Every finding on record at Sunset Park Healthcare

Based on observation, interview, and record review, the facility failed to ensure the kitchen prepared food that conserves nutritive value, is palatable, and at an appetizing temperature according to the facility's policy and procedures (P&P) titled, Food and Nutrition Services, last reviewed 3/2026, and, Food Preparation and Service, last reviewed 3/2026 when:1. The curry lemon chicken served for lunch on 8/11/2026 was dry and not at an appetizing temperature.2. The green peas with onions served for lunch on 8/11/2026 was overcooked, of a brownish, yellowish color, and not at an appetizing temperature. This failure had the potential for 35 out of 37 residents, who consume food prepared by the facility's kitchen, to experience dissatisfaction with their food, potentially leading to poor meal intake, weight loss, and a decreased quality of life in the residents. Findings: During a review of Resident 16's admission Record, dated 8/12/2026, the admission Record indicated Resident 16 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), metabolic encephalopathy (an altered state of brain function caused by a body-wide medical problem, chemical imbalance, or organ failure rather than a direct issue inside the brain), and bilateral primary osteoarthritis of knee (a degenerative joint disease affecting both knees). During a review of Resident 16's History and Physical (H&P), dated 6/5/2026, the H&P indicated Resident 16 has the capacity to understand and make decisions. During an interview on 8/10/2026 at 9:02 AM with Resident 16, Resident 16 stated the food served by the facility is always cold. During a concurrent observation and interview on 8/11/2026 at 1:06 PM with the Dietary Services Supervisor (DSS) and the Registered Dietician (RD) outside the facility's kitchen, a lunch test tray was sampled by the DSS, the RD, and the Surveyor (writer) immediately after the last resident received their lunch tray. The regular diet lunch tray contained curry lemon chicken, garlic rice, and peas with onions. The DSS used the kitchen's food thermometer to check the temperature of the food. The temperature of the chicken was 117 degrees Fahrenheit (F, a unit of measuring temperature), the peas with onions was 116.2 degrees F, and the rice was 134 degrees F. The color of the peas was a combination of brown, green, and yellow. The RD stated that the peas looked overcooked, which could lead to the peas losing their nutritional value and the residents not receiving the nutrition they need. The chicken and peas were sampled by the DSS, the RD, and the Surveyor. The temperatures of the chicken and peas were room temperature to taste, and the chicken was dry. The DSS stated the chicken was a little dry. The DSS also stated the chicken, and peas were no longer hot. The RD stated food should be served at a minimum temperature of 120 degrees F to ensure the meal is palatable and appetizing to the residents. During an interview on 8/13/2026 at 3:26 PM with the Director of Nursing (DON), DON stated, Meals must be appetizing through the way they are presented. The meal must be warm enough to be enjoyed, tasty, and palatable to eat. It is important for the meal to be at an appropriate temperature, look appetizing, and taste appetizing so residents may enjoy their meal because the residents get their nutrition from their meals. If a resident receives cold food, they may feel frustrated. During a review of the facility's policy and procedures (P&P) titled, Food and Nutrition Services, last reviewed 3/2026, the P&P indicated, Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. During a review of the facility's P&P titled, Food Preparation and Service, last reviewed 3/2026, the P&P indicated, The danger zone for food temperatures is above 41 degrees F and below 135 degrees F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. The longer food remains in the danger zone the greater the risk for growth of harmful pathogens. Therefore, potentially hazardous foods must be maintained at or below 41 degrees F or at or above 135 degrees F.Proper hot and cold temperatures are maintained during food distribution and service.

Based on observation, interview, and record review, the facility failed to ensure proper sanitation and food handling practices were upheld in the kitchen according to the facility's policy and procedures (P&P) titled, Refrigerators and Freezers, last reviewed 5/2026, Sanitization, last reviewed 5/2026, and, Food Preparation and Service, last reviewed 3/2026, when:1. A bag of brussels sprouts was stored in Reach-in Freezer (RF) 1 without a label to indicate the received date.2. The paint of the top metal rack in RF 1 was chipped, exposing the gray metal part of the rack. 3. A jar of mayonnaise was stored in Reach-in Refrigerator (RR) 1 was labeled with the incorrect use-by date.4. The thermometer in RF 2 was physically broken and could not accurately record temperatures in RF 2.5. A kitchen sanitizer bucket containing a chemical cleaning solution was stored on the same shelf immediately adjacent to clean pitchers for beverages. These failures had the potential to spread pathogens (a germ that causes disease) to 35 out of 37 residents who consume food prepared by the facility's kitchen, increasing their risk of developing foodborne illnesses (any sickness caused by eating or drinking contaminated foods or beverages) that could lead to medical complications and hospitalization. Findings: 1. During a concurrent observation and interview on 8/10/2026 at 7:47 AM with the Dietary Services Supervisor (DSS) in the kitchen, RF 1 contained an unopened frozen bag of brussels sprouts that was not labeled to indicate when the bag of brussels sprouts was received by the kitchen and stored in RF 1. DSS stated the bag of brussels sprouts should have been labeled with the date it was received and stored in RF 1. DSS stated without a food item labeled date, kitchen staff won't know how long the bag of brussels sprouts has been stored in RF 1 for, when the bag of brussels sprouts expires, and the bag of brussels sprouts should be disposed. DSS further stated if residents consume expired foods, the residents can contract foodborne illnesses. 2. During a concurrent observation and interview on 8/10/2026 at 7:51 AM with the DSS in the kitchen, the top metal storage rack of RF 1 was painted white. Along the storage rack, there was a section about 1 inch (unit of measuring length) in length where the white paint was chipped away and the gray metal of the rack was exposed. DSS stated the paint of the storage rack of RF 1 is chipped away and he needs to call maintenance to repaint the storage rack. DSS further stated the facility must ensure the storage racks of refrigerators and freezers in the kitchen do not have chipped paint because the pieces of paint could fall into the food that the residents eat, which could cause the residents to get sick. 3. During an observation on 8/10/2026 at 7:54 AM in the kitchen, RR 1 contained an opened jar of mayonnaise labeled by the kitchen staff with a received date of 8/7/2026, an opened date of 8/9/2026, and a use-by date of 7/6/2027. The jar of mayonnaise was also labeled with a manufacturer's expiration date of 7/6/2027. During a concurrent interview and record review on 8/10/2026 at 7:55 AM with the DSS, the kitchen's reference sheet titled, Dry Goods Storage Guidelines, undated, was reviewed. The reference sheet indicated mayonnaise can only be stored for two months in the refrigerator after being opened. The DSS stated this reference sheet is what the kitchen staff use for reference when labeling food with use-by dates after being opened. The DSS stated the jar of mayonnaise in RR 1 was incorrectly labeled, and the correct use-by date is 10/9/2026. The DSS stated it is important to label foods with the correct use-by date to know when they are expired and should be disposed of. The DSS further stated residents could contract foodborne illnesses if they eat foods beyond the use-by date because they are expired. 4. During a concurrent observation and interview on 8/10/2026 at 8:01 AM in the kitchen with the DSS, RF 2 contained a freezer thermometer that indicated a temperature of 32 degrees Fahrenheit (F - a unit of measuring temperature). The DSS stated the freezer thermometer inside RF 2 looks physically broken because the temperature gauge was stuck at 32 degrees. DSS stated he knows the thermometer is inaccurate and the temperature of RF 2 is not actually 32 degrees because when the temperature of RF 2 was checked in the morning it was 0 degrees F, all the food stored inside RF 2 is frozen solid, and the thermometer built into RF 2 indicates 0 degrees F. The DSS stated it is important to have a working thermometer in the freezer to ensure the food stored inside is stored at the correct temperature. If food is not stored at the correct temperature, it could spoil and cause foodborne illnesses in the residents that consume the food. 5. During a concurrent observation and interview on 8/10/2026 at 8:13 AM in the kitchen with the DSS, a red bucket containing a liquid was stored immediately adjacent to clean pitchers for beverages on a metal shelf. The DSS stated the metal shelf is used to store freshly washed beverage pitchers. The DSS stated the red bucket is the kitchen's sanitizer bucket, containing chemical cleaning solution used to clean the kitchen. The DSS stated the red bucket should not be stored on the same shelf as the pitchers for beverages because the chemical solution in the red bucket may contaminate the pitchers for beverages, which then may cause illness to the residents. During an interview on 8/13/2026 at 3:20 PM with the Director of Nursing (DON), DON stated, The kitchen must be clean and sanitary at all times. If not, it could lead to foodborne illnesses in the residents. The DON further stated foods stored in the kitchen must be labeled appropriately to know the food is still consumable and to prevent foodborne illness to the residents. The DON further stated, It is important to have working thermometers in the freezers and refrigerators to be able to monitor the temperatures food is stored at to ensure food does not spoil. The DON further stated cleaning chemicals should not be stored in the same area as dishware that is used for food and beverages because the chemicals may contaminate the dishware and cause illness in residents if consumed. During a review of the facility's policy and procedures (P&P) titled, Refrigerators and Freezers, last reviewed 5/2026, the P&P indicated, All food is appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) are marked on cases and on individual items removed from cases for storage. Use by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and use by dates are indicated once food is opened. Supervisors inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs are initiated immediately. Maintenance schedules per manufacturer guidelines are scheduled and followed. During a review of the facility's P&P titled, Sanitization, last reviewed 5/2026, the P&P indicated, The food service area is maintained in a clean and sanitary manner. All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning. During a review of the facility's P&P titled, Food Preparation and Service, last reviewed 3/2026, the P&P indicated, Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. Cross-contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned.

Based on observation, interview, and record review, the facility failed to ensure [NAME] (CK) 1 followed the diet menu and recipe instructions when preparing taco casserole (a baked dish that layers traditional taco ingredients into a single pan and is baked until hot) with a texture-modification of soft and bite-sized (SBS, a modified food texture where meals are tender, moist, and cut into small pieces measuring 1.5 centimeters (cm, a unit of measuring length) by 1.5 cm for adults) for according to the facility's recipe titled, Taco Casserole, dated 2026 and to the facility's policy and procedures (P&P) titled, Standardized Recipes, last reviewed 5/2026. CK 1 added three scoops of melted margarine to the tray of taco casserole, which was not indicated by the recipe. This failure had the potential to cause 11 out of 37 residents, who received the SBS texture-modified taco casserole, to ingest an excess number of calories and to experience dissatisfaction with the texture and/or taste of the SBS texture-modified taco casserole. Findings: During a review of the facility's menu titled, Summer Menu, undated, the menu indicated the lunch entree for 8/12/2026 was taco casserole. For the SBS texture-modification of taco casserole, the menu indicated, Chopped layers, see recipe. During an observation on 8/12/2026 at 12:10 PM in the kitchen, there was a gray pot containing a yellow liquid being kept warm on the stove. CK 1 used a ladle (a large, long-handled spoon with a deep bowl used to scoop and serve liquids) to scoop three scoops of the yellow liquid and poured the three scoops onto a tray of cooked taco casserole being kept warm on the steam table. CK 1 then used a spatula (a tool with a broad, flat, and usually flexible blade) and sliced the taco casserole into small pieces. CK 1 then began serving slices of the taco casserole onto dishes for lunch service. During an interview on 8/12/2026 at 12:34 PM with CK 1, CK 1 stated the yellow liquid he poured onto the taco casserole was melted margarine. CK 1 stated he poured the three scoops of margarine onto the taco casserole to modify its texture and make it softer for the residents who are on a SBS texture-modified diet. CK 1 further stated the SBS texture-modified diet tray of taco casserole was the only tray he added the melted margarine to. During a concurrent interview and record review on 8/12/2026 at 12:36 PM with the Dietary Services Supervisor (DSS), the facility's recipe titled, Taco Casserole, dated 2026, was reviewed. The recipe did not indicate margarine as an ingredient for cooking taco casserole. The recipe indicated for the SBS texture-modification of taco casserole, Prepare with chopped tortillas or chop casserole after cooking. Chop into pieces = 1.5 cm by 1.5 cm in size. Utilize the critical tests and the International Dysphagia Diet Standardization Initiative (IDDSI, a standard framework used to describe and test the thickness of drinks and the textures of foods for people who have trouble swallowing) audit to confirm texture meets level #6 specifications. The DSS stated adding margarine to the taco casserole is not a part of the recipe. The DSS stated CK 1 did not follow the recipe and menu for SBS texture-modified taco casserole by adding the three scoops of melted margarine. The DSS further stated adding the melted margarine adds more calories to the food, causing the residents to gain more weight unintentionally, and could negatively change the flavor of the food. During an interview on 8/13/2026 at 9:34 AM with CK1, CK 1 stated he should not have added the three scoops of margarine to the taco casserole to make the texture softer because it was not a part of the recipe. CK 1 further stated if the recipe is not followed, the food might not taste good or it could negatively affect the health of the residents. During an interview on 8/13/2026 at 2:46 PM with the Registered Dietician (RD), the RD stated recipes must be followed when cooking food because the recipes specify how to achieve the desired texture size. The RD further stated the recipe should be followed to make sure the residents do not get too much or too little of something for their health. During an interview on 8/13/2026 at 3:27 PM with the Director of Nursing (DON), DON stated, The importance of following the recipe when preparing food is to ensure the nutritional content of the food. It is to ensure that the food is prepared to taste as expected and to satisfy the residents. If the ingredients are changed, it may also change the texture. During a review of the facility's policy and procedures (P&P) titled, Standardized Recipes, last reviewed 5/2026, the P&P indicated, Standardized recipes shall be developed and used in the preparation of foods. Only tested, standardized recipes will be used to prepare food.

Based on observation, interview, and record review, the facility failed to ensure lunch was served during the routine scheduled mealtime according to the facility's policy and procedures (P&P) titled, Food and Nutrition Services, last revised 3/2026, and, Food and Nutrition Services/Meal Delivery, last revised 3/2026. This failure had the potential for 35 out of 37 residents, who consume food prepared by the facility's kitchen, to experience negative health outcomes such as low blood sugar and negative feelings of hunger, frustration, and a loss of appetite.Findings: During a review of the facility's mealtime schedule titled, Dining Hours, undated, the mealtime schedule indicated lunch is served at 12:00 PM. During an observation on 8/11/2026 at 12:50 PM outside the facility's kitchen, the first lunch tray was delivered to the first resident seated in the dining room. During an observation on 8/11/2026 at 1:05 PM in the facility's hallway, the last lunch tray was delivered to the last resident in their room. During an interview on 8/11/2026 at 1:15 PM with the Registered Dietician (RD), the RD stated the reason why lunch was served later than usual was because the kitchen team was being extra thorough to ensure the food textures were correct. The RD further stated there were extra adjustments that needed to be made to ensure the correct texture for pureed foods. The RD further stated, The meals should not have been delivered that late to the residents. The RD stated it is important to deliver meals at the regular scheduled times to provide the residents with a routine and so the residents do not go hungry. During an interview on 8/12/2026 at 1:47 PM with the Dietary Services Supervisor (DSS), the DSS stated lunch trays should start being delivered by 12:30 PM at the latest. The DSS stated the previous day's lunch (on 8/11/2026) was delivered later than usual for the facility. The DSS further stated delayed meals could cause the residents to feel hungry and angry. The DSS further stated delayed meals could cause negative health outcomes such as residents' blood sugars being too low. During an interview on 8/13/2026 at 3:25 PM with the Director of Nursing (DON), DON stated, Resident should receive their lunch by 12:30 PM the latest. It is important to adhere to scheduled mealtimes because it is a routine and the residents expect their meals at a certain time. The DON stated residents with diabetes (a chronic health condition where the blood sugar levels are too high) are more sensitive to routine mealtimes because their medications must be administered with meals. The DON further stated if residents do not receive their meals at the scheduled time, they could feel hungry, frustration, and lose their appetite for food. During a review of the facility's policy and procedures (P&P) titled, Food and Nutrition Services, last revised 3/2026, the P&P indicated, Meals are scheduled at regular times to receive at least three meals per day. Mealtimes are posted in facility common areas. Mealtimes for Lunch: 12:00 - 1:00 PM. During a review of the facility's P&P titled, Food and Nutrition Services/Meal Delivery, last revised 3/2026, the P&P indicated, Meals and/or nutritional supplements will be provided within 45 minutes of either resident request or scheduled mealtime, and in accordance with the resident's medication requirements.

Based on observation, interview, and record review, the facility failed to ensure the residents' rights to a dignified existence, self-determination, and to be treated with respect and dignity for three of three sampled residents (Residents 17, 32, and 39) as indicated in the facility's policy and procedures (P&P) titled, Quality of Life - Dignity/Respect, last reviewed 3/2026, and Dining/Assistance with Meals, last reviewed 3/2026, when: 1. Resident 39 was left sitting in a reclining chair wearing only a jacket and adult pull-up incontinence (accidental or involuntary loss of urine and stool control) brief . 2. Certified Nursing Assistant (CNA) 2 was standing over Resident 39 while feeding Resident 39 breakfast, who was lying in bed. 3. Residents 17, 32, and 39 were not given their lunch at the same time as Resident 6 while they were all seated at the same table.4. The Infection Preventionist (IP) used the label feeders when referring to Residents 17, 32, 39. These failures resulted in a violation of the residents' rights and had the potential to result in the loss of self-esteem, dignity, and self-worth for Residents 17, 32, and 39. Findings: 1. During a review of Resident 39's admission Record, dated 8/12/2026, the admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses including unspecified mood disorder (a temporary diagnosis given when a person has strong mood symptoms that cause problems in daily life), unspecified psychosis (a temporary diagnosis used when a person shows a loss of touch with reality such as seeing, hearing, or feeling things that are not real), and nutritional anemia (a blood condition where the body lacks enough health red blood cells due to the diet lacking essential vitamins). During a review of Resident 39's History and Physical (H&P), dated 5/20/2026, the H&P indicated Resident 39 does not have the capacity to understand and make decisions. During a review of Resident 39's Minimum Data Set (MDS - a resident assessment tool), dated 5/21/2026, the MDS indicated Resident 39 has severe cognitive impairment (a state of having trouble with brain functions like thinking, remembering, learning, and paying attention). The MDS also indicated Resident 39 requires maximal assistance (helper does more than half the effort) with lower body dressing and touching assistance (helper provides verbal or physical cues to assist) with eating. During a review of Resident 39's care plan, dated 7/30/2026, the care plan indicated Resident 39 has a focus area of decreased functional mobility and requires increased assistance. The care plan indicated nursing interventions that include providing Resident 39 with assistance with mobility and activities of daily living consistent with the resident's current functional status. During a concurrent observation and interview on 8/10/2026 at 9:10 AM with Registered Nurse Supervisor (RNS) 1 in Resident 39's room, Resident 39 sitting in a reclining chair wearing a jacket on her upper body and adult pull-up diapers on her lower body. RNS 1 stated she does not see Resident 39 wearing any undergarments such as trousers or sweat pants. RNS 1 stated she does not know why or how long Resident 39 has been left sitting in the reclining chair without undergarments or a blanket to cover her legs. RNS 1 stated Resident 39 should not have been left without wearing undergarments because it does not preserve Resident 39's right to dignity or preserve Resident 39's self-esteem. 2. During a concurrent observation and interview on 8/11/2026 at 7:42 AM with CNA 2 in Resident 39's room, CNA 2 was standing at the left side of Resident 39 while feeding Resident 39 breakfast, who was lying on her back in bed. CNA 2 stated she does not normally sit while feeding Resident 39 because Resident 39 tends to throw food and CNA 2 did not want her clothes to get dirty. CNA 2 further stated she knows she is supposed to sit at eye level with Resident 39 while feeding her breakfast to treat Resident 39 with respect and dignity. CNA 2 further stated by failing to sit down in a chair while feeding Resident 39, there is the potential to make Resident 39 feel uncomfortable and disrespected. 3. During a review of Resident 6's admission Record, dated 8/12/2026, the admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a brain function problem when chemical imbalances in the blood prevent the brain from getting the nutrients it needs), unspecified psychosis (a temporary diagnosis used when a person shows a loss of touch with reality such as seeing, hearing, or feeling things that are not real), and Alzheimer's disease (a progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks). During a review of Resident 6's H&P, dated 3/19/2026, the H&P indicated Resident 39 does not have the capacity to understand and make decisions. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 has severe cognitive impairment (a state of having trouble with brain functions like thinking, remembering, learning, and paying attention). The MDS also indicated Resident 6 is able to independently eat her meals. During a review of Resident 17's admission Record, dated 8/12/2026, the admission Record indicated Resident 17 was originally admitted to the facility on [DATE], and most recently admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a brain function problem when chemical imbalances in the blood prevent the brain from getting the nutrients it needs), generalized muscle weakness (an overall reduction in physical strength), and Alzheimer's disease (a progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks). During a review of Resident 17's H&P, dated 7/6/2026, the H&P indicated Resident 17 does not have the capacity to understand and make decisions. During a review of Resident 17's MDS, dated [DATE], the MDS indicated Resident 17 has severe cognitive impairment (a state of having trouble with brain functions like thinking, remembering, learning, and paying attention). The MDS also indicated Resident 17 is dependent (helper does all of the effort) in eating abilities. During a review of Resident 32's admission Record, dated 8/13/2026, the admission Record indicated Resident 32 was originally admitted to the facility on [DATE], and most recently admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a brain function problem when chemical imbalances in the blood prevent the brain from getting the nutrients it needs), Parkinson's disease (a lifelong brain disorder that affects movement and balance), and Alzheimer's disease (a progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks). During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32 is rarely/never understood. The MDS also indicated Resident 32 requires touching assistance (helper provides verbal or physical cues to assist) with eating. During an observation on 8/10/2026 at 12:45 PM in the dining room, Residents 6, 17, 32, 39 were all seated around a dining table together. Resident 6 was eating her lunch independently without assistance from staff. Residents 17, 32, and 39 did not have their lunches delivered. 4. During an interview on 8/10/2026 at 12:49 PM with the IP, the IP stated Residents 17, 32, and 39 are feeders and their lunch trays are delivered later when the Certified Nursing Assistants (CNAs) are available to feed them. During an interview on 8/12/2026 at 1:29 PM with the IP, the IP stated he called Residents 17, 32, and 39 feeders because they are residents that require assistance in being fed to eat their meals. The IP stated during meal services, the CNAs deliver the feeders their meal trays last after all the other meal trays are delivered because they require assistance from the CNAs to be fed their meals. The IP stated serving Residents 17, 32, and 39 their meals last after all other residents have been served could be considered not treating Residents 17, 32, and 39 with dignity because they are not being treated the same as the other residents and are not receiving equal treatment. The IP further stated residents seated at the same table should be served their meals at the same time to preserve their dignity. IP further stated the label feeder could be considered not treating Residents 17, 32, and 39 with dignity because they are being called by a label rather than their proper names. During an interview on 8/13/2026 at 3:33 PM with the Director of Nursing (DON), DON stated, The term dignity means to preserve a resident's self-worth. Residents have the right to be treated with dignity to make them feel human, important, and valued. The DON stated staff should call residents by their name and not by labels. The DON stated calling a resident by the label feeder is not treating the resident with respect and does not preserve the resident's dignity. The DON further stated while feedings residents, staff must be at eye-level, sitting down, facing the resident, and talking to the resident to treat the residents with dignity and respect. The DON further stated that residents who require assistance with dressing should be dressed in clean clothing that covers the upper and lower halves of their body. The DON further stated leaving a resident in only their adult pull-up diaper and no undergarments does not preserve a resident's dignity. During a review of the facility's policy and procedures (P&P) titled, Quality of Life - Dignity/Respect, last reviewed 3/2026, the P&P indicated, Residents are treated with dignity and respect at all times. Residents are groomed as they wish to be groomed. Residents are encouraged to dress in clothing that they prefer. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs . Staff are expected to treat cognitively impaired residents with dignity and sensitivity. During a review of the facility's P&P titled, Dining/Assistance with Meals, last reviewed 3/2026, the P&P indicated, Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: Not standing over residents while assisting them with meals. Avoiding the use of labels when referring to residents (e.g., feeders).

Based on observation and interview, the facility failed to ensure staff did not stand when assisting one of one resident (Resident 17) with meals according to the facility's policy and procedures (P&P) tiled Dining/Assistance with Meals, reviewed 3/2026. This deficient practice resulted in Resident 17 not being cared for in a manner that met Resident 17's individual needs with attention to dignityFindings: A review of Resident 17's admission Record indicated the facility admitted Resident 17 on 4/3/2025 and readmitted Resident 17 on 7/4/2026 with diagnoses including Major depressive disorder (mental health condition causing a deep, ongoing feeling of sadness, emptiness, and loss of joy in life), dementia (a progressive state of decline in mental abilities), and Alzheimer's (a disease characterized by a progressive decline in mental abilities). A review of Resident 17's Minimum Data Set (MDS - a resident assessment tool) dated 7/7/2026, indicated Resident 17 is cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 17 is dependent on staff with eating and all other Activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) care. During an observation on 8/11/2026, at 7:49 A.M., in Resident 17's room, Certified Nursing Assistant (CNA) 1 was standing over Resident 17 while assisting her eat her breakfast. During a concurrent observation and interview on 8/11/2026, at 7:49 A.M., with CNA 1, in Resident 17's room, CNA 1 was seen standing over Resident 17 while assisting her eat her breakfast. CNA 1 stated that he either needs to stand or seat when assisting resident with eating. CNA 1 further stated that as far as the training goes, I can either seat or stand is what I was told. During an interview on 8/13/2026, at 1:15 P.M., with the Director of Nursing (DON), the DON stated that facility staff expectation when assisting resident with eating is that staff have to be seated, are face to face with the resident they are assisting for respect and to preserve the residents comfort. A review of the facility's P&P titled Dining/Assistance with Meals, reviewed 3/2026 indicated that,Policy StatementResidents shall receive assistance with meals in a manner that meets the individual needs of each resident. Policy Interpretation and Implementation Dining Room Residents:.3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example:a. Facility/Nursing staff will be seated, not standing over residents while assisting them with meals; .

Based on observation, interview, and record review, the facility failed to ensure an accurate assessment was conducted and documented for one of one sampled residents (Resident 12) as indicated by the facility's policy and procedures (P&P) titled, Resident Assessments, last reviewed 3/2026, and, Accuracy of the Resident Assessment, last reviewed 3/2026. Resident 12's admission Record and Minimum Data Set (MDS - a resident assessment tool) did not reflect Resident 12's diagnosis of unspecified hearing loss. This failure increased Resident 12's risk of experiencing communication barriers and not receiving the required care and services from the facility. Findings: During a review of Resident 12's admission Record, dated 8/12/2026, the admission Record indicated Resident 12 was admitted to the facility on [DATE] with diagnoses including encephalopathy (a general term for any disease, damage, or problem that makes the brain work poorly), glaucoma (a group of eye diseases that damage the optic nerve), and generalized muscle weakness (a lack of physical strength felt all over the entire body rather than in just one specific spot). The admission Record also indicated a diagnosis of unspecified hearing loss (a general medical term used when a person has trouble hearing, but the doctor has not yet figured out the exact cause), which was added on 8/12/2026. During a review or Resident 12's History and Physical (H&P), dated 4/27/2026, the H&P indicated Resident 12 is very hard of hearing with no hearing aids available. The H&P indicated Resident 12 has a diagnosis of unspecified hearing loss, unspecified ear. The H&P further indicated Resident 12 has fluctuating capacity to make medical decisions. During a review of Resident 12's Care Plan (CP) titled, Resident With Hearing Problem. dated 4/27/2026, the CP indicated Resident 12 has hearing problems manifested by impaired hearing. During a review of Resident 12's Ears, Nose, and Throat Medicine (ENT, a medical specialty that treats conditions of the head and neck) Visit Summary, dated 5/13/2026, the ENT visit summary indicated Resident 12 has complained of hearing problems and an audiogram (a graph that shows the results of a hearing test) is recommended. The next follow-up is scheduled in three months awaiting medical insurance approval. During a review of Resident 12's Progress Note, dated 8/3/2026, the Progress Note indicated Resident 12 has unspecified hearing loss in an unspecified ear. During a review of Resident 12's Psychotherapy Progress Note, dated 8/7/2026, the Psychotherapy Progress Notes indicated Resident 12 is deaf/significantly hard of hearing. The Psychotherapy Progress Note further indicated Resident 12 expressed difficulty communicating and articulating his feelings due to his hearing problems. During a concurrent observation and interview on 8/10/2026 at 9:34 AM with Resident 12 in Resident 12's room, Resident 12 was lying in bed without hearing aids in either of his ears. When the Surveyor (writer) attempted to speak with Resident 12, Resident 12 pointed at his ears and shook his head left and right. The Surveyor then proceeded to communicate with Resident 12 using a phone to type out messages for Resident 12 to read. Resident 12 responded to the messages verbally and stated his hearing is bad and wishes he could hear better. Resident 12 further stated he does not have hearing aids and has been waiting for the hearing aids but is unsure what is taking so long for the facility to provide him with hearing aids. During an interview on 8/10/2026 at 9:45 AM with Restorative Nursing Assistant (RNA) 1, RNA 1 stated Resident 12 cannot hear well. RNA 1 further stated she communicates with Resident 12 through gestures such as pointing and nodding and writing her questions and answers to Resident 12 with a pen and paper. RNA 1 stated Resident 12 understands what is being communicated to him because Resident 12 responds verbally with the appropriate responses. During an interview on 8/12/2026 at 9:50 AM with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 12 has hearing loss since admission, 4/24/2026. RNS 1 further stated she communicates with Resident 12 through gestures such as pointing and nodding or shaking her head, and writing her questions and answers to Resident 12 with a pen and paper. RNS 1 stated Resident 12 understands what is being communicated to him because Resident 12 responds verbally with the appropriate responses. RNS 1 further stated that because Resident 12 has hearing loss, the facility should have documented in Resident 12's medical record about the hearing loss. RNS 1 further stated it is important for resident assessments to be accurate to be aware of the needs of the residents, the resident's diagnoses, and how nursing staff can help the residents. During an interview on 8/12/2026 at 10:15 AM with the Social Services Director (SSD), SSD stated Resident 12 was assessed by the Ears, Nose, and Throat medicine (ENT) provider on 5/13/2026. The SSD further stated it takes approximately 4-6 months for hearing aid delivery due to medical insurance approval. During a concurrent interview and record review on 8/12/2026 at 12:46 PM with the Minimum Data Set Coordinator Nurse (MDSN), Resident 12's admission Record was reviewed. The admission Record did not indicate Resident 12 has a diagnosis of hearing loss. The MDSN confirmed and stated that hearing loss is not listed on the admission Record as one of Resident 12's active diagnoses at this time. During a concurrent interview and record review on 8/12/2026 at 12:48 PM with the MDSN, Resident 12's H&P, dated 4/27/2026, was reviewed. The H&P indicated Resident 12 is very hard of hearing with no hearing aids available. The H&P indicated Resident 12 has a diagnosis of unspecified hearing loss, unspecified ear. MDSN stated because the physician had diagnosed Resident 12 with hearing loss, hearing loss should have been included as one of Resident 12's diagnosis in the admission Record and Resident 12's medical record. During a concurrent interview and record review on 8/12/2026 at 1:07 PM with the MDSN, Resident 12's MDS, dated [DATE], was reviewed. The MDS indicated Resident 12 has moderate cognitive impairment. The MDS also indicated Resident 12's ability to hear is adequate without the use of hearing aids. MDSN stated that when she completed Resident 12's MDS assessment, she did not notice Resident 12 had any difficulty with his ability to hear. MDSN further stated she did not agree with the physician's diagnosis of hearing loss, but she should have documented Resident 12's hearing loss diagnosis because it is not within the scope of practice of a nurse to diagnose residents. MDSN further stated she should have followed up and clarified with the doctor, but for now she should have added hearing loss as a diagnosis of Resident 12. MDSN further stated if residents' assessments are inaccurate, there is the potential for the resident's needs being left unmet and the resident may not receive the care that they need from the facility. During an interview on 8/13/2026 at 3:14 PM with the Director of Nursing (DON), DON stated the assessment of the resident is based off the assessment of the nurse as well as medical record review. The DON stated if the nurse performs an assessment of the resident that does not correspond with the diagnosis of the physician, the nurse is expected to document the physician's diagnosis, then follow up with the physician to ensure the accuracy of the diagnosis. The DON further stated it is important for resident assessments to be accurate to ensure the residents receive the proper care and to know how to create a plan of care for the residents. If a resident's assessment is inaccurate, it could lead to a resident's needs being left unmet. During a review of the facility's policy and procedures (P&P) titled, Resident Assessments, last reviewed 3/2026, the P&P indicated, A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements. During a review of the facility's P&P titled, Accuracy of the Resident Assessment, last reviewed 3/2026, the P&P indicated, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment.

Based on interview and record review, the facility failed to ensure that a pre-admission screening Resident Review (PASRR -a detailed assessment that determines if someone with a mental illness [like serious mental illness, intellectual disability, or related conditions] needs specialized services and the most appropriate place to receive them) level I assessment for residents identified with mental disorder was accurately completed for one of one sampled resident (Resident 8), in accordance with the facility's policy and procedures (P&P) titled Pre-admission Screening Level II Resident Review (P ASRR Level II) with review and approval date of 3/20/2026. This deficient practice had the potential to negatively affect the appropriate care and services rendered to resident 8.Findings: A review of Resident 8's admission Record indicated the facility admitted Resident 8 on 3/18/2026 and readmitted Resident 8 on 6/22/2026 with diagnoses including schizoaffective disorder (a brain condition where a person has trouble telling what is real from what is not real, like seeing or hearing things that aren't there, while also having extreme changes in their mood, like feeling super sad or overly excited), unspecified psychosis (when a person's brain tricks them and they lose touch with reality), and post-traumatic stress disorder (PTSD - a brain and feeling problem that can happen after someone sees or goes through a very scary, dangerous, or painful event). A review of Resident 8's Minimum Data Set (MDS - resident assessment tool) dated 6/27/2026, indicated Resident 8 is cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 8 requires set up or clean up assistance to substantial/maximal staff assistance with Activities of daily living (ADLs- activities such as bathing, dressing and toileting where a person performs daily) care. During a concurrent interview and record review, on 8/12/2026, at 1:35 P.M., with Registered Nurse Supervisor 2 (RNS 2), Resident 8's PASARR level I dated 6/27/2025, and face sheet were reviewed. The RNS 2 stated that Resident 8 has diagnoses of psychosis and schizoaffective disorder which is a serious mental illness, and Resident 8's PASARR level 1 that was done on 6/27/2025 question number nine indicated No that resident 8 did not have a SMI which is inaccurately documented based on Resident 8's diagnoses of psychosis and schizoaffective disorder. RNS 2 stated that having question number nine noted as a yes would change the outcome of the assessment, make if more accurate and Resident 8 would be an appropriate candidate for PASRR level II screening. RNS 2 stated that if the evaluator for PASRR level II does not come and evaluate the resident, the facility staff may not know how to appropriately care for the resident, receive a more individualized care from the facility and resident may not be categorized correctly for the care that Resident 8 needs. During a concurrent interview and record review, on 8/13/2026, at 1:18 P.M., with the director of Nursing (DON), Resident 8's PASARR level I dated 6/27/2025, and face sheet were reviewed. The DON stated that diagnoses considered as SMI include but are not limited to schizoaffective disorder and psychosis. The DON stated that Resident 8's PASARR level 1 that was done on 6/27/2025 question number nine indicated No that resident 8 did not have a SMI is inaccurately documented based on Resident 8's diagnoses schizoaffective disorder and Psychosis. The DON stated that Resident 8's PASRR level I needs to be complete and accurate for proper coordination and referral to mental health. The DON stated that mental health referral is important to be able to stabilize the resident's mental health. The DON stated a new PASRR level I will be done for Resident 8 to ensure that the assessment is accurate and a proper referral to mental health for PASRR level II is completed. A review of the facility's P&P titled, Pre-admission Screening Level II Resident Review (P ASRR Level II) with review and approval date of 3/20/2026, indicated, .PurposeTo coordinate assessments with the pre-admissions screening and resident review (PASRR) program under Medicaid/Medical to the maximum effort. Policy StatementThe facility staff will coordinate the recommendations from the level II PASRR determination and the PASRR evaluation report with the resident's assessment, care planning and transitions of care. Policy Interpretation and Implementation1.The PASRR will be completed in accordance with the Pre-Screening Resident Review (PASRR) policy.3. The admission licensed staff or designee will review completion of PASRR on admission.

Based on interview and record review, the facility failed to ensure that a pre-admission screening Resident Review (PASRR -a detailed assessment that determines if someone with a mental illness [like serious mental illness, intellectual disability, or related conditions] needs specialized services and the most appropriate place to receive them) level I assessment for residents identified with mental disorder was accurately completed for one of one sampled resident (Resident 8), according the facility's policy and procedures (P&P) titled Pre-admission Screening Level II Resident Review (P ASRR Level II) with review and approval date of 3/20/2026. This deficient practice had the potential to negatively affect the appropriate care and services rendered to resident 8.Findings; A review of Resident 8's admission Record indicated the facility admitted Resident 8 on 3/18/2026 and readmitted Resident 8 on 6/22/2026 with diagnoses including schizoaffective disorder (a brain condition where a person has trouble telling what is real from what is not real, like seeing or hearing things that aren't there, while also having extreme changes in their mood, like feeling super sad or overly excited), unspecified psychosis (when a person's brain tricks them and they lose touch with reality), and post-traumatic stress disorder (PTSD - a brain and feeling problem that can happen after someone sees or goes through a very scary, dangerous, or painful event). A review of resident 8's PASRR level I dated 6/27/2025, the PASARR level 1 indicated the assessment was negative for a serious mental illness (SMI - a mental health condition that significantly disrupts a person's ability to function in daily life, impacting their thoughts, feelings, and behaviors) and that level II mental health evaluation was not required for SMI. A review of Resident 8's Minimum Data Set (MDS - a resident assessment tool) dated 6/27/2026, indicated Resident 8 is cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 8 is requires set up or clean up assistance to substantial/maximal staff assistance with Activities of daily living (ADLs- activities such as bathing, dressing and toileting where a person performs daily) care. During a concurrent interview and record review, on 8/12/2026, at 1:35 P.M., with Registered Nurse Supervisor (RNS) 2, Resident 8's PASARR level I dated 6/27/2025, and face sheet were reviewed. The RNS 2 stated that Resident 8 has diagnoses of psychosis and schizoaffective disorder which is a serious mental illness, and Resident 8's PASARR level 1 that was done on 6/27/2025 question number nine indicated No that resident 8 did not have a SMI which is inaccurately documented based on Resident 8's diagnoses of psychosis and schizoaffective disorder. RNS 2 stated that having question number nine noted as a yes would change the outcome of the assessment, make if more accurate and Resident 8 would be an appropriate candidate for PASRR level II screening. RNS 2 stated that if the evaluator for PASRR level II does not come and evaluate the resident, the facility staff may not know how to appropriately care for the resident, receive a more individualized care from the facility and resident may not be categorized correctly for the care that Resident 8 needs. During a concurrent interview and record review, on 8/13/2026, at 1:18 P.M., with the Director of Nursing (DON), Resident 8's PASARR level I dated 6/27/2025, and face sheet were reviewed. The DON stated that diagnoses considered as SMI include but are not limited to schizoaffective disorder and psychosis. The DON stated that Resident 8's PASARR level 1 that was done on 6/27/2025 question number nine indicated No that resident 8 did not have a SMI is inaccurately documented based on Resident 8's diagnoses schizoaffective disorder and Psychosis. The DON stated that Resident 8's PASRR level I needs to be complete and accurate for proper coordination and referral to mental health. The DON stated that mental health referral is important to be able to stabilize the resident's mental health. The DON stated a new PASRR level I will be done for Resident 8 to ensure that the assessment is accurate and a proper referral to mental health for PASRR level II is completed. A review of the facility's P&P titled, Pre-admission Screening Level II Resident Review (P ASRR Level II) with review and approval date of 3/20/2026, indicated, .PurposeTo coordinate assessments with the pre-admissions screening and resident review (PASRR) program under Medicaid/Medical to the maximum effort. Policy StatementThe facility staff will coordinate the recommendations from the level II PASRR determination and the PASRR evaluation report with the resident's assessment, care planning and transitions of care. Policy Interpretation and Implementation1.The PASRR will be completed in accordance with the Pre-Screening Resident Review (PASRR) policy.3. The admission licensed staff or designee will review completion of PASRR on admission.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of one sampled resident (Resident 8) in accordance with the facility's policy and procedures (P&P) titled Care Plans, Comprehensive Person-Centered revised 3/2026, by failing to initiate a care plan for Resident 8's post-traumatic stress disorder (PTSD - a brain and feeling problem that can happen after someone sees or goes through a very scary, dangerous, or painful event) diagnosis. This deficient practice had the potential to negatively affect the delivery of necessary care and services needed for Residents 8.Findings: A review of Resident 8's admission Record indicated the facility admitted Resident 8 on 3/18/2026 and readmitted Resident 8 on 6/22/2026 with diagnoses including schizoaffective disorder (a brain condition where a person has trouble telling what is real from what is not real, like seeing or hearing things that aren't there, while also having extreme changes in their mood, like feeling super sad or overly excited), unspecified psychosis (when a person's brain tricks them and they lose touch with reality), and PTSD. A review of Resident 8's Minimum Data Set (MDS -a resident assessment tool) dated 6/27/2026, indicated Resident 8 is cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 8 requires set up or clean up assistance to substantial/maximal staff assistance with Activities of daily living (ADLs- activities such as bathing, dressing and toileting where a person performs daily) care. During a concurrent interview and record review, on 8/12/2026, at 12:57 P.M., with Registered Nurse Supervisor (RNS) 1, Resident 8's chart was reviewed. RNS 1 stated that Resident 8 has a diagnosis of PTSD, however, Resident 8 did not have a care plan for PTSD, we just added one. RNS 1 stated that the facility needs to have a care plan for PTSD for Resident 8 so the facility can be aware of what to do for the resident in regard to interventions, what to look for and how to help the residents when they are experiencing a crisis. RNS 1 stated that the Residents care plan needs to be initiated as soon as the condition is identified. RNS 1 stated the residents care plan should be done on admission as part of the resident's baseline care plan. During an interview, on 8/13/2026, at 1:07 P.M., with the Director of Nursing (DON), the DON stated that a care plan is a tool used to indicate specified residents identified needs in regards to care such as medical, psychosocial, nutritional, specified plan of care establish goals and interventions and care that the facility want to specifically provide to the resident and the specified team of clinicians needed to meet the specific goal. The DON stated that a resident with a diagnosis of PTSD needed to have a PTSD care plan so the facility staff can know how to how to handle the resident and what the specific interventions and needs were, for the coordination of care. Lack of PTSD care plan can lead to an exacerbation for the condition that can lead to outburst, emotional psychological distress. A review of the facility's P&P, titled Care Plans, Comprehensive Person-Centered revised 3/2026, indicated,Policy Statement:A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Policy Interpretation and Implementation1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: .7. The comprehensive, person-centered care plan:a. Includes measurable objectives and timeframes;b. Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including:1. Services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;2. Any specialized services to be provided as a result of PASARR recommendations; and

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 14) received the treatment and services necessary to prevent skin breakdown according to the manufacturer's undated guidelines for the Drive-branded Low Air Loss Mattress (LALM - a specialized medical support surface designed to prevent and treat skin ulcers by combining alternating pressure with a steady low-volume airflow) titled, Med-Aire 8 Alternating Pressure Mattress Replacement System With Low Air Loss User Manual, and the facility's policy and procedures (P&P) titled, Specialty Mattress - Pressure Relieving Devices, last revised 3/2026. Resident 14's LALM settings was set for a body weight of 300 pounds (lbs-unit of measurement) while Resident 14's body weight was 114 lbs. This failure placed Resident 14 at increased risk of new skin breakdown and discomfort for Resident 14. Findings: During a review of Resident 14's admission Record, dated 8/12/2026, the admission Record indicated Resident 14 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including dementia (a progressive state of decline in mental abilities), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and metabolic encephalopathy (an altered state of brain function caused by a body-wide medical problem, chemical imbalance, or organ failure rather than a direct issue inside the brain). During a review of Resident 14's History and Physical (H&P), dated 12/19/2025, the H&P indicated Resident 14 has cognitive impairment (a state of having trouble with brain functions like thinking, remembering, learning, and paying attention) and is at increased risk of developing pressure ulcers (PU - damage to the skin and soft tissue caused by staying in one position too long). During a review of Resident 14's Minimum Data Set (MDS - a resident assessment tool), dated 5/29/2026, the MDS indicated Resident 14 is rarely/never understood. The MDS indicated Resident 14 has impairment to both sides of the upper extremities (shoulder, elbow, wrist, hand). The MDS also indicated Resident 14 is dependent (helper does all the effort) when rolling left and right in bed. The MDS also indicated Resident 14 is at risk of developing PUs. During an observation on 8/10/2026 at 9:02 AM in Resident 14's room, Resident 14 was in bed and lying on top of a LALM. The Drive-branded LALM machine was turned on, and the LALM setting was set at 300 pounds (lbs-unit of measurement). During a concurrent observation and interview on 8/10/2026 at 11:18 AM with Registered Nurse Supervisor (RNS) 1 in Resident 14's room, Resident 14 was in bed and lying on top of the LALM. The Drive-branded LALM machine was turned on, and the setting was set at 300 lbs. RNS 1 stated the purpose of the LALM is to protect Resident 14's skin from skin breakdown as a preventative measure, as Resident 14 does not currently have any PUs. RNS 1 stated that Resident 14's LALM machine's setting was set at 300 lbs, and that she needed to check the physician's order to verify the correct LALM setting. During a concurrent interview and record review on 8/10/2026 at 11:20 AM with RNS 1, Resident 14's physician's order, dated 1/7/2026, was reviewed. The physician's order indicated Resident 14 may have a LALM in place in Resident 14's bed. RNS 1 stated that Resident 14's physician order does not specify what setting the LALM should be set at, but by default, the LALM should be set to Resident 14's current weight per manufacturer's guidelines. During a concurrent interview and record review on 8/10/2026 at 11:21 AM with RNS 1, Resident 14's Weights and Vitals Summary, dated 8/3/2026, was reviewed. The Weights and Vitals Summary indicated Resident 14 weighs 114 lbs. RNS 1 stated Resident 14's LALM machine setting should be set at 114 lbs. RNS 1 stated nursing staff are responsible for ensuring the LALM machine settings are set to the correct setting, and she is not sure why or when Resident 14's setting was set incorrectly. RNS 1 further stated Resident 14's LALM machine setting is incorrect, and this could lead to Resident 14 developing skin breakdown. During an interview on 8/13/2026 at 3:31 PM with the Director of Nursing (DON), the DON stated a LALM is filled with air at a specific pressure setting to offload pressure to the resident lying on top of the mattress. DON further stated the purpose of the LALM is for skin integrity management for residents. The DON stated, According to the manufacturer's guidelines, the LALM machine's setting should be set to the resident's weight. If the machine's setting is incorrect, it would defeat the purpose of the mattress, which could lead to the resident developing skin breakdown. During a review of the facility's policy and procedures (P&P) titled, Specialty Mattress - Pressure Relieving Devices, last revised March 2026, the P&P indicated, The purpose of this procedure is to provide guidelines for the appropriate pressure-relieving devices or low air loss mattress for residents at high risk of skin breakdown or further skin breakdown. Follow the LALM manufacturer's user instructions. Once the mattress inflates to its normal size, set the comfort pressure to the comfort level as stated or desired by the resident or set the mattress according to the resident's weight when a resident is not able to provide the comfort preference. During a review of the manufacturer's guidelines for the Drive-branded LALM titled, Med-Aire 8 Alternating Pressure Mattress Replacement System With Low Air Loss User Manual, undated, the manufacturer's guidelines indicated to adjust the LALM machine's pressure setting according to the weight and comfort of the patient.

Based on observation, interview, and record review, the facility failed to ensure the head of the bed was elevated at least 30-degrees (a unit of measuring rotation) during feedings for one of two sampled residents (Resident 25) according to the physician's order and the facility's policy and procedures (P&P) titled, Enteral Feedings - Safety Precautions, last revised 3/2026. Resident 25 was receiving nutrition through a gastrostomy tube (G-tube, a flexible tube surgically inserted through the abdomen into the stomach for the administration of nutrition, fluids, and medications). This failure placed Resident 25 at increased risk of aspiration (accidentally inhaling food, liquids, stomach acid, or saliva into lungs), potentially leading to respiratory distress, illness, hospitalization, and death. Findings: During a review of Resident 25's admission Record, dated 8/12/2026, the admission Record indicated Resident 25 was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities), pneumonia (a lung infection that causes the small air sacs in the lungs to swell and fill with fluid), chronic obstructive pulmonary disease (a long-term lung problem that makes it hard to breathe), and gastrostomy status (medical condition of having an artificial, surgically created opening in the stomach wall that allows a feeding tube to be inserted directly into the stomach for nutrition, hydration, and medication). During a review of Resident 25's physician's order, dated 12/16/2025, the physician's order indicated to elevate Resident 25's head of bed to a 30-45-degree angle during enteral feeding and for one hour after feeding. During a review of Resident 25's History and Physical (H&P), dated 7/15/2026, the H&P indicated Resident 25 does not have the capacity to understand and make decisions. During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool), dated 6/25/2026, the MDS indicated Resident 25 is rarely/never understood. The MDS also indicated Resident 25 is totally dependent on a helper for mobility movements such as rolling left and right in bed, moving from a sitting to lying position in bed, and moving from a lying to sitting on the side of the bed position. The MDS also indicated Resident 25 receives nutrition through a feeding tube. During a review of Resident 25's physician's order, dated 4/15/2026, the physician's order indicated to administer the enteral feed Fiber Source HN two times a day at a continuous rate of 50 milliliters (mLs - a unit of measuring volume) per hour over 20 hours through the enteral feeding pump. The physician's order also indicated to start the enteral feedings at 12 PM and turn the enteral feedings off at 10 AM or until the dose is complete, and to hold the enteral feedings for one hour before and after Synthroid (a brand-name prescription medication containing levothyroxine sodium, a man-made version of the natural thyroid hormone T4) administration. During a concurrent observation and interview on 8/11/2026 at 7:30 AM with Licensed Vocational Nurse (LVN) 1 in Resident 25's room, Resident 25 was lying nearly flat on her back in bed with the tube feeding machine on and infusing. LVN 1 stated Resident 25 is lying flat and the head of bed's angle is too low. LVN 1 stated Resident 25's head of bed angle needs to be raised higher, to at least a 35-degree angle, while the enteral feedings are being administered to Resident 25. LVN 1 stated the head of bed must be raised while enteral feedings are being administered to prevent the risk of aspiration. LVN 1 further stated Resident 25 could aspirate if the head of bed angle is flat. During an interview on 8/13/2026 at 3:28 PM with the Director of Nursing (DON), DON stated that Resident 25's head of bed should be raised to between 30 degrees-45-degrees angle during feeding to prevent the risk of aspiration to the resident. The DON also stated nursing staff have received training on how to visualize what a 30 degree-45-degree angle looks like when raising the head of the bed of the resident. The DON further stated, If a resident aspirates during enteral tube feedings, it could lead to the resident developing respiratory problems, pneumonia, or even death. During a review of the facility's policy and procedures (P&P) titled, Enteral Feeding - Safety Precautions, last revised 3/2026, the P&P indicated, Elevate the head of the bed (HOB) at least 30 degrees during tube feeding and at least 1 hour after feeding. to prevent aspiration.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 25's) supplemental oxygen was administered via nasal cannula (NC, a light plastic tube with two small tips that go softly into the nose that helps give extra oxygen to people who have trouble breathing) according to the physician's order, dated 7/2/2026, and the facility's policy and procedures (P&P) titled, Oxygen Administration, last revised 3/2026. This failure increased Resident 25's risk of experiencing shortness of breath (SOB) and developing respiratory failure (a life-threatening condition that occurs when the lungs cannot get enough oxygen into the blood). Findings: During a review of Resident 25's admission Record, dated 8/12/2026, the admission Record indicated Resident 25 was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities), pneumonia (a lung infection that causes the small air sacs in the lungs to swell and fill with fluid), chronic obstructive pulmonary disease (COPD, a long-term lung problem that makes it hard to breathe), and gastrostomy status (medical condition of having an artificial, surgically created opening in the stomach wall that allows a feeding tube to be inserted directly into the stomach for nutrition, hydration, and medication). During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool), dated 6/25/2026, the MDS indicated Resident 25 is rarely/never understood. The MDS also indicated Resident 25 is totally dependent on a helper for mobility movements such as rolling left and right in bed, moving from a sitting to lying position in bed, and moving from a lying to sitting on the side of the bed position. During a review of Resident 25's Care Plan (CP) titled, At Risk for Respiratory Distress. dated 6/29/2026, the CP indicated Resident 25 is at risk for respiratory distress due to episodes of chest congestion. The CP further indicated interventions including administering oxygen as ordered. During a review of Resident 25's Physician's Order, dated 7/2/2026, the physician's order indicated to administer oxygen at 2 liters (a unit of measuring volume) per minute via nasal cannula continuously to maintain oxygen saturation (a measurement of how well the lungs send oxygen into the blood) equal or greater than 95 percent (%, unit of measurement) for SOB, respiratory failure, pneumonia. During a review of Resident 25's History and Physical (H&P), dated 7/15/2026, the H&P indicated Resident 25 does not have the capacity to understand and make decisions. During an observation on 8/10/2026 at 9:55 AM in Resident 25's room, two CNAs finished dressing Resident 25 in a new gown while Resident 25 was lying in bed. Resident 25 was lying in bed without a NC in place in her nose and was not receiving supplemental oxygen. During a concurrent observation and interview on 8/10/2026 at 11:02 AM with Registered Nurse Supervisor (RNS) 1 in Resident 25's room, Resident 25 was lying in bed without a NC in place in her nose and was not receiving supplemental oxygen. The resident's oxygen NC was lying on top of the mattress of Resident 25's bed and beside Resident 25's left arm. The NC tubing was attached/connected to a oxygen concentrator (a medical device that pulls in room air and delivers oxygen through oxygen tubing). The oxygen concentrator was turned on and was set to administer oxygen at 2 liters per minute. RNS 1 stated Resident 25's NC was not in place in Resident 25's nose and Resident 25 was not receiving oxygen as ordered by the physician. RNS 1 further stated if Resident 25 does not receive oxygen, then Resident 25 could develop worsening SOB and wheezing. During an interview on 8/13/2026 at 3:30 PM with the Director of Nursing (DON), DON stated, It is important to administer oxygen to the residents as ordered by the physician to maintain the resident's oxygen saturation, to prevent shortness of breath, and for the resident's comfort. If oxygen is not administered as ordered, the resident could develop respiratory distress, respiratory failure, and other respiratory complications. During a review of the facility's policy and procedures (P&P) titled, Oxygen Administration, last revised 3/2026, the P&P indicated, Review the physician's orders or facility protocol for oxygen administration. Oxygen is administered by an oxygen mask, nasal cannula, and/or nasal catheter. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head. Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter).

Based on observation and interview, the facility failed to observe laundry infection prevention procedures by failing to ensure:A. Soiled linen are placed inside leak proof/resistant bags and tied securely.B. Soiled linen storage carts were closed/covered inside designated repository area.This deficient practice had the potential to spread diseases causing pathogens (bacteria, viruses and spores), cause safety and environmental hazards from uncontrolled odors, pest attraction from insects, rodents and vermin.Findings; During a tour observation of the facility soiled laundry storage area on 8/12/2026 at 1:03pm, some soiled linen were placed inside an uncovered soiled linen cart and not in leak proof resistant bag, some laundry were placed in the soiled resistant bags however, the bags were open and dirty/contaminated linen was spilling out of the bag and exposed to the elements and dirty gloves were left inside the soiled linen cart. Additionally, two blankets utilized by Residents were observed to be placed outside in the open and on top of a dusty table in a closed alleyway between Facility A and Facility B. During an interview on 8/12/2026 at 1:13pm housekeeping Supervisor (HS) stated soiled linen should be placed in clear plastic bags and securely fastened to prevent leakage and odor, states failing to place soiled linen in plastic bag and securely fastening the bag to prevent leakage and odor, leaving soiled linen and used gloves in the in an open soiled cart is an infection control issue. During an interview on 8/12/2026 at 1:21 pm infection prevention nurse (IP) stated the blankets were supposed to be placed clear plastic bags and placed in dirty linen carts and not on top of a table exposed to the dust and environmental elements. During a follow-up interview on 8/13/2026 at 1:41pm IP stated all soiled linens should be placed in a leak free bag and securely fastened before placing them (soiled linens) in the designated receptacle. IP stated some Certified Nurse Assistants (CNAs) forgot to tie the plastic bags and leak free bags. During an interview on 8/13/2026 at 2:26 pm, the Director of Nursing (DON) stated soiled linen should be placed in leak proof plastic bag and securely fastened to prevent spillage then, placed in a soiled linen cart. DON stated when soiled linen cart is full and/or no longer in use the soiled linen should be placed in a larger soiled linen receptacle designated for soiled linen only and remain covered until transported to the laundry area to be washed. DON stated failing to securely fasten and/or place soiled linen in a leak proof bag can result in unpleasant odors, attract pests, flies, which are vectors for disease carry microorganisms and is an environmental and sanitation hazard. A review of the facility policy and procedures (P&P) titled Clean and Soiled Linens dated 03/2026 indicated, he purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen . Soiled linens will be placed in a bag, transported and stored in covered Carts.

Based on observation interviews and record review, the facility failed to the laundry washing machine in good repair and maintained in a sanitary safe operating condition. This deficient practice had the potential to create severe health, safety, and regulatory compliance risks (harbor stagnant water and mold, attract pests) and, is a violation of strict Department of Health sanitation codes by disrupting the facility's capacity to maintain an adequate supply of clean, sanitized linen or personal laundry, and create physical safety hazards in tight utility spaces (restricted airflow spaces trapping lint near heating elements, escalating fire risks).Findings; During a tour of the facility laundry processing area on 8/12/2026 at 1:03pm, facility was observed to have two commercial washing machines of which one washing machine was non-operational and had various items inside the machine (unknown) and could not open. The facility had one commercial washing machine processing laundry (clothes, linens, towels etc.) for more than 80 Residents in two (2) facilities (Facility A and Facility B). During an interview on 8/12/2026 at 1:13pm housekeeping Supervisor (HS) stated the washing machine has been non-operational for more than a year, HS stated they (housekeeping staff) have been unable to open the non-operational washer stating, it locked and we have been unable to open it. During an interview on 8/12/2026 at 1:30 pm Maintenance Supervisor (MS) stated the non-operational washer has been broken for more than a year. MS was unable to provide a maintenance log and/or invoice indicating the last time the broken washer was serviced. MS also stated facility management is aware the washer is broken, MS stated he has requested washer be replaced but has been unsuccessful in obtaining a replacement. During an interview on 8/13/2026 at 2:26 pm, the Director of Nursing (DON) stated she (DON) was unaware the facility had a non-functional laundry washer that was Broken and had been non-operational for more than 1year. DON stated keeping non-functioning equipment in the laundry area could cause clutter. A review of facility policy and procedures (P&P) titled Maintenance Service dated 03/2026 indicated, the maintenance department is responsible for maintaining the . equipment in a safe and operable manner at all times. Functions of the maintenance personnel include but are not limited to establishing priorities in providing repair service, providing routinely scheduled maintenance service to all areas. The maintenance schedule shall be provided to each department director so that appropriate scheduling can be made without interruption of service to the residents. Records should be maintained in the maintenance director's office.

Based on observation, interview and record review, the facility failed to ensure a residents room did not accommodate no more than four residents per room for two of eight Resident rooms (rooms [ROOM NUMBERS]).This deficient practice had the potential to result in inadequate useable living space for the residents and working space for the healthcare providers.Findings: During a review of the facility Room Waiver letter, dated 8/11/2026, submitted by the Facility Administrator (FA), the facility room waiver letter indicated that resident rooms [ROOM NUMBERS] have six beds per room. The facility room waive letter indicated that the room sizes are spacious enough to allow unrestricted movement of all residents, the rooms have ample closet space for residents, each resident is equipped with all furnishings/privacy curtains, the health/safety of the residents are not jeopardized due to the configuration of the room and privacy is provided for all in these rooms. During a review of the facility's Client Accommodations Analysis submitted by the facility dated 8/10/2026, indicated the following rooms with their corresponding measurements:room [ROOM NUMBER] is 465.90 square feet with 6 beds (77.65 square feet per resident).room [ROOM NUMBER] is 475.0 square feet with 6 beds (79.1 square feet per resident). During the general observations of the residents' rooms on 8/10/2026 to 8/13/2026, the residents in rooms [ROOM NUMBERS] had ample space to move freely inside the rooms. There were sufficient spaces to provide freedom of movement for the residents and for nursing staff to provide care to the residents. There was also sufficient space for beds, side tables and resident care equipment. Resident bedrooms must accommodate no more than four residents per federal regulation.

Based on observation, interview, and record review, the facility failed to ensure one out one resident (Resident 9), was not exposed to cigarette smoke emanating from the patio in the smoking area during scheduled smoking hours.Resident 9 was dependent on staff for activities of daily living (ADL) and needed substantial maximal assistance to walk 10 feet (ft-unit of measurement), and patio door was door was difficult to close This deficient practice had the potential to cause eye and nasal irritation, throat and airway discomfort, nausea, headaches, and shortness of breath from direct inhalation of toxic cigarette smoke fumes.Findings: A review of Resident 9's medical record indicated Resident 9 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included type 2 diabetes mellitus (diseases that result in too much sugar in the blood), metabolic encephalopathy (brain malfunction caused by chemical imbalances or toxins in the blood.), depression (persistent feeling of sadness, emptiness, and a loss of interest or pleasure in daily activities), hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (paralysis or weakness on one side of the body caused by dead brain tissue from a blocked blood vessel), generalized muscle weakness and gastro-esophageal reflux disease (GERD- condition where stomach acid flows back up into the food pipe, causing ongoing irritation and tissue inflammation) A review of the Minimum Date Set (MDS-a resident assessment tool) dated 7/31/2026 indicated Resident 9's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. Resident 9 required supervision or touching assistance with eating, substantial maximal assistance with personal hygiene, putting on/taking off footwear, upper and lower body dressing, Resident 9 was dependent on toileting hygiene and shower/bathe self and substantial maximal assistance to walk 10 feet. During a facility tour on 8/10/2026 at 9:15 am, sliding patio door of room [ROOM NUMBER] was observed to be open. Fumes of cigarette smoke entered the room as Resident 9 lay in her bed awake exposed to cigarette smoke, Resident 9 expressed indifference and shrugged when asked about cigarette smoke fumes entering her room. Resident 9's bed that was observed to be the closest bed to the sliding patio door, the patio door was door was difficult to close, the sliding door track was observed to have dirt and worn-out /broken rollers. During an interview on 8/12/2026 at 11:10 am Maintenance Supervisor (MS), stated the sliding patio door was difficult to close because the roller for the tracks was worn out and needed to be replaced. MS also stated room [ROOM NUMBER] has not had a protective screen since covid. MS stated that disease causing vermin and insects can get inside the Residents room infect the residents. During an interview on 8/12/2026 at 11:15 am, Activities Assistant, stated room [ROOM NUMBER] sliding patio door should not be open during smoke times due to secondhand smoke exposure. AA stated secondhand smoke exposure can cause Resident to develop a cough and exacerbate other health problems like asthma (lung disease that causes swelling and tight muscles in the breathing tubes) and shortness of breath. During an interview on 8/13/2026 at 2:26 pm, the Director of Nursing (DON) stated not every Resident can tolerate cigarette smoke, cigarette smoke inhalation exposure can cause inhalation allergic reactions form the unpleasant smell and can trigger and/or exacerbate respiratory problems like asthma. A review of facility policy and procedures (P&P) titled Safe and Homelike Environment, dated, 03/2026 indicated, the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include pleasant, neutral scents. A review of the facility's P&P titled Maintenance Service dated 3/2026 indicated, maintenance shall be provided to all areas of the building . the maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

Based on interview and record review, the facility failed to protect the rights of one of two sampled residents (Resident 1) to be free from financial abuse according to facility's policy and procedures (P&P) titled, Gifts, Gratuities, and Payments, reviewed 3/2025, when Licensed Vocational Nurse (LVN) 1 over the course of three days, made several purchases including reserving a hotel room for LVN 1 and charged Resident 1's credit card during the month of 2/2026. Resident 1 did not authorize the purchases. As a result, Resident 1 was upset because LVN 1 charged $1213.02 to Resident 1's credit card without the resident's permission.Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 9/3/2025, with diagnoses including but not limited to dementia (a progressive state of decline in mental abilities), atrial fibrillation (an irregular heartbeat that can lead to blood clots and increases the risk of stroke and other heart complications) and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). A review of Resident 1's Quarterly Minimum Data Set (MDS - a resident assessment tool) dated 12/11/2025 indicated Resident 1 had severely impaired cognition (ability to think, understand, and reason) and was usually able to make self-understood, and was usually able to understand others. The MDS indicated the resident required substantial assistance with toileting hygiene, bathing and lower body dressing. The MDS also indicated Resident 1 used a manual wheelchair, required moderate assistance to walk 10 feet and did not attempt to walk 50 feet due to medical condition or safety concerns. A review of Resident 1's credit card bank statement, for the dates from 1/29/2026 to 2/25/2026 indicated the following:- On 2/21/2026, a $107 charge was made at a beauty enhancement (eyelash extension) provider- On 2/21/2026 a $1.25 charge to a person unknown reason- On 2/21/2026 a $1.25 charge to the same person for an unknown reason- On 2/22/2026 a $577.39 charge for a hotel in Las Vegas, Nevada (NV)- On 2/22/2026 a second charge to the same hotel in Las Vegas, NV in the amount of $400- On 2/24/2026, $126.13 purchase at a dry cleaners 34 miles away from the facility During an interview on 3/24/2026 at 10:48 AM with Resident 1, Resident 1 stated that LVN 1 was my nurse for a number of months. We got to know each other. She (LVN 1) brought me 3 sets of clothes and gave them to me. I offered to pay and she said no. Resident 1 stated that LVN 1 went with him to from the facility to go to the bank about four or five times. him (Resident 1) to the bank. Resident 1 stated Resident 1 has a debit card and the credit card. Resident 1 stated two or three weeks ago, he gave LVN 1 his credit card to purchase a new cell phone for him which LVN 1 delivered to Resident 1. Resident 1 stated the facility staff took his bank statements from him and then told him that LVN 1 used his credit card for unauthorized purchases. Resident 1 stated law enforcement came and spoke with him. Resident 1 further stated he did not give LVN 1 his credit card to go to Vegas nor permission to use his credit card. Resident stated all this started (incident with LVN 1) because he is too old to be driving. Resident 1 stated he wished LVN 1 had come to him first and they could have come to some agreement. Resident 1 stated he was upset that someone got into his billfold (wallet) and took it (credit card). Resident 1 stated that LVN 1 never gave him the cell phone, however, a cell phone came about four or five days after all this happened (incident with LVN 1 and the credit card). During an interview on 3/24/2026 at 12:48 PM, LVN 2 stated that LVN 1 volunteered to accompany Resident 1 to the bank and that LVN 1 was very insistent on taking Resident 1 to the bank. LVN 2 stated that, Normally we (facility) have people from activities or CNAs (certified nursing assistants) who act like escorts. I thought it was kind of weird that a charge nurse (LVN 1) would want to with him (Resident 1) to the bank. LVN 2 stated that she knew LVN 1 volunteered to accompany was Resident 1 and never anyone other residents. LVN 2 stated that the facility always in-service us that we are supposed to say no we never take money or gift cards or anything. As money goes they tell us that especially for residents it can be considered financial abuse even if they say it's a gift - we know that can change. During a phone interview on 3/24/2026 at 1:30 PM, LVN 1 stated LVN 1 escorted Resident 1 to open a bank account after work one day in January 2026. LVN 1 stated she paid the transportation costs for the trip to the bank. LVN 1 stated that Resident told her that he had to fix his account because he didn't have any money. LVN 1 stated that she would buy him cigarettes and that before the incident (credit card) LVN 1 would help Resident 1 because the resident was depressed and no one was paying attention to the resident. LVN 1 stated she asked if Resident 1 could have a temporary out on pass so he can fix his problem. No one could escort him so I finished my job and I said I could escort him so he could do what he wanted to do. I even paid for the Uber. We (Resident 1 and LVN 1) went to the bank and opened his account. LVN 1 stated Resident 1 wanted a phone and an organizer to put his stuff/things. LVN 1 stated that she don't have enough money to pay Resident 1 what the resident wanted, however, Resident 1 insisted on giving me his card so that I can buy his thing . I couldn't set it up (credit card). LVN 1 stated, My mistake I should have gone back him his card I did not realize that I was going to be off for 3 days, then he was looking for it (the credit card). I did not return his card because I was sick. I tried to use his credit card because it was not activated I asked him to try. I used the credit card to reserve a hotel. LVN 1 stated Resident 1 insisted on giving LVN 1 his credit card to buy the resident a cell phone. LVN 1 stated, I don't remember telling (Resident 1) that I used the card for the hotel reservation or how much I spent. LVN 1 also stated, I take responsibility and I paid Resident 1 back $1300 in cash to the administrator (ADMIN). During an interview on 3/24/2026 at 2:37 PM, Discharge Planner (DCP) stated on 3/14/2024, DCP entered the facility and Resident 1 was on the phone with his banking institution but he was confused, so DCP helped him with the call. DCP stated a bank person/staff member where Resident 1 banks, alerted DCP that Resident 1 had balance on his (Resident 1's) credit card. DCP stated the charges on Resident 1's credit card were suspicious. DCP further stated Resident 1 stated he (Resident 1) gave LVN 1 his credit card and LVN 1 was helping him get things done including going to the bank. DCP further stated after hearing the charges she went immediately to tell the Administrator. During an interview on 3/24/2026 at 3:54 PM, the ADMIN stated on 3/6/2026, Friday, I found out that Resident 1 gave LVN 1 his credit card to purchase a cell phone. The ADMIN further stated she verified with Resident 1 that he had not authorized the purchases. The ADMIN stated she then called LVN 1 and told her (LVN 1) that they (ADMIN and LVN 1) needed to talk. The ADMIN stated LVN 1 then came into the facility, brought $1300 in cash because that's the amount LVN 1 charged Resident 1's card and resigned immediately. The ADMIN stated that Resident 1 said previously she (LVN 1) was purchasing things for Resident 1 like the cell phone. The ADMIN also stated that after conducting an investigation into the situation (Resident 1 and LVN 1), the ADMN determined that LVN 1 financially abused Resident 1. The ADMIN stated, these are vulnerable people (residents) under no instance do we accept any gifts from residents. A review of the facility's inservice titled Resident Abuse Prohibition Training, indicated LVN 1 completed and signed the resident abuse prohibition training on 8/26/2025. The Resident Abuse Prohibition Training indicated that the different . types of abuse included misappropriation of resident's property/financial/fiduciary (is someone who manages money or property for someone else) are types of abuse. The Resident Abuse Prohibition Training under the section of Notice to Employees of Obligation to Report a Crime under the Elder Justice Act, indicated that . In an event that an allegation of abuse occurs . Report the abuse allegation to the supervisor then the supervisor will handle the suspension of the alleged abuser and will report allegation/s to the administrator. A review of the facility's Abuse Policy Acknowledgement Form, signed by LVN 1 on 8/26/2025, indicated that by signing, LVN 1 acknowledged having received the information listed below, have had sufficient opportunity to ask questions and have all my questions answered regarding our policies on abuse . Abuse Pre-Test Policy on Abuse Prevention and Mandated Reporting Abuse Reporting-Mandated Reporting Requirements . Abuse Post-Test Notice to Employees of Obligation to Report a Crime under the Elder Justice Act A review of the facility's policy and procedures (P & P) titled, Abuse Prevention, revised 3/2025, indicated, The Facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment and develops Facility policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. The Administrator as abuse prevention coordinator is responsible for the coordination and implementation of the Facility's abuse prevention, screening, and training program policies. The P&P further indicated Misappropriation of resident property and financial abuse are defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. A review of the facility's P & P titled, Gifts, Gratuities, and Payments, reviewed 3/2025, indicated our facility prohibits employees from receiving or giving any gift, gratuity, or payment for services rendered; the making of any promise(s) on behalf of the facility; or engaging in any activity, practice, or act which conflicts with the interest of the facility or its residents. The P&P further indicated:1.No employee of this facility, or any member of his/her immediate family, may give or accept any cash, gifts, special accommodations, favors, or use of property or facilities to or from anyone with whom this facility does business or is negotiating business on behalf of the facility. 2. The giving or accepting of anything of value by our employees to or from any of our suppliers, residents, family members, visitors, or other employees in any form whatsoever is prohibited. Such conduct may be criminal under certain laws. 3. This policy does not preclude gifts of items of nominal value (not to exceed $50.00 per year). Gifts bearing a supplier logo, which are distributed generally and cost no more than five dollars ($5.00), may be excluded from the fifty dollar ($50.00) annual limitation.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free of accident hazards by failing to:Ensure Resident 1 was assisted with at least two-person assist during mobility and transfer according to Resident 1's Minimum Data Set (MDS - resident assessment tool).Ensure Resident 1 was evaluated and assessed by a licensed nurse after Resident 1 slipped on the floor while giving shower according to facility's policy and procedures (P&P) titled, , Falls - Clinical Protocol, and Falls and Fall Risk, Managing.This deficiency resulted in Resident 1's fall and had the potential to place the resident at risk for recurrent falls. Findings:During a review of Resident 1's Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), muscle weakness (weakening, shrinking, and loss of muscle), muscle weakness (weakening, shrinking, and loss of muscle), abnormalities of gait (ambulation) and mobility, and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) During a review of the MDS dated [DATE], indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was severely impaired. The MDS indicated Resident 1 required total dependence (helper does all of the effort and assistance of two or more helpers is required for the resident to complete the activity) from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Physical Therapy (PT) Care Plan (CP), date initiated 12/6/2025, the PT CP indicated, (Resident 1) presents with impaired: bed mobility, functional transfer, ambulation, safety awareness. reason for use: impulsive behavior, attempts to get up unassisted, poor safety awareness, inability to control body positioning. The PT CP indicated a goal of, Resident (1) will have decreased episodes of falls through review date.During a review of Resident 1's PT Evaluation and Plan of Treatment, dated 12/6/2025, the PT Evaluation and Plan of Treatment indicated that Resident 1 required maximum assistance with bed mobility and total dependence+ (td+ - referring to a patient who requires total assistance for a task but still attempts to assist with the movement).During a review of Resident 1's Occupational Therapy (OT) Evaluation & Plan of Treatment, dated 12/6/2025, the OT Evaluation & Plan of Treatment indicated that, Cognitive-Communicative Assessment: (Resident 1's) Safety Awareness was impaired. Bathing: total dependence without attempts to initiate. Upon assessment, patient (Resident 1) demonstrates significant decline in ADLs with deficits in strength, coordination, postural control, balance, functional activity tolerance, safety awareness.During a review of Resident 1's Fall Risk Assessment (FRA), dated 2/16/2026, the FRA indicated a score of 17 (total score of 10 or above represents high risk).During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 2/16/2026, the SBAR indicated a change of condition due to status post (s/p) fall on shower room with the Certified Nursing Assistant 1 (CNA 1). The SBAR indicated a nursing note: Called by CNA (1) to shower room, patient (Resident 1) sitting on the shower chair. Patient (Resident 1) alert and verbally responsive. Observed right cheek discoloration. Per CNA (1), patient (Resident 1) stood up and landed on right side of her face and on both knees. Discoloration observed on left and right knee.During an interview with Certified Nursing Assistant 1 (CNA 1) on 2/26/2026 at 12:19 p.m., CNA 1 stated, he (CNA 1) was assigned to Resident 1 on 2/16/2026 and he gave Resident 1 a shower in the shower room. CNA 1 stated, I transferred Resident 1 from bed to shower chair on my own, she (Resident 1) was petite and light and I was able to transfer her from bed to shower chair on my own. CNA 1 stated, during shower, Resident 1 suddenly stood up on her own from the shower chair and then she fell on both her knees and ended up on her cheeks. CNA 1 stated that Resident 1 was unable to communicate, and he (CNA 1) thought Resident 1 was unable to ambulate on her own. CNA 1 stated that after Resident 1 fell from the shower chair, he called for help and picked up Resident 1 from the floor and put her back on the shower chair. CNA 1 stated, I knew I shouldn't have done that, but I picker her up right away. CNA 1 stated that the licensed nurses must assess residents first if they fell or found them on the floor before moving the resident. CNA 1 stated that he was not supposed to lift the resident after a fall, the licensed nurse must assess resident first, but he didn't want to leave her on the floor.During an interview with Director of Rehabilitation (DOR) on 2/26/2026 at 1:05 p.m., DOR stated, Resident 1 has history of falls and required two-person assist with transfer. DOR stated that Resident 1's dynamic balance is very poor and has cognitive issues due to her diagnoses. DOR stated that it does not matter how big or small a resident is, if resident requires two-person staff assist when transferring, staff need to follow the plan of care because an accident can happen.During an interview with Licensed Vocational Nurse 1 (LVN 1) on 2/26/2026 at 1:32 p.m., LVN 1 stated, she was the charge nurse for Resident 1 on 2/16/2026 when she was called by CNA 1 for help in the shower room. LVN 1 stated, she saw Resident 1 on the shower chair after CNA 1 reported that Resident 1 fell from the shower chair. LVN 1 stated, she did not witness and she did not evaluate Resident 1 on the floor after she fell.During an interview with Director of Nursing (DON) on 2/26/2026 at 1:55 p.m., DON stated, if a resident was found on the floor, CNAs must stay with the resident until help arrives and resident must be evaluated by a licensed nurse before they move the resident. DON stated, if a resident had an accident such as fall and CNAs move the resident without being evaluated by a licensed nurse first, they can create more problems, because they won't know if resident had a fracture, etc. DON stated, it does not matter if resident is light and petite, staff must check if resident have the ability to bear weight, assess their cognition first and staff must not lift a resident on their own just because they think they can do it on their own.During a review of the facility's P&P titled, Falls - Clinical Protocol, reviewed on 11/2025, the P&P indicated that, The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, and observations of the events, etc.During a review of the facility's P&P titled, Falls and Fall Risk, Managing, reviewed on 5/2025, the P&P indicated that, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Environmental factions that contribute to the risk of falls include: wet floors; poor lighting; incorrect bed height or width; obstacle in the footpath; improperly fitted or maintained wheelchairs; and footwear that is unsafe or absent. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.

Based on observation, interview and record review the facility failed to have call device (a mechanism used by residents to promptly communicate with staff) within reach for three of five sampled residents (Resident 2, 3 and 4). This failure had the potential to result in an accident and/or injury, and/or delay resident care.During a review Resident 2's admission Record dated 9/29/25 indicated Resident 2 was originally admitted to the facility on [DATE] with diagnosis including dementia (decline in abilities to remember, make judgments, think, or make decisions), abnormalities of gait and mobility, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities)During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 9/4/25 indicated Resident 2 had mild cognitive (ability to think, understand and make daily decisions) impairment and required partial/moderate assistance with most activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 2's care plan for risk for falls and associated injury, dated 6/26/25 indicated, an intervention of call light within easy reach and answer promptly.During a review Resident 3's admission Record dated 9/29/25 indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including Guillian-Barre syndrome (a condition in which the body's immune system attacks the nerves, causing weakness and numbness that gets progressively worse), dysphagia (trouble swallowing), candidiasis (fungal infection cause by a yeast-like fungus) and muscle weakness. During a review of Resident 3's MDS dated [DATE] indicated Resident 3 had mild cognitive (ability to think, understand and make daily decisions) impairment and required supervision or touching assistance to dependance on staff for assistance with most ADLs. During a review of Resident 3's care plan for risk for falls and injuries dated 9/14/25 indicated Maintain call light within reach.During a review Resident 4's admission Record dated 9/29/25 indicated Resident 4 was admitted to the facility on [DATE] with diagnosis including hypertension (HTN, high blood pressure), major depressive disorder, Wernicke's encephalopathy (severe, acute brain disorder caused by a deficiency of thiamine [vitamin B1]), and anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life). During a review of Resident 4's MDS dated [DATE] indicated Resident 4 had severe cognitive impairment and required supervision or touching assistance to partial / moderate assistance by staff for most ADLs.During a review of Resident 4's care plan for risk for falls dated revised 8/30/25 indicated call light within easy reach and answer promptly.During an observation with concurrent interview on 9/29/25 at 2:55 pm with Registered Nurse Supervisor ( RNS) 1 in Resident 2, 3 and 4's room. RNS 1 verified the call light from that room was not illuminating at the call light panel at the nurses' station which would indicate one of the residents in that room needed assistance. RNS 1 further verified Resident 3 was given a table bell to use as an alternate way of alerting the staff she needed help, and Residents 2 and 4 did not have a table bell or alternate way to get the attention of the staff while their call lights were out of order. RNS 1 stated the risk to the residents would be the staff would not be aware to address issues on time. During a review of the facility's policy and procedures Call Light, revised October 2024, indicated, When a resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure facility staff provided 1:1 monitoring and supervision to prevent repeated falls for Resident 1 in accordance with the facility ' s policy and procedures titled, Falls and Fall Risk, Managing, dated, 3/2018. The facility identified Resident 1 as a high risk for falls. As a result, on 10/1/2023-Resident 1 fell out of his wheelchair (WC) while sitting in the lobby of the facility and suffered a laceration (a deep cut or tear in the skin) and bleeding above the right eyebrow. Resident 1 was transferred to the General Acute Care Hospital (GACH) and treatment provided for the laceration. Findings: A review of Resident 1 ' s admission records (facesheet) indicated, Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-ongoing inflammatory lung disease that causes obstructed airflow from the lungs), type 2 diabetes (a problem in the way the body regulates and uses sugar), anemia (a condition in which the body does not have enough healthy red blood cells), dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (persistent and excessive worry that interferes with daily activities) and insomnia (difficulty falling or staying asleep). A review of Resident 1 ' s history and physical dated 6/8/2023, indicated Resident 1 could make needs known but could not make medical decisions. A review of Resident 1 ' s Minimum Date Set (MDS-a standardized assessment care screening tool) dated 7/28/2023, indicated Resident 1 required one person physical assist with transfers, walking in the room, dressing, toilet use and personal hygiene. A review of Resident 1 ' s Fall Risk assessment dated [DATE], indicated Resident 1 was at high risk for falls. A review of Resident 1 ' s Change of Condition (COC- a deterioration in health, mental status, or psychosocial [mental, emotional, social, and spiritual health] status) form dated 9/21/2023 at 5:57 PM, indicated Licensed Vocational Nurse 1 (LVN 1) on the evening shift (3PM to 11PM), who was in the middle of administering medications to residents, passed by the nursing station and found Resident 1 sitting on the floor. Resident 1 was touching his right forearm near his right elbow. LVN 1 noted Resident 1 was bleeding from the right forearm. The facility placed Resident 1 on close observation (monitoring for safety to prevent further falls) and X-rays (a process of taking an image of a specific body part). Resident 1 ' s Medical doctor (MD) was notified, and the MD ordered an Xray of Resident 1 ' s right elbow and forearm. A review of Resident 1 ' s X-rays dated 9/22/2023, revealed no fractures of right elbow and right forearm. However, X-ray of the chest, revealed old fractures (a break in the bone) of the 6th through 9th right ribs (bones of the chest wall). A review of Resident 1 ' s care plan for At Risk for Falls revised on 9/23/2023, indicated Resident 1 was a high risk for falls due to unsteady gait (a manner of walking). Interventions included to assess and anticipate Resident 1 ' s needs of food, thirst, toileting needs, comfort levels, body position and pain. Encourage Resident 1 to assume a standing position slowly .keep environment free of clutter and safety hazards. A review of Resident 1 ' s care plan for Actual fall initiated on 9/23/2023, indicated Resident 1 had an actual fall on 9/21/2023. The care plan also indicated resident 1 has impulsive behavior, attempts to get up unassisted, and had poor safety awareness. Interventions included to discuss ., alternatives, reason, risk, and benefits with resident or resident representative. Interventions further indicated to instruct Resident 1 not to have sudden position changes, and to monitor the resident for steadiness and balance. A review of Resident 1 ' s Nursing Progress Notes dated 9/25/2023, indicated Resident 1 ' s MD gave an order to transfer Resident 1 to the GACH for further evaluation and management due to rib fractures and Resident 1 refusing MD ' s order for a follow up rib series x-ray . Resident 1 was transferred to GACH on 9/25/2023 at 6 PM for further evaluation. A review of Resident 1 ' s Nursing Progress Notes dated 9/27/2023, indicated that on 9/27/2023 at 4:04 PM, the case manager at the GACH notified the facility that Resident 1 ' s chest X-ray completed during admission to GACH on 9/25/2023, was negative for right rib fractures. A review of Resident 1 ' s Physician ' s Order Summary dated 10/1/2023, indicated the facility readmitted Resident 1 on 10/1/2023. A review of Resident 1 ' s COC dated 10/1/2023, indicated LVN 3 documented that on 10/1/2023 at 11:30 PM, Resident 1 got up from a WC and had a fall. The COC indicated LVN 3 found Resident 1 on the floor with a bleeding laceration above the right eyebrow. LVN 3 applied dressing (padded material for wound care) to control bleeding. Emergency Medical Services (EMS-ambulance emergency services or paramedic services that provide urgent pre-hospital treatment and stabilization for serious illness and injuries and transport to definitive care) was called, and Resident 1 was transferred to GACH for further evaluation. A review of GACH emergency room Physician Notes for Resident 1 dated 10/1/2023, indicated EMS transferred Resident 1 to GACH on 10/1/2023 after Resident 1 fell from a WC. Resident 1 had a computerized tomography (CT- detailed imaging of a specific body part) scan of the head and cervical spine (neck region) with no acute (sudden onset) findings of fractures or internal (inside the body) bleeding. Resident 1 had a laceration on the forehead which was repaired with nine sutures (specialized thread used to close breaks in the skin). Resident 1 was transferred back to the facility on [DATE] at 4 AM. During an interview with LVN 1 on 10/3/2023 at 10:55 AM, LVN 1 stated that on 9/21/2023 at around 5 PM, Resident 1 was sitting in WC in front of the nursing station. LVN 1 stated she was working at the nursing station and heard Resident 1 fall. LVN 1 stated she immediately went over to Resident 1 and observed that Resident 1 had a laceration on the right forearm area near the right elbow. LVN 1 stated she applied a pressure dressing on Resident 1 ' s right forearm and assisted Resident 1 back into the WC. LVN 1 stated Resident 1 did not complain of any pain following the fall. LVN 1 stated she placed Resident 1 on close monitoring for safety to prevent further falls. LVN 1 stated she notified Resident 1 ' s MD of Resident 1 ' s fall. LVN 1 stated MD ordered an x-ray of Resident 1 ' s right arm. LVN 1 stated Resident 1 had complained earlier in the day of right rib pain and that was the reason MD ordered an X-ray of the right ribs. LVN 1 stated Resident 1 ' s right rib pain was not associated the resident ' s fall. During an interview with LVN 2 on 10/3/2023 at 3:15 PM, LVN 2 stated the facility readmitted Resident 1 from GACH on 10/1/2023 at around 8 PM. LVN 2 stated the facility transferred Resident 1 to GACH for evaluation post fall on 9/21/2023 and for urinary retention (a condition in which a person is unable to empty all the urine from the bladder [a hollow organ in the lower abdomen that stores urine]). LVN 2 stated Resident 1 was assigned a 1:1 monitor to for safety to prevent further falls. LVN 2 stated certified nursing assistant 1 (CNA 1) was assigned as a 1:1 sitter for Resident 1 to prevent Resident 1 from falling. LVN 2 stated upon readmission to the facility, LVN 2 completed a head to toe assessment on Resident 1 and that Resident 1 ' s forearm laceration had healed from Resident 1 ' s previous fall on 9/21/2023. LVN 2 stated Resident 1 was calm during the remainder of her shift, which ended at 11 PM. During an interview with CNA 1 on 10/3/2023 at 3:20 PM, CNA 1 stated that on 10/1/2023 at 8 PM, the facility readmitted Resident 1 from the GACH and that he [CNA 1] was assigned as a 1:1 sitter to monitor Resident 1 for safety to prevent falls. CNA 1 stated during his shift (3 Pm to 11 PM), Resident 1 was restless and continuously tried to get out of bed. CNA 1 stated he kept redirecting and reminding Resident 1 to remain in bed. CNA 1 stated that on 10/1/2023 at 10:58 PM, he [CNA 1] went to the nursing station and informed LVN 2 and several other staff members present (unsure who) that Resident 1 required continuous 1:1 monitoring for safety to prevent falls. CNA 1 stated that on 10/1/2023 at 11 PM, he left Resident 1 unattended and went home after his shift ended. CNA 1 stated he was unsure who was responsible to continue with 1:1 monitoring for Resident 1 after his shift ended at 11 PM. During an interview with the Medical Records Director (MRD) on 10/4/2023 at 11AM, MRD stated the facility did not have a policy and procedures on 1:1 resident monitoring. During an interview with LVN 3 on 10/4/2023 at 11:45 AM, LVN 3 stated that on 10/1/2023 at 11 PM, he started the night shift (11 PM to 7 AM) and received (hand off) report from the off going licensed nurse at the nursing station. LVN 3 stated Resident 1 was sitting in a WC across the desk from the nursing station at 11:15 PM and was unsure who placed Resident 1 in the WC. LVN 3 stated while at the nursing station, he saw Resident 1 quickly get up from the WC and fall to the ground. LVN 3 stated Resident 1 sustained a laceration above the right eyebrow and that the laceration was bleeding. LVN 3 stated he applied a dressing to the laceration and called EMS to transport Resident 1 to GACH. LVN 3 stated CNA 1 was assigned 1:1 to monitor Resident 1 for safety to prevent falls. LVN 3 stated he was unsure where the CNA assigned to Resident 1 was when Resident 1 fell . LVN 3 stated Resident 1 was transported to GACH on 10/1/2023 and that Resident 1 returned on 10/2/2023 at around 4 AM, was placed back into his bed and was assigned 1:1 monitoring for safety. During an interview and record review with the Director of Nursing (DON) on 10/4/2023 at 1 PM, the facility ' s policy and procedure titled Falls and fall Risk dated 3/2018 was reviewed. The DON stated Resident 1 was a high fall risk and confirmed that 1:1 sitter was Resident 1 specific to prevent further falls. The DON stated the facility readmitted Resident 1 on 10/1/2023 from GACH for possible rib fractures and urinary retention. The DON stated that on 10/1/2023, she told LVN 2 Resident 1 was on 1:1 monitoring for safety to prevent falls because Resident 1 was a high risk for falls. The DON stated that on 10/1/2023, LVN 3 informed her [DON] that Resident 1 had a fall from a WC on 10/1/2023 at 11:30 PM and was transported to GACH for further evaluation and management. The DON stated Resident 1 should have been on 1:1 monitoring at the time of the fall on 10/1/2023. The DON was unsure why the CNA that was scheduled on the 11PM to 7 AM shift for 1:1 monitoring was not with Resident 1. The DON stated Resident 1 ' s fall was preventable if Resident 1 was on 1:1 monitoring. A review of the facility ' s policy and procedures titled Falls and Fall Risk, Managing dated, 3/2018, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident ' s specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling .The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.

Based on observation, interview and record review, the facility's nursing staff failed to ensure residents were turned and repositioned to off load pressure from areas at risk of developing sores, at least every two hours, as a means to prevent pressure sores (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) from developing and/or recurring and to ensure residents with pressure sores receive proper treatment and services to promote healing, prevent infection and prevent new pressure sores from developing for two of 10 sampled residents (Rresidents 2, 4) Findings : Resident 4 was admitted to the facility in November 2014, with multiple pressure ulcers, which were all healed by June 2015. In October 2015 Resident 4 developed two new pressure sores, which as of April 2016, are still present. Resident 4 was observed on several occasions lying in bed in the same position for over two hours and when he was turned and repositioned pressure was not appropriately offloaded from his pressure points. This deficient practice resulted in newly developed pressure ulcers, and had the potential to place the resident at risk for developing new pressure sores and developing a recurrence of his old healed pressure sores. prevent infection and prevent new pressure sores from developing. Findings : Findings: a. A review of Resident 4's Admission Records indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The following pressure ulcers were present on admission: 1. Right ankle 2.0 centimeters (cm) x 2.0 cc, necrotic and unstageable; healed on December 26, 2014. 2. Right lateral heel unstageable 6.0 cc x 4.5 cc; healed on June 7, 2015. 3. Left lateral heel unstageable 4.0 cm x 4.0 cm; healed on March 24, 2015. 4. Left medial heel unstageable 6.0 cm x 4.5 cm; healed on March 24, 2015. On April 13, 2016, at 10:30 a.m., during an interview, the Director of Staff Development, who is also the facility's treatment nurse, stated Resident 4 was admitted to the facility with multiple pressure ulcers but they were all healed. She stated the resident's right lateral heel and sacral wound developed here at the facility but each time he was transferred to the general acute care hospital (GACH) he returned with new and worsened pressure ulcers. A Pressure Ulcer Record, dated October 30, 2015, indicated the following: 1. A right heel pressure ulcer measuring 5.0 cm x 5.5 cm with moderate sanguineous (relating to, or containing blood) drainage and odor. 2. a sacral coccyx (tailbone) pressure ulcer measuring 4.0 cm x 1.5 cm with minimal serous (a thin watery fluid found in many body cavities) drainage. A Pressure Ulcer Record, dated April 12, 2016, indicated the following: 1.An unstageable right heel pressure ulcer measuring 4.0 cm x 4.5 cm with mild odor and drainage. 2. A stage III sacral pressure ulcer measuring 8.6 cm x 4.7 cm with a mild odor, moderate drainage and documented as worsening. On April 13, 2016, at 7:30 a.m., and 10:26 a.m., Resident 4 was observed lying on his back with his torso slightly turned to the left with pressure still on his buttocks. At 11 a.m., 1 p.m., and 1:30 p.m., Resident 4 was observed lying on his back with his torso slightly turned to the right, pressure was still on his buttocks. On April 14, 2016, at 8 a.m., 10:35 a.m., and 11 a.m., 11:50 a.m., 12:30 p.m., and 2 p.m., Resident 4 was observed lying on his back with his torso slightly turned to the right, pressure was still on his buttocks. A facility Turning Schedule indicated the following: 8 am - back 10 am - window 12 PM - back 2 PM - door 4 PM - back 6 PM - window 8 PM - back 10 PM - door 12 am - back 2 am - window 4 am - back 6 am - door Care Plans, dated November 2015, indicated Resident 4 was at risk for pressure ulcers, skin breakdown and had an alteration in his skin integrity related to pressure ulcers at his sacral coccyx and right heel. The goal for the resident was to have no development of pressure ulcers, no skin breakdown and pressure ulcers will heal within 90 days. Approaches used included repositioning resident at least every two hours or more often for chair bound residents, assist with repositioning as needed and use positioning pillows to enhance proper alignment of resident's to reduce pressure at bony prominence. On April 19, 2016, at 11:15 a.m., during an interview, Certified Nursing Assistant 14 (CNA 14) stated she notices sometimes when she turns Resident 4 to one position other staff come behind her and will change his position after they provide care to him. She stated she is usually assigned to him and should check on his position more often and change it as needed. On April 19, 2016, at 3:25 p.m., during an interview, the DSD stated from where her desk is she can see if the nurses are doing their rounds. She stated she was not able to see if they were turning the residents' and could be more active with making resident rounds herself to ensure they are turned according to the turning schedule. b. A review of Resident 2 ' s admission records indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. And developed a pressure sore ( redness or break in the skin due to prolonged pressure) to the right heel after admission to the facility. A Minimum Data Set (MDS), a resident assessment tool, dated January 26, 2016, indicated the resident rarely made self understood and had the ability to sometimes understand others, had no hallucination or delusions. The resident required limited assistance with one person physical assist for eating, extensive assistance one person physical assist from staff with bed mobility, transfers, dressing, toilet use, personal hygiene, and was totally dependent for bathing. The resident was not on a turning and repositioning program, nor a pressure reducing device for bed or chair. The resident was indicated at risk of developing a pressure sore. During an observation of Resident 2 on April 12, 2016 at 8:10 a.m., heel protectors were not worn and the residents heels were not offloaded by floating his heels (not touching bed, etc.). On April 13, 2016 at 8:35 a.m., during a bed bath the resident had on one heel protector. On April 13, 2016, from 2:30 p.m., to 5:30 p.m., Resident 2 was observed laying in bed on his back without being turned or repositioned, and his heels were not offloaded. A review of Resident 2 ' s Nursing Assessment and Evaluation, dated January 15, 2016, Condition of Resident 2's Skin, indicated his skin was clear and intact. A review of the Braden Scale (used to rate risk of developing pressure sore ), dated January 15, 2016, indicated a score of 12 (scale of 12 or lower represent a high risk for developing a pressure sore). During an interview with the director of staff development (DSD), and treatment nurse, on April 14, 2016 at 3 p.m., stated Resident 2's pressure sore was acquired in house after admission ,and was being seen by the wound consultant since March 30, 2016. the DSD stated the CNA's were to turn and reposition the resident every two hours, and apply heel protectors on both feet. During a review of physicians orders dated February 28, 2016, indicated to cleanse the resident ' s right heel with normal saline, dry and apply Transparent dressing (treatment of [REDACTED]. On March 26, 2016, physicians orders indicated to cleanse the right heel pressure sore with normal saline, pat dry and apply transparent dressing, change every five days and as needed (PRN), for 30 days and to apply heel protectors when in bed. A review of Resident 2 ' s Pressure Ulcer Record, dated February 28, 2016, indicated a Stage 1(an area of the skin with persistent redness without a break in the skin that does not disappear when pressure is relieved), measured 2.0 cubic centimeter (cm) x 2.0 cm The Pressure Ulcer Record, indicated on March 5, 12, and 19, 2016, the affected reddened area remained the same size, and was responding to treatment slowly. On March 26, 2016, the pressure sore had increased in size to 3.0 cm x 4.0 cm., was brownish in color and classified as unstageable (full thickness tissue loss base of ulcer is covered by slough and/ or eschar in the wound bed). On March 30,2016, physician's orders were obtained for a wound consultant. A review of the Surgical Consult, dated March 30, 2016, indicated the resident ' s affected right heel measured 3.0 cm in length x 4.0 cm in width, depth unable to determine stage(UTD ), and wound area measured 12.0 cm. Assessment and Plan, indicated to teat daily with [MEDICATION NAME] spray (topical medication to treat pressure sores), Arterial and Venous Doppler studies were recommended, to follow up in one week, and to offload float the resident's heels. A review of the lower bilateral Arterial Doppler, dated April 4, 2016, indicated patent bilateral upper leg arteries, and bilateral Venous Doppler, indicated normal, no evidence of [MEDICAL CONDITION] of the lower extremities. A review of the Surgical Consult, dated April 12, 2016, indicated same measurement, the goal was for wound stabilization, prevention of wound decline, creation of wound healing bed and prevention of amputation, continue offloading by floating the heels. An interview and record review with the director of nurses (DON) on April 14,-2016 at 1:45 p.m., of recommendations made by the registered dietician (RD) ,the last consult with the resident was on January 31, 2016 , for multivitamins, there was no pressure sore present at the time. However, recommendations for multivitamins was implemented on March 10, 2016. The DON stated she thought she had spoken to the physician but could not locate the documentation. No documentation was found of notifying the RD after resident developed a pressure sore, and after the pressure sore size and the stage had increased. An interview with the RD on April 14, 2016 at 4:20 p.m., stated she was notified of Resident 2's pressure sore on April 13, 2016. A review of the RD Recommendations, dated April 14, 2016, indicated meal intake was variable and Prostat SF 30 cc's three times a day for 60 days, Vitamin C 500 milligrams (mg) two times a day, Zinc sulfate 220 mg every day for 30 days, to monitor labs, and adjust diet and supplements as indicated. These recommendations were done after the resident's wound had declined from a Stage 1 to an Unstageable pressure sore. An interview and record review with the DON on April 14, 2016 at 2 p.m., there was no care plan for the potential of the resident developing a pressure sore. A care plan dated February 28, 2016, for alteration in skin integrity for a Stage 1 pressure sore and indicated to to position pillows to enhance proper alignment and reduce pressure at bony prominence's, turn and reposition at least every two hours and as needed, provide pressure relieving devices, administer vitamins as ordered to enhance the healing process, and ensure resident obtains appropriate nutrition to enhance the healing process. A care plan, dated April 1, 2016, for an unstageable pressure sore at the right heel indicated to obtain an Arterial and Doppler study(test to identify decreased flow of blood). - A review of the facility policy and procedure titled, Wound and Skin Management (not dated), indicated any resident who enters the facility without pressure sores will have appropriate preventative measures taken to ensure the resident does not develop pressure ulcers unless the resident's clinical condition makes the development unavoidable. A weekly review to include have the pressure ulcer worsened, why, was the RD involved, a turning program, and adequate documentation on the plan of care and in the progress notes. A policy and procedure titled, Prevention of Pressure Ulcer, dated 2006, indicated to assess for risk of pressure ulcer development, identify high and low risk residents, assess and identify complicating conditions that may contribute to pressure ulcer development, develope a care plan to eliminate or minimize risk factors: nutrition, nutritional supplement, hydration, and pressure relief. .