Every finding on record at Tracy Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan (written plan that guides staff on daily care and safety based on the resident's needs) for one of three sampled residents (Resident 1) to address Resident 1's refusals of care, treatment, and participation in a care conference (a meeting to discuss the resident's plan of care), which prevented Resident 1 from receiving appropriate care, treatment, and care planning. This failure placed Resident 1 at risk for worsening of underlying conditions, overall health decline, and preventable complications. Findings: A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility with a diagnosis that included chronic kidney disease stage 3 B (kidneys are moderately to severely damaged and are not working well to filter waste from the blood), asthma (long-term breathing condition that makes it hard to breathe due to narrowed airways), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (weakness or paralysis on the right side of the body caused by a stroke, affecting the side normally used for the most for daily activities) , essential hypertension (high blood pressure with no single known cause), post-traumatic stress disorder (mental health condition caused by a traumatic event that leads to ongoing fear, anxiety, and emotional distress), type 2 diabetes mellitus (high blood sugar where the body still has the hormone that controls blood sugar but cannot keep blood sugar at a normal level).Review of Resident 1's Physical Therapy PT Evaluation & Plan of Treatment, dated 11/25/25, in the section, Assessment Summary.Reason for Skilled Services, the record indicated, . Pt [Patient] refusing any skilled service [medical care that requires a licensed healthcare professional].Risk Factors: Due to the document physical impairments and associated functional deficits, the patient is at risk for falls.During a concurrent interview and record review on 1/20/26 at 12:39 PM with Licensed Nurse (LN)1, Resident 1's Progress Notes, dated 11/25/25 through 12/20/25 were reviewed. The progress notes indicated that from 11/25/25 to 12/20/25, Resident 1 refused his morning medications. The progress notes on 11/26/25 at 2:59 AM, indicated Resident 1 requested not to be disturbed. The progress notes on 12/1/25 at 5:04 AM indicated Resident 1 refused a blood draw. The progress notes on 12/2/25 at 3:53 PM indicated Resident 1 refused to participate in a care conference. LN 1 stated that Resident 1's refusal of care, treatment and participation in a care conference required a care plan with effective interventions to encourage Resident 1 to accept care, treatment, and participation in a care conference. During a concurrent interview and record review on 1/20/26 at 12:45 PM with LN 1, Resident 1's care plans were reviewed. LN 1 stated that Resident 1 did not have a care plan to address refusals of care, treatment, and participation in a care conference. LN 1 further stated that without a care plan to address Resident 1's refusals of care, treatment and participation in care conference, Resident 1 was at risk for health decline.During an interview on 1/20/26 at 1:36 PM with the Director of Nursing (DON), the DON stated that when a resident refused care and treatment, nursing staff were expected to assess the resident and initiate a care plan to address the refusals and implement appropriate interventions to prevent potential health decline. A review of facility's policy and procedure (P&P) titled, Requesting: Refusing and/or Discontinuing Care or Treatment, revised on 5/17, the P&P indicated, .The interdisciplinary team [staff from different departments who work together to plan a resident's care] will assess the resident's needs and offer the resident alternative treatments, if available and pertinent, while continuing to provide other services outlined in the care plan.Review facility's P&P, titled Care Plans, Comprehensive Person-Centered revised on December 2016, the P&P indicated, .A comprehensive, person -centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The Interdisciplinary Team (IDT)[staff from different departments who work together to plan a resident's care], in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .The comprehensive, person-centered care plan will.incorporate identified problem areas; . Aid in preventing or reducing decline in the resident's functional status and /or functional levels.A review of facility's P&P titled, Using Care Plan, revised on 8/06, the P&P indicated, .The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident.

Based on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for one of three sampled residents (Resident 2) when two staff members did not perform hand hygiene (cleaning hands with soap and water or alcohol-based hand sanitizer to remove germs and prevent the spread of infection) before and after entering and exiting Resident 2's room to perform care tasks for Resident 2, who was under Enhanced Barrier Precautions (EBP-an infection-control strategy used in nursing homes to help stop the spread of hard-to-treat infection by requiring extra safety steps, such as wearing gowns and gloves during close care).This failure had the potential to spread infection and cause health problems for the residents in the facility. Findings: A review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility with diagnoses that included urinary tract infection (infection of the bladder or urinary system), unspecified Escherichia Coli as the cause of diseases (type of bacteria that can cause infection), cellulitis of buttock (bacterial skin infection causing redness swelling, and pain), local infection of the skin and subcutaneous tissue (infection involving the skin and tissue under the skin), resistance to multiple antimicrobial drugs (infection that does not respond well to several antibiotics), pressure ulcer of right buttock stage 4 (severe open wound that extends deep into tissue and muscle, Clostridium Perfringes as the cause of diseases (bacteria that can cause serious tissue and wound infections). During a concurrent observation and interview on 1/20/26 at 10:39 AM with the Director of Staff Development (DSD) by the door of Resident 2's room, an EBP sign was posted on the outside of Resident 2's room. The DSD entered Resident 2's room to respond to an activated resident's call light without performing hand hygiene, turned off the call light, and exited Resident 2's room without performing hand hygiene. The DSD stated she had not performed hand hygiene upon exiting Resident 2's room under EBP and the DSD stated hand hygiene was supposed to be performed to prevent the spread of infections in the facility.During a concurrent observation and interview on 1/20/26 at 11:55 AM with Certified Nurse Assistant (CNA)1 in the hallway by the door of Resident 2's room, an EBP sign was posted outside Resident 2's room. CNA 1 picked up a meal tray from the meal cart in the hallway and entered Resident 2's room and delivered the meal tray. CNA 1 placed the meal tray on Resident 2's over-bed table and assisted Resident 2 with meal preparation. CNA 1 then exited Resident 2's room and had not performed hand hygiene and approached the meal cart in the hallway. CNA 1 stated she forgot to perform hand hygiene after she exited the room and before she handled another resident's meal tray. CNA 1 further stated that when she did not perform hand hygiene before food handling and after contact with Resident 2's environment under EBP, other residents were placed at risk for infection. During interview on 1/20/26 at 12:12 PM with the Infection Prevention Nurse (IP), the IP stated that staff were required to perform hand hygiene before they entered and after they exited a resident's room and before and after they performed any task for residents. The IP further stated failure to perform hand hygiene placed other residents at risk for infection.During interview on 1/20/26 at 1:36 PM with the Director of Nursing (DON), the DON stated that staff were required to perform hand hygiene as part of standard precautions (basic infection prevention steps to stop the spread of germs) to break the infection cycle and prevent the spread of infection. A review of facility's policy and procedure (P&P), titled Enhanced Barrier Precaution, revised on 6/20/24, the P&P indicated .To maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.Facility staff shall post a visual alert by the resident's door indicating the high contact resident care.Residents with the following criteria.that placed them at higher risk.Wounds.A review of facility's P&P, titled, Infection Control Guidelines for All Nursing Procedures, revised on 8/12, the P&P indicated .hand hygiene.for all the following situations.After contact with objects.in the immediate vicinity of the resident.

Based on observation, interview, and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food safety when:1. Items past their use by dates and spoiled food items were stored in the dry storage pantry,2. There was no air gap or back flow prevention device installed for the food prep sink or the three compartment sink (a commercial kitchen essential with three basins for washing, rinsing, and sanitizing dishes),3. The dishwasher chlorine level was below the proper level for sanitizing dishes, and4. Dietary staff (DS) 1 and DS 2 did not perform appropriate hand hygiene while working in the kitchen.These failures had the potential to affect the flavor and palatability of the food and to lead to food borne illness (nausea, vomiting, diarrhea) for the 51 residents receiving facility prepared food.Findings: 1. During a concurrent observation and interview on 12/2/25 at 8:36 AM with the Food Service Director (FSD) in the dry storage area of the kitchen, the FSD confirmed the following items were on the shelves and available for use: a) a bottle of Worcestershire sauce with a best by date of 11/20/25, b) a soft, discolored onion, four white potatoes, and two red potatoes that were spongy and sprouted,c) spice containers of Tarragon with a use by date of 10/8/25, ginger powder use by date 11/12/25, pumpkin spice use by date 8/27/25, dill weed use by date 11/18/24, and mustard powder with a use by date of 8/8/25,d) a box of baking soda with a use by date of 10/16/25.The FSD stated the items should not be available for use beyond their use by dates. The FSD further stated use of these items could affect the flavor and diminish the residents' enjoyment of the food. The FSD confirmed spoiled food items should not be kept in the storage area.During an interview on 12/4/25 at 10:48 AM with the Registered Dietitian (RD), the RD stated food items should be labeled to inform staff of when they were received and when they were outdated. The RD further stated the use of outdated food items could affect the flavor and enjoyment of the food. The RD stated the food should be fresh and palatable, and spoiled items should be removed from storage to avoid attracting pests.A review of a facility policy titled STORAGE OF FOOD AND SUPPLIES, dated 2017, indicated, .Food and supplies will be stored properly and in a safe manner.Dry food items which have been opened.will be tightly closed, labeled and dated. These items will be used per times specified in the Dry Food Storage Guidelines.A review of a facility document titled DRY FOOD STORAGE GUIDELINES, dated 2018, indicated, This storage length is to be followed.Baking soda.Opened on shelf 6 months.Sauces-bottled.Opened on shelf 1 year.Spices opened on shelf .1 year.2. During a joint concurrent observation and interview on 12/4/25 at 8:20 AM with the Maintenance Supervisor (MS) and the Maintenance Consultant (MC), the MS confirmed there was no air gap or backflow prevention device in use for the food prep sink or the three compartment sink. The MC stated the purpose of a backflow prevention system was to prevent contaminated water from backing up into the clean sinks.During an interview on 12/4/25 at 10:48 AM with the Registered Dietitian (RD), the RD stated the lack of an air gap or backflow device under the kitchen sinks had the potential for contamination of food and dishes that could have led to food borne illnesses.A review of 2022 Food Code 5-202.13, indicated, .Backflow Prevention, Air Gap.An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE.shall be at least twice the diameter of the water supply inlet.A review of 2022 Food Code 5-202.14, indicated, .Backflow Prevention Device, Design Standard.A backflow or backsiphonage prevention device installed on a water supply system shall meet American Society of Sanitary Engineering.standards for construction, installation, maintenance, inspection, and testing for that specific application and type of device.3. During a concurrent observation and interview on 12/4/25 at 12:18 AM with DS 3, DS 3 stated she used the low temperature dishwasher in the morning to wash the dishes. DS 3 demonstrated how she used test strips to check the chlorine level in the dishwasher. The result of the test indicated the chlorine level was 25 ppm (parts per million, unit of concentration).During an interview on 12/4/25 at 12:27 PM with the FSD, FSD stated the chlorine level in the dishwasher should be 100 ppm in order to sanitize the dishes. The FSD indicated that insufficient chlorine levels could lead to un-sanitized dishes and a potential spread of infection to residents.During an interview on 12/5/25 at 8:36 AM with the RD, the RD stated that when the chlorine level in the dishwasher was too low, the dishes would not have been cleaned correctly, and the residents would have been at risk of food borne illness.A review of a facility policy titled DISH WASHING, dated 2018, indicated, .All dishes will be properly sanitized through the dishwasher.Appropriate chemicals will be used to wash, de-stain, and rinse the dishes.The chlorine should read 50-100 ppm on dish surface in final rinse. The proper chlorine level is crucial in sanitizing dishes.4. During a concurrent observation and interview on 12/4/25 at 12:15 PM with DS 2 in the kitchen, DS 2 was observed wiping her nose with a tissue. DS 2 left the kitchen and returned still holding a tissue. DS 2 again wiped her nose, disposed of the tissue in the trash can, and walked over to the steam table. When asked about hand hygiene DS 2 stated she forgot to wash her hands.During an observation on 12/4/25 at 12:34 PM, DS 1 walked out of the kitchen wearing gloves, and entered the food storage closet. DS 1 walked back into the kitchen wearing the gloves, approached a food prep cart and touched the cart. The FSD then instructed DS 1 to perform hand hygiene.During an interview on 12/5/25 at 8:36 AM with the RD, the RD stated it was her expectation that dietary staff would change their gloves and wash their hands after they blew their noses, touched their hair, or did anything else that could contaminate their hands. The RD further stated not washing hands could potentially lead to the spread of infection to the residents.A review of a facility policy titled Hand Hygiene, dated 2/27/24, indicated, .Policy: To maintain the highest standards of infection prevention and control through hand hygiene adherence.Staff shall perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.A review of a facility policy titled, GLOVE USE POLICY, dated 2018, indicated, .The appropriate use of gloves is essential in preventing food borne illness. Gloved hands are considered a food contact surface that can get contaminated or soiled. Disposable gloves are a single use item and should be discarded after each use. Wash hands when changing to a fresh pair, Gloves must never be used in place of hand washing.WHEN GLOVES NEED TO BE CHANGED.Before beginning a different task.After sneezing, coughing, smoking, eating, drinking, using a tissue or going to the toilet.After touching bare skin or hair.

Based on observation, interview, and record review, the facility failed to implement a comprehensive water safety management program based on nationally accepted standards to minimize the risk of Legionella (bacteria spreads via inhaling contaminated water and can lead to a serious lung infection) and other waterborne pathogens (a microorganism [bacteria] that exists in water sources or plumbing [pipes required for the water supply, heating and sanitation in a building] systems that can cause serious illness in people over [AGE] years of age and those with weakened immune systems) for a census of 52 residents when:a. The facility did not complete and document a facility wide assessment of potential Legionella growth areas to include flow charts;b. The facility did not implement adequate control measures;c. The facility did not establish sufficient monitoring protocols;d. The facility did not create an intervention plan for when control limits are not met.These failures put the residents and at risk of potential Legionella and other opportunistic waterborne pathogen exposure, threatening their health and well-being.Findings:During a concurrent interview and record review on 12/3/25 at 11:06 AM, with the Administrator (ADM), the ADM stated that the facility managed its own water system. The ADM stated the Maintenance Supervisor (MS) checked the water temperatures but acknowledged a gap in their current water management plan, admitting that it lacked a flow chart or diagram that indicated the water distribution throughout the facility.During an interview on 12/4/25 at 8:46 AM, the MS explained that water entered the facility from the main supply line and was distributed throughout the facility building. The MS stated he regularly checked the water temperatures and tested for Legionella annually. The MS stated in 2025, random testing was done in the visitors' restroom in the hallway (near the laundry room) because it received unfiltered water. The MS stated in 2024, testing was water testing was conducted in the kitchen. MS acknowledged he was unable to produce documentation of water testing. The MS admitted that he did not have a flow chart or diagram, lacked knowledge of control limits and measures, and was unaware of other risk areas. The MS was not able to explain the facilities process for decontaminating the building water systems, if necessary, and further stated the facility did not have an external contractor for this purpose.During an interview on 12/4/25 at 12:15 PM with the Infection Preventionist (IP), the IP indicated that she was not highly familiar with the facility's water management; however, the MS was responsible for testing and maintaining the system. The IP mentioned that the MS would inform her if there was a positive result for Legionella, upon which she would address the infection prevention aspect. The IP acknowledged deficiencies in their water management program and noted that she had previously informed the Administrator (ADM) about these issues. Additionally, the IP stated that she was unaware whether a facility risk assessment had been conducted or if any control measures were in place.During a follow-up interview on 9/4/2025 at 3:10 PM with the ADM, the ADM mentioned that the facility did not possess a diagram of their water system detailing the flow chart of inlets and outlets as water moved through the building's pipes. The only diagram available was a fire exit plan that listed the boilers but did not include any areas of concern or potential legionella risk. The ADM acknowledged that improper water management could put residents at risk of illness and emphasized the importance of having a proper plan to minimize bacterial growth and infections.A review of the facilities P&P titled, Legionella Water Management Program, revised 7/17, indicated, .c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria. g. A diagram of where control measures are applies; . h. A system to monitor control limits and effectiveness of control measures; i. A plan for when control limits are not met and/or control measures are not effective.A review of the CDC's online guide titled Overview of Water Management Programs, published 3/15/24, indicated, .Key Points.Many buildings need a water management program (WMP) for their building water system.WMPs identify hazardous conditions and outline steps to minimize the health impact of waterborne pathogens.Developing and maintaining a WMP is a multi-step process that requires continuous review.Seven steps of a Legionella WMP are to: 1. Establish a WMP team 2. Describe the building water systems 3. Identify areas where Legionella could grow and spread 4. Decide where to apply and how to monitor control measures 5. Establish interventions when control limits aren't met 6. Ensure the program runs as designed and is effective 7. Document and communicate all activities.the principle of effective water management include: Ensuring adequate disinfection.Maintaining devices to prevent.Sediment, Scale, Corrosion, Biofilm.Maintaining water temperatures to limit Legionella growth, preventing water stagnation.Once established, WMPs require regular monitoring of key areas for potentially hazardous conditions. The programs use predetermined responses to respond when control measures aren't met.Each program has to be tailored for each building at a particular point in time.In some settings, the entire building needs a WMP: Hospitals and long-term care facilities. https://www.cdc.gov/control-legionella/php/wmp/index.html

Based on observation, interview, and record review the facility failed to ensure four (4) of 20 sampled residents' (Resident 3, Resident 9, Resident 42, and Resident 53) basic grooming needs were met when:Resident 3's fingernails nails were long, jagged, and unclean;Resident 9's fingernails nails were long, jagged, and unclean;Resident 42's fingernails nails were long, jagged, unclean and Resident 42 had an odor coming from her clenched right hand;Resident 53's fingernails nails were long, jagged, and unclean. These failures had the potential for Resident 3, Resident 9, Resident 42, and Resident 53 to sustain injury and/or acquire an infection.Findings:1. During a review of Resident 3's admission RECORD, the record indicated Resident 3 was admitted to the facility in 2019, with a diagnosis which included Alzheimer's disease (a progressive disease that affects the parts of the brain that control thought, memory, and language).During a concurrent observation and interview on 12/2/25 at 9:45 AM with Resident 3 in Resident 3's room, Resident 3's fingernails were observed to be long with brown material underneath the nails. Resident 3 stated she preferred her fingernails to be clean and short. Resident 3 stated she no longer had nail clippers and relied on staff to trim her nails. During a concurrent observation and interview on 12/2/25 at 9:47 AM with the Certified Nurse Assistant (CNA) 1 in the room shared by Resident 3 and 53, Certified Nurse Assistant (CNA) 1 confirmed Resident 3's nails needed to be cleaned and trimmed. CNA 1 stated Resident 3's nails should not be soiled and should have been cared for when the resident received a shower or bed bath.2. A review of Resident 9's admission RECORD, the record indicated Resident 9 was admitted to the facility in 2024 with a diagnosis which included hemiplegia and hemiparesis (paralysis/weakness or inability to move one side of the body) affecting the left side.During a concurrent observation and interview on 12/3/25 at 8:20 AM with Resident 9 in Resident 9's room, Resident 9 was observed with long, jagged fingernails, with a dark brown substance underneath. Resident 9 stated he did not know when his fingernails were last cleaned and trimmed. 3. A review of Resident 42's admission RECORD, the record indicated she was admitted to the facility in early 2021 with a diagnosis which included hemiplegia and hemiparesis affecting the left side.During an observation on 12/2/25 at 1:37 PM in Resident 42's room, Resident 42 was observed to have long, jagged fingernails with dark material underneath. During a telephone interview on 12/2/25 at 3:45 PM with Resident 42's Responsible Party (RP) 2, RP 2 stated he trimmed Resident 42's fingernails when he visited and noticed they were long and dirty. RP 2 further stated he was not aware the facility staff trimmed fingernails.During a concurrent observation and interview on 12/4/25 at 10:03 AM with the DSD in Residents 42's room, the DSD confirmed Resident 42 had long, soiled fingernails. The DSD further confirmed an odor was present from Resident 42's clenched right hand. The DSD stated Resident 42's hands should be washed and dried daily to prevent infection. The DSD confirmed staff were not following the facility's policy for ADL care.4. A review of Resident 53's admission RECORD, the record indicated Resident 53 was admitted to the facility in 2023 with a diagnosis which included hemiplegia and hemiparesis affecting the right dominant side of the body. During a concurrent observation and interview on 12/2/25 at 9:40 AM with Resident 53 in Resident 53's room, Resident 53 stated she asked staff to trim her fingernails, and they did not. Resident 53's fingernails were observed to be long, jagged, with a dark brown material underneath the nails. Resident 53 stated she preferred her nails to be short and clean. Resident 53 further stated it was unsanitary to have long, dirty fingernails. During a concurrent observation and interview on 12/2/25, at 9:47 AM with the Certified Nurse Assistant (CNA) 1 in the room shared by Resident 3 and 53, CNA 1 confirmed Resident 53 needed nails cleaned and trimmed. CNA 1 stated the resident's nails should not have been soiled and should have been cared for when the resident received a shower or bed bath.During an interview on 12/4/25 at 8:46 AM with the Director of Staff Development (DSD), the DSD stated every CNA should have been able to trim the residents' fingernails. The DSD further stated if a resident was diabetic and at a higher risk of infection, the licensed nurse should have trimmed their fingernails. The DSD stated residents' fingernails should have been trimmed whenever they appeared soiled. The DSD stated it was her expectation that long nails would be trimmed and cleaned to prevent residents scratching themselves and causing an open area which could lead to infection. The DSD stated eating with soiled fingernails could also lead to infection. During an interview on 12/5/25 at 9:05 AM with the Director of Nurses (DON), the DON stated it was her expectation that nail care would be performed by the appropriate staff when residents received their showers. The DON further stated there was a risk to the residents of infection and unintentional skin issues if their nails were not trimmed and cleaned. A review of a facility policy titled, Supporting Activities of Daily Living (ADLs) Policy, dated 10/25, indicated, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.A review of a facility policy titled, Fingernails/Toenails, Care of, dated 2/18, indicated, .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming .Proper nail care can aid in the prevention of skin problems around the nail bed .Trimmed and smooth nails prevent the resident from accidently scratching and injuring his or her skin .

Based on observation, interview, and record review the facility failed to ensure one of twenty sampled residents (Resident 9) was free from unnecessary drugs when Resident 9 was prescribed psychotropic medications (medication that affects behavior, mood, thoughts, or perceptions) and diagnosed with schizophrenia (a serious mental illness that affects how a person thinks, feels and behaves) after admission to the facility.This failure placed Resident 9 at risk of unnecessary psychotropic medication use which could lead to medication side effects, decreased mobility, skin breakdown, and decreased ability to perform self-care tasks.Findings: A review of Resident 9's admission RECORD, indicated, he was originally admitted to the facility in mid-2017.A review of Resident 9's clinical document titled, Brief Interview for Mental Status (BIMS), (a tool used to screen for cognitive impairment, the assessment uses a point system that ranges from 0 to 15 points: a score of 13 to 15 points suggests that cognition is intact) dated 11/10/25, indicated, a score of 14.During an interview, in Resident 9's room, on 12/5/25, at 7:47 AM, Resident 9 stated he did not have any mental illness diagnoses and was not prescribed any psychotropic medications.During a telephone interview on 12/5/25, at 8:28 AM, with Resident 9's Responsible Party (RP) 3, RP 3 stated he did not know where Resident 9's schizophrenia diagnosis came from. RP 3 further stated he became aware of the diagnosis when he read Resident 9's paperwork after a hospital visit. RP 3 stated he was not sure if Resident 9's hallucinations were related to dehydration or some other medical condition.A review of Resident 9's Minimum Data Set (MDS, a federally mandated resident assessment and screening tool which identifies care needs) Section I, titled, .Active Diagnoses, dated 2/8/21, indicated, .Psychiatric/Mood Disorder.Anxiety Disorder.Depression.Psychotic Disorder (other than schizophrenia). A review of Resident 9's clinical document titled, Psychiatry Follow Up Note, dated 6/3/21, indicated, .HISTORY OF PRESENT ILLNESS. Patient admitted to facility for s/p [status post] CVA [cerebrovascular accident, stroke, when blood flow to the brain is suddenly interrupted causing brain cells to die from lack of oxygen and nutrients] and metabolic encephalopathy [brain dysfunction caused by a chemical imbalance from an underlying illness]. Today patient reports c/o [complaints of] depression, anxiety and visual hallucinations.Diagnosis.Schizophrenia, unspecified. A review of Resident 9's MDS Section I, titled, .Active Diagnoses, dated 11/24/21, indicated, .Psychiatric/Mood Disorder.Anxiety Disorder.Depression.Schizophrenia. A review of Resident 9's Medication Administration Record (MAR) dated 11/1/25 through 11/30/25, indicated, .Quetiapine Fumarate ( atypical antipsychotic medication used to treat schizophrenia) 100 mg (milligram) two times per day. and .Monitor for episodes of (Visual hallucinations), and document number of episodes every shift. The MAR indicated 1 episode of hallucinations documented on 11/22/25, there were no other episodes of hallucinations documented for the month of November.During a telephone interview on 12/5/25, at 10:07 AM, with the current Mental Health Nurse Practitioner (MHNP), the MHNP stated she had visited Resident 9 twice, and during the last visit he was asleep. The MHNP further stated she did not know Resident 9 well enough to determine if he met the criteria for a schizophrenia diagnosis. The MHNP stated the criteria for a schizophrenia diagnosis was very broad and included behaviors of visual hallucinations, disorganized thoughts, and agitation. The MHNP stated disorganized thought processes was the most frequent behavior. The MHNP further stated schizophrenia took a lot of time to diagnose and it was not something that could be done on one visit. The MHNP stated that, based on Resident 9 being alert and oriented, she would need to reassess him to rule out other issues that could lead to psychosis. The MHNP further stated it would be important to determine if Resident 9 continued to need his psychotropic medications or if they could be causing him to be sedated.During an interview on 12/5/25, at 10:56 AM, with the Director of Nurses (DON), the DON stated she was unable to find documentation in Resident 9's health record to indicate the reason for the schizophrenia diagnosis. The DON further stated she was unable to contact the MHNP who had documented the diagnosis.During a telephone interview on 12/5/25, at 1:38 PM, with Resident 9's physician, the physician stated Resident 9's condition was stable, and he was not sure who had determined the diagnosis of schizophrenia.A review of a facility policy titled, PSYCHOTROPIC MEDICATION USE, dated 6/2021, indicated, .The facility should not use psychotropic medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social or environmental cause of the resident's behaviors.Facility staff should take a holistic approach to behavior management that involves thorough assessment of underlying causes of behaviors and individualized person- centered non-drug and pharmaceutical interventions.When a Physician/Prescriber orders a psychotropic medication for a resident, Facility should ensure that Physician/Prescriber has conducted a comprehensive assessment of the resident and has documented in the clinical record that the psychopharmacologic medication is necessary.

Based on interview, and record review, the facility failed to accurately complete a Pre-admission Screening and Resident Review (PASRR, a required assessment for individuals with mental illness, intellectual or developmental disabilities, or related conditions, so that a determination of need, appropriate setting, and a set of recommendations for services to be included in the individual's plan of care is provided) for 1 of 20 sampled residents (Resident 8) when, Resident 8's level I PASRR did not reflect her diagnosis of bipolar disorder (a mental disorder characterized by periods of extreme mood swings, and causes shifts in mood, energy, activity levels, and concentration), anxiety disorder [a group of mental health conditions that cause fear, dread, and worry), major depressive disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in activities), and schizophrenia ( a serious, chronic brain disorder causing abnormal thinking, perception, and behavior, where people struggle to tell what's real from imagination).This failure resulted in a level II PASRR (a mental health screening for additional services) never being completed with the potential to affect the provision of appropriate treatment and specialized services for Resident 8 and increased her risk of having unmet behavioral health needs.Findings:Review of Resident 8's admission RECORD, indicated Resident 8 was originally admitted to the facility in spring of 2025, with a diagnosis including but not limited to, bipolar disorder, major depressive disorder, and anxiety disorder.Review of Resident 8' s [name redacted, Discharging Hospital A] History and Physical, dated 3/4/25, indicated, .History obtained from patient and previous documentation. As per record patient admitted to [Hospital name redacted] from January 18 till 21st [2025] during that admission she was managed for altered mental status.Past medical history.seizure disorder [abnormal electrical activity in the brain].bipolar disorder.seizure disorder.schizophrenia, cerebral palsy [a group of neurological disorders affecting movement, balance, and posture, caused by damage or abnormal development in the brain, often before birth or in early childhood].Nursing home medications.omeprazole [medication to reduce stomach acid] 40 mg [unit of measurement] daily.Eliquis [blood thinner medication] 5 mg.depokote [medication to treat seizures and mood disorders].Emergency Documentation- MD.ED Physician Notes.XXX[AGE] year-old female with cerebral palsy and extensive medical history.bipolar.seizure disorder.presenting from her board and care of altered mental status.Review of Resident 8's undated and untitled hospice document, indicated, . [name redacted, Resident 8] is a 65 yr [year] old female with admitting diagnosis of Acute Kidney Failure unspecified [loss of kidney function]. She was approved by hospice by [name redacted, hospice MD 2] .Past medical history pt [patient] has been hospitalized at [hospital A] .4 times since December. She has had encephalopathy [disturbance of brain function], seizure, Altered mental status.seizure disorder.schizophrenia, Bipolar disorder.Review of Resident 8's Care Plan, initiated on 3/14/25, indicated, .Altered mood pattern related to anxiety manifested by Inability to relax.Interventions. Assess resident's needs.evaluate food, thirst, toileting needs, comfort level.Notification of primary care physician and/or consulting psychiatrist regarding the escalation of inability to relax.Review of Resident 8's Care Plan, initiated on 3/14/25, indicated, .Altercation in mood and behavior pattern R/T [related to] Depression M/B [manifested by] verbalized sadness.Will have no adverse consequences through the next review date.Administer prescribed medication.Monitor black box warning signs and symptoms.Increased risk of suicidal thinking and behavior in individuals with Major Depressive Disorder and other psychiatric disorders.Monitor for signs of suicidal thinking or unusual changes in behavior .Report the MD in the event that resident exhibit black box warning signs and symptoms.Review of Resident 8's Care Plan, initiated on 3/14/25, indicated, .Alteration in behavior patter R/T DX [diagnosis] of Bipolar Disorder M/B [manifested by] mood lability.Resident will have no episode of mood lability through the next review date.Interventions.Administer prescribed anti-psychotic.Seroquel & Aripiprazole.Notification of the primary care physician and /or consulting psychiatrist regarding the escalation of mood lability.Review of Resident 8's Care Plan, initiated on 11/17/25, indicated, .The resident has a psychosocial well-being problem (actual or potential) r/t Alleged Abuse.The resident will have no indications of psychosocial well being problem by/through review date.Consult with Pastoral care, Social services, Psych services.Monitor/document residents feeling relative to (Specify.).Provide opportunities for the resident and family to participate in care.During a concurrent interview and record review on 12/5/25, at 10:34 a.m., with the Minimum Data Set (MDS, an assessment tool) Coordinator (MDS) 1, Resident 8's quarterly MDS, dated [DATE] was reviewed. The MDS 1 stated that a PASSR was needed upon admission and wherever the resident was discharged from such as an acute care hospital; they would send the PASSR file. The MDS 1 stated the quarterly MDS should have captured all active diagnoses and be accurate. The MDS further confirmed Resident 8's schizophrenia diagnosis was not captured.During a concurrent interview and record review on 12/5/25, 12:11 p.m., with the Director of Nursing (DON), Resident 8's PASSR was reviewed. The DON confirmed Resident 8's PASSR was wrong, the Interdisciplinary team (IDT, a group of professionals from different fields who work together and communicate closely to create one unified, holistic care plan for a patient, focusing on all their needs (physical, emotional, social) should have reviewed it, noticed it was incorrect, and resubmitted the PASSR. The DON stated it was important for the PASSR to be correct be it guided treatment and could have recommendations to address mental health conditions. The DON further stated there was a risk for the resident's mental health not being adequately addressed.Review of the facility Policy & Procedure (P&P) titled, ADMISSION, TRANSFER, DISCHARGE, AND BED-HOLDS, dated 2016, indicated, .PURPOSE .To provide uniform guidelines for admission .in compliance with state and federal guidelines. To promote equal access to quality care and facilitate continuity with care transitions .The facility .requires individuals diagnosed with major mental illness .or developmental disabilities to be screened prior to admission and throughout stay in accordance with PASRR requirements .Review of the facility P&P titled, Behavioral Health Services, dated 2025, indicated, .It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning and well-being .The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy[independence], privacy, socialization, independence, choice, and safety .Staff will .Complete PASARR screening .The Social Services Director shall serve as the facility's contact person for questions regarding behavioral services provided by the facility and outside sources such as physician, psychiatrist [doctor specializing in mental health], or neurologists [brain doctor] .Review of the facility Policy and Procedure (P & P) titled, Preadmission SCREENING & RESIDENT REVIEW (PASSR), dated 11/30/23, indicated, .Facility will.Coordinate assessments with he pre-admission screening and resident review (PASSR) program under Medicaid to the maximum extent practicable to avoid duplicative testing and effort to include.Incorporating the recommendations from the PASRR level II determination and the PASRR evaluation report into the resident's assessment, care planning, transitions of care.Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of in status assessment.Notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who ahs mental illness or intellectual disability for resident review.for resident review.

Based on interview and record review, the facility failed to ensure 1 of 20 sampled residents (Resident 9) Preadmission Screening and Resident Review (PASRR, a federally mandated screening of all potential nursing home residents, for mental illness and intellectual disability,to help ensure that individuals are not inappropriately placed in a nursing home, and to ensure they receive any specialized services that are required), form was updated after a significant change in mental illness diagnosis.This failure had the potential for Resident 9 to not receive the necessary care and services required to improve Resident 9's mental health condition and quality of life.Finding: A review of Resident 9's admission RECORD, indicated, he was originally admitted to the facility in mid-2017.A review of Resident 9's Minimum Data Set (MDS, a federally mandated resident assessment and screening tool which identifies care needs) Section I, titled, .Active Diagnoses, dated 2/8/21, indicated, .Psychiatric/Mood Disorder.Anxiety Disorder.Depression.Psychotic Disorder (other than schizophrenia).A review of Resident 9's clinical document titled, Preadmission Screening and Resident Review (PASRR) Level I Screening Document, dated 5/3/21, indicated, .Level I -Negative.Case Status: Closed.Reason Code-No- MI [mental illness].A review of Resident 9's clinical document titled, Psychiatry Follow Up Note, dated 6/3/21, indicated, .HISTORY OF PRESENT ILLNESS. Patient admitted to facility for s/p [status post] CVA [cerebrovascular accident, stroke, when blood flow to the brain is suddenly interrupted causing brain cells to die from lack of oxygen and nutrients] and metabolic encephalopathy [brain dysfunction caused by a chemical imbalance from an underlying illness]. Today patient reports c/o [complaints of] depression, anxiety and visual hallucinations.Diagnosis.Schizophrenia, unspecified.A review of Resident 9's MDS Section I, titled, .Active Diagnoses, dated 11/24/21, indicated, .Psychiatric/Mood Disorder.Anxiety Disorder.Depression.Schizophrenia.During an interview on 12/5/25, at 11:50 AM, with the Director of Nurses (DON), the DON stated Resident 9's PASRR should have been updated when he received the schizophrenia diagnosis. The DON further stated the purpose for updating the PASRR was to ensure Residents were evaluated for the appropriate care and services.A review of a facility policy titled, Resident Assessment- Coordination with PASRR Program, revised 10/25, indicated, .This facility coordinates assessments in accordance with the preadmission screening and Resident review (PASRR) program requirements.to ensure that individuals with a mental disorder, intellectual disability, or related condition receives care and services in the most integrated setting appropriate to their needs.Any resident who exhibits newly evident or possible serious mental disorder.will be referred promptly to the state mental health or intellectual disability authority for a level II Resident review upon a significant change in status assessment. Examples include.A Resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a new mental disorder.

Based on interview and record review the facility failed to provide services which met professional standards of quality care for one of 20 sampled residents (Resident 3) when Resident 3 expressed suicidal ideation (thinking about, considering, or planning to end one's life) and no interventions were put in place to monitor her psychosocial needs.This failure had the potential for Resident 3 to make a suicide attempt (try and end one's life) and to negatively affect her psychosocial wellbeing.A review of Resident 3's admission RECORD, indicated Resident 3 was admitted to the facility in 2019 with diagnoses which included Alzheimer's Disease (a progressive disease that affects the parts of the brain that control thought, memory, and language), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), vascular dementia, (a decline in cognitive abilities due to reduced blood flow to the brain) and delusional disorders (mental health condition in which a person has false beliefs based on an inaccurate interpretation of reality).A review of Resident 3's clinical document titled, [Company Name] Behavioral Health, dated 6/12/25, indicated, .List of symptoms/problems in patient's own words.Patient reported visual hallucinations, describing she saw her grandson being shot. She also expressed suicidal ideation with a specific plan, stating she intended to stab herself and jump off a bridge. However, due to her physical immobility, the imminent risk is limited. Nonetheless, the facility has initiate [sic] a safety plan, including increased monitoring and environmental precautions.Plan for Medication.Increase . [PSYCHIATRIC MEDICATION NAME] .A review of Resident 3's clinical document titled, Progress Notes, dated 6/13/25, signed by Resident 3's MD, indicated, .Psych [MENTAL HEALTH PRACTITIONER NAME] seen the patient with recommendation to increased [sic] [PSYCHIATRIC MEDICATION NAME] for dementia.Visit Diagnoses.Severe episode of recurrent major depressive disorder.A review of a Resident 3's clinical document titled, Progress Note, dated 6/13/25 at 2:28 PM, indicated, .Type: Nurse Notes.Author contacted RP [RESPONSIBLE PARTY NAME] .to Increase medication [PSYCHIATRIC MEDICATION NAME] and awaiting call back for consent.Nursing care will continue.During a concurrent interview and record review on 12/5/25 at 1:17 PM with the Director of Nurses (DON), the DON stated if staff were aware of Resident 3's report of suicidal ideation it was her expectation that the change of condition would have been documented and an Interdisciplinary team (IDT, group of healthcare professionals who assess and coordinate care) meeting would have been held and the needs of Resident 3 would have been determined. The DON further stated Resident 3's care plan should have been updated to reflect the care needs, the social services department should have followed up with Resident 3 for 72 hours, and if indicated, Resident 3 should have been assigned continual staff monitoring. The DON confirmed Resident 3 did not have a change of condition documented, her care plans were not updated, and there was no documentation in her clinical record to indicate staff monitored her for suicidal ideation during the month of 6/25.A review of a facility policy titled, Suicide Threats, revised 12/07, indicated, .Resident suicide threats shall be taken seriously and addressed appropriately.Staff shall report any resident threats of suicide immediately to the Nurse Supervisor/Charge Nurse.After assessing the resident in more detail, The Nurse Supervisor/Charge Nurse shall notify the resident's Attending Physician and responsible party, and shall seek further direction from the physician.All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report any changes in the resident's behavior immediately.Staff should document details of the situation objectively in the resident's medial record.

Based on observation, interview, and record review, the facility failed to ensure safe medication and medical supply storage in the medication cart (a mobile cart with stored medications and supplies needed for administration), refrigerator, and the medication room (a locked room used to store medications and supplies) for a census of 52 residents when:1. When Resident 35's expired Sennosides (a stimulating laxative used to treat constipation) 8.6 milligrams (mg, unit of measurement), and Resident 33's expired Meclizine Hydrochloride 25 mg (an antihistamine used to prevent and treat nausea, vomiting, and dizziness) were stored in the medication cart.2. a. Discontinued Intravenous (IV, tube that is placed into a vein to deliver fluids and medications) medication belonging to a discharged resident (Resident 99) was stored in an active storage area in the refrigerator of the medication room. b. Expired (outdated) nutrition powder was stored in the active storage areas of the medication room. This failed practice had the potential for risk for medication error, resident injury, adverse (bad) effects, and possible hospitalization for the residents who could have been given the medication.Findings 1. During a concurrent observation and interview on 12/04/2025 at 4:00 p.m. with Licensed Nurse (LN) 1, there were three expired oral medications stored in medication cart 2, two bottles of Senokot 8.6 mg were labeled with Resident 35's name with an expiration date of 7/31/2025. The third bottle labeled, Meclizine 25 mg with Resident 33's name listed on the bottle and an expiration date of 8/30/2025. During an interview on 12/4/25 at 4:00p.m. with Licensed Nurse 1, (LN 1) LN 1 confirmed there were two bottles of expired Senokot and one bottle of expired Meclizine left in the medication cart 2. LN 1 stated reason expired meds should not be left in the medication cart was because the medication could lose its effectiveness. During an interview on 2/5/25 at 08:54 a.m. with the Director of Nursing (DON), the DON stated facility should not have left or stored expired medications in the medication cart. The DON stated the staff should have removed the medication from the medication cart once the medication was expired and placed the discontinue medications in the cabinet in the medication room for disposition (destruction). The DON stated reasons expired med should not be left in the med cart when a medication was discontinued or a resident had been discharged from the facility was because inadvertent administration of medication to a resident could either cause adverse (bad) effects or ineffective (does not work) treatment. Review of facility's policy and procedure (P&P) titled, Medication Storage In The Facility, dated 1/25, the P&P indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . M. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, spoiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exits. O. Medication storage conditions are monitored on a routine basis and corrective action taken if problems are identified. 2. During a concurrent observation and interview on 12/3/25 at 8:40 a.m. with Licensed Nurse (LN) 2, an inspection of the facility's main medication room was conducted. The following expired and/or discontinued medications and supplements were stored in the medication room and the refrigerator: a. Intravenous [IV, refers to giving medications or fluids through a needle or tube inserted into a blood vessel] bag of . [name redacted, Resident 99] .IV DAPTOMY [medication used to treat infections] 700MG [milligram, unit of measurement]/NS [normal saline, meaning sterile salt water] 50 .DIRECTIONS.INFUSE 700 MG INTRAVENOUSLY DAILY @ [at] 100ML [unit of measurement, milliliter/ HR [hourly].Fill Date.11/6/25.PREP [preparation] TIME 4:25 PM.LOT .11/08/25.4:25 PM. for a discharged Resident 99. b. Three boxes of Juven.Therapeutic Nutrition Powder.FOR WOUND HEALING.AMINO ACID.Arginine.Glutamine., had expiration dates of 8/25, 5/25, and 9/25. LN 2 acknowledged Resident 99's IV antibiotic was stored in the locked refrigerator and stated she was a Licensed Vocational Nurse (LVN) and was unsure how long the medication was good for after being reconstituted (mixing medication with a solution) by the pharmacy. LN 2 explained the facility's Registered Nurses administered IV medications to residents. LN 2 acknowledged the Juven mix should not be in the medication room because it was expired, and staff could not give it to residents because it was not safe to consume. LN 2 stated the Juven mix contained extra amino acids and was used for residents with wounds as it aids wound healing. LN 2 further explained Juven needed to be recommended by the dietician for residents with wounds. During a concurrent observation, inspection of the facility's main medication storage room, and interview on 12/3/25 at 9:15 a.m. accompanied by the Director of Nurses (DON) in the facility's main medication storage room, the DON stated Resident 99's IV antibiotic Daptomy expired on 11/8/25 at 4:25 p.m., and stated Resident 99 had been discharged from the facility. The DON explained once IV antibiotics were received from the pharmacy the expectation was, the antibiotic should have been administered to the residents within three to six hours. The ADM stated expired resident medications should not be stored due to the risk of expired medications accidentally administered to the residents. The DON further explained that residents who were discharged from the facility should not have their medication stored in the facility's medication refrigerator. The DON explained expired medication and/or supplements could have harmed the resident, and/or the medications could have been ineffective, and/or caused adverse (bad) effects to the resident. The DON acknowledged the three boxes of Juven mix were expired and past the used by dates. The DON stated expired medications and/or supplement mixes should not be kept or stored due to not wanting them to be available for staff to administer to residents. Review of facility policy and procedure (P & P) titled, MEDICATION STORAGE IN THE FACILITY, revised 1/25, indicated, .Medications and biologicals are stored safety, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized.Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal.Medication storage conditions are monitored on a routine basis and corrective action taken if problems are identified.

Based on observation, interview, and record review, the facility failed to post the total actual staffing hours worked Per Patient Day (PPD - a metric system used to measure staffing to resident ratio over 24 hours). This failure could have given a false sense of the facility being adequality staffed to meet the resident's needs. Findings:During a concurrent observation and interview on 12/4/25 at 11:43 a.m. with the Director of Staff Development/Infection Preventionist (DSD/IP), the facility's document titled, Census and Direct Care Services Hours Per Patient Day (DHPPD), dated 12/4/25, was posted on the staff bulletin board, without an Actual Direct Care Service (ADCS - actual hours nursing staff works per resident in a day) hours on it, and with no staff signature. The DSD/IP stated she completed the actual direct care services hours on the DHPPD form either on the following work day during the day shift, or before she left the facility at 4:30 p.m. The DSD/IP further stated the reason she completed a DHPPD form each day was so that the residents, visitors, and families were aware of the amount of nursing staff assigned per resident for a 24-hour time period. During a concurrent interview and observation on 12/5/25 at 08:11 a.m. with the Director of Nursing (DON), the DON confirmed the posted DHPPD on the bulletin board did not include an actual direct care service on it. The DON stated that the facility should have visibly posted the actual PPD, so visitors and residents could have seen and had knowledge of what the facility's actual staff to resident ratio was for the day. The DON also stated when the actual PPD hours were entered late or on the following day, the facility may have had inaccurate data posted. Review of facility's policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers, dated 7/16, the P&P indicated, Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. 1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (Registered Nurses [RNs], Licensed Practical Nurses [LPNs], and Licensed Vocational Nurses [LVNs]) and the number of unlicensed nursing personnel (Certified Nursing Assistant [CNAs]) directly responsible for resident care will be posted in a prominent location (accessible to the residents and visitors) and in a clear and reasonable format. 3 The information recorded on the form shall include: . a. The name of the facility. f. Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift. g. The actual time worked during that shift for each category and type of nursing staff. h. Total number of licensed and un-licensed nursing staff working for the posted shift. 4. When computing hours of direct care staff working split shifts count only the total number of hours the individual is actually scheduled to work for the shift information being posted. (Example: You are posting data for the Day Shift. A CNA reports to work and is scheduled to work four (4) hours on the Day Shift and four (4) hours on the Evening Shift. In computing the number of hours worked for that shift, count only the four (4) hours scheduled for the Day Shift. The remaining four (4) hours would then be counted towards the totals on the Evening Shift.)

Based on observation, interview, and record review, the facility failed to ensure a total of seven (7) shared resident bedrooms (rooms 1, 3, 5, 8, 10 and 11) measured at least 80 square feet (sq. ft. - unit of measurement) per resident.This failure had the potential to result in a lack of sufficient space for the provision of resident care, to maintain privacy, and to allow for space to house the residents' personal property.Findings:During a concurrent observation and interview on 12/5/25 at 11:57 a.m. with the Maintenance Supervisor (MS), the MS confirmed there were a few rooms that did not meet the minimum 80 sq. ft. per resident in the shared bedrooms (room [ROOM NUMBER], 3, 8, 10, 11, and two other rooms). The MS measured room [ROOM NUMBER] and room [ROOM NUMBER] with a tape measure. rooms [ROOM NUMBERS] had three residents occupied in the rooms. The MS confirmed room [ROOM NUMBER] measured at 135 inches (unit of measurement) in width and 243.5 inches in length, room [ROOM NUMBER] measured at 135.5 inches in width and 246 inches in length.During a concurrent interview and record review on 12/5/25 at 11:34 a.m. with the ADM, the Department's (California Regulatory Department) document titled, Client Accommodation Analysis (CAA), dated 10/08, completed by the facility's ADM, was reviewed. The ADM confirmed the room measurements. The ADM provided the following documented room measurements for the resident rooms which did not meet the minimum space requirement of 80 sq. ft. per resident in shared bedrooms:Room Occupancy Required/actual sq. ft. Sq. Ft. per resident1 3 residents 240/231 sq. ft. 773 3 residents 240/229 sq. ft. 76.35 3 residents 240/230 sq. ft. 76.666 3 residents 240/232 sq. ft. 77.38 3 residents 240/231 sq. ft. 7710 3 residents 240/238 sq. ft. 79.311 3 residents 240/229 sq. ft. 76.3 During a concurrent observation and interview on 12/5/25 at 2:40 p.m. with the Certified Nursing Assistant (CNA) 2, CNA 2 demonstrated how she moved the beds, bedside tables, and nightstands to provide care for residents in the rooms. CNA 2 stated the CNAs had to move beds to make enough room for the lift machine (a device that assists with lifting heavy or immobile residents from the bed) and during transfers (moving a resident from one location to another location), especially with two people assistance (two people assist with the resident transfer). CNA 2 further stated the room was a bit tight, but they made use of the space that was available. During an interview on 12/4/25 at 2:47 p.m. with Resident 21, Resident 21 stated there was no concern with the room size, staff had enough space for the residents' ADL (activities of daily living - bathing, brushing hair, brushing teeth) care and enough space in the room for the equipment.Based on the findings during the recertification survey, the Department recommends granting the continuation of the Room Waiver, contingent upon compliance with federal regulations at Resident Rights (481.10) and Physical Environment (483.90).

Based on interview, and record review, the facility failed to ensure quality of care and services were provided to one of three sampled residents (Resident 1) when cardiopulmonary resuscitation (CPR- an emergency lifesaving procedure performed when the heart stops beating) was not attempted by licensed staff when Resident 1 was found unresponsive on [DATE].This failure resulted in the wishes for Resident 1's Representative/ Decisionmaker (RR) not being honored and also potentially contributed to the death of Resident 1.A review of Resident 1's admission RECORD, dated [DATE], indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD- a group of lung diseases that cause persistent airflow obstruction and breathing problems that can significantly impact quality of life and life expectancy), encounter for palliative care (medical services where a patient receives care and support related to a serious or life-limiting illness), dementia (a group of conditions that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and problem solving), hypertensive heart disease with heart failure (a condition where prolonged high blood pressure damages the heart muscle leading to the heart not pumping blood as well as it should).A review of Resident 1's medical record titled, [Hospice Company Name] [City Name] PHYSICIANS'S ORDER SHEET, dated [DATE], indicated, .admitted to [Hospice Company Name] under routine level of care.Code status: Full code [if a patient's heart and/or breathing stops, medical staff will perform all possible life-saving interventions, including CPR].A review of Resident 1's medical record document provided by the Hospice Company titled, Narrative Note, dated [DATE], indicated, .Code status: Full code .Primary Hospice [specialized care that provides physical comfort and emotional, social and spiritual support for people nearing the end of life] Diagnosis: Chronic Obstructive Pulmonary Disease.Reviewed Hospice philosophy, care and goals, coverage, medications. and.plan of care with family and facility staff. They Verbalized understanding of all instructions given. Consents were signed and reviewed with [RR/Decisionmaker's Name].in person. Provided [NAME] of Rights, patient's handbook with the review of emergency preparedness.to [RR/Decisionmaker's Name].A review of Resident 1's Physician Orders for Life Sustaining Treatment (POLST- portable medical orders communicating a patient's end-of-life wishes, ensuring they are known and honored by providers) dated [DATE], indicated, .First follow these orders, then contact Physician/NP [nurse practitioner]/PA [physician assistant]. A copy of the signed POLST form is a legally valid physician order .A .CARDIOPULMONARY RESUSCITATION (CPR): If patient has no pulse and is not breathing .Attempt Resuscitation/CPR .B .MEDICAL INTERVENTIONS .Full Treatment - primary goal of prolonging life by all medically effective means . Further review of Resident 1's POLST indicated that it was signed by the Resident 1's representative/decision maker (RR); the POLST form did not contain a physician's signature.A Review of Resident 1's Progress Notes titled, Nurses Note, dated [DATE], at 6:28 AM, indicated, .Resident was found unresponsive, unable to obtain v/s [vital signs: body temperature, pulse rate, respiration rate, blood pressure, and oxygen saturation], writer and another nurse assess resident @ [at] 0545 [5:45 AM]. [Hospice Company Name] notified and arrived @ 06:15 [6:15 AM]. Resident pronounced time of death 0618 [6:18 AM]. Further review of the Nurses Note failed to show CPR was attempted for Resident 1 when he was found unresponsive.During an interview on [DATE], at 11:12 AM, with the Director of Staff Development, the DSD confirmed Resident 1's POLST indicated he was Full Code. The DSD further confirmed that CPR was not performed on Resident 1 when he was found unresponsive on [DATE]. The DSD stated that she was assigned to Resident 1 and worked the night shift on [DATE] from 11 PM through [DATE] 11 AM. The DSD explained she was working alongside LN 1 during that shift and was training her on the floor. The DSD stated LN 1 notified her upon finding Resident 1 unresponsive in Resident 1's room. The DSD further stated that she accompanied LN 1 to Resident 1's room to assess him and acknowledged that nursing staff failed to initiate CPR. The DSD stated that in her mind, Resident 1 was unresponsive, had no heartbeat, she was unable to obtain vital signs, and was a hospice patient. The DSD further stated that she should have considered Resident 1 as Full Code; regardless of the POLST not being signed by the physician. The DSD stated LN 1 should have initiated CPR when she found Resident 1 unresponsive and not breathing to honor the RR's wishes and possibly save Resident 1's life. During a phone interview on [DATE], at 12:51 PM, with LN 1, LN 1 stated she worked alongside the DSD on the night shift for [DATE] through the morning of [DATE], and she was shadowing (involves observing a professional's work, interactions, and procedures) the DSD during the shift. LN 1 further stated that Resident 1 was found unresponsive and she was unable to obtain vital signs; stating she was .Unable to find respirations, heartbeat, not breathing . LN 1 stated she left Resident 1 unattended and left the room to locate the DSD for assistance. LN 1 confirmed she did not initiate CPR when she found Resident 1 unresponsive. LN 1 stated she did not know the facility's protocol and added that she had .Concerns to revive him . LN 1 further stated that CPR should have been initiated immediately when a resident with a Full code status was found not breathing and unresponsive. LN 1 stated Resident 1's POLST specified that Resident 1's RR wished for Resident 1 to be Full Code and that those wishes should have been followed by the nursing staff. LN 1 further stated nursing staff failed to honor the RR's wishes regarding CPR for Resident 1. During a phone interview on [DATE], at 1:18 PM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated he worked the night shift on [DATE] and Resident 1 was included in his assigned group. CNA 1 further stated that he made rounds in the residents' rooms to ensure safety and that residents' needs were met. CNA 1 stated that between 3 AM and 4 AM, he observed Resident 1 asleep but was breathing. CNA 1 further stated he did not hear or observe that a Code Blue (a call for an immediate medical emergency response for a patient who is in cardiac or respiratory arrest) was called, nor did he observe CPR being performed on Resident 1 during that shift.During a phone interview of [DATE], at 2:21 PM, with CNA 2, CNA 2 stated that she also worked the night shift on [DATE] and assisted CNA 1 with providing post-mortem care (the respectful, hygienic preparation of a deceased person's body for burial, cremation, or viewing by family) for Resident 1. CNA 2 explained that in a Code Blue situation, nursing staff who were CPR-certified were expected to initiate CPR when a Full Code resident was found unresponsive. CNA 2 stated she did not note that a Code Blue was called or that CPR was initiated by licensed staff when Resident 1 was found unresponsive on [DATE].During a phone interview on [DATE], at 3:32 PM, with the (Hospice Company Name) Director of Patient Care Services (DOPCS), the DOPCS stated that the hospice nurse had discussed Resident 1's code status with Resident 1's representative (RR), and that the hospice agency had received the representative's consent for Resident 1 to be Full Code. The DOPCS further stated the RR wanted Resident 1 to be Full Code but preferred to avoid any hospitalization. The DOPCS stated that when a resident was considered Full Code, the facility was responsible for following its own policies and procedures related to the code status. The DOPCS confirmed the facility was aware of Resident 1's code status as it was the wish and direction of Resident 1's representative.During a concurrent interview and record review on [DATE], at 4:20 PM, with the Director of Nursing (DON), Resident 1's POLST dated [DATE], Resident 1's Nurses Note dated [DATE], at 6:28 AM, and the facility's policy and procedure (P&P) titled, Cardiopulmonary Resuscitation (CPR), dated [DATE], were reviewed. The DON confirmed Resident 1 was considered Full Code. The DON further confirmed that CPR had not been initiated for Resident 1. The DON explained the process for initiating a Code Blue, stating it was the nurse's responsibility to call a Code Blue in an emergency situation when Resident 1's code status was not Do Not Resuscitate (DNR- not to perform cardiopulmonary resuscitation if a person's heart stops or they stop breathing. It is a legal document signed by a patient or their representatives). The DON stated the process began with calling Code Blue, taking the crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) immediately to the resident's location, initiating CPR, while additional staff document and called emergency medical services. The DON further stated that upon admission, the nurse would explain the code status and would review the POLST form with the resident or resident representative to provide education, after which the resident or representative would make the decision and sign the POLST form which was a legal document. The DON explained that when a resident was admitted to hospice, the hospice nurse would review the POLST with the resident or representative to inform them about their rights. The DON stated there were risks involved, explaining that CPR was a life-saving intervention and outcomes depended on the down time, which could result in the resident not receiving life-saving care or receiving care that might lead to a condition the resident would not be comfortable with. The DON further stated that the time of discovery and the amount of down time were critical factors. Review of the facility P&P indicated, .Policy.Properly trained personnel will be available to provide basic life support, including cardiopulmonary resuscitation (CPR), to those requiring emergency care, prior to arrival of emergency medical personnel, and subject to accepted professional guidelines, advance directives, and physician orders.facility staff will provide basic life support, including CPR.if.absence of a valid, Do Not Resuscitate/DNR order.In a cardiopulmonary emergency, immediately initiate, code blue emergency response to facilitate additional assistance in obtaining, implementing, and activating emergency services. Facility staff should engage in concurrent/coordinated emergency response activities, to include assessing individual (i,e. quickly evaluating responsiveness, breathlessness, pulselessness, etc.), activating 911, positioning individual for CPR, initiating chest compressions and performing rescue efforts as indicated, retrieving crash cart, verifying code status, and preparing records for emergency transfer as indicated.Initiate chest compression when pulse is absent and continue until EMS arrives, patient begins moving, or consciousness is regained. The DON acknowledged that the facility's P&P was not followed by nursing staff. The DON stated her expectation was that because Resident 1 was Full Code, CPR should have been initiated immediately. The DON further stated that the decision to perform CPR was not up to the nursing staff, as Resident 1's representative had already signed the POLST indicating that Resident 1 was Full Code.

Based on interview and record review, the facility failed to ensure preferences for end of life or emergency care would be honored for 3 of 22 sampled residents (Residents 12, 43, 49) when, 1. The facility failed to determine upon admission whether Resident 43 and Resident 49 had an Advance Directive (specific instructions about one's own health care) and, if not, determine whether they wished to formulate an Advance Directive; and, 2. The facility failed to ensure a copy of Resident 12's Advance Directive was available at the facility. These failures could have resulted in the residents' end of life wishes not being honored. Findings: 1a. During a review of Resident 43's clinical record titled, Admission Record (a document that contained the resident's demographic information), the record indicated Resident 43's diagnosis included type 2 diabetes (the body's inability to control blood sugar), and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). A review of Resident 43's clinical record titled, Preferred Intensity of Care, dated 6/7/24, signed by the Physician and Resident 43, did not indicate if Resident 43 did or did not have an Advanced Directive. A review of Resident 43's clinical record titled, Physician Orders for Life-Sustaining Treatment (POLST - physician's order indicating the resident's request for basic end of life care), dated 6/7/24, did not indicate if Resident 43 had an Advanced Directive, if it was discussed with Resident 43 or the legally recognized decisionmaker, or if Resident 43 had the capacity (understanding) to make decisions. A review of Resident 43's clinical record on 8/29/24, at 9:50 a.m., indicated Resident 43's Electronic Health Record (EHR) and paper chart did not contain a copy of an Advanced Directive on file or indicate if Resident 43 had formulated an Advanced Directive. During a concurrent interview and record review on 8/29/24, at 8:46 a.m., with the Director of Nursing (DON), Resident 43's POLST was reviewed. The DON stated she was not sure if an Advanced Directive portion of the POLST was discussed with the resident during the admission process. The DON stated there was a difference between a POLST and an Advanced Directive with the Advanced Directive giving more details about end-of-life care and wishes. The DON stated the POLST should have been completed in its entirety, verifying if an Advanced Directive was completed (and a copy obtained) or if the resident desired to have one completed. During an interview on 8/29/24, at 9:43 a.m., with Resident 43, Resident 43 stated he remembered signing some type of paper that indicated if he wanted to have compressions if his heart stopped beating or if he stopped breathing. Resident 43 stated the facility did not explain to him the meaning of an Advanced Directive or ask if he wanted to formulate an Advanced Directive. During an interview on 8/29/24, at 10:00 a.m., with Medical Records (MR 2), MR 2 stated Resident 43's Electronic Health Record (EHR) did not indicate if Resident 43 did or did not had an Advanced Directive. MR 2 stated it was the facility's responsibility to obtain a copy of Resident 43's Advanced Directive or ask if Resident 43 wanted to formulate an Advanced Directive to ensure his end-of-life wishes were honored. 1b. During a review of Resident 49's clinical record titled, Admission Record (a document that contained the resident's demographic information), indicated Resident 49's diagnosis included history of a stroke (the brain was deprived of oxygen for a time resulting in brain damage and affecting the resident's mobility and speech). A review of Resident 49's clinical record titled, Physician Orders for Life-Sustaining Treatment (POLST - physician's order indicating the resident's request for basic end of life care), dated 1/20/23, did not indicate if Resident 49 had an Advance Directive and/or if it was discussed with Resident 49 or the legally recognized decisionmaker. During an interview on 08/28/24, at 3:29 p.m., with the Social Services Director (SSD), the SSD stated during the admission process if the resident stated he did not have an Advance Directive, the SSD did not explain what an Advance Directive was or ask the resident if he wanted help formulating and Advanced Directive. During a concurrent interview and record review on 8/29/24, at 8:46 a.m., with the Director of Nursing (DON), Resident 49's POLST was reviewed. The DON stated she was not sure if an Advance Directive portion of the POLST was discussed with the resident during the admission process. The DON stated there was a difference between a POLST and an Advance Directive with the Advanced Directive giving more details about end-of-life care and wishes. The DON stated the POLST should have been filled out in its entirety verifying if an Advance Directive was completed or if the resident desired to have one completed. During an interview on 8/29/24, at 9:46 a.m., with Resident 49, Resident 49 stated he thought he had an Advance Directive, and that the facility had a copy. During an interview on 8/29/24, at 10:00 a.m., with Medical Records (MR 2), MR 2 stated Resident 49's Electronic Health Record (EHR) did not indicate if Resident 49 did or did not have an Advance Directive. MR 2 stated the facility did not have an Advance Directive on file for Resident 49. MR 2 stated it was the facility's responsibility to obtain a copy of Resident 49's Advanced Directive or ask if Resident 49 wanted to formulate an Advanced Directive to ensure his end-of-life wishes were honored. 2. During a review of Resident 12's clinical record titled, Admission Record (a document that contained the resident's demographic information), the record indicated Resident 12's diagnosis included a history of a stroke (the brain was deprived of oxygen for a time resulting in brain damage and affecting the resident's mobility and speech), type 2 diabetes (body's inability to control blood sugar), and epilepsy (intermittent, uncontrolled body movements caused by electrical dysfunction in the brain). A review of Resident 12's clinical record titled, Preferred Intensity of Care, dated 5/18/23, signed by the physician and the surrogate (stand-in) decision maker, indicated Resident 12 had an Advanced Directive and the document further indicated the facility was supposed to attach a copy of the Advanced Directive to the Preferred Intensity of Care form. A review of Resident 12's clinical record titled, Physician Orders for Life-Sustaining Treatment (POLST - physician's order indicating the resident's request for basic end of life care), dated 1/24/24, did not indicate whether or not Resident 12 had an Advanced Directive. During an interview on 8/28/24, at 3:11 p.m., with the Licensed Nurse (LN 4), LN 4 stated during the admission process, the facility should have called Resident 12's family to obtain a copy of Resident 12's Advanced Directive. During an interview on 8/28/24, at 3:29 p.m., with the Social Services Director (SSD), the SSD stated her process was, once she was made aware the resident had an Advanced Directive, she called the resident's family to obtain a copy. During a joint interview on 8/29/24, at 10:55 a.m., with the DON and the Administrator (ADM), the DON and the ADM acknowledged that Social Services should have followed up with Resident 12 regarding obtaining a copy of the Advanced Directive. During an interview on 8/29/24, at 9:59 a.m., with Resident 12's Responsibly Party (RP 1- assisted resident in making decisions), RP 1 stated Resident 12 had an Advanced Directive and she had provided a copy to the facility. During an interview on 8/29/24, at 10:00 a.m., with Medical Records (MR 2), MR 2 stated the Electronic Health Record (EHR) indicated Resident 12 had an Advanced Directive, but the facility did not have a copy on file. MR 2 stated it was the facility's responsibility to obtain a copy of Resident 12's Advanced Directive to ensure her end-of-life wishes were honored. During an interview on 8/29/24, at 10:10 a.m., with Resident 12, Resident 12 stated she had an Advanced Directive, and the facility should have had a copy of it on file. During a concurrent interview and record review on 8/29/24, at 11:03 a.m., with the DON and the Administrator (ADM), the facility's Policies and Procedures (P&Ps) titled, Advanced Directive/Individual Health Care Instructions, dated 3/22/18 and Physician Orders for Life Sustaining Treatment (POLST), dated 3/22/18, were reviewed. Advanced Directive/Individual Health Care Instructions, indicated, . Periodically conduct educational programs for facility staff, residents and family members on . How to help people complete an Advance Health Care Directive or an Individual Health Care Instruction if they so choose. The Resident has the right to . Complete advance health care directives or individual health care instructions . Physician Orders for Life Sustaining Treatment (POLST) indicated, . A qualified healthcare provider, preferably a registered nurse or social worker will review the POLST form for completeness .Once reviewed, the POLST should be copied, and the current original form placed in the resident's chart, along with the resident's Advance Directive if he/ she has one . The DON and the ADM acknowledged the POLST should have been completed in its entirety including information about the Advanced Directive. The ADM and the DON stated the admitting nurse should have notified Social Services and Social Services should have followed up with the residents and assisted them with resources to formulate an Advanced Directive if so desired. The DON and the ADM stated the P&Ps were not followed.

Based on interview, and record review, the facility did not ensure correct medications were administered for 1 of 22 sampled residents (Resident 22) when Resident 22 was admitted with the wrong discharging documents from the acute hospital and the error was not identified for three days after admission. This failure placed Resident 22 at risk for complications related to medications received which were not intended for her. and complications related to medications she should have received, but did not for three days. Findings: The Department received a report from the facility and a complaint regarding Resident 22's interfacility transfer (IFT) documents (IFT- a communication tool when transferring a patient to another facility which contains pertinent information regarding the patient's care received from the discharging facility and to continue care at the admitting facility) from the acute hospital indicated a different name and did not reflect the correct information at time of admission. This error caused Resident 22 to receive medications that were not prescribed for her until it was discovered for at least three days after admission. This report and the complaint were investigated during the facility's unannounced annual recertification survey. During a review of Resident 22's ADMISSION RECORD, indicated Resident 22 was admitted to the facility in the middle of 2024 with diagnoses which included presence of left artificial hip joint, diabetes mellitus (too much sugar in the blood), and heart disease. During a review of Resident 22's Care Plan, dated 8/3/24, the care plan indicated, .Medication error: resident was adminitered [sic] wrong medications . During an interview on 8/29/24, at 10:37 a.m. with the Admissions Coordinator (AD), the AD explained she would review all information written on the referral documents of residents considered for admission to the facility who were waiting to be discharged from the acute hospital. The AD further explained she would review the history and physicals, therapy notes, any isolation precautions, any intravenous (IV) antibiotics, and all medications the resident received while in the acute hospital. The AD continued, she would then upload the documents into the facility's point click care (PCC) system (a cloud-based healthcare software) for the nurses to review the information prior to receiving the resident to the facility. The AD stated the IFT documents received at the time of admission were the most current and correct information for the nurses to carry out the plan of care. The AD further stated the IFT report that came with Resident 22 on admission had a sticker with her name on every page. The AD added the documents itself had a different name on every page in a smaller print. During an interview on 8/29/24, at 11:16 a.m. with the Director of Nursing (DON), the DON confirmed the IFT document that came with Resident 22 at the time of admission indicated a different name but the sticker attached on every page of the IFT documents had Resident 22's name. The DON stated the IFT documents had the correct sticker attached but had the wrong name on each page of the document. The DON also confirmed the error was discovered three days after admission when the acute hospital called the facility that the IFT documents did not belong to Resident 22. During a record review of Resident 22's Inter-Facility Transfer Report, dated 8/3/24 with the DON, indicated a list of medications Resident 22 received which was not prescribed for her. The list of medications were as follows: ampicillin-an antibiotic enoxaparin-an anticoagulant melatonin-a supplement for sleep amlodipine-lower high blood pressure linaclotide-relieve chronic constipation memantine-treat memory loss in dementia metoprolol-lower high blood pressure ranolazine-treat chronic chest pain rivastigmine-treat Alzheimer's disease rosuvastatin-lower high cholestrol The DON confirmed the list of medications that were not prescribed for Resident 22. During a record review of Resident 22's Inter-Facility Transfer Report, dated 8/6/24 with the DON, indicated a list of medications prescribed for Resident 22 which she should have been receiving at the time of admission. The list of medications were as follows: oxycodone-relieve pain rivaroxaban-prevent blood clots dapagliflozin-lower blood sugar fludrocortisone-lower potassium in the blood gabapentin-used to decrease nerve pain insulin glargine-lower high blood sugar midodrine-to raise blood pressure insulin aspart-lower blood sugar semaglutide-lower blood sugar sertraline-antidepressant The DON confirmed the list of medications Resident 22 should have been receiving. The DON stated she would have expected the nursing staff to check the IFT documents thoroughly and should have been checked by everyone including the pharmacy that verified the medications. The DON further stated the nurses would call the facility's medical director (MD) to verify the orders and for the MD to visit the same day of admission or the following day of admission. During an interview on 8/29/24, at 11:43 a.m. with Licensed Nurse (LN) 3, LN 3 confirmed she would call the MD and let him know regarding a new admission, and would ask the MD if the facility could follow the orders. LN 3 stated the MD would agree and would visit the same day of the resident's admission or the following day. LN 3 explained the acute hospital called her on the third day of Resident 22's admission to check the IFT documents if it had Resident 22's name on it. LN 3 stated usually the nurses would check the stickers attached to the IFT documents because the sticker stood out but did not check the name on the document. LN 3 further stated the facility usually received IFT documents with same name on the sticker and the name on the documents. LN 3 confirmed the IFT documents should have been checked for both the stickers attached and the document itself to make sure the names matched to prevent errors in delivering wrong treatment or care that could possibly cause injury or harm to the resident. During an interview on 8/30/24, at 1:11 p.m. with LN 7, LN 7 stated he picked up resident from the acute hospital with the IFT documents. LN 7 explained he contacted the MD to continue the orders received from the acute hospital and stated he got the consent from the MD. LN 7 stated he checked the IFT documents thoroughly but did not catch the name on the sticker did not match the name on the documents. LN 7 stated that it was missed. During a review of the facility's procedure titled, Admission assessment and Follow Up: Role of the Nurse, revised September 2012, indicated, .Reconcile the list of medications from the medication history, admitting orders, the previous MAR (medication administration record), and the discharging summary from the previous institution .Contact the Attending Physician to communicate and review the findings .and obtain admission orders based on these findings .

Based on observation, interview, and record review, the facility failed to meet the needs of 1 of 22 sampled residents (Resident 12) when the facility did not adequately follow up on the resident's request for a prosthetic (artificial) leg. This failure had the potential to result in loss of independence, dignity, and decreased quality of life. Findings: During a review of Resident 12's clinical record titled, Admission Record (a document that contained the resident's demographic information), indicated Resident 12's diagnosis included Type 2 diabetes (inability to control blood sugar) and the absence of left leg above the knee. During a concurrent observation and interview on 8/27/24, at 10:34 a.m., Resident 12 was observed in her bed with her wheelchair at the bedside. Resident 12 had her left leg amputated (a limb that had been surgically removed). Resident 12 stated she had been waiting for a year for her prosthetic leg. Resident 12 stated she was willing to put in the work with Physical Therapy to get stronger in order to walk. Resident 12 stated she would have liked a prosthetic leg in order to walk to the bathroom and outside without maximum assistance. Resident 12 stated it made her feel sad that she was unable to walk. A review of Resident 12's clinical record titled, Orders, dated 6/29/23, at 7:36 a.m., by the Physician (Phys 1), indicated Resident 12 had an order for a prosthetic evaluation. During an interview on 8/28/24, at 3:02 p.m., with the Medical Director (MD), the MD stated Resident 12 was referred for a prosthetic consultation once but was unsure of the outcome. During an interview on 8/28/24, at 3 p.m., with the Director of Rehab (DR), the DR stated Resident 12 had two referrals for an evaluation for a prosthetic leg. The DR stated the prosthetic evaluation notes were not found in Resident 12's clinical record. During a phone interview on 8/28/24, at 3:14 p.m., with Responsible Party (RP) 1, RP 1 stated the facility had not given her a lot of details as to why Resident 12 had not received a prosthetic leg. RP 1 stated she purchased Resident 12 new shoes because Resident 12 had told her she was getting a prosthetic leg. During an interview on 8/29/24, at 1:22 p.m., with the DR, the DR stated the prosthetic evaluation notes should have been in Resident 12's clinical record. The DR stated without the notes in the clinical record, the physician would not know what the prosthetic evaluation recommendation was for Resident 12. The DR stated Resident 12 was last evaluated for a prosthetic last year. During a concurrent phone interview and record review on 8/29/24, at 2:47 p.m., with the Prosthetic Representative (PR), Resident 12's clinical record titled, Orthopedics Clinical Notes, dated 8/29/24, at 2:22 p.m., by the PR, was reviewed. The document indicated, . patient seems sound of mind and is highly motivated for a prothesis. We had talked about a year ago about the possibility of providing a prosthesis . Recently I had spoken with patient again and again patient is very motivated; she really has the desire to have a prosthesis and get back to standing and possibly walking . there is the argument that with a prosthesis patient has a chance to possibly improve and may have the chance to stand with assistance . The PR stated she assessed Resident 12 a couple times last year for an evaluation for a prosthetic leg. The PR stated Resident 12 was very motivated to have a prosthetic leg. During a follow up phone interview on 8/29/24 at 3:06 p.m., with the PR, the PR stated she wrote Resident 12's clinical note on 8/29/24 (the date requested by the facility), the PR stated she could not find copies of any of the past evaluation notes. The PR stated it was not her practice to provide the facility with a copy of Resident 12's evaluation notes. The PR stated Resident 12, fell through the cracks. During a joint concurrent interview and record review on 8/29/24 at 4:10 p.m., with the Director of Nursing (DON) and the Administrator (ADM), the facility's policy and procedure (P&P) titled, Quality of Life, dated 8/2009 was reviewed. The P&P indicated, .The resident's individual needs and preferences, including the need for adaptive devices . shall be evaluated upon admission and reviewed on an ongoing basis . In order to accommodate individual needs and preferences, staff attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible. The DON acknowledged the facility did not follow through with the results of the prosthetic leg assessment for Resident 12. The DON and ADM stated the P&P was not followed. A review of the facility's P&P titled, Resident Rights, 12/16, indicated, . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . communication with and access to people and services, both inside and outside the facility .

Based on observation, interview, and record review, the facility failed to ensure a homelike environment was provided for 1 of 22 sampled residents (Resident 55), when Resident 55 did not have enough room to store personal belongings. This deficient practice did not ensure a homelike environment that encouraged the use of personal belongings to the extent possible. Findings: Review of Resident 55's admission record indicated Resident 55 had been admitted to the facility in July of 2024. During a concurrent observation and interview on 8/27/24 at 12:16 PM with a family member (FM)1, FM 1 stated he was concerned about space in the room. FM1 showed the narrow closet space dedicated to Resident 55 in bed A. FM1 then stated he felt frustrated due to lack of space for the resident's personal belongings and pointed to the drawers. FM1 indicated he was unable to use the drawers dedicated to bed A, because a previous resident's name was labeled on all of bed A's drawers. FM1 further stated that he did not feel comfortable touching the belongings that were still in the drawers. During a concurrent observation and interview on 8/27/24 at 12:20 PM, Certified Nurse Assistant (CNA) 1 confirmed that another resident's name was listed on the drawers in the room that were supposed to be dedicated to the resident in bed A. CNA 1 stated she was not sure why the drawers were labeled and agreed the name and belongings should have been removed and available for use by Resident 55. During a concurrent observation and interview on 8/28/24 at 9:35 AM, Licensed Nurse (LN) 1 verified that a discharged resident's name was still labeled on the drawers assigned to Resident 55. LN 1 further stated the drawers should have been emptied and the name of the previous resident's label should have been removed. LN 1 confirmed there were still belongings in the drawer that did not belong to Resident 55. LN 1 further stated she understood that it was a problem since Resident 55 was unable to use all the space dedicated to her personal belongings. During an interview on 8/28/24 at 10:08 AM, the Director of Nursing (DON) stated it was not their policy to label resident names on the drawers, it should just have the label of bed A or bed B. The DON stated it was her expectation that all belongings be removed at the time of the discharge. The DON stated that leaving the name and belongings was a problem because the resident could not use all the space dedicated for their personal belongings. The DON further stated this situation is not in line with their policy of a homelike environment. Review of facility policy titled, Quality of Life - Homelike Environment, revised 5/17, indicated, Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible.

Based on interview, and record review, the facility failed to develop and implement a resident specific care plan (provides direction on the type of nursing care the resident may need based on their health, medication, behavioral, and psychosocial needs) for 1 of 22 sampled residents (Resident 317) when Resident 317 did not have a care plan developed for catheter care. This failure had the potential for care needs not being met for Resident 317. Findings: A review of Resident 317's ADMISSION RECORD, indicated Resident 317 was admitted to the facility in the middle of 2024 with diagnoses which included urinary tract infection and artificial openings of urinary tract status. During a review of Resident 317's Minimum Data Set, (MDS-an assessment tool) dated 8/27/24, the MDS indicated Resident 317 had an indwelling catheter (a medical device that drains urine from the bladder to a drainage bag). A review of Resident 317's Order Summary Report, indicated, .Catheter Care for Indwelling catheter every shift for catheter care cleanse area every shift monitor for redness, irritation, swelling, s/s (signs and symptoms) UTI [urinary tract infection] . During a concurrent interview and record review on 8/29/24, at 1 p.m. with Licensed Nurse (LN) 8, Resident 317's care plan dated 8/21/24 was reviewed. LN 8 stated there was no care plan created for use of an indwelling catheter. LN 8 further stated there should be a care plan created to monitor care of Resident 317 pertaining to catheter use. During an interview on 8/30/24, at 10:25 a.m. with the Director of Nursing (DON), the DON stated she would have expected a care plan for catheter care was created upon admission. The DON explained the care plan dictated everything that needed to be done for the resident and without a care plan, there was a risk for care not being met. A review of the facility's procedure titled, Catheter Care, Urinary, revised September 2014, indicated, .The purpose of this procedure is to prevent catheter associated urinary tract infections .Review the resident's care plan to assess for any special needs of the resident . A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .

Based on interview, and record review, the facility failed to provide care and services for activities of daily living (ADLs) for 1 of 22 sampled residents (Resident 22) when Resident 22 had no documented evidence a shower was given from 8/6/24 through 8/15/24. This failure had the potential to result in poor hygiene and decreased psychosocial well-being for Resident 22. Findings: A review of Resident 22's ADMISSION RECORD, indicated Resident 22 was admitted to the facility in the middle of 2024 with diagnoses which included presence of left artificial hip joint, diabetes mellitus (too much sugar in the blood), and heart disease. During a phone interview on 8/29/24, at 10:16 a.m. with Resident 22's Family Member (FM) 3, FM 3 stated Resident 22's shower schedule was Tuesdays and Saturdays. FM 3 stated Resident 22 did not receive a shower on a Tuesday. During a concurrent interview and record review on 8/30/24, at 8:09 a.m. with the Director of Staff Development (DSD), Resident 22's Shower Skin Checks Sheets were reviewed. The DSD confirmed Resident 22's shower days were Tuesdays and Saturdays. The DSD explained shower skin checks sheets were to be completed everytime the resident had a shower to indicate the residents had intact skin and these sheets were to be signed by the licensed nurse and then submitted to the DSD for review. The DSD confirmed there were no shower sheets from 8/6/24 through 8/15/24. The DSD stated nine days was too long without a shower. During a concurrent interview and record review on 8/30/24, at 8:51 a.m. with the DSD, Resident 22's Documentation Survey Report for showers was reviewed. The report indicated Resident 22 had missed showers from 8/6/24 through 8/15/24. The DSD confirmed there were shower days that were not documented as given. The DSD confirmed Resident 22 did not receive a shower as scheduled. During a subsequent interview with the DSD, the DSD stated residents would feel dirty, uncomfortable, unhygienic, and embarrassed if showers were not given as scheduled. The DSD further stated a full skin assessment would not be performed if showers were missed, which could lead to unidentified skin issues. During an interview on 8/30/24, at 10:26 a.m. with the Director of Nursing (DON), the DON stated she would have expected the residents to receive their showers as scheduled because it was a basic need. The DON further stated showers would help in preventing infections and would promote a feeling of well-being. The DON also stated it was during showers residents' skin was checked thoroughly for any new skin issues. The DON confirmed showers that were not documented were missed showers. During a review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, revised March 2018, the policy indicated, .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .including appropriate support and assistance with hygiene .bathing . A review of the facility's procedure titled, Bath, Shower/Tub, revised February 2018, indicated, .The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin .

Based on interview, and record review, the facility did not ensure correct medications were administered and correct plan of care was followed for 1 of 22 sampled residents (Resident 22) when Resident 22 was admitted with wrong discharging documents from the acute hospital and the error was not identified for 3 days after admission. This failure placed Resident 22 to not receive the necessary care and services at time of admission and three days thereafter. Findings: The Department received a report from the facility and a complaint regarding Resident 22's interfacility transfer (IFT) documents (IFT-it is a communication tool when transferring a patient to another facility which contains pertinent information regarding the patient's care received from the discharging facility and to continue care at the admitting facility) from the acute hospital indicated a different name and did not reflect the correct information at time of admission. This error caused Resident 22 to receive medications that were not prescribed for her and care that was not intended for her until it was discovered for at least three days after admission. This report and the complaint were investigated during the facility's unannounced annual recertification survey. During a review of Resident 22's ADMISSION RECORD, indicated Resident 22 was admitted to the facility in the middle of 2024 with diagnoses which included presence of left artificial hip joint, diabetes mellitus (too much sugar in the blood), and heart disease. During a review of Resident 22's Care Plan, dated 8/3/24, the care plan indicated, .Medication error: resident was adminitered [sic] wrong medications . During an interview on 8/29/24, at 10:37 a.m. with the Admissions Coordinator (AD), the AD explained she would review all information written on the referral documents of residents considered for admission to the facility who were waiting to be discharged from the acute hospital. The AD further explained she would review the history and physicals, therapy notes, any isolation precautions, any intravenous (IV) antibiotics, and all medications the resident received while in the acute hospital. The AD continued, she would then upload the documents into the facility's point click care (PCC) system (a cloud-based healthcare software) for the nurses to review the information prior to receiving the resident to the facility. The AD stated the IFT documents received at the time of admission were the most current and correct information for the nurses to carry out the plan of care. The AD further stated the IFT report that came with Resident 22 on admission had a sticker with her name on every page. The AD added the documents itself had a different name on every page in a smaller print. During an interview on 8/29/24, at 11:16 a.m. with the Director of Nursing (DON), the DON confirmed the IFT document that came with Resident 22 at the time of admission indicated a different name but the sticker attached on every page of the IFT documents had Resident 22's name. The DON stated the IFT documents had the correct sticker attached but had the wrong name on each page of the document. The DON also confirmed the error was discovered three days after admission when the acute hospital called the facility that the IFT documents did not belong to Resident 22. During a record review of Resident 22's Inter-Facility Transfer Report, dated 8/3/24 with the DON, indicated a list of medications Resident 22 received which was not prescribed for her. The list of medications were as follows: ampicillin-an antibiotic enoxaparin-an anticoagulant melatonin-a supplement for sleep amlodipine-lower high blood pressure linaclotide-relieve chronic constipation memantine-treat memory loss in dementia metoprolol-lower high blood pressure ranolazine-treat chronic chest pain rivastigmine-treat Alzheimer's disease rosuvastatin-lower high cholestrol The DON confirmed the list of medications that were not prescribed for Resident 22. During a record review of Resident 22's Inter-Facility Transfer Report, dated 8/6/24 with the DON, indicated a list of medications prescribed for Resident 22 and should have been receiving at the time of admission. The list of medications were as follows: oxycodone-relieve pain rivaroxaban-prevent blood clots dapagliflozin-lower blood sugar fludrocortisone-lower potassium in the blood gabapentin-used to decrease nerve pain insulin glargine-lower high blood sugar midodrine-lower blood pressure insulin aspart-lower blood sugar semaglutide-lower blood sugar sertraline-antidepressant The DON confirmed the list of medications Resident 22 should have been receiving. The DON stated she would have expected the nursing staff to check the IFT documents thoroughly and should have been checked by everyone including the pharmacy that verified the medications. The DON further stated the nurses would call the facility's medical director (MD) to verify the orders and for the MD to visit the same day of admission or the following day of admission. During an interview on 8/29/24, at 11:43 a.m. with Licensed Nurse (LN) 3, LN 3 confirmed she would call the MD and to let him know regarding a new admission and would ask the MD if the facility could follow the orders. LN 3 stated the MD would agree and would visit the same day of the resident's admission or the following day. LN 3 explained the acute hospital called her on the third day of Resident 22's admission to check the IFT documents if it had Resident 22's name on it. LN 3 stated usually the nurses would check the stickers attached to the IFT documents because the sticker stood out but did not check the name on the document. LN 3 further stated the facility usually received IFT documents with same name on the sticker and the name on the documents. LN 3 confirmed the IFT documents should have been checked both the stickers attached and the document itself to make sure the names matched to prevent errors in delivering wrong treatment or care that could possibly cause injury or harm to the resident. During an interview on 8/30/24, at 1:11 p.m. with LN 7, LN 7 stated he picked up resident from the acute hospital with the IFT documents. LN 7 explained he contacted the MD to continue the orders received from the acute hospital and stated he got the consent from the MD. LN 7 stated he checked the IFT documents thoroughly but did not catch the name on the sticker did not match the name on the documents. LN 7 stated that it was missed. During a review of the facility's procedure titled, Admission assessment and Follow Up: Role of the Nurse, revised September 2012, indicated, .Reconcile the list of medications from the medication history, admitting orders, the previous MAR (medication administration record), and the discharging summary from the previous institution .Contact the Attending Physician to communicate and review the findings .and obtain admission orders based on these findings .

Based on interview, and record review, the facility failed to provide required supervision for one of three sampled residents, Resident 1, who was dependent on staff for toileting and was left unattended while using the toilet. This failure resulted in Resident 1 attempting to get off the toilet independently without staff supervision which led to a fall and a head injury that resulted in Resident 1's hospitalization on [DATE] and death on [DATE]. Findings: A review of Resident 1's clinical record titled, Admission Record, (a document that contains the resident's personal information) indicated Resident 1 was admitted to the facility on [DATE] with a history that included weakness to the right side of the body following cerebrovascular disease (also called cerebrovascular accident or stroke-damage to the brain from interruption of its blood supply) difficulty walking, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 1's clinical record titled, History and Physical Examination, dated [DATE], by the Physician (Phys), indicated, Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's clinical record titled, Post Fall Interdisciplinary Team Notes, (IDT- team members from different disciplines working together and sharing resources regarding resident care), dated [DATE] at 8:26 PM, by the Director of Nursing (DON) indicated, .[Resident 1] had an episode of unwitnessed fall on [DATE] during am [day] shift around 1:15 PM. [Resident 1] was found sitting on floor in the bathroom with her head next to the sink. Visible injury noted to [Resident 1's] forehead on R [right] side temporal [head] location. Location bruised with bleeding noted .transfer [Resident 1] to ER [emergency room ] for further eval [evaluation] and treatment .Root Cause .[Resident 1] scores 7 on BIMS [BIMS- an assessment tool, 0 = severe cognitive impairment (problems with thinking, reasoning, memory, or attention) to 15 = intact cognition], requires assistance with ADLS [activities of daily living- an individual's daily self-care activities], transfers and mobility . A review of Resident 1's clinical record titled, Progress Notes, dated [DATE] at 1:56 PM, by Licensed Nurse (LN) 1 indicated, .when asked by nurse what happened resident stated, 'oh honey I don't know, I just tried getting up from the toilet to pull up my underwear and next thing you know I am on the floor . A review of Resident 1's clinical record titled, Progress Notes, dated [DATE] at 6:37 PM, by LN 2, indicated after the fall, Resident 1 was admitted to the hospital for a subarachnoid hemorrhage (bleeding in the space that surrounds the brain). A review of Resident 1's clinical record titled, Morse Fall Risk Screen, (an assessment tool used to determine the resident ' s risk of falls), dated [DATE] at 5:47 PM, indicated, Resident 1 scored a 41 - moderate risk of falls (High Risk = 45 and higher, Moderate Risk = ,d+[DATE], Low Risk = ,d+[DATE]). A review of Resident 1's clinical record titled, Minimum Data Set Section GG - Functional Abilities and Goals, (MDS - an assessment tool used to plan the care of a resident in nursing homes), dated [DATE], indicated Resident 1 was dependent (helper does all the effort and resident does none of the effort to complete the activity) on staff for toileting hygiene (the ability to maintain the area between the anus and vagina], to adjust clothes before and after voiding [urine] or having a bowel movement [stool]). The record further indicated, Resident 1 utilized a manual wheelchair and walker, and was dependent on a helper for indoor mobility (walking from room to room with or without an assistive device [wheelchair or walker]). A review of Resident 1's clinical record titled, Care Plan, initiated on [DATE], indicated, Resident 1 was a high risk for falls and injury related to poor judgement, attempting to get out of bed unassisted. A review of Resident 1's clinical record titled, Care Plan, dated [DATE], indicated, Resident 1 had an Occupational Therapy focus (OT- therapy designed to develop, recover, and improve needed function for daily living) that included a self-care deficit as evidenced by needed assistance with lower body dressing and toileting hygiene. Resident 1's Activities of Daily Living (ADL- an individual's daily self-care activities) independence fluctuated due to dementia, cognitive deficit (mental decline), and poor safety judgement. A further review of Resident 1's clinical record titled, Care plan, dated [DATE], indicated, Resident 1 was at high risk for weakness and intolerance in participation of care and ADLs. For interventions, the Certified Nursing Assistant (CNA) was expected to observe Resident 1 for signs and symptoms of the inability to participate in care and ADLs and to assist Resident 1 with ADLs if needed. During a phone interview on [DATE], at 9:17 AM, Family Member (FM) 1 stated Resident 1 was not doing well since her fall on [DATE] and had limited speech after the event. FM 1 further stated Resident 1 was now on hospice (focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life). During an interview on [DATE], at 10:45 AM, LN 3 stated factors that increased Resident 1's risk for falls was a diagnosis of dementia, advanced age, and weakness. LN 3 stated staff should not have left Resident 1 unattended in the bathroom. During an interview on [DATE], at 12:35 PM, LN 1 stated the CNA should not have left Resident 1 in the bathroom without supervision. LN 1 stated Resident 1 was found on the floor of the bathroom with blood coming from her head. LN 1 stated Resident 1 was a risk for falls and had fallen prior to admission to the facility. During an interview on [DATE], at 12:57 PM, CNA 1 stated staff should have remained just outside of Resident 1's bathroom while Resident 1 was using the toilet. During an interview on [DATE], at 1:09 PM, CNA 2 stated when Resident 1 requested privacy while using the bathroom, staff should have given her privacy but remained in the room to provide immediate assistance after Resident 1 had completed using the toilet. During an interview on [DATE], at 1:45 PM, the Director of Staff Development (DSD) stated she and the DON investigated the events leading up to Resident 1's fall. The conclusion was made that the CNA assisted Resident 1 to the bathroom and then left Resident 1's room to perform another task. Resident 1 was later found on the floor of the bathroom with a head injury. The DSD stated the CNA should not have left Resident 1 alone while she was on the toilet. During a phone interview on [DATE], at 3 PM, CNA 3 stated she assisted Resident 1 to the toilet and then shut the bathroom door for requested privacy. CNA 3 further stated Resident 1 was still on the toilet when she left Resident 1's room to perform another task. CNA 3 stated her normal practice was to stay with the resident while he/she was in the bathroom. CNA 3 further stated she thought Resident 1 would wait for help before standing up. CNA 3 stated the DON and DSD talked to her about the incident and CNA 3 was told she should have remained with Resident 1 at all times when Resident 1 was in the bathroom. During a phone interview on [DATE], at 3:08 PM, Medical Doctor (MD) 1 stated he was Resident 1's primary physician. MD 1 further stated Resident 1 was no longer alive and he had to look up what her cause of death was. MD 1 stated Resident 1 was a high risk for falls due to her taking Eliquis (generic name apixaban- a blood thinner medication) and her diagnosis of dementia. MD 1 explained it was not appropriate to leave the resident alone on the toilet and staff should have remained with Resident 1 until she was done using the bathroom and then should have been helped back to bed or the wheelchair. During a subsequent phone interview on [DATE], at 5:40 PM, MD 1 stated Resident 1's cause of death was subarachnoid hemorrhage. A review of Resident 1's Discharge Summary, from the hospital, dated [DATE], in the section CONDITION AT DISCHARGE, indicated, .[Resident 1] Unable to ambulate due to severe stroke . Further review of the section Imaging, indicated, .CT [computerized tomography scan - a series of images taken from different around the body] BRAIN WO [without] CONTRAST .Result Date: [DATE] .Previously identified left sided subacute infarcts [infarction- injury or death of tissue resulting from lack of blood supply] . are not well visualized .No hemorrhagic conversion [rupture of blood vessels after blood flow is restored after a stroke] or new acute infarcts .MRI [magnetic resonance imaging- imaging that uses strong magnetic fields to generate detailed images of organs, bones, muscles and blood vessels] BRAIN WO CONTRAST .Result Date: [DATE] .No acute intracranial hemorrhage [brain bleed] . A review of Resident 1's Discharge Summary, from the hospital, dated [DATE], in the section REASON FOR ADMISSION, indicated, .[Resident 1] .recent admission on ,d+[DATE] (week ago) of acute CVA [cerebrovascular accident- damage to the brain from interruption of its blood supply] .patient recovered well and was discharged to skilled nursing facility for rehabilitation after starting on apixaban .[Resident 1] returns to hospital today [[DATE]] after suffering a fall in the toilet, noticed mild bleeding with hematoma [solid swelling of clotted blood within the tissues] on the right frontal area [front part of the brain]. In ED [Emergency Department], CT head showed small to moderate amount of subarachnoid hemorrhage on the left posterior side .and right prefrontal [frontal lobe of brain] scalp hematoma along with old right cerebellar [brain] infarct . Further review of the section HOSPITAL COURSE, indicated, .Patient was admitted for traumatic subarachnoid hemorrhage after a fall while on apixaban .Given her advanced age, comorbidities, recent strokes ischemic [CVA] as well as subarachnoid hemorrhage, [FM 1] decided to initiate hospice care at care home and does not want [Resident 1] to go back to nursing home. Plan to discharge [Resident 1] to care home with hospice today . A review of Resident 1's CERTIFICATE OF DEATH dated [DATE], indicated, .date of death XXX[DATE] . The section CAUSE OF DEATH, indicated, .the chain of events, diseases, injuries, or complications that directly caused death .Immediate cause (final disease or condition resulting in death) . A. SUBARACHNOID HEMORRHAGE .Time interval between onset and death .1 MON [MONTH] . A review of the facility's Policy and Procedure (P&P) titled, Bathroom, Assisting a Resident to, dated ,d+[DATE], indicated, .Purpose: The purpose of this procedure is to assist the resident with ambulating to the bathroom. Preparation: Review the resident's care plan to assess for any special needs of the resident .Steps in the Procedure - Assist the resident to the bathroom. Close the bathroom door .Wait outside the door, if safety permits .When the resident has signaled or called for you, return to the bathroom. If the resident needs help in cleaning himself .Clean the perineum [area between the anus and vagina] .Assist the resident to stand .Reposition the resident's clothing .