Every finding on record at South Pasadena Care Center

Based on observation, interview, and record review, the facility failed to ensure the resident's blood pressure was not taken on the left arm in accordance with the physician's order and care plan for one of 32 sampled residents (Resident 1). This deficient practice had the potential to increase pressure and dislodge the clot or worsen venous congestion leading to pulmonary embolism (blockage in one of the pulmonary [relating to the lungs] arteries in the lungs usually caused by blood clots that travel to the lungs from the legs or other parts of the body), stroke (medical emergency that occurs when blood supply to the brain is blocked or when a blood vessel bleeds in the brain), or heart attack (blood flow that brings oxygen to the heart muscle is reduced or cut off). Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including but not limited to acute embolism (a sudden blockage of a blood vessel caused by a blood clot or other material that travels through the bloodstream and obstructs blood flow) and thrombosis (sudden formation of blood clot inside a blood vessel which can partially or completely block blood flow of the issues and organs downstream) of deep veins of left upper extremity (entire left arm), cognitive communication deficit, and atherosclerotic heart disease (a condition in which plaque buildup in the coronary arteries [an artery supplying blood to the heart] narrows and stiffens them reducing blood flow to the heart and increasing the risk of heart attack) of native coronary artery. During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment and tool), dated 7/18/2026, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was severely impaired. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with toileting hygiene, upper and lower body dressing, and sit to lying. During a record review of Resident 1's Physician's Order Summary Report, dated 7/14/2026, the report indicated no blood pressure, no injection, no blood draw on left arm due to deep vein thrombosis (DVT, a condition where a blood clot forms in a deep vein). During a record review of Resident 1's Care Plan Report, dated 7/15/2026, the Care Plan indicated Resident 1 was at risk for poor circulation to lower extremity (part of the body that extends from the hip to the toes) related to diagnosis of DVT of left upper extremity. The staff interventions included were to not take the blood pressure, injection, or blood draw on the left arm due to DVT. During a record review of Resident 1's Weights and Vitals Summary for the month of July 2026, the record indicated Resident 1's blood pressure was taken on the left arm for the following days:- 7/1/2026, 7/2/2026, 7/3/2026, 7/4/2026, 7/5/2026, 7/6/2026, 7/7/2026, 7/8/2026, 7/9/2026, 7/10/2026, 7/14/2026, 7/15/2026, 7/16/2026, 7/17/2026, 7/18/2026, 7/19/2026, 7/20/2026, 7/21/2026, 7/22/2026, 7/23/2026, 7/28/2026, 7/29/2026, 7/30/2026 (23 out of 31 days). During a record review of Resident 1's Weights and Vitals Summary for the month of August 2026, the record indicated Resident 1's blood pressure was taken on the left arm for the following days:- 8/2/2026, 8/3/2026, 8/4/2026, 8/5/2026, 8/9/2026, 8/12/2026, 8/14/2026, 8/15/2026, 8/16/2026 (nine out of 17 days). During a concurrent interview and record review on 8/18/2026 at 2 PM with Licensed Vocational Nurse 1 (LVN 1) of Resident 1's Weights and Vitals Summary, Order Summary Report, and Care Plan, LVN 1 stated the blood pressure and the specific side of the arm where the blood pressure was taken are documented after checking the resident's blood pressure. LVN 1 stated this morning (8/18/2026), LVN 1 took Resident 1's blood pressure on her left arm and documented the blood pressure was taken on the left arm. LVN 1 stated Resident 1's blood pressure was taken on the left arm on multiple days during July 2026 and August 2026 according to the review of Resident 1's Weights and Vitals Summary. LVN 1 stated that on 7/14/2026, there was a physician order that indicated not to take the blood pressure on the left arm due to DVT. LVN 1 stated Resident 1's Care Plan also indicated Resident 1 had a DVT and blood pressure should not be taken on the left arm. LVN 1 stated LVN 1 was not aware Resident 1 should not be having her blood pressure done on the left arm. LVN 1 stated if Resident 1 had a DVT on the left arm and blood pressure reading were done on the left arm, this could result in the DVT travelling in the body and could lead to a stroke. During an interview on 8/20/2026 at 10:40 AM with the Director of Nursing (DON), the DON stated staff should not be taking the blood pressure on the left arm if the physician has ordered it. The DON stated there was a possible DVT on the left arm when Resident 1 was in the general acute care hospital (GACH). The DON stated since there was a possible DVT on the left arm, taking blood pressure on the left arm could result in pain or edema. During a record review of the facility's P&P titled, Physician Orders, dated 7/2024, the P&P indicated physician orders are obtained to provide a clear direction in the care of the resident.

Based on interview and record review, the facility failed to administer medications as ordered by the physician for two (2) of 32 sampled residents (Residents 5 and 67) by failing to:Administer as needed medication for constipation (infrequent bowel movements or difficulty passing stool) for no bowel movement for three (3) days as ordered by the physician and in accordance with Resident 5's care plan. Administer eight (8) medications as ordered by the physician for Resident 67. These deficient practices had the potential to result in Resident 5 being constipated (infrequent bowel movements or difficulty passing stool) and for Resident 67's blood pressure to fluctuate and place the resident at risk of worsening heart failure (a lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen) and increase risk of a heart attack (blood flow that brings oxygen to the heart muscle is reduced or cut off) or stroke (medical emergency that occurs when blood supply to the brain is blocked or when a blood vessel bleeds in the brain). Findings:1. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE], with diagnoses including but not limited to Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement) without dyskinesia (movement disorder that often appears as uncontrolled shakes, tics, or tremors), diaphragmatic hernia (a defect or hole in the diaphragm that allows abdominal organs-such as the stomach or intestines-to move into the chest cavity, potentially impairing lung development and breathing), and hemorrhoids (swollen veins in the lower rectum and anus that can cause discomfort, bleeding, and itching). During a record review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 6/13/2026, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was severely impaired. The MDS indicated Resident 5 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with toileting hygiene, lower body dressing, sit to standing, and chair/bed-to-chair transfer. During a record review of Resident 5's Physician Order Summary Report, dated 6/9/2026, the report indicates as follows:Milk of Magnesium Concentrate Oral Suspension (Magnesium Hydroxide, medication used as a laxative for occasional constipation), give 30 milliliters (ml, unit of volume) via gastrostomy tube (G-Tube - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) as needed (PRN) for if no bowel movement for 3 days every day. Dulcolax Suppository 10 milligrams (mg, unit of measurement) (Bisacodyl - suppository to provide fast relief from occasional constipation, typically producing a bowel movement within 15 to 60 minutes). Insert one suppository rectally PRN for constipation/no bowel movement for 3 days, if Milk of Magnesium not effective. Fleet Enema (used to provide fast relief from constipation or bowel cleaning, typically producing a bowel movement within one to five minutes when used correctly) 7-19 grams (gm, unit of measurement)/118 ml (Sodium Phosphates). Insert 1 application rectally PRN for constipation/no bowel movement for 3 days every day, if Dulcolax suppository and Milk of Magnesium not effective. During a review of Resident 5's Care Plan, dated 6/11/2026, the Care Plan indicated Resident 5 is at risk for constipation related to impaired mobility/Activities of Daily Living function, and use/side effects of medications. The nursing staff interventions were to give medication as ordered: Dulcolax Suppository, Fleet Enema and Milk of Magnesium Concentrate Oral Suspension. During a review of Resident 5's Care Plan, dated 6/11/2026, the Care Plan indicated Resident 5 with Gastro-Esophageal Reflux Disease (GERD - a digestive disease in which stomach acid or contents irritates the food pipe lining) and chronic constipation requiring medication and bowel regimen to maintain gastrointestinal comfort and prevent complications. The care plan indicated the nursing staff intervention was to observe for bowel movement frequency and report absence greater than 3 days. During a record review of Resident 5's Certified Nursing Assistant (CNA) Daily Charting Form for August 2026 for three shifts 7 AM to 3 PM, 3 PM to 11 PM, and 11 PM to 7 AM, the form indicated Resident 5 did not have a bowel movement for 3 days on days: 8/1/2026, 8/2/2026, and 8/3/2026. The form also indicated Resident 5 did not have a bowel movement for four (4) days on days: 8/11/2026, 8/12/2026, 8/13/2026, and 8/14/2026. During a review of Resident 5's Medication Administration Record (MAR, a medical record used by healthcare providers to document the administration of a medication or treatment) for the month of August 2026, Resident 5 did not receive the Dulcolax suppository 10 mg, Fleet Enema 7-19 mg/118 ml, or Milk of Magnesia Concentrate Oral Suspension for the month of August. During an interview on 8/17/2026 at 2:40 PM with Resident 5 in Resident 5's room, Resident 5 stated she has been constipated and had bowel movements every 4 days. During a concurrent interview on 8/20/2026 at 9:10 AM with CNA 6, CNA 6 stated Resident 5 was dependent on toileting care. CNA 6 stated, when the resident had a bowel movement, the CNA will document the bowel movement in the CNA Daily Charting Form. CNA 6 stated the CNAs would inform the license nurse if the resident did not have a bowel movement for 3 days. During a concurrent interview and record review on 8/20/2026 at 9:20 AM with Registered Nurse Supervisor 1 (RNS 1), Resident 5's electronic health records and CNA Daily Charting Form dated from 8/1/2026 to 8/20/2026 were reviewed. RNS 1 stated the CNA should report when Resident 5 has not had a bowel movement on the third day. RNS 1 stated the CNA should have notified the charge nurse, and the charge nurse should have given a PRN medication for no bowel movement in 3 days in accordance with the physician's order. RNS 1 stated Resident 5 according to Resident 5's CNA Daily Charting Form for the month of August 2026, Resident 5 did not have a bowel movement for 3 days from 8/1/2026 to 8/3/2026 and did not have a bowel movement for 4 days from 8/11/2026 to 8/14/2026. RNS 1 stated Resident 5 was supposed to receive the PRN medication for stool/ constipation and the resident's MAR indicated it was not given the medication on 8/3/2026, 8/13/2026 and 8/14/2026. RNS 1 stated Resident 5 also receives two different stool softeners daily in addition to the PRN medication for constipation and the charge nurse needed to follow the order for the PRN medication due to Resident 5 not having a bowel movement for 3 days or more. RNS 1 stated when residents are constipated this could lead to fecal impaction (large, hard mass of stool becomes stuck in the rectum or colon, making it difficult or impossible to pass stool). RNS 1 stated not following up with Resident 5's bowel pattern could affect Resident 5 since Resident 5 had hemorrhoids and a diaphragmatic hernia. During an interview on 8/20/2026 at 10:05 AM with the Director of Nursing (DON), the DON stated CNAs needed to monitor residents' bowel patterns. The DON stated the CNA should inform the license nurse to give the as needed medication for when Resident 5 did not have a bowel movement for 3 days or more. The DON stated residents can experience pain when they do not have bowel movements for three days or longer. The DON stated constipation could result in Resident 5's diaphragmatic hernia getting bigger and result in Resident 5 having painful hemorrhoids. 2. During a review of Resident 67's admission Record, the admission record indicated Resident 67 was admitted to the facility on [DATE], with the diagnoses including but not limited to end stage renal disease (ESRD, advanced stage kidney failure), dependence on renal dialysis (a medical state where a resident relies on ongoing dialysis treatment because their kidneys can no longer filter waste, balance fluids, or manage electrolytes from the blood), heart failure, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and presence of cardiac pacemaker (a medical device that helps regulate the heart's rhythm by sending electrical impulses to the heart muscle ensuring its beats at a normal rate) and automatic (implantable) cardiac defibrillator (a small, battery-powered device implanted under the skin that monitor heart rhythms and delivers electrical shocks to correct life-threatening heart rhythms). During a record review of Resident 67's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was intact. The MDS indicated Resident 67 was dependent on toileting hygiene, shower/bathing self, and chair/bed-to-chair transfer. The MDS also indicated Resident 67 received hemodialysis (medical procedure that filters the blood of waste products when the kidneys are not able to). During a record review of Resident 67's Physician Order Summary Report, the report indicated as follows:On 5/28/2026, Apixaban (used to prevent or treat blood cloths and stroke in people with atrial fibrillation) oral tablet 5 mg: Give 1 tablet by mouth two times a day related to unspecified atrial fibrillation. On 5/28/2026, Aspirin (used to treat or prevent heart attacks, strokes, and chest pain) oral tablet chewable 81 mg: Give 1 tablet by mouth one time a day for cerebrovascular accident (CVA - stroke; damage to the brain from interruption of its blood supply) prophylaxis.On 5/28/2026, Cyanocobalamin (used for growth, cell reproduction and energy, heathy red blood cell formation) oral tablet 1000 microgram (mcg, unit of measurement): Give 1 tablet by mouth one time a day for supplement. On 5/28/2026, Ferrous Sulfate (an iron supplement used to trat or prevent low blood levels of iron) oral tablet 325 mg: Give 1 tablet by mouth one time a day related to anemia (low red blood cells). On 5/29/2026, Folic Acid oral tablet 1 mg: Give 1 tablet by mouth one time a day related to anemia. On 6/12/2026, Dialysis schedule: Tuesday, Thursday, and Saturday. 7/22/2026, Sacubitril-Valsartan (reduces risk of death from heart failure in adults with chronic heart failure) oral tablet 24-26 mg: Give 1 tablet by mouth two times a day related to heart failure. 7/30/2026, Vitamin B Complex/Vitamin C (Nephrovite, dietary supplement): Give 1 tablet by mouth one time a day for supplement. 8/5/2026, Amiodarone HCl (used to help keep the heart beating normally in people with life-threatening heart rhythm disorders of the ventricles [the lower chambers of the heart that allow blood to flow out of the heart]) oral tablet 400 mg: Give one tablet by mouth one time a day for atrial fibrillation, hold if pulse rate is less than 60. During a review of Resident 67's MAR for the month of July and August 2026, Resident 67 did not receive Amiodarone HCl 400 mg (prior order dated 5/29/2026), Aspirin 81 mg, Cyanocobalamin 1000 mcg, Ferrous Sulfate 325 mg, Folic Acid 1 mg, Nephro Vitamins 0.8 mg, Eliquis 5 mg (prior order dated 5/28/2026), Sacubitril-Valsartan 24-26 mg, Vitamin B Complex/Vitamin C, and Zinc Sulfate 220 mg on Tuesdays, Thursdays, and Saturdays for the month of July and August 2026. During a concurrent interview and record review on 8/19/2026 at 2:43 PM with RNS 1, Resident 67's MAR, Nurses Notes, and Vital Signs dated from 7/1/2026 to 8/18/2026 were reviewed. RNS 1 stated according to the resident's MAR, Resident 67's 8 medications: Amiodarone HCl, Aspirin, Cyanocobalamin, Ferrous Sulfate, Folic Acid, Nephro Vitamins, Eliquis, Sacubitril-Valsartan, Vitamin B Complex/Vitamin C, and Zinc Sulfate which were due to be given from 8 AM to 10 AM were not administered to Resident 67 on Tuesdays, Thursdays, and Saturdays for the month of July 2026 until August 2026 on the days Resident 67 left for the dialysis appointment. RNS 1 stated the licensed nurse did not administered and should have administered Resident 67's Amiodarone HCl 400 mg medication prior to Resident 67 leaving to dialysis since the license nurses could had administered the medication from 7 AM - 7:30 AM. RNS 1 stated the only reason why Resident 67's Amiodarone HCl 400 mg would not be administered was if Resident 67's heart rate was less than 60. RNS 1 stated Resident 67's heart rate in the months of July and August 2026 were not less than 60 and the medication should have been administered. RNS 1 stated there were seven other medications (Aspirin, Cyanocobalamin, Ferrous Sulfate, Folic Acid, Nephro Vitamins, Eliquis, Sacubitril-Valsartan, Vitamin B Complex/Vitamin C, and Zinc Sulfate) that the physician ordered which were not administered and should have been administered to Resident 67 per physician's order. RNS 1 stated the dialysis center staff had informed the facility staff (unable to recall when) to administer Resident 67's medications for his heart and not to hold the medications. RNS 1 stated the licensed nurses were able to hold the medications while Resident 67 was out of the facility, however the licensed nurses should have administered the medications once Resident 67 returned from dialysis in the afternoon. RNS 1 stated there was no documentation indicating a reason why Resident 67's medications were not administered other than being out on dialysis in the Nurses Notes. RNS 1 stated Resident 67 could be placed more at risk for having another heart attack or stroke since the licensed nurses were not administering Resident 67's medications as the physician prescribed. During an interview on 8/20/2026 at 10:21 AM with the DON, the DON stated the license nurses should have informed the physician that Resident 67 was going to be receiving dialysis during the time of medication administration time every Tuesdays, Thursdays, and Saturdays. The DON stated the reason being is to obtain an order from the physician if Resident 67's medication administration times could have been adjusted to either give the medication prior to or after the resident's dialysis. The DON stated the licenses nurses still needed to administer Resident 67's medications once Resident 67 returned from dialysis. The DON stated, when the license nurses missed giving Resident 67's medications in accordance with the physician's order, this could affect Resident 67's blood pressure, over working the heart, and possibly result in a stroke. During a review of the facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, dated 10/2017, the P&P indicated medications are administered in accordance with written orders of the attending physician. During a review of the facility's P&P titled, Care of the Dialysis Resident, dated 1/2021, the P&P indicated monitor for signs of fluid overload (condition where body has too much fluid causing the heart to overwork leading to heart failure and buildup of fluid in the lungs) secondary to little or no renal function: diet and medications as ordered.

Based on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure (P&P) by failing to:1. Label food in the kitchen with item name and use by date (the last date recommended for the use of the product) and/or open date.2. Discard expired food items in the kitchen.3. Ensure staff personal belong and beverages were kept off the dishwasher station area.4. Ensure chlorine level was within the recommended level. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: During a concurrent interview and observation on 8/17/2026 at 7:44 AM with the Dietary Service Supervisor 1 (DSS 1) in the kitchen, DSS 1 stated the milk in the refrigerator was opened and not labelled with open date and use by date. DSS 1 also stated there were two turkey sandwiches and one peanut butter and jelly sandwich with use by date of 8/16/2026. DSS 1 stated the three sandwiches in the refrigerator were expired and needed to be discarded. During a concurrent interview and observation on 8/17/2026 at 8:02 AM with Dietary Aide (DA) in the kitchen, DA stopped the dishwasher cycle and checked the chlorine level. DA stated the chlorine level from the dishwasher showed less than 10 parts per million (ppm, unit of measurement). DA stated the chlorine level should be at 100 ppm. During a concurrent interview and observation on 8/17/2026 at 8:02 AM with DA in the kitchen, DA stated there were three water bottles and a phone charger at the dishwasher station. DA stated the items belonged to DA and they were not supposed to be kept at the dishwasher station. During an interview on 8/17/2026 at 8:07 AM with DSS 1, DSS 1 stated every food item has an expiration date and food items needed to be labeled, dated, and discarded when expired to ensure foods were served safely to the residents. DSS 1 stated if expired food items were served to the residents this could cause the residents to experience food borne illnesses. DSS 1 stated staff should not store personal items in the kitchen and personal items should be stored in the designated areas. DSS 1 stated the regulation indicated that the chlorine level should be between 50 to 100 ppm. DSS 1 stated the washing machine was a low temperature washer, and the chlorine level should be between 50 to 100 ppm to be able to sanitize and kill any bacteria on the dishes. During an interview on 8/20/2026 at 10:20 AM with the Director of Nursing (DON), the DON stated expired food items should be discarded. The DON stated discarding expired food items should be included in the facility's P&P. During a record review of the facility's P&P titled, Labeling and Dating of Foods, dated 2023, the P&P indicated all food items in the storeroom, refrigerator, and freezer need to be labeled and dated. During a record review of the facility's undated P&P titled, Employee Personal Belongings and Beverages, the P&P indicated to main a clean, safe, and sanitary dietary department, all employee personal belonging and beverages must be stored only in their designated areas. Personal belongings, including cell phones, charges, purses, backpacks, jackets, and other personal items, must be stored in the designated employee closet. Employee drinks must be kept only in the designated employee beverage area. Personal belongings and beverages are not permitted at the dishwasher station, food preparation areas, food storage areas, serving areas, or kitchen equipment. During a record review of the facility's undated P&P titled, Dishwashing, the P&P indicated all dishes will be properly sanitized through the dishwasher. Low-temperature machine: The chlorine should read 50 to 100 ppm on dish surface in final rinse. The proper chlorine level is crucial in sanitizing the dishes.

Based on observation, interview, and record review, the facility failed to ensure proper cleaning and maintenance of three (3) of five (5) medication crushing devices by not ensuring they were free from dark, iron colored stains and tarnish colored substances.This failure had the potential to create conditions that could lead to contamination of residents' medications, increasing the risk of infection and creating an unsafe environment for resident care. Findings:During a concurrent observation and interview on 8/20/2026 at 2:56 PM with Licensed Vocational Nurse 4 (LVN 4), the medication crushing device being used was observed to be unclean, rusted, aged, and had blackened substances around the pill chamber. LVN 4 stated that the device should have been cleaned and sanitized every shift by staff, as failure to do so could contribute to infection and contamination. During a concurrent observation and interview on 8/20/2026 at 3:07 PM with the Quality Assurance Nurse (QAN), medication crushing devices were observed being used by Charge Nurses. The medication crushing devices in Carts 1, 2, and 3 were worn, corroded, and not in sanitary condition, with visible dark colored substances. The QAN stated that staff should have adequately cleaned the medication crushing devices every shift, as the devices were unclean, poorly maintained, and had accumulated dirt, creating a risk for cross contamination and compromising the quality and integrity of residents' medications. During an interview on 8/20/2026 at 3:56 PM with the Infection Prevention Nurse (IPN), the IPN stated that medication crushing devices should be cleaned by staff because failure to do so poses a risk for cross contamination and affects resident and medication safety. During an interview on 8/20/2026 at 4:03 PM with the Director of Nursing (DON), the DON stated that nurses are responsible for maintaining a sanitary condition and environment in the facility, including the medication storage room, medication carts, and medication crushing devices, as part of adherence to the facility's infection control program. During a review of the facility's Policy and Procedure (P&P) titled, Infection Control, dated 1/6/2025, the P&P indicated an infection prevention and control program is established and maintained to provide a safe , sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Surveillance tools are used for recognizing the occurrence of infections, monitoring adherence to infection prevention and control practices.

Based on observation, interview and record review, the facility failed to ensure two (2) of 32 sampled residents (Residents 2 and 6) were treated with respect and dignity by failing to ensure:Resident 2's face was clean and free of food particles. 2.a. Resident 6 was provided with, and informed of, his rights as a resident in the facility. 2.b. Resident 6 was provided with a companion/staff during dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) appointment in accordance with resident's expressed request. 3. The Resident Rights information was posted in a prominent and accessible location within the facility.These deficient practices have the potential to affect the residents' dignity, self-worth, and self-esteem. Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted to the facility on [DATE] with the following but not limited to diagnoses of chronic kidney disease (CKD - a long-term condition where the kidneys are damaged and cannot filter blood well), dementia (a progressive state of decline in mental abilities), depressive disorder (a mood disorder that causes lasting sadness, emptiness, and a loss of interest in activities), and immunodeficiency (a state where the immune system's ability to fight off infectious disease and cancer [a disease in which abnormal cells grow uncontrollably and spread to other parts of the body] is compromised or absent). During a review of Resident 2's Minimum Data Set (MDS – a resident assessment tool), dated 6/26/2026, the MDS indicated the resident was moderately impaired with cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with eating but was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. During a concurrent observation in Resident 2's room and interview on 8/17/2026 at 9:46 AM, Resident 2 was observed with yellowish-orange food particles on her face. Resident 2 stated that she feels dirty and if the surveyor can help her clean up. During a concurrent observation and interview on 8/20/2026 at 8:09 AM, Registered Nurse Supervisor 1 (RNS 1) stated Resident 2 has food particles on her face. RNS 1 also stated the Certified Nursing Assistants (CNAs) were supposed to clean the resident after eating. RNS 1 further stated Resident 2 should be kept clean and neat for dignity reasons. During an interview on 8/20/2026 at 1:45PM, the Director of Nursing (DON) stated it is not acceptable to leave the resident with food particles on her face. The DON also stated once the resident is done eating, the resident should be cleaned for hygiene and dignity purposes. During a review of the facility's Policy and Procedure (P&P) titled, Resident Dignity and Personal Privacy, dated 4/2023, the P&P indicated dignity means that when interacting with residents, staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth. The P&P also stated to groom (the practice of maintaining a neat, clean, and polished personal appearance) appropriately and to resident's desire. 2. During a review of Resident 6 's admission Record, the admission Record indicated the facility originally admitted Resident 6 on 10/2/2025 and readmitted the resident on 4/7/2026 with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified visual loss , and acquired absence of left leg below knee. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 6 had severely impaired vision and was dependent on toileting hygiene, and upper and lower body dressing. Resident 6 needed partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for oral hygiene, eating and personal hygiene. a. During a concurrent interview and record review on 8/20/2026 at 10:28 AM with Admissions Coordinator (AC), Resident 6's admission packet lacked signatures from both the resident and his family. AC stated that Resident 6 and his family had not received the copy of the Resident Rights because the admission packet was not signed by them. During an interview on 8/20/2026 at 2:35 PM with the Director of Nursing (DON), the DON stated AC was responsible for giving the admission packet, which included the Resident's Rights to Resident 6 but was unable to do so. The DON stated that without copies of their rights, residents may not know who to contact if they have grievances or complaints. The DON further stated that residents should be informed of their right to refuse care, their right to make choices, and that the facility must honor those preferences to ensure Resident 6's safety. b. During a review of Resident 6's Order Summary Report, dated 4/22/2026, the report indicated hemodialysis shall be done at the outpatient dialysis center during Mondays, Wednesdays, and Fridays. During a review of Resident 6's Care Plan Report, dated 11/10/2025, the Care Plan Report indicated that Resident 6 had alteration in elimination and visual impairment that requires staff assistance with toileting and other activities of daily living to reduce the risk of injury. During a concurrent observation and interview on 8/17/2026 at 11:55 AM with Resident 6, Resident 6 was unable to perceive his surroundings and ambulate independently. Resident 6 expressed a need for a companion and staff assistance during his dialysis appointments, as he feels unsafe, insecure, and uncomfortable when needing to use the bathroom and eat his snacks since he was blind. During an interview on 8/18/2026 at 3:17 PM with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated, Resident 6 communicated his request for a companion and staff assistance during dialysis. However, this assistance was not provided, as no staff or companion was assigned to accompany the resident. LVN 3 stated that, given Resident 6's clinical condition of being blind, the facility staff should coordinate with the dialysis center staff to ensure Resident 6 received assistance, especially when using the bathroom. During an interview on 8/20/2026 at 12:17 PM with Certified Nursing Assistant 2 (CNA 2), CNA2 stated, Resident 6 needed staff support for toileting and for consuming snacks while at dialysis because he was blind. During an interview on 8/20/20/2026 at 11:02 AM with Quality Assurance Nurse (QAN), QAN stated, Resident 6 goes to the outpatient center as the provider of the dialysis treatment, but they do not provide bedside care or toileting assistance because it is not included in the provider's contract with the facility. During an interview on 8/20/2026 at 2:35 PM with the DON, the DON stated the facility staff should coordinate with dialysis center staff, especially regarding Resident 6, as the resident is sent outside the facility's vicinity and required assistance for resident continued safety. 3. During a concurrent observation and interview on 8/20/2026 at 9:57 AM with Social Services Director (SSD), a copy of the Residents' Rights was not posted or displayed in any prominent area of the facility. The SSD stated the facility has no posting of the Resident's Rights around the facility. During an interview on 8/20/2026 at 12:17 PM with the Administrator (ADM), ADM stated that it is essential for residents to be informed of their rights so they can effectively express any concerns or issues. During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights, dated 5/2/2024, the P&P indicated employees shall treat all residents with kindness, respect and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to; be informed about his or her rights and responsibilities, have the facility respond to his or her grievances, and equal access to quality care, regardless of source of payment. Copies of Resident Rights are posted throughout the facility.

Based on observation, interview and record review, the facility failed to ensure a resident was communicated with in her preferred language and/or used a communication board (a visual tool that helps residents with limited or no speech express themselves using symbols, pictures, or illustrations) in the language that the resident was able to understand for one (1) of three (3) sampled residents (Resident 5) reviewed for communication-sensory. This deficient practice prevented Resident 5 from communicating with the staff and had the potential to delay receiving appropriate care/treatment the resident needed.Findings:During a review of Resident 5's admission Record, the admission record indicated Resident 5 was admitted to the facility on [DATE], with diagnoses including but not limited to Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement) without dyskinesia (movement disorder that often appears as uncontrolled shakes, tics, or tremors), epilepsy (an electrical brain disorder marked by episodes of loss of consciousness, or convulsions [uncontrolled shaking]) and type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel). During a record review of Resident 5's Minimum Data Set (MDS, a resident assessment and tool), dated 6/13/2026, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was severely impaired. The MDS indicated Resident 5's preferred language was Language 1 and Resident 5 needed or wanted an interpreter to communicate with a doctor or health care staff. The MDS also indicated Resident 5 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with toileting hygiene, lower body dressing, sit to standing, and chair/bed-to-chair transfer. During a record review of Resident 5's Care Plan, dated 6/11/2026, the Care Plan indicated Resident 5 has impaired communication secondary to language barrier, primary language: Language 1. Resident 5 was at risk for not being able to understand and be understood. The care plan indicated the nursing care interventions were to provide and encourage use of communication board/translator as needed. During a concurrent observation and interview on 8/17/2026 at 2:40 PM with Resident 5 in Resident 5's room, Resident 5 stated staff does not understand when the resident tries to communicate with the facility staff. Resident 5 stated she would have to wait until Family Member 1 (FM 1) came in to visit her (Resident 5) weekly to inform the staff what the resident needed. Resident 5 stated staff have never educated her about the communication board or used the communication board to communicate with her. During an interview on 8/18/2026 at 4:23 PM with Certified Nursing Assistant 5 (CNA 5), CNA 5 stated she was usually assigned to take care of Resident 5. CNA 5 stated CNA 5's method of communication with Resident 5 was by speaking to her in English and by pointing or actions. CNA 5 stated Resident 5 always spoke to CNA 5 in Resident 5's primary language and CNA 5 would respond to Resident 5, I do not understand what you are saying. During an interview on 8/20/2026 at 9:58 AM with the Director of Nursing (DON), the DON stated staff can use translation services or communication cards/boards for residents who speak in another language and not English to get information across from residents to staff and staff to residents. The DON stated Resident 5 requires assistance with activities of daily living and staff should be communicating with Resident 5 using communication [NAME] or the language that Resident 5 understands which is Language 1 to understand and meet the resident's needs timely. During a review of the facility's Policy and Procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, dated 4/2026, the P&P indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care including appropriate support and assistance with communication (speech, language, and any functional communication systems).

Based on observation, interview and record review, the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions for two (2) of 32 residents to address:Resident 10's behavior of hitting and kicking.Resident 133's use of sulfamethoxazole-trimethoprim (a combination antibiotic used to treat bacterial infections like urinary tract infections (UTI- an infection in the bladder/urinary tract), bronchitis (an inflammation of the lining of your bronchial tubes), and traveler's diarrhea (a digestive tract infection that causes loose stools and stomach cramps after eating or drinking contaminated food or water in an area with different hygiene standards).This deficient practice had the potential to result in a delay in the necessary care and services which can potentially result in injury to self or others for Resident 10 and further infection for Resident 133.Findings:1. During a review of Resident 10's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] with the following but not limited to diagnoses of legal blindness (very poor vision that cannot be fixed with glasses), violet behavior (any action that uses physical force, threats, or intense anger to hurt people, damage property, or force control), anxiety disorder (a mental health condition that causes ongoing, intense, and overwhelming worry or fear), and depression (a serious mood disorder that causes ongoing sadness, loss of interest in activities, and low energy).During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated 7/28/2026, the MDS indicated the resident was moderately impaired with cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 10 required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs and provides less than half the effort) with eating and oral hygiene but required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with upper body dressing. The MDS indicated Resident 10 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene, shower/bathe self, lower body dressing, and putting on/ taking off footwear.During an observation on 8/17/2026 at 12 PM in Resident 10's room, Resident 1 was observed being picked up by two transportation attendants for dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) appointment. Resident 1 was observed trying to hit and kick the transportation attendants, who were transferring Resident 1 from bed to gurney.During an interview on 8/19/2026 at 11 AM, Licensed Vocational Nurse 2 (LVN 2) stated Resident 10 hits and kicks and has behaved this way for as long as LVN 2 has known the resident since she started in 10/2025.During an interview on 8/19/2026 at 11:25AM, Certified Nursing Assistant 1 (CNA 1) stated Resident 10 has a tendency to hit people when he gets upset and has been that since admission [DATE]).During a concurrent review and interview with Infection Preventionist Nurse (IPN) on 8/19/2026 at 11:37 AM, Resident 1's Care Plans, dated 7/26/2026 to 8/13/2026, were reviewed. IPN stated Resident 10 did not have a care plan to address or manage the resident's behavior of hitting and kicking. IPN also stated Resident 1's behavior should have been care planned so the facility could implement interventions to address and manage the resident's behavior.During an interview on 8/20/2026 at 8:12 AM, Registered Nurse Supervisor 1 (RNS 1) stated Resident 1 should have a care plan with interventions such as monitoring, redirecting the resident and finding the underlying cause of his behavior of hitting and kicking. RNS 1 also stated that without a care plan, there is a risk for Resident 1 to harm himself or others.During an interview on 8/20/2026 at 1:22 PM, the Director of Nursing (DON) stated Resident 10 should have a care plan because the resident can risk injuring himself or others. The DON further stated the care plan should have been created when the resident was found with the behavior.During a review of the facility's Policy and Procedure (P&P) titled, Behavior Management, 01/2025, the P&P indicated the residents care plan will include identified behaviors, and appropriate interventions. 2. During a review of Resident 133's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of UTI, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities).During a review of Resident 133's MDS, dated [DATE], the MDS indicated the resident was severely impaired with cognitive skills for daily decision making. The MDS also indicated Resident 133 required partial/moderate assistance with toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear.During a review of Resident 133's Physician's Order, dated 8/15/2026, the Physician's Order indicated sulfamethoxazole-trimethoprim oral tablet 800-160 milligrams (mg - unit of measure), give one tablet by mouth 2 times a day for UTI for one week.During a concurrent review and interview with IPN on 8/20/20/2026 at 8:58 AM, Resident 133's Care Plans, dated 3/12/2026 to 8/17/2026, were reviewed. IPN stated Resident 133 did not have a care plan to address use of sulfamethoxazole-trimethoprim. IPN stated this should have been added to the care plan to ensure that the resident was monitored for signs and symptoms of infection.During an interview on 8/20/2026 at 1:50 PM, the DON stated Resident 133 should have a care plan while the resident is on antibiotic to provide proper treatment. The DON further stated Resident 133's care plan should have been developed on 8/15/2026 when the antibiotic was ordered.During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Care Plan, dated 1/2024, the P&P indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The P&P also indicated each resident's comprehensive care plan is designed to incorporate identified problem areas and incorporate risk factors associated with identified problems.

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment for one (1) of 32 sampled residents (Resident 114) in accordance with the facility's policy and procedure (P&P) when the facility failed to ensure Resident 114's wheelchair did not have dried, brownish, crust that smelled like feces on it. This deficient practice created an unsanitary environment, has the potential to contaminate clean items and can place the residents at risk for infection.Findings:During a review of Resident 114's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and morbid obesity (when a person's weight is more than 80 to 100 pounds above their ideal body weight). During a review of Resident 114's Minimum Data Set (MDS- a resident assessment tool) dated 8/5/2026, the MDS indicated Resident 114 had intact cognitive (ability to think and process information) ability. The MDS indicated Resident 114 required supervision for toileting hygiene and showering. The MDS indicated Resident 114 required set up assistance for lower body dressing and putting on/taking off footwear. The MDS indicated Resident 114 was independent for eating, oral hygiene, upper body dressing and personal hygiene. During a concurrent observation and interview on 8/17/2026 at 9:53 AM with LVN 1, dried, brownish, crust that smelled like feces was observed on Resident 114's wheelchair. LVN 1 smelled the brownish crust from about a foot away and stated there are feces on Resident 114's wheelchair and that it smells bad. LVN 1 stated that feces on a wheelchair is an infection control issue because it can spread infection around the facility. During a concurrent interview and record review on 8/20/2026 at 9:50 AM with Infection Prevention Nurse (IPN), the facility's P&P titled, Infection Prevention and Control Program, dated 1/6/2025 was reviewed. The P&P indicated:The Infection Prevention and Control Program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.The P&P reflect the current infection prevention and control standards of practice.Important facets of infection prevention include identifying possible infections and instituting measures to avoid complications or dissemination.IPN stated that having feces on a resident's wheelchair is not sanitary or safe because it is an infection control problem and may spread infection around the facility. IPN stated the policy states that residents will be provided a safe and sanitary environment. During an interview on 8/20/2026 at 11:08 AM with the Director of Nursing (DON), the DON stated that feces should not be on a resident's wheelchair because it is an infection control issue which can spread infections to other residents and staff in the facility and it is unsanitary.

Based on interview and record review, the facility failed to provide accurate documentation for two (2) of 32 sampled residents (Residents 2 and 67) by failing to:Accurately document Resident 2's Medication Regimen Review (MRR - a structured, comprehensive evaluation of all drugs a person takes-including prescriptions, over-the-counter products, and supplements-to confirm they are safe, effective, and necessary) for 7/2026. Ensure accurate documentation for fluid intake for Resident 67 who received hemodialysis (medical procedure that filters the blood of waste products when the kidneys are not able to) services.These deficient practices had the potential to affect the accuracy of clinical assessments and medical management for Residents 2 and 67. Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted to the facility on [DATE] with the following but not limited to diagnoses of chronic kidney disease (CKD - a long-term condition where the kidneys are damaged and cannot filter blood well), dementia (a progressive state of decline in mental abilities), depressive disorder (a mood disorder that causes lasting sadness, emptiness, and a loss of interest in activities), immunodeficiency (a state where the immune system's ability to fight off infectious disease and cancer is compromised or absent). During a review of Resident 2's Minimum Data Set (MDS – a resident assessment tool), dated 6/26/2026, the MDS indicated the resident was moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with eating but was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 2's MRR, dated 7/2026, the MRR indicated Resident 2 is taking a medication called Seroquel (atypical antipsychotic medication). During an interview on 8/19/2026 at 12:30 PM, Resident 2's MRR, dated 7/2026, was reviewed. Quality Assurance Nurse (QAN) stated Resident 2 is currently not taking Seroquel nor has the resident taken Seroquel during admission at the facility. QAN also stated the pharmacist did a error in documenting and it would need to be followed up with the pharmacist. During an interview on 8/19/2026 at 12:41 PM, Resident 2's MRR, dated 7/2026, was reviewed. Infection Preventionist Nurse (IPN) stated Resident 2 is not on Seroquel. IPN also stated it is a documentation error from the pharmacist that would need to be followed up and corrected. During an interview on 8/20/2026 at 10:35 AM, Registered Nurse Supervisor 1 (RNS 1) stated if a medication was mentioned in the MRR and the resident is not taking that medication, it would need to be followed up with the pharmacist to ensure it was documented in error. RNS 1 also stated that is not okay to have an inaccurate documentation in the resident's medical record. During an interview on 8/20/2026 at 1:45 PM, the Director of Nursing (DON) stated it is not okay that Resident 2 MRR mentioned a medication that the resident was not taking. The DON also stated it can be a big error if there is an inaccurate documentation. 2. During a review of Resident 67's admission Record, the admission record indicated Resident 67 was admitted to the facility on [DATE], with the diagnoses including but not limited to end stage renal disease (ESRD, advanced stage kidney failure), dependence on renal dialysis (a medical state where a resident relies on ongoing dialysis treatment because their kidneys can no longer filter waste, balance fluids, or manage electrolytes from the blood), and heart failure (a lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen). During a record review of Resident 67's Physician's Order Summary Report, dated 5/29/2026, the order indicated as follows: Fluid restriction of 1500 cubic centimeters (cc, measurement of volume)/24 hours Nursing: 540 cc, 7 AM to 3 PM shift: 300 cc, 3 PM to 11 PM shift: 180 cc, 11 PM to 7 PM shift: 60 cc, Dietary: 960 cc, Breakfast: 360 cc, Lunch: 240 cc, Dinner 360 cc. Fluid restriction of 1500 cc/24 hours Nursing: 540 cc, 7 AM to 3 PM shift: 300 cc, 3 PM to 11 PM shift: 180 cc, 11 PM to 7 AM shift: 60 cc, Dietary: 960 cc, Breakfast: 360 cc, Lunch: 240 cc, Dinner 360 cc. Fluid restriction of 1500 cc/24 hours Nursing: 540 cc, 7 AM to 3 PM shift: 300 cc, 3 PM to 11 PM shift: 180 cc, 11 PM to 7 AM shift: 60 cc, Dietary: 960 cc, Breakfast: 360 cc, Lunch: 240 cc, Dinner 360 cc, Note: Document total estimated intake and output per day (6 AM + 2 PM + 10 PM). During a record review of Resident 67's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was intact. The MDS indicated Resident 67 was dependent with toileting hygiene, shower/bathing self, and chair/bed-to-chair transfer. The MDS also indicated Resident 67 received hemodialysis. During a record review of Resident 67's Care Plan, dated 6/3/2026, the Care Plan indicated Resident 67 has ESRD, and fluid restriction order. The care plan indicated Resident 67 is at risk for fluid overload (condition where body has too much fluid causing the heart to overwork leading to heart failure and buildup of fluid in the lungs), dehydration (harmful reduction in the amount of water in the body), electrolyte imbalance (when the levels of minerals in your body, such as sodium, potassium, calcium, or magnesium, become too high or too low, disrupting normal bodily functions), shortness of breath (SOB, difficulty or discomfort in breathing), edema (swelling caused by too much fluid trapped in the body's tissues), weight changes, and hospitalization. The care plan indicated the nursing staff interventions were to follow fluid restriction order of 1500 cc/24 hours with 540 cc for nursing and 960 cc for dietary and to monitor for resident drinking fluids over restricted amount and document episodes as ordered; and record estimated intake and output as ordered and document total estimated intake and output daily. During a record review of Resident 67's Medication Administration Record (MAR, a medical record used by healthcare providers to document the administration of a medication or treatment) for the month of July 2026, it indicated the total amount of fluid intake documented per day under the fluid restriction of 1500 cc/24 hours for every eight hours record estimated intake and output, fluid restriction of 1500 cc/24 hours every shift monitor resident for episode of drinking fluids more than the restricted amount, and under the fluid restriction of 1500 cc/24 hours one time a day document total estimated intake and output per day (6 AM + 2 PM + 10 PM) did not equal the total amount of the resident's fluid intake and/ or were inconsistent for each day from 7/1/2026 to 7/31/2026. During a record review of Resident 67's MAR for the month of August 2026, it indicated the total amount of fluid intake documented per day under the fluid restriction of 1500 cc/24 hours for every 8 hours record estimated intake and output, fluid restriction of 1500 cc/24 hours every shift monitor resident for episode of drinking fluids more than the restricted amount, and fluid restriction of 1500 cc/24 hours one time a day document total estimated intake and output per day (6 AM + 2 PM + 10 PM) did not equal the total amount of the resident's fluid intake documented from 8/1/2026 to 8/19/2026. During a concurrent interview on record review on 8/19/2026 at 3:24 PM with RNS 1 of Resident 67's MAR for July 2026 and August 2026, RNS 1 stated the total fluid for all three shifts total per day should be the same when added and documented under fluid restriction of 1500 cc/24 hours for every 8 hours record estimated intake and output, fluid restriction of 1500 cc/24 hours every shift monitor resident for episode of drinking fluids more than the restricted amount, and fluid restriction of 1500 cc/24 hours one time a day document total estimated intake and output per day (6 AM + 2 PM + 10 PM) and the documentation did not have the same amount of fluid intake of Resident 67. RNS 1 stated it was important to determine how much fluid Resident 67 took for the day so Resident 67 will not have fluid overload which can place Resident 67 at risk for heart failure and not being able to expel fluid since Resident 67's kidneys were not functioning properly. During an interview on 8/20/2026 at 10:30 AM with the DON, the DON stated it was important for license nurses to document the fluid intake accurately and consistently to determine or if the amount of fluid Resident 67 was taking per day. The DON stated the license nurse should accurately document the fluid intake per day in the resident's MAR to be able to determine what the resident is taking to determine if kidney is functioning and if the resident was retaining fluid. During a record review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 5/2024, the P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled, stored and disposed of as indicated on the facility policy by failing to ensure:1. Medication belonging to a discharged resident was disposed properly.2. Proper identification and management of a loose, unlabeled tablet found underneath one of the cabinets in the medication room.This failure had the potential to compromise medication and resident safety resulting from increased risk of unsafe medication management.Findings:During a concurrent observation and interview on 8/19/2026 at 9:20 AM with Licensed Vocational Nurse 2 (LVN 2), a medication labeled with a discharged resident's identification was found stored inside one of the medication cart drawers. LVN 2 stated that the resident was discharged last 8/8/2026 and confirmed that the medication should not have remained in the cart, as retaining medications for discharged residents poses a risk for potential medication errors.During a concurrent observation and interview on 8/19/2026 at 10:22 AM with LVN 3, a single, yellow, loose, unlabeled tablet was found underneath one of the cabinets in the medication room. LVN 3 stated that such medication should not be unidentified and should be placed in the designated destruction bins located in the corner of the medication room since the facility has a policy on proper storage and disposal of medications.During an interview on 8/20/2026 at 2:05 PM with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated that nurses should promptly remove any loose, unlabeled tablet from the medication carts and destroy discontinued medications by safely disposing it into the destruction bins in accordance with the facility policy. During an interview on 8/20/2026 at 2:35 PM with the Director of Nursing (DON), the DON stated that staff should not retain any medications belonging to discharged residents in the medication cart, as doing so could lead to medication errors. The DON further stated that staff are expected to follow facility policies for medication administration, storage, and disposal, including ensuring that all expired medications are placed in designated destruction bins. The DON further stated that loose or improperly stored medications create safety risks by increasing the likelihood of medication errors, resident harm, and ineffective treatment. During a review of the facility's Policy and Procedure (P&P) titled, Disposal of Medications and medication-related supplies, dated 1/2025, the P&P indicated that discontinued medications and medications left in the facility after a resident's discharge, which do not qualify for return to the pharmacy for credit, are destroyed. All medications are placed in the proper waste container per facility policy. During a review of the facility's P&P titled, Medication storage in the facility, dated 1/2025, the P&P indicated that medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. Medication storage areas are kept clean, well-lit and free of clutter and extreme temperatures.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) receive the necessary services to maintain good personal hygiene for one (1) of three (3) sampled resident (Resident 80) reviewed for ADLs by failing to ensure Resident 80's fingernails were properly groomed. This deficient practice had the potential to result in Resident 80 causing scratch marks and increasing the risk of skin breakdown.Findings: During a review of Resident 80's admission Record, the admission record indicated Resident 80 was admitted to the facility on [DATE], with diagnoses including but not limited to contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of right and left hand, dementia (progressive brain disorder that slowly destroys memory and thinking skills), and quadriplegia (paralysis of all four limbs). During a record review of Resident 80's Minimum Data Set (MDS, a resident assessment tool), dated 5/16/2026, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was intact. The MDS indicated Resident 80 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with toileting hygiene, personal hygiene (combing hair, shaving, washing/drying face and hands), rolling left and right, and lying to sitting on side of bed. During a record review of Resident 80's Care Plan, dated 3/2/2026, the Care Plan indicated Resident 80 requires assistance in activities of daily living related to cerebral palsy (a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth), dementia, gastrostomy tube (G-Tube, a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) status, history of cerebrovascular accident (CVA - stroke; damage to the brain from interruption of its blood supply), degenerative joint disease (DJD, also known as osteoarthritis, is a chronic condition where joint cartilage and surrounding bone gradually deteriorate, causing pain, stiffness, and reduced mobility), quadriplegia, and contractures. The care plan indicated nursing staff intervention was to provide grooming activities as scheduled or as needed and trim fingernails and file jagged edges, if needed. During a concurrent observation and interview on 8/17/2026 at 9:42 AM in Resident 80's room with Resident 80, Resident 80 was lying in bed wearing bilateral splints (a supportive medical device designed to maintain proper joint alignment, prevent further shortening of muscles and tendons, and reduce stiffness) and both hands were noted with long fingernails. Resident 80 stated he wanted his fingernails cut since they felt uncomfortable being long. Resident 80 stated he was unable to clip his fingernails and does not remember when staff last clipped his fingernails. During a concurrent observation and interview on 8/18/2026 at 3:42 PM in Resident 80's room with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated Resident 80's fingernails on both hands are long. CNA 3 stated staff should check the resident's fingernails daily and should provide daily care. During a concurrent observation and interview on 8/18/2026 at 3:59 PM in Resident 80's room with Licensed Vocational Nurse 6 (LVN 6), LVN 6 stated the fingernails on the resident's both hands were pretty long. LVN 6 stated CNAs should trim residents' fingernails when the fingernails are long since the staff should be checking daily if trimming of the resident's fingernails is needed. During an interview on 8/20/2026 at 9:54 AM with the Director of Nursing (DON), the DON stated Resident 80 was dependent on staff for the resident's care and needed assistance for clipping the resident's fingernails. The DON stated the CNAs were responsible for clipping resident's fingernails when the fingernails became long enough to scratch themselves. The DON stated Resident 80 has contractures on both hands so long fingernails could potentially dig into Resident 80's skin and can placed resident at risk to sustain scratch marks or wound. During a review of the facility's Policy and Procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, dated 4/2026, the P&P indicated residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation interview and record review, the facility failed to revise the oral and dental care plan for one (1) of 32 sampled residents (Resident 49) when the resident was provided with full lower dentures on 7/27/26.This deficient practice is a potential choking hazard for Resident 49 during meals, which could result in harm and/or death.Findings: During a review of Resident 49's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of protein-calorie malnutrition (a person's diet has deficiencies, excesses, or imbalances in the energy and nutrients they need to stay healthy) and disorientation (a state of mental confusion where a person loses their sense of direction, position, or awareness of time, place, and identity). During a review of Resident 49's Physician Orders, dated 2/18/2026, the Physician Orders indicated a diet order of no added salt minced and moist texture, regular consistency, and ice cream for lunch and dinner. During a review of Resident 49's Minimum Data Set (MDS - a resident assessment tool), dated 6/20/2026, the MDS indicated the resident was independent with cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident was independent (Resident completes the activity by themselves with no assistance from a helper) with eating, oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene but required set up or clean up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) with shower/bathe self.During a review of Resident 49's Care Plan with focus oral/dental problems related to edentulous (toothless or lacking natural teeth, either entirely or partially) and wearing of full upper denture, revised 7/2/2026. The care plan indicated to assess for tolerance of prescribed diet.During a concurrent observation and interview on 8/17/2026 at 10:16AM in Resident 49's Room, Resident 49 stated she has not had her full lower dentures for over half of month. Resident 49 opened her mouth and was observed with only full upper dentures. Resident 49 further stated she is having a hard time eating and needs her full lower dentures.During an observation on 8/17/2026 at 12:35 PM in Resident 49's room, the resident was observed eating steak with onions, fried potatoes, corn with green peppers and fresh green salad; all with regular consistency, for her lunch.During a concurrent observation and interview on 8/19/2026 at 10:29AM in Resident 49's room, Certified Nursing Assistant 4 (CNA 4) stated Resident 49's lower dentures are not in her room. CNA 4 also stated she does not know Resident 49 had lower dentures.During an interview on 8/19/2026 at 10:41AM, Social Services Director (SSD) stated Resident 49 received her lower dentures on 7/27/2026. SSD stated Resident 49 has both full upper and lower dentures.During an observation on 8/19/2026 at 12:47 PM in Resident 49's room, the resident was observed eating fish Italiano, scalloped potatoes, vegetables, red and green salad, rice and peach crisp; all with regular consistency.During a concurrent review and interview with Registered Nurse Supervisor 1 (RNS 1) on 8/20/2026 at 8:20 AM, Resident 49's Care Plan with focus on oral/dental problems related to edentulous and the resident wearing full upper denture, revised 7/2/2026, was reviewed. RNS 1 stated Resident 49's care plan does not indicate the resident also had full lower dentures. RNS 1 stated Resident 49's care plan should have been revised on 7/27/26 so the staff are aware that Resident 49 has upper and lower dentures. RNS 1 also stated if Resident 49 is eating a regular consistency diet without dentures, the resident can potentially choke. RNS 1 further stated Resident 49's diet texture will need to be evaluated and potentially changed so the resident can eat safely until the lower dentures are found or replaced.During an interview on 8/20/2026 at 1:32PM, the Director of Nursing (DON) stated it is important for the residents to have their dentures when they are eating a particular diet because it can be a choking hazard. The DON also stated it is not acceptable that Resident 49 is eating with her full upper dentures and not her full lower dentures. The DON further stated Resident 49 should have his full upper and lower dentures during meals because her diet can be a choking hazard.During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Care Plan, dated 01/2024, the P&P indicated care plans are revised as changes in the resident's condition dictate. Care Plans are reviewed at least quarterly. During a review of the facility's P&P titled Dental Services, dated 01/2025, the P&P indicated direct care staff will assist residents with denture care, including removing, cleaning and storing dentures.

Based on interview and record review, the facility failed to report to the state agency (CDPH; California Department of Public Health) and Ombudsman (a trained advocate who protects the rights, safety, and welfare of people living in nursing homes, assisted living facilities, and board-and-care homes) an allegation of verbal abuse (the use of spoken or written words to hurt, control, or scare another person; a form of emotional or psychological mistreatment where someone uses negative language to gain power over someone else) for one (1) of three (3) sampled residents (Resident 1) within two (2) hours of being made aware of the allegation by local law enforcement. This failure resulted in the facility not reporting an allegation of verbal abuse to CDPH and the Ombudsman and had the potential to place other residents at risk for verbal abuse at the facility. 1. During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of dementia (a progressive state of decline in mental abilities) and generalized anxiety disorder (a mental health condition marked by constant, extreme worry about everyday things like work, health, or money). During a review of Resident 1'S Minimum Data Set (MDS - a resident assessment tool), dated 6/29/2026, the MDS indicated the resident was severely impaired (difficulty with or unable to make decisions, learn, remember things) with cognitive (ability to think, remember, and reason) skills for daily decision making. It indicated, Resident 1 needed substantial/maximal assistance (helper does more than half the effort) with putting on/taking off footwear, lower body dressing (the ability to dress and undress below the waist) and toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). Resident 1 needed partial/moderate assistance (helper does less than half the effort) with walking 10 feet, chair/bed-to-chair transfers, rolling left and right in bed and upper body dressing (the ability to dress and undress above the waist). The MDS also indicated Resident 1 needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with personal hygiene and eating.2. During a review of Resident 2's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of dementia and traumatic (painful, scary or damaging to the mind or body) subdural hemorrhage (bleeding that pools between the brain and it's outer covering) without loss of consciousness. During a review of Resident 2'S MDS, dated [DATE], the MDS indicated the resident was severely impaired with cognitive skills for daily decision making. It indicated, Resident 2 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with personal hygiene, putting on/taking off footwear, upper and lower body dressing and toileting hygiene. The MDS indicated Resident 2 needed substantial/maximal assistance with walking 10, 50 and 150 feet and chair/bed-to-chair transfers. MDS also indicated Resident 2 needed partial/moderate assistance with rolling left and right in bed and eating.3. During a review of Resident 3's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of dementia and legal blindness (severe vision loss). During a review of Resident 3'S MDS, dated [DATE], the MDS indicated the resident was severely impaired with cognitive skills for daily decision making. It indicated, Resident 3 was dependent with putting on/taking off footwear and lower body dressing. Resident 3 needed substantial/maximal assistance with chair/bed-to-chair transfers and toileting hygiene. The MDS also indicated resident needed partial/moderate assistance with upper body dressing and needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating.During an interview on 8/14/2026 at 8:56 AM with the Director of Nursing (DON), the DON stated a local law enforcement officer had come to the facility on 8/13/2026 and informed the facility of an allegation of verbal abuse made by Resident 1 who was at the General Acute Care Hospital (GACH) at the time. The DON stated the officer had told him Resident 1 stated the allegation happened at the time of her (Resident 1's) transfer from the facility to GACH on 8/12/2026 with Resident 1's roommate (unspecified). The DON also stated they were not aware of any allegation of verbal abuse by Resident 1 until the enforcement officer notified them on 8/13/2026 and he (DON) immediately notified the facility's Administrator (ADM) who had told him he (ADM) would handle reporting the allegation to the proper entities. During an interview on 8/14/2026 at 9:38 AM with ADM, ADM stated on 8/13/2026 a local law enforcement officer had come to the facility and informed the facility that Resident 1 had alleged her (Resident 1) roommate (unspecified) had used profanity (rude, offensive, or inappropriate language) towards her which he (ADM) would classify as verbal abuse. During an interview on 8/14/2026 at 11:07 AM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated for all allegations of abuse, facility staff need to notify their supervisor and ADM immediately especially since the ADM is the facility's abuse coordinator. LVN 1 also stated the timeline for abuse reporting is immediately but no later than 2 hours to local law enforcement, the Ombudsman and CDPH.During an interview on 8/14/2026 at 11:15 AM with Registered Nurse 1 (RN 1), RN 1 stated any allegation of abuse needs to be reported to the facility's abuse coordinator who is the ADM, who then reports the allegation to the Ombudsman, local law enforcement and CDPH within 2 hours.During an interview on 8/14/2026 at 11:23 AM with the DON, the DON stated nurses are responsible for reporting all allegations of abuse and the forms such as the SOC 341 (an official California Department of Social Services form titled, Report of Suspected Dependent Adult/Elder Abuse) are available for them to utilize at the facility. The DON stated the abuse coordinator who is the ADM also needs to be notified immediately. The DON also stated, any allegation of abuse needs to be reported to all agencies including CDPH, local law enforcement and the Ombudsman within 2 hours from when the allegation was made or the abuse was witnessed. The DON further stated the allegation of verbal abuse regarding Resident 1 that the facility was made aware of on 8/13/2026 was immediately reported it to the ADM who had informed him (DON) that he (ADM) was going to take care of reporting the allegation to all entities.During an interview on 8/14/2026 at 11:32 AM with ADM, ADM stated the timeframe for reporting any allegation of abuse is within 2 hours to CPDH, the Ombudsman and local law enforcement when the abuser is not diagnosed with dementia per their facility's policy. ADM also stated their facility's policy for abuse reporting had undergone a revision in March 2024 due to All Facilities Letter 24-09 (AFL; a letter from the Center for Health Care Quality [CHCQ], Licensing and Certification [L&C] Program to health facilities that are licensed or certified by L&C) dated 2/28/2024 which indicated that they would not have to report to CDPH and only to the Ombudsman and local law enforcement within 24 hours since neither resident sustained any injuries and the suspected perpetrator had a history of dementia.During the same interview and record review on 8/14/2026 at 11:32 AM with ADM, AFL 24-09 dated 2/28/2024 was reviewed. AFL 24-09 indicated, Facilities are responsible for following all applicable laws. The California Department of Public Health's failure to expressly notify facilities of statutory or regulatory requirements does not relieve facilities of their responsibility to comply with all laws and regulations. Facilities should refer to the full text of all applicable sections of the Health and Safety Code (a set of legal regulations, statutes, or standards designed to protect public well-being, safety, and health) and Title 22 (a set of California regulations that establish minimum health, safety, and operational standards for community care facilities) of the California Code of Regulations. ADM stated because the State Operations Manual (SOM - a federal guide that provides instructions and policies and procedures for state survey agencies to monitor and enforce regulations in healthcare facilities participating in Medicare/Medicaid) dated 8/8/2024, is more stringent, the more stringent regulation should always be followed and the allegation of verbal abuse should have been reported to CDPH and the Ombudsman within 2 hours from when the allegation was made. ADM further stated they will also need to review and revise their abuse reporting policy.During an interview on 8/14/2026 at 1:03 PM with the DON, the DON stated the importance of reporting any allegation of abuse within 2 hours is to capture whether there was anything harming the resident and for the facility to prioritize resident safety.During a review of the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting, revised March 2024, the P&P indicated all reports of resident abuse shall be promptly reported to agencies as defined by current regulations and will be reported by the facility ADM, of his/her designee to the local/state ombudsman and the state licensing/certification agency responsible for surveying/licensing the facility immediately or as soon as practicable, but not later than two hours after the incident occurred.

Based on observation, interview and record review, the facility failed to ensure the setting for low air loss mattress (LAL- mattress designed to prevent and treat pressure ulcer (localized damage to the skin and underlying soft tissue caused by prolonged pressure) for two of three sampled residents (Resident 1 and 2) who are admitted with pressure ulcers(an area of damaged skin and tissue that forms when sustained pressure cuts off blood flow. They commonly develop over bony areas like the heels, ankles, hips, and tailbone in people with limited mobility) were set correctly based on the residents' current weight and in accordance with their individualized care plans.This failure had the potential to cause the residents' existing pressure ulcer to worsen.Findings:1. During review of Resident 2's admission Record, dated [DATE], the admission Record indicated Resident 2 was admitted on [DATE] with diagnoses that included encephalopathy (brain disease/damage, or malfunction), muscle weakness and pressure ulcer on right buttock, stage 4 (severe, deep crater-like wound). During review of Resident 2's Minimum Data Set (MDS- resident assessment tool) dated [DATE], the MDS indicated Resident 2 has a severe cognitive impairment (loss of the ability to decide), impairment of both lower extremities, and the resident is at risk for developing pressure ulcers. During review of Resident 2's Weights and Vital (WS-body's most basic, life-sustaining measurement) Summary dated [DATE], it indicated Resident 2 weighed 188 lbs. (pounds). During review of Resident 2's Pressure Sore (pressure ulcer) Skin Problem Report-v2 (PSSPR) dated [DATE], the PSSPR indicated Resident 2 has the following Pressure Ulcers: right buttock measuring 10.0 centimeter (cm- unit of measurement) 7.0 cm x 1.2 cm Stage 4 with 100 % necrotic tissue (open sore where the surrounding tissue has died). During review of Resident 2's Care Plan Summary (CPS) dated [DATE], the CPS indicated Resident 2's LAL mattress is to be monitored every shift for the correct placement, setting and function initiated on [DATE]. During review of Resident 2's Order Summary Report (OSR) dated [DATE], the OSR indicated on [DATE], Resident 2's LAL mattress is to be monitored for the correct setting every shift, for wound/skin management. 2. During review of Resident 1's admission Record, dated [DATE], the admission Record indicated the Resident 1 was admitted on [DATE], with the diagnoses that included osteomyelitis (infection of the bone) of vertebra (the individual interlocking bones that stack on top of each other to make up your spine or backbone) and sacral region (tailbone area), stage 4 pressure ulcer on sacral region, type 2 diabetes (chronic condition where your body either resists the effects of blood sugar or doesn't make enough of it) with foot ulcer, pressure ulcers of right hip stage 3 (deep, open crater in the skin.) and an unstageable pressure ulcer (a severe wound where the true depth and damage are hidden by dead tissue) of left hip. During review of Resident 1's History and Physical (H&P) Report dated [DATE], the H&P indicated Resident 1 was identified with the following diagnoses: dementia (decline in mental ability severe enough to interfere with daily life), and extremities (EXTS, referring to arm and legs) atrophy (progressive breakdown of muscle). During review of Resident 1's Braden's Scale (a widely used, evidence-based assessment tool that healthcare professionals use to predict a patient's risk of developing pressure ulcers) dated [DATE], the Braden Scale indicated Resident 1 is at high risk for developing pressure ulcers. During review of Resident 1's PSSPR dated [DATE], the PSSPR indicated Resident 1 has the following pressure ulcers: a. right trochanter (prominent bony bumps at the top of your thigh bone) hip measuring 2.0 cm x 2.0 cm Stage 3 with 50% granulation and 50% slough (soft yellowish or white layer of dead tissue cells) b. sacro-coccyx (lower back) measuring 16.0 cm x 14.0 cm x 2.6 cm Stage 4 with tunneling (narrow, hidden channel that extends from an open sore into deeper layers of skin, fat, or muscle) of 5cm, 20% granulation and 80% necrotic tissue.c. trochanter hip measuring 8.0 cm x 5.0 cm unstageable with 100% necrotic tissue. During review of Resident 1's WS, dated [DATE], the WS indicated Resident 1 weighed 146 lbs. on [DATE]. During review of Resident 1's OSR dated [DATE], the OSR indicated Resident 1's LAL mattress is to be monitored for the correct setting every shift, for wound/skin management with order date on [DATE]. During a concurrent observation and interview on [DATE] at 10:40 a.m. with Certified Nursing Assistant (CNA) in Resident 1s room, Resident 1 was lying in bed on a LAL mattress with the setting at 200 lbs. CNA stated, she does not adjust the LAL mattress settings, and it was set at 200 lbs. During a concurrent observation and interview on [DATE] at 10:55 a.m. with the Treatment Nurse (TN) in Resident 1's room, Resident 1 was lying in bed on a LAL mattress with the mattress setting at 200 lbs. TN stated, the current setting was incorrect as Resident 1 weighs 146 lbs., and that having the wrong setting on a LAL mattress could result in the mattress being either too soft or too firm, potentially causing further harm and slowing the progression of wound healing. During a concurrent observation and interview on [DATE] at 11:00 a.m. with the TN in Resident 2's room, Resident 2 was lying in bed on a LAL mattress with the mattress setting at 240 lbs. TN stated, the current setting was incorrect as Resident 2 weighs 188 lbs., and explained that an improper LAL mattress setting can prevent the mattress from properly offloading the resident's weight, potentially worsening existing wounds or pressure ulcer. During a concurrent interview and record review on [DATE] at 3:58 p.m. with the Director of Nursing (DON), the facility's policy and procedures (P&P) titled: Policies for Air Mattress, and Care Plans Baseline, dated 1/2026 were reviewed. The P&Ps indicated resident care plans are to be implemented to meet residents immediate care needs, which may include the proper use of LAL mattress use to decrease pressure from the resident's weight in bed. The DON stated that Resident 1's correct Braden Score was 8 and explained that the purpose of the LAL mattress is to relieve pressure on wounds as they heal. The DON added that an incorrect mattress setting defeats this purpose and noted that the facility had just recently hired someone, as of yesterday, to check the LAL mattress settings. During a review of the facility's undated P & P titled, Air Mattress, indicated the purpose of the policy is to decrease pressure from the resident's weight while in bed and to promote the healing of or the prevention of pressure ulcers. The P&P also indicated, facility staff to monitor the mattress to assure that it is functioning properly and that air level assures the resident's body does not touch the bed. During a review of Brand 1 operation manual (undated), it indicated, determine the resident's weight and set the control knob to the weight setting on the control unit. During a review of the facility's P & P titled, Care Plans Baseline, dated 1/2026, indicated, the Interdisciplinary Team will review the healthcare practitioner's orders and implement a baseline care plan to meet the resident's immediate care.

Based on observation, interview, and record review, the facility failed to provide necessary daily needs and care to ensure quality of care was provided, residents' wellbeing was cared for and prevent the possible harm and illness due to Activities of Daily Living (ADL) not being provided for one (1) of two (2) sampled residents (Resident 1). These deficient practices have potentially led to residents do not have quality of life and the harm and illness that might cause due to ADL were not provided. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 1's diagnoses including but not limited to metabolic encephalopathy (a syndrome of global brain dysfunction caused by an underlying systemic illness rather than a direct physical injury to the brain), hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild loss of strength in a leg, arm, or face) following cerebral infarction (a damage to tissues in the brain due to a loss of oxygen to the area) affecting left non-dominant side and dysphagia oropharyngeal phase (difficulty moving food and liquids from the mouth into the throat and esophagus). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/6/2026, the MDS indicated Resident 1 had moderate impairment (decisions poor, cues/supervision required) for cognitive skills (the mental processes that allow people to think, learn, and solve problems) for daily decision making. The MDS indicated Resident 1 was dependent, (helper does all the effort) with the oral hygiene, toileting hygiene, shower/bath self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, roll left and right and sit to lying. During a concurrent observation and interview on 6/17/2026 at 9:35 AM with the Certified Nursing Assistant 1 (CNA 1) in Resident 1's room, observed there were scrape wounds (an injury where the top layers of skin are rubbed or torn off) on Resident 1's right shoulder and her right thigh. CNA 1 stated she did not know how these wounds happened, they were there when she came back to work after the past weekend. During a concurrent observation and interview on 6/17/2026 at 10:15 AM with the Licensed Vocational Nurse 1 (LVN 1) in Resident 1's room, LVN 1 stated per the weekend wound care nurse LVN 2's report, Resident 1's scrape on her right shoulder and right thigh were self-inflicted scratch wounds (a physical injury a person causes to their own skin, often using fingernails, sharp objects, or abrasive materials) it was happened on 6/14/2026 near 2 PM. The Situation, Background, Assessment, and Recommendation ( SBAR, a standardized, highly structured communication framework primarily used in healthcare settings to quickly and clearly convey crucial patient information) report was sent to MD. LVN 1 stated she did not witness Resident 1's skin injury when it happened. During an interview on 6/17/2026 at 4:45 PM with the Registered Nurse Supervisor (RNS), RNS stated she got a report from the LVN 2 that Resident 1 scratched herself to her right shoulder and right thigh on 6/14/2026 at 4 PM, she cut Resident 1's nails after physician was notified and wound care had performed by LVN 2. During an interview on 6/18/2026 at 7:45 AM with LVN 2, LVN 2 stated CNA 2 reported Resident 1's scratches on her right shoulder and right thigh. LVN 2 stated he did not witness Resident 1 scratched wound. LVN 2 stated he reported the incident to DON, called physician, obtained order from physician and provided wound care to Resident 1 per physician's order. During an interview on 6/18/2026 at 10:12 AM with LVN 1, LVN 1 stated the self-inflicted scratch from Resident 1's right upper shoulder skin may be from the sheets, but she saw Resident 1 has been scratching herself on her right thigh. LVN 1 also stated that she saw Resident 1's fingernails were long enough to hurt herself last week, LVN 1 stated she told CNAs to cut Resident 1's nails and cover Resident 1 skin with sheet to prevent her from touching her skin, but I did not check if CNA cut Resident 1's nail. During an interview on 6/18/2026 at 12:42 PM with the Director of Nursing (DON), DON stated there were no specific nursing staffs to cut and trim the nails for the residents. DON stated CNAs, LVNs and RNSs can cut and trim resident's' nails. DON also stated there was no specific policy for nail cutting and trimming for the residents. DON stated the facility uses Resident Dignity and Personal Privacy as a guide for nail cutting and trimming. During a review of the facility's Policy and Procedure (P&P) titled, Resident Dignity and Personal Privacy, reviewed on April 2025, the P&P indicated:Care for residents in a manner that maintains dignity and individuality:Groom appropriately and to resident desire. During a review of the facility's P&P titled, Activities of Daily Living (ADLs), Supporting, reviewed on April 2023, the P&P indicated: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate suppo1t and assistance with: hygiene (bathing dressing, grooming, and oral care).

Based on interview, and record review, the facility failed to implement a comprehensive person-centered care plan for Gastrostomy tube (G-tube, is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) by not having a documented evidence to monitor his G-tube site for one (1) of 2 sampled residents (Resident 2) as indicated on the facility's policy. This deficient practice had the potential for Resident 2 not to receive the proper care and treatment if the medications and nutrition were not administered timely through his G-tube site, which also may result in hospitalization, injury and harm. Findings:During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE] and readmitted [DATE]. Resident 2's diagnoses included hemiplegia (paralysis of one side of the body) hemiparesis (weakness on one side of the body) cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, dysphagia (difficulty swallowing), Diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose levels), and metabolic encephalopathy (an alteration of brain function or consciousness due to failure of other internal organs) During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 5/3/2026, the MDS indicated Resident 2 has severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 2 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in eating, toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, roll left and right, sit to lying, lying to sitting on side of bed and tub/ shower transfer.During a record review of Resident 2's Physician's Order (PO) dated 7/22/2025, the PO indicated Check G-tube patency and placement every shift.During a record review of Resident 2's Situation, Background, Assessment, Recommendation (SBAR, is a verbal or written communication tool that helps provide essential, concise information, usually during crucial situation) dated 8/3/2025 to 9/17/2025 was reviewed. The SBAR indicated,1.On 8/3/2025, Resident 2's G-tube was dislodged; however, Resident 2's abdominal binder was in place. Upon assessment, the binder remained intact and the GT was found with the balloon still inflated. Examination of the stoma revealed that it had already closed.2.On 8/11/2025, Resident 2's G-tube was dislodged, abdominal binder was in place. Resident 2 pulled at the G-tube connection for the Tube Feeding machine (enteral feeding pump, delivers liquid nutrition /formula directly into the stomach or small intestine via a feeding tube).3.On 8/30/2025, Resident 2's G-tube was dislodged, and the abdominal binder was in place. Resident 2 pulled the G-tube connection for the Tube Feeding machine. The G-tube balloon was intact, and an indwelling catheter was inserted on the stoma to keep it open.4.On 9/5/2025, Resident 2's G-tube was dislodged, and the abdominal binder was in place. Resident 2 pulled the G-tube connection from the Tube Feeding machine. The G-tube balloon was intact; an indwelling catheter was inserted on the stoma to keep Resident 2's gastrostomy stoma open.5.On 9/17/2025, Resident 2's G-tube was dislodged during Activities of Daily Living (ADLs, are activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) with the Certified Nursing Assistant (CNA). The G-tube balloon was intact. Resident 2's abdominal binder was open. Indwelling catheter was inserted to keep Resident 2's gastrostomy stoma open. Physician ordered to transfer Resident 2 to hospital for G-tube reinsertion. During a record review of Resident 2's Nurses' Progress Notes (NPN) dated 8/3/2025 to 9/17/2025 was reviewed. The NPN indicated that there was no documentation from the licensed staff regarding Resident 2's G-tube dislodgement between 8/11/2025 to 9/17/2025. During a review of Resident 2's Care Plan (CP) for episodes of pulling out his G-tube revised 3/12/2026, the CP interventions indicated the following: Use a draw sheet or lifting device to move the Resident Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Weekly treatment documentation During a review of Resident 2's CP for dependent on tube feeding for all nutrition and hydration initiated 3/12/2026, the CP indicated, Check G-tube site dressing every shift and as needed (PRN) for soilage, leakage or staining. Check residuals every shift and hold tube feeding if residual is above 100 milliliters (ml, unit of measurement) Check G-tube placement or patency every shift Cleanse G-tube site daily and PRN for soilage, leakage or staining. May have abdominal binder to prevent G-tube pull out During a review of Resident 2's CP for aggressive behavior towards staff and attempting to pull his G- tube initiated 3/12/2026, the CP indicated, Will apply abdominal binder to prevent G-tube dislodgement Will continue to provide safe environment for the Resident Will encourage the resident to vent out his feelings During a concurrent interview and record review on 6/18/2026 at 10:05 AM with Licensed Vocational Nurse 1 (LVN 1), Resident 2's CP for aggressive behavior towards staff and attempting to pull his G- tube initiated 3/12/2026 was reviewed. LVN 1 stated The CP had incomplete interventions. They need to add more interventions to prevent Resident 2's G-tube dislodgement. They should add monitoring for Resident 2's abdominal binder should be in place all the time. The staff should keep the G-tube out of Resident 2's reach. During a concurrent interview and record review on 6/18/2026 at 10:39 AM with LVN 3, Resident 2's CP for aggressive behavior towards staff and attempting to pull his G- tube initiated 3/12/2026 was reviewed. LVN 3 stated the CP interventions were too short. They should add more interventions, like approach Resident 2 calmly because Resident had aggressive behavior and staff should check Resident 2's abdominal binder more frequently. The staff should have consistent rounds which should be done every 2 hours to make sure Resident 2 was not pulling his G-tube. During a concurrent interview and record review on 6/18/2026 at 11:17 AM with LVN 2, Resident 2's SBAR dated 8/3/2025 to 9/17/2025 was reviewed. The SBAR indicated Resident 2 had G-tube dislodgement. LVN 2 stated that was a lot of G-tube dislodgement for Resident 2. Resident 2 was aggressive. Resident 2's non-affected hand was very strong and can reach the G-tube and will pull on it. During a concurrent interview and record review on 6/18/2026 at 11:32 AM with LVN 2, Resident 2's Treatment Administration Record dated 8/1/2025 to 8/31/2025 was reviewed. LVN 2 stated Resident 2's TAR indicated Resident 2 dressing change for his G-Tube. The staff should include checking Resident 2's abdominal binder in the Medication Administration Record (MAR, is a report detailing the drugs administered to a resident by a healthcare professional at a treatment facility), Change of Condition (COC, is a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) or SBAR documentation. If there was no documentation from the staff, it means it did not happen, and there was no abdominal binder on the Resident. LVN 2 also stated it means that no one was checking or monitoring Resident 2's abdominal binder and his behavior of pulling his G-tube. During a concurrent interview and record review on 6/18/2026 at 1:48 PM with the Director of Nursing (DON), Resident 2's SBAR dated 8/3/2025 to 9/17/2025 was reviewed. The SBAR indicated Resident 2 had episodes of G-tube dislodgement. DON stated Resident 2 had 5 episodes of pulling his G-tube, that was a lot. Resident 2 was pulling his G-tube tubing from his Tube Feeding machine; there were 2 episodes that he dropped the G-tube set up on the floor. During a concurrent interview and record review on 6/18/2026 at 1:58 PM with the DON, Resident 2's CP for aggressive behavior towards staff and attempting to pull his G- tube initiated 3/12/2026 was reviewed. DON stated the CP interventions were not enough, it was very limited. The CP should have redirected Resident 2 not pulled on his G- tube. They need to put a towel and hide the G-Tube. They need to tuck Resident 2's G-tube on the opposite side of the dominant hand where Resident 2 would not be able to reach it. Monitoring Resident 2 frequently every shift could have prevented him from pulling his G-tube. They could have prevented the G-tube dislodgement if the facility did conduct close monitoring or 1:1 supervision for Resident 2 after the first episode of dislodgement. During an interview on 6/18/2026 at 2:04 PM with the DON, DON stated when staff monitor Resident 2, the staff should have to document on the Nurse's Progress Notes (NPN). If the licensed staff did not document any monitoring, it means they did follow Resident 2's care plan. During a concurrent interview and record revie on 6/18/2026 at 2:46 PM with DON, the facility's policy and procedure (P&P) titled, Care Plan- Comprehensive Person- Centered, revised on 1/2025, the P&P indicated each resident comprehensive care plan has been designated to incorporate identified problem areas, and incorporate risk factors associated with identified problems. DON stated they did not follow the policy; they could have addressed the problem for Resident 2. During a review of the facility's P&P titled, Changes in Resident Condition revised 1/2024, The P& P indicated,3.Changes in condition are communicated from shift to shift through the 24-hour report management system.4.Changes in the resident status that affect the problem(s)/goal(s) or approach(es) on his/her care plan are documented as revisions and communicated to the interdisciplinary caregivers

Based on interview and record review, the facility failed to document records accurately and completely for one (1) of three (3) sampled residents (Residents 1) in accordance with the facility's policy and procedure (P&P) by failing to ensure oxygen administered to Resident 1 on 2/9/26 was documented on the Medication Administration Record (MAR, a medical record used by healthcare providers to document the administration of a medication or treatment) and on the SBAR Situation, Background, Assessment, Recommendation (SBAR) Communication Form (communication tool that helps provide essential, concise information). This deficient practice can result in a lack of or a delay in communication between the staff and can interrupt provision of care/intervention to Resident 1.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of chronic lymphocytic leukemia of B-cell type not achieved remission (active cancer cells, with elevated lymphocyte counts or disease symptoms persisting despite treatment.) and malignant neoplasm of prostate (cancerous tumor that originates in the prostate [small, walnut sized gland located below the bladder] gland). During a review of the Minimum Data Set (MDS, a resident assessment tool), dated 12/10/2025, the MDS indicated Resident 1 was assessed to be cognitively (a mental process of acquiring knowledge and understanding) impaired with daily decision making. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) on staff for oral hygiene, toilet hygiene, and personal hygiene. During a review of Resident 1's Order Summary, dated 1/23/2026, the Order Summary indicated to administer oxygen (O2) at two (2) to four (4) via nasal cannula (NC- a flexible tube inserted into the nostrils to deliver supplemental oxygen for patients with breathing difficulties) to five (5) to 10 liters per minute (LPM) via oxygen mask to reach O2 saturation (level of oxygen found in a person's blood) equal to or more than 92 percent (%) as needed for shortness of breath (SOB). Record O2 saturation before oxygen administration. During a review of Resident 1's MAR on February 2026, the MAR indicated to administer oxygen at 2 to 4 LPM via NC to 5 to 10 LPM via oxygen mask to reach O2 saturation equal to or more than 92% as needed for SOB and record O2 saturation before oxygen administration was blank on 2/9/2026. During a review of Resident 1's SBAR on 2/9/2026 at 4:06 PM, the SBAR did not indicate that oxygen was given upon finding Resident 1 to be unresponsive. During a concurrent record review of Resident 1's SBAR and Resident 1's MAR with LVN 1 on 3/6/2026 at 2:18 PM, LVN 1 stated, On 2/9/2026 at 3:30 PM, I administered oxygen at 10 LPM via oxygen mask to Resident 1 upon finding him unresponsive. I forgot to document in the MAR and in the SBAR communication form that oxygen was administered to him. LVN 1 stated he was supposed to document O2 saturation on the MAR and document that oxygen was administered on the SBAR. During a review of the facility's P&P titled, Charting and Documentation, dated May 2024, the P&P indicated 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. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Based on observation, interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Residents 1) were provided necessary treatment and services to prevent formation of and promote healing of pressure injury (pressure ulcers, injury to the skin and underlying tissue resulting from prolonged pressure on the skin) in accordance with the resident's care plan by failing to ensure Resident 1 was repositioned every two hours. This deficient practice had the potential to place Resident 1 at risk for skin integrity complications and to have worsening or recurrence of a pressure injury. Findings: During a record review of Resident 1's admission Record, the admission record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with the diagnoses including but not limited to paraplegia (partial or complete paralysis [loss of voluntary muscle function] of the lower half of the body with involvement of both legs), pressure ulcer of sacral (bone at the end of the spine) region stage four (4) (pressure injury is very deep, reaching into muscle and bone and causing extensive damage), pressure ulcer of left hip stage 4, pressure ulcer of right buttock stage 4, and pressure ulcer of left buttock stage 4. During a record review of Resident 1's Care Plan, dated 11/7/2025, the Care Plan indicated Resident 1 had impaired skin integrity as evidence by actual presence of sacrococcyx (the fused sacrum and coccyx, or tailbone) pressure injury stage 4. The staff interventions were to keep affected area clean and dry, observe for any adverse changes or complications and report to the physician immediately, and turning and repositioning every two hours or as needed. During a record review of Resident 1's Care Plan, dated 11/7/2025, the Care Plan indicated Resident 1 had impaired skin integrity as evidence by actual presence of left ischium pressure injury stage 4. The staff interventions were to keep affected area clean and dry, observe for any adverse changes or complications and report to the physician immediately, and turning and repositioning every two hours or as needed. During a record review of Resident 1's Physical Therapy Discharge summary, dated [DATE], the summary indicated Resident 1 will safely perform bed mobility tasks with contact guard assist (therapeutic technique used that involves maintaining light physical contact with a resident to ensure safety while promoting independence during mobility tasks) without use of siderails for proper sequencing and for task segmentation in order to enhance safe functional mobility . During a record review of Resident 1's Care Plan, dated 2/3/2026, the Care Plan indicated Resident 1 had impaired skin integrity as evidence by actual presence of left posterior hip pressure injury stage 4. The staff interventions were to keep affected area clean and dry, observe for any adverse changes or complications and report to the physician immediately, and turning and repositioning every two hours or as needed. During a record review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment and tool), dated 2/5/2026, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was intact. The MDS indicated Resident 1 had impairment on both sides of the lower extremity (hip, knee, ankle, foot). The MDS indicated Resident 1 required supervision or touching assistance (helper sets up or cleans up, resident completes activity) for rolling left and left. The MDS also indicated Resident 1 had stage 4 pressure ulcers. During an observation 2/24/2026 at 10:59 AM in Resident 1's room with Resident 1, Resident 1 was lying on his back. During an interview on 2/24/2026 at 1:13 PM with Treatment Nurse (TXN), TXN stated Resident 1 needed help with repositioning while awake and while asleep he would put a timer on his phone, however Resident 1 needed a lot more help now since he had a leg brace. During a concurrent observation and interview on 2/24/2026 at 2:21 PM in Resident 1's room with Resident 1, Resident 1 was lying in bed on his back and stated the staff have not offered to reposition him nor assisted him with repositioning. During an interview on 2/24/2026 at 2:38 PM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 needed assistance with being repositioned since he could not move his legs. CNA 1 stated staff needed to carry Resident 1's legs when repositioning from the right to left side. CNA 1 stated Resident 1 was supposed to be repositioned every two hours. CNA 1 stated repositioning every 2 hours could ensure Resident 1's circulation to the areas avoided any pressure injuries and avoid current pressure injuries from worsening. CNA 1 stated CNA 1 only repositioned Resident 1 once around 9 AM during his shift (7 AM to 3 PM) and there were no other staff who had repositioned Resident 1. CNA 1 stated Resident 1 was not efficient with repositioning himself and needed assistance with carrying Resident 1's leg brace during repositioning. CNA 1 stated once repositioned, staff also needed to make sure the brace was aligned after turning. CNA 1 stated he did not do the standard procedure of repositioning Resident 1 every 2 hours during his eight-hour shift. During an interview on 2/25/2026 at 10:39 AM with the Director of Rehabilitation (DOR), DOR stated Resident 1 was paraplegic and not able to use his lower extremities. DOR stated Resident 1 was currently wearing a knee brace and could not move the knee. DOR stated a staff needed to hold the actual leg during repositioning since the brace was hard. DOR stated Resident 1's leg does have strength since he was paraplegic. During an interview on 2/25/2026 at 1:49 PM with the Director of Nursing (DON), the DON stated Resident 1 needed assistance by staff with being repositioned every 2 hours. The DON stated that staff are still required to offer repositioning to residents, even in cases where the residents decline or are noncompliant with positioning. The DON stated staff needed to reposition Resident 1 to assist with the wound to heal. The DON stated Resident 1's wounds would be at a higher risk of deterioration if Resident 1 was not repositioned. During a record review of the facility's Policy and Procedure titled, Prevention of Pressure Injuries, revised 7/12/2023, the Policy and Procedure indicated reposition resident as indicated on the care plan.

Based on interview and record review, the facility failed to follow its policy and procedure for Changes in a Resident Condition, by failing to notify the physician on 2/7/2026 for one (1) of three (3) sampled residents (Resident 1) who had a change in condition for altered knee sensation after a witnessed fall on 2/6/2026. This deficient practice had the potential for a result in delayed provision of necessary care and services.Findings: During a record review of Resident 1's admission Record, the admission record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with the diagnoses including but not limited to paraplegia (partial or complete paralysis [loss of voluntary muscle function] of the lower half of the body with involvement of both legs), pressure ulcer of sacral (bone at the end of the spine) region stage four (4) (pressure injury is very deep, reaching into muscle and bone and causing extensive damage), and osteomyelitis (infection of bones). During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment and tool), dated 2/5/2026, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was intact. The MDS indicated Resident 1 had impairment on both sides of the lower extremity (hip, knee, ankle, foot). The MDS indicated Resident 1 required supervision or touching assistance (helper sets up or cleans up, resident completes activity) for rolling left and left and partial/moderate assistance (helper does less than half the effort) for chair/bed-to-chair transfer. The MDS also indicated Resident 1 has not had any falls since admission. During a record review of Resident 1's SBAR (an acronym for Situation-Background-Assessment-Recommendation is a technique used to provide a framework for communication between members of the health care team), dated 2/6/2026, the SBAR indicated Resident 1 had an unavoidable witnessed fall. The SBAR indicated Resident 1 was being assisted and slipped from Certified Nursing Assistant (CNA's) grasp and slid back into the wheelchair and his left foot struck the wheelchair footrest. During a record review of Resident 1's Order Review, dated 2/6/2026, the order indicated X-ray (a type of radiation that can pass through most solid materials, is used by doctors to examine the bones or organs inside the body) ordered for foot left, toe second, hips bilateral (both sides)/pelvis (a basin-shaped structure in the human body that connects the spine to the legs). During a record review of Resident 1's Radiology Results Report, dated 2/9/2026 (3 days after the fall), the report indicated possible small avulsion fracture (a piece of bone attached to a tendon or ligament gets pulled away from the main part of the bone) of the tibial tuberosity (a bony prominence located in the knee region, playing a significant role in leg movement). During an interview on 2/24/2026 at 8:16 AM with Family Member (FM), FM stated Resident 1 had a fall when he was transferred to his wheelchair on 2/6/2026. FM stated FM visited Resident 1 about 2 days after his fall (2/8/2026) and saw Resident 1's knees were very swollen. FM stated Resident 1 had informed FM he heard a crack when he fell on his knees and had been feeling a hot burning sensation on his knees for the past two days. FM stated when she asked the licensed nurse (unknown) if they did an x-ray, the licensed nurse (unknown) said they already did an x-ray on his back and foot. FM stated on 2/8/2026, FM requested the staff to contact the physician to get an order for an x-ray of Resident 1's knees. During a concurrent observation and interview on 2/24/2026 at 10:44 AM in Resident 1's room with Resident 1, Resident 1 was lying in bed with a leg brace on the right leg. Resident 1 stated he landed on both knees and heard a crack when he fell. Resident 1 stated about an hour after his fall his right leg became swollen and felt warm. Resident 1 stated the morning after his fall, he felt a burning sensation on his legs. Resident 1 stated he informed CNA 2 and CNA 3 that he felt like his legs were burning. Resident 1 stated he also informed a licensed vocational nurse (unknown) that his legs felt like they were burning. During an interview on 2/24/2026 at 3:49 PM with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Resident 1 was noncompliant with his transfer and did not hold onto CNA 2 which caused him to fall during the transfer on 2/6/2026, Resident 1's bottom was at the edge of his wheelchair, and both knees were on the floor. During an interview on 2/24/2026 at 4:13 PM with CNA 3, CNA 3 stated he saw Resident 1's knees on the floor and feet underneath the wheelchair when he entered Resident 1's room after his fall. CNA 3 stated he assisted Resident 1 onto his wheelchair. CNA 3 stated he saw redness of the upper shin of Resident 1's legs after his fall. During an interview on 2/25/2026 at 11:25 AM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she worked the day after Resident 1's fall (2/7/2026). LVN 1 stated on 2/7/2026 around 8:30 AM, Resident 1 informed her that due his back injury he didn't have any pain but Resident 1's knees were not how it usually felt. LVN 1 stated Resident 1 did not want his legs to be moved, and his knees felt different after his fall. LVN 1 stated she checked Resident 1's order and there was an x-ray already ordered for Resident 1's knee. LVN 1 stated if there was no x-ray order for Resident 1's knees, then she would have needed to let the physician know there was no x-ray order for Resident 1's knees. LVN 1 stated the physician needed to be informed of Resident 1's knee in case there was an injury to the area. During a concurrent interview and record review on 2/25/2026 at 11:50 AM with LVN 1 of Resident 1's Order Summary on 2/6/2026 indicated X-Ray was ordered for the foot left, toe second, and hips bilateral/pelvis. LVN 1 stated, I assumed it was for the whole leg. LVN 1 stated she should have messaged the physician and asked for the specific x-ray of the knee since Resident 1 since he complained about his knees after the fall. During a concurrent interview and record review on 2/25/2026 at 1:49 PM with the Director of Nursing (DON) of Resident 1's X-Ray Reports and SBAR, the DON stated there was an SBAR done on 2/6/2026 for Resident 1's witnessed fall. The DON stated Resident 1 is paraplegic and could not feel from the waist down. The DON stated the licensed nurses needed to assess the area and notify the physician if there was a change in condition. The DON stated the licensed nurses needed to inform the physician when Resident 1 informed staff of the burning sensation on his knees. The DON stated when Resident 1 informed the staff, the licensed nurse needed to inform the physician right after the assessment was done. The DON stated the facility needed to provide the right interventions at the right moment since the residents could easily deteriorate, especially in the elderly community. The DON also stated Resident 1 had a diagnosis of osteomyelitis making his bones more fragile and harder to heal. During a record review of the facility's policy and procedure titled, Changes in Resident Condition, dated 1/2024, the policy indicated the resident, attending physician and legal representative or designated family member are notified when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention.

Based on observation, interview and record review, the facility failed to ensure a safe environment free of accident hazards by not preventing smoke from entering the facility hallway leading to the front lobby as a result of a burnt Heating, Ventilation, and Air Conditioning unit's (HVAC unit, is a comprehensive system designed to regulate indoor temperature, humidity, and air quality) filter on 1/10/2026. This deficient practice had the potential to place residents, visitors, and staff at risk for smoke inhalation (damage caused to the respiratory system, airways, and lungs by breathing in harmful combustion products [smoke] from fires) which could result in respiratory irritation, including coughing, shortness of breath, and complications such as airway swelling, reduce amount of oxygen to the body, hospitalization, and death. Findings:During a telephone interview on 1/13/2026 at 5:33 PM with the Director of Nursing, the DON stated Registered Nurse 1 (RN 1) notified him on 1/10/2026 at 10:59 AM that they had noticed smoke inside the facility along the hallway leading to the facility lobby. The DON further stated paramedics (healthcare professionals trained to provide emergency medical care to individuals who are injured or ill ) were in the facility to respond to a 911 (emergency telephone number to quickly connect callers to emergency services) call for a resident with change of condition when the paramedics noticed smoke in the building. The DON also stated the smoke detector did not alarm.During an interview on 1/14/2026 at 11:42 AM with Maintenance Director (MD), MD stated on 1/10/2026 at 11:15 AM, Maintenance Staff (MS) called and informed him that there was smoke inside the facility. Later, on 1/10/2026 at 11:26 AM, MS also reported that there was a smell of smoke in the hallway, which was coming from the ceiling vent connected to HVAC unit 15.During a concurrent observation and interview on 1/14/2026 at 11:47 AM with the facility's Administrator (ADM), the HVAC unit 15's filter was observed to be partially burnt. The ADM stated the filter caught fire while workers were torching (to deliberately set something on fire) the facility's roof. The ADM further explained that the torch used to patch the roof ignited in flame, causing the HVAC filter to catch fire, and the smoke immediately travelled down the vent.During an interview on 1/14/2026 at 1:24 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that on 1/10/2026 (unable to recall the time), she smelled something burnt but did not see smoke. LVN 1 stated that an announcement was made to shut all residents' doors. LVN 1 stated shutting the residents' doors would help prevent smoke inhalation, which was harmful to residents as it can cause respiratory distress.During an interview on 1/14/2026 at 1:41 PM with LVN 2, LVN 2 stated that on 1/10/2026 (unable to recall the time), she smelled something burning inside the facility but did not see smoke. LVN 2 stated she did not hear the smoke detector alarm. LVN 2 stated that paramedics helped address the situation by turning on fans in the hallway and opening the facility's front door.During an interview on 1/14/2026 at 1:55 PM with LVN 3, LVN 3 stated that on 1/10/2026, he smelled a faint odor of some type of fumes in the hallway.During an interview on 1/14/2026 at 2:13 PM with MS, MS stated that on 1/10/2026 at 10:58 AM, he received a call from the facility's receptionist reporting that the facility smelled of smoke. MS stated that he briefly went inside the facility, then went up to the roof and saw that the filter of HVAC unit 15 was partially burnt. MS added that the workers on the roof told him the filter had caught fire.During an interview on 1/14/2026 at 2:56 PM with the Activity Director (AD), AD stated that on 1/10/2026, before 11 AM, she saw haze in the hallway and heard staff saying there was smoke.During an interview on 1/14/2026 at 3:23 PM with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated that on 1/10/2026 (unable to recall the time), CNA1 observed smoke in the hallway coming from the ceiling and smelled something like burnt plastic.During an interview on 1/14/2026 at 4:41 PM with the facility's receptionist, she stated that on 1/10/2026 (unable to recall the time), while she was in the front lobby, she smelled something burning and then saw a hazy, foggy appearance in the hallway. The Receptionist stated that Registered Nurse 2 (RN 2) announced that all residents' doors should be closed.During an interview on 1/14/2026 at 5:15 PM with the DON, the DON stated that on 1/10/2026 at 10:59 AM, RN 1 called him to report that there was smoke inside the facility. The DON stated that having smoke inside the facility is not safe for residents and added that smoke inhalation is harmful to anyone because it can cause shortness of breath, which may lead to hospitalization for residents with underlying respiratory conditions.During a review of facility's Policy and Procedure (P&P) titled, Accidents/Incidents, dated May 2018, the P&P indicated facility shall provide a safe and secure environment for staff and residents.

Based on interview and record review, the facility failed to ensure a wound for one of four sampled residents (Resident 1) received appropriate wound care and treatment services. Resident 1, who had type 1 diabetes (a condition in which the body does not make insulin; thus, could not control the amount of sugar in the blood. With diabetes, the wounds tend to heal more slowly and progress more quickly) developed a fluid filled blister on his right lateral malleolus (right ankle) on 3/25/2021 that measured 2.5 centimeters (cm, unit of measurement) (length, extent from end to end or head to toe) x 2.5 cm (width, extent from side to side) x 0.5 cm. (depth, deepest point of the wound). The wound increased in size to 2.8 cm x 2.8 cm x unable to determine [UTD, due to wound base covered by slough/necrotic (dead tissue due to reduced blood supply) tissue] and ruptured (opened) on 4/9/2021 and to 3 cm x 3 cm on 4/23/2021. The facility failed to: 1. Consult a wound specialist in a timely manner (when the wound ruptured on 4/9/2021) in accordance with Resident 1's Skin Care Plan that resulted in the rapid deterioration and delayed healing of the resident's wound. 2. Follow up with Resident 1's primary physician if additional laboratory work was needed to help assess in the healing process of the resident's wound. Resident 1's last laboratory level for [MEDICATION(S)] (a protein made by the liver where its main role is to provide nourishment to the tissues and transport hormones, vitamins, drugs, and other substances such as calcium throughout the body. [MEDICATION(S)] levels facilitate wound healing.), dated 10/15/2020 was low and the resident did not have additional labs ordered when the resident's wound to the right lateral malleolus (right ankle) increased in size in 4/9/2021, 4/23/2021, and 4/30/2021. These deficient practices resulted in the increase of Resident 1's right ankle wound to 8.6 cm x 7.4 cm x 1.2 cm. on 4/30/2021 and developing a diabetic right ankle wound infection. Resident 1 was transferred to a general acute care hospital (GACH) on 5/3/2021 and the GACH indicated that amputation (surgical removal of a body part) of the foot was considered. Findings: 1. A review of Resident 1's Admission Record indicated the facility admitted the resident on 10/26/17 and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 1/31/2020, indicated that the resident had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated that the resident required extensive assistance (resident involved in activity; staff provide weight bearing support) from staff for transferring, dressing, eating, and toileting. A review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR, a technique used to provide a communication framework between members of the health care team about a patient's condition), dated 3/25/2021, indicated that the facility informed Nurse Practitioner 1 (NP 1) at 12:45 PM that Resident 1 developed a blister on his right lateral malleolus (right ankle) and a new order for wound treatment was ordered. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's care plan titled, Skin Care Plan, dated 3/25/2021, indicated that the facility had a concern about a fluid-filled blister that the resident developed on his right lateral malleolus (right ankle). The care plan's interventions included a wound specialist consultation, and to notify the physician for skin breakdown and adverse changes. During a telephone interview and a concurrent record review, on 10/13/2021 at 2:30 PM, the Quality Assurance Nurse (QA Nurse) stated that the resident developed a blister on his right lateral malleolus (right ankle) on 3/25/2021. The QA Nurse stated that Resident 1's record titled, Non-Pressure Sore Skin Problem Report (NPSSPR), dated 3/25/2021, indicated the wound on his right lateral malleolus (right ankle) had the following measurements on the following dates: 1. 3/25/2021 - 2.5 centimeters (cm, unit of measurement) x 2.5 centimeters x 0.5 centimeters, clear fluid filled (blister). 2. 4/1/2021 - 2.5 cm x 2.5 cm x 0.5 cm, clear, fluid filled. 3. 4/8/2021 - 2.5 cm x 2.5 cm x 0.5 cm, clear, fluid filled. 4. 4/9/2021 - 2.8 cm x 2.8 cm x unable to determine, blister now ruptured. 5. 4/16/2021 - 2.8 cm x 2.8 cm x UTD 6. 4/23/2021 - 3 cm x 3 cm x UTD During a telephone interview, on 10/13/2021 at 2:30 PM, the QA Nurse stated that the facility informed the resident's Physician 3 (PHY 3) and Nurse Practitioner 1 (NP 1) on 3/25/2021 that the resident developed a blister on his right ankle and obtained a wound treatment order which the facility carried out. The QA Nurse stated that the facility also asked the vascular surgeon (PHY 1, a specialized physician that deals with arteries, veins, and lymphatic circulation) to see the resident because he was the physician who found a blockage on the resident's lower extremity when he developed a blister on his left heel in August 2020. The QA Nurse stated that PHY 1 conducted an arterial duplex scan (a test to see how blood moves through the arteries and veins) on the resident's lower extremity on 4/1/2021 but did not find any blockage. A review of Resident 1's SBAR, dated 4/9/2021, indicated that the resident's right ankle blister ruptured, and the facility notified NP 1. NP 1 gave new orders for wound treatment. The SBAR also indicated the facility called PHY 1's office to schedule an appointment for 4/20/2021 at 10 AM for evaluation of wound site as ordered. During a telephone interview, on 10/13/2021 at 2:30 PM, the QA Nurse stated that Resident 1's NPSSPR, dated 3/25/2021, indicated the wound measurement of the right lateral malleolus (right ankle) remained the same 4/920/21 (2.8 cm x 2.8 cm x UTD) and 4/16/2021 (2.8 cm x 2.8 cm x UTD) until it was re-measured by the treatment nurse on 4/23/2021 (3 cm x 3 cm x UTD) during a wound dressing change. The QA Nurse stated that they did not report the increase in wound size to the physicians or to NP 1 because the difference was not significant. A review of Resident 1's SBAR, dated 4/30/2021, indicated the resident had a change in condition with sacrococcyx moisture associated skin damage (MASD, skin breakdown due to prolong exposure to moisture), diabetic ulcer (open wounds or sores usually found of on the bottom of feet) on right lateral (to the side of) fifth (5th) metatarsal (the long bones in the foot that connects the ankle to the toes), right lateral foot, and right lateral malleolus (right ankle). During a telephone interview and a concurrent record review, on 10/13/2021 at 2:30 PM, the QA Nurse stated that Resident 1's NPSSPR, dated 4/30/2021, indicated that the resident developed two new wounds on his right foot. The first wound was on his right lateral 5th metatarsal that measured 2.4 cm x 1.5 cm x 0.1 cm and the second wound was on his right lateral foot that measured 3.6 cm x 2.1 cm x 0.1 cm. The QA Nurse stated that the facility tried to inform the resident's primary physician (PHY 3) about the new wounds, but PHY 3 was not available so the facility was not able to get a hold of PHY 3. The QA Nurse stated that since the vascular surgeon (PHY 1) would not see the resident until three months later, the facility decided to ask the facility's in-house podiatrist and wound specialist (PHY 2) to evaluate the wounds of the resident. During a telephone interview and a concurrent record review, on 10/13/2021 at 2:30 PM, the QA Nurse stated that Resident 1's Lower Extremity Wound Assessment (wound specialist notes), dated 4/30/2021, indicated the wound measurement of the right lateral malleolus (right ankle) increased from 3 cm x 3 cm x UTD to 8.6 cm x 7.4 cm x 1.2 cm. The assessment indicated treatment plan for debridement (medical removal of dead, damaged, or infected tissue). The QA Nurse stated that the facility did not ask assistance from the wound specialist (PHY 2) until 4/30/2021 because Resident 1 was under the care of the vascular surgeon (PHY 1) when the blister ruptured. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview and a concurrent record review, on 10/13/2021 at 2:30 PM, the QA Nurse stated Resident 1's SBAR, dated 5/3/2021 at 3 PM, indicated the resident developed a fluid-filled blister on his left heel and right ankle diabetic ulcer infection. The QA Nurse stated that the facility notified the wound specialist (PHY 2) and obtained a new order for antibiotic therapy because the wounds were infected. The SBAR indicated that [MEDICATION(S)] (medication used to treat skin infections) 300 milligram (mg, a unit of measurement) one tablet twice a day (BID) for 10 days was ordered for diabetic ulcer infection. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's SBAR, dated 5/3/2021 at 6:30 PM, indicated the resident had fever, weakness, and desaturation (oxygen levels less than normal range, normal range from 96 to 100 %). The SBAR indicated that the resident's vital signs (four main vital signs routinely monitored by medical professionals and health care providers include the following: body temperature, pulse rate, respiration rate/breathing rate, and blood pressure) at 6:30 PM was 100.7 degrees Fahrenheit (F, measurement of temperature), blood pressure (BP)=105/62, heart rate (HR)=84, respiration rate (RR)=20, and oxygen saturation (SpO2, percentage of oxygen level in the body) was 93% on room air. At 8:30 PM, the vital signs were 100.0 F, BP=110/58, HR=84, RR=22, SpO2=88%. Resident also started to have congestion and was suctioned and O2 was administered at 2 liters per minute (LPM, rate of O2 administered) via nasal cannula (NC, a tubing used to deliver supplement O2 for difficulty breathing). O2 was titrated (slowly increased to improve O2 saturation) and Resident 1 did not improve and 911 (a phone number used to contact the emergency services) was called at 9 PM. A review of Resident 1's record from GACH 2 titled, Emergency Physician Notes, dated 5/3/2021, indicated that GACH 2 admitted Resident 1 at 9:33 PM due to shortness of breath. Upon physical examination, the note indicated the resident had wound ulcers on bilateral feet (both feet). The record indicated that his condition was critical. Resident 1 required blood transfusion due to severe [CONDITION(S)] (condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues). A review of Resident 1's record from GACH 2 titled, Discharge Summary Narrative Report, dated 5/20/21, indicated that Resident 1 had bilateral heel ulcers, stage IV (most serious stage that extends below the subcutaneous fat into deep tissues, muscles, tendons, ligaments, and bone) and debridement was done on 5/17/2021 with amputation considered. During a telephone interview, on 10/13/2021 at 2:30 PM, the QA Nurse stated that the facility transferred the resident to a General Acute Care Hospital 2 (GACH 2) at 9 PM on the same day (on 5/3/2021) via 911 for further evaluation because the resident became weak, desaturated, and developed a fever. The QA Nurse stated that the resident did not return to the facility after the transfer. During a telephone interview, on 10/15/2021 at 10:05 AM, PHY 1 (vascular surgeon) stated that on 4/1/2021, the facility asked him to evaluate Resident 1's blister on his right lateral malleolus (right ankle). PHY 1 stated that he conducted an arterial duplex scan on the resident's lower extremity but did not find any blockage. PHY 1 stated that he did not give the resident any treatment order when Resident 1 went to his office on 4/20/2021 for a check-up. PHY 1 stated that he was a vascular surgeon and not a wound doctor. PHY 1 stated that he did not prescribe wound treatment orders. PHY 1 stated, My role in the resident's wound was only to ensure that he had no blockage in his blood vessels. During a telephone interview and record review, on 10/15/2021 at 11:45 AM, Licensed Vocational Nurse 3 (LVN 3) stated that Resident 1's NPSSPR, dated 3/25/2021, indicated LVN 3 documented the resident's wound measurement on his right lateral malleolus (right ankle) on 4/16/2021 was 2.8 cm x 2.8 cm x UTD and on 4/23/2021 was 3 cm x 3 cm x UTD. LVN 3 stated that he did not report the increase in wound size to the resident's physician because the difference in size was not significant. During a telephone interview, on 11/3/2021 at 8:15 AM, NP 1 stated that he worked under the supervision of the resident's PHY 3 (primary physician). NP 1 stated that on 3/25/2021, the facility informed him that Resident 1 developed a blister on his right lateral malleolus (right ankle). NP 1 stated that he did not see the blister but gave a wound treatment order based on the information that the licensed nurse provided him. During the same telephone interview, on 11/3/2021 at 8:15 AM, NP 1 stated that on 4/9/2021, he gave the facility another wound treatment order when the latter reported to him that the blister ruptured. NP 1 stated that he did not see the wound and his treatment order was based on what the licensed nurse reported to him. NP 1 also stated that the facility did not inform him that the wound increased in size on 4/23/21. During a telephone interview, on 11/5/2021 at 10:20 AM, PHY 3 (primary physician) stated that NP 1 worked under his supervision and communicated with him every day. PHY 3 stated that he was aware that Resident 1 developed a blister on his right lateral malleolus (right ankle) on 3/25/2021. PHY 3 stated that NP 1 gave the facility a wound treatment order and PHY 1 (vascular surgeon) ensured Resident 1's lower extremity blood vessels were not constricted (blocked). PHY 3 stated that he and NP 1 rely on the information that the facility provided them. PHY 3 stated that he would order for a wound specialist consult if the facility requested for it. During a telephone interview, on 11/4/2021 at 11 AM, the Assistant Director of Nursing (ADON) stated that the facility did not have a policy for diabetic foot care or diabetic ulcer. A review of the facility's policy titled, Wound Management, dated 2019, indicated that the licensed nurse would monitor and evaluate the effectiveness of the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. A review of Resident 1's laboratory report (a medical procedure that involves testing a sample of blood, urine, or other substance from the body), dated 10/15/20, indicated the following results: A. [MEDICATION(S)] (a protein made by the liver where its main role is to provide nourishment to the tissues and transport hormones, vitamins, drugs, and other substances such as calcium throughout the body) level was 3.0 grams per deciliter (g/dL, unit of measurement, normal range: 3.5 to 5.7 g/dL). B. Total Protein (indicates the amount of protein in the blood which help build and repair muscles, skin, and other body tissues, and fight infection) level was 5.3 g/dL (normal range: 6.4 to 8.9 g/dL). A review of Resident 1's laboratory report after admission from GACH 2, dated 5/3/2021, indicated that his [MEDICATION(S)] level was 3.0 g/dL, and the total protein level was 6.7 g/dL. During a telephone interview and a concurrent record review, on 10/13/2021 at 12:36 PM, Registered Dietitian 1 (RD 1, a health professional with special training in the use of diet and nutrition to keep the body healthy) stated Resident 1's medical record titled, Nutritional Progress Notes by Registered Dietitian, dated 11/8/2020, indicated she documented that she increased Resident 1's sugar-free liquid protein supplement to 30 cubic centimeters (cc, a unit of measurement) from once a day to twice a day because Resident 1's [MEDICATION(S)] level was 3.0 g/dL (based on the resident's lab results on 10/15/20). RD 1 stated that there was no other laboratory result after 10/15/2020 that showed his level of [MEDICATION(S)] and total protein. During a telephone interview, on 10/21/2021 at 9:20 AM, the QA Nurse stated that a follow up blood draw was only indicated if the results of the laboratory report indicated a critically low value. The QA Nurse stated that a follow up blood draw was not a standard practice of the facility. The QA Nurse stated that the last comprehensive laboratory work of Resident 1 was on 10/15/2020. During a telephone interview, on 11/4/2021 at 11 AM, the ADON stated that the facility had no policy for abnormal labs. The ADON stated as a licensed nurse, the ADON stated that she would advocate for a resident by asking the physician to order for a follow up laboratory work if the resident had a previous abnormal lab result. The ADON stated that the facility needed to obtain an order from the physician before they could draw a blood sample from the resident. During a follow up telephone interview, on 12/30/2021 at 3:30 PM, RD 1 stated that it was important to evaluate labs to help assess Resident 1's needs for healing process of his wound. RD 1 stated that she would evaluate the resident's [MEDICATION(S)] and total protein levels to determine if she needed to add supplemental liquid protein or additional protein to the resident's diet. RD 1 also stated that she would review the resident's medication regimen and recommend multivitamins (nutritional supplement), vitamin C (nutritional supplement involved in all phases of wound healing), and [MEDICATION(S)] (supplemental nutrition for growth and development of body tissues). A review of Resident 1's medical records indicated that the resident's last laboratory work was done on 12/3/2020 to check his hemoglobin A1C (a blood test that measures the average blood sugar levels over the past 3 months) level. There were no other laboratory results on file that showed the resident's level of [MEDICATION(S)] and total protein after 10/15/2020.