Every finding on record at The Gardens of El Monte

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 4) received care in accordance with professional standards of practice to attain or maintain the highest practicable physical, mental, and/or psychosocial well-being, when the facility failed to: a. Timely renew Resident 4's wound treatment order for the right lower leg after the last treatment given on [DATE]. The order expired on [DATE]. b. Timely renew Resident 4's wound treatment order for the forehead after the last treatment given on [DATE]. The order expired on [DATE]. As a result, Resident 4 did not receive wound treatment of the right lower leg for 21 days and wound treatment of the forehead for 17 days. This violation had the potential to worsen Resident 4's wounds on the right lower leg and forehead. Findings: During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including open wound to right knee, open wound to other part of head, and methicillin resistant staphylococcus aureus infection (MRSA - a type of bacteria that cannot be killed by many common antibiotics). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated [DATE], the MDS indicated Resident 4 was cognitively (thinking ability) intact. The MDS indicated Resident 4 was independent for eating, toileting hygiene, and upper/lower body dressing. During a review of Resident 4's Order Summary Report (OSR) dated [DATE], the OSR indicated Resident 4 had a wound treatment order to the right lower leg abrasion (skin injury) by cleaning the site with normal saline (salt water), patting the wound dry, applying mupirocin ointment (an antibiotic used to treat bacterial skin infections), and cover with a dry dressing. The OSR indicated the wound treatment order had an end date (expiration/stop date) of [DATE]. During a review of Resident 4's Order Summary Report (OSR) dated [DATE], the OSR indicated Resident 4 had a wound treatment order to the forehead by cleaning the site with normal saline, applying nystatin powder (a medication that stops fungal growth) and collagen (a type of wound dressing that stimulates tissue growth), and cover with a dry dressing. The OSR indicated the wound treatment order had an end date of [DATE]. During a review of Resident 4's Doctor Order (DO) dated [DATE], the DO indicated a telephone order for wound treatment of Resident 4's right lower leg on [DATE], which was confirmed by LVN 2. During a review of Resident 4's DO dated [DATE], the DO indicated a telephone order for wound treatment of Resident 4's forehead on [DATE], which was confirmed by LVN 2. During an interview on [DATE] at 2:31 PM with Licensed Vocational Nurse (LVN 3), LVN 3 stated that on [DATE], the facility no longer used a wound treatment nurse (a designated licensed nurse who specifically performed wound-related care). LVN 3 stated that as of [DATE], the charge nurses (licensed vocational nurses) were responsible for performing wound treatments on their assigned residents. LVN 3 stated a nurse practitioner (NP 1) came to the facility every Wednesday as the main wound consultant (a healthcare professional specifically focused on providing wound-related care). LVN 3 stated NP 1 assessed residents who had wounds and then issued wound treatment orders. LVN 3 stated the wound treatment orders had a start date (the date an order was to be first administered) and an end date. LVN 3 stated it was standard nursing practice to monitor the end date so that the nurses could contact the doctor or NP 1 in advance to ask if they wanted to re-new (continue an existing order), change, or discontinue (stop) a wound treatment order. LVN 3 stated an end date was listed in the treatment administration record (TAR), which was part of the resident's electronic record and needed to be reviewed by the charge nurses every shift. LVN 3 stated a wound treatment order's end date was also listed in the doctor's order via electronically or as a paper copy inside a resident's medical chart. LVN 3 stated that if a resident's wound treatment order reached its end date and the assigned nurses failed to contact the doctor or NP 1 for a possible renewed order, that particular wound treatment order would completely disappear from the TAR and could lead to delayed care because the nurses in the oncoming shifts would not have any reminder in the TAR that the order existed and needed to be followed up with the doctor. During a concurrent observation and interview on [DATE] at 10:05 AM with Resident 4, Resident 4 was lying in bed. Two separate dressings were observed on Resident 4's right leg by the shin area, and one dressing was observed across Resident 4's forehead. Resident 4 stated Resident 4 recently went to a General Acute Care Hospital (GACH 1) several days earlier because Resident 4's right leg hurt and was irritated. During an interview on [DATE] at 10:22 AM with LVN 1, LVN 1 stated the charge nurses documented on the TAR each time wound treatment was administered. LVN 1 stated before [DATE], the wound treatment nurse made rounds (the act of checking one resident after another) with NP 1. LVN 1 stated NP 1 assessed residents' wounds, took measurements, and issued wound treatment orders. LVN 1 stated the nurse who made rounds with NP 1 on a particular day was responsible for keeping track of the wound treatment orders and inputting the orders into the facility's computer system. LVN 1 stated wound treatment orders were usually for a specific duration (number of days) because wounds were supposed to be routinely reassessed for healing. When asked who was responsible for monitoring the end dates of wound treatment orders, LVN 1 stated it was the licensed nurse delegated by the DON. LVN 1 stated the charge nurse (in general) should inform the DON if a wound treatment order was going to end, and the DON would delegate a licensed nurse to follow up with the doctor or NP 1. LVN 1 stated that if a wound treatment order ended, the order would no longer be visible in the TAR. LVN 1 stated if a wound treatment order was not renewed in timely manner, the wound could remain untreated, potentially leading to an infection or worsening of the wound. During a concurrent interview and record review on [DATE] at 10:53 AM with LVN 3, Resident 4's medical chart was reviewed. LVN 3 stated Resident 4's Situational Background Appearance Review/Notify (SBAR), dated [DATE], indicated Resident 4's right leg had swelling and redness on [DATE]. LVN 3 stated the SBAR indicated Resident 4's doctor and NP 1 were notified on [DATE] with an order to transfer Resident 4 to GACH 1 for further evaluation. LVN 3 stated Resident 4's undated Hospital Report (HR) indicated that prior to Resident 4's re-admission to the facility, the GACH 1 nurse gave a verbal report that Resident 4's right leg was positive for MRSA. LVN 3 stated Resident 4's Comprehensive Resident Assessment (CRA) dated [DATE] indicated Resident 4 returned to the facility from GACH 1 on [DATE]. The CRA further indicated that during an assessment on [DATE], Resident 4 was noted to have two open wounds on the right lower leg, identified as superior (top) wound and inferior (bottom) wound. During a concurrent interview and record review on [DATE] at 11:13 AM with LVN 3, Resident 4's medical chart was reviewed. LVN 3 stated Resident 4's TAR for the month of 7/2026 indicated the last time Resident 4 received wound treatment for the right lower leg was on [DATE]. LVN 3 stated the last time Resident 4 received wound treatment for the forehead was on [DATE]. LVN 3 stated Resident 4's TAR indicated there were 21 days in which Resident 4 did not receive wound treatment for the right lower leg prior to being admitted to GACH 1 on [DATE]. LVN 3 stated Resident 4's TAR indicated there were 17 days in which Resident 4 did not receive wound treatment for the forehead prior to being admitted to GACH 1 on [DATE]. LVN 3 stated Resident 4's wound treatment orders for the right leg and forehead were not renewed timely, which resulted in delayed care provided to Resident 4. LVN 3 stated every wound should have a wound order because wound treatment should be continued until the wound was healed or resolved. During a concurrent interview and record review on [DATE] at 2:37 PM with LVN 3, Resident 4's medical chart was reviewed. LVN 3 stated Resident 4's Wound Assessment (WA) dated [DATE] indicated NP 1 measured Resident's 4's right lower leg inferior wound at 0.2 centimeters (cm - unit of measurement) long, 0.2 cm wide, and 0.1 cm deep. LVN 3 stated the WA indicated there was no right lower leg superior wound on [DATE]. LVN 3 stated Resident 4's WA indicated that on [DATE], NP 1 measured Resident's 4's forehead wound at 1.3 cm long, 1.1 cm wide, and 0.2 cm deep. During an interview on [DATE] at 10:49 AM with LVN 5, LVN 5 stated that charge nurses needed to review doctor's orders to determine when a wound treatment order was ending/expiring. LVN 5 stated wound treatment orders automatically dropped (disappeared) from the TAR when the orders ended/expired and not renewed. During an interview on [DATE] at 1:23 PM with the DON, the DON stated wound treatment orders had expiration dates, and it was primarily the charge nurses' responsibility to monitor if a wound treatment order was about to expire. The DON stated the charge nurses should first assess a resident's wound to determine if the wound still existed or was resolved. The DON stated if a wound still existed, then the charge nurses should notify the doctor or nurse practitioner that a wound treatment order's end date was approaching and clarify with the doctor or nurse practitioner to renew or change the wound treatment order. The DON stated it was important to monitor wound treatment order expiration dates to avoid delay in providing nursing care and prevent the wound from getting worse. During a review of the facility's Policy and Procedure (P&P) titled, Wound Care, dated 4/2017, the P&P indicated it is the policy of the facility to provide guidelines for the care of wounds to promote healing. The P&P further indicated the licensed nurse must verify that there is a physician's order for the procedure. During a review of the facility's undated job description (JD) for licensed vocational nurses titled, Charge Nurse Job Description, the JD indicated the responsibilities of charge nurses include performing resident assessments, performing treatments as ordered by the physician, and notifying the doctor timely as needed. During a review of the facility's undated job description (JD) for registered nurses titled, Registered Nursing Supervisor Job Description, the JD indicated the responsibilities of registered nurses included assessing and providing wound care assessment and treatment. The JD also indicated registered nurses were responsible for communicating with the physician the status of the resident condition and carrying out any orders.

Based on interview and record review, the facility failed to thoroughly investigate and document the investigation of an allegation of sexual abuse (non-consensual sexual contact of any type with a resident) for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure (P&P), titled Abuse Reporting and Prevention, revised 04/2024.This failure had the potential for Resident 1 to experience sexual abuse while in the care of the facility.(Cross Reference F609)During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 5/1/2026 with diagnoses including paranoid schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/4/2026, the MDS indicated Resident 1 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 required partial/moderate (helper does less than half the effort) assistance from staff for personal hygiene and bathing. The MDS indicated Resident 1 required supervision or touch assist (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity; assistance may be provided throughout the activity or intermediately) from staff for toileting hygiene, dressing, and putting on/taking off footwear.During a review of the facility's Census List (CL), dated 7/15/2026, the CL indicated Resident 1 resided in Room A from admission date of 5/1/2026 until a room change on 5/20/2026.During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 12/19/2025 and readmitted Resident 2 on 6/8/2026 with diagnoses including hemiplegia and hemiparesis (complete paralysis on one side of the body and partial paralysis on one side of the body that can affect the arms, legs, and facial muscles, respectively) following cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), and type 2 diabetes mellitus.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had no impairment in cognitive skills. The MDS indicated Resident 2 required supervision or touch assistance from staff for toileting hygiene, showering, putting on footwear, and bathing. The MDS indicated Resident 2 required set up or clean-up assistance from staff for dressing and personal hygiene.During an interview on 7/15/2026 at 9:10 AM, with the Administrator in Training (AIT), the AIT stated Social Worker (SW 1) at General Acute Care Hospital (GACH) notified the facility's Social Service Director (SSD) on 7/10/2026 that Resident 1 had made an allegation of sexual abuse against a male resident (unidentified) at the facility.During an interview on 7/15/2026 at 9:30 AM, with the SSD, the SSD stated SW 1 called the SSD on 7/10/2026 and notified the SSD that Resident 1 had alleged Resident 2 had exposed himself and was touching himself sexually in Resident 1's room. The SSD stated that after receiving the notification from SW 1, the SSD asked Resident 1 about the allegation. The SSD stated Resident 1 alleged to the SSD that Resident 2 would come into Resident 1's room nightly at around 11:00 PM. The SSD stated Resident 1 alleged once Resident 2 was inside Resident 1's room, Resident 2 would unzip Resident 2's pants and touch himself sexually. The SSD stated the SSD notified the AIT on 7/10/2026 of Resident 1's allegation of sexual abuse.During an interview on 7/15/2026 at 9:44 AM with Resident 1, Resident 1 stated Resident 1 was admitted to Room A on 5/1/2026. Resident 1 stated that on 5/2/2026, at around 11:00 PM, Resident 2 came into Resident 1's room (Room A) and stood at the foot of Resident 1's bed. Resident 1 stated Resident 2 was touching himself sexually at the foot of Resident 1's bed. Resident 1 stated Resident 2 repeated the same behavior nightly at the same time each night until Resident 2 was moved to room B.During a follow up interview on 7/15/2026 at 11:56 AM with the AIT, the AIT confirmed Resident 1's allegation against Resident 2 was an allegation of sexual abuse. The AIT stated that the AIT and the SSD investigated the allegation of sexual abuse. The AIT stated part of the investigation was to interview residents (in general) in the area where the allegation was supposed to have occurred. the AIT and the SSD interviewed residents (in general) in and around Room B. The AIT stated the AIT, and the SSD did not interview residents in and around Room A. The AIT stated the AIT did not retain an investigation file containing the interviews with residents (in general) or staff (in general) used to investigate the allegation of sexual abuse.During a follow up interview on 7/15/2026 at 12:05 PM with the SSD, the SSD stated that besides Resident 1's interview, the SSD did not document any interviews of residents (in general) or staff (in general) during the investigation of Resident 1's allegation of sexual abuse.During a review of the facility's P&P titled, Abuse Reporting and Prevention, revised 04/2024, the P&P indicated the reporting procedure into allegations of abuse included, . Begin an investigation file labeled Confidential Document. All interviews, reports, notes, and other pertinent documents shall be maintained in the file. The investigation of alleged abuse form is used to document the investigation. Statements from witnesses or employees who were involved or may have been involved should be documented by the employee. If they are not written by the employee, it should be documented, read to the employee and the employee should sign the statement. If the statement is not written in English a staff member may attach a paper with the interpretation in English and should sign the interpretation statement. Social Services or those assigned by the Administrator initiate an investigation which may include an interview of the involved resident(s) and other parties (volunteers, employees, visitors, etc., who have knowledge of the alleged incident) documenting on the interview record by that person. Interview records are kept confidential and maintained in a confidential file in the Administrator's office [.] A designated person completes the investigation form after the investigation is complete [.] The completed confidential file and all other material related to the incident are forwarded in its entirety to the administrator.

Based on interview and record review, the facility failed to report an allegation of sexual abuse (non-consensual sexual contact of any type with a resident) for one of three sampled residents (Resident 1) to the California Department of Public Health (the Department), the Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement, within two hours, in accordance with the facility's policy and procedure (P&P), titled Abuse Reporting and Prevention, revised 04/2024.This failure resulted in a delay in notification to the Department, the Ombudsman, and local law enforcement, and had the potential for Resident 1 to be subjected to abuse while at the facility.(Cross Reference F610)During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 5/1/2026 with diagnoses including paranoid schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/4/2026, the MDS indicated Resident 1 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 required partial/moderate (helper does less than half the effort) assistance from staff for personal hygiene and bathing. The MDS indicated Resident 1 required supervision or touch assist (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity; assistance may be provided throughout the activity or intermediately) from staff for toileting hygiene, dressing, and putting on/taking off footwear.During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 12/19/2025 and readmitted Resident 2 on 6/8/2026 with diagnoses including hemiplegia and hemiparesis (complete paralysis on one side of the body and partial paralysis on one side of the body that can affect the arms, legs, and facial muscles, respectively) following cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), and type 2 diabetes mellitus.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had no impairment in cognitive skills. The MDS indicated Resident 2 required supervision or touch assistance from staff for toileting hygiene, showering, putting on footwear, and bathing. The MDS indicated Resident 2 required set up or clean-up assistance from staff for dressing and personal hygiene.During an interview on 7/15/2026 at 9:10 AM, with the Administrator in Training (AIT), the AIT stated Social Worker (SW 1) at General Acute Care Hospital (GACH) notified the facility's Social Service Director (SSD) on 7/10/2026 that Resident 1 had made an allegation of sexual abuse against a male resident (unidentified) at the facility.During an interview on 7/15/2026 at 9:30 AM, with the SSD, the SSD stated SW 1 called the SSD on 7/10/2026 and notified the SSD that Resident 1 had alleged Resident 2 had exposed himself and was touching himself sexually in Resident 1's room. The SSD stated that after receiving the notification from SW 1, the SSD asked Resident 1 about the allegation. The SSD stated Resident 1 alleged to the SSD that Resident 2 would come into Resident 1's room nightly at around 11:00 PM. The SSD stated Resident 1 alleged once Resident 2 was inside Resident 1's room, Resident 2 would unzip Resident 2's pants and touch himself sexually. The SSD stated the SSD notified the AIT on 7/10/2026 of Resident 1's allegation of sexual abuse.During a follow-up interview on 7/15/2026 at 11:56 AM, with the AIT, the AIT confirmed Resident 1's allegation against Resident 2 was an allegation of sexual abuse. The AIT stated that the AIT did not report the allegation of sexual abuse to the Department, Ombudsman, and local law enforcement.During a review of the facility's P&P titled, Abuse Reporting and Prevention, revised 04/2024, the P&P indicated, It is the policy of this facility to ensure that alleged violations by anyone in the facility involving .abuse . are reported immediately to the administrator of the facility.The administrator, or his/her designee, will report each alleged abuse to the Ombudsman's office and the Department of Public Health immediately or within 2 hours per Section 1418.91 of the Health and Safety Code.

Based on interview and record review, the facility failed to:1. Send Resident 1 for timely medical treatment after falling and hitting his head on the floor.2. Ensure three of five sampled residents (Resident 3, Resident 4, and Resident 5) received treatment and care in accordance with the physician's order for orthostatic blood pressure monitoring (involves measuring blood pressure (BP) while lying down, sitting, and standing to assess changes) by failing to ensure Resident 3, Resident 4, and Resident 5 were monitored for orthostatic hypotension (condition in which the blood pressure quickly drops upon standing up after sitting or lying down) with two blood pressure (BP) readings on 6/7/26, 6/14/26 and 6/21/26 and observed for adverse side effects.These deficient practices had the potential to result in adverse outcomes:1. Resident 1's delay of care with possible internal bleeding from the head injury from the fall;2. Hypotension (very low blood pressure) with dizziness and fainting and could lead to falls and injuries for Resident 3, Resident 4, and Resident 5.a. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was initially admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses that included other abnormalities of gait and mobility (any noticeable, irregular change in your walking pattern) and atrial fibrillation (irregular and often very fast heart rhythm).During a review of Resident's 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/13/26, the MDS indicated Resident 1 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 needed substantial/maximal assistance with eating, oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear, and personal hygiene.During a review of Resident 1's History and Physical (H&P), dated 5/2/26, the H&P indicated Resident 1 had altered mental status to understand and make medical decisions.During a review of Resident 1's Fall Risk Evaluation, dated 5/1/26, the evaluation indicated Resident 1 scored 16 on 5/1/26, 18 on 5/28/26 and 18 on 6/11/26. The evaluation indicated a total score of 10 or above represented high risk.During a review of Resident 1's Order Summary Report, dated 6/24/26, the Order Summary Report indicated Resident 1 was ordered Eliquis (a blood thinner, used to prevent and treat blood clots) oral tablet 5 milligrams (mg, unit of measurement), one tablet by mouth two times a day for atrial fibrillation.During a review of Resident 1's Medication Administration Record (MAR) for the month of June 2026, the MAR indicated Resident 1 was prescribed Eliquis from 6/1/26 to 6/10/26 as scheduled at 09:00 a.m. and 5:00 p.m. The MAR indicated on 6/10/26 at 5:00 p.m., the scheduled does was given to Resident 1. During a review of Resident 1's Nurses Notes, dated 6/11/26 at 3:15 a.m., the note indicated CNA (unnamed) reported Resident 1 had a fall and a skin tear on Resident 1's right side of the head measuring 3 centimeters (cm, unit of measurement) length x 1-2cm width, bleeding and irregularly shaped.During a review of Resident 1's Change of Condition (COC), dated 6/11/26 indicated Resident 1 had a fall after rolling out of bed. The COC indicated resident struck the right side of Resident 1's head during the fall. Assessment indicated a skin tear, irregular shape and approximately 3 cm in length and 1-2 cm in width, bleeding, and resident alert and responsive. The COC indicated the Clinician was notified at 5:13 a.m. and the Responsible Person (RP) at 05:20 a.m. on 6/11/26.During a review of Resident 1's Nurses Notes, dated 6/11/26 at 7:15 a.m., the note indicated Resident 1 transferred to General Acute Care Hospital 2 (GACH 2) via 911.During a review of Resident 1's Medical Record, the record indicated the facility was aware of Resident 1's fall with head injury on 6/11/26 at 3:15 a.m. and Resident 1 was not transferred to GACH 2 until 7:15 a.m.During a review of Resident 1's GACH 2 medical records, the records indicated Resident 1 was seen in the Emergency Department at 7:31 a.m.During an interview on 6/25/26 with Registered Nurse 1 (RN 1), RN 1 stated LVN 5 asked RN 1 for help with Resident 1 because Resident 1 had a fall that was reported to LVN 5 at 3:15 a.m. in the morning on 6/11/26. RN 1 stated LVN 5 told RN 1 that LVN 5 texted the DON with Resident 1's [head] wound picture. RN 1 stated LVN 5 told her the DON did not respond.RN 1 stated she did not know the time when the DON called back and told LVN 5 not to send out Resident 1 via 911 because Resident 1 had a superficial wound. RN 1 stated she assessed Resident 1; she removed the bandage and Resident 1 had on and was still actively bleeding. RN 1 stated Resident 1 was on Eliquis 5 mg, twice a day for atrial fibrillation.RN 1 stated she got an MD order at 7:15AM to transfer Resident 1 to GACH 2 via 911 and Resident 1 was sent out to the hospital.RN 1 was asked why Resident 1 was not transferred to the hospital in a timely manner, and RN 1 stated, LVN 5 is a new nurse and still needed guidance from the DON. RN 1 was asked: Why is it important to send Resident 1 to the hospital in a timely manner? RN 1 stated Resident 1 might have blood clots due to the fall injury to the head or because Resident 1 was on blood thinners, there may be excessive internal bleeding in Resident 1's head.b. During a review of Resident 3's AR, the AR indicated Resident 3 was initially admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and bipolar disorder (a lifelong mental health condition characterized by severe shifts in mood, energy, and activity levels.During a review of Resident 3's H&P, dated 6/16/26, the H&P indicated Resident 3 had minor memory impairments, but had the capacity to make medical decisions.During a review of Resident's 3's MDS, dated [DATE], the MDS indicated Resident 3 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 3 needed help with oral hygiene, upper body dressing, putting on/taking off footwear.During a review of Resident 3's MAR for the month of June 2026, the MAR indicated Resident 3 was prescribed one antipsychotic medication (medications to treat psychosis) and for staff to monitor side effects related to hypotension.During a review of Resident 3's Medication Review Report for active physician orders, the report indicated the following:1. Monitor BP lying and sitting for orthostatic hypotension every week on Sunday 3-11 p.m. shift. Notify Medical Doctor (MD) if difference of systolic blood pressure (SBP, top number in a reading, measuring the maximum pressure in the arteries when your heart beats) is 20mmHg or greater or if diastolic blood pressure (DBP, the bottom number in a reading, measuring the pressure in the arteries when your heart rests between beats) is 10 mmHg or greater for use of Risperdal.During a review of Resident 3's Weights and Vitals Summary for 6/7/26 and 6/21/26, the summary indicated the orthostatic blood pressure (BP) reading was taken within a minute of the sitting and lying BP orthostatic readings. The sitting position BP was taken at 4:59 p.m. followed by the lying position BP taken at 5:00 p.m. The BP readings on 6/7/26 were as followed:6/7/26 at 4:59 p.m., 125/70 mmHg (Sitting, left arm)6/7/26 at 5:00 p.m., 128/88 mmHg (Lying, right arm)6/7/26 at 7:47 p.m., 128/88 mmHg Sitting, left arm)c. During a review of Resident 4's AR, the AR indicated Resident 4 was initially admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses that included borderline personality disorder (a mental health condition characterized by severe difficulties regulating emotions), unspecified dementia (a progressive state of decline in mental abilities), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and anxiety disorder (intense, persistent fear and dread that is disproportionate to the situation and interferes with daily life).During a review of Resident 4's H&P, dated 4/11/26, the H&P indicated Resident 4 had fluctuating capacity to understand and make decisions.During a review of Resident's 4's MDS, dated [DATE], the MDS indicated Resident 4 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 4 needed supervision with eating, oral hygiene, and personal hygiene; partial/moderate assistance with toileting hygiene, shower/bathe self, upper/lower body dressing, and putting on/taking off footwear.During a review of Resident 4's MAR for the month of June 2026, the MAR indicated Resident 4 was prescribed two antipsychotic medications (medications to treat psychosis) and for staff to monitor side effects related to hypotension. The MAR also indicated Resident 4 refused orthostatic blood pressure monitoring on Sunday, 6/7/26, Sunday, 6/14/26 and Sunday, 6/21/26. No change of condition for Resident 4's refusal for orthostatic blood pressure monitoring was found in Resident 4's medical records.During a review of Resident 4's Medication Review Report for active physician orders, the report indicated the following:1. Monitor BP lying and sitting for orthostatic hypotension every week on Sunday 3-11 p.m. shift. Notify MD if difference of SBP is 20mmHg or greater or if DBP is 10 mmHg or greater for use of Seroquel (used to treat schizophrenia, bipolar disorder, and major depressive disorder); Rexulti (used to treat schizophrenia, agitation in Alzheimer's dementia, and as an add-on therapy for major depressive disorder).During a review of Resident 4's Weights and Vitals Summary for 6/7/26, 6/14/26 and 6/21/26, the summary indicated no orthostatic blood pressure (BP) readings were taken during the 3-11 p.m. shift.d. During a review of Resident 5's AR, the AR indicated Resident 5 was initially admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses that included unspecified dementia (a progressive state of decline in mental abilities), and bipolar disorder, depression (a serious mood disorder that causes persistent sadness, loss of interest, and physical or emotional fatigue) and anxiety disorder.During a review of Resident 5's H&P, dated 4/1/26, the H&P indicated Resident 5 had fluctuating capacity to understand and make decisions.During a review of Resident's 5's MDS, dated [DATE], the MDS indicated Resident 5 was independent in eating, needed supervision with oral hygiene and personal hygiene; partial/moderate assistance with toileting hygiene, shower/bathe self, upper/lower body dressing, and putting on/taking off footwear.During a review of Resident 5's MAR for the month of June 2026, the MAR indicated Resident 5 was prescribed one antipsychotic medication and for staff to monitor side effects related to hypotension. The MAR also indicated Resident 5 refused orthostatic blood pressure monitoring on Sunday, 6/14/26 and Sunday, 6/21/26. No change of condition for Resident 5's refusal for orthostatic blood pressure monitoring was found in Resident 5's medical records.During a review of Resident 5's Medication Review Report for active physician orders, the report indicated the following:1. Monitor BP lying and sitting for orthostatic hypotension every week on Sunday 3-11 p.m. shift. Notify MD if difference of SBP is 20mmHg or greater or if DBP is 10 mmHg or greater for use of Olanzapine (used to treat schizophrenia and bipolar disorder).During a review of Resident 5's Weights and Vitals Summary for 6/14/26 and 6/21/26, the summary indicated no orthostatic blood pressure (BP) readings were taken during the 3-11 p.m. shift.During an interview on 6/23/26 at 11:06 a.m. LVN 1, LVN 1 stated LVN 1 was aware of orthostatic blood pressure monitoring because LVN 1 worked at another facility with psychiatric residents, but that some CNAs and nurses at this facility might not know because there were no policy and procedure. LVN 1 stated it was important to measure orthostatic blood pressure as ordered by the physician because psychotropic medications taken by residents could make them a high risk for falls with injury, especially if they already have trouble with their gait and mobility.During an interview with the Medical Records Director (MRD) on 6/24/26 at 4:35 p.m., MRD stated the facility did not have an orthostatic blood pressure policy.During the exit conference on 6/24/26 at 5:00 p.m. with the facility's Director of Nursing (DON), the DON stated the facility does not have a blood pressure or orthostatic hypotension blood pressure policy and procedure because taking blood pressure is a nursing standard of care.During a review of the facility's Policy and Procedure (P&P) titled, Change of Condition, revised March 2021, the P&P indicated, Policy: It is the policy of this facility that any changes in a resident's condition be thoroughly assessed and evaluated with physician notification for early clinical management to avoid unnecessary readmissions to acute hospitals. The facility may use the SBAR process to assess and evaluate the resident's change of condition.During a review of the facility's P&P titled, Fall Risk & Prevention of Injury to include Pathological Fractures, revised March 2019, the P&P indicated, Policy: It is the policy of the facility to identify residents that are at risk for falls and to implement a plan of care in an attempt to prevent falls. The P&P further indicated, If the Fall Risk Assessment score is ten (I 0) or above, the resident is at risk for falls and a plan of care will be developed with approaches in an attempt to prevent falls, including falls with serious injury. The Fall Risk Assessment will be reviewed quarterly and after each fall. If a resident sustains a fall, the licensed nurse is to be notified immediately prior to moving the resident. The licensed nurse will assess the resident immediately and an incident report will be completed with an investigation. The incident report and investigation will be given to the Director of Nurses for review.During a review of the facility's P&P titled, Medication Administration, revised April 2025, the P&P indicated, Policy: It is the policy of the facility that medications for residents be administrated in a safe and timely manner, and as prescribed. The P&P further indicated, Medications ordered for a specific resident may not be administered to another resident.During a review of the facility's P&P titled, Physician Services and Orders, revised January 2017, the P&P indicated, Policy: It is the policy of the facility that each resident remains under the care of a physician. Drugs, biologicals, laboratory services, radiology and other diagnostic services shall be administered or performed only upon the written order of a person duly licensed and authorized to prescribe such drugs and services.

Based on observation, interview, and record review, the facility failed to maintain proper storage of medications in one of two medication carts (Medication Cart 1).This deficient practice had the potential for medication dispensing errors for 25 residents who resided in the facility's Station 1 Unit. During an observation of Medication Cart 1 on 6/23/26 at 2:15 p.m., in Station 1 Unit, with Licensed Vocational Nurse 1 (LVN 1), the locked narcotics (a drug that is classified as a Schedule IV controlled substance and in moderate doses dulls the senses, relieves pain, and induces sleep) drawer with active medications was observed with 4 loose medications in the back of the narcotics drawer. The loose medication pills included one Klonopin [Clonazepam, 1mg, light green tablet, TEVA- used to prevent and treat panic disorders, seizure disorders, and acute muscle spasms] and three Ativan [Lorazepam, 0.5mg, white tablet, 5R- used to treat anxiety disorders, trouble sleeping, and seizures] tablets.During an interview on 6/23/26 at 2:15 p.m. with LVN 1, LVN 1 stated LVN 1 did not know the loose medications were in the locked box.LVN 1 stated she was not usually assigned to Station 1 Medication Cart.LVN 1 stated a resident may have refused the medication and a different nurse may have placed the medication back in the drawer.LVN 1 stated there should not be any loose medications in the narcotics drawer because someone can take them without anyone knowing.LVN 1 stated the loose medications could be compromised by light or moisture since they were not in the bubble packs (individual sealed plastic compartments corresponding to the exact date and time they should be taken) or cause a medication error, if you can not identify the pills correctly, which posed a risk to the residents.During an interview on 6/23/26 at 2:36 p.m. with the Director of Nursing (DON), the DON stated, It is not our practice to have loose medications in the narcotics drawer; I don't know how that happened. DON stated once a month the DON does the medication disposal process with the Pharmacist.During a review of the facility's Policy & Procedure (P&P) titled, Preparation and General Guidelines - IIA5: Controlled Medications, revised April 2025, the P&P indicated Policy: It is the policy of the facility that medications for residents be administrated in a safe and timely manner, and as prescribed. The P&P further indicated, .Medications ordered for a specific resident may not be administered to another resident. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It must be destroyed according to facility policy in the presence of two licensed nurses and the disposal documented on the accountability record on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules.

Based on interview and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Abuse Reporting and Prevention, for two of three sampled residents (Resident 6 and Resident 7) when the facility did not report two resident to resident abuse allegations (a claim that abuse has occurred) to the California Department of Public Health (the Department), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and to the local law enforcement, within two hours. This failure resulted in the delay of notification to the Department and had the potential for Resident 6 and Resident 7 to be subjected to abuse while at the facility. A. During a review of Resident 6's admission Record (AR),the AR indicated the facility admitted Resident 6 on 2/19/2026 with diagnoses including metabolic encephalopathy (a brain dysfunction caused by chemical imbalances in the body), paranoid schizophrenia (a type of schizophrenia [a mental illness characterized by disturbances in thought] associated with feelings of being persecuted or plotted against) and major depressive disorder (a serious mental health condition that causes a persistent feeling of sadness and loss of interest). During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 5/27/2026, the MDS indicated Resident 6's cognitive skills (ability to make daily decisions) were intact. The MDS indicated Resident 6 was independent with toileting hygiene, upper and lower body dressing, and putting on/taking off footwear. Resident 6 required set up or clean up (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for personal hygiene. Resident 6 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with showering. During a review of Resident 6's History and Physical (H&P), dated 2/20/2026, the H&P indicated Resident 6 did not have the capacity to understand and make decisions. During a review of Resident 6's SBAR Communication Form (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 6/2/2026, the SBAR indicated Resident [6] verbalized that [Resident 6] was hit by [another] resident on the chest. During an interview on 6/4/2026 at 12:15 pm with Resident 6, Resident 6 stated Resident 5 had hit Resident 6 once on the chest. B. During a review of Resident 7's AR, the AR indicated the facility originally admitted Resident 7 on 6/1/2026, with diagnoses including schizoaffective disorder, bipolar type (a mental health condition that includes features of both schizophrenia and bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]), and hypertension (high blood pressure). During a review of Resident 7's H&P, dated 6/2/2026, the H&P indicated Resident 7 could make needs known but could not make medical decisions. During a review of Resident 7's SBAR, dated 6/2/2026, the SBAR indicated, Resident [7] verbalized that [Resident 7] was hit by another resident on [the] left front shoulder while using the phone. During an interview on 6/4/2026 at 11:45 am with Resident 7, Resident 7 stated a man hit Resident 7 on Resident 7's left shoulder. During an interview on 6/4/2026 at 3:00 pm with the Social Service Director (SSD), the SSD stated on 6/2/2026 Resident 6 informed the SSD that Resident 6 was hit on the chest by a male resident during the weekend of 5/30/2026 to 5/31/2026. The SSD stated on 6/2/2026 Resident 7 informed the SSD that Resident 7 was hit on Resident 7's left shoulder by a male resident. The SSD stated on 6/2/2026 the SSD notified the Director of Nursing (DON) and the Administrator (ADM) of both incidents. During an interview with the DON on 6/4/2026 at 4:00 pm, the DON stated we did not report the alleged abuse for Resident 6 and 7 within 2 hours as per our P&P. During an interview with the ADM on 6/4/2026 at 4:15 pm, the ADM stated it was the policy of the facility to report allegations of abuse within two hours of being notified of the abuse. The ADM stated the facility was notified on 6/2/2026 of alleged abuse against Resident 6 and Resident 7 but did not report the abuse to the Department within 2 hours of being notified. During a review of the facility's P&P, dated April 2024, the P&P's purpose indicated, To ensure that residents rights are protected by providing a method of investigation and reporting of alleged violations involving mistreatment, neglect, abuse including injuries of unknown sources, unusual occurrences, unauthorized photographs, unauthorized video recordings, unauthorized postings on social media of nursing home residents and misappropriation of resident property. This also includes any physical or chemical restraint not required to treat a resident's symptoms. The P&P's policy indicated, The administrator, or his/her designee, will report each alleged abuse to the Ombudsman's office and the Department of Public Health immediately or within 2 hours.

Based on interview and record review, the facility failed to document in the residents' medical record the transfer report of two of two sampled residents (Residents 6 and 8) to a General Acute Care Hospital (GACH). These deficient practices resulted in incomplete records for Residents 6 and 8 and had the potential to affect the continuity of care.Findings: a. During a review of Resident 6's admission Record (AR), the AR indicated Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy (disease or dysfunction of the brain that alters brain function), spondylolisthesis (a spinal condition where one vertebra slips forward or backward over the one below it), low back pain and polyneuropathy (a condition characterized by damage to multiple peripheral nerves simultaneously). During a review of Resident 6's History and Physical (H&P) dated 11/27/25, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool) dated 2/13/26, the MDS indicated Resident 6 required partial/moderate (helper does less than half the effort) assistance for showers and supervision (helper provides verbal cues and/or touching/steadying and/or contact guard) assistance for upper and lower body dressing, and toileting hygiene. The MDS indicated Resident 6 required setup or clean up (helper sets up or clean up) assistance for oral hygiene and was independent (resident completes the activity by themselves with no assistance from a helper) for eating and personal hygiene. During a review of Resident 6's SBAR (Situation-Background-Assessment-Recommendation) Communication Form dated 4/2/26, the SBAR indicated Resident 6 had a change in condition of generalized pain, weakness, back pain and lethargy. During a review of Resident 6's Physician's Order (PO) dated 4/3/26 at 10:54 AM, the PO indicated to transfer Resident 6 to the GACH related to increased generalized weakness, lower back pain, and status post fall. During a review of Resident 6's Nurses Notes (NN) dated 4/3/26 at 2:32 PM, the NN indicated Resident 6 was transferred to the GACH. During a review of Resident 6's Notice of Transfer/Discharge to the Ombudsman (an official appointed to investigate individuals' complaints) dated 4/3/26, the notice indicated Resident 6's transfer or discharge was necessary for Resident 6's welfare and Resident 6's needs could not be met in the facility. During a record review of Resident 6's entire medical record (MR) in the presence of Licensed Vocational Nurse 4 (LVN 4) on 4/9/26 at 1:50 PM, there was no documented evidence indicating that the facility staff gave/provided a transfer report to the GACH for Resident 6's transfer on 4/3/26. During an interview on 4/9/2026 at 1:53 PM with LVN 4, LVN 4 stated that when a resident was transferred out to the hospital, nursing staff should call the hospital and give an endorsement report. LVN 4 stated the nursing staff should document that information in the resident's medical chart. LVN 4 stated it was important to keep a copy of the report in the resident's chart to ensure there was documentation of the hospital transfer report. During an interview with the Director of Nursing (DON) on 4/9/2026 at 2:02 PM, the DON stated the Charge Nurse (CN) or Supervisor were responsible for documenting the resident's transfer information. The DON stated nursing staff needed to document the actual report that was given to the hospital and leave a copy in the resident's chart. The DON stated if the report was not in the chart, then there was no record of the resident's transfer report. The DON stated the nursing staff who called the GACH for endorsement also needed to document when and to whom the report was given. The DON stated it was important to have transfer documentation because it included critical information given to the hospital staff that could potentially reduce errors in providing care to the residents. During a review of the facility's Policies & Procedure (P&P) titled, Discharging the Resident, revised 9/2017, the P&P indicated if the resident is being discharged to a hospital or another facility, ensure that a transfer summary is completed and that a telephone report is made to the receiving facility. b. During a review of Resident 8's AR, the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including a gastrostomy (creation of an artificial external opening into the stomach for nutritional support) and dementia (a progressive state of decline in mental abilities). During a review of Resident 8's H&P dated 1/20/2026, the H&P indicated Resident 8 was recently hospitalized for poor oral intake for the past one week. During a review of Resident 8's PO dated 1/5/2026 at 7:38 pm, the PO indicated Resident 8 will be transferred to a GACH for poor intake (eating/drinking) and unable to swallow food/pocketing. During a review of Resident 8's NN dated 1/5/2026 at 11:00 pm, the NN indicated Resident 8 was transferred out of the facility at 9:30 pm via ambulance to a GACH. During a concurrent interview and record review on 4/9/2026 at 10:45 am with Licensed Vocational Nurse 4 (LVN 4), Resident 8's entire MR were reviewed. Resident 8's MR did not indicate transfer report documents for 1/5/2026. LVN 4 stated, LVN 4 did not find the transfer packet that should be in the resident's medical record which showed the resident left the facility, the location where the resident was sent, the reason for transfer, proof of notifications, and the resident's skin assessment. During an interview on 4/9/2026 at 2:02 pm with the DON, the DON stated the transfer documents were completed by the charge nurse or supervisor. The DON stated the nursing staff needed to document the actual report given to the hospital and maintain a copy in the resident's chart. The DON stated if the documents were not in the resident's medical record, the facility did not have any records of when and to whom the transfer report was given. During a review of the facility's policy and procedure (P&P) titled, Discharging the Resident, last dated 9/2017, the P&P indicated when the resident was discharged to a hospital or another facility, staff should ensure a transfer summary was completed and that a telephone report was made to the receiving facility. The P&P indicated, staff assessed and documented the resident's condition at discharge, including skin assessment, if medical condition allowed.

Based on observation, interview, and record review, the facility failed to promote and treat two of two sampled residents (Residents 9 and 37) with respect, privacy and dignity in accordance with the facility's policy and procedure (P&P) titled Resident Right to Dignity and Privacy. These failures had the potential to cause psychosocial (mental and emotional well-being) decline and low self-esteem.Findings: a. During a review of Resident 9's admission Record (AR), the AR indicated Resident 9 was admitted to the facility on [DATE] with diagnoses including a gastrostomy (creation of an artificial external opening into the stomach for nutritional support) and Parkinson's Disease (a progressive disease marked by tremor, muscular rigidity, and slow, imprecise movements) without dyskinesia (uncontrolled movements). During a review of Resident 9's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 2/27/2026, the MDS indicated Resident 9 had severely impaired cognition (ability to understand) for daily decision making. The MDS indicated Resident 9 was dependent (helper did all the effort) on staff for oral hygiene, toileting, lower body dressing, putting on/taking off footwear, and personal hygiene. During an observation on 4/8/2026 at 8:20 am in Resident 9's room, Licensed Vocational Nurse 2 (LVN 2) pulled up Resident 9's gown and assessed Resident 9's gastrostomy tube (GT) site. LVN 2 did not pull and close the privacy curtain to provide Resident 9's privacy exposing Resident 9's abdominal area to the two roommates present in the room. During an observation on 4/8/2026 at 8:34 am, LVN 2 performed the medication pass and did not pull Resident 9's privacy curtain completely, leaving the resident's abdomen exposed to two roommates in the room. b. During a review of Resident 37's AR, the AR indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (brain dysfunction caused by diseases or toxins in the body) and dementia (a progressive state of decline in mental abilities) with other behavioral disturbances. During a review of Resident 37's MDS dated [DATE], the MDS indicated Resident 37 was rarely/never understood. The MDS indicated Resident 37 was dependent on staff for oral hygiene, toileting, lower body dressing, putting on/taking off footwear, and personal hygiene. During an observation on 4/8/2026 at 8:54 am, LVN 2 did not pull Resident 37's privacy curtain and Resident 37's door remained open during the medication pass, leaving the resident exposed to anyone passing in the hallway. During an interview on 4/8/2026 at 9:06 am with LVN 2, LVN 2 stated LVN 2 forgot to close the privacy curtains for Residents 9 and 37 and they should have been closed for privacy reasons to respect the residents' dignity during any procedures. During an interview on 4/9/2026 at 3:54 pm with the Director of Nursing (DON), the DON stated the nursing staff should pull the curtain closed for resident's privacy and dignity during any care given to a resident. During a review of the facility's P&P titled, Resident's Right to Dignity and Privacy, dated 9/2017, the P&P indicated Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect and individuality. Facility staff promotes, maintains, and protects resident privacy, including bodily privacy, when assisting with personal care and during treatment procedures.

Based on interview and record review, the facility failed to accurately date a resident's Care Plan (CP) for one of one sampled resident (Resident 16). This failure resulted in inaccurate documentation and had the potential to negatively impact the resident's quality of care.Findings: During a review of Resident 16's admission Record (AR), the AR indicated Resident 16 was admitted to the facility 3/5/2026 with diagnoses including metabolic encephalopathy (brain dysfunction caused by chemical or metabolic imbalance), bipolar disorder (mental health condition characterized by extreme mood swings), and depression (persistent sadness). During a review of Resident 16's History & Physical (H&P) dated 3/5/2026, the H&P indicated Resident 16 had fluctuating capacity to understand and make decisions. During a review of Resident 16's Minimum Data Set, dated [DATE], the MDS indicated Resident 16 had intact cognition (ability to think and process information) and required partial/moderate assistance to walk 10 feet (ft). During a concurrent interview and record review on 4/9/2026 at 3:03 p.m., Resident 16's Elopement Risk Care Plan dated of 3/6/2026 was reviewed with the Director of Nursing (DON). The DON stated the incorrect date was indicated by her as 3/6/2026 on the Elopement Risk Care Plan update. The DON stated the correct date should be 4/6/2026, the date of Resident 16's elopement. During a review of the facility's Policy and Procedure (P&P), titled, Documentation Principles, revised February 2018, the P&P indicated it is the policy of the facility that resident's clinical records shall be current and kept in detail consistent with good medical and professional practice based on the care provided to each resident. Entries must be accurate, timely, objective, specific, concise, legible, clear and descriptive.

Based on observation, interview, and record review, the facility failed to follow its policy to complete and post the nurse staffing information hours at the start of each shift. On 4/7/26, the facility did not post the nurse staffing information for the current dates and did not indicate the total number of projected hours and the actual hours of licensed and unlicensed nursing staff directly responsible for resident care per shift. This deficient practice violated the residents' right and had the potential to inaccurately reflect the actual nurses providing direct care to the residents.Findings:During a general observation at the entrance of the facility's notice board across nurse's station 1 on 4/7/26 at 9:01 AM, the Census and Direct Care Service Hours Per Patient Day (NHPPD) posted dated 4/6/26 and 4/7/26 were not updated or completed. During an interview and record review (RR) with the Director of Staff Development (DSD) on 4/09/2026 at 3:30 PM, the DSD stated the NHPPD dated 4/6/26 and 4/7/26 were not completed. DSD stated the DSD was the staff responsible to complete the nurse staffing information, but the document was being submitted by Payroll Staff (PS). During a concurrent interview with the DSD on 4/09/2026 at 3:51 PM, the DSD stated the NHPPS document was supposed to be completed and posted in the morning before 8:00 AM and the form must be completed daily. The DSD stated it was important to have the NHPPD document completed daily so staff, visitors and residents could see that the facility had enough staff to provide the care for the residents. During an interview and RR with PS on 4/09/2026 at 4:02 PM, PS stated the PS would completed the NHPPD document the next day around 12:00 PM. PS stated PS was the one to calculate the hours including the nightshift. The PS stated it was important to have an updated NHPPD so that anyone visiting the facility could see the actual and projected hours the nurses were providing care. The PS stated the NHPPD documents that had been posted dated 4/6/26 and 4/7/26 were incomplete and only had the projected hours but not the actual hours. During an interview with License Vocational Nurse (LVN1) on 4/09/2026 at 4:30 PM, LVN1 stated it was important to have the NHPPD document updated daily so the residents were aware of the actual hours they received care in the facility. LVN1 also stated it was important for staff to have access to a completed NHPPD to see if the facility was following the safe patient staffing ratios. During an interview with the Director of Nursing (DON) on 4/10/2026 at 8:00 AM, the DON stated the NHPPD documents should be completed and posted early in the morning at the beginning of the day shift. The DON stated that the PS assigned to completing the NHPPD should prioritize completing the NHPPD as one of the first tasks at the beginning of the shift. The DON stated the importance of the NHPPD was so residents, staff and visitors could have information of the staffing for the day. The DON also stated that the NHPPD also served as a record to verify that the staff listed as working were actually present and provided the resident care daily and for every shift. A review of the facility's policy and procedure titled, Staffing Nurse Information reviewed January 2017, indicated, It is the policy of the facility to post nurse staffing information daily.A. The Facility will post the following information daily at the beginning of each shifti. Facility nameii. The current dateiii. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift.

Based on interview and record review, the facility failed to monitor behavior for a high-risk elopement (a resident with an increased risk of leaving a supervised care facility) resident to prevent an elopement (patient leaves a healthcare facility without authorization or proper discharge) for one of one resident (Resident 16). This deficient practice resulted in Resident 16 eloping from the facility. Findings:During a review of Resident 16's admission Record (AR), the AR indicated Resident 16 was admitted to the facility 3/5/2026 metabolic encephalopathy (brain dysfunction), bipolar disorder (mental health condition characterized by extreme mood swings), and depression (persistent sadness). During a review of Resident 16's History & Physical (H&P), dated 3/5/2026, the H&P indicated Resident 16 had fluctuating capacity to understand and make decisions.During a review of Resident 16's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/9/2026, the MDS indicated Resident 16's cognition (ability to think and process information) was intact and had neurological conditions and required partial/moderate assistance to walk 10 feet (ft).During a record review of Resident 16's Elopement/Wander Risk Assessment, dated 3/5/26, Resident 16 had a score above 10, indicating Resident 16 was at a high risk for elopement. The Elopement/Wander Risk Assessment indicated Resident 16 had a history of 5150 (qualified officers or clinicians to involuntarily detain a person for a 72-hour mental health psychiatric hold), verbalizing wanting to go home, and closely monitored (monitor for one-to-one monitoring).During a record review of Resident 16's Elopement Risk Assessments Care Plan (ERCP), dated 3/5/26, the ERCP indicated Resident 16's elopement risk score was above 10 (high-risk) and frequent staff monitoring of resident's whereabouts.During a concurrent observation and interview, on 4/9/26, at 2:28 p.m., with the Director of Nursing (DON), an off-white-colored outside gate was observed. The DON stated the facility exit door at the back of the facility was thought to be used by Resident 16 to elope. The DON stated the facility exit door is not locked because the residents walk around the back outside area of the facility. The DON stated they think Resident 16 may have stepped on some piping observed on the ground nearby the gate and jumped over. The DON stated Resident 16 was supposed to wait for the ambulance to be transferred to the hospital and Resident 16 kept yelling and cursing at the staff. The DON stated Resident 16 was gone from the facility for about one hour and was returned to the facility by the Police Department.During a concurrent interview & record review of the Wandering Care Plan, on 4/9/26, at 3:03 p.m., with the DON, the Care Plan indicated frequent monitoring but did not indicate the frequency. The DON stated but the frequent is every hour. The DON stated the Behavior Monitoring form is used to document frequent monitoring of a resident. The DON stated the DON did not remember if the DON gave the nursing staff this form to complete for Resident 16. The DON stated that the monitoring of elopement and behavior for Resident 16 was not continuously or regularly done because they did not have the form. The DON stated there was not consistent documentation of Resident 16's whereabouts. The DON stated monitoring of Resident 16's behavior for increased wandering and exit seeking behaviors was not being monitored and documented. The DON stated monitoring was important because Resident 16 may not have been able to elope.During a record review of the facility's Policy and Procedures (P&P, titled Wandering/Exit Seeking Behavior, revised September 2019, indicated the facility will evaluate for wandering and/or exit seeking behavior and implement appropriate interventions as indicated via the evaluation process. If the resident exhibits wandering/and or exit seeking behavior, the episodes should be documented in the progress notes of the medical record. Documentation should include interventions used and their effectiveness.

Based on interview and record review, the facility failed to ensure the policy and procedure (P&P) on Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) was implemented for one of one sampled resident (Resident 37) by failing to ensure Resident 37's AD Acknowledgment Form (ADAF) was updated to reflect whether the resident had an AD. This failure had the potential for the facility staff to provide medical treatment and services against the will of the residentFindings: During a review of Resident 37's admission Record (AR), the AR indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (brain dysfunction caused by diseases or toxins in the body) and dementia (a progressive state of decline in mental abilities) with other behavioral disturbance. During a review of Resident 37's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 3/12/2026, the MDS indicated Resident 37 was rarely/never understood. The MDS indicated Resident 37 was dependent (helper did all the effort) on staff for oral hygiene, toileting, lower body dressing, putting on/taking off footwear, and personal hygiene. During a concurrent interview and record review on 4/7/2026 at 3:57 pm with Registered Nurse Supervisor 1 (RN 1), Resident 37's ADAF dated 7/30/2025 was reviewed. Resident 37's ADAF indicated Resident 37 had executed an AD and also indicated Resident 37 had not executed an AD. RN 1 stated, the statements in the ADAF were conflicting and the nursing staff would not know if Resident 37 had an AD or not. RN 1 stated, it was important to know whether Resident 37 had an AD to allow nursing staff to know how to care for Resident 37 when Resident 37 was unable to make decisions or when incapacitated during emergencies. During a concurrent interview and record review on 4/8/2026 at 11:23 am with the Social Services Director (SSD), Resident 37's ADAF dated 7/30/2025 was reviewed. Resident 37's ADAF indicated Resident 37 had executed an AD and also indicated Resident 37 had not executed an AD. The SSD stated Resident 37's ADAF needed to be clarified because one portion stated Resident 37 had an AD and the other stated Resident 37 did not have an AD. The SSD stated the ADAF needed to be accurate to determine if the resident had an AD. During an interview on 4/9/2026 at 3:55 pm with the Director of Nursing (DON), the DON stated the ADAF indicated whether the residents had an AD or not. The DON stated when both statements were checked on the ADAF, staff were unable to determine if the resident had an AD or not. The DON stated Resident 37's ADAF was confusing and the nursing staff would not be able to determine if Resident 37 had an AD or not. During a review of the facility's P&P titled, Advance Directives, revised 4/2017, the P&P indicated a resident may develop an AD relative to his/her refusal of medical or surgical treatment, which will be followed in accordance with this P&P and current State law.

Based on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services when one pill was found lying on the hallway floor. This failure had the potential to result in a resident taking the pill and leading to adverse side effects (unwanted undesirable effects that are related to a drug).Findings: During an observation on 4/7/2026 at 12:37 pm in the hallway across from Nursing Station 1, one small, round, white pill was on the hallway floor. There were two nurses in Nursing Station 1, other staff and residents were walking through the hall. During a concurrent observation and interview on 4/7/2026 at 12:41 pm with Registered Nurse Supervisor 1 (RN 1) in the hallway across from Nursing Station 1, the small, round, white pill was observed on the floor. RN 1 went to retrieve a glove to pick it up and stated, there shouldn't have been a pill on the floor. RN 1 stated, a resident could have picked it up, eaten it, and some harm could've occurred to the resident depending on what the medication was. RN 1 stated, RN 1 was unsure what the pill was and would properly dispose of it. During an interview on 4/9/2026 at 3:51 pm with the Director of Nursing (DON), the DON stated, there shouldn't be any medication on the floor because the nurse should ensure the medication was taken by the resident. The DON stated, there were confused residents who resided in the facility, one of them could have taken the pill and the staff wouldn't know what was affecting the resident. The DON stated, it was an unsafe situation for the residents. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated 4/2008, the P&P indicated medications and biologicals were stored safely, securely, and properly. The P&P indicated the medication supply was accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. During a review of the facility's policy and procedure (P&P) titled, Facility Guidelines, dated 3/2019, the P&P indicated medications were stored in locked areas.

Based on observation, interview and record review, the facility failed to encode the resident's bilateral bolster wedge cushions (used to offer support to various parts of the body) on the Minimum Data Set (MDS- a resident assessment and care screening tool) dated 2/26/2026 as a restraint for one of one sampled resident (Resident 3). This violation had the potential to negatively impact Resident 3's quality of care. Findings: During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility 8/1/2024 and readmitted on [DATE] with the diagnoses including dementia (decline in mental ability), bipolar disorder (mental health condition characterized by extreme mood swings), and depression (persistent sadness). During a review of Resident 3's History & Physical (H&P) dated 1/13/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 2/26/2026, the MDS indicated Resident 3's cognition (ability to think and process information) was severely impaired (never/rarely made decisions) and Resident 3 was dependent (helper does all the effort) on staff for eating, oral and toileting hygiene, showers, upper and lower body dressing. During a review of Resident 3's Order Summary Report (OSR) dated 1/12/2026, the OSR indicated for staff to apply bilateral bolster wedge cushion in bed as enabler (support) to assist Resident 3 to identify the edge of the bed due to poor safety awareness and unsafe self-positioning. During a review of Resident 3's undated Informed Consent (IC) signed by Resident 3's Responsible Party (RP), the IC indicated a proposed treatment for bilateral booster wedge cushion in bed as enabler to assist the resident to identify the edge of the bed due to poor safety awareness and unsafe self-positioning. During an observation of Resident 3 inside Resident 3's room on 4/7/2026 at 9:34 AM, Resident 3 was resting in bed with bilateral pillow wedges placed on each side of Resident 3. During an interview and record review (RR) with the Minimum Data Set Consultant (MDSC) in the presence of the Administrator (ADM) and Administrative Assistant (AA) on 4/8/26 at 3:00 PM, the MDSC stated bilateral bolster wedge cushions were considered to be restraints and had not been coded in Resident 3's MDS. The MDSC stated the MDS Nurse should have coded the bilateral bolster wedge cushion for Resident 3 as restraints since there was a physician's order. The MDSC stated the bilateral bolster wedge cushions were considered restraint since it was used to limit Resident 3's movements. During an interview and RR with the MDS Nurse on 4/8/26 at 3:07 PM, the MDS Nurse stated there was a signed restraint consent form in Resident 3's chart for the bilateral bolster wedge cushions but the MDS Nurse did not consider the bilateral bolster wedge cushions as restraints. The MDS Nurse stated before coding the bilateral bolster wedge cushions as a restraint in the MDS, the MDS Nurse should have clarified with the nursing staff. During an interview with Licensed Vocational Nurse 4 (LVN 4) on 4/8/2026 at 3:30 PM, LVN 4 stated the bilateral bolster wedge cushions for Resident 3 were used because Resident 3 would wiggle out of bed and the bilateral cushions prevented Resident 3 from having a fall. During an interview and RR with Registered Nurse 1 (RN1) on 4/8/2026 at 3:39 PM, RN1 stated Resident 3 had a physician's order for restraints and RN1 confirmed there was a care plan and a consent form signed by Resident 3's RP specifically for restraints. RN1 stated the bilateral bolster wedge cushions should have been coded as restraints in Resident 3's MDS. During an interview with the Director of Nursing (DON) on 4/8/2026 at 4:00 PM, the DON stated the purpose of the MDS was to document a complete assessment of a resident. The DON stated if Resident 3 had a restraint order, then it should have been coded in Resident 3's MDS. The DON stated the MDS nurse was responsible for completing the documentation. The DON stated if the restraints were not coded, then the medical record would not show the interventions for Resident 3, and the nurses would not know if they needed monitoring and/or precautionary measures for Resident 3. During an interview and RR with License Vocational Nurse 3 (LVN 3) on 4/8/2026 at 4:15 PM, LVN 3 stated bilateral bolster wedge cushions were ordered as a restraint for Resident 3. LVN 3 stated there was an order, care plan and a restraint consent that was signed for bilateral bolster wedge cushion in Resident 3's chart. LVN 3 stated it was important to have the restraints coded in the MDS because nursing staff needed access to that information for interventions and monitoring. LVN 3 stated if the restraints were not coded in the MDS then that information was not being communicated to the staff so they could provide the care, interventions and monitoring Resident 3 needed. During a concurrent interview and RR with LVN 4 on 4/9/2026 at 9:13 AM, LVN 4 stated the consent and care plan for Resident 3 indicated the bilateral bolster wedge cushion was a restraint. LVN 4 stated LVN 4 was the one who had Resident 3's RP sign the consent for the bilateral bolster wedge cushions since the resident was at risk for falls. LVN 4 stated the resident would tend to wiggle and try to get out of bed and could suffer a fall. LVN 4 stated Resident 3 had a history of a fall and it was necessary for Resident 3 to have the bilateral booster wedges in place to help prevent a fall. During a review of the facility's Policy and Procedure (P&P), titled Resident Assessment Instrument (RAI) Process, revised 4/2017, the P&P indicated the facility will utilize the Resident Assessment Instrument (RAI) process for the accurate assessment of each resident's functional capacity and health status. During a review of the facility's P&P titled, Physical Restraints, revised September 2017, the P&P indicated, It is the policy of the facility that restraints will only be used after other alternatives have been tried unsuccessfully and only with a thorough assessment, informed consent from the resident or their responsible party, a physician's order and a plan of care to address the use of the restraint. Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. If a resident cannot mentally or physically self-release, then the device is considered a restraint.

Based on interview and record review, the facility failed to revise the Care Plan (CP) for Fall for one of one sampled resident (Resident 1). This deficient practice resulted in a care plan that was not individualized, placing the resident at risk for preventable falls. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including pneumonia (lung infection), acute and chronic respiratory failure with hypoxia (life-threatening, sudden worsening of gas exchange with long-term lung disease), and abnormalities of gait and mobility (deviations from normal walking). During a review of Resident 1's History & Physical (H&P) dated 12/31/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 2/27/2026, the MDS indicated Resident 1 had intact cognition (ability to think and process information) and required supervision or touch assistance with sit to stand and walk 10 to 50 feet with two turns. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR) dated 1/23/2026, the SBAR indicated Resident 1 had an unwitnessed fall. During a concurrent interview and record review on 4/9/2026 at 12:05 p.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated Resident 1 had a fall and the interventions included more monitoring for Resident 1. LVN 4 stated Resident 1 used Resident 1's wheelchair to ambulate. During a review of Resident 1's At Risk for Falls Care Plan dated 12/30/2025 and Actual Fall Care Plan dated 1/22/2026 and 1/23/2026, LVN 4 stated Resident 1's Care Plans did not have any revisions. During a concurrent review and interview on 4/9/2026 at 2:19 p.m., with the Director of Nursing (DON), Resident 1's At Risk for Falls Care Plan and Actual Fall Care Plans dated 1/22/2026 & 1/23/2026 were reviewed. The DON stated the Care Plans were not revised and should have been revised. The DON stated it was important to revise the Care Plan so that the care will be updated and prevent further falls for the residents. During a review of the facility's Policy and Procedure (P&P), titled, Comprehensive Care Planning, revised March 2019, the P&P indicated the care plan must be reviewed and revised periodically, at least quarterly, and on an ongoing basis to reflect changes in the resident and the services provided or arranged must be consistent with each resident's written plan.

Based on observation, interview, and record review, the facility failed to ensure six of 23 resident rooms (Rooms 2, 8, 10, 11, 15, and 16) met the square footage requirement of 80 square feet (sq. ft.) per resident in multiple resident rooms. This failure had the potential for these rooms to lack enough space for activities of daily living and hinder staff from providing care to these residents.Findings: During observation of the facility on 4/7/2026 at 9:11 am to 10:21 am, Rooms 2, 8, 10, 11, 15, and 16 did not meet the minimum requirement of 80 sq. ft. per resident. The residents in these rooms were able to ambulate freely and/or maneuver in their wheelchairs freely. Nursing staff had enough space to provide care to these residents with dignity and privacy. There was space for beds, side tables, dressers and other medical equipment. During an interview with the Administrator on 04/10/2026 at 10:02 am with the Administrator (ADM), ADM stated the facility submitted a room size requirement waiver for Rooms 2, 8, 10, 11, 15, and 16.During a review of the facility's room waiver request letter dated 4/9/2026, the room waiver letter indicated there was enough space for nursing care and the health and safety of the residents occupying these rooms were not in jeopardy (harm). The room waiver letter indicated these rooms were in accordance with the needs of the residents and would not have an adverse effect on the residents' health and safety or impede the ability of any residents to attain his or her highest practicable well-being. The room waiver letter indicated the following measurements: RoomBedsSq. Ft.24286.9282151.40102152.24112151.92152147.50162147.50 The minimum square footage for a 2-bedroom is 160 sq. ft. The minimum square footage for a 4-bedroom is 320 sq. ft. During interviews with the residents both individually and collectively during the recertification survey (4/7/2026-4/10/2026), the residents did not express any concerns regarding the size of their rooms.

Based on interview and record review, the facility failed to administer Depakote (a medication used to help control mood symptoms and behavior issues) per the physician's order for one of three sampled residents (Resident 1). This violation had the potential to compromise Resident 1's health and safety.Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 1/9/2026 and readmitted Resident 1 on 3/20/2026 with diagnoses including dementia (a progressive state of decline in mental abilities) and schizophrenia (a mental illness that was characterized by disturbances in thought). During a review of Resident 1's History and Physical (H&P) dated 1/10/2026, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 1/13/2026, the MDS indicated Resident 1 had severely impaired cognition (ability to understand). The MDS indicated Resident 1 was independent with eating, oral hygiene and personal hygiene. The MDS indicated Resident 1 required moderate assistance (helper did less than half the effort) from staff with toileting hygiene, showering/ bathing, and bed-to-chair transferring. During a review of Resident 1's Order Summary Report (OSR) dated 3/20/2026, the OSR indicated a physician's order to administer Depakote three times a day for angry outburst. During an interview on 4/1/2026 at 3:32 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she did not administer Depakote to Resident 1 on 3/21/2026, 3/22/2026, and 3/23/2026 on the morning shifts. LVN 1 stated Resident 1's Depakote was not available in the medication cart and was pending pharmacy delivery. During an interview on 4/2/2026 at 11:21AM with LVN 2, LVN 2 stated it was important to administer Depakote for Resident 1's anger outburst, because it was what the physician ordered and part of the care plan. LVN 2 stated missing seven out of eight doses of Depakote would increase the risk of uncontrolled behavior. LVN 2 stated the licensed nurse should have checked with the pharmacy to obtain the Depakote from the emergency kit while waiting for the Depakote delivery. During a concurrent interview and record review on 4/2/2026 at 12:34 PM with the Director of Nursing (DON), Resident 1's March 2026 Medication Administration Record (MAR) was reviewed. The MAR indicated Resident 1 did not receive Depakote at 9 AM on 3/21/2026, 3/22/2026, and 3/23/2026. The MAR indicated Resident 1 did not receive Depakote at 1 PM on 3/21/2026, 3/22/2026, and 3/23/2026. The MAR indicated Resident 1 did not received Depakote at 5 PM on 3/22/2026. The DON stated the Depakote was part of Resident 1's psychotropic medication combination for behavioral management. The DON stated Resident 1 should have received Depakote per the physician's order because it was part of the plan of care. The DON stated it was not acceptable that the licensed nurse did not administer Depakote to Resident 1. The DON stated it was important for Resident 1 to receive Depakote because of safety. During a review of the facility's Policy and Procedure (P&P) titled Medication Ordering And Receiving From Pharmacy, dated 4/2008, the P&P indicated medications were received from the dispensing pharmacy on a timely basis. The P&P indicated if the new medications were needed before the next regular delivery, staff should inform the pharmacy of the need for prompt delivery. The P&P further indicated that the staff should use the emergency kit or emergency drug supply, as applicable, when the resident needed a medication prior to pharmacy delivery. During a review of the facility's P&P titled Medication Administration, dated 4/2025, the P&P indicated the licensed nurse must administer medications in accordance with the physician orders. The P&P further indicated that the licensed nurse must administer medications within one hour before or after their prescribed time.

Based on interview, and record review, the facility failed to ensure a safe and orderly transfer or discharge from the facility for three of ten sampled residents (Resident 1, Resident 3, and Resident 19) by failing to ensure:1. not discharge Resident 1 to another same level care Skilled Nursing Facility (SNF) 2 without physician's order, indicating the appropriate reason for discharge and providing Notice of Transfer/Discharge (NTD) to the resident to obtain a consent from the resident prior to discharge on [DATE].2. not discharge Resident 3 to another same level care SNF 3 without indicating the reason for discharge and providing NTD to the resident to obtain a consent prior to discharge 11/21/2025.3. not discharge Resident 19, who needs assistance for dressing and personal hygiene upon discharge, to an Independent Living Home (ILH) 1 on 8/1/2025, which does not meet the resident's needs.These deficient practices violated Residents 1, 3 and 19's rights and had the potential to result in impairing Residents 1, 3, and 19's physical, mental, and psychosocial well-being, and possible readmission of Resident 19.(cross reference F628)Findings:1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 9/10/2025 with diagnoses including depression (a serious mood disorder causing persistent sadness, loss of interest, and impacting feeling, thinking, and acting, affecting daily life and leading to emotional/physical problems like fatigue, sleep issues, and hopelessness), anxiety disorder (a mental health condition causing excessive, persistent fear and worry disproportionate to the situation), abnormalities of gait and mobility, and schizophrenia (a mental illness that is characterized by disturbances in thought). The AR indicated that Resident 1's responsible party (RP) is resident self. During a review of Resident 1's History and Physical (H&P), dated 9/11/2025, the H&P indicated that the resident could make needs known but cannot make medical decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 9/16/2025, the MDS indicated Resident 1 was mildly impaired in cognitive skills (ability to make daily decisions). The MDS indicated the resident required partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, shower/bathe self, upper and lower body dressing, and personal hygiene. The MDS indicated the resident required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating and oral hygiene.During a review of Resident 1's Order Summary (OS), dated 12/5/2025, the OS indicated discharge resident with home health and did not indicate the facility or location where Resident 1 would be discharged . The OS indicated there was no physician order to discharge Resident 1 to SNF 2. During a review of Resident 1's NTD, dated 12/5/2025, the NTD indicated the reason for transferring or discharging Resident 1 to SNF 2 is resident's health had improved sufficiently so that no longer require services provided by the facility. The NTD indicated there is no resident/representative's signature to verify the facility provided the NTD to Resident 1 to get a consent prior to discharge. During a phone interview on 12/9/2025 at 3:43 PM with Resident 1, Resident 1 stated Resident 1 did not get the NTD form to sign prior to his discharge on [DATE] to SNF 2. Resident 1 stated Resident 1's discharge goal was to be discharged to a lower-level care facility, not the same level care SNF. During an interview on 12/9/2025 at 2:44 PM with the Marketer/Designated Social Service (DSS), the DSS stated the DSS did not provide the NTD form to Resident 1 prior to Resident 1's discharge on [DATE]. During an interview on 12/10/2025 at 2:55 PM with the Registered Nurse (RN) 2, RN 2 stated RN 2 did not provide the NTD form to Resident 1 prior to Resident 1's discharge on [DATE].During an interview on 12/10/2025 at 3:39 PM with the Social Service Director (SSD), the SSD stated it was social service's responsibility to assess the discharge goal and do the discharge plan for residents. The SSD stated Resident 1's discharge plan was to be discharged to a lower-level care facility, not another SNF since admission until 12/4/2025. During a concurrent interview and record review on 12/12/2025 at 10:28 PM with the Assistant Director of Nursing (ADON), Resident 1's NTD form, dated 12/5/2025, was reviewed. The ADON stated the reason for discharge Resident 1 is The transfer or discharge is appropriate because your health has improved sufficiently so that you no longer required services provided by this facility and there was no resident's signature to verify the consent on the NTD form. The ADON stated Resident 1's discharge plan was to be discharged to a lower-level care facility on 12/5/2025. The ADON stated SNF 2 is the same level care facility as this facility, not a lower-level care facility. During a concurrent interview and record review on 12/12/2025 at 3:31 PM with the Director of Nursing (DON), Resident 1's NTD form, dated 12/5/2025, was reviewed. The DON stated Resident 1 is self-responsible and there was no resident's signature to verify the consent to discharge Resident 1 to SNF 2 on 12/5/2025. The DON stated it is important to get resident's signature on the NTD form to make sure residents agree, understand, and involve in the appropriate orientation and preparation for the discharge. The DON stated it is important to follow the discharge process and get an appropriate physician's discharge order to discharge the resident prior to discharge. 2. During a review of Resident 3's AR, the AR indicated Resident was admitted to facility on 11/14/2025 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and schizophrenia. The AR indicated that Resident 3's responsible party (RP) is resident self. During a review of Resident 3's H&P, dated 11/15/2025, the H&P indicated that the resident has the capacity to understand and make decisions.During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 has intact cognitive skills. The MDS indicated that the resident required partial/moderate assistance (Helper does less than half the effort) with toileting hygiene, shower/bathe self and lower body dressing. The MDS indicated the resident was independent with eating, oral hygiene, and personal hygiene.During a review of Resident 3's NTD, dated 11/21/2025, the NTD indicated that there is no reason for transferring or discharging Resident 3 to SNF 3 on 11/21/2025. The NTD indicated there is no resident/representative's signature to verify the facility provided the NTD to Resident 3 to get a consent prior to discharge. During an interview on 12/10/2025 at 2:55 PM with RN 2, RN 2 stated RN 2 did not provide the NTD form to Resident 3 prior to Resident 3's discharge on [DATE].During an interview on 12/10/2025 at 3:39 PM with the SSD, the SSD stated SSD did not provide the NTD form to Resident 3 to obtain the resident's signature prior to Resident 3's discharge on [DATE].During a concurrent interview and record review on 12/12/2025 at 10:28 PM with the ADON, Resident 3's NTD form, dated 11/21/2025, was reviewed. The ADON stated there is no reason checked for discharge Resident 3 and there was no resident's signature to verify the consent on the NTD form on 11/21/2025. During a concurrent interview and record review on 12/12/2025 at 3:31 PM with the DON, Resident 3's NTD form, dated 11/21/2025 was reviewed. The DON stated Resident 3 is self-responsible and there was no reason for Resident 3's discharge and the resident's signature to verify the consent to discharge Resident 3 to SNF 3 on 11/21/2025. The DON stated it is important to clarify the discharge reason and obtain resident's signature on the NTD form to make sure residents agree, understand, and involve in the appropriate orientation and preparation for the discharge. The DON stated it is important to follow the discharge process and ensure an appropriate discharge.3. During a review of Resident 19's AR, the AR indicated Resident 19 was originally admitted to facility on 1/31/2023, readmitted on [DATE] with diagnoses including hypertension (high blood pressure), chronic kidney disease (a long-term condition where kidneys become damaged and can't filter blood effectively, causing waste and fluid buildup), dementia (a progressive state of decline in mental abilities), and schizophrenia.During a review of Resident 19's H&P, dated 3/12/2025, the H&P indicated that the resident does not have the capacity to understand and make decisions.During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 was severely impaired in cognitive skills. The MDS indicated that the resident required partial/moderate assistance with shower/bathe self, personal hygiene and lower body dressing. The MDS indicated the resident required supervision or touching assistance with toileting hygiene and putting on/taking off footwear. During a review of Resident 19's OS, dated 7/31/2025, the OS indicated there is an order to discharge the resident to ILH 1 with home health. During a review of Resident 19's Discharge Summary/Comprehensive Assessment (DSCA), dated 8/1/2025, the DSCA indicated that Resident 19 needs assist on dressing and personal hygiene upon discharge on [DATE].During an interview on 12/12/2025 at 10:55 AM with the SSD, the SSD stated that Resident 19 needs assistance on activities of daily living (ADL- referring to basic self-care tasks like eating, bathing, and dressing, vital in healthcare for assessing patient needs) and it is inappropriate to discharge Resident 19 to ILH 1.During a concurrent interview and record review on 12/12/2025 at 3:31 PM with the DON, Resident 19's OS, dated 7/31/2025, was reviewed. The DON stated Resident 19's OS is discharging the resident to ILH 1 with home health. The DON stated it is important to follow the discharge process and ensure the resident is independent on ADL to discharge the resident to ILH to ensure an appropriate discharge.During a review of the facility's policy and procedure (P&P) titled, Discharge Process, revised 10/2017, the P&P indicated that The discharge planning process must focus on discharge planning goals and should prepare a resident to be an active partner is their post-discharge care and the transition process in an attempt to reduce factors leading to preventable readmission. The P&P indicated, Before the facility transfers or discharges a resident, the facility will notify the resident and the resident's representatives of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The P&P indicate, The facility will provide and document sufficient preparation and orientation to residents for transfer or discharge to ensure a safe and orderly transfer or discharge from the facility in a form and manner that the resident can understand. During a review of the facility's policy and procedure (P&P) titled, Notice Before Transfer of a Resident, revised 5/2016, the P&P indicated that the written notice of transfer or discharge must include The reason for transfer or discharge; The effective date of transfer or discharge; The location to which the resident is to be transferred or discharged .

Based on interview, and record review, the facility failed to ensure document the appropriate content on the Notice of Transfer/Discharge (NTD) form for three of ten sampled residents (Resident 1, Resident 3, and Resident 19) by failing to ensure:1. indicate the appropriate reason to transfer Resident 1 to another same level care Skilled Nursing Facility (SNF) 2 on 12/5/2025.2. indicate the appropriate reason to transfer Resident 3 to another same level care SNF 3 on 11/21/2025.3. indicate the location of an Independent Living Home (ILH) 1, where Resident 19 was transferred on 8/1/2025.These deficient practices result in inappropriate documentation and placing the resident at risk of misunderstanding the information in the medical records and sufficiently preparing the residents for discharge, which had the potential to impair residents' physical, mental and psychosocial well-being for Resident 1, 3, and 19.(cross reference F627)Findings:1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 9/10/2025 with diagnoses including depression (a serious mood disorder causing persistent sadness, loss of interest, and impacting feeling, thinking, and acting, affecting daily life and leading to emotional/physical problems like fatigue, sleep issues, and hopelessness), anxiety disorder (a mental health condition causing excessive, persistent fear and worry disproportionate to the situation), abnormalities of gait and mobility, and schizophrenia (a mental illness that is characterized by disturbances in thought). The AR indicated that Resident 1's responsible party (RP) is resident self. During a review of Resident 1's History and Physical (H&P), dated 9/11/2025, the H&P indicated that the resident could make needs known but cannot make medical decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 9/16/2025, the MDS indicated Resident 1 was mildly impaired in cognitive skills (ability to make daily decisions). The MDS indicated the resident required partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, shower/bathe self, upper and lower body dressing, and personal hygiene. The MDS indicated the resident required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating and oral hygiene.During a review of Resident 1's NTD, dated 12/5/2025, the NTD indicated the reason for transferring or discharging Resident 1 to SNF 2 is resident's health had improved sufficiently so that no longer require services provided by the facility. The NTD indicated that the resident was transferred to a same level care SNF as the facility.During a phone interview on 12/9/2025 at 3:43 PM with Resident 1, Resident 1 stated Resident 1 did not know the reason that the facility transferred Resident 1 on 12/5/2025 to SNF 2. Resident 1 stated Resident 1's discharge goal was to be discharged to a lower-level care facility, not the same level care SNF. During an interview on 12/9/2025 at 2:44 PM with the Marketer/Designated Social Service (DSS), the DSS stated the DSS did not provide the NTD form to Resident 1 prior to Resident 1's discharge on [DATE]. During an interview on 12/10/2025 at 3:39 PM with the Social Service Director (SSD), the SSD stated it was social service's responsibility to assess the discharge goal and do the discharge plan for residents. The SSD stated Resident 1's discharge plan was to be discharged to a lower-level care facility, not another SNF since admission until 12/4/2025. During a concurrent interview and record review on 12/12/2025 at 10:28 PM with the Assistant Director of Nursing (ADON), Resident 1's NTD form, dated 12/5/2025, was reviewed. The ADON stated the reason for discharge Resident 1 is The transfer or discharge is appropriate because your health has improved sufficiently so that you no longer required services provided by this facility. The ADON stated Resident 1's discharge plan was to be discharged to a lower-level care facility on 12/5/2025. The ADON stated SNF 2 is the same level care facility as this facility, not a lower-level care facility. During a concurrent interview and record review on 12/12/2025 at 3:31 PM with the Director of Nursing (DON), Resident 1's NTD form, dated 12/5/2025, was reviewed. The DON stated it is important to check the appropriate reason for transfer and make sure residents agree, understand, and involve in the appropriate orientation and preparation for the discharge. The DON stated it is important to follow the discharge process and document appropriately.2. During a review of Resident 3's AR, the AR indicated Resident was admitted to facility on 11/14/2025 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and schizophrenia. The AR indicated that Resident 3's responsible party (RP) is resident self. During a review of Resident 3's H&P, dated 11/15/2025, the H&P indicated that the resident has the capacity to understand and make decisions.During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 has intact cognitive skills. The MDS indicated that the resident required partial/moderate assistance (Helper does less than half the effort) with toileting hygiene, shower/bathe self and lower body dressing. The MDS indicated the resident was independent with eating, oral hygiene, and personal hygiene.During a review of Resident 3's NTD, dated 11/21/2025, the NTD indicated that there is no reason for transferring or discharging Resident 3 to SNF 3 on 11/21/2025. During a concurrent interview and record review on 12/12/2025 at 10:28 PM with the ADON, Resident 3's NTD form, dated 11/21/2025, was reviewed. The ADON stated there is no reason indicated to transfer Resident 3 to SNF 3 on 11/21/2025. During a concurrent interview and record review on 12/12/2025 at 3:31 PM with the DON, Resident 3's NTD form, dated 11/21/2025 was reviewed. The DON stated Resident 3 is self-responsible and there was no reason for Resident 3's transfer to SNF 3 on 11/21/2025. The DON stated it is important to clarify the discharge reason and make sure residents agree, understand, and involve in the appropriate orientation and preparation for the discharge. The DON stated it is important to follow the discharge process and ensure appropriate documentation.3. During a review of Resident 19's AR, the AR indicated Resident 19 was originally admitted to facility on 1/31/2023, readmitted on [DATE] with diagnoses including hypertension (high blood pressure), chronic kidney disease (a long-term condition where kidneys become damaged and can't filter blood effectively, causing waste and fluid buildup), dementia (a progressive state of decline in mental abilities), and schizophrenia.During a review of Resident 19's H&P, dated 3/12/2025, the H&P indicated that the resident does not have the capacity to understand and make decisions.During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 was severely impaired in cognitive skills. The MDS indicated that the resident required partial/moderate assistance with shower/bathe self, personal hygiene and lower body dressing. The MDS indicated the resident required supervision or touching assistance with toileting hygiene and putting on/taking off footwear. During a review of Resident 19's NTD, dated 8/1/2025, the NTD indicated that there is no location for the ILH 1, where Resident 19 was transferred on 8/1/2025. During an interview on 12/12/2025 at 3:31 PM with the DON, the DON stated it is important to follow the discharge process to complete the NTD form appropriately and ensure residents' understanding and preparation for the discharge. During a review of the facility's policy and procedure (P&P) titled, Discharge Process, revised 10/2017, the P&P indicated, Before the facility transfers or discharges a resident, the facility will notify the resident and the resident's representatives of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The P&P indicate, The facility will provide and document sufficient preparation and orientation to residents for transfer or discharge to ensure a safe and orderly transfer or discharge from the facility in a form and manner that the resident can understand. During a review of the facility's policy and procedure (P&P) titled, Notice Before Transfer of a Resident, revised 5/2016, the P&P indicated that the written notice of transfer or discharge must include The reason for transfer or discharge; The effective date of transfer or discharge; The location to which the resident is to be transferred or discharged .

Based on interview and record review, the facility failed to ensure the residents receive written notice before the resident's room or roommate in the facility being changed for two of seven sampled residents (Resident 1 and Resident 6).These deficient practices violated Resident 1 and Resident 6's rights and had the potential to affect Resident 1 and Resident 6's psychosocial well-being.(cross reference F656)Findings:a. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 9/10/2025 with diagnoses including depression (a serious mood disorder causing persistent sadness, loss of interest, and impacting feeling, thinking, and acting, affecting daily life and leading to emotional/physical problems like fatigue, sleep issues, and hopelessness), anxiety disorder (a mental health condition causing excessive, persistent fear and worry disproportionate to the situation), abnormalities of gait and mobility, and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 1's History and Physical (H&P), dated 9/11/2025, the H&P indicated that the resident could make needs known but cannot make medical decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 9/16/2025, the MDS indicated Resident 1 was mildly impaired in cognitive skills (ability to make daily decisions). The MDS indicated the resident required partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, shower/bathe self, upper and lower body dressing, and personal hygiene. The MDS indicated the resident required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating and oral hygiene.During a review of Resident 1's Notice of Room Change (NORC), dated 12/4/2025, the NORC indicated that Resident 1 had a room change from room [ROOM NUMBER]A to room [ROOM NUMBER]A on 12/4/2025. During a phone interview on 12/9/2025 at 3:43 PM with Resident 1, Resident 1 stated that Resident 1 did not receive any written notice of room change prior to the facility changed Resident 1's room from room [ROOM NUMBER]A to room [ROOM NUMBER]A on 12/4/2025 and Resident 1 did not want the room change.b. During a review of Resident 6's AR, the AR indicated Resident 6 was originally admitted to facility on 1/30/2025, readmitted on [DATE] with diagnoses including abnormalities of gait and mobility, depression, anxiety disorder, hypertension (high blood pressure), and schizophrenia.During a review of Resident 6's H&P, dated 11/27/2025, the H&P indicated that the resident has the capacity to understand and make decisions.During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 was mildly impaired in cognitive skills. The MDS indicated the resident required setup or clean-up assistance (Helper sets up or cleans up; resident completes activity) with toileting hygiene and shower/bathe self. The MDS indicated the resident was independent with upper and lower body dressing and personal hygiene.During a review of Resident 6's NORC, dated 12/5/2025, the NORC indicated that Resident 6 had a room change from room [ROOM NUMBER]A to room [ROOM NUMBER]A on 12/5/2025. During an interview on 12/10/2025 at 9:15 AM with Resident 6, Resident 6 stated Resident 6 did not receive any written notice of room change before the facility changed Resident 6's room from room [ROOM NUMBER]A to room [ROOM NUMBER]A and did not want room change on 12/5/2025. During a concurrent interview and record review on 12/12/2025 at 10:28 AM with the Assistant Director of Nursing (ADON), Resident 1 and Resident 6's NORC were reviewed. The ADON stated that there were no residents' signatures on the NORCs to verify that Resident 1 and Resident 6 had received the written NORC form before changing Resident 1's room on 12/4/2025 and Resident 6's room on 12/5/2025. The ADON stated the ADON did not give the written NORC form to Resident 1 before Resident 1's room change on 12/4/2025. The ADON stated it was the Social Service (SS)'s responsibility to give the NORC to residents and obtain consent from residents for room change. During a concurrent interview and record review on 12/12/2025 at 10:55 AM with the Social Service Director (SSD), Resident 1 and Resident 6's NORC were reviewed. The SSD stated the SSD did not give the written NORC form to Resident 1 and Resident 6 and obtain a signature from residents on the NORC form before changing Resident 1's room on 12/4/2025 and Resident 6's room on 12/5/2025. The SSD stated that the facility should give the written NORC to residents and obtain signature from them to verify the consent to change resident's room.During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights, revised 9/2017, the P&P indicated that the facility must protect and promote the rights of each resident, including the rights to receive written notice, including the reason, before the resident's room or roommate is changed.

Based on interview and record review, the facility failed to provide adequate (satisfactory or acceptable in quality or quantity) hydration (process of replacing water in the body through drinking water and eating food with high water content so every cell, tissue, and organ can properly function) for one of two sampled residents (Resident 1) as indicated in Resident 1's Untitled Care Plan (UPC), dated 5/16/2024, and the facility's policy and procedure (P&P) titled, Hydration Management, and Intake (the measurement of the fluids that enter the body) and Output (the fluids that leave the body), by failing to: 1. Ensure Resident 1's assigned Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) provided Resident 1 with adequate fluids to meet Resident 1's estimated fluid requirement of 1950 milliliters [mL- unit of measurement] to 2040 mL as assessed by Registered Dietician (RD) 1 from 5/21/2024 to 6/1/2024. 2. Ensure CNA 1, LVN 1, and LVN 2 monitored Resident 1's intake and output. 3. Ensure LVN 1 notified Resident 1's Primary Physician (PP/Medical Doctor [MD] 2) promptly (punctually [with little or no delay]) when LVN 1 noted Resident 1 struggled (had a hard time) to drink fluids on his (Resident 1's) own and needed encouragement with drinking fluids. 4. Ensure LVN 1 and LVN 2 communicated with MD 2 to obtain a physician's order for monitoring Resident 1's intake and output. As a result, on 6/1/2024 at 4 pm, Resident 1 had altered level of consciousness (ALOC- a change in state of awareness and alertness) and was difficult to arouse (awaken). Resident 1 was transferred and admitted to General Acute Care Hospital (GACH) 1 on 6/1/2024 at 5:55 pm for further evaluation/treatment and was diagnosed with hypernatremia (high concentration of sodium in the blood and occurs with inadequate fluid intake and or increased water loss) most likely from dehydration (a harmful reduction in the amount of water in the body), uremia (a condition involving abnormally high levels of waste products in the blood), and Acute Kidney Injury (AKI is when kidneys suddenly stop working properly). Cross Reference F580 Findings: During a review of Resident 1's Admission Record (AR), the AR indicated, the facility initially admitted Resident 1 to the facility on [DATE], and readmitted Resident 1 on 5/16/2024, with diagnoses that included dysphagia (difficulty swallowing) oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), unspecified chronic kidney disease (damage to the kidneys resulting to the inability of the kidneys to filter blood the way the kidneys should), and abnormalities of gait and other mobility (inability to walk normally due to injuries or underlying conditions). During a review of Resident 1's Minimum Data Set (MDS - a standardized resident assessment and care screening tool), dated 4/22/2024, the MDS indicated, Resident 1 had severely impaired cognition (ability to think, remember, and reason). The MDS indicated, Resident 1 was independent (resident completed the activity by himself) with eating, oral hygiene, and personal hygiene. The MDS indicated, Resident 1 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completed the activity) with upper body dressing, putting and taking off footwear, rolling left and right in bed, sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfers, and walking 10 feet. The MDS indicated, Resident 1 required partial/moderate assistance (helper did less than half the effort and lifted or held trunk or limbs) with toileting hygiene and showering/bathing self. During a review of Resident 1's General Chemistry (group of tests routinely ordered to determine a person's overall health status) laboratory results (results from testing a sample of blood), dated 5/15/2024, the laboratory results indicated, Resident 1's serum (blood) sodium (Na- amount of sodium [a mineral needed by the body to keep body fluids in balance] in the blood) level was 151 milliequivalents per liter (mEq/L- unit of measurement)(Normal Na level is 135 mEq/L to 145 mEq/L). During a review of Resident 1's Comprehensive Resident Assessment (CRA) dated 5/16/2024, the CRA indicated, Resident 1 needed assistance with eating/nutrition and was dependent on staff for oral hygiene. During a review of Resident 1's first Untitled Care Plan (UPC), dated 5/16/2024, the first UPC indicated, Resident 1 was at risk for dehydration. The first UPC goal indicated, facility staff would identify signs and symptoms (s/s) of dehydration such as dry eyes or mouth, fever, vomiting, urinary tract infection (UTI - infection in any part of the urinary tract, the system of organs that makes urine), poor skin turgor (skin's ability to change its shape and return to normal), change in mental status, and increased in confusion. The first UPC interventions indicated, for staff to provide Resident 1's diet as ordered, assist Resident 1 at mealtime and for all food and fluid offerings, offer fluids during activities, and monitor Resident 1 for s/s of dehydration. During a review of Resident 1's second UPC, dated 5/16/2024, the second UPC indicated, Resident 1 had the potential for fluid-electrolyte (electrolyte is mineral in the blood or other body fluids that carry electric charge and affect how the body functions) imbalance (the level of one or more electrolytes [in the body is too low or too high) related to hypernatremia. The second UPC goal indicated, Resident 1 would have no s/s of hypernatremia. The second UPC interventions indicated, for staff to ensure adequate fluid intake, monitor intake and output, and give diet as ordered. A review of Resident 1's Physician Order (PO) dated 5/19/2024, the PO indicated, an order for No Added Salt (NAS) diet, pureed (all food has been ground, pressed, and/or strained to a soft, smooth consistency, like a pudding) texture, and nectar/mildly thick liquid (liquids that are easily pourable and are comparable to heavy syrup in canned fruit) consistency. During a review of Resident 1's Registered Dietician (RD) Nutrition Risk Assessment (RDNRA) completed by RD 1 dated 5/21/2024, the RDNRA indicated, Resident 1 was on nectar thick liquid consistency and drank 400 mL to 900 mL of fluids per day plus the water pitcher at bedside (specific amount not indicated). The RDNRA indicated, Resident 1's estimated fluid needs per day was between 1950 mL to 2040 mL of fluids per day. The RDNRA indicated, Resident 1's oral intake appeared adequate to meet Resident 1's estimated needs. The RDNRA indicated, RD 1's recommendation was to continue the current plan. During a review of Resident 1's Order Summary Report (OSR), active as of 6/1/2024, the OSR indicated there was no order to monitor Resident 1's intake and output. During a review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR- a written communication tool that helps provide essential, concise information, usually during crucial situations) dated 6/1/2024, untimed, the SBAR indicated, on 6/1/2024, untimed, Resident 1 had altered level of consciousness. The SBAR indicated, Resident 1 had a heart rate of 28 beats per minute (bpm- the number of times the heart beats in one minute. Normal heart rate is 60 bpm to 100 bpm). The SBAR indicated, Resident 1's oxygen saturation (O2 sat- a measurement of oxygen level carried in the blood) was 72% (Normal oxygen saturation is 96 percent [%] to 100 %). The SBAR indicated, facility staff (unidentified) called 911 (phone number used to contact emergency services in the event of a medical emergency) and Resident 1 was transferred to GACH 1. During a review of Resident 1's GACH 1 Emergency Department Provider Note (EDPN), dated 6/1/2024 at 6:33 pm, the EDPN indicated, Resident 1 was brought in by ambulance with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions) and ALOC. The EDPN indicated, Resident 1 had a serum Na level of 169 millimoles per liter (mmol/L- unit of measurement). The EDPN indicated, Resident 1 would be admitted to GACH 1 for diagnoses of hypernatremia most likely from dehydration, uremia, and AKI. During a telephone interview on 6/14/2024 at 11:22 am with Resident 1's Medical Doctor from GACH 1 (MD 1), MD 1 stated Resident 1 was MD 1's patient while at GACH 1. MD 1 stated (in general) normal Na level was between 135 and 145 mmol/L. MD 1 stated when Resident 1 was admitted to GACH 1, Resident 1's Na level was 169 mmol/L. MD 1 stated, that kind of Na level was a dangerously high level of Na in Resident 1's blood. MD 1 stated Resident 1 was dehydrated (a harmful reduction in the amount of water in the body), emaciated (abnormally thin or weak, due to illness and/or lack of food), unable to answer questions, and had altered mental status. MD 1 stated Resident 1 required aggressive intravenous (IV- soft, flexible tube placed inside a vein to administer fluids and medication directly into the bloodstream) fluid hydration. MD 1 stated Resident 1's Na level indicated to MD 1 that Resident 1 had not received adequate hydration and nutrition for at least a week. During a concurrent interview and record review on 6/14/2024 at 4:30 pm with the Director of Nursing (DON), Resident 1's second UCP, dated 5/16/2024, and the OSR with active date of 6/1/2024 were reviewed. The second UPC's interventions indicated for staff (in general) to ensure Resident 1 received adequate fluid intake, and to monitor Resident 1's intake and output. The OSR indicated, there was no MD order to monitor Resident 1's intake and output. The DON stated when Resident 1's UPC indicated for staff to monitor intake and output, the staff needed to notify Resident 1's PP/MD 2 to obtain a physician order for it (monitoring Resident 1's intake and output). The DON stated there was no physician order to monitor Resident 1's intake and output. During a concurrent telephone interview and record review on 6/17/2024 at 11:27 am with RD 1, Resident 1's RD Nutrition Risk Assessment (RDNRA) dated 5/21/2024 was reviewed. The RDNRA indicated Resident 1 required 1950 mL to 2040 mL per day of fluids to maintain adequate hydration. RD 1 stated (in general) normal Na level was between 135-145 mmol/L. RD 1 stated when Resident 1's Na level was above 145 mmol/L, it (the high level of Na) could indicate Resident 1 was dehydrated. RD 1 stated based on Resident 1's RDNRA, Resident 1 required 1950 mL to 2040 mL per day of fluids to maintain adequate hydration. RD 1 stated when Resident 1 was not drinking Resident 1's estimated fluid needs, Resident 1 could become dehydrated and require hospitalization . RD 1 stated when Resident 1 was not meeting his estimated fluid needs, it (the fact that Resident 1 did not drink 1950 mL to 2040 mL of fluid per day) should be reported to the licensed nurses daily and reported to RD 1 and MD 2. RD 1 stated facility staff (CNAs and LVNs in general) did not inform RD 1 that Resident 1 was not drinking Resident 1's estimated fluid needs (1950 mL to 2040 mL of liquid) per day. During a follow-up and concurrent telephone interview and record review on 6/17/2024 at 12 pm with RD 1, Resident 1's medical record document titled, Task: Nutrition - Fluids, dated 5/16/2024 to 6/1/2024 was reviewed. The Task: Nutrition -Fluids, under how much did the Resident drink in ml? indicated the following: 1. On 5/16/2024: 120 mL. 2. On 5/17/2024: 350 mL. 3. On 5/18/2024: 440 mL. 4. On 5/19/2024: 930 mL. 5. On 5/20/2024: 840 mL. 6. On 5/21/2024: 360 mL. 7. On 5/22/2024: 360 mL. 8. On 5/23/2024: 420 mL. 9. On 5/24/2024: 180 mL. 10. On 5/25/2024: 340 mL. 11. On 5/26/2024: 500 mL. 12. On 5/27/2024: 530 mL. 13. On 5/28/2024: 360 mL. 14. On 5/29/2024: 200 mL. 15. On 5/30/2024: 700 mL. 16. On 5/31/2024: 280 mL. 17. On 6/1/2024: 600 mL. A concurrent interview was conducted, RD 1 stated according to Resident 1's documented total fluid intake per day, Resident 1 did not meet Resident 1's required estimated fluid needs per day from 5/16/2024 to 6/1/2024. RD 1 stated RD 1 did not review Resident 1's documented fluid intake from 5/16/2024 to 5/21/2024 when RD 1 completed Resident 1's RDNRA on 5/21/2024. RD 1 stated RD 1 could have caught that Resident 1 was not drinking enough fluids and talked to the nursing staff and informed Resident 1's physician about it (regarding Resident 1 did not consume enough fluid per day). RD 1 stated dehydration could perpetuate (to cause to continue) conditions like urinary tract infection, sepsis (a life-threatening complication of an infection), and hypernatremia and could further damage Resident 1's kidneys. During an interview on 6/17/2024 at 1:36 pm with LVN 1, LVN 1 stated LVN 1 was unaware Resident 1 had a history of hypernatremia. LVN 1 stated Resident 1 needed encouragement to drink fluids because Resident 1 would struggle at times to drink on his (Resident 1's) own (unable to recall dates and times). LVN 1 stated LVN 1 was unaware of Resident 1's estimated fluid needs per day (between 1950 mL to 2040 mL of fluids per day) to maintain adequate hydration. LVN 1 stated LVN 1 did not notify RD 1 or MD 2 that Resident 1 needed encouragement and struggled to drink liquid at times. LVN 1 stated the certified nursing assistants (CNAs) were supposed to inform the licensed nurses (LVNs) when Resident 1 was not drinking enough or was having issues with drinking fluids. LVN 1 stated licensed nurses were supposed to ensure Resident 1 was drinking enough fluids before the end of their shift and report any issues to the on-coming shift. LVN 1 stated LVN 1 did not receive any reports from any CNAs about Resident 1 not drinking enough fluids to meet Resident 1's estimated fluid needs per day. During an interview on 6/17/2024 at 1:53 pm with LVN 2, LVN 2 stated LVN 2 was not aware Resident 1 had a history of hypernatremia. LVN 2 stated Resident 1 was good at drinking fluids. LVN 2 stated CNAs documented Resident 1's total fluid intake per shift and not the LVNs. LVN 2 stated Resident 1 drank well (in general) but could not state how much Resident 1 usually drank in a day. LVN 2 stated LVN 2 did not remember Resident 1's estimated fluid needs per day. LVN 2 stated when Resident 1 was not meeting Resident 1's estimated fluid needs per day (between 1950 mL to 2040 mL of fluids per day), LVN 2 needed to encourage Resident 1 to drink fluids and document any hydration issues in Resident 1's medical record. LVN 2 stated LVN 2 did not receive any report regarding Resident 1 was not drinking enough fluids. LVN 2 stated when Resident 1 was not meeting Resident 1's estimated fluid needs per day as assessed by RD 1, LVN 2 needed to notify Resident 1's PP/MD 2 because that was considered a change of condition (COC- a change in the resident's health or functioning that requires further assessment and intervention) and LVN 2 needed to obtain new orders from MD 2 for laboratory tests for Resident 1. LVN 2 stated LVN 2 did not notify MD 2 at any point between 5/21/2024 and 6/1/2024 that Resident 1 had not drank Resident 1's estimated fluid needs per day. LVN 2 stated it was possible that Resident 1 could have elevated Na levels from not drinking enough fluids and become dehydrated. During an interview and a concurrent record review on 6/17/2024 at 3:17 pm with CNA 1, Resident 1's CRA dated 5/16/2024 indicated, Resident 1 needed assistance with eating/nutrition. CNA 1 stated Resident 1 required a lot of encouragement to drink fluids. CNA 1 stated Resident 1 was unable to drink fluids by himself because Resident 1 did not have balance of Resident 1's hands. CNA 1 stated when Resident 1 was not drinking enough, CNA 1 was supposed to report it to the assigned licensed nurse (unidentified). CNA 1 stated CNA 1 did not report any fluid intake issues to the licensed nurses because Resident 1 usually drank fluids with encouragement. CNA 1 stated CNA 1 was not sure if Resident 1 drank enough fluids during her (CNA 1's) shift and did not know where to find out how much fluids Resident 1 needed to drink during her shift. During an interview on 6/17/2024 at 4:29 pm with the DON, the DON stated licensed nurses (LVNs in general) were supposed to evaluate fluid intake weekly for each resident including Resident 1. The DON stated licensed nurses needed to ensure residents drank their estimated fluid needs per day. The DON stated nursing staff (CNAs and LVNs) could find Resident 1's assessed estimated fluid needs in Resident 1's RD notes and assessments. The DON stated CNAs needed to immediately report to the licensed nurses when Resident 1 was not drinking enough, and the licensed nurses needed to notify the Resident 1's physician (MD 2). The DON stated not drinking enough fluids was considered a change of condition because it could lead to dehydration, or it could be a sign indicated that something else was going on with Resident 1. The DON stated, it was important for all nursing staff to know Resident 1's fluid requirements. The DON stated, staff needed to report changes to the appropriate people (RD 1 and or MD 2) so Resident 1 did not suffer the consequences of dehydration. During a review of the facility's P&P titled, Intake and Output, revised in 5/2016, the P&P indicated, fluid intake and output records were evaluated at least weekly, and each evaluation shall be included in the licensed nurses' progress notes. During a review of the facility's P&P titled, Hydration Management, revised in 3/2021, the P&P indicated, the facility offered residents sufficient fluid to maintain proper hydration and health. The P&P indicated, residents received an adequate amount of fluid during the 24-hour day in accordance with each resident's individual needs and within the limitations set by physician orders as applicable. The P&P indicated, residents were screened on admission, quarterly, annually, and when there was a significant COC of status for their hydration and nutritional status. The P&P indicated, residents identified with the potential for, or actual dehydration were assessed for risk factors and appropriate recommendations would be made. The P&P indicated, the resident's plan of care was developed, implemented, evaluated, reevaluated, and revised with input from the resident and/or responsible party to develop resident-specific interventions to prevent/treat potential dehydration that could include interventions to ensure the provision of adequate fluid goals.