practice had the potential for Resident 19 to experience fatigue, shortness of breath or dizziness and for Resident 36 to experience high blood pressure which could result in harm and hospitalization to both residents. Findings: 1.During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was admitted to the facility on [DATE]. During a review of Resident 19's History and Physical (H&P), dated 1/19/2026, the H&P indicated Resident 19 had diagnoses that included status post cholecystectomy (previously undergone surgical removal of the bladder), recurrent aspiration pneumonia (repeated episodes of lung infection caused by the recurring inhalation of foreign materials into the airways and lungs), and coronary artery disease status post bypass (previous surgical treatment to bypass blocked arteries in the heart using a vessel taken from another part of the body). During a review of Resident 19's Minimum Data Set (MDS- a resident assessment tool), dated 2/11/2026, the MDS indicated Resident 19 was assessed having intact memory and cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 19 was dependent (helper does all of the effort) with eating, toileting hygiene, upper/lower body dressing, personal hygiene, and rolling left and right. During a review of Resident 19's Physician's Medications Report, dated 4/27/2026, the Physician's Medications Report indicated a physician's order for ferrous sulfate 300 milligrams (mg- unit of measurement for weight) / (per) milliliters (ml- unit of measurement for volume), give 300 mg via gastric tube (G-tube- a flexible tube surgically inserted through the wall of the abdomen directly into the stomach for feeding, fluid, and medication administration) twice daily with meals. During a review of Resident 19's Medication Administration Record (MAR), from 4/27/2026 to 4/30/2026, the MAR indicated Resident 19 was scheduled to receive ferrous sulfate 300mg/5ml solution at 8 AM. During an observation of the medication pass, on 4/27/2026, at 10:24 AM, LVN 2 administered ferrous sulfate 300mg/5ml solution via G-tube to Resident 19. During an interview, on 4/27/2026, at 10:39 AM, with LVN 2, LVN 2 stated Resident 19's ferrous sulfate was scheduled for 8 AM and 6 PM. LVN 2 stated ferrous sulfate was administered late. LVN 2 stated Resident 19's ferrous sulfate should have been administered no later than 9 AM. During an interview on 4/27/2026, at 12:42 PM, with MDS Nurse (MDS 1), MDS 1 stated Resident 19's ferrous sulfate was administered late. MDS 1 stated not giving Resident 19's ferrous sulfate as ordered can affect the therapeutic levels of medication and his treatment. MDS 1 stated it was important to give the residents' medications as scheduled and ordered by the physician and to follow the facility's P&P for medication administration. During a review of the facility's P&P titled, Medication Management: General, revised 11/2017, the P&P indicated, Medications prescribed more frequently than daily, but no more frequently than every 4 hours may be administered within 1 hour before or after the scheduled dosing time, for a total window that does not exceed 2 hours. 2. During a review of Resident 36's admission Record, the admission record indicated Resident 36 was originally admitted to the facility on [DATE], with diagnosis of respiratory failure (a condition where there's not enough oxygen in your body). During a review of Resident 36's Minimum Data Set (MDS, a resident assessment tool), dated 2/23/2026, the MDS indicated the resident's cognitive for daily decision making was severely impaired. The MDS indicated Resident 36 was dependent with eating oral hygiene, toileting hygiene, shower, upper and lower body dressing, and personal hygiene. During a review of Resident 36's Medication Reconciliation Report, dated 3/25/2026, Medication Reconciliation Report indicated the following orders: Doxazosin one (1) mg tablet, give 2 mg daily via percutaneous endoscopic gastrostomy (PEG tube, a soft feeding tube placed through the skin directly into the stomach to deliver nutrition, fluids, and medications), hold if systolic (the top number in a blood pressure reading) blood pressure is less than 95. For diagnosis of urinary retention, start date of 12/25/2025. Sodium chloride (a compressed salt pill) tablet 1 gram (unit of measurement), three (3) times a day via gastric tube. For hyponatremia (a condition where the sodium [salt] level in your blood is abnormally low), with start date of 3/18/2026. Polyethylene glycol (MiraLAX, laxative used to treat constipation), 17 grams packet, 1 each, 2 times a day via gastric tube, mix with four (4) to eight (8) ounces (unit of measurement) of water. For constipation, with start date of 10/20/2025. During a concurrent medication administration observation in Resident 36's room and interview on 4/27/2026 at 9:28 AM with LVN 3, LVN 3 stated she was not administering Resident 36's doxazosin order because the resident's heart rate was 72. During a concurrent record review and interview on 4/27/2026 at 11:35 AM with Registered Nurse 3 (RN 3), Resident 36's medication administration record (MAR) was reviewed. RN 3 verified Resident 36's doxazosin was documented not given on 4/27/2026 at 9:19, LVN 3's documentation indicated hold order for heart rate of 72. During an interview on 4/27/2026 at 4:26 PM with RN 1, RN 1 stated the doxazosin order for Resident 36 was important and was ordered to be administered once a day. RN 1 stated that if Resident 36 missed the medication, the resident might not be able to urinate and could lead to high blood pressure. RN 1 stated it was important to read medication orders properly and completely to ensure medication was administered to residents as indicated. During a review of facility's P&P titled, Medication Management: Administration of Medication by Nursing, dated 10/2003, the P&P indicated to use the MAR when administering medications. Do not give from memory. Verify medication label with MAR. The P&P indicated if vital signs are required for the administration of the medication, they must be taken within one hour by nursing personnel prior to pouring the medication. Record the reading and administer the medication and chart that it was given. The P&P also indicated special considerations for Antihypertensives medications: 1. Check the MAR, medication label or physician's order to determine blood pressure rates that the physician requests to be notified for and/or for which to hold the medication. 2. Take blood pressure before administering. Hold the medication if the blood pressure under prescribed parameters and notify the physician.

Based on observation, interview, and record review, the facility failed to secure the confidential medical records for one (1) of (1) sampled residents reviewed for privacy (Residents 33) as indicated on the facility's policy and procedure (P&P) titled Resident Privacy and Confidentiality. This deficient practice had the potential to violate the resident's right to confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the resident and/or the resident's representative) and privacy and misuse of Resident 33's Protected Health Information (PHI, any information that relates to an individual's health status, medical history, or treatment).Findings: During a review of Resident 33's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with admitting diagnoses of acute and chronic respiratory failure with hypoxia (long term breathing problem that became suddenly worse and blood oxygen level is too low). During a review of Resident 33'S Minimum Data Set (MDS - a resident assessment tool), dated 3/3/2026, the MDS indicated the resident was assessed to have severe impairment with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were severely impaired. It indicated, Resident 33 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in eating, oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene and roll left and right. During an observation on 4/25/2026 at 7:48 AM in the hallway, observed computer was left open and unattended displaying Resident 33's flow chart selection. Observed a few facility staff and three visitors passing by the hallway. During an interview on 4/26/2026 at 4:08 PM with the Registered Nurse (RN) 2, RN 2 stated, it was Respiratory Therapist (RT) who left the computer open displaying Resident 33's flow chart selection on 4/25/2026 in the hallway. RN 2 also stated the computer monitor should be turned off when the staff is stepping away from the computer to comply with HIPAA (Health Insurance Portability and Accountability Act, law that protects the privacy and security of a person's health information. Medical information should be kept private; only authorized people can see or share it. Health care workers must protect patient/ resident information). RN2 also stated this helps prevent identity theft and emphasized that privacy must be protected at all times. During a concurrent interview and record review on 4/27/2026 at 2:57 PM with the Nurse Manager (NM), the facility's P&P titled Resident Privacy and Confidentiality, revised on 5/16/2026, was reviewed. NM stated the P&P indicated that all staff using a computer must not leave the workstation or terminal unattended without first logging off or blanking the screen or using a screen saver. NM also stated the facility did not follow its P&P if when the staff left their computer screen open on 4/25/2026 in the hallway.

Based on interview and record review, the facility failed to ensure an accurate assessment of the Minimum Data Set (MDS, a resident assessment tool) for one of five sampled residents (Resident 34) reviewed for unnecessary medication, to reflect the resident's diagnosis of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). This deficient practice had the potential for the facility not to develop and implement an individualized care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives, interventions and timeframes to meet a resident's medical, nursing, and mental psychosocial needs) which could negatively affect Resident 34's overall well-being.Findings: During a review of Resident 34's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE], with diagnosis of respiratory failure (a condition where there is not enough oxygen in the body). During a record review of Resident 34's Minimum Data Set, dated [DATE], the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 34 was dependent (helper does all of the effort) with eating oral hygiene, toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. Resident 34's active diagnosis did not indicate DM. The MDS indicated Resident 34 received insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injections (the act of forcing a liquid, such as medicine, into the body using a needle). During a review of Resident 34's Care Plan, dated 4/10/2026, the Care Plan indicated Resident 34 is at risk for complications from diabetes related to hypoglycemia (abnormally low blood sugar levels) and hyperglycemia (high level of sugar in the blood). The Care Plan indicated interventions included were the following:Finger stick (quick, easy test where a tiny lancet gently pricks the fingertip to get a small drop of blood for checks like blood sugar) as ordered.Monitor for signs and symptoms hypoglycemia.Implement hypoglycemia protocol as needed.Give sliding scale insulin (way to adjust insulin doses based on the resident's current blood sugar level) as ordered. During a concurrent record review and interview on 4/27/2026 at 4:07 PM with Registered Nurse 1 (RN 1), Resident 34's medical records were reviewed. RN 1 stated Resident 34 has an order of insulin for diabetes. RN 1 stated Resident 34's diagnosis of diabetes was not reflected in the resident's MDS, dated [DATE]. During an interview on 4/27/2026 at 5 PM with MDS 1 (Minimum Data Set Nurse), MDS 1 stated Resident 34's diagnosis of diabetes was not and should have been reflected in the resident's MDS, dated [DATE]. The MDS 1 stated it was important for the MDS to be accurate to ensure the development and implementation of an individualized resident care plan. During a review of the facility's Policy and Procedure (P&P) titled, MDS-Long Term Care, dated 4/2022, the P&P indicated a purpose to establish a process that will ensure all required MDS assessments will be completed in timely and accurate manner to form an individualized care plan, to address Medicare reimbursement, and to monitor the quality of care for the resident.

Based on interview and record review, the facility failed to meet professional standards of quality for one (1) of one sampled resident (Resident 19) reviewed for abuse, by failing to assess and notify the physician after Resident 19 reported hitting his head on the headboard while getting repositioned up in bed (to move a Resident ensure a timely from the foot of the bed back toward the head of the bed) by Licensed Vocational Nurse 4 (LVN 4). This deficient practice has the potential to result in a lack of or delay in delivery of necessary care and services.Findings: During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was admitted to the facility on [DATE] . During a review of Resident 19's History and Physical (H&P), dated 1/19/2026, the H&P indicated Resident 19 had diagnoses that included status post cholecystectomy (previously undergone surgical removal of the bladder), recurrent aspiration pneumonia (repeated episodes of lung infection caused by the recurring inhalation of foreign materials into the airways and lungs), and coronary artery disease status post bypass (previous surgical treatment to bypass blocked arteries in the heart using a vessel taken from another part of the body). During a review of Resident 19's Minimum Data Set (MDS- a resident assessment tool), dated 2/11/2026, the MDS indicated Resident 19 was assessed having intact memory and cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 19 was dependent (helper does all of the effort) with eating, toileting hygiene, upper/lower body dressing, personal hygiene, and rolling left and right. During a concurrent observation and interview, on 4/25/2026, at 10:20 AM in Resident 19's room, Resident 19 was observed awake in bed, wearing a Passy Muir Valve (PMV- a one-way speaking valve placed on a tracheostomy tube to allow patients to speak, swallow, and breathe more naturally), and accompanied by his Responsible Party (RP 1). Resident 19 stated LVN 4 hit him on the head sometime in 11/2025. Resident 19 stated he informed the Nurse Manager (NM) about the incident but could not remember the date he informed NM. During an interview on 4/26/2026, at 2:50 PM, with NM, NM stated sometime in 11/2025, Resident 19 and RP 1 informed her that Resident 19 hit his head while getting pulled up on the bed by LVN 4. NM stated she did not assess or notify the physician after Resident 19 informed her he hit his head on the headboard. During a concurrent interview and record review of Resident 19's medical records on 4/27/2026, at 8:58 AM with the MDS Nurse (MDS 1), MDS 1 stated there was no documentation in Resident 19's medical record indicating that staff assessed the Resident 19 or notified his physician after he reported hitting his head while being pulled up in bed by LVN 4 in 11/2025. During an interview on 4/27/2026, at 10:44 AM, with LVN 2, LVN 2 stated licensed nurses should assess the resident and notify the physician if the resident reports hitting his head while receiving care from staff. LVN 2 stated it was important to notify the physician what the resident reported so proper tests and assessments are ordered. LVN 2 stated it was important that assessments and tests are done after a resident report being hurt to ensure their safety in the facility. During an interview, on 4/27/2026, at 11:30 AM, with Registered Nurse (1) RN 1, RN 1 stated it was standard practice for facility staff to perform a head to toe assessment (a systemic physical examination used by nurses to evaluate a resident's overall health status) after receiving a report that a resident hit his head while receiving care. RN 1 stated facility staff should also interview the resident and check for injuries. RN 1 stated it was important to notify the physician about the incident so diagnostic tests and specific assessments can be ordered. RN 1 stated it was standard practice to perform a neuro check (neurological check- a quick test to evaluate head injuries) for 72 hours after hitting his head. RN 1 stated if a resident reported hitting his head while getting pulled on the bed then it was considered a change in the resident's condition. During a review of the facility's policy and procedure (P&P), titled, Change in Resident Condition, dated 4/2022, the P&P indicated the following:It is the policy of this facility that all changes of conditions will be communicated to the physician and family or legal representative.All symptoms and unusual signs will be communicated to the physician promptly.The nurse in charge is responsible for notification of physician and family or legal representatives prior to the end of assigned shift when a change in resident's condition is noted.Document resident change in condition and response in Nursing Progress Notes, on 24-Hour Report and update resident care plan as indicated. During a review of the facility's P&P, titled, Charting, Guidelines, dated 4/2022, the P&P indicated the following:Charting should include all assessments of resident condition, all interventions taken to resolve a problem and the progress/lack of progress with the written care plan.Document normal findings as well as abnormal findings as this shows the resident was being assessed.All residents are assessed every shift and a nurse's note is written documenting any change in condition and the care given and at least once daily a nurse note is written.

Based on observation, interview and record review, the facility failed to provide the activity of resident's preference for one of two sampled residents (Resident 19) reviewed for activities in accordance with Resident 19's Activity Assessment. Resident 19 was not able to watch television for more than a year. This deficient practice resulted in Resident 19 not being able to watch television, which had the potential to affect Resident 19's quality of life, sense of self-worth, and psychosocial (how a person's mental/emotional state interacts with their social environment, relationships, and surroundings) well-being and meaningfulness.Findings:During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was admitted to the facility on [DATE]. During a review of Resident 19's History and Physical (H&P), dated 1/19/2026, the H&P indicated Resident 19 had diagnoses that included status post cholecystectomy (previously undergone surgical removal of the bladder), recurrent aspiration pneumonia (repeated episodes of lung infection caused by the recurring inhalation of foreign materials into the airways and lungs), and coronary artery disease status post bypass (previous surgical treatment to bypass blocked arteries in the heart using a vessel taken from another part of the body). During a review of Resident 19's Minimum Data Set (MDS- a resident assessment tool), dated 2/11/2026, the MDS indicated Resident 19 was assessed having intact memory and cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 19 was dependent (helper does all of the effort) with eating, toileting hygiene, upper/lower body dressing, personal hygiene, and rolling left and right. During a review of Resident 19's Activity Assessment, dated 6/3/2024, the Activity Assessment indicated Resident 19 currently preferred to watch television/movies and news/basketball games for leisure and recreation. During a review of Resident 19's Care Plan, dated 2/13/2026, the Care Plan indicated Resident 19 had an actual activity participation deficit related to bedfast/bedrest. The Care Plan interventions indicated to turn on television to provide stimulation. During a concurrent observation and interview, on 4/25/2026, at 10:30 AM in Resident 19's room, Resident 19 was observed awake in bed, wearing a Brand 1 Valve (PMV- a one-way speaking valve placed on a tracheostomy tube to allow patients to speak, swallow, and breathe more naturally). Resident 19 was accompanied by his Responsible Party (RP 1). RP 1 stated Resident 19 liked watching the news and sports. Resident 19 pointed at the television and stated his television has not worked for almost two years. RP 1 stated they (RO 1 and Resident 19) informed facility staff numerous times in the past two years that Resident 19's television did not show any channels, and the television was never fixed. Resident 19 stated he was bored and felt like the facility did not care because his television had not worked for a long time. During an interview, on 4/26/2026, at 1:53 PM, with Activities Assistant 1 (AA 1), AA 1 stated Resident 19 was alert, and his (Resident 19) preferred activity was watching sports on television. AA 1 stated Resident 19's television signal was weak which caused the channels to go on and off. AA 1 stated the Engineering Department (department responsible for maintaining equipment, infrastructure, and utilities to ensure resident safety and operations) was informed over a year ago that Resident 19's television was not working. AA 1 stated the facility was Resident 19's home and it was important to keep Resident 19 engaged and stimulated with activities that the resident prefers. AA 1 stated Resident 19 would feel frustrated because his television was not being repaired and is not working. During an interview, on 4/26/2026, at 2:19 PM, with the Nurse Manager (NM), NM stated she was aware (unable to recall since when) that Resident 19's television was not working. NM stated she sent numerous requests to engineering department to have Resident 19's television repaired but the television continued to not get fixed. NM stated it was important for Resident 19 to have a working television in the resident's room because the facility was the resident's home. NM stated the facility was responsible for providing Resident 19 with a homelike environment where the resident can have his preferred activities in his room. NM stated not fixing Resident 19's television after making numerous requests would make Resident 19 feel bored, mad, and ignored. During a record review of the facility's policy and procedure (P&P), titled, Activities Program Requirements, revised 5/2011, the P&P indicated, Activities shall be available on a daily basis.

Based on interview and record review, the facility failed to ensure a bladder training program (use of a timed schedule for bladder based on the resident's identified need and routine to maximize control of the resident's bladder function as much as possible) was implemented for one (1) of 1 sampled resident (Resident 34) reviewed for bowel and bladder care as indicated on the facility's policy and procedure (P&P) and physician's order.This deficient practice had the potential to prevent the restoration of the resident's bowel and bladder function and contribute to the development of a urinary tract infection (UTI-an infection in any part of the urinary system, including the kidneys, bladder, or urethra). Findings:During a review of Resident 34's admission Record, the admission record indicated Resident 34 was originally admitted to the facility on [DATE], with diagnosis of respiratory failure (a condition where there's not enough oxygen in your body). During a record review of Resident 34's Minimum Data Set, dated [DATE], the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 34 was dependent (helper does all of the effort) with eating oral hygiene, toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 34 has indwelling catheter (Foley catheter [brand name] a flexible tube (a catheter) inserted into the bladder that remains (dwells) there to provide continuous urinary drainage). During a review of Resident 34's Nursing Order, dated 4/24/2026, timed 1:45 PM, the Nursing Order indicated an order on 4/22/2026, to start bladder training on 4/23/2026 for three (3) days then discontinue foley. It also indicated to do bladder scan every shift for three days and if bladder scan (test that uses a handheld ultrasound device placed on the lower belly which measures how much urine is in the bladder without needing to insert a catheter) is more than 300 milliliters (ml, unit of measurement), do in and out catheter (also known as an intermittent catheter which is a thin, flexible tube that is briefly inserted through the urethra into the bladder to drain urine and then immediately removed). The order further indicated that if second bladder scan is more than 300 ml, insert back Foley catheter. During a review of Resident 34's Bladder Training record, the record indicated that on 4/23/2026 at 12 midnight, the Foley was clamped and released at 2 AM. The record indicated a last documentation on 4/24/2026 that Resident's 34 Foley was clamped at 9:30 PM and released at 11:30 PM. During a review of Resident 34's Patient Care Flowchart, dated 4/25/2026 at 12:39 AM, the Patient Care Flowchart indicated Resident 34's Foley catheter was discontinued after bladder training protocol. It further indicated that Resident 34 tolerated well, no bleeding noted and will be monitored for voiding. During an interview on 4/26/2025 at 5:13 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that Resident 34's bladder training order was not followed because Registered Nurse 4 (RN 4) discontinued the Foley catheter early. LVN 1 stated that Resident 34's Foley catheter was removed after only two (2) days, and the 3 day bladder training order was not completed. LVN 1 stated that the Foley catheter should have been removed after 3 full days of bladder training. During a concurrent record review and interview on 4/27/2026 at 2:43 PM with RN 3, Resident 34's bladder training record, dated 4/23/2026, was reviewed. RN 3 stated that the bladder training order was not followed because RN 4 removed the Foley catheter on the second day of training. RN 3 stated that not completing the 3 day bladder training did not allow enough time for Resident 34's bladder to return to normal function. RN 3 further stated as a result, six (6) hours after the Foley catheter was removed, Resident 34 retained 400 ml of urine, and an in and out catheterization was performed on 4/25/2026 at 6:16 AM to drain the urine. RN 3 stated not following the physician's order was not the facility's practice. RN 3 added that bladder training was important because it helps staff to be aware and understand the residents' voiding patterns and timing. During a concurrent record review and interview with RN 1 on 4/27/2026 at 3:38 PM, Resident 34's medical records were reviewed. RN 1 stated that Resident 34 was admitted on [DATE] with a Foley catheter for wound management. RN 1 stated that on 4/22/2026, bladder training was ordered to start on 4/23/2026. RN 1 stated that bladder training began on 4/23/2026 at 12 AM and should have ended on 4/25/2026 at 11:59 PM. RN 1 stated that bladder training was included in Resident 34's care plan, but it was not implemented. RN 1 stated that Resident 34's bladder training order and care plan were not implemented accordingly. During a review of facility's P&P titled, Bowel and Bladder Management, dated 3/2024, the P&P indicated the following purpose:To enable the resident to regain bowel and/or bladder controlTo restore the resident to the highest level of independence possibleTo improve/restore the resident's dignity, self-image and morale.To avoid the possibility of urinary tract infections from the use of indwelling catheter.To avoid the possibility of skin breakdown due to incontinence.

Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Two (2) medication errors (the observed or identified preparation of administration of medication or biologicals which is not in accordance with the prescriber's order/manufacturer's specifications/accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error which yielded a facility medication error rate of 8% for 2 of 5 sampled residents (Resident 19 and Resident 36) observed for medication administration. Licensed Vocational Nurse 2 (LVN 2) administered Resident 19's ferrous sulfate (a supplement used to increase iron levels to support red blood cell production) more than 2 hours of the scheduled dosing time of 8 AM as indicated on the physician's order and facility's policy. LVN 3 omitted (left out) Resident 36's order for doxazosin (Cardura, medication used to treat high blood pressure and symptoms of an enlarged prostate [a small, walnut-sized gland in males that sits just below the bladder and surrounds the urethra, which produces fluid that helps make semen, which carries sperm]). These deficient practices have the potential to result in harm to Resident 19 and Resident 36 by not administering medications as prescribed by the physician in order to meet their individual medication needs.Findings: During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was admitted to the facility on [DATE]. During a review of Resident 19's History and Physical (H&P), dated 1/19/2026, the H&P indicated Resident 19 had diagnoses that included status post cholecystectomy (previously undergone surgical removal of the bladder), recurrent aspiration pneumonia (repeated episodes of lung infection caused by the recurring inhalation of foreign materials into the airways and lungs), and coronary artery disease status post bypass (previous surgical treatment to bypass blocked arteries in the heart using a vessel taken from another part of the body). During a review of Resident 19's Minimum Data Set (MDS- a resident assessment tool), dated 2/11/2026, the MDS indicated Resident 19 was assessed having intact memory and cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 19 was dependent (helper does all of the effort) with eating, toileting hygiene, upper/lower body dressing, personal hygiene, and rolling left and right. During a review of Resident 19's Physician's Medications Report, dated 4/27/2026, the Physician's Medications Report indicated a physician's order for ferrous sulfate 300 milligrams (mg- unit of measurement for weight) / (per) 5 milliliters (ml- unit of measurement for volume), give 300 mg via gastric tube (G-tube- a flexible tube surgically inserted through the wall of the abdomen directly into the stomach for feeding, fluid, and medication administration) twice daily with meals. During a review of Resident 19's Medication Administration Record (MAR), from 4/27/2026 to 4/30/2026, the MAR indicated Resident 19 was scheduled to receive ferrous sulfate 300mg/5ml solution at 8 AM. During an observation of the medication pass, on 4/27/2026, at 10:24 AM, LVN 2 administered ferrous sulfate 300mg/5ml solution via G-tube to Resident 19. During an interview, on 4/27/2026, at 10:39 AM, with LVN 2, LVN 2 stated Resident 19's ferrous sulfate was scheduled for 8 AM and 6 PM. LVN 2 stated ferrous sulfate was administered late. LVN 2 stated Resident 19's ferrous sulfate should have been administered no later than 9 AM. During an interview on 4/27/2026, at 12:42 PM, with MDS Nurse (MDS 1), MDS 1 stated Resident 19's ferrous sulfate was administered late. MDS 1 stated not giving Resident 19's ferrous sulfate as ordered can affect the therapeutic levels (the specific concentration of a medication in the bloodstream that is high enough to treat a condition effectively but low enough to avoid causing harmful side effects) of medication and his treatment. MDS 1 stated it was important to give the residents' medications as scheduled and ordered by the physician and to follow the facility's P&P for medication administration. During a review of the facility's Policy and Procedure (P&P) titled, Medication Management: General, revised 11/2017, the P&P indicated, Medications prescribed more frequently than daily, but no more frequently than every 4 hours may be administered within 1 hour before or after the scheduled dosing time, for a total window that does not exceed 2 hours. 2. During a review of Resident 36's admission Record, the admission record indicated Resident 36 was originally admitted to the facility on [DATE], with diagnosis of respiratory failure (a condition where there's not enough oxygen in your body). During a review of Resident 36's Minimum Data Set (MDS, a resident assessment tool), dated 2/23/2026, the MDS indicated the resident's cognitive for daily decision making was severely impaired. The MDS indicated Resident 36 was dependent with eating oral hygiene, toileting hygiene, shower, upper and lower body dressing, and personal hygiene. During a review of Resident 36's Medication Reconciliation Report, dated 3/25/2026, Medication Reconciliation Report indicated the following orders: Doxazosin one (1) mg tablet, give 2 mg daily via percutaneous endoscopic gastrostomy (PEG tube, a soft feeding tube placed through the skin directly into the stomach to deliver nutrition, fluids, and medications), hold if systolic (the top number in a blood pressure reading) blood pressure is less than 95. For diagnosis of urinary retention, start date of 12/25/2025. Sodium chloride (a compressed salt pill) tablet 1 gram (unit of measurement), three (3) times a day via gastric tube. For hyponatremia (a condition where the sodium [salt] level in your blood is abnormally low), with start date of 3/18/2026. Polyethylene glycol (MiraLAX, laxative used to treat constipation), 17 grams packet, 1 each, 2 times a day via gastric tube, mix with four (4) to eight (8) ounces (unit of measurement) of water. For constipation, with start date of 10/20/2025. During a concurrent medication administration observation in Resident 36's room and interview on 4/27/2026 at 9:28 AM with LVN 3, LVN 3 stated she was not administering Resident 36's doxazosin order because the resident's heart rate was 72. During a concurrent record review and interview on 4/27/2026 at 11:35 AM with Registered Nurse 3 (RN 3), Resident 36's medication administration record (MAR) was reviewed. RN 3 verified Resident 36's doxazosin was documented not given on 4/27/2026 at 9:19, LVN 3's documentation indicated hold order for heart rate of 72. During an interview on 4/27/2026 at 4:26 PM with RN 1, RN 1 stated the doxazosin order for Resident 36 was important and was ordered to be administered once a day. RN 1 stated that if Resident 36 missed the medication, the resident might not be able to urinate and could lead to high blood pressure. RN 1 stated it was important to read medication orders properly and completely to ensure medication was administered to residents as indicated. During a review of facility's P&P titled, Medication Management: Administration of Medication by Nursing, dated 10/2003, the P&P indicated to use the MAR when administering medications. Do not give from memory. Verify medication label with MAR. The P&P indicated if vital signs are required for the administration of the medication, they must be taken within one hour by nursing personnel prior to pouring the medication. Record the reading and administer the medication and chart that it was given. The P&P also indicated special considerations for Antihypertensives medications: 1. Check the MAR, medication label or physician's order to determine blood pressure rates that the physician requests to be notified for and/or for which to hold the medication. 2. Take blood pressure before administering. Hold the medication if the blood pressure under prescribed parameters and notify the physician.

Based on observation, interview and record review, the facility failed to implement the discharge plan to ensure a safe discharge for one of one sampled residents (Resident 1) by failing to provide a written form of discharge notice to the resident and family members and re-evaluate resident 1's condition for discharge.These deficient practices placed Resident 1 at risk for unsafe discharge.During a review of Resident 1's History and Physical (H&P), dated 5/31/25, the H&P indicated the facility admitted Resident 1 on 5/31/2025 with diagnoses that included chronic hypoxic respiratory failure (lungs consistently cannot get enough oxygen into the blood, leading to low blood oxygen and often normal or low CO2, causing symptoms like breathlessness, bluish skin, fatigue, and fast heart rate, stemming from lung damage or blood flow issues), recent subdural hemorrhage status post craniotomy (surgery to treat a collection of blood between the brain), and protein malnutrition (conditions from insufficient intake or absorption of protein and energy [calories], leading to impaired growth, weakened immunity, muscle wasting, and severe health issues).During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 9/10/2025, the MDS indicated Resident 1 was dependent that helper does all the effort, or two helpers' assistance is required to perform activities including eating, oral hygiene, personal hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, and personal hygiene.During an interview on 12/16/2025 at 2:15 p.m. with Responsible Party (RP) 1, RP 1 stated he had a conversation with Resident 1's physician (MD 1) on 12/1/2025. RP 1 stated he expressed his concerns to the facility staff that Resident 1 was not ready to be discharged home. RP stated on 12/1/2025, he had a conversation at Resident 1's bedside with MD 1. During the conversation, MD 1 stated Resident 1 was going to be discharged to either home or a skilled nursing facility (SNF). RP 1 stated that around 11/26/2025, Resident 1 and family were told by the staff that Medicare would pay for the 100-day stay in the facility, and Resident 1 had exhausted all skilled days for SNF and therefore, after 12/1/2025, and present the amount of the monthly payment that the family was responsible for to continue Resident 1's stay in the facility. RP 1 stated the facility did not provide a 30 days written discharge notice prior to the discharge date and did not have a safe discharge plan for Resident 1. Concurrently, RP 1 stated they called the ombudsman (OM 1) and OM 1 also came to the facility and attended the interdisciplinary team meeting on 12/11/2025. In that meeting, OM 1 pointed out that that the facility had to give 30 days' written notice prior to discharge the Resident home or a skilled nursing facility (SNF).During an observation and interview on 12/16/2025 at 2:45 PM in Resident 1's room, Resident 1 was lying on bed and had limited range of motion of upper and lower extremities. Resident 1 stated he needed assistance to most of the activity of daily living (ADL) and he could only sit up on the bed edge with two-person assistance, and he was not able to walk.During an interview on 12/16/2025 at 3:00 PM with the clinical manager (RN 1), RN 1 stated that MD 1 informed family and Resident 1 regarding the discharge verbally, however, there was no written notice provided to Resident 1's family. RN 1 stated that they have been verbally telling the discharge planning. RN 1 stated that when OM 1 was onsite attending the weekly meeting with 1's family on 12/2/2025, OM1 pointed out that 30 days' written notice was required prior to discharge. RN 1 stated they did not provide the 30-day written notice to Resident 1 or family. RN 1 stated that the facility's discharge policy did not mention the 30 days' discharge written notice was required and they would revise the policy per regulation.During an interview on 12/16/2025 at 3:20 PM with the case manager (CM 1), CM stated RP 1 wanted to take Resident 1 to a SNF when Resident 1 exhausted her 100-day Medicare coverage during the IDT meeting when Resident 1 was admitted to the facility in May 2025. CM 1 stated the facility had a weekly staff meeting to discuss the discharge plan for Resident 1 and CM 1 always learnt from RP 1 that they preferred going to SNF than discharge home, regardless of whether Resident 1 was planned for dual planning, so she thought everyone was at the same goal to discharge Resident 1 was the plan. CM 1 stated she has been trying to place Resident 1 to a SNF and faxed Resident 1 information to about 84 different SNFs; however, only 2 SNFs accepted Resident 1 but both were declined by the family. CM 1 stated that they did not provide the 30-day written notice to Resident 1.During a review of the facility's subacute unit (a unit in the hospital that provides specialized, transitional care bridging the gap between intensive hospital stays [acute care] and returning home) policy and procedures (P&P) titled, Discharge Planning/Notice of Discharge, dated 2/5/2019, the P&P indicated, Once the need for discharge planning has been determined the Case Manager or Social Worker is responsible for coordinating with the resident/responsible party and appropriate disciplines/services (i.e. physician, home health coordinator, dietary, therapy, nursing, etc.). The Case Manager or Discharge Planner will initiate the Notice of Transfer or Discharge including the reason for discharge and provide it to the resident. Currently in this policy, there is no indication of 30 days of written discharge notice required to provide to the resident or resident representative.

Based on observation, interview, and record review, the facility failed to implement treatment for the prevention of pressure ulcer (painful wound caused as a result of pressure or friction) by failing to ensure that the low air loss mattress (LALM, mattress used for residents who are at risk for developing pressure ulcer or already have a pressure ulcer, designed to circulate a constant flow of air) was on the correct settings for three (3) of four (4) sampled residents (Residents 14, 21, and 136) in accordance with the facility's policy and procedure and physician's order. This deficient practice had the potential for Resident 14 and 136 to develop a pressure ulcer and for Resident 21's stage 4 pressure ulcer (full-thickness skin loss in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present) to worsen. Findings: 1. During a review of Resident 14's Admission Record, the Admission record indicated Resident 14 was admitted to the facility on [DATE]. During a review of Resident 14's History and Physical Examination (H&P), dated 5/3/2024, the H&P indicated Resident 14 had a history of cerebrovascular accident (CVA - occurs when blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel) with right sided hemiplegia (severe or complete loss of strength on one side of the body), tracheostomy (a surgically created hole in the windpipe that provides an alternate way of breathing), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). During a review of Resident 14's Minimum Data Set (MDS, resident assessment tool), dated 2/11/2025, the MDS indicated Resident 14 was moderately impaired with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making) The MDS indicated Resident 14 was dependent (helper does all of the effort) with eating, oral hygiene, toileting hygiene, and personal hygiene. The MDS also indicated Resident 14 was at risk of developing pressure ulcers/injuries and had a pressure reducing device for bed. During a review of Resident 14's Care Plan (CP) revised 2/16/2025, the CP indicated Resident 14 had a potential risk for developing pressure ulcer on his sacral and mid back. Staff interventions included were to use low air loss mattress and to position Resident 14 to avoid pressure to affected areas. During a review of Resident 14's Braden Scale (BS, used for predicting pressure sore risk) with an effective date from 3/25/2025 to 4/1/2025, the BS indicated Resident 14 had a score of 13, which indicated Resident 14 was at moderate risk for developing pressure sore. During a review of Resident 14's physician order (PO), dated 5/1/2024, the PO indicated physician's order of low air loss mattress for Resident 14 who had a history of multiple, at least stage 3 pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin.), resident being underweight, low body mass index (BMI, it was a measure that calculated a person's weight in relation to their height.) and high risk for breakdown. During an observation on 3/25/2025 at 9:24 AM in Resident 14's room, Resident 14 was observed in bed with the LALM set at Zone 1 (70 lbs. 40 kg [kilogram-unit of measurement]) During a review of facility 's Low Air Mattress Utilization List - Zone Setting Based on Weight, dated 3/27/2025, indicated Resident 14 weighed 137 lbs. and on Zone 2 setting (105lbs/55kg). During a concurrent observation on 3/26/2025 at 9:32 AM in Resident 14's room and interview with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated Resident 14 weighed 137 lbs. as of 3/22/2025 at 6:17 AM. LVN 3 stated Resident 14's LALM was currently set at level 1 for 70 lbs. LVN 3 stated LALM was set incorrectly and should have been set at Zone 2. LVN 3 stated if the LAL mattress was on a wrong setting, the LALM could worsen Resident 14's pressure ulcer. During a concurrent observation on 3/26/2025 at 9:40 AM in Resident 14's room and interview with Registered Nurse 1 (RN 1), RN 1 stated Resident 14 weighed 137 lbs. and the LALM was set at zone 1, which was too soft for resident's weight. RN 1 stated the LALM setting was too soft, which could exacerbate or worsen the resident's exiting pressure injuries. 45456 2. During a review of Resident 21's Admission Record, the admission record indicated Resident was admitted to the facility on [DATE]. During a review of Resident 21's History and Physical (H&P) dated 8/3/2024. The H&P included Resident 21's diagnoses of Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), chronic respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), and Stage 3 Pressure Ulcer (Full-thickness loss of skin. Dead and black tissue may be visible) of the sacral region (a triangular-shaped bone at the base of the spine just superior to the coccyx [tailbone]). During a review of Resident 21's MDS, dated [DATE], the MDS indicated Resident 21 was severely impaired with cognitive skills for daily decision making. The MDS indicated Resident 21 was dependent with eating, oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene and rolling in bed from left and right. The MDS also indicated Resident 21 has two Stage 1 pressure ulcer (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness) and one Stage 4 pressure ulcer upon admission. It also indicated Resident 21 was on a pressure reducing device for bed. During a review of Resident 21's Care Plan (CP) for skin integrity, dated on 7/11/2024, the CP indicated Resident 21 has potential risk for developing pressure ulcer on the sacral area and left fifth toe. Staff interventions included were to use low air loss mattress and to position Resident 21 to avoid pressure to affected areas. During a review of Resident 21's physician's order, dated 7/11/2024, the physician's order indicated support surface: low air loss mattress. During a review of Resident 21's Braden Scale with an effective date from 3/25/2025 to 3/26/2025, the BS indicated Resident 21 had a score of 12, which indicated Resident 21 was at high risk for developing pressure ulcer. During an observation on 3/25/2025 at 9:17AM inside Resident 21's room, Resident 21 was observed in bed with the LALM set at Zone 1 (70 lbs. 40 kg [kilogram-unit of measurement]) During an observation on 3/27/2025 at 9:20AM inside Resident 21's room, Resident 21's was observed in bed with the LALM set at Zone 1. During a concurrent observation and interview on 3/27/2025 at 9:50 AM with Registered Nurse 1 (RN 1), Resident 21's LALM was observed set at Zone 1. RN 1 stated, LALM was set at Zone 1. The resident (Resident 21)'s weight dated 3/17/2025 was 98 lbs. The LALM should be set at Zone 2 (105 lbs) based on her weight. The resident (Resident 21) has a wound on the sacral area. LALM was used for the resident (Resident 21)'s wound management. If the LALM was set incorrectly, it will not be effective for wound healing. During an interview on 3/28/2025 at 2:01 PM with the Director of Staff Development (DSD), the DSD stated, LALM should be based on resident's weight, or the therapeutic effect will not be effective if the resident has a wound, which might become worse. During an interview on 3/28/2025 at 3:01 PM with the Interim Director of Nursing (IDON), the IDON stated, LALM should be set at resident's weight. LALM should always be in the correct setting to prevent further complication if the resident has a skin damage. 3. During a review of Resident 136's Admission Record, the admission record indicated Resident 136 was admitted to the facility on [DATE]. Resident 136's diagnoses included chronic respiratory failure, cerebrovascular accident, and hypertension. During a review of Resident 136's MDS, dated [DATE], the MDS indicated Resident 136 was severely impaired with cognitive skills for daily decision-making. The MDS indicated Resident 136 was dependent with eating, oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene and roll left and right. During a review of Resident 136s CP, revised 2/16/2025, the CP indicated Resident 136 had a potential risk for skin injury. Staff interventions included were to use low air loss mattress, check skin every shift, inform physician if there were any changes, and to observe and report signs of skin breakdown During a review of Resident 136's BS, with an effective date of 3/28/2025, the BS indicated Resident 136 had a score of 12, which indicated Resident 136 was a high risk for developing pressure sore. During a review of Resident 136's physician order, dated 5/27/2021, the physician's order indicated special therapy bed of low air loss mattress. During an observation on 3/25/2025 at 9:50 AM inside Resident 136's room, Resident 136's was observed in bed with the LALM set at Zone 2 (105 lbs.) During an observation on 3/27/2025 at 9:25AM in Resident 136's room, Resident 136's was observed in bed with the LALM set at Zone 2 (105lbs). During a concurrent observation and interview on 3/27/2025 at 9:37 AM with RN 1, Resident 136's LALM was observed set at Zone 2 (105lbs). RN 1 stated, The resident (Resident 136)'s weight, dated 3/22/2025 was 133 lbs. The LALM should be set at Zone 3 (140 lbs) based on the resident's weight. The resident (Resident 136) does not have any skin breakdown. The LALM was used for resident (Resident 136)'s skin maintenance. If the LALM was set incorrectly, the therapeutic effect of maintaining his skin will not be effective. During a concurrent interview and record review on 3/27/2025 at 3:24 PM, with MDS Coordinator (MDSC), Resident 136's Skin assessment dated [DATE] was reviewed. MDSC stated, The resident (Resident 136) has unstageable pressure ulcer on the back prior to admission on 5/2021. The pressure ulcer on his back was healed. The LALM was used for his skin maintenance. If the LALM was in the wrong setting, the resident (Resident 136) can possibly develop a pressure ulcer. During an interview on 3/27/2025 at 3:02 PM with IDON, IDON stated, LAL should be set based on resident's weight. If there's no skin issue, the incorrect setting of LALM can create friction and more problems to the resident's skin. During a review of facility's policy and procedure (P&P) titled, Mattress, Alternating Air, revised 5/2024, the P&P indicated for the facility to use pressure-relieving mattresses as indicated by the resident's physical condition. Setting of the mattress must be appropriate to patient's weight. The policy indicated to provide stimulation and pressure relief to residents at risk for skin breakdown. To distribute weight relieving areas of pressure.

45456 Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for five (5) of 13 sampled resident (Resident 26, 12, 4, 32, and 10) in accordance with the facility's policy and procedure when: 1. Resident 26's foley catheter drainage bag (a urine collection bag) was observed touching the floor on 3/25/2025. 2. Licensed Vocational Nurse 1 (LVN 1) failed to change gloves and perform hand hygiene in between tasks during medication administration to Resident 12. 3. LVN 2 failed to change gloves and perform hand hygiene in between task during Resident 32's gastrostomy tube (G-tube, is a tube inserted through the belly that brings nutrition directly to the stomach) dressing change 4. LVN 2 failed to change gloves and perform hand hygiene in between task during medication administration to Resident 4. 5. Facility failed to clean and disinfect Resident 10's feeding pump (a device that delivers liquid nutrition and/or medications to a patient's digestive tract via a feeding tube) which was observed with brown/yellow stain on it. These deficient practices have a potential to contaminate clean items and can place the residents at risk for infection Findings 1. During a review of Resident 26's Admission Record, the admission record indicated Resident 26 was admitted to the facility on [DATE]. Resident 26's diagnoses included respiratory failure (a serious condition that makes it difficult to breathe on your respiratory system [organs/ structures in the body that allows you to breath such as lungs]), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), atrial fibrillation (Afib, is an irregular and often very rapid heartbeat), and urinary retention (a condition in which you cannot empty all the urine from the bladder) During a review of Resident 26's Minimum Data Set (MDS, a resident assessment tool), dated 3/21/2025, the MDS indicated Resident 26 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 26 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with eating, oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene and rolling from left and right while in bed. During a review of Resident 26's Care Plan (CP) for urinary elimination related to the use of urinary catheter and urinary retention, dated 3/19/2025, the CP interventions indicated to keep urinary catheter bag or dignity bag off the floor. During an observation on 3/25/2025 at 9:45 AM in Resident 26's room, Resident 26's foley catheter drainage bag was on the floor and was not covered with a dignity bag. During an interview on 3/27/2025 at 9:46 AM with Registered Nurse 1 (RN 1), RN 1 stated, The foley catheter drainage bag should not be on the floor because of infection control. Resident 26 can acquire infection when the bag is left on the floor. The dignity bag should always cover the drainage bag to provide dignity and privacy and also for infection control. During an interview on 3/28/2025 at 2:59 PM with Interim Director of Nursing (IDON), IDON stated The foley catheter drainage bag should be hanging freely, and dignity bag covering the drainage bag should not be on the floor because of infection control. During a review of the facility's policy and procedure (P&P) titled, Catheter, Indwelling: General & Irrigation, revised 7/2019, the P&P indicated to properly place the foley bag on bed. 2.During a review of Resident 12's Admission Record, the admission record indicated Resident 12 was admitted to the facility on [DATE]. During a review of Resident 12's History and Physical (H&P), dated 3/17/2024, the H& P indicated diagnoses included chronic respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), aspiration pneumonia (a lung infection that occurs when food, liquid, or other foreign substances are inhaled into the lungs), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12 was severely impaired with cognitive skills for daily decision making. The MDS indicated Resident 12 was dependent with eating, oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene and rolling from left and right while in bed. During a medication administration observation on 3/26/2025 at 1:23 PM in Resident 12's room with LVN 1, LVN 1 was observed picking up a medication bottle that fell and rolled on the floor with her gloved hands. LVN1 was then observed placing the medication on the medication tray with the other medications of Resident 12. LVN 1 did not change her gloves and continued preparing Resident 12's medications. During a medication administration observation on 3/26/2025 at 1:25 PM in Resident 12's room with LVN 1, LVN 1 was observed with the same set of gloves, was poking the container lid of a medication using the bandage scissor hanging from her waist. LVN 1 poured the medication to a medicine cup. LVN 1 held the 3 medicine cups together by holding the inside part of the cups and put them on Resident 12's overbed table. LVN 1 pulled the curtains to provide privacy and touched Resident 12's linens. LVN 1 proceeded to check Resident 12's G-tube residual, then touched the towel that was on Resident 12's chest and proceeded to administer resident's medications via G-tube. LVN 1 then administered eye drops to Resident 12's both eyes using the same gloves all along. During an interview on 3/26/2025 at 1:38 PM with LVN 1, LVN 1 stated, I have not been told to change gloves when doing different tasks in a resident's room. It is okay to touch Resident 12's curtains and administer his medications without changing gloves because it is his germs anyway. I did not know if I have to change gloves in between tasks. I do think it is okay not to change gloves. During an interview on 3/26/2025 at 1:40 PM with LVN 1, LVN 1 stated, It is not okay that I did not change my gloves after picking up the medication that rolled on the floor because it is infection control. Resident 12 can get infection. During an interview on 3/26/2025 at 1:41 PM with LVN 1, LVN 1 stated, I did not notice that I was touching the inner part of the medicine cups when I picked up the 3 medicine cups. I am not paying attention. I should not have done that because of infection control. During a review of the facility's P&P titled, Infection Control Manual- Isolation Overview, revised on 10/2007, the P&P indicated, practicing good hygiene as promptly and thoroughly as possible between patient contacts and after contact of blood, body fluids, secretions, excretions and equipment or articles contaminated by them is an important component of component of infection control and isolation precautions. Gloves are worn to reduce the likelihood that hands of personnel contaminated with microorganisms to the patient. In these situations, hands must be washed after gloves are removed. During a review of the facility's P&P titled, Administration of Medication by Nursing, revised on 9/2013, the P&P indicated, when administering eye drops, eardrops, nasal sprays, orally inhaled medications, suppositories or topical medications such as patches, always wash hands prior to and immediately following administration. Hands must be washed with soap and water. Gloves may be utilized and recommended, but hands still must be washed. 3. During a review of Resident 32's Admission Record, the admission record indicated Resident 32 was admitted to the facility on [DATE]. During a review of Resident 32's History and Physical (H&P), dated 9/18/2024, the H& P indicated diagnoses included chronic respiratory failure, gastrostomy and diabetes. During a review of Resident 32's MDS dated [DATE], the MDS indicated Resident 32 has intact cognitive skills for daily decision making. The MDS indicated Resident 32 was dependent in eating, oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene and rolling from left and right while in bed. Resident 32 was assessed to has as an abdominal Percutaneous Endoscopic Gastrostomy (PEG tube, a feeding tube that's inserted into the stomach through the abdominal wall, used to provide nutrition, fluids, and medications to residents who cannot swallow or eat normally). During an observation on 3/27/2025 at 4:44 PM in Resident 32's room with LVN 2, LVN 2 was wearing a Personal Protective Equipment (PPE, specialized clothing or equipment worn by an employee for protection against infectious materials, such as gowns, gloves, masks, and goggles) and observed touching Resident 32's clothes and opened the resident's abdominal binder (a wide belt that encircles your abdomen). LVN 2 proceeded to replace the Resident 32's dirty G-tube site dressing with a clean dressing then touched Resident 12's clothes while using the same set of gloves. During an interview on 3/27/2025 at 4:51 PM, LVN 2 stated, I forgot to change my gloves. I should have removed my dirty gloves when I removed the dirty dressing because there is a possibility that resident can have an infection. During a review of the facility's P&P titled, Infection Control Manual- Isolation Overview revised on 10/2007, the P&P indicated, gloves are worn to reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to patients during invasive or other patient-care procedures that involve touching a patient's mucous membranes and non-intact skin. 4. During a review of Resident 4's Admission Record, the admission record indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), diabetes mellitus, gastrostomy tube, and Alzheimer's disease. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 was severely impaired with cognitive skills for daily decision making. The MDS indicated Resident 4 was dependent with eating, oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene and rolling from left and right while in bed. During an observation on 3/27/2025 at 4:59 PM in Resident 4's room with LVN 2, LVN 2 was observed touching and fixing his mask with his gloved hand and started to check Resident 4's Gtube placement by aspirating residual. LVN 2 proceeded to administer Resident 12's medications via G-tube using the same set of gloves. During an interview on 3/27/2025 at 5:03 PM in front of Resident 4's room with LVN 2, LVN 2 stated, I should have changed my gloves after touching my mask before administering medications to the resident (Resident 12) because I can contaminate the resident's medications. During a review of the facility's P&P titled Infection Control Manual- Isolation Overview, revised on 10/2007, the P&P indicated, practicing good hygiene as promptly and thoroughly as possible between patient contacts and after contact of blood, body fluids, secretions, excretions and equipment or articles contaminated by them is an important component of component of infection control and isolation precautions. 5. During a review of Resident 10's Admission Record, the Admission Record indicated Resident 10 was admitted to the facility on [DATE]. During a review of Resident 10's History and Physical Examination (H&P) dated 8/23/2024, the H&P indicated Resident 10's diagnoses included chronic (long-term) respiratory failure (lung cannot properly exchange gases, causing abnormal levels of oxygen and carbon dioxide in the blood), recurrent Pneumonia (infection of one or both of the lung caused by bacteria, viruses, or fungi.) and end stage Amyotrophic Lateral Sclerosis (ALS, a severe and progressive decline in physical and cognitive function.) During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 was impaired with cognitive skills [ability to think, understand, and reason]) for daily decision making. The MDS indicated Resident 10 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on staff for toileting hygiene, oral hygiene, and upper/lower body dressing. During a concurrent observation and interview in Resident 10's room on 3/25/2025 at 9:10 AM with the present of Certified Nursing Assistant 1 (CNA 1), CNA 1 stated the base of the IV pole was visible dirty with brown/yellow substance stained. CNA 1 stated IV pole should be disinfected or cleaned every day. During an interview on 3/5/2025 at 11:12 AM with the Infection Preventive Nurse (IPN), the IPN stated daily cleaning of medical equipment/devices was essential for preventing infections and ensuring safety of the residents. During a review of the facility's policy and procedure (P&P) titled, Cleaning Products and Equipment, revised date11/2024, the P&P indicated to rduce the risk of transmission of infections and always ensure the cleanliness of patient care items and equipment. The P&P indicated that medical equipment that was used in a patient room or that came into contact with the patient, or his/her contaminated environment would be cleaned and disinfected before it could be used on any other patient. The P&P further indicated that IV pole in the patient rooms should be disinfected daily.

Based on observation, interview, and record review, the facility failed to promote dignity and respect for two (2) of 2 residents (Residents 12 and 24) by failing to ensure: 1. Licensed Vocational Nurse 1 (LVN 1) address Resident 12 with the resident's name instead of using a label prior to medication administration. 2. The curtain in Resident 24's room was fully drawn and/or the resident's door was closed while Certified Nurse Assistant 1 (CNA1) was providing incontinent care to Resident 24. This deficient practice had the potential to affect Resident 12 and 24's emotional and mental well-being. Findings: 1. During a review of Resident 12's Admission Record, the admission record indicated Resident 12 was admitted to the facility on [DATE]. Resident 12's diagnoses included metabolic encephalopathy (ME, occurs when problems with your metabolism cause brain dysfunction), diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose levels), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 12's Minimum Data Set (MDS, resident assessment tool), dated 1/292025, the MDS indicated Resident 12 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 12 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with eating, oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, and personal hygiene. During a review of Resident 12's Care Plan (CP) for Activities of Daily Living (ADLs, are activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), dated 4/9/2024, the CP indicated staff interventions/approaches included to maintain dignity / privacy. During an observation on 3/26/2025 at 1:30 PM inside Resident 12's room, LVN 1 stated, Sorry to wake you up honey! before administering the eye drops to Resident 12. During an interview on 3/26/2025 at 1:52 PM, with LVN 1, LVN 1 stated, It is not okay to call the residents Honey. We have to call them with their last name and that is how we should address the Residents, to show respect. During an interview on 3/26/2025 at 2:43 PM with the Director of Staff Development (DSD), the DSD stated, We do not call the residents 'Honey. We have to call the residents with their first or last name for respect. During an interview on 3/28/2025 at 2:53 PM, with the Director of Nursing (DON), DON stated, It is not okay to call the residents 'Honey.' The staff should be calling the residents with their last name, with Mister, Miss or Mrs (title used before a married woman's name) or title to promote respect and dignity. 44018 2. During a review of Resident 24's Admission Record, the Admission Record indicated Resident 24 was originally admitted to the facility on [DATE]. During a review of Resident 24's History and Physical Examination (H&P) dated 8/23/2024, the H&P indicated Resident 24's diagnoses included chronic (long-term) subdural hematoma (a type of bleeding near the brain that can happen after a head injury), respiratory failure (lung cannot properly exchange gases, causing abnormal levels of oxygen and carbon dioxide in the blood), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). During a review of Resident 24's MDS, dated [DATE], the MDS indicated Resident 24 was severely impaired with cognitive skills for daily decision making. The MDS indicated Resident 24 was dependent with toileting hygiene, oral hygiene, and upper/lower body dressing. During a review of Resident 24's CP initiated on 8/23/2024, the CP indicated resident had an alteration in bowel elimination (a change or disruption in the normal process of bowel movement) related to immobility, and incontinence. Staff interventions included providing diaper/pad change and providing privacy during bowel movement. During observation in Resident 24's room on 3/25/2025 at 10:45 AM, Resident 24's room door was wide opened, and the curtain was not entirely drawn while CNA 1 was providing incontinent care to Resident 24. During an interview on 3/25/2025 at 11:03 AM with CNA 1, CNA 1 stated the curtain was not closed all the way and the door was opened when she changed Resident 24. CNA 1 stated she should at least close the curtain while providing care to residents. CNA further stated it was important to provide respect, dignity, and privacy to residents. CNA 1 stated Resident 24 might feel embarrassed if not given privacy. During an interview on 3/27/2025 at 5:23 PM, with Director of Staff Development (DSD), DSD stated CNAs should closed the door and/or curtain during a personal care procedure like changing a resident, to avoid exposing the resident to unnecessary observation and violating the resident's dignity and privacy. During a record review of facility's policy and procedure (P&P) titled, Patient Rights, revised 11/2021, the P&P indicated the hospital promotes the preservation of patient rights based on a concern for personal dignity and awareness of human relationships. Recognize and respect the individuality and dignity of each patient.

Based on observation, interview, and record review, the facility failed to provide appropriate care to prevent complications of enteral feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine) for two (2) of 2 sampled residents (Resident 12 and 4) in accordance with the facility's policy and procedure by failing to: 1. Turn off the enteral feeding pump before and during medication administration via gastrostomy tube (G-tube, surgical procedure wherein a tube is inserted through the abdomen wall and into the stomach used for nutrition and medication administration) for Resident 12. 2. Ensure medications were administered by gentle instillation or gravity via syringe into Resident 4's G- tube. This deficient practice had the potential for drug-nutrient interaction, G-tube clogging, less medication absorption and efficacy which could affect Residents 12 and 4's overall wellbeing. Findings: 1. During a review of Resident 12's Admission Record, the admission record indicated Resident 12 was admitted to the facility on [DATE]. During a review of Resident 12's History and Physical (H&P), dated 3/17/2024, the H& P indicated diagnoses included chronic respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), aspiration pneumonia (a lung infection that occurs when food, liquid, or other foreign substances are inhaled into the lungs), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 12's Minimum Data Set (MDS - a resident assessment tool) dated 1/29/2025, the MDS indicated Resident 12 has severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 12 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in eating, oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene and roll left and right. During a medication administration observation on 3/26/2025 at 1:27 PM inside of Resident 12's room with Licensed Vocational Nurse 1 (LVN 1), LVN 1 was observed checking Resident 12's G-tube placement by aspirating Resident 12's gastric residual volume (GRV, refers to the amount of fluid remaining in the stomach after a meal or during tube feeding). LVN 1 proceeded to administer Resident 12's medications via G-Tube while the G-tube feeding was running. LVN 1 did not turn off Resident 12's tube feeding machine before and while administering the resident's medications. During an interview on 3/26/2025 at 1:31 PM with LVN 1, LVN 1 stated, I usually do not hold the feeding before I do my medication administration. We do not hold the tube feeding before the medication administration because it is only held for 2 hours a day, in the morning shift that starts from 8AM to 10AM. During an interview on 3/26/2025 at 1:34 PM, with LVN 1, LVN 1 stated, it was important to check G-tube placement. The tube feeding and medications are delivered to the stomach and not to the surrounding areas like the lungs. During an interview on 3/28/2025 at 2:54 PM with Interim Director of Nursing (IDON), IDON stated, During G-Tube medication administration, we always use the 5Ps of medication administration, identify the resident, and aspirate residual. We should check if the G-tube was in correct placement before starting medication administration. During an interview on 3/28/2025 at 2:57 PM with IDON, IDON stated, We should hold the tube feeding and turn off the tube feeding machine feeding prior and during medication administration via G-tube to avoid complicating with the feeding flow and spilling the feeding formula. During a review of the facility's P&P titled, Medication Administration Through a Feeding Tube, revised on 6/2017, the P&P indicated, Put continuous tube feedings on hold. Check the residual and tube placement by aspirating stomach contents and auscultating the epigastric (upper middle area of the abdomen, just below the ribs and above the belly button) area while injecting a small amount of air. 2. During a review of Resident 4's Admission Record, the admission record indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), diabetes mellitus, gastrostomy tube, and seizure (a sudden, uncontrolled burst of electrical activity in the brain). During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 has severely impaired cognitive skills for daily decision making. The MDS indicated Resident 4 has an abdominal percutaneous endoscopic gastrostomy (PEG tube, a feeding tube that is inserted into the stomach through the abdominal wall, used to provide nutrition, fluids, and medications to residents who cannot swallow or eat normally) and was dependent in eating, oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene and roll left and right. During a review of Resident 4's Physician's order, dated 7/1/2024, the physician's order indicated the following: 1. Lactulose 20 gram (gm, unit of measurement) /30 milliliters (ml, unit of measurement of volume) twice a day via G-tube for constipation 2. Rivastigmine 1.5 milligrams (mg, unit of measurement) give 1.5mg capsule twice a day (BID) with meals via G-tube for Alzheimer's Disease. During an observation on 3/27/2025 at 4:59 PM in front of Resident 4's room with LVN 2, LVN 2 mixed the 30 ml of Lactulose liquid and opened the capsule and poured the powder of Rivastigmine in a plastic cup with 50 ml of water during medication administration preparation. During an observation on 3/27/2025 at 5:01 PM in Resident 4's room with LVN 2, LVN 2 administered the first 50 ml of mixed medications with water within 2 seconds via Resident 4's G-tube with the use of the syringe plunger then administered another 30 ml of mixed medications in less than 2 seconds to Resident 4's G-tube. During an interview on 3/27/2025 at 5:06 PM with LVN 2, LVN 2 stated, It is okay to mix medications when administering via G-tube, because you can mix some medications. During an interview on 3/28/2025 at 2:56 PM with Interim Director of Nursing (IDON), IDON stated, Medications should be given one at a time, given by gravity and should not be pushed in the G-tube. We should be careful with the G-tube balloon because it might burst and possibly get dislodged. During an interview on 3/28/2025 at 3:09 PM with IDON, IDON stated, We should not mix medications. There could be complications, risk of clogging the G-Tube, and risk of drug interaction. During a review of the facility's policy and procedure (P&P) titled, Medication Management: Administration of Medication by Nursing, revised on 9/2013, the P&P indicated, the nurse shall read and follow precautionary or additional instruction available on the prescription label/package (i.e. shake well, give on empty stomach). Do not mix incompatible medications. Allow medication to infuse via gravity not bolus (a single large dose of a drug given all at once push). Never force medications/fluids through tubing. During a review of the facility's P&P titled, Medication Administration Through a Feeding Tube, revised on 6/2017, the P&P indicated, Administer medications via gentle instillation or gravity via syringe into the resident's feeding tube, flushing with a minimum of 10-15 ml sterile water between each medication.

Based on observation, interview, and record review, the facility failed to secure the confidential medical records for one (1) of three (3) residents (Residents 4) as indicated on the facility's policy. This deficient practice had the potential to violate the resident's right to confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the resident and/or the resident's representative) and privacy and misuse of Resident 4's Protected Health Information (PHI, any information that relates to an individual's health status, medical history, or treatment). Findings: During a review of Resident 4's Admission Record, the admission record indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and seizure (a sudden, uncontrolled burst of electrical activity in the brain) During a review of Resident 4's Minimum Data Set (MDS, resident assessment tool), dated 1/10/2025, the MDS indicated Resident 4 has severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 4 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in eating, oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene and roll left and right. During an observation on 3/27/2025 at 4:56 PM in the hallway with Licensed Vocational Nurse 2 (LVN 2), the monitor screen displaying the Resident 4's medication list and information such as resident's date of birth, was left turned on and unattended. The monitor screen was on top of the medication cart, parked in the hallway, in front of Resident 4's door. During an interview on 3/27/2025 at 5:04 PM, with LVN 2, LVN 2 stated, The computer monitor should be turned off when you step away from the computer to comply with HIPAA (Health Insurance Portability and Accountability Act) privacy and security rules, and to protect the resident's information. During an interview on 3/28/2025 at 8:03AM with the Director of Staff Development (DSD), DSD stated, We always have to turn off the computer screens for privacy because of HIPAA. It is important to turn off the monitors and it is the staff responsibility to follow HIPAA because not everyone is allowed to see the resident's information. During an interview on 3/28/2025 at 3:08 PM, with the Director of Nursing (DON), DON stated, The staff should not leave the computer monitor unattended especially if the resident information was displayed on the screen exposing the resident's information. The staff should always follow HIPAA regulations. During a record review of facility's Policy and Procedure (P&P) titled, Resident Privacy and Confidentiality, dated 4/2022, the P&P indicated the facility will maintain personal and clinical records in a confidential manner, including all types of records the facility might keep on a resident, whether they are medical, social, fund accounts, automated or other. All staff using a computer must not leave the workstation or terminal unattended without first logging-off or blanking the screen, using a screen, using a screen saver.

Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for the use of Apixaban (Eliquis, a prescription medicine used to treat blood clots in the veins of the legs or lungs) by not having a documented evidence to monitor the side effects and effectiveness of the medication for one (1) of 5 sampled residents (Resident 26) as indicated on the facility's policy. This deficient practice had the potential for Resident 26 not to receive the care and treatment if the medication is ineffective and resident suffers from the side effects of Eliquis such as bleeding, which may result in injury and harm. Findings: During a review of Resident 26's Admission Record, the admission record indicated Resident 26 was admitted to the facility on [DATE]. Resident 26's diagnoses included respiratory failure (a serious condition that makes it difficult to breathe on your respiratory system [organs/ structures in the body that allows you to breath such as lungs]), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), and atrial fibrillation (Afib, is an irregular and often very rapid heartbeat). During a review of Resident 26's Minimum Data Set (MDS, a resident assessment tool), dated 3/21/2025, the MDS indicated Resident 26 has severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 26 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in eating, oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene and roll left and right. During a review of Resident 26's Physician's Order, dated 10/15/2024, the physician's order indicated Apixaban five (5) milligrams (mg, unit of measure) tablet, give 5 mg twice a day (BID) via gastrostomy (surgical procedure creating an opening through the abdomen wall into the stomach, allowing for the insertion of gastrostomy tube [G-tube] used for nutrition and medication administration) tube. During a review of Resident 26's Care Plan (CP) for bleeding due to anticoagulant therapy on Eliquis due to atrial fibrillation, dated 3/19/2025, the CP interventions indicated the following: Monitor for bruising or bleeding. Monitor effectiveness/ side effects of medications. During a concurrent interview and record review on 3/27/2025 at 11:31 AM with MDS Coordinator (MDSC), Resident 26's Physician's order dated 10/15/2024 was reviewed. The physician's order indicated Apixaban give 5 mg BID via G-tube. During a concurrent interview and record review on 3/27/2025 at 11:33 AM with MDSC, Resident 26's Nurses' Progress Notes dated 3/1/2025 to 3/27/2025 were reviewed. MDSC stated the Nurses' Progress Notes did not and should have a documentation that the nursing staff monitored the side effects, such as bleeding and effectiveness of Resident 26's anticoagulant therapy. MDSC stated, Since there was no documentation it means the staff were not checking the resident (Resident 26) for bleeding while using Eliquis. During a review of the facility's policy and procedure (P&P) titled, Assessment and Care Planning, revised on 5/2014, the P&P indicated to identify resident needs and to provide a data base to be used in planning the comprehensive nursing care to meet the resident's individual needs and to assist the resident in reaching the highest level of independence as possible.

Based on observation, interview, and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 24), who was dependent on the staff, was provided with appropriate care for activities of daily living (ADLs, activities related to personal care including bathing or showering, dressing, personal hygiene, using the toilet, and eating). Resident 24's fingernails on both contracted hands (a condition where the fingers or palm of the hand become permanently bent or curled) were observed long and untrimmed. This deficient practice had the potential for Resident 24 to develop infection, skin breakdown, and injury, which could negatively affect resident's overall wellbeing. Findings: During a review of Resident 24's Admission Record, the Admission Record indicated Resident 24 was originally admitted to the facility on [DATE]. During a review of Resident 24's History and Physical Examination (H&P) dated 8/23/2024, the H&P indicated Resident 24's diagnoses included chronic (long-term) subdural hematoma (a type of bleeding near the brain that can happen after a head injury), respiratory failure (lung cannot properly exchange gases, causing abnormal levels of oxygen and carbon dioxide in the blood), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). During a review of Resident 24's Minimum Data Set (MDS, resident assessment tool), dated 12/25/2024, the MDS indicated Resident 24 was severely impaired with cognitive skills (ability to think, understand, and reason) for daily decision making. The MDS indicated Resident 24 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on toileting hygiene, oral hygiene, and upper/lower body dressing. During an observation on 3/25/2025 at 11:44 AM in Resident 24's room, Resident 24 was laying on his bed. Both of Resident 24's hands were positioned across the resident's chest, which exposed the resident's long and untrimmed nails. During an observation in Resident 24's room and interview with Certified Nursing Assistant 1 (CNA 1) on 3/25/2025 at 12:10 PM, CNA 1 confirmed Resident 24's fingernails were long, untrimmed, and touching resident's skin. CNA 1 stated fingernails care was part of daily grooming. CNA 1 stated long fingernails could harbor bacteria and could potentially lead to infection. CNA 1 stated Resident 24's fingernails touching his skin could cause skin tear. During an interview with Director of Staff Development (DSD) on 3/27/2025 at 4:11 PM, DSD stated CNA should provide appropriate grooming care to Resident 24 who was ADL dependent. DSD stated grooming care including bathing, dressing, nails care, and oral care. During a review of the facility's Policy and Procedure (P&P) titled, Grooming and Hair Care Activities, revised 5/2015, the P&P indicated grooming activities would be scheduled based on resident's need. Grooming activities may include nail care, makeup application, hair washing, and hair trimming. CNAs would provide nail care as needed for resident hygiene and safety. If a resident diabetic, licensed staff would provide fingernail trimming.