Every finding on record at Vista del Sol Care Center

Based on observation, interview and record review, the facility failed to ensure two of two sampled residents (Resident 2 and Resident 29) received care in a manner that maintained/enhanced dignity and respect by failing to ensure:1. Activity Assistant (AA) and Certified Nursing Assistant (CNA) 2 did not refer to Resident 2 and Resident 29, who needed assistance with meals, as Feeders (dehumanizing term for elderly individuals needing feeding assistance, can be a derogatory, objectifying term). 2. CNA 2 did not stand up when feeding Resident 29 during lunch. This failure had potential to negatively affect Resident 2 and Resident 29 sense of dignity and respect, for Resident 29 to feel rushed while eating. Findings: 1. During a review of Resident 29's admission Record, the admission record indicated the facility admitted the resident on 7/10/2025 with diagnoses that included but not limited to dysphagia (difficult swallowing), unspecified dementia (a progressive state of decline in mental abilities) and severe protein-calorie malnutrition (severe deficiency and/or poor absorption of protein, calories and nutrients) During a review of Resident 29's Minimum Data Set (MDS - a resident assessment tool) dated 3/17/2026, the MDS indicated that Resident 29 had severe cognitive (the mental ability to make decision of daily living). The MDS indicated Resident 29's needed maximum assist for activities of daily living (ADL - eating, oral hygiene, toileting, upper body assist, sitting to lying, lying to sitting), and was dependent on staff for personal hygiene, lower body dressing, putting/taking off footwear, sitting to standing and tub/shower transfer. During a review of Resident 2's admission Record, the admission record indicated the facility admitted the resident on 3/7/2026 with diagnoses that included but not limited to dementia, cerebral infarction (loss of blood flow to a part of the brain), pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) and severe protein-calorie malnutrition During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment. The MDS indicated Resident 2 needed maximum assist with ADL, for eating and oral hygiene and was dependent on staff for toileting, upper body assist, sitting to lying, lying to sitting, personal hygiene, lower body dressing, putting/taking off footwear, sitting to standing and tub/shower transfer. During a meal observation and concurrent interview with AA on 4/28/2026 at 12:18 pm, in the dining area, Resident 29 was observed sitting on a chair while CNA 3 was standing up and assisting Resident 29 with lunch meal. AA referred and stated that Resident 29 is a feeder. During an interview on 05/01/2026 at 8:50 am, with CNA 2, CNA 2 stated that Resident 2 is a feeder and needed assistance to eat during all meals. During a concurrent interview and record review with Director of Nursing (DON) on 04/30/2026 at 9:37 am, the State Operation Manual (SOM - A Center for Medicare and Medicaid Services document that guides the assessment on compliance with federal regulations for Medicare and Medicaid-certified nursing facilities) was reviewed. DON did not answer when asked if residents should be referred as feeders After reviewing the SOM, DON stated Staff should address the residents with their name and not call them feeder/s It (feeder) can make the residents feel bad and negatively affect their dignity. During a review of the facility's policy and procedures (P&P) titled Dignity dated 11/2024, the P&P indicated, Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labelling or referring to the resident by his or her room number, diagnosis or care needs. 2. During a review of Resident 29's admission Record, the admission record indicated the facility admitted the resident on 7/10/2025 with diagnoses that included but not limited to dysphagia (difficult swallowing), unspecified dementia (a progressive state of decline in mental abilities) and severe protein-calorie malnutrition. During the review of Resident 29's MDS dated [DATE], the MDS indicated Resident 29 had severe cognitive impairment. The MDS indicated Resident 29 needed maximum assist with ADL for eating, oral hygiene, toileting, upper body assist, sitting to lying, lying to sitting, and Resident 29 was dependent on staff for personal hygiene, During a meal observation and concurrent interview on 4/28/2026 at 12:18 pm, in dining area, Resident 29 was observed sitting on a chair while CNA 3 was standing up while assisting Resident 29 with eating lunch. CNA 3 stated that staff should not be standing up while assisting the residents with the meals. CNA 3 stated, It will make the residents feel bad; they won't like it. During an interview with DON on 4/30/2026 at 9:37 am, DON stated that staff must be sitting at resident's eye level when assisting residents with their meals. DON stated that feeding residents while standing up can affect resident's dignity negatively. During a review of the facility's policy and procedures (P&P) titled Dignity dated 11/2024, the P&P indicated, Resident will be assisted in maintaining and enhancing his or her self- esteem and self - worth.

Based on interview and record review, facility failed to promptly notify the physician and a resident representative when one of one sampled resident ( Residents 2) had a change in condition (COC - a clinical document used to record, assess, and report any sudden changes in a resident's physical, mental, or psychological status in order to ensure appropriate medical treatment can be started safely) evidenced by:1. When Resident 2 experienced six 6 pounds (lbs-unit of measurement) in 3/2026.weight loss2. When Resident 2 developed a pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) This deficient practiced violated the rights of Resident 2 and the resident's representative and had the potential to delay the necessary/essential treatment and medical care and for Resident 2. Findings: During a review of Resident 2's admission Record, the admission record indicated the facility admitted the resident on 3/7/2026 with diagnoses that included but not limited to dementia, cerebral infarction (loss of blood flow to a part of the brain), pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) and severe protein-calorie malnutrition (severe deficiency and/or poor absorption of protein, calories and nutrients). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 3/7/2026, the MDS indicated Resident 2 had severe cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 2 needed maximum assistance with activities of daily living (ADL), for eating and oral hygiene and was dependent on staff for toileting, upper body assist, sitting to lying, lying to sitting, personal hygiene, lower body dressing, putting/taking off footwear, sitting to standing and tub/shower transfer. During a concurrent telephone interview and record review on 04/30/2026 at 11:05 am, with Registered Dietician (RD). Resident 2's weights and Vitals Summary record was reviewed from 10/2025 to 4/2026. The monthly weight record indicated the following weights for Resident 2:On 10/10/2026 Resident 2 weighed 122 pounds (lbs - unit of measurement)On 11/25/2025 Resident 2 weighed 104 lbs. Resident 2 lost 18 lbs - 14.75 percent (% - unit of measurement) weight loss in a month. On 12/5/2025 Resident 2 weighed 104 lbsOn 1/13/2026 Resident 2 weighed 112 lbsOn 2/20/2026 Resident 2 weighed 106 lbs. Resident 2 lost 6 lbs (5.35 perecnt [%]) weight loss in a month. On 3/31/2026 Resident 2 weighed 113 lbs During the same interview and record review, RD stated and confirmed that the facility did not inform resident's family in 2/2026 when the resident lost 6 lbs (5.35%) in a month of weight. RD stated, Not notifying family can negatively affect resident coz if family know they can bring food or encourage resident to eat. Family won't be happy when not notified. It will make resident feel upset/sad. RD stated and confirmed that the facility did not inform resident's physician in 2/2026 when the resident lost 6 lbs (5.35% in a month) of weight. RD stated, Not notifying physician can affect the resident negatively. Resident can continue to lose weight and the resident's health can decline further which can lead to hospitalization, and even potentially death. During a concurrent interview and record review with Infection Preventionist/Treatment Nurse (IP/TP) on 04/30/2026 at 8:14 am, reviewed Resident 2's Skin Assessment document from 7/2025 to 4/2026. IP/TP verified following skin assessments:1. Resident 2 developed a pressure injury on 7/22/2025. Resident 2's mid-back pressure injury progressed to stage - 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). Measurement: 4.6 x 4.1 x 0.5 cm. No undermining (the destruction of tissue or ulcer extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface) or tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) was noted. 2. Resident 2 developed Sacrococcyx (very bottom area of the spine) pressure injury on 08/03/2025, with presence of foul odor. Pressure injury - unstageable (a severe pressure injury where the true depth and damage cannot be seen because the wound base is completely covered with dead tissue). Measurement: 6.2 x 9.5 cm. No undermining or tunneling was noted.During the same interview and record review, IP/TP agreed and verified that the family was not notified of the change in resident's pressure injury. IP/TP stated, Not notifying family, resident can feel ignored. Family can feel resident is being ignored.During an interview on 4/30/2026 at 2:26 pm with Director of Nursing (DON), DON stated, Not informing a family member/representative regarding resident's change of condition, can make them (family) feel bad and they will think that they are being ignored (by facility). During a review of the facility's policy and procedures (P&P) titled, Change of Condition revised on 12/2025, P&P indicated, The facility notifies the physician and resident representative of a significant change in resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). During a review of the facility's P&P titled, Physician Notification revised on 12/2025, P&P indicated, The facility notifies the physician and resident representative of a significant change in resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications).

Based on observation, and interview, the facility failed to ensure a comfortable, homelike environment for one out of five residents sampled (Resident 20). This failure resulted in Resident 20 not being unable to concentrate, rest, or sleep due to the continuous loud noises and conversations outside of the resident's door. Resident 20 was not allowed to close the door to reduce the noise level. Findings: A review of Resident 20's admission record, indicated the facility initially admitted Resident 20 on 3/25/2026 with diagnoses of, but not limited to, hypertension (high blood pressure), heart failure (a condition where the heart muscles become too weak to pump blood efficiently throughout the body), and hyperlipidemia (a condition of having too many fats in the blood), A review of Resident 20's minimum data set (MDS- a resident assessment tool), dated 4/6/2026, indicated Resident 20's cognitive function (the mental ability to make decisions of daily living) was moderately impaired (able to make minor decisions concerning care, alert to situation and oriented to place and time). During a concurrent observation and interview on 4/28/2026 at 8:53 am, Resident 20's room was open. During an interview, Resident 20 stated that he is not able to think or concentrate during the day or the night because of the excessive noise coming from the hallway of the facility. Resident 20 stated he asked the facility staff on several occasions to close the door to his room so that he could have some peace of mind and rest. However, the facility staff told him that the door to his room could not be closed due to the facility's policy. While inside Resident 20's room, the writer heard loud and constant noise/activity from facility staff and visitors coming from the hallway just outside the resident's room. During observation with the resident's door temporarily closed, the noise level was considerably lower to nearly silent and Resident 20 stated the noise level was acceptable with the door closed. During an interview on 4/30/2026 at 9:19 AM, Certified Nursing Assistant (CNA) 5 stated that if a resident requested to have the room door closed, CNA 5 would clear the request with the charge nurse prior to closing the door for resident safety. However, CNA 5 stated that she would not close the door upon a resident's request because of resident safety. During an interview on 4/30/2026 at 10:16 am LVN 4 stated a resident cannot close the door to his or her room because of resident safety. LVN 4 stated if the door to the resident's room is closed staff cannot observe the residents. During an interview on 4/30/2026 at 10:23 am, Registered Nurse Supervisor (RNS) 1 stated due to the fact that there is another roommate the door to a resident's room cannot be closed. RNS 1 stated that the door can be closed, depending on the circumstance if there is a single person/resident in the room. RNS 1 stated she would check with the resident's roommate if the residents are alert and oriented to see if they (residents) agree to close the door. However, RNS 1 stated that she would not be able to close the door all the way. During an interview on 04/30/2026 10:29 am, Director of Nursing (DON) stated, if a resident was in a single room and the resident asks to close the door, I would be able to close the door partially, but not all the way. DON stated that if a resident has a roommate, the staff cannot close the door all the way if the resident asks to have the door closed due to noise. The DON stated per her nursing judgment, it would be best not to close the door to the resident's room for resident safety. During a review of the facilities policy titled Safe Environment with revision date: January 2025 indicated:Policy Statement:The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely.Definitions:Comfortable Sound Levels: do not interfere with resident's hearing and enhance privacy when privacy is desired and encouraged interaction when social participation is desired. Of particular concern to comfortable sound levels is the residents' control over unwanted noise.

Based on interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- an assessment and care screening tool) related to Pre -admission Screening and Resident Review (PASRR -a safety check done before someone enters a Medicaid-certified nursing home to ensure the facility can meet their specific needs, or if they would be better served in the community) was accurately documented [NAME] to the facility's policy and procedure (P&P) titled Accuracy of Assessments, dated 1/2025 for one of six sampled residents (Resident 42). This deficient practice had the potential to negatively affect Resident 42's plan of care and delivery of necessary care and services. A review of Resident 42's admission Record indicated the facility admitted Resident 42 on 4/24/2022, and readmitted resident 42 on 12/28/2025 with diagnoses including major depressive disorder (a serious mental health condition characterized by a persistent low mood, deep sadness, or a loss of interest in activities), Bipolar (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Resident 42's Minimum Data Set (MDS - resident assessment tool) dated 5/9/2025, indicated Resident 42 is cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 42 required substantial/maximal to setup/clean up assistance from staff with Activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) care. The MDS further indicated that .is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? . 0, No. A review of Resident 42's PASRR dated 6/8/2024 indicated .results of level I screening: Level I -positive . reason code: Suspected mental illness.A review of Resident 42's Health and Physical exam (a comprehensive health exam of a patient) dated, 7/30/2025 indicated . diagnosis of bipolar and schizophrenia. During a concurrent interview and record review on 5/1/2026, at 11:41 A.M., with the minimum data set (MDS) nurse, Resident 42's MDS assessment dated [DATE] section A, PASRR dated 6/8/2024 and H&P dated 7/30/2025, were reviewed. MDS Nurse stated the MDS section A indicated that Resident 42 had no mental illness, however, the PASRR level I assessment dated [DATE] indicated that resident 42 was positive for mental illness. MDS nurse stated that MDS assessments need to be accurate to ensure that a good impression of the type of care that the residents require is being portrayed. MDS nurse stated that the MDS was inaccurate because it indicated that resident did not have mental illness when however, resident had a diagnosis of major depressive disorder and schizophrenia. During an interview on 5/1/2026, at 12:37 P.M., with the Director of nursing (DON), the DON stated that the MDS assessment is a comprehensive assessment which includes all the interdisciplinary team's input to set the residents individualized care plan and interventions. The DON nurse stated that the MDS needs to be accurate so the facility staff can give the resident the right individual interventions and ensure that the is collaboration between the facility and the Center for Medicaid/Medicare (CMS). The DON stated if the MDS is inaccurate, the resident may not get the proper interventions they need and wrong information being sent to CMS. A review of the facility's P&P, titled, Accuracy of Assessments, revised 1/2025, indicated,Policy Statements:The MDS assessment must accurately reflect the residents' status including: .Intent:To ensure each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline.Definition:Accuracy of Assessment: The appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the RAI.GUID ELINESFacilities are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.5. The assessment must represent an accurate picture of the residents' status during the observation period of the MOS.

Based on observation, interview, and record review, for one of five sampled residents (Resident 8), the facility failed to:1.Complete the Preadmission Screening and Resident Review (PASRR - a screening evaluation used to determine whether placement in a long-term care facility is appropriate for the resident) Level I (a tool that helps identify possible serious mental illness and/or intellectual/development disability) assessment when Resident 8's re-admitted to the facility on [DATE].2. Notify the mental health authority promptly after admitting Resident 8 to the facility on 1/26/2026 with diagnoses of schizoaffective disorder with bipolar type (a rare type of mental illness that has symptoms of both schizophrenia [a serious mental illness characterized by disturbances in thought] and symptoms of bipolar [extreme highs-mania and severe lows-depression]), generalized anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry about everyday things-such as health, finances, or family-lasting for at least six months), and Down syndrome (a genetic condition occurring when a person is born with an extra copy of chromosome (genes- which are instructions that determine physical traits and guide growth) 21, resulting in 47 chromosomes instead of the usual 46). These deficient practices of failing to complete PASRR Level I assessment and notify the mental health authority promptly related to the diagnoses of schizoaffective disorder with bipolar type, generalized anxiety disorder, and Down syndrome, placed Resident 8 at increased risk of not identifying possible serious mental illness and not provide interventions tailored to Resident 8's specific nursing care and needs. Findings: During a review of Resident 's face sheet (admission Record - a document containing demographic and diagnostic information) indicated, Resident 8 was admitted to the facility on [DATE], and was re-admitted on [DATE] and again on 1/26/2026 with the following medical diagnoses: schizoaffective disorder with bipolar type, generalized anxiety disorder, and Down syndrome. During a review of Resident 8's History and Physical (H&P - a physician's complete patient examination) dated 1/28/2026, indicated, Resident 8 did not have the capacity to understand and make decisions. During a review of Resident 8's Minimum Data Set, (MDS - a resident assessment tool) dated 2/04/2026, indicated, Resident 8 had moderately impaired cognition (make poor decisions, cues and supervisions required). During a review of Resident 8's care plan (CP - a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) on using psychotropic medication, Risperdal (risperidone - use to treat symptoms of bipolar disorder and schizophrenia) for schizophrenia, with a initiation date of 2/21/2026, indicated, Resident 8's CP goal indicated Resident 8 will be free from drug related complications including movement disorder (conditions that causes either increase movements or reduced or slow movements), discomfort, hypotension (low blood pressure), gait (walk) disturbance, constipation, or cognitive (thinking, remembering, judging and problem solving)/behavioral (actions, reactions, or functioning, often in response to social, psychological, or environmental stimuli) impairment. The CP intervention included to monitor and document for side effects and effectiveness. During an interview on 5/01/2026 at 2:32 PM with the MDS Coordinator (MDS - a licensed nurse who is adequately assessing nursing home residents' needs and coordinating personalized, resident-driven care based on those assessments), MDS stated when Resident 8's PASARR Level 1 was not completed when Resident 8 was admitted to the facility. MDS Coordinator stated that Resident 8 might not get the medical treatment [Resident 8] needs. MDS Coordinator stated that the Director of Nursing (DON) and MDS Coordinator share the responsibility in ensuring PASARR Level I is completed during a resident's of admission at the facility. During an interview on 5/01/2026 at 2:43 PM with the DON, DON stated that Resident 8's medical diagnoses and intellectual development (ID /or cognitive development - refers to the growth of a a person's ability to think, reason, and understand the world) would quality for a PASARR Level I screening. During a review of the facility's policy and procedures (P&P - explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Preadmission Screening and Resident Review (PASARR) with a revision date of 1/2025, indicated, PASARR process requires all applicants to Medicaid-certified nursing facilities be screened for possible serious mental d/o, intellectual disabilities, and related conditions; referred to Level I identification completed prior to admission to a nursing facility and if the facility identifies the admitting agency did not complete the Level I screen, facility staff will immediately initiate the screen.

Based on observation, interview, and record review, the facility failed to develop/initiate a comprehensive care plan for constipation within seven days of admission on e of four residents (Resident 49) who was receiving medications for constipation (having fewer than three bowel movements per week, characterized by hard, dry, or lumpy stools that are difficult or painful to pass). This deficiency had the potential for the facility to not meet the needs and necessary services for Resident 49 and also the potential for hospitalization. Findings: During a review of Resident 49's admission record (face sheet - a document containing demographic and diagnostic information) indicated Resident 49 was admitted to the facility on [DATE] with the following diagnoses: acute embolism and thrombosis of unspecified deep veins of lower extremity, bilateral (acute embolism and thrombosis of unspecified deep veins of lower extremity, bilateral), difficulty in walking, essential (primary) hypertension (high blood pressure), heart failure (when heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), hyperlipidemia (high cholesterol [fat] in the body), moderate protein-calorie malnutrition (not enough protein [animal and plant foods] and calories [energy from food] consumed into the body), neuralgia and neuritis (Neuralgia - is intense, shock-like nerve pain), pain in left knee and unspecified atrial fibrillation (an irregular and often very rapid heart rhythm). During a review of Resident 49's Physician Order Summary Report (a condensed, organized document summarizing a patient's key medical information, including diagnoses, treatments, current medications, test results, and follow-up instructions) dated 2/06/2026, the Report indicated medication orders as follows:Famotidine 40 milligrams (mg-unit dose measurement) tablet, give one tablet by mouth one time a day for gastroesophageal reflux disease (GERD - a condition where stomach acid frequently flows back into the esophagus, irritating its lining) to relieve heartburn. Docusate Sodium 100 mg tablet to give one tablet by mouth one time a day for bowel movement and to hold if diarrhea given as a stool softenerPolyethylene glycol powder 1 packet by mouth every 24 hours as needed for constipation. During a review of Resident 49's Minimum Data Set (MDS - a resident assessment tool) dated 2/09/2026, indicated, Resident 49 was cognitively intact (a person's thinking and reasoning abilities are functioning properly and are not significantly impaired). The MDS also indicated that Resident 49 used mobility devices (helps a person walk or move from place to place when one has a disability or injury) such as walker and a wheelchair to get around. During a review of Resident 49's history and physical (H&P - a physician's complete patient examination) dated 2/27/2026 indicated, Resident 49 had the capacity to understand and make decisions. During a review of Nursing Progress Notes (captures the details of a patient's health status, treatment progress, and any changes in their condition over time) dated 4/10/2026 at 1:18 AM, indicated Resident 49 refused to take medications for bowel management, and to drink water. During a review of Resident 49's care plans (CP - a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient), there was no care plan for constipation for Resident 49. During a concurrent interview and record review on 4/30/2026 at 3:07 PM with licensed vocational nurse (LVN) 5,Resident 49's medical chart was reviewed. LVN 5 stated and confirmed that there was no care plan for Resident 49's constipation. LVN 5 stated, I don't know why did not write a care plan for (Resident 49's) constipation. LVN 5 also stated, it's no good to not have bowel movement.[Resident 49] will have abdominal pain, bowel obstruction, and it's not good if [Resident 49] don't go to the bathroom. During a concurrent interview and record review on 5/01/2026 at 1:38 PM with the Registered Nurse Supervisor (RNS) 1, Resident 49's medical chart was reviewed. RNS 1 stated and confirmed that there was no care plan for Resident 49's constipation. When asked the potential harm to Resident 49 when a care plan for constipation was not written, RNS 1 stated we failed to address her problems, her needs. During a review of the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Develop-Implement Comprehensive Care Plans with a revision date of 1/2025 indicated that the care plans shall describe the resident's needs and preferences and how the facility will assist in meeting these needs and preferences. During a review of the facility's P&P titled admission of a Resident with a revision date of 1/2025 indicated, care plans should be started on admission. During a review of the facility's P&P titled Comprehensive Care Plans-Timing with a revision date of 1/2025 indicated, each resident has a comprehensive care plan developed within seven days after completion of the comprehensive assessment and comprehensive care plan must be completed.no more than 21 days after admission.

Based on interview and record review, facility failed to develop and implement a care plan for weight loss for two of two sampled residents (Resident 2 and Resident 49) according to the facility's policy and procedures (P&P) titled Develop-Implement Comprehensive Care Plans dated 1/2026.This deficient practice had potential to failure in the delivery of necessary care and services for Resident 2 and Resident 49. Findings: 1.During a review of Resident 2's admission Record, the admission record indicated the facility admitted the resident on 3/7/2026 with diagnoses that included but not limited to dementia (a decline in cognitive function—including memory, language, and problem-solving—severe enough to interfere with daily life), cerebral infarction (stroke-loss of blood flow to a part of the brain), pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) and severe protein-calorie malnutrition (severe deficiency and/or poor absorption of protein, calories and nutrients) During a review of Resident 2's Minimum Data Set (MDS – a resident assessment tool) dated 3/7/2026, the MDS indicated Resident 2 had severe cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 2 needed maximum assistance with activities of daily living (ADL) for eating and oral hygiene and was dependent on staff for toileting, upper body assistance, sitting to lying, lying to sitting, personal hygiene, lower body dressing, putting/taking off footwear, sitting to standing and tub/shower transfer. During a concurrent telephone interview and record review on 04/30/2026 at 11:05 am, with Registered Dietician (RD), Resident 2's care plan on weight loss initiated on 2/13/2026 and the Weights and Vitals Summary, dietician notes, care plan, nurses progress notes and record from 10/2025 to 4/2026 were reviewed. A care plan was not developed in 11/2025 after Resident 2 lost 18 pounds (lbs – unit of measurement) of weight. A care plan was developed in 2/2026 for weight loss but not implemented. The care plan interventions included to monitor Resident 2's weight weekly with a target date of 5/24/2026. The monthly weight record indicated the facility weighed Resident 2 monthly. However, the facility did not weigh Resident 2 weekly from 2/13/2026 to 4/30/2026 as per the care plan. The monthly weights and Vitals Summary record indicated the following weights for Resident 2: On 10/10/2026 Resident 2 weighed 122 pounds On 11/25/2025 Resident 2 weighed 104 lbs. Resident 2 lost 18 lbs. On 12/5/2025 Resident 2 weighed 104 lbs On 1/13/2026 Resident 2 weighed 112 lbs On 2/20/2026 Resident 2 weighed 106 lbs. Resident 2 lost 6 lbs. On 3/31/2026 Resident weighed 113 lbs.During the same interview and record review, RD stated and confirmed there was no care plan initiated or implemented for Resident 2's weight loss. RD stated Resident 2 had 14.75 percent (% - unit of measurement) weight loss. RD stated by there was no care plan initiated for Resident 2 for weight loss and not initiating a care plan, can affect the resident negatively. Resident can continue to lose weight and the resident's health can decline further which can lead to hospitalization, and even potentially death. During an interview on 4/30/2026 at 2:26 pm with Director of Nursing (DON), DON stated that no care plan initiated and implemented upon significant weight loss can affect resident's health negatively. DON stated that considering Resident 2's comorbidities (resident with 2 or more illness at the same time), resident's health can further decline which can lead to more pressure ulcers, hospitalization and even lead to death. During a review of the facility's policy and procedures (P&P) titled Weight Management dated 12/2024, the P&P indicated, the weight management committee will review and update the resident's care plan as indicated. During a review of the facility's P&P titled Develop-Implement Comprehensive Care Plans dated 1/2026, the P&P indicated, Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. 2. During a review of Resident 49's admission record (face sheet - a document containing demographic and diagnostic information) indicated Resident 49 was admitted to the facility on [DATE] with the following diagnoses: acute embolism and thrombosis of unspecified deep veins of lower extremity, bilateral (acute embolism and thrombosis of unspecified deep veins of lower extremity, bilateral), difficulty in walking, essential (primary) hypertension (abnormally high blood pressure not caused by a medical condition), heart failure (when heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), hyperlipidemia (high cholesterol [fat] in the body), moderate protein-calorie malnutrition (not enough protein [animal and plant foods] and calories [energy from food] consumed into the body), neuralgia and neuritis (Neuralgia is intense, shock-like nerve pain. Neuritis is the actual inflammation of a nerve), pain in left knee and unspecified atrial fibrillation (an irregular and often very rapid heart rhythm). During a review of Resident 49's Physician Order Summary Report (a condensed, organized document summarizing a patient's key medical information, including diagnoses, treatments, current medications, test results, and follow-up instructions) dated 2/06/2026 was reviewed. The physician order summary report indicated Resident 49 was receiving the following medications: Famotidine 40 milligrams (mg- unit dose measurement) mg tablet to give one tablet by mouth one time a day for gastroesophageal reflux disease (GERD - a condition where stomach acid frequently flows back into the esophagus, irritating its lining). Docusate sodium 100 mg tablet to give one tablet by mouth one time a day for bowel movement and to hold if diarrhea given as a stool softener. Polyethylene glycol powder 1 packet by mouth every 24 hours as needed for constipation. During a review of Resident 49's Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 2/09/2026, indicated, Resident 49 was cognitively intact (a person's thinking and reasoning abilities are functioning properly and are not significantly impaired). The MDS also indicated that Resident 49 used mobility devices (helps a person walk or move from place to place when one has a disability or injury) such as walker and a wheelchair to get around. During a review of Resident 49's history and physical (H&P – a physician's complete patient examination) dated 2/27/2026 indicated, Resident 49 had the capacity to understand and make decisions. During a review of Nursing Progress Notes (captures the details of a patient's health status, treatment progress, and any changes in their condition over time) dated 4/10/2026 at 1:18 AM, Resident 49 refused to take medications for bowel management, and to drink water. During a review of Resident 49's care plans (CP - a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient), there was no care plan for constipation for Resident 49. During a concurrent interview and record review on 4/30/2026 at 3:07 PM with licensed vocational nurse (LVN) 5, Resident 49's medical chart was reviewed. LVN 5 stated and confirmed there was no care plan for Resident 49's constipation. LVN 5 stated, I don't know why i did not write a care plan for (Resident 49's) constipation. LVN 5 also stated it's no good to not have bowel movement.[Resident 49] will have abdominal pain, bowel obstruction, and it's not good if [Resident 49] don't go to the bathroom. During a concurrent interview and record review on 5/01/2026 at 1:38 PM with the Registered Nurse Supervisor (RNS) 1, Resident 49's medical chart was reviewed. RNS 1 stated and confirmed there was no care plan for Resident 49's constipation. When asked the potential harm to Resident 49 when a care plan for constipation was not written, RNS 1 stated, we failed to address her problems, her needs. During a review of the facility's policy and procedures (P&P – policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Develop-Implement Comprehensive Care Plans with a revision date of 1/2025 indicated that, the care plans shall describe the resident's needs and preferences and how the facility will assist in meeting these needs and preferences. During a review of the facility's P&P titled admission of a Resident with a revision date of 1/2025 indicated, care plans should be started on admission. During a review of the facility's P&P titled Comprehensive Care Plans-Timing with a revision date of 1/2025 indicated, each resident has a comprehensive care plan developed within seven days after completion of the comprehensive assessment and comprehensive care plan must be completed.no more than 21 days after admission.

Based on observation, interview, and record review, the facility failed to initiate/develop a comprehensive care plan within seven days after re-admission for one of four residents (Resident 25) who was on oxygen therapy. This deficiency had the potential for Resident 25 to experience undesired health effects related to the administration of oxygen not limited to hypoxia (a dangerous medical condition where body tissues or organs do not receive enough oxygen, potentially causing severe damage or death within minutes), hospitalization and death. Findings: During a review of Resident 25's admission record (face sheet - a document containing demographic and diagnostic information) indicated Resident 25 was admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnoses: acute kidney failure), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), anemia (a condition marked by a lack of healthy red blood cells or hemoglobin, reducing oxygen flow to body organs, which causes fatigue, weakness, pale skin, and shortness of breath), acute metabolic acidosis (a serious condition characterized by an excess of acid in the blood often caused by kidney failure, severe diarrhea, or uncontrolled diabetes), unspecified dementia with unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), heart failure unspecified (when heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), presence of cardiac and vascular implant and graft ( cardiac implants refer to devices placed inside the heart or chest to regulate or support heart function, while cardiac grafts are blood vessels used to bypass blocked arteries or vein), muscle weakness, and dependence on supplemental oxygen (a )medical treatment providing extra oxygen to people whose blood oxygen levels are too low). During a review of the facility's In-Service Education (a professional development for workers aimed to enhance their skills, knowledge, and competence to improve job performance) sign-in sheet dated 2/24/2026 indicated, facility staff were educated on management of resident with respiratory symptoms. During a review of Resident 25's history and physical (H&P - a physician's complete patient examination) dated 2/27/2026 indicated, Resident 25 had the capacity to understand and make decisions. During a review of Resident 25's Physician Order Summary Report (a condensed, organized document summarizing a patient's key medical information, including diagnoses, treatments, current medications, test results, and follow-up instructions), the Report did not indicate an order for supplemental oxygen after Resident 25 was re-admitted to the facility on [DATE]. During a review of Nursing Progress Notes (captures the details of a patient's health status, treatment progress, and any changes in their condition over time) dated 4/08/2026 at 11:22 PM, indicated Resident 25 was on 3 liter per minute (LPM - unit of measurement) of oxygen via nasal cannula (a lightweight, flexible tube used to deliver supplemental oxygen directly into a patient's nostrils). During a review of Nursing Progress Notes dated 4/10/2026 at 1:18 AM, Resident 25 was on 2 LPM of oxygen via nasal cannula. During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool) dated 4/13/2026, indicated, Resident 25 was cognitively intact (a person's thinking and reasoning abilities are functioning properly and are not significantly impaired). The MDS also indicated that Resident 25 was on continuous oxygen therapy while a resident at the facility. The MDS also indicated that Resident 25 used mobility devices (helps a person walk or move from place to place when one has a disability or injury) such as walker and a wheelchair to get around. The MDS also indicated that Resident 25 needed moderate to maximal assistance with toileting hygiene (maintaining cleanliness before and after using the toilet) due to muscle weakness. During a review of Resident 25's physician progress notes (a doctor's written record that documents a patient's health status, treatment, and care plan) dated 4/16/2026 indicated, Resident 25 was improving with current treatment of supplemental oxygen at 2.5 Liters per minute (LPM - oxygen flow rates are measured in LPM, determining how much supplemental oxygen a device delivers to a patient). During a review of Resident 25's care plan (CP - a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient), there was no care plan on providing supplemental oxygen to Resident 25. During an observation on 4/28/2026 at 8:58 AM with Resident 25, Resident 25 was receiving supplemental oxygen at 3 LPM per nasal cannula. During a concurrent observation, interview, and record review on 4/28/2026 at 11:34 AM with a licensed vocational nurse (LVN) 1, Resident 25 was observed in the room receiving 3 LPM of supplemental oxygen via a nasal cannula. LVN 1 reviewed physician's order for supplemental oxygen after Resident 25's readmission on [DATE], LVN 1 stated there is no order. LVN 1 stated I did not check [Resident 25's] oxygen saturation (measures the percentage of oxygen-carrying hemoglobin in the blood) this morning. LVN 1 stated oxygen is a medication and that LVN 1 did not check a physician's order for providing supplemental oxygen to Resident 25. LVN 1 stated LVN 1 assumed there was an order from a physician. LVN 1 also stated Resident 25 may become over oxygenated (occurs when tissues and organs are exposed to an excess supply of oxygen, usually from supplemental oxygen, hyperbaric therapy, or ventilators, leading to oxygen toxicity) and may have an altered mental status (AMS - a broad, non-specific term describing a change in a person's baseline awareness, cognition, or consciousness). During a concurrent observation, interview and record review on 4/28/2026 at 12:22 PM with a Respiratory Therapist (RT), Resident 25 was observed in the room receiving 3 LPM of supplemental oxygen via a nasal cannula. RT stated there is no order anywhere for supplemental oxygen after reviewing Resident 25's Physician Orders. RT stated I didn't read the doctor's order because it's a repeat every day. I thought it's there again today. When asked what is wrong with giving Resident 25 supplemental oxygen without a doctor's order, RT replied maybe it might kill her. During an interview on 4/28/2026 at 12:35 PM with the Registered Nurse Supervisor (RNS) 1, RNS 1 stated, if there is no order [for supplemental oxygen from a physician], you are not following the protocol of the order. During a concurrent interview and record review on 4/28/2026 at 12:47 PM with MDS, MDS stated, I am sure I saw it. I might have found it somewhere. There is probably an order when asked if there was a physician order for supplemental oxygen for Resident 25. After reviewing the Physician's Order with MDS for supplemental oxygen, MDS stated I can't find any orders here. MDS stated that the staff did not obtain an order from the physician. The physician will determine the right amount of oxygen to give. We (staff) have to do our care within our scope of practice. During a review of Nursing Progress Notes dated 4/29/2026 at 7:22 AM, Resident 25 was on 3.5 LPM of oxygen via nasal cannula. During a concurrent interview and record review on 5/01/2026 at 12:58 PM with LVN 1, LVN 1 stated, there was no care plan for O2 administration. When asked why LVN 1 did not initiate a care plan for O2 administration, LVN 1 stated I was not aware that there is no order for an O2. LVN 1 stated when a care plan was not created, Resident 25 could die, improper administration, becomes hypoxic (a dangerous medical condition where body tissues or organs do not receive enough oxygen, potentially causing severe damage or death within minutes) quickly. During a concurrent interview and record review on 5/01/2026 at 1:19 PM with RNS 1, RNS 1 stated as one of the RNS, I will do the initial care plan. RNS 1 stated without a care plan for O2 administration, staff may not meeting [Resident 25's] needs, we neglect the patient. I would say we failed to give the proper treatment.may lead to distress. During a review of the facility's policy and procedures (P&P - explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Develop-Implement Comprehensive Care Plans with a revision date of 1/2025 indicated that, the care plans shall describe the resident's needs and preferences and how the facility will assist in meeting these needs and preferences. During a review of the facility's P&P titled admission of a Resident with a revision date of 1/2025 indicated, care plans should be started on admission. During a review of the facility's P&P titled Comprehensive Care Plans-Timing with a revision date of 1/2025 indicated, each resident has a comprehensive care plan developed within seven days after completion of the comprehensive assessment and comprehensive care plan must be completed.no more than 21 days after admission. During a review of the facility's P&P titled Physician Medication Orders with a revision date of 1/2025 indicated, medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications.

Based on observation, interview, and record review, the facility failed to ensure a change in condition (COC - a clinical document used to record, assess, and report any sudden changes in a resident's physical, mental, or psychological status in order to ensure appropriate medical treatment can be started safely) assessment was completed and appropriate interventions implemented for one of one sampled resident (Resident 2) who had diagnosis of severe protein-calorie malnutrition (severe deficiency and/or poor absorption of protein, calories and nutrients) when Resident2 experienced 5.35 percent (% - unit of measurement) weight loss in a month. This deficient practice had potential to failure in the delivery of necessary care and services for Resident 2's highest practicable physical well-being. Findings: During a review of Resident 2's admission Record, the admission record indicated the facility admitted the resident on 3/7/2026 with diagnoses that included but not limited to dementia, cerebral infarction (loss of blood flow to a part of the brain), pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) and severe protein-calorie malnutrition (severe deficiency and/or poor absorption of protein, calories and nutrients). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 3/7/2026, the MDS indicated Resident 2 had severe cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 2 needed maximum staff assistance with activities of daily living (ADL), for eating/drinking and oral hygiene and was dependent on staff for toileting, upper body assist, sitting to lying, lying to sitting, personal hygiene, lower body dressing, putting/taking off footwear, sitting to standing and tub/shower transfer. During a concurrent telephone interview and record review on 4/30/2026 at 11:05 am, with Registered Dietician (RD). Resident 2's weights and Vitals Summary was reviewed from 10/2025 to 4/2026. The monthly weight record indicated the following weights for Resident 2:On 10/10/2025 Resident 2 weighed 122 pounds (lbs - unit of measurement)On 11/25/2025 Resident 2 weighed 104 lbs. Resident 2 lost 18 lbs - 14.75 percent weight loss in a month. On 12/5/2025 Resident 2 weighed 104 lbsOn 1/13/2026 Resident 2 weighed 112 lbsOn 2/20/2026 Resident 2 weighed 106 lbs. Resident 2 lost 6 lbs (5.35 percent (%-unit of measurement) weight loss. On 3/31/2026 Resident weighed 113 lbs. During the same interview and record, RD stated and confirmed that the facility did not initiate a COC in 2/2026 when Resident 2 lost 6 lbs (5.35% in a month). RD stated not initiating a COC, can affect the resident negatively. Resident can continue to lose weight and the resident's health can decline further which can lead to hospitalization, and even potentially death. During an interview on 04/30/2026 at 2:26 pm with Director of Nursing (DON), DON stated that the facility did not initiate a COC when Resident 2 experienced significant weight loss. DON stated that weight loss can affect a resident's health negatively. DON stated that considering Resident 2's comorbidities (resident with 2 or more illness at the same time), resident's health can further decline which can lead to more pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence), hospitalization and even lead to death. During a review of the facility's policy and procedures (P&P) titled, RD Assessment revised on 12/2025, P&P indicated that, unplanned weight loss greater than 5% in a month is severe weight loss. During a review of the facility's P&P titled, Change of Condition revised on 12/2025, P&P indicated that, There is need to alter treatment significantly and notifies the physician and resident representative for any significant change in resident's physical, mental or psychosocial status.

Based on interview and record review, the facility failed to ensure that low air loss mattress (LAL -a medical-grade mattress that prevents and treats pressure ulcers [bedsores] by constantly blowing air through tiny holes in the fabric, keeping the patient's skin cool and dry) guidelines were adhered to for maximal effectiveness of the LAL mattress and resident comfort in accordance with the facility's policy and procedures (P&P) titled Low Air Loss Mattress revision date 11/2024, for one of one sampled residents (Resident 7). This deficient practice had the potential to significantly compromise Resident 7's safety, leading to serious skin breakdown, infection, increased discomfort and possibly hospitalization. Findings: A review of Resident 7's admission Record indicated the facility admitted Resident 7 on 10/7/2025 with diagnoses including pressure ulcer (PU - localized damage to the skin and/or underlying tissue usually over a bony prominence) of sacral (a large, triangular-shaped bone at the very base of your spine) region, dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), and protein-calorie malnutrition (a serious condition where the body does not get enough protein, calories, or nutrients, causing it to break down its own tissues for energy). A review of the physician order dated 2/24/2026, indicated check for LAL mattress for wound management .settings are based on residents' weight. A review of Resident 7's Minimum Data Set (MDS - a resident assessment tool) dated 3/10/2026, indicated Resident 7 is cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 7 was dependent on staff with Activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) care. MDS further indicated that Resident 7 has one unstageable PU. During an observation on 4/28/2026, at 7:24 A.M., in Resident 7's room, LAL mattress setting indicated 320 pounds (lbs -unit of measure), the label on the LAL mattress pump indicated that resident 7 as of 4/17/26 is 89 lbs. During a concurrent observation and interview, on 4/28/2026, at 7:39 A.M., with Treatment Nurse (TN), in Resident 7's room, the LAL mattress was set at 320 lbs. The TN stated that Resident 7's has a sacral coccyx pressure ulcer and that the LAL should be set at 89lbs based on resident current weight but is currently set at 320lbs. The TN stated that having the resident on a LAL mattress is to prevent friction, which can cause the wound to get bigger and may not be beneficial to the resident causing the wound to get bigger. The TN stated that the resident LAL mattress should be soft and fluffy, and setting of 320 will cause it to be dense and hard. During an interview, on 5/1/2026, at 12:43 P.M., with the Director of Nursing (DON), the DON stated that LAL mattress is set to the resident's current weight to ensure the effectiveness of the LAL mattress. The DON stated that having the LAL mattress settings on a higher than the required setting may lead to worsening of the wound, delaying the resident wound healing and ultimately adversely affection the psychosocial wellbeing of the resident. A review of the facility's P&P, titled, Low Air Loss Mattress revision date 11/2025, indicated,POLICY STATEMENTThe facility has guidelines to provide residents with a low air loss mattress to reduce skin irritation and breakdown; and to allow maximal effectiveness of the low air loss mattress when a physician orders such therapy.PURPOSETo provide staff with guidelines for residents with low air loss mattresses for maximal effectiveness of the air mattress, and patient comfort.GUIDELINES.12. For maintenance, cleaning, settings and care, the facility shall follow the manufacturers' guidelines. A review of the Operators Manual, Med-Aire Melody Alternating Pressure Low Air Loss Mattress Replacement System, undated, indicated,.Operating Instructions.Step 6Determine the patient's weight and set the control knob to that weight setting on the control unit.

Based on interview and record review, the facility failed to:1. Implement the recommendations of the facility's Registered Dietician (RD - a food and nutrition expert who has completed extensive training to help people manage their health through eating)according to the facility's policy and procedures (P&P) titled Assisted Nutrition and Hydration, dated 1/2025 when Registered Dieticians (RD - a food and nutrition expert who has completed extensive training to help people manage their health through eating) for one of three sampled residents (Resident 7).This deficient practice had the potential to cause worsening weigh loss and possibly hospitalization for Resident 7.2. Ensure that staff changed enteral feeding formula (a method of delivering liquid nutrition directly into the stomach or small intestine when a person cannot eat or swallow safely) and the enteral feed tubing (a flexible tube for delivering nutrient-rich liquid formula directly into the stomach or small intestine) after 24 hours for one of one sampled resident (Resident 38) according to the facility's policy and procedures (P&P) titled the facility's P&P titled, Care Plan revised 12/2025.This deficient practice had potential for Resident 38 to suffer abdominal discomfort and infection. Findings: 1.A review of Resident 7's admission Record indicated the facility admitted Resident 7 on 10/7/2025 with diagnoses including pressure ulcer (PU - localized damage to the skin and/or underlying tissue usually over a bony prominence) of sacral (a large, triangular-shaped bone at the very base of your spine) region, dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), and protein-calorie malnutrition (a serious condition where the body does not get enough protein, calories, or nutrients, causing it to break down its own tissues for energy). A review of the VCSL-Nutritional Care -V2 notes dated 2/23/2026, indicated. low body weight, low body max index (BMI simple numerical score based on your height and weight that tells you if you are in a healthy weight range) . BMI low indicating potential nutritional risk . interventions 1. Prostat (highly concentrated liquid protein supplement) sugar free (SF) 30 cubic centimeters (cc -unit of measure in liquid) every day/100 calorie (Cal. - unit of measurement for energy)/ 15 grams (gm -unit of measure in weight) protein (meet estimated needs to promote wound healing). 2. Increase Jevity 1.5 (nutrient-dense liquid formula designed for tube feeding) to 55 cc per hour for 20 hours, 1100 cc per1650 calories (promote weight gain and wound healing) . A review of Resident 7's physician order dated 2/27/2026 indicated Pro stat (a concentrated, hydrolyzed collagen medical food designed for rapid absorption to treat wounds, muscle loss, and protein-energy malnutrition) one time a day . A review of Resident 7's physician order dated 2/27/2026 indicated enteral feed Jevity 1.5 to infuse (administer) at 55 cubic centimeters (cc-unit of measurement) per hour (hr) cc/hr . A review of Resident 7's Minimum Data Set (MDS – resident assessment tool) dated 3/10/2026, indicated Resident 7 is cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 7 was dependent on staff with Activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) care. MDS further indicated that Resident 7 has one unstageable PU. During a concurrent telephone interview and record review on 4/30/2026, at 1:13 P.M., with the RD, the RD stated that on 2/23/2026, the RD recommended that resident 7's Jevity 1.5 be increased from 50cc's to 55 cc's and start resident on Prostat 30 cc's as well for weight loss. The RD stated that RD recommendations are supposed to be carried out per standard of practice within 72 hours of being given. The RD stated that Resident 7 had recommendations from 2/23/2026 were not carried out until 2/27/2026. The RD stated that not carrying out the RD recommendations timely may potentially lead to more weight loss, and possibly hospitalization. During a concurrent interview and record review, on 5/1/2026, at 8:40 A.M., with Licensed Vocational Nurse (LVN) 2, Resident 7's electronic record was reviewed. LVN 2 stated that Resident 7 had RD recommendations given on 2/23/2026 to increase Jevity 1.5 from 50 cc's to 55 cc's and to start resident 7 on Prostat 30cc's daily. LVN 2 stated that RD recommendations are carried out immediately upon receipt. LVN 2 stated that Resident 7's RD recommendations from 2/23/2026 were not carried out until 2/27/2026 according to the orders in the chart. LVN 2 stated that not following RD recommendations timely may lead to a compromise in the resident's health because the resident is not getting the right nutrients leading to a decline in physical health, confusion and decreased mobility. During an interview, on 5/1/2026, at 12:47 P.M., with the Director of Nursing (DON), the DON stated that RD recommendations need to be carried out within 3 days of being provided, preferably carried out immediately within the day. The DON stated that not increasing the tube feeding formular rate and stating resident on Prostat per RD recommendations may lead to weight loss, delay in wound healing and malnutrition. A review of the facility's P&P, titled Assisted Nutrition and Hydration, dated 1/2025, indicated, POLICY To provide facility personnel with guidelines to ensure that a resident maintains acceptable parameters of nutritional status is offered sufficient fluid intake to maintain proper hydration and health; and is offered a therapeutic diet when ordered. Note: Assisted nutrition and hydration. (Includes nasogastric and gastrostomy Include percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids. INTENT The intent of this requirement is ta provide staff guidelines to ensure that the resident maintains, to the extent possible, acceptable parameters ol nutritional and hydration status and that the facility: Provides nutritional and hydration core and services to each resident, consistent with the rewidens comprehensive assessment. Recognizes, evaluates, and addresses the needs ol every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition and hydration; and Provides a therapeutic diet that considers the resident's clinical condition, and preferences, when there is a nutritional indication. Guidelines: The facility assists the residents to maintain, to the extent possible, acceptable parameters of n nutrition I and hydration status . The interdisciplinary team provides nutritional and hydration care and services to each resident, consistent with the resident's comprehensive assessment. 9. The facility follows professional standards of practice recommending . 2. During a review of Resident 38's MDS dated [DATE], indicated Resident 2 had severe cognitive impairment. The MDS indicated that Resident 38 needed maximum assist for activities of daily living (ADL - eating, oral hygiene, toileting, upper body assist, sitting to lying, lying to sitting, personal hygiene, lower body dressing, putting/taking off footwear and sitting to standing), and was dependent on staff for tub/shower transfer. During an observation on 4/28/2026 at 7:24 am, Resident 38 was observed in bed and was connected to enteral feeding (a method of delivering nutrients, fluids and medications in liquid form into the stomach or small intestine through a soft flexible tube to someone who is not able to eat or drink safely which was connected to a feeding pump. The enteral feeding was turned off. The enteral feeding was labeled with a date of4/26/2026 and timed 9 p.m. During an interview with License Vocational Nurse (LVN) 3 on 04/28/2026 at 1:20 pm, LVN 3 stated, G-tube feeding should have changed and G-tube feeding tube should be labeled with date and time because, we (staff) will not know when to change it. Using gastric tube (G-tube) feeding for longer than 24 hours can cause abdominal discomfort or an infection. During an interview with Director of Nursing (DON) on 04/30/2026 at 9:37 am, DON stated that the enteral feeding must be discarded after 24 hours of opening and the enteral feeding tubing must be changed after 24 hours of opening. DON stated that using Enteral formula for longer than 24 hours can cause abdominal issues and infection. During the review of the facility's policy and procedures (P&P) titled, Care Plan revised 12/2025, indicated that, is not clear about how often enteral feeding and enteral feed tubing should be changed, and enteral feeding/tubing care plan.

Based on observation, interview, and record review, the facility failed to obtain a physician's order for supplemental oxygen (O2) administration for one of four sampled residents (Resident 25), the facility failed to : This deficiency had the potential for Resident 25 to experience undesired health effects related to the administration of oxygen not limited to hypoxia (a dangerous medical condition where body tissues or organs do not receive enough oxygen, potentially causing severe damage or death within minutes), hospitalization and death. Findings: During a review of Resident 25's admission record (face sheet - a document containing demographic and diagnostic information) indicated Resident 25 was admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnoses: acute kidney failure), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), anemia (a condition marked by a lack of healthy red blood cells or hemoglobin, reducing oxygen flow to body organs, which causes fatigue, weakness, pale skin, and shortness of breath), acute metabolic acidosis (a serious condition characterized by an excess of acid in the blood often caused by kidney failure, severe diarrhea, or uncontrolled diabetes), unspecified dementia with unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), heart failure unspecified (when heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), presence of cardiac and vascular implant and graft ( cardiac implants refer to devices placed inside the heart or chest to regulate or support heart function, while cardiac grafts are blood vessels used to bypass blocked arteries or vein), muscle weakness, and dependence on supplemental oxygen (a )medical treatment providing extra oxygen to people whose blood oxygen levels are too low). During a review of the facility's In-Service Education (a professional development for workers aimed to enhance their skills, knowledge, and competence to improve job performance) sign-in sheet dated 2/24/2026 indicated, facility staff were educated on management of resident with respiratory symptoms. During a review of Resident 25's history and physical (H&P - a physician's complete patient examination) dated 2/27/2026 indicated, Resident 25 had the capacity to understand and make decisions. During a review of Resident 25's Physician Order Summary Report (a condensed, organized document summarizing a patient's key medical information, including diagnoses, treatments, current medications, test results, and follow-up instructions), the Report did not indicate an order for supplemental oxygen after Resident 25 was re-admitted to the facility on [DATE]. During a review of Nursing Progress Notes (captures the details of a patient's health status, treatment progress, and any changes in their condition over time) dated 4/08/2026 at 11:22 PM, indicated Resident 25 was on 3 LPM of oxygen via nasal cannula (a lightweight, flexible tube used to deliver supplemental oxygen directly into a patient's nostrils). During a review of Nursing Progress Notes dated 4/10/2026 at 1:18 AM, Resident 25 was on 2 LPM of oxygen via nasal cannula. During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool) dated 4/13/2026, indicated, Resident 25 was cognitively intact (a person's thinking and reasoning abilities are functioning properly and are not significantly impaired). The MDS also indicated that Resident 25 was on continuous oxygen therapy while a resident at the facility. The MDS also indicated that Resident 25 used mobility devices (helps a person walk or move from place to place when one has a disability or injury) such as walker and a wheelchair to get around. The MDS also indicated that Resident 25 needed moderate to maximal assistance with toileting hygiene (maintaining cleanliness before and after using the toilet) due to muscle weakness. During a review of Resident 25's physician progress notes (a doctor's written record that documents a patient's health status, treatment, and care plan) dated 4/16/2026 indicated, Resident 25 was improving with current treatment of supplemental oxygen at 2.5 Liters per minute (LPM - oxygen flow rates are measured in LPM, determining how much supplemental oxygen a device delivers to a patient). During a review of Resident 25's care plan (CP - a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient), there was no care plan on providing supplemental oxygen to Resident 25. During an observation on 4/28/2026 at 8:58 AM with Resident 25, Resident 25 was receiving supplemental oxygen at 3 liter per minute (LPM - unit of measurement) per nasal cannula (a flexible used to administer oxygen). During a concurrent observation, interview, and record review on 4/28/2026 at 11:34 AM with licensed vocational nurse (LVN) 1, Resident 25 was observed in the room receiving 3 LPM of supplemental oxygen via a nasal cannula. LVN 1 then reviewed physician's order for supplemental oxygen after Resident 25's readmission on [DATE], LVN 1 stated there is no order. LVN 1 stated, I did not check [Resident 25's] oxygen saturation (measures the percentage of oxygen-carrying hemoglobin in the blood) this morning (4/28/2026). LVN 1 stated oxygen is a medication and that LVN 1 did not check a physician's order for providing supplemental oxygen to Resident 25. LVN 1 stated LVN 1 assumed there was an order from a physician. LVN 1 also stated Resident 25 may become over oxygenated (occurs when tissues and organs are exposed to an excess supply of oxygen, usually from supplemental oxygen, hyperbaric therapy, or ventilators, leading to oxygen toxicity) and may have an altered mental status (AMS - a broad, non-specific term describing a change in a person's baseline awareness, cognition, or consciousness). During a concurrent observation, interview and record review on 4/28/2026 at 12:22 PM with a Respiratory Therapist (RT), Resident 25 was observed in the room receiving 3 LPM of supplemental oxygen via a nasal cannula. RT stated there is no order anywhere for supplemental oxygen after reviewing Resident 25's Physician Orders. RT stated, I didn't read the doctor's order because it's a repeat every day. I thought it's there again today. RT stated that administering supplemental oxygen to Resident 25 without a doctor's order, RT replied maybe it might kill her. During an interview on 4/28/2026 at 12:35 PM with the Registered Nurse Supervisor (RNS) 1, RNS 1 stated , if there is no order [for supplemental oxygen from a physician], you are not following the protocol of the order. During a concurrent interview and record review on 4/28/2026 at 12:47 PM with MDS, MDS stated, I am sure I saw it. I might have found it somewhere. There is probably an order when asked if there was a physician order for supplemental oxygen for Resident 25. After reviewing the Physician's Order with MDS for supplemental oxygen, MDS stated I can't find any orders here. MDS stated that the staff did not obtain an order from the physician. The physician will determine the right amount of oxygen to give. We (staff) have to do our care within our scope of practice. During a review of Nursing Progress Notes dated 4/29/2026 at 7:22 AM, Resident 25 was on 3.5 LPM of oxygen via nasal cannula. During a concurrent interview and record review on 5/01/2026 at 12:58 PM with LVN 1, LVN 1 stated there was no care plan for O2 administration. When asked why LVN 1 did not initiate a care plan for O2 administration, LVN 1 stated, I was not aware that there is no order for an O2. LVN 1 stated when a care plan was not created, Resident 25 could die, improper administration, becomes hypoxic (a dangerous medical condition where body tissues or organs do not receive enough oxygen, potentially causing severe damage or death within minutes) quickly. During a concurrent interview and record review on 5/01/2026 at 1:19 PM with RNS 1, RNS 1 stated, as one of the (RNS), I will do the initial care plan. RNS 1 stated without a care plan for O2 administration, staff may not meeting [Resident 25's] needs, we neglect the patient. I would say we failed to give the proper treatment.may lead to distress. During a review of the facility's policy and procedures (P&P - document explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Develop-Implement Comprehensive Care Plans with a revision date of 1/2025 indicated that, the care plans shall describe the resident's needs and preferences and how the facility will assist in meeting these needs and preferences. During a review of the facility's P&P titled admission of a Resident with a revision date of 1/2025 indicated, care plans should be started on admission. During a review of the facility's P&P titled Comprehensive Care Plans-Timing with a revision date of 1/2025 indicated, each resident has a comprehensive care plan developed within seven days after completion of the comprehensive assessment and comprehensive care plan must be completed.no more than 21 days after admission. During a review of the facility's P&P titled Physician Medication Orders with a revision date of 1/2025 indicated, medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications.

Based on observation and interview, the facility failed to implement Health insurance portability and Accountability Act (HIPAA - protect sensitive health information from being shared without knowledge or consent) and to provide care in a manner that promoted and enhanced the resident's quality of life, dignity, respect and individuality for and ensure that care for one of three sampled Residents (Resident 54) according to the facility's policy and procedure (P&P) titled Dignity and Respect, dated 1/2025. This deficient practice resulted in the violation of HIPPA and dignity rights for Resident 54.Findings: A review of Resident 54's admission Record indicated the facility admitted Resident 54 on 4/17/2026 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), diabetes (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and major depressive disorder (persistent low mood, deep sadness, or a loss of interest in activities). A review of Resident 54's Minimum Data Set (MDS - resident assessment tool) dated 4/23/2026, indicated Resident 54 was cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 54 was dependent on staff with Activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) care. During an observation on 4/30/2026, at 8:19 A.M., in the hallway by the nursing station across from resident room [ROOM NUMBER], Licensed Vocational Nurse (LVN) 1, was seen preparing medications for Resident 54. Resident 54's information not limited to name and diagnoses was visible on the medication laptop on top of the medication cart (Med Cart). LVN 1 then proceeded to explain what the medications were for and then gave the medications to Resident 54 while several residents walked by LVN 1 and Resident 54. During an interview, on 4/30/2026, at 8:40 A.M., with LVN 1, LVN 1 stated that resident medications should be administered in the residents room and not in the hallway for Health insurance portability and Accountability Act (HIPAA - protect sensitive health information from being shared without knowledge or consent) purpose as well as residents privacy and dignity. During an interview, on 5/1/2026, at 12:57 P.M., with the Director of Nursing (DON), the DON stated that resident medication should be administered in the resident's room or in a private space to protect the dignity of the resident. The DON stated that if dignity and privacy is not provided to the resident, it may affect the residents' psychosocial wellbeing and violates HIPAA for the residents. A review of the facility's policy and procedures (P&P), titled titled Dignity and Respect, dated 1/2025, indicated,POLICY STATEMENTEach resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.INTENTTo provide staff with guidelines to ensure residents are treated with kindness, respect, and dignity.GUIDELINES1.The facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.5. Residents shall be treated with dignity and respect at all times.Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.15. Staff shall maintain an environment in which confidential clinical information is protected.

Based on observation, interview and record review, the facility failed to ensure two of two staff (Certified Nursing Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1) practiced infection control standards according to the facility facility's policy and procedures (P&P) titled Standard Precautions, dated 12/2025 when:1.CNA 1 did not remove a gown (personal protective equipment-PPE) when exiting a resident's isolation room (a specialized, private room designed to separate a patient from others to control the spread of infections or protect vulnerable patients).2. LVN 1 did not disinfect (the process of using chemicals or physical agent to kill/destroy bacteria and other very small living things that cause disease) the blood pressure machine ( a device to monitor/check blood pressure) between residents. This deficient practice had the potential to spread infection in the facility leading to hospitalization.Findings: A review of Resident 6's admission Record indicated the facility admitted Resident 6 on 3/11/2026 with diagnoses including bipolar (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), and hypertension (HTN-high blood pressure). A review of Resident 6's Minimum Data Set (MDS - resident assessment tool) dated 3/17/2026, indicated Resident 6 was cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 6 was dependent on staff with Activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) care. A review of Resident 7's admission Record indicated the facility admitted Resident 7 on 10/7/2025 with diagnoses including pressure ulcer (PU - localized damage to the skin and/or underlying tissue usually over a bony prominence) of sacral (a large, triangular-shaped bone at the very base of your spine) region, dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), and protein-calorie malnutrition (a serious condition where the body does not get enough protein, calories, or nutrients, causing it to break down its own tissues for energy). A review of Resident 7's MDS dated [DATE], indicated Resident 7 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 7 was dependent on staff with ADL (activities such as bathing, dressing and toileting a person performs daily) care. The MDS further indicated that Resident 7 has one unstageable PU. A review of Resident 8's admission Record indicated the facility admitted Resident 8 on 12/4/2023 and resident was readmitted [DATE] with diagnoses including bipolar (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), aphasia (a disorder that makes it difficult to speak), and HTN. A review of Resident 8's MDS dated [DATE], indicated Resident 8 is cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 8 was dependent on staff with ADL (activities such as bathing, dressing and toileting a person performs daily) care. During an observation on 4/28/2026, at 9:47 A.M, in the hallway by resident room [ROOM NUMBER], CNA 1 was seen exiting room [ROOM NUMBER] into the hallway wearing an isolation gown on. During an interview on 4/28/2026, at 9:48 A.M, with CNA 1, CNA 1 stated that the Isolation gown should have been taken off inside the resident's room before coming out for infection control. During an observation on 4/30/2026, at 8:12 A.M, LVN 1 was seen using a blood pressure machine between Resident 6 and Resident 8 without disinfecting it between residents. During an interview on 4/30/2026, at 8:40 A.M, with LVN 1, LVN 1 stated that BP machine needs to be disinfected between residents to prevent infection. LVN 1 stated that she should have disinfected the BP machine between Resident 6 and Resident 8 however, she did not. During an interview on 5/1/2026, at 12:06 P.M, with Treatment Nurse (TN), TN stated that personal protective equipment (PPE - specialized clothing or gear worn to prevent you from getting hurt, sick, or injured while working or doing a project) need to be doffed (removed or taken off) before leaving the residents room and perform hand hygiene after. TN stated that facility staff should not have PPE on in the hallway to prevent transmission of infection/infection control. The TN stated BP machines need to be disinfected before and after each use to kill bacteria and prevent infection. TN stated if BP machine is used without being disinfected between residents, it may lead to the residents being sick. During an interview on 5/1/2026, at 12:57 P.M, with the Director of Nursing (DON), the DON stated that facility staff need to remove the PPE in the resident's room and wash their hands. The DON stated that facility staff should not have PPE in the hallway because having PPE in the hallway can transmit bacteria to other residents and staff in the hallway. The DON further stated that facility staff expectations is that BP machines need to be sanitized after each resident use for infection control purposes and prevent any cross contamination. A review of the facility's P&P, titled Standard Precautions dated 12/2025, indicated,POLICY STATEMENT:Standard Precautions shall be used at all times, when coring for residents regardless of their suspected or confirmed infection status. Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others.The facility shall make every effort to use the [NAME] restrictive approach to managing individuals with potentially communicable infections. Transmission-Based Precautions shall only be used when transmission cannot be prevented by less restrictive measures.INTENT,The staff will Transmission-Based Precautions whenever measures make stringent than Standard Precautions are needed to prevent or control the spread of infection.The Center' for Disease Control [NAME] established three types of Transmission-Based precaution (airborne, droplet and contact) have been established.Resident-Care Equipment1. When possible, dedicate the use of non-critical resident-care equipment items such as a stethoscope, sphygmomanometer, bedside commode, or electronic rectal thermometer to a single resident (or cohort of residents) to avoid sharing between residents.2. Items that must be shared shall be cleaned and disinfected between resident use.3. PPE should be donned upon entering the room and properly discarding before exiling the resident room, to contain pathogens; and when staff will have contact with the patient or potentially affected surfaces in the resident's room.

Based on interview and record review, the licensed nursing staff failed to offer the influenza (flu) vaccine as required or appropriate to one of five sampled residents (Resident 38). This deficient practice placed Resident 38 increased risk of acquiring and transmitting the flu to other residents in the facility. Findings: A review of Resident 38's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), difficulty swallowing and high blood pressure. A review of Resident 38's Minimum Data Set (MDS- a resident assessment tool) dated 4/10/2026, indicated the resident's cognition (ability to think and reason) was severely impaired. A review of Resident 38's Immunization Report, dated 5/4/2026, indicated Resident 38 last received the flu vaccine on 3/25/2025. During a concurrent interview and record review on 5/1/2026 at 10:56 AM, Resident 38 and Resident 38's immunization records were reviewed. The Infection Preventionist/Treatment Nurse (IP/TN) stated facility had not offered Resident 38 the flu vaccination during the last flu season. The IP/TN stated the flu shot is offered to all residents yearly. IP/TN further stated the flu vaccine is given to prevent the resident from becoming infected or spreading the infection in the facility. During an interview on 5/1/2026 at 1:03 PM, the Director of Nursing (DON) stated the facility inquires about the resident's vaccination status upon admission. The DON further stated the flu vaccine is offered yearly to prevent residents from becoming ill and to prevent infection. A review of the facility's policy and procedures (P&P) titled, Influenza and Pneumococcal Immunization, revised 1/2025, indicated, the facility maintains procedures for immunization against influenza and pneumococcal disease in accordance with national standards of practice to minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza and pneumonia. The P&P also indicated:- The facility vaccinates eligible residents with the influenza and/or the pneumococcal vaccine(s), unless the resident had previously received the vaccine, refused, or had a medical contraindication present. - Each resident or the resident's representative receives education regarding the benefits and potential side effects of immunization.

Based on interview and record review, the licensed nursing staff failed to offer the Coronavirus Disease (COVID-19) vaccination to two of five sampled residents (Resident 2). This deficient practice placed Resident 2 at a higher risk of acquiring and transmitting the COVID-19 to other residents in the facility. Findings: A review of Resident 2's admission Record indicated the facility originally admitted the resident on 9/8/2021 and readmitted on [DATE], with diagnoses of dementia (a progressive state of decline in mental abilities), pressure Ulcer/injury Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) and gastro-esophageal reflux disease (GERD- frequent heartburn). A review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 3/11/2026, indicated Resident 2 had severely impaired cognition (never/rarely made decisions). The MDS indicated the resident is dependent for toileting and personal hygiene. A review of Resident 2's Immunization Audit Report, dated 5/4/2026, indicated Resident 2 last received the COVID-19 vaccination 3/15/2024. During a concurrent interview and record review on 5/1/2026 at 11:30 AM, Resident 2's immunization records and progress notes were reviewed. The Infection Preventionist/Treatment Nurse (IP/TN) stated there was no record that Resident 2 was offered the updated COVID-19 vaccine or that Resident 2 declined the vaccination. IP/TN further stated the facility offers updated COVID vaccinations to all residents in order to prevent the resident from acquiring the infection. During an interview on 5/1/2026 at 1:03 PM, the Director of Nursing (DON) stated the facility offer the COVID-19 boosters on 3/10/2026. The DON further stated that the COVID vaccine is offered annually. The DON also stated COVID symptoms have a rapid onset and the vaccine protects the resident from having worse symptoms or hospitalizations. A review of the facility's policy and procedures titled, Infection Control - COVID-19 Immunizations, dated 1/2025, indicated:- All residents and/or resident representatives and staff shall be educated on the COVID-19 vaccine they are offered in a manner they can understand- Education covers the benefits and potential side effects of the vaccine including common reactions such as aches or fever, and rare reactions such as anaphylaxis.- The resident or resident representative shall be provided the opportunity to refuse the vaccine and to change their decision about vaccination at any time.

Based on observation, interview, and record review, the facility failed to ensure that Certified Nurse's Aide (CNA) 3 reported the alleged violation of abuse to the facility Administrator (Admin) within 2 hours of receiving report of abuse allegation f for one of three sampled residents (Resident 1) according to facility policy and procedures titled, Reporting of Alleged Violations with a review date of 01/2025. This deficient practice of failing to report the alleged violation of abuse had the potential to result in delayed investigation by California Department of Public Health (CDPD) of the abuse in the facility and failure to protect Resident 1 from further abuse. Findings: During a review of Resident 1's admission record (face sheet - a document containing demographic and diagnostic information) indicated Resident 1 was admitted to the facility on [DATE] with the following diagnoses: unilateral primary osteoarthritis, right knee, generalized muscle weakness (lack of physical or muscle strength), major depressive disorder, recurrent (a mood disorder that causes a persistent feeling of sadness and loss of interest), spondylosis without myelopathy (age-related wear and tear in the spine, specifically the cervical [neck] or lumbar [lower back] areas, without any nerve compression or spinal cord damage), and type 2 diabetes mellitus without complications (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's history and physical (H&P - a physician's complete patient examination) dated 11/05/2025 indicated, Resident 1 had the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 11/05/2025, indicated, Resident 1 had intact cognition (a person's thinking and reasoning abilities are functioning properly and are not significantly impaired). During a review of Resident 1's care plan (CP - a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) dated 11/11/2025, indicated, Resident 1 had an alleged accusation of sexual abuse by a CNA. The CP goal indicated Resident 1 will establish a sense of safety and trust within the facility. The CP interventions included assigning resident to another CNA, re-enforce training of professional boundaries and abuse prevention, assess Resident 1 for possible injuries, closely monitor Resident 1's whereabouts through visual check. During a review of the facility's In-Service Education (a professional development for workers aimed to enhance their skills, knowledge, and competence to improve job performance) sign-in sheet dated 11/11/2025 indicated, CNA 3 signed in and received Allegation of abuse must be reported immediately to abuse coordinator education. During an interview on 11/13/2025 at 1 PM with Resident 1, Resident 1 stated CNA 2 told Resident 1, Oh, you have a nice boob (breast) while CNA 2 was assisting Resident 1 with the shower. Resident 1 also stated that after CNA 2 made Resident 1's bed, CNA 2 kissed Resident 1 on the right cheek then left Resident 1's room. Resident 1 stated feeling shocked, [CNA 2] is not suppose to say anything about any part of my body. Resident 1 stated reporting the alleged abuse to CNA 3 on 11/10/2025 right away. During an interview on 11/13/2025 at 3:14 PM, CNA 3 stated Resident 1 approached CNA 3 with the an allegation that CNA 2 told Resident 1 this new CNA [2] told me I have nice breast. CNA 3 stated Resident 1 did not say anything else. CNA 3 stated, I was charting when [Resident 1] approached me. CNA 3 was asked what CNA 3 did with the information about an allegation of abuse, CNA 3 stated, I just finished my charting. Then later I came home, that was my fault. I should have told someone. That was my mistake. I should have reported this. CNA 3 was asked what CNA 3 should have done after Resident 1 reported to CNA 3 an allegation of abuse, CNA 3 responded I have to report it right way to the Administrator to solve the problem. CNA 3 stated the allegation of abuse was reported to [CNA 3's] supervisor the next day, 11/11/2025 when CNA 3 came back to work. During a review of the facility policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Reporting of Alleged Violations with a reviewed of 01/2025 indicated, Employees must immediately report any suspected abuse or incidents of abuse to the Administrator and/or Director of Nursing Service.

Based on interview and record review the facility failed to implement its abuse prevention program policy and procedure by failing to verify potential candidate's background check for a history of abuse, neglect, or mistreatment prior to the employee start working in the facility for one Certi ed Nursing Assistant (CNA 1).This failure had the potential for mistreatment, neglect, misappropriation of property, and abuse of residents.Findings:During a concurrent interview and record review on 9/16/2025 at 2:01 p.m. with the Director of Staff Development (DSD) of CNA 1 file, it indicated CNA 1 was hired on 1/7 2025. CNA 1 had been working with a registered sex offender background record and that did not match the CNA's name or date of birth matching with their California identi cation card. The DSD stated that the pre-employment veri cation process should have accurate and stated the CNA's name and date of birth before the employee's start date. The DSD stated, she was unsure how the document indicating a registered sex offender ended up in the CNA's employee le.During an interview with the Director of Nurses (DON) 9/16/2025, at 2:43 PM,DON stated that when there is no employee background check done this puts the residents at risk of abuse, and is a safety concern. The DON stated she did not see the registered sex offender record in the chart and stated she did not recognize the individual's picture on the record.During a review of the facility's policy and procedure (P and P) titled, Abuse Prevention Program, dated 08/2006, the P and P indicated that the facility is committed to conducting thorough employee background checks to ensure the safety and well-being of its residents. The policy clearly states, The facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals. Furthermore, the policy prohibits the employment of individuals found guilty of exploitation, mistreatment of residents, and misappropriation of their property.

Based on interview and record review, the facility failed to investigate allegations of sexual abuse (non-consensual sexual contact of any type or sexual harassment), for one of three sampled residents (Resident 3) and report to California Department of Public Health (CDPH), Ombudsman (a representative that helps families and residents in long-term care facilities by investigating and resolving complaints and serving as an advocate), and to the local law enforcement within 2 hours, failed to suspend the individual involved in the abuse allegations.This deficient practice had the potential to place other facility residents at risk for abuse, and delay required onsite inspection by CDPH. A review of Resident 3's admission record indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis including reduced mobility (having difficulty moving around easily or freely, affecting your ability to perform daily tasks like walking, standing), unspecified altered mental status (thinking, awareness, or behavior has changed from their normal state), essential primary hypertension (when the pressure in your blood vessels is too high). A review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 9/10/2025 indicated, the resident is cognitively intact (ability to acquire and understand knowledge), does not have change in behavior, dependent on toileting hygiene, (Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Requires substantial/maximal assistance for shower/bath self (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) During an interview on 9/16/2025 at 10:59 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated, I have worked with Resident 3 once or twice, he is dependent on staff to transfer and feeding. Resident 3 is alert and oriented, able to express his needs, and recognizes staff. During an interview on 9/16/2025 at 11:56 AM with the social services director (SS), SS stated, a day after Resident 3 was transferred from the facility, I was contacted by a General Acute Care Hospital (GACH) social worker about abuse allegations against Resident 3. SS stated, the facility has not started investigation of the abuse allegations and have not reported to the appropriate agencies. SS stated, abuse allegations should be reported within 2 hours to CDPH, ombudsman, law enforcement, family, and physician. During an interview on 9/16/2025 at 1:40 PM with MDS coordinator, MDS stated, it is known Resident 3 has been aggressive to staff, the care plan and MDS assessment is in progress. Resident 3 did not exhibit signs of abuse. During an interview on 9/16/2025 at 2 PM with the Director of Staffing Development (DSD), the DSD stated, any abuse allegations should be reported to the abuse coordinator. The process for abuse allegations is, report the allegations within 2 hours and follow the facility abuse investigation protocol. During an interview on 9/16/2025 at 2:44 PM with the Director of Nursing (DON), the DON stated, we have a process for abuse allegations. We must report the allegations within 2 hours, suspend involved staff, and update care plans. Report to CDPH, ombudsman, law enforcement, physician and family members, and start investigations. The DON stated, a couple of days ago the facility SS informed me, she has received a call from GACH staff. GACH staff has informed the facility SS, department of health services (DHS) will be called for abuse allegations. DON stated, I told staff to document what took place, I did not start investigation. The employee involved in the abuse allegations is not suspended. During an interview on 9/17/2025 at 10:28 AM with the facility Administrator (ADM), the ADM stated, staff should have followed the abuse allegation protocol. The process for any abuse allegation is for the facility to initiate investigation by calling CDPH, reporting to ombudsman, isolating the victim, calling law enforcement, education, and suspend if the alleged abuser is staff. The ADM stated, the employee involved in the abuse allegations is suspended as of today 9/17/2025, reporting the abuse allegation to the appropriate agencies and investigation has started. A review of the facility's Policies and Procedure (P&P) titled Abuse Investigate/Prevent/Report Alleged Violation reviewed on January 2025 indicated, To ensure resident safety, employees accused of participating in the alleged abuse will be suspended until the findings of the investigation have been reviewed by the administrator. Ensures that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made.

Based on observation, interview, and record review, the facility failed to revise fall interventions to prevent repeated falls for one of four residents (Resident 1). Resident 1 was at risk for fall. As a result, Resident 1 suffered an unwitnessed fall on 6/07/2025 and was transferred to a general acute care hospital (GACH - a health facility having professional responsibility and an organized medical staff that provides 24-hour inpatient care) for further evaluation and care. The deficient practice also had the potential for Resident 1 to sustain serious injury and death. Findings: During a record review, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), displaced fracture of the neck of the femur (thigh bone), lack of coordination, and difficulty walking. During a record review, Resident 1's Care Plan (CP- a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient)) on decline functional mobility and difficulty walking was created on 11/14/2024. The CP had a revision date of 6/06/2025. There CP goals and interventions did not reflect Resident 1 fell again on 6/07/2025. During a record review, Resident 1's Fall Risk Assessment (evaluates a person's likelihood of falling and identifies factors that increase their risks) dated 2/12/2025 indicated, Resident 1's fall risk score was three (a score of 10 or above represents high risk for falls). During a record review, Resident1's CP on actual fall incident initiated on 2/12/2025 and revised on 6/08/2025, indicated Resident 1 had a fall on 6/07/2025. The CP goal indicated Resident 1 will not sustain any injury from actual fall for a month. The CP interventions included to attend to Resident 1's needs immediately, to remind the resident to use the call light (a communication device that allows patients to request assistance from nurses or other healthcare staff), call light within reach, instruct Resident 1 to get up slowly and sit at the edge of the bed then stand up, and all items necessary that Resident 1 needed must be reachable. The CP goals and interventions did not reflect that Resident 1 fell again on 6/07/2025. During a record review, Resident 1's CP on non-compliant with safety initiated on 2/18/2025. The CP goal indicated Resident 1 will have no further fall or injury from fall daily in the next 90 days. The CP did not reflect revised goals and interventions in how the facility would prevent repeated falls. During a record review, Resident 1's Fall Risk assessment dated [DATE] indicated Resident 1's fall risk score was 10. During a record review, Resident 1's Situation-Background-Assessment-Recommendation (SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents) dated 6/07/2025, indicated, Resident 1 was found lying on the floor on her right side with head up .around 5:45 PM. The SBAR indicated Resident 1 was able to move all four extremities (both arms and both legs), denied any pain. A medical doctor (MD) was notified who ordered to transfer Resident 1 to a GACH for further evaluation and treatment related to the unwitnessed fall. Resident 1's family member was also notified. During a record review, Resident 1's GACH's computer tomography (CT - a medical imaging technique that uses x-rays and computer technology to create detailed images of the body) of the neck and spine dated 6/07/2025, indicated no evidence of compression fracture or traumatic subluxation (partial dislocation) of the cervical spine. During a record review, Resident 1's GACH's x-ray of the right forearm (from elbow to the wrist) dated 6/07/2025, indicated no evidence of acute displaced fracture (bone break that has moved out of their normal alignment) or dislocation (a disruption of the normal position of the ends of two or more bones where they meet at a joint). During a record review, Resident 1's GACH's x-ray of the right knee dated 6/07/2025, indicated no evidence of acute displaced fracture or dislocation. During a record review, Resident 1's GACH's x-ray of the tibia (shin bone of the lower leg) and fibula (calf bone of the lower leg) dated 6/07/2025, indicated no evidence of acute displaced fracture or dislocation. During a record review, Resident 1's GACH's CT of the brain dated 6/07/2025, indicated no intracranial hemorrhage (bleeding between the brain and the skull) During a record review, Resident 1's GACH's Inter-Facility Transfer Report dated 6/07/2025, indicated, Resident 1 had precautions in place: high fall risk patient and potential age-related cognitive decline patient. The report also indicated, Resident 1's account of the fall seems to change on repeat questioning. During a record review, Resident 1's GACH's Hospital Classification Declaration, dated 6/07/2025, indicated, Resident 1 was at high risk for additional falls due to Resident 1's age ([AGE] years old), diagnoses including and mild dementia. During a record review of Resident 1's Fall Risk assessment dated [DATE] indicated, Resident 1's fall risk score was 12 (a score of 10 or above represents high risk for falls). During an observation and interview on 6/18/2025 with Resident 1 in the resident's room, Resident 1 was observed to be confused. Resident 1 stated Resident 1 was at home with her children and the current date was September. During an interview on 6/18/2025 at 2 PM with Certified Nurse's Aide (CNA) 1, CNA 1 stated Resident 1's dementia is getting worse. During a concurrent interview and record review on 6/23/2025 at 2:17 PM with Licensed Vocational Nurse (LVN) 1, Resident 1's CP for actual fall incident on 6/07/2025 was reviewed. LVN 1 stated the CP did not indicate any revisions done for the fall of 6/07/2025. LVN 1 stated, the CP does not tell me it was or wasn't done. LVN 1 stated whenever a resident has another fall incident, LVN 1 creates a new care plan rather than revise the initial CP to address a new/repeated fall incident. LVN 1 stated for every fall, there should be another care plan. LVN 1 stated the initial CP interventions of placing the call light within reach and reminding the resident not to get up without assistance were not effective regardless of how many times we educate. LVN 1 stated Resident 1 may continue to have multiple fractures. During a concurrent interview and record review on 6/23/2025 at 2:43 PM with Registered Nurse Supervisor (RNS) 1, Resident 1's CP for actual fall incident on 6/07/2025. RNS 1 stated the interventions of the call light being within reach and reminding the resident not to get up without assistance, were not appropriate given Resident 1 has dementia and forgetfulness. RNS 1 stated I don't' think it's helping [Resident 1] .if we come up with a safety .a better way for [Resident 1] .such as every now and then, visual check. When asked if the stated interventions helped prevent Resident 1 from falling again, RNS 1 no, because 9Resident 1] fell again. RNS 1 stated a new CP should be written for each fall incident. RNS 1 stated only the revision date of 6/07/2025 was updated in the resident's CP and that the CP's goals and interventions were not revised to reflect Resident 1's most recent fall incident. During a concurrent interview and record review on 6/23/2025 at 3:32 PM with Director of Nursing (DON), Resident 1's CP on actual fall incident on 6/07/2025 was reviewed. DON acknowledged and stated that the CP indicated revision date was changed, but the CP goals and interventions were not changed/revised/updated to reflect Resident 1's most recent fall incident. DON stated that the facility expects the licensed nurses to follow the documentation and fall P&P, the in-services on fall risk/management. DON stated, this is what our problem is, they are not listening. During a record review, the facility policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Care Plans, Comprehensive Person-Centered reviewed date of 12/2016 indicated, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition changes. During a record review, the facility P&P titled Dementia - Clinical Protocol reviewed date of 3/2015 indicated, The IDT (Interdisciplinary Team - a group of different healthcare professionals working together towards a common goal for a resident) will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. During a record review, the facility P&P titled Fall and Fall Risk, Managing reviewed date of 12/2007 indicated, The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. The P&P also indicated, If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents, (Resident 9), who was at risk for dehydration (lack of drinking sufficient fluids to meet the body's need) and malnutrition (food ingested [eaten]) does not provide enough nutrients or the right balance for optimal health), was offered sufficient food and did not experience unplanned severe weight (wt) loss (a body weight loss of greater than five [5] percent [% - unit of measure] in one month). The facility failed to: 1. Identify interventions related to Resident 9's poor food intake since admission to prevent progressive wt loss. 2. Monitor and document Resident 9's high protein nutrition (HPN - supplement nutritional drink with high protein) intake to determine Resident 9's intake met his nutritional needs. 3. Develop intervention including frequent foods and snacks when Resident 9 yelled or asked for food. 4. Ensure Registered Dietitian 1 (RD 1) promptly evaluated Resident 9 after the resident was identified with severe wt loss of 12 pounds (lbs - unit of measurement) on 2/2/2024. 5. Implement facility's policy and procedures (P&P) on Fortified Food (the process of adding nutrients to foods that are not naturally present or are insufficient in the original food ) Program to provide appropriate and equivalent food substitute for Resident 9 who had intolerance to dairy products. 6. Implement the facility's P&P on Weight Variance Assessment and Interventions when Resident 9 was identified with 12 lbs wt loss on 2/2/2024. 7. Implement Resident 9's care plan interventions related to alteration in nutrition, severe protein-calorie malnutrition, and wt loss. These deficient practices resulted in: 1. Resident 9 experienced 12 lbs severe wt loss in one month from 1/5/2024 to 2/2/2024 (equivalent to 7.8% of Resident 9's body weight). 2. Resident 9 was agitated, complained of being hungry, and kept requesting for more food on multiple occasions. 3. Resident 9 not been assessed and re-evaluated by a Registered Dietician (RD for 20 days after Resident 9 experience 12 lbs wt loss in one month. These deficient practices had the potential for further decline and complications related to Resident 9's: 1. Severe protein-calorie malnutrition (the state of inadequate intake of food [as a source of protein, calories, and other essential nutrients] in the body). 2. Stage four (4) pressure ulcer (severe tissue damage caused by injury to skin and underlying tissue resulting from prolonged pressure on the skin; a stage four is the largest and deepest of all pressure ulcer stages). Findings: A review of Resident 9's Admission Record indicated the facility originally admitted Resident 9 on 12/18/2020 with a readmitted d 1/4/2024. Resident 9's diagnoses included unspecified severe protein-calorie malnutrition, type 2 diabetes mellitus (long-term condition in which the body has trouble controlling blood sugar and using it for energy), and recurrent depressive disorder (when a person has experienced depressive symptoms [feelings of sadness and/or a loss of interest in activities you once enjoyed] for most of the day, for more days than not over two years). A review of Resident 9's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 1/9/2024, indicated Resident 9 had a severely impaired cognition (ability to comprehend, think, solve problem, process information, and make decisions). The MDS indicated Resident 9 required moderate staff assistance with eating and weighed 154 pounds (lbs). The MDS indicated Resident 9 was on a mechanically altered diet (foods are mechanically altered by whipping, blending, grinding, chopping, or mashing so that they are easy to chew and swallow) and therapeutic diet (meal plan that control and promote the intake of certain foods or nutrients). The MDS also indicated Resident 9 was admitted with a Stage4 pressure ulcer. A review of Resident 9's Physician Order, dated 1/12/2024, indicated: - Puree (foods that have a soft, pudding like consistency), controlled carbohydrate diet (CCHO - same number of carbohydrates every day to help people manage blood sugar levels), fortified (food with extra nutrients added to increase the calories and protein) diet with thin liquids (watery liquids) - Four ounces (oz.) HPN three times daily for poor oral intake (low food /liquids ingestion). A review of Resident 9's Care Plan, revised on 1/6/2024 for Resident 9's risk for dehydration and weight loss fluctuation, had a goal for Resident 9 not having significant weight changes of 5 lbs or more monthly. The interventions included monitoring Resident 9's skin turgor for tenting (very slow to return to normal, or the skin tents up during a check; this can indicate severe dehydration that needs quick treatment), monitoring for dry mouth, muscle cramps, and changes in mental status. A review of Resident 9's Care Plan revised on 1/7/2024 for Resident 9's severe protein-calorie malnutrition, had a goal for Resident 9 to gain one to two lbs per month in the next three months. The care plan interventions included monitoring Resident 9's weight loss and report to the physician and the RD promptly (if any wt loss). A review of Resident 9's Nutritional Care Assessment (NCA) form, documented by RD 1 on 1/12/2024, indicated Resident 9 weighed 154 lbs and was 66 inches tall. Resident 9's usual weight range was 186-193 lbs, the ideal body weight (IBW) range was128-156 lbs, with a desirable BW range of 149-159 lbs. RD 1 assessed Resident 9's daily caloric needs range 25-30 calorie per kilogram of weight cal/kg) equivalent to 1750-2100 calories per day. Resident 9's daily protein needs range from 1.4-1.5 grams (gm -unit of measurement)/kg equivalent to 98-105 gm ER [NAME]. The NCA form indicated Resident 9's Body Mass Index (BMI - a tool used to estimate the amount of body fat; a BMI less than 18.5 falls is considered underweight) was 24.85. The NCA form indicated the goal was to maintain Resident 9's current body wt. A review of Resident 9's Weekly Weights Record indicated: 1/5/2024: 154 lbs. Admission wt. 1/12/2024: 151 lbs. Three (3) lbs wt loss in seven (7) days. 1/19/2024: 148 lbs. Six (6) lbs wt loss in 14 days. 1/26/2024: 145 lbs. Nine (9) lbs wt loss in 21 days. 2/2/2024: 142 lbs. 12 lbs wt loss in 28 days and in four weeks (one month). 2/7/2024: 144 lbs. 2 lbs weight gain. A review of Resident 9's meal consumption percentage indicated the following: 1/9/2024 - Breakfast (B) 50%; Lunch (L) 50%; Dinner (D): 60% 1/10/2024 - no meal % recorded. 1/11/2024 - B 75%; L 50%, D 40% 1/12/2024 - B 50%; L 35%, D 30% 1/13/2024 - B 25%; L 40%, D 30% 1/14/2024 - B 25%, L 25%, D 50% 1/15/2024 - B 75%; L no record, D 50% The percentage of the HPN consumed was not recorded. A review of Resident 9's Situation - Background - Assessment - Recommendation (SBAR - a written or verbal communication tool used by the healthcare team to provide essential and concise information, usually during crucial situations), dated 2/7/2024, documented by Licensed Vocational Nurse 2 (LVN 2), indicated, Resident 9 had weight loss of 12 lbs in one month (five days after Resident 9 was weighed and the weight was 142 lbs). The Nurse Practitioner (working for the attending physician) was notified and gave no new orders. The SBAR did not indicate if the RD was notified of Resident 9's 12 lbs wt loss in one month for further recommendation as per the Care Plan. A review of Resident 9's Care Plan, initiated on 1/6/2024 for Resident 9's risk for dehydration and weight loss fluctuation, indicated it was revised on 2/7/2024, to include Resident 9's 12-lbs weight loss in one month. A review of Resident 9's Care Plan revised on 1/7/2024 for Resident 9's severe protein-calorie malnutrition indicated it was revised on 2/7/2024 to include in the interventions to report Resident 9's wt loss to the physician and the RD. A review of Resident 9's Dietary Progress Notes, dated 2/22/2024, indicated Resident 9's wt of 142 lbs was down to 12 lbs in one month (a 7.8% wt loss), the current diet of pureed fortified CCHO, 4 oz HPN three times a day provided 600 calories and 8 gm of protein). RD 1's recommendations included to: - Discontinue (DC-stop) four oz HPN (no dairy) - Give Boost glucose control (a nutritional drink, no dairy, specially formulated for people with diabetes) one can twice daily - 474 millimeter (ml)/380 calories/32 gm protein (supplement) - Change diet to puree CCHO (discontinue the fortified diet due to no dairy for beverage). On 3/23/2024 at 5:20 p.m., during an interview, Licensed Vocational Nurse 2 (LVN 2) stated Resident 9 had 12 lbs wt loss and that LVN 2 had initiated the SBAR dated 2/7/2024. LVN 2 stated not remembering if RD 1 was notified of Resident 9's severe wt loss. On 3/23/2024 at 5:58 p.m., during an interview with RD 1 and concurrent review of Resident 9's Dietary Progress Notes dated 2/22/2024 were reviewed. RD 1 stated Resident 9 had a severe wt loss in a month after admission. RD 1 stated she recommended to discontinue the fortified diet due to Resident 9's digestive (the process of breaking down food into substances the body can use for energy, tissue growth, and repair) issues with dairy products. RD 1 stated, with fortified diet, [Resident 9] is receiving additional 600 calories per day. RD 1 further stated Resident 9 was given Boost Glucose Control twice daily as a substitute which had/contained 380 Cal per day. RD 1 stated the facility did not notify RD of Resident 9's wt loss on 2/2/2024. RD 1 did not provide documented evidence the Interdisciplinary Team (IDT - a group from different healthcare who work together to help residents to receive the care they need) met to address Resident 9's wt loss of more than 5% in one month. A review of Resident 9's Physician Orders, dated 2/22/2024, indicated to give Resident 9 CCHO diet pureed texture, thin liquid consistency, which was changed from Puree CCHO fortified diet, thin liquid, and Boost Glucose twice a day. During a concurrent observation and interview with LVN 3 on 3/24/2024 at 8:45 p.m., Resident 9 was observed yelling from Resident 9's room. LVN 3 stated Resident 9, yells at night because he is hungry and would always ask for more food on a daily basis. LVN 3 walked into the kitchen after Resident 9 asked for more food, but LVN 3 did not provide food to Resident 9. During a concurrent observation in Resident 9's room and interview with Resident 9 on 3/25/2024 at 9:27 a.m., Resident 9 stated, I have not been eating good. I want water, Resident 9 was observed with loose and sagging skin. During an interview with Certified Nursing Assistant 2 (CNA 2) on 3/25/2024 at 11:20 a.m., CNA 2 stated Resident 9 needed assistance with eating and yelled from his room and would always ask for more water and food. CNA 2 stated would yell for food. On 3/25/2024 at 11:47 a.m., during an interview, RD 1 stated, she recommended to discontinue Resident 9's fortified diet and HPN on 2/22/2024. RD 1 stated Resident 9 was receiving 600 Cal per day while on fortified diet and was now receiving 380 Cal per day while on CCHO puree diet and Boost Glucose Control twice a day. When asked the reasons the calories were decreased from 600 Cal to 380 Cal on 2/22/2024 after Resident 9 had a wt loss of 7.8% in one month, RD 1 stated, because [Resident 9] had digestive issues with milk. When asked if milk could be substituted with other non-dairy products when residents were on fortified diet, RD 1 stated, Yes, milk can be substituted with butter or mayonnaise. RD 1 further stated not been aware Resident 9 yelled for more food because Resident 9 was hungry. RD stated, when a resident receives less calories, it can cause them to be hungry and agitated. On 3/25/2024 at 1:07 p.m., Resident 9 was observed in bed assisted by CNA 2 and ate 80 % of his lunch tray. During an interview on 3/25/2024 at 1:11 p.m., the Dietary Supervisor (DS) stated the kitchen provided Resident 9 with mocha mix (non-dairy drink) as a substitute of milk because Resident 9 could not have dairy products. DS stated, Resident 9 was not on any fortified food other than mocha mix. Resident 9 was given the Boost supplement as ordered. On 3/25/2024 at 6:11 p.m., Resident 9 observed in bed assisted with eating and ate 70% of his dinner. During a concurrent observation and interview with Registered Nurse 2 (RN 2) and Resident 9 on 3/25/2024 at 8:12 p.m., Resident 9 was in bed yelling. Resident 9 said, I want ice cream, please. RN 2 stated Resident 9 already ate dinner and that Resident 9 frequently exhibited agitation saying he was hungry. A review of the facility's P&P titled, Weight Variance Assessment and Intervention reviewed by the facility on 2/22/2024, indicated, it is the policy of this facility to identify significant weight variance, assess and intervene using good nursing practice and then utilizing an interdisciplinary weight variance committee. A review of the facility's P&P titled, Fortified Food Program, reviewed by the facility on 2/22/2024, indicated, food preferences are obtained and foods high in calories and protein will be provided to help maintain or gain weight. Milk/dairy intolerant residents there are different options and will need to be individualized per likes and dislikes of specific products . follow the lactose free and the fortified pattern on the menu extension sheets which may be further individualized using the fortified foods program sheet: a minimum of two (2) items need to be served per meal. A review of the facility's P&P titled, Fortified Diets, reviewed by the facility on 2/22/2024, indicated, a fortified diet is available for those residents who are deemed at nutritional risk and in need of increased calories and protein by the registered dietitian or interdisciplinary team. Examples of foods that may be fortified: hot cereal, milk, cream soup, mashed potatoes, pudding, ice cream . If a resident chooses not to eat the items typically served on a fortified diet or is unable to tolerate foods, alternative options to increase calories will be implemented. A review of the facility's P&P titled, Job Description - Consultant Dietitian, reviewed by the facility on 2/22/2024, indicated, primary function to evaluate and monitor food services systems and nutritional status of residents . evaluates and monitors food service systems, making recommendations for a conformance level that will provide nutritionally adequate, acceptable quality food.

Based on observation, interview, and record review, the facility failed to provide respiratory treatment and care for one of 16 sampled residents (Resident 13), who had chronic obstructive pulmonary disease (COPD, group of diseases that cause airflow blockage and breathing-related problems) and history of pneumonia (a serious infection of one or both lungs in which the air sacs fill with pus and other liquid). The facility failed to: 1. Closely monitor Resident 13's respiratory condition, including response to treatment after being identified to have a change of condition (COC, a sudden clinically important deviation from a patient's baseline) when Resident 13 develop a cough on 3/20/2024. 2. Perform a complete respiratory assessment (breathing rate, pattern and effort, skin color, chest configuration, and symmetry of expansion of the chest with each breath) as per policies and procedures (P&P) on Residents COC, Pneumonia, Bronchitis [inflammation of the lining of bronchial tubes, which carry air to and from the lungs], and Lower Respiratory Infections -Clinical Protocol, and Resident Examination and Assessment. 3. Monitor and notify the attending physician (Physician 1) about Resident 13's worsening cough. 4. Notify Physician 1, on 3/21/2024, of Resident 13's chest X-ray results and recommendation to repeat X-rays if symptoms persisted or worsened. These deficient practices resulted in: 1. A four-day delay for Resident 13 to receive respiratory care consistent with Resident 13's respiratory symptoms. 2. Resident 13 having inability to sleep, fatigue (extreme sense of tiredness and lack of energy that can interfere with a person's usual daily activities), poor appetite, and loss of ability to taste food/fluids. 3. Transferring Resident 13 to General Acute Care Hospital 1 (GACH 1) on 3/24/2024, because of fever, coughing, and difficulty breathing. At GACH 1, Resident 13 was diagnosed with pneumonia and required intravenous (IV- delivered into a vein) antibiotics (medications used to treat infection). These deficient practices had the potential for further decline and complications related to increased risk for sepsis (a life-threatening infection in the blood that travels throughout the entire body), respiratory failure, organ failure, and death. Findings: A review of Resident 13's Admission Record indicated the facility initially admitted Resident 13 on 6/23/2023, and the most recent readmission was dated on 1/6/2024. Resident 13's diagnoses included pneumonia, asthma (chronic [ongoing] disease in which the bronchial [passages in the lungs] that extend from the trachea [windpipe] and airways in the lungs that become narrowed and swollen, making it difficult to breathe), and hypertension (high blood pressure). A review of Resident 13's Physician Order, dated 1/6/2024, indicated to administer Ipratropium-Albuterol Inhalation Solution (combination medication used to help control the symptoms of lung diseases and treat air flow blockage) ipratropium 0.5 milligrams (mg) - albuterol 3 mg (2.5 mg base) in three milliliters (ml) solution, vial inhaler, every four hours as needed for SOB (shortness of breath). A review of Resident 13's Minimum Data Set (MDS - standardized assessment and care screening tool) dated 1/10/2024, indicated Resident 13 had moderate impaired cognition (ability to comprehend, think, solve problem, process information, and make decisions). The MDS indicated, Resident 13 required substantial to maximum assistance for activities of daily living (ADLs such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). A review of Resident 13's History and Physical exam (H&P) completed by Physician 1 on 1/25/2024, indicated that Resident 13 had the capacity to understand and make decisions. A review of Resident 13's COC, dated 3/20/2024 and timed at 9:22 p.m., indicated Resident 13 had nonproductive cough (a cough that is dry and does not produce sputum [mixture of saliva and mucus coughed up]). The COC did not include Resident 13's respiratory assessment. A review of Resident 13's chest X-rays results, dated 3/21/2024, indicated no acute focal consolidation (fluid or other material that consolidates inside the lung) or effusion (buildup of fluid between the chest cavity and the tissue lining the lungs). The x-ray indicated, if Resident 13's symptoms persisted or worsened, then the recommendation was to repeat frontal (front) and lateral (side) chest X-rays. A review of Resident 13's COC, dated 3/23/2024 and timed at 5:37 pm, indicated Resident 13 had productive cough and redness on the eyes, the respiration was even and unlabored (easy/relaxed), there was no shortness of breath, and Resident 13 did not get good sleep in the past two nights (3/21/2024 and 3/22/2024). The COC indicated the Director of Nursing (DON), assessed Resident 13 and the lung sounds were clear and no wheezing (high-pitched whistling sound made while breathing) was noted. The COC indicated Resident 13 did not have fever (high body temperature) or change in level of consciousness. The COC indicated Physician 1 was notified about Resident 13's COC on 3/23/2024 at around 5:15 pm and ordered Robitussin Peak Cold DM (Dextromethorphan-Guaifenesin - a combination medication used to relieve coughs) oral (by mouth) syrup 100 -10 milligrams (mg- unit of measurement) per 5 milliliters (ml- unit of measurement), every four hours as needed for 30 days. A review of Resident 13's nursing Progress Note, dated 3/24/2024 at 6:25 pm, indicated that on 3/24/2024 at 5 pm, Family Member 1 (FM 1) called concerned about Resident 13's difficulty of breathing. The Progress Note indicated Resident 13's oxygen saturation (02 sat - amount of oxygen in the blood) was 94 percent (% - normal range is 95-100%) while Resident 13 was on oxygen at two liters per minute (2 L/min) via nasal cannula (NS- a flexible tube used to deliver oxygen through the nose). The Progress Note indicated Physician 1 was notified regarding Resident 13 having difficulty of breathing with new orders. A review of Resident 13's Physician Order dated 3/24/2024, indicated to administer oxygen inhalation at 2L/min via nasal cannula as needed for shortness of breath/comfort. A review of Resident 13's Physician Progress Note dated 3/24/2024, no time specified, indicated Resident 13's 02 sat was 90%, had cough and rhonchi (coarse, loud sounds caused by constricted larger airways) upon chest assessment. A review of Resident 13's nursing Progress Note, dated 3/24/2024 indicated that at 6:40 pm Resident 13 developed a fever of 100.7 degrees Fahrenheit (F- normal body temperature range is between 97 F and 99 F), Physician 1 was notified and ordered transferring Resident 13 to GACH 1. A review of Resident 13's Transfer to Hospital Summary form, dated 3/24/2024 at 10:40 pm, indicated Resident 13 was transferred to GACH 1 due to fever, coughing, and difficulty breathing. A review of Resident 13's GACH Emergency Department note dated 3/24/2024, untimed, indicated, Resident 13 presented with cough and SOB. GACH Emergency Department note indicated, Resident 13, reported that over the past week, [Resident 13] was having increased congested sounding cough, but unable to bring up any sputum. GACH Emergency Department note indicated, [Resident 13] reported to facility staff associated shortness of breath, with increased wheezing sensation requiring oxygen. GACH ED diagnosed Resident 13 with pneumonia. A review of Resident 13's GACH 1 chest X-ray report dated 3/25/2024 and timed at 12:32 am, indicated, subtle patchy infiltrates (areas filled with fluid, may be a manifestation of aspiration [breathing in food particles in airway]) in the right lower lung zone. A review of Resident 13's GACH 1 Infectious Disease Specialist Progress Note, dated 3/28/2024, indicated Resident 13 was treated for pneumonia with IV Zosyn (a combination of two antibiotics namely piperacillin and tazobactam) 3.375 grams (gm, unit of measurement). The Progress Note indicated to discontinue Zosyn and continue Levaquin (levofloxacin - antibiotic) 500 mg for three more days. On 3/24/2024 at 10:15 a.m., during a concurrent interview with the Director of Nursing (DON) and a review of Resident 13's clinical record, the DON could not find documented evidence that a care plan was developed on 3/20/2024, when Resident 13 was identify to be coughing. On 3/23/2024 at 10:30 am, during an observation, Resident 13 was sitting in a wheelchair outside room, in the hallway and was not receiving oxygen therapy. Upon interview, Resident 13 was observed coughing continuously. Resident 13 stated feeling tired, was unable to sleep because of constantly coughing during the night and was bothering others with the cough. Resident 13 stated feeling that other residents were staring when coughing. Resident 13's eyes appeared watery, red, and sunken. Resident 13 stated having nonproductive cough for a couple days and felt fatigued from not being able to sleep. Resident 13 stated receiving medication (Ipratropium- Albuterol) inhalation (via inhaler, a device that gets medicine directly into a person's lungs. The medicine is a mist or spray that the person breathes in), but the medication was not working. A review of Resident 13's Care Plan developed on 3/23/2024 for Resident 13's having a productive cough, included in the interventions: -Monitoring for any shortness of breath and notify Physician 1. -Administering medication as ordered, Robitussin Peak Gold DM oral syrup every four hours for 30 days. -Monitoring vital signs (measurement of the body's most basic functions such as heartbeat and breathing rates, and body temperature) every shift for the next three days and notify Physician 1 if any significant or any abnormalities. On 3/23/24 at 4:10 pm, a concurrent observation in Resident 13's room and interview with Resident 13 in the presence of the Director of Nursing (DON) was conducted. Resident 13 was in bed and appeared tired. Resident 13's eyes were watery, red, and sunken in. Resident 13 reported coughing for a few days and unable to cough up any sputum. Resident 13 stated feeling fatigued from not sleeping well at night due to constantly coughing. Resident 13 stated having no appetite and unable to taste food since the cough started which the nurses were aware. Resident 13 stated the nurses were giving some type of liquid medication, which did not work at all. The DON auscultated (examine by listening to the sounds of the heart, lungs, arteries, and belly using a stethoscope (a medical instrument used for listening to sounds in the body) Resident 13's lungs and stated Resident 13's lungs were clear (no abnormal sounds). The DON stated the respiratory assessment must be performed when a resident displays any respiratory concerns including coughing. The DON stated Resident 13 should have had a respiratory assessment as soon as Resident 13 started coughing on 3/20/2024, to identify problems and prevent worsening of Resident 13's condition. On 3/23/2024 at 4:30 pm, during an interview Licensed Vocational Nurse 1 (LVN 1) stated that on 3/18/2024, Resident 13 received COVID-19 vaccine and developed a cough approximately two days after. LVN 1 stated Resident 13's cough was a reaction to the vaccine. On 3/23/2024 at 4:43 p.m., during a concurrent interview with the DON and a review of Resident 13's clinical record, the DON stated there was no documentation Physician 1 was notified of the chest X-rays report and the recommendation from the radiologist (a medical doctors that specialize in diagnosing and treating injuries and diseases using medical imaging [radiology] procedures such as X-rays) to repeat the X-rays if cough persisted or worsened. The DON admitted that not notifying Physician 1 led to a delay in Resident 13's care. On 3/23/2024 at 5 pm, during a telephone interview, Physician 1 (who was also the facility's medical director), stated the nurses did not inform him of Resident 13's worsening cough and the recommendations to repeat chest x-ray the if symptoms (cough) persisted or worsened was not implemented. Physician 1 stated not being informed Resident 13 had the eyes red and sunken. MD 1 stated, it was normal part of aging to feel fatigued, be unable to sleep, and have some type of discomfort such as aches. A review of facility's policy and procedures (P&P) titled, Change in a Resident's Condition or Status revised 2/22/2024, indicated, Our facility shall promptly notify the resident, his or her Attending Physician, Attending Licensed Healthcare Practitioner acting within the scope of his or her professional /licensure, representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments., resident rights, etc.). Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and relevant and pertinent information for the provider, including (for example) information prompted by the SBAR [Situation - Background - Assessment - Recommendation, a written or verbal communication tool used by the healthcare team to provide essential and concise information, usually during crucial situations). The P&P also indicated, policy interpretation and implementation included, the nurse will notify the resident's Attending Physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. A review of a facility P&P titled, Pneumonia, Bronchitis, and Lower Respiratory Infections -Clinical Protocol revised, 2/22/2024, indicated, as part of assessment and recognition: I. As part of the initial assessment, the physician will help identify residents who have recently had pneumonia or bronchitis and who are at risk for getting respiratory infections (for example, those with COPD or a history of respiratory failure). 2. The staff will identify residents with symptoms that suggest possible bronchitis or pneumonia (for example, dyspnea (at rest and/or on exertion), tachypnea, increased sputum production, chest pain, chronic cough, or hemoptysis [blood in the mucus]). 3. The staff and physician will identify individual risk, such as significant oral or dental disease, presence of a feeding tube, or clinically significant swallowing abnormalities. The P&P also included: Clinical signs suggesting more severe cases may tachypnea (respiratory rate in the upper 20's [breaths per minute]) with labored [difficult] respirations, unstable vital signs, and a substantial and persistent decline in pulse oximetry results of greater than 3% from baseline. A review of a facility P&P titled, Resident Examination and Assessment, with a revision date of 2/2014, indicated, The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. Under respiratory physical exam, it listed: a. Lung sounds (upper and lower lobes) for wheezing, rales (small clicking, bubbling, or rattling sounds in the lungs), rhonchi, or crackles (bubbling or popping sounds). b. Irregular or labored respirations. c. Cough (productive or nonproductive); and d. Consistency and color of sputum.

Based on interview and record review, the facility failed to protect one of four sampled residents (Resident 1) identified as a high risk for fall from repeated falls by failing to: 1. Identify and evaluate hazard(s) and risk(s) related to the resident's specific risk and causes to prevent further falls and injuries. 2. Implement an intervention to address the nature of category of falling in which the resident fell . Resident 1 fell from the wheelchair in the three incidents of falls. 3. Implement Resident 1's care plan for Risk for Fall which indicated that the physician would document the presence of uncorrectable risk factors including reason why an additional search for causes is unlikely to be helpful. These deficient practices resulted in Resident 1 falling three times and sustaining injuries in the facility on the following dates: a. On 3/2/2023, Resident 1 was found on the floor with a bump and laceration (a cut or tear in skin or flesh) on his left forehead after falling out of his wheelchair. b. On 4/12/2023, Resident 1 was found on the floor with a laceration on his left forehead after he stood up from his wheelchair and fell . c. On 5/2/2023, Resident 1 was found on the floor with a skin scrape measuring 1 centimeter (cm, unit of measurement) x 0.3 cm on his forehead after attempting to reach for an object from his wheelchair. Findings: A review of Resident 1's Admission Record (Face sheet) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including rheumatoid arthritis (a chronic inflammatory disease that causes joint inflammation [A normal part of the body's response to injury or infection] and pain), difficulty in walking, muscle wasting and atrophy (loss of muscle tissue), muscle weakness and polyneuropathy (damage in the peripheral nerves). A review of Resident 1's fall assessment, dated 2/22/2023 (day of admission), indicated Resident 1 was a high risk for fall secondary to his balance problem while standing, balance problem while walking, jerking or instability when making turns, required use of assistive devices and use of antiseizure (medication used to treat seizure [uncontrollable shaking caused by abnormal electrical activity in the brain]) and psychotropic medications (medication used to treat mental health disorders). Resident 1 scored a 10 on the fall risk assessment and with any score of 10 or greater, the resident is considered a high risk for potential falls. A review of Resident 1's care plan for At Risk for Fall Injury dated 2/22/2023 indicated to minimize the risk for falls in the next three months. Interventions included to assess resident for propensity for falls, assess current fall precaution interventions, monitor anticipate/intervene for factors causing prior falls, and maintain call light within reach. A review of Resident 1's Change of Condition (COC) completed by Licensed Vocational Nurse 1 (LVN 1), dated 3/2/2023, indicated Resident 1 fell out of his wheelchair on 3/2/2023. The COC indicated Patient (Resident 1) was observed by Physical Therapist (PT) sitting in wheelchair. PT delivered letters to social services and returned to floor. PT heard a thud (a dull, heavy sound, such as that made by an object falling to the ground) in room. PT observed resident on floor face down. Patient (Resident 1) stated only pain on his forehead. CNA (Certified Nursing Assistant) utilized a gait belt to assist resident back to bed. Patient stated he was reaching for the newspaper on the floor when he fell . Patient was instructed to use call light for assistance when he needs help. Patient stated he will try next time. The COC indicated Resident 1 experienced pain on the back of his neck 45 minutes after his fall. A review of Resident 1's Physician Order, dated 3/2/2023, indicated Forehead injury - cleanse area with normal saline (N/S, a solution used to clean wounds), and pat dry. Apply triple antibiotic (an ointment applied to the skin to treat and prevent minor skin infections) to area. Leave open to air. Ice pack as needed for swelling for 10 days. A review of Resident 1's Treatment Record for March 2023 indicated Resident 1 received treatment to his forehead laceration of cleansing with normal saline, pat dry and application of triple antibiotic ointment once a day for 10 days from 3/2/2023 to 3/11/2023. A review of Resident 1's Care Conference Review (CCR), dated 3/2/2023, indicated six staff members (Director of Nursing [DON], Minimum Data Set Nurse [MDS 1], Licensed Vocational Nurse 1 [LVN 1], Dietary Services Supervisor [DSS], Social Services Director [SSD], and Certified Nursing Assistant 1 [CNA 1]) met to discuss Resident 1's incident of fall on 3/2/2023. The CCR indicated Resident 1 was sitting on his wheelchair while reading a newspaper when the newspaper fell , and he tried to pick it up. Resident 1 lost his balance and fell face down and obtained a bump and small laceration in his left forehead. The CCR indicated initial treatment was rendered and ice pack was applied to the bump on the left forehead. The CCR also indicated Resident 1 was observed with a purplish discoloration on the left small finger. A review of the Interview Record written by Physical Therapy Assistant 1 (PTA 1), dated 3/2/2023, indicated PTA 1 observed Resident 1 sitting on his wheelchair when he walked by Resident 1's room. After 30 seconds, he heard a thud come from Resident 1's room. He saw Resident 1 on the floor. The note indicated that according to Resident 1, he was reaching for a newspaper on the floor when he fell from his chair. A record review of Resident 1's care plan for high risk for fall dated 3/2/2023, indicated a goal of reduce the risk of fall times 90 days. Interventions included to provide safety education to the resident, and risk of falling, call light within reach and answered promptly, encourage resident to call for assistance as needed, and keep bed at lowest position and wheels locked. A record review of Resident 1's care plan for high risk for fall related to actual fall on 3/2/2023, dated 3/2/2023, indicated interventions included the following: 1. As needed the physician will document the presence of uncorrectable risk factors including reason why any additional search for causes is unlikely to be helpful. 2. Staff and Physician will re-evaluate the situation and consider other possible reason for falling. 3. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature of category of falling until falling reduces or stops or until a reason is identified for its continuation for example if the individual continues to try to get up and walk without waiting for assistance. A review of Resident 1's Minimum Data Set (MDS - an assessment and care screening tool), dated 3/7/2023, indicated Resident 1 has moderate impairment in cognition (thought process). The MDS also indicated Resident 1 needed limited assistance in bed mobility (moving to and from lying position, turning side to side) and eating but needed extensive assistance (resident involved in activity and staff provide weight-bearing support) in transferring, walking, locomotion on and off unit, dressing, toilet use and personal hygiene. A review of Resident 1's post-fall assessment (first fall) dated 3/8/2023, indicated Resident 1 was a high risk for fall secondary to having a history of 1-2 falls in the past 3 months, balance problem while standing, balance problem while waking, change in gait pattern when walking through doorway, jerking or instability when making turns, required use of assistive devices, use of psychotropics and having arthritis. Resident 1 scored 15 on the fall risk assessment and with any score of 10 or greater, the resident is considered a high risk for potential falls. A review of Resident 1's Physician Progress Note by Physician 1, dated 3/10/2023, indicated, under the section History that Resident 1 has generalized weakness. Under the section Assessment of the progress note indicated Resident 1 has a gait disorder. A review of Resident 1's Physician Progress Notes by Physician 1, dated 4/7/2023, indicated, under the section History that Resident 1 has generalized weakness and per Physical Therapist. Resident 1 uses a walker but have episodes of sudden loss of control and is a fall risk. Under the section Assessment of the progress note indicated Resident 1 has rheumatoid arthritis (RA) and a gait disorder. A review of Resident 1's COC, dated 4/12/2023, indicated Resident 1 was Observed lying on floor, curled up in a semi-fetal position (a position where the person's knees are curled inward toward his/her chest) at foot of bed with head pressed against the wall adjacent to bathroom door. The COC further indicated that at 12:05 pm, LVN 1 ran into Resident 1's room and observed Resident 1 lying on his left side in a semi-fetal position at the foot of the bed with his head pressed against the wall adjacent to the bathroom door. Resident 1's wheelchair was two feet away from him. The COC indicated that when Resident 1 was asked what happened, he stated he was organizing his clothes because his wife was coming to pick up laundry. A review of the Physician Order, dated 4/12/2023, indicated Left forehead injury - cleanse area with N/S, pat dry, apply triple antibiotic, and leave open to air. Apply ice pack for swelling for 10 days. A review of Resident 1's Treatment Record for April 2023 indicated Resident 1 received treatment to his left forehead laceration of cleansing with normal saline, pat dry and application of triple antibiotic ointment once a day for 10 days from 4/12/2023 to 4/19/2023 (day of visit). A review of Resident 1's Care Conference Review (CCR), dated 4/12/2023, indicated five (DON, DSS, SSD, Physical Therapy Assistant 1 [PTA 1] and CNA 1) interdisciplinary members met to discuss Resident 1's fall incident on 4/12/2023. The CCR indicated Resident was observed by a licensed nurse (unidentified) that pass by on a fetal position and obtained a scratch to the left forehead. The note further indicated Upon further investigation and medication regimen review (an evaluation of the resident's medications with a goal to promote positive outcomes and minimize adverse consequences related to the medication), resident has gabapentin (medication for nerve pain), bupropion (medication for depression), Paxil (medication for depression) that can cause drowsiness, sedation, dizziness that may cause resident to fall. The diagnosis of the resident is also one of the reasons that resident will fall, such as anemia (a condition in which the blood does not have enough healthy red blood cells), RA, peripheral neuropathy and resident was admitted here with nausea and vomiting. Therefore, it is concluded that the cause of the fall is the medication and resident's anemia, RA and peripheral neuropathy. A review of the updated Resident 1's care plan for high risk for fall related to actual fall on 3/2/2023 and 4/12/2023, dated 4/12/2023, indicated interventions included as needed the physician will document the presence of uncorrectable risk factors including reason why any additional search for causes is unlikely to be helpful. A review of Resident 1's post-fall assessment (second fall), dated 4/14/2023, indicated Resident 1 is a high risk for fall secondary to having a history of 1-2 falls in the past 3 months, balance problem while standing, balance problem while walking, use of psychotropics and having arthritis. Resident 1 scored 10 on the fall risk assessment and with any score of 10 or greater, the resident is considered a high risk for potential falls. A review of Resident 1's fall risk re-assessment, dated 4/24/2023, indicated Resident 1 is a high risk for fall secondary to having a history of 1-2 falls in the past 3 months, balance problem while standing, balance problem while walking, change in gait pattern when walking through doorway, jerking or instability when making turns, required use of assistive devices, use of psychotropics medications and having arthritis. Resident 1 scored 17 on the fall risk assessment and with any score of 10 or greater, the resident is considered a high risk for potential falls. A review of Resident 1's COC, dated 5/2/2023, indicated Resident 1 had an unwitnessed fall. The COC indicated Resident 1 was found on the floor lying on his right side and leaning on his right arm with his legs underneath the wheelchair. Resident 1 was noted with a skin scrape on his mid forehead that measured 1 cm x 0.3 cm (centimeter, unit of measurement) and a slight amount of blood on his forehead. A review of the Order Summary Report, dated 5/2/2023, indicated an order of Mid Forehead skin scrape: Cleanse with NS (normal saline), pat dry applies Triple ATB (antibiotic) ointment and cover with dry dressing every day shift for 14 days. A review of the post-fall assessment, dated 5/3/2023, indicated Resident 1 is a high risk for fall secondary to having three (3) or more falls in the past 3 months, balance problem while standing, balance problem while walking, decreased muscular coordination, jerking or instability when making turns, required use of assistive device (i.e. [that is], cane, wheelchair, walker, or furniture), use of psychotropic medications and having arthritis. Resident 1 scored 19 on the fall risk assessment and with any score of 10 or greater, the resident is considered a high risk for potential falls. A review of the Order Summary Report, dated 5/3/2023, indicated an order for Adding seat belt to patient wheelchair in attempt to prevent falls. Patient will be educated and trained for taking belt on and off. Will have in-service for nursing staff education. During an interview on 5/17/2023 at 1:52 pm, Physical Therapy Assistant (PTA 1) stated and confirmed Resident 1 fell in the facility three times. PTA 1 stated and confirmed for Resident 1's fall on 3/2/2023, he observed Resident 1 reading a newspaper when he passed by his room. After 10 seconds later, he found Resident 1 on the floor, lying on his stomach with his head on the floor. PTA 1 stated Resident 1 fell from his wheelchair. PTA 1 stated Resident 1 told him he (Resident 1) was reaching down for a newspaper from his wheelchair when fell face down. PTA 1 stated he observed Resident 1's forehead bleeding when he found him. During an interview on 5/17/2023 at 2:48 pm, LVN 1 stated Resident 1 fell in the facility three times on 3/2/2023, 4/12/2023 and 5/2/2023. LVN 1 stated Resident 1 sustained a small cut on his forehead after the 1st fall on 3/2/2023, a bump and abrasion on his left forehead after the 2nd fall on 4/12/2023, and a skin scrape on his mid forehead after the 3rd fall on 5/2/2023. LVN 1 stated Resident 1 was reaching for a newspaper on the floor from his wheelchair when he fell on [DATE]. LVN 1 stated and confirmed she was the LVN who helped Resident 1 after his second fall on 4/12/2023. LVN 1 stated she found Resident 1 lying on the floor on his left side in a semi-fetal position next to the wall by the bathroom door. LVN 1 stated and confirmed Resident 1 sustained an abrasion that bled a little on his left forehead, which required first aid treatment and ice. LVN 1 stated he learned Resident 1 was on his wheelchair prior to the second fall moving around his room and overreached for his clothes and fell . LVN 1 stated and confirmed she was also the LVN who helped Resident 1 after his third fall on 5/2/2023. LVN 1 stated she found Resident 1 on the floor lying on his right side with his feet underneath the wheelchair. LVN 1 stated Resident 1 sustained a mid-forehead scrape. LVN 1 stated she learned from Resident 1 that he fell after attempting to reach for an object that he dropped on the floor. During an interview on 5/17/2023 at 3:50 pm, the Director of Nursing (DON) stated and confirmed Resident 1 was identified as a high risk for fall based on the fall assessment on 2/22/2023, 3/8/2023, 4/14/2023, 4/24/2023 and 5/3/2023. The DON stated Resident 1 had three falls while in the facility. The DON stated Resident 1's first fall was on 3/2/2023. The DON stated that according to Resident 1, a newspaper that he was reading fell on the floor, so he tried to reach for it while sitting on his wheelchair; when he (Resident 1) reached for the newspaper, he lost balance and fell . The DON stated Resident 1 sustained a cut on his left forehead. The DON stated the facility provided a 1 on 1 sitter to Resident 1 from 3/2/2023 to 3/7/2023 and continued with hourly rounding after 3/7/2023. The DON stated and confirmed Resident 1 fell again on 4/12/2023. The DON stated that according to Resident 1, he stood up from his wheelchair and attempted to reach for the clothes that were hanging at the foot of his bed. The DON stated Resident 1 sustained an abrasion on his left forehead after the 2nd fall. The DON stated and confirmed Resident 1 fell again on 5/2/2023 for the 3rd time. The DON stated she was not in the facility but learned Resident 1 was reaching for something on the floor from his wheelchair before he was found on the floor. The DON stated Resident 1 sustained a scrape on his forehead after the 3rd fall. During a concurrent interview and record review on 5/17/2023 at 3:50 pm of the resident's care plan titled High Risk for Fall, initiated on 2/26/2023, the DON stated and confirmed that the care plan failed to address the nature of all three falls which is Resident 1 falling from his wheelchair or losing balance after standing up from his wheelchair. The DON stated that after Resident 1's 2nd fall on 4/12/2023, there was no new interventions implemented in the care plan. The DON stated the intervention of As needed the physician will document the presence of uncorrectable risk factors including reason why an additional search for causes is unlikely to be helpful that was initiated on 3/2/2023 and re-initiated on 4/12/2023 and 4/19/2023 was not followed since Resident 1's physician (Physician 1) did not document any uncorrectable risk factors in his notes. The DON stated the facility addressed the need for a self-releasing belt belts (a seat belt that has a quick release button or easy release that is used as a fall preventive measure to help remind residents to call for assistance before exiting a chair or wheelchair) only on 5/3/2023, which is after the 3rd fall. A review of the facility's policy and procedures (P & P) tiled Falls and Fall Risk, Managing, revised 12/2007, indicated Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident form falling and to try to minimize complications from falling. A review of the facility's P & P titled Fall Risk Assessment, revied 12/2007, indicated The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. The policy indicated The staff with the support of the Attending Physician, will evaluate functional and psychological factors (factors that concern a person's mind and thoughts) that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition. A review of the facility's P & P titled Falls - Clinical Protocol, revised 12/2012, indicated Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. The policy also indicated If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions. A review of the facility's P & P titled Fall Prevention Program, dated 3/8/2023, indicated that it is the facility's goal to reduce and minimize episodes of falls and injuries. The policy indicated that in the event a resident is determined to be a risk for falls, the facility will initiate fall prevention measures such as, but not limited to, low bed, floor mat, bed / wheelchair alarm, pressure sensitive alarm, transfer pole, assisted devices / transfer aides and nonskid footwear. The same policy further indicated the facility should use least restrictive devices prior to application of physical restraints as it relates to the actual fall including least restrictive devices such as half lap trays (a wheelchair accessory that provide a sturdy surface to temporarily hold items or arms conveniently) and self-releasing belts.

Based on observation, interview, and record review, the facility failed to provide one to one supervision monitoring (a sitter), and to ensure that the care plan reflected the actual assessment for one of six sampled residents (Resident 1), who was identified as high risk for fall and have had multiple falls on 2/26/2023 and 3/8/2023. These deficient practices resulted in Resident 1 sustaining a right eyebrow laceration (a deep cut or tear in skin or flesh) on 2/26/2023, where Resident 1 was transferred to General Acute Care Hospital (GACH) for a physical examination, a Computed Tomography (CT, a medical imaging scan used to obtain detailed internal images of the body) of the brain and spine, and laceration repair. Resident 1 sustained an abrasion on the right side of the forehead on 3/8/2023 above the laceration on 2/26/2023. Findings: A review of Resident 1 ' s Admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including injuries of abdomen, difficulty in walking, dementia (loss of cognitive functioning such as thinking, remembering, or reasoning to such extent that it interferes with a person ' s daily life and activities) and repeated falls. A review of Resident 1 ' s fall risk assessment, dated 2/26/2023 at 4:43 am, indicated Resident 1 was high risk for fall secondary to his disorientation, history of 1-2 falls in the past three months, being chair bound, poor vision status, balance problem while standing, balance problem while walking, decreased muscular coordination, change in gait pattern when walking through doorway, jerking or unstable when making turns and required use of assistive devices (cane, wheelchair or walker). Resident 1 scored 18 on the fall risk assessment and with any score of 10 or greater, the resident is considered a high risk for potential falls. A review of Resident 1 ' s admission data collection (Admission assessment), dated 2/26/2023 at 12:20 pm, indicated Resident 1 was admitted on [DATE] at 7:50 pm with diagnoses that included multiple falls and dementia. A review of Resident 1 ' s Change of Condition (COC), dated 2/26/2023 at 4:52 pm, indicated Resident 1 was admitted to the facility on [DATE] at 7:50 pm and per the hospital report during transfer, resident have history of multiple falls and a diagnosis of dementia. The COC further indicated that on 2/26/2023 at 4:30 pm Resident observed standing by the door of room (deducted) and noted with one inch laceration with blood on his right eyebrow. A review of Resident 1 ' s Physician Order, dated 2/26/2023, indicated to transfer Resident 1 to the nearest hospital via 911 (universal telephone number the gives the public direct access to the Public Safety. Answering point where emergency services such as the fire department, police or paramedics can be dispatched to a location). A review of Resident 1 ' s Progress Notes, dated 2/26/2023, indicated Resident 1 was sent out to GACH via medical emergency transportation for laceration over his right eyebrow at 4:40 pm. A subsequent note indicated Resident 1 came back from the hospital (GACH) at 11:20 pm with five sutures on his right eyebrow. A review of Resident 1 ' s GACH After Visit Summary from the emergency room , dated 2/26/2023, indicated Resident 1 was diagnosed with laceration of the forehead. Resident 1 underwent a CT scan of the brain and spine and was treated with a laceration repair. A review of Resident 1 ' s CT of the brain result from the GACH, dated 2/26/2023, indicated a result of Possible small right anterior frontal scalp hematoma (a solid swelling of clotted blood within the tissues). A review of Resident 1 ' s baseline care plan, dated 2/27/2023, indicated Resident 1 ' s initial admission goals is to regain his physical strength and balance due to status post multiple falls. A review of Resident 1 ' s care plan, no title, initiated on 2/27/2023, indicated Resident 1 is at risk for fall due to his cognitive impairment and dementia. The goal of the care plan is to minimize Resident 1 ' s incidence of fall and injury for the next three months. Interventions included in the care plan are one on one monitoring (a sitter). A review of Resident 1 ' s Progress Note, dated 2/27/2023, indicated Resident 1 attempted to stand on several occasions without assistance. A review of Resident 1 ' s Progress Note, dated 2/27/2023 at 6:30 pm, indicated Resident 1 tried to get out of bed by himself and despite explaining risks involved, he continued to try to get out without assistance or pressing the call light. There was no indication that Resident 1 had a sitter. A review of Resident 1 ' s Progress Note, dated 2/28/2023, indicated Resident 1 is getting up and down climbs over the side rails. A review of Resident 1 ' s Minimum Data Set (MDS - an assessment and care screening tool), dated 3/1/2023, indicated Resident 1 has impaired cognition (thought process) and needed extensive assistance (resident involved in activity, staff provide weight-bearing support) in bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use and personal hygiene. A review of Resident 1 ' s COC, dated 3/8/2023, indicated Patient is observed sitting in bed with new wound injury to right forehead. The same COC indicated that the patient was observed with a new cut on right side of forehead with serosanguineous (contains or relates to both blood and the liquid part of blood) discharge) on side of face. A review of Resident 1 ' s Progress Note, dated 3/8/2023, indicated at 7:15 am this morning during round resident was found in bed aware and alert with purple discoloration and small cut on his right side of upper forehead and above right eyebrow. Resident is confused and was unable to remember what happened or how he has discoloration or cut on forehead . There was no indication that Resident 1 had a sitter. A review of Resident 1 ' s care plan titled Fall Risk, revised dated on 3/8/2023, indicated Resident 1 is at risk for fall related to the alleged falls on 2/26/2023 and 3/8/2023 in addition to his diagnosis of dementia, history of multiple falls, hypertension (high blood pressure) and use of psychotropic (a chemical substance that changes functions of the nervous system, and results in alterations in perception, mood, consciousness, cognition, or behavior) medications. The goals of the care plan are to: 1) Reduce the risk of Resident 1 ' s falls in the next 90 days, 2) Resident 1 will be free from fall related to injuries in the next 90 days. Interventions added into the care plan on 3/8/2023 included 72 hours of one-on-one monitoring due to alleged fall; Anticipate resident ' s needs prior to leaving room; and Provide safety education to the resident and risks of falling. During an interview on 3/20/2023 at 12:08 pm, Certified Nursing Assistant 1 (CNA 1) stated he found Resident 1 on 3/8/2023 at approximately 6:45 am holding a napkin on his forehead. CNA 1 stated the napkin had dried blood and Resident 1 had a bump in his forehead. CNA 1 stated Resident 1 told him he fell . During an interview on 3/20/2023 at 12:29 pm, Licensed Vocational Nurse 1 (LVN 1) stated that on 3/8/2023 at approximately 7 am, after being informed by staff, she went into Resident 1 ' s room and found him to have an abrasion and swelling on his forehead. According to LVN 1, Resident 1 stated he fell . LVN 1 was unable to state if Resident 1 was provided a safety education as indicated in the care plan. LVN 1 stated Resident 1 had no sitter at the time of the fall. During an observation and a concurrent interview on 3/20/2023 at 12:40 pm, Resident 1 was observed with a linear (arranged in or extending along a straight or nearly straight line) scar (an area of fibrous tissue that replaces normal skin after an injury) above his right eyebrow and a small bump above the scar. When asked how he got both the scar and the bump, Resident 1 stated I fell . Resident 1 was not able to expand on how he fell . During an interview on 3/20/2023 at 1:22 pm, the Director of Nursing (DON) stated that on 3/8/2023, Resident 1 was found to have an abrasion on the right forehead just above the laceration from a fall on 2/26/2023. The DON stated she saw blood on the side rail of Resident 1 ' s bed and thought he may have bumped his head on the side rail. The DON stated and confirmed that Resident 1 is a very fall risk, and that she knew Resident 1 had multiple falls from his previous facility when Resident 1 was admitted to the facility. The DON further confirmed and stated that Resident 1 ' s care plan, with no title, initiated on 2/27/2023 was done after the incident on 2/26/2023, indicating Resident 1 was at risk for fall due to his cognitive impairment and dementia. During a phone interview on 3/20/2023 at 1:50 pm, Responsible Party 1 (RP 1) stated Resident 1 have had a history of fall and dementia. RP 1 further stated the facility was aware of Resident 1 ' s high risk for fall from the day Resident 1 was admitted to the facility. During an interview on 4/11/2023 at 11:40 am, the DON stated and confirmed there was a discrepancy on Resident 1 ' s fall risk assessment and some of his fall care plans. The DON stated and confirmed Resident 1 was identified as high fall risk based on his fall risk assessment on 2/26/2023 but three of the fall risk care plans only identified Resident 1 as at risk. The DON further stated it was important to identify resident as high risk versus at risk for accuracy. The DON also stated and confirmed that Resident 1 received 1 on 1 monitoring after the first incident of unknown origin on 2/26/2023 for only 72 hours. A review of the facility ' s policy and procedures (P &P) titled Fall Risk Assessment, revised on 12/2007, indicated The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. A review of the facility ' s P & P Falls - Clinical Protocol, revised on 12/2012, indicated Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. A review of the facility ' s P & P, titled Falls and Fall Risk, Managing, revised 12/2007, indicated Based on previous evaluations and current data, the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident form falling and to try to minimize complications from falling.