Every finding on record at Simi Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure the observance of proper sanitation and food handling practices when the Dietary Manager (DM) and 3 Dietary Staff (DS1, DS2, DS3), failed to wear a beard restraint during food handling. This failure had the potential to result in foodborne illnesses among the residents. During a concurrent observation and interview on 8/3/26 at 11:55 AM with the DM in the kitchen during lunch food service, the DM, DS1, DS2, and DS3 were all observed with facial hair present and no beard restraint used. The DM agreed that all facial hair should be covered by a beard restraint in the kitchen to prevent potential contamination of the food. During a review of the facility's policy and procedure titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, revised November 2022, indicated in part . Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens.

Based on interview and record review the facility failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST-a care directive during life threatening situations) matched the electronic medical record (EMR) in one of twenty-two sampled residents (Resident 2). This failure had the potential to violate Resident 2's rights on administering life-sustaining treatments during an emergency because of inaccurate or inconsistent documentation in the EMR.During review of Resident 2's admission Record (AR), dated 7/9/26, the AR indicates resident was admitted to the facility with diagnoses that included oropharyngeal dysphagia (difficulty swallowing and moving food from the mouth to the throat) and a gastrostomy (an opening from the outside of the abdomen directly into the stomach for the placement of a feeding tube [g-tube] to deliver liquid food, fluids, and medicine). During review of Resident 2's POLST, dated 2/14/26, the POLST indicated life sustaining treatment choice for long term artificial nutrition, including feeding tubes. Review of Resident 2's EMR indicated a physician order for no artificial means of nutrition including feeding tubes. During a concurrent interview and record review on 8/4/26 at 3:32 p.m. with Director of Nursing (DON), Resident 2's POLST and EMR were reviewed. DON acknowledged the EMR did not match Resident 2's POLST choices. During review of the facility's policy and procedure (P&P) titled Advance Directives, dated 9/2022, indicates in part, The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy.2. The director of nursing services (DNS) or designee notifies the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in the residents medical record and plan of care.4. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directives.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-Resident assessment and care screening tool used to guide care) was accurate for one of twenty-two sampled residents (Resident 57) when Resident 57's special treatments, procedures, and programs under section O, for oxygen therapy was left blank. This failure had the potential to result in Resident 57's identified care needs to go unmet and for the resident's medical record to be inaccurate. During review of Resident 57's admission Record (AR), dated 4/28/26, the AR indicated Resident 57 was admitted to the facility on [DATE] with diagnoses including idiopathic pulmonary fibrosis (thickening and scarring of the lung tissue that blocks oxygen from easily passing into the bloodstream, making it hard to breathe). Resident 57's MDS Assessments Section O, dated 7/6/26, the box for oxygen therapy was blank, indicating Resident 57 was not receiving oxygen. During a concurrent interview and review on 8/5/26 at 10:22 a.m. with Minimum Data Set Coordinator (MDSC), Resident 57's MDS dated [DATE] was reviewed. MDSC indicated section O in the MDS was answered after reviewing the resident's EMR for a 7-day lookback period. MDSC reviewed Resident 57's daily skilled nursing evaluations dated 6/29/26 through 7/5/26 and acknowledged the evaluations indicated Resident 57 was on two liters of oxygen via nasal cannula. MDS acknowledged that Resident 57's respiratory status was not accurately reflected in section O of the MDS. Review of the Resident Assessment Instrument manual (RAI), pages 8-9, dated October 2025, indicates in part, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status .an accurate assessment requires collecting information from multiple sources .Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. A copy of the facility's policy for MDS assessments was requested, however the two policies provided titled Interdisciplinary Care Planning and Comprehensive Person-Centered Care Plan did not address federal regulation at 42 CFR 483.20 (b)(1)(xviii) which indicates the comprehensive assessment must capture accurate clinical data.

Based on interviews and record review, the facility failed to ensure their nursing staff met professional standards of practice for two (2) of 22 sampled residents (Resident 84 and Resident 57) when:Physician's orders for medication were not followed for Resident 84Acetaminophen (medicine used to lower fever and ease mild or moderate pain) was administered to Resident 57 without a physician's order These failures had the potential to negatively impact resident's health. 1. Review of [NAME] and [NAME], 7th Edition, Mosby's Fundamentals of Nursing, page 419 in the section titled, Legal Implications in Nursing Practice indicates, Nurses are obligated to follow physician order unless they believe they orders are in error or would harm clients. During a review of Resident 84's admission Record, dated 8/4/26, the AD indicated Resident 84 was admitted on [DATE] with diagnoses of metabolic encephalopathy (a problem in the brain caused y a chemical imbalance in the blood), overactive bladder (condition that causes a sudden, strong need to urinate), dementia (loss of memory, language, problem-solving and other thinking abilities). During an observation on 8/4/26 at 9:33 a.m., Licensed Nurse 1 was observed administering Cranberry tablet (a medication use to prevent urinary tract infections) 450 mg (milligram – unit of measurement) to Resident 84. During a concurrent interview and record review on 8/4/26 at 11:22 a.m., with LN 1, Resident 84's Order Summary Report was reviewed. Resident 84's OSR indicated a physician order for Cranberry oral capsule 130 mg give 1 capsule three times a day. LN 1 confirmed 450mg was administered instead of the ordered 130 mg. LN 1 stated yes, it was the wrong dose, and acknowledged he did not follow the physician's order and did not check the right dosage before administering the medication. During a review of the facility's policy and procedure (P&P) titled Administering Medications dated April 2019, the P&P indicated Medications are administered in accordance with prescriber orders . The individual administering the medication checks the label THREE (3) time to verify . the right dosage . before giving the medication. 2. During review of Resident 57's admission Record (AR), dated 4/28/26, the AR indicated Resident 57 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (infection in any part of the urinary system) and hydronephrosis with renal and ureteral calculous obstruction (swelling and urine backup caused by hard mineral deposits stuck inside the kidney or the drainage tube leading to the bladder). During an interview on 8/3/26 at 11:26 a.m. with Resident #57, Resident 57 indicated having pain at a level 6 (on a 1-10 pain scale with 10 being the worst) and was given Tylenol (brand name for acetaminophen) around 8:00 a.m. During review of Resident 57's Order Summary (OS), dated 8/3/26, it was noted that there was no physician order for Tylenol. During a follow up interview on 8/3/26 at 3:10 p.m. with Resident 57, in the presence of Licensed Nurse (LN 1) Resident 57 reiterated that LN 1 gave the resident Tylenol for pain. LN 1 indicated Resident 57 was offered hydrocodone/acetaminophen (medicine used to treat moderate to severe pain) but the resident refused and instead asked for Tylenol. LN 1 stated the resident was given two tablets of 325 mg (milligrams) of Tylenol at around 8:30 a.m. Subsequently, LN 1 reviewed Resident 57's order summary and acknowledged there was no physician order for Tylenol. During an interview on 8/3/26 at 3:36 p.m. with Director of Nursing (DON) in the presence of LN 1, DON indicated that staff contact the physician to obtain orders when a resident requests a medication that is not on the OS. During review of the facility's policy and procedure titled, Administering Medications, dated April 2019, indicated in part, Medications are administered in a safe and timely manner, and as prescribed.

Based on observation, interview, and record review, the facility failed to provide respiratory care services consistent with professional standards of practice for one in twenty-two sampled residents (Residents 57) when the prescribed oxygen dose was not administered as ordered by the physician and the oxygen humidification bottle (sterile water used to make delivery of oxygen more comfortable) was empty and expired. These failures resulted in Resident 57 receiving more oxygen than needed and had the potential to result in negative health outcomes.During an observation on [DATE] at 12:39 p.m., Resident 57 was lying on a bed wearing a nasal cannula attached to a humidified oxygen concentrator. The oxygen meter read 2.5 liters per minute (LPM) and the humidification bottle had a documented open date of [DATE]. During review of Resident 57's Order Summary (OS), dated [DATE], the OS indicated oxygen at 2 LPM via nasal cannula (NC - a small plastic tube that sits in the nose) for desaturation (when blood oxygen drops too low) to titrate (raise or lower the flow to reach the target) to maintain >91%. (keep the pulse oximeter reading above ninety-one percent) as needed. During a concurrent observation, interview, and review on [DATE] at 1:27 p.m. with Infection Prevention Nurse (IP), IP confirmed Resident 57's oxygen was set at 2.5 LPM and the oxygen humidification bottle on the concentrator had a documented open date of [DATE]. IP reviewed Resident 57's physician orders for oxygen and acknowledged the order was for 2 liters, not 2.5 liters. When IP was asked questions about the humidification bottles, IP referred surveyor to speak with respiratory staff. During an interview on [DATE] at 1:33 p.m. with Respiratory Therapist (RT), RT indicated that respiratory staff change the humidification bottles on the oxygen concentrators twice a week but only for the sub-acute residents. RT indicated that Resident 57's oxygen tubing and humidification bottles were changed by nursing staff. During an interview on [DATE] at 1:37 p.m. with Director of Nursing (DON), DON was asked how often the humidification bottles were changed on the oxygen concentrators, DON stated when the bottle is empty. During an interview on [DATE] at 2:03 p.m. with Registered Nurse (LN 4), LN 4. LN 4 confirmed Resident 57's oxygen was set at 2.5 LPM instead of 2 LPM and the humidification bottle was empty and expired. LN 4 acknowledged the humidifier bottle was not changed within 7 days as required by facility policy. During review of the facility's policy and procedure (P&P) titled Oxygen Humidifiers, undated, the P&P indicates in part, 3. The intact system shall be used for a MAXIMUM OF SEVEN DAYS. Label the container and oxygen tubing with date change. During review of the facility's P&P titled, Administering Medications, dated [DATE], indicated in part, Medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders.

Based on interview and record review, the facility failed to ensure appropriate pain assessment and management was provided for one in twenty-two sampled residents (57) when Resident 57 was administered two acetaminophen (medication used to treat mild to moderate pain) 325 milligrams (mg) tablets for abdominal pain rated at a 5 (on a pain scale of 1 to 10 with 10 being the worst) without a physician order, without documenting in the medical record the medication was administered, and no re-assessment on the efficacy of the pain medication. This failure has the potential of inappropriately managing Resident 57's pain impacting their health and well-being.During review of Resident 57's admission Record (AR), dated 4/28/26, the AR indicated Resident 57 was admitted to the facility on [DATE] with diagnoses including urinary tract (a group of organs [kidneys, ureters, bladder, and urethra] the body uses to make pee and clear out waste) infection and hydronephrosis with renal and ureteral calculous obstruction (swelling and urine backup caused by hard mineral deposits stuck inside the kidney or the drainage tube leading to the bladder). The Minimum Data Set (MDS - a standardized assessment and care screening tool used to guide resident care), dated 7/7/26, indicates Resident 57's Brief Interview for Mental Status score (BIMS - a 0-to-15 measurement of a person's memory, learning, and orientation used to track brain function and guide support. Scores13 to 15 indicate cognition is intact [normal thinking], scores 8 to 12 indicate moderate impairment, and scores 0 to 7 indicate severe impairment) was 12. During an interview on 8/3/26 at 11:26 a.m. with Resident #57, Resident 57 indicated having pain at a level 6 (on a 1-10 pain scale with 10 being the worst) on the right mid back and lower abdominal area and feeling burning during urination. Resident 57 acknowledged telling the nurse about the pain and was given Tylenol (brand name for acetaminophen) around 8:00 a.m. but it was ineffective. During review of Resident 57's Order Summary (OS), dated 8/3/26, it was noted that there was no physician order for Tylenol. Review of Resident 57's nursing assessment dated [DATE] at 10:59 a.m. indicated a pain level of 0. During a follow up interview on 8/3/26 at 3:10 p.m. with Resident 57, in the presence of Licensed Nurse (LN 1) Resident 57 reiterated having pain and being given Tylenol in the morning with no pain relief. Resident 57 also stated it burns when I go pee. LN 1 acknowledged Resident 57 was assessed for pain in the morning and at that time Resident 57 had rated the pain at a level 5 (on 1-10 pain scale). Resident 57 indicated the pain level was now a 6. LN 1 indicated Resident 57 was offered Hydrocodone/Acetaminophen but refused and requested Tylenol instead. LN 1 stated that two tablets of 325 mg (milligrams) for a total of 650 mg were given to the resident at around 8:30 a.m. LN 1 was asked if Resident 57's pain was reassessed after administering Tylenol, LN 1 said no. Subsequently, LN 1 reviewed Resident 57's order summary and the nursing assessment that LN 1 performed earlier that day time stamped at 10:59 a.m. LN 1 confirmed there was no physician order to administer Tylenol and that the nursing assessment dated [DATE] at 10:59 a.m. indicated Resident 57's pain was 0.LN 1 acknowledged that LN 1 administered Tylenol without first obtaining a physician order, documenting an inaccurate pain level in Resident 57's nursing assessment, not following up with the resident to reassess pain, and not documenting Resident 57's source of pain (location or duration) in the medical record. During an interview on 8/3/26 at 3:36 p.m. with Director of Nursing (DON) in the presence of LN 1, DON indicated that staff contact the physician to obtain orders when a resident requests medication that is not on the OS. LN 1 verbalized to DON that Resident 57 was given 650 mg of Tylenol for pain without a physician's order, the pain was not re-assessed after giving the Tylenol, and did not document Resident 57's complaint of pain, level of pain, specifics related to the pain (location or duration) or that Tylenol was given. During review of facility's policy and procedure (P&P) titled, Pain - Clinical Protocol, dated October 2022, indicates in part, The physician and staff will identify individuals who have pain or who are at risk for having pain.The nursing staff will assess each individual for pain.when there is onset of new pain or worsening of existing pain. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity.The physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain.The staff will reassess the individual's pain and related consequences at regular intervals.

Based on observation, interview, and record review, the facility failed to ensure medications were labeled and stored appropriately when:Eight expired medications were stored in Medication Cart 1 and 2.One bottle of Dronabinol (medication used to treat severe nausea or stimulate appetite) was not stored in the refrigerator as recommended by the manufacturer These failures had the potential for residents to receive expired and ineffective medications.1. During a concurrent observation and interview on 8/5/26 starting at 2:15 p.m., with Licensed Nurse (LN) 4 at nurse station 1, the following medications were observed to be expired:Medication Cart 2- one bottle of Oyster shell Calcium plus vitamin D (supplement) with an expiration date of 04/2026- one bottle of Bismuth Subsalicylate liquid (medication used to treat upset stomach and diarrhea) with an expiration date of 05/2026- one opened foil packet of Ipratropium bromide and albuterol sulfate (liquid inhalation medication), opened date of 7/28/26 for Resident 22- one opened foil packet of Ipratropium bromide and albuterol sulfate, opened date of 7/10/26 for Resident 6- one opened foil packet of Ipratropium bromide and albuterol sulfate, undated for Resident 86- one opened foil packet of Budesonide (liquid inhalation medication), undated for Resident 22Medication Cart 1- one opened foil packet of Budesonide, undated for Resident 51- one opened foil packet of Ipratropium bromide and albuterol, undated for Resident 86LN 4 stated the undated packets should have an open date on them and are considered expired if they do not. LN 4 confirmed the above-mentioned medications are expired and should have been discarded. During a review of the facility's policy and procedure (P&P) titled Facility Auditing & Removal of Expired and Discontinued Medications undated, indicated, The medication nurse will remove expired medications from the drug storage areas so they are not administered to residents.2. During a concurrent observation and interview on 8/5/26 at 2:36 p.m., with Licensed Nurse (LN) 2, one bottle of Dronabinol for Resident 85 was observed stored in the narcotic drawer of Medication Cart 2. LN 2 stated he removed the Dronabinol bottle from the refrigerator around 7:30 a.m. and then stored it in the narcotic drawer.During a concurrent interview and record review on 8/6/26 at 11:56 a.m., with the Assistant Director of Nursing (ADON) the Manufacturer's Instructions (MI) for Dronabinol titled Dronabinol Drug Facts and Comparison dated 7/1/26 was reviewed. The MI indicated, Storage/Stability. Capsules. Store in a cool environment between 8 degrees C (Celsius) and 15 degrees F (Fahrenheit)or refrigerated. ADON stated the medication should not have been stored at room temperature because it decreases the potency of the medication. During an interview on 8/6/26 at 2:16 p.m., with the Director of Nursing (DON), DON stated Dronabinol should have not been stored in the medication cart and should have been returned to the refrigerator after being administered. During a review of the facility's policy and procedure (P&P) titled Medication storage and labeling undated, the P&P indicated Drugs requiring refrigeration shall be stored in a refrigerator between 2 degrees C (36 degrees F) and 8 degrees C (46 degrees F).

Based on interview and record review, the facility failed to ensure an accurate medical record for one in twenty-two sampled residents (Resident 57) when oxygen therapy and acetaminophen (medicine used to treat mild to moderate pain) were not documented in Resident 57's medical record. These failures resulted in an inaccurate medical record and unmonitored responses to oxygen and pain therapy.During a concurrent observation and interview on 8/3/26 at 12:39 p.m., Resident 57 was lying in bed wearing a nasal cannula (a small plastic tube that sits in the nose) and receiving 2.5 liters per minute (LPM) of oxygen. Resident 57 indicated having pain at a level 6 (on a 1-10 pain scale with 10 being the worst). Resident 57 stated staff administered Tylenol (brand name for acetaminophen) at around 8:00 a.m. but did not provide pain relief. During review of Resident 57's Order Summary (OS- a record of a doctor's medical directives, treatments, medications, and diagnostic tests), dated 8/3/26, the OS indicated oxygen at 2 LPM via nasal cannula for desaturation (when blood oxygen drops too low) to titrate (raise or lower the flow to reach the target) to maintain >91%. (keep the pulse oximeter reading above ninety-one percent) as needed. There was no physician order for Tylenol. Review of the Skilled Nursing Evaluations (SNE - daily assessments performed by licensed nurses to monitor residents' treatment response, track unstable conditions, and adjust the plan of care as needed), dated June 29, 2026 - July 31, 2026, indicated oxygen was administered on 6/29/26, 6/30/26, 7/2/26, 7/3/26, 7/15/26, 7/21/26, 7/23/26, 7/27/26, 7/28/26, 7/29/26. However, the Respiratory Treatment Administration Record (log of respiratory treatments given to a resident), with the same aforementioned dates indicated Resident 57 did not receive oxygen.Review of the nursing assessment, dated 8/3/26, indicated resident 57's pain was 0 indicating Resident 57 had no pain. Further review of Resident 57's medical record showed no evidence that the resident had pain in the morning on 8/3/26 or that acetaminophen was administered. During a concurrent interview and review on 8/5/26 at 10:22 a.m. with Minimum Data Set Coordinator (MDSC), Resident 57's Respiratory Treatment Administration Records and SNE's for June and July 2026 were reviewed. MDSC stated the information recorded in the SNE's contradicted the information in the Respiratory Treatment Administration Records. MDSC acknowledged that per the SNE's, Resident 57 was administered oxygen on various dates, but the Respiratory Treatment Administration Records indicated no oxygen was given. MDSC stated that both areas of a resident's medical record should match. During a concurrent interview and review on 8/3/26026 at 3:10 p.m. with Licensed Vocational Nurse (LN 1), Resident 57's medical record was reviewed. LN 1 confirmed that Resident 57 verbalized having pain at a level 5. LN 1 acknowledged giving Resident 57 two tablets of 325 mg (total of 650 mg) of acetaminophen at around 8:30 a.m. without a physician's order and not documenting it was given, dose or route. LN 1 also confirmed entering Resident 57's pain level as 0 instead of 5 in the nursing assessment dated [DATE]. During review of facility's policy and procedure (P&P) titled Charting and Documentation, dated July 2017, indicates in part, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.2. The following information is to be documented in the resident medical record: b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition.

Based on observation, interview, and record review, the facility failed to keep a resident free from hazards and provide the necessary monitoring and supervision for a resident with known diagnoses with Claustrophobia (an anxiety disorder characterized by an intense, irrational fear of confined or enclosed spaces) when a resident eloped from facility through the room window without staff notification for one of three sampled residents (Resident 1). This failure placed the resident at risk for serious injury and harm. During a review of Resident 1's admission Record (AR), Resident 1 was admitted to facility on 1/23/25 with diagnoses including, Altered Mental Status (a change in a person's normal thinking or awareness), Nontraumatic Chronic Subdural Hemorrhage (a slow developing collection of old blood on the surface of the brain that happens without a recent injury often due to fragile blood vessels), Type 2 diabetes mellitus (chronic metabolic disorder characterized by insulin resistance and relative insulin deficiency, leading to high blood sugar), Paroxysmal Atrial Fibrillation (a heart rhythm problem where the heart suddenly beats fast and irregularly, then returns to normal on its own), and Claustrophobia (an anxiety disorder characterized by an intense, irrational fear of confined or enclosed spaces).During an interview with the Director of Nursing (DON) and Administrator (ADM) on 3/19/26 at 2:40 p.m. DON stated that at approximately 5:00 a.m. on 3/19/26, Licensed Nurse (LN 1) called to inform her of a possible elopement. Per DON, LN 1 reported to DON she had completed her medication pass around 4:30 a.m. at which time Resident 1 was observed still in bed. When the Certified Nursing Assistant (CNA 1) conducted rounds shortly thereafter, Resident 1 was again reported to be present in her room. A while later, Resident 1 was discovered missing from the unit with exact time unknown. Paramedics arrived at the facility and informed staff that Resident 1 was found outside, sitting in the facility parking lot. Resident 1 was subsequently taken to the emergency room (ER) for further evaluation related to complaints of leg pain, though no visible injuries or bleeding were noted. Following this incident, DON and ADM instructed staff to account for all other residents in the facility.During a phone interview on 3/19/26 at 3:00 p.m. with LN 1, LN 1 stated that Resident 1 was last seen in bed at approximately 4:30 a.m., during the medication pass. LN 1 claimed, she was not aware of how or when Resident 1 had the ability to open or manipulate the window latch.A review of Resident 1's Progress Notes dated 12/11/25, showed that Resident 1 had a diagnosis of Claustrophobia and a review of Resident 1's Care Plan (CP) did not reveal any documentation addressing the resident's diagnosis of claustrophobia or interventions tailored to manage triggers associated with an intense, irrational fear of confined or enclosed spaces.During an observation of a facility tour on 3/19/26 at 2:10 p.m. Resident 1's bedroom window was observed to have an easy latch mechanism that allowed the window to be fully opened without any restriction.During a concurrent observation and interview on 3/19/26 at 2:35 p.m. with the Maintenance Manager (MM) and DON in Resident 1's room, the MM demonstrated that the window slid completely open using a simple latch mechanism requiring minimal force. Subsequent inspection of adjacent rooms in the same hallway showed identical, easy-latch mechanisms on windows with no safety stop, restrictor or alarm systems in place, presenting a potential exit risk without staff notification.A review of facility's policy and procedure (P&P) revised March 2019 and titled Wandering and Elopement the P&P states, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. A review of facility's P&P titled Safety and Supervision of Residents, dated 2017, the P&P indicated, Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for one of three residents (Resident 1) by failing to ensure a physician signature was obtained for Resident 1's, Physician Orders for Life-Sustaining Treatment (POLST), form dated 10/24/25.This failure resulted in conflicting medical records and delayed timely emergency medical decision-making during a change in Resident 1's condition, including during the emergency response preceding the resident's death.During a review of the Resident 1's admission Record (AR), the AR indicated Resident 1 was an [AGE] year-old female, initially admitted to facility on 06/18/2020 with the last re-admission date of 06/16/2025. Resident 1's diagnoses included, fracture (break) of left humerus (upper arm), acute and chronic respiratory failure with hypoxia (a condition in which the lungs are unable to deliver enough oxygen into the blood, occurring both suddenly and over time, resulting in dangerously low oxygen levels), Interstitial Pulmonary Disease (a group of lung disorders that cause scarring and stiffness of the lungs, making breathing difficult and reducing oxygen exchange, Pneumonia (a lung infection causing inflammation and fluid in the lungs, which can worsen breathing and oxygenation), Chronic Kidney Disease with Hypertensive Heart Disease and Heart Failure (long-standing kidney disease combined with high blood pressure and heart failure, which can cause fluid buildup in the lungs and worsen breathing). During a review of Resident 1's Progress Note (PN), dated 11/26/25 at 2:32 p.m., the PN indicated, at 7:45 - 8 a.m., CNA delivered breakfast tray with feeding assist and resident tolerating few bites and sips of juice. Approx. 8:15 - 8:20 a.m. nurse called to room by RNA (Restorative Nurse Aide) who stated, resident unresponsive. 911 called.During a review of the Emergency Medical Services (EMS), report dated 11/26/25 at 8:28 a.m., the Report indicated, Arrived on scene to a skilled nursing facility to find an 84 yo female patient lying supine in bed pulseless and apneic. Arrest (cardiac) was witnessed and story was unclear. Facility staff reported conflicting information. Last known well was approximately 30 minutes prior to EMS arrival. Basic Life Support (BLS) measures were initiated initially due to uncertainty regarding Do Not Resuscitate (DNR) status. Patient had 2 DNR forms both marked DNR but the most recent form not being signed. Family was contacted by the skilled nursing facility. Daughter was reached and stated she wants full resuscitation measures to be performed.During a review of Resident 1's POLST forms, the POLST forms indicated, POLST dated 10/05/2023 had the following checked, DNR, selective treatment and trial period of artificial nutrition and signed by the physician on 10/6/23. POLST dated 10/25/2024 had the following checked, DNR, selective treatment and no artificial means of nutrition. There was no physician signature on the form.During a review of Resident 1's Order Summary Report (OSR), dated 11/25/25, the OSR indicated, an active order dated 8/6/25 DNR (Do Not Resuscitate), SELECTIVE TREATMENT, NO ARTIFICAL MEANS OF NUTRITION INCLUDING FEEDING TUBES.During an interview on 12/22/25 at 11 a.m. with the Director of Nursing (DON), the DON stated when EMS arrived, There were two POLST forms-one signed by the doctor and the other not signed. The signed POLST was from 2023, and the newer POLST from 2024 reflected similar treatment selections but was missing the physician's signature. The DON stated EMS expressed confusion regarding which POLST to follow. The DON further stated that responsibility for ensuring completion of the POLST form rests with the admission nurse, the DON, and the social services team. The DON acknowledged that upon Resident 1's readmission, the updated POLST form was overlooked for physician's signature. During a review of the facility's policy and procedure (P&P) titled, Physician Orders for Life Sustaining Treatment (POLST), dated 01/09, the P&P indicated, Procedures: 2a Review the documents for validity. MUST be signed by the physician and the resident or the legally recognized health care decisionmaker. If the resident is a readmit to this facility, ask the resident or legally recognized health care decisionmaker if the document is still current.

Based on observation, interview, and record review, the facility failed to ensure there was a full time Director of Food and Nutrition Services (DFN) who met the federal and state's education qualification requirements to carry out the functions of the food and nutrition services. In addition, the facility failed to ensure the part-time contracted Registered Dietitian (RD) provided sufficient frequently scheduled consultation to the DFN to include overseeing kitchen sanitation, food preparation, meal service and food storage.This failure that had the potential to place 69 of 69 residents who received meals from the kitchen at an increased risk of foodborne illness and/or unmet nutritional needs. During an interview on 08/4/25 at 9 a.m. with Dietary Aide (DA) in the kitchen, DA stated they had a full-time dietary manager and there was an assistant manager, but both were off today. During an interview on 8/4/25 at 10:29 a.m. with per diem (was on site to help for a limited time) Dietary Services Supervisor (PD-DSS), PD-DSS stated the DFN that had worked at the facility for a year in the role of Dietary Manager (DM) was to take the Certified Dietary Manager (CDM) exam in June 2025 but did not. PD-DSS stated was aware the DM did not meet the federal nor state qualifications to function as the DFN (used interchangeably with DM) responsible for the daily management of foodservice operations. The DM called the facility that morning to quit. PD-DSS stated the facility called her on 8/4/25 to come to the facility to assist the kitchen staff and was not the facility’s full time qualified DFN, the facility did not have a full-time RD but instead had a part-time contracted RD. During a telephone interview on 8/5/25 at 12:28 p.m. with RD, RD stated was a contracted RD to work part-time and was aware the DM who had worked at the facility for a year as a DM did not meet the federal or state qualifications as he still needed to take the CDM exam. RD stated the last time she completed oversight of the foodservice operations was in February 2025 that was documented on a form titled, “RD Monthly Kitchen Rounds Checklist (RDKRCL),” dated 2/26/25, in which a copy was provided to the Administrator. RD stated she did not provide sufficient frequently scheduled consultation to the DM to provide effective oversight over foodservice operation systems and did not follow up to ensure deficits noted on the RDKRCL, dated 2/26/25, were addressed to ensure processes were in place for the health and safety of residents. the During a review of “RDKRCL,” dated 2/26/25, the RDKRCL indicated, “Menu, zero printed for staff . Check Food Handler exp [expiration] dates, CDM/ServSafe Manager?, zero substitution log found.” During an interview on 8/5/25 at 12:54 p.m. with the Administrator (ADN), ADN stated he confirmed the person that had filled the role as DFN (DM) for the past year had not met the federal or state education requirements and was unqualified. ADN stated he had been at the facility for four weeks. ADN stated he had recently been informed by the RD that the last completed “RD Monthly Kitchen Rounds Checklist” was completed in February 2025. ADN stated RD had not provided sufficient frequently scheduled consultation to the DM and verified the person that had been the facility’s DM during the past year was unqualified. During an interview on 8/5/25 at 1:50 p.m. with Dietary Aide (2) and PD-DSS, DA 2 stated he had been assisting the DM but was not a CDM nor graduated from a state approved DSS (Dietary Services Supervisor) program. DA 2 stated he wanted to take the on-line program to become a CDM. PD-DSS stated DA 2 was a dietary aide. During a review of the facility’s policy and procedure (P&P) titled, “Personnel Management,” dated 2023, the P&P indicated, “Policy: A qualified FNS Director, chosen by the Administrator, is responsible for the total operation of the Food & Nutrition Services Department. All Food & Nutrition service is performed under their direction. Procedure: If a person is not a Registered Dietitian, they must meet the Federal and State laws and receive regular consultation from a Registered Dietitian or have met equivalent requirements.” During a review of the facility’s job description (JD) titled, “Position: FNS Director,” dated 2018, the “JD” indicated, “Qualifications: Must meet the qualifications of a FNS Director as stated under State & Federal regulations. Duties and Responsibilities: The supervisor will confer regularly with the Administrator, Director of Nursing, and Dietary Consultant, and keep them informed of both the problems and progress of the Food & Nutrition Service Department. Is responsible for the preparation and service of all food and ensures that approved menus and accompanying recipes are followed. Is responsible for maintaining cleanliness of kitchen equipment and follows all department of health regulations. Review, update and follow policies and procedures.” During a review of the facility’s “Contractual Agreement (CA),” with the RD, dated 11/1/24, the “CA” indicated, “Consults with Administration regarding planning, Dietary Department policy development, establishing goals and principles and integrating the Dietary Department into the facility’s total program. Supports the Director of Dietary Services in maintaining department standards of food selection, receiving, storage, preparation, and service as needed. Monitors food service operations to ensure conformance to nutritional, safety, sanitation and quality standards, as well as state and federal regulations. Maintains and provides written reports of each consultation visit including data, clinical tasks completed, sanitation inspection reports when completed, comments, goals and/or recommendations.”

Based on observation, interview, and record review, the facility failed to ensure sanitation and food safety in the kitchen when: 1. Multiple opened and prepared food items were unlabeled or undated in the reach-in-freezer, walk-in refrigerator and dry storage areas. 2. The walk-in refrigerator and dry storage room were not maintained in clean and sanitary condition, as evidenced by cracked fixtures, holes in the ceiling, debris on the floor and shelving, dust built up on fans and pipes, and visible black residue on walls. 3. Clean food service equipment was not handled and stored in a sanitary manner as evidenced by designating visibly soiled equipment as clean and handling clean rack of dishes with unwashed hands. These deficient practices had the potential to contribute to environmental cross-contamination, promote bacterial growth and lead to foodborne illness, thus placing 69 of 69 residents who consume facility prepared meals at risk. Findings: 1. During a concurrent observation and interview on 8/4/25 at 9:06 a.m. with the Dietary Aide (DA), a cardboard box of frozen broccoli in a blue plastic bag located in the reach-in freezer was not dated as to when opened. The DA stated an open date should be on the bag containing the broccoli, but it was missing. During a concurrent observation and interview on 8/4/25 at 9:07 a.m. with the DA, a box of opened, frozen diced carrots had a handwritten date of 7/30/25 on the cardboard. DA stated 7/30/25 was the date received at the facility when the box of frozen carrots was unopened. DA stated the bag of frozen carrots should have been dated once opened and was not. During a concurrent observation and interview on 8/4/25 at 9:42 a.m. with the DA, multiple cases of Mighty Shakes that contained individual sized Mighty Shakes, dated 7/31/25 were stored in the walk-in refrigerator. DA stated the date on the case, 7/31/25 was the received date to the facility in which the cases were placed in the freezer. There was no date indicating when the box that stored individual sized of unopened Mighty Shakes was placed in the refrigerator to begin thawing. DA stated the thaw process should have a date once begun to ensure the manufacturer's guidelines were followed that indicated the product must be consumed within 14 days of thawing. In this case, the thawing time had not exceeded the manufacturer's guidelines, however, without a dating mechanism in place there was potential for this to occur in the future and DA stated staff need to date the case of frozen Mighty Shakes once placed in the refrigerator. During a concurrent observation and interview on 8/4/25 at 9:48 a.m. with Dishwasher (DW 2), in the smaller chamber of the walk-in refrigerator, an 8-quart food container with a red lid containing a liquid substance at the 2-quart level, was missing a label. Yellow colored residue was noted on various parts of the container, particularly around the 5.5-liter or 6-quart markings. DW 2 stated the container stored chicken broth, and it should have been dated and was not. During a review of facility's policy and procedure (P&P) titled, Procedure for Freezer Storage, dated 2018, the P&P indicated, All frozen foods should be labeled and dated. During a review of facility's P&P titled, Labeling and Dating of Foods, dated 2020, the P&P indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Food delivered to the facility needs to be marked with a received date. Newly opened food items will need to be closed and labeled with an open date and use by date.All prepared foods need to be covered, labeled and dated. Leftovers will be covered, labeled and dated.2. During a concurrent observation and interview on 8/4/25 at 9:15 a.m. with [NAME] 2 and DA, cracks were noted on the light fixture inside the dry storage room. In addition, several holes were observed on the ceiling next to the light fixture, as well as debris (some yellow in color) were seen scattered on the floor next to the food shelves. [NAME] 2 and DA confirmed and acknowledged the overall unkemptness of the dry storage room. During a concurrent observation and interview on 8/4/25 at 9:22 a.m. with [NAME] 2, in the dry storage room, a 22-quart (qt) sized bin containing cheerios filled to 16 qt was not dated. DW 2 stated the bin that stored cheerios should have been dated and was not. The lid of the bin had debris on it. [NAME] 2 removed the lid, examined it closely and stated, The lid needs to be scrubbed. During an observation on 8/4/25 at 9:32 a.m., the walk-in refrigerator had loaves of bread in original bags stored in close proximity under the ceiling pipes. The pipes were wrapped in black tape, with dust buildup observed around the fans and scattered on walls and ceiling. During a concurrent observation and interview on 8/4/25 at 9:35 a.m. with [NAME] 2, paint chipping and a black substance were noted on the wall behind milk racks. In addition, extensive buildup of dust along the walls and dark colored spots on the floor were observed within the walk-in refrigerator. [NAME] 2 scraped some residue off the wall and a visible black colored substance was noted on the tip of her fingernail she used to scrape with. [NAME] 2 acknowledged the overall lack of cleanliness. During a review of facility's P&P titled, Walls, Ceilings, and Light Fixtures, dated 2023, the P&P indicated, 1. Walls and ceilings must be free of chipped and/or peeling paint. 2. Walls and ceilings must be washed thoroughly. heavily soiled surfaces must be cleaned more frequently, as necessary. 3. Replace light fixtures as needed. During a review of facility's P&P titled, Storage of Food and Supplies, dated 2020, the P&P indicated, 1) The storeroom should be well-lighted, well-ventilated, cool, dry, and clean at all times. 6) . Bins/containers are to be labeled, covered and dated. 8) . All food will be dated- month, day, year. 9) Dry food items that have been opened, such as . dry cereal, etc., will be tightly closed, labeled, and dated .13) Do not store bread in the refrigerator. During a review of facility's P&P titled, Ingredient Bins, dated 2023, the P&P indicated, 1. Empty bin and take it to the cart was or dishwashing area. 2. Scrub interior and exterior of the bin with detergent . 6. Never restock without removing the older material and cleaning the bin.During a review of facility's P&P titled, Refrigerators and Freezers, dated 2001, the P&P indicated, Refrigerators and freezers are kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis and more often as necessary. 3. During a concurrent observation and interview on 8/4/25 at 9:29 a.m. with [NAME] 2, a piece of white debris was observed on the bottom of one of the inverted, maroon colored drinking mugs resting on the clean rack. The rack, storing clean mugs, was being used to prop the door to the dry storage room open. [NAME] 2 scraped off the debris with her nail, identified it as dried food. During an observation on 8/4/25 at 2:43 p.m. in the kitchen, the DW was observed washing dishes alone. DW proceeded to push a clean rack with newly washed dishes in it with bare hands after handling dirty dishes with the same ungloved hands without washing hands. During a concurrent observation and interview on 8/4/25 at 2:50 p.m. with DA 2, DA 2 was observed using a cloth to wipe down a 3-tier meal tray cart. DA 2 stated the cloth was obtained from a red bucket with a sanitizing solution. DA 2 stated the cart was not cleaned with detergent first prior to sanitizing the cart. After showing the leftover debris observed on the cart that he stated was just sanitized, DA 2 acknowledged the debris and stated the food service utility cart will be re-cleaned. During a review of facility's P&P titled, Sanitation, dated 2018, the P&P indicated, 2).Each employee shall know how to operate and clean all equipment in his specific work area. 9) All utensils, counters, shelves and equipment shall be kept clean., 15) All Food & Nutrition service staff shall know the proper hand washing techniques. 20) A minimum of two employees will be used when dishes are machine washed. One will handle the soiled area, and one will handle the clean side. If an employee does not need to go from soiled end to clean end, a strict hand washing routine must be followed. During a review of the Food and Drug Administration (FDA) Food Code (FDAFC), dated 2022, the FDAFC indicated, When to Wash. Food employees shall clean their hands and exposed portions of their arms.immediately. (E) After handling soiled equipment or utensils; (F).as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks;. and (I) After engaging in other activities that contaminate the hands.

Based on observation, interview, and record review, the facility failed to ensure that1. All medications stored in the facility's drug storage areas were available for use and had not expired.2. Pharmaceutical E-Kits (Emergency Kits containing antibiotics, sedatives, pain medications in limited quantities intended for use when supplies are limited) were replaced after opening.These failures had the potential to affect the efficacy and availability of medications administered to residents. Findings: 1. During a review of the facility’s policy and procedure (P&P) titled, “Storage of Medications,” dated 1/2025, the P&P indicated, “Procedures…n. Outdated, contaminated, or deteriorated medications…shall be immediately removed from stock…” During a concurrent observation and interview on [DATE] at 10:58 a.m. with the Infection Preventionist (IP) in Station 1 Medication Room, storage cabinets and countertop baskets used for storage of medications were observed. The following six items were found to be expired: 1. Normal Saline unit doses (sterile single use doses) two boxes expiration date 5/2023. 2. Phosphorus Supplement with Sodium and Potassium (used as a dietary supplement) expired date 7/2024. 3. Valproic Acid (used to treat certain types of seizures) two bottles expired dates [DATE] and [DATE]. 4. Lactulose (synthetic sugar used to treat constipation) one bottle expired date [DATE]. 5. Sucralfate (used to treat ulcers in the intestines) two bottles expired date [DATE]. 6. Mineral Oil (used to treat constipation) one bottle expired date 4/2024. The IP confirmed the medications should have been disposed of per the facility’s P&P. During a concurrent observation and interview on [DATE] at 3:37 p.m. with the IP at Medication Cart 1, one box of Bisacodyl (Dulcolax) (a laxative for constipation) was found with an expiration date of 6/2025. The IP confirmed the medication should have been disposed of per the facility’s P&P. During a concurrent observation and interview on [DATE] at 3:48 p.m. with the IP at Medication Cart 2, the following two, unused containers were found to be expired: 1. Ondansetron (used for nausea and vomiting) expiration date [DATE]. 2. Hyoscyamine (used to control irritable bowel) expiration date [DATE]. The IP confirmed the medications should have been disposed of per the facility’s P&P. 2. During a review of the facility’s P&P titled, “Emergency Pharmacy Services/Emergency Kit,” dated 1/2025, the P&P indicated, “Procedures…k. All kits must be replaced within 72 hours of opening”. During a concurrent observation and interview on [DATE] at 11:42 a.m. with Registered Nurse 2 (RN2) in the Medication Storage Room, one of three E-Kits was observed to be open. During a concurrent interview and record review on [DATE] at 11:48 a.m. with the IP and RN2, two billing slips were found inside of the open E-kits. The billing slips were dated [DATE] and [DATE]. RN2 stated, while referencing the electronic health record, that the “pharmacy had been called by the night shift on [DATE]”. The IP acknowledged the replacement of the E-kit was beyond the 72 hours as indicated in the facility’s P&P. During a concurrent interview and record review on [DATE] at 3:10 p.m. with Licensed Vocational Nurse 1 (LVN1), LVN2, and the IP, the E-kit on Cart 4 had been opened. The billing slip indicated the E-kit had been opened on [DATE] “day shift”. LVN1 and LVN 2 stated, “Pharmacy had been called on [DATE] on the night shift”. The IP acknowledged the replacement of the E-kit was beyond the 72 hours as indicated in the facility’s P&P.

Based on interview, and record review, the facility failed to provide monthly medication reviews for the months of May, June, and July 2025 for 4 of 19 sampled residents (Residents 7, 101, 2, and 12).This failure has the potential to result in residents having side effects or adverse reactions to medications and the attending physician not to be notified. During a review of Resident 7’s “admission Record (AR),” dated 8/5/25, the “AR” indicated, Resident 7 was admitted to the facility on [DATE] with diagnoses including, but not limited to colostomy status (a surgical procedure that creates an opening (stoma) in the colon, bringing it to the surface of the abdomen, to allow for the passage of stool when normal bowel function is disrupted), gastrostomy status (an opening into the stomach from the abdominal wall made surgically for the introduction of food), and neuromuscular dysfunction of the bladder (a condition where the nerves controlling the bladder and urinary sphincter muscles don't function properly). During a concurrent interview and record review, on 8/6/25 at 3:40 p.m. with the Director of Nursing (DON), Residents 7, 2 and 12's medical record was reviewed for evidence of the required monthly drug regimen (MRR) review by a licensed pharmacist. The DON was unable to locate any documentation of an MRR for Residents 7, 2 an 12 for the months of May, June, or July of 2025. During a review of Resident 101's Order Summary Report, dated August 7, 2025, the Order Summary Report indicated Seroquel oral tablet give 12.5 mg by mouth two times a day for Psychosis m/b agitation/hitting, aggression to peers. During a concurrent interview and record review, on 8/6/25 at 4:46 p.m. with the Director of Nursing (DON), Residents 101's medical record was reviewed for evidence of the required monthly drug regimen (MRR) review by a licensed pharmacist. The DON was unable to locate any documentation of an MRR for Resident 101 for the months of May, June, or July of 2025. During a review of the facility’s policy and procedure (P&P) titled, “Monthly Drug Regimen Review,” dated 1/2025, the P&P indicated, “The consultant pharmacist shall review the medication regimen of each resident at least monthly.”

Based on observation, interview, and record review, the facility failed to ensure:1. Medications were stored in accordance with manufacturers' storage specifications and/or the facility's policies and procedures (P&P).2. Medication room storage temperatures were continually monitored.These failures had the potential to affect the efficacy and availability of medications administered to residents and alter the delivery of these medications. Findings: 1. During a concurrent interview and record review on 8/4/2025 at 11:10 a.m. with the Infection Preventionist (IP), the manufacturers specifications for Bisacodyl (Dulcolax) (laxative used to treat constipation) and Acetaminophen (Tylenol) (pain reliever and fever reducer) suppositories (per rectum) were reviewed. The manufacturer’s labels indicated: a. Bisacodyl 10 mg suppositories “Store at temperatures below 25 degrees Celsius (C) (77 degrees Fahrenheit (F))” b. Acetaminophen 650 mg suppositories Store at 20-25 degrees C (68-77 degrees F)” The IP confirmed the thermometer hanging on the wall read 80 degrees F, which was warmer than the manufacturer’s specifications. During a review of the facility’s policy and procedure (P&P) titled, “Storage of Medications,” dated 1/2025, the P&P indicated, “Storage Table: “Levabuterol - use within 14 days of opening pouch”; “Budesonide – use within 14 days of opening pouch”; “Albuterol/Ipratropium – 7 days once removed from foil pack”. During a concurrent interview and record review on 8/4/2025 at 3:48 p.m. with the IP, in the Subacute Medication Cart, the facility’s P&P titled, Storage of Medications,” was reviewed for inhalant medications (medications breathed in) and the manufacturer’s specifications on the medication packaging. The following medications had opened foil protective packaging which had not been dated: 1. Levalbuterol (used to prevent and treat narrowing of the airways) three boxes “Once the foil ouch is opened, the vials should be used within two weeks. Once removed from the foil pouch the individual vials should be used within one week.” 2. Budesonide (reducing swelling and inflammation) one box “once foil is open, use ampules in two weeks.” 3. Ipratropium Bromide and Albuterol (opens up airways in the lungs, making it easier to breathe) inhalation one box “… Once removed from the foil pouch the individual vials should be used within one week”. The IP reviewed the specifications on the manufacturer packaging and confirmed the medications should have been dated and/or disposed of according to the facility’s P&P and manufacturer specifications. 2. During a concurrent interview and record review on 8/4/25 at 11:58 a.m. with the IP and the Director of Nursing (DON) the facility’s “Daily Room Temperature Monitoring Log,” dated April and May 2025 were reviewed. Temperature logs for the months of June, July, and the start of August 2025 were not available. The log indicated, temperatures were only recorded for four days for the month of April and nine days for the month of May. The IP confirmed the missing dates on the temperature monitoring logs and stated the Director of Nursing (DON) may have the missing months for June, July, and the start of August. The DON could not provide the missing temperature monitoring logs. During a review of the facility’s policy and procedure (P&P) titled, “Storage of Medications,” dated 1/2025, the P&P indicated, “Procedures, j. Medications requiring storage at ‘room temperature’ shall be kept in temperatures ranging for 15 degrees C (59 degrees F) to 30 degrees C (86 degrees F).”

Based on observation, interview, and record review, the facility failed to ensure the observance of proper infection control practices for five of six sampled residents (Residents 5, 6,18, 20, and 54) and 12 unsampled residents (Residents 16, 21, 27, 39, 45, 48, 53, 74, 80, 92, 95, 100, and 106).This failure had the potential to result in infectious outbreaks compromising the health, safety and welfare of residents, visitors, staff and the public.Findings: During an initial tour observation on 8/4/25, starting at 9:16 a.m., the following were noted: Resident 5 - Nebulizer plastic storage bag undated. Resident 6 – Nebulizer plastic storage bag undated. Resident 16 – Nebulizer plastic storage bag undated. Resident 18 – Nebulizer tubing and plastic storage bag undated. Resident 20 - Nebulizer tubing had no date. The plastic storage for nebulizer was dated 7/16/25. Yankauer (a rigid suction device) was undated, the plastic storage bag was dated 7/16/25. Resident 21 - Nebulizer plastic storage bag undated. Resident 27 - Urinary catheter bag undated. Resident 45 - Nebulizer tubing and plastic storage bag undated. Resident 48 – No date on urine bag. Resident 53 - Nebulizer plastic storage bag undated. Resident 54 - Nebulizer tubing and plastic storage bag undated. Resident 74 - Nebulizer plastic storage bag undated. Resident 80 - Nebulizer plastic storage bag undated. Resident 92 - Nebulizer plastic storage bag undated. Resident 95 - Nebulizer plastic storage bag undated. Resident 100 - Nebulizer plastic storage bag undated. Resident 106 - Suction cannister undated. During an interview on 8/4/25 at 10:40 a.m. with the respiratory therapist (RT), the RT concurred that everything should be labeled indicating the date it was changed. During a review of the facility’s policy and procedure (P&P) titled, Disposable Circuits and Supply Change, dated 5/1/24, the P&P indicated in part, “B. xii. Label the new circuits with date of change” and “II. P. Label with date of change”. During a review of Resident 39’s Physician Active Orders ([NAME]), dated 8/5/25, the [NAME] indicated, “Enhanced Barrier - precautions due to foley catheter, g-tube every shift ensure all staff wear proper PPE (Personal Protective Equipment- refers to specialized clothing and gear worn by healthcare professionals to minimize exposure to infectious materials, body fluids, and other hazards) when performing high contact activities. During a concurrent observation and interview on 8/4/25 at 11:19 a.m. with Resident 39, in the resident’s room, a gastrostomy tube feeding and a urinary catheter were observed. There was no enhanced barrier precautions signage posted outside Resident 39’s room and no PPE was available inside or outside the room. Resident 39 stated that she has had a colostomy on right upper abdomen, G-tube, and urinary catheter since admission to the facility. During a concurrent observation and interview on 8/5/25 10:56 a.m. with the Infection Preventionist (IP) in Resident 39’s room, the IP stated that he was not sure of why Resident 39 was not on enhanced barrier precautions (EBP), and confirmed that there was an physician order for it. IP further stated that he will make sure that there’s a PPE cart in Residents 39 room. IP was then observed placing the EBP signage outside the room. During a review of the facility’s P&P titled, Multidrug - Resistant Organism, dated 8/2019, the P&P indicated, Because environment surfaces and medical equipment, especially those in close proximity to the resident, may be contaminated, don gowns and gloves before or upon entry to the resident's room or cubicle. During a review of the facility’s P&P titled, Personal Protective Equipment, dated 2018, the P&P indicated, PPE required for transmission-based precautions is maintained outside and inside the resident's room, as needed.

Based on observation, interview, and record review, the facility failed to provide breakfast at a later time than the routinely scheduled breakfast time for 1 of 69 residents (Resident 33) when Resident 33 requested breakfast be delivered between 9-9:30 a.m. This failure resulted in Resident 33's food being cold and unpalatable by the time the resident woke up around 9-9:30 a.m. and had the potential to diminish Resident 33's autonomy and quality of life.Findings: During an interview on 8/4/25 at 11:30 a.m. with Resident 33 in the resident's room, Resident 33 stated she preferred to sleep late in the mornings. The facility delivers breakfast trays early. As a result, the food was cold and unpalatable by the time she woke up around 9-9:30 a.m.During an interview on 8/5/25 at 9:30 a.m. with certified nursing assistant 2 (CNA 2), CNA2 reported Resident 33 typically sleeps through breakfast and wakes up around 9:30 am. CNA 2 confirmed the tray is delivered early and left on the bedside table. During a concurrent observation and interview on 8/5/25 at 9:35 a.m. in Resident 33's room with Resident 33's private caregiver (PC), Resident 33 was asleep and the breakfast meal tray was on Resident 33's bedside table, untouched. Resident 33's PC stated Resident 33 does not like to eat breakfast early and that the issue has been raised with the facility before, but staff continue to deliver trays early and leave them at the bedside. During an interview on 8/6/25 at 2:15 p.m. with Resident 33 in the resident's room, Resident 33 stated by the time she wakes, the food has become ‘cold and does not taste good anymore'. Resident 33 stated she asks for her food to be reheated or requests an alternative, but there are long delays and by the time food is provided, it is often close to lunchtime. As a result, she skips breakfast most days. Resident 33 added that this issue has created tension with her son, who calls daily to confirm whether she ate breakfast, and she stated that although she has repeatedly asked for her mealtime preference to be honored, the facility has not yet accommodated her request. During a review of Resident 33's History and Physical Examination (H&P), dated 2/24/25, the H&P indicated, Resident 33 had the mental capacity to understand and make decisions. During a review of Resident 33's Care Plan (CP), initiated 2/24/25, revised on 3/5/25 with the target date of 8/21/25, the CP indicated, resident . at risk for altered nutrition/hydration r/t: severe protein calorie malnutrition. with goal to respect resident right to choose/refuse meals, honor food/fluids preferences. During a phone interview on 8/5/25 at 12:29 p.m. with the Registered Dietician (RD), the RD stated the facility should honor residents' mealtime requests, As long as they are reasonable and within a two-hour window for food safety. This can be planned, like for dialysis residents. The RD also verbalized the facility should have care plans in place for Resident 33 to receive breakfast meal tray at her preferred breakfast time. During an interview on 8/6/25 at 2:30 p.m. with per diem dietary services supervisor (PD-DSS), PD-DSS stated Resident 33 gets served breakfast between 7:30 a.m. to 7:45 a.m. daily.During a concurrent interview and chart review on 8/5/25 at 3:16 p.m. with the Director of Nursing (DON), the DON attempted to locate any entries regarding Resident 33's preferred breakfast time in the resident's chart but was unable to locate any entries. After reviewing Resident 33's care plan, nutritional notes, and other sections of the chart, the DON stated, If there were any care plans regarding her preference for a later breakfast mealtime, they would be documented in the nutritional care plans, but they are not. During a review of facility's policy and procedure (P&P) titled, Meal Service, dated 2023, the P&P indicated, 6.However, resident preferences for mealtime shall be honored. 7. The goal is to serve cold food cold and hot food hot.

Based on observation, interview, and record review, the facility failed to conduct a gradual dose reduction for psychotropic medications for 1 of 19 sampled residents (Resident 101). This failure had the potential to result in Resident 101 receiving unnecessary medication and having complications from the medication.Findings:During an observation on 8/5/25 at 12:42 p.m. Resident 101 was observed sleeping in bed. During a review of Resident 101's Face Sheet, the Face Sheet indicated, Resident 101 was admitted to the facility on [DATE] with diagnoses including, anxiety and traumatic brain injury.During an interview on 8/6/25 at 12:32 p.m. with Resident 101's Family Member (FM), the FM was concerned about Resident 101's medication regimen. FM stated Resident 101 sleeps during the day and is awake most of the night. FM further stated Resident 101 was taking a sleeping pill but did not know what time it was given.During a review of Resident 101's Order Summary Report, dated 8/7/25 the Order Summary Report indicated, an order dated 5/9/25 for Seroquel Oral Tablet (Quetiapine Fumarate) (antipsychotic medication used to treat several mental health conditions) Give 12.5 mg by mouth two times a day for Psychosis (a mental health condition characterized by a loss of contact with reality) m/b (manifested by) agitation/hitting, aggression to peers.During an interview on 08/06/25 at 4:46 p.m. with Director of Nursing (DON), DON was unable to locate the monthly medication reviews from the pharmacy for the months of May, June, and July 2025. DON stated no gradual dose reduction was documented for the months of May, June, and July 2025. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated July 2022, the P&P indicated, Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications.During a review of the facility's P&P titled, Pharmaceutical Services Policy and Procedures Manual, dated 1/25, the P&P indicated, Resident-specific Drug Regimen Review (DRR) recommendations and findings shall be documented and acted upon by the facility and/or physician.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) documentation in their medical record was accurate when wrongfully documenting that the resident is not currently on an antibiotic medication. This failure has the potential to create confusion upon health care team reviewing documentation and deciding the next best course of treatment. Findings: During a review of Resident 2's Physician's Orders, dated 6/16/25, the Physician's Orders indicated, Cephalexin Oral Capsule 500 MG (oral antibiotic medication) to be given 1 capsule by mouth two times a day for Pneumonia community acquired. During a review of Resident 2's Progress Notes, from 6/16/25 thru 8/5/25, the Progress Notes indicated, ten entries dated, 6/24, 6/28, 6/30, 7/7, 7/12, 7/29, 7/30, 7/31, 8/2, and 8/4/25 where nursing staff marked under special care that Resident 2 was not currently on antibiotics. During an interview on 8/6/25 at 11:46 a.m. with Assistant Director of Nursing (ADON), ADON confirmed Resident 2 is currently on antibiotics and the charting was not accurate. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, Revised July 2017, the P&P indicated, Documentation in the medical record will be objective .and accurate.

Based on record review and interview, the facility failed to ensure one of six sampled residents (Resident 18) was assessed for a PASARR (Pre-admission Screening and Resident Review - a Federal Program that ensures individuals with serious mental illness, intellectual disabilities, or related conditions are placed in nursing facilities and receive necessary services) after a COC (change of condition) for mental illness.This failure resulted in Resident 18 not being properly evaluated and possibly referred to receiving care and services in the most integrated setting appropriate to their needs.Findings:During a review of Resident 18's Electronic Medical Administration Record (eMAR) [a digital record of all medications to be administered or has been administered to a resident] dated August 2025, the eMAR indicated, an order for Seroquel (a medication to treat mental health conditions) Oral tablet 125 mg. (milligrams) via G-tube (GT - a feeding tube inserted through the abdominal wall directly into the stomach) every 8 hours for Psychosis (a mental disorder characterized by a disconnection from reality).During a review of Resident 18's PASARR (Pre-admission Screening and Resident Review - a Federal Program that ensures individuals with serious mental illness, intellectual disabilities, or related conditions are placed in nursing facilities and receive necessary services), the most recent PASARR on record was dated 8/14/23. No recent PASARR was completed to reflect the order for Seroquel on 1/20/25.During a concurrent interview and record review on 8/4/25 at 3:38 p.m. with the Director of Nursing (DON), Resident 18's eMAR was reviewed. The most recent PASSAR document was dated 8/14/23. The DON concurred that the PASSAR dated 8/14/23 was the most recent PASSAR. The DON stated, The staff did not re-evaluate the resident (Resident 18) for a new PASSAR on 1/20/25.During a review of the facility's policy and procedure (P&P) titled, Pre-admission SCREENING RESIDENT REVIEW LEVEL 1 (PASRR), dated October 2018, the P&P indicated, VII. The facility MDS Coordinator is responsible to access and ensure updates to the PASRR is done per MDS guidelines.

Based on interview and record review, the facility failed to administer ordered morning medications, including sliding scale insulin, and failed to monitor blood glucose levels as ordered for one of seven sampled residents (Resident 1). This failure resulted in Resident 1 experiencing critically high blood glucose levels, becoming unresponsive, requiring emergency medical treatment, and ultimately dying following transfer to an acute care hospital. Findings: During a review of Resident 1's admission Record (AR), dated 6/3/25, the AR indicated, Resident 1 was admitted in the facility on 4/24/25 with diagnoses including, diabetes mellitus type 1 (DM 1, condition in which the body cannot produce insulin or produces so little that insulin therapy is required to survive), Parkinson's disease (a progressive neurological disorder that primarily affects movement, causing symptoms like tremors, stiffness, and slow movement), hypertensive heart disease with heart failure (a condition resulting from long-term, uncontrolled high blood pressure that specifically leads to heart failure). During an interview on 6/2/25 at 5:45 p.m. with Licensed Nurse (LN 4), LN 4 stated that on 5/3/25, the licensed staff scheduled to work the overnight shift from 11 p.m. - 7 a.m. called off, was not able to work the 11 p.m. - 7 a.m. shift on 5/3/25. LN 4 stated the nurses from 3 p.m. - 11 p.m. shift stayed until 2 a.m. per administrator approval. LN 4 confirmed there was no licensed nurse on the skilled unit (Resident 1's unit) from 2 a.m. to 7 a.m. on 5/4/25. LN 4 further stated the scheduled 5 a.m.- 6:30 a.m. medications were not administered to residents during that time. Review of the staffing schedules indicated, on 5/4/25 from 2 a.m. to 7 a.m. there were four CNAs on the skilled unit, no licensed nurses. The subacute unit had two CNAs, one Licensed Vocational Nurse and one Registered Nurse. During an interview on 6/3/25 at 1:35 p.m. with LN 2, LN 2 stated that on 5/3/25 they were scheduled to work the 3 p.m. - 11 p.m. shift. LN 2 stated that one of the night shift nurses called off around 7 p.m., followed by another night shift nurse at 10:30 p.m. Multiple calls and messages were sent to the Director of Nursing (DON), Director Staff Development (DSD, and Administrator to report the staffing issue, but no response was received. LN 2 stated around 1 a.m. they spoke with the Administrator who gave approval for them to leave at 2 a.m. LN 2 stated they informed the sub-acute nurses they were leaving the skilled unit at 2 a.m. per the Administrator's approval. During a review of Resident 1's Physician's Order (PO), dated 4/24/25, the PO indicated, administer Insulin Lispro 100 UNIT/ML (milliliter) inject as per sliding scale: if blood glucose 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; >400 = 12 units, subcutaneously (SQ, under the skin) before meals for DM (Diabetes Mellitus) at 6:30 a.m., 11:30 a.m. and 4:30 p.m. During a review of Resident 1's Medication Administration Record (MAR), dated 5/4/25 at 6:30 a.m., the MAR indicated, there was no documentation of insulin administration and blood glucose monitoring for that morning dose scheduled for 6:30 a.m. There was also no nursing progress note explaining the omission or indicating the physician was notified. During a review of Resident 1's PN, dated 5/4/25 at 9 a.m., the PN indicated, Resident is sleeping, unable to administer medication, There was no documentation of further attempts, no blood sugar check, and no physician notification. During a review of Resident 1's PN, dated 5/4/25 at 10:30, the PN indicated, Insulin Lispro Subcutaneous 100 UNIT/ML inject as per sliding scale . resident is sleeping, unable to administer medication. No documentation indicated that the blood glucose was checked. During a review of Resident 1's Care Plan (CP), dated 4/25/25, the CP indicated, Resident 1 had potential for hypoglycemia/hyperglycemia (low/high blood sugar) related to their DM 1 diagnosis. The CP Interventions included: Administer medication as ordered. Monitor blood sugar levels as ordered. During a review of Resident 1's SBAR Communication Form (SBARCF), dated 5/4/25, the SBARCF indicated, Resident 1 was found unresponsive at 10:30 a.m. and could not be aroused by verbal or tactile stimuli. Initial oxygen saturation (a measure of how much oxygen is carried in your blood) was 73% then increased to 97% within one minute after administering oxygen via non-rebreather mask. Blood glucose results were unable to read, glucometer displayed HI. Physician was notified and recommended to send Resident 1 to emergency room (ER). During a review of Resident 1's hospital records titled, Emergency Department Reports (EDR), dated 5/4/25, the EDR indicated, Brought in by Advanced Life Support (ALS) ambulance from [name of skilled nursing facility] for hyperglycemia and altered mental status since this morning . Patient in on nonrebreather (oxygen mask designed to deliver high concentrations of oxygen to a patient), unresponsive to verbal and painful stimuli. Glucose read high, >650. During a review of Resident 1's hospital records titled, Discharge Summaries Notes, dated 5/6/25 at 10:32 a.m., the Notes indicated, Palliative care consulted due to poor prognosis. admitted to ICU (intensive care unit) for further evaluation. Patient was evaluated by palliative care and family decided on comfort care. Patient passed away shortly after. Resident 1 passed on 5/5/25 with final diagnoses including, acute hyperkalemia (high potassium levels), respiratory failure, acute kidney injury, altered mental status, cardiac arrest, and diabetes ketoacidosis (a serious, potentially life-threatening complication of diabetes where the body produces excess ketones due to a lack of insulin). During an interview on 6/3/25 at 8:15 a.m. with Licensed Nurse (LN) 1, LN 1 stated when she arrived for her 7 a.m. shift on 5/4/25, the night Certified Nursing Assistant (CNA) informed her that no licensed nurse was on duty between 2 a.m. and 7 am. LN 1 stated there was no handoff report, and she did not know whether Resident 1 received the scheduled 6 a.m. medications. LN 1 further stated she did not check Resident 1's blood sugar until the resident became unresponsive around 10 a.m., and the glucometer displayed a reading of HI. LN 1 observed Resident 1 was sleeping and snoring, but unresponsive to tactile stimulation. LN 1 further stated that morning was not able to give Resident 1 his medications because he had been sleeping. Also, the CNA informed her (LN 1) that Resident 1 had refused eating breakfast. During an interview on 6/25/25 at 5:18 p.m. with Licensed Nurse Supervisor (LNS), LNS stated on 5/4/25 around 10 a.m., Resident 1 was found unresponsive and non-arousable. LNS stated the physician was notified, and Resident 1's blood glucose was checked. The glucometer displayed a reading of HI. An ambulance was called and upon arrival, paramedics confirmed the same HI glucose reading. LNS stated that when she arrived for her 7 a.m. shift, there was no licensed nurse present on the skilled unit. LNS attempted to contact the DON, DSD, and Administrator to report the overnight staffing issues, but no response was received. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, the P&P indicated, The comprehensive, person-centered care plan will: describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. During a review of the facility's P&P titled, Administering Medication, dated April 2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescribed orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 1) was transferred from the bed to a wheelchair using a two-person assist while using a mechanical lift. This failure resulted in Resident 1 falling during transfer from the bed to a wheelchair, using a mechanical lift solely by Nursing Assistant 1 (NA1). As a result of the fall Resident 1 sustaining multiple right rib fractures, a right scapular fracture, and a right posterior parietal scalp hematoma, that required immediate hospitalization . Findings: Review of Resident 1's face sheet indicated [DIAGNOSES REDACTED].(windpipe) for the purpose of establishing and maintaining a patent airway). Review of Resident 1's Minimum Data Set (MDS - resident assessment of healthcare, functional needs, and abilities) dated 9/15/19, indicated Resident 1 had no speech, rarely or never understood, but sometimes understands others, and highly impaired vision. Resident 1's cognitive skills were severely impaired, with a Brief Interview for Mental Status (BIMS - a test used to get a quick snapshot of how well a resident functions cognitively at the moment; 13-15 cognitively intact, 08-12 moderately impaired, and 00-07 severe impairment) score of 00. The Resident's functional status included total dependence, requiring two or more-person physical assist during transfers to and from bed, chair or wheelchair. The MDS also showed resident as not steady, and only able to stabilize with staff assistance during surface-to-surface transfers between bed and chair or wheelchair, and functional limitations showed impairment on both upper and lower extremities. Review of Resident 1's Fall Risk Assessment (FRA), completed quarterly (at a minimum), last assessment at 9/12/19 indicated a score of 14, with a score of 10 or above indicating a high risk for falls. Further review of the FRA, indicated Resident 1 had the following risk factors: a) disoriented, b) chair bound and/or assist with elimination, c) poor vision status, d) not able to perform gait balance, e) takes 3-4 medications (Anesthetics, [MEDICATION NAME], Antihypertensives, [MEDICAL CONDITION], Benzodiazepines, Cathartics, Diuretics, Hypoglycemics, Narcotics, [MEDICAL CONDITION], Sedatives/Hypnotics), and f) 1-2 present predisposing diseases ([MEDICAL CONDITIONS], [MEDICAL CONDITIONS], Loss of limb(s), [MEDICAL CONDITION], Arthritis, [MEDICAL CONDITION], Fractures). Review of Resident 1's Resident Care Plan for Falls, dated 4/5/18, and last re-evaluated on 9/19, indicated Resident 1 was at risk for falls due to [MEDICAL CONDITION] with [MEDICAL CONDITION], non-ambulatory (does not walk), total assist with activities of daily living, major [MEDICAL CONDITION] (a persistently depressed mood or loss of interest in activities) with Anti-Depressant medication, [MEDICAL CONDITION] (a disease affecting movement, often including tremors), [MEDICAL CONDITION] (nerve cell activity in the brain is disturbed from previous [MEDICAL CONDITION] such as trauma or stroke), and Hypertension (increased blood pressure levels). Care plan interventions included providing resident with a safe and clutter free environment, keeping assistive device in working order, providing visual checks and verbal cues, bed in lowest position, and use of mechanical lift for transfer. Review of Resident 1's Resident Care Plan on ADL (activities of daily living) Functioning, dated 4/5/18 and last re-evaluated on 9/19, indicated Resident 1 required assistance (total X2 persons) with transfers using a mechanical lift. Review of Resident 1's ADL Flowsheet, dated (MONTH) 2019, indicated Resident 1 had Dependence/Total Dependence listed as her ADL Self-Performance and a two or more-person physical assist with ADL Support Provided during bed mobility and transfers. Review of the SBAR (Situation, Background, Appearance/Evaluation, Review/Notify) Communication Form, dated 11/17/2019, indicated in part, At 1010 a.m., CNA called charge nurse due to patient's fall while being transferred to the wheelchair from her bed using Hoyer Lift, patient was hooked to the sling in order for transfer and during the process, she slid from the sling. When charge nurse entered the room, patient was found on the floor on her right side with her head on the metal rod (base) of the Hoyer Lift .Patient was also found to be de-saturating with O2 level in low 80s . Further review of the SBAR Form indicated, a bump on the right side of head, no open wound and bleeding noted .at 10:14, attending physician was called and received an order to transfer to (name of the hospital) ER via 911 .patient's son was informed via phone of patient's transfer at 10:42. Review of Resident 1's Physician Telephone Orders, dated 11/17/19, at 10:15 a.m., indicated, Transfer to (name of the hospital) ER (911) (Pt fell on floor). Review of Resident 1's hospital emergency room report (History and Physicals - H&P), dated 11/17/2019, indicated Resident 1 .presented from long term facility after fall while getting into wheelchair .turned blue per SNF staff, pt alert, nonverbal, requiring assisted ventilation [MEDICAL CONDITION].workup in ED showed severe [MEDICAL CONDITION] .[MEDICAL CONDITION] switched to a cuffed one and pt was placed on vent .sent to ICU for further workup. A review of the 1 view Portable Chest X-Ray (used in hospitals to perform imaging on patients who are in critical condition that they cannot be easily transported to the radiology department) report, dated 11/17/2019, shows that Resident 1 has a Small right lower lung infiltrate (a substance denser than air, usually associated with Pneumonia (an inflammation in one or both lungs usually caused by [MEDICAL CONDITION] or bacteria)) and a small right effusion (a buildup of fluid between the tissues that line the lungs and the chest). A review of the Computerized [NAME]ography Angiogram of the Chest (a test that uses a scanner to produce detailed images of blood vessels and tissues around the chest area) report, dated 11/17/2019, indicated Resident 1 suffered multiple right rib fractures (an injury that occurs when one of the bones in the rib cage cracks), right lower lung consolidation (a normally compressible lung tissue that is filled with liquid instead of air), small right pleural effusion, and right scapular fracture (a break/crack on the right shoulder blade). A review of the Computerized [NAME]ography of the Brain (uses special scanning equipment to help assess for head injuries) report, dated 11/17/2019, indicated Resident 1 had a right posterior parietal scalp hematoma (an injury involving the outside part of the skull, often felt as a bump on the head). During an interview on 1/8/20, at 4:00 p.m., with the Administrator (ADM), the ADM stated, my best guess is that the hook from the sling that was supposed to latch on, did not go in all the way. So when the body moved to one side, it detached and the Resident fell . When asked if it would have made a difference having another person during the transfer, the ADM further states, honestly, I don't know, because if there was another person assisting, they would most likely be on the other side of the bed. So if the Resident fell on NA1's side, the other person would not have done anything to prevent it. But then again, we won't know for sure .maybe that other person would make sure the hooks are properly latched .I don't know. During an interview on 1/8/20, at 4:30 p.m., with the Director of Nursing (DON), when asked why the transfer was only done by one person, the DON stated, I really don't know why she didn't ask for help .she was supposed to, but did not . During an observation and concurrent interview on 1/8/20, at 4:55 p.m., with Nursing Assistant 1 (NA1), NA1 demonstrated how resident 1 fell on [DATE]. NA1 states that as she was turning the lift toward the right side, she felt and saw the left base of the lift tilt above the floor, thus causing the sling's hook to detach, causing the Resident to fall down on the floor, on top of the lift's leg base. NA1 also confirmed that she was the only one that attempted to transfer the Resident. When asked why she didn't ask for help, NA1 further stated, I wanted to ask help, but no one usually gives help around here . During a review of the facility's undated document titled, Transferring & Lifting Using Hoyer Lift, the document indicated in part, Check ADL Profile: If marked mechanical lift, use lift. Always 2 people when using mechanical lift .Moving Resident: Always 2 CNAs when using lift, watch head, feet, legs of the resident. During a review of the facility's undated policy and procedure (P&P) titled, Using a Portable Lifting Machine, the P&P indicated in part, The portable lift can be used by one nursing assistant if the resident can participate in the lifting procedures. If not, two (2) nursing assistants will be required to perform the procedure. During a review of the facility's undated P&P titled, Fall Prevention Policy, the P&P indicated in part, The care plan will state the goals, interventions and approaches for every resident who is identified as being at risk for falls .direct care providers will be instructed regarding approaches and goals for the management of the resident's fall risk.