Every finding on record at Sierra View Care Center

Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for two of two sampled residents (Residents 5 and 12) in accordance with the facility's policy and procedure (P&P) titled Call lights: Accessibility and Timely Response. These failures had the potential for Residents 5 and 12 not to receive necessary care and services in a timely manner and placed the residents at risk for falls/injury Findings: a. During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 10/30/2025 and readmitted on [DATE] with diagnoses including unspecified glaucoma (condition that causes damage to the eye's optic nerve [carries electrical impulses from the eye to the brain, which converts the impulses into the things seen]) and myopathy (disorder that directly affects skeletal muscle tissue, causing primary muscle weakness, cramping, or stiffness). During a review of Resident 5's Fall Risk Assessment (FRA- method of assessing a patient's likelihood of falling) dated 3/23/2026, the FRA indicated Resident 5 was assessed as high risk for falls because Resident 5 was disoriented, chairbound, had poor vision and required the use of assistive devices. During a review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 3/23/2026, the MDS indicated Resident 5 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 5 was dependent (helper does all the effort) on staff for toileting, shower, upper/lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 5 needed maximum assistance (helper does more than half the effort) from staff for oral hygiene and personal hygiene. During a review of Resident 5's untitled Care Plan (CP) revised 4/18/2026, the CP indicated Resident 5 was at risk for falls related to impaired mobility, impaired vision and required assistance with activities of daily living (ADL). The CP intervention indicated for nursing staff to place the call light within Resident 5's reach and encourage Resident 5 to use it for assistance as needed. The CP also indicated Resident 5 needed prompt response to all requested assistance. During an observation on 4/21/2026 at 9:18 am inside Resident 5's room, Resident 5 was awake, lying in bed and unable to find the call light. Resident 5 stated Resident 5 could not find Resident 5's call light. During a concurrent observation in Resident 5's room and interview on 4/21/2026 at 9:35 am with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated CNA 1 could not find Resident 5's call light. CNA 1 stated Resident 5 could not ask for help if the call light was not within reach and not accessible to Resident 5. During a concurrent observation in Resident 5's room and interview on 4/21/2026 at 9:36 am with Registered Nurse 1 (RN 1), RN 1 was looking for Resident 5's call light. RN 1 stated, a call pad was below the pillow of Resident 5. RN 1 stated, the call pad should be within reach and next to Resident 5 for Resident 5 to call for assistance if Resident 5 needed help. RN 1 stated, Resident 5 would not be able to receive care if the call light or call pad was not accessible to the resident. During a review of the facility's P&P titled, Call lights: Accessibility and Timely Response, dated 12/19/2022, the P&P indicated Staff will ensure the call light was within reach of resident and secured, as needed. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. b. During a review of Resident 12's AR, the AR indicated the facility initially admitted Resident 12 on 4/5/2024 and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness on one side of the body) and dementia (a progressive state of decline in mental abilities). During a review of Resident 12's untitled CP dated 4/7/2024, the CP indicated Resident 12 had activities of daily living (ADL) self-care performance deficit related to hemiplegia, hemiparesis and dementia. The CP interventions included encouraging Resident 12 to use the bell to call for assistance. During a review of Resident 12's MDS dated [DATE], the MDS indicated Resident 12 had severely impaired cognition. The MDS indicated Resident 12 required substantial/maximal assistance (helper did more than half the effort) with oral hygiene, upper body dressing and personal hygiene. The MDS indicated Resident 12 was dependent with toileting, shower, and lower body dressing. During a concurrent observation inside Resident 12's room and interview on 4/21/2026 at 8:35 am with Certified Nurse Assistant 3 (CNA 3), Resident 12 was in bed with a splint (a rigid or flexible medical device to immobilize, support or protect and injured part) applied on Resident 12's left hand. The call light was located up on the left side of the bed next to the pillow. CNA 3 stated Resident 12 could not move Resident 12's left hand. CNA 3 stated the call light should be placed next to Resident 12's right hand where the resident could reach and call when help or assistance was needed. During an interview on 4/23/2026 at 3:53 pm with the Director of Nursing (DON), the DON stated the resident's call light should be placed next and close to the resident's strong arm and hand to be able to call for help and staff could timely address the resident's needs. During a review of the facility's P&P titled, Call Lights: Accessibility and Timely Response, revised on 12/19/2022, the P&P indicated, Staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. Each resident shall, as much as possible, be evaluated for unique needs and preferences to determine any special accommodation that may be needed for the resident to utilize the call system. Staff will ensure the call light is within reach of resident and secured, as needed.

Based on observation, interview, and record review, the facility failed to develop and implement specific, comprehensive, and individualized person-centered care plans to meet the residents' needs for three of three sampled residents (Residents 13, 100 and 42) by failing to: a. Accurately identify specific activity intervention for Resident 13.b.1 and b.2. Identify and implement specific CP interventions that reflect Resident 100's actual and specific needs.c. Develop an individualized care plan to address scaling and stiffness of Resident 42's bilateral lower extremities (BLE) after application of A&D ointment on 3/18/2026. These failures resulted in the residents not receiving individualized care to maintain the residents' highest practicable physical, mental, and psychosocial well-being. Findings: a. During a review of Resident 13's admission Record (AR), the AR indicated the facility admitted Resident 13 on 1/23/2016 and readmitted on [DATE] with diagnoses including blindness, bipolar disorder (mood swings that ranged from the lows of depression to elevated periods of emotional highs), and generalized muscle weakness. During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool) dated 2/11/2026, the MDS indicated Resident 13 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 13 required supervision from staff with eating. The MDS indicated Resident 13 required maximal assistance (helper did more than half the effort) from staff with oral hygiene and personal hygiene. The MDS indicated Resident 13 was dependent (helper did all the effort) on staff with toileting hygiene, showering/bathing, upper/lower body dressing and mobility. During a review of Resident 13's Social Service Assessment (SSA) dated 2/11/2026, the SSA indicated Resident 13 did not have a family. The SSA indicated the facility's interdisciplinary team (IDT- a group of staff who worked together to plan and review a resident's care) assisted Resident 13 in medical decision making. During a review of Resident 13's History and Physical (H&P) dated 2/28/2026, the H&P indicated Resident 13 did not have the capacity to understand and make decisions. During a concurrent record review and interview with Licensed Vocational Nurse 5 (LVN 5) on 4/23/2026 at 11:26 AM, Resident 13's AR dated 4/23/2026 was reviewed. LVN 5 stated the AR indicated Resident 13 did not have family or friend contacts. LVN 5 stated the AR indicated the facility's IDT was the substitute decision maker (someone who made care choices for the resident when the resident could not speak for themself) for Resident 13. During a concurrent record review and interview with LVN 5 on 4/23/2026 at 11:26 AM, Resident 13's activity care plan (CP) revised 8/22/2025 was reviewed. LVN 5 stated the CP interventions included inviting/ encouraging Resident 13's family members to attend activities with Resident 13 to support participation. LVN 5 stated the CP intervention was not applicable to Resident 13 since Resident 13 did not have a family. LVN 5 stated the facility IDT should have removed the intervention regarding family members to attend activities with Resident 13. LVN 5 stated the facility could not achieve the established goal for Resident 13 without the specific resident-centered CP and could delay necessary care. LVN 5 stated it was important to have specific, individualized, and resident-centered CP. LVN 5 stated the facility's IDT developed CP for residents upon admission, quarterly, and as needed (PRN) for changes. During an interview with the Activity Director (AD) on 4/23/2026 at 12:03 PM, the AD stated Resident 13 did not have a family. The AD stated Resident 13's CP should be specific and resident centered. b.1. During a review of Resident 100's AR, the AR indicated the facility admitted Resident 100 on 4/18/2026 with diagnoses including osteomyelitis (inflammation of the bone or bone marrow) and bacteremia (germs got into the blood). During a review of Resident 100's H&P dated 4/20/2026, the H&P indicated Resident 100 had the capacity to make medical decisions. During a review of Resident 100's MDS dated [DATE], the MDS indicated Resident 100 had moderately impaired cognition. The MDS indicated Resident 100 required supervision from staff with eating. The MDS indicated Resident 100 required moderate assistance (helper did less than half the effort) from staff with oral hygiene and personal hygiene. The MDS indicated Resident 100 was dependent on staff with toileting hygiene, showering/bathing, and mobility. During a concurrent record review and interview with LVN 5 on 4/23/2026 at 11:36 AM, Resident 100's Order Summary Report (OSR) dated 4/23/2026 was reviewed. LVN 5 stated the OSR indicated Resident 100 was not on intravenous (IV- medicine or fluid that went straight into a vein) hydration. During a concurrent record review and interview with LVN 5 on 4/23/2026 at 11:36 AM, Resident 100's IV therapy CP dated 4/20/2026 was reviewed. The CP indicated an intervention for licensed nursing staff to observe signs and symptoms of fluid under or overload when on IV hydration. LVN 5 stated the CP intervention was not specific for Resident 100. b.2. During a review of Resident 100's OSR dated 4/23/2026, the OSR indicated Resident 100 had an active order of ampicillin (medication to kill germ) two grams IV every six hours for bacteremia. The order was dated 4/18/2026. During a review of Resident 100's IV Administration Report (IVAR) dated from 4/18/2026 to 4/23/2026, the IVAR indicated Resident 100 received 20 out of 20 doses of ampicillin. During a concurrent record review and interview with LVN 5 on 4/23/2026 at 11:36 AM, Resident 100's IV therapy CP dated 4/20/2026 was reviewed. The CP indicated an intervention for licensed nursing staff to check for signs of nephrotoxicity (harm to the kidneys caused by a drug) and observe for hearing changes including ringing in the ears. LVN 5 stated the licensed nursing staff should follow and implement the CP interventions. During a concurrent record review and interview with LVN 5 on 4/23/2026 at 11:36 AM, Resident 100's Nursing Progress Notes (NPN) from 4/18/2026 to 4/23/2026 were reviewed. The NPN did not indicate documentation/ monitoring for signs of nephrotoxicity or hearing changes on Resident 100. LVN 5 stated the licensed nurses should document for signs of nephrotoxicity and/or any hearing changes in the NPN as indicated in Resident 100's CP. During a concurrent record review and interview with LVN 5 on 4/23/2026 at 11:36 AM, Resident 100's Medication Administration Report (MAR) dated 4/18/2026 to 4/23/2026 were reviewed. LVN 5 stated Resident 100's MAR did not indicate documentation for signs of nephrotoxicity or hearing changes. LVN 5 stated the licensed nurses could document the signs of nephrotoxicity and/or any hearing changes to Resident 100 in the MAR. During an interview on 4/23/2026 at 12:14 PM with the Infection Preventionist Nurse (IPN), the IPN stated all nursing staff and the care team should monitor Resident 100 for any hearing changes while Resident 100 was taking ampicillin. The IPN stated a physician's order was not needed to monitor Resident 100's hearing changes because it was the standard of practice. The IPN stated the licensed nurse should document Resident 100's hearing assessment in the NPN, MAR, and/or in other forms of medical record. The IPN stated it was important to monitor and document Resident 100's hearing assessment while on ampicillin. The IPN stated that without proper monitoring and documentation would increase the risk of Resident 100 to experience hearing loss. During an interview on 4/23/2026 at 3:43 PM with the Director of Nursing (DON), the DON stated the CP indicated interventions to address and meet the residents' current and specific needs. The DON stated the CP intervention should be specific and resident centered. The DON stated it was important to implement interventions on the CP. During a review of the facility's P&P titled, Comprehensive Care Plans, revised 12/19/2022, the P&P indicated the facility should develop and implement a comprehensive resident-centered CP for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the resident's comprehensive assessment. The P&P indicated the comprehensive CP should be developed within seven days after the completion of the comprehensive MDS assessment. The P&P indicated the CP should address the factors identified by the interdisciplinary team. The P&P further indicated the CP should have specific interventions that reflected the resident's needs. c. During a review of Resident 42's AR, the AR indicated Resident 42 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease (slow, progressive circulatory disorder), osteoarthritis (degenerative joint disease), and mental disorders (disturbances in cognition, emotional regulation, or behavior). During a review of Resident 42's H&P dated 10/31/2025, the H&P indicated Resident 42 was awake and alert. The H&P did not indicate Resident 42's ability to make and understand medical decisions. During a review of Resident 42's MDS dated [DATE], the MDS indicated Resident 42 had intact cognition. During a concurrent observation and interview on 4/21/2026, at 11:35 AM, with Resident 42, Resident 42 stated A&D ointment was applied on Resident 42's BLE on 3/18/2026. Resident 42 stated Resident 42 had scaling and stiffness of Resident 42's BLE and toes after the A&D ointment was applied. During an interview on 4/23/2026, at 9:40 AM with the IPN, the IPN stated the Treatment Nurse (TN) changed the type of A&D ointment applied to Resident 42 from the packet to the tube. During an interview on 4/23/2026, at 3:23 PM with the TN, the TN stated the TN applied the A&D ointment to Resident 42's BLE. The TN stated when the TN was later notified about Resident 42's skin condition, the TN stated the TN observed flakiness and scaling on Resident 42's BLE. The TN stated Resident 42 complained of tightness on Resident 42's BLE. The TN stated the TN did not report the skin condition to the physician. The TN stated it was important to report to the physician so that the physician and Resident 42 would know the cause of the tightness on Resident 42's BLE. During a concurrent interview on 4/24/2026, at 11:11 AM with Licensed Vocational Nurse 7 (LVN 7) and record review of Resident 42's entire care plans, there was no CP developed to address Resident 42's complaint of tightness on Resident 42's BLE. There was also no Situation, Background, Assessment, Recommendation (SBAR- structured, standardized communication framework) in Resident 42's clinical record indicating Resident 42 complained of stiffness and tightness on Resident 42's BLE after A&D ointment use on 3/18/2026. During an interview on 4/24/2026 at 11:32 AM with Minimum Data Set Coordinator (MDS C), the MDS C stated it was important to develop a care plan with specific target interventions to solve the problem. The MDS C stated there should have been an SBAR/Change of Condition (COC- documentation of significant, acute, or unexpected deviation from a patient's baseline) of Resident 42's scaling and stiffness of BLE following the application of the A&D ointment to Resident 42 on 3/18/2026. During an interview on 4/24/2026, at 11:50 AM with Registered Nurse 4 (RN 4), RN 4 stated it was important to develop a care plan to address the resident's specific needs and to guide staff on what needed to be done. RN 4 stated there was no SBAR/COC created on 3/18/2026 related to Resident 42's complaint of scaling of skin and stiffness of BLE. During a review of the facility's P&P titled, Comprehensive Care Plans, revised 12/19/2022, the P&P indicated the facility should develop and implement a comprehensive resident-centered CP for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the resident's comprehensive assessment. The P&P indicated the comprehensive CP should be developed within seven days after the completion of the comprehensive MDS assessment. The P&P indicated the CP should address the factors identified by the interdisciplinary team. The P&P further indicated the CP should have specific interventions that reflected the resident's needs.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for residents with indwelling catheter (including suprapubic catheter [a thin, flexible tube inserted through a small abdominal incision into the bladder to drain urine], nephrostomy tube [a thin, flexible catheter inserted through the skin on the lower back into the kidney to drain urine], or a Foley catheter [a soft, flexible tube inserted through the urethra or abdominal wall into the bladder to continuously drain urine into an external bag] ) for two of three sampled residents (Residents 6 and 55) by failing to: a. Ensure Resident 6's suprapubic catheter tubing was secured on Resident 6's thigh.b. Ensure Resident 55's Foley catheter tubing was secured on Resident 55's thigh. These failures placed Residents 6 and 55 at risk for infection and injury related to the use of indwelling catheter.Findings: a. During a review of Resident 6's admission Record (AR), the AR indicated the facility initially admitted Resident 6 on 6/9/2023 and readmitted on [DATE] with diagnoses including obstructive and reflux uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow) and benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland). During a review of Resident 6's Order Summary Report (OSR) dated 2/9/2026, the OSR indicated Resident 6 had an order for staff to apply catheter stabilization device to secure foley catheter in place and to check placement every shift. During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool) dated 3/25/2026, the MDS indicated Resident 6 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 6 was dependent (helper does all of the effort) from staff with oral hygiene, toileting, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 6's undated Care Plan (P), the CP indicated Resident 6 had an indwelling catheter (suprapubic) for obstructive and reflux uropathy. The CP intervention indicated for nursing staff to apply catheter stabilization device to secure the catheter in place and to check placement. During a concurrent observation inside Resident 6's room and interview on 4/21/2026 at 8:47 am with Registered Nurse 1 (RN 1), Resident 6 was asleep in bed with FC hanging on the left side of the bed. RN 1 stated Resident 6's suprapubic catheter tubing did not have a catheter securement device and was not secured on Resident 6's thigh. RN 1 stated the suprapubic catheter tubing should be secured properly on Resident 6's thigh to prevent pulling out of the tubing and to prevent injury during Resident 6's movement. During a concurrent observation inside Resident 6's room and interview on 4/21/2026 at 12:30 pm with Treatment Nurse 1 (TN 1), TN 1 stated the securement lock was on Resident 6's right thigh while the catheter tubing was hanging on the left side of the bed. TN 1 stated, the catheter tubing should have been secured on Resident 6's thigh to prevent Resident 6 from pulling the tube that could cause pain and injury. During a review of the facility's Policy and Procedure (P&P) titled, Catheter Care revised 12/23/2023, the P&P indicated, It is the policy of the facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. b. During a review of Resident 55's AR, the AR indicated the facility initially admitted Resident 55 on 2/20/2020 and readmitted on [DATE] with diagnoses including chronic kidney disease (CKD, progressive loss of kidney function), heart failure (HF, a heart disorder which causes the heart to not pump the blood efficiently), and dementia (a progressive state of decline in mental abilities). During a review of Resident 55's untitled CP dated 9/16/2021, the CP indicated Resident 55 had an indwelling catheter and was at high risk for catheter related infection or trauma. The CP goals indicated Resident 55 would not show signs and symptoms of urinary infection and remain free from catheter-related trauma. During a review of Resident 55's OSR dated 2/12/2026, the OSR indicated Resident 55 had an order for staff to apply catheter stabilization device to secure Resident 55's foley catheter was in place. During a review of Resident 55's MDS dated [DATE], the MDS indicated Resident 55 had intact cognition. The MDS indicated Resident 55 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completed activity) with eating and oral hygiene, required partial/moderate assistance (helper did less than half the effort) with upper body dressing and personal hygiene and dependent (helper did all the effort) with toileting. The MDS indicated Resident 55 had an indwelling catheter. During a concurrent observation inside Resident 55's room and interview on 4/21/2026 at 9:01 am with Licensed Vocational Nurse 1 (LVN 1), Resident 55 was lying in bed with a foley catheter. LVN 1 stated Resident 55's Foley catheter was not connected to the catheter securement device. LVN 1 stated the foley catheter tubing should be secured to prevent getting pulled out during movement and cause trauma or injury to Resident 55. During an interview on 4/23/2026 at 3:50 pm with the Director of Nursing (DON), the DON stated the foley catheter tubing should be secured on the resident's thigh to prevent from pulling and getting dislodged during bed mobility. During a review of the facility's P&P titled, Catheter Care, revised on 12/23/2023, the P&P indicated, To ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Ensure straps were snug but not tight.

Based on observation, interview, and record review, the facility failed to: a. Provide necessary care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition/medication directly to the stomach) site as ordered by the physician and as indicated in the plan of care for one of two sampled residents (Resident 3).b. Elevate the resident's head of the bed (HOB) while receiving feeding formula through the GT in accordance with the resident's plan of care and physician's order for one of two sampled residents (Resident 65). These failures had the potential to result in complications related to tube feedings for Residents 53 and 65. Findings: a. During a review of Resident 3's admission Record (AR), the AR indicated the facility initially admitted Resident 3 on 6/4/2024 and readmitted on [DATE] with diagnoses including encounter for attention to GT and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 3's Order Summary Report (OSR) dated 2/20/2026, the OSR indicated for licensed staff to clean the GT site with Normal Saline (NS, a saltwater solution), pat dry and cover with dry dressing, every day shift. During a review of Resident 3's Care Plan (CP) for wound management on the GT site, revised 2/23/2026, the CP intervention indicated for the nursing staff to cleanse the GT site with NS, pat dry and cover with dry dressing. During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 2/24/2026, the MDS indicated Resident 3 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 3 was dependent (helper does all of the effort) from staff with hygiene toileting, shower, upper and lower body dressing and putting on/taking off footwear. During a review of Resident 3's CP for tube feeding related to dysphagia (difficulty swallowing) revised 2/25/2026, the CP intervention indicated for nursing staff to provide local care to GT site as ordered and monitor for signs and symptoms of infection. During an observation 4/21/2026 at 9:14 am, together with Registered Nurse 1 (RN 1), Resident 3 was awake, lying in bed. Resident 3's GT site had a dressing dated 4/19/2026 with light brown colored drainage from the GT site. During an interview on 4/21/2026 at 10:40 am with RN 1, RN 1 stated Resident 3's GT site dressing was not changed yesterday, 4/20/2026. RN 1 stated Resident 3's GT dressing should have been changed daily to prevent infection and to assess the site if there were signs and symptoms of infection. During an interview on 4/21/2026 at 1:11 pm with the Treatment Nurse (TN), the TN stated the TN forgot to change Resident 3's GT site dressing on 4/20/2026. The TN stated Resident 3's GT site dressing needed to be cleaned and changed daily as ordered by the physician to prevent infection. During an interview on 4/24/2026, at 9:11 am, with the Director of Nursing (DON), the DON stated Resident 3's GT site dressing should be changed daily as ordered by the doctor and as needed. The DON stated Licensed Nurses were responsible to change the GT site dressing to prevent infection and skin complications on the GT site. b. During a review of Resident 6's AR, the AR indicated the facility initially admitted Resident 6 on 6/9/2023 and readmitted on [DATE] with diagnoses including encounter for attention to GT, obstructive and reflux uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow) and benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland). During a review of Resident 6's undated CP, the CP indicated Resident 6 required tube feeding related to dysphagia. The CP intervention indicated for nursing staff to keep Resident 6's head of bed elevated at least 30-45 degrees during and 30 minutes after tube feeding. During a review of Resident 6's OSR dated 3/23/2026, the OSR indicated for staff to elevate Resident 6's HOB at a minimum 30 degrees at all times during administration of feedings or medications every shift. During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 had severely impaired cognition. The MDS indicated Resident 6 was dependent on staff with oral hygiene toileting, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a concurrent observation and interview on 4/21/2026 at 10 am, together with RN 1, Resident 6 was asleep lying flat in bed, in supine position and connected to an ongoing GT feeding at 50 ml/hr. RN 1 stated, Resident was on supine position and Resident 6's HOB should have been elevated from 30 to 45 degrees while feeding was ongoing to prevent aspiration (food/liquid accidentally goes into the airway or lungs). During an interview on 4/24/2026, at 9:14 am, with the DON, the DON stated Resident 6's HOB should have been elevated at least 30 degrees while on GT feeding to prevent aspiration. During a review of the facility's undated Policy and Procedure (P&P) titled, Gastrostomy Site Care, dated 12/19/2022 the P&P indicated It is the policy of the facility to perform gastrostomy site care as ordered and per current standards of practice. Using normal saline, gently clean the area around the tube and continue in an outward circular fashion, ensuring that under the bolster is cleaned.

Based on observation, interview, and record review, the facility failed to ensure safe food storage practices in one of one facility kitchen, by failing to: a. Discard an open loaf of wheat bread beyond its use-by-date (the last date the food was considered safe to eat) of 4/20/2026 in the kitchen bread storage area. b. Discard an open plastic container of baking soda beyond its use-by-date of 4/15/2026 in the kitchen dry storage area. c. Discard an open pack of tortilla beyond its use-by-date of 4/19/2026 in the kitchen walk-in refrigerator. d. Discard a tray of grilled cheese sandwiches and pizzas beyond its use-by-date of 4/20/2026 in the kitchen walk-in refrigerator. These deficient practices had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) for the residents.Findings: a. During a concurrent observation and interview with the Dietary Supervisor (DS) on 4/21/2026 at 8:26 AM, in the kitchen bread storage area, there was one open loaf of wheat bread beyond its use-by-date of 4/20/2026. The DS stated the kitchen staff should discard the bread because it was beyond the use-by-date of 4/20/2026. b. During a concurrent observation and interview with the DS on 4/21/2026 at 8:40 AM, in the kitchen dry storage area, there was one open plastic container of baking soda beyond its use-by-date of 4/15/2026. The DS stated the kitchen staff should discard the baking soda because it was beyond the use-by-date of 4/15/2026. c. During a concurrent observation and interview with the DS on 4/21/2026 at 8:47 AM, in the kitchen walk-in refrigerator, there was one open pack of tortilla beyond its use-by-date of 4/19/2026. The DS stated the kitchen staff should discard the pack of tortilla because it was beyond the use-by-date of 4/19/2026. d. During a concurrent observation and interview with the DS on 4/21/2026 at 8:52 AM, in the kitchen walk-in refrigerator, there was one tray of grilled cheese sandwiches and pizzas beyond its use-by-date of 4/20/2026. The DS stated the kitchen staff should discard the tray of grilled cheese sandwiches and pizzas because it was beyond the use-by-date of 4/20/2026. During an interview with the Infection Preventionist Nurse (IPN) on 4/23/2026 at 9:38 AM, the IPN stated staff should throw away the food beyond the use-by-date because it could cause food-borne illnesses. The IPN stated it was not acceptable to have food for the residents beyond the used-by-date. The IPN stated it was part of infection control to discard food beyond the use-by-date. During an interview with the DS on 4/23/2026 at 10:39 AM, the DS stated it would affect the quality of the food when food was beyond the used-by-date. The DS stated the bread would lose moisture after the use-by date. The DS stated it was not acceptable to provide food beyond the used-by-date because it could cause nausea and vomiting. The DS stated it was part of infection control and quality of care to provide the best quality of food to the residents. During a review of the facility's Policy and Procedure (P&P) titled, Date Marking for Food Safety, revised 12/19/2022, the P&P indicated staff should clearly marked the food to indicate the date or day by which the food shall be consumed or discarded. During a review of the facility's P&P titled, Food storage, revised 8/29/2023, the P&P indicated staff should discard any outdated food products.

Based on interview and record review, for two of two sampled residents (Residents 11 and 100), the licensed nurse failed to timely document on the residents' medical record: a. Resident 11's respiratory assessment on 4/21/2026. b. Resident 100's ampicillin (medication to kill bacteria) administration on 4/22/2026. These deficient practices had the potential to result in lack of communication between staff and delay and interrupt the provision of care needed to maintain the residents' highest practicable, physical, mental, and psychosocial well-being. Findings: a. During a review of Resident 11's admission Record (AR), the AR indicated the facility admitted Resident 11 on 4/24/2025 and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), asthma (a condition where the airways got swollen and made it hard for the resident to breathe) and dementia (a progressive state of decline in mental abilities). During a review of Resident 11's History and Physical (H&P) dated 4/26/2025, the H&P indicated Resident 11 had the capacity to understand and make decisions. During a review of Resident 11's Minimum Data Set (MDS, a resident assessment tool) dated 1/28/2026, the MDS indicated Resident 11 had moderately impaired cognition (ability to understand). The MDS indicated Resident 11 required supervision from staff with eating and oral hygiene. The MDS indicated Resident 11 required maximal assistance (helper did more than half the effort) from staff with showering/ bathing, and personal hygiene. The MDS indicated Resident 11 was dependent (helper did all effort) on staff with toileting hygiene and bed-to-chair transferring. During a concurrent observation and interview with Registered Nurse 1 (RN 1) on 4/21/2026 at 3:30 PM, at Resident 11's bedside, RN 1 assessed Resident 11's lung sounds and breathing. RN 1 stated RN 1 assessed Resident 11 for chest congestion (a buildup of mucus that made the chest feel tight and breathing harder). During a concurrent record review and interview with RN 1 on 4/23/2026 at 2:02 PM, Resident 11's Nurses Progress Note (NPN) dated from 4/20/2026 to 4/21/2026 were reviewed. The NPN did not indicate Resident 11's respiratory assessment by RN 1 on 4/21/2026. RN 1 stated RN 1 should have documented Resident 11's respiratory assessment on 4/21/2026 in the NPN. RN 1 stated RN 1 did not document because RN 1 was just helping the 3 PM-11 PM shift. During an interview with the Director of Nursing (DON) on 4/23/2026 at 3:43 PM, the DON stated the licensed nurse (in general) should document in the residents' progress note after assessment was done. The DON stated it was important to document the residents' assessment in case of the need to notify the physician for any change in condition. The DON stated the license nurse should document the interventions that were done to the residents for continuity of care. b. During a review of Resident 100's AR, the AR indicated the facility admitted Resident 100 on 4/18/2026 with diagnoses including osteomyelitis (inflammation of the bone or bone marrow) and bacteremia (germs in the blood). During a review of Resident 100's H&P dated 4/20/2026, the H&P indicated Resident 100 had the capacity to make medical decisions. During a review of Resident 100's MDS dated [DATE], the MDS indicated Resident 100 had moderately impaired cognition. The MDS indicated Resident 100 required supervision from staff with eating. The MDS indicated Resident 100 required moderate assistance (helper did less than half the effort) from staff with oral hygiene and personal hygiene. The MDS indicated Resident 100 was dependent on staff with toileting hygiene, showering/bathing, and mobility. During a review of Resident 100's Order Summary Report (OSR) with active orders as of 4/23/2026, the OSR indicated Resident 100 had an active order of intravenous (IV- medicine or fluid that went straight into a vein) ampicillin (medication to kill germ) two grams (gm-unit of measurement) every six hours for bacteremia. The order was dated 4/18/2026. During a concurrent record review and interview with Licensed Vocational Nurse 5 (LVN 5) on 4/23/2026 at 11:36 AM, Resident 100's IV Administration Report (IVAR) from 4/1/2026 to 4/23/2026 was reviewed. The IVAR indicated RN 1 administered ampicillin for the 12 PM dose to Resident 100 on 4/21/2026 at 6:58 PM. LVN 5 stated the IVAR indicated RN 1 did not document the ampicillin 12 PM dose timely. LVN 5 stated it was important to document timely to confirm the medication was administered timely. LVN 5 stated the licensed nurse should sign the IVAR when the medication was administered, at the time of service, within the ordered time frame. LVN 5 stated, not documenting timely affected the continuity of residents' care. During an interview with RN 1 on 4/23/2026 at 2:44 PM, RN 1 stated RN 1 did not document the ampicillin 12 PM dose timely for Resident 100 on 4/21/2026 because RN 1 was busy. During an interview with the Director of Nursing (DON) on 4/23/2026 at 3:43 PM, the DON stated it was not acceptable to document the ampicillin 12 PM dose at 6:58 PM on 4/21/2026. The DON stated it was the standard of practice to document medication administration timely at the time of service. During a review of the facility's Policy and Procedure (P&P) titled Documentation in Medical Record, dated 12/19/2022, the P&P indicated the licensed staff should document all assessments, observations, and services provided in the resident's medical record at the time of service, but no later than the shift. The P&P indicated documentation should be timely. During a review of the facility's P&P titled Medication Administration, dated 12/19/2022, the P&P indicated the licensed nurse should administer medication within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. The P&P further indicated the licensed nurse should sign the medication administration record after administrating the medication.

Based on observation, interview, and record review, the facility failed to implement and follow infection prevention procedures to prevent the transmission of infectious organisms for two of three sampled residents (Residents 100 and 101) by failing to: a. Ensure the licensed nurse accurately label Resident 100's midline dressing (a clean cover that protected the midline [small tube in a vein that gave fluids or medicine] site) on 4/21/2026. b. Ensure Resident 101's Care Giver 1 (CG1) wore the required personal protective equipment (PPE - clothing and equipment to provide protection against hazardous substances and/or environments) while providing care to Resident 101 who was on Enhanced Barrier Precaution (EBP- extra safety steps using gown and gloves to stop germs from spreading during close care of the resident). These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for Residents 100 and 101. Findings: a. During a review of Resident 100's admission Record (AR), the AR indicated the facility admitted Resident 100 on 4/18/2026 with diagnoses including osteomyelitis (inflammation of the bone or bone marrow) and bacteremia (germs in the blood). During a review of Resident 100's History and Physical (H&P) dated 4/20/2026, the H&P indicated Resident 100 had the capacity to make medical decisions. During a review of Resident 100's Minimum Data Set (MDS- a resident assessment tool) dated 4/22/2026, the MDS indicated Resident 100 had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 100 required supervision from staff with eating. The MDS indicated Resident 100 required moderate assistance (helper did less than half the effort) from staff with oral hygiene and personal hygiene. The MDS indicated Resident 100 was dependent (helper did all the effort) on staff with toileting hygiene, showering/bathing, and mobility. During a review of Resident 100's Order Summary Report (OSR) with active orders as of 4/23/2026, the OSR indicated Resident 100 had an order for licensed staff to change the midline dressing upon admission and as needed for site maintenance. The order was dated 4/18/2026. During a review of Resident 100's Intravenous (medicine or fluid that went straight into a vein) Administration Report (IVAR) dated 4/23/2026, the IVAR indicated Registered Nurse 3 (RN 3) changed Resident 100's midline dressing on 4/20/2026 at 9 PM. During an observation on 4/21/2026 at 10:37 AM, at Resident 100's bedside, Resident 100's midline dressing did not have a date. During an observation on 4/21/2026 at 12:35 PM, at the facility's dining room, Resident 100's midline dressing did not have a date. During an interview on 4/23/2026 at 11:36 AM with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated it was important to date the midline dressing to ensure it was monitored daily, for staff to know when it was changed, and when the next dressing change would be. LVN 5 stated it was not acceptable for the midline dressing to be undated. LVN 5 stated licensed nurses should check the midline dressing to ensure it was intact and dated. LVN 5 stated when the licensed nurse noted the midline dressing did not have a date, the licensed nurse should have informed the RN. LVN 5 stated dating the midline dressing was part of infection control precaution and professional standards of practice. LVN 5 stated the undated midline dressing increased the risk for infection at the midline site. During a concurrent interview and pictures review on 4/23/2026 at 12:14 PM with the Infection Preventionist Nurse (IPN), the pictures dated 4/21/2026 at 10:37 AM and 12:35 PM were reviewed. The IPN stated the pictures indicated the midline dressing did not have a date. The IPN stated the RN should have dated the midline site dressing during change of dressing. The IPN stated it was important to keep the midline site clean. During an interview on 4/23/2026 at 1:48 PM with RN 1, RN 1 stated the RN should have changed and dated the midline dressing to prevent infection at the midline site. During a review of the facility's Policy and Procedure (P&P) titled Peripheral Intravenous Catheter Insertion, Maintenance, and Removal, revised 3/17/2025, the P&P indicated the facility should ensure the peripheral intravenous catheters were maintained consistent with current standards of practice. The P&P indicated the nurse should label the dressing with the date the dressing change was performed. b. During a review of Resident 101's AR, the AR indicated the facility admitted Resident 101 on 4/13/2026 with diagnoses including sepsis (life-threatening condition that arises when the body's response to infection injures its own tissues and organs) and encounter for attention to gastrostomy (GT-creation of an artificial external opening into the stomach for nutritional support). During a review of Resident 101's OSR dated 4/14/2026, the OSR indicated to place Resident 101 on EBP related to GT and history of Extended Spectrum Beta-Lactamase (ESBL - bacteria that is not easily killed by antibiotics) in urine. The order further indicated to apply EBP to prevent the spread of infections for specific care activities such as morning and evening care, toileting and changing incontinence briefs, caring for devices and giving medical treatments, wound care, mobility assistance and preparing to leave the room and cleaning and disinfecting the environment. During a review of Resident 101's untitled Care Plan (CP) dated 4/14/2026, the CP indicated Resident 101 was at risk for infection related to septicemia (a serious, life-threatening infection)/urinary tract infection (UTI, infection that affects part of the urinary tract) and presence of GT. The CP indicated for nursing staff to educate the resident/representative on techniques to prevent infection, such as handwashing, adequate rest, nutrition and avoidance of crowds. The CP intervention also included to place Resident 101 on EBP. During a review of Resident 101's MDS dated [DATE], the MDS indicated Resident 101 had severely impaired cognition. The MDS indicated Resident 101 was dependent (helper does all the effort) to staff for oral hygiene, toileting, shower, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. During an observation on 4/23/2026 at 8:19 am, Resident 101 was awake lying in bed in Resident 101's room. Resident 101's Care Giver 1 (CG1) was cleaning Resident 101's arms, face and neck with wet towel without wearing gown and gloves. During an interview on 4/23/2026 at 8:49 am, together with Licensed Vocational Nurse 6 (LVN 6), LVN 6 stated Resident 101 was placed on EBP for the presence of GT. LVN 6 stated visitors and CG 1 needed to wear the required PPE while providing care to Resident 101. LVN 6 stated CG 1 did not wear a gown and gloves while providing care to Resident 101. LVN 6 stated CG 1 needed to wear the required PPE to prevent the spread of infection. During an interview on 4/23/2026 at 9:26 am with CG 1, CG 1 stated CG 1 did not wear a gown and gloves while providing care to Resident 101. CG 1 stated CG 1 knew the purpose of wearing the required PPE while providing care to Resident 101 to prevent the spread of infection. During an interview on 4/24/2026 at 9:07 am with the facility's Director of Nursing (DON), the DON stated caregivers, visitors and staff needed to wear gown, gloves and masks before providing direct care to residents on EBP. During a review of the facility's P&P titled, EBP, revised on 3/10/2025, the P&P indicated, It is the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. EBP are indicated for residents with any of the following: etc. indwelling medical devices (e.g., feeding tube) even if the resident is not known to be infected. Implementation of Enhanced Barrier Precautions: Make gowns and gloves available prior to performing task. Provide education to residents and visitors. High-contact resident care activities include dressing, bathing/showering etc.providing hygiene. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.

Based on observation, interview, and record review, the facility failed to protect the identifiable health information (any information that could be used to identify the individual, such as the full name, date of birth , etc.) on the ampicillin (medication to kill germ) intravenous (IV- medicine or fluid that went straight into a vein) bag to be exposed for one of one sampled resident (Resident 100). This deficient practice had the potential to result in unauthorized disclosure of Resident 100's personal information to unauthorized users resulting in breach of privacy.Findings: During a review of Resident 100's admission Record (AR), the AR indicated the facility admitted Resident 100 on 4/18/2026 with diagnoses including osteomyelitis (inflammation of bone or bone marrow) and bacteremia (germs got into the blood). During a review of Resident 100's History and Physical (H&P) dated 4/20/2026, the H&P indicated Resident 100 had the capacity to make medical decisions. During a review of Resident 100's Minimum Data Set (MDS- a resident assessment tool) dated 4/22/2026, the MDS indicated Resident 100 had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 100 required supervision from staff with eating. The MDS indicated Resident 100 required moderate assistance (helper did less than half the effort) from staff with oral hygiene and personal hygiene. The MDS indicated Resident 100 was dependent (helper did all the effort) on staff with toileting hygiene, showering/bathing, and mobility. During a review of Resident 100's Order Summary Report (OSR) with active orders as of 4/23/2026, the OSR indicated Resident 100 had an order of ampicillin IV for bacteremia. The order was dated 4/18/2026. During an observation on 4/21/2026 at 10:37 AM, at Resident 100's bedside, Resident 100's ampicillin IV bag was hanging on the IV pole (a tall stand that held the resident's IV fluids or medications) with Resident 100's health information (first and last name and room number) uncovered. Resident 100's ampicillin IV bag was unattended by facility staff and not connected to Resident 100. During an observation on 4/23/2026 at 2:52 PM, at Resident 100's bedside, Resident 100's ampicillin IV bag was hanging on the IV pole with Resident 100's health information uncovered. During an interview with Registered Nurse 1 (RN 1) on 4/23/2026 at 2:44 PM, RN 1 stated RN 1 did not cover Resident 100's health information on the ampicillin IV bag while hanging on the IV pole at Resident 100's bedside. RN 1 stated it risked exposing Resident 100's health information to unauthorized people. RN 1 stated visitors, housekeeping and maintenance personnel did not need to know Resident 100's health information nor the prescribed medication. RN 1 stated it was Resident 100's right to privacy by protecting Resident 100's health information. RN 1 stated it was important for everyone in the facility to protect the residents' rights to privacy. During an interview with the Director of Nursing (DON) on 4/23/2026 at 3:43 PM, the DON stated the housekeeper and maintenance personnel had access to residents' rooms and did not need to know the residents' health information. The DON stated everyone in the facility should protect the residents' health information as much as possible in accordance with Health Insurance Portability and Accountability Act (HIPPA- federal law that protected a resident's health information) laws. During a review of the facility's Policy and Procedure (P&P) titled Confidentiality of Personal and Medical Records, revised on 12/19/2022, the P&P indicated the facility should honor the resident's right to secure and confidential personal and medical records. The P&P indicated it included the right to confidentiality of all information contained in a resident's records, regardless of the form of storage or location of the record. The P&P indicated the facility should safeguard the content of information including written documentation from unauthorized disclosure without the consent of the individual and/or the individual's surrogate or representative. The P&P further indicated resident's personal or medical information should not be left unattended or viewable by unauthorized persons.

Based on interview and record review, the facility failed to ensure Dietary recommendation by the facility's Registered Dietician was acted upon for one of one sampled resident (Resident 3) in accordance with the facility's policy and procedure (P&P) titled Nutritional and Dietary Supplements This deficient practice had the potential to result in adverse consequences for Resident 3. Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility initially admitted Resident 3 on 6/4/2024 and readmitted on [DATE] with diagnoses including hyperlipidemia (high level of fats in the blood), anemia (decrease in the total amount of red blood cells in the blood) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 2/24/2026, the MDS indicated Resident 3 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 3 was dependent (helper does all of the effort) from staff with eating, toileting, shower, upper and lower body dressing and putting on/taking off footwear. During a review of Resident 3's triglyceride level laboratory result dated 2/25/2026, the laboratory result indicated Resident 3's triglyceride level was 226 milligrams per deciliter (mg/dl - unit of measurement). The normal triglyceride level was below 150 mg/dl. During a review of Resident 3's Nutritional Assessment (NA) dated 2/25/2026, the NA indicated the facility's Registered Dietitian (RD) recommended omega three oral capsule 1,200 milligrams (mg, unit of measurement) once daily for elevated triglycerides. During a review of Resident 3's untitled Care Plan (CP) revised 4/8/2026, the CP indicated Resident 3 had actual/potential nutritional problems related to hyperlipidemia, anemia and dementia. The CP intervention indicated for the RD to evaluate and make diet change recommendations as needed. During an interview and record review on 4/22/2026 at 9:24 am with Registered Nurse 1 (RN 1), Resident 3's medical records (PointClickCare - PCC, a cloud-based software) were reviewed. RN 1 stated Resident 3 received RD recommendation of omega three oral capsule 1,200 mg for elevated triglycerides. RN 1 stated, it was RN 1's responsibility to carry out the RD recommendation. RN 1 stated RN 1 did not follow up with Resident 3's primary physician. RN 1 stated the purpose of RD recommendation was to check the nutritional needs of the residents. RN 1 stated Resident 3's triglyceride level was elevated at 226 mg/dl. During a concurrent interview and record review of the Medical Nutritional Therapy Assessment Recommendations Form (MNTARF) on 4/22/2026 at 9:26 am, RN 1 stated, RN 1 received the RD recommendation for Resident 3 on 2/25/2026. RN 1 stated Resident 3 had a recommendation to start omega three oral capsule 1,200 mg once daily for elevated triglycerides. During an interview on 4/22/2026 at 9:28 am, with the Director of Nursing (DON), the DON stated there was no specific timeframe to carry out or to act upon the RD recommendations. The DON stated the RD recommendations should be acted upon as soon as possible. The DON stated, the purpose of RD recommendation was to ensure the resident's nutritional needs were met as recommended. The DON stated if the RD recommendation was not acted upon, Resident 3's needs and goals would not be met as recommended. During a review of the facility's P&P titled, Nutritional and Dietary Supplements, dated 12/19/2022, the P&P indicated, It is the policy of the facility that nutritional and dietary supplements will be used to complement a resident's dietary needs in order to maintain adequate nutritional status and resident's highest practicable level of well-being. Resident's nutritional status will be accurately and consistently assessed upon admission and on an as needed basis to identify a resident at nutritional risk and address risk factors for impaired nutritional status. Supplements may be recommended by a Registered Dietitian and implemented post physician orders.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for a resident on oxygen therapy (treatment that provides supplemental, or extra oxygen) and breathing treatments (medicine delivered via nebulizer [device that turns liquid medicine into fine mist]) in accordance with professional standards of practice for one of two sampled residents (Resident 22). This failure placed Resident 22 at risk of infections which could lead to respiratory complications. Findings: During a review of Resident 22's admission Record (AR), the AR indicated the facility admitted Resident 22 on 12/22/2025 with diagnoses including acute respiratory failure (ARF, respiratory system suddenly fails to exchange gas) with hypoxia (deficiency in the amount of oxygen reaching body tissues), heart failure (HF, a heart disorder which causes the heart to not pump blood efficiently) and anxiety (feeling of fear, dread, and apprehension). During a review of Resident 22's untitled Care Plan (CP) dated 12/22/2025, the CP indicated Resident 22 was on oxygen therapy related to shortness of breath. The CP goals indicated for Resident 22 not to have signs and symptoms of poor oxygen absorption. During a review of Resident 22's Order Summary Report (OSR) dated 12/22/2025, the OSR indicated Resident 22 had an order for oxygen via nasal cannula (NC, a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at two liters per minute (l/min) and an order for breathing treatment of albuterol solution, three milliliters (ml- unit of measurement) to be administered via nebulizer every six hours for shortness of breath or wheezing (abnormal breath sound) dated 12/23/2025. During a review of Resident 22's Minimum Data Set (MDS, a resident assessment tool) dated 12/26/2025, the MDS indicated Resident 22 had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 22 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene, upper body dressing and personal hygiene and partial/moderate assistance (helper did less than half the effort) with toileting, shower and lower body dressing. During a concurrent observation of Resident 22's room and interview on 4/21/2026 at 9:18 am with Licensed Vocational Nurse 3 (LVN 3), Resident 22 was not in the room. Resident 22's nebulizer mask was left hanging on the bedrail and the oxygen tubing was left on the bed. LVN 3 stated that the nebulizer mask and oxygen tubing should be stored inside the transparent bag intended for storage of respiratory supplies when not in use to prevent contamination and spread of infection. During an interview on 4/23/2026 at 3:52 pm with the Director of Nursing (DON), the DON stated all respiratory supplies should be placed inside the clear, transparent bag when not in use for infection control. During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration, revised on 5/20/2024, the P&P indicated, Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include to keep delivery services covered in plastic bag when not in use.

Based on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 4) had a safe and clutter-free room environment when:1. Resident 4's room was full of clutter on top of and alongside Resident 4's bed.2. Multiple packs of cigarettes were inside Resident 4's bedside drawer.3. Resident 4 had medications at the bedside without a physician's order and without locked storage for medications at the bedside.This failure placed Resident 4 at risk for danger of falls and injuries, and risk of fire with a cluttered area of flammable materials (ability to ignite easily and burn rapidly) on top of and alongside Resident 4's bed. This failure also had the potential for Resident 4 and other residents to have an unmonitored adverse reaction to medications.During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was initially admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses which included bilateral spinal stenosis (when the space inside the backbone is too small), Post-Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), repeated falls, lower back pain, tobacco use, and chronic pain syndrome (a condition where pain lasts for more than 3-6 months, often continuing long after an injury has healed).During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 3/2/26, the MDS indicated Resident 4 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 4 required supervision with eating, oral hygiene, upper body dressing, and personal hygiene. Resident 4 also required partial/moderate assistance with toileting hygiene, showering/bathing self, lower body dressing, and putting on/taking off footwear.During a review of Resident 4's History and Physical (H&P), dated 2/28/26, the H&P indicated Resident 4 had the capacity to understand and make medical decisions.During a review of Resident 4's Care Plan Report (CPR), initiated on 1/27/23, the CPR indicated Resident 4 has personal belongings on the floor, around the bed, on top of the bed, and refuses to have staff clean and declutter room. The CPR also indicated Resident 4 was at risk for falls due to clutter around room. The CPR interventions included assisting Resident 4 with keeping area clean and clutter free, creating a regular schedule for cleaning Resident 4's room, encouraging Resident 4 to participate in sorting/discarding items, and offering alternative measures to keep personal items in safe and clutter free areas as needed.During a review of Resident 4's CPR, initiated on 6/19/23, the CPR indicated Resident 4 was at high risk for further falls and injuries due to history of falls, poor safety and judgement, and desires to be independent. The CPR interventions included keeping environment free from clutter and hazards and providing Resident 4 safety education as needed.During a review of Resident 4's Social Services Note (SSN), dated 2/12/26, the SSN indicated Resident 4 was educated on his behavior of hoarding (accumulating excessive personal items such as clothing, snacks, candies, food and other personal items) and how Resident 4's behaviors posed a health, safety and tripping hazard to Resident 4, Resident 4's roommates and facility staff.During a review of Resident 4's SSN, dated 2/13/26, the note indicated the Social Services Director (SSD) visited Resident 4 who had a preference of storing food condiments, mail, food snacks on bed side dresser and bed side table longer than a day. The note also indicated the SSD would follow up on Resident 4's cleaning status often.During a review of Resident 4's Social Services Assessment Note, dated 3/2/26, the note indicated, Other mood/behavior concerns (not treated with medication): Resident is noncompliant with room cleanliness.During a review of Resident 4's SSN from 3/3/26 to 3/31/26, there were no other notes regarding Social Services following up on Resident 4's room environment.During a concurrent observation and interview on 4/9/26 at 2:15 pm in Resident 4's room, the room was full of clutter on top of and alongside Resident 4's bed. On the right side of Resident 4's bed there were bags of clothes and other items cluttered against the wall/bed and together they blocked access on the right side of Resident 4's bed. On the left side of the bed and on top of the bed were various clothes, and other items (hats, paper napkins, surgical mask, a comb, an apple, cookies in a small bag, a green plastic clothes hangar, socks, gloves, a stuffed animal). Resident 4's food tray is sitting on top of and near the clothes. On the left side of Resident 4's bed is a 3-drawer dresser with multiple items cluttered on top and in the first drawer which is pulled out enough to see a couple packs of cigarettes, and clothes on the floor in front of the 3-drawer dresser. Resident 4 stated Resident 4 threw Resident 4's dirty clothes on that spot on the floor for laundry to come and pick up. Resident 4 stated Resident 4 had sinus issues inside the nose and pointed to both sides of Resident 4's nose. Resident 4 stated Resident 4 had a bottle of Benadryl (treats symptoms of hay fever, upper respiratory allergies, and common cold) capsules in Resident 4's 3-drawer dresser that Resident 4 used for sinus problem, but Resident 4 thought someone at night came into Resident 4's room and stole the bottle out of the 3-drawer dresser. Resident 4 stated Resident 4 had some Benadryl capsules in Resident 4's jacket pocket. Resident 4 was observed taking out 2 capsules from Resident 4's jacket pocket and placing the capsules on the bed. The capsules were small and half pink and half white in color.During an interview with the SSD on 4/9/26 at 3:19 pm, SSD stated Resident 4 was non-compliant and refused to clean Resident 4's room. SSD stated SSD advised Resident 4 to clean Resident 4's room, but Resident 4 stated Resident 4 liked Resident 4's room and bed that way.During an interview with Certified Nursing Assistant 2 (CNA 2) on 4/9/26 at 4:15 pm., CNA 2 stated, Resident 4 is usually calm and only gets mad if you touch any of (Resident 4's) stuff. CNA 2 stated, If Resident 4 needs something, (Resident 4) will ask for it. CNA 2 stated, I don't touch Resident 4's stuff. CNA 2 stated, All staff know not to touch (Resident 4's) stuff. CNA 2 stated, Resident 4's room has been full of clutter for five years.During an interview with the Administrator (ADM) and Director of Nursing (DON) on 4/9/26 at 4:50 pm, ADM and DON stated that Resident 4's room had been cleaned before, but the current room status happened recently. ADM and DON stated Resident 4's room environment was cluttered due to Resident 4's ongoing hoarding of various items. ADM and DON stated that the surrounding items around Resident 4's bed created a safety and health hazard as well as a tripping hazard for staff caring for Resident 4. When asked if Resident 4 had medications at the bedside, the ADM denied the ADM knew Resident 4 had Benadryl in Resident 4's room and self-medicating. The DON confirmed the DON visited Resident 4's room on 4/9/26 and saw 2 pink and white Benadryl capsules on Resident 4's bed. Both the ADM and the DON stated Resident 4 did not have an Interdisciplinary Team assessment for self-medicating.During a review of the facility's P&P titled, Resident Personal Belongings, revised 12/19/22, the P&P indicated, Policy: It is the policy of this facility to protect the resident's right to possess personal belongings such as clothing and furnishings for their use while in the facility and assure the personal belongings and/or possessions are rightfully returned to the resident, or to the resident's representative in the event of the resident's death or discharge from the facility. Policy Explanation and Compliance Guidelines: The facility may refuse to allow a resident to retain his or her personal possession(s) due to the following reasons: a) Insufficient space in resident's room; b) As protection of health and safety; c) To maintain and prevent the infringement of other resident's rights. The P&P further indicated, The facility will ensure resident belongings are kept in a neat and orderly fashion and maintained in each resident's room.During a review of the facility's P&P titled, Safe and Homelike Environment, revised 12/19/22, the P&P indicated, Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. The P&P further indicated, Policy Explanation and Compliance Guidelines: The facility will allow residents to use their personal belongings, including furnishings and clothing (as space permits) to assist in creating and maintaining a homelike environment. This use must not infringe upon the rights or health and safety of other residents.During a review of the facility's P&P titled, Resident Rights, revised 12/19/22, the P&P indicated, Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The P&P further indicated, Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.During a review of the facility's P&P titled, Resident Rights, revised 12/19/22, the P&P indicated, Resident rights. Planning and Implementing Care. The resident has the right to be informed of, and participate in, his or her treatment, including: The right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate.

Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was assessed for readmission to the first available bed in a semi-private room after Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 7/22/2025, in accordance with the facility's policy and procedure (P&P) titled, readmission to Facility, when the facility failed to request Resident 1's updated information and referral from GACH 1 on 7/31/2025 after GACH 1 contacted the facility regarding Resident 1's readmission to the facility. This deficient practice resulted in Resident 1 remaining in GACH 1 from 7/31/2025 through 8/6/2025 following an inquiry from GACH 1 for Resident 1 to be transferred back to the facility.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/22/2025 without diagnosis information. During a review of Resident 1's Order Summary Report (OSR), dated 8/1/2025, the OSR indicated there was a physician's order to admit Resident 1 to the facility on 7/22/2025. The OSR indicated there was a physician's order for Resident 1 to receive medications for high cholesterol, for seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and for schizophrenia (a mental illness that is characterized by disturbances in thought). The OSR also indicated there was a physician's order to transfer Resident 1 to GACH 1 for increased confusion on 7/22/2025. During a review of Resident 1's Care Plan (CP), dated 7/22/2025, the CP indicated Resident 1 had impaired cognitive function (ability to remember things, solve problems, or make decisions) or impaired thought processes related to dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Notice of Transfer/Discharge (NTD), dated 7/22/2025, the NTD indicated the reason for Resident 1's transfer was necessary for the resident's welfare and the resident's needs cannot be met in the facility. During a review of Resident 1's Psych ED Initial Eval (PEDIE) from GACH 1, dated 7/24/2025, the PEDIE indicated Resident 1 had neurocognitive disorder (decreased mental function due to a medical disease), likely exacerbated (made worse) by hepatic encephalopathy (brain dysfunction caused by liver's inability to remove toxins from the blood). The PEDIE also indicated there was no evidence Resident 1 had primary psychiatric illness. During a review of Resident 1's Internal Med Inpatient Progress Note - Final Report (INIPN-FR) from GACH 1, dated 7/31/2025, the INIPN-FR indicated Resident 1 had no behavioral issue and the discharge planning is medically stable for placement to lower level of care on 7/31/2025. During a review of Resident 1's Grievance Form (GF), dated 7/31/2025, the GF indicated the MD/A filled out the GF. The GF indicated MD/A refused to accept Resident 1 back from GACH 1 when GACH 1 SS 1 contacted MD/A by telephone on 7/31/2025 regarding transferring Resident 1 back to the facility. During an interview on 8/4/2025 at 1:48 p.m. with the Marketing Director/admission (MD/A), the MD/A stated MD/A refused to readmit Resident 1 when GACH 1 Social Services (SS) 1 contacted the facility regarding transferring Resident 1 back to the facility on 7/31/2025 because of the behavior exhibited by Resident 1 during Resident 1's previous stay. The MD/A stated the facility did not receive, request, and review Resident 1's updated information and referral from GACH 1, following the inquiry from GACH 1, when GACH 1 SS 1 contacted the facility on 7/31/2025. The MD/A stated usually the DON and the Infection Preventionist (IP) review the referral from GACH (in general) to determine if the facility can provide appropriate care to the resident and provide approval for admissions to the facility. The MD/A stated MD/A did not inform the DON about GACH 1's inquiry about transferring Resident 1 back to the facility. During a concurrent interview and record review on 8/1/2025 at 3:52 p.m. with Registered Nurse (RN) 1, Resident 1's Progress Notes (PN), dated 7/22/2025, were reviewed. RN 1 stated that on 7/22/2025, around 2 p.m., Resident 1 was newly admitted to the facility from GACH 2. RN 1 stated that Resident 1 was transferred to GACH 1 on 7/22/2025 around 9 p.m. for further evaluation of Resident 1's behaviors and increased confusion. Resident 1's PN, dated 7/22/2025 and timed at 9:17 pm, indicated Resident 1 went in other resident's rooms, removed items from other resident's closet, wandered aimlessly up and down the hallway, and touched medication carts and other items. The PN also indicated staff were able to redirect Resident 1 and assisted Resident 1 back into Resident 1's room or wheelchair but Resident 1 continued to repeat the same behaviors. The PN indicated Resident 1 was transferred to GACH 1 for further evaluation due to Resident 1's behaviors and increased confusion. During an interview with the DON on 8/4/2025 at 4:15 p.m., the DON stated the DON did not know GACH 1 called the facility on 7/31/2025 regarding transferring Resident 1 back to the facility. The DON stated the facility should have requested updated information from GACH 1 regarding Resident 1's condition on 7/31/2025 so that the DON and the IP could review Resident 1's records to determine if the facility could provide care to meet Resident 1's needs. The DON stated Resident 1 would be accepted for readmission to the facility with dementia and on psychoactive medications (affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) if Resident 1 did not have any behavioral issues (persistent and disruptive behaviors that negatively impact an individual's ability to function effectively in daily life and social interactions). The DON stated the facility could readmit Resident 1 if the facility could meet Resident 1's needs. During a concurrent interview and record review on 8/1/2025 at 4:23 p.m. with the DON, Resident 1's Order Summary Report (OSR), dated 7/22/2025, were reviewed. The DON stated there was an order to admit Resident 1 on 7/22/2025 and an order to transfer Resident 1 to GACH 1 for increased confusion on 7/22/2025. The DON confirmed Resident 1 was admitted to the facility and transferred to GACH 1 on 7/22/2025. The DON stated that the DON had not received an inquiry from GACH 1 for transferring Resident back to the facility after 7/22/2025. During a concurrent interview and record review on 8/1/2025 at 4:25 p.m. with the admission Coordinator (AC), the Daily Census, dated 7/31/2025, was reviewed. The AC stated that bed was available for admitting Resident 1 on 7/31/2025. During a review of the facility's Census List dated 7/30/2025, 7/31/2025, 8/2/2025, and 8/3/2025, the Census List indicated that:On 7/30/2025, room [ROOM NUMBER]A bed, room [ROOM NUMBER]B bed and room [ROOM NUMBER]B bed were empty and available.On 7/31/2025, room [ROOM NUMBER]B bed and room [ROOM NUMBER]A bed were empty and available.On 8/2/2025, room [ROOM NUMBER]D bed and room [ROOM NUMBER]A bed were empty and available.On 8/3/2025, room [ROOM NUMBER]D bed was empty and available.During a review of the facility's policy and procedure (P&P) titled, readmission to Facility, dated 12/19/2022, the P&P indicated, Residents who seek to return to the facility after the expiration of the bed-hold period or when state law does not provide for bed-holds, are allowed to return to their previous room if available or immediately to the first available bed in a semi-private room provided that the resident still requires the services provided by the facility and is eligible for Medicare skilled nursing facility or Medicaid nursing facility services.The facility will not evaluate the resident based on their condition when originally transferred to the hospital. If the facility determines it will not be permitting the resident to return, the medical record should show evidence that the facility made efforts to ascertain an accurate status of the resident's condition.to ensure the resident's condition and needs are within the nursing home's scope of care, based on its facility assessment, prior to hospital discharge.

Based on interview and record review, the facility failed to follow the facility's policy on Advance Directives (AD, written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for three of three sampled residents (Residents 17, 28 and 31) by failing to: 1. Ensure Residents 28 and 31's Advance Directive Acknowledgement Form (ADA) was filled out. 2. Ensure a copy of Resident 17's AD was in the medical chart. These failures had the potential for Residents 17, 28 and 31's preferences not carried out by the facility staff, affecting the residents quality of life. Findings: a. During a review of Resident 31's Admission Record (AR), the AR indicated Resident 31 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and lower back pain. During a review of Resident 31's History and Physical (H&P, formal document of a medical provider's examination of a patient) dated 4/18/2024, the H&P indicated Resident 31 had the capacity to understand and make decisions. During a concurrent interview and record review on 2/18/2025 at 11:43 AM with the Social Services Director (SSD), Resident 31's ADA form dated 4/15/2024 was reviewed. The SSD stated the ADA form was not filled out completely and stated there should be a check mark on the form if Resident 31 did or did not have an AD. The SSD stated the risk of not completing the ADA form was that the facility could provide services that were not in accordance with the resident's AD if the resident had formulated an AD. During an interview on 2/20/2025 at 2:30 PM with the Director of Nursing (DON), the DON stated the ADA forms should be filled out completed to indicate the facility inquired if the resident had an AD. The DON stated, the resident would receive the wrong services and the facility would not know the resident's preferences in receiving care during emergency if the ADA form was not filled out. 40438 b. During a review of Resident 17's Admission Record (AR), the AR indicated Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing traumatic event). During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), dated 12/4/2024, the MDS indicated, Resident 17 had a moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 17 required substantial/maximal assistance (helper did more than half the effort) with oral and toileting hygiene, shower, and personal hygiene. During a concurrent interview and record review on 2/19/2025 at 12:11 pm with the Social Services Director (SSD), Resident 17's Physician Orders for Life-Sustaining Treatment (POLST, a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of-life), dated 11/3/2021, and Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) Acknowledgement Form, dated 7/4/2024 were reviewed. The SSD stated the POLST indicated Resident 17 had no AD. The SSD stated the ADA Form indicated Resident 17 had not executed an AD. The ADA Form had a written note that Resident 17 wished to have an AD in place. The SSD stated there were no records indicated that Resident 17's family member was followed up on an AD or arrangement was done to formulate an AD. During an interview on 2/20/2025 at 12:09 pm with the Director of Nursing (DON), the DON stated AD should be in Resident 17's chart (medical record) upon Resident 17's admission. The DON stated the AD helped staff to determine Resident 17's wishes and preferences regarding care in the facility. During a review of the facility's policy and procedure (P&P) titled, Resident Rights Regarding Treatment and Advance Directives, revised 12/19/2022, the P&P indicated, On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident, if cognitively able to, would like to formulate an advance directive. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. 49252 c). During a review of Resident 28's Admission Record (AR), the AR indicated Resident 28 was originally admitted into the facility on [DATE] and readmitted into the facility on [DATE] with diagnoses that included depression (a mood disorder that may cause persistent sadness or loss of interest in activities) and chest pain. During a review of Resident 28's Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life), dated 9/23/2024, the POLST indicated Resident 28 had a legally recognized decision maker. During a review of Resident 28's History and Physical (H&P), dated 9/30/2024, the H&P indicated Resident 28 was awake, alert, and followed commands. During a review of Resident 28's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment, dated 2/4/20245, the MDS indicated Resident 28 had severely impaired cognition and used a wheelchair for mobility. During a concurrent interview and record review on 2/18/2025 at 11:45 am with the Social Services Director (SSD), Resident 28's Advanced Directive Acknowledgment (ADA) Form, dated 9/23/2024 was reviewed. The ADA Form did not indicate (by checking one of the following statements) that Resident 28 had or had not executed an advance directive. The SSD stated, the ADA form should have been completed on admission and was not complete, making it invalid. During an interview on 2/20/2025 at 2:30 pm with the Director of Nursing (DON), the DON stated the ADA Form should be entirely filled out to indicate if the resident had an Advance Directive. The DON further stated, this allows them to know the resident's wishes, preferences and prevent the risk of the resident receiving the wrong services. During a review of the facility's policy and procedure (P&P) titled, Residents' Rights Regarding Treatment and Advance Directives, last revised 12/19/2022, indicated it was the facility's policy to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate an advance directive. The P&P indicated, on admission the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident, if cognitively able to, would like to formulate an advance directive. The P&P indicated, in the event the resident is unable to formulate an advance directive due to cognitive impairment the facility will provide information and education to the resident's representative about the right to refuse medical or surgical treatment and formulate an advance directive.

Based on interview and record review, the facility failed to develop a specific and individualized person-centered care plan to meet the needs of trauma (a psychological and physiological response to an overwhelming, distressing, or life-threatening event or series of events) survivor residents for two of two sampled residents (Residents 17 and 54). These failures had the potential for Residents 17 and 54 not to receive the necessary care, treatment, and services. Findings: a. During a review of Resident 17's Admission Record (AR), the AR indicated, Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing traumatic event). During a review of Resident 17's Trauma Informed Care Screener (TICS, a tool or process that helps identify if someone had experienced trauma), dated 7/5/2024, the TICS result indicated Resident 17 had positive trauma screen. During a review of Resident 17's History of Present Illness (HPI), dated 8/11/2024, the HPI indicated Resident 17 had history of PTSD. During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), dated 12/4/2024, the MDS indicated, Resident 17 had a moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 17 required substantial/maximal assistance (helper did more than half the effort) with oral and toileting hygiene, shower, and personal hygiene. During a concurrent interview and record review on 2/19/2025 at 3:00 pm with the Registered Nurse Supervisor 1 (RN 1), Resident 17's Care Plans (CP) were reviewed. RN 1 stated, Resident 17 was a veteran and had a diagnosis of PTSD. RN 1 stated there was no care plan developed for Resident 17 to address the diagnosis of PTSD. RN 1 stated care plan should be developed for the staff to know the resident's triggers, and to developed interventions specific for the resident to prevent re-traumatization (experiences where past traumatic memories were triggered). During an interview on 2/20/2025 at 12:09 pm with the Director of Nursing (DON), the DON stated, Resident 17 who had diagnosis of PTSD should had a care plan specific for the needs of the resident to identify Resident 17's triggers and address his symptoms to prevent relapse of an old trauma. During a review of the facility's policy and procedure (P&P) titled. Trauma Informed Care, revised 12/19/2022, the P&P indicated, Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety. These interventions will also recognize the survivors' need to be respected, informed, connected, and hopeful regarding their own recovery. 36924 b. During a review of Resident 54's Admission Record (AR), the AR indicated the facility readmitted Resident 54 into the facility on [DATE] with diagnoses that included post-traumatic stress disorder (PTSD- mental health condition caused by an extremely stressful or terrifying event) and spinal stenosis (spaces inside the bones of the spine get too small). During a review of Resident 54's Minimum Data Set (MDS, a resident assessment tool), dated 1/8/25, the MDS indicated Resident 54 was cognitively intact (ability to understand and process thoughts), and required supervision or touching assistance with upper body dressing and personal hygiene and partial/moderate assistance with lower body dressing and toileting hygiene. During a record review of Resident 54's clinical record and Care Plans, Resident 54 did not have a Care Plan for Resident 54's PTSD diagnosis. During a concurrent interview and record review, on 2/20/25, at 10:37 a.m., of Resident 54's Care Plans, with LVN 2, LVN 2 stated Yes, Resident 54 has a PTSD diagnosis. LVN 2 stated Resident 54's behavior can be non-compliant, such as when Resident 54 does not want tray removed, does not adhere to schedules, and hoarding tendencies. LVN 2 stated PTSD is caused by flashbacks (sudden, involuntary re-experiences of a past event). LVN 2 stated LVN 2 knows Resident 54 is a veteran (served in the armed forces of their country), and maybe has bad memories of things that happened. LVN 2 stated Resident 54 did not have a specific Care Plan for PTSD, but there should be one because of the diagnosis and there should be a specific Plan of Care for PTSD. During an interview, on 2/20/25, at 3:02 p.m. with the Director of Nursing (DON), the DON stated that Resident 54 has a diagnosis of PTSD and is a Vietnam Veteran (served in the United States Armed Forces during the Vietnam War). The DON stated Resident 54 had discussed his experiences with DON. The DON stated per facility policy, Resident 54 requires a Care Plan specific to PTSD. The DON stated it is important to develop an individualized Care Plan for a resident with PTSD to manage symptoms and triggers. During a record review of the facility's Policy & Procedure (P&P), titled, Trauma Informed Care, dated, 2022, the policy indicated it is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Trauma-Informed Care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization.

Based on observation, interview, and record review, the facility failed to follow its policy and procedure for infection control and prevention for three of five sampled residents (Residents 10, 59, and 74), by failing to: a. Ensure Staff wore the appropriate Personal Protective Equipment (PPE- minimizes exposure to hazards) while providing care five residents on Enhanced Barrier Precautions (EBP- infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms) while providing care to Resident 74. b. Ensure an appropriate signage indicating Resident 59's transmission-based precaution (TBP, set of infection control guidelines used in healthcare settings to prevent the spread of infectious diseases than can be transmitted through contact with an infected person) was posted outside the resident's room. c. Ensure Certified Nursing Assistant 4 (CNA 4) wore the required PPE when changing Resident 10's linen. These deficient practices had the potential to result in cross contamination and the spread of infection. Findings: a. During a review of Resident 74's Admission Record (AR), the AR indicated the facility readmitted Resident 74 on 1/26/25 with diagnoses that included COVID 19 (virus), methicillin resistant staphylococcus aureus (MRSA- bacteria resistant to many antibiotics), immunodeficiency (condition that weakens or eliminates the immune system's ability to fight disease and infection). During a review of Resident 74's Minimum Data Set (MDS, a resident assessment tool), dated 1/30/25, the MDS indicated Resident 74 was severely cognitively impaired (ability to understand and process thoughts) and was on isolation or quarantine for active infectious disease. During a review of Resident 74's History & Physical (H&P), dated 2/2/25, the H&P indicated Resident 74 did not have the capacity to make medical decisions. During a concurrent observation and interview, on 2/18/25, at 3:58 p.m., Certified Nurse Assistant (CNA 5) was observed changing Resident 74's diaper. Resident 74 was on Enhanced Barrier Precautions (EBP). CNA 5 was observed wearing gloves and not wearing a gown while changing Resident 74. CNA 5 stated CNA 5 was changing Resident 74 and CNA 5 should be wearing a gown, mask, and gloves when changing Resident 74. CNA 5 stated CNA 5 was not wearing a gown while CNA 5 was changing Resident 74's diaper. CNA 5 stated CNA 5 should wear a gown. CNA 5 stated it was important because it's EBP you don't want to get sick and Personal Protective Equipment (PPE) protects her and the resident. During an interview, 2/19/25, at 3:10 p.m., with Licensed Vocational Nurse (LVN 4), LVN 4 stated EBP was used mostly when the resident has a gastrointestinal tube (delivers liquid nutrition directly to the stomach or small intestine) (G-tube- delivers liquid nutrition directly to the stomach or small intestine), multidrug-resistant organism (MDRO- resistant to multiple antibiotics or antifungals), or a wound. LVN 4 stated the resident is vulnerable to anything and we want to protect them. LVN 4 stated during cleaning and changing residents, it is very important, and staff need to wear a gown and gloves when a resident is on EBP and wearing only gloves is not the right way. The staff have to gown up and put your gloves on. During an interview, on 2/20/25, at 12:23 p.m., CNA 3 stated EBP is for our protection and the residents' protection. When a resident has a G-tube, catheter (a tube inserted into your bladder to freely drain urine), intravenous line (IV- a way to give fluids, medicine, nutrition, or blood directly into the blood stream through a vein), it is easier for them to get infection or spread infection to us. CNA 3 stated there are signs near the front of the door and stickers by the door that let us know if a resident is on EBP. CNA 3 stated the appropriate PPE to be worn when providing care to an EBP resident includes gloves, gowns, mask, and a face shield, depending on the kind of condition they have. CNA 3 stated using the proper PPE is important because it provides protection for us, the resident and other residents from any kind of infection or illness. During an interview, on 2/20/25, at 1:54 p.m., with the Infection Preventionist (IP), the IP stated not using the proper PPE affects the resident's safety and presents a risk for infections. The IP stated the PPE to be worn when providing care to EBP residents is gown and gloves. The IP stated If staff is wearing only gloves and no gown while changing a resident on EBP, the staff is not wearing proper PPE. During a record review of the facility's Policy & Procedure (P&P), titled, Enhanced Barrier Precautions, dated 2024, the policy indicated Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves during high contact resident care activities. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities. High-contact resident care activities include changing briefs or assisting when toileting. 40438 b. During a review of Resident 59's Admission Record (AR), the AR indicated Resident 59 was admitted to the facility on [DATE] with diagnoses that included osteoporosis (weak and brittle bones due to lack of calcium and vitamin D), unsteadiness (pattern of walking that's unstable) on feet, and anxiety (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 59's Minimum Data Sheet (MDS, a resident assessment tool), dated 1/6/2025, the MDS indicated Resident 59 had a severely impaired cognition (ability to understand and process information). The MDS indicated Resident 59 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating, oral hygiene and upper body dressing; and partial/moderate assistance (helper did less than half the effort) with toileting, shower, lower body dressing and personal hygiene. During a review of Resident 59's Specimen Preliminary Report (SPR), dated 2/3/2025, the SPR indicated Resident 59 had resistance to Extended-spectrum beta lactamase (ESBL, a bacterial infection resistant to many antibiotics making them harder to treat) in the urine. During a review of Resident 59's Order Summary Report (OSR), dated 2/10/2025, the OSR indicated Resident 59 was on contact isolation related to ESBL of the urine. During a concurrent observation and interview on 2/18/2025 at 10:47 am with the Treatment Nurse (TN) outside Resident 59's room. The TN stated Resident 59 was on Enhanced Barrier Precaution (EBP, a set of infection control practices that use gowns and gloves to reduce the spread of multidrug-resistant organisms [MDROs]) because Resident 59 had a positive ESBL in the urine. During a concurrent interview and record review on 2/18/2025 at 3:25 pm with the Infection Prevention Nurse (IPN), Resident 59's medical records (chart) and PointClickCare (PCC, a cloud-based software platform) were reviewed. IPN stated, there was no documented evidence that Resident was cleared out of contact isolation (a type of infection control precaution used to prevent the spread of infectious diseases that are transmitted through direct contact with an infected person or their environment) and infection was colonized (when microorganism, like bacteria or fungi, lives on or inside the body without causing a disease). The IPN stated Resident 59 should be maintained on contact isolation until cleared to prevent spread of infection to the other residents. During an interview on 2/20/2025 at 12:09 pm with the Director of Nursing (DON), the DON stated, Resident 59 who was on transmission-based precautions should be reassessed and cleared out of infection for the safety of the other residents in the facility and cohorted properly. During a review of the facility's P&P titled, Transmission-Based (Isolation) Precautions, revised 7/18/2023, the P&P indicated, Cohorting residents with the same pathogen. The order for transmission-based precautions/isolation will specify the type of precaution and reason for the transmission-based precaution. The duration will depend upon the infectious agent or organism involved. Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside of the resident's room, wing, or facility wide. Additionally, either the CDC category of transmission-based precautions (e.g., contact, droplet, or airborne) or instructions to see the nurse before entering will be included in the signage. The facility will have PPE readily available near the entrance of the resident's room and will don appropriate PPE before or upon entry into the environment of a resident on transmission-based precautions. 48905 c. During a review of Resident 10's AR, the AR indicated Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included quadriplegia (paralysis of both arms and legs) and dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday tasks). During a review of Resident 10's H&P dated 4/30/2024, the H&P indicated Resident 10 did not have the capacity to understand and make decisions. During a review of Resident 10's Order Summary Report (OSR) dated 6/21/2024, the OSR indicated an active physician's order for EBP related to risk for multidrug resistant organism infection (MDRO, bacteria that is resistant to antibiotics) due to presence of a gastrostomy tube (G-tube, thin flexible tube that is inserted into the stomach). During a review of Resident 10's MDS dated [DATE], the MDS indicated Resident 10 had problems with short-term and long-term memory and was dependent on staff for rolling left and right. During a review of Resident 10's undated and untitled care plan (CP), the CP indicated Resident 10 was on EBP as of 5/31/2023. The CP indicated for staff to wear gown and mask when changing contaminated linen. During a concurrent observation and interview on 2/18/2025 at 10:43 AM with Certified Nursing Assistant 4 (CNA 4) in Resident 10's room, an EBP sign was posted outside Resident 10's room. CNA 4 was inside Resident 10's room and was changing Resident 10's linen. CNA 4 was only wearing gloves. CNA 4 stated CNA 4 was not wearing the full PPE when changing Resident 10's linen and should have worn a gown and gloves. CNA 4 stated wearing the required PPE would prevent the transmission or microorganisms (germs). CNA 4 stated, gown and gloves should have been worn when changing the resident's linens because it was considered a high contact activity. During an interview on 2/20/2025 at 1:52 PM with the Infection Prevention Nurse (IPN), the IPN stated staff needed to wear the required PPE prior to entering an EBP room and when changing the resident's linen. The IPN stated, not wearing PPE would put the resident at risk for infection. During an interview on 2/20/2025 at 2:41 PM with the Director of Nursing (DON), the DON stated staff needed to wear the required PPE for direct and high contact activity in EBP rooms. The DON stated changing linens would be considered a high contact activity. The DON stated not donning the required PPE could spread infection. During a review of the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precautions revised 6/17/2024, the P&P indicated PPE for EBP was necessary when performing high-contact care activities which included changing linens.

Based on observation, interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Informed Consent, for the use of wander guard alarm (a system of wearable bracelets and sensors that helps keep residents safe in healthcare facilities) for one of three sampled residents (Resident 59). This failure violated Resident 59's right and placed Resident 59 at risk for psychological distress related to the discomfort from wearing the alarm and the sound of the alarm. Findings: During a review of Resident 59's Admission Record (AR), the AR indicated Resident 59 was admitted to the facility on [DATE] with diagnoses that included osteoporosis (weak and brittle bones due to lack of calcium and vitamin D), unsteadiness (pattern of walking that's unstable) on feet, and anxiety (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 59's Elopement Risk (ER), dated 12/22/2024, the ER indicated Resident 59 was at risk for elopement. During a review of Resident 59's Minimum Data Sheet (MDS, a resident assessment tool), dated 1/6/2025, the MDS indicated, Resident 59 had a severely impaired cognition (ability to understand and process information). The MDS indicated Resident 59 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating, oral hygiene and upper body dressing; and partial/moderate assistance (helper did less than half the effort) with toileting, shower, lower body dressing and personal hygiene. During an observation on 2/18/2025 at 10:47 am in the dining room, Resident 59 was sitting on his wheelchair with wander guard alarm bracelet on his right wrist. During a concurrent interview and record review on 2/20/2025 at 10:51 am with Licensed Vocational Nurse 4 (LVN 4), Resident 59's medical records (chart) and PointClickCare (PCC, a cloud-based software platform) were reviewed. LVN 4 stated there was no documented evidence that consent was obtained before the application of a wander guard. LVN 4 stated consent should be obtained to make sure the resident or his responsible party was informed and purpose on the use of wander guard was explained. During an interview on 2/20/2025 at 12:09 pm with the Director of Nursing (DON), the DON stated, the use of a wander guard alarm system involved a prolonged use of a device and should be consented before its application. DON stated the risks and benefits of using the device should be explained to prevent causing anxiety and discomfort from wearing the device and its sound. During a review of the facility's policy and procedure (P&P) titled, Resident Alarms, revised 12/19/2022, the P&P indicated, The facility shall establish and utilize a systematic approach for the safe and appropriate use of resident alarms, including efforts to identify risk; evaluate and analyze risk; implement interventions to reduce risk; and monitor for effectiveness of the interventions and modifying interventions when necessary. During a review of the facility's P&P titled, Informed Consent, revised 12/19/2022, the P&P indicated, When situations arise that involve complex decisions, the facility will verify that informed consent had been obtained prior to any medical intervention or treatment is initiated, including, but not limited to, administration of psychotherapeutic medications, application of a physical restraint or the prolonged use of a device that may lead to the inability to regain use of a normal body function and for transfer and discharge.

Based on observation, interview, and record review, the facility failed to ensure call light was within reach for one of one sampled resident (Resident 89). This failure had the potential for Resident 89 not to received necessary care and services and put Resident 89 at risk for fall. Findings: During a review of Resident 89's Admission Record (AR), the AR indicated Resident 89 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), depressive disorder (a mental health condition characterized by persistent feelings of sadness, hopelessness, and loss on interest or pleasure in activities) and unsteadiness on feet (gait instability). During a review of Resident 89's Minimum Data Set (MDS, a resident assessment tool), dated 2/4/2025, the MDS indicated, Resident 89 had a severely impaired cognition (ability to understand and process information). The MDS indicated Resident 89 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral and toileting hygiene, shower, upper, lower body dressing and personal hygiene. During a revie w of Resident 89's undated Care Plan (CP), the CP indicated Resident 89 was at risk for falls. The CP interventions included to place the resident's call light within reach and encourage the resident to use the call light for assistance as needed. The CP indicated Resident 89 needed prompt response to all requests for assistance. During a concurrent observation and interview on 2/18/2025 at 10:09 am with Certified Nurse Assistant 1 (CNA 1) inside Resident 89's room, Resident 89 was lying in bed with the call light hanging on the wall. Resident 89 stated she did not know where the call light was. CNA 1 stated Resident 89's call light should be placed next to Resident 89 where the resident could see the call light and able to call staff when Resident 89 needs help. During an interview on 2/20/2025 at 12:09 pm with the Director of Nursing (DON), the DON stated, call light should be within easy reach of the resident. by the bedside to be utilized when needed and needs could be addressed immediately. During a review of the facility's policy and procedure (P&P) titled, Call Lights: Accessibility and Timely Response, revised 12/19/2022, the P&P indicated, The purpose of this policy is to assure the facility is adequately equipped with a call lights. The P&P indicated staff will ensure the call light is within reach of residents and secured, as needed.

Based on interview and record review, the facility failed to complete the Level I Pre-Admission Screening and Resident Review (PASRR) for one of 21 sampled residents (Resident 5) that were in the facility for more than 30 days. This failure had the potential to place the resident at risk for delayed care and to not receive care and services for a mental or intellectual disability. Findings: During a review of Resident 5's Admission Record (AR), the AR indicated the facility readmitted Resident 5 to the facility on [DATE] with diagnoses that included malignant neoplasm of esophagus (cancer of the tube that runs from the throat to the stomach) and bipolar disorder (episodes of mood swings from depressive lows to manic highs). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 2/3/25, the MDS indicated Resident 5 was severely cognitively impaired (ability to understand and process thoughts), and was totally dependent in lower body dressing and personal and toileting hygiene. During a record review of Resident 5's clinical record, Resident 5's clinical record indicated on 6/13/23, Resident 5's Pre-Admission Screening and Resident Review I (PASARR- a federal requirement to determine need and appropriate setting for services) evaluation result was positive, and Resident 5 required a PASARR II evaluation. During an interview, on 2/21/25, at 12:21 p.m., with Admissions Coordinator (AC), the AC stated the AC completes admission and screens resident for PASARR I. The AC stated the AC usually receives the patient from the hospital so AC requests PASARR I from the hospital and AC gives PASARR I to the Minimum Data Set Assistant (MDS A). The AC stated MDS A is responsible for PASARR II. During an interview and record review of Resident 5's PASARR I, on 2/21/25, at 12:34 p.m., with MDS A, MDS A stated the PASARR I is triggered for residents with psychiatric diagnosis or medication or mentally disabled. The PASARR Department (PD) contacts MDS A for additional information or may interview resident, review medications, and confirm if on 5150 hold (involuntary psychiatric detention) of if on any lockdown. After the PASARR I is reviewed by the PD, the PD will update the facility, and a screen letter and determination letter are entered in the PASARR system. The MDS A stated if the resident discharges and returns, a new PASARR I screening is completed by MDS A to trigger another PASARR II and the resident is treated like a new admission because they may have a different diagnosis or medication. The MDS A stated another PASARR I evaluation should have been completed for Resident 5 upon readmission by Admissions, MDS A, or from the hospital to determine if a PASARR II was still needed. MDS A stated PASARR is used to determine if the resident needs the services, psychiatric evaluation or psychiatric services. MDS A stated there should have been a PASARR I screening completed between 6/13/23 and 1/28/25 for Resident 5 due to Resident 5 was readmitted and in facility for more than 30 days. MDS A stated Resident 5 was readmitted to the facility on [DATE] and 5/6/24 from the hospital and there was no PASARR I completed for Resident 5. During a record review of the facility's Policy and Procedure (P&P), titled, Resident Assessment-Coordination with PASARR Program, dated 2022, the policy and procedure indicated all applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. Exceptions to the preadmission screening program include those individuals who: a. Are admitted directly from a hospital. b. Are admitted directly from the hospital, requires nursing facility services for the condition for which the individual received care in the hospital, and has been certified by the attending physician before admission that the individual is likely to require less than 30 days of nursing facility services. If a resident who was not screened due to an exception above and the resident remains in the facility longer than 30 days: a. the facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID, or a related condition to the appropriate state-designated authority for Level II PASARR evaluation and determination. b. The Level II resident review must be completed within 40 calendar days of admission.

Based interview and record review, the facility failed to develop a care plan (CP) for the use of Zoloft (medication used to treat depression [persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities]) for one of one sampled resident (Resident 41). This failure had the potential for inconsistency of care for Resident 41 and risk for unnecessary psychotropic medication use. Findings: During a review of Resident 41's Admission Record (AR), the AR indicated Resident 41 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included major depressive disorder and hypertension (high blood pressure). During a review of Resident 41's History and Physical (H&P) dated 11/2/2023, the H&P indicated Resident 41 had the capacity to understand and make decisions. During a review of Resident 41's Order Summary Report (OSR) dated 10/24/2024, the OSR indicated Resident 41 had an active order for Zoloft 50 milligrams (mg, unit of measurement) once a day for depression, manifested by verbalization of sadness. During a review of Resident 41's Minimum Data Set (MDS, a standardized assessment tool) dated 12/5/2024, the MDS indicated Resident 41's had moderately impaired cognitive abilities (ability to think, learn and process information). During a concurrent interview and record review on 2/20/2025 at 10:59 AM with Registered Nurse Supervisor 2 (RN 2), Resident 41's medical record was reviewed. RN 2 stated there was no CP for the use of Zoloft and stated there should be a CP so that staff can monitor if the medication was working and to guide the staff on consistently implementing specific interventions for Resident 41. During an interview on 2/20/2025 at 2:47 PM with the Director of Nursing (DON), the DON stated there was no CP for Zoloft use for Resident 41. The DON stated there should be a CP so that staff would implement interventions for monitoring the effectiveness of the medication for Resident 41. During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Care Plans revised 12/19/2022, the P&P indicated the comprehensive CP will include measurable objectives and timeframes to meet the resident's needs as identified in the comprehensive assessment. The objectives will be utilized to monitor the resident's progress and alternative interventions will be documented as needed.

Based on interview and record review, the facility failed to provide the resident with management for constipation for five days (2/15/25, 2/16/25, 2/17/25, 2/18/25, 2/19/25) for one of one sampled resident (Resident 142). This failure resulted in a delay in receiving necessary care & services to manage Resident 142 constipation and had the potential to result in adverse consequences for Resident 142. Findings: During a review of Resident 142's Admission Record (AR), the AR indicated the facility admitted the resident on 7/1/24 and readmitted on [DATE] with diagnoses that included othopedic aftercare following surgical amputation (care provided following a medical procedure that involves removal of a body part) and obesity (excessive accumulation of body fat). During a review of Resident 142's History & Physical (H&P) dated 2/16/25, the H&P indicated Resident 142 had the capacity to make medical decisions. During a review of Resident 142's Minimum Data Set (MDS, a resident assessment tool) dated 2/18/25, the MDS indicated Resident 142 had moderately impaired cognition (ability to understand and process thoughts) and required supervision or touching assistance with upper body dressing, dependent for lower body dressing and toileting hygiene. During an interview on 2/18/25, at 10:54 a.m., with Resident 142, Resident 142 stated Resident 142 had constipation. Resident 142 stated Resident 142 did not have bowel movement (BM) since the previous Wednesday, 2/12/25 while in the hospital. Resident 142 stated Resident 142 was taking Norco but does not want Norco because of the side effects of constipation. During a concurrent interview and record review on 2/20/25 at 10:47 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 142 complained of constipation and LVN 2 administered Milk of Magnesia (MOM) on 2/19/25 at 12:00 p.m. with no bowel movement (BM) result. LVN 2 stated residents were rechecked/reassessed in about an hour after medications are given to determine medication effectiveness. LVN 2 stated LVN 2 did not document effectiveness of MOM on Resident 142's MAR. LVN 2 stated LVN 2 was assigned to Resident 142 on 2/18/25 and 2/19/25. LVN 2 stated LVN 2 saw in the resident's medical record that Resident 142 did not have a BM for three days. LVN 2 stated, usually there was a standing Physician's Order (MDO) that if MOM was ineffective, licensed staff needed to give a suppository or maybe enema but Resident 142 did not have this order. LVN 2 stated, for Resident 142, if the medication was ineffective, the physician should have been notified. Resident 142's MAR and Progress Notes indicated there was no follow up or additional medication given for constipation for Resident 142 on 2/19/25 and LVN 2 did not call the physician to report medication ineffectiveness. LVN 2 stated, constipation would affect Resident 142's health and could result in complications and patient discomfort. During a review of Resident 142's MAR for 2/1/25 -2/28/25, the MAR indicated Resident 142's last BM was on 2/14/25. The MAR indicated MOM was not given on 2/15/25, 2/16/25, 2/17/25, and 2/18/25. During a review of Resident 142's Pain Management Care Plan (CP) undated, the CP indicated for staff to monitor, document, and report adverse reaction to analgesic therapy. During a review of the facility's Policy and Procedure (P&P), titled, Provision of Quality Care, dated 2022, the P&P indicated each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to provide one of two sampled residents (Resident 1) with the needed respiratory (relating to or affecting respiration (breathing)) care including: 1. Failure to follow Resident 1's care plan for respiratory function by not taking the respiratory rate and lung sounds during assessment for shortness of breath (SOB). 2. Failure to notify Resident 1's physician on [DATE], when Resident 1's shortness of breath required a non-rebreathing (NRB) mask (a device that deliver a high concentration (100%) of oxygen (O2)). 3. Failure to take Resident 1's vital signs (reflect essential body functions, including heart rate, respiratory rate, temperature, and blood pressure) and assess Resident 1's inability to sleep as a result of being afraid something would happen if he closed his eyes. 4. Failure to implement the facility's policy on pulse oximetry (a test used to measure the oxygen level (oxygen saturation, measurement of oxygen concentration in the blood and normal range 90% to 100%) of the blood) by not reporting any abnormal results to the physician and policy on oxygen therapy by not consistently indicating the flow rate of oxygen therapy administered to Resident 1. As a result, on [DATE], Resident 1 experienced severe respiratory distress, cardiopulmonary arrest ([MEDICAL CONDITION] - the heart stop working) requiring cardiopulmonary resuscitation (CPR - a lifesaving technique useful in many emergencies in which someone's breathing or heartbeat had stopped), paramedics (emergency rescue team) transferred Resident 1 to General Acute Care Hospital 2 (GACH 2), where he died on [DATE]. Findings: A record review of the Resident 1's Record of Admission indicated Resident 1 was admitted to the facility, on [DATE] at 12:46 a.m., with the [DIAGNOSES REDACTED]. A record review of the Resident 1's Nursing Admission Assessment form dated [DATE], timed at 12:46 a.m., indicated Resident 1 had rhonchi (continuous low pitched, rattling breath sounds often resemble snoring) and the breathing was irregular. Resident 1 had mild labored (difficulty) breathing with oxygen at two liters per minutes (2 L/min, unit of measurement). A record review of the Resident 1's Care Plan developed on admission ([DATE]) for Resident 1's impaired respiratory function related to [DIAGNOSES REDACTED]. A record review of the Resident 1's admission orders [REDACTED] - Apply Resident 1 a Bi-level Positive Airway Pressure ([MEDICAL CONDITION] - a type of ventilator that helps with breathing and is administered with oxygen) from 9 p.m. to 7 a.m. - Administer nebulization (small machine that turns liquid into mist) with [MEDICATION NAME] (medication to open the airway - respiratory treatment) three milliliters (ml, unit of measurement) via Hand-Held nebulizer (HHN- small machine that turns liquid medicine into a mist) every six hours while awake and every two hours as needed (PRN) for shortness of breath. - Apply oxygen at 2 L/min via nasal cannula (N/C - a plastic tubing with two prongs to fit in the nostrils). A record review of the Resident 1's Physician order [REDACTED]. A record review of the Resident 1's Nursing Notes, dated [DATE], had the following entries by Licensed Vocational Nurse 1 (LVN 1): At 9:30 a.m., LVN 1 documented Resident 1 complained of shortness of breath, the oxygen saturation was 92% (normal range 90% - 100%) and the heart rate was 80 (normal range 60 to 100 beats per minute (bpm)). Resident 1 was administered hand held nebulizer (HHN, breathing treatment medication). At 10:45 a.m., LVN 1 documented Resident 1 had shortness of breath during physical therapy (PT) treatment. LVN 1 applied 100% oxygen NRB mask. LVN 1 left Resident 1 with PT when Resident 1's oxygen saturation was 90% and heart rate was 96 bpm. At 11:45, LVN 1 administered HHN respiratory treatment for [REDACTED]. At 12:30 p.m., LVN 1 documented Resident 1 refused to eat lunch or anything by mouth. Resident 1 had N/C (no O2 flow rate documented). At 1:50 p.m., LVN 1 administered HHN respiratory treatment for [REDACTED]. A record review of the Resident 1's Nursing Notes, dated [DATE], had the following entries by Registered Nurse 1 (RN 1): At 1:40 p.m., Registered Nurse 1 (RN 1) documented Resident 1 was requesting for breathing treatment, heart rate was 78 bpm, and O2 saturation was 96%. RN 1 documented Resident 1 had no shortness of breath, coughing, and congestion. At 3:15 p.m., RN 1 documented Resident 1 was receiving oxygen at 2 L/min and did not have shortness of breath. A record review of the Nursing Notes dated [DATE], timed at 4 p.m. and 6 p.m., indicated LVN 3 documented Resident 1 was receiving oxygen at 2 L/min and did not have shortness of breath. A record review of the Nurses Notes, dated [DATE], had the following entries by LVN 4: At 2:30 a.m., LVN 4 documented Resident 1 was anxious, and stated he (Resident 1) was unable to sleep and scared to close his eyes. LVN 4 documented, Resident added that something might happen. LVN 4 did not document checking Resident 1's lung sounds, O2 saturation, and vital signs. At 5 a.m., LVN 4 documented no coughing and congestion noted. A record review of the Nursing Notes, dated [DATE], had the following entries by RN 2: At 8 a.m., RN 2 documented Resident 1 was pale looking, had marked abdominal distention, and did not sleep well last night. At 10:45 a.m., RN 2 documented Resident 1 had shortness of breath, had abdominal pain, the oxygen saturation was 88%, the blood pressure was ,[DATE] millimeters of mercury (mmHg, unit of measurement, and normal range more than 120 over 80 and less than 140 over 90 (,[DATE] - ,[DATE])), and the heart rate was 80 bpm. Resident 1 was placed on 100% NRB mask. RN 2 called at 8 a.m. and at 10 a.m., Resident 1's physician to ask for a sleep aid medication. Resident 1's physician did not return RN 2's calls. At 10:50 a.m., RN 2 documented Resident 1 was more pale, was breathing through his mouth, and both hands had weak grip (ability to squeeze hand). At 10:58 a.m., RN 2 documented calling 911 (paramedics). At 11:06 a.m. RN 2 documented Resident 1 stopped breathing, had no pulse (heart rate), and CPR was initiated. A record review of the Ambulance Service Patient Care Report dated [DATE], timed at 11:07 a.m., indicated Resident 1 had agonal breathing (gasping respiration) with no pulse upon paramedics' arrival. Paramedics continued CPR. A record review of the GACH 2 Emergency Department (ED) History & Physical (H&P), dated [DATE] at 11:49 a.m., indicated Resident 1's physical exam of the respiratory was coarse breath sounds (small clicking, bubbling, or rattling sounds in the lungs) bilateral (both, left and right lungs). Resident 1 was intubated (a tube - endotracheal tube (ET), inserted through the mouth to assist with breathing) at 11:55 a.m. The portable chest X-ray (diagnostic exam to evaluate the lungs) indicated Resident 1 had moderate bilateral congestion with right lower lobe infiltrates (any blockage to an air space in a lung caused by the build-up of a substance that's foreign to the lung). A record review of the GACH 2 Death Summary Report indicated date of admission was [DATE], and date of death was [DATE]. The report indicated Resident 1 was intubated in the ED, brought to Surgical Intensive Care Unit (SICU), continued to worsen, and died on [DATE]. A record review of the Certificate of Death indicated the death date was on [DATE], at 2:45 a.m., and Resident 1's cause of death was cardiopulmonary arrest, septic shock (serious condition that occurs when a body-wide infection leads to dangerous low blood pressure), and ischemic [MEDICAL CONDITION] (blood flow to part of the large intestine is reduced due to narrowing or blocked blood vessels). During an interview, on [DATE] at 7:18 a.m., Certified Nursing Assistant 1 (CNA 1) stated she worked 7 a.m. to 3 p.m. shift on [DATE], and Resident 1 had on and off breathing problem, and CNA 1 notified LVN 1. CNA 1 stated on [DATE] at the start of the shift (7 a.m. to 3 p.m.), Resident 1 kept telling her (CNA 1) he could not breath. During an interview, on [DATE] at 7:23 a.m., LVN 1 stated on [DATE], Resident 1 improved with the NRB mask and its use did not require notification to Resident 1's physician or to RN 1. LVN 1 stated on [DATE] at 10:50 a.m., CNA 1 reported Resident 1's stomach was hurting and was short of breath. LVN 1 stated CNA 1 notified RN 2. During an interview on [DATE] at 9:58 a.m., RN 2 stated, on [DATE] at 10:45 a.m., CNA 1 had reported Resident 1 had SOB. RN 2 stated Resident 1 was purse lip breathing (a breathing technique that consists of exhaling through tightly pressed (pursed) lips and inhaling through the nose with the mouth with O2 saturation of 88% on O2 2L/min via N/C, and was pale. RN 2 stated a 100% non-rebreathing mask was administered, but Resident 1's color was becoming more pale, continued breathing through his mouth, and both hand grips were weak. RN 2 stated she called 911. RN 2 stated she did not recall assessing Resident 1's lung sounds and vital signs. During an interview, on [DATE] at 3:20 pm., LVN 4 stated, on [DATE] from 11 p.m. to 7 a.m., Resident 1 was nervous, could not sleep, scared to close his eyes, and stating something might happen. LVN 4 stated Resident 1 was not SOB. LVN 4 stated if Resident 1 was in any distress, he would check the vital signs, and for SOB, he would check the O2 saturation. LVN 4 stated physician was not notified. A record review of the facility's policy on Change in Resident's Condition and Status dated ,[DATE], indicated the facility shall promptly notify the resident, his or her attending physician of changes in the resident's medical/mental condition and/or status including changes in level of care. A record review of the facility's policy on Measuring Respiration, undated, indicated the purpose was to determine how many times the resident breathes in and out. The reporting and documentation included respiratory rate, if respirations were easy or labored, and if the respiration was noisy. A record review of the facility's policy on Oxygen Therapy dated ,[DATE], indicated oxygen will be administered as ordered by the physician or as an emergency measure until a physician's orders [REDACTED]. A record review of the facility's policy on Pulse Oximetry dated ,[DATE], indicated pulse oximetry was to obtain and utilize the results of the oxygen saturation in the assessment of the resident's respiratory status or condition. Reporting any unusual observation to the physician and any failure of physician's orders [REDACTED].