Every finding on record at Stanley Healthcare Center

Based on observation, interview, medical record review, facility P&P review, facility document review, and the California Code of Regulations review, the facility failed to ensure a staff member was onsite during the evening and night shift, who could provide the respiratory services to the residents, in accordance with the residents' plan of care. * For the past year, on the evening and night shift, the facility failed to ensure a staff member was on site at the facility, who could provide respiratory services to the residents with oxygen titration orders. These failures had the potential to result in negative health outcomes for the residents. Findings: Review of the California Code of Regulations, Title 16, Section 1399.365, showed the respiratory care services the LVNs may perform in the long-term care setting. The respiratory services LVNs may not perform included the initial setup, change out, or replacement of a breathing circuit or adjustment of the oxygen liter flow or oxygen concentration. Review of the 2026 Facility Assessment revised 3/19/26, showed the purpose of the Facility Assessment is to determine what resources are necessary to care for the residents competently during both day-to-day operations and emergencies. Utilization of the Facility Assessment is to make decisions about our direct care staff needs, as well as our capabilities to provide services to the residents in our facility. This is a competency-based approach and focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. Residents will be admitted to the facility as long as their nursing and medical needs can be met by the facility. When a resident has been admitted to the facility and whose care needs cannot be met, the resident's physician will be immediately notified in effort to receive and order for the resident to be transferred to a facility that can meet the needs, care, and services required. Review of the Facility Assessment resident profile showed the following resident respiratory system conditions/diseases which the facility can provide care for: COPD, pneumonia, asthma, chronic lung disease, and respiratory failure. The average number of the residents receiving oxygen therapy at the facility was six. The Facility Assessment included the facility's staffing plan. The staffing plan showed the facility maintains adequate staffing on each shift to ensure that the residents' needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. The facility staffing plan showed the number of RNs who are assigned to each shift. Day shift 1 (one) RN, evening shift 0 (zero) RNs, and night shift 0 (zero) RNs. Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed the purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation includes verification there is a physician's order for the procedure. Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident. Assemble oxygen equipment and supplies as needed. Oxygen therapy is administered by an oxygen mask, nasal cannula, and/or nasal catheter. A list of residents with active orders for the oxygen therapy was requested from the facility. Review of the Order Listing Report dated 4/6/26, showed 13 of 27 residents who resided at the facility had active orders for supplemental oxygen continuously and/or as needed. Residents 5 and 27 were included on the list and had orders for supplemental oxygen. 1. Medical record review for Resident 27 was initiated on 4/6/26. Resident 27 was admitted to the facility on [DATE]. Review of Resident 27's H&P examination dated 1/21/26, showed Resident 27 had a diagnosis of COPD and CHF. Resident 27's H&P showed he had the capacity to understand and make decisions. Review of Resident 27's active orders showed a physician's order dated 2/26/26, to monitor his oxygen saturation every shift and notify the physician if Resident 27's oxygen saturation was less than 92 percent. Resident 27 also had an order dated 2/26/26, for oxygen to be administered continuously at rate of two LPM (Fi02 28 percent) via nasal cannula for COPD. Additionally, Resident 27 had a physician's order dated 7/29/25, for BiPAP (FiO2 30 percent) at bedtime (at 2100 hours) which was to be removed in the morning (at 0600 hours). Review of Resident 27's Care Plan Report showed a care plan focus titled Ineffective Breathing Pattern related to acute and chronic respiratory failure, COPD, and dyspnea, initiated 7/6/25. The care plan interventions included monitoring Resident 27's oxygen saturation every shift, administering oxygen via nasal cannula at a rate of two LPM (Fi02 28 percent) as needed for shortness of breath and/or COPD exacerbation, and to apply BiPAP (Fi02 30 percent) at bedtime (at 2100 hours) for obstructive apnea. On 4/6/26 at 0820 hours, an observation and concurrent interview was conducted with Resident 27. Resident 27 was observed lying in his bed. Resident 27 was observed receiving continuous oxygen from an oxygen concentrator, at a rate of 2 LPM via nasal cannula. Resident 27 stated he received continuous oxygen for difficulty when breathing. A BiPAP machine was observed on top of Resident 27's bedside table. Resident 27 stated the nurse applied his BiPAP mask (with supplemental oxygen) every night at approximately 2100 hours and removed the BiPAP mask every morning at approximately 0600 hours. Resident 27 stated after the nurse removed his BiPAP mask in the morning, the nurse would then set up his oxygen concentrator to administer continuous oxygen at a rate of 2 LPM via nasal cannula. On 4/7/26 at 1512 hours, an interview, Facility Assessment review, and concurrent medical record review for Resident 27 was conducted with the DON. The DON verified the 2026 Facility Assessment showed the facility could provide respiratory services to the residents, in accordance with the physician's orders and the residents' plan of care. The DON verified the 2026 Facility Assessment was accurate specific to the RN staffing on the evening and night shift. The DON stated for the last year the facility did not have a RN assigned to work the evening or night shift at the facility. The DON stated LVNs were assigned to work the evening and night shift. The DON was asked what respiratory services LVNs could provide to the residents on the evening and night shift. The DON stated the LVNs could provide basic respiratory tasks and services and administer oxygen in emergent situations. The DON stated LVN basic respiratory tasks and services did not include the adjustment or titration of oxygen liter flow or oxygen concentration, in non-emergent situations. The DON verified on the evening and night shift, the facility did not have a nurse on site who could provide the respiratory services to the residents with oxygen titration orders. The DON then reviewed Resident 27's medical record. The DON verified Resident 27 had an active order for oxygen to be administered continuously by oxygen concentrator at rate of two LPM (Fi02 28 percent) via nasal cannula, for COPD. The DON stated the LVN assigned to the evening shift would remove Resident 27's continuous oxygen (administered by oxygen concentrator via nasal cannula) every evening at approximately 2100 hours, and then apply Resident 27's ordered BiPAP (FiO2 30 percent). The DON stated in the morning at approximately 0600 hours, the LVN would remove Resident 27's BiPAP and set up Resident 27's oxygen concentrator to administer continuous oxygen at a rate of 2 LPM via nasal cannula. The DON verified LVN basic respiratory tasks and services did not include the adjustment or titration of Resident 27's oxygen liter flow or oxygen concentration by the LVNs; however, the facility did not have an RN on site for the evening or night shift. 2. Medical record review for Resident 5 was initiated on 4/6/26. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's H&P examination dated 1/16/26, showed Resident 5 had a diagnosis of CHF. Review of Resident 5's active orders showed a physician's order dated 2/20/26, to monitor her oxygen saturation every shift for CHF. Additionally, Resident 5 had a physician's order dated 2/21/26, for oxygen to be administered continuously at rate of two LPM via nasal cannula, for CHF. Review of Resident 5's Care Plan Report showed a care plan focus titled Non-Compliant with Oxygen use, initiated 3/16/26. The care plan goals included Resident 5 will maintain an oxygen saturation greater than 90 percent. Care plan interventions included to monitor Resident 5's oxygen saturation level every shift and as needed. Review of Resident 5's Oxygen Saturation Summary showed the LVNs intermittently administered supplemental oxygen therapy to Resident 5. Examples included on 3/29/26 at 1524 hours, Resident 5's oxygen saturation was measured at 98 percent on room air. Then on 3/29/26 at 1758 hours, Resident 5 received oxygen via nasal cannula at a rate of 2 LPM and her oxygen saturation was measured at 98 percent. On 3/30/26 at 1420 hours, Resident 5's oxygen saturation was measured at 97 percent on room air. Then on 3/30/26 at 1854 hours, Resident 5 received oxygen via nasal cannula at a rate of 2 LPM and her oxygen saturation was measured at 97 percent. On 4/4/26 at 1406 hours, Resident 5's oxygen saturation was measured at 97 percent on room air. Then on 4/4/26 at 1922 hours, Resident 5 received oxygen via nasal cannula at a rate of 2 LPM and her oxygen saturation was measured at 97 percent. On 4/6/26 at 1335 hours, Resident 5's oxygen saturation was measured at 98 percent on room air. Then on 4/6/26 at 2336 hours, Resident 5 received oxygen via nasal cannula at a rate of 2 LPM and her oxygen saturation was measured at 96 percent. On 4/7/26 at 1520 hours, an interview and concurrent medical record review for Resident 5 was conducted with the DON. The DON verified Resident 5 had an active physician's order to monitor her oxygen saturation every shift and to administer oxygen continuously at rate of two LPM via nasal cannula, for CHF. The DON verified Resident 5's Oxygen Saturation Summary showed Resident 5 intermittently received supplemental oxygen therapy on the evening and night shift, throughout the months of March and April 2026. The DON stated Resident 5 would fluctuate between compliance and noncompliance with her continuous oxygen order. The DON verified the LVN basic respiratory tasks and services did not include the adjustment or titration of Resident 5's oxygen liter flow or oxygen concentration by LVNs; however, the facility did not have an RN on site for the evening or night shift.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen for 27 of 27 residents who consumed food prepared in the kitchen. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * Unlabeled and undated white powder was observed stored inside a plastic measuring cup on the countertop shelf. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the food prepared in the facility's kitchen.Findings: Review of the facility's Diet Type Report dated 4/7/26, showed 27 of 27 residents consumed the food prepared in the kitchen. 1. Review of the facility's P&P titled Hoods, Filters, and Vents dated 2023 showed the hoods must be cleaned every two weeks and must be free of dust and grease. According to the USDA Food Code 2022 Section 4-204.11 Ventilation Hood Systems, Drip Prevention, the dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean. On 4/6/26 at 0806 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with [NAME] 1. The kitchen hood over the stove had black, dirt residue. [NAME] 1 acknowledged the findings and stated the evening [NAME] cleaned the hood once a week on Wednesdays and the hood was also cleaned by an outside company. The sticker on the hood showed it was last serviced on 10/27/25. 2. Review of the facility's P&P titled Sanitation dated 2023 showed all the utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. Plastic ware, china, and glassware that becomes unsightly, unsanitary, or hazardous because of chips, cracks, or loss of glaze shall be discarded. Plastic ware is bleached as necessary to prevent staining. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 4/6/26 at 0806 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with [NAME] 1. The following was observed and verified by [NAME] 1:- One stainless steel scoop with a blue handle had an uneven edge.- One stainless steel scoop with a black handle partially melted.- Two stainless steel slotted scoops with gray handles partially melted.- One stainless steel scoop with a dark gray handle partially cracked.- One stainless steel whisk with deformed shape.- One rubber spatula with a red handle had chipped, cracked edges, and discolored.- One stainless steel dough cutter deformed and bent at the edges.- One dark brown cutting board had sticky, white residue. 3. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2022, 4-602.13, Nonfood- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 4/6/26 at 0806 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with [NAME] 1. The following was observed and verified by [NAME] 1:- One stainless steel scoop with a blue handle had fuzzy films.- Two stainless steel scoops with black handles had fuzzy films.- One stainless steel scoop with a green handle had water marks and fuzzy films. - Four stainless steel scoops with dark gray handles had dry water marks and fuzzy films.- One stainless steel scoop with light gray handle had fuzzy films.- Two stainless steel spoons had fuzzy films.- One stainless steel slotted spoon had dry water marks.- One stainless steel spatula had dry water marks.- Two measuring cups had dry, crusted residue. 4. Review of the facility's P&P titled Sanitation dated 2023 showed separate chopping boards are to be used for preparing meats and vegetables. After each use, chopping boards shall be thoroughly cleaned and sanitized. According to the USDA Food Code 2022 Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. On 4/6/26 at 0806 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with [NAME] 1. The yellow and blue cutting boards were observed fuzzy, heavily marred, and had deep grooves. [NAME] 1 verified the findings. 5. According to the USDA Food Code 2017, Section 3-302.12, certain foods may be difficult to identify after they are removed from their original packaging. Consumers may be allergic to certain foods or ingredients. The mistaken use of an ingredient, when the consumer has specifically requested that it not be used, may result in severe medical consequences. The mistaken use of food from unlabeled containers could result in chemical poisoning. For example, foodborne illness and death have resulted from the use of unlabeled salt, instead of sugar, in infant formula and special dietary foods. Liquid foods, such as oils, and granular foods that may resemble cleaning compounds are also of particular concern. On 4/6/26 at 0806 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with [NAME] 1. An unlabeled and undated white powder was observed stored inside a plastic measuring cup on the countertop shelf. [NAME] 1 verified the findings and stated it was a food thickener, and it should have been labeled and dated. On 4/6/26 at 1529 hours, an interview was conducted with the DSS. The DSS acknowledged all the above findings and stated the following:- The hood over the stove was cleaned every six months by an outside company and the [NAME] cleans it every Wednesday. It should be kept clean and sanitary for infection control purposes and fire hazard.- All deformed and worn-out utensils should have been discarded and replaced for sanitation and infection control purposes.- The chipped spatula should not be used because particles could fall and mix in to the food.- All the dirty with dry crusted residue utensils should have been rewashed and sanitized for infection control purposes. - The cutting boards should have been replaced to prevent bacteria growth when not properly washed.-The food thickener should have been labeled and dated.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to implement their infection control program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program for the months of May 2025 through February 2026. The facility conducted surveillance of the resident's infections only when the residents were prescribed antimicrobial medications and/or if the residents were diagnosed with an infection. The facility failed to determine whether the residents who exhibited the signs and symptoms of infection and were not prescribed antimicrobial medications met the facility's criteria for infection (utilizing McGeer's Criteria). The facility failed to include these residents in the facility's infection control surveillance program. * The facility failed to ensure the clean laundry sorting table remained free from the staff's personal items. The laundry staff's purse and jacket were observed lying on the clean laundry sorting table. * The facility failed to ensure Resident 24's urinal was not stored on top of his overbed table adjacent to his water pitcher. These failures posed the risk for not preventing and identifying the residents infections and controlling the potential transmission of communicable diseases to other residents, staff, and visitors throughout the facility.Findings: 1. Review of the facility's P&P titled Surveillance for Infections revised 9/2017 showed the Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and HAIs, to guide appropriate interventions, and prevent future infections. The criteria for such infections are based on the current standard definitions of infections. The Nursing Staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infections. The Infection Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. Using the current suggested criteria for HAIs, determine if the resident has a HAI. For targeted surveillance collect information monthly from individual resident infection reports and enter line listing of infections by resident for the entire month. Summarize monthly data for each nursing unit by site and by pathogens. On 4/9/26 at 0842 hours, an interview and concurrent facility document review was conducted with the IP. The IP was asked to explain the facility's infection surveillance program specific to the residents. The IP stated when a resident exhibited signs and/or symptoms of infection and was prescribed an antimicrobial medication, or was diagnosed with an infection, she would then determine if the resident met the McGeer's Criteria. The IP stated the McGeer's Criteria was utilized to determine if a resident had a true infection. Review of the facility's Infection Surveillance Monthly Reports from May 2025 through February 2026 showed the following infection surveillance data for HAIs, CAIs, and residents who did not meet the McGeer's Criteria (DNMC): -5/2025: HAI - 7, CAI – 2, and DNMC - 0 -6/2025: HAI - 1, CAI – 0, and DNMC - 0 -7/2025: HAI – 4, CAI – 5, and DNMC - 0 -8/2025: HAI - 4, CAI – 1, and DNMC - 0 -9/2025: HAI - 0, CAI – 2, and DNMC - 0 -10/2025: HAI - 3, CAI – 7, and DNMC - 0 -11/2025: HAI -3, CAI –1, and DNMC –0 -12/2025: HAI - 5, CAI – 1, and DNMC - 0 -1/2026: HAI - 4, CAI –4, and DNMC - 0 -2/2026: HAI - 7, CAI – 0, and DNMC – 0 Further review of the facility's Infection Surveillance Monthly Reports from May 2025 through February 2026 showed documentation that all the residents included in the facility's infection surveillance program were determined to have either a HAI or CAI (with prescribed antimicrobial medications or having been diagnosed with an infection). The Infection Prevention and Control Surveillance logs failed to show any residents who did not meet the McGeer's criteria. The IP verified between the months of May 2025 through February 2026 no resident in the facility was classified as having not met the McGeer's Criteria. The IP was asked when a resident at the facility exhibited signs and/or symptoms of infection and was not prescribed antimicrobial medications (or was not diagnosed with an infection) if the facility initiated the McGeer's criteria form and included these residents in the facility's infection surveillance program. The IP stated the facility did not initiate the McGeer's criteria form for residents who exhibited signs and/or symptoms of infection and were not prescribed antimicrobial medications (or were not diagnosed with an infection). The IP was asked how many residents had met McGeer's criteria and were not prescribed antimicrobial medications, from May 2025 through February 2026 (excluding residents who were diagnosed with an infection). The IP stated she was uncertain, as the facility did not initiate the McGeer's criteria form for the residents who exhibited signs and/or symptoms of infections and were not prescribed antimicrobial medications (or had not been diagnosed with an infection). 2. Review of the facility's P&P titled Laundry and Linen revised 2014 showed to separate soiled and clean linen at all times. Keep soiled and clean linen separate at all times. On 4/8/26 at 1503 hours, an observation and concurrent interview was conducted with Housekeeper 1. An observation of the facility's laundry room was conducted with Housekeeper 1. The counter designated for clean laundry sorting was observed with Housekeeper 1's purse and jacket lying on the countertop, adjacent to clean linens. Housekeeper 1 verified the findings and stated the staff personal items should not be stored on the clean laundry sorting counter adjacent to clean linens, for infection control. 3. Medical record review for Resident 24 was initiated on 4/6/26. Resident 24 was admitted to the facility on [DATE]. Review of Resident 24's H&P examination dated 2/18/26, showed the resident had the capacity to understand and make decisions. On 4/6/26 at 0832 hours, during the initial tour of the facility, Resident 24 was observed awake, lying in the bed. The overbed table was observed with urinals with urine and adjacent to Resident 24 water pitcher. Resident 24 stated that he was waiting for the CNA to empty the urinals. On 4/6/26 at 0842 hours, an observation and concurrent interview for Resident 24 was conducted with CNA 1. CNA 1 stated the urinals should not be on the overbed table where the clean water pitcher was, to prevent infection. On 4/9/26 at 0957 hours, an interview was conducted with the DON. The DON was asked about the process where the urinals should be placed. The DON stated it was not supposed to be on top of the overbed table, and needed to be placed at the side of the overbed table to prevent infection and for sanitary purposes. The DON verified the above findings. On 4/9/26 at 1039 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, and facility P&P review, the facility failed to ensure the garbage was properly stored in one of one garbage dumpster. This failure had the potential to attract pests and rodents that carry diseases.Findings: Review of the facility's P&P titled Miscellaneous Areas, Garbage and Trash dated 2023 showed the garbage and trash cans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed. According to the 2022 FDA Food Code, the outside garbage receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. On 4/6/26 at 0740 hours, an observation of the facility's one outside garbage dumpster was conducted. The garbage dumpster was observed with the lid partially propped open by the garbage bags, preventing the lid from fully closing. On 4/6/26 at 1529 hours, an interview was conducted with the DSS. The DSS was shown a photograph of the dumpster taken on 4/6/26 at 0740 hours. The DSS verified the above findings and stated the dumpster lid should be fully closed at all times, to prevent rodents from entering or exiting the trash and for infection control purposes.

Based on interview and medical record review, the facility failed to ensure the PASRR Level 1 Screening (identifies if a resident has a suspected mental illness or intellectual/developmental disability or related condition) contained accurate information specific to mental illness, for one of two residents (Resident 4) reviewed for PASRR. *Resident 4 had a diagnosis of bipolar disorder; however, the PASRR Level 1 Screening showed Resident 4 had no diagnosed mental illness. This failure had the potential for Resident 4 not to receive a PASRR Level II Mental Health Evaluation (determines if the resident can benefit from specialized mental health services), which posed the risk for Resident 4 not obtaining recommendations for specialized services to address the resident's mental health needs.Findings: Medical record review for Resident 4 was initiated on 4/6/26. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's PASRR Level 1 Screening results dated 1/13/25, showed Resident 4 had no diagnosed serious mental illness. Review of Resident 4's Neuropsychiatric assessment dated [DATE], showed Resident 4 had a diagnosis of bipolar disorder and PTSD. On 4/7/26 at 1013 hours, an interview and concurrent medical record review for Resident 4 was conducted with the DON. The DON reviewed Resident 4's medical record and verified Resident 4's PASRR Level I Screening dated 1/13/25, showed Resident 4 had no diagnosed serious mental illness. The DON verified this information was incorrect as Resident 4 had a diagnosis of bipolar disorder and PTSD. The DON stated the PASRR Level 1 Screening needed to contain accurate information, to ensure a Level II mental health evaluation was conducted if needed, which was performed to determine if a resident would benefit from specialized mental health services.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the required physician visits were done timely for one of 13 final sampled residents (Resident 15). * The facility failed to ensure Resident 15 was visited by the physician every 60 days. This failure had the potential to result in an undetected decline in medical, health, or psychosocial condition and can lead to a delay in the necessary care, treatment, and services.Findings: 1. Review of the facility's P&P titled Physician Visits revised 4/2013 showed the attending physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. After the first ninety (90) days, if the attending physician determines that a resident need not be seen by him/her every thirty (30) days, an alternate schedule of visits maybe established, but not to exceed every sixty (60) days. A physician assistant or nurse practitioner may make alternate visits after the initial ninety (90) days following admission, unless restricted by law or regulation. Medical record review for Resident 15 was initiated on 4/6/26. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's MDS quarterly assessment dated [DATE], showed Resident 15 had a BIMS (Brief Interview for Mental Status) score of 3 (which meant severe cognitive impairment). Review of Resident 15's Physician Visit Notes failed to show documented evidence the required physician's visits were made between January to April 2026. On 4/9/26 at 0957 hours, an interview and concurrent medical record review for Resident 15 was conducted with the DON. The DON verified the last face to face documented physician visit for Resident 15 was on 12/30/25. The DON further stated that there should be a monthly visit from the physician. On 4/9/26 at 1039 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 8%. One of three licensed nurses (LVN 2) was found to have made errors during the medication administration to one final sampled resident (Resident 4). * LVN 2 failed to administer the cholecalciferol (supplement) and fluticasone (medication to treat allergies) medications as ordered for Resident 4 due to the unavailability of the medications. These failures had the potential to negatively affect the residents' health conditions and posed the risk of possible complications or delays in interventions. Findings: Review of the facility's P&P titled Administering Medications revised April 2019 showed the medications are administered in a safe and timely manner and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. 1. On 4/7/26 at 0834 hours, a medication administration observation for Resident 4 was conducted with LVN 2. LVN 2 prepared and administered the following medications to Resident 4:- one tablet of Abilify (antipsychotic medication) 20 mg- one tablet of docusate sodium (stool softener) 100 mg- one tablet of finasteride (medication to treat enlarged prostate gland causing difficulty urinating) 5 mg- one tablet of vitamin B-12 (supplement) 500 mcg- two tablet of Keppra (medication to treat seizures)1000mg (total 2000 mg)- one tablet of potassium chloride (supplement) 20 mEq- one tablet of lacosamide (medication to treat seizures)100 mg- clear lax (a stool softener to relieve occasional constipation) 17 grams with 6 oz. of water- Refresh liquigel (used to relieve dry eyes) Medical record review for Resident 4 was initiated on 4/6/26. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's Order Summary Report showed the following physician's order:- dated 7/13/25, to administer cholecalciferol 125 mcg (5000 unit) one tablet by mouth one time a day for supplement - dated 7/13/25, to administer fluticasone nasal spray 50 mcg one spray in both nostrils twice a day for allergy On 4/7/26 at 0923 hours, an interview and concurrent medical record review for Resident 4 was conducted with LVN 2. LVN 2 verified there were no available supplies of the cholecalciferol and fluticasone medications for Resident 4 to be given during the medication administration. On 4/9/26 at 0957 hours, an interview was conducted with the DON. The DON stated during the administration of medications, if the medication was not available in the medication cart, the licensed nurses were expected to follow up with the central supply/pharmacy to obtain the medication and administer the medication as soon as possible. The DON further stated if the medication was held, she expected the licensed nurse to inform the physician and document in the progress notes the reason the medication was held. On 4/9/26 at 1039 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility document review, the facility failed to follow up the MRR recommendation for one of five sampled residents (Resident 6) reviewed for unnecessary medications. * The facility failed to implement the pharmacy recommendations approved by physician to change the ibandronate (medication to prevent bone weakening) administration time for Resident 6. This failure placed Resident 6 at an increased risk for developing preventable adverse effects of the medication. Findings: Medical record review for Resident 6 was initiated on 4/6/26. Resident 6 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 6's H&P examination dated 10/26/25, showed the resident had no capacity to understand and make decisions. Review of Resident 6 's Order Summary Report showed the following physician order dated 10/26/25, may administer ibandronate 150 mg one tablet once a month on every 28th day of the month, give with eight ounces of water and have the resident remain in an upright position for at least one hour after administration. Review of Resident 6's MAR for March 2026 showed the ibandronate 150 mg medication was given on 3/28/26 at 0600 hours. Review of Resident 6's MRR for March 2026 showed a recommendation from the pharmacy consultant to change the ibandronate administration time at 0600 hours to 0500 hours. On 4/9/26 at 0913 hours, an interview and concurrent medical record review for Resident 6 was conducted with the DON. The DON verified the recommendation of the pharmacy consultant was not followed and stated she missed the recommendation. On 4/9/26 at 1430 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, and facility P&P, the facility failed to provide the necessary pharmacy services to ensure the proper storage of medications for one of three medication carts (Medication Cart 1) inspected. * The facility failed to ensure the treatment supplies were stored properly. This failure had the potential to alter the efficacy of the stored treatment supplies and pose the risk of infection to the residents.Findings: Review of the facility's P&P titled Storage of Medication Labeling and Storage revised 2/2023 showed the nursing staff is responsible for maintaining the storage and preparation areas in a clean, safe and sanitary manner. On 4/6/25 at 1046 hours, an observation of Medication Cart A and concurrent interview was conducted with the DON. The following was observed:- one individual pack of sterile gauze bandage roll open with package's description showed it contained sterile in unopened, undamaged package.- three individual pack open Medi strip reinforced wound closure, with package's description showed it was a single use only dressing. During the observation and concurrent interview with the DON, the DON was asked about the process of opening an individual pack supply. The DON stated the individual pack was a single use only and needed to discard all open and unused pouches to maintain the individual package was sterile. The DON verified the above findings. On 4/9/26 at 1039 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete and accurately documented for four of 13 final sampled residents (Residents 2, 6, 8, and 11). * The facility failed to ensure the safety assessment for siderails usage for Residents 2, 6, and 11 were accurate in accordance with the physician's orders. * The facility failed to ensure Resident 6's informed consent for buspirone (medication to treat anxiety), and citalopram (medication to treat depression) were maintained in the residents' medical record. * The facility failed to ensure Resident 8's blood pressure access site was accurately documented in the medical record. * The facility failed to ensure Section D of Resident 11's POLST (Physician Orders for Life-Sustaining Treatment) was signed and dated by the physician. These failures have the potential for the residents care needs not being met as their medical information were inaccurate and incomplete.Findings: 1. Review of the facility's P&P titled Hemodialysis Access Care revised 9/2010 showed the hemodialysis devices may only be accessed by medical personnel who have received training and demonstrated clinical competency regarding the use of these devices. To prevent infection and/or clotting, do not use the access arm to take blood pressure. Medical record review for Resident 8 was initiated on 4/6/26. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's Order Summary Report showed the following physician order dated 7/13/24, dialysis site left arm shunt. Review of Resident 8's care plan problem for hemodialysis related to renal failure dated 11/7/24, showed interventions including to not draw blood or take blood pressure on the left arm. Review of Resident 8's H&P examination dated 6/15/25, showed the resident had the capacity to understand and make decisions. Review of Resident 8's documentation of blood pressure for March and April 2026 showed the following:- on 3/8/26 at 1711 hours, a blood pressure reading of 128/64 mmHg on the left arm;- on 3/9/26 at 1722 hours, a blood pressure reading of 121/72 mmHg on the left arm;- on 3/11/26 at 1028 hours, a blood pressure reading of 120/70 mmHg on the left arm;- on 3/23/26 at 1906 hours, a blood pressure reading of 130/66 mmHg on the left arm;- on 3/27/26 at 1707 hours, a blood pressure reading of 132/71 mmHg on the left arm;- on 3/29/26 at 1115 hours, a blood pressure reading of 132/68 mmHg on the left arm; and- on 4/2/26 at 1700 hours, a blood pressure reading of 128/78 mmHg on the left arm. On 4/6/26 at 0838 hours, during the initial tour of the facility, Resident 8 was observed awake, lying in bed, with AV shunt noted on the left arm. Resident 8 stated he went to dialysis every Tuesday and Saturday. On 4/9/26 at 0848 hours, an interview was conducted with Resident 8. Resident 8 stated he never allowed the licensed nurses to take his BP on the left upper arm. On 4/9/26 at 0957 hours, an interview and concurrent medical record review for Resident 8 was conducted with the DON. The DON verified the BPs were not taken on Resident 8's left arm and the documentation for the BP readings for March and April 2026 were inaccurate. The DON further stated taking the BP on the access site will increase the resident's risk for infection and blood clot to the left AV shunt. On 4/9/26 at 1039 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 2. Review of the facility's P&P titled Psychotropic Medication Use revised 7/2023 showed the signed informed consent must be placed in the resident's chart. Medical record review for Resident 6 was initiated on 4/6/26. Resident 6 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 6's H&P examination dated 10/26/25, showed the resident does not have the capacity to understand and make decisions. Review of Resident 6's Order Summary Report dated 4/9/26, showed the following physician's orders:- dated 2/2/26, to administer citalopram 10 mg to give one tablet every morning and at bedtime for depression manifested by crying and sad facial features; and- dated 2/27/26, to administer buspirone 15 mg to give one tablet two times a day for anxiety manifested by persistent screaming. Further review of Resident 6's medical record failed to show documented evidence a copy of the informed consent for the buspirone and citalopram medications were placed in the resident's chart. On 4/8/26 at 1349 hours, an interview and concurrent medical record review for Resident 6 was conducted with the DON. The DON verified the informed consents for the buspirone and citalopram medications were not accessible in Resident 6's medical record. (Cross reference F552) 3. Medical record review for Resident 11 was initiated on 4/6/26. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's POLST dated 8/7/25, showed under Section D-Information and Signatures, the signature of the physician and date were left blank. Review of Resident 11's H&P examination dated 4/2/26, showed Resident 11 had the capacity to understand and make decisions. On 4/9/26 at 1054 hours, an interview and concurrent medical record review for Resident 11 was conducted with DON. The DON verified the signature of the physician and date were blank on the POLST form. The DON further stated the physician should have signed and dated the POLST. 4. Review of the facility's P&P titled Proper Use of Side Rails revised 12/2016 showed the purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. a. Medical record review for Resident 2 was initiated on 4/6/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's MDS quarterly assessment dated [DATE], showed Resident 2 had a BIMS score of 15 (which meant cognitively intact). Review of Resident 2's Safety Assessment for Side rail usage dated 4/1/26, showed an assessment for the one-fourth side rail. Review of Resident 2's Order Summary Report showed a physician's order dated 4/3/26, for may have bilateral one-half side rails up while in bed for mobility and repositioning. On 4/6/26 at 0911 hours, during the initial tour of the facility, Resident 2 was observed lying in bed. The bilateral one-half side rails in bed were not elevated. On 4/8/26 at 1542 hours, an interview and concurrent medical record review for Resident 2 was conducted with the DON. The DON verified the above findings. b. Medical record review for Resident 6 was initiated on 4/6/26. Resident 6 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 6's H&P examination dated 10/26/25, showed the resident had no capacity to understand and make decisions. Review of Resident 6's Safety Assessment for Side rail usage dated 4/1/26 showed an assessment for one-fourth side rail. Review of Resident 6's Order Summary Report showed a physician's order dated 4/6/26, for may have bilateral one-half side rails up while in bed for mobility and repositioning. On 4/6/26 at 0911 hours, during the initial tour of the facility, Resident 6 was observed lying in bed with bilateral one-half elevated. On 4/8/26 at 1349 hours, an interview and concurrent medical record review for Resident 6 was conducted with the DON. The DON verified the above findings. c. Medical record review for Resident 11 was initiated on 4/6/26. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's H&P examination dated 10/26/25, showed the resident had no capacity to understand and make decisions. Review of Resident 11's Safety Assessment for Side rail usage dated 4/1/26 showed an assessment for the one-fourth side rail. Review of Resident 11's Order Summary Report showed a physician's order dated 4/3/26, for may have bilateral one-half side rails up while in bed for mobility and repositioning. On 4/6/26 at 0923 hours, during the initial tour of the facility, Resident 11 was observed lying in bed with bilateral one-half elevated. On 4/9/26 at 1054 hours, an interview and concurrent medical record review for Resident 6 was conducted with the DON. The DON verified the above findings. On 4/9/26 at 1430 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the informed consent was obtained for the use of the bilateral side rails and psychotropic medications for one of five final sampled residents (Residents 6) reviewed for unnecessary medications. * The facility failed to obtain an informed consent for Resident 6's use of the lorazepam (medication to treat anxiety), buspirone (medication to treat anxiety), and bilateral side rail use. In addition, the facility failed to update the informed consent for citalopram (medication to treat depression) when the medication was increased for Resident 6. These failures had the potential for Resident 6 to be unaware of the risks associated with the use of psychotropic medications and bilateral side rails which could negatively affect the resident's well-being.Findings: Review of the facility's P&P titled Psychotropic Medication Use revised 7/2023 showed anytime new orders are received that results in a material change in circumstances or risk, a new informed consent is required. All informed consent verifications must be in writing prior to initiation of the treatment or procedure. Acceptable forms are:a. The facility Verification of Informed Consent Form completed and sign by the prescribing physician.b. A written, signed statement from the ordering healthcare practitioner stating that informed consent was obtained and who it was obtained from.The signed Informed consent must be placed in the resident's chart. Review of the facility's P&P titled Proper Use of Side Rails revised 12/2016 showed the purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptom. Consent for side rails use will be obtained from the resident or legal representative after presenting potential benefits and risks. Medical record review for Resident 6 was initiated on 4/6/26. Resident 6 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 6's H&P examination dated 10/26/25, showed the resident had no capacity to understand and make decisions. Review of Resident 6's Order Summary Report dated 4/9/26, showed the following physician's orders:- dated 10/31/25, to administer lorazepam 0.5 mg to give one tablet every Tuesday and Friday for anxiety manifested by aggression on shower days;- dated 2/2/26, to administer citalopram 10 mg to give one tablet every morning and at bedtime for depression manifested by crying and sad facial features;- dated 2/27/26, to administer buspirone 15 mg to give one tablet two times a day for anxiety manifested by persistent screaming; and- dated 4/6/26, for may have bilateral one half siderails up while in bed for mobility and repositioning. a. Review of Resident 6's medical record failed to show informed consents for buspirone and lorazepam medications, and bilateral one-half siderails were obtained. b. Further review of Resident 6's medical record failed to show an informed consent was obtained when the citalopram medication was increased from citalopram 10 mg one time a daily to citalopram 10 mg every morning and at bedtime. On 4/6/26 at 0930 hours, during the initial tour of the facility. Resident 6 was observed lying in bed with the bilateral one- half siderails elevated. On 4/8/26 at 1106 hours, an interview and concurrent interview for Resident 6 was conducted with CNA 1. CNA 1 stated Resident 6 used the side rails to hold during diaper changes. On 4/8/26 at 1349 hours, an interview and concurrent medical record review for Resident 6 was conducted with the DON. The DON verified the informed consents for the lorazepam buspirone medications and bilateral one-half side rails were not obtained. The DON stated the informed consent should have being obtained to inform the risk of the use of the psychotropic medications and bilateral one-half rails. The DON verified all the above findings. On 4/9/26 at 1430 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Residents 3) reviewed for unnecessary psychotropic medications was free from unnecessary psychotropic drugs. * The facility failed to monitor Resident 3's orthostatic (a sudden drop in blood pressure upon standing, defined as a reduction of greater than or equal to 20 mmHg systolic or 10 mmHg diastolic within three minutes of standing which may cause dizziness, lightheadedness, and fainting) blood pressure related to the use of the quetiapine (antipsychotic medication). In addition, the facility failed to document what nonpharmacological interventions were attempted when Resident 3 had episodes of bizarre delusions related to the use of the quetiapine medication. This failure had the potential for Resident 3 to have adverse complications from the medication and to not provide accurate data to the prescriber in determining the dose adjustments of the psychotropic medications for the resident. Findings: Review of the facility's P&P titled Psychotropic Medication Use revised 7/2022 showed the residents will not receive medications that are not clinically indicated to treat a specific condition. Nonpharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medication when possible. Residents receiving psychotropic medications are monitored for adverse consequences, including; cardiovascular effect - irregular heart rate or pulse, palpitations, lightheadedness, shortness of breath, diaphoresis, chest/arm pain, increased blood pressure, and orthostatic hypotension. 1. Medical record review for Resident 3 was initiated on 4/6/26. Resident 3 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 3's care plan problem for the use of the psychotropic medications quetiapine related to schizoaffective disorder dated 2/4/25, showed interventions included to monitor for orthostatic hypotension - monitor blood pressure while lying and sitting. Notify MD if there's a drop of 20 mmHg or more in the SBP; 10 mmHg on DBP every Monday day shift. Review of Resident 3's Order Summary Report showed the following physician's orders:- dated 10/31/25, to monitor nonpharmacological interventions for anti-psychotic medication: 1) Offer to talk with the resident and redirect the resident with a calm and reassuring conversation.2) Assist the resident to identify triggers/measures that relieve fear and to set goals. every shift - dated 2/18/26, to administer quetiapine 100 mg medication by mouth, in the morning for schizoaffective disorder as manifested by bizarre delusions.- dated 2/18/26, to administer quetiapine 200 mg medication by mouth, in the evening for schizoaffective disorder as manifested by bizarre delusions. Review of Resident 3's MDS quarterly assessment 1/10/26, showed Resident 3 with a BIMS score of 14, which meant cognitively intact. Review of Resident 3's MARs for March and April 2026 failed to show Resident 3's orthostatic blood pressure in the lying and sitting position were monitored. Further review of Resident 3's medical record failed to show what nonpharmacological interventions were attempted when Resident 3 had episodes of bizarre delusions on the following dates and times:-dated 4/2/26, day shift - two episodes; -dated 4/3/26, day shift - two episodes;-dated 4/4/26, day shift - two episodes;-dated 4/4/26, evening shift - one episode;-dated 4/5/26, evening shift - one episode;-dated 4/6/26, evening shift - one episode; and-dated 4/7/26, day shift - two episodes On 4/7/26 at 1355 hours, an interview and concurrent medical record review for Resident 3 was conducted with the DON. The DON stated the reading for orthostatic hypotension should have systolic and diastolic blood pressure reading for the lying and sitting position to monitor the side effects of the medication, where the drop in the resident's blood pressure may cause dizziness, fainting and potential fall. The DON verified the above findings and further stated the licensed nurse should have documented what nonpharmacological interventions were used to be effective. On 4/9/26 at 1039 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the availability of the prescribed medications for one of five sampled residents (Resident 5) reviewed for unnecessary medications. * Resident 5 had a physician's order for Cobenfy (psychotherapeutic medication). The licensed nurse was unable to administer the evening dose of Cobenfy on two consecutive days, due to the unavailability of the medication. This failure posed the risk for inhibiting the therapeutic effects of the medication.Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed the medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with the prescriber orders, including any required time frame. Medical record review for Resident 5 was initiated on 4/6/26. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's Order Summary Report showed a physician's order dated 2/20/26, to administer Cobenfy 100-20 mg capsule orally two times a day (at 0900 and 1700 hours) for schizophrenia manifested by bizarre delusions. Review of Resident 5's MAR dated 3/2026 showed documentation that the licensed nurse failed to administer Resident 5's Cobenfy 100-20 mg capsule orally on 3/28 and 3/29/26, at 1700 hours. Review of Resident 5's Administration note dated 3/28/26 at 1827 hours, showed Resident 5's Cobenfy 100-20 mg capsule was not administered on 3/28/26 at 1700 hours, due to the unavailability of the medication. Resident 5's physician and the pharmacy were informed. Review of Resident 5's Administration note dated 3/29/26 at 1753 hours, showed Resident 5's Cobenfy 100-20 mg capsule was not administered on 3/29/26 at 1700 hours, due to the unavailability of the medication. Further review of the documentation showed as per the pharmacy, Resident 5's medication was on order. On 4/7/26 at 1408 hours, an interview and concurrent medical record review for Resident 5 was conducted with the DON. The DON verified Resident 5 did not receive her Cobenfy 100-20 mg oral capsule on 3/28 and 3/29/26 at 1700 hours, in accordance with the physician's order. The DON stated her expectation was the pharmacy should ensure Resident 5's Cobenfy was available to be administered, in accordance with the physician' s order. The DON stated administering the Cobenfy medication as ordered by the physician was important to ensure effective management of Resident 5's symptoms associated with schizophrenia.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of four final sampled residents (Residents 2 and 6) reviewed for the use of side rails remained free from the accident hazards associated with the use of the elevated side rails. * The facility failed to ensure the side rails assessment was accurate or completed, and/or the least restrictive measures were provided prior to the use of the side rails for Residents 2 and 6. These failures had the potential to put the residents at risk for entrapment and serious injuries. Findings: Review of the facility's P&P titled Proper Use of Side Rails revised 12/2016 showed the purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptom. When side rails usage is appropriate, the facility will assess the space between the mattress and siderails to reduce the risks for entrapment (the amount of space may vary, depending on the type of bed and mattress being used. - Less restrictive intervention that will be incorporated in the care planning include:a. Providing restorative care to enhance abilities to stand safely and to walk;b. Providing trapeze to increase bed mobility;c. Placing the bed lower to the floor and surrounding the bed with a soft mat;d. Equipping the resident with a device that monitors attempts to arise;e. Providing staff monitoring at night with periodic assisted toileting for residents attempting to arise to use the bathroom; and/[NAME]. Furnishing visual and verbal reminders to use the call bell for residents who can comprehend this information.- Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of siderails. 1. Medical record review for Resident 2 was initiated on 4/6/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Bed Rail assessment dated [DATE], failed to show an assessment which showed the reason Resident 2 needed siderails, and least restrictive interventions were tried prior to the use of side rails. Review of Resident 2's MDS quarterly assessment dated [DATE], showed Resident 2 had a BIMS score of 15 (which meant cognitively intact). Review of Resident 2's Order Summary Report showed a physician's order dated 4/3/26, for may have bilateral one-half side rails up while in bed for mobility and repositioning. On 4/6/26 at 0921 hours, during the initial tour of the facility, Resident 2 was observed lying in bed. The bilateral one-half siderails in bed were not elevated. On 4/8/26 at 1542 hours, an interview and concurrent medical record review for Resident 2 was conducted with the DON. The DON verified the above findings and stated an assessment for least restrictive interventions should have been tried prior to the use of the side rails. 2. Medical record review for Resident 6 was initiated on 4/6/26. Resident 6 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 6's Bed Rail assessment dated [DATE], failed to show an assessment to show the reason Resident 6 needed siderails, and the least restrictive interventions were tried prior to the use of the side rails. Review of Resident 6's H&P examination dated 10/26/25, showed the resident had no capacity to understand and make decisions. Review of Resident 6's Order Summary Report showed a physician's order dated 4/6/26, for may have bilateral one-half side rails up while in bed for mobility and repositioning. On 4/6/26 at 0911 hours, during the initial tour of the facility, Resident 6 was observed lying in bed with bilateral one-half side rails elevated. On 4/8/26 at 1349 hours, an interview and concurrent medical record review for Resident 6 was conducted with the DON. The DON verified the above findings and stated an assessment for the least restrictive interventions should have been tried prior to the use of the side rails. On 4/9/26 at 1430 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, and medical record review, the facility failed to ensure the appropriate dialysis (a life-sustaining treatment for kidney failure that filters waste and excess fluids from the blood) care was provided for one of 13 final sampled residents (Residents 8) who was receiving dialysis services. * The facility failed to ensure a dialysis emergency kit was available at the bedside for Resident 8. This failure had the potential for the resident to experience medical complications.Findings: 1. Medical record review for Resident 8 was initiated on 4/6/26. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's Order Summary Report showed a physician's order dated 7/13/24, to check the dialysis site for bleeding and signs or symptoms of infection every shift. Review of Resident 8's Order Summary Report showed a physician's order dated 7/13/24, for left arm AV shunt (a direct connection between an artery and a vein, often surgically created in the arm for hemodialysis) dialysis site. Review of Resident 8's H&P examination dated 6/15/25, showed Resident 8 had the capacity to understand and make decisions. On 4/6/26 at 0838 hours, during the initial tour of the facility, Resident 8 was observed awake, lying in the bed with left arm AV shunt. Resident 8 stated he went to the dialysis every Tuesday and Saturday. Further observation of Resident 8's room failed to show a dialysis emergency kit was available at the resident's bedside. On 4/6/25 at 1001 hours, an interview was conducted with LVN 1. LVN 1 verified the above findings and stated the dialysis emergency kit was needed to be available to use when there was bleeding at Resident 8's dialysis site. On 4/9/25 at 0957 hours, an interview was conducted with the DON. The DON stated the resident who had dialysis should always be checked for bleeding at the dialysis access site. The DON further stated the dialysis emergency kit was important to always be available and accessible in the resident's room for any complications observed in the dialysis access site. The DON was informed and acknowledged the above findings. On 4/9/26 at 1039 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure one of 13 final sampled residents (Resident 8) attained and maintained their highest practicable physical well-being. * The facility failed to apply the foot cradle for Resident 8 in accordance with the physician's order. This failure had the potential for delays in providing the necessary care and services for Resident 8.Findings: 1. Medical record review for Resident 8 was initiated on 4/6/26. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's Order Summary Report showed a physician's order dated 7/13/24, for may have foot cradle in bed to prevent skin breakdown. Review of Resident 8's H&P examination dated 6/15/25, showed the resident had the capacity to understand and make decisions. On 4/6/26 at 0838 hours, during the initial tour of the facility, Resident 8 was observed awake, lying in the bed. Further observation of Resident 8's room failed to show a foot cradle in bed. On 4/9/26 at 0858 hours, an observation and concurrent interview for Resident 8 was conducted with CNA 2. CNA 2 verified there was no foot cradle attached to the bed for Resident 8. On 4/9/26 at 0859 hours, an interview and concurrent medical record review for Resident 8 was conducted with the DON. The DON verified the above findings. The DON stated the foot cradle was used to prevent skin breakdown for Resident 8. On 4/9/26 at 1039 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, and facility document review, the facility failed to ensure the daily nursing PPD was posted with an accurate information. * The facility failed to update the daily nursing PPD with the correct date, staffing data, and census. This failure had the potential for the residents and visitors to not be informed about the facility's staffing.Findings: On 4/7/26 at 0940 hours, an observation was conducted of the daily nursing PPD posting. Review of the facility's daily nursing PPD showed a date of 3/31/26. Review of the facility's daily nursing PPD posted on the wall near the business office, failed to show the correct date, census, and staffing data. On 4/7/26 at 1005 hours, an interview was conducted with the DSD. The DSD stated the NOC or morning shift charge nurses were the staff responsible for removing the old projection and replacing it with their new projection each day. The DSD stated the daily nursing PPD posting was important due to having admissions and discharges often, and to ensure they were not over or understaffed. The DSD acknowledged and verified the above findings.

Based on interview, and facility document review, the facility failed to ensure an employee working as a CNA (a healthcare professional who provides basic resident care and support) at the facility held a valid and up-to-date license and met competency evaluation requirements for training. This failure had the potential to result in an unlicensed CNA providing direct care to the residents without proper the certification and training, and placing the residents' safety at risk.Findings:On 1/28/26, CDPH, L&C Program was forwarded a complaint from the CNA Misconduct, which showed CNA 1 picked up an afternoon shift on 1/26/26, at the facility. However, the person who showed up and claimed to be CNA 1 was male. The complainant alleged CNA 1 stole a TV out of the utility closet and left the scheduled shift. Upon further investigation by the facility, showed CNA 1 was a female individual and the male individual who showed up for the afternoon shift was unlicensed and working under CNA 1's license. On 2/4/26 at 1021 hours, an interview and facility document was conducted with the DON. Reviewed the facility's CDPH 530 (Nursing Staffing Assignment and Sign-in Sheet) form dated 1/26/26 with the DON, which showed CNA 1's time in and time out on 1/26/26. On 2/4/26 at 1456 hours, an interview was conducted with the DSD/IP. The DSD/IP stated her responsibilities included the verifying the employees' identity and license, conducting background check, providing orientations to the new facility staff, completing the schedule, conducting CNA audits, in-services, and administering vaccines. The DSD/IP stated on 1/26/26, CNA 1 from Registry Company 1 was scheduled to work for the evening shift (1500-2300 hours). When the evening shift started, the DSD/IP met the male individual, who presented to be CNA 1 and signed the assignment sheet. The DSD/IP stated she provided the facility orientation to CNA 1. The DSD/IP stated CNA 2 then provided a brief orientation to CNA 1 regarding the residents' care. The DSD/IP stated she did not check and/or verify CNA 1's identity using a government issued identification and their CNA license prior to or upon the start of the shift. In addition, the DSD/IP stated on 1/26/26 around 2200 hours, she received a message from LVN 1 informing her about CNA 1 leaving the facility with a television from the utility room and without a notice. Furthermore, the DSD/IP stated she was responsible for checking and verifying the identity and license of the unidentified male individual from Registry Company 1. The DSD/IP stated the negative outcome for failing to check and verify the facility staff or the registry staffs' identity and license was the potential to compromise the residents' safety. The DSD/IP stated she informed the Administrator and investigated the allegations and on 1/27/26, she found out CNA 1 was a female individual after she checked CNA 1's profile and identification on Registry Company 1. The DSD/IP stated she called CNA 1's phone number and CNA 1 verified with the DSD/IP that she did not accept the registry shift and did not come in to work at the facility on 1/26/26. The DSD/IP stated she did not know if the unidentified male individual, who presented to be CNA 1 from Registry Company 1 had a valid and current CNA license, and competency evaluation. On 2/5/26 at 1208 hours, an interview was conducted with the Administrator. The Administrator stated the DSD/IP and himself had access to Registry Company 1, however, the DSD/IP was mainly responsible for requesting the registry staff as needed. The Administrator stated prior to the incident on 1/26/26 with CNA 1, the facility did not require to check and verify the registry staffs' identity using a government ID and their license since Registry Company 1 was supposed to check the registry staffs' identity and license. In addition, the Administrator stated the facility used only Registry Company 1 to request registry staff. On 2/5/26 at 1446 hours, an interview was conducted with the DON and DSD/IP. The DSD/IP stated she did not make an employee personnel file for any of the registry staff. The DSD/IP stated the employee personnel file of CNA 1 was obtained after the incident on 1/26/26. In addition, the DSD/IP stated she did not check and/or verify the identity, license, certification, and competency evaluations of all the registry staff from Registry Company 1 prior to 1/27/26. The DSD/IP stated she would not know if the registry staff who accepted the shift posted on Registry Company 1 was the same individual who showed up to facility to provide care for the residents and had an active license, since the facility did not check and/or verify their identity, license and their competency evaluation. On 2/5/26 at 1540 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary respiratory care and services were provided for four of four sampled residents (Residents 1, 2, 3 and 4). * The facility failed to ensure Resident 1 had an order to suction secretions. * The facility failed to ensure Resident 2's oxygen nasal cannula was stored in the bag according to the facility's P&P. * The facility failed to ensure Resident 3's nebulizer administration set-up was changed every seven days according to the facility's P&P. * The facility failed to ensure Resident 4's CPAP washable filter, mask, nasal pillows and tubing were cleaned according to the manufacturer's guideline and facility P&P while the resident was in the facility. These failures had the potential to negatively affect the residents' medical conditions. 1. Review of the facility's P&P titled Suctioning Upper Airway (Oral Pharyngeal Suctioning) revised on 10/2010 showed to verify there is a physician's order for this procedure. Review the physician's order for facility protocol for suctioning. Review of Resident 1's medical record was initiated on 6/19/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 11/19/24, showed Resident 1 had no capacity to understand and make decisions. Review of Resident 1's care plan initiated 4/20/25, showed risk for infection related to cough and congestion with intervention to maintain a clear airway by encouraging resident to clear own secretion with effective coughing. If the secretions cannot be cleared, suction as ordered required to clear secretions. On 6/19/25 at 0808 hours, an observation was conducted of Resident 1 in the resident's room. Resident 1 had a suction machine on his night stand table connected with Yankauer suction tubing in a plastic bag dated 6/8/25, that was inside the night stand drawer. On 6/19/25 at 0832 hours, an observation of Resident 1 and a concurrent interview was conducted with the DSD. The DSD verified the Yankauer suction had some fluid residue, was used and the storage bag was dated 6/8/25. On 6/19/25 at 1100 hours, an interview was conducted with the DON. The DON stated she expects the night shift LVN to change the Yankauer suction every week and label the and supposed to label the plastic bag with resident's name and date. In addition, review of Resident 1's Order Summary as of 6/22/25, failed to show a physician's order for suctioning. On 6/25/25 at 1530 hours, an interview and concurrent record review was conducted with the DON. The DON verified Resident 1's Order Summary failed to show an order to suction the resident. The DON stated there should be an order for suctioning of the airway. 2. Review of the facility's P&P titled Departmental (Respiratory Therapy) - Prevention of Infection revised on 11/2011 showed in infection control considerations related to oxygen administration, to keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. Review of Resident 2's medical record was initiated on 6/19/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 3/13/25, showed Resident 2 had no capacity to understand and make decisions. Review of Resident 2's Order Summary showed a physician's order dated 5/1/25, to administer oxygen at 2-5 liters per minute via nasal cannula as needed. Review of Resident 2's MDS assessment dated [DATE], showed resident had BIMS score of 3 indicating the resident had severe cognitive impairment. Review of Resident 2's plan of care failed to show a care plan was developed for the resident's use of the oxygen. On 6/19/25 at 0812 hours, an observation was conducted of Resident 2 in the resident's room. Resident 2's oxygen concentrator was turned off at the resident's bedside. The nasal cannula tubing was not properly stored in the plastic bag hanged on the oxygen concentrator and part of the tubing was out of the plastic bag and touching the floor. On 6/19/25 at 0825 hours, an observation and a concurrent interview was conducted with the DSD. The DSD verified the nasal cannula was not properly stored in the plastic bag. The DSD stated the nasal cannula tubing should be stored properly and should not touch the floor for infection control. The DSD removed the nasal cannula tubing. The DSD further stated she will replace the nasal cannula. On 6/19/25 at 1100 hours, an interview was conducted with the DON. The DON stated she expects the nurses to store the entire nasal cannula tubing in the bag when not in use. 3. Review of the facility's P&P titled Departmental (Respiratory Therapy) - Prevention of Infection revised on 11/2011 showed in infection control considerations related to medication nebulizers/ continuous aerosol, store the circuit in plastic bag, marked with date and resident's name, between uses; and discard the administration set-up every seven days. Review of Resident 3's medical record was initiated on 6/19/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 3/13/25, showed Resident 3 could make needs known but could not make medical decisions. Review of Resident 3's MDS assessment dated [DATE], showed resident had BIMS score of 6 indicating the resident had severe cognitive impairment. Review of Resident 3's Order Summary showed a physician's order dated 5/31/25, to administer ipratropium-albuterol (a bronchodilator medication used to relax the muscles around the airways in the lungs, making it easier to breathe) inhalation solution 0.5-2.5 mg/ml 1 vial every four hours as needed for coughing or wheezing. On 6/19/25 at 0816 hours, Resident 3's nebulizer tubing was observed on the resident's nightstand in a plastic bag with no name and was dated 6/10/25. On 6/19/25 at 0820 hours, an observation and concurrent interview was conducted with the DSD. The DSD verified Resident 3's nebulizer tubing was in the plastic bag with no name and was dated 6/10/25. On 6/19/25 at 1100 hours, an interview was conducted with the DON. The DON stated she expects the night shift LVN to change the nebulizer tubing every week and supposed to label the plastic bag with resident's name and date. 4. Review of the facility's P&P titled CPAP/ BiPAP Support dated 3/2015 showed under the general guidance for cleaning: to clean humidifier weekly and air dry; rinse washable filter under running water once a week to remove dust and debris; and mask, nasal pillows and tubing, clean daily by placing in warm, soapy water and soaking/ agitating for 5 minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry between uses. Review of Resident 4's closed medical record was initiated on 6/19/25. Resident 4 was admitted to the facility on [DATE] and was discharged to acute care hospital on 5/29/25. Review of Resident 4's H&P examination dated 3/13/25, showed Resident 4 could make needs known but could not make medical decisions. Review of Resident 4's MDS assessment dated [DATE], showed resident had BIMS score of 15 indicating the resident had intact cognitive function. Review of Resident 4's Order Summary dated 5/31/25 showed a physician's order dated 5/12/25, may use CPAP machine at bedside, pressure setting 4.0, oxygen at 2 liters per minute, no humidification, for sleep apnea. Further review of Resident 4's medical record failed to show evidence the CPAP's washable filter, mask, nasal pillows and tubing were cleaned while the resident was in the facility. On 6/19/25 at 1510 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON verified Resident 4 uses CPAP at night. The DON verified CPAP's washable filter, mask, nasal pillows and tubing were not cleaned while the resident was in the facility. The DON further stated she would provide in-service to the licensed staff.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide written information to the residents about a bed-hold information upon the resident transferring to an acute care hospital for three of three sampled residents (Residents 1, 2, and 3). These failures had the potential for the residents not receiving accurate information to determine if they wanted a bed-hold and to return to the facility. Findings: Review of the facility'sP&P titled Bed-Holds and Returns revised March 2017 showed prior to a transfer, written information will be given to the residents and their representative that explains in detail the residents' rights and limitations regarding bed-holds, the reserve bed payment policy, and the per diem rate to hold a bed beyond the state's bed-hold period. Review of the facility's Bedhold Notification Upon Transfer form showed the form was to be completed upon transfer and to provide a copy to the resident or their responsible party. The form showed the resident, or their responsible party was notified of their options to hold the bed and had check boxes to show if a bed-hold was desired, not desired, not appliable, or not eligible for a bed-hold, but still desired to pay privately for a bed-hold. 1. Closed medical record review for Resident 1 was initiated on 5/29/25. Resident 1 was admitted to the facility on [DATE], and transferred to an acute care hospital on 5/17/25. Review of Resident 1's medical record failed to show the resident was provided information on the bed-hold options. 2. Medical record review for Resident 2 was initiated on 5/29/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's EHR census showed the resident went on an acute care hospital on a paid leave on 5/1/25, and returned to the facility on [DATE]. Review of Resident 2's medical record failed to show the resident or her responsible party was provided with the information on their bed-hold options. 3. Medical record review for Resident 3 was initiated on 5/29/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's EHR census showed the resident went on an acute care hospital on a paid leave 4/30/25, and returned to the facility on [DATE]. Review of Resident 3's medical record failed to show the resident or responsible party wasprovided with the information on their bed-hold options. On 5/29/25 at 1012 hours, an interview and concurrent medical record review for Residents 1, 2, and 3 was conducted with LVN 1. LVN 1 stated she was the nurse for Residents 1, 2, and 3, when they were transferred to the acute care hospitals. LVN 1 stated the facility obtained the physician's orders for the residents to have bed-holds if admitted to the acute care hospital. LVN 1 stated their process for the bed-hold wasafter receiving the notification from the acute care hospital the resident was being admitted , the LVN was then to call and ask if the resident or responsible party wanted a bed-hold. LVN 1 stated they did not provide anything in writing to the residents or their responsible partyabout bed-hold options. When asked what options LVN 1 discussed with the residents or responsible parties, LVN 1replied she only asked if they wanted a bed-hold and did not know any particulars about who was responsible for the bed-hold payments. On 5/29/25 at 1150 hours, an interview was conducted with the Administrator. The Administrator stated all the residents should be offered written information about the bed-hold options upon transferring out of the facility.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 14 final sampled residents (Resident 1) received the appropriate services needed to maintain acceptable parameters of nutritional status when: 1. The facility failed to implement the interventions to maintain Resident 1's nutritional status when Resident 1 experienced the following insidious weight loss (gradual, unintended, progressive weight loss over time): - 4 lbs, (3%) from 12/2/22 to 1/4/23, - 10 lbs (7%) from 10/3/22 to 1/4/23, and - 12 lbs (8%) from 8/5/22 to 1/4/22. 2. The facility failed to ensure the nutrition evaluations were performed by a qualified Registered Dietitian. 3. The facility failed to revise the resident-centered plan of care for Resident 1 to reflect the insidious weight loss from 8/5/22 to 1/4/23, and poor PO intake. These failures caused Resident 1 to experience severe weight loss of 11 pounds, 7.9% from 11/1/22 to 2/1/23; and severe weight loss of 16 pounds, 11% from 8/5/22 to 2/1/23. Findings: A professional reference review of the National Library of Medicine titled, An approach to the management of unintentional weight loss in elderly people, dated March 15, 2005, showed, Unintentional weight loss, or the involuntary decline in total body weight over time, is common among elderly people who live at home. Weight loss in elderly people can have a deleterious effect on the ability to function and on quality of life and is associated with an increase in mortality over a 12-month period .Unintentional weight loss is the involuntary decline in total body weight over time. In clinical practice, it is encountered in up to 8% of all adult outpatients and 27% of frail people [AGE] years and older. Weight loss is an important risk factor in elderly patients. It is associated with increased mortality, which can range from 9% to as high as 38% within 1 to 2.5 years after weight loss has occurred .Weight loss of 4%-5% or more of body weight within 1 year, or 10% or more over 5-[AGE] years or longer, is associated with increased mortality or morbidity or both. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC552892/ A professional reference review of BSN (Balance Senior Nutrition) Solutions, titled, Weight Loss in the Elderly: When Should You Be Concerned? dated March 19, 2018, showed, According to the Centers for Medicaid and Medicare services (CMS), weight can be a useful indicator of nutritional status when evaluated within the context of the individual's personal history and overall condition. Significant unintended changes in weight (loss or gain) or insidious weight loss may indicate a nutritional problem. Insidious weight loss refers to a gradual, unintended, progressive weight loss over time. https://www.bsnsolutions.net/weight-loss-in-the-elderly-when-should-you-be-concerned-clone#:~:text=%E2%80%9CInsidious%20weight%20loss%E2%80%9D%20refers%20to,progressive%20weight%20loss%20over%20time. A professional reference review of Dietetics in Healthcare Communities, a dietetic practice group of the American Dietetic Association titled Unintended Weight Loss in Older Adults: ADA Evidence Based Practice Guidelines dated 2011 showed, Most reference tables do not include elderly individuals in their subject pool, and thus these tables are not age adjusted. Standard height and weight tables and BMI tables are therefore not valid for use in older adults. https://higherlogicdownload.s3.amazonaws.com/THEACADEMY/4556f4af-bcea-4fd9-8fc9-5647e0d15658/UploadedImages/DHCC/Documents/UWL.pdf 1. Review of the facility's P&P titled Nutrition Assessment revised 10/2017 showed in part, 1. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. 2. As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. Review of the facility's P&P titled Weight Assessment and Intervention undated showed in part, the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .4. The Dietitian will respond within 24 hours of receipt of written notification. 5. The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. 6. The threshold for significant, unplanned and undesired weight loss will be based on the follow criteria [where percentage of body weight loss = (usual weight - actual weight) / (usual weight) x 100: a. one month - 5% weight loss is significant; greater than 5% is severe, b. three months - 7.5% weight loss is significant; great than 7.5% is severe, c. six months - 10% weight loss is significant; greater than 10% is severe . Analysis 2. The Physician and multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk for weight loss . Medical record review for Resident 1 was initiated on 5/2/23. Resident 1 was readmitted to the facility on [DATE], with diagnoses including Non-ST elevation myocardial infarction (NSTEMI), a type of heart attack and muscle weakness. Review of Resident 1's Annual History and Physical Examination dated 4/11/23, showed Resident 1 could make needs known but could not make medical decisions. Review of Resident 1's Physician's Order dated 12/1/22 to 1/31/22, showed the orders dated 4/16/21, for Regular No Added Salt diet and multivitamin one tablet PO QD for supplement. Review of the facility's document titled Vital Signs Grid from 4/16/21 through 5/3/23, showed the following weights and comparisons for Resident 1: * On 12/2/22 = 136 lbs, -7 lbs, a 4.9% insidious weight loss in three months [comparison weight on 9/1/22, 143 lbs], * On 1/4/23 = 132 lbs, -4 lbs, a 3% insidious weight loss in one month [comparison weight on 12/2/22, 136 lbs]; -10 lbs, a 7% insidious weight loss in three months [comparison weight on 10/3/22, 142 lbs]; and -11 lbs, a 7.7% insidious weight loss in six months [comparison weight on 7/5/22, 143 lbs]. * On 2/1/23 = 128 lbs, -4 lbs, a 3% insidious weight loss in one month [comparison weight on 1/4/23, 132 lbs]; -11 lbs, an 8% severe weight loss in three months [comparison weight on 11/1/22, 139 lbs]; -16 lbs, a 11% severe weight loss in six months [comparison weight on 8/5/22, 144 lbs]. Review of the facility's document titled Resident Care Details dated 11/1/22 to 4/30/23, showed Resident 1's PO intake for the following months: * For the month of November 2022, 48% of the 89 meals recorded, the intake was less than or equal to 50% intake. * For the month of December 2022, 38% of the 90 meals recorded, the intake was less than or equal to 50% intake. * For the month of January 2023, 35% of the 88 meals recorded, the intake was less than or equal to 50% intake. Review of the facility's document titled Nutrition Evaluation completed by the Certified Dietary Manager on 8/24/22, showed Resident 1's weight on 8/19/22 was 144 lbs. The resident had no weight gain or loss, was not at risk for weight loss and dehydration, and was on a Regular NAS (No Added Salt) diet. The document also showed no recommendations at this time, no concerns, and continue to monitor monthly weights. The Nutrition Evaluation form did not include Resident 1's PO intake. Review of the facility's document titled Nutrition Evaluation completed by the Certified Dietary Manager on 12/1/22, showed Resident 1's weight on 11/1/22, was 139 lbs. The resident had no weight gain or loss, was at risk for weight loss and dehydration, and was on a Regular NAS diet. The document showed N/A for nutrition interventions/recommendations and to continue to monitor monthly weight and po intake. The Nutrition Evaluation form did not include Resident 1's PO intake. Review of the facility's document titled Departmental Notes- Dietary completed by the RDN on 12/14/22, showed the RD notes were for a follow up on the resident's PO intake. The note showed the following: weight: 136 lbs, BMI (body mass index) 22.6, and normal status. Resident 1 had three lbs weight loss for one month, seven lbs weight loss for three months, and six lbs weight loss for six months. Resident 1 had been showing variable, low PO intake. Resident 1 had variable PO intake with an average of 20-40-50-70% of all meals. Per the Certified Dietary Manager, Resident 1 refused to eat, notifying the nursing staff that she was not hungry. Dietary offered nutritional supplements, but the resident refused. The note showed a recommendation for appetite stimulant to improve PO intake; and would continue to monitor weights, labs, and PO intake. Review of the facility's document titled Nutritional Screening and Assessment - annual completed by the Certified Dietary Manager and RDN on 2/28/23, showed the current weight 128 lbs; IBWR (ideal body weight range) 121#--125#-138#; recent weight change: loss of 4 lbs in one month, loss of 11 lbs (8%) in three months, and loss of 16 lbs (11%) in six months. The document showed estimated calories needs for weight maintenance based on actual body weight 25-30 calories/kg (kilogram) 1450-1740 calories; and recommendation for four-ounce HPN (High Protein Nourishment) BID (twice a day) at lunch and dinner. Review of the facility's document titled Nursing Summary completed by LVN 4 on 12/14/22 at 2240 hours, showed the resident's weight was 136 lbs on 12/2/22, with excellent appetite and no changes in condition. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by RN 1 on 12/18/22 at 1028 hours, showed Resident 1 was on monitoring for poor PO intake, consumed 75% breakfast, and given fluid as tolerated. The note showed snacks offered in between meals .will continue to monitor. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by LVN 4 on 12/18/22 at 0807 hours, showed Resident 1 had an episode of poor PO intake during dinner, consumed 30% of dinner. The note showed alternate offered and refused .will continue to monitor. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by LVN 6 on 12/18/22 at 0724 hours, showed for Resident 1 to continue monitoring for low appetite. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by LVN 5 on 12/19/22 at 1230 hours, showed in part, decreased appetite, ate 20% of breakfast and 30% of lunch, and when encouraged to eat, the resident became agitated and began to ramble and say things not pertaining to meal. When redirected, the resident stated, I don't want to eat or I can't eat or I don't like this food. When asked what meal she preferred or what other food she would like to eat, the resident said nothing or yelled to leave her alone. Provided food that the family said she liked, but the resident also refused the meals. The note showed encouraged supplements and fluids as the resident could tolerate. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by LVN 4 on 12/19/22 at 2257 hours, showed no episode of poor PO intake during dinner and consumed 100% of dinner. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by the DSD/IP on 12/20/22 at 1103 hours, showed in part, the physician ordered CBC (complete blood count), CMP (complete metabolic panel), UA (urinalysis)/c+s (culture plus sensitivity). Review of the facility's document titled Departmental Notes- General Nurses Notes completed by LVN 4 on 12/20/22 at 1939 hours, showed the resident consumed 50% of dinner, alternate was offered and refused, and fluids were encouraged and offered as tolerated. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by the DON on 2/3/23 at 2217 hours, showed Resident 1's weight was reviewed and the resident 's weight loss for six months. Resident 1 had a declining appetite. Physician 1 was made aware of the IDT recommendations for weekly weights, RD consult, fortify diet, and four-ounce HPN BID between meals; and agreed. Review of the facility's document titled Weight Variance Committee for Resident 1 dated 2/3/23, showed the following IDT members were present: the Certified Dietary Manager, DON, and SSD. The RDN was not present. The note showed the resident's average meal intake for breakfast, lunch, and dinner was 25-50%. The current weight was 128 lbs and BMI <22, and the identified weight trend was documented as -16 lbs x 6 months, with the known or suspected cause of decreased appetite. The current interventions was documented as none, and the physician and responsible party were notified on 2/3/23. Review of Resident 1's Physician Progress Notes dated 10/7/22, showed Resident 1's weight was 143 lbs, and to continue with the current orders. Review of Resident 1's Physician Progress Note dated 11/7/22, showed Resident 1 was doing fair and ate ok, and to continue with the current treatment. Review of Resident 1's Physician Progress Note dated 12/9/22, showed Resident 1 was alert, and to continue with the current medications. Review of Resident 1's Physician Progress Note dated 1/20/23, showed Resident 1 was awake but confused on and off, and to continue with the present plan. Review of Resident 1's Physician Progress Note dated 2/5/23, showed Resident 1 was doing fair, except more forgetful. The document showed oral intake fair, weight 128 lbs, and to continue with the current treatment. During the lunch meal dining observation on 5/02/23 at 1208 hours, Resident 1 was observed sitting in the resident dining room with two other residents at the table. Resident 1 appeared thin, confused, and was not eating her lunch. Resident 1 was asked why she was not eating, she replied, I have too much at home. The DSD then asked Resident 1 if she wanted something else to eat but Resident 1 refused a meal alternative. Resident 1 consumed four ounces of juice and four ounces of HPN. On 5/2/23 at 1513 hours, Resident 1 was observed in the hallway sitting in her wheelchair drinking four ounces of HPN. On 5/02/23 at 1400 hours, an interview was conducted with the RDN. The RDN was asked to explain the resident weight loss protocol for the facility. The RDN stated significant weight loss of 5% in a month, 7.5% in three months, and 10% in six months were reviewed. The RDN talked to the DON but was not part of the IDT weight variance meeting. The RDN stated she was not involved in creating or revising the resident's care plans. On 5/3/23 at 1539 hours, an electronic medical review of Resident 1 and concurrent interview was conducted with the DON. The DON was asked to explain the resident's weight loss protocol for the facility. The DON explained the residents with significant weight loss of 5% in a month, 7.5% in three months, and 10% weight loss in six months were followed in the IDT weight variance committee. The nurses were responsible to notify the physician and resident's responsible party of any significant weight change. The DON stated the IDT weight variance committee included herself, the Certified Dietary Manager, and social service. The RDN was not part of the IDT weight variance committee, but the RDN asked the Certified Dietary Manager or DON about any residents with changes. The DON stated the RDN completed a report after each visit with recommendations. The DON and nursing received a copy of the RDN weekly report and recommendations. The charge nurse was responsible to notify the physician of the RDN's recommendations and write an order. If the physician did not agree with the RDN's recommendation, the charge nurse should document such in the resident's medical record. The DON was asked how the facility handled the residents with insidious weight loss. The DON stated if the residents experienced insidious weight loss, the IDT would intervene with the same protocol as significant weight loss. The DON was asked about Resident 1's weight loss. The DON stated Resident 1 was currently being followed in the IDT weight variance committee. The DON confirmed Resident 1 was first reviewed by the IDT weight variance committee on 2/3/23, due to a significant weight loss of 16 lbs in six months. The DON was asked who was responsible for weight change calculations. The DON stated the RDN calculated weight changes, but she could also run a report. Resident 1's weight report was reviewed with the DON. The DON confirmed Resident 1 had insidious weight loss of four lbs (3%) from 12/2/22 to 1/4/23, 10 lbs (7%) from 10/3/22 to 1/4/23, and 12 lbs (8%) from 8/5/22 to 1/4/22. The DON confirmed Resident 1's insidious weight loss between 1/4/23 and 8/5/23 was not discussed in the IDT weight variance committee. When asked what the facility's criteria to follow a resident with insidious weight loss was, the DON stated if the resident became underweight. The DON was asked if a resident with poor PO intake would be followed in the IDT weight variance committee. The DON confirmed if a resident had poor PO intake that would be addressed in the IDT weight variance committee. The DON was asked to review Resident 1`s medical record during the month of December when Resident 1 experienced insidious weight loss and poor PO intake. The DON stated on 12/14/22, the RDN wrote a note that addressed Resident 1's insidious weight loss and poor PO intake. The DON acknowledged on 12/14/22, the RDN recommended an appetite stimulant for Resident 1. The DON confirmed there was no note from nursing showing the physician was contacted regarding the RDN's recommendation for an appetite stimulant. The DON confirmed the RDN recommendations should be completed within 72 hours of receiving the recommendations. The DON was asked how she was notified of the RDN recommendations. The DON stated she received a paper copy of the RDN's report and recommendations. The DON was asked how she ensured the RDN recommendations were completed. The DON stated the nursing usually put the completed RDN recommendations under the door of her office, but the DON had discarded the completed RDN recommendations. The DON stated she only kept the original RDN recommendation reports. The DON was not able to confirm she received any RDN recommendation reports from December 2022. The DON stated she did not remember seeing the RDN in December 2022 and thought the RDN had worked virtually. The DON stated on 12/18/22, Resident 1 was on a change of condition (COC) monitoring due to poor intake. The DON stated the facility's procedure for a COC did not include a change of condition form, and the nursing staff was only required to monitor the resident for 72 hours. The DON stated the nursing staff was responsible to notify the physician and resident responsible party of any change of condition. The DON confirmed there was no note showing the physician or Resident 1's responsible party were notified of Resident 1's poor intake. The DON stated on 12/20/22, the physician ordered a lab work for Resident 1, therefore, the nursing staff must have notified the physician of Resident 1's poor po intake. The DON was asked if any other interventions such as weekly weight monitoring were implemented for Resident 1 in December 2022. The DON confirmed no interventions to mitigate Resident 1's weight loss or poor intake was added for Resident 1 in December 2022. The DON confirmed Resident 1 was discussed in the IDT meeting on 2/3/23, related to a severe weight loss of 16 lbs, 11% since 8/5/22, due to declining appetite. The IDT recommended weekly weights, RD consult, fortify diet, four-ounce HPN (high protein nourishment) twice a day between meals. The DON acknowledged waiting until 2/3/23, to address Resident 1's weight loss with the IDT was not timely. The DON confirmed the RDN did not re-evaluate Resident 1 since 12/14/22. The DON confirmed the next RDN evaluation was completed on 2/28/23. The DON acknowledged waiting until 2/28/23, more than two months after Resident 1 began losing weight and since the previous RD evaluation on 12/14/22, was not considered timely. On 5/4/23 at 1321 hours, a telephone interview was conducted with the RDN. The RDN was asked the facility process with monthly weights. The RDN stated she obtained a paper copy of the monthly weights from the weight book. The RDN calculated significant weight changes of 5% in a month, 7.5% in three months, and 10% in six months. She stated she only addressed significant weight change. The RDN wrote her recommendations on a paper form and gave a copy to the DON. When asked if only residents with weight loss were discussed in the weight variance committee, the RDN stated she was not sure what residents were discussed since she did not attend the weight variance committee meeting. The RDN was asked how she ensured her recommendations were completed. The RDN stated if the resident came back on her radar, she would follow up on her recommendations. The RDN confirmed she had no system to ensure her recommendations were completed. The RDN further stated she did not check to see if the nursing had completed her recommendations. The RDN was asked how she was notified of a resident with poor PO intake. The RDN stated the CDM would either tell her verbally or write a note in the RD binder. Resident 1's electronic medical record was reviewed with the RDN. The RDN acknowledged she wrote a note on 12/14/22, for Resident 1 regarding poor PO intake and gradual weight loss. The RDN acknowledged she recommended an appetite stimulant for Resident 1. The RDN stated she could not recall if she worked virtually in December or on site. The RDN stated if she worked virtually, she would take a picture of her recommendations and text it to the DON or call the DON and relay her recommendations. The RDN was asked if she documented she called or texted the DON with her recommendation. The RDN stated she did not document how her recommendations were communicated to the DON in December 2022. The RDN confirmed she did not have a system how to communicate the recommendations for the residents when she was working virtually. The RDN was asked what other interventions she would consider if a resident was not eating. The RDN agreed that weekly weights should have been recommended for Resident 1 in December. The RDN then stated the weekly weights were only recommended for those residents who had experienced significant weight loss. The RDN was asked if she was familiar with the term insidious weight loss. The RDN was not familiar with the term insidious weight loss but agreed that unplanned weight loss whether significant or gradual was not desirable in the elderly population. The RDN was asked when the next nutrition assessment was completed for Resident 1. The RDN stated an annual nutrition assessment was completed on 2/28/23. The RDN was asked when she received the resident monthly weights. The RDN stated she received the resident monthly weights during the first week of each month. The RDN acknowledged waiting until 2/28/23, to assess Resident 1's severe weight loss of 11 lbs, 7.9% in three months and 16 lbs, 11% in six months was not ideal. On 5/4/23 at 1546 hours, a follow-up interview was conducted with the DON. The DON was asked if she received a picture the RDN's recommendations in December via text message or email from the RDN. The DON confirmed after checking her emails and phone records, she did not receive the recommendations from the RDN. The DON further confirmed the RDN recommendations she had were from 11/29/22 to 1/3/23, the DON stated she had no other RDN recommendations between those dates. On 5/5/23 at 1035 hours, a telephone interview was conducted Physician 1. Physician 1 declined to discuss Resident 1 and stated he was on an airplane. On 5/5/23 at 1048 hours, an interview was conducted with Resident 1's family member. Resident 1's family member stated they were aware the resident had lost weight and had not been eating well for about six months. 2. Review of the facility's P&P titled Nutrition Assessment revised 10/2017 showed in part, 1. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. Review of the facility document titled Director, Nutritional Services Job Description signed and dated by the Certified Dietary Manager on 9/12/16, showed to ensures the timely preparation and delivery of nutritious and attractive meals and supplements to all residents according to physician order and in compliance with Federal, State and company requirements; maintains a safe and sanitary working environment; ensures that meals are served according to expressed resident preferences; plan, implements and revises menus to meet resident needs; and interacts effectively with other resident services according to total care plan approach. Review of the electronic medical record for Resident 1 and concurrent telephone interview was conducted with the RDN on 5/04/23 at 1321 hours. The RDN confirmed the Certified Dietary Manager completed the quarterly nutrition evaluations for all residents. The quarterly nutrition evaluation for Resident 1 dated 12/1/22, was reviewed with the RDN. The RDN confirmed the quarterly nutrition evaluation showed Resident 1's weight of 139 lbs was from 11/1/22. The RDN confirmed the quarterly nutrition evaluation showed Resident 1 had not lost weight, was not at weight loss and dehydrations risks, and did not have any nutrition interventions/recommendations; and to continue to monitor monthly weights and po intake. The RDN agreed the 12/2/22 weight of 136 should have been included in the December quarterly nutrition evaluation and the insidious weight loss of seven lbs (6%) from 9/1/22 to 12/2/22, should have been addressed in the quarterly nutrition evaluation. The RDN further agreed that Resident 1 was at risk for weight loss and dehydration due to poor PO intake. The RDN confirmed the nutrition evaluation form did not include the residents' PO intake. The RDN was asked if she reviewed the quarterly nutrition evaluations that were completed by the Certified Dietary Manager. The RDN confirmed she did not review the quarterly nutrition evaluations completed by the Certified Dietary Manager. The RDN further stated she was not aware the CDM was not a qualified individual to perform nutrition evaluations. On 5/5/23 at 1331 hours, an interview was conducted with the Administrator. The Administrator was not aware a Certified Dietary Manager was not qualified to complete the resident assessments. The Administrator was not aware of the California business and professions code 2586 which stated the RD was the professional permitted to conduct medical nutrition therapy which includes assessment, determination of nutrition diagnosis and recommendation and implementation of nutrition care and intervention. The Administrator agreed the RD should be cosigning or completing the quarterly nutrition evaluations. Cross reference to F836. 3. Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 12/2016 showed in part, 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of the facility's P&P titled Weight Assessment and Intervention undated showed in part, the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or the resident's legal surrogate. 2. Individualized care plans will address to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Timeframes and parameters for monitoring and reassessment. On 5/3/23 at 1539 hours, a review of Resident 1's electronic medical record and concurrent interview was conducted with the DON. The DON stated the nursing staff was responsible for the resident's care plans. The DON confirmed Resident 1's poor intake in December and insidious weight loss from 8/5/22 to 1/4/23, had not been added to Resident 1's care plan but should have been added. On 5/4/23 at 1321 hours an interview was conducted with the RDN. The RDN stated she was not involved in resident care planning. Cross reference to F657.