Every finding on record at The Californian Pasadena Healthcare

Based on observation, interview, and record review, the facility failed to verify the resident's identify before medication administration for two (2) of 2 sampled residents (Resident 1 and 2). This deficient practice has the potential to result in medication errors and had the potential to cause dangerous allergic reactions, toxic overdoses (when a person takes more of a substance than their body can safely process, creating a dangerous and overwhelming level of toxicity), or untreated conditions to Resident 1 and Resident 2. 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus with hyperglycemia (chronic high blood sugar condition where the body does not use insulin well, causing blood sugar levels to rise higher than normal) and abnormalities of gait and mobility (deviations from a normal, smooth walking pattern or an overall reduction in the ability to move freely and safely). During a review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 7/29/2026, the MDS indicated Resident 1 had moderate cognitive impairment with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 needed substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, shower/bath self, lower body dressing and putting on/taking off footwear. The MDS also indicated Resident 1 needed partial or moderate assistance, (helper does less than half the effort) with oral hygiene and upper body dressing. MDS also indicated Resident 1 needed supervision or touching assistance, (helper provides verbal cues and /or touching/steadying and/or contact guard assistance as resident completes activity) for personal hygiene and need set up or clean-up assistance (helper sets up or cleans up; resident completes activity) for eating. During an observation on 8/24/2026 at 10:18 AM with LVN 1 inside Resident 1's room, observed LVN 1 did not check Resident 1's patient identification band (ID band, a secure wristband that displays core identifying information like a patient's name, birth date, and medical record number to prevent medical errors), before LVN 1 administrated three (3) oral medications to Resident 1. 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease without heart failure (a structural heart damage, a thickened heart muscle caused by long-term high blood pressure before the heart fails to pump blood properly), and abnormalities of gait and mobility. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had moderate cognitive impairment with cognitive skills for daily decision making. The MDS indicated Resident 2 was dependent (helper does all of the effort) with lower body dressing, putting on/taking off footwear and needed substantial/maximal assistance for toileting hygiene, shower/bath self. The MDS indicated Resident 2 needed supervision or touching assistance for eating, oral and personal hygiene. During an observation on 8/24/2026 at 10:32 AM with Licensed Vocational Nurse (LVN) 1 next to the Medication Cart number 1 (MC1) in front of Resident 2's room, observed LVN 1 picked up a medication cup from the floor and LVN 1 tossed it to the small trash can next to the MC 1 without performing hand hygiene (cleaning hands regularly using either soap and water or an alcohol-based hand rub to stop germs from spreading). LVN 1 then continued to prepare medications for Resident 2. During an observation on 8/24/2026 at 10:42 AM with LVN 1 inside Resident 2's room, observed LVN 1 did not check Resident 2's patient ID band, did not verify with Resident 2 the resident's date of birth and name before LVN 1 administrated five (5) oral medications to Resident 2. During an interview on 8/24/2026 at 10:58 AM with LVN 1 next to MC1, LVN 1 stated she should have performed hand hygiene after she picked up the medication cup from the floor to prevent contaminating the medications LVN 1 prepared for Resident 2 and it can introduce harmful pathogens to the resident. LVN 1 also stated it is very important to verify the resident's identity before administration of medications to ensure that the right patient receives the right drug, dose, and time, and prevent severe medication errors. During an interview on 8/25/2026 at 2:56 PM with the Director of Nursing (DON), the DON stated it is very important to verify the resident's identify before medication administration to ensure that the right patient receives the right drug, dose, and time, preventing severe medical errors. The DON also stated hand hygiene is critical before medication administration to prevent transferring harmful germs and bacteria to the residents or the medication supplies. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, revised April 2019, the P&P indicated medications are administered in a safe and timely manner, and as prescribed. The P&P also indicated the individual administering medications verify the resident's identity before giving the resident his/her medication and the methods of identifying the residents include:Checking identification band.Checking photograph attached to medical record.If necessary, verifying resident identification with other facility personnel.Staff follow established facility infection control procedures (handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. During a review of the facility's P&P titled, Handwashing /Hand Hygiene, revised August 2019, the P&P indicated this facility considers hand hygiene the primary means to prevent trye spread of infections. The P&P also indicated use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:After handling used dressings, contaminated equipment, etc.Before preparing or handling medications.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents such as fall for (1) one of (5) five sampled residents (Resident 3) who had history of falling while in the facility by failing to:Ensure Resident 3's risk for fall care plan initiated on [DATE] was resident- centered to reflect the resident's need for partial moderate assistance (helper does less than half the effort) during toileting, sit to stand and toilet transfer.Implement the actual fall care plan interventions to move Resident 3 to a room closer to the nursing station that was added on [DATE] and [DATE].Provide Resident 3 with a bedside commode (a portable, movable toilet placed near a bed for individuals who cannot safely or easily walk to the bathroom) for Resident 3 to use at resident's bedside to prevent the resident from falling in accordance with the physician's order dated [DATE]. Provide partial moderate assistance and/ or stand by assistance (SBA- meaning a staff member or therapist stays within arm's reach of the patient for safety without making direct physical contact) to Resident 3 when the resident was trying to stand up from a sitting position on [DATE] while in the dining/ activity room, in accordance with the resident's Minimum Data Set (MDS, resident assessment tool) and physical therapy (PT, a healthcare profession and treatment focused on improving, maintaining, or restoring physical strength, mobility, and movement function) note. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture of T11-T12 vertebra, subsequent encounter for fracture with routine healing (the recovery phase of a front-side bone collapse in one's lower thoracic spine, and the bone is healing normally), abnormalities of gait and mobility (deviations from a normal, smooth walking pattern or an overall reduction in the ability to move freely and safely), and muscle weakness (a reduction in muscle strength where you cannot move a muscle normally, even when you try as hard as you can). During a review of Resident 3's Minimum Data Set (MDS, resident assessment tool), dated [DATE], the MDS indicated Resident 3 had severe cognitive impairment with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. It indicated Resident 3 needed partial or moderate assistance with toileting, hygiene, shower/bath self, upper and lower body dressing and putting on/taking off footwear, sit to stand and toilet transfer. The MDS also indicated Resident 3 needed supervision or touching assistance, (helper provides verbal cues and /or touching/steadying and/or contact guard assistance as resident completes activity) for personal hygiene and needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) for eating and oral hygiene. During a review of Resident 3's Situation, Background, Assessment, and Recommendation (SBAR, a structured communication tool used to share critical information quickly and clearly) dated [DATE] was reviewed, the SBAR indicated Resident 3 was found on the floor by certified nursing assistant (CNA) at 9:10 PM and Resident 3 was sitting on her bottom. During a review of Resident 3's SBAR, dated [DATE] was reviewed, the SBAR indicated CNA 1 observed Resident 3 had a fall while Resident 3 was walking toward bathroom from the resident's bed. During a review of Resident 3's Care Plan Report (CPR) for actual fall date initiated on [DATE] and revised on [DATE], the CPR interventions indicated relocating the resident to room closer to nursing station. During a review of Resident 3's Order Summary Report (OSR) for the month of [DATE], the OSR indicated Resident may have bedside commode due to falls was ordered on [DATE]. During a review of Resident 3's SBAR, dated [DATE] was reviewed, the SBAR indicated Resident 3 had a witnessed fall (an event where an unplanned descent to the floor or a lower surface is directly observed by a staff member, caregiver, or another person as it happens) in the dining room by CNA 2 while Resident 3 tried to get up from the resident's wheelchair and tried to use the bathroom. During an observation on [DATE] at 11 AM in Room A, there was no bedside commode in Room A next to Resident 1's bed. During an interview on [DATE] at 2:35 PM with CNA 1, CNA 1 stated she was collecting lunch trays in front of Resident 3's room on [DATE] after lunch when she (CNA 1) saw Resident 3 was standing up next to the resident's bed and the resident was walking toward to the restroom direction, then Resident 3 fell suddenly. CNA 1 stated there was no staff inside that room to help Resident 3 to use the bathroom. During an interview on [DATE] at 3:05 PM with CNA 2, CNA 2 stated she was preparing tea and coffee in the dining room next to CNA 2's coffee cart near the dining room entrance on [DATE] around 5 PM when Resident 3 fell while in the dining area. CNA 2 stated her back was facing the resident and when she turned around Resident 3 stood up from the resident's wheelchair, and the resident fell to the floor near the sliding door. CNA 2 stated no staff were near or within an arm's reach of Resident 3 at the time to provide partial moderate assistance when the resident stood up. CNA 2 stated Resident 3 need assistance when standing up from a sitting position and when the resident needs to use the restroom. During a concurrent interview and record review on [DATE] at 11:35 PM with the Physical Therapist (PT), the physical therapy treatment encounter notes dated [DATE] and [DATE] were reviewed. PT stated according to the notes Resident 3 needed SBA when changing position from sit- to- stand and chair/bed- to- chair transfer. PT stated Resident 3 needs staff within an arm length distance to supervise and provide touching assistance when needed by Resident 3 especially when resident changes position from sitting position to standing position to prevent the resident from falling. During a concurrent interview and record review on [DATE] at 12:10 PM with the Minimum Data Set Nure (MDSN), Resident 3's MDS dated [DATE] was reviewed. MDS indicated Resident 3 needed partial or moderate assistance with sit- to- stand and toilet transfer. MDSN stated it means Resident 3 need helper lifts, holds, or supports trunk or limbs but provides less than half the effort for Resident 3 to transfer out of bed or from sitting position to a standing position and to walk to the restroom. MDSN stated Resident 3 was not supposed to be left alone without staff monitoring or supervising the resident on [DATE] when the resident is in wheelchair while in the dining room so staff can assist the resident when the resident needed to stand up and use the restroom. During an observation on [DATE] at 2:10 PM in the dining room, observed, Resident 3 was sitting alone in the wheelchair watching television with other residents. There were no staff sitting next to Resident 3 or near Resident 3 to monitor the resident, and to provide SBA or partial moderate assistance when needed. During an observation on [DATE] at 12 PM in Room A, there was no bedside commode in Room A next to Resident 1's bed. During a concurrent observation in Resident 3's room, interview and record review on [DATE] at 12:10 PM with Assistant Director of Nursing (ADON), Resident 3's OSR dated [DATE] was reviewed. The OSR indicated Resident 3 may have bedside commode due to history of falls. ADON confirmed, there was no bedside commode observed in Resident 3's room and near the resident's bedside. ADON stated there should a bedside commode provided for Resident 3 so the resident can use it to prevent the resident from walking to the restroom and prevent another fall incident. ADON stated it is very important to follow physician's orders such as the bedside commode and implement interventions such as providing the assistance the resident needs in accordance with the MDS and PT evaluation note to prevent Resident 3 from falling again. During a concurrent observation and interview on [DATE] at 4:10 PM with CNA 3 inside Resident 3's room, CNA3 stated there had never been a bedside commode inside Resident 3's room since [DATE]. CNA 3 stated she did not know there was a physician's order for the bedside commode for Resident 3. During a concurrent interview and record review on [DATE] at 12:20 PM with MDSN, Resident 3's MDS dated [DATE] and the Care Plan Report (CPR) for risk for fall initiated on [DATE] were reviewed. MDSN stated according to the resident's MDS, Resident 3 need partial moderate assistance to transfer out of bed, stand from a sitting position and walk to the restroom and Resident 3's care plan for risk for fall dated [DATE] indicated encourage to stand up slowly and did not indicate the resident need assistance from staff when changing position from sitting to standing. MDSN also stated other staff will not know that Resident 3 need help for transfer from sitting to standing position and to assist resident to safely transfer to the restroom if it was not in the resident's care plan interventions for risk for fall. During a concurrent observation, interview and record review on [DATE] at 1:20 PM with ADON, CPR for actual fall dated [DATE] and [DATE], and facility daily census dated from [DATE] to [DATE] were reviewed. The census indicated Resident 3 has been in Room A (Resident 3's room) since [DATE] and no room changes was done to ensure resident's room was near the nurse's station. ADON stated the facility should have moved Resident 3 to the room closer to the nursing station so it would have prevented the resident from repeated falling after her first fall on [DATE]. During an interview on [DATE] at 10:56 AM with the Director of Nursing (DON), the DON stated it is very important to monitor, supervise and provide assistance to Resident 3 to prevent the resident from any falls when the resident is up in her wheelchair and/ or when changing position from sitting to standing position. The DON also stated it is very important to follow physician's order to put a bedside commode next to Resident 3's bedside per physician's order, so that it can help to prevent the resident from falling when the resident needs to use the restroom. The DON also stated it is very important for the caregivers to implement the interventions in the resident's care plans such as the room change near the nurse's station to ensure Resident 3 is assisted when the resident needs to go to the restroom. During a concurrent interview and record review on [DATE] at 2:46 PM with the DON, the facility's Policy and Procedure (P&P) titled, Falls and Fall Risk, Managing revised [DATE] was reviewed, the P&P indicated 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. The P&P indicated the staff, with the input of the attending physician, will implement 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 and indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 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.The DON stated Resident 3 had multiple falls while in the facility and the facility should have investigated or determined the underlying cause of the fall to ensure appropriate interventions are provided for the resident. The DON also stated, the P&P was not followed because they were not able to implement resident- centered care plan, evaluate the effectiveness of the previous interventions and investigate to determine the cause of the fall. During a concurrent interview and record review on [DATE] at 4:04 PM with the DON, the P&P titled, Care Planning/Revision - Interdisciplinary Team revised [DATE] was reviewed, the P&P indicated the interdisciplinary team (IDT- a diverse team of healthcare professionals collaborates closely to design, manage, and deliver a resident's recovery plan) is responsible for the development of resident care plans. The P&P also indicated resident care plans are developed according to the timeframes and established criteria and are based on resident assessments and developed by an IDT.

Based on observation, interview, and record review, the facility failed to remove and discard one expired Naloxone HCL Nasal Spray (NHNS, an emergency medicine used to quickly reverse a life-threatening opioid overdose [ a life-threatening medical emergency that happens when a person consumes a toxic amount of an opioid drug, overwhelming the body's central nervous system and slowing or stopping breathing]) bottle from the facility's crash cart (CC, a wheeled, portable medical cabinet containing emergency medications and life-saving equipment used to stabilize a resident experiencing a sudden, life-threatening medical crisis). This failure increased the risk of residents receiving a medication that had become ineffective or toxic due to improper storage, possibly leading to health complications resulting in hospitalization or death. During a concurrent observation and interview on 8/25/2026 at 2:39 PM next to the CC with the presence of Assistant Director of Nursing (ADON), the box of the NHNS was found with expiration date in April 2026. ADON stated, the expired NHNS was not discarded and replaced in accordance with the facility's policy and procedure. ADON stated the expired drug can lose its chemical stability and fail to treat critical conditions, and it can cause delays in life-saving care while staff search for a replacement. During an interview on 8/25/2026 at 2:49 PM with the Director of Nursing (DON), the DON stated it is very important to ensure all the emergency drugs are safe, compliant and ready for immediate use to prevent any delay in life-saving care during a life-threatening emergency. The DON stated there was no specific policy for the expired medications and the facility uses their policy titled Hazardous Waste Pharmaceuticals and Administering Medications as guide for the expired medications. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, revised April 2019, the P&P indicated, the expiration/beyond use date on the medication label is checked prior to administering the medication. During a review of the facility's P&P titled, Hazardous Waste Pharmaceuticals, revised April 2019, the P&P indicated, unused and expired pharmaceuticals may be disposed of through a contracted reverse distributor, which is defined as: any person that receives and accumulates prescription pharmaceuticals that are potentially creditable hazardous waste pharmaceuticals for the purpose of facilitating or verifying manufacturer credit. Any person, including forward distributors, third-party logistics providers, and pharmaceutical manufacturers, that processes prescription pharmaceuticals for the facilitation or verification of manufacturer credit is considered a reverse distributor.

Based on observation, interview, and record review, the facility failed to promote dignity and respect for two (2) of three (3) sampled residents (Resident 3 and 4) in accordance with the facility's policy and procedure (P&P) when:On 7/30/2026 and 7/31/2026, facility staff did not ensure Resident 3's lunch meal tray was served within the facility's scheduled mealtimes. 2. On 7/30/2026, Licensed Vocational Nurse 1 (LVN 1) did not ensure Resident 4 was given medication in a private room such as the resident's room and not in the dining room while wearing gloves. These deficient practices have the potential to affect Residents 3 and 4 sense of self-worth and self-esteem, which could negatively impact the residents' emotional and mental well being.Findings:1. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses that included dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (a feeling of worry, fear, or uneasiness about what might happen). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 7/18/2026, the MDS indicated Resident 3 had moderately impaired (decisions poor; cues/supervision required) cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 3 required supervision (helper provides verbal cues) with eating, oral hygiene, upper body dressing and personal hygiene. The MDS indicated Resident 3 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/ bathe self, lower body dressing, and putting on/ taking off footwear. During a concurrent observation and interview with Treatment Nurse (TN) on 7/30/2026 at 12:14 PM in the dining room, Resident 3 was observed sitting on her wheelchair with 4 other residents in the dining table. Resident 3's lunch tray was not on the table, and the other 4 residents were eating their lunch. TN verified Resident 3 has no lunch tray yet, and Resident 3 is watching the other 4 residents eating, and the other resident (Resident 5) already finished eating the lunch meal as evidenced by empty plate in front of Resident 5. TN stated he did not know why Resident 3's lunch tray was not included in the trays delivered with the other 4 residents' in the dining room. During an interview on 7/30/2026 at 4:28 PM with Assistant Director of Nursing (ADON), she stated Resident 3 was not served lunch meal on time which should have been between 12 noon to 12:15 PM with other residents in the dining room. ADON stated Resident 3's lunch meal tray was late, and Resident 3 would feel left out and upset. During an observation on 7/31/2026 at 12:15 PM in the dining room, Resident 3 was sitting in her wheelchair, seated on the dining table with 3 other residents. Resident 3 was observed with no lunch tray, and the other 3 residents are eating their lunch. During an interview on 7/31/2026 at 1:46 with the Director of Nursing (DON), the DON explained that delays can cause residents to feel hungry and upset, and Resident 3 could feel frustrated and disrespected while waiting for her tray and watching other residents eating. During an interview on 7/31/2026 at 2:44 PM with Dietary Supervisor (DS), she stated, she did not know why Resident 3's lunch meal tray was not included in the food cart for residents in the dining room and was not served with the other residents' lunch trays on 7/30/2026 and 7/31/2026. DS stated whatever system they were doing now between the activity staff who provides the list of residents in the dining room to the kitchen staff is not working, because Resident 3's lunch meal tray was late and was not included in the food cart on 7/30/2026 and 7/31/2026. DS added it is not fair for a resident to watch other residents eat, the resident who were served late can feel hungry, angry or upset. During a review of the facility's P&P titled, Dining Room Audits, dated 2001, the P&P indicated the facility audits the food and nutrition services department regularly to ensure that resident needs are met and that dining is a safe and pleasant experience for residents. The P&P also indicated facility will assess whether residents at each table are served together. 2. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included mood disorder (a mental health condition that causes intense, ongoing shifts in a person's emotional state), intellectual disability (a lifelong condition that starts during childhood, trouble learning, thinking, and solving problems than most other people), and cerebral palsy (a group of permanent conditions that affect body movement, muscle control, and posture). During a review of Resident 4's MDS, dated [DATE] the MDS indicated Resident 4 had modified independence (some difficulty in new situations only) cognitive skills for daily decision making. The MDS indicated Resident 4 required substantial/maximal assistance with eating, oral hygiene, upper body dressing and personal hygiene. The MDS indicated Resident 4 was dependent on staff with toileting hygiene, shower, lower body dressing and putting on/taking off footwear. During a concurrent observation and interview with TN on 7/30/2026 at 12:15 PM in the dining room, Resident 4 was observed sitting on his wheelchair with other residents, and LVN 1 who was wearing gloves was administering medication to Resident 4. TN stated LVN 1 was wearing gloves during medication administration orally to Resident 4. TN stated it was not the facility's practice that the resident is given medication in a public area such as the dining room. TN stated, Resident 4 should have been assisted back to the resident's room and medication administration should have been done in the resident's room where it is private and no other residents watching Resident 4 being given medications. TN stated LVN 1 should have performed hand hygiene, wherein using the hand sanitizer before and after giving medication, instead of wearing gloves. During an interview on 7/31/2026 at 1:47 PM with the DON, she stated LVN 1 should have assisted Resident 4 from the dining room, back to the resident's room to administer the medication. The DON stated Resident 4 might feel like staff does not like the resident because LVN 1 was wearing gloves when administering medication in the dining room. The DON stated other residents who were in the dining room might even think that Resident 4 has an infectious disease (an illness caused by tiny living germs) that is why the staff needed to wear gloves during medication administration. The DON stated giving Resident 4's medication in the dining room where other residents can see it and LVN 1 wearing gloves while giving the resident's medication can make Resident 4 feel disrespected. During a review of the facility's P&P titled, Quality of Life- Dignity, revised February 2020, the P&P indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated residents are treated with dignity and respect at all times. During a review of LVN 1's employee record titled Hand Hygiene Knowledge-Based Competency, dated 6/11/2026, indicated hand hygiene and alcohol-based hand rub (a liquid, gel, or foam product containing alcohol that you put on your hands to kill germs quickly without using water) should be performed before and after handling medications.

Based on observation, interview, and record review, the facility failed to accurately measure the Liquid Whole Eggs with Citric Acid (liquid whole eggs or egg whites in a carton) on 7/31/2026 for one (1) of one sampled resident who received eggs with veggies. This deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake, and weight loss for Resident 1 who received eggs with veggies.Findings: During a review of Resident 1 's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of abnormalities of gait and a history of falling. During a review of Resident 1 's History and Physical Examination (H&P), dated 6/17/2026, the H&P indicated Resident 1 has the capacity to understand and make decisions. During a review of Resident 1's meal ticket (specifies a resident's exact diet order, portion sizes, allergies, and menu selections for staff to safely serve the correct food) dated 7/31/2026, the meal ticket indicated Resident 1 likes dry cereal and milk, and eggs with veggies. During observation on 7/31/2026 at 6:55 AM in the facility's kitchen, the Dietary [NAME] Helper (DCH 1) was observed pouring Liquid Whole Eggs with Citric Acid from the box onto the pan without measuring the liquid. During an interview on 7/31/2026 at 11:35 AM with Dietary Supervisor (DS), DS stated they are not supposed to estimate recipes, and ingredient must be measured using the appropriate measuring equipment to ensure the facility follows and provides proper nutrition to the resident and ensure palatability (how pleasant or acceptable a food, drink, or medicine tastes, or how easy it is to eat or drink) of the food for the resident. During a concurrent interview and record review on 7/31/2026 at 12:31 PM, with DCH 1 the handling instructions for Liquid Whole Eggs with Citric Acid undated was reviewed. DCH 1 stated the handling instruction indicated that for portion control, 1 large egg liquid is equivalent to three (3) tablespoons of the liquid. DCH 1 also stated he only poured the egg and did not measure it and acknowledged he should have measured the egg. During a concurrent interview and record review on 7/31/2026 at 3:40 PM with the Director of Nursing (DON), the facility's policy and procedure titled Menu, revised in 2021, was reviewed. The policy indicated menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board. The DON stated the policy indicated that menus are developed and prepared to meet residents' choices and needs. The DON also stated that the menus are supposed to be followed, and ingredients measured for therapeutic diets to ensure proper nutrition is given to residents.

Based on interview and record review, the facility failed to ensure that the Restorative Nursing assistant (RNA , Certified Nursing Assistant [CNA] who has extra training to help patients recover lost physical skills, improve mobility, and maintain their independence) had current training and demonstrated competency in the proper use of a gait belt (assistive medical device worn around a person's waist to help caregivers safely support, stabilize, and transfer individuals with mobility or balance challenges ) for resident transfers and / or ambulation. This deficient practice had the potential to place residents at risk for falls, injury, or unsafe transfer or ambulation.Findings: During a concurrent interview and record review on 7/31/2026 at 1:45 PM with the Infection Prevention Nurse (IPN), RNA's employee files were reviewed. IPN stated there was no current training and competency on gait belt found in the RNA's employee file. IPN explained the last gait belt training was dated 11/1/2021. IPN further stated gait belt training was supposed to be completed annually for resident's safety, so staff would know how to use the equipment properly and prevent possible accidents and harm to the residents. IPN also stated it was the Director of Staff Development's (DSD- manages, plans, and oversees education, training, and compliance programs for the nursing staff) responsibility to provide the gait belt training every year. During a concurrent interview and record review on 7/31/2026 at 3:18 PM with the Director of Nursing (DON), the facility's employee's job description titled Director of Staff Development, revised as of 10/2020 was reviewed. The DON stated according to the job description it was an essential function of the DSD to participate in the annual facility assessment by providing staff analysis, competency reports, and a gap analysis of training requirements and oversee and maintain personnel records. The DON stated, the DSD is also responsible for developing and maintaining written job description and performance evaluation for the CNA position. During a concurrent interview and record review on 7/31/2026 at 3:20 PM with the DON, the facility's Policy and Procedures (P&P) titled Professional Standards, revised on 1/2025, was reviewed. The DON stated that the purpose was to establish the requirement that all employees and contractors perform services in accordance with accepted professional standards of care, ensuring competence, safety, and regulatory compliance. The DON stated that the P&P was not followed; staff were supposed to be trained before using any equipment initially upon hire, annually, or as needed to decrease potential injury and ensure resident and staff safety and competency. During a concurrent interview and record review on 7/31/2026 at 3:34 PM with the Administrator (ADM), the Facility Assessment (an evaluation of the residents needs and staff resources required to provide proper care) dated 8/1/2025 and updated 7/31/2026 was reviewed. The ADM stated the facility assessment indicated, under Staff Training/Education and Competencies:The Director of Staff Development and/or designee are following strict guidelines and facility protocols in providing training and education to newly hired facility staff, current facility staff, and registry/contract staff, monitoring the training program's progress, and ongoing violation of the training.Skills competencies are completed yearly and as needed.

Based on observation, interview, and record review, the facility failed to ensure one (1) of two sampled residents (Reisdent 2) environment was free from accident hazard when a medicine cup of potassium (electrolyte supplements used to treat or prevent low blood potassium (hypokalemia) was left at Resident 2's bedside and failed to assess Resident 1's ability to self- administer medications. This failure had the potential to result in other residents inadvertently ingesting medication intended for Resident 2. Findings: During a review of Resident 2's admission Record, it was noted that the resident was initially admitted to the facility on [DATE] with diagnoses of muscle weakness, hypertension (high blood pressure), and depression (severe feelings of sadness and hopelessness). During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 6/11/2026, the MDS indicated that the resident had moderately impaired cognitive skills for daily decision-making. The MDS indicated Resident 2 needed partial to moderate assistance (helper does less than half the effort) with eating, oral hygiene, and personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, and washing and drying face and hands). During an observation on 7/30/2026 at 10:28AM, in Resident 2's room, on Resident 2's bedside table there was an unattended medicine cup full of a bright orange liquid that had not been consumed. During a concurrent observation and interview on 7/30/2026 at 10:28 AM, with Licensed Vocational Nurse (LVN) 1, in Resident 2's room, the unattended medicine cup full of bright orange liquid was observed. LVN 1 stated the medication on the table is Resident 2' potassium. LVN 1 stated Resident 2 told LVN 1 that the resident wanted to take the medication at a later time. LVN 1 stated the importance of seeing the patient take all of the resident's medication, was to ensure Resident 2 will not have any health concerns. During a concurrent interview and record review on 7/30/2026 at 1:01 PM, with LVN 2, Resident 2's Order Summary for Active orders, dated 6/5/2026 to 7/30/2026 was reviewed. The Order Summary indicated Resident 2 had no orders for self-medication administration. During a concurrent interview and record review on 7/30/2026 at 1:05 PM, with LVN 2, Residents 2's Admission/readmission Initial Assessment dated 06/06/26 was reviewed. The Admission/readmission Initial Assessment indicated that the resident did not have authorization to self administer medication. LVN 2 stated Resident 2's having medication left unattended without a nurse at the bedside was an issue because Resident 2's initial assessment indicated the resident was unable to safely self-administer medications. LVN 2 stated, LVN 1 should have watched Resident 2 take all of the resident's medications, to ensure that other residents would not have the opportunity to access or potentially take Resident 2's medications. During a concurrent interview and record review on 7/30/26 at 2:16 PM with Assistant Director of Nursing (ADON), Resident 2's Admission/readmission Initial Assessment, dated 06/06/26 and Care Plan for month of June 2026 and July 2026 were reviewed. The Admission/readmission Initial Assessment and Care Plan indicated, Resident 1 was not approved for self administration and should have been directly monitored by nursing staff for the entire medication administration. ADON stated, nurses must stay with the resident and watch the resident finish the medications during mediation administration unless the resident can self-administer so resident is not at risk for safety issues such as a resident ingesting the wrong medication. ADON stated Resident 2 did not have anything in the resident's care plan or assessments indicating medication self-administration was authorized. During a review of the facility's policy and procedure titled, Safety and Supervision of Residents, revised February 2021, it indicated the facility strives to make the environment as free from accident hazards as possible. The policy also indicated the facility- oriented and resident- oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual risk factors, and then adjust interventions accordingly. During a review of the facility's policy and procedure titled, Administering Medications, revised April 2025, indicated residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.

Based on observation, interview, and record review, the facility failed to ensure that food temperatures were checked and documented prior to serving breakfast when the temperature of the frittata and oatmeal were not checked on 07/31/2026. This deficient practice had the potential to place residents at risk for foodborne illness (any sickness caused by eating or drinking contaminated food or beverages) due to food not being maintained at safe temperatures.Findings: During an observation on 7/31/2026 at 7:02 AM at the facility kitchen during tray line (assembly line system used by the dietary department to efficiently build and prepare individual resident meal trays), observed [NAME] 1 serving the frittata without checking the temperature. During an observation on 7/31/2026 at 7:32 AM in the facility kitchen during tray line, Dietary Supervisor (DS) pulled out a tray with 12 bowls of oatmeal, and the temperature of the oatmeal was not checked prior to serving it to the residents. During an interview on 07/31/2026 at 11:35 AM with DS, DS stated she did not check the temperature of the oatmeal after taking it out of the oven. DS also stated, even though it was hot, she should have checked the temperature for residents' safety. During an interview on 07/31/2026 at 12:31 PM with [NAME] 1, [NAME] 1 stated he forgot to check the temperature of the frittata before serving it. [NAME] 1 also stated kitchen staff are supposed to check the food before they start serving the food to make sure it is at the correct temperature for resident's safety. During a review of the facility's Policy and Procedures (P&P) titled Food Preparation and Service, dated 2021, the P&P indicated the food and nutrition service employee prepares, distributes, and serves food in a manner that complies with safe food handling practices. It indicated proper hot and cold temperatures are maintained during distribution and service and foods that are held in the temperature danger zone are discarded after our (4) hours.

Based on observation, interview, and record review, the facility failed to ensure proper handling and storage of laboratory specimens (a biological sample such as blood, urine, or tissue collected from a patient to undergo testing, analysis, or diagnosis) for one (1) of 1 specimen refrigerator (specialized cooling unit designed for storing temperature-sensitive materials, such as urine. stool, sputum blood or other sample before they are transported to the laboratory for testing to maintain specimen at the proper temperature) by not ensuring that: The specimen refrigerator has a thermometer (an instrument used to measure temperature or temperature changes) to ensure the temperature remains within the accepted range, maintaining the viability of the laboratory specimens stored inside the refrigerator.One urine sample did not have a label identifying resident's name, date and time collected. These deficient practices have the potential to compromise the integrity and viability of specimens, which may affect the accuracy and timeliness of laboratory test results, as well as resident care and treatment decisions.Findings: During a concurrent observation of the facility's specimen refrigerator and interview on 07/15/2026 at 8:35 AM with the Director of Nursing (DON), there was no thermometer inside the specimen refrigerator, and a bottle of urine specimen was not labeled with resident's name, date and time of collection. The DON stated the specimen refrigerator did not have a thermometer inside and the urine specimen was not labeled. During an interview on 07/17/2026 at 3:40 PM with the DON, the DON stated the specimen refrigerator did not have a thermometer, and the urine specimen had no name-only a room number, making it impossible to identify the owner of the urine. The DON also stated the refrigerator needs to have a thermometer to ensure the refrigerator remains within the accepted range to ensure the viability of the specimens stored inside the refrigerator. During a concurrent interview and record review on 07/17/2026 at 4:06 PM of the facility's policy and procedure (P&P) titled Cultures, Specimen Collection for, dated 2001, with the Infection Preventionist Nurse (IPN), the IPN stated the P&P indicated the purpose was correct collection and handling of culture specimens to help ensure more accurate and timely results and subsequent treatment. The IPN stated the P&P indicated under the procedure and guidelines that labeling of the specimen must include: Resident's nameLocation of the resident (room and room number)Physician orderingDate and time specimen was collectedSource of specimenTest desiredName of the person collecting the specimen The IPN also stated that the P&P was not followed, the urine sample was not labeled, and the specimen refrigerator did not have a thermometer.

Based on observation, interviews, and record review, the facility failed to ensure that medications were securely stored and properly disposed of by failing to ensure: Two (2) of three (3) medication carts (Med Cart, mobile cart used by nursing staff to store, organized and administer medication to residents) were unlocked and unattended.Discontinued medications were disposed of in accordance with the facility's policies and procedures.Three (3) of 14 emergency kits (E-kit, sealed container that holds a limited supply of emergency medications that can be used immediately while waiting for medication from the pharmacy) were sealed.The Medication refrigerator located in the medication room was locked. These deficient practices had the potential to allow unauthorized access to medications, increase the risk of medication errors and medication diversion (unauthorized taking, misuse transfer , or theft of medication from its intended patient or patient or purpose), lead to accidental ingestion, compromise the integrity of emergency medications, and create an unsafe medication storage environment for residents.Findings:1. During an observation on [DATE] at 7:53 AM in the facility hallway near the elevator, Med Cart B was observed unlocked and unattended.During an interview on [DATE] at 2:18 PM with License Vocational Nurse, (LVN 2) stated that she should not have left Med Cart B unlocked and unattended. LVN 2 stated that as soon as you turn your back on the cart, you should lock it because somebody could take the medicationsDuring an interview on [DATE] at 2:06 PM with LVN 4, LVN 4 stated that she should not have left Med Cart C unlocked and unattended. LVN 4 also stated that the narcotic key was left on top of Med Cart C. LVN 4 emphasized that it is important to lock the med cart at all times because there are residents with dementia (progressive brain disorder that slowly destroys memory and thinking skills) who could have an accident. 2.During a concurrent observation and interview on [DATE] at 8:45 AM in the facility's medication room with the Director of Nursing (DON), the DON stated that the medication room was cluttered and disorganized. [NAME] boxes on the floor were filled with discontinued medications. The DON also stated that the medication room was overcrowded with discontinued medications and medication supplies. During a concurrent observation and interview on [DATE] at 8:46 AM in the facility's medication room with the DON, the DON stated that the discarded medication bin (designated container used to collect medications that are expired, discontinued, damaged, or no longer needed until they are disposed of according to facility policy and procedure) was not closed and was filled with loose tablets, capsules, and medications. The DON stated that the medications in the discarded medication bin should be destroyed and the bin should be closed, so nobody can use the discarded medications. 3. During a concurrent observation and interview on [DATE] at 8:47AM in the facility medication room with the DON, the DON stated that the antibiotic (medication that fights bacterial infection) E-kit was used and unsealed. The DON stated that once the Ekit is used, the licensed nurses were supposed to re-seal it with black zip tie and return to pharmacy within 72 hours. During a concurrent observation and interview on [DATE] at 8:51 AM with the DON, the DON stated that the fridge Ekit containing regular intramuscular medication (medications that are routinely given as a shot into a muscle) and subcutaneous injections (medication injections into the fatty tissue just beneath the skin, not into muscle) was used and unsealed. The DON stated that once the Ekit is used, the licensed nurses were supposed to re-seal it with black zip tie and return to pharmacy within 72 hours. During a concurrent observation and interview on [DATE] at 2:40 PM of Med Cart B with LVN 2, LVN 2 stated that the narcotic Ekit was used and unsealed on Med Cart B. LVN 2 stated the narcotic Ekit should be resealed after every use by the nurse who opened it and will be responsible in sending it back to pharmacy for replacement. 4. During a concurrent observation and interview on [DATE] at 7:48 AM with the DON, the DON stated that the medication refrigerator in the medication room was unlocked, unorganized, and had ice buildup. During a concurrent interview and record review on [DATE] at 3:47 PM with the DON, the facility's Policy and Procedures (P&P) titled Storage of Medication, Biologicals, and Medical Supplies, revised date 10/2024, was reviewed. The DON stated that the P&P indicated that the facility shall store all drugs, biologicals, and medical supplies in a safe, secure, and orderly manner. Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals (medicine made from living cells that treat certain diseases) shall be locked when not in use, and a tray or cart used to transport such items shall not be left unattended if open or otherwise potentially available to others. Only persons authorized to prepare and administer medication shall have access to the medication room, including any key. The DON stated that this P&P was not followed. It should be followed for safety and to prevent the risk of medication errors and unauthorized access to medications. During a concurrent interview and record review on [DATE] at 3:49 PM with the DON, the facility's P&P) titled, Discarding and Destroying Medications, revised date 10/2025, was reviewed. The DON stated that the P&P indicated that medications that cannot be returned to the dispensing pharmacy are disposed of in accordance with federal, state, and local regulations governing the management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances. For unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the Environmental Protection Agency (EPA, government agency that helps protect people and the environment) recommends destruction and disposal of the substances with other solid waste, following these steps:Remove the medication from the original container.Mix the medication, either liquid or solid, with an undesirable substance. Undesirable substances include sand, coffee grounds, kitty litter, or other absorbent materials. Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures to ensure the accurate acquisition and administration of drugs and biologicals to meet the needs of two (2) out of four (4) sampled residents (Residents 1 and 2), in accordance with the facility's policy and procedure (P&P), by failing to: Administer Pregabalin (medication commonly used to treat neuropathy (damage or dysfunction of the nerves) Pregabalin 75 milligram (mg, unit of measurement) capsule for neuropathic pain (nerve pain) in accordance with the physician's order on 7/15/2026.Document in Resident 2's Cefalexin (antibiotic for treating bacterial infections) count sheet that Cefalexin 500 mg capsule for the resident's infection, status post laminectomy (surgery to relieve pressure on a nerve in the spine (back) was administered on 7/15/2026. This deficient practice had the potential to result in unmanaged pain due to missed dose of Pregabalin and inaccurate medication records which could lead to medication errors, duplicate dosing or missed treatment.Findings: 1. During a review of Resident 1's admission Record, the record indicated, the resident was initially admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel) and hypertension (high blood pressure). During a review of Resident 1'S Minimum Data Set (MDS - a resident assessment tool), dated 7/6/2026 the MDS indicated the resident's cognition was moderately impaired (ability to think, remember, and reason) with cognitive skills for daily decision making. It also indicated, Resident 1 needed supervision or touching assistance (helper provides verbal cues) on eating, oral hygiene and partial moderate assistance (helper does more than half of the effort) on toilet hygiene (ability to maintain perineal hygiene) and personal hygiene (the ability to maintain personal hygiene). During a concurrent observation, interview and record review on 7/15/2026 at 11:58 AM with Licensed Vocational Nurse (LVN) 1, Resident 1's Medication Administration Record (MAR, official record that helps ensure medication are given safely, correctly and on time. It also serves as legal documentation of medication administration) for the month of July 2026 was reviewed. The MAR indicated Pregabalin 75 mg was administered to Resident 1 at 9 AM. LVN 1 stated Resident 1's Pregabalin 75 mg count sheet log and bubble pack (a sealed package that keeps each medication dose separate and protected until it is given to the resident) were observed on the medication cart (Med Cart A, a mobile cart used by nurses or medical staff to store, organize, and administer medications to residents). LVN 1 stated the Pregabalin count sheet indicated there were 29 medications available. LVN 1 stated the actual number of medications in the Pregabalin 75 mg bubble pack was 30 because Resident 1's Pregabalin 75 mg was not given, but it was signed as given in the resident's MAR. LVN 1 also stated the medication bubble pack and the count sheet were supposed to match and the MAR should not be signed if the medication was not given in accordance with the physician's order. 2. During a review of Resident 2 's admission Record, the record indicated that the resident was initially admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus, sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood), and muscle weakness. During a review of Resident 2 's MDS, dated [DATE], the MDS indicated the resident's cognition was moderately impaired, with cognitive skills for daily decision making. It also indicated Resident 2 needed setup and cleanup or cleanup assistance (helper sets up or cleans up; resident completes the activity) for eating, and supervision or touching assistance on personal hygiene. During a concurrent observation and interview on 7/15/2026 at 3 PM with LVN 2, LVN 2 stated that Resident 2's Cefalexin 500 mg count sheet log and bubble pack were observed in Med Cart B. LVN 2 stated the count sheet log indicated 86 Cefalexin 500 mg capsules were available, but the actual count of Cefalexin 500 mg in the bubble pack was 85. LVN 2 stated that she gave one to Resident 2 and forgot to sign the Cefalexin count sheet on 7/15/2026. LVN 2 also stated that she was supposed to sign the Cefalexin count sheet as soon as possible after administering the medication to prevent possible double dosing or missed doses. During a concurrent interview and record review on 7/17/2026 at 4:16 PM with LVN 3, the facility's Policy and Procedures (P&P) titled Administering Medications, revised April 2025, was reviewed. LVN 3 stated the P&P indicated medications are administered in a safe and timely manner and as prescribed. LVN 3 stated the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. LVN 3 also stated that the P&P indicated that as required or indicated for the medication, the individual administering the medication records in the resident's medical record: the date and time the medication was administered, dosage, route of administration, signature, and title of the person administering the drug. LVN 3 stated they use the standard medication administration process, Pour, Pass, and Sign which means preparing the medication, giving the medication, and documenting after the resident receives the medication. LVN 3 also stated that signing before administering medication or failing to sign after administration can result in medication errors (preventable mistake inventory involving medication that affects a resident's safety or treatment) and inaccurate records.

Based on observation, interview, and record review, the facility failed to ensure it was adequately equipped to allow two (2) of 2 sampled Residents (Residents 3 and 4) to call for staff assistance through a communication system in accordance with the facility's policy by failing to ensure: 1. Resident 3's call light was within resident's reach and call light system produced an audible alert at the nurses' station panel board when activated.2. Resident 4's call light was within resident's reach and call light system produced an audible alert at the nurses' station panel board when activated. These deficient practices had the potential to delay residents' assistance and increase Residents 3 and 4's risk of falls.Findings: 1.During a review of Resident 3's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of lack of coordination, hypertension (high blood pressure) and history of falling. During a review of Resident 3'S Minimum Data Set (MDS - a resident assessment tool), dated 6/17/2026 the MDS indicated the resident had severe impairment; cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were severely impaired. Resident 3 needed partial moderate assistance (helper does less than half the effort) on eating, oral hygiene and personal hygiene. During a concurrent observation and interview on 7/15/2026 at 8:26 AM with the Director of Nursing (DON) in Resident 3's room, the DON stated that Resident 3's call light was clipped to the head of the bed and was out of the resident's reach, preventing the resident from calling for assistance. During a concurrent observation and interview on 7/15/2026 at 11 AM with Licensed Vocational Nurse 5 (LVN 5) at Nurses' Station 2, LVN 5 stated that Resident 3's room's call light system was lit on the panel board but did not produce any a sound. LVN 5 also stated that it should emit an audible alert to notify the staff. During a concurrent interview and record review on 7/16/2026 at 4:16 PM with LVN 3, Resident 3's care plan was reviewed. LVN 3 stated that the care plan, initiated on 6/10/2026, indicated that Resident 3 was at risk for falls and injury related to generalized weakness and decreased mobility. The care plan intervention indicated that the call light should be maintained within reach. 2. During a review of Resident 4 's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of hemiplegia (complete paralysis on one side of the body) and hemiparesis (weakness on one side), epilepsy (brain condition that causes repeated seizures due to abnormal electrical activity in the brain) and lack of coordination. During a review of Resident 4 's MDS, dated [DATE], the MDS indicated the resident had moderately impaired cognitive skills (the mental action or process of acquiring knowledge and understanding) for daily decision making. Resident 4 required setup and clean-up assistance (the helper sets up or cleans up, and the resident completes the activity) for eating, and supervision and touching assistance (the helper provides verbal cues and/or touching or steadying as the resident completes the task) for personal hygiene. During an observation and interview on 7/16/2026 at 10:28 AM in Resident 4's room, Resident 4 was in bed awake. Resident 4 stated that nobody had answered the call light and it had been weeks. Resident 4 pressed the call light, and the light above the door was visibly illuminated, however, it did not produce any sound at Nurses' Station 1, as verified by the Administrator (ADMN). During an interview on 7/16/2026 at 2:06 PM with LVN 4, LVN 4 stated that call lights are supposed to be answered right away for residents' safety. LVN 4 also stated that Resident 4's call light was broken. LVN 4 stated sometimes the light above the resident's room would turn on but there would be no sound. During a concurrent observation and interview on 7/16/2026 at 3 PM in Resident 4's room with LVN 4, LVN 4 stated that the call light for Resident 4 was on top of his bedside table near the wall, which was far away from the resident. During a concurrent interview and record review of Resident 4's care plan on 7/16/2026 at 4:18 PM with LVN 3, LVN 3 stated that the care plan, initiated on 8/26/2025, indicated that Resident 4 was at risk for a decline in Activities of Daily Living (ADLs - activities related to personal care that include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). The care plan interventions indicated that the call light should be placed within reach, and the residents should be encouraged to use the call light bell for assistance. LVN 3 stated that the care plan was not followed. LVN added that call lights are supposed to be within reach at all times. During an interview on 7/16/2026 at 2:25 PM with the Maintenance Director, the Maintenance Director stated that it was important that the nurses inform maintenance if the call light or bed control is not working or is damaged. The Maintenance Directo stated that the call light is how residents communicate, and that a company is coming tonight to fix the panel. The MD also stated that bed control wiring should be fully covered for safety, to prevent electric shock. During a concurrent interview and record review on 7/16/2026 at 4:10PM with LVN 3, the facility's Policy and Procedures (P&P) titled, Call Light, revised 10/2024, was reviewed. LVN 3 stated that the purpose of this procedure was to respond to the residents' requests and needs. When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. Report all defective call light to the nurse supervisor promptly. LVN 3 stated that the P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure a safe environment for two (2) of three (3) sampled Residents (Residents 4 and 5), in accordance with the facility's policy by failing to ensure Residents 4 and 5's bed controls were peeling, with exposed wiring This deficient practice had the potential to expose Residents 4 and 5 to injury from malfunctioning or damaged equipment.Findings: 1. During a review of Resident 4 's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of hemiplegia (complete paralysis on one side of the body) and hemiparesis (weakness on one side), epilepsy (brain condition that causes repeated seizures due to abnormal electrical activity in the brain) and lack of coordination. During a review of Resident 4 's MDS, dated [DATE], the MDS indicated the resident had moderately impaired cognitive skills (the mental action or process of acquiring knowledge and understanding) for daily decision making. Resident 4 required setup and clean-up assistance (the helper sets up or cleans up, and the resident completes the activity) for eating, and supervision and touching assistance (the helper provides verbal cues and/or touching or steadying as the resident completes the task) for personal hygiene. During an observation on 7/16/2026 at 10:28 AM in Resident 4's room, Resident 4 was observed lying in bed. Resident 4's bed control was observed with an exposed wiring. 2. During a review of Resident 5's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of abnormalities of gait and mobility, weakness and depression (severe feelings of sadness and hopelessness). During a review of Resident 5'S MDS dated [DATE] the MDS indicated the resident has severe impairment with cognitive skills for daily decision making were severely impaired. Resident 5 required set up or clean up assistance on eating, and supervision and touching assistance on personal hygiene. During an observation on 7/15/2026 at 8:41 AM in Resident 5's room, Resident 5 was observed eating breakfast in bed. Resident 5's bed control was observed with an exposed wiring. During a concurrent observation and interview on 7/15/2026 at 8:43 AM with the Director of Nursing (DON), the DON stated that the bed control wiring for Resident 5 was exposed and peeling. The DON stated that it should not be exposed due to the risk of electric burns. During an interview on 7/16/2026 at 2:25 PM with the Maintenance Director, the Maintenance Director stated that it was important that the nurses inform maintenance if the call light or bed control is not working or is damaged. The Maintenance Director stated that the call light is how residents communicate, and that a company is coming tonight to fix the panel. The Maintenance Director also stated that bed control wiring should be fully covered for safety, to prevent electric shock. During a concurrent interview and record review on 7/16/2026 at 4:12 PM with Licensed Vocational Nurse 3 (LVN 3), the facility's Policy and Procedure (P&P) titled, Maintenance Service, revised 12/2009, were reviewed. LVN 3 stated that the P&P indicated that maintenance service shall be provided to all areas of the building, grounds, and equipment. The maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. The functions of maintenance personnel include maintaining the building in good repair and free of hazards; maintaining the heating/cooling system, plumbing fixtures, and wiring; and maintaining the paging system in good working order. LVN 3 stated that the P&P was not followed. LVN 3 stated the bed controls should have no exposed wires, as this could result in electric shock.

Based on interview and record review, the facility failed to develop an individualized/person-centered care plan (CP) with goals and interventions for one (1) out of three (3) sampled residents (Resident 1) after Resident 1 had a change of condition (CoC) for productive cough and increased secretions on 2/28/2026 in accordance with the facility's policy and procedure (P&P). This deficient practice left Resident 1's productive cough and increased secretions not treated and led to the symptoms becoming worse and potentially led to irreversible conditions.Findings:During a review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that include but not limited to myalgia (muscle pain) of head and neck and spondylosis (age related breakdown of the spine), cervical spondylosis without myelopathy or radiculopathy is an age-related wear-and-tear condition affecting the neck (cervical spine), oropharyngeal dysphagia is difficulty transferring food from the mouth to the esophagus. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/16/2026, the MDS indicated Resident 1 had intact cognitive (ability to think and process information) ability. The MDS indicated Resident 1 required partial assistance (helper does less than half the effort) for toileting hygiene, showering, upper/lower body dressing, putting on/taking off footwear. The MDS indicated Resident 1 required supervision for oral hygiene. The MDS indicated Resident 1 required set up assistance for eating. During a concurrent interview and record review on 5/19/2026 at 4:09 PM with Licensed Vocational Nurse 1(LVN 1), Resident 1's SBAR Form (Situation, Background, Assessment, Recommendation Communication Form that use to inform MDs for a CoC), dated 2/28/2026 and Resident 1's CP dated from 9/9/2025 to 5/16/2026 was reviewed. The SBAR indicated that Resident 1 had a productive cough with excessive secretions. There were no CP for Resident 1's CoC of productive cough with excessive secretions. LVN stated that Resident 1 should have a CP to address his CoC of productive cough and excessive secretions. LVN 1 stated that CPs should be done to assess if interventions are needed and effective and modify plans as necessary to achieve a resident's well-being to reach the care goals for Resident 1. LVN 1 stated that if a resident does not have a CP they are not receive proper care and their condition may worsen. During a concurrent interview and record review on 5/19/2026 at 4:39 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, Resident 1's SBAR Communication Form dated 2/28/2026 and Resident 1's CPs dated 9/9/2025 to 5/16/2026 were reviewed. The SBAR indicated that Resident 1 had a productive cough with excessive secretions. The CPs review indicated that Resident 1 did not have a CP for productive cough with excessive secretions.The P&P indicated:A comprehensive, person-centered CP that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Reflects currently recognized standards of practice for problem areas and conditions.When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.The DON stated that the policy indicates that a resident must have a CP done if they have a significant change in condition. The DON stated Resident 1 had a CoC of productive cough and excessive secretions on 2/28/2026, Resident 1 should have had a CP done for his CoC to treat and prevent worsening of Resident 1's conditions.

Based on interview and record review, the facility failed to ensure competencies and skills sets to provide nursing and related services were completed for five (5) of 5 sampled employees in accordance with facility assessment and facility's policy and procedures (P&P). This deficient practice had the potential to cause an increased risk for improper resident assessments, and inadequate documentation which could negatively impact the quality of care to the residents.Cross referenced with 755Findings:During a concurrent review and interview on 2/19/2026 at 10:43 AM with Director of Staff Development (DSD), Certified Nurse Assistant 3's (CNA 3) employee records were reviewed. DSD stated CNA 3 was hired on 9/18/2017. DSD stated CNA 3 did not have documented evidence of completed skills competency evaluation upon hire and annually. DSD stated the facility has a form titled, Certified Nursing Assistant Skills Competency Log, which is used in evaluating the competency of the CNAs' skills upon hire, and yearly thereafter. DSD stated the skills competency log includes but is not limited to evaluating CNAs for activities of daily living, vital signs, feeding techniques, and resident's rights. During a concurrent record review and interview on 2/19/2026 at 10:44 AM with DSD, CNA 4's employee records were reviewed. DSD stated CNA 4 was hired on 9/8/2025. DSD stated CNA 4 did not have documented evidence of completed skills competency evaluation upon hire. During a concurrent record review and interview on 2/19/2026 at 10:45 AM with DSD, CNA 5's employee records were reviewed. DSD stated CNA 5 was hired on 8/21/2023. DSD stated CNA 5 did not have documented evidence of completed skills competency evaluation upon hire and annually. DSD stated it is important to evaluate CNA's skills competency before releasing them from orientation to know if the employee needs more training and to ensure resident's safety. During a concurrent record review and interview on 2/19/2026 at 10:51 AM with DSD, Licensed Vocational Nurse 3's (LVN 3) employee records were reviewed. DSD stated LVN 3 was hired on 12/23/2024. DSD stated LVN 3 did not have documented evidence of completed skills competency evaluation upon hire and annually. DSD stated the facility has a form titled, Licensed Nurse Core Clinical Competencies, which is used in evaluating the competency of the Licensed Nurses' skills upon hire, and yearly thereafter. DSD stated the skills competency log includes but is not limited to evaluating licensed nurses for blood sugar monitoring (the process of measuring the amount of sugar in the blood), medication administration, documentation of change of condition and care planning. DSD stated all employees should have completed and should be deemed competent for the skills required of them, upon hire and annually to ensure that the licensed nurses are capable of providing the necessary care for the residents. During a concurrent record review and interview on 2/19/2026 at 10:52 AM with DSD, Registered Nurse Supervisor 1's (RNS 1) employee records were reviewed. DSD stated RNS 1 was hired on 12/10/2025. DSD stated RNS 1 did not have documented evidence of completed skills competency evaluation upon hire. DSD stated the Director of Nursing (DON) was in charge of conducting the skills competency evaluation for registered nurses upon hire and annually. The DSD stated she files the completed competency skills evaluation in the RN's employee file once received from the DON.During a review of the Facility Assessment, updated 1/19/2026, the Facility Assessment indicated DSD and/or designee are following strictly the guidelines and facility's protocol in providing training and education to the newly hired facility staff, and current facility staff, monitoring the training progress and ongoing validation of the training. It also indicated skills competencies are done yearly and as needed.During a review of facility's P&P titled, Competency of Nursing Staff, revised May 2019, the P&P indicated facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment.

Based on observation, interview, and record review, the facility failed to ensure proper food handling practices in accordance with the facility's policy and procedure (P&P) by failing to ensure: Three (3) individually prepared ice cream bowls were labeled with use by date.An open gallon container of ice cream, opened on 2/18/2026 has a use by date of 6 months after open date.Kitchen freezer 1 (KF1) was clean, without crumbs and ice-build up. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing food borne illness (food poisoning- with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) which could lead to other serious medical complications and hospitalization.Findings:1.During the initial tour on 2/17/2026 at 8:08 AM, in the facility's kitchen, 3 individually prepared ice creams were observed with a label date of 2/16/2026. During an interview on 2/19/2026 at 1:59 PM with the Facility Chef (FC), the FC stated 3 individually prepared ice creams dated 2/16/2026 were missing a use by date label. The FC stated 2/16/26 date on the 3 individually prepared ice creams was the preparation date. The FC stated serving food without a use by date is not safe for residents, may cause confusion among kitchen staff, and could result in untimely disposal if foods are not properly labeled with a use by date. 2. During an observation in the kitchen on 2/19/2026 at 6:24 AM, Kitchen Freezer 2 (KF2) was observed with one gallon of ice cream, with open date of 2/18/2026, and use by date of 10/15/2026 (approximately eight months from open date). During an interview on 2/19/2026 at 7:25 AM with FC, FC stated the one gallon of ice cream was opened yesterday, 2/18/2026, and kitchen staff (unknown) labeled the ice cream incorrectly. use by date according to manufacturer's use by date of 10/15/2026. During a concurrent observation, policy review and interview on 2/19/2026 at 8 AM with Dietary Service Supervisor (DSS), DSS stated the facility's P&P titled. Freezer Storage Guidelines, dated 2023, indicated that the ice cream can be kept in the freezer for 6 months. The DSS stated that the 1 gallon of ice cream's use by date should have been labeled 8/18/2026, and not 10/15/2026. 3. During an observation in the kitchen on 2/19/2026 at 6:25, KF 1 was observed dirty with crumbs and ice built up that dripped down to the bottom of KF1. During a concurrent observation and interview on 2/19/2026 at 2 PM with the FC, FC verified that the KF1 was not clean. FC stated the bottom level of KF1 was dirty with crumbs and was also observed with a pool of frozen liquid that dripped from the top part of the freezer. FC stated there was ice built up on the top portion of KF1. FC stated a dirty freezer was not acceptable because it can cause food contamination (introducing harmful or unwanted substances) which was harmful to the residents that could possibly cause sickness such as diarrhea. During an interview on 2/20/2026 at 2:13 PM with DSS, the DSS stated she did not know why there was pool of frozen liquid on the bottom of KF1. DSS stated the water must have dripped from the top part of KF1 where there were some ice-built ups. The DSS stated this was unsanitary because it can contaminate the food that was stored in KF1 which could cause residents to get sick. During a review of facility's P&P titled, Refrigerators and Freezers, revised November 2022, the P&P indicated the facility will ensure safe refrigerator and freezer maintenance, temperatures and sanitation, and will observe food expiration guidelines. During a review of facility's P&P titled Food Receiving and Storage, revised November 2024, the P&P indicated all foods stored in the refrigerator or freezer are covered, labeled and dated use by date).

Based on observation, interview and record review, the facility failed to follow its infection control policies and procedures by failing to ensure:Staff donned (putting on) full personal protective equipment (PPE; clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments such as a gown, gloves and mask) prior to entering Resident 16's room and staff performed proper hand hygiene by washing their hands with soap and water after leaving Resident 16's room who was under contact isolation (a transmission based precautions to stop germs from spreading through direct touch with a patient or indirect touch with contaminated objects in their environment) for Clostridium Difficile (C. diff; a highly contagious bacterial infection that causes an infection of the colon [the longest part of the long intestine]) infection. A documented evidence for daily water temperature control monitoring for the facility's water management program.Resident 48's breathing treatment mask and tubing (deliver aerosolized medication directly to the lungs. It includes vinyl mask, medication cup and plastic tube) and respiratory set up bag were changed every seven (7) days per facility's policy. These failures had the potential to result in spread of infection to other residents in the facility.Findings: During a review of Resident 16's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of hemiplegia (severe or complete paralysis affecting one vertical side of the body, often including the arm, leg and face) and hemiparesis (partial weakness or reduced motor function affecting one entire side of the body) following cerebral infarction (stroke - the death of brain tissue as a result of ischemia [when blood flow and oxygen is reduced in a part of the body]) affecting the right dominant side and enterocolitis (the inflammation of both the small intestine and the colon [large intestine] often causing severe abdominal pain, diarrhea, fever and vomiting) due to C.diff. During a review of Resident 16'S Minimum Data Set (MDS – a resident assessment tool), dated 1/29/2026, the MDS indicated the resident had severe impairment (never/rarely made decisions) with cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 16 needed substantial/maximal assistance (helper does more than half the effort) with putting on/taking off footwear, lower body dressing (the ability to dress and undress below the waist) and toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having bowel movements). The MDS also indicated Resident 16 needed partial/moderate assistance (helper does less than half the effort) with going from sitting to standing, upper body dressing (the ability to dress and undress above the waist) and personal hygiene. It indicated, Resident 16 also needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with rolling left and right in bed and going from lying down to sitting on the side of the bed and needed setup or clean-up assistance (helper sets up or cleans up; resident complete activity) with eating. During a review of Resident 16's Order Summary Report dated 2/17/2026 to 2/19/2026, Resident 16's Order Summary Report indicated an order initiated on 2/16/2026 to observe contact isolation secondary to resident being C.diff positive and all activities of daily living (ADLs; activities such as bathing, dressing and toileting a person performs daily), activities, skilled rehabilitation services, and dining services will be provided in the resident's room.During a review of Resident 16's Care Plan, dated 2/17/2026, Resident 16's Care Plan indicated Resident 16 required contact isolation precautions related to C.diff and indicated interventions including to observe contact isolation secondary to Resident 16 being C.diff positive with all ADLs, activities, skilled rehabilitation services and dining services being provided inside the resident's room and to perform hand washing before patient care, if hands are soiled and after patient care.During an observation on 2/17/2026 at 9:08 AM in the hallway outside of Resident 16's room, a contact precautions sign was observed outside the door indicating to stop, see the nurse before entering the room and to clean hands, wear a gown and gloves on room entry and to clean hands when exiting.During an observation on 2/17/2026 at 10:53 AM inside Resident 16's room, Housekeeping (HK) was observed entering Resident 16's room without donning PPE and removed the glove box on the wall to the right of Resident 16's bed and changed it with a new box of gloves. HK was then observed exiting Resident 16's room without washing her hands.During an interview on 2/17/2026 at 11:03 AM with Infection Preventionist (IP), IP stated she observed HK enter Resident 16's room earlier who is on contact isolation precautions for C.diff without donning PPE or washing her hands after she exited the room.During an interview on 2/18/2026 at 2:51 PM with IP, IP stated on 2/17/2026 IP on 2/17/2026 at around 10:53 AM, IP had observed HK walk into Resident 16's room who was on contact isolation for C.diff without donning PPE, then changed the glove box in the resident's room, and HK exited the room without washing her hands. IP stated HK should have stopped and checked to see what isolation Resident 16 had prior to entering the room, washed her (HK) hands, donned PPE and gloves and then stepped into the room. IP also stated, HK should have washed her hands prior to exiting the room. IP further stated it is important to follow the facility's proper infection control protocol prior to entering a room on contact isolation for C.diff helps prevent cross contamination and prevents the spread of infection.During an observation on 2/19/2026 at 6:20 AM in the hallway outside of Resident 16's room, Medical Records (MR) was observed doffing PPE and using the alcohol based hand sanitizer upon exiting Resident 16's room. MR was not observed to wash her hands with soap and water. During an interview on 2/19/2026 at 5:23 AM with MR and the Director of Nursing (DON), MR stated she did not wash her hands with soap and water upon exiting Resident 16's room and only used the alcohol- based hand sanitizer. The DON stated, MR should have washed her hands with soap and water upon exiting Resident 16's room since the resident is on contact isolation precautions for C.diff.During a concurrent observation and interview on 2/19/2026 at 6:25 AM with the DON, in the hallway outside of Resident 16's room, Certified Nursing Assistant 2 (CNA 2) was observed entering Resident 16's room without donning PPE and touched the gloves inside the room to the right of Resident 16's bed. The DON stated CNA 2 should have donned full PPE prior to entering Resident 26's room and touching anything from the resident's environment or room.During an interview on 2/20/2026 at 2:52 PM with the DON and Assistant Director of Nursing (ADON), both the DON and ADON stated it is the expectation of all staff to wear proper PPE prior to entering Resident 16's room because the resident is on contact isolation for C.diff and the proper PPE includes wearing a mask, gown and gloves and upon exiting need to doff (remove) their PPE and do hand washing with soap and water and not just the alcohol based hand sanitizer. Both the DON and ADON further stated if this protocol is not followed there is a risk for the infection to spread to others in the facility. During a review of the facility's policy and procedure (P&P) titled, Standard Precautions (the minimum, baseline infection control practices used by healthcare workers for all patients, regardless of their suspected or confirmed infection status), Enhanced Barrier Precautions (EBP; infection control measures in nursing homes requiring staff to wear gowns and gloves during high-contact care [e.g. (in example) bathing, dressing, changing linens and wound care] for residents with wounds, medical devices or known antibiotic resistant germ colonization [the process where bacteria or other microbes settle, grow and multiply on body surfaces without causing infection]) and Transmission Based Precautions (used in addition to standard precautions as a second-level of infection control), revised 5/20/2025, the P&P indicted its purpose was to provide guidelines for infection control practices to reduce the potential for transmission of pathogens and multi-drug resistant organisms and viruses. The P&P also indicated under Contact Precautions that, Contact Precautions are an extension of Standard Precautions it is required that gowns and gloves are worn for all contact with body fluids as well as contact with environmental surfaces in the patient's/resident's room. During a review of the facility's P&P titled, Clostridium Difficile, revised October 2024, the P&P indicated, Measures are taken to prevent the occurrence of Clostridium difficile infections (CDI) among residents. Precautions are taken while caring for residents with C. difficile to prevent transmission to other residents. The P&P also indicated: The primary reservoirs for C. difficile are infected people and surfaces. Spores can persist on resident-care items and surfaces for several months and are resistant to some common cleaning and disinfection methods. Steps toward prevention and early intervention include frequent hand washing with soap and water by staff and residents. 2. During an interview on 2/18/2026 at 1:52 PM with Maintenance Supervisor (MS), MS stated the control measures (actions that can be taken to reduce the potential of exposure to a hazard) for the water management program is checking water temperatures of random rooms at the facility every day. MS stated since he just started two (2) months ago, he is still trying to figure out his own system and does not have a log but would look for the previous Maintenance Supervisor's log.During an interview on 2/18/2026 at 2:25 PM with MS, MS stated he has been checking the water temperatures everyday for the last 2 months but has not been documenting the temperatures in a log. MS also stated he could not find any water temperature log previously kept by the Maintenance Supervisor before him. MS further stated it is important to document the daily water temperature checks in a log to show that it is being done since checking the water temperatures are for the resident's safety.During an interview on 2/20/2026 at 2:29 PM with MS, MS stated there was no log kept documenting the results of the daily water temperature checks since he started as MS and stated he could not find any water temperature log from the previous Maintenance Supervisor.During an interview on 2/20/2026 at 3:29 PM with the DON, the DON stated it is important to keep a log of the daily water temperature checks to ensure the water management controls are within range. During a review of the facility's P&P titled, Legionella (a bacterium which cases legionnaires' disease [a severe form of pneumonia – lung inflammation usually caused by infection]) Water Management Program, revised 5/22/2025, the P&P indicated, the water management program includes the following elements: the control limits or parameters that are acceptable and that are monitored, a system to monitor limits and the effectiveness of control measures and documentation of the program.During a review of the facility's P&P titled, Water Temperatures, Safety of, revised December 2020, the P&P indicated, maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log and maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. 3. During a review of Resident 48's admission Record indicated Resident 48 was admitted to the facility on [DATE], with diagnoses that included unspecified asthma, uncomplicated (chronic inflammatory lung disease characterized by narrowed, mucus-filled airways that cause wheezing, coughing, chest tightness, and shortness of breath, a chronic respiratory condition, representing a diagnosis where specific details are not fully documented), generalized muscle weakness (a widespread reduction in physical strength affecting muscles throughout the body rather than a single, isolated area), and presence of cardiac (an electronic device that is implanted in the body to monitor heart rate and rhythm). During a review of the MDS- dated 1/29/2026, indicated Resident 48 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 48 is dependent, (helper does all of the effort) with the toilet transfer, sit to stand, shower/bathe self, lower body dressing, and putting on/ taking off footwear. The MDS also indicated Resident 48 needed substantial/maximal assistance in toileting hygiene, upper body dressing, and sit to lying. Resident 48 needed partial or moderate assistance, with eating, oral hygiene and personal hygiene. During a review of Resident 48's Physician Orders, dated 1/28/2026, it indicated Resident 48 has an order for Albuterol Sulfate Nebulization solution (a sterile, preservative-free, short-acting bronchodilator solution used in a nebulizer machine [a medical device that converts liquid medication into a fine mist, allowing it to be inhaled directly into the lungs through a mouthpiece or face mask ], to treat acute asthma attacks, wheezing, and COPD symptoms by opening airways) 2.5 milligram (mg a unit of measurement)/3 milliliter, (ml- a metric unit for measuring liquid volume) inhale orally via nebulizer every six hours as needed for shortness of breath and wheezing (an uncomfortable feeling of not getting enough air, and a high-pitched whistling sound caused by narrowed airways). During an observation on 2/17/2026 at 9:55 AM in Resident 48's room, observed Resident 48's breathing treatment mask and tubing was stored inside a respiratory/patient set up bag dated 2/1/2026. There was no date on the breathing treatment mask nor the tubing beside the date on the respiratory/patient set up bag. During an interview on 2/17/2026 at 1:45 PM with Licensed Vocational Nurse (LVN1), LVN 1 stated Resident 48's breathing treatment mask, tubing and respiratory/ patient set up bag are supposed to be changed every seven days by night shift nurses to help prevent infection. LVN 1 stated, the label on the respiratory/ patient set up bag was dated 2/1/2026 and the breathing treatment mask and respiratory/ patient set up bag should have been changed on 2/8/2026 but it was not changed. During an interview on 2/18/2026 at 4:25 PM with Registered Nurse 1(RN1), RN 1 stated Resident 48's breathing treatment mask, tubing and the respiratory set up bag are supposed to be changed every seven days per facility's policy, and it is to prevent the accumulation of bacteria and germs that can cause lung infection if not changed accordingly. During an interview on 2/20/2026 at 11:14 AM with Infection Preventionist Nurse (IP), IP nurse confirmed the breathing treatment mask and tubing is supposed to be stored inside a clean respiratory set up bag with date of first use to determine when it needs to be changed with a new set. IPN also stated it is important to change the breathing treatment mask, tubing and respiratory set up bag every seven days to prevent infection and cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). During a record review of the facility's policy and procedure titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised October 2024, the policy indicated the purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. The policy also indicated the following steps for the use of the device: When equipment is completely dry, store it in a plastic bag with the resident's name and the date on it. Change equipment and tubing every seven days, or according to facility protocol.

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable sanitary and home-like environment for two (2) of three (3) sampled residents (Residents 37 and 41) reviewed for environment, by failing to ensure:The television (TV) of Resident 37 was functioning.The curtain in Resident 41's room above the sliding door was fully connected with the end of the curtain hanging down from the curtain rail. These failures have the potential to negatively affect Resident 37's well-being and quality of life and in addition had the potential to cause an unsafe environment for Resident 41 and staff to be placed at risk for injury.Findings: 1. During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was originally admitted to the facility on [DATE]. The admission record also indicated Resident 37's diagnoses included multiple fractures of pelvis (breaks in multiple bones between the lower abdomen and upper thighs), abnormalities of gait (manner of walking) and mobility (the ability to move or be moved freely and easily), and lack of coordination. During a review of Resident 37's Minimum Data Set (MDS – a resident assessment tool), dated 1/18/2026, the MDS indicated Resident 37 had modified independence (some difficulty in new situations only) cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 37 was assessed to need setup or clean-up assistance (helper sets up or cleans up) with eating. The MDS indicated Resident 37 was assessed to need supervision or touching assistance (helper provides verbal cues and/or touching/steadying assistance) with oral and personal hygiene. The MDS indicated Resident 37 was assessed to need partial/moderate assistance (helper does less than half the effort) with upper body dressing. The MDS indicated Resident 37 was assessed to need substantial/maximal assistance (helper does more than half the effort. helper lifts or holds trunks or limbs and provides more than half the effort) with toileting, showering, lower body dressing, and putting on/taking off footwear. During a review of Resident 37's Social Services admission assessment dated [DATE], it indicated Resident 37 was able to verbally communicate needs. It also indicated Resident 37 functioned independently in all parts of life. During a concurrent observation and interview on 2/17/2026 at 2:19 PM in Resident 37's room, the TV was off. Resident 37 stated the TV in her room was not working (unable to recall since when). Resident 37 also stated she likes watching TV that Resident 37 told facility staff about the TV not working. During an interview on 2/19/2026 at 2:16 PM with Maintenance Supervisor (MS), MS stated it was never reported to him that Resident 37's TV was not functioning. MS stated, he was not made aware that Resident 37's TV was not functioning until surveyor told him so. MS stated Resident 37 did not have a TV remote control to begin with. MS stated the facility's practice when resident's TV is not working/functioning is to verbally report to him if he is around and/ or record it on the maintenance logbook. MS stated Resident 37's TV issue was not recorded in the maintenance logbook and should have been recorded in the maintenance log. MS stated that any staff can log in the maintenance log. During an interview on 2/20/2026 at 3:14 PM with Director of Nursing (DON), the DON stated residents' TV should be functioning all the time and that all residents should be provided with TV remote control to use in turning on the TV. The DON stated residents' TV should be working so residents could use it at any time and enjoy the shows the residents want to watch. 2. During a review of Resident 41's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of hereditary (the passing of biological traits from the parents to their offspring through genetics or DNA) and idiopathic (spontaneous) neuropathy (damage to the nerves outside the brain and spinal cord, often causing pain, numbness, tingling, or weakness) and abnormalities of gait (unusual walking patterns) and mobility (impaired movement, coordination and balance). During a review of Resident 41'S MDS, dated [DATE], the MDS indicated the resident was moderately impaired (decisions poor; cues/supervision required) with cognitive skills for daily decision making. Resident 41 needed substantial/maximal assistance with going from sitting to standing, putting on/taking off footwear and lower body dressing (the ability to dress and undress below the waist). Resident 41 needed partial/moderate assistance with chair/bed-to-chair transfers (the ability to transfer to and from a bed to a chair [or wheelchair]), upper body dressing (the ability to dress and undress above the waist). Resident 41 also needed setup or clean-up assistance with rolling left and right in bed and eating. During a concurrent observation and interview on 2/17/2026 at 9:13 AM with Resident 41 in the resident's room, the curtain above the sliding door next to Resident 41's bed was observed to be open and not securely attached to the curtain rail with the top right side of the curtain falling. Resident 41 stated she had complained about it to staff that the curtain is not fully blocking out the light at night, and it needs to be fixed. During an observation on 2/18/2026 at 8:51 AM inside Resident 41's room, the curtain above the sliding door next to Resident 41's bed was observed to be open and not be securely attached to the curtain rail with the top right side of the curtain falling. During an observation on 2/18/2026 at 2:40 PM inside Resident 41's room, the curtain above the sliding door to next to Resident 41's bed was observed to be open and not be securely attached to the curtain rail with the top right side of the curtain falling down.During an observation on 2/19/2026 at 7:20 AM inside Resident 41's room, the curtain above the sliding door next to Resident 41's bed was observed to be fully closed with the top right end of the curtain not securely attached to the curtain rail and falling down.During and observation on 2/19/2026 at 9:55 AM inside Resident 41's room, the curtain above the sliding door to next to Resident 41's bed was observed to be open and not be securely attached to the curtain rail with the top right side of the curtain falling down.During a concurrent observation and interview on 2/19/2026 at 11:12 AM with Resident 41 in her room, the curtain above the sliding door to next to Resident 41's bed was observed to be open and not be securely attached to the curtain rail with the right side of the curtain falling down. Resident 41 stated she has asked the staff to fix it and it still had not been done. During a concurrent observation and interview on 2/19/2026 at 1:22 PM with MS, the curtain above the sliding door to next to Resident 41's bed was observed to be open and not be securely attached to the curtain rail with the top right side of the curtain falling down. MS stated the curtain is falling and it should not be like that since it can pose a safety issue and potentially fall on the resident. During an interview on 2/20/2026 at 10:50 PM with Assistant Director of Nursing (ADON), ADON stated Resident 41's curtain should not have been falling off the curtain rail because it could potentially be a hazard and is not homelike. During an interview on 2/20/2026 at 3:16 PM with the DON, the DON stated Resident 41's curtain should have been fully secured to the curtain rail because it could have posed as a safety hazard.During a review of the facility's policy and procedure (P&P) titled, Safe and Homelike Environment, revised 3/20/2025, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The P&P also indicated the facility staff, and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. During a review of the facility's P&P titled, Television/TV revised April 2025, the P&P indicated: Ensure televisions are accessible and positioned for optimal viewing comfort. Maintenance Department will be responsible for any issues related to the use of television.

Based on observation and interview, the facility failed to close the privacy curtain (fabric barrier suspended from ceiling tracks to divide shared rooms, providing patients with immediate visual privacy, dignity, and a sense of security during examinations or treatment) to provide privacy for one (1) of twenty-three sampled residents (Resident 9), who was only wearing a diaper when the resident was returning to her bed from the bathroom. This failure violated the resident's right to be treated with dignity and respect which can affect Resident 9 's psychological, emotional, and physical well-being During a review of Resident 9's admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included dementia in other diseases classified elsewhere (cognitive decline caused by underlying conditions rather than primary Alzheimer's or vascular dementia [brain damage or disease, resulting in a severe, progressive decline in cognitive function memory, reasoning, and behavior, that interferes with daily life]), hypertensive heart disease without heart failure ( the early-to-intermediate stage of structural heart damage caused by chronic, uncontrolled high blood pressure), and other abnormalities of gait and mobility (walking patterns or movement difficulties that do not fit into specific classifications like shuffling, limping, or stumbling). During a review of the Minimum Data Set (MDS- a resident assessment tool) dated 12/19/2025, indicated Resident 9 is severely impaired (never/ rarely made decisions) for cognitive skills (the mental processes that allow people to think, learn, and solve problems) for daily decision making. The MDS also indicated Resident 9 needs setup or clean-up assistance (helper sets up or cleans up) with eating, and Resident 9 needs supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for oral hygiene, personal hygiene, roll left and right, sit to lying and sit to stand. The MDS indicated, Resident 9 needs substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs but provides more than half the effort) for toileting hygiene, shower, bathe self, lower body dressing, putting on/ taking off footwear. During an observation on 2/18/2024 at 12:20 PM near Nursing Station 1 and the front lobby area, Resident 9 was visible from outside the resident's room while Resident 9 is walking back to her bed from the bathroom (inside the resident's room) without being covered with a towel or clothing, and the resident was wearing a diaper. Registered Nursing Supervisor (RNS) 1 was present in the room assisting Resident 9, and Resident 9's privacy curtain was not closed. During an interview on 2/18/2024 at 12:35 PM, RNS 1 stated he should have provided privacy to Resident 9 by properly covering the reisdent and making sure the privacy curtain was closed while RNS 1 assisted Resident 9 back to the resident's bed. RNS 1 stated it is essential to protect Resident 9's dignity and treat the reisdent with respect. During an interview on 2/20/2026 at 1:35 PM with the Director of Nursing (DON), the DON stated it is very important to provide privacy to residents in the facility. The DON also stated respecting patient privacy is foundational to ethical, patient-centered care and respecting individual's autonomy. During a review of the facility's Policy and Procedure titled Quality of Life - Dignity , dated February 2020, indicated the following:Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.Residents are always treated with dignity and respect. Demeaning practices and standards of care that compromise dignity is prohibited. Staff are expected to treat cognitively impaired residents with dignity and sensitivity.

Based on interview and record review the facility failed to ensure one ( 1) of five (5) sampled residents (Resident 38) reviewed for unnecessary medication have a specific indication for the use of valproic acid (a prescription medication used primarily to prevent and treat seizure [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and a mood stabilizer) as indicated on the facility's policy. This deficient practice had the potential to place Resident 38 at risk for significant adverse consequences (serious negative outcomes resulting from an event, action, or situation) from the use of unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior), which could result in impairment or decline in the residents' mental, physical condition, functional, and psychosocial status.Findings: During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was initially admitted to the facility on [DATE]. Resident 38's diagnoses included dementia (a progressive state of decline in mental abilities), metabolic encephalopathy (temporary or permanent brain dysfunction), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 38's Minimum Data Set (MDS - a resident assessment tool), dated 12/6/2025, the MDS indicated Resident 38 had moderately impaired (decisions poor, sues/supervision required) cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 38 had symptoms of feeling down, depressed and hopeless. The MDS indicated Resident 38 required substantial/maximal assistance (helper does more than half the effort) with eating and personal hygiene. The MDS indicated Resident 38 was dependent (helper does all of the effort) with oral and toileting hygiene, shower, upper and lower body dressing and putting on/off footwear. The MDS indicated Resident 38 was taking antipsychotic medications (primarily used to treat psychosis [a condition that affects how a person perceives reality]). During a review of Resident 38's Progress Notes, dated 12/12/2025, by Psychiatric Nurse Practitioner (PNP, an advanced practice registered nurse, authorized to assess, diagnose, and treat individuals with mental health disorders), the Progress Notes indicated to continue Depakote (valproic acid) regimen for mood stabilization. The Progress Notes indicated Resident 38's current diagnoses were dementia and depression. Resident 38's Progress Notes did not indicate a diagnosis of mood disorder (also called an affective disorder, a category of mental health conditions where the primary disruption involves a person's emotional state, causing significant deviation from their usual mood patterns). During a review of Resident 38's Order Summary Report, dated 2/18/2026, the Order Summary Report indicated Valproic acid oral solution 250 milligrams (mg, unit of measurement) per five (5) milliliters (ml, unit of measurement), give 5 ml by mouth every eight (8) hours for mood disorder manifested by mood swings from pleasant to irritable, ordered on 12/2/2025. During a concurrent record review and interview on 2/20/2026 at 8:04 AM with Assistant Director of Nursing (ADON), Resident 38's Valproic acid order was reviewed. ADON verified Resident 38 has an order for Valproic acid for mood disorder, ordered on 12/2/2025. ADON stated the diagnosis of mood disorder as an indication for the use of Valproic Acid was incorrect because Resident 38 was not diagnosed with mood disorder. Resident 38's medical records did not indicate any diagnosis of mood disorder. During an interview on 2/20/2026 at 3:11 PM, with the Director of Nursing (DON), the DON stated it was important to have an accurate diagnosis as an indication for use of any medication to ensure the resident receives the correct medication for the correct indication. The DON stated psychotropic medication orders should have a resident's diagnosis and the behavior that resident is manifesting, to ensure the medication is necessary for the resident. The DON stated the PNP Progress Notes did not indicate that Resident 38 has a diagnosis of mood disorder. Therefore, the use of valproic acid was unnecessary. During a review of Facility's Policy and Procedure (P&P) titled, Unnecessary Medication/Medication Therapy, revised April 2007, the P&P indicated each resident's medication regimen shall include only those medications necessary to treat existing conditions. Medication use shall be consistent with an individual's condition. All medication orders will be supported by appropriate care processes and practices.

Based on interview and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 3) who was assessed at risk for falls and with diagnoses of dementia (a progressive state of decline in mental abilities) was free from falls and injury in accordance with the resident's care plan for At risk for fall and Occupational Therapist (OT; a healthcare provider who helps you improve your ability to perform daily tasks like getting dressed or using a computer) Evaluation & Plan of Treatment (OTEPT) to provide maximal assistance (helper does more than half the effort) to the resident when showering/bathing. On 12/3/2024, in the facility's shower room, Certified Nurse Assistant (CNA) 3 turned away from Resident 3 to grab the chucks (under pad - a kind of ultra-absorbent incontinence [lack of voluntary control over urination or defecation] products that are designed to be placed on the top of a bed, wheelchair, or any surface you want to protect) and clean towel leaving the resident unattended while in the shower chair. This deficient practice resulted in Resident 3 leaning forward and falling in the shower room on 12/3/2024 around 10:40 AM. Resident 3 fell backwards in a supine (facing up) position where the resident struck her head during the fall. Resident 3 experienced pain to her head (specific location not specified). The paramedics (a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) came to pick up the resident and identified a hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) on the back of Resident 3's head. Resident 3 was sent to General Acute Care Hospital (GACH) by the paramedics on 12/3/2024 (time unknown) where the resident was found to have an acute (sudden) anterior (front) left second through sixth rib (slender curve bones protecting the lungs) fractures (a break in a bone) and was admitted to the GACH's Intensive Care Unit (ICU; a specialized hospital ward that provides intensive medical care to critically ill or injured patients who require close monitoring and life-support measures). Findings: During a review of Resident 3's Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM; a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia, schizophrenia (a mental illness that is characterized by disturbances in thought) and history of falling. During a review of Resident 3's Admission Fall Risk Assessment (AFRA), dated 11/26/2024, AFRA indicated Resident 3 was a fall risk. During a review of Resident 3's Care Plan (CP), dated 11/26/2024, the CP indicated Resident 3 was at risk for falls related to history of multiple falls prior to admission, seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), history of loss of consciousness and wheelchair bound with unsteady transfer. The CP indicated the CP goal was resident will have no injuries related to falls and interventions included: 1. Assess and anticipate resident's needs: body positioning. 2. Keep environment free of clutter and safety hazards. 3. Refer to rehabilitation (health care services that help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired) for evaluation and treatment as indicated. During a review of Resident 3's Psychologist Intake Note (PIN), dated 11/28/2024, the PIN indicated Resident 3 had poor insight, poor judgement/impulse control and functional status was severely impaired. During a review of Resident 3's History and Physical (H&P), dated 12/2/2024, the H&P indicated Resident 3 does not have the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool), dated 12/3/2024, the MDS indicated the resident was assessed to have moderately impaired cognition (capable of remembering, learning new things, concentrating, or making decisions that affect everyday life) and required maximal assistance for showering/bathing. The MDS also indicated Resident 3 was assessed to require moderate assistance (helper does less than half the effort) for toileting, upper/lower body dressing and taking on/off footwear. In addition, the MDS indicated Resident 3 had a fall in the last month prior to admission. During a review of Resident 3's Paramedic Report (PR), dated 12/3/2024, the PR indicated: 1. Resident 3 was found to have a hematoma to the posterior (back) left side of the resident's head. 2. Staff (unspecified) reported Resident 3 fell backwards while taking a shower, hitting the back of the resident's head on the floor. 3. Staff (unspecified) reported Resident 3 loss consciousness for about five (5) seconds. 4. Resident 3 was taken to GACH. During a review of Resident 3's GACH Trauma Surgery History and Physical (TSHP), dated 12/3/2024 entered at 12:33 PM, the TSHP indicated Resident 3 sustained a ground level fall in the shower, complained of head pain and had a scalp (skin covering the head) hematoma. TSHP indicated a Computed Tomography (CT; a computerized x-ray [a quick, painless test that captures images of the structures inside the body] imaging procedure) of Resident 3's chest, abdomen, and pelvis (the bones between the lower abdomen and upper thighs that connect the spine to the legs) were performed with findings of acute anterior left second through sixth rib fractures. TSHP indicated Resident 3 was admitted to the GACH's ICU. During a review of Resident 3's Interdisciplinary Team Progress Note (IDT), dated 12/3/2024 entered at 4:55 PM, the IDT indicated Resident 3 had a witnessed fall on 12/3/2024 at around 10:40 AM in the facility's shower room. IDT indicated Resident 3 was seated in a shower chair while being assisted by CNA 3 and Certified Nursing Assistant Student (Student 1). IDT indicated CNA 3 turned to grab a clean towel but Resident 3 leaned forward causing the shower chair to flip. IDT indicated Resident 3 fell backwards in a supine position and struck the residents head (not specified where the resident hit her head) during the fall. IDT indicated Resident 3 was assessed by staff but later in the resident's room, the resident complained of pain to her head. IDT indicated paramedics came to pick up the resident to transfer to GACH and the paramedics identified a hematoma on the back of Resident 3's head. During an interview on 12/17/2024 at 1:06 PM, CNA 3 stated, on 12/3/2024, CNA 3 was with Resident 3 in the shower room. Resident 3 was sitting in the shower chair while Student 1 was at the right side of the resident buttoning Resident 3 's gown. CNA 3 stated Student 1 was using both of her hands while buttoning Resident 3's gown when Resident 3 fell . CNA 3 stated she was behind Resident 3 and turned around to put a chuck and clean towel on the resident's wheelchair to prepare transferring Resident 3. CNA 3 stated while she was turned facing away from Resident 3, she suddenly heard a loud noise, a sound that something fell , she turned around and saw Resident 3 on the floor on her left side with the resident's chest area and stomach on the floor. CNA 3 stated she did not actually see Resident 3 falling as she (CNA 3) was not facing the resident and was fixing the chuck and clean towel in the wheelchair. CNA 3 stated, to prevent Resident 3 from falling, Resident 3 should not be left unattended. CNA 3 stated, Resident 3 cannot sit on her own that was why CNA 3 always need someone to be with her when showering Resident 3. CNA 3 stated she did not try to find another CNA to assist her on 12/3/2024 to provide shower to Resident 3 since she had Student 1 with her but should have looked for another CNA to assist. During a concurrent interview and record review with Physical Therapist (PT, a healthcare provider who helps you improve how your body performs physical movements) 1 on 12/17/2024 at 2:12 PM, Resident 3's PT Evaluation & Plan of Treatment (PTEPT) dated 11/27/2024 was reviewed. The PTEPT indicated: 1. Resident 3 had a history of fall. 2. Resident 3 required maximal assistance to stand from sitting. 3. Resident 3 required maximal assistance to transfer from chair to chair. 4. Resident 3 had impaired strength to both lower extremities (legs). PT 1 stated, Resident 3 had a fall at home due to possible seizure. She overestimated her abilities. She could not get on the wheelchair by herself. Her mind would stray to random incidents or topics. PT 1 also stated it would not be safe to take your eyes off and hands off Resident 3 when taking a shower since the resident was assessed to need maximal assistance during shower. During a concurrent interview and record review with OT 1 on 12/17/2024 at 2:17 PM, Resident 3's OTEPT dated 11/27/2024 was reviewed. OTEPT indicated: 1. Resident 3 was a fall risk, had dementia and was hard of hearing. 2. Resident 3 required maximal assistance for showering/bathing. OT 1 stated, She (Resident 3) was maximum assist for showers. That would require one helper. They would do the scrubbing, rinsing, drying. She required a shower chair. She required touching assistance for safety. OT 1 stated it would not be safe to leave Resident 3 unassisted or take your eyes off and hands off Resident 3 during a shower or after shower. During an interview on 12/17/2024 at 3:20 PM with Student 1, Student 1 stated on 12/3/2024 between 10:30 AM to 11 AM, Student 1 was shadowing (observing) CNA 3 and have just completed assisting CNA 3 showering Resident 3. Student 1 stated she was at the right side of Resident 3, there was a low divider between her and the resident, while assisting CNA 3 to shower Resident 3. Student 1 stated Resident 3 was facing the wall where the shower head is, while the resident was sitting on the shower chair. Student 1 stated CNA 3 handed her Resident 3's gown and Student 1 was buttoning Resident 3's gown using both of her hands when Resident 3 leaned forward and fell . Student 1 stated it happened so fast that she did not get a chance to go around the divider to catch Resident 3 from falling. Student 1 stated CNA 3 was behind Resident 3, and CNA 3 was not facing Resident 3 because CNA 3 was putting the chuck and clean towel on the wheelchair to prepare to transfer the resident. Student 1 stated Resident 3 landed on her back and/or on the left side. Student 1 stated she did not see Resident 3 hit her head but Resident 3 was complaining of pain on the head after the fall. Student 1 stated CNA 3 did not tell her that Resident 3 was a risk for fall. During a concurrent interview and record review on 12/18/2024 at 11:58 AM with the Director of Nursing (DON), Online Nurse Assistant Training Program Clinical Training Site Agreement (Training Agreement - contract between the Student 1's school and the facility indicating the terms and limitations of CNA students with regards to resident's care) dated 2/2022 was reviewed. The Training Agreement form indicated facility staff may not be used to proctor, shadow, or teach the training program students. The DON stated, the contract indicated, the nursing student including Student 1 should not be doing the CNA's work, or doings hands on care to the residents without the presence of the school's instructor. The DON also stated CNA 3 should not have relied on the help of Student 1 when showering residents. During a concurrent interview and record review on 12/18/2024 at 12:05 PM with the DON, the facility's policy, and procedure (P&P) titled, Fall and Fall Risk Managing dated 3/2018 was reviewed. The P&P indicated: 1. 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. 2. Environmental factors that contribute to the risk of falls include wet floors. 3. Resident conditions that may contribute to the risk of falls include delirium and other cognitive impairment, lower extremity weakness, balance, and gait (a person's manner of walking) disorders and incontinence. The DON stated, the policy indicated, fall risk factors include wet floors, delirium and other cognitive impairment, lower extremity weakness, incontinence, and balance and gait disorders. The DON stated, Resident 3 was in the shower room where the floor was wet, and the resident has dementia, incontinence, balance and gait problems and lower extremity weakness. The DON also stated, all these factors increase the Resident 3 risk for falls and the CNA should not have turned away from the resident to get chucks and clean towel. The DON stated Reisdent 3's fall could have been prevented if CNA 3 did not leave the resident unattended/ turned away from the resident to get chucks and clean towel on 12/3/2024.