Every finding on record at Sunset Manor Conv Hosp

Based on interview, and record review, the facility failed to develop and implement an individualized care plan (a document that outlines a person's health needs and the care they require) for one of four sampled residents (Resident 1) when: 1. Facility staff did not ensure a care plan was developed for Resident 1 owning a vehicle while being a resident at the facility. 2. Facility staff did not ensure a care plan was developed for Resident 1 leaving the facility unannounced. 3. Facility staff did not ensure a care plan was developed for Resident 1's choice of going to sit in Resident 1's car. 4. Facility staff did not ensure to have an Interdisciplinary Team (IDT) meeting to address Resident 1's leaving the facility unannounced that would lead to an against medical advice (AMA) discharge. These deficient practices negatively affected Resident 1's care and created an immediate risk to Resident 1's safety and quality of life. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included respiratory failure (serious condition that makes it difficult to breathe, lungs cannot get enough oxygen into the blood) and polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body). During a review of Resident 1's History and Physical Examination (H&P, physician clinical evaluation and examination of the resident), dated 7/31/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/10/2026, the MDS indicated Resident 1's cognitive skills (reasoning, learning, and problem-solving) for daily decision making was intact. The MDS indicated Resident 1 was independent for eating, oral hygiene and upper body dressing. The MDS indicated Resident 1 required set up or clean up assistance for toileting hygiene, shower/bathing, lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 1's electronic medical record, there was no Physician Orders, dated prior to 8/6/2026, that indicated Resident 1 was not allowed to sit in Resident 1's car and Resident 1 was not allowed to drive Resident 1's car. During a review of Resident 1's electronic medical record, Resident 1's care plan for Resident 1's continuous leaving the facility unannounced was not in Resident 1's medical record. During a review of Resident 1's electronic medical record, Resident 1's care plan for Resident 1's choice to sit in Resident 1's car was not in Resident 1's medical record. During a review of Resident 1's electronic medical record, Resident 1's care plan for Resident 1 parking Resident 1's vehicle while a Resident at the facility was not in Resident 1's medical record. During a review of Resident 1's Interdisciplinary Team (IDT) meetings notes, Resident 1 IDT meeting notes that addressed Resident 1 leaving the facility unannounced would lead to an against medical advice (AMA) discharge was not in Resident 1's medical record. During an interview on 8/19/2026 at 1:10 p.m. with Social Services Director (SSD), the SSD stated Resident had a history of leaving the facility unannounced. The SSD stated on 8/6/2026 Resident 1 left the facility announced and returned to the facility the next day (8/7/2026). The SSD stated Resident 1 owned a car but was not allowed to come and go as Resident 1 wished. The SSD stated a resident that owns a car should have a care plan for what resident was allowed to do or not to do with the car. During an interview on 8/19/2026 at 2:52 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had left the facility unannounced a couple of times before. LVN 1 stated Resident 1 was allowed to go to Resident 1's car but was not allowed to leave the facility on Resident 1's car. LVN 1 stated Resident 1's care plan should include what Resident 1 was allowed to do while owning a car because it was part of Resident 1's care. LVN 1 stated if there was no care plan it would create miscommunication for nurses because nurses would not know what Resident 1 was allowed to do. During an interview on 8/20/2026 at 9:17 a.m. with LVN 2, LVN 2 stated LVN 2 did not know if Resident 1 was allowed to go to Resident 1's car. LVN 2 stated nursing staff had informed LVN 2 about Resident 1 leaving the facility unannounced. LVN 2 stated it was important to have a care plan for Resident 1's treatment plan for owning a car. LVN 2 stated a care plan was the guidance for nurses to know a resident's medical history and what Resident 1 was allowed or not allowed to do. LVN 2 stated it was a safety risk not to have a care plan for Resident 1 having a car while a resident at the facility. During an interview on 8/20/2026 at 10:26 a.m. with LVN 3, LVN 3 stated Resident 1 went in and out of Resident 1's car all the time. LVN 3 stated Resident 1 was allowed to go to Resident 1's car but was not allowed to leave on Resident 1's car. LVN 3 stated Resident 1 should have a care plan for not driving off the facility. LVN 3 stated it was important for Resident 3 to have a care plan for Resident 1's safety and to prevent Resident 1 leaving the facility. During an interview on 8/20/2026 at 12:20 p.m. with Director of Nursing (DON), the DON stated Resident 1 was not allowed to go to Resident 1's car and Resident 1 was not allowed to leave on Resident 1's car. The DON stated Resident 1 had left the faciity on Resident 1's car multiple times before. The DON stated a care plan was used to help guide the care of residents. The DO stated everything about residents got care planned. The DON stated if something did not get care planned there was a risk for nursing staff not to know what to do in situations. The DON stated there was an IDT meeting with Resident 1 to discuss if Resident 1 left the facility unannounced it would be an AMA discharge. The DON stated an IDT meeting was done to discuss Resident 1's choices for owning a car while being a resident at the facility. During a concurrent interview and record review on 8/20/2026 at 1:10 p.m. with DON, Resident 1's IDT meeting notes were reviewed. The IDT meeting notes indicated there were no IDT meeting notes to discuss about Resident 1's AMA discharge. The DON stated based on documentation it does not show Resident 1 was informed if Resident 1 left on Resident 1's car that would be an AMA discharge. The DON stated there was no way of knowing if Resident 1 was notified of the AMA discharge. During a concurrent interview and record review on 8/20/2026 at 1:17 p.m. with DON, Resident 1's Care Plan was reviewed. The care plan indicated there was no care plan for Resident 1 leaving the facility unannounced, no care plan about Resident 1 going to Resident 1's car, and if Resident 1 was allowed to leave the facility on Resident 1's car. The DON stated there should have been a care plan indicating Resident 1 had left the facility multiple times. The DON stated a care plan should have been developed after the first incident of when Resident 1 left the faciity on Resident 1's car. During a review of facilities Policy and Procedure (P&P) titled, Comprehensive Care Plans, dated 10/2022, the P&P indicated the facility would develop and implement a comprehensive person-centered care plan or each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The P&P indicated a comprehensive care plan would be prepared by an interdisciplinary team. The P&P indicated interdisciplinary team would inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternative options. The P&P indicated the facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative.

Based on interview and record review, the facility failed to evaluate and determine the level of care needed for one of three residents (Resident 1) as indicated in the facility policy and procedure titled, Transfer and Discharge (including AMA). This deficient practice resulted in Resident 1 arriving at the facility and being sent back to General Acute Care Hospital (GACH) Emergency Department (ER). A review of the facility's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes (DM-a chronic condition where blood sugar levels are too high) with diabetic chronic kidney disease (occurs when high blood sugar harms the tiny blood filters in the kidneys), and dependance of renal dialysis (HD-use of external machine and dialyzer [filter] to clean blood through an access point in an arm or leg).A review of Resident 1's History and Physical (H&P), dated 7/14/2026 indicated Resident 1 had the capacity to understand and make decisions.During an interview on 07/14/2026 at 2:15 p.m. with admission Coordinator/Marketer/Licensed Vocational Nurse (ACM-LVN), the ACM stated ACM gave case manager (CM) at GACH a bed (assigning or admitting a patient/resident to a specific physical bed) for Resident 1, report (a verbal and written clinical handover where hospital medical staff share patient details, medical history, and care plans with the receiving facility staff) was taken by the facility Registered Nurse (RN), Resident 1 arrived to the facility, and per ACM's instructions returned Resident 1 back to GACH ER. ACM stated the reason was that the facility did not have authorization for Resident 1's HD transportation scheduled for the 7/14/2026 (Tuesday), Thursday, and Saturday. ACM stated Resident 1 could have had a change in condition during transportation back to GACH and could have been harmed.During an interview on 7/15/2026 at 2:00 p.m. with RN 1, RN 1 stated GACH was notified Resident 1 was assigned a bed and the evening RN took report, so the resident arrived to the facility in an ambulance and sent back to GACH. RN 1 stated the facility policy for newly admitted residents was to call the admitting doctor for residents (in general) and receive orders as to what the doctor would like the facility to do (for care, treatment, and/or services). RN 1 stated, in this case the policy for admission and transfer was not followed. RN1 stated Resident 1 was sent back to GACH which placed Resident 1 in danger of a health decline during transportation.During an interview on 7/15/2026 at 3:00 p.m. with Social Service Director (SSD), the SSD stated Resident 1 could have been admitted , and in the morning, SSD would have called the insurance to obtain transportation benefits, or the other option which was to ask for authorization from our Administrator to pay out of pocket since Resident 1 was already admitted to the facility.During a review of the facility's P&P titled, admission of a Resident, revised on 3/10/2025 indicated Residents are admitted to the facility under orders of the attending physician.During a review of the facility's P&P titled, Transfer and Discharge (including AMA), dated 12/19/2022, indicated, It is policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source. Policy Explanation and Compliance Guidelines: The facility will evaluate and determine the level of care needed for the resident prior to admission to ensure the facility's ability to meet the resident's needs.During a review of the facility's P&P titled, Transportation, revised on 1/22/2024, indicated the facility shall help arrange transportation for residents as needed. The P&P indicated, social services will help the resident as needed to obtain transportation. The P&P indicated, the facility will assist in arranging transportation to or from the facility when the resident's health insurance does not cover the cost. The P&P indicated, inquires concerning transportation should be referred to social services.

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for two of two sampled residents (Residents 1 and 48) in accordance with the facility's policy and procedure (P&P) titled Call Lights: Accessibility and Timely Response. These failures had the potential to delay meeting Residents 1 and 48's needs and placed the residents at risk for fall or accident/injury. Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 3/28/2026 with diagnoses that included muscle wasting and atrophy, other abnormalities of gait (a person's manner of walking and mobility (the ability to move) and schizophrenia (a mental illness characterized by disturbances in thought). During a review of Resident 1's Fall Risk Assessment (FRA- method of assessing a patient's likelihood of falling) dated 3/28/2026, the FRA indicated Resident 1 was assessed as high risk for falls due to Resident 1 having intermittent confusion, was chairbound, had balance problem while standing and walking and required the use of assistive devices. During a review of Resident 1's untitled Care Plan (CP) revised on 3/30/2026, the CP indicated Resident 1 was at risk for falls related to confusion, gait/balance problems and being unaware of safety needs. The CP intervention indicated for the nursing staff to place Resident 1's call light within reach and encourage Resident 1 to use it for assistance as needed. The CP indicated Resident 1 needed prompt response to all requested assistance. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 4/7/2026, the MDS indicated Resident 1 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 needed moderate assistance (helper does less than half the effort) from staff for eating, oral hygiene, and upper body dressing. The MDS indicated Resident 5 needed maximum assistance (helper does more than half the effort) from staff for toileting, shower, lower body dressing and putting on/taking off footwear. During a concurrent observation and interview on 5/19/2026 at 9:46 am, Resident 1 was awake, lying in bed and unable to find the call light. Resident 1 stated Resident 1 could not find Resident 1's call light. Resident 1's call light was hanging on the left lower part of the bed's side rail. During a concurrent observation and interview on 5/19/2026 at 9:49 am with the Director of Staff and Development (DSD), the DSD stated Resident 1's call light was on the left side of the bed hanging and Resident 1 was unable to reach the call light. During an interview on 5/19/2026 at 10:20 am with the DSD, the DSD stated Resident 1 was unable to reach and access the call light because it was hanging on the lower left side of the bed. The DSD stated Resident 1 would use the call light if help or assistance was needed. During an interview on 5/21/2026 at 3:38 pm with the facility's Director of Nursing (DON), the DON stated Resident 1's call light needed to be within reach at all times for the residents to be able to ask for help and assistance from staff if needed. b. During a review of Resident 48's AR, the AR indicated Resident 48 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and a history of falling. During a review of Resident 48's History and Physical (H&P) dated 6/26/2025, the H&P indicated Resident 48 was weak, confused, and was unable to make decisions regarding Resident 48's care. During a review of Resident 48's untitled CP revised on 7/16/2025, the CP indicated Resident 48 was at risk for recurrent falls. The CP interventions indicated for staff to provide a safe environment with the call light within reach and prompt response to all of Resident 48's requests for assistance. During a review of Resident 48's MDS dated [DATE], the MDS indicated Resident 48 was dependent (helper does all of the effort) to move from lying on the back to sitting on the side of the bed without back support. During an observation on 5/19/2026 at 9:51 am in Resident 48's room, Resident 48 was in bed with the call light on the floor. During a concurrent observation and interview on 5/19/2026 at 9:59 am with Certified Nurse Assistant 1 (CNA 1) in Resident 48's room, Resident 48's call light was on the floor. CNA 1 picked up the call light and placed it on Resident 48's blanket and stated, the call light should not be on the floor and needed to be within reach, so that Resident 48 could call in case anything was needed. During an interview on 5/20/2026 at 11:32 am with Registered Nurse Supervisor 1 (RN 1), RN 1 stated the call light should always be within the resident's reach and accessible to allow the residents to call the nurse if they needed assistance. RN 1 stated, if the call light was not within reach, the resident's safety and needs cannot be met. During an interview on 5/21/2026 at 3:38 pm with the DON, the DON stated the resident's call light needed to be within reach so the residents can request assistance any time. During a review of the facility's P&P titled, Call Lights: Accessibility and Timely Response, revised 1/16/2026, the P&P indicated, the call system would be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on interview and record review, the facility failed to ensure policies and procedures (P&P) on Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) were implemented for two of two sampled residents (Residents 12 and 64) by failing to: a. Ensure Resident 12's Advance Healthcare Directive Acknowledgement Form (ADAF-form that indicated a resident or resident's representative were informed of their rights regarding medical treatments, Advance Directive formulation, and whether an AD was created) was not missing information and completely filled out. b. Ensure Resident 64's copy of Physician Orders for Life-Sustaining Treatment (POLST, a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end of life) and AD acknowledgement form were in Resident 64's binder and/or uploaded in Resident 64's electronic medical record (EMR). These failures had the potential for the facility staff to provide medical care and services against the will and preferences of Residents 12 and 64. Findings: a. During a review of Resident 12's admission Record (AR), the AR indicated Resident 12 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (brain dysfunction caused by diseases or toxins in the body) and dementia (a progressive state of decline in mental abilities). During a review of Resident 12's History and Physical (H&P) dated 9/18/2025, the H&P indicated Resident 12 had dementia and was unable to make any decisions. During a review of Resident 12's ADAF dated 9/17/2025, the ADAF did not indicate Resident 12's medical record number (MRN) and the resident representative's name/relationship and facility staff names who signed the ADAF. During a concurrent interview and record review on 5/20/2026 at 1:21 pm with the Social Services Director (SSD), Resident 12's ADAF was reviewed. The ADAF did not indicate Resident 12's MRN, Resident 12's representative's name/relationship and the facility staff names who signed the form. The SSD stated Resident 12's ADAF was not accurately done so the ADAF was not complete. The SSD stated based on Resident 12's ADAF, you could not tell who signed as the responsible party (RP- resident representative). The SSD stated the staff who signed the ADAF should have printed their name. The SSD stated, the ADAF was filled out upon admission and needed to be complete because it was a legal document used to ensure the resident's/RP's wishes were followed. During an interview on 5/21/2026 at 3:40 pm with the Director of Nursing (DON), the DON stated Resident 12's ADAF should be completely filled out. The DON stated, the ADAF was a very important piece of information that allowed the facility to follow the resident's/resident representative's wishes for end-of-life care. During a review of the facility's Policy and Procedure (P&P) titled, Documentation in Medical Record, revised 12/19/2022, the P&P indicated, documentation should be accurate, relevant, and complete. The P&P indicated, each entry would be signed with the name and credentials of the person making the entry. During a review of the facility's P&P titled, Resident's Rights Regarding Treatment and Advance Directives, revised 12/19/2022, the P&P indicated any decision making regarding the resident's choices will be documented in the resident's medical record. b. During a review of Resident 64's admission Record (AR), the AR indicated the facility admitted Resident 64 on 4/11/2026 with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) and right knee joint replacement surgery (removes damaged bone and cartilage in a joint and replaces with durable artificial implants). During a review of Resident 64's Minimum Data Set (MDS, a resident assessment tool), dated 4/15/2026, the MDS indicated Resident 64 had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 64 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene, upper body dressing and personal hygiene. The MDS indicated Resident 64 required partial/moderate assistance (helper did less than half the effort) with toileting, and lower body dressing. The MDS indicated Resident 64 was dependent (helper did all the effort, resident did none of the effort to complete the activity) with shower. During a concurrent interview and record review on 5/19/2026 at 2:15 pm with the Medical Records staff (MR), Resident 64's binder (binder with residents' physical copy of POLST and AD acknowledgement form) and Resident 64's EMR were reviewed. The MR stated there was no copy of POLST and AD acknowledgement form in the binder and there was no copy uploaded in Resident 64's EMR. The MR stated Resident 64 was admitted to the facility on [DATE] and had been in the facility for five (5) weeks. During an interview on 5/19/2026 at 2:18 pm with Registered Nurse Supervisor 2 (RN 2), RN 2 stated POLST and AD acknowledgement form should be filled and completed upon admission to ensure the resident or responsible party were informed of the resident's rights to formulate an AD and received information to determine resident's preferences and wishes regarding care in the facility and during emergency. During an interview on 5/21/2026 at 3:34 pm with the Director of Nursing (DON), the DON stated a copy of POLST and AD acknowledgement form should be in the binder, a copy uploaded in the resident's EMR and accessible to the staff to address and identify the resident's end-of-life wishes and preferences. During a review of the facility's P&P titled, Residents' Rights Regarding Treatment and Advance Directives, implemented on 12/19/2022, the P&P indicated, On admission, the facility will determine if the resident has executed and advance directive, and if not, determine whether the resident, if cognitively able to, would like to formulate an advance directive. The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive.

Based on interview and record review, the facility failed to prevent unnecessary use of psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) according to the facility's policy and procedure and the resident's care plan for two of five sampled residents (Residents 1 and 73) by failing to: a. Ensure the adverse side effects (unwanted or harmful effect) was monitored for the use of Divalproex ( mood stabilizer or treatment of seizures ), Clozapine (antianxiety medication to treat anxiety [group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear]), Olanzapine (antipsychotic medication to treat mental disorder) oral tablet 5 milligrams (mg, unit of measurement) and Trazodone (antidepressant - medication to treat depression [mood disorder that causes a persistent feeling of sadness and loss of interest]) for Resident 1. b. Ensure Resident 73's Duloxetine antidepressant use included specific target behavior for use. These deficient practices had the potential to result in significant adverse (harmful) consequences for Residents 1 and 73. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 3/28/2026 with diagnoses including muscle wasting and atrophy, schizophrenia (a mental illness that is characterized by disturbances in thought) and unspecified psychosis (loss of contact with reality). During a review of Resident 1's untitled Care Plan (CP) initiated on 3/30/2026, the CP indicated Resident 1 was on sedative (medication that slows down brain activity to produce calmness, relieve anxiety, or sleep)/hypnotic (prescription sleeping pills) therapy of Trazodone related to insomnia (trouble falling asleep or staying asleep). The CP intervention indicated for nursing staff to administer psychotropic medications as ordered by the physician and to monitor for any side effects. During a review of Resident 1's Order Summary Report (OSR) dated 3/30/2026, the OSR indicated for licensed staff to administer Divalproex Sodium Oral Tablet Delayed Release (Divalproex Sodium) 250 milligrams (mg- unit of measurement) by mouth two times a day for mood stabilizer manifested by mood swings. During a review of Resident 1's OSR dated 4/2/2026, the OSR indicated for licensed staff to administer Clozapine oral tablet 50 mg one tablet by mouth one time a day for schizophrenia manifested by auditory hallucinations (when a person hears sounds that are not present in the environment). During a review of Resident 1's untitled CP initiated on 4/2/2026, the CP indicated Resident 1 was on psychotropic medication Clozapine related to schizophrenia manifested by auditory hallucinations. The CP indicated Resident 1 was on Olanzapine for psychosis and Divalproex for mood stabilizer. The CP intervention indicated for nursing staff to administer psychotropic medications as ordered by the physician and to monitor for side effects. During a review of Resident 1's OSR dated 4/7/2026, the OSR indicated for licensed staff to administer Olanzapine oral tablet 10 mg 1 tablet by mouth one time a day for psychosis manifested by increased aggression. During a review of Resident 1's OSR dated 4/7/2026, the OSR indicated for licensed staff to administer Trazodone HCI Oral Tablet 100 mg one tablet by mouth at bedtime for depression manifested by inability to sleep. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 4/7/2026, the MDS indicated Resident 1 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 needed moderate assistance (helper does less than half the effort) from staff for eating, oral hygiene, and upper body dressing. The MDS indicated Resident 5 needed maximum assistance (helper does more than half the effort) from staff for toileting, shower, lower body dressing and putting on/taking off footwear. During a concurrent interview on 5/20/2026 at 12:50 pm with the facility's Director of Nursing (DON) and record review of Resident 1's medical records (PointClickCare - PCC, a cloud-based software) was reviewed. The DON stated there was no monitoring done for Resident 1's adverse side effects of Divalproex, Clozapine, Olanzapine and Trazodone used. The DON stated psychotropic medication side effects needed to be monitored every shift by licensed nurses to prevent adverse reactions of medications. b. During a review of Resident 73's AR, the AR indicated the facility admitted Resident 73 on 2/6/2026 with diagnoses including respiratory failure (a condition when the lungs cannot get enough oxygen into the blood) and depression. During a review of Resident 73's untitled CP initiated on 2/6/2026, the CP indicated Resident 73 was on antidepressant medication Duloxetine related to depression. The CP intervention indicated for nursing staff to monitor/document/report as needed any adverse reactions to antidepressant therapy: dry mouth, constipation, blurred vision, disorientation, confusion, difficulty urinating, hypertension (high blood pressure), dark urine, yellow skin, nausea and vomiting, lethargy (an abnormal state of extreme tiredness and severe lack of energy), drooling, dizziness, diarrhea, anxiety (emotion characterized by an unpleasant state of inner turmoil), nervousness, insomnia, somnolence (excessive drowsiness or a strong desire to sleep during the day), weight gain, anorexia (an eating disorder that causes a severe and strong fear of gaining weight), or increased appetite; many of these effects can increase the risk for falls. During a review of Resident 73's untitled CP initiated on 2/9/2026, the CP indicated Resident 73 was on Duloxetine for depression manifested by sad facial expressions. The CP intervention indicated for nursing staff to administer medications as ordered and to monitor/document for side effects and effectiveness. During a review of Resident 73's OSR dated 4/8/2026, the OSR indicated for licensed staff to administer Duloxetine Hydrochloride Oral Capsule Delayed Release Sprinkle 30 mg by mouth one time a day for depression manifested by sad facial expressions. During a review of Resident 73's MDS dated [DATE], the MDS indicated Resident 73 had moderately impaired cognition for daily decision making. The MDS indicated Resident 73 needed maximum assistance (helper does more than half the effort) from staff for toileting and shower. The MDS indicated Resident 5 needed moderate assistance from staff for lower body dressing and set up assistance (helper sets up or cleans up) for eating, oral hygiene, upper body dressing and personal hygiene. During a concurrent interview on 5/20/2026 at 12:31 pm with the facility's DON and record review of Resident 73's PCC, the DON stated Resident 73 was on Duloxetine for depression manifested by sad facial expressions. The DON stated sad facial expression was not a specific target behavior. The DON stated Resident 73 was able to express needs and feelings. During a review of the facility's Policy and Procedure (P&P) titled, Use of Psychotropic Medication, revised 1/16/2026, the P&P indicated, Psychotropic medications are to be used only when a practitioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). The effects of psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive care plan. The resident's response to the medication(s), including progress towards the goal and presence/absence of adverse consequences, shall be documented in the resident's medical record.

Based on interview and record review, the facility failed to develop a specific and individualized resident-centered care plan to meet the residents' needs for two of two sampled residents (Residents 14 and 26) by failing to:a. Develop a care plan for Resident 14 who was on enhanced barrier precaution (EBP, infection control measures to prevent the spread of multidrug resistant organisms [MDRO]). b. Develop a care plan for Resident 26 for the use of antibiotic therapy (medications used to treat and prevent infections caused by bacteria). These failures had the potential for Residents 14 and 26 not to receive necessary care, treatment, and services to address the residents' specific needs. Findings: a. During a review of Resident 14's admission Record (AR), the AR indicated the facility admitted Resident 14 on 3/1/2026 with diagnoses including End Stage Renal Disease (ESRD- a condition in which the kidneys cease functioning on a permanent basis) and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 14's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 3/5/2026, the MDS indicated Resident 14 was receiving dialysis. During a review of 14's Order Summary Report (OSR), the OSR indicated Resident 14 had an active order for Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities and are indicated for residents with infections, wounds, and indwelling medical devices) related to a right arm arteriovenous shunt (direct connection between an artery and a vein created for medical treatment), ordered on 4/24/2026. During a concurrent observation and interview on 5/19/2026 at 11:20 am with Resident 14 in the patio area, Resident 14 had a right upper arm dressing. Resident 14 stated, Resident 14 received hemodialysis treatments every Tuesdays, Thursdays, and Saturdays. During a concurrent interview and record review on 5/20/2026 at 2:47 pm with Licensed Vocational Nurse 1 (LVN 1), Resident 14's current Care Plans (CP) was reviewed and did not indicate a care plan addressing Resident 14's EBP. LVN 1 stated Resident 14 had a physician's order for EBP and Resident 14 should have a CP to prevent an infection of the AV shunt, harmful to Resident 14. During an interview on 5/21/2026 at 3:36 pm with the Director of Nursing (DON), the DON stated CPs should be resident-specific and a CP should be initiated and implemented for EBP. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, last revised 1/16/2026, the P&P indicated, it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident. The P&P indicated, the comprehensive CP would describe at a minimum the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. During a review of Resident 26's AR, the AR indicated the facility admitted Resident 26 on 4/13/2026 with diagnoses including pneumonia (an infection/inflammation in the lungs), infection of left lower extremity amputation (surgical removal of the portion of the leg) stump, and peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 26's Minimum Data Set (MDS, a resident assessment tool) dated 5/1/2026, the MDS indicated Resident 26 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 26 required partial/moderate assistance (helper did less than half the effort) with oral hygiene and upper body dressing. The MDS indicated Resident 26 was dependent (helper did all the effort, resident did none) with toileting and showering/bathing self. During a review of Resident 26's Order Summary Report (OSR) dated 5/13/2026, the OSR indicated Resident 26 had an order for Bactrim DS (a combination prescription antibiotic) tablet 800-160 milligrams (mg-unit of measurement), two times a day for left below the knee (BKA, surgical removal of the portion of the leg below the knee) infection. During a concurrent interview and record review on 5/21/2026 at 12:25 pm with the Director of Staff Development (DSD), Resident 26's OSR dated 5/13/2026 and CPs were reviewed. The DSD stated Resident 26 had a left BKA infection and was on antibiotic therapy up to 5/25/2026. The DSD stated there was no care plan developed and initiated for Resident 2 for the use of antibiotics. The DSD stated the resident's care plan should be developed for any concerns of the resident based on diagnosis, assessment, medication, and treatment. The DSD stated Resident 26 should have a care plan to address the use of antibiotics to monitor Resident 26's response to the treatment or intervention and presence of any side effects (any secondary unintended effect of a medical treatment or medication) and/or adverse reactions (unintended, harmful, or unpleasant effect caused by medication, treatment or procedure). During an interview on 5/21/2026 at 3:34 pm with the Director of Nursing (DON), the DON stated a care plan needed to have interventions and goals specific to the residents to guide staff on how to provide necessary care and to monitor and determine if interventions developed in the care plan were effective. During a review of the facility's Policy and Procedures (P&P) titled, Comprehensive Care Plans, reviewed on 1/16/2026, the P&P indicated, The comprehensive care plan will describe, at a minimum, the following: The services are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment.

Based on observation, interview, and record review, the facility failed to revise the resident's care plan for one of one sampled resident (Resident 73) to reflect Pneumocystis Jirovecii Pneumonia (PJP, life-threatening fungal lung infection) prophylaxis in accordance with the facility's Policy and Procedure (P&P) on comprehensive care plan. This failure had the potential to not provide Resident 73 with necessary care and services and compromise Resident 73's safety. Findings: During a review of Resident 73's admission Record (AR), the AR indicated the facility admitted Resident 73 on 2/6/2026 with diagnoses including respiratory failure (a condition when the lungs cannot get enough oxygen into the blood) and depression (persistent feeling of sadness and loss of interest). During a review of Resident 73's untitled Care Plan (CP) initiated on 2/6/2026, the CP indicated Resident 73 was on antibiotic therapy of Bactrim Double Strength (antibiotic used to kill bacteria causing infections) Oral tablet 800 to 160 milligram (mg, unit of measurement) related to encephalitis (swelling or inflammation of the brain). The CP intervention indicated for licensed nursing staff to administer antibiotic medication as ordered by the physician. During a review of Resident 73's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/7/2026, the MDS indicated Resident 73 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 73 needed maximum assistance (helper does more than half the effort) from staff for toileting and showering. The MDS indicated Resident 5 needed moderate assistance (helper does less than half the effort) from staff for lower body dressing and set up assistance (helper sets up or cleans up) from staff for eating, oral hygiene, upper body dressing and personal hygiene. During a review of Resident 73's Order Summary Report (OSR) dated 5/14/2026, the OSR indicated for licensed staff to administer Bactrim DS Oral Tablet 800 - 160 mg, 1 tablet by mouth in the morning every Monday, Wednesday, Friday for Pneumocystis Jirovecii Pneumonia. During an observation on 5/19/2026 at 12:21 am inside Resident 73's room, Resident 73 was awake, lying in bed. During a concurrent interview and record review on 5/20/2026 at 11:25 pm with the Quality Assurance Nurse (QAN) of Resident 73's medical records (PointClickCare - PCC, a cloud-based software) was reviewed. The QAN stated Resident 73's CP for antibiotic therapy was not revised when the licensed nurse received the order from the physician on 5/14/2026 for PJP prophylaxis. The QAN stated the licensed nurse should revise the CP when there was a change in the resident's condition that needed nursing interventions to be updated. The QAN stated Resident 73's CP needed to be updated to provide necessary and quality care, according to the resident's needs while receiving antibiotics. During an interview on 5/21/2026 at 3:36 pm with the Director of Nursing (DON), the DON stated the licensed nurse did not update Resident 73's CP for antibiotic use to reflect what Resident 73 was treated for. The DON stated Resident 73's CP should have been revised to guide the staff on how to provide care and treatment to Resident 73. During a review of the facility's P&P titled, Comprehensive Care Plans, revised 1/16/2026, the P&P indicated, The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on observation, interview, and record review, the facility failed to ensure non-English speaking (refers to an individual who cannot speak or understand or have difficulty speaking or understanding the English language) residents were provided with a communication board/device in a language that the resident understood for one of one sampled resident (Resident 2). This failure had the potential to affect Resident 2's communication with staff resulting in delay in the provision of care, treatment and service to Resident 2.Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 2/6/2026 with diagnoses including dementia (a progressive state of decline in mental abilities), anxiety (a feeling of fear, dread, or unease) and history of falling. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 5/7/2026, the MDS indicated Resident 2's preferred language was Cantonese. The MDS indicated Resident 2 had severely impaired cognition (ability to understand and process information) for daily decision making. The MDS indicated Resident 2 required partial/moderate assistance (helper did less than half the effort) with oral hygiene, upper body dressing and personal hygiene. The MDS indicated Resident 2 was dependent (helper did all the effort) with toileting, shower and lower body dressing. During a concurrent observation inside Resident 2's room and interview on 5/19/2026 at 9:40 am with Restorative Nurse Assistant 1(RNA 1), Resident 2 was speaking in a language other than English. RNA 1 stated Resident 2's language was Cantonese. RNA 1 stated Resident 2 did not speak or understand English. RNA 1 stated Resident 2 did not have a communication board in the room. RNA 1 stated that residents whose primary language (language an individual uses most frequently and proficiently) was not English should have a communication board with pictures and descriptions of their spoken language in the room. RNA 1 stated the communication board would assist the residents to communicate basic needs and help staff better understand and meet the residents' needs. During an interview on 5/21/2026 at 3:34 pm with the Director of Nursing (DON), the DON stated all non-verbal, but alert and oriented residents and non-English speaking residents should have a communication board in the room to express their needs and for staff to be able to address the resident's needs appropriately. During a review of the facility's Policy and Procedures (P&P) titled, Effective Communication, revised 1/16/2026, the P&P indicated, Staff will communicate with the resident, using techniques identified in their plan of care, and in accordance with his/her established routine for communication, as possible. Adaptive techniques include but are not limited to: Using communication boards or writing materials (i.e. write legibly, in plain terms).

Based on observation, interview, and record review, the facility failed to ensure the Foley Catheter (FC, a thin, flexible, rubber or plastic tube used to drain urine from the bladder) was secured on the resident's thigh in accordance with the facility's Policy and Procedure (P&P) Indwelling Catheter Use and Removal, for one of two sampled residents (Resident 27). This failure had the potential to result in catheter-related complications for Resident 27.Findings: During a review of Resident 27's admission Record (AR), the AR indicated the facility admitted Resident 27 on 5/4/2026 with diagnoses including obstructive and reflux uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional) and benign prostatic hyperplasia (BPH, a noncancerous enlargement of the prostate gland). During a review of Resident 27's untitled Care Plan (CP) initiated on 5/5/2026, the CP indicated Resident 27 had an indwelling catheter related to obstructive and reflux uropathy due to BPH. The CP intervention indicated for nursing staff to monitor/document for pain/discomfort due to the use of a catheter. During a review of Resident 27's Minimum Data Set (MDS, a resident assessment tool) dated 5/8/2026, the MDS indicated Resident 27 had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 27 was dependent (helper does all of the effort) from staff with toileting, shower, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 27 needed maximum (helper does more than half the effort) assistance from staff with oral hygiene, upper body dressing and personal hygiene. During a review of Resident 27's Order Summary Report (OSR) dated 5/5/2026, the OSR indicated for licensed staff to insert indwelling (foley) catheter, French (a type of catheter) 16 (size of the catheter), change for blockage, leaking, pulled out and excessive sedimentation (visible particles in the urine); change catheter drainage bag as needed and with every change of FC as needed for obstructive uropathy. During an observation on 5/19/2026 at 9:39 am inside Resident 27's room, Resident 27 was awake, lying in bed with FC hanging on the right side of the bed. During a concurrent observation inside Resident 27's room and interview on 5/19/2026 at 9:42 am with the Director of Staff and Development (DSD), the DSD stated Resident 27's FC tubing was not secured with a securement device. The DSD stated the FC tubing should be secured properly on Resident 27's right thigh to prevent the tubing from being pulled out and to prevent injury during Resident 27's movement or activities of daily living (ADL). During an interview on 5/21/2026 at 3:30 pm with the facility's Director of Nursing (DON), the DON stated, Resident 27's FC tubing needed to be secured with a securement device to ensure the FC would not be pulled out during care and prevent injury to the resident. During a review of the facility's Policy and Procedure (P&P) titled Indwelling Catheter Use and Removal, revised 1/16/2026, the P&P indicated, Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodgement of the catheter and securement of the catheter to facilitate flow of urine, prevention of kinks in the tubing and positioning below the level of the bladder.

Based on observation, interview, and record review, the facility failed to ensure residents on oxygen therapy (treatment that provides supplemental, or extra oxygen) had an oxygen in use warning sign posted outside the room for one of one sampled resident (Resident 26). This failure placed Resident 26, facility staff and visitors at risk of the dangers of accidental fire and injury. Findings: During a review of Resident 26's admission Record (AR), the AR indicated the facility admitted Resident 26 on 4/13/2026 with diagnoses including pneumonia (an infection/inflammation in the lungs), dementia (a progressive state of decline in mental abilities), and heart failure (HF, a heart disorder which causes the heart to not pump blood efficiently). During a review of Resident 26's untitled Care Plan (CP) initiated on 4/24/2026, the CP indicated Resident 26 had altered respiratory status/difficulty breathing. The CP goals included Resident 26 would not have complications related to shortness of breath and signs and symptoms of poor oxygen absorption. During a review of Resident 26's Minimum Data Set (MDS, a resident assessment tool) dated 5/1/2026, the MDS indicated Resident 26 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 26 required partial/moderate assistance (helper did less than half the effort) with oral hygiene and upper body dressing. The MDS indicated Resident 26 was dependent (helper did all the effort, resident did none of the effort to complete the activity) with toileting and shower. During a review of Resident 26's Order Summary Report dated 5/13/2026, the OSR indicated Resident 26 had an order for oxygen via (by way of/through) nasal cannula (NC, a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at 2 liters per minute (l/min) as needed for shortness of breath/wheezing (abnormal breath sound). During a concurrent observation inside Resident 26's room and interview on 5/20/2026 at 1:16 pm with the Infection Prevention Nurse (IPN), Resident 26 was in bed with ongoing oxygen at 2 l/min via NC. The IPN stated there was no oxygen in use warning sign posted outside Resident 26's room. The IPN stated all residents with ongoing oxygen therapy should have an oxygen in use warning sign posted outside the residents' room indicating oxygen was in use and smoking was prohibited and to remind visitors and other residents not to smoke inside the room for the safety of the resident and staff in the facility. During an interview on 5/21/2026 at 3:34 pm with the Director of Nursing (DON), the DON stated residents on oxygen therapy should have an oxygen in use warning sign posted outside the residents' room to alert visitors and residents not to smoke inside the residents' room to avoid fire and for residents' safety. During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Concentrator, revised 1/16/2026, the P&P indicated, The purpose of the policy is to establish responsibilities for the care and use of oxygen concentrators. Place an oxygen warning sign on the resident's door. Remove smoking materials, electric razors or other spark-generating electrical appliances from the room and explain the reasons to the resident.

Based on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) on the use of bed rails/siderails (adjustable metal or rigid plastic bars attached to the bed) for one of one sampled resident (Resident 64). This failure placed Resident 64 at risk for entrapment and injury from the use of bed rails.Findings: During a review of Resident 64's admission Record (AR), the AR indicated the facility admitted Resident 64 on 4/11/2026 with diagnoses including osteoarthritis (a progressive disorder of the joints caused by a gradual loss of cartilage) and right knee joint replacement surgery (removal of damaged bone and cartilage in a joint and replaced with durable artificial implants). During a review of Resident 64's Bed Rails Assessment (BRA) dated 4/11/2026, the BRA indicated Resident 64 did not need the use of bed rails. During a review of Resident 64's Minimum Data Set (MDS, a resident assessment tool) dated 4/15/2026, the MDS indicated Resident 64 had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 64 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene, upper body dressing and personal hygiene. The MDS indicated Resident 64 required partial/moderate assistance (helper did less than half the effort) with toileting, and lower body dressing. The MDS indicated Resident 64 was dependent (helper did all the effort, resident did none of the effort to complete the activity) with shower. During a review of Resident 64's Order Summary Report (OSR) with active orders as of 5/19/2026, the OSR did not indicate an order for the use of bilateral one-half (1/2) bed rails) for Resident 64. During a concurrent observation inside Resident 64's room and interview on 5/19/2026 at 9:58 am with Certified Nurse Assistant 2 (CNA 2), Resident 64 was sitting on the edge of the bed with bed rails/siderails up on both sides of the bed. CNA 2 stated Resident 64 was able to sit, stand and walk with supervision. Resident 64 stated Resident 64 did not need the siderails and did not request the installation of siderails. During a concurrent interview and record review on 5/19/2026 at 2:15 pm with the Medical Records staff (MR), Resident 64's electronic medical record (EMR), OSR with active orders as of May 2026 and BRA dated 4/11/2026 were reviewed. The MR stated the OSR did not indicate Resident 64 had an order for the use of bilateral 1/2 bed rails. The MR stated the BRA did not indicate Resident 64 needed the use of side rails during the assessment. The MR stated Resident 64 did not have a consent for the use of bilateral 1/2 siderails in the EMR. During an interview on 5/19/2026 at 2:20 pm with Registered Nurse Supervisor 2 (RN 2), RN 2 stated residents with bed siderails should have a physician's order and consent obtained from the resident or responsible party before the installation of bed rails/siderails for the safety of the resident and to prevent injury. During an interview on 5/21/2026 at 3:34 pm with the Director of Nursing (DON), the DON stated a physician's order and consent should be obtained before the installation of bed rails/siderails because bed rails/siderails were considered as restraints and this would prevent potential entrapment and injury to the residents. During a review of the facility's P&P titled, Proper Use of Bed Rails, revised 1/16/2026, the P&P indicated, Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. This information should be presented in an understandable manner, and consent given voluntarily, free from coercion. Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified bed rail and medical diagnosis, condition, symptom, or functional reason for the use of the bed rail.

Based on observation, interview, and record review, the facility failed to keep one of two laundry dryers in a safe, operating, and sanitary condition for residents. This failure had the potential to result in spread of infection and posed as potential fire hazard. Findings: During a concurrent observation and interview on 5/21/2026 at 12:40 pm with Housekeeping 1 (HKP 1) in the facility's laundry room, there were two dryers (container to put wet laundry for drying) in the facility's laundry room. One dryer had multiple random thick patches of light brown material on the dryer lint trap. HKP 1 stated HKP 1 did not monitor, sign and complete the Dryer Lint Clean Out Schedule Form because it was unreadable. HKP 1 stated the dryer lint trap needed to be cleaned every 2 hours to avoid potential fire. During a concurrent interview on 5/21/2026 at 12:42 pm with Housekeeping Supervisor (HKP Sup) and record review of the Dryer Lint Clean Out Schedule Form, the HKP Sup stated the dryer lint trap was thick and lint has accumulated. The HKP Sup stated the dryer lint trap should have been cleaned every 2 hours to avoid fire and prevent infection. The HKP Sup stated the Dryer Lint Clean Out Schedule Form was filled out by mistake by the Housekeeping Staff (unidentified) this morning. The HKP Sup stated the unidentified HK staff filled out the form until 8pm on 5/21/2026. The HKP Sup stated the Dryer Lint Clean Out Schedule Form should be filled out timely every after cleaning and not in advance. During a review of the undated facility's Policy and Procedure (P&P) titled, Lint Trap Cleaning Policy, the P&P indicated, All laundry staff required to clean and inspect dryer lint traps every 2 hours during operational hours and additionally whenever excessive lint buildup is observed. Proper lint trap maintenance is mandatory for fire prevention, infection control and equipment safety. Laundry staff shall document lint trap cleanings on the designated Laundry Lint Trap Cleaning Log including date, time cleaned, and employee initials/signature.

Based on observation, interview and record review, the facility failed to implement the care plan for one of three sampled residents (Resident 1) by failing to ensure Resident 1 did not have clutter around Resident 1's bed. This deficient practice placed Resident 1 at risk for falls and injuries from excessive clutter surrounding Resident 1's bed.Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses that included COPD (Chronic obstructive pulmonary disease, a chronic lung disease causing difficulty in breathing), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily functioning), and depression (a persistent sadness, loss of interest in activities, and low energy, severely impacting daily life). During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated [DATE], the H&P indicated Resident 1 had minor memory impairments but had the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], the MDS indicated Resident 1's cognitive skills (ability to make daily decisions) was intact. The MDS also indicated Resident 1 was independent (completed activity with no assistance with helper) with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and with mobility and walking. During a review of Resident 1's Social Services Notes (SSN), dated [DATE], the SSN indicated Resident 1 was educated about how too much clutter around her bed posed a safety hazard to both Resident 1 and Resident 1's roommates. The SSN also indicated Resident 1 refused to allow the facility to store Resident 1's belongings in an alternate location instead of at the bedside. During a review of Resident 1's medical record, there were no other notes from [DATE] to [DATE] regarding assisting or encouraging Resident 1 to remove the clutter from Resident 1's room. During a review of Resident 1's Care Plan Report (CPR), initiated on [DATE], the CPR indicated Resident 1 was at risk for falls due to incontinence (lack of voluntary control over urination and/or bowel movement) and history of falls. The CPR interventions included providing Resident 1 a safe environment free from spills and/or clutter. During a review of Resident 1's CPR, initiated on [DATE], the CPR indicated Resident 1 had a behavior problem of hoarding (a mental health condition marked by a persistent inability to discard possessions, leading to excessive accumulation that clutters living spaces, disrupts daily life, and causes distress) related to anxiety and depression. The CPR interventions included for the Interdisciplinary Team (IDT, a team of professionals from various disciplines who work in collaboration to address the resident's care) to follow up with Resident 1 regarding hoarding behavior and intervening as necessary to protect the rights and safety of others. The CPR indicated there had been no updates or changes to the CPR since it was initiated on [DATE]. During an observation on [DATE] at 2 pm, in Resident 1's room, Resident 1's bed was surrounded by stacked up boxes, crates, and bags filled with clothes. Resident 3's bed was next to Resident 1's bed and there was hardly any room to get to Resident 3's bed due to the clutter around Resident 1's bed. During an interview on [DATE] at 4:05 pm with Resident 3, Resident 1's roommate, Resident 3 stated Resident 3's bed was next to Resident 1's bed and staff (in general) had difficulty providing Resident 3 assistance due to the clutter around Resident 1's bed. During an interview on [DATE] at 4:15 pm with Certified Nursing Assistant (CNA 2), CNA 2 stated it was hard for CNA 2 to help other residents in Resident 1's room because of Resident 1's belongings. During a review of the facility's Policy & Procedure (P&P) titled, Comprehensive Care Plans, revised [DATE], the P&P indicated, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The P&P further indicated, The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

Based on interviews and record review, the facility failed to ensure one of three sampled residents (Resident 1) received mail and other packages within 24 hours of delivery.This deficient practice violated Resident 1's right to receive mail promptly (delivery of mail or other materials to the resident within 24 hours of delivery) and had the potential to impact Resident 1's well-being.Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 4/25/2025 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), acute pulmonary edema (rapid accumulation of fluid in the lungs) and anxiety disorder (a mental health condition characterized by excessive worry and fear that interferes with daily life). During a review of Resident 1's History and Physical (H&P) dated 8/13/2025, the H&P indicated Resident 1 had the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 10/31/2025, the MDS indicated Resident 1 had intact cognition (ability to make daily decisions). The MDS indicated Resident 1 was independent of dressing, shower/bathe self, toileting hygiene and personal hygiene. During an interview on 11/25/2025 at 9:10 AM with Resident 1, Resident 1 stated the facility's Social Service gave the mail to Resident 1 from Supplemental Security Income (SSI) dated 9/1/2025 in November 2025. During a concurrent interview and record review on 11/25/2025 at 3:55 PM with the facility's Social Service Director (SSD), Resident 1's mail from SSI dated 9/1/2025 on the first page of the letter, was reviewed. The SSD stated the SSD did not know what date the mail was delivered to the facility, and the SSD delivered the letter to Resident 1 in October 2025 after receiving the letter for a couple weeks already. The SSD stated the facility did not have any documentation to trace and record the date of receiving and delivering mail to the residents. During a concurrent interview and record review on 11/26/2025 at 10:01 AM with the facility's Social Service Assistant (SSA), Resident 1's mail from SSI dated 9/1/2025 was reviewed. The SSA stated the SSA and the SSD gave the mail to Resident 1 in October 2025. The SSA stated the facility's Social Service Department was responsible for delivering mail to the residents but there was no documentation to trace and record the date of receiving and delivering mail to the residents. During an interview on 11/26/2025 at 10:39 AM with the facility's Business Office Assistant (BOA), the BOA stated, the Social Service Department was responsible for delivering the letters and packages to residents after receiving them. The BOA stated the facility does not deliver mail or packages to residents on weekends (Saturdays and Sundays) because there was no Social Service staff during the weekends. During a concurrent interview and record review on 11/26/2025 at 12:01 PM with the facility's Director of Nursing (DON), the DON stated the facility did not have a policy and procedure on tracing received mails and packages and delivering them to the residents.

Based on interview and record review, the facility failed to ensure the nursing staff implemented person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) for one of two sampled residents (Resident 2) by failing to monitor Resident 2's symptoms of increased confusion/physical abusive towards staff. These deficient practices had the potential to place Resident 2 at risk of not receiving the individualized care services to attain or maintain highest practicable physical, mental, and psychosocial well-being.Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to facility on 2/17/2025 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness) following nontraumatic intracerebral hemorrhage (bleeding within the brain, most commonly due to high blood pressure, trauma, or other blood vessel issues) affecting left non-dominant side, acute kidney failure (rapid loss of kidney function, where the kidneys can no longer effectively filter waste, balance fluids, and maintain electrolytes), and neuromuscular dysfunction of bladder (occurs when nerve damage disrupts communication between the brain and the bladder, leading to symptoms like loss of bladder control, frequent urination, or difficulty emptying the bladder). During a review of Resident 2's History and Physical (H&P), dated 2/20/2025, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 8/22/2025, the MDS indicated Resident 2 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with oral hygiene, toileting hygiene, shower/bathe self, lower body dressing, and personal hygiene. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with upper body dressing. During a review of Resident 2's Care Plan Report(CP), initiated on 9/5/2025, the CP indicated Resident 2 had increased confusion/physical abusive towards staff, and the facility will monitor resident for worsening of symptoms. During a concurrent interview and record review on 11/20/2025 at 11:38 AM with the Registered Nurse (RN) 2, Resident 2's Medication Administration Record (MAR), Monitoring Record (MR), and CP for September, October, and November 2025 were reviewed. RN 2 stated there was no documentation to indicate the implementation of the CP, such as monitoring Resident 2 for worsening symptoms. RN 2 stated Resident 2 should be monitored according to the CP to improve the resident's safety and well-being. During a concurrent interview and record review on 11/20/2025 at 1:28 PM with the Licensed Vocational Nurse (LVN) 3, Resident 2's MAR, MR, and CP for September, October, and November 2025 were reviewed. LVN 3 stated there was no monitoring record for Resident 2, and the staff should have monitored Resident 2's symptoms of confusion/physical abusive towards staff to implement the CP. During a concurrent interview and record review on 11/20/2025 at 1:37 PM with the Director of Nursing (DON), Resident 2's MAR, MR, and CP for September, October, and November 2025 were reviewed. The DON stated that the facility did not monitor Resident 2's symptoms of confusion/physical abusive towards staff according to the interventions indicated in the resident's CP. During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Care Plans, implemented on 12/19/2022 and revised on 1/31/2025, the P&P indicated that the facility should develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The P&P indicated, Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on interview and record review, the facility failed to ensure the licensed nurse implemented the facility's Policy and Procedure (P&P) titled Medication Orders by failing to indicate the severity of the pain level for the pain medication order for one of two sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk of not receiving the optimal therapeutic effect (desirable and beneficial effects resulting from a medical treatment) of the medication, which had the potential to impair Resident 1's wellbeing.Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 8/15/2025 with diagnoses including hemiplegia (total paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (as a result of disrupted blood flow to the brain due to problems with the blood vessels) affecting left non-dominant side, type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (a type of nerve damage that can happen with diabetes), and aphasia (a disorder that makes it difficult to speak) following cerebral infarction.During a review of Resident 1's History and Physical (H&P) dated 8/16/2025, the H&P indicated Resident 1 could not make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 8/18/2025, the MDS indicated Resident 1 had severely impaired cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for oral hygiene, bathing, upper body dressing, personal hygiene, and toileting hygiene. During a review of Resident 1's Order Summary Report (OSR), dated 11/19/2025, the OSR indicated Resident 1 had a medication order for hydrocodone-acetaminophen ( medication to relieve pain) oral tablet 5-325 milligrams (mg-measuring unit), one tablet via (through) the gastrostomy tube (G-Tube, a surgical opening fitted with a device to allow feedings/medications administered directly into the stomach) every four hours as needed for pain, with order start date of 11/3/2025. During a concurrent interview and record review on 11/20/2025 at 11:38 AM with Registered Nurse 2 (RN 2), Resident 1's Medication Administration Record (MAR) and OSR for November 2025 were reviewed. The MAR indicated Resident 1 was administered hydrocodone-acetaminophen 5-325 mg via G-Tube for pain levels ranging from 4 to 9 on a 0 to 10 pain scale rating (a numerical rating scale, which 0 equals to no pain, 10 equals to the worst pain possible; 1-3 mild pain, 4-6 moderate pain and 7-10 severe pain) on several days. RN 2 stated Resident 1's order for hydrocodone-acetaminophen did not indicate to administer the pain medication based on pain level by using a numerical scale but the MAR indicated the licensed nurse administered hydrocodone-acetaminophen to Resident 1 based on pain level of 4 to 9. RN 2 stated Resident 1's order for hydrocodone-acetaminophen should have been clarified by the licensed nurse with Resident 1's physician to indicate hydrocodone-acetaminophen was for moderate and/or severe pain. During a concurrent interview and record review on 11/20/2025 at 1:28 PM with Licensed Vocational Nurse 3 (LVN 3), Resident 1's MAR and OSR for November 2025 were reviewed. LVN 3 stated the licensed nurse who entered the order for Resident 1's hydrocodone-acetaminophen should have indicated the pain medication was for moderate or severe pain. During a concurrent interview and record review on 11/20/2025 at 1:37 PM with the Director of Nursing (DON), Resident 1's MAR and OSR for November 2025 were reviewed. The DON stated the licensed nurse failed to enter the hydrocodone-acetaminophen medication order correctly for Resident 1. The DON stated the order for hydrocodone-acetaminophen for Resident 1 should be clarified with the physician and entered with indication for moderate and/or severe pain for Resident 1. The DON stated it was important for the nurses to enter the order accurately. During a review of the facility's P&P titled, Medication Orders, revised 1/31/2025, the P&P indicated, Elements of the Medication Order:i. Diagnosis or indication for use.j. PRN (as needed) orders should also specify the condition for which they are being administered, (e.g., as needed for sleep).The P&P indicated, Documentation of Medication Orders:b. Clarify the order. During a review of the facility's P&P titled, Pain Management, revised 3/17/2025, the P&P indicated the facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain. The P&P indicated the facility would ask the patient to rate the intensity of his/her pain using a numerical scale, a verbal or visual descriptor that is appropriate and preferred by the resident. The P&P indicated factors influencing the choice of treatments include:a. The cause, location and severity of resident's pain .P&P indicated pharmacological interventions will follow a systematic approach for selecting medications and doses to treat pain. general principles the facility will utilize for prescribing analgesics:a. Evaluate the resident's medical condition, current medication regimen, cause and severity of the pain and course of illness to determine the most appropriate analgesic therapy for pain.

Based on interview and record review, the facility failed to ensure three of three sampled residents (Resident 30, 31 and 34) and/or their representatives were provided information regarding the right to formulate an advance directive (AD, legal documents that provide instructions for medical care and only go into effect if the person cannot communicate his/her own wishes) when: a. Resident 34 did not receive information regarding AD. b. Resident 30's AD Acknowledgement Form was filled out inaccurately. c. Resident 31's AD Acknowledgement Form was filled out inaccurately. These failures had the potential to result in Residents 30, 31, and 34 and/or their representatives to not be informed of their rights and receive unwanted and/or unnecessary life-sustaining care and treatment. Findings: a. During a review of Resident 34's Admission Record (AR), the AR indicated Resident 34 was readmitted to the facility on [DATE], with diagnoses that included diabetes mellitus (elevated blood sugars), cirrhosis of the liver (liver damage where healthy cells are replaced by scar tissue), and dependence on renal dialysis (a treatment for people whose kidneys are failing). During a review of Resident 34's History and Physical (H&P), dated 12/5/2024, the H&P indicated Resident 34 had the capacity to understand and make decisions. During a review of Resident 34's Minimum Data Set (MDS, a resident assessment tool), dated 1/31/2025, the MDS indicated Resident 34 was cognitively intact (able to think, learn, and remember) and required substantial/maximal assistance (helper does less than half the effort) with toileting hygiene and shower/bathing. During a concurrent interview and record review on 3/18/2025 at 3:13 pm with Licensed Vocational Nurse (LVN) 6, Resident 34's paper and electronic chart were reviewed. LVN 6 stated Resident 34 did not have an AD in her charts. LVN 6 stated the AD was important to document to know and record the resident's wishes and instruct the facility on who will carry them out. During an interview on 3/20/2025 at 3:46 pm with the Director of Nursing (DON), the DON stated the AD was important to determine the resident's wishes regarding provision of medical treatment and services. During an interview on 3/21/2025 at 9:52 am with Resident 34, Resident 34 was awake, alert and oriented. Resident 34 stated Resident 34 was not aware of an AD and staff did not provide was Resident 34 with any information about an AD. Resident 34 stated, I would like to know more to make good decisions about my care. During a review of the facility's policy and procedure (P&P) titled, Residents' Rights Regarding Treatment and Advance Directive, revised on 12/9/2024, the P&P indicated, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. The P&P indicated, The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive. 42781 b. During a review of Resident 30's AR, the AR indicated Resident 30 was admitted to the facility on [DATE] with diagnoses that included abnormalities of gait (a person's manner of walking) and mobility (the ability to move) and need for assistance and personal care. During a review of Resident 30's H&P, dated 12/15/2024, the H&P indicated Resident 30 had the capacity to understand and make decisions. During a review of Resident 30's MDS, dated [DATE], the MDS indicated Resident 30 had moderate impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated, Resident 30 required maximum assistance (helper does less than half the effort) with oral hygiene, upper body dressing and personal hygiene. The MDS indicated, Resident 30 was dependent (helper does all of the effort) on staff for toileting hygiene, shower, lower body dressing, and putting on or taking off footwear. During an interview and concurrent record review on 3/18/2025 at 2:46 pm, Resident 30's AD Acknowledgement Form was reviewed, with Social Service Director (SSD), the SSD stated, the AD Acknowledgement Form was not filled out accurately. The SSD stated, the form should indicate if Resident 30 [or Resident 30's responsible party] executed and had not executed and AD. The SSD stated, AD Form needed to be filled up accurately. c.During a review of Resident 31's AR, the AR indicated Resident 31 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine). During a review of Resident 31's MDS, dated [DATE], the MDS indicated, Resident 31 had intact cognition for daily decision making. The MDS indicated, Resident 31 required maximum assistance with shower and putting on/taking off footwear. The MDS indicated, Resident 31 require moderate (helper does less than half of the effort) with toileting hygiene, upper body dressing and lower body dressing. During an interview and concurrent record review on 3/18/2025 at 3:02 pm, with LVN 5, Resident 31's AD Acknowledgement Form was reviewed. LVN 5 stated, Resident 31 did not execute an AD. LVN 5 stated, I filled up the AD Form incorrectly. LVN 5 stated an AD was legal documentation for medical decisions indicating [Resident 31's] wants and wishes during [medical] emergencies. During an interview on 3/20/2025 at 10:20 am, with the facility's Director of Nursing (DON), the DON stated, AD Acknowledgement Forms needed to be filled out completely. The facility's DON stated the AD Form's purpose was to know what the resident's wants and wishes were in case of [medical] emergencies. During a review of the facility's Policy and Procedure (P&P), titled, Residents' Rights Regarding Treatment and Advance Directives, revised 12/9/2024, the P&P indicated, on admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident, if cognitively able to, would like to formulate advance directive. The P&P indicated. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff.

Based on interview and record review, the facility failed to ensure irregularities identified from the monthly drug regimen review reported by the facility's pharmacist were acted upon for two of five sampled residents (Residents 20 and 34): a. Resident 34's pharmacist recommendation to order laboratory test to monitor the increased risk of rhabdomyolysis (a serious medical condition of a breakdown of muscle tissue, releasing harmful substances into the bloodstream) was not acted upon. b. Resident 20's pharmacist recommendation to discontinue Benadryl (medication to treat pain and itching) was not acted upon. These deficient practices had the potential for unnecessary medication administration. Findings: a. During a review of Resident 34's Admission Record (AR), the AR indicated Resident 34 was readmitted to the facility on [DATE] with diagnoses that included diabetes (elevated blood sugar), cirrhosis of the liver (liver damage replaced by scar tissue) and dependence on renal dialysis (a treatment for people whose kidneys are failing). During a review of Resident 34's History and Physical (H&P) dated 12/5/2024, the H&P indicated Resident 34 had the capacity to understand and make decisions. During a review of Resident 34's Physician Orders (PO) dated 1/5/2025, the PO indicated for Resident 34 to receive Lipitor (Atorvastatin, a statin [a class of medication] that can treat high cholesterol and triglyceride levels) 10 milligrams (mg-unit of measurement) by mouth (PO) nightly (HS) and Tricor (Fenofibrate, a fibric acid [a class of lipid lowering medication] a medication to lower high cholesterol and triglyceride levels) 145 mg by mouth in the afternoon (QD). During a review of Resident 34's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 1/31/2025, the MDS indicated Resident 34 was cognitively intact and required maximal assistance (helper does less than half the effort) with toilet hygiene, shower and bathing. During a review of Resident 34's Medication Administration Record (MAR) for March 2025, the MAR indicated Resident 34 received Lipitor 10 mg PO HS by mouth nightly (HS) and Tricor (Fenofibrate, 145 mg PO in the afternoon (QD) from 3/1/2025 to 3/18/2025. During a record review of a document titled Note to Attending Physician/Prescriber ([NAME]), from the facilities pharmacist, dated 2/27/2025, the [NAME] indicated, The resident currently received Fenofibrate and Lipitor daily and to be aware that fibric acid in combination with a statin can increase the risk of rhabdomyolysis and require careful monitoring as to new labeling changes are no longer approved a fibric acid to be used with statins due to lack of CV (cardiovascular) benefit and more risks with the combos and to please consider ordering a FLP( a blood test the measures cholesterol and triglyceride level after a period of fasting) . to re-evaluate if Fenofibrate could be discontinued or assess risk versus benefit of continued concurrent (the same time). The [NAME] portion titled Physician/Prescribers Response, was left blank. During an interview with the facility's Director of Nursing (DON) on 3/20/2025 at 4:04 pm and a concurrent record review of Resident 34's electronic and paper chart, the DON stated as of 3/20/2025, Resident 34 was currently receiving Tricor and Lipitor. The DON stated the pharmacist recommendation review (MRR) should be followed as soon as possible, within a week. The DON stated following up on pharmacist recommendations were important to ensure the resident's medication were regulated by a pharmacist and residents received proper/safe medications. 42781 b.During a review of Resident 20's AR, the AR indicated Resident 20 was admitted to the facility on [DATE] with diagnoses that included personal history of other infectious and parasitic (an organism, or living thing, that lives on or inside another organism) diseases. During a review of Resident 20's MDS, dated [DATE], the MDS indicated Resident 20 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 20 required maximum assistance (helper does less than half the effort) with toileting hygiene and lower body dressing. During a review of Resident 20's Order Summary Report (OSR), dated active as of 3/20/2025, the OSR included the following physician orders, 1.Allergy Relief Oral Tablet 10 mg (Loratadine, [Claritin is the common brand name] medication used to treat allergy symptoms, including runny or stuffy nose, sneezing, watery eyes, and itching of the eyes, nose or throat), give one (1) tablet by mouth in the morning for allergy relief, start date 12/22/2023. 2. Benadryl Allergy (medication used to treat allergic reactions) oral tablet 25 mg by mouth every six (6) hours as needed for itching, start date 12/6/2024. During a review of a facility document (regarding Resident 20) titled, Note to Attending Physician/Prescriber, dated 1/31/2025, completed by the facility's PC, the note's recommendation indicated if Resident 20 had a chronic (long standing) itch, to consider discontinuing as needed Benadryl and start Claritin (Loratadine) 10 mg by mouth daily for chronic itch. During a concurrent record review and interview with Licensed Vocational Nurse 1 (LVN 1) on 3/20/2025 at 9:47 am, Resident 20's medical record (chart) was reviewed. LVN 1 stated Benadryl was not discontinued. LVN 1 stated, the purpose of MRR was for the pharmacy to check the medications monthly to control [administration of] unnecessary medications the residents were taking. During an interview on 3/20/2025 at 9:55 am, with the facility's Director of Nursing (DON), the DON stated, the MRR was a monthly recommendation [from the pharmacist] that licensed nurses were supposed to carry out. The DON stated, there was no other clinical documentation that indicated the monthly recommendation [to discontinue Benadryl for Resident 20] from the pharmacist dated 1/31/2025 was carried out. During a review of the facility's Policy and Procedure (P&P), titled Medication Regimen Review, revised on 1/31/2025, the P&P indicated the drug regimen was reviewed at least once a month by a licensed pharmacist and included a review of the resident's medical chart. The P&P indicated, if the pharmacist should identify an irregularity that required urgent action to protect a resident, the DON or designee was informed . Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in one of one facility kitchen. During initial tour of the kitchen, a 22-ounce (oz) bottle of basil pesto sauce was observed with an unreadable best by or used by date. This deficient practice had the potential for improper food storage, which could lead to foodborne illnesses (illness caused by consuming contaminated food or beverages) to the residents who received food from the kitchen. Findings: During an initial tour and observation of the kitchen on 3/18/2025 at 8:58 am with the Assistant [NAME] (AC), a 22 oz. bottle of pesto sauce was observed inside the facility's freezer. The AC stated the pesto sauce bottle's use by or best by date was unreadable. The AC stated best by or used by dates were important to determine when the product was edible for consumption and when to discard to prevent possible food borne illnesses to the residents. During a review of the facility's Policy and Procedure (P&P) titled Date Marking for Food Safety, revised 1/31/2025, the P&P indicated the facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded.

Based on observation, interview, and record review, the facility failed to ensure the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for one of one sampled resident (Resident 55). This failure had the potential to result in resident not receiving assistance in a timely manner when needed. Findings: During a review of Resident 55's Admission Record (AR), the AR indicated Resident 55 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control) and tinea unguium (a fungal infection of the nails) During a review of Resident 55's Minimum Data Set (MDS, a resident assessment tool) dated 3/7/2025, the MDS indicated Resident 55 had clear speech, usually understood others and usually made self-understood. Resident 55 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) for personal hygiene, eating and roll left and right. During an observation on 3/18/2025 at 11:08 am in Resident 55's room, Resident 55 was lying in bed. Resident 55's call light was wrapped outside of the left bedrail. Resident 55 stated Resident 55 was not able to find the call light and not able to reach it. During a concurrent interview, Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated, Resident 55's call light was facing outside of the bedrail and Resident 55 needed help to reach it. LVN 2 stated the call light should be placed within easy reach of the resident to use to call for help when needed. LVN 2 stated Resident 55 could get hurt trying to get out of bed by himself if the call light was not within reach. During a review of the facility's Policy and Procedure (P&P) titled, Call Lights: Accessibility and Timely Response, dated 12/9/2024, the P&P indicated Staff will ensure the call light is within reach of the resident and secured, as needed.

Based on observation, interview, and record review, the facility failed to provide a safe environment as indicated in the facility's policies and procedures (P&P) titled, Preventive Maintenance Program, and Safe and Homelike Environment, for one of three sampled residents (Resident 1) by failing to: 1. Ensure the Maintenance Director (TMD) had a schedule of maintenance services for Resident 1's bed remote control coil line (coiled remote-control cord). 2. Ensure Certified Nurse Assistant 2 (CNA 2) prevented Resident 1 from grabbing onto Resident 1's damaged/broken bed remote control coil hanging on Resident 1's right bed side rail (an adjustable bar attached to a bed to help patients/residents move around) during care. As a result, on 12/17/2024 at 5 am, Resident 1 sustained a laceration (a wound when skin, tissue, and/or muscle was torn or cut open) on Resident 1's inner right hand between the thumb and index finger (also known as the pointer finger, or first finger) measuring 2 centimeters (cm-unit of measurement) in length, by 0.2 cm in width and by 0.2 in depth. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) on 12/17/2024 at 10:45 am and required seven surgical sutures (stitches, length of thread used to join up pieces of tissue) for wound closure. Resident 1 had six stitches (a medical procedure that uses thread and a needle to close wounds) along the right thumb with ragged edges and one stitch on the base of the index finger with skin tear (a traumatic wound that occurs when the skin's layers separate). Cross Reference: F908 Findings: During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/29/2024 with diagnoses that included type II Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (a condition when the heart is not able to pump enough blood and oxygen to the body's organs) and respiratory failure (a condition when the lungs cannot get enough oxygen into the blood). During a review of Resident 1's History and Physical (H&P, a formal and complete assessment of the resident by a physician) dated 9/17/2024, the H&P indicated Resident 1 was non-verbal and did not have the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 12/3/2024, the MDS indicated Resident 1 had unclear speech and severely impaired cognition (thinking, reasoning, or remembering for daily decision making). The MDS indicated Resident 1 was dependent (helper does all the effort, resident does none of the effort to complete the activity) for toileting, showering, dressing and chair/bed-to-chair transfers. During a review of Resident 1's Progress Notes (PN), dated 12/17/2024, timed at 5 am, the PN indicated Resident 1 sustained an inner right-hand cut (laceration) when Resident 1 held onto the right bed side rail while being cleaned and turned by CNA 2. During a review of Resident 1's PN, dated 12/17/2024, timed at 5:46 am, the PN indicated Resident 1 had an open cut/wound on the inner right hand. The PN indicated Resident 1's right hand wound was acquired in the facility and measured 2 cm in length by 0.2 cm in width and 0.2 cm in depth. During a review of Resident 1's Physician's Order (PO) dated 12/17/2024 (untimed), the PO indicated to transfer Resident 1 to GACH 1 due to right hand cut. During a review of Resident 1's PN dated 12/17/2024, timed at 10:45 am, the PN indicated Resident 1 was transferred to GACH 1 due to a cut on the right hand. During a review of GACH 1's Emergency Department Note (EDN) dated 12/17/2024, the EDN indicated Resident 1 had a right-hand laceration and received laceration repair. The EDN indicated Resident 1's right hand laceration was closed with seven stitches. During a review of Resident 1's PN dated 12/17/2024, timed at 6:20 pm, the PN indicated Resident 1 was readmitted back to the facility from GACH 1 after treatment of Resident 1's laceration to the right palm (the grasping side of the hand) of the hand. The PN indicated Resident 1 had six stitches along the right thumb with ragged edges and one stitch on the base of the index finger with skin tear. During an observation of Resident 1's right hand in Resident 1's room on 1/3/2025 at 11:24 am, Resident 1 was lying in bed with eyes closed. Resident 1's right hand was wrapped with dry bandage roll (a long, rolled-up piece of absorbent material used to cover wounds, apply pressure, and secure dressings). During an observation of Resident 1's right palm, in Resident 1's room and concurrent interview with Licensed Vocational Nurse 1 (LVN 1) on 1/3/2025 at 11:29 am, Resident 1's right palm had seven stitches between the thumb and the index finger. LVN 1 stated, Resident 1 was sent to GACH 1 on 12/17/2024 due to a cut to the right hand from Resident 1's bed remote control coil line. LVN 1 stated, the outer hard plastic layer of Resident 1's bed remote control coil line was broken, and part of the coil was pointing out. LVN 1 stated, when CNA 2 turned and repositioned Resident 1, Resident 1 grabbed onto the sharp broken part (plastic) of the bed remote control coil line, and Resident 1 sustained a laceration of Resident 1's right hand/palm. LVN 1 stated, staff (in general) need to ensure Resident 1's equipment was in good condition to prevent injury to Resident 1. LVN 1 stated, maintenance staff need to routinely check all devices and equipment to ensure the equipment and devices were in good condition and working properly for resident's safety. During an interview with the Maintenance Assistant (MA) on 1/3/2025 at 12 pm, the MA stated, the MA did an investigation on 12/17/2024 after Resident 1 sustained a right-hand laceration. The MA stated, Resident 1's bed remote control coil line was broken. The MA stated the inside of the electric wire was exposed, and the outer layer/hard plastic was peeled off, forming a sharp pointed edge. The MA stated, there was blood stain on the broken part of Resident 1's bed remote control coil. The MA stated, checking the bed remote control was not part of the Maintenance Department's routine task since MA started working at the facility nine months ago. The MA stated, the Maintenance Department would only check the bed remote control upon request. The MA stated, checking the bed remote control was added to the Maintenance Department's routine task after the incident with Resident 1, who sustained a laceration of the inner right hand on 12/17/2024. The MA stated, it was important to check all resident's equipment routinely including the bed remote control to ensure resident's safety and to prevent injury to the residents. The MA stated, if the Maintenance Department performed a routine check and found the broken bed control coil line earlier, Resident 1's injury could have been prevented. During a concurrent review of Resident 1's Interdisciplinary Team (IDT, a group of healthcare professionals who work together to provide patient care), Progress Note dated 12/17/2024, timed at 2:27 pm, and an interview with the facility's Director of Nursing (DON) on 1/3/2025 at 1:17 pm, the IDT Progress Note indicated on 12/17/2024 around 5 am, Resident 1 was being turned and changed by CNA 2 and CNA 2 saw Resident 1 holding onto the siderail on the right side of the bed with bloody open cut in the inner right hand between Resident 1's thumb and index finger. The IDT Progress Note indicated Resident 1's bed control coil line was damaged with the hard plastic sticking out. The DON stated Resident 1 grabbed onto Resident 1's damaged/broken bed coil line and sustained an injury on Resident 1 right hand. The DON stated, it was important to routinely check all medical devices and equipment and to keep them in good condition for resident's safety. The DON stated, Resident 1's injury (laceration to the right inner hand) could be avoided if the facility maintained its equipment in good condition. During an interview with the facility's Administrator (ADM) on 1/3/2025 at 3:01 pm, the ADM stated CNA 2 was terminated. The ADM and Surveyor 1 called CNA 2 for a telephone interview and CNA 2 did not answer the phone call. During a review of the facility's P&P titled, Safe and Homelike Environment, dated 12/19/2022, the P&P indicated The facility will provide a safe, clean, comfortable, and homelike environment. The P&P indicated This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. During a review of the facility's P&P titled, Preventive Maintenance Program, dated 12/19/2022, the P&P indicated A preventive maintenance program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The P&P indicated The maintenance director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

Based on observation, interview, and record review, the facility failed to ensure the resident was free of accident for one of two sample residents (Resident 1). Certified Nursing Assistant 1 (CNA 1) gave a hot shower to Resident 1, who was unable to communicate verbally or by gestures and was dependent on staff for care, without checking the water temperature was tolerable for Resident 1. As a result, on 12/31/18, Resident 1 sustained blisters (second [MEDICAL CONDITION]- skin damage that extend beyond the top layer of the skin) to the left hand and the right and left inner thighs, and scrotum (testicles) from exposure to scalding (burn from hot liquid) water temperature for unknown length of time during the shower. Resident 1 required indwelling urinary catheter for wound management and transfer to General Acute Care Hospital 1 (GACH 1) where the thigh burned injuries were found infected. Findings: A review of Resident 1's Record of Admission indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A [MEDICAL CONDITION] is inserted through the hole and secured in place with a strap around your neck) and stroke (a medical condition in which reduced blood flow to the brain results in cell death) with [MEDICAL CONDITION] (unable to move or feel one side of the body). A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care-planning tool) dated 11/27/18, indicated Resident 1 did not speak and was dependent of two-staff assist with bed mobility, personal hygiene, dressing, and bathing. Resident 1 was incontinent (unable to control urination or bowel movement) and was dependent on a gastrostomy tube (GT - a soft tube surgically inserted on the stomach through the abdominal wall to administer medications and food). A review of the Resident 1's Licensed Nurses Notes dated 12/31/18, timed at 10:20 a.m., indicated CNA 1 notified Treatment Nurse 1 (TN 1) of an open blister to the left and right inner thighs and left hand after showering. Licensed Vocational Nurse 1 (LVN 1) assisted CNA 1 to bring Resident 1 to the shower room (Tub room [ROOM NUMBER]) and noted Resident did not have skin problems. CNA 1 checked the water temperature after turning the shower head on to shower Resident 1's thigh areas and adjusted it after noticing it was a little hot and continued to shower Resident 1. CNA 1 could not recall the length of time she showered Resident 1. Resident 1 received first aid treatment and did not show signs of pain. A review of the Non-Pressure Sore Skin Problem Report dated 12/31/18, indicated Resident 1 had a right and left inner thigh open blisters, with no measurement. The report did not include the size of the burns. A review of the Resident 1' Physician's Orders dated 12/31/18, included: - Tylenol ([MEDICATION NAME] - pain medication) administration to Resident 1 through the GT every six hours, for pain management; - Cleansing Resident 1's left hand, right and left inner thighs with normal saline solution (salt solution), apply [MEDICATION NAME] cream (antibiotic used [MEDICAL CONDITION] prevent infection), cover wounds with xeroform gauze (an absorbent wound dressing), and then wrap with Kerlix gauze (woven bandage) daily for 14 days; and, - Inserting an indwelling urinary catheter (a tubing that drains urine from the bladder into a bag outside the body) attached to a drainage bag for wound management for 14 days. A review of the Non-Pressure Sore Skin Problem Report dated 1/3/19, indicated Resident 1's left thigh burn area measured 14 centimeters (cm) in length by 14 cm in width. The right thigh burn area measured 11 cm in length by 12 cm in, and the blisters to the left hand remained intact. A review of the Licensed Nurses Notes dated 1/5/19, timed at 7 p.m., indicated Family Member 1 (FM 1) visited Resident 1 and requested a transfer to GACH 1. A Physician's Order dated 1/5/19, timed at 9:10 p.m., indicated to transfer Resident 1 to GACH 1 for evaluation and treatment of [REDACTED]. A review of the Licensed Nurses Notes dated 1/5/19, timed at 10:10 p.m., indicated the facility transferred Resident 1 to GACH 1 emergency room . A review of Resident 1's GACH 1 Emergency Documentation dated 1/5/19, indicated: a. Left hand with blisters in digits (fingers) one, two, three, and four, full thickness burn, no drainage or foul odor. b. Bilateral inner thighs with pink and white desquamation (the shedding of the outer layers of the skin), surrounding area pink in color. c. Right inner thigh with approximately 9 cm by 8 cm burn with purulent (pus) drainage. d. Left inner thigh with approximate 14 cm by12 cm burn with purulent drainage. e. Mid scrotum area skin tear of approximately 0.5 cm by 12 cm with no drainage. A review of the facility's Investigation Report dated 12/31/18 and conducted by the Director of Nursing (DON) indicated CNA 1 and LVN 1 transferred Resident 1 to Tub room [ROOM NUMBER]. LVN 1 left CNA 1 with Resident 1 in Tub room [ROOM NUMBER] after assisting her with transferring Resident 1 in the tub. CNA 1 turned on the water faucet and did not check the water temperature first. CNA 1 pointed the shower head directly onto Resident 1's thighs. CNA 1 adjusted the water temperature when she felt it was a little hot and continued showering Resident 1. The report indicated LVN 1 stated that Resident 1 did not have blisters or skin issues when she assisted CNA 1 in transferring Resident 1 in the tub. A review of the Summary/Intervention/Conclusion of the Investigation dated 1/4/19, indicated CNA 1 might have left the water running on Resident 1's thighs for a time which resulted in scalding and blister. A review of the facility policy and procedure titled, Shower/Tub revised on (MONTH) 2010, indicated staff should test the water temperature is heating to 105 degrees Fahrenheit using a bath thermometer or by using the staff's elbow. If using a shower, the facility staff should regulate the temperature and the flow of the water, then roll the bath chair next to the tub or shower. A review of the facility policy titled, Building Systems Water Systems and Temperature Control, dated 3/1/16, indicated staff should check water temperatures periodically in rooms used by residents such as bathrooms and showers to ensure that hot water used by residents was heating to 105 - 115 degrees Fahrenheit (or applicable requirement). During an observation and interview, on 2/15/19 at 1:15 p.m., Maintenance Supervisor 1 (MS 1) stated he checked the water temperature in showers and tub rooms daily. During the observation, the temperature of the water from the shower head in Tub room [ROOM NUMBER] was 116 degrees Fahrenheit after one minute. A sign was posted on the wall indicating to all nursing staff to check water temperature before giving a shower/bath. When asked how nursing staff checks the water temperature before bathing the residents, MS 1 stated the staff used their hands because he had the bath thermometer kept in his office. MS 1 added the Shower/Tub Rooms did not have available bath thermometers for nurses to use. During an interview with CNA 1, on 2/15/19 at 2:10 p.m., in the presence of CNA 2 (assisting with English translation), stated that after turning on the water she washed Resident 1's head first and then the body. CNA 1 stated during that time, everything was okay. CNAs 1 and 2 stated they were not sure if there was a bath thermometer available to check water temperature before showering residents. CNAs 1 and 2 reported they tested the water temperature by feeling the water against the back of their hands. CNA 1 stated she could not remember if she checked the temperature before showering Resident 1. CNA 1 stated she noticed Resident 1's thighs turned red when she was about to rinse Resident 1. CNA 1 stated she immediately turned off the water and called LVN 1. CNA 1 reported the inner thighs looked like a map of four closed water-filled blisters. During an interview, on 2/15/19 at 2:50 p.m., the Director of Nursing (DON) stated CNA 1 might have left the water running for a time causing Resident 1's skin to scald and blister. The DON stated staff should feel the water temperature through their skin and if the temperature was comfortable for staff, it should be comfortable for the residents too.