Every finding on record at Valley View Post Acute

Based on interview and record review, the facility failed to ensure two of two sampled residents' (Residents 41 and 86's) Minimum Data Set (MDS, a resident assessment tool) reflected an accurate assessment, by failing to: a. Ensure Resident 86's fall on 5/28/2026 was coded accurately in MDS assessment dated [DATE]. b. Ensure Resident 41's number of days that insulin (a hormone that helps a resident's body use sugar for energy) injections were received since admission was coded accurately in the initial MDS assessment dated [DATE]. These deficient practices resulted in inaccurate reporting to the Centers of Medicare and Medicaid Services (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) for Residents 41 and 86, and had the potential to result in Residents 41 and 86 not receiving interventions to address specific care concerns. Findings a. During a review of Resident 86's admission Record (AR), the AR indicated the facility admitted Resident 86 on 5/15/2026 with diagnoses including cerebral infraction (brain damage), dementia (a progressive state of decline in mental abilities), and muscle wasting and atrophy (loss of muscle tissue and strength). During a review of Resident 86's History and Physical (H&P) dated 5/17/2026, the H&P indicated Resident 86 did not have the capacity to understand and make decisions. During a review of Resident 86's Change in Condition Evaluation (COCE) dated 5/28/2026, the COCE indicated Resident 86 had a fall in the afternoon of 5/28/2026. During a review of Resident 86's MDS dated [DATE], the MDS indicated Resident 86 had severely impaired cognition. The MDS indicated Resident 86 was dependent on staff with oral hygiene, toileting hygiene, showering/ bathing, and bed-to-chair transferring. During a concurrent record review and interview with MDS Coordinator (MDSC) on 6/17/2026 at 12:32 pm, Resident 86's MDS dated [DATE] was reviewed. The MDS indicated Resident 86 did not have a fall since admission. The MDSC stated the MDS dated [DATE] indicate Resident 86 had no falls since admission. The MDSC stated Resident 86's MDS assessment was not an accurate assessment, and it was an error. The MDSC stated the MDS assessment should have coded 1. Yes that resident had a fall since admission. The MDSC stated the MDSC should modify Resident 86's MDS assessment to reflect the fall incident on 5/28/2026. The MDSC stated the CMS did not receive accurate resident information. The MDSC stated it was important to have an accurate MDS assessment because it was the legal medical record. The MDSC stated the MDSC gathered resident's information from resident's medical records, interviewing the residents, and attending assessment references and daily staff meetings. The MDSC stated the MDSC signed the MDS assessment to attest accuracy before transmitting it to the CMS. During an interview with the Director of Nursing (DON) on 6/18/2026 at 12:39 pm, the DON stated it was important to have accurate MDS assessments to submit to the CMS. The DON stated the facility received reimbursement from the CMS. The DON stated the MDSC signed to confirm that the information was accurate. During a review of the facility's Policy and Procedure (P&P) titled, Resident Assessment, revised in 10/2023, the P&P indicated that all persons who had completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. b. During a review of Resident 41's admission Record (AR), dated 4/6/2026, the AR indicated Resident 41 was originally admitted on [DATE] with no re-admission date. The AR indicated Resident 41's diagnoses included type 2 diabetes (a condition where the body either stops responding to a hormone called insulin or does not make enough of it), non-Hodgkin lymphoma (a cancer affecting white blood cells which results in a weakened immune system), and anemia (a condition where a person does not have enough healthy red blood cells to carry oxygen throughout the body). During a review of Resident 41's History and Physical Examination (H&P – a comprehensive assessment of a resident's medical condition), dated 4/7/2026, the H&P indicated Resident 41 has the capacity to understand and make decisions. During a review of Resident 41's Minimum Data Set (MDS – a resident assessment tool), dated 5/8/2026, the MDS indicated Resident 41 was cognitively intact (ability to think and process information). The MDS also indicated Resident 41 needed maximal assistance (a helper does more than half of the effort of the activity) for toileting hygiene and shower/bathe. During a review of Resident 41's Physician (MD) Order Summary, dated 6/18/2026, the MD Order Summary indicated there was no doctor's order for insulin injections to be administered on Resident 41 (started 4/6/2026). The MD Order Summary indicated Mounjaro (a medication that acts like natural gut hormones to help lower blood sugar and decrease appetite) 2.5 milligrams (unit of measurement) was ordered to be given via injections every Wednesday to treat Resident 41's type 2 diabetes. During a concurrent interview and record review on 6/18/2026 at 2:10 pm with the MDS Coordinator (MDSC), Resident 41's MDS dated [DATE] was reviewed. The MDSC stated that whenever a new resident was admitted to the facility, the facility must complete an initial MDS assessment and submit it to CMS within 14 days upon that resident's admission. The MDSC stated MDS assessments should match and be consistent with a resident's diagnoses. The MDSC stated Resident 41 was originally admitted on [DATE] and was not re-admitted since then. The MDSC stated Resident 41 was diagnosed with type 2 diabetes. The MDSC stated Section N of Resident 41's initial MDS assessment, dated 4/13/2026, indicated Resident 41 received insulin injections for one day since Resident 41's admission. The MDSC stated Resident 41 did not have a physician's order for insulin injections. The MDSC stated that upon admission, Resident 41's Physician had ordered Mounjaro to be given via injection to treat Resident 41's type 2 diabetes. The MDSC stated Mounjaro is not the same medication as insulin. The MDSC stated Section N of Resident 41's initial MDS assessment was incorrect because it should not have indicated that Resident 41 received insulin injections for one day since admission date. The MDSC stated the facility must give CMS accurate information regarding all medications Resident 41 has taken within a set period of time. The MDSC stated MDS assessments are important because resident care plans are created based on issues triggered from the MDS assessments. During an interview on 6/18/2026 at 2:44 pm with the DON, the DON stated MDS assessments were used to identify residents' conditions so that nursing staff know how to provide residents with specific care. The DON stated it was important to be accurate when completing Resident 41's initial MDS assessment. The DON stated an MDS assessment is used when creating a care plan. The DON stated when the MDS assessment for Resident 41 was incorrect, Resident 41's care plan would not be addressing Resident 41's needs accurately. During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, dated 10/2023, the P&P indicated a comprehensive assessment of each resident is completed at intervals designated by OBRA regulations (Omnibus Budget Reconciliation Act of 1990 – federal standards of care and rights for people living in certified nursing homes). The P&P further indicated [i]nformation in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews.

Based on interview and record review, the facility failed to develop and implement specific, comprehensive, and individualized person-centered care plans (CP) to meet the residents' needs for three of four sampled residents (Residents 10, 75, and 86) by failing to:a. Develop an individualized CP to address the automatic implantable cardioverter-defibrillator (AICD, a small, battery-powered medical device implanted in the chest that continuously monitored the resident's heart rate) for Resident 10. c. Develop an individualized CP to address smoking safety for Resident 75. d. Develop an individualized CP to address the actual fall on 5/28/2026 for Resident 86. These deficient practices had the potential for Residents 10, 75 and 86 not to received appropriate nursing care based on Residents 10, 75 and 86's needs. Findings: a. During a review of Resident 10's admission Record (AR), the AR indicated the facility admitted Resident 10 on 5/5/2026 with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and atrial fibrillation (the heart beat fast and irregular). During a review of Resident 10's Inpatient Progress Note (IPN) from General Acute Care Hospital 1 (GACH 1), dated 5/2/2026, the IPN indicated Resident 10 had an AICD. During a review of Resident 10's History and Physical (H&P) dated 5/6/2026, the H&P indicated Resident 10 had the capacity to understand and make decisions. During a review of Resident 10's Minimum Data Set (MDS, a resident assessment tool) dated 5/11/2026, the MDS indicated Resident 10 had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 10 required maximal assistance (helper did more than half the effort) from staff with eating, oral hygiene, personal hygiene, and bed-to-chair transferring. The MDS indicated Resident 10 was dependent on staff for toileting hygiene, showering, and bathing. During a review of Resident 10's entire CP, there was no CP developed to address Resident 10's AICD. During an interview with Resident 10 on 6/16/2026 at 12:25 pm, Resident 10 stated that Resident 10 had AICD for cardiac issues. During a concurrent record review and interview with the Director of Nursing (DON) on 6/18/2026 at 12:27 pm, Resident 10's IPN from GACH 1 dated 5/2/2026 indicated the resident has an AICD. The DON stated the IPN indicated Resident 10 had an AICD. The DON stated that the DON requested the AICD information and detail from Resident 10's cardiologist. The DON stated that the DON should have reviewed Resident 10's GACH 1 record more thoroughly. The DON stated it was important to review the AICD information so staff would know how to take care of Resident 10 and implement the appropriate intervention to meet Resident 10's needs. The DON stated the CP for AICD was developed today. The DON stated the licensed nurse should have initiated the CP for the AICD upon admission and when staff found out that Resident 10 had the AICD. The DON stated the purpose of CP was for staff to provide care to residents, to know the residents' needs, and to meet the residents' needs. The DON stated, the CP also indicated the potential risk and how to prevent and take care of the issue when arose. The DON stated the AICD was a defibrillator implant, and it was important for staff to be aware of it (Resident 10's AICD). The DON stated facility staff might not know how to intervene with the AICD related issues without a CP. The DON stated the CP should be specific and resident centered. b. During a review of Resident 75's AR, the AR indicated the facility admitted Resident 75 on 6/15/2025 with diagnoses including epilepsy (sudden bursts of abnormal brain activity that caused brief shaking or loss of awareness) and muscle wasting and atrophy (loss of muscle tissue and strength). During a review of Resident 75's H&P dated 12/20/2025, the H&P indicated Resident 75 did not have the capacity to understand and make decisions. The H&P indicated that Resident 75 had history of tobacco use. During a review of Resident 75's MDS dated [DATE], the MDS indicated Resident 75 had severely impaired cognition. The MDS indicated Resident 75 required setup assistance from staff with eating and oral hygiene. The MDS indicated Resident 75 required supervision from staff with personal hygiene. The MDS indicated Resident 75 required moderate assistance (helper did less than half the effort) from staff with toileting hygiene, showering/ bathing, and bed-to-chair transferring. During a review of Resident 75's Smoking Observation/Assessment (SOA) dated 3/26/2026, the SOA indicated Resident 75 smoked cigarettes and required staff supervision. During an observation on 6/17/2026 at 9:09 am, in facility's smoking patio, Resident 75 was smoking cigarette under the Activity Director (AD)'s supervision. During a concurrent record review and interview with the MDS Coordinator (MDSC) on 6/17/2026 at 12:59 pm, Resident 75's entire care plans were reviewed and there was CP for Resident 75's smoking safety. The MDSC stated there was no CP developed to address smoking safety for Resident 75. The MDSC stated the licensed nurse should initiate the CP for smoking upon knowing that Resident 75 was a smoker and after the completion of the smoking assessment. The MDSC stated Resident 75 was at risk of injury with potential burn without a smoking CP. During an interview with the DON on 6/18/2026 at 12:39 pm, the DON stated there should be a specific and resident centered CP to address smoking. The DON stated the smoking CP should indicate how to take care of and assist smokers. The DON stated that the smoking CP ensured safety during smoking sessions. c. During a review of Resident 86's AR, the AR indicated the facility admitted Resident 86 on 5/15/2026 with diagnoses including cerebral infraction (brain damage), dementia (a progressive state of decline in mental abilities), and muscle wasting and atrophy. During a review of Resident 86's H&P dated 5/17/2026, the H&P indicated Resident 86 did not have the capacity to understand and make decisions. During a review of Resident 86's Change in Condition Evaluation (COCE) dated 5/28/2026, the COCE indicated Resident 86 had a fall in the afternoon of 5/28/2026. During a review of Resident 86's MDS dated [DATE], the MDS indicated Resident 86 had severely impaired cognition. The MDS indicated Resident 86 was dependent on staff with oral hygiene, toileting hygiene, showering/bathing, and bed-to-chair transferring. During a concurrent record review and interview with the MDSC on 6/17/2026 at 12:32 pm, Resident 86's entire care plans were reviewed and there was no CP for fall. The MDSC stated there was no CP developed to address Resident 86's fall on 5/28/2026. The MDSC stated the licensed nurse should initiate the fall CP on 5/28/2026 because that was the time and date the actual fall happened. The MDSC stated the facility should not delay the care. The MDSC stated the MDSC should review the CP quarterly and when there was a change of condition in residents. The MDSC stated the CP ensured staff to provide care for and anticipate residents' needs, to provide medication prescribed by the doctor, and to implement the interventions. The MDSC stated the facility should have a CP addressing the fall on 5/28/26 to continue to provide care and to prevent fall. During an interview with the DON on 6/18/2026 at 12:39 pm, the DON stated there should be a CP for fall so the staff would know the interventions to prevent falls. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2025, the P&P indicated the facility should develop a comprehensive and person-centered care plan to meet the resident's physical, psychosocial and functional needs. The P&P indicated that the facility should develop a comprehensive, person-centered care plan within seven days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21days after admission. The P&P further indicated the CP should reflect currently recognized standards of practice for problem areas and conditions.

Based on observation, interview, and record review, the facility failed to maintain a safe environment for one of one sampled resident (Resident 75) and one of one facility hallway, when:a. Resident 75 had a pack of cigarettes (tobacco wrapped in paper) on the wheelchair at bedside on 6/16/2026.b. The facility did not ensure the floor in the hallway and residents' rooms were free from water after showering the residents. These deficient practices had the potential to increase the risk of accidental fire, injury and harm for the residents, staff and visitors in the facility.Findings: a. During a review of Resident 75's admission Record (AR), the AR indicated the facility admitted Resident 75 on 6/15/2025 with diagnoses including epilepsy (sudden bursts of abnormal brain activity that caused brief shaking or loss of awareness) and muscle wasting and atrophy (loss of muscle tissue and strength). During a review of Resident 75's History and Physical (H&P) dated 12/20/2025, the H&P indicated Resident 75 did not have the capacity to understand and make decisions. The H&P indicated Resident 75 had a history of tobacco use. During a review of Resident 75's Minimum Data Set (MDS, a resident assessment tool) dated 3/25/2026, the MDS indicated Resident 75 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 75 required setup assistance from staff with eating and oral hygiene. The MDS indicated Resident 75 required supervision from staff with personal hygiene. The MDS indicated Resident 75 required moderate assistance (helper did less than half the effort) from staff with toileting hygiene, showering/ bathing, and bed-to-chair transferring. During a review of Resident 75's Smoking Observation/Assessment (SOA) dated 3/26/2026, the SOA indicated Resident 75 smoked cigarettes and required staff supervision. During a concurrent observation and interview on 6/16/2026 at 11:20 am, inside Resident 75's room, Resident 75 was awake and sitting in a wheelchair at bedside. There was a pack of cigarettes next to Resident 75's right hip in the wheelchair. Resident 75 opened the cigarettes pack and there were cigarettes stored inside the pack. Resident 75 stated Resident 75's brother brought the pack of cigarette for Resident 75 to smoke. During a concurrent observation and interview on 6/16/2026 at 12:31 pm, inside Resident 75's room together with the Director of Nursing (DON), there was a pack of cigarettes next to Resident 75's right hip in the wheelchair. The DON stated cigarettes should be stored with the Activity staff. The DON stated the residents should not keep cigarettes in the room because it was a risk for fire and injury in case the residents smoke inside the room. The DON stated Resident 75 could light up the cigarette without any staff supervision. The DON stated the staff who received the residents' cigarettes should ensure proper storage of the cigarettes. During an interview on 6/17/2026 at 9:09 am with the Activity Director (AD), the AD stated the activity department stored and locked residents' cigarettes and lighters in the activity cabinet. The AD stated it was for safety precaution and ensure staff supervision when residents smoke. The AD stated, if the resident kept cigarettes in possession, the resident could smoke in the room and accidentally cause fire. The AD stated the residents could also share the cigarette with other residents. During a review of the facility's Policy and Procedure (P&P) titled, Smoking Policy-Residents, dated 10/2023, the P&P indicated the facility should maintain safe resident smoking practices. The P&P indicated residents without independent smoking privileges might not have or keep any smoking items, including cigarettes, except under direct supervision. b. During an observation on 6/16/2026 at 11:25 am, there was water on the floor of the facility hallway. During an observation on 6/16/2026 at 11:25 am, there was water on the floor in Room A. During a concurrent observation and interview on 6/16/2026 at 11:47 am with Certified Nurse Assistant 2 (CNA 2), there was water on the floor in the facility hallway and Room B. CNA 2 stated the water on the floor in the facility hallway and Room B was from transporting a resident from the shower room to Room B. CNA 2 stated CNA 2 informed the Maintenance Supervisor (MS) about the water on the floor 15 minutes ago. CNA 2 stated it was dangerous to have water on the floor because somebody could fall. During an interview on 6/16/2026 at 11:56 am with the MS, the MS stated it was important to clean up the water on the floor immediately because anybody could slip and fall. During a review of the facility's P&P titled, Safety and Supervision of Residents, dated 7/2024, the P&P indicated the facility should make the environment as free from accident hazards as possible. The P&P indicated the facility-wide priorities were resident safety and supervisions and assistance to prevent accidents. The P&P further indicated that safety risks and environmental hazards should be identified on an ongoing basis.

Based on observation, interview, and record review, the facility failed to implement its policy and procedures (P&P) titled, Respiratory Therapy-Prevention of Infection, dated March 2024, for two of two sampled residents (Resident 11 and Resident 63) by failing to ensure Resident 11's and Resident 63's nasal cannula (NC, a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) tubing was labeled when changed.This failure had the potential to result in contamination of Resident 11's and Resident 63's care equipment, placing the residents at risk of infection.a. During a review of Resident 11's admission Record (AR), the AR indicated Resident 11 was admitted to the facility on [DATE] with diagnoses that included cancer of bronchus (a major airway in the lower respiratory tract that conducts air from the trachea [windpipe] into the lungs) or lung and respiratory failure (when the lungs cannot get enough oxygen into the blood or remove carbon dioxide [waste gas made in the body's cells] from the blood).During a review of Resident 11's Order Summary Report (OSR), the OSR indicated Resident 11 had an active order to change the oxygen cannula every week on Sunday, ordered on 4/13/2026.During a review of Resident 11's Care Plan (CP), dated 4/15/2026, the CP indicated Resident 11 required the use of continuous oxygen related to Stage 4 (most advanced stage of cancer) lung cancer with an intervention to change humidification and oxygen tubing as indicated.During a review of Resident 11's Minimum Data Set (MDS, a resident assessment tool), dated 4/19/2026, the MDS indicated Resident 11 received oxygen therapy while a resident.During a concurrent observation and interview on 6/16/2026 at 10:21 am with the Assistant Director of Nursing (ADON) in Resident 11's room, Resident 11 was wearing NC tubing which was unlabeled. ADON stated Resident 11 was receiving two liters of oxygen via NC. ADON stated Resident 11's tubing was not dated and should have been to allow staff (in general) to know when replacement was needed. ADON stated, weekly tubing changes were done to ensure the tubing was changed routinely to prevent any mucus build up or infections.During an interview on 6/18/2026 at 10:35 am with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated Resident 11 needed continuous oxygen for respiratory failure and pleural effusion (a collection of fluid around the lungs). LVN 4 stated oxygen tubing was changed every week or as needed with the date changed written on the tubing for infection control purposes.b. During a review of Resident 63's AR, the AR indicated Resident 63 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (brain disease, damage, or malfunction caused by an illness or organs that are not working as well as they should) and pleural effusion.During a review of Resident 63's History & Physical (H&P), dated 5/19/2026, the H&P indicated Resident 63 had the capacity to understand and make decisions.During a review of Resident 63's MDS, dated [DATE], the MDS indicated Resident 63 had severely impaired cognition (ability to think).During a review of Resident 63's OSR, the OSR indicated Resident 63 had an active order to change the nasal cannula every week and as needed, every day shift, every Sunday, ordered on 6/7/2026.During a review of Resident 63's Care Plan (CP), revised on 5/29/2026, the CP indicated, Resident 63 required the use of continuous oxygen related to congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and shortness of breath with an intervention to change humidification and oxygen tubing as indicated.During an interview on 6/18/2026 at 1:03 pm with the Director of Nursing (DON), DON stated it was important to label oxygen tubing with the last date it was replaced to prevent the residents from contracting a respiratory infection.During a review of the facility's policy and procedure (P&P) titled, Respiratory Therapy-Prevention of Infection, date March 2024, the P&P indicated the purpose of the P&P was to guide prevention of infection associated with respiratory therapy tasks and equipment. The P&P indicated, change the oxygen cannula and tubing every seven (7) days, or as needed.

Based on observation, interview, and record review, the facility failed to discard seven mustard bottles with a use by date of 5/27/2026 from the dry food storage room in one of one facility kitchen (Kitchen 1). This deficient practice had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) for the residents. Findings: During an interview on 6/16/2026 at 9:35 am with the Dietary Supervisor (DS) inside the kitchen's dry food storage room, the DS stated the kitchen staff will place a label on newly delivered dry food items, such as canned goods and boxed food mixtures. The DS stated the label would indicate when the food item was received and its expiration date. The DS stated that when the expiration date is already stamped on the food item, the kitchen staff does not need to list the expiration date on the label. The DS stated that when new dry food items were delivered, the old food items were placed at the front of the shelves, and the new food items were placed at the back of the shelves to ensure that foods with an earlier expiration date are used first. During a concurrent observation and interview on 6/16/2026 at 9:39 am with the DS inside the kitchen's dry food storage room, there were even mustard bottles, each containing 13 ounces of mustard with expiration date of 5/27/2026. The DS stated these seven mustard bottles had a use by date of 5/27/2026. The DS stated these seven mustard bottles should have been discarded to prevent possible food-borne illnesses to the residents. The DS removed the seven mustard bottles from the kitchen's dry food storage room. During an interview on 6/18/2026 at 1:27 pm with the Director of Nursing (DON), the DON stated expired food could possibly be rotten and potentially cause food positioning when the residents consume expired food. The DON stated, it is important to follow expiration dates on food items in order to protect residents and promote food safety. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated 11/2025, the P&P indicated non-refrigerated foods.are stored in a designated 'dry storage' unit which is temperature and humidity controlled, free of inspections and rodents and kept clean. The P&P further indicated foods shall be received and stored in a manner that complies with safe food handling practices.

Based on observation, interview, and record review, the facility failed to implement infection control in accordance with its policy in one of one facility kitchen (Kitchen 1), when the following items intended for staff use were kept inside the kitchen's dry food storage room: a. An unlabeled resealable bag (one gallon size) containing plastic spoons, sugar packets, coffee creamer packets, and tea bags. b. An unlabeled resealable bag (one quart size) containing plastic cup lids. c. A wooden caddy organizer (wooden box divided into smaller sections) containing individual packets of sugar, coffee creamer, hot sauce, and ketchup. These deficient practices had the potential to spread infection among residents in the facility. Findings: During an observation on 6/16/2026 at 9:30 am inside the kitchen's dry food storage room, an unlabeled resealable bag containing plastic spoons, sugar packets, coffee creamer packets, and tea bags was observed on a food shelf near canned goods and boxed food mixtures. During an observation on 6/16/2026 at 9:31 am inside the kitchen's dry food storage room, an unlabeled resealable bag containing plastic cup lids, and a wooden caddy organizer containing individual packets of sugar, coffee creamer, hot sauce, and ketchup (condiments) were observed on a food shelf near canned goods and boxed food mixtures. During a concurrent observation and interview on 6/16/2026 at 9:42 am with the Dietary Supervisor (DS) inside the kitchen's dry food storage room, the DS stated the unlabeled, resealable bags and wooden caddy containing plastic spoons, plastic cup lids, and various condiments belonged to the nursing staff. The DS stated whenever there were leftover plastic spoons, plastic cup lids, and condiment packets, those items were placed inside the resealable bags and wooden caddy. The DS stated the plastic spoons, plastic cup lids, and various condiments were not supposed to be inside the dry food storage room. The DS stated the dry food storage room in the kitchen was for residents' food only. The DS stated it was possible that a staff member might accidentally take a spoon, cup lid, or condiment packet from the unlabeled, resealable bags or wooden caddy, and then give them to a resident which could potentially lead to the spread of infection. The DS removed the unlabeled, resealable bags and wooden caddy from the dry food storage room. During an interview on 6/18/2026 at 1:27 pm with the DON, the DON stated plastic spoons, plastic cup lids, and condiment packets that were intended for staff use should not be kept in the kitchen's dry food storage room, due to the possibility of spreading infection to residents. The DON stated the plastic spoons, plastic cup lids, and condiment packets should be removed from the dry food storage room and kept in a staff member's personal bag, personal locker, or in the employee lounge. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 10/2018, the P&P indicated an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary environment and comfortable environment and to help prevent the development and transmission of communicable disease and infections. The P&P further indicated the important facets of infection prevention include identifying possible infections.[and] instituting measures to avoid complications or dissemination.

Based on observation, interview, and record review, the facility failed to have an effective pest control program for one of one sampled resident (Resident 15).This failure resulted in gnats (tiny, two-winged flying insects) in Resident 15's room and in patient care areas being a nuisance and had the potential to lead to food contamination and infection risks.During a review of Resident 15's admission Record (AR), the AR indicated the facility admitted Resident 15 on 12/31/2025 with diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and low back pain.During a review of Resident 15's History & Physical (H&P), dated 3/6/2026, the H&P indicated the resident had the capacity to understand and make decisions.During a concurrent observation and interview on 6/16/2026 at10:30 am with Resident 15 in Resident 15's room, five gnats were flying around, and one gnat flew at the surveyor's face during the resident interview. Resident 15 stated Resident 15 initially noticed the gnats a few weeks ago and witnessed them in Resident 15's room and near the reception desk. Resident 15 stated the gnats were annoying to Resident 15 and other residents, and the gnats were usually right in Resident 15's face.During further observation and interview on 6/16/2026 at 10:33 am, Resident 15's room was clean with one small plant observed on Resident 15's roommate's nightstand without any insects in or near it. Resident 15 stated the roommate arrived yesterday. Resident 15 got out of bed to adjust the privacy curtain dispersing the gnats.During a concurrent observation and interview on 6/16/2026 at 10:35 am with Licensed Vocational Nurse 2 (LVN 2) in Resident 15's room, two gnats were observed on the wall in Resident 15's room. LVN 2 stated LVN 2 did not see any food or fruit inside the room as the cause for the gnats. LVN 2 stated for infection control reasons, it was not humane nor safe to have insects in the facility. LVN 2 proceeded to kill one gnat on the wall.During an observation on 6/18/2026 at 8:40 am in the conference room, surveyors observed a gnat flying around the room which then landed on the upper windowsill.During a concurrent observation and interview on 6/18/2026 at 10:18 am with LVN 2 in the Nurses' Station, a gnat was flying around. LVN 2 stated LVN 2 saw the gnat in the nurses' station.During an interview on 6/18/2026 at 11:37 am with the Maintenance Supervisor (MS), MS stated the facility had a pest control program in place but was unaware of the gnats until 6/16/2026.During an interview on 6/18/2026 at 1:01 pm with the Director of Nursing (DON), DON stated there shouldn't be any insects in a resident's room as they could get into their food or belongings and it was an infection risk. DON further stated it was also not a homelike environment.During an interview on 6/18/2026 at 2:12 pm with the family member of Resident 15's roommate (FAM 1), FAM 1 stated the small plant was taken home the night before and did not have any bugs or gnats.During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, dated February 2024, the P&P indicated the facility staff and management maximized, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting which included a clean, sanitary, and orderly environment.During a review of the facility's policy and procedure (P&P) titled, Pest Control, dated April 2026, the P&P indicated the facility shall maintain an effective pest control program. The P&P indicated the facility maintains an on-going pest control program to ensure that the building was kept free of insects and rodents.

Based on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nursing staff to assist a resident when in need) within reach for one of two sampled residents (Resident 59). This deficient practice had the potential to prevent Resident 59 from being unable to call for nursing assistance when needed. Findings: During a review of Resident 59's admission Record (AR), dated 11/21/2023, the AR indicated Resident 59 was originally admitted to the facility on [DATE] with no re-admission date. The AR indicated Resident 59's diagnoses included morbid obesity (a chronic disease in which a person weighs 100 pounds or more over his/her ideal body weight), muscle wasting and atrophy (when the muscles shrink and lose strength due to lack of use), and chronic obstructive pulmonary disease (a group of long-term lung diseases that cause damaged airways and trapped air, making it difficult to breathe). During a review of Resident 59's Care Plan (CP) Report titled, Falls: Resident is at risk for falls with or without injury related to antihypertensive medication, antipsychotic medication, history of falls, last revised on 8/21/2024, the CP indicated an intervention to keep call light within Resident 59's reach and to keep Resident 59 in supervised view as much as possible. During a review of Resident 59's History and Physical Examination (H&P - a comprehensive assessment of a resident's medical condition), dated 11/24/2025, the H&P indicated Resident 59 has an above the knee amputation of the left leg (the surgical removal of the left leg starting somewhere above the kneecap). The H&P also indicated Resident 59 had the capacity to understand and make decisions. During a review of Resident 59's Minimum Data Set (MDS - a resident assessment tool), dated 3/30/2026, the MDS indicated Resident 59 was cognitively intact (able to understand and process information). The MDS indicated Resident 59 was dependent (a helper does all of the effort of the activity) for toileting hygiene, shower/bathe, and personal hygiene. During a concurrent observation and interview on 6/16/2026 at 10:36 a.m. with Resident 59 lying in bed, Resident 59 stated Resident 59 needed nursing assistance. Resident 59's call light was located on the floor behind the head of Resident 59's bed. Resident 59 stated that Resident 59 often did not have the call light within reach. When asked how Resident 59 communicated with the nursing staff, Resident 59 stated Resident 59 would watch the hallway from bedside and then yell at staff passing by. During a concurrent observation and interview on 6/16/2026 at 10:50 a.m. with CNA 3 next to Resident 59's bedside, CNA 3 stated Resident 59's call light was on the floor behind the head of Resident 59's bed. CNA 3 stated the nursing staff should make regular rounds (when a staff member routinely checks on each resident) to ensure the call light is within a resident's reach. CNA 3 stated call lights are important for resident safety because it is how residents communicate with the nursing staff. During an interview on 6/18/2026 at 1:27 pm with the Director of Nursing (DON), DON stated the purpose of call lights is so that residents can get assistance when needed. DON stated certified nursing assistants are required to make rounds at least every two hours. DON stated whenever licensed nurses enter a resident room, the nurses should always make sure the call light is within reach and that the environment is safe. DON stated if a resident cannot reach a call light, then care cannot be rendered appropriately. During a review of the facility's policy and procedure (P&P) titled, Call System, Residents dated 4/2025, the P&P indicated residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member of a centralized workstation. The P&P further indicated that each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on interview and record review, the facility failed to ensure the initial Minimum Data Set (MDS - a resident assessment tool) assessment for one of two sampled residents (Residents 41) was completed within 14 days after Resident 41's admission on [DATE], in accordance with statutory regulations. This deficient practice resulted in the late completion of Resident 41's initial MDS assessment and the potential to result in delayed care planning. Findings: During a review of Resident 41's admission Record (AR), dated 4/6/2026, the AR indicated Resident 41 was originally admitted on [DATE] with no re-admission date. The AR indicated Resident 41's diagnoses included type 2 diabetes (a condition where the body either stops responding to a hormone called insulin or does not make enough of it), non-Hodgkin lymphoma (a cancer affecting white blood cells which results in a weakened immune system), and anemia (a condition where a person does not have enough healthy red blood cells to carry oxygen throughout the body). During a review of Resident 41's History and Physical Examination (H&P - a comprehensive assessment of a resident's medical condition), dated 4/7/2026, the H&P indicated Resident 41 has the capacity to understand and make decisions. During a review of Resident 41's MDS, the MDS indicated Resident 41 was cognitively intact (ability to think and process information). The MDS also indicated Resident 41 needed maximal assistance (a helper does more than half of the effort of the activity) for toileting hygiene and shower/bathe. During a concurrent interview and record review on 6/18/2026 at 2:10 pm with the MDS Coordinator (MDSC), Resident 41's electronic medical record was reviewed. The MDSC stated that whenever a new resident was admitted to the facility, the facility must complete an initial MDS assessment and submit it electronically to the Centers of Medicare and Medicaid Services (CMS - a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) within 14 days upon that resident's admission. The MDSC stated another MDS assessment must be completed every quarter (three months) and every year. The MDSC stated MDS assessments should match and be consistent with a resident's diagnoses. The MDSC stated Resident 41 was originally admitted on [DATE] and was not re-admitted since then (4/6/2026). The MDSC stated Resident 41's initial MDS assessment was completed, locked and submitted late on 4/21/2026. The MDSC stated it was important to complete and submit the MDS assessment timely in order to comply with the rules and regulations. During an interview on 6/18/2026 at 2:44 pm with DON, the DON stated MDS assessments were used to identify residents' conditions so that the nursing staff know how to provide residents with specific care. The DON stated the facility submits MDS assessments to CMS in order to obtain reimbursements based on the assessment findings. The DON stated the facility should comply with the submission deadlines for MDS assessments. During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, dated 10/2023, the P&P indicated a comprehensive assessment of each resident is completed at intervals designated by OBRA regulations (Omnibus Budget Reconciliation Act of 1990 - federal standards of care and rights for people living in certified nursing homes). The P&P further indicated OBRA-Required Assessments are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. OBRA assessments include admission Assessment.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 50), had a revised care plan for a hemodialysis (HD, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) schedule and fluid restriction.This failure placed Resident 50 at risk for improper HD care, fluid overload, and other HD related complications.During a review of Resident 50's admission Record (AR), the AR indicated Resident 50 was readmitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease (ESRD-irreversible kidney failure), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed).During a review of Resident 50's History & Physical (H&P, physician's clinical evaluation and examination of the resident), dated 5/16/2026, the H&P indicated to continue with Resident 50's hemodialysis as scheduled. The H&P indicated Resident 50 had fluctuating capacity to understand and make decisions. During a review of Resident 50's Order Summary Report (OSR), the OSR indicated Resident 50 had active orders for:1. Dialysis treatments four times per week on Tuesdays, Thursdays, Saturdays and Wednesdays, ordered on 5/13/2026.2. Fluid restriction of 1,000 milliliters (ml, unit of volume measurement) total, with fluid received from Nursing, 400 ml total: 7 am to 3 pm shift- 180 ml, 3pm to 11pm shift- 150 ml, 11pm to 7am shift- 70 ml, and fluid received from Dietary, 600 ml total: Breakfast- 240 ml, Lunch- 240 ml, Dinner 120 ml, ordered on 5/19/2026.During a review of Resident 50's Care Plan (CP), the CP indicated Resident 50 needed HD related to renal failure with the following interventions:1. To encourage Resident 50 to go for scheduled dialysis appointments on Mondays, Wednesdays, and Fridays, last revised on 3/18/2025.2. Fluid restriction of 1,000 ml per day with Dietary providing 760 ml (Breakfast- 280ml, Lunch- 240 ml, Dinner- 240 ml) and Nursing providing 160 ml (80 ml during each shift), initiated on 2/19/2026.During a concurrent interview and record review on 6/18/2026 at 10:50 am with Licensed Vocational Nurse 3 (LVN 3), Resident 50's CP was reviewed. The CP indicated that Resident 50 had HD treatments on Mondays, Wednesdays, and Fridays and had a 1,000 ml per day fluid restriction with Dietary providing 760 ml of fluid and Nursing providing 160 ml of fluid. LVN 3 stated Resident 50 received dialysis on Tuesdays, Thursdays, Saturdays and had an extra HD day on Wednesdays. LVN 3 stated the CP is updated by charge nurses anytime the resident has a change and stated Resident 50's CP should have been updated to reflect the scheduled HD days and fluid restriction when the orders were received.During an interview on 6/18/2026 at 1:04 pm with the Director of Nursing (DON), DON stated the CP should be updated when there's a change with the resident, a new order, and quarterly. DON stated, it was important for the resident to have an updated CP so that nursing staff would know the appropriate interventions for the resident and know how to properly care for the resident. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last revised March 2025, the P&P indicated, a comprehensive, person-centered CP that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs were developed and implemented for each resident. The P&P indicated, assessments of residents were ongoing, and CPs were revised as information about the residents and the residents' conditions changed.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 82) had both Pressure Relief Ankle-Foot Orthosis (PRAFO, adjustable, rigid brace that prevents contracture [a stiffening/shortening at any joint, that reduces the joint's range of motion] and prevents pressure ulcer [localized damage to the skin and/or underlying tissue usually over a bony prominence] on the heels) braces on as ordered by the physician.This failure had the potential for Resident 82 developing worsening muscle weakness, worsening foot drop (inability or difficulty to lift the front part of the foot, causing toes to drag along the ground when walking) and pressure ulcers on the heels.During a review of Resident 82's admission Record (AR), the AR indicated the facility readmitted Resident 82 on 8/23/2025 with diagnoses that included contractures of both ankles and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities).During a review of Resident 82's History & Physical (H&P, physician's clinical evaluation and examination of the resident), dated 8/25/2025, the H&P indicated Resident 82 had contractures in all four limbs (both arms and both legs).During a review of Resident 82's Care Plan (CP), dated 11/18/2025, the CP indicated Resident 82 was at risk for decline and/or complications with range of motion (ROM, the full movement potential of a joint) in joints, decreased mobility and movement, decreased muscle strength, decreased functional use of extremity, pain, deformity, contracture, and/or skin breakdown. The CP included interventions for the Restorative Nursing Assistant (RNA, certified nursing assistant who had special training in ambulation, range of motion exercises, applying and removing splints, and positioning) to apply bilateral PRAFO braces every day, five times a week for three to four hours and to check the resident's skin integrity.During a review of Resident 82's Order Summary Report (OSR), the OSR indicated Resident 82 had an active order, dated 11/18/2025, for the RNA to apply bilateral PRAFO braces every day five times a week for up to four hours or as tolerated.During a review of Resident 82's Minimum Data Set (MDS, a resident assessment tool), dated 5/27/2026, the MDS indicated Resident 82's cognitive skills (ability to think, learn, remember, use judgement, and make decisions) were severely impaired. The MDS indicated Resident 82 was dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily), to move around in bed, and to transfer from a bed to a chair or wheelchair. The MDS also indicated Resident 82 had impaired ROM on both lower extremities.During an observation on 6/16/2026 at 9:45 am, Resident 82 was in bed with a PRAFO brace on the right lower extremity and another PRAFO brace lying on the bed.During a concurrent observation and interview on 6/16/2026 at 9:51 am with Licensed Vocational Nurse 1 (LVN 1), Resident 82 was observed with a PRAFO brace only on the right lower extremity. LVN 1 stated both braces should be on to straighten out Resident 82's feet and to prevent Resident 82's foot drop from worsening.During an interview on 6/16/2026 at 9:54 am with RNA 1, RNA 1 stated Resident 82 wears the PRAFO braces for foot drop and should remain on for four hours.During an interview on 6/16/2026 at 9:54 am with the Director of Rehabilitation (DOR), DOR stated Resident 82 had PRAFO braces for foot drop. DOR stated the PRAFO braces limit the progression of Resident 82's foot drop and if not worn may lead to a progression of the ankle's contracture.During a review of the facility's policy and procedure (P&P) titled, Resident Mobility and Range of Motion, last revised July 2023, the P&P indicated residents with limited ROM will receive treatment and services to increase and/or prevent a further decrease in ROM. The P&P indicated, interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts.

Based on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Foods Brought by Family/Visitors, by failing to label and properly store the outside food for Resident 72 This deficient practice had the potential to result in food-borne illnesses (food poisoning) for Resident 72 and could lead to serious medical complications and hospitalization. Findings: During a review of Resident 72 's admission Record (AR), the AR indicated the facility admitted Resident 72 on 4/10/2026 with diagnoses including hypertension (HTN, high blood pressure) and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control). During a review of Resident 72's History and Physical (H&P) dated 4/13/2026, the H&P indicated Resident 72 had the capacity to understand and make decisions. During a review of Resident 72's Minimum Data Set (MDS, a resident assessment tool) dated 4/16/2026, the MDS indicated Resident 72 had moderately impaired cognition (ability to understand). The MDS indicated it was very important for Resident 72 to have snacks available between meals. The MDS indicated Resident 72 required moderate assistance (helper did less than half the effort) from staff with eating, oral hygiene, and personal hygiene. The MDS indicated Resident 72 required maximal assistance (helper did more than half the effort) from staff with toileting hygiene, showering/ bathing, and bed-to-chair transferring. During a concurrent observation and interview on 6/16/2026 at 10:58 am in Resident 72 's room, there was a bottle of opened and unlabeled Italian dressing at Resident 72 's bedside. The Italian dressing bottle indicated to refrigerate after opening. Resident 72 stated Resident 72's family brought the Italian dressing couple days ago. Resident 72 stated Resident 72 used the Italian dressing for salad served in the facility. During an observation on 6/16/2026 at 12:46 pm, in Resident 72 's room, there was a bottle of opened and unlabeled Italian dressing at Resident 72 's bedside. During a concurrent observation and interview with Certified Nurse Assistant 1 (CNA 1) on 6/17/2026 at 11:47 am in Resident 72 's room, there was a bottle of opened and unlabeled Italian dressing at Resident 72 's bedside. CNA 1 stated the Italian dressing bottle was opened and not labeled. CNA 1 stated the Italian dressing bottle should be labelled with resident's name and the received date. CNA 1 stated anyone who made rounds should check everything in the residents' rooms. CNA 1 stated staff should bring outside food from visitors to the charge nurse. CNA 1 stated staff need to make sure the food was the right diet and safe for residents to eat. CNA 1 stated staff should refrigerate the unfinished outside food in the residents' refrigerator. CNA 1 stated facility staff should label all outside food with the received date, time, and resident's name and room number. CNA 1 stated, labeling the outside food with resident's name so no one else could use the food because different residents had different diets. CNA 1 stated storing the food in the residents' refrigerator was for infection control. During an interview with the Infection Preventionist Nurse (IPN) on 6/18/2026 at 12:08 pm, the IPN stated the staff should use a marker to write the resident's name and the received date on all outside food. The IPN stated it was an infection control practice to prevent bacteria growth. The IPN stated staff outside food could be stored in the residents' refrigerator for three days. The IPN stated it prevented food poison. The IPN stated residents with food poison might experience throwing up, diarrhea, and dehydration (the body lost too much water and important fluids). The IPN stated the certified nurse assistant should be the first one to notice the outside food and should have resident's family members to bring outside food to the charge nurse to ensure correct texture to prevent choking for residents. The IPN stated staff should label and store appropriately the outside food. During a concurrent pictures review and interview with the Director of Nursing (DON) on 6/18/2026 at 12:39 pm, the pictures dated 6/16/2026 at 10:58 am and 10:59 am were reviewed. The DON stated the pictures indicated Resident 72 's Italian dressing bottle did not have labels of resident's name or date. The DON stated the pictures indicated the Italian dressing bottle should be stored in refrigerator. The DON stated staff would know when the food was still good to be consumed and when to discard it by labeling the outside food. The DON stated it was to prevent food poisoning with upset stomach. During a review of the facility's P&P titled, Foods Brought in by Family/Visitors, dated 5/28/2025, the P&P indicated the staff should label the food, brought by family/ visitors that was left with resident to consume later, with the resident's name, the item, and the used by date. The P&P indicated the staff should store the perishable food in a refrigerator.

Based on interview and record review, the facility failed to report an injury of unknown source to the California Department of Public Health (CDPH) for one of ten sampled residents (Resident 1). This failure resulted in the delay of notification to CDPH and had the potential for Resident 1 to be subjected to abuse while at the facility. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included cerebral infarction (damage to brain tissue caused by loss of blood flow to a part of the brain) and left side hemiparesis (weakness in the arm, leg, and face on one side of the body). During a review of Resident 1's History and Physical Examination (H&P, physician clinical evaluation and examination of the resident), dated 11/12/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/16/2026, the MDS indicated Resident 1's cognitive skills (ability to think, learn, remember, use judgement, and make decisions) for daily decision making was severely impaired. The MDS indicated Resident 1 had short-term and long-term memory problems. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort to complete the activity) for eating, oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 1 was dependent on staff for toileting hygiene, showering/bathing, lower body dressing, and putting on and taking off shoes. The MDS indicated Resident 1 had impairment of range of motion on upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) affecting one side of Resident 1's body. During a review of Resident 1's Change in Condition Evaluation (CIC), dated 5/29/2026, the CIC indicated Resident 1 had a scratch on upper lip and redness to eyes. During a review of Resident 1's CIC, dated 5/31/2026, the CIC indicated Resident 1 had redness around eyes on 5/29/2026 that changed to purple and yellow in color. During an interview on 6/3/2026 at 1:17 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated CNA 1 noticed bruises on Resident 1's face and CNA 1 did not know how Resident 1 got hurt. CNA 1 stated staff (in general) did not know how Resident 1 got hurt because it was not witnessed. During an interview on 6/3/2026 at 1:45 p.m. with Restorative Nursing Assistant (RNA) 1, RNA 1 stated during morning meeting on Sunday, 5/31/2026, they (nursing staff) discussed Resident 1's discoloration on the face. RNA 1 stated RNA 1 did not know how Resident 1 got hurt. RNA 1 stated Resident 1's discoloration on the face was not witnessed, it was discovered. During an interview on 6/3/2026 at 2:05 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had bruising under both eyes and around upper lip. LVN 1 stated LVN 1 was informed about Resident 1's bruises during handoff report. LVN 1 stated the nurse from previous shift observed Resident 1's bruises but did not witness Resident 1 getting hurt. During an interview on 6/4/2026 at 9:58 a.m. with CNA 2, CNA 2 stated CNA 2 observed bruises on Resident 1's right forearm. CNA 2 stated CNA 2 did not know how Resident 1 got the bruises. CNA 2 stated no one had witnessed how Resident 1 got hurt. During an interview on 6/4/2026 at 2:42 p.m. with Director of Nursing (DON), the DON stated an injury of unknown source was when an injury occurred and staff (in general) did not know how it happened. The DON stated that when there was injury of an unknown source, the facility must report it to CDPH and conduct an investigation to find out how the resident got hurt. The DON stated after facility's investigation, the facility determined Resident 1's injuries were due to Resident 1 hitting the bedrail because that was normal behavior for Resident 1 and the incident was not reported to CDPH. The DON stated staff (in general) did not witness Resident 1 hurt Resident 1's face. The DON stated the bruises were discovered and reported to licensed nurses. During a review of the facility's policy and procedure (P&P) titled, Investigating Resident Injuries, dated 4/2026, the P&P indicated all resident injuries were investigated. The P&P indicated descriptions in the medical record must be objective and sufficiently detailed and should not speculate about causes. The P&P indicated if an incident/accident was suspected, nursing would complete the facility-approved accident/incident form. The P&P indicated an injury of unknown source was an injury that met both of the following conditions:The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident.The injury is suspicious because of:The extent of the injury, the location of the injury, or the number of injuries observed at one particular point on time, or the incidence of injuries over time. During a review of facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 4/2026, the P&P indicated all reports of resident abuse (including injuries of unknown origin) are reported to local, state, federal agencies and thoroughly investigated by the facility management. The P&P indicated findings of all investigations are documented and reported, and if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The P&P indicated the administrator or the individual making the allegation immediately reports his or her suspicion to the state licensing/certification agency responsible for survey/licensing the facility. The P&P indicated immediately was defined as a. within two hours of an allegation involving abuse or result in serious bodily injury orb. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury

Based on interview and record review, the facility failed to develop and implement a care plan (summary of a person's health condition, care needs, treatments, goals of treatment, and specific interventions for each identified condition or care need) for one of ten sampled residents (Resident 1) when: 1. There was no care plan regarding Resident 1's fall on 5/3/2026 found in Resident 1's medical record. 2. There was no care plan regarding Resident 1's behavior of getting Resident 1's arm stuck in the bed rail found in the Resident 1's medical record. These failures had the potential for Resident 1 not receiving appropriate care and services.During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included cerebral infarction (damage to brain tissue caused by loss of blood flow to a part of the brain) and left side hemiparesis (weakness in the arm, leg, and face on one side of the body). During a review of Resident 1's History and Physical Examination (H&P, physician clinical evaluation and examination of the resident), dated 11/12/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/16/2026, the MDS indicated Resident 1's cognitive skills (ability to think, learn, remember, use judgement, and make decisions) for daily decision making was severely impaired. The MDS indicated Resident 1 had short-term and long-term memory problems. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort to complete the activity) for eating, oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 1 was dependent on staff for toileting hygiene, showering/bathing, lower body dressing, and putting on and taking off shoes. The MDS indicated Resident 1 had impairment of range of motion on upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) affecting one side of Resident 1's body. During a review of Resident 1's Change in Condition Evaluation (CIC), dated 5/3/2026, the CIC indicated Resident 1 was found sitting on the floor and suffered abrasions to Resident 1's midback. During a review of Resident 1's electronic medical record, there was no care plan regarding Resident 1's fall on 5/3/2026 found in Resident 1's medical record. During a review of Resident 1's Nursing Progress Notes (NPNs), dated 5/28/2026 to 5/30/2026, the NPNs indicated Resident 1 had a behavior of putting arm in bed rail. During a review of Resident 1's Doctor Progress Note (DPN), dated 5/28/2026, the DPN indicated Resident 1 exhibited behavior of wrapping Resident 1's arms around side rails. During a review of Resident 1's electronic medical record, there was no care plan regarding Resident 1's behavior of wrapping Resident 1's arm around the bed rail found in the medical record. During an interview on 6/4/2026 at 1:50 p.m. with the Director of Nursing (DON), the DON stated a care plan was used to initiate care and to identify issues that a resident has. The DON stated resident health problems, goals and interventions are implemented in the care plan. The DON stated it was important to develop a care plan to make sure residents received care and treatments necessary for their health issues. The DON stated if something did not get care planned, staff would not be aware of resident health issues. During an interview on 6/4/2026 at 2:22 p.m. with the DON, the DON stated Resident 1 had a behavior of placing Resident 1's right arm through the bed rail. The DON stated staff (licensed nurses) should have developed a care plan for Resident 1's repetitive behavior of getting Resident 1's arm stuck in the bed rail. The DON stated a care plan was required to assist nursing staff on how to handle future behaviors.During a review of facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 4/2026, the P&P indicated the comprehensive person-centered care plan:a. Included measurable objectives and time framesb. Described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review the facility failed to ensure one of ten sampled residents (Resident 1) received care and services to prevent accidents when: 1. A Fall Risk Assessment (evaluation conducted to predict the likelihood that a resident will fall) was not completed after Resident 1 had a fall on 5/3/2026. 2. Resident 1 was not assessed by Rehabilitation Department (unit dedicated to help individuals restore physical, mental, cognitive, or vocational abilities lost due to disease, injury, or surgery) after Resident 1's fall on 5/3/2026. 3. Change of Condition (COC, a sudden clinically important deviation in the resident's health or functioning that requires further assessments and interventions) Evaluation was completed when Resident 1's arm got stuck in bed rail.These deficient practices placed Resident 1 at risk for injuries from accidents and had the potential for Resident 1 not receiving appropriate care and services to prevent accidents. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included cerebral infarction (damage to brain tissue caused by loss of blood flow to a part of the brain) and left side hemiparesis (weakness in the arm, leg, and face on one side of the body).During a review of Resident 1's History and Physical Examination (H&P, physician clinical evaluation and examination of the resident), dated 11/12/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/16/2026, the MDS indicated Resident 1's cognitive skills (ability to think, learn, remember, use judgement, and make decisions) for daily decision making was severely impaired. The MDS indicated Resident 1 had short-term and long-term memory problems. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort to complete the activity) for eating, oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 1 was dependent on staff for toileting hygiene, showering/bathing, lower body dressing, and putting on and taking off shoes. The MDS indicated Resident 1 had impairment of range of motion on upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) affecting one side of Resident 1's body. During a review of Resident 1's COC, dated 5/3/2026, the COC indicated Resident 1 was found sitting on the floor and suffered abrasions to Resident 1's midback. During a review of Resident 1's electronic medical record, there was no Fall Risk Assessment by Nursing Department and/or Rehabilitation Department after Resident 1 fell on 5/3/2026, found the in the medical record. During a review of Resident 1's electronic medical record, there was no COC regarding Resident 1's right arm getting stuck in the bed rail found in the medical record.During an interview on 6/3/2026 at 1:17 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated CNA 1 discovered Resident 1 had the resident's right arm stuck in the gaps of the bed rail. CNA 1 stated a licensed nurse (unidentified) had to remove Resident 1's right arm out of the bed rail. CNA 1 stated after Resident 1's right arm was removed, CNA 1 noticed Resident 1's right forearm had red marks. CNA 1 stated Resident 1 always placed Resident 1's arm in the bed rail. CNA 1 stated Resident 1 required assistance to get arm out of the bed rail and that was the reason why CNA 1 called a licensed nurse.During an interview on 6/3/2026 at 1:52 p.m. with Licensed Vocational Nurse (LVN) 1, LVN1 stated Resident 1 moved a lot in bed and had the ability to place Resident 1's arm through gaps in the bed rail. LVN 1 stated Resident 1 often placed Resident 1's arm through the gaps in the bed rail. LVN 1 stated LVN 1 observed Resident 1 had redness to right forearm.During an interview on 6/4/2026 at 9:58 a.m. with CNA 2, CNA 2 stated Resident 1 had a fall last month (May 2026). CNA 2 stated CNA 2 was informed Resident 1 was found sitting on the floor by Resident 1's bed. CNA 2 stated Resident 1 constantly placed arm in bed rail. CNA 2 stated CNA 2 observed bruises on Resident 1's right arm.During an interview on 6/4/2026 at 11:40 a.m. with Director of Rehabilitation (DOR), the DOR stated a Post Fall Screen (evaluation conducted by a physical or occupational therapist to identify new physical impairments, functional decline, or a change in status following a resident fall) had to be completed by the Rehabilitation Department after a resident fall. The DOR stated a fall was when a resident's buttocks, knees or body touched the floor. The DOR stated a Fall Risk Assessment was required after a resident's fall to make sure the resident did not suffer any injury that would be harmful to the resident. The DOR stated after completing the assessment, the DOR would be able to refer the resident to required rehabilitation services. The DOR stated if a Post Fall Screen was not completed there would be a risk in overlooking injuries, fractures and pain and interventions would not be implemented. The DOR stated DOR was not informed about Resident 1's fall and the Rehabilitation Department should have been notified.During an interview on 6/4/2026 at 1:50 p.m. with Director of Nursing (DON), the DON stated a change of condition was when something unusual happened to a resident, something that was not resident's baseline. The DON stated it was important to document all changes of condition to inform staff what is going on with residents. The DON stated if changes of condition did not get documented there was a risk of further decline, staff would not be aware of residents' situation, and the residents would not receive the appropriate care and treatment. The DON stated Resident 1 required COC documentation for when Resident 1's arm got stuck on bed rail because Resident 1 sustained redness to right arm.During an interview on 6/4/2026 at 2:13 p.m. with DON, the DON stated a Fall Risk Assessment was completed on admission, after a fall and quarterly. The DON stated a Fall Risk Assessment was completed to assess a resident's risk in falling. The DON stated if a Fall Risk Assessment was not completed staff would not implement interventions and would not know resident's current risk in falling. The DON stated Resident 1 did not have a fall, Resident 1 was found sitting on the floor. The DON stated staff did not observe Resident 1 get off the bed and land on the floor, so Resident 1 did not fall. The DON stated Resident 1 was not on DON's top list for falls because Resident 1 was able to get off the bed. The DON stated finding Resident 1, who required staff assistance for all activities of daily living, on the floor was not considered a fall and that was why Resident 1 did not have a Fall Risk Assessment. The DON stated Resident 1 was found sitting on the floor and it was not treated as a fall and that was why Rehabilitation Department was not notified. The DON stated when Resident 1 was found sitting on the floor Resident 1 sustained abrasions on Resident 1's back.During a review of facility's Policy and Procedure (P&P) titled, Change in a Resident's Condition or Status, dated 4/2026, the P&P indicated the nurse would record in resident's medical record information relative to changes in the resident's medical/mental condition or status. During a review of facility's P&P titled Falls and Fall Risk, Managing, dated 4/2026, the P&P indicated when a resident was found on the floor, a fall is considered to have occurred. During a review of facility's P&P titled Fall Risk Assessment, dated 4/2026, the P&P indicated nursing staff, in conjunction with attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident centered falls prevention plan based on relevant assessment information.

Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was permitted for readmission to the first available bed in a semi-private room after Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on [DATE] and transferred to Long-Term Acute Care Hospital (LTACH) 1 on [DATE], in accordance with the facility's policy and procedure (P&P) titled, Bed-Holds and Returns, when the facility failed to permit the resident in a manageable condition return to the facility on [DATE].This deficient practice resulted in Resident 1 remaining in Long-Term Acute Care Hospital (LTACH) 1 on [DATE] following an inquiry from LTACH 1 for Resident 1 to be transferred back to the facility.Findings:a. A review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on [DATE] with diagnoses including disorder involving the immune mechanism (the immune system malfunctions), type 2 diabetes mellitus with complication (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), abnormalities gait and mobility, and chronic total occlusion of artery of the extremities (a complete, long-term [more than three months] blockage of blood vessels, in the arms and legs).A review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated that the resident could raise needs known, but cannot make medical decisions.A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 1 was moderate impaired in cognitive skills (ability to make daily decisions). The MDS indicated that the resident required partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. A review of Resident 1's Progress Notes (PN), dated [DATE], the PN indicated that Resident 1 was transferred to GACH 1 on [DATE] at approximately 2:50 AM for evaluation and treatment related to Resident 1's failure to thrive with a bed hold for seven days.A review of Resident 1's Physician Progress Notes (PPN) from LTACH 1, dated [DATE], the PPN indicated Resident 1 improved and stabilized. The PPN indicated that Resident 1 was transferred from a General Acute Care Hospital (GACH) 1 to LTACH 1 on [DATE] for continuation of care.b. A review of Resident 10's admission Record, the admission Record indicated the facility originally admitted Resident 10 on [DATE], and readmitted on [DATE] with diagnoses including encephalopathy (a group of conditions [disease, damage or malfunction] that cause brain dysfunction), immunodeficiency (results from a failure or absence of elements of the immune system), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic kidney disease (CKD- a condition in which the kidneys are damaged and can't filter blood).A review of Resident 10's History and Physical (H&P), dated [DATE], the H&P indicated that the resident had fluctuating capacity to understand and make decisions.A review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 was severely impaired in cognitive skills. The MDS indicated that the resident was dependent (Helper does all of the effort. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. The MDS indicated that the resident required partial/moderate assistance with oral hygiene.A review of Resident 10's Order Summary Report (OSR), dated [DATE], the OSR indicated that Resident 10 was admitted to the facility on [DATE].c. A review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on [DATE] with diagnoses including type 2 DM, CKD, fracture of left pubis (break bones in pelvis, often caused by high energy trauma [falls, car accidents]) and history of falling.A review of Resident 6's History and Physical (H&P), dated [DATE], the H&P indicated that the resident had capacity to understand and make decisions.A review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 was moderately impaired in cognitive skills. The MDS indicated that the resident was dependent on toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. The MDS indicated that the resident required substantial/maximal assistance (Helper lifts or holds trunk or limbs and provides more than half the effort) with upper body dressing and personal hygiene.During a concurrent interview and record review on [DATE] at 3:09 PM with the Marketing (MA), the facility's Census, dated from [DATE] to [DATE] was reviewed. The MA stated the MA received the inquiry for readmitting Resident 1 on [DATE] and the facility refused to readmit Resident 1 on [DATE] due to there was no Candida Auris (C. Auris- is a type of yeast that can cause severe illness and spread easily among very sick patients in healthcare facilities) isolation bed for Resident 1. The MA stated room [ROOM NUMBER], 2, and 3 were semi-private room with two beds and each room had one female bed available on [DATE] and [DATE]. The MA stated room [ROOM NUMBER], 2, 3, and 4 had one female bed available on [DATE]. The MA stated the facility could arrange the four rooms to make one room available from [DATE] to [DATE]. The MA stated the facility made room [ROOM NUMBER] available and readmitted Resident 10 on [DATE].During a concurrent interview and record review on [DATE] at 3:48 PM with the Assistant Director of Nursing (ADON), the facility's Census, dated from [DATE] to [DATE] were reviewed. The ADON stated room [ROOM NUMBER], 2, and 3 were semi-private room with two beds and each room had one female bed available on [DATE] and [DATE] and room [ROOM NUMBER], 2, 3, and 4 had one female bed available on [DATE]. The ADON stated the facility could arrange the four rooms to make one room available from [DATE] to [DATE]. The ADON stated the facility could make room [ROOM NUMBER] available and readmit Resident 1 on [DATE] due to the facility made room [ROOM NUMBER] available and admitted Resident 10 on [DATE].During a concurrent interview and record review with the administrator (ADM) on [DATE] at 8:34 AM, the facility's Census, dated from [DATE] to [DATE], and the inquiry fax from LTACH 1, dated [DATE], were reviewed. The ADM stated the facility received the inquiry fax from LTACH 1 on [DATE] at 6:17 PM and refused to readmit Resident 1 on [DATE]. The ADM stated the facility made room [ROOM NUMBER] available to admit Resident 10 on [DATE]. The ADM stated the facility should readmit Resident 1 due to the facility could make room [ROOM NUMBER] available to readmit Resident 1 on [DATE].During a concurrent interview and record review on [DATE] at 9:52 AM with the Infection Preventionist (IP), the facility's Census, dated from [DATE] to [DATE], and Enhanced Barrier Precautions resident list, dated from [DATE] to [DATE], were reviewed. The IP stated the facility needs to make an empty room as a C. Auris isolation room due to the facility does not have any residents on C. Auris isolation since [DATE]. The IP nurse stated the facility should make room [ROOM NUMBER] empty as a C. Auris isolation room and readmit Resident 1 on [DATE].During an interview on [DATE] at 10:18 AM with Resident 6, Resident 6 stated the facility never asked the resident to change rooms and Resident 6 stated Resident 6 would agree to change rooms if the facility asked.A review of Resident 6's Progress Notes (PN) on [DATE], the PN indicated there were no progress notes written regarding Resident 6 refused to change rooms.A review of the facility's policy and procedure (P&P) titled, Bed-Holds and Returns, revised 10/2022, the P&P indicated, The requirement that residents be permitted to return to the facility following hospitalization or therapeutic leave applies to all residents regardless of payer source. The P&P indicated, Following a hospitalization, residents whom staff are concerned about permitting to return due to their clinical/behavioral condition at the time of transfer are evaluated based on their current condition, not their condition when originally transferred. The P&P indicated, Residents who seek to return to the facility after the state bed-hold period has expired (or when state law does not provide for bed-holds) are allowed to return to their previous room if available or immediately to the first available bed provided that the resident:a. still requires the services provided by the facility; andb. is eligible for Medicare skilled nursing facility or Medicaid nursing facility services.

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for two of two sampled residents (Resident 241 and Resident 28) in accordance with the facility's policy titled Answering the Call Light. This failure had the potential to result in Resident 241 and Resident 28 not receiving care or receiving delayed services to meet the residents' needs and could result in a fall or injury. Findings: During a review of Resident 241's Admission Record (AR), the AR indicated Resident 241 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included muscle wasting (weakening, shrinking, and loss of muscle) and atrophy (decrease in size or wasting away of a body part or tissue) and abnormalities of gait (a person's manner of walking) and mobility (the ability to move). During a review of Resident 241's Care Plan dated 3/27/2025, the Care Plan indicated Resident 241 was at risk for falls related to impaired cognition and unsteady gait. The Care Plan intervention indicated for the nursing staff have Resident 241's call light within reach and to educate and remind the resident to call for assistance with all transfers. During a review of Resident 241's Fall Risk Evaluation (FRE- method of assessing a patient's likelihood of falling) dated 4/17/2025, the FRE indicated Resident 241 was assessed as high risk for falls due to moderately impaired vision, dependent on staff and incontinent (involuntary loss of bladder or bowel control), ambulatory with problems and with devices (gait unsteady), During a review of Resident 241's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 4/23/2025, the MDS indicated, Resident 241 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 241 was dependent (helper does all of the effort) on staff for eating, oral hygiene, toileting hygiene, shower, upper/lower body dressing, putting on/off footwear and personal hygiene. During a concurrent observation and interview on 4/29/2025 at 9:24 a.m., with the Infection Prevention Nurse (IPN), Resident 241 was asleep, lying in bed with the call light hanging on the top of the bed board. The IPN stated Resident 241 was unable to reach the call light. The IPN stated the call light needed to be within easy reach at all times for Resident 241 to use to call for assistance from the staff. During an interview on 4/30/2025 at 3:50 a.m. with the facility's Director of Nursing (DON), the facility's DON stated, a residents' call light needed to be within reach at all times for residents to be able to use it to call for assistance from the staff to maintain residents' safety. During a review of the facility's Policy and Procedure (P&P) titled, Answering the Call Light. dated 10/2010, the P&P indicated when the resident is in bed or in a chair be sure the call light is within easy reach of the resident. 49252 b. During a review of Resident 28's Admission Record (AR), the AR indicated Resident 28 was admitted to the facility on [DATE] with diagnoses that included anemia (a condition where the body does not have enough healthy red blood cells) and muscle weakness. During a review of Resident 28's History & Physical (H&P), dated 11/11/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 28's Minimum Data Set (MDS, a resident assessment tool), dated 2/25/2025, the MDS indicated Resident 28 had severely impaired cognition (ability to understand), used a wheelchair, and needed substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunks or limbs and provides more than half the effort) for toilet transferring (ability to get on and off a toilet or commode). During a review of Resident 28's Fall Risk Observation/Assessment (FRO), dated 3/21/2025, the FRO indicated Resident 28 was at a high risk for falls. During an observation on 4/29/2025 at 10:22 a.m. while in Resident 28's room, Resident 28 was in her wheelchair on the right side of her bed (when facing the wall) pointing to the bathroom, verbally requesting assistance. There was no call light visible and within Resident 28's reach. During a concurrent observation and interview on 4/29/2025 at 10:23 a.m. with Infection Preventionist Nurse (IPN) while in Resident 28's room the IPN pulled at Resident 28's call light wire and placed the call light near Resident 28, clipping it onto the pillow. The IPN stated Resident 28 knew how to use the call light, but it was not within reach. The IPN further stated, the call light needed to be within reach of residents to allow them to call for assistance, if needed. During an interview on 5/2/2025 at 10:24 a.m. with the Director of Nursing (DON), the DON stated Resident 28 was at high risk for falls. The DON further stated, call lights should always be within the resident's reach for safety, to allow the resident to request help or assistance. The DON stated, if the resident was unable to ask for assistance they could fall if they attempted to get up alone. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, revised 3/2024, the P&P indicated, the purpose of the procedure is to respond to the resident's requests and needs. The P&P indicated, when the resident is in bed or in a chair be sure the call light is within easy reach of the resident.

Based on interview and record review, the facility failed to accurately encode the hearing capability and the discharge status on the Minimum Data Set (MDS- a resident assessment and care screening tool), for two of two sampled residents (Residents 51 and 88). a. Resident 51's hearing need was not addressed resulting in a delay in evaluation for hearing aids. b. Resident 88 discharge status was incorrectly coded as discharged to a General Acute Care Hospital on 2/15/25. Resident 88 was discharged to Skilled Nursing Facility (SNF). These failures resulted in inaccurate assessment and had the potential to negatively affect the residents' quality of life. Findings: a. During a review of Resident 51's Admission Record (AR), the AR indicated the facility readmitted the resident on 3/21/25 with diagnoses that included encephalopathy (neurologic disorder), acute pulmonary edema (too much fluid in the lungs), and chronic kidney disease (kidney failure). During a review of Resident 51's MDS dated [DATE], the MDS indicated Resident 51 had severely impaired cognition (ability to understand) and required substantial/maximal assistance with sitting to stand and upper & lower body dressing, personal and toileting hygiene. During an interview on 4/29/25 at 9:49 a.m., Resident 51 was observed putting his hand up and Resident 51 stated he could not hear when interview was attempted. During an interview on 4/29/25 at 9:55 a.m., with Certified Nurse Assistant 3 (CNA 3), CNA 3 stated CNA 3 had to talk loud to Resident 51. CNA 3 stated Resident 51 cannot hear and had no hearing aid. During an interview on 5/2/25 at 9:48 a.m., with CNA 7, CNA 7 stated Resident 51 had difficulty hearing CNA 7 when CNA 7 speaks because of Resident 51's facial expression. CNA 7 stated Resident 51 would lean over to hear. CNA 7 stated CNA 7 had to be in front of Resident 51 and CNA 7 had to speak slowly. CNA 7 stated CNA 7 did not see a hearing aid for Resident 51. CNA 7 stated Resident 51 had a hard time hearing and Resident 51 could benefit from a hearing aide. During a subsequent interview on 5/2/25 at 12:58 p.m. with Resident 51, Resident 51 stated Resident 51 was hard of hearing and Resident 51 would read lips. Resident 51 stated Resident 51 had no hearing aid and Resident 51 would like to have a hearing aid. During an interview and concurrent record review on 5/2/25 at 1:04 p.m., with Minimum Data Set Coordinator 1 (MDSC 1), MDSC 1 stated, when completing a resident's MDS, MDSC 1 would see the resident and ask questions. MDSC 1 stated MDSC 1 would ask the resident if the resident could hear well and if the resident would say yes then there was no difficulty in the resident's hearing. MDSC 1 stated MDSC 1 asked Resident 51 if Resident 51 was able to hear MDSC 1 adequately using a normal tone of voice. MDSC 1 stated Resident 51 did not complain of being hard of hearing at that time of the assessment. During an interview on 5/2/25 at 3:35 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the MDS should match Resident 51's current condition. The ADON stated it was important for the MDS to match the resident's condition as a basis for care and services the resident needed. During a review of the facility's Policy & Procedure (P&P), titled, Certifying Accuracy of the Resident Assessment, dated May 2024, the P&P indicated all residents of the facility receive appropriate, high-quality care and services in accordance with state regulations, federal laws, and evidence-based best practices, promoting dignity, safety, and quality of life. 42781 b. During a review of Resident 88's Admission Record (AR), the admission record indicated Resident 88 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and essential hypertension (high blood pressure). During a review of Resident 88's Progress Notes, dated 2/14/2025, at 1:02 p.m. the notes indicated that Resident 88 was accepted for facility transfer to a SNF for continued long term care. During a review of Resident 88's Order Summary Report, dated 2/15/2025, the report indicated Discharge Resident 88 to SNF for continued long term care per family request on Saturday, 2/15/2025. During a review of Resident 88's Discharge Summary, dated 2/15/2025, at 9 a.m., the notes indicated that Resident 88 was transferred to a SNF for continued long term care. During a review of Resident 88's Progress Notes, dated 2/15/2025, at 9:28 a.m., the notes indicated that Resident 88 was taken by the driver to a SNF. During a review of Resident 88's MDS, dated [DATE], the MDS indicated Resident 88 was discharged to a short-term general hospital. During a concurrent interview and record review of Resident 88's MDS Nurse 1 (MDS N 1) on 5/1/2025 at 10:56 am, MDSN 1 stated Resident 88 was coded as discharged to a short-term general hospital. MDSN 1 stated Resident 88 was discharged to a SNF on 2/15/2025 and not to a general hospital. MDSN 1 stated, Resident 88's MDS assessment needed to be coded discharged to SNF. MDSN 1 stated Resident 88's MDS assessment needed to be coded accurately to provide accurate information to the Centers for Medicare and Medicaid services. During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, dated 10/2024, the P&P indicated, a comprehensive assessment of each resident is completed at intervals designated by Omnibus Budget Reconciliation Act (OBRA) regulations and Prospective Payment System (PPS) requirements. The P&P indicated, OBRA required assessments are federally mandated and must be performed for all residents of Medicare and/or Medicaid certified nursing homes including discharge assessment (return anticipated and return not anticipated). The P&P indicate the resident assessment coordinator is responsible for ensuring the interdisciplinary team conducts timely and appropriate resident assessments.

Based on observation, interview and record review, the facility failed to implement its policy and procedure on Nutritional Management and Care Plans, Comprehensive Person - Centered for two of two sampled residents (Resident 84 and Resident 15) by failing to: a. Ensure Resident 84's fluid intake was accurately monitored as ordered by the primary doctor and an individualized/person-centered care plan was developed and implemented. b. Ensure Resident 15 had weekly weights recorded after a 15-pound (lb.) weight gain. These failures had the potential to result in complications related to electrolyte imbalance for Residents 84 and 15. Findings: a. During a review of Resident 84's Admission Record (AR), the AR indicated Resident 84 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included muscle wasting (weakening, shrinking, and loss of muscle) and atrophy (decrease in size or wasting away of a body part or tissue) and abnormalities of gait (a person's manner of walking) and mobility (the ability to move) and hypo-osmolality and hyponatremia (a condition where the sodium [an electrolyte that helps regulate the amount of water] level in the blood is abnormally low). During a review of Resident 84's Sodium (Na) Level result, dated 4/9/2025, Resident 84's Na level was 122 milliequivalents per liter (mEq/L, unit of measurement). Normal Na range was 136-145 mEq/L. During a review of Resident 84's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 4/19/2025, the MDS indicated, Resident 84 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 84 was dependent (helper does all of the effort) on staff for toileting hygiene, shower, upper/lower body dressing and putting on/off footwear. During a review of Resident 84's Order Summary Report (OSR), dated 4/21/2025, the OSR indicated Resident 84 had an order for fluid restriction (FR, limits the amount of fluids a person consumes each day) of 1,200 cubic centimeters/24 hours (cc/24 hr., measure of volume per day) allotted for dietary of 240 cc for breakfast, 120 cc for lunch, 120 cc for dinner, 120 cc for bedtime, and for nursing of 300 cc for 7 a.m. to 3 p.m. shift, 200 cc for 3 p.m. to 11 p.m. shift and 100 cc for 11 p.m. to 7 a.m. shift. During an observation on 4/29/2025 at 9:18 a.m. while inside Resident 84's room, Resident 84 was awake lying in bed, with a water pitcher at the bedside. During an observation on 4/29/2025 at 12:14 p.m. while inside Resident 84's room, Resident 84 was sitting in bed, with a water pitcher at the bedside. Resident 84 requested cranberry juice from Licensed Vocational Nurse 1 (LVN 1). During an observation on 4/29/2025 at 12:27 p.m. while inside Resident 84's room, Resident 84 consumed a cup of cranberry juice. During an observation on 4/29/2025 at 12:35 p.m. while inside Resident 84's room, Resident 84 requested a cup of juice from Certified Nurse Assistant 9 (CNA 9). CNA 9 stated, she will get back to Resident 84 and get him a cup of juice. During an interview on 5/2/2025 at 10:25 am with CNA 2, the CNA 2 stated Resident 84 was on fluid restriction. CNA 2 stated, she did not document the fluid intake of the resident. The CNA 2 stated there was no clinical documentation that Resident 884's fluid intake was documented or monitored. During an interview on 5/2/2025 at 10:31 a.m. with LVN 9, LVN 9 stated, Resident 84 was placed on fluid restriction of 1,200 cc/day as ordered by the primary doctor. LVN 9 stated there was no documentation or monitoring of Resident 84's fluid intake. LVN 9 stated, Resident 84 needed to be placed on monitoring for fluid intake every meal and when taking medications every shift. LVN 9 stated that Resident 84's Na (Sodium) level was low, and fluid intake needed not to be more than 1,200 cc in a day. During a concurrent interview and record review of Resident 84's medical record (PointClickCare - PCC, a cloud-based software used in long-term and post-acute care facilities) on 5/2/2025 at 11:57 a.m. with the facility's Director of Nursing (DON), the DON stated, Resident 84 was placed on a fluid restriction of 1,200 cc/day. The facility DON stated Resident 84's fluid intake needed to be documented in the Medication Administration Record (MAR) at the end of the shift from medication fluid intake and from the meal tray. The DON stated there was no other clinical documentation that Resident 84's fluid intake was monitored. The DON stated, if fluid intake was not monitored it could cause an electrolyte imbalance. The facility DON stated there was no care plan initiated for Resident 84 who has fluid restriction. The DON stated the care plan needed to be developed and implemented to provide proper treatment and intervention which was specific and individualized to meet the resident's goal. During a review of the facility's undated policy and procedure (P&P) titled, Fluid Restriction, the P&P indicated, the fluid restrictions will be followed per physician's order and monitored by nursing staff for resident compliance. The P&P indicated Fluid Restriction should be documented on the Electronic Medication Administration Record and integrated in the resident's care plan. The P&P indicated, if a resident's fluid was restricted, water pitchers should not be available at the bedside unless evaluated as appropriate. During a review of the facility's undated policy and procedure (P&P) titled, Nutritional Management, the P&P indicated, to ensure timely response to residents' nutritional needs, it was recommended that the nutritional recommendations be implemented and documented within no more than 72 -hours from the time they are issued. During a review of the facility's undated policy and procedure (P&P) titled, Care Plans, Comprehensive Person - Centered, the P&P indicated, the comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (admission, Annual or Significant Change in Status), and no more than 21 days after admission. 49252 b. During a review of Resident 15's Admission Record (AR), the AR indicated Resident 15 was readmitted to the facility on [DATE] with diagnoses that included ESRD (End Stage Renal Disease-irreversible kidney failure) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 15's History & Physical (H&P), dated 3/30/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set (MDS, a resident assessment tool), dated 4/5/2025, the MDS indicated Resident 15 had intact cognition (ability to understand). During an interview on 4/29/2025 at 11:10 am, while in Resident 15's room, Resident 15 stated she had gained 15 lbs. During a review of Resident 15's Nutritional Risk Review (NRR), dated 4/11/2025, the NRR indicated Resident 15 had a 15.46 lb. weight gain and the Registered Dietitian recommendations included to add weekly weights for four weeks. During a review of Resident 15's April 2025 Weights Summary, dated 4/1/2025 to 4/30/2025, the summary indicated no weight measurements were recorded for Resident 15 between 4/12/2025 to 4/23/2025. During a review of Resident 15's Progress notes, dated 4/14/2025 at 5:54 pm, the Progress note indicated Resident 15's physician was made aware of the RD recommendations which were approved to be carried out by the facility. During an interview on 5/1/2025 at 12:10 pm with the Registered Dietitian (RD), the RD stated the facility needs to carry out the RD recommendations within 72 hours if the physician approved. The RD further stated, if there was a significant change in weight, weekly weights would allow them to see if the resident's issues continued or were resolved and were used to ensure patient safety. During a review of Resident 15's Order Summary Report, dated 5/2/2025, the report indicated there was no order present for weekly weights. During a concurrent interview and record review on 5/2/2025 at 10:31 am with the Director of Nursing (DON), the NRR dated 4/11/2025 was reviewed. The NRR included a recommendation for weekly weights for four weeks. The DON stated there should have been an order for weekly weights because Resident 15's physician approved all the RD recommendations, but it was forgotten and not ordered. The DON stated Resident 15 needed monitoring for significant changes in weight because she was a dialysis resident and might have fluid retention. During a review of the facility's policy and procedure (P&P) titled, Nutritional Management, dated 2001, the P&P indicated, to ensure timely response to residents' nutritional needs, it is recommended that the nutritional recommendations be implemented and documented within no more than 72-hours from the time they are issued.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) site as ordered by the physician and as indicated in the plan of care for two of two sampled residents (Residents 42 and 7). These failures had the potential for complications related to tube feedings for Residents 42 and 7. Findings: a. During a review of Resident 42's Admission Record (AR), the AR indicated Resident 42 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness on one side of the body, often affecting the arm, leg, and the face) and gastrostomy (a surgical opening fitted with a device to allow to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 42's Minimum Data Set (MDS, a resident assessment tool), dated 3/28/2025, the MDS indicated Resident 42 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 42 required partial/moderate assistance (helper did less than half the effort) with oral hygiene and upper body dressing and substantial/maximal assistance (helper did more than half the effort) with toileting, shower, lower body dressing and personal hygiene. The MDS indicated Resident 42 had feeding tube for nutrition. During a review of Resident 42's Order Summary Report (OSR) dated 11/21/2023, the OSR indicated Resident 42 had an order for licensed staff to clean the GT site with normal saline solution (NSS), pat dry, cover with draining sponge and secure with retention tape daily and as needed. During a review of Resident 42's untitled Care Plan (CP) dated 4/11/2025, the CP indicated Resident 42 had GT dislodgement and GT replacement. The CP interventions included GT site care per protocol every shift and as needed. During a concurrent observation inside Resident 42's room and interview on 4/29/2025 at 10:14 am with Certified Nurse Assistant 5 (CNA 5), Resident 42 was in bed and lying in bed on her back. Resident 42's GT site did not have a drain sponge dressing and was not secured. b. During a review of Resident 7's AR, the AR indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia, hemiparesis and dysphagia (difficulty swallowing). During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 had severely impaired cognition and dependent (helper did all the effort, resident did none of the effort to complete the activity) with eating, oral hygiene, toileting, shower, upper/lower body dressing and personal hygiene. The MDS indicated Resident 7 had a feeding tube for nutrition. During a review of Resident 7's OSR dated 11/23/2024, the OSR indicated Resident 7 had an order for licensed staff to clean the GT site with NSS, pat dry, cover with draining sponge and secure with retention tape daily and as needed. During a review of Resident 7's untitled CP dated 7/16/2024, the CP indicated Resident 7 had a GT and was at risk for enteral nutrition complications related to clogged tubing, infection and tubing displacement. The CP goals included for the GT insertion site be free of signs and symptoms of infection and complications. During a concurrent observation inside Resident 7's room and interview on 4/29/2025 at 9:39 am with the Restorative Nurse Assistant (RNA), the RNA stated Resident 7's GT site did not have a drain sponge dressing and was not secured. During an interview on 4/30/2025 at 3:50 pm with the Director of Nursing (DON), the DON stated the GT site should be kept clean, covered and secured as ordered by the physician for infection prevention, to prevent dislodgement and to prevent skin irritation on the surrounding area around the GT site. During a review of the facility's Policy and Procedure (P&P) titled, Gastrostomy/Jejunostomy Site Care, revised 10/2024, the P&P indicated, The procedure is to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown and infection. Verify that there is a physician's order for this procedure. Apply the T-drain sponge to the area, hold in place with retention tape.

Based on interview and record review, the facility failed to provide appropriate pain management for one of six sampled residents (Resident 4) by failing to: 1. Ensure Licensed Vocational Nurses (LVN) 3 and 4 called Medical Doctor (MD) 1 to obtain a new order when Resident 4 experienced lower back pain (pain in lower portion of the back) ranging from eight (8) to 10 out of 10 based on a numerical rating scale (NRS, requiring the resident to rate their pain on a defined scale, zero (0) to 10, 0 being no pain, one (1) to three (3) being mild pain, four (4) to six (6) being moderate pain, seven (7) to nine (9) being severe pain and 10 being the worst pain imaginable/very severe pain) on 10/18/2023, at 4 am. 2. Ensure MD 1 and the Medical Director (MDD) authorized the pharmacy to deliver Norco (Hydrocodone-acetaminophen, medication used to treat moderate pain) 5-325 milligram (mg, unit of measurement) per Resident 4 ' s Order Listing Report (OLR). As a result of these failures, on 10/18/2023, Resident 4 endured 12 hours of severe lower back pain (from 10/18/2023, at 4:25 am to 10/18/2034, at 4:09 pm) before Resident 4 was transferred to General Acute Care Hospital (GACH) 1 and received Morphine (narcotic medication used to treat severe pain) for pain relief. Cross Reference: F580 and F710 Findings: 1. During a review of Resident 4 ' s Admission Record (AR), the AR indicated the facility admitted Resident 4 on 10/17/2023 with diagnoses including unspecified low back pain, muscle wasting and atrophy (thinning of muscle mass caused by disuse of the muscles), and abnormalities of gait and mobility (inability to walk normally due to injuries of underlying conditions). During a review of Resident 4 ' s emergency room Physician Note from GACH 1, dated 10/18/2023 at 4:06 pm, the note indicated Resident 4 was diagnosed with acute exacerbation (flare-up of symptoms from an existing illness) of chronic (long-term) lumbar (lower) back pain. Resident 4 received acetaminophen (mild pain medication) 1000 milligram (mg- unit of measurement) by mouth on 10/18/2023, at 4:09 pm. The note indicated Resident 4 received morphine sulfate injection four (4) mg by intra-muscular injection (shot into the muscle) on 10/18/2023, at 4:10 pm. During a review of Resident 4 ' s Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 10/26/2023, the MDS indicated Resident 4 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 4 required partial/moderate (staff provided less than half the effort and lifts or holds trunk) with eating, oral hygiene, and personal hygiene. The MDS indicated Resident 4 was dependent (staff provided total help) with toileting hygiene and showering/bathing self. During an interview on 12/8/2023 at 10:55 am, with Resident 4, Resident 4 stated on 10/18/2023, Resident 4 ' s pain was at an eight (8, severe pain) out of 10 on the pain NRS. Resident 4 stated on 10/18/2023, at 4 am, Resident 4 received one (1) dose of Norco. Resident 4 stated when the pain returned (unknown time) Resident 4 requested for Resident 4 ' s next dose of pain medication and the nurse (unable to identify) told Resident 4 the medication was not ready. Resident 4 stated Resident 4 requested pain medication all morning. Resident 4 stated Resident 4 ' s pain was unmanaged (no relief) and no one in the facility helped Resident 4 with pain relief. Resident 4 stated Resident 4 called 9-1-1 (emergency medical services) and Resident 4 was transported to GACH 1 at 2 pm for pain management. Resident 4 stated Resident 4 was given Morphine (unable to indicate the dose) at GACH 1 on 10/18/2023, at 4:09 pm (12 hours later). Resident 4 stated Resident felt worthless, awful, and about to die when the facility failed to address Resident 4 ' s pain management concerns. During a concurrent interview and record review on 12/8/2023 at 12:27 pm, with the MDS Nurse (MDSN), Resident 4 ' s Order Listing Report (OLR), dated October 2023 and MAR, dated October 2023 were reviewed. The MDSN stated Resident 4 ' s OLR indicated Resident 4 was ordered Norco 5-325 mg, give one (1) tablet every four hours (q4h) as needed for moderate pain on 10/17/2023 by MD 1. The MDSN stated Resident 4 ' s MAR indicated Resident 4 received Norco 5-325 mg for 10 of 10 pain on 10/18/2023 at 4:25 am. The MDSN stated 10 of 10 pain was considered severe pain and the worst pain a resident (in general) would have. The MDSN stated Resident 4 ' s Norco 5-325 mg prescribed medication was not appropriate to treat Resident 4 ' s severe pain. The MDSN stated LVN 4 did not contact MD 1 to report to MD 1 to request for a stronger pain medication to treat severe pain. During a concurrent interview and record review on 12/8/2023 at 12:52 pm, with the Director of Nursing (DON), Resident 4 ' s Progress Notes, dated 10/18/2023 were reviewed. The DON stated Resident 4 ' s notes did not indicate staff attempted to inform MD 1 of Resident 4 ' s severe pain level. The DON stated Resident 4 ' s pain level was eight (8) out of 10 on 10/18/2023, at 12:40 pm. The DON stated eight (8) out of 10 was considered severe pain. The DON stated Norco was not intended to treat severe pain and was not an appropriate medication for Resident 4. The DON stated being in severe pain could affect Resident 4 ' s cognition, ability to make decisions, answer questions, and function. The DON stated Resident 4 called 9-1-1 and was transferred to GACH 1 for pain management. During a review of Resident 4 ' s Progress Note, dated 10/18/23, timed 2:55 pm, the note indicated Resident 4 had an order to transfer Resident 4 to GACH 1 for an evaluation and management of severe pain. The note indicated transportation services were arranged for Resident 4 to be transferred to GACH 1. During a telephone interview on 12/18/2023 at 2:46 pm, with LVN 3, LVN 3 stated Resident 4 called 9-1-1 because Resident 4 was in so much pain. LVN 3 stated LVN 3 did not attempt to reach MD 1 to inform MD 1 of Resident 4 ' s severe pain. LVN 3 stated LVN 3 attempted to call MD 1 on 10/18/2023, at 10:53 am and at 12:40 pm to get the Norco 5-325 mg medication authorized for pharmacy to deliver the Norco. LVN 3 stated Resident 4 called 9-1-1 before MD 1 response to LVN 3 ' s phone calls. During an interview on 12/8/2023 at 4:54 pm, with the DON, the DON stated Resident 4 was experiencing pain for 12 hours without receiving appropriate pain medication. The DON stated pain was subjective and it was the nursing staffs ' (in general) responsibility to maintain Resident 4 ' s comfort level and attempt to inform MD 1 when Resident 4 was in pain. The DON stated Resident 4 ' s pain was not being managed appropriately with the medication ordered (Norco). The DON stated, being in that much pain could affect a resident ' s mood, cause anger, frustration, and lead to depression. 2. During a concurrent interview and record review on 12/8/2023 at 12:27 pm, with the MDSN, Resident 4 ' s Progress Note dated 10/18/2023 at 7:38 am was reviewed. The MDSN stated LVN 3 indicated Resident ' s 4 Norco dose on 10/18/2023 at 4:25 am was taken from the facility ' s emergency kit (e-kit- medication kit used when pharmacy has not delivered consistent doses). During a concurrent interview and record review on 12/8/2023 at 12:52 pm, with the DON, the DON reviewed Resident 4 ' s OLR and Progress Notes, dated 10/18/2023. The DON stated on 10/17/2023, MD 1 ordered for Resident 4 to receive Norco 5-325 mg for pain management, however MD 1 had not provided an authorization for the medication to be delivered by the pharmacy. The DON stated Norco 5-325 mg was a controlled substance (high potential for abuse, with use potentially leading to severe psychological or physical dependence), and it required MD 1 to contact the pharmacist (unidentified) to authorize the delivery of narcotic medications (Norco), as a safety measure. The DON stated a medication e-kit was used when a medication was not otherwise available in instances such as a newly admitted residents (in general) and/or for newly prescribed medications. The DON stated Resident 4 was a newly admitted resident and the Norco order was pending an authorization by MD 1 for medication delivery. The DON stated only one (1) dose of Norco 5-325 mg was available in the e-kit which was administered to Resident 4. During a telephone interview on 12/8/2023 at 2:02 pm, with MD 1, MD 1 stated the protocol for signing authorization on a narcotic or controlled substance medication. MD 1 stat should not take more than 20 minutes. During a concurrent review of telephone record an interview on 12/8/2023 at 2:46 pm, with LVN 3, LVN 3 stated LVN 3 attempted to reach both MD 1 and the MDD multiple times throughout LVN 3 ' s shift on 10/18/2023 at 10: 53 am, 123:40 pm and 1:55 pm. LVN 3 stated LVN 3 was attempting to reach MD 1 to get Norco authorized for delivery for Resident 4 but she did not get a call back from MD 1 nor MDD. During a telephone interview on 12/8/2023 at 3:29 pm, with the MDD, the MDD stated part of the MDD ' s job was to be available if the primary physicians (in general) were not available. The MDD stated the MDD worked to solve problems related to medical issues at the facility. The MDD stated the MDD was on-call and available 24 hours a day, seven days a week. During a review of the facility ' s PP titled, Guidelines for Notifying Physicians of Clinical Problems, dated September 2017, the PP indicated the guidelines were intended to help ensure that medical care problems were communicated to the medical staff in a timely, efficient and effective manner and that all significant changes in a resident/patient status are assessed and documented in the medical record. The PP indicated the charge nurse or supervisor should contact the attending physician if a clinical situation appears to require immediate discussion and management. The PP indicated the practitioner was responsible for responding in a timely manner to calls, especially regarding immediate notification problems. The PP indicated immediate notification (acute) problems included the symptoms, and/or signs such as sudden onset or a marked changed (for example, much more severe or frequent) compared to usual or baseline and are unrelieved by measures which had already been prescribed or attempted. During a review of the facility ' s PP titled, Pain Assessment and Management, revised October 2022, the PP indicated the purpose was to help staff identify pain in the resident, and to develop interventions that were consistent with the resident ' s goals and needs that addressed the underlying causes of pain. The PP indicated pain management was defined as the process of alleviating the resident ' s pain abased on his or her clinical condition and established treatment goals. The PP indicated acute pain (or significant worsening of chronic pain) should be assessed every 30 minutes to 60 minutes after the onset and reassessed as indicated until relief is obtained. The PP indicated if pain had not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. The PP indicated to report the following information to the physician or other practitioner: significant changes in the level of the resident ' s pain and prolonged, unrelieved pain despite care plan interventions.

Based on observation, interview, and record review, the facility failed to follow its Policies and Procedures on Safety and Supervision of Residents and Wandering and Elopements for five of five sampled residents (Residents 1, 2, 3, 4 and 5), by failing to ensure: 1. The Interdisciplinary team (IDT, a team of professionals from various disciplines who work together to address the resident's care) conducted a meeting after Resident 1 eloped on [DATE] to analyze information about the resident's elopement and develop nursing interventions to prevent further elopement. 2. The Administrator (ADM) and the Director of Nurse (DON) did not place Resident 1 in a room that had a large open window (49 inches in length by 47 inches in width, and 29 ,d+[DATE] inches from the resident's floor) that led to the main street where the resident could exit the facility. As a result, on [DATE], at 4:46 am, Resident 1 who had a history of elopement (occurs when a resident leaves the premises or a safe area without authorization) left the facility unsupervised and deceased (died ) on the street. Residents 2, 3, 4, and 5 were at risk for leaving the facility unsupervised. On [DATE] at 6:53 pm, during an investigation of a facility reported incident, the Department of Public Health called an Immediate Jeopardy situation (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident), regarding Resident 1's elopement and the risk for Residents 2, 3, 4, and 5 to elope, in the presence of the facility's ADM, DON, and Quality Assurance Nurse (QAN). On [DATE] at 4:19 pm, the facility submitted an acceptable plan of action (POA, a list of steps taken to correct the deficient practices). The surveyors verified and confirmed the implementation of the POA to prevent Residents 2, 3, 4 and 5 from elopement while onsite by observation, interview, and record review. The surveyors confirmed the removal of the IJ on [DATE] at 4:25 pm in the presence of the DON and the QAN. The acceptable IJ Removal Plan included the following: a. On [DATE], the QAN completed Wandering (walking around without and clear purpose or direction) Risk Assessments for the residents, and Registered Nurse Supervisor 2 (RNS 2) initiated Resident 5's wander alarm per Resident 5's physician order (MD 1). b. On [DATE], the facility's DON, QAN, and the Infection Prevention Nurse (IPN, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment), reviewed Wandering Risk Assessments for the identified at risk residents (Residents 2, 3, 4 and 5), and revised/updated the care plan interventions for these residents. c. On [DATE], LVN 9 initiated Resident 4's wander alarm per Resident 4's physician order (MD 2). d. On [DATE], Maintenance Supervisor 1 (MS 1) installed additional alarm systems (a total of five) to exit doors with wander alarm system to monitor at risk residents. Staff were made aware of the additional alarms. e. On [DATE], the DON and the QAN assessed Residents 2, 3, 4, and 5 for any signs of wandering behavior. The DON updated the Wandering Risk Assessments, reviewed the implementation of the care plan interventions, and obtained an order to monitor the residents' wandering behavior every shift. f. On [DATE], the QAN checked Residents 2's, 3's, 4's, and 5's rooms, and he did not identify additional exits that place the residents at risk for elopement. g. On [DATE], the Director of Staff Development (DSD) in-serviced Licensed Vocational Nurses, (LVNs) regarding post elopement assessment and identifying elopement seeking behavior. h. On [DATE], the DSD in-serviced Certified Nursing Assistants (CNAs) regarding monitoring residents who were at risk for wander, conduct visual checks and document the visual checks every hour. i. On [DATE], the DSD met with the IDT to discuss specific elopement care plan innervations such as appropriate room placement away from exit doors, use of wander guard bracelet, implement visual check every hour and provide pleasant diversions for at risk residents. Findings: 1. A review of Resident 1's Admission Record indicated the facility admitted the resident on [DATE] with diagnoses which included [CONDITION(S)] (a brain disorder that causes uncontrollable movements, such as shaking, stiffness, and difficulty with balance/ coordination) and heart disease (range of conditions that affect the heart). A review of Resident 1's Situation, Background, Appearance, Review (SBAR, a form that strengthening communication between nurses and other healthcare professionals) Communication Form, dated [DATE], timed at 6 am, indicated, at 2:10 am, Resident 1 eloped from the facility unsupervised while in the wheelchair. A review of Resident 1's care plan created for elopement risk, initiated on [DATE], indicated Resident 1 was at risk for elopement due to history of attempts to leave facility unattended. The care plan indicated the goal was for Resident 1 not to leave the facility unattended and for the nursing staff (in general) to monitor Resident 1's location. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], indicated Resident 1's cognitive (ability to think and process information) status was severely (extremely) impaired. The MDS indicated Resident 1 had limited ability to express ideas and wants and responded adequately to simple and direct communication. The MDS indicated Resident 1 required extensive assistance (resident involved in activity; staff provide guided maneuvering) from one person to transfer to and from the bed, chair, wheelchair, and to a standing position. A review of Resident 1's Physical Therapy (PT, focuses on helping improve your movement, mobility, and function) Treatment Note, dated [DATE], indicated Resident 1 was able to ambulate (walk) using a front wheel walker (a device that gives additional support to maintain balance or stability while walking) for support up to 300 feet. The note indicated Resident 1 required verbal cues for safety and proper speed especially when maneuvering around obstacles and busy hallway. A review of Resident 1's paramedic (emergency services) report dated [DATE], timed at 4:46 am, indicated a bystander saw Resident 1 collapse. The report indicated the paramedics arrived at the scene at 4:53 am and performed cardiopulmonary resuscitation (CPR, refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased) for twenty minutes. The report indicated Resident 1 was pronounced dead at 5:21 am. The report indicated local law enforcement was on the scene and stated the facility staff was unaware Resident 1 left the facility. A review of Resident 1's Progress Notes dated [DATE], timed at 5:30 am, indicated on [DATE] at 1:25 am, LVN 1 saw Resident 1 in his room, lying in bed. The notes indicated on [DATE] at 5:30 am, Police Officer 1(PO 1) from the local police department called the facility inquiring about Resident 1. The notes indicated the PO 1 stated Resident 1 was found unresponsive on the sidewalk located 0.6 miles from the facility. The notes indicated the paramedics performed CPR on Resident 1, but they were unable to revive the resident. The notes indicated Resident 1's time of death was 5:21 am. A review of the facility's Five-Day Report dated [DATE], untimed, indicated on [DATE] at 5:30 am, PO 1 informed the facility that they (the police) responded to a call from a bystander who had seen a man (identified as Resident 1) laying down on the sidewalk 0.6 miles from the facility. The report indicated when the police responded to the scene Resident 1 was unresponsive, the emergency services performed CPR, but the resident was pronounced dead at 5:21 am. The report indicated the man was identified by his wristband as Resident 1. During an interview on [DATE] at 9:23 am, the QAN stated there was a probability Resident 1 eloped on [DATE] from the resident's window located inside his room. The QAN stated Resident 1 had history of eloping from the facility on [DATE]. During an observation in Resident 1's room, on [DATE] at 1:18 pm, there was one window across from the room door with 2 panels (flat rectangular piece of glass), side-by-side on one wall. The window edge was 29 ,d+[DATE] inches from Resident 1's floor and 32 inches from the ground outside of the facility. The 2 panels were opened outward, and the hinges (movable joints or mechanisms on which a door or a window swing as it opens and closes) were on the outside. The window was measured 49 inches in length and 47 inches in width. There were no screens on the windows. During a concurrent observation in Resident 1's room and interview with MS 1 on [DATE] at 2:57 pm, MS 1 stated Resident 1's room was the only resident room in the facility with no sliding windows. MS 1 stated all sliding windows have a stopper and could not open all the way. MS 1 stated there were no wander alarm system on any windows in the facility. Upon observation, the windows in Resident 1's room did not have a stopper and could be open all the way. In a concurrent observation outside the facility with MS 1, there was a path from Resident 1's room windows which led to the street. MS 1 stated the facility's gate which led to the main street was kept open. During an interview on [DATE] at 3:08 pm, the QAN stated Resident 1 eloped on [DATE] at 2:10 am, but the resident's record did not indicate a detailed description of Resident 1's elopement except it indicated Resident 1 eloped from the facility unsupervised while in the wheelchair. The QAN stated the facility did not have any documented evidence that an IDT meeting was conducted to address the resident's elopement on [DATE]. The QAN stated the facility needed to conduct an IDT meeting after the resident's elopement on [DATE] to address Resident 1's elopement and to develop nursing interventions to prevent future elopements. During an interview on [DATE], at 3:10 pm, the DON stated Resident 1 had eloped from the facility on [DATE]. The DON stated she was not aware Resident 1's room had a large window that could be open all the way. During an interview on [DATE], at 3:25 pm, the ADM stated Resident 1 had eloped from the facility on [DATE]. The ADM stated he was not aware Resident 1's room had a large window that could be open all the way. During an interview on [DATE] at 11:55 am, CNA 1 stated he last saw Resident 1 sitting on the edge of the resident's bed on [DATE] at 3:05 am. CNA 1 stated on [DATE] at 5 am, after RNS 1 told him that Resident 1 was not in the facility, he and the rest of staff checked on all the other residents. CNA 1 stated he found Resident 1's wheelchair along with the sweater that Resident 1 often wore next to Resident 1's bed. CNA 1 stated he did not hear any alarm go off during his shift. During an interview on [DATE] at 12:10 pm, LVN 1 stated she last saw Resident 1 lying in bed on [DATE] at 1:25 am. LVN 1 stated on [DATE] at 5:30 am, LVN 2 informed her a PO 2 called the facility and told LVN 2 they (police) found and performed CPR on Resident 1, but Resident 1 died . LVN 1 stated she notified RNS 1 and she called a Code Pink, (facility's emergency code to alert staff a resident is missing) after she found out Resident 1 was not in the facility. LVN 1 stated all staff checked on the other residents and checked all exit door alarms. LVN 1 stated she found Resident 1's red sweater on the resident's bed, Resident 1's wheelchair was at the bedside, and Resident 1's room window was crack open (open a little bit) LVN 1 stated she did not hear any alarm go off during her shift. During an interview on [DATE] at 12:50 pm, RNS 1 stated she last saw Resident 1 sleeping on his bed on [DATE] between 12 am to 2 am. RNS 1 stated on [DATE] after 5 am, the facility phone rang while she was in the medication room. RNS 1 stated when she got out of the medication room, LVN 1 and LVN 2 informed her Resident 1 eloped. RNS 1 stated she called a Code Pink. RNS 1 stated all staff started to check on all other residents and outside grounds of the facility. RNS 1 stated the facility windows were always kept closed but LVN 1 told her Resident 1's room window was opened a little bit. RNS 1 stated Resident 1 was at risk for eloping and the resident had a wander alarm bracelet on. During an interview with the DON on [DATE] at 2:52 pm, she stated she reviewed Resident 1's Clinical Record dated [DATE] and was unable to find documented evidence indicate that Resident 1's location was monitored as specified in Resident 1's elopement risk care plan. The DON stated Resident 1's elopement risk care plan was not implemented. During an interview with PO 2 on [DATE] at 10:38 pm, he stated he received a call from the local police department's dispatcher on [DATE] at 4:44 am regarding a man on a sidewalk who was not responding to touch. PO 2 stated a bystander saw the man collapsed. PO 2 stated upon their (police officers) arrival to the scene, the man was not breathing, and they performed CPR. PO 2 stated they found out the man was Resident 1 because the man had mail and paperwork that had Resident 1's name, date of birth, and the facility name. PO 2 stated the fire department arrived and took over to continue CPR. PO 2 stated CPR was performed for about 25 to 30 minutes and Resident 1 was pronounced deceased (dead) on the scene at 5:21 am. PO 2 stated PO 1 called to inform the facility about Resident 1 was pronounced deceased . 2. A review of Resident 2's Admission record indicated the facility admitted the resident on [DATE] and readmitted the resident on [DATE] with diagnoses which included dementia (loss of memory and other mental abilities severe enough to interfere with daily life), and abnormalities of mobility. A review of Resident 2's Wandering Observation/Assessment, dated [DATE], timed at 4:21 pm, indicated the resident was at risk for wandering. 3. A review of Resident 3's Admission record indicated the facility admitted the resident on [DATE] and readmitted the resident on [DATE] with diagnoses which included dementia and dysphagia (difficulty in swallowing). A review of Resident 3's Order Summary dated [DATE], timed at 11:59 pm, indicated to place a wander guard to monitor the resident's location and to alert staff to prevent the resident from leaving the facility. 4. A review of Resident 4's Admission record indicated the facility admitted the resident on [DATE] with diagnoses which included [CONDITION(S)] and dementia. A review of Resident 4's Wandering Observation/Assessment, dated [DATE], timed at 12:11 pm, indicated the resident was at risk for wandering. 5. A Review of Resident 5's Admission record indicated the facility admitted the resident on [DATE] with diagnoses which included dementia and heart failure. A review of Resident 5's Wandering Observation/Assessment, dated [DATE], timed at 11:29 am, indicated the resident was at risk for wandering. A review of the facility's policy and procedure, titled Safety and Supervision of Residents, dated ,d+[DATE], indicated Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI (Quality Assurance and Performance Improvement, plan of action to improve quality of life, and quality of care and services provided in the facility) reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. The policy indicated, When accident hazards are identified, QAPI/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. The policy indicated, The IDT shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. A review of the facility's policy and procedure, titled Wandering and Elopements, dated ,d+[DATE], indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The policy indicated, If [a resident] is identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.

Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 1 and 2) were free from involuntary seclusion (separation of a resident from other residents or from her/his room or confinement to her/his room with or without roommates against the resident's will, or the will of the resident representative). The facility failed to protect Residents 1 and 2 from involuntary seclusion when: 1. Certified Nursing Assistant (CNA 1) left Residents 1 and 2 inside their room involuntarily secluded without staff present in the Red Cohort [isolation rea, area only for residents who have laboratory confirmed Coronavirus-19 (COVID-19, a respiratory illness that can spread from person to person) with or without symptoms, regardless of vaccination status]. 2. CNA 1 closed Resident 1's and 2's door and tied the door handle with a clear trash bag to the handrail from the outside of the door to prevent the residents' egress (exit) from the room while CNA 1 left his assigned area. These deficient practices had the potential for Residents 1 and 2 to further experience incidents of involuntary seclusion that could lead to serious injury, serious harm, serious impairment, or death. The Department called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, impairment, or death to a resident) situation on 8/12/2022, at 5:32 pm, in presence of the Administrator (ADM) and the Director of Nursing (DON). The ADM and DON were informed of the facility's failure to have a system in place to ensure Residents 1 and 2 were free from involuntary seclusion. The Department notified the ADM and the DON that CNA 1 tied Resident 1's door with a plastic bag to the handrail from the outside of the door and left Residents 1 and 2 involuntarily secluded without staff present, resulted in potential serious harm that threatened the health and safety for Residents 1 and 2. On 8/13/22, 6:40, pm the facility submitted an acceptable plan of action (POA, a list of steps taken to correct the deficient practices). While onsite, the surveyor verified and confirmed the implementation of the POA by observation, interview, record review. and confirmed the removal of the immediate jeopardy on 8/13/2022 at 8:47 pm in the presence of the ADM. The acceptable IJ Removal Plan included the following: 1. On 8/12/2022, the ADM removed CNA 1 from his assignment. 2. On 8/12/22, the Quality Assurance Nurse (QAN) conducted a one-to-one education for staff regarding not leaving assignments unsupervised before going on break, and not applying any devices that would impede resident's freedom to go in and out of room. 3. On 8/12/2022, the QAN reassessed Residents 1, 2, and other residents in the Red Cohort to see if they had sustained any injuries that could have happened while unattended. 4. On 8/12/22, the ADM reported the incident to the local law enforcement and the Ombudsman [an official appointed to investigate individuals' complaints against maladministration (inefficient or dishonest administration)]. 5. On 8/12/22, the QAN and the Infection Prevention Nurse (IPN, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment), made rounds on all rooms and did not see any similar issues with trash bags tied to the door. 6. On 8/12/22, the ADM checked all doors and made sure that the doors were not locked. 7. On 8/12/22, the Social Service Director (SSD) and licensed staff checked all other resident to ensure that they felt safe in the facility. 8. 8/12/22 and 8/13/22, the ADM conducted in-service trainings regarding Prevention of Resident Abuse including involuntary seclusion to 98/124 staff. The ADM and the Director of Staff Development (DSD) would continue to conduct abuse and involuntary seclusion in-services training to 26 more staff who are currently on vacation and medical leave before they start their first day of work. (Cross Reference F689) Findings: 1. A review of Resident 1's Admission Record indicated the facility admitted the resident on 2/7/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's History and Physical dated 2/8/2022, indicated the resident could make needs known but could not make medical decisions. A review of Resident 1's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/13/2022, indicated Resident 1 was severely impaired in cognitive skills (ability to make decisions). The MDS indicated Resident 1 had behavior of wandering and required supervision (oversight, encouragement, or cueing) with all activities of daily livings (ADLs) such as with walking and toileting. A review of Resident 1's Care Plan for Fall, dated 8/9/2022, indicated for staff to assist Resident 1 with Activities of Daily Livings (ADLs), transfers, mobility and to provide a safe environment for the resident at all times. 2. A review of Resident 2's Admission Record indicated the facility admitted the resident on 8/5/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 2's MDS, dated [DATE], indicated Resident 2 was severely impaired in cognitive skills. The MDS indicated the resident required extensive assistance with one person assist for bed mobility, transfers, toilet use and totally dependent with locomotion (how resident moves between locations). A review of Resident 2's Care Plan for Fall dated 8/6/2022, indicated for staff to assist Resident 2 with ADLs such as bed mobility and transfers. During an observation on 8/12/2022 at 10:30 am, with the QAN in the facility's Red Cohort, there was a stand-up folding screen partition (divider) that served as a barrier between the Red Cohort and the Yellow Cohort (area for residents potentially exposed to COVID-19, mixed quarantine & symptomatic cohort). The QAN called CNA 1's name through the barrier and there was no answer. There were spaces in between the divider enough to see there were three rooms in the Red Cohort. The QAN pointed at room [ROOM NUMBER] and stated it was the charting room and bathroom for the Red Cohort and pointed at room [ROOM NUMBER] with a closed door and stated there were two residents (Residents 1 and 2) in that room. During further observation of the closed door from room [ROOM NUMBER], there was a clear, plastic trash bag wrapped around the door handle and tied to the handrail on the outside of the door. During an interview on 8/12/2022 at 10:34 am, CNA 2 came out of room [ROOM NUMBER] in the Yellow Cohort, she peeked through the divider when asked to check what was on the door in room [ROOM NUMBER]. CNA 2 stated it looked like a trash bag was used to tie the door closed. During an observation and interview on 8/12/2022 at 10:35 am with the QAN, the QAN did not answer when asked what was on the door handle. The QAN immediately left and went out to the patio near the Red Cohort. CNA 1 was not at the patio area. The QAN went back to room [ROOM NUMBER], inside the Red Cohort and the clear trash bag tied to the door handle was removed. During an observation on 8/12/2022 at 10:39 am, CNA 1 entered the door into the Red Cohort and went straight to the charting room. During an observation on 8/12/2022 at 10:43 am, Resident 1 was sitting on the toilet by herself. Resident 1 had a dark discoloration on her left eye. CNA 1 and QAN went inside Resident 1's room and CNA 1 assisted Resident 1 back to bed. During a concurrent observation and interview on 8/12/2022 at 10:46 am, Resident 2 was lying in bed, talking incoherently to simple questions. Resident 2 was able to move both her arms and legs. During a concurrent observation and interview on 8/12/2022 at 10:50 am, there was a dark discoloration to Resident 1's left eye, the QAN stated Resident 1 had a dark, maroon discoloration on her left eye and that the resident got the discoloration from a fall on 8/9/2022. Resident 1 did not answer when the surveyor asked for her name. During an interview on 8/12/2022 at 10:55 am, CNA 1 stated he left the facility and went to a store to buy food. CNA 1 stated he closed and tied Resident 1's and 2's door with a trash bag because Resident 1 kept walking out of the room. CNA 1 stated he was aware that it was wrong to leave the facility and it was wrong to use the trash bag to tie the residents' door closed. During an interview on 8/12/2022 at 11:20 am, CNA 1 stated he did not communicate with other staff when he left his assigned area because they were busy. CNA 1 stated the only way he could ask other staff for help beyond the Red Zone was to yell out loud if there was a staff on the other side of the barrier. CNA 1 stated there was no work phone in the Red Cohort. During an interview on 8/12/2022 at 11:29 am, the IPN stated staff are not allowed to leave the facility and leave the residents unattended. During an interview on 8/12/2022 at 12:50 pm, CNA 3 stated Resident 1 liked to walk around, and Resident 2 had not attempted to get out of bed. CNA 3 stated Resident 2 was newly admitted to the facility, and she did not know if Resident 2 was able to ambulate (walk) or not. During an interview on 8/12/2022 at 1:06 pm, CNA 2 stated Resident 1 liked to walk and was at risk for falls because Resident 1 needed staff assistance for ambulation. During an interview on 8/12/2022 at 2:30 pm, CNA 2 stated It is not okay to tie the door closed like that, that's abuse. During an interview on 8/12/2022 at 4:16 pm, CNA 3 stated staff should not tie the door closed from the outside because that was abuse and confinement. During an observation and interview on 8/12/2022, at 4:23 pm, a noise came from inside Resident 1's room, CNA 3 stated it was Resident 1 who was trying to go outside. CNA 3 went inside the resident's room. CNA 3 stated Resident 1 went back to bed. A review of the facility's Policy and Procedure, titled Abuse, Neglect and Misappropriation Prevention Program, revised in April 2021, indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation but not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on observation, interview, and record review, the facility failed to provide appropriate care and services to one of three sampled residents (Resident 39), who were assessed for nutritional risk in a total sample of 24 residents, in accordance with the facility's policy and procedures by failing to: a. Ensure the Registered Dietician 1 (RD 1) and Dietary/Food Service Director (a facility staff that work along with the Registered Dietician to develop healthy menus for individual patients as part of an overall treatment plan) appropriately assessed Resident 39 for the cause of weight loss and recommended interventions to prevent further weight loss. b. Evaluate Resident 39 for problem with swallowing. c. Obtain a laboratory tests to identify impaired nutrition. d. Provide nutritional supplement (products that are used to complement a resident's dietary needs) and/or snacks as recommended by the RD. e. Assess and monitor Resident 39's decreased oral intake of meals, food dislikes and preferences, and to ensure documentation of food intake was accurate. f. Assess for Resident 39's refusal to use denture and refer to the dentist as needed. g. Review and revise Resident 39's plan of care to address weight loss. These deficient practices resulted in Resident 39's severe weight loss from 176 pounds (lbs.) to 150 lbs. (14.77 percent (%)) in six months. Findings: A review of Resident 39's Admission Record, indicated Resident 39 was admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS), a resident assessment and care screening tool, dated 10/29/18, indicated Resident 39 was able to verbalize his needs, usually able to understand others with moderate memory and cognitive (ability to think and reason) impairment, and required supervision with one person assistance with transfers, personal hygiene and eating. A review of Resident 39's plan of care, developed on 1/23/18 and updated on 7/31/18 and 12/10/18, for Resident 39's nutritional risk related to mechanical (one in which the texture of the diet is altered) altered diet, admission [DIAGNOSES REDACTED]. To ensure Resident 39 tolerated diet in 90 days, the facility will provide medication and supplements as ordered, encourage resident to swallow and chew each bite, monitor intake of all meals and offer snacks between meals and honor food preference. On 12/14/18, at 8:24 a.m., during a facility tour, Resident 39 was observed sitting up in the wheelchair. In a concurrent interview, Resident 39 stated, I did not eat breakfast today (12/14/18) and yesterday (12/13/18), the food is too sweet. The doctor told me to avoid sweets. On 12/14/18, at 8:30 a.m., during an interview, Certified Nursing Assistant 3 (CNA 3) stated Resident 39 consumed a little bit of his breakfast. During an observation with CNA 3, Resident 39's breakfast tray contained pureed French toast, cream of wheat, a glass of juice and rice milk that was not consumed. CNA 3 explained, Oh, he only drank tea so that is 0%. He did not eat anything. A review of Resident 39's ADL (Activities of Daily Living) Record indicated the following: 1. 12/13/18, consumed 75% for breakfast 2. 12/14/18, consumed 75% for breakfast On 12/14/18, at 11:23 a.m., a review of Resident 39s clinical record with Registered Nurse Supervisor (RN 2) indicated the following: a. Resident 39's weight record, titled, Weight and Vitals Summary form, indicated the following weight loss trends: 1. 6/4/18 - 176.8 pounds (lbs.) 2. 6/12/18 - 168.1 lbs. 3. 7/6/18 - 161.6 lbs. 4. 8/3/18 - 159.5 lbs. 5. 9/3/18 - 154.5 lbs. 6. 10/8/18 - 153 lbs. 7. 11/3/18 - 152 lbs. 8. 12/5/18 - 150 lbs. In concurrent interview, RN 2 stated, Resident 39 gained weight due to [MEDICAL CONDITION] (excess body fluid in the body) in (MONTH) (YEAR) and resolved in (MONTH) (YEAR), but Resident 39 continued to lose weight even when the [MEDICAL CONDITION] resolved and when the diuretics (a water pill or medication used to treat [MEDICAL CONDITION]) was discontinued in (MONTH) (YEAR). RN 2 stated, We do not know why he is still losing weight. b. A review of Resident 39's Nutritional Assessment, dated 7/28/18, timed at 6:59 p.m., indicated Resident 39's diet was changed from advanced dysphasia diet to puree (foods that have been processed in a blender that need a minimal amount of chewing and are easily swallowed) for resident's complaint of difficulty swallowing and food getting stuck in the throat. There was no documented RD recommendation to the physician for swallowing evaluation. In a concurrent interview, RN 2 stated, there was no recommendation from the RD therefore, there was no physician order to refer Resident 39 for swallowing evaluation. RN 2 stated there was no documentation that Resident 39 was evaluated for difficulty with swallowing. c. A review of the Nursing Progress Notes, dated 7/28/18, timed at 8:13 p.m., indicated, Resident 39's primary physician was informed of the Nutritional Care Recommendation to change diet to puree per Resident 39's request due to difficulty swallowing. d. There was no documented RD recommendation to the physician for laboratory tests to be obtained to determine the cause or severity of Resident 39's weight loss. RN 2 stated, there was no documentation that laboratory tests were recommended by the RD to address weight loss. RN 2 stated there were no laboratory tests done. e. There was no documented evidence that supplemental protein were provided to Resident 39 to promote weight gain. f. There was no documented evidence the Registered Dietician comprehensively assessed Resident 39, or the Dietary/Food Service Director identified the possible cause(s) of Resident 39's weight loss and provided interventions to prevent further weight loss. g. The Nutrition Assessment Note, dated 12/5/18, at 6:56 p.m., indicated: 1. Resident 39 had a weight loss of +/-10% current weight 150 lbs. with IBW (Ideal Body Weight) 142 lbs. in the last 180 days. 2. Current diet-dysphagia puree 3. Weight loss due to variable oral intake-less than 75% The Dietary/Food Service Director recommendation included: Supplemental snacks BID (twice a day), multivitamin tablet once a day, fortified cereal (food containing increased vitamins and minerals) for breakfast, continue current diet, monitor oral intake and no new labs was recommended. On 12/14/18, at 12:48 p.m., during an interview with the responsible party/Family 1 (FAM 1) in the presence of Resident 39, stated Resident 39 had a denture placed sometime in the beginning of last year. However, Resident 39 could not use it more than 5 minutes because of the pain and it was hard for him to chew so he never used it, the facility staff were aware. FAM 1 stated the dentist never came to see him and adjust the dentures. FAM 1 stated Resident 39 lost weight recently, he just seems to lose wait too much too soon. FAM 1 stated Resident 39 does not like the puree because it is not as appetizing as the regular food, but he has no teeth, with difficulty chewing and swallowing, so we requested for puree diet instead. Resident 39 stated, he always felt tired and requested if he could get assistance with feeding because he felt weak on his hands when eating. A review of Dental Progress Notes, dated 12/30/16, indicated Resident 39 received upper and lower dentures. On 12/14/18 at 2:48 p.m., a review of Resident 39's snack intake record, untitled, indicated there was no documented evidence Resident 39 was monitored to ensure Resident 39 was provided and consumed snacks twice a day. During a concurrent interview, RN 2 stated there was no documentation that Resident 39 consumed a snack twice a day in between meals at 10 a.m. and 2 p.m. as recommended by the RD. On 12/14/18, at 3:47 p.m., during an interview and concurrent record review, the Social Service Designee (SSD) stated, Resident 39's severe weight loss was due to resolving [MEDICAL CONDITION], use of diuretic and variable food intake that was discussed with the resident and the responsible party/family (FAM 1) on 12/6/18, timed at 9:41 p.m. The SSD stated he did not refer Resident 39 to the dentist for evaluation of pain when using dentures, and speech therapist for evaluation for difficulty chewing and swallowing which were important for residents with weight loss. On 12/17/18, at 10:51 a.m., during an interview with the Dietary Supervisor (DS) stated Resident 39 had a significant weight loss and was supposed to receive snacks BID as recommended by the Dietary/Food Service Director. During a concurrent review of Resident 39's snack intake record, untitled, indicated Resident 39 consumed 50%-100% of the snack given in the evening, ((HS) hour of sleep), from 5/2018 to 12/2018. There was no documentation Resident 39 consumed snacks BID. The DS stated the snack was supposed to be provided BID at 10 a.m. and 2 p.m. to Resident 39 to prevent further weight loss. On 12/17/18, at 1:48 p.m., during an interview, the RD Regional Supervisor (RD 2) stated, when a resident loses weight, a comprehensive dietary assessment should be conducted to determine the cause of weight loss. RD 2 stated assessment should include: a. Dental issues such as the ability to chew and recommend to the physician a dental evaluation. b. Swallowing difficulty and recommend to the physician a swallowing evaluation. c. Percentage of the food intake, food preferences and allergies [REDACTED].>d. Medications that affect the weight. e. Recommend to the physician laboratory tests to determine protein and [MEDICATION NAME] (protein made by the liver) levels in the blood and basic metabolic panel ((BMP) a blood test obtained to determine the current status of a person's metabolism, kidneys, blood sugar level, and electrolyte and acid/base balance). During the same interview, RD 2 stated Resident 39 was not evaluated for the difficulty swallowing, difficulty chewing, food preferences were not assessed and the food intake was not monitored for accurate recording. RD 2 stated laboratory tests were not done to determine the possible cause of weight loss and provided nutritional supplement as needed. A review of the facility policy and procedures titled, Nutrition Hydration Management, updated 3/16/16, indicated the IDT (interdisciplinary team, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) will develop a plan of care for enhancing oral intake and hydration which included interventions for functional difficulties which may affect ability to eat or drink independently and observe oral intake of meals, supplements and snacks and complete the Meal Monitor Data Collection Sheet when ordered or indicated. A review of the facility job description of the Registered Dietician, updated on 9/1/17, the essential function of the dietician included: complete a comprehensive nutritional assessment, including the MDS, CAA (Care Area Assessment), care plan development in accordance with the federal and state regulatory guidance and standard of care, and consult with the residents, residents family and interdisciplinary team as needed regarding plan of care for residents. A review of the facility policy and procedures, dated 11/28/15, titled, Notification of Change in Condition, the facility will immediately inform the resident, consult with the physician and notify resident's health care decision maker when there is a significant change in the resident's physical, mental and psychosocial status such a deterioration in health. A review of the facility policy and procedures titled, Social Service-Job Description, indicated, the SSD would work with the residents, families, significant others, and staff to provide support and information for more proactive role in self-advocacy to improve quality of life/care for individual residents. The SSD will develop systems of collaboration with community-based providers.